EP-5236 ^� = DE AKTMENT OF INDUSTRIAL ACCIDENTS
600 WASHINGTON STREET
✓amen Car^ooe+; BOSTON, MASSACHUS FTh 02111
Sore—ssione•
WORKERS' COMPENSATION INSURANCE AFFIDAVIT
JAYSAN GAS SERVICE
80 County Road
I, P n_ RaY 74f,
(litcnscciperzn:ttccj E. FREETQwt'.. MA 02717
with a principal place of business/residence at:
(Ciro/Srate Zip)
do hereby certify, under the pains and penalties of perjury, that:
I am an employer providing the following workers' compensation coverage for my employees working on this
job 7 J/j/
East-ettl CdSua-l-t-y—In . CO 142 F3 6SA� {
Insurance Company Policy Number
[ j I am a so,e prop.:eroi and have no one working for me.
( 1 I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed bei
who have the following workers' compensation insurance policies:
Name of Contractor Insurance Company/Policy Number
Name of Contractor Insurance Company/Policy Number
Name of Contractor
Insurance Company/Poiicti• Number
Q I am a homeowner performing all the work myself.
NOTE: Please be aware that while homeowners who employ persons to do maintenance, construction or repair work on a
dwelling of not more than three uniu in which the homeowner also resides or on the grounds appurtenant thereto are not generally
considered to be employers under the Workers' Compensation Act(GL C. 152,sea. 1(5)), application by a homeowner for licens
or permit may evidence the legal status of an employer under the Workers' Compensation Act.
I understand that a copy of this statement will be forwarded to the Department of Industrial Accidents' Office of insurance for coverage
verification and that failure to secure coverage as reouired under Section 25A of MGL 152 can lead to the imposition of c:minai penal:
consisting of a fine of up to SI 500.00 and/or imprisonment of up to one year and civil penaides in the form of a Stop Work Order and
tine of S 100.00 a day against me.
Signed this l day of �?Xl- 19
L.__nsec Permir Licznsor,''Pcrmi„or
,•-•"-,; '!:h .-' -- - . -'.- •-
fl';'-i-iki0,-W.F.,i';'•,*ft-k-'1'f,-",,--4115-4':-47-,4-,#,,44!: , .",,,,-.•;'''.z,e,;-?,*;;:''''';',''''''''''',,,;';'';''';6 ri.-':''',;.',4'''.:.1:1',r''''--_:'''':,:''':4 liti;44011410,1117:t.::-Ira.61:W.W ,-' : - .... T., i '-''' '"4.1...g.,'',.,:::),:•-i,e'',CA:kkA-..'4.•
':'''Vi';''',''''F.:''''°`':? `,'"''t 5'-j•-•";.;''.1'k".'.1:.;•4 06'‘''`'..'i'l.i''..:', /;..,i4ki,J..-,14,;,,,,,,„ -:,,,,,,,,.,-,„ :7.;....,...-",,,,,..4 .ito,'*,IZ11,77.71:iw,7,74R,14;,4,,,,,;.z:;,i,.;,ti,„,6tAzv:.:. .t.,4_-.4,,,V.R",,')IN!,7,;',kill::1;,,%-•
if-J-I-,vpi',....;:;.4:4:NnfarfSzc::.;::i:WtqtAis:: .:'e.-;'-';-.'. .:7".,...4,t,e*g...i.Z;:,5:S,4Per,:q*kSra"4PV::WAfitL,g:'f,'A'':'C!:;L::VA'Ak:V,#:5**Z<qFKM4'•'*i*rk::P.?4?RY* Vt:t:.1:::,*' : '
'4Z-0-t7": •;. ; . , 4,6' -.''. ;.:, :.;.,.;‘:::-X'..':: ::t.'.f.' 1' ' ;',,ii;Z:::: ::;.:';''''''',',::0:: :`,..4.':: :;'i';'' ::,.,',''''':::',;:.„
„ii:'kt'4;44-= ..-' g4*1,14p.ir,',.')xof*:.,.,.....„.,:., ,-,,,, ,,,,.„.,r'„,. , ,:,-i ., .....,i.-3,0-, : r ,.:,:f4,
r.,:::.Jaz*:.:Io::. k..,4s:,;t.'1:-,'.,-,-=,5•_;,,.',-,:::::: ,_„?....:'..,:-:',,,,' ,'.,.f-,';;:.-:!'t',':':',.,fv,::::::'-,,,t,r,::: :.,T....;:',..!;:,:lr.:17.,.:,...,,,•...,,:,:!!„-,,,,,,,:-.:,::z,,,:,!,7,7,, ,v,z3:::,,,,f,,,,,:,:gi7p.:;:i'...e-,.7.,...,11‘.;25v,-,1.,-.!,:-.,:ff_::,,:A.--.4--.:::,:: :::
i-4,,-,-..-,i**- 7:,--.I.--;*,,--:*,%Aft.,,'!',i,,,,141.,-,...-A3,-,.-.",,,..-...,:.:.,--t-4,,-4.14,„;:, ,i,$,,,,,;,-4-: ,::,,',a:,;" I•y.,,,,,..,_:;4.--i,,,,,,,,;.,:„,,,,,.•,„.,.,i,,:.:.,-iwitifriii64-0,,„,!i,,'".tf-,"a"-;,vi,?-,'-'iii.V.4:4.:,,F' '4':-'Y'---""""-,',' -.",..4*-'''..-4v'-"'"4"--'!.,14,ACtiii,i:A4,
,'. '•;.- .'.,',::±•... ''•.''''. p ,1:, '• • .:.,.• .,,,,.• ,.,:.-..:,••,..,,,:•_ ;i.,,.,:..',- :,:::::1 ,:::4,..‘",-. . ''''::::-:-,•-. ,
* IY-- vatlinri-..-ocatiet,.;,r, i Iv w, \1\)Ckf:no Date
,c,, >. 1.---Pv .-- •-. ..' ,--:, -. : :A,,..:......,,:::,.:_:-.7,,•',:f.'..,,,,....:-.:-:.',-; ;;-,.`,..-..,:...,,:,, , ..
„ ......,.. . ,
,.,..„ .....::: :•,:,. :::,... ::::;;.::::,60,..:.,_.:- .: .,,,•.,,,•,:::.,_,..,..,._.". .r.,_. 17-1 ..:- . ,, .: 0 . . . _ ,. •Plans,L,,,. , ,.:r."1:, ,,,.-:,;,...,...
Now'-'-:- , f:',.-.-' ':Itenijvation Lj . Replacement Submitted- -1.;;H:J„
. . _ ., . ., . • , . ,.
., . . . . . .
. •,- •-: • (4 'tx..1 c6 • . '; Z :. ' 2- •,,.; •
. ,
g ril • : - ' ,0 . •, .-. •
ci) ri) U F4 o4 '1.-i : ' •
• w g Cl)
'<—
Pk'. -*:;---f-7:',,--c7„,t7tri, 0 w .< it240 (:) ,,, • . ...1 •
N., 1,14 4:4
.•-• E-4 cel >
'.."'• -'---H7*411V.:-"•f,711. Con 04 (.5.- U W C4 Z C4 g C) E•4 Z 1--H-:0 4:t ..‹: E":4 c 4 .4 eE :x ; 'L."0 C): .8C4. •C4. , ' ... ,:' ,.:...
• • SUB-BSMT.
BASEMENT
- - '1' 1-- :,ii_st FLOOR,- •
G ,,
._
. , . .
2rid FLOOR
• ' • 3rd FLOOR --•' :' -.
,_r
4. FLOOR
•
•
" ' . ' - ' '75thLOOR-'?4 7-''..: .,.- : .- .,. ---'' - • - • .
6t.h.,FLOOR- ' r .,.- 4- . . ..,
, .
7th:TLOOR: •: .:,:.=_ ,
- - 8th FLOOR '- .• - , - . ....
Installing Company Name JAYSAN GAS SERVICE Check One: Certificate ..
80 County Road • .
'Address , „ . , ' P.O.
• .• - C.'rREOtTwNi, MA86x146 02/.ti - A : -' '''''''''''' ' .'' - . : . ' • '''-:' .
,- - . --- -
City State Yip Code C Partner
Business Telephone: Z‘ — -.1..1 ,15 , ,770.77 1-1 Firm/Co.
Name of Licensed Plumber.or Ga• sfitter rc04\.)\C-lik) A (.._, 0.2(-Af 1,
INSURANCE COVERAGE: Check111119t.
I havett-current liability insurance policy or its substantial,equivalent. Yes,1.5o D
1 - . If you have checked-_.-s;please indicate the type coverage by checking the appropriate box.
• -:--------7,:.-.„-.., . •,7._ . .
i.--.T...:iiaboyinttirance'policy,'.. Other type of indemnity Bond
' ' • . '-'• #0ERIANBORANC*,1VAIV1ER:I am aware that thelieensee does not have the Insurance coverage required by Chapter 142 of the Mass.General ,•,
•-•,Litvs,:andIhnintY4ignanii*,on:thia-,•petntit apPliciItiOn*tives.thiS requirement.
-: . . , ,•: . • . . -,' ... . . ,
•-:-.r. _ t. . _-••:.,.. - •• , . ' •' .: •
• Check One:
„ .__......— ..- : .. • _. , . „ ,. ..._.Owner Li Agent
•-• • - • ' .
Sigliadiit*OtOltil*e*.A$ Pt:-_ -•-, '-''-' :,-:-:--..:,'-. •-•:•',' ',- . :- • . : • ... , - ', • -.1': •::::: :;:,-,*::,',i.,-.,'!-',.,;,-.,-.-:.:;.: ,,. - , _ I':,:--- , : :, , : :; ,-.,;7:.:.,-,,,-..,::,_:yi.„.,,,!...!4,....,,,....,,,..,:.:-..irfr.,.:,._.:; , ,,,: .,..,,,;..,7._.:„.,..,,_.:..,„;.-„,,,..„,-;.,.--..-;.:.-',:- l'•: ,_, ,- ;.- ... bava,460livi,44i404,and„.
. -- submittediti010t:WW4***11---§f100)-110#740404.149PuPP'A:I:41"IT . , .kS°F.9RCPMk.!,--,,y;, ,..,,,,,,,,,. , , ,, -,,,,,,,,,-, :-•-.:,,-,;, ..,.:.:.-.. .-:::::.. .., ..,,. •
44Wk,0*.4e0i40(-.4q0t4.00$410400000# #41!!!.. i.IPA104414t,t!041,.!',,x"!q9144714A6issuedi ..-,.- .-:', ',: -:...±.-
,:,.. 1..... ..ift,i1i#-;zitt compliance41#-#4:PPF1,,t11:...,Pmvisionstt'‘. .5. •;-! ; .1:-': '-<1;0ii';g,-..,,,J-:'.-:-i-,.-;:: 71.4:::,1±.-:,:-..:'.::,.:,--::•
A:.::.1Ti7Af-R-;1',F:aY10:r"-l'irg:M:?:;', ;s-'f : -,:';-:: ':':'''''::'::-j'.::,'-'z':',1:j!;?-.i..Vk :E';'j-r ; ;i,'i;;. t!cii..:it'''it'.-'j:.1'.0iT-? :1)4...IP.'.;;:::';',.t:: :;',:',',,r-. .. .':1'::,•'..'-',.;.",'- '-.... ..
r
-,.:,:,-.--:i...,..;,.:',::: : :':!..W.,,*11:- .ci.:,;,Ki.,..Alit.',.--,l'Aliifa,;;ii.V.I.f..t,,t'V-0-.Z.'`r''.t4:',:.1,:iY;RiitEi',..r2.„,i.:',.'„'::31:'-f.§::',;.,';;?.11,,,:-:',0,e. ,,,,...',:jp:':,• ::,..::-',•ii..-ri,"t: ii::',V;1.-,''''.,.',.... .:4',..ti'...'.,,-;;;;?..--f-4,,,, ii':i",.CV:-f':,,,,,4.::..:-:-.,
.-!',1,4--,,,e0,,,,,e.40:,,,44-wk-,,.,?;:-:=;,:„i,-,,,,,-,.-:,,,,:-.-T,,,,,.,,-...,-;4..,.,::7,.,-..,..,„4.,:,;,,:„.:.,.. .4;..-- ,-,:y:,,-,:,,,,..,:.,3:,„..-::.},:;',4--.Z.;,':-..f.,::,!:!44675*-iriV"--'7Y:f4,',.1 -::7,-,•-;'::;',.r:s-::-4,!'.'.-;.';',',.,1.--;i4',"'-',"4-•-•',.;,‘:'''.:-?,';":•'-.7'--‘,1:.:'=:::",-.- i?".","-'."';'7i,"`:!-:. ..,:l'ki,16"e-AiW:37r,t4:1'...,-,,,:-.4i
..w-:.;:.. --..--.--:-.-,f.-. .4:...,--. :;:i.::;• -.. 4 ,,,',W,.. .i..;: ::c. ,-,,,: ii' 4 .'•" ,;;;- Z ;:;,::, :,:.;,.„,•is;;;.•,:;,k- .,f- .4..',-...4.,,Lwai.4,3V:-;f7';:,,,„,.,:f.,:.'
'---,-,-- --.5-:,-,',..,,,,•,,,.5q,.,, Ai.. .,!,.::: ;;:7;:5177, - ; -.7,.:7,•,:;A:t-:;,' if ,:,-- Y,• .:•:,'_,-: ,,,,i,; ),..4 '____,_, Ylie1.,.."..i .'_' ',Ii.i'•..'i..:: " -,,...4-,,::','. .r.:.,":','•-:'-:-..,:,,,,',,t.-1'.:'''''''-''''''''''
--.----:---::,-,..•,',::--,;,.•,..,:,i-titietirii----;.::,::::Nis , 113 JOURNEYMAN: ::',,':;:.'•.'':'' '• License-. ., '. :f-'"".r'" :''.',:.'::::::',-;.. -,::::......:....,,',. .--f:•-•:';:::, -.. • ';:.',"•!:::;.:•••-"...,Z"--':': -.'
- ..,<.•";,,::_:;,..-,,..',..-,i-:;.:.,,..-;!,.::-.Ti::::4.;:::e_iiA,:•;4•:::, :•;,,.-... -•'.-:: -.:-.--1- -±,:.-'••;•-•:_:-:-,• :-:::-••;',Arr:Z•0? ''''.'.;.----.::-,i-- '-'.'..•.,•-.- '• ''':,- ,..:7:,!..:,;,.**•!?....;;;f:- .•-•:'.'-,''=;• -.',''':-:::- ..-'''.?••••_'•.'.. .. .., ,..---., :•, ;.::•.?,: ::-.:'-.:•--:''. • ' - .'- '
h //
a
�4 .' '� •�" "� ,' '' F°e' ;,.may �c F...i4 k c $+�
\
\s‘k rt‘
t,,,•
0.
t.
1.4
...... ,....„:....t
A .
�o-41 :
r� 0 o
...2
0-3
�' v b
a-r. a 0 n` O rod\`. C
F .4 � . z �� 5
d ._ tz, d o
- n › `v
CA
tri
O C
4
k
b 0
4.1
cn
4ku}a*ii F a LdL'e 'b s f ; i ,,,.
.- ._•., .4t � F . 2 ',, � e ',1'- u y '? tr , Ct �i k te + ti Y _ ff'Y u1y m ZZ'i, o ,--
' F ks n "`� Y 3 z �y � r „��s t r't'e ° d, •, W fit r ` 3 ,.'.-,v •
; 1 b r 0 } f � asff > r . r+ ,:e �rs - • '