PP-662 •
E COMMONWEALTH OF MASSACHUSETTS
P•
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 WASHINGTON STREET
•
James Camoaeu BOSTON, MASSACHUSETTS 02111
romnssroner
WORKERS' COMPENSATION INSURANCE AFFIDAVIT
(licensee/p erm i rtee)
with a principal place of business/residence at
37 '`/ otor Ct&&0--_
(Cry/S p)
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 this
job.
✓ AI-F&StLI l A sC( JOT L/ cti CC i on a 7 0-7 4
Insurance Company Policy Number
[) I am a sole prop.:erox and have no one working for me.
[ ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors lined beiov
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
0 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 a
dwelling of not more than three units in which the homeowner also resides or on the grounds appurtenant thereto are not generally
considered to be employers under the Workers' Compensation Act(GL C. 152,sea. 1(5)),application by a homeowner for a license
or permit may evidence the legal sums of as employer under the Workers' Compensation Act.
I understand that a copy of this statement will be forwarded to the Department of Industrial Accidents'Office of Insurance for coverage
verification and that failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to SI 500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fine of 5100.00 a day against m .
Signed this al't+ day of 4//s---- , 19 9r
Licensee/Perminec Licensor/Permittor
I4ASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING \\
DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential
vners Name "l.. r�j,i.,r� (, `7t ners Address �---(4/ /127-4� STt d>1�Oau care
6°1elp
Lsr Building Location /,�%•2? Cif-w�1r Nd ' C 6 Date c>2//0/ Z
New Ek. Renovation ❑ Replacement ❑ Plans Submitted ❑
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P SUB-BSMT.
BASEMENT
1st FLOOR ---...„---_
2nd FLOOR � --,..---__
1 3rd FLOOR
7 4th FLOOR
`
v�� 5th FLOOR
� 6th FLOOR
11
7th FLOOR
Sth FLOOit /
Installing Company Name .l • J�I 'II)/ 14 Check One: Certificate
Address •
'7 IIcor, . ❑ Corp.
City ( L L./14 27/, State ' 14- 7ip Code 69 Sc36.0 ❑ Partner •
Business Telephone: . .--bet- 7/1?''O7 r✓ Firm/Co.
Name of Licensed Plumber or Gasfitter ,-L(5ZL )GT-C:Cs'o(Q
INSURANCE COVERAGE: Check OjJe✓
I have a current liability insurance policy or its substantial equivalent. Yes o❑
If you have checked yes,please indicate the type coverage by checking the appropriate box.
11'A ability 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.
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 r
Chapter 142 of dr al Laws.
B yi L/ /—a_.,y Type of License:
- ®' S nature o Licen"sed Plumbed
Title �t . i.!i Et-PIASTER
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gibs/Town alli_"..�, __,. ❑ JOURNEYMAN License Number j' C'i
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