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HomeMy WebLinkAboutMiscellaneous - 707 TURNPIKE STREET 4/30/2018I r This certifies that ....... �LJ.�._(.}..�1"�/�1!�-�- ........... has permission to perform ... (,/45.&� Z� �.... . wiring in the building of at .7z? Sr ....... orth Andover, Mass. Fee ..P..O.=F7. Lic. No. J.L.454.3. ..... .. �,! LECTRIC LL INSPECT OR/ Check # 11039 �'O° O //la�a�uteaiFs Official Use only �.,Wd a/Nim s Pcr„it No. _ 1 l �3 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All wax to be psforzoW m aco ft= WA meMamach�s i Com (ban 1. R7CMP. 12..00 (P -LEASE PP&W NIIVK OR TM AU WOMaTIO1V Date: G ig or Town at �(4c .lf,� /; �-ry� To the Inspector of Wilres: By this application the notice of his or her iu top m me electrical work described below. Location (Street &Number) C'OK2G.,,•/' s/4J Owner orTenant 7 7 Tdephoee No. Owner's Address - Is this permit in coujunctim with a building perms. Yes ❑ No Purpose of Buiidforg ❑ (CheckAppropriate Boz) Utility Authorization No. -Eidsting Service Amps 1 Volts Overhead ❑ Un dgrd ❑ Na. of Meters New Service -Amps � 1 Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: of Recessed Luminaires of Lnmivaire Outs of Luh of Receptacle Outs of Switches of Ranges of Waste Disposers of Dishwashers of Dryers - - EVI Hydromassage Bathtubs OTHER: Of (*-SURL (Paddle) Fans of not Tubs *Wwg!!mad- ❑ s Of on Barsers of Gas Burners l of Air Can& °b rea Heating KW Appliances KW. No. or s Ballasts of Motors Total HP Generators KVA ❑ °- of Units CY g ALARMS No. Of Zones o. at Hetection an Devtees o. ofAhudg Devices Aiertiu Devhas ❑ IN ❑ OfhW No. of or FAsuivalent Data Wirigg: Na o[Devicts or FAmivalent eeomm us g� IVO. of Devices or Equivalent Auw* adAdanaf dmffYdnbed. arcs t ain d by the impretar ofrrea f . Estimated Value of Electrical Werk: (When � by mzmic4W whey) Wart to Start Inspeclioos to be icqncstcd in accordance with MEC Rutc 10. and upon can,91etiOn. INSURANC19 COYSRAGIL Unless waived by the owl w. na Petmit fur the pa% of electrical work may issue unless the lig provides proof of insurance inch -;con „ coveaage or its substantial equivalent The undcrji> drat such coverage is io farrq, and bon ecddbited proof ofsamc to the pemtit issuing office, CHECK ONE: 94SURANCE dj BOND ❑ UnM ❑ (SPecW) I ov0, wider the paFirs=d peaa0w ofp"lw9, M& Ike &forma k. on a& br tate and complete. FIRM NAME: 17,x% i D is L r f -'f$ -r CAL C M -r *c �i+.iGt IAC. NG.: Licensee: JORV c D [ b Fs. iL Siguature -Z�G NO.: Cfl�uxrble.erttcr eeentpt-indtelAoenseaum6er�j -- ,� - Bns.Tel. No.z`17i' -•rr�%-b1�2 Address: WL#*iT 5r i�hti-�' #An . i W *Per M.G.L c. 147, s. 57-61, socenty work m pmt o{p� AIL Tel. No:`�#i& 3 7 -� 73 yt OWNER'S INSURANCE WAIT ML. Iwo aware that the �Y L Uc. No. reqWred by law- By my agnakne below. I hereby waive I'i`i does iI a the the liability insrnamx eoveragc uormalt7► Owner/Agent I an ( ane) ❑ owner ❑ owner's aMnL Signature Telephone No.PERMIT FEE: r le- 3 Name (Business/omanizationhndividual): Address: 87 BELMONT ST DAVID ELECTRICAL CONTRACTING LLC mum m n mmuuvr-m MP. uitKo Phone #-. 978-WZ-6Z62 Are you an employee? Check the appropriate box: The Commonwealth ofMassachusetts Print Fo `- Department oflndushidAccidents have hired the sub -contractors Office oflnres*adons listed on the attached sheet 1 Congress Stree4 Suite 100 Thi sub -contractors have Boston, MA 02114-2017 employees and have workers' www.masxg0V1ttlia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/omanizationhndividual): Address: 87 BELMONT ST DAVID ELECTRICAL CONTRACTING LLC mum m n mmuuvr-m MP. uitKo Phone #-. 978-WZ-6Z62 Are you an employee? Check the appropriate box: 1. Q I am a employer with 7 4- ❑ I am a general contractor and I employees (full and/or part -tine).# have hired the sub -contractors 20 I am a sole proprietor or partner- listed on the attached sheet ship and have no employees Thi sub -contractors have working for me in any opacity. employees and have workers' [No workers' comp- insurance comp- insurance.* required-] 5. We are a corporation and its 3. 1 am a homeowner doing all work offieelrs have exercised their myself [No workers' comp- right of exemption per MGL insurance required-] t c.152, §1(4), and we have no employees. [No workers' comm. insurance required -1 Type of project (required): 6. 0 New construction 7. ❑ Remodeling 8. ❑ Demolition 9 ❑ Building addition 10-FZI Electrical repairs or additions 11.[❑ Plumbing repairs or additions 120 Roof repairs 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 mast submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state why or not those entities have employees. If the sub-conhactors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation ins. urate for my employees Below is the policy and job site information. Insurance Company Name: THE HARTFORD Policy # or Self -ins. Lic. #: 08 WEC C18293 ���7 �7^ Expiration Date: MARCH 1, 2013 Job Site Address: '/v / / � �/o,,A� SE-City/State/Zip: IV,4141,-4A 4 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 th lator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for i=ce coverageyerification. ! rv i rrI f,.! rMF7r;r ! t..fi��' tt a rr t t r lir t t t 't t,• r r r t r r rr r �t ✓ Offichd ase eniv. Do no wdfe in && area, m be completed by city or town offid t City or Town: PermidLicense # Issuing Authority (carte one): 1. Board of Health 2. Bm'kling Department 3. Crtyll'own Clerk 4 Electrical Inspector 5. Plumbing Inspector 6. Usher Contact Person- Phone#: 1 4F a Date ......./ . ZZ - 0 - TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... ....... flIx.1f .... ....................................... has permission to perform ........... wiring in the building of ..... ......... Ir... ..... zte-e..J. at..Ze!.7 ...... 1k,6.7.A1I1I.I ....... ................... . North Andovei, Mass. Fee ../.Z -.A. -...;,-A) Lie. No, ............... PE,LtE PICAL'IN'SPE R Check #%/ I= Commonwealth of massa ehusettsE71/071 Official Use Only Department of Fire Ser -vices b BOARD OF FIRE PREVENTION REGULATIONS and Fee Checked - r4PPLIG�4,1'IOIV FOR PERMIT .T pp�aleaveblank All work to be performed in accordance with the , RF VR M ELECTRICAL WORK (PLEASE PRlIVT �r1NK OR TYPES INFO�4T14 Code (MEC), 527 CMR 12.00 City or Town oh NORTH A.NDOV]ER ' Date: l — Z By this application the enders' To the Ins ector of Wires; fined vex �otice of his or her. intention to P Location (Street &Number) ,,, , ;-4gerfoim the electricaj work described below. vr� �' Owner or Tenant Owner's Address a Telephone No. Is this Hermit In conjunction whir b ' Purpose of Building�diug Permit? yes No ❑ (Check Appropriate Boa) Existing Service s Utility Authorization No. Volts �—•� NewNew----- Se�Ce Overhead ❑ .: Un d Amps ' 1 _1 No, of Meters Number of Feeders and. �P _________,_,Volts Overhead ❑ Undgrd El ❑ No, of Meters Location and Nature of proposed Electrical Work w f in' Ck i No. of Recessed LuminairesCom let' no the owin No. of Cer7.-Snap. (Paddle) Pio. of L d aaire Outlets Fans N�?. -0Pf.R�.e6:T���.. Swimming Pool ` ❑n- No. of Receptacle Outlets dove ❑ No. of On Burners No. of Switches No. of Gas Borers No. of Ranges No. ofAir Cond.Total No. of Waste DisposersTons ` s '..••-..•--.-er ons No, of Dishwashers Totua �-_....�..� Space/Area Heating KW A r No. of Dryers- Heating Appliances o. o ate. X, Heaters KW °• ° o. of - Si No. Hydromassage Bathtubs s Ballasts. No. ofMotors Total Hp table may be waived by the I- its o o. o - TransformersXVA o. o mergency lg g Ba Units FIRE ALARMS No: of Zones 0 . . et on an Init*in tiri¢ Devices 10. of Alerting Devices C0 neCctlon ❑ Other Estimated Value of Electrical Work Attach additional detail f desiretZ oras fired b the I Work to Start (When required by munical policy) Y ►rspector of Wires ]NSURANCE COVE Inspections to be requested in accordance with RAGE: 'Unless waived by fire owner, no MEC Rule 10, and upon completion. the license provides proof of liability insurance including permit for the Performance of electrical work may undersigned certifies that such coverage is ' e g completed operation" coverage or its substantial equivalent. issue uTnhiess CHFLK ONE: INSURANCE has exhibited. proof of same to the permit issuing office. I certify, under the pains and penalties o ❑ 071MR ❑ (Specify..) . FLRM NAME; fperjurv, that the information on this . % e� applicaxion is true and complete. Licensee: Sl LIC. NO.a�.�,, (!f a cable, r PP sign , Address: exempt m the kcerrse number [� LIC. NO,• ' a *Per M.G.L c. I47, s. 57-6I, security work requires D Bus. TeL No.: OWNER'S INSURANCE W ep�ent Public SafetyAIL TeL No.: AIVER: I am aware that the Li "S" License: Lic. No. required by law. By my signature below, I hereb waive Licensee does not have the liability insurance cove Owner/Agent y 'bis requirement I am the (check one o rage normally Signature ) ❑ wner ❑ TeleplzOneNo. Eg��� ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL 1. ROUG SPECTION: — ( Failed — [ ] Re -inspection required ($50.00) - [ j Inspectors' comments: (Inspectors' Sign re - no initlals) Date 2. FINAL INSPECTION: Passed - Failed —1 t (Inspettors' Signature - 3. UNDER GROUND INSPECTION: Passed — [ j Failed — ( j Inspectors' comments: k.uuspeczors • bignature - no 4. INSPECTION — SERVICE: DATE CALLED NATIONAL GRID: Passed — [ j Failed — [ .] Inspectors' comments: - no 5. INSPECTION - OTHER: Passed — I j Failed — Inspectors' comments: -3- t Z Date Date NAME: Re -inspection required ($50.00) - Date - Re -inspection reauired (S50-0111 - I i Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA, TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS 10 BE CHARGED. Date. . 9525 <:�•,:1ti TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING %c��1/�� hh�ff.44-eThis certifies that..l�� yittC /(ffG„ l / i� T 110has permission to perform . �-.!�`�.. "plumbingthebuildings of ..c...... at ...... Sr .. , No h Andover, Mass. Fee.3s: ic. 6 o.Z�G .G ' PLUMBING INS Check ." �� `� � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY ( MA DATE [Z F t I PERMIT # JOBSITE ADDRESS _�/)" C ( OWNER'S NAME POWNER ADDRESS I TEL 11FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: � RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES EO NODI FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB f { �{ __.- i _ ► { I _J _I _____I _.( _ _ _ I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM► DEDICATED GAS/OIL/SAND SYSTEM f __,_,.,, _ ( ; L-3- .- ^ 1 -_m , I _i _.- -_ _,l __.__.. I _ __( ._--__._ j- .I !1 I DEDICATED GREASE SYSTEM _ I _..__..I (____._ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER __- DRINKING FOUNTAIN___I ____ -.1 _--__-_1 FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR(INTERIOR)I KITCHEN SINK LAVATORY I _____I __.__.._1 ROOF DRAIN ____--._I .____1 ---__! _-« .__.__I ._._.I ___«-._j -___.J .-.-.._-1 SHOWER STALL SERVICE / MOP SINK TOILET URINAL ........... . i :..__.__! ..._ _A.- I._WASHING WASHINGMACHINE CONNECTION i WATER HEATER ALL TYPES I WATER PIPING OTHER.._-...._._�_._...__Y-___.. - .----� - INSURANCE COVERAGE: I 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 TY OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY © BOND_l OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 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 accu to the est o y knowledge and that all plumbing work and installations perforrrled under the permit issued for this application will be in com ' hEe i II a 'ne ision of the Massachusetts State PlumbingC de and Chapter 42 of the General Laws. ot PLUMBER'S N E L �Zl2l/i�I JLICENSE # SIGNA URE MP CORPORATION P! _go!PARTNERSHIP 0# LLCQ COMPANY NAME ADDRESS G�_" fciJr i CITY j STATE = ZIP TEL FAX CELL _j EMAIL rA H Z o H U a �a w N O z' } O � � W O w a z u _ 3 c CO w cn d LLI ® > L LL CO a p z a � w a � U J a CL a v� U w EE w LL W F O O H U W a as a a The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations VV 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip:, Phone #: Ayre you an employer? Check the appropriate box: 1/❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship andhave no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 11. El Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. S t Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: 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). 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 certto under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 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 employeiis 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 producedacceptableevidence 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., M.A. 02111 TeX. # 617-727-4900 ext 406 or 1-87TMASS-AFB Revised 5-26-05 Faze # 617-727-7749 www.wass.govfdia Date.. W� //a....... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION IN This certifies that.. ar,, ' has permission for gas installation . . ......... in the buildings of ... GAq . n t . ! ..................... t� at ... o7.. 1,rt . ....T .. North/ . dover; Mass. � 4_ Fee. ��%,-U Lic. No. %���! .. !l!c`Zt : a74 C. . GASINSPECTOR Check # Z r r VVA * MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE J PERMIT# - JOBSITE ADDRESS -��_! U!w' 6 OWNER'S NAME f� P _ GOWNER ADDRESS TE FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL -_- EDUCATIONAL D RESIDENTIAL CLEARLY NEW: D RENOVATION: REPLACEMENT: 0 PLANS SUBMITTED: YES F-11 N0 APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 1 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR u - . FURNACE 1 _� J1 L___ ! GENERATOR r J I =j GRILLE ( .r I, 1 7_ INFRARED HEATER _ _ 1— ... - ��- -- q 1 _ .F _- - LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER F__j WATER HEATER _OTHER F =L-3 I _.3. I ,L=— I �� (�� 1 I _ . I � J ! I _ I INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent wh' meets the requirements of MGL. Ch. 142 YES IQ NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY -_ . OTHER TYPE INDEMNITY E] 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 [� E] 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 accu toa best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp 'ance w II rt- rt�provision of the Massachusetts State Plumbing Co& and apter 142of he General Laws. ^ PLUMBER-GASF TER NAME -(y _ !� �( LICENSE # SIGNATURE MP GF � JP [-:jj JGF LPGI 0 CORPORATION PARTNERSHIP ©#= LLC [3# COMPANY NAME: _.. ._/�'---___._--(_� ADDRESS CITY STATE =ZIP TEL FAX - CELLod M.EMAIL VVA * W z° o H U W a w v � o❑, a z o y� W } D � ~ W F a V w �* Z V) QCl) CL W 5 > o w W w V) a o a a a H a a a Cd EE w F- U- H °z 0 H u a a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 SV www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 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. t 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. #: fob Site Address: Expiration Date: City/State/Zip: kttach 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 :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 if up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certt& tinder the pains and penalties of perjury that the information provided above is true and correct. signature: Date Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia