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HomeMy WebLinkAboutBLDE-21-001612 (2) The Commonwealth of Massachusetts tC i Department of Industrial Accidents ® lEE t,',. 1 Congress Street,Suite 100 Boston,MA 02114-2017 *'�,.,- www massgovfdia Workers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Rex Burger Electrical, Inc. Address: 2045 Main Street City/State/Zip: Marstons Mills, MA 02648 Phone#: (508)332-6985 Are you an employer?Check the appropriate boxc Type of project(required): I.M lam a employer with 2 employees(full am/or part-time).* 7. 0 New construction 2.1: 1 am a sole proprietor or partnership and have no employees working for me in $. Remodeling any rap:,wity.(No workers'comp.insurance required:) 3.©1 atn a homeowner doing all work myself[No workers'camp:insurance required.]* 9. ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all ware on my property 1 will 10®Building addition " ensure that all contractors either have workers'compensation insurance or are sole 1 1.Q Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 lam a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp,insurance.$ I3.❑ROOF repairs 6.3 We are a corporation and its officers have exercised their right of exemption per MGI c, 14.0 Other 152,111(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. 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: Our insurance agent will fax our policies to the Building Department Policy#or Self-ins.Lic.#: Expiration Dates Job Site Address: 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 MGI.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 certrfy and penalties of perjury that the information provided above is true and correct Si nature: • J Pulle , M.E. Date: 08/31/2020 Phone tf: ' Official use only. Do not write in this area,to be completed by city or town offfiiclai i City or Town: Permit/License Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: t