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Home My WebLink AboutBuilding Permit #9487G - 85 FLAGSHIP DRIVE 8/26/2014Date... .............. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Ze .... ...... This certifies that ................. .. . ..................... ................ .............. has pertnission for gas installation in the buildings of .... T ............... y ............. ........................................ at ...... C67 ........... ............................... . North Andover, Mass. Fee.:w�� .... Lic. NU.. I.L10 . . ................................................ GASINSPECTOR Check # C% 14� C 7 MASSACHUSETTS U NIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK. CITY MA DATE PERMIT JOBSITE ADDRESS OWNER'S NAME G OWNER ADDRESS cl T E z TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT I CLEARLY NEW:E1 RENOVATION: D REPLACEMENT: ER"' PLANS SUBMITTED: YES D NOD APPLIANCES I FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER L:j BOOSTER ED CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR I=. Al FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER LINVENTED ROOM HEATER V*TER HEATER OTHEk-F INSURANCE COVERAG I have a current liability nsurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES EfNO 0 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY B 0 N D f--Jl OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my* signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true a d a u t to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com nce vVith ertine Massachusetts State Plumbing Code and Chapter 142 of t e General Laws. a A (2, ��M— PLUMBER-GASFITTER NAME M—JdAK-�)1- LICENSE# .22, o SIGNATURE MP 0 MGF UJI JP EfJGFF LPGI CORPORATION E]# PARTNERSHIP 0#= LLCEI#= COMPANY NAMEI -CY JADDRESS CITY STATE zip TEL I'L :2 FAX CELL EMAIL -44 A �-4 IL ft w cn < LLI CO CL w w Cl) z 0 rZ a. a_ < t6 Ln di 3: w LL V) w a I The Commonwealth ofMassachusetts Department ofIndustrialAcclilints Office of Investigations 600 Washington Street Boston., MA 02111 wwwmass.gov1d1a Workers' Compensation Insurance Affidavit: Buflders/Contractors/Ele,ctriciansfplumbers Applicant Information Please Print Legibly Name, (Business/Organi-zatioiVJndividual): Address: city/state/zip: Phone #: Are you an employer? Check the appropriate box: - 1. El I am a employer with 0 4. 0 1 am a general contractor and I (fiffl and/or part-time).* have hired the sub -contractors _pjnployees 2. [R I am a sole proprietor or partner- listed on the attached sheet. I ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. El We are a corporation and its required.] officers have exercised their 3111 am a homeowner -doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Typo of project (required): 6. F1 Now construction 7. E] Remodeling 8. F1 Demolition 9. E] Building addition 10.El Electrical repairs or additions 11.[] Plumbing repairs or additions 12.Q Roof repairs 13. [1 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they sire doing all work and then hire outside contractors must submit a now affidavit indicating such. TContractors that check this b ox must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that isproviding workers' compensation insurancefor my employees. Below is thepolicy andjoh site information. Insurance Company Policy # or 8 elf -ins. Lic. Job Site Address: Expiration.Date: Pity/State/Zip: Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requireclunder Section 25A ofMGL o. 152 can lead to the imposition of criminal penalties o ' fa fine up to $1,500.00 and/or on& -year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine ofup 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 certio undqr the .(Q, F-3 4 th at th e information provided ah I v i's true and correct. - n�+w 8 � N ,-//3 Official use only. Do not write in this area, to he com pleted by cl(v or town official City or Town: Permit(License 9 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone de Information and Instruction' -s 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 offilre, - express or implied, oral or written." An emplow�is defined as "an individual, partnership, association, corporation or other legal entity� or any two or more of the foregoing engaged in ajoint enteiprise, 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. I MGL chapter 152, §25C(6) also states that "every state or Ideal 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'Weither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have b cen presented to the contracting authority." Applicants Please fill out the workers, compensation affidavit completely, by checking ffie 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 (LLQ or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If anLT—C orLLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirma�tionof insurance coverage. Also be sure to sign and date'the affidavit. The affidavit should be, retumedto the city or town that thic 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 printedlegibly. 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/lice'nse number which will be used as a reference number. In addition, an applicant that �aiist submit multiple p eimit/licens o applic ations 'M' any given year, need only submit one, affidavit indicating current policy information (ifnecessaty) and under "Job Site Address" the applicant should write "all locations in—(City or town)." A copy ofthe 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 ii on file for Riture permits or licenses. A now 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 ofinvestigations . 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 CommoRwealth of Massachusetts Department offadustidal Accidents Office of jawstigationg 600 Washington Stroa BostQnMA02111 TQJ. # 617-727-4900 at 406 or 1-877,MASS, AFE Revised 5-26-05 Fax# 617-727-7749 'UrTSMIF -'j, No I "" —4") Date . ................ :�'/ TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that .............................................................................................. has permission to perform ....... . ............ ......................................................... wiring in the building of ................................ a ....................... ! ........................... at ....... ................. ............. .... North Andover, Mass. Fee�!�.� ....... ........ Lic. No.'o- -t ............. .......................................... ................... ELECTRicAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Ser*e At (fammunwralt4 of Ifusuditmetto Depwiment of Pub4c Safety BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 F�i Office Use Only perimnif OccupAncy Fee Owdod LP 3/90 Ileave biank) APPLICATION FOR PERMIT- TO PERFORM ELECTRICAL WORK All —k 10 be Wimmed in &ccwdance voth the mm"Kiiiwits Electrical Cuie. S27 CMjt 12:0D (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date City or Town of . �/b D 0 L) L:- rz- To the Inspeciat, of Wi The undersigned appi _-7-W res) li (Or a mit 10 perform the electrical work described below. Location (Street & Number) --- It) 7- L/ t 4 (. S /V I P t? Owner or Tenant ___0 *-k J A, 9- (_ u I L D ki G � 0 C) 6 7 65 7 - 0 Y r Ov�ners. Address 35-5 X-1 i D P t C-- 5, V rt U Cz W I L A-4 CD 70 44 -7 A-1 /9 0/ ?1 Is this -permit in conjunction with a building permit: YeSU No LJ (Check Appropriate Box) Purpose of Building —Utility Authorization No. -0(-.790 Existing Service Amps Vohs Overhead El Undgrd No. of Meters New Service 2_0 ()Amps 0-0 "D Volts Overhead 11 Undgrd No. of Meters Number of Feeders and Ampactry Location and Nature Of Proposed bectrical Work 6 M P L) No. of Lighting Outlets TOTAL No. of Hot Tubs No. of Transformers KVA 'No. of Lighting Fixtures Swimming Pool Above In. jtrnd. gmd. Generators KVA No. of Emergency Lighting No. of Reciewle Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners ra FIRE ALARMS No. of Zores No. of Ranges No. of Air Conditioners Tons No. of Detection and Initiating Devices Heat Total Tow No. of Sounding Devim, No. of Dispmals No. Of Pumps Tons KW No. of Sel(Contained No. of Dishwashers SpacelArea Heating KW DeNction5oundini; Devices M No. of Dryers —Heating Devices KW LocalD Conunnection Other No. 01 No. of Voltage No. of Water Heale . fs KW Signs Ballasts Wiring No. ro massage Tubs No. of Motors Total HP OTHER: NSURANCE COVERAGE: Pursuant to the requiremerits of Mas usttes General Uws I have a current Liability insurance Policy including Completed Operations Coverage or its substantial equivalent. YES 0 NO 0 1 have submitted valid proof uf same to this office. YES 0 NO IJ It you have checked YES, please indicate the type of coverage by checking the appropriate box. r'rV INSURANCE BOND 11 OTHERD (Please Specify) (Expiration DaW Estimated Value of Electrical Work S Work to Start Inspection Date Requested: Rough Final Signed under the penalties of perjury: FIRM NAME 1/1 M-0 11- 1E_ rZ C_�- 21 tc_ C, LIC. NO. -7 3 -3 Licensee Ao r4o Ai Y #Yuq G iLe Si nare LIC. NO. Address . _(05' /4 L) C,Q 2, 1.) U �J t T_ 1' A V 141 L L- 4 r) Bus. Tel. No.,q;f -->7,L- 5Z 7 7 AIL Tel. No. OWNER'$ INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusm General Laws, and that my signature on this permit application waives this requirement. 0wner Agent (Please check one) Date. 4023 TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING This certifies that ....... has permission to perform"ef, Z,- ................. plumbin �in th buildings of ..... )W;-� ... at. —AP .. ..... ......... .......... North Andover, I'as FJ4.....Lic. oA7A ..... . ......... ?--i-7-:-vPLUMBING 11164ECTOR 05/12/99 11:18 83-00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer n�� 'MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING - (Print or Type) IV, AIVPWt�4< Mass. Date j�& 19 q9 Permit -14 Building Location Ownees Name, L,tl RC744A /C/-��I,�/2ik2��Z2Ae6M-Occupan New 0 Renovation 0 ReplacementX Plans Submitted: Ye64q/ No 0 FIXTURES t. - -IR Installing Company Name A �SL6"I—vz- Address ?�o Business T Name of Licensed Plumber Check one: - Certificate 0 Corporation • Partnership • 'Firm/Co. INSURANCE COVERAGE: I have a curreWflability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No 0 If you have;)h%ec ed Yes, please indicate the type coverage by checking the appropriate box A liability insurance policy Other type of Indemnity 0 Bond F-1 OWNER'S INSURANCE WArVER: 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 El Agent C1 S4gnature of Owner or Owner's Agent I hereby cerbty 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 perforrxied under th rmit i - lor this application Y411 be in compliance mfith all ng and Cha 4 f e r I Laws. pertinent provisions of the Massachusetts State Plumbin BY 'Pl6m r Sgnatur�rlcf Linefifted P Title Type of Licen ter Journe Marro City/Town APPPOVED (OFFICE USE ONLY) Ucense Number Iwo IN Installing Company Name A �SL6"I—vz- Address ?�o Business T Name of Licensed Plumber Check one: - Certificate 0 Corporation • Partnership • 'Firm/Co. INSURANCE COVERAGE: I have a curreWflability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No 0 If you have;)h%ec ed Yes, please indicate the type coverage by checking the appropriate box A liability insurance policy Other type of Indemnity 0 Bond F-1 OWNER'S INSURANCE WArVER: 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 El Agent C1 S4gnature of Owner or Owner's Agent I hereby cerbty 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 perforrxied under th rmit i - lor this application Y411 be in compliance mfith all ng and Cha 4 f e r I Laws. pertinent provisions of the Massachusetts State Plumbin BY 'Pl6m r Sgnatur�rlcf Linefifted P Title Type of Licen ter Journe Marro City/Town APPPOVED (OFFICE USE ONLY) Ucense Number Date ..... ��. C7-2 .... 0.9 .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING '4CMU This certifies that . ........ . . .......... ............. has permission toperform--1�1--70- --� ... ................................ 1-3 �?" //- wiring in the building of JS� .................. North Andover, Mass. ........... Fee4l� ........... Lic. No-;-?.q� ..Uz .......... Check # 8232 LOMmonwealth of Massachusetts Official Use On Department of Fire Services Permit No. BOARD OF FIRE PREVENTION R'EG.ULATIONS FOccupancy and Fee Checked I[Rev. -1/07] APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the MassachuseM Electrical Code (hI 527 CMR 12.00 (PLEASE PPWflVNK0P, YYPE ALL E&ORAMTJON). Date: .City or Town of. NORTH ANDOVER -To the Inspector of Wires:. By this application the unders' igned gives notice of perform the electrical work described below. Location (Street & Number) Owner or Tenant Telephone No. Owner'sAddress 'Al Is this permit in colliftuction with a building permit? Yes No (Check Appropriate Box) Purpose of Building C1L1V,,rI Utility Authorization No. E31sting Service Amps Volts Overhead* - - - - - - - New Seryice Amps volts UndgrdO No.'of Meters Overhead Undgrd No. of Meters Number of Feeders and Ampacity Location and NRture of Proposed Electrical Work: CA ec� r CO3 L�j )'A r C_ CL elk 5 -4 No. of Recessed Luminaires Comple on a the floudn le he waived by the � 9E_�Omof ,D!!, evices Local III crip, No. of C -Susp. (Paddle) Fans -Wires. NO. of Total No. of Luminaire Outlets No. of Hot Tubs Transformers KVA N o. of o. Eofater H atj Kw Heaters No. of� Generators KVA No. of Luminaires Swimming PoC!j Abye 'I , -.11111 ''I'll, .... :!! ting I I 1 11 1 1', No. of Receptacie Outlets IL No. of Oil BOXners Battery No. of Switches No. of Devic�s 0-f Equivalent T el eio M—Muw c at-io -ni- y—iring. iFIRE ALARMS INo of Zones OTHER: No. of Devical; No. of Gas Burners -No. of Derecuon ;�d No. of Ranges ]Heat No. of Air Cond. Initiating Devices accordance with MEc Rule 10, and upon completion, 'NSURA,NCE COVERAGE: Unless waived by the owner, Tons _s No. of Alerting Devices No. of Waste D os isp ers P 4�ab�erTo�n KZW11 I— ... INo. of Dis hwashers Space/Area Heating KW ,D!!, evices Local III crip, No. of Dryers 7 Heating App"nees KW 0 ecti n 0 Other OerurltY bYstenI N o. of o. Eofater H atj Kw Heaters No. of� No. of Devi ces or Equivalent Si s Banasft. �'ffi Data Wiring. No. Hydroma ssage Bathtubs No. of Motors Total HP s HP No. of Devic�s 0-f Equivalent T el eio M—Muw c at-io -ni- y—iring. OTHER: No. of Devical; Estimated Value of Electrical Work: CW , ,U Attach additional detail if desired, or as required the ector Of Wires. (When required by Work to Start )L T munic ipal policy.) Inspections tD be requested in accordance with MEc Rule 10, and upon completion, 'NSURA,NCE COVERAGE: Unless waived by the owner, no Permit for the performance of el the fir-ensee Provides proof of liability insurance including -1 ectrical work may issue unless completed operation" coverage or its substantial equivalent The undersigned certifies that such covem ge is in force, and has. exhibited proof of same to the Permit issuing office.. CHECK ONE: INSURANCE I cerd e 2'."BOND 7 OTHER EI (Specify:) .fy, under th ndpenaldes ofperjury, dwt the inform adon on MiT FIRM NAMEE: rc r aPpficadon is true and compkta 'a,, C�s L Licensee: 1JC. NO. - Signature (If applicabl e, enter 11 e:��empt " in the license number lin — LIC.NO.: 3Q.31 il Address: 6S C, tk� -1 J. ri tQ � PAC,- cjkV�5 Bus. Tel. No.:32_1_,n:1 - -1 �S% *Per M.G.L c. 147, s. 57-61, security work requires Depart3ment of public Safety,,Ss— AIL Tel. No.:Sot- 4,q,%�kq -1 OWNER'S INSURANCE WArnR: I am aw 'License: Lic. No. are that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I here by waive this -1 . requirement Owner/Agent I am the (check one) r owner D owner's agent Signature Telephone No. PERWT FEE: S /cZf w 4 AOL N ly 4 �g 11 x P - The Common weakk of Massachusett Department of IndustrW Accidents Office of Investigations 600 Waskinpion Street a Boston, M4 02111 WWW.n=sevv1Wia Worken, Compensation lwh.ranee AffidaviL- Buflders/CentractorrM 501i Mt information ectlicians/Plumbers Nalne (Busi.ness/OTL�anizafionlindividuai): Address:__LS_A_,c-u citystaft/zip: -kkulp-lU� mc" C, Ek�e CA r kr C_ C_ Phonek. Are you an employer? Check the RPPr.oProte box: 1. a mnpioyer with 4. 1 am R genmul contractor and I employees. (full 2. ED I ama.sole propand/or part-time).* rietor. or have himid the st&wntractors listed partner- ship and have no employees on1he attached sheet These stL&contractors have working Ibr me Jn any capacity. [No wodml cOmp. insurancie work=' comp. insurance. 5. We are a Corporation and its required.) I arn a homeowner doing offic= have exercised their all work right of exemption per MGL -myself [No -workers' comp. C. - 152, § 1(4),'and we hav�- no insurance required.) t -employees, [No workers' comp. insurance Type -of Project (required):' 6. New construct ion 7. Remodeling S. Demolition 9. M Buildin * 1 9 addition 10. 0 Electrical rcPairs or additions Plumbing repairs- or addifior. 12.E] koof repairs 13. [1 Other *Any applicant that checks ba # I most also fff ut the :Z�� i section beiew showing their worked' bompenation poiicy m- liumeOW11M Who Submit this eff,&Vit indicidng -they am doing all work and then hire outside con TonnutiotL 4conoactors t6t check this box mustaftchgd 8, Mtin,,d sheersh Motots must submit A new liffidavit indimfiq such. OwiRg. the mun.- of the sub-cortynctom and tii, worke _, camp. policy nfam"on. M am an eMP10Ydr J*9V-iSPrPVjding:WVrkM' contpensadopt insurmcefor nV. agp&yem infornzadon. BeiOw ;S. Me peficy andjuh *e Insurance company PORCY # or Self -ins. Lic. #: Expiration Date: Job Site Address: U. city/stateir, U, (AC, Attach a copy of theworkers' c in PinSlition Policy declaration page (showing the policy Bum Failure to her and expiratinin dqte� "Ocm cOvemge as required under Section 25A of MGL c. 152 can lead to the impositiOT) of cruninal pertaifics of a r fine up to $1,500A andlor one-year imprisonment, as well as civil penalties in the form Of R STOP WDRK ORDER and a fine ay Investigations of the DIA for insurance coverage verification. a e orvar of up to $250.00 11.d against the violaWr. Be advised that a copy of this statement m y b f ded to the Office of I do �X Wy Unaer rhe paim andpenaldes OfPeriurY thid the pro Wded abOve is true and correa Si Date - Phone 4. OUTichd Mse only. Do not write in ama, to be conp&ered by c&y or Own OffCW "ci' e Y * Do no' w City or Town: 'e in I uiiig Autbor;�(cimie 0; e ssuing AuthoritY (cimie one): Permit/License g Department 3. City/Town Clerk 4. -Electrical Inspector S. Plumbing I . nspedor I. Board of Health 2- Buildift 6 601 . Otb&r -tor Contact P Contact Person: Phone#. Information and Instructions Massachusetts General, Laws chapter I S2 requires all employers to provide work=' compensation for their ernployees. Pursuant to this statute, an entployee is defined as "...every person in the servic'e of another under any contract ofbirt, express or implied, oral or written." Am employer is defined as "an individual, partnership, assc>diation, corpora6an or other logal entil:y, or any two or more of-the'forepmig engaged in ajoint enteiprise, and including the lepl representatives of a deceased. employer, or the retL,'vF-.r or trustet-of an individual, partnership, association. or other Ipgal artity, employing =pioyees. 14owever the own6r. of a dwelling house having not more thin three apaxtments and who resides th=in, or the, occupant of the dwelling house of another who employs persons. to do maintenance, construction or repair wdrk on such dwelling house or on the grounds or building appurtenant thereto shaU not b=use of such employment be deemed to be an employer." MOL chapter 152, §25C(6) also states the "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to opamte is business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence -of compliance with the insurance I coverage requimd." Addhionally, MOL chapter I S2, §25C(7) states "Neither the commonwe:aIth nor any of its political subdivisions shall enter into any contract for the performance of public work tintil -acceptable evidence of compliance with the insurance Tequirernents 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-contrados) name(s), address(es) ELind phon.e number(s) along with their certificate(s)'of � insurimce. Limited Liability Companies (LLC) or Limitod Liability Partnerships (LLP) with no employees other then the members or pmtn=, are not required to carry workers' compensation insunince. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavitmay be submitted to the Department of Industrial Accidents for confirrna:tion of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should be returned to the city. ortmn that ffie application for the pem'it or li== is being mquemd, not'the Department of Industrial Accidents. Shoufd you have any questions regarding the law or if you am required to obtain a workws! coMpensation policy, pinse-call the Depart-rient at the number listed below, Self-insured companies should entertheir self-insurancielicame i3umber on ffie' appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department his provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to con= you regarding the applicant. Please be sum to fill in the permit/license nurnber which %vill be used as a mf=erice number. In addition, an applicant that. in ust submit multiple permit/license applications in any given yW, need only submit one affidavit indiading,current policyinformation (if necessary) and under.."Job Site Address" the applicant should.w.rite "all locations in -(City or town)." A eDM ofibe affidavit that has beCi officially stzrriped 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 libenses. Anew affidavit must be filled out each year. Wham a home owner or citizen is obtaining a license or permit not related to any bus;iness or commercial venture (i.e. a dog license of permit to bum leaves etc.) said pers6n is NOT required to. complete this affidavit. 71it Offica of Investiptions would lik-e to fl=k you in advance for Your cooperation and should you have any questions, pleas: do not. hesitate to give us a call. ne Dopartment's address, telephone ana fax number The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investiogations 600 Wadiington Stri-_et Boston, MA 0-2111 I TeL 617-7274900 6xt 406 or 1-977-MASSAFE R.evised 5-26-05 Fax 4 617-727-7744 wwwmass.gov/dia