The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 26 CIDERPRESS WAY 4/30/2018tr: s- Date..JAI.1�41 .......... TOWN OF NORTH ANDOVER This certifies that.... ... .......��... has permission to perform.. .P.. . plumbing i thj buildings of........... at..:.......±..(!PL!1(............... y Fee l �. ,P.-.... Lic. No... PERMIT FOR PLUMBING `7 Check # Z 1 7 1� Q �n tM/�i` North Andover, Mass. !nv.......................................................... PLUMBING INSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT # b - JOBSITE ADDRESS % OWNER'S NAME OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL [ PRINT CLEARLY ^/ NEW: RENOVATION: t� ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 ` 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES VNO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY d 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compl' nce w' all P tinent sion f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. c PLUMBER'S NAME AAZ-LICENSE # �S-� J SIGMA RE MPV JP ❑ CORPORATION # PARTNERSHIP ❑ ## LLC ❑ # /❑ 1` � 1\� Vim/ / COMPANY NAME ► ADDRESS CIC�I! et�i CITY �.Q / STATE � "� ZIP :j -�P TEL 1--/ TL! FAX CELL 3 /Sly EMAIL TOO �H O � z O w a � z w L Q o z � z m H o w � � z O Ln Lnw �k w z E- U_ O W [ti.. � a o z C:) a w m w w w The Commonwealth of Massachusetts YDepartme"t of Industrial A-ccide6Yts. Office of Investigatioirs 600 f!<lashh gton Street Boston, _MA 02111 witymmass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Conjo-ractoi•s/Electiricians/Pluinbeu•s a Name (Business/Organization/Individual): Address: City/State/Zip: G4yhone kre you an eanployer? Check I to appropriate box: V, am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors ❑ 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. employees and have workers' [No workers' comp. insurance comp. insurance.t required.] 5. ❑ L� I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 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): b. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions I2.❑ Roof repairs 13.❑ Other my applicant that checks box til must also rill out the section below showing their workers' compensation policy information. 3omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Iontractors that check this box must attached an additional sheet showing the name of the sub -contractors *and state whether or not those entities have iployees. If the sub -contractors have employees, they must provide their workers' comp. policy number. am an employer that isproviding workers' compensation Insurance for nils employees. Below is the policy mrd job site formation. tsurance Company Name: olicy # or Self -ins. Lic. #: 3b Site Address: Expiration Date: City/State/Zip: .ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivesfigations of the DIA for insurance coverage verification. do hereby cerfi zinde!�#te pains and penalties of pezj5q�ltfz�t [he information provided above is true and correct. F Offzchd case only. Do not write in this area, to be completed by cit i or town offreiaL City or Town: Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone 4: n4� f'"^.•OFAN `'4 •" Town Of Andover �• �'a�ii[eira�OLtiE'y $100 plus $5 per fixture New Domestic Construction – 4 units or more 36 Bardet Street Renovation _ Andover MA 01810 Replacement - Existing Fixtures ONLY $50 plus $5 per fixture Backflow Preventer Residential and Commercial (for boilers and irrigation systems) Plumbing S Gas Fees New Commercial / Industrial Effective September, 2012 Plumbing Inspector . Richard Danforth (978) 623-8305 Fax No.: (978) 623-8320 Office Hours: 8:00 a.m. - 10:00 a.m. 0 NEW: New Construction and Additions 0 RENOVATION: Plumbing within the existing system 0 REPLACEMENT: Removal and replacement of a fixture to the existing piping ALL TENANT RT -UPS ARE CONSIDERED "NEW" ALL GAS BOILERS AND WATER HEATERS REQUIRE A PLUMBING PERMIT WATER HEATERS AND OIL BRUNERS REQUIRE AN ELECTRICAL PERMIT PLUMBING FEES Residential —� $50 plus $5 per appliance New Domestic Construction – ueto 3 Units $100 plus $5 per fixture New Domestic Construction – 4 units or more $200 plus $5 per fixture Renovation _ _$50 plus $5 per fixture Replacement - Existing Fixtures ONLY $50 plus $5 per fixture Backflow Preventer Residential and Commercial (for boilers and irrigation systems) $50 plus $5 per fixture New Commercial / Industrial $200 plus $5 per fixture Commercial – Renovation $100 lus $5 per fixture Commercial Replacement – Existing Fixtures ONLY $100 plus $5 Ler fixture GAS FEES Residential $50 plus $5 per appliance Gas Stove/Heater $50 plus $5 pera liance New Domestic Construction – up to 3 Units $75 plus $5 per appliance Capped Sewer Lines New Domestic Construction – 4 units or more $150 plus $5 per appliance Inspection after hours (minimum Fee) Renovation (Domestic) $50 Plus $5 pera Double Permit Fee __ _j liance Replacement (Domestic) Existing Appliances ONLY $50 plus $5 pera liance Gas Boiler / Furnace / Conversion Burner (Domestic) EACH $50 plus $5 per appliance New Commercial / Industrial $150 plus $5 pera liance Commercial – Renovation $100 plus $5 pera liance __ _ Commercial Replacement – Existing Fixtures ONLY $100 plus $5 per appliance Gas Boiler / Furnace / Conversion Burner (Commercial) EACH I $100 plus $5 pera liance MISCELLANEOUS Gas Log/Fire Place $50 plus $5 per appliance Gas Stove/Heater $50 plus $5 pera liance Utility / Bar Sinks $50 plus $5 pera liance Capped Sewer Lines $50.00 Re -inspection Fee 1 $50.00 Inspection after hours (minimum Fee) $200.00 Work started without a permit Double Permit Fee __ _j _-_ ......"-- -' rya, ,,,,y ,,,,, ut,t,,,r anun are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit Fall P tinent i i n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BGASFITTER NAME LICENSE # 40 SIGN URE MP JP ❑ JGF ❑ LPGI ❑ CORPORATION [:]I, PARTIVERShIIP ❑ # LLC ❑ # COMPANY NA4E, AD ' DRESS CITY4—" STATE ��C " t ZIP TEL FAX _ CELL { �•- �a% EMAIL a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ;:11;;(f .i J. CITY ,E=. (LES MA DATE _ PERMIT #I JOBSITE ADDRESS r�r� fj' OWNER'S NAME d3 GOWNER r ADDRESS _ _ TEL FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL I❑ ❑ RESIDENTIAL CLEARLY NEW: [RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES Z FLOORS— BSM i 2 3 4 5 6 7 B 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR — GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM 1 SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER. WATER HEATER OTHER - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERA BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 17 OTHER TYPE INDEMNITY ❑ BOND ❑ 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 El AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and informntinn t hnuo —i,., mn a , _ a:__ .� _ ___,•__.._ _ _-_ ......"-- -' rya, ,,,,y ,,,,, ut,t,,,r anun are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit Fall P tinent i i n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BGASFITTER NAME LICENSE # 40 SIGN URE MP JP ❑ JGF ❑ LPGI ❑ CORPORATION [:]I, PARTIVERShIIP ❑ # LLC ❑ # COMPANY NA4E, AD ' DRESS CITY4—" STATE ��C " t ZIP TEL FAX _ CELL { �•- �a% EMAIL a c� O z z O M U a _z L L }❑ W ti W � � O � Z O � � U zo a. � Q v T =� Q � w z u� u; W z z 0 U w z U W U O ' C4 The Uonnnonwealth ofTllassachu,yett's Department of bidustricd.A.ceidew's Of' lCe t)f Iritresti�ations 600 0" isEringion 'treet Boston, l'B'a`t11 02111 i v.vi v. rrrass.govIdia Workers' Compensation Insurance Affidavit: Buildell•s/Cont¢•actoi-s/Eleetricians/Plumbers 2licant Information � — Please Print JLeLlibl, Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: 1-0 ) Are y U an employer? Clteclt: the appropriate box: I am a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors _. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees working for me in any capacity. [No workers' comp. insurance required] ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.) t These sttb-contractors have employees and have workers' comp. insurance.! 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c 152, S ](4). and we have no employees. [No workers' comp. insurance uired.] Type of project (required): 6. ❑ New constniction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other u1y -applicant that checks box ##I must also fill out the section below showing their workers' compensation policy information. iomeo,ners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. .ontractors that check this box must attached an additional sheet showing the name of the sub-contractors"and state whether or not those entities have tployees. If the sub -contractors have employees, they must provide their workers` comp. policy number. were an employer• that is providing wor•hers' compensaiion insurance for rr Y emplovees. Below is the policY acrd job sire for n -Cation. surance Company blame: Aicy # or Self -ins. Lic. #: tb Site Ad Expiration Date: City/State/Zip: ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certir under tl* paid arrd penalties operjury that the irrjorrsratio,-t provided above is twee and correct. #: Ail -13 Official rise only. Do not write- in this area, io be completed by citlr or• to}vrt officiaL City or Town: Permit/License # Issuing Authority (circle one): 1. ]Board of Health 2. Building Department 3. City/Town Clerl, 4. Electrical Inspector S. DlotnibinB Inspector 6. Other Contact Persort: Phone #: ;v OLS•: Town of Andover ,taa.Tin''+r 36 Brartlet Street Y• fps :.t�.'.:�5,�� Aildovel, MA 01810 q ` tiY $50 plus $5 per fixture �Yy ♦�, P1urrlbi na Gas Fees Backflow Preventer Residential and Commercial (for boilers and irrigation systems) Effective September, 2012 Plumbing Inspector Richard Danforth (978) 623-5305 Fax No.: (978) 623-8320 Office Hours: 5:00 a.m. - 10:00 a.m. 0 NEW: New Construction and Additions 0 RENOVATION: Plumbing within the existing system 0 REPLACE, vIENT: Removal and replacement of a fixture to the existing piping ALL TENANT FIT -UPS ARE CONSIDERED "NEW" ALL GAS BOILERS AND WATER HEATERS REQUIRE A PLUMBING PERMIT WATER HEATERS AND OIL BRUNERS REQUIRE AN ELECTRICAL PERMIT PLUMBING FEES Residential $75 plus $5 her appliance New Domestic Construction — up to 3 Units $100 plus $5 per fixture New Domestic Construction — 4 units or more $200 plus $5 per fixture Renovation $50 plus $5 per fixture Replacement - Existing Fixtures ONLY $50 Plus $5 per fixture Backflow Preventer Residential and Commercial (for boilers and irrigation systems) $50 plus $5 per fixture New Commercial / Industrial $200 plus $5 per fixture Commercial —Renovation `_ll1lus $5 per fixture Commercial Replacement —Existing Fixtures ONLY ^— $100 plus $5 per fixture GAS FEES Residential New Domestic Construction — up to 3 Units $75 plus $5 her appliance New Domestic Construction — 4 units or more $150 plus $5 per appliance Renovation (Domestic) $50 plus $5 per appliance Replacement (Domestic) Existing Appliances ONLY $50 Plus $5 pera liance Gas Boiler / Funlace / Conversion Burner (Domestic) EACH $50 plus $5 per appliance New Commercial / Industrial $150 plus $5 per appliance Commercial — Renovation $100 plus $5 per appliance Commercial Replacement — Existing Fixtures ONLY $100le s $5 ,ger appliance LGas Boiler /. Furnace / Conversion Burner (Commercial) EACH $100 lis $5 erappliance MISCELLANEOUS Gas Log/Fire Place $50 plus $5 pera liance Gas Stove/Heater Utility / Bar Sinks $50 Plus $5 PsLaylplianca $50 plus $5 )er appliance Capped Sewer Lines $50.00 Reinspection Fee $50.00 Inspection after hours (minimum fee) $200.00 Work started withoit a permit Double Permit Fee Date.... �.1.1....�.1f... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that...........!.......'X........�c.....p:fl.................................................... has permission for ga . i stall ion ...Q}....�'............................... in the buildings of ..............1P p ..... ..! ��1.......L-L.C--............................ at ...... ........n... ..U; Pr..fL.�777..7I....... Fee ...................... Lic. N�....i......,�?........ Check # �i 1 j .., North Andover, Mass. ................................................ GASINSPECTOR �� Pll 0�-17��-� rJ a I (— z v-/ Date............................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING �.�,; This certifies that .......................... .��,. ............................................................................................ has permission to perform ................................................... -'� n.....:,:........................................... wiring in the building of......... 1 L-12-1 ... `, � ,� ................................................... �% (f1,%ih'C ► ✓Zc C 5.............� , North Andover, Mass. Fee..ZNo...........,.. .........f .4.'.. ....... . �.......... . j ELECTRICAL INSPECTOR Check # ` D Commonwealth of Massachusetts Official Use Only MEM Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C), 527 CMR 12.00 (PLEASE PRINT IN NK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Insp ctor of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 2 „t is SS c,J Owner or TenantTelephone No. Owner's Address 7 X 4, .4- DV t:J , of 4 - Is this permit in conjunction with a building permit? Yes [gr No ❑ (Check Appropriate Box) Purpose of Building (\ S ( „vim✓} -C_— Utility Authorization No. - Existing Service Amps / Volts .q New Service Amps / Volts Number of Feeders and Ampacity Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ Location and Nature of Proposed Electrical Work: 7 No. of Meters No. of Meters Comnletion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans v No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ jNo. of Emergency Lighting rnd. grnd. 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 g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number .. ' Tons " " " "'"' KW .."'..... "' No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances KW Security De icl s or Equivalent No. of Water T No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of {Hires. Estimated Value of Electrical Work: (, %�p�_ (When required by municipal policy.) Work to Start: I t I (0 I E 3 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 E�" BOND ❑ OTHER ❑ (Specify:) Icertify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM N) Licensee: (If applica! Address: *Per M.G OWNER'S INSURANCE WAIVER: LIC. NO.: M LTC. NO.: 1-7) n S Tel. No.: 8-1r2.e g Z- Tel. No.: � -2.k ? 76-2:. , - - . - - - - Lic. No. I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) [] owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ❑ 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 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 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 conceming 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 0 Failed ❑' Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass F?1 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: �. r. r� Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: ' Inspectors Signature: Date: FINAL INSPECTI Pass IN . K Failed 0 Re- Inspection Required ($.) ❑ Inspectors Commen ./ Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com i 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):� L aLE;t✓�-v r Address:- Pot_ -c City/State/Zip: 5 r ews �-�t d 3S6S Phone #: Gid 3iS-v £sb Z A,reyy r -an employer? Check the appropriate box: 1. L1 I 7 4. ❑ I am a contractor and I Type of project (required): am a employer with general 6. [g'New construction employees (full and/or part-time).* have hired the sub -contractors 7. ❑ Remodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet.1 ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑Building addition [No workers' comp. insurance required.] officers have exercised their 10. F1 Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] i employees. [No workers' 13. ❑ Other comp. insurance required.] �%ny applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they aie 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. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:, L i A/0 ✓ t Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: 2ej. C City/State/Zip: /int , sE,� ��"t,-4 Attach a copy of the workers' compensation policy decl ation 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 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 cer ify under the pains and penalties of perjury that the information provided above is rtrue and correct. Sianature. , i Date: -) S_ .�_? __0 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 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 ventuie (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. I 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 Mo s sachu s etts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 TO, # 617-727-4900 ext 406 or 1-877:MASSAFB Revised 5-26-05 Fax # 617-727-7749 __www-masa.gov1dia