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HomeMy WebLinkAboutMiscellaneous - 50 BOXFORD STREET 4/30/2018 (2)/ 50 BOXF 00030000j0 The Commonwealth of Massachusetts ��� J� Department of Industrial Accidents ! Office of Investigations i��it� 600 Broshington Street ,�,i Boston, MA 02111 www_nzassgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le-ably Name(Business/Organization/individual): C � / Address: City/State/Zip:_ `?ivy t4, I Ir K Phone#: Are yo n employer?Cheek.the appropriate box: I. I am a employer with 4. Type of Prete(reunited):❑ I am a general contractor and I employees(full and/or part-time).* have Lured the sub-contractors ❑New construction 2.❑ I am.a:sole proprietor or partner_ listed on the attached sheet.I 7• ❑Remodeling ship and have no employees These sub-contractors have 8. Demos' workingfor mei' anworkers' Q Demolition acs y cap tycomp.insurance, g, Building[No workers'comp. insurance 5. ❑ We are a corporation and its ❑ ng addition required.] officems have exercised their 10.0 Electrical repairs or additions 3.❑ I air a homeowner doing all work right of exemption per MGL 1 LE Lambing repairs or additions Myself[No-workers'comp. c. 152, §I(4),and we have no insurance re uired. t 12.[]Roof I airs q .employees. [No workers' rep comp. irtsurancerequired_] 1317 Other "Any applicant that checks boxy$t must also fill out the section below showing their workers''compensation policy information. t Homeowners who submit this stridavit indicating they are doing all worst and then ham outside contractors must submit a new affidavit indicating each. ;Camnt tore that check this box must anacbed an addr"tional sheat shoving.them of indicating and their worfcas'cecr p.polfc;information. 1 am an employer that is provi4ng:workers'compensation insurance for my employeem Below is the policy and.job site . information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address:_ 3 City/State/Zip Z► l) ��,��_ Attach a copy of the workers' compensation policy cEecEaration Failure to spage(showing the policy number and expiration dam ecure coverage as required under Section 25A of MGL e. 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. !do hereby cern er the ains andpenaky of perfury that the infnrmadon provided above ia•ftne androrreet Signature: Date: III-0 Phone#: Official use only. Do not write in this arra,to he confleted 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 S. Plumbing Inspector b.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all emp I oyers 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 ormore of the'fomping engaged in a joint enterprise,and including the legal representatives of a deceased employer,br the receiver ortrustee of an individual,partnership,associatio nor other legal entity,employing ing employees.'However the P 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 bemuse 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 ito 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),addres (es)and phone number(s)along with their certificates)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'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 wiII 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 ofthe 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. When 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 Commonwcadth 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 Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia 1 � MASSACHUSETTS nNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING ype or print) Date lG jZ -7 U I NORTH ANDOVER, MASSACHUSETTS �7 Building Locations < ' I� ` Permit# Amount S Owner's Name / New Renovation ❑ Replacement ❑ Plans Submitted ❑ m — n Z %.A ? .ci 1.1 Z '� J s U Q v .r B A SE .M E N T I I S T. F L U 0 R 2 N D . F L O O R / 3 R D . F L 0 O R 1T II FLO G It 5 T 5. F I. o o R 6T II FI- U O R 7'r it F L 0 0 It s r 11 F 1. o o R I I (Print or-C'� Ct 6) �- Check one: Certificate lnsta(lin_Company Name— 4?44 e 4�— Address S� (-v �l ❑ Partner. � . /� r✓t by eCit Business Telephone (y �r!o-Q S ❑-� Firrn Co. Name of Licensed Plumber or Gas Fitter 1 �L�r!P � --2 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ©� No r7 If you have checked ves, please indicate the type cover-age by checkin,, the appropriate box. Liability insurance policy ©� Other type of indemnity ❑ Bond F7 Owner's Insurance Waiver: [am aware that the licensee does not have the Insurance coverage required by Chapter 1421 of the Mass. General Laws. and that my signature on this permit application waives this requirement_ Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I herebv certifv that all of the details and intbrnation I have submitted (or entered) in above application are true and accurate to the best ofmy knowledge and that all plumbing work and installations pertbrmed under Permit Issued fbr this application will be in compliance with all pertinent provisions ut the Massach tts S Gas Code a Chapter 1-4"_' o the Gen � Laws. Bv: / Signature of License lumber Or Gas Fitter Title ©Plumber d So CitviTuwn ❑ Gas Fitter Icense ;vumoer �PPRC�� EDi >Fric= us ri.vl ❑ Joumevman i I I I I