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Home My WebLink AboutPermits - Permits - 99 TURNPIKE STREET (3) The Commonwealth of Massachusetts Department ofludustrialAceldents t _ 1 Congress Street, Suite 100 _ Boston,MA 02114 2017 W1V11:7a ass.g'ovIdia WOVIrers'Compensation Insurance Affidavit:Builders/Contr actorsM14etricians/Plumthers. TO BE FILLDWITH THIa FEINTING AUTHORITY. Applicant:Information Please Print Legibly Name(Business/Organization/fnd ividual): Address: e'—'j e City/State/Zip: 'hone#: r" 44 Are you an employer?Check tjio appro riate box; Type of project(fequir•ed): 1,❑I am aemployerwith employees(full and/orpart-time). 7, El New COnshuetion 2,❑1 am a sole proprietor or partnership and have no employees Working for me in 8. 0 Re Odelirlg any capacity,[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself 1No workers'comp.insuranco required.]t 1 Demolition 10 E]Building addition 4.❑I ant a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have tvorke€s'compensation insurance or are sole 1 f.❑Electrical repairs or additions proprictors with no employees. 12.0 Phtmbing repairs or additions 5�I a general contractor and I have hired the sub-contractors listed on the attached sheet. T m a hese sub-contractors have employees and have workers'comp.insurance.t 13. Roof repairs 6.Q We are a corporation and its officers,have exercised their right of exemption per MOL c. 14.❑Other 152,§1(4),and rye have no employees.1No workers'comp.insurance required.] , rr;. ., *Any applicant that checks box#1 must also fill out the section below showing their workers'eompensationpolicy information, f homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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-eoritractors 1 aye employees,1hey must provide their workers'comp.policy number.' .I am an employer that is pr'ovidhig ivoi1r6,s'conipensatlOn insurance for my employees.'Below is tare policy and job site information. _ Insurance Company Name: _t�i>_��C-�. U—/-� Policy#or Self-ins,Lie.#; A C 2 �j� �j� ��Sj h�i1�piration Data: / M rob Site Address: E �t E'er�c "j City/State/Zip: ti1r Attach a copy of the workers' cmpensation policy declaration page(Showing the policy number and expiration date). Failure to secure coverage as required under MGL e. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment;as well as civil penalties in the form of a STOP WORD.ORDER and a fine ofup to$250.00 a day against the violator.A copy of this statement may be forwarded to the Offico of Investigations of the DIA for insurance coverage verification. I do Hereby certify under the pants and perlaltiessoo?fPerjmy that the iirforination pr ovid'ed above is true and con ect Signature: ��p{v C! �� Date: 4&1: -1 Phone Official rise only. Do not write hi this area,to he 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 M Information and. Instructions J' Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for thee°employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract aliire, 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 commomyc alth 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=corrtractor(s)name(s),address(es)and-phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Ihdustrial Accidents for confirmation ofinsurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retutned 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 arc required to obtain a workers' compensation policy,please call the Department at the number listed below. Self iin'sured 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 writo"all locations in (city or• town)."A copy of tIre 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1.-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia The Commonwealth of Massachusetts Department of IndustrialAceldents I Congress Street, Suite 100 Boston,AM 02I19 2017 wjvw.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/ContractorsMlectricianslPlumhers. TO BE FILED WITH TM PRRMCTTING AUTHORITY. Applicant Information Please Print Le 'bl NaMo(Business/Organ.izatiori/Iudiv:idu41): ? ��(`y►/,S" %(tTfj/tJ Address: 2-16 071- City/State/Zip: Phone#: Are you an employer?Checkt6 spproptiatc box: Type of project:(required): 1.❑I am a employer with empIoyem(full and/or part-time).* 7. F1 New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. 04'emodeling any capacity.[No workers'cornp.insurance required.] �`-' 9. ❑Demolition 3.❑ nt I a a homeowner doing all work myself[No workers'comp,insurance required.]t 10 ❑Building addition 4.Q I ant a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either havo workers'compensation insurance or are sole 11.❑Electrical repairs or additions p€opiietors withno employees. ' 12. �_,/ Q Plumbing repairs or additions 511/1 I am a general contractor and I have hired the sub-contactors listed on the attached sheet. �3. Rookie a1T8 6`-'These sub contractors Made employees and have workers'comp.insuraace.4 p 6.Q We are a corporation and its office iceIrs have exercised their right of exemption per MOI,c. M.❑Other 152,§1(4),and eve have no employees.[No workers'comp,insurance required.] ;. *Any applicant that checks box#1 must also fill out the section below showing their-%vorkers'compensation policy information. t Homeowners who sabmit this affidavit indicating they are doing all work and then hire outside contractors must subnrlt 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 havo employees. If the sub-6il6ciors have employees,They must provide their workers'comp,policy number. I rain an employer Mai is providing workers'compensation insurance for my err:ployees. Below is the polley and job site irfor iltation. Insurance Company Name: L&OXZY Policy#or Self-ins,Lie. 74(3 , Expiration Date: 2 W 7 Job Site Address: Zip:� tL City/state �(1. Attach,a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). pailure to secure coverage as required under•MOL o. 152,§25A is a criminal violation punishable by a fine tip to$1,500.00 and/or one-year imprisonment;as well as civil'penalties in the form of STOP WORD ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify tinder thepains andpenaltles ofpei jury that the it forj allou provided alcove is true and correct. Signature: Date: ,— Phone#: Official use only. Do not write in this area,to be completed by city or torprr official• City or Town: -permit/License# Issuing Authority(circle one): ; 1.Board of Health 2.BuildingDepartment 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 6f 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 bd 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 commomyealth 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-contractor(s)nanre(s),address(es)and-phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(UP)with no employees other than the members or partners,are not required to carry workers'compensation insurance, Jf an LLC or LLP does have employees,a policy is required. lie advised that this affidavit may be submitted to the Depatt ment of Industrial Accidents for•confirmation of insurance coverage. Also lie 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 wbrlcers' compensatior%poliey,please call the Department at the number listed below. Self-iirsured companies should'enter their self-insurance license number on the appropriate line. City or ToNvn Officials Please be sure that the affidavit is complete and printed legibly. The Departnnent 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 pollcy 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. 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number; The Commonwealth of Massachusetts bepaitment of Industdal Aceidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia MASSACHU SETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY --j MA DATE PEI!!�ZWIT# JOBSITE ADDRESS OWNER'S NAME ]r _j OWNER ADDRESS T FAX TYPE OR OCCU7Y TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL Ell PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES [I— NO nj FIXTURES 1 FLOOR- 13SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM E.1 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR� i __J __J r-'71 _ .__ ! , ( _... .._.,I _."JI J LAVATORY POOF DRAIN SHOWER STALL __J1 J SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION I _J WATER HEATER ALL TYPES E-1 1 -1 1 J I WATER PIPING J== I I== MUNI INSURANCE COVERAGE: I have a current jigbility insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATET E TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE OTHER TYPE OF INDEMNITY Ij 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 0 SIGNATURE OF OWNER OR AGENT hereby certifythat all of the details and Information I have submitted or entered regarding this application�rq_kue_andAccurate ttb�b t f my knowledge 0 es 0 and that all plumbing work and Installations performed under the permit Issued for this application will b compliance Ql�th--Iafl Perlin t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ..... .................. PLUMB S NAME — LICENSE# SIGNATURE MP ip CORPORATION 0#=PARTNERSHIP LLC L:�t E .J 0 1;;:::---�I - J- COMPANY NAME — ADDRESS 11 CITY ISTATE . — ZIP R. TEL FAX L "\N N UGH PLUMBING INSPYWtTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No Ok, 7 -/3-/.s THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIIEW NOTES i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK = — . CITY "�_ . . m. . MA DATE _. . _ .__._w PERMIT# JOBSPTE ADDRESS L` 7 :. � L _ OWNER'S NAME _ x � OWNER ADDRESS TEL� __�__ _ FAX L_ T'iTEOR OCCUPA YTYPE COMMERCIAL EDUCATIONAL „ RESIDENTIAL____ _ PRINT CLEARLY NEW: _ RENOVATION:�.,I.( REPLACEMENT:01 PLANS SUBMITTED: YES[I NO APPLIANCES`1 FLOORS- Bsm 1 2 3 q 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER- CONVERSION BURNER w J _. CJ - Jf(��J a _m COOK STOVE DIRECT VENT HEATER 1 r I ((—- C J(`I C J f I.- —(MF [ Eli— DRYER FIREPLACEFRYOLATOR FURNACE GENERATOR . GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT �. r-f�� .._ I�� 1 �I ..._... f E --r OVEN POOL HEATER __ „ _ ROOM/SPACE HEATER ROOF TOP UNIr TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER ._ ... J me INSURANCE COVERAGE _ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF CVVEGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY e_ i BOND _.l 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 [� J1 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 compli nce'wi h"all`Pert en rovislon of the Massachusetts State Plumbing Code, d-O apt 142 of the General Laws. PLUMB Ft-GASFITTER NAME LICENSE#ZIR( � ---S GNAT0RE MP2MGF E_ JP .__.1 JGF LPGI COR ORATION - C A I L- #I PARTNERSHIP®.#( �LLC -# COMPANY NAME:.._.. . -,.�"" 4, _ 'ADDRESS CITY -. 9 STATE ZIP - L .. a TEL FAX _--__ �CEL EiVIAIL ROUGH GAS lNSPFCTJON,6OTES. THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES 40—r- Z Yes No `7'-1 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ � FEE: $ PERMIT# PLAN REVIEW NOTES