EP-13080 The Commonwealth of Massachusetts
( 6 Department of Industrial Accidents
- ICO/ YOSI/g8!
6000// Washington Street
Ci yi Boston,Mass. 02111 x
Workers' Compensation Insurance Affidavit
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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
I am an employer providing workers' compensation for my employees working on this job.
romnanyname: ,-.2/97P
address:
city: % � � t e ohonet Te%!%9AP' a( cc, Lov r
insurance co. ST /9s-S"c,Ace ti (' volley* /00,2;r/?'
CI I am a sole proprietor,general contractor, or homeowner(circle one)and have hired the contractors listed below who havr
the following workers' compensation polices:
company name:
address:
city: phone#r
insurance co.
company name:
address: - -
city: phone#:
insurance en. policy#
Failure to secure coverage as required under Section 25A of MMGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or
one years'imprisonment as well 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 hereby certify under the pains and penalties of perjuty that the information provided above is true and correct
Signature "..- //�J-G/r, jr7,7571 e Daze /VI/ /77
Print name j/i/,i ,o/ 1%/Y/?�C/P� Phone# S -6-7I-.2 6-2 _
ri
official use only do not write in this area to be completed by city or town official
city or town: permit/license# °Building Department T.
Licensing Board
check if immediate response is required - °Selectmen's Office
❑Health Department
contact person: phone#: °Other
(revrstd 355 PPAI
f - r
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 c
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 hay
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, telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, Ma. 02111
fax#: (617) 727-7749
phone #: (617) 727-4900 ext. 406, 409 or 375
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TOWN OF baiTMOUTH 1.3080
BUILDING RECEIPTS
COLLECTOR'S OFFICE
Names` • q Property ✓ 1 Date / r /`: ./' o"
t I�� .` Y Y'1 i-t�G 1 Owner: o 1 JL . IA- fL,k �0 &if 01 L /C/
Job Location: t; t / . , -os. R GE
/ -& (fit 4 (/✓Ur.-
t i f ) cr. White Copy-Collector's Office
Plot: 1 ! Lot: y .�� _ Q ellow Copy-Customer's Receipt
t I O t% `7 , (\ \-i Pink Copy-File Copy
CL, GreeryCopy-Buik'cting Department
Phone: - S CI. C
/-
tsik VP --
Description General Ledger#'s Ref.9 Amount
License&Permits-Building 01000-44105
License&Permits-Building Misc. 01000 44105 //
License&Permits-Electrical 01000-44106 -1 cry', j``'+ J;
License&Permits-Plumbing&Gas 01000 44107
Other Department Revenue 01000-42420
This is not a Permit or License for Building.Plumbing or Gas Received By: __;1,/ 2 `
•" """'° Office Use Only
The Commonwealth of Massachusetts Permit No.
Occupancy&Fee Checked
-• ['� (leave blank)
/I Department of Pubic Safety
BOARD OF FIRE PREVENTION REGU&71ONS 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. 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
The undersigned applies for a permit to perform the electrical work described below. /
Location (Street & Number) 7 / o'/3 ram/r it-Cr he- Jo el C 4" /7a r7 f177ZC7a /74,
Owner or Tenant 72-21 p frh /�?i?7,'zr/7! ("Cc,h C/2
Owner's Address 3/49/ -; /7-7r,/vn Rr /-z/,/ p1 Vtog ifeti, r 27 '
Is this permit in coniunction with a building pei-rniti -- - _ Yes ❑ No ❑ -
-- (Check Appropriate Box)
Purpose of Building (I e,Ci Grentierce' Utility Authorization No.
Existing Service h Amps Ci O Volts Overhead ❑ Undgrd ❑ No. of Meters e2_
New Service C) .2 Amps s9 a10 Volts Overhead ❑ Undgrd 2 No. of Meters /
Number of Feeders and Ampacity < ' ...Z/7/0 437r7-7.0S
r Location and Nature of Proposed Electrical Work 7 /?vta rile L/-2 ;on f/ ,q.'n11 vr,- .j'".c/-/cr 4/4n
. #r/ Ca,vt/pere 2170 1 hr! `oriP zit 7I'/e G/pve t27,t/PrS
-! No. of Lighting Outlets No. of Hot Tubs Total
—II - No. of Transformers KVA
.r No. of Lighting Fixtures Swimming Pooldve ❑ �d ❑ Generators KVA
,.4 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
Ranges - Total No. of Detection and
No. of Ran
g / No. of Air Cond. Tons Initiating Devices
No. of Disposals Heat Total Total
po J 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 ❑ Municipal ❑
/ - Local Connection Other
No. of No. of Low Voltage
No. of Water Heaters KW
/ Signs Ballasts Wiring
No. Hydro Massage Tubs I No. of Motors Total HP I
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Liability Insurance Policyjncludipg Completed Operations Coverage or its substantial equivalent. YES 2 NO 0 I have submitted
valid proof of same to this office. YES IIX I NO U If you have checked YES,please indicate the type of coverage by checking the appropriate box.
INSURANCE BOND 0 OTHER El] (Please Specify) j/vc7nS"SUaaaner C&• 79f'rea-%n2y/y j�6/oo0
(E ration Date)
Estimated Value of Electrical Work $ /f. FrC70
Work to Start .<'cvo ri Inspection Date Requested: Rough LY//C t°a-et Final W✓Kr tC'i2/P
Signed under the penalties of perjury:
FIRM NAME /Jr'ns 'r{ ,7c/ZCc'c c
LIC. NO. cf 2 Y
Licensee S'r3 f-7-7 Signature�l�l 'zz _ BG� e—oy- LIC. NO. Skin C
Tel. No.
Address 2P Pr.e%i Cr /'</ fir v.e/1 /7/9- r697zOAlt. Tel. No. ,40�-- err—2e/
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by
Massachusetts.General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one)
Telephone No. - PERMIT FEE $
(Signature of Owner or Agent) _ _