GP-040 V COMMONWEAL1171. tat MS., A l J.
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_ DF.PAMMEIT OF INDUSTRIALAC®EN'tS
y_ 600 WASHING-TON STREEr
James - Camooe$+
BOSTON, 02111
Car.- sslone•
WORKERS' COMPENSATIONINStTRANCEAFFIDAVIT
I. �l Fd�dL�tl _ fJ1
(licensee/perchi/tee)
with a principal place of businesslresidence ac
12�S _ �b,C rAce ,Jae ADo ;x h L l r cs a D 2-71-0
(Cry/SateiMpj
do hereby certify, under the pains and penalties of perjury, than
[ I I am an employer providing the following workers' compensation coverage for my employees working
job.
Insurance Company Policy Number
[J I am a sole prop.:etot and have no one wor:zing for me.
[ 1, I am a sole proprietor. general contractor or homeowner (circle one) and have hired the contractors Iir.
who have the following workers' compensation ine,erzn=poliden
Name of Contraaor Insurance Company/Policy Number
Name of Contractor Insuranc Company/Policy Number
Name of Contractor - Insuran¢ Company/Folic! Number
I am a homeowner performing ail the work myselL _
NOT: Please be aware that while homeowners who empiovpersons to do vreainr•n=nee.mnsnuaion or repair
dwelling of not more than three units in whim the homeowner also resides or on the grounds appurteasnt thereto am not ;
considered to be employers under the Workers' Compensation Act(CsL C. 152.sea. 1(5)I,applIcasion by t homeowner fo
or permit may evidence the legal status of an employer under the Woritai Compensation Act
I understand that a copy of this stateaetet will be forwarded to the Deparmseat of Industial Aaidenti Office of Insurance to
verification and that failure to secure coverage as required under Secdon SSA of MC I.152 an lead to the imposition of c
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consisting of a fine of up to SI 500.00 and/or imprisonment of up to one year pad civil peaaiam in the fora of a Stop Work '
fine of SI 00.00 a day a¢ainat me.
Signed this day of , 19
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
DARTMOUTH,�t; /MASS. Type of Occupancy-Commercial F Residential Pi
Owners Name no41/21/ S chat-We Er/ED Owners Address f DJuc4eeQ/
Building Location 3 A'AuelaVat. a rr� 1 12 Date 7 2 Y 9
New RenovatioaA OUTH EUlit.it nt D Plans Submitted
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SUB-BSMT.
BASEMENT
1st FLOOR x X
2nd FLOOR
3rd FLOOR
2,7 4th FLOOR
5th FLOOR
7. 6th FLOOR
7th FLOOR
8th FLOOR
Installing Company Name "Mr-Ai ?AS Check One: Certificate
Addressf4se. A c'A e (o42r /Pe,r [ Corp.
City Se Da A( / State AIQ Zip Code 0 2 2'VV 7 I I Partner
cy
Business Telephone: / 7^2 6 7`f0 ❑ Firm/Co.
Name of Licensed Plumber or Gasfitter lad 7 v7u -te e
INSURANCE COVERAGE: Check.Oner
I have a current liability insurance policy or its substantial equivalent. Yes di No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity Bond
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.General
Laws,and that my signature on this permit application waives this requirement.
t
Check One: '
Owner ❑ Agent ❑
Signature of Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and
accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued
for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and
Chapter 142 of the General Laws.
B y _ Type` of License: WI I$a/ 7 1ee .i a 444
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Title L7 MASTER Signature of Lied Pumber or(Gasfitter
City/Town 0 JOURNEYMAN License Number -2 9-7
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