HomeMy WebLinkAboutContractor License/insurance •
t." Commonwealth of Massachusetts -Division of Professional Licensure —
Board of Building Regulations�( and Standards nh rowmvil,pea/tA e/'c'as::ariatettJ 1,,
Constr1T�`tsptlU f2rvisor Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
CS-009013 Type: Individual
tplres'OS/11/2022 _ Registration Expiration
GREGORY M,tAULEV 4 f. , %-r t13822 02/01/Expiration
33A BAXTER A,VENUEI r ,- ' '
019
WEST YARMOSJTH Mt• t 3 Gregory M.CBti
�• t' Gregory Cauley
1 r)Isy.•,t.ii��� 33A Baxter Ave.; � �g —
W.Yarmouth,MA 03
�/ ryCommissioner do K. DFimc.Q k, ,., i .- - Undersecreta
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BUILDING DEPARTMENT
The Commonwealth of Massachusetts
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Department of Industrial Accidents
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lip 5t Office of Investigations
= tv Lafayette City Center
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2 Avenue de Lafayette, Boston,MA 02111-1750
1 V www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ✓✓��� Please Print Legibly
Name (Business/Organization/Individual): C"--/ ZS.s2 C '-E
Address: `3 A paperc-e iefe
City/State/Zip: e,ci ( Phone ars--0
Are you an employer? heck the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
�loyees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.Le l am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp.insurance comp.insurance.:
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
e9 .]
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbin repairs or additions
myself. [No workers' comp. right of exemption per MGL
yP 12. oof repairs
insurance required.] t c. 152,§1(4),and we have no 13.0 Other
employees. [No workers'
comp.insurance required.]
*My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: 'f /-441a,' -i 2/) City/State/Zip:4S p 1�1�
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and pe allies of pedury that the ' ormation provided above is true and correct.
Signature: Date: /1/ a6
Phone#: 25 X-C `Pa"5-S
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority(check one):
1DBoard of Health 20 Building Department 3.City/Town Clerk 4.0 Electrical Inspector 50Plumbing
Inspector 6.0Other
Contact Person: Phone#: