32A-088 (2) ° �'° -� The Commonwealth
of Massac ZIISettS .
Department ofIndustrial Accidents
f=ib V M
,
4IV n 1 0 . �.,'`- j� Office of Investigations
• 600 Washington Street •
p u p rl -
Boston, ML4 02111
www.massgov /dig
Workers' Compensation Insurance Affidavit: Builders/ Contractors (Electricians /Plumbers
Applicant Information
Please Print Legibly
3Ille ( Business /organization/Indivi / ) vll t S I{ r,,, zt i. �2 ✓� T.�d62
Address: 3p C�t�e e /f y
City /State/Zip: <4e.:_
1y �, -, P 0
� .... Phone. #: c �rT"
Are yo employer? Check the appropriate box:
p 4. 0 I am a general contractor and I
Type of project (required): i'
l • I am a employer with -
employees (full and/or part - time).* have hired the sub - contractors 6. 0 New cons
onstruction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub - contractors have 8. 0 Denoli;ion
working for me in an ca act employees and have workers'
Y p t5' 9. 0 Building addition
[No workers' comp. insurance camp. insurance
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. I am- a- homeowaer- doing- all -werlc- - -z5 ave. ercaae- their ----I-L0 Plumbbingrepairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 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 #I 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 is the policy and job site
information. / ,
__ __ Insurance Company Name: l G n _ �' of / t / e —
Policy # or Self-ins. Lic. #: ? 7 '/ 5 '0 . Expiration Date: �'cf el
Job Site Address: t L (r cif') ,fie Cit /Statelzxp :' FI,A, Ai. c1
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 $1500.00 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. Ile advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance covera:e verification.
I do hereby certz der the pains , penalties ofperjury that the information provided above is_truenr &correct
4 O
Signature: / ate: .
Phone #: t ' dPC .
Official use only. Do not write in this arrea, to be cot pletedby 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. EIectrical lnspector Sector PIu mbin�Inspector _
6. Other
Contact Person: Phone #:
1
C Ulvli. - S e a te nt anl
P
CI11 _ ;
PERSONS CONTRACTING WITH UNREu-
Building DO NOT HAVE ACCESS TO THE GUARANI t
Cat. ,ory:
BUILDING r ..
Permit # BP- 2010 -0246
Project # JS -2010- 000310
Est. Cost: $6775.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class:
Contractor: License:
Use Group:
WESTERN MASS MASONS 089376
Lot Size(sq. U RC(100)/ THE
g ft.): 5880.60 WESTERN MASS MASONS
Zoning:
AT: 25 GRAVES AVE
Phone: Insurance:
Applicant Address: (413) 540 - 1959 WC
383 COLLEGE HIGHWAY
SOUTHAMPTONMA01073 ISSUED ON:9/2/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:REBUILD CHIMNEY
POST THIS CARD SO IT IS VISIBLE FROM D.P.W. THE STREET Building Inspector
Inspector of Plumbing Inspector of Wiring
Service: Meter:
Underground: Footings:
Rough: Rough:
House # Foundation:
Driveway Final:
Final: Final: Rough Frame:
Gas:
Fire D Fireplace /Chimney:
Insulation:
Rough: Oil:
Final:
Final: Smoke:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Si � nature:
Certificate of Occu•anc Date Paid: Amount:
Feel e.
X5,00
A 1
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: - Not Applicable ❑
Name of License Holder : j9 i /'Cc / <' 9
License Number
4/ 't Expiration Date
/,
Telephone
9. Registered l the lmgrovementContracto ;; .. Not Applicable ❑
(Aje (CrAJ .Z /(/-111,1j /'3 V
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M. G. L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildi permit.
Signed Affidavit Attached Yes ( No ❑
1 g$. meYc iierExemi iofl
T_he_current_exemption for "homeowners" was extended to include Owner-occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own 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.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference'to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
inrlliamptnri [Jr finances. te - ancr o • `. • . - • " .4 + - o > • • = a -ttsGeneral- Laws- Annotated.
Homeowner Signature