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EP-21012 4 -------.....milm.111111111111.MV - ' The Commonwealth of Massachusetts =_ (Ze Department of Industrial Accidents ,,# _= Office ofInvestigations �/ 600 Washington Street :" _'cr, Boston,Mass. 02111 Workers' Compensation Insurance Affidavit AlifficalitifritoiiiiatiOnT " 'leas ' ! e I 1 %%filly1)11 %1 f0.4"`..,,/t/ i�, , /,,,,,ri`,;,./. name: location: city phone# CI I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity ice- I am an employer providing workers' compensation for my employees working on this job. company name: �/er_D 2?....0, 1 4' (-,- ,.: 'c._/. : r e` Address: fe . 2 / city: itiP �'7 © � phone#. insurance co. �/ Ce it.I/ policy# C.- 6 le"3 O 3 r `", " 4)' ,,�%f//%/06^^mom/////i/%/%,;z////G/O'.i,/4'/ i i;i 0, f,„/ /,, %%/ /%/9' ID 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# r. , % //,0A Z::::..,, /z''/////''''' ''////%%i. i/5///j////%//////v/7, /z z, /z,, /r'�///,yvsr%s,:.,./,,,, /f v,/ , l, company name: address: city: phone#:': insurance co. policy# t 4..:5�a ce nece9sa. .% h r. 1 4ty,/,,Y m,<//'/. %,,,,,,%%/ %,:'e ,,, ,,/ // f./` /'v%.4.A /z.;,, %'y% Failure to secure coverage as required under Section 25A of 11IGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 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 certify under the pains and penalties of perjury that the information provided above is true and correct.Signature e'=,Ao ar,1-3e--- -- Date g-—Q // 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# f Building Department ['Licensing Board !j ['check if immediate response is required ['Selectmen's Office ['Health Department 14 contact person: phone#; fOther .R (revised 3/95 PJA) 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 including 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. 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. f_a1 ff4 7N���% :Rz17,7E40 1.x7r�r 4f/,.lye Yfl /dr /r" 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. / 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 TOWN OF .MOUTH . BUILDING RECEIPTS COLLECTOR'S OFFICE v; Name: tf: ` s / `1 , ',. -Property `" Date: , `re ' �2/ ` 4— , i Owner: ;�. —, 1 Job Location: / .•l'ia f /' `` , ,,, White Copy-Collector's Office f • T Yellow CopyCustomer's Receipt Plot: r Lot: t :, - P r a ;: 3't t .'.---' ' Pink Copy-File Copy Green Copy.__-Building Department Phone: . 1 w� , t,„ i Description General Ledger#'s Rif.3 Amount License&Permits-Building 01000-44105 License&Permits-Building Misc. 01000-44105 License&Permits-Electrical 01000-44106 ,- `' (i , /%' —7/ f,72 License&Permits-Plumbing&Gas 01000-44107 Other Department Revenue 01000-42420 "- This is not a Permit or License for Building.Plumbing or Gas Received By: ' J i " Commonwealth.WI Vamachuiet Official Use Only =•= cc��rr�� cc77 Permit No. I"= iji=9Department of•}ire.erviced -_ BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked *,• Town of Dartmouth (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK • All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: -'5'6 / By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) /S /270.1!.),d rrz.e� L,9-4f. Owner or Tenant i° uLL-[/41C'_s Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes K No n (Check Appropriate Box) Purpose of Building f L c ( �'fJE7i e C Utility Authorization No. Existing Service Amps / Volts Overhead Undgrd No.of Meters New Service Amps / Volts Overhead Undgrd No.of Meters Number of Feeders and Ampacity s Location and Nature of Proposed Electrical Work:4.4..), €_ /910/., 777,0 ti , Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of formers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above gmd. In- gm d. Bt of Emergencyency Lighting Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices t No.of Ranges : No.of Air Cond. Tons No.of Alerting Devices `* No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices 1 No.of Dishwashers Space/Area Heating KW Local Municipal Connection Other Security Systems: No.of Dryers Heating Appliances KW No.of Devices or Equivalent • No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. INSURANCE COVERAGE:Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE X BOND OTHER (Specify:) Estimated Value of Electrical Work: ? peas•, (Expiration Date) r (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify, under the pains anL penalties of perjury,that the information on this application is true and complete. FIRM NAME: FrLeD c I c R L 5'j7 e C LIC.NO. /1-/. ( '9 7 Licensee: Signature ,= :14t,//gj1,,0G_ LIC.NO. (If applicable,enter" mpt"in the license number line.) J! Bus.Tel.No. J�7'f,-P Address: AO . ZdTC6 75" ' /U-6 • 'fog- • ei 2`/sl,4. Alt.Tel.No.: OWNER'S INSURANCE WAIVER:I am aware that the Licensee does not have the liability insurance covers a normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) owner owner's agent Owner/Agent Signature Telephone No. PERMIT FEE: $ ?AOID ? '''' - Plat 79 Lot - 4. • 0 * p * g it, 0 ,T, 0 . y c •"� o in- aoo ° C b b -, it. et. _� bow r w �N 1 a V in W rb - o� r a ,° . e' O N 0 z A y CI p a at° o Pi S .. a c tri ,� ; 0 c C7 y v d ' C 't n m o C 5 o*k, . ' 0. . t7Fi r � o , 6 IP T ... ,..,Q� rr A Q OO y N y N CA Le b k b1 CD r M APPLICATION FOR PERMIT TO INSTALL AND REQUEST FOR ELECTRICAL SEA E Inspector of Wires-Town of DARTMOUTH Massachusetts Customer on(Street#) L) Temporary New Installation Change of Service Starting Date Job Description Service entrance voltage Amperage Phase Wire size(cu.or al.) Conductor per phase Number of meters Water heater Off peak:Yes No Electrical Contractor License# Telephone# Address Additional Remarks WR Number CERTIFICATE OF INSPECTION To the COMMONWEALTH ELECTRIC COMPANY. The installation described above has been completed and has this day been inspected and approval granted for connection to your service. Inspector of Wires Date Code: WIRING INSPECTOR TO BE NOTIFIED WHEN WORK IS READY FOR INSPECTION Permit is Good for One Year From Date of Issue