GP-5262 • The Commonwealth ofMassachusetts
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Department of Industrial Atcr:dentr
Offfca of Iftwarthis
--,? 600 Washington Street
Boston,Mass. 02111
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Workers' Compensation Insurance Affidavit
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[ i am a homeowner performing all work myself!
7 am a sole proprietor and have no one working in any capacity
[ i am an employer providing workers' compensationt�far my employees workinggsoon this job.
comoany name: Piice�x 4-n Coro Y 7�- 4 I& atioi . ...::
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[ i am a sole proprietor. general cnntract4r. or homeowner(cycle one) and have hired the contractors listed below w
the roilowing workers compensation polices:
comcanV name:
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Failure :o secure coverage as required under Secnon 25A of 31GL ISZ can lead to the imposition of criminal penalties of a fine SI_70.00
one earn imprisonment as well as civil penalties in the form of a STOP WORK ORDER ands line ofSI00.00 a day against me. I undentaac
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverageveriffeation.
I do hereby cernfi• • pains and penalties of perjury that the information provided above is Mae and t onec.
Si.ras:e 1974;;-/D
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otTiciai use only do not write in this are:to be completed by city or tows official
cin•or town:
permttllitsttse s# r-8uiidiag Department
CLicensing Board
_ :neckilimmediate response is required CSeleesmea's Office
-on:ar. ❑erson: Omit Ft: [Health Department
Other
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
r' DARTMOUTH, MASS. Type,of Occupancy-Commercial ❑ Residential Er
Owners Name J c�Ir/e5 2/ 2 T,vwsky Ownersdl Address 3 cU a lietr Iva/
Building Location 3 W4Rb/eZ Watt- Somyknari ,RJR, Date 2 "/0 2
New Ti Renovation ❑ Replacement ❑ Plans Submitted ❑
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SUB-BSMT. V
BASEMENT
1st FLOOR
2nd FLOOR
73rd FLOOR
4th FLOOR
5th FLOOR
6th FLOOR
I 7th FLOOR
e'vJAI 8th FLOOR
Installing Company Name 4/77 /�-ng /� Check One: Certificate
Address 02 ES rani ee Se, , RV-Corp.
City /14o Dates, State /4 Zip Code b 27197 ❑ Partner
Business Telephone: 5
19- 17/Z ❑ Firm/Co.
Name of Licensed Plumber or Gasfitter `c164'4 411/1-‘4+G"`al
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INSURANCE COVERAGE: Chec :
I have a current liability insurance policy or its substantial equivalent. Yes No❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
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.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)in above application are true and
accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued
for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and
Chapter 142 of the General Laws. �/'o
B y Type of License: 2/eid/ 77�2/�rw
Signature f Licensed Plumber or G fitter
Title 0/MASTER
City/Town ❑ JOURNEYMAN License Number ^'2 9,2
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