EP-576-97 1. The Commonwealth ofMassachureas
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i=o Department of7ndustiial Accidents
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..-7` 600 Washington Street
17 •
W�'/ Boston, M`3 :. ass. OZIII
Workers' Compensation Insurance Affidavit
'Aoniiettreinf tnttarionr- : t. _- — _ Na. ce titvan_
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? i am a homeowner performing all work myself
I am a sole proprietor and have no one working in any capacity
C I am an employer providing workers compensation for my employees working on this job. nik•
any na e• ,c.y ...
address / ` - -
cin•-
nheme#t -
insurance co.
— nnfirv0:
sole ;eprie.:ar, geegeneral cnntracorr. or ho.t:owner. {circle one) and have hired the contractors listed below wh
z
the .following workers' compensation polices:
rnmoanv name:
• address:
sin•
nffoner€r
insurance co. ..
—.--�— nn?iry•tr
,_. - ---
comoany name:
address.
rip•:
tabotteii
insurance co. _. • . . nnfiesrr -
:lttieh iliditionailiTeitiftteeessar - a------`0,.- +a,r --- -- - -- - - - - -- - •- - ---- =r .
Failure to secure coverage as required under Secnon iSA of MGL 152 can lead to the imposition of criminal pennies of a fine up to SI-500.00 anc
one ears imprisonment as well as civil penalties in the form ofa STOP WORT{ORDER and a fine ofSI00.00 a day against me. I understand tha
cop) of this statement may be forwarded the Ore of estigations of the DIA for coverage verification.
I do hereby e nder the pal penaer perjure•that the information provided above is orte and correct
Signature ,/� /�
� �� / Date / 2:2--J
Pr..t \ 1. e5 1
� �� t � Phone 2 y �
official use Dahl do not write in this area to be completedwa by city orto official
•• city or town:
permitAlcense# =Building Department
check if immediate response is required =licensing Board
t_ =Selectmen's Office
contact person: =Health Department
phone#: nOther
I
•
Information and Instructions
Massachusetts General Laws chapter 152 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 m
the foregoing engaged in a joint enterprise, and including. the legal representatii'es 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 _rounds or building appurtenant thereto shall not because of such employment be deemed to be an empic\
MCI_ 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
been presented to the contracting authority.
1pp,i can ts — _.
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation ana
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.
nor the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are re^::ire
to obtain a workers' 'ompensation policy, please call the Department at the number listed below.
- -+• �-^.,� ?,_��..:i- ;._.::_ K-' • _ — _
Cin• or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided-aspace at the bottom
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant P!;
be sure to rill in the permit/license number which will be used as a reference number. The affidavits may be returnec.
the Department by mail or FAX unless other arrangements have been made.
The Offi. of Investigations would like to thank you in advance for you cooperation and should you have any quesrc
please .:o not hesitate to give us a call.
-17:e 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 m: (617) 727-7749
phone 1: (617) 727-4900 ext. 406. 409 or 375
RECEIPT FOR PERMIT s
TOWN OF DARTMOUTH -5 /�J(/ 5:7 J
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Date qZ1/- _ 7 7
Received From 1
Owner n x.:
Location if -*.....C. /0t-
Type (Nt..d--fR,-
Amount Paid 0 -
Received By ay ' 0 i )C -,t,C 4�iik
NO TAX ' SS () t TOWN OF DARTMOU Ham ; 00605
tea:' BUILDING RECEIPTS
COLLECTOR'S OFFICE
I
Name:- . Property Date: / y .
Owner: -
Job Location: i n - i (` - -
. � White Copy-Collector's Office.
Plot f: i - Lot: <- - - - Yellow Copy-Customer's Receipt
/ �.l - Pink Copy-File Copy
i Green Copy-Building Department
Phone:
Description General Ledger#'s TOYAVAIE.RARTMOU`IIF! Amount
TAX CO11E0311'8Orr10E
License&Permits-Building 01000-44105.,
License&Permits-Building Misc. 01000-44t0s JA /2 t)t)/
License&Permits-Electrical 01000-44106 S (9 503 L>4 C
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License&Permits-Plumbing&Gas 01000-44107 �( /J /
Other Department Revenue 01000-42420 �fr�ay
This is not&Permit or License for Building,P1 mbing or Gas Received By: ` ` `,�.;_ -0-4¢ A"
A `. Permit No.
zef . _ .
The Commonwealth of MassachusettsOffice
f�tt Use Only
7" 2'7
P. '`� r
(leave blank'f Occupancy&Fee Checked
Department of Public Safety / a 7
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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 / — •2:2- `9 7
The undersigned applies for a permit to performor the electrical work described below.
Location (Street &Num / if I rvot�U4amov /j( Vf -
Owner or Tenant J nieS s/Lr-
Owner's Address If Yi VOLGG-L th ,/D/r///t
Is this permit in conjunction with a building permit: Yes 0 No E (Check Appropriate Box)
Purpose of Building FA-MiL y v<nni Utility Authorization No.
Existing Service 20d Amps /7 D / ,7 DC.Volts Overhead 0 Undgrd PI No. of Meters J
New Service Amps / Volts Overhead 0 Undgrd ❑ No. of Meters
Number of Feeders and Ampacity •
'
Location and Nature of Proposed Electrical Work
' No. of Lighting Outlets t 3 No. of Hot Tubs No. of Transformers KVA
G No. of Lighting Fixtures a Swimming Pool :rnbodve ❑ gna ❑ Generators KVA
No. of Receptacle Outlets `") No. of Oil Burners No. of Emergency Lighting
Battery Units •
No. of Switch Outlets 2 No. of Gas Burners FIRE ALARMS NO. of Zones
No. of Ranges No. of Air Cond. Total No. of Detection and
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 Devices KW Municipal
Local Connection ❑ Other
No. of Water Heaters KW No. of No. of Low Voltage
Signs Ballasts Wiring
Wo. Hydro Massage Tubs No. of Motors Total HP
OTHER:
his
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Liability Insurance Polic mcludine Completed Operations Coverage or its substantial equivalent. YES 0 NC I have submitted
valid proof of same to this office. YES Li NO 0 If you have checked YES,please indicate the type of coverage by checking the appropriate box.
INSURANCE ❑ BOND 0 OTHER 0 (Please Specify)
Estimated Value of Electrical Work 1-/ 0
(Expiration Date,
Work to Start / 3- 0 —7 Inspection Date Requested: Rough / t -`I-2" Final W/L-L C47LL
Signed under the pe of perjury
FIRM NAME //�, LIC. NO. • / S'
Licensee / [/J7'rr'P'./1 � Signature 11 �T c.�g.�� C. Al
/� �/-a,6 a'co b D (/ ✓ll P Bus. TeL .•
Address /C/ e.. �/?.T A][. Tel. No.
OWN INSURANC 12• am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by
Ma usetts Gene `I s. dot my signature on this permit application waitvees [Miss requirement. Owner Agent (Please check ones
i S,enature or uw er or Telephone No. .32 C ` L 1 j PERMIT FEE $ 02 o