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Home My WebLink AboutBuilding Permit #568 - 23 UNION STREET 3/24/2010 BUILDING PERMIT Of$O DT 6�ti TOWN OF NORTH ANDOVER F ION t - APPLICATFOR PLAN EXAMINATION Permit NO: Date Received Date Issued: Z' —L/O IMPORTANT: Applicant must complete all items on this page LOCATION_ ,,,. S4, Print / PROPERTY WNER . L ( e di Prit MAP 21 PARCEL: ZONING DISTRICT- Historic District yes no 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 PREFORMED: �Jt4J 0 c F / 4 Ide, tifcat'on PleasePe or Print Clearly) OWNER: Name: 1` (47-ri (/ /J � LPhone: Address: f a`s� Upi(d r, CONTRACTOR Name: w c)OO Phone: 63 ' g-q Address: /J, 14, Supervisor's Construction License: Exp. Date: ) 124 Home Improvement License: I v G(,o 3 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: $ FEE: $ "'1-D Check No.: Receipt No.: r 3 NOTE: Persons contracting with unre istered contractors do not have access to the guaranty fund f. Signature of Agent/Owner / - Signature of contractor -x��c� 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 - xFORM ' DATE REJECTED ;BATE APPROVED` PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS 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 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 ❑ 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:Building Permit Revised 2008 �3 Locatio g IV(D �� 2 No. Date ✓�L �ORTM TOWN OF NORTH ANDOVER F 9 • i Certificate of Occupancy $ Eta Building/Frame Permit Fee $ 3ACMUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 0 22 U 'l 5 Building Inspector NORTH Town of 4AndoverNo. 00 O Lo dover, Mass. 01 T _ CA 1 11 COC HIC HE WICK y�. �d A0RATEO PPS` S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT......... . �.`�.............IQ. BUILDING INSPECTOR .v 4r... ...................................................... Foundation has permission to erect........................................ buildings on.. �......... %,61, , Rough tobe occupied as................ ..........DLO-OW lco................................................................................ Chimney provided that the person accepting this permit shall in everyrespect conform to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Final 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 UNLESS CONSTRU STARTS ELECTRICAL INSPECTOR Rough ....... Service BUILDING IN Final Occupancy Permit Required to Ocatpy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. SEE REVERSE SIDE Smoke Det. 4 North Andover MIMAP 23 Union Street March 18, 2010 r 014.0- 6 `a 46 S '�tN �f D-(Nr2n � a Union.Strect CONDO r $� Interstates Interstate —Major Roads Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, Roads Meters Data Sources:The data for this map was produced by Merrimack NORTH Valley Planning Commission(MVPC)using date provided by the Town of Co Easements �f tt`ILC �� North Andover.Additional data provided by the Executive Orrice of C3 MVPC Boundary ? �t *e CQ Environmental Affairs/MassGIS.The Information depicted on this map is Parcels .>t' L for planning purposes only.It may not be adequate for legal boundary F •^• 9 definition or regulatory Interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING M t► THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY i i ,^, Y OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT # o •� ♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION SgACHuSE 1"=46 ft .{�E � y North Andover MIMAP 23 Union Street March 18, 2010 01 .0- 014.0-0018 1 .0-014.0-0018 014.0-0016 014.0-0014 014.0-0027 014.0-0028 014.0-0030 014.0-0031 014.0-0032 014.0-0029 3, 50. 51, 7 74' --------Union Street 108' 69' 66' 66' 014.0-0035 014.0-0005 CONDO 014.0-0036 014.0-0057 014.0-0021 CONDO 14.0 0034 _Rall Una Interstates Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, —Interstate —Major Roads Meters Data Sources:The data for this map was produced by Merrimack NORTq Valley Planning Commission(MVPC)using data provided by the Town of Roads Of •`�C ,� North Andover.Additional data provided by the Executive Office of r Easements ? mat •e 00 Environmental Affairs/MassGIS.The Information depicted on this map Is Trails 3 L for planning purposes only.It may not be adequate for legal boundary O fsdefinition or regulatory Interpretallon.THE TOWN OF NORTH ANDOVER ❑MVPC Boundary ~ 9 MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING O Municipal Boundary * ♦ THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY ♦ i ,^, JF OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT O Parcels +► o ,� • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF Hydrographlc Features ��^o��•�o��•."�cj THIS INFORMATION Streams ,SSACNUS�t =.�Wetlands Exempt Lands 1"=46 ft "�° Residential Property Record Card PARCEL_ID:210/014.0-0029-0000.0 MAP:014.0 BLOCK:0029 LOT:0000.0 PARCEL ADDRESS:23-25 UNION STREET FY:2010 PARCEL INFORMATION Use-Code: 104 Sale Price: 1 Book: 01571 Road Type: T Inspect Date: 01/24/2006 Tax Class: T Sale Date: 04/25/82 Page: 0312 Rd Condition: P Meas Date: 06/06/2000 Owner: Tot Fin Area: 2498 Sale Type: P Cert/Doc: Traffic: M Entrance: NELSON,SUSAN L Tot Land Area: 0.20 Sale Valid: A Water: Collect Id: SGC C/O NEARY,WILLIAM F. Grantor: NELSON SCOTT W Sewer: Inspect Reas: Address: 23 UNION STREET Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/° Indust-B/L% / Open Sp-B/L% / NORTH ANDOVER MA 01845 RESIDENCE INFORMATION LAND INFORMATION Style: DK Tot Rooms: 7 Main Fn Area: 1187 Attic: Y NBHD CODE: 4 NBHD CLASS: 4 ZONE: R4 Story Height: 2.35 Bedrooms: 4 Up Fn Area: 1311 Bsmt Area: 1187 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class Roof: G Full Baths: 2 Add Fn Area: Fn Bsmt Area: 1 P 104 S 8700 0.200 144,149 Ext Wall: AB Half Baths: Unfin Area: 290 Bsmt Grade: DETACHED STRUCTURE INFORMATION Masonry Trim: Ext Bath Fix: 0 Tot Fin Area: 2498 Str Unit Msr-1 Msr-2 E-YR-BIt Grade Cond%Good P/F/E/R Cost Class Foundation: ST Bath Qua[: T RCNLD: 170667 Kitch Qual: T Eff Yr Built: 1962 Mkt Adj: SE S 64 0.00 1988 A A ///88 200 Heat Type: ST Ext Kitch: Year Built: '-1920 )Sound Value: VALUATION INFORMATION Fuel Type: O Grade: A Cost Bldg: 170,700 Current Total: 315,000 Bldg: 170,900 Land: 144,100 MktLnd: 144,100 Fireplace: 0 Bsmt Gar Cap: Condition: A Aft Str Val 1: Prior Total: 346,200 Bldg: 188,300 Land: 157,900 MktLnd: 157,900 Central AC: N Bsmt Gar SF: Pct Complete: Att Str Val2: Aft Gar SF: %Good P/F/E/R: /100//72 Porch Tyne Porch Area Porch Grade Factor E 78 P 182 SKETCH PHOTO 4 4 X40 t.R Picture 26 1187Sq.R Available 44 8 13 6 78 Sq.R 6 r Parcel ID:210/014.0-0029-0000.0 as of 3/18/10 Page 1 of 1 BUILDING CERTIFICATION PLAN SET IRON ROD n' IRON ROD co v L 0 T AREA o000 14,015. sq. ft. N 108.4' HE SET IRON ROD PROPOSED 16'x 30.4' SET ! DECK IRON ROD IQ 36.8' `25.4 00 NROOF- N Qo PORCH OVER O� N NCF 1 5 X12' .6 PORCH SET 1> SET IRON ROD �_ 72.50' !IRON ROD UNION ST f SETBACKS ON THIS PLAN ARE FOR THE DETERMINATION OF ZONING REQUIREMENTS ONLY. REFERENCE OF ArgORAS•RUCTURES ARETHAT THE LOCATED AND/ DEED: BOOK »776 PLAN: PLANE 7553 JAMES Gs AS SHOWN. D. PAGE: 47 AHO i 35383 STREET 23-25 UNION ST CITY NORTH ANDOVER, MA _ APPLICANT WILLIAM NEARY rrrrY 77t�� f DATE 11/24/2009 SCALE1"=30, JOB# 5753 �IHO ASURII�'YINr 62 CRICKET LANE P.L.S. DRACUT, MA. 01826 -47 �f7 G13 - � 9 e °� /V h F+ -� I Ll re 45 f-baf}''tiJ GI i �S Z L0/10 39Vd NnHSdOd 09008998L609008598L6 OE=Et OTOZ/8Z/Z0 (603) 898-4468 CONTRACT No. (800) 458-4468 A.J. WOOD CONSTRUCTION, INC. P.O. Bog 1769 Salem, New Hampshire 03079 Email:info@ajwoodconstruction.net Website:avrw.ajwoodconstruction.net ROOFING•SIDING•VINYL REPLACEMENT WINDOWS•DECKS Workmen"s Compensation and Public Liability Carried on All Work Date.February-23,2010 I (we), the undersigned, hereby accept your proposal to furnish Labor and Materials to perform the following work on premises located at the following address: No. 23 Union St. N.Andover MA (Street) (City) (State) (Zipcode) Owner's Name Bill Neary Tel. (781)405-9004 Address SAME AS ABOVE SPECIFICATIONS OF CONTRACT Install a 19x16 foot pressure treated deck with a 10x5 landing and two (2) sets of stairs Enclose bottom with lattice For the sum of$7.500.00 De sit.$4 A944)"ue with signed contract $�-366'ti0 Due when project is 100%complete Oder agrees that the title oi`equity in this property is his and is security for this contract. IN WITNESS WHEREOF the undersigned has(have)hereunto set his (their)hand(s)the day and year first above written. Buyer(s)Acknowledge Receiving a Completed Legible Copy of This Contract. This contract may be voided by the Owners giving written notice to the Contractor by ordinary mail within three full business days following the date hereof. L.S. (Legal owner of op to be improved) By / _ �' L.S. (Authorized Agent) (Husband or wife of legal owner) 93-te -� Boa�ui! zriZe lons an San �" s g � One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 106603 Type: Private Corporation Expiration: 7/24/2010 Tr# 270264 AJ WOOD CONSTRUCTION, INC. Richard Smith PO BOX 1769 SALEM, NH 03079 Update Address and return card.Mark reason for change. Address n Renewal F-1 Employment ❑ Lost Card DPS-CA1 0 5OM-07/07-PC8490 �ItE Z?0!)L))2f3)2lUBlLLLIt•6� �llaarac/auael74 Board of Building Regulatiofis and Standards License or registration valid for individul use only = HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: V Registration: 106603 Board of Building Regulations and Standards - Expiration: 7/24/2010 Tr# 270264 One Ashburton Place Rm 1301 Type: Private Corporation Boston,Ma.02108 AJ WOOD CONSTRUCTION,INC. Richard Smith — 4 RUSTIC LANE ,� ` � I< ' DERRY,NH 03038 Administrator Not valid withou signature Commonwealth of Massachusetts Division of Occupation!Safety Massachusetts- Department of Public SafetA Laura M.Marlin,Commissioner Board of Buildinh Re-ulationN ani) Staodv-ds Deleader-Contractor Construction Supervisor License RICHARD S. SMITH �tl License: CS 70882 Eff.Date 07/01/09 - Restricted to: 00 Exp.Date 07/10/10 �. RICHARD J SMITH DC001721 I PO BOX 1769 Memberof C.O.N.E.S.T.130 ' SALEM, NH 0_3079AL !!!! f l IIIIIIIIIIII�IIII�IIIIIII�IIIIIIIIIIIII�III�III�IIIII BOSTON-RENEW � ��- �y�� Expiration: 7/28/2011 t'ummi.�inncr Tr--: 19314 The Commonwealth of Massachusetts Department o f Industrial Accidents Office of Investigations 600 Washington Street Boston, AM 02111 ww►t.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeaibI. Name (Business/Organization/Individual): Address: --� taeq City/State/Zip: phone#: c6q Are you an employer?Check the appropriate box: am a employer with 77. 7Remodehng ject(required): 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors construction 2.❑ I am a sole proprietor or partner-p r listed on the attached sheet ship and have no employees These sub-contractors have working for me in any capacity. workers' comp. g E]Demolition insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition required.] officers have exercised their 10.0 Electrical repairs 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 insurance required.] t employees. [No workers' 12.❑Roof repairs comp.insurance required.] 13 1 Other& :Any applicant that checks box ul must also illi oat the sectio"below showing their workers s'coin,—saticn. r y cc 'homeowners who submit this affidavit indicating they are doing all work and then hire outs $Contractors that check this box must attached an additional sheet showing 'de contractors matt submit a new affidavit indicating such. 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: Policy#or Self-ins.Lie. # Expiration Da Job Site Address:2` City/State/Zip: ft� mo olos7j e(showing Attach a copy of the workers'compensation policy declaration pagng 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 cerci,fy under the pains and penalties of perjury that the information provided above is true and correct Sr atu Phone#: EPerson: only. Do not write in this area, to be completed by city or town official n: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical InspectoEu -] son: 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 Vmrn that the application for the perrnit 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 than 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 Investibations !7 640 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE Revised 5-26-05 Fax#617-72.7-7749 vmm,.rnass.gov/dia Date. ,,Oft �.T ti, TOWN OF RTH ANDOVER 3? .. °t ° p PERM-1 FOR PLUMBING �/ +O e•n ,SSACMUSE� This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform� ':.Yy"G . . . . . . . . . . . . . . . . . . . . . . --v 2� / plumbing in the buildings of . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . at . . . . . . .. . . . . . . . . . . . . . . . . . . . . , North Andover, Mass. Few/. . . . .U c. No�. PLUMBING INSPECTOR Check # 14 D V 82 -69 J I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Z�j L¢�1 G7 t j p Date /� Building Location Owners Name U i ` y Perm;t# a T e of Occupancy Amount New Renovation -� Replacement Plans Submitted Yes ❑ No FIXTURES a wtoo cc x w M FLOOR 3MFLOOR 41H FLOOR 5M it" 6M FLOOR 91HFLOOR (Print or type) > Check one: Certificate Installing Company Name � �/ �'I, ,E- ~'/ Corp. Address �� partner. usmess Telephone �Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the t e of insurance coverage by checking the appropriate box: Liability insurance policy ff Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusett to ode pte of the General Laws. By' igna ure o icense um er Type of Plumbin License Title City/Town icenseIN111110er APPROVED(OMCE USE ONLY Master � journeyman ``s \ The Cnmmanwealfh of Mwachuset& k� Department of Industrial Accidents tt � Office of Investi alio g ns. 600 *1ashingtun Street Boston, MA 02111 c www m=s gov/dia . Workers, Compensation Iusurance Affidavit: Budders/Contractors/Eieatriciiaas/Pfambe Applicant Information rs Please Print Legibly Name (Business/Orgauization/Individual): ,/4 I L Address: �f� i is _ e j — Citystate/Zip: /i9s �Z� Phone#: . -7 1 -- 7Z-_3 Are you RD employer4 Check the appropriate box: I.❑ I am a employer with_ 4, ❑ I am a general contractor and iF7n project(required): ,�_, ployees(full and/or part-' etrm .* have bsred the sub-contractorsow construction 2•Li'l I am.a sole proprietor or partner. listed on the attached sheet Remodeling ship and have no employees g These sctb-contractors have molition working for me an any capacity, work=-S' comp.insurance. [No workers'comp.}asurance 5. ❑ We arc a corporation and its ilding addition required.] officers have exercised their ectrical repairs or 3.❑ I am a homeowner doing all work right of exemption per MGL mbin additionsmyself[No•warkers,co g repairs or additions mP• Q 152, §I(4),�and we have no of}nsursnce required].t employees [Na workers' repatrs comp• insurance required.] e 'Any appficarrt that checks holt{l must also fill out the section below abowing their workent'bompmewion policy information, t Iiomeowncrs who submit this affidavit indicating they art Bain all 4canunctors that check this box must an additioasl g sheet show°,end then him outside conuactors must'submit a new affidavit indicrifiag such. show in, the name of the sub.camractom and their worknra'co I ale ane k ger that is camp.Policy infonnadon. P 1 P' --µrltrrg:r�orkera' o Fonzperssari�in information, insurancefor ny.mployees: Below it the p le' cj grid job site . Insurance Company Name: ' Policy#or Self-ins.Lie.#:�j ti (�Q y Z S —7 Expiration Date: Z !D Job Site Address: owin j �t?141dagz Attach a copy of the workers' coal ' Failure to sCrt3'�tate/Zip: pensation policy 6eclarafiou page(showing the policy Dumber and expiration date), . ecure coverage as required under Section 25A of MGL C. 152 can lead to the imposition of criminal penalties of a fine up to$I,500.00 and/or ane-year imprisonment,as well as civil penalties in the form of a STOP WORK ORUER and of up to$250.00 a day against the violater• Be advised that a copy of this statement may be forwarded to the a fine Investigations of the DIA for insurance coverage verification. Office of I do hereby cerfify under the a Penalties afPe that the information Provided above is 1!rue and rowed Si tort: Date: l� Phone#: 7le _ g - Z C Of, iciat use oafy. do not write in this area[n be co let np. ed by city or town.ofcxa( City or Town: Permit/License# Issuing Aafhority(circle one): I. Board of Health 2. Building Department 3.City/Tovvn Cierk 4.Electrical Inspector S.Piumbing Inspector 6.Other Contact Person: Phone#: Information a ind Instructions Massachusetts General Laws chapter 152 requires all emp'I overs to provide workers' compensation for their employees. Pursuant to this statute,an orgiloyee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written" 1' An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the'fbmping engaged in a joint enterprise,and includi"g the legal representatives of a deceased employer,or the receiver ertrustet of an individual,partnership,association or other legal entity,employing employees: •Howeverthe owner.of a dwelling house having not more than three apa-rtments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair wdrk on such dwelling house or on the grounds or building appurtenant thereto shall not because of such etrploymerht be deemed to be an employer." MOL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of license or permit to operate a business or *o construct buildings in the commonwealth for any applicant who has not produced acceptable evidence.o'F compliance with the insurance coverage required" Additionally, VOL chapter 152,§25C(7)states"Neither the commonwealthnor any of its political subdivisions shall enter into any contract for the perfrnmance of public work- tartil-acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the corttracting authority." Applicants Please fill out the workers'compensation.affidavit comp14--tely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractors)name(s),address(es).Fund 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,arc not required to carry workerscoirnpensation insurance. Van LLC or LLP does have empioyees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insur met 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 nurmber,listed below. Self m-cured oom panies shall P.ntRrfh= self insurance-licanse number on the'appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Depart mert hes provided a space at the botmm of the affidavit.for you to fill out in the event the Office of Investigations has to contact you regarding the applicarrt. Please be sure to fill in the permit/license number which will be used as a mferccn=number. In addition,an applicant that must submit multiple permit/licerhse applications in any given year,need only.submit one affidavit indicatingcurrent poiicy:information(if necessary)and under"Job Sit-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 affrdaOt is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen i 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 pws6n is NOT required to complete this affidavit Thr Office of investigation 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 umberThe Commonwcmlth of Massachusetts Department of 132dustxial Accidents Office of InwatiIIations 600 Washington Street Boston, MA 02111 TeL#617-7274900 Ext 406 or 1-977-MASSAFE Revised 5-26-05 Fax;9 617-727-7744 www.man.gov/dia