32A-231 (2) * ._
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 Depaitnient of Industrial
Accidents for confrrmation.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 a. .ro.riate 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 c 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
Depattinent of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 021.14 -2017
Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE
Rc i sed 7 - 2010
Fax # 617 727 - 7749
www.mass.gov /dia
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 I52, §25C(6) also states that "every state or kcal 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 Accident's. 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 Industtal Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114 -2017
•
Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE
Revised 7 -2010
Fax # 617-727-7749
4 www.mass,gov /dia
' SECTION 8 - CONSTRUCTION SERVICES
t
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
EATtlififid. .li'oir Ism ro ementf o ractoV „ -, l° Not Applicable ❑
01.-w rl a lx. to CA NEW RTI-1 .r PA T t, c:.
Company Name Registration Number
w( vw t LLca lv\R N r i°i" i L?0'f1 IAA) E 7'
Address ' 3 Expiration Date
ti1C . ir 0.,CiE;(0 Telephone 5 3 - 9 RAI
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 building permit.
Signed Affidavit Attached Yes ❑ No ❑
11:. omo Owner Ee
The 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
Northampton Ordinances, State an' Local Zoning La • . : State of Massachusetts General Laws Annotated.
Homeowner Signature agal■—■111111h, Mk
-"NNIRIVII, NIP
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
•;4.' "• is erect 'oa e: mproverrren ontra 'i: 4 =° Not Applicable ❑
Ors N 1 2 t DuaG1 4-k EA IPW - - PfrrIQ
Company Name Registration Number
Ilq Lk-A MRN`;e:Tf 61 E fl NAO�E�
Address 443 . Expiration Date
tt1C k ),0I 8w Telephone 538 - 9PA
�. WORKER ve
SECTION 10- Sr COMPENSATION .lNSURANCEAEFIDAV1T4M L° 5Z, 25C(8) 1R
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 building permit.
Signed Affidavit Attached Yes ❑ No ❑
am Nal • . amnion
The 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 1083.5.1.
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
_ -. _ Northampton Ordinances, State an Local Zoning La State of Massachusetts General Laws Annotated.
Homeowner Signature
. . ,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by oning ' ' - .-----
/
This column to be filled in by t
.-/
Building Department ' I
- i
.,
Lot Size
Frontage - li
Setbacks Front ? 1
Side L: R:---`--= L:i , 1 R:1 ; ___
Rear .
Building Height i
! I I
. ,
Bldg. Square Footage F ______, 1 .......____ 1
Open Space Footage % r _____.
(Lot area minus bldg & paved ; f t I______ i
parking)
# of Parking Spaces
Fill:
(volume & Location) ! i .
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW .1.4.1 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
1 , ,
IF YES: enter Book ! Page I and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO 4) DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained
, Date Issued:
C. Do any signs exist on the property? YES 0 NO
. a .
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
k ..
Existing Proposed Required by'Loning --f
This column to be filled in by #
Building Department 1 i
Lot Size 1 1' 1 1 1 s
Frontage 9 ' '
Setbacks Front E_—_I
Side L:_ R:! i L:L R:L ? 1
Rear
1 1 ,
Building Height = 1
Bldg. Square Footage
Open Space Footage .,
(Lot area minus bldg & paved i" 1 i I =
parking)
# of Parking Spaces = = E I
Fill: I
1
(volume & Location) -
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW i:4 YES
IF YES, date issued:{
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Pagel 1 and /or Document it
B. Does the site contain a brook, body of water or wetlands? NO .4 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
ti
i C. Do any signs exist on the property? YES 0 NO *
IF YES, describe size, type and location: I
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO iy®
IF YES, describe size, type and location
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO A
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
i
1
rp