HomeMy WebLinkAboutCertificate of Insurance - BLDX-23-15579 23018c\The Commonwealth of Massachusetts
Dep artmenl of Industrial Acc idents
1 Congress Street, Suite 100
Boston, MA 02114-2017
\\iorkcrs' compensation Ins"'"""JI#;ffi..i'riY*aoorr^.ronnlectricians/ptumbers.
TO BE FILED WITH TEE PERMTTTING .4,ITTHORITY.
tion PI t
Name (Busincsyorganiz.ation/tndividual) :?
Address:q.
CitylStatelZip:(l Phone#: d '\
Ar. yor to .mploycr? Ct.rL tb. tpproprirt. borl
l.Ql am a crnptrycr wit \
".ptoy"o (tull and/or pan-timc).*
Z.!l am a solc propnctor or parbcrship and havc no anployces working for mr inany c.Orcity. [No wo*.rs' comp_ insurracc rcquircd.]-
3.!t am r homcowncr doing dl lDrk rE !elf. [No wortm'comp. inslmrrcr rcquilcd ] r
l.!l am a homcor,vncr and w l bc hiring coflEacto6 to conduc s.ll wo* on rry propqty. I willcnsur! thtl dl coafador! aithcr havc li/odirn' corpgo*tion ir-rr-"e o"-o" aolc '
proprictors vith no rrrployets,
5.[l an r g.rErl cofilctor ud I hlvc hirld Or suu,coN-aqtors listcd on thc,tllchcd sh.ct
I nesc slrD-conElcbrs hlvc clployccs and hrvc workcrs, comp. insuraocc.t
6.flWe are a corporatio[ ud iB offccts h[vc rrrirEd thci right of rf,rmpdoD Dcr MGL c.152, il(4), ed wc hrve no .mploy.€s. [No workcrs, comp. iasuran". i.luiial
applicant thar chrcks box # I rnust also fill our tha section bclow showing thcir \r&rkr6'coEpcnsstion policy informltio!"tHomcowncls \r,ho submit dris rffdavit indicrting thcy arc doiu ,ll .,^,ort 8nd thcn hirc outsidc contractoE must submit I ncw affdavit indicring suctllcontractor thql chcck this box mus echcd an additioEl shcat showing tlE rlmc of thc suEoontsactors ard statc whctha or not thosc cntitics have
Type of project (required):
7. ! New constuction
8. ! Remodeling
9. E Demolition
l0 E Buildiry addition
I l.EElectrical repairs or additions
12. EPlumbing repairs or additions
l3.flRoof repain
14 fl Other
lftha suuc.nE aators har,c cmployeca,dEy tuun provid! thc wortlrs'policy oumbcr
I am an enqloyet that is provtding worken' compensalion insurancelor nqt emplolees Below Ls the policy andjob sitein/ormation
Lrsurance Company Name:Rc.f.,
Poliry # or Self-ins. Lic. #:\Expiration Date:
Job Site Address City/Stardzip:Attrch r copy of thc workers' compensation declaration pege (showing the policy number rnd expintion dete).
Failure to secure coverage as rcquired under MGL c. 152, $25A is a criminal violation punishable by a fine up to $1,500.00and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine ofup to $250.00 aday against thc violator. A copy ofthis statement may be forwarded to the Of6ce of lavestigations ofthe DIA for iusurancecoverage verification
I do hereby the pains and on providcd above is true and conecl
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2' Bu ding Departmetrt 3' city/Town clerk 4. Electricar Inspector 5. prumbing Inspector
Phone #:
Issuing Authority (
l. Board of Health
6. Other
circle one);
Official use only. Do nol write in thb drea, to be compteted b! ciry or lo ,n offrcial
CoIttact PersoE:
City or Town:PermiVLicense #
IH}S CERNFCTIE ls ISSUED A3 A IATTEA Of
'IFORIATIOII
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DAA IE REITIOI)EU G & COIISIflrcT]OtJ
CEI{TERVILI.E
CERTIFICATE OF LIABILITY I]TISURANCE
TH]S IS TO CERTIFY THAT TH€ FOL'CES OF $ITNTNCE L6I=D BELOA/ tiAVE A€EN ISgJ€O TO I}€ T'6IR€O NAT€D AAOVE FOR TI€ POLICY PEROO
INDICAIED, T}OIWIIHSTATOII{G ir{Y REoURIMEi.T IERM OR COI{OIIION OF AI{Y COtfiRrcI OR OIHER OOCLT ENT WfTH RESPECI TO I$IICH THIS
TTY PERTA!\ II€ II.EiURA{CE AFrcRD€O AY ltE POLICIES DESCREEO HEREIII IS SUA.,ECT TO AlL TT€ IERMS
E(C!USrO|{S ArO CO{OmONS OF SUCs POJCTES. UtrrIS sl.lollrv rl Y HA!/E BEEN RECi]CED BY PA]D CLAIrS
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CERTIFICATE OF LIABILITY INSURANCE
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