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Home My WebLink AboutBuilding Permit #558 - 32 HARKAWAY ROAD 2/7/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: J` Date Received Date Issued.. 13 IMPORTANT: Applicant must complete all items on this page =ATION 3 t `�n .wry_7 C� /� 1It�'lO Rdnt. PRQR TkY'QWNER % Print 100•Year�oid,Structure ye n MAP-'NO:- PARCEL•-: ZONING'DISTRICT: Nistoric�pistrict yes n Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition XTwo or more family ❑ Industrial, ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑rSeptic, o.WeII = ❑ Floodplain ❑Wetlands. ❑ Watershed District 11 Water/Sewer _ DESCRIPTION OF WORK TO BE PERFORMED: l�niycfo/ _.�h��_�_k'�:�o�" ani/ ��,�� e'�Y cv�:// , a�j�v� �✓o �:tr�C�it�.-- ei�V)'j a At,/ 114A(�r.'ar C/1141- Identification /darIdentification Please Type or Print Clearly) OWNER: Name: ;7U/q,'v l rpm 2 Phone: 9'15x, Address: 3,;L ty��v/�Y �l� ,g 1iL 'op z ONTRACT0R .Name: ,vim 6) Phone: 9 7k -7-7 y1 n/ Address: &61 9 UL% J/ Gtr , '/r1 0/-0 StaperVisor�s;;Construction License:�'S' p S 3� Exp. `Date:,1'2- 2-l� -HbMpe!,mprovement,License A//5-5-9,2 Exp. Date` ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASEp•QN$W.00 PER S.F. Total Project Cost: $ FEE: Check No.: Receipt No.: d `1 NOTE: Persons contracti ith unregis+cactors do not have access to the guarantyfund SignatureofAgent/Owner,. ure of contracto�:.Plans Submitted ❑ Plans Waived d Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zonin,j 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 TowL Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster onsite yes no Located at:�l24 Main Street _ . Fire Departinent 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 leo MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use El Notified for pickup - Date Doc.Building Permit Revised 2010 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 o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o 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 o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products (VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application o Certified Proposed Plot Plan o 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 o Mass check Energy Compliance Report o 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 subm;tted with the building application Doc: Doc.Buil,iing Permit Revised 2012 Location 2 �i✓ No. � 13 Date • ' TOWN OF NORTH ANDOVER s s . Certificate of Occupancy $ g Building/Frame Permit Fee $CQ =� r Foundation Permit Fee $' , 4' Other Permit Fee TOTAL Check# l 26143 Building Inspector Enter construction cost for fee cal - North Andover Fee Caladat/on Construction Cost $ 17,675.00 m $ - $ 212.10 Plumbing Fee $ 26.51 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 26.51 Total fees collected $ 365.13 32 Harkaway Road 558-13 on 2/7/2013 Remodel Bathroom, Remove and Apply Drywall, Replace 2 exterior doors and 2 interior doors, and 2 windows F NORTH Town of :,TAndover O .``l. '1 to No. hver, Mass, ' 3 �� COC NIC Nl WWN V1. ADR�TED PP� S s � BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System C, . . .THIS CERTIFIES THAT ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, BUILDING INSPECTOR has permission to t ..... ................. ,,,� �i�,lt� Foundation p e . .. .. .. ....buildings on .f ,. • Rough to be occupied as ... � 'l Lrkt-A%lfI.AftAChimney provided that the erson acce tin this ermit shall i�everY res ect conform to the termsoApplication Final on file in 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU STA Rough ugh ' rvice ............ .. .... .........................................y.r Final -------6UILsD1R INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. SEE REVERSE SIDE ATTIC- • Remove Insulation baseboard - $125.00 • Seal whole attic wood&framing for odor control 640 $$150.00-$200.00 • Install new Insulation $870.00-$100.00 • Install two light bulbs on attic corners from existing electric drop $25.00 Total ATTIC$1,470.00 GENERAL • Dumpster located at 34 Harkaway Rd is sharable among parties • Permit $800.00 TOTAL GENERAL$800. TOTAL ITEMS ABOVE $6,784.42 TOTAL CONTRACT AMOUNT $17,675.02 Time Frames: Work will start on Thursday February 7 2013 and It will end on March 7,2013 All related repairs,replacements or additions must meet all local,state and building codes. A copy of General Contractor License, Insurance,Liability Insurance and Workman Comp, Including Licenses,Liability Insurance and Workman Comp of all subcontractors must be provided. An initial payment of$5,000.00 is due to start work on the day of contract signing. (Phase 1). A second payment of$4,000.00 shall be received when Bathroom&Kitchen work are successfully completed and inspected by town inspector. Phase 2 of construction. A Third payment of$3,000.00 shall be received when the project is successfully completed and inspected by town inspector. Also Appropriate billing format must be provided for insurance purposes. Details to be submitted by Mr.Juan C. Lopez. A Final payment of$5,675.00 will be received when Mr. Juan C. Lopez receives the depreciation monies from the Insurance company. This document and the above details are agreed upon by Pagan Contracting Inc and Mr.Juan C. Lopez. This document will be used as a binding contract between the parties. Customer Signature (� ^'' g February 5 2013 Contractor Signature February 5 2013 Page 3 of 3 PROPOSAL PAGAN CONTRACTING INC 91A Market ST Lawrence, MA 01843 (978)697-4363 cvcpito@verizon.net Customer Name: Juan C.Lopez Property Address: 32 Harkaway Rd,North Andover,MA 01845 Contract Type: Renovations to Fire Damaged Home Residential: Multi Family Residence Contract Date: February 4,2013 Scope of Services-32 Harkaway Rd, North Andover,MA 01845 1sT FLOOR-LEFT ENTRY • Remove and replace 1 exterior metal door unit-$188.00-$175.00 • Remove and replace 1 exterior door casing 2%"-34 $188.00-$175.00 • Install 1 new exterior door lockset&deadbolt-$139.00 • Install 1 exterior storm door-$249.00-$75.00 TOTAL LEFT ENTRY=$1,189.00 KITCHEN • Remove and replace''/:"drywall-hung,tape smooth finish-118.75 sf $100.00- $500.00 • Remove old, replace with new and suspended ceiling-201.48 sf $180.19 -$700.00 • Remove and replace all room baseboard $98.31-$75.00 • Pluming $100.00-$200.00 TOTAL KITCHEN=$1,962.50 LIVING/DINING ROOM/CLOSET • Remove and replace drywall wall(next to stairs)-approx 240 sf $143.01-$1,000.00 • Replace pine base 1"x 6"-approx 33 -materials and labor In ft$20.13-$40.00 • Remove and replace 1 interior door unit$76.00-$100.00 • Remove and replace casing/door trim-$29.84-$100.00 • Replace interior door know-$9.97 • Remove and replace all room baseboard -$263.26 - $125.00 Remove and replace front door$299.00-$175.00 Remove and replace screen door$249.00-$75.00 Install new door lock$139.00 TOTAL LIVING ROOM$2,844.21 STAIR TO BASEMENT/BASEMENT • Replace wood floor fir-sand and finished-approx 9 sf-materials&labor per sq ft • Furring strip 32.15 sf= Page 1 of 3 • Remove and replace 2 coat plaster over r4"gypsum core blue board 87 sf= • Seal the surface area with latex based stain blocker TOTAL BASEMENT STAIRS$ 2nd FLOOR-CENTER HALL/CLOSET(inside) • Remove and replace%"drywall 278.32 sf$150.00-$250.00 TOTAL HALLWAY$400.00 2n'FLOOR-FRONT BEDROOM AND CLOSET • Replace 1 double hung vinyl clad window unit that is boarded $220.00-$150.00 • Remove and replace%"drywall,hung,taped smooth finish-103.32 sf $85.00-$300.00 • Remove and replace all room baseboard-14 If $261.97 -$125.00 TOTAL FRONT BEDROOM$1,141.97 2nd FLOOR-BATHROOM • 5/8"drywall-hung,taped with smooth wall finish 46.25 sf $49.05-$225.00 • Remove tear out vinyl&underlayment 46.25 sf $100.00 • Underlayment X"hardboard 46.25 sf $64.74 • Vinyl floor or the 46.25 sf $73.54 • Fiberglass tub&shower combination $488.00 • Shower faucet $165.00 • Bathroom vent/exhaust out $18.46 • Window trim set-casing and stop $25.44-$50.00 • Window sill 3 $41.61-$50.00 • Plumbing $300.00-$2,800.00 • Remove and replace Baseboard $71.36-$75.00 TOTAL BATHROOM$4,547.20 2nd FLOOR-MIDDLE BEDROOM/CLOSET • Scrape ceiling 2 coats 486.50 sf $124.94-$600.00 • Quote: Replace entire ceiling$ 148.19-$700.00 • Remove and replace all room baseboard $223.08-$125.00 TOTAL MIDDLE BEDROOM/CLOSET$1,196.57 2nd FLOOR-REAR BEDROOM/CLOSET • Remove and replace all room baseboard $223.08-$125.00 • Fix ceiling area near window • Remove and replace ceiling $148.19 -$700.00 TOTAL REAR BEDROOM/CLOSET$1,196.57 BASEMENT • Remove and replace one vinyl hopper windows $102.00 -150.00 • Install handrail round/oval wall mounted 12 If$-approved as code issue on insurance paperwork. $75.00 • Build stairs $300.00-$300.00 TOTAL BASEMENT$927.00 Page 2 of 3 Ira � COMMON POUCY DECLARATIONS Policy No. Renewal of Number R PKG E 002435-03 R PKG E 002435-02 INSURANCE IS PROVIDED BY ROCKHILL INSURANCE COMPANY Named Insured and Mailing Address qty KANSAS CITY,MISSOURI i _ Leocadio.Paulin dba L. A. Construction SUrpleX Underwriters Inc ' 41 Bourque Street PO Sox 6070 Lawrence, MA 01843 Warwick.RI 02887 i PodoY = From Til 28 2012 To Aril 28 2 013 12:01 A.M.Standard Time at your Malling address shown above. s otherwise Endorsed Business Lead-based paint abatement contracting(including the removal&replacement of windows&doors,only if 0" performed in con unction with lead-based Paint abatement contracting) Form of individual Business: IN RETURN FOR THE PAYMENT OF THE PREMIUM.AND SUBJECT TO ALL OF THE TERMS OF THIS POLICY.WE AGREE WITH YOU TO PROVIDE THE INSURANCE STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. COVERAGE PART LIMITS OF INSURANCE COVERAGE PART(FORM NUMBER) Commercial General Liability Coverage CG 00 01 12 04 General Aggregate Limit $1.000,000.00 Products-Completed Operations Aggregate Limit: $1,000,000.00 Personal and Advertising Injury Limit: $1,000.000.00 Any one person or organization Each Occurrence Limit: $1.000,000.00 Damages to Premises Rented to You Limit $ 50,000.00 Any one premises Medical Expense Limit: lens $ 5.000:00 Any one person Contractors Pollution Liability Coverage-occurrence RH1C 6201 1111 Aggregate Limit., $1,000,000.00 Each Pollution Condition limit: $1,000,000.00 S x7 PREMIUM 2,750.00 (25 96 MINIMUM EARNED PREMIUM) 688.00 TERRORISM(IF PURCHASED IS 100%MINIMUM EARNED) N/A Premium shown is payable: at inception TOTAL MINIMUM&DEPOSIT PREMIUM 2,750.00 Additional Form(s)and Endorsement(s)that are made a part of this policy at time of issue and that add,change,exclude or limit coverage are listed below. 'owls aoo acre Forms end Ertlasameds nsbwn in apeHlfe Coverage PWVCo amgs Fano Dadmsrons. Date of Issue 5RB 5/28/12 couMerslgned < !' THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS,COVERAGE PART DELI=WS COVERAGE PART COVERAGE FORMS)AND FORMS AND ENDORSEMENTS,IF ANY,ISSUED TO FORM A PART THEREOF,COMPLETE THE ABOVE-NUMBERED POLICY. RHIC 6000(BHI) Includes copyrighted material of insurance Services Office,Inc. Page 1 of 2 with its permission RightFax C3-2 5/10/2012 9:12:47 AM PAGE 3/003 Fax Server t�sslZ DATE S�IO012 TM CERMCATEISffiSQED ASAMATTEROF RiF'ORMATIONOIILY AND COMMS NORIGBTS IIlONInfMC IrICATSBOLDER.T= CERTRICATEDOES NO?AFFiRMAIMMYORIiB"2MMV APM 06EXTEND OR ALTER T!$COVERAGEAFFORDBD BYTBSPOUCMS MOW.THIS CERIMCATE OF INSURANCE DOES NOT CONSTIOMMACONTRACT M mEII TBS ffiSmcnlSURBf,ADTIWRMD RI SEI. t'WOWIOR PRODUCER.AND TBECBlT1FICATEBDWBR. WOItTAWT,-Ifft aMftaft holder Is MAMMAL MAL Ow Ptd}must be endorset tf t3UBROCsATm IS WAwm sub w to" terms and csiMmrs of ft td►.mtM 1 oldis nW=*ftan mwimann rlt.A stMKM t antIfteotilleft does not confer lulls to the Cartfllcate holler in feu of such endo umw t(s PRODUCER CONTACT T A SULLIVAN AGENCY INC PHONE 344 SO UNION STREET FAx LAWRENCE,MA 01843 E AM �> ADDR�;s- PIW000ER alsToMERIOW MURSD 4MEMAYFORDEW COVERAGE NAIC# LA CONMUC7TON LLC 11�i1RF.R ACE AMERICAN MURANIM COMPANY 41 BOURQUE ST B: LAWRENCE,MA 01841 itU73RitR DISURER D II�[HtHtt S ENStNM F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER. TWisTOCMUrVMMTMMPOUCBSSOFRiSi1RAMCBIZ WMDWBAVEBEPNtS50PDTOTBEPOMMMUMABOVEFMMMPOV=pzRmDmwAim NoTwnmSTA!R)MMYPJ QUMrMMfr,TMUORCONDnwNOFANYCONTRACr=OTHBRDOCUh(WI'VII$R8sFEf7Towwwn St�t3IrWAMMAYBE D►`90FAORMAYPERTMKTHEBOURANCEAFPORDEDBYMMPOIRMDEQBH MISSOMWFTOMLMM1ERWZKCLM Ig ANDCONNUOMOFSUCR POL MS.Id0MOWWNMAYBAYEBIff RWOMBYPAWMADEL DMR TYPE OFRGURANCE AM StZtiY PCffJMNe1lMM POuCYEFF POL7cvmip LATA I78 IY Di6E VMD CENERALLL49M £ACSOOCURMCE I ❑Co1+II�EC(N,oEt768ALLiAB1u1T .DAIdALfETOYD,RtFD I PREl1=Oak o�e�ee 0 CLMAMMK ❑ OCCUR MID F7@t2L45f/lo m S 0 Pmsowu.aA»v i IIiIURT 0 GDMtALAOGMMM f GQi'L AGGRboA7ELAQrAPPL1E8PEE: Q mucT Orxomcr 0 t= s AM ADTOMOEM LTARMLM COUMMO ME f LDip' 0 MTAVPo SODII.TBOOAT ; 0 ALLOYPNFDAD3o8 BODBrYkIIURY f 0 SCHEDMEDAUM RWPMTDMUM f 0 BOEDAUM s 0 Now owm m ms f 0 0 GMUMALUS 000WR EMMOCCe12BFNfE s 0 EMMLIM 0 CLABM.MADE AoazseaATE f 0 t 0 REIan=s s WORKERS,COIIDGQ ulba T � A ANDEMPLOYERSLUMUTV WA l8A 11ORY Y!N Ulm Alit PROPRMT+OMAiaNW Ela VrOMMUMSER Y MA MUMS= 05/02/2012 L100,000 aaaanIDl ( — (MAIIDKL+DRYIIP1tEA D'yes,des�a-=A rDEMPTSONOF - Y1s16 s100,000 oPPRATiMbdw 6500000 DIWwOFOpM7WxwAcMToxwVzmcmGiQedtA00RD 101.AdBroodReeMls �EoptesgxsirrpeeD CODE947 I CARPEMMY ADELEADW Zi�BhFtJICFS�YPRmBC�CIOEII1Et�10ffij7SH�D� IyOE��ODVBRAGE DIVISION OF OCCMA77ONAL$SAFBPY CHARLES FHUSLEYBUILDING BHO"AMOFTNEABOMEOmmmmEopOLjCWqECANCEUM8EFM 19 SPANIFORD ST FI-2 TNM MWIIIATiCII DATR HEREOF.NOTICE WAL BE DMAWW III BOSTON MA 02114 ACCORDANCacrNTtl THE POLICY pROVMION& 8r°awl�taclea�v � , The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 ,. www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers !, Applicant Information / Please Print Legibly Name(Business/Organization/Individual): Address: lt City/State/Zip: L n w,/y/ ja kre you an employer?Check the appropriate box: Type of project(required): ZI am a employer with 4. ❑ I am a general contractor and I 6 ❑New construction employees(full and/or part-time).* have hired the sub-contractors EJ I am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling 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 are a corporation and its required.] officers have exercised their 10F1 Electrical repairs or additions ❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing 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.] 1311 Other ty applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. )meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. W urn employer that is providing workers'compensation insurance for my employees. Below is the policy anti job site irmation. urance Company Name: icy#or Self-ins.Lid.#: Expiration Date: Site Address. 111PI /,e,/7 /tCity/State/Zip: ach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 tp to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of �stigations of the DIA for insurance coverage verification. hereby cer uncler the pains and penalties ofperjury that the information provided above is true and correct. iature: Date: ne#: ?fficial use only. Do not write in this area to be completed by c4 or town official :ity or Town: Permit/License# ssuing Authority(circle one): .Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Other '.nntart Pnrenn• Phnnr#! 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 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, Tease do not hesitate to give us a call. he Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1.877-MASSAFE Rax:g 617,797,774.9 '. TPE COMMONWEALTH OF MASSACHUSETTS . ITT Exocm=Oo=oFLAsmAmDWoRxpuKmDv4ELamaNT DEPA OF TABOR STANDARDS 19-STMMMWSMWBWTOMMASSACRMM02114 DE MCONTRALTORMC W •LA OONMRUMON CO: 41 BOURQUE ST -1AWRENM MA 01843 LICENSIL-W 01838 SES: y;Nsg25,- VDAMWnweem ` �after_ j • . : 4 LHOcAnI®Pauulbo Eif_Hate OSMSM2 . IJOCA D16 PAUI N D , 6gxada Aa B/t3 i 41 tl9QD1a97 LA1IC Rl 01843 Cc4NE&T.~ . sosroN.�ry eta . � �s. �iN3N4.'Iff�tdl�Q�a lff!.frCIC.lfC1�S�Y� • - .•.--��05 � � t�tAECS�CL'3�Iil255 RC�Y3IQ4tOD . HOrHE FLIPROVEMB T CONTRACMR Reglstmffon: 145522 Type: - : t•: Expittnon: 2/3/2013 Individual L bCADIO PAUUNO - r IEOCADIO PAUUNO .41 WVkGUIe S r UWRR ICE,WIA-01843 Usd ry