Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
17D-019 (13)
fi The Commonwealth of Massachusetts Department of Industrial Accidents 1- - = office ollnrest/If loos ` -, 600 Washington Street f*Floor Boston,Mass. 02111 ' Workers' Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors P..... .. .......... .. ..........:::..........:.::::......:::::.......:: ................ ..::.:::. lse x. name C',�t�c(��2y� address: �S Z.-No p city state: (� C�'� zip: phone# work site location full address): S tN I am a homeowner performing all work myself. Project Type: ❑New Construction MRemodel I am a sole proprietor and have no one working in any capacity. ❑Building Addition ❑ I am an employer providing workers'compensation for my employees working on this job. comigany name: address: city shone#: insurance co. noHcv# :: . ._.. . ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired ......the contractors listed below who have the following workers' compensation polices: comtianv name• address: e#' Insurance co nolicy comnanv name: ddr s:: cit phone#: insurance co oli # .77777.all shrrt:i�f:ttrc taslx....ttEt►ental ........................... Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains enalties of perjury that the information provided above is true and corrrect. Signature 77 Date /�F✓�-s Print name C� Phone ::;,.................................................. offichd use only do not write in this area to be completed by city or town official city or town: permMicense# []Building Department (]Licensing Board ❑check if immediate response is required QSeketmen's Office OHealth Department contact person: phone#; (] her (revved Sept 2003) :•'tiiF::iiiC i2; ttat:a<+t;:i:rat:'•• ?:: Y' - - -- ........... 11 7"lZl'} U�1�'SER E ........_ . - . ... . ... .... ... ........_._ . . LICENSED CONSTRUCTION SUPERVISOR: LICENSE: Name(print) Number Expiration Date X Address Signature Telephone City/State/Zip REGISTERED HOME IMPROVEMENT CONTRACTOR: REGISTRATION: Company Name Number Expiration Date X Address Signature Telephone Cit /State/Zi 13E1TRIlGTLD1t7; x . Items: Estimated Cost(Dollars) 1. Land $ 2. Building $ C�C� 3. Electrical $ 4. Plumbing $ 5. TOTAL= (I +2 +3 +4) $ Soa fl�lf #°tDiETI3 +C'11©1 as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury: SIGNATURE OF OWNER/AGENT DATE OFFICIAL NOTES: RECEIVED PAYMENT: '. . The Commonwealth of Massachusetts 1/ s State Board of Building Regulations& Standards + [� ( �,� 7 Massachusetts State Building Code 780 CMR ♦r ..: -. . . - :.. - .- .: �lP�'�1+CA�IUD�:ef�1Sf� irJ�T t�l�,9I1�,�ItiIIYAT'L 31�k1 �� 4 Building Commissioner Date.}approved'?" Owner of Record: Address: �cv.c Cep NAME (print) �. X SIGNATURE Tele honer Authorized Agent: Address: NAME(print) X SIGNATURE Telephone: Property Address: Assessors'Map&Parcel#. Lot#: House# Street ��QQ�VJ ��1t. Map Number Parcel Number Zoning Information: Property Dimensions: vy�L � Z010 3� <k 1��r Zoning District Propose Use Lot Area(S q. Feet Frontage Ft. Water Supply(M.G.L.40§54) Sewage Disposal System Flood Zone Information Public k Private Public. Private Zone Outside Zone _ Building Setbacks feet Front Yard Side Yards Rear Yard Required Provided Re uired Provided Required Provided z� lS l /S l - v Size of Building No. of Feet, Front: Zc_�,� u No. of Feet, Rear: "zo L 0 No. of Feet, Deep: / i, Height of Building:_ S Ft of Buildin : �/9Z ? '1>CI1�TIO C��'P�t�PON V M.0. New Construction ❑ Existing Building Repair(s) ( Alteration(s) ❑ Addition ❑ Accessory Bldg ❑ Demolition ❑ Other: (specify) BRIEF DESCRIPTION OF PROPOSED WORK: _ y :, DWI is Workers'Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the Building Permit Signed Affidavit Attached: Yes No❑