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EP-2146 The Commonwealth o 'Ma rsachuretts= — � __ =/ Department of Industrial'� � ? Zoikrisaiffigis `- =, ?;; 600 OfffCWQs Washington Street ''tea-may_,;.: Boston,Mass, OZI II Workers' Compensation Insurance Affidavit ,LAy.pli=rr in Ormarront- ;?.__--�=- - _s::`� �:4I-. ar<^- . _•- ------- Tom• IOC_:•^^• ,G- (--0- <s'--(1 r - ,( %rc-c- L. , 6L,= 7 X / E I am a homeowner performing ail work myself. n 2' I am a sole proprietor and have no one working in any capacity . i am an employer providing workers' compensation for my empioyees working on this job. - maanv name: 6_, 1/4 address: gjr.. ti) _ ehane-0: 4/ — 7 -5- ,6 insurance co. I am a sole proprietor. generai cnntractir. or bo:=owner(carte one) and have hied the contractors listed below wh,= the roilow•ing workers' compensation poiices: Company name: address: yl cin•! nhone•d--) insrr-nce co. AY co �on� name: .,, ‘ . address: • city! nhone•d:- jns!rance^-o• Attzen Sddidoiiii heetiftreeii—ar-- - ---• :.._ --:` --7- -_ Failure to secure coverage ss reauirea under Secnon:SA of MMGL ISZ can Imo to the imposition of crinnnai penammof a tine up to SI=00.00 anc one ears imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a tiaeofSI00.00 a da coon of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification y against me. I understand the I do hereby cerrin•under "e pains an •penalties of perjury that the inforn=ion provided above is sate and cone . Sire ! ��-.12 ' . ' p.:_: name 5d ff'I/ Phoned `/e/- 7,- 5 . otTicsai use onto do not waste in this area to be completed by city or town official city or town: permit/license t# r-tBudding Department _ :neck if immediate response is required [(Licensing Board CSeiectmen's Office contsc: r [Health Department e son: 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 two or the foregoing engaged in a joint enterprise, and including the legal representatiti 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 grounds or building appurtenant thereto shall not because of such employment be deemed to be an empic: MMtGL chapter 152 section 25 also states that every state or local Iicensing agency shaII 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 enmpliance With the insurance coverage required. Additionally, neither the commonwealthnor 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 chante. been presented to the contracting authority. F'.cr ..::_-,.-s:.:.tt_.a.�i i1£`--' '7e.S: as,,,Y=x.+.p=Pt.:..�-�;r�n.,�. _ _ �pp;icants _ _. .. _Y,.: Please fiii 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 Iicense is being requested. not the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are recu:r: to obtain a workers' compensation policy, please call the Department at the number listed below. r-f:'!�i. "•k•.s tee.__... _ - - • _ _ - City or Towns Please Oe sure that-the-affidavit is complete and printed ie_ibiy. The Department has prov idedeispace at the borc re the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant. 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 Oft:.. of Investigations would Iike to thank you in advance for you cooperation and should you have any quest:: please eo not hesitate to give us a call. • 1The Department's address. telephone and fax number: J The Commonwealth Of Massachusetts • Department of Industrial Accidents Office of Investigations 600 Washington Street Boston. Ma. 02111 fax R: (617) '27-;7 49 . nhnne j- (617) '7:---19(10 eTt_ .:flSS 1no „r COMMONWEALTH OF MASSACHUSETTS DIVISION OF REGISTRATION AS A REGOF FOEL ICIANS \;I EP/ ELECTR ICI IS HL { E TO PAUL M B1A 1 *17 102 PERRY `T CENTRAL FAY. ; 863-191 34805 E 07/31/98 992898 LICENSE NO. I EXPIRATION DATE I SERIAL NO. ( 4 _- \• 1 milmonimmownrI TOWN OF DARTMOUTH .‘'"''.- ' BUILDING RECEIPTS NO TAX ISSUES COLLECTORS OFFICE Name -, :,. Property Date: 1, ill . '., ,`, `' Owner: - 2 ,-- . Job Location: ` White Copy-Collector's Office Plot: Lot: ' ' Yellow Copy-Customer's Receipt Pink Copy-File Copy Green Copy-Building Department Phone: k Description General Ledger#'s O iT �cc*. F C Amount License&Permits-Building 01000-44105 IOC on l D91 License&Permits-Building Misc. 01000 44105 5 i 1i License&Permits Electrical 01000-44106 ` `' - : Fri License&Permits-Plwnbing&Gas 01000-44107, Other Department Revenue 01000-42420 �; ,' � f This is not a Permit or License for Building,Plumbing or Gas Received By: r 'r ° - --- -t The Commonwealth of Massachusetts Permit No. ._ Occupancy&Fee Checked `�_ Department of Public Safety (leave blank) _I f- • BOARD OF FIRE 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 CMRR�12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date —��/_ 7 The undersigned applies for a permit to perform the electrical work describedi� below. Location (Street& Number) ,� 7 S ti 8a Vtc 0, UU11.ITh 0firm o j7ti , M A 0 7 y 7 Owner or Tenant 'gut 6_ P. !C us y v Owner's Address S 4 rn P !/ Is this permit in conjunction with a building permit: Yes Zi No Er (Check Appropriate Box) Purpose of Building o (fo r ro c . —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 / Location and Nitere ;-sf Proposed Electrical Work IA /JU& .4/J1/h//1i AO- 7 No. of Lighting Outlets No. of Hot Tubs Total gh g No. of Transformers KVA- �_ No. of Lighting Fixtures Switiu.,:► Pool Above b ve , grad. ❑ 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 No.of Ranges No. of Air Cond. Total No. of Detection and g Tons Initiating Devices No. of Disposals No. of Pumps Tons Total 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 ❑ ConncciPion ❑ Other No. of Water Heaters KW No. of No. of Low Voltage -- _ - ___ ____ Signs Ballasts Wiring No. Hydro Massage T-ubs `o. of Motors ;Total HP -OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policx_incluft Completed Operations Coverage or its substantial equivalent. YES ❑NO 0 I have submi valid proof of same to this office. YES NO Ll If you have checked YES,please indicate the type of coverage by checking the appropriate t INSURANCE 0 BOND 0 OTHER 0 (Please Specify) (expiration Dat Estimated Value of Electrical Work$ 3SF7 Work to Start .5--.?0 "17 Inspection Date Requested: Rough Final - l 7- Signed under the penalties of perjury: FIRM NAME ''�� LIC. NO. Licensee T*i. - "eX� Signature -r•--' -� /1 1G�. LIC NO: 7 s Bus. Tel. No. 4 / -7a�.-S3R'c 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 require( M achusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) �S Telephone No. • PERMIT FEE $ i Srenature or Ow er orr gent) y h H I I I� II 1 L I__ I __ _--1 11 —-L __ ;� ina 3 C� ct ti .;..0F. --, ! 'JI l� to i ,Z I - - ...:j cr. I cs2 a1 o © t:) C C O I . ` ` o OO \ �" 4 a z CZ a II 4 h) .k. Irif if II , ig ii r my . -.1'1 RI ' c l : .....„. .7. 1 . i . :11 t z r E