wagner permit app p5The C: oittirtottw}ettlikof .,Vf tssrtcliusctts
U- Iitl r7attent of Industrial Accidents
I Cott ress ,street, Suite 100
4 u)-kern' t`ompe cation Insurance Affidavit. ll� a lf'�►ntrxeiut �.I €ride �t3r'1't� fter�.
TO HE FILED WITH THE I'i~:RN11171NC At *110 VI4.
A a lic.ant Information Please Print I.urE bIN
Nameli3rasi >�i3tY�aztsr�tu�an incia,°�cftaaii��.ff_ ��_ik".�.`a"1-_.._
C itylStatelzip: _,Yrt.rE��-�!✓- AA
Are tnm an empkk%rr" Check the u1spreprsafe box.
Phone #: (i /1312 z i cl 13
t.Q 1 am :a crliployur usIII emfpluj,Ccs (full arstlw Parmirm1_*
A2, 1.am a :xale prt,tSncttM ur lxuuserSParp and hate nu Lntf Eu,hza uuaicsasv fie nx rn
ata t Alta tty #:tiu u trtisrrs' wrsp. nsuranrr xtuat� ti. J
1 am a hurtmm sset doins all ttiurk sn� r:lf. [fro +koricm, curssp artetdr lee r"uark-d'i
401 xva a 1suirwwA ncr and u rll Fre l trots wiamlo€� iLa cundtict ;all a, irk on ray rt4vtty, l w l
mNum that all euntra:.tur+ eIdk.,r lw c x tt:rg` etssrgXm: Tacna imurunce rr We w1c
pwpnetorn with no empla,y x-�
501 ru a f.,c aal a onuu for rill I ha: e hmd AAC : tsa *ol art
esc salt t tretracttvrs lm,cc emmpluyuca and hal l ,wrLcrn'.:cuctp. mkuramc.=
60 We are is %;oTpoxwum and tt.� offs,;sr)* haht exec med dmi rrgtht of cxensption per l4'tS.it_ c.
13'. §lf4l<and -At: hshe no ertlplvyve]. l'du %cnk.r-' i•i*tnp. mn, anis: st:yunrd.j
Tvpe of project (required):
7. 0 Nets, construction
lwi. C,."Rt.'irtc,clelirig,
_ etnulitis�n
I U C] Building .addition
l I Electrical rcWifa or additions
12.0 Plumbing repair. ;air additions
13.] Roof repair5
14_ 00the.r
*,Am, applicant that drank% box I%! muA aibw till uut t}sa xt ticm lsrluu SFstrth ixar thew wvskcr,' . uattlacxtsaisisn trulWN anftxrnattu"
4 fkmntuvt ncr% athu as omit thus afflulstat uuts aung they brc dmig ull +hurl: aad dwal latrc isestaitlr, inttr es tars mmi aubnrat a raw affttlaacit andihatrat: 3ucl:
'L mrMaa tt ', tlusi dhetk tht:, lu>a muss atts3mi an axltlriiunal shim shuwins dw murrc of Lilt: and >taic atltetlser m ntit th,.s a Mslty. h34,V
tsuplt ;ec> IY t1a ,isLM-l'a+slt:ya Gars ha, etrtlsl+sts e , tilatt tnu>t 1,na•.tdeLheir curl rea` .esrrsp. to+i�cr nwnla r.
I ant an empiayer th a! i� providing workers' c°ampramition insurance for nr3y emphrj-ee+a, Below is the policy and job site
information.
In,urratts•r f anip n),, `+,'aiiic::
Policy # or Sc:1#=itt,. L..ic. �:_ _ _ _ �y Expiration Date:
:rob Site Address: Cs vistate: Lip:
Attach a ropy of the workers' comp .+adon policy declaration pt�e (showing the polit-Y namber and expiration ante).
Failure to cx (aft: coverage as required and r MGL t:. 152, §25A is a criminal vsolation puni3hatilc by a line up to 51.5t1(3 OO
antVor one-year itnp€isonment, as well as civil penalties in the fctriti ofa STOP WORK ORDER and a #inn of tip to S250.00 a
clay againsi die violator. A copy if this statc^.rtumt rutty be forwarded to the fJ#Tice of Investigations ofthe DIA for insurini e
Coxerko Venfic:aiun.
i do la;¢relr). cent; 1 er the srtitts attad aaIt' 8 of {ferlrtrt' that the i fcirtrtrrti>7rr rr�iirtrsi above is tare rrrrti c r�rreet
sta��,�ttttirr� � _ 1a 1 ) Date- 0 �Z—
Official mm onr- Do not smite in this area, to be completed br tin, or trout( offie at
City or'rowoz
P rmitlLieeatse
Issuing Authority (circle tone):
1. Board of Ifealth 2. Building Department 3. {'ityfyo-4n Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. (other
Contact Person:
Phone #: