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HomeMy WebLinkAboutBuilding Permit #868 - 202 GREAT POND ROAD 6/13/2013TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: at I > (Y IMPORTANT: Applicant must complete all items on this page 'P I'M -13 0 -9 no Q -'0- S, r! �O o*' !In 40C ®r : RA, PRO*.,' :PARCEL H�fiq f -o F i &JO i 9t f i gg no-� i 0 -a TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El New Building iKne family 0 Addition D Two or more family El Industrial OPIteration No. of units: [I Commercial El Repair, replacement 0 Assessory Bldg El Others: 0 Demolition 0 Other wo, n d§ Efl:W, 40" qt�r, h- I R -.- DESPRIPTION OF WORK TO BE PERFORMED: V\ CA o- JnaTk,,^nnxA in ko-gem& &-&-T— OWNER: Name: Address: ification Please Type or Print Clearly) cxbcc- Ph T -Q;--(9NTTRA'GTFQP,,,' N H,-honb*,,3 y 10V Name: 4A 17 Address. a....... 0 C"k $0_l �S-Upe ii§of,'s.Obh uq-fibhQiE-ehs�e:-. &S- .0 ,rove. H,' o men't��'-Jbienso.,". J -b- cftp / I f uc�' I - Y 7,)e ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. 'Total Project Cost: FEE:$ C Check No.: Receipt No.: NOTE: Persons contra wnWiikml nregiisteread contractors do not have access to the guaranty and 'Signature of- �'enyowhet-. Plane .qiihmiffPr1 n PInncz Wnixipri F1 ('Prfifitnri Pint Plan F1 Stnmnprl Piqn--, F1 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OYSEWERAGE.DISPOSAL Public Sewer ❑ TanningWassage/BodyArt Fl. - 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 PLANNING & DEVELOPMENT ❑ COMMENTS DATE APPROVED CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . _ ePlanning Board Decision: Comments '4Conservation Decision: Comments Water & Seger Connectio7➢/SlQna$ure � Dafe Driveway Permit DPW Tawn Taw]Engineer: Sign Located 384 FIRE -DEPARTWENT - Temp Dumpster on site yes no Located at'124 Main`Strdet Fire Depa�iziefit.!§igiiatureldate COMMENTS od Street enSlon dumber of Stories: Total square feet of floor area, based on Exterior dimensions. �otal land area, sq. ft.: LECTRICAL: Movement of meter location, mast or service drop requires approval of lectrrical Inspector Yes No �A��ER®SIE LITERATURE: Yes No. NIGL Chapter 166 Section 21A- F and G min.$100-$1000 fine 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 TOTE: 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application Q Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ® Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products OTE. All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit lin 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 app> al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording rrmst be subm:-tted with the building application Doc: Doc.Bui!ding permit Revised 2012 Me Check # Date 13 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $- TOTAL $ '97ild—ing Inspector I Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ - $ 180.00 Plumbing Fee $ 22.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 22.50 Total fees collected $ 325.00 202 Great Pond Road 868-13 on 6/13/2013 Add a Bathroom in the Basement CM a� M x ii O O a mU L y \ O LL Y ?O N U N N o Z z m C (a 'O O LL t O d' d C i U LL 0 z z d t O w c LL 0 Z v W W -C O 2' N U ` Ln O LL W a ? O d' C LL W cc a W LL LL • L 7%CU i CO z L) N a+ Y O N r 'p O C O t4 V .�0-4 —, � as dQ . o° Q , PIM.IM, 0 s E o = C R v O d � �J L � �m > � � L a� o,=aNi>o N -0 o = =0)� rAq s C�Q N O MM o d 0z MA 0 0 V; ma = 3 Lo� QC.CD CD �. r 0 .N c-0 ED � o=c = 0 0. d O N W = a O O LL ' � L Ig W = � 0-=";: OLU LU E N O .•.. y,,, :ir v v E.v V Q 0-0 cn 0 4- 2 cc O O = O H "s - CLOO w 0 r O E d IL Ln cn N _ O as a� m L O CD C ._ O N CD ._ O z O Q J O O H V . W :a c� c m U) r OU � O z V W _ H U) a- z xLLJ O U) Lu W J a= E w 55 E z N N •E CLL O v CL V .Q c) CL(A w L: CL = r_ m m 9JImprovement Sain,>Rf.e C This fo= satisfies an basic requirements of the slate's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard Ianguage to protect homeowners. Seek Iegal advice if necessary. Any person plannting home improvements should first obtain a copy of "A Massachusetts Consumer Guide to Home Improvement" before agreeingto any work on your residence. You may obtain a free copy by caltiag 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 formation 'Contractor ) lffilrmafimn StreetAddress (do notuse aPost Office Box address a Conic tor/ Salesperson/ Own ane 200 G� Pd( City/Town State Zip Code Bpsiness Address (must include.a street address) 1]aytune Phone EveningPhone City/To State pilingA—dd ZipCode ress (It different from above) © 6 r n (00/ Business Phone 33 7- ederal Employer ID or S.S. Number a0 3'D SLS taw requires that mast Itomc HomeImprowmentcontmetorneg;Number Exphtiondate , Improvement contractors have a valid registration number` % L `/9D 6 The Contractor agrees to do the following work for the Homeowner: J (Describe in detail the work to completed, specifyingthe type, brand, and grade of materials to be used, use additional sheets ifnecessarv.) Required Permits -The following building permits are required and wM be secured by the contractor as -the homeowner's agent: (Owners who secure their own permits:WM be excluded from the Guaranty Fund provisions of MGL chapter 142.A_.) Proposed Start and Completion Schedule - The following schedule will be adhered to unless circumstances beyond the contractor's control arise 43 Date when contractor will begin contracted woxlc. U(9/_3Dat0 when contracted wozk will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to performthe work, furnishthe material and labor specified above for the total sum of. e Payments will be made according to the following schedule: W S Vpon signing contract (not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater) $ `ou by / / or upon completion of $ by or upon completion of � upon completion Of the contract. (Law forbids demanding fall payment eontraetis completed to bothpariy's satisfaction) . The followingmaterial/equipmentmustbespecial $ to be paid for ordered before the contractedworlc begins ;r_ order A - to meetthe completion schedule.(.P.r.) $ to be paid for NOTES: (*) Including all mance charges ('i°i1°) Law requires that any deposit or down payment required by the contractor before workbegins 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 advande to meet the completion schedule. •..� wuu actor: u ivo u'Yes aII terms of the warran mast be aihtched to the contract Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless ofthe actions of any third Patty/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and Iabor underthis a Bement 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, c alce sure the contractor has a valid Home Improvement Contractor Rete etratzon. The law requires most home improvement contractors and subcontractors to be registered with the Director ofliome Improvement Contractor Registration. You may inquire about contractor registration by writing to thoDireetor at 10 ParkPlaza, Room 5170, Boston, MA 10211 r by calling .617-97 8787 or 888-283-3757. c Does the contractor have insurance? Aslc the Contractor for his insurance company information so that you can. conium coverage, or ask to see a copy of a "proof of insurance" document. o Know your rights and responsibilities. Read the Important Infozmation on the reverse side of ibis form and get a copy of the Consumer Guide to the Home Improvemen! 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. Seethe attached notice of cancellation form for an explanation of this right. ]DO NO7C''SxGN 7C IfS CO TRACT IF THERE ARE ANY ffAM, SPACEStTr QO deal copies of the contra t must be completed and signed• one copy should go to the homeovmer. Theothercopyshoaldbelceptby flee contractor. Homeownegnaivxe Contractor's Signature 'Date Date Connlracfor 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 affordedto 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 :C .7n 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 patties 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 nardes. Homeowner's Mghts A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 14.2A) and other consumer Protection laws (i.e. MGL chapter 93A) may not be waived in anyway, 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 worlananEce 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/homeowmr 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 patties. Contracted work may not begin uui0 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.paymeut schedule in cases where the homeowner deems him/herself to be financially insecure, However, in insi ices where a contractor dooms hhDiameif to be financially insecure, the contractor may require that the balance o££wids not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of fluids :C= said -account would require the signatures of both parties. Additional Wormation .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'visitthe OCABRwebsite atl1_//ww�v.mass.gov/ocabx! 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 HCC website at bttn-j wv,�,v.tnass gov/oeabi/ Go online to view the status of a Home Improvement Contractor's Registration: .11Q): /db.state ma us/lioyneirnyrovement/licenseelist ash For assistance with informal mediation of disputes or to register -formall complaints against a business, calx: Consumex Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4.800, 50&755-2548 or 413-734-3114. version 2.1-11/22/2010 '�CERTIFICATE OF LIABILITY INSURANCE 6Ai13M/20 3rr' 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 NP-AC)MNTEA01 Derek Coffey W. Gochis IneuranCe A an PHONE (781)272-9306 i(Arc,N91_091)272-1362 113 Cambridge St. ADDRESS: rnwuuaK 00005204 Burlington MA 01803 INSURER(S)AFFORDING COVERAGE NAIC0 INSURED INSURER A;C0IIImer0e InS . Co . 34754 INSURER 0: Rene's Custom Carpentry, DBA: Rene Peront INSURERC: 2 Rag Rock Rd. --- INSURER D: INSURER E: Woburn MA 01801 INSURER F COVERAGES CFRTIrICATF NI IMRFR•CL13613 01143 RFVIRIAN MIIMCIFR• 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 OF 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, IN3Ii ADDL SUER POLICY'EFF I POLICY•r;*P LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIODIYYYY MM DD GENERAL LIABILITY EACH OCCURRENCE S }i COMMERCIAL GENERAL LIABILITY I PRF.MI ES (EaENTED pq�MISE5 (C•e occurrence) s ___500,000 _ 100,000 A I CLAIMS -MADE �� x OCCUR CYQDS 7/2012 6/ 7/6/2013 MED EXP (Any arleParton) s _ _-•5,_000 PERSONAL & ADV INJURY 3 500,000 OENERAI. AGGREGATE S 11000,000 GEN'L AGGREGATE LIMIT APPLIESPEA PRODUCTS - COMP_IOP AGG $ 1, 000 , 000 X POLICY PRO- LOG _ $ AUTOMOBILE LIABILITY COMBINED SINGLE UMI S (Ea accidont) ANY AUTO BODILY INJURY (Per person) S ALL OWNED AUTOS BODILY INJURY (Par accident) S SCHEDULED AUTOS i PROPERTY DAMAGE HIRED AUTOS (Per aectlanl) i 5 NON -OWNED AUTOS $ UMBRELLA LIAR I OCCUR I EACH OCCURRENCE S "CEBe LIAR I CLAIMS -MADE AOGREGATE S DEDUCTIBLE g -._ _. _•_ •--.--_- RETENTION S• $ WORKERS COMPENSATIONWC STATU• OTH- AND EMPLOYERS' LIABILITY YIN ANY TORY LIMITS ; ER. - PROPRIETOR/PARTNEWEXECUTIVEI OFFICERIMEMBER EXCLUDED? NIA E.L. EACH ACCIDENT - $ (Mandatory In NH) E L, DISEASE . EA EMPLOYE S If gal dew1bo under DESCRIPTION OF OPERATIONS below EL, DISEASE - POLICY LIMIT S DESCRIPTION OP OPERATIONS I LOCATIONS I VEHICLES (Ahach ACORD 101, Additional Roalarhe 9ohedula, If mora opaca In raqulrod) (978)688-9542 TOWN OF NORTH ANDOVER MA BUILDING DEPARTMENT 1600 OSGOOD ST NO ANDOVER, MA ACORD 25 (2009/08) INS025 (200909) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ®1988-2008 ACORD CORPORATION. All rights The ACORD name and logo are registered marks of ACORD 1.00/100in XVi 60:Z1. EI.WCU9 RENE' L. PERONT CUSTOM CARPENTRY 2 Rag Rock Dr. Woburn, MA 01801 REMODELING CONTRACT To install a new bathroom, in basement level, to include a toilet, sink, and 3' x 3' shower, at 202 Great Pond Rd. North Andover, MA for Mr. Charles 1Z. Della Croce. Payment to be made as follows: 1/3 down payment 1/3 at 50% completion Balance upon satisfactory completion Total Price $15,000.00 I hereby agree to all terms and conditions of this contract Homeowner & 0& Date: Ce < < 5 1 v3 Contractor. F Date: L13113 The Commonwealth of Massachusetts Department of IndustriqlAccidints Office of Investigations qu 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address:_ v- O\a a K o o)l U f, City/State/Zip: 46 6 urn AA o i% ©i Phone #:meq )A7- /Oo Y - Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I ployees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ Ne construction 7. emodeling 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 11. F] Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:, Policy # or Self -ins. Lic. M. Expiration Date:. Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pain JJ d penalties of perjury that the information provided above is true and correct. Signature: a�w) `�-�_ nsta. Phone #: 3'M Da7 —) 0® T Official use only. Do not write in this area, to be 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 - - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the 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 licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their 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 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 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 in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to 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 and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of I>avestigatlons 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877�MASSAFI Revised 5-26-05 Fax ## 617-727-7749 www.zn,ass,govfdla