EP-12578 C
,,' s--_-- The Commonwealth of Massachusetts
- 1=( ' Department of Industrial Accidents
=tel= gillceollevesllgatlons
v_{W 600 Washington Street
,,3 Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
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name: L/
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Jocation: 6CQ 1IOaII47
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I am a homeowner performing all work myself.
tirI 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. policy#
O 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. - policy
t
company name:
address:
ciri: _ phone#:
insurance co. policy#
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Failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 3100.00 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 /dr �O`try?:t.2L/ Date /A � 2
Print name 4 I E I ra[���j2f 5 Phone#(CD d I 4�q- �L' -
: official use only do not write in this area to be completed by city or town official /
city or town: permit/license# nBuilding Department
❑Licensing Board
check if immediate response is required °Selectmen's Office s
Health Department j
contact person: phone#; nOther ii
(revised 3/95 PM)
7 y 4,
Informatiot 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 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 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 ct;:rtracting authority.
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.
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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
i
TOWN OARTMOUTH 12578
BUILDING RECEIPTS
COLLECTOR'S OFFICE
Name 1 t -
- r , ` / / t .-} Property t` Date r %�C/ 59
LAY:,,,'. Id -.�L \-: c:i-t-z-- Owner: J '.,i -- ' l r
Job Location: - t-5/, 4(
White Copy-Collectors Office
? Lot: r" Yellow Copy-Customer's Receipt
Plot:
v 5; Pink Copy=File Copy
Green Copy-Building Department
Phone:
Description General Ledger#'s Ref:# Amount
Town 0F arm tTH
License&Permits-Building 01000-44105 COLLECTOR'S Of Ct
- License&Permits-Building Misc. 01000-44105 7 JAIL
1r J License&Permits Electrical 01000-44106
License&Permits-Plumbing&Gas 01000-44107 P tc'2
Other Department Revenue 01000-42420 C .'z
This is not a Permit or License for Building,Plumbing or Gas Received By: ..)1
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7 ;- The Commonwealth of Massachusetts Permit No
T r — . Opp &Fee Choked
• -�A _ (kax blank)
Department of Public4afety
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BOARD OF FIRE PREVENTION REGULATIONS.527 CMR 12.110 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) Data —g`--a—
The undersigned applies for a permit// �� to perform the electrical work describede below. •
Location (Street St Number) ✓ '-r Z 0 Th( L{.4, /2Ja
Owner or Tenant 6 1 ZU . l5€r i c, to t 4 i4 V..t/
Owner's Address .SA014 _
Is this permit in conjunction withpermit:a building p : Yes 0/No 0 (Check Appropriate Box)
Purpose of Building etc I Abii t' 4 L Utility Amhoa)zadon No.—
F:;Ring Service Amps ! Volts Overhead 0 Undgrd Q No. of Meters
New Service .2 A /'2/2 / Volts Overhead 0 Undgrd No. of Meters
Numh N of. Feeders and Ampacity
Location and Nature of Proposed Etectricai Work 2 09' 1/ N 7 //i 4
°i
»t- No. of Lighting Outten No. of Hot Tubs No. of Transformers rKVA
q " No. of Lighting Frxmres Swimming Pool . ❑ vsmd. ❑ Geaaaoas KVA
No. of Receptacle Outlets No. of Oil Burners No. of>U i�ncY Lighting
Battery' No. of Switch Outlets No. of Gas Burners HRH ALARMS NO. of Zones
• No. of Ranges No. of Air Conti Total No. of Detection and
Tons Initiating Devices
No. of Disposals Hest Total Total
!" No. of Pttirios tons KW No. of Sounding Devizes •
No. of Dishwashers Space/Area Heating Kw No. of Self Contained
DetectiontSotmding Devices
No. of Dryers Heating Devices KW Local ❑ M1°'rih:Caon 0 Other
Comern
No. of Water Heaters KW No.s f Ballasts
Low Voltage
Wiring
No. Hydro Massage Tubs No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Liability Insurance Policy inclndding Completed Operations Coverage or its substantial equivalent. YES 0 NO ❑ I have submu:
valid proof of same/to this office. YES 0 NO Ll If you have checked YES,please indicate the type of coverage by checking the appropriate
INSURANCE NQ BOND 0 OTHER 0 (Please Specify)
(bap:ration Dace
- •— Estimated Value of Electipal Work t 4 rAt a
Work to Start 1 Inspection Date Requested: Rough t /C Final
Signed under the penald of perjury:
FIRMNAMEr yaf l ✓)c/Y- i2 D/ g i•/1(L{{. Gai '9CIGG' uc.-No. 29/79
Licensee .4)947c Signature lei (..- 'r----ame-✓ LiC 'NO. /r
Bus. Tel.:,No.
Address G�ri An1w -y PHI �i (/� .)'11� oZ72�/ Aura.Na. ��.,
OWNER'S INSURANCE WAIVER:/I am aware that the Licensee does not have the insurance coverage r its s dal equivalent as reeturec
Massacnusens General Laws. and that my signature on this permit application waives this requirement. Owner Agent �(Fll(eeaaserAcheeick one:
Is — Telephone No. PERM T FEES `•""'
Sianallrr of Owner's Aoe ',
.
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•APPLICATION FOR PERMIT TO INSTALL AND REQUEST FOR ELECTRICAL SER c4
Inspector of Wiressi--1•own of Dg/t;ii/)l(,(ih Massachusetts f
Customer $ E fJ`j 4i'4 ig14 14/ r on(Street#) 90 gh/�.fy1`J)k k% 3..i- _
Lot# '34 in the village of
g _utility pole#or underground#
Customer's billing address SEn I C
Temporary New Installation V Change of Service Starting Date
Job Description Zep Ali d4 elfr uttd SY(C//C4
Service entrance voltag% /20/2/0 _Amperage 2,07,7 Phase /
Wire size(et or al.) '//i _Conductor per phase
Number of mete / Water heater _Off peak:Yes . No
rile?
Electrical ContractorJ9g(/1e 1i e/ ?/2t5 License# 27/ e / Telephone (i 2' '4 d 7f le
Address ,601 /3✓2/ Ja'r4/ , Au i IZtv1r,nM, #172 /
Additional Remarks
• CERTIFICATE OF INSPECTION
To the COMMONWEALTH El EECTRIC COMPANY. The installation described ab. - be''completed mas this day been inspected and
approval granted for connection to your service.
Inspector of Wires_ ,.. apde- Date__/0 .17
WIRING IN-PaCTOR TO BE NOTIFIED WHEN WORK IS READY FOR INSPECTION
IPermit is Good for One Year From Date of Issue