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GP-403 _ : COMMONWEALTH OF MASSACHUSETTS DEI'AIC'MENI' OF INDUSTRIAL ACCIDENTS 600 WASHINGTON STREET • James. Camooei, BOSTON, MASSACHUS.i73 02111 Car;m,ssione• WORKERS' COMPENSATION INSURANCE Al. iDAVIT (I icensee/permi tree) with a principal place of business/residence at: (City/State/Zip) do hereby certify, under the pains and penalties of perjury, that: [J I am an employer providing the following workers' compensation coverage for my employees working on this ,job. Insurance Company Policy Number ic I am a sole prop.ietot and have no one IA 3rkiug for me. [) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below 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 on a dwelling of not more than three units in which the homeowner also resides or on the grounds appurtenant thereto are not generally considered to be employers under the Workers' Compensation Act(GI—C. 152,sea. 1(5)),application by a homeowner for a license or permit may evidence the legal status 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 coverage verification and that failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties 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 and a fine of 5100.00 a day against me. day of Signed this 1-�c Cat u�r � S g � 7 , 19 7 111A- it YV7 Li censee/Permirret Licensor/Permirror tn C) Z . V) g , A •N• C..) P.I7 ik, Ilit' CA € i Cp4 1 %Ili c4 1 3 . II) 74 ! Pk .,.... i 1 P-4 © ! v_ 1 , 'f 1 4 I 1 g kr 1 - - e = 0 0 E-. U 44 E-4 c, Li00 ,s-i.. 'I' c• c.-1 0 ccl 172 c.,4-, V.' :,, ' ,,`) „ ci -: :_:• cc- ,—, z \ o Pet ---,< d ----) Lrr,-, -. 0 -- u N • MU i 11111111 ,6*:':: cl ) z ri 0-, 1:14110111 :. :4. w.4 a• I C..) E-i .r y;_ie .-MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential /1 , / Owners Name ./' �ri�5� ' Owners Address 17 Sci,t '1Ct'- Building Location e de Ud�t Date 1%A-- _ L. P. New Renovation Replacement n Plans Submitted n w w 0 o H x Z d o c4w o � � zH * Z Q Q z o O ►� 1 as v� F" w W O o a a Wrip w "i = _ _ w w Z Q W H A x -== o H z a H Il �, w W O O > w H W a H W W _ w z � Z O E-' Z '..� ¢ w d O O O W W F" x 0 C7 x w 3 Q ( a U w L1 a H O SUB-BSMT. BASEMENT 1st FLOOR 2nd FLOOR j3rd FLOOR 4th FLOOR C 5th FLOOR �� i 6th FLOOR 7th FLOOR 8th FLOOR Installing Company Name cO4/4 G Check One: Certificate Address /5-b /1i S/ 6 ❑ Corp. City 4) '-k--. State /114ri-Zip Code eV 2 n Partner Business Telephone: 7 9 —e eli n Firm/Co. _ Name of Licensed Plumber or Gasfitter -Size INSURANCE COVERAGE: Check O I have a current liability insurance policy or its substantial equivalent. Yes No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. • t 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 Plumbing Code and Chapter 142 of the Gene Laws. B y +'`' / Type of License: C.2ea'( &/.- -. ? Signature of Licensed Plumber or Gasfitter Title `cam -'6,1� =< -1 ASTER / (/ Town iY�i�Zru ❑ JOURNEYMAN License Number /` " '