HomeMy WebLinkAboutBuilding Permit #83-14 - 190 BRIDGES LANE 7/24/2014BUILDING PERMIT �"6 '6
0
TOWN OF NORTH ANDOVER
0
APPLICATION FOR PLAN EXAMINATION
41
Permit No#: Date Received
Date Issued:
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
)40ne family
0 Addition
El Two or more family
0 Industrial
81teration
No. of units:
0 Commercial
0 Repair, replacement
11 Assessory Bldg
El Others:
0 Demolition
El Other
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F9, ed Vistric-P= 4:-r k
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DESCRIPTION OF WORK TO BE PERFORMED:
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Identification - Please Type or Print Clearly
OWNER: Name: P�one: 417- 04-
ArfdrPq-,-
ARCH ITECT/ENGI NEER Phone:
FEE SCHEDULE.BULDING PERMIT. $12.00 PER
Total Project Cost: $ S)S, 0 �-�
ESTIMATED COST
ON $125.00 PER S.F.
ceipt No.:_ a —+8-1 ( '
not have a&--.v.v to the Pruaranhi fund
f
Locationm
Date
No.
TOWN OF NORTH ANDOVER
Certificate of occupancy
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee
TOTAL
Check #
z� Building Inspector
Plans Submitted 0 Plans Waived F1 Certified Plot Plan El Stamped Plans F1
TYPE OF SEWERAGE DISFO-SAL
Public Sewer
Tanning/Massage/Body Art n
Swimming Pools El
Well
Tobacco Sales 0
Food Packaging/Sales [I
Private (septic tank, etc.
Permanent Dumpster on Site F]
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF- U FORM
PLANNING & DEVELOPMENT Reviewed On Signature
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: -Zoning Decision/receipt submitted yes_
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/signature & Date Driveway Permit
DPW Town Engineer: Signature:
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 21 A —F and G rnin.$100-$1000 fine
Doc -Building Pennit 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
• Building Permit Application
• Workers Comp Affidavit
• Photo Copy Of H.I.C. And/Or C.S.L. Licenses
ca Copy of Contract
o Floor Plan Or Proposed Interi . or Work
ij 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
Lj Photo Copy of H.I.C. And C.S.L. Licenses
• Copy Of Contract
• Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
• Mass check Energy Compliance Report (if Applicable)
• Engineering Affidavits for Engineered products
IOTE: 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
La Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (if Applicable)
a Copy of Contract
Mass check Energy Compliance Report
Lj Engineering Affidavits for Engineered products
OTE: 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
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 70�000.00
m
$ -
$
840.00
Plumbing Fee
$
105.00
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
105.00
Total fees collected
$
1,150.00
190 Bridges Lane
083-14 on 7/24/2014
Kitchen Remodel
Proposal
James Construction
353 Grove Street
Melrose MA 02176
Phone 781-665-4112
Proposal submitted to: Kristin Comeau Phone#: 978-208-1503
Street Address: 190 Bridges Lane Date: 2/11/2014
City, State & Zip Code: North Andover MA 0 1845 Email: Kcomol279@yahoo.com
We h ereby submit specifications and estimates for kitchen renovations:
• Obtain building permit:
Schedule all necessary inspections
IE: Building, plumbing and electrical
• Demolition:
Prep all areas to prevent unnecessary dust and debris in living area
Demo existing kitchen down to studs
Demo structural wall(s) in areas discussed
Remove al construction debris caused by us
• Framing:
Provide and install structural beam (wood)
Discussed steel beam with my engineer and based on length we would need a 16 inch high beam
This would be a challenge (because of the weight of beam) so we will remove the one structural wall
and have the post down entering the family room
• Windows:
Provide and install I new window (Majesty by Harvey)
I have figured on using PVC trim which looks just like wood but will not warp, cup or crack. It also
takes paint better
Patch all siding where necessary
• Insulation:
Install all necessary fire blocking and caulking
Insulate all exposed exterior walls with R- 15 batt insulation
• Blueboard and plaster:
Hang blueboard on all new woTk
Patch all other areas accordingly
Skim coat plaster smooth throughout new work
• Interior trim:
Install kitchen according to approved plans
Install crown molding
Provideand install interior trimat all new openings (match existing)
• Flooring:
Provide and install 2 1/4" oak to match existing
We will do a saw cut between hallway and dining room instead of toothing in new to old
Sand seal and 2 coats of poly
All flooring to meet flush where possible
Cut wood
• Plumbing:
Provide all necessary rough and finish plumbing
Install kitchen sink(farmers)
Install sink faucet
Install dishwasher
Provide and install water line to fridge
Install disposal
All work to conform to Mass state code
Heating:
Relocate heat where necessary using existing system
Electrical:
Provide all rough and finish electrical for renovations
Install all necessary circuits to compensate for new electrical
Provide and install 9 recessed cans
Install and pendant lighting over island/table area
Provide and install all wiring to power new equipment
Provide and install under cabinet lighting at proper locations
All work to be done according to approved plans
Miscellaneous:
I have included labor for installing tile back splash in kitchen
All tile and grout provided by homeowner
Cost: $35,000.00
Please contact me with any further questions you may have concerning this proposal.
All work to be completed in a workmanlike manner according to standard practices. Any alterations or deviation
from above specifications involving additional cost will become an extra charge over and beyond the estimate.
Our workers are covered by workman's compensation.
Authorized Signature:
Note: This proposal may be withdrawn by us if not accepted within 30 days.
Date of Acceptance: Customer Signature:
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Office of Consumer Affairs & Business Regulation - Mass.Gov
The Official Website of the Office of Consumer Affairs & Business Regulation (OCABR)
Consumer Affairs and Business Regulation
Home Consumer Rights and Resources Home Improvement Contracting
HIC Registration Complaints
Registration 160623
Registrant JAMES CONSTRUCTION
Name JOHN MAGUIRE
Address 353 GROVE
City, State MELROSE, MA 02176
Zip
Expiration 08/08/2014
Date
Complaints Details
No complaints found for this registrant.
You can also view arbitration and Guaranly Fund history.
Back To Search
2012 Commonwealth of Massachusetts.
Mass.Gov@ is a registered service mark of the Commonwealth of Massachusetts.
http://services.oca.state.ma.us/hic/licdetails.aspx7txtSearchLN=62072
7/23/14 9:00 AM
Home Imorovement Contracto
Registration Home Page
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The Commonveafth ofHassachuselts
Office ofInvesfigadons
6 -W
00 ashftion Street
Boston., HA 02111
vww.muss.gov1dhz
Workej$, comp emation bsurance Affidavit: BvgdersfContrao
Npid (Busini
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Iffliect
Phone it: -7 (Y I" 7J'C1--
�!�applicaut that chedb bDX01 must aIEOR:U6utihosertionbel6ws�o-wmgtheFworkerecompensattonpouoywionnation.
a now affidavit Indicstifig sVch.
Homec)wners who submitihigaWdELvitludl(;atingtheybiod(
ping allworK and fh+Mra outside contractors must' submil
�ContraotorsihatohcokthNbDxmllst attached �a�'ddjjjonaj sheet showmig the natrn of the su]4�-coiitractors audthekwoibra' comp. policy Mbimation.
em ' S MOWISACT levandfabsife
ployepthailsprovidingworlfersleompeiisationinsuraneoforriymployee. 01 J
infoxmuflon.
Insurance CompanyNama;.
Expiration. Date;
Policy 9 or 8 dlf�� - Y11G. -V:
lob Site Address' pity/State,171p:
Attach a copy offha-Vorkers, C()M)Peniation-polleytieclara-uon page (sliowing.the policy number and explratloA date).
S a
Failure to secure G-ovaraga.as requireclunder Section 25A ofMGL 0. 152 can lead to iho imPOSNO-u Of erb'kalPOnal 6 Of
fbie VP to $1,500.00 andlior one-year imprisonment, 6 -weilas cj0penaffies in the form of a STOP -WORK ORDFR and a fine
ofupto$250.()O a day aga�jsttjjay.1olaior. Be advised that a copyof thisstatement maybe folwazdedto the Office -of.
Investigations oftho DIA for insurance, coverage voiffication,
ereby cert& under jIlepains q,7japenalges OfFerpry & at #1 e infonnaaonmo videct ak o Ye fs trae and eorrect
'��n — — nnfa. /4 -
Of i� Wn ff' a
.f1clal use oply, vo not vrife hz 61s area, to be convIeted by el or to 0 lei I
City or'Town: Permitt/License 0
f8suing Authority (circle due):
1.)3oardofUealth.9,.]3uffdMgl)epartment 3-Cify/Town Clerk 4. Electrical Inspector 5-Plumbingluspector
6. Other
"I
Are you t hu employer? Check. thia_a_ppro. Pilate box:
I.E] I am a employer with
4-. [] -1 am a general coirtractor and I
employeeg (fall and/or part-time).*
have hkadthe sub-oditactors
listed on flia attached sheet.
2/R I ain a solo Proprietor OrPattile-r-
-ship and lava no-amplOY003
These sub-confractoxg have,
worling forma in any capacity.
-workers, comp. insmance.
5. El We ara a core oragon. and its
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officers have axorcl-sea.their
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I am a homoovaer
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Myself PTO W91kays, bomp.
c. 152, §1(4), 1 we, have no
insurancara .1 Ti
employe6s. workers,
Vi
comp. inswainrequired-1
�!�applicaut that chedb bDX01 must aIEOR:U6utihosertionbel6ws�o-wmgtheFworkerecompensattonpouoywionnation.
a now affidavit Indicstifig sVch.
Homec)wners who submitihigaWdELvitludl(;atingtheybiod(
ping allworK and fh+Mra outside contractors must' submil
�ContraotorsihatohcokthNbDxmllst attached �a�'ddjjjonaj sheet showmig the natrn of the su]4�-coiitractors audthekwoibra' comp. policy Mbimation.
em ' S MOWISACT levandfabsife
ployepthailsprovidingworlfersleompeiisationinsuraneoforriymployee. 01 J
infoxmuflon.
Insurance CompanyNama;.
Expiration. Date;
Policy 9 or 8 dlf�� - Y11G. -V:
lob Site Address' pity/State,171p:
Attach a copy offha-Vorkers, C()M)Peniation-polleytieclara-uon page (sliowing.the policy number and explratloA date).
S a
Failure to secure G-ovaraga.as requireclunder Section 25A ofMGL 0. 152 can lead to iho imPOSNO-u Of erb'kalPOnal 6 Of
fbie VP to $1,500.00 andlior one-year imprisonment, 6 -weilas cj0penaffies in the form of a STOP -WORK ORDFR and a fine
ofupto$250.()O a day aga�jsttjjay.1olaior. Be advised that a copyof thisstatement maybe folwazdedto the Office -of.
Investigations oftho DIA for insurance, coverage voiffication,
ereby cert& under jIlepains q,7japenalges OfFerpry & at #1 e infonnaaonmo videct ak o Ye fs trae and eorrect
'��n — — nnfa. /4 -
Of i� Wn ff' a
.f1clal use oply, vo not vrife hz 61s area, to be convIeted by el or to 0 lei I
City or'Town: Permitt/License 0
f8suing Authority (circle due):
1.)3oardofUealth.9,.]3uffdMgl)epartment 3-Cify/Town Clerk 4. Electrical Inspector 5-Plumbingluspector
6. Other
"I
Information a
ad Instructions
'Bneralf'aws chapter 152NqUir6s alleMaployers toprovidoworkers, compensation for Eekemployoos.
Mass-achusetts (T
PursnaiitOtfilsstatute, perriployee is do&ed as ",--0V0rYPeTsonki the service of anotherunder any contract ofhjra,-
express orhapJ14 oral orwxitteu.-
ARMT10YOS defined as "an individual;,partnership., association, borpoxationar other logalentiV, Or any
of engaged in ajolt onteipffie, and including the, legal:re
prosentatives of Evdccoasedqpapl9pr,, or the
I:Odeiv'eror*-ii�La'df'atLkdivid-aal, partnerght� as�oclafiou or other legal entity, omployingenip ' 'I
loyees. 116wavar M6
OvMer Of a dwelhgho-asohav:ffignotmorethaathroo apartments and who realdoskere1% or A�c&iipaatofthe
dwoft house of another who emPloYs Persons to do maintenance, construction orrop* work on su6h dwoUhg house
or ontho grounds or building appurtenant thereto shallnot because of sU&d1uployment be deemed to be an omployor.,,'
MOL chapter 152, §25C(6) also states that' or Ual Reensing agency shallv�tUold the issa'ance or
renewal of a license or permit to op erate a business or to construct buildings in Me commonwealth for any
aPPlicant Who has not pro d -aced -acceptable evidence of compliance with the insurance coverage regi4red.11
Additionally; MaL chap�tor 15�, §.25C(7) States'Weither the commonwealth nor any of its p olitical sub ivilsiom shall
ontox into qny c onfract for Me p arformance ofpublic WO& until �ccqptabla evidence of coinplj�nce with the insurance
xoq*omaafs of this chapter have b a on presented to. 16 contracting authorlfy2'
Applicants
I'loas-OPLU out the Workers, compomailon, affidavit completely, by checking ffia boxes that apply to yo sitaajionaad�if
ur
A6cojsary, -supply mb-contraztor@uame(s), address(es) andphonenumber(s) along with their coracate(s) of
insurance. f-imitedL!abffityCompanies(fLC)orLimitedLiab!Rtyparta,) haA
-r4s (LU) with no employees Other t tho
RIP-Mbers OXP�rtnors, arenotrequIredto can7workers, C01nVQJ1Sat1Onh=aUGo. If aULLTC orLLP doo3have
QJ13Pl0YG99,aPoHGybXeq*ed. Be advised thatfbi� affidavit may bB submitted to the Department of Indusinal
Accidents fbT conffimation of juslZance c . J
Overage. Also be sue to sign and date Me affidavit. The affidavit should
be letaniddto the �fty or-tova that 1h6 application fox thopernit'or -us' d aft :, (,
lice 61sbelgreqao qq,?jottheD4 t f
1idustrialAcoldents. Shouldyou have any questions regarding the law or
com i?YOU are xoquiredto Atak a*orkers,
p onsationpolloy, please call the Department at ft number listed below. Self-hi=od companies Aould enter their
sOlf-JUsurmcc, license number on Mff appropriate line. . . I
QtY Or Town Of Ucials
Pleasabosurethattho affidavitis complete audprintodlegibly. The, Department has provided a space at the bottom
oftheaf:Hdavitfoxyout000-at;UtT:Loe
,Vent the Office of kv6stigatioms has to c0ntactYou regarding the applicant.
Ploas.a be-suro to fff inthO POWlitTGOWD number Wldchwill be used as a reference number, fhadditionanapplicalat
thatinust submitmultiPle, PormitIRGOM0 aVPRGat10uS:h any given year, need only submit onG afffdavitindicaffig cm�nt
PORGY infonnation (iftocessaty) and nader "Yob No Addr6se; the applicant shouldwtite "afflooations fu or
."�&� otthoaffidavItthathasbo' --ifoity
tov&) OPY onoffirlayst�n.VedormarkedbyEacityortoym
a may b a provided to the
P.Plicalitas.prIDoffhatavalfdaffcdaeL._isonfdo�orftwepemiitsorlicenses. A116waffi&VItinistb fillodouteach
year. *Where a liome omor or citizen is obtaining a license Ox-�onlit not related to any business or commorcial venture
(i.e. a dog license oriormit to bum loaves eta.) said person is NOT required to complete, this affidavit.
The Office 6f lnvos�gations*would like to thank you in advance for your cooperation and shouldyou have any questions,
PleasO do nd hesitate to give us a call.
Tho D ep artmelit, s ad dres s, taloph one, a-hd fax numb or:
ThQ qg,.hV
Off tce of TAwattga-ama
�Qowa J Suagm stceqt
B QA032�, 9- & 02111
TOL 4 617-72&4900 at 406 Qx- 1-87-7�
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"�vjsed 5-26-05 617-727-7749
Stap�le
eldet,
s
Permit NO:_��(g
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
in dustrial
Alteration
No. of units:
Commercial
Others:
Repair, replacement
Assessory Bldg
Demolition
Other
e*p ic
�!p aJ n;1'
IvIvatersh Dis�nqt
5 r/ S- 6 w
_MtIE'
Sle
k,
zd
I 1UN Ur VVUMtX I U t5t: VXht-UPCMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
ARCHITECT/ENGI NEER - -4.0ek-1 __'� Phone:
Address: -Reg. No.
FEE SCHEDULE.BULDING PERMIT. $1Z00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 7& lie FEE: $ 1
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
Location
No. Date
14ORTAI
TOWN OF NORTH
ANDOVER
41
Certificate of Occupancy
$
Building/Frame Permit Fee
$
Foundation Permit Fee
Other Permit Fee
TOTAL
Check v-3#
2 2
- 0-e—
—�
Building
Inspector
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 DATEAPPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
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:
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
ATURE: Yes — No,
M -GL Chapter 166 Section 21 A —F and G min.$100-$l 000 fine
NOTES and DATA — (For department use)
LJ Notified for picku p - Date
. ..... . ....... . ............... . ............. . .
Doc -Building Permit Revised 2010
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
Li 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 issuan,ce of Bldg Permit
Addition Or Decks
a Building Permit Application
Ei Certified Surveyed Plot Plan
Li Workers Comp Affidavit
L3 Photo Copy of H.I.C. And C.S.L. Licenses
u Copy Of Contract
Ei Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
ci ' Mass check Energy Compliance Report (If Applicable)
u 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)
u Building Permit Application
Li Certified Proposed Plot Plan
• Photo of H.I.C. And C.S.L. Licenses
• Workers Comp Affidavit .
Ei Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Ap p-licable)
• 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 2008
The COmmOnwezlth of Massachusetts
Department Of rndustrial Accidents
Office. Of rn vestioations
Tf7asjz�in,,Wn Street
Bostopz, .4" 02
Workers' Compensation In WWW.Massgorl&a
surance Afffidavit: Builders/Contra
APPlicant Informating ctors/Electricians/Plumbers
Name (Business/organizationdridivi dual):
Address:
City/State/zip: I -A r
-------- Pbone #:
you an employer? Chei
em
n Type of project (required):
A -re YOU an employer? Check the appropriate bop
F, - EEI I am a employer with 4. D4am a gmeFral 7cOntractor and I
employees (full and/or -part-time).* � I
have hired the sub -contractors 6. New construrtin
)�a to
2. E] I am a Sole PrOPrietor or partner- listed on the attached sheet 7. 7�4emodhiig
ship and have no employees These Sul>-cOntractors have
working for me in any capacity. workers, 8. 7 Demolition
[NO workers' comp. insurance cc)mP. insurance.
5. We are a corporation and its 9. F7 Building addition
required,] repairs or additions
I am a homeowner doing all w officers have exercised their 10 -El Electrical
myself. [No workers, r ork right of exemption per MGL .11-11 Plumbing repairs or
insurance required omp. c. 152,,§1(4), and we have no 12.7 Roof repairs additions
employees. [No work=,
comp. in 13. 0 Other
msLlrancc required.)
:-j'�-YaPPE-Ent thatch-ecl—s boi tl must als(I 0 out thtse,_Jjc�b.' -----------
E=Wmg their work-
liameOvlmets v�]10 submit this affidavit indicating they are doing all work- T'
�COnt=t= that checi, this box must __ I and thm'hire outside contracton m,,.,
an additional sheet showing the name of the sub_con submit a new affid-,it indicating such.
tmctcn and their workers' comp. policy infortuation.
am at, emPloYer that is Providing workers compensation iftsxtrancefor
informqfio& MY employees. Below is thePolicy andjob site
Insurance CompEiny Name:
Policy # or Self -ins; Lic. #.
Expiration Date:
Job Site Address -----------
Attach R copy Of the workers' co A- City/State/Zip:
mPensRtiOn Policy declarati,011 paoe --------------
Failure to secure coverage as required under Section 25 . Ao (Showing the policy number and expiration date).
fine up to $1,500.00 and/Or One-YeaT imprisonment, as we f"MCiL c. 152 can lead to the imposition of c - riminal Penalties of a
11 as Civil penalties in the form of a
of up to S250.00 a day against the violator. Re advised that a ccpy of this statement may STOP WORK ORDER and a fine
Investigations of the DIA for insurance coverage verification. be forwarded to the Office of
I do hereby cerVfy.under the pains andpenahics ofp-
criury thr-* the information Provided aboc zs true and correct .
Phone#: .7 V'�/ 2?- 7>
Official use onlY. Do not write it, this area, to be c
COMPleteif hT ci�l or town officiaL
City or Town:
PermitUcense #
Issuing, Authority (circle one):
L Board of Health 2. Building, Department 3. City/Towji
6. Other Clerk 4. Electrical inspector 5. plmrnhing In r
spe tor
Contact Person:
---- ----------- Phone #.
Information an- d'Instructions
MassachuseM General Laws chapter 152 requires all emplov4--rs to provide wor r , nip a on fo e I
ke s co ens ti r th ir emp oytes.
Pursuant to this statute, an employee is defined as "...every Pe'--rson in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individua-L partnership, associ=-xtion, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including t3he legal representatives of a deceased employer, or the
receiver or trustee ofan individual, partnership, association Dx- other legal entity, employing employees. However the
owner of a dwelling house having not mom than three apartnaLents and who resides therein, or the occupant of the
dwelling house of another who employs persons tO do maintt--mance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not bt-,czause of such. employment be deemed to be an employcr."
MGL chapter 152, §25C(6) also states that "every state or 19,.c�al licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to t--anstruct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of cozmprmce with the inmwance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the c--ommonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work IMTE acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contraLcting authority.vi
,kpplicants
Please fill out the workers' compensation affidavit comPlettl3i, 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 U. -ability Partnerships (LLP) with.no employees other than the
members or Partners,. are not required to carry workers' comp ensation 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 insiirance coverage. Also be svire to si�gln and date the affidaviL The affidavit should
be returned totht city ortown the,. the applicationfor the peroaft license;
r or is being requestted, not the benarcment of
Industrial Accidents. Should you have any.questions regardirxg the law or if you are rmfuircd to obtain a 'workers'
compensation policy, pleme call the Department at the numbmr listed below. Self-insured companies should enter their
—self-insurance license number on the appropfiate line.
City or TowE Officials
Please be sure U= the affidavit is complete and printed legibly. The Department has provided a space at the bottom
ofthe 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 permittlicense number which Will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any g3rven yew, need only submit one affidavit indicating current
policy information (if necessary) and under '.'Job Site Addresr," the applicant should write "all locations in _(city or
town)." A copy of the affidavit that has been offici,;My &&Mptd or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future Per Xnits or license&. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license orpmwd not related to any business. or commercial vent=
(i.e. a dog licensc--or perinit to bum leaves etc.) said person is NOT required to complete this affidavit -
The Office of Investigations would like to tban 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, L-lephone.and.fax--number........
The Commonwealtb� of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Wwalington street
Boston, �LA 0.2111
Tel. # 617-727-4900 ext4,06 or 1-977-MiASSAFF,
Revised 5-26-05 Fw, # 617-72,7-7749
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