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Home My WebLink AboutMiscellaneous - 201 CORTLAND DRIVE 4/30/2018st•.• z uQa N LLJ am \) '_' U \� \,"\\j 0Q � H � W4 O O \ 2 0 vZ° V V o .a M+1 °�°,( u ;r - a, 0'. cn LLJ am \) '_' U \� \,"\\j 0Q :moo O \ 2 V V C C rr CF �o S c. N c 1:1 . c E �i;m a \� i C O �. �' y N 03 CM CD ``4 m ._ m R O c" CLU &Z co ( y m m C' dCt m IS . V NZ � O LC d _ m m : h m =3: : C f.. o 104- CL vimof- IV m z .y I-- az5 cc z LU CA3 m o m� c g CO2 = a' '00 �aO.y'� O Coy =tea m� R� U O O v v CD E CDO V Z 03 CL O y � C ..0 C CO) p 'O O y O O 'E m m 0 CD � O � Lft G3 �3 O G O e_cv o a CMQ Co C cc C v 00 CO2 Z C3 C co CL V y cc i. C . C y ca W 0 to 19 W LU 19 ,W,ww Y/ w APPLICATION FOR CERTIFICATE OF OCCUPANCYnNSPECTION Building Permit # ADDRESSILOCATION OF PROPERTY: Z b' Ca-ry(04 CIVIt Map /OJ C Parcel 3 ! Lot Number SUBDIVISION K"401ty-*- . U DATE REQUESTED FILED/READY FOR INSPECTION 41 SY i0 CLOSING DATE ON PROPERTY: (O 1 D FIVE (5) 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 CpDES. k .t _V Permit Issued to: Address lS LL- C ROUTIN (,91t' ) 10 CONSERVATION PLANNING C, .L (a NIS a DPW - WATER METER ? 1�m T SEWERIWATER CONNECTION NOTE DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW 444' Signature File: Application for OC form revised Jan 2007 APPLICATION FOR CERTIFICATE OF OCCUPANCYnNSPECTION Building Permit # ADDRESSILOCATION OF PROPERTY: 261 care(4 pA� ,t Map /iOC Parcel 3 / Lot Number U �J )7 V-'( SUBDIVISION R"4a6e— �6mrf,-Ow DATE REQUESTED FILED/READY FOR INSPECTION (01, -1110 CLOSING DATE ON PROPERTY:�I1 x,10 FIVE (5) 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 CpDES. Permit Issued to: OI Address IS U RO TI CONSERVATION PLANNING (,N .Ljdt3 NIA 0 DPW - WATER METERC) n T SEWERIWATER CONNECTION(a� f j O NOTE LLC FV DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW �1 OSignature File: Application for OC form revised Jan 2007 R n -z- Date ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ ........ W.APRC)Q has permission to perform .......... ��..... YqvR .................................. wiring in the building of ..... M.tt:T� ...................... L. ...(— 4, (L .................. at ..�' AL ....................................... orth Andover, Mass. Lic. No. r ................ jM�&L �&SW'TOI� Check #-2,90 9 3 7 (U) K� Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 9' Occupancy and Fee Checked tev. 1/07] (1-- APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME ), 5 7 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INF'ORMATIOA9 Date: City or Town of. NORTH ANDOVER l By this application the undersigned gives notice of his or her intention to p�orm theelectrical wo dctol Of ies described Location (Street & Number) >) _below. Owner or Tenant Owner's Address Telephone No.17 Is this permit in conjunction with a building permit? Yesr' Purpose of Building ❑ No ❑ (Check Appropriate Box) �f f� Utility Authorization No. --23 / U_ Existing Service Amps_/ _Volts Overhead ❑ Undgrd ❑ No, of Meters New Service 01�0 Amps 9y /Volts Overhead ❑ UndgrdR� No. of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical ork: 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 Completion of the No. of CeiL-Susp. (Paddle) Fans of Hot Tubs Swimming Pool `°abodve ❑ �-n No. of Oil Burners - No. of Gas Burners No. of Air Space/Area Heating KW of Dryers Heating Appliances KW of Water I No. of Heaters No. of Si s Ballasts. o. Hydromassage Bathtubs OTHER: of Motors Total HP vn tablem be waived b the Ins ector No. of Total Transformers �A Generators ` KVA o* o mergency ig g Batt e Units FIRE ALARMS rl;;, of zones No. of Detection and Initiating Devices No. of Alerting Devices o. of elf -Contained Detection/Alertin Devices Local ❑ Munip Conneccitialon ❑ Other Security Systems: No. of Devices or Equivalent Data Wiring: No. of Devices or E uivalent 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: Work to Stark (When required by municipal policy.) Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent The undersigned certifies that such cov rage 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 o er u that the inform non FIRM NAME: this application is true and complete - LIC. fP J r1', r n.if LIC. NO.: Licensee: 74s.57-61, Signature(If applicabl entin the license num r line.)LIC. NO.Address: Bus. Tel. No.:$*Per M.G. c. 1, security work requires D - „ „ AIL Tel. No.: o. OWNER'S INSURANCE WAIVER: I am aware that the Licens a doles not have the liability insurance License: Lic. lcovera a nonnall 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. FPE"l-TFEE. S , 3A ZI, J I [4 I The Commonwealth of Massachusetts UfDepartment of Industrial Accidents Office ofInvestigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers r Name (Business/Organization/Individual): /1 v, ,, Address: City/State/Zip:�� Phone #: Are you -nn employer? Check the appropriate box: 1. I am a employer with L 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. : ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work Myself [No workers' comp. insurance required.] t • A nv ATTt:n fb., . _,. L These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] _- -- --- Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.7 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other --1 1u vut UIV SecdOn OeiM;, s:^.OR!!^.b :heir wOr - compensation po l2Cy information. Homeou vers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. , 9 , Insurance Company Name: Policy # or Self -ins. Lic. #:__/J,�� / Expiration Date: ,� Job Site Address: C� �/- . City/State/Zip: ;LZe; A�F/�l 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 cern sunder a pains and penalties 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other D Contact Person: Phone #: R3 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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 appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 east 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 mrww.rnass,gov/dia Date ..........A .. ..... . TOWN OF NORTH ANDOVER p • PERMIT FOR GAS INSTALLATION This certifies that ...,�!.J. ... (�/.� ... ?w ......... . has permission for gas installation ........... in the buildings of ..'11.?r-a'Q...or'? ... ��'/ {; �GG at ... a I.......(1 ........ North Andover, Mass. Fee. .16v ... Lic. No.. .... !, / ............ GAS INSPECTOR Check # / 3 r)1 7211 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations Owner's Name New Renovation ❑ Replacement ❑ Permit # Amount $ f; Plans Sub tted ❑ i r MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations Owner's Name New Renovation ❑ Replacement ❑ Permit # Amount $ f; Plans Sub tted ❑ (Print or type) Address Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company ❑ Corp. r D"�//l/LIrL ❑ Partner. i ® Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ET No If you have checked yes, please in ate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ L b—..1, , —+;A,+1—+ -11 -,r,L....7..a_.1_ .........ivaiia—a l i,avc JUU1111LLGU kor enterea) 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 GasoCodF and ChVtVy of the General Laws. By: Title City/Town IAPPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber l y 4S 7 as Fitter License Number ElMaster ❑ Journeyman w vi rA y � U o a a a H ° U M x z a z >x dU v' a w W m a. o Wi" ow oa o 3 F O SUB-BASEM ENT a U > BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 1± 8.TH. FLOOR — —L—j (Print or type) Address Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company ❑ Corp. r D"�//l/LIrL ❑ Partner. i ® Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ET No If you have checked yes, please in ate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ L b—..1, , —+;A,+1—+ -11 -,r,L....7..a_.1_ .........ivaiia—a l i,avc JUU1111LLGU kor enterea) 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 GasoCodF and ChVtVy of the General Laws. By: Title City/Town IAPPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber l y 4S 7 as Fitter License Number ElMaster ❑ Journeyman The Commonwealth of Massachusetts Department o f Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/orpart-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet t ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t * A n ....[in F UL _L-- f_ ___ y These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.7 Roof repairs 13.0 Other =r--- — - --•W r.-« uu uu:me secuaa oe!o•• sooty nb f.^eir workers' compensation policy nfo.Watioa. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date.: Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 3 6. Other Contact Person: Permit/License # City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: .d t. Information an d 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 i Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the 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 ret•--ned to the city or tawm that the application for the permit or license is being requestea, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the pemiittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 0.2111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 wvvur.mass.-gov/dia Date. /0. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING S CHUS This certifies that 1,("/. /6.1a17..... . ........... has permission to perform ..... ........ plumbing in the buildings of ... at ...... 2 . North Andover, Mass. Feek:)Uq .... Lic. No.. . ......... ................... / Lu WING INSPECTOR Check # 860 MASSACHUSETTS UNIFORM APPLICATION FOP, PERMIT TO DO PLUMBING (Type or Print) NORTH ANDOVER, MASSACHUSETTS Building Location i Owner /46/ of New Renovation , o/i'lm6�i Replacement Ti YVIPY T77► LV O Date Permit # Amount Plans Submitted Yes ❑ No ❑ (Print or type) 1 Check one: Certificate Installing Company Name /- ❑Corp. Address ' ❑ Partner. Business Telephonie ❑ Firm/Co. Name of Licensed Plumber: Im t Insurance C2ymge: Indicate the of insurance coverage by checking the appropriate box: Liability insurance policy Other type of maty 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 MassachusettsSta Plumbing Chapter 142 of the General Laws. By. , n Title Type of Plumbing License cityaown /S.Q 7 APPROVED toFFcE vsE orn,Y rcense Numoer Master Er Joumeyman 4- -, ti -, ti The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers nnliV2nf fnfnrrn,,"-- Name (Business/Organization/Individual): Address: A City/State/Zip: Phone #: .Are you an employer? Check the appropriate boa: l . ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I. am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. ❑ We are a corporation and its Officers have exercised their right of exemption per MGL C. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] ;A y applicant that cheaksbos Yl must also fillout the section beson- sho•,,er .s '1 b her. woriza-s! comp, sation policy information. Homeo:vners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am ann employer that is providing workers' compensatio information. n insurance for my employees. Below is the policy and job site [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. incnrance required.] t Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. [] Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct Simafore: Date.: Phone #: Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 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 apartraents 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." P MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s).name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the 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 ci y or town that the application for the pernait or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permittlicense applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. T'he Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8 77 -MASSA -FE Fax # 617.727-7749 Revised 5-26-05 wwu,.mass.govfdia