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HomeMy WebLinkAboutBuilding Permit #633 - 1521 GREAT POND ROAD 4/1/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received / Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print ,.- PROPERTY OWNER SCC Print 100 Year Old Structure yes no MAP NO: 0 PARCEL: ZONING. DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPO ED USE Resi ntial Non- Residential ❑ New Building 170ne family ❑Additi0 11 Two or more family El Industrial ❑Alt= No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands. ❑ Watershed District 11 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: (-, C,(-CCA Phone: Address: CONTRACTOR Name: ' ivjn �---L.,Phone: Address: �'��� ��� yLl St.� 6-�501�11 Supervisor's Construction License: t c ` 1 Z Exp. Date: 10 1-z, Home Improvement License: Exp. Date: t 4 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ (o560 FEE: $ f Check No.: �"� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to r my fund Signature of Agent/Owner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stampe Plans ❑ Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Building Permit Revised 2012 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 DANCER 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 r ❑mea Hot Plan U StamQrPlans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 4 F E OF SEWERAGE DISPOSALSwimming Pools 0 lic Sewer Tanning/Massage/Body Art ❑l ❑ Tobacco Sales ❑ Food Packaging/Sales Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:variance, Petition No: Zoning Decision/receipt submitted yes -.- N Planning Board Decision: Comments Conservation Decision: Comments t th Drivewa Permit -ust be,llVaterr & Sewer Connection/Signature&Date DPW Town ]Engineer: Signature: Located 384 Osgood Street FIRE`DEPARTMFNT -Temp Dumpster on site yes no Located at-124 Main Street Fire Departrnentlsignature/date COMMENTS Location 4S2 No. Date • • • TOWN OF NORTH ANDOVER • . : Certificate of Occupancy $ �" Building/Frame Permit Fee $ . ; Foundation Permit Fee $ �' Other Permit Fee $ TOTAL $ Check# `TJ ,6' <- i 26240 Building Inspector Fully Licensed and Insured • Member of MA Better Business Bureau Member of NH Better Business Bureau �W CDD�D� �5. GAF Cert.ME#20212 HIC Reg#166661 EIN#26-1081508 MA CSL#014728 --T_ Genera/ Contracting, LLC ion -71AWEVL� 51 S. Broadway#2214 Salem, NH 03079 (603) 890-0084 1'0 Stevens Street#141 Andover, MA 01810 (978)475-0095 STL SU ITTED TO � PH E 'DATE EfAAIL CI A ,AN P COD JOB LOCATION 2P. 1 Completely protect the home with tarps to catch falling debris. Respect and protect shrubbery and flower beds. Strip off existing roofing material down to the bare roof deck. Inspect the roof deck for structural defects. Determine the condition of the underlying plywood or boards, and repair and replace as necessary,. Install VZ _7s Sit,/a C,r 1 mechanically fasten with 3.41drill point screws and 3 " stress plates. Install •01210 401`114 b� membrane overhang on all roof edges at a minimum of 1" Install termination bar on all roof edges. Seal memb�ne overhang with lap sealant. Install membrane to roof deck withf�'� Install 3 X ��rXr aluminum drip edge to perimeter of roof. (color) Install all proper flashings to membrane (i.e. cover tape, un-cured cover tape, witches' hats.). Install lap sealant to seal all seams and penetrations. Thoroughly clean up and dispose of all roofing debris on property. Magnetically sweep property for nails. Notes: .5fr: o(4 .SGt; ks F 4a. ` T �ccll� Arc-0 *w�,:FC l0 StG I G.) C t.,.rf{-C k ?C t 4X,, of��n,t c� �O +�n+ T� c�,�S e. ic. 7'_5f01( r P /e- ArCAIT"k, ,_4c•Il Pro S4c 4 ✓SjaHer l� �c r 4e a es. +C4!!, � btr lt;. � �- 44ch riff�' r <orxjkr F/ens�r,�+�y CtOte) . ect c4 }-rect. v i(ANGysEdmunds General Contracting will:• Obtain all necessary construction-related permits to complete this project• Perform work as efficiently as possible without sacrificing quality.• Furnish and install all necessary materials to complete the project. • Provide a thorough clean-up and disposal of all debris generated during pE,dmunds General Contracting LLC agrees.,to commence work on/or about`and desc'�ibed work vvill'becompletedin aboutys. - '' - •--- F. - _ _ _ Product Upgrade 1: b Product Upgrade 2: Contractor's employees are fully covered by workmen's compensation and in enforcing the terms and co f the cont any lien in liability insurance. connection herewith. Upon completion of the above work,all undersigned agree to execute and It is further agreed that this contract may be assigned by the contractor,and deliver to the contractor,their joint note in accordance with his(their)above also that the obligations hereof shall bind and apply to their heirs,successors obligations as requested by contractor.Upon refusal to do so,contractor may or estates of the parties. at its option declare the entire contract price or so much as then remains unpaid,immediately due and payable. It is agreed that,if permitted by law, Edmunds General Contracting LLC guarantees all workmanship performed for contractor shall be paid by the owner(s)all reasonable costs,attorney fees, 495� years.All materials installed are guaranteed per manufacturer's and expenses,in addition to the amount due and unpaid,that shall be incurred warranty. 'Edmunds General Contracting LLC will provide the materials,labor and di osaI to replace up to 64 sq.ft.o 000ff-decking/and 20 it of fascia at no additional cost. Any additional materials including labor and disposal will be replaced at 7�r per sheet or 7 I u✓ linear foot. Edmunds General Contracting, LLC agrees t0 furnish the material and All material is guaranteed as specified.All work to be completed in a workmanlike manner according to standard practice.Any alteration or deviation from above specifications involving extra costs will be executed only upon written labor Om le n accordant: with the above specifications,for the sum orders,and will become an extra charge over and above the stated contract pace:Contractor Is not responsible for /� damage due to high winds,tornadoes,hurricanes,fire or other hazards.Owner(3riig ee to carry fire tomado and other Of d • dollars ($ 411 necessary insurance.Contractor is considerate of owner's landscaping and but due to the nature of the roofing 66Vinstallation some damage may occur,We attempt to minimize any damage,and will not be held responsible If any Payment Terms: f ©�� damage occurs. Contractor is not responsible for any damage to the interior of property,Including pre-existing • Ade deposit Of_ conditions(i.e.water stains,crumbling plaster,exposed nails)or conditions resulting from application of materials as p (no to exceed 1/3 of the total contract)is due specified above.Items in the attic may need toJC1.1nar,,red by the owner.Contractor Is not responsible for damage start of work.The balance of� is due when work is Completed to the caused by ice dam build-up.All agreements a gupon n es, Ccidents,or delays beyond our control. satisfaction of all parties. &S Jot v" • For your convenience we o r ff}E inancing and at,epf al�major credit cards. OK Authorized Signature: / If you elect one of these options we will add an additionajl5%to the contract ., dmunds General Contracting LLC price stated above to cover dealer/merchant fees. Note: This proposal may be withdrawn by us if not accepted within • A finance charge of 1.5%per month(18%per year)will be charged on past due accounts over 30 days days. MCCEtltalICE Of PTOP00af -The above prices,specifications,and 00 NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. conditions are satisfactory and are hereby accepted.You are authorized to do the work as specified.Payment will be made as outlined above. Authorized Signature: Date of acceptance: � ��a /c.�i`f� Authorized Signature: 1 All home improvement contractors shall be registered.Any inquiries about a contractor or subcontractor relating to a registration should be directed to:Office of Consumer Affairs and Business Regulation,10 Park Plaza,Suite 5170,Boston,MA 02116(Phone:617-973-8700). . Owners who secure their own construction-related permits or deal with unregistered contractors shall be excluded from access to the Guarantee Fund provisions of MGL.c.142A The owner will receive a signed copy of this contract before work will commence.The owner has three(3)business days to cancel this contract and Incur no penalty.Correspondence should be directed to Edmunds General Contracting LLC at the above address. Rev.04/11 r',ully Licensed and Insured • Member of MA Better Business Bureau jkopo!6al Member of NH Better Business Bureau GAF Cert.ME#20212 HIC Reg#166661 f EIN#26-1081508MA CSL#104728 LW OSHA 30 Hour Construction Safety Traininggo D EPA Lead Safe Certified 47F �$ �— General Contracting, LLC 4 M 51 S. Broadway#2214 Salem, NH 03079 (603) 890-0084 10 Stevens Street#141 Andover, MA 01810 (978)475-0095 PROP AL SUBMITTED TO PHONE DATE r Z 3 I! 13 TREET E-MAIL v F CITY,STATE,AND IP CODE JOB LOCATION .M,A Tc t<s bur Ll j 61C &, Ser.PA It s.S 4�L, 6 -.1 t�l bCX-,'N S 5+0,U 1 i2G+,,j bi fx4er OLe-C ?1, .1-ro ,� 64e< 4-0 SPnu D L..A' PS F c-� F O Ct l�I,ll �<Ito-(1 A Edmunds General Contracting will: • Obtain all necessary construction-related permits to complete this project. • Perform work as efficiently as possible without sacrificing quality. • Furnish and install all necessary materials to completeithe project. •'Prcvitle a tfiorough�learr-up grid'disposal" ai1ebrrs=g'eri [ed`duriii� t Edmunds General Contracting LLC agrees to commence work on/or about and described work will be completed in about days. Product Upgrade 1: Product Upgrade 2: 0\ r U" Fdeliver 's employees are fully covered by workmen's compensation and in enforcing the terms and conditions of the contract and/or any lien in urance. /1 ' connectiori?herewith. pletion of the above work,all undersigned agree to execute and It is further agree.d1hat this contract may be assigned by the contractor,and the contractor,their joint note in accordance with his(their)above also that the:obligations hereof shall bind and apply to their heirs,successors s as requested by contractor.Upon refusal to do so,coritractor may or estates of the parties.n declare the entire contract price or so much as then remains unpaid,immediately due and payable.It is agreed that,if permitted by law, Edmunds General Contracting LLC guarantees all workmanship performed for contractor shall be paid by the owner(s)all reasonable costs,attorney fees, 2-5—years.All materials installed aro guaranteed per'manufacturer's and expenses,in addition to the amount due and unpaid,that shall be incurred warranty. 'Edmunds General Contracting LLC will provide the materials,labor and disposal to replace up to-64 sq.ft. f r of decking .2o ft of fascia of no additional cost. Any additional materials including labor and disposal will be replaced at, 71D per sheet or Y linear tibt. Edmunds General Contracting, LLC agrees to fu nish the material and All material is guaranteed as specified.All work to be completed in a workmanlike manner according to standard practice.Any alteration or deviation from above specifications involving extra costs will be executed only upon written I. labor complete in accordance with the above specifications,for the sum orders,and will become an extra charge over and above the stated contract price..Contractor Is not responsible for J s .� damage due to high winds,tornadoes,hurricanes,fire or other hazards.Owner(s)agree to carry fire tomadd-and other of J"r4 PvNIWJ ->�_..�,dot b dollars($ �� necessary insurance.Contractor is considerate of owner's landscaping and but due to the nature of the roofing 7 installation some damage may occur.We attempt to minimize any damage,and will not be held responsible if any �v"/ao /"C�] damage occurs. Contractor is not responsible for any damage to the interior of property,Including pre-existing Payment Terms: 17�J,Q conditions(i.e''.water stains,crumbling plaster,exposed nails)or conditions resulfing from applicatlon of materials as specified above.Items in the attic may need to be cgqvvered by the owner.Contractor isnot responsible for damage • A deposit of X(not to exceed 1/3 of the total contract) is caused by ice dam build-up.All agreements a contiAgent upon strikes,acct ants,or delays beyond our control. due upon start of work.The balance of ZOO r9� is due when work Authorized Signature: �^ is completed to the satisfaction of all parties5,xt, dm lids General Contracting LLC • A finance charge of 1.5% per month (18% per year)will be charged on Note: This proposal may be withdrawn by us if not accepted within past due accounts over 30 days days. 07ea ce of propozat -The above prices,specifications,and 00 NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. coe satisfactory and are hereby accepted.You are authorized10-do y�� t thpecified.Payment will be made as outlined above.., i �`yAuthorized Signature: :2l/L�iS/t f ^^� �/aTf !Deptance: -T /;2t J / Authorized Signature: t T' All home Improvement contractors shall be registered.Any inquiries about a contractor or subcontractor relating to a registration should be directed to:Office of Consumer Affairs and Business Regulation,10 Park Plaza,Suite 5170,Boston,MA 02116(Phone:617-973.8700). Owners who secure their own construction—related permits or deal with unregistered contractors shall be excluded from access to the Guarantee Fund provisions of MGL.c.142A ' 1 5'he owner will receive a signed copy of this contract before work will commence.The owner has three(3)business days to cancel this contract and Incur no penalty.Correspondence should be directed to Edmunds General Contracting LLC at the above address. Rev.04/11 f NORTH F Town of 6Andover No. Cz LwK, h ver, Mass, RA COCKICHIWICK ORATED S V BOARD OF HEALTH Food/Kitchen PERMIT LD Septic System 6 0 THIS CERTIFIES THATVia... ,,, BUILDING INSPECTOR ..........VhA .......... ...... ...... ........... Foundation has permission to erec .. buildings on .. _r Rough to be occupied as ....... ..... /. . ... . ... ... ........... ......... ...... Chimney provided that the person accepting this pe 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 MONT S ELECTRICAL INSPECTOR UNLESS CONS TRU S N TS Rough Service .......... ........ ............. .................. Final BUILD610 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 L EDMUN-1 OP iD: DM DATE(MMIDUNYYY) CERTIFICATE OF LIABILITY INSURANCE 0312912013 HIS 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(ie9) 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 endomemen s. CONTACT PRODUCER Phone:603-890-6439 NAME•: Planri ht Insurance-Salem PHONE AIC No E-MAIL 224 Main Street Suite 3C Fax:603-890-6621 IC r Salem,NH 03079 ADDRESS; James A Santo INSURERS AFFORDING COVERAGE NAI(g INSURER A:St Pahl Sur lug Lines Ins Co INSURED (Edmunds General INBURPRH.Riverport Insurance Com an 36684 Contractor LLC INBURERC: PO Box 2214 INSURER D! Salem,NH 03079 INSURER IE= INBU ERF COVERAGES CERTIFICATE NUMBER: 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, TYPE OF INSURANCE POLICY NUMBER CLI Y MMl NYYY LIMITS DEN 1 000,00 GENERAL LIABIIJTY EACH OCCURRENCE 8 � COMMERCIAL GENERAL LIABILITY 8091281 11111/2012 11/11/2013 p EMIBEB occur ce $ 50,00 CLAIM9�IADE r OCCUR MED EXF(Any one person S 5,00 PERSONAL6 ADV INJURY $ 1,000,00 - GENERAL AGGREGATE $ 2,000,00 PRODUCTS-COMPIOP AGG S 2,000,00 'L AGGREGATE LIMIT APPLIES PER:POLICY PRO, LOC COMBIN SINGL 'MIT AUTOMOBILE LIABILITY Es ac'dan BODILY INJURY(Per pereon) S ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ALTOS NON-OWNED PER AMAG g HIRED AUTOS AUTOS Pera idem $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LMB HCLAIMS-MADEI AGGREGATE S DEP RETENTION Wt STATU- I OTH- WORKERS COMPENSATION X TLIMI AND EMPLOYERS'LIA6IUTY100,000 B ANY PROPRIETORlPARTNERIEXECUTIVE YIN Vycass3000az6oa 0410312012 04103I2013 E L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A 3A NO00,000 (Mandatory inNHl E.L.E.LDISEASE-EAEMPLOYE6 S Ifes describe under E,L.DISEASE•POLICY LIMIT DESCRIPTI N OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VF141GLES (Attach ACORD 101,Addlticnal Remark:Sehedula,If more space is raqulred) David Edmonds is excluded from workers Compensation cove-rags Town of North Andover - fax f1978-689-9542 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE VALL BE DELIVERED IN ACCORDANCE WTH THE POLICY PROVISIONS, Town of North Andover Attn: Building Inspector AUTHORIZED REPRESENTATIVE Osgood Street North North Andover, MA 01845 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010/05) The ACORD name and logo are registered marks of ACORD r" Massachusetts- Deportment of Puhli' Safet% Board of Buildim, Re-ulations and St:utdards Construction Supervisor License License: CS 104728 DAVID EDMUNDS P.O- BOX 2214 SALEM, NH 03079 Expiration: 10/3/2013 ( unmis�ionvr Tr#: 104728 �dl>Lr1za77dceCYl/�a/U!•GpJ1<ccfLUJe/Yd Office of Consumer Affairs&Busifjess Regulation _ OME IMPROVEMENT CONTRACTOR 'egistration: 166661 Type: xpiration:- ,6/21/2014 Corporation EDMUNDS GENERAL CONTRACTING,LLC. . DAVID EDMUNDS .18 ASHFORD RD HAMPSTEAD,NH 03841 Undersecretary } 1 l / The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information �Please Print LeLyibiy Name(Business/Organization/Individual): Address: Pe 0 I ( >e,4 City/State/Zip: 5a., �)� Phone#: G 3Q5 --7 7 3 ��M I,re�Ya- n employer?Check the appropriate box: Type of project(required): I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors El am a sole proprietor or partner- listed on the attached sheet.# ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers' comp.insurance. 9 y p t3'• F1 Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions ❑ I am a homeowner doing all work right of exemption per MGL 11.0 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' 1311 Other comp,insurance required.] iy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. `ri iin employer that is providing workers'compensation insurance for my employees. Below is the policy and job site brmation. I urance Company Name. � .icy#or Self-ins.Lid.#: 1,;t L- L,5 Expiration Date: C Site Address: City/State/Zip: GA 15 ;ach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 >p to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of estigations of the DIA fo surance,coverage verification. hereby certify ainde a pai s d e ald s ofperjury that the information provided above is true and correct. nature: Date: ine 01D ?L ?fficial use only. Do not write in thi area,to be completed by city or town official. �ity or Town: Permit/License# Issuing Authority(circle one): .Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector �.Other 'nnfarf Parenn• Phnnr ft• 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. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business oT 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. he 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 Rax#1 F17..7?7.,7749