HomeMy WebLinkAboutMiscellaneous - 39 HIGH STREET 4/30/2018 (2)W
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20837
-Plumbing Penn it - In Conjunction with a Building Permit [Commercial or Residential)
Tuesday, Jul 05, 2016 08:51 AM
TIMELINE
Submission 1—i -d c,
15
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0 Plumbing Peroilt Re%iew
0
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0 Pp.nillt fee James Gi eene 39 H IGH STRE ET NORTH AN DOVER, MA
978-423-7694
j—g-33-0—ce-
RCG NORTH ANDOVER MILL' LLC
Attachments
-OTQHJDI0G1FTueju1 O5_2016_12:50:.PDF
Primary Contractor Cb..v
Search for your carn-atto. using the search bar belo- Either the Firm's Name or licensee # is
required.
James P Greene
15152 Master Plumber
046012016
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The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street, Suite 100
Boston, AM 02114-2 017
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Buffders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERAHTTING AUTHORITY.
Name (Business/Organization/Individual):
r fu
Address:
City/State/Zip: SAICAA / All-) OJ07�- Phone 3 - 741 V
Are you an employer? Che�k &e appiopriaie box:
Type of project (Tequired):
I.F1 I am a employer with employees (full and/or part-time).* 7. UTNew construction
2. Ufl I am a sole proprietor or partnership and have no employees working for me in 8. E: Remodeling
/_1%11 any capacity. [No wo�kers' comp. insurance required.] §. 0 Demolition
3. [j I am a homeowner doing all work myself, [No workers' comp, insurance required.] t
10 Building addition
4. Fj I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole 11.[] Electrical repairs or additions
proprietors with no employees.
12. Plumbing repairs or additions
5. n I am a general contractor and I have hired the sub -contractors listed on the attached sheet. D E]Ro6f repairs
Thesie sub-contractor*s fiave employees and have workers' comp. insurance.T
� P . . 14. Ej Othbr
6. Fj We are a corporation pd its pffigers have exercised their right of 'exemption per MGL C.
e' . [No workers' comp. insurance required.]
152, § 1(4), -4 have 4QF oy��s
*Any applicant that checks box #1 mu'st also fill out the section below showing their workers' compensation policy inform.ation.
t Homeowners who submit 4iis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must -attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. if the sub-.o'fi6ci6rs have L�ploy'ees, iticy mus . t provide their workers' comp. policy number.
I am an employer that ispioviding workers' compensation insurancefor my employees.' Below is thepolicy andjob site
information.
Insurance Company N
Policy # or Self -ins. Lie. #:
Expiration
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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Eavestigations of the DIA for insurance
coverage verification.
I do hereby certifj der thepains a ofperjury that th e information provided above is true and correct.
Q;-+-- nn nnfi-.. _7/ 57 f/X'
Official use on7y. Do not write in this area, to be completed by city or town official
City or Town: . . PermitlLicense ff.
Issuing Authority (circle one): i
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,
expres's 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 ajoint 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 emplo�ees. 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 b6 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.7
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 ampletely, by checking the'boxes that apply to your situation and, if
necessary, supply sub-'contractoi(s) name(s), address(es) and -phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ 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 Depaitment of - Ifidustrial
Accidents fb� confirmationof 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 requ�red to obtain a workers'
compensatioii Policy, please call the Department at the number listed below. Self-insur6d 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
poll' information (if necessary) and under "Job Site Address" the applicant should write "all locations in
Gy _(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 burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia