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The Cammanweaith ofMnxsjcfnse is
_ Depamnento�Tndrts �
Aidenr •
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Offitemlinatazalin
600WarhingtStreet •�_.= Boston, Mass: 02111
Workers' Compensation Insurance
Affidavit
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C i an a Homeowner performing a1I work myself.
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C i am a sole proprie:or and have no one working in any capacity
lear--. an employer providing workers' compensation fanny
employees worxiag on this job.
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I aril a sole proprietor. general. cnnrraci;,r. or horn_-orroe�� - `""�zow wr.
(crrie one) •'"�•�. •�
the .'ciiowing W and the onttartors listed below we workers' camoersation polices:
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Fan ure !oseegre coverage asrequire¢unaer ecaon a of MG 152canIesatotheimnmitionoftslmta>vt�--cn'
one 'ears imprisonment as well,as civil penalties in the farm ate STOP WORK ORDER god a anegflioo.00 st day against mr_ I understand tr.7
Copy of this statement may de forwarded to the three of Investigations of the DIA for coverage penmen of a sine up to 5I__lL0(1 a..
ge+'et'itlruinn.
da rnerect•cer try under die pains and penalties afpecirtm Mar Mr infornr:nan ratted above is and cant
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Hate "Iiir
• offlc:ai use only do nor went in this area to be completed by city anon official
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etty Cr town:
Permittlttsme rt rtsuildiw;Department
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-eca ifimmeciare response is required phone CUccnsittg Board
• cSelectm.en's Office
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Information and Instructions
Massachusetts General Laws chanter 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 an:.
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 7
the foregoing engaged in a joint enterprise. and including the legal representati�es of a deceased employer_ or:he
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 grounds or building appurtenant thereto shall not because of such employment be deemed to be an ernp
MGL chapter 152 section 25 also states that every state or local licensing agency shaII withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
- applicant kilo-has nut produced acceptable evidence of compliance with the insurance coverage-required.
Additionally, neither the commomvealth 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 ch.ap::
been presented to the contracting authority.
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1Qpiicants •
Please frii 1 I the workers compensation affidavit completely, by checking the box that applies to your situation an
suppying company names. address and phone numbers as all affidavits may be submitted to the Department of
Industriai 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 req_:-
to obtain a workers' 'ompensation policy, please call the Department at the number listed below.
, - _ .
City or Towns
Please ce sure that the affidavit is complete and minted lezfbh•. The De.,arrment has provided a,space at th .,or .-
the affidavit for you to fill out in the event the Office of Investigations has to contact _you regarding the applicant.
be sure :o rill in the permirilicense number which will be used as a reference number. The affidavits may be rename
;he Department by mail or FAX unless other arrangements have been made.
The Ofti.a of Investigations would like to thank you in advance for you cooperation and should you have any clues
please _o not hesitate to give us a call.
Te Department's address. telephone and fa±number:
The Commonwealth Of Massachusetts
• Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston. Ma. 02111
fax #: (617) -7749
phone =: (61-i -27-4900 ext. 406. .1n9 or
iASSACHUSETTS -UNIFORM APPLICATION FOR • PERMIT TO DO PLUMBING
DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential; L!/
Owners Name Le? 6 `I�F�'�-51O Owners Address q�y — .—
Building Location 1 1�` 14 `4I t Date 2,— V.- / d ._
New ❑r Renovation ❑ Replacement E Plans Submitted L.�
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SUB-BSMT. 55
BASEMENT i f Y i ::
lst FLOOR \ \ t i
2nd FLOOR i 1 ■
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3rd FLOOR l 1
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4th FLOOR
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5th FLOOR ,)
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7th FLOOR ISM
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i 8th FLOOR ■•
Intalling Company Name ko Au 0-4Q. te--4°AL) Check One: Certificate
Address y� oo �� e-� ❑ Corp.
City 0t SSttaa+te��/litts.i Zip Code jl��V ❑ Partner
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Business Telephone: £ 3 6j [*Firm/Co. _.
Name of Licensed Plumber or Gasfitter / —
INSURANCE COVERAGE: Check NoE
I have a current liability insurance policy us substantial equivalent. Yes No
If you have checked yes. please indi the type coverage by checking the appropriate box.
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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.G.neral
Laws.and that my signature on this permit application waives this requirement.
Check One:
Owner D 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 issu d
for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and
Chapter 142 of the General Laws. _/, _.
B y Type of • ��e: �(y�/�/
Title ASTER Sienature of Licensed Plumber
City Town '_= JOURNEYMAN License Number 1/// a----)
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