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IBUILDING DEPARTMENT
s-\
ca t Information
Name (Business/Organizatiolrlndividual)
Address:
The Commonwealth of Massachasetts
D 0p Af lne nt of In d ustri a I A cc id ents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www. mass.gov/dia
\\:orkers' Compensation Insurance Affidavit: Builders/Contracto rs/Electricia ns/P lum bers'
TO BE FILED WITH THE PERMITTING .A.LITHOzuT\',
Please rint ibt
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Phone #://LCitylStatelzip
'eny applicant that check box # I mus! also fill out the section bclo* showing lheir
i 116ms6wrers who submit this affidavii indicating they are doing dl work and then
iconEaclo6 that cbeck this box Eust anached an additional sheet showing lhe name
New constructton
Remodeling
Demolition
Building addition
ElEctrical repairs or additions
Plumbing repairs or additions
Roofrepairs
Expiration Date
ate
7.
8.
9.
10
I1
17
l3
14 - Other
worklrs' colDpensadon policy info.mation
hire oulside contr-actors lllust subrnit a ncw affidavl! llrdlcating such'
of the sub-contractors and state whethd or not those entities have
employees. lfthe sub-.coDEactors have emPloyees, ',lrey must provide thelr workers'comp. polrry oumber
I am an employer that is prot iding workers' compensation insurance for my employees- Below is the PolicJ andiob site
information
lnsura:rce Company N"rn"'-
PoLicy # or Self-ins. Lic. #
Job Site Address City/Stale/Zrp
Attach a copy ofthe workers' compensation policy declaration page (showing the poticy number and expiration date)'
Failure to secure coverage as required under MGL c. I52, $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 $250.00 a
day against the violator. A copy ofthis statement may be forwarded to the Office of lnvestigations ofthe DIA for insurance
coverage verification.
I do herebv c r tlte p es of perjury that the information provided above is trud and correct.n
P
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I am a employer with
-employees
(full and/or part'timc).*
I am a sole ptoprietor or parbership and have no ehployees working for me in
any capaclty. [No workers comp rnsLrrance required.]
I am a homeo\,r'ner doing ail work myself. [No workcrs' comp rnsurance required ] I
I am a homeo\rtler and will be hiring contractors to conduct all work on my Propefty I will
ensure that all conu-aclors eithcr have workers' compe$ation insuance or arc sole
propnetors with no cmPIoYaes.
I am a gencrdl conEaclor and I have hited the sub-cooEactors listcd on t\e attached sheet'
These sub-conttactoE have employees and have workers' comp. nsurance.l
6.[ We ar" a corporatro! and its officers have exe.clsed their ogh! ofexcmpijon Per MGL c
152, Sl(4), and we havc no employees. [No workers' comp. insutance required.]
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Official use only. Do nolwrite in lhis area, to be completed by city or town ofJicial.
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Permit,/License #
Contact Perso n:
Citv or Town:
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Type of project (required):
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Phone #: