HomeMy WebLinkAboutMiscellaneous - 10 FURBER AVENUE 4/30/2018Date . I � lz) I !Z, -
This certifies that -A.'. A'n . T . .........
has permission to perform. 5.'5f�'4-- 0-�
r................
wiring in the building of --A�-�
.. ..............................
A4at ...... C-) <6?�- -0 ...... I NDqh Andover, Mass.
ELEC RICAL INSPECTO
Check#
I 12 3 4
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official UseOnly
Permit No. L... ,
Occupancy and Fee Checked
[Rev. 1/071 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 PRINT IN INK OR TYPE ALL INFORMATION) 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)
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit? Yes L
Purpose of Building \/1 i
Telephone No.
No ❑ (Check Appropriate Box)
Utility Authorization No.
Existing Service Amps / Volts Overhead ❑
New Service Amps / Volts Overhead ❑
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Undgrd ❑ No. of Meters
Undgrd ❑ No. of Meters
h 4'T, jbk ) trtAn .. iv
K � kl-dA 4 -PAW 1wt%AXJ A b+ Ro -6,9A ,vletion ofthe following table may be t aived by 4Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets Co
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑In- Elo.
rnd. grnd.
of Emergency LigFiting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers ""
Heat Pump
Totals:
I Number
...
Tons
""'."""'.
KW
"
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers ^—'
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers 1
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water
Heaters I
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: I I Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE C VE GE: 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 coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE W OND ❑ OTHER ❑ (Specify:)
I certify, tinder thepains andpenalties ofperjury that the information on this application is true and complete.
FIRM NAME:. U CI LIC. NO.:_MjIA
2
Licensee: & ..� �� l�L Signature LIC. NO.: 0 1)
(Ifapplicable, enter "exempt" the license nu berline. Bus. Tel. No.: Cf 79 91 S' 3911
Address: aaE Pcj ^yt k �� Alt. Tel. No.: 60 63s L S39
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. 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 PERMIT FEE: $
Signature Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, fine or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § K.
Permits shall be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass M
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass n
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
'
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INPECTION:
Pass ?
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com
lip
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
QI
Address:
City/State/Zipl- LywlUt, fA,A 013A` e Phone #: q7t - `3V a7
Are ygu an employer? Check the appropriate box:
1. E3rI am a employer with &
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I 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.]
officers have exercised their
3. ❑ I 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.] i
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.5Alectrical repairs or additions
11.0 Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
tAny applicant that checks box # I must also fill out the section below showing their workers' compensation policy information.
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
tam 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:
fob Site Address: City/State/Zip:
kttach a•copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
.me 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
)f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
nvestigations of the DIA for insurance coverage verification.
do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
'hone #:
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 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, 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
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 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 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 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 Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www,mass.gov/dia
Date. . A,// ..........
r� I 1 0
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLA11ON
x -
This certifies that ............... zazi
...........................
has permission for gas installation A914 f-
....................
in the buildings of. .q, t �,n � / .............
at North, Andover, Mass.
Fee Lic. No.'j ..................
GAS INSPECTOR
Check# /—?� z
40
I;�scHir,, Coli. aI, i:ame:_ Jed$ ?.3
Address:1/ 4 CnLil •� `Q City/Town: h ,"
State: 4-
Business Tel:' q 70 _
Fax:
Name of Licensed Plumber:
Cl 'ok Orae
❑ Corporation
❑ Partnership
❑ FirMICompany
IIVSIIRA�Ir+t r+lwrr�w.... '
1 have a current lia_ bility insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 942 Yes ❑ No ❑
If you have checked Yes,lease indicate the he type of coverage by checking the appropriate box below.
A liability insurance policy. �_ Other t '
ype of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 742 of the
Massachusetts General Laws, and that mysignature on this permit application waives this requirement.
Check One Only
>i nature of Owner or Owner's Agent Owner ❑ Agent ❑
I hereby certify that all of the details and information 1 have submitted (or entered) regarding this application are true and
Knowledge and that all plumbing h , g y r p PP accurate to the best of my
p. m_in work k and installations Performed under the permit issued for this application will be in compliance with all
PertinentroTvisior� of the Mas �chusetts State Plumbing Code and Chapter 142 of the General Laws.
r
Type of License:
❑ Plumber
.Y/Town ❑ Master
'PRO'95—(6FFicE USE ONLY) ❑Journeyman
Signature of LicensedPlPluumber
License Number: I
a
10
.µ
1
r
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT
TO DO PLUMBING
City/Town-ti MA. Date:
/�Perfffl�t�
Building Location: LO L11(ted (11-f yr
Type of Occupancy: Commercial
Owners Name:
e
❑ Educational ❑
Industrial ❑
Institutional ❑ Residential [�
New: ❑ Alteration: ❑ Renovation: ❑ Replacement:❑ ❑
Plans Submitted: Yes ❑ No
FIXTURES
DEDICATED
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BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
4' FLOOR
ST" FLOOR
6T" FLOOR
7T" FLOOR
8T" FLOOR
I;�scHir,, Coli. aI, i:ame:_ Jed$ ?.3
Address:1/ 4 CnLil •� `Q City/Town: h ,"
State: 4-
Business Tel:' q 70 _
Fax:
Name of Licensed Plumber:
Cl 'ok Orae
❑ Corporation
❑ Partnership
❑ FirMICompany
IIVSIIRA�Ir+t r+lwrr�w.... '
1 have a current lia_ bility insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 942 Yes ❑ No ❑
If you have checked Yes,lease indicate the he type of coverage by checking the appropriate box below.
A liability insurance policy. �_ Other t '
ype of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 742 of the
Massachusetts General Laws, and that mysignature on this permit application waives this requirement.
Check One Only
>i nature of Owner or Owner's Agent Owner ❑ Agent ❑
I hereby certify that all of the details and information 1 have submitted (or entered) regarding this application are true and
Knowledge and that all plumbing h , g y r p PP accurate to the best of my
p. m_in work k and installations Performed under the permit issued for this application will be in compliance with all
PertinentroTvisior� of the Mas �chusetts State Plumbing Code and Chapter 142 of the General Laws.
r
Type of License:
❑ Plumber
.Y/Town ❑ Master
'PRO'95—(6FFicE USE ONLY) ❑Journeyman
Signature of LicensedPlPluumber
License Number: I
a
10
The Commonwealth ofMassachusetts
Department oflndustriabiceidents
Office oflnvesflgatlong
600 Washingtpn Street
Boston, MA 02111
yY
www.massgovIdia
Workers' Compensation Insurance Affidavit: Builders/ContractorsXlectricians/Plumbers
Mlieanf Tnfnrrnai4---
Name (Business/Organization/fndividual):
Address:_ ff 6 �G%., (rl . 1`
City/State/Zip: � 5 !:%zc� /'d?
Phone #: _�� • 60 y —
A,7re.,yo employer? Check the appropriate box:
l • l 1 am a employer with _
4. ❑ T am a general contractor and Z
em ees (full and/or part-time).*
have hired the sub -contractors
2• 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.
[No workers' comp, insurance
workers' comp, insurance.
5. ❑
We ai o a corporation and its
required.]
3. ❑ T am a homeowner doing
.officers have exercised their
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 re wired
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ EIectrical repairs or additions
ILD Plumbingrepairs or additions
12.❑ Roofrepairs
q 13.❑ Other r
*Any applicant that checks bo
i Homeowners x#1 must also fill out the section below showing their workers' compensation policy information. !
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 must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information.
-["In an employer tla at is providing workers' compensation insu-rance fOF my eynployees Belo w is the policy and jab site
Information.
Insurance Company Name
Policy # or Self -ins. Lie. #,
Expiration Date:
Job Site Address: ,
Attach a copy of the workers' cCity/State/Zip:
ompensation 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 maybe forwarded to the Office of
Investigations of the DTA, for insurance coverage verification.
r do hereby certify under thepains andpenalties ofperjury tliat the information provided above is true anti correct
vffcczal use only. Do not write in fills area, to be completed by city or town official.
City or Town:
Permit/Heenea it
Issuing Authority (circle one): .
I. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person:
Phone #:
91 b2
'tSA HUS
This certifies that
Date...
..... .. ...
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING. %%
aqrj F2,,-,� Jw
..................................... ......
has permission to perform 1-47 ....... / ....... r. J. ..
plumbing in the bul*ldl*ngs of S�J?.Ph�wlc ...................
at. ....................... North Andover, Mass.
Fee��q Lic. No.15.1(-"6 .......
PLUMBING INSPECTOR
Check # 1Y � ?-
-S\: - - \f
Fx You /my
L,2- - 47
Cer "C/
(� 7 iv q,- /-/ -/ 9�0,0
NOTICE,
The Town of North Andover Building Department has
noticed that your electrical service is in need of repair.
Please contact an electrician immediately. Prior to
restoration of your service this repair needs to be
performed.
National Grid has notified us that they intend to have
0110
t
SUB BSIVff
BASEMENT
1 FOL1 FOL OR
2 LF OOR
17 OOFLR
4 FOL4 FOL OR
5 F OOL5 R
6 F OOL6 R
7 FL 007 FL R
8 F OLO8 R
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: 01'1 o pt, 7MA. Date•
Permit#
Building Location: Q U6 PC aVe
T Owners Name: _ ��rPi1e✓)
Type of Occupancy: Commercial ❑ Educational
❑ Industrial ❑ Institutional ❑ Residential [ jZ
New: ❑ Alteration: ❑ Renovation:
❑ Replacement: ❑ Plans Submitted: Yes
❑ No ❑
FIXTURES t
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in _ o W w co _ CO W
W Cn m O W w W O IW
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ZO Q' N J Q Q m u.l O Z 0 F H LL W I'- W W Q
m o o LL 0 X X > 0 O N > Z
o a � ac � > > > � o v
Installing Company Name:/� ,S �3 Check One Ont
Y Certificate #
Address:❑Corporation
City/Town: YI SL �v Stater'!
Business Tel: % _ to Fax: ElPartnership
Name of Licensed Plumber/Gas Fitter: �� ❑ FirmlCompany
cida
INSURANCE COVERAGE:
I have
INSURANCE
Iiabili insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No
If you have checked Yes, please indicate the ❑
type of coverage by checking the appropriate box below.
A liability insurance policy
Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Si nature of Owner or Owner's Agent Owner ❑ Agent ❑
c checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and
accurate c the best a my Knowledge and that all plumbing work and installations performed under the permit issued forth is application will be d
compliance with all Pertinent pro 'si In
of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Type of License:
-�,_ � ���
EJ Plumber
Title !j2/f ' ❑ Gas4itter
aster Signature of Licensed Plumber/Gas Fitter
Cityrrown ❑Journeyman D OFFICEUSE ONLY El
l�
APPROVELP Installer License Number: 8
t
The Commonwealth ofMassachusetts
Department of lhdustrial Accidents
Office of Investigations
600 Washington Street
s
Boston, MA. 0211_1
www.mass govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
mli'cant Wnrmnfinn
Name (Business/Organization/Individual):_
Address:
31-1
City/State/Zip: r) co Sri k�l A phone #: 7 —Z6 �U
Are you an employer? Check 1'e appropriate
box:
1. ❑ I am a employer with
4. '
❑ I am a general contractor and I
e, mpI s (full and/or part-time).*
have hired the sub -contractors
2• L`j- T aim a sole proprietor or partner-
ship and have no employees
listed on the attached shget t
These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
workers' comp, insurance.
5. ❑ We
aie a corporation and its
required.]
3. ❑ I am a homeowner doing
.officers have exercised their
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'
COMA insurance required ]
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.❑Roof repairs
13.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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.
Xam an employer that is providing w
inorkers' compensation insurance for my employees Below is the policy and job site
formation.
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 maybe forwarded to the Office of
Investigations of the DIA, for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
uJilcial 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):
I. Board of Health 2. Building Department 3. City/Town Clerk
6. Other
4. Electrical Inspector 5. Plumbing Inspector
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, 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
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 ofpublic 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 Depailmment 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 referencd number. In addition, an applicant
that must submit multiple perrait/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 tor any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOTrequired 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 Co�-twaonwealth off M assachosetcs
Department of Judustrial Accidents
Office of Investigations
600 Washington Stroet
Boston; MSA 02111,
Tol. # 617-727-4900 ext 4406 or i�877,mA.SSAFE
Revised 5-26-05 Fax # 617-^727-7749
www.mass.g4v/dia