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Get MA Worker's Compensation Insurance Affidavit 2013

D correct. Signature: Dat e: Phone #: Official use only. Do not write in this area, to be completed by city or town official . City or Town: ___________________________________ Permit/License #_________________________________ Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other ______________________________ Contact Person:_________________________________________ Phone #:___________________________.

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