HomeMy WebLinkAboutCertificate of Insurance - BLDX-23-15505 21392:b-\The Co mtno nw ealth of Massac l, usetts
Departmenl of I ndustrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
\Yorkers' compensation ,"."rrr""l;';ffilff]/"lhoot.r"to.srsrecrriciaus/prumbers.
TO BE FILED WITH TIIE PERMI?TING AITTHORITY.
Name GusinesVOrganization/lodividual):J
Address: ( 0.6or 3111
&ln-z-k--
CitylSt,;telzipl ^*l @07 { Phone #:Tfl .373- bSfJ_
Any appljcant that ch€cks box # I must also filI out ttl. section below showing thcir *orkers,compensation policy info roationHo.DeownelB who submit tis afrdavit indicating tley are doing a.ll work rrd thcn hirl orsid. corfractDrs Eust submit a new affdavit indic.li!1g suclltconu'actors ttrat chcck this box must sttachcd an additional shect sholring thc rladlc ofth! sub-contsactoE .nd sbt whedtcr or Dot those cmiti6 havc
Ar. you r[ coploycr? Chcck thr rpproprirt. bor:
l.fll an a employer widr employees (tull and./or pan-tirne).1
2EI am a sole proprietor or paffrership and havc no employees working for mc in
8ny clIlacty. [No workers' comp. insurancc requirEd.]
3 . ! I am a honcou,ncr doing all work Eyself [No wo*crs' comp. insurarrcc requirEd.] t
+.[l am a horncowner and wiu be hiring oofltractors to condud all \r,o* on my propefty. I willctlsur. thEt all contradors cidte' have ' odicG' compeosation insurance or'; soleproprietor lrith no @ployees.
I 8!l a gloerrl contsac,br and I have hircd lhc suLcontsactors listcd oD the atbched shcet.
Thesc suEconFactors have crployecs ald h8vc.!,rorkers' comp. insurancal
6.[We uc a corporatio! rnd its offc.(s have excrciscd thet rigbt of a("mption prr MGL c
I 52. g I (4), ad we hwe no .t[ploycts. [No workcrs' comp. iosurzncc rcquirial
sI
eroployecs. lf thg sub-cootractors hsvr eEployees, they rou*their \,rorters' comp.numberplovidc
I am an etnployt thut is Ptoviding worken' compansdion itsurance for nzy enployea. Betow ts the poticy andjob siteinlormdion-
lnsurance Company Name:
Policy # or Self-ins, Lic. #:Expiration Date:
Job Site Address: City/Statdzip:_Attach a copy of the workers' compensation policy declaratiou page (showing the poti"y uoilEilr
"oa "rpi."tioo a"t.;,
Iai-lure to secure coverage as required under MGL c. 152, $25A is a criminal violation punishable by a fine up to $1,500.00and/or on+year imprisonmenl, as well as cMl penalties in the form of a STOp WORKbRDER and a fine of up to $250.00 aday against the violaor. A copy of this statement may be forwarded to the Oftice of Investigations of the DIA for iusurancecoverage verification.
I do hereby ce ily
77
d penalties 6f perjury ia Uu information provided above is true c0rted
o
use o l!. Donot 'rite in thb areq to be conlptded by city or town offrcial
;: fifi:: "t'*'" 2' Buitding Departurent 3. city/Tov,n crerk 4. Erectricar rnspector 5. prumbing Inspector
PermiULicense #
Phone #:
Olficial
Contact Person:
Issuing Authority (circle one):
City or Town:
Type of project (required):
7. I New consruction
8.EFGmoaeling
9. ElDemolition
10 f] Building addition
1 I . flElectrical repairs or additions
i2. flPlumbing repairs or additions
13.I Roofrepain
14. EOther_