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HomeMy WebLinkAboutBuilding Permit #456 - 1 GREENE STREET 12/21/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: 2-" 1 IMPORTANT: Applicant must complete all items on this p ge � c LOCATION , ;Print PROPERTY�OWNER¶r a r All MAP NO:C PARCEL © ' OMNI G DISTRICT Historic Distr=ict j yes S lachine Shop Village " yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic; PV 611 F1iotlpiaan =Wetlands Watersl3ed'District WaterSewer' v DESCRIPTION OF WORK TO BE PERFORMED: .S ig l?e Identification 'Please ype or Print Clearly) OWNER: Name: AM&ZIV6 Phone: Address: AF s CONTRACTOR Nam .e U� Phon41 e: Address '... �4Supervisor's�Coir nstruetion ficense. cP1, Expt btesm)Njel ome 1rr provement,Licensd/ Exp Date " •" , ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ /' �� FEE: $ Check No.: r 13 � Receipt No.: O � NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund signature of Agent/Owner _Signature Ucor tractor -: Plans Submitted Plans Waived Certified Plot Plan Stamped Plans Building Department The following is a list of the required forms to be filled out for,the appropriate permit to be obtained. Roofing,Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy p p Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008 TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic.tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM . DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water,& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Lo ted 384 Osgood Street FIRE DE0AR�MEN �Ternpp- u-- s er—on situ yes no Located at'124Maih,Street � �� r Fire depart sent=si n turelc ate,.. x..�.. _4 `COMMENTS' Dimension .Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use) i ❑ Notified for pickup Date ................... .-......................._-........................_.......................-...._.........._._....__...._...................... _. Doc:.Building Permit Revised 2008 K.' /\_I• /`l 1-1D,,tsJfV6— I/V7.--fl„r., rf. Location No. Date . NORT#j TOWN OF NORTH ANDOVER�f`f O R w ” Certificate of Occupancy $ �'�s'•••°• MUEco' Building/Frame Permit Fee ACS Foundation Permit Fee $ F Other Permit Fee $ f F TOTAL $ Check #`l -?--I I J —t r 22707 Building Inspector e10RTly Tovm Of L Andover LL A K E V dover, Mass., COCMICME.CK �d A0 A T E D S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System /1 ' A BUILDING INSPECTOR THIS CERTIFIES THAT r1.� �OJ�• ' �o�� Q........................ ......................... .......................................: Foundation A _ has permission to erect........................................ buildings on ...6* ......h'l.�. u( t......JII�,{/Y. A ....... Rough to be occupied as......... .. ........I . '!•..... ! •D.b. . Chimney ................................................................. y provided that the person accepti g this permit shall in eve espect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover., PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRU N STARTS Rough ........ .................................................................................................... Service BUILDING INSPECTOR Final Occupancy 'Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove F nagh No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner { Street No. ILSEE REVERSE SIDE Smoke Det. • TGLRC Inc. dba Lambert Roofing Company In Business Since 1932 T. ambers fin,l December 17,2009 Name: North Andover Housing Authority Address: One Mokeski Meadows North Andover,MA 01845 Phone: 978-682-3932 Salesperson: Richard T. Lambert Steep Slope Roofing System Proposal TGLRC Inc. dba Lambert Roofing Company will provide certificate of insurances demonstrating that we are fully insured for workers compensation, general liability, automobile liability and a $5,000,000.00 umbrella policy. This documentation will be sent through the US mail or VIA E- MAIL/FAX to the above named party if not already provided. Upon completion of the roof and final payment, a shingle manufacturers warranty and our executed two (2) year workmanship warranty will be sent to the named party. Work to be Performed And Materials to be Utilized Conditions: • Old section of Main roof Approx. 1,400 SR • This quote does include Davis-Bacon wage. A Standard two (2)year workmanship warranty applies in addition to a(30 year) shingle manufacturer's warranty. • Under no circtu-nstance will the watertight integrity of the building be in any way compromised. • All work will be performed to the standards and expectations dictated by the 7`E' edition building code and proper roofing practices founded in NRCA roof covering and waterproofing manual.. 1) Apre-roof walk around will be executed to observe and document any pre-existing conditions and or any special considerations. 2) Ensure landscaping and dwelling is and will remain properly protected. Please take special note that ditring demo of the cvisting roof system all valuables non- fastened are subject to falling daring denco and debris 1vill fall in the attic so preparing I EIN#51-05033313 265 Winter St Haverhill,MA NIA Reg.Hic# 149221 Phone(978)374-9224 Fax(978)521-5791 MA Lie. #UCS 078130 E-Mail at lamUettroofinga,aol.eom Single-Ply Lie. #1711 Please visit us on the Web at www.lambertroofine.net TGLRC Inc. dba Lambert Roofing Company In Business Since 1932 for this mill reduce a disappointment and inconvenient clean rip. Lambert Roofing Evill not be responsible for the above mentioned preparation. 3) Prepare for re-roofing by ensuring all safety measures are taken in accordance with OSHA and CMR Standards. 4) Remove existing layers of shingles down to the wood roof decking and properly disposed of debris from the jobsite in a container provided by TGLRC, INC. 5) Inspect Fascia and Rake boards, if we discover rotted wood,removal and replacement will be perfonned at an additional cost of: • $8.00 per lineal foot of Fascia and/or rake boards,pre-primed pine up to 1"x 8" width • Crown and Cornice Molding will be custom quoted depending on the material required All material will be removed, disposed of and replaced. If wood roof decking and trim is sound,we will re-attach any loose wood to the rafters, sweep deck and prepare for installation. 6) Furnish and install new %roof sheathing to the area receiving new roof shingles. 7) Install Aluminum White Drip Edge to all rakes and eaves of the roof perimeter as required. 8) Apply Ice & Water Shield Underlayrnent 6' up roofs transition, around all roof penetrations including chimneys,pipes and any base tie-ins to walls. 9) Apply premium felt paper to the balance of the wood deck. 10) Furnish and install: • Shingle Type: "30 Year Architectural Roof Shingles. • Color: to Match existing. The use, as our standard, a hurricane nailing system recommended in northeast regions. This means, ave install sbc(6) nails per shingle to reduce the risk of shingles being damaged by high winds and the iveather changes we encounter. 11) Chimney Re-Leading • Re-lead Chimney using new lead as required. • Any roof penetrations will receive new pipe flanges as required and dictated by proper roofing practices 2 E1N#51-05033313 265 Winter 5t Haverhill,MA 1111 Reg.Hic#149221 Phone(978)374-9224 Fax(978)521-5791 HA Lic. #UCS 075130 E-Mail at lambertroofin�@,aol.com Shigle-Ply Lic. #1711 Please visit us on the Web at mmlambertroofine.net TGLRC Inc. dba Lambert Roofing Company In Business Since 1932 12) Ridge Vents or Roof Vents: • Cut back roof decking a minimum of 2" as per manufacturers specifications • Furnish and install new "Air Vent"Shingle Vent U shingle cap over style Ridge Vent System at all eligible ridges. 13) All debris generated by TGLRC Inc. dba Lambert Roofing Company will be cleaned up on a daily basis and properly disposed of from the jobsite in a container provided by TGLRC, INC. Roofing Warranties: UPON COMPLETION AND PAYMENT IN FULL A TWO YEAR NON PRO-RATED GAURANTEE ON ALL WORKMANSHIP WILL BE HONERED AND ISSUED BY "T.G.L.R.C. INC". A THIRTY YEAR PRO-RATED WARRANTY WILL BE ISSUED ON SHINGLES BY MANUFACTURER. TGLRC Inc. dba Lambert Roofing Company agrees to: • Conunence the described work on or about December 2009 (weather permitting) • The described work will be completed in about(2)working days • Shall not be held liable for delays due to circumstances beyond our control • Shall not be held liable for any damages to landscape, attics and or fixtures due to circumstances beyond our control • Shall not be held liable and roofs are not covered under the workmanship warranty, for pre-existing conditions including but not limited to: o Mold and or wood rot o Defective, faulty,rotted or worn building counterparts such as,but not limited to: siding, gutters, masonry, plumbing and windows, all of which may jeopardize the watertight integrity of the structure if not in sound condition • Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence Required Permits A building and dumpster permit may be required to remove and replace your roof. It is our obligation to secure these permits if required as the homeowner's agent. Note:owners who secure their owu permits or deal n,ith ulll•egistered contractors ale&Ycluded fl•oni the Gual•anty Fund provisions of MGL c. 142A Additional Attached Documents Agreements or Provisions • Insurance Documentation if not already provided • Arbitration Agreement • Contractor Registration Information • Notice of Cancellation Form 3 EIN#51-05033313 265 Winter St Haverhill,MA AJA Reg. Hic#149221 Phone(978)374-9224 Fax(978)521-5791 r1119 Lic. #UCS 078130 E-Mail at lambel•troofina a,aol.com Single-Ply Lie. #1711 Please visit us on the Web at www.lainbertroofiniz.net TGLRC Inc. dba Lambert Roofing Company In Business Since 1932 This contract is the complete contract unless a signed Change Order has been executed between TGLRC Inc. dba Lambert Roaring Company and the owner Contract Price and Customer 4bliLrations The total cost for all permits,warranty, labor and materials is: $1.2,967.00 Payment Terms: • 1/3 DOWN,progressive payment,upon completion payment is due in full • A finance charge of 1.5%per month(18%per year)will be added to all invoices on the 31 day. All legal and or collection fees will be paid by the binding holder of this contract • The law requires that any deposit or down payment required by TGLRC Inc.dba Lambert Roofing Company before the work begins may not exceed the greater of 0 1/3 of the total contract price or: o The actual cost of Special or Custom made materials which must be special ordered in advance to meet the completion schedule Acceptance of the Contract Proposal DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES OR ANY UNRESOLVED ITEMS NOTE; Due to volatile pricing on building products,this contract is valid for 15 days of receipt. You way cancel this agreement if it has been signed by a partly thereto at a place other than an address of the sellar, which may be the main office or branch thereof,provided you notify the seller in uyrifing at the main office by orrlinay Huai!posted,by telegram sent or by delivery,not later than nnidnighrt of the third business dayfollouling the signing of the agreement. Because of the three(3)day Notice of Cancellation, work may not commence for a minimum of seven(7)days after we receive this signed contract unless the contract is signed at our office. Signatures Date:'0 Please sign, Iceep a copy and return one copj,tfpon acceptance. "Quality Workmanship You Can Trust" Thank you for the opportunity to provide you with this proposal and or contract. Sincerely, Richard J. Lambert President/Quality Control, TGLRC, Inc. dba Lambert Roofing Company 4 E1N#51-05033313 265 Winter St Haverhill,MA HA Reg. Hie#1492?1 Phone(978)374-9224 Fax(978)521-5791 NIS!Lie, #UCS 078130 E-Mail at lambertroofina waol.com Single-Ply Lie, #1711 Please visit us on the Web at www.lambertroofing.net i i '== Massachusetts- Depa-t'lent ut P hlic Safet\ Board of Building Re uations a d Standards Construction.Sup rivisor I is nse License- CS 78130 Restricted to: 00 RICHARD J LAMBERT 95 MAPLE AVE ATKINSON, NH 03811 Ex ' rate n 6/ p , 2/2010 ^ rrt# 27762 I i i II Offi of Consumer Affairs and usiness Regulation 0 Park Plaza - Suite 5170 stop, Massae iusetts 02116 bme hT.provement'(DamiWor Registration Registration: 149221 Type: Private Corporation f Expiration: 12/6/2011 Tr# 290268 LAMBERT ROOFIN CO RICHARD LAMBE - 265 WINTER STREVETHAVERHILL, MA 0 11330 Update Address and return card.Mark reason for change. [] Address Renewal Ej Employment Lost Card S-CA1 to 5OM-04/04-G101216 I i j i I ""` —D,rx, 11••ICA .-. � �� � �MI �.l" DAIkIRIM�DDIYYI PRODtIC6R 08/31/2009 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ALLAN IIQSORAACE A®NCY INC. ONLY AND t:ONFE RS NO RIGHTS UPON THE CERTIFICATE 63 1/2 Jefferson Avenue 2nd F HOWER. 74S CERTIFICATE DOES NOT AMEND.EXTEND OR P.0. a0X 511 ALTER THE C0vMrF AFFORDED BY YJ40 bro ICIES BELOW. SALEM "A 01970-0611 _99MPANL5 AFFORDING COVERAGE COMPANY - --`— -------_- .-- _ ._ A Seneca Insurance Company INSURED ..._....._----_.. TGLRC INC db& COMPANY I.ambazt Roofing R 3afetg Insurance Group 265 WIMP, STMT RAVIETWILl- C Landma k Insurance Company COMPANY AI6 COVE�GES - D TNIS•I$TO CERTIFY THAT THE POLICIES OF INSURANCE LWEQ 8ELOW HAVE BEEN IS$M TO TFIE IN&JRED NAMED ABOVE FOR THE POLICY PERIOD INQICATEp,NOTWIT!187ANpING ANY REQUIREmE NT TERM OR CONDITION OF ANY CONTRACTOR QTHER OOCUMF.NT YVrfF1 RESPECT TO 1MiICN THIS CERTIFICATE MAY P.E ISSUED OR AAAI PERTAIN TNE'INSURANCE AFFORDED SY THE POI,IC{ES DE^SC,RIBt�HEREIN IS 5UB IECTTO All THE TERMS, EXCLUSIONS ANO t`+ONplYIQNS Of SUO'POL16-1di LIMITS SHOWN MAY HAVE BEEN REDUCED SY PaiD Ci AIMS. Co ----..... _.— TYPE OF INSURANCE _._...... m Pouch Nue�1 POLICY POLICY RAMON OKII(MMAiD M PATE(MIWQWM LINfTs GRHERAL UABILITY X COMPREHENSIVE FOM SGL3000422 11/12/2009 11/12/2()09 B04ILY8UURy*cc s 1,Oo0t000 X PREMISESIOPERATIONS BOUT Y944JRYAGG a 2,00o,00 A W01110ROUNO / / / PRO?EItTYDAmAGEOCC a 2 0061000 Pfk00 CT s MPLV E WPF:R / PROPS TY OAm g AGG X PROOUC'1'BtCOMPt�YEDOvER X CONTRACTUAL / / / / 81 a PO COWINED OCC g T INDEPENDENtCONTRACTORS 118PD0OM61NBpAGG ; - X BROAD FORM PROPERTY OMArg / / PERSONAL MLURY AGG•-_- $ 1,400,000 S PERSONALIH•pW �d�•ca1 RmM- g 5 000 auTolloelLe LIAeILITY ' �- - - ANY AUTO BoblLy INJURY 8 8 X ALL OWD ALN08(Prwaw pvW) 203$19 qq��OwnlEfbn gCPS 07/16/2009 07/16/2410 , s X [(>ihar man rotate Paeaen�efl —_..._ ._. 8 HIRED AUTOS (Par aqRdeml, X NON-OWNEOAtnOs / / / / PROPERTY DAMAGE — OARACB UABIUTY 8qp S PROPERT!OaMq( -- EXCMLIA&LITY loomena ) $ 1,000,000 (' $ Un9BRELlAFORM 46x03 EACH OCCURRENCE__ i _5,400 000 11/12/2008 11/12/2009 TE t - `-' O7iiEiilhlAtdUMBRELLAFORdI 5,000 Ooo D �c�n>��+sai►rna AND & �-- - �+-oYERWUA6IUTY 099341Q5 $TA>U. 0TH 08/28/2009 00/28/2010 II&_ _ .En, THE PR4PRIETT3Po x INCL EL EACH=IDENT 5 1, 000 000 0 0 PARTNER9lEJ(lrCUTIVE / / / / _ POLIC7LIMIT s i,000,000 OFFlCEFLg AttE; E�IC4 EL Dl EA R. OTHER EL DISEASE EAENPLOYEE 1 444 000 I DE3CWPT10NOFOP♦:Rp ,pCATCOH5N�LI•J�g ....—_.. ._I __..__..-- __.__.__ CERTIFICATE HOLDER t 97 s I 521-5791 SK41W ANY OF THE ABOVE DESCRM0 POUCIFS BE CAurenED SUORE TH4 TGLRC dba Lambert p,00f ing dMRnnoN DATE T"O'W,THE WIlR+IG COMPANY WILL 8NDEAVOR YO MAIL 265 Winter Street 30 PAVSVjP4 "NOTICE To THE GERTIFICAI E hOLDER NAMED TO THE LEFT. BUT FARM TO MAIL SUCH NOTICE SMALL IMPOSE NO 06I144TION OR LIABILITY OF K=UPON THE COMPANY,ITS OR REPA MENYAtWYEs. Savehill DSA fl1630� TIVE A�ORt3•tel:(11'9b) Y 4r U'.!I��w�! ' .ACORU CORi'ORATION 1888. Transmission Journal DEC-16-2009 0703 PM WED WorkCentre M20i Series Machine ID : LAMBERT ROOFING Serial Number : RYU006532....... Fax Number • 9785215791 No. Name/Number Start Time Time Mode Page Results 401 19785213767 12-01 02:16PM 00'16" ECM 001/001 0.K 402 19784652379 12-01 02:37PM 00'12" ECM 002/002 0.K 403 16173810402 12-02 10:44AM 00'12" ECM 001/001 O.K 404 18888902300 12-02 12:42PM 00'58" ECM 005/005 0.K 405 9783742337 12-02 01:46PM 00'12" ECM 001/001 0.K 406 19789377500 12-02 04:12PM 00'20" ECM 003/003 0.K 407 9785631704 12-03 09:46AM 00'00" G3 000/002 No Answer 408 9785631704 12-03 09:50AM 00'00" G3 000/002 No Answer 409 19783737443 12-03 11:09AM 00'18" ECM 001/001 0.K 410 9785213767 12-03 11:25AM 01'12" ECM 005/005 0.K 411 19783738062 12-03 12:19PM 00'56" ECM 002/002 0.K 412 15742943450 12-04 12:16PM 00'20" ECM 001/001 0.K 413 19783742337 12-04 12:25PM 00'12" ECM 001/001 0.K 414 19783722312 12-07 08:19AM 00'00" G3 000/003 No Answer 415 19783722312 12-07 08:23AM 00'00" G3 000/003 No Answer 416 19783722312 12-07 09:11AM 00'00" G3 000/003 No Answer 417 19783722312 12-07 09:15AM 00'00" G3 000/003 No Answer 418 19787445140 12-07 04:09PM 02'24" ECM 004/004 0.K 419 19782784008 12-08 12:51PM 00'00" G3 000/003 No Answer 420 19782784008 12-08 12:56PM 00'34" ECM 003/003 0.K 421 19787445140 12-09 02:OOPM 01'44" ECM 003/003 0.K 422 15106522703 12-09 03:09PM 00'20" ECM 001/001 0.K 423 17813916001 12-09 05:30PM 01'38" ECM 006/006 0.K 424 19785218177 12-10 09:14AM 00'12" ECM 001/001 0.K 425 19785218177 12-10 03:17PM 00'12" ECM 001/001 0.K 426 19783886866 12-10 03:22PM 00'28" ECM 001/001 0.K 427 19782833567 12-10 04:IOPM 00'00" G3 000/005 No Answer 428 19782833567 12-10 04:15PM 00'48" ECM 005/005 0.K 429 19785269409 12-11 03:43PM 00'36" ECM 005/005 0.K 430 18885267372 12-11 03:57PM 01'42" ECM 006/006 0.K 431 16033823289 12-14 12:25PM 00'38" ECM 002/002 0.K 432 16037458875 12-14 03:38PM 00'38" ECM 001/004 Comm. Error 433 16037458875 12-14 03:42PM 00'00" G3 000/004 Line Busy 434 16037458875 12-14 03:45PM 01'16" ECM 004/004 0.K 435 19785213767 12-14 03:57PM 00'00" G3 000/003 No Answer 436 19785213767 12-14 04:01 PM 00'58" ECM 003/003 0.K 437 19785572130 12-15 10:02AM 00'16" ECM 002/002 0.K 438 19787455483 12-15 12:53PM 00'16" ECM 002/002 0.K 439 19783737443 12-15 01:37PM 00'18" ECM 001/001 0.K 440 19784695093 12-15 02:52PM 00'14" ECM 002/002 0.K 441 19783732830 12-15 03:13PM 00'10" ECM 001/001 0.K 442 15087932968 12-15 04:55PM 01'46" ECM 003/003 0.K 443 16033823510 12-16 10:36AM 00'00" G3 000/002 No Answer 444 16033823289 12-16 10:40AM 00'24" ECM 002/002 0.K 445 16033823510 12-16 10:40AM 00'00" G3 000/002 No Answer 446 16039269039 12-16 01:44PM 00'28" ECM 002/002 0.K 447 19785213767 12-16 02:19PM 03'10" ECM 010/010 0.K 448 16036260939 12-16 02:55PM 00'38" ECM 003/003 0.K 449 19783737443 12-16 04:26PM 00'20" ECM 001/001 0.K 450 16176636801 12-16 07:02PM 00'28" ECM 001/001 0.K Total Time : 00:27:44 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations IV 600 Washington Street Boston, MA 02111 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#: Are you an employer?Check the appropriate box: Type of project(required): 1.�am a employer with �0 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet I 7• ❑Remodeling ship and have no employees These sub-contractors have 8. []Demolition working for me in any capacity. workers' comp.insurance. o workers' comp. insurance 5. 9. ❑Building addition � p. ❑ We are a corporation and its required.] officers have exercised their 10.F-1 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.E]Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13.❑Other '.Any applicant that checks box Yi must also fill out the section below shmvz:b 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 their workers'comp.policy information. 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.#: LV 4/S Expiration Dater Job Site Address: �/lP /.�e' �,L`�'/ � City/State/Zipr/� � ,`�� Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).6 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 und epi nalties of perjury that the information provided above is true and correct. Simature: 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#: 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 15.2, §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-contractors)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+ie 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 permittlicense 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 bum 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 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass..gov/dia