GP-32068 e A.
;\_ The Commonwealth of Massachusetts
_ — IP Department of Industrial Accidents
x — gl!lceoflolesllgalloes
,.)
600 Washington Street
,-� Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
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: wi 1 ki ncon lac Snppl y, inn
address: 329 Wilbur Avenue
city: Somerset, MA 02725 nhone#: 508-672-0242
insuranceco. American Interstate Ins . , Co. oolicV# AVWCMA1154342003
❑ 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: phone#:
insurance co. aolicv#
company name:
address:
city: ohone#:
insuranceco. - policy#
Failure to secure coverage as required under Section 25A of BIGL 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 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.
f do hereby certify It er the pains andte peenaltie�//�j perjury that the information provided above is true and correct.
Signature ;13, Lf/f��� ,�, . ' Date Aa/) 3/03
Print name /jA /P 3. W,/%ns, n
�` Phone# ,S'p8—a. 7,2— 0.2-5...
official use only do not write in this area to be completed by city or town official
city or town: permit/license# flBuilding Department
Licensing Board
Selectmen's Office
oHealth Department
check if immediate response is required
contact person:
phone#; fOther
revised 3/95 PIA)
TOWN OF DARTMOUTH 32063
BUILDING RECEIPTS
COLLECTOR'S OFFICE �` � 4 •
3 la / 0 ' -11 A3.L' J .',lb"Lk '- Prof ty ,j .,,;;,j�,�.t��''-I if,
� Date //j . _J __)X. �,;7
milt f/
Job Location: " / _ 1 /(.�r j�.. " /' �-
,-. 4f t- 6---s // TOWN OFDARTMOUTH
/ COt1ECTON'SOFFICE Whit Copy-Collector'sOffice
/�j
Plot: ' I7) Lot:. / felk Copy-Customers Receipt
! _ 'ink opy-File Copy
UECi 493,7ree Copy-Building Department
Phone: -
LR11
Description General Ledger#'s Ref.# Amount
License&Permits-Building 01000-44105
License&Permits-Building Misc. 01000-44105
License&Permits-Electrical 01000-44106 i
License&Permits-Plumbing&;G s .' 01000-44107 � L „fir s it jrj
Other Department Revenue 01000-42420 \.„
This is not a Permit or License for Building,Plumbing or Gas Received By:
e
F ` •
Ir:Ai1 ACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential -
Owners Name Pcber ( FP it if iPvL Owners Address
Building Location 3 y f"l i//e v t %D v' Date /t/a 3/0 3
New [ — Renovation ❑ Replacement ❑ Plans Submitted ❑
rn
Wz zvi z0
w w a Q D F x x a
A. d aF trj � �" zzoE o
ft O u. ¢CO th x p z
x
I' _ 1 Q 0wQx w0ril 0 a0a' a w
E �t' _ �di � a Uw c, z a0A �- x
I r 14 t7 [1.]
Z en F -2 x W W 43 w F F x
a F t,
"'-, wuz
z w > g w R Z ¢ a ¢ 6 o aO 0 OO re) w N
a x O C7 w 0 3 A c� a U x > A a F � O
SUB-BSMT. _
BASEMENT
1st FLOOR X. X
-."_`+1 2nd FLOOR 7
t ,S
1`'"- 3rd FLOOR
- 4th FLOOR
5th FLOOR
ii " 6th FLOOR _
7th FLOOR
at-1/ 8th FLOOR
r Installing Company Name I/lain <ph 6;:xs cvna
Check One: Certificate •
✓/ Address 3 c 9 Lc///A u,- A v P. [, Corp.
City camel-se/ State Md. 7ip Code oa 7c s— ❑ Partner
Business Telephone: Sc)8- Jn 2,) - 0 2 V ,- / ❑ Firm/Co.
Name of Licensed Plumber or Gasfitter //d d/P y /3. W /Ln son
/INSURANCE COVERAGE: Check One:
I have a current liability insurance policy or its substantial equivalent Yes -No 0
If you have checked yes, please indicate 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.
Check One:
Owner 0 Agent ❑
Signature of Owner's Agent - •
I hereby certify that all of the details and information I have submitted(or entered) in above application are trie 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. > i I C 0 )?
B y Type of License: K
Signature of L. ensed Plumber or Gasfitter
Title 0 MASTER •
City/Town g JOURNEYMAN License Number 357a
r.4
N
Et' A a N
1.4
a.
coi
0
1:4 Ilk
0 Nt #14a Ai
A.
z
r
tZ c o
p F E
a a z iC ,..
a. ta
a, .
a
A A AO 'z w ry 0
p A O E.O ,Q \ w -A °tom A
z t \5 < o a w =`
55 c. z a o a , �i�
EOOS W z �: 0 c r,
a 1 F \ m 'la a 0
a a w
ca. It* risl ID le Z 4
,.,
_ .1/43:
: R.
Yb�4 • g .
z .4
a
Cill a.
n
0
-41
A
n