EP-935 •
The Commonwealth ° iasrad:user&
ti ; =j2; Deparrnrenr o, 'IndustrialAccideMs
600 Washington Street
Boston,Mass. 02111
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Workers' Compensation Insurance Affidavit
A.p..pti=rrtirttormanom- .._.. -
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[ 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.
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sornronv name: •
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addre r
ztry 2he i�
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insurance co.
sf:
L I am a sole proprtetor. ge ierai cnntrac�o borr.owner(circle one) and have Mie. t=contrartors listed below Wn:
the 'oiiowins workers' compensation polices:
cam:1a11v name:
address: -
tin .
nfroneii-
ins„rcrce co.
voIicv
cornrory name: -
address •
pit~~ ofione*-•
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insurance^_o.
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etticasddidoniisht`eiifrer r--• - .._. ,_..- -- -
Failure :o securecorage as reautrea unaer Secnon 'EA of 11GL 152 can lead to the imposition of ertmsnss penalties of a sloeuup to SI_500.00 an:
one ears imprisonment as well as civil penalties in the forth of a STOP WORK ORDER and a fine ofSI00.00 a day against me. I understand
cony of this statement may be forwarded so the Office of Investigations of the DIA for coverage veriDeation.
1 no hereby rerun•u. • he pa r'1�p- ies of perJurr rhea she information provided above it tree and corrr�.
-77••
Pit:• � • Phone •
otliicsai use oniy do not wrtre in this area to be carepieted by city or town oiMotel
tiny or town:
permit/Ileease t# n8uildiag Department
[tt.icensing Hoard
;neck if immediate response is reauired MSelectmen's Office
[Heaith Department
:ertac: "-son: phone P•
Other
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all empiovers to provide workers' compensation c-
employees. As quoted from the "law", an employee is defined as every person in the service of another under an:
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 -
the foregoing engaged in a joint enterprise, and including the Ie_al representati�es of a deceased employer. or .e
receiver or trustee of an individual , partnership, association or other legal entity, employing employees. Howeve.
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 dweiiin_
or on the _rounds or building appurtenant thereto shall not because of such employment be deemed to be an err.:
MGL chanter 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 nor 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 thischap:.
been presented to the contracting authority.
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pi i can ts
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation an
suppiving 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 dare the affidavit. The
affidavit should be returned to the city or town that the application for the permit or Iicense is being requested.
nor the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are rec.:::
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 Ie_ibly. The Department ent has provide -a:space at :he bc::_n-
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the appiican:.
be sure to fill in the permit/license number which wiIl be used as a reference number. The affidavits may be rerurnt
the Department by mail or FAX unless other arrangements have been made.
The Off:.. of Investigations would like to thank you in advance for you cooperation and should you have any ques:
piedse ..o not hesitate to give us a call.
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Department's address. telephone and fax number:y
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston. Ma. 02111
fax frk (617) 727-7 7 49
phone -. (6I7 —=900 ext. 406. 4U9 or 3'"5
TOWN OF DARTMOUTH
BUILDING RECEIPTS �����
NO TAX
ISSUES COLLECTOR S OFFICE
Name: . f `; < �! Property x t`-i' Date: ,�` ,;�f
k?
f;_ =i` t{ Owner: .` �f
Job Location :'i i, ( /,) ,1 j t._..
C�y •, _ White Copy-Collector's Office
!"' , .-" q,Q`✓ I J f/ Yellow CopyCustomer's Receipt
Plot: r Lot Z 1 /
/ Pink Copy File Copy
�'�tt Green Copy-Building Department
Phone: Ei c
Description General Ledger#'s Ref.# Amount
License&Permits-Building 01000-44105
License&Permits-Building Misc. 01000-44105
License&Permits-Electrical 01000-44106 '~ �r' • r ' _,,
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420
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This is not a Permit or License for Building,Plumbing or Gas Received By: : F `..-64 ---t ' {,- ( "
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!I-_ - - Depuriment Of Pub F x •1 - � (kavebtank)
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR TZh00 I/90
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APPLICATION FOR PERMIT O PERFORM ELECTRICAL WOE
ou
Town of Dartmth
All work to be performed in accordance with the Massachusetts Electrical Code. 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) YDate Ste-'%
The undersigned applies for a permit to perform the electrical work described below
Location (Street&Number) Cv � � (�,q�}�€ f1
Owner or Tenant s,E �1 Op TP ,Z •
Owner's Address ,1/}
Is this permit in conjunction with a building permit: :
t Y rO No ❑ €, ? (Check Appropriate Bo
- Purpose of B Y' . =��-��� � �_ � ,.-
adding °5 ' t
Uality Awhorirauon No
Existing Service Ai, ups /c�� / �`� Volts Z
, OverheadET Undts1grd E -No. of Meters
New Service / Volts Overhead ❑ U 1 a' ndgrd � No. of Meters`_
Number of Feeders and Am. c , _ . > g ,
L
Location and Natere of ' sed Electrical Work f if--- .j. -A- , , '
No. of Lighting Outlets No. of Hot Tubs r' ^Tots!
•.- - -f �� . � �No. of Transformers
No. of Lighting Fixtures Swimming Pool e Q Generators `KVA
No. of Receptacle Outlets
No. of Oil Burners ,� ; ,k No.
Emergency mts Lighting
No. of Switch Outlets No. of Gas Burners ` r. f
- . FIRE ALARMS NO. of Zones
No. of Ranges Total No. of Detection and No. of Air Cond Tons - Initiating Devices
No. of Disposals No. of Heat ,Total Total
Pumps Tons = `KW No. of Sounding Devices
No. of Dishwashers Space/Area Heating KW No. of Self Contained
DetectioNSoundiag Devices
No. of Dryers Heating Devices KW Municipal 0
Local Connection Other
No. of Water Heaters KW No. of - No. oBallff : Low Voltage
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Signs ; ...
Wuia¢ ,
No. Hydro Massage Tubs No. of Motors -
Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General
I have a current Liability Insurance Polic iincludinn Completed Operations CoverageLaws '
valid proof of same to this office. YES NO LL.!! Ifyou have checked YES,please d � v�era' O❑ I have subr
,_,/ � rndacate the type of coverage by checJdng the appropriate
INSURANCE lYJ BOND ❑ OTHER ❑ ease :
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T�1�
Estimated Value of Electrical Work :` ' i „ f (�cpuanon t5
Work to Start - � � � .
Inspection Date Requested: Rough i cc� f A Final
Signed under the penalties of perjury;
Licensee fe/ g i 2r)1( 1 f 1-1 _ Signature J "�� - %!�:►B i LIC. N0�3
►� i LIC. NO `I'3(moo&
Address / Bus. Tel. No
OWNER'S INSURANCE WAIVER: I am aware that the Lar&�does nc covTel.ragNo S'—
Massachusetts General Laws, and that mysignaturenot have the insurance coverage orits substannal equivalent as require
on this permit application waives this requirement. Owner•-Agent (Please check one;
Iggnature of Owner or Agent) Telephone No. PERMIT FEE S
SI\Ns.
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