EP-37239 The Commonwealth ofMassachusetts
Department of Industrial Accidents
- I`= Mt:ofiarestigatiaiS
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit: BwldmadlumomglElectnc.tl Contractors
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address 5"3 W;11SCote fl-ve
cm— SO mef Jul state: t71 A zip: O t7et b phone# SOS- y7?-- 74/77
,cork die location (till address): T$(e, 11'l i1prs Zgrf beu ct-din M Vet" D1747
E I am a homeowner performing all work myself. Project Type: [ New Construction ❑ Remodel
j_v/I in a sole proprietor and have no one working in any capacity. E Building Addition «
E I am an employer providing workers' compensation for my employees working on this job.
cmmpany name:
address:
d ty: phone#:
insurance co. Tidier#
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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 cn milky# .
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company name:
address:
city: Phone#:
ine fr.:nce co. nolicv
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Failure to secure coverage as required under Section 25A of MIGL 152 can lead to the imposition of criminal penalties ofa fine up to 51500.00 and/or
one years'imprisonment as well as civil penalties in the form ofa STOP WORK ORDER and a line of SI00.00 a day against me. I understand that a
copy of this statement may he forwarded to the Office of Investigations of the DIA for coverage verification.
1 do hereby certify under rah pains and penalties� of perjury that the information provided above is true and correct
Si' a:tire �/ / • Date /a- 3- cti
Print panic IJh " p1 ten An %O Phone# $0 —4/79-'7477
official use only do not write in this area to be completed by city or town official
city or town: permit/Bcense d OBuilding Department
❑Licensing Board
E.check if immediate response is required ❑Selectmen's Office
❑Health Department
contact person: phone'=; ElOther
Information and Instructions
ylasa.:husetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
e:nplo ees. .\s 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.
\n emriurer is defined as an individual, partnership. association, corporation other legal entity, oeany,two or more of
the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, Cr the receiver or
trustee of an individual . partnership.association or other legal entity, employing employees. However the owner of a
dwell in_ 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.
\1GL 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 contracting
authority.
444br 4
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please
supply company name, address and phone numbers along with a certificate of insurance 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.
:ittreta
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
he sure to till 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
riffle: of fodestigations
600 Washington Street
Boston, Ma. 02111
fax ;V: (617) 727-7749
phone #: (617) 727-4900 ext. 406
TOWN OF DARTMOUTH k ,�
i I
1 BUILDING RECEIPTS /01W
to
9 u U � - � es, tCOLLECTOR'S OFFICE �,-
Name: ! / Property - Date j `r
‘ 0 , 'f14 fJ.J J Owner: -- 1 /{S G-- ^� i J 4
i J
lob Losati i f --�
v �f �// /eil ,f-,�<.t. c 4/71
/ / , ..i White Copy-Collectors Office
Plot: v^-) -
Lot: / ' tFeIlow Copy-Customers Receipt
>Ifl 7}— '�.l A ✓ opy c File Copy
—Green Copy-Building Department
Phone -
1
Description General Ledger Ws vL #- Amount
License&Permits-Building 01000-44105
License&Permits-Building Misc. 01000-44105 r
License&Permity-lectrical ) 01000-44106 —. /
License&Permits'---P-lumbing- Gas 01000-44107 fY t ..-------
Other Department Revenue 01000-42420
This is not a Permit or License for Building,Plumbing or Gas Received By: - 7 '7 `f-r
am n Q, q��j
4 1l,-\ l,onyunonwea/h o//c�/77/assac'wells Official Use O 1
it=•�1 = ..CJeparimenl al'Jere Serviced Permit No. 7
-=14 - BOARD OF FIRE PREVENTION REGULATIONS Occupancy and FeeCheckedj/J
�� �•8 • - .e ..(Rev. 11/99J (leave blank)
Town of Dartmouth k
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL W K
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: /Q-3-O`/
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) 2(o ;lie is izor , ,7 r/t,.-e_
�/
Owner or Tenant An 'Ivor Sow?a Telephone No. 36�(0 7 9- /O39.
Owner's Address Some
Is this permit in conjunction with a building permit? Yes pi' No I I (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead fl Undgrd No.of Meters _
New Service Amps / Volts Overhead I I Undgrd I I No.of Meters —
Number of Feeders and Ampacity rt
Location and Nature of Proposed Electrical Work: /D m %nJC/n n O c.v,inn/fry 000/
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of TransTotal
KVAl No.of Lighting Outlets No.of Hot Tubs Generators KVA
No.of Lighting Fixtures Swimming Pool Above In- No.of Emergency Lighting
gmd. gmd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detection and,
Initiating Devices
No.of Ranges No.of Air Cond. Tans No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: Detection/Alening Devices
No.of Dishwashers Space/Area Heating KW Local Municipal ri
Connection Other •
No.of Dryers Heating Appliances KW Security Systems: •
No.of Devices or Equivalent .
t No.of Water No.of No.of Data Wiringg
Heaters KW Signs Ballasts No.ofDevices or Equivalent
INo.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
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 for and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOI1ID OTHER I I (Specify:) L,yd,'i'/y /a -cY
(Expiration Date)
Estimated Value of Electrical Work: 100 (When required by municipal policy.)
Work to Start: /01-3-09 Inspections to be requested in accordance with MEC Rule 10,and upon completion.
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: ,. LIC.NO.
Licensee: .50%." b;On.r„-,o Signature '✓'2" LIC.NO. 36,Ito&'G;
(If applicable,enter"exempt"in the licRnsenumber le..) ��� Bus.Tel.No.: ,5b8- 77d-7Y77
Address: C)S3 H;1Is,4e Weise 7 Mn Oa72(, Alt.Tel.No.:
OWNER'S INSURANCE WAIVER:I am aware that the Licensee does not have the liability insurance covera a normally required by law. By
my signature below,I hereby waive this requirement. I am the(check one) I I owner I I owner's agent
Owner/Agent
Signature Telephone No. PERMIT FEE:$ i�U
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