HomeMy WebLinkAboutMiscellaneous - 252 RALEIGH TAVERN LANE 4/30/2018O
A - .. - /`�,
Date.......................e,...........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
.. / ..................
This certifies that .... .......
has permission to perform ...................a. ................................
wiringin the building of ....................................................................................
atS..:7.... . / ........ North Andover Ma
..
Fee -.:.R-5 ....... ... Lic. No.7Z?.7.-,,14 03 .............. .. .... ..... ...
fiUicrRICAL INSPEc-roR
Check #
9048
lf1mmonwea114 of Vadjackwetb
2eparEmenl: of/ ire Serviced
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.
o_
Occupancy and Fee Checked.5
[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 1200
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) . Date: /0 a —0
City or Town of: � �� ' Ila-,/\ J 1q dg To the Inspector of Wi s:
By this application the undersignedgives notice oaf is or her intention to perform the electrical work described below.
Location (Street & Number) aki �r��iDaC.l_ 4-0,—.
Owner or Tenant
Owner's Address
Telephone No.7��-�{�cj
Is this permit in conjunction with a buildin permit? Yes �] No ❑ . (Check Appropriate Box)
Purpose of Building �� A 0 / Utility Authorization No,
Existing Service Amps / t) Vats Overhead ❑ Undgrd No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity l
Location and Nature of Proposed Electrical Work: - C-4 Ssec i C I.r�C� PPA
i I^ s gut) li ti U ✓1e,L. V f ' � 4
t Comnlettnn nftha fn1inwino tnhlo inn„ ho y,niyo i h„ tha
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. grnd.
o. ol Emergency Lighting
Battery Units
No. of Receptacle Outlets
No, of Oil Burners
FIRE EA::R=MSNo,
of Zones
No. of Switches
No, of Gas Burners
o. 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
" """ ' "'""
KW
""""' ' """""'
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances Kms,
Security Systems:*
No. of Devices or Equivalent
No. of WaterK``
Heaters
o. of No. of
Si ns Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER: \�
.4O0 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: d— .- 09 Insp ctions 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 the pains and penalties oferjury, .that th nforrnation on this application is true and complete,
FIRM NA E: 0ZL L LIC. NO,:—,6Q�
Licensee: Z( CAW Signature LIC. NO.:
(If applicable, enter kexempt" in the license number line.) Bus. Tel. No. — (�
Address: Alt. Tel. No.:
*Per M.G.L, c. 147, s. 57-61, security 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/Agentf PERMIT FEE: $°�
Signature Telephone No,_
Date .. ... !? .
OE .NOFTM
�p TOWN OF NORMAN DOVER
+: PERMIT FOR GAS INSTALLATION
This certifies that.. U .............................
has permission for gas installation .
in the buildings -of .:
' ?. f. '-.:./; North Andover, Mass.
Fee:' ! . oA . Lic. No .J41 y;/` . .........
GAS IPPE TTOR
Check #
6726
t
MASSA,CHUSMS UNIFORM APPUCATION FOIA PERMIT TO OU t-AZ:;.,i-1I I It'U
—� (Print or- Type)
1�1 POc ALL-
Mass. Date I Z 3�,�acl Permit # `
Building Lotion 7 1 LL4,i t M ��yam Owner's Name
I
i Type.,of'Occvpanc/ f�Z1 104 o. T t ra
New C3 Renovation CDRe;�Iacement Plans• $ubmitted: Yes❑ No Cj�
I - Installing -Company Name '
Address 5
Rrnr- d5 '"A
Business T
Name of I ieensed Plumber or Gas Fitter
Check one: Certiricate
❑ dorporation
❑ . Partnership
jB�F`ima/Co.
INSURANCE COVERAGE.
I have a current I' insuranc= policy. or itss substantial equivalent which meets the requirements of MGL Ch. 142..
Yes No ❑
If you have. checked yes, please in/dicata1he type coverage by, checking the appropriate box
A liability insurance policy 1✓Y 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:
Owner❑ Agent ❑
Signature of Owner or Owners Agent
I hereby certify that all of the details and infoFination I haveIsubmitted (or entered) in above application are true and accurate to the best of my
kncwiedge and that all plumbing work and installations performed under the peirnit issued f IFati will be in compliance with all
pertinent provisions of the Massachusetts State.Gas Code and Chapter 142 of the General
- T�of License:- %'�' ••-- -�-'." •-----_._
Plumber Signature of licensed elumoer at Gas Fitter
Title
er License Number. ,7
City/Town ❑,tumeyman
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STH FLOOR
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7TH FLOOR .
8TH FLOOR
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I - Installing -Company Name '
Address 5
Rrnr- d5 '"A
Business T
Name of I ieensed Plumber or Gas Fitter
Check one: Certiricate
❑ dorporation
❑ . Partnership
jB�F`ima/Co.
INSURANCE COVERAGE.
I have a current I' insuranc= policy. or itss substantial equivalent which meets the requirements of MGL Ch. 142..
Yes No ❑
If you have. checked yes, please in/dicata1he type coverage by, checking the appropriate box
A liability insurance policy 1✓Y 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:
Owner❑ Agent ❑
Signature of Owner or Owners Agent
I hereby certify that all of the details and infoFination I haveIsubmitted (or entered) in above application are true and accurate to the best of my
kncwiedge and that all plumbing work and installations performed under the peirnit issued f IFati will be in compliance with all
pertinent provisions of the Massachusetts State.Gas Code and Chapter 142 of the General
- T�of License:- %'�' ••-- -�-'." •-----_._
Plumber Signature of licensed elumoer at Gas Fitter
Title
er License Number. ,7
City/Town ❑,tumeyman
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Date.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
1
This certifies that .... � J. .............................
has permission to perform` `-?;-'.......................
plumbing in the.b�uildings of .*....`.. ..........................
? �...... :`�'�... !.�""``" North Andover, Mass.
at .
Fee .. c.'...... Lic. No..... ..? ....................... .
/ (/ PLUM 81NG INSPECTOR
Check # `� r)lv`7
RIYTI IRFC
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: 0 M,i�t1 Vi , MA. Date: a C I Permit#
Building Location:.. . - 2 ilii 4 �+ .�A ✓zrU� _ _. �w T. Owners Name:' /�:, i
Type of Occupancy: Commercial; Educational; Industrial :/ Institutional Residential
New Alteration.: Renovation Replacement Plans Submitted: Yes No
RIYTI IRFC
INSURANGE t:OVF-KAGt:-_.-
(have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes; ✓_ ' No
If you have checked Yes. please indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy t/^ Other type of indemnity Bond
OWNER'S INSURANCE WAIVER: l 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 Agent
Si nature of Owner or Owners Hgem
I hereby certify that all of the details and Information I have submitter! (or entered) regarding this application are true and accurate to the best of my
nartnrmad under the oerm{t issued for this application will be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of we
By Type of License: ----------
✓ Signature of Licensed Plumber
Title Plumber
Master-
City/Town.- „ License Number: 13471
APPROVED (OFFICE USEJourneyman.loumeyman
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SUB BSMT.
BASEMENT
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2 FLOOR
3 FLOOR
4TH -FLOOR
6 FLOOR
6 FLOOR
7m FLOOR
8 FLOOR
Check One Only Certificate #
Installing Company Name:. P.H.D_Plumbing
--
_
Corporation
Address: Dorian Drive
City/Town
Bradford
;State: MA;
_15 -
_,-
Partnership
Business Tel: 978-556-5617
Fax
978-372-6139
Firm/Company
Name of Licensed Plumber , Roberto Fiaiani
INSURANGE t:OVF-KAGt:-_.-
(have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes; ✓_ ' No
If you have checked Yes. please indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy t/^ Other type of indemnity Bond
OWNER'S INSURANCE WAIVER: l 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 Agent
Si nature of Owner or Owners Hgem
I hereby certify that all of the details and Information I have submitter! (or entered) regarding this application are true and accurate to the best of my
nartnrmad under the oerm{t issued for this application will be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of we
By Type of License: ----------
✓ Signature of Licensed Plumber
Title Plumber
Master-
City/Town.- „ License Number: 13471
APPROVED (OFFICE USEJourneyman.loumeyman
11;
Date
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ... � ...... -./
has permission to perform
plumbing in. the buildings of .......................
I
North Andover, Mass.
Fe11LieN �--........
PLUM1�NSPECT01
Check #
8257
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
z' �Date
Building Location -3(541-3(541� �� ►Ci:� Owners Name !Vh t�C? j°� C Permit#
Amount
Type of Occupancy
Newr Renovation Replacement Plans Submitted Yes ❑ No ❑
(Print or type) �
Installing Company Name `J �1t1 et Cj Qty
Addres `� L • i� �� �`1�
Name of Licensed Plumber:
Insurance Coverage: Indicate the
Liability insurance policy ❑
type of insurance coverage by cckin
Other type of indemnity
Check one: Certificate.
Corp.
Partner.
Firm/Co.
to box:
Bond
Insurance ai er: I. the u si ave bee ade aware that the licensee of this application does not have any one of the above
thr
ignatur Owner ❑ Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are Ve and accurate to the
best of my knowledge and that all plumbing work and ins o s performed un a Pe s d for thi ' pplication will be in
compliance with all pertinent provisions of the Massa sePlumb' o Ch r 14 the General Laws.
By:
SignaLure o 'Icenscu riumDerC
Title ype of Plumbing License
City/Town icense NumDer - Master Journeyman ❑
APPROVED (OFFICE USE ONLY
I
A
Policy # or Self -ins. Lic.
--- ez_4_.— Q x?iration Date: 12
Job Site Address:
/Stste/Zip:
Attach a copy of the workers' eozrepensation policy tleclaratioD page (showing the policy number and expiration date). .
Failure to secure coverage as required under Section 25A of MGL c, 152 can lead to
fine up to $1,500.00 and/or one-year imprisonment, as well $s civil penalties in the farm of a STOP WORK ORDER the imposition of criminal and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarde
Investigations of the DIA for insurance coverage verification. d to the Office of
I do hereby
OiTicial use
City or Town:
me =r0T"1ation Provided above is true and rorred
Do not write in this ama, In be Cotfler nd by or town okra[
Pl-r—M. /License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/'rown Clerk 4. Electrical Inspector 5. Piumbing Inspector
6.Ot6e''r
Contact Person-
Phone #:
The Commonwealth of Massachusetts
1 I
Hair
Department ofindustrial Accidents
Office Investigations
4
of
600 *"=hington Street
Boston, MA 62111
c ; www mussgov/dia .
Workers' Compensation ins uance AffidaviL_ Builders/Contractors/Eiectricians/Piumbers
A licant Information
Please Print Leoibl
Name (Business/Organiratiot�/Individual);
��
t
Address 36 � 161
City/state/Zig:
S ! Phone #:. l'—,2�/'—'
A you pioyer4 Cizeek.the appropriate box: ---._
I I am a employer with 4. ❑ 1 am a general contractor and I Type of Project (required):
2. ❑employees (full and/or part-time).*
I am .a.sole proprietor or
have biired the sub -contractors 6' ❑Now 00 ction :
listed
partner-
ship and have no employees
on the attached sheet x 7odeiing
These su&contractor; have
8' Q Demolition
working for me in any capacity,
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its 9 ❑ Building addition
required.)
3.E3I am a homeowner doing all work
myself
officers have exercised their 1Q.0 Electrical
right of excrruption per MDL l 1.❑ plumbing reps or additions
nP
[No -w comp.
insurance required.].t
or additions
c 152, § 1(4), and we have no g
-cnaployee:s. [No workers' 12.0 Roof repairs
comp• insurance required.] 13.❑.Other
*%nY aPPi�t filet checks bo>L' #I must ehto frit oat the section blow showing their ,,k'' wcomPensetion policy information.
1 fiomeownmirs who submit this affidavit indicating
they amt tloin an
_ SCtintraetots that check this box must g N'Oric'end then hdt otnside conttactots muat'submit a new affidavit indica*
an additional sheet ahowiy the Harm of die sub-c=m=t= and their workers' ce such
t am an employer drat tv ;o.:s �g:;;:arkers'
infarmadom
m. PcFi� ir�miation.
compertsaxa►n insurunre or
f ' ertinloyem Below is tlsePoficJ' Qnd
job site .
Insurance Company Name:
Policy # or Self -ins. Lic.
--- ez_4_.— Q x?iration Date: 12
Job Site Address:
/Stste/Zip:
Attach a copy of the workers' eozrepensation policy tleclaratioD page (showing the policy number and expiration date). .
Failure to secure coverage as required under Section 25A of MGL c, 152 can lead to
fine up to $1,500.00 and/or one-year imprisonment, as well $s civil penalties in the farm of a STOP WORK ORDER the imposition of criminal and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarde
Investigations of the DIA for insurance coverage verification. d to the Office of
I do hereby
OiTicial use
City or Town:
me =r0T"1ation Provided above is true and rorred
Do not write in this ama, In be Cotfler nd by or town okra[
Pl-r—M. /License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/'rown Clerk 4. Electrical Inspector 5. Piumbing Inspector
6.Ot6e''r
Contact Person-
Phone #:
Information a end Instructions
Massachusetts General Laws chapter 152 requires all emp Ioyers 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, mc:xdiation, 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 ortrmtee- of an individuaL'partnership, association or other legal entity, employing employees; 'Howevc die
owner•of a dwelling house having not more than three apartmentts and who resides therein, or the occupant of the y v
dwelling house of another who employs persons to do maimtenance, construction or repair work m such dwelling house
or on the grounds or building appurtenant thereto shaU not because of such mupioyment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state er local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or tto construct buildings in the commonwealtb for any
applicant who has not produced acceptable evidence -of compliance with the insurance'coverage required."
Additionally, MOL chapter 152, §25C(7) states "Neither t3he commonwealth nor any of its political subdivisions shall
enter unto any contract for the per Frnsttitrnce of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the caitnwting authority.-.
Applicants
Please fill out the workers' compensation• affidavit compien-tely, by checking the boxes that appiy.to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es)_arid phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or LimitedLiability Partnerships (LLP) with no employees other than the
members or partners, arc not required to workers' eornpensation insurance. Ifan LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial c
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 ti►at the application for the permit or license is being requested, not the Department of
Industrial Acoidents. Should you have any .questions regarding the law or if you are required to obtain a workers' -
oompensation policy, please -call the Dgmtment at the nurmber iisted below, Selt=ms�*ed er..np"�i eF�n��id ,�.,r tt, r
self insuran=—iiame number on tlte'appropriate. lire.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department hes 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 permitJlicense number which w-iIl be used as a reference number. In addition, an appiicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicaiing•current
policy :information (if necessary) and under "Job Site Address" the applicant should write~ "all locations in (city or
town)." A copy oftbe 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 futare permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permitnot related to any business or commercial venture
(i.e. a dog license or permifto bum leaves etc.) said persor3 is NOT required to complete this affidavit
The Office of Invesiisations would ltflm to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a tail.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Deptntrneat of Fmdust W Accidents
Office of Investigations
600 Washington Street
Boston, A!IA 02111
TeL # 617-7274900 ext 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax # 617-727-7744
www.mam.gov/dia
4
Date...................
,ORT#1
Ot
TOWN OF NORTH AND, VER
PERMIT FOR GAS INSTALLATION
This certifies that ... ...........
;has permission for gas installation ............................
in the buildings of
at2....... 'or`th—
e--� y Andover, Mass,
.... Lic. No..6? 't .
Fee .........
GAS INSPE OR
Check #
6962
MASSACHUSETTS UNIFORM APPLICATON FORPERMTT TO DO GAS FITTING
(Type or print) Date A
�
NORTH ANDOVER, MASSACHUSETTS
Building Locations �.J ' — �1 L��1�-''V Permit.#
Amount $ p�
�'s O �p ii' Owner's Name
New ❑ Renovation Replacement Plans Submitted ❑
(Print or type)
Name of Licensed Plumber or Gas Fitter �a`�%��,%��� U-� %� 14-,
Check one: Certificatelnto lin o pany
ElCorp. .��
❑ Partner.
❑ Firm/Co
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No 13
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
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 State Gas Code and Chapter 142 of the General Laws.
By:
Title
City/Town
(OFFICE USE ONLY)
Sipature of Licensed Plumbr as Fitter
umber
Gas er lcense Number
aster
Journeyman
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SUB-BASEM ENT
B A S E M ENT
1ST. FLOOR
/
2 N D. F L O O R
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
8TH. FLOOR
(Print or type)
Name of Licensed Plumber or Gas Fitter �a`�%��,%��� U-� %� 14-,
Check one: Certificatelnto lin o pany
ElCorp. .��
❑ Partner.
❑ Firm/Co
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No 13
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
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 State Gas Code and Chapter 142 of the General Laws.
By:
Title
City/Town
(OFFICE USE ONLY)
Sipature of Licensed Plumbr as Fitter
umber
Gas er lcense Number
aster
Journeyman
a
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, JlL4 02111
www.mass.gov/dia
Workers' Compensation Insurance A.Mdavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: �� (v
City/State/Zip: S A\)c�J S rK 4 019 Phone #: -761 q0
J
Are you an employer? Check the appropriate bog:
1. 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. t
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
These sub -contractors have
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.].
Type of project (required):
6. ❑ New construction
7/Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
R A.........T'.. 7. 1 1.... C.
..,y applicant ant that checks box 9, ..u&— a,,...11 out the section below showing their workers' compensation 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.
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.
Insurance Company
Policy # or Self -ins. Lic. #: �f K,)i<,dQ�j%� �.'tj Expiration Date: 1 Z 3lo
lc v,c yk I Tla ' y n
Job Site Address:C
OCL City/State/Zip: v\ aeVeti"
u
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
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 #•
v o
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 apartrnents 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 affidaAf'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 permittlicense 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 Iicenses. 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
DTartment of Industrial Accidents
Office of Investigations
600 Washington. Street
Boston, MA 0.2111
Tel # 617-7274900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-Q5 www.mass.govfdia