HomeMy WebLinkAboutBuilding Permit #889 - 158 MAIN STREET 6/19/2013 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0:
Date Received
Date Issued:
I PO TTANT•Applicant must complete all items on this page
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LOCATION '�� .: '��N:� t 9� 11.0Rnn
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i xY*OV111VER
PRORERT_ _ c vno
Pnnt 100�Y.ears - ;Str
'.MAP,Nq:a _P,ARCEL�__ZONINGIDISTRICT:: _HistoncDist`rict� ,yes
• es no:
F. <�Mac{iine,Shop,,Villaget. ..y,
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition El Two or more family ❑ Industrial
i�,Alteration No. of units: ❑Commercial
Others:
,,Repair, replacement El Assessor Bldg
ElDemolition ;;
i
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF-SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ .. Swimming 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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION Reviewed on
Signature
COMMENTS
HEALTH 'Reviewed on Signafure
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes -
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection's
i nafure� Date
Driveway Permit
DPW Tow ]Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yeas no
Located at'124 MainStreet L
Fire ®epaornef t 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
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DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A-F and G min.$100-$1000 fine
NOTES and DATA— (For department ease
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El Notified for pickup - Date
�oc.Building Permit Revised 2010
F
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 i
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
�OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
o Certified Surveyed Plot Plan
o Workers Comp.Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
Li Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
i0TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
o Certified Proposed Plot Plan
Li Photo of H.I.C. And C.S.L. Licenses
o .Workers Comp Affidavit
Li 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
q0TE: 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 app:al 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
Location
No. Date J�
• TOWN OF NORTH ANDOVER
=r`v Certificate of Occupancy $
w Building/Frame Permit Fee o,` $�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
J J J i Building Inspector
i
Enter construction cost for fee cal - North Andover Fee Calculation
Construction Cost
$ 42,000.00 m
$ - $ 504.00
Plumbing Fee $ 63.00
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 63.00
Total fees collected $ 730.00
i
158 Main Street
889-13 on 6/19/13
St. Gregory's Church- Basement Renovation of classrooms, office and hallway
i
2.3 The Owners shall provide and pay for the Builders Risk Insurance required for the Project,
and name the Contractor as Co-Beneficiary-
3.
oBeneficiary.3. Contractor's Responsibilities.
3.1 The Contractor shall be responsible for obtaining the completed Plans and for obtaining all
necessary permits required by governmental authorities in order to complete the Project. The Owner
agrees to pe for or reimburse the Contractor for the cost of the Plans,Engineering and all necessary
permits or application fees incurred to constrict the Project over and above the guaranteed maximum
price.
3.2 The Contractor agrees to use his best efforts to complete the Project.
3.3 The Contractor shall be free to retain any subcontractor or agent whom the Contractor
desires to employ in order to complete the Project.
4. Cost of the Proiect: Contractor's Fee.
The parties agree that the Contractor shall construct the project on a cost basis(cost+10%
mark up+100/6 fee). The Contractor shall be paid his fee with each progress payment received and the
balance,if any,shall be paid at the time of final payment. The guaranteed maximum price including
contractor's fees shall not exceed$42.000.00 except as hereinbefore or hereinafter provided.
5. Changes in the Work
5.1 The Owner may make changes in the work provided that the Contractor shall agree to such
changes. The Contractor shall be paid a 20%Fee on all changes which increase the cost of the work. The
estimated value of each change in the work shall be added/or deducted from the guaranteed maximum
price.
5.2 If changes in the work are required to comply with local,state or federal laws,rules,
regulations or requirements which are not applicable at the time of the execution of this Agreement,the
guaranteed maximum price shall be adjusted to reflect the cast of such changes. Such changes shall
include,by way of illustration and not limitation,compliance with the Environmental Protection Agency
rules and regulations,air and water pollution control or wet lands regulations and other agencies and
authorities.
6. Payment for the Project.
On behalf of the Owners,the Contractor shall submit requests for progress payments. As
indicated in Paragraph 4,each progress payment shall include the Contractor's fee for the proportionate
cost of the Project.
7.A Hazardous Waste.
The Contractor shall have no responsibility with regards to any hazardous waste discovered
on the Property. If the Contractor encounters hazardous waste at any time during the Project,the
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Contractor shall notify the Owners,who shall have the sole responsibility to remove said hazardous waste
at their sole expense. The Contractor shall be entitled to suspend all work on the Project until said
hazardous waste is removed to the satisfaction of all necessary,federal,state,or local governmental ,
authorities. If the Project is suspended due to hazardous waste on the Property,the Contractor shall be
entitled to payment of his proportionate to the cost of the Project up to that time.
73 Ledge. The Contractor will have no financial responsibility within the contract price.
S. Termination of the Contract.
If the Owners terminate this agreement for any reason,the Owners shall reimburse the
Contractor for any unpaid costs of the work due the Contractor plus the unpaid balance of the Contractor's
fee computed upon the cost of the work to the date of termination at Contractor's 201/o fee.
9. Miscellaneous Provisions.
This agreement shall constitute the full and complete Agreement of the parties. Any
modifications or amendments to this Agreement shall be in writing and signed by all of the parties hereto.
This Agreement shall be binding upon the heirs and executors of the parties,and shall be governed by the
laws of the State of New Hampshire.
10. All home improvement contractors and subcontractors shall be registered and any inquiries
About a contractor or subcontractor relating to registration should be directed to:
Office of Consumer Affairs and Business Regulation
Ten Park Plaza,Suite 5170 Boston,MA 02116
Phone:(617)973-8700
11. Arbitration:
The contractor and the homeowner hereby mutually agree in advance that in the event
that the contractor has a dispute concerning;this contract,the contractor may submit such dispute to a
private ailbitratt'-an ce which has by the Office of Consumer Affairs and Business
Re the the to such arbitration as provided in MGLcl42A.
Owner
Contracto
NOTICE: The signatures of the parties above apply on ly to the agreement of the parties to alternate
dispute resolution initiated by the contractor. The owner may initiate alternative dispute resolution even
where this section is not signed Magi*by the parties
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
4
Witness Richard Shahtanian Date
Chairman of the Building Committee
Witness Michael A.Collins Date
DB/A: Michael A. Collins Co
NORT1i
Town of E : ndover
O ti. `
0%
No. -
C% h , ver, Mass, c1 • ��
I A- CCC.11CtlRWIC.
S U
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
THIS CERTIFIES THAT ........��..T....... :.. .. ........................................................................ BUILDING INSPECTOR
S ....'................... Foundation
�C.
I
has permission to erect .......................... buildings on .... G ........�.�..t.:✓ ......
.A� ....Jl..�.� Rough
to be occupied as .. J'M ..."�....... �V
�... chimney
rovided that the erson acce tin this ermit shall in eve res ect conform to the terms of theacationp p p g p ry p 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
UNLESS CONSTRUCTI N S RTS 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.
SEE REVERSE SIDE
Michael A. Collins Co. FED ID#02-0326800
429 North Main Street
Salem,NH 03079
Contractor's License CS 61.961 Home Improvement Tr#149508
St.Gregory Armenian Apostolic Church
158 Main Street
North Andover,MA 01845
AGREEMENT
Agreement made this 20"day of May,2013,by and between Michael A.Collins,d/b/a Michael A.
Collins Co.(the"Contractor"),and St.Gregory Armenian Apostolic Church(collectively,the"Owners").
WHEREAS,the Owners desire to retain the Contactor to renovate and remodel classroom areas and
office space to the existing building located at 158 Main Street,North Andover,MA(the"Property").
becoming the("Project").
NOW THEREFORE,the parties intending to be legally bound hereby agree as follows:
1. SCOPE OF WORK. The scope of work,or Project,shall consist of the following work described
below. Work will start on June 10,2013 and will be complete by September 10,2013.
1. Demolition of existing space.
2. Interior doors —solid birch/with glass.
3. Interior woodwork(white satin finish)
4. Interior Plaster(painted off white)
5. Smoke detector's according to code
6. Carpet @$20 per yard
7. Refurbish existing Hardwood$2.75 per sq(entire first floor)
8. Closets shelves(white vinyl)
9. White bath fixtures
10. Total renovate two bathrooms (1 Ladies and 1 Mens)
11. Remove and replace drop ceilings
12. Remove paneling and install sheetrock
13. Electric to code(by others)
14. Plumbing(by others)
15. Remove all demolition
16. Full cleanup at completion of project
2. Owners responsibilities.
2.1 The Owners shall provide to Contractor full information regarding their requirements for the
Project. The Owners hereby designate Richard Shahtanian,Chairman of the Building Committee as the
person who shall be fully acquainted with the scope of the work,and who has authority to approve
changes in the scope of the work,render decisions promptly,finish information expeditiously,and
execute all necessary documents on behalf of the Owners to complete the Project,including requests for
payment and all necessary applications to governmental authorities.
2.2 If the Owners become aware of any fault or non-conformance in the Project or Plans,they
shall give prompt written notice thereof to the Contractor.
05-31 -' 13 09 ;38 FROM- Crass Ins Manchester 803-841-5082 T-452 P0001/0001 F-894
A MI
CERTIFICATE OF LIABILITY INSURANCE D/31/201IDDIY
5/31/ 3
3
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(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the pollcy,certain Policies may require an ondomement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER NAME: Lynn Blanchard
FIAI/Crass InauranCe PH NE , (603)6159-3218 FAX
1100 Elm Street An RF Q.lblanch&rd@crossagency.com
INSURERPI AFFORDING COVERAGE MAIC 0
Manchester NH 03101 INSURFRA:Tudor Insurance
INSURED INSURER®TYaVelerS Indemnit Co.
Michael A. Collins Company INSURER C:
PO BOX 281 INSURER 0:
INSURER15;
North Salem NH 03073-0281 INSURERF:
COVERAGES CERTIFICATE NUMBERCL1353186271 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,
ILTR TYPE OF INSURANCE AOOLSUER POLICY NUMaFg MOLICYo LIMITS
_LwDGENERAL LIA9ILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAPMI. F e 5 50,000
A Ci1A1MS-MAGE T OCCUR PP809807 6/19/201« 6/19/2013 MED EXP(Any one person $ l0,000
PERSONAL&ADV INJURY S 11000,000
GENERAL AGGREGATE L 2,000,000
G£N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000
% POLICY D PRO LOC g
AUTOMOBILE LIABILITY COMBINED L
Ea aocident
ANY AUTO BODILY INJURY(Per person) $
ALL AUTOS'ED AUULEO
TOSaOOILY INJURY(Per accident) S
HIREDAUTOS AUTOS
NON-OWNED PROPERTYDAMAG
AUTOS Peraaadent S
S
UMaRELW LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAO CLAIMSWADE AGGREGATE $
DED kF NTION S
B WORKERS COMPENSATION 4255P43 I WC STATL H-
$
AND EMPLOYERS'LIA91UV YIN
ANY PROPR19TOR/PARTNER/EXECUTIVE (34.) WK
OFFIC£R/MEMRER EXCLUPED? y N I A E.L.EACHACGOENT 5 100,000
(Mandatory In NH) iahiial Collino excluded 6/13/2012 6/13/2013
If es,deso&6 under
E.L.DISEASE-EAEMPIpY6 $ 100,000
y
DESCRIPTIONOF OPERATIONS betpw E.L.DISEASE-POLICY LIMIT 5 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES (Attach ACORD 101,Additional Remarka Schedule,If more space Is required)
Refer to policy for exclusionary endorsomonts and special provisions.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
St. Gregory's Church ACCORDANCE WITH THE POLICY PROVISIONS.
158 Main Street
North Andover, MA 01845 AUTHORIZED REPRESENTATIVE
bebra Notaalk/BN5 01W
ACORD 25(2010105) ®1988-2010 ACORD CORPORATION. All rights reserved.
INS025 anannn,Q+ Tho ArAAf�namA Anri tnnn aro ranietararl manta of APe)pn
The Commonwealth Of M2SSachusetts
Department of Fire Services
Office of the State Fire Marshal.
=i R 0.Box]025 State.Road,Stow-MA 01775 .
'APPLICATION FOR PERMIT
Date: ej___3U—
N. A n:d o v e r T erm.it'No
TC
__ _1t71ar Town.) (HApplicable) Dig.Safe Numb
In accordanecwith the provisions of NLG-L. Chapter 10 as
provided in Section 527 CMR 34 application is hereby made Start Date
by
(Full name.ofperso Fina or Corporation) 1
State clearly Addmss _L—p �. ,+�cXe✓L
purpose — ! (^� CU �t_�7 .
for " (Street orP_C.Box City orTawn) '
which pemait
is requested For pcmaissioato locate dumpster- for const r t;nn /r nnvat; nn/rlPmnl ; r; nn
of building.
Comments: dumpster must be .25 ` from structure orcove . w
se
(Give location by street and no.,or dcscn cin suchmanncr as,to prov-ied adequate identification oflocation)
Name of competent'operator Cert Na,
(VApplicable)
Datelssucd-rejected By
�� (Signatum off-AD—nlicant)
Date of expimtion ( �� Fr$ 5 0 .0 0 Paid
Th:e -CO.Mmonwenalth o assaeh se
Department of Fire Services
ofl;lce cf the State Fire 102rshal
P.0.Box 1025 Stite Road,Stow,lvL4 01775
PERMIT
North Aadover 'ermitNo Date:
(Cibj of Town) (Lf Applicable) °Dig Safe Number
In accordancz with the provisions of Ivt G L.�4 8 Ghapter�r aspmvidecl in section' S 7 7 (M /� /✓
R 3 4 SL%-t Date
This Pcrmitis granted to:.��� t' fee C,�
Full name ofpetsoo,Firm or Corporation �1/�4 "� SS
Pennissionto locate dumpster . for construction/renovation/demotion of build •
1nb.
COc dumpster must be , 2.51 from structure
Rcsif unable to lace with re wired
trictioas:clearance dumpster must be c% overed with 1 wood or tar2 end ofwork day
at :r
(Give location by street and no.,o*ceiasuc manner s ov}e adequa identification of Iccatio50 .00 Fire Chief
Chis Permit will expire ° t:E"r' ignatur ,ranting permit) Ofzical grantingpcmtit
. - -.. w (Tide)
l£Z wl �au.gss!unnq?
£1,0Z/L/L :uo!lendxg .
£L0£0 HN 'W31VS N {
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1,9619 So :8su031-1
SBu11IaMb Alluae j-OM.L
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sp.trpuriS Pur sualirWa� uq�yn8 s oO P trog
.. 1,t;r.S-)ililnd.l0 auawjiril,)a -st�asnyirssi�iN
EverGreen Environmental Health ft Safety,Inc <a,
Conducted by Associated General Contractors
. of Vermont
Certificate'of Attendance and Successful Completion
Renovator Initial-English Per 40 CFR 745.225
h... Mike Collins
P.O. Box 281
N. Salem, NH 03073
$w Certificate Numbed:
R-1-19630-10-00288
Y.
1.
o�'./�aaoac�uaelta
Office of Consumer AffMrs,&B siness Regulation ,z
TEL
Rn:egisVOool,495U8 Type:
Expindom <4*MOU Individual'
A
_- Or
MICHAEL COLLI.
�¢
429 NORTH MAIN ;
S9 EM,NH 03979 Undersecretary
lcx The Commonwealth o,f Massachusetts , -
Department oflndustriglAccidents
Office of Investigations
600 Washington Street
.Boston,MA 02111
vmmass gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractor8/Electricians/Plumbera
Applicant Information Please Print Legibly
NaMe,(Businessl0rgani'zatio0ndividual):N)►6-wArE-I, 00l,kkwqg �0
PO Box (o AIA 0 �Z3
Address: A�►1UOAR-Ga', b ► ; t) -1�tlllel
City/State/Zip: &] -hF-rn ?3n�aPhone#W) 2 2 _t1532
Aroe y u an employer?Check the appropriate box: Type of project(required):
LLQ
1. I am a employer with 4• ❑ l m a general contractor and 1 6. ❑New construction
employees(full and/or part-time)* have liireathe sub-contractors
2.El am a sole proprietor or partner-
listedon the attached sheet. 7• Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9, [:].Building addition
co
[No workers comp.insurance 5• El We are a tp oration and its 10.E]Electrical repairs or additions
required.] officers have exercised their
3111 am a homeowner-doing all work right of exemption per MGL I LE]Numbing repairs or additions
myself.[No workers'comp. c.152,§1(4),and wehave no 12,[]Roofrepairs
insurance required.]t employees.[No workers' 13.❑Other
comp.insurance required a
Any applicant that checks box#1 must also fill outthe section bel6w showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they Ere doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
l 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.#: ch� 1 �''�� ExpirationDate:
lob Site Address:, pitylstate/Zip: 'MA �t
Attach a copy of the workers'compensation policy Eteclaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby c rte uttrier thepains and penalties ofperjury that the information provided above is true and correct.
Si ature: UQ Date:
Phone#• LD `" S L V-
Official use only. Do not write in this area,to he completed by city or town official
City or Town: Permit0cense#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town CIerk 4.EIectrical Inspector 5.PIumbing Inspector
6.Other
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 ofhire,
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 j oint 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 ofthe
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 Ideal 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 ofpublic work until acceptable evidence of compliance with the insurance
requirements ofthis chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),addresses)and phone numbers)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members orpartuers,are notrequired to carry workers'compensation insurance. IfanLLC or LLP does have
employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retumed 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 ro riline.
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/licenseapplications 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 orpermit to bum leaves etc)said person is NOTrequired 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:
Tho CQMMC) woaltl o S assachl�setts
DepaztYx�extt OfTadustdat Accxdants
• Q�'�ee o�x�tye�ti�atiou� '
600-Was_hlogto.11 Street
BostwMA02111
Tei,#617-72?-4900 est 4O6 Qx Z-g77,:M .SS.AFF,