GP-19444 T -, The Commonwealth of Ylassachusetts
(? Department of Industrial Accidents
l __. ' __: glficeof/nvesIgations
�__� 600 Washington Street
a °` Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
ApI1 nr atiori r f � a , , lea
name: PAUL DCMELO & SON
PLUMBING & HEATING
location: 2015 Reed Street
SOMERSET, MA 02726 n J0 (7�l_�i� _�`��
city phone#� !'( 0 /`
❑ I am a homeowner performing all work myself.
A'I am a sole proprietor and have no one working in any capacity
LT a ia �. .=
I am an employer providing workers' compensation for my employees working.on this job.
corn nenga me• - - -
address:
city: \ h
'N
insurance co. -- policy# ✓
I am a sole proprietor, generalcontractor, or homeowner(circle one)and have hiredlhe contractors listed below who have
the following workers' compensation polices:
company name: - /f
f�.
address: - ff w
y r/
fgfr
insurance_co. f`�\. policy#
companv.name: - -
address: - /
insurance-co.
WE ' `s $ e - a ks ,,,,,, iS,`1-:3,c.: 7i w ,rt.,:', ,r r.%,, .. s k",,,` ?m".'+^.n?3" ' f. ...?'417' Lam
Failure to secure coverages required under Section 25A of MGL 152 can lead to the imposition of crimin enalties of a fine up to 51,500.00 and/or
one years'imprisonmen 4s well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.01 : day against me. I understand that a
copy of this statement ay be forwarded to the Of • of Investigations of the DIA for coverage verification.
I do hereby r,r!'4 der tke pa' s /nd pe at-r perjury that the information provided above is true an core t.
_ Y / 9/�/
Signature 'dining i LL .A. �_. Date J
Print name '� �. SS — Phone# �j li 1 //)7� --,
ay official use only do not write in this area to be completed by city or town official
:ic
g. city or town: permit/license nBuilding Department
$$ Licensing Board
t.: 0 check if immediate response is required oSelectmen's Office
4 0Health Department
if
contact person: phone#; nOther
4
µ
(revised 3/95 PJA)
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
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.
MGi,chapter 152 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 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 1 9 d
44
BUILDINGECEIPTS
COLLECTOR'S OFFICE
Name: I? G;1't. /3.�' )f 0.Property 2_t, �l ,Z-: Date: .
1ff
- Owner:
Job Location: f�) 3 /' ,
White Copy-Collector's Office
Plot: r Lot: 1/ _- _ Yellow Copy-Customers Receipt
cF' . Pink Copy-File Copy
Green Copy-Building Department
Phone:
TOWN OF DARTtMOU H /.r'- . (64:1
COLLECT OFFS Ol-t ICE _ 1.
Description General Ledger#'s Ref.# Amount
License&Permits-Building 01000-441)5
License&Permits-Building Misc. 01000-44105 - '
License&Permits-Electrical 01000-44106 P S 0 ® tom
License&Permits-Plumbing Sr Gas 01000-44107 7/ 1 Vf. / t
Other Department Revenue 01000-42420
\A This is not a Permit or License for Building,Plumbing or Gas Received By: J z
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASF7TTING
DARTMOUTH MASS. Type of Occupancy-Conurm,.cciai ❑ Residential
Owners Name GO F + raoLLO nderS Owners Address
ir
Building Location j ) WQ r 'i k LA Date LI 1 1 0
New 1A Renovation E Replace nt ❑ Plans Submitted P
rn
x rei
,p� � z x � o
117
c — °�= 55 a 0wa = aw E- ( aa > a w I'e� o1
• y m a z U w caw ¢ cg e o E. x Ix � '
'W w � y .. ¢ xaa awwte
�_, zaw ,aw., aa = Ha cocoZ0zwo � Fx S
a x o x x u. 3 c C a U ce > a °a Ew- 2 C • sr--
GSUB-BSMT.
BASEMENT ����M����M��MIf�®��fl _
2nd FLOOR I""„"","„"„
\t 3rd FLOOR
wr'�rytR d 5th FLOOR
1� -
r 6th FLOOR l;f
Sth FLOOR iiiiiiiiiiiiiiiiiiii ,
�..������..�.����.�� _ s, ,'ii
Installing Company Name PAUL DEMELO & ;ON Check One: Certificate
PLUMBING & HEATING
Address 2015 Read Street ❑ Corp.
SOMERSET, MA 02726
City State Zip Code ❑ Partner
Business Telephone: Firm/Co.
r
•
Name of Licensed Plumber or Gasefitter u k L P ID
INSGTtA.NCE COVERAGE: 'th
avttTitffRn ' •- insurance policy or its substantial equivalent. Yes No ❑
If you have checked yes, indicate the type coverage by checking the a prop' to box.
A liability insurance policy _er type of indemnity Bond
OWNER'S INSURAFCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter l62 of the Mass. General
Laws.and that my signature on this permit application waives this requirement.
Check One:
Owner 0 Agent 0
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 perform the permit issued
for this application will be in compliance with all pertinent provisions of the c usetts S lumbing Cod and
Chapter 142 of the General Laws.
B y Type of License: C.---i--s-2
Signature of Licensed Plumber or Gasfitter
Title MASTER 1 b.]�
CityiTown ❑ JOURNEYMAN License Number C1
Plat Lo 7- - 43
cr
Et
o
° C
. . E z/ C ;
e . \ , _
I .. . ° \ / \
* KiV,,,t.:c(;4
!
v pia , ,
. % c \ } }
$ ® \
cn } / {
i e
C1 : rn
\ 2
I
1flM
j1;\ �.�
Z
§ / §
/ \ ° ° ' ( j ��
r5 § » , ; _
LW
0.
\ gqg
,9 /
_ - 5 5 c § » ,
§ a .
>
* ®
` mk c, m cz
a
»