HomeMy WebLinkAboutMiscellaneous - 15 DOUGLAS ROAD 4/30/2018 BUILDING FILE
11
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,firm 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,§3L.
Permits shall-be limited as to the time of ongoing construction activity,and may be.deemed-by-the-Inspector_of-Wires abandoned-and_invaliddf 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 orthe installing entity stated on the permit application.
El 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.
ule 8—Permit/Date Closed: C`2;�---/ **,Note:Reapply for new permi�
0 Permit Extension Act—Permit/Date Closed:
3 1 Date...... ...?:....7.. ./. .
HOR711
TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
,SSACH
This certifies that ........ ."ri..........`......Z.,.?...........`.`,7 ..........................
has permission to perform .�.c.......Ir. ......
ot
wiring in the building of........1: `'...... .... °.{.....................................
i /
at..../.�........la ..h'.>.......1�x..........................North Ando r,Mass.
Fee...3U.......... Lic.No. / !. mow.... ..:
LECTRICAL INS R
Check # -
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. lV5
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [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 ININK OR TYPE ALL INFORMATION) Date:
— S4dt 101-S
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) l5
Owner or Tenant Telephone No.
Owner's Addresser �1L�
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appeopriate Box)
Purpose of Buildings - Utility Authorization No. o
Existing Service2� � Amps 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: LocAberA. -
Completion of the following table may be waived by the Inspector o Wires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans TransTotal
Trsformers KVA
&o.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- 1:1
o.o mergency Lighting
rnd. rnd. 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
Initiatin2 Devices
No.of Ranges No.of Air Cond. Total Tons g o.o
No. Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal E] Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of WaterKW No.of No.of Data Wiring:
Heaters Signs BallastsNo.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.
Estinrlated 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 coverage is i force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE V BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and pe [ties of perjury,that the infor ion his application is true and complete.4,21
FIRM NAME: n1�O vu-yJ Je_ _ , LIC.NO.: / ✓I �1
Licensee:1"V�A10„0\ Signature LIC.NO.: n�
(Ifopplicable, enter rr,"exempt"in the license numberline.) Bus.Tel.No.: (+ I� 3� 70b%5
Address: 10 Uf,t�P�tz 51 �0 'p'CAS /hyo sSy Alt.Tel.No.:
*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
Owner/Agent
Signature Telephone No. PERMIT FEE. $ ,�
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):77: � 7�� ��
Address:
City/State/Zip: �� L7 �J D('yJ Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
1.1�k I am a employer with 4. ❑ I am a general contractor and 1 6. New construction
employees(full and/or part-ttme).
* 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 lOElectrical 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' 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.
$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: �j V(0, L. (Z�_,Policy#or Self-ins.Lic.#: � (�� a•f j (') I L Expiration Date:Job Site Address: �JDOSI� - City/State/Zip: ri
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 he y certify er ins a t the information provided above is true and correct.
Signature: te:
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#:
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,firm 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,§3L.
Permits shall-be limited as to the time ofongoing construction activity,and may be-deemed-by-the-Inspector-of-Wires abandoned_and_invalid.ifhe—. ._
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 pemmit shall be terminated upon the written
request of either the owner or.the installing entity stated on the permit application.
n 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 extending1hrough August 15,2012.
C ile —Permit/Date Closed: Dote:Reapply for new permK
❑✓Permit Extension Act—Permit/Date Closed:
T 9872
Datg .".f ....✓f........
NORT/,
°•t"`° '•�"� TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
SACHUS�h
,This certifies
has permission to perform,�<./.^-.....t ......&n.T..... ...'^.':.........
wiring in the building of..... !��?� .... /�,�"
....... ..................................
at.... .... a� � ...... .T................ .... ..North Andover,Mass.
Fee.//P..: ..... Lic.NoA.I&r.�.......... . . . .... .. ......
2 J CMCA.I
Check # ✓/
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. IF
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/071 Leave blank
APPLICATION FOR PERMIT TO PERF I RM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK ORTYPEALLINFO TION) Date:
City or Town of- WA"tionto
To the Inspector of Wires:
By this application the undersi ed gives not' e of his or her inti perfo the electrical work described below.
Location(Street�&Number) `
4Kr
Owner or Tenant .S f /r/ Teleph e No.
Owner's Address t,7 6
Is this permit in conjunction with a building permit? Yes No ❑ BLDG PERMIT#
Purpose of Building `r1 4 ? /�4 Utility Authorization No.
Existing Service 040 Amps /J-,-/ �Yc Volts Overhead r
L �Undgrd❑ No.of Meters
New Service I,` Amps /.l4, / PVc Volts Overhead P"'�_Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location N and a --�
n Nature of Proposed Electrical Work: � Z � -
.G�vr e
"
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total.
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No. of Luminaires Swimming Pool Above ❑ In ❑ o.o mergency ig mg
rnd. grud. Batte y Units
1ZTo. of Recepiacle 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. TonaTofal No.of Alerting Devices
' No. of Waste Disposers Heat Pump Number .Tons. KW No.of Self-Contained
Totals:
Detection/Alertin Devices
No. of Dishwashers / Space/Area Heating KW Local❑ Municipal E] other
Connection
No. of Dryers Heating Appliances KW Security Systems:
No.of Devices or E uivalent
No. of Water No.of No.of
Heaters KW Data Wiring:
Signs Ballasts 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: / 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 coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I cery, eai ndeialties of perjury,that th/e��l information on this application is true and com let / �
. /
FIRM NAME: �/�_ + Lt�.�, ",Z_
LIC.NO.: oil
I Jj/
Licensee: -- � e/Aj Signature LIC.NO.:
(If applicable, enter "exempt"in the licenseumber 1i e.) Bus.Tel.No.:
Address: (11 ppm, � ( > >�+y,Z_- (�M) Alt.Tel.No.• l 0
*Per M.G.L.c. 47,s.57-61,gecurity work requires Department of Public Safety"S"Licen 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
Signature Telephone No. PERMIT FEE. $
ELECTRICAL PERMIT NO. INSPECTION
ELECTRICAL INSPECTOR-DOUG SMALL PORT:
r
1.ROUGH INSPECTION:
Passed— Failed—[ ] Re-inspection required($50.00)
Inspectors'comments:
/l
(Inspectors'Signature-no initials) Date
Passed
INSPECTION:
Failed—[ ) Re-inspection required($50.00)-[ j
comments:
` C
(Inspectors'Signature-no initials) Date
ets'
SPECTION:
Failed—[ ] Re-inspection required($50.00)Signature-.no initials)
Date
4.INSPECTION—SERVICE:
ATE CALLED NATIONAL GRID: NAME:
Passed—[ j Failed—[ ] Re-inspection required($50.00)
Inspectors'comments:
(Inspectors'Signature-no initials) Date
R
OTHER:
Failed—[ ] Re-inspection required($50.00)-nts:
pectors'Signature-no initials) Date
DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED.
r
r
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston,MA 02111
U www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors[Electricians/Plurabers
Applicant Information Please Print Legibl
Name(Business/Organization/Individual):
Address: rz,JP VV
i
City/State/Zip: <}J Qlko rr4 Mo Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
m a employer with'_ 4. ❑ I am a general contractor and I 6. ❑New construction:
employees(full and/or part time).* have hired the sub-contractors
2.El am a sole proprietor or partner- listed on the attached sheet.? 7• F1 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 10.0 Electrical repairs or additions
required.] officers have exercised their
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 �re q uired. employees.[No workers'
13.F1 other
comp.insurance required.]
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.
lam an employes that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
r
Insurance Company Name: <1AVAY QTM13
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 WORD ORDER and a flue
of up to$2 .00 a day against the violator. Be advised that a copy ofthis statement maybe forwarded to the Office of
Investi ti s f the DIA for insurance coverage verification.
X do lies a cer ' er the a dpenalties of perjury that the information provide ab ve is true and correct.
Si ature: Date:
Phone#:
F
only. Do not write in this area,to be completed by city or town official
n: PermitUcense#
hority(circle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son: Phone#:
9061 Date. t
0t4, TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
,SSACMUS� 1
This certifies that . . . tM-': .^. . . . . . .
. . . . . . . .
f
has permission to perform . . . .Y ��►�- . .N—f)tt- . . . . . . .
plumbing in the buildings of . .-.: A`. .'�. . . . . . . . . . . . . . . . . .
at . . .1O.��L� �, , ,��'�.- . . . , NorthAndover, Mass.
Fee ?J .Lic. No..1.33 .7.
PLUMBING INSPECTOR
Check # 0-7
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: MA. Date: "3—
4 — Permit#
Building Location: � W r
Owners Name: 1 vy)
Type of Occupancy: Commercial❑ Educational❑ Industrial[] Institutional❑ Residential
New:❑ Alteration:❑ Renovation: Replacement:
❑ Plans Submitted: Yes❑ No❑
FIXTURES
DEDICATED
a z SYSTEMS
z z
w Y O
>LLJ
Z
Q [n x Cn vi O
z G• W z Q C' 2 � y
Q C�5
cn x in Q w E- w Z y H Z O Q Q w
D Q O Q Z 0 4' Z y C7 c X Q v1 F Q
Q ld x LL 0 3 wz o �- o w N j `�' z �. x Q
LLJ U
Q H v_ai O F_v- O j O LL p a Z Z vxi P P w dT O y
a m m o o LL x s o z o a �-
g vi _j cc0 tQ 3 O~ ti w Q cn
-SUB BSMT. d 3
BASEMENT
1sT FLOOR /
2ND FLOOR
3RD FLOOR
4T"FLOOR
ST"FLOOR
6T"FLOOR
7T"FLOOR ,
8T"FLOOR
Installing Company flame: Check One Only Certificate
Address: 0 Corporation
City/Town: ^1 State:
❑
Partnership Tel: � �
Fax:
V'Firm/Company
Name of licensed Plumber:
INSURANCE COVERAGE:
have a current liability 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.eff 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 A ent Owner ❑ Agent ❑
I hereby certify that all of the details and information 1 have submitted(or entered)regarding tfiis application are true and accurate Knowledge and that all plumbing work and i nstallations performed under the permit issued forthis application will be in compliance to t with all t of r,y
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 o,the General Laws.
S _By
Type of License:
Title
RrPlumber Signature of Licensed umber
ityrfown 'Master 3
kPPROVED(OFFICE USE O LY) ❑•Journeyman License Number:
0
10 - Date. . . .
88
TOWN OF NORTH ANDOVER ,s
PERMIT FOR PLUMBING
,SSACM0
This certifies that . . . . . . . . . . ... . .
has permission to perform . . . . /A . . . . . . . . . . . . .
plumbing in the buildings of . . ,�9. �. .t.
. . . . . . . . . . . . . . . . . . . . . . . .
at . . .,,� . . . .D.<, .c .�(
.North Andover, Mass.
Fee. y.2 . . . .Lic. No.2. PLc j . . . . . . .
'-PLUMBING INSPELQIR
Check # . 16V 3
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: & A V 00 O'er MA. Date: � �� �v Permit#
Building Location: U Owners Name:✓t M At f X
. 11
Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential)4
New:❑ Alteration:❑ Renovation: Replacement:❑ Plans Submitted: Yes❑ No❑
FIXTURES
DEDICATED
z SYSTEMS
W z
Z {A H
W ,[ O D
W Z LA of = N N 0 o
H C9 z H Y Q N U w (7 OWC Q�Q Z
a Q Q w Z D N Q H
z CA = N Q w Z w Z tn O a f- Q of W Q
oae oco a W o a z = z oc Z n O u a LL = Q 3
LL ~ A W O L W N J Q 2 W W � O W W
w v ►_- x Oa O 3 v Z Q p 3 a Y z �n °J o I Q
Ln v� O > > O 0 Z Q Q Q Z LA w Q
a m m e s LL = Y 0 a 3
SUB BSMT.
BASEMENT
15T FLOOR ( --Lit
r
2ND FLOOR
3RD FLOOR
4'FLOOR
5T"FLOOR
CH FLOOR
7T"FLOOR
8T"FLOOR
/ Check One Only Certificate#
Installing Company Name: za! ` fie'11 re.
/ J El Partnership Address: / ^12 �� �ty/Town: l-f i'1 U 1C�/Pr'�' State:�l
Partnership
Business Tel: )? R627-36) Fax: ❑Firm/Company
Name of Licensed Plumber: W'Q re f f-
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 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 INS RANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts eneral Laws,and that my signature on this permit application waives this requirement.
qhegk One Only
Owner Agent ❑
ure of Owner or Owner's ent
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 Char r 142 of the General Laws.
By Type of License:
Title ❑ Plumber Signature of L censed Plumber
City/Town ❑Master
APPROVED OFFICE USE ONLY njourneyman License Number: -12-
S^�
The Commonwealth of Massachusetts
• Department of Industrial Accidents
, l 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'Le ibl
Name(Business/Organization/Individual):
Address:
City/State/Zip: Co tlPhone#:-� 1��� .3736
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 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors r, ,.,,//
2. ]�atn a sole proprietor orpartner-
listed on the attached sheet. �J'�emodeling
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 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] employees.[No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#I 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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors acid 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
Investigations of the DIA for insurance.coverage verification.
I do hereby cer .y nder th pal s an.(l penalties ofpeijury that the information provided above is true and correct.
Si nature: Date: C
Phone r7i /
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-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 f
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 confinnation 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 pen-nit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pen-nit/license applications inany 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 pen-nits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or pen-nit 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.#617-727-4400 ext 406 or 1-87TMASSAFE
Revised 5-26-05 Fax#617-727-7744
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