HomeMy WebLinkAboutMiscellaneous - 25 COPLEY CIRCLE 4/30/2018(BE RRISPCTEN PLAN
NORTHERN ASSOCIATES, INC. _
68 PARK STREET 2ND FLOOR ANDOVER, MA. 01810 TEL -(978) 8.37-33D35`FAX:(F78t 2007/ 57
MOP.TGAGOP,:.EE_AINIE ChR15`MA" ?LAN PE ; 12330
LOCK -HON: 25 COPLEY CIRCL SCALE: 1 "=30'
CITY.STATE: N. ANDOVER, NAA JOB #: 2 14.03200
DATE: 10,30/20 i I
DRAINAGE
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LOT 22
12,57; S.P.
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L= 12 0-01
03.60'
P,=200.001
COPLEY CRCLE
NOM Landover MIMAP 25 Copy
Circe October 28, 2014
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'
No. � � � Date KO. -
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TOWN OF NORTH ANDOVER
0
�:
+ * MOM
Certificate of Occupancy
$
'
Building/Frame Permit Fee
$ C�
;
,,V cm 5th
Foundation Permit Fee
$
Other Permit Fee
$
d
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
t
1/ _ , � `�Jr.... �Building Inspector
Qk .�
*� r
Div. Public Works
Location z ss i
too."I Date
2 2-
Div. Public Works
A
TOWN OF NORTH
ANDOVEP
Certificate of Occupancy
$ Sib 9'
Building/Frame Permit Fee
$
Foundation Permit Fee
$
N
Other Permit Fee
$
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
$
Building Inspector
Div. Public Works
Location ��1�' �'C�_ci,,-, 414—
No. �Q Ca
Date 5 �� - 95
�pR7"
A
TOWN OF NORTH ANDOVEppA
• p: •.o ,•,�O
OL
V7
Certificate of Occupancy $ r=
�,
+•
Building/Frame Permit Fee $
... :.. ,.
sA04 tt�
GMUs
Foundation Permit Fee $
, '
•
Other Permit Fee $_
�. J
r,
Sewer Connection Fee $ ��'•'r�
• S `/� f-�
Water Connection Fee $ c77 7' 5-0
TOTAL
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Build' g I/ns�ctor
Div u is Works �� "
PERS aT NO. ZZG APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS.
PAGE 1
MAP 4JO.I
LOT NO.
2 RECORD OF OWNERSHIP :DATE
BOOK :PAGE
ZONE SUB DIV. LOT NO.� C—ILot
LOCATION C ,� cli,-c
2.��. "�(el
PURPOSE OF BUILDING v
OWNER'S NAME
''aVr`
O. OF STORIES /. ZEVf
/
OWNER'S ADDRESS
`�'3 72-wrh
r���Y S
BASEMENT OR SLAB
a�St '" -ems j
Z�A-o
ARCHITECT'S NAME -' /1
BUILDER'S NAME `�` IC, �11`,vl
A/I r
SIZE OF FLOOR TIMBERS IST ?N /D 2ND ��f
D 3RD
SPAN
DISTANCE TO NEARES
41)BUILDING 4 /f,
DIMENSIONS OF SILLS
POSTS
DISTANCE FROM STREET
DISTANCE FROM LOT LINES - SIDES
^
';l REAR REAR
` V�
GIRDERS
/�f� !
AREA OF LOT
FRONTAGE
/
HEIGHT OF FOUNDATION THICKNESS /v
IS BUILDING NEW �' s
SIZE OF FOOTING / X
9 �
v
IS BUILDING ADDITION
a
MATERIAL OF CHIMNEY n��
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS
OF CODE
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
.�r7
INSTRUCTIONS
PERMIT FOR FOUNDATION ONLY
SEE BOTH SIDES REGULATED BY PARA. 114.8-S. B.C.
PAGE 1 FILL OUT SECTIONS 1 - 3
PAGE 2 FILL OUT SECTIONS 1 - 12 DATE 3 FEE PAID
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING PECTOR
DATE FILED
SIGNATURE O -OWNER OR AUTHOR ZED AGENT
FEE Vzcoc>►OD PERMIT FORFRAMEAUILDIN
Sb' oo c o
PERMIT GRANTED sl It 1 19
DATE: Q S" FEE PAID•M
ly
�L-M UISLd�rt,;�p 'zoo —
II Y xn ma
jo
3 PROPERTY 19FORMATION
LAND COST
EST. BLDG. COST
EST. BLDG. COST PER SQ FT.
s
EST. BLDG. COST PER ROOM/ P/'7f
SEPTIC PERMIT NO. �-n
4 APPROVED BY
NUILDING
OWNER TEL. IY�//�
CONTR. TEL. #
CONTR. LIC. a
H.I.C. k
83to4,���I
8�t�t
a31�ZZI$—
BUILDING RECORD
1 OCCUPANCY 12 ,
SINGLE FAMILY
NO. OF ROOMS
!Xl$;pkIES
MULTI FAMILY' ' " OFFICES
O
APARTMENTS
CONSTRUCTION
2 FOUNDATION
2nd.
8 INTERIOR
FINISH
CONCRETE
I
3
1
2 I3
_
CONCRETE BL K.PINE
BRICK OR STONE
`�
HARDW D
PIERS
PLASTER
DRY VJALL •
UNFIN
_
3 BASEMENT
AREA FULL FIN. B M AREA
'/. 1/7 '/
FIN. ATTIC AREA
NO B M T
HEAD ROOM _
FIRE PLACES
MODERN KITCHEN
4 WALLS I 9 FLOORS
CLAPBOARDS
B
1
22
J 3
DROP SIDING
CONCRETE
WOOD SHINGLES
EARTH
ASPHALT SIDING
HARDw D
ASBESTOS SIDING
COMMON
A$PH. TILE
VERT. SIDING
_
STUCCO ON MASONRY
STUCCO ON FRAME ..:
BRICK ON MAS
_
ATTIC STRS. & FLOOR _
BRICK ON FRAME
CONC. OR CINDER B K.
WIRING
STONE ON MASONRY
STONE ON FRAME
SUPERIORPOOR _
ADEQUATE NONE
10 PLUMBING
BATH 13 FIX.) LA
5 ROOF
GABLE HIP
GAMBREL MANSARD
FLAT SHED
TOILET RM. (2 FIX.)
WATER CLOSET
_
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
_
TAR & GRAVEL
STALL SHOWER
_
ROLL ROOFING
FIXTURES
_
TILE FLOOR
_
q.MODERN
TILE DADO
6 -FRAMING
11 HEATING
WOOD JOIST
1
PIPELESS FURNACE
FORCED HOT AIR FURN. '
TIMBER BMS. •& COLS.
_
STEAM
STEEL BMS. & COLS:'
_
HOT W'T'R OR VAPOR
WOOD RAFTERS
_
AIR CONDITIONING
_
RADIANT H G
UNIT HEATERS
GAS
IL
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA-
RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. -
7
NO. OF ROOMS
O
.. • ;.•� � !+^!^
l l• �
B'M'T
2nd.
ELECTRIC
�__
_ _{ _-� i �. _ � - '. •1,1: ��
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NO HEATING
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FORM U — IAT REMMWE FORM
INSTRUCTIONS:. This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or.state law,
regulations or requirements.
****************Applicant fills out this section******************
APPLICANT: (fc)4h/f .5,TowP ( �o� ih��Pa//'� Phone
LOCATION: AssSLessor's Map Number Parcel
Subdivision (. LU12 5-70;1,e C�105'5't h Lots)
Street ifnV7 QL/ CSI- C Ae St. Nu.-=er 'ZS
*
***********************Official Use Only*******************x****
c
RECOMMENDATIONS OF T WN GENTS:
Date Ancroved 512
Consarr; at:.on Ad :' nistratcr Date Rejected
CC = e:
Date Approved 51,3n Z5 -
Town Planner Date Re j ec-ed
Coro ;en zs
DO
Fco:: ea_th
111.4
Date Approved
Date Re-iec ad
Date Apprcved
Date Re j ec =e-4
wcr:;s - se,.;er,'water connections
- driveway per-iitq-(�J
Fire epar-ment
�Rec:—,redby Build
Data
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,SSACHU$
This certifies that
Date .. %
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
................ .
has permission to perform ..... �.. ."� . ..................... .
Z l�
nlumbine in the buildines of ... C. % ... L ....................... .
at ......... C. .....�.... North Andover, Mass.
17 7
1
Fee.. v... Lic. No..�.'...... ...... t,. .. / ........
PLUMBING INSPECTOR
Check #
VJ�./
i
MASSACHUSETTS UNIFORM "PLICATION FOR PERMIT TO DO PLUMBING
(Type or lit)
NORTH ANDOVER, MASSACHUSETTS
T,
Owner
New ❑ Renovation Replacement
VW Tn.,1Mo
Date -4?Q/ID
Permit #
Amount
Plans Submitted yes ❑ No
(Printor ) w , Chec ne: Certificate
Installing Company Name L
�. Corp. 11409
Address
Fie. 1A w AKnI r r .niA a.% flaw— Partner.
Business Telephone , Firm/Co.
Name of Licensed Plumber: L ,
Insurance Coverage: Indica
!Ltbf type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity Bond
Insurance Waiver: I, the un igned, 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 Mass efts tate bing Co Cha
142 of the General Laws.
By:
��_ mgnanue o kens um
Title
Type of Plumbing License
City/Town '�
APPROVED (OFFICE USE ONLYincense ort�r_ Master � Journeyman ❑
�v
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AM 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
p
_Aplicant Information
Please P- nt Le�bl'
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/or part-time).*
2. ❑ I am a sole proprietor or
have hired the sub -contractors
listed
partner-
on the attached sheet
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption MGL
myself. [No workers' comp.
per
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. ❑ Electrical repairs or additions
11.11 Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
t u _• n ne:ov..' Snowing theL^ worl:TpOlrc}' rIIror�:�joII.
omeowners 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 isproviding workers' compensation insurance for my employees. Below is thepolicy 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 offciaL
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
bereturned to the city 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 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, IMA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAEE
Fax # 617-727-7749
Revised 5-26-05 www.mass._gov/dia
Date .... ........ .
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p o ry0
o� ° TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ..r1� r� !X P .'� ./� .....................
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has permission for gas installation .......... ! ................ .
in the buildings of ...,rh? .G.. ......................... .
r
at ... .. ,North Andover, Mass.
Fee. :2.C?.... Lic. No. .)..`....... �Lr:....: `..... .
I GAS INSPECT*OR
Check #
710/7
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
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Building Locations
Owner's Name
New1:1Renovation Replacement
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Date476 I'D
Permit # /
Amount $
CrliZo�!
Plans Submitted ❑
Name of Licensed Plumber or Gas Fitter /.-J24*"— N -A LIA wl—,
C ec one: CertificatejnsWing Company
Corp.
Partner.
Firm/Co.
INSURANCE COVERAGE Check o
I have a current liability Insurance policy or it's substantial equivalent. Yes . NoO
If you have checked y_es, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity Bond ri
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
___I _____ __ __ ..._ w ................,.. , "Q ,uuuuuou kur enTerea/ in aoove 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 Gas Code and Chapter 142 of the General Laws.
Title
City/Town
IAPPROVED (OFFICE USE ONLY)
Signature of Licensed t4imber Or Gas Fitter
Plumber
Gas Fitter icense NUMn4er
Master 7
Journeyman
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SUB-BASEM ENT
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1ST. FLO O R
2N'D. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
8TH. •FLOOR
Name of Licensed Plumber or Gas Fitter /.-J24*"— N -A LIA wl—,
C ec one: CertificatejnsWing Company
Corp.
Partner.
Firm/Co.
INSURANCE COVERAGE Check o
I have a current liability Insurance policy or it's substantial equivalent. Yes . NoO
If you have checked y_es, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity Bond ri
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
___I _____ __ __ ..._ w ................,.. , "Q ,uuuuuou kur enTerea/ in aoove 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 Gas Code and Chapter 142 of the General Laws.
Title
City/Town
IAPPROVED (OFFICE USE ONLY)
Signature of Licensed t4imber Or Gas Fitter
Plumber
Gas Fitter icense NUMn4er
Master 7
Journeyman
J
The Commonwealth of1lfassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
wwW-massgov/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 boa:
L ❑ I am a employer with
4. ElI am a general contractor and I
employees (full and/or part-time).*
2. ❑
have hired the sub -contractors
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.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3. ❑ 1 am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself [No workers' comp.
C. 152, § 1(4), and we have no
insurance required_] t
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.❑ Roof repairs
13. [1 Other
=NU I-- (JUR c:e sectio` betoW shol nnb their Worl:e s' compensnion policy information.
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.
lam 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 cerkfy under the pains andpenalties of perjury that the information provided above is true and correct
Signature:
Date.:
Phone #:
11 Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town:
Issuing Authority (circle one):
Permit/License #
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 aparwxents 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 coxnpliance 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 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 Depa=ent of
Industrial Accidents. Should you have any questions regardirig 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 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-72.7-7749
V mm,.mass- aov/dia