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HomeMy WebLinkAboutMiscellaneous - 13 WILSON ROAD 4/30/2018CrJ Q I This certifies that A !.fn ... 6�C t.�....................... . has permission for gas installation ..... F y(AW-i'.:.............. , a_ in the buildings of .... i�. •... .`� ................... at ..... W '. t C,.�. 99 :........ . , North Andover, Mass. Fee . .. Lic. No. 10301... ....... .� . . GASINSPECTOR Check # Zoe' 8388 VW MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY, _ Y _ _ rr MA DATE PERMIT # JOBSITE ADDRESS � S +� _ �OWNER'S NAME GOWNER ADDRESS T _ — TEFAx_ TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL ( EDUCATIONAL] RESIDENTIAL' CLEARLY NEW: 0 RENOVATION: Ell" REPLACEMENT: _ _; PLANS SUBMITTED: YES --.I NOD APPLIANCES Z FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1 14 BOILER BOOSTER - CONVERSION BURNER— COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE -1 _-� !.. —D. _-1 FRYOLATOR Tz-J _-- _ --_ .J I _-. _. I - -. L__ l FURNACE r -I L _.- ( L� �' ., — -- 1- -- - --1 - ---� - GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN -- POOL HEATER ROOM/SPACE HEATERI -- ROOF TOP UNIT TEST UNIT HEATER!_ UNVENTED ROOM HEATER ((!I;_..__ IIi _ I..._ I_,._ I__ --{;.. ;_____�i---_. :- (� .I WATER HEATER OTHER - J i- --,J L --- - l L, ( INSURANCE COVERAGE XNO have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES D_! 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY—._({ BOND E] 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. C CK ONE ONL OWNER ENT Q SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information 1 have submitted or entered regarding this appli ation are true and cur to the be m no ledge and that all plumbing work and installations performed under the permit issued for this application wi be in complianc ith I e ent pr is' n oft e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAM JYlA+.6._._ LICENSE #6�V (�I SI TURE MPGF ,1 JP .___! JG []! LPGI( CORPORATION _ I #y.y3 I PARTNERSHIP D# { LLC [(�#_f COMPANY NAM _./(�`� �� �Ull''.ADDRESS�S.rX - -"� - - ---- - - -- --- - - - - -� CITY f STATE ZIP .�s_�__,_._ITEL FAX CELL.___._�EMAIL G-_6 _-- VW Q H z° 0 H U w a w C ❑ a z o y� W } � ~ W [O a Z W 3 a W 5 a W ® w c� w w d w Cf) a o a a a U J E., a IL Q T 6i M: w Ara e .e Oa °z v z C7 o a � y At 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 Address: J U C) City/State/Zip:L"C)� �, ' Phone #: �I y an employer? Check he appropriate box: AFa1 m 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.] t employees. [No workers' comp. 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 Homeowners who submit this affidavit indicating they are doing all work and then hire outside 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: NT -M Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address:4_ U ayr K' (q 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 3f up to $2 day against the violate advised that a copy of this statement may be forwarded to the Office of [nvesti tions of the forAurapwe ov age verification. i do her%certffy und0rie inAandAe&i ties of perjury that the information provided above is true and correct. -,2D - 26 / a I - &_23 Cp 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 #: A 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 -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 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.y/f 9583 TOWN TOWN OF NORTH ANDOVER •-� '.'. �� OL PERMIT FOR PLUMBING NSACMU� C�a'S HPC?kG V" This certifies that ....... ...... has permission to perform .............. .............. plumbing in the buildings of .... °` °`- ............... at ........( ... V"'.. , `So�.1 `r`` �' _ � ........ , ort ndover, Mass. Fee?.� ?�.. Lie. No. Check „" 3b 3C1 PL BING INSPECTOR DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTEF KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK WASHING MACHINE CONNECTION CITY rJJL MA DATE PERMIT # OTHER JOBSITE ADDRESS OWNER'S NAME/ z -o—.- POWNER ADDRESS TEL FAX f TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL O RESIDENTIAL, PRINT Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT CLEARLY NEW: RENOVATION:,W REPLACEMENT: Q PLANS SUBMITTED: YES.! NO 01 FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB FAX % 2' i CELLP27- %S i EMAIL SP4------- CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SANDSYSTEM........__.I ,- r` -- - —ji ____,J DEDICATED GREASE SYSTEM _..__ ..f �.� ! 4 ) _! s DEDICATED GRAY WATER SYSTEM _^.__._! DEDICATED WATER RECYCLE SYSTEM I ....... .... 1 DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTEF KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES= '- WATER PIPING OTHER f ` INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ( NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY g- OTHER TYPE OF INDEMNITY ! BOND Q 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 and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co ce with all Pertinen�provl:s!�Qnof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME i LICENSE # / S G1 IRE MP JP Q CORPORATION n# =PARTNERSHIP Oft ` LLC U # COMPANY NAME��,�- _Lij ADDRESS - 3 ZIP GJ S j 1 CITY, STATE TEL � x_2"6 FAX % 2' i CELLP27- %S i EMAIL SP4------- . V 11 z p y ❑ } LU ui w LL The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UV-. www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: �w 1 /f City/State/Zip: ��// / / �? Tom/ ! Phone #: 17 7 —,6 57 — 7� ? Are you an employer? Check the appropriate box: L. tl 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.] 1 employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F1 Electrical repairs or additions 11. F1 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. Homeowners who submit this affidavit indicating they are doing all work and then hire outside 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. am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site nformation. nsurance Company Name: 'olicy # or Self -ins. Lic. #: Expiration Date: ob Site Address: City/State/Zip: ,ttach 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 ine 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 hereb ertif un er the pains and pen ties of perjury that the information provided above is trace and correct. i ature: �� Date: l7 hone #: Official case 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 Icontract 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 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 evised 5-26-05 Fax 4 617-727-7749 www,mass.gov/dia iThis certifies that 6(�, n . v �} has permission to perform . k.- !-(- 6 0..r - . V" -P r� ek ............. wiring in the building of .. S -A— p� ........................ at ..... >..... J ......... ,North Andover, Mass. Fee . P.2... Lic. No. M4 C? .. Mb .................... ... ELECTRICAL INSPECTOR �i'i heck # IZo� 108 Commonwealth of !Massachusetts , Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS .k 1 Official Use Only Permit No. // r a iK- 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 Code52 0 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: 7� City or Town of: NORTH ANDOVER To the nspector of Wires: By this application the undersigned gives notice of his r her intention to perform the electrical work described below. Location (Street & Num Owner or Tenant Owner's Address saw C ZC!�� Gr'i /Sal% Is this permit in conjunction ith a building permit? Yes ff No ❑ Telephone No. (Check Appropriate Box) Purpose of Building G U 7c— Utility Authorization No. Existing Service 670 0 Amps IdPl dYlWVolts Overhead [� Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity L Location and Nature of Proposed Electrical Work: !'.,,,..,L,f..,,n Mil- fnllnwina tnhly mm; he waived by the InsDector 01 Wires. &n/ Attach aaamonat aerait y aestreu, ur us teyutteu uy -- �.. t . , r •• •• ��• Estimated Value of Elec i al Work: GGA (When required by municipal policy.) Work to Start: 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 cover ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under thegins ins and enalties oo p rjury, that ze informatio n this application is true and complete. FIRM NAME:. 0� J / �V �iO � f LIC. NO.: - Licensee: cj CG %T sry ey Signature LIC. NO.: (If applicable, e�r�'j,er "ex mpt" i the license number ine.) us. Tel. No.: 1 / ��7 Address: 06 %� �G S �� N n� Alt. Tel. No.: Ori c?f7a?3S *Per M.G.L c. 147, s. 5 -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 I PERMIT FEE: $ /%%. OO Signature Telephone No. -No. of Total No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires J �' Swimming PoolBattery =�� o.o mergency ig ting Units No. of Receptacle Outlets Gp No. of Oil Burners FIRE ALARMS No. of Zones Gas Burners No. of Detection and No. of Switches No. of Initiating Devices No. of Ranges No. of Air Cond. Tonal No. of Alerting Devices Hear Number.. Tons K ........... No. of Self -Contained No. of Waste Disposers tap Detection/Alerting Devices No. of Dishwashers % Space/Area Heating KW ni Local ❑ CoMin cipal nnection [:1Other No. of Dryers Heating Appliances KW Security Systems:*` No. of Devices or Equivalent No. of WaterKW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or E uivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivalent OTHER: &n/ Attach aaamonat aerait y aestreu, ur us teyutteu uy -- �.. t . , r •• •• ��• Estimated Value of Elec i al Work: GGA (When required by municipal policy.) Work to Start: 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 cover ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under thegins ins and enalties oo p rjury, that ze informatio n this application is true and complete. FIRM NAME:. 0� J / �V �iO � f LIC. NO.: - Licensee: cj CG %T sry ey Signature LIC. NO.: (If applicable, e�r�'j,er "ex mpt" i the license number ine.) us. Tel. No.: 1 / ��7 Address: 06 %� �G S �� N n� Alt. Tel. No.: Ori c?f7a?3S *Per M.G.L c. 147, s. 5 -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 I PERMIT FEE: $ /%%. OO Signature Telephone No. 0 0 r .. �►z,�(C���'{.(A���[{�(,3(��'�•f�1'���►''-''{{{3���(/�j'f'�J.'ye'�T��{��j��f,P� e�y' �i��'xu����T+�'®?�.'�`� _ • — J1J-4VVL.C.�L.(•xa.i�l.�VT.®���• • •. .� r ' •' �� + � �.'asse��--[ � • �'aflet��� � � �e~�ns�ecti xe0uixe� (��0.00)-[ � . -TWvector6, comments. (ffis�odorsl mgn.ahwe -)ID WHals) Pate- , 'assec� •- � � �'azlec�-- [ � ate-xrzs� eetZo�xec�uixet� (��OAQ) � [ ] as�ectoXs' coxnxaenis: (�uspecioxs�,�ignaiuxe�ao 7nftasj ))ate . CA %ERi'n W'A ^A ONAt 0�11-1113; sseri--[ I 'PectbrS9 eo3nmeufs: lauef.-- (.�ttspectoxs',�zgnaiuze��.o�nzizaxs? . r KM al. �nspectzou,xequixe� 'e--[azie��[-tenspectZottzequizeti(50.00)�[ ectas' co-rhme0s. Date •.(-.W`.SZJP.�'LOY�'�t�Xgllc`3.'ECiZ'�i��to,4ni�za3s} �iaie ' 5 n,p IPA n arp Ta rc*: lvgp1.prpx:rr x.cl vnrp .. r 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): Address: 15� 76 l/r4 ,�4YI T SY City/State/Zip:/00,1,57'a Phone #: 3Az Are you employer? Check the appropriate box: 1. Plam. 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. # 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.❑ Electrical repairs or additions 11. [1 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside 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. Lie. #: a C 9 6 O Expiration Job Site Address: 1 �/ /SG City/State/Zip: f'V b ✓ �� /G �Q'Gj/�` 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 a er the ns a hies of perjury that the information provided ab�o e is`true d correct. Si unafnra i,n bate:• Ade Phone #: 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 numbef. 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 Kevised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia Project Title PROPOSED RENOVATION TO THE SZCZAPA RESIDENCE 13 WILSON ROAD NORTH ANDOVER, MA 01845 Drawing Title FIRST FLOOR PLAN D. F. VALENTE A R C H I T E C T & P L A N N E R 571 MAIN STREET REAR S 0 U T H M E D F 0 R D MEDFORD, MASSACHUSETTS 02155-6552 TELEPHONE 7 8 1- 3 9 5- 0 1 2 0 FASCIMILE 781-395-8702 Drawn By PPT Scale 1/81) = 1'-0" Date 09/05/12 Drawing Number 1 'I C/) O O D z ! z rx I rri oCn 0 — z� C)--t _ imcg O O �-1 o p o f �� ;0 0 - = n a i Cm DX_ rcn 6'-8 i w v i-m <X Irn O C -tet- I� _ P m OO z 2 -p- I O ❑ N o C I h!l x f _� rri I z z 7- m m Z 2X o v q D E Z(/) 0-I �*t I�*1 O D z '' o Z1 z 9'-5" 7'—,6 10'-4" _ 27'L--5"Il irn r �rn Project Title PROPOSED RENOVATION TO THE SZCZAPA RESIDENCE 13 WILSON ROAD NORTH ANDOVER, MA 01845 Drawing Title FIRST FLOOR PLAN D. F. VALENTE A R C H I T E C T & P L A N N E R 571 MAIN STREET REAR S 0 U T H M E D F 0 R D MEDFORD, MASSACHUSETTS 02155-6552 TELEPHONE 7 8 1- 3 9 5- 0 1 2 0 FASCIMILE 781-395-8702 Drawn By PPT Scale 1/81) = 1'-0" Date 09/05/12 Drawing Number 1 This certifies that ........ ....... has permission for gas installation ......................... in the buildings of. / 3..w zc'z-af- t" 470 at ... 13... 1,1.. ... .............. ,North Andover, Mass. Fee 49%eP.0 . . Lic. No.......... . GAS INSPE(S-TOR Check # 1219 8470 c;"�°T•'�c TOWN OF NORTH ANDOVER ' PERMIT FOR PLUMBING 'SS CHO This certifies that ... 4�J.4_. f-c�!1a/,Yh .. �al 1 �. ............. . has permission to perform plume in t} a tt�ij�digs ... . �C at ..................................... . North Aradver, Mass. Fee-U(?4 .. Lic. No.......... .. � ......... . PLUMBING NSPE (�R Check # Z/ �T/ WHITE: Applicant CANARY: Building Dept. PINK: Treasurer -� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r GOWNER TYPE OR PRINT CLEARLY CITY NORTH ANDOVER MA DATE 11/28/12 PERMIT # 2 y7a JOBSITE ADDRESS 13 WILSON RD. OWNER'S NAME MICHAEL SZCZAPA ADDRESS SAME TEL FAX OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL ® RESIDENTIAL NEW: ® RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES[] N0[j APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER INSURANCE COVERAGE I have a current liabilily insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES [3 NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ® BOND Q 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 ® 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 and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE #24833 SIGNATURE MP ® MGF ® JP (j JGF ® LPGI ® CORPORATION ®# PARTNERSHIP ®# LLC ®# COMPANY NAME:HALLORAN PLUMBING ADDRESS 826 DALE ST. CITY NORTH ANDOVER STATE MA ZIP 01845 TEL 978-685-9504 FAX CELL EMAIL - POWNER TYPE OR PRINT CLEARLY CITY NORTH ANDOVER MA DATE 11/28/12 PERMIT # JOBSITE ADDRESS 13 WILSON RD. OWNER'S NAME MICHAEL SZCZAPA ADDRESS SAME TEL FAX OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL ® RESIDENTIAL NEW: ® RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES ® NOQ FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FQOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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: OWNER ® AGENT Q 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 and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME TOM HALLORAN LICENSE # 24833 SIGNATURE MP® JPQ CORPORATION❑# PARTNERSHIP®# LLC®# COMPANY NAME HALLORAN PLUMBING ADDRESS 826 DALE ST. CITY NORTH ANDOVER STATE MA ZIP 01845 TEL 978-685-9504 FAX 978-208-0840 CELL EMAIL The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street � g Boston, MA 02111 r www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Pleas_ a Print Legibly Name (Business/Organization/Individual):&i 11,4 L1_ec4 Al Address: g"oZ 13.4 LL✓ ST- City/State/Zip: j City/State/Zip: 4Aa,<7b' A'' '140614�AZ /"- Phone #: 97 8' -:5-0,o2- - 9L5 -D Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. &rI am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.T required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F1 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 Homeowners who submit this affidavit indicating they are doing all work and then hire outside 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 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 isproviding workers' compensation insurance for my employees. Below is the policy and job site information. 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 under the pains and penalties of perjury that the information provided above is true and correct. Phone #: %%�- a� - %�S o y 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 E1e t . I I 6. Other Contact Person: . c A %ca nspector 5. Plumbing Inspector Phone #: BUILDING DEPARTMENT Community Development Division Mike Szczapa 13 Wilson Rd. North Andover MA 01845 August 6, 2012 The structural repairs and code violations listed on the permit application shall be completed before an occupancy permit is issued. All work shall conform to 780CMR Building code Stn edition. Thank you for your attention to this matter. If you have any questions, please call Brian Leathe at the Building Department. 978-688-9545. Very truly yours, (G -Tk--g-- Brian Leathe Building Department 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9545 Fax 918.688.9542 Web www.townofnorthandover.com 1. 9416 Date.-d.l.. 7/.d... ``° '• "� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that 46 C! G+ "— _ .......................C......... .................... ................... has permission to perform ..] ....... ke' ok. ................... wiring in the buildingof ...%i!x.-..... `..e ....... at ....12..... .d.j..54 <O.......r� ........................ orth Andover, Mass. Fee .... h .<. Lic. No...... � f z... .......�. ............ ELECTRICAL INSPECTOR Check # a ti Commonwealth of Massachusetts official Use Oniy Department of Fire Services Permit No. 1 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked 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 PM7EV AW OR TYPE ALL INFORMATION) Date: -C2 / /0 City or Town of. NORTH ANDOVER By this application the undersigned gives notice of his or her intention to perform the To the Inspector electrical workidescribed below. Location (Street & Number) 13 Owner or Tenant 1? z Z` Owner's Address �A AA 4P, /7 Telephone No. v Is this permit in conjunction with a building permit? Purpose of Building Existing Service _100 Amps 1201 Dolts New Service A O Amps J o l ZtQ Volts Number of Feeders and.Ampacity Lo ti Yes ❑ No L V (Check Appropriate Box) Utility Authorization No.� Overhead Ly Undgrd ❑ No. of Meters / Overhead MUndgrd ❑ No. of Meters ca on and Nature of Proposed Electrical Work: 200 �� .Biot^y� ctc>. cI-ri�� 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 Ceil.-Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool AboveIn_ d. d. ❑ No. of Oil Burners No. of Gas Burners No. of Air Cond. Total !e:at:Pu�mnpDumber���n- _ Space/Area Heating KW o. of Dryers Heating Appliances KW o. of water, No. of No. of Heaters Signs Ballasts, o. Hydromassage Bathtubs No. of Motors Total HP OTHER: table may be waived b the Inspector jNo. of Total nsformers KVA nerators KVA o mergency tg g te Units FIRE ALARMS N.of?.ones o. of Detection and Initiating Devices No. of Alerting Devices o. of Self -Contained Detection/Alerting Devices Local ❑ Municipal Connection ❑ Outer Security Systems: No. of Devices or Equivalent Data Wiring: No. of Devices or Equivalent Telecommunications Wiring: No. of Devices or Eauivalent 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: 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 ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ .(Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. r FIRM NAME: v G ncQl LIC. NO.: Q1a2 C Licensee: _'' p�(�''�- Cf�l.��l'I°L Signature (If applicable, ant r "exempt " in the license number line.) LIC. NO.: Address: Y �(to� � ©� �� Bus. Tel. No.: 77R *Per M.G.L c. 147, s. 57-61, security work requires D „ „ Alt'. Tel. No.: Department of Public Safety S License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the Iiability 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. S .� A The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information - Please Print Le�bly Name (Business/Organization/individual): Address: City/State/Zip: n Phone #: Are you an employer? Check the appropriate box: I. ❑ I 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. $ 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 exer ' ed +,,-.-' ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t cis right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' COMP. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. Demolition 9. Building addition 10.7 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other —r-rr••-••••• •••••• •••••.-=:�. w:,vr, ri wusl »:�U 11L' ULLL IIIc S�nOL' Qe?4l.' S.^.QR'1.^.b :he3* wOF'kL':5 COmj,.:.iSatlQn IJo11C}' SfOZ22i.'.t`On. t Homeoners who submit this affidavit indicating they are doing all work and then hire outside 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: a 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 under the pains and penalties of perjury that the information provided above is true and correct Simature: Date Phone #: 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 #: b 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 than 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 R 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. 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