HomeMy WebLinkAboutCertificate of Insurance - BLDX-24-133 37669A'The Commonwealth of Massachusetts
Department of Industrial Acciden*
1 Congress Street, Suite 100
Boston, MA 02114-2017
\Yorkers' compensarion ,r.u'"'".'nH;ffit;{?rYliJarrrrr"rr*rEre*ricirns/prumbers.
TO BE FILED WTTH THE PERMIITING ATTTHORITY.
Name (Businesyorganization/lodividual)l
t
Address: 4[S t/*
Citylstztelzip Phone#: @^493-txl*
Ar! you tr cEployrr? Ctcck the.pproprilt. bor:
l.!l am a cmployer witr cmployccs (full and/or pan-time).*
Z.[ll am a solc proprirtsor partrcrship 8nd hayc no cmployccs worting formc in
any capacity. [Nowo*r(s' comp. ircurancc rcquircd.]
3.!l am a homco*mcr doing sll uork Eysclf [No wo*as' comp. insrnncr nquiFd.] I
+.[ t arn a horurrncr ard will b. hiring contractoE to qonduct all wo* on rry prop€rty. I will
cflsurc 6El tll contreors ei$cr havc nrodicrs' compcosation irl$rrncr or arr sole
Eolrictors wi$ no .sployccs.
S.!t ao a garent conElcbr rnd t hlvc hiEd thc sub-contrrctoB li$rd on the atbchcd shlcL
Thcsc sub-cotltsactols hlvc cftployacs ard bavc wortcrs' coop. irsurmcat
6-[Wc arc a corpontion and its ofrcrrs have cxEctuc.t ttEir right of qrmpriol pcr MGL c.
152, I I (4), and tv! havc no rmplqyeG. [No worlcrs' comp. hsuraDcs Gguind.]
Type of project (required):
7. E New consfuction
8. ! Remodeling
9. E Demolition
l0 E BuildiDg addition
I l.EElectrical repairs or additions
I 2. E Plumbing repairs or additions
13E
14.f1 Dc lur
Roofrepairs
otherstDr
Xt?lA(uutr"T
t$DDr,,
I am an enployer that is providing worken' cotnpansolion insurance lor rty etnployea- Below b the pohcy and job site
hformatiott"
hsurancc Company Name:_
Policy # or Self-ins. Lic. #:Expiration Darc:_
Job Site Address: City/Statdzip:_
Attech a copy of tte workers' compensation policy dedaretion pege (showing the policy number and erpiraton da-tey,
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 on+yeu imprisonment, as well as civil penalties in tle form of a STOP WORKbRDER 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 of the DIA for insurance
ooverage verification.
I do hereby certify th and alties of perjury thal the inlormation provided above is iue and corred"
o
Official we only. Do not wfite in this arca, to be complded b! cjty ot town official
l' Board of H*lth 2. Building Depsrtment 3. City/Town Clerk 4. Electrical Inspector 5. plumbing lnspector6. Otler
Permit/License #
Phone #:Contect Person:
Issuing Authority (circle one):
City or Town:
P