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HomeMy WebLinkAboutBuilding Permit #391-14 - 127 OLYMPIC LANE 10/28/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NDate Received 0: '1 Date Issued: 1u zqd r� IMPORTANT: A plicant must complete all items on this page : - : f LOCATfON - - _ d - �- PROPERTY GINNER _ _c��tr �,V ` I - - - - . _ -a -A Fnnt 100 Year Old Structure; yes'' no i t MAP;NO: -� PARCE.L ��' __ZONINGtiDIS,TRICT _ Histoeic District ly_ a. —- -.= - - M - -- - achme�Shop V�Ilage, Y-- .no rT�w . TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family 11 Addition 11 Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial s Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ , _v- R _ P - - Septic q 1Nell ❑`Flood lain [7 Wetlands ❑ INatershed'Qistrict ,a o_1Nate�l�Sewer: •__-..�-:_- - w .� -�- -�_ - - _�-_, - - - -- -- - - �DESC�IPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: ©�v des j� Phone: Address: I 0 M CONTRACTOR' iName:.L IMc� Phone K 4 �^ Y_ - -- . Address:�f S U? `fr7 'Exp !Date: I J C Supervisor's Construction`License 3 1 _ xp E --� -./-� - P ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED gO.�N,$125.00 PER S.F. r Total Project Cost: $ AUCs FEE: $ Uy Check No.: ZSrl Receipt No.: !� _I NOTE: Persons contracting with unregistered contractors do not have access to th guaranty fund Si nature of A ent/Owner �: SI nature of contractor = " .g g _.9 ..__.._. _ -.. .- oi.,.,,. Pinnc \n/nixiari F1 C:Prtifipd Plot Plan ❑ Stamped Plans Plans Submitted ❑ PlansWaived-❑ Certified Plot Plan ❑ Stamped Plans ❑ TI'PE_O1{.SEWERAGE;UISP:OSAL Public Sewer ❑ Tanning/MassageBody-Art ❑. . .Swimming Pools ❑ Well ❑ . Tobacco.Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc.- ❑ -- Permanent Dumpster on Site ❑ r THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM :. DATE REJECTED: DATE.APPROVED PLANNING & DEVELOPMENT' ❑ ❑ COMMENTS CONSERVATION Reviewed on Siqnature I 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 Tow;21Engineer: Signature: Located 384 Osgood Street FIRE DEMRTNI ENT =Temp Dempster on site yes no Located-at 124 Main Street._ . -Fire'Depar'tmerit sigrraturelelate` COMMENTS -Dim-ension Number of Stories: Total square feet of floor area, based on Exterior dimensions. .Total land area; sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL-Chapter-166-Section 21A-F and G min.$100-$1000.fine NOTES and DATA— (For department use B Notified for pickup - Date { i Doe.Building Permit Revised 2010 i 1 Building Department The fol;swing 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 o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work o 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 o Certified Surveyed Plot Plan o Workers Comp Affidavit o 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) j 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 o 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) o Copy of Contract o Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all casi s if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apo-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.tted with the building application Doc: Doc.Bui!ding Permit Revised 2012 NORTH Town Of t E ndover / No. % h ver, MassSzeAoZaQ®j HIC"t WICK y1' RATED P'Y���S S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ........... .....l.#...........t.OkS ... ...................... ................................................ BUILDING INSPECTOR Foundation has Jhas permission to erect .......................... buildings on ......2....... .. ... ...� ....,�401!4�............. Rough t0be occupied as ....... 1� ..... ...... .... ................................................................. 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI ST RTS 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 PROPOSAL L.E. Morgan Construction Company WeAccepf: 86 Billerica Avenue,Unit#Y VISA N. Billerica,MA 01862 - Office: (978)670-4747/Fax. (978)670-6477 P SAL SUBMITTED DATE 4 T � JOa ME C AIR ZIP tit JOS LOCATION ACT C LPHONE OTHERX00 PHONE Strip down to the wood deck, _� layers of shingles, dispose of debris to a licensed recycling facility: Install 61 ice and water shield at the gutters feet of 'c shield in valleys. Install 8" aluminum drip edge on all perimeters, color choice . White,)t Mi ,r4rown, 0 Copper. Install asphalt saturated lb. felt paper on the remainder o decking. Install gear architectural asphalt shingles, and hurricane nail. Tnstall ridge vest manufactured by CQ to all ridges and dormers. Install --D`^ new skylight flashing kits manufactured by / ( Flash all cheek galls, pipes, skylights, and penetrations to manufactures specifications. Remove existing lead flashing on 4 chimneys and install new lead flashing. Install matching cap shingles to all ridges, hips and dormers. WE P>ROIPOS.6 hereby to furnish material and labor-complete in•accordance with above specifications,for the sum of. s5 r dollars All material is guaranteed to be as specified.All work to be completed in a workmanlike mannor aeeording to standard pracdoea.Any alteration or deviation from above Authorized Signature. specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.Our workers are fully covered Note:This proposal may be withdrawn Q by WDrkmen's Compensation Insurance and Liability Insumnco. by us if not accepted within / 0 clava. F NCE OF PROPOSA1L-The above prices, Date of acceptance: s and conditions are satisfactory and are 'Aurhorised Signature:ted.You are authorized,to do the work asyment w i.0 be made as outlined above. Authorized signature: Additional Remarks- ,—'-MON MORGA-1 OP ID: LL '44 oRo1 CERTIFICATE 4F LIABILITY INSURANCE °1012412013ATE ' 10f24f2013 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: 9 the certificate holder is an ADDITIONAL INSURED, the poficy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCERN Phone:978-686-2266 CONTACT Lisa North Andover Insurance Agency Fax:978-686-6410 C,No PH :978-686-2266 M.J. Foster Insurance Services E (WC Arc No): 978-686-6410 163 Main St. ADORE North Andover, MA 01845 ss:Ilariviere nafins.com Jonathan Duggan INSURER(S)AFFORDING COVERAGE NAIC#F INSURERA:ZURICH INSURANCE COMPANY INSURED L E Morgan Construction Inc INSURERB: Lawrence E Morgan PO Box 75 MSURERc: North Billerica,MA 01862 INSURER 0: INSURER E: INSURERF: --mss r— COVERAGES CERTIFICATE NUMBER: ION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE .bURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OF-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. LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POMLICDI EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAG 0 RENTED PREMISES Ea occurrence $ CLAIMS-MADE M OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATELIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ JECT—1 POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS ALTOS Per accident) ccident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIME&VIADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS'LIABILITY X TORY LIMITS X ER A ANY PROPRIETORIPARTNERIEXECUTIVE YIN 6ZZUB-5B73831-I-II 12114/2012 12/14/2013 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATION below E.L.DISEASE-POLICY LIMIT 1$ 1,000,00 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,N more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET NORTH ANDOVER,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD AC40 DR 10/23/20° CERTIFICATE OF LIABILITY INSURANCE DATE 3/2013 IYYYY) �" 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 endorsemengs). PRODUCER Phone: (978)562-5652 Farc 978-562-7120 REACT Welsh&Parker Insurance Agency,Inc. WELSH&PARKER INSURANCE AGENCY,INC. PHONE Ax 131 COOLIDGE STREET,SUITE 100 E-MAIL Ext: 978 562-5652 (ac,Nel: 978-562-7120 HUDSON MA 01749 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER :Western World Ins Co 1 Conexco Ins Agcy INSURED LE MORGAN CONSTRUCTION INC INSURER B Scottsdale Insurance Co/Conexco Ins Agcy PO BOX 75 INSURER :Merchants Insurance Group NORTH BILLERICA MA 01862 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 56196 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. INS TYPE OF INSURANCE AD a SUB POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRMIDD LMMIDDIYYY Jl' _ A GENERAL LIABILITY NPP8114808 04/13/13 04/13/14 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES 100,000 PREMISES(Ea once) $ CLAIMS-MADE I --I OCCUR MED.EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY JPERCOT- LOC $ c AUTOMOBILE LIABILITY TBD 10113/13 10/13/14 CO(Ea aMBINED SINGLE LIMB ccident) $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS TOSX HIRED AUTOS PROPERTY DAMAGE $ TOS (per accident) B UMBRELLA LIAB X OCCUR XLS0087784 04/13/13 04/13114 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I RETENTION$ $ WC SI OTH WORKERS COMPENSATION TORY LIMITS ER $ AND EMPLOYERS' LIABILITY ANY PROPRIEfORIPARTNERIEXECUTIVE �YIN E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) RIA E.LDISEASE-EA EMPLOYEE $ X yes,describe under DESCRIPTION OF OPERATIONS below ILL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1600 Osgood Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORED REPRESENTATIVE Attention: Michael Lombard ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Massachusetts -Department of Public Safety _- -- __. $ �fe�ir��r.a�zcnc�ecaj�l cf,�7�[<cJJr�c/tu:;el } Soard of Building Regulations and Standards Office of Consumer Affairs&BusifiessRegulation Construction Su en-isor € OME IMPROVEMENT CONTRACTOR P - i e istration: T e: License: CS-079476 -F � 9 .137913 Yp tt` t I, `��~` c��.� r - gxpiration 1/27/2Q15: Individual LAWRENCE E MQRGANJR '', P LAWRENCE E.MORGAN JR: 86 BILLERICA AVE UMT�;1'. s i N BILLERICA NFA Q1862 ;.f LAWRENCE MORGANJR'. '.t \ ' 86 BILLERICA AVE UNIT 1: g i��p c—' 't f4t Expiration z N.BILLERICA,MA 01862`- .l.�. Undersecretary Commissioner 06/03/2015 This card acknowledges that th, 5ecipieS�t has sdccessfully completed a # U.S-Department of Lab r 3Q,hour Oc upattonat:Sa#e1y and Health Traiping.Course fn �4 Occupational Safety and Health A.df n,n!strat on Construction SafefY and Health �� has successfully completed a 1D-hour Occupational Safety and Heatth Training Course in Construction Safety&Health rvu.-e � � � — Low s Rom RZ 06X*69 (Trainer name_pflnt or type). (Course end date) I `* firainerl foatel The Commonwealth of Massachusetts - Department of IndustriglAccidents Office of Invesfigations 600 Washington Street .Boston,MA 02111 U1 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Conti°actors/Electrri.cians/Plumbers Applicant Information Please Print Legibly Name(Businessiorgmi'zationftdividual): L- F nu On, Address: F(A City/State/Zip:/U (,eA"_(, YW1A l 2 Phone#: c)_ 7� Are you an employer?Check the appropriate box: 'Type of project(required): 1 T am a employer with 4• ❑ T am a general contractor and T 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2111 am a soleproprietor orpartner- 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 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner,doing all work right of exemption per MGL ILE]Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance .re uiredemployees.[No workers' required.] 13.0 other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached anadditional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that 1s providing workers'compensation insurance for my employees. Below is the policy antl job site information. Insurance Company Name: 2 V r to 6nS_ C - Policy#or S elf-ins.Lic.#: U 6 ,-e � �j�3 �� - 17— Expiration Date: 1 (1 Job Site Address: 01 t L { n City/State/Zip: MM Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 cert' under the pains andpenalties ofperjury that the information provided ab ea is true and correct. Si afore: Date: 16 �3 Phone#: D O 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.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - Information and Instruction's 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 lie-ensing 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-contractors)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 maybe 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/lice'nse number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications an any given year,need only submit one affidavit indicating current Policy information(ifnecessary)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 C=Aonwealth of ma:.ssachvsetts Depaftent ofZndustrlal Accidents OfAee of Iavestigatiom 600 Wasbtingkon,St (e,a BostonMA02111 TQL#617-727,4900 at 406 Qn 1:-877, '.ASS.AFF, Revised 5-26-05 Fax#617-727-7749