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Permit expires 180 days from 1
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The Commonwealth of Massachusetts
�`== gl Department of Industrial Accidents
el= 1 Congress Street,Suite 100
• =au Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): C-11 / LY--,
Address: Z t,t, /L,cc �
City/State/Zip: S - /44 f%1-oc , _ Z Phone#: 5 O9 a 7 Z 9' f q
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with employees(full and/or part-time).* 7. 0 New construction
2:giI am a sole proprietor or partnership and have no employees working for me in $. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
3. I am a homeowner doingall work 9. ❑Demolition
❑ myself.[No workers'comp.insurance required.]t
4.❑I am my a homeowner and will be hiring contractors to conduct all work onI will 10 ❑ Building addition
property.
ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet
These sub-contractors have employees and have workers'comp.insurances 13.E-.]Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ,Q-('
Policy#or Self-ins.Lie.#t,/CC .Soo SC l SPA/ , 'a otei•t- Expiration Date: Ode b y
Job Site Address: j9-L%1 4/27n ' (q-r/c- , City/State/Zip: S
Attach a copy of the workers' compensation policy declaration page(showing the policy numbdr and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: 7 — Date: /(l-C/ to
Phone#: S Ci 3 `Z 9 f!r'1
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority (circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#: