EP-30771•
r ' The Commonwealth Of Massachusetts
••
Department of Industrial Accidents
Office of Investigations
. 600 Washington Street . •
•
Boston, Mass. 02111 •
Workers' Compensation Insurance Affidavit
i .0 m.JQ )Qiy¢ 4 tmic,lt. ' : Ea# _ tp Q 1 �. . ;w ^ -
name: go4f11 c0--40 a //i
!oration: eA e 6 P tl^ its.? e ..
city: - 0 d�,l� rv, ,ti( . phone#
7
- ❑ I am a homeowner performing all work myself. "
❑ I-am a sole proprietor and have no one working in any capacity.
❑' I am an employer providing workers'compensation for my employees working on this job.
¢ s:8„ n 8xa 'wx4as W p axa' `[" >r'&au Nagx''c8 c[ Y „xx.<ra P r 89.FI. n 8Q 0t 8. . epyt :. < lf. b,*d �d C.3a`'.
s: p�sFp�`ayr .,` �. ',°aYSF` QF g_ . . �#'; « `ate r F rz V% ` i.a LP 8'
33an1�a r 5 Y s r ta,a k a t �SY s r ` : a r x E r a OVOli f s Fr aras: AI $xS t s y k A h.�Y z =y"a '-a ':
lllf r �,},4 ie EY a i cii .s 4s>{. art s
2 ._,e xx i aFtaie dA• Q`g e u s q s h,A :: •a "�1l kx..,[ Qa1` t Y x a s 3 3k . 4 s 3S a ..
" ** ,.. aY .... ...,., r rx „.eis•..: ..`4 sft -....1 m= `. ,a''' a �,rS.,n'¢. '' ,b, Qn :S S.. �cr n1 .z- -.. 'g
..»., .¢a. '4;" ,`amx- . Qi. S ,�ri.;, x.. .,,,,,. b W:c , ^g .
sM S a O tD xtx .': 3 ¢ nPt t isY 9;,,i tr' i x¢� �Lt' s 3 i a�tz e E a,tssr.ys i s x x 3 d3 ii 8 o t 3 i
1 >£' .R s»rm. ak i : r 5•tc4 < eAt r iss ". y s yi,U 8. to 'x v d:«..:4 ?%".rietr
1 >: 3 s lM aVA- .. Qi�ka e9M sa nz7i f"' M t'.:: M. IN ; s°a* !d3 r xra:,: Y a•� i 5Y a is: a5`L s'£.?Q r sY£
On.x6'8 S 8 Q .e.. t.Qi ile S.Q. .a.".i [...a[�.-tib a wA..ta.i. ... rY£ t fQ ;i' e 6 '4 x k U x;,:,[ Qz x rax: Pa"`a'
e .w3 ••fy$Ya ari•^
.9kink:
.-( ,a .. ;.. F:e'e. .nka ;,
� ��SY.Si...I-¢LdR�mk [se.1" .n gr g. ., us aaa t Satkahe SP.
0 I am g sole proprietor; eneral contractor, or homeowner (circle one) and have hired the contractors listed below who have
the foliov`'L. compensation policies:
t o xC55t i Ls x a tr a * sa a a 1 t 1 '> 5 a 8'x I¢ t ¢F 3 a t a4 as a< a 8 3Qt ;
a rs 3" s :; 3t [4;s - 1Y at a r aott. ifr »^Q r tlkar_:. F4a 8 -"?a iai Rs lta L9 ': s £"r ',k aFraat;'P S:
g6,i5ibf¢8 ffift`Y4. "$ . +��.-_�a�s_ ' +�[4.G , . L �X:; e'Y` x Sb,
3 m -tx4s iiZ fw,,, RS A 6£5x ) F -Y Q s�F"J Sa MYYxt
s 4 7 �b>.�1;'�. `sa I 1 y�' Yam, 3 sys. S r ° a� s a a E x tns ;
-f i aia as,,,„.r s & ^'. .am a s Asa t •,-r t s.bks rs8 4 .Y't` u
¢ t .,3r'L r n� , n 4 M I Ht x r,> 2 Y f ' anNi,e n kt#Q �, .t ""¢. l
�ia:O x r i 3 $ A s L sx 3r �3 x taz ^ ,sl a°`�rr .
` s 9,y��}!. .a` " {` i. Set z•at t 4 l '�� s �
•
,gob [ar t k si:�ia T`caE do?„-- $ g ,Y a Zxgi- .sti, a. `CS,S: M'e.r gx..sa z.tt .a ',mi F+la a a r
fists .Cs,C`(Y.•£ x)as '`.s. .:: a. a '.. to si u £�,av`dt a. ,^yQ a b 3 -Q t ,t t3i z 3$d 45..; t Yad'i P8mf exQler3:.T a,8,a1...
E t y.E t 1 3 ''.. ' Q t .,E r. x Qy w ar a n s r. f. +[t.. '$
"'$., .fny'a ".-tm ,as , d,,4 ` a ✓O 't:," a Y 3st::u f Y eza% L S ,� 35 a x6F '[r si a ,a '-� .T.
i' "l .Afar •.a f :::.:'- Y�b.,� ,.. - ! °3» 'Feat. a+e `.Q ' �. a t.t �T +e :: n a: .,`a j' sa...:
rn �5 lb i
s'e s a e 4 E s r,3 t i :: it o4£U s Y p1' e:. t Q Y 9 }'eat r s' hat
:iii"Itlf t :- aa'Qe ti_ .S `rt.1 .ak+vw O reasa r a s x a .Y 6`..�°.n.b`«.. ,Q.,:. w r; d - t b a
"t. `vY,ry- n '`u "[ `FSrs. ta3.& d ro �'•
p.S"a. t . 353 a as : w d Q: g S� sr hs •R er£s t 8:\Q i S a' i r 3 Y a 9 •35sf r ) Y : dF e 3' r3t8£'t'a� %a^ a j'
y 'a i s amiaa;.. 8 ca,,,t r 1. 1»an . ss i ai s£ iawa ` x5 .x "' `!.,Sas.< o * , ,,. r.5 s 1'.'.. i s�w�a.e Z b a9a.Ya
.• :aaa$r i Y Y , a ¢a a s a pa.. .a 'Sax 8# r r x 4 3�s .s r x - "a `£.. fa x M e!a f' S
I L tixce'Co i l a ,x, as ,t a £ t s s s 1 s .sz 3 .. a• t 3 [/�. i F E'! 3 t s F 3 r.'
.F..a. . bt.. [.9.o .. Y wJ„P.✓^'. ascr hook 3.t..a, is eF. oNia[ a_ "..ti4i
:sad, £S&3 .A. .tr.. • .i*aa.. ..,Sex .. e' a y . :;a. .,.... . ;s:+.4. ,.{,•'.r,....;a^ ..4 C •tD:. •^ .:.. •,x.a s:?.
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 $1,500.00
and/or.one years' imprisonment as well as civil penalties in the form'of a STOP WORK ORDER and a fine of$100.00 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 hereby'certify th •the pains and penalties'ofpe;jury that the-information provided above is true and correct."
�� =o�
Signature: // Date q-a
•
Print Name: f of lit y L.l 3''rA Phone # 31/6 9 ",S=1 37/yt
official use only -do not write in this area to be completed by city of town official _ •
❑Building Department
city or town: permit/license# ❑Licensing Board'
•
❑ check if immediate response is required ❑Selectmen's Office
❑Health Department
contact person: phone# ❑Other
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation fort
their employees. As quoted from the "law", an employee is defined as every person in the service of another \
under any contract of hira 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 com-
monwealth for any applicant who has not produced acceptable evidence of compliance with the insur-
ance 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 insur-
ance requirements of this chapter have been presented to the contracting authority.
...,$ �, niarT six
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 your cooperation and should you have any
questions, please do not hesitate to call.
b: wp .. ., Y mays nu 'kW? s� " a: � .AaSS gME co�isa � `sx tz � �.:�m The Department's address, telephone, and fax number:
> The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations '
600 Washington Street
Boston, Mass. 02111
fax #: (617) 727-7749
phone #: (617) 727-4900 ext. 406, 409, or 375
TOWN OF-DARTMOUTH 30$71
BUILDING RECEIPTS
COLLECTOR'S OFFICE
/
Name .;9 /� ~Lf + :,• .Property ' / -: .f _.. ..., - Date: ,f •+ f; _`
Owner. �_j
i
Job Location: J �• s r F. j�. /
t.� t ^,Uk White Copy-Collectoi s Office
Plot: - %C Lot: e s .,-- r v 04 doh, e;'t�t Yellow Copy-Customer's Receipt
( `-t `.j L..i CO`,ti:cc- Pink Copy-File Copy
Green Copy-Buidine,D?partment
V
Phone: S�p 2_c) 2��3 �, i t.,,, ...d'
r n
Description- 't � General Ledger#'s Refs,# -s� - Amount
License&Permits-Building 01000-44105
License&Permits-Building Misc. 01000-44105 \
License&PermitsElecfrical ` 01000-44106 /1 iiL y`. 2[f) , t'- v) j
i
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420 --_--
This is no a Permit or License for Building.Plumbing or Gas Received By: -' `a` y
pz /J g� �//// /
`_'. .\ e,mmonweatth of tttamacLWetb Official Use Only
i,- -[i p cc77 Permit No.
tc _'i71t__ Thepartment o/Jire-ccervical
• } '' BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
,6 [Rev. 11/99]
of Dartmouth
Town (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: ?2C--c
By this application the undersigned� gives (}
not, a of his or her intention o perform the electrical work described below.
Location(Street&Number) eke, .e Y]
Owner or Tenant b tT t ,7 S or- e Telephone No.
Owner's Address V
Is this permit in conjunction with a building permit? Yes I I No I I (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead O Undgrd fl No.of Meters
New Service Amps / Volts Overhead❑ Undgrd No.of Meters
Number of Feeders and Ampacity `�
Location and N e of Proposed Electrical Work: f//r--Q. / 1 o / A go / e a yt
Pe c <
Completion ojthe JollowrnR table may be waived by the Inspector of Wires.
No.of Recessed Fixtures No.ofCeil:Susp.(Paddle)Fans No.Tra of
KVA
No.of Lighting Outlets No.of Hot Tubs /
Generstors KVA
No.of Lighting Fixtures Swimming Pool Aba e In-
gmd[1 Battery Unitgsency Lighting
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners - No.of Detection and
Initiating Devices
r
No.of Ranges - No.of Air Cond. Tons No.of Alerting Devices
1 No.of Waste Disposers Heat Pump Number Tons KW No.ofSelf-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local a Municipal El
Connection Other •
No.of Dryers Heating Appliances KWSecurity Systems: '
No.of Devices or Equivalent .
No.of Water No.of No.of Data W iring:
Heaters KW Signs Ballasts No.of evices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
INSURANCE COVERAGE:Unless waived by the owner,no permit for the performance of electrical work may issue unless the
licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned
certifies that such coverage is in fmpf and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE VI BOND n OTHER I I (Specify:)
(Expiration Date)
Estimated Value of Electrical Work: ge-V,<Qr)J (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
I certify, under thf pains an tt ofperjuty, that the information on this application is true and complete.
FIRM NAME: A/yct /,P i. C DC.NO. g7�'7LL
Licensee: , �E Y l lye Signature ' LIC.NO.
(If applicable,enter exemp in the 'c nse number line.) Bus.Tel.No.: t
Address: 9 7 Ada. ��� �'( �1,s4 e,1 Y Alt.Tel.No.: 94j(�c 7
OWNER'S INSURANCE WAIVER:I am aware tha he Licensee does not have the liability insut'ance cover a nomtally regnirbt76y�3W. B
my signature below,I hereby waive this requirement. I am the(check one) I I owner owner's agent
Owner/Agent
Signature Telephone No. PERMIT FEE:$
Plat (a 6 Lot c2 - czt3 6
CT
7 � ',7 CO a4p6 ly
i
AoRD
-g � �
O k O
C
s v
ttikE , b 0
Li
R '
2. ro
i �
? c b
o b o N
r
n
Fr co ir it* * * � o CZ
a
til 4
kJ
-i f z y do iy
i
0 o d � CO
0 ;
a
...%.... 0 Pak
ict VD
CD
• 5 3 s
R co
o
lk
t OD En
r •
ro N C
O
1
N. O
75 V
00
N
1/40 Lk)00