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HomeMy WebLinkAboutBuilding Permit #596-11 - 11 CAMDEN STREET 3/8/2011 r TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:,. I4 Date Received Date Issued IMPORTANT:Applicant must com Tete all items on this page LOCATION ► Gov-�o��� S� N . RV\Ck -MA a t8 q S Print PROPERTY OWNER Lcoy�rA Na.r g>v-\ �!- Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building N One family 0 Addition [ITwo or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ®.Demolition ❑ Other - vat UP 3r" .w-7.g -,�A.�r ±s "`o""x a""S..� 1 *'�� -��n a'FloodpWetlands.,_ ❑ Watershed,Distrit;�"..':��-� :<�.., - DESCRIPTION OF WORK TO BE PERFORMED: lvvx "I" �e3tvr, � Gb VC.� �j� l �' p �A'�- Cha l�S ✓LCI lz-)G� It— Identification t-Identification Please Type or Print Clearly) OWNER: Name: L.Qay-n M CQ V-en lae - Phone: 5 jA C 2 L O Cgs Address: ,Ao(e-v\. 5'�- I,3I'Cxay,- r CONTRACTOR Name: KQSo Gt-p Jba Qvylgm jC (Ayrt4�ione: ?k 6$ -Ja-t{ a Address: M ' o Supervisor's Construction License: 0 Exp. Date: Home Improvement License: I Exp. Date: X2-13 I I 1 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT;$?2.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ 1 17qct CA LA FEE: $ / .0 Check No.: 33 0 2` Receipt No.: NOTE: Persons contr ctin wit unregistered contractors do l khave access to the gu n fug Signature of Agent/Ow er _ _ ure ocontracto_ f :.;; Location �� Cun�z-,wv z-r-- No. Date MORTiy TOWN OF NORTH ANDOVER O 9 Certificate of Occupancy $ AcHus t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2 3 9 Building Inspector - t j I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dingpster,on site yes t no Located at 124 Main Street Fire Department signature/date 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) ❑ Not for pickup Call Email I Date Time Contact Name Doc.Building Pennit Revised 2014 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 rin 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/Cross Section/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 i 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 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:Building Permit Revised 2014 14 CAMDEN STREET ` J 210/ 885.-0007'0000.0 I k i k ` NORTH '9 0 of : over o No. o dower, Mass., 2COCHICHEWICK �ADRATED P? C BOARD OF HEALTH Food/Kitchen Septic System PERMIT T . D BUILDING INSPECTOR. THIS CERTIFIES THAT......... .4.GJ.r.�...... I�,G�.r.Q�,,c? ........................................ . ••• •••••••••••••• Foundation has permission to erect....................:.................... buildings on .... .(........C'.a ft' 4........... . Rough Chimney to be occupied.as..........��-'Gt. .... .... . ......... ...... !t.c..r................................................................ provided that the person accepting this permll in every respec 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 Final v - PERMIT EXPIRES IN ONTHS UNLESS CONSTRU S ARTS ELECTRICAL INSPECTOR Rough ........... .......................................................................... Service BUILDING INSPECTOR 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. r ; From:Patrice FaxID:McDonald Agency Page 2 of 3 Date:3/8/2011 01:40 PM Page:2 of 3 /"p'1 OP ID: PI CERTIFICATE OF LIABILITY INSURANCE F DAT 03/0803!08D/YYYV) /11 THIS CERTIFICATE IS 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(ies)must be endorsed. If SUBROGATION 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 lieu of such endorsement(s). PRODUCER 608-788-6160 CONTACT Stanley McDonald Agency IL IncPHONE FAX 2018 State Road P.O.Box 1446 608-788-7012 A/C No Ext): (A/C No): LaCrosse,WI 54602-1446 E-MAIL David R.McDonald ADDRESS: PRODUCER WHITKE1 CUSTOMER IDlF: INSURER(S)AFFORDING COVERAGE NAIC 0 INSURED KeJo Corporation dba INSURER A:Tudor Insurance Company 37982 Servpro of Lawrence INSURER B:Travelers Property Casualty 25674 See Note For Named Insured INSURER C: P.O. Box 328 Lawrence,MA 01842 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY.HAVE BEEN REDUCED BY PAID CLAIMS. INSR TR TYPE OF INSURANCE ANS L WVD POLICY NUMBER MSUBR M/LDID/YYYY MMCY EFF /DDmYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY PGP0730650 03/01/11 03/01/12 PREM SEAGES Ea occurrence) $ 300,000 CLAIMS-MADE FX I OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY JPEO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Peraccident) NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? F—] N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Property Section 7107P412 03/01/11 03/01/12 675,00 B EmployeeDishonesty 7107P412 03/01/11 03/01/12 25,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHCLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION NARDLA1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Laura Nardone ACCORDANCE WITH THE POLICY PROVISIONS. 11 Camden Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD MAR-08-2011 TUE 03;33 PM SERVPRO OF LAWRENCE FAX NO, 9786877706 P. 02 From:Patrice FaxlD:McDonald Agency Page 2 of 3 pato:3la/2011 01:43 M Page:2 of 3 OP ID;PI PATE(I WOO/YYVY) ,4co�v- CERTIFICATE OF LIABILITY INSURANCE Ioehf �..� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HO ER.THIS AT CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 13Y THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERM, ALI rHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the ceRlOcate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION 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 ri ghte to the certificate holder in Ilou of such endorsement s PRODUCER 6013-798-6160 c t=' FAX Stanley McDonald Agency IL Inc 608-788-701 PHo AIC No. 2018 State Road P. Sox 1446 LaCrosse WI 54602-1446 A ass: David R.Me Donald c TU WNITKFE1 INBuRt S AFFORDING COVERAGE MAIC IF INSURERA!Tudor Insurance Com an 37662 INSURED KeJo Corporation dba 25674 Servpro of Lawrence INBLIReR s:Travelers Pro eertY Casualty_. See Note For Named Insured IyBURERC: — -- P.O.Box 328 INSURERD: Lawrence,MA 01842 INSURERS, — INsuRe F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER; FQR THIS IS TO CERTIFY THAT THE POLICIES Of INSURANCE LISTED BELOW HAVE BEEN ISSUED CT OR OTHER THE INSURED NAMED WITH RESPECT TO POR THE P ICY PETHIS RIOD DITION OF ANY CO CERTIFICATENM Y BE ISSUED NOR MAY EPERTAIN.THE INSURANCE REMENT,TERM OR aAFF RDFS Y THE POLI ESDESCRIBED HEREINT IS TO ALL THE�TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDoUCED BBYY P PODE11 �• LlMtra --- I dR Ell POLICY NUMBER MIDD Y TYPE OF INSURANCE � 1,000,00 aENERALL1A61LITY EA�HOCCURRENGF $ _ 03/01111 09!01112 pR�nnMeS ao0 $ 900,00 A X CGMMtRCIPLGtNERALI•In61LITV PGPO730650 5,00 MED EXP(Anv 0110 OGM-0n) $ GLnIMSav1A0� OCCUR 1,000,00 PER60NAL B AOV IN,4IRV $ GENFPALAGGREGATC $ 2,000,00 PRODUCTS-COMP/OF AGG $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: $^ PRO- POUCY LOC COM@INED SINGLE LIMB Z AUroMOBILE LIABILITY (Ea accident) —_ 60DILY IN.WRY(Parpor:on) b _ ANYAUTO — ALL OWNED AUTOS F30DILY mla1RY(Par aCpdonn 1 PROPE — SCHEDULED AUTOS (PPr accloord) AGE Z Apnll HRED AUTOS NON-OWNED AUTOG Z EALHOCCURRENCF._ UMPSELLA LK a clGcuR $_ AGGREGATE — EXCEBB LIAR CLAIMSMIADE g DFMCT ISLE S RkTENTION wC STA7 M7•UOTH- WOWERS COMPENSATION f Y L I - AND 19MPLOYERVUABLITY Y/N E.L EACH ACCIDENT $ ANY F'ROPRIE1ORIPARTN9RIE)(ECUTIVE N 1 A El DISEASE.6A EMPLOYEE $ OFFICER MEMBEREXCLUDED4 --- (Idtntlrtoly Ih NH) 61.DISEASE-POLICY LIMIT i I yyeea.d-CA1>0 under 675,0 OESCRPTION OF OPERATIO S below 7107P412 03/01111 03101112 B Property Section 03101/11 03101/12 25,D0 g EmployeeDishonesty 7107P412 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Aaach ACORO 161,Ad4ldond+0d610,If mon rpac0 Is roqulnld) CERT FICATFR CA LA ON NARDLA1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CAN ELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, Laura Nardone 11 Camden Street AUTHORIZED REPRESENTATIVE North Andover,MA 01848 ®1889-2008 ACORD CORPORATION. All eights reserved. ACORD 26(2008109) The ACORD name and logo are registered marks of ACORD 'GG Ig Office of Consumer Affairs and usiness Regulation g n w 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 158271 i ' Type: Private Corporation Expiration: 12/31/2011KEJO CORPORATION Tr# 291205 GREGG WHITE P.O. BOX 328 r LAWRENCE, MA 01842 } f 7 Update Address and return card.Mark reason for change. 3-CAT 0 50M-04/04•G701216 Ej Address E] Renewal El Employment E] Lost Card E'VjOffice of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration x,158271 Office of Consumer Affairs and Business Regulation xpirationl2/31J2011 Tr# 291205 10 Park Plaza-Suite 5170 Type, 1'rlvat�CorpAration Boston,MA 02116 KEJO CORPORA[ > ~r GREGG WHITE' -• 8 BLAKELIN STREET Fes' 49a �_ I LAWRENCE, Undersecretary Not va Ithou signatur Restricted to: 00 `3 00- Unrestricted IG-1 2 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Refer to: WWW.Mass.Gov/DPS •° of _.--- Authorization to Perform Services and DirectionPayment Customer Name: Date of Loss: Loss Address: Cl/F' len City: _ /q/� � State: --- Zip: Insurance/Client: 7f xA—/ Claim Number(if available): The undersigned client, being the building owner, owner's_ representative, or resident, authorizes the Provider identified below to perform any and all necessary cleaning and/or restoration services on Client's property located at the property address below, and with respect to items that need to be cleaned at a remote location to remove and clean such items as necessary. Client authorizesInsurance Company, herein referred to as "Insurance Company," to pay Provider solely and directly for that portion of the work covered by Client's insurance policy. If, for any reason, Client receives a check from Insurance Company made payable to Client, Client agrees to pay Provider immediately upon receipt of the check. In order to expedite payment to Provider, Client hereby appoints Provider as attorney-in-fact, authorizing Provider to endorse Client's name on Insurance Company checks or drafts, and to deposit Insurance Company checks or drafts for Provider services. Client agrees to pay Client's deductible in the amount of $ ? that applies to this claim. If any amounts owing to Provider for Provider services are not covered by insurance, Client agrees to pay those amounts to Provider within fifteen (15) days of Client's receipt of invoice. It is fully understood that.Client and its agents, successors, assigns and heirs are personally responsible for any and all deductibles and any costs not covered by insurance. Interest and finance charges will be charged at the maximum allowable by law, or at 1.5% per month, l whichever is less, on accounts over thirty(30) days past due.Time is of the essence. Client agrees that Provider is working for the Client and not Client's insurance company or any agent/adjuster. Property Owned By: Remarks: I HAVE READ THIS AUTHORIZATION TO PERFORM SERVICES AND DIRECTION OF PAYMENT, INCLUDING THE TERMS AND CONDITIONS OF SERVICE ON THE REVERSE SIDE HEREOF,AND AGREE TO SAME. Client's Signature: rovider's Signature: Printed Name: LCULYCA Franchise Legal Name: �C7 Client Reviewed Customer Information Form: O Y O N d/b/a SERVPRO° of: Date: Date: White: SERVPRO° Yellow: Claims Professional Pink: Customer ©SERVPRO'INTELLECTUAL PROPERTY,Inc. ALL RIGHTS RESERVED FE-051707 1.0 28000 11/10 Each SERVPRO®Franchise is Independently Owned and Operated. W 91?e -� Office of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement`Contractor Registration Registration: 158271 Type: Private Corporation Expiration: 12/31/2011 Tr# 291205 KEJO CORPORATION GREGG WHITE =� > P.O. BOX 328 LAWRENCE, MA 01842 ' /7 �'� ,•. `i�w Update Address and return card.Mark reason for change. P PS-CA1 0 50M-04/04-G101216 Address [-] Renewal E] Employment E] Lost Card tie V/6'IJ7/IJZO�I2CU o���ac�ivael,/d Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: `= Office of Consumer Affairs and Business Re ulation �;1 Registratiop .58271 g Ex iratio�t 12131/2011 Tr# 291205 10 Park Plaza-Suite 5170 P r r _= —• Boston,MA 02116 Type;j,1._-nv e..C_.orp&ation I E" ERB KEJO CORPORATtbN GREGG WHITE � � 8 BLAKELIN STREET ".',,.: LAWRENCE,MA 01Undersecretary Not va ithou signatur I -'�- Massachusetts- Department of Public SafctN \ Board of Building Rc!aulutions and Standar' (Is . Construction Supervisor License License: CS 67690 Restricted to: 00 - GREGG M WHITE 4 CHATBURN RD WINDHAM, NH 03087 Expiration: 2/20/2012 ('umn�iaimier Tr#: 16305 The Commonwealth of Massachusetts F e, Department oflndustrial Accidents r Office of Investigations ,r" _P600 Washington Street �%f� Boston,MA 02111 _ � www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print'LegiblY Name (Business/Organization/Individual): KA)p CpC Q DBA &!Y i()( j erC �t l�(rl`e►ilC"� Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): LN I am a employer with 4. ❑ I am a general contractor and I 6. F1 New construction employees Cii>r part-time).* have hired the sub-contractors 2.El 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. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.]1 employees.[No workers' comp. insurance required.] 13.n Other *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. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors acid 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. Lie.#: Expiration Date: Job Site Address: Cam4r-_149L4L ST City/State/Zip:(tf, d'er"_ 1/�'D v?4s- 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido herebytet ti under the airs and penalties of perjury that the information provided above is true and tort ect Signature: Date: 8 Phone#: T79 6W 'Uo"(4 Official use only. Do not write in this area,to be completer)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'haviiig,no zraore than three apartiients 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 apputtenanl theretd sh�ll'not because of such employment be deemed to be an employer." MGL.chapter 152,§25C(.6)also states that"every state or locahlcensing 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 cavy workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confinnation 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 pen-nit 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 Iegibly. 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. mit/license number which will be used as a.rd'fer_ence number.;In addition an applicant Please be,sure to fill in the per tliatmi4submitmulti le, erniitllicensea lications in.an ` P P pp y 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 pen-nits 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 Massae usetts - Department of Industrial.Accidents Office of Tnvestigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-87:7-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia