HomeMy WebLinkAboutWiring Permit - Permits #11757 - 50 CHRISTIAN WAY 8/1/2013 i
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PERMIT FOR WIRING
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WARD OF FRE PFWaKMW REWLATa&
.IrA FOR PERW TO ftERFOW a CTPJCAL WORK
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Department of Industrial Access
Office of Investigations r
I Congress Street,Suite.100
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Boston,. A 0 .1.14-2017
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www.massgov1dia
Workers' Compensation Insurance Affidavit.Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LA. 'b
Nacre(Business/org or,/Tndivi ): �
Address: t 5 r
f t%
Are you an employer?Check the appropriate box:
_City/State/Zip�_Z64,��IILA� Type of project(required):
1. l am a employer with _. 4. �] .1 a.m.a.general contractor andl
employees(full and/or part-time),
have hiredthe sub-contractors 6. ❑New construction
listed on the attached sheet, 7. �[Remodeling
'�.� 1 am a sole proprietor or partner- r
ship and have no employees these sub-contractors have 8. Demolition l
working for mein any capacity.acity. employees and have workers"
caul it5sttt azce.t 9. ®.Building addition
[No workers comp,insurance p•
required.] 5. We are a corporation and its 10.t4 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their l I.El Plumbing repairs or additions
myself right of exemption V,
y [No workers comp. p" n per lvlCr� . Roof repairs P trs
insurance required..]t c, 152,§1(4),and we have,no 1~��
employees. [No workers' 13.[1 other K
comp.insurance required.]
*Any applicant than checks box#1 must also fill out the section below showing their workers'compensation o ation policy inforaratirnx.
*
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llaartrxrwrncrs who submit this affidavit indicating they am doing all woos and then him,crcats9dc:comnictors must submit a new afE"xiaiv3t ittrucating such.
k;ontnrctrrrs that check this box must attached an additional sheet showing the name of the sutra mmotra s and state der or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'cramp,policy number,
I ant an enW&yer that is providing workers'conWenwdon insurancefor my engrloyeat Bdowis thepoliey cued job she
infotiataturn.
Insurance Company tame:_..6.qA , 7......__. 7C, l C
Policy#or Self-ins..Lic.#:— i� C .-____..___._..�.. � _
._.�..._,�- .„, _�� . Expiration.bate._;����""Z
L _ city/sZip, .
Job Site
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Attach a co ,,.
. Address:
_of the workers'( `„ t copy rkers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of 1vtGL c. 151.can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisownent,as well as civil penalties in the form.of STOP WORK.ORDER and a fine
of up fa"$250,00 a clay against the violator. Be advised that a copy ofthis statement,may he forwarded to the Office of
Investigations of the D1A for insurance coverage verification.
I do hereb certi a airs an " o er" that the in ormatuxn provided above Is trace and corrects
Signature: _ . _ .. _ .. _ D .._ 16, /'ter
Phone
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OffwW arse only. Do not write in this area,to be completed by city oar town offie&Lr
City or Town: _ Prmit/T icense
Issuing Authority(circle one); /
. I.Board of Health 2.Building Department 3.City/Town Clerk. 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person. w� _ :Phone
ia�
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