HomeMy WebLinkAboutBuilding Permit #505-2011 - 1132 SALEM STREET 12/28/2010 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: �0// Date Received
Date Issued: aIze—le
IMPORTANT:Applicant must complete all items on this page
LOCATION
Pri t
PROPERTY OWNER r-t
Print
MAP NO:/1Z' -• PARCEL: -S-4ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
ResiSkntial Non- Residential
❑ New Building D-6ne family
❑Addition ❑Two or more family ❑ Industrial
❑A ration No. of units: ❑ Commercial
Ql�epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
DaSe°ptic ®Wel ®pFXl odp a�n; DEW kW, nd ® W,atershedTDsct �"
i®Water/Sewed �.a Y a 1F m R
DESCRIPTION OF WORK O BE P�ERFORME �-, Q
c~ 1 1 I c t (e �S -e I
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Iden ' kation eas T e or Print Clearly)
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OWNER: Name Phone: 1 .6j /C)oV
Address: 1 17 3oZ S� S
CONTRACTOR Name: ()t Phone:
Ii
Address:% \ki IC�f!
. Date:'
Supervisor's Construction License: ' O g S D Ex OZ
p � � P
f•
Home %� 7
Improvement License: o9 1 U _Exp. Date: i
P p ^'l
NEER R Phone: 40 �.
_,;
jAddress: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$12.00 PER00.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $� ,) FEE: $ ✓��
Check No.: �/ Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the anty fu
Signature of A ent/Qwner i nature of;contractor
r
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
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
Building Permit Application
❑ Certified Surveyed Plot Plan
u Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable).
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o 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
40TE: 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
:hat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
nust be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
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
i
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 Dumpster on site yes 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.
I
Total land area, sq. ft.:
a l
ELECTRICAL: Movement of Meter location, mast or service drop requires pproyaof
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
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U Notified for pickup - Date
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Doc:.Building Permit Revised 2008
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Location
No. '' s�� Date /2 2Z-- /o
NORTIy TOWN OF NORTH ANDOVER
3:0�,t`,o •,hO
O
N R
9
Certificate of Occupancy $
.T CMOS' Building/Frame Permit Fee $
r:
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
r
23819
B ilding I,pspector
Name: Pr�DPP_� ICL(Ah Fully
Address: a• P - Ultimate Chimney Sweep Inc. Licensed
Town: G�x1do e, 1_8®0_499_2726
� p (� _ I COD Insured
Phone: 1 C10 C�'1CI�LtUi'1 �-�j��I�t1 't+�m��" Serving Eastern MA &RI
Email: Technician l� �� Date,*a51 to WWWULTIMATECHIMNEYSWEEP.COM
Chimney Cap (100% Stainless Steel)
Chimney Liners(l00% Stainless Steel)lifetime warranty All liner prices includes labor and material Helps prevent animals,debris,and water
Size $
Chimney Line unline deteriorated/shifted/cracked/collapsed/new appliance Size $
1 Size $
Roo : Steep Fla Mild Slate Ladder Staging Chimney Location: Side Middl Chase Cover (Aluminum)$
Quote Dampers (Lymance / Locktop II)
Oil / Gas Pipe: #Conn Ft Flue Tile: Unlined Btus $ Size x $
Oil / Gas Pipe: #Conn Ft Flue Tile: Unlined Btus $ Size x $
Fireplace W: t-11 H: A Ft d-V i Flue Tile: Unlined ,a X l 3$�
Fireplace `W: L1) H: Ft�a Flue Tile: Unlined la1[I(o 'tea—o s Quote
WS/Pellet/Insert/Freestanding Pipe FT Flue Tile: Unlined $
*Permit costs are an additional fee(determined by the City or Town) Smoke tite(seals chamber)
*Gas liners require a licensed plumber for final connection at Homeowners expense Replace flue the x
Additional Comments: Clean-out Door x
Dryer vent cleaning
Crownwash(helps protect brick)
Chimney Rebuild (All rebuilds prices include removal of all brick and debris) *Chainwhip:(creosote removal)
Roof: Steep Flat Slate Mild Ladder Staging Location: Middle Side Waterproof brick/deck
Reseal Flashing(helps prevent leaks)
1#of Rows: #Bricks per Row: Brick Color: Total Bricks: REBUILD $ Relead Chimney Ft.
#Flues Flue Size: x x :x E F: 1 t Utrowel(atticibasement)
Repoint Firebox
2#of Rows: #Bricks per Row: Bricg,,Aolor. Total B • s: I -D $
p Rebuild firebox# R/Y
#Flues Flue Size: x TAT I �`
,� N�d� p Gutter Cleaning
r � Duct Cleaning
Repoint chimney $ RepoinBiE-W�GHAM ,Ak 2t/ ,
_8 79 #Y Recommend to clean Flues
Additional Comments FP WS PS OIL GAS
I
Proposal valid for Days/Year
*Chainwhip quotes are valid for 30 days
There is a minimum deposit of 30%for any authorized work described in the proposal.All deposits are NON REFUNDABLE Total of all proposed work$
Remaining balance is due upon completion.All material is guaranteed to be as specified.All work to be completed in a substantial Appointment Date Time
workmanlike manner according to specifications.Any work involving extra costs will be executed only upon written orders,and will Deposit Received qL ) D p /D
become an extra charge over and about the estimate.Property owner to carry fire,tornado,and other necessary insurance. Our workers are
fully covered by Workmen's Compensati Insurance.Upon signing you agree to the terms and conditions of this contract I have received Consumer Education Material
Customer Signature DateaP j c+
✓,(�O face of Consumer Affai and Business Regulation
10 Park Plaza Suite 5170
° Boston, Massachusetts 02116
Home Improvem_111 Contractor Registration.
Registration: 124978 "
J Type: Supplement Card
Expiration: 9/19/2011
Ultimate Chimney Sweep, INC. . 1 _
KEN CYPHERS ----�----
90 Mendon St. -
Bellingham, MA 02019 " l -
�;1� -� S�s- Update Address and return card:Mark reason for change..
❑ Address [j Renewal F-] Employment ❑ Lost Card
DPS-CA1 0 5OM-04/04-G101216
�ie Tho�nonaoxusp� ./�"aaaac`u�aelta
0,
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
Registrations _124978 TYpe'' laza-Suite 17
10 Park P S 5 0
Expiration 94911 Supplement�7ard Boston,MA 02116
201
it~
Ultimate Chimney,,§w'/ I
WENT FROM 7-;7;5EMPLO
YE_ES
`�
KEN CYPHERS�`y,e-�}�-,'::•:�'
90 Mendon St.
Bellingham,-MA 02019'-= Undersecretary 4Not signature
I
The Commonwealth of Massachusetts
c , Department of Industrial Accidents
" A Office of Investigations
�.�. 600 Washington Street
P -
Boston,MA 02111
°M .V www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please PrintLegibly
ii
Name (Business/Organization/I ividual): j QUI t vl/�
Address: G0
City/State/Zip: E ( Lone#: 7 /
Are you an-employer?Check the ap ropriate box: Type of project(required):
1. m a employer with--� 4. ❑ I ain a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I atm 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.] i
officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12,0 Roofi'irs
insurance required.]t employees. [No workers' 13.�he 11.4,4Y
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 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:2 ,r t CC)
Policy#or Self-ins. Lic.#: a M Expiration Date:
Job Site Address: _S+ City/State/Zip:Q R4C)0 E� V A(0 0f�
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.
I do hereby cert' under the pains and penalties of peijury that the information provided above is true and correct.
Si nature: Date:
/;
Phone
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner.of a dwelling house having not more than three aparhnents 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 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 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 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 pen-nit/license number which will b@.used as a reference number. In addition,an applicant
that must submit multiple permit/license applications inany 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 Massachusetts
t; Department of Industrial Accidents
Office of Investigations
600 Washington Street -
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFB
Revised 5-26-OS Fax#617-727-7749
.
w1VvW.mass.gov/dia
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Client#: 55806 ULTIMCHI
ACORD. CERTIFICATE OF LIABILITY INSURANCE DAT-fMM' 010 Y.
00
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDS/R41:2010
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICITH
ES
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. Is
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 ail endorsement.A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Starkweather&ShepleyNAME.
" Donna M- Canario
PO Box 549 PHONE(A/C,No,Ext):401 435-3600 FAX
Providence, RI 02901 401 431-9309
E-MAIL IA/C.No)
-0549 ADDRESS dcanario@starshep.com
401 435-3600 PRODUCER
CUSTOMER ID#
INSURED INSURER(S)AFFORDING COVERAGE ,MAIC a
Ultimate Chimney Sweep, Inc. INSURER A:Tudor Insurance Company 37982
90 MENDON STREET INSURER B:Firemans Fund Insurance Co
BELLINGHAM, MA 02019 INSURER C Zurich American Cos
INSURER D:Travelers Insurance Company 25674
INSURER E:
COVERAGES NsuRER F
CERTIFICATE NUMBER:
THIS IS?-O CERT IFY THAT I HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TFIE INSURED NAMED ABOVE REVISION ORUMBER'I HE ICY PERIOD
INDICA]ED NOTwill-iSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CON IRACT OR OTHER DOCUMENT 'WITH RESPECT TO%NHiCH THIS
CERT";CA1 E IMAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFF ORDED BY I HE POLICIES]DESCRIBED HEREIN IS SUBJECT TO ALL IHE TERP,1S
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.OMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NSR
LTR TYPE OF
NSR WVD INSURANCE A.DL SUER POLICY EFF 'POLICY EXP ,
POLICY POLICY EFF
MMI.. ...-
A GENERAL LIABILITY MLIMITS
X C, BRP0000101 08/05/2010 08/05/2011 EACH OccUHRENCE. _ E Al!:A5 JAI AGE TO N D <1.000,000
X uc c I./!1 PF N SES fE. r.rrv,t.r; 550,000
X BI/PD Ded:5,000 ^(`D ExP IA,, 50
P=_RS)NAL N.Jk :1.000,000
oE„ GENERAt.AGI;m!?,CIA
ES, X2.000,000
PRODUCTS r;ol.:>O=A, G 52,000,000
D AUTOMOBILE uaewrY -------------------
BA1954N14510
03/13/2010 03/13/2011 C-%`S:NED SINGE
1.000,000
�._ BOD::� !rdJU.RY: oe -
'" Pei
X _C HEDo--=1 Aj-.",S BOl7fl.Y INJURY Par,iro;nE'..: .
X 4e,I-.-
�-. Pi2t�on.a-Y:2:-.i4AGc
X :a:ocmn;
B UMBRELLA LIAB
Excess une
ocCJH SSE0048130280 08/05/2010 08/05/2011 EACH OCCUi-'.R-NC.
CL.AIIvtS-MS51.000,000
E:_CAr;G,rEGATt= x1,000,000
S c
C WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY 060311 M563 09/25/2010 09/25/2011 X ; iw L TLLIMJ-,
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Food/Kitchen
Septic System
.PERMIT T
BUILDING INSPECTOR
THIS CERTIFIES THAT....6?X�...... - .......................................•...• 5. •��•`� .............................................. Foundation
.....
has permission to erect........................................ buildings on .. . G.. .:'!�17....Y�..................... Rough
��c�� � �` Chimney
to be occupied as ��
........................ ........... ..............................................................................................................................
provided that the person accepting this permit shall in every respect 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
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIO STARTS Rough
. r�. ...!`��.-r->.........................
Service
BUILDING INSPECTOR Final
Occupancy Permit Required t0 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.
Date//.-,/!?:.....el......
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
S CHUS
This certifies that ......5..,F'1.41x4 n........Ia. t........
.....................
has permission to perform ... ......... ....................
wiring in the building of...CQ—(f!3.........0... .. ..............
...... .......
at......us.z ........z ..t4.. .................**** Aorth Andover,Mass.
Fee Lic.No...._...CA,4 ...C....... ./
..C/....... . .. .........
ELECfRICAL INSPECTOR
Check #
. 9 '12 3
z Commonwealth of Massachusetts official Use only
Department of Fire services Permit No.
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/07] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WO
All work to be performed in accordance_with the Massachusetts Electrical Code(MEC),527 CMR 12.00 RK
(PLEASE PRINTININK OR TYPE ALL INFORMATION
City or Town of: NORTH ANDOVER ) Date: //-/�-
By this application the undersigned To.the Inspector of Wires:
gn gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) , S le j f
Owner or Tenant _ � ,�S'�C1��)rah✓1
Owner's Address Telephone No.
Is this permit in conjunction with a building permit? Yes
NO ❑ (Check Appropriate Boa)
Purpose of Building ectI� Utility Authorization No.
Existing Service Amps / _Volts Overhead
❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead
❑ Undgrd❑ No.of Meters
Number of Feeders and.Arnaci
p ty
Location and Nature of Proposed Electrical Work:
Com let. n o the ollowin table may be waived b the Inspector of Wires.
No.of Recessed Luminaires F
-Susga.(Paddle)Fans No.of Total .
Transformers KVA
No.of Luminaire Outlets Tubs Generators KVA
No.of Luminaires S Pool Above ❑ In_ o.o mergency ig g
d• d. Ba.
Units
No.of Receptacle Outlets �D urners
FT�RE ALARMS N1�1o.'of Zones
No.of Switches Burners No..of Detection and
Initiatin Devices
No.of Ranges No.of Air Cond. T i
Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: -- Detection/AlertingDevices
No.of Dishwashers Space/Area Heating KW Local❑ vnicipal
Connection ❑ Other
No.of Dryers Heating AppliancesSecurity Systems;
No.of Water KW No.of Devices or Equivalent
KW
Heaters No.of
No. Data Wiring:
Si s Ballaass ts . No.of Devices or Equivalent
�. No.Hydromassage Bathtubs No.of Motors Total Hp Telecommunications Wiring;
OTHER No.of Devices or E uivalent
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: ZSC&
OD (When required by municipal poIicy.)
Work to Stark /J-/O-0 ' Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE 9- BOND ❑ OTHER ❑ (Specify:) 4�
I certify,under the pains andpenaldes ofperjury,
FIRM NAME: that the information on this application is true and complete-
Licensee:
ompleteLicensee: c�� LIC.NO.:
- � n Signature LIC.NO.: 3s
(If applicable, enter`exempt"in he license umber line.)
Address: 71n Bus.Tel.No.6o?3S3C'/
*Per M.G.L c. 147,s.c i-61,security work requires D Alt.Tel.No.:
OWNER'S INSURANCE WAIVER: I am aware that the Department
a does not have,t'License:
Lic.No.
required by law. By my signature below,I hereby waive this requirement I am the(check one) ❑owner coverage
oo owner's agent
lly
Owner/Aent
Signature" Telephone No. PERMIT FEE: S
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'A The Commonwealth of Massachusetts
Department of Industrial Accidents
Office ofInvestigations
600 Washington Street
Boston, A"-02111
www.mass govldia
Workers' Compensation Insurance Affidavit:. Builders/Contractors/Electricians/Plumbers
Aaplica.nt InformationPlease Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: (ti,,�m )f- ()Wb Phone#:
Are you an employer? Check the appropriate bog:
Type of project(required):
L❑ 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 8. ❑Demolition
working for in any capacity. workers'comp. insurance. g,. ❑ Building addition
[No workers' comp. insurance 5• We.are a
p ❑ corporation and its
} required] officers have exercised their 10. Electrical repairs or additio
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
i myself. [No workers' comp. c. 152, §.l(4), and we have no 12.❑Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required). 13.❑ Other
*Any applicant that checks•box 4l m-a-so fill out the section below showin their workers'compensation policy mformstion
g p cy
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such..
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information
I am an employer that is providing workers'compensation insurance for my employees Belo
information. w is the policy and job site
Insurance Company Name:
Policy#or Self-ins. Lic.#: 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 DIA for insurance coverage verification.
I do hereby certify under the pains and penaftkes ofperjury that the information provided above is true and correct
signafore: Date: %1-/0-O�
Phone 603 93S /;L
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#:
I
i
Information and Instructions `o
Massachusetts General Laws chapter 152 requires all employers toprovide 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 apartrnents 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 Iicensing 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 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 t
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 any4 uestions,
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, M-A 0.211.1
Tel. 617-727-4900 ext 4:06 or 1-877 MASSAFE
Fax# 617-72.7-7749
Revised 5-26-05
Vi 7.maSS.L-ov/c is