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Home My WebLink AboutMiscellaneous - 81 BONNY LANE 4/30/2018 (2)N_ O_ W N Q O O O O O O O Date. .17/1/�;7 ........ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... *4 ... ..... .. .............. has permission for gas installation ............. in the buildings of ... 0,4,21-ck, ........................... ............. at a......... . ........... North dover, Mass. Fee. 7S Lic. No. 4SM GAS INSPECTOR Check # 8049 d. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE PERMIT# J [ JOBSITEADDRESS [�) z ti /t/ U7 ]OWNER'S NAME C. Wn GOWNERADDRESS TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONALRESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT: 0 PLANS SUBMITTED: YES NO [j APPLIANCES I FLOORS— BSM 1 2r3 4 6 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR J GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOFTOP UNIT !TEST UNIT HEATER I UNVENTED ROOM HEATER rWATERHEATER J: INSURANCE COVERAGE I have a current jigbftinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NANO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COV7EAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY iV OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER: I am aviare that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts Generat. Laws, and that my signature on this permit application waives this requirement. CHECKONEONLY: OWNER 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 auW.Iccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application vAl be incompla th all Pertinent provii fon the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTEIR, LICENSE#1�2551 VI -T-17-- SIGNATURE IMP MGF JP JGF S LPGICORPORATION PARTNERSHIP FILLC f COMPANY NAMERESS Z AJ --j jADD \) " - CITY U5' 64i STATE [VA_jZIP L._-0If Lf.iTEL FAXAC ELL jEMAIL' o � a DO�pirbmiuf qfhRrW&taTAm*kj7& oft4hme'romms i6/h! lY�rsdrirtgttrrt!�re�t A 02111 un t:te�rs Wdm -vervW&I&Ij70jkI""d40h site josmuczconwmp /Wa m MAOEPA, e... - A I. i^ I J6S'IbA(hTbms,--- 8 OPJA). 1 2-1v kuhaka cow, lor( ftwortmecompem.ation pigmydocramomirpagg (srmwmg"f',, Pon", )I*o?rIhTT(r.oXp rrarjou(TaW Wilma ORD Manirmfiat, Of Z- - op— rz Td .7 Wvl�rkwqdjr- ov"mitaft"ftffAft-, gra-4 ro 1.01 ' h -U& BhffdIA9'Dq?;3Xtfffcm a P -MI, 4 Ekdr-ICA, Immuer%, 5; rtmffMig, rMpemv. 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A NI-I&M44m imd Ilmsont tm* _ GWM$m on Prowd PTO* crilnobd�omormatw-Seetiei -I'my"COMMLOO-41%, Aw&)WPJ'Wivdehned as IWA intlivjdtW, pafte any twaor more empwAm dWeliftnellsworanothermlio sn�Hrd3i,ell'iiFg110um 'of - Wan emplo-Yee- er-RteflbIWfReS9r VIV)6116 y 4 Addilibnaffy,, MOL cjj,��r i n coVG-Ve M.p req u ked.'" *NLiffrcrriie:commonvealftnureWof ftpQrjr=f -SbA, OROT into anyountract for theqwrffirnmw SuDdiiVikibnS.- r. Pbm fff cKil *0 WbrkeW cozupettsaiioa offf&v Ilie-bomtha;-.aPPIY,, fa yoursitmatinn orad, if nem'aW-Su"b" sub-CoRFmft)rR)mme(#. RddiCn@4andI;io;w numb imumum Umiled Liabift, C"mnpmjbqLLq QrLiiR&d(LWI, .. I , . - ate(4of lit wqlbyms-offierlhwithe Accliftnts,foy. confunlation.0fijIsurallce t coverage. Theaffidswitshould notiftee Deportment of bridustriR Accidents. �Ompop§a Yfibapblir, "Prmo call ilne W�- . _ Self Aokddenter-therr Cily,or T-owil Officiw, PkW b& - `cure jhat-fire affidavit is e Dopal.n ent haspn. NEd OvAceat ht:bDR6 r-(ffrdp.afh a Oryomcif n lipsfo,c0quefyou S Ift-aaftb% --m appribant gj- yen MWIT A, copy ofthuaffiffawhfiat fimbem Offib" may, bmprovidcd to ffi C', aPOkaur aspreof-fliaLa.vai-ff affil is fd�fO",KIfimPm, At OF'fibe-me,%. A orreach. We' not relAraf(you fo- yl 1nvf ficxita to gine FLS a cath any qmOslibas. The. C4mDTCm,9rte V *SW MPadmcl-d of 104st"Acem1w* Off-rce Of-Enk"dormw 60OV29fifilgfon Rjeet- -ROSIM.M&I 0211111-1 TCL 0.617-72 7-4900 extW of 1-4774JA '727 774 Date ........ / 1.. i. TOWN OF NORTH A, -34 -34V41' PERM I;PFQR-,WIRING -) t,- — This certifies that .................................................... ............ has permission to perform ......... �/7- ............................ wiring in the building of ...... c. /r-., ..................................... at ...... ..................................... ........................... .North Andover, Mass. Fee.—TO.. .. Lic. No..174(�?A .......rl - - — ----- LEC 14SP Check# 373 -3 1 2 10526 ` Commonwealth of Massachusetts Official Use Only el A Permit No. Department of Fire Services Occupancy and Fee Checked •` BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071geavebiank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEA SE PRINT IN INK OR TYPE ALL INFORMATION) Date: I L— a7— 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) d I`� % AN/" L Owner or Tenant Aim 6 P IceeP(,C Telephone No. 1 i Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 'n Utility Authorization No. Existing Service AW Amps �J /�9volts 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: Completion of the following table may he waived by the Inspector of Wires. Attach additional detail tf desired, or as required by the inspector of Wires. Estimated Value of Electrical Work: %L �� %� (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: 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 cover ge is in force, and has exhibited proof of same to the permit issuing office. ONE: INSURANCE VBOND ❑ OTHER ❑ (Specify:) I ceiWfy, under the ains and penalti�,s o perjury, that the information on this application is true and complete. AO A FIRM NAME: tie 00 LIC. NO.: 17 0 VI ALO Licensee: ?iFj Signature LIC. NO.: 6*4 l e� afapplicable1I enter "exem the license number line.) Bus. Tel. No.: / Address: lAVE �� B!9 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires 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 PERMIT FEE. $ No. of Total No- of Recessed Luminaires / No. of Cell.-Susp. (Paddle) Fans Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ nd. rnd. o. o cy ig ng Batter Units Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones Detection and NO.. No. of Switches No. of Gas Burners I nitiatin Devises No. of Ranges �j No. of Air Cond. Toonsl No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Disposers P Totals: ...................... Deteetion/Alertin Devices No. of Dishwashers Space/Area Heating KW Municipal Local ❑ Connection E] other Dryers No. of D ry Heating Appliances ICS' Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts . No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivalent OTHER: Attach additional detail tf desired, or as required by the inspector of Wires. Estimated Value of Electrical Work: %L �� %� (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: 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 cover ge is in force, and has exhibited proof of same to the permit issuing office. ONE: INSURANCE VBOND ❑ OTHER ❑ (Specify:) I ceiWfy, under the ains and penalti�,s o perjury, that the information on this application is true and complete. AO A FIRM NAME: tie 00 LIC. NO.: 17 0 VI ALO Licensee: ?iFj Signature LIC. NO.: 6*4 l e� afapplicable1I enter "exem the license number line.) Bus. Tel. No.: / Address: lAVE �� B!9 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires 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 PERMIT FEE. $ ! E 4 Y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 { ' www.hwss gov/dia . Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Eleotricians/Plumbers Ar plicant Information �, tt�� ,,Qt • t'; Please Print Legibiy + t sa Name (Business/Organization/Individual):�t',j't�.:r Address: City/State/Zip: Phone Are you an employer? Check.the appropriate ,- box: 1. ❑ I dm'a employer with 4. ❑ I am a general contractor and f employees (full and/or part-time).* 2• ❑_ Team .a.sol�e,prgpn�et have hired the sub -contractors t r or,pa� trier- sh$p`a�lctha`�e`zio'el es, e% site PR the attached sheet. A y'Mes iisu" &contractors have working for main any capacity. [No workers' comp, insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I din a homeowner doing all work officers have exercised their right of exemption per MGL myself, [No•workers' comp. c, 1.52, § 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 I0.❑ Electrical repairs or additions I.❑ Plumbing repairs or additions -12.❑ Roof repairs 13.❑.Other "Any applicant that checks bol-# l must also fill out the section below showing their workers' bompensationt icy information, t Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such. $contractors that Check this box must attached an additional shect showir- ►he nsne of the sub Contreotor and tirCir workers' camp. polici infaration. t a an emplayer that esprovldMg:worAeAs' compensadon insuranceformy employees:� iiiformadoPi elow is Ilsepolicyandjob site ' Insurance Company 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 maybe forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct S_ icrtature: Date• Official use only. Do not w. ria In this area, to be co„ .•plated bey ci y or town official r 4 - n Re • R�,y. r t� r.1.41 n.o City. ,Town: r �!k . OVA 1,4 Permit/License 1N 4 y,Vthority (circle one): t�,,g oa *f Health 2. Buildiitgt§f•ty{�py� Ele ° • • d • a� 6�ther" ` e lyInspet' >s3t uc�6i In�peator Contact Person: Phone The Commonwealth ofMassachusetts Department oflndustria[Accidents Office oflnvestigations 600 Washington Street Boston, MA 021.11 Y www.massgov/ilia Workers' Compensation Insurance Affidavit: guilders/Contractors[Electricians/Plumbers A licant Information please Print Le ibl Name (Business/Organization/individual): Address:_ 14 J41-��A x Ayr City/State/Zip: !T'M�.��iOly /�l�di►�%%10 Phone #: 9,7e- iotoh - r 3 / 0 Are yo* employer? Check the appropriate boxc ' 1 !� 1 am 2 • a employer with 4. ❑ T Me (full and/or part-time).* 2. ❑ I am sole proprietor or have hired the ub co tractoontractr r a listed partner- ship and have no employees t on the attached sheget. I These sub -contractors have working for me in any capacity. [No workers' comp, insurance workers' comp, insurance. 5. ❑ We, are a corporation and its 3. ❑required.] T am a homeowner doing all work officers have exercised their right of exemption MGL [No workers' comp. per c. 152, § 1(4), and we have no insurance required.] 'i' employees. [No workers' comp insuran Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. [] Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11 .0 Plumbing repairs or additions I2.❑ Roofrepairs cerequired.] I I3.Flo ther 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Confractors that check this box must attached an additional sheet showing the name of the sub -contractors and their wnrir, 1 ind_� CUM (in p oyer MatispYoviding workers' compensation insuYanceforin employees Below is tTzepolicy and job site information. Insurance Company Name: u✓ie,�- yut,GJ�j�(, r Policy # or Self -ins. Lie. #:_ i . SA �, Expiration Date - I V - Lo/z_ Job Site Address: �� /�%® �i � jj 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 civilpenalties in the form of a STOP WORK ORDER and a Of up to $250.00 a day against the violator. Be advisefined that a copy ofthis statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. r 7- ••� G",Y cerzJy under t/zepains an dpenalties ofperjury thatthe infor"tafionpsovided above is true anticorrect. aw Official use only. Do not write an this area, to be completed by city or town official. City or Town: Permit/License ff Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/To6.Other wn Clerk 4. Electrical inspector 5. Plumbing Inspector for t7 Al -1011 Contact Person: Phone #: I f nformation and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more Of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other le al e owner of a dwellin ho e M . • g 11�$;� empIoyin9 employees. However the g y?gare than th'te;ap�t'ihetts ai d who rside'therein, or the occupant of the dwelling house"of izother w a�einploys persons to do maintenance, construction OArepa„2'r wo*+d such dy¢alI> g,house or on the grounds or building appurtenant thereto shall not because of such employment bd deemed to bean employer." MGL chapter . % <§2 C�6) aIs seta eb kyat evg ystate or local lice'is ng`aXhe'Y�shall'w,ithhoId the issuance -or renewal of a IicensE or permit iooperate 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 ofpublie 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 numbers) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) withno 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 regarding the law or if you are required to obtain a workrs' e Industrial Accidents. Should you have any questions reg compensation policy,; please call the Department at the number listed below. Self insured companies should enter their self-insurance Iicense number on the appropriate line. City or Town O£ficials Please be sure that the affidavit is complete and printed legibly. The Department hasp�yiia space atthe bottom of the affidavit.for".you ld,F€iIl out ilthe event the Office of Investigations e has to contact yyou ard r�giug�apcant.', , Please be sute'to'fiIL the permitlltceA�se number which will be used as a reference nuni'ber'. In additioh, hn hpplicant' that must submit nal iple I rhiitilicen,e.spplications in any given year, need only submit one affidavit indicating current policy information (ifiielJs'sary) 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 homeowner 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, t r at elephone aril fax number: The Cay`-moaamealLt of Massaehosetts Department of ladustrial Accidents O ee Of InVestigati'OUS _ 600 Washington Street Boston; MA 02111 TEI. # 617.727-•4900 ext 406 or 1-877-MA.SS.AFE Revised 5-26-05 Fax # 617-727-7749 Www.rnass.mv/dia 9231 Date—a—Y TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Agmean�v btu — This certifies that .............. has permission to perform .... Kk..................... rq. plumbing in the buildings of. ........... at. S1 14 17"- ....... North Andover, Mass. Fee 2..-9, AL i c. No. . . .4*).L ............ (8 ' - PLUMBING INSPECTOR Check # 16 Z/ -SUB BSMT. BASEMENT 1ST F OOL R 2ND F OOL R 3RD FLOOR -----_ 4T" FLOOR 5T" F OOL R 6T" FL 00 R im F R 3T" FLOOR MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town:_ MA. Date: '1#2-- /Z — / / c, Permit# Building Location: c71 60 Vii% /U Owners Name: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional El ❑ Residential New: ❑ Alteration: ❑ Renovation: Replacement: ❑ Plans Submitted: Yes n No n FIXTURES I.3me: 196AI Lr2 f'L 0 l� v3ia� ��Nh tiC"A Address: �'/!C.QS:f/t �i1i City/Town: HID 3 CC 0AY 7 State:. BusinessTeL_r�'�r) (`/ �i6 5 Fax: '7OP7504t�oS� Nameof Licensed Plumber: INSURANCE COVERAGE• Sic. r�i C, r. ❑ Corporation ❑ Partnership ❑ Firm/Company A-)C?YIC Id'1 77/ 107 DEDICATED V) ca LL z F Z Q Z o w o: a W a _ U Q CID ¢ < m W Cq Q X cn o LU 1% h o z�� O 0- O Z ¢ O � 911 Z S2 [n a Z > g p Q > 3 �, O 0 � a 3 O N Z in a vNi z ►�- Q OLLI U C7 3 3 c 3 X 0l I.3me: 196AI Lr2 f'L 0 l� v3ia� ��Nh tiC"A Address: �'/!C.QS:f/t �i1i City/Town: HID 3 CC 0AY 7 State:. BusinessTeL_r�'�r) (`/ �i6 5 Fax: '7OP7504t�oS� Nameof Licensed Plumber: INSURANCE COVERAGE• Sic. r�i C, r. ❑ Corporation ❑ Partnership ❑ Firm/Company A-)C?YIC Id'1 77/ 107 DEDICATED V) ca z F H Q Z i t. - have a current Iiabilifv insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If you have checked Yes, please indicate the -type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity E] Bond ❑ OWNER'S INSURANCE WAIVER: 1 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 Si nature of Owner or Owner's A ent Owner ElAgent E]f hereby certify that all of the details and information 1 have submitted (or entered) regarding this application are true anaccur fa �� -. Knowledge and that all p1!!r!7bing t:crk 2nd installations performed under the permit issued for this application will be in -compliance with all Pertinent provision of the ash chusetts State Plumbing Code and Chapter 942 of the General Laws. a fc t..� „�� of my 3y --—yp ype of License: -itte Plumber nature of" Icensed '- ber ify/iown Master PPROVED (OFFICE USE ONLY) �]JOurneyman License Number; Z5I The Commonwealth of Massachusetts Department ofln dustrial A cciden ts Office of Investigationg 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/ContractorsXlectricians/Plumbers InUi nIni• TnfnrV" �-" _ Name (Business/Organization/Individual): /j AJ C,2 r/'Z Ll t_ tdll,l 6, Address: -3 L-jY L- R SD a-' LN City/State/Zip: �1010 LL -7 0ry 10V4- OIL? 4 Lf 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).* 2. I am a sole proprietor or have hired the sub -contractors listed partner - on the attached sheet. ? ship and have no employees These sub -contractors have working for mein any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing .officers have exercised their 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 j 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.❑ Roofrepairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lie. #: ll Expiration Date: Job Site Address: 00,A) GL' AIv Q lle— � 14 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 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' that a copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby ce r;7y under thep tri ns edpenalt ofperjury Mat the informationProvided above is true and correct 1( i� L �� 10 Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUcense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 6. Other _13 / 4. Electrical Inspector 5. PIumbing Inspector 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 apartimnts and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall'withhold the issuance'or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants PIease 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 confirmatiori 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 onIy 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 marred 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: `1'he Commonwealth olMirassad'husetts Depadment of Industrial .Accidents Office of Investigations 600 Washington street Boston; .M. -A 02111 Tel. 4 61.7.727-4900 ext 406 or 1.,877.MASS.AFE Revised 5-26-05 Fax #,617-727-7749 www.mass.l;avfdia. a -COW A46h•w EALfI4- oir m A SAC u E7TS LICENSED ASA JOUR ISSUES THE ABOVE .. AN, PLUM'b%� AN 7- LICENSE TO: Iir JONCZVX 3 .EMERSON LN NIDD s; MA olg4g-, 25596 00 05/01/12 78471