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HomeMy WebLinkAboutBuilding Permit #535 - 1072 JOHNSON STREET 2/2/2007 X??TOWN OF NORTH ANDOVER APPLICA F$R PLAN EXAMINATION O�N�e oT a gti0 2 '6 0 0 ti A Permit NO: � � Date Received �� U� �9SSACHU`-'���h ATID Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 40' Jafla�sa^S / Print PROPERTY OWNER ``/N/� �S,6 /&Y Print MAP NO. 0 ?7 a,--PARCEL: S ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building XOne family ❑ Addition ❑Two or more family ❑Industrial ;KAlteration No. of units: ❑Repair,replacement ❑Assessory Bldg ❑Commercial ❑Demolition ❑Moving(relocation) ❑ Other ❑ Others: ❑Foundation only DESCRIPTION OF WORK TO BE PREFOR ED AJ %Slit) /T0� / Identification Please Type or Print Clearly) OWNER: Name: G wbiq So I4 c I Phone: Address: l o 7 2 1l o LJ r7 S ✓� CONTRACTOR Name: /QD,CiCi�f- �' �OL� Phone: g7$4118,a -dam/3 Address: I CO' N)64'1) -'$F- M67-14a&-4 , y"IA of$y q Supervisor's Construction License: CS 0,3"S'749 Exp. Date: biaDb' Home Improvement License: 19011$4) Exp. Date: 11967 ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost :$ `dS, — _FEE:$_66 Check No.: o(7-2 Receipt No.: Page Iof4 TYPE OF SEWERAGE DISPOSAL Public Sewer 11Tanning/Massage/Body Art F] Swimming Pools 11 Well F1Tobacco Sales ❑ Food Packaging/Sales ❑ Permanent Dumpster on Site ❑ Private(septic tank,etc. ❑ Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor \— A���- 4511-17 Plans Submitted ❑ Plansawed Certified Plot Plan ❑ Stamped Plans F1 THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM DATE REJECTED DATE APPROVED PLANNING& DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE OVED HEALTH ❑ ❑�' l/i/rte 7 COMMENTS 47 FIRE IIEPARTMENT - Temp 0umpster-on site yes - no - Fire Dejaartment signature/date > ,- 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 Building Setback Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA—(For department use) Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPEORM05 Created IMC.Jan.2006 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 Addition Or Decks ❑ Building Permit Application ❑ 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) New Construction (Single and Two Family) ❑ Building Permit Application k ❑ 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 Compliance Report 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Page 4 of 4 Location / ! d h h`f o n ) I' J No. (, Date e9 r,:)"! MORT" TOWN OF NORTH ANDOVER f 1 3? • • oL Certificate of Occupancy $ us Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ r� �7 TOTAL $ Check # U19971 � Building Inspector 4 Contractor Agreement .............................................................................................................................................................................................................................. THIS AGREEMENT made 29th day of January, 2007 by and between BC Squared Carpentry, hereinafter called the Contractor and Linda Soucy, hereinafter called the Owner. Witnesseth, that the Contractor and the Owner for the consideration names as follows: Article 1. Scope of the Work The Contractor shall furnish all of the materials and perform all of the work shown on the Drawings and/or described in the Specifications entitled Exhibit A, as annexed hereto as it pertains to work to be performed on property at 1072 Johnson Street, No. Andover, MA. Article 2. Time of Completion The work to be performed under this Contract shall be commenced on or before January 28, 2007 and shall be substantially completed on or before March10, 2007. Time is of the essence. Article 3. The Contract Price The Owner shall pay the Contractor for the material and labor to be performed under the Contract the sum of Five thousand Dollars ($5,000), subject to additions and deductions pursuant to authorized change order. Article 4. Progress Payments Payments of the Contract Price shall be paid in the manner following: one third at start, one third when job is 50% complete, one third when job is complete. Article 5. General Provisions Any alteration or deviation from the above specifications, including but not limited to any such alterations of deviation involving additional material and/or labor costs, will be executed only upon written order for same, signed by Owner and Contractor, and if there is any charge for such alteration or deviation, the additional charge will be added to the contract price of this contract. If payment is not made when due, Contractor may suspend work on the job until such time as all payments due have been made. A failure to make payments for a period in excess of 10 business days from the due date of the payment shall be deemed a material breach of this contract. In addition, the following general provisions apply: 1. All work shall be completed in a workman-like manner and in compliance with all building codes and other applicable laws. 2. The contractor shall work from a plan developed in conjunction with the homeowner and the homeowner's plumber. The contractor shall furnish a description of the work to be done and the agreed consideration for the work. 3. To the extent required by law all work shall be performed by individuals duly licensed and authorized by law to perform said work. 4. Contractor may at its discretion engage sub-contractors to perform work hereunder, provided Contractor shall fully pay said sub-contractor and in all www.socrates.com Page 1 of 2 SS4301-230•Rev.05/04 i E TOWN OF NORTH ANDOVER c10RTM APPLICATION FOR PLAN EXAMINATION ott.�•� 6;'tio � 6 O` Permit NO: Date Received +� i +�w"o1 + Zoo Date Issued: 9SSwCHus�� IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER---//N Print MAP NO. D Q/PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building XOne family ❑ Addition ❑Two or more family 11 Industrial Iteration No. of units: ❑Repair, replacement ❑Assessory Bldg ❑ Commercial ❑ Demolition ❑ Moving relocation ❑Other ❑ Others: ❑Foundation only DE CRIPTION OF WORK TO BE PREFORN 3ED / Identification Please Type or Print Clearly) OWNER: Name: G /A/b i s c �l Phone: 97$-6S-3-7Z Address: lo 7 Z 1 D h 4 s ovl . CONTRACTOR Name: 140, fir' 0. Phone: 978-6ed -6,5'/3 Address: I CO' P4MD -'A= ME?"11 ae-M 04A 011 Yy Supervisor's Construction License: CS OJ'S749 Exp. Date: Home Improvement License: 140,1$0 Exp. Date: Jyh,4 h007,. ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost S `�Oy n _FEE:$ Check No.: Receipt No.: Page I of 4 TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools ❑ ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales [I Permanent Dumpster on Site ❑ Private(septic tank,etc. Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owne Signature of contractor '4�we�.' 44c' Plans Submitted ❑ Plans aived Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM „ DATE REJECTED DATE APPROVED PLANNING& DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED T OVED HEALTH ❑ DA11//0 7 COMMENTS7r��t--- 47 FIRE DEPARTMENT - Temp.Dumpster on site yes no Fire Department signature/date COMMENTS: e 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 TOWN OF NORTH ANDOVER JI APPLICATION FOR PLAN EXAMINATION cf ro so N Permit NO: Date Received 10 Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION /� V D `/d-450J / Print PROPERTY OWNER /� 1A0,4 04h14 Print MAP NO.: /49• A PARCEL: 5Z ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential New Building )LOne family C Addition Two or more family _'Industrial Alteration No. of units: XRepair, replacement ❑Assessory Bldg Commercial Demolition Moving(relocation) Other Others: i Foundation only DESCRIPTION OF WORK TO BE PREFORMED S'� Identification Please'Type or Print Clearly) OWNER: Ivtame: rl/ /d'1 6uc Phone: 1y 63" Address: /0'il Joi/iu,SDrU �7�" /ye �N�d✓ D/�f Name: 415enr ,(., GE w L= Phone: 7, J,.Z-o�/3 CONTRACTOR ar � Address: Supervisor's Construction License: CSS 05yw9 Exp. Date: Homc Improvement License: 1AU vT JfZ Exp. Date: ///sel f ARCHITECT!ENGINEER Name: Phone: :address: Reg. No. FEE SCHEDULE:BULDING PERNUT.$11.00 PER 51000.00 OF THE TOTAL ESTIMATED COST BASED ON 5115.00 PER S.F. Total Project Cost :S x12.00=FEE:S Check No.: Receipt No.: Fa,e iof 4 TYPE OF SEWERAGE DISPOSAL Tanning/Massage,'Body Art f_ Swimming Pools Public Sewer Tobacco Sales Food Packaging/Sales Well _ – "— _ Permanent Dumpster on Site _ rivate(septic tank,e _ Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner Y,4 L Signature of Contractor Z V �Ief- Plans Submitted ❑ Plans Waived 6rtified Plot Plan ❑ 'Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM DATE REJECTED DATE APPROVED '1 PLANNING & DEVELOPMENT ❑ ❑ ❑Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other COMMENTS TE REJECTED DATE APPR,OVVEE,D., CONSERVATIO �� U s yb COMMENTS S fi C DATE REJECTEDD TE A P VED HEALTH \"QOMMENTS Zoning Board of Appeals: Variance,Petition No: Zoning Decision receipt submitted yes __ Planning Board Decision: _..__Comments Conservation Decision: Continents Water& Sewer connection/Signature& Date Drivewav Permit Temp Dumpster on site yes_no_ Fire Department signature/date ___ .r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_/en j ((?/j-115' 1/L� `S/� 1 c7 Owner: Sc�i/G Date of Inspection: I SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. L ` is r L 1 t/2 STY %F 15.6 07 PORT 222 JOHNSON w 7- _ S7ftT': y5 "l(4 r� PL" oPLA" 1N NOR.TH A 10 o VE, MASS. PREPARED MR �►Of LIMA 51AUCY k/ 1072 JOHNSON ST NORTH ANDOVER MASSACHUSETTS 01845 DAT& NO VEJMM 11, 2004 10 r NOTES 1. SEE TOWN OF NORTH ANDOVER ASSESSORS MAP #107A, LOT #50 AND PLAN #5080, PLAN #4402 AND DEED BOOK #3480 PAGE #61 E.N.D.R.D. FOR SITE. 2. ALL NON PAVED DISTURBED AREAS TO BE LOAM AND SEED. 36" WIDE "MIRAFI 100X" 410'1 SILTATION CONTROL FABRIC STAKED HAYBALES ATTACHED TO 4'-6" WOODEN STAKES SILT FENCE BEHIND 2 WOODEN STAKES EXISTING STAKED HAYBALES LEGEND [/fPER HAYBALE (T'P•) GRADE STAKED MOUND SOIL AGAINST FENCE W.F.D. WOOD FRAME DWELLING HAYBALES 6R BRICK 3'-0" SILTATION I N/F NOW OR FORMERLY ? CONTROL FABRIC FLOW 1 TO EDGE _ EXIST. EXISTING J q. 6" PROP. PROPOSED ABOVE GRADE 4'-6" WETLANDS BIT. CONC. BITUMINOUS CONCRETE BELOW GRADE V-6" WOODEN TE THRESHOLD ELEVATION BELOW STAKES - --160-- CONTOUR ELEVATION GRADE 160X12 SPOT ELEVATION > -1L EDGE OF WETLANDS 0 'e µ SILTATION CONTROL FENCE & STAKED HAYBALES DETAIL O 3A WETLAND FIELD FLAG •14"MAPLE TREE WITH SIZE AND TYPE SCALE: N.T.S. AQ '' /09 LOT #50 AREA=254,908 S.F.t =5.85 AC.t SE DETAIL / BE OW RIGHT � I 1 \ 150.1 / 156.37 JOHNSON S z TREE? 10A 1/155.65 m� OVERALL PLAN 9AAL = 80' \\8A A i/i 5A 154.79 ., ►_ 200. 6A 154.04 Z ♦ z 0 •♦ \�� 3A X47 APLE�, I 160` � mom\\ 157. 9r �\ ` j ♦ z ' \ aC 154.13 m o ��� \ A 'n \ \ C, ` ` • TA \l to 9PQ ^ EDGE OF WOODSSHEp p s �!O [DRIP/ CROWN/ EDGE--' \\♦ Q ?s OF SCRUB] LINE \ \ x.32------ __ 2 DECKOD 0 14 MAPLE b0.08 161. 9 16 8 \ EXIST. TE_ \ 15 � 112 S EE)6ST. CAR'>tRT TO BE TY 1S-.ig \ tWIPEG RAGECTED D AN t'� $�\ 1 8 #1072 ERPORT 22\ E�196:45LAB GRADE TO PLAN OF LAND PROP. BE MATCHED, EXIST. SITE LANRSaC X 163.0 62. GRADING TO REMAIN IN g � 164-"- _ 16 .0 X9 \ \ PROP. SILT FENCE 5 ADDITGN v� ^ \� Z} 1 .63\ y&jtf,.WLES NORTH ANDOVER, MASSACHUSETTS PROP. CEM. ry di v 3 i ,` SHOiYING PROPOSED ADDITION \ 16 PROP. TEMP. SOIL CONC. PAVERS m o .�OCKPILE AREA PREPARED FOR 150'1 62.73 LINDA SOUCY 63.70 - I 1072 JOHNSON STREET a X66 ��CZ3.11 162'51 62 NORTH ANDOVER MASSACHUSETTS 01845 ? \�� DATESEPTEMBER 28. 2006 _164 166.61 SCALE: AS NOTED JOHNSON 66.46 �36 0' 20' 40' 80' 12V STREET \mss 165.21 MERRIMACK ENGINEERING SERVICES g 66 PARK STREET 1 = 20, ANDOVER MASSACHUSETTS 01810 F t&ORTH `' Town of t 4 over 0 r:w. - No. idover, Mass., egg;;-a`? 0 - LAKE COCMIC..".CK V 7�ADRATED P"' �y S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.........L.c.r�.� ...... ��....... ..................... �. .............�•_ ............................................... Foundation has permission to erect ...../esftandiiBy-Laws buildings on L 6 ��— d �K '! ' ......... .J. ................................ ........ Rough to be occupied as Chimney p ! r�r... ..............�.. ............................................................................................................... provided that the person accepting this pehl in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Co 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 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU S S Rough ......................... Service BUILDING Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. instances remain responsible for the proper completion of this Contract. 5. Contractor shall furnish Owner appropriate releases or waivers of lien for all work performed or materials provided at the time the next periodic payment shall be due. 6. All change orders shall be in writing and signed both by Owner and Contractor, and shall be incorporated in, and become part of the contract. 7. Contractor warrants it is adequately insured for injury to its employees and others incurring loss or injury as a result of the acts of Contractor or its employees or sub-contractors. 8. Contractor shall at its own expense obtain all permits necessary for the work to be performed. 9. Contractor agrees to remove all debris and leave the premises in broom clean condition. 10. In the event Owner shall fail to pay any periodic or installment payment due hereunder, Contractor may cease work without breach pending payment or resolution of any dispute. 11.All disputes hereunder shall be resolved by binding arbitration in accordance with rules of the American Arbitration Association. 12. Contractor shall not be liable for any delay due to circumstances beyond its control including strikes, casualty or general unavailability of materials. 13. Contractor warrants all work for a period of 60 months following completion. Article 6. Additional Terms See Appendix A Signed this --29 day of , 20 ©7 Name of Owner: Linda Soucy By (Signature): Name of Contractor: Robert Cole dba BCSquared Carpentry By (Signature): �. Street Address: 1 Conrad Street City/State/Zip: Methuen, MA 01844 Telephone No.: (978) 682-0513 Contractor's Licenser No.: CS055749 www.socrates.com Page 2 of 2 S94301-230•Rev.05/04 i Appendix A BC Squared Carpentry will provide the following in the establishment of an approximately 6' x 10' bathroom in the new Great Room at 1072 Johnson: - frame 2x4 walls with an opening for a 2-6 x 6-8 interior entry door - provide insulation, wallboard and plaster and trim carpentry as required to match the rest of the Great Room. - provide for the installation of electrical outlets, switches and fixtures as required by code and/or designated by the homeowner Note: a plumbing contractor retained by the homeowner will be responsible for installing and arranging for the inspection of all plumbing aspects of this project 5E_�� KITCHF-N CAf31Nr:-r VEN1201? PE�516N FOR PACK PA5E/ WAi, CAPING?" tix�srr�� LAYOUT E_�X151N6 CHINA CL05l;t ov 1t 0 OVA 4.1 TO C klflc INE l' lb M G AtH� ,inr 11 �© II I t7om 0 N II II CR�Af p00M 11 II I II' II II :201-011 H:s rok - fiH 'VAVI' l"iO UNI 15 50uc� T I\G 5M NC� rA,IN �X51'ING I?.O, 1072 JOHN50N 511\FFr UNI-r NOPTH ANPOM, MA I "L3UMp-OUT" The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 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): � ��} u� Address: / ;,v4V :S- City/State/Zip: �Ivall_xj / hone.#: ����') 6 9� -o,S/3 Are you an employer?Check the appropriate box: Type of project(required):, 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.[1 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing 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. tContractors 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.M 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 IA for insurance coverage verification. I do hereby cern under a and alties of perjury that the information provided ab ve is tr a and correct. Signa e: Date: lyje 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 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-con6actor(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 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 ---- _ _.---- ---- ---- - ---Fax#617=727=7749 --- --- ------- Revised 11-22-06 www.mass.govfdia