29-042 (3) 49 PIONEER KNLS BP-2018-1167
GIs#- COMMONWEALTH OF MASSACHUSETTS
Map-.Block:29-042 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category' Above snoundpool BUILDING PERMIT
Permit# BP-2018-1167
Proiect# JS-2018-002095
Est.Cost:$7700.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const,Class: Contractor: License:
Use Group: TEDDY BEAR POOLS & SPA_
Lot size(sa. fo 80150.40 Owner: CAREY DENNIS P&JOANNE L
zones Applicant: TEDDY BEAR POOLS & SPA
AT. 49 PIONEER KNLS
Applicant Address: Phone: Insurance:
41 EAST ST (413) 594-2666 0
CHICOPEEMA01020 ISSUED ON.•5/1112018 0:00:00
TO PERFORM THE FOLLOWING WORK:ABOVE GROUND POOL"'DOES NOT INCLUDE
DECK - SEE ATTACHED POOL REGULATIONS'
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy signature:
FeeType: Date Paid: Amount:
Building 5/II/2018 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File k BP-2018-1167
APPLICANT/CONTACT PERSON TEDDY BEAR POOLS&SPA
ADDRESS/PHONE 41 EAST ST CHICOPEE (413)594-2666 O
PROPERTY LOCATION 49 PIONEER KNLS
MAP 29 PARCEL 042 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
NCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid .
Typeof onstructioo: ABOVE GROUND POOL vocs NOT
New Construction SFE AttACA-, VddL iZ6GVLAT(0P5
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THJ,FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN,FPRMATION PRESENTED:
Approved_Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance•
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
_Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
RECEIVED �, � ru war
Y - 4 �g r i� n tin
NA �iry of ort ampton d �t ���a� ,�,+�
,.
Buil De rtment
OF BUimiNG INS in treat
WHAMPTON.MAm
Northampton, MA 01060
phone 413-587-1240 Fax 413-567-1272
L i
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: tecibn m be wrrplated by Office
/�� 7�onee/L /4nol(s' MaP Lee_ Dyo� unit
I lo2e: lce »9 . O/UGC 7,e OwlayDlMdc+
Eke SL District CB District
SECTION 2-PROPERTY OWNERSMPIAUTHORIZED AGENT
21 Owner of Record
C �R Tion ee(L knells lciaeoc-c i ,4. QInC,2
Name(Pd anent Mailing A Jnass:Sb 9—8 IOC7
TelepNo.
Sgnature
2.2 AulhorUed Anent
Name(Print) Current Maung Pddresa'
Sg.ture Telephone
BECTON 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)lo be Official Use only
m hated brmil applicant
1. Building pcx� L r/��O O • G C (a)Building Permit Fee
2. Electrical ` rJ-'06 , n cn (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fae
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) 41e ao Check Numbar
This Section For Official Use Only
Bidding Penna Number: Dale
Issued:
Signature:
Building Commasiwwranspecbrof Buik ings Date
CoC`1
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information bWs[Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
itis column w be filled in by
Building DeWrounx
Lot Size
Fronto e •
( -
Setbacks Front
Side 1- uR:i.._ _ .i Ll R Rcur
Building Heigh
Bldg.Square Footage —I �f_ .-
Open Space Footage
(Lot arta minus Wit& xvd
Parking)
NofParkin Spaces --
Fill:
volumc&rotation '- ......_.. .._ _._ .......__ _.___.
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW O YES O
IF YES, date issued`:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW O YES O
IF YES: enter Book Page' and/or Document
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O 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 par of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION D WORK
New House ❑ AddHion ❑ Replaeemam Windows Alteration(s) ❑ Roofing 13Or Doors
Accessory Bldg. ❑ DamWition ❑ New Signe [O] Decks [I7 Siding t0] Other(01
Brief Description of Proposed ' II
Work: Q Pon(, AbA U e. c- 6)0Y-Vd
T �
Alteration of odsting bedrocm_Yes--�C No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes G' No
Plans Attached Roll -Sheet
69,If Now f oW6;iRl1 OT 00"M to ex"1O bowel M. tt k1ligwit"O:
a. Use of building :One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
I. Method of heating? Fireplaces or Woodsloves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction Within 100 ft.of wetlands?_Yes _No. Is construction within 100 yr. floodplain_Yes_No
Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? -Yes—No.
I. Septic Tank_ City Sewer_ Private Well_ City water Supply_
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR
CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
pro '
hereby authorize
to act on my m all murd ative to work authorized by this building permit applic4lian.
signature of Dale
1 I z7Q .)J I -�, l�-� ,as Owner/Authorized
Agent hereby declare that the statements and in 'on on the foregoing application am true and accurate,to the best of my knowledge
and belief.
Signed u the pains and panaltie of jury.
Print Name
sgnelure of /Agem Date
SECTION B-CONSTRUCTION SERVICES
8.1 Licenaed Construction Sunervlsor: Not Applicable ❑
Name of U,Hold.r':Tin 1� V 2�d�oc_ OVi-S 1� � r /1` rI
I Loren Number
Atltlress °
Expiraboif _
Date
yr3 -5 9SF-aG��
Signature TeleW.
Not Applicable ❑
Company Name Regishation Number
Cla-� o �l `�� �
Address Expi2aDme
Telephone
SECTION 10.WORKERS'COMPENSATION INSURANCE AFFDAWT(WOML m 152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this ethdavil will result
in the denial of the issuance of the building permit.
Signed AffidavitAnached Yes....... ❑ No...... ❑
City of Northampton
Kaasachnaetta
naPAaaaar or' D(TtWIRG ZNSPl Xcffl; tV.
212 Win Street a Municipal Buildingh\ 0C
Morthanpton, tar 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration,renovation, repair, modernization, conversion,
improvement,removal,demolition, or contraction of an addition to any pre-existing ownreroccupied building containing
at least orre but not more than Pour dwelling units....or to structures which are adjacent to such residence arbuildinJ'be
done by registered contractors.
Note.If the homeowner has contracted with a corporation or LLC,that entity crust be registered
TypeofWork: PeoL — ,babe, gro..wtd Est. Cost: ' 000. 00
Address of Work:69 Py c)dn e&- Kiyd is' . (' `2�'rtiC C'-i /n P . 6 I C 6,;L
Dale of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
Job under 51,000.00
_Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.C.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBHITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for building permit as th wne f the above erty.
iDc3i. Sk�� � d-
Date Owner Name and Signature
City of Northampton
Massachusetts
11812 a n PS OF BOILOZal Iaa uil ur NS
212 IrGiY Sttaet •IWnW 01 Huildieg u Y pc
aortA..ptov, 101 01060 k�l
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
peril all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
knells ��a��n��tM/� .ol��---
(Please print house number ands e[name)
Is to be disposed of at:
�f4 fit onee2 Lu ofttfzi;y�
(Please prKms .lhon
Or will be disposed of in a dumpster onsite rented or leased from:
Te�>4 �(ZkAs� S�.G{1;<c�ee /nA i oc
ompanY Name aM ss)
1
Sig tu�mit Applicant Owner Date " d
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The C ntnunsweahh ofMassaehusetts
Department oflndustrfaLAccidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.nassgov/dia
ww.1-kers'Compeasation Inamsince Affidavit:Bnilders/Contraemrs/Eleetridans/pinmbers
TO BE FHM WITH THE PFSMTDNO AOTHORTIY.
Aootieant Information Phase Print I.embiv
Name(Busivcsatthge naticrandividml);Teddy Bear Pools & Spas
Address:41 East Street
City/State/Zip:Chicopee, MA 01020 Phone#:413'5942666
Arc Yon av empoye!!t2uk We appropriate bs: 'type of project(required):
1.01-- Ploy«with 100 empatas(hstl mdswtart-limn).' 7. ❑New construction
2.❑1®asolep pmWmpmm« pmdhavemewplayeww«king fwuc m 8. E]Remodeling
my�Ky.[No wmkua'
3 F-11 am a hmuaow�vdosgan wmtmymtf[No w«kms'amp.insmmesryuirtd.7 t 9. El Demolition
4.❑lamahoaeaw,ar mtlwJt eeb'vingcmbmmmmwnanec au wodcmmy propary. tw,u 10E]Building addition
.dwarf msmad trdvrb..Mles'.Pmaetoa{mvnmemmescte 1L Electrical rapaits or additions
«opdet .anoemplvy. 12. Plumbing repairs or additions
5,M I em o genual mahectormdIhave Ntdtm sub mntractms 4wA on do ova bNsbM. 13.❑Roofrepaus
'rhessubeoauacmnlaveesco a andbmvemetcelc Iw«mecs
6.❑Wameacwpwationad vs olL«mbavc r..weiwltheasightofexuopeonpaMOLc 14. ✓QOther P0OI
152,§t(4),andwebavem enpioyas[No wodms'pmp.bnutmeesquud]
'Any�Plirmitshet•J cksbms#1 amstalso Lll moths stem Mlmv shaamCtLmwutus'wnpmsetim PpBey>tdome
t Baneowr.«s who mbmit dtira6WavitiudiuWgflsy Hdoivgall wwkmdtbenhhe mdsitleamhmmrssmsrtsubmRa.new atEtlnamdiceboasuds
ICmb,tes. fdcbeek Poivbmwhave Mhedmd1b,ne +hcasmwingtlwoma ofthesv lic,aa «smdsmk Watbraweot those mtifio have
miplo5m. If she sb�vwhecoma have emplayae,ihnY nnffi psmvide tlav vaakas'�p.puiiry mmbw.
Taman employer thatsprmatingworkers'compensation imwsweeformyemployees. Below is thepoacy andjoh site
information-
Insurance camparty Nam.-Acadia Insurance
nformationInsuranceeompanyName:AcadiaInsurance Company
Policy orSeltins.Lie.#:WPA0382194-16 ExplrarionDate:04/01/2019
r
`
lob Site Address �� `l� ),t�(� � �J1 I ) City/State2iP:1'a' b\ /) 17) 06 6
Attach a ropy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage m required under MOL e.152,§25A is a criminal violation punishable by a fins up io$1,500.00
and/"one-yem imp isomnent,as well as civil pmaltics in the form of a STOP WORK ORDER and a fine ofup to$250.00 a
day against the violator.A copy ofPofs smtemevtmay be forwarded to the Office ofluvestigetions ofthe DIA for insurance
coverage verification.
Ido hereby cerafy under the pains andpwasUles ofperjary that tke information provided above is true andc'orre
Si®atur TED HEBERT _ Data,
Phone#: 413-594-2666
Official use only. Do sot wrke in this area,m be wVlded by dry or town offrdaL
Cityor Town:__ __ _ Permit/License#
Lssuing Authority(circle one):
1.Board of Health 2.Building Department 3.Chyffown Clerk 4,Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
The Commonwealth of Massachusetts
Department oflndustrialAceidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.massg"Idia
WIV.rkers'Compeavation Insurance Affidavit:Builders/Contractors/ElectriciansMumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Ammlicant Information \ Please Print Leebly
Name(Business/Orggaaniratia individuall):/ IJ+yJI/I 1 S p(L�c.y
Address: 0 r on teff Ci n.0 �S r
City/State/Zip: OQeK?Ce rnfi. 01062- Phone#: 4/,3"-5gy— f��UU
Are you av emphs rf Cheek the apprapriafe hon Type of project(required):
I.[I am a cmrloye w;m cnployco(fun anNorpmt-nine)• 7. []New construction
20 Iamasole pmpdaotmpeaoetship and have tw employee wotkivg for.in g. ❑Remodeling
ant capacity.Mo woreeri cum,.mane ce rcquitN]
30Iamahomrowmerdoing all work mlalf lNo workers'comp.irsnnoce requhed]' q" ❑Demolition
4�Iema nemeownerandwill hehiring conmctasmcondomall wol,m myproperty. twill 10 Building addition
ensure dealer contractors timer bare wcueeatemgwnsaaanm,mwoemme sole 11.[]Electrical repairs or additions
pmpmams with no employees, 12.❑Plumbing repairs or additions
Slav agenetd cormcwr ardlhavehired me xub-wnwtwrs lited on me cached sheet. ]J❑Roof repairs
These subcontractors have employees mdhave workers covin.insuravice.:
6.[]We are a coryondon and its omceri base exercised their right ofearngtion per MGL c. 14.$Other.(.lJO L-
152,¢I(4),and we have no employers.INo wodn%romp.insman«required]
•My applicant mat cheeks box#1 must also fill out me,section blow showing their workers'erm xassom, be,ofomntion
t Hnmeovmers who actual this affidavit mdieaing they are doing all work and man hire ouaih eonmulon must submit a new au"vit ualkating such,
lCormcmrs that check min box must atuched an addaiond sheet showing the some rf me subcontractors and sane whtmer or nm mdse comics have
employees. If an,.1n,o Imams have employees,met must provide they workers'carp.W fi,,number.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy andjob site
information.
Insurance Company Name:
Policy#or Self-ins.Liic.'�7#: Expiration Date:
: �y
Job Site Address % 7rn PO.O /)r�/Y �4mt FA s —Cityistate/Zip: C��6(o oZJ
Attach a copy of the workers'compensation policy deelarafion page(showing the Polley number and expiration date).
Failure to secure coverage as required under MGL a 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and,or one-year imprisonment,as well as civil penalties in the forth of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains andpeaddes ofperjury that the information provided above is true and correct
n Simature. Date:
Phone#:
Oficial use only. Do not write in this area,In be completed by city or town allicial
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
Contac[Person: Phone M
City of Northampton
s ... :.. �
Massachusetts
z
nsraNamrr or wzI rnu INSPscTX0KS
212 Nein street • Nunlcip l euildiv �
N rtLeepton, M1 01060 u�fti pC
Massachusetts Residential Building Code
Section 110.R5.L2
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.
Section 11085.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R5,provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner shall act as supervisor.
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 persons) you hire to perform work for you
under this permit.
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers in provide workers'compensation for their employees.
Pursuant to this su mte,an employee is defined as"...every person in the service of another under any contract ofhire,
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 ajoint 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 he 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 say
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 you situation and,if
necessary,supply subcontractors)name(s),address(es)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required in 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 ofirim nce coverage. Also be sure to sign and date the affidavit The affidavit should
be mounted 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'
comperiestion 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 Twain Officials
Please be sue that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you m fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pennitlficense 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 in the
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit most be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related many business or commercial venture
(i.e.a dog license or permit to bun leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel- #617-727-4900 ext 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 W .mass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers w 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 m 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 your insurance company's name,address and phone number along with a certificate 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 Departnent 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 m 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 pennitllicense 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). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proaf that a valid affidavit is on file for fumre permits or licenses. A new affidavit
most 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 bum leaves etc.)said person is NOT required to complete this
affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Departrnent of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
w .mass.gov/dia
Fmm Rm,isd 02-2315
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