EP-17386 i
1 The Commonivealth of Massachusetts
Department oflndustrialAccidents
Office ol/nvestigatians
600 Washington Street
? Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
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name: /77 iA / )/a) L F�-/� 1„� /� h ,Q /9
location: c y tS tJ ///P/G /1 /4'nt c(
city Fcce .R )1 / 9EK r /7,/9 • phone# / t:P-/
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El I am a homeowner performing all work myself.
3.4`am a sole proprietor and have no one working in any capacity
f," 2`^S- f='x'>s` roe, 'ate"us
I am an employer providing workers' compensation for my employees working on this job.
company name: - -
address:
city: phone#:
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:
com_p_anv name:
address:
city: phone•
#:
insurance:co. - policy#
comnanv name: /A.) /zC '% . O c
address:
city: p h
phone#:
insurance co. policy#
3 1621ait' ono` el ecess y - z;uc'`SSS. c rr=,
Failure to secure coverage as required under Section 25A of 1IGL 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 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 doh certify under the pains and penalties of perjury that the information provided above is true and correct
Signatu. Date 9 /.. v -o
Print name ,�J �y
-�< Phone# ✓� af���-e`S-
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
❑check if immediate response is required OSeleetmen's Office
❑Health Department
a contact person: phone#; (Other
Devised 3/95 PIA)
i
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.
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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.
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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 17386
BUILDING RECEIPTS
COLLECTOR'S OFFICE
Name: • , , Property .. Date:
Ji a .. '....i ,.. � ! l� 1.._. l?,_r Owner: I. 1` �.�-\ lY :. � _/
Job Location: -
t White.Copy-Collector's Office
Plot: Lot: ' TOWN 01 DARTMOUTH Yellow Copy-Customers Receipt
COLLECTOR'S OFFICE pink Copy-File Copy
Green Copy-Building Department
Phone:
SEP 2 1 2000 it ;
Description General Ledger, 's CS t�#07 Amount
�
License&Permits-Building - 01000-44105
License&Permits-Building Misc. 01000-44105
License&Permits-Electrical 01000-44106
License&Permits-Plumbing&Gas 01000-44107 1 , i
Other Department Revenue 01000-42420
This is not a Permit or License for Building,Plumbing or Gas Received By: 2
. )__ Commomvealtl o/t/Icudachuselfd Official Use Only
• Ecc'yy�� 7Permit No.
✓JeParfinenf of.Mire�ervices
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
Dartmouth Town of [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 T C)
TYPE ALL INFORMATION) Date: /1/4-/ /0)
By this application the undersigned gives notice o his or a intention erform the electrical work desEribed below.
Location(Street&Number) /T5Q� L ( /•,',
Owner or Tenant ( i AttilA cLLAl r-- Telephone No. :, ;
Owner's Address '-t.:
nIs this permit in conjunction with a building permit? Yes �{/ No (Check Appropriate Box)�'� • '
Purpose of Building �T Utility Authorization No.
Existing Service Amps / Volts Overhead I I Undgrd No.of Meters
New Service _Amps / Volts Overhead I Undgrd I I No. of Meters
Number o Feeders and pacity 'l1 v '
Location and Nature of Proposed Electrical Work: �1(A v Q
Completion of the following table may be waived by the Inspector of Wire.
No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans NTransformerso Total
KVA
No.of Lighting Outlets No.of Hot Tubs Generators KVA
No.of Lighting Fixtures Swimming Pool Above In- No.of Emergency Lighting
t gmd. I gmd� I Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
1 No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
r No.of Waste Disposers Heat Pump Number Tons KW I No.of Self-Contained
Totals: Detection/Alerting Devices
r No.of Dishwashers Space/Area Heating KW Local Municipal
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 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 issuing office.
CHECK ONE: INSURANCE%El -BOND I I OTHER I I (Specify:)
(Expiration Date)
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
I cert , under the pains and alties ofperjury, that the information on this application is true and complete.
FIRM NAME: �//%�Cf... /=Veje, - LIC.NO.,0223S cr
Licensee: /-y p �tgna LIC.NO.
(If applicable,enter"exem t"in the license number line.) c"� rr✓ Bus.Tel.No.C7CD .f—
Address: d 0ce Py},E'�//�/,S2/v S tI~ ,e , /e Alt.Tel.No.:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance covers a normally required by law. By
my signature below,I hereby waive this requirement. I am the(check one) I I owner I owner's agent
Owner/Agent
Signature Telephone No. PERMIT FEE:$ 0L'b '
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APPLICATION FOR PERMIT TO INSTALL AND REQUEST FOR ELECTRICAL SERVICE
Inspector of Wires-Town of t-A ,.y assF usetts
Customer �0-3yssit„,s (Street#) f S 9.
cvrc_?
Lot# in the village of utility pole#or underground#
Customer's bil ing address
Temporary /Co _New Installation Change of Service Starting Date
Job Description
Service entrance voltage tam as( e--) Amperage / 0 Co Phase / D/
Wire size(cu. oral.) t{=J) t Conductor per phase / Q
Number of meters 1 Water heater Off peak: Yes No `"""t 7cQF"9 7 S 5
Electrical Contracto Qj �\nse# elephone# 7e3 72- 0
Additional Remarks
CERTIFICATE OF INSPECTION 0 ^ /
To the COMMONWEALTH ELECTRIC COMPANY. The installation described alp. I leen comple .: and has this day been inspected and
approval granted for connection to your service. / 7/7-
Inspector of Wires /-/v / �
j l ' Date
WIRING INSPECTOR TO BE NOTIFIED WHEN WORK IS READY FOR INSPECTION
Permit is Good for One Year From Date of Issue
•
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COMMONWEALTxOFMASSrCHUS -
DIVISION OF REGISTRATION
OF ELECTRICIANS
AS A REG JOURNEYMAN ELECTRICIAN
ISSUES THIS LICENSE TO
MANUEL A PEREIRA s k
-284 MERIGIAN,. ST N *
FALL RIVER- 'M.A•. 02720-4684
}
22358. E
07/31/01 677454
LICENSE NO NIC 211111110212211
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