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Home My WebLink AboutBuilding Permit #896-14 - 28 DUNCAN DRIVE 6/10/2014BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: I Date Received Date Issued: 0 IMPORTANT: Applicant must complete all items on this pafze LOCATION Z),'11-) A'YA tl Print 1 PROPERTY OWNER ; , %L` C L7 i I ( Print MAP/6 G PARCEL: %% ZONING DISTRICT: 100 Year Structure yes no Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE l�/ L%%1 / ` -� Residential Non- Residential ❑ New Building ne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE P El -✓4 wGu! S ram -i -n 1!r k ZFORMED: ,021� Identification - Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Address: �- %/ (�� C �? '` /tom►�S �� l�/ L%%1 / ` -� Supervisor's Construction License: /1; C- 6 Exp. Date: .3 l Home Improvement License: / S .) - k,-' —` ARCHITECT/ENGINEER Address: Date: /, -z / 4--- Phone: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASEDON$125.00 PER S.F. ll-t\�Uv Total Project Cost: $ FEE: $ `1v Check No.: I 1�1 Receipt No.: 2-14' (6,3 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Ownerignature of contractor 16'•NO0 T Location2— � N o.�n ('0 — I A -�) U,, (, -1.-) —Df2 1,j C- Date TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee $ 40 M Foundation Permit Fee Other Permit Fee TOTAL Check# Building Inspector A* 14 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swinuning 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 Reviewed On COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Signature Reviewed on Signature Reviewed Sianature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments to Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: uocatea M4 us ooa 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.: 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 NOTE5 and DATA — (For department use ❑ Notified for pickup Call Email 1 Date Time Contact Name Doc.Building Permit Revised 2014 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products 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: Building Permit Revised 2014 a 0. z CD �r Q. D c• -0 O 00 C CL a CD O CD CLO c0 CD CD O 7 Lwl cn O U) 0 r_ CD CD CD U� U) v Z X CDa CD filb c� z m cn 0 Z cnC O C Z G) Z a m X a //Tv VJ z Im ic O o��o __ fOq = , (S <D N in �CD CDc°-) I n Q- C.) m O' � N S 'a -1 ra FD N h � - IDO O. N W M -0 N O CD 2 Qa- D c co CLrt N o S' '. 0 CCD �D CD -0"a O o ca O 0 N �+ Nz CD -a : O • � O• :mmw D CD C Q. O 0 CC. o � — N O CD E N 03 T r CD N •�� as D p- 41 Cc) Ola =0 � a'� 0 O O � C O � N O CD C) N o �. DCD (D-0 0 � _rt G) O Q 0 • V) LnW T 7,7 T N Z7 T m T (i T (D T 0 rF C O O (D O 3' O j' 0 O O (D O _S �. 77 (D ((D 04 D'q 00 00 7 Q (D ''.' S n S S S Q n \ Z rD rD d (� 0 f+ `* m j S W '-� m C C 3 ' W m N '° 2 o W W a z v o Z cZi D (n (- O O 0 T m z z H x m D Z z 0 0 0 x O IM 0 c Jesse Germain POTSmodeml __W& (5/6) 05/30/2014 11:21:41 AM -05C ACC?R&DATE CERTIFICATE OF LIABILITY INSURANCE (MM/DDnYYY) 5/29/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(iss) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Foy Insurance Group - Manchester 1889 Elm St Manchester NH 03104 CONTACT Lisa B1550n PH OIC,NE . (603) 641-8111 AIX No : (603) 641-9849 ADDRIESS:lisa.bisson@foyinsurance.com INSURERS AFFORDING COVERAGE NAIC K INSURERAMerchants Mutual Insurance 23329 INSURED STEPHEN BRISSETTE 291 WEST ERIE STREET MANCHESTER NH 03102-5058 INSURER B: INSURERC: INSURER D INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER:Rev Master 2013 - 14 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INISR LTR TYPE OF INSURANCE AWLINLM11 INSR WVD POLICY NUMBER POLICY EFF MM/ODIYYYY POLICY EXP MMIDDIYYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X� OCCUR X MU 82 77 11 11 BOP9097148 /11/2013 7/11/2014 EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 500,000 MED EXP (Any one person) $ 15,000 PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ A AUTOMOBILE LIABILITY ANYAUTO ALL OWN ED SCHEDULED AUTOS X AUTOS NON OWNED X HIRED AUTOS X AUTOS X Comp $250 1 X I Coll $500 API040224 10/21/2013 10/21/2019 COMBINED SINGLE LIMIT Ea accident 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accidenQ $ PROPERTY DAMAGE Per accident $ Medical payments $ 5,000 UMBRELLA LIABOCCUR EXCESS LIAB HCLAIMS-MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YfN ANY PROPRIETORPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? N❑ (Mandatory In NH) It yes, describe under DESCRIPTION OF OPERATIONS below N/A A State NH CAI033879 10/4/2013 10/4/2014 X WCS ATU- 0 H- IMFTSI ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTIONOFOPERATIONS/LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) Paul Schmitt 28 Duncan Drive N. Andover, MA 01845 ACORD 25 (2010105) INS025 onton.9)w SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE sa Bisson/EJESSE O 1988-2010 ACORD CORPORATION. All rights reserved. Tho ar ARn name anri Innn aro ronictarorl markt of ar nRn Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor Specialty License: CSSL-100468 t� ts Stephen A Brissette= .. #/--Aj 291 W. Erie Street Manchester NH 63102 ` f: a-' �j.'I "` Expiration Commissioner 04/23/2016 Office of Consumer Affairs and usiness Regulation - 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 152802 Type: Individual Expiration: 10/2!2014 STEPHEN BRISSETTE T STEPHEN BRISSETTE 71 291 WEST ERIE ST. MANCHESTER, NH 03102 , DPS -CAI 0 50M -04/04G1012166 D /� --------- ✓i2e 't�ovtmnonlUe� oy �GL¢60aCftuJe�6 —' :L, Office of Consumer Affairs & B siness Regulation r; �o HOME IMPROVEMENT CONTRACTOR k Registration: 152802 Type: Expiration: 10/2/2014 Individual � P STEPHEN BRISSETTE " Tr# 231608 Update Address and return card. Mark reason for change. ❑ Address D Renewal n Employment n Lost Card License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 STEPHEN BRISSETTE 291 WEST ERIE ST. - Z��",�c�{ MANCHESTER, NH 03102 Undersecretary Not valid without signature CHELMSFORD FIREPLACE CENTER, LLC 73 SUMMER STREET CHELMSFORD, MA 01824 Bill To SCHMITT,PAUL& DEBBIE 28 DUNCAN DR N. ANDOVER, MA 01845 Ship To Invoice Date Invoice # 5/24/2014 8963 SCHMITT, PAUL& DEBBIE 28 DUNCAN DR N. ANDOVER, MA 01845 P.O. Number Terms Rep Ship Via F.O.B. Project 978-689-4347 5/24/2014 Quantity Item Code Description Price Each Amount 1 350420 OSLO F500 MATTE BLACK WOOD STOVE 2,693.00 2,693.00T WITH FILIGIRE, SCREEN AND SIDE DOOR LOCKS DISCOUNT JOTUL ON LINE COUPON CUSTOMER DISCOUNT -200.00 -200.00 SUBTOTAL 2,493.00 DISCOUNT CUSTOMER DISCOUNT -43.00 -43.00 TCE-206K 6 IN 20 FT SS KIT 449.00 449.00T DISCOUNT STATE VOUCHER CUSTOMER DISCOUNT -750.00 -750.00 VISA PAYMENT VISA CREDIT CARD PAYMENT -2,149.00 -2,149.00 Sales Tax 6.25% 181.19 Total $181.19 • Jotul F 500 C 510 Heat Output': 70,000 BTU -- ;, / - Heating Capacity': E 48„ 1220 mm Up to 2, DOO sq. ft. I Overall Efficiency 3: 72% Emissions: 3.20 rams/hr. Burn Time: up o 9 hours Log Length: up to 22" Flue Size: 6" Weight: 445 lbs. Mobile Home Appr vaI Optional Accessories • Bottom Heat Weld #154330 • Rear Heat Shiel J #154332 • Outside Air Kit 1r-4333 • Floor Bracket Ki #750304 • Side Door Lock Kit #155850 • Short Legs (red ces height 21/4") • Spark Screen #35:)169 • Stovetop Therrqiometer #5002 Hearth Proted ion Any of the following t-iree forms constitutes approved hearth protection: • the hearth protection must extend 18" (203 m) from both the front and side doors. • any UL, ULC or arnock-Hersey listed hearth bo rc. (no bottom heat shield required) • any noncombus ib a material that has a minimum R -value of 1.6 (no bottom i ea: shield required). • A Bottom heat shield is required for alcove installation. ~I_ 2„ 51 mm 28" 716 mm 1 � I IIIiliiiLII1111.! Ir �. 28 1/4" ---+• 1 •,F-_"—.- 718 m m , Figure 45. F 500 Oslo dimensions. See clearance chart on page 21 for flue collar centerline positions. -- -�8" 203 mm .:� 470_t E ,� k _ - o Min. �.�� ..gin .• 00 50.1/2" 1283 mm , 18" 457 rIM 45` mm r Min. 54 t/ " "". 1378 m Figure 44. minimum, ear th Dimensions. Alcove Installation Requirements • This side load door must be locked closed unless a 36" clearance can be maintained to that side. • Chimney connection requires listed double-wall pipe. • Optional Bottom Heat Shield must be installed. • UL/ULC or WH listed hearth pad or a noncombustible material having a minimum R value of 1.6. • If used, wall protection must extend 48" (122 cm) from the floor, includ- ing bottom air space. • Min.Ceiling &Connector Clearance, Fig.49. A: Top or Rear Exit from hearth Unprotected: 691/2" (176.5 cm) Protected: 431/2" (110.5 cm) Fireplace Clearances A: Stove to Mantel, max. depth 12": 30" 762 mm B: Stove to Top Trim,1" thick or less: 16" 4o6 mm C: Stove to Side Trim,1"thick or less 12" 305 mm Figure 46. Mantel & Trim Clearances. Maximum Heat Outputbased on kg of dry hardwood burned per hour. Heating Capacity and Bu n Time will vary depending on home construction, climate, fuel type, and operation. Overall Effcienry is base on a burn rate of .75 kg hardwood per hour. 20 j 16 1/4" .f 413 mm "► �...... 271/4" 692 mm Top Exit 29„ 737 mm 25" Rear Exit 535 mm 281/4" 717 mm 18" 460 mm i ■ Max. Depth 48 1220 MM • 14„ -r- -r►i 14"�I- 1355 mm 355 mm1 561/2" —_�..1 1435 mm Figure 41. Alcove with no wall protection. I 40 1/2" 1015 mm Figure 48. Alcove w/ wall protection. Min. Wall Shield Height 48„ 1220 mm Max. Depth j 1220 mm Figure 49. Alcove Ceiling and Double-wall Connector Cleoronces. 12" 300 mm -- ;, / - Max. Depth E 48„ 1220 mm E 0 I I __._. I 40 1/2" 1015 mm Figure 48. Alcove w/ wall protection. Min. Wall Shield Height 48„ 1220 mm Max. Depth j 1220 mm Figure 49. Alcove Ceiling and Double-wall Connector Cleoronces. 0 • `'Stave Clearance Diagrams / Top & Rear Exit UNPROTECTED WALLS 281/8 715 mm .... +----------- _t 18" 211:8.. 457 mm 537 mm /8" mal 3 _ '3 59 3/4" rH E1i-T 1518 mm ---- 281/8" � 715 TT1m r'.. 10 254 mm 334 mm h `7 u38 mm 356 mm .-- I SS 3/4" HEARTH EXT 1416 mm--._ ...._.. y 281/8" { I 715mm-1 1 6' 152 mm 1/£" 232 mm f•' 'i 46 5/8" 1184 mm 14" 59 3/4" 356 mm T• -----t 18 mm HEARTH EXT 5 20 t/2" -1 523 MM 13" 330 mm ,' 20 1/2" z 523 mm 13 .��e,• 330mm y. 161/2" MI* 9" x_ 9" z2g mm 421 mm -5e 3 I 3 16 5/8" PROTECTED PER NFPA 211 OR CAN 201/8" 512 mm 12" 305 MM 'r --- 384 mm 55 S/8" 1438 mm - 3 3 f _ 1518 mm 201/8" 10" 2S4 mm 131/8" -r- t 335 mm r� t 485/8" �!E ( �I m u3 mm F k - in �•--113/4" • 3 HEARTH EXT. -1315 mm -----•I 201/8" 512 MM 6" 152 mm -� 91/8. }-- z3!MM I _- t i I q6 5/8 (r I 1184 mm I3 513/4" HEARTH Exr. 1315 mm_.__..._...._ 9" 229 mm % f -f"" Ply k Js ! 9+ -•6�' •�52 m lYP� 161/2" - 421 MMN i 161/x" 1 qz1 mm 3 I 3 13 5/8" S % 13 5/8" 345 mm yi Nr 3 3 11 Note: i) Hearth Extension calculations include the protection requirement measured forward from the load doo-0r d door glass pane. Chimney Connector Clearances 161/2" UNPROTECTED PROTECTED 421mmr--. � i 9' 2z mm 16 U2" 4zt mm rA CAN/CSA 8.365-M93 4' OSingle Wall 18" / 46o mm 12" / 300 mm Double Wall 6" / 18o mm 6" / 18o mm s' _.1 10 3 ''• i 3 18" / 46o mm 9" 229 mm % f -f"" Ply k Js ! 9+ -•6�' •�52 m lYP� 161/2" - 421 MMN i 161/x" 1 qz1 mm 3 I 3 13 5/8" S % 13 5/8" 345 mm yi Nr 3 3 11 Note: i) Hearth Extension calculations include the protection requirement measured forward from the load doo-0r d door glass pane. Chimney Connector Clearances UNPROTECTED PROTECTED SURFACE SURFACE per NFPA 211 or rA CAN/CSA 8.365-M93 OSingle Wall 18" / 46o mm 12" / 300 mm Double Wall 6" / 18o mm 6" / 18o mm s' _.1 EI_ Single Wa.l 18" / 46o mm 12" / 300 mm Double Wall 6" / 150 mm 6" / 15o mm 21 Mobile Home Installation The F Soo Oslo is approved for in- stallation into -nc bile homes in the US. and Canada. • The stove mus be secured to the floor of them bile home. Use Floor Bracket K t 750304, • Use Outside Aii Kit 154333 to provide outsid combustion air, • Use only list=ed ouble-wall pipe for the chimney connection. • The stove must be grounded to the mobile horr a chassis. • The stove must otherwise be installed in accc rdance with 24CRR, Part 328 (HUD). Consult your to al building in- spector or fire offic als about restric- tions and requirem nts in your area prior to installatio . The Commonwealth ofMassachusetts - .Department o, flndustrigl Aceldie is Office OfIfivesiigatzons 600 Washington Street Boston, MA 02111 www.massgov/ctza Workers' Compensation Insurance Affidavit: BuRders/Cont°actors/Electx ciansIrliimbexs A.pp�[cant �folrmation Please Print LedbXv • Name(Businesslorganizaiionft&idual): �) 4 e 4 Qnm / a t Address: -?—I t lt`o� ( rC 4T7 4' I l + r / City/8tate/Zip:1-Y.* Xo Li . ' �� A `V Phone #: fd o' -7 c Axe yo an employer? Ch -k the ppropriatebox: Type of project (required): 1. I I am a employer with 4• ❑ X am a general contractor and I 6. New construction employees (full and/or Part-time').* have Mod the sub -contractors 2. ❑ I am a sole proprietor or partner listed on the attached sheet. 7• ❑Remodeling Ship and'have nonemployees These sub -contractors have S. [] Demolition working forme in any capacity. workers' comp. insurance, q. ElBuilding addition [No workers' comp. zn.surance 5. ❑ We are a corporation and its 10 [] Electrical repairs or additions required.] officers have exercised.their 3.E1 X am a homeowner doing all workright of exemption per MGL 1I.[(Plumbingxepairs or additions myself [No workers' comp. c. 152,§1(4), andwehaveno 12.❑ Roofxepairs insurancere edi employees. [Noworkers' �'. � 13.0 Other comp. insurance required.] xAny applicantthat checks box#f must also fill out the section below showingtheir workers' compensagonpolloy information. 1-1-10meowners who submit ibis affidavit indicatingthey tie doing allworlc and then hire outside contractors must submit anew affidavit indicating such. Untractors that cheAthis box must attached as additional sheet showingthe name of the sub. -contractors and their workers' comp. policy information. law an employer that is providing worrliers' compensation insurimee for my employees' Below is thepoliey andjoh site information. Insurance Company Name; Policy ## or Self- ins. Lic. M: tN C A J O �,? 9 7 ( Expiration Date: rob Site Address:, 2- 40''L4 C el � 7/0/ jCity/state/zip:%o�Lj %P'Z 6d �2 �4 Attach a co aftbe workers' conn ensation otic declaration page showin .the policy number and expiration _ date copy P P Y pg ( g p Y) failure to secure coverage as requiredunder Section 25A ofMGL o. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as wallas civil penalties in the form of a STOP WORD ORDER. and a fie 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 liereby certify uride� tileiiains and penalties ofperjury tliat the information provided above is true and correct. - ,/ } it - 4 A,_v / l� C; no, 7 o S f Official use oltly. Do not write in tliis area, to be completed by city or town offzcial City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Cfty/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other ContactPerson: Phone M. 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 defnn as "...every person id the service of another under any contract od hire, - express or implied, oral or wxitten2l Au employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two ormore ofthe foregoing engaged in a joint enterprise, and including the legal representatives of a• deceased employer, or the receiver ox trustee ofan individual, partnership, association or other legal entity, employing employees. 1%wever the owner of a dwelling house having notmore 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 employes." 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 ofpublic 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 &0 boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), addresses) andphonenumber(s) along with their cergeate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notrequired to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may besubmitted tothe Department ofIndustrial Accidents fox 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 thepermit 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 obtairt 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 andpninted legibly. The Department has provided a space at the bottom of the affidavit for you to 1111 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, fu addition, an applicant that must submitmultiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnecessmy) and under "fob Site Address" the applicant shouldwrite "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 -ii on file dor future permits or licenses. Anew affidavit must b e, filled out each year. Where a home owner or citizen is obtaining a license orpermit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves eta.) said person is NOT required to complete this affidavit. The Office of Investigations would line 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 abd fax number. Tho Ca onwut'althOfMlauachufts Dopattel t QUAdu*ial Accidents Of oe Ofrn,Vestip-001M 600 Vlwash w(M Sheet Boston, . 021 z z Td. 0- 617-72Z-4900 oyd M Qx 1-877: .FF Revised 5-26-05 Fax # 617-727-7749 www mqs%gov1dia