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HomeMy WebLinkAboutMiscellaneous - 262 RALEIGH TAVERN LANE 4/30/2018S., 51 1 m ,;a z mi .11 . Date.r--)..�.- .�o ................. 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Idohereb certyzy under the pains andgenafties "feilury that the information provided above is true and correct. 978-423-8350 Official use only. Do not write in this area, to be completed by city or town offxiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: .BOARD El, TYPE -A. 831346 4,11 ThQn.DetaM AWQ AD FwftWJwm _NEV� HAMPSHIRE STATE OF OF FETY & LICENSING BUREAU NAMEROBE 1. 63651 M 2. 3. EXPIRES: 1013V26 -1-T' DePartment of POW '"W"usetts 89ar-d Of HWWing Regulafiem ano S Constuetba- Supervisor Lkense CS Trm .:-'OOARD EL'-: . . . . . . . . . . M - ECTRICIANS J OG UM S' E -90 T 0 -n7 4,11 ThQn.DetaM AWQ AD FwftWJwm _NEV� HAMPSHIRE STATE OF OF FETY & LICENSING BUREAU NAMEROBE 1. 63651 M 2. 3. EXPIRES: 1013V26 -1-T' DePartment of POW '"W"usetts 89ar-d Of HWWing Regulafiem ano S Constuetba- Supervisor Lkense CS Trm Date. . -roll, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ;7�: . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . has nermission for izas installafion-.-,e,-;,�-.-.zc ................... in the buildings.of Fee .... Lic. No. <� 9C--7* Check # 16 5�5- 6070 .................... Andover, Mass. T; ............ IN R MASSACHUSETrS PERNffFT0D0GASFrrnNG (Type or print) Date 0 �L NORTH ANDOVER, MASSACHUSETTS Building Locations co lei Permit # —?Osgi,767 .4), &A/ty Owner's Name Amount$ 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. I z < M W z 1- 9 0 U M W �< > C4 z Q W Z z z It Z Z - > z U > z Z X SID B-BASEM ENT > B A S E M E N T IIST. IF L 0 0 R T—T 2ND. FLOOR 3 R D . F L 0 0 R 4 T H . F L 0 0 R 5 T H . IF L 0 0 R 6TH IF L 0 0 R 7 T H F L 0 0 R 18T H F L 0 0 R (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. 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 .k - rAX, 11nn7c, co w w W z W 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 Cd New: V Alteration: E] Renovation: E] Replacement: E] Plans Submitted: Yes El No El rAX, 11nn7c, co w w W z W Cd Ck: 11-- of 0 WWL) L) W 0 U) 1XII: ZF- F- (D 9 2312 -J>- W 0� LU E womwix lXWOPS 0 WW 0z co W > 0 Lu LU ca 0 F- F- < 0 a. W 11-- a 0 F - X 5: WqWW W>01-'Wwga-jwi��Cf) Z 0 0 lif a: COO Lu 9 W Z W 0 W co _j 1-- < F- 0 z < M W -j 0 a z LL C0:rzWWlX 0 W W > I.- Z W W F- W W > 0 0 a. 0 W W Z Z W > I-- 0 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