The URL can be used to link to this page

EP-35690 - The Commonwealth of Massachusetts _ - Department of Industrial Accidents tstlilies of///R sU/iUI/S 600 Washington Street Boston,Mass. 02111 Workers'Com emotion Insurance Affidavit:Buildin lumbinWElectrical Contractors name: addre • city state: zip: phone# • work site location(full address): ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel Ni I am a sole troprietor and have no one workin in an calaci . ❑Buildin Addition ® I am an employer providing workers'compensation for my employees working on this job. company name: address: city: Phone#: insurance co. oli # ❑ 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. ioli # company name: address: city: phone#: insurance co. li # iii�iiioiaiiaiiiiiiii0aaaiaaaiiii/��iiii��, 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$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 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# DBunding Department •. ❑Lfcenshng Board ❑check if immediate response is required ❑Selectmen's Office DHealth Department contact person: phone#; ❑Other (revised Sept.2003) 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. Please supply company name,address and phone numbers along with a certificate of insurance 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. 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 Accident s Snits cfInvestigatieos 600 Washington Street Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext.406 TOWN OF DA TMOUTH 3 5690 BUILDING RECEIPTS A ,� COLLECTOR'S OFFICE , Na'me.a ,z,.,..a-f,,. ! C,,b P a e.. ,, ,„ f 4 Date -- i / Owner: t it ,./ f Job Location: , O ; - ., , ,. ,,�'d `" •� t s ,k 6, , , C�= •te-Copy-Collectors Office Plot Lot ` F ` i ,r,,,� Copy-Customer's Receipt !' \C ii V{.t c"�` op -File Copy c.,GQ0- \ Green Cop -Building Department Phone: f `1 ;% C. e Description General Ledger#'s ef. 1'. �� . Amount License&Permits-Building 01000-44105 -o- - .- -.; License&Permits-Building Misc. 01000-44105 ` 1 j ! r i , License&Permits-Electrical 01000-44106 /�.. -f 1: �_,�` License&Permits-Plumbing&Gas 01000-44107 J Other Department Revenue 01000-42420 This is not a Permit or License for Building,Plumbing or Gas Received By: 1 Commomwea/tI o///lamach.uaelte Official Use Only _ ' -- Permit No. to, = 1 2eparinu3ni oi 3ire Serviceo BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked ,'„`0 Town of Dartmouth [Rev. 11/99] (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: 7f `2 1 ® 4 By this application the undersigned gives notice of his he 'nten` n to orm a electric work described below. Location(Street&Number) Owner or Tenant Telephone No. Owner's Address 75 / Is this permit in conjunction wi buildi permit? Yes - No I (Check Appropriate Box) Purpose of Building / Utility Authorization No. - Existing Service Am / d Volts Overhead Undgrd I I No.of Meters New Service Amps / Volts Overhead I I Undgrd I I No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Te jQ.�r , "(9,6 i( Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans Noansf rmers Total No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above In- No.of Emergency Lighting gmd. gmd. 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 y Initiating Devices No.of Ranges No.of Air C Tons No.of Alerting Devices ti_ No.of Waste Disposers Heat Pump lnber Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating .. , Local Municipal Connection I I Other • No.of Dryers Heating Appliances di KW Security Systems: No.of Devices or Equivalent . No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.orf 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 I I BOND OTHER I I (Specify:) 'j (Expiration Date) Estimated Value of Electrical Work: eeto P: C.- (When required by municipal policy.) Work to Start: �,,/y/4�� Inspections to be requested in accordance with MEC Rule 10,and upon completion. I cert j, under the ' s an pen ti s ofperju , at the information on this application is true and complete. FIRM NAME: © LIC.NO. Licensee: Signs Adz LIC.NO. (If applicable,enter"exempt"in the license number line.)✓ Bus.Tel.No.: `G' 41 Address: 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 I�l owner's agent Owner/Agent Signature Telephone No. PERMIT FEE:$ Plat r7 / Lot CPI - •�-� x * fp * p * p m r -3 z ._ v, v, 0 c) c> 0 rp O 4 P .a `C3 'C3 9 O O A: O 'C3 dN.oF.p, oE 5 z> 5 `" (.° -- c;;% n co 11111111101...1.4 Ly y a \ �fl,a crq �. � lH .a C a ft r. cm as O 0 O O k §. NEI0E'. a. x, 7,- ‘.; rh ,-7 Fr., .P'C ':>13 - t z , . 1116 \,..u\ E. :. -.% .- * * i o m 3 0 CO o y z O , z y 9 3 z cr X y o b cp— sfb FD' FA -crs a -P a k Y (n c„ 2 O 1 y N ti ti so o