HomeMy WebLinkAboutMiscellaneous - 125 PEACH TREE LANE 4/30/2018 (11) n
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Deptirlownt of1ndustria1Accidenrs
Office ofInvadgaikns
X Congress Street Su#e 190
.Sosim,MA 02114-2017
www.tNQa gavIdia
Workers'Compensation Insurance Affidavit:Baittiers/CoatnwtordElectrieitusfPlumbers
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Nanrze(Ansist /Orgariiaatiorl/Inaivutua2>: SolarCi Corp. -'-
Addrm: 3055 Clearview Way
Cit /State/Zi : San Mateo CA. 94402 phone#: 8. 88-765-2489
Are you-an elaplayer?Check the appropriate box: Type ofproject(required):
1.JZ1 am a employer with 5,000 4- ❑ I am a general contractor aW 1
employees(full and/orpart-time).«
have hired the sub-contractors, ❑deer consRtxtion
2.❑ 1 am a sole proprictor or partner- listed on the attached sheet. 7. ❑Retnodeling
ship and have no employees These sal-contractors have g. ❑Demolition
working forme in any capacity. employees and have workers'
cam insurasrce 1 9❑ Building addition
END workers comp,i�nsttrarnce p•
relWred,l 5-.❑ We we a calporadott and its 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I1.❑.1%mbing repairs or additions
myself.[No workers'comp. right orexem ptiari per MGL 12.❑Roofrepairs
insurance required)t c. 153,11(4),and we have no
employees.two workers' 13@✓ other Solar/PV
cmp.in ur nrce required.]
*Aay applicemters dm checks box#1 mast also til!out tha sa tim below show tg tbeir woda�'coo atRw potioY wbrmwon.
t Homwwowho submit this aMdavh indiee &ftY ate doing ag wart:gad am Woutsidc coutrxtms must submit a new gtttdtrvit indicalingsaeh.
=Cosmsotors that dnd this box must attached an a Widoaat abeam showkV the naw or"subs snd state whettrcr or not thou erdities beve
emptoyoas. If the s actors havc OWIopas,they=t Fronde ttx it woriters'comp puliey mnber.
xeern-irr-sesmes.� -
I am an employer tlrat fr prot etg verkers'compensatim km mreefor my employees. Bdow is the policy and job site
delfrrrgiatlon.
insurance company Name: Zurich American Insurance Company
Policy#or Solt ins,Lia.#: WC0182015-00 Expiration Date:9/1/2016
Job Site Address: a ,GIG ia-Wf e. �.-(�Ylk- City/State/-ip: (y oyj h An d �
oe.e-
Att'aeh a copy of the workers'compensation policy ducluration page(showing the policy number and expiration date).
Failure to secure coverage as required tinder Section 25A of MGL o. 152 can lead to the imposition of ceanirad penalties of a
fine tip to S1,500.00 and/or one-year imprisonment,as well as civil penallies in the form of a STOP WORK ORDER and a yore
of up to WOM-a day against the violatcsr. Be advised that a copy of this statement may be forwarded to the Offrea of
investlgatlons of the VIA for insurance coverage verification.
.1 do herehycer#fy ar the pains and pensfiles of perjury that the lay f orxWVV pmQed above is true and correct
Matu
1'11rnte�:
1f khd ure only. Do trot xvrhe In this area,0 be txmpdeterd by rity or toren oj)kiaL
City or Town:
pegpse�{
hLuving Authority(circle one),
1.Board of li'ealih 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
1Corrtact Person: Phone#: