HomeMy WebLinkAboutMiscellaneous - 203 Gronville LaneThe Commonwealth of Massachusetts
Department of Industrial Accidents
AV= dIDrest "Aw
600 Washin,-ton Street,
Boston, .class. 03111
Workers' Compensation Insurance Affidavit
�1 1atpfa homeowner performing all work myself.
LZA am a sole proprietor and have no one working in any capacity
Failure to secure coverage as required under Section :5a of NIGL 1552 an lead to the imposition of criminal penalties of a fine up to SIS00.00 and/or
one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of SIoo.00 a day against me. I understand that a
copy of this statement may be forwarded to the OMce of Investigations of the DEA for coverage verification.
I do hereby terrify under -the pw*ns and analties of
Print name
th= the infornsadon provided above is true and corn
Date
off)eial use only do not write in this area to be completed by city or tows official
4
city or town: permit(Ucenm A —,Building Department
CLicensing Board
check if immediate response is required CSelectmen's Office
C31iealth Department
contact, person: pboa c !: r'tOther
(mwaW 1195 P1A)