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HomeMy WebLinkAboutMiscellaneous - 931 TURNPIKE STREET 4/30/2018Date... 46�.h4... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION •SSAGNUSE� /�-f ' This certifies that.. .. !� �.. ��'.�4.s�i�e. has permission for gas installation . �! i r . ? 41- .. . in the buildings of ... 496'.le Y, . .......................... . at .....�-? u m p! ..Jl t ... N, orth 'n over,; Mass. Fee.Iiit? k'.. Lic. No. i0O %- GAS INSPECTOR Check # ��� 8224 s � s Date. TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING ��' SACMUSE' This certifies that .. /V'0r 7.. has permission to perform ... / plumbing in the buildings of .... olg. )h ............. .. . 7...... v�/� / ,.N rth Andover, Mass. at . 3/ %"../?... .. j / Fee,,?.�.-ate. Lic. No ........ ..�,�ilp.�.,- .. '..... . PLUMBING INSPECTOR Check # 1 1 I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY : cl i / G� _ _..__�_ MA DATE G- — 2 7 T/ ? Jj PERMIT # JOBSITE ADDRESS3 (_ v✓��(i—�I OWNER'S NAME — GOWNER -I ADDRESS S� TEIFAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL RESIDENTIAL CLEARLY NEWEI RENOVATION: El REPLACEMENT: PLANS SUBMITTED: YES Q NO[]I APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER LEI ( L I = I I = .- BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER _,I ( _ T .-J .— DRYER FIREPLACE.- �— _J =j FRYOLATOR FURNACE GENERATOR GRILLE I--t_� .1 INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN _ 1 POOL HEATER _ ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER ----I - 77- -= 1l i .r_- INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES ONO D IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ij OTHER TYPE INDEMNITY ©l BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 4GENT �l SIGNATURE OF OWNER OR AGENT t; 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 ti!i k owledge and that all plumbing work and installations performed under the permit issued for this application will be in compliancewithall Perti n pro v i n the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 1= aid i LICENSE# I jc-�,3I SIGN URE MP MGF JPn JGF LPGIE] CORPORATION 0#3�y PARTNERSHIP D# _ (LLC# COMPANY NAME: _J1 ADDRESS I..1j- CITY STATE � ZIP G1 TEL % FAX..&G/I CELL 7r� z i 4 oJJEMAIL i GOD 0 z 0 H U W M o Z ONF W � O� a Z LU ft 3 < w t� co a w O w L w c a 0 a, a a nom.' U a a a S w x w F- LL W H Q z 0 H U W C7 The Commonwealth of Massachusetts Department of IndustriqlAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):'yN Address: 7 Z t/v Com. City/State/Zip: tf� y, e—Le— Phone #: G 7 F tli Q Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I — employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they 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. / Insurance Company Name:. 1 Sf o, 1 Policy # or Self -ins. Lic. #: Expiration 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 of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert unrjer tM pard penpltes of perjury that the information provided above is true and correct. q7 U Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information and. Instructions - Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, • express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Sired Boston} MA. 02111 TeX. # 617-7274900 ext. 406 or 1-877�MASSA88 Revised 5-26-05 Fax # 617-727-7749 www mass,govldia Daw ....... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that'. ...................... has permission for gas installation ..... .. in the buildings of ................... at qw. x ........ I North Andover, Mass. Fee. Lic. No... i?/.' . ll t� .... . GAS INSPECT R Check# 7981 ' kA FIXTURES MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING b CitylTown: , MA. Date: Permit# r Building Location: LJF Owners Name:.�2 Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential ^ New: []" Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No,� FIXTURES INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Che k One Only CLP Q %J�2�-v Owner Agent ❑ By checkina this box[]: I herebv certifv that all of the details and information I have submitted (or entered) reaardina this aoolication 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. Type of License: By (9'('lumber Title ❑ Gas Fitter Si ature of Licensed Plumber/Gas Fitter 91Vlaster p I City/town ❑Journeyman License Number: APPROVED OFFICE USE ONLY ❑ LP Installer rn Cd ~ to U O F IM — O UJ J (n ~ N 0 W W O z Z O 0 FW- m 0� W O �- W F=- X N W j 1 w Q a Z W W w? 9 = CoLLI a w F- z w �+_+ W > z V W W >- z W fn 0 J O z -j 0 W J Q Q m W O z u_ � W F- O ~ H OC W W F- tU 0 0 U. LD L9 2= J O a W F- >>> O SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR �( Installing Company Name: G2EG' 11l/e zA Check One Only Certificate # _ 'i r-' � Address:,� �1V � City/Town:c!�/,-,�" State: >✓ ❑ Corporation ,k El Partnership Business Tel: 6 d 3 13-C, s? X55. Fax: ❑ Firm/Company Name of Licensed Plumber/Gas Fitter: 6,6f- ' e c I -A4 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Che k One Only CLP Q %J�2�-v Owner Agent ❑ By checkina this box[]: I herebv certifv that all of the details and information I have submitted (or entered) reaardina this aoolication 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. Type of License: By (9'('lumber Title ❑ Gas Fitter Si ature of Licensed Plumber/Gas Fitter 91Vlaster p I City/town ❑Journeyman License Number: APPROVED OFFICE USE ONLY ❑ LP Installer 0 CONTROL # H 0 0 2 513 IMPORTANT _ If this license is lost or destroyed, notify your' Board at the: Division of Professional Licensure, 1000 Washington St., i Suite 710, Boston, MA 02118-6100. If your name or address shown is changed, notify your board ' of correct name or address to insure proper mailing of next Renewal Application. Always refer to your licensenumber. This license is subject to the provisions of the General Laws as amended. It is a personal privilege, and must not be loaned or assigned to any other person. Keep this license on your person or posted as required by law. The Commonwealth ofMassachusetts Department ofludustrial.Accidents Office oflnvestigations 600 Washington Street Boston, MA 021-11 yY Workers' Compensation Insurance Affidavit Bui dens/COntra.CtOrs/Elect�ricians/PI � licant Tnforlmaiion umbers •nl:._ T • Name (Business/Organization/Individual): �. avca.a V �. 1l iJ16 .LtC Lpl Address: % City/State/Zip: S, L,e,? A1111 U S d? ' C? Phone #; 6 Are you an employer? Check the appropriate box: I • I am a employer with 4.Type ❑ I am a general contractor of project (required): 2. Wemployees (full and/or part-time).* 1 am a sole proprietor or and I have hired the sub -contractors 6. ❑ New construction partner- ship and have no employees listed on the attached sheget. t These sub -contractors have 7. ❑ Remodeling . working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 8. ❑ Demolition 9. ❑ Building addition required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption 10.❑ EIectrical repairs or additions Myself [No workers' comp. per MGL c. 152, §1(4), and we have no 11.❑plumbing repairs or additions insurance required.] r employees. [No workers' 12•❑ Roofrepairs com insur 13 ❑ r)+7, P• ance required.] er Any applicant that checks box #I 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. tContractoo 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 employeif that is providing workers' compensation insurance fos my employees Below is tTze policy and job site infofmation. Insurance Company Name: Policy # or Self -ins. Lic. #: ExpirationDate: 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 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. Z' do Izereby certi Jzder tlte��zzy�d penalties ofperjury tliat the inforazzation provided above is trice and correct. i57is-5- ✓J.1_111c us•e only..uo not write an MIS area, to be completed by city or tow n of City or Town: _ Permit/r.,.— e m Issuing Authority (circle one): I- Board of Health 2. Building Department 3. Cty/Town Clerk' 6. 4. Electrical inspector S. Plumbing Inspector Contact Person: Phone #• Ir .1 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 guy 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 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) andphone 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 thisaffidavit 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 maybe 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 notrelated to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOTrequired 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: T11 -1a CoUM-10IMeallth oft Massachusetts Departmeiat of Jadustrhd Accidents Office of inveMigations 600 Washington Street Boston; MA 02111 Tel. # 617-727-4900 ext 406 ox X,$77-mASS.AFE Revised 5-26-05 Fax # 617,727-7749 Www.mas&gQvMa Date( 9463 v. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 1P SA US This certifies that`''`" ..e..t ... 4.4 e.2.;2........... - i ..... ............. has permission to perform plumbi in the buildings of ........................... at ..... �eAl't ......... . . .. Sir-?/- / y !�o rthh AAn dd/. v r,. Mass. 4A Fee ...... Lic. No.A(�C5. . ... ...... ..... PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY i_ _ ue MA DATE �_Z !Z i PERMIT#. JOBSITE ADDRESS OWNER'S NAME 2 , k POWNER ADDRESS ' _ _s TEL �j G 3 Z , i /_ FAX ___ TYPE OR OCCUPANCY TYPE COMMERCIAL Ell EDUCATIONAL Q RESIDENTIALP PRINT CLEARLY NEW: © RENOVATION: 0 REPLACEMENT: ® PLANS SUBMITTED: YES ® NOQ FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUBk CROSS CONNECTION DEVICE! DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ,_,___._. k L __.___{ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER _- k ..- __- _J .....___! k __I _i FLOOR/AREA DRAIN INTERCEPTOR (INTERIOR) _ ! J ! ! ...__ I I I 1 � _.._._l ._.__..._.4 _I ` (_.__--_i KITCHEN SINK LAVATORYr ROOF DRAIN SHOWER STALL k � � k I k J ( I I k--_.-.i —1 k SERVICE / MOP SINK I)--___-I _-€TOILET._ URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER I �! _-.i .._.__..._1 -- - __ ._._..i _...__( INSURANCE COVERAGE: O have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES�O �1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY �' OTHER TYPE OF INDEMNITY BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGE 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 acc t to the b st of kno edge and that all plumbing work and installations performed under the permit issued for this application will be in co lian wi all ertinen rovi on oft e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ �,_yr - J _ ..- _ _. _ LICENSE # - b C 73 _! MP .Q----_JP Q CORPORATION F-I# _ PARTNERSHIPD#_' COMPANY NAME�� ; ADDRESS CITY ���,��/«STATE ZIP C7 /1' �� �TEL - FAX CELL -0-31 EMAIL H O z O F U W Ln W � o 7g W � W LU O z W aLU co O a a w � uJ co p o a w� J a a a S W W H O z 0 H U W P� CS Pa a p G/ The Commonwealth of Massachusetts Department of Industrigl Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information j� Please Print Le0b Name (Business/Organization/Individual): I V gt{ 10-4--,V `�U, Address: G ? C City/State/Zip: v e -L- L`-� Phone #: 7 7J- 6J,7 2 o J' Are you an employer? Check the appropriate box: 1. PTam a employer with / U 4. ❑ I am a general contractor and I employees (full and/or part-time).* have ]tired the sub -contractors 2. ❑ 1 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. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.[] -Plumbing repairs or additions 12.0 Roof repairs H ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy anal job site information. A Insurance Company Policy # or Self -ins. Lie. #: U 1 �!_. L,� Imo- 1"tr Expiration Date: � ._ r 3 Job Site Address: City/Rtate/Z.in- 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 insuranc co rage yelif ation. I do hereby 7 0 that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License e^ ZY--/2- 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 Informati®n 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 sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth ofMassachusetts Department of Industrial ,A,ccidents Office of Investigations 600 Washington. Street Boston} MA, 02111 TeX. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass,govIdia 5 q 1v 2a.1P tcE Location No.Z Date ` S'A '8,751 Div. 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