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HomeMy WebLinkAboutBuilding Permit #510 - 276 MASSACHUSETTS AVENUE 2/12/2010TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: ,)�U Date Received Date Issued:. 2 - IMPORTANT: IMPORTANT: Applicant must complete all items on this page LOCATION '7-7rTV PROPERTY OWNER_ nt Print MAPNO :PARCEL: ZONING DISTRICT:� Historc`District yes Ca i 17,476. 6 -2- Machine,Shop-Villaae .. r ves t o� TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One fami Addition Two or more family Industrial No. of units: Commercial -AlteratioD Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplaiin Wetlands Watershed District Water/Sewer OWNER: Name:_ K TO BE PERFORMED: riease i ype or rrinr t-iearip ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ of 0©0 FEE: $ Z K 00 Check No.: 533 Receipt No.:`�- NOTE-: Persons contracting with u istered contractors do not have access to the guaranty fund Signature of Agent/Ovvne Signature of contractor 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 a 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: Doc.Building Permit Revised 2008 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 CONSERVATION Reviewed on Signature COMMENTS, V HEALTH COMMENTS Reviewed on • -Signature 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 Usgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: I /� ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine No Doc:.Building Permit Revised 2008 Location No. �'�/y Date MORTh TOWN OF NORTH ANDOVER O� ..an ,• 1ti0 i _' • OL JAM A Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �3v Check # 22797 Building Inspector V NA1- Jason S. Hayden, Genera! Contractor 5 Gunstock Drive Kingston, NH 03848 Jhaydenl2l3@yahoo.com (978) 697-6362 CONTRACT February 12, 2010 TO: Deb Lord, Claire O'Brien 276 Massachusetts Avenue North Andover, MA 01845 (978) 687-2575 GENERAL: This contract is for the following work and materials (if noted) to be performed by the contractor on the property address above. OVERVIEW: Create a finished basement and remodel existing bathroom. Build new walls, install (5) new doors, install new floor and new suspended ceiling new space will be fully insulated see attached design for basement layout PRICE: $ 20,000 TERMS: Down payment of 1/3 due before project start date All other payments to be scheduled as milestones are completed. Timely payment by the owner of all sums due under this contract is of the essence to this contract. DELIVERY: The work will begin during week of Feb 15, 2010, and will be completed, absent unusual circumstances, Estimated 4- 6 weeks to complete PERMITS & CODE: All work to be done under this contract will be in accordance with the building codes presently in force in the Town of North Andover, MA. The contractor shall obtain all necessary permits and pay all required permit and plan fees. SPECIFIC This contract will be completed by the contractor in a good and workmanlike REQUIREMENTS manner, using good quality materials. The parties agree upon the following FOR MATERIALS materials specifications and work description, together with any plans or AND specifications incorporated herein. WORKMANSHIP: MA Supervisor's Construction License # 78189 MA Home Improvement Contractor License #149663 Jason S. Hayden, General Contractor 5 Gunstock Drive Kingston, NH 03848 Jhayden1213@yahoo.com (978) 697-6362 ITEM DESCRIPTION bub -floor: Install dimpled, heavy-duty gray plastic membrane over the existing concrete slab. The membrane is installed with its dimples down to create a 5/16 inch air space above the slab. Seams will be taped with a moisture proof tape. Install Advantech moisture resistant, engineered wood panels over the plastic membrane. 4'x 8' Advantech panels will be %" thick with tongue and groove sides. Panels will be screwed down to the concrete slab with specialized masonry screws. Screws will be countersunk to enhance finish flooring installation Finished flooring provided by others 2 Walls: Install 1" Owens-Corning foamular rigid insulation to foundation walls to provide a thermal break between the concrete and the new stud walls. Insulation panels will be glued to foundation walls with a rigid insulation caulking. Build new 2 x 4 stud walls All perimeter walls will have R-13 Kraft faced insulation. All interior wall surfaces will be finished with '/2" moisture and mold resistant drywall. Drywall seams will be taped and finished with three coats of joint compound. All screws will be covered with compound and sanded smooth 3{ Ceiling: Install new suspended ceiling per customer's choice. Install soffit where plumbing pipes are lower than the final finished ceiling. 4 Doors: Remove existing basement door and install 3'0 x 6'6" exterior door. Door will be insulated, have full weather stripping. Includes basic, bright brass lockset. Utility doors — (2) @ 3'0" x 6'8" Laundry door — (1) @ 3'0" x 6'8" Bathroom door — (1) @ 2'8" x 6'8" 5( Trim: Each door will have flat casing; will be primed Each window will have flat casing; will be primed Baseboard will be 5 %" tall "speedbase" 6IWindows. Install (5) American Craftsman vim cement windows 31 "w x 18 3/"h MA Supervisor's Construction License # 78189 MA Home Improvement Contractor License #149663 Note 1 Note 2 Jason S. Hayden, General Contractor 5 Gunstock Drive Kingston, NH 03848 Jhaydenl2l3@yahoo.com (978) 697-6362 Also included: Acquisition of required Building permit Pre -construction meeting Clean up and disposal of all construction debris Not included: Electrical work HVAC Finished Flooring Painting The contractor shall provide the owner with his own waiver or cumulative subcontractor's waivers equal to the amount paid for any progress payment. The contractor may cease operations if any progress payment is not made by the owner as required herein, and proceed to collect any balance due with any legal remedy. Alternatively, the contractor may continue operations, as set forth in the attached General Conditions. Attached hereto are General Conditions governing the rights and obligations of the parties to this contract. The parties are further subject to the laws of these state governing contracts and mechanics' liens. We have hereunto set our hands this day ofJ�./�� �1 Owner Contractor , 2010 MA Supervisor's Construction License # 78189 MA Home Improvement Contractor License #149663 Jason S. Hayden, General Contractor 5 Gunstock Drive Kingston, NH 03848 Jhayden1213@yahoo.com (978) 697-6362 GENERAL CONDITIONS These General Conditions are part of the contract between (owners) and (contractor) Jason S. Hayden for work at 276 Massachusetts Avenue, North Andover, MA CONTRACTOR'S DUTIES — GENERAL 1.1 To direct and control the work contracted for in accordance with the terms of this contract and all applicable codes, laws, and regulations, and as the building permits, if any, issued for this project require. 1.2 To inspect the site, examine the plans and specifications if any, and supervised all of the contractor's employees, and to direct the work of all subcontractor selected by contractor. 1.3 To maintain the work site in a safe and clean condition, to the extent consistent with the contract. 1.4 To advise the owner promptly if concealed conditions are ascertained which require additional or different work, and to proceed in such event in accordance with this agreement. 2. OWNER'S DUTIES — GENERAL 2.1 To provide adequate utilities for the work agreed upon. 2.2 To advise the contractor of any condition of the property which affects contractor's ability to perform. 2.3 To provide secure storage areas for materials delivered to the work site. 2.4 To execute in a timely manner all permit applications and other documents necessary for the work to proceed. 2.5 To perform no work on the project without written agreement with the contractor. In order to avoid interfering with workers. 2.6 To make no agreements with any tradesperson, subcontractor, or contractor's employee outside the scope of this contract without the written consent of the contractor. 2.7 Owner shall be entitled to make periodic inspections of the work site when accompanied by a representative of the contractor, provided such inspections do not interfere with the work and can, in the sole judgment of the contractor, be made safely. Any other entry onto the construction site shall be at owner's risk. 2.8 Owner shall notify his insurance agent of the execution of this Agreement and obtain any necessary Riders to his current coverage or any locally customary forms of coverage, such as Builder's Risk, to cover owner's interests and liabilities during the construction process. 3. MATERIAL SUBSTITUTION Contractor reserves the right to substitute other materials, products and/or labor, of similar, equal or superior quality, utility, or color. 4. DELAY Contractor shall not be responsible for delays caused by events beyond the control of the contractor, including but not limited to: strikes, war, acts of God, riots, governmental regulations and restrictions. Delays caused by owner's failure to make allowance materials' selections or caused by the performance by contractor of extras or necessary work (as described in Section 6) shall likewise be excusable delays. 5. INSURANCE Contractor agrees to maintain al necessary forms of insurance to protect the owner from liability for any occurrence arising from the performance of this contract. Contractor agrees that he shall cover his own employees for worker's compensation and carry general liability, and that all forms of insurance carried hereunder shall be with reputable companies licensed to do business in this state. Owner agrees to carry full coverage on the subject property covering owner's risk of loss during the construction period, together with all special forms required by reason of the performance of this contract. Specifically, owner shall contact owner's insurance agent and secure any necessary Builder's risk coverage prior to the commencement of the work. MA Supervisor's Construction License # 78189 MA Home Improvement Contractor License #149663 Jason S. Hayden, General Contractor 5 Gunstock Drive Kingston, NH 03848 Jhayden1213@yahoo.com (978) 697-6362 6. HIDDEN, CONCEALED, AND UNFORESEEABLE CONDITIONS The parties agree that in the event contractor discovers a condition requiring an extra cost that they shall proceed as follows: The contractor shall notify the owner verbally at once to expedite agreement as to the charge to correct or cure such contidition, and provide a written estimate as soon as practicable. The parties must agree to such extra charges, or agree to a resolution method, or this contract may be canceled by either of them. For purposes of this section, a "hidden, concealed and unforeseeable condition" shall mean a condition not readily observable to a prudent contractor inspecting the subject property for the purpose of performing this contract. 7. EXTRAS Any extra work or materials desired by the owner shall be agreed upon in writing and such extras shall become a part of this contract. Unless otherwise agreed, extras shall be paid for as performed. Failure of the owner to sign an extras order shall not preclude recovery for same by contractor, and acceptance of said extra work or materials shall be presumed, unless there is written notice to the contrary. Contractor shall advise owner at the time of agreement on an extra as to any additional time required to perform this contract. 8. SUBCONTRACTORS 8.1 Contractor shall select subcontractors as required to complete this contract. Owner acknowledges that various portions of the work will be done by subcontractors. Any subcontractor selected by the contractor shall have all requisite licenses for the work to be done by such subcontractor, and the contractor shall issue subcontracts in writing whose specifications are consistent with this agreement. 8.2 It shall be the duty of the contractor to use reasonable care in the selection of subcontractors. Absent objectionable performance by any subcontractor, the selection of subcontractors shall be with the contractor exclusively. The contractor shall require all subcontractors to have such types of insurance in force as are required to hold harmless and indemnify the owner from any claim for injuries of property damage by any agent or employee of any subcontractor. 8.3 Contractor shall pay subcontractors on a timely basis and obtain from subcontractors any necessary documentation required to release their lien rights, if any, as the work proceeds. 8.4 Contractor shall exercise reasonable care in the selection of materials used by subcontractors, but shall not be responsible for later discovered materials' defects or damages from installation methods, not reasonably ascertainable at the time of installation. 9. TERMINATION AND CANCELLATION The contractor may terminate and cancel this contract if any payment called for hereunder is not received as scheduled, provided that notice is given to the owner as provided below. Upon such termination, the contractor shall have all remedies provided by law, including such lien rights as then apply. The owner may terminate this contract upon the following conditions: 9.1 Failure of the contractor, or his subcontractors, to pursue the work contracted for, absent excusable delay, as provided in Section 4 above, for a continuous period of seven days, without a written agreement permitting same, which may be satisfied by a simple notation to this agreement. 9.2 Failure of the contractor to rectify any condition regarding which building code enforcement authority has issued a citation or violation notice, within seven day's notice of such violation, unless owner and contractor otherwise agree. 9.3 Any other failure to perform this contract required by the terms of this contract. 9.4 No termination shall be effective unless 10 days notice of owner's intent are given as provided below, during which time the default may be cured by the contractor. MA Supervisor's Construction License # 78189 MA Home Improvement Contractor License #149663 Jason S. Hayden, General Contractor 5 Gunstock Drive Kingston, NH 03848 Jhaydenl2l3@yahoo.com (978) 697-6362 10. WARRANTIES 10.1 The work of the contractor including materials and labor, shall be guaranteed for a period of one year, during which period contractor shall at its own expense correct any defect arising from its work unless Section 8.4 of these General Conditions applies. This provision is in lieu of all other warranties, express or implied, and owner has no action at law or in equity against the contractor after said date. 10.2 Any and all warranties for appliances or mechanical systems shall be delivered to owner when contractor's final payment is received. 10.3 Notwithstanding any manufacturer's warranty of any component, appliance, or system, no action may be brought against the contractor on this contract, for the performance of this work, except as provided above. 11. NOTICES Notices may be sent to either party at the addresses shown above, or mailed by certified or registered mail. Any mailed notice shall be deemed given as of the date of mailing. 12. SEVERABILITY If any portion of this agreement is found invalid or unenforceable by any court, the remaining provisions shall remain in force between the parties. 13. ENTIRE AGREEMENT This contract consists of the uments defined above, and constitutes the entire agreement of the parties. It can beodified only by a written do c ent. We have hereunto set our hands this 1t day of� 2010, Owne LContractorV , V V �V V MA Supervisor's Construction License # 78189 MA Home Improvement Contractor License #149663 2|/ � CERTIFICATE OF LIABILITY INSURANCE OP ID JR HAYDJAI DATE(MMIOD/YYYY) 02/08/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Talbot Insurance Agency, Inc. 221 Chelmsford Street ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Chelmsford MA 01824 LIMITS Phone : 978-256-3367 Fax : 978-256-8215 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Hartford Insurance Co. INSURER B: Jason S. Hayden 5 Gunstock Road Kingston NH 03848 INSURER C: INSURER 0: INSURER E: %.VVCKRVCJ 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATECMEMIFDFDE� DATE(MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE F—] OCCUR PREMISES (Ea occurence) $ MED EXP (Any one person) $ PERSONAL $ ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JET LOC PRODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO (Ea accident) SINGLE LIMIT $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per person) $ HIRED AUTOS NON -OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS / UMBRELLA LIABILITY OCCUR O CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION A AND EMPLOYERS' LIABILITY Y / N ANY PRR/MEMBER/EXCLUD IE� ECUTIV OFFICE(Mandatory 6S60UB-8166B64-8 04/22/09 04/22/10 TORY LIMITS ER E.L. EACH ACCIDENT $ 100000 E.L. DISEASE- EA EMPLOYEE $ 100000 In NH) l— l If yes, describe under E.L. DISEASE - POLICY LIMIT $ 500000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERA71ONS I LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Evidence of insurance for work performed by Jason Hayden @ the residents of "Deb Lord, 276 Mass Ave, N. Andover, MA 01845 fore remodel project. This Workers Compensation Policy does not provide coverage for"Jason Hayden" I.CK I IriGA 1 t HOLUEk CANCELLATION Town of North Andover Building Department 120 Main Street North Andover MA 01845 ACORD 25 (2009101) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIOI TOWNNAN I DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. The ACORD name and logo are registered marks of ACORD reserved. T 1\• w Downer Brothers Landscaping, Inc. 21 Main Street North Andover, MA 01845 978-975-5106 20900 Deb Lord 276 Mass �ve North Andover, MA 01845 Proposal For 2100 - Backyard Landscape Renovation n Property Address: 276 Mass Ave North Andover Proposed on Stock Note Unit Price Salesman CHU- Extended Price REMOVE/RELAY EXISITNG PATIO 1.00 UN 800.00 800.00 GRADING 1.00 UN 780.00 780.00 L6WN INSTALL 1.00 SF 700.00 700.04 PATIO EXTENSION 1.00 UN ---- 2,940.00 2,940.00 WALL w/ 3 STEPS 1.00 UN 3,600.00 3,600.00 LAYOUT BY DESIGNER 2.00 HR 75.00 150.00 CORLISS PLANT DELIVERY 1.00 EA 100.00 100.00 PLANTING FERTILIZER, HEALTHY START 1.00 EA 29.25 29.25 PLANTING MIX, CORLISS 3.00 EA 19.50 58.50 PLANTING LABOR 1.00 HR 832.00 832.00 MAPLE, THREADLEAF CRIMSON, /3.5-4' 1.00 EA 334.62 334.62 BUTTERFLY BUSH, CHARMING SUMMER 3G 2.00 EA 33.60 67.21 BOXWOOD, GREEN MOUND 18-24" 3.00 EA 86.51 259.55 9 55 C.DAYLILLY, HAPPY RETURNS 1.5G 7.00 EA 14.28 100.00 C.SALVIA, BLUE HILL 1.5G 6.00 EA 14.28 85.72 C.CLEMATIS, HYBRIDS 3G 2.00 EA 42.9085.80 C.GRASS, FOUNTAIN LITTLE BUNNY 2G 3.00 EA 16.00 48.01 MULCH, DRK 2YDS. 2.00 UN 80.00 160.00 Sub Total.......... 11,130.66 Total ................. 11,130.66 Excavating and grading- backyard to be'cut' to create a flat area between the pooljand the house. The newly created area will be used for the patio extension, flat lawn space and plantings. A retaining wall using the same wall material will be used to hold up grade from the excavating. The wall be installed on a crushed stone footing, backfilled with crushed stone, and a drain pipe with filter fabric used. The wall will have three steps made out of the same material leading up to the pool gate. A small walk will take you from. the steps to the pool deck. FYictinn natin to ha The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizariort/Individual):_ V��N � D� - Address: ' 13' 6 VN �;T City/State/Zip: N�_Q N ��fhone #: T,9� �al7l?7v12 7eu an employer? Check the appropriate box: 1am a employer with 0 _ 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. workers' comp. insurance. [No workers' comp. insurance S. El We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ Ne construction 7. Remodeling 8. ❑ Demolition 9. Building addition 10.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other t' -�.r .-ryu•�=••a a �aa~.:,s :r�r. r, i tJ use »iso 1W out the se_tlon 'Jeiow s—hQwy.b +her womers, compensation policy information. 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. #:_ 656002 . 116('p f j� + - G Expiration Date: /O Job Site Address: 2-7 LA�AV 6,--- City/State/Zip: 41 d 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 insurance coverage verification. I do hereby certi t oder the n pen ties of perjury that the information provided above is true and correct Si ature: �l V Date.: Phone #: Official use only. Do not write in this area, to be completed by city or town offtciaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other 4. Electrical Inspector 5. Plumbing Inspector 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 15.2, §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 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 Off ce of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-72.7-7749 Revised 5-26-05 www.mass..gov/dia W W Cd w w x w ® v e � z C7. z A 'LA Z a C� ca a O w � � ' fq C O w a F' w A C O e LL • O -LDO u 2 p °� a ®:C cm a G P44 U c w a rL c w u W W Z w°' cn iz w d c� ao w w a w G w o z cn v Q O cn ui O CE COD Z N O i CO, c cc CR O CD cm m 0 CD c �C N O t r.+ 0 2c O O 5 i1 T CD 01 E C■ L O Z CD CL O CO) � C � c cm CD y CL-) ■g mCD 0 co m CL P- CD C O O O O a cl- ca cc Cc v J ■O a o ,C? C Z CD 0 CL u y O C C C c CO2 0 W ce W y 'LA Z C o ' fq C = m O. p W C O e LL • O -LDO N = C = y ' .y .O ®:C cm V O C Vi d O O 'O C-e m O CE COD Z N O i CO, c cc CR O CD cm m 0 CD c �C N O t r.+ 0 2c O O 5 i1 T CD 01 E C■ L O Z CD CL O CO) � C � c cm CD y CL-) ■g mCD 0 co m CL P- CD C O O O O a cl- ca cc Cc v J ■O a o ,C? 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