EP-48-96 T =`--- The Commonwealth ofMassachusetts
a"- - / Department of lndustrifl Accidents
_ Of!JCEollares!pallag
'‘�- 600 Washington Street
47 Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
• •llcairtinfi A iati.n:- ft_::•:.—.«. .. - ; '--.3 . 4-trriMli 4hgE#"' ill -- , ,;s.�_• - _ . - ...
f Gi
Ctt1' of sA
•l a homeowner performing all work myself. phone
jpel a sole proprietor and have no one working in anv ca?c'ty •
I am an employer providing workers' compensation tar my employees working on this job.
comoanv name:
address:
ctn: phone#: •
insurance co.
C lam a sole proprietorA :ri a enerai cnntractJr, or hoowner(cycle one) and have hired the contractors listed below who h.
the :olTowtng workers' compensation polices:
om •tn.• name:
7- ,C",� �
address: .
insurance co.
•
comoanv name:
address: ..
cif : phene#- -
insurance co. '':Qoiie #=
Attica idditioniiiiieitlfmcMsan-• -;.- .:.:-. :.<----:.... . '—.'' V_x,;:. - -- - ;`.=._-
Failure to secure coverage as required under Section SA of MGL 152 can lead to the imposition of criminal penalties of a line up to 51.5.00.00 anwc
one ears' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a tine ofS100.00 a day against me. I understand that
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature
Date
Print name
Phone#
•% official use only do not write in this area to be completed by city or town official =�;.;
city or town:
permit/license# (=Buiiding Department
Qlcensing Board
? •_ coed:if immediate response is required Selectmen's Office
F_
CHealth Department
contact person: phone rs; rlOther_
Information and Instructions
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, parmership, association. corporation or other legal entity, or any two or me-
the foregoing engaged in a joint enterprise, and including the Iegal representatives of a deceased employer, or the
receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However t1:
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 no
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employe
MGL chapter 152 section 25 also states that every state or Iocal licensing agencz• 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.
AdditionaIIy, 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.
.., . _�.s rtG•fir s.aM -u.d.+o'tY+'t!w-ate;.n i R-- =�
'_
ippiicants
Please till 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 require:
to obtain a workers' compensation policy, please call the Department at the number listed below.
- - .—= s- ,»-c�c:. «�':.. 2'3.—r: �" '._. ._._; • - -
— - — " '_- '' mow. »r'f= - '`� • "__ - . - -__
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided--aspace at the bottom c
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 Oft";.. of Investigations would like to thank you in advance for you cooperation and should you have any questior
please co not hesitate to give us a call.
T :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 #: (617) 72 7-7749
phone 4: (617) 727-4900 ext. 406. 409 or 375
RECEIPT FOR PERMIT .-- r-
ouuy. TOWN OF DARTMOUTH "
qQis� /�/� PERMIT-NO:
No
Date ♦ "'' ?
Received From �` �.%
Owner .J--iL2 . ' '---
`
Location j L_r _./ _ �,
Type = -1,
Amount Paid /I7 ) /
Received By y``71.-�' �� .f 7 2
,�r`
Office Use Only
The Commonwealth of Massachusetts Permit No.
-* — Occupancy&Fee Checked6W
l- Department of Public Safety (leave blank)
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. 5 M 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date /4 /71
The undersigned applies for a permit to perform the Gil%electricalle work,described below. /
Location(Street&Number) / 1-.-Ai,
Owner or Tenant /WO iiF�
Owner's Address k&1f1Gti "---- d 9 / 71/2 f'? Pdit; Re /171
Is this permit in conjunction with a building permit:n Yes No ❑ (Check Appropriate Box)
Purpose of Building Pe///��� Utility Authorization No.
Existing Service Amps____/ Volts Overhead ❑ Undgrd ❑ No. of Meters
ew Service /CS DAmps,--- Yt7/ /d 0 Volts Overhead ❑ Undgrd 1J' No. of Meters
Number of Feeders and Ampacity ,7- —
Location and Nature of Proposed Electrical Work )(,fe A)e/riA-- Dwel/ity
No. of Lighting Outlets / ) No. of Hot Tubs KVAal
T
g No. of Transformers
No. of Lighting Fixtures Swimming Pool ode ❑ d ❑ Generators KVA
No. of Receptacle Outlets , O No. of OA Burners / No. of Emergency Lighting
Battery Units
No. of Switch Outlets No. of Gas Burners FIRE ALARMS NO. of Zones
Total No. of Detection and
No. of Ranges No. of Air Cond. Tons Initiating Devices
No. of Disposals No. of Pumps Tonsl Total No. of Sounding Devices
No. of Dishwashers Space/Area Heating KW No. of Self Contained Detection/Sounding Devices
No. of Dryers Heating Devices KW Local ❑ Municipalnnection 7 Other
Co
No. of No. of Low Voltage
No. of Water Heaters KW Signs Ballasts Wiring
No. Hydro Massage Tubs No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the uirements of Massachusetts General Laws
I have a current LiabilityInsurance Policym din Completed Operations Coverage or its substantial equivalent. YES O ❑ I have s�ibmitted
valid proof of same t is office. YES NO LI If you have checked YES,please indicate the type of coverage by checking the appropriate box.
INSURANCE BOND 0 OTHER 0 (Please S c'fy) Gi:)(9-1-e, c� ', +aq e on Date)
Estimated Value of.7f cal Work$
Work to Start L Inspection Date Requested: Rough Final
Signed under the penalties of perjury:
FIRM NAME V eX.c f 3 / Eei,4 6 LIC. NO.r-W0 a.r '-
Licensee Signature LIC. NO.
�j/� /�- Bus. Te. No.
Address / V fly"65/ t116/1�iL / , AA-1tl` Alt. Tel.No. /2'� �d
OWNER'S INSURANCE ER: I am aware at the Licensee does not have the insurance coverage or its substantial equivalent as required by
Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one)
(Signature of Owner or Agent) Telephone No. PERMIT FEE $
_ 1
Q
_
r; n
• \Fi 1— a�.ov�
filtiii I.°.
v =1
`I t" r' 3 � p
�, �",� ��5�f j
V3) j rp °_i n A Z ` K
""JC
dAll
w G ' ° v 3 paral z ° pC c
Cl
o s ° � �r
c �1i � c
o �I °o
is) e_
l I II I I �_ •-
•
1) t •
r i; 5
c cn
\ I
)
W"fR_WR_INFO WORK RFO' IEST INFORMATION PAGE 1 OE I
Y1L 25 , 1.°9E
0 - I--\
\
L
...(\f\
W r)Ple Requost No : 1.167? pirciplyEcOto !. 2? JIILP6 Req . Oete : 01 - AUG-96
Enteror4 ey : ril Eu..0 , ,-l&rrATP CT I.;E A Pto /Pov Codol
WE' Tyoo : N E W 'SE'kir 2 Pici 1 A.
,...2
r.'n1 8A"'s PrsVI
WP Str'tUS1 1-1C ' Aonuel KWP1
--1-- ' ,,r iti, i Li)1 ti G DEPT. o mnr.' Long KW:
WE' r")ne,C'r4nt'in^ : 1Y-1/RP "' O - ,..- c-E.W oWE'. 1T
W c! N7.,•,m.DICI:c4f"mr • °E°ETRA , 5100TPITINn
E..,• rvic. AHH^':";s1 le, MEDETROS 1.. h ,Ar..r:fttl -
C ' ty - OAPTmolJTP
oni r, (0.:4eir,ou r.;,:.) I i ni 49 irrn_ F ' (:)1• • P"' n't :
r."1• Sir..1'1?r" 1 Ynl."'“ l.nt" e A.P.Y i
''''''-°.17;ACT '-',Pr,"- Tvnn
7E cf_Ar-q c:T cl_ Cr7- (
0. FNT0NInscoL4 FLprT ( 08 ' 1,1 -.7-LP ,
APTOGEWATPP , MI'\ 1":, 2-(1 ELECT ( ) - v
EI FrrqTrAL
RFOI)TREmEr!TP Porvior Voltelo : 12n/240 M4 IPP mumnor of motors : 1
Amoornool 15" Tyns of Hnet :
Ph .- . : 1 M-Ttr N'_im'',,..,,rI
i-Y1C-t_s .1. r) tiOnl LOC7ATTON n'':' AT HAN"0-JOIE ON NORTHWEST CORNER
PROPERTY OR RIGHT SIDE FACING HOUSETLM93EE
1 OM)
IIIIIIIIIIIMMMMMIIIIV