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HomeMy WebLinkAboutBuilding Permit #009-13 - 15 EMPIRE DRIVE 7/2/2012 pORTH BUILDING PERMIT o��t,�o" go ti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION G Permit NO: / s Date Received �SSACHU`��� Date Issued: 7 2 IMPORTANT: Applicant must complete all items on this page LOCATION rJ,64#21) ,J` 6-M PME A pyE Print. _ PROPERTY-OW N ER LLC Print MAP NO: PARCEL:/q±/ ONING DISTRICT: Historic District yes Rnor Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Resi ential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other 'Septic Well Floodplain Wetlands Watershed District V.Wa'ter/Sewer DESCRIPTION OF WORK TO BE PREFORMED: NSf UC �1tiJ6L.r Fi4Wti�`� AS Identification Please Type or Print Clearly) OWNER: Name: ©�2C, AP-py,L AG6- LLe Phone: 979-R?/3194 Address cef OSE '9-3 CONTRACTOR Name-Eo'.IDT MESS/M4 Phoneq Y W1.5 16 l? AddressOOAJ &)Cr J !3�• (;1!?60&1.l rJP AAh .. 01931. Supervisor's Construction License, Exp. Date: Home Improvement License IbI Exp. Date- Id 47 13 ARCHITECT/ENGINEEESP. Phone: -35'2- 9319 Address/- AYJ A G-,,6aW+ ,uA) (�/j D f g33 Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ l o� FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner ? � � Signature of contractoo S'- Location No. (!)o 7 Date i i. i • TOWN OF NORTH ANDOVER F.,z • Certificate of Occupancy $ Building/Frame Permit Fee $3 �:0 G -- Foundation Permit Fee $ Other Permit Fee $ I TOTAL $ Check# 3y 3� 25479 /'Building Inspector i Location No. — Date 7 -all I • - TOWN OF NORTH ANDOVER 5N. �1'Is`b�4q ` � . Certificate of Occupancy $ BOG Building/Frame Permit Fee $ oG Foundation Permit Fee $ Other Permit Fee $ TOTAL $ w Check# 25479 Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer V Tanning/MassageBody Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site V 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 i Conservation Decision: Comments Water & Sewer Connection/Signature&Da a [Drivewav Perm' DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster o sit. ye no Located at.124 Main Street Fire Department signature/date 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) i ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 _----- n 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) ❑ BuildingPermit Application pp cation ❑ 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 NORTH r � . . FSE ,. _ w. . _ _ aAtt ve . No. D09 .==0013 -� - h ver, Mass, coc tic"twic.c A04ATED S U BOARD OF HEALTH -T T LD Food/Kitchen PERMI Septic System LZ .. rr /��� F /-/,(f............... ,. ... BUILDING INSPECTOR THIS CERTIFIES THAT .......... ........ ............................. .................. .... ............ f, ��, founds.ion has permission to erect g 1�/✓ �-�� .......�... . .�'�.�s<............................ to be occupied as .................................................... °`���. f... ��;......................................... eye Chi provided that the person accepting this permit shall in every respect conform to the terms of the application inai 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. PL WING INSP CTOR ole VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION' ARTS etc Service ............. ..... .. .,............................... BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building ou7Z/a,,�- �51011,Z— Y p Display in a Cons icuous Place on the Premises — Do Not Remove p 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. ORT#1 t s c . ve' '* O No. 0 — 13 t - h ver, Mass, [OCNIC Nl W1CN V �d RATED ►PP,`�(5 S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ..........LZ..r.� 'iZ ' �/.. .66E .............. BUILDING INSPECTOR f,� �% � founds.ion has permission to erect .......................... buildings on/./ ........ ...�.1'1. ............................ ems. J% to be occupied as ................... ...�r(7.`�vG�.:5�::.'nnl'( v .- ���� f ..... ...... ......................... Chi e 4// provided that the person accepting this permit shall in every respect conform to he terms of the application F 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. PL ��M ING INSP CTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Al�%� Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION' ARTS Service ............. ... .esli..4,1 �/JI.. ..V. ..,...... ..,..................... BUILDING INSPECTOR j t GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz Display in a Cons icuous Place on the Premises - Do Not Remove EOfale- No p Y p 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. CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 009-13 on 7/2/2012 Date: October 18, 2012 THIS CERTIFIES THAT THE BUILDING LOCATED ON 15 Empire Drive MAY BE OCCUPIED AS single family home IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Robert Messina 277 Washington Street Groveland,MA 01834 Building Inspector Fee: Pre Paid Receipt: 25479 Check : 3038 � NORTy '9 O TLED rbs r�.O °' APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION "A 01 may* BUILDING PERMIT # 0D l� 9SSACHU`+E� ADDRESS/LOCATION OF PROPERTY: �� Map AC Parcel k9-E Lot Number �z9 SUBDIVISION: DE=C9 A9-D LLA6 E DATE REQUESTED FILED/READY FOR INSPECTION: CLOSING DATE ON PROPERTY: Z / FIVE (5)DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20.00)WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. APPLICANT SIGNATURE Permit Issued to:D(�CN Ary i LU(5& oLLC Address:07/7 \,/JASH(NCqT R2 SreeT C/ ROUTING ,�( TOWN ENGINEER, SITE PLAN—DRIVE-WAY REVIEW L1 D ' -7-�nw CONSERVATION PLANNING DPW-WATER METER SEWER CONNECTION DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST .DP SIGNATURE File:Application for OC form revised Jan 2007/2011 NORry q O SLEO 6t �O 6 OL APPLICATION FOR CERTIFICATE OF OCCUPANCYANSPECTION �qs R^T•�'P"��� BUILDING PERMIT # f90 �' 13 . S CHUS ADDRESS/LOCATION OF PROPERTY: f S- /1'I j° pe U e— MapJA7 C Parcel o-{�l L Lot Number / SUBDIVISION: De=Cg A D LLAC E i DATE REQUESTED FILED/READY FOR INSPECTION: CLOSING DATE ON PROPERTY: i FIVE (5)DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20.00)WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. APPLICANT SIGNATURE Permit Issued to:Dg-CN ArT i LU6 a LLC Address:,2'27 WAsHIU -Fox) s4tce1 CT nocLA lb l OIR5'7 ROUTING TOWN ENGINEER, SITE PLAN—DRIVE-WAY REVIEW �D -7 v /0 � l CONSERVATION M0411 i PLANNING DPW-WATER METER SEWER CONNECTION t� i DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DP SIGNATURE File:Application for OC form revised Jan 2007/2011 LAWRENCE H. OGDEN,P.E. 198 EAST MAIN STREET 978-352-8318 fax 978 352-2858 cell: 978-502-5921 August 7,2012 Mr. Robert Messina Orchard Village LLC. 277 Washington Street Groveland,Ma 01834 RE: THE PARSONS REVISED PLAN GB#R6314 Lot 29 Empire Drive,North Andover,Ma. 01845 Dear Mr. Messina As you requested I visited the site 8/6/12 to review the installation of the Engineered Materials consisting of LVLs and Engineered Joist utilized in the framing of the aboveproject. These are shown on plans prepared by G.J. Bruno and Associates A- 1 to A-5 Dated 12/28/11 with the framing sheets certified by me 1/20/12. I met with Mr. Jeff Horne and discussed the following items that require completion: 1.0 Nailing of the garage door sheathing per detail sheet A-5 2.0 Installation of the deck lateral load connection shhet A-5 3.0 Installation of Simpson ACE caps at post to beam at porch. Based on the above site visit and based on what I could visibly see I can certify that to the best of my knowledge the LVLs members and Engineered Joist utilized in the framing as shown on the drawings are installed properly and meet the loading conditions of the 8th Edition of the Massachusetts State Building Code for 1&2 Family Residences. All other framing requirements of the drawings and code, including but not limited to materials,nailing schedules,blocking, connections and other details are the responsibility of the licensed construction supervisor responsible for the project. Should you have any questions please do not hesitate to call. i Yoursly, ������``N Of '� G cfl `x'/7/1 Z- O L ence H. Ogden P.E. Structural 27765 F seas o �,'ST O' Cc: Mr. Gerry Bruno Mr. Jeff Home sS��NAL ENG` Copy mailed to Mr. Robert Messina r1: NORTH - - w. .. . . . .. .( . . ver 0 � No. bo --- 13 0LAKI ti �Dh ver, Mass, COCHICMWICK �ok AD4A-rED r.f C) S U BOARD OF HEALTH PERM T T LD Food/Kitchen Septic System �e �� �� BUILDING INSPECTOR THIS CERTIFIES THAT L �/� Foundation . c:... ' . s<........................... has permission to erect.......................... buildings on/ Rough to be occupied as .rte`' ��'G�..�..°.`. .... ...... r.:. Chimneyy 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 CONSTRUCTION ARTS Rough Service ............. ..... .s�4:{�rLs'�...... ..:`. ............................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildink 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 i I MAScheck COMPLIANCE REPORT I I Massachusetts Energy Code I Permit # I MAScheck Software Version 2.01 Release 2 i I I I I Checked by/Date I I CITY: North Andover STATE: Massachusetts HDD: 6322 CONSTRUCTION TYPE: 1 or 2 Family, Detached HEATING SYSTEM TYPE: Other (Non-Electric Resistance) DATE: 6-28-2012 DATE OF PLANS: 8/8/09 TITLE: The Waverly PROJECT INFORMATION: Orchard Village Lot 29, #15 Empire Drive N.Andover, MA 01845 COMPANY INFORMATION: Orchard Village, LLC Messina Development Co. , Inc. COMPLIANCE: PASSES Required UA = 592 Your Home = 336 Area or Cavity Cont. Glazing/Door Perimeter R-Value R-Value U-Value UA ------------------------------------------------------------------------------- CEILINGS 1232 38 .0 0.0 37 WALLS: Wood Frame, 16" O.C. 2773 20.0 0. 0 164 BSMT: Conc. 8 .0' ht/7.0 ' bg/0.0' insul 0 0.0 0. 0 0 GLAZING: Windows or Doors 283 0.350 99 DOORS 70 0.000 0 FLOORS: Over Unconditioned Space 1105 30. 0 0.0 36 HVAC EQUIPMENT: Furnace, 96.0 AFUE HVAC EQUIPMENT: Air Conditioner, 13.0 SEER ------------------------------------------------------------------------------- COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 1250 of the design load as specified in Sections 780CMR 1310 and J4. 4. Builder/Designer Date Massachusetts Energy Code MAScheck Software Version 2 . 01 Release 2 The Waverly DATE: 6-28-2012 Bldg. l Dept. l Use I I I CEILINGS: [ ] I 1. R-38 Comments/Location I WALLS: [ ] I 1. Wood Frame, 16" O.C. , R-20 Comments/Location i I BASEMENT WALLS: [ ] I 1 . Conc. 8. 0 ' ht/7 .0' bg/0.0 ' insul, R-0 (uninsulated) Comments/Location I WINDOWS AND GLASS DOORS: [ ] I 1 . U-value: 0.35 For windows without labeled U-values, describe features: I # Panes Frame Type Thermal Break? [ ] Yes [ ] No I Comments/Location I DOORS: [ ] I 1. U-value: 0 I Comments/Location I FLOORS: [ ] I 1. Over Unconditioned Space, R-30 I Comments/Location I I HVAC EQUIPMENT: [ ] I 1. Furnace, 96. 0 AFUE or higher I Make and Model Number [ ] I 2. Air Conditioner, 13.0 SEER or higher I Make and Model Number I AIR LEAKAGE: [ ] ( Joints, penetrations, and all other such openings in the building envelope that are sources of air leakage must be sealed. When I installed in the building envelope, recessed lighting fixtures shall meet one of the following requirements: I 1. Type IC rated, manufactured with no penetrations between the I inside of the recessed fixture and ceiling cavity and sealed or I gasketed to prevent air leakage into the unconditioned space. I 2. Type IC rated, in accordance with Standard ASTM E 283, with no i more than 2.0 cfm (0. 944 L/s) air movement from the the I conditioned space to the ceiling cavity. The lighting fixture I shall have been tested at 75 PA or 1.57 lbs/ft2 pressure I difference and shall be labeled. I VAPOR RETARDER: [ ] I Required on the warm-in-winter side of all non-vented framed I ceilings, walls, and floors. I MATERIALS IDENTIFICATION: [ ] I Materials and equipment must be identified so that compliance can I be determined. Manufacturer manuals for all installed heating I and cooling equipment and service water heating equipment must be provided. Insulation R-values, glazing U-values, and heating and I cooling equipment efficiency must be clearly marked on the building I plans or specifications. I I DUCT INSULATION: [ ] I Ducts shall be insulated per Table J4.4.7. 1. � I I DUCT CONSTRUCTION: [ ] I All accessible joints, seams, and connections of supply and return I ductwork located outside conditioned space, including stud bays or I joist cavities/spaces used to transport air, shall be sealed I using mastic and fibrous backing tape installed according to the I manufacturer' s installation instructions. Mesh tape may be i omitted where gaps are less than 1/8 inch. Duct tape is not I permitted. The HVAC system must provide a means for balancing I air and water systems. I I TEMPERATURE CONTROLS: [ ] I Thermostats are required for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating I. and/or cooling input to each zone or floor shall be provided. I I HVAC EQUIPMENT SIZING: [ ] I Rated output capacity of the heating/cooling system is I not greater than 125% of the design load as specified I in Sections 780CMR 1310 and J4 .4 . I SWIMMING POOLS: [ ] I All heated swimming pools must have an on/off heater switch and I require a cover unless over 20% of the heating energy is from I non-depletable sources. Pool pumps require a time clock. I I HVAC PIPING INSULATION: [ ] I HVAC piping conveying fluids above 120 F or chilled fluids I below 55 F must be insulated to the following levels (in. ) : I PIPE SIZES (in. ) I HEATING SYSTEMS: TEMP (F) 2" RUNOUTS 0-1" 1.25-2" 2 .5-4" I Low pressure/temp. 201-250 1.0 1.5 1.5 2. 0 I Low temperature 120-200 0.5 1. 0 1. 0 1. 5 I Steam condensate any 1.0 1. 0 1.5 2. 0 I COOLING SYSTEMS: I Chilled water or 40-55 0.5 0. 5 0.75 1. 0 I refrigerant below 40 1. 0 1. 0 1.5 1.5 I I CIRCULATING HOT WATER SYSTEMS: [ ] I Insulate circulating hot water pipes to the following levels (in. ) : I PIPE SIZES (in. ) I NON-CIRCULATING I CIRCULATING MAINS & RUNOUTS I HEATED WATER TEMP (F) : RUNOUTS 0-1" I 0-1.25" 1.5-2.0" 2.0+" 170-180 0.5 I 1.0 1 .5 2 . 0 140-160 0.5 I 0. 5 1.0 1. 5 100-130 0.5 I 0.5 0.5 1. 0 I ----NOTES TO FIELD (Building Department Use Only) ------------------------- I I I I i I i F- 12.V I I F- 132.4' I EASEMENT - Q IL 0 1 , . N W 1 _ 26.1' � r � LOT 29 EXIST FND. EL.=274.9' �c0 1 6'- W 116.2 �INOFAt, MICHAEL 90 O= J. yG oSERGI 1 v N0.33191 y �OFESSIO�P �qhD SURV I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO HE HORIZONTAL SETBACK REQUIREMENTS OF THE LOCAL APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED. (THIS CERTIFICATION DOES NOTCONSIDERANYOHER RESTRICTIONS SUCHAS COVENANTS,WETLANDS,EASEMENTS, ORDERS FOUNDATION LOCA TION THIS DRAWING SHALL NOTBE USED BYHECLIENTFORANY PURPOSE OTHER THAN THAT OUTLINED ABOVE,EXCEPT WITH THE WRITTEN PERMISSION OF &SERGI INC. CLIENT- ENTERPRISE BANK FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT OF CHRISTIANSEN&SERGI INC.AND ANY UNAUTHORIZED USE IS TAKES NO LOCATION.•#15EMPIREDR. NORTHANDOVER,MA. FORHTHE NAUHORIZEDUSEOFTHIIS DRAWING ORPONSANY/BILITY INFORMATION CONTAINED HEREON. DA TE:6119112 SCALE-1-30' BASED ON SCALED DATA ONLY HE PRIMARY STRUCTURE SHOWN/S NOT LOCATED/N A FLOOD HAZARD ZONEAS SHOWN ON FEMA FLOOD INSURANCE RA TE MAP.COMMUNITY NO.:250096 0008C DATE.�'&W1993ZONEX J PROFESSIONAL ENGINEERS& LAND SURVEYORS CHRISTIANSEN & SERGI, INC, 160 SUMMER STREET, HAVERHILL, MASSACHUSETTS 01830 WWW.CSI-ENGR.COM TEL. 978-373-0310 FAX. 978-372-3960 D WG.NO.:06029.001.047 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-contractors)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 the _`y -town th=t the aPPliCa ion for the per—n 0..1� , i_b 1'g reguieS'_'d,no the Denartr e— of by retl_�r `ve to e��s Cl: r ng��P a e9 i 4�• t ' A t r -r-- 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 Aacidents Office of Invesfivat ons 600 Washington Street Boston,MA 02111 Tel. A.617-72.7-4900 ext 406 or 1-8.77 NIASSAFE Revised 5-26-05 Fax#6.17-727-7749 The Commonwealth of Massachusetts Department of fndustriall4ccidents Office offiavestigations 600 Washington Street Boston, MA 02111 www.mass:gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electridans/P A brant Information lumbers . Please Print Legibly Name(Business/Organization/Individual): LLA6 •Address: - - –– — City/State/ZiP p(�� �� �,Q DI S� Phone k,?700 r2. e you an employer?Check the appropriate boa: I am aemployer with 4. ❑ I am a general contractor and Ir7. [] f project(required):mployees(full and/orpart-time).' have hired the sub-contractors New construction I am a sole proprietor or partner- listed on the attached sheet.I Remodeling ship and have no employees These sub-:contractors have 8. .❑Demolition working for me in any capacity. workers'comp.insurance. [No workers'comp,insurance 5. ❑ We are a corporation and its 9. ❑Building addition required.] officers have exercised their 10.❑Electrical repairs or additions 3.E3.1 am a homeowner doing all work right of exemption per MGL .11-El Plumbing repairs or additions myself. [No workers'comp. C. 152,§1(4),and we have no required.]t 12.❑Roof repairs insurance re q ] employees. [No tivorkers' COMP.insurance required.] I3.❑Other "A-"•3'E�?`icau:that ebec s bo.=.�l m�st also fll cut the section helor. :he•.*,��. �: i _ information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am an employer that is providing workers'compensation information. insurance for my employees Below is the policy and job site Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/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 ofMGL 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 cent5y under the pains and penalties of perjury that the information provided above is true and correct c Sienature: Z Z Date: Phone#: �•- f TO [6. fficial use only. Do not write in this area, to be completed by city or town officiaL ty or Town: Permit/License# suing Authority(circle one): Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector Otherntact Person: Phone#: