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HomeMy WebLinkAboutBuilding Permit #72 - 2125 TURNPIKE STREET 7/30/2007BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: %:a • U IMPORTANT: Applicant must complete all items on this page LOCATION �MA� r PROPERTY PROPERTY OWNER "%D m r fly'[ u-1, Print MAP NO: PARCEL: ' ZONING DISTRICT: Historic District Machine Shop v' �t`eD I br'NO\ Are yes no ves no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New BuildingOne family Addition –Two more family Industrial Altera ion No. of units: Commercial Repair, replacement Assessory Bldg Others: tion Other ti Well Floodplain Wetlands Watershed District Water/Sewer t .DESCRIPTION PF WORK TO BIE PREFORMED: It) 0A &CrnyA2W I . Wn,�d cjcuwy, is Identification Please Tvbe or Print OWNER: Name: CONTRACTOR Name: Address 1+ Supervisor's Construction License:_,C_ 631q � 2- Exp. i ARCHITECT/ENGINEER Phone:-$] JY2, 0110 Address: VI la MIP4 W Reg. No.Wo FEE SCHEDULE: BULDING PERMIT: $12.00 P�ERR" $1000.00 OF THE TAI ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: FEE: $ I Check No.: Receipt No.: 0C NOTE: Persons contracting with unrstere contr o not have acc s o ie guaranty 0© 0 o,F' . , . • �� ,i`/rsj . 1 rr I . ►�►i�►�I�'%fly' 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 COMMENTS 4-rONSERVA COMMENTS DATE REJECTED TV REJECTED 0)) DATE APPROVED DATE REJECTED DATE APPROVED HEALTHY *61 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes i/ no Located at 124 Main Street Fire Department signature/date � 2'-" �F-o COMMENTS 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 2 1 A —F and G min.$100-$1000 fine NOTES and DATA — (For department use) ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 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 DEPARTMENT:BPFORM07 Revised 2.2007 Locatio^ 115' T x Nvo% tL� _ No. 2-- Date koRTR TOWN OF NORTH ANDOVER S Certificate of Occupancy $ ro ... .s . i 'ss�cMus t` Building/Frame Permit Fee $ Foundation Permit Fee $ fr - Other Permit Fee $ TOTAL $ Check # 204tl Building Inspector -,,Of cxfsr�t,� 6:efjD 'PJ20IV50 LAS �(. 97.0 1 0 _-- 131/•S k `i5.6 1\ X TO AvwAY 10 x 95.3 .......... 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(3fvn r 1101 4. Nl u tot Town Clerk Tune Sump Town of North Andover ZONING'BOARD OF APPEALS �EuC�� ;4�Y Albert P. Manzi M Esq. Chairman Ellen P. McIntyre, Vice -Chairman Richard J. Byers, Esq. Clerk Joseph D. LaGrasse David R. Webster Associate Members Thomas D. Ippolito Richard M. Vaillancourt Daniel S. Braese, Esq. Any appeal shall be filed within (20) days after the date of filing of this notice in the office of the Town Clerk, per Mass. Gen- L. ch. 40A. 617 Bohn and Heidi Watters 01.1 +-,o 1 '" 0 2007 MAY 22 F1'i 1: 55 1. MSS ADDRESS: 2125 Turnpike Street North Andover, MA 01845 This is to certify that twenty (20) days have elapsed from date of decision, flied without filing of an ppeai. Notice of Decision Date ><ye 3' Year 2007 Joyce Bradshaw Town Clerk at: 2125 Tern ike Street HEARING(S): April to & May 9, 2007 PETITION: 2007-M TYPING DATE: May 15, 2007 The North Andover Board of Appeals held a public hearing at its regular meeting in the Town Hall top floor � MA on Tuesday May 9 meeting room, 120 Main Street, North Andover, , 2007 at 7:30 PM upon the application of John and Heidi Watters, 2125 Turnpike Street (Map 108.C, Parcel 54), North Andover requesting a dimensional Variance from Section 7, Paragraph 7.3 & and Table 2 of the Zoning Bylaw for relief of the right side setback in order to construct a proposed two -stall attached garage addition to an existing conforming structure on an existing conforming lot. Said premise affected is property with frontage on the West side of Turnpike Street within the R-2 zoning district Legal notices were sent to all names on the abutter's list and were published in the Eagle -Tribune, a newspaper of general circulation m the Town of North Andover, on March 26 & April 2, 2007. The following voting members were present: Ellen P. McIntyre, Richard L Byers, Esq. Albert P. Manzi III, Esq. and Thomas D. Ippolito. The following non-voting members were present: David R Webster and Richard M. Vaillanoourt. Upon a motion by Richard J. Byers, Esq. and 2°d by Ellen P. McIntyre the Board voted to GRANT a dimensional Variance from Section 7, Paragraph 7.3 and Table 2 of the Zoning Bylaw for relief of 7' from the right side setback m order to construct a proposed 2 -stall attached garage per the following application and plans: 7Da;te 2125 Street 108.C, Parcel 54), North Andover, MA 10845 an Title: Plan of Land in North Andover, Mass., owned John F. and Heidi F. Watters 8t Revised Dates): 3/9/2007, [si 3/10/2007 ered Professional Scott L. Giles, #13972, Scott LGiles RP.L.S., Frank S. Giles RP.L.S., Surveyor: 50 Deer Meadow Road, North Andover, Mass. rBuflilan Title: Watters Residence, 2125 T ike St., N. Andover, MA ® 2007, Nancy J. Twomey, Twomey Design, 23 California Road, Readin MA 01867 1.30.07 Sheet/Drawing. Sheets 1 throu 7 Voting in favor: Ellen P. McIntyre, Richard J. Byers, Albert P. Manzi, III, Esq. and Thomas D. Ippolito. I El056 ATTEST: 06-1.4-2007 & i-jB = 26ct A True Copy Page 1 of 2 9�'"' p , 'v'' Town Clerk 1600 Osgood Street, Building 20 - Suite 2-36, North Andover, Massachusetts 01845 Phone - 978-688-9541 Fax - 978-688-9542 Web - www.to1Amofnorthand0ver.c0m / T Albert P. Manzi D1, Esq. Chairman Ellen P. MclntyTe. Vice -Chairman Richard J. Byers, Esq. Clerk Joseph D. LaGrasse David R Webster .Associate tviemhers Thomas D. Ippolito Richard M. Vaillancourt Daniel S. Braese, Esq. Town of North Andover ZONING BOARD OF APPEALS 0 �O Town Clerk Time Stamp RE"f i`vt: r� 2001 MAY 22 FH 1: sJ The Board finds that owing to circumstances relating to the location of the existing dwelling on the lot as located on the aforementioned plan and, the existing well m the front yard, and the existing septic system in the back yard, as represented, particularly effects the dwelling and lot, but does not affect generally the Residential 2 zoning district in which it is located, a literal enforcement of the provisions of Section 10, Paragraph 10.4 and Section 7, Paragraph 7.3 (Yard Setbacks) & Table 2 would involve a substantial hardship to the petitioner, and that relief may be granted without substantial detriment to the public good, and without nullifying or substantially derogating from the intent or purpose of the North Andover Bylaw. The Board further waives the applicant's fees for said application. Furthermore, if the rights authorized by the Variance are not exercised within one (1) year of the date of the grant, it shall lapse, and may be re-established only after notice, and a new hearing. Furthermore, if a Special Permit granted under the provisions contained herein shall be deemed to have lapsed after a two (2) year period from the date on which the Special Permit was granted unless substantial use or construction has commenced, it shall lapse and may be re-established only after notice, and a new hearing. A/1 I- e:!�:JaA4Z�E-- Andover Zonis Board of Appeals P. Manzi a Esq., Chairman lien P. McIntyre, mice -Chairman Richard J. Byers, Esq., Clerk Thomas D. Ippolito Decision 2007-008. M108.CP05 Page 2 of 2 1600 Osgood Street, Building 20 - Suite 2-36; North Andover, Massachusetts 01845 Phone - 978-688-9541 Fax - 978-688-9542 Web - w,xv%v.townoihorthandover.com r A 309 Pearl. Stm Readi.n,g, MA 01867-1352 Mr. John and Mrs. Heidi Watters 2125 Turnpike Street North Andover, MA 01845 978 258-7020 watterlu _comcast.net iwatters _GPINET.corn 781-944-0202 Email: dwebb0202@a.ol.com July 1, 2007 Re: Specifications for Remodeling Project at 2125 Turnpike St. N. Andover. Douglass Design and Construction, Inc. submit for your consideration the following proposal for the construction services you requested. The details of the proposal are given in the specifications below in conjunction with the drawings by Twomey Design 6/28/2007 sheets 1 — 6 and S1 & S2. Thank you for your consideration of Douglass Design and Construction, Inc. We look forward to working with you on your remodeling project. Please feel free to call with any questions regarding this proposal. Project Specifications General 1. Owner will remove and relocate all personal items that are to be maintained. DDC will assist in moving large items. 2. Owner realizes that a project of this magnitude will disrupt living arrangements. DDC, Inc. will make reasonable attempts to mitigate such disturbances and holds no liability withstanding. 3. Due to the nature of remodeling and issues at the interfaces between the new and old structures, unforeseen or concealed items may cause additional design and construction costs to be incurred. These items will be discussed with the owner as soon as possible and the owner should maintain a reasonable contingency for such items. 4. DDC will make provisions for maintaining a clean work site and confine material to the affected work areas. Dust and dirt will migrate to all corners of the existing house. Final I of 6 MA LIC #CS031962 MA HIC # 106767 309 Pearl St - 781 -944-0202 Reading, MA 01867-1352 Einail: dwebb0202@aol.coin dusting and clean up of the house including the addition will be the responsibility of the owner. DDC, Inc. will remove all construction debris and leave the job site broom clean upon completion. 5. Owner realizes that the coordination of this project is critical and will make all reasonable attempts to provide requested decisions and information as soon as possible to the contractor. 6. Access to the site will be over the front lawn. The front lawn will be damaged during the project due to the impact of heavy trucking. Reconstruction of the lawn is the owner's responsibility and is not included in this contract. 7. Access to the construction site will be via the owner's driveway. All necessary construction equipment and delivery equipment will access the site in this manner. The driveway may incur damage, the repair of which is wholly the owner's responsibility. There are no provisions or allowances in this contract for repair of any damage. Plans and Permits 1. DDC will compile owner provided plans and file permit. 2. Owner to provide check for permit fee. The fee is payable via a check to "The Town of North Andover". This permit fee is not included in the contract price. 3. Owner to provide plot plan. Site Work 1. Demolish and remove existing side deck 2. Layout site for excavation. 3. Excavate and remove unnecessary fill materials to provide for the construction of foundations as per the plan. 4. Backfill foundations with materials reserved on site for such and rough grade around the foundation areas. 5. Final grading and landscaping is not included in this contract. 6. Driveway work is not included in this contract. 2of6 MA LIC #CS031962 MA HIC #106767 309 Pearl StreE.. Reading, MA 01867-1352 Foundation 781-944-0202 Einail: dwebb0202@aol.com 1. Provide new concrete foundations per plan for addition garage/mudroom addition on right side of the existing house.. 2. Foundations to be poured with 10" x 20" concrete footing, 10" concrete walls. All concrete to be 3000 -psi minimum. 3. Install %" stone compacted under slabs. 4. Pour 4" concrete floor in the garage area, smooth trowel finish. 5. Slab to have #10 6x6 wire mesh reinforcing. Frame and Exterior 1. Provide and install all framing elements as detailed on plans to construct additions and interior frame elements. 2. Provide and install exterior trim to match existing house, i.e. rakes, fascias, soffits, mudsills, and corner boards. 3. Provide and install Anderson MFG. 400 Series windows according to the plans. Windows to have fine line between the glass grills, screens, and white hardware. All windows to be ordered pre -finished white interior and exterior as available from Anderson. 4. Provide and install new roofing to match existing, including flashing, ice and water shield, etc. 5. Provide and install new double window in second floor bedroom #2. 6. Provide and install new "4° Clapboard Style" vinyl siding on addition. 7. Provide and install new Aluminum gutters and downspouts on addition. 8. No exterior painting is included in this contract. Interior General 1. Frame interior elements per plan 2. Demolish and remove existing interior elements as required for construction. 3. Provide temporary dust barriers, keep site broom clean, remove all trash to barrels or on site dumpster. As stated in General conditions, DDC, Inc. is responsible for removal of all construction debris from the site. 4. All areas indicated for painting will be; walls to be primed and painted two coats, ceilings to be two coats, woodwork primed and painted two coats. 3 of 6 MA LIC #CS031962 MA HIC #106767 309 Pearl StreE Reading, MA 01867-1352 781-944-0202 Ein.ail: divebbO202@aol.com 5. Remove and patch window in second floor bedroom (#2). Replace rear window with new double window. Trim to match existing second floor trim. Mudroom/Laundry 1. Provide and install insulation; walls R-13, ceiling and floors R-30 2. Replace door to the existing house in the den with new 15 Light French door with casing to match existing. 3. Provide and install wiring for recess lights, and switches in the mudroom, laundry, and outside porch. 4. Rework and extend the heating loop on the existing zone for mudroom, and laundry. 5. Install owner provided tile flooring. 6. Provide and install rough and finish plumbing for new laundry room with slop sink. 7. Install owner provided 'cabinets, counters, and plumbing fixtures. 8. Door to the front porch to be 9 Light Smooth Star Fiberglass. Garage 1. Provide and install wiring including four (4) outlets, lights, switches, and garage door wiring. 2. No insulation provided in this contract. 3. Provide and install 5/8" firecode blue board and plaster walls and ceiling loose trowel finish. 4. Concrete floor to be trowel smooth finish. 5. Provide and install two (2) composite panel overhead garage doors with openers. 6. Provide and install stairs to mudroom with plywood treads and risers, and wooden rail. 7. Construct exterior back step as necessary to meet grade at rear door. 8. Exterior door to the yard is 9 Light Smooth Star Fiberglass. 9. No paint in the garage area. Exterior Details Front Porch 1. Construct frame with pressure treated lumber elements. 2. Provide and install decking — composite plastic "Fiberon" or equivalent. 3. Posts and columns to be composite "Premier Rail' 4of6 MA LIC #CS031962 MA HIC #106767 309 Pearl Street Reading, MA 01867-1352 4. Construct one set of wooden steps with composite treads to grade. 5. Provide, and install recess lights in vinyl -beaded ceiling. 6. Provide and install composite lattice under deck. Total cost of products and services per drawings and as listed in the specifications given above. Payment terms are on the attached "Payment Schedule". Thank you for your consideration of this proposal. Respectfully, Douglass EMebb, President Douglass Design and Construction, Inc. Owners Acceptance: Date: 7/1/0-7 781-944-0202 Errutil: dm�ebb0202@aol.com? $74,494.00 5of6 MA LIC #CS031962 MA RIC #106767 REScheck Software Version 3.7.3 Compliance Certificate Project Title: WATTERS RESIDENCE Report Date: 06/27/07 Data filename: Watters Garage.rck Energy Code: Location: Construction Type: Heating Type: Glazing Area Percentage: Heating Degree Days: Construction Site: 2125 Turnpike Street N. Andover, MA 01845 Massachusetts Energy Code North Andover, Massachusetts 1 or 2 Family, Detached Other (Non -Electric Resistance) 1% 6322 Owner/Agent: Heidi and John Watters 2125 Turnpike Street N. Andover, MA 01845 (978)258-7020 Permit # Permit Date Designer/Contractor: Nancy Twomey Twomey Design Associates 23 California Road Reading, MA 01867 (781)942-0146 nj2me@comcast.net Compliance: Passes Maximum UA: 57 Your Home UA: 53 --> 7.0% Better Than Code (UA) Ceiling 1: Flat Ceiling or Scissor Truss: 152 38.0 0.0 Wall 1: Wood Frame, 16" o.c.: 384 13.0 0.0 Window 1: Wood Frame:Double Pane with Low -E: 4 0.330 Door 1: Solid: 19 0.330 Door 2: Solid: 19 0.330 Floor 1: All -Wood Joist/Truss:Over Unconditioned Space: 152 19.0 0.0 28 Compliance Statement: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the Massachusetts Energy Code requirements in REScheck Version 3.7.3 and to comply with the mandatory requirements listed in the REScheck Inspection Checklist. The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the design load as specified in Sections 780CMR 1310 and J4.4. 1+�/ NSI , "rl�r0tZ '1VJ0M L� -Des 1,6-/J /1�5pC 49 S /077 :ompany Name Date WATTERS RESIDENCE Page 1 of 1 z O U) 0 06 z W ° — � 0 a) N p U) 00 L Q N c 0OpO 00Mo�- Q O (moi rn �' o LO CL 0 ca c y 1- Y rn N O O CD Qj Rf O ~ � i d � 0o03 m V C6 �— ap E 'T— C.0 cro W �IKOO U O c) o Cm -t =3�G zo O w v .� +� 4—in to OQ O _j 0 N , co o U) �0 W O COco Z W LD N ~co U 1 •� o U) z O U 7 v C O V L d E 7 a n i q main J Z n .o •J R U ' rid rt Q O (moi rn �' o LO CL 0 ca c y 1- Y ACORD., CERTIFICATE OF LIABILITY INSURANCE I DATEhird:DDiY CSR n4 1)QLtGLA.S � 07/02/07 HIS CERTIFICATES ISSUED AS A MATTER OF INFORMA-TICN j ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ..ncterley Insurance Agency HOLCER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 493 Trapelo Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. _ Lclmont MA 02478- (Pnone, 617--484-5216 Fax_617-489-4626 _ -- I INSURERS AFFORDING COVERAGE NAIL 3 I Ir'�''-'`=` =' azbeila Pzntection Ynsuzanca I , ! Douglas Design & Constru_tion 309 Pearl Street Reading IIA 01867 �'`:VERAC,pS , I -• Hanover Insurance company 2-1292 1F'rJ" : PF r ,'- f.� .G , ri. Tf, 7[ T�rd� h, 4"J , -IFF, %F Ur THF:Ur)! NF,*CA i r 1�i =�•� .' �r:::r �. � I•. :_, _ i+ ..- I n! v_I i L_, _... � 4-: .._` r __-:�(.' �1,irt t- '.jJ-�:JF 1 - - t A;,! E'.. t P S•_ J _�= E .°. I :� ,I.'I -- — -- -- ?PCZ EFFtCr . E r QFC I_ ,i-IRnTfb.4 --- -ia.•._ -'-1rE �F Ir;S,1R;.'LCE PJLIC" t:U! lEER --T"ENEMALLIABILITY DATE Uv1 ,, UDi";• ph`E �h1rA,'CG'Y1'} :.Irrll'': I _F a1.,00o,000 i40_.. - �L'_ L $5Ci0028lE�� 06 06f:'", 06f OF%nfi "� �^--' f �' a S0 000 -- -- -- — _ - _- ----- - 1,aaa,aaa _ L'�.'_^JL ._ L' 01V 0 art V„UTohi BILE _AF,RIT( I _IndC I,F_ ry--` L RAl AF08406192 O8%11f0' OEi llf O8 I!-"'�:c •,t' - i 250000 `.EULLL_,.! 7 I'Fr� r;s.. 500000 —--------------j "-.- 100000 ,j':,;= -RACE 04151 ITi -�,�--.— F.O-ESa:'UMSRELLALIABILIT° ".-CH r ! 1 I 311 I I i � DF ��s .ornPEJ�ATIorJwJ r --+h I v c F c 'r lEkS LIABILITY WC'1767006 02/27/07 'II 021/i''f0$ cl F- i ,� 100ono F_ -E t:g.: F IEE; > lacoaD 1 - 7I se_ I - E 00001 --- -� N _ -- _ ' 1 'i F! ,h,•r• � ::PER�TI:�^Js, �aCAT!p'�o, .E-1CLES ExCLUS!ONS BY EmO0RSRAEi ; SPE -:',L PFO�131Ctn j� i '1 -RTIFiCATE HOLDER t s john Watters { '125 Turnpike Street N Andovex MA 01845 WATTER5 CANCELLATION _ ShCU'LD ANY of THE ABuvE DE3CRIBED POLICIES FIE CANCELL_D 8E.7'oRE NE EX'r'iRATION DATE THEREO; , THE ISSUVIC IMSUP,EF'NILL ENDEAVOR TO r1AI 10 DAys '%'?!TTEM NOTICE To 1 HE CE?TR= _4.TE H_IUER NAMED T_ THE LEFT, BUT FAILURE TG DO SC SHALL Ih?PCS'c dO CEL iG-TION OR L14BILIT; OF ANY K' ND UPON -HE 1 ISIRER tT3 AGP-I'S nR REPRESE:N7ATNES. John. +c; A.CQRD CORPORATION 1988 RECEIPT Printed:06-14-2007 ® 8:26:02 Essex North Registry Robert F. Kelley Register Trans#: 84355 Oper:CARMENT JOHN F 8 HEIDI F WATTERS Ctl#: 11 Rec:6-14-2007 ® 8:26:01a DOC DESCRIPTION TRANS AMT -I q --------- PLAN 16-7 Surcharge CPA $20.00 20.00 5.00 TECH FEE 5.00 Plan recording 50.00 Total fees: 75.00 ------------------------------------- ------------------------------------- Book: 10791 Page: 94 Inst#: 18056 Ctl#: 12 Rec:6-14-2007 $ 8:26:01a NAND 2125 TURNPIKE ST DOC DESCRIPTION TRANS AMT --- ----------- --------- DECISION Surcharge CPA $20.00 20.00 50.00 recording fee 50.00 5.00 TECH FEE 5.00 Total fees: 75.00 *** Total charges: 150.00 CASH PMT PAYMENT -CASH 150.00 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations °1 'u 600 Washington Street p , Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: `Z, f) G1 I'ecl- City/State/Zip: Phone #: � t 1 4 i �-1 E-1 Areu an employer? Check the a'(fpropriate box: 1. 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. 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. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. �uilding addition 10. F1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. F-1 Roof repairs 13.❑ Other *Any applicant that checks boz # I 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. r B 0 x Insurance Company Name: Policy # or Self -ins. Lic. #: �t V 0 0 `E' Expiration Date: 7i�h_oo Job Site Address: '2,,-- ('>,S I l�.Vtn fh 4 S City/State/Zip: 4A- AAG M 0 I8(D 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 y against the violator. Be advised that a y of this statement may be forwarded to the Office of Investigations o the DIA for insurance coverage verificati t I do hereb ce nder the pains andpefla ry that the information provided abov is tru�and correct rt IV, � Sigature: nate /� /lX � � � � 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 pen-nit/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 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia N m x m //m Yom/� I m y v m y e� —CD d � � O 0 Z y CLn� r c c c CL CO) aCc -0 0 v CD �� O rF Q % d CD CD a c CD OR av y C I 00 MID1 L cn V/ J O z cn �n d O ?.� o =r z C c o a OAPS CO cm "o y to 0 CL!f T Z 00.2 =,r CA NOm o CD masm = y O o y A N �• �� o G7 O y O W ?=� :1 CA = n = �.m �� _ CL Cos d y = to Q C w— a ,.� .� O y CA ,� co1 = m O 0 0 cn -Iwo: o,N% N = m o N y 3 0D o y O �• n m �I1 �'CD ® ,.d nD O O z Y Fm _ m CD ' a p � 0 CD �•: o C: J=CD: dd as crC Gam. ol � VMS*: cpi "(n� bn 9 wpCp o 7� n. o �, w o E ,.d z w n z o � g p, d O • 4 0 do 0=3 0 P=h Q C