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HomeMy WebLinkAboutBuilding Permit #409 - 223 Boxford Street 11/24/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: d-� Date Received Date Issued: L IMP RTANT:Applicant must complete all items on this page LOCATION F-3-3 3'xg1 a `S Print PROPERTY OWNER Print MAP N0P,4RCEL:ZONING DISTRICT. Historic District yes !Machine 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, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: QdVQ Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: g-w f-ucrj.,r;vo 3,ji%.o i e4s7c Ag-Phone: -2 at S Z r- Address: S7 ca w a s 4 .•i J �. s-: , 4i�a�� r%,'k 023 Supervisor's Construction License: Exp. Date: Home lmprovement'License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST)BAA,SE9D ON$125.00 PER S.F. Total Project Cost: $ Check No.: � Receipt NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 4Signature of Agent/Owner Signature of contracto Location No. Date �ORTN TOWN OF NORTH ANDOVER 3? •. • O f w Certificate of Occupancy $ JACM.S< Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 22655 Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Swimming Pools Tanning/Massage/Body Art Well Tobacco Sales Food Packaging/Sales i 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 .J HEALTH Reviewed on Signature COMMENTS 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: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date 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 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date 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: Doc.Building Permit Revised 2008 tAORTH Town of Andover 0 No. 14 0 _ff-7 dover, Mass., COC NIC HEWICK 0RATED BOARD OF HEALTH Food/Kitchen Septic System PERMIT T D BUILDING INSPECTOR THIS CERTIFIES THAT.......... id......... ........................... .........................................I.......... Foundation has permission to erect......................................... buildings on .... 0,(.....)..I .................... '�a- .........................r ... . .. ........ Rough to be occupied as........... ........t..........00..?.k. ..;!E�� ........ ............................................... Chimney provided that the person accepting this permit shall in every ip 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 �G��� PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTR%RUI�.�%ON STARTS Rough ........... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy 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. New England Build and Restore,Inc. 590 Washington St.Pembroke,MA.02359 Professional building damage evaluation&repair experts (781)826-7212 Fax(781)826-0240 Client: TODD,GREGORY Home: (978)984-5722 Property: 233 BOXFORD ST NORTH ANDOVER,MA 01845-3225 Home: 233 BOXFORD ST NORTH ANDOVER,MA 01845-3225 Operator Info: Operator: DKELLY Estimator: Arnold,Jonathan Business: (781)826-7212 x 24 Business: 590 Washington Street Pembroke,MA 02359 Type of Estimate: OTHER REAS Date Entered: 9/23/2009 Date Assigned: Date Est.Completed: 10/29/2009 Date Job Completed: Estimate: 5661S1 This estimate is based solely on the findings at the time of our inspection.NEBR Inc.reserves the right to amend this estimate should hidden or unforeseen damages and/or building code violations or unsuitable job site access be discovered during or prior to construction. NEBR Inc.has estimated this project based on completing the entire scope of work as written,performing all phases in a continuous'workman like manner. All work to be performed within normal working hours. NEBR Inc.to have complete control of job site at all times which includes the following but not limited to: Job supervision and scheduling, Subcontractor selection and scheduling,job site access,and construction methods and materials. Job site access may be limited by NEBR Inc. for safety reasons at any time during construction.No work to be allowed by owner or any other parties without written approval from NEBR Inc. After the pre-construction meeting is completed,any and all requests for changes to the scope of work or changes to the project under construction,shall be addressed in writing to the contractor NEBR Inc. on the form provided to the owner by the contractor,called"change order request".Once the form has been submitted to NEBR Inc.,we will calculate the cost of the requested changes,if any,and submit them in writing to the owner for approval.Upon approval of both parties will sign the change order and the changes shall be completed.Payment for approved change orders are due at the signing of said change orders.Change orders can affect the construction schedule and projected completion date. New England Build and Restore,Inc. 590 Washington St.Pembroke,MA.02359 Professional building damage evaluation&repair experts (781)826-7212 Fax(781)826-0240 56615_1 Demolition DESCRIPTION QNTY 1. Dumpster load-Approx.30 yards,5-7 tons of debris 2.00 EA Note:Due to the weight of the chimney debris job will require two dumpsters Main Level Main house DESCRIPTION QNTY 2. Remove Tear off composite roofing(no haul off) 5.49 SQ 3. R&R Sheathing-plywood- 1/2"CDX 224.00 SF Note: Seven sheets sheathing repair. Includes access for framing repair 4. R&R Drip edge 32.00 LF 5. R&R Drip edge/gutter apron 33.83 LF Note: Vented drip edge 6. Ice&water shield 199.00 SF 7. Roofing felt-30 lb. 5.49 SQ 8. R&R Flashing-pipe jack 1.00 EA 9. R&R Chimney flashing-average(32"x 36") 1.00 EA 10. 3 tab-25 yr.-comp.shingle roofing-w/out felt 6.33 SQ 11. R&R Continuous ridge vent-shingle-over style 34.33 LF 12. Ridge cap-composition shingles 34.33 LF Sunroom DESCRIPTION QNTY 13. Remove Tear off composite roofing(no haul off) 1.20 SQ 14. R&R Flashing, 14"wide 10.00 LF 15. R&R Drip edge 24.00 LF 16. Roofing felt- 15 lb. 1.20 SQ 17. 3 tab-25 yr.-comp. shingle roofing-w/out felt 1.33 SQ 18. R&R Continuous ridge vent-shingle-over style 12.00 LF 19. Ridge cap-composition shingles 12.00 LF Rear exterior Formula Elevation 34'4" x...x 16' 10" DESCRIPTION QNTY 20. Two ladders with jacks and plank(per day) 2.00 DA 21. 5/4"x 6"x 10'#1 treated pine(material only) 2.00 EA 22. Carpenter-General Framer-per hour 3.00 HR 56615_1 11/19/2009 Page:2 New England Build and Restore, Inc. 590 Washington St.Pembroke,MA.02359 Professional building damage evaluation&repair experts (781)826-7212 Fax(781)826-0240 CONTINUED-Rear exterior DESCRIPTION QNTY Note: Labor and material to replace corner trm as needed 23. R&R Drain/Vent line-PVC pipe with fitting and hanger,4" 18.00 LF Note: Radon vent Left exterior Formula Elevation 25'x...x 19' DESCRIPTION QNTY 24. R&R Fascia- 1"x 6"-#1 pine 16.00 LF 25. R&R Fascia- 1"x 4"-#1 pine 16.00 LF 26. R&R House wrap(air/moisture barrier) 30.00 SF 27. R&R Siding-beveled-cedar(clapboard) 30.00 SF Masonry DESCRIPTION QNTY 28. Scaffold-per section(per day) 42.00 DA Note: 7 Sections of Scaffolding for 6 Days 29. R&R Masonry fireplace&chimney-two story home 1.00 EA 30. R&R Add for tall masonry chimney over 15'(per vertical LF) 4.00 LF 31. R&R Fireplace-chimney cap-sheetmetal 1.00 EA Attic Formula Peaked 34'4"x 25'x 0" DESCRIPTION QNTY 32. Rafters-2x10-stick frame roof(using rafter length) 16.00 LF 33. R&R 1"x 8"lumber(.667 BF per LF) 8.00 LF Note: Collar tie 34. R&R Drain/Vent line-PVC pipe with fitting and hanger,4" 6.00 LF Note: Replace vent pipe 35. R&R Batt insulation- 10"-R30 200.00 SF Bathroom DESCRIPTION QNTY 36. R&R Exhaust fan-Standard grade 1.00 EA Note: Replace cover 56615_1 11/19/2009 Page: 3 New England Build and Restore,Inc. 590 Washington St.Pembroke,MA.02359 Professional building damage evaluation&repair experts (781)826-7212 Fax(781)826-0240 Code DESCRIPTION QNTY 37. Iee&water shield 138.99 SF Note: Up 6'along eaves General DESCRIPTION QNTY 38. Temporary toilet(per month) 1.00 MO Grand Total 21,726.59 Arnold,Jonathan Grand Total Areas: 1,427.93 SF Walls 1,099.20 SF Ceiling 2,527.14 SF Walls and Ceiling 858.33 SF Floor 95.37 SY Flooring 178.00 LF Floor Perimeter 1,177.93 SF Long Wall 1,177.93 SF Short Wall 199.05 LF Ceil.Perimeter 0.00 Floor Area 0.00 Total Area 0.00 Interior Wall Area 287.22 Exterior Wall Area 0.00 Exterior Perimeter of Walls 1,339.49 Surface Area 13.39 Number of Squares 196.80 Total Perimeter Length 46.33 Total Ridge Length 0.00 Total Hip Length 5661S_1 11/19/2009 Page:4 G7/LTJ LGG7 1L:L3 n bbH PAGE b'L/aZ ttAiY MSM ...� insurted f / {aim( umber 1� o "orizadoo.Ta.1kepair (To Be Sighed pdor+tz Beginning Ser*esi.Repeirs) TO. $Mte Farm Fift sad CsuaUy CbrrPUnY I haus agreed to use th'a State F*m Pre rder.Service Pri&awL't witu Stand the toe ofIt is pM9remU voluntary and I have bees offemd tate vppoftrfq-to choose any indepeadent.mtrwW andkr hWepgpdent servits pravIde*) partIcIptino in the Stat® Farstt Premier Setvice Proton: f also udderstrd f tey We,Rgiepmdeq,contactors andtor independent service providm-fir:d.by std and npl uyl to ate ktrm lnsurance Companaes. undevftnd State farm is payhV for tMe repairs to ttte open y domage coYered-tinder nW poky, a0jedt to ftse deducible and the polig(s terms and conditions,and IM State Farm is not emckggg#5..opilon under the IMuMce 60&'ad to repair or replace"-part of the property damaged. I have.seiectad and authorfe �.�� � „�, ;� ��---�— b to perform vepalm as indioated.on ftir estimate due to a Ions on [, ,�• E uttd taad my deliuctUe Wpayable to the authofteai independent.-COntrartdr an for i ep et service pravtder�s). independent car ractoi Amor{roependent ser*,e.,provider) for any repairs, or additions{ agree reetopaymy tnwrosemet .made at my dlredfoh,that are aot.oWwred under my palloy. q/ 't go (Date) ��(Year)� �t�std Sf�nattfre� s To b2cOMMW b e Qo Repair Start Date: Time: a)k lM Earna3ed Cimp4et{on Date: —I /_--- 1'd528�.i� .4.�8:7:Ao8 Hl�a BBH PAGE 01102 NEBR NEIN ENGLAND BUILD & RESTORE, INC. Rhe, Water&Storm Damp Repairs WORK AUTHORIZATION & PAYMENT REQUEST FORM Friday, September 25, 2009 NEER JOB #: 5661S CLAIM #: 21-QO04-389 INSURED: Gregory Todd Address. 233 Boxford Street North Andover, MA 01845 I, Gregory Todd do hereby direct New England Build and Restore, Inc. to perform any and all necessary work including: ' f Ki v)e s�,�+.�.&' �-4 I,mac 49,1111 � + O4-•7 4 d ir. 7a 1A us Ir I also authorize my insurance company; State Farm Insurance to:pay NESk Inc.directly for the work performed and request that their name be included on any check issued to me relative to this insurance claim. I am also aware of my responsibility as the properly owner to pay my deductible of$/ _b•6%to NEBR, Inc. regory To6 Date - fir NEBR, Inc. Jonathan Arnold, Account Manager 590 Washington Street Pembroke.Massachusetts 02359•TEL:(7813 826-7212 (781)826-0240 www,neAbr.com ...mom. 11--"VV 11.1/ riVi rayttl:G OT 3 I� CERTIFICATE OF LIABILITY INSURANCE OP ID JE DATE(MMIDDIYYYY) PRODUCER NEWBU-2 11/18/09 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE McSweeney & Ricci Ins Ag Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 2021 Ocean Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Marshfield MA 02050 Phone: 781-837-7788 Fax:781-837-3399 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Guard Insurance Group New England Build & Restore, INSURER B: Steadfast Insurance Company Inc INSURER C: Peerless Insurance Company 24198 590 Washington Street Pembroke MA 02359 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. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDIYYYY) DATE(MMIDD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 B X COMMERCIAL GENERAL LIABILITY GPL596562701 03/08/09 03/08/10 PREMISES(Ea occurence) $100,000 X CLAIMS MADE ❑OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 X I POLICY jEa LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT C ANY AUTO BA8566858 12/19/08 12/19/09 (Ea accident) $1,000,000 ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY $ (Per person) X HIRED AUTOS X NON-OWNED AUTOS BODILY INJURY(Per (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT :` $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY. AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ 1,000,000 B OCCUR CLAIMS SE0596563301 03/08/09 03/08/10 AGGREGATE $ DEDUCTIBLE $ RETENTION $10,000 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y 1 N TORY LIMITS X ER A ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ jQEy�CQQ$O$rj 11/01/09 11/01/10 E.L.EACH ACCIDENT $500000 OFFICER/MEMBER EXCLUDED? (Mandatory in NE.L.DISEASE-EA EMPLOYEE $500000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500000 OTHER B Pollution GPL596562701 03/08/09 03/08/10 Pollution 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION TGWNWAl DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED ACORD 25(2009101) © 88-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD �' �1ze C/IOm/�?2UJ 1 Board of Building Regulations and Standards r I HOME IMPROVEMENT CONTRACTOR rt Registratao 137817 Expixation 119/2011 Type Supplement Card 9 NEW ENGLAND Bt9ILRES)TOR i 56W� THAN ARND D ✓ /1 � 590 WASHINGTON PEMBROKE,MA 0235 ✓ Admrnistrator ;! ✓fie �omrmwouvea/CLiuo�/�aaaac�zuaeCf `nj\\ Board of Building Regulations and Standards 1 Construction Supervisor License ' I' License �,CS 95021 Birthdate -1/7/1980 _— Tr# 95021 Ex ration 117/2010 � "An= 00 { I II JONATHAN ARNOLD� �' F-6 BA DRIVE i NORTH ATTLEBORO MA 02760 Commissioner The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, 2IIA-02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name (Business/Organization/Individual): W F-"&4-" LIS iat2 e Address: • fo Nfs1-6A� s City/State/Zip: ?,-Z l A I {/AA .0235'`( Phone#: `?,S1 - g2� - 7 Z/ Z Are you an employer? Check the appropriate bog: Type of project(required): 1.Er I am a employer with .9-0 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling ship 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-ElElectricalrepairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. C. 152, §1(4),and we have no 12.[ Roof repairs insurance required.] t employees. No workers' 13.0 Other comp. insurance required.] * .:,y applicant that checks box III,must also tall out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing ail 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 thepolicy and job site information Insurance Company Name: 17A r'r.6%c..., r�P Policy#or Self-ins. Lic.#: U tz,cJ L c,o g o A r,' Expiration Date: 1 Job Site Address: ,2-3.3 ?cs%c S i City/State/Zip:/�R.co►�rt2_ty p o�b5/f 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 andpenalties ofperjury that the information provided above is true and correct Signafore: Date: e& o Phone#: ?9/- $2G— ?2(7 Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitlLicense# 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 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. 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 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 0.2111 Tel. 4 617-7274900 ext 406 or 1-977-MASSAFE Fax 4 617-727-7749 Revised 5-26-OS wurw.mass.govldia