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HomeMy WebLinkAboutBuilding Permit #284 - 148 MAIN STREET 10/22/2008 i BUILDING PERMIT ot"°oT"qti TOWN OF NORTH ANDOVER oa a�"`_ '_•°.`° °off ' APPLICATION FOR PLAN EXAMINATION Permit NO: ` Date Received 79��R7ED c`� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION / Iq 0 t'-&1 4-.- Print PROPERTY OWNER G/ -, �d &A (1 L /P'2 I,U Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Z (9 Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: A0 Ide tificatio }} Ple se a or Print Clearly) OWNER: Name: I'a �.. d'� Phone: �1'( 3C)` a?o Address: S v 5 , CA CONTRACTOR Name: tf� (•.o Phone: ? — -- Z 0 C Address: el 6 11 S 4AC c 11-r Supervisor's Construction License; - l Exp. Date: ✓ Home Improvement License: l 1 Exp. Date U ARCHITECT/ENGINEER E'_lGt h ti Phone: Address: A7e i a refd,(162) ,, Reg. No._`�,Z 3 FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ '� ZU� yy FEE: $ rI f Check No.: � 7 �� Receipt No.: of NOTE: Persons contracting with un gistered contractors do not have access to the guaranty fund nature of A LS _ gent/Owner '�gnature of contractor 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 Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT Temp Dumpster on site yes no Located at 124,Main Street Fire Department signatureldate COMMENTS 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.$100-$1000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 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 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) ❑ 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 ❑ 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location /�� ,Aw s, No. Date A0 MOA1N TOWN OF NORTH ANDOVER Of . ,Go , 1ti O? •' OOw Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Feel $ Other Permit Fee $ TOTAL $ Check # J r,, K;;L��� Building Inspector NpRTH Town of And No. - LA= = odover, Mass.,A_* ago �. I� COC MIC HE WICK V AORATED BOARD OF HEALTH Food/Kitchen PERM T T D_ Septic System BUILDING INSPECTOR 40 THIS CERTIFIES THAT...... . .........h......:..... N. .....:. .. �: .... ...................:........................................ Foundation has permission to erect....................... ................ buildings on .....�xr......����.....wl .................... Rough to be occupied as.. � .... ��� ....... ............. ........ ............................... Chimney provided that the p do accepting this permit shaPinee� iie- pectconform tot terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN. 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU TART Rough .......... ........ ........................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. The Owner and Contractor agree as set forth below: ARTICLE 1 CONTRACT DOCUMENTS The Contract Documents consist of this agreement, AIA General Conditions (1997), Drawings, Specifications, Addenda, and Bid Form issued prior to the execution of this Contract, and are as fully a part of this Contract as if attached to this Agreement or repeated herein. ARTICLE 2 SCOPE OF WORK The Contractor agrees to perform all of the work necessary for the completion of the project. The Project shall include all work as described in the specifications and shown on the plans contained in the package identified as Repair/ Replacement of an Existing Concrete Deck and Associated Work prepared by the Project Manager. ARTICLE 3 DATE OF COMMENCEMENT AND FINAL COMPLETION The date of commencement shall be the date of this Agreement, as first written above, unless a different date is stated below or provision is made for the date to be fixed in a Notice to Proceed issued by the Owner. The Contractor shall achieve Final Completion no later than 45 days after commencement of work. For every Calendar Day thereafter, a liquidated damages penalty shall be assessed at the rate of$100.00 per day until the project is 100% complete. Extensions will be given for unusual weather patterns and inclement weather that cause delays in the project. ARTICLE 4 CONTRACT SUM The Owner shall pay the Contractor in current funds for the Contractor's performance of the Contract the Contract Sum of$ —7 2,C)C7 subject to additions and deductions as provided in the Contract Documents. Unit Prices are as follows: Labor Rate for Misc. Repairs (incl. OH) $ Q%hour Materials Mark-up L S Page 2 ARTICLE 5 PROGRESS PAYMENTS Based upon Applications for Payment submitted to the Project Manager (for review and approval) on AIA for G702 & G703, and forwarded to the Owner, the Owner shall make progress payments on the account of the Contract Sum to the Contractor as provided below and elsewhere in the Contract Documents. Each Application for Payment shall be based upon the Schedule of Values submitted by the Contractor in accordance with the Contract Documents. The Schedule of Values shall allocate the entire Contract Sum amount the various portions-of the Work and be prepared in such form and supported by such data to substantiate its accuracy as the Project Manager may require. Application for Payment shall indicate the percentage of completion of each portion of the Work as of the end of the period covered by the Application for Payment. The amount of each progress payment shall be the approved percentage of completion (less previous payments) less 10% retainage. Payments shall be made within 30 days for the date of approval of the Application for Payment. ARTICLE 6 FIANAL PAYMENT Final Payment, constituting the entire unpaid balances of the Contract Sum shall be made by the Owner to the Contractor when (1) the Contract has been fully performed by the Contractor including the submission of all warranty related paperwork, (2) a final Application for Payment has been submitted and approved and (3) Release of Liens forms from all suppliers have been submitted. ARTICLE 7 TERMINATION OR SUSPENSION The Contract may be terminated or suspended by the Owner or Contractor as provided for in the General Conditions. Page 3 This Agreement is entered into as of the day and year first written above and is executed in at least three original copies of which one is to be delivered to the Contractor, one to the Project Manager for use in administration of the Contract and the remainder to the Owner. OWNER CONTRACTOR ignature) v �cd (Signat r r (Prhibid Name and Title) (Printed Name and Title) Page 4 CONTRACT This agreement is made as of: Between the Owner: The Sutton Pond Condominium Association 148 Main Street North Andover, MA 01845 and the Contractor. The Project is: Repair/ Replacement of an Existing Concrete Deck and Associated Work. The Project Manager is: Shawmut Property Management 733 Turnpike Street#221 North Andover MA 01845 Page 1 PROJECT DRAWINGS 116 /"o ,gyp 27" 48' 46%2 9 SHAWMUT PROPERTY MANAGEMENT proiect: E3m cow Title• p► jb.M\IIEW Drawing#: C Scale: ' at Drawn b p O$EMS O.C. *3 BARS 12.'0.C. FENT 1l1EVJ .. �4pCOilER #4 BARS 12pO.C. 5u I �FAdillMt►1E 1 1 + 1 i . 1 1 immustm(3*fin BARS 8"O.c. TIAS A VROX.wEK PmimstY C oorD lo� wj%mmto 14 Mrs Vac. a r OF PANE 4tF]tZMtC M 3 BARS 12"ac. SNAWMUT PROPERTY MANAGEMENT Proiect: 0t 11 H PW Title: FxLcKnM �ta�ntx�ew,� Drawing#: CM Jp - Scale: to Datc: Drawn b P N E (NEER tG _.. STRUCTURAL AND CIVIL ENGINEERING Lt. 08102.01 Page 1 of 2 RMX Northeast, Inc. July 29, 2008 213 West Street Milford, MA 01757 Attn: Mr. Christian Wright Job No. 08055 Re: Structural Evaluation of Specific Components of a Residential Concrete Slab Deck in the Building Known as Sutton Pond Condominiums, North Andover, MA Dear Mr. Wright, As requested, on July 29, 2008, I visited Sutton Pond Condominiums, North Andover, MA to observe a specific damaged reinforced concrete slab deck and offer my opinion as to the cause of the damage and to recommend action to be taken to remedy the situation. This evaluation will address the indicated damaged deck only and assumes that the entire building is in structural compliance of the Massachusetts Building Code. No drawings of the decks were available, so this evaluation was performed utilizing observations only. Findings The quadrilateral shaped 5" thick cantilevered slab deck extends out from the building face 5'-0". Approximately three square feet of a corner of the concrete slab has been removed leaving the reinforcement in place. This was reportedly performed because that portion of the slab had cracked to a degree that it presented a hazard. With the exposed reinforcement, it was easy to determine that the structural reinforcement for the cantilever structure (perpendicular to the building face) was#6 bars at 8" on center as the top reinforcement with#4 bars at 12" on center on the bottom The out of plane reinforcement (parallel to the building face) was#3 bars at 12"top and bottom. The difficulty I see with the slab design is to maintain adequate concrete cover of the reinforcement with only a 5" thick slab. ACI-318 requires 2"of reinforcement concrete cover against forms or slab tops. The cumulative reinforcement thickness alone amounts to 2". Therefore, to meet minimum requirements, the slab should have been 6"thick and that assumes that the top and bottom reinforcement mats bear on one another. Efficient top and bottom reinforcement mats have a vertical dimension between them sufficient enough to place one mat in tension and the other in compression. However, it should be noted that the slab to building interface was observed to be sound and not structurally compromised. The exposed reinforcement was in very good shape and the quantity is more than adequate to support live and dead loads for the deck as long as the full development of the#6 reinforcement bars is realized, meaning that the#6 bars extend an adequate depth into the interior building slab. This appears to be the case. 12 SLEIGH ROAD . CHELMSFORD, MA 01824 . PHONE:(978)2564014 . FAX: (978)250-3764 ♦ email: paulphelan@comcast.net Page 2 of 2 RMX Ll. 08102.01 July 29, 2008 It is my opinion that there are two possible factors that lead to the concrete deterioration. It is surmised that the top of the slab developed a crack(s) which allowed water to infiltrate the slab. Any freeze/thaw phenomenon would lead to increased cracking and concrete spawling and separating. It is also possible that the deck was overloaded or at some point subject to a dynamic load which caused significant deflection also causing cracks. Either one or both of these outside factors coupled with the minimal concrete coverage of the reinforcement likely lead to additional deterioration of the concrete. Recommendations All remaining loose concrete should be chiseled off and the chiseled face cleaned. The face should be treated with a"Weld Crete" or similar concrete bonding enhancer. The missing slab area should be formed up to complete the 5"thick slab. The exposed reinforcement should be cleaned of corrosion, etc. and tied together with wire to assure that the bulk of the reinforcement will favor the middle of the slab depth with some deference to the slab top. Higher strength concrete(4000 PSI or better) should be placed with maximum aggregate size %". The top of the slab should maintain a slight pitch to avoid ponding. ACI-318 (American Concrete Institute) requirements should be followed during placement and curing to assure proper concrete strength and properties. After proper curing, the top of the slab should be cleaned thoroughly and sealed with an accepted outdoor concrete sealer. It is also recommended that all exterior decks in the complex be cleaned and sealed to minimize similar future occurrences on other decks. It is recommended that Phelan Engineering or a suitable agent be employed to visit the site during the reconstruction process to assure an acceptable structure is obtained. Please call if you have any questions. Regards, Of M, PAUL A. J o`er PHELAN JR. �J Q� STRUCTURAL n 42538 G Paul A. Phelan, Jr., P.E. i i ti J/ Board of BuildingRegulations and Standards }, HOME IMP"VEMIENT CONTRACTOR t RegtstMdri:'.153188 Elcptrstla� 1�'it2008 TrS 253234 Type. Pri"ie Corporation j S 8 M RESTORATION.AQ RACTiNG INC PAUL BRUNO I 107 ORLEANS ST ,anGZt.�ti• I '! EAST BOSTON,MA 02128 Administrator 622 G$ Teo- 10k— PAUL E$Rtj,QO 4 pWmN,MA 02128-` i �l3�2 S�+tI�R�1'� `' `: moi,-G._ -�.•..,�'- " _ I Date: 10/21/2008 Time: 3:45 PM To: Paul 13 17815984581 Page: 001 AC W,. CERTIFICATE OF LIABILITY INSURANCE 10/21/` o 9 PRODUCER (617)472-3000 FAX (617)472-7248 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Burgin, Pl atner, Hurley Insurance Agency, LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 14 Franklin St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Quincy, MA 02169 Jean A Sul l i van INSURERS AFFORDING COVERAGE NAIC 4 wauRED B & M Restoration & Contracting, Inc. INSURERA: Employer's Fire Ins Co 20648 107 Orleans St INSURER B: AIG East Boston, MA 02128 INSURER C: INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD TYPEOFINSURANCE POLICYNUMBER POLICYEFFECTIVE POLICY EXPIRATIONLTR INSR LIMB GEnERALLIAELRY FB11.111735 03/17/2008 03/17/2009 EACHOCCURRENCE $ 2,000 0 X7 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 30-0 O CLAIMS MADE I OCCUR MED EXP(Any one person) $ 5.0 AT-- PERSONAL 6 ADV INJURY $ 2,000,0 GENERAL AGGREGATE $ 4,000,01 GENTL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 4,000.000 X POLICY PRO-CT LOC AUTOMOBILE LIABILITY F81UI173S 03/17/2008 03/17/2009 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILceY INJURY $ A SCHEDULED AUTOS (Per f5on) 2,000,000 X HIRED AUTOS BODILY INJURY $ X NON OWNED AUTOS (Per accident) 4 OOO O 00 PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AM WC696S751 V 06/10/2008 06/10/2009 X WC STATU- R MTS OTH- EMPLOYERS'LIABILITY ER- B ANY PROPRIETORIPARTNEWEXECUTIVE E.L.EACH ACCIDENT $ 11000,000 OFFICERIMEMBER EXCLUDED? It yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,OOO O SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,ooc OTHER DESCRIPTION OF OPERATIONS/ OCATIONSIVEHICLESIEXCLUSIONSADDED BYENDORSEMENT/SPECIALPROVISIONS Project: Repair Balconies hawmut Property as additional insured for General Liability CERTIFICATE HOLDER CANCELLA11ON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THE EcW,THE ISSUING INSURER WILL ENDEAVOR TO MAL 30 DAYS WRITTEN NOTICE TO THE CERTIFCATE HOLDER NAMED TO THE LEFT, Sutton Pond Condomi mi um Assoc BUT FAILURE TO MAL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 148 Main Street OF ANY KID UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. N Andover, MA 01845 AUTHORIZED REPRESENTATIVE Michael Prendergast/JAS AGORD 25(2001108) MACORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street 11\ n Boston MA 02111 V=" www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print L 'hJ( l Name (Business/Organization/Individual):--.8 v ! k. r4 Address: City/State/Zip: {'t-IA,5 O,;L 14-_ Phone#: Are you an employer?Check the appropriate box: Type of project(required): L[�1 rn a employer with_�_ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for 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 ME] 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.] t employees. [No workers' comp. insurance required.] 13.❑ Other *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t.. Homeowners wha suhmit.titis aeitdavii i��uieatir:o L:ey ait uviEie uE.- r a"`then;-,irf outside contractors must submit a new affidavit indicating such. $Contractors that check this box mast attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 1 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.#: l j` `� Expiration Date: Job Site Address: � :/"LCity S atte/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the ins and penalties of perjury that the information provided above ' true nd correct Si-onature: Date: /Q 21 (/ Phone 2 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three 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 anvquestions 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have 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 Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia