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BP-54513 Permit No. BP-54513 BUILDING p attPERVIIDp „Gig# 4037 00 C.ommwnabl o1 tlla¢yaaaetb Map; 10976 ? TOWN-orDARTMOUTH,: ot::- ..6024,,;`: .�. 400 Slocum Road Dartinouth,;MA 02747 Sub Lot: 11. , .0005 phone:.($08)910-1820 (508)910.1838 Category: ':TO INSTALL Project ._ ;,JS-2009-000680:` PERMISSION IS IIEREBY _GRANTEDTO: Est.Cost:. ,$3500.00 - JR Fee:-. ,-$75.00�: Contractor. - cense: Phone#. Const Class: _ _ ^= ROBERTCABRAL. "4 I#Lk5796 -,(508)993-5577 : Use Group B4 ! Engineer: tot size(sq ft}> 1J8A i Zoning '" 'SUB 4pplicant. ' a Phone tad New Const IV A/A . > JOSEPH M DASILVA (508)998,8952 Alt.Coast A OWNER: "- ,+ Date.Typed 09Y9-2008 DASILVA JOSEPH M&"DQNNAJDA&1L"A DATE ISSUED: f '1 t, / _ TO PERFORM THE FOLLOWING WORK: Install HAMPTON HI300 fireplace wood insert Project Location: 19 SHINGLE ISLAND LN Approved/Issued By: I;.�f•W..r.{ - -. DAVID BRUNE E,LOCAL BUILDING INSPECTOR 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 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 Buildin Zoning Permit. Signature of Owner/Agent: Comments: PERMIT NUMBER IS REQUIRED WHEN REQUESTING INSPECTIQNS/RF-INSPECTION FEES 141IJST BE PAID BEFORE RECEIVING ANO1 HER,INSPECTION/REPLACEMENT EEE WILL ItgoeQVIIEWOE 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 • t -N TOWN OF 43ARTMOUTH BUILDING RECEIPTS ' ; I X COLLECTOR'S OFFICE ' f_ / 7 Name ' J I 1 ash . perty .J r.:-l 4l / `! /` "' -fie w. til . ''�. i.�::.. Date: r� Owner: Job Locat • ion: . fl L-'" •\ f '"// l / r i'. White Copy-Collectors Office Plot: - ` t _ ✓ Lot: jC j7 Yellow Copy-Customers Receipt yt_ Pink Copy-File Copy Green Copy-Building Department Phone: - - Description General Ledger#'s Ref # - / Amount License&Permits-Building 01000-44105 ( ;'/ 7 fi}� /�� e;'' ' / License&Permits-Building Misc. 01000-44105 License&Permits-Electrical 01000-44106 TOWN OF DAfl ; . 1 License&Permits-Plumbing&Gas 01000-44107 COLLECTOR'S OFFICE Other Department Revenue 01000-42420 SEP 1 g 2008 This is not a Permit or License for Building,Plumbing or Gas Received By: \' ' 1 1 SO 3-7qz. RESIDENTIAL ❑ Approval in Part(Per 780CA:R.5111.13) CDC -OACit:4P ' it-%"9%`s'S' ¢ $25.00 APPLICATION FEE IS NON RE-FUNDABLE & NON-TRANSFERABLE DATE RECEIVED in,. DARTMOUTH BUILDING DEPARTMENTT. f 9 �; 400 Slocum Road, P.O. Box 79399" _ , - rn , 2 52 ,i a i Dartmouth, MA 02747 y ' Phone: 508-910-1820 Fax: 508-910-1838 -IRfi9 www.town.da rtmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING IS SECTION FOR OFFICIAL USE ONLY LL RECEIVED BY. BUILDING PERMIT NUMB EE3} DATE SENT FOR REVIEW: DATE ISSUED OK TOISSUE-SIGNATURE: tJ� %�a ttLs. �t#zcJ DATE: �� Z� Zoning District __ Proposed Use: Zone O B ❑A EI V Aquifer Zone ' THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: '" ❑Board of - ❑Board of 0 Cons. ❑Demo 4 O DPW • `ElElec. .0 Energy Report -` Appeals Health .Commission Affidavit "Card Sent ;' Cut Off • - Follow-up* O Fire O Gas ❑Planning ❑Sewer Card .: O Water Card Zoning•., ❑Other „Chief Cut Off -Board '.Cut Off._ --Cut Off *REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A`PERMIT. s DEPARTMENTAL LAA PROVAL Zoning Review: Signature: C7�+^�Gr/4e.4., Date: 7 it-1,l—) 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: ,ym'Sv a u.. WOO _i AisO?..'r SECTION 1 -SITE INFORMATION 1.1 Property Address: 19 MA/6CC /SCAALA LA NE 1.2 Assessors Map Lot Number: y „...-- Lot Area (sf.) Frontage Map LotLa - 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 0 No Date: 1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: ❑ Municipal 0 Private Well 0 Municipal ❑ On Site Disposal System 0 CONSTRUCTION PLANS ❑ SITE PLAN 0 ENERGY REPORT RESIDENTIAL SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner Record: TorEPH m. DA-r/Cvla l9 S ,',GLe /rCAN& tn<, bAarncu'N asa Name(print) Contact Address hone Number (rob)99T-8 94".2 2.2 Authorized Agent: A5 4-Ifki 11P912e).1 C rrinlvi �� S'iA r . 1 t6V1� Name(print) Contact Address Phone Number SECTION 3 -CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Ka.); i-1e 2 ,/( Not Applicable 0 Licensed Construction Supervisor: License Number: CS L'r73O i l Address: 3(,) £orrIL) .Ib S ;�,F�-•-r'1 cow—a,ta.t -OA QzYLy Expiration Date: Signature: � Telephone:j, <Cj53-rc j) /—o -o9 3.2 Registered Home Improvement Contractor: Not Applicable 0 Are you a Home Improvement Contractor subject to(780 CMR.110.R6)? fd Yes 0 No If No,go to the next section! Are you claming exemption from the requirements? ❑Yes 0 No J� 'I If Yes, submit the required affidavit! Company Name:ASA 1-icJA ( I jr2:il j. Ct t'n nlL—(/ Registration Number(if none, state"none"): Address: /OS STXFT '2oArb : /i; i niat-rYnoc5iM1 t v n k /ts7S(r, Signature: f Telephone/lCy'c3 5'S77 Expiration Date: ?y-y er 711 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 trick)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 carries 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: ❑Yes ❑ No SECTION 5-DESCRIPTION OF PROPOSED WORK(Check all applicable) ❑ Deck 0 Pool 0 Repairs 0 Alteration 0 Chimney/Fireplace 0 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): ❑Boiler(heating)-fuel gas(natural or propane),fuel oil,electricity,other(specify): 0 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: JQrs-TA C3ucTh i,tilS 2-r 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) J 2)y?}j)` SECTION 7A-OWNER AUTHORIZATION (to be completed when owners agent or contractor applies for building permit) (Please Print) I, TafEPH m. bAJ'(L VA ,as Owner of the subject property hereby authorize Ask f 4 LJPr/ H c.Afl4 to act on my behalf, in all matters relative to work authorized by this building permit application. 4Cn,,ue �41/ `7//9,o2org / Sig ture of Owner Date SECTION 7B-OWNERIAUTHORIZED AGENT DECLARATION I, 3i-T i-1/,JAI Pc31.Z")4 'C-1 u 4 J,L , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurhte,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Signature of Owner/Authorized Agent Date SECTION 8-INSPECTOR'S REVIEW/COMMENTS L 1. Date plan reviewed: I I' 2. DENIED (see project review worksheet): Date: 3. HOLD �,/ � Reason: /t .t? __ Date: 4. HOLD subject to Zoning Board of Appeals action: Date: Comments: 9 Inspectors Signature: 11�K-!�r^.lt� / Yam-"✓j" -----. Date: /' 1Z SECTION 9-APPLICANT NOTIFICATION Applicant informed of above: Date: Time: Clerk: Comments: SECTION 10-OFFICE/INSPECTOR'S NOTES - 1 r Less Application Fee:$25:30 Remaining Balaae' Total Permit Fee: $ Other$Amount$ ----73 TOTAL FEE: Gross Area-New Construction total sq.ft. Gross Area-Alteration total sq.ft. Permit Issued to: 17 1 t ST /1 1) ✓ Agi .(%T U / . ern U4.Leyeyeec ''�� LJUtz (lc iiusevc. r SECTION 11 ADDITIONAL COMMENTS/SKETCHES -. SA"1,4 ?.d/4,../ Len. /Ct!ji.nh� ��i m • /' 'ermit No. BP-54513 Project Location: 19 SHINGLE ISLAND LN Commonwealth `of' Massachusetts TOWN OF DARTMOUTH Mep : 00�6°° 400`Slocum Road,Dartmouth,MA 02'747 Lat.'. ,0'024 D PPhoone '(508)910-1820 Faz: (508)910-1838 Snblot'` `` 0005 B V Il .DING PF,RIVIIT Category: TO INSTAT T ' Project# JS-2009-000680 Est.Cost: $3500 00 FIELD INSPECTION Pee- $75>00 Const:Class: Use Group: R4 Contractor: License: Phone#: Lot Size(sq.ftJ 1.18A ROBERT CABRAL 111-125796 (508)993-5577 Zoning: SRB Engineer: License: Phone#: New Const.: N/A Alt:Censt.: 4 k Applicant: Phone#: Ceiling: JOSEPH M BASILVA7. (508)998-8952 Walls; OWNER: Floor; DASILVA JOSEPH NL ,DON A J BASIL Glazing: DATE ISSUED: ,���_ "�' `� TO PERFORM THE FOLLOWING WORK:• Install HAMPTON HI300 fireplace wood insert DATE TIME TYPE OF INSPECTION&REMARKS INITIAL /(-ZZ�� �jsf gurni( -K_.,� b/-c om:Diane Trepan(er At Hadley-Insurit Group FaXID: To:Bianca Date:4/24/2008 03:37 PM Page:1 of 1 - ACORD. CERTIFICATE OF LIABILITY INSURANCE OPID DT DAM(MM!DD/YYYY) ASHAW-1 04/24/0S>RODUCER T - • • HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION - ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Insurit Agency, Inc. - - HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 246 Duress St ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Fall .River .NA 02720 - Phone: 508-672-0551 Fax:508-673-0322 INSURERS AFFORDING COVERAGE NAIC# NSURED - � INSURER A: James River. Insurance Co INSURER B: am Inc./Granite state Ins Co. Ash Awa Hearth & Chimney, Inc INSURERC: - _ 703 State Rd INSURERD: No. Dartmouth MA 02747 INSURER E: *— COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTNRHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTM RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AU.THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _TIT NSRD TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDNYI DATE(MMIDD ) LIMITS • GENERAL LIABILITY • EACH OCCURRENCE A X COMMERCIAL GENERAL LIABILITY 00011408-2 0E/12/07 08/12 08 1MN Qt 1Utttry1� S50,00,c00 / PREMISES(Es occurance) $50,0c0 CLAIMS MADE X OCCUR • MED EXP(Arty one person) $Excluded PERSONAL&ADV INJURY $S,OOc,000 • GENT.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 • PRODUCTS-COMP/OP AGG $2,000,000 POLICY 11 JECTP ri LOC - - - AUTOMOBILE LIABILITY • - ' • ANY AUTO COMBINED SINGLE LIMIT (ES eeGtlen[} $ ALL OWNED AUTOS SCHEDULED AUTOS - BODILY INJURY • (Per person) $ 1 • HIRED AUTOS - NON-OWNED AUi05 • - BODILY INJURY (Per scolded) $ PROPERTY DAMAGE - (Per ecNtlent $ GARAGE LIABILITY ANY AUTO I` AUTO ONLY-EAACCIDENT $ OTHER THAN EA ACC $ - AUTO ONLY: EXCESS/UMBRELLA LIABILITY Ate' $ _ EACH OCCURRENCE $1,000,000 A X OCCUR(( ���� ( CLAIMS MADE 00011425-2 08/12./07 • '08/12/08 AGGREGATE S1,009,000 DEDUCTIBLE ' . - $ X RETENTION $ . $ WORKERS COMPENSATION AND - $ VVY AT UTH- LrTY • EMPLOYERS'LIABI ITG aI RY LIMITS I ER B ANY PROPRIETOR/PARTNER/EXECUTIVE WC 6970607. 04/24/08 04/24/09 E.L.EACH ACCIDENT $100000 OFFICEWNIEMBER EXCLUDED? • . (ryes,describe under E.L.DISEASE-EA EMPLOYEE $100000 _ SPECIAL PROVISIONS below: • - OTHER E.L.Di$FA.F-POLICY LIMIT $S00000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS .. — t • CERTIFICATE HOLDER • CANCELLATION y441 • INSU'002 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION . DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN • - NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 60 SHALL INSURED IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED RC-PRESENTATIVE Paul C. Burke, LIA CIC CRM ACORD 25(2001108) • I 0 ACORD CORPORATION 1988 07-30-'08 08:51 FROM-Ash Away Hearth & Ch 508-993-5588 T-076 P001/001 F-296 & a o/Sac e ^ �aff ff' Board of Building Regulations and Standards r ►(_ �r One Ashburton Place - Room 1301 •z._- Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 125796 Type: Private Corporation Expiration: 3/4/2010 Tr# 265133 ASHAWAY HEARTH &CHIMNEY INC. ROBERT CABRAL 703 STATE RD. DARTMOUTH, MA 02747 — Update Address stud return card.Mark reason for change. Address 0 Renewal El Employment 0 Lost Card ascot © saM-ouosreseas gmanonevecta o/. as 4 .ea Board of Building Regulations and Standards License or registration valid for Individul use only ii.":n 9� G�, s"v HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to; Board of Building Regulations and Standards iRegistration: 125796 One Ashburton Place Rm 1301 •`�.e Expiration: 3/4/2010 nit 265133 Boston,Ma,02108 Typo: Private Corporation ASHAWAY HEARTH;&CHIMNEY INC. 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Airrvtct,.'T J, MA Phone it: SSTs-`- -- 5c47 Are you an employer? Check the appropriate box: Type of project(required): 1.® I am a employer with 1:0 4. n I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.n I am a sole proprietor or partner- listed on the attached sheet. : T n 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. ❑ We are a corporation and its required.] officers have exercised their tan Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' comp. insurance required] 13.n Other L JO -1 %�eT `Any applicant that checks box it 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 suck *Contractors 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. �-f..._1 n5"'� O `� Insurance Company Name: � � �rA—� _.1-�JS Policy#or Self-ins. Lic. #: LA3G S j c ?iz) Expiration Date: q-z 4-0 9 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the pains and penalties of perjuty that the information provided above is true and correit. Signature: It Date: 5--?-z-o.eir Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as "an individual,partnership, association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have L,uployees, 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 Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia