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HomeMy WebLinkAboutBuilding Permit #741-14 - 201 OSGOOD STREET 4/22/2014BUILDING PERMIT �� b���"v"*6.,ryc TOWN OF NORTH ANDOVER 1 APPLICATION FOR PLAN EXAMINATION + Permit NO. f,7 \ Date Received * 'p +� (�9SS�t� Date Issued: �v l cHus IMPORTANT: Applicant must complete all items on this page LOCATION U I U D c A PROPERTY OWNER tev J Print uS MAP NO: PARCEL:-tL Print ZONING DISTRICT: Historic District Machine Shop Vil yes no ves no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer CkA n A �. wk�A— C,�, ,i° 6 , A—A T OWNER: Name: Address: Identification Please Type or Print Clearly) Ph C( s+ N. Q nd ovc r (-na t �7�- �?3 �- -S--3 1 8415 CONTRACTOR Name: v Phone: 50 2 y V-5 g 7 7 JaOntj V- JD F -)n ,SOn Address: t Pr T( W V" Supervisor's Construction License: Exp. CS0177U9 Home Improvement License: Exp. 1-7 �3Ca� J (YYG� ())g -7(o 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: $ 1(4.)00() FEE: $ ' Check No.: Receipt No.: NOTE: Persons contr t with unregistered contractors do not have access to the guaranty f", d Signature of Agent/Owner =. Signature of contractor .f±AAW - '- Plans -Submitted ❑ -Plans Waived ❑. ,--.Certified Plot Plan ❑ . Stamped Plans ❑ TYPE OF:SEWERAGED3SRDSAL Public Sewer ❑ Tanning/MassageBodyArt ❑ Swimming Pools ❑ Well ❑ Tobacco.Sales Food Packaging/Sales ❑ Private : (septic tank, etc:_ El._ - : -. � permanent Dunpster on oSite El THE -FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM -:,..'DATE REJECTED DATE;APPR-OVED PLANNING & -DEVELOPMENT ❑ ❑ COMMENTS -CONSERVATION COMMENTS HEALTH COMMENTS Reviewed on Sidnature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comme Conservation Decision: Commen Water & Sewer Con neCtion/Si_gnature & Date Driveway Permit DPW Toon;:; engineer: Signature: Located 384 FIRE DEPARTMENT -`Temp Dump;ster on site yes.. no Located -at 124.Mair, Street - Fire Departmeiitsignatureldate- COMMENTS Street ,Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total- land area, sq. ft.; ELECTRICAL: Movement of. Meter location; niast-or service drop requires approval of Electrical Inspector Yes No DANGERZONE LITERATURE: Yes No MGL -Chapter- 166. Section 21A -F and G min.$10041000 .fine IVU I hS and DATA — (For department use ® Notified for pickup - Date Doe.Building Permit Revised 2010 Building Department `-The fol;-3wing'ig a list of -the required.forms to be -filled ouffor:the appropriate permit to be obtained. Roofivg, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I:C. And/0'r C.S.L Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o 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) o 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 o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o 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 apw• 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.Bui?ding Permit Revised 2012 "� I Ds!�ODCT Location (moi No. - Date �Z•- �� Check # R TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $Ak�- Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector 0 w 0 rA E9* = J w LL Ol7 02 m v U Y \ a O O Nm h N U a Q) N O U a Z Z c O a 7 LL 0C w N C LL O a Z Z J d t d' - F LL W a Z u or U J L1J ..0 7 d' v u i y _ fo LL O w h Z Q C7 L j w _ N LL W Q w w oC LL N c CO Z y, CU v N ++ in v O V7 i of o O CL a► 0a — o NCLO d N ANON; E a► E h � c F' o� � o — ,No �P O *'� 3 CLCc y J m ' C 41 O > y 0 O y _ :� aE0o . a► o z n.C.o N O 0 c L Qua �� v+r.c 0 ' Q cc N CL O '� N O V m N W O - O O LLO '' Na O V1 'Q s O umlW E lu V c���0 v as 0-0 Cl) 0 '> � _ O O +o+ O 0 al L Z � 3:ni 0 PA 4r 0 w CL U) z 0 z 0 J m v 0 • N Z 2 U C.� 0 E Z 0 r� L: CL cm 00 me so JIMJOHNSON CEDAR SIDING * WOOD SHINGLES *HOME IMPROVEMENT TAX ID# 030607842 CONSTRUCTION SUPERVISOR LICENSE# CS077709 HIS LIC# 178362 FULLY INSURED 11 Woodcrest Drive, Tewksbury, NLA 01876 Phone (978) 851-3858 Mobile (508) 344-5877 DATE: April 21, 2014 Klaus Szyska 201 Osgood Street N. Andover, MA 01845 )OB LOCATION: 201 Osgood Street, N. Andover, MA DESCRIPTION., House Remove existing cedar siding on house Replace with pre -primed finger jointed cedar clapboard Prim all cut ends — nails will be SS ring nails Install Taypar paper/tape all seams Install round soffet vents every 16" Replace one(1) 1x8 cornerboard — cracked, broken board Remove debris Install new window flashing Install new shutters on front and two sides Barn Remove existing cedar siding from front of barn only Install pre -primed finger jointed cedar siding front of barn only Repair pine trim on rear of garage Total job cost: Payment Schedule: $10,000.00 upon completion of striping/repapering/stock delivery/main house $6,000.00 upon completion of job James V. Johnson, Contractor Klaus Szyska, Homeowner $16,000.00 A� V CERTIFICATE OF LIABILITY INSURANCE ��( 4/21/14 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 polic)(ies) 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: G.M. INSURANCE CENTER, INC. PHONE FAX 978) 937-0280 • (978) 937-5747 I No: 850 CHELMSFORD STREET E-MAIL ADDRESS: LOWELL, MA 01851 INSURER(SIAFFORDING COVERAGE NAIC# INSURED James Johnson 11 Woodcrest Drive Tewksbury, MA 01876 INSURER A : INSURER B: F: COVERAGES CERTIFICATE N UMBER: 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 LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF M/DD/Y POLICY EXP MMIDD/YYYY UMTS B GENERALLIABILITY' X COMMERCIALGENERAL LIABILITY CLAIMS -MADE � OCCUR BMA0019798 6/7/13 15Arf"I EACH OCCURRENCE $ 11000,000 O RE DPREMISES AMAGE (EaccNTEDnce$ 100,000 MED EXP (Arty one person) $ 10,000 PERSONAL &ADV INJURY $ ] 000,000 GENERAL AGGREGATE $ 2,000,000 RGEN'LAGGREGATELIMITAPPLIESPER POLICY PRO LOC PRODUCTS-OOMP/OPAGG $ 2000000 $ AUTOMOBILE LIABILITY ANYAUTO ALLOWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS _ AUTOS COMBCdErt) INGLELIMR $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ araccidenI $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY. ANY PROPRIEIOR/PARTNER/EXECUTNE Y/N OFFICERMIEMBER EXCLUDED? 7 (Mandatory in NH) If es, describe under DESCRIPTION OF OPERATIONS below N/A TBD 4/21/14 4/21/1 X WCSTATU- -ER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE -EA EMPLOYEE $ 100,000 E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space isreguired) t;LKIItIGAILMVLUtK - t.AN%,rLLAIIVIY TOWN OF NORTH ANDOVER 120 MAIN STREET NORTH ANDOVER, MA 01845 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 ,.. - - © 1988-2010 ACORD CORPORATION. II riahts reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: ow Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements ofthe 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 Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Name Company Name Street Address (do not use a Post Office Box address) Contractor/ Salesperson/ Owner Name City/Town State Zip Code Business Address (must include a street address) Daytime Phone Evening Phone CitytTown State Zip Code Mailing Address (It different from above) Business Phone IFederal Employer ID or S.S. Number Lary requires that most home improvement contractors have valid registration number Hame Improvement Contractor Reg. Numbs Expuationdate 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 necessary.) fr6�°S'4 L Required Permits -The following building permits are required Proposed Start and Completion Schedule -The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work. MGL chapter 142A.) Date 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 be made 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) by / / or upon completion of by _/ / or upon completion of $ 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 $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be 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 express warranty being provided by the contractor? ❑ No ❑ Yes fall terms of the 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 affeement 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 Improvement Contractor Reeistration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home hnprovement 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 so that 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. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of the contr et must be completed d signed. One copy should go to the homeowner. The other copy should be kept by the co tractor. V Home er's Signature Con tor's Signature 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 contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws, chapter 142A. Homeowner's Signature Contractor's Signature NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section 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 the 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 about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" 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 http://www.mass.Rov/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 HIC website at http://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeimprovement/licenseelist.aV 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 -11/22/2010 A NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR OBLIGATION, WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE, AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU CANCELLATION NOTICE, AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED, ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION, YOU MAY RETAIN OR DESPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO, THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO [Name of Seller], AT [Address of Seller's Place of Business] NOT LATER THAN MIDNIGHT OF (date). I HEREBY CANCEL THIS TRANSACTION. Date: Buyer's Signature: M The Commonwealth of Massachuseds - Depapiment of ludiistrirclAccidii�-ts Office oflnvesiigations 600 Washington Street .Foston, MA 02111 www.massgov/rlia Workers' Compensation Insurance Affidavit: Builders/Contractors/Blectriciansfflliimbers A�pulieant Xnforrnation . Please Print Legitbly ' NaMC (Rusin oss/Orgauizaiionftd%vidual): JA44 e s V o h n�oN .Address: W D Q b CCCS 1 1) k- City/State/Zip: Tf( KS bur y Phone #: Are you an employer? Cheel a appropriate box: Type of project (required): 1. ] T am a employer with 4. ❑ I am a general contractor and 1 6. [] New construction employees (full and/or - ' e). 2. El am a sole proprietor or p or -listed have hired the sub -contractors on the attached sheet. 7• ❑Remodeling ship auld'have na employees These sub -contractors have 8. E] Demolition working for me in any capacity. workers' comp, insurance. 5. ElWe are a corporalon and its 9. Building addition [No workers' comp. hnsurance required.] officers have exexcised.theix 10.[] Electrical repairs or additions 3. El am a homeowner doing all work right of exemption per MGL ME] Plumbingxepairs or additions myself. [NO workers, comp. c.152, §1(4), and we have no 12.❑ Roofrepairs insurancere edi �'. � employees. [No workers' 13.❑ Other comp. insurance required.] Mny applicautthat checks box#1 must also fill outthe section below showingtheir workers' compensaffoupolicy information. %'Homeowners who submit this affidavit indicatingthe j� ke doing allwork and then hire outside contractors must submit a new affidavit indicating such. TContractors that cheokthis box must attached an additional sheet showingthe 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 in, formation. insurance Company Name: fi r'� Fo Policy # or Self ins. Lic. #: Expiration Date: _ r Job Site Address: Z O I OS C-oo !� ST_ *-Moo V ff -Pity/ State/Zip: Attach, a copy o#the workers' compensation.'p oliey declaration page (showing the policy number and expiration date). Failure to secure coverage as reuiredunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a :Cue 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. B e advised that a copy of Ibis statement may b e forwarded to the Office of- Investigations fInvestigations of the ATA for insurance coverage verification. Ido lierehy cert under thepains an�cl pengfes of perjury &at the information provided above is true and correct. Phone #: Official use only. Do not write in Mis area, to he completed by city or town official. City or Town: PermitlLicense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbinglnspector 6. Other - Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation fo: their employees. Pursuant to this statute, an employee is defined as "...every person tri the service of another under any contract of hire, express or implied, oral or written." An employee is defined as "an individual, partnership, association, corporation or other legal entity, or anytwo ormore of the foregoing engaged in a j oint enterprise, and including the legal representatives of wdeceased employer, or the receiver ortrustee 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 employes." MGL chapter 152, §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 subdivi'sions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the iasuxance requirements of this chapter have beenpresented to the contracting authority." Applicants Please frill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supplysub-contractors) name(s), addxess(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 notrequiredto carry workers' compensation insurance. If an LLC orLLP 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 tali, 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 andprinted 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 -sue to fill in the permit/license number which will be used as a reference number. In addition, an applicant thatmust submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Sob 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. ii on file *for future permits or licenses. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license ox p ermit not related to any business or commercial venture (i.e. a dog license orliermit to burn leaves etc.) said person is NOTrequired to complete this a�Cxdavit. The Office of Investigations would like to thank you in advance fox your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Tho Co oa toalthofWassachyseils Department offhdusfxial Acddents office ofJA-'VestzgAtim 600 Wakkgtoia. St:eet Boston, 0.21.11 TO, # 617-7-2Z-4900 W 406 or 1;-877,M SAF., Devised 526-05 Fax 617-72M749 • v�.�ass,govf�a 2' m � \ \ Cl) \ $ CM, \ \ \§\ «:a»y§�22� 3§} \ \CD0 / f§� 'J2 . s@® a:7 7 \ / b r§ o o > H / a £ _ m ; . / ] 2 2 O m \ Coc . 2 ° 9- E k § « ] ■ , , 00� e o } \ 2 \ 2 _ w mm,�\ } ° . % \ 2 \ / Wim( =■k\@ . § / ■ m �& «� \ t6 ? » m x; . /c27�' z�\J$ N) f/ \r / f �. } / 7 2 CD/ k �§ ' Eƒ « o % W � /