GP-472 . �t., -- `-a The C4mmonpealth ofMossachuseus • •
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r~ - - f Department of »dustitical Accidents
1 q ' 0/OCd olt p i{ - .. • t 600 Washington Street
Boston,Mass 02111
`'� Workers' Compensation Insurance Affidavit
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I am a homeowner performing all work myself. '' •
g:I • a sole proprietor and have no one working in any capacity
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f r .44 44)employer providing workers'comps sation for my employees w " .`'." ''.` ` ..L=__• ,�
4 - 4orking on this�ob.
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josurance co 4d J�'�h'7.- .il",t. `: 4- -policy*:
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i am a sole proprietor,general r.nntwdctor,=or uoToaow.uct • ;• _
" •, - p .- (circle one)and have hired the contractors listed below why tiaFe
? p the following workers' compensation ices , , .
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Failure to secure coverage as required under Section 25A of h1GL 152 can lead to the imposition of criminal pen#ldes of a flue up to 51.500.00 and/or
oat,Viers`tutprisonment as well as civil penalties in the form of a STOP WORK ORDER and a line of S100.00 a day against me. 1 understand that a
' £Qp)'fit the st;teillgg may be forwarded to the O1nice of investigations of the DIA for cavern!ve•ii tiM,
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1 Ala hereby':ccall j'wt4er the pains and penalties of perjury that the information provided above is fore and correct.
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7 otrigiii Usc•Qtdy,- - do not write io Ibis area to be completed by city or town official
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•city or town
permit/license N QBniiding Department
•= CI check.if immediate response is required 0Liceosio;Board E
QSelectmen's Office
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cotat�ct person; ` phone 0; 0Otber
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' MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
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City, Town �� t e t- # 2>�
- Building urri- r° . , t
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�` L( jq Svi,Uc�Awce Ito Name V i 4 Y ( 0` ) /ik' s
AT: Location •"'( _
"�' .ial, 6 y/ g' fly _
Type of Occupancy: 11e (cia-LC>Gt."/2.,/
G NewP Renovation ❑ Replacement
Plans Submitted Yes 0 No ❑
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BASEMENT
1ST FLOOR R -r--r I.
2ND FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR _
7TH FLOOR
8TH FLOOR
(Print or Type) / . Check One: Certificate
Installing Company Name k 5�1 S hG c3S/t°/'� egA„, (� Corp.
Address rVeyj c lam- /vdt y ❑ Partnership
\A J e3 j Rj I Mi" t ❑ Firm/Company
Business Telephone 5- 67, _ 121O Name icensed Plumber or asfitter
ai-wer .
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
I have informed the owner or his agent that I do not have liability insurance including completed operations coverage.
Signature of Owner/Agent
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I have a current liability insura, .o'•••to include completed operations coverage. ❑
By - > TYPE LICENSE:
Title irAV" d--._*,- �'+ ❑ Plumber Signature 1 ice sedr
Plumber orr e asfitte
fifty/Town ,c---i' ,I X Gasfitter J Cal
APPROVED (OFFICE USE ONLY) El Master h c' ( /er
0 Journeyman License Number
BC-55A
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