HomeMy WebLinkAboutMiscellaneous - 93 ROCKY BROOK ROAD 4/30/2018 (17)The Commonwealth of Massachusetts
z Department. of Industrial Accidents
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1 Congress Street, Suite 100
Boston, MA 02114-2017
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www mass.gov/dia
Workers' Compensation Insurance Affidavit:. Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Business/Organization/Individual):
Address: Lclv.-& I
City/State/Zip: q-&1-60% .. CJ (`J C1 Phone. #: 535 "YU,35
Are you an employer? Check the appropriate box: .
1.❑ I am a employer with employees (full and/or part-time).*
2.01 sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp, insurance required.]
3. a I ani a homeowner doing all work myself. [No workers' comp. insurance required.] t
4.61 am a homeowner and will be hiring contractors to conduct all work on my.ptoperty. I will
ensure that all contractors either haveworkers' compensation insurance or are sole
proprietors with no employees.
5.O 1 am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance,t
6.❑ We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7. ❑Ne construction
S. emodeling
9. Q Demolition
10 ❑ Building addition
11.Electrical repairs or additions
12. Q Plumbing repairs or, additions
13.0 Roof repairs
14. Q Other
*Any applicant that checks box #I 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 on. employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
informtion. r"�1
Insurance Company Name:
Policy # or Self -ins. Lic. #: L, CSC,- 1� (o C! S Expiration Date: ! ) (0
Job Site Address: iia City/State/Zip: w /r�hotiCJvty- tMt4 U 1 NS
Attach a copy of the workers' compensation policy declaration page (showing the policy 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 of the DIA for insurance
coverage verification.
/ do hereby certify ui:dr the pains and penalties of perjury that the information providedabov is tr and correct:
Si nature:(C ra
Date:
Phone #: l 7 �-._ 716 —! 3 V 6 t
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person
Phone