EP-760 The Commonwealth ofilassac-humus
` r=a Department of Industrial,� Accr�ents
'• ` .13 01110E01/OYESlIQ Eps
600 Washington Street
'" Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
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E I am a homeowner performing all work myself.
i am a sole oroorietor and have no one working in any capacity
i am an employer providing workers' compensation for my employees working on this job.
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address
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[ I am a sole propnetor. general cnntract..r. or homeowner(circle one) and have hired the contractors listed belo w
:ge :pilowing workers' compensation polices:
cocranv name:
adcressr
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name: .
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cin• eftnnert-.
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insurance co. --.
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Fan ure :a secure coverage as requtren under Seaton 25A of MGL 152 can lad to the:mpoatdon of criminal Insides of a line up to 51_00.
one 'can imprisonment as well as civil penalties in the form ofa STOP WORK ORDER and fine ofS100.00 a day against me. I undent:
cony of this statement may he forwarded to the Office of Investigations of the DIA for coverage verification.
/do hereby cerrri•under the pains and pen erjun•rho the information pravrded above is trae and correc
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Phone*
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oillciai use only do nor write in this area to be compiened by city or town official
city or town:
permiUlttmse lit ntluiidiag Depsrrmcr
Clieeming Board
_ :neck if immediate response is required :Selectmen's alike
n ,.or. CHesith Department
phone Pt "-Otter
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Information and Instructions <�
`iazz.,,....user s General Laws chapter 152 section _5 requires all employers to provide workers' compensation :
employees. As Quoted from the "law", an employee is defined as even person in the service of another under
contract of hire. express or implied, oral or written.
An empiorer is defined as an individual, partnership. association. corporation or other legal entire, or any nyc
the foregoing engaged in a joint enterprise. and including the lecai representatives of a deceased employer. or :r
receiver or trustee of an individual , partnership, association or other ie_ai entin', employing employees. Howe!
owner of a dwelling d e.11n_ house having not more than three apartments and_ , arme...� Ana who resides therein. or the occupant of:
dwelling house of another who employspersons to do main
tenance constructionrepair P ance . work '�c- or on such a grit:
or on the _rounds or building appurtenant thereto shaII not because of such empiovrnent be deemed to be an em
MCI chapter :52 section _5 also states that every state or local Iicensing agency shall withhold the issuance
renew ai of a license or permit to operate a business or to construct buildings in the commonwealth for an:
applicant who has not produced acceptable_etiideuce of compliance with tirre'-insurancezovenre reouireci"
-kali-tiarlaily, neither the commonwealth nor any of its political subdivisions shall enter into any contract for:he
peribr=anC2 of public work until acceptable evidence of compliance with the insurance requirements of:his
been esented to the contracting authority.
.-....:. -..� • ... �.y F--.firs. _ - _
\ppiicants
Pease ill in :he workers' compensation affidavit completely, by checking the box that applies to your situation
suD:iyin_ company names. address and phone numbers as all affidavits may be submitted :o the Depa.—en: of
Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The
should be returned tc' the city or town that the application for the rmit or license is being r es:ed.
_ . = Depar:ment of Industrial Accidents. Should you have any questions renardinet the "law" or if you are rec
workers' -ornpensation policy, please call the Department at :he number listed below.
pr Towns
sure>_ , '... .ha,:hat-the-affidavit-is prate a -r The .--, _ - -
_ _I�t: .J .,.::. :a5�rti�iq a z � at y
af=azvir for you to fill out in the event the Office of Investigations has to contact vital regarding .he applicant.
__ sure to fill in the permit/license number which will be used as a reference number. The affidavits may be rem.-
;:e Depa-neat by mail or FAX unless other arrangements have been made.
G.`=.: of investigations would like to thank you in advance for you cooperation and should you have any due
_.__se _c riot hesitate to give us a call.
• -• ��L•�_ t lid-SC-.YM ._ ___ .. �. _ _ _ ...
__ 9ecar:•:.en: s address. telephone and fax number:
• The Commonwealth Of Massachusetts
Department ofIndustrial .Accidents
Office of Investigations
600 Washington Street
Boston, Ma. 02111
fax =: (617 -1'49
phone =: (617 -4900 ext. . :no or. r�
TOWN OF DARTMOUTH i 1 2
No TAx l �s BUILDING RECEIPTS
S COLLECTOR'S OFFICE
Narite: a Property Date: (�
J/ I .
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Owner: -f -
Job Location: -
Plot: Lot: Yellow Copy-.Customers Receipt
Pink Copy-File Copy
Green Copy-Building Department
Phone:
Description General Ledger Ws Ref.# Amount
License&Permits-Building 01000-44105
License&Permits Building Misc. 01000-44105 II ( H
Tex CftCI Tft OFFICE
License&Permits-Electrical 01000-44106 e
APR ' 6-1991 -
License&Permits-Plumbing&Gas 01000-44107 c.
Other Department Revenue 01000-42420 S A S 03
This is not a Permit or License for Building,Plumbing or Gas Received By:
.4.
" The Commonwealth of Massachusetts Permit No. " �_
- C Occupancy&Fee Checked -
c/ 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
AU work to be performed in accordance with the Massachusetts Electrical Code. 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date V ge-9 7
The undersigned applies for a permit to perform the electrical work described below. �
Location (Street&Number) GO 5 ` -re Q le cQ • Y
Owner or Tenant Th1n CCS1t.Qnv?C /)
Owner's Address J 0t Y/1 -C
Is this permit in conjunction with a building permit. Yes 0 No gl (Check Appropriate Box)
Purpose of Building - Utility Authorization No. - —- -- -
Existing Service ____ amps 1 20/ 'LqQ Volts Overhead rill Undgrd 0 No. of Meters f
New Service f Amps 20/2(k) Volts Overhead E. Undgrd 0 No. of Meters
Number of Feeders and Ampacity ` • n
Location7 and Nature of Proposed Electricall1 /W/�ork �ne p!GCc_/ V7)e+12 &i, R cli AI /?'S c/t
Ces-15-r.NG (,t/Gi S Qt�l It'd Qo, AutiS< &Ur}nq am G CC f 1 en \
No,of Lighting Outlets No. of Hot Tubs J No. of Transformers Total
No.tof Lighting Fixtures Above In-
Bh g Swimming Pool . ❑ 0 Generators KVA
No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting
Batten)Umts
No. of Switch Outlets No. of Gas Burners FIRE ALARMS NO. of Zones
No. of Ranges No. of Air Cond. Total No. of Detection and .
B Tons Initiating Devices
Total of Disposals No. of fps Total No. of Sounding Devices
No. of Dishwashers Space/Area Heating KW No. of Self Contained
Detection/Sounding Devices
No. of Dryers Heating Devices KW Local 0 Cormecnon D Other
_No._of Water Heaters KW No. of No. of Low Voltage
.Sivas _ Ballasts _ Wiring
,
No. Hydro Massage Tubs No. of Motors Total HP
OTHER:
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INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
N4 I have a current Liability Insurance Po' cludin Completed Operations Coverage or its substantial equivalent. YES O ❑ I have suLmi
valid proof of sam to this office. YES NO Li If you have checked YES,please indicate the type of coverage by checking the appropriate t
INSURANCE BOND 0 OTHER 0 (Please Specify) Pe 77v1 5 Z 3 ) -
(txpuauon Vat.
Estimated Value of ElectricalWork 4 S`
Work to Start T'57 Inspection Date Requested: Rough Final 7
Signed under the penalties of perjury: 11
FIRM NAME 01 fl tS#A C
L L eL e Tee' c LIC. NO!/1'3$3(
Licensee Ft c hC CC Mc,I S X c 11 Signature f (..5 v�,\J.IC. NO.E33�Ye_
Bus. Tel. No.1 y 737/7
Address I w �m�1/ ST f��U^i � ? Alt.TeL No. 7
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as requirec
Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one)
Telephone No. PERMIT FEE 5 `� U
)signature of owner or Agenu
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