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PP-209 The Commonwealth of Massachusetts =t Department of Industrialelaratlentr flffceo// ODs = 600 Washington Street nz " Boston, Mass 02111 Workers' Compensation Insurance Affidavit Appiir~rrtMI- mationr..:w.. ._ .p1" s..t)m u • cc— icec. i am a homeowner performing ail work myself. phone am a sole proDrietcr and have no one working in any capacirv • am an employer providing workers' compensation for my employees working on this job. +st+one d• . • .. . .. . VYIDAJS likiS - •*miters, • . .. a sole propnetor. general cnntract.,r. or homeowner(carafe one) and have hired the canuartos listed below • ••- - :0%\trig '.corkers' compensation polices: ctr^ -V name, ace ._-. - . . ._. . ... nhnnear nnii r. r stieecti:mcenstrv` --- �._•... , --r _ _ Secure coverage as recutren under Secnon_EA of J1G1-152 can teaa to the imposition of atmsnai penalties of a fine up to 51_00.C. r.. . ._rs mortsonment as well as civil penalties in the form of a STOP WORK ORDER and a fine ofSI00.00 a day against me. I undenua et m of tlis statemenr may be forwarded to the Office of Investigations of the DIA for coverage verification. e. '" cencn'a • atnr�and nenaltfet otperisr rrho):the rnorrrr$an provided above is Sae and rrt . - --`>�cry''!// tLd'-/ �"`_---� • can %/ °hone* Sy 4- /7i. use only do nor write in this area to be completed by city anon official an-or rownt permitilleeese R rguiiding Department licensing Board — peps if immediate response!c required [Seiee:aea's Orrice ._... phone-. QHeaith Department -- _ —Otte. Information and Instructions `1�-=,:_..user, General Laws chanter 152 section 25 requires all employers to provide workers' compensation : em:io'•eec. A s quoted from the "law", an employee is defined as ever person in the service of another under : tort,:act of hire. express or implied, oral or written. An employers defined as an individual, partnership. association. act-ne n Jr other legal entire'. or any zwc :he : m_ ;o engaged in a joint enterprise. and including the legal , rese.aa::yes of a deceased employer. or rece:.. er or trustee of an individual , parmershtp. association or other ! dai entin', employing employees. Howe' owner of a dwelling house havingapartments not more than threeapartments and who resides therein. or the occupant of M.civ.eiii-_ :rouse of another who employs persons to do maintenance , construction or repair work on such dwell•: or :he grounds Jr building _p urteWant theretoshall noto because _z Jr such employment be deemed to be an err.; _ chapter :__ section _5 also states that every state or local licensing agency shall withhold the issuance rent<.ti al of a license or permit to operate a business or to construct buildings in the commonwealth for an- _ anpiicantwho_has net-produced acceptable-evidence of compliance with the insurance coverage required. 'ad . neither the commonwealth nor any of its political subdi v is:.:ns . .- oI public work unIIl acceptable evidence of compliance • •-: , ins enterne into any contract of for the compliance _ of :.._ . - recuirements vI ___. ___..._,. to the contracting authority. .• .�.." . "'_ char ...ram� ��..�..�.� -.ems ._.. -• _ _ _ \po,icants ?lease -.. ... :he •.Porkers" compensation affidavit completely. by :necking - _ :he bps that applies to your SiCua:io- -- - . _... parr, names. address and phone numbers as all affidavits may be submined to the Depa:-a-en: of - c:aens for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The tha_... re returned tr the city or town that the application .forth _ ' ... .. Jr license is being . ^.,� ---. ...._..: of Industrial Accidents. Should you havees: __ -p,. asation policy, call any � __ '.",._ . _=*stag :he "law" or ifyou are r-..- please it the Depa.- e: a: number listed below. .,«os =. _ -h._ai:;dav'it is complete and printed ea] "he. Deportment c- __ ' :-ou to till our in the event the . _ h Office of nvesrs_aaons : �n ... :2S to contact yCu .__a.*... g :4e nse number which will be used as a reference erdtr _ _ _;_rtmen: by mail or FAX unless other arrangements have been made. number. The _r,Ieaylu may be . investigations would like to than!: you in advance for you cooperation and should you have any ;cue_ -- . ..estate to give us a call. - • r. ..__� - -----. men:-s address. telephone and fax number: • The Commonwealth Of Massachusetts Department of Industrial .accidents Office of Investigations 600 Washington Street "Bosion. Ma. 02111 fax =: (617) 727-7-49 phone =: (61"• _ onn _n , no -c -MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING DARTMOUTH, MASS. Type of Occupancy-Commercial n Residential a Owners Name Ph t e- lM A PI Owners Address Building Location 7o G-,LJFINO-14 De_ Date 1114 (ii, New Renovation Replacement ❑ Plans Submitted ❑ o1 _ 72 z kci z up H z lTar * rIIla /, o z w N w H U. x rn w � H z�¢ 3 H rl �- U Z O x a ¢ w a ¢ w Z A a z a a 0 w { w x ¢ x 3 o x 3 aaC a o ix H ¢ A w Q a� w J- H U > F O 0- v) H z O O rn Z u1 E" O U x H ¢ ¢ x 4 ¢ Q o ¢ a a ¢ a a ¢ o ¢ H 3 .a w to A o a 3 x H rn w 0 x A ¢ a ca o SUB-BSMT. I BASEMENT 1 r:-->,,_ n 1st FLOOR 1 I A 4 / 2nd FLOOR Z ?j Z _ t 3rd FLOOR jA 4th FLOOR Sth FLOOR � „ j I I . . 6th FLOOR tisc.17t 7th FLOOR 8th FLOOR Installing Company Name 7 t' Q\c C6 Check One: Certificate Address -RD 1201:y \,\BZ- ❑ Corp. C•ity ���°�`� State M i _ Zip Code OZ3 L{7 ❑ Partner Business Telephone: %I G - Z l 7(� ` El Firm/Co. Name of Licensed Plumber or Gasfitter ' J �/6'/95 INSURANCE COVERAGE: Check 1Jne: I have a current liability insurance policy or its substantial equivalent. Yes No❑ If you va cEprke es, please indicate the type coverage by checking the appropriate box. A liability insurance polic Other type of indemnity Bond 1 OWNER'S INSURANCE WAIVER:1 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 ❑ 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. v/////,J /(6 B y Type of License: �vu/ 1 (g'. Title ❑ MASTER Signature of Licensed Plumber City/Town JCIOURNEYMAN License Number' oc 6 / C. § / \ . \ \ § t « ® 2 Ti: o . k Vcii _ § , i ) /\ , \ \ § k \ } § j \ \ \ &\ • \ % § k 1 / _ o ' . : § •2 § \ No ` A § E «§ . } � ` ® \ \} ® © ° • ° § '!� }} $ 5 / ; ° & w 3 \ , ®; F. t §^ . CI . a / /` / \V $\ § ®k: .4111111r , \ ° k i � _ § § I § )