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Home My WebLink AboutMiscellaneous - 22 BRIGHTWOOD AVENUE 4/30/20182012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the Person, firm. or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be.deemed -by-theJnspector-of Wires abandoned-and-invalidlfhe-- or she has determined that the aufhorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 20 10 and extended by Sections 74 and 75 of Chapter 23 8 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this puipose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence� during the qualifying period beginning on August 15, 2008 and extending'through August 15, 2012. &-Aule 8 — Permit/Date Closed: e: Reapply for new permit ,4epermit Extension Act — Permit/Date Closed: - �7-.f �? Date........ ................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... ............................................ .......................... has permission to perform .... ........................................... .",wiring in the building of ......... ................................................. at ................. I .......................... ... .,4,, Orth Andover, Mass. ........... Fee-:R'-� ............ Lic. No. . . ....... AUK Ei 1E -TRICAL INSPECTOR Check # 8852 � Commonwealth of Massachusetts MOM MM Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Wk Occupancy and Fee Checked_ [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code ( EC), 5 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL INFORMATION) Date: 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 work described below. Location (Street & Number) „� /* Owner or Tenantor4py ,p Telephone No. Owner's Address 4-/ Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building A/p �Je- - Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd Q No. of Meters Number of Feeders and Ampacity r Location and Nature of Proposed Electrical Work: _ Completion of the followin table may be waived by 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 SwimmingAbove In- o. o mergency lg g Pool d. ❑ d. ❑ Batte Units No. of Receptacle Outlets :No. of Oil Burners FIRE ALARMS No. of ZonesNo. of Switches No. of Gas Burners No. -of Detection and InitiatinLy Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers EE]EHeamp Number Tons KW No. of Self -Contained als: Detection/AlertingDevices r No. of Dishwashers rea Heating KW Local ❑ Municipal Connection ❑Other No. of Dryers Heating Appliances K W SeA�of ms: No. of water ces or Equivalent No. of No. of Heaters ICS' Signs Ballasts . Data Wiring: - No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total gp Telecommunications Wiring: OTHER: 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.) t Work to Start Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove a 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 andpenalties ofperjury, that the information on this application is true and complete - FIRM NAME: LIC. NO.: Licensee: fl. j� G Signature ..� LIC. NO.- (If 12 D� (If applicable, enter "exem t " in t e license number line.) Address: L/ L/ , V e V2 4`aN �� Bus. Tel. No.: Alt. Tel. No.: 9 LF.�? *Per M.G.L C. 147, s.-57-61, seonnry work requires 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: $� vb' �I l k, 1 -4n j r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 t' = www nxass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plambers Name (Business/Orgsniza6on/Individual):_ 1? /� '� V Address: City/,State/Zip: 4 A, /,10 vGr' 4 Phone #:_. 9 % fl �,� U tlC Z Are you an employer? Check.the appropriate box: l . ElI am a employer with 4. F1I am a general contractor and I Type of project (required: e}aaployees (full and/or part-time).* have hired the sub -contractors h' ❑ New construction 2. R5 am a.sole proprietor or partner- listed on the attached sheet 1 7• ❑ Remodeling ship and have no employees These suit -contractors have 8. Q Demolition working for mein any capacity, [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its g, ❑ Building addition required.] 3. ❑ I ain a homeowner doing officers have exercised their 10.❑ Electrical repairs or additions all work right of exemption per MOL 1 l.❑ Plumbing repairs or additions myself. [No -workers' comp, c. 152, § 1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required-] uutt "Ks oox A i must also fill out the section below showing their workets' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hila outside contractors must submit a new affidavit indicating such. 4--mtractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. formation. an employer that is prgwdi►rg infoworkers' compensation insurance for my employees, Below is the policy and job site Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: -,� Attach a copy of the workers' compensatiion 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 c� under the pains and penaltt'es of jury that the information provided ob�ye is true et. (� "ll Sivrratrrr• e - ficial 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 -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, 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 numberlisted below. Self-insured companies should enter their self-insurance Iicense 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 permitflicense 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 ext 406 or 1-8.77-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.govIdle .0 -Z� 9 �K -1-.q P. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ( /' LK This certifies that .... ?Aly ............. .................... has permission to perform ......... ...... plumbing in the buildings of ....................... at . ..... North Andover, Mass. Fee, ... ....... PLUMBIN/6'AN/SPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER MASSACHUSETTS Building Location g� Renovation ri FTYTT Tie ipc Plans Submitted Yes Date Permit # u �- Amount cjo? <79 I (Print or type) Check one: Certificate Installing Company Name ��l'"' 11 Corp. C G d Address 82 0, Partner. mPartner. 2 Business Telephone Firm/Co. Name of Licensed Plumber: _ /,/�i insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: ixiability insurance policy ❑ Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ Agent ❑ 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 Sta� urbing C9d Chapterf the General Laws. Title City/Town APPROVED (OFFICE USE ONLY Tye of Plumbing License icense NUM5777—` Master J Journeyman .El MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS B 'Id' L O04)n,�— /17 _ U mgoc�ations New D Renovation SU MEN T BASEMENT IST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. F L 0 0 R 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) Name /U Permit # l4I P d l . Owner's Name Amount $— Lent Plans Submitted y � x a m w F d W Z H z x w w U z d fie Date.. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ....:E ..�1/ 1 -"4 has permission for gas _installation,.!:c in the buildings ofat •«, North Andover, Mass. Fee ^A.. 17 . Lie. o.�/� Check # ✓v 6461 Check one: Certificate Installing Company 11 Corp. Partner. " Firm/Co. I No[3 Bond required by Chapter 142 of the plication are true and accurate to the ied for this application will be in of thef eneral Laws. Fitter WW a� U F• > FW - d Check one: Certificate Installing Company 11 Corp. Partner. " Firm/Co. I No[3 Bond required by Chapter 142 of the plication are true and accurate to the ied for this application will be in of thef eneral Laws. Fitter A A . is�. W Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ................. has permission to perform eo� plumbing in -,the buildirigstof X4 ...................... I � 1�7144el I' e5C 4CNort�'Andover,'Mass. at...... ......... A Fee.-��-Z--.�. Lic'. No.,vA`f.—/- Alk PLUMBING INSPECTOR Check# lqlgv "' 6 3 5 'A ;r' Date. .......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Nzz� This certifies that , . . ................ ......... / has permission for 8ys installation in the buildings of . ...................... � - X. "Ce, -North Andover, Mass. at FeeA -r� Lic. No.. PECTOR Cfiecko ."54- ,b5l m fn D ro ro D 0 z ro 0 ro Z M 3J O -1 O O O D D H M -i J z a z a r V M 0 -4 0 X 119, CD 0 rA CD F� cc M 51 CD CD A E 0 Kc, C, c-, C' 0 gt �D 0 0 CD 0 PA -0 CL c- p� rc3D ::s E� ID C) 0 CD 0 CD 0. l,q LD H 0. CD ro oll 'Ic; -coo. tq 0 CD CD Rp C, �D CD 0 9 C:) co p n - CD CD 0 - C, . " �3 8, 59 CD Ca. q CD, R. co 5 CD CD >4 C� E�Q E, 0 > g P o- IC, ci CD a cp 0 0 P: t3 CL -.3 101, :3. 0 .10 C) C) ,0.,o R-4 FF IK t.J C, I 0023 10 Date./7//—// ........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................................... ....................... has permission to perform .... �.5� ... wiring in the building of .... ...... e�v ........................................ at ........................ . /Nrth Andovei, Mass. Fee.,�Z.P�� Lic. No. 1.3-4V60.\6 ....... i * ELECIt INSP�E Check # w -Commonwealth of Massachusetts 7and ial Use Only Department of Fire Services PermiQ BOARD OF FIRE PREVENTION REGULATIONS OccupChecked fRev. 1/hlanlrl 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 ININK OR TYPE ALL INFORMATION) Date: q, /20 / ZQ City or Town oh NORTH ANDOVER 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) '22 jjy,,s,�y` waoo� Vz Owner or Tenant Telephone No. Ct 7t - 2 S 3- 3 C b 3 Owner's Address Is this permit in conjunction with a building permit? Yes ®, No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts New Service Amps Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: SCY v, 'C e— Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Luminaire Outlets No. of Hot Tubs No. of Luminaires Swimming Pool Above ❑ In- rnd. gyrn No. of Receptacle Outlets No. of Oil Burners No. of Switches No. of Gas Burners No. of Ranges No. of Air Cond. Total Tons No. of Waste Disposers Heat Pump Totals: Number.. ................. Tons I No. of Dishwashers Space/Area Heating KW N'o. of Dryers No. of Water k, Heaters Heating Appliances KW No. of No. of Signs Ballasts No. Hydromassage Bathtubs No. of Motors Total HP OTHER: wing table may be waived by the Ins ectot No. of Total Transformers KVA Generators KVA o.0 mergency ig tmg ElBatte Units FIRE ALARMSN=Zones d No. of Detection an Initiating Devices No. of Alerting Devices No. of Self -Contained Detection/Alertingr Devices Local ❑ Municipal Connection Other Security Systems:'' No. of Devices or Equivalent Data Wiring: ` TNo. of Devices or E uivalent Telecommunications Wiring: No. of Devices orEauivalent 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: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under t1 a pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: l av a LX/ 1-74,,.L LIC. NO.: Licensee: Signature (If applicable, enter "exempt" in the license number line.) LIC. NO.: Address: '-l2 Z t, 4 /r di,cvkf/.` r O r Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Dep a ent of Public Safety "S" License: Alt 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.P ERMIT FEE: $ ELECTRICAL PERMIT NO. _INSPEenoN ELECTRICAL INSPECTOR - DOUG. SMALL PORT: I. ROU GH Passed — [ ] � Failed— [ ] Re -inspection requirecT ($50.00) - j ] inspectors' comments: (Inspectors' Signature - no initials) paecn�7. f 7 required ($50.00) - Inspectors' comments: =•.mak... �vx u uASuaLLLA e 3. UNDERGROUND INSPECTION: Passed — [ ] Failed— [ ] Inspectors' comments: (Inspectors' Signature - no n 4. INSPECTION — SERVICE: DATE CALLED NATIONAL GRID: Passed— [ ] Failed — [ ] Inspectors' comments: NAME: Date Date Date (Inspectors' Signature - no initials) Date 5. INSPECTION - OTHER. — Passed — [ ] Failed — [ ] Re -inspection required ($50.00) Inspectors' comments: (Inspeetors' Signature - no initials) Date D OOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF TO.E AREA TO BE INSPECTED IS N'OT ACCESSIBLE AND ,A. RE -.INSPECTION OF $50.00 IS TO BE CHARGED. 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 Applicant Information Please Print Legibly Name (Business/Organization/Individual):av� Address: q2 2 City/State/Zip:' Phone #: aj 7S' 3- 3 3 Q 4l Are you an employer? Check the appropriate box: 1. Z -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. # 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' ;a 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.❑ Roof repairs 13.❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. I Vomeowners 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: o-t7`=S Q S C/Ya N,f < Policy # or Self -ins. Lic. #: I Ya $ 3 l Expiration Date: 3 / 7 / Ze /Z Job Site Address: ZZ %3r•'�d� w¢�� yr City/State/Zip:.a/, G ticr f 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. Sivnature: Date - 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 Contact Person: Phone #: \~4L 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 -MASSA -FE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia