HomeMy WebLinkAboutBuilding Permit #1310-2016 - 33 HERRICK ROAD 6/16/2016 1
BUILDING PERMIT ` NORrN 9 0
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TOWN OF NORTH ANDOVER -�
APPLICATION FOR PLAN EXAMINATION
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Permit No#: ! FF � Date ReceivedRArED
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Date Issued:® 6 G�%�
IMPORTANT: Applicant must complete all items on this age
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LOCATION
Print
PROPERTY OWNER
Print 100 Year Structure yes no
MAP PARCEL: =ZONING DISTRICT: Historic District yes nQ
Machine Shop Village yes (�
TYPE OF IMPROVEMENT PROPOSED USE
Resj#6ntial Non- Residential
❑ New Building KOne family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: El Commercial
WRepair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
El Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed. District,
0 Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: i� -e�� -e ca, Phone:
Address:
Contractor Name: i K, Ph one: &
Email: 'K� , fZ c�-�� -
-C,;
Address: - (ZI N. Al-, 8 o v-e-r-
Supervisor's Construction License: C S 0 S 0`72-) Exp. Date:
Home Improvement License: Z I Z'3 Exp. Date: I ' 2,0
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: $ t') FEE: $
Check No.: 0411 Receipt No.: o
�-14::
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
J
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
PLANNING & DEVELOPMENT Reviewed On Signature_
aAUJAV
COMMENTS
—V)A
CONSERVATION Reviewed on �p Lo
Lo Si nature
COMMENTSj\1n CO a`
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
LEI RE DEPARTMENT k `4ernp�#Durnpster�+0onsite° y s trios Y
[Locatediat�(IJ.4 VIainnkSt
P Fire Dep�artmentstsi nature/date;...._
�EC:®MMENT�S°:
I
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)
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised.2014
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
4. Building Permit Application
;r< Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
4. Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
:Ib Building Permit Application
Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
4, Copy Of Contract
.� Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
4 Mass check Energy Compliance Report (If Applicable)
' Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
4 Building Permit Application
4. 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
2012 IECC Energy code
4� Engineering Affidavits for Engineered products
OTE: 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
Deeds. One co and roof of recording
The applicant must then et this recorded at the Registry of D copy p g
that the appeal period is over. T pp g g Y
must be submitted with the building application
Doe:Building Permit Revised 2014
Ali
Location
No. za'' Date 4
• - TOWN OF NORTH ANDOVER
• Certificate of Occupancy $
Building/Frame Permit Fee $ -
6w--Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
r Building Inspector J
:r ;
tAORTH
Town of ndover
O .yam.
No. 61
2
z h ver, Mass
_fp I
COCNICM!"WICM y1�
X1,95 RAreo
V BOARD OF HEALTH
Food/Kitchen
PERMI T D Septic System
/ BUILDING INSPECTOR
THIS CERTIFIES THAT ... .... . . r.� .
i Foundation
has permission to erect buildings on .. ... ....#X.101414.4... .. ..............
..........................
Rough
to be occupied as . .. .. ..... . .. ...... . ..� ..........."...................................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application 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 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONS ION Rough
Service
..
. .. .. ......... Final
BUILDIN CTO
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Fina'
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
i
i
AGREEMENT FOR SERVICES
This CONTRACT satisfies all basic requirements of the State's Home Improvement Contractor
Law(M.G.Lc.142A),but does not preclude parties from adding language to protect their specific interests.
Seek legal advice if necessary.Before agreeing to any home improvement work on your residence you
should obtain a free copy of"Consumer Guide to Home Improvement Contractor Law"by calling the
Office of Consumer Affairs and Business Regulation's Information Hotline at 617-973-8787.
You may cancel this Agreement if is has been signed by a party thereto at a place other than an
address of K&R Contractors,Inc.,which may be its main office or branch thereof,provided you notify K
&R Contractors,Inc.,in writing at its main office or branch by ordinary mail posted,by Telegram sent or
by delivery,not later than midnight of the third business day following the signing of the Agreement.
See Attached Notice Of Cancellation For An Explanation Of This Right.
Homeowner Information Contractor/Owner Name:
Loik or Jennifer Henderson Kenneth Roy,President
33 Herrick Rd Business Street Address
North Andover,Ma 01845 K&R Contractors,Inc.
1 Campbell Road
North Andover,MA 01845
Business Phone:978.726.5062
Federal Employer ID 000961723
Salesperson(s): Kenneth Roy,President
Contractor Registration: 80721 Exp.Date: 4/29/15
MA Sup.license: 137557
WORK TO BE PERFORMED AND MATERIALS TO BE USED
Contractor Agrees To Do The Following Work For Homeowner:Replace landing on Herrick st.side
Work to include: Remove old landing while supporting existing roof.Install 2 footings.Build new landing
to same size with PVC grey decking,new Radience railings in white,and lattice around deck and stairs',and
frame wrapped in PCV white board.
The following schedule will be adhered to unless circumstances beyond the contractor's control arise*
Work Scheduled To Begin:6/15/16
Expected Date Of Completion: 6/30/16
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
The Contractor agrees to perform the work,furnish the material and labor specified above for the
SUM OF$4350
Payments will be made to the following SCHEDULE:
i
$2350 due upon signing this contract
$2000 due upon completion of project as outlined here
Law requires that any depositor down payment required by the contractor before work begins may not
exceed the greater of
(a)one-third of the total contract price or
(b)the actual cost of any special equipment or custom made material which must be special ordered in
advance to meet the completion schedde*)No final payment shall be demanded until the contract is
completed to the satisfaction of the parties thereto.
OTHER EMPORTANT PROVISIONS
You are dealing with a Registered Home Improvement Contractor and are entitled to certain rights under
the provisions of 780 CMR R6 and M.G.L.c.
142A.
Payments: If payment is not received as per the Contract,then the Owner shall be responsible for all
attorneys'fees,court costs,and other costs incurred by the Contractor and enforcing Contractor's rights
hereunder.
i
Pets: Homeowner agrees to keep all pets out of the work area and take whatever steps are necessary to
safeguard them from any harm that may come to them as a result of the work being performed under this
Contract,including but not limited to injury on or outside the Premises or ingestion or inhalation of,or
contact with,hazardous substances. Company assumes no responsibility for any harm to the pets as a result
of the work performed under this Contract. Further,Homeowner shall take all steps necessary to protect
Contractor,its agents,servants,contractors and employees,from any harm as a result of contact with said
pets.
Characteristics of wood: Wood is a hygroscopic material. Wood swells and/or shrinks in relation to the
humidity,temperature and environmental conditions of its surrounding. Generally,wood flooring is
expected to shrink in any conditions and expand when exposed to moist conditions.
Natural wood also contains variations of graining,texture,hardness and/or knots,depending on the wood
chosen.Contractor cannot be responsible for the natural features of the wood chosen. Contractor is not
responsible for shrinkage,checking,swelling,or other conditions which are the normal condition of wood
or the result of household or environmental humidity,heat,cold,or other conditions.
Colors: You may choose colors and finishes for the parts being used in
your remodeling project. It is important to remember that a color or finish you see at the store or in a
showroom may not look the same in your home,especially after all of the different colors and finishes are
brought together upon the completion of a project. In addition,one manufacturer's named color is not the
same as another manufacturer's named color.The Contractor cannot be responsible for the appearance or
lack of coverage from Homeowner/chosen paints and/or stains and finishes.
Building Officials: Any additional costs incurred by Contractor as a result of decisions made by Building',
Officials will be the responsibility of the Homeowner.The costs of additional workwill be calculated as
follows:cost of materials plus an hourly rate of$45 per man hour.
Liens: In the event of non-j ustifiable non-payment,Homeowner's residence or property may be subject to'
a Mechanic's lien as a consequence of signing this Contract.
Utilities: The Contractor will use reasonable efforts to notify the Homeowner in advance of any
interruption of utility services. However,there may be instances where the Contractor must shut down
these services without advanced notice. Homeowner must arrange for emergency backup service for any
utility critical equipment such as medical devices and computers. The Homeowner must also notify the
Contractor at the start of the work day if you will be engaged in any utility critical activities in that the
Contractor makes a notification inwriting in the daily log book or otherwise.
Additional work Any additional workrequested by the Homeowner which is beyond the scope of the
work to be performed as set forth in this Agreement,shall be the subject of a separate agreement,and/or if
not,subject to the same terms and conditions as set forth in this Agreement and billed on a time pi us cost of
materials basis at Contractor's normal hourly rate.
Contractor's normal hourly rate per man hour is$45.
In the event that additional work is to be performed on an hourly plus cost of materials basis,the
Homeowner shall be required to execute a Change Order which shall include Contractor's best estimate as
to the time required,together with the cost of labor as well as the type and cost of materials necessary.
Delays: Contractor is not responsible for delays attributable to
Homeowner initiated modifications or additions,or for delays incurred due to the actions or inactions of
city/town officials,strikes,acts of God,unfulfilled customer obligations,vendor delays,interference by
other tradesperson,customer supplied items or other delays beyond Contractor's reasonable control.
Contractor will use reasonable efforts to stay on each job until substantial completion by allotting specific
time periods to each Homeowner to complete each job in as timely a manner as possible. In the event that
Homeowner does not allow Contractor and/or bis employees or sub-contractors access to the residence or
property so as to allow Contractor to perform his obligations and/or to complete the scope of work in as
timely a manner as possible,other than for reason of safety or other reasons mutually agreed to between
Homeowner and Contractor,then the Homeowner shall be responsible to pay Contractor the sum of
$500.00 per day,on a pro rata basis,to cover the costs of delay. Contractor reserves the right to suspend
work and/or delivery of materials in the event of unjustified non-payment. In such event,the Contractor
shall have no liability to the Homeowner for alleged delays or damages due to said suspension.
Punch-list Items: The Homeowner agrees that routine"punch list"or repair items after substantial
completion are outside the agreed scope of services,and covered by Contractor's warranty obligation and
will be completed as soon as practicable and according to Contractor's and Homeowner's mutual
availability. Homeowner agrees that it shall use his/her best efforts to make himself/herself available to
observe and/or sign off on the completion of any such punch-list Items,and that the approval of one
Homeowner regarding the completion of any such punch-listitems,as well as change orders shall be
binding upon all Homeowners.
Unforeseen Conditions/Circumstances: Contractor shall not be responsible for any changes at the request
of the Building Inspector. Contractor shall also not be responsible for any unforeseen bedrock/ledge or
latent defects such as structural and/or dry rot or insect damage to the existing structure,or for preexisting
faulty or inadequate wiring or plumbing.
Contractor shall also not be responsible for any pre-existing code violation or responsible for correcting
contiguous work completed by others not under the Contractor's authority.
Insurance: Homeowner agrees to carry fire,theft,vandalism,liability and all other necessary insurances to
protect their personal property while construction is in progress. Contractor will carry all required and
necessary insurances including worker's compensation insurance. Contractor will ensure that all personnel
including sub-contractors will be covered by all required and necessary insurance including worker's
compensation insurance.
Homeowner's Cancellation Rights: In addition to the rights the Homeowner has,asset forth in the
attached Notice of Cancellation,the Homeowner may have rights under other Massachusetts Statutes,
including M.G.L.c.93 §48,MG.L.c.140D,§10 and M.G.L.c.255D§ 14.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Identical copies of the
contract shoal d go to the homeowner and the contractor.
dodoo verified dodo. verified
06/13/16 SS,PM EDT �� 06/13/16 10:21 PM EDT
TBV3.3ZR2-KSDS-GJ3H PVBB-LWOM-XAFZ-WBC
Homeowner's Signature:
dod.op ven5td
C� SJDW XC V-NPZ5 EDT
SJDW-XCFV-NPZS-QJ03
By. Kenneth Roy
Its: President
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of
the seller,which maybe his main office or branch thereof,provided you notify the seller in writing at hi s
main office or branch by ordinary mail posted,by telegram sent or by delivery,not later than midnight of
the third business day following the signing of the agreement.
See attached nonce of cancellation for an explanation of this right.
NO WORK WILL BEGIN UNTIL BOTH PARTIES SIGN THE CONTRACT AND THE OWNER
RECEIVES A COPY
REQUIRED PERMITS
The following building permits are required.It is the obligation of the contractor to secure such as the
homeowners agent
Electrical rough and finish
Plumbing rough and finish
Insulation
Framing insp.
Finish and occupancy
NOTE- Owners who secure their own permits or deal with unregistered contractors are excluded from the
Guaranty Fund provisions of MGL c. 142A.
EXPRESS WARRANTY
All workmanship and materials to be free of material defect for a period of one(1)year. During the
Warranty period,the Company may,at its option,either repair or replace products or workmanship which
prove to be defective. This Warranty shall not apply to defects or damage arising from improper or
inadequate maintenance by the customer,customer's applied products,unauthorized modification or
misuse,damage incurred as a result of acts of God or civil strife,or normal characteristics of the materials
such as wood shrinking,expanding and otherwise reacting to moisture or environmental conditions. The
Company's liability is limited to the repair or replacement,at its option,set forth herein and Company shall
not be liable for any consequential,sequential,incidental or other damages not set forth herein.The
Warranty set forth hereinis exclusive,and no other Warranty,whether written or oral,is expressed or
implied. Company specifically disclaims the implied Warranties of Merchantability and Fitness for a
Particular Purpose.
NOTE:All home improvement contractors and subcontractors shall be registered and any inquires about a
contractor subcontractor relating to a registration should he directed to:
Director,Home Imiprovement Contractor Registration One Ashburton Place,Room 1301 Boston,MA
02108
617-727-8598
Unless otherwise noted within this document,the contract shall not imply that any lien or other security
interest has been placed on the residence,
ARBITRATION
The contractor and the homeowner hereby mutually agree in advance that in the even the contractor has a
dispute concerning this contract,the contractor may subnit such dispute to a private arbitration service
which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business
Regulation ch arbitration as provided in M,G,L.c.142A.
dotloop verified
IJitl--o
06/15/16 7:S8AM EDT
KU7G•VfPJ-BAFl-CUVE
Contractor:
i� / dotloop verified PM �[ dotloop verified
Kf4wog/ 0E/13/E7.:SKHN-ZH �T/G4wpX/ 06/13/6X
-EU0M EDT
HOITICOW rier: VRG2-P9IKHN-ZHRS 06/13/NTX•EU05 E DT
NOTICE:THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF
THE PARTIES TO ALTERNATIVE DISPUTE SETFLEMENT INITIATED BY THE CONTRACTOR.
THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS
SECTION IS NOTSEPARATELY SIGNED BY THE PARTIES.
ACCELERATION OF PAYMENT
Homeowner's Financial Insecurity-A Contractor may not demand payments in advance of the dates
specified on the payment schedule in cases where the homeowner deems lint/herself to be financially
insecure.
Contractor's Financial Insecurity-In instances where a contractor deems himself/herself to be financially
insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work. Withdrawal from said account would require
the signatures of both parties.
Homeowner agrees to allow reasonable access to allow Contractor to reasonably attempt to remedy any
outstanding uncompleted,disputed or non-satisfactory item.
If you have general questions or need additional information about The Home Improvement Contractor
Law,contact,
Consumer Information Hotline
Commonwealth of Massachusetts
Office of Consumer Affairs and Business Regulation 10 Park Plaza.,Room 5170 Boston,MA 02116
617-973-8787
If you have questions about Contractor Registration,contact:
Director of Home Improvement Contractor Registration Board of Building Regulations and Standards One
Ashburton Place,Room 1301 Boston,MA 02108 617-727-3700,x25205
NOTICE OF CANCELLATION
YOU MAY CANCEL THIS TRANSACTION,WITHOUT PENALTY OR OBLIGATION,WITHIN
THREE
(3)BUSINESS DAYS FROM THE ABOVE DATI?
IF YOU CANCEL,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE
CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE
RETURNED WITHIN TEN(10)BUSINESS DAYS FOLLOWING RECEIPT BY THE CONTRACTOR
OF YOUR CANCELLATION NOTICE,AND ANY SECURITY INTEREST ARISING OUT OF THE
TRANSACTION WILL BE CANCELLED.
i
IF YOU CANCEL,YOU MUST MAKE AVAILABLE TO THE CONTRACTOR AT YOUR
RESIDENCE,IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED,ANY GOODS
DELIVERED TO YOU UNDER THIS CONTRACT;OR YOU MAY,IF YOU WISH,COMPLY WITH
THE INSTRUCTIONS OF THE CONTRACTOR REGARDING THE RETURN SHIPMENT OF THE
GOODS AT THE SELLER'S EXPENSE AND RISK.
IF YOU DO MAKE THE GOODS AVAILABLE TO THE CONTRACTOR AND THE CONTRACTOR
DOES NOT PICK THEM UP WITHIN TWENTY(20)DAYS OF THE DATE OF CANCELLATION,
YOU MAY RETAIN OR DISPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF
YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER,OR IF YOU AGREE TO
RETURN THE GOODS TO THE CONTRACTOR AND FAIL TO DO SO,THEN YOU REMAIN
LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT.
TO CANCEL THIS TRANSACTION,MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS
CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE,OR SEND A TELEGRAM TO
K&R Contractors,Inc.
1 Campbell Road,North Andover,MA 01845
NOT LATER THAN MIDNIGHT G OF TBD.
I HEREBY CANCEL THIS TRANSACTION.
Date:
Buyer's Signature:
Received:
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The Commonwealth of Massachusetts
f .Department of.Iadustrzal.Aecidents
a d I 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 Legib
Name(Business/Organization/bidividual): d I� • C f S
Address: C O
City/State/Zip: N Phone#: of 7$ Z G
Are you an employer?Che.cktlie appropriate box:
Type of project(required):
1.❑I ata a employer with employees(fall and/or part-time).* 7. 0 New construction
2.f5q I am a sole proprietor or partnership and have no employees working for me.in 8. 0 Remo delitig
any capacity.[No workers'comp.insurance required]
3.Q I am a homeowner doing all work myself[No workers'comp..iusurance required.]i 9. F1 Demolition
❑
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11:A Electrical repairs or additions
proprietors with no employees.
12.[]Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t p
6.FJ We are a corporation and its officers have exercised their right of exemption pez MGL c. 14.Q'Other
152;§1(4),and we have nQ,employees.[No workers'comp.insurance required.]
*Any applicant that checks box 4l must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit:this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
-tContractors jhat 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-cori646rs have employees they must provide their workers'comp..policy number.'.:
lam'' an employer that is pioviding workers'compensation insurance for my employees'.Below is the policy andyob site
information.
Insurance,Company Name: .
Policy##or Self-ins,Lic.#: Expiration Date:
� 1
Job Site Address: ' < Aeec), 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 e. 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.
X do hereby certify nder the paints an enaldes of peiyury that the information provided above is true and correct.
Signature: Date: '
Phone#: ot 7 4 - 72 - 6-0
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.Boar of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact'!Person: Phone#:
Information and Instructions
Massachusetts General Laws cL ,x 152 requires all employers to provide workers'compensation for their employees.
I •:rte r.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contrdct of lure,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,ox 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 b6 deemed to be an employer.
MGL chapter 152,§25C(6)also states that"every state or Iocal licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commoxjv alto,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.
insurance
enter into an contract for the performance of public work until acceptable evidence of compliance with thezn
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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. LimitedUability 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 foi•confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retumed 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'
- e companies should'entertheir
compensatiori'policy,please call the Department at the number listed below. Self msur d mp ,
self insurance 1 oerse 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 proofthat a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address telephone and fax number:
P � 1�
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
Massachusetts -Department of Public Safety I
Board of Building Regulations and Standards
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License: CS-080721
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Commissioner 04/29/2017
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Office of Consumer Affairs&Business Regulation I
— HOME IMPROVEMENT CONTRACTOR
Registration: y=1,62123 Type:
Expiration: :1120!2017 Private Corporatio;
K& CONTRACTORS,INC
KENNETH ROY
1 CAMPBELL RD.
N.ANDOVER,MA 01845 'A Undersecretary
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