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PP-636 • The Commonwealth of Massachusetts Department of Industrial Accidents a Offceo/f OBfbos 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit ii 'inf- an n— _ — == I a homeowner performing all work myself. vhnnc'± I\a'am a sole Proprietor and have no one working in any capacity i am an empl0}•er prov �iding w0/ken' compensationa for my employ working on this lob comoanv name:-. 1\..Idl' K1lin < vt.+l. . - :. address: - cirvi ohnne#: insurance co. nofiev . i am a sole pr'Pn..or. general cnn:ractjr. or homeowner(circle one) and have hired the contractors listed below wh_ the :allowing workers' compensation polices: comvanv name: addrese: - . ... cin !Thome* - inr,rnce co. _. .. .... .. _nenirv-of coe:c,r.v name: cirvi nftani**- - Insuranceep, IIgftersts; .anseaaddi:Iola iiheeirfineessarv- - =-_-' ----- . '- Failure to secure coverage as required under Secnon 255A af.MGL 152 as ind to the imposition of criminal aitin of a tine up <.00.00 an one ears' imprisonment as well as civil penalties in the form oh STOP WORK ORDER and a floe of5100.00 a day against me. I underhand th copy of this star nt may be forwarded to the Office of Investigations of the DIA for coverage verification. I as hereby c f •under the pains and penalties ofperjuzy that the information provided above is mac and carrel • vicrarcre Dace l ` �l Print name Phone r€ 22-:- official use only do not write in this area to be completed by city ortown official Cary Cr town: permitileeme _—.—___Q$uilding Department _ :neck if immediate response is required Qliccnsing Board QSeieermen`s Office :vitae: Berson: phone#: nether Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all empioyers to provide workers' compensation for employees. As quoted from the "law", an employee is defined as even- person in the service of another under ar.:j contract of hire. express or implied, oral or written. An employer is defined as an individual, partnership. association. corporation or other legal entire, or any two or - the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer. or:he receiver or trustee of an individual , partnership, association or other legal entity, employing employees. Howeve: 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 grounds or building appurtenant thereto shall not because of such employment be deemed to be an empic 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 - - -applicant«o-h-a3 nor produced-acceptable evid-ettzctn[compliance with the insurance coverage required: - Additionaily, 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 chap: been presented to the contracting authority. zy -z .Y- x�7. --•-- _ _ ..__... .. .i,. '-__• ...�-. - ss..4_�_.'...J�.�-':.''Sit a^'.+�::.._. .__ .— _", _.. ....- ...... 1.ppiicants —� Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation a. 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. nor the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are re^::: o^ta:^ a workers' nompensation policy, please call the Department at the number listed below. _ ti:_ . � - - -- - Cin or Towns »« ^e 1rr •hay the arrina� t_is c_-m'mniere anti nrinred le.^+niy_ The 9e r-t_m e_n,- n,?c prriv ire_„a:eiro it the the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. be sure to fill in the permivlicense number which will be used as a reference number. The affidavits may be rent the Department by mail or FAX unless other arrangements have been made. The Off:.. of Investigations would Iike to thank you in advance for you cooperation and should you have any cues please .:o not hesitate to give us a call: • 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 =: (6171 727-4900 ext. 406. 409 or 375 MASSACHUSETTS UNIFORM APPLICATION 'FOR PERMIT TO DO PLUMBING " 1 ,.., DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential. 0 Owners Name '17kd%.i O..C� Ct)wnersAddressBuilding Location 4 (eor mofri-- Date I' 267-(PO New 71Renovation n Replacement ❑ Plans Submitted n �/7/ z cn wcn a ca C.) H p z c ] ,a to rn rn x w < H h x p, z r Liz OwOSa - x ‹ wzo a1rZ- wHZ A • a ¢ oaQwxx > FoQ � a, ic ww . H O a aO ¢ H¢ v) < o p O ¢ Q o 3 �xi- V) gca .axHInwoxo ¢ 3xfao SUB-BSMT. BASEMENT o/ 1st FLOOR I I I I I 2 2nd FLOOR a .2.. I 1 l /i 3rd FLOOR 4th FLOOR 7. l 5th FLOOR f 5 I, 6th FLOOR 41 7th FLOOR /(Ij I 8th FLOOR Installing Company Name. i,ifd �! �A Y:14a 41, r `! )1 heck One: Certificate Address l.� SA oJ t ?v ❑ Corp. l City :v 6- / State VLrt- Zip Code D.Z71.0 ❑ Partner Business Telephone: - f` ❑� Firm/Co. Name of Licensed Plumber or Gasfitter 1 -t,'f . hoc,w .5U, ( _- t ✓� w7(1 I have INSURANCE COVERAGE: Cs_ o I have a current liability insurance policy or its substantial equivalent. Yes o E If you have checked yes,please indicate the type coverage by checking the a ropriate box. 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 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 installalQQQQQQns performed under the permit issued for this application will be in compliance with all pertinent provisions of tssachusetts State Plumbing Code and Chapter 142 of the en ral Laws. YYYYYY B y Ty f License: �%-`•-• t Signature of Licensed Plumber Tit - MASTER OW/Town JOURNEYMAN License Number I(CI r / - - % % k - . . , / d , § ® ~ 6 \ ~ 2 0 I ® ^ § ^ ! z * z a ; § / A \ & 3 = 5 • ° f \ § ) i ; 2 \ E \ a /f \0 F. w \ ? \ ° �2 �� . S \ I ) c© z o k t § \ \ \k ) ; t; ; • > il / § k / \ `� .* ~§ V i\ § < y/ yt� ^ �\ : (S.:" r ` �� % * , / �°" • 2 k ) � �