HomeMy WebLinkAboutBuilding Permit #782-11 - 362 OSGOOD STREET 5/20/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:
Date Issued:
IMPORTANT:
must
Date Received
all items on this
MAP NO: '95 PARCELZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
El Two or more family
11 Industrial
9A'lteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
y
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• Identifications Please T�Print Clearly)
OWNER: Name:
Address: t �� c2
CONTRACTOR Name:
Address:
Phone:
X3`7 14 01��
V
Supervisor's Construction License:'` 7 Exp. Date:
p _
Home Improvement License: % �� Exp. Date: / �w
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT- $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F.
Total Project Cost: FEE: $ % D o
Check No.: /D3 </ Receipt No.: vZzll ri e
OTE: Per ns ontractin with unregistered contractors do not have access to the guaranty fund
F - --
- r =;Sr
Sig 'ture�o �agent/Owner<=•'- _ _ - - g�...�_z._._.-.—� -- _ -
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
❑ 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
I
❑ 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
10TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
I all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
'a t the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
u st be submitted with the building application
Doc: Doc.Building permit Revised 2008mi
Plans Submitted ❑ - Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
EPubHe
WERAGE DISPOSAL
❑ Tanning/MassageBody Art ❑ S� ""g Pools ❑ Tobacco Sales ❑Food Packaging/Sales ❑c tank, etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
0
DATE APPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comm
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
COACV.IENTS
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 2008
Location
No. 7,5P2 Date p
r
MOATM TOWN OF NORTH ANDOVER
f �
r A
Certificate of Occupancy $
Cwt� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
I
Check # M
24i 68
Building Inspector
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No. of
Builders License # 58443
Home Construction Reg. # 109288
(T Too
o
00UPLO
(781) 944-1994 (978) 664-2557
"The Areas Oldest and Most Reputable Roofing Company"
P.O. Box 637, North Reading, MA 01864
RO
P"02=
POS MITTEDTO
HONE���
DATES t
`� lv r
STREET %
36 � (✓ CJ� .,cr
JOB NAME
CITY, STATEI/JDVYIP CODE ve r
JOB LOCATION
We hereby submit specifications and estimates for:
l4'J RRip/& Remove all shingle debris from roof & job site with our own di posal truck:
Ud1 layer ❑ 2 layers ❑ 3 layers or more 1 '
Ct� Repair/or Replace any roof decking; not to exceed 50sq. ft. (additional at $1.70 per ft.)
Install 8" aluminum drip-edge/and rake -edge along entire perimeter. Choice of mill kite r brown
Install ICE & WATER underlayment along horizontal ea es, valle s, sidewalls, sky -lights and chimneys
Install premium base sheet underlayment between ro f de d roofing shingles
La+:i Install your choice of Tamko/GAF or IKO Lifetime archit ,ct I 'rof shingles
* See manufacturer warranty policy for more details
,��
�_d// Install new aluminum vent -pipe flange (s)
l�f Chimney (s) -counter-flash and re -step existing flashing
❑ Cut & Install new lead flashing
❑ Continuous Ridge -vent with low profile design, hidden by shingle caps
❑ Soffit -ventilation ❑ Roof louver -vents
❑ Seamless aluminum gutters - custom fabricated at job site by our own gutter machine
❑ Downspouts ❑ Leaf gutter guards
®� Other
pp /4
�tC JaL Gfr1� 1' J 171 t^ �ttt� ` ! 1� J ih1 r
*Please Note: All items in roof attic should be removed or covered due to falling roof particles, at time of roof tear -off
Price includes all items above that are checked only / others may be priced separately upon request.
We jJrnpnse hereby to furnish material and labor - complete in accordance with above specifications, for the sum of:
J` • Total price not including options. dollars ($ % U ).
ayment to be made as follows:
30% deposit required before ordering materials. Balance due in full upon day of completion.
Please make all payments out to Kenneth Duval, mailed to: P.O. Box 637, No. Reading, MA 01864
Late charges of $50 per week for all outstanding bills due upon day of Authorized
completion. Signature
- Accepting proposal means agreeing to the terms of the enclosed binder Note: This proposal may be
cnntrart withrirawn by i is if not nrrantari within riavc
Massachusetts Home Improvement Sample Contract
This form satisfies all basic requirements of the state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard
language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of "A
Massachusetts Consumer Guide to Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the
Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website.
Homeowner Information
Contractor Information
Name
y g Name
L 1 C
LL
{S
/'��
Stl/eet Address (dont use a Post Office Box address)
Co11nt�or_/ Salesperson/ Owner, Namew
�tP C�
r
JK�✓L l� ��—�"
City/Town State Zip Code
B ins (must include a street address)
a -- � 7!-PU
3-7
Daytime Phone Evening Phone
City/Town State Zip Code
M O )&-641
Mailing Address (It different from above)
BusinessfFlione lFederal Employer ID or S.S. Number
ragairea that most borneo
Imvem®t Commaor Reg. Nwnber
Expiretwa date�w
rarre�.titm unb�
. ,W a,roaa"m�r
7lm
—7 3 3 �
g�� �C
The Contractor agrees to do the following work for the Homeowner:
(Describe in det�aaiijl the work to compleetted,,�specifyin�g/ the type, d, and grade of materials to be used, u � add' ' a e .)
O
on
a ems. 1 r
Required Permits - The following building permits are required Proposed Start and Completion Schedule - The following schedule will
and will be secured by the contractor as the homeowners agent: be adhered to unless circumstances beyond the contractor's control arise
(Owners who secure their own permits will be ���,QQ��11 d Li jf
e_
excluded from the Guaranty Fund provisions of a71gDate when contractor will begin contracted work.
MGL chapter 142A.)I V ° �f
Date when contracted work will be substantially completed
Total Contract Price and Payment Schedule
The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of:
Payments will be made according to the following schedule:
upon signing contract (not to exceed 1/3 of the totalcontractcontra/ct price 9S the cost of special order items, whichever is greater)
by _/_/_ or upon completion of W /� S 1-7
by _/_/_ or upon completion of
upon completion of the contract. (Law forbids demanding full payment until 1contract //is completed to both party's satisfaction)
The following material/equipment must be special $ to be paid for
ordered before the contracted work begins in order
to meet the completion schedule.(**) $ to be paid for
NOTES: (*) Including all finance charges (**) law requires that any deposit or down -payment required by the contractor before work begins may
not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of any special equipment or custom made material
which must be special ordered in advance to meet the completion schedule.
Express Warranty - is an express warranty beine provided by the contractor? ❑ No MYes (alt terms of the warranty must be attached to the contract)
Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third
party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for
materials and labor under this aereement
Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the
contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices
carefully before signing this contract.
• Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear.
• Make sure the contractor has a valid Home Improvement Contractor Reeistration. The law requires most home improvement contractors and
subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor
registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757.
• Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to
see a copy of a "proof of insurance" document.
• Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer
Guide to the Home Improvement Contractor Law.
You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the
contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the
third business day following the signing of this agreement. Seethe attached notice of cancellation form for an explanation of this right.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM
Two identical copies of the contract mast be completed and signed. One copy should go to the homeowner. The other copy should be kept by the cco m nctoorr.. ,(
cowner's Si lure ontractor's Signature
Date Date
Contractor Arbitration
The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an
alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a
n..
contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless
both parties agree to the optional clause provided below. This clause would give the contractor the same right to
arbitration as is afforded to the homeowner by the Home Improvement Contractor Law.
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute
concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by
the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required
to subm' o such arbitration as provided In assachusetts General Laws, chapter 142A.
c
H eowner's figna aContractor's Signature
TICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute
resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this
section is not separately signed by the parties.
Homeowner's Rights
A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer
protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, homeowners
may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law.
Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of
the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a
timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor
guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties
provided by the contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for
a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be
added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have
questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below).
Execution of Contract
The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced
documents have been attached. Parties are also advised not to sign the document until all blank sections have been
filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to
be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing
and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of
the contract, and the three day rescission period has expired.
Accelerated Payments
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the
homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself
to be financially insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the
signatures of both parties.
Additional Information
If you have general questions or need additional information about the Home Improvement Contractor Law or other
consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement"
contact:
Consumer Information Hotline
Office of Consumer Affairs and Business Regulation
10 Park Plaza, Room 5170, Boston, MA 02116
617-973-8787, 888-283-3757 or visit the OCABR website at http://www.mass. gov/ocabr/
If you want to verify the registration of a contractor or if you have questions or need additional information specifically
about the contractor registration component of the Home Improvement Contractor Law, contact:
Director of Home Improvement Contractor Registration
Office of Consumer Affairs and Business Regulation
10 Park Plaza, Room 5170, Boston, MA 02116
617-973-8787, 888-283-3757 or visit the HIC website at http://www.mass.pov/ocabr/
Go online to view the status of a Home Improvement Contractor's Registration:
http://db. state.ma.us/homeimprovement/licenseelist. asp
For assistance with informal mediation of disputes or to register formal complaints against a business, call:
Consumer Complaint Section
Office of the Attorney General
617-727-8400
AND/OR
Better Business Bureau
508-652-4800, 508-755-2548 or 413-734-3114
vmi"a 2.1-11/22/2010
m
- Massachusetts - Department of Public Safeth
Board of Building.r
Rc�ulations and Standards
Construction Supervisor License
License: CS 58443
Restricted to: 00
KENNETH P DUVAL
PO BOX 190/72 NORTH ST
N READING, MA 01864
c
J �s Expiration: 12/10/2011
< unnnissi1O�" Tr#: 10475
Office of Consumer Affairs & B siness Regulation
HOME IMPROVEMENT CONTRACTOR
Registration:,rt167338 Type:
Expiration: b/16/2012 LLC
D AL R00FINGtLL-G
KENNETH DUVAL
72 NORTH ST
NO. READING. MA
Undersecretary
NOTICE
TO
EMPLOYEES
NOTICE
TO
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 — http://www.mass.gov/dia,
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that
I (we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
THE TRAVELERS INSURANCE COMPANIES
NAME OF INSURANCE COMPANY
P.O. BOX 1 450
MIDDLEBORO, MA 02344-1450
ADDRESS OF INSURANCE COMPANY
(7PJUB-023ON91 -9-11
POLICY NUMBER
GILBERT INS AGCY
137 MAIN ST
03-11-11 TO 03-11-12
EFFECTIVE DATES
READING MA 01 867
NAME OF INSURANCE AGENT ADDRESS PHONE #
DUVAL ROOFING LLC 184 PARK STREET
K
NORTH READING
MA 01 864
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY)
MEDICAL TREATMENT
DATE
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment . to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably
connected to the workrelated injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL
ADDRESS
TO BE POSTED BY EMPLOYER
001638 W20P1G02
-- www.mass.gov/dia
Workers5 Compensation Insurance Affidavit: Builders/Contractot-S/ElectriciaDs/Plumbers
Applicant Information Please Plint Legibly
Nalne (Business/Organization/Individual): Duval Roofing, LLC
Address: KI
PO Box 637
01'864
Uty/State/Zip:
Phone #:
Are
an employer? Check the appropriate box:
1 . a e_mnloyer fix,' h _ 4. (ul 1 am a general conh-arter and 1
/�.tt an _alt ) � have hired the sub-contr=ct ':S
e;,,p v^yeeS �cu,t a„w�c Kaci-iiriccJ. ..
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required-]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
*Anv annl�r nt t1. )—i t.-,. — _
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.1
S. We are a corporation and its
officers have exercised their
right of exemption per MGL
C. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required]
`7'
Type of project (required):
6. n New construction
7. ❑ Remodeling
8. El Demolition
9. D Building addition
10.0 Electrical repairs or additions
11.0 Plumbing repairs or additions
12. Roof repairs
13.0 Other
- - --
.-.-.0 J1 uctuw snowing tnetr workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box mull attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
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 #.ar Self -ins. Lic. 8:_.ntioi'Da te:
3ob.Site Adihes� City/State/Zip;
Attach a copy of the workers'compensa ion policy declaration page (Showbig the p6licy nuniber'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 cern -und/er the pains and penalties of perjury that the information provided above is true and correct.
C_
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
"101
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: pr,— 44
The Commonwealth of Massa chusetts
Department of Industrial Acez'dents
t '' = -
Office of Investigations
Washin ion Street
Boston, NLA 02111
-- www.mass.gov/dia
Workers5 Compensation Insurance Affidavit: Builders/Contractot-S/ElectriciaDs/Plumbers
Applicant Information Please Plint Legibly
Nalne (Business/Organization/Individual): Duval Roofing, LLC
Address: KI
PO Box 637
01'864
Uty/State/Zip:
Phone #:
Are
an employer? Check the appropriate box:
1 . a e_mnloyer fix,' h _ 4. (ul 1 am a general conh-arter and 1
/�.tt an _alt ) � have hired the sub-contr=ct ':S
e;,,p v^yeeS �cu,t a„w�c Kaci-iiriccJ. ..
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required-]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
*Anv annl�r nt t1. )—i t.-,. — _
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.1
S. We are a corporation and its
officers have exercised their
right of exemption per MGL
C. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required]
`7'
Type of project (required):
6. n New construction
7. ❑ Remodeling
8. El Demolition
9. D Building addition
10.0 Electrical repairs or additions
11.0 Plumbing repairs or additions
12. Roof repairs
13.0 Other
- - --
.-.-.0 J1 uctuw snowing tnetr workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box mull attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
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 #.ar Self -ins. Lic. 8:_.ntioi'Da te:
3ob.Site Adihes� City/State/Zip;
Attach a copy of the workers'compensa ion policy declaration page (Showbig the p6licy nuniber'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 cern -und/er the pains and penalties of perjury that the information provided above is true and correct.
C_
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
"101
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: pr,— 44
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 1 S2, §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-contractor(s) name(s), address(es) and phone numbers) along with their certificate(s).-of
insurance. Limited Liability Companies (LLC) or Limited Liability Par nerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP doeshave-
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confu-oration 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 olit in the event the Of ice. of l.nvestigati.ons 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.. 7n addition an applicant
that niust submit mti11iple.penniU]icense applicatrons,in any:given .year, need.o.rily.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 maybe 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 burn 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 Investigafions
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE
Fax # 617-727-7749
Revised 4-24-07
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