PP-531 COMMONWEALTH OF MASSACHUSETTS
DErAICMENT OF INDUSTRIAL ACC EN S
600 WASHINGTON STREET
James.: Gamoae+: BOSTON, MASSACHUSti i 02111
nor--,ss,one• WORKERS' COMPENSATION INSURANCE AFFIDAVIT
I, TLur Sou2 ci A', 'TS1 Pi Pin . H-eg Tr'n �►
(licensees permi ttee)
with a principal place of business/residence at:
P o. 13ax aGs F1 i t hciven M A O a.-7/
(Cry/State/Zip)
do hereby certify, under the pains and penalties of perjury, that•.
[Q4 am an employer providing the following workers' compensation coverage for my employees working on th
job.
H9rcForck 171&JZ N8OS�
Insurance Company Policy Number
[] I am a sole prop.:erot and have no one working for me.
[ ] I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed b
who have the following workers' compensation insurance policies:
Name of Contractor Insurance Company/Policy Number
Name of Contractor Insurance Company/Policy Number
Name of Contractor - Insurance Company/Policy Number
Q I am a homeowner performing all the work myself.
NOTE: Please be aware that while homeowners who employ persons to do maintenance.construction or repair work of
dwelling of not more than three units in which the homeowner also resides or on the grounds appurtenant thereto are not general
considered to be employers under the Workers' Compensation Act(GL.C. 152,sea. 1(5)),application by a homeowner for a lice
or permit may evidence the legal sums of an employer under the Workers' Compensation Act.
I understand that a copy of this statement will be forwarded to the Department of Industrial Accidents'Office of Insurance for cover
verification and that failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal pal
consisting of a fine of up to S1500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order a
fine of S 100.00 a day against me.
Signed this I ; 16 ' day of S P , 19 '7s
a:04,
Licensee:Permirtet Licensor/Permittor
%MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
DARTMOUTH, MASS. Type of Occupancy-Commercial n Residential E/'
Owners Name 0-Q r r€ Owners Address 'Sq 1V1 A.
Building Location 20 S Ua r'i O q n C. Rd . Date '" Pi /42l t 9 15
New D Renovation n Replacement ❑ Plans Submitted ❑
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P SUB-BSMT.
BASEMENT
1st FLOOR
2nd FLOOR r , 4
3rd FLOOR
4th FLOOR
5th FLOOR
6th FLOOR
7th FLOOR
8th FLOOR
Installing Company Name P. Z,S . PiP;nt % fl-eciri115 Check One: Certificate
Address Po, Box aGs 7 Corp.
City Ff i IPl1gv-f f State M A Zip Code O 3-1 el n Partner
Business Telephone: (39 0 - &' 4 rj_- Firm/Co.
Name of Licensed Plumber or Gasfitter f>r t I u I -0 s 0c..'R Cj
INSURANCE COVERAGE: Check Owe:
I have a current liability insurance policy or its substantial equivalent. Yes LOJ/IQo❑
i If you have checked yes,please indicate the type coverage by checking the appropriate box. ()
!�
A liability insurance policy Other type of indemnity Bond
! OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.General
Laws,and that my signature on this permit application waives this requirement.
Check One:
Owner ❑ Agent ❑
Signature of Owner's Agent
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 the permit issued
for this application will be in compliance with all pertinent provisions of the Massachusetts State Plu • Code and
Chapter 142 of the„General Laws.
B y �`R"/ ,�-c�% Type of License:
�i% � �� / Signature of L ns lumber
Title . .� r.,: �r��fj, er r�7- LIMASTER
C4*/Town f?A,,--0z 7 0 JOURNEYMAN License Number I 09,39
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