HomeMy WebLinkAboutBuilding Permit #738 - 274 CHESTNUT STREET 6/13/2002Permit N0: 12 ?-
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
A i
Date Received
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One fami
Addition
Two or more family
Industrial
Iteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
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D SCRIPTION OF WORK TO BE PREFORMED:
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Identification Please Type or Print Clearly)
OWNER: Name: CIA Ibly Phone: f:le T2 P(- 924 9
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: $ S3 -1-2-3, FEE: $
/ 0 5 / 3 Z -f- /.,2 ,4dN -O!r - ;a 134v
Check No.: G s. S? 3 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Location ( � 1 (- L 4,,,u�
No. -sem
3 � Date 13
NORT" TOWN OF NORTH ANDOVER
O: �.ao ., ,x•00
L
i
Certificate of Occupancy $
IF
SA .... Xi
Building/Frame Permit Fee $ � r
�s�ct
Foundation Permit Fee $
Other Permit Fee $
/ TOTAL $
T
Check # U �/ d
2 + L `, Building Inspector
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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature &Date 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.$100-$1000 fine
NUI t5 ana UA I A - (For department use
❑ Notified for pickup - Date
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
o 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
JUN -11-2008 WED 03:24 PM MOYNIHAN KITCHEN DEPT
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ANDOVER, MA 01810 COXSACKIE, NY 12051 HATFIELD, MA 01038 PORTLAND, ME 04103
146 Dascomb Road Hudson Valley Commercial Park 125 Chestnut Street 203 Read Street
1-800-222-7981 1-800-222-7303 1-800-922-0191 1-800-442-6734
Fax: 1-800-242-4533 Fax: 1-800-222-7304 Fax: 1-800-922-0296 Fax: 1-800-443-0331
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by VAyerhaeuser
TJ -Beam 6.30 Serial Number.
User. 1 6/12/20083:36:01 PM
Page 1 Engine VCI%-: 6.30.14
3 Pcs of 13/4" x 7114" 1.9E Microllam® LVL
THIS PRODUCT MEETS OR EXCEEDS THE SET DESIGN
CONTROLS FOR THE APPLICATION AND LOADS LISTED
Product Diagram is Conceptual.
LOADS:
Analysis is for a Header (Flush Beam) Member. Tributary Load Width: 4'
Primary Load Group - Residential - Living Areas (psf): 40.0 Live at 100 % duration, 12.0 Dead
SUPPORTS:
Input Bearing Vertical Reactions (Ibs)
Width Length Live/Dead/UpliWrotal
1 Stud wall 3.50" 1.50" 960 / 351 / 0 /1311
2 Stud wall 3.50" 1.50" 960 / 351 / 0 /1311
Detail Other
Al: Blocking 1 Ply 1 1/2" x 7 1/4" 1.5E TimberStrand@ LSL
Al: Blocking 1 Ply 1 1/2" x 71/4" 1.5E TimberStrand® LSL
-See iLevel® Specifier's/Builder's
Guide for detail(s): Al: Blocking
DESIGN CONTROLS:
�r
r521
i
d
12'
Control
Product Diagram is Conceptual.
LOADS:
Analysis is for a Header (Flush Beam) Member. Tributary Load Width: 4'
Primary Load Group - Residential - Living Areas (psf): 40.0 Live at 100 % duration, 12.0 Dead
SUPPORTS:
Input Bearing Vertical Reactions (Ibs)
Width Length Live/Dead/UpliWrotal
1 Stud wall 3.50" 1.50" 960 / 351 / 0 /1311
2 Stud wall 3.50" 1.50" 960 / 351 / 0 /1311
Detail Other
Al: Blocking 1 Ply 1 1/2" x 7 1/4" 1.5E TimberStrand@ LSL
Al: Blocking 1 Ply 1 1/2" x 71/4" 1.5E TimberStrand® LSL
-See iLevel® Specifier's/Builder's
Guide for detail(s): Al: Blocking
DESIGN CONTROLS:
Maximum
Design
Control
Result
Location
Shear (lbs) 1275
-1115
7232
Passed (15%)
Rt. end Span 1 under Floor loading
Moment (Ft -Lbs) 3718
3718
10672
Passed (35%)
MID Span 1
under Floor loading
Live Load Defl (in)
0.219
0.292
Passed (U639)
MID Span 1
under Floor loading
Total Load Defl (in)
0.299
0.313
Passed (U468)
MID Span 1
under Floor loading
-Deflection Criteria: STANDARD(LL:U480,TL:U240). Additional checks follow.
-TL:0.313"
-Bracing(Lu): All compression edges (top and bottom) must be braced at 12' o/c unless detailed otherwise. Proper attachment and positioning of lateral
bracing is required to achieve member stability.
ADDITIONAL NOTES:
-IMPORTANT! The analysis presented is output from software developed by iLevel®. iLevel® warrants the sizing of its products by this software will
be accomplished in accordance with iLevel® product design criteria and code accepted design values. The specific product application, input design
loads, and stated dimensions have been provided by the software user. This output has not been reviewed by an iLeveND Associate.
-Not all products are readily available. Check with your supplier or iLevel® technical representative for product availability.
-THIS ANALYSIS FOR iLevel@ PRODUCTS ONLY! PRODUCT SUBSTITUTION VOIDS THIS ANALYSIS.
-Allowable Stress Design methodology was used for Building Code UBC analyzing the iLevel® Distribution product listed above.
-Note: See iLevel® Specifiers/Builders Guide for multiple py connection.
PROJECT INFORMATION:
Copyright 0 2007 by iLevel®, Federal Way, WA.
Microllam® is a registered trademark of iLevel®.
OPERATOR INFORMATION:
peter leblanc
jackson lumber
215 market st
lawrence, MA 01842
Phone: 978 6891009
Fax : 978 6891087
pleblanc@jacksoniumber.com
0
0\ r.
byUeyerhaeUS- 3 Pcs of 13/4" x 71/4" 1.9E Microllam® LVL
TJ -Beam 6.30 Serial Number.
User:, 6/12120083:36:01 PM THIS PRODUCT MEETS OR EXCEEDS THE SET DESIGN
Page 2 Engine Vgion: 6.30.14
CONTROLS FOR THE APPLICATION AND LOADS LISTED
Load Grpup: Primary Load Group
^ 11' 8.00" ^
Max. Vertical Reaction Total (lbs) 1311 1311
Max. Vertical Reaction Live (lbs) 960 960
Required Bearing Length in 1.50(W) 1.50(W)
Max. Unbraced Length (in) 144
Loading on all spans, LDF = 0.90 , 1.0 Dead
Shear at Support (lbs) 299 -299
Max Shear at Support (lbs) 341 -341
Member Reaction (lbs) 341 341
Support Reaction (lbs) 351 351
Moment (Ft -Lbs) 996
Loading on all spans, LDF = 1.00 , 1.0 Dead + 1.0 Floor
Shear at Support (lbs) 1115 -1115
Max Shear at Support (lbs) 1275 -1275
Member Reaction (lbs) 1275 1275
Support Reaction (lbs) 1311 1311
Moment (Ft -Lbs) 3718
Live Deflection (in) 0.219
Total Deflection (in) 0.299
PROJECT INFORMATION:
Copyright 8 2007 by iLevel®, Federal Way, WA.
Microllam® is a registered trademark of iLevel®.
OPERATOR INFORMATION:
peter leblanc
jackson lumber
215 market st
lawrence, MA 01842
Phone: 978 6891009
Fax : 978 6891087
pleblanc@jacksonlumber.com
0
z.
``ll
by wEyerhaeuser
TJ -Beam® 6.30 Serial Number.
User: 1 6/12/2008 3:40:19 PM
Page 1 Engine Version: 6.30.14
2 PCs of 13/4" x 117/8" 1.9E Microllam® LVL
THIS PRODUCT MEETS OR EXCEEDS THE SET DESIGN
CONTROLS FOR THE APPLICATION AND LOADS LISTED
Product Diagram is Conceptual.
LOADS:
Analysis is for a Header (Flush Beam) Member. Tributary Load Width: 4'
Primary Load Group - Residential - Living Areas (psf): 40.0 Live at 100 % duration, 12.0 Dead
SUPPORTS:
Input Bearing Vertical Reactions (Ibs)
Width Length Live/Dead/Uplift/Total
1 Stud wall 3.50" 1.50" 1280 /476 / 0 /1756
2 Stud wall 3.50" 1.50" 1280 /476 / 0 /1756
Detail Other
A3: Rim Board 1 Ply 1 1/4" x 117/8" 0.8E TJ -Strand Rim Board®
A3: Rim Board 1 Ply 1 1/4" x 117/8" 0.8E TJ -Strand Rim Board®
-See iLevel® Specter's/Builders
Guide for detail(s): A3: Rim Board
DESIGN CONTROLS:
1 ,
,2❑
Maximum
16'
Control
Product Diagram is Conceptual.
LOADS:
Analysis is for a Header (Flush Beam) Member. Tributary Load Width: 4'
Primary Load Group - Residential - Living Areas (psf): 40.0 Live at 100 % duration, 12.0 Dead
SUPPORTS:
Input Bearing Vertical Reactions (Ibs)
Width Length Live/Dead/Uplift/Total
1 Stud wall 3.50" 1.50" 1280 /476 / 0 /1756
2 Stud wall 3.50" 1.50" 1280 /476 / 0 /1756
Detail Other
A3: Rim Board 1 Ply 1 1/4" x 117/8" 0.8E TJ -Strand Rim Board®
A3: Rim Board 1 Ply 1 1/4" x 117/8" 0.8E TJ -Strand Rim Board®
-See iLevel® Specter's/Builders
Guide for detail(s): A3: Rim Board
DESIGN CONTROLS:
Maximum
Design
Control
Result
Location
Shear (Ibs) 1719
-1475
7897
Passed (19%)
Rt. end Span 1 under Floor loading
Moment (Ft -Lbs) 6734
6734
17848
Passed (38%)
MID Span 1
under Floor loading
Live Load Defl (in)
0.248
0.392
Passed (U758)
MID Span 1
under Floor loading
Total Load Dell (in)
0.340
0.783
Passed (0553)
MID Span 1
under Floor loading
-Deflection Criteria: STANDARD(LL:L/480,TL:U240).
-Bracing(Lu): All compression edges (top and bottom) must be braced at 16' o/c unless detailed otherwise. Proper attachment and positioning of lateral
bracing is required to achieve member stability.
ADDITIONAL NOTES:
-IMPORTANT! The analysis presented is output from software developed by iLevel@. iLevelV warrants the sizing of its products by this software will
be accomplished in accordance with iLevel® product design criteria and code accepted design values. The specific product application, input design
loads, and stated dimensions have been provided by the software user. This output has not been reviewed by an iLevelD Associate.
-Not all products are readily available. Check with your supplier or iLevel® technical representative for product availability.
-THIS ANALYSIS FOR iLevel® PRODUCTS ONLY! PRODUCT SUBSTITUTION VOIDS THIS ANALYSIS.
-Allowable Stress Design methodology was used for Building Code UBC analyzing the iLevel® Distribution product listed above.
-Note: See iLevel® Specifiers/Builders Guide for multiple ply connection.
PROJECT INFORMATION:
OPERATOR INFORMATION:
peter leblanc
jac kson lumber
215 market st
lawrence, MA 01842
Phone: 978 6891009
Fax : 978 6891087
pleblanc@jacksoniumber.com
Copyright 6 2007 by iLevel®, Federal Way, WA.
Microllam® is a registered trademark of iLevel®.
-' S JW
E3
kLib�yeyerhaeuser
2 PCS of 13/4" x 117/8" 1.9E Microllam® LVL
TJ -Beam® 6.30 Serial Number
User. 1 6/12/2M3:40:19PM THIS PRODUCT MEETS OR EXCEEDS THE SET DESIGN
Page Engine Version: 6.30.14 CONTROLS FOR THE APPLICATION AND LOADS LISTED
Load Group: Primary Load Group
A 15, 8.00" ^
Max. Vertical Reaction Total (lbs) 1756 1756
Max. Vertical Reaction Live (lbs) 1280 1280
Required Searing Length in 1.50(W) 1.50(W)
Max. Unbraced Length (in) 192
Loading on all spans, LDF = 0.90 , 1.0 Dead
Shear at Support (lbs) 400 -400
Max Shear at Support (lbs) 466 -466
Member Reaction (lbs) 466 466
Support Reaction (lbs) 476 476
Moment (Ft -Lbs) 1825
Loading on all spans, LDF = 1.00 , 1.0 Dead + 1.0 Floor
Shear at Support (lbs) 1475 -1475
Max Shear at Support (lbs) 1719 -1719
Member Reaction (lbs) 1719 1719
Support Reaction (lbs) 1756 1756
Moment (Ft -Lbs) 6734
Live Deflection (in) 0.248
Total Deflection (in) 0.340
PROJECT INFORMATION:
Copyright O 2007 by iLevel®, Federal Way, WA.
MicrollamO is a registered trademark of iLevel®.
OPERATOR INFORMATION:
peter leblanc
jackson lumber
215 market st
lawrence, MA 01842
Phone: 978 6891009
Fax : 978 6891087
pleblanc@jacksonlumber.com
PROPOSAL SUBMITTED TO
STREET (�
a -? Y
CITY, STATE and ZIP CODE
ARCHITECT
Proposal Page No.
STEPHEN M. KEISLING
Building & Remodeling
68 Glencrest Drive
NORTH ANDOVER, MASSACHUSETTS 01845
MA Lie. 027489 Home Imp. 101846
Phone 682-2072
DATE OF PLANS
PHONE
JOB NAME
kztc.
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JOB LOCATION
DATE
of Pages
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JOB PHONE
We hereby submit specifications and estimates for:
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coete in accordance with above specifications, for the sum of:
Payment to be made as follows: _
All material is guaranteed to be as specified. All work to be completed• in a workmanlike
manner according to standard practices. Any alteration or deviation from above specifications Authorized
involving extra costs will be executed only upon written orders, and will become an extra Signature _
charge over and above the estimate. All agreements contingent upon strikes, accidents
dollars ($
or delays beyond our control. Owner to carry fire„tornado and other necessary insurance. Note: This proposal may be
Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within
�1irtP�ltFlritP O1 ru Qsttl —The above prices, specifications f
and conditions are satisfactory and are hereby accepted. You are authorized Signature
to do the work as specified. Payment will be made as ut in d above. r
Date of Acceptance:
Signature.L
days.
;�ptr�r�v��icxt
STEPHEN M. KEISLING <>'��
Building & remodeling � �A$��`'
68 Glencrest Drive f ty �
NORTH ANDOVER, MASSACHUSETTS 01845
MA Uc. 027489 Home lmpv. 101846
Rhone 682-2472 Cr
PROPOSAL SUBMITTED TO PHONE DATE
1`
STREET
JOB NAME ✓ . o�;r,;,:;:,,.:
CITY, STATE and ZIP} CODES JOB LOCATION
ARCHITECT
DATE OF PLANS
T50�PHONE
hereby submit specifications and estimates for:
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We prapgSP hereby to furnish material and labor — complete in accordance with above specifications, for the sum of:
dollars ($
Payment to be made as follows:
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above specifications Authorized
involving extra costs will be executed only upon written orders, and will become an extra Signature
charge over and above the estimate. All agreements contingent upon strikes, accidents ) ;
or delays beyond our control. Owner to carry fire, tomado and other necessary insurance. Note: This proposal may be
--els are Wily covered by Workmans Compensation Insurance.
Arreptunre of Proposal— The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized
to do the work as specified. Payment will be made as' outlined above.
Date of Acceptance: s,_S QU1-1
wanurawn uy us It not accepted within
SignatureT/ ,
Signature '
days.
Page No. of Pages
STEPHEN M. KEISLIN {'
Building & Remodeling
68 Glencrest Drive =-
NORTH ANDOVER, MASSAGHUSETi S O1845 1 -
MA Lic. 427489 Home 4mpv. 101846
Phone 682-2072 `
PROPOSAL SUBMITTED TO l t
PHONE
Ci
DATE
STREET i
J B A E
CITY, -STATE and ZIP CODE
pD -
c�rztoiel 'yyl G�
JOB LOCATION
ARCHITECT
DATE OF PLANS
JOB PHONE
We hereby submit specifications and estimates for:
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We ProPOR hereby to furnish material and labor — complete in accordance with above specifications, for the sum of:
X! `rP
dollars ($ ).
Payment to be made as follows:
All material is guaranteed to be as spec'rfied. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above specifications Authorized IM
Signature
involving extra costs will be executed only upon written orders, and will become an extra
charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control. Owner to carry fire,Qornado and other necessary insurance. Note: This proposal may be
n,,. ,.,,,.,.,..., ...,. ,,.........a k,. M...6..,.,...� 1— ... ,., withdrawn by us if not accepted within days.
Arreptaurr of Proposal— The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized
to do the work as specified. Payment will be made as outlined above.
Date of Acceptance:
i1
Signature J.
I r.
Signature
3oard of Building Regulations , and Standards
Construction Supervisor License
Licen"se�,CS 27489
Birthdate: 71,16/1953
Exolration:-7iiR/2nnq Tr# 17077
STEPHEN M KEIS�NG,=
68 GLENCREST DR
N ANDOVER, MA 01845
commissioner
,per ✓k, COo7x�nU�z �a� a��/'�u�a��eu6e
�\ Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration,: 101846
Expiration: 6/29/2010 Tr# 268336
Type: Individual
STEPHEN M. KEISLING
Stephen Keisling
68 Glenncrest Dr.
N. Andover, MA 01845 Administrator
L
FARM FAMILY CASUALTY INSURANCE COMPANY
Issuing Office - P.O. Box 656 • Albany, New York 12201-0656
CONTRACTORS ADVANTAGE BOP000916903
® DECLARATION PAGE
Policy Number: 2005XO431 Agent No: 3485 Agent Phone: 978-887-8304
UGONE -JOHNSON INSURANCE AGENCY, IN
10 S MAIN ST STE 208
TOPSFIELD MA 01983-1834
Name and Mailing Address of First Named Insured:
STEPHEN KEISLING
68 GLENCREST DR
N ANDOVER MA 01 845-1 31 5
The Insured is: INDIVIDUAL
Transaction Type: RENEWAL
Policy Period: From 03/21/2008 To 03/21/2009
Business Description: CARPENTRY
Business Property Coverages
11110kirrrgs
Business Personal Property
Business Income and Extra Expense
Other Endorsements
Transaction Effective: 03/21/2008
12:01 A.M. Standard Time
Total Limit of Liability Term ADDL/RTN
Premium Premium
$5,000 $25.00
Actual Loss Sustained Not
Exceeding 12 Months
SEE SCHEDULE
BUSINESSOWNERS LIABILITY
Except for Fire Legal Liability, each paid claim for the following coverages reduces the amount of insurance we
provide during the applicable annual period.
Business Liability Limits of Insurance
Bodily Injury/Property Damage $500,000 EACH OCCURRENCE
$1,000,000 AGGREGATE
$1,000,000 AGGREGATE FOR
PRODUCTS/COMPLETED
OPERATIONS HAZARD
Medical Expenses
Fire Legal Liability
Other Endorsements
$5,000 EACH PERSON
$50,000 ANYONE FIRE OR EXPLOSION
SEE SCHEDULE
POLICY SUBJECT TO ANNUAL AUDIT: YES TOTAL PREMIUM $
The Declarations, Schedules and These Forms and Endorsements Make Up Your Complete Policy:
BP00021299 BP00060197 BP00090197 BPO1080398 8P04170196 BP04190689 BP04961001 BPO5140103
BP07010197 BP10040498 BF30061103 BF40380902 BF40390303 BF41090204 F199020107
Page: 1 of 2
ANX-3190
INSURED COPY
Countersigned By
Authorized Representative
Processed Date: 02/14/2008
The Commonwealth of Massachusetts
Department of Industrial Accidents
giaW Office of Investigations
600 Washington Street
+� t� Boston, MA 02111
°M swww.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): s�2Oi(P1Jl S�� G -
Address: 9 01tJ 1 l4- S% &-eC i
City/State/Zip
Phone. #: 9V 3/f 'd'YS %
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.$
required.]
5. ❑ We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, §1(4), and we have no
employees. [No workers'
comp. insurance required.l
Type of project (required)`:,,
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
1 L Plumbing repairs or additions
12. ❑ Roof repairs
13. ❑ 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.
TContractors 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:
Policy # or Self -ins. Lic. #:_
Job Site Address:
Expiration Date:
City/State/Zip:
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
Investieations of the DIA for insurance coverage verification.
I do hereby certify unger the pains and penglties of perjury that the information provided above is true and correct
6—/2 -OF
Official use only. Do not write in this area, to be completed by city or 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 local licensing agency shall withhold the issuance or
renewal of a license or permit to,opera 2 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 -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 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 perniit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 11=22-06
www.mass.gov/dia
i I I Brockway -Smith Company '
www.brosco.com T
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ANDOVER, MA 01810 COXSACKIE, NY 12051 HATFIELD, MA 01038 PORTLAND, ME 04103
146 Dascomb Road Hudson Valley Commercial Park 125 Chestnut Street 203 Read Street
1-800-222-7981 1-800-222-7303 1-800-922-0191 1-800-442-6734
Fax: 1-800-242-4533 Fax: 1-800-222-7304 Fax: 1-800-922-0296 Fax: 1-800-443-0331
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