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15 APPLETON STREET - BUILDING JACKET 10333 No. 53L-3 HASTINGS. WN Certificate No: 633-12 Building Permit No.: 633-12 Commonwealth of Massachusetts City of Salem Building Electrical Mechanical Perrrtits This is to Certify that the RESIDENCE located at ----------------------------------------------------- Dwelling Type 15 APPLETON STREET in the CITY OF SALEM ----------------------------------------------------------------------- ---------------------------------------------------------- --------- Address Town/City Name IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY OCCUPANCY PERMIT FOR 15 APPLETON STREET(LISTED AS A(2) FAMILY) This pern it is granted in conformity with the Statutes and ordinances relating thereto, and expires unless sooner suspended or revoked. Expiration Date Issued On: Mon Jul 23, 2012 -- --------------- - ---------- ------- Geoi 2012 Des Lauriers Municipal Solutions,Inc. ----------- ---------- - - --- 1-i - - -`-------------------- � fX` _ _ _ _ _____________Jy_�__ 15 APPLETON STREET 633-12 IS#: 4245 COMMONWEALTH OF MASSACHUSETTS Pkv ka.,r.- 27 �r B10Ck CITY OF SALEM I .v, V'I'. �vr a c*e.$�� , Low 0224 ' 'f i u,,;� cdrb-n Category REMODEL 4">w�� �Pennt#�u� �� �331z- '!"w ��:=�a. BUILDING PERMIT �Prolect# t ' Y JS 2 012-00 1 5 90 s- Est. Cost: . ' . $50,000.00 Fee Charged:';';$355.00 aA Balance Due: $oo PERMISSION IS HEREBY GRANTED TO: Const Class:;; s� - »Contractor: License: Expires Use Group Y'6': JOSEPH GAGNON STATE-031807 Lot Size(sq tt.) 09899306 �,Ir, . r' -", - Zoning '* '. ?-5 R2 ., ,s v Owner: JOSEPH GAGNON Units Gained: P- 1A R icantc JOSEPH GAGNON - Units Lost:,;"£a a „ _d AT: 15 APPLETON STREET Dig Safe ISSUED ON: 30-Jan-2012 AMENDED ON. t EXPIRES ON: 30-Jul-2012 TO PERFORM THE FOLLOWING WORK: REMODEL(2)KITCHENS (3)BATHS REPAIR ROOF AND NEW WINDOWS AND OTHER GENERAL REMODELING.bl; POST THIS CARD SO IT IS VISIBLE FROM THE STREET Electric Gas Plumbing Building Underground: - Underground: Underground: Excavation: i Service: l r. . q f 4�� .. .._ -. ]. �,�,Q/U : Footings:.. . _ Rough: ���/:� - Rough: Rou 1°".T rr Foundation: Final:J/ Z% Final Final (i Rough Frame: �. (j 3/ Fireplace/Chimney- D.P.W. Fire Health Insulation: Com/ V J j kil/l Meter: Oil: (/(,' ( oL • Final Hous"', Smoke: 7 r Water: Alarm: [ Assessor Sewer. Sprinklers: Final rr1``N�/``�� "l V THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOL RULES AND REGULATIONS. Signature: Fee Type; ReceiptNo: DotePaid: CheckNo: ' Amount: _ BUILDING - REC-2012-001771 30-Jan-12 146 $355.00 IMPORTANT:OWNER OR GnNTP.4CTOR"LUST ARRANGE FOR PERIOD:-INSPEC?IONS.DURING CONSTRUCTION.SEE CURRENTRUILDING CODE— CHAPTER ODECHAPTER i FOR'LIS?OF,REQUIRED INSPECTIONS. _ - ' ' i z4 z t< CALL 976-619-5641 TO SCHEDULE AN INSPECTION GeoTMSO 2012 Des Lauriers Municipal Solutions,Inc. 1 y j? a� c� V�w VSQVE AD CITY OF SALEM ,BUILDI _ PERMIT- - The C'onrrnonweallh of Massachusetts y, Board of Building Regulations and Standards CITY OF Massachusetts State Building Coda, 780 CMR SALENI Building Permit Application 'fo Construct Repair, Renovate Or Demolish Re iwd.lhir '011 One-or Ttru-Famd.v Du ellin•p This Section For 011icial Use Dill Building Permit Number: Date Ap lie ; °- �{�r (huWing Oliicial(Print Nmn� Signature Date SECTION I:SITE INFO IATION -- 1.1 Property Address.�_ 1.2 Assessors Map& Parcel Numbers /_tom A e�e/CeZvim/ �I 1.la Is this an accepted street?yes no Map Number Parcel Numb r IJ Zoning Information: r 1.4 Property Dimensions: i Zoning District Pmpos d Use Lot Area(sq 11) Frontage(II) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Reyuircd Provided Reyuircd Provided 1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: — Outside Flood Zone? Municipal ❑ On site disposal system ❑ Check it' us❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Putner'of Record: - Jysca4R67Ktmod,,i eA4Soo Nimne(Print) I City.State.ZIP - e a t v, No.and Street Telephone 7 Email Add ss SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of roposed 1Vork=: � Ss A-, i v ��� , SECTION J: ESTIMATED CONSTRUCTION COSTS Ikon Estimated Costs: (Laborand.\laterials) Official Use Only I. Building S 1. Building Permit Fee: S Indicate how ree is determined: 2. Electrical S ❑Standard CilyiTosvn Application Fee Cl Total Project C'ost'tltem 6)x multiplier _ _x 1. Plumbing S ?. Other Fens: S P - --- - J, \lechvtical ill\'.\<'I S List: Suppression) S Total \II Fees: S ChcekNo. _ _('heck:\muunt: Cash \mount: n. Total Project Cost: 5 ❑Paid in Full ❑Outsrulding Batuue Due: �� � CIUh��rd'�✓L. SECTION5: CONSI'MicriONSERVICES 5.1 Construction Super%risur License(CS1.) License Numlicr 'oration Rae I ist Csl. I'%PC H" PC Description an'di—Stirccl I inrcstricicd I 11kiddilILS Lin to 35.000 CU 11 lle,(rictcd 1&2 Fawilv DAwl1inu State,/I N1 %lasollry RC Rwllnu Coverina %k S Window and Siding SF Solid Fuel Burning Appliances 1 Insulation 1'elciiholic Finail address 1) Demolition 5.2 Registered Home Improvement Contractor(HIC) —C, IIIC Ilegistration Nunilicr Expiralioi Uule F11—C Collipill) N un-or I 11C Ite 4 0 a�rcsd N ind ", I Entail IV714 P�::26 7 City/Town,Slap�KIP e1cphont SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. I Signed Affidavit Attached? Yes ..........e No...........(3 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Ninne(E[ectrunic Signature) Date SECTION 7b:OWNEWOR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. 47 Date Prii Signature) NOTES: 1. An Owner%%ho obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor (nut registered in he Home Improvement Cuntrictur(HIC) Program).will 1a) have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be round at IIIA11 ,`,,I Information on the Construction Supervisor License can be round at 2, \k lien substantial work is planned,provide the information below: Total floor area(sq. fl.) I including garage. finished basement.attics,decks or purch i Gross li%Ing area i sq. it.) Habitable room count \umber ol'Greplaces Number offiedruoins \L1011'Wrol'bathrooms Number oflialt'haths I%pc ot'lleMing S�swnl Number ofdccks, porches I' lie ol'Qoklling N' S1011 FinJosed 011011 1. 1 ot.il Project Square Fooiagc-ma) lit:substituted flor-1'otai Project Cost- CjZy OF 5:1LEN12 N[LISSACHCS.ETTS c BUILDING DEPAItT,%LENT I < 120 WASHINGTON STREET, 3sa FLOOR TEL (978) 745-9595 Rmx(978) 740-9846 Kl_),fBE.RLEY DRISCOLL NLAYOR T fioSUs ST.PiEms DIRECTOR OF Pt3LIC PROPERTY/8UrLDING CO NL%I ISS[ON E R Workers' Compensation Insurance Affidavit: Builders/Contras torn/Electricians/Plumbers Applicant Infnrmatinn Please Print Legibly More IBuaimss,Organ imticrvIndividual): ) a sgftep/C • GA ,oy Got.) Address:e7;d City/State/Zip: AQ .� z,224 0'�V Phone k:_ 7)P- ��,���7 7 Are you an employer?Check the appropriate box. Type of project(required): I.111 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction /iitployces(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached shecL : 7. ❑Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers'camp. insurance. 9. Building addition (No workers'comp.insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself.(No workers'sump. C. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.) f employees. [No workers' 13,0 Other sump, insurance requircd.) •Anv applitwi drat chwks box el most also rill uui the uctiuo below showing their workers'companudun pulley inAi mation. r I I,xnuuwnen who whmit this affidavit indicting they are doing all work and then hire umside tantmctors mmt mhmil a new anldavit indicting such. nuncrun that check this box muss anwhed an uWitiurad,heel showing the nwne of rho subtonuuton and their workers'comp.pulley inramution. fain an employer that is providing workers'compensation insurancejar my employee& Below is the policy andjob site injorm"don. I n.curance Company Name: _ _ Policy 4 or Self-inns. Lic. 6: - Expiration Date: Iob Site Address: - City/State/Zip: Vtach acopy of the workers' compensation pulley declaration page(showing the policy number and expiration data). Failure to secure coverage as required under Section 25A ol'3IGL c. 152 can lead to the imposition ofcriminal penalties of a fine up to SI,500.00 and/ur one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to SM.00 aday against the violator. Ile advised that a copy or this.aatement may b:furwardcd to the Office of Invesligaiions of dtc DIA fur insurance coverage vcrilicatiun. l do hereby certify under the pains and a nallies ujperjury that the iufunnutiott provided above iv true turd correct. rhnne,� `T7�9d'1✓ 36'97 i OJJicial use ratty. Du not write in this area,to be completed by city ur tuwn njJ&iaL i City ar fawn: __ PermitlLlccnse 4 LsauingAtohurily(circleone): __... .._—.__ ......--- I. Guard ul Ilcalth Z. IluilJln., Deparlutcnl I.Cilylfnwn Clerk J. Electrical Inspector 5. Phunbing lurpeetor 6.Other I Contact Persmt: _ Phone Ih. 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 anuther 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 ajoint 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 not any of its political'subdivisions shall enter into any cuntract 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)name(s),address(es)and 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,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. Sclf-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 tilt 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 ctc.)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- t _ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 cxt 406 or 1-877-MASSAFE Fax#617-727-7749 Rcviscd 5-?6-05 www.mass.gov/din The C'onunomveahh ol'Massachuscits y 1� Board of Building Regulations and Standards CITY OF /' sr Massachusetts State Building Cute. 780 CMR SALEM ra•t;,,,r.tr„r inn �+ Building Permit APplic;ttion To Construct. Repair. Rcnov; Demolish a ^� One-or Tuvr-Fann(r Dtrelliu,\f U Fhis Section For 011icial Use 01 Building Permit Number: -- Date Applied: ( _ Building Official(Print N;unc) . igf. re Ou c SECTION I:SITE 1 FORNIATi L I Properly AJJres 1.2 Assessors Map& Parcel Numbers /S--/PGo/his.✓S� 1.1alsihilfartacce ted street? -es no Nfap Nwnher Parcel NuniNr 1.3 Zoning lnfortnatlon: a - � 1.4 Property Dimensions: ;'�Zoning Disvicl Proposed Ise Lot Area(sy 11) Frontage Ilq 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Y;u•d Requircd Provided Required Provided Required Provided 1.6 Water Supply:(M.G.1.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public a Private❑ Zone: _ Outside Flood Zu ? Check if es !site disposul S)stein ❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Owner(of Itecor : N;_une l Pnnlf City.Stan,ZIP Q 1, bAIV e 57gL 2Zj'-_ s ,rr No.and Street ° d ruiephone .moil dd SECTION J: DESCRIPT N OF PROPOSED WORK'(check a I that apply) New Construction❑ E.xisting Building Owner-Occupied ❑ Repairs(s) W Alteration(s) ❑ Addition ❑ Demolition ❑ accessory Bldg.❑ Number of Units Z Other ❑ Specify: Brief Description of Proposed Work': ' 0/� I 9�e a SECTION a: ESTIMATED CONSTRUCTION COSTS Itcm Estimated Costs: ILabur nd.\laterials) Ofllclal Use Only I. Building S G I. Building Permit Fee: S Indicate how fee is determined: '. Electrical S ❑Standard Citffown Application Fee ❑Total Ppjecl Cost'(Item 6)x multiplier x ?. I'IumMny S '. Other Fees: S 4. .Vxhanic.11 ilf\.1(') S List: 5. \lech:mical iFirc ----__ ---------- -- -- i Su„rv%sioni S Total A11 Fees: S 'heck No. ('heck Amount: l',uh \nu nmt: o. Total project Cost: S 0 _ _.. ❑ Paid in Full ❑OuuumJing B,hince Due: 2 _ Cos. SEC 1'ION S: CONSI'RUCTION 5FHVICES S.I ('mistruction Supilsor License(CSI.I D_. icensc Ni \pir;uinn ,»c Name of I. Holder I is(CSI. F%Pe(see helo\0.__._—__ l ----`- I)PC Dexriptiun No. .tnd Slraet I 1 htrestricted I IIuildin+s tio to 15,001)cu. IL1 R Restricted I&2 Famill Dwcllin Cil)ifo\\n..Stute .I ' .. ._ AI 11;uon NC Itrhdin Cl _ 11'S N'induw and SiJin SF Solid Purl numing,\Ppliances of n/ I Insulation 'I'ele hone .it❑J cs m D I Demolition 5.2 Registered flume Improvement Contractor(11 ► 3Zllil -F S IIIC Registration Ni Expiration Date IIIC'Comps Name I I I C'Registrant N l to V �a le �i1 ,�i 1�2tyC ne 6s .v .i• <4W? No.aid St�rreet L'muil aJ •ss .40 Ci /Town,State I refs hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 152.1 25Ci Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of theylssuaaofthebu(Iding p tSigned Affidavit Attached? Yes ....... No........... SECTION 7a: OWNER AUTHORIZATION O BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize to act on my behalf,in all matter relative to work authorized by this building permit application. Print Owner's Nane(Electronic Signature) Dune SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this aappplication is true and accurate to the best of my knowledge and understanding. Print Dii '.snv:\uthori uj' gent's N;une .ectr nic Signature) Dote cr NOTES: I. An O%ii\rhu obtains a building permit to do his her own work,or an owner who hires an unregistered contractor (nut registered in the Hume Improvement Contractor(HIC) Program).will no have access to the arbitration program or guai fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at \\\\\\ m.r•. !\ 4.i Information on the Construction Supervisor License can be found at \ \\\ nl.ls;�w% fits 2. \\'hen substantial\vork is planned,provide the information below; fowl lloor area(sq. n.l - I including gunge, finished basement attics,decks or porch l 61li\ing Area lsy. 111 __- Habitable roomcoum __. ._.. \umber of fireplaces .. _ _ _ \umher of bedrooms \tunher of hathr.wmi Number oflialf huthi I'!lie of hmtting s)ilem . . _ Number of decks, porches 1 11\1+e�+) e\4+lin ( \g i\>len) _ I?Itclo5eJ ell _ 1. "hii,il I'rojccl Square Foo»Ige-n»q he slibititini Iltr-I'olal I'ruje❑Cl � rti us kCHUSETCS ©LILDLNG DEP.IRT.% LVT 1_0 WASJ4NGTON STR!W jw FLOOR rM (978) 745.9591 KIMBFR, Y DVXOLL FAX(978) 740.99" MAYO)t T)Iowu sr.PMUS DIRECTOR OF PLaUC PROPERTY/at:MDL%qG CO-%OIISSIONER Construction Debris DISP0531 Affidavit (required for sU demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.J Debris, and the provisions of MGL c 40, S 34; Building Permit a 11, S I JOA. is issued with the condition that the debris resulting from I I 1 work shell be disposed of in a properly licensed waste disposal facility as defined by;gGL c The debris will be transported by: (name of h tiler) The debris will be disposed of in 1-7 C�C'li (name of raclhty) 0 (iddna or ra.dlly) +lr aNra ofperml I• nr —' v CITY OF SM-Elf, 1 XSSACHUSETTS v BUILDING DEPARTMENT 120 W.\SHLNGTON STREET, S'a FLOOR TEL (978) 745-9595 FkX(973) 740-9846 KI\tIlERLEY DRISCOLL ),LAYOR I HonitS ST.PIERRE DIRECTOR OF Pl 8LIC PROPERTY/Bt:ILDING CO\L\IISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrician%/Plumbers Applicant Information Please Print Legibly Name t0ueiixaArganirmiom,In/diivvitlual): _,,A Address: L e��An�� �2l✓� c Uaw�/l�/� _ rat/n City/State/Zip: 0 Phone If:_ 97�- �� 369 — Are yoaan employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑N w construction "Oployces(full and/or part-time)." have hired the sub-contractors 2. 1 am a sole proprietor or partner- lived on the attached sheet t 7• Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity, workers'comp.insurance. y, ❑ Building addition [No workers'camp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I t.❑ Plumbing repairs or additions myself. [\o workers'comp. C. 152,¢1(4).and we have no 12.❑ Roof repairs insurance required.) t employees. [No workers' camp. insurance required.) 13•❑Other IAny applicant our vis ka box rt must also rill out till suctiuo below showing their worken'compematiun puliuy intlam,ulon. I hvn.usaft"who sahmil this atllMvil indicating they an doing all work and then hire outride contractnn midi.nthmit a new JMdavit indicting such.�Ginnaatun that chalk this box must atnch xi an addiliurwl cheer showing the name of the rub<umracWn and their worked comp,policy insdrmation. l am an employer that 1s pruviding worken'cunrpearatlun hlsurance for my emp/uyeex Below/s flit policy and jab site irrfornrution. Insurance Company Name: Policy 4 or Self-ins. Lic, d: Expiration Date: Job Site Address: City/State/zip: Attacb a copy of the workers'compensation pulley declaration page(showing the policy number and expiration data). Failure to secure coverage as required under Section 25A of SIGL c. 152 can lead to the imposition of criminal penalties of a tine up to 51,500.00 and/or one-year imprisonment,as wall as civil penalties in the torn of a STOP WORK ORDER and a line of up to 5250.00 a day against lilt violamr. Ile advised that a copy of this statement may bu forwarded to the Office of Ln rstigwiunx of the DIA for insurance coverage verification. 1 flu hdreby certify under the poops and peaul of perjury that the h1fonnulluu provided above,is true uud c'urrecR Sig•n t l /l - Data: / —J-i/ 7s., Z i i011idol use only. Du not sprite in driv area,to be cunrplefed by city ur town fr/Jiciui Giryor'1'uwn: __ Pl•fmi0.1 cnse.4 Issuing Atilhurily (circle unc): _.. I. Board of Ilcalth 2. Ruildins, Deparhncnt 3.Ci(y4own Clerk 4. Flectrical Inspector 5. Plumbing Inspector 6.Outer _-- ! Gsnlact I'crsun: Phanc I7: I Information and Instructions \lassachuscus 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 ajoint 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 .f or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." hiGL chapter 152, §25C(6)also states that"every state or local licensing agency shalt 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 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 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 an 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 till in the permitilicense 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 ctc.)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 Street Boston, MA 02111 Tel. 9 617-727-4900 ext 406 or 1-877-MASSAFE Fax k 617-727-7749 Revisud 5-1-6-05 www.mass.gov/din