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EP-25374
i T--_-__3 The Commonwealth of Massachusetts t- " wu Department of Industrial Accidents q- < ,,Ni = ' r= Ofice0Nnyes!!galiens ?. 600 Washington Street N� Boston,Mass. 02111 i Workers' Compensation Insurance Affidavit Applicant"mformafion ""',nmr-7"i.�leasePR epJi. tr41 :. ,, g .._. ,. � � . + _ _ ....,• name: 4 Zt.'r---intk.c_- location: "S3; QLyvw:>..f be c city C' --rn‘-t) '''-- — .• A- phone# "So Tc- '-C—o1d0 O I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one working in any capacity "fir:. . „. r:. -----.; s --;, `may. z '&cl lam an employer providing workers' compensation for my employees working on this job. comoanv name: Ca i 'esALc,.g., address: e5 3•S -19‘....\w_.z- -�_ "\s , city: \A^'x-'ncs\.a-ao,c l.. wjst_ 0 c?.."a phone#: CO-As 1."' e+""In1t:, insurance co. `-'e\c\r- \ t.TJ-12Ac-Ca e-o- policy# tt.1('..t c -let's Sciir�3 ,•• : -=;alau. - : 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# .+ ...a.Xiz=A.kaXSXS.x::r u' ,YhFw'so...;4dr :.. company name: address: city; _. phone#: insurance co. - policy# ?°Attach a i)honali-heet if necessa - a T" t"tr r ' " sr �i Failure to secure coverage as required under Section 25A of'IGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP\VORK 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. 1 do hereby certify under the p e ' s of perjury that the information provided above is true and correct Signature - Date \ /tf 2 Print name Phone# - ec - -e-4,1-a.-V66 g official use only do not write in this area to be completed by city or town official city or town: permit/license# °Building Department Licensing Board c check if immediate response is required °Selectmen's Office °Health Department contact person: phone#; pother (raised 3/95 PJA) Information 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 includirg 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 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 required to obtain a workers' compensation policy, please call the Department at the number listed below. ,$$yy' 5 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. r x i;sx >$r2',7L d .n."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 OS DARTMOUTH 25374 BUILDING RECEIPTS COLLECTOR'S OFFICE Name: ! i1 Pro er f %:-� / _ Date: j /i R. L . ; '�—'. P h' - 1. rt r-r 1 r � %.. (- _ X i- f '��h.- C J . f1fiG�?�' i Owner: - Job Location: i 1i—" / White Copy-Coliector's Office Plot: `21 / Lot: 1, /r '� ' � Yellow Copy-Customer's Receipt J „T s 1 ` J� Pink Copy-File Copy Green Copy-Building Department Phone: - r± Fi r^ JUL 2 9 2002 -- ' Description General Ledger#'sc Alf_ p Amount License&Permits-Building 01000-44105 License&Permits-Building Misc. 01000-44105 ) License&Permits-Electrical t 9 r 6:81000 2 61j 1 try 2 fly % ' / License&Permits-Plumbing&Gas. = i 01000-44107 Other Department Revenue 01000-42420 -, r - 5f li This is not a Permit or License for Building,Plumbing or Gas Received By: 47 1Al"--1 l.,omnwnwea/h,o/tr/aeaacAudette Official Use Only 1 "_ = 1 ccyy�� cc77 �i Permit No. 1 . -,:. Tepartment oi.}ire Serviced P 3_AL E BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked ''a., ,off ' Dartmouth G [Rev. 11/99 Town of`La/tmouth (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK 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: 'Z 1\--N 10-2- By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) kAo-c Owner or Tenant Lierci,.,o� -rig-., to,A Caoe,czo Telephone No.6,--‘,Tr_ ZL t-� Owner's Address Lik,3 0-0._uloe,,,. SA-.;'. Q..;.,-ter uat\. Is this permit in conjunction with a building permit? Yes \( No pi (Check Appropriate Box) a Purpose of Building 5‘ q\n nw C- , .ly \L-.,.a_ Utility Auth orization No. Existing Servic traps—i--yetts Overhead Undgrd No. of Meters New Service \o-t, Amps / Volts Overhead F. Undgrd I` No.of Meters r Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 'T n . aaN-‘u` ' -act C0ss'n. mot.,,, IS- O`au-) ,-..e . , C t uc IA. e pc�.+..- \+- ¢-r..'•WS -. ,32 D1 Completion ofthefollowing table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above In- No.of Emergency Lighting gmd. I gmd.I I 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 ft No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained ,,. Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local Municipal nn Connection LJ Other No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of evices or Equivalent No.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 force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE I I BOND I I OTHER (Specify:) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Pee,4Nrc> Inspections to be requested in accordance with MEC Rule 10,and upon completion. I cert(fy, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: "Q r v�,p....1. �-Via-v-c. LIC.NO. 'a 3 Co up Licensee: a mac,,, Signature .'C « (2,. - &_/ LIC.NO. - t\0 (If applicable,Pnte�exempt"in the license number line.) js Bus.Tel.No.: Ciy1-t,-1 co Address: Alt.Tel.No.: et.L11-0-1 oe OWNER'S INSURANCE WAIVER:I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) owner owner's agent Owner/Agent . Signature Telephone No. 1.41-4-Iwo PERMIT FEE: $ Pa lV Lot /- � `\ ` _ y E , E m r x _ m : _ . \ \ I CD ES tiI & lif • k \ \ e \ _ \ 0 �& c ) , @ ) / / 2 \ / . % \ / \ \ \ } 2 ; /. - ® / \ o o c / ` - « § \ ; , , F . x - \ % § \ \ 2 \ E ~ 2 ` n / } . ) © \ c it 00 (41 lib . t • \` ) )