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13-099 (9) _ o It\ 1 r commortwywIth n/'tetsraltt°1►attMt!t rierortmeivi of lndutfriot 4ei idr'rtfs t c"rot +r ,trrrtw, Smite 100 {e' -I Brctr», N 11l1 f i 4-200 ii tvitioc.mot t.iirov din Wetltihers'Cool premtimk istersseet Affidavit: HuiirkreVontreetnrv'Fiectrictnnn/t'lumfrert. TOR, tttIP%Mit Iltt r'lltItaIIINt; tt'htttt1il"i. �eatLks t Islltrt3nsei Plesat Print Lattlb(x Nartle tout irx cc i tot iturattort r tn*follio 1 Done RPOt_CPOroneY ►ddres:P 0 Box 1054. 45 Mein Street. Lind B City/State/7i ,Wilksmtbunii.MA 01096 Phone 0:413-340-1399 i1' Are tea as reaps.•r.t t leech the appragrriate hens Type of project(required): l ©I am a employe with rerreeinotee troll ardor pirei.tmw • 7. 0 New construction 0 I am a role onsprortor rr parmerthep and have no enifiloores woken for me in 8. ❑ Remodeling any oirweils i`dc,%extra,'comp mornareee irritants! 9. ❑Demolition t❑i am a hs+mMwner einem all work mvasdf No workers'esmp insurance required i 10 0 Building addition A❑1 am a homeowner and will he hmttg etn+traereas to conduct all work on my property I will ensure that all t centramms either have wowket a'compensatam insurance or are sole 1 1.0 Electrical repairs or additions Norm-ion with no emptiest" 12.0 Plumbing repairs or additions s❑i am a general cvontrachx and 1 have hued the Sub-contractors listed on the attached sheet. 13.1:Roof repairs Ter sub,e nttac'*ors haw employees and have workers'comp insurance 1 14.El Other fireplace framing c,❑We are correlationa and its office have exercised their right of exemption per MGL c 1 t-.>lull,and we have no employees No workers'comp insurance required.I 'Ans applicant that checks hox II must also till out the section below showing their workers'compensation policy information. r Homeowners who suhnii this atfdavit indicating thec 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 repairers If the sub-contractors hair emplo}ees,they must provide their workers'comp policy number I an,an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site information. Insurance Company Name: f-( Yi1 L C`'1Qit \(bxtp (',i Policy#or Self-ins.Lic.#: \NC,Y 01525(00 0 Expiration Date: DO I7.022. Job Site Address: i10 l i PoOd City/State/Zip: une)O }- C)I O,O 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: crkt.tyliDate: T a.Ot . Phone#:413-340-1399 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#: