GP-22376 The Commonwealth of Massachusetts
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10ka_a_ I Department of Industrial Accidents
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\ 600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
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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
am an employer providing workers' compensation for my employees working on this job.
comnanv name:
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address: ! Y3 1 (9- /7 i /1/41- V. /
city: f 0fT�f'e19 -7-f� phone#: t 4,11/ -�/t/ 7 /C./_
insurance co. f/J ��`' ` �C � � -H./ . -policy# V1y O e o ;/? -- L
❑ 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#: -
insuranceco. - - policy#
company name:
address:
city:
' phone#:
insurance co. policy#
Failure to secure coverage as required under Section 25A of NICL 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$I00.00 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 certif. d he pains and penalties of perjury that the information provided above is true and correct.
Signature �/f-2--- _-C2i(_. Date /c) V— e7
Print name Phone#
xcofcial use only do not write in this area to he completed by city or town official
city or town: permit/license# oBuilding Department r<
❑Licensing Board
0 check if immediate response is required oSelectmen's Office
Health Department i
contact person: phone ft; fOther
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(revised 3/95 PJA)
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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.
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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.
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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
7
TOWN OF DARTMOUTH 22376
BUILDING RECEIPTS
COLLECTOR'S OFFICE
Name: i ittc,
I :9 Ownerty / 4 oT K A-{4 1-L 5 Date: 1 1 f t+
Job Location: . t i _ l C
I `� i4 0 0 AGA) ti#u v4
White Copy-Collector's Office
Plot Lot: -� Yellow Copy-Customer's Receipt
� � Pink Copy-Pile Copy
111 ` Green Copy-Building Department
Phone: - -
C:t2 i7 72.
Description General Ledge #'s T9,wI ; ORWsf r ^ )C hE Amount
_GOIF License&Permits-Building 01000-4410 1 I 1,
License&Permits-Building Misc. 01000-4410i DEC 4
License&Permits-Electrical 01000-44106 L i
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License&Permits-Plumbin &Gas^ 01000-4410� 'z a" F j -,� -Pt d� G b
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Other Department Revenue 01000-42420
This is not a Permit or License for Building,Plumbing or Gas Received By:
DARTMOUTH, MASS. Type
/of Occupancy-Commercial ❑ Residential ❑
Owners Name G Gr -iuZ % /1"'g Owners Address CU//.tr1L 1k eta- V70
Building Location Aid 4M-it/tic-Tot /9 ' l
Date Al < G/
New Renovation 0 Replacement 0 Plans Submitted ❑
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SUB-BSMT.
BASEMENT
1st FLOOR
2nd FLOOR
3rd FLOOR
4th FLOOR
5th FLOOR
6th FLOOR
7th FLOOR
8th FLOOR
Installing Company Name cC A (fVK Check One: Certificate
Address f���j �/�� /��// 0 Corp.
City sla/,tfi-1-1 State /91, 7ip Code 4'J 7 7) ❑ Partner
Business Telephone: CP11, 0'. 4 SL 0 Firm/Co.
Name of Licensed Plumber or Gasfitter CYr,e-GZ
INSURANCE COVERAGE: •'Cheek On
I have a current liability insurance policy or its substantial equivalent. Yes fl❑
If you have checked yes,please indicate the type coverage by checking the appropriate box.
CeerlWier type of indemnity Bond
OWNER'S LNSURANCE WAIVER:I am aware that the licensee does not hare the insurance coverage required by Chapter 142 of the Mass.General
Laws,and that my signature on this pemut application waives this requirement.
Check One:
Owner 0 Agent 0
Signature of Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered) in above application are true and
accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued
for this application will be in compliance with all pertinent provisions of the Mass setts State Plumbing Code and
Chapter 142 of the General Laws.
B y Type of License:
gnature of Licensed PI er or fitter
Title 2 MASTER�
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City/Town 4 t RNEYNIAN License Number ��
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