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HomeMy WebLinkAboutMiscellaneous - 97 LOST POND LANE 4/30/2018 (2)i .................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ThisCertifies that ................ ...... ............................... �6 .......... .......... .... �2) has permission for gas nstallation;,-1.6 ....... ... ...... s....... in the buildings of ......... ..... S C- ........................................................................................ at ..... 7 North Andover, Mass. Fee !.....O .. . .... Lic. No. /'�55.v ....... .... /112;� ................................................ ..... .... .................. GAS INSPECTOR Check # 93 VYL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE [� �, P J PERMIT # JOBSITE ADDRESS K —n OWNER'S NAME GOWNER ADDRESS _ TEL JFAX�� TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: E] RENOVATION: El REPLACEMENT: ® PLANS SUBMITTED: YES Q NOEJI APPLIANCES 1 FLOORS- BSM' 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER j FIREPLACE FRYOLATOR =T— FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER_ LIVENTED ROOM HEATER WATER HEATER A- HER- -� ��--- �-- INSURANCE COVERAGE 1-4 have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch.142 YES j _ D IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW �I LIABILITY INSURANCE POLICY [] OTHER TYPE 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. CHECK ONE ONLY: OWNER 0 AGENT O 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 cur to to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com nc ith all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER -G SATTER NAM{� --� /�� _ LICENSE # ,S SIGNATURE MP [&l6GF [:][ JP JGF 0 LPGI © CORPORATION ©# = PARTNERSHIP 0#= LLC E]# COMPANY NAME: ADDRESS Br►rp)C ,b �� � _�/��li�/� _ CITY' _ �� STATE ®ZIP p2%S`TEL FAX _ CELL EMAIL r -- l� H z z~ 0 H U W P� W � o z O Nrl W � W OH a Z U w �* W � � a "' S o w a w w w U a 0 a w a U ' J E a a Q � � w x w 1- LL H z° 0 H U a a N �� The Commonwealth of Massachusetts - Department of IndustriglAccidents Office of Investigations 600 Washington Street Boston, MA. 02111 qu www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: - Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner - have hired the sub -contractors listed on the attached sheet. �• ❑Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its g• ❑ Building addition [No workers' comp. insurance required.] officers have exercised their 10.E] Electrical repairs or additions 3. ❑ I am a homeowner doing allwork right of exemption per MGL 11. E] Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), andwehaveno 12,❑ Roofrepairs required.] insurance . re uired employees. [No workers' 13J] Other comp. insurance required.] xAny applicant that checks box 41 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 anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that 1s providing workers' compensation insurance for my employees. Below is the poldcy and job site information. Insurance Company Policy # or S elf -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 requiredunder Section 25A of MGL o.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. X do hereby cert yy under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: _ Phone #: 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 ofhire,. express or implied, oral or. written" An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced.acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any ofits 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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only. submit one affidavit indicating current Policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Co onmlt� ofMassarlivsetts Dop.aftent of Judwidaf Accidents Office ofIn1yestigatims 600 Washington, Sixoet Boston} MA 02111 TQL # 617-72.7-4900 W406 or 1-877:MASSAFF, Revised 5-26-05 Pax # 617-727-7749 [xi.TYIACC ¢nTX�r�ia 10545 This certifies that...,Ap- has permission to perform Date .C -.'.>..l 7-01 t-), .... ......................... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ............................. u uka.+ plumbing in the buildings of ....... 1,,.) .... .................................... at ....... � ................................... .................................... , North Andover, Mass. Fee N�� ...... Lic. No. .15R14.... .. HI) ................................................................... Check 4 PLUMBING INSPECTOR 6-1-2-A 14 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE I 16� JJ PERMIT # 16 JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS qi ����_ TEL FAX TYPE OR OCCUPANCY TYPE CO MME CIAL ® EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: Ell Ne� • PLANS SUBMITTED: YES NO J FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIL/SAND SYSTEM _} _ _ I E DEDICATED GREASE SYSTEM _ } _.._._ ( = DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM { DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN( INTERCEPTOR (INTERIOR) (( f _._.{ _.__. —1 KITCHEN SINK LAVATORY_._-- ROOF DRAIN SHOWER STALL SERVICE / MOP SINK _ _ _.(_ _( ( ( __-1 _..._,_{ _ _.1 __.._._f __( __.__.( ._._J _._.__ { ._._ __( – -- } TOILET 1 I __-- _( __-__J ______F --.J== J ._. .a __ ._ . - k ____.-.{ ______1 _f __—_ __ URINAL_.— WASHINGMACHINECONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER -._._..._ 1 __j _( INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESGKO IF YOU CHECKED YES, PLEASE INDICATE THE T E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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. CHECK ONE ONLY: OWNER Q AGENT 10 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true an 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 co i with all Pertinent provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER' NAME _ (1e1'�, _�C `i ( LICENSE SIGNATURE (VIP JPD CORPORATION RJ PARTNERSHIP# ;LLC COMPANY NAME Y�u�rt�t0o I ADDRESS j CITY ( STATE ® ZIP } I, TEL _qg3_ 1S, }j FAX _ , 11 CELLe u EMAILL W Z O H U a w o� z y� p H � W � � H Z W OLLIJ O Q W N a w W U) p z a w� U J a 9L N ui z W F- LL H O H a a f. The Commonwealth of Massachusetts - Department of IndustrialAccidints Office of Investigations quo 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leyib -ly Name (Business/OrganizatiorAndividual): Y�V1 Address: Cly. SLP City/StatPhone #: r Are yo an employer? Check the appropriate box: 1. 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. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its [No workers' comp. insurance 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.] employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 1011 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then.bire outside contractors must submit anew affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that 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 DTP, for insurance coverage verification. Y do hereby ce der thepains and penalties ofperjury that the information provided above is true and correct. Signature: — ,« )_ __ Date: e� �� 9 � V _ 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 employes." 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 bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Depaftent of Industrial .Accidents, Af9ce of Investigations 600 Washington Street Boston} MA, 02111 Tel, # 617-727,4900 ext 406 or 1-877 AIASIRAFF Revised 5-26-05 Fax # 617-727-7749 www.znass,go�ldxa Ll r Commbnvalth oflLlas usetts Division`of Registrati Board of Plumbi 90 -EAST �W REVERE: w. Master Plu r PL15994-M 05/Q1/2014 1 License No. Expiration Date._ 005040 t Serial No. I Division of Professional Licensure: License Search Division of Professional Licensure ,ecGvi State Agencies A -Z Topics Home > Division of Professional Licensure > r f eib'ln° as . v�n UCENWE Name:STEVEN M. FERRO REVERE, MA R fi 'mij bis ILii Ihas; addftjmd L:kxKses, cik here to view Licensing Board: PUIMEEPS & C4WTFflM License Type: MASTER PLUMBER License Number: 15994 Status: _ LFE945E SCHEDU LED TO BE IPG IIIF IED Expiration Date: 5/1/2016 Issue Date: 4/1/2013 Exam Date: 4/1/2013 This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. Page 1 of 1 Mass.Gov ONLINE SERVICES a Lkmse Ineate'a I.iicei 0nfine; CQntMd Vbre.._. REFERENCES & RELATEDINFO 1 GWssaq ca5 codes More --- a http://license.reg.state.ma.us/public/pubLicenseQ.asp?board code=PL&type class= M&li... 5/19/2014 1%4P Date........................... I ........ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...... ........... .. ... ........................ has permission for gas,!,stallation ... .. ....... in the buildings of1-,6'USf'-15—- ...................................................................... at ........ 9 7 Zas�'Z­­ ... ... 9 ............................................................................ �4, North Andover, Mass. Fee-_ ..... Lic. No. �,v.z z........ ................ GAS INSPECTOR--.... Check #K Wz 9352 •`C- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY r1 r, Ove r 11nn/1 MA DATE - I PERMIT # JOSITE ADDRESS I, 7_ J„ LCA S� 0 _ OWNER'S NAME r� y}U SS GOWNER _ ADDRESS U h TE 12-1Q��-703 FAX TPR NT OCCUPANCY TYPE COMMERCIAL [ EDUCATIONAL RESIDENTIAL CLEARLY NEW: d RENOVATION: E] REPLACEMENT: ® PLANS SUBMITTED: YES ❑J NO R APPLIANCES Z FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER JI BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER L FIREPLACE FRYOLATOR ..._. FURNACE GENERATOR -=i -- I --.-J I _..1 I_ I . _� _ I I_ — .1 -- . =I E .—D. _ _ I r _T1 --j- GRILLE INFRARED HEATER- LABORATORY COCKS- MAKEUP AIR UNIT.__ OVEN POOL HEATER - ._..... F . - =—i ROOM/ SPACE HEATER ROOF TOP UNIT- TEST v a►6U ,f 9,ro v o ____ I UNIT HEATER __ I UNVENTED ROOM HEATER WATER HEATER OTHER - -—�- -- ......._.... I . INSURANCE COVERAGE .I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 1 _ NO El IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERA Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ( BOND I OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and 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 comp'='th Perttnt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME T._j _.e>_O_MLLa LICENSE # D%a 30 SIGNATURE MP MGF 0 JP ® JGF LPGI CORPORATION ©# � II PARTNERSHIP 0#= LLC [J# � COMPANY NAME:I!S___IIADDRESS CITY W ,p STATE ZIP O/ TEL - - - - FAX - CELLa2d_3!o WAIL - - — - -- 0AL-_ \' H O z z H ' U W W o z Ow N El CA} F_- W [Oi a ftZ Cl) w O cn w a w w w cn a g a a a ice. U F, a m a � w x w F- L. cn H zz 0 H U a �7 J: ry The Commonwealth ofMassachusetts - Department of IndustrialAccidents Office o fInvestigations 600 Washington Street Boston, MA. 02111 qu www.massgov/dia Workers' Compensation Insurance .Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le�iblY Name (Business/Orgaaization/Individual): �6 fi ►'f Address: dZ 4 VV4 Uns� eyh� City/State/Zip:, w r -f I c,_e 01�q) Phone #: 77 Are y an employer? Check the appropriate box: Typo of project (required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. E] Now construction employees (full and/or part-time). 2. El employees am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance.9, ❑Building addition [No workers' comp. insurance 5. ElWe are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ I am a homeowner, doing all work officers have exercised their right of exemption per MGL 11.[] Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs required.) insurance . re uired employees. [No workers' 13.�therlJ /1 rSrGu� � S comp. insurance required.] 1%ny 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 Lire doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 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 requiredunder Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP -WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cIAA under Chep i s and penalties ofperjury that the informationprovid/ed' above is true and correct. n2�____. .. _ .% nit !0 7 �- � L �_/ -2Y-- 360 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 Information and Instructions. Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract ofhire,- express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not producedacceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any ofits 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 numbers) along with their certificates) 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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current Policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or -permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The CommoRwealth ofMassorlivsPtts Dap.artmeut offadustdal Accidents Office QUIRVestigations 600 WashiVo» Street Boston} MA 02111 Tol, # 617-727-4900 oxt 406 or 1.-877�MASSA.�,, Revised 5-26-05 Bax# 617-727-7749 VVWW.mace anvhlln .0�