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HomeMy WebLinkAboutBuilding Permit #636-13 - 32 FOXHILL ROAD 4/1/2013TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: �'�/ Date Received Date Issued: 3 IMPORTANT• Applicant must complete all items on this page d i'PR®PERTtY®WNER_- Rnnt✓ 10.OYear�0ld�Str cu tures' yes nodi MAPNO' PARCEL' 4 ZONING)DISTRICT y _ `Hrs�toncDistnct 4 yes, noa MachmeShopVillage yes no TYPE OF IMPROVEMENT PROPOSED USE Res'dential Non- Residential ❑ New Building Kone family ❑ Addition ❑ Two or more family ❑ Industrial Alteration- No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑;Septics OsWell :' ❑}Floodplam� ®1Netlands, Oj Watershed®istnct }, ❑�1Nater/Sewer, � _ � __ - F .�-- _ — - DESCRIPTION OF WORK TOBE PERFORMED: �`11 tk ;: f t A tt. wo i e"� 1 VNJ Q i� V q Sf J f o Identification Please Type or Print learly) nxNNFR• Name. l^71 ,"n AG / _RI I:.: S'l li`uur\ Phone: 66&_� I �� �- , .� a—, a—.. �'y •� is �`, Y S_ c v lid "$upervisor s C,or struct ons Lieense . �_�'l � ( . Exp 'Date C Z`3 I t �7 Ht 60., rovementLicense Ex _ Date_, i `'� ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost. $ Z � 6i!�_ �� FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistged contractors do not have access t he gpAra* f Plans Submitted ❑ Plans Waived 11 Certified Plot Plan ❑ Stamped Plans ❑ 9 Location /Z 1�ol N b-36 -/3 Z12 o. Date 0. TOWN OF NORTH ANDOVER Z Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee TOTAL $ Check # 26243 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ .. Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc: ❑ Permanent Dumpster on Site ❑ f ! THE FOLLOWING SECTIONS FOR OFFICE USE ONLY _ INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS f CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Com Conservation Decision: Comments -a� Water & Sewer Connection/Driveway Permit DPW Two Engineer: Signature: Located 384 Osgood Street FIRE 'DEPARTMENT - Temp Dumpster on site yes no Located at 124,Main .Street Fire Departerit signature/date ` 4 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 Nu i t5 ana UA I A — wor Oepartment use ® Notified for pickup - Date Doe.Building Permit Revised 2010 Building Department The fohowing 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 appy al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Bui?ding Permit Revised 2012 Enter construction cost for fee cal'- North Andover Fee Calculation Construction Cost $ 24,617.00 m $ - $ 295.40 Plumbing Fee $ 36.93 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 36.93 Total fees collected $ 469.26 32" Fox Hill Road 636-13 on 4/l/2013 Kitchen Remodel From:KNAPP,SCHEINCK& CO INS .6177422832 04/01/2013 13:18 #339 P.002/002 '1 INLAQUA-01 SWHITEHURST CERTIFICATE OF LIABILITY INSURANCE DATE(MM,DD/YYYY)- 1/1712013 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 i BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATEHOLDER, ! - — --- --------- ---- ---....... ..... .... - ---- --- - ._._......._....... __......-- -- -- -----' - --- - ---- - --- -----..__I IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) 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 CONTACT�- NAME: rKnapp, Schenck & Company Insurance Agency, Inc. I -PHONE 617 742-3366 1 FAX '137 Lewis Wharf lac Nu E.%� -_ ).--4--------------------(ac, Nor (617) 742-2832 Boston, MA 02110 i E-MAIL - ,_ADDRESS; — _ INSURER(S) AFFORDING COVERAGE NAIC p INSURER A: Endurance American Specialty Ins CO —.------.._ .............. -------- ' INSURED .,__.__----------------------------._.._....._._....._ t„Inland Quality Builders, LCC 28 Meadow Lane Westford, MA 01886 COVERAGES CERTIFICATE NUMBER: _ REVISION NUMBER: I THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY. PERIOD i INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS i 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. WSR AOOL?SIIBR'- ----_----------- -...----- --_--.'----............—,.._...-.__._.__._...._..__._.__....... I _TYPE OF INSURANCE -- _- INS -ID; _ -- POLICY NUMBERMWDDMfYY MM _---� -----) �.(--.-lDD/YYW)--------------_--- LIMITS � I GENERAL LIABILITY � 1 I ' ` OCCURRENCE EACH E RR E .-..-----� $-..___..._....._--.__._.__-- A - 1,000,000.; A I X COMMERCIAL GENERAL L 9/1/2012 9/1/2013 ' _ IABILITY s ICBC10001218100 PDA 6a y6I ER ED --------'-` } PREMISES.. Ea occu rents S 100,000' CLAIMS -MADE rX OCCUR I ! _.._.�...._.__ _J i t MERD EXP (Any one person) _ $---_ 5,000, _ I PE SONAL & ADV INJURY_ ... ,,., ... 1,000,0001 — - - ----- __! $ _ _ ' 1 GENERAL AGGREGATE 2,000,00_0 GEN'L AGGREGATE LIMIT APPLIES PER:'PRODUCTS - COMPIOP AGG ' S M. 1-------�- POr- �^ ------ i--'----------------------------'-- ---._. - - - --- - .i-._$..__.._..__...._-1-,0_0._0.__,0. _0_.-0_j1 PRO- LICY' LOC --..........- I ...... AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I ANY AUTO BODILY INJURY (Per person) S -i ALL OWNED I SCHEDULED -- ... ............_._..-------- - ...--.....-------' _-. AUTOSBODILY INJURY AUTOS (Per accident)]$ 1 _._.._..._._._._____C._.._....._.._..( . ............... ._.__ _.. :HIRED AUTOS NON -OWNED IPROPER7Y dAM�` '" _-_ .._.... AUTOS _. PER ACCIDENT i __- ' � UMBRELLA LIAB i�-j--.............---— ------- .----- +---- i OCCUR (EXCESS UAB EACH OCCURRENCE CLAIMS -MADE; y._-....__-...__..._._.__.._._.._._-! AGGREGATE .� _DED I,� RETENTION $ _L.. ........ ..-_ I ! I ' S �_- i WORKERS COMPENSATION WC STATU-OTH-' AND EMPLOYERS' LIABILITY YIN I _ TORY_LIM_ITS 1 I �R ! ANY PROPRIETOR/PARTNER/EXECUTIVE (` E.L. EACH ACCIDENT 1 S I OFFICER/MEMBER EXCLUDED? ' N / A (Mandatory in NH) If yes, describe under ! I ' E.L. DISEASE _-_E_AE_MPLO_ EMPLOYEE! S DESCRIPTION OF OPERATIONS below 1 ---------_ - - ...................-..__._ E.L. DISEASE - POLICY LIMIT S .._._...._..- — '---- ----- ._ .. I ! DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Workers Compensation coverage is active and in good standing. A Certificate of Insurance will come directly from the carrier. TE HOLDER Town of North Andover, Building Department 1600 Osgood Street North Andover, MA 01845 CANCELLA 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 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD H W 2 LL.0 D O m .00 O LL LL E a0+ >- N O_ N cr O H Z OZ Z m O ra 7 LCL 0 K ? 41 :EO U C cc O WLLJ d Z J d bo O K C LL �. O U H Z J V W J LU O 41 u 6�1 N LL w O LLI a H Z H L O d' C LL C G d LLI a LLI LL � O 7 CO z O �.:i N N N Y N two o _ 2 �r CL ar mQ o O o S . � I � V 0• • � � � W Z 1E cm � o.= N�O� P ; o L v•3 QJ E N N An cc O = Qi > \\ _ •a O O U) ' :!.! O E 4' CL U) tm c• r . a d .c s m 1 PCNL m 0 ® ; 8 = _ 1 Q .oCD 0 Q' m '� N F•- O N V m CD CO LU W C 'o +t-' 0, _ O LL 2 e N C O N YO •� Z 'E V -0 r v O • V m O -a � ,•,,, Q �1 CO) to ` m .p - O O F-1 H t 0 J- rLo V > Q GW,. Z CD 00 O cfl0 Z U W W F— , CL Cl) w0 � U ti W LLJ —i m Z 07 •N N w N f Inland Quality Builders 28 meadow Lu Westford, MA 01886 Phone # 617-839-2659 Proposal For: Name / Address Amanda & Billy Sullivan 32 Fox hill Rd North Andover, MA 01845 °<F k INLAND QUALITY BUILDERS LLC GENERAL CONTRACTOR NEW CONSTRUCTION / REMODELING 1vw.L1l�uadQ.ualityl3uilders.com Description IQB proposes the following scope of work listed below: Date Estimate # 1/7/2013 344 Dail@hiluidQualityBuilders.com Project Kitchen diswasher 1... Laundry Room. Plumbing, IQB will disconnect and move stackable laundry unit into the garage and reconnect after floor is fixed. Plumbing, IQB will disconnect toilet and reset. ( IQB Did not carry disconnecting the vanity and replacing, not sure if subfloor is damage that far over. IQB will determine at the time the subfloor is exposed.) IQB to remove bifold doors in laundry room and also the door to the kitchen. IQB will also reinstall the doors when project is completed. IQB will demo all baseboard and door casing in laundry room to allow access to take up existing slate tile, 1/4" cement board and 1/2" plywood to allow access to subfloor. IQB will do all the demoing in the bathroom and laundry + closest and dispose into dumpster that will be located on job site. IQB will supply new 1/4" cement board over the new subfloor in the bathroom and laundry room that is 97 sq ft. IQB will also install and grout new 12 x 12 slate tile in the bathroom and laundry room. Material IQB will supply new 12x12 slate tile and grout. IQB will carry 115 sq ft of slate tile. IQB will install supply new baseboard in laundry room and also install and supply casing on bathroom door, laundry room bifold, kitchen door, garage door and exterior door. IQB will supply casing and labor to install it. Painting, IQB will paint all trim and doors with one coat on the old trim and two coats on the new baseboard and casing in the laundry room. IQB will paint and patch walls where needed with one coat on walls and two coats on patches. IQB will supply all paint and labor. Kitchen / Living room floors: IQB will demo and rip up kitchen and living room hardwood floors due to leaking dishwasher. IQB will rip up around 570 sq ft of hardwood flooring and dispose into dumpster that will be located on jobsite. Also remove quarter round around the entire floor. IQB will install 570 sq ft of 3 1/4" century prefinish red oak with a stain. IQB will supply and install wood. Thank you for giving IQB the opportunity to provide this quote for you! I Total This proposal expires one month from the date written All work is warranted for materials and labor for a minimum of one year. This proposal is valid for one month from the date above. The total listed above is the total cost of your project as outlined above. Change Orders will be written for all changes in the scope of the work. Each change order must be approved by you before work begins. Payment for all change orders is expected at the time they are signed.If this proposal is accepted please sign one copy and return it to Inland Quality Builders. We also understand that Inland Quality Builders reserves the right to delay completion of the work for nonpayment of any invoices. Signature below acknowledges receipt of two Rights of Rescission forms included L..,___. Signature nate / /2012 Customer Signature nate / /2012 hdand Quality Builders Represenitive Page 1 Inland Quality Builders 28 meadow U Westford, MA 01886 Phone # 617-839-2659 Proposal For: Name / Address Amanda & Billy Sullivan 32 Fox hill Rd North Andover, MA 01845 a S � t M �. 'Z YL Y � • l : . � GENERAL CONTRACTOR NEW CONSTRUCTION / REMODELING ���'r1v.Llhuid(Zualilyl3uilde�s.com Date Estimate # 1/7/2013 344 Daii@lia-,UidQuality]3ader,s.com Project Kitchen diswasher 1... Description IQB will install and supply new quarter round where hardwood floors is going. IQB will supply material and labor. Painting, IQB will paint all baseboard in living room and kitchen after floors are installed. IQB will supply paint and labor. Kitchen: IQB will remove Refrigerator into the dining and also remove the dishwasher into the dinning room. IQB will also reconnect. Plumbing, IQB will remove kitchen faucet and sink and reconnect, to allow the granite to be removed. Electrical, IQB will disconnect dishwasher and reconnect. IQB to also disconnect electrical plates to outlets and swishes and reinstall after tile back splash is completed IQB to remove 3x3 slate tile back splash in the kitchen that is 20 sq ft. IQB will install new board to except the tile backsplash, and install tile and grout. IQB is removing backsplash to allow for granite removal. Material, Tile and grout for backsplash. 3x3 slate tile + grout. 20 sq ft of kitchen granite counter tops in order to replaces lazy susan and end cabinet due to water damage. IQB will remove and replace granite with two seems. Cabinets, IQB to remove and replace corner lazy susan next to the left of the dishwasher and also remove the cabinet to the right of the dishwasher. IQB will remove due to water damage, IQB to supply new lazy susan primed with maple construction and new 24" single door and draw base cabinet with finish end panel, primed with maple construction. IQB will also supply new toekick for the cabinets. Painting, IQB will paint all kitchen cabinets that connect to these base cabinets to create a consistent look. IQB will apply two coats of benjamin moore oil paint to the base and upper cabinets. IQB will supply labor and paint. Miscellaneous items: Moving items in eat in kitchen and living room and storing in the play area. IQB will also put back furniture after floors are complete. Thank you for giving IQB the opportunity to provide this quote for you! I Tota This proposal expires one month from the date written All work is warranted for materials and labor for a minimum of one year. This proposal is valid for one month from the date above. The total listed above is the total cost of your project as outlined above. Change Orders will be written for all changes in the scope of the work. Each change order must be approved by you before work begins. Payment for all change orders is expected at the time they are signed.If this proposal is accepted please sign one copy and return it to Inland Quality Builders. We also understand that Inland Quality Builders reserves the right to delay completion of the work for nonpayment of any invoices. Signature below acknowledges receipt of two Rights of Rescission forms included L..1..... Signature Signature /2012 Customer /2012 Inland Quality Builders Represenitive Page 2 lnta.nd Quality Builders Date Estimate # µms' 28 meadow Ln k INLAND Westford, MA 01886 �, ��� 1/7/2013 344 �QUALITY � 1LDF GENERAL CONTRACTOR Phone 617-839-2659 Dan@InlandQualityBuilders.com # � , 1 R � t..; Proposal For: Name I Address Amanda & Billy Sullivan 32 Fox hill Rd North Andover, MA 01845 Project Kitchen diswasher 1... Description I Total IQB included 10% for overhead and 10% profit in each line item. Payment: Deposit $ 7000.00 I st payment $ when demoing complete. $ 7000.00 2nd payment when hardwood floors are completed. $ 7000.00 3rd Payment completion of job. $ 3616.94 i I Thank you for giving IQB the opportunity to provide this quote for you! I Total $24,616.94 This proposal expires one month from the date written All work is warranted for materials and labor for a minimum of one year. This proposal is valid for one month from the date above. The total listed above is the total cost of your project as outlined above. Change Orders will be written for all changes in the scope of the work. Each change order mustbe approved by you before work begins. Payment for all change orders is expected at the time they are signed.If this proposal is accepted please sign one copy and return it to Inland Quality Builders. We also understand that Inland Quality Builders reserves the right to delay completion of the work for npayment of any invoices. Signature below acknowledges receipt of two Rights of Rescission forms included 1...,-- Signature"1613 ate a / JQ /;i Customer Signature bate / /2012 inland Quality Builders Represenitive The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Uf www.massgov/dia ffnQnranVP. Affidavit: Builders/Contractors/Electricians/Plumbers Address:_ a LU J City/State/Zip:42Phone-k,5 Ar ou an employer? Check the appropriate bog: 1. [0I am a employer with 1— 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors listed on the attached sheet.These 2. ❑ I am a sole proprietor or partner- sub -contractors have ship and'have no employees working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their required.] 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. r c. 152, § 1(4), and we have no employees. [No workers' insurance required.] comp. insurance required.] Type of project (required): 6. ❑ New construction 7. Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.E] Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T-1 Homeowners who submit this affidavit indicating they a're 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: G e, �' U`J Policy # or Self -ins. Lic. #: 5 o° Expiration Date: Job Site Address: ��- �r`i i City/State/Zip: Pv& Wver., olicy declaration page (showing the policy number and expiration date). Attach a copy of the workers' compensation p Failure to secure coverage as requiredunder 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 the information provided above is true and correct. n+A• L,(-%-1_� 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. PIumbing Inspector 6. Other Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be. deemed to be an: employer." MGL chapter 152, .§25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to 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 4 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 the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. AIso 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 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: Tho Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street Boston, MA, 02111 Tei, # 617-72.7-4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax # 617-727-7749 www.mass,gov/clia r Department of Public Safm Board of BuildingRe�-ulations and Standards Construction Supervisor License License: CS 94579 DANIEL J MCGONIGLE 28 MEADOW LANE WESTFORD, MA 01886 c -- J Expiration: 10/23/2013 ( nmri..i ncr Tr#: 6831 c Office of Consumer Affairs & Bsidess Regulation �elf — OME IMPROVEMENT CONTRACTOR egistration: 167038 Type: xpiration:.:8/2/201`4 DBA g _ INLA QUALITY BUILDERS DANIEL MCGONIGLE° 69 ARNOLD AVE. g v� LOWELL, MA 01852 Undersecretary