EP-21392 _= The Commonwealth of Massachusetts
t - Department of Industrial Accidents
Office ofiiv/OS11,3llettS
C" _ _4. 600 Washington Street
'>. �' Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
:l/ ,11,Slfit)t rrart; / -- r .,,,:;. ,e, 1.4•., Aptsr ala[
name: � 11 L —
location: �� Lam'j f 1%,e - b ' Iry✓
city J/(T/�'j,/ fr 0 Cf )9j phone#
0 I am homeowner performing all work myself. .
am a sole proprietor and have no one working in any capacity
•
• 0 1 am an employer providing workers' compensation for my employees working on this job.
company name: -
address: -
city: phone#.
insurance co - nolicy# - -
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:
company name:
address:
city: nhone#.
insurance co. .policy# ..
comoanvnaive:
address:
city: nitone#f
insurance co. notiev#
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 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 correct.
Signature Date
Print name Phone#
official use only do not write in this area to be completed by city or town ofncial
city or town: permit/license# °Building Department
°Licensing Board
°check if immediate response is required °Selectmeda Office°Health Department
contact person: • phone#; °Other
(revised 3/95 NA)
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 includir.g 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.
.eye M h ry
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 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.
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#: (617) 727-7749
phone#: (617) 727-4900 ext. 406, 409 or 375
TOWN OF DAM-MOUTH 21 392
BUILDING RECEIPTS
COLLECTOR'S OFFICEp (/r
Name: i `ate I 1.. Property ! V �f� Date: qq 1 i-2 �/ ,
�. U L ) Owner: 1 'j t
Job Locati ! - t. ; -* _ !
v� t �t'' f� J L ,}
_ ollector's Office
1 �C� , tgtt� ''�` 'i�t YelowCopyte Copy-CCustomer's Receipt
Plot: - Lot: { ,tt ,
V 4� i 1 G Pink Copy-File Copy
t, Green Copy-Building Department
Phone: 1 1 2001 f`�
" " gee" SEr
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e
Description a General Ledger#'s Re£ # + Amount
License&Permits-Building 01000-44105
License&Permits-Building Misc. 01000-44105
License&Permits-Electrical 01000-44106 �� c-,_ 1
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420
This is not a Permit or License for Building,Plumbing or Gas Received By: ` -----
if
Commonwealth of r/laddacIntuits Official Use Only
to_• 0 cy� c7 [� Permit No.
l-Ai JJeparlmenl o/�3ire Serviced
� e BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
? ' — ` 'Town of(Dartmouth [Rev. 11/99] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),
✓/
j 527 CMR 12.00
9�/(PLEASE PRINT IN INK OR TYPE A INFORMATION) Date:. (/
By this application the undersign ves n tic of his or h r intention to perform the electrical work described below.
Location(Street&Nu��b rn) to
Owner or Tenant v/(! / �f � �/// � > Telephone No.
Owner's Address / Q' 10 y� � L� Atfle.
Is this permit in conjunction with a b it ' g permit? Yes _� Non (Check Appropriate Box)
Purpose of Buildin t' Utility Authorization No.
Existing Service Amps Volts Overhead Undgrd No.of Meters
New Service Amps _ / Volts Overhead Undgrd No.of Meters
Number of Feeders and Ainpacity `
Location and Nature of Proposed Electrical Work: / P c,Z) 2t 9e y7
Completion of thefollowingll table may be waived by the Inspector of Wires.
No.of Recessed Fixtures i No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Lighting Outlets No.of Hot Tubs
Generators KVA
No.of Lighting Fixtures Swimming Pool ode Igmd Battery U- No.of Lighting
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons
rNo.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local Municipal
Connection Other
Security Systems:
No.of Dryers Heating Appliances KW No.of Devices or Equivalent
No.of Water No.of No.of Data Wirin :
Heaters KW Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
INSURANCE COVERAGE:Unless waived by the owner,no permit for the performance of electrical work may issue unless the
licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned
certifies that such coverage is in f rce, as exhibited proof of same to the permit issuing offic p q
CHECK ONE: INSURANCE OND OTHER (Specify:)�1. ,� �,.� 5/t2- -ti-
(Expiration Date)
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
I certifii, under the paias and pents of per that the information on this application is true and complete. �n 1
FIRM NAME: use_�� j���g� _J� LIC.NO n' 1
Licensee: Signature
Jlp LIC.NO.
(If applicable, enter" empt" • ce/• yyyum4e�'line.j ��`"_ ,n� q Bus.Tel.No.:
Address: � �J� /S�f 0 j 3 c2 i Alt.Tel.No.:
OWNER'SINSURAN�CE WMVE� R:Imam aware that the icensee does not�have the liability insurance coverage normally required by aw. By
my signature below,I hereby waive this requirement. I am the(check one) owner owner's agent
Owner/Agent
Signature Telephone No. [JERMITFEE: $
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APPLICATION FOR PERMIT TO INSTALL AND REQUEST FOR ELECTRICA 40�DI'y` CE r
Inspector of Wires-Town of DARTMOUTH Massachusetts
Customer on(Street#)
Temporary New Installation Change of Service Starting Date
Job Description
Service entrance voltage Amperage Phase
Wire size(cu. or al.) Conductor per phase
Number of meters Water heater Off peak:Yes No
Electrical Contractor License# Telephone#
Address
Additional Remarks
WR Number
CERTIFICATE OF INSPECTION
To the COMMONWEALTH ELECTRIC COMPANY. The installation described above has been completed and has this day been inspected and
approval granted for connection to your service.
Inspector of Wires Date
Code:
WIRING INSPECTOR TO BE NOTIFIED WHEN WORK IS READY FOR INSPECTION
Permit is Good for One Year From Date of Issue