EP-7179 •
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... The Commonwealth of Massachusetts
IN a ,_(i`a Department of Industrial Accidents
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Workers' Compensation Insurance Affidavit
iTiiir'ric iii Cu eurii"uiar-- - -
name: I AkvNAS `hOAls-
location: e D QO s a-S`I
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city FP:.t-Nape• t•-•\p 99569CI
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❑ I am a homeowner performing all work myself.
® I am a sole proprietor and have no one working in any capacity
❑ 1 am an employer providing workers' compensation for my employees working on this job.
company name:
address:
city: ! phone#:•
insurance co. policy#
CI I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices:
company name
address:
city: phone#r
''Insurance co: policy#-
t
fnmpany name
. ..
_
addrm:
city: ohone#:
insurance-cm - noliey#:. . .
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or
one years'imprisonment as weal as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herb • under the pain d penalties of perjury that the information provided above is true an correct
Signature Date 7/1 1 cal I
Print name `illorna.S k'II a&LI- Phone# 11969152
official use only do not write in this area to be completed by city or town official .
city or town: permit/lieense# Building Department
❑Licensing Board
check if immediate response is required DSeleetmen's Office
Department
contact person: phone#: °Other
(revised 3/95 PIA)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the `law", an employee is defined as every person in the service of another under any
contract of hire, express or implied, oral or written.
An employer is defined as an individual, partnership, association,corporation or other legal entity, or any two or more of
the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual , partnership, association or other,legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.
Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the
performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have
been presented to the contracting authority.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names,address and phone numbers as all affidavits may be submitted to the Department of
Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The
affidavit should be returned to the city or town that the application for the permit or license is being requested,
not the Department of Industrial Accidents. Should you have any questions regarding the "law"or if you are required
to obtain a workers' compensation policy, please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
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The Department's address. mien:rc. _ and 1a,, n- . . I. --- — — —
The Co:nat..,... _: rn s,z.c t tss'::
Dersart-r_cnz o �..-:rit::matzl Acc_L..r'tj
dtffce at inuestiaalialls
600 Washington Street
Boston,Ma. 02111
fax #: (617) 727-7749
phone #: (617) 727-4900 ext. 406. 409 or 375
Office UseOnly
)t ,; The Commonwealth of Massachusetts Permit No.
Occupancy&Fee Checked
c ,tn =gt (leave blank)
Department of Public Safety
_..4'
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
Town of Dartmouth
All work to be performed in accordance with the Massachusetts Electrical Code. 5 7 C R 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 7!19 'g
The undersigned applies for a permit to perform the electrical work described below.
Location (Street& Number) �j I I Notl ett'j LAM_
Owner or Tenant 4 e ` Q°\scot ,
Owner's Address 544"A-
Is this permit in conjunction with a building permit: Yes tJ No 0 (Check Appropriate Box)
Purpose of Building Utility Authorization No.
2Zu
Existing Service 201 Amps / I Volts Overhead ❑ Undgrd El No. of Meters_
New Service ______Amps , Volts Overhead ❑ Undgrd 0 No. of Meters
Number of Feeders and Ampacity ( (�
Location and Nature of Proposed :lear �ical Work I Ott 0A. )h� e D tn� 9a0I
No. of Lighting Outlets No. of Hot Tubs
No. of Transformers KVA
No. of Lighting Fixtures swimming Poolctnbiodv.e ❑ d 0 Generators KVA
No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting
Battery Units
No. of Switch Outlets No. of Gas Burners FIRE ALARMS NO. of Zones
G
No. of Ranges No. of Air Cond. Total No. gD�'c and
Heat Total Total
4. No. of Disposals No. of Pumps Tons KW No. of Sounding Devices
No. of Dishwashers Space/Area Heating KW No. of Self Contained
Detection/Sounding Devices
No. of Dryers Heating Devices KW Local 0 Municipal n ❑ Other
Co
No. of Water Heaters KW No. of No. of Low Voltage
Signs Ballasts Wiring
No. Hydro Massage Tubs No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Liability Insurance Policx.:mcluding Completed Operations Coverage or its substantial equivalent. YES NO ❑ I have submit
valid proof of same to this office. YES NO If you have checked YFS,please indicate the type of coverage by checking the appropriate b
INSURANCE ® BOND 0 OTHER 0 (Please Specify) MIxt„yla (A5, Shot S1
(bxpuauon Date
Estimated Value of Electrical Work$
Work to Start Inspection Date Requested: Rough Final
Signed under the penalties of perjury:
FIRM NAME 11,,, [/j(f�-L �� LIC. NO.
Licensee '-T O1%,41 K+MAA�e_ Signature "F^rr"" LIC. NO. CC2/110
Pa &ou any FA ishilM " h. 62.711 Bus. Tel. No.
Address Alt.Tel. No. el 11455)-
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required
Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent Please check hhe k one:
Telephone No. PERMIT FEE 5
(Signature of Uwner or Agent) -
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TOWW-OF DARTMOUTH e/ ,C
BUILDING RECEIPTS
COLLECTOR'S OFFICE
Name:.. I f ' f s I, I Property. ) r /- ..1 t _ Date: s> > � / ><b C.
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Job.Location: p ,.
t i :..CCk Len T4�,->-'i (A Ti
White Copy-Collector's Office
f'� F' ' TOWN OF DARTMOUT{�ellow Copy-Customer's Receipt
Plot t .Pi' ; Lot: i_ 7 row
Co File Co
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C t //'� c COLLECTOR'S OFFICEGreen Copy-Building Department
Phone ( Ci 7 �.i JUL i 4 1998 it et
Description General Ledger#'s Ref.# Amount
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License&Permits-Building 01000-44105 S G 07
License&Permits-Building Misc. 01000-44105
License&Permits-Electrical 01000-44106 ,,i---t-4-1
- 2 6 0
i2
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420
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This is not a Permit or License for Building,Plumbing or Gas Received By: 1L, a i-'l_ --f%ti l'11j i li
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