The debris will be disposed of in: inten: meott (74 Location of Facility Ce f VAL i pth if Si ignatyfe i of Applicant a\as\v9 Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information
The debris will be disposed of in: ileus meow (74 Location of Facility Sig atyfe of Applicant os\13 Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly
The debris will be disposed of in: inleus moor (7A Location of Facility Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Legibly Applicant Information (Business/Organization/Individual
| h fi { Signatyfe of Applicant Nw 1 ate Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RedStar Construction
The debris will be disposed of in: inten: meot (74 Location of Facility AA ALL Signatyfee of Applicant ssa v3 ate| Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print
Location of Facility OLSignatyfe Wh of Applicant Qa Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia y Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RedStar
Location of Facility Signatyfe of Applicant 2129\13 Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 s www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Legibly Applicant Information Name (Business/Organization/Individual): RedStar
Location of Facility Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 -* www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RedStar Construction Services, Inc.
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Location of Facility Signatyfe of Applicant alghovs Date Dedicated to excellence in public service ee \dg 3eNa jihad The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/
Location of Facility Signatyfe of Applicant q\B\rovs Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RedStar
Location of Facility Signatyfe of Applicant \g\ 1024 Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Legibly Applicant Information Name (Business/Organization/Individual): RedStar
Location of Facility Signatyfe of Applicant ali Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 , www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RedStar
Location of Facility Signatyfe of Applicant a\\ Q\1072 Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 = www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Legibly Applicant Information Name (Business/Organization/Individual):
Location of Facility Signatyfe of Applicant Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual); RedStar Construction
Location of Facility Oi Mh Signatyfe of Applicant Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Builders/Contractors/Electricians/Plumbers Affidavit: Workers Compensation Insurance Please Print Legibly Applicant Information Name (Business/Organization/Individual): RedStar
Location of Facility Signatyfe of Applicant Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Legibly Applicant Information Name (Business/Organization/Individual): RedStar Construction
Location of Facility Signatyfe of Applicant Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Legibly Applicant Information (Business/Organization/Individual): RedStar Construction
Location of Facility Signatyfe of Applicant Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1 750 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Legibly Applicant Information Name (Business/Organization/Individual): RedStar Construction
Location of Facility Signatyfe of Applicant Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RedStar Construction
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Location of Facility QML AD Signatyfe of Applicant Alehs Date 7 Dedicated to excellence in public service Gaetan The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 e www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/
Location of Facility PLSignatyfeMhof Applicant Aigo mB ate Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Legibly Applicant Information Name (Business/Organization/Individual): RedStar
Location of Facility OLSignatyfe AW of Applicant a i423 Date Dedicated to excellence in public service ere The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 Es Sd www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Legibly Applicant Information Name (Business/Organization/Individual
Location of Facility UAW Signatyfe of Applicant W223 Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia = Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RedStar
Location of Facility Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Legibly Applicant Information Name (Business/Organization/Individual): RedStar Construction Services, Inc.
Location of Facility OWLSignatyfeWhof Applicant \\t4h22 Date Dedicated to excellence in public service rm 7 TENT The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations B Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual
Location of Facility Signatyfe of Applicant Dedicated to excellence in public service a) 7) pibdd TENa The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RedStar
Location of Facility OiSignatyfeWhof Applicant Qilrs Date | Dedicated to excellence in public service Tha id ih a TSN3 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center re 2 Avenue de Lafayette, Boston, MA 02111-1750 eee www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Legibly Applicant Information Name (Business/Organization
Location of Facility Signatyfe of Applicant Q\u\rs Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 = www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RedStar
. |, Department of Industrial Accidents Office of Investigations Lafayette City Center iI 2 Avenue de Lafayette, Boston, MA 02111-1750. www.mass.gov/dia Workers Compensation Insurance Affidavit: BudersCotracatear Applicant Information Name ians/Plumbers dalPledse Print Legibly (Business/Organization/Individual): RedStar Construction Services, Inc. i ns "4 Address: 313 Washington Street At City/State/Zip: Newton, MA 02458 Phone #: 617-243.
Location of Facility Signatyfe of Applicant Date Dedicated to excellence in public service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RedStar Construction