HomeMy WebLinkAbout51 Station Ave The Commonwealth of Massachusetts
!; _ t. Department of Industrial Accidents
s!i1'` 1 Congress Street,Suite 100
€�krj 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 't Please Print Legibly
Name (Business/Organization/Individual): M I GfF (Ji(1 1 1 o'1.YL5
Address: (d4Z t,< AL T 7>L )-
City/State/Zip: MA-- D Z7 7°Phone#: —?Zo—Z 3 —7 DO O
i
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. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. CI Demolition
10❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13 aRoof repairs
These sub-contractors have employees and have workers'comp.insurance.:
67111We are a corporation and its officers have exercised their right of exemption per MGL c. 14.['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:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 51 s7tCL4 OY \ City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number 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 pa' sand penaltie f p ry that the information provided above is true and correct
Signature: 7 Date: (/r S/zcz
Phone#: 7 Z —Z3I —/0 0 0
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#:
.
� , Commonwealth of Massachusetts
/) DivisionCo of Professional Licensure
(�Lp
Board of Building Regulations and Standards
Const� {lprvisor
/J
CS-101155I U ires: 08/27/2020
/ MICHAEL A l lLLIA yil' /;
692 WALNUT IAIN":'t I
/ ROCHESTER MA1027 4.• ��
`4)/SS33L�-1.\�
Commissioner l/""r
r ____
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE;Individual
Reaiat atio}I Expiration
3-- 02/19/2021 f---...,...,
MICHAEL WILUAMB t b°
MICHAEL WILLIAMS-
692 WALNUT PLAIN RO �k "��
ROCHESTER,MA 02770
Undersecretary