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\ The Commonwealth of Massachusetts
Department of Industrial Accidents
> tilBl�ce efalisrs
600 Washington Street, 7" Floor
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
An cslint isformtttiaxs Please PRINT kQibhv
name: RICHARD J. PITERA
167 Station Ave.
address: So Yarmoilth, MA 00664
city state• zip: phone #
I am a homeowner performing all work myself. Project Type: ❑ New Construction
I am a sole proprietor and have no one working in any capacity. ❑ Building Addition
❑ I am an employer providing workers' compensation for my employees working on this job.
company name R3 C 0.
address: 161 6toft ; o -t ky�R
city: S Ot&,l k 1 aV mo%4 tl L (M& o a6to4 phone # �"� r^ D S Ig 0_7130
❑ I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
company name:
address:
City: phone #•
imurance co. g
•
Failure to secure coverage as regn fired under Section 25A of MGL 152 can lead to We imposition of criminal penalties of a fine up to $1,9,fteo and/or
ape years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a
COPY of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify uxde Hie ins and penalties of perjury that the information provided above is true and correct.
iignature_T Date 2 O O
Print name C� .a ✓ 1/' 0. oil.
- Phone # � (? � "' ago — 713 A
official use only do not write in this area to be completed by city or town official
city or town: permit/ icense # ❑Building Department
❑ check If immediate response is required
contact person:
(mL-d scpt 2003)
❑Lkensing Board
❑sdeclmen's Office
❑Health Department
Phone #; ❑othcr