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Home My WebLink AboutBuilding Permit #206 - 25 MARTIN AVENUE 9/12/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 0 Date Received Date Issued: 1,14L IMPORTANT: Applicant must complete all items on this page LOCATIO� �l�/ /�t� Avg Print PROPERTY OWNER Unit# Print MAP NO:�f *PARCEL: VZONING DISTRICT: Historic District yes o Machine Shop Village e es Y no 100 year-old structure yes <115P TYPE OF IMPROVEMENT PROPOSED USE Resi ential Non- Residential ❑ New Building Vbne,family ❑Addition ❑Two or more family ❑ Industrial ANite No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ,W _ T r_ Septics ❑;Welll ®'Floodplain}" ❑jWetlands3 IT,WatershediDrstnct _ ❑ Water/Sewer i _ DESCRIPTION OF WORK TO BE,PERFORMED- fLPy/3tt�/ (Identificat n, Please Ty e or Print Clearly) OWNER: Name: G Phone: Address: c s (0i,� &� CONTRACTOR Name: 2 / Phone: 7S-d`- Address: Ca6zf 2 Supervisor's Construction License: 0,S 096 5/,'- Exp. Date: Home Improvement License: ZaPs� Exp. Date: 0 C94/.3 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.-$12,00 PER$9000.00 OF THE TOTAL ESTIMATED COSTBA ED ON$125.00 PER S.F. Total Project Cost: $ � � FEE: $ Check No.: '� Receipt No.: NOTE: Persons contracting with unre iste red contractors do not have access t e g my fund ;Signature of AgentZOwn . -... re o con rac or: . ..-----�� 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 atlon ❑ 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 MOTE: 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 o 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 2008mi Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tann Swimming Pools ❑ Tanning/Massage/Body Art ❑ 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 r 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 ■ L Dimension Number of Stories: f Total square feet of floor area, based on Exterior dimensions. I Total land area, sq. ft.:1�, 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 i ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi i _ Location e'::/Jul No6 Date MORTh TOWN OF NORTH ANDOVER � A A i + , ; Certificate of Occupancy $ 4 Building/Frame/Frame Permit Fee $ s�CHU 9 ` f Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # cJ 24568 Building Inspector TO" AORTH Of s over _ . 0 . . ,:. TO o over, Mass., ,�• Z•1 T O '= LAKE COCKICMEWICK 5 RATED BOARD OF HEALTH Food/Kitchen Septic System .PERMIT T U BUILDING INSPECTOR THIS CERTIFIES THAT.................. ....... ...... ....... ..................................... •••""" Foundation has permission to erect.... ........ :....................... uildings on ...35..... ........... ... ..��.................. Rough _ to be occupied as Chimney 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 b q ELECTRICAL INSPECTOR UNLESS CONSTRUC 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. ,6,. J es e�°1 (tP eC 0 pgF pt(iee ME E�o�• 51213`: Noe eME�MPRo. g ax eveta<9 p RO Rod �M�� 26 N" laNsachrtsettst'luturns .0 ,ulStandar 1� Bound of Buildinl� Rc,r construction Supervisor.License ieznseI'S 90047 ROBERT D DROUIN 250 SAWMILL DRIVE DRACUT, MA 01*26 Expiration: 9/30/2012 Tr#: 1963 . e BOB'S HOME IMPROVEMENTS 250 Sawmill Drive Dracut,MA 01826 HIC#147848 CS#090047 Mary D'Ang elo 35 Martin Ave N.Andover,MA RE:Kitchen 06/13/2011 Demo existing kitchen and remove debris from premises.Open wall behind fireplace for closet and eliminate Partition wall to prep for island counter. Reframe for closet next to utility cabinet Prep walls for new cabinets-skim area's needed,and prime-patch ceiling area's needed after electrical Paint ceiling in den,kitchen,hallway and living room and 2 bath trim Paint paneling in den area Paint walls and trim in all rooms to color chosen by customer(purchased by contractor) Install new pergo floor&0 sq ft allowance)from kitchen and down hallway,finish off with trim along baseboard. Install new kitchen cabinets as designed by Norfolk. ELECTRICAL- Add 8 recessed can lighting and 2 pendants over island.Have dimmer switch for recessed cans Instail GFI outlets as needed per code along counters ad plugs needed to supply island cabinets Rewire for dishwasher PLUMBING: Redo any plumbing needed for new install Install new water supply line for new fridge Install gas line for new gas stove BATHROOMS: Demo existing quest bathroom floor and add hardback subfloor Install new tiles(not included)and grout(not included)and seal when done. MASTER BATH: Demo old tile and floor,remove toilet and sink. Install new sheetrock on walls,skim and prep for painting. Tile and grout floor(not included)and seal c Paint bathroom colors chosen by customer purchased by contactor. a Install new cabinets and-toilet. TOTAL PRICE: $ 17,890.00 ) Vill j\ Method of Payment: $'Q Lid $500.00 due on signed agreement � 1st payment of$7500.00 due at start 2nd payment of$5000.00 due after rough electrical and plumbing,sheetrock,and painting - Final Payment after completion and customer satisfaction Approx.Start date 8/8/20011 Finish date a prox.2-3 weeks Q / This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Name Company Name Street Address( o t use a Post Office Boi address) Contractor/Salesperson/Owner Name 2/�0 City/Town State Zip Code siness Address(must include a street address) em 4zli Daytime Phone Evening Phone City/Town State Zip Code - 00 - ? -eQ"7 0XS--wa - Mailing Address(It different from above) Business Phone I Federal Employer ID or S.S.Number Home Improvement Contractor Reg.Number Expiration date Law requires that most home improvement contractors have n valid registration number The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifyL*nthe type,brand,and de of in terials to be used,use additional sheets if necessa1y.) Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of �' - ate when contractor will begin contracted work MGL chapter 142A.) Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: � (*) Payments will be made according to the following schedule: $ 71y,toupon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ by % /_i // or upon completion of c $ by _/ / or upon completion of ` , pon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) OC� owing material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be paid for NOTES:(*)Including all finance charges(**)Law 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 of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty beine provided by the contractor? ❑No❑Yes(all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement 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 lien or other security interest has been placed on the 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 questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration.tration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form 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 than the contractor's normal place of business,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 than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY B, ANK SPACES!!! Two identical copies of the contract must be completed and signed. One copy should go to the ho weer. The othe, copy should be kept by the contractor. Homeowns Signature <7 Contractor's Signiftfe Date Date i 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 right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor 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 submit to such arbitration as provided In Massachusetts General Laws, chapter 142A. Homeowner's Signature- Contractor's Signature NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner 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 may be 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 rescission 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 Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at http://www.mass.gov/ocabr/ 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 Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at hn://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: hM://db.state.ma:us/homeimprovement/licenseelist.asp 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 or 413-734-3114 Version 2.1-11/22/2010 s ACORDTM CERTIFICATE OF LIABILITY INSURANCE 06 113/2011 PRODUMR (978) 937-5747 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION G.M. INSURANCE CENTER, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ~ 850 CHELMSFORD STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. LOWELL MA 01851- INSURERS AFFORDING COVERAGE - NAIC# INSURED wsLmA:Main Street America Gro Drouin, Robert p0URER8;Assoc. Industries of MA 250 Sawmill Road WsullRa INISUiE20 Dracut MA 01826- INSURER I- COVERAGES THE POUCIES 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 WHICHTHIS 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 AWL LTR W TYPE OFINSURA_NICE POLWYNURQM DATE DATE E7�IRAM LIMM A X ae&F-:-A9nm DW79317 01/23/2011 01/23/2012 EACH $ 1,000,000 IED X �=IVQE C>BiERAL LUSLTTY Fa i�er�e $ 50,000 ®OCCUR / / / / MED EXP&V one pmpfO $ 2,000 lR3RSONAL&ADVINJURY $ 1,000,000 GENERAI-AGGREMTE $ 2,000,000 GEITLAGGREGATE UMITAPPLIESPER: PRODUCTS-COMPAOPA 8 2,000,000 POLICY JMr Loc / / / / PDA AL TOMOSME LIAMLITY / / / / COMBINED SINGLE UMIr S ANIYAUTO F 6 ALLOYIINEDAUTOS / / / / BODILY1NJURY $ SCHEDU.EDAUTOS (Perms) WPM AUTOS / / / / BOOILYSQURY S NON4N&EDAUTOS (Parlaodit0 PROPERTY DAMAGE GARAOELIABILITY AUTO ONLY-EAACCIDENT S ANYAUTO / / / / OTHERTHAN EAACC S AUTOONLY: NGG s E)WESS lNISRELLA Lf48RM / / / / EACH OCCURRENCE $ OCCUR CLAIMS MADE AGG'REGAT'E S DEDUCTMLE RETENnON $ I p �TH.i B uuOt�SCOBIPEN8AT10NAND VWC6011893012011 05/11/2011 05/11/2012 X TORYIJIBTS gR EMPLOYERW LIABILITY E L Faces AccmENr $ 100,000 ANY PROPRIETORIP,� OFRCEPAdEMBEREKCLUDED? / / / / ELDISEIISE-EAEMPLO S 100,000 If yam,describe ander SPECIAL PROVISIONS bakm E.LDISEASE-POLICYUNMi S 500,000 OTHER OMCMPTLONOFOPERATTONSILOCATTO ALTDEDBY PROVOO S THE WORIGJZS CONPwSSTION DOES NOT PROVUM COYRFAM VOR THE SOLS PROPRIETOR CERTIFICATE HOLDER CANCELLATION ( ) — (978) 208-1765 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIDN DATE THEFMOF, THE OWNG INSURER VV{LL ENDEAVOR TO MNL 10 DAyswmTTr:NNDmm-ro-niEcEF(nF=A-rEHmDERmAmm-TonmLorr,Bm FAIWRE TO DO SO SHALL IBFOSE NO 08UOATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS ORREPRESENTATIVE& RiTATWVE N. ANDOVER MR 01845— jollam' ACORD 25(2001N8) a ACORMORPORATION 1888 The Commonwealth of Massachusetts TED Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Pr><nt Legibly Name(Business/Organization/Individual): &0 S Address: City/State/Zip: C �J hone #: F[5�1 employer?Check the appropriate box: _ em to er with 4. �'pe of project(required):p y ❑ I am a general contractor and I yees(full and/or part-time).* have hired the sub-contractors6 ❑New constructionsole proprietor or partner- listed on the attached shget. 7• �El Rem.odeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. [No workers' comp,insurance 5. El We are a corporation and its 9 F1 Building addition required.] officers have exercised their 10-❑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 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.0 Other *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 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.Lic.#: y6de 16v0/J -2,30 k Expiration Date: 1— 11—2—o Z Job Site Address:_ 3 S City/State/Zip.Al,_,X 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• surance coverage verification. I do hereIcy der ains and penalties of perjury that the information provided above is true and correct. Si natureDate: — Phone#: [Ci l use only. Do not write in this area,to be completed by city or town official. Town: Permit/License# Authority(circle one): d of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspectorrt 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,empi employees. Howe ver 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 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 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 us a call. The Department's address,telephone and fax number: The Comn-to. wealtl of vlassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-72=7-4900 ext 406 or 1.-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia