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BP-66081 Permit No. BP-66081 BUILDING PERMIT GIS#: - 3296.00 Commonwealth of'Massachusetts Map: 0066 TOWN OF DARTMOUTH Lot: 0002 400 Slocum.Road,Dartmouth,MA 02747 Sub-Lot 0082 Phone:(508)910-1820 • Fax (508)910-1838 Category: ROOF Project it JS-2012-002021 PERMISSION IS HEREBY GRANTED TO: Est..Cost:.. $2500.00- Contractor: - :.License: . Phone if: Fee $75.00 Coast.Class: - Engineer License: Phone if: Use Group: R3 Lot Size(sq.ft.) 45124 Applicant - Phone#i: Zoning: SRB - ALEXANDRE FERNANDES (508)995-3928 Aquifer Zone: N/A OWNER: Flood Zone: .. ZONE X FERNANDES ALE RE L New Const.: N/A A/Np/ Alt Coast 395 sq.ft. DATE ISSUED: %[J_y[ Date Typed: 04-09-2012 TO PERFORM THE FOLLOWING WORK: Construct roof over existing patio PER PLANrr Approved/Issued By: YOJe/o/gtion: 3 GOLDFINCH DR C / VF flO DAVID TT ,LOCAL BUI ING INSPECTOR All work shall comply with 780 CMR 8r"Ed.(MGL Chap.143)and any other applicable Mass.Laws or Codes and plans on file. SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED. UPON COMPLETION OF WORK,FINAL INSPECTION IS REQUIRED. THIS PERMIT WILL EXPIRE PER 780 CMR 5111.8(NOT MORE THAN 3 EXTENSIONS WILL BE GRANTED)OR ON ISSUANCE OF A REGULAR OCCUPANCY PERMIT. I hereby certify that the proposed work is authorized by the owner of record and I have been authorized by the owner to make this application as his agent and to receive this permit, I further understand other agencies may have reason to STOP WORK if items under their jurisdiction are not met; not withstanding the issuance of this Build ngg/Zoning Per .} t. Signature of Owner/Agent: k C LA "Persons contracting with unregistered contractors do not have access to the guaranty fund(as set forth in MGL c.142A)" Inspector of Inspector of D.P.W.Inspector Building Inspector Inspector of Gas Fire Department Plumbing Wiring Water Service#: Footings: Underground: Oil: Underground: Service: Foundation: Rough: Smoke: Rough: Rough: Sewer Service#: Rough Frame: Insulation: Final: Final: Final: Cross Connection Final: Final: Treasury: Board of Health E-911 Additional Comments: Planning Board Prior to issuance of Certificate of Occupancy/Completion,this card must be returned to the Building Department with all necessary inspections signed off. Department phone numbers are listed on the white"Required Inspections"document provided with the issuance of the building permit. POST CARD SO IT IS VISIBLE FROM THE STREET 0 TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT 66152 PHONE 508-910.1820 FAX:-5087910-1838 f L-- V a l 'a. €. /`r. ! .. - c-- Name: , / wn�: l u "/� Date.F Job Location: *,,.,./ /' -�`L / i //i r if (ie "' Map v Lo) f ' P Description General Ledger#'s Ref. # , Amount Building & Building Misc. 01000-44105 i/ 1 ,,,; A ;`_,, l 1 Electrical 01000-44Qli'vN OF DARTMOUTHPlumbing & Gas 01000-44IGGMLL CTOR'S OFFICE Trench Safety 01000-44129 PR j j 2012 Other Department Revenue 01000-42420 y White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By f ‘'i...,1 THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS 0 TOWN OF DAR j _• I r , . t:1 ENT RECEIPT 6 NS V 31 PHO r- tr'-91 - F,. 1 .lr ei / r Name: 7 r'r;i, r > Property Owner: ,;!:;:; C. Date: Cifil/5 i/c' Job Location: _> ( 2 ,/ 7 % i,/ ( 11'' Map: V Lot - '7' Description General Ledger#'s Ref. # Amount Building& Building Misc. 01000-44105 ,fT GP D� S Electrical 01000-44106 COLLECTO ►�/1°UTH R'S C�FFICC Plumbing & Gas 01000-44107 APR 052017 Trench Safety 01000-44129 Other Depaitinent Revenue 01000-42420 White-Collectors Office Yellow Co }'/�py-Customer's Receipt Pink Copy-Hmlding Deptsncnt Received By ✓-.-p��i .r/yi-,� j(,.4,}''„._._. THIS IS NOT A PERMITILICENSE FOR BUILDING,ELECTRICAL, PLUMBING OR;GAS RESIDENTIAL ❑ Phased Approval(R106.3.3) �y`'C� S25.00 APPLICATION FEE IS NON RE-FDNDABLE & 1T1F LE 1: �n'?` ' `DA-ECEIVED PBm +\ DARTMOUTH BUILDING DEPARTMENT � "` mil 81 56 Ic >r r}11 sI 400 Slocum Road, P.O. Box 79399 mi. APR -5 3 - �1 Dartmouth, MA 02747 ,....1.2fiy,%� Phone: 508-910-1820 Fax: 508-910-1838 www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY: �b /L/�i�,LI .— BUILDING PERMIT NUMBEP4 . DATE=.ISSUED:' ppaayy SIGNATUREuK } DATE ' APR 0 01L `>,' ;s Building Commissloner/Inspector.of Buildings „a ° .: fair' Zoning District .S proposed Use. Zone: l B ❑A 0 V . "Aquifer Zone: ) THE FOLLOWING A NC ( , JIg & ❑Board of oard of ons. ❑D El DPW 0 Elec. ❑Energy Report. Appeals -,Health Commission (davit Card Sent: - . Cut Off Follow-up* 0 Fire ` 0 Gas 0 Planning ❑Sewer Card 0 Water Card U Zoning' 0 Other Chief "Cut Off Board ,CUE Off Cut Off *REQUIRES INSPECTOR'S REVIEW:BEFORE THE ISSUANCE OFA PERMIT. ' DEPARTMENTAL:APPROVAL �o ; ard of Health: Olt._ Signature: 3 ///�,,�� na Date: Sonservation CommissionWt Signature: � ���f l _____ice_ Date: v Other: Signature: Date: Signature: Date: Signature: k Date: Brief description of work being performed: Oue c -ehLL'S(lam O /at.2 S3in SECTION�1=;„SITE.INFORMATION u 1 1.1 Property Address:s�/ J &oC 1b I r cµ (JR. ./JMou rl/ .4'9 1.2 Assessors Map&Lot Number: ��'tt c Lot Area(sf.) /5 io2 q Frontage ag3- Li i Map r.� Lot 0G - 00 Required Provided Front Yard Ye _ 1.3 Historical District ❑Yes €3'Nc Side Yard y Year Built /995 Rear Yard ❑Altering more than 25% per side of building 1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposa System: Has application been s:;.t.a.d to the Historic Commission? ❑ Municipal I riivate Well ❑ Municipal iskiin Site Disposal System ❑Yes Date: Revised 10/11 0 CONSTRUCTION PLANS ❑ SITE PLAN 0 ENERGY REPORT Cerit(- 77Y- qa2dA- FCC 69) RESIDENTIAL SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner Record: (Sd ) -3-Rae7 /-1 bj 3 6.4bribzw 17070e,q77/77/20,77 Name(print) Contact Address Phone Number 2.2 Authorized Agent: • Name(print) Contact Address Phone Number . , SECTION 3-CONSTRUCTION SERVICES_ 3.1 Licensed Construction Supervisor/Specialty License: License Number: Company Name/Contractor Name: Address: Expiration Date: Signature: Telephone: 3.2 Homeowner Exemption-One&Two Family Only Section 110.R5.1.3.1 Exception: FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section;provides that if a Homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor. For the purposes of this section only,a"Homeowner-is defined as follows: 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 dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a Homeowner. If you are applying under this section sign below: Signature: atioklaite. SECTION 4-WORKER'S COMPENSATION INSURANCE AFFIDAVIT(IVIGL c 152§25) _ Worker's 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. Signed Affidavit Attached: El Yes 0 No SECTION 5 7 DESCRIPTION OF PROPOSED-WORK(Check all aPplicable) O Deck 0 Pool 0 Repairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove 0 New Construction"' 0 Accessory Bldg. 0 Roofing/Siding ipefirt<ier (Energy report required) (Shed/Garage) (Specify below) Cato 6)(CT/iw.; otL (33770 El Addition 0 Replacement window/door soff6P-'76b o Demolition (Energy report required) No. of windows Doors CO/I663a (Specify below) *If new construction, please complete the following: Single Family: No. of Bedrooms No.of Baths Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1 No of Bedrooms Unit 2 No.of Baths Unit 2 o Fumace(hot air)-fuel gas(natural or propane),fuel oil,electricity,other(specify): 0 Boiler(heating)-fuel gas(natural or propane),fuel oil,electricity,other(specify): o HVAC(combined unit)-primary fuel,natural gas,propane,electricity,other(specify): :?tir6ioning-(separate unit) one of the above to be provided 0 Hot Water Gas Electric Fuel Oil Other SECTION 6-ESTIMATED CONSTRUCTION COST . Item Estimated Cost($)to be completed by permit applicant 1. Building a..),SC,X) 2. Electrical 3 Plumbing 4. Mechanical (HVAC) 5. Total=(1 +2+3+4) SO() SECTION 7A*.-OWNER AUTHORIZATION (to be completed when owners agent or contractor applies for building permit) (Please Print) , 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. Signature of Owner Date SECTION 78 OWNER/AUTHORIZED AGENT DECLARATION, <J- r ilk)(P(N)t5PLE L-642,N3 A-NI DeS as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. if-e6r0.44d,( Fra4.0,1.0frin e‘--46 L3/426/v20 Signature of Owner/Authorized Agent Date SECTION 8-OFFICE/INSPECTOR'S NOTES Less Application Fee: $25.00 Remaining Balance: $ SO — Total Permit Fee: $ Other$Amount$ Gross Area-New Construction total sq. ft. Gross Area-Alteration total sq. ft. S Permit Issued to: ecy2.0,5 rierzer— nvice_s /9-77 0/e2g,4--(9-4.-t SECTION 9-ADDITIONALCOMMENTS/SKETCHES Locaton of Debris Remove! par MGL 0.40 Sec.54 e4 77er-C-46-b Zcc1oU XcJtJcr ()lee ?:es-7-Tc 73 Jo' .07% 1/7/4/ 2_ - 6(2/ CA/R) &Li-0 tx_ )ermit No. BP-66081 Project Location: 3 GOLDFINCH DR Commonwealth of Massachusetts TOWN OF DARTMOUTH M P#` 0066.00 400 Slocum Road, Dartmouth,MA 02747 Lot: 0002 Phone: (508) 910-1820 • Fax: (508)910-1838 Sublot: 0082 CategBUILDING PERMIT Project#: ,TS--2O012_002021 FIELD INSPECTION Fee Est. $$7500000 Const.Class: Use Group: R3 Contractor. License: Phone#: Lot Size(sq. ft.) 45124 Zoning: SRB' Engineer License. Phone# Aquifer Zone: N/A Applicant Phone#: Flood,Zone: ZONE X ALEXANDRE FERNANDES (508)995-3928 New Const.: N/A OWNER: : Alt..Const.: N/A FERNANDES ALEXAN DATE ISSUED: ll TO PERFORM THE FOLLOWING WORK: Construct roof over existing patio PER PLAN DATE TIME TYPE OF INSPECTION&REMARKS INITIAL J S-/?-/2,360 & Fat,,Oo i lam L J O /S 1 Z 3/6 bun ems- ��2,t—� yr O/_ kl3 J //;z 2L 27_55 //10 6/c r RESIDENTIAL ❑ Phased Approv� �_S f, ticpT • $25.00 APPLICATION FEE IS NON rFUNWAHICE &` -TRANSFERABLE �o-,�µou—°ri DARTMOUTH BUILDING D P Tl NjS Q�1 9' a$ DATE RECEIVED ' n� I; ��;. 400 Slocum Road, P.O. Box 7 .:99 l �� %,r Dartmouth, MA 02747 �`,54, ! Phone: 508-910-1820 Fax: 508-910-1838 www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY -5-- e1 fiy-lir"' (`.1, � BUILDING PERMIT NUMBS mr SIGNATURE: z DA A'_ `4 ' . Building'Commissioner/Inspector of Buildings Zoning District Proposed Use. Zone:., X 6 B, ❑A V Aquifer Zone: `THE FOLLOWING AGENCIES SHOULD BE NOTIFIED O Board of oard of - ons., O Demo 0 DPW = - 0 sec, -0 Energy Report Appeals ��.Health , CO,rdtinssfon Affidavit Cary Sent attic* Follow-up'- C.Fire- 'CI Gas ❑Planning -b Sewer Card I7 Water Card 0 Zoning ''�'-0 Other Chief - -Cut Off Board Cut Off "Cut Off 'REQUIRES INSPECTORS.REVIEW BEFORE THE ISSUANCE OF A PERMIT. . . - DEPARTMENTAL APPROVAL' vi/Board of Health: Signature: Date: iveonservation Commission: Signature: . / 2 �/ Date: Y--f-/2-- Other: Signature: Date: Signature: Date: Signature: Date: Brief description of work being performed: (‘cc, cps c --\(c ( Pscr- ��1/4'r‘ _ _ - /� f� T SECTIdN 1 -_SITE INFORMATION - --- - '�f , , 1.1 Property Address: 3 GOLb f I riC H- I6R. b4er//'Ia)7W ,419 1.2 Assessors Map&Lot Number Lot Area(sf.) US ic2 q Frontage (M3. y i Map C/ Lot 02 - rF02 Required Provided Front Yard I© _ 1.3 Historical District ❑Yes €tit Side Yard l- Year Built i q r [] Rear Yard 0 Altering more than 25% per side of building 1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: Has application beensubmitted to the Historic Commission? ❑ Municipal vate Well 0 Municipal -'d Site Disposal System 0 Yes .Pd6te Date: Revised 10/11 ❑ CONSTRUCTION PLANS 0 SITE PLAN ❑ ENERGY REPORT a ji I ( ' S310N 1H213N30 NOLLOfZLLSNO0 I I 0 I1 11 rolruesbunpipayo _ I IaNb' NI .lO1d I I . f G n { I I s �"s. I VW 'HLnomaYO 13NV1 HONI.JO100 £ 1 '4 . : • VAIV±VSVW I L_ I J ,gyp j IE 531g11 ��o i 5eosx�L AcIONVO SadNVNElad 1 o Ii I Q sl I� j I If O. m `j 1) Q f 0 Lyj a 11 ? 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Box 79399 2117 APR -5 AM 9: 08 % ci Dartmouth, MA 02747 `� s>Y� Phone: 508-910-1820 Fax: 508-910-1838 www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY 1 � 1 BUILDING PERMIT NUMBE ,7 TEISSUED r SIGNATURE Buildin Commissioner/Insector of Buildings �. 9 ti p Zoning District -'Proposed Use Zone: .`O X 0 B Q A PS/ Aquifer Zone: a THE FOLLOWING AGENCIES SHOULD BE NOTIFIED . 0 Board - oard of ons= _ 0 Demo ? _ Cf,DPW t:0 Elec. 0 Energy Rdport Appeals _Health ' '-. Commission i-Affidavit CardSent - Cut Off Followup ❑Fare -`; Q`'Gas ❑Planning € `17-Sewer Card- '" ❑Water Card :O Zoning �~ 6 Other� Chief' aCutOtt Board, utOf .;,CutOff .*-REQUIRES i INSPECTOR'S REVIEW'BEFORE THE`ISSUANCE"OF A PERMIT. DEPARTMENTAL AxxPPROVAI �oard of Health: Signature: A 1') Date: A •S .2.012— conservation Commission: Signature: Date: Other: Signature: Date: Signature: Date: Signature: Date: Brief description of work being performed: f f W` I --9 l 5-t t n O\ (n Q.,i-�� c, ,..,,,.,,,,:..„,„:„.::::„'7•;''''.:1;'W" -±t'--V71: V:, 1,1,;'-'.:::'_';:':-.T:::i ': j':'-::;:.'SECTION 1 -SITE INFORMATHA . _ ,_ 1.1 Property Address: 3 C'oLb t I(4Cµ OR, Ageriwo0 r7/ ' '4 1.2 Assessors Map&Lot Number: Lot Area(sf.) UC l' ti Frontage ?S'.3- H I Map 66. Lot 02 - �r� Required Provided Front Yard SiQ — 1.3 Historical Districtt (3 €3'IV Yes o Side Yard �.S Year Built . ;c! 9 Rear Yard 9A 0 Altering more than 25% per side of building 1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: Has application been submitted to the Historic Commission? ❑ Municipalvate Well 0 Municipal ®'On Site Disposal System ElYes LU.Pdb/ Date: Revised 10/11 ❑ CONSTRUCTION PLANS 0 SITE PLAN 0 ENERGY REPORT 1 S310N 1V2l31\130 N01101181SN00 I� i c0Lllas EuRieap ovo ; Q N b N b —I d 1 O l d, �i �� (5* 1YIN 'H1f10W12fVO '3NV1 HONI301OD fdh €��aez ( IAdONt/O S3aNb'NlJ3d o Ii i S310N j 31YQ SN06N31i J Zm 4' O W O cto o ZE x ^� Et V. 1l 2 v) Z Li W > U z U •: y o� 1- 0 Q Z t4 Z O 30 3nll�4 a�iaoNos = Z? z o Q CIit Z- z ",o Qz 000 0 0 C ? ino m )' oy 'o 0w mw � " c I CO ° ¢ o z mY o �= oUZ /--' v=i m � 03 3- 11') Q 3Q WM �W CC �- G Cl- a iaj �> I ,I I pla 0 N //�� 0 0 un W-+ (n O W N W 2 Q. Q. O a. 03 UO Op WOtlO- O3F m ¢ 2 COw -1 ti,2 �U tiZ act � h CO ¢ ¢O U^ U fn F- V) W Z Z U W Q p V)Q 1 W� Z O O¢ OQ OW WQ tc ¢ O 3 Kti ox x ^J^ � �0 00 ~ EizLij m)-cc ro En --.IRw W • LL 'Y' Z W w o a U W J p p 0 3 G O I- 0 CO 0I � 22 33 Z 2�0 OQW o22 WO O to O O L- �fn 4 m �. W � 1- ` p O N U a� • Ni v PPS o o } ` 0 io U 1 q3 �V\U< 2 la- W m z I�r A \, 2 CI-W Z� 1itnC C90 o n o ow awl a En v) co N (/' 2 1- Cc co En W 0 V1 X Z N W v K ¢1'� W¢ QdZ �3 1 v. �W� O� ZWO ¢W I Q' N JV� Zti 3�U U Z > 2 �cn wOOW ccW 2-+� 0 ='O NZ pUNW 3p Lug¢ ¢ W ~ 0 Wcs akdIWU et �2� z �j �� �� U¢�0 WZ ¢U� U �'i p0 ��ZU yW 03, a j CtI: II WWf+ Q '' tyj -4 Z000 `CZ $2¢ k ' fwn 3 W 1 3 0� �U WOU O Lu¢ -sfnU j W O 2 �'- ��1z3� 'cc WO mom ¢ z >¢zo a?y- zLiO 03 o 1. V3 { w ti-p OOQz b_a zoWz W Vwi o it O0 8 W WRW¢ W� 2 W W 2 ma ma W� mO 2W�� m2 ZO mZ 3 ~ ay 000¢o aq W¢WpQ ¢ O J 00 O Z wo Wp3W W¢ "Q•- in t 2a ¢ W¢ Q it I:: ��00 KQ>- Cl tin. CC¢ H cn Z12 2N U, ¢0 y2rj CC -.Lt.CO W OZ V1 0 Z2 ZXO� z�m ,v2W O� 3 v) z ZO > tuts W 2U W¢ I� OU OWWW 002 09�� ti� ¢ ti° 0 The Commonwealth of Massachusetts Department of Industrial Accidents ' _ Office of Investigations 600 Washington Street t? Boston, MA 02111 •-7 �<-r www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Infformation �/ /� Please Print Legibly Name (Business/Organization/Individual): /ALE-/,9"v b2 6 FER,v, A.)� Address: 3 Cot b Fltvt<ft- b City/State/Zip: R 7- ii e-f IQII 6)7V7Phone #: (SOF 9 S 707 Are you an employer? Check the.appropriate box: Type of oject(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ew construction employees (full and/or part-time).* have hired the sub-contractors 2.El 4 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. [1Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* r fired.] 5. ❑ We are a corporation and its 10.n Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11.n Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks b us o fop ' below showing their workers'compensation policy information. t Homeowners who submit ' 'Tay di�t�} ing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this b _-rtb%tz aghe ad additional( eet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contras orshave employees,they must provide their workers'comp.policy number. 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.#: Expiration Date: Job Site Address: i v/�Gtp�it c%r City/State/Zip: NI 4(si� (T77`7.7 Attach a copy of the worker ' compensation policy declaration page(showing the poi' tuber 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 ofthe DIA for insurance coverage verification. I do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct. Sitnatur,�. a4,46 �f O.�ltir,%nrez— Date: $/6/« 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#: 4 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 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 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)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 burn 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 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 Revised 4-24-07 www.mass.gov/dia .. a 0 a N-0 rn cr a m r ' '4 4 a 0 cl to y. o • v 3 a o a0 N°b o > y ccz em o 2 2 my i cne ti x az 3 z .. o eo or tt 17 r r b r t.,- 3 o 'r' 7 O to m a to O °,x �21. w so n pz 0 0 el in 3 C x �p y 3 zx a , y n,N b rill m ti C cn .i.i 0 : a a a0 W �01p a�M .: - �' �7 O a x CO N p 47 3o oe 4 Kx °zti5 y c > c O ' Oti y . 0zz;' Z y 2 cnn «� cox n mn o p Oo . w b oob "Ct Zrn ,.f c a A o _ EF,r ET O m n n o A -' a n {y� a b a` e • n e o E. o FL w .`�, o, �A. tz M c O A to N g' to: c: �i ��3} �lc�y�, O N r Co r' C A " O *'1. C. �'k. jtil A Vwi to a 1 n Yi r+N ti • x n ] h, . 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