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HomeMy WebLinkAboutMiscellaneous - 48 CIDERPRESS WAY 4/30/2018 4 OA- BUILDING ELLE 1!I .I. I f Date . .. . TOWN OF NORTH ANDOVER PERMIT FOR WIRING i ` This certifies that . . has permission to perform . . Z vo. .O Q.N t0. Q . . . . . . . . . . . . . . . . . wiring in the building of . . . . . . . . . . . . . . . . . P. ,Q r�}; � .. at . . . _.-� Q. ( a :1,• � .P��� . :'! , orth Andover, ass. Fee . Lic. No. ELECTRICAL INSPECTOR Check# a 'I0929 commonwealth of Massachusetts official Use only - a Department of Fire Services PernutNo._� �,g BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code ),527 CMR 12.00 (PLEASEPRINT.ININKORTYPEALLMON&TION) Date: 7 3 � '2_ City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersig �&es�nofice �hlss her intention to perform the electrical work described below. Location(Street&Numbel Ci 5 S w Owner or Tenant tis (X—C— Telephone No. Owner's Address J Is this permit in conjunction with a building permit? Yes No El (Check Appropriate Box) Purpose of Building I�5 ,;�e.v1 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: Com letion of the followin table m be waived hy the Ins ector of Wires. No.of Recessed Luminaires 1 No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA, No.of Luminaire Outlets Zp No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- El o mergency Lighting rnd. rnd. Batter Units No.of Receptacle Outlets "d� 0 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices - No.of Ranges ( No.of Air Cond. Ton sl 3 No.of Alerting Devices i No.of Waste Disposers Heat Pump Number Tons ' KW No.of Self-Contained J _ ..........._..-w....�.........._....-.._..._ }o Totals: " "'-'�""' Detection/Alerting Devices No.o;Dryers washers Space/Area Heating KW Local❑ Municipal [I Other Connection No.olHeating Appliances RW ecDevicsoNo.or No.of No.of Devices or E uivalent ters �' Bal as Data Wiring: signs Ballasts No.of Devices or uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or E uivalent �J Attach additional detail ifdesired,oras required by the Inspector of Wires. Estimated Value f Electrical Work: Au 0 0. (When required by municipal policy.) Work to Start:-) Z 1 L Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCECOVERAGE: 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 cov ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjury,that the information on this application is true and cor piece. FIRM NAME:$ LIC.NO.: 2A Licensee:yV �� �ySignature LIC.NO.: (If applicable,ente `exempt"in the license number line.) Bus.Tel.No.• • 2¢��e Address: L 'Per M.G.L c. 147,s.57-61,sec ity work requires Department ofPublic Safety"S"License: Alt. Lie.No. b Tel.N 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:$ % 1 Y _ NGEM&ALPE3 FILE I'�sset - Waited--[ xegt&eCT($50.00) Zspe-13 Comments: - rt A i tr. nspectoxs7i atuxe offals) Date Rassed Failed-1 Ito 3cns�ectiox�xer uiz eco($50.00)--[ Tnpectoxs'co encs• (tnsi'ectors'uignature, o fnifi s) Date GROM M81 O'assed--j ] wiled--j ) ?fie-xuspectionrequired($50.00)-[ J inspectors'comments: (Inspectors}$ignatuxe-).o initials) Pate 4.i�TsPECT01--BEY JnC+'; . DATE C'A:rLNBnM4a+ONA.*':tC-71� : NAM: �'assed—[ � �`ailed•-[ � �e-inspectionxegwired($50.OD)�( � ' laspeetbxs'comm.enfs: (7xtspectors' ignatuxe Ino initials) Date �.WSP CTION•-OMR: 'assed--[ ] Iailer --[ ate inspection xeciuized($50.00)•-[ 7 - Lisp ectoxa'colhm.en.fs: . • 5 ("Lisp ectoxs'Slinahwe-.no Inydals) hate DO OP,TAGj5.ARE TO DE MMED ObT.AM EEFT ON 191TE N TM.AMA TO 3E INRECTU D ISNOT .ACCESMIE AM.A MUSPECTION OE 550,0 0 is TO_DY, J The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations U9 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): &A, Address: ',� Pw4_4 6u!A:q r0n-sy, y2t City/State/Zip:. �y N�5+� ti� a3 Y�Lff Phone#: !R �5 3 7 S_ok b Z_ Are you an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with_ o 4. ❑ I am a general contractor and I 6. age-w— 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. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g, ❑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 1 LE]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.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this 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 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: G( -&( 5 5 W City/State/Zip:l\M_ A n 62 J )�_ tit •t, D l f-q s Attach a copy of the workers'compensation policy de laration 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. Ido hereby c t!,fy under the pains and penalties of perjury that the information provided above i 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 ofpublic 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 numbers)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 Coxnmonwealth.of Massachusetts Department of Industrial Accidents Office ofIavest3gatlons 600 Washington Street Boston.,MA.02111 TO,#617-727-4900 at 406 ox 1-877rMASSABF Revised 5-26-05 Fax#617-727-7749 wwwanass.govfdia Date. . . . / . .. HORTM °F .ao ,ti0 o� °1, TOWN OF NORTH ANDOVER • - PERMIT FOR GAS INSTALLATION SAC NUSE�Sy n This certifies that has permission for gas installation . . . . . . . . . . in the/buildings of at Tc .�� .` 1 . . . . . . . . . . North ZARd, er, Mas . Fee.A�?,OLic. No. � � .,. . . . . GAS INSPECTOR Check# /9/3 8236 Date 9472 NORTH TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 40 emus� This certifies that �... . . . . . . . . . . . has permission to perform . A4v,k�Ae `I.�v� . . . . . . . plumbing in the buildings of . . . 17; at . . . . �li,. .� i- /eS�". . . . . . . . . . . , Nord A ndoydr, Mass. Y yLic. No.. Fee.l L! �5�� 7 .. . . . . . . . �r �. . . . PLUMBING INSPECTOR Check # ���3 1 r ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK W Ir / 4 CITY MA DATE PERMIT# JOBSITE ADDRESS y S I OWNER'S NAME P OWNER ADDRESS A A _I TEL o3- 3`i3� _ FAX I TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: _, RENOVATION:® REPLACEMENT: © PLANS SUBMITTED: YES NOD 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 GASIOIUSAND SYSTEM ! DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM __..__.J DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER -1 ----1 _._._..-I .-__---_( . ___1 -1 F FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK ( _ -_.._.( I ( __.._._I .__._....J I l .....-_.I ---_-_ I 1 .____..._i (=E1 _._.__._j LAVATORY ( _. ._..J -2-111---1 .._-_._J ROOF DRAIN SHOWER STALL SERVICE/MOP SINK _. ..�1 TOILET _..._._.... _.____._I URINAL .._.._____l WASHING MACHINE CONNECTION WATERHEATER ALL TYPES .___i .. ..__( WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES PJ'NO -1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY _2 OTHER TYPE OF INDEMNITY 0 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT J._! 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 Witp all P rtinent i ' f the Massachusetts State Plumbing Code and Chapter 1 of the General Laws. PLUMBER'S NAME _ (LICENSE# -/j,7JI SIGNATURE MP Rf JP CORPORATION F]# _ j PARTNERSHIP 0# LLC a COMPANY NAME &4 jtl ADDRESS CITY t IISTATE ZIPFAX CELL js EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes---No-,— THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES Y ' The Commonwealth of Massachusetts Ln Department of Industrial Accidents Office of Investigations UV 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):T//"( Address: City/State/Zip: Phone#:_ _(2 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.❑ I 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 officers have exercised their 10.F1 Electrical repairs or additions required.] 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.]r 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. i 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 certlo under the pains andpenalties 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 4: F - i 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 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 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,NIA,02111 Tel,#617-727_4900 at 406 or 1-877:MASSAFE Revised 5-26-05 FaY,#617-727-7749 wwv.mass,gov/dia r �I •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY i �l MA DATE PERMIT# JOBSITE ADDRESS �t" �'< e✓h C OWNER'S NAME GOWNER ADDRESSFAX_ TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL F-] EDUCATIONAL RESIDENTIAL 4 CLEARLY NEW:RENOVATION:El REPLACEMENT:0 PLANS SUBMITTED: YES NO® APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 EE 13 14 BOILER j x�I l _ -( ! BOOSTER _ CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE __I UJ .1 FRYOLATOR FURNACE GENERATOR � GRILLE -- INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT —w - ) TEST UNIT HEATERJJ (+^ UNVENTED ROOM HEATER I1�_ I - i. . _ _ _,I WATER HEATER OTHER T INSURANCE COVERAGE. have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES _ NNO 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [12"'� OTHER TYPE INDEMNITY Ej BOND F 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 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 pro ' ion the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBE -GASFITTER NAME LICENSE#_ �J SIGNATURE MP 7MGF E-11 JP _J JGF L ( PGI CORPORATION 0# -�PARTNERSHIP 0#='LLC I#= COMPANY NAME: ADDRESS ^ CITY STATE ZIP TEL FAX - - CELL j--[NAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ _❑ 117 FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of IndustrialAccWnts Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly Name(Business/Organization/Individual): fid! 6& Address: �UAC.'�– City/State/Zip: P 441W Ok Phone#: L H3 —r-� 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 � have hired the sub-contractors 6. El New construction employees(full and/or part-time). 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. El We are a corporation and its required.] officers have exercised their 1011 Electrical repairs or additions 3111 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.❑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. 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.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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certto under the pains and penalties of perjury that the information provided above is true and correct. Simature: 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 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 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 Conmonwoalth,ofMassachusetts Dopartment of Industrial Accidents Office of Investigations 600 Washington Stre.et Boston?M.A.02111 Tel.#617-7274900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax#617-727-7749 wvt wmass.gov/dia