HomeMy WebLinkAboutHomeowner License Exemption - 223 FOREST STREET 1/8/2008 4kN
The Commonwealti, of Massachusetts
Department Of Lndustria[Accidcnts
4 1
Office 0-f 117vestigations
ii I f 600 Wash in,.,ton Street
Bostorz, M4 02111
WVorkers' Compensation Insurance-k-f-fidavit: Iguilders/Contractors/Electridiang/plumbers
Applicant Information - Please Print Leo
ibly
Name (Business/Organization/individual):
Address:
City/State/Zip: ' )l Phone#:
2 7
Are you an employer? Check the appropriate box:
0 and I Ty'❑ f project(required):
6 �o w construction I El I an a employer with 4, ❑ 1 am a general contractor and I Type of project(required):
eemployees(full and/or Part-time).* have hired the sub-contractors .6. El Naw construction
e I oy'
Remode
M o�
[2.E7�Y1 am a sole proprietor or partner- listed on the attached sheet 7. El Remodeling
ship and have no employees These sub-contractors have 7 Demolition
working for me in any capacity. workers, comp. insurance. 9. 0 Building addition
[No workers' comp. insurance 5- ❑ We are a corporation and its
required.] Officers have exercised.their 10-0 Electrical repairs or additions
3. I am a homeowner doing all work right of exemption Per MGL I I-El Plumbing repairs or additions
myself. [No workers' comp. c. I52, 1(4) and we have no
insurance required.] t employees. [No.workers' 12.7 Roof repairs
. comp, insurance required.] 13.El Other
"Any applicant,that checks box#I must also fill out the section beiom,
'I'lDmeownen who submit tbis afl-idevit indicatin. showing their workers'compensation policy information.
I afe,u6i""�!!IW-'rh at-d fhen hiz-;�outside
lConu=tors that check this box must attached an additional sheet showing the 00"Ifurlors nuLst submit a ne%k,HiTlda%,i
he name of ssub_-on-,,=tor�and .1 indicating such.
I am an employer that is providin,-, workers'compensation iluuran their workers'mmp,Pol ic:3,information.
information
ceJor nT etnpiqVecs, Below is the policy and job site
Insurance Company Name:
Policy 4 or Self-.ins. Lic.
Expiration Date.-
Job Site Address:
City/state/zip:
Attach 2 copy of the workers' compensation-policy declaration Mae(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
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of STOP WORK ORDER and a fine
of up to S250M 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.
Idohereb cerrt�J�under the pains andee
Sicznature: 7nalzies ofp
rl)
c
c7uthat tile information provided above is true and correct
7 Date:
Phone 9:
0 Of,ficial use onip, Do not write in this area, to be completed by city or town official
' 'c
f / s
ia use o
T wn.
"i", Do""'w
in this
R A thor one):
City or Town:
PermitiLicense 4
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
Other lector
6.=Other
Contact
Contact Person: Phone
Information and Instroctions
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 includir2.g 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 of r 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 forany
applicant who has not produced acceptable evidence WF 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 compi-eteiy,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 afficiavit 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 Iicense is being requested,not the Department of
Industrial Accidents. Should you have any questions rep-rdirg the-la%R,or if you are required to obtain a workers'
compensation policy,please call the Department at the nu-rnber:listed below. Self-insured companies should eater 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 permif/iicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/iicense applications in arty 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 an),business or commercial venture
(i.e. a dog license or permit to burnleaves 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 13ndustrial Accidents
Office of faveAigations
600 Washington Street
Baston, MA 02111
Tel 4 617-727-4100 ext 406 or 1-977-MASSAFE
Revised 5-26=05
Fax 4 617-727-7749
Nkrww.mass,gov/dla
0ORTh TOWN OF NORTH ANDOVER
01 .1,120 ,4 °
0 OFFICE OF
0
BUILDING DEPARTMENT
VL 1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
Gerald A. Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
Please print
DATE: r
JOB LOCATION: ;'2zi
Number Street Address Map/Lot
HOMEOWNER
Name Home Phone Work Phone
PRESENT MAILING ADDRESS
City Town Sift Zip Code
The current exemption for"`homeowners"was extended to include owner-occupied dwellings to two units or less
and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the
owner acts as supervisor). State Building (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended
to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not
be considered a homeowner.
The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other
Applicable codes,by-laws,rules and regulations.
The undersigned"homeownee'certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
_,(7
HOMEOWNERS SIGNAIRM
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Foim Homeownem Exemption
110APDOF \PPEALS689-9541 CONSERV-010N 685-9530 JTE.U31i 08-9540 PLAN`-NING 688-9535