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HomeMy WebLinkAboutBuilding Permit #754-14 - 1132 SALEM STREET 4/28/2014 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page ,...1. .. . LQCATION `�7= 1��Y�1T �tiY }�Zt1 ,— }- ` Pmt PROPERTY OWNER rint 1 o0 Year 010:Structure yes no M'AP NO: t PARCEL-- ZONING DISTRICT Historic Districf s no Machine Shop Village _ yes y no .TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building . One family ❑Addition ❑Two or more family ❑ Industrial JkAIteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other = 0 V1/etlands ❑ Watershed D - -- o Septic ❑Well Flootlplain istrict ❑Water/Sewer tt DESCRIPTION OF WORK TO BE PERFORMED: Iden tificatio Please Type or Print Clearly) �WNER: NamePhonk -10©O Address: CONTRACTOR 'Name: 'U> 1 Phone ��-1� LOQ =Sg51 Address: Qlei -- - Su e-rvisor's.Construction License: _06 016E .. Ex Date:_ Home Improvement-License,:. -2A_ r.__., -_ _ -Exp Date:_ _I •Z50. .. _ 5 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: $ A0 000 00 FEE: $ Check No.: Receipt No.: 17-14 I tD NOTE: Persons contracting with unregistered contractors do not have access oLguaranty fund Plans Submitted E Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Building Department The foh wing is'a list of;the.required.forms to be filled out for:the appropriate:permit to.be obtained. R.00firg, Siding, Interior Rehabilitation Permits a' Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o 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 a Building Permit Application L3 Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o 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) o 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 Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit i In all cas<s.if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apu•�al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.+ted with the building application Doc: Doc.Bui?ding Permit Revised 2012 I Plans Submitted 0 -,Plans--. ;_.Certified Plot Plan ❑ Stamped Plans ❑ .TYPE:0"EWERAGE,DiSPOSAL Public Sewer ❑ Tanning/Massage/13ody Art ❑ Swimming Pools ❑ Well ❑_ Tobacco.Sales 0 Food Packaging/Sales ❑ -Private,(septic tank,etc- Permanent on Site -THE-FOLLOWING SECTIONS FORR-OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF'- U FORM DATE REJECTED DATE:APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS I • ,CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature- 4� COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments �'1 Conservation Decision: Comments Wates' & Sewer Connection/Signature& Date Driveway Permit DPW Tow;: Engineer: Signature: Located 384 Osgood Street FIRE DEPARTM. `•Temp Dumpster on site yes no Located at.,124iMair, Street _ 'F re Fire Departme►it�ignature/date ` COMMENT"S"' ``�` Diiiiensi0n - Number of Stories: Total square feet of floor area, based on Exterior dimensions. :Total land area, sq. ft.: ELECTRICAL: Movement of.Meter,location, niast-or service drop requires approval of Electrical Inspector Yes No DANGERZONE LITERATURE: . -Yes No MGL.Chapter 166.Section 21A-F and G min.$100-$1000..fine NOTES and DATA— For department use ® Notified for pickup - Date Doc.Building Permit Revised 2010 I {{ -� Location yvl No. �� " ,l. Date . - TOWN OF NORTH-ANDOVER 5,tb �6' • Certificate of Occupancy $ .� i Building/Frame Permit Fee $�>j Tk Foundation Permit Fee $ Other Permit Fee $ ' TOTAL $ Check# I I 27496 uilding Inspector Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $) 30,000.00) m $ - $ 360.00 Plumbing Fee $ 45.00 Gas Fee 100 comm. $) 110:0 00) Electrical Fee $ 45.00 Total fees collected $ 550.00 1132 Salem Street 754-14 on 4/28/2014 Remodel Bathroom I NORTII Town of ndover 0 No. yC� h ver, Mass ZRIq T OLAKE C OC.ACNE WICK 4A-riEcp J"" tl BOARD OF HEALTH Food/Kitchen PERM T T D Septic System THIS CERTIFIES THAT .',Q.SI d .................................................... BUILDING INSPECTOR ....................... ........... ..... . ........... .. .......... Foundation has permission to erect .......................... buildings on ...1131... 1� ............. Rough tobe occupied as ....... .. ..... .... � .... ................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MO TS ELECTRICAL INSPECTOR UNLESS CONSTRUN TS 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. Bathroom Notes: o i a o 3064 1)1) Tile flooring to be selected and purchased byOL o, - t D o owner M _ o 2) Tile wainscott, up 36" (please price as optional) 00 ' M 'I .8 3) Full tile shower, including ceiling, tiled niche for C NDRY � - ' C '' � i � shampoo, shower bench Ln 4'- x s'-s" 'E '-6" 8'-3" f 4) Glass door and panel at shower, see elevations 2:9 sq ft ' 'CD �1 N 5) All cabinetry and fixtures to be selected and ►, a.N + purchased by owner > 6) Shower valve and head to be on opposite walls -° ATH a NEW CLOS T-1 °x 11'-0 a 7) Shower head on wall and seperate hand shower Q 4'-1"x 2'-7" N H L 9 sq.ft !" ,, 8) Salvage existing tub, store in garage t 14_sq ft - " 4'_6^ E B 9) Windows must be tempered o (.r ft Al 74 snZ Painte Hallway Notes: �sheve -'/� F -toss 2oss' a Salvage and reinstall existing wood floor kand/ ca E ,jamb-s�nrit¢h � 0 � _ Q► fAih�ts i jal! c ° Laundry: /hew ios ts, ��, Dryer is gas and doors will need to be partially u? %jp; 3 a 3'-2" 2'-11" louvered for air flow M Provide pan and floor drain for washer � j',) - Closets: Alternate flooring may be chosen if there is p 00 insufficent salvaged flooring CD CID Doors: have information from the previous contractor on NEW CLOS this. He paid $272 per panel, including jamb, but no t 5-11"x 8'-11" trim. There are (3) doors being salvaged in the o 63 sq ft project. One should be used for the new master a^Ni bedroom closet. If possible, another should be used for the linen closet in the bathroom. The 3rd MASTER BDRM should be salvaged and stored. ate, t7 2nd Floor 1� O O O rn M CO O o_ Q MM L ° C Q -C t D) Vanity Wall ° z N Glass Glass � Wall between tub and Door 0 0 L shower may become ® O taller for more privacy 0 L U') aS ca a� C1 F) Shower Wall C ° New Windows and Cabinetry 0 o M P 9 ? 9 P 6 4 0 ® P 06 0 to Q O C Q - L A) Kitchen/Entry Wall 4- Ln E U) N M i C L 0 ® o ® ® o V) 0 F1 F1 I Q1 I � Q C N F) Closets on Second Floor 9 n I J O W O O O ^� s W C i L �J Glen Aspeslagh & Sothy Orn - 1132 Salem St, North Andover, MA 508-369-1000 12:47:06 PM PST (GMT-8) FROM: 100005-TO: 1"/813L1Ub/3 AC"RL> CERTIFICATE OF LIABILITY INSURANCE DATE( °°"`YM 2/28/2011 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 endorsemen s. PRODUCER JAMES J MURPHY CONTACT ONE CENTRE ST 2ND FL PHONE I Fax MALDEN,MA 021480000 E-MAIL '�"°' ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC 0 NSURERA: LMInsurance Corporation 33600 INSURED INSURERS: STEPHEN CHAISSON = DBA CHAISSON CONSTRUCT!ON&-REMODELING_._.__ - WSURERC: 165 GREEN STREET JNSURERD: " MARLBLEHEAD MA 01945 INSURERE: INSURER F COVERAGES CERTIFICATE NUMBER: 19380245 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 TYPE OF INSURANCED BR POLICY NUMBER MMIDD YY POLICY EFF POLICY EXP LTR MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE RENTED CLAIMS-MADE 1:1OCCUR PREMISES T a occurrence) $ MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY❑ LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY 99M.ccident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peraccident UMBRELLAW48 OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ A WORKERS COMPENSATION WC5-31 S-376759-023 9/20/2013 9/20/2014RTU EOTRH NO - AEMPLOYERS'LIABILITY TY ANY PROPRIETORIPARTNERfEXECUTNE Y/" E.L.EACH ACCIDENT $ 100000 OFFICER/MEMBERD(CLUDEO? (Mandatory in N") ❑Y NIA E.L.DISEASE-EA EMPLOYE $ 100000 if yes,descrba under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe allached if more space is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR STEPHEN CHAISSON This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage- CERTIF OL"D CANCELLATION LATTN: F MARBLEHEAD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN UILDING DEPT. ACCORDANCEWITHTHEPOLICYPROVISIONS. RD UEAa1945 AUTHORIZED REPRESENTATIVE LM Insurance Corporation O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD CERT NO.: 19390245 OWL Dangas 2/29/2014 12:,15:26 Pn Paqe 1 of 1 Mas sachuse Board Of Builq s �epartme nt Constrgctio g Regulat- Of public Saf Licens Superti.i. and St ety e, sor an CS-0 dards 16S NW ��'�5p�66 is S Green st C SO ',, 1. 14 Cof y)il J�.��.fu 1.1 Expirt- 02113/2a0Oner 15 Office of Consumer ��"` ` Affairs&Bus OME IMPROVEiness Regulation MENI T CONT f egistration: :;145292 CONTRACTOR I XPiration:_-1t6L201'S_=- Type: _ DBA CHAISSON CONST:&REMODELING STEPHEN CHAISSO:f� 165 GREEN ST MARBLEHEAD MA 01945 Undersecretary r' One or Two-Family Dwelling The Commonwealth of Massachusetts Board of Building Regulations and Standards Ulf Massachusetts State Building Code-780 CMR T,his,Section Fpr OfficialUse Oaloh n, 141, Building Permit Number Date of application Signature Building Commissioner/Local Inspector Date SECTION 1: SITE FO INRMATION. 1.1 Property Address 1.2 Assessors Map&Parcel Numbers I V I S ale' 106 k s z Is this an accepted street? Yes 81 No ❑ Map Number(s) Parcel Number(s) 1.3 Zoning Information 1.4 Property Dimensions � 1 10aJodo '318'' Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(feet) Front Yard Side Yard Rear Yard Required 26 Provided , d Required I Provided t pp Required 36 1 Provided >10p 1.6 Water and Sewer Municipal 1.7 Flood Zone Information 1.8 Conservation Commission Private 19 On site disposal ❑ Flood Zone N/A❑ DEP Number 40- N/A❑ 1.9 Old&Historic Commission 1.10 Site Plan Review 1.11 ZBA Special Permit COA Number N/A❑ Date filed N/A❑ Date filed N/A❑ SECTION 2: PROPERTY OWNERSHIP 2.1 Owner of Record en J\fr-J lt3a Name(Print) Address for Service �C- S(J� r361 -� ��'� Signature of Owner Telephone SECTION 3: DESCRIPTION OF PROPOSED WORD(check all that apply) Y Existing Building ❑ New Construction ❑ Accessory Bldg. ❑ Addition ❑ Alteration(s) Repair(s) ❑ Demolition ❑ Owner-Occupied ❑ Number of Units Other ❑ Specify: Description of Proposed Work: n 4 SECTION 4: ESTIMATED CONSTRUCTION COST, BUILDING PERMIT FEE Item Estimated Cost This Section For Official Use Only_ (labor and materials) 1. Building $ Building: $10/$1000 2.Electrical $ Building+Plumbing: $12/$1000 Building+Electrical: $13/$1000 3. Plumbing $ Building+Electrical+Plumbing combined: $151$1000- 4.Mechanical (HVAC) $ Total project cost(labor and materials)$ 5.Fire Suppression $ Fee multiplier from above$ /$1000 6.Total Project Cost $ Permit Fee$ Receipt Number SECTION 5: GONSTRUGTION SERVICES " x 1,111tonstruction Supervisor License(CSL) License Expiration Date Name of CSL Tye Description U Unrestricted(up to 35,000 Cu.Ft.) Address R Restricted 1&2 Family Dwelling M Masonry Only Signature RC Residential Roofing Covering WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Telephone D Residential Demolition 5.2 Home Improvement Contractor Registration(HIC) Registration Expiration Date HIC Company Name or HIC Registrant Name Address Signature Telephone SECTION& WORKER'S COMPENSATION.INSURANCEr'AF -T-.(MGL;"c 152:§ 25C(6)) Worker's Compensation Insurance affidavit must be.completed and submitted with this application. Failure to provide an insurance affidavit may result in the denial of a building permit. Signed affidavit attached? Yes ❑ No ❑ SECTION 7a: OWNER AUTIiORIZATION TO BE COMPLETED`WHENOW)`WS AGENT DR` '"Y R CONTRACTOR APPLIES FOR:BUILDING PERMIT I, as Owner of the subject property,hereby authorize to act on my behalf in all matters relevant to work authorized by this building permit application. Signature of Owner Date SECTION 7b: OWNER OR AUTHORIZED AGENT DECLARATION ' . as Owner or Authorized Agent,hereby declare that the statements and information on the foregoing application are true'and accurate,to the best of my knowledge and belief.. - Ll 11 1L( Signature of Owner or Authorized Agent (Signed under the pains and penalties of perjury) Date SECTION.8: DEBRIS DISPOSAL All dumpsters of six(6)cubic yards or more are required to have a permit from the Marblehead Fire department: call 781-639-3428. In accordance with the provisions of 780 CMR and MGL c40,§54 a condition of issuance of this building permit is that debris resulting from any work performed shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL ell 1,§ 150a. DEBRIS DISPOSAL LOCATION SIGNATURE OF APPLICANT NOTE An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor(not registered in the Home Improvement Contractor(HIC)Program)will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street ,i Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 11 Please Print Legibiv Name (Business/Organization/Individual): C,!*t, gSOJ\ CJ(),tt' V!f 1 W Address: IE,S Gtw4 City/State/Zip: rL t.6 MiN Phone#: 0 J 1 10, S Are you an employer?Check the appropriate box: Type of project(required): 1.R I am a employer with �- 4. E] 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 shipand have no employees These sub-contractors have S. Demolition working forme in any capacity. employees and have workers' 9. [No workers": comp.insurance comp•insurance.$ Building addition required.] 5. ❑ We are a corporation and its 1011 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself..[No workers'comp. right of exemption per MGL 12.E]Roof repairs insurance required.]t c. 152,§1(4),and we have no f employees.[No workers' 13.❑Other 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. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. i I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company Name: L1t��rt Tn! Policy#or Self-ins.Lic.#: �j C.S. �r _�-���o) Expiration Date: 2_012-014 Job Site Address:_k_J'_Z Tbig,n S No An City/State/Zip: �k), a4zu_p- �C � 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 u to$1 500.00 and/or one-year,im P � nsonmen y p t,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. ! �Idoherebyc i under the pains and penalties of perjury that the information provided above is true and correcti afore: 1 Date: 4 Z-t ?_0(a Phone#:C�r6\) I l>� 5 49 Official use only. Do not write in this area,to be completed by city or town offikial 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-contractor(s)name(s),address(es)and phone number(s)along with their certificates)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 4-24-07 www,mass.gov/dia