GP-4107 " The Commonwealth of3farsachuretts
t_ department of industrial Accidents
a Otflc:ol sandssilloDs
600 Washington Street
`,_;- ' Boston,Mars. 02111
Workers' Compensation Insurance Affidavit
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e ire e., D/1OL s PL16 Co.
Ei am a homeowner performing all work myself. � rhone ,`��' � �
rgi 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.
comeatn• name: • •
address:
fit.`..
none i#r
insurance co.
noficY
L . I ain a sole pr'1DrIt or general cnt ractJr. or homeowner(circle one) and hive hired the contractors listedbebelow•r.�
the :3iIo wing workers' compensation polices:
comeanv name:
address:
cin•7
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cc."2,r.v ,amen
address!
Girt.7
jetene*
insurance co. .
•Cr.id di � � ' roiie+if:'
ail-Riff _.
Fati ur a :a secure coverage as required under Secnon 25A of IMGL 152 can lend to the imposition of crrmstul aities o t
.00
one ears :mprtsonment as well as civil penalties in the form of a STOP WORK ORDER and a fine ofS100.00 a day aga nst me. I uadersrandc
cony of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do .^erect cerrir"z•under the pains and penalties of perfurr that the information provided above is trace and correi.
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ot3iaai use only do nor write in this area to be completed by city or town official
,. ctty or town:
permitllIceose# rr8uiiding Department
_ :neck if immediate response is required CLicensing$oard
CSeiecrmen's Office
:er:ac: Gerson: CHeaitb Department
phones;
^Other
•
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation fc:
empioyees. 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 vo or
the fore_oing engaged in a joint enterprise, and including the legal representatives of a deceased employer. or:he
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 aparrments 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 dweilin=
or on the _rounds or building appurtenant thereto shall not because of such employment be deemed to be an empi
---- MCIL =hate -e^ A..�:.._ �e also section also states-hat ery-sttlite-or-o-cai licensing agency Shall withhold the issuance a
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 Ivith 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 compiiance wit': the insurance requirements of this cap:
been presented to the contracting authority.
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\ppiicants - r — - =
pllease fill in the workers' compensation affidavit completely, by checking the box that applies to your situation a
supplying company names. address and phone numbers as ail 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 tc, the city or town that the appiication forpermit c.. -. � or license is being requested.
nor :ne Depam;,ent of Industrial Accidents. Should y ou have any questions re^arcing the "law- or if-
you are red::
= a workers' compensation policy, please call the Department atbelow.
i1� number :ISIeC
City or Towns --
Pease be sure that the affidavit is complete and printed legibly. The Department ;,
. affidavit � ,,.. �. . ,as proyia"ec��_��ce at the .c�
it for you to fill out in the event the Office of investigations has to contact you regarding :he ap:iicant.
sure :o fill in the per;nit'license number which will be used as a reference number. The affidavits may be
:he 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 cues
L'iease _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 =: (61 i -7749
phone -. (617 -2--4900 ext. 406. =lla or 7-5
''' IV!ASACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING I. P
DARTMOUTH, MASS. Type of Occupancy-Commercial Residential xi
Owners Name 2€ iN 6,Tui. A Owners Address
Building Location 4'2-- .5 L.) IV b A W C e Date Oct, cad 7� l 77 7
New FA Renovation n Replacement Plans Submitted
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BASEMENT
1st FLOOR / 1
2nd FLOOR
3rd FLOOR
4th FLOOR
5th FLOOR
6th FLOOR
7th FLOOR N
8th FLOOR _
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Installing Company Name PAL)A. S Pi Er• Co, Check One: Certificate
?- Address 713 Cc re. N Sr n Corp.
CitySO 7ilie r S e T State iYI Zip Code 6 a. 74' n Partner
Business Telephone: .5' f C7?- 3 3 7 NI Firm/Co. _
Name of Licensed Plumber or Gasfitter PAO L Le v e S Q? W e _
INSURANCE COVERAGE: Check One:
I have a current liability insurance policy or its substantial equivalent. Yes X No ❑
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 n this pe it application waives this requirement.
Check One:
G'�` Vs- Owner Xt 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 Plumbing Code and
Chapter 142 of the General Laws.
B y Type of License: deiv--,
Si ture oPPLicensed Plumber r Gasfitter
Title ❑ MASTER
City/Town A JOURNEYMAN License Number /-C1 cL 6
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