PP-6555 1
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The Commonwealth of Massachusetts
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9yU (7a Department of Industrial Accidents
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� t -. 600 Washington Street
Boston,on,Mass. 02111
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Workers' Compensation Insurance Affidavit
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name'
location:
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❑ I am a homeowner performing all work myself.
❑ I am a sole proprietor and have no one working in any capacity
a I am an employer providing workers' compensation for my employees working on this job.
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company name: t"cE K /' /v+-i kn.
address:- /a ' le i/ Cr
city: !i v4n t _owns* 5:e, SS=C YPa 7
insurance co: policy#
❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices:
company name:
Address: . . _. . .. ..
city:- phone#: .. .
fnsorance-co. polity# ---
n
company name:
Address:
city: phone#:
insurance-co. nolfey#
Failure to secure coverage as required under Section 25A of h1GL 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or
one years'Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 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 do hereby certify under the pains and penalties of perjury that the information provided above is true and MRCS
Signature !)ate
Print name Phone#
official use only do not write in this area to be conft Is sted by city or town official
city or town: .._ permiNleemeN
" -- [(Building Department
[(Licensing Board
[Selectmen's Office
❑check if immediate response is required
contact person: hone M� ❑Health Department
]Other
uwued 3,95 PIA)
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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.
Applicant's
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. te:enhcr._ and fax nu. . --
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l)epartrez8 o r.rdus,ri-! Atec_i.cvI-j
dffice of investigations
600 Washington Street
Boston,Ma. 02111
fax #: (617) 727-7749
phone #: (617) 727-4900 ext. 406. 409 or 375
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING 1
DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential• ❑
Owners Name De/7 t2 dC r.:A'etch/// Owners dress
Building Location l7 T 1�3 � /� jL Da f'2 a
New 11.l Renovation ❑ Replacement ❑ Plans Submitted ❑
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SUB-BSMT.
BASEMENT 1 {
P 1st FLOOR 1 + I I • ..,i
2nd FLOOR I 2_ I 4 t Ns
3rd FLOOR
l 7( 4th FLOOR
5th FLOOR
6th FLOOR it
7th FLOOR - ir
8th FLOOR /
Installing Company Name �/ r ,,' P(c':nb�-i� Check One: Certificate
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Address 1. 2_2 , a/`� '/ E Corp.
City : t:� ,1-
1 State , ``i 7ip Code a' 7 4 ❑ Partner
Business Telephone: 5 63 E, <c ;/l 3 /L❑ Firm/Co.
Name of Licensed Plumber or Gasfitter /�4ir t,- /`I:4 z /,..,
INSURANCE COVERAGE: Cheek One:
I have a current liability insurance policy or its substantial equivalent. Yes 1Jo 0
If you have checked yes,please erdicate 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.
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Check One:
Owner 0 Agent 0
A 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. % s
B y Type of License: v 41-
Title MASTER Signature of Licensed Plumber
City/Town 7.7 0 JOURNEYMAN License Number /)- 73
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