BP-56810 Permit No. BP-56810 BUILDING PERMIT
GIS'#: 3612.00 Commonwealth of Massachusetts
Map:; 0070 . = • TOWN OF-DARTMOUTH
Lot:'- 0011 • 400 Stocum Road,Dartmouth,MA 02747
Sub-Lot: 0000 - - Phone.(508)910-1820 • Fax:(508)910-1838
Category: TO OCCUPY . JR <11
Project# B5-2009-002364
Est.Cost "=5 .$75.00, ;'," PERMISSION IS HEREBY GRANTED TO:
•$75.00 - -
Coast.Class: Contractor: - License:` Phone#:
Use Group: R4
Lot Size(sq.ft.) ` 2.07A Engineer. License: Phone#:
Zoning. , , SRB
New Coast N/A Applicant: Phone#:
Alt Coast: N/A" t ROBERT FERREIRA - (508)642-7512
Date Typed: 06-10-2009; OWNER°
�' FERREIRA ROBERT&,C STINA TRREIIi.A --;
DATE ISSUED:
TO PERFORM THE FOLLOWING WORK: -
Home occupation for landscaping business with one truck and one trailer "Robert Ferreira Landscape,tree, &
equipment
Business Name: ROBERT FERREIRA LANDSCAPE, TREE, & EQUIPMENT
'ro ect Local) 34 LLERS DR
Approved/Issued By: t, `��_ s � ire _ _ i`
DAVID BR I` ,La CAL 4 *1 . - l\ 'E OR
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 t e owner of record and I have be authorized by the owner to make this application as his agent
and to receive this permit, I further understand othe, agencies may ve reason to OP WORK if items under their jurisdiction are not met; not
withstanding the issuance of this Building/Zoning Per t.
Signature of Owner/Agent: �`t Comments: PERMIT NUMBER IS REQUIRED WHEN REQUESTINGINSPECTIONS/RE-INSPECTIONFEES MUST BE PAID
BEFORE RECEIVING ANOTHER INSPECTION/REPLACEMENT 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:
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
TOWN OF DARTMOUTH
a
Y'1 BUILDING I EC TPTS - ,0 ,
1a-
1
PHONE: 508-910-1820 FM: 508-910-1838 37419
_
•
Name: 'r / s` -- Property .1 Date: J /y.`- f
/t / /
Job Location: -'i''� S.. ' -. TOWN OF DARTMOUTH '
�`) / ! f / I /
J COLLECTOR S OFFICY Yellow
copy-customer's Office Receipt
'\,7 r1 Pink Copy-File Copy
Map: f�/ Lot: `// JULi 2 9 2009 Green Copy-Building Department
/
Phone: MAJ 13
Description General Ledger#'s Ref. # Amount
License &Permits -Building 01000-44105 4
License & Permits - Building Misc. 01000-44105 ,
License & Permits -Electrical 01000-44106
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-T
���� , TOWN OF DARTMQUTH
, y% BUILDING REC5IP1t p n
V �;1°ti 2 5 CThF NE:--508.910-1820 FAX 508.910-1838 `�'�V
� A L
Property / Date: /
</_.-•i'... c , CI Owner: F-;/ 1 '� /� //J 5
Job Location: White Copy•Collector's Office
3( L / j\/ Yellow Copy-Customer's Receipt
////4v> /' /`.c._ - Pink Copy-File Copy
Map: Lot: Green Copy-Building Department ,
29 //
Phone: `l '
Description General Ledger#'s Ref.# / Amount
License & Permits - Building 01000-44105 2 / ' �y '
•
License &Permits - Building Misc. 01000-44105 ' ,•-•,
License &Permits - Electrical 01000-44106I. LE.0 ; T� /
J F
License & Permits - Plumbing & Gas 01000-44107 MPY 2 1; 2009 (> i/
License & Permits- Trench Safety 01000-44129 v-• w 4 ri
tr., 4 a .y. rv.
Other Department Revenue 01000-42420
THIS IS NOT A PERMIT OR LICENSE FOR BUILDING, PLU IBINQ OR OAS
Received By: a-` >e?-_-F;
RESIDENTIAL ❑Approval in Part(Per 780 CMR.5111.13)
$25.00 APPLICATION FEE IS NON RE-cxWIILE & NON-TRANSFERABLE
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O Box 79399,4y 7 �� 4 t ti
:o x; I'll- a= � _
z _ _ Dartmouth, MA 02747 ` '
. y' Phone: 508-910-1820 Fax: 508-910-1838
\..M1fifi �j
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: Cr - BUILDING PERMIT NUMBER: �O,
DATE SENT FOR RE EW: C a- 0, ,DATE ISSUED.
O.K.TO ISSUE SIGNATURE:
Zoning District Proposed Use: Ltd Zone: C ❑ B ❑A ❑V Aquifer Zone
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
13 Board of: 0 Board of 0 Cons. 0 Demo ❑DPW El Elec 0 Energy Report .
Appeals ` Health Commission Affidavit- ' Card Sent Cut Off Follow up
.LI Fire -- ¢Gas ❑Planning 0 Sewer Card 0 Water Card- Ij Zoning 0 Other
_ Chief �- Cut Off Board Cut Off =Cut Off `- _
*REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OFcA PERMIT"i
DEPA NTAL PRO�/AL .
Zoning ReviewSignature: tY��' Date:
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date: -
Other: _ Signature: Date:
Brief description of work being performed:
/ SECTION I -SITE INFORMATION
1.1 Property Address: 7/ ' /41/`/e''? 19/4 1.2 Assessors Map&Lot Number:
Lot Area(sf.) Frontage Map Lot// -
Required Provided
Front Yard 1.3 Historical District 0 Yes 0 No
Side Yard Has application been submitted to the Historic Commission?
Rear Yard - 0 Yes ❑ No Date:
1.4 ater Supply(MGL c49 s54): 1.5 S age Disposal Syste
r ❑Municipal VPrivate Well ❑ Municipal frOn Site Disposal System
ecciafriaff
G ®- /' �-- tj /�rya,ZC&"C l /h.ee. ,t f
❑ CONSTRUCTION PLANS SITE PLAN ❑ ENERGY RE ORT
RESIDENTIAL
SECTION 2-PROPERTY OWNERSHIP UTHORIZED AGENT:
.1 'Owner Record:
A ® beet' Terre; nq ) , ;/�, s OX col-611Z 757e
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: 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.110.R6)? 0 Yes 0 No
If No,go to the next section!
Are you claming exemption from the requirements? ❑ 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 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 rmming all the work myself.
Owners Name (print):
/Signatute: By
By signninging the�abo ,the
�h7o owner acknowledges that there will be no eligibility to the Guaranty Fund
Date: 02 /of
.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 unde'this tionssign tf low:o
Signature: // 'd✓"✓L�f' „--
Your signature carries certain responsibilities,including but not necessarily limited to,general liability
SECTION 4-WORKER'S COMPENSATION INSURANCE AFFIDAVIT(MGL c 152§25)
1 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: 0 Yes ❑ No
SECTION 5-DESCRIPTION OF PROPOSED WORK(Check all applicable)
0 Deck 0 Pool 0 Repairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/PelletWo Stove
0 New Construction* 0 Accessory Bldg. 0 Roofing/Siding iB Other
(Energy report required) (Shed/Garage) (Specify below)
0 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):
0 HVAC(combined unit)-primary fuel, natural gas,propane,electricity,other( f/ V s(
❑Air conditioning-(separate unit) )�� /C'
❑None of the above to be provided (//u��/ C.
❑Hot Water: Gas Electric Fuel Oil Other
Description of proposed work:
„ . ,A,IA a LiJ -7-7 I i t/G tic--
/�U 1 �/'a , , ,o mil rs V. �/��i o efri
SECTIO 6- STIMATE ONSTRUCTION COS
Item _ Estimated Cost($)to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC) �
5. Total=(1 +2+3+4) `[J�
SECTION 7A-OWN RAHO TInN-.-; '
(to be completed when owners agent or contractor applies tor building permit)
(Please Print)
I, µ�assq tj wner of the subject property hereby authorize
to act on my behalf, in all matters relativ to or a i zed by this building permit application.
Signature of Owner / Date
SECTION 78-OWNER/AUTHORIZED AGENT DECLARATION`
h "4rLer
, as Owner/Authorized Agent hereby declare that the statements and information
the foregoing application are true and accurate,to the best of my knowledge and belief.
Signed and the ' nndd pen ties of perjury.
•
Signature of Owner/Authorized gent Date
F
SECTION 8-INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed: 5-'07 9'-0
2. DENIED(see project review worksheet):
Date:
3. HOLD
Reason: ,,tn.-C__ Date:
4. HOLD subject to Zoning Board of Appeals action: Date:Comments:
Inspector's Signature:Lk, Date: 5 29-0 2
, S CTIO .9-APPLICANT NOTIFICATION
Applicant informed of above: Date: / TimO /}P Clerk
Comments: vv
SECTION 10 OFFICE/INSPECTOR'S NOTES
Less Application Fee:$25.00 Remaining Balance: $ S'D
Total Permit Fee: $ 7
Other$Amount$
TOTAL FEE: 7 5 ' Gross Area-New Construction total sq.ft.
Gross Area-Alteration/ total sq.ft.
Permit Issued to: �e e:re'Lr)U /,,, If.„_ ..1 r 7 G'c� (tU4.14ac<
C‘- itiax7nr /6Q it?,af; ��r Ado&cMpZ7 gCrtc' tr.',tit:tot e4,-7—"
1 6
SECTION 11 -ADDITIONAL'COMMENTS/SKETCHES ` '
4.
12
10
c) 04il _
2l j2IIi
( ( Cft,: C
of
7 bektimAt)
'ermit No. BP-56810 Project Location: 34 MILLERS DR
Commonwealth of Massachusetts
TOWN OF DARTMOUTH M p# oo `°°
400 Slocum Road,Dartmouth,MA 02747 Lot: 0011
Phone: (508)910-1820 • Fax: (508)910-1838_ Sublot: 0000
RUIT ,DING PERMIT Category:
J- OCCUPY
9c 02 64
BUSINESS NAME:ROBERT FERREIRA LANDSCAPE, Est.Cost: $75.00
TREE, & EQUIPMENT Fee: $75.00
Coast.Class:
FIELD INSPECTION use
GroLot Size�q, et.) 2.Ro;A
Zoning: SRB
Contractor: License: Phone#: New Const.: N/A
Architect.• License: Phone#:
Alt.Const.: N/A
Applicant Phone#:
ROBERT FER
REIRA (508) 642-7512
OWNER:
FERREIRA ROBERT&,CHRISTINA P FERREIRA
DATE ISSUED: � ffJ _ l�,�E__
TO PERFORM THE FOLLOWING WORK: II IIVV_ ��ttll, ��}'
YYWW,��11
Home occupation for landscaping business with one truck and one trailer "Robert Ferreira Landscape,tree, &
equipment
DATE TIME TYPE OF INSPECTION& REMARKS INITIAL
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Permit No. BP-56810 BUILDING 4`�S
r, h 1 1 ;ems a' rl �e t e
�i/ � ( r, � tplo .;ytSioc e9R0ad8 rer�qu 747 8p
a r>o 1 I I; „ ,, N q R� 0� 0�18 • �0C F 5i�8), �1B3S k � /
EriMc;;�p-E . 'Y1� �E �(6���i�FlflC1'r4r mod. 9�9 c` M 4y *._ T n t«�i mot' ' R FL
L '6r6 tl }f 7 y�y.i'Iltrl'IY :t1. 7..v e$ u r 4. L 5\
P 1 °`t `5 n PERMISSION KC $Pa f p ' , '>` x a •
5 d -a r
rtt L�i� °";�}+ t i ^..,��-:,,�:5" 7s '�Y Ya' 4 7°�Siv �� % �y ,a..
gst!71 �� n dt f tt :17 i a vs Contractor sio sa � , F; r 1 P ne 1
I9, . ttig�mIG fe r,7, rF. '.4"'- Engineer: i ell S e; PBo e# i
.fi�n �g i 4 4:k sw. Applicant $ I * p gPhone `
'4:1.' e10. .tee 5:.YNYs risika7 j y ROBERT RE .I A'rta s,^" a�"° yt" Sj(> 7b12
It
f t ': a +*F I I (I ,k;„, `' ;`X i OWNER: 6u m F »iin > ... e
»f. 1�s"5tn%cam. n '$ i jvt' �/ e
`� t FERREIRA RO T n°
iN:DATE ISSUED: , "yi ...°`
g nv t,l, is d.6 40
TO PERFORM THE FOLLOWING WORK: » ,fi �_
Home occupation for landscaping business with one truck d oo ebt2Cl;�'�it"cibele`Beira Landscape, tree,&
equipment ask r,x
Business Name: ROBERT FERREIRA LANDSCAPE, TREE, & EQUIPMENT
'ro 'ct Local' : 34 LERS DR
Approved/Issued By: 4 `.
DAVID BR ,L CAL OR
All work shall comply with 780 CMR 711'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 t owner of record and I have b authorized by the owner to make this application as his agent
and to receive this permit,I further understand othe/agencies ma e reason to OP WORK if items under their jurisdiction are not met; not
withstanding the issuance of this Building/Zoning Per t.
Signature of Owner/Agent: t` G%
Comments: PERMVirreti MBER ISR'LQU1BEDt REQUESTING I1;s,T,SPEC'T'TIO S/RE='INSpECin1ONnEstigtiSt B PAW
BEFORE,13�EC'EI' VOV ?R?$S>'Fa@�`f,O I'LACEM +f .E ivILL BE. �QUYlitb?OF IJSeS'TCARD
"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 Serviced: Footings: Underground: Oil:
Underground Service:
Foundation:
Rough: :Smoke:
Rough: Rough: Sewer Service#: Rough Frame:
Insulation: Final•
Final: Final:
Cross Connection Final: Final. Act
Treasury: ?'f•-o' 6�
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 ail 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
DARTMOUTH ; , MASSACHUSETT S
cO C-, VJ I
OFFICE OF THE TOWN CLERK a /c" TOWN CLERK
400 SLocuM Rom) • P. O. Box 79399 `Cf ' 1�64 , Lynn M. Mede i ros
DARTMOUTH,MA 02747-0985 TEL: (508)910-1800 • FAX: (508)910-1894
/'14& l / ,2009
TO: BUSINESS CERTIFICATE APPLICANT,
IT IS THE APPLICANT=S RESPONSIBILITY TO INQUIRE WITH THE BUILDING
DEPARTMENT IF THEY ARE IN COMPLIANCE WITH THE ZONING LAW REGULATIONS OR
WHETHER AN OCCUPANCY PERMIT IS REQUIRED REGARDING THE ISSUANCE OF THIS
BUSINESS CERTIFICATE.
THE TOWN CLERK=S OFFICE WILL RECORD THE NAME OF THE BUSINESS ONLY.
GETTING A BUSINESS LICENCE F OM THIS OFFI DOES NOT EXEMPT THE APPLICANT
FROM ANY VIOLATION OF THE ZONIN AWS.PLEASE SIGN: SIGNATURE: G/
J
xivelle
/l' 0b G Uv / ) /�i
BUSINESS NAME: �f0 keel-
�`' �Pr�Pi�Q
BUSINESS ADDRESS: 3y 'tare itare 5 U1< 61% �hdrv,nir' nhr; in >y9
TYPE OF BUSINESS: 1.4444e,9 i ()re
TEL#: Sig _ G y2- 7CT1'Z-
5 / ,/�)9
TOWN CLERK ONLY: /� �7 (zip Cud t v
G C/NUMBER OF CERTIFICATE: ? n O.& 9--'/
Lear LL.+t
DATE: 07 d - ( %+ ........„.......zie
BUILDING DEPARTMENT SIGNATURE: b
/,', 1144:
BUILDING DEPARTMENT COMMENT
itto
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' The COMMOtiwealth of Massachusetts
Department of Industrial Accidents
pi ii
Office o;Investigations
itl ci
00 Washington t e?P
7 'i�r
4:: � r
';.? Boston, MA 02111
' " ' www.mass.gov/tliet
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
-
Mamica ;i information Please Print Legibly
� e (Businesst!{L �ganizatton!lnddividnal)' C� 1/ P!`' r�''/'t�i l�
ss:
4/State/Zip: /V- &Ar io/4 f't M C2 QW/Phone #: S 0T-to 1 Z
Are you an employer? Cheek the appropriate box: I
i i Type of project(required):
4. f1 I am a contractor and l '
1.n 1 n < employer with I general � 6. ❑ New construction
I tpioyees (full and/or part-time).* have hired the sub-contractors i I
1 I sole listed on the attached sheet. 7_ [1 Remodeling
2. I am a ore proprietor or partner-
ship and have no employees These sub-contractors have I 8. f Demolition
employees and have workers' t
working for me in any capacity. 9. I I Building addition
I [No workers' comp. insurance comp. insurance.II-
required.]
5. p We are a cornoranon and its 1 I lv l Electrical repairs or additions
' I I
I fl I officers have exercised their I f repairs
3. am a homeowner doing all work1.. Plumbing or additions
myself [No workers' comp. right of exemption per M L
i 'L.Lj Roof repairs
insurance required.) ` c. 152,§I(4), and we have no
employees. [No workers' 13. Other
•
comp insurance required.]
*Any applicant that checks box 1I roust also fill out the section below showing their workers'compensation policy information.
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: FILE COPY ,
Policy #or Self-ins. Lie. #: Expiration Date:
/Site Address' / // ty/staeizi :'3 y /�Jil/Pt" S /r�( t ptl/ thlentrm4 niysJozv"
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 he forwarded to the Office of
investigations of the DIA for insurance coverage verification.
I do hereby certin, ride, tl rains nil penalties of perjury that the information provided above is true and correct.
- 4 Q
mature: .1, 77. _---__ — Date: ?1.n e 9, l,00D-
P ne #:
fOfficial 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
I Contact Person:
I Phone#:
information and . nt ct
Massachusetts General Laws chapter 152 requires all employers to provide workes' compensation for then employees.
Pursuant to ;is statue, an ert.pThree is defined as ". every person in the service of another under any contract of hire.
express Or ;rr�i;llcC, 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 he 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, MGI, chapter 152, §25C(7)slates "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 till 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 numbers)along with their certificate(s)o
insurance. Limited Liability Companies (LTC)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 arc 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 Pill 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