The Commonwealth of Massachusetts
59 Town Hall Square, Falmouth, MA 02540
(508) 495-7470
CONSTRUCTION ADDRESS:______________________________________________________________________________________
OWNER :_____________________________________________________________________________________________________
EMAIL: _____________________________________________________________________________________________________
COMPANY NAME:_____________________________________________________________________________________________
HOMEOWNER UCSL RCSL MSL Lic. #_________________ HIC Reg.# ________________
*****Persons contracting with unregistered contractors do not have access to the guaranty fund (as set forth in MGL c.142A)*****
Historical District: Yes No Flood Hazard Zone: Yes No Lead Certificate: Yes No
Year Structure Was Built: ___________
Replacement windows: #____with no header change Replacement doors: #_____with no header change
Replacement windows: #____ with header changes* Replacement doors: #____ with header change*
*plans are required *plans are required
Siding: # of squares ____ Material used** ___________ Exposure: ______ inches to weather
**if vinyl Manufactur er: _____________ Model: ______________
Re-roof: # of Squares____ Roof to be done: ____ % Mnf: __________ Model:___________Rtng/Yrs: ______
stripping old shingles; if going over _____layers of existing roof complete following:
RAFTER: Size_________Span____________Spacing__________ Type SPF or HEM Weight per sq of shingle_______________
Estimated Cost of Construction $_____________________
I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand
that any false answer(s) will be just cause for denial or revocation of my license and for prosecution under M.G.L. Ch. 268, Section 1.
Applicant’s Signature:_____________________________________________ Date:_______________________
*****Persons contracting with unregistered contractors do not have access to the guaranty fund (as set forth in MGL c.142A)*****
Approved By:____________________________________________________ Date:______________________
Building Commissioner/Inspector
Expires 180 days from issue date.
Fee $__________________
Date issued:____________
Town of Falmouth
Building and Zoning Department
59 Town Hall Square
Falmouth, MA 02540
508-495-7470 – Fax 508-548-4290
Property Owner Affidavit
Property owner must complete and sign this form if using an agent/builder
I, _________________________, as Owner of the subject
Property Owner (print)
property at ____________________________ hereby
Property Location
authorize ______________________________ to act on
my behalf, in all matters relative to this building permit
application. I also certify under the pains and penalties of
perjury that the estimated value/contract amount of:
$________ as stated on the building permit application is
true and accurate.
__________________________ ___________
Legal Owner’s Signature Date
__________________________ ___________
Applicant/Agent/C.S. Signature Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Workers’ Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):______________________________________________________
City/State/Zip:_____________________________ Phone #:________________________________
*Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information.
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
Insurance Company Name:____________________________________________________________________________
Policy # or Self-ins. Lic. #:__________________________________________ 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 c. 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 $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 and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone #:
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 #:_________________________________
Type of project (required):
7. New construction
8. Remodeling
9. Demolition
10 Building addition
11. Electrical repairs or additions
12. Plumbing repairs or additions
13. Roof repairs
14. Other____________________
1. I am a employer with _________employees (full and/or part-time).*
2. I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers’ comp. insurance required.]
3. I am a homeowner doing all work myself. [No workers’ comp. insurance required.]
4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers’ compensation insurance or are sole
proprietors with no employees.
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers’ comp. insurance.
6. We are a corporation and its officers have exercised their right of exemption per MGL c.
152, §1(4), and we have no employees. [No workers’ comp. insurance required.]
Are you an employer? Check the appropriate box:
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.”
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 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