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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 suchr 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 MassachuseftsDepartment of Indusfiial Accidents
1 Congress Street, Suite 100Boston, It4A 02 ll 4-20 I 7
www,mass.gou/diaorkers' compensatio" t':f:t',::l,TP.:*:*1*:l?TlH:?f'r'i,."rrcians/Prumbers'
W# C42{- Phone #: W4ey-gytType of ProJect (required):
Z. I New construction8. I Remodeling9. I Demolitionto 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' #rExpiration Datel
/ftruJob
Da notwrite ltt this urea, to be conpleled by city or tow,, offieial'
City or TorruIssuing Authorih' (circle one):t. Boaid of Health 2, Building Department 3. City/Torvn Clerk 4. Electrlcal lnsPector 5' Plumbing Inspector
(s; t
Contsct Person: -"--, .,, . ,- ' '- ' '
uilEllt Lrl rupllG DaTeIV
w #;:;'ffi;;;#ffi;il;;***Cl,i I ll S t u- t.1 r:ti'iI t t SU pr,* l-l" i s,i I t" 5 t.-u'i:'i; i ta I i' -v
License: cSsL{P$Itf.-*o" i*: . "1"/'t
MATTIilWCOXJ" ffi*'/r,,.iu)'
i+ fruOrev Street t ffi' tr 'iSouthnaarcy ndrF-olqffiW# (
", ,,wd..r *-
'il*,,a&b)r'rt\"\ flxpIt.attorr0/}12812017Commissioner
a%-W@{MOffice of Cor,"'-er Affairs and Bu(iness Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 021 16
Home Imptouement Contraotor Registrationouo,.,,?l)il,
ll,Xl?i.o,,o,*,onE*Piruiion' gl13l2}1t Tfr 270774
OLDE HADLEIGH HEARTH & HOME CENiT
YA.'l[[Hrf'?#r, srRErr nr g3
s. unolrY, MA 01075Update Address and return card' Mark reason for change'
,- Address f- l Renewal i Employment I Lost (lartlL-,
SCA 1 ':'; 20M'05/11
E IMPROVEMENT CONTRACTOR;H,;; - rYPe:
xpirationr ;9t13t2011Private CorPoration
orri'="iott,cH HEARTH & H.ME .ENTER INC
MATTHEW COXi 19 WILLTMANSETT STRETT RT 3 -4Lz-?44'-3 f,qoi-gY, MA 01075 undersecret&ry
License or registration valid for individul use only
U'*i"i" tft. exf,iration date' If found return to:
;;;;; c;sumer Affairs and Business Regulation
10 Park Plaza ' Suite 5170Boston' MA 02116
iiot valid without sign
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AGORD 25 (2010105)phoflct
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