EP-12127 "'-"� .=_3 The Commonwealth of Massachusetts
- ' z,Ml ( Department of Industrial Accidents
t' -e=ie1— DIWeeel/0 100iisas
} 600 Washington Street
is Boston,Mass. 02111
ts.-rvs� Workers' Compensation Insurance Affidavit
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0 I am a homeowner performing all work myself.
[rI am a sole proprietor and have no one working in any capacity
0 I am an employer providing workers' compensation for my employees working on this job.
comoanv name.
Address: .. ,.�
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city: pjSonat"#
insurance-en. ;:' " .;$ftW# ...:; ......"' .._ ,.
0 I am a sole proprietor,general contractor, or homeowner(circle one)and have hired the contactors listed below who have
the following workers' compensation polices:
compa yname:
Address:
city: phone#.
insurance co. - _ - >.ptiltey# .. .
comoanv name:
„
address: .__
city: ohone#:
insurance co. �.0Q .
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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 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 5100.00 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 certi nder the pains and- penalties� of perjury that the information provided above is true and correct
Signature 0d 1-,- tz.- Date .8-fe..<
Printname Tc3kr bt01c\•\• ci- Phone# 573' "(03T-i 796
official use only do not write in this area to be completed by city or town official'
city or town: permit/liceme it I'IBuirdiog Department
°Licensing Board
GI °Selectmen's Officecheck if immediate response is required
°Health Department
contact person: _ phone#; r°Other__
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(revisea 3/95 P/AI
Information and Instructions a. x
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for the:
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 mon
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 thf
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 hot
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 1
been presented to the contracting 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 requirec
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 out in the event the Office of Investigations has to contact you regarding the applicant. Ple
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned
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 questic
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
TOWN OF. DARTMOUTH 17127
BUILDING ECEIPTS
COLLECTORS OFFICE
7 / !� '
_t-- ,� - Date: / / `._� f
l ' Pro ert
Namej / %iv` ./��•�l` /�`.'`':.>`1r'''t Owne_ry �%i.� j'-
r
-.Job Location: / :`y i'V i - / < tier �._.�
{ ;, i r.'. / `, White Copy-Collectors Office
Yellow Copy-Customer's Receipt
Plot. ' Lot -_) "' t-;' Pink Copy-Pile Copy
Green Copy-Building Department
Phone: - -
Description General Ledger#'s Ref.# of oa Sk:,0? Amount
tc
License&Permits-Building 01000-44105 \ 1.“jSOR
License&Permits-Building Misc. 01000-44105 41i,
\ /�9�9
/
License&Permits-Electrical 01000-44106 �%j 4, ' / / � C-t/'i
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:
The Commonwealth of Massachusetts Plant No
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BOARD OF FIRE PREVENTION REGULATIONS.527 CMR 1W0 3/90
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
Town of Dartmouth
- All work to be performed in accordance with the Massachusetts Flea ical.code. 527 CMR I2:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date ..-IC) S`1
The undersigned applies for a permit to perform the electrical work described below.
,
Location (Street&Number)
`W. M I Ikri _Mr ilk
Owner or Tenant K ri 5 .SOu' .s t
Owner's Address I I Gs,'hot, 54. '—T `t l l eRlie✓ { yYl it C>:-7 a 3
7s this permit in conjunction with a building permit: ma/
Yes L'� No 0 (Check Appropriate Box)
Purpose of Building t `ae Utility Atmhorktacon No.
Existing Service Amps c Volts Overhead 0 Undgrd ' No. of Meters
New Service _Z2t2 Amps 3r-Fb r Ida Volts Overhead 0 Undgrd iV No. ofMeteny1 _
Number of Feeders and Atttpacity r2 ere f3 .1 rr e..,m l
Location and Nature of Proposed Electrical Work W l`tf InOu SP
t No. of Lighting Outlets No. of Hot Tubs I No. of Transformers KVA
RVA
No. of Lighting Fixtures IS Swimming Pool r & 0 Generators KVA
No. of Receptacle Outlets 5 No. of Oil Burners I No.of Emergency Lighting
Battery Units
No. of Switch Outlets No. of Gas Bunters FIRE ALARMS NO. of Zones
No. of Ranges I No. of Air Cond. Total No. of Detection and
Tons Initiating Devices
Heat T
No. of Disposals No. of Pts Tons ICR No. of Sounding Devices • S
t l Space/Area Heating KW No. of Self Contained
No. of Dishwashers Detection/Sounding Devices 9
No. of Dryers I Heating Devices KW Municipal
No. of No. of Local ❑ Cdnnecrion 0 Other
No. of Water Heaters KW Si¢ti Ballasts Low Voltage`-i'U �p ra` 1
Winne c� cr �e(1
No. Hydro Massage Tubs No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws rq/
I have a current Liability Insurance Policy*biding Completed Operations Coverage or its substantial equivalent. YES i=NO [ I have submt:
valid proof of same to this office. YES L NO IJ If you have checked YES.please indicate the type of coverage by checking the appropriate b
INSURANCE giBOND ❑OTHER ❑ (Please Specify) L c'G L h;)r -7 7.-,
Estimated Value of cal Work c cony
1 lbapazoon stay.
Work to Start C r 7 o Inspection tate Requested: Rough wii /' CC// Final
Signed under the penalties of perjury:
FIRM NAME ISC. NO.
Licensee 151n. Lbt Yenai ta.,..-, Signature O. ere —__ p� NO. i
nn Bus. Tel. No. q'7' '-G�3�s''`3?9 �
Address;-S;3 +r 1)S;c4-e AIR I Sorne;se t 1 MP,- 03-701(o AIt.Tel.No. Co S 467 7-17/e
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as require:
Massachusetts General Laws. and that my signature on this permit application waives this requirement. Owner Agent (Please check one:
Teierhore No. PER?.UT FEE
Signature of Owner's Agent
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APPLICATION FOR PERMIT TO INSTALL AND REQUEST FOR ELECTRICAL SERVICE r
Inspector of Wires-Town of Tiq,-•}y„u�4 Massachusetts i,
Customer Kyy, cakzei, on(Street#) ;)ke cS tte , C, r
Lot# in the village of utility pole#or underground# C
Customer's billing address 1I- GT-4.0„..-‘ 5> lI "Rf r I al R 037,a':3
Temporary New Installation ✓ Change of Service Starting Date Is-/-7-(4 y
Job Description LI%) Kt kro1/4 Irk o{,e:-5r -.-,A Servi'ce
Service entrance voltage a`te)) as Amperage Phase /
Wire size(cu.or�j) cf f b Conductor per phase /
Number of meters / Water heater — Off peak:Yes No
Electrical Contractor 3otet.-, bi 1'\ License# 3c,1 co tt c Telephone# 97 $-6 38-9 75.b
Address L'3 i{;11Sice ichfrc jcriery.,e ynet 0.3-?a6
,-
Additional Remarks ��
CERTIFICATE OF INSPECTION
To the COMMONWEALTH ELECTRIC COMPANY. The installation described e has been completed and has this day been inspected and
approval granted for connection to your service. I�/ y -s/��/y
Inspector of Wires U(s' (, �JZ1 Date ^/ii� ��/
WIRING INSPECTOR TO BE NOTIFIED WHEN WORK IS READY FOR INSPECTION
Permit is Good for One Year From Date of Issue