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HomeMy WebLinkAboutBuilding Permit #223-2016 - 24 COVENTRY LANE 2/24/2015 NORTy BUILDING PERMIT t6 gtio 11� TOWN OF NORTH ANDOVER h.y6 APPLICATION FOR PLAN EXAMINATION Permit No#:oI2-3-2-6(41 /pOIRTA-NT: Date Received gSSRCH `S Date Issued: v 02 11 Applicant must complete all items on this page LOCATION C O 6" el/;r- N Pr ' PROPERTY OWNER Q) 4 A( l,fi-/�( ✓ k-/4 l/ "— Print 100 Year structure yes no MAP G'� j PARCEL: 1� ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Buildingne family El Addition [I Two or more family El Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other S❑ etic �.Well; El:Floodplain` Wetlands Waterhed�Dstnct. �. , ��Water/Sewed - DESCRIPTION OF WORK TO ELP PERFORMED: go Identification- Please Type or Print Clearly OWNER: Name: Dl„li�//f'kg¢y /�� Phone:�� ��7�/ �3�� Address: CR L/ Contractor Name: � � -N 49 hone: f ��� -6S�f 67� �- I Email: Address: 16-5 �' �f�"U Supervisor's Construction License: 0 Exp. Date: �a Home Improvement License: 167335 Exp. Date: 71711- ARCH ITECT/ENGI NEER lARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PER $92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ //, FEE: $ Check No.: 3 ff C Receipt No.:c�)-go23U NOTE: Persons contracting with unregistered contractors do not have acces the g aranty fun - Location N —' Date i s. • - TOWN OF NORTH ANDOVER i . k Certificate of Occupancy $ w, Building/Frame Permit Fee $ cjk, 'J Foundation Permit Fee $ Other Permit Fee $ TOTAL $ d Check# 24 23 n Building Inspector � � Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL E Public Sewer ❑ Tanning/Massage/Body Art ❑ Swinnning Pools ❑ wen ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS i 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 y ' Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town.Engineer: Signature: Located 384 Osgood Street tFIREDEPARaTMENI'' Temp,�Dumpste�aonsit � ye .'��; sin aced at'12 Main l t r xy a € _a � 11 m � ��� �a (Street .' _- ;,F'ire Departments nature ' ` =,f /date •.3,"` '4- s y' t4 'N,y tV:r- h i t :s � rt F4 w - 4 .d'. T r >3�0• t .p C®MIVIEIVT;S� 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 Call Email f Date Time Contact Name Doc.Building Pennit Revised 2014 r Budding 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks k 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/Cross Section/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 sign off from Fire Department prior to issuance of Bldg Permit permits require s p OTE: All dumpster p q g 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 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 2014 NORTH own of s �� ndover 0 :�. No. 3, 2 d h ver, Mass, 4 coc«�c«ew�cw 1• S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System / THIS CERTIFIES THATBUILDING INSPECTOR ........... D.q1&C'r*: :....Y%.�� ............ ...................................... ..... CFoundation has permission to erect . ...................... buildings on Q.. ....... .Q!�t!`.:'!:.. .. ft —� ......� ...................... .� Rough tobe occupied as ...... ............ ......�........................................................................................ Chimney provided that the person accepting this p mit shall in every respect conform to the terms of the application Final on file in 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 038% UNLESS CONSTRUCTION A Rough Service ...................... ................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. Page# of pages CS # 022fi80 978-688-6737 HIC# 103358 A. J. Walsh & Sons or 159A Waverly Road 1-978-912-2853 North Andover, MA 01845 Proposal Subrn `ed To: Job Name Job# Address T Job Location G1 � Date ! Date of Plans Phone# �,/ F f Architect We hereby submit specifications and estimates for. S� p F We propose hereby to furnish material,and labor—comp letin accordance with the above specifications for the sum of: $ Q ,�. ' f� -e5—e'--V �� Dollars with payments to be made as follows:. ws F eAlt 5�b Any alteration or deviation fro spedrications involving extra costs MI be Respectfully executed only"upon written order,and will become an extra charge over and submitted above the estimate.AD agreements contingent upon strikes,accidents,or delays (� beyond our cohtroi. Note—this proposal may be withdrawn by usrf not accepted within days. r SCC¢PtOM 0fOID01 The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the work as specified. Payments wlll be made as outlined above. Date of Acceptances Signature From: 07/12/2015 14:48 #151 P.093/016 4coRD® CERTIFICATE OF LIABILITY INSURANCE DATE011121DD/YYYY) f• 01/12/2015 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). 'RODUCER 00775-001 5H2pp�pN�Ag�CT Durso&Jankowski Insurance Agency Inc IUC.No.Ext: (978)682-5175 .No; (978)794-0313 AIC 198 Mass Ave Suite 10113 RMSS: North Andover,MA 01845 A.I.M.Mutual Insurance Company VSURED INSURER B Arthur Walsh A J Walsh & Sons 55 Pleasant Street INSURER North Andover, MA 01845 INSURER E: 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 C (M POLICY CLAIIMS.p I>� TYPE OF INSURANCE I�OSRyBp POLICY NUMBER MA1lDO/YWY {PMja[jnYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGETPREMISESORENTED $ mrencel CLAIMS-MADE F—]OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ OLICYRO- OC AUTOMOBILE LIABILITY COMBINEDISINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS i nt $ UMBRELLALIA13 HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE S yyQR{DEEDDg Cptl,�� RETENTION$ t//C gTT 77UU T�{ S ANky ERRMopPLRO��YEEE77ROpSVLp&ffiILNIET�Y/EX YY�/NN X TORY LAMITS OER A OFFICERMIEMBER EXCLUOED9 ECUTNE,"4 N/A AWC-400-7014648-2014A 11/14/2014 11/14/2015 E.L.EACH ACCIDENT $ 100,000.00 (Mandatory In Nuun�H)) E.L.DISEASE.EA EMPLOYEE S 100,000.00 DYE�sCRIF"N116PERATIONSbelow E.L.DISEASE-POLICY LIMIT S 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) The workers compensation policy does not provide coverage for Arthur J Walsh CERTIFICATE HOLDER CANCELLATION Town Of North Andover 1600 Osgood Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE North Andover,MA 01845 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE '�X6..4 ©1988-2010 ACORD CORPORATION.All rights reserved, ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD A _.. Office of Consumer Affairs&Business Regulation ME IMPROVEMENT_.CONTRACTOR egistration: ` 0 58` Type: xpiration: =� '�� Private Corporation s. A.J.WALSH&SOt � . Arthur Walsh t � 55 Pleasant St N Andover,MA 01845 - Undersecretary r Massachusetts -Department of Public Safety. Board-of Building Regulations and Standards Constructiori Supervisor License: CS-022680 `:; cr:vis „ ARTHUR J WALS, i 159A WAVERLY2D N ANDOVER MA 01 .•�+•� ► � Expiration Commissioner 06/09/2016 MASSACHUSETTS HOME IMPROVEMENT CONTRACT This form satis5es-all basic mW of the state's Home Improvement Cotitraetor Law(MGL chapter 142A),tint doer not itieiude standard language to protect homeowners. Seek legal advice If necessary,"Any person plaming home pprovemtints should'fust obtain a copy of"a Massachusettc consumer guide to home,improvtmient"before agteeing.to any work on yourriesidenee.You may obtain-a free copy by'calling the Office of Consumer.Affairs,and Business Regulation's Consumer Information Hotline at6i7-973'd8787 or 1.888:283-375.7. . Homeowner Information Contractor Information arae , i PmY Street Xddress( of use a Post Offi ox ) tractor/ 0 Name ov Q owe S de ess A (must include as street address) Da bone EvethingPhone Hfl own State Code Mailing Address(It di from above) Pb ederal Employer ffD or SX.Number tavnegW=tWtZ1WLomeim Home ICM=MrR92.N—be Hspbali®Qae '- The Contractor agrees to do the following work for the Homeo ner: CL 12"loot e Il equired'•PeriWts-The-following building permits are mgWred Proposed Start add'Completion Schedule-The fdlloaibg schedule will and will be secuted:by the contractor as the homeowner's agen( be adhered to twi ess circumstances beyond the conrract&st control arise (Owners who:,secure their own permits will be excludedfrom:the Guaranty Fund'provisions of MGL chapter 142A.) Date when boiitractor will begin contracted work Date when contractid .work willbe substantially completed.. Total Contract Price and PaymentSchedule , The Contractor.agrees to pdrform the'work,fiunish the material and labor specified above for the total sum of S7�V � (s) Payments will be mile according m the following schedule: $�7 006.�`oJn.signmg contract(nottb exceed 1/3 of the total:wntract price.gt the coscof speoial order items,whichever is:greater) $ by / / or upon completion of $ by / / or upon completion of S updn completion of the contract (Law forbids demanding fall payment until.contract is completed to both party's.satisfaction) The following material equipment must be special S to be paid for ordered before the coutracted work'begins in order S to be paid for to meet schedule.(••) NOTES:(•)Including all finance charges(••)Law requires that any deposit or down-paymert required by the contractor beforework begins may notexeeed the greater of(a)one-third of the total watract price or(b)the actual con of any special equipment or custom made material which must be special ordered in advance to meet the complexion schedule. Express Warranty-Is m expresswarranty bein4 nrovlded by the ontractor' No Yes .(all terms of i � traettSubcontractors The contractor agrees to be solely responsible for completion ofthe work descrbhdmflonid party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and Is under this aereement Contract Acceptance-Upon signing,this document becomes a binding.contract underlaw. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest)w been placed on die residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read'and fully understand it, Ask'clueations ifsondtxhirig"is unclear. • Make sure the contractor has a valid Home Immovement ContractorAcuistraflon The Idtiw requires most home improvement contractors and. subcontractors to be registered with the Director ofHome Improvement Contractor Registration. You may inquire about.contractor registration by writing to the Director at One Ashburton Place,Room 1301'r-1109011,MA 02108 orby.calling 617-727-3200 of 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 ImporLmi laformtion ter the everseside of fbis foim'and get a copy of the Consumer Guide to the Home improvement Contractor Law. You may cancel this agreement if it has been signed at a place other thanthe contmctdr's normal place ofbusiness,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later thea midnight of the. third business day following the signing of this agreement.See the-attached notice of cancellation form for an explanation of.tbis right DO NOT SIGN THIS CON T IF THERE ARE ANY BLANK SPACESM Two idmticel copies of the eponact taut be eoomleled m pee copy*xndd go�aw�, Ore oopy�sbooWbet ale by rnotractor. omcowner's SignatureContractor's Signa 4 f Date L Date Q_ Contractor Arbiteli b The Home Improvement Contractor L-aw Vmvides;homeowners withthe right-to-initiate•an arbitration action(as an alternative tapourt actioa)if they.,have a 4ispute with a contractor. The.same.tight is nod automatically afforded to"a. contractor,how..ever.:.Tbecontractor,wouid have;-to resolve any..dispute be/she.ltas with a homeowner in court unless both parties agree to.the optionit Clause provided below..This clause wouldgive the-contractor the same right to arbitration as is afforded to the homeownenb'y 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 toe private arbitration firm which has been.approved by the Secretary of the Executive Office of Consumet'Affairs and Business Regulation andthe consumer shall be required ubmit to such arbitration asgyp rovided In• s chusetts General Laws,cha 42A. , owner's SignAture Contractor's Signature NOTICE:"The signatures of the parties abov,3only agreement of the parties to alternative dispute resolution initiated by the contractor::The:homeowner: tive.:dispute resolution even where this section.is not Separatelysignedby`:thepartiesr:: Homeowner's Rights A homeowner's-rights und, the.Home'Improvement Contractor Law(MGL chapter I42A)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 able -for completing the work as described,in a t Contractor Law. The contractor is p g the Home Improvemen Co TeSP� timely and rworkrnanlike 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 wairanties 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.may be added:to the. terms of the contract as longtheydo 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 d_uRlicate and should not be signed until a copy of O'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 cinginal'contract must be in writing and agreed to by both parties.Contracted words 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 inadvance.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 words. 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 consurirer iights,or if you wish to.:O n a:fi'ee copy.of"A Consumer.Guide to the Home Improvement.Contractor Law,"•contact. . . Cgnsumier Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 (617)973-8787 or 1-(888)281.3757 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 T (617)727-3200 oil-80b-Z23-0933 For assistance with informal mediation'of disputes or to register formal complaints against a busijfess;call:' Coftsuffie'06mplaint Section Office of the Attorney General (617)727-8400 SAND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)734-3114 The Commonwealth of Massachusetts Department oflndustrialAccidents d I Congress Street,Suite 100 Boston,MA.02114-2017 y�;�•°` www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNIITTING AUTHORITY. Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): Address: /S"Y& q� City/State/Zip:e!J�D a ��FAff 737 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with /.. : employees(full and/or part-time):* 7. ❑New construction 2.FJ I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.FJ I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.Q Plum repairs or additions 5.]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.04toof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.Q Other 152,§1(4),and we have nq employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: (/. / /4t7 /11�✓i1 , �f.�`� — Policy#or Self-ins.Lie.#: 2(/�� ��� �� Expiration Date: Job Site Address:c4City/State/Zip: Attach a copy of the workers'compens n policy declaration page(showing the policy number and expiration date . Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby certunder the pains and penalties of perjury that the information provided above is true and correct. /p 4 c.f�j� Signature: Date: / l5 Phone#• �� �� ��7 Official use only. Do not write in this area,to be completed by city os'town official.. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or Iocal 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 fihe boxes that apply to your situation and,if necessary,supply sub-contractors)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 foi•confirmation of insurance coverage. Also be sure to sign and date the affiidavit. 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 pernvit/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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-AIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia