HomeMy WebLinkAboutCertificate of Insurance - BLDX-24-104 36656Th e Co mmo nw ea lth o1f M as s ac lt us etts
D ep a rtme nt of I n d ustrial A cc idents
I Congress Street, Suite 100
Boston, MA 02114-2017
\\:orkers' compensatior ,"rr."'"""#X;frf,,1{?r(!Jrla",r,^,r",r/Erectricians/prumbers.
TO BE FILED WITH TEE PER}IITTING .A,ITTHORITY.
ation
Name (Businesyorganizatior/lndividual) :)')tn /zt* 1/,n,
t PI e t b
Address:
CitylState/Zip:2 o a26 Phone#: ,f?F-a ad
Type of project (required)
New mnstruction
Remodeling
Demolition
Building addition
Elecrical repairs or additions
Plumbing repairs or additions
Lf Root reDarrs
Other
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Any appl ican! thar checks box # I must also fill outthc scction bclow showing thcir workers'compensation policy informatioD-
Homco\rrlcrs who submit tlxs affidavit indi cating thry are doi-og all work and thcn hirc ousidc con!-actors must submjt a ncw affdavi! indicating suc[rcotu'aclors lhat chcck this box must attached an addilional shect showing thc name ofth. suLconE?ctors and stalc whether or noa thosc entities havccmployees. If tbc sub-cootractors have cmployees, thcy must providc thclr workcrs'comp. pollcy number
Ar. you an .mploycr? Chcck th. appropriat. bor:
l.t!l I am a emploler with .Z- cmployecs (full and.ior pan-rimc) r
I am a solc propiictor or parhership and hav. no employees working for me in
any capacity. [No worlie$' comp. insurancc required.]
3.! I am a homcowner doing all work myself. [No workcrs, comp. insurance rcquirrd ] i
I am a homeorrncr and wiil bc hi.ing contracio.s to conduct all wo* on my propclty. I will
enslrc that all cont'actols eithcr havc workcrs' compcnsation insuranc" o. *" ,ola '
prcpricto.s with no Employccs.
I am a gcncral conE-dctor and I havc hircd thc sub-conEactors listcd on $e attachcd shcc!.
Thcsc sub-contracrors havc cmployecs and havc workers, comp. insr.uancc.l
Wc aI. a corpo.alion and its ofricers have cxrrciscd thet righ! ofcxcmplon pcr MGL c.
152, S I (4), and wc havc no employecs. [No workers, comp. insuraoce rcquired.]
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I am an emPloJer thot b protiding workers' compensation insurancefor my employees. Below is the potic! andjob siteinlormation
.lnsurance Company Name::7./1t77, <
Policy#orSetf-ins.Lic.#: /,A/,aX b HUfiql0 y1tl?223 ExpirationDate:z1'u1LL7- 7 7
JobsiteAddress: ZZ /.l'/t2//z.l:S/ f .f Ciry/State/zip
Attach a copy ofthe workers' compensation policy declaration page (showingthe poticy number and expiration date).
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 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 ofthe DIA for insurance
coverage verification.
I do hereby cefiify the pains o.nd. penakies of perjury that the information provid.ed. above is trud and coruect.
Phone #:.5^"Y- 46>-€2*
OfJicial use only. Do not wtite in this arua, to be completed by city or town officiaL
Issuing Authority (circle one):
l Boardof Health 2. Building Department 3, City/Town Cterk 4. Electrical lnspector 5. Plumbing Inspector
6, Other
Perm it/License #
Contact Person: Phoue #:
City or Town:
CERTIFICATE OF LIABIUTY INSURANCE
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