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- CERTIFICATE 4` USE & OCCUPANCY
TOWN OF N I TH ANDOVER
/ Building Permit Number 673(6/5/09)__ Date: August 4, 2009
THIS CERTIFIES THAT.
THE BUILDING LOCATED ON 184 Cortland Drive
MAY BE OCCUPIED AS Single Family Dwelling
IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING
CODE AND SUCH OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to: Meetinghouse Commons LLC
115 Carterfield Rd
North Andover MA 01845
Building Inspector
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APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION
Buildina Permit # 67,3
ADDRESS/LOCATION OF PROPERTY: f ? y CQ
Map f 0 C. Parcel 3 Lot Number 0 M )T 33
SUBDIVISION
DATE REQUESTED FILED/READY FOR INSPECTION 306 71391
CLOSING DATE ON PROPERTY:
FIVE (6) DAYS NOTICE PRIOR TO CLOSING DATE IS 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 APPLICABLE CODES.
Permit Issued to:
Address
N
U RO ING 4 Y10
CONSERVATION vep FILO #'242,-1114
PLANNING 71 PIA- C 1,. 4 o B
DPW -WATER METER E �.., �1)�y
SEWERIWATER CONNECTION
NOTE
04
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST
Signature
File: Application for OC form revised Jan 2007
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that. req.!.rl ...... !<�gfre-44-
has permission to perform ........% ............................
wiring in the building of ... $15-..149 V kL a
.........................................................
North Andover, Mass.
Fee,. ... Lic. No . ............. .................
Check
j71
I
Commonwealth of Massachusetts
Official Use Only
Department of Fire Services Permit No.
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked s,5
[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 12.001Z
r Y O R K
(PLEASE PRINT IN DX OR TYPE ALL INFORAM TION) Date:
City or Town of: NORTH ANDOVER
To the Inspec or of Wires:
By this application the undersigned gives notice of his or er intention to erfoim the electrical work described below.
Location (Street &Number) d �•� G„ Z -.
Owner or Tenant
Owner's Address
�� GT Telephone No.
Is this permit in conjunction with a building permit? YesNo .VZ E7 ZyV f
Purpose of Building ❑ (Check Appropriate Box) go
°' Z Utility Authorization No.
Existing Service Amps /Volts Overhead
❑ Undgrd ❑ No. of Meters
New Service Amps Volts Overhead
❑ Undgrd �� , No. of Meters
Number of Feeders and.Ampacity(f 2/ �
Location and Nature of Proposed Electrical' Work,
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
No. of Luminaire Outlets,.
No. of Hot Tubs
No. of Luminaires
Swimming pool Above cnn d ❑ n-
.
No. of Receptacle Outlets
INo. of Oil Burners
No. of Switches
No. of Gas Burners
No. of Ranges
No. of Air Cond. Total
No. of Waste Disposers
Tons
Heat PNsj!!t�
To
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Appliances KW
No. of Water I
Heaters
No. of No. of
Signs Ballasts.
o. Hydromassage Bathtubs No. of Motors
OTHER:
on table may be waived by the Inspector of Wires.
No. of Total .
Transformers KVA
Generators KVA
o. o mergency 1,1gating
❑ i2nN.....�.
TRE ALARMS JNo. of ?manes
47 Of Detection and
Initiating Devices .
o. of Alerting Devices
o. of Self -Contained
e_tection/Alerting Devices
Kcal ❑ Municipal
Connection ❑ Other
Icurity Systems:*
No, of Devices or Equivalent
ata Wiring:
No. of Devices or Eauivalent
Total HP I i eiecommunicatione
No. of Devices or
Estimated Value of Electrical Work:D �O(, �
Attach additional detail if desired, or as required by the Inspector of Wires.
(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 certify, under the pains and penalties� of perjury, that the information on this application is true and complete -
FIRM
NAME: W n G i C�,v
.A
Licensee: ��t h �Signature LIC. NO.:
(If applicable enter "exempt " in the license number line.) LIC. NO.. (i oSb d
Address: Bus. TeL No.: f�
*Per M.G.L c. 147, s. 57-61, security work requires D „ , Alt. Tel. No.:
Department the Li t ns 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 g 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: $�" or'
6 e -le t11- & r - Occ
AV`
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I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washing ton Street
Boston, MA 02111
c : www.mass gov/dia .
Workers'
Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
rinlirnnf Tn$n.•..._4-:__
Nazi (Business/organiza6on/Individual):
Address:��
City/State/Zip: �l/, )(�P� /1it�' Phone #: .
Are you an employer? Check.the appropriate box:
I. I am
a employer with __6'2f
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_
on the attached sheet
ship and have no employees
These sub -contractors have
working for mein any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.)
3. ❑ I am a homeowner doing
officershave exercised their
all work
right of exemption per MGL
Myself [No -workers' comp.
c. 152, § I(4),'and we have no
insurance required.] t
employees. [No workers'
comp. insurance required..]
Type of project (requires:
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition _
9. ❑ Building addition
10.0 Electrical repairs or additions
I I.❑ Plumbing repairs or additions
12.❑ Roof -repairs
13.[].Other
Er E MUSE also tut 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 outsid
;Carittactors that check this box must e contractors trust submit a new affidavit indicating such
attached an additional sheer showing the name of the sub -contractors and their workers' comp• policy informsdon.
I am an employer that is providing:worhers' compensation insurance for my employees: Below is the
information. policy and job site .
Insurance Company Name:__' y 47y4,
Policy # or Self -ins., Lie.. Expiration Date:
Sob Site Address: j <7(j 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 certinder t pains and penalties of perjury that the information provided above is true and coned
07xial 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 S. Plumbing Inspector
6. Other
Contact Person: Phone #:
S
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) acid phone number(s) along with their certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to cavy 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'appropriaw 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 AccidentsG,4'
Office of Investigations _
600 Washington Street s -y 44/.
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax # 617-727-7744
www.mass.gov/dia
00
Date.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ...............
has permission to perform ......
plumbing in the buildings of ....... ........... ........
at ........... /-/," North Andover, Mass.
Fee'.'73 Lic. No..! . .......
PL WING INSPECTOR
Check # 'Mo R
8101
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date
Building Location Owners Name g Permit #
Amount
Type of Occupancy
Newd Renovation1:1 Replacement Plans Submitted Yes No ❑
:I
1
40
.i ilk
..O-.-...M---.M®O--------.
• ,
...--.--.M-.MMMMMM-...-.-
,,��rin�����■�����������MMM
(Print or type)` /� ��_ / Check one: Certificate
Installing Company Name%i l /�I % Corp.
Address U I� Partner.
40 30-7C
Msi ess Telephone — Firm/Co.
Name of Licensed Plumber: / I'[/(,Lid—W 4�._
Insurance Coverage: Indicate the t pe of insurance coverage by checking the ate 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 I
Owner ❑ Agent
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 Smote Plu bin de an _ t 2 of the General Laws.
By: igna ure or Licensee rium ear
Title
Type of Plumbing License
City/Townis nse um er Master Journeyman E]APPROROAPPROVED �or-r-tcE USE ONLY
r� +
The Commonwealth o Massachuse
ki
.f tis
Department of Industrial Accidents
Office Investigations
of
600 lfj Kington Street
p„
Boston, MA 02111
1 Zr
w9w mems govIdca .
Workers' Compensation Inseu-ance Affidavit: Builders/Co ntractors/Eiectricians/Piumbers
I.
Alicant nformation
Please Print Led
Name (Business/Org8nizatlona✓Individual):
Address:
City/.State/Zip:
Phone #: .
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4. ❑ I am a Type of Project (required):
general contractor and 1
employees (full andlorpert-time).*
2. ❑ I am .a:sole proprietor or
have hired the sub-contractors b. ❑ New construction
partner-
ship and have no employees
listed ort, the attached sheet � �. ❑ Remodeling
These sub-contractors have
working for me .in any capacity,
[No workers' comp, insurance
workers, comp. insurance. 8. ❑ Demolition
5. ❑ We are a corporation and its 9• ❑ Building addition
required.]
3.[3I ant a homeowner doing
officers have exercised their 10. El Electrical reps or additions
all work
myself. [No-workers' comp.
right of exemption per MGL 11.❑ Plumbin
C. 152, § 1(4), and we have no g TePairs or additions
insurance required.] t
.employees. [No workers' 12•❑ Roof mpairs
comp. huttrancerequired.] t317.0ther
'Any applicant that checks bot: # 1 must also fill out the section below showing their workers' cofnpensation policy informaEion
t Flomeownets who sabmit this affidavit indicating they ate doing ori work end then hrte outside
;Contractors that
contractors
check this box must &hotbed an add•'fiana sheet showier the name of the sub-con nn submit a new affidavit indicetiag such.
ttactm and their workers' Comm Folie information.
I ant an employer that is
providutg:workers, Campensatfan insurance or
information. f jM employees: Below is *1PoMlyand job site .
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address:
City/Swrzip.
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
fine up to $1,500.00 andlor on imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and ai
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 fine
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 rorrert
Of}f"d use only. Do not write in this &req to be compieted by city or town offilciaL
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electri
6. Other cal Inspector S. Plumbing Inspector
,, �� Contact Person•
Phone #:
4 -
Information
Information and Instructions j
Massachusetts General Laws chapter 152 requires all emp 7 oyers 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, assodiation, corporation or other legal entity, or any two or more
of the'foregoing engaged in a joint enterprise, and includirig the legal representatives of a deceased employer, or the
receiver orbu tee of an individual, partnership, associatiorn 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.oir compliance with the insurance' coverage required." �.
Additionally, MGL chapter 152, §25C(7) states "Neither t3he 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 cor&uc&g 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) acid phone number(s) along with their certificates) 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 shouid
be returned to the city or town that the .application for the permit or license is being requested, notthe 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 i' inured crmp i chn��ld Par then
self-insumnce-liceme number on the'appropriate tine.
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 applicant.
Please be sure to fill in the permit/license number which wili 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
avit is on file for futrae permits or licenses. A new affidavit must be filled out each
applicant as proof that a valid affid
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 investigations would 1-ke 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 1-977-MASSAFE
Fax # 617-727-77451
Revised 5-26-05
www.mass.gov/dia
/ r
Date..
MORTM
Of
'` TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ... (. . . �f� ! ..f ! . ...... .
has permission for gas installation{.A,1?.e
in the buildings of .... .. / ! ... �?...!(... ... .
at ..................... ....... .... , North Andover, Mass.
Fee. q L:... Lic. No../ i.! 5' ./ . .:
QASINSPECTOR y
Check # U a
190=5
MASSAMUSETTS UMRM APPUICATON FOR PERM TO DO GAS FITTING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Logations _ /k y Z&C_ AA
Owner's Name
New Renovation ❑ Replacement
SU B -BASEM ENT
BASEMENT
IST.
FLOOR
2ND.
FLOOR
3RD.
FLOOR
4TH.
FLOOR
5TH.
FLOOR
6TH.
FLOOR
7TH.
FLOOR.
;TH.'
FLOOR.
(Print or type)
Name
Address
Date71(07
S
Permit #
Amount $
Plans Submitted ❑
Name ofLicensed Plumber'or Gas Fitter
/ Check one: Certificate Installing Company
Y Corp.
Partner.
�� ❑
Firm/Co.
INSURANCE COVERAGE
I have a current liability Insurance•poI' or it's substantial equivalent Check o
If you have checked yes• please' icate the type coverage by checking the appropriate bs tr No❑
Liability insurance policy Other type of ind
emnity ❑ Bond ❑
Owner's Insurance Waiver I am aware that the licensee does not the Insurance coverage required b Chapter
Mass. General Laws, and that my signature on this permit application waives this requirement. y P r 142 of the
Signature of Owner or Owner's Agent Check one:
Owner Agent
I hereby certify that all of the details and information I have submitted (or entered) in above pplicatio13
n are true an
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will to in
' d accurate to the
compliance with all pertinent provisions of the Mas sachuse State
as C e any�42 of the General Laws.
Title
APPROVED (OFFICE USE ONLn
Signature of Licensed Plumkuumer�—
r Gitter
❑ Plumber ❑ as Fitter Icense
tJ Master
❑ Journeyman
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Name ofLicensed Plumber'or Gas Fitter
/ Check one: Certificate Installing Company
Y Corp.
Partner.
�� ❑
Firm/Co.
INSURANCE COVERAGE
I have a current liability Insurance•poI' or it's substantial equivalent Check o
If you have checked yes• please' icate the type coverage by checking the appropriate bs tr No❑
Liability insurance policy Other type of ind
emnity ❑ Bond ❑
Owner's Insurance Waiver I am aware that the licensee does not the Insurance coverage required b Chapter
Mass. General Laws, and that my signature on this permit application waives this requirement. y P r 142 of the
Signature of Owner or Owner's Agent Check one:
Owner Agent
I hereby certify that all of the details and information I have submitted (or entered) in above pplicatio13
n are true an
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will to in
' d accurate to the
compliance with all pertinent provisions of the Mas sachuse State
as C e any�42 of the General Laws.
Title
APPROVED (OFFICE USE ONLn
Signature of Licensed Plumkuumer�—
r Gitter
❑ Plumber ❑ as Fitter Icense
tJ Master
❑ Journeyman
Q0
Inc L onunonwealth of Massachusetts
1
�/ Department o
1, ! qty L -f -industrial A.,idents
C Office o {
.f IitveStle atlOn;T
600 Was
hinVon street
l;ostoaz, M,q 62111
r , wxn•ct
Workers' Compensation InsuranceAffidavit.
if a
I lkaanf Information A £ic�avit. $uijders/Contractors/Electridians/Piumbers
Name }$usiness/C) ganirationMdividual):
Address:
City/State/Zip:
Phone #.
Are you an employer? Check the appropriate box:
1 • ❑ I an a employer
with
4. ❑ I am a QA l
employees (r'till and/or part-time).* ""
2. ❑ 1 stn
o contractor
have hired thesub-cntr
a sole proprietor or partner_
ship and have no employees
actorsI
listed oxi the attached sheet �
working for me in any capacity.
These su
workers,b-contractors have
No workers' comp. insurance
5.. ❑ We arcomp. insurance.
corporation
regttired.]
3. ❑ l an a homeowner doing
and its
cers have exercised. their
all work
myself
Y [No. workers' comp,
insurance
rig t of Xemption per MGL
C. 1S2' e 1 and we
we have
required.] t
no
employees. [No
.
cam
Type of project (required):
'6•. ❑ New construction
�• ❑ Remodeling .
8• ❑ Demolition
9 ❑ Bui}ding addition
10:11 Electrical repairs oradditions
I1.❑ Plumbing repairs' or additions
110 Roof repairs
Any app3icant that checks box # I .must also fill out the section below p o Su Ce required.] 13 ❑Other
+ ilomcowners who submit.tilis a,�itdavit indicating L`rer me duit:. t; s=.;: ng their work' compensation
xConuaetors that ch-*, this box must attached an additional sheet showing W iu fn_ p° miortnatton.
'n hire outside coniracfurs mus[ submit a now affidavit indimon
am
the' name of the soh-caraactors and th S a::ah.
i ammati muloycr that is providing worke s $ corr�ePrs ori insurance or , Dir workers' comp. poiics, inionnation.
f ny employees. Belorn is the poficy and job site
Insurance Company Name:
Policy # or Self .ins. Lic. #:
Sob Site Address: Expiration Date:
Attach a copy of the workers' comtoetas9s�.,'.,..s:..,, ,r _City/Sta&zip:_
-__ .._, •a, atzion page (showing the policy Dumber and expiration date).
.Failure to secure coverage as required under Section 2�A of
fine up to iI,500.00 and/or one-year imprisonment MGL c. 152 can lead to the imposition of criminal penalties of a
of up to .S2 y y pr. advised
a well as civil penalties in the form of a STOP WORK ORDER and a fine
50.00 a da Painst fine violator. BeSe advised that a co
Investigations of the DIA for insurance coverage verification, of this statement may be forwarded to the .
Office of
I do hsrnhu ��.•�;�, .....,r� .� .
of perjurJ' Zh,', the in or
l oration provided above is true
and correct
DciaL use nn1 p. Do not write in this area, to be con�olezed h3, city or toff
wn octal
City or Town;:
Issuing Authority (circle one): Permitucense ,*
1. Board of Health 2. Building Department 3. City/Townfi. Other Clark 4. Electrics[ Inspector r 5. Piumbino
b Inspector
Contact Person:
Phone #
iniormanon 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 ".. 0 -ver -y person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is donned as `pan individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and includi-ing the legal representatives of a deceased employer, or the
receiver or trustee of an individual,. partnership, associate on or other legal entity, employing employees. However the
owner of a dwelling house having not more than .three ap ai-trnents and who resides therein, or the occupant of the
dwelling house of another who
employs persons to do matint-nance, construction or repair work on such dwelling ho—e
or on the grounds or building appurtenant thereto shall.not because of such employment be deemed to be an employ
MGL chapter 152, §25C(6) also slates that "every state o r local licensing agency shall withhoid the issuance or
renewal of a iicense or penTnitto operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence af compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states 'Neither -the commonwealth nor any of its political subdivisions shalil
enter into any contract for the performance of public werl< ural 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 compl-etely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) naine(s), address(es) and phone numbers) 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. rf an LLC or LLP does have -
employees, a policy is required. Be advised. that this affici.avit maybe submitted to the Department of. Industrial
Accidents for confirmation of insurance coverage. Also 11be sure to sien and date the affidavit. Theaffidavitshould
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 ►re°ardung the iavu, or. if you are mquired to obtain a workers'
compensation policy, please call the Department at the n�znber:lis�.ed bel
low. Sef insured companies should enter their
self-insurance license number on the atmropriate line.
City or Town Officials
Please be sure that the afndsvit .is complete and printed legibly, The Department has provided a space at the bottom
of the affidavit foryou 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 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 starnped 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 filled out each
year. Where, a home owner or citiz-n 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 Departrnent's address, telephone and fax number.
The Commonwealth of Massachusetts
Department ofImidustrial Accidents.
Office of Lnvestibafions
600 Washgton Street
Boston; SLA G2111
Tel. # 617-727-4900 Mrt 406 c r 1-9..7 MASS.4FE
Revised 5-26=05 Fay # 61 7-72.7-7749
wVM'.mass.govlura