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HomeMy WebLinkAboutBuilding Permit #342-15 - 20 COLONIAL AVENUE 10/7/2014 BUILDING PERMITOORTH t`.' °.9ti0 TOWN OF NORTH ANDOVER o� y - - °�, APPLICATION FOR PLAN EXAMINATION M h Permit No#: Date Received �SSACHU`��� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION U l A�, , Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: /'Zl ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Buildingne family [I Addition ❑ won—,e or more family ❑ Industrial 0 Alteration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic []Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer CRIPTION OF WORK TO BE PERFOR w ED: Identification- Please Type or Print Clearly Q�� / OWNER: Name: Phon / 4D J �O Address: C20 Contractor Nam e: Z r Address:, s17MW /ep �,�r � Supervisor's Construction License: ��D�4 Exp. Date: Z. Home Improvement License: / 0� "� _Exp. Date- a' /A; ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. 2 Total Project Cost: $ 4'��J��: FEE: $ 1 U Z . Check No.: �riP Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guar ty fund Signature of Agent/Owner. _ ignature of contractor ti Locations No.25A2 Date e - TOWN OF NORTH ANDOVER • + Certificate of Occupancy $ SII Building/Frame Permit Fee $ X Foundation Permit Fee $ � Other Permit Fee $ TOTAL $ Check# 4 61 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS 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: Locate_d 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS q `6ti o L to 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 NOTES and DATA — (For department use) ❑ Notified for pickup Call Email Date Time Contact Name 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 ❑ 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 o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ 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 ❑ 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 Li Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 NORT1� Town of o - '1 No. - W C,o h ver, Mass, 4 -o6v 1. COCNICMIWICN X1,9 RA Te D 0"P S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .......ab'n1.4... 6.0.4 BUILDING INSPECTOR .... .......... . Foundation has.permission to erect .......................... buildings on ..o. 1�. .� � �„ W ....x . ..... ............................................................ Rough to be occupied as .....!EA .. . .......�'....��ro.�......... Chimney 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS 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. RightFax C3-1 10/6/2014 10 : 27 : 35 AM PAGE 2/002 Fax Server A'cQCERTIFICATE OF LIABILITY INSURANCE 10/0 /YYYY) 10/06/201/2014 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PAYCHEX INSURANCE AGENCY INC (A/CNN o,Ext):(877)362-6785 (a/c,No): (877)677-0447 150 SAWGRASS DR E-MAIL ROCHESTER, NY 14620 ADDRESS: a chex@travelers.com (877)362-6785 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT INSURED INSURER B: 2 PENN LLC INSURER C 81 STARD RD. SEABROOK, NH 03874 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 471752425111972 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADOL SUBR POLICYEFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YY MM/DD/YYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any oneperson) $ PERSONAL&ADV INJURY $ GENLAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ ElPPO F—]POLICY JECT LOC PRODUCTS-COMP/OPAGG $ OTHER: ACOMBINED SINGLE LIMIT AUTOMOBILE LIABILITY $ (Ea accident) ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ A WORKERS COMPENSATION N/A UB-5840P522-14 01/20/2014 01/20/2015 X sER FORT AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $100,000 OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS f LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION CITY NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1600 OSGOOD ST BLDG 20 STE 2035 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE � • ��", ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Super isor Spei:altN License: CSSL-100188 LAS, —�I CI SS George D Pennimair 81 Stard Rd r, s .Ajc)/\q Seabrook NH 03974i 5i,2, j /JL_ j1'141`` Expiration Commissioner 01/08/2016 Vfle (Qa77znla7ztueQ'G��a�U!/Lcc9JcrcfLrcJe��Q Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR egistration: 160121 Type: xpiration: 6/25/2016 DBA — I 2PENN i GEORGE PENNIMAN 27 PICKENS AVE. SEABROOK,NH 03874 Undersecretary 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 pd Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Hom er Info ahon Contractor Information aura^ no Company Name Q l� Stree[ ddress(do not us`ee as Past(?Rice address) Contractor/-PooSPcnninnari alesperson/Owner Na nee tY � Stale Zip Code Burin!Ad (must include a street dress) F# 38 I}aytt one Evening Phone Crty/I'own State Zip Code Mailing Address(h different fiom above -t I u •� `-'' Business Phone Federal Employer ID or S.S.Number I—requim that moo bome Home tmteonmcrt ComactnrRc&Nm W Fap ndate :npm reg tm otnumber a I LO n 12-1 2b 1�{ a valid registntioo number The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if neces�.) Required Permits-The following building permits are required Proposed Start and Completion Schedule` g schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractors control arise (Owners who secure their own permits will be `� excluded from the Guaranty Fund provisions of O J7Date when contractor will begin contracted work. MGL chapter 142A.) c O YDate when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of. Payments will bWade according to the following schedule: upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) - $ / or upon completion of $ _/ or n completion of $A, � �upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special t ✓to be paid for .�-- ordered before the contracted vwrk begins in order to meet the completion schedule.(**) S Abe paid for NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express warranty-Is an *mess warranty being provided brthe cootnctory — ❑No❑Yes fall terms of warranty must be attached to the contract) Subcontractors The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home bnorovement Contractor Re stration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information sothat you can confirm coverage,or ask to see a copy of a"proof of insurance"document • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. d at a place other than the contractor's normal place of business,provided you notify the You may cancel this agreement if it has been signe contractor in writing at his/her main office or branch Pce by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the s4kfollowing the signing of ent. See the attached notice of cancellation form for an explanation of this right. D NOT STRACT IF THERE ARE ANY BLANK SPACES!!! T'wocopies of to t be couple and si should to the hoeueoaver.The other should be i cePY So cops' /kept by the eowractor. o ign Contractor's Sign _.- Sir• iY �' �f- . � �P Date Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The co d the homeowner hereby tually agree in advance that in the event the contractor has a dispute ceming this con t,the contrac r y submit the dispute to a private arbitration firm which has been approved by the Secretary of the Exe utive 0 onsumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitr vi d M chusetts General Laws,chapter 142A. er a Contractor's S' ature Ho s OTICE: a sign tures of the parties above apply only to the agreement of the parties to alternative dispute resol n initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this tion is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided.by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where e homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional.Information If you have general questions or need additional information at►A�Massachusetts Coout the Home nsumer Guide to Home Imp oprovement Contractor Law�ement r other consumer rights,or if you wish to obtain a free copy contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at bgp://www mass.eov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the MC website at httV-//wwWmass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http//db stale ma us/homeimprovement/licenseeiist.as For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 version 2.1-tin_v2010 We CQmmumaM offfassa0useft 00 WaAiaeon S`iled -8040711 MA 02. 11 WNW-massy gerPlAz ' Workexo'CoxnpemationbsuraxtceMdavif:7 n erg fCo c o I Icy re c an 1�'iii�b�c, nAgan 'X ase xzn h NaMO(Business/dzgaztizationlind%viduat}^ L L Address. CityfSta��f �, �e2-a�lL DL Phol,e 9��- 7Z 5 ` (-/4-IT ,xf) ou an employer?ekeel p appxoydatebox. Typo of project(xe%*ed)' 1, ara a employer with _ 4. 0 x ain a gal exal cautactox a-Ad I 6,. []Now e, ew c6nst 60A emplayees(��xlland(axpax�time}T have hiredthemb-contractors listed ontho atiached sheet; `/. f]Remodeling 2.❑ S am a-ole proplotor or pa fnc sip and'liava�za.employees These sub-contractors lxave S. �Demolition woxkiug foxxne in as oapacity. workers,comp.insurance, 9, 1(Bugding addition PTO worliexs'comp.instamnce S. E]Weaxe a xatioxx CI its 10.]Electricalxepairs ox additions xe�ed.] o�C"zcexs haveavo exexcised.their xiht o.�exemption or MOL 1141 PIumbing,xepairs or additions 3.[ Z am a homeowner doing all work g p p myself u oworlcers'comp. c.152,§l�'},andwehave a -t2 00%xe taixs insuxazzc re ed. employees.[S awoxkers' 1 .CI©tliex � coxnp.insnrancexeciuixed.� . ;Any applicanitlaat ohecksbox0f musEaisOfillauttheseogoncompensation.policy Womation. S omeovtners wbu submittbis affidavitmdreatingthey 'to dying a1lworl andtben hue outside Contractors mvstsuhmt ane-w affidapit indieaivig size&. x�ontracfors�diat cb.eekthis bob mustaffached an additional sbeetsliovtingtbename oi'the suh-coniraetors andthei�workers'comp.polzcyinfozmaiion. x am carr ern `oyet'tiic fsovicingoer *cornpe�aat�or�insr�Yarzce fot<Y.�y exIoyees. Seror iz/ieralicy rirt �oi�`e iYZ,f0;7'�li1Z�L072. �� 2nsuxance Cornprany�l'ame;. / ��✓.��i�-t .. �olioy r ox eZ ins. ic.#. ✓S S�.RS�a— 1 0' ExpixationData: fob bite fi cldxess;; _C,e Ian,e�r� fC%tylSfate/dip: /v the%V ttac a copy oz t ewox exs'conzpensatiox�-Polxeyaecbxatzoupage(stow.iug,tltepolley Umubexand ePitatzo�x elate). Failure to secuxo covexago as xegxedunder Section 25.(x.of1V.�'Gl,c.152 can leadto the imposition o£eximinal enaTtzes of a :fto up to$x,500.00 andlox ono-year impxiso�vneritx as we'll.as ObApenardes in e£arxo of a TOP-WORK OEDE and a Mme ol:up to$250.0o a clay againstthe-violator. De advised that a copy-oDhis statementmVbo forwardedto the 000 flf• Investigations ofthe DIA.fox inspxance covexago Vexiflcation. too Xiereby eel-ggip under tl2e jainst anti renal ieg of pe.�,j lY trial a`rie ir2,�oM9at`ion provir�eakO 9 ue aNd eoffee�, Si axe• Data: #- P Ofcifl u s a mly, Do not rl'rife in 616 area,to be eomWTeted by city or town ofeiaf. +CRy or Town: Eexxaztl ,zceuse# fsaingAnthoxity(circle ooze); I.Board offfaalth�.Builcli�agDe axt�xten� �.Cityl 'owbt Cle�l .ElectxicaY i eetox . 'l hingJCrts�ecto 6 Outer Information and Instructions Massachusetts CenexalLaws chapter 152xeclttires all em: topxovidewoxkexs'compensationfoxtheiremployees. Purstxarit to this statute,an e�riloyee is defined as",•,every person ii t�1ie service of another under any contract o hire; • o4ress orimplied,oral a itten." . .�.er�Zoye�is defined as"an.z�cdipzdual,paxinexshz�,assoczatzo�cox�aratzon o�otliex regal entity,ox aay eta oxmore Of tba toxegg�ng engaged in a jolht enterprise,and includingthe legali-eprosentatives ofwdeceased einpl4 ex,. or the redeivex o trustee ofan dividual,paxtuership,association or other legal entity,employing employees. Mwaver the owner of a dwe7Iinglxousahavivgnatxnoxethantbxee aparknents andwboxeszdas',.hereiu,oxt�,e occu,�anto£the dwellinglouse ofmother who employs,persons to do maintenance,construdiouoxxepaxrwoxleonsukdwellYnghouse or on the grounds orbui&g appurtenant thereto sballnot because of such ein ploymeatba deemedta ba an employer.,, MUL chapter 152,§25C(6)also states that"every state or Neal�C-ening agency shall withhold the issuance or renewal of a Reense or pemit to operate a business or to construct buildings in the commonwealth for any applicant who has not pro drzced•acceptable evidence of compliance with,the insurance coverage required:' Addition0y;1VCL chapter 152,§25C(7)states"Neither the commonwealthnox any ofits political subdivions shall enter into any contract fox ilia performance ofpublie work until acceptable evidence of coznplianca with,trio insurance requirements Of this cha&xhavebempresentedtatUmotractingauthority2' A11cants Pleaso fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation,an(%if iiecessaxy,supply sub-coniractox(s name(s�,addresses andhonenumbex(s)alongwztb their cextzftcate(s)of insurance. LunitedLlabilityCompanies(LLC)orUm.&dL4bilit Partnerships(LLp)v&hno employees othexthattthe members orpgrtnexs,are notreq_uixadto carry workers'compensatiozzinsuranca. Is anLLC oxLLP doeshava employees,apolicy isreguired. Ba advisedthatthis af�davitmaybe mbmittedto theDepartanent of Industrial Accidents for confirmation ofinsurance coverage. Also be sure to sign,and date the afdavi: 1te afadavit should bexetumedto the city or townthattha application fox theperuiit orlicenseisbeingxecpzested,notheDepaxtment of fadustrialAccidenfs. Shouldyou have any cluestionsregardingihe law or you axerecluiredta obtain a*orkexs' comp enation policy,please call the T epartm ent at the mzmbex Iisfed below Self insured companies should enter their • se7finsuran-ca�cense number ontlte appropriate lixte. City or Town 0MCIals I'leasabesuxathattltea"r"�tdavitxseompleteanclpxinteclZegibly. TfteDepartmenthaspxovidedaspaceatthebofLoxrt ofthe aff!1davitforyou tof[RMtiu.tha event the Office Oflnvestigafionshasto contactyouregarding the applicant. Pleasabe-sure to flu t/llcensenumbexwbichwillbeused asareference number, haddition,auappi1cattL theor-est submitmaltipla permit/11cense applicatIons in,any'gzvenyear,need only submit one afadavit iudicatingo &tr&& poky Momzation(ifnecessm7)and under"Yob Sito Address"the appiicanta ouldwxite"alllacatiorzsin (city or towzt:'AcopyA&afffdaei that hasbeanOfdciallystainpedOrInaTkudbythecityortown.maybapxovidedtothe applicant as ptbofthat a valid orlYcenses. Anew affxdavitmustbDiMeLaouteach Year.Where ahomeowner or citizen is obtaining a license oxpennitnotrelated to anybusi ums or commercial venture (i,e.a clog license orpermt to burn leaves eta.)said person is NOT required to complete this affidavit. . The Office of Xnvosdgatfons would Rka to thatkyou in advaucefor your cooperaflon and shouldyo-uhave any questions, " ,please do Rotb.esitafo to give us a call. ThuDepaAm.eaes address,telephone andfaxnumber. The CQM-.mu -Galth ofMawsaoAv._.SP 6 Q Was�ngtaa.Stxeqt DoatQn, 02111 TOL 9 617"72L,4.-0Q Wx4o6 Qr I-87 MMM _ ReviA 5 2605