38B-216 (7) 54 FORT ST BP-2018-1181
GIs n: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 38B-216 CITY OF NORTHAMPTON
Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categorv'ADDITION&RENOVATION BUILDING PERMIT
Permit# BP-2018-1181
Project ft JS-2018-002118
Est.Cost: $285000.00
Fee,$1853.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor. License:
Use Grouo: BENTON D COOK 049209
Lot Sizc(sa. ft.): 19602.00 Owner: POLLETO MARCO&VICTORIA
Zoning-URB(85)/SC(16)/ Applicant: BENTON D COOK
AT: 54 FORT ST
Applicant Address: Phone: Insurance:
908 BERNARDSTON RD (413) 478-1078 O
GREENFIELDMA01301 ISSUED ON.612212018 0.00:00
TO PERFORM THE FOLLOWING WORKADD NEW GARAGE AND STORY AND A HALF
CONNECTING TO HOUSE AND FINISH EXISTING HOUSE
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 Denartmen[ Fireplace/Chimney:
Rough: OJ1; 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 Occunancv Si¢nature:
FeeTvpe: Date Paid: Amount:
Building 6/22/20180:00:00 $1853.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
NCf0 BCiTE2 PIAN
File#BP-2018-1181
RE%(w i fMcot,
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J,
APPLICANT/CONTACT PERSON BENT( J D COOK ��L S �, Ctd'`
ADDRESS/PHONE 908 BERNARDSTON D GREENFE D (413)478-10780
O
PROPERTY LOCATION 54 FORT Sr
MAP 38B PARCEL 216 001 ZONE URE i>)/SCOL Favra
THIS SE( 'ION FOR OF!11 1A USE ONLY:
PERM f APPLICATIOF '1HECKI.IST
.N' .OSFC QUIRED DATE
ZONING FORM FILLED OUT _
Fee Paid
Buildm Permit Filled out
Fee Paid
Typeof Construction: ADD NEW GARAGE ANDS _ ALF CONNECTING TO HOUSE AND
FINISH EXISTING HOUSE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included,
Owner/Statement or Licemse 049209
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INATION PRESENTED:
_Approved_Additional permits requited(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Pmject _Site P6M 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
lition Delay
rBl �
� Z /
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.
Marco and Victoria Poletto 1/17/18 Project: 54 Fort Street
55 Falls Road Northampton, MA
Sunderland, MA
CR&C will restore the Poletto's house at 54 Fort Street and
build the addition and attached garage as shown in the Nancy
Schwartz drawings dated 1/16/18. These additions are to be
U0 built within the original footprint of the home's now demolished
west wing and outside the wetlands 100' buffer zone as defined
C on the SVE Associates Existing Conditions Plan dated 10/9/15
ookand re-checked this November by Ward Smith, the Professional
RESTORATION& Wetlands Scientist who did the wetlands delineation for SVE in
CONSTRUCTION 2015.
908 BERNARDSMN ROAD Old foundation to be repaired/restored; new foundations
GREH FFD,MA. 01301 to be poured concrete and brick with new chimney and Rumford
fireplace on east wall of existing house. Insulation to be
413-475-3833 polyurethane foam. Gas, hot water heat to be radiant first floor,
wall hung rads on second floor. New first and second floor baths,
new kitchen with custom cabinets and stone tops, hardwood
floors and custom poplar trim (4.5"belly mould/rosettes/plinth
blocks) to be used throughout.
New driveway apron to be oil/stone, siding w.r.cedar
clapboard, trim 5/4"x5" cedar, windows to be Marvin 2 over 2
dbl. hung and 4lite casements similar to existing newer Marvins
at rear of house. New roof to be Certainteed 50 year archs.
Exterior paint to be monochrome, possibly second color for
garage and addition.
All above to be completed on a cost plus, time and material
basis for the estimated cost of$285,000. to be paid 1/3 at start,
second 1/3 at drywall start, fifth 1/6 at substantial completion,
final 1/6 at finish.
Benton Cook Marco Poletto Victoria Poletto
/lid/�o/8
Department use only
MAY1CQ y71do am on States of permit
Building De art nt Curb CutOmeeway Permit
4�",
EPT.DF nusolNSewedSepNC AvallabildyNORTHAMR7ON. WaterMrell AvailebllNorthampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 P1ovshe Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION g 0- I f' "�/
1.1 Progeny Address's' This section to be completed by office Map ✓? Lot —C2jcUnit
YY Zone Overlay District
Elm SL Dhnmd CS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
-Name(Pbi Current Mailing Mdress:
� -
Telephone
Signature
2.2 Authorized Agent: (30
90 ss �n�-ds l2cPC-f Id
Name Current Mailing A ss:
ignature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted bV Permit applicant
1. Building n (a)Building Permit Fee
2. Electrical $ �T(y-o (b)Estimated Total Cost of
t Construction from 6
3. Plumbing �{�) Building Permit Fee
4. Mechanical(HVAC) --ij
5. Fire Protection
6. Total=(1 +2+3+4+5) Ll rer�..--»r�--0
Check Number 7�
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signatur .
Il gg Comi oberllnspe1ctor of Buildings Date
C oy ✓ e S �O @ yoQ1 l G0rn
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
F',. ^e► YAM "
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed RequiredbyZoning
This column to be filled ir�by
- - - budding Depanmer,
Lot Size
Fronts e
Setbacks Front
Side L R:.. L... R. .... _
Rear
Building Height -
Bldg. Square Footage
Open Space Footage % _.
(L t area minae tilde&pared
parking)
#of Parking Spaces ---
Fill
p-olvmn&Locnfion)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Re istry of Deeds?
NO O DONT KNOW YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES (D
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 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
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,ox,mvation,or filling)over f acre or is it part of a common plan
that will disturb over f acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
A
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [ Siding[f Other[O)
Brief: ri;c pti of Pr / I f ��r VV,
Work:=o Q �O '� 541"1"'14 Awn (I Q I't Q l
Alteration of existing bedroom_Yes No Adding new bedroom Yes No
Attached Narrative nn Renovaf g shed basement Yes No
Plans Attached Rall -Sheet 0 h 41 N 1$ � O +Yf &�C� Pi1'- t dd
ea.If New house and or additioi existing hOusing.complete the followir :
a. Use of building: One Family Two Farl Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? UCf.57
V
17—
J.
-tl. Proposed Square footage of new construction.
e. Numberof sh nes? {a - Obe
I. Method of healing? qal 14,0 /!A t Qk Fireplaces or Woodstoves Number of each I •�'�'
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
I. Is construction within 100 fli of wetlands? Yes —V—No. Is con
struction within 100 yr. floodplain_Yes V No
j. Depth of basement or cellar floor below finished grade K- S ?/(ey I<,
k. Will building conform to the Building and Zoning regulations? Yes No
�I. Septic Tank_ City Sewer 1� Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ,as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner t� /ter,,,1 ,/ /� Date
�
9 l...p l/R 05 !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 poi s and penalties of rjury. 1 _
Print Name
J ��
Signatu f OwnerlAgenl Date
SECTION 8-CONSTRUCTION SERVICES
6.1 Licensed Construction Suoerv'sor: Not Applicable ❑ ny,,
Name of License Hold., r n Q(,3o I � a
Ll
Atltlr Exp� tion DD e
Signature / Telephone
9.Re/ilstered Home Im rovement Co tractor //JJ ^}/� Not Applicable 11 q
Rue
CompanyName Registration Number
Ale +r�
Adtlress ''//�{ //�J� Expiration�D/-at�el
C-� nQ ' 1 r J' vr- Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§2SC(6)) ZS
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.._.. ❑
City of Northampton
+' Massachusetts 25e >
DBOF BUILDING INSPECTIONS
Y1212 MainMa1n Street Municipal Building at
Northampton, Ml 01060
AFFIDAVIT
Nome 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("H1C").
M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owneroccupied building containing
at least one but not more than Pour dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:if the homeowner has contracted with a corporation or LLC,that entity must be registered
{ �
Type of Work: /IJ jJ, �to4l s��-./- /rQ-d 1 15� fit. Cosr.�
Address of Work:
Date of Permit Appheation.
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):
—Job under S 1,000.00
_Owner obtaining own permit(explain):
_Building not owneroccupied
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.G.L.Chapter 142.A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of pequry:
I hereby apply for a building permit as the agent of thhee owner:
eel
Date Contractor Name BIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts
' DEPARTMENT OF BUILDING INSPECTIONS 2 J
® m
212 Nein Street 0 Municipal Building a`
NO2NamptOnr Mi 01060
Massachusetts Residential Building Code
Section I I O R5.1.2
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 110.R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 1 I O.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 thejob 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.
City of Northampton
? Massachusetts 21c °%
f' -17
DEPARTMENT OF BUILDING INSPECTIONS V
212 Main Street •Municipal Building
�r
Northampton, NA 01060 Iry �.�\3D
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit 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:
' tq Tom¢ q -jt-.
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
c &/01(w ,V-\- - W/ /fc-m
(Company Name and Address)
ignature of P6mit Ap 'cant c r OwneV Date
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 Commonwealth ofMassaehusetts
Department oflndustrial Accidents
L Congress Street, Suite
/ Boston, MA 021t 1 4-2 01 7 7
www.males.goP/dia
11 orkers'Compensation Insurance Affidavit: Bui[ders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING.AUTHORITY.
Applicant Information Please Print Le ibl
NameTusireasss/Organizatioo�m7ndividual): 6pok ke 5 1x-4,1 j
Address: '2P
3451
7 �--
City/State/Zip: <' 0 Phone#: !�(,3 4- 752,.x` 3"
Are you an employer?Check the appropriate box: Type of project(required):
1 r-1 I am a employer with-employees(full and/or par-larch 7. %Newoonstroetiou
2®lamasole pmpriemrerpenncrship and have no employees working formers S. %Remodeling
cepaciry.IN.workerscompinsurance required] q_ El Demolition
3.❑I a n a homeowner doing all work myself[No workers'comp_insurance requiund I t
4 1 am a homeowner and will be hiring contractors to conduct all work on my pmpcny. Iwill 10 F]Building addition
are that all mw
contractors either have work '' m .a
penbon insurance or are sole ILQ Electrical repairs or additions
pr1opectors wi0 no employees 12.❑Plumbing repairs or additions
5.C]1 am a general convacte,and I have hired the subcontractors hoods m the mtached sheet, sits
These subcommntors have employees and have workers com13. Roof[ep_insurance.1 ❑ p
6.Fj We am a wtporation and its offi,drs have cxcreord that,right ofcvennin m letcou-c. 14. Other
152,§I(4),end we have no ampioyns_No workers'compinsurance requa d)
'AnyapplicaatchatchecksboxW must also fill out the section below showing their workers'compensation policy information.
'Han who about his eKdavit maidaring they are doing all work and their hire outside contractors must submit anew affidavit indicating such
Contractors that check this box must stanched an additional sheet showing the name of the subcontractors and state whether on not those entities have
emplovars. If the sub-wnturnmrs hall employes,they most provid c their workers comp for icy number.
/am an employer that is providing workers'compensation insurance for rap employees. Below is the policy portion site
information.
Insurance Company Name:
Policy#or Self-ins. Lia 0, Expiration Date:
Job Site Address: 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 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 form of a STOP WORK ORDER and a fine of up to 5250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations orthe DIA for insurance
coverage verification.
/da hereby certify under the pains a p/e�n�aflties afper/j/uf'Lhatthe informaffon prmided above is true/s/�d cogrrect.
Si nature: // K// D t S/(G/ / p
Phone# /—/ / 3 1 f 6 53' 11
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License 4
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 9:
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 hue,
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 be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shat[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."
Additionatly,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 ofthis chapter have been presented to the contracting authority."
Applicants
Please fill at the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone numbers)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 sore 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 pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitllicense applications in any given year,need only submit one affidavit indicating current
policy information(ifnecessary)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 prooftbat 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 bum 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-IS 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 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,m 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 authonN,."
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 otherthan 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 afTrdaviL The affidavit should be returned lathe city ortown
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 permir/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). 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 bum 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
Boston,MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Foran Revised 01-2-15