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PP-644 The Commonwealth of Massachusetts r 4fir Department of Industrialeiceidems ac =� OflJCBoll�p�00S ? ` 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit pticantintormanon—..__�.::. , PleasefBan — - par e: LP)L.i6 / ar7,--e 77 -. loc_::er: / GE �//,�el-e U'— C r J cit ( I/''la ✓1 . Dicer 4 7y7-✓ S��f/ i am a home wner performing all work myself. phone Edam a sole proprietor and have no one working in any capacity • r i am an employer providing workers' compensation for my employees working on this job. company name: address sin.. ohmic Or - • insurance co.E 1 am a sole roprietor. general cnn:ract.tr. or homeowner(carte one) _tnci have hired the contrartors listed b row who i the following workers' compensation polices: company name: • address; uhone* - insurance co. — --�_ noiirvii company name: address: city: .. _ihonewr• • insurance cp. '.an oohcv#`- aenadditionafsheeiifaecess'an- -->_•--•�.. .. . _ Failure to secure coverage as required under Section 25A of 741GL 152 can lead to the imposition of criminal penalties of aat tine uup to S1_500.00 and. one d ears' imprisonment as well as civil penalties in the form ofa STOP WORK ORDER and a fine ofSIo0.o0 a day against me. I understand that copy of this stateme may be forwarded to the Office (Investigations of the DIA for coverage verification. I do hereby ce h• der e pains and penal:! of 'err that the information provided above is nut and correct Signature Date /�`b IS Print name c)/2LI ./-�5 � v itcJrit -Q — Phone# -71/ 7- OS I/ • official use only do not write in this area to be completed by city or town official city or town: permitAhxnse# QBuiiding Department ci• _ cneck if immediate response is required QLiccasing Board Qselecten's Office contact person: phone#; QHeaah Department �Otber aer • • Information and Instructions r Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for:. 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 to 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 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 or on the _rounds or building appurtenant thereto shall not because of such employment be deemed to be an empio> MGL chapter I52 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 appncant< o Cias 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 been presented to the contracting authority. 1ppiicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation anc 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 reeuir 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 nroyided-a space at the bottom. the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. P be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be rename. the Department by mail or FAX unless other arrangements have been made. The Offi.: of Investigations would Iike to thank you in advance for you cooperation and should you have any quest, please co not hesitate to give us a call. T :: 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 r4: (617) 727-4900 ext. 406. 409 or 375 :MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBINGIN DARTMOUTH, MASS. Type of Occupancy-Commercial El Residential L�1 Owners Name, erAY a43 Owners A ress ar Building Location la a t7 4A-e t caeGt`Q--/ Date - / /6/9 5- New ❑ Renovation I I Replacement 7 Plans Submitted � �- ,,,02 z 4 z H > w i \ CID Q z z a l � /. ocA zw � Ftx � HQL:4 (1) , � zaz3 st �_ z F w d y A a rn a .a z a '" O o ` `s§' F v x 3 o z 3 a o F z_ Q H it. v x s�,cc`' Q H Q ¢ x C4 CC Q O Q Oa Oa d c4 a ¢ O d E, w cn A Q a 3 x E. c4 w 0 x Q ¢ x w 0 SUB-BSMT. BASEMENT ( 1 1st FLOOR I . l 2nd FLOOR j I I O 3rd FLOOR b 4th FLOOR 5th FLOOR 6th FLOOR 7th FLOOR 8th FLOOR Installing Company Name V6 S f/g # H"T6 Check One: Certificate Address I.el l. ' -0C_ Al✓a Corp. City7l yWfd l41 State fli 4 Zip Code 6.?36 v ❑ Partner Business Telephone: 7 V 7" 04-5-4( /1 Firm/Co. Name of Licensed Plumber or Gasfitter E//;i 09///✓5 !� - /- L" / �i G' INSURANCE COVERAGE: CheclvOne: I have a current liability insurance policy or its substantial equivalent. Yes®®No E If you have checked yes, please i cate the type coverage by checking the appropriate box. 1 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 t Laws,and that my signature on this permit application waives this requirement. . Check One: Owner E 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 install. ',ns .-rformed under the pe it issued for this application will be in compliance with all pertinent provisions oft e Massachusetts tale Phunbi g C de and Chapter 142 of the General Laws. B y Type of ' ense: `e '-7- Title S' tature of Licensed Plumber ASTER �/ I261y/Town ❑ JOURNEYMAN License Number `(/ Z.5-,..? § f I / �\ i } W tst I _ / i $ 2 \ •a ) \ .5 . & / \ 3 § 3 E ] § k / § ° § F. \ \ \ 2 \ \ . \ ®® : . - § , o = »% c § \E + ,. \ - & g . ; \/ \ k k \\ . . / j\ N , / ) \ ] / o § 2 \ Co / ,° / # Z e © ‘° ( y , / 2/ g \ \§ ® Cill - g �Z § \ ! • § ° k § > 47 rn d