,4" s\ uffis KWf *Wa,,, ililr.l*# wiih inr PERM lrrlNc AUruoRlrY' N ame (Business/Organization/lndividualli xa,",i, ///f fi/r//tufitl'r{' .9. City/S :HM:IJTTXII"; .Ac;pph*,t tt*.',*k' b"x #l most slso fill otrl thc se"'t'l:,:'""i-J::'J:l5iliil #.;;ffi;;;;;;;;,"*,;ubrnit o new afficlavit indicatins such r r{nn "o,,"nsrs who surrmir ,n'. 'itii',i, irJi . ;-l*l ::: ll:::*:i:,t'"T,*:T;""'::f.'."",*crors and s*re wherher ot oot rhose cntities havc liimruH;lm*:ffilHl'*m:.ii:':F1;i:i*:yd'Y"1il:r:*"Jll-:*n:*'-s*re whe'1hero'roo'lnosecn'1i'iieshavc The Commonwealth of Massachusefts Department of Indusfiial Accidents 1 Congress Street, Suite 100 Boston, It4A 02 ll 4-20 I 7 www,mass.gou/dia orkers' compensatio" t':f:t',::l,TP.:*:*1*:l?TlH:?f'r'i,."rrcians/Prumbers' W# C42{- Phone #: W4ey-gyt Type of ProJect (required): Z. I New construction 8. I Remodeling 9. I Demolition to f] suitding addition i t.I Electrical repairs or additions 12. I Ptumbing repairs or additions 1.3.I Roof rePairs ,.fii,i",iuAU-wudsb'z A.. you ,n cmployer? Chec* the tpProprlete hox: r ffii * a crnployer with *L *anployees (full ond/or part-time)'r r l--l I .n o sole proprietor or porrncrship and havc no ctnployees workitg for me in - * un, cspacity. Iitlo rvorkers' comp' insurancc rcquut,ro l l.[ t um a homeorvncr doirtg all *ork nlyse]l [No worhcrs' comp insurunce required'J ' a.l-I I anr a holncowner and will ho hirinB contractor lo conducl ell lvolt on lny pmpeny l will - .ns,,re tut all .orttu"ruo "ith"i nuJ-* *o'Lcrs' compensation insurance or are solc PmPrietors widr no ernPloYtc's' 5.{--l I arn a general conuaclor and I have hired the sub-conractors listed on the atlached sheet' * 'rhese sub-cono."to" nuJ''Jtp[y*t ""a hgvc rvotkers' cornp insurance l o.[-'l we ure o corpomdtm ald its officos hove exerciscd their right of exelnprion pcr MCL c' 152, li l(4), arrd u'e have tttit'pf nl'tt*' INo u'orkers' comp' insutance tequircd ] their workefs' ,rsatlon insurance for my employees Below ls lhe policy atrtl iob site /st'; '//..5'tl r{lzlt lf the sub'conracors have inlormotion, Insuratrce ComPanY Name: Policy # or Self-ins. Lic' #r Expiration Datel /ftru Job Da notwrite ltt this urea, to be conpleled by city or tow,, offieial' City or Torru Issuing Authorih' (circle one): t. Boaid of Health 2, Building Department 3. City/Torvn Clerk 4. Electrlcal lnsPector 5' Plumbing Inspector (s; t Contsct Person: -"--, .,, . ,- ' '- ' '