HomeMy WebLinkAboutMiscellaneous - 187 CORTLAND DRIVE 4/30/2018m
2
Date ...... ..... �..... ...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that A A L,0 Je- -4-4-. " '
r.
Z�-
.........................................................................
has permission to perform .............................................
...... .... ....
wiring in the building of �� .... . ............ 11 ........ ..... : .........
................ ....................
Feel-v�... Lic. No.Z. �-n .......
. Check # —'--Z -L�
0 9 61
Mass.
U
A
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 'f 9tol
Occupancy and Fee Checked
Lev, 1/07] (jpnvehlankl
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 MR 12.00
(PLEASE PRINTININK OR TYPE ALL INFORMATION) Date:
City or Town of. NORTH ANDOVER
To the Inspector Wi es:
By this application the undersigned gives notice of hisor her intention to perform the electrical work described below.
Location (Street & Number) � � $' � /�I �
Owner or Tenant ( l
Owner's Address
-Al 3. LLC, Telephone No. . X 3,
Is this permit in conjunction with a building permit? yes No v
Purpose of Building /C ❑ (Check Appropriate Boa)
--�---- Utility Authorization No. '7` j / y3 dj%�f
Existing Service Amps / Volts Overhead ❑ Und d /
�A� ❑ No. of Meters
New Service rxw_ Amps 1ol�volts Overhead ❑ Und rd
g No. of Meters
Number of Feeders and.Ampacity P If ��� �� �rNl
Location and Nature of Proposed Elechic!/al Work.
No. of Recessed Luminaires
No. of Luminaire Outlets
No. of Luminaires
No. of Receptacle Outlets
No. of Switches
No. of Ranges
No. of Waste Disposers
No. of Dishwashers
No. of Dryers
Heaters KW
Hydromassage Bathtubs
OTHER:
o the ollowing table may be waived by rho
No. of Ceil.-Susp. (Paddle) F
No. of Hot Tubs
Swimming Pool Above ❑
d.
No. of Oil Burners
No, of Gas Burners
No. of Air Cond. To
To
Heat Pumfl!!!�T`Lni Total
Space/Area Heating KW
`Heating Appliances
No. of No. of
Signs Balla4
No. of Motors Total
ansJFIRE
. of Total
ansformers KVA
nerators KVA
In-.
rind.tte
o mergency ig g
Units
ALARMS No. of Znes
..of Detection and
Initiatin Devices
us
.
No. of Alerting Devices
_._'.
- _-�
o. of Self -Contained
Detection/Alerting, Devices
Local ❑ Mumcipal
❑ Other
Connection
KW
Security Systems:*
No. of Devices or Equivalent
f
;ts
Data Wiring:
.
No. of Devices or E nivalent
HP
Telecommunications Wiring;
No. of Devices or Equivalent
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 StartInspections to be requested in accordance with MEG 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 JZ BOND ❑ OTHER ❑ (Specify:)
I certify, under the uts and enalttes o p )
p fperjury, that the information on this application is true and complete.
FIRM NAME: 1ly' n ( a/ r
S � ` _
GY �/ C«i..� LIC. NO.:
Licensee: /r/jy/ ell SignatureLIC. NO.:
(If applicable, enter "exempt " in the license number line.)
Address: r,� �� �� Bus. Tel No.: %7ZS?U
*Per M.G.L c. 147, s. 57 -61, -security work requires D „ „ Lice Alt: Tel. No.: 9 r aft f
q Department of Public Safety S License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement I am the (check one) ❑ owner ❑ owner's agent
Owner/Agent
Signature Telephone No. PERMIT FEE: $ ot'o
L
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 NZashington Street
Boston, MA 02111
www.moss.gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectricians/Pittmbers
nt
MUCant Infa atinn
Name (BusinesslOrganizadon/Individual): c
Address:�2�
Citystate/Zip:
IVA Phone #:.
Are Y!�employer? C'heek.theap priate box:
I am
• Ly'I a employer with ��0
4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
2. ❑ 1 am a:sole proprietor or
have Fired the sub -contractors
listed
partner-
ship and have no employees
ani the attached sheet, t
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. ❑ 1 am s homeowner doing
officers have exercised their
all work
right of exemption per MGL
myself. [No -workers, comp.
c. 1.52, § I (4),' and we have no
insurance required.) t
..employees. [No workers'
comp. insurance required.1
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
I l.❑ Plumbing repairs or additions
12.[] Roof -repairs
13-M Other
;Any applicarrt that checks boy' # l must also fill out the section below showing their workers' compensation
homeowners who submit this affidavit indicating they are doing all work and then hire outside c ntractom musticy submit infba naw affidavit indica
4Contractors that check this box must attached an additional sheet showingthe name of the su hag such.
b -contractors and their works' camp. an employer that isp policy infnrmatien.
1 am Providing: :wor
nfornratiort, S te' compensation insurance for m1' employees; Below is the policy and job site .
Insurance Company Name;
Policy # or Self -ins. Lie.
Expiration Date:
Job Site Address:2
City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy cumber and expiration date).
Failure to secure coverage as required under Section 25A of MGL e. 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 tray be forwarded to the Office of
Investigations of the DIA for' coverage verification.
1 do hereby certify undir f paimeandpenaldes of perjury that the information provided above is true and correct
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
6. Other Z Building Department 3. City/Town Clerk 4. Electrical Inspector 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 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 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 cant' 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, 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 nurnber listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (.if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy offhe 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 lnvestigptions 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 Investibations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 www.mass.gov/dia
CERTIFICATE OF USE &OCCUPANCY
-TOWN OF NORTH ANDOVER
Building Permit # 44 Date: September 14, 2009
THIS CERTIFIES THAT
THE BUILDING LOCATED ON: 187 Nnrt
May be occupied as a Single Family Dwelling in accordance with
the provisions of the Massachusetts State Building Code and other
Regulation that may apply.
Certificate Issued to: Meetinghouse Commons LLC
115 Carter Fields Road
North Andover MA 01845
Inspector of Buildings
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Date ..V ... .... .
p` to ,s"YO
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
Io
o
This certifies that . A&. h&Z .... P �/ ...........
has permission for gas installation .. 44'! ���!?4'..........
in the buildings of ....�C?�.a`'/�'................
at.......s�I jS..77.... ���'1 �-.... , North Andover, Mass.
Feey�Q ... Lic. No.. /1/5.7 . �........... .
GAS�iNS CTOR
Check # /U
�Vf:��
MASSACHUSETTS UNIFORM APPLICA-fON FOR PMWr TO DO
(Type or print) FnG
NORTH ANDOVER, MASSACHUSETTS
Building Loriations �a 7 (otlr4 rt,
Date d
(Print or type) k &
Name
Name of.Licensed Plumber'or Gas Fitter
Check one: Certificate Installing Company
Corp. .
0 Partner.
FinWCo.
INSURANCE ;liability
RAGE
! have a currenInsurance.poI" or it's substantial equivalent Check on .
If you have chees. please ' Icate the type coverage by checki n YesLiabilityinsurancepolicy g the appropriate box No�
Other' type of indemnity D
Owner's Insurance Waiver O13
ther
aware that the licensee does not have the`-+gond
Mass. General Laws, and that my signature on this.permi appii�cation ��,�VeInsurance j� age required b
gy Chapter 142 of the
Signature of Owner or Owner's Agent Check one:
hereby certify that all of the details and information I have submitted (or en d) in OVAILT � ppent
best of my knowledge and that all plumbing work and, installations performed under Permit Issued foron compliance with all pertinent provisions of the Massachusetts S e are true and accurate to the
�Gas ode d Chapter is application will be in
, / �, of the General Laws.
Title
Signature of Licensed Plumber Or Gas Fitter
1:3 Plumber
City/Town; /s—/S 7
Gas Fitter License Number
"Master
—_
kPPRO VED (OFFICE USE ONLr Journeyman
Permit #
rJ^ r /�
Owner's Name
..
Amount $
New ❑ Renovation
Replacement
❑
Plans Submitted
4
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_BASEMENT
CS
U'
m°
a� O
1ST. FLO0R
1
2N D. FLOOR
3RD. FLOOR
4TH. FLOOR
TH. FLOOR
6TH. FLOOR
' 7TH. FLOOR.
8TH. FLOOR.
(Print or type) k &
Name
Name of.Licensed Plumber'or Gas Fitter
Check one: Certificate Installing Company
Corp. .
0 Partner.
FinWCo.
INSURANCE ;liability
RAGE
! have a currenInsurance.poI" or it's substantial equivalent Check on .
If you have chees. please ' Icate the type coverage by checki n YesLiabilityinsurancepolicy g the appropriate box No�
Other' type of indemnity D
Owner's Insurance Waiver O13
ther
aware that the licensee does not have the`-+gond
Mass. General Laws, and that my signature on this.permi appii�cation ��,�VeInsurance j� age required b
gy Chapter 142 of the
Signature of Owner or Owner's Agent Check one:
hereby certify that all of the details and information I have submitted (or en d) in OVAILT � ppent
best of my knowledge and that all plumbing work and, installations performed under Permit Issued foron compliance with all pertinent provisions of the Massachusetts S e are true and accurate to the
�Gas ode d Chapter is application will be in
, / �, of the General Laws.
Title
Signature of Licensed Plumber Or Gas Fitter
1:3 Plumber
City/Town; /s—/S 7
Gas Fitter License Number
"Master
—_
kPPRO VED (OFFICE USE ONLr Journeyman
-�•.aiiiwCQLrn of Massachuset>
I' v
trne
De ardccstrl'
1, 1 Ii r�/fid
lP D nt of Inal.4ccidents.
�� Ce Of IRVeStZe QL`10ns
?I� ' 600 W
i ¢shinoton Street
Bast" MA 62111
kr -
n Ins)1di
urance w - ss°nt
Workere Compensatioa
)Iica.nt Information �davlt; guilders/Contractors/Electridians/plttmhers
Name (Bu siness/OrganizaboMndividualj:
Address:
City/Rate/Zip:
Phone #:
Are you an
employer? Check the ro
PP Priate box:
I . I am a employer with
to ----
.—P----- 4. ❑ 1 am a
Y ..s (full and/or part-time).
2. ❑ I am a sole proprietor or partner_
ship and have no employees
working for mein any capacity.
No workers' comp. insurance
required-]
3 • ❑ I an a homeowner doing all work
myself. [No workers' comp,
insurance required.] t
M-- erd contractor and I
have hired the sub -contractors
Iisted a>o the atrached sheet t
These si"b-contr`actors have
workers'
ED We area comp. insurance..
ofncers hcorporation and its
ave exercised.theii
right of ex.mptiOn per MGL
C. IS2, § 1(4), and wt have no
.employees. [No workers'
calm
TYPE of project (required):
.6•. ❑ New construction
�• ❑ RernodeIing .
g ❑ Demolition
9- D Building addition
Electrical repairs or additions
1' 1'D Plumbing repairs or additions
12=11Roof repairs
`Aml appiicmt_thm cheeks box 9 .must also fill out the section below sh. insurance required.] �13.Lj Ot}tef
ti-iorneownets who subinii.tliis ai£davh indithey are duirgto;he W.,
rtg th-irworkers'compensation
fm
xCanuactors ilial eheci; this box.must ai�hed an addilionai sheet showing }}TILL ihcn hire outside oonuuciurs nus[ su'omi hon.
e Mme Of the sub ocnt =tOm and their wor new atn� poli Mlit en .song --ch.
I am an. eneploper the is pravrdino !corers' co , erg' Com
irfornsatio2 � �otz :.�- e3 i�nnation.
s.=_ �r+ance Jor ng, employes.
Insurance Company Name:
Policy # or Self .ins. Lia.. #:
Below is the policy atidjob`site
Job Site Address: Expiration Date:
Misch $copy of the workers' compensation policy declaration o Cita'/Statv/Z;p:
Failure to secure coverage as required under Section 25A of Pa°e (showiou the oli
fine up to SI,500.00 and/or one-year imprisonment. P e3' number and expirafion date}.
MGL c. 152 can leadd to the imposition of criminal p�ttalties of a
Of up to .S250.00 a da o • a5 well as civil penalties in the form of a STOP WORK ORDER and aft
y a=amst the violator. Be advised that a copy of this statement ma
Investigations of -the DIA for insurance coverage v- if fine
be forwarded to the Office of
Ido herebj, certify ander the paimc andpenalties of perjury that the inforrizafir►rr
Sisnature: provided above is tragi and correct
Phone #:
DffcciaL use nrrip• Do not write in &,& area, to be complezed.by, it or town o cera[
City or Towa:
Issuing Authority (circle one): Permit/LIceRse #
1. Board of health 2. guiiding Department 3. City/Town Clerk 4. Electrical
6. Other inspector 5. PiumbrrrQ
Inspector
Contact Pemmr:
Phone#};
.Li11Vl maLIUH mim lustl ucTions 4
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 contras( of h ire,
express or implied; oral or written.^
An employer is defined as `pan individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and incluair:g the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, associati on or other legal entity, employing employees. However the
owner of a dwelling house.having not more than .three ap, artments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maim-nance, construction or mpair work on such dwelling house
or on the grounds or building appurtenant thereto shall.not because of such employment be d,.emed to be an employer."
MGL chapter 152, §25C(6) also states that "every slate or 10ca1 licensing agency shall withhold the issuance or
renewal of a license or permit% operate a bnsiness or- to construct buiidingus in the commonwealth for. Roy
applicant who has not produced acceptable evidence o�,f 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 contrast for the performance of public worl< mil 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 compZ-etely, 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 certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other titan the
members or partners, are not required .to carry.workers' compensation insurance. if an LLC tr LLP does have
employees, a policy is required_ Be advised that this affidavit may submitted to the Department of. Industrial
Accidents for confirmation of insurance coverage.. ;Also be snare to sign and date the affidavit: Theaffidavit should
be returned to the city or town that the application for the Penn -it ar license is being requested, not the Departnent of
Industrial Accidents, Should you have any questions relgreLrding the ia%v ar. if you arc mquircd to obtain a workcrs' r
compensation policy, please call the Department at the m.-znber:lis+.ed below. Self insured companies should enter their
sett insurance license n*.rmber on the appropriate line.
City or Town Officials
Please be sure that the of idavit .is complete and printed legibly. The Department has provid:-d a space at the botbm
of the affidavit foryou to fill out in theevent the Office of Investigations has to contact you regarding the appiimnt.
Please be sure to fill in the permitJlicense number which vv 11 be used as a reference number. In addition, an applicant
that must submit multiple permitlhcense applications in arty given year, need only submit one affidavit indicating current
Policy information (if necessary) and under "Job Site Adcix-ess" 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 filled out each
year. Where, a home owner or situ, -n is obtaining a licenses or permit not related to any business or commercial venture
(i.e. a. dog license or permit to burn'imaves etc.) said person is NOT required to complete this affidavit.
The Office of investigations would like to.thank you in aclva.nce 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, numb -r:
The Cammonwtadth of Massachusetts
I3cpartment Of Lnd=tial Accid nts,
Office of Ei veritigations
640 WasbLington Street
Briton; MA 02111
Tel. 4 617-727-4900 e= 406 crr 1-877 MASSAFE
Revised 5-26=05 Fax # 61 7-72.7-7749
�w�'-mass.gov/cite
Date. /. .
f
_*
'% "c TOWN OF NORTH ANDOVER
of
oIs PERMIT FOR PLUMBING
This certifies that .... / . � ..k'e... :''. . ��.......... .
has permission to perform ...... ,�0...f�4.d.�f _ ............. .
plumbing in the buildings of J.l%: ��."..- ..'�.� ...... .
at .....North�..r....�G��.� Andover, Mass.
Fee d? Q ... Lic. No.. �—` 7 ........�....:................ .
PLUMBING INSPECTOR
Check ,'i �U�- -?"�
8175
0
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
G (Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location _(C !J Owners Name
/ Type of Occupancy
t
/ 1 Date g
(-permit #
Amount
New 10 Renovation 0 Replacement 1:1 Plans Submitted Yes ❑ No
(Print or type) �f Check one: Certificate
Installing Company Name k,/7�/ / ❑ Corp.
Address 20 h L��? ElPartner.
OT
Business Telephone (� US S72, — Firm/Co.
Name of Licensed Plumber://V/14a.Q,
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Insurance Coverage: Indicate the t of insurance coverage by checking the appropriate box:
Liability insurance policy11 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 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 State Plumbi Co and t 42 of the General Laws.
By:
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Type of Plumbing License
Title S 1Y 7
City/Town icense um eT� rr Master Journeyman ❑
APPROVED torECE USE ONLY
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(Print or type) �f Check one: Certificate
Installing Company Name k,/7�/ / ❑ Corp.
Address 20 h L��? ElPartner.
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Business Telephone (� US S72, — Firm/Co.
Name of Licensed Plumber://V/14a.Q,
-ja A41
Insurance Coverage: Indicate the t of insurance coverage by checking the appropriate box:
Liability insurance policy11 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 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 State Plumbi Co and t 42 of the General Laws.
By:
.,.b.,....uav vi i.iwnsea riu11- '
Type of Plumbing License
Title S 1Y 7
City/Town icense um eT� rr Master Journeyman ❑
APPROVED torECE USE ONLY
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The Commonwealth of Massachusetts
Department of industrial Accidents
Office of Investigations
600 birashington Street
Boston, MA 02111
ww_m s gov/dia .
Workers' Compensation wInsurance Affidavit: Builders/Contractors/Electriciansipiambers
A licant Iaformation .
Please Print Lebl
NBIIle (Business/prgeniration/Individual);
City/Stawzip:
Phone #: .
Are you an employer? Cheek.the aPP�Pte boz:
t. ❑ I am
a employer with
4. ❑ I am a general contractor and I
employees (fun and/or—` *
Part-time).*
2. ❑ I am .a.sole proprietor or
have hired the sub -contactors
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
3. ❑required.]
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
em to ees.
• P Y [No workers'
comp insurance ."A
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9- ❑ Building addition
10.[] .Electrical repairs or additions
11.❑ Plumbing repairs or additions
I2.❑ Roof repairs
req ] 13.7.0ther
Any icant that checks bot # l must also fill out the section below showing their worketc' oompensetion poiicy mformahon
t IiomeawnM who submit this affidavit indicating they ars doing an work and than hire outside contractors
lcontractors that check this box must attached an additional sheat shown • the name of the sub -contractors and
submit a new affidavit indicating such.
their workers' coma- ens;-.....a......,a-_
uric an employer that is proviX1ng:workerscompensation insurance for my employe= Below is thePolicy-... .:..
inform on. and job site .
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address.
City/SwAzip.
Attach a copy of the workers' compeosafion policy declaration page (showing the and a fine
policy numband expiration date
er
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the i
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form mposition ercriminal penalties of a
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 a STOP WORK QRDER aa
Investigations of the DIA for insurance coverage verification,of
1 do hereby certify under the pains and penalties of perjury that the information provided above is tote and rowed
�:--� -
ficial use only. Do not write in this area, to he completed b illy or town official
City or Town;
Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/T-In Cierk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person:
Phone #:
. 4/
Information and Instructions
Massachusetts General Laws chapter 152 requires all emp foyers 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 includirag the legal representatives of a deceased employer, or the
receiver ortrustee 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, MOL 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 certificate(s) of �
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. if an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of industrial
Accidents for confirmation of insurance coverage.. Also 'be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the .application for.the permit or license is being requested, not'the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please -call the Department at the number listed below. Self irtstured oo ani- shoLId enter thofr
self-insurance license number on the' appropriate Nine.
City or Town Officials
Please be sure that the affidavit is compiete 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 vviIl be used as a reference number. in addition, an appikant
that must submit multiple permit1license 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 hike to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
TeL # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 www-mass.gov/dia