EP-3428 •
The Commonwealth of.Massachnserts
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Department of Industrial Accidents •
? /; 011icsoll r
'- 600 Washington •
Boston,Mass; OZII
licnr• Workers' Compensation Insurance Affidavit
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a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity •
an employer provlomo workers compensation for my employees working on this job.
m m na •
address• ... -
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insurance co.
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am a sole proprietor- general cnntracur, or from 20waer
(circle one) had have furd the contractors .fired below
x r =the :oilowing workers' compensation polices:
on, any name:
address•
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dry,
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insurance co. - -
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com^+nv name:
address: .
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snrance c ..
,lttaea sddicoiisi sheeitfine•— 17-17r-
Failure m secure coverage as requsrea nosier Seenors;SA otJIGL ISZ Can lead to •~ -
one s ears-secure
coverage
as well as the imposition o anc
eon' eathis imprisonment
ntmaaheecivilpenaltiesintheformetaSTOPWOpjO Pwtia notmtaa! 0adayagaasinee. tond_ tan0that
forwarded to the Office of Investigations of the D ��had a fine gfSI00,0a a day against ma I understand that
IA for coverage verification.
I do r,erecr cernn•under the pains and penalties ofperfurr rhea the it o on provided above is was and coma.
Siar.an:re
•
Date
Pr-.-a: ✓ Q
one
official use only do not was ona otIIeiat write in this area to be completed by city ort -
ci n�or town:
Y
permitilieeose se Building Departnteer
_ :neck if immediate response is required ;
crUccasing Board
QSeleetmen's Office
phonen;
rents::On son: CHGa6Departmeat
"Other
• Information and Instructions
Massachusetts General Laws chapter I52 section 25 requires all employers to provide workers' compensation fer
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-
the foregoing engaged in a joint enterprise, and including the legal representati�es of a deceased employer. or the
receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However
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
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an empic:
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 evidenceof 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 ahapte
been presented to the contracting authority.
its '- — .1Ign�.`- 33 -.—r„ = - :.. =is<
1ppitcants — . .. __
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation an..
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 dare 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 rec±r:
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-aspace at the borcttt
the affidavit for you to fill out in the event the Office of Investigations has to contact you recording the applicant. ?'
be sure to till in the permitilicense number which will be used as a reference number. The affidavits may be returtec
the Department by mail or FAX unless other arrangements have been made.
The Of%.a of Investigations would like to thank you in advance for you cooperation and should you have any questi:
piesse .:o not hesitate to give us a call.
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T.:: Department's address. telephone and fax number
The Commonwealth Of.Massachusetts
• Department of Industrial Accidents
8ifica of Invest 112110ns
600 Washington Street
Boston. Ma. 02111
fax m: (617) 727-7749
phone 1: (617) —27-4900 ext 406. 4(10 ,,,. --e
TOWN OF DARTMOUTHBUILDING RECEIPTS
,F s
NO TAX ISSUE !
COLLECTORS OFFICE
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Name. 'j property
1' / /
--�� 7t- Pro er / .Date: r�`
Owner: �' �
Job Loea6on: . f _. ; ! ✓l
White Copy-Collector's Office
Plot: - f Lot: / Yellow Copy-Customer's Receipt
v !i` `/' J Pink Copy-Flle Copy
- - - -
Green Copy-Building Department
Phone:
Description General Ledger#'s Ref.# l Amount
License&Permits-Building 01000-44105
License&Permits-Building Miser 01000-44105 TOWN OF DARTh1 UTt
License&Permits-Electrical 01000-44106 TAX GOLLEL.14:5(. 1-11.1'rl/ C.
License&Permits-Plumbing&Gas 01000-44107 nib D e
Other Department Revenue 01000-42420 S A S �
This is not a Permit or License for Building,Plumbing or Gas Received By. - y r X/ •
The Commonwealth of Massachusetts Permit No.
)E - Occupancy&Fee Checked
„� (leave blank)
{ Department of Public Safety
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
Town of Dartmouth
All work to be performed in accordance with the Massachusetts Electrical Coder 527 CM. 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Sp`' iv/0 /9)i
The undersigned applies for a pe 't to perform the cal work d 'bed below.
Location (Street&Number) �j� � A
B ILA- /i'� 9pOwner or Tenant �" L?3Q �Y"Address �.(� � i>>1lr/910.,./.)--
Owner's '-sd.
Is this permit in conjunction with a buildiinnermit: Yes Ilk ❑ (Check Appropriate Box)
Purpose of Building C�(!lr1-D Utility Authorization No.
Existing Service ,'^_Amps )�7��/ Volts Overhead ❑ Undgrd �❑ No. of Meter' Q
New Service 'Amps?([, /a1Voits Overhead ❑ Uudgrd 1� No. of Meters_
Number of Feeders and Ampacity . PP—` a-
I.ration and Nature of Proposed Electrical Work ' Ct) /,4-/7 /Vee '
No. of Lighting Outlets /� No. of Hot Tubs �A 8h g No. of Transformers
�No. of Lighting Futures if Swimming Pool grrnnd.e ❑ mod, ❑ Generators KVA
No. of Receptacle Outlets u No. of Oil Burners / No. of Emergency Lighting
Battery Units
No. of Switch Outlets t.f— No. of Gas Burners FIRE ALARMS NO. of Zones
No. of Ranges / No. of Air Cond. Tonal No. of Detection and
Tons Initiating Devices
eat No. of Disposals No. of Pumps Too s l TKW No. of Sounding Devices
No. of Dishwashers / Space/Area Heating KW No. of Self Contained //
Detection/Sounding Devices 7
No. of Dryers / Heating Devices ICW Local ❑ Cornet on ❑ Other
No. of Water Heaters KW No. of No. of Low Voltage
Signs Ballasts Wiring k
No. Hydro Massage Tubs No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws ,�
I have a current Liability Insurance Policy luding Completed Operations Coverage or its substantial equivalent. YES inNO La I have submit
valid proof of sameythis office. YES Lot NO LJ If you have checked YES,ple care the of coverage by checking thje�appmp be
INSURANCE BOND 0 OTHER 0 (Please Specify) l� �� �.'� J ac to
�7 I ( puauon Date
Estimated Value of Electrical Work$ c�°,, On) f. %/
Work to Start Inspection Date Requested: Rough bei ( $// Final '_.t ..
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Signed under the penalti/ey�gf perjury.?
FIRM NAME �Ye L� `"'Y LIC. Nam.
Licensee f/ Signature LIC. NO.
�j{' Bus. Tel. No. 7"/y O.S.
Address . 1 r � c a UO �t r ��,\i Alt.Tel. No. J
OWNER'S INSURAN ER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required
Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one)
Telephone No. PERMIT FEE S—
t Signature of Owner or Agent)
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APPLICATION FOR PERMIT TO INSTALL AND REQUEST r (. r
FOR ELECTRICAL SERVICE l.J/
Inspector of -Wiring Permit# COM/EI tric#
Town of Massachusetts Building Permit# Date '
ea
Customer .Q zi /- : Ii�fiv( on(Street#) a 4� elm/i fp Pe5 ,�/�f1 Lot# -in the village of , utility pole number or underground number
Customers billing address
• Temporary New installation lease' Change of service Starting Date
'F Job description
Service entrance v age67%7 .Q Amperage-i- Phase
Wire size (cu.o ) Conductor per phase.
Number of meters f Water heater Off peak:Yes— No____
l Estimated load: Electric heat kw,fights kw, Range - dryer Motors, H.P.& Phase
Ready for first mspectio �..- Ready for final inspectionl .ls�w�r'a/
Electrical Contractor �e Lic.# ees-it' - Telephone#•,0°`z".
t'' Address ir
. 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 / S/
0
CERTIFICATE OF INSPECTION ( ✓ 7�
D. E /�
To the COMMONWEALTH ELECTRIC COMPANY,The installation described above has beFri c/ t d and ha illy been inspe fd and
approval granted for connection to your service. _ - ii .,'
Inspec sr of Wires
WIRING INSPECTOR TO BE NOTIFIED WHEN WORK IS READY FOR INSPECTION
Permit Good For One Year From Date Of Issue CA 46-1
White COM/Electric - Green Inspector Canary—Town Receipt Pink—Inspectors Copy Goldenrod—Electrical Contractor
to COM/Electric
LAST TRANSACTION REPORT FOR HP FAX-700 SERIES VERSION: 01 . 03
FAX NAME: DART. BUILDING DEPT. DATE: 16-OCT-97
FAX NUMBER: 508 999 0738 TIME: 13:07
DATE TIMF REMOTF FAX NAME AND NUMBFR DURATION PG RESULT DIAGNOSTIC
16-OCT 13:05 S COM ELECTRIC 9-9999368----5108 0:01 :08 2 OK 663840100088
S=FAX SENT
I=POLL IN(FAX RECEIVED)
O=POLLED OUT(FAX SENT)
TO PRINT THIS REPORT AUTOMATICALLY. SELECT AUTOMATIC REPORTS IN THE SETTINGS MENU.
TO PRINT MANUALLY. PRESS THE REPORT/SPACE BUTTON. THEN PRESS ENTER.