EP-17740 4'
\\__ The Commonwealth of Massachusetts
ter_
��IA( - —( Department ofIi dnstrlplAccidents
'� ' --= , Office aliavestikelians
- 600 Washington Street
t
w3. -A Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
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name: `r7 /9-/V / 2)7 p CtC(_� /Z' /9-
location: ; F c{ t�t' (7l E g /Z/,77_..) S I.._
city Fig1 I R f 0 F' GZ 0e(42 - % �P-y s�--
ohone# � Of? ci; 76 03l--Z_
0 I m a homeowner performing all work myself.
EL-ram a sole proprietor and have no one working in any capacity
0 1 am an employer providing workers' compensation for my employees working.on this job.
company name: -
address: -
•city: - phone#:
insurance-co. - policy#
0 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:
city: f i /,.:: / 17 /' I) /= p t ' phone#: .�-'ca 1.' 6" In G r--,,42-"
insurance`co. - - policy#
comoany:name:
address:
city:
insurance-.co - - - aolicy#
mesa 'p�` &'.'.�-_
Failure to secure coverage as required under Section 25A of Mt.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 fine 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.
t do her certify under the pains and penalties of perjury that the information provided above is true and correct
Signatures 4i �Y1 pL/I ,�l�I i+t` Date / o/ v/iy CM
Print name l 6J,1y 'D j / Phone# ,5 ) Rif 7,Ce7 3
4.
official use only do not write in this area to be completed by city or town official
city or town: permit/license# °Building Department
°Licensing Board
0 check if immediate response is required °Selectmen's Office
❑Health Department
contact person: phone#; ❑Other
mn arms c139 -F -tr=ewamser_,.ac���
e:! „�_�
(revised yes PM)
Informa#ion`-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 3ha11 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.
. i .a v. ;P:xtit:4€t-
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
APPLICATION FOR PERMIT TO INSTALL AND REQUEST
FOR ELECTRICAL SERVICE
Inspector of Wires Wiring Permit# - COM/Electric#
Town of IJ , ik- WI f`)' CI / Massachusetts ;Wilding Permit# Date
Customer: i 41 > g- F- t1/!9"-fi 1, _S on(Street#) /-5- , /9 / k E ! -4';',0521=7
Lot# in the village of /• x7 ''/1'%rr " $rity pole number or underground number
Customers billing address, � e— J>� )!/'/"1 J `c f '
Temporary - New installation ( .— Change of service Starting Date ' r'( %' v/'c
Job description !A) / 1r /V T //.1 I-/,> (/ /-_- .°.1 /, f 67
n .a _ H rfir / /L fS /v
Service entrance voltage /�� v �� �! C- Amperage Phase
Wire size(cu.or al.) gee, > Conductor per phaseNumber of meter'�s f Water heater Off peak:Yes_ No
Estimated load:Electric heat kw, lights ' kw, Range '%' dryer y.Motors, H.P.& Phase
Ready for first inspection Ready for final inspection
Electrical Contractor ➢ ) . 9 _y ./ ,0,d_ /2 FT f /Lic.# s �'� $' c . Telephone# °5-eT: '�
Address 9 W.�1 7 r-2,C1 /tU ��A l �.n /•/ .' 1 i �' f1 �.� C C ' '' z
Additional Remarks:
Do Not Write Below This Line
ELECTRICAL WIRING INSPECTION CERTIFICATE
INSPECTOR OF WIRES
INSPECTIONS - DATE - FEE CHARGE
Temporary Service
Roughing in
Service and Meter -Off Peak Meter
Final Approval
Disapproved*
'For the following reasons
CERTIFICATE OF INSPECTION DATE
To the COMMONWEALTH ELECTRIC COMPANY.The installation described above has been completed and has this day been inspected and
approval granted for connection to your service.
Inspector of Wires
WIRING INSPECTOR TO BE NOTIFIED WHEN WORK IS READY FOR INSPECTION
Permit Good For One Year From Date Of Issue CA46-1
White—COM/Electric Green—Inspector. Canary—Town Receipt Pink—Inspector's Copy Goldenrod—Electrical Contractor
to COM/Electric
TOWN OF ` JARTMOUTH
-BUILDING RECEIPTS 3A
COLLECTOR'S OFFICE
f -.
Name: /., r� s-'r - - ..t s
/�, / f t ;C(y .. - Property "/ e-1 l Date: '/. - .1 V� -? )
Owner: .X .� 11.:sc..,i%L- -' / I :, _J
Job Location: i
Plot / i j - ,i - white Copy-Collector's Office
Lot:✓mot /� jCtt��03 YellowCopy-Customer'sReceipt
l Cu-^ Pink Copy-File Copy
Phone: "' Green Copy-Building Department
ri 2
Description tact Led er#'s - M1�=.rag. �'9
..e. n ij G $ . .# Amount
License&Permits-Buildi @ 3t. i;` il1000-44105
0
License&Permits-Building Misc. 01000-44105 - ! /
f'
License&Permits-Electrical 01000-44106 % ,C%
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420
This is not a Permit or License for Building,Plumbin$ J or Gas Received By: �1`
, �
Commonweall4a o/fl'addachusetis Official Use Only
n
m 1 ccyy p Permit No.
`-= rot �n eUeParlmenl o ire-Cervices
tat- BOARD OF FIRE PREVENTION REGULATIONS -`, Occupancy and Fee Checked
Town of Dartmouth [Rev. 11/99] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: / O/ 2 O 0
By this application the undersigned gives notice of his or her intention to perform the electrical w',ck described below.
Location(Street&Number)
Owner or Tenant 0 #9- A. ,C , 5'�J/ �aP� Telephone No.
Owner's Address S(. S" ,'a'c/c,/S� ,��q//�/v/- 2
Is this permit in conjunction with a building permit? Yes No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead Undgrd No. of Meters
New Service n' 60 Amps /-o/fz t%o Volts Overhead I I Undgrd L_- No.of Meters /
Number of Feeders and Ampacity `3 y/es A /
Location and Nature of Proposed Electrical Work: i t.) Bh-C N E u) /-( D wits
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Fixtures 5 r No.of Ceil:Susp.(Paddle)Fans No.of. Total
Transformers KVA
No.of Lighting Outlets No.of Hot Tubs / Generators KVA
No.of Lighting Fixtures Swimming Pool Above In- No.of Emergency Lighting
/ f-- gmd- gmdl I Battery Units
No.of Receptacle Outlets V 5-- No.of Oil Burners ( FIRE ALARMS No.of Zones
I to
Na of Swits - No.of Gas Burners Na of Detection and
Initiating Devices
x No.of Ranges 4K / No.of Air Cond. n y2)ys,Total No.of Alerting Devices 0
t
No.of Waste Dispo rs; Heat Pump Number Tons KW No.of Self-Contained /
- 3 g Totals: Detection/Alerting Devices h
No.of Dishwashers / Space/Area Heating KW Local p j Municipal
./i Connection Other
No.of Dryers Heating Appliances KW Security Systems:
/ No.of Devices or Equivalent
No.of Water • No.of No.of Data Wiring
Heaters KW Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs c No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the
licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned
certifies that such coverage is in force,� and has exhibited proof of same to the permit issu' g of e.,
CHECK ONE: INSURANCE Cif/BOND I I OTHER (Specify:) c - �// a
x 'ration Date)'
Estimated Value of El ctrical Work: / �t) y (When required by municipal policy.
Work to Start: j c �` CJ( p ,-� (�Inspe tThndto be requested in accordance with MEC Rule 10,and upon completion.
I certify, under the pa ns a penalties ofperjury, that the information on this application is true and complete.
FIRM NAME: T7 /2 e / Q /- LIC.NO.
Licensee: //� ��g /� -^/ QA ignature LIC.NO.
(If applicable,enter' empt"in the license number line) � Bus.Tel.No.: �oBS76 a-c�i�Z,
Address:4tS ( r p t bll f,U F////P< �'C 72
f � a Z 7 2b Alt.Tel. No.: g 9S:S
OWNER'S INSUkANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By
my signature below,I hereby waive this requirement. I am the(check one) owner owner's agent
Owner/Agent
Signature Telephone No. PERMIT FEE: $
Plat G& Lot; -/
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APPLICATION FOR PERMIT TO INSTALL AND REQUEST FOR ELECTRICAL SERVICE
Inspector of Wires-Town of ,i9 fl F o UtHMassachusetts /�, / l�/
Customer C/R I I 44u�r,Q S on(Street#) / 3— G�Ji9/Q/,3,Ci'k �v�y
Lot# 6' 7 in the village of utility pole#or underground#
Customer's billing address 5% S— _44do f cO /j) Sit ,ry9/J P 1/E,1/
Temporary New Installation — Change of Service Starting Date /cc/, y,'t
Job Description (Of (2 fr:' Pr: w f-1 C) (Lc C ,C 6WO/Cr. /r2 )GP S ii f ./12)/C4/
Service entrance voltage o Amperage 9 0 e; Phase /
Wire size(cu.or al.) t Conductor per phase f
Number of meters ( Water heater Off peak: Yes No CCU 7a P 7 7 j--
Electrical Contractor IJ /9-/0/1) y Pr 0p ,Q A-License# ,='j,.3 s t Telephone# 5 6 ppg. 2 G o 3 2`;
c
Address O �I rn /92t2 ( 1) 11 t) sr .. fj9//'/cY '/2 -an o-2 , es :2'> 2-C'
Additional Remarks
CERTIFICATE OF INSPECTION
To the COMMONWEALTH ELECTRIC COMPANY. The installation described ove has b mpleted and has this day been inspected and
approval granted for connection to your service. /�/
Inspector of � Date AFI (f
WIRING INSPECTOR TO BE NOTIFIED WHEN WORK IS READY FOR INSPECTION
Permit is Good for One Year From Date of Issue