HomeMy WebLinkAboutBuilding Permit #022-14 - 150 BRENTWOOD CIRCLE 7/8/2013 j TOWN OF NORTH ANDOVER
gC� APPLICATION FOR PLAN EXAMINATION
Permit NO: _ Date Received
Date Issued: i
IMPORTANT:Applicant must complete all items on this page
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-LOCATION �a .
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PROPERTY OWNER �) f �.I�SAA-,'«l
Pant; 166Pte r,01d Structure yes50)
MAPaNO., -PARCEZ®NING DISST' I,Histo�ic Dlstnctk yeS j
} � _ Machine Sfop3Villager 'yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑New Building F1One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other _r
' ❑F oo'dIain' : D�\N ands ®�`1NatershediDistr�ict
❑"Sepfic n ❑�Well, u� 4 p, ,
Wate%Sewed :`` `{ i ° .. °._ :' �r 4 � '
xa -� , a� T� .: a
r DESCRIPTION OF WORK TO BF PERFORMED:
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et (`
Identification Please Type or Print Clearly)
OWNER: Name:�AN d- �-+S �• Cr12 U Phone [a 0- Z�` 9(3
Address: Eti� w�� >' ��2 c��. c � > t� UA
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CONTRACTORName
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4'' a.
�n t � rn,a {c rev r s z
dd
Aress Va'
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t.ew
Supervisor s Construction Licensees dfd '�3Q Exp: _
.rte.. t v ,`d` .r Tr,-TS'r'�.:c. " ' t�•''ir Y '"`r� •-` �,?yr $ y,+.'^.,..,
-�'[''�',•ywTE.X f Q k't°teh`'f f .tt *„fie w� v� t�iR a _��.s "tsa -:� - .'R. �'"-;'; � +_y s -
Honie
r Z � .�..z� .�,�r:�• Exp: Datey .�0�.�,Ia.3; "1
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BOLDING PERMIT:$11.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $ �~
Check No.:
Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
_Signature of Agent/Ow r;-' ®-��.,Sig7ature of contractor
Plan. Submitted Plans Waived ❑ Certified Plot Plan Stamped Plans ❑
Location eL
i t
No. Zz— ) u Date ' 1
i
• • TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ JZ
r Foundation Permit Fee $
Other Permit Fee
TLD
TOTAL ley
TOTAL $
Check# � -39
i
26592
Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped-Plans ❑.•,,,;
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.__
Total land area, sq. ft.:
ELECTRICAL: Movement of fetor location, mast or service drop requires approval of
Electrical Inspector Yes No
DATER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A-F and G min.$1o0-$1000 fine
NOTES and DATA— For department use
zZ - ec)
® Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
o 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
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:Building Permit Revised 2014
Enter construction cost for fee cal - North Andover Fee Calculation
Construction Cost
... .
$ - $ 379.80
Plumbing Fee $ 47.48
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 47.48
Total fees collected $ 574.75
150 Brentwood Circle
022-14 on 718/13
Install Inground 27x41 Pool
rtORTH
own of
2 t �� ndover
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No. 12 — 14
ver Mass •
cocroc«ew.c« 1'
S V BOARD OF HEALTH
PERMIT T LD Food/Kitchen
Septic System
THIS CERTIFIES THAT . C40V .............• BUILDING INSPECTOR
Foundation
has permission to erect.......................... buildings on ..1. .V........6. •�• •...... ► .ft••
.'. Rough
to be occupied as .. ... ... �........ . . . A1/ ... ' .b ....®........................ Chimney
provided that the person accepting this permit sha 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
PERM I r.�EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONST IONS ARTS
A Rough
Service
..........
.... � ........ ...................
....... . .....
BUILDING: INSPECTOR Final
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
;LI I(= r, nai 6, rni -IHAJ 1116121 iWWVI101 IWW LIIyI IU:,.ui B iu-4; nu nlijuYGi %iw4i4ti YUu/ UC:JU OUJLJI rJ LJI ry o-u
Client#:53642 FAMiLYP00L1
ACORD, CERTIFICATE OF LIABILITY INSURANCE D6,7512aD;YYYYI
6!15!2013
THIS CERTIFICATE I3 ISSUED ASA 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 155UING[W-)UFER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT;If the certificate holder is an ADDITIONAL INSURED,the policy(les)must W 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).
PRODUCER
NAME: _
FLUB International New Englandp+ora=_ 978 657.5100 MAIL 86g-475-7959
299 Ballardvale St IA1C No,EKtt: �� A7C,Nej�9
Wilmington,MA 01887 ADDRESS:_ �
INBURER SI AFFORDING COVERAGE i_NAIC%
87557-5100 -- ---- INSURER A:NaUtiiUS Ins CO --� ---I --
INSURED INSURER B:Technology Insurance Co l
Family Pools&Patios Inc. INSURER c:Acadia Insurance Company131325
INSURER D:Safety Insurance Co
70 S.Broadway
Lawrence,MA 01843 NSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEC BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INUICATEO. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDt?ICN OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT'0 WHICH THIS
CER71FICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY 74E POLICIES DESCRIBED HEREIN IS SUBJECT TO AL'- THE TERM,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LI1V'hT3 SHOWN MAY HAVE BEEN FEDUCED Er' PAID CLAIMS.
9TYPEOFiNSURANC£ OLS•5R POLICY Eff POLICYEXP Llh§iTE
LTR )&I 'ULICYNUMSER MMIDDITYYYI imfjmDlYYYY _
A GENERAL LIABILITY j NN139379 D911912012 09(191201 EACH OCCURa_NCv t T11000.000
COP1Fv'ERCdALGENERAL LIABILITY I �Rr�i��IY�EN>'EEn-p' $100000
CL0.MS4,4DE �OCCUR PA_DEXP(.Any:r,spaisor) $5,000
X BUPD Ded.2,500 PERSONAL d ADY IN,RIrtY $1,J0 ,0 000
GENEeALAeG,EGATE $2,000,000
GEN'L AaGRli;ATE 11,17 APPUFS-eR: PRODUCTS.COMProP^.cs 1¢210001000
P6!_tCY ,PIECT I LOC __
AUTOMOBILE LIABILITY D "1den't 6L Ll vhf
D HX
3947232 -- 2(3112052 12131/201 'Eatx:clIg_,'Z $1,000,000
ANYAUTO I BODILYINJi,RY(%er Ue'son; $
ALL OYWIED SCHEL:iLEDBOUr.Y iNiURY(?ar ac>iderH)AUTOS AUTOS H!REO AUTOS X 011INED �PRCFL RTI'DO,MP.GE $
F.UTOS e lcir'apli
UhMRELLA LIAB HOCCUR EACH OCCURRENCE - $ �-
EXCESB LIAR CLAIMS-MADE AGGRIE $
GED RET:.hFtONS $
B WORKERSCOMPENSATIOIdTWC33350D6 12131f201212/31(201 WCSTATJ OTH-
AND EMPLOYERS'LIABIL!rY YIN TORY J,1ITS
ANY PROPRPOR'?W.NERIEXEC�UTIVE rE.LEACH ACCOEVT $500000
OFFICERMIEIABEREXCLUDED`^, 7 N'A
(Mersaetery In kH; E.L DISEASE.EA.EMR;OYeE $500,000
I'yes,dascnbo undar
DESCRIPTION CF OPERA.TION5 I>Ekra El DISEASE-POLICY LffYI-1$500,000
C Property CFA018008416 911912012 09119/201 i vrs limits
Spec Form Repl Cost Ded$1000
I
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(Atlath AC301n1,Addilbnel Remarks Schaduls,if mora space Ia raquirad)
Workers Compensation has Blanket Waiver of Subrogation,as required by executed contract.titlark in NY is
excluded;new construction of 10+units is excluded.Re:Dan&Lisa Carroll,150 Brentwood Cir,NO Andover
MA.
CERTIFICATE HOLDER CANCELLATION
Town of North Andover sNOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
TME EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED Bi
1600 Osgood St ACCORDANCE WITH THE POLICY PROVISIONS.
North Andover,MA 01845
AUTHORIZED REPRESEN7ATIYE
®1988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD
*SN74901MB"21 S EH002
Board, :a Bvildi£➢t'ltf.''}+i:•37it;�}�
Lscer,se: C5 10330 —
WILLIAM C POULOS
70 S BROADWAY
LAWRENCE,iVIA_01843
Gam -� ..... _..,... .. _
Expiration: 7/19!2013
P cti;ii...us3cE' Tr�: 209138
F RP
Office of Consumer Affairs sand Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 118204
Type: Supplement Card
FAMILY POOLS & PATIOS INC Expiration: 2/1312015
GLEN' WIGGIN --
70 S. BROADWAY _ --- - ------:-__ — - —'----_--
LAWRENCE, MA 01843
Update Address and return card.Mark reason for change.
SCA i t. 2CM-0511. / J `i Address "j Renewalj_! Employment f 1, Lost Card
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. if found return to:
F Office of Consumer Affairs and Business Regulation
egistration: 118204 Type
— 10 Park Plaza-Suite 5170
Expiration: 2/13/2015 Supplement :.and Boston,MA G2116.
FAMILY POOLS&PATIOS INC
GLEN WIGGIN
70 S.BROADWAY
LAWRENCE,MA 01843 '
Undersecretary Not valid without Signa-6
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70 South Broadwayf 45 Route 125
Lawrence,MA 01843 Kingston,NH 03848
1 el:978-688-8307 Ulu Tel:603-642-9909
Fax:978-688-1949 s,NCE»�a»�R Fax:603-642-9906
providing a full line of services and supplies
fully licensed and insured
www.familypoolsonline.com
Name CLCA J 1.5 e, C."V ra (I Date 2 L4 JLA�VLA_ Zo it 3
Address r t LA_ d 6C rrC�-c City t-J. 1k,J 'Site `'� zip 044
Home Phone Work Phone Cell (0 R31 9 1-3 (-Add'I#
Cross Street/Directions C-H\ (r-f c.A pX� 1^,t s
Estimated Start Date Estimated Completion Date
We propose to furnish and install on vin gunite >0 x W t C \r" PoA r �wimrning pool for the
sum of
O
THIS PRICE INCLUDES:
•Normal Excavation up to 8 hours on day of dig •Manual vacuum cleaner kit •Waterline Tile(6•)
•Backfill and Sub-Grade up to 3 hours 3-Step stainless ladder •Liner Choice Z- ?J ✓'^�" lJ
•Underwater White Light tQt"_ t •Rope and floats •Test Kit S w y r+•�
•Steel Reinforcing per Engineered Plans for gunite _ •Initial balancing chemicals •Surface skimmer(s)
•Steel Structure per Engineered Plans for vinyl •8 to 12 Wk supply of maintenance chemicals •Dual Main Drains
•Over-Flo Line for added protection (supply depends on pool size) •Coping G``—^ 1.
•Pressure testing of plumbing during construction •Leaf net •Steps NL
•Ten Year Plumbing Guarantee(see specifications) •Wall brush •Handrails 'r."
•
Transferable Lifetime Structural Warranty •Extension pole •Filterr .._.___
(plumbed no more than 25ft from pool)
•Pump&motor
THIS PRICE DOES NOT INCLUDE: 4 W rt e_r t P:
•Any plumbing over 25ftfrom pool.Additional runs are not recommended but would be at a cost of$ z per foot per line.
•Machine time in excess of that specified above.Additional machine time to be billed at$ including machine,operator,and laborer,due with second pool payment.
•All hours of trucking will be charged at$_ {�per hour per truck due with second pool payment.
•Any dumping costs incurred for disposal of ledge,large rocks,garbage,stumps buried or otherwise,building materials,unsuitable or nonstructural sols,or any unforeseen material that must
be removed.
•Removal of ledge or large rocks by way of a Starr bit,chipper,or blasting.
Additional fill,if necessary,for proper backfill or reshaping of hole,supply or spreading of loam,reseeding of grass.
•Patio,fence,retaining wall,or any accessory items other than noted on contract.
Electrical wiring,fuel connections,heater venting,fuel storage tanks or permits.
Repair or replacement of sprinkler systems or any buried items such as well lines,drywells,leach fields,electrical lines,cables,etc.that are damaged during construction.
•Costs due to water or soil conditions(ex.day,peat,live sand,excessive rock,etc.)requiring a stone pack of the hole.The stone pack will be at an extra charge of$ minimum to
$ 9" maximum and at the discretion of the job supervisor.Additional machine time and/or materials necessary to rectify such a condition will beat a cost over and above the stone
pack and will be quoted by the job supervisor:
Water to fill pool.
Initials
CUSTOMERS MUST SUPPLY:
Access for all trucks and equipment •Building and Electrical Permits or assume the costs necessary to obtain such permits.
Water and electric necessary for construction of pool •Customer mustwater cure Gunite shell for 1 to 10 days if applicable.
•Water to fill pool immediately uponinteriorfinish `�
NOTES: FLk t �7� — 1 t .k (l x+e-` u ,., P r TG,
U
r
OPTIONS: TOTALS:
Diving Board ( } `•`
( ) Basic Pool Price
Solar Cover $
Additional Pool Lighting (A ,Z � ) +;-<--• Options $ L 60
Heater ( )
Environpool Plus,8 hd+2 surface ( ) �_ � SUBTOTAL $ Q -7 S_-&-�-4 f g w
Additional Floor Heads ( ) "`"' tG
?_5%Sales Tax
Polaris Vac-Sweep
Polaris retrofit only ( ) TOTAL 4 2641) $ 3 2.L11
Swimout/Bench St,�v�S(��,({L ) 3��+'� j� $ Oy
•Interior Finish t ) ... Less 10%Deposit i
Spa 9'j= - q p
Automated Control System ( } ... Balance of Contract t
Salt Chlorine Generator
Other (� \c no,,l S
PAYMENTS: 113 EXCAVATION 113 BACKFILL+EXTRAS 113 SYSTEM START-UP
The buyer hereby agrees to pay, in full,the total amount of this transaction upon start-up of the installed pool.Your salesman or job supervisor will meet with
you prior to excavation at which time all decisions including pool size,shape,elevation;liner print,and all options must be final.Changes after this date will be
subject to extra charges,where applicable,and will result in unavoidable delays.You,the Buyer,may cancel this transaction at any time prior to midnight of the
third business day after the date of this transaction.Credit card payments not accepted on contract amount.
BUYE C' date 2-413
SELLER L1t t9 L--e' date CO-BUYER date
d
�J.' j 7..0�71
LOT 36
LOT 39
260.00'
58.0
D
PROPOS
ADlnpND
o a o VV
�o a2
LOT 38 °" o3 LOT 3705. 2 V
21 �� wW 44,000 SF
o
o W O ,y0
` 000
�aV
PLAN REFERENCE: NERD #4869
I CER77FY THAT THE PRISTRUCTURE LOCATION PLAN THE HORIZONTAL SETBACK4RY REQUIREMEN7S OF THS7RUCTURE SHOWN COCAL S TO
APPLICABLE ZONING BY—LAWS IN EFFECT WHEN CONSTRUCTED.
(THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER
RESTRICTIONS SUCH AS COVENANTS, WETLANDS, EASEMENTS,
CLIENT:
DANIEL C A R R OLL ORDERS OF CONDMONS, ETC.)
THIS CERTIFICATION 1S MADE AND LIMITED
TO THE ABOVE CLIENT.
THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY
PURPOSE OTHER THAN THAT OUTLINED ABOVE, EXCEPT WITH THE
WRITTEN PERMISSION Of COUNTY LAND SURVEYS INC.
COUNTY LAND SURVEYS INC. TAKES NO RESPONSIBILITY FOR THE
UNAORIZED USE OF
LOCA TION: 150 BRENTWOOD CIRCLE CONT ED HEREON. THIS DRAWING OR ANY INFORMATION
NORTH ANDOVER, MA BASED ON SCALED DATA ONLY THE PRIMARY STRUCTURE SHOWN
R NOT LOCATED /N A FLOOD HAZARD ZONE AS SHOWN ON FEMA
FLOOD INSURANCE RATE MAP:
SCALE: 1"=50' DATE: 9-26-11
REVISED 6-21-13• POOL (ONLY) COMMUNITY NO.: 250098-0007-C DATE: 6-2-93
ZONE: (IF APPLICABLE)
COUNTY LANt' SURVEYS, INC.
Professional Land Surveyors`PO Box 543,Gloucester,MA 01931-0543'078)282-0443
,jaim�� &.610
North Andover MIMAP brentwood June 27,2013
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Interstates
—Interstate
—Mapr Roads Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83,
Roads Meters Data Sources:The data for this map was produced by Merrimack
NORTH Valley Planning Commission(MVPC)using data provided by the Town of
CI Easements �� t`ao '� North Andover.Additional data provided by the Executive Office of
0 MVPC Boundary, r •�< ^e�� Environmental AffairsMtassGlS.The information depicted on this map is
❑Parcels 3 L for planning purposes only.It may not be adequate for legal boundary
F — 9 deFlnitionormgulatoryinterpmtation.THE TOWN OF NORTH ANDOVER
MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
i } THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
♦ ^4 OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
THIS INFORMATION
�,SSACH Sal
1"=386 ft •�°
The Commonwealth of Massachusetts
Department ofIndustria[Accidents
Office of Investigations
600 Washington Street
Boston,MA.02111
www.massgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): `���''�
Address: �;� �� �Ya 4-0arn!)
City/State/Zip: .rar nor NA, tl(V-,f 3Phone#: �? " �s-g k 2o7
Are you an employer?Check the appropriate box: Type of project(required):
1 LZII am a em to er with 3'o 4. El am a general contractor and I '
p y � have hired the sub-contractors 6. W New construction
employees(full and/or part-time).
2.❑ I am a sole proprietor or partner- listed on the attached sheet. F1 Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. E]Building addition
[No workers' comp.insurance 5. El We are a corporation and its
required.] officers have exercised their 10.E]Electrical repairs or additions
3.F] 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' 13.[i Other Q W'""` a
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 indicatingthey aie doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name:. ��A44n L,%,s _
Policy#or Self-ins.Lic.#: 13-3.1500(10 Expiration Date: 4L'
Job Site Address: j5p 3&6^lT�b Gt 2 L I e City/State/Zip: /T►'ti d �� J4.4' l
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 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 DTA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Simature: & o Date: 1t- Zie)l�
Phone#: q7 k
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 S.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-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 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 permittlicense 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 ofMassacl?usPtts
Department of irmdustdal Accidents
Office offlavestigations
600 Washington Street
Boston.,M,A,02111
TO,#617-72.7-4900 ext 406 or 1-877-MASSAFB
Revised 5-26-05 11aY,0 617-727-7749
WWWMass,gov/dia