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BP-61139 Permit No. BP-61139 BUILDING, PERMIT GIS#: 3741.00 Commonwealth of Massachusetts Map: 0071 - TOWN OFDARTMOUTH. Lot: 0061 400 Slocum Road,Dartmouth,MA 02747 Sub-Lot: 0000 Phone:(508)910-1820 • Fax:(508)910-1838 Category:. WINDOWS/DOOR/ - - JR PORCH Project# JS-2011-000644 - PERMISSION IS HEREBY GRANTED TO: Est.Cost $6775.00: Fee: $150.00 Contractor License: Phone#r Const.Class: - DANA PICKUP JR CS-95228 (508)997-1111 Use Group: R3 HI-100503 Lot Size(sq.ft.)- 218521 - Engineer License: Phone# Zoning:. _. SRB - - Aquifer Zone: ZONE Applicant: Phone#} Flood Zone: ZONE X CARE FREE HOMES INC. - (508)997-1111 New.Const.: 36 sq.ft. OWNER: Alt.Const: N/A ' GIFFORD ALTON D JR _ Date Typed: 09-28-2012 •``�� j, 1 DATE ISSUED: / U 1 / /� TO PERFORM THE FOLLOWING WORK: Replace one door and two windows SAME SIZE, SAME OPENING/construct a 4'x 9'porch on rear of residence Pro°°ect LocationA 613. OLD FALL RIVER RD Approved/Issued By: .,f_ / � DAVID BRUNETTE,LOCAL BUILDING 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.v€tck 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 forth understand other agencies may h ason to STOP WORK if items under their jurisdiction are not met; not withstanding the issuance of this Build/'n oning Permit. Signature of Owner/Agent: / Comments: PERMIT NUMBER IS REQUIRED WHEN REQUESTIN/ SPECTIONS/RE-INSPECTION FEES MUST BE PAID BEFORE RECEIVING ANOTHER INSPECTION/REPLACEMEN`Y 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 ;' BUILDING RECEIPTS ;.PHqRE-' 508-W101820. FAX 59,8-910.1838 e: 1:3 O 3 Nam .? eroperty f7 rj;: Date: I / �f rj /1 } f Owner: / , / :,.;:�_" r`1 rya i I! a Job Location: i ,� Jl'' - GVhite Copy-Collector's Office / ' ,1 i t -'7 , /; �,� Yellow Copy-Customer's Receipt �° U 7F G // t -t f �+-f;i`f c Pink Copy-Pile Copy Map: Lot: - Green Copy-Building Department /{Phone: Description General Ledger#'s Ref. # / Amount) License &Permits - Building 01000-44105 49A/4 /- /2 c it License &Permits -Building Misc. 01000-44105 I 'J Ji License & Permits - Electrical 01000-44106 C "-_-- • License &Permits -Plumbing & Gas 01000-44107 II,, 'g 2 License & Permits - Trench Safety 01000-44129 "l Other Department Revenue 01000-42420 THIS IS NOT A PERMIT OR LICENSE FOR BUILDING, PL9MBING OR GAS Received By: r R ,-?..t TOWN OF DARTMOUTH BUILD1NG RECEIPTS PHONE: 508-910.1820 ' FAX: 508-910.1838 O l-L 3 9 rropeny Lily;✓ , ! l Date ,+` 'Job Location :' ✓ i +�y ,. / r' .' , ' r.. White Copy Collector Office, Owner• • f _`..'' / f f / �`. «•Z' a".-._,. Copy Customer's Receipt "'Pink Copy-File Copy Map: f. Lot: i Green Copy-Building Department i Phone: Description General Ledger#'s Ref. # Amount License &Permits -Building 01000-44105 License & Permits -Building Misc. 01000-44105 /V' 4; / '✓ 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: RESIDENTIAL ❑ Approval in Part(Per 780 CMR.5111.13) $25.00 APPLICATION FEE IS NON BE-FUNDABLE & NON-TRANSFE$ S, 7-—) ".-DATE RECEIVED ---- %;3 rt,.' DARTMOUTH BUILDING DEPARTMENT 400 Slocum Road, P.O. Box 79399 �c�r S I'll r; 1 a ADartmouth, MA 02747 30<:`M1a.— 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 ' t 1IS SECTION FOR OFFICIAL USE ONLY j RECEIVEDhBY r ', a a -' ' s' l B e , u ,z �j em UEtptNGP TNUM / _.. DATE SENTFOR REVIEW / DATE ISSUED=_ iF Q :` x -= r:' ..�.r c. V;°` s .. '1 1 a3 .._ .�,fPn C" �' . ��TO ISStlE ' 'r47A`LURE .; s. �i :*° °:=>�,L /M x--":re- DATA; tF ' r t _ 7 IU B ❑A A Zane rai t '� `rroposdUs u ne : tZnng Du 1 THE FOLLOWING AGENcIE SHOULD BE NOTIFIED - ' I a.`cons. w�'r` ar'3i- `�.a "�`- i' e`v.. Ct Energy Report fl OBaartof ada oGors-" 3 emo tJ h: n. Appeals Health ?,,;.. Commission =.A7futavit Ca d Sent' -` Gut Off - Follow-up ul O Fire Q'Gas ❑Planning 4,Li-Sewer Car{(, O Water Card ,,a ❑Zoning 0 Other _; Chie Cat Oify *' S . Board ..- + ut Oft _'..'3° CutOff a i.k . .t,f,. r ^.ar";c . ' a , i�r o-"'r t i n'�� wee:i..�r"-u rc �. t Tk'.:..._ ,, wFai n*-tee".- ,v`x REQUIRES INSPECTOR'S.REVIEW B€FORE THE ISSUANCE=OF A PERMIT. '= ` -'" DEPARTMENTAL;APPROVA Zoning Review: Signature: c,2T 2.c t...ey� Date: SEP 2 4 2010 .. Energy Report: • Signature: Date: Fire Chief: Signature: &/aa Date: Board of Health: Signature: Date: Conservation Commission: Signature: Date: Other: Signature: � }� Dat�: Brief description of work being performed: //J�/!L's�1 �Li -, ; . SECTfYS(V1:-SITEINFORMAttONasamr -- ` " 1.1 Property Address: 6 13 O( '( _ lie- 4 1.2 AssessorsM�a/p&Lot Numberr//�/�� Lot Area (sf.) Frontage Map / Lot `t' - Required Provided Front Yard 1.3 Historical District ❑Yes GN7'o„ Side Yard Rear Yard Year Built 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? 0 Municipal 0 Private Well 0 Municipal 0 On Site Disposal System 0 Yes 0 No Date: ❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT Page 1 • RESIDENTIAL SECTION 2-PRORERT*OWNERSHIPfAUTHORIZED AGENT 2.1 Owner Record: - Name(print) Contact Adtlress Phone Number 2.3..Authorized is , 7 k ;k q41— Name(print) ContactAddress/kUw Phone Number z'T,SECTOOI+I3=,.CbNS,rRUCTIONmSERVtCf--S 3.1 Licensed Construction Supervisor/Specialty License: License Number: ( . 'Z a 1 Company Name/Contractor Name: JA/ C Address: Z.3°t V�r ,j';�11, , Expiration Date: O 37E27 2 Signature: 1)yb, � ,Telephone: 90/-7 — t 1 I 3.2 Registered Home Improvement Contractor: Not Applicable ❑ 0 Are you a Home Improvement Contractor subject to(780 CMR.110.R6)? Pes 0 No F Are you claming exemption from the requirements? 0 Yes ❑ No If Yes, Go to Section 3.3 Company Name/Contractor Name: ewe, cre,,2 b-41j,4".e,4 Registration Number(if none, state"none"): C Address: )4tA t/ ' ( Doc 03 E Signature: tWi .-/ Telephone: 5Gw-2, Expiration Date: 67/!7/2 .N 3.3 For Residential Remodel Work Only C PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: E QUESTIONS OR COMPLAINTS call or write: (S) 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 individua shall be engaged in directly supervising persons engaged in construction,reconstruction,alteration,repair,removal or demolition involving the structural elements of building 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 Constructioi 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 Homeowne 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 whic 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 tha one home in a two-year period shall not be considered a Homeowner If you ar applying under this sectiorysi low: Signature: si a ure carries ye- in response ilities, including but not necessarily limited to,general liability Page 2 SECTION 4-WORKER'S COMPENSATION INSURANCE;AFFIDAVIT,{MGL 152§ =, , 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: !Bites ❑ No `" " 5 SECTION 5-DESCRIPTION OF PROPOSED WORK(Cheek alf applicable'}„. [Deck 0 Pool 0 Repairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove 0 New Construction* 0 Accessory Bldg. 0 Roofing/Siding ❑Other (Energy report required) (Shed/Garage)he (Specify below) 0 Addition L9'Replacement window/door 0 Demolition (Energy report required) No. of windows a Doors I (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 0 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 ❑Air conditioning-(separate unit) ❑ None of the above to be provided ❑ Hot Water: Gas Electric Fuel Oil Other r Description poof proposed work: p( ci 104,0r �- 2 w/` ✓S 9 °'e� - tpuz ct 9 � �r L enr f47.‘"r- o 4- AtJ - ,::,,._ , .;:ir SECT,ION:S ,:ESTIMATED„('fONSTRU£''f'j4It„GQS7`; aF an _ ta Item Estimated Cost($)to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total=(1 +2+3+4) `1f' 671C ;: 'SECTION7d 01NNERAUTHORIZ T(OlV ,r 2 r VI ` `" (to becompleted when owner's agenGor.c©rf(racfocapplies�foFr rtd)n6 {t ,_ ?, yr. (Please Print)^ �j I�L1it G e cc. , as Owner of the subject property hereby authorize Vot.t.� to act on my behalf,' yp in all matters relative to work authorized by this building permit application. Signature oa pV ' 'e 7�0 Date 9© (Lj 'd SECTION TB-OWNER/AUTNORIZED AGENT DECLARATION „` = `I I, 1},(AA. (( Lj t//� ,as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application bre true and accurate,to the best of my knowledge and belief. g d under the pains and le of perjury. I16/// (Signature ofwne thor z d Agent Date Page 3 _-. < SECTION a;INSPECTOR` iREVIEW/COMMENTS iS =:.'-'."-: --:. ',,,:.:•-;,- -7,..—ceus, , rx ,n,s 1. Date plan reviewed: SEP 2 4 2010 2. DENIED(see project review worksheet): Date: 3. HOLD �// Reason: /t"ft'_ Date: 4. HOLD subject to Zoning Board of Appeals action: Date: Comments: Inspector's Signature: OLa`-' DateSEP 2 4 2010 ._ , CTIO - -APPLICANT:NOTIFICATION ri: _ . --ti-±,±giiitiii Applicant informed/of/f bove:� Date- v T. e: /2: /Clerk: Comments: //'1 /`� �j!'( / /f� , t. _g , 4. . , GTION 10- FFIGE/INSPEGTOR'S NOTES A ,"„, '.ws ._ 'm- -s.; _ Less Application Fee: $25.00 Remaining Balance: $ / �s Total Permit Fee: $ 3 b / Other$Amount$ TOTAL FEE: ! �J Gross Area-New Construction total sq. ft. 3.4 Gross Area-Alteration totai sq.ft. IL / 2 c(107s4 T.. v , S� ,, -.9 /ass /� Permit Issued to: 40401,-- CielD/1-0-Itcry C LTYJ d�/t / ) day c- } a _. . , "SECTION:11-(ADDITIONAL COMMENTS/SKETCHES _ ( ivoou 'r/o 7 C ,/al&A �5' ff' 6%2r2 /,„ Page 4 1 permit No. BP-61139 Project Location: 613 OLD FALL RIVER RD Commonwealth of Massachusetts ' ,00 TOWN OF DARTMOUTH GIS#: 3741Map: 3741. 400 Slocum Road,Dartmouth,MA 02747 Lot: 0061 Phone: (508)910-1820 • Fax: (508)910-1838 Sublot: 0000 BUILDING PERMIT Category: WINDOWS/DO OR/PORCH FIELD INSPECTION Est.Co t: $6;S oo°°644 Fee: $150.00 Contractor License: Phone#: Const.Class: Use Group: R3 DANA PICKUP JR CS-95228 (508)997-1111 Lot Size(sq.ft.) 218521 HI-100503 Zoning: Slip Engineer: License: Phone#: Aquifer Zone: ZONE 3 Applicant: Phone#: Flood Zone: ZONE X CARE FREE HOMES INC (508) 997-1111 New Const.: 36 sq.ft. OWNER: >.. t r n «r- Alt.Consta N/A GIFFORD ALTON D JR L.)� J � I r!,y DATE ISSUED: TO PERFORM THE FOLLOWING WORK: Replace one door and two windows SAME SIZE, SAME OPENING/construct a 4' x 9' porch on rear of residence DATE TIME TYPE OF INSPECTION&REMARKS INITIAL Lls '-s Oct 06 2010 10: 31 DARTMOUTH BOARD OF HEALTH 15089101893 p. 1 RESIDENTIAL ❑Approval in Part(Per 780 CMR.5111.13) $25.00 APPLICATION FEE IS NON A$D;.FITNDADDLE di N t INT-TRANSEPPI L '1-,n Sa-rr, - 11" AITE RECEIVED - n ` DARTMOUTH BUILDING DEPARTMENT j 400 Slocum Road, P.O. Box 79399 ' T"i C 5 AN o 10 y Dartmouth, MA 02747 s' . .r I Phone: 508-910-1820 Fax: 508-910-1838 www.town.dartmouth,ma.us APPLICATION TO CONSTRUC . REPAIR, RENOVATE OR DEMOLISH A ON: OR TWO FAMILY DWELLING j 1 a1+' T .4 71lz( -- ' er' KI c,'- t` e, sue t "RxaaT 5 y`, n 1 .ry r i 'ra-n T mow•, d.. '1.g ` Ott s u . 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"�L � 4 a t� t:.� " a F r t 1 . .� •'-' FI 4 ss 7 t Ca 1 8 I'.-F f i i .._r e t 1 �t 'a e;� E T i .� vd ''v„ . n i i4itili '`..n v *-„id -e i t yre a'T 4 J' :112,5; r-' ,T 1 c r li ti ..�i3 -:_"' r'� �,. I 2 ti i t om F �t t '' 9 e -,.. . ,. 'tV�p1.- .E:'.R`.'S .�.:. -�. .,. 1<... s'"r'-`t":,.;i`�.ry'9"j iw$�' 47E �+...! ..'ct' �„E"' �w-, - Zoning Review: - Signature: -.,eie;:L' /y+� Date: SEP 2 4-2010 Energy Report - - Signature:. Date: Fire Chief: Signature: Date:Board of Health:- Signature: Date 13/40///d , Conservation Commission: Signature: Date: l Other. Signature; Da Brief description of work being performed: 1.1 Property Address: 613 ji wU1W Lb , 1.2 Assessors M/e pNumber/in ` 7/'&Lot Number/pin/J Lot Area (sf.) Frontage - Map 1f Lot Required Provided Front Yard - - 1.3 Historical Dis riot - ❑Yes a -.o Side Yard Rear Yard • Year Built ❑Altering me re Than 25%per side of building 1.4 Water Supply(MGL o40 s54): 1.5 Sewage Disposal System: Has application be en submitted to the Historic Commission? ❑Municipal- t7 Private Weil ❑Municipal ❑On Site Disposal System ❑Yes 0 No Date:El CONSTRUCTION PLANS Cj SITE PLAN 0 ENERGY REPORT Page - :MIassachusetts - Department of Public Safetc )2g31Board of Building Regulations and Standards Construction Supervisor License License: Cs 95228 Restricted to: 00 DANA PICKUP 19 HAMLET STREET FAIRHAVEN, MA O2719 s Se; Ss Expiration: 3/22/2012 ('onus issioner Tr#: 18680 Jibe "lOomvr209t/set>.a' o°✓vGaaG¢cr(zuGe a Office of Consumer Affairs&Business Regulation �, — - HOMEIMPROVEMENT CONTRACTOR f _ Registration 100503 Type: Explra104179412 Supplement( CARE FREE HOMES;,tPT'C_, DANA PICKUP JR 239 Huttleston av8;.,Fairhaven, MA 02719` Undersecretary FILE COPY SEP-15-2010 09 :03 AM P. 03 SWnall:33779 ACORD,,, CERTIFICATE OF LIABILITY INSURANCE „eD„" "'R THE CIRTIPICATM III ISSUED AS A MATHS OF aMORMATION NNO MONT,UPON DM eAlhy IMuranoe Money,Ills HDt.DSR,TWONLY ANDPICIRTWICATE DOES NOT AMEND CERTIFICATE, OR 51 Pullman Street ALTER 971E COVERAGE AFFORDED By THE POLICIES BELOW. Woroe,Mr,MA 01606 Me 7514150 INSURERS AFFORDING COVERAGE NAIC D I�SM !NUM!" IMerquerd InMOanoe dummy Cant Ems Names Inc mum"TH Orval Casualty Insurance Companies 23D Hu wastan Avenue raURSR I FNlhaven,MA 0271E MEURERD: mI5 ER& THE POLICIn OF INSURANCE LIMED BELOW HAVE BEEN IeeUEOTo THE"Sump NAME°ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITMSYAHORO ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT wan RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE ROUGES DEM[RISED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONOMONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE SEEN REDUCED S 'PAID CLAIMS.Illk Pp{ICySI��IeO vnt __,1, TO srISWMICE 'aCTIaaeat rULM-'Y4rSCTa/a PlataWYIAgN- �M+r DATI oT MIe.Y.' h"A uMR seam LMaIU Y EACH 000URRwH e { oDisimaaAL arssopw. MADE I rry R❑occtCLAMl9 enrni�'I L CLAM MOD OS WO au MONO { MOON&&ADP PUMP I ODOMAGOREOATE I ^sera DDRSUAA11E�LOMOSTA PUSS Fa IPOLICYI IRCf I 16CC PRODUCTS-GINIMPASB i B AUTONOMLSLNstet COAOIIUIQ 07101M0 07/DMMI COMM)MOLE LSIR ANYA`RO RA AeAaMQ s1,060,00p r..Alt MNIDAUTON lay X saMoute AUTOS (At—IIRv $ X MRIDAURa X NON ANDS ONN UAW) { GARAGE LIABILITYzw:,u;7 ow , AM'AUTO _Mutts.EA ACODENT s OTHIR TMAN FAACC $ AUTO CNLYI A00 { SlcMNAONILA UAM M ]OCCUR 0WMS MIOE EACH OCCURAMNC! 3 AOORRA7{ { a f {A moues DDNSlpTS18ARp CAYCIAI0S7 ODtl1MD ODO1 'X I ( �teeLevmwuASLOY PNVPSDPRIPCNVPANTHCANINOCUTOT OPyPµIICEWMEMSER S{ULAIDPJIT EL EACH ACCIDWI' 71,000,000 �,..SSFC6ML PApVlJIONS taw DIOSASE.EASNPUDYSTI i1.ODQ.DDO OHMES.mom-POUCY LINT s7.000,000 DYCAPROM OF omouffoNa I LOCATIONS/VSMICU=I MKCLUSRMA WOW w 60oeORDIT IS ECNL PROMOTION CERTIRI TI Napo ,`� CANCELLATION MOULD ANY w NNE AIM Swum POLICES NO cANCEleo NNW Ma mPRARON Town ofDaltmauth DATETNBwsP,TNaaRIND INNS POUJINOGYattTOMAR —,0- Nee MUTTS. Building Deportment NOW TO MtCemmicATs HE DERNMMDTOME LOT..INFAaum TOW a1 SMALL 400 Slocum Road Wan NO OMLSAIMON OR 41MM SPA IONS UPON TM{ North Dartmouth,MA OneIwUMSA in AMMO OR IryMloeMrATafu ANNON@DR@POEDTATR! 01,4 /S--*Cott')26t )I of 2 DI42387 1pg2 0*CORD CORPORATION fete A it r 'i \4\ St - -. ze (mkt- fret klAvve — ( �(; R� - l l( ( r �1- 1 b8 (( - -f---0/ L it IF y s. 3 _. N, _6 \ J S . 4 r Ntss _ a 1 Vn N 4- ! b L i3j 1*1 �D 1, r s 0 1-7:- j Al - o S r ,I N 3 iA xI. - ll's till.again r try ' 0 s . _ H �� V y .- a ..'• �9� .r Li, — >'' ^; 2 IS 'ly •- Y ,Y y/ L L_ -L ,. c "--4 n . L....t...." Lcu c, .„.S s g xy a IL ? 3 7 h,. The Commonwealth of Massachusetts rI\ r Department of Industrial Accidents isii Office of Investigations F j: 600 Washington Street iris. .9 —7 irk V\,, .1,y Boston, MA 02111 __ _ www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Cortcrefil, aui,e.. Address: 2? q i(v4,1,,S 1dd. Ave- , City/State/Zip: Fiti,e\A-u1I,-(,G, AAA Phone #: /07—i fi/ Check the appropriate box: Are yo n employer? Type of project wired 4. am a general contractor and I yp (required): ) I. I am a employer with ❑ I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- These on the attached sheet. 7. emodeling ship and have no employees These subcontractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. nsurance.t required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ 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' 13.0 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 y information. Insurance Company Name: r Policy# or Self-ins.Lic.#:_ e, 13 EiJ 0 t 7 Expiration Date: ,� /// Job Site Address Cj 13 a I U i/ 11 E(rG r City/State/Zip: / d-i 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 hereb ertify the p ' d penalties of perjury that the information provided above is true and correct. Signature: >r ' Date: 9/ / 6 1 / 0 Phone#: `jl`7 - ( ll/ 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 ajoint 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