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HomeMy WebLinkAboutBuilding Permit #112-14 - 105 FOXHILL ROAD 8/1/2013 I TOWN OF NORTH ANDOVER il2-j�{ APPLICATION FOR PLAN EXAMINATION ^� Permit N0: Date Received Date Issued: - r - • 3 IMPORTANT: Applicant must complete all items on this page F _ Priht I PROPERTiY ®W.NER� 4 Pnrit 1009Year OIdIStructurej` yes? aMAP:NQ _ PARCE _- NING,DIST�RICT �HistoncdDistnctd yes , - - . "Ma "S Yest 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 X Others: ❑ Demolition ❑ Other '- m ❑ Septics ❑+WelltFloodplain-= ❑1%lletlands: T '� ❑ WatershedDist`rctff z + 3. t ❑{V1%ater/S:ewen DESCRIPTION OF WORK TO BE PERFORMED: 2 k 2-4 \/k w, 1•h 1 �t.�uww....-t dy Identification Please Type or Print Clearly) OWNER: Name: c,e. G t,-tst-vm.e-_ Phone: Address: o lk T7A Y3 . S +T--' 4 u yy '� 37 r •� r 1 G.L CONTRACTORt' NameA hone's Address � v�A vJ � �R �t�vJ�1° �_1�. �� =D i g_1- } Supervisor'sConstruction�License: o� X33© Expo Date o .I 113 �`' Y Home ImprovementLlcense . ARCHITECT/ENGINEER Phone: k Address: Reg. No. I FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.'' ,, Total Project Cost: $ 7,D7.01�0 FEE: $ �d a � Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund f'contractor Signature of Age.nt/Owner :xs , Ik Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ Location/b.(� 0xv c // No. Date 4 o - TOWN OF NORTH ANDOVER e Certificate of Occupancy $ q Building/Frame Permit Fee 7 s Foundation Permit Fee $ i` Other Permit Fee $ •�'`� ,,. ''�� TOTAL $ 'E. ' Check 26692 . Building Inspector Plans Submitted ❑ PlansWaived-11 Certified Plot Plan El. Stamped Plans F1TYPE OF.SEWERAGEDISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑. . Swimming Pools ❑ Well ❑ I 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 ❑ Zi l- COMMENTS of✓1 E/9o25) — GoYt, �ion iy, gyley-c� CONSERVATION Reviewed on Signature COMMENTS D `- O& (-a M HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments & Sewer Connection/Signature Dafe Driveway Permit DPW To`vda Engineer: Signature: Located 384 Osgood Street FIRE DEPARTIlfI►=.NT - Temp Dumpster on site yes no Located at 124 Mairr.Street Fire Dep asignati�reldate s J., COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Dieter 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 1 ® Notified for pickup - Date Doe.Building Permit Revised 2010 Building Department The fd,jwing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofivg, 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 (1f Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits'for Engineered products (VOTE: 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 o 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) o Copy of.Contract Li Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products MOTE: 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 app,-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application i I Doc: Doc.Building Permit Revised 2012 r Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 20,700.00 m $ - $ 248.40 Plumbing Fee $ 31.05 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 31.05 Total fees collected $ 410.50 105 Fox Hill Road 112-14 on 8/1/13 In Ground Pool Anc ve- to No. I Z 0 h ver, Mass OLANG COC NIC 0411 WICK V� A�J�^TEto) ►Pp,�'�y S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System 6,4THIS CERTIFIES THAT ,{. �., ..='t1�A •.......... BUILDING INSPECTOR ................................................... .. .......... tc Foundation has permission to erect .........................: buildings on ..�.Q,........... ... .. .......%�,............. Rough to be occupied as ......' .. .. ..... ..... .�� ........ a. ............. Chimney provided that the person accepting this peeat rmit in eve respect conform to the terms of the application p p p 9 p every p pp Final on file in 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN54ONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC ST S Rough Service ........... .... .......................................... .............. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE S 4 _ 4 ftR q fifi-nn 24'-0" 8. 0 - y ST-4800 ST-9602 ST 9602 " _ ---------- S-0" - 24'-2" 23'-3 7/8" ' 26-10" IF f $ltail�Alz 3'-0" T = ST-4800 ST-9602 ST 9602 RACES&DECK SUPPORTS AT PANEL JOINTS AS SHOWN 3.4„ a ti,'0 I 4'-0..�. 10' 0" 3 0 7'-0,. :.{ �- THIS DOCUMENT IS FOR ILLUSTRATIVE PURPOSES ONLY. nents Alpha .makes only those representations which are stated In Its written warranty.Any other representations,statements,or contracts agent or employeeof Alpha3.Theconstructioncustomer nrmethods illustrated here arersuggest ooduced yes and apply only ` p a 3 Mfg Y attributable to the dealer/contractor only.The dealer or contractor who sails or Installs your pool Is an independent contractor and is nota 9-A safety line,with buoys,is to be permanentlyattached V-0'to the shallow side of the int of first sloe r ` P to normal ground conditions.There may be additional precautions and/or methods of constructsrls[o bedetermined byonsibility and s the is[he respons b Ilty of the contractor who is not an agent of the manufacturer of the component parts.-Installation is to ..... ......................�m,�no dictated by various around conditions.'fhl _____;,,,,,�„�,�„r,,,,,,��,,,�enccT ori EXCEED A.N.S.I./N.S.P.L/A.P.S.P.RECOMMENDED STANDARDS:NO DIVING' .? A� Board n itadldinu ,--d t CL;ise': CS 10330 WILLIAM C POULoS t 70 S BROADWAY LAWRENCE, NEA 41.843 i Expiration: 7/19/2013 ! tiiti :e tic^ Ti20968 VV t=, Office of Consumer Affairs W Business Regula��tion 10 Park Plaza - Suite 5170 .Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 118204 Type: Supplement Card FAMILY POOLS & PATIOS INC Expiration: 2i13i2015 GLEN WIGGIN --- - - - - - - ---. _ __- 70 S. BROADWAY ,LAWRENCE, MA 01843 Update Address and return card.Mark reason for change. ' sca 1 20M-05117 Address `j Renewal i.. ! employment Lost Card ���� � -Jlrulritrr„rr�/!G r/'• l(cri.;[ir�rrJr%/.; fficr of Consumcr Affairs&Business Regulation License or registration valid for individul use only before the expiration date.. if found return to: ME IMPROVEMENT CONTRACTOR P� h Office of Consumer Affairs and Business Regulation egistration: 11!8204 Type 10 Park Plaza-'Suite 5:170_ Expiration: 2/13/2015 Supplement.'ard Boston,Mil;02116 FAMILY POOLS&PATIOS INC GLEN WIGGIN 70 S.BROADWAY LAWRENCE,MA 01843 Undersecretary Not valid without signa u :Eileen P. Hart, PAI -Hub International New Engi TO:COI a req: NRND (Gladstone) (16033471400) 25:08 06/26/13 EST P9 6-6 Client#: 53642 FAMILYPOOLi IDATE(MMJDDIYYYY) ACOR®�, CERTIFICATE OF LIABILITY INSURANCE 612612013 THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed.If SUBROGA T ICON IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder In Ileu of such endorsement(s). PRODUCER HUB International New England PH0` 978 657.5100 866-475-7959 299 Bailardvale St ac.No.Ell: A.c.Nc: '_ Wilmington,MA 01887 ADDRESS: INSURER(S)AFFORDING COVERAGE NAiC ff 978 657-5100 INSURER A:Nautilus Ins Co INSURED INSURER 8,Technology Insurance Co ^ Family Pools&Patios Inc. INSURER c:Acadia Insurance Company X31325 INSURER D:Safety Insurance CO TO S.Broadway INSURER E: Lawrence,MA 01843 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 13 TO CERTIFY THAT THE PDLICiES CF INSURANCE LISTED BELOW HA`.IE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOC INDICATED. NOTVNITHSrANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR 07HER DOCUMENT 0TH RESPECT-0 bVHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AL_ THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMiTS SHOWN MAY HAVE BEEN REDUCED EY PAID CLAIMS. IN6R. TYPE OF INSURANCE D L USR GUCY Eff POLICY EXP LIMITS LTR Y POLICY MM/DD/YYYY LMAfDDIYYYY A GENERALUABIUTY NN138379 9H 912012 09!191201 EACH'0CCURR=NCE $1 004 000 X COMMERCIAL GENERAL LIABILITY $AMAGE TO RENTED REFi11S -JEa occur ea $100,000 CLAIMS-MADE ®OCCUR M L'EXP(Any ens Wrsnr} n 5,<1od X SUPD Ded:2,500 PERSONAL I ADv INJURY $1,000,00C GENERAL ACGREGATE x2,000,000 G£ML AGGSE3ATE LIMIT APPLIES PER* I PRODUCTS (iP.1PrGPA.GG 0,000,000 POLICY 71 TPA_ F LOC FD A970MOBILELIABILITY 3947232 112511t20112 12/31/201 Ea caE�[�INrLE:_�JPIT $1000,000 ANY AUTO BODILY INJURY $ ALL OWNED X SCHEDULED BODILY INJURY(.tee:ece:rM; x AUTOS AUTOS X HIRED AUT OL HX NON-OWNED PROPERTY DAMAGE AUTOS iPe'r(bd�rW UMBRELLALINB XCUR EACH OCCURRENCE 4 EXCESS LIAR :;LAIMS-MADE AGGREGA'E DED RETENTIONS $ _ WORKERS COMPENSATION j Sz=.TJ OTH- B TVUC3335006 213112012 12!311201 AND EMPLOYERS'LIABILITY T Y'RJIT P OFFICERIME°MBEREXCLU IES ECUTI\rE,1 NIA E L EACH ACCtDEVT $500,000 NandatoN In NHI u E L.DISEASE.E!,=IAPLOYEE $500.000 it yes cestnba under DESCRIPTION OF OPERATIONS ItElow E.L.DISEASE POLICY LIMI' $500,000 CProperty CFA018008416 D911912012 09/191201 vr5 limits Spec Foan Rep[Cost ed$1000 i DESCRIP71ON OF OPERATIONS 1 LOCATIONS!VEHICLES;Attach ACORD 101,Additional Remarks Schedule,N more space Is required) Workers Compensation has Blanket Waiver of Subrogation,as required by executed contract,Work In NY Is excluded;new construction of 10+units is excluded.re:Gladstone,105 Fox Hill Rd,North Andover. I CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCP.IBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOMCE VILL BE DELIVERED IN 1600 Osgood St ACCORDANCE WITH THE POLICY PROVISIONS, North Andover,MA 01845 AUTHORIZED REPRESEN i ATIVE 'Ar Cts 1988-2010 ACORD CORPORATION,All rights reserved. ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD SS91462981MS"216 EH002 70 South Broadway45 Route 125 Lawrence,MA 01843 r°f Kingston,NH 03848 Tel:978-688-8307 f } Tel:603-642-9909 Fax:978-688-1949 Fax:603-642-9906 providing a full line of services and supplies fully licensed and insured www.familypoolsonline.com Q_ S a{-. 2,517— Name 51ZName H" ., M, (�(6,�x 4,•i Date Z A'Avi�r_ Zc it Address — S Fc x } 111 f�tc4: City Q. h-J d ra C State I'Liik ZipHomePhone ` f 1?4. 141� Work Phone Cell Addl# Cross Street/Directions s- l'4<•.s uK cv, =ter - Estimated Start Date Estimated Completion Date We propose to furnish and install one vinyl gunite d 2�u 2r{ 2 t2F�° (2F _ swimming pool for the sum of$ 15-&V0" THIS PRICE INCLUDES: Normal Excavation up to 8 hours on day of dig Manual vacuum cleaner kit Waterline Tile(6') Backfill and Sub-Grade up to 3 hours 3-Step stainless ladder Liner Choice Underwater White Rope and floats Test Kit Steel Reinforcing per Engineered Plans for gunite Initial balancing chemicals •Surface slimmer(s) t •Steel Structure per Engineered Plans for vinyl •8 to 12 Wk supply of maintenance chemicals •Dual Main Drains Over-Flo Line for added protection (supply depends on pool size) Coping _ _ Pressure testing of plumbing during construction Leaf net •Steps t � A Ten Year Plumbing Guarantee(see specifications) Wall brush Handrails Transferable Lfetme Structural WarcantyExtension pole Filter `' >' "-rr`t"e= (plumbed no mo(e than 5ft from pool) Pump&motor lie THIS PRICE DOES NOT INCLUDE: ti'it+1i:i- 1�, •Any plumbing over 25ft from pool.Additional runs are not recommended but would be ata cost cf$ per toot per line. Machine fime in excess of that specified above.A ditional machine time to be billed at$—I(ON including machine,operator,and laborer,due with second pool payment. All hours of trucking will be charged at$ V per hour per truck due with second pool payment Any dumping costs incurred for disposal of ledge,large rocks,garbage,stumps buried or otherwise,building materials,unsuitable or nonstructural soils,or any unforeseen material that must be removed. Removal of ledge or large rocks by way of a Starr bit,chipper,or blasting. Additional fill,if necessary,for proper backfill or reshaping of hole,supply or spreading of loam,reseeding of grass. Patio,fence,retaining wall,or any accessory items other than noted on contract. Electrical wiring,fuel connections,heater venting,fuel storage tanks or permits. Repair or replacement of sprinkler systems or any buried items such as well lines,drywells,leach fields,electrical lines,cables,etc.that are damaged during constructi r Cos duer to water or soil conditions(ex.clay,peat,live sand,excessive rock,etc.)requiring a stone pack of the hole.The stone pack will be at an extra charge of$ ' minimum to $ lit,' maximum and at the discretion of the job supervisor.Additional machine time and/or materials necessary to rectify such a condition will beat a cost over ad above the stone pack and will be quoted by the job supervisor. Water to fill pool. CUSTOMERS MUST SUPPLY: _Initials Access for all trucks and equipment Building and Electrical Permits or assume the costs necessary to obtain such permits. Water and electric necessary for construction of pool Customer must water cure Gunite shelf for 1 to 10 days-d applicable. Water to fill pool immediately upon interior finish NOTES: til;i t - iAk hCLCq 1AAx'= LJZ -- J rA 041(k e s C ry OPTIONS: TOTALS: Diving Board ( ) Solar Cover ( ) Basic Pool Price $ � ` Additional Pool Lighting { ) �.s E?� p rs t,.�,p, P�tyl ) L� Options 8 Heater �I Environpool Plus,8 hd+2 surface ( ) SUBTOTAL $ >I'D 0 Additional Floor Heads 03% Polaris Vac-Sweep ( ) 03%Sales,Tjax n,6 C Polaris retrofit only { ) TOTAL 'y �� $ I.J 4 7 Swimoul/Bench Interior Finish ( ) Less1D%Deposit $ Spa I ) BalanceotContract $ I3 _ Automated Control System ( ) Salt Chlorine Generator ( Art ) 1 fN Other ( ) PAYMENTS:113 EXCAVATION 113 BACKFILL+EXTRAS 113 SYSTEM START-UP The buyer hereby agrees to pay,in full,the total amount of this transaction upon start-up of the installed pool.Your salesman or job supervisor Will meet with you prior to excavation at which time all decisions including pool size,shape,elevation,liner print,and all options must be final.Changes after this date will be subject to extra charges,where applicable,and Will result in unavoidable delays.You,the Buyer,may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.Credit card payments not accepted on contract amount. b 1" ' BUYER date c r SELLER "° date`7��CO BUYER date The Commonwealth of Massachusetts. Department ofIndustriglACCldents 07 Office of Investigations 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/Orgariizatiohgindividual): F ki4uwt/ V Address: —10 '59, City/State/Zi LANJ AA, o tkO Phone#:_ 91(- Are Y'Are you an employer?Checktheappropriate box: Type of project(required): 1.PT I am a employer with 32� 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).` have hired the sub-contractors 2111 am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. E]Building addition [No workers' comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.[1 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions <N '. m selfo workerscomp. c. , ,and we have no Y p 152 §1(4) 12.0 Roofxepairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other rN1A.ut,A Y� *Any applicant that checks boxk must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this bokimist attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that is providing workerscompensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lie. Expiration Date: 3 Job Site Address:-(o,�_' l( City/State/Zip: 0, A✓\ , .ol r Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby cert under the pains and penalties ofperjury that flte information provided above is true and correct. Signature: Date: Z-1 - ?.0 i 3 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 apartriieik'anci w;ho i 6fdes 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,§256(6 also that`every state or local lice'tnsing agency shall�withH6ld'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,'�ff policy s.required. Be advised that this affidavit maybe 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,thatthe affidavitis complete and printed legibly. The Department has provided aspace 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,fil 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(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 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. r The Department's address,teleplione and fax number: The Coin-monwtaltla ofM-assacliusPfts 0 Department of Industrial,Accidents Office of Iavestigatiions 604 Washingtou Street Boston?MA.02111 Tel.#617-72.7-4900 ext 406 or 1-877-MASS.AFF Revised 5-26-05 Faze#617-727-7749 vrv.mass,govfdia