PP-21175r _ .-..4k,
T =_-= = _ The Commonwealth of Massachusetts
--_I Department of Industrial Accidents
3 Office ollnvestlgat/ons
ks.
600 Washington Street
� Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
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name: 6 - . — --
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location: /u( T/�.its,�>"-0 fte? .
city 1Lki-1iU_$'U.±Lt..` phone#
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
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G I am an employer providing workers' compensation for my employees working.on this• b.
company name:. /.. 'Lb1/t- SI/k-S - <l. /�.. }
address:
city: phone#.
insurance co. policy# •
El 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#.
insurance:co. policy#
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company,name: •
address:
city: phone#:
insurance co. polio #
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Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK 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.
I do hereby certi under re pains na perjury that the information provided above is true and correct
Signature d` C Date i '-33---itrA
Print name "--Pai/LC`l&I ( (ii U P 1 V Ck Phone# 9?-/-77 J
�m official use only do not write in this area to be completed by city or town offie;a1 -,
city or town: permit/license# nBuilding Department f
Licensing Board
4 0 check if immediate response is required Selectmen's Office
Health Department
contact person: phone#; nOther _
n
(revised 3/95 PJA)
TOWN OF DART MOUTH 211 w
BUILDING RECEIPTS
COLLECTOR'S OFFICE
Name I fi4 1 0 I St^" i re,i,,,,-- Property ;. ) ! . " Date: "�s ' f--
Owner: i tit t l�"t..' t ( 1 • .%
ri
Job Location: _ t`t'E 1; ("� i • I �.
-7I f, d�F _%�White Copy-Collectors Office
Plot: 1 Lot C"` ", Yellow Copy-Customer's Receipt
>" Pink Copy-•File Copy
0 7 u;Green Copy-Building Department
Phone:
-- `'
Description I
-. a Z a a Led #'s Ref.# ` Amount
r---
License&Permits-Builder i ' 01000-44105
License&Permits-Building Misc. 01000-44105
•
License&Permits Electrical 01000-44106 ---
License&Permit-Plumb "&Gas 01000-44107 I ---
I
-
Other Department Revenue 01000-42420
This is not a Permit or License for Building.Plumbing or Gas Received By: {
TOWN OF DARTMOUTH 211.75
BUILDING. RECEIPTS
COLLE_CTOR'S OFFICE
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1 >' Property g Date: 1'`�%Name : 64 (r'['v ;- lye, t' z._ P h' -. ,e �� { r . i 5 l s
Owner: . t. Vt r k. t' --L" 0 , ! ; ; ,_. 1,
v
Job Location: ( } a,f
White Copy-Collector's Office
Plot: Lot: - Yellow Copy-Customer's Receipt
a° I Pink Copy-File Copy
- Green Copy-Building Department
Phone: ,
) ,,,it, ::....n.0 6' 1
Description General Ledger#'s Ref.# Amount
License&Permits-Building 01000-44105
License&Permits-Building Misc. 01000-44105
License&Permits-Electrical 01000-44106 ;,,
License&Permi Plumbini Gas 01000-44107 d '` �
f
Other Department Revenue 01000-42420
This is not a Permit or License for Building.Plumbing or Gas Received By: 1
---. f.m
. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
DARTMOUTH, MASS. Type of Occupancy-Commercial IllResidential Ei'-"-N
Owners Name 'Its t(t`.
Owners Address ,
Building Locationk-
N 1 @ .'c/...S ' " ate
New IJ/ Renovation ❑ Replacement ❑ Plans Submitted ❑
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P SUB-BSMT. _
BASEMENT
1st FLOOR
2nd FLOOR r 7'a' f
_
-+�— 3rd FLOOR _
/`'' 4th FLOOR
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s 5th FLOOR
6th FLOOR
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7th FLOOR
8th FLOOR
Installing Company Name F , . s heck One: Certificate
Address qOJ J (14,, ❑ Corp.
..---^ "` c 1 ❑ Partner
City tzar State Zip C,ofde
Business Telephone: 6�__S_ 9 _2 7 c- Firm/Co.
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Name of Licensed Plumber or Gasfitter C\ am_...tQL„.Q.1() OXP.A.,......-.*
INSURANCE COVERAGE: Check
I have a current liability insurance policy or its substantial equivalent. Ye o 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 my signature on this permit application waives this requirement.
Check One:
Owner ❑ 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 assac s State Plumbing Code and
Chapter 142 of the General Laws.
B y Type of License:
Sig hire of Licens lumber
Title ASTER
City/Town ❑ JOURNEYMAN License Number ( ' 0 C 3
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