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EP 1999 The Commonwealth of Massachusetts . .v -.- -10 —( Department of Industrial Accidents 0 011icaoflansllpaltsas .. _ 600 Washington Street Boston,Mass 02111 �' Workers' Compensation Insurance Affidavit .4,/ilb• r1.i,rllil:m:i;ii,�t:LC.:;:::• ., ,. ..�....,...-. .- ;... _.."'tar=�7a'2 ii;;a;u F...(-7'J1il 1'..__ .. _.. _.___._.--- ... .—_.--.. ...._. ... ...._ name: Jocation: 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. comnanv name: address 'g CC phone#:- - insurance en. noilcv# • ❑ I am a sole proprietor,general contractnr_or homeowner(circle one)and have hired the contractortlisted below who have, the following workers'compensation polices: • eomnanv name:' Address: .— . •. nhone#i . • insnranee cn, nolicv#- V • - - comnanv name: adder nhone#: insaranctt_ -- noiiev#': .. Failure to secure coverage as required under Section 25A of,AIGL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 and/or one Years'imprisonment as wed 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 certify under the pains and penalties of perjuty 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# r Bniiding Department • ['Licensing Board ['check if immediate response is required ['Selectmen's Office ['Health Department contact person: phone#: COther i revlsm 3195 PIM • • G S Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for ti 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 m 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, owner of a dwelling house having not more than three apartments and who resides therein,Ior the occupantg ofyees. the However dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling 1- or on the grounds or building appurtenant thereto shall not because ofsuch employment be deemed to be an empio� 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 been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation anc 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 ing the"law" to obtain a workers' compensation policy, please call the Department at the number listed below.or if you are require City or Towns _ J =t-. _ a� - - Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant PI be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returnee 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 an uestic please do not hesitate to give us a call. y q • , ..'i;;:-, � -.�y. -:i`.rc.-"a.:� �-�:'e�1_ '.~_`ra- -5 ..qq...��r.�r�s__-«qrr___.. � c'r+ .. �.ra,�F _ . - L.ile' 77Cir r. ..:_'Y n'GRa�• _ L^�_ � �;-4�..,t'.,,'...f:�r.....- a-`..µ}'.:..._ � yr.,^,t,. i�'`��;_Y,.. :- Department's address, tat phcr._ and x nti ... ..r, — - _..•.._. __.___.. The Ccim ..L:. ._.ith 1)ermrt-rr=1 . Tadmirizi Office of levesUf7augtgs __ 600 Washington Street Boston.Ma. 02111 fax #: (617) 727-7 749 phone 4: (617) 727-4900 ext. 406. 409 or 375 Office Use Only 4�==,-, The Commonwealth of Massachusetts Permit No. ' _.- __ Occupancy&Fee Checked `rDepartment of Public Safety (leave blank) -Miff BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 /2-7 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK Town of Dartmouth All work to be performed in accordance with the Massachusetts Electrical Code. 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date The undersigned applies for a permit to perform the electricallerica work described below.t , Location (Street & Number) `� © , Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building 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 Loc .lion and Nature of Proposed Electrical Work ' otal No. of Lighting Outlets No. of Hot Tubs KVA � g No. of Transformers KVA No. of Lighting FixturesSwimming Pow ode ❑ d E Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS NO. of Zones Ranges No. of Air Cond. Total No. of Detection and No. of Ran g Tons Initiating Devices Heat Total Total No. of Disposals No. of Pumps Tons KW No. of Sounding Devices . No. of Dishwashers Space/Area Heating KW No. of Self Contained Detection/Sounding Devices No. of Dryers HeatingDevices KW ❑ Municipal ❑ ry �� Connection Other 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 requirements of Massachusetts General Laws I have a current Liability Insurance Polic including Completed Operations Coverage or its substantial equivalent. YES ❑NO ❑ I have submit valid proof of same to this office. YES Li NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate k INSURANCE ❑ BOND ❑ OTHER ❑ (Please Specify) (Expiration Date Estimated Value of Electrical Work$_ Work to Start Inspection Date Requested: Rough Final Signed under the penalties of perjury: n FIRM NAME �/1/�� r LIC. NO. Licensee Signature LIC. NO. Bus. Tel. No. Address Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as requirec Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one i Telephone No. PERMIT FEE S _ (Signature or Owner or Agent) • .F 2V AY .. t ---,tri .o ril v .OF.'14 4 O; • trlilli\ en 3 r rn z xi Cc a ° .-3 ..3 CI r. 12 ti) m i C 0 3 C i Z n c °) c G: �' p 0 i1 \ pt2i 74) `� o ° o 3 .., 155 Z cmq CAS Ico v l y = el '17ifl ♦ !r. C� 'N z