PP-2623 The Commonwealth ofM¢ss usas
r ia; Department ofrndwtrial Accidents
OIIICEo!/apis •
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600 Washington Street
Boston,Mass. 02111
Workers' Compensation Laurance Affidavit
AoPttcritintnrmarion r.—
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[ i am a homeowner performing
P rming all work myself.
am a sole proprietor and have no one working in any capacity
i ar„ an employer providing workers' compensation for my employees
working on this job.
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. a sole proprietor. general contracts. or how m2owner c r( ele one) and have hired the cantrartors lisle below wn
:he :oiiowing workers' comoensation polices:
Comnant• name:
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ins„runt- co
ccrr,ry name:
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Failure :o secure coverage as retina-ea under Section_SA of JMGL 152 can lean to the imposition
one 'ears. imprisonment as well as civilpenaltiesintheformofaSTOPdsLoftofsto peachy ofalineeptondst aha
WORK ORDER ands fine enton..ftfl a illy agaimt me. I understand the
copy of this statement may be forwarded to the Office of Investigations of the DIA for pereragt vet-Menton.
I do hereby tern-.under die pa' and penalties o e ur•rhea the in o(F rl f rm:aeotr pravftfid above rs aIIe and coma.
Sicr.^tnr •
-
ate •
Pry..name
•_% official use only do nor write in this am to be completed by aty ortown official
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city or town:
permittnee sep Building Department
_ creek if immediate response is required QUccnsing Board
['Selectmen's Office
`etr0n` phonex; QHeatthDepartment
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• Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers- compensation r'er
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
the foregoing engaged in a joint enterprise. and including the legal representatic es of a deceased employer. or the
receiver or trustee of an individual , parmership, 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:.
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 bniLugs_i_n the cc_mnmo'nwe&th for anti-
-app-ictmrwho 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.
1ppiicants
Please fill in the workers* compensation affidavit completely, by checking the box that applies to your situation arc:
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 rec_ire
to obtain a workers' compensation policy, please call the Department at the number listed below.
City or Towns
Please '_e sure that the affidavit is complete and printed legibly. The Deparrment has prosideda.space at the bond-
the affidavit for you to ftnI out in the event the Office of Investigations has to contact you regarding the applicant. Ph
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returr:ed
the Department by mail or FAX unless other arrangements have been made.
The Off.., of Investigations would like to thank you in advance for you cooperation and should you have any quest':
please o not hesitate to give us a call.
Department's address. telephone and fax number:+'
The Commonwealth Of Massachusetts
• Department of Industrial Accidents
Office of inv0stigations
600 Washington Street
Boston, Ma. 02111
fax ^ (617) 72'7 7 49 v
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1VIASSACHUSETTS UNIFORM APPLICATION FOR• PERMIT TO DO PLUMBING
DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential ® //�., J
Owners Name dadN 7rtPe t4 Owners Address 6 ccAta6La AS7AN0 /. g a
Building Location S4$IS Date 7/ram/y7
New 14 Renovation ❑ Replacement ❑ Plans Submitted
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1.3 SUB-BSMT.
BASEMENT I
1st FLOOR r ( I ( I
2nd FLOOR _
3rd FLOOR
4th FLOOR
/o 5th FLOOR
6th FLOOR
7th FLOOR
8th FLOOR /� �I
Installing Company Name t4 4b/IID/r7, /"i 0,v,c-& Check One: Certificate
Address /a /./z&i'f,t) b 2. er ❑ Corp.
City Ah, /5`Uh'A/ State ✓f- i Zip Code 4 y/q El Partner
Business Telephone: /"O Dg 3L2---0%w (Mile 3 ❑ Firm/Co.
Name of Licensed Plumber or Gasfitter R A 9 4 DE 4 . il p All C.D
1 INSURANCE COVERAGE: Check One:
I have a current liability insurance policy or its substantial equivalent. Yes 0 No 0
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity Bond
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.General
Laws,and that m gnature on this permit a lication waives this requirement.
Check One:
Ir /.-V - '"f� �€ Owner 0 Agent 0
/ /Signature of(Ywner's gent
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 Massachusetts S 1 e Plumbing Cod d
Chapter 142 of the General Laws.
B y Type of License:
Title g MASTER nature of Lic sedd lumber
City/Town I: JOURNEYMAN License Number /D/I. i
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