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PP-602 — The Commonwealth of Massachusetts 1 - ( Department of Industrial Accidents _ Office ofleresdgatloas _= f 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Iican m ahon ` name: location: cif _phone# I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity © I am an employer providing workers'compensation for my employees working on this job. company name: _ i' �. .,"i; ', . i,;. t L i:j` , , `- address: 2 ]:Li c-. T _ city: '.:P st DoL t , 11a. 027Q0 phone#: 50c-679-0319 insurance co. nn r,l P Tp c. c o.policy# CC—'1'.1 ' 30 • I am a sole proprietor, general contractor. or homeowner(circle one) and have� ietor,p phired the contractors listed below w:.o have the following workers' compensation polices: company name: address: ctti: phone#: insurance co. policy company name: address: city: phone#: insurance co. policy# .Attaeh addititina!sheet tf necessary :ex � 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 51.500.00 and/or one'ears'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of5100.00 a day against me. I understand that a cops of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 7 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature ( fit-ss Date /t-'`©v d. l`??1" Print name 'Donald L. Ouellette Phone# 503--679-0319 % offiicial use only do not write in this area to be completed by city or town official vi city or town: permit/license# OBuilding Department f,= i. (]Licensing Board 0 check if immediate response is required ['Selectmen's Office ['Health Department contact person: phone#; t. ❑Other e isea3-9;P)AI MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) E TOWN OF DARTMOUTH Date �0� 19 �f __11 __- .1.1 t ____,__._ Permit # `� Building ,r-s� Owner ' s _ AT: Location NameC i (6• J( J' P / d ThC r,q (Fi9- Type of Occupancy: New gJ Renovation 0 Replacement 0\ Plans ,� J6`- ' FIXTURES Submitted: Yes ❑ No ❑ r z z to a z Y N 0 O z = 9 W Z 1�� w Y to v a to 0 la CC Z z a I- to 1 N W co tun x Fa- 0 W to Y a a w a °. d x o o z a m o w >" 4 I- U) Z etcn CC 0 4 m z a . X O u. m I- 0 4 z a z z x a ow 1.- 14 i 4 W IL scil. WCC ; 4 F- 4• 4 = N th 4 4 O a O O.,I 4 a W a 4 O 4 F' w J �+ Y J 00 0 A G ..I x I- o u. O n 0 4 tr ut O o (� SUB—BSMT. BASEMENT / 1ST FLOOR / / ' I _ _ 2ND FLOOR A L 1 J 3RD FLOOR 4TH FLOOR 5TH FLOOR 6THFLOOR 7TH FLOOR 8TH FLOOR (Print or Type) Installing Company Nam O/ -i.. �,®(, ettei`eheck One: Certificate 0 Corp. Address cD- G-U(i L Partnership bk--)er e< '-'-.7/(t- 14 0 Firm/Company -- Business Telephone(?—29.-'U; f Name of Licensed Plumber . i 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 Permit issued for this application wiii be in compliance with all pertinent pro- visions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By e31-7-14 Ol_AA..., Titl L _ Signature of Licensed Plumber a:ElyType of Plumbing License /Town: gb63 ���'YYY APPROVED (OFFICE USE ONLY) License Number IYJ Master 0 Journeyman r Y w rx1 H C) x rli En _ rt ,O'a 'OF.,'A ri O� ZCI H 4 'd{ S `� t ~ 441 AV`, `, `7 y , Q, v Z lt ���snxI5 ftl Ilk X 7:i Ca H r\ 1 Z H M I r to a �; •• of N ,--.= Z 7y ; H -- 'z O 7 0 N I1 F: d v r o ® ��', t7 CI �, ti --4 b cam' W X b O c=i> cam+ 3 N O= r+ j z ....,4- 0 N• fD a cL� !D 2� , ;/ K O ,1-- :/\-. ,,.:c12.-o:.-ii n i , , cn til 34