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HomeMy WebLinkAboutBuilding Permit #171-11 - 150 PINE RIDGE ROAD 8/26/2010 BUILDING-PERMIT NORry t`�o TOWN OF NORTH ANDOVER o � S�2 yE„tr, APPLICATION FOR PLAN EXAMINATION Permit NO: 7�/� Date Received A A��.,....�. ,. 6 '' �G ✓� 0 7 �AwTeo w!I �J Date Issued: �SSgct+usE�� yT� - IMPORTANT:Applicant must complete all items on this page ,.'ta,;..f�•s x.,-.::�. max.^I� .ri.,;:3. �� �,s-+a is:, �+-' pr:.�.,; -s� _.a..�:_, _ �. ze.e,��,. r_-. _ _7., } x..s7�;�.•-n` .e ��,.i,�.^� _ _ -sYs fi:=_ ..�' --r �'-` �a '``N�-=•'-x,.;e''.,-+._-'-i;•Y,r ur ice..: vr�k.- t -t Y (I �S' ,�, `�'I"`�}`x,h,�i, 7.'.=;'.�:;#•: '�s TMr- � � � 3 fir.,,�e`,,.c{i�t..r-,et ,...••-�,� -' �' ;,�.? -U-„� -••- yTrE- 'rF.,-+" r-4`'si�.?L ,".rcl -"' �•Pi '. r �k' rtt� �F-7�. aio r _ F' ,r•-r'a ."ne'.r;.Y: s,: A ^ _ r� � z`r.isc"�,r,,'�.,�.-v�r'.�-''��4a�.��--'h.,ytT`5� �`"�-. rr.±?�� �a�:� - .'�L 2�y '��i�:'�4�-r,_�z�,:.:;tip: _ - _ _ ^^T.:•."*','z' .,ter y ' �'� n� � �`7r�-.M _ ',� -_'�_�•'r;-�`' e�.,...•.��_�-.,g.'�f� ,=',s�i�.=•cryr-;u-.�a_yE.,:, „r plc_ a: �• �� ::s?l.:'�� .- �n��� i'•�=/x;.' .F. f--,I rrz�� V=;.�'I_j h:�.� � _,.:-�'�"'_^tE�Cs?.':=F..'.n, �r 41?uc+^i=ct,:.. ,.�:c•�'F,r.-5.y, {f "`�zr��. - _ _I.rl,1:L -.5.,:5,: „�_'c'K :,y. ^����.��-•,.r�t.a rs - '�:-^mac - :,�•" $f�:;S�-a:_ ,:,.�••-'_,-.. 1 �.:'3`s,��"`�w,,.,.s(,.anfc,�:._r.'. _ _ r:r<a?*ir C. ..k'. _ .r��,. -..�, .aa•` ..s '"✓a..: --.�I._-•._..;�T•9;r _ _ c t � t s, , 'n -�,d:,..c _i.� .,. .,-•,,,_--,.w.,....:c.-.. -,.--.: �': ,:��' - - -•rte' ' _ hQ•:. 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'^�c�.��. .+:.��iJ�._,r�i:F���+M�� •��Y '���1J i� �,Ga'F ¢ ❑ � � �•$ts"s ''~9._' � ,j„y�-• r. � � •,.a.`7JtF'�`'�r7�-��'�•' �u���x �.1� J"� r�`d�,`�r1L�a ��`� .S"a^rc-i 9i'3`x�'` "4+s cr L-��- �. � a�:,�' Kr3�� 1`l�.e, t x-c,r-� a�-��x �,pTM.�,a,.�,,�'�`.�t�`. ..���,<-'�•����'��.,�r'�5r;��r�?-rye'r':r�4.,fid•�. aa���'S��'��rl�i'('JI��k�����,�,��:� g n _... .._,....__..�...� F_,Y:..2.u. x;�ra..w �J'u�i: �> '�, ,rr=`. 5'�+ •a--�� ,ea �"' �-,.,�.. �`�'�' a r.� ,�` --tc� F.a I �"1, - .,-�t•N�r._e.4.ri-„�,� _"C'�'= r-'�°'fr,':::�.�_,'t4'--�>_.`•-..����!a--'��'.,r�wr��"�S `�i��� ��e>"" ;��' " �.���y� DESCRIPTION OF WORK TO BE PREFORMED: e �5 G6�U✓C 0� d/� f l�d�/ j �plc�j of lmc A04057 Identification PIease Type or Print Clearly) OWNER: Name: `3'Ut�V' ..I—Gzc[r r..A Phone: Address: �__-"• ''-.srz`-?er ,�•�`",Fr.. so-'7" sl,.-,•�GPY" °>'z' .u�+, ;s• _ 30 •'7r c•«.tr.? .r Y.+'moi-„ _ Y g+.a`� -��-"r Din r ap9'^ ' `--6 ',�: - '<t; 3x'`-� .t �''m:•#' ..€ FPS,-�ti`.: 'lym "a`.,' •- '•- L'czm$ ,'-.: - -` . �-Y, u a I •a;� w 9 3£: _ at,3•Y^F t i' rr. -t r T Y S,�_1�.. �f ac4_ _ ,e, F • ..`27rt�-• ,.d•.' `} t-:l •trY,3yFc �le�T"':'-:f •3[ f ?,. 1s '. ,I. ,{y.1=timr' F'cs�... -e 7 ��` ,-�, rJ1€Itc `,.,h��n a- :-:ar, �urrYax+ ay;�j s-":I_��,i'ir-C �'�r•:;>},ra., - - ti. W.:�;!qa-m J .Ye ���`�L:��_kti.-•..R,/y.a.15'r.•+1•-,�N..,{.1�'��”'y,F��Y'v���,.Tl"°9l1�'t�''•�uf;t�'Yr��"n`kant�iwr.fi•'I�rli`-i.-J�'��7'""•`?�'AT..;�"Y;"�.:y'lrEN 1000��,•]''1.i"'-I`i-f7%:�4.�y"�t5:,t-'��.��-:„#n,•'.��.-ry�^Y��:";�x�P,'e4lae�..,.- •,',�-'c�y�yr,-`'r'n5t•)r<...�•.,;'-•<r'.r.>•rSw l �r £e!'3,e.,;'rs.,}.-h:�;z•��tgJrC,3^-P,'xT3•'r.­"'^I_x:'��%P•r-��C�_•��7^`����a-"c:•'M1•-•^'"�PS-:�L�.-"-a"A^-•w�-'._r�rs"'•�r+r`�?eI?1. 7i�l„��=v5-x.%'-,�b.;�e_tt`(;d,..'17.i'G�'""��•`r,''�d1�tr'���'•j>"Ya�.�.,a?�,,riI`��'.1-FL�!�'',,.Iy'-�^.:'��l_i.ti. -F y.' ,,,,���� r�,'",�*�Z-l„p-..�x�., - �z:'�-t.�;? tiy, 4-' �T(�z_t.F�i,�v..-,•nf ,-�ru,s ��s,, � � �,. �����-aE�'�•��y y,-�r�.a•}�.�sgt%Si, mss„'�•:�ln msi-t;iwyrr�,�is-�-. :'�`rhR�'8'�• :�p�aa4n_.';�`-�i.., -':.;:$` ,��','� •fF'1 � - '�` ...0 f a.+i.y c `z �^ StY,.i �,. .rr.-;�;n ;:i z:.� ti„dY. , ,rl rtia: ._,,.:�:,•. .:s ��.Y.+rzS cac:%.^ •,ay�Ge}^a:'�3....�el��."•--�'Y'•^t-- 2�? ir'����'�,v, y� F �,,��•...,,"__/Yk � ^,'F.e'ts"'->'' d fC i � � a: 6 •Y's �-r CrJ ci. kYy,l'ri�.'St 4^, £y-"`7':e! .,.,_ `� C ��--.•"' � f]7� ��t}T,,/�av ,nq. T��s.��..�,::��,;,4:; a_,.� xrl�.� .� �r:..e';='t� ��f� z t a�a��:,. �. .�'�'•�s �. ,Y�rAY�`r s:l>.37.Wr-���1?13l? �63Aa,�':J�,Y-. � � -,�� ��yy �..5�'�j .a,,,2r�Jq, .�� �i"t"V.�•7i'r�•�:. ?��E �"�';•ii� :>.�a-ar�ix� .r:� �F; ey%(,.,C'l'T,Y!'rylFl�•a^^•_�:�ti 1 c7, ..>r '�'"n,. 4^.:r,,,. ARCHITECT/ENGINEER Phone: Address: 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: $ 7 s ��y FEE: ' Check No.: Recei t No.:•NOTE: Personscontra ng with unregistered contractors do not 1Ae ace o t eta Iatydyn d ureic#�1nYaruner 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 e'Building Permit Application a- Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses e-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 o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ ivi Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools' �- a 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 11 HEALTH Reviewed on Signature COMMENTS r 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 - 'n..;,._::1: »�iYEi;> =.<`rn.'..i:�i�,:��:.�=;-^":'-.�;ii`r i DNR ir . steno sye es _ - -r_- r 4 =leer , �P ► _ _-: WDA _ a_ r4 s�... .':ave .:l;f .:i?� ✓.YL'i'�'_:. - - _ .., �_ -b1�� _�z..y. ,...._.._:_..w ,_a_......_._..,,1f .•. .�...:�.r.^`_it....-,_ - _ -'L••':;_�ir�•„':`?R!:� sL•ocated.�a� J � _ 4,r_. — - - = - :est•- _ � .�.. .�y. ._ •• '4'•� p - _ i .ark: �S - - _ W' - — . _..........: ..,^._...may t ......�.............. _ - _ _ Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: l t 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 Doe.Building Permit Revised 2010 Location No. Date f NORTH TOWN OF NORTH ANDOVER Rt. ��0�•t`•o �_°,BOO L * ; ; Certificate of Occupancy $ Building/Frame/Frame Permit Fee $ J�cMuse 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2 3 63Y 1Building Inspector Quinlan & Rand Builders 34 Trinity Court North Andover, MA 01845 Tim Quinlan / Jeff Rand 978-457-0528 / 978-457-2698 CONTRACT Customer: John & Colleen Dias 150 Pine Ridge Rd. North Andover MA 01845 Description of work Remove existing clapboards and corner boards. Install new PVC corner boards and trim windows with 5/4 x 4 PVC trim and PVC 1 sub-sills. Install new Tyvek house wrap. Install 6-/4 HardiePlank clapboards pre-finished in Light Mist color. All windows and corner boards will have Vicor water barrier installed underneath. Clapboards shall be caulked with color matched caulking where they butt into windows and corner boards. No work to be done above the top row of clapboards. Any unseen rotted plywood under the clapboards will need to be replaced at additional cost. All debris to be disposed of by contractor. Total cost $ 18,475.00 ` 7 Customer Authorization: _ iv Signatur Dat Quinlan & Rand Builders carries $ 1,000,000 General liability insurance. MA CSL # 55288 HIC # 11108 e �G G� ORTH Tovm of And O No. 7/, _ o over, Mass., O 1. I� COCHICHEWICK V %p�oRATED P'P -`y lel BOARD OF HEALTH PERMIT T Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......... o . .......... . . ,..5...:n.......................................:................................................ Foundation �Qhas permission to erect........................................ buildings on .1,00..........' 1 V. Z'm. ..... ........ "' Rough to be occupied as .....�..r. L.�. .......P LAw.0 ....�.- ..����....... Chimney provided that the person accep iin this perfnit shall in every respect conform to the 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 CONSTRUC N TS 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 Lathingor Wall To Be Done Dry Dry FIRE DEPARTMENT Until Inspected' and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. UW HOME IMPROVEMENT CONTRACTOR'' Registration; 11.. X089 Expiration:`11/25/2^010 Tr# ,,277125 Type,�Partnership` i QQ1NLN;4&RAND,BUIL'DERS a ; , TiMOTHY QIJINLAN _ y 34 TRINITY CT (. N ANDOVER, MA 01845 - a { 4dministratoi- _s`. �9assachu�ctts Boar DeP•tr 1ment d 0f Building of Public Safeti. Construction Supervi tions and Standard License: CS Pervisor License Restrictect to: 00 55288 TIMOTHY R QUINLAN 34 TRI .m NITY CT NO ANDOVER, MA 01845 _ ('�n�nissiuner Expiration: 3/5/2012 ,v Tr#: 22,563 •ri '. xb M '# R..tY�xi fW DATE(MMIDDIYYYY) ACORQ CERTIFICATE OF LIABILITY INSURANCE 08/25/2010 PRODUCER 978,374.6352 FAX 978.521.5127 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION COSTELLO INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 2 South Kimball St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO Box 5248 Bradford, MA 01835 INSURERS AFFORDING COVERAGE NAIC# INSURED Quinlan & Rand Contractors INSURERA: National Grange Mutual Ins. Co 14788 34 Trinity Court INSURER B: No Andover, MA 01945 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' CY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DDIYYYY DATE MM/DDIYYYY LIMITS GENERAL LIABILITY MPS73609 03/12/2010 03/12/2011 EACH OCCURRENCE $ 1,000,000 Eff- X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 500,000 CLAIMS MADE ®OCCUR MED EXP(Any one person) $ 10,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR EICLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION - AND EMPLOYERS'LIABILITY Y/N TORY LIMITS I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE" E.L.EACH ACCIDENT is OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR John & Colleen Dias REPRESENTATIVES. 150 Pine Ridge Road AUTHORIZED REPRESENTATIVE North Andover, MA 01845 Ben Costello ACORD 25(2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD IMPORTANT olic ies If the certificate holder is an ADDITIONAL INSURED,the P Y( )must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s),authorized representative or producer,and the certificate holder, nor does it affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001108) NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 1 OA. The debris will be disposed of in: 14&5e,4) f,9&-t1&tX 57-NMek) (Location of Facility) Signa re of Permit Applicant Date The Commonwealth of Massachusetts Department of Industrial Accidents '<< Ai AUL, 'In Office of Investigations e.? 600 Washington Street F Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �yl�(JL�t"�/ Y�" (�AAO ��(4 6.4 57 Address:. :?L/ T!�t� 17-( 67-t City/State/Zip: N � OUi�dl NA_ 6& Phone#: %�7�/"�q5 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I atn a general contractor and I 6. New construction ployee (full and/or part-time).* have hired the sub-contractors ❑ 2. I am a sole proprietor or partner- listed on the attached sheet. E] Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 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.❑ Other 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. lContractors 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 the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: 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 requited 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 tl a pai s a e ties of perjury that the information provided above is true and correct Si nature: Date: (� Phone#: 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 confinnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of .Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permitllicense 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 pennit 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 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