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Home My WebLink AboutMiscellaneous - 83 BEVERLY STREET 4/30/2018a 0 0 0 0 0 0 6/9/2016 ., 20557 This is an e -permit. To learn more, scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20557 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that Jeffrey Hutnick has permission for gas installation test gas pipe in the buildings of Eric Seigel at 84 BEVERLY STREET, North Andover, Mass. Lic. No. 3532 Date: June 09, 2016 NVorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERTNUTTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/Individual): Callahan A/C & Heating Services, Inc Address: 91 Belmont Street City/State/Zip: North Andover, MA 01846 Phone-: 978-689-9233 Are you an employer? Check the appropriate box: I _Q✓ I am a employer with 25 employees (full and/or part-time).* 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.M I am a homeoNNmer doing all work myself. [No workers' comp. insurance required.] t 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property_ I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sbeet. These sub -contractors have employees and have workers' comp. insurance.-* 6.❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152; §1(4), and we have no employees. [No workers' comp. insurance required] Type of project (required): 7. ❑ New construction 8. F1 Remodeling 4. ❑ Demolition 10 Q Building addition 11.[] Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13.❑Roof repairs 14. E] Other *Any applicant that checks box tl 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. :Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp_ policy number. I am an employer tliat is pioviding ivorkers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: AmGUARD lns Co Policy # or Self -ins- Lic. #: CAWC604073 Expiration Date: 9/25/16 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 MGL c. 152, §25A is a criminal violation punishable by a fine up to S 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 5250.00 a day against the violator. A copy of this statement may be fonvarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ander the pains and penalties ofperjiny that the infor7natfon provided above is true and correct Signature: Jl� ��' Date: Phone #: 978-689-9233 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 #1- The Commonwealth of Massachusetts �- Department of IndustrialAccidents 1 Congress Street, Suite 100 =r! (; Boston NIA 02114-2017 .o j' w1•irmmass gov/dia NVorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERTNUTTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/Individual): Callahan A/C & Heating Services, Inc Address: 91 Belmont Street City/State/Zip: North Andover, MA 01846 Phone-: 978-689-9233 Are you an employer? Check the appropriate box: I _Q✓ I am a employer with 25 employees (full and/or part-time).* 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.M I am a homeoNNmer doing all work myself. [No workers' comp. insurance required.] t 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property_ I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sbeet. These sub -contractors have employees and have workers' comp. insurance.-* 6.❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152; §1(4), and we have no employees. [No workers' comp. insurance required] Type of project (required): 7. ❑ New construction 8. F1 Remodeling 4. ❑ Demolition 10 Q Building addition 11.[] Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13.❑Roof repairs 14. E] Other *Any applicant that checks box tl 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. :Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp_ policy number. I am an employer tliat is pioviding ivorkers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: AmGUARD lns Co Policy # or Self -ins- Lic. #: CAWC604073 Expiration Date: 9/25/16 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 MGL c. 152, §25A is a criminal violation punishable by a fine up to S 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 5250.00 a day against the violator. A copy of this statement may be fonvarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ander the pains and penalties ofperjiny that the infor7natfon provided above is true and correct Signature: Jl� ��' Date: Phone #: 978-689-9233 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 #1- OP ID: PS cc3�e� CERTIFICATE OF LIABILITY INSURANCE �--�^ DATE(MMI0DIYYYY) 1117 612015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER- THIS CER 11FICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Foster Sullivan insurance 163 Main St. North Andover, MA 01845 Stephen Sullivan CONTACT Pete Sullivan NAME: PHONEPHc c. No. E4:978-686-2266 ( Fa c. No): 978-686-6410 =,SAIL fiDDRESS: psuilivan@,fostersullivangroup.eom PRODUCER CALLA -1 CUSTOMER ID._ RNSURER(S)AFFORDINGCOVEERAGE I NAICt 09125!2016 INSURED Services A C and Heating Services, Inc. Kate Callahan IISURA:LIBERTY MUTUAL INS CO_ 23043 ER 1NSURERB:GUARD INSURANCE COMPANY I INSURERC: 91 Belmont Street INSURERD: North Andover, MA 01845 INSURER E: I S INSURER F : I AUTOMOBILE X WVtKAGES CERTIFICATE NUMRFR- P=IIICInN NI IIIAMCM- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWr1HSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. IN LTR I TYPEOF INSURANCE INSR I POLICY NUMBER I PMODNYYY) I MMtDDY LIMITS A GENERAL LIABILITY X I COMMERCIAL ,ERCIAL GENERAL LCAFILIT f CLAAAS-I,1ADE � OCCUR ICONTRACTUALLIAB ' X I � �CBP4016154 I 10912512015 IMED ! � 09125!2016 EACH OCCURRENCE Is 1,000,00 I paEig+i =s a oc� �,.c) s 100,000 EXP (Any on_ per ron) I ; 5,000 PERSONAL&ArJVs4JJRY $ 1,000,00 GENERAL AGGREGATE Is 2,000,00 GENiAG, GREGATELIMITAPPLIES PER: I (POLICY FX l -'O- F1 LOC IPP.ODUCTS-COMPIOPAGG IS 2,000,00 I S A AUTOMOBILE X LIABILITY ANY AUTO ALL Ot:Tir'� AUTOS� SCHFDULr'UArrOS HlR�AUTOS NON-OvVNED AUTOS X 1 II ( BA4544035 � t � 10912512015 11 � � 09/25/2016 t I COI+BINED SINGLE LIWIF I (Ea accident) 1,000,00 BODILY N-JURY(Per person) $ fiODi L`f S�13URY (Fr accident) $ X X PROPERTY O.kPhaw=_ (P.�::.CC��) S A x UMBRELLALIAS EXCESS UABcLAta44DE X OCCUR X ICUSS09334 09!2512015 jj ( 09/25/2016 EACH OCCUPRB-.CE Is 55,000,00 AGC-AT"S 5,000 00 ' Dc�UClcL '- 1 I $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY ?ROPRIEI ORIPAR r�+'SVDC-rUriVcY IN OMC�J1;�A ? r7 CLUDE7t (Mandatory in NH)=.L Ityas. dascYbe umder DESCRIPTION OF OPERATIONS belc.( MIA i 1 CAWC604073 ; { I 09/25/2015 � I 09125/2016 (( � JvATU- X I ORY LI v11 S I I _� �yC I yCCtrr�N 15 500,000 DiSFD:S--E;a"PLOY=c S 500,00 E —1 POLICY LIMIfr I S 500,000 -DISEASE- DESCRIPTION OF OPERATIONS I LOCATIONS I VEiICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) EVIDENCE" faX # 978 688-9542 I-hK I I I-1t.;A I h tiUI-WhK C:ANCELLA HUN TOWN OF NORTH ANDOVER 1600 OSGOOD STREET NORTH ANDOVER, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE VJILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED R_EPRESEN.-AT'VE G 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD I MAW - Date ................ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...... ....... ....... has permission to perform ................. plumbing in the buildings of at. 0 ......................... North Andover, Mass. Fee-. ..... Lic. No.//.. . 11 .. .............. PLUMBING INSPECTOR Check # 5522 (Type or print) NORTH AND, Building Locatio MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING MASSACHUSETTS C O S >L.t" 4P r/ s / C New ri Renovation Name T e of Occupancy Cr' Replacement 0 Plans Submitted Yes Date O�L Permit # Amount No Q (Print or type) / �^ �� Check one: Certificate kistalling Company Name ' Corp. Address Ap, Partner. usiness Telephone — Vim�/Co. Name of Licensed Plumber: .Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: El Liability insurance policy Other type of indemnity D Bond Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance ignature Owner D Agent hereby certify that all of the details and information I have submitted (or entered) in above a on are true and accurate to the best of my knowledge and that all plumbing work and Inst lations orme der Pe ued or s plication will be in tance wim an perunem provisions of own ROVED (OFFICE USE ONLY the Massachlumb od hapt eneral Laws. 1,,,4ype of Plumbing License — //9t7 7 cense NumDer Master Joumeyman D 10 .4 Date/—.'��.—!�f ..... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . S/� j� 1(!�� . . e --j. )� .................... has permission for gas installation ......... .......... in the buildings of at . ... /ge- 7..,,5.- it ........ North Andover, Mass. Fee. Lic. No.. . ..................... GASINSPECTOR Check # 705-0, r1 J AV 9 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations�T- Owner's Name New ❑ Renovation ❑ Replacement Date Permit # Amount $ SS . Sk; na Plans Submitted r] (Print or type) r( f( _ + Name S j'tip VLA NU YVI b� Ak t (4K (,Ay Address 4. Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company ElCorp. Partner. Firm/Co. INSURANCE COVERAGE Check one• I have a current liability Insurance policy or it's substantial equivalent. Yes NoO If you have checked }_es, please mi the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 13 Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not Gave the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 1 b—.V...—.4!a.ah..a-11 ..0 at_. -_a_ --1___1._r - - - - .... --- �- •-•� ..�w=•� �--------------av-- . i-avc buuuuurAt for emerea) in above application are true and accurate to the best of my knowledge and that all plumbing work and installationsormed and it Issued for this application will be in compliance with all pertinent provisions of the Massachuse C apter 142 of the General Laws. I Title City/Town iiYYKV V hl) (OFFICE USE ONLY) I gnature of Licensed Plumber Or Gas Fitter Plumber G itter lCenset mer Master Journeyman d eq d x o D O z w vl C4 w U F w z O F v O O > F W Gdr7 x x r z F w F W G7 p > w 0 W Z V O F C4 R" W o x w � � 0 z > rn SUB-BASEM ENT D o0„ F O B A S E M ENT IST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8.TH. FLOOR (Print or type) r( f( _ + Name S j'tip VLA NU YVI b� Ak t (4K (,Ay Address 4. Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company ElCorp. Partner. Firm/Co. INSURANCE COVERAGE Check one• I have a current liability Insurance policy or it's substantial equivalent. Yes NoO If you have checked }_es, please mi the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 13 Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not Gave the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 1 b—.V...—.4!a.ah..a-11 ..0 at_. -_a_ --1___1._r - - - - .... --- �- •-•� ..�w=•� �--------------av-- . i-avc buuuuurAt for emerea) in above application are true and accurate to the best of my knowledge and that all plumbing work and installationsormed and it Issued for this application will be in compliance with all pertinent provisions of the Massachuse C apter 142 of the General Laws. I Title City/Town iiYYKV V hl) (OFFICE USE ONLY) I gnature of Licensed Plumber Or Gas Fitter Plumber G itter lCenset mer Master Journeyman The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kVJ 600 Washington Street Boston, MA 02111 www.mass,govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers nnlirant Name(Business/Organizadon/Ind�vA ividual):_ �(j)C��if' � YJltl� t Address: CA,'� %tV - +7 City/State/Zip:_. AtLsLa, K(q o 66q_ Phone #: Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ElI am a general contractor and I ee loyees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. $ ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance required.] ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t A nv ann?ira.,r workers' comp. insurance. 5. ❑ We are a corporation and its Officers have exercised their right of exemption per MGL C. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. [] New construction 7. 7 Remodeling 8. 0 Demolition 9. ❑ Building addition 10. [] Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ R-9repairs 13. Other v¢1 Lac Secuon. pe!ow S.J'mgng thWr Pr-4✓xs' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and thea 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. #: Job Site Address: Expiration Date: 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. 1 do hereby certify nd r the din d penalties ofperjury that the information provided above is true and correct Si ature�Date.: Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): I. Board of Health 2. Building Department 3 6. Other Contact Person: Permit/License # City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: A 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 -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 seine to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permait 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 permittlicense applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid 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 Investi a ations 600 Washington Street Boston, ASIA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 mmm, mass-govfdia Date. � / �'. /. (..; . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING /4/x This certifies that has permission to perform ................................ C4 ss-c� plumbing the -buildings of ...... ....................... a t ..... /.� . IA7-c ....... North Andover, Mass. 57 Fee. Lic. No .......... — e ,'I, �— ................ //PLUMBING INSPECTOR Check # //3 8205 F MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location New Date 9 O )wners Name Qldt-.SS (� Permit #_F L u Amount of Occu anc fi Renovation 1:1 Replacement 11 FIXTI Tu V C Plans Submitted Yes ❑ No ❑ (Print or type) Check one: Certificate Installing Company Name WLLArfi— ❑Corp. Address Partner. 11 hay -wt_ c� 2 co Busmess Telephone (r�('J Z _ / c� Firm/Co. Name of Licensed Plumber: Ylkt �% t1k lk Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy a Other type of indemnity ❑ Bond ❑ Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature I Owner ❑ Agent 11 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts�W P nbin)7Code a ,S 142 of the General Laws. Title City/Town APPROVED (OFFICE USE ONLY Type of Plumbing License 7 icense Numoer Master Journeyman ❑ AlkThe Commonitia ea&h of Massachusetts 1 t Department of Industrial Accidents Office of Investigations a f c 600 WasiiiR�ton Street Boston, MA 02111 ` Workers' Compensation Insurance www_ mmsgovldia . Affidavit. Builders/Coatractors/Eiectriri$�1Pj� A190imnt Information bers Name (Business/Drgsnira6onAndividual): Please Print LeQibE Addross: CitylSte&zip: #: . Phone--------------- Are you an employer4 Check -the aPproP�t box: - 1. ❑ I° am a employer with 4. ❑ I am a general contractor and I Type Project(required): 2• ❑mnPloyees (fu0 and/or pert -time).* I am .a so}e proprietor. or have hired the sub -contractors 6. ❑New construction partner- ship and have no employees listed on the attached sheet. = 7. ❑ Remodeling These working for me m any capacity, [No workers' comp. }asurance sub-eontraetors have workers' comp. insurance. 8. Q Demolition 5. ❑ Weare a 9- [] Building addition 3.❑required,] I am & homeowner do' mg all work corporation and its officers have exercised their 1Q.11 Electrical repairs oraddiiions right of exemption MOL myself [Tlo•warkers' comp. per 1 l.❑ Plumbing repairs or additions c, t52, § 1(4), and we have no insurance required.] t employees. [No workers' 12 0 Roof r cpairs I'Any applientit that cheeks boi# I mutt aiso fill out the t Homeowners who comp. insuranacmquired_] 13.11 ether section below showin g their warkstc' oompensation submit this at�davit indi®ting they ars linin all policy information IC mftctors than check this box roust atm , g wot9c end then hire outside contractors must submit a new afiidavit indica* such. QFr:d an adtFitiaas, sheat showir mmtms and their �g• the name of the sub -corn ' work=rc. . cocup. po..,,J mfmmstior.. 1 art an employer that is Pr,?Vi&r19;work=r compensation tnsrcranee or informaiiort f� my. enpployem Below it the Poles, Insurance Company Name: andjob site . Policy # or Self -ins. Lic. 9: • Expiration Date: - Job Site Address: • City Attach a copy of the workers' compeasatioa policy declaration page (sbowia; the poli � Failure to secure Coverage as c3 lumber and expiration dz*4 g required tinder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $ I,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER enol a fine in a to tions 0 a day Afaagainst 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. r.7 L_ _t. y 1� "JY unoer me pars and penalties of perjury that the information proves above tine and coned �s..Y. ure nay. Do not write in th& area, in be camplered by city or town okra( City or Town Permit/License # Issuing Authority (circle one): 1. Board of Health 6.OEErer 2- Building Department 3. City/Town 'Clerk4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone #: Information a. nd Instructions Massachusetts General Laws chapter 152 requires all emp Ioyem 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 ofthe'f6mgoing engaged in a joint enterprise, and includirig the legal representatives of a doceased employer, or the receiver ortntstee•of an individual, partnership, association or other legal entity, employing employees. 'lioweverthe owner -of a dwelling house having not more than three apaartmen s and who resides therein, or the occupant of the dwelling house of another who employs persons to do mai-ntenance, construction or repair wdrk on such dwelling house or on the grounds or building appurtenant thereto shaU 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 license or permit to operate a business or *o construct buildings in the commonwealth for any applicant who has not produced acceptable evidence -of compliance with the insurance'coverstge required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perinrmance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the corttracting authority." Applicants Please fill out the workers' compensation• affidavit compimtely, by checking the boxes that apply to your situation and, if necessary, supply sub-cotaractor(s) name(s;L address(es). mind phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, art not pito carry workers' coTrnpensafion 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 peimit or license is being requested, not'the Department of Industrial Accidents. Should you havt any .questions regarding the law or if you arc required to obtain it workers' oompensation policy, pleast-ed the Department at the number. listed below. Self m- su_+td c�+mpanie: should eittr the self insurance -license number on the'appropr[ste line. City or Town Officials Please be sure that the afndavit is complete and printed legibly. The Department has provided a space at the bottmn 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 %%-iII 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 indicatingcurrent policy information (if necessary) and under "Job Site Address" the appiicant 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 verdure (i.e. a dog license or permit to bum leaves etc.) said pmo' n is NOT required to complete this affidaviL The Office of investigations would like to thank you in advance for your cooperation and should you have any qustions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of lmdustW Accidents Office of Investigations 600 Washington Street Bosfon, MA 42111 TeL 9 617-727-4900 ext 406 or 1-977-MASSAFE Fax 0 617-727-7744 Revised 5-26-05 www.mass.gov/dia