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HomeMy WebLinkAboutBuilding Permit #235-2012 - 28 MARBLERIDGE ROAD 9/18/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: i-"—Qo/Z Date Received Date Issued: MfIll E4PORTANT:Applicant must complete all items on this page LOCATION - PROPERTY OWNER Print �,!)/ C C.�/��_6 Unit# Print MAP NO:-3 aPARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Resicjential Non- Residential ❑ New Building KOne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition PeOther --� - I®Se __R_ll� . e - P - - �-� _ -� p �®FLood lain ❑ Wetlands ®;WatershedlDist ., Water/Se T DESCRIPTION OF WORK TO BE PERFORMED: (Identification Please Type or Print Clearly) OWNER: Name: � y) �l�C/��Z/� Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: 12 Home Improvement License: / (/ Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULD/NG PER $92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: od J FEE: Check No.: /IFS�7` Receipt NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Cnn�ti ira•nf�'Onan�/(lnmar�', �., , ;:r _ , ..* ,.. .:-:;�k.= �f 7 Ciitnaffi�c nfcnnfrontn ;i J � 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 I ❑ 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 Permil Addition or Decks ❑ Building Permit Application u Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Flo or/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 r ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster r ermits require signn of from Fire Department prior to issuance of Bldg .Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008mi Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools El Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS L I +a 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 NOTES and DATA— For department nt use I i I I i ❑ Notified for pickup - Date i Doc:.Building Permit Revised 2011 June/mi Location lzf ! `"7G No. Date 6 NORTH TOWN OF NORTH ANDOVER 3 Certificate of Occupancy $ NuS Building/Frame Permit Fee $ 22z Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ;' Check It 439 j� 24599 / Building Inspector NORTH Town of tAndover .. . No. 0 . dover, Mass., C?// `i Q LAKE +Q co CMI C HE WIC., '7,9S0RArEo PP�,�,�� BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR «,v® THISCERTIFIES THAT..........'................r�................................................................................................................................... Foundation has permission to erect........................................ buildings on . /c .F.....��..°.. . . ............... Rough t0 be OCCUpled as.... ... .. .. f`:..1?. . ............................... .. Chimney .......... ... ...fi".. .... . ........... :............................................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final- this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONIS UNLESS ELECTRICAL INSPECTOR �J 1`�I LESS CONS T �O'lJ C� STARTS Rough .- f :�.: ................................................. Service .................... ..tom... �... BUILDING INSPECTOR Final Occupancy Permit Required t® Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry wall To Be Done FIRE,DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE smoke Det. Office of Consumer Affairs andBusiness Regulation 10 Park Plaza. - Suite 5170 '"yy Boston,.Massachusetts 02116 , nHome ImProvement C. 'It' cto r Registration n w^� Registration: 121604 ` MR F Type: Individual c WEN Expiration: 5/2412012 Tr# 293905 QUINN'S CONSTRUCTION THOMAS QUINN ! 868:MAMMOTH RD. DRACUT, MA 01,826 _.. Update Address and return card.Mark reason for change. DPS-CAI a 50M-04/04-G101216 ❑ Address ❑ Renewal Employment Lost Card ,per ✓� � �� a�✓1�,�� Office of Consumer Affaus& License ogre istration valid for individtil use only Business Regulation g y HOME IMPROVEMENT CONTRACTOR before theexpiration date If found.return to: OfSce of Consumer Affairs and Business Regulation Re istratio`. g .��29t09 Expiration( _�af24f2012 Tr# 293905 1'O Park Plaza-Suite 517.0 Type` lrvttival Boston,MA 02116 QUINN'S CONSTRQCT[OT1 THOMAS QUINN 868 MAMMOTH R© DRACUT MA 01826 Undersecretary; t.. Not valid with out signature jamu; INIaS "iehusetts- Dgmriment of Public Safet-, Board of Ruddingi Regulaii:on and StitudArds Restricted.to: 00 Construction Supervisor License 00- Unrestricted. License: CS 39732 1G-1 2 Family Homes Ritstticted to: 00. '? THOMAS-J.'-.Q6,INl9 3 868 MAMMOTH RD; � Failure to possess a current edition of the DRACUT, MAU1826 �a � Massachusetts State Building Code is cause for revocation of this license. Refer to: VVWW.Mass:.Gov/DPS Expiration: 3/25/2012 (vnunisiencr Tr#: 18330 Contract Tom Quinn Employer ID # x(978) 265.2390 M QUINN'S CONSTRUCTION 868 Mammoth Road • Dracut, Massachusetts 01826 Name ` Date StreAress(Not Post Orrfice Box)dAQ I�? l� Job Name City/Town, State&Zipcode Job Location Dime Phone: Evening Phone: C1/ 5� � Job Phone Mailing address(if different from above) Salesperson(s): /'7) t ,// Contractor Registration#: `j� 'J Exp. Date: We hereby submit specifications and estimates for: JCS r JU fv �-' _ /?r• /r/-!t/G ,u >( t rw' r1.�-/ //x� ,�' C °ter�`7 ✓r✓� f /' �- 1.�it (T / ! i ./,�'.�S✓"� z Z/' 11'L 111 ./ C�.� G4 ' /-,Js ?"moiez elk ,�� � �r'� ,�/c/ Wil`?/ 1 r� ,.? sw� �� .0 " ,C/ �r �s�',� G.�'�.!�� �f'' <'�•f-1!';`� _ '�/' /✓.� �- /.l--r /���J�� � !^�'�/lc''r � v v7,� " /r-''1iL..i" ,iv�l� .-/ �G./,fJ'//�i-7 � /�%� % f-�'sa-�-�r�� .� -�;>�:' �� L../"..S �-G- ,� � tet✓''1 f CC1C U } /XI /../ � Thefollowing scheduled will be adhered to unless circumstances beyond the contractor's control arise: Work scheduled to begin: f/---92122vll Expected Date of Completion: (Date Contractor Will Be Contracted Work) (Date When Contracted Work Will Be Sustantially /Completed) TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE THE CONTRACTOR RHES TO PERFORM THE WORK, FURNISH THE MATERIALAND LABOR SPECIFIED ABOVE FOR THE SUM 0 includes all finance charges in this amount* Payments will be made accordin to the following SCHEDULE: $upon signing contract(*Not to exceed 113 of the total contract price OR the cost of special order items, whichever is greater*). WWW_ U By _/- / or upon completion of $ N- � B / /—or upon completion of $ --- � p Y� -- ` `. /--- `�_`_ �'=z4r� s�1�1------------- $ �a3�djNZupon completion of the contract(*Law forbids demanding full payment until contract is completed to both parties'satisfaction 7._ In order to meet the completion schedule,the following material/equipment must be special ordered before the contracted work begins.(*Law requires that any deposit or down payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contractor price or(b) the actual cost of any special equipment or custom made material which must be ordered in advance to meet the completion schedule*): $ to be paid for DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Identical copies` u of-the contract should go to the homeowner and the contractor Home Owners Signature:l' -_,�.+ 'Date: Contractors U1�/ Contractors Signature: _-, '1 'Date: You may cancel this agreement if it has.b en signed by a party thereto at a place other than an address of the seller, which may be his main office or branch thereof, provided you notify the seller in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of the agreement. 'J =rom:Bonnie Welch FaxID:9784549343 Page 1 of 1 Date:5/262011 12:16 PM Page:1 of 1 OP ID: BW CERTIFICATE 4F LIABILITY INSURANCE DAT05126 0512611111 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(ies)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 ACT PRODUCER 978-459-8681 NAME: Francis Provencher Insurance 978-454-9343 PHONE FAx AJC No Ext AIC,No): Agency, Inc. E-MAIL 530 Rogers Street PRODUCER Lowell,MA 01852 CUSTOMER ID r.QUI N N-1 INSURERS)AFFORDING COVERAGE NAIC# INSURED Quinn's Construction INSURER A:Endurance American Specialty 868 Mammoth Rd. INSURERS:Commerce Insurance Company 34754 Dracut,MA 01826 ENSURER C INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR TYPE OF INSURANCE ADOL S POLICY EFF POLICY EXP LTR INSR 4WD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CBC10000052400 01/13111 01113/12 AMAGISES ES ED DEa occurrence $ 50,000 PREM CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV IN.URY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) B ANY AUTO BBGS68 05/07/11 05107/12 BODILYINJURY(Per person) $ 250,000 ALL OWNED AUTOS BODILY INJURY(Per accident) $ 500,000 X SCHEDULEDAUTOS X HIRED AUTOS PeraccidTnt)AMAGE $ 250,000 X NON-OWNED AUTOS $ UMBRELLA UABOCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY �,I N TORYLIMITS ER ANY PROPRIETORIPARTNERF-XECUTIVEE.L.EACH ACCIDENT $ OFRCERIMEMBER EXCLUDED? ❑ N J A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE.$ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) **CERTIFICATE FOR WORKERS'COMP COVERAGE WILL BE ISSUED DIRECTLY FROM THE COMPANY WITHIN 2 BUSINESS DAYS** CERTIFICATE HOLDER CANCELLATION LO W E001 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 O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD RightFax C2-1 5/27/2011 7 : 55 : 23 AM PAGE 2/002 Fax Server ACORD. CERTIFICATE OF LIABILITY INSURANCE 05/27/2011 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(ies)must be endorsed. If SUBROGATION IS WAIVED,subjectto the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s)- PRODUCER CONTACT NAME: PHONE FAX FILANCIS E PI-OVENCIIER INS (AIC,No,Ext): FAX 530 ROGERS STRiE'I' E-MAIL (A/C,No): ADDRESS: PRODUCER LOWELL.MA 01852 CUSTOMER ID#: 26F9G INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: HARTFORD CROUP INSURER B: QUINN THOMAS DBA QUINNS CONSTRUCTION INSURER C: INSURER D: 868 MAMMOTH RD INSURER E: DRACUT.MA 01826 INSURER F: COVERAGES CERTIFICATE NUMBER: 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- INSR ADDLSUBR POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM\DDIYYYY) (MM,DOIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED CLAIMS MADE OCCUR- PREMISES(Ea occurrence) MED EXP(Any one person) S PERSONAL 3h ADV INJURY S GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROJECT LOC PRODUCTS-COMP/OP AGG S AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY S SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY S NON-OWNED AUTOS (Per accident)PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE DEDUCTIBLE AGGREGATE $ RETENTION S $ S WORKER'S COMPENSATION AND WC S1AIUTORYLIMITS OTHER EMPLOYER'S LIABILITY YIN UB-4116P704-11 01/15!2011 (11/15/2(112 E.L.EACH ACCIDENT S 100,000 ANY f'ROPERIIORIPARTNER'EXECUTIVE Y 1:XCI tinFO? E-L.DISEASE-EA EMPLOYEE $ 100.000 OI=FICERlMFURf-R (Mandatory in NH) 11 yos,desc.dh'i unde, E-L.DISEASE POLICY LIMIT S 500,000 DESCRIPTION Or-OPr_RATIONS L-lo, DESCRIPTION OF 0PERATIONSILOCATIONSiVEHICLES/RESTRICTIONSisPECIAL ITEMS THIS RFPL',CI?S ANY PRIOR CERTIFICATE ISSUED TO THE cixi,i KATE HOI.DI•R AFFECTING WORKERS CONIP CCATAAGE. THE\VORICI:RY CO F_NSATION POLIO'DOES NOT PROIVIDE COVERAGE FOR nUL•NN T 101,1AS- CERTIFICATE HOLDER CANCELLATION 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 ACORD 25(2009109) Romani Ayer 1988-2009 ACORD CORPORATION. All rights reserved. The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MM 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/OrganizatiorAndividual): Address: '�' 2y /C� City/State/Zip:���� aP one: [2. re y u an employer?Check t appropriate box: _ I am a emp ith 4. Type of project(required): ❑ I am a general contractor and Iemployes(full nd/or part-time).* have hired the sub-contractors6 ❑New construction ❑ I am a sole prietor or partner- listed on the attached sheget.$ [7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. [No workers' comp,insurance 5. El We are a corporation and its 9 E]Building addition required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11lumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12,0 Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 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. $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. Expiration Date: �S ��9 r � fJ Job Site Address:_ ,/!'/' ��,� �� City/State/Zip: /C/O /��// 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 certify under the pains and penalties ofperjury that the information provided above i true a correct. Si nater S hone#: CQ e-­ Date: P [Contact e only. Do not write in this area,to be completed by city or town official. wn: Permit/License# thority(circle one): I. Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other rson: 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 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 COIM-iowwealth of l4assachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111. Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia