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BP-59574 Permit No, BP 59574 : : BUILDING PERMIT ` GISW gS t— l33aoo .� , ° Corr�r6ltnWeaI.th of"IVIassachipsefts • -- - s Map sfP-'''-�"i� °0066 4 r�-,, . �. er^ ' - - - x Ma ' 02r ". � � .e '` ' TOWN O1rDARTMOUTH`i' z m - "L. T:ot ' n H.' 00 3 z f' Fp ..er —p tt- - ,�. g� ,� 400 Slocum Raada�artmopth,MA 02747 ,� � F Sub Lot•1"--e�"r 't0i3J.a� t'�-Ar �(-`k'* �f'`° s. "" z - _ y ,tiPho`ne (,508)91,0 1820 • Fa'z+ 5 8)9i0 1 38 +` •Categor iag a"+1',` rslUl'�-,'>u-s' �°'a".u' r :;" z.Tt4 e - X a�� ry '. st 4, t k ,. - �Proj ctt aymeI.; s4.0j6-001811 --- PERMISSIONISHEREBYGR9NTEDTO: .` {{``' 'lEst.Cost t- �< $39000Q_ ' ''r` ,c `� . # x / i-= zy .� • - '• TEA ` Eta . a Fee w - '" 't $7500� ''`-€-"rz` t'' Contractor ' `,3y „�`'a,� .. -1,"' . ,-�, .ConstE lass Ita, a n f r �;} ;, „Ereenseg ,h\- : Ph ne#* "f f II6o�G�coiritt ') ,:. ttT?Ifi� i r,"`k'".xwi '1" Engineer r .',. "3`,k,`; h<' y, ccense^ $"Phone# a;`� g1,gtSize(sq'j ft)'�'41000 �.es"a."rlS ne- .�,. g x„ ,.{ f 1m - Zowag ;= 3 SRt ' '� '"fdr z . �z'4 i rmn ` t. ,s >m kY Applicant a vz*'�,rw c �� Phone l�j;"{4 Agmfelit; oriel iN/A x s ry� - a CHRISTOPHER�1)BOGIE � t � � :�- tIctid ne io Cn 5.x � 2 krr' - .- :-.1 995-8660 x ' �� � ,a7Ayx,�+ ' OWNER: r 4� i� :.:x P,.rTy.� � • ,fic Al1.� ,IN w;C,aotts�' 4. 192;s`g ftt � gliei LSO. BOGIE CHRISTOIIHER t,� + s '.., rAIE Cg find P" (,1�li `�'`,�Cslcs'r 1� .DATE ISSUED. '-.1 '�". V' _ . . ''�e�? s' '' X'2 `,�e, TDate Typtt'a+� J.,°6' 042120`10�1'` i as— . - "# ." -a. ;- '� 5.s .1• '.bi z - - g TO PERFORM THE FOLLOWING WORK: " -"�'" '" c ter »'' - _ Constnlct a''12'x 16' shed PER PLAN ro�ect Loc on. 3 WREN LN Approved/issued By: -_ ;tDAYID BRUNETTE,LOCAL BUII.DING INSPECTOR _ All work shall comply with 780 CMR 7"'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 r WILL EXPIRE PER 780 CMR 5110 9(NOT,MORE THAN 3 EXTENSIONS WILL BE GRANTED)OR ON ISSUANCE OE A REGULAR`OCCUPANCY <` I hereby certify that the proposed work is authorized by the owner of record and I have been authorized by the ownerto make this application as his agent and tu,recetye.this-permit, Ifurther and 'stand other agencies may have reason-to STOP WORK if items under their inrisdiction are not met;not withstanding the issuance of this Budding/ n g Permit - Signature of Owner/Agent � Comments PERMIT NUMBER IS REQUIREQ WHENREQUESTING INSPECTIONS/RE=INSPECTION FEES MUST BE PAID BEFORE RECEIVING ANOTHER INSPECTION/REPLACEMENT FEE WILL BE RE - _ ,.. .,�. .. :� ... QUIItED;OFLOST�CARl) � =�_ - "Persons contracting with unregistered contractors do hot have access to the guaranty fund(as set forth in MGL c.142A)" Inspector ofa :Inspector of ' DPW Inspector': Building Inspector Inspector of Gas'. Fire:Department -'.Plumbing:,'. :Wiring �', , _ - <- _Water Service# - Footiggs: - - - Underground: Oil - Underground: Service: - . — _ - - _ Foundation•- - . .. _ _ - - Rough Rough: Sewer Service#: Rough Frame:. - Rough , _ .. Smoke: - Insulation';' ' Final - - • Cross Connection Final• Final• - - - - _ _ _ _ _ __ - - - Additional Comu_ients Planning Board _ - -, -- Prior to issuance of Certificate of Occupancy/Completion this card must be-returned to the Building Department with all necessary ,- inspections signed oft 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 - TOWNCIF DARTMOUTH ', y BUILDING RECE ' PHONE: 508-910-1820 FAX: -18TAX 1 i ! a ,. i 4 ti L. Name: '''1 Property 'Date / " / l i i1 Job Location: i �) White Copy-Collector's Office ') +U j i% /ref i.. % Yellow Copy-Customer's Receipt i t_.''-".' Pink Cop y-File Copy Map: r Lot. / Green Copy-Building Department &iMi ''''' . / i / Phone: ` i Description General Ledger#'s 7(e # _,. Amount License & Permits - Building 01000-44105 p License &Permits - Building Misc. 01000-44105 " License & Permits - Electrical 01000-44106 ---f License & Permits -Plumbing & Gas 01000-44107 License & Permits - Trench Safety 01000-44129 Other Department Revenue 01000-42420 » \ \ ' THIS IS NOT A PERMIT OR LICENSE FOR BUILDING, PLUMBING OR GAS Received By.-<A ,,'vr7:'7,- itj 71-(.42, RESIDENTIAL 0 FOUNDATION ONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE & NO FERABLE �i<` * w ` DARTMOUTH BUILDING DEPARTMENT DART -'E[v, T / " a° -. w - 1 400 Slocum Road, P.O. Box 79399 2010 APR - I All 11: 38 ��ry);,('iy Dartmouth, MA 02747 508-910-1820 FAX 508-910-1838 API'LICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A.ONE OR TWO FAMILY DWELLING THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY: 'SCALDING LDING PERMIT DATE SENT FOR'REVIEW: �' inn NUMBER: .51 v PATE ISSUEDt 5 1 OK TO ISSUE-SIGNATURE. • ,,,,, R.:,•. ` � .DATEAPR ' S 20t9 Rudd, ,c, Zoning DistrieSk.d Proposed Use: is Zone: Pa'C 0 B 0 A 0 V Outside rI 1 quifer Zone �b THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: ❑Board of 0 Board of OCon.Corn. ' ❑'Demo 0 DPW 0 Eke. 0 Energy Report Appeals Health Affidavit Card Sent: Cut Off Follow-up* ❑Fire 0 Gas ❑Planning 0 Sewer Card 0 Water Card 0 ❑Other PI Chief Cut Off Board* /Cut Off /Cut Off Zoning *REQUIRES INSPECTOR'S REVIEW BEFORE TILE ISSUANCE OF A PERMIT. DE/PARRT%1 ENTAL APPROVAL Zoning Review: Signaune: «y> � ,_Date:-- 13 2010 Energy Report: Signature: __._.___ __-Date: ______. Fire Chief: Signature:_,_ Date: Board of Health: Signature:_ ___Pate:_,_______ .I Conservation Commission: Signature: Date: -- -- Other: Signature: __ Date:_,_ ___ Description of work being performed: -i.Z, >1 (G` SL.P _—____ '; SECTION I-SITE INFORMATION-, - - NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑yes ❑ no 3 t,)SLEuu LPdue 1.2 Assessors Map& Lot Number: 1.1 Property Address: N,bpQTMokISbtt M( - 011 {7 Map Lot -1-31_Nearest Cross Street: 6DN4$1R2.0 1A iE Subdivision Name: 5oN ie_D IACQ.r..5 _ 1.3 historical District ❑ yes ❑ no Total Land Area Sq.Ft.: Has application been submitted to the Historic Commission? r _ .".. I AC-O.0 ❑yes ❑ no Date: 1.4 Water Supply(MGL c 40 § 54): (pt. ` . 1.5 Sewage Disposal System: 1 1L C bidg.4mnsWIdgapp.res:and Page 1 ROE.January 2005 - RESIDENTIAL • sr.nroN 2-PROPRRTY OWNERSArP/AttTHORI7P,n-AGENT 2.1 Owner of Record: T �j Wi!•EN (-p&E soe.- aNRIST �f2 oPN V• b0(21E +‘) 'C)F1Qlmo,T.It. MA 03147 195-1466O Name(print) Contact Address Phone Number 2.2 Authorized Agent: Name(print) Contact Address Phone Number SECTION:$-CONSTRUCTION SERVIEES - 3.1 Licensed Construction Supervisor: Not Applicable❑ Licensed Construction Supervisor License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor: Not Applicable❑ Are you a Home Improvement Contractor subject to(780 CMR-6)? ❑ yes ❑ no If no, go to the next section! Are you claiming exemption from the requirement? 0 yes ❑no If yes, submit the required affidavit! Company Name Registration Number(if none, state"none") Address Signature Telephone Expiration Date 3.3 For Residential Remodel Work Only PERSONS CONTRACCING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: QUESTIONS OR COMPLAINTS call or write: Home Improvement Contractors Registration, One Ashburton Place-Room 1301, Boston, MA 02108, (617) 727.8598 O tiers Name( ' �t)) �] ('Jt -tsTopa1LcL 1). t0G1C Signature � '"-"'r"'Y','.r_. �• (���(,�T�Qp� y'11,{`O by signing the above,the home owner acknowledges that there will be no eligibilty to the Guaranty Fund Date 3.4 Homeowner Exemption -One&Two Family Only FOR HOsIFO W SERS WI1D INTEND TO PERFOR,\I AND BE RESI'ONSIRLF FOR Ti IEtR OWN 1'Renn 109.1.1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section t 16.0,etketi se July I, 1952,no individual shall be engaged in directly supervising persons engaged in construction,reconstmcnon,alteration,repair.removal or demolition involving the structural elements orbuildings or structures,unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction Supervisors. Exception: Any Homeowner pertbmdng work for which a Building Pcnnit 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: Persons)who owns a parcel ofland 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 Cann structures. A person who constructs more than one home in a two-year period shall not be considered a Homeowner, ilsf you are appl, n•t )derthis section s besiy y: o ature: •,2qi •Jh!-J(rp��p __ Your signature carries cc am responsibilities,including bun not necessarily limited to,general liability C:tbldg.formsBldeapp.res wpd Page 2 Rev.January 2005 RESIDENTIAL NOTICE TO LICENSED coNTRAcroRs: The Building Code provides in the Rules and Regulations section that any licensed Construction Supervisor,whether or not they have taken the permit arc responsible for code compliance. (see Appendix of 780 CMR R5.2.15) • SECTION 4-:WORKER'S COMPENSATIO'4 INSURANCE AFFIDAVIT(MGL C 152§25) 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. Signed Affidavit Attached: ❑yes ❑ n 0 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all,applicable) ❑ new construction* ❑ addition ❑ alteration ❑ repairs 0 chimney/ ❑ woodstove (energy report required) (energy report required) fireplace ❑ deck ❑ pool Nireessory bldg. ❑ replacement window door ❑other ❑demolition (shed/garage) no. of windows_ doors_ (specify below): (specify below): * If new construction, please complete the following: Single Family: no. of bedrooms no. of baths Two Family: no. of bedrooms unit I no. of baths unit I no. of bedrooms unit 2 no. of baths unit 2 o Furnace(hot air) - fuel gas(natural or propane), fuel oil, electricity,other(specify):____ _ —_...__., • Boiler(heating)- fuel gas(natural or propane), fuel oil, electricity, other(specify): ❑ HVAC (combined unit)-primary fuel,natural gas, propane, electricity,other(specify):_____ _ • Air conditioning-(separate unit) ❑ None of the above to be provided G Hot Water: Gas Electric Fuel Oil Other • Brief Description of Proposed Work: c„./1 /7 C Hot S75e cC SECTION-6 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(S) to be completed by permit applicant Buildiw' 2. Electrical 3. Plumbinu 4. Mechanical (HVAC) 5. Total =(I ! 2 -1 3 4) *Estimated Total $ 7, 5 00 SECTION 7A-OWIN ER'AUTHORIZ,ATION (to be completed when otiner's agent or contractor applies for building permit) (plea" rint) �/� I R lS[OP k !/r761 E ,as Owner of the subject property hereby authorize I-ATla(,EE N 061E to act on inv behal it atters relativ t work authorized by this building permit application. k590u5e • (/c) Signature of Onu Date SECTION 7B-OWNER/AUTRORI7F.D AGENT DECLARATIOY }>` �1 R.iS1OQr{YC. '&61t , 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 lei r the pains and penalties of perjury. v E t t 0▪ Signature of Owner/Authorized __... _.- ate C:bldg.G,rmslBldeapp.res.upd Page 3 Rev.January 2005 RESIDENTIAL SECTION 8 INSPECTOR'S REVIEW/COMMENTS I. Date plan reviewed: APR 1 5 2010 , 2. DENIED(see project review --- -- worksheet): --_ Date: 3. HOLD reason: lT�_4--(- -- _— ___..----- Date: 4. HOLD subject to Zoning Board of Appeals action: Date: Commentls: Inspector's Signature: ,th/1DAPR 1 5 2010 ,UN '- . LICANT NOTIFICATION ^_ —_— Applicant infer 1 of abo .e i �e : /1) ins Clerk Comments:_ 10 0 Ama, _ � . _._. J J SECTION.10-OFFICE)TN PECTO 'S NOjI]fr!- C 2 Total Permit Fee: S ___ .- is s - Less Application Fee: S .00 Remaining Balance: _ TOTAL PEE: Gross Area -New Construction total sq. ft /%Z Gross Area- Alteration total sq. ft. Permit Issued To. / Lgsr,',u,c r -- /.294/6 1/"- ¢-14-4.2-.-- ,p,- 4-1P "I SECTION 11-ADDITIONALtCOMMENTS/SKETCI►ES • C_-Lldg.furmsf3tdgapp.res--pd I'age 4 Re,. January 2005 'ermit No. BP-59574 Project Location: 3 WREN LN Commonwealth of Massachusetts TOWN OF DARTMOUTH G P# 334500 400 Slocum Road,Dartmouth,MA 02747 Lot: D002 Phone:(508)910-1820 • Fax: (508)910-1838 Sublot: 0131 BUILDING PERMIT Cory: SHE 0-001811 FIELD INSPECTION Est.Cost: $7500° Const.Class:'.. Use Group: U '' Contractor License. Phone#: Lot Size(sq.ft.) 41000 Engineer: License: Phone#: Zoning: . SRB' Aquifer Zone: N/A Applicant: Phone#: Flood Zone: ZONE C CHRISTOPHER D BOGIE (508) 995-8660 New Const.: 192 sq.ft. OWNER: Alt.Const.: N/A BOGIE CHRISTOPHER D DATE ISSUED: 5 7//a TO PERFORM THE FOLLOWING WOR1 M D II 1 Construct a 12' x 16' shed PER PLAN (Le, !s 1T[�[ DATE TIME TYPE OF INSPECTION&REMARKS INITIAL //7-- RESIDENTIAL - 0 0 FOLINDATION ONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE & NDN,a,'���OT4FERABLE n ��r ,ttf`nnx. E`L �LI-Y,I4v T. r;% '''a;A DARTMOUTH BUILDING DEPARTMENTis f / ' -'1v A) 400 Slocum Road, P.O. Box 79399 2010 APR - I AM II: 38 o.,� � Dartmouth, MA 02747 F \,'.: _� 508-910-1820 F:UY 508-910-1838 a 74 APPI.ICATIO F'rO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR Two FAMILY DFVELTdNG. TftIS SECTION FOR OFFICIAL U?SELONLY. - RECEIVED BY: ut / O 1 BUILDING PERVCIT DATC,SENTFORRLVEC4i'. - /O ..i k IJW3ER:` 5 g1 DATE'ISSUED. O . TOISSLE-SIGNATURE a DtTE PR 1 5 20 ' Bmldmg scsal - - Zoning Districf• r�% Propaied Use: / Zone C' ❑ B ❑:1 0 Y` ' Outsrde FI tY qu_ Zone - THE FOLLOWING AGENCIES SHOULD BE NOTIFIED ❑Board of ❑Board of ❑Con.Coin ❑Demo ❑ DPW - ❑LIce. ❑EnergyReport - Appeals He�tth - 4ffidwit; , Card Sent Cut Off Fallow ug" ❑Fire CI Gas ❑Pluming '- ❑Sewer:Card 0 Water Card ❑ ❑Other Ch - :Cut Off Board*.; -' /Cut Off /'Cuion'' ' Zoning *''REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF.4PERlYI1T. - DEPARTMENTAL;APPROVAL = - Zoning Review: Signature: trn7c-Z. &/&cZ. __Date: t •; 1 5 ?fl1Ilii Energy Report: Signattre: _�_______,_^ Date: -- Fire Chief Signature:_ Date: 1 Board of Health: Signature: G4'�`/�`r l. Date: •.j = Conservation Commission: Signature: -_____ -.--Date: . Other: Signature: — Date:_ Description of work being performed: _L Z _ (6 __ SIe G— _._._...__.___.__ — SECTION I—BETE INFORMATION NLir1BFf2 OF PLANS SLEtMTTTF,D: SITE PLAN SUBMIT teDt. ❑ yes ID 3 W.QC.r Let 1.2 Assessors Map&Lot Number: 1.1 Property Address: N.QAr2mc3TLtt M 621I ._ Map (00 Lot_ 1. - /.3I Nearest Cross Street: . ''tJ ti}IRO V i LG_` '�� 7T'"" Subdivision Name: 5tsvC22it¢i) AC01-, 1.3 Historical District ❑ yes 0 no Total Land Area Sq.Ft.: Has application been submitted to the Historic Commission? I' 1 ACQ.0 _ ____ ❑yes Otto Datc: ___._ I 1.4 Water Supply(MGL e 40 § 54): 1.5 Sewage Disposal System: C.'.b[crPenns`R dgapp.res.v,pd Page 1 - Rev.January 2005 S • i al Sr ` = 4 IC 3 oar I- __I ,_- __,ii in Es. to CC co to � K U ,Yy ] T � n W x J Z Ct • m N W ini ' F- - v Cr . ' id s In, IP W IL J> n J r U O Z I- D'�t_7C '� N , °" oW n. I— Z O O H A W J Ft Caci • Q J JZLt O / 0IL' ,- rn0 jN 3' jdj / b++i 2NSO Otp ¢ 2 `1citaO O Oi F I IMAOHIB dhm0 W N Litsrs moJin V- O > _�x,UP v a F 1 d s 2 F ^0+ loth rii I ` .01_ \ LLI CI I- E < ' i \ CC Li D m � J isti O CIO > % 63 \\ z clo h 6 O <t- Q �O 0 x _ • _T - c. 51 as n '0� 2 0 �mOCO� um cn mC M CD W0t7OtoCOu • ° ' • a1 rei vi6OC -4) WI/ D Z r 1- re) re) � '(S V �� C�� (n Q QQQ4 1 It.` ( ÷ <,\.0 , the Basic Shed , . RECEIVED t €jARi n, ,.,,, nc FT-PT. '�, cox plywood 2010 APR - I AM II: 43 Shingles . 1x8 Ridge board I. . . • / 15 lb. felt paper • 2x6 Rafters ; ••,.><+-•" :�kk. ISPdgfid, a " Metal Jnp edge ,.,$ 2x4 7 Gable surds ltaPl1t � f1x8 Fascia :\, tiagaSlialalliak' I etillt.f.,:. s. ,mod ,' ., z 'i allit- ice►. 2x4 Double 1 %II +�'NIL ;. �r \ ?r .t. top platei. d % 'ram I I ..0Heads ri:P �1 ri - 11 I• I li 1 .„ , flll 1,11 r I. ail l i.... ..., 1. ., .if LI I I r 2x4 Jill jLJ 'H tj •i ilIi IRough sill `, i t ,. me _ I •, il II l I I 11 I r ,:tiL-4 Li i 1 t ,1 i� i; I �. .I 64i �� 7 . ' is PlywoOc • JJJ .� UiJutg 2x8 End joist bilk‘ IDoor treck • -Tr- Trimmer studs 1P NE N t ► Aoe /100 ,it :cid., i 4Y TBCi COx . I . , 41114 i I • plywood sublloot j Blocking 2x8 Rim joist I i 2x4s . Entry ramp 6x8 Pressure-treated skid 3+lstssn.,derail Presst,e treated turnbut - -- O e a 0 g o 0 o O c> 0 0 '0 0 1 Q o 0 o y o e o 0 o vi0 0 � NM Il) V] VI S R .� Y"Y O. l� +.�. [�V M 'n oc VI o C h N V' O , N iF V y N .Mi M �. a VI .�. M y H O d ` ''''0�/� o o ay N ^ �/1 `y' p '03 r v-iO C ai �` 'V1 �` J 0.'s. M �! O O Q ,�O O O f 4 1 AY: R C F I 0 0 O U o O F� NC. 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E ., O: FF O [z C�aCC q ' F G33 2 ' 33w 'K ' tee 5 , b o CN 4� q 0 1 a e' m y P. o ° w V `o `o `o o w F T m m t X a y v °i . f T O A o $ ie it o o v ss V, 8 U o o o o o 7 `U-' o w U Q CC U DN m it C .1 r - vi Um c m ita' ti✓.5 S. c ,- s' 6 F F1-- 1-- H RLL , -C1A _C.fh14. _i The Commonwealth of Massachusetts Department oflndustrialAccidents �j -t �N Office of Investigations �_ 600 Washington Street `?„, r Boston, MA 02111 Itt _ ,/,•.' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly ' Name (Business/Organization/Individual): .(`.c4La �� .�rJt Address: 3 CUi'24ti ka j(J City/State/Zip: /N , 00-,- ,A-4-(A A Phone#: 5?)6—R 9 c-11p 6 0 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. E Building addition workers' comp. insurance comp. insurance.t equired.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions officers have exercised their 11. Plumbingrepairs or additions 3. I am a homeowner doing all work P 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' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit 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 have employees. If the sub-contractors have 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: t91 f%`'a r f Policy#or Self-ins.Lic.#: t Expiration Date: Job Site Address: ,3 &*'tK- hf City/State/Zip: ,D/lr ib-J`l 4019 (T279"7 Attach a copy of the workers' compensation policy declaration page(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 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 of the DIA for insurance coverage verification. I do hereby ce • under the pan)srg/�7�dpenalties of perjury that the information provided above is true and correct. Signature: i Y vw / ' V Cw Date: V/7/0 Phone#: 5a oa -e__- l' 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#: 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 • Revised 4-24-07 Fax# 617-727-7749 www.mass.gov/dia