HomeMy WebLinkAboutWire Permit - Permits #11787 - 41 NORTH CROSS ROAD 8/13/2013 Aim
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
J
Name (Business/Organization/Individual): NO 75h CAS r- t-4,Fr-'t1z"CAA S'&P-6114 ES21 //V
Address: Y 361
!� AIZYAIA 9r, PO ROY --
city/state/Zip:ICL-1�/ R ��O;��/?Phone#:
Are you an employer? Check the appropriate box: Type of project(required):
1.91 am a employer with_,Oz 4. F� I am a general contractor and 1 6. 0 New construction
employees (full and/or part-time).* have hired the sub-contractors oe
2.M I am a sole proprietor or partner- listed on the attached sheet. 7. 14 Remodeling
ship and have no employees These sub-contractors have 8. Fj Demolition
working for me in any capacity. employees and have workers' 9. E] Building addition
[No workers' comp. insurance comp. insurance.1
required.] 5. F] We are a corporation and its I 0,KElectrical repairs or additions
3.0 1 am a homeowner doing all work officers have exercised their 1 I.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.M Roof repairs
insurance required.] t c. 152, §1(4),and we have no 131-1 Other
employees. [No workers'
comp. insurance required.]_
*Any 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. ell,
Insurance Company Name:_ t 7 &A 4
'Policy#or Self-ins. Lie.#: A10 V.1 C Z Expiration Date:
Job Site Address: L+1 N, CrOSS RCOd City/State/Zip:N-A� e �I%VO-
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 th pains an enald Tperjury tl. t the information provided above is true and correct.
Signature:.....- Date:
Phone 7/-//7
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):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: