HomeMy WebLinkAboutCertificate of Insurance - BLDX-23-15587 23214The Commonwealth of Massachusetts
D ep artme nt of I nd ustr ial A cc ide nts
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
\liot'kers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers-
TO BE FILED WITH THE PEF.l\IITTING .4.LITHORITY.
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Name (BusinesyOrganization{ndividual) I
PI e t
2 E
Address: 3tZ 3 t-.,u._.{ N
Cily/StatelZip /L Phone #-8o
7.
8.
9.
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Type of project (required)
New construction
Remodeling
Demolitior
Building addition
I i.E Electical repairs or additions
12. I Plumbing repairs or additions
13. ! Roof repairs
14 fl Other
*Any applicant that checks box
T Hooeowners who submit this
tconE-aclon that check this box
#l must also till out thc section below showing their workers' compensalion policy info.mation-
affidavit indicating they are doing all work and then hirE ouBide co[tractors must submit a new affrdavt iDdrcating such.
must aftached an addidonal sheet showing the narne of the sub-co[tracto.s and state whether or not those entities haveemployees. Ifthe su[contlactors have employees, thcy must provide their workers' comp. policy outlber
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Arc you an rmploy.r? Check the eppropriate box:
l.[ I am a employer with _cmployees (full and/or pan-time).*
2.Qflarn a sole proprietoror partnership and have no cmployees working formein
any capacity. [No workers' comp. insurance required.]
I am a homeowner doing all work.oyself [No workcrs'comp. insumnce required.] i
I am a homcowner a[d will be hiring contractors to conduct all work on rlly property. I will
ensure lhat all contractors eitld have workers' compensation insurance oa ale sole
proprietoas with no employees.
I am a geneBl contractor and I have hired the sub-contractors listed on the aftached sheet.
Thcse sub-conE-actpls have employecs and have workers, comp. insurance_l
We arc a corporalion and its ofriccls have exercised their right ofexemptjon pcr MGL c.
i 52, $ l(4), and we havc no employecs. [No workers' comp_ insurance rcquired.]
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I am an employer thal is p
infornnttort
Jnsuraace Company Name
roviding worken' compensation iasurancefor my efiployees. Below is thepolicy arul job site
, TrA'J-'s
Policy # or Self-hs.tic.*: 0/JeA 41.tfl?lo< - Z-) 3 Expintion Date f-z a
Job Site Address 8o alaz City/State/Zip:as-
Attach a copy ofthe workers' compensation policy declaration page (showing the poticy nu ber and erpiration drte).
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 penaities in the form of a STOP WORK ORDER and a fine of up to $250.00 a
day against the violator. A copy ofthis statement may be forwarded to the Office of lnvestigations of the DIA for insurance
coverage verification.
I do hercby certify under the ains and. penalties of perjury that the information provided above is trud and coffect.
Si ature:Dateb-?)P ne #:
OfJicial use only. Do not w te in this area, to be compkted by city or town official.
Issuing Authority (circle one):
1. Boerd of Health 2. Building Department 3, City/Town Clerk 4. Etectrical Inspector 5. Plumbing Inspector
6. other
PermittLicense #
Contsct Person:
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Phone #:
City or Town: _