BP-49136 Permit No. BP-49136 BUILDING P EMIT
Tore "v. TOWN OFDtRT' 1OUTJI
i 4 , 1b1 ail l 400 Slocum to id °Dartm outk 0274 "
Phone (508}91 1$20 o I i 08)9 0 l$38
PERMISSION HERE YGRA TED TO:
Contractor. a e� Phone it;
4 1,44
a a3s, " LEONARD J SIMAvSKt 9$„ (5Q8230�
' Engineer: ic
Phone#
� ..a
p + tt Ttr, Applicant: F V.
Phane#�
• A 1 ROOFINGf&cVI'IP�QWS � :- °(508)230 5025
r OwwER:
eon,"te t.. ' CANTO ROGER,B€a& � �4� -a 4
DATE ISSUED:
TO PERFORM THE FOLLOWING WORK:
Strip/re-roof
P-,jet Location:. 5 LD PIERCE RI)
Approved/Issued By: '
DAVID W MAT OS,LOCAL BUILDING INSPECTOR&ZONING ENFORCEMENT OFFICER
All work shall comply with 780 CMR 611I 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 111.8(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 a ies may have reason to OP WORK i tems under their jurisdiction are not met; not
withstanding the issuance of this Building/Zoning Per it.
Signature of Owner/Agent: /
Comments P ;R IilillR v ._..
°� � s� `� ,
"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
f
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 IQ 0 rt
'BUILDING RECEIPTS !
r COLLECTOR'S OFFICE
_ fj N /
. J ar% j r'f.va ' ,..-! '{r r, 1...-1 r /f -j
Name 7r 4, .-/ f Troperty ! Date: ,r' i-i �/
Owner: ._ t
Job Location ,.— / 1.1':d '- '' i
`, ' , '�—.---,-C-7 .��'�.'_-- ` /' `` -- 1-c�vVt�l oP IDAATMOU
TO
rt , j ai i FrrOR'C OFFi cite Copy-Collectors Office
.- i f Yellow Copy-Customer's Receipt
Plot: l, I ;' Lot: 1 ,;.
f / - / = ' ; 1 ak 3 0 Z =Pink Copy-File Copy
Green Copy-Building Department
Phone: !r: _ ,..,
p a
NM cil
..�. � ...,_sue��d�
Description General Ledger#'s Ref.# Amount
License&Permits-Building 01000-44105 �zr a, r.=`r c.—
License&Permits-Building Misc. 01000-44105 f:'
License&Permits-Electrical 01000-44106
License&Permits-Plumbing&Gas 01000-44107
Other Department Revenue 01000-42420
j
This is not a Permit or License for Building,Plumbing or Gas Received/By:F��`
0 SPECIAL PERMIT(Per 780 CMR 111.13)
$25.00 APPLICATION FEE IS NON RE-FUNDABLE az NON-TRANSFERABLE
DATE,RECEIVED
"���"��;`-. DARTMOUTH BUILDING DEPARTMENT `'
,. '1l 400 Slocum Road P.O. Box 79399
%-y � T Dartmouth, MA 02747
° . sy' Phone: 508-910-1820 Fax: 508-910-1838 • , . - . ,)•. r.
1 fi64���
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS E TION FOR OFFICIAL USE ONLY
RECEIVED BY: BUILDING PERMIT NUMB R: V 9,,
DATE SENT FOR REVIEW: t30 7
DATE ISSUED: x-3f J 6 7
O.K.TO ISSUE-SIGNATURE: i 7" �! GLitil
f DATE: �./�3 r/0 ?
- l
Zoning District: S r ( Proposed Use: �Iz'J Zone: 0 C ❑ B ❑A ❑V Aquifer Zone:
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑Board of ❑Board of 0 Cons. 0 Demo 0 DPW 0 Elec. ❑Energy Report.;
Appeals Health Commission Affidavit Card Sent: Cut Off Follow-up*
0 Fire 0 Gas 0 Planning 0 Sewer Card 0 Water Card ❑`Zoning 0 Other
Chief Cut Off Board Cut Off. Cut Off
*REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DE RTMENTAL APPROVAL
Zoning Review: Signature: /L9 <ZC'i �� -' Date: � 3//0
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 1 -SITE INFORMATION
1.1 Property Address: IS 0,c.. spree i 1.2 Assessors t• ; Lot Numb :
1� L� '�
Nearest Cross Street: 4 tSt1i ( � Map i _ Lot
Subdivision Name:
1.3 Historical District ❑Yes ❑ No
Total Land Area Sq. Feet: Has application been submitted to the Historic Commission?
❑Yes ❑ No Date:
1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Private Well ❑ Municipal ❑ On Site Disposal System
0 CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner Record:
PO CIS/r- Co-A--to - is oil raltYrc-,f R,1 edi,41, DI, 9cc 13VC-
Name(print) Contact Address Phone Number
2.2 Authorized Agent:
L vvori &11=&i i r 1- ,solit 4 cep S2A ).30:sbar
Name(print) Contact Address O23A- Phone Number
SECTION 3"-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Leo,,44 1 Not Applicable 0
Licensed Construction Supervisor: 1.-.,ea,,,z_ License Number: 01.b
() Address: 1 t Ly 0 h ych,11414-61:c')( Expiration Date:
LLI Signature: i Telephone:
CO
z 3.2 Registered Home I rovement Contractor:
Not Applicable❑
W
0 Are you a Home Improvement Contractor subject to(780 CMR-6)? 0 Yes 0 No
If No, go to the next section!
u. Are you claming exemption from the requirements? 0 Yes 0 No
0 If Yes, submit the required affidavit!
aCompany Name: t, Si t w�,gl&`. At. ry G,npy J- Registration Number(if none, state"none"):
O Address: / tI t-s7 04 ' /,g c f�� ()2,V)k ! -`1�1'1
Signature: Telephone: nrb Pl Expiration Date: - (o 0
3.3 For Residential Rem el 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
0 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
1091.1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0,effective July 1,1982,no individual
shall be engaged in directly supervising persons engaged in construction,reconstruction,alteration,repair,removal or demolition involving the structural elements of buildings
or structures,unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction
Supervisors.
Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section;provides that if a Homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor.
For the purposes of this section only,a"Homeowner"is defined as follows: Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which
there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than
one home in a two-year period shall not be considered a Homeowner.
If you are applying under this section sign below:
Signature:
Your signature carries certain responsibilities,including but not necessarily limited to,general liability
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction
Supervisor,whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
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 0 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. )(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):
❑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: <-4-nh re S {'r� y;c�cn f r f' Sww,,<
AeLn.v Cta ,/04- --744,71p.1 Gvy -
SECTION 6-ESTIMATED CONSTRUCTION COST
Item Estimated Cost($)to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical(HVAC) jt'9
5. Total=(1 +2+3+4) J
/ i`
SECTION 7A OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(Please P ' ) <
I, �1 •Q I(l GAj�a , as Owner of the subject property hereby authorize Z.-ek J 1141c4(4' At f�j 4ax.pCh
to act on my belf, in all matters relative to work authorized by this building permit application.
(. c'c/A.)
Signatu f Owner D
SECTION 7B-OWNER/AUTHORIZED`AGENT DECLARATION
I, 1,_,,A31.,4,-1 c LZ'�► , 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 an enalties erjury.
Signature Owner/Autho ed Agent Date
SECTION 8-INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2. DENIED(see project review worksheet):
Date:
3. HOLD
Reason: Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
ff/�
Inspector's Signature: /(,t/ ' � -`Y� Date: N....c71.7.///Ci 7
SECTION 9-APPLICANT NOTIFICATION
Applicant informed of above: Date: Time: Clerk:
Comments:
SECTION 10-OFFICE/INSPECTOR'S NOTES
Less Application Fee: GO ?cc', C7C Remaining Balance: $
Total Permit Fee: $ ,S C 0
Other$Amount$
TOTAL FEE: 2<-C C) Gross Area-New Construction total sq.ft.
Gross Area-Alteration total sq.ft.
Permit Issued to: S / /n / /° .¢ /n/ /rYY00 >
SECTION 11 -ADDITIONAL COMMENTS/SKETCHES
��r lc
,��, Sg_�� ° s �rofe�t Location: 15 OLD PIERCE RD
Common assdchusettS
TOWN OFF ART MOUTH M #• �� 0080°°
400'.°Slocum Road,Dartmouth,MA 02747 Lot ,,,J1012
Phone.
(508)910-1820• Fax (508)910-1838 Sublot ,, 0004
BRIT ,DING PER-IVIIT projectg # xc OF
5-2007 02730
$S9$5•00 Est Cost
FIELD INSPE CTION Fee: 5 0°
Coast:Class
Contractor:
License: Phone#: Ube Group R4
LEONARD J SIMANSKI License.
102e98 (508)230-5025 Lot Size(sq ft,). 2 42A
Engineer: License' Phone#: Zor�ing SRB
New Const 1 T/A
Alt Const ,' `` NIA
Applicant � Phone#:License-
Ceiling: �.
A 1 ROOFING &"WINDOWS (508)230-5025 Walls
OWNER: �'.
Floor:. , _-
CANTO ROGER B'&KIlVIBRA Glazing:
DATE ISSUED: /�/10
7 ;sr" , ,
TO PERFORM THE FOLLOWING WORK:
Strip/re-roof
v
DATE TIME TYPE OF INSPECTION&REMARKS J INITIAL
-1.- Y � ,� Th' -- � �,�
i
I
4
g2e -6 „( .,.
_,...„
tri.v.! Board of Building e ulations •
=- One Ashburton Pace, Rm 1301 .,f }
Boston, Ma 02108-1618
License: CONSTRUCTION SUPERVISOR LICENSE Birthdate: 02/29/1956 ,
Number: CS 020218 Expires: 03/01/2008 Restricted To: 00
LEONARD J SIMANSKI
11 LYNDA RD
SO EASTON, MA 02375
Tr. no: 14501
Keep top for receipt and change of address notification.
DPS-CA1 0+ 50M-04/05-PC8698
..ciiite -c
�n--,....„___,__ji„--- Board of Building Regulati ns an Standards
Qt,------7/ One Ashburton Place - Room 1301
= Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 102998
Type: DBA
Expiration: 7/6/2008
Al ROOFING & WINDOWS
Leonard Simanski I
11 Lynda Road
S. Easton, MA 02375
I
Update Address and return card.Mark reason for change.
- Address Renewal Employment Lost Card
DPS-CA1 0 50M-05/06-PC8490p J,/
6�7tte eo�nmtoouueaa of/iiac sadu e `_:
Board of Building Regulations and Standards License or registration valid for individul use only
i�-* y1t=�7 HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
.� Board of Building Regulations and Standards
X — Re istratton:
�� 9 102200 One Ashburton Place Rm 1301
Expiration:;_ 7/6/2008
- Boston,Ma.02108
Type:.DBA
Al ROOFING&WINDOWS
Leonard Simanski -.
11 Lynda Road N '' � i
S. Easton, MA 02375 Deputy Administrator Not valid without signature 4 f�
FiLEILE COpyr .
,y. .
r
Apr 12 07 11 : 55a ALPHA INSURANCE AGENCY 978. 459 6131 p. 1
AC
DATE(MM/DD/VYYY)
ORD
,M CERTIFICATE OF LIABILITY INSURANCE I DATE
PRODUCER (978)459-4547 THIS CERTIFICATE IS:ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS.NO RIGHTS UPON THE CERTIFICATE
Alpha Insurance Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
House Account ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
11 MiII Street
Lowel I, MA 01852 INSURERS AFFORDING COVERAGE N/I,IC#
INSURED M & C ROOFING
INSURER A:P ENN AMER I CA
_
55 AGAWAM ST #11 INSURER B:Safety Ins Co —
LOWELL, MA 01852 INsuRERc:Granite State --
•
(978)361-7074 Ext. INSURER D
INSURER E:
COVERAGES
THE POLICIES OFBELOW HAVE BEEN ISSUED TO THE INSURED NAMED AVE FR 7HE POLICY PERIOD INDICATED.NOTWITHSTN
ANY REEQUIREMENT,STERM OR CONDDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RBSPECTOTO WHICH THIS CERTIFICATE MAY BE ISSUED OAR DING
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LIMITS
WW1 ADD'L • POLICY EFFECTIVE 1 POLICY EXPIRATION
LTR NSRD TYPE or INSURANCE POLICY •
NUMBER DATE(MM/DD/YV) I DATE IMM/DD/YVI
EACH OCCURRENCE S 1,000500
GENERAL LIABILITY -DAMAGE tU RENTED 60 000
X COMMERCIAL GENERAL LIABILITY 9957419 01/05/2007 01/05/2008 PREMISES(Es accurenoe) $ —. 5,000
MED EXP(Any one person) $
X I CLAIMS MADE OCCUR 1 PERSONAL&ACV INJURY $ 1,000,000
A
GENERAL AGGREGATE $ 2,000,000
PRODUCTS•COMPIOPAGO $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
•
POLICY PRO-- LOC
AUTOMOBILE LIABILITY COMBINED(Es BINED SINGLE LIMIT $100/300 nl)
X ANY AUTO 5053578 02/09/2007 02/09/2008 c
ALL OWNED AUTOS BODILY INJURY $ 100,000
(Per person)
B SCHEDULED AUTOS
HIRED AUTOS BODILY INJURY $ 300,000
(Per accident)
NON-OWNED AUTOS
PROPERTY DAMAGE $ 100,000
(Per accident) i`
i
AUTO ONLY-EA ACCIDENT $
GARAGE LIABILITY
OTHER THAN EA ACC $
1ANYAUTO AUTO ONLY: AGG $
EACH OCCURRENCE $
EXCESS/UMBRELLA LIABILITY
AGGREGATE $
OCCUR CLAIMS MADE
•
DEDUCTIBLE
$
RETENTION $ WC STATU- OTH-
WORKERS COMPENSATION AND X I WO LIMITS I ER
EMPLOYERS'LIABILITY 0385324 01/05/2007 01/05/2008 EL.EACH ACCIDENT $ 500,000
OFFICERIMEMBR/PARER EXCLUDED?XECUTIVE
C. ANY PROPRtE E.L.DISEASE-EA EMPLOYEE $ 500,000
It yes,describe under E.L.DISEASE•POLICY LIMIT _$ 500,000
SPECIAL PROVISIONS below
OTHER I I•
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS .,
CERTIFICATE HOLDER CANCELLATION •
•
Al ROOFING SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
14 Linda Rd 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 80 SHALL
Easton MA 02375 IMPOSE NO OBLIGATION • ABILITY OF Y IND UPON THE INSUREF,Sye}�OPJJTS OR
REPRESENTATIVES.
i .
AUTHORIZED REPRESS T' I '
•
ACORD 25(2001/08) 0 ACO CORPORATION 1988
di Liberty _.
pit Mutual.. Liberty Mutual Group
P.O.6o.,-_02
Portsmouth, NH 03tc:-
Telephone: (800) o5= tea=
October26, 2005 FAX: (603)
E Mail: I\l5 Libert.
LEONARDSI:\IANSKI DI3A Al ROOFING
11 LYNDA RD
SOUTH EASTON, `IA 02375
RE: Your Workers Compensation policy
Policy number: WC2-31S-331198-035
Effective date: October 0S,2005
Dear Policyholder:
Liberty Mutual is pleased to have been selected to service Your Workers Compensation povc'.. We are
completing our review of your application and e\pect to send Your policy, along with an e''.p:.i:'.,,,,ory service package. within thenext 30 days. However, to assist You in the interim, we are
with your newly assigned policy number, (referenced above). �u
It you need to report a claim, please fa\ to 1 :
For all other claims related issues, please call (•3C-0) 702-502�.
Prompt reporting of accidents is critical. It enables us to get in`,ok ed in treatment eari'.-,
medical costs and set the stage for a successful return to work. -•-_
For certificates of insurance, underwriting, billing or loss prevention questions, please cal.
For any other questions You may have. please contact Your producer.
Producer of Record: VIVEIROS INS AGCY INC
Producer Phone No. (50S) 252-3312 se
If you open operations in additional states, please contact Your producer. Depending on t7,2 . we may
or may not he able to provide coverage for
• ‘\'e look forward to servicing your business.
Sincerely,
Jeff Eldridge
Involuntary Market Operations
cc: VIVEIROS INS AGCY INC
FILE copy
IM00260995 WC2-31S-331198-035
Page-1
The Commonwealth of Massachusetts
ar_ Department of Industrial Accidents
= =. Office of Investigations
600 Washington Street
°'l�'= ' Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibly
Name (Business/Organization/Individual): L ,. cc-/ S (L
Address: if L\1 4t
lee"
City/State/Zip: .S 1->"WI j vlik Phone #: 5 ,)30 SOS
Are you an employer?Check the appropriat• box: Type of project(required):
1.❑ I am a employer with 4. PV am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. $ 7 ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
E
required.] officers have exercised their 10.0 lectrtcal repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.]t 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 their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: CU' (Wed- S e ' ceJ J b-.JC Ao rij ,
Policy#or Self-ins. Lic. #: 0343 5 YXy qf'r,tt15. Expiration Date: 191 %S^ o tt 1<s -6$
Job Site Address: i 5— 00 P'trsr ✓j 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 certif u er the pains a d Wallies perjury that the information provided above is true and correct.
Signature: Date: S- 3 i1'
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
F I n
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the 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