Loading...
HomeMy WebLinkAboutBuilding Permit #254 - 300 WEBSTER WOODS 10/9/2008 BUILDING PERMITof"O oT 6' �ti �4` a saOio TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION e: CMIK Permit NO: Date Received G - r 4j 9Acg%re �SSgCHU c Date Issued: 'djl-� IMPORTANT:Applicant must complete all items on this page LOCATION On ��() ()� Lav--e Print PROPERTY OWNER ,, t� ,.": 4- a C.,G_ Print NEAP NO: f PARCEL: ZONING DISTRICT.- Historic District yes Machine Shop Village .yesno' TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial- Repair, replacement Assessory Bldg ?,::Jak 9 C- Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer - DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: oma\ JgQme�o_ 'S if r Phone: C/ 7Ka Z7%-?,63( Address: -�>O A t'ol<- CONTRACTOR Name: c e� �o Phoney ? Address: -7'7 Supervisor's Construction License: S. Z Ifo Exp. Date: Home ImprovementLicense: 'S� Exp. Date- `7 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 ProjectCost: $ Y 3l/, C0 FEE: Check No.: �/ 3 Receipt No.:o2/S �� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fun �j gnature of Agent/Owner Signature of_contractor 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 ij COMMENTS al IDL� L/ 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 -Ternp Dumpster on:site yes no Located;at 1_24'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 NOTES and DATA— (For department use �J�Cdfin K ❑ Notified for pickup - Date Doc.Building Permit.Revised 2008 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report . ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Dor.INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location4:?0D No. Date &ORT#f TOWN OF NORTH ANDOVER O?O•�f•w I•,hooR F y • i � Certificate of Occupancy $ r 4 s' NuSEt�• Building/Frame Permit Fee $ �' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # � 2566 Building Inspector b T0VM VAORTH of _ 0 No. Z S y o dover, Mass../,. 0 lAK COCHICKEWICK A. ADRATED `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT t ............. .............................. ..•.. .. .. `a... .. .......................... .......... . ..... .... .... .... ..... ....... Foundation � z has permission to erect........................................ buildings on .. ...................... . .0. ... ...... Rough p to be occupied as A&116... ... ...0.44....V.... .. ....44m A ..............�........ r-ri P6� Chimn yeprovided that the person accepting this permit shall in every respect conform to the terms of the o 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 srdp PERMIT EXPIRES IN. b MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRV OA STARTS Rough ...... .................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to 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. �ro�o�ac� B FrIa ERUBE CONSTRUCTION 771 Salem Street Fully Licensed & Insured Groveland, MA 01834 Phone: 978-521-2544 Remodeling • Additions • Custom Homes PROPOSAXt ITTED TO PHONE# 4"78,;23-8. Z�y,3� DATE d' GL-Vy) V L FAX# J, L°l` STREET JOB NAME 300 �b�ter woods ,�rt CITY,STATE AND ZIPCO E r ,/ JOB LOCATION ESTIMATOR DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: /-,. A SGGYO . . . . � . .G �c . 1= � C . � ry.). .&���u'�S . . . . . . . . . . . . . . . . . . . . .6. s,�s: s. . c� . r-e mo va_L. . �,t .cam.,. ,zn u� Q.�. .or .. n e�u. . �Ca0c L -re t 71- .p � . . . . . . C- 1 a j-�:tn� .C�r. , . . . . . . OP./Or. -6o.ice.pa-I-R-d. .4.y . 0.t,0(44-.a''. . ./- a nC4r eAS.. 1/V Pri 6.e- -e-C . . .b.y .G�. 3 r. tm. .� .�.r�SSS ter- - -ACL. . -� 1�n i,--. .vvi-C.(. . . . . . . . . ter ra. C). u�. .�`.V G.. . .fri.m. . c � c j�P-e . �- rs. .t�� .. . . .l_..r a.. . Ln _..uU. . . . . . . . . . . rcuvv. ng... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1�. t L . . 6��.r. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ./9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . �e 3PCOpol5e hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: dollars Payment to be made as follows r c 1/3 w fn n rm G -c= All work to be completed in a workmanlike manner according to standard practices.Any alter- ation or deviation from above specifications involving extra costs will be executed only upon Respectfully written orders,and will become an extra charge over and above the estimate.This estimate is submitted by for completing the job as described above.It is based on our evaluation and does not include material price increases or additional labor and materials which may be required should unfore- Note:This proposal may be seen problems or adverse weather conditions arise atter the work has started,or delays beyond withdrawn by us if not accepted within days. our control.Our workers are fully covered by Workmen's Compensation Insurance. 2treptance Of propomal—The above prices, specifications and conditions are satisfactory and are hereby accepted.You are authorized Signature to do the work as specified.Payment will be made as outlined above. Signature Date of Acceptance: PrOP05al BERUBE CONSTRUCTION F10 F& 771 Salem Street Fully Licensed & Insured ~ Groveland, MA 01834 Phone: 978-521-2544 ,_R�gmodeling • Additions • Custom Homes PROP SUBMITTED TO PHONE#� DATE FAX# � 7 4 STREET t I JOB NAME t1C1 CITY,STATE ZIPn, Id( JOB LOCATION ESTIMATOR DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: l f a , . . . . . . . . . . . .��Y0T). . �. . . C� �p(Gctea tai t . �� X . . t' J -{n�r° . . �C pi � a. . .c . . ;., . . . �.��cc� ��x-e. ct� c C ha -cL— . . . . . . 0.L.t . . . . . . . . . . . . . . . . . . . . . . . . . . .1 n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . .. . . .. . .l?C. o�v. . n. . . . a. . . -.:. .4 Uu f.�. . . . . . C �l r .� q. � U . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . .TLP— .-F. . -��L c�a�� t.�: mac. . rte..., Q. . Pp ) .Oc}r. .S 1-- r C' t�. : .1, -rst. . . . . . . . . . . . . . . . . . . . . . . . . Wt+J,. t`�y. L-vt-. 5 u-a�. .h; ►'C a' . . . .L V.L.Y.u_.s0. .vm�� . .u+S�� . .��4.kkr- . . . .s � . . .. . . . ua.. . . ILL. 6, . . . re.e e5 r�. . . . c ' �souiz. ur��L.�C(ni&r . . .. . . . . .� . .. . . . . . f . . . . . . . . . C i f7 fj Z �e PrOPoge hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: ). Payment to be made as follows: dollars($ All work to be completed in a workmanlike manner according to standard practices.Any alter- ation or deviation from above specifications involving extra costs will be executed only upon Respectfully written orders,and will become an extra charge over and above the estimate.This estimate is submitted by for completing the job as described above.It is based on our evaluation and does not include material price increases or additional labor and materials which may be required should unfore- Note:This proposal may be seen problems or adverse weather conditions arise after the work has started,or delays beyond withdrawn by us if not accepted within days. our control.Our workers are fully covered by Workmen's Compensation Insurance. Z1CCCPtanCC Of VrOPOMi—The above prices, specifications and conditions are satisfactory and are hereby accepted.You are authorized Signature to do the work as specified.Payment will be made as outlined above. Signature Date of Acceptance: Propotal po_q� 2__ BERUBE CONSTRUCTION 771 Salem Street Fully Licensed & Insured Phone: 978-521-2544 V_ tGr oveland, MA 01834 Remodeling • Additions * Custom Homes P POS EMITTED TO PHONE# q-n, 1ST. DATE C�y✓i i c.. FAX# , ` I ` STREETL�� �b4 EM AMY l �r� A-_._ JOB NAME / aD L LD-b C— � CITY,STATE- IP COD � JOB LOCATION O ESTIMATOR ` DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: . . . . . . . . . . . . . . . . . . . . . b ( ,. . . . . . fl.L. .,b�-. .IX-1, L---�i�c 1 t - �. . . t vt f-t� cc� � '�. . . . . . .fit-(fie . . . . . �-'�. . . -�-<sQ . . . . . . . . . . . . .Al'o . bujq . . . . . . . . . . . . PALOX . . .,..� . . . . . . . . . . . . . . . . . . . . .��--er LA-,.)�.�-. .`. `. . . . . , . . b.�... . v u , fl t,�: . . . Gt,.` t h L-M Lam?k_.�vt:LL. i! - C &L,_ . . . . . . 7.�. Par�* 'i • . . . . . .-eL . . . . . .��...., a_ � . . . . . . . . . .. . . . . . . . . . . . . . . . .a.. . .. . . . , . . -I t-tv f ps-�. . .�r C.�.... .�C�o�.,. .--�--�1.-�-r.r'vs'-, . �:i�t�-tai©i�. . . . . . L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . � . . . . . . . v.r.1. . n LL _L. fi..� . c�i1I . . G ���-� Ve l f`. . . . . . . . . . . A.P. J�- rl�lla4r .p"�It p . .t-h� 4zd.. AID .�j�c.r_�r�LC)__Cc-CC�.P . .[ C1. ��s•.3� . . . . . r. 4 .� /fib. . . --? 5� OfiGi�CZ �jC1. V9e PrOP05e hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: K.0 c i�t� l rr1Z j �r Payment to made as follows: J dollars($ All work to be completed in a workmanlike manner according to standard ractices.Any alter- ation or deviation from above specifications involving extra costs will be executed only upon Respectfully written orders,and will become an extra charge over and above the estimate.This estimate is submitted by for completingthe as described above.It is based on our evaluation an 1 d does not include material price increases or additional labor and materials which may be required should unfore- Notd:This proposal may be f) seen problems or adverse weather conditions arise after the work has started,or delays beyond withdrawn by us if not accepted within C days. our control.Our workers are fully covered by Workmen's Compensation Insurance. Rtuptance Of PropofSal —The above prices, specifications and conditions are satisfactory and are hereby accepted.You are authorized Signature to do the work as specified.Payment will be made as outlined above. Signature Date of Acceptance: 'BQ AWMVRA 149f Construction.Supervisor-License License: CS 65246 Expiration -12/16/2009 Tr# 10123 " '_ �Restrrcttzan 110`r I SCOTT A BERUBE ,,r t iG— 771 SALEM ST GROVELAND MA 014-34 Commissioner `t;e {�oarasno�ur a ndards; � Regulationsand Sta Board of Building �pCTOR —r OVEMEN7 CON HOME 1MPR i f Registration: 119555 Tr# 1 OB4 �1 Expiration: 712612009 ; 'i Type: DBA h BERUBE CONSTRUCTION ` SCOTT BER �p 771 SALEM ST Administrator GROVEIAND,MA 01834 - - } POO\ �-ocov�)(Z. r.�L:.tRoo _ 10 �")(� � C it�A� ����W CSA ZX(I 1 e-5 S LA N X t � , eo cacre.:k e. \ a� t 2'-o'' •'�. i ,� �r��� 3 � _��ri����� ���b �� .. _� � � ���� ��� .� F���� _� T �.� �. ��..� f j.: �..� �r /f �� �� L �% �� ''�. '�� j' .. ..........I XF yrgrj 4i --77 1w t Note:Propery Line Dato Token From A Definitive Subdivision Plan P ( O n o fL O n d Campbell Forest, North Andover, Moss. Drawn For TDJ Development Corp. By Andover Consultonts, Inc. Doted December 4, 1991, Revised l n March 12, 1992, And Recorded In The Essex County North Registry Of Deeds As Mon No. 12784. - North Andover, Mass. N/F Scott &Kim Arn S h o w i n g Proposed /n—Ground Pool 334.45' i- WFna _ _ 300 Webster Woods Lane i will -�- _ i i \ Wilds, _=�- Prepared For H°r°"q Ve9°r°tee W'r-°-z-- Pamela & Joel Sita k i War?By others ]blacrse Pr t k Re roposed 18"-24"Sivub the /"WFi1J I (Top 12B) ���`' I \. P�hlerN'ghbush Blueberry ws,o] or Red-osis.mgwaad) Scole: 1" - 20' Dote:May 1, 2008 1 r. Lot 21A Revised•May 21. 2008 N F,rieeiny / ao�eaev rI \ Reviseot June 5. 2008 _ swrn set\ 54,971 S.F. Wd1 061--_ Rebooted \\\(Typ/awf WF WFros� Poposed'moles, Zoning District: Sew Fcred Wth Iter Proposed Crovify ----�---- f \ Fre!° oak Ro 8_.3y w°a Residential District 2 HFl i] 1 i6 I �' t woc°��on I WF raf CB�',1WrJ rWith Fe tp °e tie f (r Top Of War -4 Nota' Poposed Poo/Filler Shah Be A No—Bokash _ 104A '�- tyP-IpJ Crop V ies I19.B-126J "•� Type Filtration System. �\ / \ \ t \\ ps�fe b �.� Note:Oat wn/s USIGS.hterpdoted Post AM sloped -- / \ `ly i—)'�- q - Woods WoaLine j r \\ '�`\y e7'102 jlVf r00 � O Poposed Pea 14, Locus Map (Not ro Soda) 50' No Budd Zme� 126 ` ----` Deck Cry \ Exisring�— \`` - P W°fenre t28 �' \ A�eo Raped �\ Poposed Pergola 138 r __ Existi� �\— \� ° \ Dock Popo,ed Pover /� r >' T B Removed \ e Potio ---_ m 3ti h Mvnc Existing Dwelling P eased \\\ a isrng (TVP.) ` Ga.fMw pev. 127.J' Wakway HBe •e Bald _ Re WW 1 4" c bSe` To main __ Matei �� 100' Welland T� — e e°Ly q° r Huffer Z 3eI 0 Er tng P Pop—ed Gravity La"dOWed I To en Re- b Brock Retaining X36—' Area Rp-Rgn L e e n d NIFF1sotrrc 128 Urm Swaraja & War Hy other, -- 1 G—Ld Loomed 890 Urmi/a Ranjan (4 to M°) M°ter u\ - -{— &seeded a zx (TRP V res 132-130) ].re• e—Z'Lown�nL., 0 \\ \\ \� X Existing Grade / srap Edge Of 101 i-'�-�.r05 top,of war W.%17ds. r' �e srowvd K® rww v�r� gado �Kd) X40. 869,50 p5 2 `fa :d, �yF'Q / 25' No — Uu'Is p f o° Disturb Zone . 1�i0so, NO Sud Zone . 1"s reoakiearror--\ ._ y er' WooQls Bu�er Zeon ----- L e eorram Ehv. Vuies V ' `(e lP�bl c 50' fy.PJ Continuous Row Of Stoked Hoy Soles J--Erlst✓q Gro°° .,.,.. �p Faced With ri7ter Fabric .... ................ sT o p0 0 o c mien Q0 00 �Pe –Morin roFA Ina Cevslvq P°J --�F— �—�\soereor w Fl,d=va.Ne £bigineera�Q S✓reyora GFnmonrn tc1 ConmdraMa-Land ffse Ptarmere Gravity Retaining Wall System aop;Od Bosteeaesad serfs U-1 sto 1 (Unreinforced) g°j°8�B7B6 271Z–NOI PDF created with polFactory trial version vmw.odffactorv.wm • E . i i C 1 + F 1 � I ' J r \ The Commonwealth of Massachusetts Department of Industrial Accidents K i WA, 1 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/Organization/Individual): Address: - 1 City/State/Zip: Gyb V RA CoA a Phone#:—!g 7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I ert ployees(full and/or part-time).* have hired the sub-contractors .6. ,❑ New construction 2 am a sole proprietor or partner- listed on the attached sheet. $ ?. 2 Kemodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We area corporation and its required.] officers have exercised.their 10:❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL l 1.❑ Plumbing repairs or additions myself. [No workers' comp. C. 1,52, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp, insurance required.] 1.3.❑ Other *Any applicant that checks box#t 1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit.ihis of idavil indicating they are doing ail work atUi then him outside contractors must submit anew affidavit indicating such. tContractors 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. Lie.#: LS`7 7 1(- Z Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 15 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. Ido hereby ce;iunderlhepai s and penalties of perjury that the information provided above ' tru and correct Siortature: Date: U G� Phone#: 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 permitto 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 compli etely,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 carryworkers' 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 pennitliieense 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 burn 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 Offiice of Investigations 600 Washington Street Boston, MA 02111 Tel. 4 617-7274300 ext 406 or 1-877-MASSAFE Fax 4 617-727-7749 Revised 5-26=05 www.mass.gov/dia