EP-11744 t. •The Commonwealth of Massachusetts
iStrz�( Department of Industrial Accidents
t 17°
)I 49" ..
I= 600 Washington Street
- ./- Boston,Mast 02111
Workers' Compensation Insurance Affidavit
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name: -
location
city
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p I am a homeowner performing all work myself.
C I am a sole proprietor and have no one working in any capacity
Ef�am an employer providing workers' compensation for my
employees working on this job.
eomoanv name•*/6 r��C1t-/ ,V.. c:4%.c l-c-c4 Z.-e--,/1 A2/
address:. OW-c.>"A- 0 •
city: 14--////,2--e—c J7'9. 72 plum to. 6- = »2 .
insurance co. -- Ciro.,'A .l<i, i ..n.t noiiry# /��//3 -
0 I am a sole propritwr,general co`ntrac tnr. or homeowner(sirete one)and have hired the contlactorsFlisted below who have
the following workers'compensation polices:
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address:
ntvr - !Then* _- :.
jnmruneeco: • noifrv# - • - -
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canton,/name: •
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address: -• . .
city:- obone#
insuranceco. noiicr#•.. -
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 SI.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.
I do hereby ecru),under the pains and
ppenalti f perjury t the information provided above is tine and correct
Signatute �y-eit-- Date 1-7�-�
Print name /o i"Se,riz/cif.-- ij Phone# G'7��7701— i
official use only do not write in this area to be completed by city or town official •
•
city or town: - permit/license a °Building Department
°Licensing Board
°check if Immediate response is required °Selectmen's Office
contact person: phone#: CHeaith Department
°Other
i rmssa J/95 PIA)
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Information and Instructions
Massachusetts General Laws chapter l52 section 25 requires all employers to provide workers' compensation for
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 n
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
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
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an empic
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or
renewal oh a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptableevidence of compliance with me insurance coverage requited.
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 chapts
been presented to the contracting authority.
-
Applicants — • "�= }it _.
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation an
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 Icense is being requested,
not the Department of Industrial Accidents. Should you have any questions regarding the "law'or if you are requi:
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
the affidavit for you to fill cut in the event the Office of investigations has to contact you regarding the applicant F
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returns
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 quest
please do not hesitate to give us a call.
The Department's address, te;en'rc.._ and fi..ae.-;. r. _.....-• - _-- •- --
The
l)enar*-r_>.r_• , :. ^flu":. .d rico
. .
riffles; of tnvestitlalsacls
600 Washington Street
Boston.Ma. 02111
fax 0: (617) 727-7749
phone 0: (617) 727-4900 ext. 406. 409 or 375
% _ - TOWN OrDARTMOUTH - 4 --1 A A
`. -..- i BUILDING RECEIPTS
COLLECTOR'S OFFICE
Name: I. E. a ' C~ ` /,.-f-` i/{ r/r 'roperty ( € , ? r ,, i Date: r-' /� I�LRi
LS.. r -. ` vt i __r, ! C__'S owner: �,, (A �t i;;a k. _.A_ �./ t `
Job Location: Js ! r --?; wit • s !
•
?-t 10 r. r \ ' LUi 1 3-..,} AAA White Copy-Collector's Office
Plot: u"_ Lot: / OPR•0 OC\CE Pink Copy--File Copy
Customer'sYellow Copy- Receipt
`'`JG.�O . Green Copy-.$uilding Department
Phone: ��GOL�E 0
/l. -fa 2
Description General Ledger#'s l f(]j° Amount
License&Permits-Building _ 01000-44105 cr�u'YY��
License&Permits-Building Misc. 01000-44105 _.--
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License&Permits-Electrical 01000-44106 n
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: L
a Office Use Only
_ The Commonwealth of Massachusetts Permit No. •
Occupancy&Fee Checked
`�i Department of Public Safety (leave blank)If
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 74 /"j
The undersigned applies for
aP��j�rmit to perform the electrical work described below./i Location (Street&Number)/'f�' � /in-S /S..7a-ic r
Owner or Tenant 1�..c�r/7-- ,C-1/0zi/L '-J
Owner's Address
•
Is this permit in conjunction with a building permit: Yes 0 No la----
(Check Appropriate Box)
Purpose of Building Utility Authorize ' n No.
A
Existing Service 2 Amps /7C) / 2(CO Volts Overhead *--Undgrd ❑J� No. of Meters /
New Service �� Amps/76 /p2yGfrolts Overhead 0 Undgrd-LJ No. of Meters
Number of Feeders and Ampacity •
Location and Nature of Proposed Electrical Work 77C- 2 /i7 GP :a- 74J ,t tGg----) Li- ✓V,a_o✓
No. of Lighting Outlets No. of Hot Tubs TVA
g No. of Transformers TVA
( No. of Lighting Fixtures Swimming Pool ode gmd. 0 Generators KVA
No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting
y Battery Units
No. of Switch Outlets No. of Gas Burners FIRE ALARMS NO. of Zones
Total No. of Detection and
No. of Ranges No. of Air Cond. 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
Detection/Sounding Devices
No. of Dryers Heating Local Co Devices KWMunicipal
nnection 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 Mass�usetts General Laws ,
I have a current Liability. surance Polic includi�n$Completed Opera ns Coverage or its substantial equivalent. YES ❑ DP eve submittt
valid proof of same t s office. YES LJ NO Li If you have checked YES,please indicate the type of coverage by checking the appropriate be
INSURANCE BOND ❑ OTHER ❑ (Please Specify) Expiration Date)
Estimated Value of ctrjdal Work S _
Work to Start 7 S— _Inspection Date Requested: Rough Final 7/
Signed under the penalties of perjury: / �J
FIRM NAME f417 �`2% � _4.� LIC. NO
Licensee Signature /l f c�w- ,G�S' LIC. NO.
Bps. Tel. No. �'Jj-77 i
Address r-t i iiv IC�Z > 7d c-i ii-1A- -77-- Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required i-
Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one)
Telephone No. PERMIT FEE $ S-w
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