HomeMy WebLinkAboutBuilding Permit #729-11 - 219 FRENCH FARM ROAD 4/29/2011BUILDING PERMIT
TOWN OF NORTH ANDOVER
r 1 APPLICATION FOR PLAN EXAMINATION
Permit NO: ` Date..Received
Date Issued:1-1
IMPORTANT: Applicant must complete all items on this
LOCATION 219 1 FA 1�--D`
Pri .
PROPERTY OWNER: J USPM Ef
Print
`MAP 210 ?ARCS �—Z` ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Reside '
Non- Residential
New Building
ne famil
Addition
Two or more family'
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Other
Septic Well
Floodplain Wetlands
Watershed'District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
Al
^ Q�(M 11 In ' L�j Evr
Identification Please Type or Print Clearly)
OWNER: Name: Z"USTW ,NAVEf Phone:
Address: ---Li 9 Fg11/co -F"M go /Q,Alva uch I ff)q
CONTRACTOR Name:�Dmmai /nAki-mi t7 Phone: 1?7�;- '02,33 6 O
Address: 1Yq AQDISW AVC
Supervisor's Construction License: Exp. Date:, w
Home Improvement License: /c) - 9b/ Exp: Date: 0 -1'7_-/,
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ (o, 300 C- FEE: $ !3,4C*- J^
Check No.: ���' Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/owner Signature of contractor
Locatiorf� 1
No.Date
MORT� �k
TOWN OF NORTH AIiDOVER
F S
:'e Certificate of Occupancy $4
s4CMU54� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
241U7
Building Inspector
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
y
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
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED DATE APPROVED
Reviewed on Signature
Reviewed on Signature
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
DPW Town Engineer: Signature:
FIRE DEPARTMENT Temp Dumpster on site
Located at 124 'Main Street
Fire Department signature/date
COMMENTS.
Locateo 5364 USQooa 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
NOTES and DATA — (For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2010
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
:wilding Permit Application
Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
&-,"6opy of Contract
❑ Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products /*-',
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
o Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
o 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 2008
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OP ID: GZ
CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDIYYYY)
01/26/11
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER 978-688-4667
TO Insurance, Inc. (MA) 978-682-9037
One Griffin Brook Dr Ste 100
Methuen, MA 018444865
Select P & C CSA
ACT
NNAAME,
arc°NH Ext: I FAXNe
E-MAIL
ADDRESS:
PRODUCER
CUSTOMERIDd: DMCON-1
INSURERS AFFORDING COVERAGE MAIC #
INSURED D M Construction
INSURER A: Nautilus Insurance Company 17370
INSURERB:
Darren Martino
INSURER C:
44 Adison Ave
Methuen, MA 01844
INSURER D
INSURER E:
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
POLICY NUMBER
MMIp Y EFF
POLICY DD EXP
LIMITS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
NNO6760
09121/10
09/21111P
EACH OCCURRENCE S 1,000,00
ISES Ea N ,,'ance S 300,00
MED EXP (My one Person) S 5,00
CLAIMS -MADE n OCCUR
PERSONAL & ADV INJURY $ 1,000,00
GENERAL AGGREGATE $ 2,000,00
rN'LAGGREGATE LIMIT APPLIES PER
PRODUCTS-COMPIOPAGG $ 2.000.00
S
POLICY PRO- LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
(Ea accident)
BODILY INJURY (Per person) $
ANY AUTO
BODILY INJURY (Per accident) S
ALL OWNED AUTOS
PROPERTY DAMAGE S
(Per accident)
SCHEDULED AUTOS
HIRED AUTOS
S
NON-OWNEDAUTOS
S
UMBRELLALIAB
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIAB
HOCCUR
CLAIMS -MADE
DEDUCTIBLE
S
S
STATU- OTH-
TOWCRS
RETENTION S
WORKERSCOMPENSATION
AND EMPLOYERS' LIABILITY Yi
ANY PROPRIETORIPARTNERIEXECUTIVE
E.L. EACH ACCIDENT $
E L DISEASE - EA EMPLOYE S
�N
OFFiCERIMEMBER EXCLUDEO't
(Mandatory In NH)
N i A
E.L DISEASE -POLICY LIMIT S
Ilyes,desuibeunder
DESCRIPTION OF OPERATIONSbetO'N
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Addltlonal Remarks Schedule, H more space Is required)
Carpentry - Residential
Justin Hayes
219 French Farm Road
Andover, MA 01810
ACORD 26 (2009109)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Select P & C CSA
V ] VOO-AMW M.W"M vvnr vlv+t wn. e+n .ynw ,cuv..ow.
The ACORD name and logo are registered marks of ACORD
DM Construction
Building with the QUALITY and Character of yesteryear.
44 Addison Ave Ext.
Methuen, MA 01844
(978) 685-3037
Estimate Submitted To: Construction Supervisors License 66342
Justin and Jody Hayes
219 French Farm Rd.
N. Andover, MA
Home Improvement Registration 124961
We hereby purpose to furnish the materials indicated and perform the labor necessary for the
completion of:
Exterior renovations and home improvements(See specifications sheet)
All material is guaranteed to be as specified, and the above work to be performed in accordance
with the drawings and specifications submitted for above work and completion in a substantial
workmanlike manner in the sum of Seventy six thousand eight hundred dollars -$76,800.00
Payments to be made as follows:
$1,000.00 Upon execution of contract.
$5,000.00 Upon ordering windows
$10,000.00 When work begins
Remaining payments as work progresses.
Respectfully submitted: Darren Martino
Any alteration or deviation from the above specifications involving extra costs will be executed
only upon written order, and will become an extra charge over and above the estimate. All
agreements contingent upon accidents, or delays beyond our control.
Note -This proposal may be
withdrawn if not accepted within 10 days.
Proposal Date 03/25/11
ACCEPTANCE OF PROPOSAL
The above prices, specifications, and conditions are satisfactory and are hereby accepted. You
are authorized to do the work as specified. Payments will be made as outlined above.
Date: '�161 Signature: fm~
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
UILDING DEPT. COPY
IM YES RESIDENCE
Specifications Sheet
Scope of work. Remove and replace existing roofing, siding, exterior trim, windows, and
gutters. Painting of trim, siding, and entry door.
Permits
DM Construction is responsible for obtaining the following permits required: building
permit for roofing/siding/windows and a debris removal permit. The cost of all permits
necessary is not included in this estimate and will be billed separately.
Debris Removal
DM Construction is responsible for all debris generated. A container will be placed on
site to ensure a clean work site. The container is for debris generated by DM Construction only;
it is not intended for homeowner use.
Demolition
ROOFING -The roof of the main house and great room will be stripped down to
plywood*. All shingles, ridge vents, drip edge, and felt paper will be removed.
*If any roof plywood is found to be rotted or damaged this will incur extra cost.
SIDING All siding and shutters will be removed. Shutters will be saved/reinstalled.
EXTERIOR TRIM -All exterior trim including: fascia, soffit, rake boards, corner boards,
window trim, kick boards, etc. will be removed.
WINDOWS -All existing windows in the house (excluding the windows in the sunroom,
basement windows, and the kitchen window) will be completely removed. The interior window
trim for these windows will be removed.
GUTTERS -All existing gutters on the house will be removed.
DOORS -Remove the existing front door unit w/side lites. Remove the existing front storm
door unit.
MISCELLANEOUS -Remove the existing gable end vents.
Roofing
Installation of new drip edge, ridge vent, and roof felt paper. Installation of 3 ' of ice and
water shield along all roof edges. Installation of ice and water shield where the roof of the great
room meets the gable end of the main house. Ice and water shield will lap from the roof 18" up
onto the gable end. Installation of new step flashing. Installation of a 30 year architectural
shingle(GAF or IKO-Color to be selected from stock colors only).
Sunroom roof -Installation of new %Z " substrate roof board over the existing sunroom
roof. Installation of new drip edge. Installation of a new rubber roof, glued down to the new
substrate.
IM YES RESIDENCE
Specifications Sheet
Siding
Installation of new Hardiplank clapboard siding on Tyvek housewrap. Siding will have a
textured cedar mill finish. Siding will be installed with a 15 year factory applied coating from
the manufacturer. Color to be selected from one of Hardiplanks standard colors. Siding will be
installed with galvanized rings nails with S " exposure to the weather.
Exterior trim
All exterior trim boards including: fascia, soffit, rake boards, corner boards(8'), kick
boards, and any miscellaneous blocks will be pvc(Azec or equivalent): The overhang in the front
of the house will have white vinyl soff t panels applied. Aluminum soffit vent strips will be
installed along all soffits necessary. 4' jlat stock pvc window surrounds to be installed around
all window units. Surrounds to have mitered corners, flat stock on 3 sides, and a sill on the
bottom.
Gutters
Installation of new seamless white gutters and downspouts on the entire house.
Windows
Remove all existing windows from the house, excluding the kitchen window and the
windows in the sunroom. Remove all interior window casings and sills. Modify openings to
accommodate new window units, using existing headers. Installation of new Anderson window
units. Install new interior window casing(3 %2 " colonial casing) and sill. Install new exterior
pvc window casing with built in j -channel. (4" wide —flat stock) Frame for new windows in
family room gable end comprised of 4 double hung windows and 4 transoms above.
Doors
Window Specifications
Anderson 400 Series Tilt wash double hung window units.
-Finelight grills between the glass 12 over 12
-Exterior-white vinyl
-Interior-white pre -finished from factory
-Screens-white
-Hardware-white
-Glass-low-e smart sun glass
Installation of a new front door unit.
Thermatru S210 Door unit
36" x 80" w/2 -12" side lights(S308SL)
Oil rubbed bronze sill
Brushed nickel hinges
Dbl bore for deabbolt
PVC Exterior casing
Installation of a new storm door unit.
Anderson 36" x 80" Contemporary deluxe -interchangeable full view
Nickel hardware and white exterior.
IM YES RESIDENCE
MISCELLANEOUS
Exterior Painting
SidinQ_The newly installed clapboards will come with a 15 year factory coating in one of
Hardiplank's stock colors. One additional coat of paint will be applied over the factory coating
after the siding has been installed.
Trim- All newly installed pvc trim boards will be painted white.
Doors -The new front door will be painted. (Color to be determined) The existing garage
doors will receive one coat of white paint.
Shutters -The existing shutters will be painted. (Color to be determined)
All paints to be Benjamin Moore, California, or equivalent.
Siding Accessories
Accessory blocks for coach lights, spot lights, and exhaustfans will be pvc or vinyl.
Miscellaneous
Remove and reinstall existing coach lights and spot lights.
The condensate lines on the right side of the house will be boxed in with pvc trim boards.
Square off garage openings and install new pvc trim boards.
Frame in and close off existing gable vents.
Remove, save, and reinstall all existing shutters.
The existing window in the kitchen and windows in the sunroom will remain.
This estimate does not include new garage doors.
This estimate does not include any interior painting.
This estimate does not include any relocation or new electrical.
HA YES RESIDENCE
MISCELLANEOUS
Note: Due to the nature of wood and plastic and the drastic temperature and humidity
changes in our region, you may notice the movement and shrinking of the interior and
exterior trim. This is typical of the region and is not due to defective installation.
Change Orders Any changes from the existing plans or increased scope of work involving
extra costs will become an extra charge over and above the contract price. Change order
agreements must be signed before any work commences.
The following schedule will be adhered to, unless circumstances beyond our control arise:
Time frame for completion: From the date demolition begins to project completion 8-10 weeks
All work to be done Monday -Friday between the hours of 7.00 am — 6:00 pm.
If deemed necessary to work any other times, the homeowner will be consulted first.
MEMBER OF THE BETTER BUSINESS BUREAU
HOME IMPROVEMENT CONTRACTOR: -124961*
CONSTRUCTION SUPERVISOR LICENSE: CS 066342
*All home improvement contractors and subcontractors shall be registered. Any inquiries
about a contractor or subcontractor relating to registration shall be directed to:
Office of Consumer Affairs and Business Regulation
Ten Park Plaza, Suite 5170
Boston, ALL 02113
Phone: (617) 973-8700
DM Construction
Building with the QUALITY and Character of yesteryear.
44 Addison Ave Ext.
Methuen, MA 01844
(978) 685-3037
CONTRACTOR ARBITRATAION AGREEMENT
The Home Improvement Contractor Law provides homeowners with the right to
initiate an arbitration action(as an alternative to court action) if they have a dispute
with a contractor. The same right is not automatically afforded to a contractor
however. The contractor would have to resolve any dispute he/she has with a
homeowner in court unless both parties agree to the optional clause provided below.
This clause would give the contractor the same right to arbitration as is afforded to
the homeowner by the Home Improvement Contractor Law.
The Contractor (Darren Martino) and the Homeowners (Justin & Jody Hayes)
hereby mutually agree in advance that in the event the contractor has a dispute
concerning this contract, the contractor may submit the dispute to a private
arbitration firm which has been approved by the Secretary of the Executive Office
of Consumer Affairs and business
Regulation and the consumer shall be required to submit to such arbitration as
provided In Massachusetts General Laws, chapter 142A.
Home per's b4nature
Cou tors Signature
UILDN- DEPARTMENT COPD
DM Construction
Building with the QUALITY and Character of yesteryear.
44 Addison Ave Ext.
Methuen, MA 01844
(978) 685-3037
NOTICE OF CANCELLATION
03/25/11
You may cancel this transaction, without any penalty or obligation, within three business days from the
above date.
If you cancel, any property traded in, any payments made by you under the agreement, and any
negotiable instrument executed by you will be returned within ten business days following receipt by the seller of
your cancellation notice, and any security interest arising out of the transaction will be cancelled
If you cancel, you must make available to the seller at your residence, in substantially as good condition
as when received, any goods delivered to you under this agreement, or you may if you wish, comply with the
instructions of the seller regarding the return shipment of the goods at the seller's expense and risk.
If you do make the goods available to the seller and the seller does not pick them up within twenty days
of the date ofyour notice of cancellation, you may retain or dispose of the goods without any further obligation.
If you fail to make the goods available to the seller, or if you agree to return the goods to the seller and fail to do
so, then you remain liable for performance of all obligations under the contract.
To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any
other written notice to:
NAME OF SELLER: DARREN MARTINO
ADDRESS. 44 ADDISONAVE EXT METHUEN, MA 01844
NOT LATER THANMIDNIGHT OF. MARCH 28.2011
I HEREBY CANCEL THIS TRANSCA TION
Date.
Buyer's Signature:
I (we each) acknowledge receipt of two copies of this form
Buyer: I
Buyer:
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor License
Commissioner
Expiration: 8/15/2011
Tr#: 1170
� - ✓1ze �ealt�C a��,aeaaciuceP,ka
:a
Office of Consumer Affairs & BBusiness Regulation
HOME IMPROVEMENT CONTRACTOR
Registration:." -124961
a Expiration:— -'6117/2011
Tr# 288159
Type, ---- Individual
DARREN MARTINO
Darren MARTINIO
44.ADDISON AVE "EXT.
�-—
METHUEN, MA 01844 =
Undersecretary
. C—\ 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: ZYW
City/State/Zip: (S1 ytj Phone #:
Are you an employer? Check the appropriate box:
L ❑ I am a employer with
4. ❑ I am a general contractor and I
ployees (full and/or part-time).*
have hired the sub -contractors
2. I am a sole proprietor or partner-
listed on the attached sheet I
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. 0 Remodeling
8. 0 Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.0 Roof repairs
13.Q-1(5ther S 1D jAJ C4W1 j00W!
- -: s,• a.au au ou: me seunoa neics, sdosvinb • - yr i e s' comp--s-anon Policyi f * acn.
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 isproviding workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
�-�
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
Contact Person:
Permit/License #
3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector
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 ret Led to the c1 v that o f -'L license i being requested, t Department f
tort or town than she applicatton �o: u:e pert or u erase s b ...g ...gaest�a, no .he Deparcn n o
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 bum 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
Revised 5-26-05
Fax # 617-72.7-7749
www.mass.gov/dia