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EP-29060 The Commonwealth ofMassaschusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit n 2sva Applicant information: ' Please PRINT Legibly -. '�+^.*':= >` -r^- _�'' name: location: city phone# ❑ I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one working in any capacity ❑ I am an employer providing workers' compensation for my employees working on this job. company name: address: city phone# insurance co. phone# ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation policies: company name: address: city phone# —' insurance co. phone# �''F' t. . . . �'% 7, 2'tt' company name: address: city phone# insurance co. phone# ff.1 Attach additional sheet if necessary c� `' { 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$100.00 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 ofperjury 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 official city or town: permit/license it ❑ Building Department in Licensing Board ❑ check if immediate response is required ❑ Selectmen's Office Health Department contact person: phone#: ❑ Other intormation and Instructions . \lassachusetts General Latws chapter 152 section 25 requires all employers to provide workers' compensation for their oio ees. 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 emnlorer is defined as an individual. partnership, association. corporation or other legal entity, oranyttwo or more 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 how or on the _rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. NIGL chanter I52 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 ht been presented to the contracting. authority. — — _ Applicants • Please :ill 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 he 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'riumber listed below. Ciry 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 till out in the event the Office of Investigations has to contact you regarding the applicant. Plea he sure to till in the permit/license number which will be used as a reference number. The affidavits may be returned t 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 question 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 DARTMVIOUTH 29060 • BUILDING R EIPTS �. \ + COLLECTOR'S OFFICE ` • / 1 _ Date ���, jr s Name: td f(�4` L i Property } ( i t je ] 4 +t i Owner + Job Location: 1 - Jk. e •• 1 1• . , , - + ji i . �- : ,- 71 ` E . , White Copy-Collectors Office Ploti n f _. Lot: ' - ' �° Yellow Copy-Customer's Receipt tb ' -- - t �` - Pink Copy-File Copy l '5 1 ttp - 93—j Green Copy-Building Department Phone r.c .�.. i a t .): 1 o J , t : j uwit hhP G ) _ rs y Description General Ledger Ws c ",;`Ref.W# Amount License&Permits-Building 01000-44105 License&Permits-Building Misc. 01000-44105 License&Permits-Electrical 01000-44106 - 5 v License&Permits-Plumbing&Gas 01000-44107 Other Department Revenue 01000-42420 i This is not a Permit or License for Building,Plumbing or Gas Received By: - ----0 -- --- \l. �1\ Commonwealth.of{�rtaaacketia Official Use Only c� g c7 Permit No. wa=_7ti t Jiepariment of-}ire Serviced E•' r BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked ` =, . [Rev. 11/99] Town of(Dartmouth (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: S 12...5 103 By this application the undersigned lives notice of his or her intention to perform the electrical work described below. Location(Street&Number) I 1,69 K 12 OYt9 Owner or Tenant bA 1 Y b\&\ S\%= I‘,1 Telephone No. Owner's Address- 12-.BcI Q Is this permit in conjunction with a building permit? Yes y( No I I (Check Appropriate Box) Purpose of Building P. i' €l.(£ g $V19a Utility Authorization No. - Existing Service l aD Amps i W / aSS Volts Overhead)( Undgrd — No.of Meters I New Service Zoo Amps la / Zb Volts Overhead Undgrd gi No. of Meters Number of Feeders and Ampacity 119,9-Mj-R 60 4\ SvW-mk-L -ro t3 )fc w1) Location and Nature of Proposed Electrical Work: \W 51N9tk .Sk ct - . 1PNt 13t1J WITILI3 Completion of she following table may be waived by the Inspector of Wires. No.of Recessed Fixtures — No.of Ceil:Susp.(Paddle)Fans r--- No.of Total Transformers KVA No.of Lighting Outlets 1 No.of Hot Tubs Generators KVA No.of Lighting Fixtures 11 (, Swimming Pool ^Above In- No.of Emergency Lighting gmd. gmd.I I Battery Units No.of Receptacle Outlets T No.of Oil Burners C FIRE ALARMS No.of Zones No.of Switches4 - No.of Gas Burners r.—, No.of Detection and Initiating Devices No.of Ranges �� No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained 4 ^'�. Totals: Detection/Alerting Devices ,--\No.of Dishwashers ^ Space/Area Heating KW Local I Municipal Connection Other No.of Dryers ' — Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water r---__ r--. No.of No.of Data Wiring: Heaters KW Signs - Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors -- Total HP Telecommunications Wiring: l 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 force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE I BOND I I OTHER (Specify:) `7 1(0 (Expira'on Date) Estimated Value f E ectrical We (When required by municipal policy.) Work to Start: L(24 03 spections to be requested in a r e with MEC Rule 10,and upon completion. I cert,, under the pains and Enalties r f(}rerjury, that the information t pplication is true and complete. p FIRM NAME: C IN1'ol)q --R\u IC`; - LIC.NO. .I1) (l b Licensee: ?AA._ SrnOug Signature s LIC.NO. 2 , b (If applicable, enter"exempt"in the license number line.) - Bus.Tel.No.: l 12 - I Address: 11 Can./N CV b€ *"p 'Nil 03\ . Alt.Tel.No.:fcD OWNER'S INSURANCE WAIVER:I ann aware that the Licensee does not have the liability insurance covers a normally required by law. By my signature below, I hereby waive this requirement. I am the(check one) owner J owner's agent Owner/Agent Signature Telephone No. PERMIT FEE: $ Plat & Lo t/0- ^a ƒ ƒ / / \ 3 E / \ / / E .) § / § % § § y § / » § ƒ - » ; ; § o / / $ y ¥ , , # \ Inc \ _ ) b 4 \ ° a ; \ , CD rn \ ) / ® . 4 ° ® \ / @ g § [ ( \ § \ ( \ * � n 2 - ® to „ z 2 S_ ) § \ § �.ik § � '' ) / glii \ a. • � a. Z k ~ CrQ I R 51? . / / a pm � \ 2 \ fs \ cz or it oo ACV - . co r > ) _ S© ?