PP-518 ra-
.,. COMMONWEALTH OF iv1ASSACHUSETTS
DEFARTNiFNT OF L'^IDUSTRIALACCIDENTS
600 WASHINGTON STREET •
James Camoaei; BOSTON, MASSACHUSh11S 02111
�or.- ss one WORKERS' COMPENSATION INSURANCE AFFIDAVIT
I, A ALL
(I i censeei p errni nee)
with a principal place of business/residence ac r-P
. 3 7 tar r�{ `1' z tnovTh, ml%. C(CitytdZip)
do hereby certify, under the pains and penalties of perjury, that
[] I am an employer providing the following workers' compensation coverage for my employees working on thi
job.
!a o !T/ A-
insurance Company Policy Number
[ ] I am a scie proprietot and have no one working for me.
[ ] I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed be
who have the following workers' compensation insurance policies:
Name of Contractor Insurance Company/Policy Number
Name of Contractor Insurance Company/Policy Number
Name of Contractor Insurance Company/Policy Number
Q I am a homeowner performing all the work myself.
NOTE Please be aware that while homeowners who employ persons to do maintenance.construction or repair work on
dwelling of not more than three uniu in which the homeowner also resides or on the grounds appurtenant thereto are not generall:
considered to be employers under the Workers' Compensation Act(GL C. 152.sea. 1(5)),appliation by a homeowner for a lime
or permit may evidence the legal status of an employer under the Workers' Compensation Act.
I understand that a copy of this statement will be forwarded to the Department of Industrial Accidents' Offtre of Insurance for coven{
verification and that failure to secure coverage as required under Section 25A of MCL 152 can lead to the imposition of criminal peas:1
consisting of a fine of up to S1500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order an.'I
fink of SI00.00(1Y/LcjL.c.)7
a day�against me.
Signed this day ofOe/ 19
Licensee/Permitter Licenser/Permitter
41 —- ♦ `
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential
Owners Name Cac,✓i T-r[L ic] +O(L- Owners Address �/W 1''-1 14,sn T .
l.o"Tal % /
Building Location c��i �✓� �fr1Cl� +�IeiUGS Date A' �0
New V Renovation n Replacement ❑ Plans Submitted ❑
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SUB-BSMT.
07( x BASEMENT —
L 1st FLOOR ^ — — --- -
2nd FLOOR —
/ u\t\ 3rd FLOOR
4th FLOOR
5th FLOOR
6th FLOOR
7th FLOOR
8th FLOOR
7)
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Installing Company Name - \ L1 CC4i2?$ /n! 6Check One: Certificate
Address 87 ?0OkS U Corp.
City pk/YStit5t/11"r State knil I Zip Code 098&75 ❑ Partner
Business Telephone: CTOR- 7 1�R6,o 7 q Firm/Co.
Name of Licensed Plumber or Gasfitter ill-NA £s? \I jC-GZf/(.r __
INSURANCE COVERAGE: Check One:
I have a current liability insurance policy or its substantial equivalent. Yes D 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
r, 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.
Check One:
Owner ❑ Agent 0
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 Sta Plumbing Code and
Chapter 142 of the General Laws.
J
B y , Type of License:
Signature icen Plumber
Title tr. .1, e ' ASTER Q,
t /Town as » • 0 JOURNEYMAN License Number C420.3
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