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PP-18081 6r, x.• bu - - _==3 The Commonwealth of Massachusetts s Department of Indusiral Accidents '^ : - O//ICOO!/ONCStlgBIIOOS 600 Washington Street ,s w Boston,Mass. 02111 Workers' Compensation Insurance Affidavit ,ii i,il'y t i, isir iiriiii + .e.;1-_.. rlicil ft: -slaind t di1.... . .: True* PAUL DEMELO & SON location: PLUMBING & HEATING 4015 Read Street . city • SOMERSET, MA 02726 phone# 6 73 t6,3/ 3 0 I am a homeowner performing all work myself. /ga I am a sole proprietor and have no one working in any capacity 0 I am an employer providing workers' compensation for my employees working on this job. comoa ,name: address: city: ohone#. Insurance co. policy# 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: comnanvname: address: city: phone#. insurance co. policy# company-name: - Address: city: - - ohone#t Insurance co. policy# ,y. r r t - .•_I:ram;, it-.; ?s* 1 r Failure to secure coverage as required under Section 25A of MCL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 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 ce n er the pain and penal ' of perjury ii the info, ' provided above is true and correct..^a Signature C`/t�'L/ %/" G� ,./f� Date „ 1 1 7 1 VO Print name v fir ( , E i-'t G LID Phone# (n -7 ?) - l)2) 1 3 official use only do not write in this area to be completed by city or town official city or town: permit/license# f'IBuildiog Department ['Licensing Board ['Selectmen's Office ['lfealth Department ['check if immediate response is required contact person: phone#; f7Other (revised 3/95 NA) • 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. MGL 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. �d" .�,i,.. :;i,z, .13 : ; :: -1'e, „,,:rrF:i � ,' � '� ,�vu�z1 .mv.u,.'. ..i.. ,........:4....r.Frc„av„u.., i..- 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. "xxr F ,t:Z.+? .u+ N„ .d Y , : Ws ....ss:v:,,`�" 'i,._r9'ii��1:`F'd A?SY�u'R +$"aE�shb c9�.va�be '+' ._. r ',f��'-' ' • ., r % 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 I AR` 1OUTH 18081 ro TAx issuEs /i/,t „. i A(. - , -ir zj- IN C COLLECTOR'SE OFFICE 4 b?1t-( t/ - / + i )• Ne: f j r°Perty .L"L/� ci7 r_..- Date: �} fbbL ahon: / / - /V��—"f Lt ff l/ t=" J r. White Copy-Collector's Office Plot: /` Lot: f7 f�; 3 Yellow Copy-Customer's Receipt �L Pink Copy-File Copy Green Copy-Building Department Phone: Description General Ledger#'s Ref.# Amount YAWN Of AARTMAI IT License&Permits Building 01000-44105 COLLECTOR'S OFFICE • License&Permits-Building Misc. 01000-44105 License&Permits-Ele tric5c., 01000-44106 v 200� i//d License&Permits u‘bingf Gas 01000 44107 l! 10 /r/) c_--ems - 03 Other Department Revenue 01000-42420 This is not a Permit or License for Building.Plumbing or Gas Received By: / MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO F: ...,i 1NG `. aa3 DARTMOUTH MASS. Type of Occupancy-Commercial ❑ /Residential g�3 u�l a Owners Name'/ 2_-f`� +-ems Owners Address.5'6,�-u-0 W M/ Wr_ Building Location /5 LI Xoz.�I e r Wa Date // / / 7/Oa — New gl Renovation ❑ Re cement ❑ Plans Submitted R Z • rn rn to " Z F > W F y J (� < z W a W w .3 Q • E.. z a C7 In CO `..- rn < a p; x O a E9. �� O z w F w E- U cd .- tz Z Z ►� z a rn - rn rn x y < w rn rn < rn < = < 3 k e1= Uzao ] a -11 .. 4zC < azaaa .1tr. e �� 14z< m 5 zzx3 1rjaFa < < caIL ;a :.. d F > F O y y O y E-' Z Op rn Z W e" O U x 3 a e a m en c c a 5 x H cn I s. 0 a a a 5 aC m o SUB-BSMT. BASEMENT I P 1st FLOOR I I I ( M• } 2nd FLOOR 02 r9, 3rd FLOOR iO ()V l 4th FLOOR ,A 5th FLOOR 't 6th FLOOR go\ 3 Db 7th FLOOR 8th FLOOR Installing Company Name 1 iu\ C I (P 1©'1-- _-)DI'l Check One: Certificate Address a no- Pe rt C( St JJ__ ❑ Corp. City�E�Y}V b- i f State 1 n P Zip Code na71RCJ ❑ Partner Business Telephone: 1niO ` n, 13 S Firm/Co. _ "1I Name of Licensed Plumber or Gasfitter C ( k. i en .�P_ Ole In I`%; INSURANCE COVERAGE ChOne: /Ji I have a current liability insurance policy or its substantial equivalent. Yes No❑ If you es,please indicate the type coverage by checking the appropriate box. ��, A liability insurance policy Other type of indemnity Bond I 'S INSURANCE WAIVER:I am aware that the licensee don not haw 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 lication are true and accurate to the best of my knowledge and that all plumbing work and ins ' ns performed er the permit Issued for this application will be in compliance with all pertinent provisio the Massachusetts to PI mg a and Chapter 142 of the General Laws. - .. - ,/ • B y Type-Of License: --}h :t L/ Title MASTER I b1< ignature of Licensed Plumber . Plat 6 Co Lot - y � y• a ' e Dartmouth Building Department , 400 Slocum Road P.D. Box 79399 508-999-0720 Dartmouth, MA 02747 FAX 508-999-0738 APPLICATION FOR PERMIT TO DO PLUMBING Fee //3 — Number/7()F/ Name & Type of Building: /694)01 .S Location of Building: /3-- Gua rAla-K / ifciam 1/c tn b t c- e` "e License#: is )(5 O Service/Temp Service U ok CI failed* Date Insp. * comments r [cough .CCU failed* Date /4j Insp.<- ✓..) 0 * comments l yArer f a 1., r c / Final 421111C3 failed* Date oAL Insp. cim * comments /3o e //0/ Remarks: IZ�� PERMIT GRANTED Ann Inspector of e'"s Date: ////7 6 6