GP-650 The Commonwealth ofMarsachgselts.. ,
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Y1-:._ ... ia! - - .....
y , Departmentof Indurtrtal Accidents •
_ OJI/CEDfInsr-szIQ9llp,s
600 Washington Street
4�± Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
rlppiicnt-intormation — -- •-c_Alesst=
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C I am a homeowner performing all work myself.
t_ i am a le proprietor and have no one working,in any capacity -
arr. an employer providing,_ workers' compensation for my employees working on this job.
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romnan• ame.. . '!`c�3 - S�6J- Q li•2-�-ST di?/�/. r •T._,✓r'. �V-C�.'t
city* f ve S/ f/�Pi < nhnne ect
�979 qJ
jn<urcnce co. (/ 0e-der Pi V trefn-C_ , noHcv0: wC( a E/']S yffw/Y
C I am a sole proprietor. general c<it-tract.dr. or homeowner(cads one) and have hired the conrartors listed below ••
the fpilowlne workers' compensation polices:
rnmram• narilee . _- _.
.;ddre«; . -. ::.. . ..: -
ctn..
incur-ante co.
gampanv name: -
;dd. .
et n•
gin- &tone*.
jncurance eo.
Attaeaaddsaoaatsheetifinecsarv- . ._-... ..-._ . °'stt-sa . ,Failure to to secure coverage as required unoer Section iSA of M1GI.152 an lead to the imposition of criminal penalties of a fine up to S1_100.;
one,ears' Imonsonmens as well as civil penalties in the form of a STOP 14i'ORK ORDER and a?at nct1Q0110. td.v.gsi3et me I understa
copy of this statement may be forwarded to the Ofice of Investigations of the DIA for coverage yeri(tation.
I do hereby cenin u • e pa s and gym:t tin of perjury rhos the infornrthan provided above is nice and wrr^r
cie.:-n:e Dare � cT —.9")•‘
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Pr'nt tam; Phone it
_' official use only do not wnte in this area to be completed by city or town official
citf or town: - - •permit/11 me N (]Building Departme
I:Licensing Board
:nem: if immediate response is required ,.. ❑sefeetmen's Office
[Health Department
/ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type))
IP /VU. Aflndvr% , Mass. Date ,s 3 19 94
City, Town Permit # G Sa
Building '1 Owner's
�" AT: Location y GO LcL�/rL�G�e. ✓K_ Name nave- ��i�l�' S
G ,—,/ Type of Occupancy: /2G't
New Renovation ❑ Replacement ❑
6�0,:7' Plans Submitted Yes ❑ No ❑
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SUB—BSMT.
97 BASEMENT
Y 1ST FLOOR / - I
2ND FLOOR
3RD FLOOR
4TH FLOOR •
STH FLOOR
8TH FLOOR '
7TH FLOOR
8TH FLOOR
(Print or Type) Check One: Certificate
Installing Company Nam
1
Address El❑ Partnership
WESAbih A - ❑ Firm/Company
Business Telephone Name of Lice Plumberfi r Gasfitter
ssfl— 679- 7 d `N GdvTa
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 Permit issued for this application will be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
I have informed the owner or his agent that I do not have liability insurance including completed operations coverage.
r
Signature of Owner .-en;
I have a current liability insuranar include completed operations coverage. ❑
By TYPE LICENSE:
Till, �_. 0 Plumber
Signature
�W Itter Plumber or Gasfitter
S/Town <<!�
❑ Master ///c9 of
APPROVED (OFFICE USE ONLY)
ID Journeyman License Number
BC-55A
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