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BP-79837
Permit No. BP-79837 BUILDING PERMIT GIS#: 4030.00 Commonwealth of Massachusetts Map: 0076 T&VN OF DARTMOUTH Lot: 0022 400 Slocum Road,Dartmouth,MA 02747 Sub-Lot: 0011 Phone: (508):910-1820 . Fax: (508)910-1838 Category: RE-ROOF Project# JS-2016-001687 PERMISSION IS HEREBY GRANTED TO: Est.Cost: $11476.00 Contractor. - License: . - Phone#: Fee: $75.00 HERBERT P LEPAGE ' CSSL-099705 (508)295-6483 Const.Class: HI-171452 Use Group: R3 Engineer. License. Phone#: Lot Size(sq.ft.) 40000 Zoning: SRB Applicant: Phone#: Aquifer Zone: N/A LEPAGE&SONS ROOFING LLC (508)295-6483 Flood Zone: ZONE X - OWNER: New Const.: N/A VANGEL JACQUELINE M ,�.. Alt.Const: N/A • Date Typed: 12-07-2015 DATE ISSUED: TO PERFORM THE FOLLOWING WORK: Strip/re-roof residence A ation: Approved/Issued By: V `/ oe/ 15 SUNDANCE RD DAVID BRUNETTE,LOCA BUILDING INSPECTOR All work shall comply with 780 CAR 8Tn Ed.(MGL Chap.143)and any other applicable Mass.Laws or Codes and plans on file. Schedule appropriate inspections as required. Upon completion,final inspection is required. 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 agen ' may have reason to STOP WORK if it sder their jurisdiction are not met; not withstanding the issuance of this Building/Zopiog-Pcfl Signature of Owner/Ageatti"- "Persons contractin with unre' istered contract s doygUm 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: 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 r '"i fe °!.,IV e ,(40 UTH : BUILDING DEPARTMENT RECEIPT 7 9 8 3 7 ' 0` : 08-910-1820 FAX: 508-910-1838 `ro'�i. / 0 j a l�" 1 74 'a—'v 2 1 :t Date(1/7i� Name: ¢ ... y , Pro e caner: / /i Job Location: ✓ /L7 /,G 761( 6h fl Map: Lot: ,% Description General Ledger#'s Ref. # Amount Building & Building Misc. cpART,,:!1-44105, ( 9S 6 2)' 1 il,Electrical da y.1 0100b + 106 Plumbing & Gas 1- rtr9t O-44 07 Trench Safety v» 01000-4 29 LI Other Department Revenue rant b:4 4 2420 f White-Collector's Office Yellow Copy '. �-, k-Customer's Receipt Pink Copy-Rtilding Department Received$y THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS RESIDENTIAL 0 Phased Approval(R106.3.3) $25.00 APPLICATION FEE IS NON RE-FITVDA LE at NON-T8 ,�,uu : P; +:3:A.ff,;' r "= DARTMOUTH BUILDING DEPARTMENT � l s� � (o >r=_'�at=` 400 Slocum Road 20I3 DEC -7 PM 12: 32 Dartmouth, MA 02747 1/47::4 ,,/)1 Phone: 508-910-1820 Fax: 508-910-1838 www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING - THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY: BUILDING PERMIT NUMBER! DATE ISSUED: SIGNATUR4.E: tsLv1?Lp—��%'a� d � ^ DATE: /,'.' ? /S-' Building Commissioner/Inspector of Buildings Zoning District: S kg Proposed Use: Zone: t3X ❑B ❑A 0 V Aquifer Zone: THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: DPW ❑Board of 0 Board of ❑Cons. ❑Planning = 0 Address 0 Engineering 0 Cross`. Appeals Health Commission Card Connection ❑Fire`. 0 Gas ❑Electric ❑Other ❑Water Card 0 Sewer Card Chief Cut Off Cut Off Cut Off Cut Off DEPARTMENTAL APPROVAL(S) Board of Health: Signature: Date: Conservation Commission: Signature: Date: D.P.W.: Signature: Date: Fire Chief: Signature: Date: Other: Signature: /� Date: Brief description of work being performed: ✓ ! " '= SECTION 1-StRMATION / t 1.1 Property Address: 5 S-°Z"v/' 4 3'22 — 1.2 Assessors Ma &Lot Number: Contact Person: , &viil 4 k ' Map �6 Lot P) /7 Phone Number �p-,-296--�5�-"S 1.3 Historical District ❑Yes ❑ No 1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: Year Built 0 Municipal ❑ Municipal ❑Altering more than 25%per side of building ❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commission? ❑Yes ❑ No Date: Revised 5/13 El CONSTRUCTION PLANS ® SITE PLAN ❑ ENERGY REPORT RESIDENTIAL SECTION 2-PROPERTV:OWNERSHIP/AUTHORIZED AGENT - 2.1 Owner Record: Name(print) Contact Address Phone Number 2.2 Aut (zed Agent: • / rr — t— 121-726-e— ST Name print) Contact Address Phone Number . SECTION 3'-CONSTRUCTION'SERVICES , 3.1 Licensed Construction Supervisor/Specialty License: S License Number: Company Name/Contractor Name: 76— 44 /i Address: !J�� / 4 GCL- S Expiration Date: Signature: Telephone:,S?} �✓- 6r,“ // 3.2 Homeowne xemption-O &Two _ ec ion 110.R5.1.3.1 Exception: HOMEOWNER END TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT Exceptio ny Homeowner oNi rk for which a Building Permit is required shall be exempt from the provisions of this section;provides that if a Homeowner engages a r ire 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 sectio gn below: Signature: SECTION WOR- ERILCOMPENSATION,INSDONCE AFPIDAVIT(MGL C152§: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: 0 Yes 0 No SECTION 5.DESCRIPTION OP PROPOSED WORK(Cheek all applicable) ❑ Deck 0 Pool 0 Repairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove ❑ New Construction* 0 Accessory Bldg. 0 Addition 0 Roofing/Siding 0 Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) No.of windows Doors ❑ DEMOLITION (specify): Location of debris removal(per MGL C.40 Sec 54): 0 Dumpster on site 0 Dumpster On Street Facility Name: Location: 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): ❑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 ❑ Hot Water: Gas Electric Fuel Oil Other SECTION S=ESTIMATED.CONSTRUCTION COST Item Estimated Cost($)to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing • 4 Mechanical I) 5 Total- (1 +2+3+4) 1-17 SECTION7A-OWNERA0THORiZATION" "'." (to be completed-then owner's agent or.conttactbr applies forbullding permit) r (Please Print) , as O er of the subject property hereby authorize to act on my behalf, in all matters relative to work authori d by thi uildi permit a lication. /Z Si nature of Owner /S Date . ECTION 7B-OWNER/AUTHORIZED AGENT DECI-ARATION , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains . • penalties of perjury. //r- ! Z Signat .--of ! ne •uthori -di..--- Date SECTION.$-OFFICEi,INSPECTOR`S tNOTES " L---- Less Application Fee: $25.00 Remaining Balance: $ Total Permit Fee: $ 7r Other$Amount$ • Gross Area-New Construction total sq.ft. Gross Area-Alteration total sq.ft. OO Permit Issued to f O-nzi2. ..Jic.71,4,6e-eGr_Psy/G'� ;%SEGTIot 9,-DESCR1pfro pmo $EINGPERFORMED 9-C77YLL!�� Permit No. BP-79837 Project Location: 15 SUNDANCE RD Commonwealth :':,off Massachusetts ' ' �r fi ; zcs < '40Sl,�odYs l: 6 nou A0 b i80 i r -(50$ 10483Se ‘CPne 5 )9 - a�. Try>L=�D11 C7 l�° �� k- y s.f^yaw az �. ‘it--_,- Eak•kkq '� i�� i �. h as x'^ ° ' F,'. T-4-'7" , is'` 1* r } , „:ems, s - dS la: ...tee ,e i. s 1w r5 awfi`3 -N*4„A'a, a 0 FC€f,'i�i ,7 r 'su` wKs- R Contrae o e: one#: w < 'ti 0.1711±— x {' '705 7 508 295-6483 '�3 nr33233=, F ' k HERBFt "5P= �AG Eft v,3 :1 3i i y 9 y ) �JF, �= y4 h „;;;: f Engineer Y aa,�. , �,�rtv„,d° a s* ,id- Phone#. ''4341 , av116 iltoS €,.“,e Applicant: e 6 w�< w„ 1 Y Phone #: rkik�'•k �[a�f 7{tl' LEPAGE & SONS ROOFING 1`C �e}�te (508) 5 - tl a' 295-6483Lk" , , „—Liss •,, OWNER: ,-. k : b1 i+m va:B.SJ.a" )yi . ^`"'end �Q � VANGEL JACQUELINE _ . _,� '' ''' DATE ISSUED: /a 9/s TO PERFORM THE FOLLOWING WORK: Strip/re-roof residence DATE TIME TYPE OF INSPECTION&REMARKS - INITIAL'- - From:Ashley M Paiva FaxID: Page2of2 Date:423201510:06AMPage:2of2 LEPAAND-01 PAA2 4coRL7" CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDIYYYYI 4/2312 01 5 ITHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. This CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONT(508)678.0309 rNAAMEALT Ashley Paiva Viveiros Insurance Agency,Inc. NC°No Ertl: 508.676.0309 NC,Nol: 375 Airport Road E-MAIL Fall River,MA 02720 ADDRESS:APaiva@ViveirosInsurance.com INSURER'S)AFFORDING COVERAGE NAIC k INSURER A:Admiral Insurance Company INSURED Lepage and Sons Roofing,LLC INSURERS:Applied Underwriters 32 Pierce St. INSURERC: Rochester, MA 02770- INSURERD: INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POOL SUER POLICY EFF POUCYEXP N LIMITS LIR INSR VND POLICY NUMBER IMMIDD1YYYI IMMDW IYY) GENERALLIABILITY - EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERALLIABILRY CA000018541 11/26/2014 11126/2015 UAMAGt IUHtNIEu s 50,000 PREMISES(Ea PCDlrrence) CLAIMS-MADE X OCCUR MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 �GEN'LAGGREGATE UMITAPPUES PER PRODUCTS-COMP/OP AGG $ 2,000,000 A I POLICY n JFGT [1 LOC AUTOMOBILE LIABILITY COMBNED SINGLE UMR (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS _AUTOS BODILY INJURY(Per accident) S HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS $ AUTOS (PER ACCIDENT • UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB CIAIMS-MADE AGGREGATE• $ DED RETENTION S• $ WORKERSCOMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY[MIS ER B ANY ICERIMEMBERPEXCLUDED?A ECIRME YIN NIA 0830067 8/13/2013 8/13/2016 E.L EACH ACCIDENT $ 500,000 (Mandatory In Nlt) E.L DISEASE-EA EMPLOYEE S 500,000 If Yes,Jesuibe wide, DESCRIPTION OF OPERATIONS below E.L DISEASE-POUCYUMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD Tat,Additional Remark,Schedule,if more apace is requIred) Project Location: Capeview Seafood,Dartmouth MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE Town of Dartmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 400 Slocum Road ACCORDANCE WITH THE POLICY PROVISIONS. Dartmouth, MA 02747- AUTHORIZED REPRESENTATIVE - yi /} sr- I I U 4T ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD A whole house LePage & Sons Roofing Lic. 134094 CS-99705 Job name I Matt Van Gel gmatt vange1015-00350 address 15 Sundance Dr Town Dartmouth State Ma s k4 1 ,_ ,, § �S work I Date 1-Jul 508-295-6483 cell 1 j strip install mafllsq total/se #squares total I $ - 30 year ART i 26.00 1 $ 8,970.00 layover Pro 40 26.00 i $ 442.00 premium 30 year ART $ - special ! $ - second layer wood removal j $ - $ 9,562 Velux solar] $ - Grace adder 1.00 $ 150.00 extended additional charges: cost per qty: cost Dormer $ 70.00 dormer 1 $ - Hip roof $ 10.00 sq $ - Pitch 7-10 $ 15.00 sq $ - Pitch >10 $__-25.00 sq $ - valley $ 60.00 ea 6.00ISi 360.00 Chimney Flashing _ $ 350.00 ea $ - -- Tar paper $ 128.00 roll 2.00 $ 256.00 Ridge Vent $ 5.50 ft 45.00 $ 247.50 Dumpster j _ per quote job 450.00 Vent Boots $ 60.00 ea 1.00 $ 60.00 drip edge j $ 8.50 ea 1 $ - Ice&Water Barrier $ 3.00 ft 180.00 $ 540.00 Grace premium $ 1,914 Description of work to be performed: I Strip roof and haul away all debris. Ice and water the first 6 feet of roof deck then synthetic paper the balance of the roof. Apply ridgevent and remove and replace all pipe boots with new. I I I Grace ice and water to first 6 feet of roof deck. i j Certainteed Pro roof shingles spec'd j j ! Signed: Herbert P. LePage J color: Certainteed Pro weatherwood Total: J ! $ 11,476 I Deposit(50 % req'd before material delivery) paid # -6000 o T paid #9248 $ (5,476) requested start date BALANCE DUE $ (1) Special instructions Page 1 Details Page 1 of 1 The Official Website of the_Executive Office of Public Safety and Seculity(EOPSSI i Public Safety . I "'.vats, . Mass. ,7�, Mass ov`ome State Agenaes ,�J' `^r & S ., a _!,,i*s i n*w C „t 1 }t-t �RR 9"x"�' 'ter ': C 7 rt _: zr 'z :W uc.:72z is . ii,;.aes.,.`uc"ai':;+ ga v...-.34,� a. ..,_5' _. v.. -.h ";..#4 a�aav �, .. 0 ..".,mL,v . .. .l._ .. > .1 >. .. _irensee Details pamograph u ic Informs g ll ame: T P LEPAGE Gender: Owner Name: cense Address Information dress. Address 2: City: ROCHESTER State: MA Zipcode: 02770 ountry: U ted tates [cense `fin orrmation [cense o: CS 0 License Type: Construction Supervisor Specialty Profession: Building Licenses Date of Last Renewal: 1/10/2014 Issue Date: Expiration Date: 1/6/2016 License Status: Active Today's Date: 12/7/2015 Secondary License: Doing Business As: atus Change: Li ns Renewal reregi e L Remati on nicensee: Relationship: Attribute Of License No: CSSL-099705 Discipline No Discipline Information I Documentum rClose Window ©2011 Commonwealth of Massachusetts Site Policies Contact Us CI L ropy http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=1&license_id=288570& 12/7/2015 Office of Consumer Affairs&Business Regulation-Mass.Gov Page 1 of 1 The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) Consumer Affairs and Business Regulation ,,. Home Consumer Rights and Resources Home Improvement Contracting HIC Registration Complaints (\/1 Affairs a uns Ragulalion geneses.:maw anourr : Registration# 171452 Home Improvement Contractor Registrant LEPAGE AND SONS ROOFING LLC. Registration Home Page Name HERBERT LEPAGE Address 32 PIERCE ST City, State Zip ROCHESTER, MA 02770 Expiration Date 03/19/2017 • orComplaints Details CCI?� No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search ©2012 Commonwealth of Massachusetts. Mass.Gov®is a registered service mark of the Commonwealth of Massachusetts. httnsq/services.nca.state.ma ns/hic/licdetails.asnx?txtSearc,hTN=73'i36 17/7/2015 The Commonwealth of Massachusetts 1 1 Department of Industrial SMII 1 Congress Street, Suite 100 4?e:: E J-{o„®" Boston,MA 02114-2017 _� www.mass.gov/dia «Yorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH 1HE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): l//I C 24"— Address: hZ j/fe`/Z6-- S 7 City/State/Zip: /C % /t.� Phone#: , 5c-ey9 o>reS Are you an employer?Check the appropriate box: Type of project(required): � L1Ett-nt a employer with employees(full and/or part-time).* 7. El New construction 20 I am a sole proprietor or partnership and have no employees working for me in 8. Ei Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doingall work myself 9. ❑Demolition y [No workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.nRoof repairs These sub-contractors have employees and have workers'comp.insurance.[ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'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. tContractors 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: SUiC ? 4tOev(o&fZ(nj'C Policy#or Self-ins.Lic.#: .?_.;j GCS& L7 Expiration Date: Job Site Address: f L cil/ on - )/PI' City/State/Zip: ' net. tY P �` Z��. ( Attach a copy of the workers' compensation policy declaration page(showing the policy num-er and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify underlhe pains' amities of perjury that the information rovided above is true and correct. Si nature: /� Date: 3- 7 Phone#: /%G. tom'. Official use only. Do not 'e in this area,to be conrgfetedfiy city or town official. ..----- Cityor Town: Permit/License# Issuing Author' irdeone): 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 Department's address,telephone and fax number: • The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia