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Home My WebLink AboutBuilding Permit #263 - 125 JOHNNY CAKE STREET 4/4/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: V2�,t- Date Received Date Issued: vl 4- ( IMPORTANT: Applicant must complete all items on this page LOCATION �Uh C K� S Print PROPERTY OWNER (V\)A Q k W t6 Print 100 Year Old Structure yes •%-- MAP NO: !'o_l PARCEL: ( 9(' ZONING DISTRICT: - Historic District yes x�e- Machine Shop Village yes 44o- TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Buildingne family ❑Addition ❑Two or more family ❑ Industrial p.A(teration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: fhArL�<, W 0-S 5 -e-r- Phone: of-71_ 6$7 6 rad Address: CA Ic.c Sb- CONTRACTOR Name: Phone: Address: Supervisor's Construction License: CS 6 S-4-71 6 Exp. Date:__/ Home Improvement License: a ��b Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT•$12 0 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ p� Check No.: Receipt No.: �- NOTE: Persons4cnitra�cting with unregistered contractors do not have access to the guaranty fund ,Signature of Agent/Owner Signature of contractor Plans Submitted F1ans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ 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 Siqnature 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 Departinent signative/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. area, s Total land a . ft.:q 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.$10041000 fine NOTES and DATA— For department use EJ Notified for pickup - Date S I Doc.Building Permit Revised 2010 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 o Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ 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 ❑ 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) L3 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 Li 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: Doc.Building Permit Revised 2012 Location '�' a 4 6ti` aw No. �;�� Dat,&'T y • ' TOWN OF NORTH ANDOVER • ��'TIJt?;D I O � Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee $ �i Other Permit Fee $ TOTAL $ Check# 6 25782 Building Inspector Enter construction cost for fee cal - North Andover Fee Cakulation Construction Cost $ 62,809.00 m $ - $ 753.71 Plumbing Fee $ 94.21 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 94.21 Total fees collected $ 1,042.14 125 Johnny Cake Street 263-13 on 10/4/12 Kitchen Remodel f f i /ea•n� ! -"!gi�t`i� -•�t-�l-� .-;"t.�s�_�,_a�_ -L!]1� �� :_ ��1�j�_ �....L�-� ;`�1 z.)3/m"V tr8o f,4 oc_ Nsig- L_J sQ1,. 4,zt ci _� ,f ,� "IMNva ka LNG n yyjy�c 3 -We. bi „flP F C d Vy rid �! 5 r� `� • 3c�. `�� „fir �+ L,qM M 0 0 0 0 0 '2 cla o44 �O N 1N t+H'.7 S 9 FRANCIS H. COLLOPY Structural Engineering Services FRANCIS H. COLLOPY,P.E. P.O. Box 1684 Registered Professional Engineer Seabrook, NH 03874 Tel:603 760-2273 Sept 4,2012 Mr Jim Testa Testa Construction 5 Appleton St North Andover,MA 01845 Dear Mr Testa: The purpose of this Report is to provide you with the results of my recent site inspection at the Webster Residence at 125Johnny Cake St in No.Andover,MA. During this site visit,I made the appropriate measurements necessary in order to design the required 13'-2"beam to carry the second floor and attic loading over the opening to be made in a first floor bearing wall over the main beam of this residence. I am enclosing Design Sheet DI that shows final design details.I have provided two optional sizes of LVL's required,and the recommended support columns as each end of the new beam,at the first floor level,and a required column in the basement level under the support column above at the interior wall support of the new beam. If you have any questions in this regard,please do not hesitate to call this Office,and we can discuss it further. tri OFyr Sincerely, J a FRANCIS H. T, c COLLOPY ty 172 W Francis H. Collopy, P.E. S/®MAl Structural Engineer Enclosure: Design Sheet D 1 i-•' FRANCIS H. COLLOPY PE JOB Structural Engineer SHEET NO. 1 OF r P.O. Box 1684 CALCULATED BY �/ ` DATE 71W/ 7- Seabrook, Seabrook, NH 03874 TEL: 603 760-2273 CHECKED BY DATE SCALE 6 ..... ..... ..... ...... ............. i J� i i ........:.... i i L ..............: MoVf_...._F r i{n�G -.1-L -�57 _..,--------_.:........_...............<.............:..._._......:................__.....,......_. ._.. ..... ..... _.... ...... ..... ...... ............':. ...... ............... .@...+.-.._-r..-..-.-_L...-.-_......3.7...._.S............ ._.05......+. F...... 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F ss ',....._L..C:,....:.......... .... j �..� r , tkORTH ve" 'o 0 No. - �3 o*9R_A. h '%' ver, Mass, coc"Ic"NWIcK yI RP o0A?^TEO S tl BOARD OF HEALTH PERMIT LD Food/Kitchen Septic System THIS CERTIFIES THAT A41�IR. ........G�. .. BUILDING INSPECTOR .................. Foundation has permission to erect ........ ......... buildings on .zes. :Y*;".e . Rough tobe occupied as *WWM0W............KI ......... ................ ....................................................................... 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 NTH S, ELECTRICAL INSPECTOR UNLESS CONSTRUC 0 TA T 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. SEE REVERSE SIDE r` r f `r i I f, Massachusetts -Department of Public Safety " Board of Building Regulations and Standards Construction Supervisor License: CS-054718 JAMES M TESTA-` 5 APPLETON ST. (� N ANDOVER MA 0184 Expiration Commissioner 06/08/2014 r�oryrtnco�zur.ad �\ Office of Consumer Affairs&Business Regulation I HOME IMPROVEMENT CONTRACTOR Type.' Registration: %'120296 Expiration: 11/19/2013 DBA_ TESTA BUILDING;&,REMODELING` � JAMES TESTA � .:: ,•�; 5 APPLETON STREET ga N.ANDOVER,MA 01845 Undersecretary 1, i i i Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-054718 JAMES M TESTA 5 APPLETON ST' N ANDOVER NLk 01845 { Expiration Commissioner 0610812014 " t 'i ✓�ie toarrrnna�u o�✓vcaaoczc�i+.�ael� _ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENTCONTRpCTOR Registration:, 120296 Type: Expiration:' I.1/1.912013 DBA TESTA BUILDING,&REMODELING JAMES TESTA 5 APPLETON STREET=-; � �-�- N.ANDOVER,MA 01845 Undersecretary r F FI= a TA Building and Remodeling Start date Oct. 5th 5 APPLETON STREET Finish date Nov. 16th NORTH ANDOVER , MA 01845 HIC Lic. 120296 Expires 11/19/13 (978) 682 2023 CSL Lic. CS 54718 Expires 6/8/14 Proposal October 1 2012 Proposal Submitted To: Mark and Emily Webster Phone : (978) 687-1668 125 Johnny Cake Street North Andover, MA 01845 Job: Remodel kitchen Obtain building permit Complete removal of all demolition and construction materials generated by Testa Building and Remodeling and its subcontractors. DEMOLITION : Remove all cabinets and counter tops. Totally gut walls down to the studs and the floor down to the sub floor in the kitchen,Remove the wall between the kitchen and the Dining room installing a beam. CONSTRUCTION: Remove and replace the window over the sink with an Anderson casement window. Install a flush beam in place of the wall between the kitchen and dining room. Remove window and install a door going to the deck to be. PLUMBING : Remove the radiators and supply and install a new kick space heater. Kitchen sinks to stay in same location. Hook up the rest of the kitchen plumbing fixtures. Note : There is no allowances for plumbing fixtures ELECTRICAL: Add new circuits in the kitchen area where needed. Rewire kitchen to code. Supply and install 9 recessed lights. Supply and install under cabinet lights. Wire all new appliances. Replace the smoke alarm in the mud room. Note : There is no allowances for light fixture other than the one specified . PLASTER : Hang 'h blue board and plaster all walls and ceiling. Re plaster the dining room and the mud room ceiling smooth. CARPENTRY : Install all the kitchen cabinets and moldingas per the designers drawings. Install new trim in the P l� g kitchen around the windows and doors to match the existing trim in the house. Install crown molding around kitchen that matches the cabinets. Install some type of archway between the kitchen and the dining room with basic columns. Installation of all kitchen appliances. FLOOR : Install Approx. 352 sq. ft. of 2t/a inch oak flooring to match the flooring in the rest of the house. Sand ,stain to match as close as possible to the rest of the floor sand apply three coats of finish . TILE: Install tile along the back splash Labor and adhesive supplied Tile supplied by owner. VENTING : Pipe the exhaust blower for the stove. Will provide all duct work needed. THE HOME OWNERS WILL SUPPLY CABINETS AND APPLIANCES . THERE ISN FOR PAINTING O ALLOWANCE E OW C O PINING OR STAINING INTERIOR OR EXTERIOR A finance charge of V/2%per month(18%per year)will apply to all accounts over 30 days past due. In the event collection activity is required the customer shall be responsible for all costs associated with collection,including reasonable attorney's fees. I propose hereby to furnish material and labor complete in accordance with above specifications, for the sum of: $31,406.00 Thirty One Thousand Four Hundred and Six-Dollars 11—One- third to start,one-third after rough inspection ,one- third upon completion. I\ Authorized signature 2 0 f nnnn I reserve the right to cancel this contract if not accepted in 30_days Signature Signatur DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners.Seek legal advice if necessary.Any person planning home improvements should fust obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. (Owners who secure their own permits will be y excluded from the Guaranty Fund provisions of 0a 3� Date when contractor will begin contracted work. MGL chapter 142A.) Exxppress Warranty-Is an express warranty being provided by the contractor? lJ0 No �� r Lam" Yes(all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement. Contract Acceptance-Upon signing,this document becomes a binding contract under law.Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence.Review the following cautions and notices carefully before signing this contract. •Don't be pressured into signing the contract.Take time to read and fully understand it.Ask questions if something is unclear. •Make sure the contractor has a valid Home Improvement Contractor Registration The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration.You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. •Does the contractor have insurance?Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. •Know your rights and responsibilities.Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement.See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of the ntrac m be ted and signed.One copy should go to omeowner.The other copy should be kept by the contractor. o wner's Signature Contractor's Signature OC-4 3/1 Ld 1 1. Date D T Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws,chapter 142 o e er's Signature Contractor's Signature NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e. MGL chapter 93A)may not be waived in any way,even by agreement.However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law.Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner.Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose.An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor.Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work.Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of"A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza.,Room 5170,Boston, MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at http://NVNNAv.mass..gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston, MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at http://wuxv.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: litti)://db.state.ma.us/liomeimprovemeiit/licenseelist.as For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800, 508-755-2548 or 413-734-3114 version 2.1-11/22/201 NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION,WITHOUT PENALTY OR OBLIGATION, WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU CANCELLATION NOTICE,AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELED. IF YOU CANCEL,YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED,ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION, YOU MAY RETAIN OR DESPISE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO, THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO [Name of Seller],AT [Address of Seller's Place of Business]NOT LATER THAN MIDNIGHT OF o Lt 3 1�,4 (date). I HEREBA CANCEL THIS TRANSACTION. ' G Date: 7 Buyer's Signature: �� GC The Commonwealth of Massachusetts 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): _Tt S Address: tY P A N.1 cr A1,� a`Phone#: �t Ci /State/Zi : /ya Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.211 am a sole proprietor or partner- listed on the attached sheet. # � E]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.E]Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 1311 Other comp,insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. F am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 'reformation. assurance Company Name: ?olicy#or Self-ins.Lic.#: Expiration Date: lob Site Address: City/State/Zip: tttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). a ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 &up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby cert der the pains and enalties of perjury that the information provided above is true and correct. 'li nature: ago Date: 'hone#: $I �? g— (0 g )- —a o a-7 Official use only. Do not write in this area,to be completed by city or town offacial. 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 certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to 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 Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE E�evised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia