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HomeMy WebLinkAboutBuilding Permit #911 - 25 OGUNQUIT ROAD 6/18/2012BUILDING PERMIT TOWN OF NORTH ANDOVER t APPLICATION FOR PLAN EXAMINATION C�% `�/ Permit N0: ` ` Date Received d I / i v Date Issued: IMPORTANT: Applicant must complete all items on this page 5 yif iL nn, 41 � z ". t �y 2 RQ Pr OWNER '' Pfi J "`a MAP.h NO PARCEL ZOr111VG [1STRGT FIstoric DIs#rtct ye's 1 nog t 1t achilrle Shop VIQag ye ri TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family. ❑ Industrial ❑ Alteration No. of units: U Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other z fl SeptEc'` C7 VlLell a ❑ Floodpl Ir%r D Wetlands tU VVaterst ed D�str�ct , t o lNaterlewer- y . ^ z DESCRIPTION Ur VVUKIX i u tst rmr-rum r -u. Identification Please Type or Print Clearly) x OWNER: Name: Phone: Address: J ti ¢ CONTRACTraR Name a Phone" ��q* Address Supervi'sor's Construction License 5 . l Expo Date Y '"' 4.lnw.o Irrt"r,rnvamantil� af1CP r _ E�cn: Rate.. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ C7 FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT ❑ COMMENTS DATE REJECTED DATE APPROVED RI DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED H11z,ALTH ❑ COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Driveway Permit Located at 384 Osgood Street 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.s100-s1000 fine Doc.Building Permit Revised 2007 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Locationr if - / 1c, No.—�!j / I Date /I), -- If Check# 25429 TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee. Foundation Permit Fee Other Permit Fee TOTAL Building Inspector 'I I NI Z w 0 EpL Juj W LL 0 Q m C 41m u Y 'p o LL E N Ln2 N 'y a N o C. z Z O J C: m C n LL Of w T v U LL o z N Z Z m J C. 4o K LL cc N z U J W to w Uai (A LL O LU a Ln N Q to OC F LL C G a W � W LL m p Z 01 v N cuQ Y o N O H n� W Z7 N V O E O Z CL O Co cn 0 �C Q A �E W W 0-0 i �a v G O O 0- 0- cm - 0 - c a P0-0 •_ 'a V J � Z W O CL V U) m WWF •� i U) 6 LLI U) W W 19 W U) O� +� C t4 p •Q. L as I L C' N C CD m tm 0 c 0 L V O H n� W Z7 N V O E O Z CL O Co cn 0 �C Q A �E W W 0-0 i �a v G O O 0- 0- cm - 0 - c a P0-0 •_ 'a V J � Z W O CL V U) m WWF •� i U) 6 LLI U) W W 19 W U) • do I Q W LL 0 Oz Q m C .CC aV_+ \ O LL E ate+ T U w N G WLU d z z m C 'O O LL L O W cu C L U C LL O CL z d L O cr C IL cc O LU N z Q U �„ W W L o d' U c V) C Il. O a CA z L 7 cc C I.L CWC G X W oWc U. N L m O Z N }i N Y O (n �I O 0 a R o •Q L o. a� • R y- o o, N v O L Q• Y M °w' c J�.0 0 C L cm _O = i R Q' o • V N CL � J T�>� R c °) N a, O �.m o U) -0 c • iQ N +•+ L t E0 c as o z h Q' _ '0 (Ao :t•U) �• 3 � o L ...: tkl a� .: 7r a •� O = •O F�— 0 w O .t� m ujW_ C -0— O O LL •�- M N = C.•O O N 7 w y=+ w •E 0 V a o� ti 0 .> �- 0c N .Q O F- t .0.. Qo0 I 2 Z G Z Cl) w a. W I_- W CL m E V. L` `Fv Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-026791 RONALD G LAM%R T 265WINTERST. HAVERHILL MA 018311 :< ✓.s ` �(�L if i41 ' `Xpiration . Commissioner 01/17/2014 Details Licensee Details Demographic Information Full Name: RICHARD J LAMBERT Gender: Owner Name: License Address Information Page I of 1 Address: 94 PICADILLY RD Address 2: Profession: City: HAMPSTEAD State: NH ipcode: 03841 Country: United States License Information License No: CS -078130 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: Issue Date: 6/3/2010 Expiration Date: 6/2/2012 License Status: Expired Today's Date: 6/18/2012 Secondary License: Doing Business As: Status Chan e: 17 Prerequisite Information No Prerequisite Information Discipline No Discipline Information Documentum http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=l &license_id=267079& 6/18/2012 \ �"'P aSw:�:_2�::�P3?!�(Z� �",di:'�'%l:1w:�I'iti '• i1Dti+arLS Aii• 3DQi?�i"Fi X�T2ie7dT)'nt di .2. i?UVPti,'tri� ��t ! ,;` ris Lie ;:se: --5 781311 RICHARD J. t;AMSERT 94 PiCADILLY RD L :r HMPSTEAD, IVH 03841 �_�....ry �� M X73-?•`?�++; :. 612120 w -. .30062 _= V- ' 1 Offic ®f Consumer Affairs and er y usiness Regulation 1 0 Park Plaza. - Suite 51.70 Poston, Massae setts 02116 %6e Improvement C'P rct®regisratiol . 'l:.... . ReqA -; TVpe: Private COro(.)'M . . 11g �i;�:;:�,::: ExPirat6on: 72I612013 ,ICHARID LAMBERT � �. _- 265 'VVINT�tR STREET HAVER HILL, MA 01830 UPd2te Address and irourra .❑ Address CERTIFICAiM OF iia. A N::• . VEi�ii iC T - AF�9 ��Y.�� " 03 !GOg,/?^l .. '�i E� Y 'C!R l �'�$$1iEw�..'i ��R '' i� 'S E C'.cRrEF6C T HOLDER. Tr r ~LOQ; • -' €;S : ER ; IFiCA";E d Car Db ZXTEND OR ALTM 1!F COVERASE AFP EPF ESENTA T VE dry PROD a`CER AND :J He C� �idA'M { � i E A f�C?�f t!"�C'{� �Fl �!! �,d 9Y THE POLIC i _,--�--�-� . t t�6S4JItER(Sj, AUTH0Ric,. f� Lire c'e��ate holdsi is iha e;;,,s . Conditions ADDITION -A. tN�UpR,car pogr���1 dust � �;� as the pati rYt cectai3t Poticies m �rSq,_sacl. S� pz.f3GA i is tS'�AIVED �r i'1 !--e:S Uri s.ucb endo t LBir4' an eR( .tn+ em A statL"�-"t C , si3%f �C rea4{s,.IEis eertc�i .ate des rsa: C01f8i rights to t. .:..v�l�^: _.:•.�c,,;r,;��7:��' �C�?tiiC�t i*�C. = as:»cv �"ezrol@ xameras :.._,.... 2nd Floor 1978) C;= w&Lmins;arance:.. ccim iti iNSUk 1 0 370-4 12 aFFORO,,,, C i�tf:E¢aGF IR AR - �zxs. Co. e &uRsxe:afety r. RC�f, ."Cs INNER , C - rnpaay. �� & Sta a 9IS Ins , INSt.'RE!?D;C I:gFs Il$i.r3Z3Z] c�.. omparl?.._ Q1 3 �NSURERE: _ ,...... ER7WIGA ImsumF- THAT THE POUCIES OF INSURANCE E eST i} @aEt�AViG SEEAi t$�c p zQ fFfiE S r tS@f�F� NUMBER: v dl ;';' i4•�' z't'':�17i sST tlwiir A!V _ ._._.-. L'•r,.._ . Y P.EOSlERE�ilEt6F" itR�/; dR GOE�tf,+iF3E7€�t fia CrJ3ETRACT L:.RED N4,�fED AZOVE "rOR THE PO`! o._.>, :- :,.M ; S� ;SSliEQ c3{t >bgflY P£RfAIi�. TYf= iFdSi3 t SJR OTHER iOCt1?AEt4T VWTS I RLSFECT TnL,, isC;i xi,ry- CONDITIONS -OF SUCH POLICIES, i.@WgTS RAgNf AF.. DED BY THE PQLiCiES Dt:SCPti°�u !�EPEI � i4 E F -- -- S44+�i�1t'@ti $J{f4Y HAVE BEEN �UCEDBY P rr SUBJECT TO ALL THE l t�;i !' OF iNSL;RGkCE SRI AID CLAirv1c,;, IA-sn it Y f AP TF1.: ";.x Jr j i -!C E1'aP-0Y1=R5' ^'sAEiL:.Y --i'kRATIO S!LOCATI-N.sIVB[t!CfES ANaeFt _r ; - - > f =()RD 10], Addisonat 12etTft S-,- dufk < H more s ^- ^--- ------ _<:....., eseloz�ne t '+LL', D3eroP',�UtZyp(Zt Development Pace ISrequsreo? cxY> <- ?• ,-� g � ,C, L�rewbti axe Dever cs meet r Holding ,i.C.P�esnbuz7POit . �,erating P01din. LLC,, - • •_mac S:F ,2na tyria4vn so�s, tr� = ..C.r 99me-1t LiraY t? arta�.8_ i -..� In -C. Ai�wb'�r�ort LLC d P 5� _� ?�e,, :ni ,s... �- i. ori81 y �iar�d5. • I+ir�D. Managa~r LLC, 3jjR 1*,EwbUXYPOrt RealCv a E.. T il= CA. T E HOLDER SHOULD ANY OF THE Ai},OVE DESCRIeFr,, RO=.-ICFS BE C' _ NCE,.! EU SL C THE EXPtRF►?iOFF €1RTE THEt�EO=, NOTICE WILL BE DEUVER =t1. AOCORDANCE.WITH THE PoUcy PROVtS4�jA:3. AUTHOR[ZED REPRESENTATIVE 9)4666 -tit.n ,. I EACH OCC4RRc14C.;. IdQ-eGr,00t�u©Lt4:54s^J3 ill/12 J^^<011_/y2/2012i PSC" •-_SESLIA a _i.L`(q.^Iil 1 ]V, { i uff-$i cxpfrk Ip xPrt g�- t i PE?i$^7vAi. E AaV R1'kW,"i C",EW-*RAIAr,^`..FtEGA7L Y V.• _0 PRC;:AjCT'S - , .OtJlBttifiei SitJt��E ttRiii-'" - !G2^`s824 � � �a 116/6011;07/16/2G12. BC;JftYtKsttu•r+�pa.�.,.r:or,: 3 i — j,Rer Orr. !PFOPER7:Uvt.GG� _ s ! ACGr2E':,ATr, r ^I?nYCOEM, �GCOOi-60 23Qc Sl28/-7011 ICB 2 t_ t_)I yr •SC - FA EMPLI 1 ; r 1 1 c .is POLiCY IIM-r z --i'kRATIO S!LOCATI-N.sIVB[t!CfES ANaeFt _r ; - - > f =()RD 10], Addisonat 12etTft S-,- dufk < H more s ^- ^--- ------ _<:....., eseloz�ne t '+LL', D3eroP',�UtZyp(Zt Development Pace ISrequsreo? cxY> <- ?• ,-� g � ,C, L�rewbti axe Dever cs meet r Holding ,i.C.P�esnbuz7POit . �,erating P01din. LLC,, - • •_mac S:F ,2na tyria4vn so�s, tr� = ..C.r 99me-1t LiraY t? arta�.8_ i -..� In -C. Ai�wb'�r�ort LLC d P 5� _� ?�e,, :ni ,s... �- i. ori81 y �iar�d5. • I+ir�D. Managa~r LLC, 3jjR 1*,EwbUXYPOrt RealCv a E.. T il= CA. T E HOLDER SHOULD ANY OF THE Ai},OVE DESCRIeFr,, RO=.-ICFS BE C' _ NCE,.! EU SL C THE EXPtRF►?iOFF €1RTE THEt�EO=, NOTICE WILL BE DEUVER =t1. AOCORDANCE.WITH THE PoUcy PROVtS4�jA:3. AUTHOR[ZED REPRESENTATIVE 9)4666 -tit.n ,. Jun 1512 02:15p North Shore Dog �P EIN # 51-054-3313 BBB. Haverhill, MA 978.374.9224 M Reg. HIC # 149221 Lawrence MA 978. 687. 7339 RA Lia UCS # 78130 Single -Ply License# 171 *Licensed *Insured Tom Dragosits 25 Ogunquit Rd N. Andover, plass 01845 Telephone: 1-978-609-8316 978-777-1429 p.1 T. 'OUR PROOF is ON N932> 1 YOUR ROOF' f F ;� Ip R t saMc�_. Hampton NEI 603.929.9224 1 Hampstead NH 603.329.8200 Toll Free 1.888. SOS. ROOF 265 Winter Street Haverhill !t4 01830 *Factory Trained Date: 06/12/2012 *Factory Certified E-MAIL: tom@nsdog.com Billing Address: 25 Ogunquit Rd, n. Andover, Mass Jab Address: Same SCOPE OF WORK Appprox 400 sq ft (roof leak repair) The following information listed below refers to work performed on the front inside roof valley ONLY between (2) adjacent dormers Prepare for re -roofing by ensuring all safety measures in accordance with OSHA standard regulations and landscape is properly protected. Remove existing layers of shingles down to roof deck and dispose of in a legal fashion from the job site. Inspect wood deck, if we discover any rotted wood, replacement will be performed Jun 1512 02:15p North Shore Dog 978-777-1429 p.2 at $3.95 per ft for boards and $50.00 per sheet of plywood if we need to skin over any roof area. If wood is sound we will re—nail loose roof boarding and prepare for roofing- Install oofin Install 8" drip edge to all rakes and eaves. Color TBD. I *Apply lee & water shield on the entire surface of inside valley formed by adjacent dormers r * Apply new matching Architectural Shingles to roof deck *Install new: 50 Year CertainTeed Landmark or G A F Timberline H -D Limited Lifetime Architectural shingles or equal. Color to be selected by owners' All nailing is Hurricane. All debris generated by Lambert Roofing Co., Inc. will be cleaned up and . disposed of from the job site in a legal fashion. Under no circumstances will the watertight integrity of the building be compromised. TOTAL COST... $2,500.00 (Two Thousand Five hundred dollars) TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE Payment will be made according to the following work schedule: 1/3 down upon delivery of materials $800.00 (Eight hundred Dollars) Balance due upon completion of work $1, 700.00 (One thousand Seven Hundred Dollars) (Law forbids demanding full payment until contract is completed to both party's satisfaction) 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 or by delivery, not later than midnight of the third business day following the signing of this agreement. See attached notice of cancellation for an explanation of this right. Jun 1512 02:15p North Shore Dog 978-777-1429 p.3 DO NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES ;Accnepta. f the Contract .Proposal f Owner (s) S gnature (s) : t Date: !_ �M.kt.2/4�owi�� Contractor's Signature: Company Insurances Date: www.lambertroofing.com TGLRC Inc. DBA Lambert Roofing Company will provide certification of insurances, demonstrating that we are fully insured for worker's compensations, general liability, automobile liability and an umbrella policy. This documentation will be sent through the US mail to the above named party if not already provided. TGLRC Inc. dba Lambert Roofing Company agrees to: • Commence the described work on or about June 2012 • Complete the described work in approximately (1) day • Not be held liable for delays due to circumstances beyond our control. • Not be held liable for any damages to landscape and or fixtures due to circumstances beyond our control. • Not be held liable and riot covered under the workmanship warranty, for pre-existing conditions including but not limited to: • Mold and or wood rot, defective, faulty, rotted or worn building counterparts such as, but no limited to: siding, roofing, masonry, plumbing and windows, all of which may jeopardize the watertight integrity of the structure. • Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence. • This contract is the complete contract unless a signed Change Order has been executed between TGLRC Inc. DBA Lambert Roofing Company and the-Homeowner/Business Owner or Agent. 6 Jun 151202:15p Permits North Shore Dog 978-777-1429 A building permit may be required to remove and replace your roof. It is our obligation to secure these permits if required as the home owner's agent. [Vote Homeowners who secure their own permits or deal with unregistered contractors are excluded from the Guaranty Fund provisions of MGL c. 142A. Accelerated Payment 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. Payment Terms A finance charge of 1.5% a month (18% per year) will be added to all invoices on the 31" day. All legal and or collection fees Will be paid by the binding holder of this contract. • The law requires that any deposit or down payment required by TGLRC Inc. dba Lambert Roofing Company before work begins may not exceed the greater of — 1%3 of the total contract price or: The actual cost of Special or Custom made materials which must be special ordered in advance to meet the completion schedule. Arbitration The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this contract, the contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided in KGL c 142A. Owner: 1 Date: ,:,ev t� o -S r l S a`24S 0Q4AJQUr'7- n, � Aoy ii , H,+ 01Isrly Jun 1512 02:15p North Shore Dog 978-777-1429 p.5 Contractor: Date: L� Contractor Registration All home improvement contractors and subcontractors must be registered, any inquiries about a contractor or subcontractor relating to a registration should be directed to: Contractor Registration: Director of Home Improvement Contractor Registration Board of Building Regulations and Standards One Ashburton Place, Rm. 1341 Boston, MA 02108 (617) 727-3200 Hoge Improvement Contractor Law: Consumer Information Hotline Commonwealth of Massachusetts Office .of Consumer Affairs and Business Regulations 10 Park Plaza, Rm. 5170 Boston, MA 02116 (617) 973-8787 For assistance with informal mediation of disputes or to register formal complaints against a business, call= Consumer Complaint Section Office of the Attornev General (617) 727-8400 ,%/OR Better Business Bureau (508) 652-4800 (508) 755--2548 (413) 734-3114 Cancellation Jun 1512 02:16p North Shore Dog 978-777-1429 p.6 You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller, which may be in the main office or branch thereof, provided you notify the seller in writing at the main office by ordinary mail posted, by telegram sent or by delivery, no later than that midnight o he third business day following the signing of the agreement. INITIALS ALI\ The Commonwealth oflMassachusetts Department of Industrial Accidents Office of IrnVestigations ..600 Washington Street Boston, MM 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers 3olicant Informnlinn Name (Business/organizafion/Individual): - - Address: City/State/Zip: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. E]I am a general contractor and I employees (full and/orpart-time).* 2. ❑ I am a sole proprietor or have hired the sub -contractors listed partner- ship and have no employees on the attached sheet. t These sub -'Contractors have working for me in any capacity. jNo workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption MGL myself. [No workers' comp. per C. 152, § 1(4), and we, have no insurance required.] t employees. [No workers' comp, msurance required.] I Ik A -. r., �, ap?hcan: that checks box M roust also 11111 out the section b tov., ahorri.,R ng awork and then hire outside contractors must submit a new affidavit indicating such. Homeowners who submit this affidavit indicating they are _ information. doill 'Contractors that check this box must attached as additional sheet showing the name of the sub -contractors and their workers' comp, policy information. i o an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. �? 91,570 a Type of project (required):' 6. ❑ New construction 7. [] Remodeling 8..❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions .11 -11 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Insurance Company N Policy # or Self -ins. Lic. Expiration Date: Job Site Address: City/State/Zip:�— Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). d Failure to secure coverage as required under Section 25A ofMGL 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' 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 DTA for insurance coverage verification. Ido hereby certify under the nau�-penalties ofperjur�� that the information provided above is true and correct Official use only. Do not write in this area, to be City or Town: by city or town offciaL Permit/I,icense # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. PIumbing 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 onsuch dwelling--houseor 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 iicensing•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), addresses) and phone number(s) along with their certificates) 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 bb ret�.Led to the city or town that the Fpplicauor for the peannit o: lice se is being mques*.ed, not the D part ent 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 perinits 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 f6r 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 02111 Tel. # 617-727-4900 ext 406 or 1-8.77 MAS.SAFE Revised 5-26-05 Fax # 6.17-727-7749