HomeMy WebLinkAboutBuilding Permit #437-2017 - 205 BARKER STREET 10/24/2016 NORTH
BUILDING PERMIT °�
TOWN OF NORTH ANDOVER o
APPLICATION FOR PLAN EXAMINATION
of ��a
Permit No#: Date Received ��'°R rE°yea �y
�,may gSSAC NUS��
Date Issued:
EWPORTANT: Applicant must complete all items on this page
a ;
' LOG�AT1DNi -
PROOERTY OWNER' Cc'_ '- _ - -- - _ _ -
Y
_r Pnnt lt)D.,YearSf;ucture no
_ _
MAPPARCEL: ZONING ®1STRICT'______H�stonc Di`s"_tnct= ye nod
_ ._ _ - -.
Machine Shop,Village ye� 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
p Septic �rWell, Floodplain p Wetlands L=] Watershetl:D�stnct
_0
,WaterlSevirer -
DESCR�PTION�OF WORK TO BE PERFO MFDt
IaU h1 ,c
I
Identification- Please Type or Print Clearly �3��
OWNER: Name: 1 S C `��'1) y Phone: �7S 77�
Address: arCr�
CP d
Contract Name:. 9r I _ _C,7 j,_ _Phone:_-
Email ._ er_.
u�
Atldress _.
Supervisor's;Cons ruction.License. E-w Date
_ _
Horneilm�ro, ement License:_ . �1- - G D- �_. __ T Exp_ ®ate
ARCHITECT/ENGINEER Phone:
i
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ IS d O O FEE: $ 1
Check No.: Receipt No.: `d��
NOTE: Persons cont acting with unregistered contractors do not have access to the guaranty fund
signature of Agent/Owner Signature of contractor '
Location � Z ,
No.43f ( Date
• - TOWN OF NORTH ANDOVER
t ,
• Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $ _
TOTAL $ !
Check#
Building Inspector
c
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
i
i
CONSERVATION Reviewed on Siqnature
COMMENTS
Y+
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals:Variance, Petition No:
Zoning
• g Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
_ Located 384 Osgood Street
FJREDEPi4RT empDum to
F MENTI p
si r on site ,yes ono _
rLoc-at-e'd 24AMaiWfireet
FiretDepartrrienignature/date
COMM
ENTS
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 Permit 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
❑ 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
❑ 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
NORTH
Town of
s _ sAndover
4 O `1. ~•�
hver, Mass, Za Z!O
COCNIC
NEWIC ��' a
S U
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT ........� A.L..S.Sa.!d......... I10......... BUILDING INSPECTOR
has permission to erect ............ buildings on . �irr. z�0e�� 57r Foundation
.............. .... . .. ........ . .................
Rough
to be occupied as .vow/?ingjtfils �
.. .. ru........ZI4�..�.�.�... ............................... Chimney
provided that the person accepermit 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 CONSTR TION T Rough
Service
.. . .. ... . . ..........
Final
BUILDING INS CTO
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.
STORE COPY
INSTALLATION SERVICES CUSTOMER CONTRACT
f
LOWE'S OF SALEM, NH, STORE ff 2382STORE PHONE:(603)681-4218
541 SOUTH BROADWAY SALESPERSON:
SALEM, NH 03079-4499 SALESPERSON ID: 1357741
Document Print Date:09/21/2016
This is only a Quote for the merchandise and services printed below. This becomes an agreement upon payment and issuance of a Lowe's receipt, upon which the entire agreement, including the
specifically completed pages of this document,the Terms and Conditions Included with this document,the applicable portion(s)of Lowe's receipt,andany other addenda or attachments hereto,shall
be referred to herein as this"Contract.'PLEASE READ T D E SIGNING,
Lowe's Registration or Contractor License Number/Lowe's Contractor Name
Lowe's Home Centers, LLC-MA HIC NO.: 148688 Lowe's Home Centers,LLC-FEIN:56-0748358
- Customer Name - - Home Phone
SOLD CHRISTINA CATINO 978-771-3116
Customer Address Other Phone
TO 205 BARKER ST 978-771-3116
City State/Province Zip/Postal Code
NORTH ANDOVER MA 01845
PROJECT SUMMARY
Category Comments/Scope of Work Amount Addendum Reference Barcode
PROJECT SELLING No Comments $ 683.82 485628890 - PSI-
F-ELECTRICAL
PROJECT SELLING Customer declined shower door $ 393208 485621916 - PSi-
F-PLUMBING
PROJECT SELLING. No Comments $ 1753.28 485628863 - PSI-FLOORING'
TILE �
PROJECT SELLING No Comments $ 3468.75 475941771 PSI-GEN SVCS
i
PROJECT SELLING No Comments $ 1406.68 485628947 - PSI-
PAINT-MILLWORK
Store 2382 Project Summary for CHRISTINA CATINO Page 1 of 7
i
STORE COPY
PROJECT SELLING No Comments $ 978,75 485628908 - PSI-
R-ELECTRICAL
PROJECT SELLING No Comments $ 2943.50 485622040 - PSI-
R-PLUMBING
Materials Price $ 4330.1101
Note: Please see Contract Addenda for a more detailed merchandise and installation description. Labor Charges $ 10911.7
Detail Deduction -$ 75.0
PHOTO RELEASE: Customer grants to Lowe's and Lowe's employees the right to take photographs of all work performed at the Premisis related to this Con-
tract, and irrevocably grants to Lowe's all right, title and interest in and to the photographs for use in all markets and media, worldwide, in perpetuity. Customer
authorizes Lowe's to copyright, use and publish the photographs in print and/or electronically, and agrees that Lowe's may use such photographs for any lawful
purpose, including, but not limited to, marketing, advertising, publicity, illustration, training and Web content. By initialing here, Customer agrees to the forego-
ing. [Customer to initial to the left].
Additional Specifications: Federal law requires Lowe's to provide you with the pamphlet Renovate Right: Important Lead Hazard Information for Families,
Child Care Providers and Schools. By signing this Contract, Customer acknowledges having received a copy of this pamphlet before work began informing
Customer of the potential risk of the lead hazard exposure from renovation activity to be performed in Customer's dwelling unit.
TOTAL CHARGES OF ALL MERCHANDISE AND SERVICES 'where applicable
n SUB-TOTAL $15166.8
*TAX $ 0.0
DELIVERY $ 0.0
ORDER TOTAL $15166.8
BALANCE DUE
Work is to commence upon resonable availiablity of Contractor and/or any special order or custom made Good(s)which is anticipated to be 1 (: [fill In date].Es-
timated completion date is_ � _/ „ [fill in date].
Said estimated substantial completion dat is not of the essence. A statement of any contingencies that would materially change said estimated substantial completion date is as fol-
lows:
(if applicable, insert a statement of such contingencies).
Store 2382 Project Summary for CHRISTINA CATINO Page 2 of 7
STORE COPY
NOTICE TO CUSTOMER
I
All items listed in this contract and specification sheet(s)are to be installed under conditions agreed upon at time of purchase and at the price appearing on this contract form.This assumes sound ex-
isting substructures,superstructure and points of attachments.Extra labor or material incident to installation necessitated by defective substructures,superstructure,points of attachment,or the moving
of fixtures or appliances to be billed at extra cost to customer.
IF THE CONTRACT TOTAL IS St 000 00 OR LESS Customer must pay in full.
EXCEEDSColopLgIg THIS SEC-nON ONLy WHEN THE CONTRACT TOTAL
Customer to Pay in Full;OR
[^)Customer to use the following payment schedule:
(1)Deposit$ to be paid upon signing contract.Deposit should be 1/3 the total contract price;and
(2)Payment of$ to be paid anytime after this Contract is signed and before commencement of installation,I/We authorize Lowe's to do one of the following(check appropriate box be-
low):
[—)Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed;or
[_]Deposit my/our check for the amount of the payment indicated above anytime after the date this Contract is signed;and
(3)Final payment of$100.00 to be paid upon completion of the installation and both parties'satisfaction.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CONTAINED IN THIS CONTRACT AND WHICH FOLLOW
THE SIGNATURE PAGE(s).BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ,UNDERSTAND AND AGREE TO THE TERMS.AND CONDITIONS SET FORTH IN THIS
CONTRACT.YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE.
NOTICE REGARDING ARBITRAI]T Q,[_V AGREEMENT FOR CLAIMS COVERED BY M.G.L.c 142A
,LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT,THAT LOWE'S MAY SUBMIT SUCH DIS-
PUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS
AND THE OWNEFJ SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN M.G.L.c.1 42A.
d
.....-_....-..
Low 4IHome Center`i I C
By:,.__. Date.
Owner
By: Date:
Qg-Owner or Witness
THE SIGNATURES OF THE PARTIES ABOVE Y To THE AGREEMENT OF THE PARTIgS TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY LOWE'S PURSUANIIDLIVIS&L
INITIATEc.142A,THE OWNER MAY BE PERMITTED TO ALTERNATIVE DI TI EVEN WHERE THE SECTION ABOVE IS NOT SEPERATELYBY THE PARTIES,
WITNESS OUR HAND(S)and SEAL(S)BELOW THIS DAY OF _ .._
Store 2382 Project Summary for CHRISTINA CATINO Page 3 of 7
North Andover — Online Permit Application FAQs
How long is this.going to take?
Only a few minutes. The first application may take a few additional steps because of registering and learning
the new process. But after that, it'll be even quicker!
How do I get started and apply for a permit?
1. Go to northandoverma.viewpointcloud.com.
2. Scroll down to Building Department and click Explore.
3. Choose the type of permit (Electrical, Gas, or Plumbing) by clicking Select.
4. Click Start next to the application you'd like to complete.
5. You'll be prompted to log in.
If you're logging in for the first time:
■ Select Sign Up.
■ Enter in your email address.
■ Enter in what you'd like your password to be.
Please note: Passwords must have at least 8 characters and include 1 upper case letter, 1
- lower case letter, and 1 digit.
If you've previously registered on a ViewPoint Cloud site (in North Andover or another town):
■ Enter in your email address and password.
Please note: If you cannot remember your credentials, click on "Don't remember your
password?"to reset your information.
6. Once you're logged in, follow the stepson each page to complete the application.
Whenou-re all done dont or et to to
Y - 9 out!
_
When do 1 pay my permit fee?
! It is strongly recommended that you pay after the permit application has been reviewed and approved by an
inspector. Once you have submitted the permit application,the estimated permit fee will be listed in the
Timeline section (click on Permit Fee). This is only an estimate and might change after the application is
reviewed by an inspector— particularly if additional information is required by the inspector.
*Note: Electrical Permits have a minimum fee of$55 for Residential projects and a $125 for Commercial
projects. Currently, however,this minimum is not reflected in the estimated fee amount for Electrical
permits so that you may see an amount less than these minimum fees. If this occurs, department staff
will adjust the amount to reflect the appropriate minimum fee. We expect to have this issue resolved.
very soon.
You will get notice via email once your application has been approved by an inspector. At that time, you have
the option of paying online (by credit card) or in person. Paying online will-save you a trip back to our office.
Please note that if you chose to pay by credit card,there is an additional 2.9% processing fee (this fee will
already be included in the estimated fee amount).
If a permit is in conjunction with a building permit, the fee cannot be calculated until the inspector reviews the
permit. At the time of submission no permit fee will be displayed and payment cannot be made until the fee is
assigned.
While we prefer that you avoid doing so, if you are already at our office and you do not want to come back,
you may leave a check for the estimated permit fee amount (minus the 2.9% credit card processing fee that is
worked in) listed on the Timeline section. We will not accept a blank check. Also,the payment will not be
processed until the inspector has reviewed and approved the permit application and confirmed the final
permit fee amount.
I received a notification about paying my permit fee. How do I pay online?
Once you have received notification that the permit application is approved and payment is due, simply:
1. Click on the link in the email.
-2. If you're not already, login with your email address and password.
3. Follow the steps on the page to enter your credit card information and pay.
Paying online is easy and automatic, plus all of your information is secure!
What if I don't Want to pay with a credit card?
That's ok. Once you're notified that payment is due, you can come to the office and pay with a check.
What happens next?
After you pay your fee,you'll be notified via e-mail that the permit is available. The permit can be printed
from home (or from any computer with access to a printer). You don't need to come back to pick up your
permit!
Remember
• You can monitor the status of the application from home and see if any other action is needed online!
Just log in to the site and click on Inbox (on the left) to see any current tasks that need your attention
and your active records (current applications).
• Now that you have an account, you can use the same email address and password to apply for all of
you future permits.
STORE COPY
i
Lowe's Hame C nters.LLC
i
B _ l/t/t : -'^, C c C r✓f1•,`
—_ � (Seat) (Seal}
By:_� Owner
Print Name:- j1r1 {."r �'�i�,,12 �. t,�L Print Name: i fto "l Y1
Address: - '.i uPv, RC1 rav-�t Co-Owner or Witness:..__ (Seal)
CITY: ( `' J
_C:-_..!_�...�.._ State:..... -7-1 Zip Print Name:
Customer acknowledges receipt of a true copy which was completely filled in prior to Customer's execution hereof.You the customer may cancel this transaction at any time prior to midnight on
the third business day after the date of this transaction.See the attached Notice of Right to Cancel for an explanation of this right.
i
�h
I
Store 2382 Project Summary for CHRISTINA LATINO Page 4 of 7
I
NOTICE OF RIGHT TO CANCEL 41�-S 19 16 �f .-5�i Y177/
Your Right to Cancel 6 z S /c!7 �,7(,zS"i ,8
You are entering into LOWE'S Installed Sales Contract Number s zzcw �he "Contract") that
may result in a lien or security interest on your home in which property (the "Property" ) is to be in-
stalled pursuant to the Contract. You have a right to cancel the Contract, without cost, penalty or ob-
ligation, at any time prior to midnight of the third business day after the latest of (i) the date of the
Contract, which is rS f Z � r , , (year), (ii) the date you received this Notice
of Right to Cancel, and (iii)``if you have paid or will be paying for the Contract by using your LOWE'S
private label credit card, the date you received your Truth-In-Lending disclosures in connection with
such credit card.
Effects of Cancellation
If you cancel the Contract, the lien or security interest on your home is also canceled. Within 20 cal-
endar days (except in Connecticut where the period is 10 business days) of receiving your notice of
cancellation, we must take any necessary steps to reflect the fact that the lien or security interest on
your home has been canceled, and we must return to you any money or property you have given us
or anyone else in connection with the Contract.
How to Cancel
If you decide to cancel tate Contract,you may do so by notifying us in writing, by mail,telegram,or personal delivery,at:
LOWE'S 030U
You may use any written statement that is signed and dated by you and states your intention to can-
cel, or you may use this notice by dating and signing below. Keep one copy of this notice no matter
how you notify us because it contains important information about your rights. To be effective, you
must drop your cancellation notice in the mailbox, file it for telegraphic transmission, or deliver it to us
by other means at the above address no later than midnight of v � rG
(year) (or midnight of the third business day after the latest of the thr6e events/listed above).
I WISH TO CANCEL.
(Customer's/Resident Owner's Signature) (date)
Print Name
ACKNOWLEDGEMENT OF RECEIPT OF DISCLOSURES AND CERTIFICATION
On this 21st day of September, 2016 (year), each of you hereby acknowledges receipt of two (2) cop-
ies of the foregoing Notice of Right to Cancel; each of you who is a party to the Contract hereby ac-
knowledges receipt of one (1) copy of the fully executed and dated Contract; if any of you has paid or
will pay for the Contract by using your LOWE'S private label credit card, you hereby acknowledge
having received the Truth-In-Lending disclosures in connection with such credit card; and you certify,
represent and warrant to LOWE'S that you are all of the customers who signed the Contract and all of
the persons who own and reside in the home in which the Property is to be installed pursuant to the
Contract.
4 j f
(SEAL) lf 1 (SEAL)
.a �
SS-
Print Name �—
Print Name
(SEAL.)
Witness
Print Name
NOTE : Each Customer who is a party to the Contract and each Resident Owner of the home must sign above.
-,.De Commonwealth of Massachusetts
z Department of IndustrzalAccidents
X Congress Street,Suite 00
Boston,MA 02114-2017
www mass.gov/dla
a'iM 5��y
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plnmbers.
TO BE FILED WITH THE PFpdyM iNG AUTHORITY. Please Print Le 'bl
A �licaut Information
Name(Business/Orgabization/Individual)'
Address-
Ci /State/Zi Phone#: < <
Ase you an employer?Check the appropriate box. TyP pro
'ect a 'red
Ch
traction
em to ees full and/or part-time).'• ']. �Nev7 dOTLS
I.Ell am a employer with P y
to ees Working forme in 8. []Remodeliiig
Py
2.❑I am a sole proprietor or partnership and have no em
any capacity.[No workers'comp.insurance required.] 9, ❑Demolition
3.Q lam a homeowner doing all work myself[No workers'comp.insurance required.]t 10 Q Building addition
<11 am a homeowner and will be hiring contractors to conduct all work on my property. I will
11.❑Electrical repor additions
ensure that all contractors either have workers'compensation insurance or are sole
airs
proprietors with no employees. 12,Q:FP utnblrig repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 110 R.b6f repairs
These sub contractors have employees and have workers' t
kers'comp.insurance. 14.Q Other
6.❑We are a corporation and its.officers have exercised their right of exemption per MGL c.
152,§1(4),andwe have no employees.[No workers'comp.insurance required.]
licy informatiom
•*Any applicant that check',box#1 d�mdr 0uating�Y aze a�gl��work and then hire outside howing theirworkers' aontrac o�s moist submit a new affidavit indicating such.
Homeowners who submit•this affi•.
tContractors that check this iiox trust attached an additional sheet showing the name c the sub-contractors and state whether or not(hose entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
lam an employer that is providingworker=s'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name-
Expiration Date:
Policy#or Self-iris.Lic.#:.
City/State/Zip:
Job Site Address:
i olicy declaration page(showing the policy number and expiuration date).
Attach a copy of the workers' compensation p
0.00
Failure to secure coverage as required under MGL ttez52,s in§he form 5A is a criminal iWORK ORDER aby a nd a fine f up to $2ab up to 00.00 a
and/or one-year imprisonment,as well as civil penal
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
c v Hereby certify under thepains and penalties ofperjury that the information provided above is true and correct.
Date:
Signature:
Phone#: i
Official use only. Do not write in this area,to be completed by city or town official.
City or Town' Permit/License#
1 -issuing Authority(circle one):
1 1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Phone#:
Contact Person:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their ernpl6yees.
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 6f 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 b6 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 xequired."
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 certificates)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 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
IndustrialAccidents. 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext.7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
a101'rae:C"Cleceaettl ; Massachusetts -Department of Public Safety
ice of Consumer Affairs&Business,Regulation {{ Board of Building Regulations and Standards
13 ME IMPROVEMENT CONT i 4 ' Construction Su erg i.+ur ,
{ _ _ CONTRACTOR F
J egistration: 1f9E23,:, } License: CS-107986 r,
Expiratlor>i•.� Type:
g!6/2017 _ _
Supplement Card PETER J MACK e�
Dube Construction Plus,,Enc o
� r
31 SCENIC DRIVE r
7 DERRY NH 0308
PETER MACK
J10 Bricketts Mill Road,Suite;'C" ! �'
Hampstead, NH 03841 t.. `l i Expiration
Undersecretary 06!26/2018
Commissioner
1
�i
•U
'I I