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GP-22782 The Commonwealth of-Massachusetts l ~ raj__(de Department of Industrial Accidents a', F{ Office offnvestigations 600 Washington Street \y\ � spa g/ Boston, Mass. 02111 - Workers' Compensation Insurance Affidavit ADpbc nit Information - y "" Please PRINT le`ibi ;rr o r <° r �/��jq� ,,�u.._� .2::1...: l�i � name: / /U i��(C;-S,_b ....n_._..,..,�...... ....:.........�,....._ locationp Li �. tS((,, city L-\C�f) l cis I/ � : t--(C nhone# Cb�� f-00)-719. ❑ I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one working in any capacity 17 ,,,, .141a ifY127, S 0 r:-/ OTam an employer providing workers' compensation for my employees working,on this job. CO mpanv name: address: city: - phone#: insurance co policy# 70 a . X1251,.:..:rz ❑ I am a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: address: city: phone#: insurance co. policy# co m panv name: address: city: phone#: insurance co policy# Attachaddit nalsheetifnecessaty _ hr? Failure to secure coverage as required under Section 25A of NIG L 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a tine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby erttif, ruler the pains nd penalties of perjury that the information provided above is true and correct. Signature C aBQ1f �j Date / —42`d7 Print name �� a'7't4) )_ I'Z.. Phone# Gi 15`r ?CV-76 7 official use only do not write in this area to be completed by city or town official city or town: permit/license# nBuilding Department Licensing Board ❑check if immediate response is required ❑Selectmen's Office °- Health Department ? contact person: phone#; nOther i eaM a95 P1A) 1 Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their 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 more of i 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 the 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 house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. I MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuanze or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has 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 have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and 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 required 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 provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The 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#: (617) 727-4900 ext. 406, 409 or 375 TOWN OF DARTMOUTH s.3-, 3 9 , aY, BUILDING RECEIPTS COLLECTOR'S OFFICE i /�, r. Name: ,1,- / ;:M :2-b-- Property o� F o ,; m. - - Date: / �s''� ,'/ 7 i : ,, ' Owner: :, j `I ' Job Location: ; i�j /; / f v /;,GC-I._0_• „ ice..-SIC �U ,{ ,t,ft •s White Copy-Collector's Office Plot: /, 'j j Lot: y1 Yellow Copy-Customers Receipt / Pink Copy-File Copy Ii vi Aa. Green Copy-Building Department. Phone: (;;; , P N VIDescri Description G z Ref.# Amount License&Permits-Building 01000-44105 l,� t3 V License&Permits-Building Misc. 01000-44105 License&Permits-Electrical 01000-44106 ) License&Permits-Plumbing& as - 01000-44107 Lz. r f' 1 6 ie Other Department Revenue . 01000-42420 This is not a Permit or License for Building.Plumbing or Gas Received By: it, ) MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING a DARTMOUTH, MASS. of Occupancy-Commercial ❑ Residential 0Owners Name )\D j Zefr-7-10 Owners Address L C7c) Ill ts-pc-- bk Building Location 6 Lam- b.nfi L41. Date 1—L —t 2— New ❑ Renovation E Replacement IS- Plans Submitted ❑ ch z a vi ZO w cn tait cn e4 p co, x X to in' '' -ccC4 cn W ¢ gil it O 0 Cl. C4 , •C4 a U W v, Z ¢ a p F- a _1_(' W W cn y Z Q x CG t4 W x W F W E- Z y c4 __ OP Z a F Z W W 0 p > w F U a v' W, z I., ¢ w > ar¢ xZ ¢ a < < oomaow WE_ axO zW 3Ca0aUa > oaE- o SUB-BSMT. / BASEMENT t 1st FLOOR 2nd FLOOR 3rd FLOOR 4th FLOOR • 5th FLOOR (" 6th FLOOR 7th FLOOR • 8th FLOOR Installing Company Name J (S-s Check One: Certificate Add �rress 4.0 L1etP-- tf l;61 ❑ Corp. Cit}U CQDc ojao State U `r 1' 7ip Code C P-3 c4C ❑ Partner Business Telephone: ��k?'f7C5a:X) ❑ Firm/Co. Name of Licensed Plumber or Gas fitter ljzDtJbc-- V k8-)L _ • INSURANCE COVERAGE: ''Check One: I have a current liability insurance policy or its substantial equivalent. Yes 0 No 0 If you have checked yes, please indicate the type coverage by checking the appropriate 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 installati ormed under the permit issued for this application will be in compliance with all pertinent provisions of the assach ens State Plumbing Code and Chapter 142 of the General Laws. B y Type of License: Signature of Licens Plumber o Gast-ter Title ❑ MASTER mac} City/Town "IOURNEYMAN License Number 263 Plat / 6 Lot 2—2�\ / , E , E 2 0 C 20 z : : % \ , cr"® ` / ) § . _ - .. ; @ G $ , / ~ \ \ \ ¥ \ \ 0. - C , �/ ( \ \ 7 z OS i ® t ' . 9 \ .. \ ¢ e r { Q E E r- C . \ _ ) E PlP o $ $ / E 2 c E w \ %d 3 ` . — # ® , m k / 7 / ( ° ` ( / ' w E ` � \ b \ . S).-3n < � $ • \ _ N/ et _ — R § 2 } . . >< i on LA LA 11 N.N. ! 4 ° t �. y \NI: > .V \ \ 4 , \ \ % N) W \\ ( \ / . « @I » . . r ©