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HomeMy WebLinkAboutMiscellaneous - 47 HIGH STREET 4/30/2018 (3) BUILDING FILE 4 Date............................................. N�pTM TOWN OF NORTH ANDOVER 03? * PERMIT FOR WIRING 'This certifies that ............................................................................................................................ haspermission to perform .......................................................................................................... wiringin the building of............................................................................................................... ,.at ..........................................................................................................North Andover,Mass. Fee..............................Lic.No. ................. ......................... ..:., .... - .... ELWC cAL&N WC*TOR Check# �41 4 (fOmmonwealth of;Vaijachuselb Official Use Only e[ partment 47ire Service.4 Permit No.' 12460 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEA SE PRINT IN INK OR TYPE ALL INFORMA TION) Dated? City oc T.o.Vn of: YoA 7f Aw boy:ff2 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) ftl /-41&}q 51- Sri 1 fe #/0L Owner or Tenant Lemm Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building - rp u ding �.pryi UNlitv.AuthorizationNo. 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: /jUS7 AC.( Z�2GA,9- &A2-, I CCTV, Ls2 c ScJ�d2.� izli4t2) nn,,,^/3 "— Sc c "I Completionvof thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA Y No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above E] In- ❑ o.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges Total g No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number I Tons I KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security SNo.of Dystems:* evices or Equivalent to No.ofater , No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or E uivale t No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the7nspector of Wires. Estimated Value of Electrical Work: 01000, 00 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE V/BOND ❑ OTHER ❑ (Specify:) I cent;fy,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: PA,.)L `T i�clu Signature LIC.NO.: (If applicable,enter"exempt"in the license number line.) Bus.Tel.No. 7 M0 Address: faro T' 6kE S%, /'fpL�/2_p� /L(�y, �a3 Alt.Tel.No.:q___i _q 3 *Per M.G.L.c. 147,s.57-61,securi work requires Department of Public Safety"S"License: Lic.No. '35 -bp !(, 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 Signature Telephone No. PERMIT FEE: $ I�`)— 1 _ � Commonwealth ofMasscacliusetts Department of Industrial Accidents Office€gfInvesagatlons 600 Washj,,x lon Stprcet Boston, ,%4 021.71 www.ni ass.govldi a WorIkers' ( aompensadon Insurance Affidavit: ]3uilders/COnt actors +lectricians/ 'lumbers pplic zzt Plense Print_.�Legibly i�i3.Ti',� t�`c3v.sines/rrg�u:izatiarJtrr:ividua�i; City/State/Z-'-p:______,___. Phonek Are you ar, employer'. Check the appropriate box: i ^z a genera;c Type of project(reciuir-ed): _: m errvio rer .vi orcactor 41 c.: I employees(5,111 .nidior nt pa -rime)." have hued the sub-coractors 1 ? 5. F.7 've.v ccnstat crion L ,amu 1 2.t— i am a sole ;roprieto.-or�at'ser listed on 1h! at- . r. 11 sheetr 1 ?Z.emodeiing ship and have oo employees These sub-contractors have I i � --r , I � 1 �. I � emolition %vorkirig' Co-, i-new,w,^,,,--y capacic.:, employ ecs and have ivOr�+;'r�' :d iNc `•vorti-rs' -cinp. Lisurzric, coI7:D. i:Ls ranct'.' i "• Bt.Elidil lg adij1R01 ,e{'.1ie j ,VL - aI� a corporatioi?and:T 0-0 r'lecMcal repairs or 1 El !am a h imovmer;oiv.,A -,.v Mcers :lav-,exerciod tL`aetr 1j 1 �i j •t...(�_, t. _ 11' .t Wg mpaix or add!..-,,,,s rnJs:'!f. N;., .v^re-s comp �e- �: :L t --- { ? Roof, 's RSi:'ai1Ce :eqt.11;eu? ` C. =5 2, §I(s}; aridtvC ':aVe i0 , 't"—' ..nlpl , ees.[No v.--orkers' 3,'V] Othel °Any:^plica t uliatc`ec`u box�i must also;it :� ciur•'^.low;ho vias s eir;workers'corrqpcnsatnicn,policy info:-r�3ron. iiom�e-x,-icrs,.vh s brut ,"is zti;i vit i:td a.r`�z t7e. o,ng I work ani:Fen Wre cum,c"!�P.t.-='zGs r u;t Subrnit a new affidavit indicat-ing s:rc^_ `r �tCoaractors that check this box MM a�.�^cd an OEM!sheet sho-bg t^e nmx o the s.b-�_ontracr-ors and shite w'-:ether or not those entities have Wlo` n. Ile S KwituntOrs�a`/rcrmoicvices.:Fe:'mu,;t nrn'n rfr.i•:-:r :wnr: COMMONWEALTH OF MASSACHUSETTS-~ • t . . BOARD'OF I ELECTRICIANS. ISSUES THE FOLLOWING CIGENSE AS' -f A REGISTERED SYSTEM CONTRA& 1'RdL r5 _ _ Q TROCK I �. ` , � t•``, , A'.�I 15 COTTAGE' ST , z. �,`�'HOLBROOK. MA 02343-1045 f 8 C 07/31/16 61738 OMMO ----_ NWEAL.H OF�gl1g$AC.HUSETT • S BOAR)�'OF EC}. ISSUES LfTR1CI.THE FOLLOWINhHS A C L't CE_NS-E REGI S7E I RED SYSTEM TECHNlCIgN r:. 13AU S TROCK! _ Z 15 COTTAGE ST . HOL BROpK �_ W ' U _ 2 42:;` p..:. oMA 02343_1.045 . +� p Date... . `. .�� .... i 0 �• u �. cF NORr,y,ti TOWN OF NORTH ANDOVER 03r•,. .,� OOH n PERMIT FOR PLUMBING CHUt � s.C .... .......... � +i This certifies that. I...i.. 1....................... .. Q oti e `.,has permission to perform.. .P ..................... ... ........................................ plumbing in the buildings at............`::..........! �� .k��� ........... ................ North Andover, Mass. Fee..1....1.4..Lic-No. 13152— M.6................................................................... PLUMBING INSPECTOR Check# 4�9 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY ^/2 r-A A NGoVe 2 MA DATE V1,511Y PERMIT# I? 4W JOBSITE ADDRESS! /4I6h + (AAT C- OWNER'S NAME e G' ',�U POWNERADDRESS 0A K 6.1 giCQ t7' TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK / LAVATORY / ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY UZ OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ 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 provision of the. Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Jr-1 /"I Ge ffN'r— LICENSE# 15151 SIGNATURE MP 4 JP❑ 08A CORPORATION❑# PARTNERSHIP❑# LLC❑# nary COMPANY NAME J-6 M P G(2 0.0 ADDRESS '7V c/o)+° CITY—.5A f e M STATE NO ZIP 0307 TEL FAX CELL EMAIL J'Z!h I ree- 33 0 c6 c JIN 16 4,000e ~ The Commonwealth of Massachusetts - Department of Inclustrigl Accidiiks Office of Invesfigations 600 Washington Street Boston,HA 02111 www.massgov/clia Workers' Compensation Ynsurance Affidavit:Builders/Conti.actors/Electricians/Plumbers Apulicanf Information Please Print Legibly Name(Business/Organizationffudividual): ) f�C�1 e_ �� �-!� Address: 7 4 City/State/Zip: le M , V NJ 0 Phone#: 97R r 'XA'2 J 74 9-`'2 Are you an employer?Check the appropriate box: Type of project(required): 4. ❑ 1 am a general contractor and 1 •on Now.1.�( lam a employer with�_ 6. ❑N w constructs_ employees(fall and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑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 10 F1 Electrical repairs or additions required.] officers have exercised their 3.❑ 1 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.b Roofrepairs insurance required.] employees.[No workers' 13.❑Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section bel6w showing their Workers'compensation policy information. t'Homeowners who submit this affidavit indicating they tie 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: �ry I v City/State/Zip: A161,A /V A1'0d V e k f co o the workers'coin ensation olio declaration page(showing the policy number and expiration date). Attach a copy f p P Y Failure to secure coverage as requiredunder Section 25A of MGL o. 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 STOR WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert&under the pains and penalties of perjury that the information provided above is true and correct. - Siafore: Date: t/ Phone# 2T7Z-7-/af6 9:11/ 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 Instruction's 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 chapterhave beenpresented 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 maybe 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 multiplepermit/licensea c ' p h applications in an given ear e Pp need only sub Y g Y mit one affidavit' Y mdicatin current policy information ifnecess and under"Job " g ( m ) 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. Anew affidavit must be filled out each year.Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves eta.)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 Coxr_monwalth of M_?SS?r?av,5Ptts DDP.artment offndwWal.Accidents Off toe QUAVIOsizgatious 600 Was gtoa SUQi�t Boston,:MA.02111. TQ1,#61.7-227-4900 oA 406 ox 1-877-MASSAk Revised 5-26-05 Fax#617-727'7249 Www.Mm.,govfdia OERS .. . .• . . a Eli AND VASfi1TT��5 fEC'�t� f /�S A_MASTER r'�,1.1.(!1!'M%R' i :=ISSUES THE ABOVE LICENSE TO: �5`i1h1►=S P ,GREEN E m Br?ID-GE. ST N : t. !SALT:'14; NH 03079-327 t �' r• �� 05!O1!14• 1£37554' !CENSE NO. EXPIRATION DATE SERIAL NO. i. Date....... .. ... ......... .. .... . TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING This certifies that ............ .......t.... ............................................... has permission to pe --------------i�i.71-� ...... ..!o....................................................................... ..... ... / I .wiring in the building of................. (f G.............................................................................................. at ....`I..AZ .................................................. North Andover,Mass. ........... ee, N!e-o"........Lic.No. LECTRICAL INSPECTOR ('i eck# 3 0 2 29 Commonwealth of Massachusetts Official Use Only a Department of Fire Services Permit No. Occupancy and Fee Checked a BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C,527 MR 12.00 (PLEASE PRINTW)NKORTYPEALLINFORAMTION) Date: ��� ��/` City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives -7notice of s or her intentio t perfo/rm the electricalwork described below. Location(Street&Number) if/ �/? ,I, �Z�ei l� PAP, Owner or Tenants Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ;9. No ❑ (Check Appropriate Box) Purpose of Building 61��/?� 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 following table may be waived by the Inspector of Wires. Trans No. of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: - "'"' '" "..""".. "' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or E uivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent l/ No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) X certify,cinder the pains and enalties ofperjury,that the inf tion on this application is true and complete. FIRM NAME: " / C LIC.NO.: _ Licensee: Gf'v Signature LIC.NO./f S& (If applicable,ent empt"ill the license err line Bus.Tel.No.• Address: T 19Gd �� r/, �� Alt.Tel.No.- O *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166, §32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass IN Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: r Z / Inspectors Signature: Date: FINAL INSPECTION: PassY,M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department oflndustriglAccidents Office of Investigations 600 Washington Street Boston,MA.02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lep-ibly Name(Business/Organization/Individual): 1p,,z6ea Address: �S L� �/✓'�/?l �� City/State/Zip: Gl/6)A e,"AArOl& Phone#: 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 1011 Electrical repairs or additions J required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions j myself.[No workers'comp. c.15%§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 ire 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 their workers'comp.policy information. lam an employer that isprovi('ing workers'compensation insurance for my employees. Below is thepollcy andjob site information. C f Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation Policy declaration page(showing the policy number and expiration date). allure to secure coverage as requiredunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a me 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 �Nup to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DTA.for insurance coverage verification. Ido hereby certify under the pains andpenalties ofperjury that the information provided above istrueand correct. - Signature: Date: Phone#• 6✓ .2 2 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.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: Information and Instruct ion** ' 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 ofhire, 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 chapterhave 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 notrequired 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(ifnecessary)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. Anew 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: Tho Commonwoaltl ofMossaohusetts Department offadustdal.Acexdents Office of Investigations 600 WaOingtoa Street Boston MA 02111 Tel,A 617-727-4900 ort 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617"727-7749 XX7VjW maae am.&Iin