31B-201 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
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
www.mass.gov/dia
tj The Commonwealth of Massachusetts
Print Form
Department of Industrial Accidents
Office Investigations 31 (3 "
.ff of Investi g
4
1 Congress Street,Suite 100
-, 4L Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Consigli Construction Co.Inc.
Address:72 Sumner Street
City/State/Zip:Milford MA 01757 Phone#:508 458 0543
Are you an employer?Check the appropriate box: Type of project(required):
1. A 1 am a employer with 350 4. 4 I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 12 Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. 0 We are a corporation and its 10.fA Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs 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#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 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:Old Republic General
Policy#or Self-ins.Lic.#:A2DW96831203 Expiration Date:12/30/2013
Job Site Address: Elm Street City/State/Zip:Northampton, MA 01603
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 c• it under he pa' and penalties of perjury that the information provided above is true and correct.
Signature:I /144 I Date
Phone#: 5-b, ils'' 0
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#:
i The Commonwealth of Massachusetts
Department of Public Safety Docket Number
r
Ai.
Architectural Access 1 card
. One Ashburton Place, Room 1310 (Office Use Only)
�" Boston Massachusetts 02108-1618
Phone: 617-727-0660
Fax: 617-727-0665
www.mass.gov/dps
REQUEST FOR ADJUDICATORY HEARING
RE:
Name and address of building as appearing on application for variance
I, , do hereby request that the Architectural Access Board
conduct an informal Adjudicatory Hearing in accordance with the provisions of 801 CMR Rule 1.02 et.
seq. as I am aggrieved by the decision of the Board with respect to Section(s)
of the Rules and Regulations of the Architectural Access Board, 521 CMR.
I understand that I may request such a hearing within thirty(30) days of receipt of the Notice of Action.
Date:
Signature
PLEASE PRINT:
Name
Address
City/Town State Zip Code
E-mail
Telephone
PLEASE NOTE:
This form must be received by the Board within thirty (30) days after receipt of the Notice of Action.
Rev, 01/10
-620
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Deval L.Patrick eAirkeelb, a2!O6P-l6lc
Governor ��f Thomas G.Gatzunis,P.E.
Timothy P.Murray "" Commissioner
Lieutenant Governor J(rCx a. -,, 7,0665 Thomas P.Hopkins
Andrea J.Cabral ¢ply/, Director
Secretary eeteGree-. �0 e/d,
7 _ Docket Number V 13 021
NOTICE OF ACTION
RE: Dormitory Building Smith College' 93 Elm Street ' Northampton
1. A request for a variance was filed with the Board by Rockwood J. Edwards (Applicant) on January 25, 2013 .
The applicant has requested variances from the following sections of the 06 Rules and Regulations of the Board:
Section: Description:
26.6.3 Petitioner seeks relief from the 18' inch latch pull side clearance as proposed in the application.
27.3 Petitioner seeks relief from having to provide compliant nosings as proposed in the application.
2. The application was heard by the Board as an incoming case on Monday, February 11, 2013
3. After reviewing all materials submitted to the Board, the Board voted as follows:
GRANT: the variance to Section 26.6.3 and 27.3 as proposed in the application submitted, for the reason that
impracticability (see definitions of impracticability in Section 5 of 521 CMR) has been proven in this case.
•
PLEASE NOTE:All documentation (written and visual) verifying that the conditions of the variance
have been met must be submitted to the AAB Office as soon as the required work is completed.
Any person aggrieved by the above decision may request an adjudicatory hearing before the Board within 30 days of
receipt of this decision by filing the attached request for an adjudicatory hearing. If after 30 days, a request for an
adjudicatory hearing is not received, the above decision becomes a final decision and the appeal process is through
Superior Court.
Date: February 14, 2013 f
cc: Local Disability Commission Chairperson
Local Building Inspector ARCHITECTURAL ACCESS BOARD
Independent Living Center
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Deval L Patri k "" �"" �`"
Goernor Thomas G.Gatzunis,P.E.
'9j Commissioner
Timothy P.' jr M ay ! Fa 2 2V /q yG1 q ,�+
.ieutenant Gore or ft e/(lQ' 67,7-/2A9er - Thomas P.Hopkins
Director
Andrea J.Cab f DEPT..OF E;L i;; t, PECTIONS
Secretary NCRTHAMM ON,NA 01060 faGy, may, y/
TO: Local Building Inspector Docket Number V 13 021
Local Disability Commission
Independent Living Center
FROM: ARCHITECTURAL ACCESS BOARD
RE: Dormitory Building Smith College
93 Elm Street
Northampton
Date: 2/14/2013
Enclosed please find the following material regarding the above location:
Application for Variance _ V Decision of the Board
Notice of Hearing Correspondence
Letter of Meeting
The purpose of this memo is to advise you of action taken or to be taken by
this Board. If you have any information which may assist the Board in reaching
a decision in this case, you may call this office or you may submit comments in
writing.