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HomeMy WebLinkAboutMiscellaneous - 261 WAVERLY ROAD 4/30/2018 (2)o rn 951 1 Date ..... 7 -..1I -.A92.. ...... .. ... . ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............. ............ .................... has permission to perform .......... .................. ................ wiring in the building of ........ 611-.,2 /.3. f!! < .............................................. at ....... / ....... North Andover Mass. TiFee.:�-e ................ L c. No. ..... fi.Z .................. Check # 4//-7 ... ELECIIICAL INS r6R :40.0 gnassacliusetts Electrical Code Amendments 527 CMR12.00 § Rule 8: in accordance -with thc provisions of MG.L. c. 143, §. 3L, the permit application form to provide notice ofinstallation ofwIring sh . all 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. 01 c. 166, § 32, an electrical permit shall he issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification ' of completion ofthe work as required in MG.L. c. 143, § 3L. I Permits shalLbe limited as to the time of ongoing construction activity, and may bedeemed-by-theJnspector-of-W.ires . abandoned-and-irwalid-ne— or shehas determined tl�a't the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upoa written application, an extension oftime for completion ofwork shall be p&uritted for reasonable cause. A permit shall be terminated upon the written request ofeither the owner or the installing entity stated on the.pormit application. n The Permit Extension Act was created by 5ection 173 ofChaMt r 24G ofthe Acts of2010 and extended by S ections.74 and 75 of Chapter 23 8 of the Acts of 2012. The purpose of this act is to promotejobi'growth and long-term economic recovery and the Permit Extension Act farthers this purp ose by establishing an automatic four-year extension to certain-pennits and licenses concerning theYs e. or development ofreal prop erty. With limited exceptions, the Act automatically dxtends, for four years beyond its othe�wls e applicable expiration date, any permit or approval that was 'in eflect or existence' during the qualifying period beginning on August 15, 20 . 08.and extend-mgthrough August 15,2012. r--- Pguoo — PermittDate Closed: 0 Permit Extension Aet — Permit/Date Closed: *** Note:.Reapply for new perm- itV "I -� t,vmmw1wcan,i1 vi 1via2P.'JC1W14J.*AcLw --- - --- - '" l Department of Fire Services Permit No. c7,5-1 Occupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: -7- [3—Ly 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) 9 -Col Cn1ol V - L7 Owner or Tenant ` o 6a r +-- 0t to bo n S Telephone No. Owner's Address J rii vwP Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building �9 t �-]p� Utility Authorization No. Existing Service 100 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: t�-� `�6t ✓Ld (��i Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. rnd. Wo -. -OT Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I 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 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 HeatingAppliances pp KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring:. No. of Devices or Equivalent OTHER: -'Vk t:t V w n Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (1'r ©D w (When required by municipal policy.) Work to Start: %-1 & - t O Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE. Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and nalties of perjury, that the information on this a plication is true and complete. FIRM NAME: Jed k I I 64,e C, LIC. NO.: 3 Z - Licensee: Iaot. s k Signature LIC. NO.: ,, p (If applicable, enter "exem t" in the license num er line.) BUS. Tel. NO.'S 7CQ l 3 �'LfJ Address: [ l ra ✓"v01 M ,n (2� rb,o u -F //'LA O L 0 t 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 Owner/Agent PERMIT FEE: $ Signature Telephone No. 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 Lelzibly Name (Business/Organization/Individual):�J Address: 11-5—o --tl m ~ 6,�h �—:d City/State/Zip W-1, c a � .A^-,\ 0LRZC. M Phone #: Gl �7 ? 7 u 1— `3 (6 Ct 0(2 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).* have hired the sub -contractors 2. tm 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 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 #I must also fill 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. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 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 cert' un er the ins and penalties of perjury that the information provided above is true and correct. Signature: Date: `7— % 3 1 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 #: Date. . �//; /—"� ........ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that S ..................................... has permission, for, gas installation ............. in the buildings of ............................ at j . .. ........... North Andover, Mass. Fee. Lic. No.. ..... .... GASINSPECTOR Check 4 io o 7293 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FrMNG (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations oe/I 1/ Permit # /n � Amount $ n�y i�1? r�l Owner's Name 4e 6.-2,1 / (;�- I , d New ❑ Renovation ® Replacement ❑ Plans Submitted ❑ (Print or typ�e)j;/j Check one: Certificate Installing Company Name T'�� SD�� / %'` Corp. Partner. OFinn/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes [El NoEj 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 - - - -v u-- — — uI. a -ll- ll1 1111a'LvLL uavc SuonnLLea dor enterea) 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 Massachys5ts State Gas Code and Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter 0 Plumber e-1, e 5 — 0 Gas Fitter Eicense Number 01 Master 0 Journeyman i u� /a 1� ,SUB-BASEM ENT :3RD. FLOOR 4TH. FLOOR i5TH. FLOOR :6TH. FLOOR 17TH. FLOOR (Print or typ�e)j;/j Check one: Certificate Installing Company Name T'�� SD�� / %'` Corp. Partner. OFinn/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes [El NoEj 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 - - - -v u-- — — uI. a -ll- ll1 1111a'LvLL uavc SuonnLLea dor enterea) 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 Massachys5ts State Gas Code and Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter 0 Plumber e-1, e 5 — 0 Gas Fitter Eicense Number 01 Master 0 Journeyman i u� /a 1� The Commonwealth of Massachusetts Department o f Industrial Accidents Office of Investigations ky 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print y Name (Business/Organization/Individual): 57a /,/ c, Address:-, Ci /State/Zi : 7rt� 'dy l t3' P �%i�%� a� ` g Phone #: Are you an employer? Check the appropriate box- ox: LEI L ❑ I am a employer with 4. ❑ I am a general contractor and I employees (fiill and/or part-time).* 2. PTI have hired the sub -contractors am a'sole proprietor or partner- listed on the attached sheet I 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 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 Z Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other u .1 r. J iur ccr me seen"_ oeio�r snov tnb '-^e r 0,,C= ' compens non pelrcy nfo: a to_ 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. I am an employer that is providing workers' compensation insurance for my employees. B information. elow is the policy and job site Insurance Company Name:_. �ts /j,2 D- 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: �'L z_ -_..— Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 3 6. Other Contact Person: Permit/License # City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector Phone #: AO c. 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 orother 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 cox npliance 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(g) 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 peraitOr license is being requested, not the Department of Industrial Accidents. Should you have any questions regardirLg 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 homeowner 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 lndusfzial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 . ext 4406 or 1-877-MASSAFE Revised 5 -26 -OS Fax # 617-727-7749 wurw.mass.-gov/din Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING .... P �. (-.� ................... This certifies that PAI? - has permission to perform ... PC '�-. Q Y. 1141.0*. -7 ................... plumbing in the buildings of ...................... at.;. .......... �. ., North Andover, Mass. Lic. No.. .. ....... Fee. PLUMBING IN9PECTOR Check 8362 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO ]DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS n Date _ Building Permit Amount Type of Occupancy New Renovation Replacement ® Plans Submitted Yes ® No 1WYYTTTR F (Print -or type) Q Check one: Certificate Installing Company Name P4 4 sem'S / '� [a Corp. Address �u w S % I't�Jr- ' 7 Lis El Partner. Business Telephone / Z 17 5�- / �r 2 / �° _�/ Firm/Co. Name of -Licensed Plumber: S /7 #sL.y •� � S - Insurance Coverage: Indicate the type of insurance coverage by checking the appropriatebox: Liability insurance policy ® Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent E] I hereby certify that all of the details and information I have submitted (or enfered) 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 ac State Plumbing Code and Chapter 142 of the General Laws. By: Signa of Licensedum er Type of Plumbing License Title / �z ZiS City/Town License NumDer Master 01 Journeyman APPROVED (OFFICE USE ONLY J .J • • MOONS % Now mom (Print -or type) Q Check one: Certificate Installing Company Name P4 4 sem'S / '� [a Corp. Address �u w S % I't�Jr- ' 7 Lis El Partner. Business Telephone / Z 17 5�- / �r 2 / �° _�/ Firm/Co. Name of -Licensed Plumber: S /7 #sL.y •� � S - Insurance Coverage: Indicate the type of insurance coverage by checking the appropriatebox: Liability insurance policy ® Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent E] I hereby certify that all of the details and information I have submitted (or enfered) 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 ac State Plumbing Code and Chapter 142 of the General Laws. By: Signa of Licensedum er Type of Plumbing License Title / �z ZiS City/Town License NumDer Master 01 Journeyman APPROVED (OFFICE USE ONLY The ComrnonwBrzZth of Alassachusetts Department o f £ndustrial Accidents Office of16ivestigadons ..600 Washingon Street Bostorz, 3L4 02111 wrvw.mersSgov/din . Workers' Compensation Tllasurance Affldavlt: Builders/Contractors/electricians/Plumbers AD licant •Information Please Print Lec-d Name (Business/Organization/Individual): 10,4 Address: u City/State/Zip: lVe- 1 -Are ou I y an emp oyer. Check the appropriate box: 1 • L] I am a employer with 4. ❑ I am a gen eral contractor af6da employees (full and/orpart-time).* 2. I am a sole and I have hired the sub -contractors proprietor or partner- Misted on �e attached sheet ship and have no employees These sul}oontractors have working for mein any capacity. workers' comp, insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its 3. ❑retluired.] I am a homeowner doing work officers have exercised their all myself [No workers' comp. right of exemption per MGL c. 152, § I (4), and we have no insurance required.] t employees. [No workers' POMP. insivancP, required,] ti=.--he.Us bo ::4: m+11c;?so uaa, out f_^.e sect.,_ bt:aw Flerneowners who suhm't'" aho-^:. s = = worI= Cou ^��-4 Type of project (required): 6• ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. (] Bmldmg addition 10•0 Electrical repairs or additions .11. [] Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other t ttus vrt rnda atmg they a dcing all wck and then hireoutside contractors 4,u- sub -.mit ew amdavit indi sting such. +Contractors that check this box � = attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy infonaaEM -ram an employer that isproviding workers' compensationinsurance f information or my employees Below' is the policy andjob site Insurance Compiny Name: �� Policy # or Self -ins. Lic. #: a-piration 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 ofMGL 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 civ" penalties in the form of a a of up to $250:00 a day against the violator. Be advised that a copSTOP WORK ORDER and a fine copy STOP statement may be forwarded to the Office Investigations of the DIA for insurance coverage verification of I do hereby cera under the pains and penalties of perjure th rrr the information. provided above'is true and correct. Siffiature: Official use only. Do not write•in this area, to be completed by city or town offciaL City or Town: Issuing Authority (circle one): P` ermit/License # Y_ Board of Health 2. Building Department 3. City/Town II Clerk - 6. Other 4. EIectrical Inspector S. PIumbing Inspector Contact person: Phone '#: d► Information an- d Instructions t 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, partnefship, associattion, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including t7ae legal representatives of a deceased employer, or the receiver or trustee of an indivimial, parinerghip, association mg other legal entity, employing employees. However the owner of a dwelling house having not more than three apartroLents and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintemnce, 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 Iocal licensing'agency shall withhold -the issuance or renewal of a incense or permit to operate a' business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of colrnpliance 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 m-t:a acceptable evidence of compliance with the insu=c requirements of this chapter have been. presented to the contracting authority.' Applicants Please fiIl'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 numbers) along with their certificate(s) of insunance. Limited Liability Companies (LLC) or Limited Liability partnerships (LLP) with.no employees other than the members or partners,. are not required to carry workers' comp ernsation 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 siur-e to si„xa and date the affidavit. The affidavit should be returned to the vity 4r town that the au`uuGadcm tui the Pe cense ' being reg2 ested -not t e �rF><i$' or license S , Depare W ent of Industrial Accidents. Should you have any questions regardi=g the lav: or u you are =QYi ed to obtain a workers' compensation policy, please call the Department at the uumbe x listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Ofticials Please be sure that the affidavit is complete and printed legibl3,. The Department has provideds. space at the bottom of the affidavit for you to a 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 oflnvestigations would tike 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..faxnumber._.. The Commonwealtlh of Massachusetts Department of Endustrial Accidents Office of lnresttaafions ' 600 Washino--�n Street Boston, MA 02111 Tel. #• 617-727-490.0 eget 4=0.6 er 1-8 ""7 -MASSA FE Fax # 6.17-727-7749 Revised {-26-05 � � ' vmm,.mass. govfdia