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HomeMy WebLinkAboutMiscellaneous - 40 CIDERPRESS WAY 4/30/2018 1 N 1 Date . TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . . . . has permission to perform . . ./.U&z/. . . er„� . . . . . . . . . . . . . . wiring in the building of . . . . /� �-r{t .l,��, �. ... . . . . . at .4/D. .['� ��kr . . ._0xe . . . . . . . . . . . . . North Andover, Mass. Fee ?; C.,dll . Lic. No. TI41111� . . . . . . . . . r ��i�r�/.>. l•� i ELECTRICALINSPECTbR / Check# N Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL INFORMATION) DaterEJ, t I_- 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) A 5L✓ Owner or Tenant 6 Lo c,5 6 60 M a.v5 Telephone No. ) 7-Z 6 3 Owner's Address /1 1 tiaL /I I ^- Is this permit in conjunction with a building permit? Yes [D"' No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service 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: Completion of the followin table may be waived by the Inspector of Wires. of No.of Recessed Luminaires No.of Ceil: TransSusp.(Paddle)Fans Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA AboveIn- o.o mergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. 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. Tons TotNo.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P .......................TtlDetection/Alerting Devices Municipal Other No.of Dishwashers Space/Area Heating KW Local❑ ❑ Connection Heating Appliances KW Security Systems:* No.of Dryers No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Telecoo.mmunications Wiring No.Hydromassage Bathtubs No.of Motors Total HP of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Valuef Ele trical Work: 1 t ty ap_ (When required by municipal policy.) Work to Start: t 7-- Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VERAGE: 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 cove e is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify,under the ams and penalties of perjury,that the information on this application is true and complete. FIRM NAME: . avc- LIC.NO.:-M OSS Licensee:M L"A CL �"l,'�G�c}✓•9-t-� Signature � LTC.NO.:1--Z7 (If applicable ent r "exempt"in the license number line.) \ Bus.Tel.No.: 9 Address: S`j[)� r �✓tK tl.�- •�',. 65Tn.� � _ Alt.Tel.No.: 2'q� *Per M.G.L c. 147,s.57-61,se urity 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 agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. f ^ ... • �JUJI•lU.�.LJ.K'V��.�J`/��.+T]v(J�.�-I�i�,LyL���®•� {y.+�^�j �('f'�•� �13��`LsJ+..�.�J.{.x.�v�®J-•��i '— .Ro1Ttr •71�7C� 0�1� _ . �'�ssei�- _ — �+'afleflNr � �e fnspeet�oxt�'e�uzz'ecT(��O.DD)•-� J �s�ectp ' opame�afs: - ' ( nspeeozs',zgna •agon fi Ts) date �'asse�--• •�'aflec��[ ) � ate-�ns�ection�et�uixer�(��O.OD)w[ � _ , �n�iectaxs'c4�extfs; 99 (Znsiectoxs',zgn fuze.- 7nz{aaXs) date 'sssec�--[ � �'azIec�--j � ate-znspeettonxet�uirec�(��O.UO)�j' ] as,�ectoxs'comments; • [lnspectoxs� ignatuxe-+�o a�if�aTs) Pate ' NAME:. �,�sctbxs'coanme�t�s; (&spectoxs'Hzgnatuxe-io MILIaxs) date �",�EC�'xOS�'-•OAK: ' 'eco•--�' � �:azXer�•-•[ ). 'ate�nsp ectzott xer��vxet�($�0.0 D)-•[ � eetoxs'c4znm.erifs; _ . • S .- f�,:�.s�ectox�°�zgnattxre•-xto xnitia�s) date . 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): Address: 3 1'—tA,5 ,6 o� City/State/Zip: ...(s S -/,o ,J 6 ,,yq 0UR-Phone#: ? ) -6- 3 2 S1-o R-,6 Z Are yob an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ew construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I 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.]t employees. [No workers' 13.❑Other comp.insurance required.] *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 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: -c — �,��D�4t_ ( 4. S Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: O City/State/Zip: IVU• -,,.4 q- Attach a copy of the workers' compensation policy decla ation 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 nder the pains and penalties of perjury that the information provided above is trice and correct. 3i nature: . Date: E L-- Phone#: �n q 3 ) �- -0,wc? _- 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-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)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 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 venture (i.e.a dog license or permit to burn 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 Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 TO. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Date 9582 "°RTM TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SA U This certifies that . . .v�. 'C�o e �LP ee has permission to perform -ytu--. . . . . . . . . . . . . . . . . . . plumbing in the buildings of .zq��k,,. . 10. . . . . . . . . . . . . . . . at . . . GG . . . .C��P� • •PSS. . . . . . . . . .. rt ndover, Mass. Fee?3.&. .4�.Lic. No.j'?! ��. . .', . . . . . . . . . . . . . . . P MBI G INSPECTOR Check µ Il� t A MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY A -7 3 MA DATE __ ( PERMIT# JOBSITE ADDRESS Z/Q_ �.,Q OWNER'S NAME POWNER ADDRESS _ ( TELE__ __________ FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL O1 RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES ! NOD FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 S 9 10 11 12 1314 BATHTUB _ __I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM ! DEDICATED GASIOILISAND SYSTEM ! _.....___! a - -I ( _..,_.._.I -RI __. 1 ! I __...__l —..._.! ._1 �_ __! DEDICATED GREASE SYSTEM __..1 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER _..! . _ .._f ...... -1 =:--' ___i _ 1 -.I ._._._... -1 _J ._1 ! _f ._..-._....I FLOOR IAREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY _ ( -) .__. _� ...---1I ... ---! -- _I ,__...! --- I ----.._J _:....._._1 ...._._J _J1 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK . ! I ! 1 ...__.__.! I I -......._-._1 ._._._I .._..._.-1 __.J TOILET 1 -- .---! ._ _.. .1 ------! ___._( _....__.__1 URINAL1 .....__... --..-._—! f __---.._.( .._....._..I ...-_-___! .__......_._i _.._..._i .__._...._` .._._...__i r WASHING MACHINE CONNECTION {WATER HEATER ALL TYPESWATER PIPING -- I OTHER I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES((NO [1 IF YOU CHECKED YES,PLEASE INDICATE THE T OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Di 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 0 AGENT 10 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 compliance with all Pertinent p visio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# . lS/ .._� SIGNATURE MP d JP 0 CORPORATION 0# —_ PARTNERSHIP 0#I--�-. I LLC + COMPANY NAME LADDRESS CITYi STATE ZIP ���x.� TEL FAX �— CELL q!�j/4PAIL ,✓ ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ;7 T FEE: $ PERMIT# PLAN REVIEW NOTES a r A 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): Address: cU pp `/ City/State/Zip: b/ lVif/ '6306 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. [:11 am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.# E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I 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.]1 employees. [No workers' comp.insurance required.] 13.❑Other 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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. ain an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site nformation. nsurance Company Name: 'olicy#or Self-ins.Lic.4: Expiration Date: ob 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 ine 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 rivestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. ip-nature: Date: hone#: 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#: ob 4 A � . 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-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)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 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 venture (i.e.a dog license or permit to burn 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 Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE evised 5-26-05 Fax# 617-727-7749 www,mass.gov/dia Date . . , . bw°C'Tcrp'J,Wa',, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . . . .v . . . . . . . . . . . . has permission for gas installation . °^J. . in the buildings of., . . . . . . . . . . . . . . . . . . . . . . . at . . f. . . .. . `. .'. l v �!r.c. . . . . Andover, Mass. Fee . ('v ,��. . Lic. No.)5 6.1. . . �. .�. . . . . . . . . . . . . . . . . . . Check# 9 � GAS INSPECTOR { X 5 0 V '' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 7 or 1 CITY /,�/moi A-4_dor� � MA DATE / / PER # JOBSITE ADDRESSir OWNER'S NAME GOWNER ADDRESS - _ TEL — _ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL�__I EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:[3' RENOVATION:D-J REPLACEMENT:0 PLANS SUBMITTED: YES F-11 NO Q APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ I- _ _. I _ I ( 1 _ I BOOSTER CONVERSION BURNER COOK STOVE 1I - i. 1 _ ._ I Jil. ., � . DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER . LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER _ ROOF TOP UNIT TEST UNIT HEATER I J _.--_ I- UNVENTED ROOM HEATER WATER HEATER OTHER ----- - -- --- _,._-J __JI II 1 11 INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES __ NO Q 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE HECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY E] B 0 N D �_-I 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 E( AGENT El SIGNATURE OF OWNER OR AGENT 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 compliance with all Pertinent provision oftbe Massachusetts State Plumbing Code and Chapter 142 of the General Laws. F �2XZ7� PLUMBER-GASFITTER NAME - -- =!I LICENSE#� SIGNATURE MP RfMGF��I JP D JGF[I) LPGI© CORPORATION _J# PARTNERSHIP[I#[ LLC�I# COMPANY NAME: _.._. ._ ..�✓_ - ---G,,�..____ _.f.._L .___._-_-__-�ADDRESS CITYSTATEZIP 4 TEL .LL .��31_.----� FAX CELL f)k- EMAIL ---- ---- ------- - 1v ROUGH GAS INSPECTION NOTES / THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES /D -/d-/2 ✓-� ���I a' Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES M s , The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations IV 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): Address: oG6 �Qih City/State/Zip: �l r(�y Q 3o2G Phone#: 3 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.# ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I 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.]t employees.[No workers' comp.insurance required.] 13.[i 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 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:. Policy#or Self-ins.Lie.#: 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 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 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 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 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 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 Industrial.Accidents Office of Investigations 600 Washington Street Boston.,SLA,02111 Tel,#617-727-4900 ext 406 or 1-87T MASSAFB Revised 5-26-05 Fax#>`617-727-7749 __WWW-mass,govfdia