Fillable Wood Pellet Coal Stove Application (Town of Hopedale)

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Wood Pellet Coal Stove Application (Town of Hopedale)

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BROWSE TOWN OF HOPEDALE (MA) FORMS

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TOWN OF HOPEDALE
78 Hopedale Street - P.O. Box 7
Hopedale, Massachusetts 01747
Tel: 508-634-2203 x 216 Fax: 508-634-2200
Building Department
SOLID FUEL BURNING STOVE APPLICATION
WOOD/PELLET/COAL
Owners Name: _____________________Address: _________________________Phone# ________________
Contractor: ______________________Address: __________________________Phone#_________________
CSL#:______________ HIC REG #______________ Cost $ ________________
Type of stove (circle):
Insert
Free Standing Chimney Type (circle): New Existing
Manufacturer
____________
Model # _____________________
Type of fuel to be burned
Location of stove_______________________
Please attach manufactures specification of clearances from combustibles
I, the undersigned Owner, hereby apply for a Building Permit to comply with the Ma. State Building Code and
all other applicable laws pertaining to the project; and that I will NOT have access to the Guaranty Fund
(G.L.
c. 142A, sub sec 13(b) if I i. Contract with a contractor who is not registered with the State, I also
understand
that I shall install the required Carbon Monoxide Detectors per 527 CMR. 31.00 Prior to the time of Final
inspection.
Owner's Signature
Date
_
I, the Licensed Contractor, agree to perform and be responsible for all work approved under this application in
conformance with M l401.6 of the MA Amendments to the Ma. State Bldg. Code. I also understand that I
shall
install the required Carbon Monoxide Detectors per 527 CMR 31.00 prior to the time of Final inspection.
Contractor’s Signature: ________________________________ Date: _____________________
Permit# ______________________ Date: _______________________________ Fee: ____________________
(Please provide copies.)
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center
2 Avenue de Lafayette, Boston, MA 02111-1750
www.mass.gov/dia
Workers’ Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):_________________________________________________ _
Address:__________________________________________________________________________
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
information.
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 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 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 (check o
ne):
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):
6. New construction
7. Remodeling
8. Demolition
9. Building addition
10. Electrical repairs or additions
11. Plumbing repairs or additions
12. Roof repairs
13. Other____________________
1. I am a employer with _________
employees (full and/or part-time).*
2. I am a sole proprietor or partner-
ship 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.]
†
Are you an employer? Check the appropriate box:
4. 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.
‡
5. 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.]
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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
Lafayette City Center, 2 Avenue de Lafayette
Boston, MA 02111-1750
Tel. (617) 727-4900 or 1-877-MASSAFE
Fax (617) 727-7749
www.mass.gov/dia
Revised 7-2019
HOMEOWNER LICENSE EXEMPTION AGREEMENT
HOMEOWNER: ________________________________________________________________
ADDRESS: _____________________________________________________________________
The undersigned HOMEOWNER requests permission to act as a Supervisor to undertake a
construction related project at the above referenced address without the benefit of a properly
licensed contractor under the following terms and conditions:
1. According to the Massachusetts State Building Code, Section 108.3.5, the current
exemption for “HOMEOWNERS” was extended to include owner occupied dwellings
of two units or less and to allow such homeowners to engage an individual for hire
who does not possess a license, provided that the owner acts as the supervisor.
2. By definition, a person who owns a parcel of land on which he or she resides or
intends to reside, on which there is, or is intended to be a one to two family
dwelling, attached or detached structure accessory to such use and/or farm
structures, but not manufactured/modular structure, shall be considered a
HOMEOWNER. A person who constructs more than one home in a two-year period
shall not be considered a homeowner.
3. The HOMEOWNER will be fully responsible for submission of a complete permit
application, site plans, building plans, and any other documentation required by the
Building Department to understand the scope and complexity of the work proposed
4. The HOMEOWNER certifies that he or she fully understands the requirement of the
Massachusetts State Building Code as It relate to the particular project being
undertaken by the permit, and that the HOMEOWNER ASSUMES FULL
RESPONSIBILITY for compliance with all applicable codes, ordinances, and inspection
procedures.
This Agreement is executed as part of the Building Permit Application.
Homeowner’s signature:
____________________________________Date:____________________________
_____________________________________________________________________________
Approved by Building Inspector:
____________________________________________________
Permit#________________________ Issue Date: ________________________________
* PLEASE SEE OTHER SIDE *
License Exemption Warning
Be advised that a majority of those citizens who sign the Homeowner’s Exemption
Agreement on the reverse side are not fully aware of the responsibilities that go
along with assuming the role of “Contractor”. By seeking this exemption, you
assume significant risks. Please note:
• You are now personally responsible for all work on this project.
• You are responsible to see that all work meets the Mass. Bldg. Codes.
• You must supervise all work.
• You must call the Bldg. Dept. to schedule all required inspections.
• You have waived your rights and are no longer entitled to any Claim against
the Massachusetts HIC Guaranty Fund.
• You are the General Contractor of the project and a court of law will view
you as such if you are sued, or if you should have the need to sue another
party.
• Your subcontractors may place liens on your property.
• Any worker injured on your project may sue you if you do not carry
Worker’s Compensation Insurance.
• Failure to carry Worker’s Compensation Insurance may result in criminal
penalties, i.e. fines and/or imprisonment.
By definition, a person who owns a parcel of land on which he or she resides or
intends to reside, on which there is, or is intended to be a one to two family
dwelling, attached or detached structure accessory to such use and/or farm
structures, but not manufactured/modular structure, shall be considered a
HOMEOWNER. A person who constructs more than one home in a two-year
period shall not be considered a homeowner.
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Wood Pellet Coal Stove Application (Town of Hopedale)

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Completed 14 July 2020

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