HomeMy WebLinkAboutBLDG-19-01446 c/� 180 zb— 118377 8`
Ty 0 0 T 3y _ � O = - O � C C -I ,O .T] T O � � Z OO � � T OOn O W CD D \, ;
-- O 'o , a m m ca T y 2 D z Z 0 0 0 < f F, T 53 Z �7 < m < m c z O m n ,i Illlllllli�
c y y .c x < o 0 0 b '��c aa+1
� cJm z O m mmm -f T K rzmO � rmz OTm OT. < tnm — ro 0 1� �� ten
o y m »Q , c xxzim v mm D � -i � m � a 7�J e� QIIIII
❑ n m � � x 0b � � c—, 73m z t - II miillI
1a N •zG m =' m H - = c mO � mm - Dpo 0Om Om Z << 5 73 m yPi ..,.,.n
co pc z G) 0 N-•Z S? 0 Gm, m --IiX/ A zOm z -< m -Imz CO K
= D 0 co a .- G x m 0 ni x C D = o, 4-3
U < m ❑ T p1 m d A ~ m -z-i O m y C m O 0 - n
f �= Z Z m r = -ai o 23 T �mfl T 0 Z c
73 T 0 V) co r c m
Ov ZAZ 3 °-' m r -0 o ❑ D A m D
m C Z D C u D r m 77 Z D a ti` !/1
r = O ❑ 03= nam @ a CO c 1 0 0 o D
L r0 ` m 0y m O . m y m d 7 m 330
0
D T m m m w m a C-. < z chi Z -D fn W t% 2
❑ m = a m z 2 -o p mCo
w C
C v = o a Z 5• - D o < N
0 G_) a % m 3 O ‘“31
m Z S o I I m z
m m Po ❑ m N a= Z G d m c i_ _ i -� ,I 1 ❑ m
ID
O n m m m c7 T '^ •
JJJ"'
�,v N D y ,.9 fliñ!I'!!!
.< � O Omym 1 I1 1Z
m n-, v O m * m 7a � % .II "< O
D o s 0 0
a5al
o m � i l i i 0 DT. 1
in 73 rT1 Dm o A mZ v = m = m X
0 itI Ill iO • •� -iDo N ON v m` •t, m 5� 3 m r7Z (A m a I i ii II 1z pm3omZvm rn pill ' �` MM\ -33
NO v o m z rt
m0a1 j - j ❑$ = T E v -o 1 ` i , -I A 3
I
q 113 mT. ❑ x . I � I
F,
/ .- 0 o 1 , J 'l
rn m' i i -m IT , I- i
\ m m -
El `• OmO GI IIZO "ri OI CO I--
0, m0• 2 r 1 i 1 71
cr, 0. J � (iZ 13
co fw < 1 I. ii
. o• 0II 1 j C -Io �03
�yp I1 I � ~-0 I - _
. 1 •i , . I0
M t11'
, ' ,Il
I- 'T a w ❑ N N l" �1 i i 1 % l i X
O m, g T 1 1 ' [n 2
NB y ,•-•
❑ i N ❑
.� A 2 -� ,I L i h 1 i � 1 - l 1 -C�
F 0 I � 1 z O
The Commonwealth of Massachusetts *
`wsl�t= i Department oflndustrialAccidents
t,
'illi= t I Congress Street,Suite 100
%
;�_E Boston,MA 02114-2017
�.� wwwmassgov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO., INC
Address:8 REARDON CIRCLE
City/State/Zip:SOUTH YARMOUTH, MA 02664. Phone#:508-394-7778
Are you an employer?Check the appropriate box: Business Type(required):
1.1:1 I am a employer with 13 employees(full and/ 5. 0 Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing
no employees.[No workers'comp.insurance required]**
4.❑ We are a non-protd organization,staffed by volunteers, t}{�ilealthCare
with no employees.[No workers'comp.insurance req.] 12.0 Other
*Any applicant that checks box MI must also fill out the section below showing their workers'compensation policy information.
*"If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box 41.
lam an employer that Is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY
Insurer's Address:23 COMMONWEALTH AVE
City/State/Zip: CHESTNUT HILL, MA 02467 .
Policy#or Self-ins.Lie.#1821A Expiration Date:01/01/20(9
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi , the albs and jenalties o perjury that the information provided above is true and correct
Signature: Y' ' tlZw Arr... Date: ia 131 /17 ....1.1
Phone#:508-394-7778
Official use only. Do not write In this area,to be completed by city or town official - 0
City or Town: Permit/License#
•Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office \ 1 t\I
6.Other
Contact Person: Phone#: \`
www.mass.gov/dia \ .It`\