EP-229-96 The Commonwealth
�* � '�=--;, --sit; •• Department of
o achusettr -
r Accidents
. ..,___ OIlICEO!/ Qds
•r' � - 600 Washington Street
4/ Boston,Mass. 02111
Workers Compensation Insurance
liczitrtinTnrmanon:-=:=_.. - — ease il Aili"itiavit
name: CV c � �7'�✓S = -—
city c // if?1ci ei.-- -
phone'. ' 5 _p 2 c o
I am a homeowner performing all work myself.
s1 am a sole proprietor and have no one working in any capacity -
[ 1 am an employer providing workers' compensation for my employees working on this job.
comoanv name: •
address: .. .. .
es
ciry• .
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insurance co.
Tel am a sole
proprietor, general ^nntractjr.-Or hom.owner(c rcle one)and have hired the contactors listed below whz
the tbilowing workers' compensation polices:
comoanv name: /-7e.-7 --:
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re": / r'u/ as i-
in' ,i .�l tam -. . •
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insurance co.
-
comoanv name:
address:
tiro•• _
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insurance co.
�lttucit id _ - - - -soiie4#_:� -
- naisreefffmct1sar`. �_-- -- 1- -
Failure to secure coverage as requires under Secnon 25A of 1MGL can lad to the imposition , ��- to • �,
152 of criminal peaaities of a fine up SI=00.00 aaa
one+ears' imprisonment as well as civil penalties in the form of a STOP WO*K ORDER and a fine ofS100.00 a dB
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification y against me. I understand tilt;
I do hereby cerrifi•under the pains and penalties of perjury thin the information provided aboveis trste and corrers.
Sisratur- , .. // •
-- — '` �" Date 5����Gs'
Pr'rt ram-
one> )am --O'c�o
;`% official use only
do not write in this area to be completed by city or town official —i
• tiny or town:
permit/license# MOuilding Department
neckif immediate response is required QLiectuing Board
F_ QSeieetmen's Office
QHealth Department
contact person: phone*: Other
Information and Instructions '""„
•
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for:
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 nvo or rn
the foregoing engaged in a joint enterprise, and including the legal representatn•es of a deceased employer. or the
receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However
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
or on the _rounds or building appurtenant thereto shall not because of such employment be deemed to be an-empic:.
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 insnrance cc age--r-e-q-uir.:Ii: -
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.
;:_�,::- ice.c-.-�, �.--- ..,.�-----►-- == - - --
kppiicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation an.:
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 require
:o obtain a workers' clompensation 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 De a•t-rient has pro':'idec-.ascac at_he
the affidavit for-you to fill out in the event the Office of Investigations has to contact You regarding the applicant. Pl:
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be recurred
the Department by mail or FAX unless other arrangements have been made.
The Off:.. of Investigations would Iike to thank you in advance for you cooperation and should you have any questic
please -o not hesitate to give us a call.
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 th4: (617) 727 %49
phone F',4: (617) 27-4900 ext. 406. 409 or 375
TOWN OF DARTMOUTH MI oUTR,M r
�
4?.se PERMIT NO.
a
y� _ No
Date_ -* i
Received From -4 g - 4. --
17
Owner re .1 ��-..Ak e, ... 4r, 11. .. -
Location Iii______, _ L e, ✓„ . �v � .. . _c . f •
a
Type �'%�_tea.. --e._L. ..-,
�- 1 /1 , )
Amount Paid �.r r
,,,,,-- )7
Received Bye.. 0._ 1- ._ e,_ y1
j
Office Use Onl (4,1 ‘„
The Commonwealth of Massachusetts Permit No.
____ Occupancy&Fee Checked
1_1T6 f (leave blank / �lcc
Department of Public Safety
BOARD OF ARE PREVENTION REGULATIONS 527 CMR 12:00 3/90
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 q//U /'1 a
The undersigned applies for a permit to perform the/electrical work described below. I,c)
Location (Street&Number) - 'Z --5�it'1Of c s1 C' c'' ,/, e < it C--33
Owner or Tenant 4 t'ir7 a,,--al 6° lc. •
Owner's Address 4 2 S,z fr-,fie,H C -
Is this permit in conjunction with a building permit: Yes [ No ❑ (Check Appropriate Box)
Purpose of Building ..5/ky/C - /II/ r may- Utility Authorization No.
Existing Service _______Amps_______/ Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service 20c Amps /'O / 2 zG Volts Overhead ❑ Undgrd El No. of Meters /
Number of Feeders and Ampacity 3 w/ 2 d a
Location and Nature of Proposed Electrical Work Gc� I.(�v
/' ` ./ 14- S ez'_v cv'C' tm
No. of Lighting Outlets'' / S No.of Hot Tubs No. of Transformers KVal
No. of Lighting Fixtures . / S Swimming Pool Above ❑ mod. 0 Generators KVA
No. of Receptacle Outlets.•. .f p No. of Oil Burners B. of EUmmerrgency Lighting
ts
No. of Switch Outlets ,.: / 5- No. of Gas Burners FIRE ALARMS NO. of Zones
ta Total No. of Detection and
No. of Ranges No. of Air Cond. Tons Initiating Devices
ToNo. of Disposals No. of Pumps Ton TKWI No. of Sounding Devices
No. of Dishwashers Space/Area Heating KW No. of Self Contained
Detection/Sounding Devices
No. of Dryers Heating Devices KW Local E Conne c on ❑ Other
No. of Water Heaters KW No. of No. of Low Voltage
Signs Ballasts Wiring
-- Fi;. Hydro Massage Tubs_ 1 No.of Motors Total HP i
No
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Liability Insurance Polic mcludin Completed Operations Coverage or its substantial equivalent. YES ❑NO ❑ I have submitt.
valid proof of same to this office. YES LI NO LJ If you have checked YES,please indicate the type of coverage by checking the appropriate be
'"INSURANCE CI BOND El OTHER ❑ (Please Specify) / .19, /,7`/ 1 . C`9
Estimated Value ofjlectrical W rk$ 2SaO '� ao
(Expiration Date
Work to Start "'-t Si / Inspection Date Requested: Rough 1—" ./ ,16 7t 1 1'� Final i /1 Ai d . o
Signed under the penalties of perj
/ l
FIRM NAME 7�t/ Ou/G�l� ��C f i
�� LIC. NO. /--? /S4
Licensee �cT_ i 4 /7 r"e"/-' Signature j�� � � LIC. NO. 26.ee.i-i
j ; Bus. Tel. No.
U;Address _3/ F-/i/wocC// CA, ,�`-Q` /( , �e✓ Alt. Tel. No. lD 7-/ e' 9 o
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required i
Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one)
Telephone No. 6`9-7.)b PERMIT FEE S S'/6
(signature of Owner or Agent)
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