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HomeMy WebLinkAboutBuilding Permit #835-12 - 211 ROSEMONT DRIVE 5/21/2012Permit NO: k / 'L natA 1cQmQri- BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received .i`2 ijE"�`\�. `.�• 76 q ti TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building 5nE— fami Addition Two or more family Industrial Alteration No. of units: Commercial replacemen Assessory Bldg Others: emo i io Other Floodlain �=�`4���Wbtlandss ,�'��' `� �Waterst ed District �� Water/Sewer�� h. k DESCRIPTION OF WORK TO BE PREFORMED: (� -� _\%cam]\ r_ 1^ � n ik��®ia \\ � _ . �\ C'_• Clear OWNER: Name: Acitiress: Phone: 1-i )t�- 4 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: $ y01/. 01 Check No.: No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agert/Ovvner Signature oftcontractor . 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Y v Conservation Decision: Comments 4 Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: 4 T ta�iM•`• LobatedfatA24 Mai F=iresDepartme iu yW COMMENTRS '� Located 384 j DUmD of onsite .yes .' ...:n T iinc "e;.a•`�' - 1 : 4 # - * � > �` � ]' �y, In v�...I 4 } ,z 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, 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 f NOTES and DATA — (For department use) f . Il f ® Notified for pickup - Date F Doc.Building Permit Revised 2008 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/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ 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: INSPECTIONAL SERVICES DEPARTMENTMFORM07 Revised 2.2008 Location ,F2 Date s� al Xg No. -�f TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee $ //,g el, 6,0 Foundation Permit Fee '14.4 A. 'A Other Permit Fee $ TOTAL Check #;V3 A, 25325 building Inspector Q rA rA P O w P-4 I I L O c cs Z CD C. O CO) I C_cm CO) p 'O CD — CL) �E m m CD CD co ~ � C 3� CD CL) D O co cc o a o- cma c .,a y C� V "FL oco CO2C Z 15 CD CL V C c .0 C _c CL 0 w° 0. cn ° w w 00 w° w°' v U _� w ° w cis w WG a W :3 U) 0 w x O. " w co w z a W C c4 o CO Q o CO O w P-4 I I L O c cs Z CD C. O CO) I C_cm CO) p 'O CD — CL) �E m m CD CD co ~ � C 3� CD CL) D O co cc o a o- cma c .,a y C� V "FL oco CO2C Z 15 CD CL V C c .0 C _c CL c c as c c s o ` c N O C L) CJ •nom O O C O m CO3 4' E a CE D a y L3! ON o Co c ~ y O s Cm "\m -Cc, �\ c�3 , CO. h �+ CA C m CQ J y moi• C •� cc co C C a y CIO O Em m o c m t = O cm �+ m p C3 y O . m a - CA • O r cc C o o C - CZ = m m rte.+ 03 a N F .. CO On... •y c r•+ O .� � CZt C =� CD C,* Z CO CWS `m v m O F- R a•` N = Cl Z CL m�lb O w P-4 I I L O c cs Z CD C. O CO) I C_cm CO) p 'O CD — CL) �E m m CD CD co ~ � C 3� CD CL) D O co cc o a o- cma c .,a y C� V "FL oco CO2C Z 15 CD CL V C c .0 C _c CL F-1 Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING -Al Thiscertifies that .............................................................................. I ............. has permission to perform ............ 49 ............................................... wiring in the building of ............. 5.JrA.,W .. I ................. - 77� ...... 1).4 ....... liorth—Andover, Mass. ........................ ....... ... .... ...... 47 �-03 � 71V Fee..:�.A .......... Lic. No . ............. .................... i . .......... ....... ........ ELECTRICAL INSPECTOR Check # 0889 Official Use Only Commonwealth of Massachusetts Permit No. �( Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT I7V INK OR TYPE ALL INFORMATION) Date: (!�> lj //— City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant z (n %A Gd -A Telephone No. Owner's Addres ) k D (- Is Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead [J Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of P posed Electrical Work: Completion PlAefiollowing table may be wain d by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- E] rnd. rnd. No. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number . . .. Tons ... ... KW .......... No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances g pp ' Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under Chep ins and penal 'e of perjury, that the nform tion on this application is true and comple n FIRM NAME: 1 C" . L®r ? �:Y� LIC. NO.A QP�1' J Licensee:::3-;.= Signature LIC. NO.� 3 lr'j ' (If applicable, enter " empt" in the licen number I' e.) ( 1 Bus. Tel. No.: Iz— Address: l� 1.1 b� h -vJ )-1 f )' Y Alt. Tel. No.: *Per M.G.L . 147, s.07-61, security work requires Department of ublic Safety "S"'License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have theliability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. . y r • �JJJL•l\L!�•4.l�.fli.�Q'+T.L[1�1�f.L7.� ��®��° 'jj^�j �i+'j7 ���.1'1`U��.�7 J -`6+1.x• ®J�+•R� ._ • _ '�sseoi [ xwea--•[ ] e-xuspeeizoa Xegt zetX($�O.gD) [ 3ns,�ec#ozs' �copzme�fs: (%enPrfnre5.4Yia7t2'�t1Ye~no.�"r�fiiaTsl Pate F:2. 0MAL INS'po'cilon JCns,D ectoti: S' co7n7m�e7xts; (filspectors' gign.ature -)to Wfla date Passed - �'zis�ectoxs' co7mxnents: , rim nectors91 gnata0-no Pate asseci—[ } is,�ectors' eoxnme�tfs: ectors' 81gaature - 710 �ecto?'s' corztxn.eri�s: _ te-xnspect�ion. xeq Date ~C 7 I �J n sip eetors" �zgnature - 740 �Ltliia�S} Trate � i D>off• T'.A,ag ..AM T013 MMD OVEAM UFT OMPIT-U lff TMAMATOBBINSPICTEMS NOT The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 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: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I . r ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F1 Electrical repairs or additions 11.❑ 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. t Homeowners who submit this affidavit, indicating they are 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: L Policy # or Self -ins. Lie. #: JohtSite Expiration Date: 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. 1 Flo hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 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-contractor(s) 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 Investigations 600 Washington Street Boston, MA 021.11 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.govldia r 9445 Date.(P TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies tha�—.��. ......... ............... has permission to perform plumbin .�in the buildings of .................. at ........................... . No h v Mass. Fee,57,��P Lic. NoA41�1. . AiP;LUMBING INS CTOR Check # r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - Z i CITY _ j MA DATE ,� PERMIT # JOBSITE ADDRESS Q�'t�j1�0��%�.l7 OWNER'S NAME ! 4 �U P OWNER ADDRESS D L� _ TEL 7 _ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL ® RESIDENTIALA PRINT CLEARLY NEW: RENOVATIONS REPLACEMENT: 7?T'1) PLANS SUBMITTED: YES [�I NO©I ''8 FIXTURES Z FLOOR- BS//M 1 2 3 4 5 6 7 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR (INTERIOR KITCHEN SINK ! --_._► __.__.t ___ _._...__.t __._ f ___. I _..-___J ._.__-J----__-i ---.- i --_ -_ __.-..__f ..__..._! LAVATORY I _..._.._.._{ _ ..._.-! __ _[ .____-_! .-.____! __..._....-! ____1 ...---..__J _..__.._.J ___I .___..__? . { ► __..__--I F�J ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _i _� .__ . } __ t WATER PIPING 1 I J _.__[ I - 1 OTHER __------ -�---._._..!- �_. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESP NO R OF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY9 OTHER TYPE OF INDEMNITY D BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER E-11 AGENT Ell SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my >knowledde and that all plumbing work and installations performed under the permit issued for this application will be in com nce with all P entip 'QI; Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME �_ �% 11�L ]LICENSE # k SIGN RE M16 JP 0 CORPORATION n# _. _. -- j PARTNERSHIP 0# LLC I COMPANY NAME �f//� / ; ADDRESS i CITY �CL3 f'L���� II STATE . p ZIP TEL FAX k CELL EMAIL H O z 0 H w a w �a zt w W o z W (LLLI � a w LLI w cn p a a o � w ¢ � U J a � w x w LLH z z o H w a z as a The Commonwealth ofMassachusetts Department of Industrial Accidents Office ofInvestigations 600 Washington Street Boston, MA 02.711 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Name (Business/organization/Individual): - Address:.. City/State/Zip:j®j®fj/�/l%f����' Phone #: Are you an employer? Check the appropriate box: 1. [I am a employer with �_ 4. ❑ I am a general contractor and I employees (full and/or part-time).*' 2. ❑ I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet. I ship and have no employees These subcontractors have working for me in any capacity, [No workers' comp. insurance 5. ❑ workers' comp, insurance. We are a corporation and its required.] 3. ❑ .I am a homeowner doing all work officers have exercised their 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. ❑ New construction 7. Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions ;11.❑ Plumbing repairs or additions 12.0. Roof repairs 13.❑ Other *A-31 applicant that chec:s box #1 must also flLi out the section below show;-- i:^.eir wcrzr �' eoWY-sation Policy info railer T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit ftnew 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 Policy # or Self -ins. Lic. #: �7� 2 �� Expiration Date: / Job Site Addressy� City /Slate/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 the pains information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town offzciaL City or Town: Permit/License „ Issuing Authority (circle one): Z. Board of Health 2. Building 6. Other Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector Contact Person: Phone Information ait d 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 houseor 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 iicensing'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 coimpiiance 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-contractor(s) 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 may be submitted.to the Department of Industrial Accidents for confirmation of insurance coverage. Also be were to sign and date -the affidavit. The affidavit should be, rotor—ince to the city or town. th=t ltt- application— <y_riu being regaesto�d, not the Departr-:;n. or 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 homeowner 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 Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77 MASSAEE Revised 5-26-05 Fax 4 617-727-7749 txrcxmF� rn aan frr.tsErT; o The Commonwealth of Massachusetts Department of Industrial Accidents Office Of.fnvestigations ..600 Washington Street Boston, AM 02111 www muss gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers M iennt rnfnrM044n , Name (Business/Organization/Individual):—, 4 - - - - Address: -- -P - . -- --c. o \`'1' b� Phone #: Are you an employer? Check the appropriate box; 1. ❑ T am a employer with 4. ❑ I am It general contractor and I employees (full and/or part-time).*' 2. Tam have hired the sub -contractors a sole proprietor or partner- listed on the attached sheet. T ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We area corporation and its required.] 3. ❑ am a homeowner doing officers have exercised their .I all work myself: (No workers' comp. right of exemption per MGL c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] "'Y appilicant that cheeks be #1 must also fill out the t sh T g section b ow - .. ^�ir —4—T Type of project (required):' ❑ 6. New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions .11 - 0 Plumbing repairs or additions 12.❑ Roof repairs 13.E1 Other C�omPmsa`L'011 omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must su moi 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. lam an employer that is providing workers' compensation insurance for my employees Belomy is the policy and job site information. 1 1 Insurance Company Name: , Policy # or Self -ins. Lic. #:_ �� ��� \1� 1 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 ofMGL 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 pains and penalties of perjurer that the information provide abole is true and correct Official use only. Do not write in this area, to be completed by city or town offlciaL City or Town: Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. PIumbing inspector 6. Other Contact Person: Phone #: Informati®n aid 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 6r 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 6r building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,' §35C(6) also states that "every state or local licensing�aQency 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 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 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 bc- rounrund to the city or too n that 'we app licatio is being request.- , nat nY 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 Depaitment 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 f6r your cooperation and should you have any questions, please do n6fliesitate to give us a call. The Department's address, telephone and fax number: The Commonweal& of Massachusetts Department of Industrial Accidents Office Ofluwestibaflons 600 Washington Street Boston, MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-8.77 MASSAFE Fax # 6.17-727-7749 Revised 5-26-05 «TTrnr--"/,T.- 4. r Ar F Unless otherwise noted within'this document -this agreement shall riot imply that any lien or other security interest has been placed on the residence. In witness, each party to this agreement has caused it to be executed on the date indicated below. CON E RACTOR; O�otNER DAVID H. NELSON Harsh Sanc rawala 4 cross street pepperell 211 Rosemont Drive MA. 01463 North Andover MA. 01845 DATE `DATE_ Ydb nndy cancel this agreement if it has been signed at a place cthe# than the CONTRACTOR'S normal place of business. provide you notify the CONTRACTOR in writing at his/her 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 . -ij ► not Si r 1 h s ce ti aut ii t r are any® blank spaces!!