HomeMy WebLinkAboutBuilding Permit #1329-2016 - 129 WEYLAND CIRCLE 4/22/2016 BUILDING PERMIT �ao�arr�
_ 4
T®IiVN OF N®I�TrFI AN®®@��R
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received Z �Rp°RarEo Pe¢y��
C US
Date Issued:
ORTANT: Applicant must complete all items on this page
LOC►rA I®N
NOR)
€1'.�R®P1'OVUL NSFJAJ-
'
�Cint 100 Yea Struc u Byes no
MPTPRCELZ®NING'DIST,[FZICT Historic ®istr�tctl dye to
Machine Shop Village ye no µ;'
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑Two or more family ❑ Industrial
C-Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
a_...�_ <F.. {�--•, n a..a-® ..':.Ka"°`° .yy',•r�.. � _ <- tiF ,7 ..: „^, 'f��:;
Sept�c`�, 1®Well I t® Flo dpl n #®a Wetlands tWatershed ®istrlct}` s
®Water/Sewer �'
DESCRIPTION OF WORK TO BE PERFORMED: i
1 n sv
Identification- Please Type or Print Cleary
OWNER: Name: Z o rL w 14!`r',e e'l Phone:
Address: 1 a Ot We y L;,A., n C!mac. 1AE� rVoA-TA 4/y.tDQ✓e j
j a
Contra for,Names ! _Sp Jt►' Ga�hone � X33 _____. ..
Ad ress � (S S
SuperUt sConi str�u�ct1, LLIicense;r _ . ADW 1:
Home Mm pa
License � EXp, ®ate= -
s 3
.r,
x
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE;BULDING PERMIT.•$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ �{.�-a U . FEE: $ �!
Check No.: Receipt No.: 3-6S L1v
NOTE: Persons contracting with unregistered contractors do not have access to the gua my fund
------
SI nature of Agent/Owner Signattare ofco,nfrac ,.
J
i
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 ❑ j
j
i
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF m U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS `
HEALTH Reviewed on Signature
COMMENTS
Y
Zoring Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
i
Planning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer Connection/Si�nalure&Dafe Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
IRE DEP'ARMENTemp' "iTDumpster onsite,r,'es �, , ' ono �z...�� "i
L�ocatedaf;(124MainSqget� ` '`: . a `"`'ter;"�, ;� •Std -- - 1
Fire Departmet
tignature/date4
,:;. i{.}k ` '• ^ �r`1•ty''` `s-,9x r
C011/IMENTS
Dimension
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.$1oo-$1000 fine
NOTES and DATA-- (For department use)
i
® Notified for pickup Call Email
Date Time Contact Name 3
Doe.Building Permit Revised 2014
i
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
❑ Engineering Affidavits for Engineered products
OTE: 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/Cross Section/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
DTE: 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
a Engineering Affidavits for Engineered products
ATE: 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
Doe:Building Permit Revised 2014
Location
No. k-�2) Z-O I Date (-P r 2 7 ��
. • TOWN OF NORTH ANDOVER
lob
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
i
�, a� Building Inspector
NORTfy
Town of : _ ndover
h , ver, Mass, (AoJt 61
T O LAK!
COCKICKl WICK
�dA3.
1S V
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
0THIS CERTIFIES THAT .............26f 14...... 0be BUILDING INSPECTOR
j201 w! Foundation
has permission to erect .................... .. buildings on ... ................ .1.0............�........ . �.......
�. Rough
AN*to be occupied as ........... .. ........ ......1 ..`... ...........:.................................... Chimney
provided that the person ac epting 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONST TION S Rough
Service
.. ..... ....... ....... ......... ..... .............
Final
BUILDI IN PECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildin-e 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.
This fort 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 first 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.
Homeowner Information Contractor Information
Name Company Name
7,0K14 W li ckt; 1' enloa( tLr
Street Address(do not use a Post Office Box address) Contractor/Salesperson/Owner Name
12L4 Wr-l (- 4) OWE s STAC-V Dirt,
City/Town State Zip Code Business Address(must include a street address)
oP.Tk 14n►Oov o s YS wt 40044CO, WA o f S Y r
Daytime Phone Evening Phone City/1'own State Zip Code
78 - VL c - 76 S (Mo - 333?
Mailing Address(It different from above) Business Phone Federal Employer ID or S.S.Number
Home Impement ContrictorReg.Number Expimlion dote
Lrr sequins that most home rov
m m n ve
*vlid regtnulon number 17q 313 7/x 7 Aa of b
The Contractor agrees to do the following work for the Homeowner.
(Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.)
3w*b Lo�.Nc n. G* s F', a PAgct
F„c ware s / 1.vsvLp4-1fo0V
T'r t M 4"'D"U�,Zk
Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will
and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise
(Owners who secure their own permits will be
excluded from the Guaranty Fund provisions of �4 to when contractor will begin contracted work.
MGL chapter 142A.)
6/X'/#V1kDate when contracted work will be substantially completed.
Total Contract Price and Payment Schedule ^ O 0 #
The Contractor agrees to perform the work,finish the material and labor specified above for the total sum of
Payments will be made according to the following schedule:
$ ���O• 00 upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater)
$ Y'by_/_/_or upon completion of W/C1 F"/ r p 1",oin f L j#("
$ _ by or upon completion of f-41 A# T— A4431 y
$ loo' upon completion of the contract. (Lawforbidsdemapding full pay`meen�t/�u�ntil(l cc000n_ctrract is completed to both party's satisfaction)
J�, The following material/equipment must be special L• $(. a to be paid f r q,-,9� p
x 1 ordered before the contracted work begins in order et
to meet the completion schedule.(") $ to be paid for
FRNOTES:(•)Including all finance charges('•)taw requires that any deposit or down-payment required by the contractor before work begins may
not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material
which must be special ordered in advance to meet the completion schedule.
0 Express Warranty-Is an express warranty being Provided by the contractor? ❑No❑Yes fall 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 or the contract must be completed and signed.One copy should go to the homeowner.The other copy should be kept by the contractor.
'PHomeoApfs Signature actor's Signature
5-/2 1 //
Date Date a'�C��o
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 Secret of the Executive Office of Consumer Affairs and d Business Regulation and the consumer shall be required
to submit to such arbitration as provided In Massachusetts General Laws,chaptF 142A.
G
RforneovNiers Signature C actor'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
maybe 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://www.mass.aov/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://www.mass.gov/ocabr/
Go online to view the status of a Home Improvement Contractor's Registration:
htti):Hdb.state.ma.us/homeimprovement/licenseelist.asp
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 2.1-11/22/2010
NOTE When finishing the area;.round the hood,5/8"clearance above hood is required for hood installation.
G —
G
J K
� Hood
I C
D
B
D
K Junction
It �=ACnBlower box access
access panel Gas line
access
�.. (both
--- H ---•� sides) 00
Top View Front View
Left Side View Right Side View
Model A B C D(door) E
F G H I J K
35"Model 32 tB(816) 283/4(730) 221/4(565) 323/8(822) 35114(895) 25(635) 121/2(317) 32 7/8(835) 6 7/8(175) 17(432} 101/6(256)
40"Model 371/8(943) 331/4(845) 271/4(692) 373!8(949) 401/4(1022) 30(762j 15(381) 377/8(962) 67/8(175) 17(432) 101/6(256)
45"Model 371/8(943) 331!4(845) 271/4(692) 423/8(1076) 451/4(1149) 35(889) 171/2(445) 42 7B(1089) 6 748(175) 17(432) 101/6(256)
1 1
Minimum clearances* Wall Finishes/Surrounds/Mantels
Back 1"(26'"m)tovRypper}m45" Ide1ls,8lla11ers1R";13mm) NOTE:Combustible wall finish materials and/or surround materials
� Pper 0"(Omm)toSpacers must not be allowed to encroach the area defined by the fireplace
Sides 112" 13 mm)to wrapper front face(black sheet metal).Never allow combustible materials
o"�0 mm)to Spacers to be positioned in front of or overlapping the fireplace face.
Top Standoffs 0"(0 mm)to top standoffs Non-combustible materials,such as surrounds and other fireplace
Floor 0"(o mm) trim,may be installed on the fireplace face,but they must not cover
From Bottom of unit any portion of the removable glass panel or control compartment.
to Ceiling 64"(1626 mm) Vertical installation clearances to combustible mantels vary
according to the depth of the mantel.Mantels constructed of non-
Vent 3"p6 mmSi Top••• combustible materials may be installed at any height above the
1"(25.4 mm}—Sides and Bottom fireplace opening.However,do not allow anything to hang below
Front Service Clearance— the fireplace hood.
clearance immediately in 36" 914 mm)
front of viewing areas) ( Minimum clearance requirements include an ro'ections such as
'3'(76 mm)above any herizentalrinclined vent component. shelves,window sills,mantels,etc.above the(replace.
Is located avORIt least 6 ft abovarance can e the fireplace on horizontal runs when first elbow 175 NOTE,or avoid higher,on theunderside of thted finish e muse antel finish materials rated
Combustible side clearances Mantel height
At 6"minimum
side wall
clearance,a
combustible
wall can project Top View of ( --Mantel depth
to any length. Fireplace 18(457)
16(406)
a' Combustible materials
45 14s ° E
I� 31/2" allowed in shaded area (356)
" (89 mm) "Safe Zone".
12(305)'
. Combustible walls 254 10 '
shown in dark gray ( )
203 _.
- -- - - Combustible mantel 8( )
legs may project
beyond either side of
the fireplace opening (305) (203)-L(102) Z Hood
as long as they are kept 10 6 2
within the shaded area in.(mm) (254) (152) (51)
illustrated here. A
6" Fireplace
(152 mm)
ScorpioTA°and ScorpioCD Series Direct-Vent Gas Fireplace
Framing . o
Fireplace framin 9P
s ecrfications Roof framing dimensions
Pitch C p
NOTE:Dimension"D"is the Framing
required framing depth when 101/2 construction to be 0/12 101/2" 101/2"
the finish material(drywall) (267) 2 x 4,or larger. c (267 mm) (267 mm)
thickness is 112"(13mm). 6/12 10112" 12"
Vent Framing—Top Vent (267 mm) (305 mm)
with One 90°Elbow l n 12/12 101/2" 173/4'
31/8 7(178)�L (267 mm
(1�Q ) (451 mm)
(308)
Termination heights for vents above flat or sloped roofs
Roof Pitch Termination
Height*
B C Flat to 6/12 1.0 it(0.3 m)
2 fl Vet9p1
6112 to 7/12 1.25 it(0.38 m)
E
nl""m won 7/12 to 8/12 1.5 ft(0.46 m)
Vent 8/12 to 9/12 2.0 it(0.61 m)
112 A
9!12 to 10!12 2.5 ft(0.76 m)
Ifton *
A 10112 to 11/12 3.25 ft(0.99 m)
Hashloy\
Inches(millimeters) 11/12 to 12/12 4.0 it(1.22 m)
12/12 to 14112 5.0 it(1.52 m) '
Model A* B C D E vemylip 14/12 to 16/12 6.0 ft(1.83 m)
35"Model 353,-B- 361/4-895 383/4-984 18-457 233/8-594 16/12 to 18/12 7.0 it(2.13 m)
40"Model 40318-1026 411/4-1 43 314-1111 18-45 281/4-717 18/12 to 20112 7.5 it(2.29 m)
F45--Model 45318-1153 411/4-1048 43 3l4-1111 18-457 281/4-717 'Indicates lowest point of ventilation 20/12 to 21/12 8.0 ft(2.44 m)
C=Minimum height of top vent installations
E=Minimum height of rear vent installations Framing the ceiling opening Routing the gas line
'Minimum opening size;additional 1/8"per side is recommended. 101/2"(267 mm) Left side front
'�� minimum corner of
1y � fireplace framing
Fireplace framing specifications—
comer installation with horizontal termination Roo Pipe coupling
101/2"
Framing (267 mm) ; (recommended)
E % minimum
1 inch from corner to framing v
/ 'x(178) ceilin Plumb
/• Framing A/ Bob 3" 75/8
/c i (76 mm)�!' (195mm)
/ O _
I �
V
Installing the horizontal termination
F* A Inches In rear- To eeb mbimfe mater
(MM)
rotBeYtooBiaRmmmmeeemat
wdh
Back wall of clase/encosure(including finishing lsis tning materials �elbow a� BYE
We of tee wan. Termhaden*
Model A B c D E tz113• c17°► tot
F (388 ntm! 287wie
35" 353/8
59VP 421116 1 30114 14114 6518
899 1511 768 362 168 1138 mm)
3'
40" 4025 6162116 45111 323116 15718 81.2 i (76 mm)
7(125 7521 1152 818 403 216 i
45" 45 318 1153 703/81788 49314 35114 17 V2 10114 sws `r (23.a000)
264 895 445 260 X
1 � �
This document is intended as a planning guide to highlight trade-related installation and finish uuevaemvimwnl�a
information.It does not replace the included installation manual.Information is subject to change NorOe Stmeaa me ctekrAne o7
ma FrtmMOymtryl.
without notice.See the manual for more detailed information. Mb.awaetoson
6b46"Ye7dSeetiee.
Teleacopic rlet 56Wee, WApplmeee.
t:Rov or A�pliaae tdpr** Bw 018pp0me
'recommended IHP Iertllination 101:H1968.
'With terannation Idt only,6-9114'
P/N 900298-05 Rev.A 10/2014
I
it low
} Vi i { -
1
;-
r I ,
i I I
1 ► 1i ! � � � _ ' 1 III , " �
1 I 1-t x I
I
I ,
t -
'
-loop i
all
i I
1 ► t 1 � 1 1 � ; j
I
• i
The Commonwealth of Massachusetts
Department oflndustrialAccidents
" - - I Congress Street,Suite 100
Boston,MA 02114-2017
;�`t www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNIITTiNG AUTHORITY.
Applicant Information / Please Print Legibly
Name(Business/Organization/Individual): �19-y v�C.N !�1 c D�/r hlV w.5 1z O*Vk 07 Q
Address: 15 S T19 L J) /
01 r Y14
City/State/Zip: N 2 T61 Iq 1VI�l p,"/Phone#: 7 (p 3 337
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction
2. am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.FJ I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 ❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5.❑I am a general contractor and 1 have hired the sub contractors listed on the attached sheet. 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.$
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no.employees.[No workers'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 mustattached 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:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: tA/ P �, 64,y C i /L. City/State/Zip:
Attach a copy of the workers'compen ation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance
coverage verification.
Ido hereby certify uliderthepain nd penalties of perjury that the information provided above is true and correct.
Signature: Date: 5�A
Phone#: 3 3 3 7
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
Information and Instructions
j 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'
compensatioii'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 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 Department's address,,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,A4,02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-NIASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
Office of Consumer Affairs&Bnsiess Regulation
ME IMPROVEMENT CONTRACTOR Type.
egistration: 179313 DBA
xpiration TIW12016
HUTCHINS HOME IA31PR0ilEME7
PAUL HUTCHINS 4i
121 FARNUM STREET',',.,
NORTH ANDOVER,Mg 01 `� Undersecretary
f- Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-059105
Construction Supervisor
PAUL G.HUTCHINS
15 STACY DRIVE
NORTH ANDOVER MA 01845
Expiration:
Commissioner 0510512018 }