HomeMy WebLinkAboutMiscellaneous - 14 ANNIS STREET 4/30/2018 / 14 ANNIS STREET
210/014.0-0045-0000.0
�I
i
I
r Date".&......w....
d
f NORTH 1
TOWN OF NORTH ANDOVER
0 p PERMIT FOR WIRING
SACMUS�
r
This certifies that ................................................
has permission to perform .. !✓v....... ..................................
wiring in the building of... r1,�r...� ...V r t " `rf<
. ...................................................
at..........&...... ...........f.r .................. orth Andover,Mass.
Fee.r,7 I.......... Lic.No..f> .. . , . ... �'.
.... ... . .. . ..... .. . . ... . .
ELE CAL INSPECTOR
y O.
Check # ?
936
Commonwealth of Massachusetts Official Use Only
Permit No.
Department Of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/07] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 Y Y
(PLEASE PRINTW INK OR TYPE ALL INFORA"TION) Date:
City or Town of: NORTH ANDOVER
ed To.the Inspector of Wires:
By this application the undersi
gn gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) /Y s4.
Owner or Tenants t k
Owner's Address /y Telephone No.
Is this permit in conjunction with a building permit? Yes
Purpose of Building ❑ NO ® (Check Appropriate Box)
�� nl Utility Authorization No. �"�. n 19
Existing Service Amps /�(�/2 Volts
Overhead, Undgrd❑ No.of Meters
New Service Amps / Volts Overhead
❑ Undgrd ❑ No.of Meters
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work:
Com lesion of the followin table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil.-Sus o.of Total
r p.(Paddle)Fans
No,of Luminaire Outlets Transformers
��'
No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above In-d• ED Batt
d• o.o ery
mergency lg g
�
--, No.of Receptacle Outlets No.of Oil Burners Units
FIRE ALARMS N_; of zones
No.of Switches No.of Gas Burners No.of Detection and
No.of Ranges Initiatin Devices
g No.of Air Cond. °�
Tons No.of Alerting Devices
No.of Waste Disposers eat PumP _ umber Tons KW No,of a -Contained
Totals: - -"- Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal
No.of Dryers Head A Connection Other
g Appliances K, Security Systems:*
No.of Water No.of No.of Devices or Equivalent
Heaters KW No.of
Si Data Wiring:
Signs Ballasts .
No.Hydromassage Bathtubs No.of Devices or E ufvalent
No.of Motors Total gp No.
wiring-
OTHER:
No,of Devices or E uivalent
r •
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work:
Work to Start (When required by municipal policy.)
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
undersigned certifies that such coverage is in f
the licensee provides proof of liability insurance including "completed operation"coverage or its substantial equivalent The
orce,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE 0 BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME:
Licensee: /� `l i G LIC.NO.:
Signator LIC.NO.:
(If applicable, a ter "exempt"in the license number line) 1�O i717
Address: Bus.TeL No.:
*Per M.G.L c. 147,s.57-61,security work requires Dty AIL Tel.No.:
OWNER'S INSURANCE WAIVER: I am aware that tl e II cens a does noSaft have the liability Lncic.e normally
No.
required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner coverage
❑ owner's agent
Owner/Agent
Signature Telephone No. PERMIT FEE: $
r
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Uf 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: ' 446- S
City/State/Zip:_ (Qi,'re vt C r_ 0114. Phone
Are you an employer?Check the appropriate box:
Type of project(required):
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 6. []New construction
2.5t I am a sole proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance.
[No workers' comp. insurance 5. 9. ❑Building addition
p ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.] t employees_ [No workers'
comp.insurance required.) 13.❑Other
'.Any applicant that checks box#1 must also fill out the section below showing .heir work='com,^e::sation policy information.
I Homeowners who submit this afada-vi<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. 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
i Investigations of the DIA for insurance coverage verification.
I do hereby certify un r the pains and pe s of perjury that the information provided above is true nd correct
Si ature: ��-
Date:
Phone#:
En only. Do not write in this area, to be completed by city or town official
n Permit/License#
hority(circle one):Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son: 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 ti
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 Y
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 applicatton 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05
wu-A7.mas _govfdia
3 .. 5
Date.Aye
.......... ..................
OF p►OAT/.�,�
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
Hu�ttg
This certifies that ../W. ..... ...............................................................................
has permission for gas installation .....
................... ../ .......
in the bugl ingsof............................................................
........................... ..........................
at... �f.. f .... .................................... ... ....... h dover, Mass.
Fees- ...... ... Lic. NO .......... '.... ..................................................
�^— � G SINSPECTOR
Check#
U . V '.
-` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�I
CITY --- MA DATE Z5- JJPERMIT# —
JOBSITE ADDRESS q/-bi1N1 S STS _ � OWNER'S NAME L
GOWNER ADDRESS TE _ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EJ] EDUCATIONAL RESIDENTIAL Rr
PRINT
CLEARLY NEW:E1 RENOVATION: REPLACEMENTS PLANS SUBMITTED: YES NO
APPLIANCES'l FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER =1_ I . f =D
BOOSTER
CONVERSION BURNER.
COOK STOVE
DIRECT VENT HEATER
DRYERS _ - -� � . . _ L� _.. 11
FIREPLACE )
FRYOLATOR � _ _m_1��► - _ �z - I - -_I
FURNACE
GENERATOR I - -
GRILLE I _1 - -. _._ - . I---_-�._. .—_ � J �l _..
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT __ T.. I
OVEN
POOL HEATER J I - -- - . }
ROOM/SPACE HEATER
ROOFTOP UNIT
TEST _ _( __. ( ! I^- I= [ J
UNIT HEATER
UNVENTED'ROOM HEATER
WATER HEATER I L.__.
OTHER . =J ..I _
--
L-JIL 1)1 111 1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES -_1 NO Ej
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Ej BOND EJI
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. _
CHEC `ONE ONLY: WNER —1 AGENT
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted or entered regarding this application re true and acc rate t st o my o le e
and that all plumbing work and installations performed under the permit issued for this application will be in ompliance nt provi ' n-o
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUM BER-GASFITTER NAME _ _ LICENSE# /��a/� SIGN URE
MPI MGF JP[I JGF LPGI 0 CORPORATIONd# _ ...3 f PARTNERSHIP[3# LLC E]#
COMPANY N lk_ _ ADDRESS
CITY STATE ZIP TEL
FAX CEL G_ EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION WATES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
' r?
11 aL The Commonwealth of Massachusetts
_ _
Department of lndustrittlAccidents
Office of Investigations
IF 600 Washington Street
Boston,MA. 02111
www.mass gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): \ a
Address: ►�1�-�— Z
City/State/Zip:
Are you an employer?Check the appropriate box: Type of project(required):
10 I am a employer with_ 4. ❑ 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. �• Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.[:1 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.F1 Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers' 13.❑Other
comp.insurance required.]
*Any applicant that checks box#1 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.
TContrartors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy anal joh site
information.
Insurance Company Names
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address- /vy lf��-�-� �' 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 requiredunder 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 wel s civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.0 against the violator. Be advisea py of this statement may be forwarded to the Office of
Investigatio of the D for incur c coverage ifi on.
Ido het• y cert under Ize p in nd enalt s etj that the information provided above is true and correct.
SigLiafar Date:
Phone#: Ito ,
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 wlio 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 maybe 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 retained 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Com m. onwealth of Massa chus-tts
Department of Industrial Accidents
Office ofIuvestigat ions
600 Washington Street
Boston,MA,02'111
Tei,#617-727-4900 ext 406 or 1-877-:MASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mtass,go�fd�a
Date. ./..�.�. .�. L
NORTIy
TOWN OF NORTH ANDOVER
p D
• - PERMIT FOR GAS INSTALLATION
SSACMUSEtS
This certifies that . .�. .�:. . . . S.�4 A.`�". P. .s�". 1�
has permission for gas inst llation . . . . . .V V.e Y e. A... . . . . . .
in the buildings of . .1 .0. . . . .
at . . . . . . . . ..r. � . . . ., North Andover, Mass.
Fee. . (�I�. Lic. No. .Lr. . . . . . .. . . . . . . . . . . . . . . .
GAS INSPECTOR
Check#
8271
.9
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY `'YI _ _ c�v �'-"�- _ MA DATE 7 J _/ PERMIT#
JOBSITE ADDRESS l --_- N/W 1 S OWNER'S NAME
GOWNER ADDRESS FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL E] RESIDENTIAL
PRINT
CLEARLY NEW:Ej RENOVATION:F REPLACEMENT:F—Lt-"" PLANS SUBMITTED: YES F NO 0
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 �_..�_[ - -1 _..J - -_ -
LABORATORY COCKS _ �I -1 I -1 T-�( I - I�_. L _. J.!_�1 I
MAKEUP AIR UNIT _ _ L:
OVEN
POOL HEATER
ROOM/SPACE HEATER z� I
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
JI I III illL
INSURANCE COVERAGE -
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES JEIO (�
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.
CHECK ONE ONLY: OWNER E] AGENTC_-_I,I__I(
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted or entered regarding this application are true nd ac urate 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 i ce h all P rtinent p visio f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME(� .-� - .-,,.. .�• -c j LICENSE#[:::::g
IGNATURE
MP[�jrMGF 0 JP n JGFLPGI __i CORPORATION[ # PARTNERSHIP0.1#1-..._-.__--___�LLC O
COMPANY NAME: _•��_. `ekr. -l_,___ .__'`'lf I ADDRESS Dy 1tSit ...-_-------_..-------_____._.___.._..-----__--
CITYU. - C)_U - - _. __� STATE FWA ZIPd ^� TEL G �
FAX iN � CELLEMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
ti
FEE: $ PERMIT#
I a �� PLAN REVIEW NOTES
' The Commonwealth of Massachusetts
Department of IndustriglAccidents
Office of Investigations
if 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): � !7
Address: D /3
City/Staty U - Phone#: j 7
Are you an employer?Check the appropriate bog: Type of project(required):
1.21 am a employer with ?/ 4. ❑ I am a general contractor and I
6. FJ New construction
employees(full and/or part-time).* have Hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.1 7• ❑Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
workingfor me in an capacity. workers'comp.insurance.
Y p tY• 9. E]Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.E]Plumbing repairs or additions
myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers'
comp.insurance required.] 13.n'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 ace 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:- l'L��f-• �'�
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 1 l.( 0-KIW 1' 5 cr City/State/Zip: —2-L, _4 `C
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder 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 cert' nd tltepains ndpenalt's ofper'ury that the information provided above is true and correct.
Si afore: � Date:
Phone#• Cz' -79
(0 Dig
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.EIectrical 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-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 maybe 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 COMMOnwealthofMassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,1A 02111
Tel.#617-727-4900 ext 406 or 1-877,7MASSAFB
Revised 5-26-05 Fax#617-727-7749
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