EP-7064 _'� The Commonwealth of Massachusetts
4m "l Department of Industrial Accidents
RI �ffasi OMCSIII /as oaa
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600 Washington Street
Boston,Mass. 02111
•~" Workers' Compensation Insurance Affidavit
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0 I am a homeowner performing all work myself.
�am a sole proprietor and have no one working in any capacity
0 I am an employer providing workers' compensation for my employees working on this job.
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0 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:
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common name•-
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Failure to secure coverage as required under Section 2SA of MGL 152 can end to the imposition of criminal petwltits of a One up to S1J00.00 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 do hereby cen1fy cur the pains and penalties (perjury th a information provided above is pvrx¢��
Signazore -4''' , � �// .:2 /i _. - Date /(�`/ -
Print name G c°z 7 C - ;'-S2 l✓ S Pltone# 7�0 -� 71 -3
official use only do not write in this area to be completed by city or town official -
city or town: petsniNit:eme# I]Bolidiog Department
DU:ensiog Board
0 cheek if immediate response is required ['Selectmen's OfficecHealth Department
contact person: • phone p: 1"lOther
i suss 195 PM)
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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 "taw", 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 c
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 has
been presented to the contracting authority.
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 ail 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.
The Department's address, teienhct and fax mart 1. — _'+ _ -
The Coma?..:f..._.:a' i =. r:ias.Zca:rst&..
Den:trmest rariuscr l .r_c__ite
'Utica of liMues:10at1olus
600 Washington Street
Boston. Ma. 02111
fax #: (617) 727-7749
phone #: (617) 727-4900 ext. 406. 409 or 375
TOWN OF DARTMOUTH 07064
BUILDING RECEIPTS
COLLECTOR'S OFFICE
TOWN Of DARTMOUTH
Name: / rtr 17. Property l'Il� COLLECpTORS OfFJCE Date: - /i iCf 11\ t.._..!.L. \ -� ?{;' CL'i l . OwneI: �9 !! i fir'1.! LS' f?f t.. i �.�. - ( / J' / I:}
JobLocahon it i L- , t ry _ — 19�'$j
fJ�`:r, '�. ' t 'i =` White Copy-Collectors Office
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Lot: _��j(�'
f 01 Yellow Copy-Customerg 's Receipt
rPlot: Pink Copy-File Copy.
Green Copy Building Department
Description General Ledger#'s Ref.# Amount
License&Permits-Building 01000-44105
License&Peivuts-Building Misc. 01000-44105
License&Permits-Electrical 01000-44106 w/ C.Cl
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420
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This is not a Permit or License for Building,Plumbing or Gas Received By: W>{i i,t. -` k i t.h r :(A...,----
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OfficeUseunty
�':i The Commonwealth of Massachusetts Permit No.
Occupancy&Fee Checked_
G `lii cr Department of Public Safety (leave blank)
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 Code. 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date -7/6/Ze
The undersigned applies for a permit to perform the electrical work described below. (OreN(Street&Number) JLO T 7<� cS zp c��jiir/CIC/ f (�J� c
Owner or Tenant in iC JiQ e/ ft U 1/a �J
Owner's Address {
Is this permit in conjunction with a building pertni• Yes No ❑ (Check Appropriate Box)
Purpose of Building J/'ci t// °hi C Utility Authorization No. C u/S 9 ?TO
Existing Service Amps / / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service I t/ p&/2U / 2 YOVolts Overhead ❑ Undgrd No. of Meters 7
Number of Feeders and Ampacity
Lot .lion and Nature of Proposed Electrical Work Rif/ C 4ekv home
No. of Lighting Outlets No. of Hot Tubs Total
�(� No. of Transformers KVA
No. of Lighting Futures AbovSwimming Poolgrad.e ❑ mod. ❑ Generators KVA
No. of Receptacle Outlets YS' No. of Oil Burners / No. of Emergency Lighting
/ Battery Units
No. of Switch Outlets /d No. of Gas Burners FIRE ALARMS NO. of Zones
No. of Ranges No. of Air Cond. Total No. of Detection and
Tons Initiating Devices
Heat Total Total
No. of Disposals No. of Pumps Tons KW No. of Sounding Devices .
No. of Dishwashers Space/Area Heating KW No. of Self Contained
/ DetectiorvSounding Devices
No. of Dryers / Heating Devices KW Local ❑ Conned on ❑ Other
No. of Water Heaters KW No. of No. of Low Voltage
Signs Ballasts Wiring
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 Policyytsluffing Completed Operations Coverage or its substantial equivalent. YES NO 0 I have subrn
valid proof of same to office. YES [7 NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate t
INSURANCE MalBOND ❑ OTHER 0 (Please Specify) tExpuauon ua:.
Estimated Value of Electri Work$ S—bac . ar Work to Start7/ a/qtr Inspection Date Requested: Rough 7/7 /9Xl/ Final ti4 ////ea I
Signed under the 6/ �penalties of perjury: `•
/ /
FIRM NAME de 6ctsQ✓uJ r/r .0- LIC. N 31
Licensee C0-g� ,Oil SO71K"I Signature -/zq�/ sy _ n�'�z_.. UC7 ND it
Bus. Tel. No. 7 44 _ 3
Address_f 2 ////I y C kM 1 S> rtrer0 "7 Ain Alt.Tel. No. ..X 3 —S—G o=3
OWNER'S INSURANCE/WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as require:
Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent Please c eck one!
Telephone No. PERMIT FEE 5 'L
:Signature oI Owner or Anent)
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