23B-046 (134) FEB-23-1999 i5r00 COOLEY DICKINSON 413 592 2959 P_02iO3
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m DEPARTMENT OF BUfLDrNG INSPECTIONS /
212 Main Street a Municipal 13uilding
Northampton, Mass. 01060
WORKER'S COMTENSATION 1NSMkNCE AFT XAAVIT
(Uler==)
with a primcipal plane of busiuess/residence at:
C000 0,ck Wsom Haul rAc
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6y (phone#) 5&A
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do hereby certify, under the pains and penalties of perju , dul.
( ) i am an employer providing the following worker's compensation coverage for my
employees working on this job-
S elf iU rU& G ieev.Se 76,9_ ��
(Insurance Company) (Poti-Munber) (E.Ypiruoa Da- ,
(� a sole r Tie geaeral coamctor or homeowner(t;ucle oue) and have hirui
�... the contractors listed below who have the following worker's compensation policies:
Amok
(N=c of Cnntmc_wr) (IanLraact Company!Policy Nurnbcr) (Ey.i abon Dme)
(Name of Contractor) ansumzoc CotmauytPoliey Number) (Expirauon Dare)
Y(Name of Com actor) (l surulcz Compazry/Policy Number) (Expiration Date)
V (Name of Contractor) (Incnranm Comnany/Policy Number) (Eamiratlon Date)
(.nark ndditiar)at dtoet dneomary to include cnGxaunon pertt n,og to Q c+oMo=rs)
( am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NO'M-.pica=be awue tad ale homoowmm who employ pert=to do tafitamaax eocelmm or repair work oo a dwelling or
net morn tbaa tk m uu&it wtrich the bomsoww ft=dm or as tM gttiot o appurteoam thereto ate om g awv ky aemtdcred to be
eu*aym under the svmkaes oamp=satim Ad(GL 157.ral(5)1 nppLimdoa by a baz waw• fan'a t;ftame or p"Voil may eviaepm 0-
leg.►1 asama of m aanTployar under the WOAdea COG*az almm Ad
t uoadatdand dut a copy nl tb 6 a %tk aml may bo fwwwdad to tbo Dapartcome of loduaMt,t Acddom.!09Loo of tIIAYaooe for the
down-id-va;.$catiao 404th"L-.ikue to emu:cant w urdcf SOMQu 23 A of AIOL 152 can feed to tba irrrparitioa of aimnsi peudiies
eemuffing aft F.e of up to S I,S00,00 ad/ae ip�of up to nee 1TQ and dvU pema ua is dre form of a Stop Work(hdc ud a
ring of S100.OU a day aga rat tae
Fm drpctrnmral uae mlY
a� Permit Number
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i e of Pt �,itite