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Home My WebLink AboutMiscellaneous - 50 BEVERLY STREET 4/30/2018 50 BEVERLY STREET 210/008.0-0038-0000.0 r� V Date:. . Y/0.. r ,AORTM 1�_ r� Of ..ao 4, o? �' TOWN OF NORTH ANDOVER . PERMIT FOR GAS INSTALLATION �,SSACHUSEt w � This certifies that . . . . :r. �' . . . �.: ` J. . . .. . . . . . . . . . . U has permission for gas installation" !a... . .. . . . . . . . . . . . . in the buildings of . . . . . . . . . .. .. ... -,Z ... . . . . . . . . . . . . . . . . . . at . . .: . . . . . �* `. . .. . . . . . . . , North Andover, Mass. Fee.% . . . . . Lic. No. �� '�. y- . . . . . . . . . . . GAS INSPECTOR Check# ©��`� 2,1? LI f /4 d MASSACHUSETTS UND ORM APPLICATON FOR PERMIT TO DO GAS FITMG (Type or print) may, NORTH ANDOVER, MASSACHUSETTS Date ' v7 Building Loqations 1` Permit# ' , H tM �l�1J Owner's Name Amount$ �- New© Renovation ❑ Replacement ❑ Plans Submitted ❑ ' � W ri C W O p .y �i O = Z W w b Q x a z `� c > Q d w -t a F. w o > W u a o Q O C z w vF"i SUB -BASE M ENT C7 V a o p G BASEM ENT 1ST. FLOOR 2N D . FLOOR 3RD . FLOOR 4TH . FLOOR TH . FLOOR 6TH . FLOOR 7TH . FLOOR. tiTH . FLOOR. (Print or type) Name_ �l7(t.�.�Q-� Ou fv Check one: Certificate Installing Company Address P4 0 Corp. rr_rrf U,fs t3 <VI/� © l gc(a f ❑ Partner. Business a ep one �O Firm/Co. Name of.Licensed Pfumber'or Gas Fitter A ml-v-lo M INSURANCE COVERAGE I have a current liability insurance'policy or it's substantial equivalent Check one: If you have checked ves,please indicate the type coverage by checking the Yes ® No❑ Liabiflty insurance oli g appropriate box. p �' Other type of indemnity jut 13Bond Owner's Insurance Waiver I am aware that the licensee does not_havethe Insurance coverage required by Chapter 142 of the Mass. General Laws,and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: wner 13 Agent 1 hereby certify that all of the details and information I have submitted(or eOered)in above application are true best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in ' d accurate to the compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Genera!Laws. By: Signature of Licensed Plumb r Title as Fitter ❑ Plumber City/Town; G(lP l>[ ❑ Gas Fitter (cense umber ❑ Master APPROVED(OFFICE USE ONLY) ❑ Journeyman fie u0n2m0ft'vealM of Massachusetz<c nt of Departme " t. Industrial Accidents „> Office of Investigations 600 Wash sh inVon Street L Bt'stolz M4 0 111 Workers' Com ensation insurance W�-muss.,0p1din P davit: builders/Coctors/Eiectridi,,ns/Plttm4er A lica.nf Irtforuration ntra s Name (Business/Or n Please print Le_Ny gattizationMdividual): tv[ C Address: 6c Pc�-( � City/State/zip: / -(a-(�f fin( n(S?a Phone Are you an employer?Check the appropriate box: 1.❑ 1 an, a employer with 4. ❑ 1 am a Type of project employees(hill and/or part )erne * '-neral contractor and I (required): ?{� I am a sole r have hired the subcontractors .6• ❑ New cstruction p oprietor or partner- listed oti the attached sheet 7• ❑ RernodeIing ship and have no the These s working for in any capaci ub-contractors have ❑ workers' comp. ins 8' Demolition [No workers com . insurance 6. ❑ We area P urance. ❑ Building P corporation and its 9' g addition tegtured_) 3.❑ 1 am a homeowner doing all work right of officers hx�n exercised-their )0❑ Electrical repairs or additions myself. [No workers' comp. c. 152 P. on per MGL 11.aPlumbing r. insurance required.] t 1(4) and we have no 'Pans or additions 'mPloyees. [No workers' 12=0 Roof repairs COMP. ?nsurance required] 13.7 Other 1" applicant that checks box atso fill out the section below shov�n t Homeowners who submit. ibis flipdavit inuiCatitt�Lief a euiEi• g th-rr workers'compensation li 2Contractoa Thal ch wt:a - Po c1'iniomuttint, eek this box.musi eu��hire ��'tt�-c;orltm�ctomsnd ust su'omii n newattached an addiie name of fi: amdavit inci:;ting such. f Qui 211 atheir work=,comrnplc},e-1h�is aroveo'irco,�,ore.�'cr�rerfstn insurance foep poIic; inionnation. information P J •-•m Belo►v is the oft Insurance Company Name: p c'andlnb site Policy 4 or Self.ins. Lic.#: Job Site Address: Expiration Date: Attach a copy of the workers' compensation policy decFaration Q City/Sweezip' r Failure to secure cove page showinu rage as required under Section 2 ( g the policy number and expiration state). fine up to $1,500.00 and/or one-year imprisonmentSA ll MGL c. 152 can lead to the imposition of criminal penalties of a � ;as well of up to.S250.00 a day against the violator. Be advised that a civil P-,nalnes in the form of a STOP WORK ORDER and a fine Investigations of the DIA for insurance coverage verification•copy of this statement mai,be forwarded to the Office of I do hereby certifj,u e pains and penalt<es o er u .rP .! r3 that the cnformdtion provided ve is Sisnature: a and correct Phone 97Qate: a Df cial use only. Do ant write M this area, to be conrplerd.h3'city or to wn o t ' ff ctaL City or Town: Issuing Authority(circle one): Permit/License 4 1. Board of Health 2. Building Department 3. CitylTovt,n Clerk 4Electrical 6. Other . inspector 5. Plumbing Inspector Contact Person: Phone# lniormanon 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"..tver-y 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 inclucii-ng the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, associati an or other legal entity,employing employees. However the owner of a dwelling house having not more than.three ap artments and who resides therein, or the occupant of the dwelling house of another who employs persons to do m. irit,.-nance,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 1S2, §25C(6)also states that"every state o r local licensing agency shall withhold the issuance or renewal of a license or permit.to operate s business or to construct buiidings is the commonwealth for-any appiicant 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 compi-etely,by checking the boxes that apply to your situation and,if necessary,supply sub-c6ntractor(s)name(s), address(es) and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limit~d Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carryworkers'compensation insurance. if an LLC-or LLP does have_ employees, a policy is required. Be advised that this afficLavit may 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 Accident, Should you have any questions regi rding the-law c r.if you are rcquirrd to obtain a workers' compensation policy,please call the Department at the ntianbor:listed below. Self insured com-Palies should enter their self-insurance license number on the aDDronriat:e 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 foryou to fill out in the event the Office of Investigations has to contact you regarding the appiimnL Please be sure to fill in the permitllicense 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 applicantshould 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 ar Iicenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a Iicens= 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 Dtpartment Of lmdustrial Accidents. Office of LavertigatiEons 600 'V ashEing is Street Briton; MA 0211 I Tel. # 617-727-4900.C=..406 or 1-877-MA,SSAFE Revised 5-26=05 Fax 4 617-72 7-7749 WW '.mam.gov/dia FORM U - IAT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ******************AAppllicant fills/gout this section***************** APPLICANT: `/'Sr �r KJ� �,✓ (_.d Phone cis (-.5 80-'6 LOCATION: Assessor's Map Number Parcel Subdivision / Lot(s) Street St. Number 50 ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments ylaty .11_s v�' 1 ll_L Q Date Approved2.(Q q.�j- Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected h:_ �1 Date Approved Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections ] - driveway permit Fire Department Received by Building Inspector Date -~ ~ ~ Air Quality Experts, Inc. 3 Brentwood Avenue Salem, N.H. 03079 603-894-6465 JULY 9/ l993 MO. ANDOVER BOARD OF HEALTH �20 MAIN STREET NO. ANDOVER, MA o' 845 DEAR SIR: ENCLOSED PLEASE FIND A COPY OF NOTlFI[ATICN SEI-,i- TG THE S'rATE FOR AN ASBESTOS ABATEME1111T PROJECT, THE JOB WILL TAKE PLACE ON JULY 24, PR0JECT: 50' 52 BEVERLY STI;.-EET NO . ANDVER, 1A 01845 ANY QUES�IONS CONCERNING THlS MATTEh_ 5IOULD BE DIkECT.::D TO MY ATTENTION. SINCER.E�,T ' CHR�S'OPHER THOMPSON PRE6�DET A , � Commonwealth of Massachusetts Asbestos Notification form— ANF-001 Asbestos Abatement Description ll� E r 1. Facility location: FANNIE MAE 59 BEVERLY ST. .................................................................................................... ................................................................................................................................... DISTRUCTIOBS Name Address 1.All sections of this ..N.0 AND.GVER.............................................. Q.1.$.. .``a................................ b..0..3..-.6..3.5.,-2..7..3.5.................. form must be completed Cfry/fawi Zip rode Telephone in order to comply with theDepartment of . .................................................................................................................................................................................................. Environmental WlwrlsIis*w,lsneocew building narre,/,wing.Door.room Protection notification 2. Is the facility occupied? CYes O No requirements of 310 CMR 1.15(ten working days prior notification is 3. Asbestos Contractor: required otany abatement AIR QUALITY EXPERTS, INC. 349 SO. BROADWAY #8 Wclec4:and the ....................._................................._....._..._...................................................................._......._..... _ .._...................................................... Department of labor Address endIndustries equ SALEM, NH'•' 03079 603-894-6465 notificationrequirements _........................ ...................................................... ........................................................................ of 453 CMR 6.12 (ten Cirypown Tip code Telephone. days prior notification is requiredotANY AC 000167 WRITTEN .. ................... . .......... .. ...__.......__............._...._._..... abalement proied greater . ........... .......................................................... Dif Ucucu/ Cant. .rell Ty.lr(wdlterWerbal) ' than three linear or square/W4. 4. On-Site Project Supervisor/Foreman: 2.Submit(kiginalForm CHRISTOPHER THOMPSON SF07797 To: Narrre DLI Cenif n6un! Commonwealth of Massachusatts 5. Project Monitor: Asbestas Program P,O.B.120087 .........................................................................:........................... ................................................................................................................................... Boston,MA 02112• Marne DUCerafirariwi/ 0087 6. Asbestos Analytical Lab: I.This form may be usedfor notifying the ..................................................................................................... ................................................................................................................................... US.Envtonmental Maine DLICeitfirabon/ Protection Agency Region 3 �� (Mon.-Fri.)-9 3 7-•l ) 1ofasbestos demoltion/ 7. Project start date--J---/—end date _speclficworkhours (Sat.Sun. renovation operationssubyy CFR Sub art M).NESHS(40 8 What type of project is this? (circle one): demolition 54nd1aron oarer(exldain) CFR Subpart M). roouwUse ony 9. Describe the asbestos abatement procedures to be used (c'c ): place enclarure fullconlanment decamp encapsulation Aposafonfy omeNexplain) naaofion r Re**Die 10. Is the job being conducted D Indoors D outdoors? raw— 1.10 %,ffA ao 11. Total amount of each type of 43bestos Containing Materials(ACM)to be handled on pipes or ducts(linear ft.) or other surfaces(square ft.) to be removed,enclosed or encapsulated: •fineadsquare feet boiler,breaching,dud,lank surface coatings...�_Q thermal,solid core pipe insulation....... corrugated or layered paper pipe insulation...iL ' insulating cement.................. spray-on fireproofing.....................�- iroweYsprayercoatings.............. _J cloths,woven fabrics....................._� uansite board,wall board............. ollw(please describe).................... 12. Describe the decontamination system(s)to be used: GLOVE......BAG..............._............................................................................................................................................................................. r ............................................................................................................................................................................................................................... 13. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(8): W.E.T....REMOVAL....I.N.T.Q....6MIL....ROL.Y....ASBESTOS LABELED BAGS.............!..................................... .........................._..........._........................................_. ............................................:......................................................................................._........ 14. For Emergency Asbestos Abatement Operations,the DEP and DLI officials who evaluated the emergency: ........ .............................. Nacre of DEP011irial Title ...........................:.................................................................... ......................................................................................._.......................................... Date olAuthodrabon WWI/ ..................................................................................................... .................................................................................................................................. Name of DU OlGcial Tltle .................................................._................................................ .................................................................................................................................. Dare or Autim'd1icvi weber/_... 15. Do prevailing wage rates apply as per M.G.L.c.149,§26,27,or 27A-F to this project? D Yes No Rev.6A2. Facility Description •-� 1. Current or prior use of facility: ......................................................................................... ...5.......................................................................` :.......................................................... 2. Is the facility owner-occupied residential with 4 units or less? 0 Yes No 3. Facility Owner: .F AN N I E M AE .19...0.0.....M AR.K ET.....$.`.�'..,.......S.U.I.��.�a......8..Q..Q.......... ....................... Name Address _._...........__..........RHSLLAP.ELP.H1.1Wy......R.P........................................................................................................................ Gry/fown tip code rete#- 4. Facility's Owner's On-Site Manager: .. WA............. . . ........... .. ..... ........................... Name Addrps ....................................... Clry/fow+'r tip ark releWarK 5. General Contractor: nim.....................C. P.....�(aN�.�.l�J� ��••Z.:r Ad................................... ..L.....WA h P�. �a.�;. .L......{ . .............. ..............................0 EI,MSF•pP. ..........M.A..... .................... ................................ . Zip code AlephonY ........ ,.{:�. ..W.. .�,.�.------ ..:r.�..3............ Clry/rown a Contractor's Workers Comp.Insurer — Policy/ Exp.Date 6. What is the size of the facility? (sq ft)_(i of florins) 93 Asbestos Transportation and Disposal 1, Transporter of asbestos-containing waste material from sit to temporary storage site(if necessary)to final disposal site: AIR QUALITY EXPERTS, INC. 349 SO. BROADWAY #8 .................................................................................................... .................................................................................................................................. Nxn r klress SALEM, NEW HAMPSHIRE 03079 603-894-6465 ... .. ....................................:......... ................ _.._...... ...._. ... ............... ...._. ........_... _. . Ciry/fown Zip ark Teleidxxre 2. Transporter of asbestos-containing waste material trum removal/temporary storage site to final disposal site: SAME Ni........ ... ... . .. .................................................. ........... ..... ........ ...... A . ''..rti...nes..s...... . .................................................................................................................... ne ........ .............. .... .......... ......................................... .. .. ..... ................. . Note:Transfer Cily/fuw Zipade releirlwne Stations must 3. Refuse transfer t'o and owner(if applicable): compty with the j�, R Solid Waste Division regula- ........... ................................................................................. .A.. ..... ........................................................................................................................ dd.. .ress. tions 310 CMR 18.00 ..................................................... ........................................................................... C41To An ante ieleWxxre 4. Final Disposal Site: TURNKEY LANDFILL WASTE MANAGEMENT OF NEW HAMPSHIRE . .............................................................................:....................... .................................................................................................................................... (oolion Nme Owwrs NxrK 90 ROCHESTER NECK RD. .......................................................................................................................................................................................................................................... Addrus ROCHESTER, NEW HAMPSHIRE 03867 603-332-2386 ....................................................................... .................... ...................... ..... ......................................................................... r CiryAown txr ode leleNarx Certification The undersigned hereby states,under the penalties of perjury,that he/she has read the Commonwealth of Massachusetts Regulations for the Removal,Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15,and that the information contained in this notification is true and correct to the best of his/her knowledg and belief. CHRISTOPHER THOMPSON i(; S / Sol 7-09-93 .................................. .. ....................................... ........................... ........................................................ Print Name Autlionted S7ynalure Oale Note:Contractor mustsignthis PRESIDENT AIR QUALITY EXPERTS, INC.603-894-6465 form for&l _......._............................................................_.......................................................................................................... ................................................... Padlip7/fitle Nepmsenliny. fdeWxxx notification purposes 349 SO. BROADWAY #8 SALEM, NH 03079 Adrlrass Ci/fawn ZUrrrxk Fee exempt(City.Town,district,municipal housing authority,owner-occupied residential of four units or less)?0 yes C no Sticker#(from front d form): 0✓ U � 1 if i I Address-6-0 136—V6A-�Y _ ST Title of File Page of Date File Open: Date file closed: Doc Dwcument/Action Tifile Date of ke—fer to action other Purpose of Document/Act Document/ document/ n and notes Num. Action -Department -------------- Board of Appeals — Board of He planning Board — Conservation Commission — Buiiding Department � G_ Date..�4...J./...�'.��.... NORTq °ft"`°:• '"° TOWN OF NORTH ANDOVER 3: '• °t o PERMIT FOR WIRING ,SSACMUS� h This certifies that ... !�....:.. I ... * has permission to perform / l wiring in the building of........ ..`: .a- �f;�, ............................. l ,North Andover, ass. v<r'.. �9 Fee.........S............ Lic.No. ..? ..............4LEMIC �IISPE2� c r Check /i U � i �� 294 Commonwealth of Massachusetts Official Use Only r„ Department of Fire Services Permit Iv°.— (f7 2�' 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 CM 2.00 rY (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: c City or Town of: NORTH ANDOVER To the Ins�brf�fes: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) & i l Owner or Tenant Telephone No.a7 fj 6192 7<18 Owner's Address Is this permit in conjunction with a building permit? Yes Purpose of Building � NO ❑ (Check Appropriate Box) Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ 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 nay be waived by the Inspector of Wires. No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans No.of Total Transformers ICDA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool gd . Battery No.of Receptacle Outlets No.of On Burners FIRE ALARMS No of Zones No.of Switches No.of Gas Burners No.of Detection and No.of Ranges No.of Air Cond. Total Initiating Devices Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number _ons KW No.of Self-CVech Totals: —_ ~' �' Deteetion/AIeevices No.of Dishwashers Space/Area Heating Local❑ Mu No.of Dryers Heating A Con ❑ Omer g ppliances ICw Security Syst No.of Water No.of No.of DevE uiv entHeaters Imo' Si s Ballasts . Data Wiring: No.of DevE uivalentNo.Hydromassage Bathtubs No.of Motors Total HP TelecommuniWiring:OTHER: No.of Devuivalent Attach additional detail if desired,or as required by the Inspector of Wires. � Estimated Value of Electric 1 Work: (When required by municipal policy.) Work to Start 0 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C GE: 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:) I certify,under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: C Licensee: LIC.NO.: 4 3 Signature LIC.NO.: (If applicable, enter "exempt"in the license number line.) Address: �C/� �C,[.L �/ C` r Bus.TeL No.: 50?2�fi7eg9lp *Per M.G.L c 147,s. 57-61,security work requires D „ „ Alt.Tel.No.:!72f !46 2 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 El owner's agent Owner/Agent Signature Telephone No. PERMIT FEE: S s., . / , ��C �v r�� / G - �^�oy .. �� z. Alk g The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mss&gov/dia . Workers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leably Name (Business/Orpnirafion/Individual)_ Address:_ City/State/Zip /' Phone #: . Are y an employer?Check.the appropriate box: 1.2�Iam employer with�_ 4. ❑ 1 am a general contractor and I Type of project(required): yees(full and/or part-time).* have hired the sub-contractors b ❑New construction 2. .sole proprietor or partner- listed on the attached sheet # 7• (1 Remodeling ship and have no employees These sub-contractors have S. Q Demolition working for me.in any capacity, workers' comp.insurance. [No workers'comp. insurance 5. Q We are a corporation and its g' F1 Building addition required.) 10.❑Electrical required.) officers have exercised their repairs or additions 3.Q 1 aim a homeowner doing all work right of exemption per MGL 11.E] Plumbing repairs or additions myself, [No-workirs'comp, C. 152, §1(4),'and we have no l2. Roof insurance required.)t ❑ repairs eq ] .employees. [No workers' 13.[3 Other comp. insurance required..] *Any applicant that checks bob#l must also fill out the section below showing their workers'compensation Policy infon bon, m t Homeowners who submit this affiddavit indicating they ars doing all work and then hire outside contractors must submit a new afridavit indicating such. =Corrtractots that check this box must attached an additional sheat showing the name of the sub•coetracton and their wortcers'torr . ti infomration. P Po ey I amu ion,employer t ir�f js proniautg:woricers s compensation insurance for my employees: Below is the policy and job site infarnration.. 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 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 under the pains and penaltie of perjury that the information provided above ' true and correct Sitmature: C O Date: Phone#: Offxial use only. Do not write in this area,to be completed by city or town of ciaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Cierk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all emp foyers 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." At enrloyer 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 jreceiver or trustee of an individual,partnership,association or other legal entity,employing employees. •However the , _own6r:of a dwelling house having not more than three apartments and who resides therein,or the occupant of theelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house oon 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 V.o 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 perfornrance 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 numberlisted below. Self-insured companies should enter their self insurance license number on the'approprate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department hes 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 vvilI be used as a reference number. In addition,an applicant that must submit multiple permittlicense 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 aff davit 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 as 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 1-8-77-MASSAFE Fax 4 617-727-7749 Revised 5-26-05 www-m ss.gOv/dia