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HomeMy WebLinkAboutBuilding Permit #847 - 179 HAY MEADOW ROAD 5/30/2012BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: 30 " iJ-" IMPORTANT: Applicant must complete all items on this page LOCATI PROPERTY .OWNER h� MAP NO:/� PARCEL: •.7� �i•U -Prin ING DISTRICT: Historic District Machine Shoo Villaae yes, TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential . y TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Ad l ' Two or more family Industrial Alterati No. of units: Commercial epair, replacement Assessory Bldg Others: Demolition Other 'Septic Well Floodplain . Wetlands Watershed District 'Water/Sewer OWNER: Name: Address: .1179 DESCRIPION OF WORK T E PREFORMED: r Identification Please Type or Print Clearly)7 / alS Phone: � f 0-4t-�_ CONTRACTOR Name -e.. Phone: f7s_ Address ./wta,� :�.o l.�/yz✓`� Supervisor's Consrf u`cc on Li — /t7� -7 Exp. Date: Home Improvement. License:. e!!!�/ ��S"� a Exp. Date:. ARCHITECT/ENGINEER�'"�-- Phone: Address: Reg. No FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ J���� 0FEE: $ U CJq Check No.: Receipt No.: C�l s 3� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor 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 PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIREMEPARTMENT Temp Dumpster onsite yes no Located,at 124 Maim, treet 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 NU I is and [JAI A - (For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 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 �hoto Copy Of H.I.C. And/Or C.S.L. Licenses ❑dopy of Contract oor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products NOTE: AI 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) o 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 submitted with the building application Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location/ e, [Me 4 Check #AZ411 25339 Date �) - -1.10 - /C>4— TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL $- Building Inspector . ® W O fZ v U) U ° n p w O r2 v .� U C w a W p � G x x W " W inn p w' J) r. it O mon O w p x W W v N O m O z, �� U)cn �] e O G c o F `o c C', = : O C cc o t7 iscc.: A s o CD � 4- c L--` oCD o r: .0 CL (� �o o c , C2 0 V Q1 • b 4 y = Cf) CO2 cm O y C C � •fl fl m . yCc, o 0 �y 0 CD o C U) EDw Cm t•E oo� m P-4 :ca a•y o . c�Z o :coo C _ ® o c M o. y m H m COD D r fir'cc �rA cm• C.3 CD CL. C2 Z v s D E� m y o C O F- a f 4-4 ts a� o, C _ C y C h m m � C3 CD H CL.�..� CD a2 cm CDOL o a d. C? C y — 'C C CcC C.3 -j '0 "FL C3 G3 ca X C G3 V CO) � C is uj 0 M/ LU Y/ W LU 09 W U) 44 ti I Proposal Twomey & Legare Contracting Inc. Building & remodeling 87 Belmont St. North Andover Ma. 01845 Phone 978-685-7447 Fax i-4-685-7446 To: George & Michelle Tagarelis 179 Hay meadow Road. No. Andover Ma. 01845 978-685-9155 Exhibit B March 29, 2012 Thank you for the opportunity to quote the following project. The TWOMEYAND LEGARE CONTRACTING price is based on our discussion on June 16, 2011 concerning your project at the above address. The following is a description of work as discussed. • Renovation of new kitchen 1. Demo- strip drywall from ceilings and walls in kitchen area and Rip up floor to sub floor. Also floors in back hall and foyer. 2. Remove wall next to fridge, closet walls and opening to living room. Living room opening Size will be determined when demo is complete. Remove 3 foyer closet doors. 3. Insulate exterior walls to code and insulate wall that backs up to bath for sound. 4. Wire new kitchen to code. 5. New appliances by owner. 6. Frame opening for new kitchen window. Close in slider opening for a new doorway. 7. Blue board and plaster on ceilings and walls. Smooth walls, sand swirl ceilings. 8. Install new cabinets. Cabinets by owner 9. New granite tops ( see allowance page ) 10. All painting by contractor. Kitchen and new trim, new doors, new base, hall and foyer. 11. Match all new interior trim as close as possible 12. Replace exterior trim and siding around new window and door after installation. 13. Contractor responsible for all permits and inspections. 14. Contractor responsible for removal of all debris. 15. Owner responsible for kitchen design and cabinets. 16. New floor in kitchen and back hall to be new hardwood flooring match and blend to living room & dining room as close as possible. 17. Vent range hood. Hood by owner. 18. ,Pull old tile in foyer and replace with new, add %4 inch cement board. Also tile back splash.-*. 19. Owner responsible for removal of personal property in work area. ! ,e • Plumbing New plumbing to include. 1. Replace 2 — sections of baseboard heat, and add 1 — toe kick heater under sink. 2. Supply all water and drain pipe needed for new kitchen. 3. New shut offs on water lines. 4. Add water line to fridge. 5. Supply water and drain for new dishwasher. 6. Install new garbage disposal. • Electrical Almost all of the electrical will be replaced to bring to code and new layout. 1. Supply all electrical demo and new wiring needed for new area. 2. Additional charge for any smoke or co2 detectors. 3. 8- recessed cans. Fixtures by contractor 4. 2- hanging light. Fixtures by owner 5. Plugs and switches to code 6. 2- dimmer switches. 7. Wire new stove location and 2- wall ovens. 8. Under cabinet lighting under 4 areas: 9. Wire dishwasher and garbage disposal. A3 0. Wire range hood. • Window specs 1- Anderson triple unit over sink. Window to be determined. • Exterior Door Specs 1- Thurma True fiberglass door, 3-0x6-8 Full view glass no grids. 1- Harvey full view storm door. • Interior Door Specs. Replace 3- doors, in front foyer. 3- Solid core, smooth masonite doors with door knobs. • Drywall 1. All drywall patches and plastering associated with project by contractor. • Painting 1. 2. 3. 4. Paint - Kitchen & foyer areas. Blend exterior as close as possible. Owner needs to remove items off walls prior to the start of the demo. Paint any new trim in hall and foyer. Sign r Date 4 Q,- Allowance Page 1. Kitchen window 2. Full view exterior door 3. Storm door 4. Cabinets By Owner 5. Granite Tops 6. Fixtures — Sink / Faucet and garbage disposal 7. Tile & Grout, material only $850.00 $400.00 $ 200.00 $0 $3,900.00 $1,400.00 $440.00 Project Total and Payment schedule Exhibit D 1St signing of contract $7,000.00 2nd The day work starts $10,000.00 3rd Completion of plumbing Electrical roughs $10,000.00 4th Install of cabinets no tops $7,000.00 5th Completion of 90% of $3,000.00 painting 6thSubstantial completion of project and final sign off. $1,400.00 Job Total $38,400.00 Balance $31,400.00 -� $2111400.00'(' $11,400.00'4 $4,400.00 $1,400.00 Note — With no delays due to products that are ordered or cabinet's, Completion date of 4 to 6 weeks after start of demo of kitchen. Sign JQA, Date �j� l . 4 - Twomey & Legare Contracting, Inc. Professional Building / Remodeling 87 Belmont Street North Andover, MA 01845 HIC #136779 North Andover - 987.685.7447 Haverhill - 978.556.1547 CONTRACT ff 1. Date of Contract Signing: H t 41 L 2. List of Documents/Counterparts of this agreement: A. Contract B. Specifications/Proposal (See Exhibit B attached) C. Drawing/Plan (see Exhibit C attached) D. Payment Schedule (see Exhibit D attached) E. Limited Warranty (see Exhibit E attached) F. General Notes (See Exhibit F attached) 3. Parties to Contract: A. Contractor: Twomey & Legare Contracting, Inc. Shaun Twomey/Doug Legare Federal ID# 20-3436110 Address: 87 Belmont Street, No. Andover, Ma 01845 Contractor Registration No.: 136779 B. Homeowner: George & Michelle Tagarelis 179 Hay meadow Road North Andover Ma, 01845 978-685-9155 4. Description of work to be done and the materials to be used: See Specifications (Exhibit B) 5. Total amount agreed to be paid for work to be performed under the contract: 6. Time schedule of payment to be made under the contract, finance charges for late fees (if any)*: See Payment Schedule (Exhibit D) *Any deposit req ,Wed to be paid in advance of the start of the work shall not exceed one third f the total contract price or actual cost of any material or Owner Initials: Contract Contractor Initials;_ Page 1 of 4 I equipment of a specific pr custom made nature, which must be ordered in advance of the start of the work to assure that the project will proceed on schedule. No final payment shall be demanded until the contract is completed to the satisfaction of all parties. 7. A. Date work is scheduled to begin: (see No. 14 below) B. Date work is scheduled to be substantially completed: (see No. 14 below 8. Notice: A. All home improvement contractors and subcontractors shall be registered and any inquiries about a contractor and/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 (617) 973-8700 B. For contractor's registration number, see first page. C. Homeowners have a three (3) day cancellation right under MGL Ch. 93 § 48; MGL Ch. 140D § 10; or MGL Ch. 255D § 14 as may be applicable. See attached Notice of Cancellation. D. For homeowner's warranty rights, see 780 CMR R6 and MGL Ch. 142A. 9. There is no lien or security interest on the residence as a consequence of this contract. 10. Permit Notice: A. The following permits will be required in connection with the work to be performed on your property: Building — Electrical — Plumbing B. It is the obligation of the contractor to obtain these permits as the Homeowner's agent. C. Any homeowner who secures their own construction -related permits or deals with unregistered contractors shall be excluded from access to the guarantee fund. Owner Initials: 1 Contract Contractor Initials: Page 2 of 4 11. Contractor reserves the right, if he deems himself to be insecure, to require, as a prerequisite to continue work, that the balance of funds due under the terms of the contract, which are in possession of the owner, be placed in a joint escrow account requiring the signatures of the contractor and the homeowner, for withdrawal. 12. The parties agree that no work shall begin prior to the signing of the contract, transmittal to the owner a copy of the contract and the expiration of any applicable rescission period. 13. Arbitration Clause: 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 arbitration service which has been approved by the Office of Consumer Affairs and Business Regulations and the consumer shall be required to submit to such arbitration as provided in MGL Ch. 142A. 14. Other Provisions: A. Commencement and Completion of Work - Contractor agrees to proceed diligently with the agreed upon work, commencing promptly, following: The completion of the Title V installation and certification of compliance by the town. • Issuance of a building permit by the town. B. Final payment shall be upon the satisfaction of the homeowner. The parties agree that the issuance of a certificate of occupancy and/or final inspection shall be the objective standard that the contract has been complete and the parties satisfied. Any final punch list items shall be reduced to writing, with an estimated date for completion. The parties agree that no escrow will be held for punch list items. C. Insurance — Contract agrees to provide evidence of liability, workers compensation an a risk insurance. Owner agrees to provide copy of hazard insur ces r i11 q ed by contractor to coordinate a policies. Owner Signature: Date: _ -��� i2- Owner Signature: Date: Z1116 A Owner Initials: Contract Contractor Initials: Page 3 of 4 Contractor Signature: Date: Contractor Signature: Date: Notice: The signatures of the parties above apply only 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 separately by the parties. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES ontractor �tte4/ Owner Initials: Owner Contractor Contract Contractor Initials: Page 4 of 4 Date Date AUG -24-2011 WED 04;09 PM FAX N0. 9784750303 P. 05 11IL 1 H�o- CERTIFICATE OF LIABILlT INSURANCE )DUCER DATE (MMR)O/yyyY) herty Insurance Agency, Inc. THIS C08/24111 ERTIFICATE tS ISSUED A5 A MATTER OF INFORMATION )- Box 1985 ON L AND CONFERS NO RIGHTS UPON THE CERTIFICATE Elm Street HO L ER. ThIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALT R TME COVERAGE AFFORDED t3Y THE POLICIES BELOW, dower, MA 01890 RID INSUR /iS AFFORDING COVERAGE Twomey 6 Legere Contacting, Inc. INSURER : Arbelia Protection ins Com an NAIL p PO Box 366 INSURER North Andover, MA 01845 INSURER LISTED E REQUIRE OF INSURANCE CONDI BELOW AN BEEN ISSUED TO THE INSURED NAMED BOvE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING Y REQUIREMENT. TERM NC CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RES TO WHIGH THIS CERTIFICATE MAY"BE ISSUED OR NY PERTAIN. THE TE LIMITS SHOWN ED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO qlL THE TEAMS, EXCLUSIONS AND CONDITIONS OF SUCH LIC(GS. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. L N9 TYPE OFINSURANCE A GENERAL LIABILITY POLICY NUMBER OTC E EC POAU EXPIRATION X COMMERCIAL GENERAL LIABILITY 8500043255 06/22/11 LIMITS 11 06122/12 EACH OCCURRENCE E1 OOO OQQ CLAIMS MADE ' x' OCCUR DAMAGE TO RENTED $100 000 MED rXP (Any one oaseni �C A... AGGREOq�TE LIMIT APPLIES PER: ..N "MOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEOULEDAUTOS MIRED AUTOS NON.OWNEO AUTO$ GARAGE LIABILITY r ELIA LIABIyTY CLAIMS MADE E $ WI RIVERS COMPENSATION AND E LOYERg' LIABILITY A PROPRIETOR,PARTNEWEXBCUTIVE OF ICERIMEMBER EXCLUDED? OF OPERATIONS 1 LOCATIONS, VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT, SPECIAL operations usual to Twomey & Legare Contracting, Inc... GENERAL AGGREGATE PRODUCTS - COMFIOP AGG COMBINED SINGLE LIMIT (Eearciderl) BODILY INJURY (Per penan) BODILY INJURY (Per acc dont)ROPERT PROPERTY DAMAGE (Per accident) AUTO ONLY - EA ACCIDEN' OTHER THAN IP -A AC AUTO ONLY. E SHOULD ANY OF Y1 Town of North Andover I IE ABOVE DESCRIBED POLIES BE CANCELLEp 1600 Osgood Street DATE THEREOF, FORE ISSUING)NBURER WILL ENDEAVOR North Andover, MA 01845 NOTICE TO THE CE TO MAIL AY WRITTEN TIFICATE HOLDER NAMED TO THE LEFT, BH�L MPOSE NO OBI..10 �AUTHORIZEDREPrjk BUT FAILURE DO S0 tON OR LIABILITY OF ANY KIND UPON THE INSURER, RESENTATIVES ITS AGENTS OR cre�n.v ACORO 2� (2001/08) 1 Of 2 #.S27512/M27509 DML m ACD CORPORATION 1988 DATE (MM/DD/YYYYI -- - GERT_I-FICAUE OF LIABILITY._IN.SURAN.CE . . TMI1%X,EATIFICATE 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 policy, certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu"of such endorsement(s). PRODUCER CONTACT NAME: DOHERTY INS AGENCY INC PHONE FAx (AIC, No, Ext PO BOX 1985 EIA L ADDRESS: PRODUCER ANDOVER, MA 01810 CUSTOMER ID#: 22YMX INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: 'TRAVELERS INDEMNITY COMPANY INSURER B: TWOMEY & LEGARE CONTRACTING INC INSURER C: INSURER D: PO BOX 366 INSURER E: NORTH ANDOVER, MA 01845 INSURER F: 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 ALCTHE TERMS, -EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY " HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY DAMAGE TO CLAIMS MADE OCCUR. PREMISES (Eaoccurrence) NTED S 0 ED FRCP (Any one person) S PERSONAL & ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY 0 PROJECT 0 LOC PRODUCTS - COMP/OP AGG S AUTOMOBILE LIABILITY COMBINED SINGLE S ANY AUTO LIMIT (Ea accident) ALL OWNEDAUTOS BODILY INJURY S SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY S (Per accident) NON -OWNED AUTOS PROPERTY DAMAGE s (Per accident) UMBRELLA LIABB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS -MADE AGGREGATE S DEDUCTIBLE S RETENTION $ WORKER'S COMPENSATION AND we STATUTORY LIMITS OTHER EMPLOYER'S LIABILITY YIN UB-029OM994-11 09/18/2011 09/18/2012 E. L EACH ACCIDENT $ 500,000 ANY PROPERITOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - FA EMPLOYEE $ 500,000 (Mandatory in NH) E.L. DISEASE - POLICY LIMIT $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONSISPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP 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 r, Charles J Clark ACORD 25 (2009109) 1988-2009 ACORD CORPORATION. All rights reserved. lilssitchusetts - Department of Public Safety Board of Building Regulations and'Sundimls I I Construction Supervisor License License: CS 67560 SHAUN M TWOMEY 61 PATROIT ST N ANDOVER, MA 01845 Expiration: 10/25/2013 Tr#: 4913 )LI-i-sachusett,, - Delmi-iment of Public Sai'm Boa -(1 of Buildin--f Reululations.and Stjjjj(Ijjv('l.S Suoervi-cor License License: CS 55108 DOUGLAS J LEGARE 79 GARY AVE HAVERHILL, MA 01830 Expiration: 9/212012 (' ,cnndsi„iter Tr#: 2766 077 Office o onsumer ffairs ok 13 siness egiila on HOME IMPROVEMENT CONTRACTOR Registratiom. 136779 Type: Expiration: 812612012 Partnership fW666 + LEGARE-CONTRACTING INC. SHAWN TWOMEY 87 BELMONT ST. N. ANDOVER, MA 6848 undersecretary ALIN\ The Commonwealth of Massachusetts Department of Industria114ccidents Office of 1-nvestigations ..600 Washington Street Boston, M4 02111 www mass go Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / ,/�PIease Prmt Legibly Name (Business/Organization/Individual):� x.,ft/ Address: City/State/Zip: � 1Phone ���j – . 7 Are youan employer. Check the appropriate boa: 1. ❑ I am a employer with_ I 4. ❑ I am a general contractor and I employees (full and/or part-time).** 2. ❑ I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet t ship and have no employees These sub -:contractors have working for me in any capacity. orkersI comp. insurance. [No workers' comp. insurance 5.VJ We are a corporation and its required.] 3-0.1 am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No workers' comp. C. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. In required.] *Any arp 1e21i that ch rs bas 1 nr t also fill "1 the section b lmv ���nrirR 4—U.... , 'f Type of project (required):' 6. F-1cor remoae�g uction 7. 8. E] Demolition 9. El Building addition 10-ElElectricalrepairs or additions 1 1-n Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other w ::,w, coWpMsstion policy inform--tiom omeowners who submit this affidavit indicating they are doing affidavit indicating such. all work and then hire outside contractors must submit a new '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 far my employees Below is the policy and job site information. --�--�'' Insurance Compiny Name: /!—�L ✓,%%� 1—C' /�„ �.l �%, Policy # or Self -ins. Lie. #: —• Expiration Date: Job Site Address ��—�N /State/Zip: Attach a copy of the worke ' compensation no City/State/Zip: declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofM.GL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do hereby certify . nder the pain nd penalties of perjury that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town offzcid City or Town: PermitUcense # Issuing Authority (circle one): L Board of Health 2. Building Department 3. city/Town Clerk 4. Electri 6. Other cal Inspector 5. Plumbing inspector 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 dwellinghouse.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 15.2,' §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 certificates) 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 anLLC 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 datethe affidavit. The affidavit should be r etL,med to the city or town at tat? a p l.'sG� `ion for he pe r icon � .c. beingrequested, t ' t of u_> t :.t ? j! � that the i-�bShcl o_ l< _ .R i b •rb no the Depar�*.rert_ Industrial Accidents. Should you have any questions regaraincg 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 0ff;ce of Investigations 600 Washinggton. Street Boston, MA 0.2111 Tel. # 617-727-4940 ext 406 or 1-8.77 MASSAFE Fax # 617-727-7749 Revised 5-26-05 1 _.