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HomeMy WebLinkAboutBuilding Permit #311-14 - 198 LANCASTER ROAD 10/2/2013 TOWN OF NORTH ANDOVER f APPLICATION FOR PLAN EXAMINATION Permit NO: ` Date Received Date Issued: U IMPORTANT: Applicant must complete all items on this page .,.. LOCATION -� Print PROPERTY OWNER(ryrn n�1� _ Print 100 Year Old Structure yes MAP NO: #�4, PARCEL: tv ZONING DISTRICT: Historic District yes -Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential j ❑ New Building 'One family ❑Addition ❑Two or more family ❑ Industrial [Iteration No. of units: ❑ Commercial . Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: k1(z(1,(,1d2x S I'd i v 4'Qm e 1C,,e,-q(10ev ga's e_62ik Identification Please Type or Print Clearly) q OWNER: Name: 1►nn � 1���, Phone: /78 _'��7_CX�3 s Address: CONTRACTOR Name: rti v WAtS G � Phone. 3. 6 G/—6 3K4 Address: tqioAi 1 5ytr AD3&�v Supervisor's Construction License:G s-/� C(93/621 Exp. Date:-, 2— ) Home Improvement License. Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 HE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ / �i.�� FEE: $ Check No.: Receipt No.: S NOTE: Persons cont acting with is ered contractors do not have access to th guaran un Signature o6kg-6nt/Owner-' Signature of contracfor Plans Submitted ❑ Pl ns Waived ❑ Certified Plot Plan ❑Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ - - 4 .TYPE_OP SEWERAGE:DiSPOSAL- Public Sewer ❑ Tanning/MassageBodyArt ❑... Swimming Pools ❑ Well ❑ Tobacco.Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc- F1- .. 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 HEA JH Reviewed on Signature i COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comments Conservation Decision: Comments i Water & Sewer Connection/Signature& Date Driveway Permit DPW Tow;! Engineer: Signature: Located 384 Osgood Street FIREDEPARTMENT -'Temp Dumpster on siteyes.. . no Located-at 124 Mair Street -Fire b_ epartme►rtsignature/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.$10041000 fine NOTES and DATA— For department use El Notified for pickup - Date Doe.Building Permit Revised 2010 i i Building Department .--The fol;-3wing is-a list of the required forms to be filled out for the appropriate.permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o 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 cas<s if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apo,>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 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 30,500.00 m $ - $ 366.00 Plumbing Fee $ 45.75 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 45.75 Total fees collected $ 557.50 I 198 Lancaster Road 311-14 on 10/3/13 Kitchen Remodel 1 10/02/2013 WED 15;02 FAX 1 781 324 4253 Paul MurphT Insurance 2001/001 2/2013 6;55:06 AM PST (GMT-8) FROM. 7.00005-TO: 11813244253 page: 2 of 2 GATa CERTIFICATE OF LIABILITY INSURANCE E(MM/DD/YVYY) 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 CONSTrrvm 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 WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement an this certificate does not confer rights to the certificate holder in lieu of such andorsemen s . PRODUCER. PAUL.T MURPHY INSURANCE AGENCY INC AME: 628 BROADWAY MALDEN, MA 02148 DDRESS: INSURE S AFFORDING COVERAGE NAtC I IfSURERA INSURED YrSIrRER e: ARTHUR WATSON DBA AF WATSON GENERAL.CONTRACTING nsuR�ao: 3 EDGEMONT ST INS UREK D DERRY NH 03038 IISUREREc INS URE.F! COVERAGES CERTIFICATE NUMBER; 179 2132 REVISION NUMBER: THIS Is TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED SSELOW 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 DESCREED HEREIN IS SIJOJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. UASRWOL POLICY EFF POLICY CXV LTR TYPE Of INSURANCE13=11011POLICY NUMBER IAIOD/yYW) (MM1bDrv-ryyj LIMITS CANERALLIARILITY EACHOCCURRENCE S COMMERCIAL GENERAL LIABILITY PREM YO RENTED PRKM4A - Fa NTEDnco S CLAIMS-MADE 7 OCCUR MEq KafP lMy ono porwn S PER-RONAL R ADV INJURY $ CC-NFRAt.AGGREGATE L 0EN'L AGGREGATE LIMIT APPLIEC PER. PRODUCTS-COMPIOP AGO $ POLICY PRO- LOC S AUTOMOBILE LIABILDY eeCC�an1�1 $ ANY AUTO BODILY INJURY(Per peraen)ALL g vR AUTOSULEO AVTOBODILY INJURY(Per eeridgno S NON- HIREOAUTOS R AUTOS �eed'Oent S 5 S UMIURELIA LIAB OCCUR EACH OCCURRENCE S EXCESS UA9 CLAMS-MADE A00REOAT2 S DEO RETENTION S E E S A WORKERS COMPENSATION Y/N WCS-318-384095-013 1/5/2013 1/512014 WC ST'�T7R t +- AfiO EMPLOYERS'LIABILnYTOW OFFIANYCEWMLMULK EXCLuoC i GCUrnG a NIA E.L.EACH ACCIDENT $ 100000 (Mendaloy L,NK) E.L.D19EAt3E•EA ENPLOVEE S 100000 II yes.deserae under 10ESCRIPTION OF OPERATIONS Dclo E.L.DIRFASE-POUCY LIMIY s 500000 DEBCRIPTION OP OPDRATIONS/LOCATIONS/VL'MCLPS (A(laeh ACOI(U 10 t,Addltlonal Renarke Smedulo,If nwm spam Is mgVlrea) THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FORARTHUR WATSON. Workcrs compunsalion insuraneo covom9a applies only to the,workers compensation laws of Ole state MA. CERTIFICATE HOLDER CAN ON SITOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF NORTH ANDOVER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 198 LANCASTER ROAD ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER MA 01845 AUTHORIZED REPRESENTA)Nr Jett Eldridge 0 1988-2090 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo arer registered marks of ACORD SEAS NCI,. 1�99t11v Ccrcwr cCoc: l5�oxap OOD OazocRcrlQn PY9VlOU:lyy&*sued'rtiJSCd LeS. 1G Cert1.1.C.Att. crnec Ci en su ersedes ALL Np Rf Town of 000 _ No. 3 4— I � �t � y � z � ver, Mass • • O COC NI[M wKM I•P��.�5 S v BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT 101..1 LP. BUILDING INSPECTOR �� Foundation has permission to erect ........ buildings on I..�........1U••• Q ••••••......�cL, .,. Rough .��I.. ...... Chimney to be occupied as .......... . !.. .... ................. y provided that the person accepting this permit shall�in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final �6 • PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR S Rough UNLESS CONSTRUC ST g 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 from inside comer of 70314 angled wall to ceenterof sink mindo, from inside vomer of ='4 angte wsuto n_n e 393 4--321 of arra �iaet 31318-1 77 1 i2,141 1i _ �2 114—IS _-40 � r 21 1,g * 2S 1S 24 201; 151 49 Mt i� 314" dirrensio, %i rngr n.i£e edge 14 to granite edge Din-endo from cabinet , 37 114 4 1'1118 39 fete tes4 �S e fsr� 112 14 1 14 103 •1 112 I 314 30 1319.. 30, 3011311 3 £8, 11 dimension from wall Overhang on fsreide of island by cook tea; to fimished end panel ug 5eQ S'° 37 of island ouerrseng on.sidin=g safe of island is 1210_25" Sid 1A �5 E g 151 1 errsib«from wall 'Iczak'dtSEofisLand, 55718 36 i ; I .45118 dimension:from firs zhed back knensio i fmm grantee panel on island to i,dga to 9 anite edge face of cabinet 51 40I 6 , 6769 - - 28 27 2 34 1 a•4 34 1',14 Z 1 912-20 33 112 20-1 irk 2 398 1 A.F. Watson General Contracting Estimate 3 Edgemont Street Derry,NH 03038 DATE ESTIMATE# Tel. 603-437-6134 Cell#603-661-5360 7/6/2013 1537 NAMEIADDRESS Jim&Kerry Pinho 198 Lancaster Road North Andover,MA 01845 TERMS PROJECT Due on receipt Kitchen ITEM DESCRIPTION QTY COST TOTAL Permit Town of N.Andover building permit fee Allowance 350.00 350.00 labor Carpenter's labor 120 42.00 5,040.00 1.Remove existing appliances,sink,counter tops, cabinets,strip walls and ceiling as needed. 2.Install blue board as needed walls and ceiling. 3.Install ducting for hood,Install cabinetry per plan Miscellaneous Miscellaneous 150.00 150.00 Blbd4x12 4'X 12'X 1/2"Blue Board 8 16.42 131.36 plaster Plaster veneer 2 16.52 33.04 Plastering Plastering 1,200.00 1,200.00 Plumbing Plumbing Allowance: 2,000.00 2,000.00 Electrical Electrical Allowance: 2,000.00 2,000.00 Disposal Disposal of construction debree 450.00 450.00 Flooring Floor Sanding&Finishing 1,500.00 1,500.00 Painting Painting 1,000.00 1,000.00 Subtotal labor&Materials 13,854.40 Cont.fee Contractors 10%Fee profit+overhead 10.00% 1,385.44 Note The Above prices are estimated costs and will be PF.00 0.00 adjusted to actual costs. " I I V ,. '�d THANK-YOU A.F.WATSON TO OIfb "' $15,239.84 SIGNATURE OWNERS SIGNATUREq�� rl- zz�4' jl�w Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulations Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information i�ameCompany Name }. �r J j11� at <eit R (4\6 �ISotU Cs Cmc Street Address(do not use a P t Office Box address Contractor/ alesperson/Ow�ner`Naame L ac</Z�e f �xo Vv A ,,,j Ci !T State Zip Code Business Add (must include a street ad MOL a $4s 3 eMvti S Daytime Phone Evening Phone City?own State Zip Code 7 Oe (` 0303F Mailing Address(It different from above) Business Phone, eral Employer ID or S.S.Number Og ionic lmprorattad Contr�torReg.Nuodia E�'vmioodaze tareraarmrthat mart home tmptm. t emn aon haze a.ad trghtmdon anmber D o The Contractor agrees to do the following work for the Homeowner: (Describe in detail the murk to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary (Yt )Ve ax i Aco' CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDDNYYY) `,,,i' 09/30/2013 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Obrey Insurance Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1E Commons Drive Unit 27 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Londonderry NH 03053 INSURERS AFFORDING COVERAGE NAIC# INSURED Af Watson General Contracting INSURER A: MAIN STREET AMERICA 3 Edgemont St INSURER 8: INSURER C: Derry NH 03038 INSURER D: INSURER E COVERAGES THEPOLICIESOFINSURANCELISTEDBELOWHAVEBEENISSUEDTOTHEINSUREDNAMEDABOVEFORTHEPOLICYPERIODINDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCEAFFORDEDBYTHE POLICIESDESCRIBED HEREINISSUBJECTTOALLTHETERMS,EXCLUSIONSANDCONDITIONSOFSUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE S1,000,000 A X COMMERCIAL GENERAL LIABILITY MPT4750C 10/21/2012 10/21/2013 DAMAGE TO RENTED $100,00 CLAIMS MADE Fx_1 OCCUR MED EXP(Any oneperson) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG s2,000,000 POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT A ANY AUTO BITS304C 10/21/2012 10/21/2013 (Ea accident) $1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ Xi HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTOONLY-EAACCIDENT $ ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG S EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE S OCCUR F—I CLAIMS MADE AGGREGATE S S DEDUCTIBLE $ RETENTION S S WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N FIR ANY PROPRIETOR/PARTNER/EXECUTIVII EL.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOY S If yes,describe under SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Job: 3198 Lancaster Rd,N Andover,MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION TOWN OF NORTH ANDOVER DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN 103 MILL POND NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR NORTH ANDOVER,MA 01845 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE _ -�-© <JO> ACORD 25(2009101) 01988-2009 ACORD CORPOEWION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth ofMassachusetts - Department of IndustriglAccidents Office of Investigations 600 Washington Street Boston,MA.02111 www.mas.s gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please`Print Legibly Name(Business/Organi'zation/[ndividual): �� IIAI�61_11�j C��f c,1 Kcs - Address: Q �:Y City/State/Zip: 1 e C S V 6363k Phone#: C 0 3- CC / Aramean employer?Check the appropriate box: Typo of project(required): a employer with 2 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a soleproprietor orpartner- listed on the attached sheet. �• E]Remodeling ship and'have no employees These sub-contractors have S. [I Demolition working for me in any capacity. workers'comp.insurance. 9• [l Building addition [No workers'comp.insurance 5. We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner,.doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),a-ad we have no 12.QRoofrepairs insurance required.)► employees.[No workers' 13.❑Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showingtheir workers'compensation policy information. T Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis 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 for my employees Below is the policy and job site information. 1 p Insurance Company Name: L k�e��,! I -A o c,,_` Policy##or Self-ins.Lie.0: V til S 3�s— 3 -095_ 613 Expiration Date: Job Site Address: ��� �arrnS�t��- _City/State/Zip: {t/, 12 X 6& Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o. 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 DTA for insurance coverage verification. - Ido laereby ce p ' pe ofperjury that the information provided above is true and correct. Signature: Date: Phone 9: Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing 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 joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.,, MGL chapter 152,§25C(6)also states that"every state or local lie-ensing 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 ofits 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-contractors)name(s),address(es)and phonenumber(s)along withtheix certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LL C 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 returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications an any given year,need only submit one affidavit indicating current PORGY information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or py of the affidavit that has been officia town)"A co 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 per 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 burn leaves etc)said person is NOT required to complete this affidavit.' The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone anal fax number: - The Commonwealt�ofMTassa.,chweits Depazbent offadusWal AAcolClents Office of f"Ostigatiom 600 Wasbingtoa Steet . Boston ,021 Z 1 Tei,#617-727-4900 ext 406 oz 1-877-MASS.AFF, Revised 5-26-05 Fax#617-727-7749 Location No. Date 0 Z o - TOWN OF NORTH ANDOVER e Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee $ TOTAL $ Check#Ll�� 2 O V 6 ✓ fl 5 Building Inspector