HomeMy WebLinkAboutBuilding Permit #780 - 25 DUDLEY STREET 6/3/2010Permit NO:!
Date Issued: (/J r
LOCA
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
IMPORTANT: A
Sf
Date Received
must complete all items on this
Aj�, Print a4 AW
PROPERTY OWNER`
Print
MAP 210 PARCEL: ZONING DISTRICT: Historic District
!Machine Shop Vl
yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
emo replacement
Assessory Bldg
Others:
Demo ition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
OWNER: Nam
Address:
CONTRACTOR Ni
UtbL;KIF i FUN ter UKK TO BE PREFORMED:
�C&ee ��
Please Type or Print
ON
)1
c� Phone: 6 J- z /
hone:
(A
Supervisor's Construction License: C23 &ko 3 Exp. Date:
Home Improvement License: // 7 S Exp. Date:: d I 12-011)
11)
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ % 7' i/ZV FEE: $
Check No.: ��Receipt No.:��y
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fun
Signature of Agent/Owner Signature of contractor
Location C;�ry ` S
No. Date
TOWN OF NORTH ANDOVER
9
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2 3
Building Inspector
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales
Private (septic tank, etc.
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed
COMMENTS
.HEALTH
0
COMMENTS
a-
�\A
Reviewed on Signature
I
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work Al �
❑ Engineering Affidavits for Engineered products �-
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Building Permit Revised 2008
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Date..
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that............ J--
........................ 4 .......................................................
has permission to perform ...... 41rA ev�... . ..... ......
wiring in the building of .........S.L./ -'?`, z ......................................................
at .......... ........ ......... 5,7 .......... No h Andover, Mass.
'7
Fee.��—� ... Lic. No/Z. �le ......... '. eze
LCGTRICAL 1NSPHCTOR
Check # ':;00 bl
9U63
Commonwealth of Massachusetts
Department of Fire Services
Official Use Only
Permit No. --
BOARD OF FIRE PREVENTION REGULATIONS
�.
Occupancy and Fee Checked
[Rev. 1/07] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINTININK OR TYPE ALL INFOWATIOA9 Date:
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) ZS-
Owner or Tenant rvd E (. X49.. Y en .. ) J (i 1^
Owner's Address -SIC
Telephone No.
Is this permit in conjunction with a building permit?
- -_
Yes No
� ❑ (Check Appropriate Box)
Purpose of Building$' / ,a
Utility Authorization No.
(n
Existing Service _ tips) Amps I /:7->, Volts
Overhead
Undgrd ❑
No. of Meters
New Service c2v n_ Amps j 14) /n16 Volts
Overhead E9/
Und rd
g ❑
No. of Meters �1
Number of Feeders and Ampacity
Totals:
- _......_._......_ ._....._...........
_
Location and Nature of Proposed Electrical Work:
Hous t-, g 1JUa -fi Ii J, - nn
No. of Recessed Luminaires
No. of Luminaire Outlets
No. of Luminaires
— No, of Receptacle Outlets
No. of Switches
No. of Ranges
No. of Waste Disposers
No. of Dishwashers
No. of Dryers
No. of Water KW
Heaters
No. Hydromassage Bathtubs
OTHER:
the
o. of Ceil.-Susp. (Paddle) Fans
No. of Hot Tubs
Heating Appliances KW
No.. of o. of
Signs Ballasts .
No. of Motors Total HP
table may be waived by the
i ranstormers KVA .
Generators KVA
o.
of Emergency.Lighting
❑
Battery Units
FIRE ALARMS No. of Zones
No.. of- Detection and
Initiating Devices 7r
No. of Alerting Devices
Local
❑ iviumctpal
rann,I ❑ Omer
No. of
Data Wiri
No. of
No. of Devices or
Wires.
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: Q (When required by municipal policy.)
Work to Start: / 0 j n �j Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cove a ism force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ n(Spec
I certify, under the pains andpenalties o )
_ P � ofperjury, that t e information on this application is true and complete -
FIRM NAME: � � +�-
LIC. NO.:
Licensee: �!`��,t Signat a r -
(If applicable, enter"exempt " in the license number line.) LIC. NO.:
Address: P Bus. Tel. No7�i'
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. L cl. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE. $
Swimming Pool `°'Dove E-li
rnd. 1
d.
3 O
No. of Oil Burners
14
No, of Gas Burners
No. of Air Cond. Total
Tons
Heat Pump
Number ons
Totals:
- _......_._......_ ._....._...........
Space/Area Heating KW
Heating Appliances KW
No.. of o. of
Signs Ballasts .
No. of Motors Total HP
table may be waived by the
i ranstormers KVA .
Generators KVA
o.
of Emergency.Lighting
❑
Battery Units
FIRE ALARMS No. of Zones
No.. of- Detection and
Initiating Devices 7r
No. of Alerting Devices
Local
❑ iviumctpal
rann,I ❑ Omer
No. of
Data Wiri
No. of
No. of Devices or
Wires.
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: Q (When required by municipal policy.)
Work to Start: / 0 j n �j Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cove a ism force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ n(Spec
I certify, under the pains andpenalties o )
_ P � ofperjury, that t e information on this application is true and complete -
FIRM NAME: � � +�-
LIC. NO.:
Licensee: �!`��,t Signat a r -
(If applicable, enter"exempt " in the license number line.) LIC. NO.:
Address: P Bus. Tel. No7�i'
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. L cl. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE. $
_A
t ; www.mass gov/dia .
Workers' Compensation Insitrance Affidavit: Builders/Contractors/Electricians/Plumbers
Aaplicant Information Please Print Legibly
Naii a (Business/organization/Individual): -\,Ti)i ` )Nl1 A/A & r
City/State/Zip:aTj e 2, 1 f - - -
-
Phone #:
Q -2C-121 q7.?�
Are you an employer? Check the appropriate box:
The Commonwealth of Massachusetts
k� 1
w�
Department of Industrial Accidents
r
Office of Investigations
" !
600 Washington Street
Boston, MA 02111
These sub -contractors have
working for me in any capacity,
[No workers' comp. insurance
t ; www.mass gov/dia .
Workers' Compensation Insitrance Affidavit: Builders/Contractors/Electricians/Plumbers
Aaplicant Information Please Print Legibly
Naii a (Business/organization/Individual): -\,Ti)i ` )Nl1 A/A & r
City/State/Zip:aTj e 2, 1 f - - -
-
Phone #:
Q -2C-121 q7.?�
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4, ❑ I am a general contractor and I
,t employees (full and/or part-time).*
2. QI 1: am asole proprietor or
have hired the sub -contractors
listed t
partner-
on the attached sheet
ship and have no employees
These sub -contractors have
working for me in any capacity,
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3. ❑ i am a homeowner doing
officers have exercised their
all work
right of exemption per MGL
myself. [No-worke'rs' comp,
c. 1.52, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required_]
*Aviv 4;... -
Type of project (required):
6. ®'New construction
7. ❑ Remodeling
8. ❑ Demoiition
9, ❑ Building addition
10. ❑ Electrical repairs or additions
11.[I Plumbing repairs or additions
12.❑ Roof repairs
13.0 Other
-- —R � +nusi also nu out the section below showing their workers' oompensation policy infomtatiott
t homeowners who submit this affidavit indicating they are doing all work and then hire outside
xConhactors that check this box must attached an additional shoot showing the trArns of 6, sub -contractors contractors must submit a new affidavit indicating such.
and their workers' comp. policy information.
I am an employer that is.providing workers' compensation insurance,for my employees: Below is the
information. policy and job site .
Insurance Company Name:
Policy # or Self -ins. Lic.
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required. under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500,00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify beat and en es of perjury„that the information provided above is correct,` true and correct,
S1 late`'l • / [J -:J 4
Phone #: `
Of, Jcial use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health Z Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, 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, br the
receiver or tntstee 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, §25C(6) 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, MGL chapter 152, §25C(7) states "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."
Applicants
Please fill out the workers' compensation, affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their
self-insurance license number on the'appropriate line.
City or Town Officials
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 permittlicense number which will be used as a reference number. in addition, an applicant
that must submit multiple permittlicense applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7744
Revised 5-26-05 www.mass.gov/dia
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that– -- .........
may^
has permission to perform. � .?-4-�:�-�.:.. :*.�:? ......
plumbing in the buildings of ..�^-' .-. a�'' ' ............
at ..—,5.... ....... ......... North Andover, Mass.
% (o �' moi- 7
Fee'.... Lu. No........� .,:.... , ..,.� .............. .
y/ PLUMBING INSPECTOR
Check #�"�
8567
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
s�
Owner
New Renovation E] Replacement IN Plans Submitted Yes
FTXTI TR Tc
Date - to
Permit 3
Amount y/
No
(Print or type) /C12Check one:
CertificateInstalling Company NameM
❑ Corp.
Address �� < /91.7�-, X �i fi/a 6 � Partner.
4� <
Business Telephone s" Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner 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 permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts eta lura ing Code and4Chapter 142 of the General Laws.
By: /
kensumner
Type of Plumbing License
Titlei '2q
Cit icense um Der Master Journeyman
,APPROVED (OFFICE USE ONLY
✓4
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of investigations
600 Washington Street
. Ut Boston, AM 02111
www mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeQ><bly
Name (Business/Organization/Individual): S
Address:_ �,/ 0 66> K o?,O (-,-
City/State/Zip: City/State/Zip:
4� Phone #:
comp. tnsurance required.]
'Any applicant that checks box #1 must aisc, t
t Pili out Ehe section be. Cowin_ t} Air w
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11. ® Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
Homeowners who submit this affidavit indicating they are doing all work and then hire utside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees; Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic.
Expiration Date:
j
Job Site Address: A_) City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do h�cer�Wjfft5y,ns andpenalties of perjury that the information provided above is true and correct
Si at — ,/ /O
Date:
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk
6. Other
Contact Person:
4. Electrical Inspector 5. Plumbing Inspector
Phone #:
Are you an employer? Check the appropriate box:
1. ElI am a employer with
4. [:]I am a general contractor and I
employees (full and/or part-time).*
2.,1 I
have hired the sub -contractors
am a sole proprietor or partner-
listed on the attached sheet t
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. tnsurance required.]
'Any applicant that checks box #1 must aisc, t
t Pili out Ehe section be. Cowin_ t} Air w
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11. ® Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
Homeowners who submit this affidavit indicating they are doing all work and then hire utside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees; Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic.
Expiration Date:
j
Job Site Address: A_) City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do h�cer�Wjfft5y,ns andpenalties of perjury that the information provided above is true and correct
Si at — ,/ /O
Date:
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk
6. Other
Contact Person:
4. Electrical Inspector 5. Plumbing Inspector
Phone #:
/, j
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, 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, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or C5
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, MGL chapter 152, §25C(7) states "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."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required Be advised that this affidavit 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 return red to the city or town at the application for the pennait 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. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
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. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE
Fax # 617-72.7-7749
Revised 5-26-05
www.rnass._gov/dia