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HomeMy WebLinkAboutBuilding Permit #284 - 22 PERIWINKLE WAY 10/22/2008 BUILDING PERMITC�No oT 6 FO- ?`bt �6 O� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION + ey t Permit NO: Date Received �,4" oRA7Eo 9SSACHUS�� Date Issued: ZZ—o IMPORTANT: Applicant must complete all items on this page LOCAl'1ON o - Print PROPERTY OWNER �� 1t , "agoPhnt MAPiNO: PARCEL: ` ZONING DISTRICT HistoricDis#riot yes no Mache.Shop Village- yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration_.._�-� No. of units: Commercial Repair, replacemeht Assessory Bldg Others: f Demolition I Other SepticWell Floodplain. Wetlands, Watershed7District. _ - DESCRIPTION OF WORK TO BE PREFORMED: �`"~I'��15� [��'� ��-�Jdpi ow'� c� 1 •�Gf i�r4�'l-�yLecz*-t Identification Please Type or Print Clearly) OWNER: Name: J-p 5(sp A- a iLr 1W6 Phone: ao Address: ,� U tNku CONTRACTOR =Narne: `c' gdl-f" 2�40AX Phone: . '� � Address: ­7 l rJ ' 04:fwcr- zzr °1 Stiperuisoes Construction License: " Exp. Bate. l Horne,Improvement:License: � �-/ 5` Exp. Date; 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: $ ©o .-- FEE: $ Check No.: 3- ,,3 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund signature of Age caner = y Signature of contractor : i 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 A Building Permit Application p, Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract A Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products ti /a NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application L3 Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract Li 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) U Building Permit Application o 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 o Mass check Energy Compliance Report o 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 2.2008 l r 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 Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS A Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: g g Located 384 Osgood Street FIRE-DEPARTMENT -Temp Durnpster on-site yes no Located at 924 MainStreet - �ire-bepartmerit zignature/date _. COMMENTS 'i ,I i 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 A PP 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 I i ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 t Location act• 1Pt� J LJ)A No. &q Date MORTh TOWN OF NORTH ANDOVER 0�,.... ,•7yQ s ^• ; Certificate of Occupancy $ ��;•^•;��' Building/Frame Permit Fee $ � Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 3�•-� 216 '40 .[ Building Inspector :w . K & K CUM 1-RUCTION LLC 71 WOOD DRIVE ESSEX, MA. 01929 978.375.4624 HOME IMPROVOVEM ENT CONTRACT Homeowner Information Contractor Information Name ———— orn—ly ame KA 1-4 nJcf _A ,�tIcet Address(do 110(use a Past Office Box address) 64--JZ=1 ontractor,Salesperson Owner�_amc -70S(s 41— Jccr woo __9 State Zip Code u suriess Address(must include a street address) Delue Dayfirric phonenS one State-- (0(4 S-a 6's Sd Ic- M.A iMailing Address(It different from—above) — Etn-C.;�L�ID��S.S. ounh k'"Mm—M t(,WrJCW Kcg,Nunftf lispimlinn The Contractor agrees to do the following work for the Hornet) ner:pincement wmmctors lure a /Y (Descilric in aclon + — 1 1�-?—/S—(� I ;, ,spedymglyl,11-1u,allor graue of lfl�l—U�cMa Required Permits-The.following building permits are required Proposed Start and Completion Schedule-The following schedule will and will he secured by the contractor as the homeoNvirer's agent, be adhered to unless circumstances beyond the contractor's control arise (Owner-,who secure their own permits will be excluded from the Guaranty Fund provisions of1c when contractor will begin contracted work. MGL chapter 142A.) OI-Q-71 U- R). 30AR—Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work.liarnish the material and labor specified above for the total suit)of Pavinents will be made according to the following schedule: upon signing contract(not to exceed 113 of total contract price or file cost of'special order items,whichever is greater) by L0jk?10_?or upon completion of by 40 _?or upon completion of_-5-A-4 &Z )E&k $4 605> 4 —j .—upon completion of the contract. (]-,a%%,forbids demanding full payment until contract is completed to both party's salisfuciion) The following material/equipment must he special S Y,0M to he paid for f—/LA M I-V 6 LU sI ^ + 5 itee r tzoicic— ordered before the contracted work begins in order S__/f r�op� to be paid for 10 meet[Ile completion schedule(**) 00 0 IL_ NOTES:(*)Including all finance charges(**)taw requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost ol'any special equipment or custom made material which'trust lie special ordered in advance to meet the completion schedule. brine nmvide I by the co tr Our? No Yes (all terms ofthe warranty muqt he ny—hgd i. tracft Subcontractor,%-The contractor agrees to be solely responsible for completion of the work de regardless of the actions of any third contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for party/%uhcontrachrr utilized by the comrac scribed materials and labor tinder this a recrojelit Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any hen or other security interest has been placed on the residence. Review the fbilovling,cautions and notices carefully Ocibre signing this contract. • Don't be pressured into signing,the contract.Take little to read and IbIly understand it. Ask questions ifsomething is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration, The law requires most home improvement contractors and subcontractors to he registered with the Directurroff-lome Improvement Contractor Registration. You may inquire about contractor registration by writing tothe Director at One Ashburton Place.Room 1301,Boston.MA 02108orby calling 617-727-3200or 1-800-223-0933. • Does the contractor have insurance? Check to see that your contractor is Properly insured. • Know your rights and responsibilities. Read the important Information(in the reverse side of this form ar Guide to the Home Improvement Contractor Law. and get a copy ofthe Consumer You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her mail)office or branch of lice 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. See the attached notice ofcancelfation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! ellocall copi 0 lie f lie contract 111"I he completed load signed(Me copy should go to the hornicowne'.'rhc Mile,copy should be kept by the conalicl., 'op,'or' T, it I Ionicooviter's 'igna tire Cont�Ior,_S-g-,.� Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same tight 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 and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration 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 submisuch arb�tirn as provided In Massachusetts Genera!Laws,-chapter]a?A. Homeowner's g lure Contractor's Signature NOTICE:The,'gn tures of the�hom tie above apply only to the agreement of the parties to alternative dispute resolution initiated by the c ctor. The wrier may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree maybe added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day recission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Consumer Guide to the Home Improvement Contractor Law,"contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 021 16 (617)973-8787 or 1-(888)2833757 If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Bureau of Building Regulations and Standards One Ashburton Place,Room 1301,Boston,MA 02108 (617)727-3200 or 1-800-223-0933 For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)734-3114 NORTH TONM Of No. 2 8 00"LAK o dower, Mass.A 0, dva �. COCHICHEWICK V 7,9 ADRATE D S BOARD OF HEALTH Food/Kitchen PERMIT T D _ Septic System • BUILDING.INSPECTOR THIS CERTIFIES THAT..... D....r'fir!!!!,. ... ......... ................. Foundation has permission to erect........................................ b ildings on 4 � ... ... .� "'.'` Rough • T a Chimney to be occupied as &.91101~.. ..... . ............................................................_.......... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU STARTS Rough ........ .. .. ........ .................. ................................. Service BUIL TOR Final Occupancy Permit Required to Ocmpy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. R & R CONSTRUCTION LLC. 71 Wood Drive cell#978-375-4624 10/4/08 Essex, MA. 01929 1 JOE DEERING 22 PERRIWINKLE WAY N. ANDOVER , MA. 603-203-6452 We are pleased to submit the following bid.- Job id:Job Description: FINISH BASEMENT AS PER PLAN MATERIALS QUANTITY DESCRIPTION UNIT PRICE TOTAL FRAMING LUMBER ... SHEET ROCK AND JOINT COMPOUND 41000.00.. DOORS..AND TRIM 1,800.fl0`. ADDITIONAL LUMBER FOR CHANGE WILL BILL AT PURCHASE W/NO MARKUP. PLUMB TOILETTE,TUB, SUMP WELL,PUMP AND FIXTURES N/A PERMIT FEE AND VANITY NOT INC.. ELEC SWITCHES,PLUGS, 100AMP SUB PANEL,AND12 REC. LIGHTS, INC. PERMIT FEEAND VANITY LIGHT NOT INC. HVAC INC EVERYTHING. Materials total: 5;800.00 SERVICE HOURS DESCRIPTION CHARGES TOTAL FRAMING 4,800.04'. SHEETROCK 4,800.00 TRIM 2,400.00 PLUMBING ...... HVAC ELECTRIC *** CHANGES TO ORIGIONAL PLAN **** QDT. FRAMING $ao.oa ELEC , PLUMBING IF ANY UNK. Service total: 1,2;800:00 Total bid price: 18,600.00 RESPECTFULLY SUBMITTED ROBEfRT REPUCCI S 1�Al trD t'^ --_ Bd'ar'c7'o HOME IMPROVEMENT CONTRACTOR Registration: } 127156 4 Expiration 9/14/2010 Tr# 273817 Type _Private Corporation R&R CONSTRUCTIONgLLC ROBERT REPUCCI 71 WOOD DR. n ESSEX, MA 01929 Administrator Board of ' Bdiuilng �egn�a`a-d St,Construction Supervisor ndardQse License License; Cs B68716 irthdate 11/21/1965 _u Exp�rat�on ^� x i'� ' 11%21/2008 Restncfion 00 ;"" ROBERT J REPUCCI = 71 WOOD DRkcif ESSEX, MA 01929 �\�K, ��,, ,',•: _� �� �,�� _ *• Commissioner _- k r 08/26/2008 08: 39 9784697046 EK SURVEY PAGE 01/01 MORTGAGE PLOT PLAN E K SURVEY INC •HAVERHILL,MA• Phone 9784891985 4 Fax 978409-7046 MORTGAGOR 3Z5jef 9 lam!- ' X4S*AtVfi IM041b DEED REF. (0-3/7 PG' i✓o I ADDRESS OF PRINCIPLE BUILDING PLAN REF. '(J7'VL Z2 DATE OF INSPECTION A,.&. /4. Ze&6 d/- ANDow&e, A44 SCALE 1" sf Sri - LoT'9 �, I 4t tZZ' LoT ro wA4 T. G✓ CERTIFICATION TO: JUS/ & RA= IAJArR R4uw RUDEL % The location of the prinolple atructure/a This Mortgage Pld Plan was prepared speoifncaity for No.36866 ,CoNAwR it mortgage purposes only and it is not intended or represarded 'ffCIS1EASI with the local zoning bylaws in effect when constructed to be a property line or land survey.Tris plan is not to be used ". psi 5J and/or is exempt from violation enforcement to establish any of the property Imes for any purpose.No action under Mass 8.1.. TNle VII,Chap.40A,Sec.7. responsibility is extended to the land owner or occupant. Sub*d building is not In a Flood Hazard Area. This certification is based on the location of survey marker O Subject bulldlrg is in a Flood Hazard Area. of others. Flood Ha=rd determined from the FIRM map11�SDa -OW&C JOB 0 291;90 pasted !A/c(97 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYpY) TM 08/05/2000 PRODUCER (978)887-4900 FAX (978)887-2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Edward F. Sennott Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 16 South Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. Box 4S7 Topsfield, MA 01983 INSURERS AFFORDING COVERAGE NAIC# INSURED R & R Construction LLC INSURERA: Nautilus Insurance Co. DBA: C/O Robert Repucci INSURER B: 71 Wood Drive INSURER C: Essex, MA 01929 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR NSR DATE MMIDD DATE MMIDD/YY LIMITS GENERAL LIABILITY NC730170 11/23/2007 11/23/2008 EACH OCCURRENCE $ 1,000,0001 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES Ea occurence 50,000 CLAIMS MADE a OCCUR MED EXP(Any one person) $ 5.00 A PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1!000,00 POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑ CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATti- I I nTFr-- EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$ -T OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS E: 22 Brook St, Reading, MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL Twp-e#-Re diD9 *Ov,,t,J OF A), AN owj*- 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, ..,, n--4i. RT BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY (0�' ` OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Reading. MA 01867 ' / ©Q OS(>0a6Sf� AUTHORIZED REPRESENTATIVE -4 n! yh,4a( Peter Sennott/LA A9"-a.....-7 ACORD 25(2001108) FAX: (781)942-9071 ©ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s),authorized representative or producer,and the certificate holder, nor does it affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001108) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 t j www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizatiori/Individual): � j&LX_t1 oA_1 L(—C-_ Address: -71 L_.)oC>(.,� I`> A UT City/State/Zip: SSS (sA— M& C1 Phone 4:9)Cy" -1>-7 S� qC�Z Are you an employer?Check the appropriate box: Type of project(required): 1.El an a employer with 4. El am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling s ip and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9• ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10:0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1.1.❑ Plumbing repairs or additions myself. [No workers' comp. c. 1.52, §1(4),and we have no 12.❑ Roofre pairs insurance required.] t employees. [No workers' comp. insurance required.] 13.[] Other tAny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information, Homeowners wird submit this affidavit indicating they are doing all work at-ad inen hire outside contraciors musi submii 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: /1*u7' I t_ V (.N S Lam•. e�- Policy#or Self-.ins. Lic.#: ,IV C ��0 121-5 Expiration Date: U .Job Site Address:_ `� f r t City/State/Zip: o j . 4)je&_At1_ 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 ofperjury that the information provided above is true and correct SiQrtature: ^ Date /Oi Zl D Phone#: c�_7i.7 S-- (-I `2 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#: I 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 cant'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. Theaffidavit 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 lam,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 as a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Depar rnent of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26=05. www.mass.gov/dia , 0 4 Ilk _ SIG kr �, }t 1 4t pa 61 4 ��r