Loading...
EP-5493 �� _---__-__S The Commonwealth of Massachusetts l o — _y/ui (fib Department of Industrial Accidents (i 1=-�e OJficeof/mrestlgat/oos �;r-It. i_,_ 600 Washington Street e4. � '~ Boston,Mass. 02111 Workers' Compensation Insurance Affidavit name: location: ci phone# I am a homeowner performing all work myself. LI I am a sole proprietor and have no one working in any capacity n I am an employer providing workers' compensation for my employees working on this job. company name fry-- S L- — Pi '7-7 .4s;)` (A-/. address f city: A L"—'l e 71'ZY ) phone#: ?' 93 `7"1 ?/ insurance co. L 7�fl Al 4 174-1---" poiicv# IV C_ 93 7l )oO'L1 0 I at!,a s- 'e proprietor,general contractor,or homeowner(circle one)and ha•.:hired the contractors listed below who have the following workers'compensation polices: company name: address:. city phone#: insurance co: policy# , company name: address: city: phone#: _ insurance cos policy#... Failure to secure coverage as required under Section 25A of MG L 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. do hereby certify under the pains and penalties of perjury p�erjury that the information provided above is true and correct. c Signature G �1'�- 1`�// Date 31 /9 � ,a1 Print name ee-t2 L 2i/37d tom/ Phone# ?9) — / 2 7 / official use only do not write in this area to be completteed by city or town official • city or town: permit/license# nBuilding Department Board 0 check if immediate response is required 0Sel ctmen's Office ['Health Department contact person: phone#; QOther _ • (revised 3/95 PIA) • Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their 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 more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the 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 house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. 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 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 compliance with the insurance requirements of this chapter have been presented to the contracting authority. ". s. -- �,r_1.4.�.",' +F �;�r���e*'"f+.n�«�r ,� . dg.s���x 'z��" �,.....,.,...c._a�.�,._._.,_.-.. • � _ .. Applicants _ Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and 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 required to obtain a workers' compensation policy, please call the Department at the number listed below. � //4 /A. may . • ., . .ri�wvfu!srrdve. n�.e�., . . N.,ri... aFu.._ City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, tel nhc;... and Fax :;�� ..- t. -_ _....__. The COmun.:ii.. .-iitliDenartynzqt ^�i ii"1.L��'•'s��_'�i! .:.'... tIL dffice of investigaiieiis 600 Washington Street Boston.Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 TOWN OF DARTMOUTH riq4o.1 -,.., . _....,, BUILDIFFE-CEIPTS COLLECTOR'S OFFICE ._-.' .••, ,•,--:, .,.., 9, it s- . •. , Name: /1 i ( . .4, l''''' Property ..--11 ,-- , ,- ::" I -,' '-'-'" Date: `4 Owner:k. /6 21:.,.i L-- V ft.,...4.;r, L.I,:,„ , i lfr job Location: ,/,,< /7, ' /) iLl /..4.,' // / -.' /- 41' White Copy-Collector's Office Plot: z , t t -7-. Lot: , ., / ''-f Yellow Copy-Customer's Receipt 1' - ' _,,...., e ee" c- Pink Copy-File Copy Green Copy-Building Department Phone: Description General Ledger#'s Ref.# Amount License&Permits-Building 01000-44105 License&Permits-Building Misc. 01000-44105 z'' ,.:' , / License&Permits-Electrical 01000-44106 - i , e e'r,...-, le. e*:" ( ' /el License&Permits-Plumbing&Gas 01000-44107 Other Department Revenue 01000-42420 ,...A ; : / , , i' / This is not a Permit or License for Building,Plumbing or Gas , Received By::•''''NZ, c-'7A 2 A /--1-7 ; / 7 /,---7' (-- ,.....12 - 4- - .&,,, 4,....., ,... (....„„,.4, , # ,,,,„ ._ , r Office Use Only The Commonwealth of Massachusetts_ Permit No . w -_ occupancy&Fee Checked ` -- Department of Public Safety (leave blank) -_ 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 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date ?' - The undersigned applies for a permit to perform the electrical work described below. Location (Street& Number) . S}�41-4-d-4)1-L 6 iv p L I/✓), Owner or Tenant C -1 i(: C t LC LA-if s D T.-ILL— Lil t¢ , I ZE— /uS Owner's Address �--�/ Is this permit in conjunction with a building permit: Yes ❑ No L� (Check Appropriate Box) Purpose of Building 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 Lot. .Eon and Nature of Proposed Electrical Work,__: Ce'i ki-A el--•1-AP 2)/T71A— Ts& 65Z/S 7-7 Al 6--- • 62u-P—O—L— 1-1= — S)4,6s za-- j 517 ( 6hva) No. of Lighting Outlets No. of Hot Tubs Total No. of Transformers KVA No. of Lighting Fixtures Swimming Pool Above In- Generators KVA grnd. ❑ gtnd. ❑ 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 andTons Initiating Devices i. Heat Total Total Tons p KW No. of Disposals No. of Pumps No. of Sounding Devices 1, No. of Dishwashers Space/Area Heating KW No. of Self Contained Detection/Sounding Devices No. of Dryers HeatingDevices KW ❑ Municipal ❑ry Local Connection Other No. of Water Heaters KW No. of No. of Low Voltage I Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws �/� I have a current Liability Insurance Policpluding Completed Operations Coverage or its substantial equivalent. YES 1 NNO 0 I have submit valid proof of same t this office. YES NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate b INSURANCE C BOND 0 OTHER 0 (Please Specify) • 6/i/Q Estimated Value of Electrical Work$ /© 291 ( puatton Date `1 Work to Start Inspection Date Requested: Rough Final Signed under the penalties of perjury: FIRM NAME ` `�`- s —6t-f il---1-71,, �`' /Ai C- J/ LIC. NO. �2-G Licensee 9 Z4 L_ t�/p�U y Signature pet-L.// a.- L//-Q��� �J LIC. NO. I "4 '9 Bus. . No. Address '>? I l-tS U �iI/ S/: A/L-` fiJ r-t9K O Alt. Tel. No. r 7`72 I OWNER'S INSURANCE W ER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one Telephone No. PERMIT FEE S (Signature of Uwner or Agent) cf F 7 ,„. _.___ rc. ,., ... • .._, r, 021 1 4 . . Cr/ � m �i& c ' o 2 > I z CI a i 70 2I o`PN . E , o 3 ci) � , n ` . c C "� z O • m F\N. ------1 — G;-.iJ C ;; . i .1- a g • G