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Jd:PFGI'L18�'AIOA 7D.A.PEA141T �.E�NG GRANTED
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BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Ro�f,�f�lnstall Siding, Construct D , Shed, Pool,
Repair/Hep 2 Other• ,
PLEASE FlLL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSWG
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owners Name L�`.`GG�A� ���•',Po S .
Address S Phone ,s G E'iu a� �7�C�, Lvz� �5�� a �� s
ArchitecYs Name
Address & Phone ! )
Mechanics Name �r��G � G�u �i���R �
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<� r's`� �`� / , Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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� The Commonwealth ofMassachusetts
G Department of Industrial Accidents
O�ce of Investigations
� ` 600 Washington Sireet
Boston, MA 02111
www mass.gov/dia
Workers' Compensation Insurance Aflidavit: Bui�ders/Contractors/Electricians/Plumbers
Auulicant Information Please Print Lesiblv
Name (ausiness/organizarion/Inaivianal): ��G L � C� 1�� �i`7.�f/2
Address: �� l���k' Jf.{ � �F/�/P�
City/State/Zip: ��'i/d�'�i /ftt� ��1�/'��one#: 7�� ,�.�/ ����S
Are you an employer? Check the appropriate boa: Type oi project(required):
4. ❑ I am a general contractor and I
1.0 I am a employer with 6. ❑ New construction
e loyees(full and/or par[-time).' have hfred the sub-contractors
i 2.�a sole proprietor or parmer-
listed on the attached sheet = �• ❑ Remodeling
ship and have no employees T'hese sub-contractors bave 8. ❑ Demolition
working for me in any capacity. workers' cornp. insurance. 9. ❑ Building addilion
[No workers' comp. insurance 5. ❑ We are a corporation and its • 10.❑ Electrical repairs or addirions
r��� officers have exercised their
3.❑ I am a homeowner doing all work right of exemprion per MGL 11.� Plumbing repairs or additions
myself. [No worke�s' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance requued.] i emPloyees. [No workers' 13.� Other
comp. inswance required.]
•Any applicant that checks box#1 must elso Sll out Ne section below showing the'v workets'comprnsetiov policy informetion:
t Homeownets who submit this af6davit mdiceting tLey are doing all work end then hire outside comrectors must submit e new�davit mdicating such
- IContracims Uiat check this box must attacfied an ndditional sheet showing the neme of the subcontractors end their wo�cere'cart�.policy information.
I am an employer that is providing workers'compensution insurance for my emplayees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Eacpiration Date:
Job Site Addtess: City/State/Zip:
Attach a copy of t6e workers' compensation policy declaration page(showing the policy number and eapiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can]ead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-yeaz imprisonment, as well as civil penalties in tUe 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 Uils statement may be forwazded to the Office of
Invesrigations of the DIA for insurance coverage verification.
I do hereby c¢rtify under the pa' un enalties o rjury that e injormation provided above Is true and conect
Simauue• �� � Date: �T
Phone#• � g� " � Q� � 7 5��' S
O�cial use only. Do not write in this area,to be completed by c&y or town ofj'iciaL
City or Town• PermiULicense#
Issuing Authority(circie one):
1.Board of Health 2_Building Department 3.CityfCowu Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
lniormation ana insiruc��uns
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their e�loyees.
�
Pursuant to tbis statute, an rmployee 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 indmdual,parmership, association, cocporation 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 eu�loyer,or the
receiver or trustee of an individual,Pazmership,association or other legal entity,eu�loymg employces. However the
owner of a dwelling house having not more than three aparhnents 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 gounds 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 s6ell withhold the issuaace or
renewal of a license or permit to operate a business or to construct buildings in t6e commonwealth for any
appticant who has not produced acceptable evidence of compliance with tLe insurance coverage requi'red."
Additionally,MGL chapter 152, §25C(�states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work untii acceptable evidence of co�liance wi1L the insurance
requuements of this chapter Lave been presented to the contracting authoriry."
Appticants
Please fill out tl�e workers' compensation affidavit completely,by checking tLe boxes that apgly to your situation and, if
necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certi5cate(s)of
ce. Limited Liability Companies(LLC)or Limited Liability Parmerships(LLP)with no employees other than the
insuran
members or artners, are not requued to cazry worke�s' compensation insurance. If an LLC or LLP does have
P
D ent of Indusu�ial
employees,a policy is required. Be advised that this affidavit may be submitted to the eparpn
Accidents for confvmation of insurance coverage. Also be sure to sign and date the�davit. The affidavit should
be reUuned to the ci or town that the application for the permit or license is being requested,not the Depariment of
Ty
,
Industrial Accidents. Should you have any quesrions regarding the law or if}rou aze required to obtain a workers
compensation policy,please call the Deparlmeat at the number listed below. Self-insured companies should enter their
self-insurance license number on the appmpriate line.
City or Town Ofltcials
Please be sure that the affidavit is complete and printed legbly. The Department has pmvided a space at the bottom
to 811 out in the event the Office of Investigations has to contact you regarding the applicant
of the affidavit for you , . ,
Please be sure to fill in the P
ernrit/license number wluch will be used as a reference number. In addibon,an appl�cant
that must submit multiple pemriUlicense applications in any�ven 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 ttiat has been officially stamped or marked by the city or town may be provided to the
I applicant as proof that a valid affidavit is on file for fuAue permits or licenses. A new affidavit must be filled out each
yeaz.Where a home owner or cidzen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or pemut to bum leaves etc.)said person is NOT requffed to complete this affidavit
T6e Office of Investigations would lilce to ihank you in advance for your cooperation and should you have any questions,
please do not hesitate to ave us a call.
The DepaztrnenYs address„telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents " , '
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
xev�sed s-2�-os �,�ss.gov/dia
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