PP-3165 •
`--.. ` z, The Commonwealth of Massachusetts
kii rj —'43 Department ofIndustriul Accidents
�: _ Office oll ess
'' '€�• 600 Washington Street
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_-!'� Boston,Mass. 02111
`—� Workers' Compensation Insurance Affidaftgt
:' lieantinf mai- n— :. = l�s�- - r- -
name: Jose Ij �'7A C /: JrAA/
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Joanne:7.)e 1q L l>nA./7 Ll A/Af/ /di
can• ~ A'e�fel C.,/ A,- nhnne# t'7A ?- it, CO
-am a homeowner performing all work myself. •
E I am a sole proprietor and have no one working in any capacity
E I am an employer providing workers' compensation for my employees working on this job.
.
company name: - -
address:
tin.:
ohonafN
insurance co. policy# • '
-
E I am a sole proprietor, general contractor, or horneow aer wercle one)and have hired the contractors listed below wtfo h_
the following workers' compensation polices:
company name: -. .
_
address: - -
city:
insurance co.
.
. ... . .. . . .. .
company name: - - -
address. -.. .. ... ._
yin.. `. nhone#r _
insurance co. rimer#+ . . ..
Attach additional sheet iftreeeisan - -=-Y• -...._. , t.•-. .'. ... :: :_:�"�`,�;:;54*t�'�-;?'�•--
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a tine up to SL500.00 audit
one yens' imprisonment as well as civil penalties in the form of a STOP WORK ORDER soda line ofSI00.00 a day against me. I understand that
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
•
1 do hereby cent under the pains and penalties perjury that the information provided above it carte and correct.
Signature i+i yY'nele" 44".. Date _a oy ic- /-<i 9 7
Print am T f.479h NMI ,C sir // Phoned_217- 76( 1
L• official use only do not write in this area to be completed by city or town official t
.
city or town: permiWeenaeIt 17Buiiding Department _,
�ucensing Board
check if immediate response is required �Sefeetmen's O(Lee
contact person: phone#; ❑Health Departmen[
PlOther
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for thei
employees. As quoted from the `law", an employee is defined as even 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 entire, or any two or more
the foregoing engaged in a ioint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual , partnership, association or other legal entire, 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 hou
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 r permit?.—; operate a-business or to construct buildings in the cojnmonwealth 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 ha
been presented to the contracting authority.
_... ..... `y. .. _
1ppiicants _
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 affidatit is-complete and- rinted-legtbly - he Department has p1IIyidec'aspace at-the bottom-of-
the
affidavit for you to fill out in the event the Office of Investigations has to contact ydu regarding the applicant Plea
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned -
the Department by mail or FAX unless other arrangements have been made.
The Offi.a of Investigations would like to thank you in advance for you cooperation and should you have any question._
please ::o not hesitate to give us a call. -
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 0: (617) 727-7749
phone ': (6I71 72741900 ext. 406. 409 or 375
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential
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Owners NameMA T tip S i- Owners Address r /-/A R fi 64 t'/
Building Location 407- 63 coAr, 6'/r I Date 9--/9- 9
New ® Renovation Replacement Plans Submitted ❑
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P SUB-BSMT.
BASEMENT
1st FLOOR �/
l 2nd FLOOR 2 2
3rd FLOOR
4th FLOOR
�v 5th FLOOR
k 6th FLOOR
7th FLOOR
i 8th FLOOR
Installing Company Name i7 " Mn r L Ca A/y Check One: Certificate
Address /F 14I6aA'y o -,..4,0 ri.p/ ❑ Corp.
City flpN4fiU ‘.�is- State XiAr-rt Zip CodceJ7'>.'2 ❑ Partner
Business Telephone: '7 L 2'J/S'7 n Firm/Co. - -
Name of Licensed Plumber or Gasfitter T�� �MQ r .L ft rl
INSURANCE COVERAGE: Check ne:
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 0
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 perrnit 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.
B y Type of License: Ps.A O ®' w
Title ❑ MASTER S' t�f i nsed er
City/Town ❑ JOURNEYMAN License Number ____
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