Loading...
HomeMy WebLinkAboutBuilding Permit #739-15 - 328 MAIN STREET 3/28/2015ORT �N Nq BUILDING PERMIT 3? TOWN OF NORTH ANDOVER ° t APPLICATION FOR PLAN EXAMINATION Permit NO:Date Received;o4� Date Issued: ANT: Applicant must complete all items on this LOCATION 328 Main St Print PROPERTY OWNER Eugene Beliveau & Maryann Beliveau Print MAP NO:43/0035 PARCEL: 210 ZONING DISTRICT: R4 Historic District yes' no Machine Shop Villaae ves no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building R One family ❑ Addition ❑ Two or more family ❑ Industrial [Alteration No. of units: ❑ Commercial ® Repair, replacement ❑ Assessory Bldg ❑ Others: l� Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer Repair structure from recent tree damage. Remove roof and wall down to sub -floor. Rebuild to existing footprint. Open wall to kitchen. Replace floor in kitchen. Supplement --- Remove and replace existing kitchen cabinets. Relocate dishwasher. Move sink. OWNER: Name Address Identification Please Type or Print Clearly) Eugene & Maryann Beliveau Phone: 978-828-4393 .17R NAnin Rt Nnrth Anrinvor NAn CONTRACTOR Name: Restoration Management, LLC Phone: 603-264-1127 Address: 100 Carl Dr, Unit 11 B Manchester, NH Supervisor's Construction License: Exp. Date:, cs-106038 9/26/2015 Home Improvement License: Exp. Date:'] ARCHITECT/ENGINEER Team Engineering Phone: 603-497-3137 Address: 67B North Mast St, Goffstown, NH Reg. No. FEE SCHEDULE: BOLDING PERMIT: $1200 PER $1000.00 OF THE TOTAL ESTIMATED COST2ASED ON $125.00 PER S.F. Total Project Cost: $ 31,115.59 FEE: $ Check No.: IQ Z, Receipt No.: NOTE: Persons colnfycting with unregistered contractors do not have ac t e ant fu d ,0r i, y Signature of Agent/Owner Signature of c- - -acto_ BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received Date Issued: I k IMPORTANT: Applicant must complete all items on this -page LOCATION Print_ - PROPERTY OWNER Pririf 100 Year Structure yes no MAP PARCEL:---,,, he ZONING. DISTRICT: _ _ Historic District yes no __..__ Machine Shop Village .yes no 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 ❑ Others: ❑ Demolition ❑ Other Septic ❑'Well ❑ Floodplain ❑ Wetlands ❑ Watershed :District El Water/Sewer UtSGKIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: Phone: Address: 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 Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund f —r Plans Submitted ❑ x Plans Waived ❑ Certified Plo- TYPF° F 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 PLANNING & DEVELOPMENT Reviewed On Signature, COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed on Signature Reviewed on Signature ` Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes 6 ' s� Planning Board Decision: Conservation Decision: Commen Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp pumpster bhl site yes a no_� _. Located, at 124. Main Street - r COMMENTS Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use ❑ Notified for pickup Call Emai Date Time Doc.Building Permit Revised 2014 Contact Name No I 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 a Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit u Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (if Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 `t' I Location 3lin No. Date v Check # 29�� TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL 0 r 5 Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost C $ 31,1P 115.00 m $ - $ 373.38 Plumbing Fee $ 46.67 Gas Fee 100 comm. $� 10,0'.001 Electrical Fee $ 46.67 Total fees collected $ 566.73 328 Main Street Kitchen Remodel 739-15 on 3/26/2015 N C � � � Q � O CD Z CLr-�• su o *b C 70 CL N 0 Om ��su z� < 0 CD Z -q (Do zX CL C Cl) cr Q. 0 — �G _ CD --IZ 0 CD. o O Z CD ca a O CD Z CL 0c.rz D tD 0.U) b Cl) CD ;t cn O m Z c 0 z O CD Z < n CD O 0 0 •D -I c p.. CD O m O rtrtp'C7 Z p O U) rpt CD N 'rl -h =S N nCD N p SD CD 0 CD tin CD D O n —I (Q• N Q rr O O � W ' " = CD TD CL O O S' * < (O CD O 0• N `A (O N p oCD O a O DCD Uriv o= R �Q CD NCCD CDrM U) 0C C ni C � ONS y O 0b , R Ax CD fir. � F * '{ • � CD xle CDD �S s n N o0 v M h C CD @ o 91) ci 0 o CL Ln 3 O M M Mm V)W q — Z O C � m T7o S. O �- T 7' Or Ln O < !� ro X O �C S T N x O C T 61 S m O C S O C Q •+ m "6 f7 N < O O \ n = m v rn y m N z A O m D (A cmm 0 C Z cn mm'1 �O j C o z L m O 3 S : W > D O m 2 s �I 0 c PROPOSAL: Submitted To: Mary Beliveau RESTORATION MANAGEMENT, LLC 100 Carl Dr, Unit 1.1B Manchester, NH 03103 OFFICE: 603-413-5883 / 888-743-0245 FAX: 603-379-3323 Project Location: 328 Main St North Andover MA Prepared By: Tom Kaloyanides Restoration Management, LLC 100 Carl Dr, Unit 11B Manchester, NH 03103 603-264-1127(m) 603-782-0766(o) 603-379-3323 (f) tkaloyanides@rm-nh.com March 25, 2015 Attached is a revised estimate that reflects recent changes and additions from the original. Changes include: 1) New cabinets and granite tops 2) Plumbing and heat changes in the kitchen 3) Baseboard heat in the living room 4) Electrical for kitchen remodel Incremental cost: $31,115.59 a'.t d'UV44"' Signature Date Proposal valid for 30 days from this date: 3/25/2015 Contract Total: 132,635.84 3/25/2015 We, the owners of said property and policy, herein -after referred to as OWNER, authorize Restoration Management, LLC, herein -after referred to as CONTRACTOR, to make repairs to our property located at: 0Mal RESTORATION MANAGEMENT, LLC ® 100 Carl Dr, Unit I IB ® Manchester, NH 03103 OFFICE: 603-413-5883 / 888-743-0245 FAX: 603-379-3323 OWNER(s) Printed Name: Mary Beliveau Phone: (978) 828-4393 Loss Address: 328 Main St North Andover MA The date and approximate time of damage: OWNER agrees that the total scope and cost of remedy will be supported in accordance with the original and approved estimate. Any changes to the work as originally estimated and approved will require a supplemental estimate to be prepared by CONTRACTOR and approved by the adjuster of the insurance company. Any order that extends beyond the scope of remedy requires a change order estimate and must be approved by the OWNER and CONTRACTOR. This work authorization, along with the original and approved estimate, supplemental estimates and change order estimates as applicable, constitutes the contractual obligations of the OWNER and CONTRACTOR. OWNER understands and agrees with the following: CONTRACTOR has no connection with the insurance company or its adjuster. OWNER has the authority to authorize CONTRACTOR to make said repairs. Any deductibles owed are the responsibility of the OWNER. Any work not covered by the Insurance Company, including any change orders, must be paid by the OWNER. Terms and Conditions: 1. The repairs, replacement, or additions authorized herein relate to the specifications on the front page of this contract of those attached hereto and do not cover pre-existing deficiencies unless specifically stated. 2. All materials used will be standard stock materials, unless otherwise specified and will match existing materials within reasonable tolerance as to color, texture, design, etc. 3. All painting of existing surfaces is estimate to return existing paint surfaces to same color; any changes in color or type of material will be done at extra cost to owner. 4. The contract price is based on completion during normal working hours and owners agree to provide access to the job site as required for completion of the work. Owners electricity, water, and toilet are to be made available to the contractors personnel during the course of the work. 5. Any work deleted from the work authorization must be agreed to by both the owner and contractor in writing, and the owner will be reimbursed for the work in an amount equal to the contractors projected cost on said work. 6. The Contractor will take reasonable steps to prevent the theft, disappearance of or damage to jewelry, art objects, silver, gold antiques or personal items in the OWNER's home by ensuring that all company personnel or sub -contractors have been thoroughly screened and the all personnel and sub -contractors only access areas within the OWNER's home, where work is being conducted. The OWNER will take reasonable steps to ensure that all valuables are stored in locked rooms, to which the CONTRACTOR's personnel have no access. 7. The contractor guarantees all workmanship covered by this authorization for a period of two years from date of use by owner. All materials used are covered by the normal guarantees, if any, provided by the manufacturers or suppliers. 8. The CONTRACTOR agrees to make all repairs in accordance with this written estimate for the total price of: $101,520.25. The OWNER is not responsible for any charges in excess of the agreed amount of the contract, unless both parties agree in writing to any modifications or changes. 9. ARBITRATION AND CHOICE OF LAW - All disputes, controversies, claims or differences, which arise between the parties out of or in connection to this agreement, including the scope and applicability of this arbitration clause, shall be finally settled under the rules of the American Arbitration Association by one arbitrator appointed in accordance with said rules. The RM1007_BELIVEAU_XO-3 3/25/2015 Page:2 7.11 RESTORATION MANAGEMENT, LLC ® 100 Carl Dr, Unit 11B ® Manchester, NH 03103 OFFICE: 603-413-5883 / 888-743-0245 FAX: 603-379-3323 place of the arbitration shall be Manchester, New Hampshire. The interpretation, construction and legal order: (i) the language of the Agreement; (ii) the intention of the parties to the Agreement; and (iii) by reference to the laws of the State of New Hampshire. The loosing party will be responsible for the total cost of arbitration as well as expenses associated with the dispute. All overdue and unpaid balances are subject to a 1.5% per month compound rate of interest. 1.0. Warranty work will not be paid for by CONTRACTOR when performed by others unless agreed to in advance. 11. Restoration Management, LLC may photograph and or record the repair process throughout its various stages. I understand that this material may be used in various publications, public affairs releases, or advertising related endeavors in print, on television and online. OWNER authorizes Mortgage Company to cooperate with CONTRACTOR in the handling of all matters associated with this insurance loss and grants approval for CONTRACTOR to discuss all such matters with the mortgage servicer. Mortgage Company: Account#: Insurance Company: Home Owner Policy #: OWNER authorizes the Insurance Company to make payment due to CONTRACTOR directly to CONTRACTOR. Where applicable, the owner further authorizes the Mortgage Company to make payments due to the CONTRACTOR directly to CONTRACTOR. If OWNER is named on the payment, OWNER agrees to promptly endorse said payment authorizing Mortgage Company to disburse payments to CONTRACTOR. If payment is made to the OWNER, OWNER will deposit payment into an escrow account in a bank acceptable to CONTRACTOR and disburse payment to CONTRACTOR as due. Disbursement of said funds will be according to the following milestones: 50% upon acceptance. 25% at 50% complete. Balance due at completion. The CONTRACTOR agrees to accept all payments as they are released by the Mortgage Company or the Insurance Company, including the Recoverable Depreciation without penalty to the OWNER if the CONTRACTOR is also named as a payee on the check. OWNER(s) Signature: � (4,0 Date: Statement of Satisfaction & Com tion I have thoroughly reviewed all of the work performed and completed by Restoration Management, LLC.. I certify that all work performed and materials supplied by the contractor are in accordance with the work authorization and estimate. OWNER(s) Signature: Date: RM1007_BELIVEAU XO -3 3/25/2015 Page: 3 .1919Z -.S101- ..Z .iZ O O ei 4-4Oas - - .,t,,6— „8 191 .,1, ,6 Oi ,ZI % „6,£Z .101 ,Zi r From:Jessica Thamm FaAD°603-673-7290 Page 2 of 4,r^3 F„ Date:3l26/2015 10:43 AM Page:2 of 4 h RESTO-1 r OP ID: JT A`CORO" CERTIFICATE OF LIABILITY INSURANCE..312612015 Ff4DAOTEI'�MIDDlYYYY) 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(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 Boyd & Boufford, LLC 8 Main Street Amherst, NH 03031 CONTACT PHONE '(AIC' A1C No Ext :603-673-7228No): 603-673-7290 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC q 01/17/2015 INSURERA:Acadla Insurance 31325 EACH OCCURRENCE $ 1,000,000 INSURED Restoration Management LLC dba Legacy Flooring 100 Carl Drive INSURER B: INSURER C INSURER D: Manchester, NH 03103 INSURER E: PRODUCTS- COMP/OP AGG $ 2,000,000 INSURER F : A COVERAGES CFRTIFICATF NI IM4IFR- 09\1IQIMKI KIIInnDCD- 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EF MM/DDIYYYV OL E MMIDD/WYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR CPA5081564-12 01/17/2015 01/17/2016 EACH OCCURRENCE $ 1,000,000 TO REN ED PREMISES Ea occurrence $ 250,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC FIOTHER:, GENERAL AGGREGATE $ 2,000,000 PRODUCTS- COMP/OP AGG $ 2,000,000 $ A AUTOMOBILE X LIABILITYO ANY AUTO, ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS CAA5135505-11 01/17/2015 01/17/2016 aBINEDISINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CUA5081565-12 01/17/2015 01/17/2016 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 DE I I RETENTION $ $ A WORKERS COMPENSATION ANDEMPLOYERS'L[ABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y 1 N OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N I A CA5081566-12 01/17/2015 01/17/2016 P ROTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1 $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Town of North Andover 566 Main St North Andover, MA 01845 LA_l►19a9,_11LfJ;I 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 Al 600( .?> ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD IlE :'lid►— ®earl® The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Ma nrxne i-yv & n4- LL_ C. Address: f ( 0 41 l2 City/State/Zip:,�.eq.!C-)Q?jfMPhone #: Etre you an employer? Check tlie appropriate box: 1. ❑ I am a employer with , employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. F1 I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. F.Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. F1 Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Ca f° ua ; Tp.�)I ,w,'' ce, Policy # or Self -ins. Lic. #: 3 Expiration Date: Job Site Address: IS28 r0p i n<�AmZklt?./ m 14 City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certifijAWer thepgtns apd penalties of perjury that the information provided above is true and correct. 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 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia N D 00 = 2 n r D o D D . 4 .o M U)cn o fn m' 3 m � Do z z 0 o @ m o y Wj ic Zr Zx..:� O y J y''lAA, m B v i Iil t 53 I� t; oho z 1U j1 f O N z� I j 0 N 0 N M ara m v E yo== C) Zoo =>DD m�cncn mX r- O ZZOy w�p0 O�.U) W cn W 00 O 0 N a � 0 0 � N y;s YmotD� N YC La S12. y a cc Q m m to ❑ H a Nh c U') 6 tO X y n: � • y C � 5 010 0 m o 42 yo== C) Zoo =>DD m�cncn mX r- O ZZOy w�p0 O�.U) W cn n W 00 O 0 N a � 0 (A nco c � N La y a cc Q m m to ❑ H a Nh c U') 6 tO X o� CA_ 010 0 N Q 0 N) 00 �a 0 .� o, �pr • ❑° a O o� o �m A u°a toCL n W 00 O 0 N rr na0 0 (A nco c � N La cc Q a c U') 6 tO X o� CA_