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HomeMy WebLinkAboutMiscellaneous - 8 WALKER ROAD 4/30/2018 (2)`, N Date .... U................... � � ................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... RIQ tt— (P-� 0, W.,- .................................................................................................................... has permission to perform 6 i 11-i � e VY0 4� 4 .......................................................... wiring in the building of ............ ........ .................................................................. .... . ... ..... ..... u ", at .... A ...... P.�CKSL. North Andover, Mass. Fee ... 151D . . ...... Lic. No%16 . . ...... ........... ......... .. . ..... ............. f=rRicAL INNS R Check # I "i r, �l 11 ' Commonwealth of Massachusetts OfficialUj Use Only De artment of Fire Services Permit No. p Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] peaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATIOA9 Date: ! p b 3 �\ City or Town of: NORTH ANDOVER To the Inspector of Wires: (� By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) (e Owner or Tenant V lldlc ,a 91- A17,11-r,� 6 Telephone No. Owner's Address „ & Ko Se ue-174 i -/✓e / /Y!s'l / Is this permit in conjunction with a building permit? Yes [g-' No ❑ (Check Appropriate Box) Purpose of Building RP- 5. Dc o-mp—ram 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: e_ Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans v Total Trsformers KVA Trans No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above ❑ In - Swimming Pool ❑ rnd. rnd. o. omergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of SwitchesNo. 3 of Gas Burners No. of Detection and Initiating Devices No. of Ran es g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number - ­ Tons 1-* " KW.........: No. of Self -Contained Detectio /Alerting Devices No. of Dishwashers t S ace/Area Heating KW P g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW SecuritNo. o Devices or Equivalent No. of Water Heaters KW No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent Hydromassage Bathtubs No. H 3' g No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: O o Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �=0 Q * (When required by municipal policy.) Work to Start: 3 Inspections to be requested in accordance with MEC Rule 10, and upon completion. 11i SURANCE OVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless th6 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:) Icertify, andel thepains andpenalties ofperju , that the i formation on this application is true and complete. _ FIRM NAME: + LIC. NO.: Salo 16 = ij Licensee: :Poty- f, i l k l O a k k Signature LIC. NO.: 5"oZ(d (If applicable, enter "exempt" in the licenseumber line.) Bus. Tel. No.• Address: to Z-IwVat' AO -p( A)11M,1A cY 4' A M4 C2114`7 Alt. Tel. No.: 6/7-076--,SYsy *Per M G L c 147 e57-61 security work regitlres Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent FPEPK,-T FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass IN Failed 0 Re- inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: r PARTIAL ROUGH INSPECTION: Pass [N Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP TION: Pass EN Failed Re- Inspection Required ($.) ❑ Inspectors Comm":_ i Inspectors Signature. Date: ]FINAL INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth ofMassachusetts Department of lhdustrigl Accidents 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/1•ndividual):a�-h VyGl S Address: l p L- I City/State/Zip:, RJi 1 Mi N6/M nL Phone #: �i¢/ 7- S i 3�9y Are ygx'an employer? Check the appropriate box: Type of: project (required): 1. I am a employer with 4. ❑ T am a general contractor and T 6. E] Now construction employees (full and/or part-time).* 2111 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. I �• [aE'l�emodeling ship and'have no employees working for me in any capacity. These sub -contractors have workers' comp. insurance. 8. ❑ Demolition 9• [] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. Electrical repairs or additions required.] 3. ❑ I am a homeowner, doing all work officers have exercised their 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.] i employees. [No workers' 13.[J Other comp. insurance required.] "Any applicant that checks box #1 must also fill out the section be18w showing their workers' compensation policy information. T 14omeowners who submit this affidavit indicating they ere 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: &l 7—Ai.Sc9rCtA( P D LMA- LLL Policy # or Self -ins. Lie. #: 19 iAP C2Q a o t k o- Expiration Date:: Z 1 t //t 5/ _ V"� �e R� City/State/Zip: UIQ ve / ✓ � C Job Site Address: , 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 flue 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 uptto $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 Merely certifLunder the paligantipenrylft'cs ofperjury that the information provided ab ye is�rue and correct. Phone#• &/Z`5 /S _3r74 Official use only. Do not write in this area, to he completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information and Instruction -8 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 (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Coxr onwalthofMassar?awetls Department of fadustrial Accidents Office of layestigations 600 Washingtoa Street Basion? MA 021 X Z Tel # 61.7-727-4900 Qxt 406 or- 1-877rM•ASS.A F, Revised 5-26-05 Fax # 617-727-7749 �,v�w.mace an�rEri;a 1 �, This certifies that ..`,.� G,� "I....�'r'c.�'c � ..r-- 1`_ ............. . has permission to perform ...� �... ,�.... , , , .. plumbing in the buildings of ....�,�.....�, .�.G�...........' at ..'K..{;,�,2, UA . U-0-A A: 7 .... North Andover, Mass. Fee .7 .. . Lic. No..(.3` ,-,,.� . ... 4—tm."O ... .. . PLUMBING If SPEKT Check # ( i � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY L Qr _ _ I MA DATE j _ _ ( PERMIT # I C) IS � Aw P TYPE OR PRINT CLEARLY JOBSITE ADDRESS Z OWNER'S NAME OWNER ADDRESS f2Q v Irr, FAX I TEL 8 !� ..__ OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIALi] NEW: RENOVATION: REPLACEMENT: [9 PLANS SUBMITTED: YES 0 NO© FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _..-__I .._.-..._1 I ._.__J ....____� .._.___. 1 __.___I __.._...._.i .._.___! .__. __► __.__. _! _ .�i �I DEDICATED GASIOIL/SAND SYSTEM L�I _.. _.. ! _ I .__`_I _..__._ i ._.,__..._.I I E DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I .._.____E E _-._-! ___..__f ...__,__R ! __-__J __._._.-!-- -------- _______I ----.__1_._. { DEDICATED WATER RECYCLE SYSTEM DISHWASHER I __._._.._I ______I ____4 _______I -___...i (____._._.! ___.__.. _______I DRINKING FOUNTAIN ___I _._._.._I _.__I _-___._E FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR (INTERIOR) f __.___..__i .__.__.__i _______i= _ i __.-.__1 .._.___i ---j= KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK (__.___ I _--__.._I .-.____i _-_-_-_ -__ ___i - --_____I ___-.._k __._._ 1 ._.___i _ __ . ! TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 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 Fj NO OF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY E] BOND .. I 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 01 AGENT J[] 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 Pertine ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Az PLUMBER'S NAME ..., m _ _ _�ab t s � IILICENSE # -_I3.4/5*q SI MP [D JP E-A CORPORATION �#�_ ! iPARTNERSHIPD# t LLC COMPANY NAME �h�w ,rFy I"la�. I ADDRESS 733 `7i�rn �, S��t•e F CITY r /VY A tYP�L� STATE A _ ZIP O 18 _�. _ TEL FAX CELLI EMAIL -� �1 z o ED w ❑ 0 LU a w w The Commonwealth of Massachusetts Department of IndustriqlAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EI Please Print Le Builders/Contractors/Electricians/Plumbers Applicant Infoation ly 1 l'o .rr -1 Name (Business/organizatiorAndividual): e Sh4wv� u A Address: "7 3 3 _Tu_�, r S 4_ a a a City/State/Zip: �) o r��, q S Phone #: g civ ' 3 3— y O 3 0 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 listed on the attached sheet. # 2. El am a sole proprietor or partner- These sub -contractors have ship and'have no employees working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their required.] 3111 am a homeowner doing all work right of exemption per MGL myself. [No workers comp. c. 152, § 1(4), and we have no employees. o workers' insurance required.] i comp. insurance required.] Type of project (required): 6. ❑ New construction 7. El 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 A must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they Lire 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. gC" Insurance Company Name:? o & Vov e� `_i- P—ration Date: Policy # or Self -ins. Lic. #: e- 'V 7u (Z � `1 ` _ p Job Site Address:8 W o 1K�, U- i "r — Crty/State ip. c 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. Ido hereby ce fy under thepains andpenalties ofperjury that the information provided above is true and correct. Date: 9A3�t3 00 — — Cic-) 3 a 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. PIumbing Inspector 6. Other Contact Person: Phone 3 Deems, Maura From: Ray [rvibert07@gmail.com] Sent: Thursday, August 29, 2013 12:59 PM To: Deems, Maura Subject: #8 walker rd. unit #7 > Hi Maura, > I would like to withdraw my plumbing permit for #8 Walker rd, unit #7. I will no longer be performing any work on this particular job. Thank you. > Thank you, > Ray Vibert Plumbing & Heating > Sent from my iPhone Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: http://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. 1 This certifies that �J has permission to perform plumbing in the buildings of. . at ... Ad ... %orth Andover, Mass. Fee A-7—�).*.*L*ic.No.6�L/-�.. PLUMBING INSPECTOR Cheek# 14 5 - &i°4- 16,Z - / MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - CITY S 49C_1 MA DATE PERMIT#- 1 0 I J D JOBSITE ADDRESS '.bOWNER'S NAME �(1C t�► S_ P OWNER ADDRESS 4 d S eves �w ,gym �c�. A TEL _ T $' g4 5 _ �f �1 FAX =_ TYPE OR OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL D RESIDENTIAL PRINT CLEARLY NEW: El RENOVATION: REPLACEMENT: 0I PLANS SUBMITTED: YES NON FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM I i f DEDICATED GRAY WATER SYSTEM I ___R .___. _ i { _ _._ .._ _J __.. _ _.._i DEDICATED WATER RECYCLE SYSTEM f DISHWASHER DRINKING FOUNTAIN_.-_._-�---_.-._f -__._1 I ___.._.! _ __..1 --------I ....... 11 R FOOD DISPOSER E__J FLOOR/AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK- LAVATORY ROOF DRAIN SHOWER STALL RVICE / MOP SINK l 1 ( ___._ I .—._.---! TOILET l R _ _ J J URINAL I ..-____J .-_-__---_____I _._.__I ___.._.J .___.__-1 ..____I _.._._.._.J ..__._._I .-_-__f ------1 F__.J .._..__I _...___ .J WASHING MACHINE CONNECTION { I F-77 a r _. I ... . I I I WATER HEATER ALL TYPES I WATER PIPING OTHER _J I R I INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND DI 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 R AGENT L SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / PLUMBER'S NAMEL3tbl LICENSE # 3 SIGNATURE MPI JP D CORPORATION Rf # PARTNERSHIP El# LLC �#I COMPANY NAME ; gyp, ADDRESS CITY i�.S k�( j�eay ; STATE ; ZIP ►i`j TEL FAX _ j CELL - ..._-.... E EMAIL 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-contractor(s) name(s), address(es) and phone number(s) along with their certifcate(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} MA. 02111 Tel. # 617-727-4900 ext 406 or 1-877,MA.SSAFE Revised 5-26-05 Fax # 617-727-•7749 wWw.rnass,gov/dla ANY The Commonwealth oflilassachusetts - Department of IndustriqlAccid&ts Office of Investigations 600 Washington Street Boston, ,NIA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizationffndividual):N m t' o nC Address: i.r City/State/Zip:_ ` V e jaV .1 r h► P �@ `�7�o Phone #:- % ' q �7 Ll 971 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. t] New construction employees (full and/or part-time).* 2.,X I am a sole proprietor orpartner- have hired the sub -contractors listed on the attached sheet. 7. ❑ Remodeling ship and'have no employees 'These sub -contractors have 8. ❑ Demolition working for mein any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.[] Electrical repairs or additions required.l officers have exercised their 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.❑Roofrepairs insurance required.] t employees. [No workers' 13.❑Other comp. insurance required] *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew 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 1s 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 requiredunder Section 25A ofMGL 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 certify under the pains andpenalties ofperjury that the information provided above is true and correct. -0-15 IV Phone #: 979- D^ 997- 38 7Y Official use only. Do not write in this area, to be completed by city or town offtclal. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone Information and Instruction -8 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 (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Coxr onwalthofMassar?awetls Department of fadustrial Accidents Office of layestigations 600 Washingtoa Street Basion? MA 021 X Z Tel # 61.7-727-4900 Qxt 406 or- 1-877rM•ASS.A F, Revised 5-26-05 Fax # 617-727-7749 �,v�w.mace an�rEri;a ., ,may � 4J , —4 1-- M m I . 0 r o 1-:, Fi-a! C :rl cn (n mr- I C 0 t3 C mT chis mm Z C30 L- m m 741 (n Lo r 33M 3>3> x m 0 0 m < -n m Dm Cf)> 3> 6 4 M mu). CD 4LO 4-1 00 1-4 d 0 O ON ;o cn la3 in ., ,may � 4J , —4 1-- M m I . 0 r o 1-:, Fi-a! C :rl cn (n mr- I C 0 t3 C mT chis mm Z L- m m 741 (n Lo r 3>3> x m 0 0 m < -n m Dm Cf)> 3> 6 4 M mu). CD z to ;om , (J) m 4-1 00 1-4 d 0 O ON ;o cn la3 in • CO