HomeMy WebLinkAboutMiscellaneous - 172 CORTLAND DRIVE 4/30/20181�.
Pate.. ..........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that I ...�41
;!% 1! �� ...................,
has permission to perform ,,/......................................................
.... . .... ....
wiring in the building of...
... 6.5. North Andover, Mass.
171V
.......... Lic. No . ............. ............L
4
ELECTRICAL IN R ....
Check #
8171-0el 5
Commonwealth of Massachusetts othcial Use only
Department of Fire Services Permit NO, �%�'?
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 PRINT IN WK OR TYPE ALL INFORM -4 TION) Date:
City or Town of: NORTH ANDOVER
or f Wi
By this application the undersigned gives notice of hiTo the Inspec res:
s or her into perform the electrical work described'below.
Location (Street & Number) % 7.),/��fl�1 X,.
Owner or Tenant
Owner's Address ��--�%1. t� Telephone No.
Is this permit in conjunction with a building permit? Yes`
Purpose of BuildingNO ❑ (Check Appropriate Box
_ /�') h�M e' ) Utility Authorization No. G %���
Existing Service Amps / Volts Overhead
❑ Undgrd ❑ No. of Meters
New Service ca2_M Amps / Y8 Volts Overhead
❑ UndgrdR_ No. of Meters
Number of Feeders and.Ampacity 4 /
Location and Nature of Proposed Electrical Work:
AA_
M Wtr7:�r / ,c,t
of Recessed Luminaires
No. of Luminaire Outlets
of Luminaires
of Receptacle Outlets
No. of Switches
No. of Ranges
No. of Waste Disposers
------------
No. of Dishwashers
vo. of Dryers
o.
Heaters KW
Hydromassage Bathtubs
' ompletion of the olloudo table
No. of Ceil.-Susp- (Paddle) Fans No.
ra.
No. of Hot Tubs Tr-a
Gen
Swimming Pool Above ❑ In_ o•
d. d. Batt
No. of Oil Burners FIR
No, of Gas Burners NO..i
of Air Cond.
Space/Area Heating KW
Heating Appliances KW
Ivo. of
Ballasts.
o. of Motors Total HP
ay be waived by the Inspector of Wires
Total
formers KVA
'ators KVA
r,mergency LigbE g -
Units
ALARMS No. of Zones
G. of Alerting Devices
o. of Self -Contained
etection/Alerting Devices
Deal ❑ C omcipal
Connection F-1 other
•ciuitySystems:*
No. of Devices or Equivalent
ita Wiring:
No. of Devices or Equivalent
:lecommumcations Wiring.
No. of Devices or Eauivaimf
Estimated Value of Electrical W ------Attach additional detail if desired, or as required by the Inspector of Wires.
— (When required by municipal policy.)
Work to Start: ork: INSURANCInspections to be requested in accordance with MEC Rule 10, and upon completion.
E 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 k BOND ❑ OTHER ❑ (Specify:)
I certify,
under the pains and penalties of perjury, that the in ormation on this application is true and complete.
FIRM NAME:
LIC. NO.:
Licensee: �t,/i�+ �✓c�l�z-� Signature
(If applicable, enter "ex e pt " in the license number line.) LIC. NO.: d�
Address: 1 P Bus. TeL No.: � 7:9
*Per *Per M.G.L c. 147, s. 57-61, security work requires D Alt. Tel. No.:[��r0�
Department of Public Safety "S" License: Tel 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: $
00,
ote I
Y14A
��/' • The Commonwealth of Massachusetts
Department o_ f Industrial Accidents
t l
! Office of Investigations
.�`
`.��� ;� 600 Washington Street
Ite.
.�; Boston, MA 02111
c www .massgov/dia .
Workers' Compensation Insiwrance Affidavit: Builders/Contractors/Electricians/Plumbers
Aoolicant Information
Please Print Le-gibl
Name (Business/prganiration/lndividuai): L'(jl,
L 1 Cev -S
Address:
City/State/Zip• _ aV,--/ .Uil' Phone #:7, �o 0 3.s_
Are you an employer? Check-the appropriate box:
1XI' am a employer with4 Type of Project (required):
--•� ❑ l am a genera[ contractor and I
employees (full and/or part-time).* have hired the sub-contractors b• ❑ New construction
2. ❑ I 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.
[No workers comp. insurance 5. 9• ❑ Building addition
❑ We are a corporation and its
3. ❑required.] officers have exercised their 10.0 Electrical repairs or additions
I am a homeowner doing ail work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No•workers' comp. c. 152, § 1(4), and we have no
t 12.0 Roof repairs
insurance .required.)
.employees. [No workers'
COMP. mstuanee required_] 13.0 Other
`Any applicant that checks bol #I must also fill out the section below showing their workers' compensation policy information
t Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such
;--Mmwtors that check this box must attached an additional sheet showing the creme of the sub-contractors and their workers' eom , oli information.
P P cy
I am cr er.loyer that is.pt»tnding warliers 9
information,compensation insurance for my employees: Below is the policy and job site
j
Insurance Company Name:
Policy # or Self--ins. Lie. #:
Expiration Date: p7 D .
Job Site Address: I ✓ y�l,� �. ��
Attach a copy of the workers' compensCity/State/Zi
ation policy declar atiou 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 DTA for insurance coverage verification.
I do All certify under t pains and penalties ofPerjury that the information provided above is true and correct.
Si Lure:
Date: Z 1 r%.
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):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector
6. Other 5. Plumbing Inspector
Contact Person: Phone #•
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the'foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. 'However the
owner. of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance; construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shaU 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 perfar nance 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-contracto (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 requiredto 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, nottire 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 numberlisted 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 perrnit/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
Departinent of Industrial Accidents
Office of investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-977-MASSAFE
Fax ## 617-727-774
Revised 5-26-05
www.mass.govIdle
� *N
.!
CERTIFICATE OF USE & OCCUPANCY
TOWN F NORTH ANDOVER.
Permit 647 (5/27/09) Date: July 8, 2009
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 172 Cortland Drive
MAY BE OCCUPIED AS . Single Family Dwelling
ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE
AND SUCH OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to: Meeting House Commons
Carter Field koad
North Andover MA 01845
Building Inspector
i,
0 1� x
�U
iW
a
Xz
04
w J
W v
J
oca,
0
0
aG
v
►�
�
A
U
v �
�
� .J J
W
�
0
b •„
w° Cf)w��'
� � �
U ; w
a �
W,
W
w
w
ro
cn
a w
rA U) C/)
0 1� x
�U
iW
Qu W
w
z
0
0
v
�I
0
a
0
z
O
H
H
O Eo
c�
o
IKN
O C
CS C5
_ ACL\�fl p, C
�j :eve
4 ' O O
:L o
0
o Ea
C
N
o o.
ca
EE
c \ vvts cm
rr
CD c
CA
- m J
C � �
m
Em
a `
(�mm
�coa
p,ct
);ooh
� vi o
. Z
Ci CL
Q i i m C
= o :mea
F- p y '.s
~
W
F- •y KIM
�° c
U o Q CDCD .0 cm
CO2 n O -s USE
= A L 0 N O
H .c $ n 4- ao
E
L_
IE
y
0
y
•c
cm
CD
CDc
m
`o
CD
c
•C
N
0
L
O
Z
O
g
O
�O
�U
iW
w
z
0
0
v
v
QCr
U
U)
Q•
W
u
0
co
0
c■
L
O
Z O
O.
O CO)
� C
CD
I C CM
COD 0
C
y O O
'F m m
~ CD_
G3 c0 �
■v
O �G3
O C O
i
R O d
o- c a
caccc
as
CO2 Z G3
V
ca
O O
C■�
C
c
CLCOD
Lij
0
Y/
ui
19
W
LLI
rg
W
N
•
Buildina Permit #
ADDRESS/LOCATION OF PROPERTY:
Map % G Parcel 3 Lot Number �3S
SUBDIVISION �A � " ele"1n i
E)
'DATE REQUESTED FILED/READY FOR INSPECTION'' S D�
CLOSING DATE ON PROPERTY:
FIVE (51 DAYS NOTICE PRIOR TO CLOSING DATE 1S REQUIRED
ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE-
INSPECTION FEE OF TWENTY DOLLARS $20.00) WILL BE CHARGED IF THE STRUCTURE
DOES NOT MEET ALL APPLICARI_F MnFq
Permit Issued to: M-ee,,T J 4o;e CommoLS Lr L. C
Address _i tS� Gt4er yitts R,0J, N
C/ ROWING
�� P FRLg
CONSERVATION`Z'{2� Illy
PLANNING
DPW - WATER METER
r
SEWERIWATER CONNECTION 46q
NOTE
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST
r ,
DPW 0, 1
Signature
File: Application for OC form revised Jan 2007
Date .............
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ....% % .!.....! ! ............: .
has permission to perform ....,y!/ -.i ....Tri.: .4, . . . . . . . . . . . . .
plumbing in the buildings of ...../.AAeiC ...if f�'�......�... .
at ...,� ... �GY/..?��!!.�!............... . North Andover, Mass.
Fee.Lic. No... S!% ...... ff..�...�;�.,-1 .........
f PLUMBING INSPECTOR
Check N 1G ° 7
8090
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
("Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location
New
Renovation
Date (O Z
)wners Name
p (Permit #
Amount
of Occupancy
Replacement IJ Plans Submitted Yes No ❑
(Print or type)� Check one: Certificate
Installing Company Name ❑ Corp.
Address Partner.
Business elep one / Firm/Co.
Name of Licensed Plumber: /6" 4
Insurance Coverage: Indicate th pe of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature IOwner ❑ Agent ri
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts_ State P mb' de an p 42 of the General Laws.
By: igna ure nseu Flumoer
Title
Type of Plumbing License
1 � --
City/Town
icense um er Master
APPROVED (OFFICE USE ONLY Journeyman ❑
r
i
i ilk
....M
....................
• `
.-.--..-..---.-....-----.
mmammrmrm
MMMMMMMMMMMM���
MMMMMMMMMMMMMMMMMMMMM
MM
MMMMMMMMMMMMMMMMMMMMMMMM
i-o..mmmmmmmmmmmmmmmmmmmmmmmm�
(Print or type)� Check one: Certificate
Installing Company Name ❑ Corp.
Address Partner.
Business elep one / Firm/Co.
Name of Licensed Plumber: /6" 4
Insurance Coverage: Indicate th pe of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature IOwner ❑ Agent ri
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts_ State P mb' de an p 42 of the General Laws.
By: igna ure nseu Flumoer
Title
Type of Plumbing License
1 � --
City/Town
icense um er Master
APPROVED (OFFICE USE ONLY Journeyman ❑
The Commonwealth of Massachusetts
k� Department of Industrial Accidents
Office of Investigations
ii 600 Washington Street
,��� /
. Boston, MA 02111
Workers' Cwww_nurss.gov/dia .
ompensation Insurance Affidavit: Bailders/Contractors/Eieetricians/Plumbers
ipiiicant Information .
Name (Business/Orgaoiza6an/Individual):
Address:
City/.State/Zip:
Phone #: .
Are you an employer? Check -the appropriate box:
1. ❑ I am a employer
with
4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
2.[] I am.a:sole proprietor or
have hired the sub -contractors
listed
partner.
ship and have no employees
on the attached sheet i
These sub -contractors have
working for me .in any capacity,
[No workers, comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
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 (requimd):
6. ❑ New construction
7. ❑ Remodeling
8. Q Demolition
9. ❑ Building. addition
10.❑ .Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.[].Other
*Any applicant that checks boz #I must also tilt ou
Homeownt the section below showing theirwork V' ompensation policy mformatron
t ers who submit this affidavit indicating they ars doing an work and than him outside conuaetors must submft a new affidavit indicating such.
' ;Contractors that check this box must anacbed an Additional sheatshowiug the name of the sub-cantmetors and their workers' comp. policy information.
I am an employer that is provi&n.-:workers I compensation insurance for my. employeeL Below is the policy and job sift .
information.
insurance Company
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address:
City/swzlzip:
Failure to s
Attach a copy of the workers' compensation policy deciaration page (showing the policy number and expiration datte� .
ecure coverage as required. under Section 25A of MGL c. 152 cart 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 CIPMER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of th
Investigations of the DIA for insurance coverage verification. is statement may be forwarded to the Office of
I do hereby certify under the pains and penalties of perjury Mar the information provided above is true and correct
Official ase only. Do not write in this area, to he completed by city or town affirzaL
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
�, , . � Contact Person: Phone #:
,r
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, assodia6on, corporation or other legal entity, or any two or more
of the'foreping engaged in a joint enterprise, and including the legal represenffitives 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, 525C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate s 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, MCL chapter 152, §25C(7) states "Neither t3he commonwealth nor any of its political subdivisions shall
enter into any contract for the perfonmance 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 nuanberlisted below, Self. -insured companies should enter their
self insurance- license number on &e* appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department hes 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 applicmt.
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 fdrae permits or licenses. A new affidavit must be filled out each
year. When 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 lnvesti0ions 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
Bosfon, MA 02111
TeL # 617-7274900 ext 406 or 1-8.77-MASSAFE
Fax # 617-727-7744
Revised 5-26-05 www.mass,gov/dia
f NORTH
L
Date.....................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ... !. ....... .....:.."... .
has permission for gas installation ".�.�� �!! . /./�& e ........
in the buildings of .....7m A ... .............. , , ..... .
i
..at ... �C-�.... �!�� �w•! .......... North Andover, Mass.
Fee...G.... Lic. No..
GAS INSPECTOR
Check # U v
6758
MASSACHUSETTS UNII+iORM APPLICA 'rON FOR PERMrr TO DO GAS RrMG
(Type or print)
NORTH ANDOVER, MASSACHUSETTS Date v2
Building Loqations
Permit #
Owner's Name Amount S
New Renovation D
Replacement ❑ Plans Submitted "
'
2
w
W
v'
a
a
0
F
a
an
W
O
U
x
C
s
Gt7
O
z
Z'
H Z
x
Cf
W
F
C
O
C
>
14"e
✓
Z
d w
y
E"
x
z
z
p
A
w
G
w
SU B-BASEM ENT
C
''
z
C7
;
O
0
z
o
BASEMENT
U
>
p
0
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR.
STH. FLOOR.
- - r.,..s worx ana installations performed under Permit Issued for this applicationwill e in curate to the
compliance with all pertinent provisions of the Massachusetts State Gas
ode d Ch er .14 the General Laws.
7By:.Signature of Licensed Plumber Or Gas Fitter
E3 Plumber
; Gas FitterLicense um er
Master
APPROVED (OFFICE USE 011 � Journeyman
1 ne commonwealth of 11fassachusetts
Department of Industrial Accidlents
Offce of Irnvemie ations
600 WashinoQton Street
L'ostoez, M4 62111
wwxI_rr24=4 oi,/cfia
Workers' CompeIIsation ins urance.Afidavit,guilders/Co
ntracirors
)Iicant Information /Eieciriciaas/Pillmbers
�aIIle (Business/OrganizationMdividual):
Address:
City/State/Zip:
Are you an employer? Check the appropriate box:
. ❑ I an a employer with q ❑ i
Phone #:
lo� p , amaa—n i
em
Y ..s (frill and/or art -time .*
2. ❑ 1 am a sole proprietor or partner-
ship and have no employees
working for mein any capacity.
[No workers' comp. insurance
required_]
3. ❑ I am a homeowner doing all work
Myself [No. workers' comp.
insurance required.] t
L- -- er,a contractor and I
have hired the sub-
contractors
Iisted oat the attached sheet, I
These sLeb_contractors have
workers' comp, insurance.
$ ❑ we are .a corporation and its
°ffic= have exemised.their
right of exemption per MGL
c. 152, § 1(4), and we have no
'emplOYees. [No .workers'
corn
Type of project (required):
.6•. ❑ New construction
❑ Remodeling .
S. ❑ Demoiition
9. ❑ Building addition
Electrical repairs or additions
Pl=bing repairs or additions
I2 [] Roof repairs
p. insurance required.] 13 ❑Other
*Any applicant.thm checks box #1 .must also fill our the section below sho
t Homnownets wbo submit •fiiis affidavit irldicarin� their arc c uiE?� a ,.�.` W1ng their work Re
xConnactors that checl: this box -must attached ori additional shit showing 00m nsation policy information,
ru inon hire out$iae conirru tuts rnusi su'omii n new amrinvir inaiciirtF
the none of the soh cc ,aactors and their workers' comp, policy iimring ion.
I atrt an. employer Qi is providil workers, c nnpe;7sadorz irzsurance or ,
information. f employees. Below
rs Che policy ana'job site
Insurance Company Name:
Policy # or Self .ins. Lic. #:
Job Site Address:
Expiration Date:
Attach a copy of the workers' compensation policy tieeEac-afion a City/S�Zip:
.Failure to secure coverage as required under Section 25A of pace �showin' the Policy number and expiration date).
fine up to 51,500.00 and/or one-year im sonme MGL c. 152 can lead to the imposition of criminal penalties of a
of up to .S250.00 a da. g int a5 well as civil penalties in the form of a STOP WORK O
against the violator. Be advised that a copy of this statement may PMER and a fine
investigations of.the DIA for insurance cov-rage verification_
be forwarded to the 'Office of
y cerujy under the pains and penalties of pc7urf' rha� the informadon provided above is Crue and correct
Signature:
Uncial use onip. Do not write in this area, to be Completed by city ortown official
City or Town:
Issuing Authority (circle one):
Permit/License #
1. Board of Health 2. Building Department 3. CitylTown Clark 4. Electrical Inspector 6. Other p ctor S. Piumbiag Inspector
Contact Person:
Phone
i-mormation ce nd instructions •�
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an em
playee is defined. as ".. -ver-y 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 incluriin.g the legal representatives of a deceased employer, or the
receives 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 ap a tments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do ma.int-nance, construction or repair work on such dwelling house
or on the grounds of building appuurtdtrant the shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state a r local licensing agency shall withhold the issuance or
renewal of a license or permitto operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence mf compliance with the insurance coverage required.°
Additionally, MGL chapter 152, 925C(7) states "Ne"rther -tune commonwealth nor any of its poiftical subdivisions shall
enter into any contract for the performance of public worlic until acceptable evidence of compliance with the insurance
requirements of -this chapter have been presented to the corrtlacdng authority,"
Applicants
Please fill out the workers' compensation affidavit compl-etely, by checking the boxes that apply to your situation and, if
necessary, supply sub-cbntractor(s) name(s), address(es)and phone number(s) along with their c—errificate(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 catry.workers' compensation insurance. if an LLC or LLP does have..
employees, a policy is required_ Be advised. that this afficlavitmay.be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the. affidavit Theaffidavitshouid
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 Mge rding the iam, o7 if you are required to obtain a workers'
compensation policy; please call the Department at the nn-arrber:Iisted below. Self insu.-ed companies should enter their
self insurance license number on the avpropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bowm
of the affidavit foryou to fill out in theevent the Office of Investigations has to contact you regarding the appii=L
Please be sure to fill in the permit/license nurnbcr which will be used as a reference number. In addition, an applicant
that must submit multiple perrnMicense applications in arty 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 Iicenses. A new affidavit must be fulled out each
year. Where, a home owner or citizen is obtaining a licens-- 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 fay, number.
The Commonwealth of Massachusetts
Department of lmdustrial Accidents.
Office of Investigations
600 'WasbEington Street
Boston, SIA 02111
Tel. # 617-727-4900. Cit 406 c r 1-877 MASSAFE
Revised 5-26=05
Fax # 617-727-7749
VFWUi'.IF ass. c ov/dia