HomeMy WebLinkAboutBuilding Permit #291 - 125 CAMPION ROAD 10/16/2007 3
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION of"�0 a +ti
o
1 t
Permit NO: �4Date Received + i
Date Issued: scHUSE���
IMPORTANT: Applicant must complete all items on this page
LOCATION
Q � CZ)PROPERTY OWNER 241 JU � (CTP
Print
MAP NO.: PARCEL: ZONING DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑New Building ❑ One family
❑ Addition ❑ Two or more family ❑ Industrial
WAlteration No.of units:
Repair, replacement ❑ Assessory Bldg ❑Commercial
Demolition
E. Moving(relocation) ❑Other ❑ Others:
❑ Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
� lac `-t ( LI,n ,(ws,, �orS
S- ry Uc=A �4ax,�
Identification Please Type or Print Cle ly)
OWNER: Name: Phone: �(p
�-r—
Address: \a QJ
p
CONTRACTOR Name: zf) Phone: I ( �
Address: ) --,)n no A
I 'L / M _... o ls ,�.�
Supervisor's Construction License)(4��/ Exp. Date:
Home Improvement License: �fT 0) Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT.S12.00 PER 51000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost :$ ,.5 FEE:$
Check No.:— � b Receipt No.:
Page Io('4
..... -:
.
.,
..
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.. ..:' Vii—
Location '"] r��i���G /�
No.
Date ��/�-��'
NoRTN TOWN OF NORTH ANDOVER .;
? _ ' °�
f 9
Certificate of Occupancy $
s
�,s'��M�S i�' Building/Frame Permit Fee $ t�v
1 Foundation Permit Fee $
Other Permit Fee $
TOTAL $
! Check # ��JS
{
. 2I0
Building Inspector .
.
TYPE OF SEWERAGE DISPOSAL i Swimming Pools C
Tanning/Massage/Body Art
Public Sewer
Tobacco Sales ❑ Food Packaging/Sales C
Well ❑ � -
Permanent Dumpster on Site
Private(septic tank,etc. Electric Meter location to
project
NOTE: Persons contracts w'h unregisterec ontractors tl not have access to lite gu ran y fund
Signature of Agent/Owner ignature of contractor
Plans Submitted ❑ P ns Waived ❑ Certified Plot Plan ❑ to ped 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 DATE APPROVED
HEALTH ❑ ❑
COMMENTS
FIRE DEPARTMENT - Temp Dumpster on site yes no
Fire Department 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/Siunature& Date .Driveway Permit
I
i
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)
Pan 3 of
Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05
Created)WC.Jan.=006
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
❑ 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 DEPARTNIEN'r:RPFORN105
Page 4 of 4
�AORT#q
Town of
0 N.-
No.
O LAKE o dover, lVlass.,Me I fs- a a r,
COCHICHEWICK ��
ORATED
BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT 3 U*14,r........... .*i. le.e r........
Foundation
has permission to erect........................................ buildings on ./�s. �� t� � .:.. Rough
to be occupied as....q.,........ t ...��/ �1� ...... .............� �...... 0. �................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms o 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 CONSTRU STS Rough
. ........................................................... .......... Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place o'n the Premises — Do Not Remove Final
No Lathing or D' 7 wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
Uot UU U'r lU:U4P lJuncan u'rU bbu Uuul lo.U
renewal
BY ANDERSEN' .Indo.repI-1
Customer Service 800-573-7606
104 Otis St.-Northborough,MA 01532-Main:(508)919.0000•Fax:(508)919-0903
J&L Windows,Inc.dba Renewal by Andersen•Contractor License 11149601�Expiration Date 09/2312008
WINDOW AGREEMENT
SOLD TO:!5"f �� rY%k"r, DATE: T
ADDRESS: � r-1 f� PHONE-Home:6f��) �nFx 5177
CITY: --STATE: ZIP:1-3 1 CSy 'c� PHONE-Work: (IS
JOB SITE ADDRESS(if different):
Approximate Start Date:1 Approximate Completion Date:
SPECIFICATIONS
Renewal by Andersen approved materials will be furnished and installed to these specifications:
1. Install total of: windows.
2. Quantity of windows:
t _Double Hung(DB)$l'Equal sash ❑Cottage sash(1/3 top,2/3 bottom) ❑Oriel sash(2/3 top,113 bottom)
Casement(CW) ❑Hinge right ❑Hinge left(as viewed from exterior):OStandard handle OMetro handle
_Double Casement(COW) ❑Standard handle ❑Metro handle
Casement I Picture/Casement(CPW) ❑1:1:1 or ❑1:2:1 OStandard handle ❑Metra handle
2 Lite Gliding Window(GW)
Glider/Picture/Glider(GPW) ❑1:1:1 or O 1:2:1
Awning Window(AW)
Picture Window(PW)
_Bay or Bow Window:
3. X Yes ❑No #Windows to be Custom Fit Replacement:
4. X Yes ❑No #of sills to be replaced:-_
5. ❑Yes'8 No #Windows to be New Construction Full frame(Includes new interior&exterior casings):
Exterior casings: ❑Pine J°d Maintenance-free material ❑Factory applied 908 Fibrex brickmold Ll
6. Glazing to be:`%q High Performance ❑Other If other,please specify: /
7. Exterior color to be:;M White ❑Sand ❑Canvas ❑Terratone
8. Interior color to be: ;R White ❑Sand ❑Canvas ❑Terratone ❑Wood
Note:Interior color can only be white,wood or same color as exterior. Wood interiors need to be finished by Gust.
9. Hardware: R White ❑Stone ❑Canvas❑Brass Double Hung: Install lifts? ❑Yes ❑No
10. ❑Yes VNo Removal of metal frames or grilles #of Units:
11. ❑Yes 8 No Install new paint-ready or stain-ready casings. Inside or outside stops#of openings:_
Interior casing#of openings: Exterior casings tf 7nings: ❑Pine ❑Maintenance free material
12.Customer aware that RbA does not do any paintinq�( �1 Cust.initials
13. ❑Yes X No Wrap exterior casings with aluminum toll stock: color.
Note:Required with storm window removal.Removal of storm windows will leave screw holes in casing.
14.New windows to have: ❑Half or;K Full screens Screens to be: ❑Fiberglass ❑Aluminum
15.Windows to have grilles: ❑Yes IX No If Yes: ❑Grille Between Glass(GBG) ❑Removable Interior Wood(INTW)
❑Full Divided Light(FDL) Grille patterns:
E E E E 11 T11
DH OH OH OH CW/Picture Glider CPWarGPVJ
'use additional sheet if needed Customer approved(initials):
16.)4 Yes ❑No Insulate,caulk and seal windows with three-point system to prevent water and air infiltration.
17. Yes ❑No Remove and dispose of existing windows and storm
18. Yes ❑No Clean Up. All job related debris removed.Vacuum nightly.
19. Yes ❑No Insurance. All workers compensation and liability insurance maintained.
20. (;'Yes ❑No Warranty.Given to customer upon completion and receipt of full payment. `
21.Additional information:
Sd-)Z,C
1�
22. Regular Retail Price:$ e
23.Total Project Amount: All available discounts have been applledAp Yes ❑No
24. Is Project to be paid iD:EkCash ❑Financed ❑Combination of Cash and Finance
25.Cash Deposit(1/3):$ -`l 119 (— 113 of balance due at start of job and final 113 due at completion of job.
If remaining 213 payment is made by credit card,an additional fee of 3%will be added to cover fee charged by Credit Card
26.X Yes ❑No Financed, If Yes,Amount Financed: (Account#: )
27.AYes ❑No Customer agrees to be present on the final day of Installation for final inspection and to deliver final payment.
28. Yes 11 No Homeowner gives RBA approval to place a yard sign on their lawn at the time of measure.
29. es ❑No Building Permit-As a convenience the company will secure the building permit.The fee for the
permit is not included in the agreement price and a separate check is required at the time of sale for this fee.
'RENEWAL BY ANDERSEN'IS NOT RESPONSIBLE FOR ANY EXISTING SECURITY SYSTEMS OR CONDITIONS THAT COULD NOT HAVE
BEEN SEEN PRIOR TO OPENING THE WALLS.PLEASE REMOVE ALL SHADES,VERTICALS,BLINDS,CURTAINS,DRAPES OR WINDOW
MOUNTED AIR CONDITIONERS,AND ANY FURNITURE AT LEAST SIX FEET AWAY FROM WINDOWS AND DOORS PRIOR TO THE
INSTALLATION OF YOUR NEW WINDOWS. INSTALLERS ARE NOT RESPONSIBLE FOR THE REMOVAL OR INSTALLATION OF THESE TYPES
OF ITEMS.'SALESMAN HAS NO AUTHORIZATION TO CHANGE ANY ITEMS OR MAKE ANY REPRESENTATIONS OTHER THAN CONTAINED IN
THIS AGREEMENT AND"OWNER'REPRESENTS THAT NONE HAVE BEEN MADE TO,OR RELIED UPON BY'OWNER."YOU ARE ENTITLED TO
A COMPLETELY FILLED IN DUPLICATE OF THIS AGREEMENT.'CONTRACT SUBJECT TO FINAL INSPECTION BY RENEWAL BY ANDERSEN
CONSTRUCTION DEPARTMENT.'TERMS AND CONDITIONS THAT GOVERN THIS CONTRACT ARE PRINTED ON THE REVERSE SIDE.This
contract Is a legal document.Your Renewal by Andersen products will be especially made4o-order for you.UNDER NO CIRCUMSTANCES WILL
REVISIONS OR CANCELLATION I ATION BE POSSIBLE BEYOND THE THIRD BUSINESS DAY AFTER THE CONTRACT HAS BEEN SIGNED AND
OEPOSITPAID BY SIGNINGR T T TdE ABOVE SPECIFICATIONS FOR THE RUA PRODUCTS YOU ARE
ORDERING ARE CORRECT.
RbARep.Signature: - Date: p D
Customer Signature: t^ `'`Customer Signature:
r
White—Renswalby Andersen Yellow—installation Pink-Homeowner
02-02-07
1
re al
NFJC -
NOD*Fenestlgop
WoodNinyl Composite FF
RatingCoundO Dual Argon Low E
Double Hung _-
ENERGY PERFORMANCE RATINGS
U-Factor(U.S)/I-P Solar Heat Gain ('^--fficient 1
Om320 -1111133
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance
0w54
Manufacturer stipulates that these ratings conform to applicable NFRC procedures for determining whole product ,
performance.NFRC ratings are determined fore fixed set of environmental condltlons and a specific product size.
NFRC does not recommend any product and does not warrant the suitability of any product for any specific use.
Consult manufacturer's literature for other product performance Information.
WWW.nfrc.o
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LLIillaCifiW "� �a � /
DESIGN PRESSURE(PSF)
Man Wmam and Door
H - L C 2 5 100-003-53763-006
Testedto ANSr 'DAIol .S.2-97or NAGS-02. Manufacturer stiutatee conformnnce to the applicable standards
Meets or exceeds M.E.C.,C,E.C,&I.E.C.C.Air Infiiltratlon requirements WDMA Hallmark Certification program. -
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Te al
r•pyn.►,ror
Ww>rFFcryA�1OM1 WoodNlpyl Composite frame
i41Mp Catri;IlA Ouat' Argon low E
Picture .
'ENERGY PERFORMANCE RATINGS
`U4actor(.U,S)/I-P • Solar Meat Gain Coefficient =
' '-."-0 3.2
ADDITIONAL PERFORMANCERATINGS'
Visible Transmittance
- M.n+►chlnr�{`yVIu M�N:.,nY+M•NM�iMyiW M{I.rIIO N.e.�w.sMM'1!pry4l�n�wtM1�/nMc � .
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k/�c�w.m l r�:wr..M�tM'M/wt:�/1«t s.l�ilw gl A.+vtiMh�l1^Y Mw•�ti•+n�q..liq va. '
. - - �o.q:vM.r..nv�.aw/,N•nrow l.rlM.f/n�V�/!�Mn.^...�MtM�Mn. .. - � � ,. .
.DESIGN PRESSURE-(PsF) '
F X50 4-021
M.tw Rt q.,.1.P'S.G,9.Ee,116q 'Rio n WoriA A.Me!�k a l.r h.MM -
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AC 3RC � CERTIFICATE OFIABILITY INSURANCE09!07/ 007
PRODUCES THIS:CERTIFIICATE IS ISSUED AS A MATTER OF INFORMATION
Joseph Mct<eone ONLY' AND CONFEE2S NO RIGHTS UPON THE CERTIFICATE
JP MCKeon..iriSuraric :Agency, Inc. HOLDER THIS CERTIFICATE DOES NOT: AMEND, EXTEND. OR:
ALTER THE..COVERAGE AFFORDED BY.THE POLICIES:BELOW;
P:0. BOz 333
E
Ann Arbor, M1 48106-0333. _.: INSURERS AFFORDING COVERAGE ......, jNAIC#_w. .
iN�uY1I n f2eTtawal by Anderson i� > R A.. Ifgrd In #aranceamltljL
J&L Windows,Inc.
INSURERs I�
104 Otis St I IP154i C
•
Northb5ro:uO,MA 015`32 INSUP.i P p.
aNS�,IRIrI{e.
THE POLICIES:OF:INSURANCE LISTED BELOW HAVE BEEN 1SSUED:TO THE INSUA NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOWATHSTANDING
ANY REQUIREMENT: TERM OR CONDITION OF ANY.CONTRACTOR:6TH15R..D.00UMENT WTH:05SPECTTO WHICH THIS CERTIFICATE MAY RE ISSUED OR;
tr Y OEITTAJR THE INtURANCE AFFOODEb BY THE,POLtc[ES DESCRIBED.HEREIN IS;SUBJECT:TO ALL THE TERMS,;EXCLUSIONS ANO�CONO.ITIONS OF SVC.H
PC1LiCIIrS.AGt3AEGJA't�LitaIITS SitpWN.?�R7 HAVE BEEN.REDkfiCED"SY`PAID C6AIMS:
1VSR POIIGYi FFEGTiVE POLIMEXPIRATiON
POUGYNUMl9BR .:. x UMITS:: .
B:: GE,iEAALLIA8ILITY HER8.858850: 9/7/07 9!7/08 , r°tURR. CIi Ct4l' 4a
_X dQMMERCV taENe i a aura I
x. d MCO[XP(Any vno us ni 1. 10 000;
CLAIMS h1A0E ���CCLi(? �.._.� .._-----i
P.ERSONAL&ADVINJUgV S
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�G£tdiLLRALAGuREGi3c. 8 ._._.
C.EN`L AGGRE i'E Uwr 4PPupS PEr+ - RODUt TS;Dty&aP PAGG s' 000,00ti,.
j. POLICY. PRtk: : LO
A AUTOI�t18dLELfA81LtCY: 35 N1GC:XD.638:8 loll/08.._ loll/08 I cL3r TyaifEu:B ILLI LiI T s 1,0I}0,000
ANY AUTO. --- �
,�( ALLI9NNEORiil05: BODILY&NJURY I -
(Per person):
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SGMEbuad Aufm !
Hi1iET)AU70S I SOCILY 1Yd„(kmy
I NQN-OWNED AUTOS: (PLr i d9r131
3.. PROPERTY DAMAGE.
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OARAOE LIAslu.T:Y _
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ECES5AHApR1A LIABILITY EACH tkQURRMCC I S
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JD'L3GCUP � ICLAIMSMADE::'
AGGR>tAATE
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5
VX,STATU (:` :30TH I ..
A WOPKERSCOMPENBATtONANO '35 WEiGt��8861 111/07 01!01!08 ?L4RY.S.I U� „_.L f I _
SIAPLQYEP;<LIABILITY. I, El.EACH ACCIMNT.. ,f
ANY PROPRICYOIVARTNERIEXEG$TME
OFF10ERMEMSER EXCLUDED") I: El,04SEASE EA EMPLONVE 1:f. 000 000.
HyYe�dasdst:aundor: __ ._— _
SPECiALPAt1Vi51ONSbnCow EL OlSEAS'P POLI^YUMIT s. 5Q0M0.
OTHER
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DESCiuPTiDN OF'OPERATIONS I LOCATIONS I VEHICLES I UCLUSIONS ADJEO IVY ENDORSEMENT I SPECIAL.PROVISIONS .
.......... ... ............. . .......
_ . .
CERTIFICATE HOLOER CANGELLA7IdIV
S�tiuLD ANY OP T11E A80i+E OESCIt18E0 PORiGfES'8E CANCEII.ED SEF03iE THE E7tPIRATitift '
DATE:THEREOF;:THE iSSWNG iN8URER Witt ENDEAVOR:TO 7N L.:::30 OA1B WRITTEN
_.
Home TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 00 SHALL::
IMPOSE NO OGU¢ATION OR LIABILITY Of ANY KIND UPON:THE:INSURER,ITS AGENTS OR:
'REPKESEATATivem
A CAiS`EG: PR tSENTA7!(VE _-.
AGORD 25(20011.00, ,
' ACOft CC1FiR'ORAIC)N 1988
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✓� V/O'J97i!)7.0�/ZCl/Ep�/� /1L✓(/GCld6�LlLQQ�,ja
Board of Building Regulations/and Standards
ConstructiorY;Supenri5or License
License CS 74251
Birthdate 3!9%1963
�xpiretion x/9(2009 Tr# 11065 \
JOHN K ESLER
- i 104 OTIS ST
NORTHBORO,-MA 01532 Commissioner
fie �jom�mzoouvecrl!✓z oy�✓�i'iiaacze,/uiaP,�
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registrafi
J
_Rn:,, 149601 3
Expiration 1124/2008
fiyie S;upp1ement Card
RENEWAL BY ANpERSON
KATHLEEN BLANCHAFZt)
104 OTIS STREET .„
NORTHBOROUGH, MA OmY532J � ��w`
Administrator
F
The Commonwealth of Massachusetts
f Department of Industrial Accidents
Office of Investigations ;
600 Washington Street _
Boston, MA 02111
•� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual) �t ���O 02-S "
Address: 1 V Q�T ) S S T 9 E ET .
City/State/Zip: N)OK j 16010. 01532 Phone. 9) 09q0
Are you an employer?Check the appropriate bog: Type of project(required):
1. Ito 3 O ' 4. [:] I am a general contractor and I
/// am a employer with 6.. ❑New construction
employees(full and/or part-time).* have hired the tach Conti actors
2.❑ I am a sole_. ro.rietor or partner- listed on the attached sheet. 7. Remodeling
P -I` -
ship and have no employees These sub-contractorshave g, E]'Demolition
working for mein any capacity. employees and have workers' 9. E]Building addition
[No workers'.comp. insurance comp.insurance.
required.] 5. We are a corporation and its 10.❑ 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.❑'Roof repairs
insurance required.]t ` c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
pomp.insurance re uire
mP d.q ]
*Any applicant
that checks box#.l.must also fill ll out theec'on below showin _their workers'Com ensati n p l,i_cy m,.f.
ord
tion.
t Homeownerswho submt 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 is providing workers'compensation insurance for my employees. Below is the policy and job site
information: ;
Insurance Company Name: P CCNU lJ � S -
Policy#or Self-ins.Lica#: 35 Li 13 0 19 8(0 Expiration Date:
Job Site Addres/4S C 77 291&J /Q D 11:&1 City/State/Zip:A/1,Vwll eyz_1 MA,`'0-/�yS
Attach a copy of the}porkers',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 Iead to the.impositior of criminal penalties of a
fine - and the
ne u to 1 500.00 an or one ear imprisonment,as well as civil penalties the form of a STOP WORK ORDER a f
$ d/ t e e
� P Y mP � P
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 t for 'nsurance covers a verification.
I do hereby ce yy under t psi nd penalties of perjury that the information provided above is true and correct:.
Si ature: Date: A0' b ' 6
Phone#: SOS g19 U 9 90 \
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:
Ii%formation and Instructions
Massachusetts General Laws 844pter 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;:massociation,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 uiis chapter have Leen presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along withaheir certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not regiiired to carry workers' compensation insurance. If an LLC or LLQ 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 cityor 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.-insuredcompanies should enter their
self-insurance license number on the appropriate line.
City.or Town Officials,
Please be sure that the affidavit-i5'complete and printed legibly.' The Departrient has provided 4—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 numbermbich 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 Addre&'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-;affldavit is on Yi1e for future permits or licenses. A new aff.Uvi(mus!be filled out each
year.Where a home owner or cityzefi is obtaining a license or.permit not related to any business or commercial venture
(i.e. a dog license or perm t,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
Department of IgAustrial Accidents
Office'of InVestigatious
600 Washington Street
Boston,IIIA 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Fax#'617-727-7749
Revised 11-22-06 _
www.mass:gov/dia
The Commonwealth of Massachusetts
1 Department of Industrial Accidents
' rr
L Office of Investigations
K-.
_.'`' 600 Washington Street
': 111t;s
� Boston MA 02111
www massg ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address: j (�E
City/State/Zip: K10a_4nb)U) �4A— U���*hone#:ISD� •lIRDVO
Are on an employer?Check the appropriate box: Type of project(required):
1 I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 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.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.] fi 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.
TContractocs that check this box must attached an additional sheet showing the name of the sub-contractors and their worker;'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. Lic.#: �� � < V/ Expiration Date: �' V�
Job Site Address: ) City/State/Zip: (Jo
Attach a copy of the workers'compen tion 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$250.0 ay against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations,of th DIA for insurance coverage verification.
I do hereby certif under the pains enalties of perjury that the information provided above is true and correct.
Si nature: � Date: h-�
Phone#: v
Official use only. Do not write in this area,to be completed by city or town official
City or To n: 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#: