BP-54283 Permit No. BP-54283 BUILDING PERMIT :�
CISS#: 3478.00 Co m seachusettn
TOWN OF DARTMOUTH -._
400 Slocum Road,Dartmouth,MA 02747 ,
Sub-Lot 0000 Phone::(508)910-1820 • Fax: (508)910-1838
Category: °TO INSTALL: ,
Project# - JS-2009-000580 PERMISSION IS HEREBY GRANTED TO:
Jst,`Cost — S30000
$75.0(" ' _` ^ ' Contractor: Licenser;' Phone#:= "
Const.Class: STEPHEN W CONTOIS CS-13125 (508)994-4046
Use,Gronn: - R4 ? Engineer. License; Phone#:.
Lot Size(sq.'ft.) 3.21A-
Zoning: SRB `- Applicant. „Sr Phone#:
New ConSL: :- .N/A 'y PHOENIX SHEETMETAL INC (508)994-4046
Alt.Consf: N/A� OIVNER: '
Date Typed: 09-08-2008 - RILEY MICHAEL&,ROBI A RILEY
DATE ISSUED:
TO PERFORM THE FOLLOWING WORK:
Wood stove insert into existing fireplace and line chimney
Project Lion 30(/J/7�//�A,RTMOUTHFARMS TR
Approved/Issued By: J2 ._) ::t nt ' ✓ �� _
DA BRUNETTE,LOCAL BUILbING INSPECTOR
All work shall comply with 780 CMR 7Ta 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 5110.9(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 Building/Zon Permit.
Signature of Owner/Agent: ,
Comments: PERMIT NUMBER IS REQUIRED %11EN REQUESTJNG INSPECTIONS/RE-INSPECTION FEES MUST BE PAID
BEFORE RECEIVING ANOTHER INSPECTIOAI/REPL'ACEMENT FEE WILL BE:REQUIRED OF LOST CARD
"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: -
BoardofHealth E-9Il
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
TOWN OF DARTMOUTH 5 283
��p■'
a BUILDING RECEIPTS
l SU COLLECTOR'S OFFICE
Name: ' i V . ? ` i 1 '!�.,`l, Property At I, Date: c 76f , ✓}..
t t,[., �;�fr ;'r . Owner: -f
ri
Job Location �` ,\
TOWN OF DARTMOMe Copy-Collector's Office
Plot: 7 rrl Lot: -' r01 J FCTQR'S oFFY4tow Copy-Customer's Receipt
v t� _ t j� AUGPink Copy-File Copy
U200t_Green Copy-Building Department
Phone - ate - Oh.. ' /Co2,J
Description General Ledger#'s Ref.# Amount
License&Permits-Building 01000-44105 tk
L
License&Permits-Building Misc. 01000-44105
License&Permits-Electrical 01000-44106
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420 j
-
This is not a Permit or License for Building.Plumbing or Gas Received By: / ,
RESIDENTIAL o Approval in Part(Per 780 CMR.5111.13)
$25.00 APPLICATION FEE IS NON 'If-FUNDABLE.1k;NON-Tf*NSFEIIABLE
DATE-RECEIVED
/�`gUTN DARTMOUTH BUILDING DEPARTMENT
Q N
1 5rr 400 Slocum Road, P.O. Box 79399
- n 0 c,-; 3: 15
`mood YT; Dartmouth, MA 02747
-,1 f 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 ECTION,F/O�R OFFICIAL USE ONLY
RECEIVED BY: �"�JC BUILDING PERMIT N�U�M.�jBER:
DATE SENT FOR REVIEW: �(�d ' DATE ISSUED:��l/f)I►
O.K.TO ISSUE-SIGNATURE: �, -r �'� DATE "
fr
Zoning District:__. SL ; Proposed Use: Zone: 0 ❑ B ❑A ❑V Aquifer Zone Tom_
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: t
❑Board of ❑Board of 0 Cons. = 0 Demo 0 DPW - 0 Elec. ❑Energy Report
Appeals . Health `.Commission Affidavit° Card_ Sent: - Cut Off' Follow up*
0 Fire -r 0 Gas 0 Planning -- 0 Sewer Card ❑-Water Card 0 Zoning ❑Other
Chief but Off Board Cut Off-_. Cut Off -
*REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF APERMIT. ; .-
L
DEPARTMENTAAPPROVAL - -.
Zoning Review: Signature:' ,�[�-9-, 1 .-eif-1-['// Date: ? 7 vl-'-
Energy Report: Signature: Date:
Fire Chief: Signature: Date: 1
j
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Brief description of work being performed: Ly10-pica /ii f_P L-( iv ce_J
1 SECTION�� 1 -SITE INFORMATION
1.1 Property Address: 3(h a.-yIN,(i c. I`M J/_iJ 1.2 Assessors M p& Lot Number:
Lot Area (sf.) Frontage Map Lot 58 -
Required Provided
Front Yard 1.3 Historical District 0 Yes ❑ No
Side Yard _ Has application been submitted to the Historic Commission?
Rear Yard 0 Yes 0 No Date:_
1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Private Well 0 Municipal ❑ On Site Disposal System
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
1
RESIDENTIAL
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner Record:
i
f�iich3P.l 2,ley_ 30 bacicmou+h kafms (ail C5:EYq -ici48
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 .-ec('f QCi1+c\S Not Applicable 0
Licensed Construction Supervisor: \ " License Number: in
131 )
Address:5 v c S �l�X,lr-l-n'ci i-c-h t k oa--4 ..'. j Expiration Date:
Signature: a ��cr �,✓ Telephone: i
3.2 Registere Home Improvement Contractor: / Not Applicable 0
Are you a Home Improvement Contractor subject to(780 CMR.110.R6)? 0 Yes El No
If No, go to the next section!
Are you darning exemption from the requirements? 0 Yes 0 No
If Yes, submit the required affidavit!
Company Name:t'n RA S e-}k �f�(J `/ ( Registration Number(if none, state"none"):
Address: 3r3 C ISM. R , C j X l\( l����� cLi R�yl1:I�� �/f�I�I b,,
Signature: j` }-' —•\ �.�. .Et Telephone:,'D i 41g1'04.0 Expiration Date:
/
3.3 For Residential Remodel Work Only
PERSONS CONTRACTING 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
❑ I am a Homeowner performing all the work myself.
Owners Name (print):
Signature:
By signing the above,the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
Date:
3.4 Homeowner Exemption-One&Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
5108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0,effective July 1,1982,no individual
shall be engaged in directly supervising persons engaged in construction,reconstruction,alteration,repair,removal or demolition involving the structural elements of buildings
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 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: •
Your signature caries certain responsibilities,including but not necessarily limited to,general liability
SECTION 4-WORKER'S COMPENSATION INSURANCE AFFIDAVIT.(MGL 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: lwles ❑ No
SECTION 5-DESCRIPTION OF PROPOSED WORK(Check all applicable)
❑ Deck 0 Pool 0 Repairs 0 Alteration 0 Chimney/Fireplace la Woodstove/Pellet Stove
❑New Construction' 0 Accessory Bldg. 0 Roofing/Siding 0 Other
(Energy report required) (Shed/Garage) (Specify below)
❑Addition 0 Replacement window/door 0 Demolition
(Energy report required) No.of windows_ Doors_ (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
❑Furnace(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):
❑HVAC(combined unit)-primary fuel,natural gas,propane,electricity,other
❑Air conditioning-(separate unit)
❑None of the above to be provided
❑Hot Water: Gas Electric Fuel Oil Other
Description of proposed work:
InCPrklanni.3snie. i hexis-tin@6tEp\ce C,tnlline CIniTyiney
SECTION 6-ESTIMATED CONSTRUCTION COST
Item Estimated Cost($)to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical(HVAC)
5. Total=(1 +2+3+4) W eeor CC
SECTION 7A-OWNER AUTHORIZATION
(to be completed when owners agent or contractor applies for building permit)
(Please1 � Print) n I,, /�' —1
I, N�1 C arV;\ K 11r.v ,as Owner of the subject property hereby authorize.-ks4(_,PJ�! eL �S
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7B-OWNER/AUTHORIZED AGENT DECLARATION
Ii c-CA p�ey e J y/ Cl4. , as Owner/Authorized Agent hereby declare that the statements and information
on t e f egoing application are true and accurate,to the best of my knowledge and belief.
Signed u e pain and [tie ,of perjury.
g197 if
ign tur f Ow er u prized A nt Date
r - SECTION 8-INSPECTOR'S REVIEW/COMMENTS TI : -
1. Date plan reviewed: ( Y99✓ar
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason: /2O7t-4-1 Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature: l SI(2.4-1--e-S2 . .4 , Date: ect7--/9•.'a
- : r... ::SETION9-APPLICANT,NOTIFI ATION /f
Applicant informed of ove: �/ tte: o Time: Clerk:
I Comments: b �EL—
SECTION 10-OFFICE/INSPECTOR S NOTES :" _. - • -.
/ Less Application Fee:$2J9B Remaining Balance: $ �/
Total Permit Fee: $ / -
Other$Amount$ 7 J
TOTAL FEE: Gross Area-New Construction total sq.ft.
Gross Area-Alteration total sq.ft.
Permit Issued to: tact-
SECTION11 -ADDITION�ENTS!SKETCHES
1
L_IU(tk5
12 inn
fi
- //
'ermit No. BP-54283 Project Location: 30 DARTMOUTH FARMS TR
Commonwealth of Massachusetts
M p �066°°
TOWN OF DARTMOUTH
400 Slocum Road,Dartmouth,MA 02747 Lot: 0058
Phone: (508)910-1820• Fax: (508)910-1838;. Suhlot`
BUII ;DING PERMIT P t# I- INSTALL 0
Est Cost: $3000 00
FIELD INSPECTION Fee, . $3000.
Const..Class:
Use Group: R4
Contractor: License. Phone#: Lot Size(sq.It.} 3:21A
STEPHEN W CONTOIS .CS-13125 (508) 994-4046 Zoning: :SRB
Engineer: • license `'hone#: Neiv:Guist: `-N/A .,
Alt.Const.: N/A
Applicant: Phone#: Ceiling:
PHOENIX SHEET METAL INC (508) 994-4046 Walls .
OWNER: :.
Floor.m
RILEY MICHAEL&, OB A RILEY Glazing:
DATE ISSUED: 1
TO PERFORM THE FOLLOWING WORK:
Wood stove insert into existing fireplace and line chimney
DATE TIME TYPE OF INSPECTION&REMARKS INITIAL
,�! �or,'as` C�G�c-c . /cwt bit- c7
n 7n F i - n1
09/08/2008 13:28 5089944391 PHOENIX/S/M PAGE 01/01
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A!._Q8P CERTIFICATE OF LIABILITY INSURANCE DATE(M(WD0PYYY)
9/4/2008
PRODUCER (508)679-6418 FAX: (508)679-6410 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Frank X. Perron Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
1311 Bedford Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P. O. Box 4158
Fall River MA 02723 _ INSURERSAFFORDING COVERAGE NAIC#
INSURED INSURER A:Hartford Insurance Group 00914
PHOENIX SHEET METAL INC INSURER B:Star Insurance Company
53 COVE RD
INSURER C:
INSURER D:
SOUTH DARTMOUTH MA 02748 INSURERE:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY
REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,
AGGREGATE I IMITS RHOWN MAY HAyEBEErEPSLQEO BY PAID C.LEJM%
•
INSR gen% I POLICY EFFECTIVE POLICY EXPIRATION "�
LTR JN9RD TYPE OF INSURANCE POLICY NUMBER PATE(MMID DATE(MMIDDffY) LIMITS
-
X GENERAL LIABILITY
EACH OCCURRENCE $ 1,000_,000
X COMMERCIAL,GENERAL LIABILITY DAMAGE O ENTEO
A X ea MIS / aar a., E 300,000
CLAIMS MACS X OCCOR OSSEAUS9179 10/17/2007 10/17/2008 MED En-(Am onopIH&N s 10,000
PERSONAIA YINJURY $ 1,000,000
EA'ERAI.AGGREGATE $ 2,000,000
GEM,AOOREOATEPPLI((22MpIIT APPLIES PER: PRPDUCTS-COMP/OP AGO $ 2,000,000
n J)_X FOUCY l ' CT n LOC , .
AUTOMOBILE ugmLITY COMBINED SINGLE LIMIT
x
1111 ANYAUTO (Ea ealtlal)
I
ALL OWNED AUTOS a w '°' BODILY INJURY
SCHEDULED AUTOS
¢,p a; I (Per parson) $
HIRED AUTOS BODILY INJURY
NONAW.VED AUTOS (Per AetltlnnU 1
PROPERTY DAMAGE $
(Par aaynnq
GARAGE.LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACO_S
AUTO ONLY: AGO S
EXCESWUMDREL.LA LUIRILITY • EACH(IS.5',JJHRELLCE $
OCCUR I I CLAIMS MADE AGGREGATE $
$
. DEDUCTIBLE - ,,_ .....5
RETENTION S „_ $
B WORKERS COMPENFATIONAND II OTTM
MP ELOYERS-LIABILITY TZO I1 STAT15 X 6R
ANY PROPRIETOR/PARTNERIEXECUTIVG Et EA,fHACGDENT S 500,000
OFFICERPWEMBER EXCLUDED? FPC0117375 9/29/2008 8/29/2009 ELDISEASE•EA EMPLOYEES 500,000
if yes.Boson??under
SPECIAL PROVISIONA¢PIcy E.L.DISEASE-POLICY LIMIT S 500,000
OTHER
DESORIPTION Of OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDED DY ENDORSEMENT/SPECIAL PROVISIONS
Project: - '
..
CERTIFICATE HOLDER CANCELLATION
at I SHOULD ANT OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAB
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT '
FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER ITS AGENTS OR REPRESENTATIVES.
AUTHORQED REPRESENTATIVE
B FrcitaS/F7CPBF1 '"----ceelet,ALAS-siL_, - -ter y}_..,
ACORD 25(2001/08) OACORD CORPORATION 1988
�VCnpR n.m,.
PAGE 01/01
08/28/2008 15:26 5089944391 PHOENIX
/9/M
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Safety Clearances
READ ALL INSTRUCTIONS BEFORE INSTALLING
AND USING THIS APPLIANCE.RESULTIFAILURE TO DAMAGE, Masonry o r
INSTRUCTIONS MAY RESULT IN PROPERTY DAMAGE,
BODILY INJURY, OR EVEN DEATH.
We strongly
etrctoshave that smoke
slyintors stalediyot lled.
may Factory Built
If smoke detectors have been previously installed,you may
notice that they are operating more frequently.This may be
due to curing of stove paint or fumes caused by accidentally Minimum Clearances to Combustibles
leaving the fire door open. Do not disconnect the detectors. (Measured From Insert Body)
If necessary, relocate them to reduce their sensitivity.
Adjacent Sidewall 8.5 in. (216 mm.)
SAFETY NOTICE: If this stove is not properly installed, a Mantel 21 in. (533 mm.)
house fire may result. For your safety, follow the installa- Top Facing 21 in. (533 mm.)
tion directions. Consult local building or fire officials about Side Facing (1.5 in. extension) .8.5 in1216 mm.)
restrictions and installation inspection requirements in your
area.
The services of competent installer, certified by the Wood
Energy Technical program (WETT) - in Canada, Hearth
Education Foundation(HEARTH)-in U.S.A.(or equivalent)
are strongly recommended.
kti
H r. t,i, . . 3 tin
t ,v
Of
Fig. # 1
Mantel or Top Facing
MO a��lt��I --
a I__-
•■ I 1 Ire ■•
Elm
ir— ----rti
Adjacent fall = I�t��--at. M_ iIPS.1 1 4(L0L12)
mmoilo
42"
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SUMINSERTA 230606-20 PACIFIC 3
ENERGY
The Commonwealth of Massachusetts
>— Department of Industrial Accidents
3� 1
__ 441=_ Office of Investigations
= 54 600 Washington Street . 'LJ ;1
Boston, MA 02111
is
www mass.gov/din
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant o Information
� Please Print Legibly
Name (Business/Organization/Individual): _ l x �-1 Y. e- Me-({.„.I , 'QC .
Address: fl3 cow 1c d
City/State/Zip:S IDArno( kiiik ,M c-R Phone #: W2.gq i_j-yoH&
Are you an employer? Check the appropriate box: Type of project(required):
1.0 I am a employer with 5 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
72.El I am a sole proprietor or partner- listed on the attached sheet ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. n Building addition
[No workers' comp. insurance 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.n Roof repairs
insurance required.] t employees. [No workers' 13p Other New\\()SA1
comp. insurance required.] . �i a .i •
'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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: I nLi,,.I�UfCE. �tir"i 1 ""'ri
\lCU\If-3�-5 g,.
Policy#or Self-ins.Lic. #: Expiration Date: 8)aq I w� l i
Job Site Addr r l City/State/Zip 141PA H A 6:2,- -(.
Attach a co of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to se a coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1, .00 and/or one-year ' risonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250. day against the vio tor. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of DIA for insur r coverage verification.
I do hereby certi under...Ie:win maples of perjury that the information provided above is true and correct:
Signature: Date: 0 7/0e)
Phone#: ;" gc7i-LJ()%-167
Official icial 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 pennit/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 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 5-26-05 vt ww,mass.govidia