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Miscellaneous - 216 REA STREET 4/30/2018
N 0073 Date ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................. J . . .... .... ... ........ ....... ...... ............................. has permission to perform ..... n�� .... .................. i ........ wiring in the building of ............. -Y ...................................... A --;* S r at... .... ......... Rt ....................................... North Andover, Mass. Fee ... I .......... Lic. No:9!?.T4!F ........... ...... 1(.. Check ff —4q --F--6 ELEcrRICAL INSPECT16R V cl u 4� .44 kip JINI, _2 A 0 4'l �5 0- 2 49 ck 4b 2 C'q 4) A V R - , 0 6 - -9 S N_00 "0 '0 b 0 U�:al �R t, 0:0 - S. E4 '48 ;3 ;:1 bl, 0�1 -d;3 g lod 0:, :-2, g 0 0 v4 C', -4 7t.; 'A 0 --p o -0 4.� 0 00 w cn -,ZW 0 to C.4 w c, o bD P� ;:t 9A.0 Wo 0 rk 4 ;9 o 'p, 'a " f� 0 X- o 0 0 'o 4 3,4 o t� d3 o tp cl I '8 -� - -- 0 'o J� vto �o "A ,0 cod bil op, ,j o IS 0, t� 4-4 0 +0 -4 -0 w 0 0 -,g 2 o A A. 0- co-, -43, 0- M. 01. CII 0 pq I C, ol 0 0 .ig P41 RIP k 00 Z Commonwealth o f Mamac4ujelb Official Use Only cc�� c7 Permit No. 1 �Q eUepartment W Jim Serviceb Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: ` C; , 9" City or Town of. &I Pl1 d J 01 To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) c;216 ge Ct < <j f7'1 ee 4 Owner or Tenant 00, a Ito (���+j ti ) 6,Y Telephone No. Owner's Address Is this permit in conjunction th a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building e,g)cl 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 Location and Nature o Pro osed Electrical Work: Completion of the following table may be waived bV the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o Emergency Lighting Batte Units No. of Receptacle Outlets o. of Oil Burners Z FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Dis osers Heat Pump Number Tons KW ...... JX.W No. of Self -Contained p Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW al El Other Local ❑ MunicipConnection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water K`,i, No. of No. of Data Wiring: Heaters Signs BallastsNo. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value Qf Electr al Work: ga — (When required by municipal policy.) Work to Start: 41h , Inspections to be requested in accordance with MEC Rule 1.0, 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 cover ge is in force, and has exhibited proof of same to the permit ming office. CHECK ONE: INSURANCE ,OND ❑ OTHER ❑ (Specify:) 2Ui /- ► C .1015, I certify, under the pains and pen es of perjury, that the information on t 'application is true and complete FIRM NAME: "— 0 LIC. NO.: 1, $ �' Licensee: (If applicable, enter "tempt"in Address: *Per M.G.L. c. f47, s. 57-61, security v OWNER'S INSURANCE WAIVER: Signatu�tcjo `QiJ� LIC. NO.: a Bus. Tel. No.: �o L Alt. Tel. No.: zz�' ;� I-, Department of Public Safety "S" License: Lic. No. 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. Owner/Agent Signature _ Telephone No. I am the (check one ❑ owner ❑ owner's a ent. PERMIT FEE. $ 11210 Date ..... TOWN OF NORTH ANDOVER I This certifies that ....... .. �p ... ... ..... ..................... 14 . . . .... . . has pern-lission to orm .... ........... ...................................... plumbing in the b ildin s of ... ...... ...................... ...... : . .... .. ....... 7 � y �* ................. at ........ . .. e -a-- North Andover, Mass. A .... 4 .. ........................................................... Fee.... A Lic. No. I ';j-� 4 ..................... ................................................................................. PLUMBING INSPECTOR PERMIT FOR PLUMBING Check # / 7 Y72- 05 m MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK )1 71 ,. CITY _ ode ( MA DATE 2 ?a PERMIT# JOBSITE ADDRESS G Q e 4 1�7 OWNER'S NAME P OWNER ADDRESS TEL 6 ( 9 Q3 NS X13` FAX TYPE OR OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:. REPLACEMENT: Q PLANS SUBMITTED: YES E0 NO[.-( FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM.___ _ I _( DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREADRAIN _....... INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY _.._..__..! ___J ____-► --____.i ..-_..._f _._-_.J ( (-_-.-_1 ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL i WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER __._ _ .__.__--._� . ( f ! .._._._._.l ._- �-1 ! '---�---}------.._.► .-..__._! ._._._...__( ( _( INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES)o NO Ell IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY K OTHER TYPE OF INDEMNITY D BOND D OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will b ce al Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME 1 tL c2 LICENSE #$ 2 l ( SI NATURE IVIP a JP P CORPORATION ( LLC -r@#©PARTNERSHIPD# COMPANY NAME Slj-A;" 0,r 11 ADDRESS f S) I CITY �tttSc(Vy t° _.... - - -- O j TEL � STATE _ /J � ZIP 2. I'4C FAX CELL(13`b4 _9T�11 EMAIL o rl z LU a w w LL. a The Commonwealth of Massa chusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: City/State/Zip: ��ct �e 6�J Phone #: Gtr 21 2 23 I Are you an employer? Check the appropriate box: Type of project (required): 1. r I am a employer with _employees (full and/or part-time). 7. F1 New construction 21 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity. [No workers' comp. insurance required.] 3.FJ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 9. 0 Demolition 10 Building addition 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.E] Plumbing repairs or additions 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13.0 Roof repairs These sub -contractors have employees and have workers' comp. insurance.1 6. ❑ We are a corporation and its officers have exercised their right of 'exemption per MGL c. 14. Q Other 152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] 7. *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. 1 Insurance Company Name: 5 F`J.J e odd �`� CX UX-aff\Ce Policy # or Self -ins. Lie. #: W CG ,(b0 --Sz)\ 28 0 — 2-01'A IS Expiration Date: 0 � — � 3 A (�, Job Site Address: 2!`(;�, �0. S `i' City/State/Zip: �J r4h rtA Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify a and penalties ofperjury 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 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-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 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia ti iv COMMONWEALTH OF MASSACHUSETTS BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE. I. LICENSED AS A MASTER PI:UMBERIQ JULIO SEGUNDO CORTEZ 58 ANDOVER RD z BILLERICA MA 0182-1936 1;214 05/01 /16 - 209712 LICENSE USA 98 END 4dNUMBER -' 05-10-20'10 NONE S99275904'.' �Up 3 DOB '07-18-2015 m 07.;46 R= tL IEST 5 3Ex &NONE C JPRTEZ 2 LID S • 58 ANDOVER RD BILLERiCA, MA 01821-1936 5 DD.111-MOR-07-15-2009 iv COMMONWEALTH OF MASSACHUSETTS BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE. I. LICENSED AS A MASTER PI:UMBERIQ JULIO SEGUNDO CORTEZ 58 ANDOVER RD z BILLERICA MA 0182-1936 1;214 05/01 /16 - 209712 Date. 6�12 .5 ......... OF NORTH ANDOVER RMIT FOR WIRING . .......... .. . ............................... 1 16,64, wiring in the building of ..... . -Ile ..... 7 ...................................................................... at..2./c ................... ; ...... ass. .......... &�� .... 0 -a .............. Fee Lic. No.1k . .. ..... ........... t .................................................. Check # 16ql ELECTRICAL INSPECTOR /,77 lfomrnonwea& o f Wamachuseth Official 7Use -�Only r aL Jep.,tment o/ ire �ervicea Permit No I (/" ► //v Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [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 12.00 (PLEASE PRINT IN INK OR TYPE LL INFORMATION) Date: 311,Sr City or Town of.A©1,ep_ To the I srector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 0216 Q -e41 Owner or Tenant A_ e� Telephone No. Owner's Address Is this permit in conjunction with a building permit? Ves © No Purpose of Building j% ej';-W e-.tc 16,e'-4/ Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ Location and Nature of Proposed Electrical Work: /3 C bio No. of Meters No. of Meters Completion of the. following table may be waived by the Inspector of Wires. No. of Recessed Luminaires12 No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets .2 No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o Emergency Lighting Battery Units No. of Receptacle Outlets ,2 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump I Number I Tons KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW ecurityystems: No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Elec ical Work: A00 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE OVERAGE: 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 Q—BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties of perjury, that the information on this application is true and complete. FIRM NAME: /C-/13 C/,- LIC. NO.: Afroqi Licensee: / a✓ge e- Z Signature ZI E__ LIC. N (If applicable. ent�t�,.�xempt, in the license number line.) /J Bus. Tel. No Address: J �/ e," l e n/ r�'�9 /� 0,40 e( 91 Alt. Tel. No.. *Per M.G.L. c. 147, s. 57-61, security i7ork requires Department of Pu lic Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: 1 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 a ent. Owner/Agent Signature Telephone No. FERMIT.FEE- $ - CV I t h i� The Commonwealth of Massachusetts Department ofIndustrial Accidents h - I Congress Street, Suite 100 a Boston, MA 02114-2017 www mass.gov/dia OtM S�V Workers' Compensation Insurance Affidavit: Builders/Contractors/E lectricians/Plum ers. TO BE FILED WITH THE PERMITTING AUTAORITY. AIMul:YLllL illAva....,..ay.. _. Name (Business/Organization/lndividual): Serv,'Ces j,VL Address: �`7 P" Ste' e 62 Phone #: r Are you an employer? Che& tth'e�alpproprlate box: 1.® I am a employer with I employees (full and/or part-time)."% 2.FJ I am a sole proprietor or Partnership 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 4. ❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑I am a general contractor and I have hired the sub contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. Q 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.] Z )—)0,6 Type of project (required): 7. ❑ N6W'c6nstr6ction 8. Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions la,Q Plumbing repairs or additions 13•. 0 Ro6f repairs 14.n Other *Any applicant that checks bbk 41 must also fill out the section below showing their workers' compensation policy information. 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 bok must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. .1 am an employer that is providing workers' compensation insurance for my employees..Below is the policy and job site information. / eQ tj G Insurance Company Name: 0 / 1 n�� Z — ��- 3 lj ` D{ Z Expiration Date: 0-?! Policy # or Self -ins. Lic. #: y � � /1�" Job Site Address: Z 1 G Rt°� S� Y. �d"�� City/State/Zip: 1- 14)j ALA ��`� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. X do Hereby 'certify under the pains and penalties of perjury that the information provided above is rue and correct. Sienature N,/V/ 6 I"G{S )el- Date: 6/ Phone #: -11 l 170 g 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 Phone #: Contact 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 enierprise, 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 Pleasb 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 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 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 thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "fob 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 9473 Date.7// q11 71. TOWN OF NORTH ANDOVER 'A PERMIT FOR PLUMBING This certifies that ........... has permission to perform plumbing in the buildingspf ..................... at .2- ........ . rth ver, SS. Fee.'// Lic. No./O:�O*/* ... Check # PLUMBING INSPECT R MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE /0- /Z 11PERMIT# JOBSITE ADDRESS 6ILiA=A S' OWNER'S NAME POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Ell EDUCATIONAL © RESIDENTIAA PRINT CLEARLY NEW: ._ f RENOVATION REPLACEMENT: Q PLANS SUBMITTED: YES © NOD FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB __( CROSS CONNECTION DEVICE I DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ! DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM =-I DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR INTERIOR _ (l ..-_-.._ KITCHEN SINK ( _..._.__l __...__J ( ( (! J .._._ ..__.i LAVATORY-_(-.._.___( ._....__( -.._.___.J _______J _.__._.f _._._....( .___.__! .-_.____( .__.._J .----..-.{ ..._.___J _ f ►--_.___J ROOF DRAIN (_--_-.__� _...__.f .__�_( ..--- (_.__.1 .___J .__-__I ._.___J __ ___f ..---___.I ..__.__ ► __.J ! _._._..6 SHOWER STALL _i ._.._.__J ! j ( f ( � _-I ...__..__._( F7-7=17- L. -_-I SERVICE / MOP SINK - (----._..J ( _—f J .._.___( J .-. _--_ TOILET URINAL... _...... _( _..._____i .___..__J _.._._.J _......_.__._f __.-__.__! _---_._ WASHING MACHINE CONNECTION WATER HEATER ALL TYPES_ WATER PIPING _ (! ._ ._.._( _._....J f _ ! (_ ..__ ( _ .f _. i OTHER �- __(_ ._-? _( ...---.._.J __( I ....___f _I L ..... ... .......... .-._. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO �f IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L2! OTHER TYPE OF INDEMNITY DI BOND Ej OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. HECK ONE LY: OWNER OPA ENT ID SIGNATURE OF OWNER OR AGENT t hereby certify that all of the details and information I have submitted or entered regarding this appli ation are true an acc to the be t my nowledge and that all plumbing work and installations performed under the permit issued for this application wi a in com Iia all ertinent visio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAM f w -.11 . fir I LICENSE # - 030 / ! ATURE MP 0 JP Ell CORPORATION [�I # ��f 3 -]PARTNERSHIP O#=LLC COMPANY NAjlt.�p-t;ADDRESS ...�uJ CITY STATE ZIP 6 TEL FA); w.. G=6b I CEL....._� EMAIL W H O z z 0 H U W W � o rl z a ❑ � w O W a a* z u LU X: I -- I-- < w C/3 IL tx ® > w Cf) a p z a w a � U J a a � a � w x w W H o H v w a t7 a a Cx7 O a p The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations kvi 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information j Please Print Legibly Name (Business/Organization/Individual): Address: PGC --.)4- City/State/Zip: City/State/Zip: Phone #: �� (� I �a N.r% Are ydu an employer? Check the appropriate box: 1 I am a employer with 4 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7.4 Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f Homeowners who submit this affidavit indicating they aie 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:.ft/MOA Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: n(x e- Ate• 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 requiredunder Section 25A of MGL o. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year impri nment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $2 day against viol�Colraljze e advised that a copy of this statement maybe forwarded to the Office of Inve Rations of the IA fo suran verification. I do-howby certio 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: PermitUcense # - t6- tot 2, 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 #: i 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 ofhire,- 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 Tel, # 6177274900 at 406 or 1-877,7MASSA_FE Revised 5-26-05 Fax # 617-727-7749 __WWW-Mass,gov/dia Date.'.V. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that lic'A i All .. �- Ax ... has permission to perform ..... )�D�r plumbing in the buildings of ........... at .... ..................... , North Andover, Mass. '-O..Lic. No. PLUMBING INSPECTOR Check I'Ul S�2 MASSACHUSETTS U % (Print or Type) ' UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING Mass. Date Building Location -� — Permit # y / n Owner's Na NewType of Occupancy Residentia G 4- .;...c Renovation ❑ Replacement FIXTURES Plans Submitted: Yes G No O BASEMENT IST S --FSR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH-" LOOK 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name erlltage Ht.g. &P1 Address g' CO - Inc. -4 irl � - S Business Telephone 781, Name of Licensed Plumber INSURANCE 'am, Ma 02180 Gordon Switzer � V Z W O � W z ar z 0. aQ1 rtT Sa x V) J N y < 2 O Y Z xx r N x di Q F - NJ W O I- < < 'j N m x 1. *< m Q y ¢ W 30 O Y V) C W W s to I O N ¢ L. 0 a N O F >- 0 J U < y 3 r.. w f- -< > ►- S rn lui J. � 2 I N a. y c Q. O LL W a Cr r" < 0 J a C ] u. a `- Y ¢ . 3 Installing Company Name erlltage Ht.g. &P1 Address g' CO - Inc. -4 irl � - S Business Telephone 781, Name of Licensed Plumber INSURANCE 'am, Ma 02180 Gordon Switzer Check one: CX Corporation- 0 orporation❑ Partnership n Firm/Co. Certificate 714 I have a current liability nsuran6e Yes NoQpolicy or its substantial equivalent which meets the requirements of MGL Ch. 142. . If you have checked, .please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S fNSURANCE Watti/E-: I am aware that the licensee does ot have the insuranca c required by overage Chapter 142 of the Mass._,General; Laws, n and that my signature on this permit application waives this requirement. Check one: q ement. Signature of Owner or Owner_'s gcerit Owner Q Agent I hereby certify that all of the details and -information I have submitted (or entered) in above application are true Q knowledge and that all plumbing work and installaiions:performed under -the permit issued for this application willbe compliance with Pertinent provisions of the Massact usetts State Plumbin Code and Chapter and accurate to the best of my By p 2'of the General Laws, th all Title Signature of Licensed Plumber City/Town Type of License: Master APPROVED (OFFICE USE ONLY) Journeyman Q License Number 8 3 2 2 o %i" Watts 9D bCp oa water lite to water boiler-- C/ � V W O � W z ar z 0. aQ1 rtT Sa x {J 49 c o xx r N x di z 3 ` J CU 3 /n�4 Check one: CX Corporation- 0 orporation❑ Partnership n Firm/Co. Certificate 714 I have a current liability nsuran6e Yes NoQpolicy or its substantial equivalent which meets the requirements of MGL Ch. 142. . If you have checked, .please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S fNSURANCE Watti/E-: I am aware that the licensee does ot have the insuranca c required by overage Chapter 142 of the Mass._,General; Laws, n and that my signature on this permit application waives this requirement. Check one: q ement. Signature of Owner or Owner_'s gcerit Owner Q Agent I hereby certify that all of the details and -information I have submitted (or entered) in above application are true Q knowledge and that all plumbing work and installaiions:performed under -the permit issued for this application willbe compliance with Pertinent provisions of the Massact usetts State Plumbin Code and Chapter and accurate to the best of my By p 2'of the General Laws, th all Title Signature of Licensed Plumber City/Town Type of License: Master APPROVED (OFFICE USE ONLY) Journeyman Q License Number 8 3 2 2 o %i" Watts 9D bCp oa water lite to water boiler-- C/ N y z cla � A z a O O. W 0 :D 0 w N U t: LL X LL O O cc z a O i 2 LL O Z U. O Z O LU m � U � � U �), J y LL < N r, W Y i 1 N i J N 4 � • Z M. U � W �), y , z i � z_ LL � A y cc W A J d Date 7:�� . 7-C.6). . No 4- 2 'U-*' I TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING This certifies that . .................... has permission to perform,,�.1/�l_:-,�.--7:Y,�/����, ................... �' . ................. plumbing in -the buildings of at .................... North Andover, Mass. ......... Fe6.:� ...... Lic. No.. PLIJIVI,�Bl* *b ECTOR 1;S WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) 1i N r r2 , Mass. Date _Ve4t—) Permit # Building Location 2 !! (o PQ Owner's Name PIIS S 4 Ate) Is 1+t�AR ,J Type of Occupancy 1� 5 D E Iv tl New ❑ Renovation ❑ Replacement LES P ns Submitted: Yes ❑ No ❑ FIXTURES Installing Company Name f' Ot' ,EeT 42 ,58MM 4'TAeQ Check one: Certificate Address CO RC I4 ma n l p Corporation lY) E T+4 t' C- AJ - ill r4 C) r Si (lel ❑ Partnership Business Telephone klf ,? - iq7 I 9-A�/Co Name of Licensed Plumber ;f r3r=,r'T /� SA,vlrvlrq rrcl�c" INSURANCE COVERAGE: I have ayes current jabildy insura C3ce policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked Ye, please indicate the type coverage by checking the appropriate box. A liability insurance policy 21 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: r% -- • ---- Owner ❑ Agent O 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 ormed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum�,tge and apter of the oral Laws. Title re of Ucensed Plum r Citylfown Type of License: Master Journeyman p APPROVED 0 IC U ONL License Number D 3 1 I' Installing Company Name f' Ot' ,EeT 42 ,58MM 4'TAeQ Check one: Certificate Address CO RC I4 ma n l p Corporation lY) E T+4 t' C- AJ - ill r4 C) r Si (lel ❑ Partnership Business Telephone klf ,? - iq7 I 9-A�/Co Name of Licensed Plumber ;f r3r=,r'T /� SA,vlrvlrq rrcl�c" INSURANCE COVERAGE: I have ayes current jabildy insura C3ce policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked Ye, please indicate the type coverage by checking the appropriate box. A liability insurance policy 21 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: r% -- • ---- Owner ❑ Agent O 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 ormed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum�,tge and apter of the oral Laws. Title re of Ucensed Plum r Citylfown Type of License: Master Journeyman p APPROVED 0 IC U ONL License Number D 3 1 FE N V m A O w F1 T m m Date. —. X4 Lxtb TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certi fies has permission to perform ... wiring in the building of il� /F . ...................... at. 1� A ........... jb;orth Andover, Mass. 'Fee......... ......... ELECTRICAL INSPECTOR 'theck 12- 'q/ 10949 . 'd d) rg 0 0 44 0 qg co In OR C5 b ,4 6-�� f 01 C4 0 A-8 A gt .a -,u C) C,q o 0 , A R A t w �j g R o 4 0— b 0 0 C:.:ai 2 'w ;3 0 bo 0 49 bl) 0 00. -0 0 41 C, 0 S�Z o 00 M, . > G .0 .0 al g A —P4 0 0 ;g, �8 1, -A 'd "it N Pk ;h A �o cn CD o 0 o 0 ;g t rl. ov. '4J 'rWj 11 4� bd 4141 -0 o F1 9 0 .4J 0 0 C." to C04 cl t9 Ego 04 Commonwealth of Massachusetts Oficial Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: �, % 2 — /.C_ City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical wor described belo Location (Street & Number) Owner or Tenant z elephone No. Owner's Address . C_ S Is this permit in conjunction with a building permit? YesNo ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts erhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion o the followin table may be waived by the In ector of Wires. No. of Recessed Luminaires Z No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets / No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- Elo. rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets C' No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Dis posers p Heat Pump Totals: Number * Tons I KW_ ** ' No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of WaterKW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start:2-17 - .1 — 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 force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) I certify, under thepains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME:. rS� + l 4 fir- LIC. NO.: 3--5 Licensee: /Z,,, sem- �s�..• w Signature, LIC. NO.: (If applicable, ey ett r "exempt" in the license number line.) Bus. Tel. N0.• Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Departure f 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 PERMIT FEE. $ Signature Telephone No. f ... ._ • .+JJUJ�f�LIS.J-VI.'V'�'�t/�i.*�QJ.L��..I�f.(L:S.��'j.�I.�.j*�'®pyo• %.�^�j �`(+']'� •� ��13��vJ+.J.�.47 JI�J�IiJt.�.J.: _ �R1.LlLJ-A`•-f.RI,�Y..i.K •�.5..7lY./.l. �Jl'7. �.y• • .. ._ � .. �_ • y • Tns�tectax-s' coznm.e�xts: (his&&fors' gIguatare..l.o iniixals) Slate 3.' MrRCROT_TND INgRACTION: _ �asse��-� � �'aS�ec�--I � 7�te�xnspectio�xec�uirer�($�U.OD)�j ] �'ns�ectors' comments: , Cmspectors'Sigmi -•+ao Initials) Data WIVE CALLR.,NAQ ±ONA:I� C- ts,�ectbxs' eolnm.epfs: NA r +: . (�ius�ectors',�zguatuxe�ztoj�nitzals) - Jlate �seci-,� � �'azSer�-,[ ]-'�te�nspeciioxtxec�ttixe�.($50.OD)�[) pectors' Cwhmments: luspeetors'Szgnatuze�xtoinitials} date a OR T'.A,GN AM TO FE FILLED 9 -UTA X EFT ONRITFMTMAPXA TO 3E MSTACTE3D YO NOT The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UV. www.mass.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: 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. ❑ 1 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. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Dat - Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-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 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia