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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

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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

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Contsct Person: -"--, .,, . ,- ' '- ' '

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'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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