HomeMy WebLinkAboutMiscellaneous - 262 RALEIGH TAVERN LANE 4/30/2018S., 51 1
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...... 0 ...... ......... ............... & ...... 6V Le, f—lp QA-��
......................................................
has permission to perform . .................................................................
wiring in the building of ........... .......
... ...... .... .
.................................... M .........................
at .... ......... ....... North Andover, Ma ss.
Fee..67 .... 1� ....... Lic. No.! ..... . ... .. ... ... .. .... .
ELEMUcAL lNsPEu7i,6
Check #
12399
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.
Date Issued:
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEQ, 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORAMTION) Date: 1/10/12
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) 262 Raleigh Tavem Way Map: Lot:
Owner or Tenant Phil Lukens
Telephone No. 508-577-8889
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Fixtures
Owner's Address same
No. of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Is this permit in conjunction with a building permit?
Yes El No
M (Check Appropriate Box)
1Vo_.oTKm__ergency Lighting
Purpose of Building Residence
Utility Authorization No.
AA!!tELE!�ts
Existing Service Amps Vo Its
Overhead
Undgrd No. of Meters
I No. of Zones
New Service Amps Volts
Overhead
Undgrd No. of Meters
Number Feeders Ampacity
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
of and
No. of Waste Disposers
Heat Pum p
I.Numbe
............... r
Location and Nature of Proposed Electrical Work: Wiring of 201(w generator
KW
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Fixtures
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Swimming Pool Above o In- 1:1
1Vo_.oTKm__ergency Lighting
grnd. grnd.
AA!!tELE!�ts
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 Pum p
I.Numbe
............... r
s
Ton ...........
KW
No. of Self -Contained
Totals :
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating 10A1
Local [:] Mun'c'P�l El Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:
No. of Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs _7No.
of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER: Yearly Maintenance Permit
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: $3,900.00 (When required by municipal policy.)
WorktoStart: 1/10/12 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 licen-
see 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 issuirig-otfice.
CHECK ONE: INSURANCE 0 BOND [:1 OTHEIZ [_1 (Specify:
I certify, under the pains andpenalties of perjury, that the informatioW
FIRM NAME:
Inc
Licensee: Robert 1. Branca Sign
*Per M.G.L. c. 147, s. 57-61, security work requires Depai
(If applicable, enter "exempt" in the license number line.)
Address: 19 Dale St, Andover, MA ZiD: 01�1
VWINER'N INSURANCE WAIVER: I am aware tnat Me Licensee does not have
signature below, I hereby waive this requirement. I am the (check one) [I owner
Owner/Agent Signature Phone:
application is true and complete.
LIC. NO.: 14302
LIC. NO.:
"S" License: LIC.NO.: S:
Bus. Tel. No.: 978-475-4995
Alt. Tel. No.: 978-423-8350
the liability insurance coverage normally required by law. By my
El owner's agent. Permit Fee: $ —Please Advise
_L110011— 6_14-4�
7
7
AC40RDK' CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDNYYY)
1213012011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY qR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER Phone: (978)474-0810 Fax: (978)474-0890
JONATHAN M SAMEL CIC LIA
SAMEL INSURANCE AGENCY, INC.
15 CENTRAL STREET
ANDOVER MA 01810
Samel Insurance Agency, Inc
NME_
PHONE Ax
(,C. N., Ext): 978-474-0810 1("C. No): 978-474-0890
E-MAIL
RESS, info@samel-ins.com
.
PRODUCE R 1254
CUSTOMER ID:
INSURER(S) AFFORDING COVERAGE NAIC #
03/23/12
J
IN . SURED ANDOVER ELECTRIC SERVICES INC
PO PDX 629
ANQdVER. MA dt810
INSURER A Maryland Casualty Company
INSURER B Citation Insurance Company
INSURER C National Union Fire Ins Co of Pittsburgh PA
INSURER D: National Union Fire Ins Co of Pittsburgh PA
INSURER E
PRODUCTS - COMP/OP AGG $ 2,000,000
INSURER F
B
COVERAGES CERTIFICATE NUMBER: 32539 REVISION NUMBER -
THIS IS TO CERTIFY THAT THE POLICIES. OF INSURANCE. LISTED 13ELOW HAVE BEEN ISSUED TO THE -INSURED -NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
CONDITI Q MITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSR
TYPE OF INSURANCE
ADUL
INSR
SUBR
VIVO
POLICY NUMBER
POLICY EFF
IMMIDDIYYYYI
POLICY EXP
IMMIDDIYYYYI
LIMITS
A
GENERAL LIABIUTY
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE I X ] OCCUR
CFP016027733
03/23/11
03/23/12
J
EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
PREMISES (Ea occurencel $
MED. EXP (Any one person) $ 10,000
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000;000
GEHL AGGREGATE LIMIT APPLIES PER-
POLICY mcT
[�] 'PrRo- Fl�oc
PRODUCTS - COMP/OP AGG $ 2,000,000
$
B
AUTOMOBILE
X
X
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
KW7918
03/23/11
03123/12
COMBINED SINGLE LIMIT
(Ea accident) $ 1,000,000
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
PROPERTY DAMAGE
(Per accident) $
$
C
X
UMBRELLA LIAB
EXCESS LIAB
OCCvk
CLAIMS -MADE
TBA
01101/12
01/01/13
EACH OCCURRENCE $ 1,000,000
AGGREGATE $
DEDUCTIBLE
RETENTION $
$
$
D
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORWARTNERIENECUTIVE
OFFICERIMEMBER EXCLUDED? FN]
(Mandatory In NH)
If yes, desctibe under
DESCRIPTION OF OPERATIONS below
NIA
WC9763814
04/28/11
04/28/12
X I TWC,,STAT,,U,�, I 1 0- $
PR
E.L. EACH ACCIDENT - 500,000
$
E.L. DISEASE -EA EMPLOYEE 500,000
E.L. DISEASE -POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, ff more space is required)
Operations typical to coMmercial and residential electrical contractor.
CERTIFICATE HOLDER CANCELLATION �
TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
120 MAIN STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
NORTH ANDOVER, MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Attention:
/Jonathan K&mel
ORD 25 (2009/09) 1988-2009 ACORD CORPORATION. All rights reservec
The ACORD name and l000 are reoistered marks of ACORD
t -
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Buflders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Andover Electric Services, Inc.
Address: 19 Dale St
, MA 01810
Phone #:978-475-4995
Are you an employer? Check the appropriate box:
1. R1 I am a employer with 5
4. [:] I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2.0 1 am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
required.]
comp. insuranceJ
5. F-1 We are a corporation and its
3. F-1 I am a homeowner doing all work
officers have exercised their
myself [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
comm insurance reouired.1
Type of project (required):
6. F1 New construction
7. E] Remodeling
8. n Demolition
9. Building addition
10. Electrical repairs or additions
I L E] Plumbing repairs or additions
12.n Roof repairs
13.n 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 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 state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' cornp. policy number.
I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy andjob site
information.
Insurance Company Name: Chartis
WC 9763814 _4/28/12
Policy # or Self -ins. Lic. Expiration Dme.
Job Site Address: Qrj� 1&�4ATO_yP rn City/State/Zip: AVO /NJ,
QY4 _. �"A)An
Attach a copy of the workers' co4ensation policy declarAon 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Idohereb certyzy under the pains andgenafties "feilury that the information provided above is true and correct.
978-423-8350
Official use only. Do not write in this area, to be completed by city or town offxiaL
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
.BOARD
El,
TYPE
-A.
831346
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_NEV� HAMPSHIRE
STATE OF
OF FETY & LICENSING
BUREAU
NAMEROBE
1. 63651 M
2.
3.
EXPIRES: 1013V26 -1-T'
DePartment of POW
'"W"usetts
89ar-d Of HWWing Regulafiem
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Constuetba- Supervisor Lkense
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_NEV� HAMPSHIRE
STATE OF
OF FETY & LICENSING
BUREAU
NAMEROBE
1. 63651 M
2.
3.
EXPIRES: 1013V26 -1-T'
DePartment of POW
'"W"usetts
89ar-d Of HWWing Regulafiem
ano S
Constuetba- Supervisor Lkense
CS
Trm
Date. .
-roll, TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ;7�:
. . . . . . . . . . . . . . . . . . ... . . . . . . . . . .
has nermission for izas installafion-.-,e,-;,�-.-.zc ...................
in the buildings.of
Fee .... Lic. No. <� 9C--7*
Check # 16 5�5-
6070
....................
Andover, Mass.
T; ............
IN R
MASSACHUSETrS
PERNffFT0D0GASFrrnNG
(Type or print) Date 0 �L
NORTH ANDOVER, MASSACHUSETTS
Building Locations co lei Permit # —?Osgi,767
.4), &A/ty Owner's Name Amount$
New Renovation Replacement FV'- Plans Submitted 0
11 L -i
(Print or type)
Name :#o Fm
Address
r14.1
ness
Name of Licensed Plumber or Gas Fitter
Che k one: Certificate Installing Company
b Corp.
ElPartner.
13-rir-m/co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 13 No13
vou have checked Yes, please md' e the type coverage by checking the appropriate box.
i1ty insurance policy Other type of indemnity
13 Bond 1:3
,,*/ner'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
best of my knowledge and that all plumbing work and installatil�s pe ed under Permit Issued for d
compliance with all pertinent provisions of the Massachusetts �a, �dkand Chapter 1,42 of the C4
By:
Title
City/Town
I I
APPROVED (OFFICE USE ONLY)
Sienature-Ur
ETPl-umber
[3Gas Fitter
1-1 Master
FOS,lbumeyman
Lu
i -ed Plumber Or Gas Fitter
License Number
true
and accurate to the
appl ication will be in
-ral Laws.
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(Print or type)
Name :#o Fm
Address
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ness
Name of Licensed Plumber or Gas Fitter
Che k one: Certificate Installing Company
b Corp.
ElPartner.
13-rir-m/co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 13 No13
vou have checked Yes, please md' e the type coverage by checking the appropriate box.
i1ty insurance policy Other type of indemnity
13 Bond 1:3
,,*/ner'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
best of my knowledge and that all plumbing work and installatil�s pe ed under Permit Issued for d
compliance with all pertinent provisions of the Massachusetts �a, �dkand Chapter 1,42 of the C4
By:
Title
City/Town
I I
APPROVED (OFFICE USE ONLY)
Sienature-Ur
ETPl-umber
[3Gas Fitter
1-1 Master
FOS,lbumeyman
Lu
i -ed Plumber Or Gas Fitter
License Number
true
and accurate to the
appl ication will be in
-ral Laws.
X-511- --.�
TOWN OF NORTH ANDOVER
"PERMIT FOR GAS INSTALLATION
r
This certifies that .......... . ........
has permission for gas installation . . ;A,'79r1 ............
in the buildings of ...
at
North Andover, Ws.
Fee. Lic. No. 40. w1w
GAS INSPECTOR
Check# WW
8012
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town:k&4 llk)du;�6— , MA. Date: 2 b "> ha Permit#
Building Location wners Name: y f-1 L42
Type of Occupancy: Commercial E] Educational E] Industrial F] Institutional [] Residential
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New: V Alteration: E]
Renovation: E] Replacement: E] Plans Submitted: Yes El No El
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SUB BSMT.
BASEMENT
15T FLOOR
2 No FLOOR
-r"-F--LOOR
4 TH FLOOR
5T" FLOOR
6T" FL60R
7 IH FLOOR
8'" FLOOR
Installing Company Name:
Check One Only Certificate #
Address: W(2- & A iA.) City/Town: State:A./h(
0 Corporation
Business Tel-64)�!
KF6
Fax:
El Partnership
El Firm/Company
Name of Licensed Plumber/Gas Fitter:
L -/)o
INSURANCE COVERAGE:
s 2?7
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Ye No E3
If you. have checked. Yes, please indicate the type of coverage by checking the appropriate box below.
A.Ilability insurance policy Other type of indemnity El 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
Signature of Owner or Owner's Agent Owner n Agent El
By checking this - box E]; I hereby certify that all of the details and information I have submitted (or entered) regardinq this aDDlication are true and
y UW 411U L11'a d1l plurnuing worK ana installations performed underthe Permit issued forthis aoolication will he in
ul 11—ILVIUVIwUll U, mu ivia55acilusetis btate viuml)jp+k;ode and ChapterW of the Genral Laws.
By Type of License:
El Plumber KIP A
El Gas Fitter Af Licensi—ed 4PIum er/Gas Fitter
Title El Master NgTa-ture , ZUiceL Xs�li�tt�e
Cityrrown Eliourneyman License Number:21�
APPROVED (OFFICE USE ONLY) El LP Installer
The Commonwealth of Massachusetts
Department ofindustrialAccidents
Office of Lnvestigations
..600 Wa.shington Street
Boston, MA 02111
www-mass.govldia
Workers' Compensation Insurance Affidavit: Buffders/Contractors/Electricians/Plumbers
mficant Infarmsti-in-
Name (Business/Organizafion/Individual):
S P
Addre s: 7"(-
City/State/Zip:,A,,.,�-�v,,A A,1
Pbone #:
Type of project (required):
6. F New construction
7. Remodeling
8. Demolition
9. E] Building addition
10. El Electrical repairs or additions
11 -0 Plumbing repairs or additions
12 -El Roof repairs
13.El Other
comP�--On P0uCY mlormation.
n0meOwn= 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'compensadon
informatio& InSziranceJor mY employees. Below is thepolicy andiob site
Insurance Compiny
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 OfM . GL 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 D1A for insurance coverage verification.
I do herebY
,0q�11nr?VffNsandp19desqfperjur that e information provided a veis ue ndcorrect.
3 th Yo )r a
Phone#:
FOfficial =use only. Do not write in this apea� to be cOmPleted by city or town official ----
City or Town:
PermitfLicense
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CitylTown Ci rk 4. Electri al Inspe tor b
6. Other e c c 5 um ing
g Inspector
Contact Person:
Phone
Are y an employer? Check the appropriate boxi
*
LEI I am a employer with —
4. F-1 I am a general contractor and I
wmffiployees (full and/o 5 �_time)-
have hired the sub -contractors
2. VI 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. 1 am a homeowner doing
officers have exercised their
all work
right Of exemption per MGL
myself. [No workers' comp.
c. 152, § 1 (4), and we have no
in . surance required.] t
employees. [No workers'
cOmp. insurance required.]
-AmYPPPlic :that ,k,- b I must also fill e Aese
t
Type of project (required):
6. F New construction
7. Remodeling
8. Demolition
9. E] Building addition
10. El Electrical repairs or additions
11 -0 Plumbing repairs or additions
12 -El Roof repairs
13.El Other
comP�--On P0uCY mlormation.
n0meOwn= 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'compensadon
informatio& InSziranceJor mY employees. Below is thepolicy andiob site
Insurance Compiny
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 OfM . GL 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 D1A for insurance coverage verification.
I do herebY
,0q�11nr?VffNsandp19desqfperjur that e information provided a veis ue ndcorrect.
3 th Yo )r a
Phone#:
FOfficial =use only. Do not write in this apea� to be cOmPleted by city or town official ----
City or Town:
PermitfLicense
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CitylTown Ci rk 4. Electri al Inspe tor b
6. Other e c c 5 um ing
g Inspector
Contact Person:
Phone
Information aitd 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 writtem"
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 employ.e; 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 aparbnents and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maint--inance, 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'aggency 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 coinpliance 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 un -til 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 suh�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) withno 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 thal� the appli ation. for the pernmit "Li,enseisbeinngre: not the Depwrtmon of
Uc or I questod,
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 numbt-,r 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 offici�lly 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 f6r 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 Investi-ations
a5F
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 4,06 or 1-8.77-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
,%Nmm7.mass...gov/dia