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HomeMy WebLinkAboutBuilding Permit #115-15 - 1555 TURNPIKE STREET 7/31/2014 BUILDING PERMIT N°DT b qti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION H T Permit No Date Received �gSSACHUs���� Date Issued: I P RTANT:Applicant must complete all items on this page LOCATION -4� *At j � ��b r!J C�' � i�lr{�S � f 3 SSS �c,ur�•�c�1�.,� . z Print �7l8y S-" PROPERTY OWNER,�fb�l e kktzs Z!� jd�Qw 100 Year Structure yes MAP PARCEL: ZONING DISTRICT: _ __Historic District yes Machine Shop Village yes ( TYPE OF IMPROVEMENT PROPOSED USE Resid tial Non- Residential ❑ New Building Ldne family ❑Addition ❑Two or more family ❑ Industrial T19eration No. of units: / ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands q Watershed District ©Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: / ,,,: Iden tificat}' n- Please Type or Print Clearly OWNER: Name: DeZ411cf ikftt, Phone: Address: Contractor Name: e . alb Phone: Address: _/Z i!? _.,A - eX9 __ Supervisor's Construction Licenses DS ��°j5� Exp. Date:_1 Home Improvement License: y. . __ Exp. 'Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ c�l r (���- FEE: $ 3�2• Check No.: f J 0 Receipt No.: ,) —`- NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/__ Signature of contracto Gid x—,k'�A14 W Plans Submitted [�" Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools _ ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ h Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM i PLANNING & DEVELOPMENT Reviewed On Signature_ i COMMENTS CONSERVATION Reviewed on Signature COMMENTS ,HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes i Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: g g Located 384 Osgood Street FIRE D-EPARTMENT - Tem 11 Dumpster on site yes _ �,no _ Located at 92.4 Main Street Fire Department signature/date COMMENTS i I Dimension I 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) II i I ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 IA-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 o 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) j ❑ 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) i d/Building Permit Application d ertified 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 -lydraulic 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 Location No. ` Date l e TOWN OF NORTH ANDOVER o ; Y_ Certificate of Occupancy $ �w Building/Frame Permit Fee $�4 Foundation Permit Fee $ Other Permit Fee $ . a U sr *' ` TOTAL $ Check#A/3 x0 27343 Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 313000.00 m $ - $ 372.00 Plumbing Fee $ 46.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 46.50 Total fees collected $ 565.00 1555Turnpike Street 115-15 on 8/1/14 Kitchen Remodel, 2 Bath Remodels I i r. , NORT►i • . w. .. . . _ c . . ve. o . .......... No. O * , h ti ver, Mass, coc"Ic"awicw y1 A�RATEO PPA�.�y S U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System .. _. THIS CERTIFIES THAT ....... w� BUILDING INSPECTOR .......... I. .. ..�.►.G.......... ..►........... +.... ....�.......................... . Foundation has permission to erect .......................... buildings on .....�. ...T.VA!1q.fA •••. Rough to be occupied as ................C1. ......4.......... ... 11� ... ... .......:..:/•�.�. ...t!.MHC. � chimney provided that the person accepting this permit shall in every respect conform tthe 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 a , PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC N SIC TS Rough Service .......... ... .... ...... .................................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place onthePremises — 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. 12 Pine Ave. Middleton, MA 01949 Date: MM Limas 978-836-6055 7/17/2014 rmdevirgilio@gmaii.com (Owners Name) MA Contractor License No. CS055395 1555 Turnpike St. N. Andover, MA 01845 MA Home Improvement Contractor Proposal/Job Number: (City,State,Zip) Registration No. 147925 07172014 317_.6);;'?0 1 (Telephone-FAX) Second customer/Job address/e-mail Wt-ht-ri-bi propa-zp to himi-sh nll mgterial and equipment and perform all lahor nprpssaW to rnmplt-tt-tht-fbilowing work.* Furnish the construction permit for the"Prospect Mortgage" kitchen, basement and bathroom renovations as outlined in the contract between customer and Goddard's dated 6/23114.Oversee construction schedule and town inspections. Assist customer with the general layout of kitchen design,material purchases,quality assurance of cabinets and finish materials as delivered and installed. The contracting agents full name is Ricahrd Michael DeVirgilio.Richard is a fully licensed and state registered contractor in good standing with the Commonwealth of MA.This information has been made available in accordance with MA general law.All material is guaranteed to be as specified.All work is to be performed in accordance with the drawings and specifications submitted.Any changes involving extra costs be will executed in writing upon signed mutual agreement by both parties wth additional charges noted.All agreements are contingent upon strikes,accidents,schedule or shipping delays beyond our control.Richard is insured for liability and workers compensation as required by law,copies of certificate available upon request Owner to carry all other necesssary insurance.All cancelled material orders are subject to a 10%restocking charge.All special orders are a non-refundable final sale.All work to be completed in a substantial workmanlike manner for the surae of. $1,000.00 (One thousand x)r/100) With payments to be made as follows: $500.00 deposit $500.00 upon final inspection You,the buyer,may cancel this transaction at any time prior to midnight of the third buisness day-After the window for cancellation by the buyer has passed said cancellation shall be deemed a material breach of this contract which entities the contractor to 200/6 of the total contract price.Cancellation without lawful excuse is a violation of the law.It is the obligation of the contractor to obtain all permits,the cost of which have been included in the abovenoted price.the final building inspection shall be called for by the contractor upon reciept of final payment Homewoners that secure their own permits are excluded from the guaranty fund provisions of chapter 142A of Massachusetts General Law.Contractors are required by law to be registered with the Board of Building RegistrationY-0.Box 871 Taunton,MA 02780(508)821-9375. This proposal may be withdrawn if CONTRACTOR- ..... not accepted within 10 days. You are hereby authorized to fumish all material,equipment and labor to complete the work described in the above proposal,for which 1,we,the undersigned agree to pay the amount stated in said proposal in accordance with the terms thereof.Any change involving extra cost of labor or materials will be executed only after submission and acceptance of a written change order.By signing this contract the signatory acknowledges that they are authorized to do so and assume all fiduciary responsiblities for this contractual agreeement Do not sign this contract if there are any blank spaces. Date- OWNER I j AGENT: Date: 01:58 ?M Prospect 203K PAI P. 002 s7 n>sce�r„Farm V&M64 .(975)664-2274 Fa=(978)664-2539 pRWWrMORMAxC`E DEBRA LMAS 1555 TORWM ST -N6FCM AlovEp,mAoI.845 f R4'STAI'I4NS` LABORS KITCHM $40 30YAWOXSMI)CMSTER $S6U F113iYIC�-CO LMM m $I369 ( = r J ITC FLOOR $560� �� $$245 IT'S CA$I3 $1800 $S00 $2340 QRANns !V75 $b44 $875 /H00XUFliBWWA=LII+u - �'RICALIIi13I�IC3/NI�LIGHTIN® . $675 0 - . DRY44� L/PAR-IT $17,325:04 , BA31WOM• 4 ' $564 - $56U :• i Ls3�E3N $7(14 $704 ? T UB I TORSI $400'- -$400 : pL�4'e/INCLUI3 $1004 SM 133A B/fflowm STALL BOOK UP3 ..°'.<.. ICAL.1 DATE LIGHTING $304 $304 S� ; II+LSTATI ATIM/COWL 4 $564 $560 r r DBLULRATH TUR/fflJONRIM STALL I NEW TOILM I SMS $46Q f I?FI.00IRlTLIB S[II;ROYJ 4 $284 wo ACCBSSQRIES ILit3R'M f MIRROBS • 8A4'B�IDOfiJi�(��� $5460 -• 3 pEp32tTAppLIC&ION/PBRIV3TFFE$ $555 • Gp,RAGX3/ O CEI4B WALL/-MAKE`f O ORIORIAL CONDITION $5w REMOM CE.ROOT3�t� MAT 3`�I'I3flOR GAUGE TRIM �0 • R 1tF!R aACI�ILOMN 908 WINDOW CASINO.6 _ FRSC'M/SCRAM/p SAND PAINT C" d DB PUB I MO / RI 0 REAR � '! M()v,RL0wflRLEM $31,€I44.Q@ TOTTAL3zRC Mff Massachusetts -Department of Public Safety Board of Building Regulations and Standatds Construction Supen-iwir �--� License: CS-055395 RICHARD M DEVjRGILiO - - - - 12 PINE AVE NMDLETON MA 01949 `X Expiration Commissioner 11/14/2014 �_ __+`��C�/rc�arirnrurrrnecrrll r f:':�2asaac/r%:ells � Office of Consumer Affairs&Business Regulation OME IMPRt)YI`MENT CONTRACTOR egistrafian: -147925 Type: fj xpiratlon_ 8/23/2015 DBA f DETAIL RENOVATIONS&REMODELING RICHARD DEVIRGILIO 12 PINK AVE MIDDLE-TON,MA 01949 - e Undersecretary 10611 v j - 1 ,t t� „ r tl v ,1�/ ff 24 :; 18" ,� 27 ;1 /+021 1 111 ;/ i A(gtB �V i' i i 2 ;A6 36,t V t i 3�„I V 301, y i t �W18361-1 E'J s l W2736S �. i H00030-2 i t ! U 09R KANG B30RT t _ CO ; INSURANCE BINDER DATE 044/15/14115114YYY, THIS BINDER IS A TEMPORARY INSURANCE CONTRACT,SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM. ` AGENCY 1 COMPANY �IBINDER#� !Utica First Insurance First Insurance Service EXPIRATION 1 11 Whitney Drive DATE EFFECTIVE TIME DATE TIME ❑ AM 03/14115 ❑ 12:01 AM Peabody,MA 01960 03/14/14 ❑ PM ❑ NOON PHONE THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY LAIC No Exit: (978)531-4461 FN No- (978)531-1081 CODE: SUB CODE: PER EXPIRING POLICY* ART5051785-00 AGENCY DESCRIPTION OF OPERATIONSIVEHICLESIPROPERTY(including Location) CUSTOMER to: INSURED General Liability only as a carpenter Richard DeVirgilio I 12 Pine Avenue Middleton,MA 01949 1 COVERAGES LIMITS TYPE OF INSURANCE COVERAGE/FORMS DEDUCTIBLE COINS N. AMOUNT PROPERTY CAUSES OF LOSS ' U BASIC ❑ BROAD ❑ SPEC El Fj GENERAL LIABILITY EACH OCCURRENCE $ 1.000,000.00 COMMERCIAL GENERAL LIABILrrY RENTED PREMISES S 000'00 ❑ ❑ CLAIMS MADE iri OCCUR MED EXP(Any one person S 5,000.00 ❑ PERSONAL&ADV INJURY 5 I El GENERAL AGGREGATE $ 2,000,000-00 ❑ RETRO DATE FOR CLAIMS MADE: PRODUCTS-COMPIOP AGG S 2,000,000.001 VEHICLE LIABILITY I COMBINED SINGLE LIMIT S ❑ ANY AUTO BODILY INJURY(Per person) S F-1 ALL OWNED AUTOS BODILY INJURY(Per accident) S I ❑ SCHEDULED AUTOS PROPERTY DAMAGE S ! ❑ HIRED AUTOS MEDICAL PAYMENTS $El NON-OWNED AUTOS PERSONAL INJURY PROT $ ❑ UNINSURED MOTORIST $ ❑ S VEHICLE PHYSICAL DAMAGE DED ❑ ALL VEHICLES ❑ SCHEDULED VEHICLES ❑ ACTUAL CASH VALUE ElCOLLISION: ❑ SrATED AMOUNT S ❑ OTHER THAN COL: ❑ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ❑ ANY AUTO OTHER THAN AUTO ONLY: I ❑ EACH ACCIDENT S ❑ AGGREGATE $ ' EXCESS LIABILITY EACH OCCURRENCE S ❑ UMBRELLA FORM AGGREGATE S OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: SELF-INSURED RETENTION S WC STATUTORY LIMITS WORKER'S COMPENSATION E-L EACH ACCIDENT $ AND EMPLOYER'S LIABILITY E.L.DISEASE-EA EMPLOYEE S E.L DISEASE-POLICY LIMIT $ SPECIAL General Liability only as a carpenter FEES 5 CONDITIONS I TAXES S OTHER COVERAGES ESTIMATED TOTAL PREMIUM $ NAME&ADDRESS ❑ MORTGAGEE ❑ADDITIONAL INSURED ❑ LOSS PAYEE ❑ I LOAN# ` AUTHORIZED REPRESENTATIVE ACORD 75(2010104) OF Page 1 of 2 ©1993-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD �'� CERTIFICATE OF LIABILITY INSURANCE DA3/20'°>YYYY' 3/3/2019 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($), 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 endomement(s). PRODUCER CxA EpCT Barbara McDonough Gilbert Insurance Agency, Inc. PItoNE Exii. (781)942-2225 FAX NO).(781)942-2226 137 Main Street ArLss:bmcdonough@gilbertinsurance.com INSU AFFORDING COVERAGE NAIC# Reading MA 01867-3922 INSURER A.Travelers Indemnity of CT 25682 INSURED INSURER B-;1beT Mutual Ins. Co. 0030 A & R GODDARD CORP INSURERC: 3 BOW STREET INSURER D: INSURER E NORTH READING MA, 01864 INSURER F: COVERAGES CERTIFICATE NUMBER-CL13101000592 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 ADDL POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DD /YY GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENT COMMERCIAL GENERAL LIABILITY PREMISES Ea oocurn�nce $ CLAIMS-MADE �OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY 5 GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY M PRO LOC $ AUTOMOBILE LIABILITY (Eaa asci ard) E LIMITs 500,000 BODILY INJURY(Per person) !S A I ANY AUTO ALL OWNED X SCHEDULED 36H2384 /10/2013 /10/2014 BODILY INJURY(Per axideli) $ AUTOS AUTOS SED PROPERTY DAMAGEX r,I NON-OWN $ HIRED AUTOS AUTOS Madiaal payments 5 5 000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE b DEO RETEMION B IPJORKERS COMPENSATION I WC SATU OTH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YJN EL EACH ACCIDENT $ 1O0OOO OFFICERAAEMB H)EXCLUDED t N J A (Mandatory in NH) KC231S31. 1865033 /19/2013 /19/2014 EL DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below RD 405 Additional Remarks Schedule,R more space Is required) DESCRIPTION OF OPERATIONS 1 LOCATIONS t VEHICLES(Attach ACO , Evidence of Coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE M Gilbert, CIC/BARSAR ACORD 25(2010/05) 01ga8-2010 ACORD CORPORATION. All rights reserved. INS025 ontmsi m Tiro At'nRn nnrrm anri Innn mra rrania4aroA m�rirc of annan The Commonwealth o•f Massachusetts Department o,ffadusNal-Accz his • . Office o,f investigations 600 Washington Street Boston,.A 02111 -www mass govlcfia wQxl exs'Compensation insurance Affidavit:Bui derigfContractors/Electr icians/Plifi !.bers Apnheant onm.ation Please P xn e bX i Name,(Businessforganization&dividuat): -A.ddress: � 6>C&,- CifylSta�et�ip:��� '®Gd', ��: Phone : $-'�(` Y'' 2 Z 7 y Are yo employer?Check the,appropriate box: Type of project(r�egdred.): 1, am a employer with t _ 4� ❑X am a general contractor and I g• []Now constz�tclzoA f employees(fall andloxpax fine)* haveliiredtho m -contractors ,[] T am.a sola propxietar ox paztner listed on the attached sheet� 7• F]Remodeling ship and'haveno.employees Thesemb-contractoxshave S. [(Demolition workers'comp.insurance. 9. g�� addition working forme in any capacity. ❑ g [Nb workers'comp.insurance 5. Q We axe a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised.theix 3.[� X e a a homeowner doing all wont right of exemption.per MGL 11..[[I'lumbingxepairs or additions Myself Moworkers'comp. c•152,§1(4),andwehaveno 12•[(R00fxepairs insuxancereq red.J? employees.[No workers' 13.0 Otlier comp.insurance required,] Any applicautthat checks box#I must also fill outthe section below showingtheir workers'compensat[onpolicg infounation. Homeowners•who submitihis affidavit indicating they 6e doing allworlc and then hire outside contractors must submit anew affidavit indicating Web, TContractom that cheAthis boy must attached au additional sheet showingthe name ofthe sub.-conEeactors and theirworkers'comp.policy information. Iamanemployerthatisprovicli49WOrkels'compensationinsuranceformyernplopees BeXott�isthepolicyaratijobsite iYz,fv;rmatior2. Insurance Company Name /—/Z2 /; Z policy#or Selz.Ins.Lac.ff: wc- Z� 7 ���tl� k657-09- Expiration.Data: �zv Toll Site.A.ddress' t s^r t l V Citylstate zip: Attach a copy oft eworkers'compensa oxt-policydeclaration page(showing•the policy number and expirafi a elate). Failure to secure coverage as xequiredunder Section 25A,ofMGL o,152 care lead to the imposition of criminalpenalties of a fine up to$1,500.00 and/or one-year imprison m ent,as wallas civilpenalties in the fom�of a STOP-WORK ORDER and a fnte ofup to$250.OQ a day against the violator. Be advised that a copy of this statementmay be foxwaxded to the Office of- investigations ofthe DTA.for insurance coverage verification. doliereby cert u�icler tlielinins and ties ofperjury&at tit information provided above is ftue and eo rect. - si ature: Date: Phone#• v �� Oficial use gnly. .Do not write in this area,to be completed by city or town official City or Tovvxr: Permif/License# Issuing.A.uthority(circle one): 1.Board of Health 2.BuildingJDepartment 3.CityMowu Clerk 4.Electrical Inspector 5.Plumbing Inspector f.Outer - - - Information and Insi°netion - Massachusetts General Laws chapter 152 requires all employers to provideworkers'compensation for their•employees. Pursuait to this statute,an ergployee is defined as",..every person iri the service of another under any contract of hire; express orimplied,oral orwxitten , An employgrjs defined as"an individual,partnership,association,corporation or other legal entity,or anytwo oxxAoxe of the,t6rego7nj engaged in a joint enterprise,and includingthe legal representatives ofwdeceased emplgex,.ox the xedeivex outrusfee of as individual,partnership,association or other legal entity,employing employees. S666vex tha owner of a dwelling househaviagnotmore thantbree apartments and who resides thereb,orthe occupant ofthe dwellinghouse of another who employs persons to do maintenance,consfxuctioa oxrepair work on such dwelling house or onthe grounds orbuilding appurtenant thereto shallnot because of such,employment be deemed to be an employes." 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"Neitherthe commonwealthnor any of its political subdivisions shall enter into any contract for the p erforxmnee ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have b Ben presented to the confracting authority." Applicants Please fail out the workers'compensaiion affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-confractor(s)name(s),addresses)and�honenumbex(s)along with their cerMcate(s)of Insurance. Limited Liability Companies(LLC)orLimitedLiabilityPartnerships(LLP)withno employees otherthanthe members orpartuers,arenotrequixedto carryworkers'compensation.insurance. Han LLIC orLLP does have employees,apolicyzsxequired. Be advised thattbis af ff davit maybe submitted to the Department of Thdastrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. the affidavit should be retumed to the city or town that the application for the permit or license is being requested,not the D ebartment of Industrial Accidenfs. Shouldyou have any questions regarding the Jaw or if you are xequired to obtain a* rkers' compensationpoEcy,please call the Department atfhemnberlisted below. Selfinsuredcompanies should enter their • self insurance Incense number on th.e appropriate line. . City or Town Officials Please be sure thatthe affidavit is complete andpxiated legibly. TheDepartmenthasprovided aspace atthebottom Of the affidavit for youto fill out in the event the Office of investigations has to contactyouxegarding the applicant Please be-sure to fill inthe pexmit/Jicense number whichwill be used as a referencenumber. 7n,addition,an applicant thatm-ust submitmultiple pexmif/Rcense applications is any givenyear,need only submit one affidavit indicating current PORGY information(ifneeessaxy)and under"Job Site Address"the applicant shouldwxite"alllocations 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 applicantaspzaofthatavalidaffZdavit•ison,:Moe oxfuturepemiitsorlicenses. Anew affidavitmustbefilledbut each year.'Whem a home owner or citizen is obtaining a license ox permit not related to any business or commercial ventuxe (i.e.a dog license orpetmit to burn leaves eta.)said person is NOTrequired to complete this affidavit. The Office of Investigations would like to thank you in advance for your coaperation and should you have any ciuestlons, please do not hesitate to give us a call. The Depaxt7ment's address,telephone and fax numb ex: ThQGa on-wtalthorm-anacAv&P-ta Dcpax(Mevt dkdu*ial.Accldmla Office offAv ttgA-00ma BMon,MA 02111 AF Revised 5 2605 Fax#617"727"7749 ' �•�a��,g�•vfdia. •