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HomeMy WebLinkAboutMiscellaneous - 250 BARKER STREET 4/30/2018 (2)N Lib�qyMutual. INSURANCE September 16, 2015 Town of North Andover Attn: Building Inspector 120 Main Street North Andover, MA 01845 Liberty Mutual Insurance New England Region Central Property Unit 75 Sylvan Street Danvers, MA 01923 Tel: (800)566-0323 Re: Property Address: 250 Barker St, North Andover, Ma 01845 Policy Number: H3221215805002 Underwriting Company: Liberty Mutual Fire Insurance Company Claim Number: 031968834-0001 Date of Loss: 2/20/2015 Attn: Town/City Official Pursuant to M.G.L. c. 139, § 3B, please be aware that a homeowners insurance claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or causes the condition of a building or other structure to render Mass. General Laws, Ch. 143, 5 6 applicable. You are required to notify Liberty Mutual by certified mail in accordance with Mass. General Laws Ch. 175, §99, if you intend to initiate proceedings designed to perfect alien pursuant to Mass. General Laws, Ch. 139, § 3A & B, or Mass. General Laws, Ch. 143, § 9, or Mass. General Laws, Ch. 111, § 127B. This letter should not be construed as a waiver or estoppel of any of the terms, conditions or defenses afforded by the policy or applicable law. Please direct your notice to the attention of the undersigned and include a reference to the above captioned property address, policy number, claim number, and date of loss. Sincerely, Liberty Mutual Support Liberty Mutual Insurance New England Region Central Property Unit 1-800-566-0323 ................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that...o tjfl.. C e ."" ................\ ....................................................................................... has permission to perform .................e -A r a wiring in the building of,,,N,�►- .............................................................................................. at ......2�....... co r �1...... _ orth Andover, Mass ...................................... ((��/.� Fee.!��� ............ Lic. No. MN ....`......d.............j..�.... .. .................... ELECTRICAL SPWMR Check # 12356 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use 0 ly Permit No. Ii 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 JQ, 5;7 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATIOl 9 Date: j / 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) OR) Owner or Tenant S Teeepbone No.9 784o?4?- S-/1 Owner's Address Sc1wi Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building 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 of Proposed Electrical Work: Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans u No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA o�Gv No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. grnd. No. of Emergency Lighting Battery Units No. of Receptacle Outlets 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 g No. of Waste Disposers 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 Water KW Heaters No. of BalNo. asllasts Signs Ba Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER I?,�Ka- /�Ic�Ey�Cd77K �'cc�t3�r�/�lL • _ Gni✓ Attach additional detau if desired or as required by the Inspector of Wlres. Estimated Value o Electrical Work: % p UU , U77 (When required by municipal policy.) Work to Start: 5' / 3 //q Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE O RAGE: 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 X BOND ❑ OTHER ❑ (Specify:) I certify, tinder thndpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: - eC GC P LIC. NO.:(�.3,�'�Z Licensee: —go6ulo Signa r LIC. NO.: foiY Al /Z (Ifapplicable,enter"exe t' in license / B�ius. Tel.No.-O-&P'/ 7976 Address: 90!t ar c s i�le2rnL G.c S ��7 0:rwa Alt. Tel. No.:ln3- P1a0-l�S'i% *Per M.G.L c. 147, s. 57-61, security work requues 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' agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. 603 ❑ 2012 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 (S 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. r Permits shall be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized 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 2010 and extended by Sections 74 and 75 of Chapter 238 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 purpose 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. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass [d Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: too/? Inspecto Signature: ' 12--�T�,; Date: FINAL INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: 17-1 -- Inspectors Signature: Dat DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com 1% 0 The Commonwealth of Massachusetts Department of Industrigl 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 Ledbly Name (Business/Organization/Individual): #: 603 -6PY -2?'20 Are you an employer? Check the appropriate box: 10 I am a employer with *-> ( d• ❑ 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 3111 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.] i 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. ❑ Other *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 a're doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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. r1 Insurance Company Name:. Policy # or Self --ins. Lie. #: us �'r`� � �0 Q Expiration Date: Job Site Address-.0's-6�Cc � 1A� City/State/Zip: kg Ha/ Q/J Y 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 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 ofup 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 DTA for insurance coverage verification. I do herebikz'mW[V under fiVI ins and Phone #: COD3 �Pa l Z Lu that the information provided abgve 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 -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 maybe 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 permithicense 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 Comi4onwalth of Mossacl,usPtts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA, 02111 Tel, # 617-7274900 ext 406 or 1-877�,AMMAFE Revised 5-26-05 Fax # 617-727-7749 cWww.mass,gov/dia 3 GENERATOR APPLICATION DATE: S ) t, I I '1 iocnrwn: 2,� 6"v- 54.vo+ OWNERS NAME: dJaJ1ZQ �Q-- GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: PHONE NUMBER: ELECTRICAL RESIDENTIAL "Vil GAS COMMERCIAL LOCATION OF GENERATOR: *ZONING DISTRICT: P,,Z *PLANNING APPROVAL (IF IN WATERSHED) *CONSERVATION APPROVAL�� c� Uti� (1 TEMPORARY r North Andover MIMAP May 13, 2014 06L04K*5 061.0-0029 061.0-0028 #278 061.-0027 - #266 e ` 061.0-0026 r• ` #254 #271 #250 R2 061.0.0030 0610-0083 #269 034-0-•0010 F 061.0-0040 c 4 _ 1 A #249 � ....�u.. ._.. .-_. Vii......_ �,:....__. _." _ �I£LL.::'�ti.,�•���,. _........_... 061:4400163_.�',� • �� r .i. j- w1, - _ ' S'l�il. aaF- w •� Se�l1' �'1iiix' w%'. �.�. _ _ _. `.1.e' k #205 ` _.� _ wkt , .k, wwt,.: sk IB6200011 FJ ' Rail Line::Wetlands Zoning Interstates ^. Exempt Lands _ I Busine C Busine s 1 District s 2 District ` €1orizont-ii Dawn: MA Stat lane Coonfinate System, Damn NA1781 gR Roads L rEasements a Bu me M Businei Genera®Business �Planne s 3 District s 4 District District Commercial Dev .Meters Data Sources, Tr e':date for thin map was peadu�ed by Meaintack V 10Y PN,"Nna Ce �; missk,n (MVFdC tying data prvvXted by the'rown of zM1f �yi.Em e Nddrondlecner faysl r"ai GIspT utWomathe E depteted Officon ,T tk arch Fyn this mala ie. : EnvlPdnln9rfE,Yf APPA ra tsansC$5 The to rtilaCpIt OMVPD Boundary OMunicipal Boundary ZoningOverlay Y "Corrido 0Corrido OComido Industri Development Dist Development Dist Development Dist I 1 District }E } maynotbeel., _- } yttnii or s o . nteny.„eMtmn THE TOWN Of W)R 4 ANDOVER t- 9 : MAKES NO WARRANTTES,. EXPRESSED OR WPOED, ONCE. RNiNG i "FNF ACCURACY, i}i7ttiPLCfEAtC S REtiti&±7.lih. BAdult Entertainment -': Ind 2 District _ } Cli'dSUfTA£stL.!"FY. F i OF THESE DATK THE 0DO"town OverlayDistrict ii ind!Zt :l 3 District } r u TOWN OF NORTH ANDOVER HOES NOT A°'SNt+tFA%"tY6.iah£++tEti`k'ASSOCIATFE7 Vr�4FH THE tPSE Cz42 t9iSUE�E #;F UWateric District Water Protection QIndustri Reside IS District ce 1 District TM8 W OR�'ATtON 0 Parcels Reside G Rasidece ce2 District 3 District C: Hydrographic Features -- streams 1" = 150 ft de de de ce 4 District ce 5 District ce 6 District �a a esidential District 3 Print Ownerl STONE, DAVID M Owner2 LAUREN E B STONE Address 250 BARKER STREET PropertyID 061.0-0083-0000.0 Lot Size 1.43 A Fiscal Year 2013 Land Use Code 101 Last Sale Date 36725 Book/Page 5806 Total Valuation $482200 Building Type CP Year Built 1989 Finished Area 2492 sq. ft. Assessor Map NorthAndoverAssessorMap61_26x36.pdf More Info: Click here for Assessor website Z Page 1 of 1 http://mimap.mvpc. orgINorthAndovermimap/Identify. aspx?datatab=ParcelBasic&id=061.... 5/13/2014 Date.......�.... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Thiscertifies that.................................................................................................... ,has pennission for gas installation ...._....�1� ......................................................... inthe buildings of ...........^ .'-..,...................................................................... at ....�.�.........f}.�-...�`.., North Andover, Mass. Feed... �.... Lic. No. `s'!.. GASINSPECTOR Check # '/F 6/ .2n 3A FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 10'NO [j IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Er OTHER TYPE INDEMNITY ® BOND f J1 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 0 AGENT [ZjI SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are trurah rate to st of my knowledc and that all plumbing work and installations performed under the permit issued for this application will be in co all provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �— PLUMBER-GASFITTER NAME LICENSE # SIGNATURE MP ®J MGF [j JP JGF { LPGIE1 CORPORATION# �PARTNERSHIP®# © © G� LLC [J# COMPANY NAME:]ADDRESS CITY _ I STATE ZIP f`_ TEL FAX CELL EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY^ I 1 / �/�C.plr/� ��( MA DATE PERMIT # JOBSITE ADDRESS �X J , OWNER'S NAME L GOWNER ADDRESS TE FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: d RENOVATION: El REPLACEMENT: ® PLANS SUBMITTED: YESE] NOQ APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE C.� _ .... DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 10'NO [j IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Er OTHER TYPE INDEMNITY ® BOND f J1 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 0 AGENT [ZjI SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are trurah rate to st of my knowledc and that all plumbing work and installations performed under the permit issued for this application will be in co all provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �— PLUMBER-GASFITTER NAME LICENSE # SIGNATURE MP ®J MGF [j JP JGF { LPGIE1 CORPORATION# �PARTNERSHIP®# © © G� LLC [J# COMPANY NAME:]ADDRESS CITY _ I STATE ZIP f`_ TEL FAX CELL EMAIL N El} N W a w LU The Commonwealth of Massachusetts 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: 01 W S , V, City/State/Zip: W , ��, yy,g yg � 6 Phone #: Sze - -o"G1,J l Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I mployees (full and/or part-time).* have )fired 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. ❑ I am a homeowner doing all work- right of exemption per MGL mvself. Wo workers' coma. c. 152, § 1(4), and we have no insurance required.] t 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 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit a new affidavit indicating such. • tContractors 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 'V information. Insurance Company Name: Policy # or Self -ins. Lie. Job Site Address: Expiration Date: 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. Ido hereby certo under thepains andpenalties ofperjury that the information provided above is true and correct. Signature: 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): 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' comi_ pensa tinn insumnrP Tf an T T r .,r eds ziai employees, a policy is required. Be advised that this affidavit maybe 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 r 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 TTL # 617-727-4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax # 61.7-727-7749 vvwwwmass.gov/dia .:COMMONWEALTH OF MASSACt iUSEWS `--' .�^ems �. __ _... �- PLUMBERS AND GASFtTTERS. - LICENSED AS A.-4©URNEYMAXPLUMBER ISSUFSTHE'ABOVF UCQUSE TO:-.-.- DAVID ro: DAVID F_ THEI 89 WESTST' WE-STF-00=DMA 01886-_I25 _ 23015 05/01/14 164684.- ate.