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HomeMy WebLinkAboutBuilding Permit #234-15 - 1504 SALEM STREET 9/4/2014 BUILDING PERMIT NORTH .pFSt�eo bgti0 TOWN OF NORTH ANDOVER N� .6 0 APPLICATION FOR PLAN EXAMINATION 3 _<� * Q .� Permit No#: Date Received �q,T.0 0ey gSSACHU`��� Date Issued: /9 I P RTANT: Applicant must complete all items on this page LOCATION -Sm-&7 int PROPERTY OWNER = _ Print100 Year Structure yes no MAP PARCEL:4 _ZONING DISTRICT: Historic District ye no _ - - Machine Shop Village ye, no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑Addition ❑Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septic ❑Well Q Floodplain ❑Wetlands ❑ Watershed District t Water/Sewer I- DESCRIPTI NOF WO K TO BE PERFORMED: I I 1SK &JOWCAg cASiy6 CMA6 f &S6✓6JT ON/WA� 6 SYS. 514/s/' Z x 2 /fT ? 2 ~ R00,M ry Y-46P r95 .g 6QZ nation- Please Type or Print Clearly OWNER: Name: S/6wK_ Phone: ?74? ZS Address: /S(x/ -ifC45015n Contractor'Name:Z Phone: -XI-771 7q4_7 Address: (96> `S�W#igr KG/M �/�/IUa✓��" �2(�� qfG - Exp. Date: .-/ Supervisor's Construction License _ v — Home Improvement License: l 7�3 - _--_ Exp. Date: /."Z_&s ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00�i00 PER$1000.00 OF THE TOTAL ESTIMATED COST fBASED ON$125.00 PER S.F. Total Project Cost: $ ZO�• FEE: $ `�T`T •� Check No.: Receipt No.: al 9 g Z-, NOTE: Persons contracting nregistered contractors do not have access t the uaranty fund Signature o Agen Owne __ Signature of contractor 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/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 i ❑ 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 Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer 7 Tanning/Massage/Body Art ❑ Swimmning 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on % y Si natur� r COMMENTS - HEALTH Reviewed on Signature COMMENTS 1i Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes 1 e i Planning Board Decision: Comments I 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 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) E i i ❑ Notified for pickup Call Email Date Time Contact Name I Doc.Building Permit Revised 2014 Location Iso 4 < 7--77 J. No. Date /1 f e - TOWN OF NORTH ANDOVER+ n Certificate of Occupancy $ Building/Frame Permit Fee WI /Foundation Permit Fee $ Other Permit Fee $ {/ ATED TOTAL $ Check# Y 27 9 82 "'"''wilding Inspector Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 283686.00 m $ - $ 344.23 Plumbing Fee $ 43.03 Gas Fee 100 comm. $ 100.00 Electrical Fee 43.03 Total fees collected $ 530.29 1504 Salem Street 234-15 on 9/4/2014 Finish Basement I I FORTH own of ndover 0 No. 13+ 115 soh ver, Mass, COC NIC N(WICN S V BOARD OF HEALTH Food/Kitchen Septic System THIS CERTIFIES THAT .....PERMIT 4►... . .......S .. . .. .................................................. BUILDING INSPECTOR has permission to erect ........... buildings on �. :......:. ........... ... .! . .. .... Foundation 2040 Rough to be occupied as ................. .. . ...... .........................�... � ... �"�Cs1....�.L�1,dp. Chimney 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 3 UNLESS CONSTRUC ON ARTS Rough Service ......... ..................................................................... Final BUILDING INSPECTOR 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. 'he Cozmnonweaft o•f il2"assaeh.aseft - - .�eprx.��ieniof�ic��cst�rt�lAccrc�en� Qfflee o•f:�mAgafeons 6#0 WashineonSireei .Roston,MA 02111 www rnassgovIdxa �x ex 'tCompe a o a n a ce A xc avz :SuiXc erg ICorn�xac oxo Mlectre planm11'Ziii bexo AppligantWormafta Please PAntLe m Name(Brisiaess[orgeniaatioailSnd%vidiaal}: Address: �� ���H!v» /Z Phone 4:, fl 2/ !� Are yoemployer?Cheektho wropxiatebox: 'Type ofprojeet(re%lure(1}: 1• emploper with 4S s 4. El Z am.a general contractor and I 6. []ZO661:9 Onc&A employees(fullancT(axpazfifne)•T have hiredthesu�b-confracfors 2.[l I am a sola proprietor or partner listed on the attached sheep T `�• ship and`havena•employees , These sub confxactoxs hava 8. �[Demolition working f'ox me in any capacity. workers'comp.insurance. S. ❑Building audition [Na workers'comp.in.suxance 5. ❑We are;a corporation and its 10,f]Electrical repairs or additions e o�xcexs have exercised.vheir re d.� e "s o ad "`ons ri ht ofexam tion erMGL 11".[�Plumbangx parr x dztr 3.❑ I am a horn eowz U doing all work g p p myself[go workexs'comp. G.152,§I(4),andwehaw no -2.P2.0ofxePairs irtsurar[cere ed. employees.[No workers' 1311 Ovliex comp.insurancereguireQ Atiy applicanithas checks hox#Z musEalso X511 ouithese�tion belo�rshovringtlieirvrorkers'compensationpolicy znfomafion. Homeownerswho submitthisafEtdavitind�cafingihey2zedoingsuworT andthenhireoutsidecontractorsmustsuhmitanentaffidavitindica5ngsuch. xCon-k'acforsihatcheckfhisho�mustaftachedanadditienalsheetshov,�ingthenameo�thesub-confracforsandtbei�v,�orkers'com�r.poHcpinformaizon, _Tim an exnpr�y�N t�icciisp�avzdi�tg luo�ker�'eornpe�z�at�an ksufan four y ex�loyees; �etow i���ie�oliey ar2cija�,�z�`e ire,folrnation. Insurance CormpanyNama Policy#ox Self ins.Idc.#; �C� 2�'7/� Expiration Date: ,U d'ob Site Address,— I S Y � l JJ'� CitylS�ate/Zip: Af �11✓Z`'� Attach acopy a the woxkers'comp ensafionpolicycleclaxafzonpage(show.iug•tAepoNcynmuherand expiraVondate). yailum to secure coverage as xegmeclmder Sectlon 25A.of MOL o.152 can.lead to the imposition of criminal penalties of a �,e up to$1,500.00 and/or ow-ye hnpxzsonment,as well a;civilpenalties in the tom.ofa STOP WORD ODDER.and a.fmG ofup to$250.0 Q a day againutthe violator: Be advised that a copy ofthis sfatern,entmay'be foxwardedto the Ofece of Tnvestigaffons of:the DIA.for ihman.ce coverage ver%fication. x do hereby ee.'a e�tl pa r2 ci er2aXtie�ofperja!ly dirt#ile in ormation provided above%�true a d eormet Simature: Data., Thon.e# 72 w/ Z l UIJ�iD ofciazage mly, Vo not wrife in triis area,to be conwleted by city or town ofcial: City or Town: Fermzfl.Oicense f DsuingAnthority(circle Mae): 1.l30ard Of]ffealfh I.BuilcliugJ)eparfinent 3.Cityf owzt Clerk 4.Eleefxicalxuspector 5.Plumbing Inspector f.Whex - - information and Instructions . - Massachusetfs General Laws chapter 152 requires all employers to provide Wo comp ensation for them employees. ..pars-aa to this statute,an employee is defined as"...everyperson iii.the service of another under any coxilract of hire; • express or implied,oral oxwxitten." . .An er�loyei%j�defnred as"an individual,paz-tnexshi-p,assoczaizon,corporafiorx o�otliexlegaX er�iity,ox anyflvo oxnzore, , of-the Foregoing engaged in a joint enterprise,and includingthe,legal xepxesentatives ofa'deceased emplg ex,.ox the receiver ox-i i ee 6faa ludivldual,partnership,association or other legal entity,employing employees, h oWevex th'e ownero.iadwellinghousehaviugnotmoxethaatbreeapartmentsazldwhoresidesthexei�z,ortheoccupant 0VO dwelling7iouse of another who employs persons to da maintenance,.constaOtion orxepair work on,such dwellinghouse or onthe grounds oxbuilding appuxLenant thereto shallnot because"of such em: loyment;be deemedto be an employer:" MGL chapter 152,§25C(6)also states that"every state or to cal lic-e6sing agency shall�vl ilZold the issuance or renewal of a license or permit to operate a business or to constrict buildings xnthe commonWealtlx for any applicant vvho has not pro duced.acceptable evidence of compliance with.the uzguran.ce'covoxagaeuzrecl;' Additionally;MGL eha�tex 152,§,25C(7)stafes"Neither the commonwealth nor any of its political sureq uirea.sha11 entexinto any contxactfoxthe performance ofpubiicworkuntil acceptable evidence of compliance with,the ins-axance requirements ozthis chaptexhave beenpresented to the contracting authority." A pplicants - Meas,pFU out the Workers'compensation affidavit completely,by checldng the boxes that apply to your situadon and,if nocessaxy,supplysrrb_contractox(s)name(s),addxess(es)and phone numbers)along with theft cermcate(s)of insurance. Limited Liability Companies(LLC)or Limited LiabxiifyPartnerships(LLp)with no employees otherihattthe members or partners,are,notrecluiradto carry workers'compensationiasurance. LanLLC oxLII'doesh of employees,apolicy is required. Be advisedthattbis of idavitmay be submitiedto theDepartment of Industrial Accidents fax confirmation of insurance coverage. Also b e sure to siga and date the aif~Zdavit. ite affidavit should b e xefuruedto the city or town that the application fox thepemut or license is being requested,riot the Department or hndusfrzal.Accidenis. Shouldyou have any questions regarding the law or if you are xeguixed to obtain,a*orkers' comp ensatioapolicy,Please call the Department attbemtmberlistedbelot . Sel-insuzedcompanies skouldouter their sal-Rusurance Rcense number on the appropriate line. City or Town Mcials l'Xeasabesurethat'cbeaz,zclavifiscompleteandpxintedlegibly. The,Departm.enthasprovicledaspace atthe,bottom ox the a'Edavit fox you to ill out in the event the Office of hnvestigations has to contactyOu regarding the applicant. Please be-sure to n1l in the permit/license number which Wi11 be used as a xefexence number;.In addition,an applicant thatmust submitmultiple ermifJlicensa applications in any givenyear,need only submit one affidavit indicating current policy iufomiation,(Xnecessazy)and under"J'ob Site Address"the applicant should-wAte"alllocationsin (city or town),Acopyoh"hoaf davit'th.a:Ehasbeenofficially siainpedormarked bythecity ortownmaybepxovidedtothe applxeantasproof that avalidafczdavitzsonfde ori5ifurepexmiisorlicenses. Anew afddavitrnustbefclledbut each year.'Whare ahome owner or citizen is obtaining alicense oxpexmitnotrelatedto anybusiuess or commercial ventuxe (i.e.a dog license orpermit to bum leaves etc.)said Person is NOTxo p hod to complete this affidavit. The Office of hnvest gations would like to thane you i a advance For your cooperation and should you have any questions, please do notho4tate to give us a call. `h'he.DepaxEment's address,telephone and fa�numbex: T)P aTxreUt QfTWJ-aaWaJ Acolde to Otte o_'Tn•VmR attain - 6b 0n Q e#40,6 Q-1-87%"OAFE Revised 5-26-OS 617M7-7749 www-MangovIchia A�R>D® CERTIFICATE OF LIABILITY INSURANCE DATE(MM ONYYY) N`''� 5/28/2014 THIS CERTIFICATE IS ISSUED AS A 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 ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be 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). PRODUCERAC NAME F. COrdarO Andrew G. Gordon, Inc. PHONEjAr (781)659-2262 Fax (781)659-1725 306 Washington Street "AIL .bill@agordon.com INSURE AFFORDING COVERAGE NA1C# Norwell MA 02061 INSURER APeerless Insurance 4198 INSURED INSURER B R11 ri:m Insurance Co=any 21750 Lux Renovations, LLC, INSURERC:Star Insurance Company 8023 60 Shawmut Road INSURER 0: INSURER E c Canton MA 02021 INSURER F: COVERAGES CERTIFICATE NUMBER:SAMlPLE 052814 REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER IWDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO PREMISES R o TE15 ce $ 100,000 A CLAIMS-MADE OCCUR 8512851 /5/2013 /5/2014 MED EXP(Any we n) $ 5,000 PERSONAL>IADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ 2,,000,000 nX POLICY jPERPT El LOC $ AUTOMOBILE LIABILITY BINED SINGLE OMIT 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED rv--1 SCHEDULED GC10007161409 /17/2014 /17/2015 AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED SWNEDAUTPPROPERTY DAMAGE unInwred mtttorist BI rmffi $ XI UMBRELLA UAB HOCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS UAB CLAIMS-MADE AGGREGATE $ 1,000,000 I DED i X I RETENTION 10,000 =8511953 /5/2013 /5/2014 $ C WORKERS COMPENSATION WC STATU- OTH AND EMPLOYERS LIABILITY YIN X ANY PROPRIETORIPARTNERIEXECUIIVE OFFICEFUMEMBER EXCLUDED? 0 N I A EL EACH ACCIDENT $ 1000000 (Mandatory tri NH) 428715 /24/2014 /24/2015 EL DISEASE-EA EMnO $ 1,000,000 IF yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS i LOCATIONS/VEHICLES(Attach ACORD tat,AddiBorml Remarks Schedule;H more apace is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE W0.L BE DELIVERED IN Lux Renovations, LLC — SAMPLE ACCORDANCE WITH THE POLICY PROVISIONS. SAMPLE SAMPLE, MA 02021 AUTHORIZED REPRESENTATIVE F. Cordaro/CO$WIL � WiLyq.:�„ �%1srzx%ti! ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(2olom).oi The ACORD name and logo are registered marks of ACORD Office o Consumer A airstBusmess &gul�atio n 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 /'lYvh\ Home Improvement contractor Registration Registration: 137943 Type: Supplement Card OWENS CORNING BASEMENT FIN]S`.ffN f� - Expiration: 1/29/2015 DANIEL WALSH _' 60 SHAWMUT RD CANTON, MA 02021 ` ' Update Address and return card.Mark reason for change. SCA 1 is 20M-05/11 Ty+y{ Address [] Renewal M Employment Lost Card �e c0anvnzoovcueal�a�Cac�ivaeGto ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation egistration:-_137943;-=. Type. 10 Park Plaza-Suite 5170 Expiration _ i29120f5: Supplement ":ard Boston,MA 02116 Y' OWENS CORNING+BASEMENT FINISHING SYS DANIEL WALSH 60 SHAWMUT RD ' CANTON,MA 02021 Undersecretary Not valid without signature Massachusetts _ Department of Public Safety Board of Building Regulations and Standards Construction Supen icor License: CS-079893 ter:rr.ti DANIEL F WALSjt -- ' 488]KENDALL RD TEWKSBURY WA 0�` Expiration Commissioner 10/05/2015 MI�.. y Ell 31�i��3Gs � �o� Date. . . . . . .`. �,�,OW O NORTH 1 TOWN OF NORTH ANDOVER ai ,��o ,•�y0 3j �•t,f ... OL o PERMIT FOR PLUMBING ��x s _ a SSACHUS� This certifies that . . . . . . . . . . i has permission to perform . . . . . . . .'. .'- ---. . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . .0 y. .� 5 ...,.-�.- . . . . . .,North Andover, Mass. Fee.1� .Lic. No/<�C1L�5� ! . . . . PL'UMBv G INSPECTOR Check # �' 6 8582 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,.MASSACHUSETTS Date �+L Building Location y S q-�m '>T- (7-- ZL-7 ZU/,L>Permit00, # v` Owner Amount New ❑ Renovation Replacement Plans Submitted Yes No FIXTURES SUB M B4SU*W >ST)�DQt IID�2 2 3MROOR 4M EWM Rt1r. , 6WHOM 7M E[DM - SIH Hrm Iniint or )Company /�6/✓1 L,V-S�is Check one: Certificate � InstallingCom Name Corp. Address 7 ' d;F�irrm/Co. �Q htt e(�S /UAC- Business Telephone Name of Licensed Plumber: 6 vY) Insurance Coverage Indicate the of 4surance coverage by checking the appropriate box: Liability insiugnce policy ET Other type of indemnity ❑ Bond Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the j best of my knowledge and that all plumbing w and tallations erf, ed under p -t Issued f this application will be in compliance with all pertinent provisions of e Mas =tts S PI Co g ter I the Goeeneral Laws. By. uIre o ceps noer Title ype of kumb- License Q City/Town icense umoer APPROVED(OFFICE USE ONLY Master Journeyman / " The Commonwealth of Massachusetts Department of Industrial 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 Lea►bly Name (Business/Organization/Individual): Address: P-6- f!y City/State/Zip: �q,4,va-v> MA_ Phone Are you an a ployer?Check the appropriate box- 1. Type of project(required):❑ I employer with 4. ❑ 1 am a general contractor and I ployees(full and/or part-time).* have hired the sub-contractors 6. ❑Nejw6onstruction 2. 1 am a sole proprietor or partner- listed on the attached sheet 7 emodehng 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. 9. Building addition ' p ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 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.] 13.0 Other Any applicant that checks box Y1 mra ust also fill out the section below scow• i:.e_a v✓a �,' mY rsation policyinformation- Homeowners t who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box 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. Belo w is thepolicy andlb information. site Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: ` Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declarat_iOn 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. Ido he certify lldeP-the p s penaltie f perju that the information provided above is ue and c rrect Simature: 2 2 G f Date.: Phone#: Offic' us 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 b. 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 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 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 Inv-estibations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax #617-72.7-7749 Revised 5-26-05 vArvvu,.mass_govt dia