CCF02062021_00002The Commonwealth of Mnssarhusetts
.. �' Department of Industrial Arcidints
, i I Congress Street, Suite 100
Boston, MA 02114-2017
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www nmss.golafdio
'Markers' Compensation Insurance Affidavit: Buildersl['ontractors[Ekctricians/Plumber.
TO HE FILED WUM THE PER4fITfING Ata-MORIT1.
llinlitant {nf+;rauatiun Please Print Leeibly
STTI�(l3usiatcs3'Otatlazation`lttclltticivat): John Landry
Address: 104 North Elm Street
Cityi'state/zip: Northampton, Ma 01060
Arr you an emnplotier'r Check the apprupriale anus:
Phone #: 413-204-9880
1.® 1 ant a cmployrr with .-_- _---cmpkticcs (full andyr part -ti awl-*
10 1 am a wle pnrprii fur ur paatacrship and hate no cnWbwcs working fur era in
any capacity. [Nu wurker cum. irnurancr required.)
3 a hue 2w h ner doing all aurk my elf. [No %wkus- cuuV. imurancc riqua-W.]
4.n lira a hunwown.r mil will la,: hiring wntrsclurs to conduct all work on m}• prVP4ztr. 1 will
t ertsurc chat all contrw1un either have vsorkers' nt gwnsatrun imsurancr ur am sok
prupnewrs k ah no etnplvyrc.%.
501 ar a fugal cunuactur and 1 hate hired Elie ob-cuntriactura listed cm the duatiicd Avcci_
Thcsc sub-cvntrrctura hart rmpluyccf and hate'+ -Akers' sump. imurarLLr.�
6.[J We am a coTpuratiun and its offiken hat c excrtiscd their right of cxernptium per MOL C.
1�2 > 1141. and we lista no vrnplueres. [Nu workers• comp. insorancc rcyui ed.l
Type of project (required):
7. 2'New construction
S. modstang
9. ❑ Demolition
10 Building addition
I l ❑ Electrical repairs or additions
12.❑' Plumbing repairs or additions
13. Root repairs
14_ Q Other
•Any applithat ehtxks box al Haul alai till out the wLtion hrluty shutting thea uuriera eonwcns-atiun policy infurumii n-
+ Iknncvyurrers who salmi[ this a1Tis tit iadieating [trey are doing all work and there hire outsicic cuntrwLtrx mtL-t subnut a new affiula4it indicating swat
"Contractors that cheek this box must artac heti an adclitiunal sheet shwa ins- the name of flu sub-curt€nrc•[or, and -tau a hohes ur not tho w entitics hate
cinpluyec-s_ If the Sub-cuntractor% hate carlsloveca. they rust prvt idc their t%orkcrs" vtnnp. policy nwnber.
I am err enipfoyer that is providing workers . compensation insurance fur my employees. Below is the policy and job site
information.
Insurance Company Name:
Policyti or Self -ins. Lis. #:
Expiration Date:
Jots Site Address: City: State, -Zip:
Attach a copy of the workers* compensation polity declaration page (showing the polic% number and expiration date).
Failure to secure coverage as required under MGL c. 152. §25A is a criminal violation punishable by a fine up it_F 51,tt)U.W
and'or one-year imprisonment. as 4ve11 as civil penalties in the farm of a STOP WORK ORDER :incl a fine of up to 5250.Qf) a
day :against the violator_ A copy of this statement may be forwarded to the Office of [n;estigations t?f'the DIA for insurance
coverage verification.
I do hereby certify under the Imins rand penaiiies of perjury that the information pro i-ided above is trite and correct
John Landry ,,UA- I"",,,, Date: 02/08/2021
413-204-9880
Official use only. ,Do not write in this area, to be completed by city or town official.
City or Town;
PermiLaLicense #
Issuing Authority (circle one).
1. Board of Health Z. Building Department 3. Uity Town t'Ierk 4. Electrical Inspector i. Plumbing Inspector
b. tither
Contact Person
Phone #: