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Home My WebLink AboutBuilding Permit #497 - 33 WEST WOODBRIDGE ROAD 12/20/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: #1Date Received Date Issued: /Q54 -P id I ORTANT: Applicant must complete all items on this pate LOCATION j.3 lief Oa C/,4&., e ea Print PROPERTY OWNER F�A,*f1Zd .��/.( %� 0/ - unit # Print MAP NO: O-0 PARCEL: 00/y ZONING DISTRICT: Historic District yes Machine Shop Village yes o 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building XOne family ❑ Addition ❑ Two or more family ❑ Industrial 'Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other S pti Well r, = F4NI F, oodp M57M,`:y; ® etlands .`.�z ® aters ed istnct ` X ~ ' : E!,11ter��Se�wer 3 i pRac <�".`�r, �;. DESCRIPTION OF WORK TO BE PERFORMED: By X C/ &1+-&_C fi e J U S x&- % Z IzeaM r i.� Bs�r� �,P,�T f► .ems � 14, /. /.Pe,Z4 7e . b rvA LL L %��2. 3^' . /L L11114 4 --re &t9_ d (Identification Please Type or Print Clearly) OWNER: Name: �c 6V,41r_d xe/S 4,o 6'. Phone: �7P Address: 33 k.) eYI— X4,Ws e Ai4-ai CONTRACTOR Name: eve �eiS t la �- Phone: 97,P 3/ y -P Vs 7 Address: �I' t T� X-/— sAzis A/9s 2 - Supervisor's Supervisor's Construction License: a 9V d' 9 Exp. Date: 2-16-2o /-3 Home Improvement License: ARCHITECT/ENGINEE Address /0/.P SSG Exp. Date: G a 9 - 20-112. Phone: W FEE SCHEDULE: BULDING PERMIT; $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $_ 9 0a, FEE: $ iq Check No.: -..-...Q 6 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the gugmap fund N 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 COMMENTS DATE REJECTED El DATE APPROVED CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature COMMENTS 4 Zoning 18oard of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use ® Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products VOTE: 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 COTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit a all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording lust be submitted with the building application Doc: Doc.Building Permit Revised 2008mi Location, 3 tiwd1` a�lJ(JMG.�•t. No. Date l/ 40RTIJ TOWN OF NORTH ANDOVER L s o •; s Certificate of Occupancy $ --Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ /,, TOTAL $ Check # 0-P3 24904 Building Inspector o as � ;.e o C3 C h O C �a'o A C ev cc_ := 2 O i c D C. � c :.o co r C :C.) s cmCD :mC m O �N h N CD m N a = C N y A C O � av w =CD o, caz 2, CA i� .O .� cm p CL C •O _ ® C. o N H yOa y O ~ m COD ui ca CL:5 C ■Nam�'o,e�.� O a OOO A _O� C* m' g U � - 16 a ¢ O x b °o w v CA aa, co a � co G o u. � o w r. 'c U x a°' w c�° cn w a�' w W v W 4— cn q Sd0 cn . o as � ;.e o C3 C h O C �a'o A C ev cc_ := 2 O i c D C. � c :.o co r C :C.) s cmCD :mC m O �N h N CD m N a = C N y A C O � av w =CD o, caz 2, CA i� .O .� cm p CL C •O _ ® C. o N H yOa y O ~ m COD ui ca CL:5 C ■Nam�'o,e�.� O a O� _O� C* m' g 16 f U .2 P4 2 O a� 0 E c■ L v zCD CL O y 43 cm O •� CO)CD �..� m m �c L- 93- m e_cv o a a ca o c Rcc •a o D COD Z CD 0 CL V CO) ccC C c LU cl LU Y/ W W W U) Ask AdIlk FARM FAMILY CASUALTY INSURANCE COMPANY Issuing Office - P.O. Box 656 0 Albany, New York 12201-0656 CONTRACTORS ADVANTAGE BOP000916906 ® DECLARATION PAGE Policy Number: 2005XO431 Agent No: 3485 Agent Phone: 978-887-8304 UGONE JOHNSON INSURANCE AGENCY, IN 7 GROVE ST STE 201 TOPSFIELD MA 01983-1862 Name and Mailing Address of First Named Insured: STEPHEN KEISLING 99TH STW SALISBURY MA 01952-1702 The Insured is: INDIVIDUAL Transaction Type: RENEWAL Policy Period: From 03/21/2011 To 03/21/2012 Business Description: CARPENTRY Business Property Coverages Buildings Business Personal Property Business Income and Extra Expense Other Endorsements Transaction Effective: 03/21/2011 12:01 A.M. Standard Time Total Limit of Liability Term ADDURTN Premium Premium $5,000 $22.00 Actual Loss Sustained Not Exceeding 12 Months SEE SCHEDULE BUSINESSOWNERS LIABILITY Except for Fire Legal Liability, each paid claim for the following coverages reduces the amount of insurance we provide during the applicable annual period. Business Liability Limits of Insurance Bodily Injury/Property Damage $500,000 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 AGGREGATE FOR PRODUCTS/COMPLETED OPERATIONS HAZARD Medical Expenses Fire Legal Liability Other Endorsements $5,000 EACH PERSON $50,000 ANYONE FIRE OR EXPLOSION SEE SCHEDULE POLICY SUBJECT TO ANNUAL AUDIT: YES TOTAL PREMIUM The Declarations, Schedules and These Forms and Endorsements Make Up Your Comple et P 'ol cy: BP00021299 BP00060197 BP00090197 BPO4170196 BP04190689 BP04961001 SPOS140103 BP07010197 BPI 0040498 BF30061103 SF40380902 BF40390303 BF40861010 BF40910708 OF40921010 OF41090204 BF41321008 F199020108 Page: 1 of 2 ANX-3190 INSURED COPY Countersigned By Authorized Representative Processed Date: 02/15/2011 Qffif&,-o :(6nsumer At' airs & Bdsinr. Regulation HOME IMPROVEMENT CONTRACTOR Registration: ,101846 Type: Expiration: $/2912012 Individual STEPHEN M. KEISLING Stephen. Keisling 9 NINTH STREET SALISBURY, MA 019526-:. r. Undersecretary �-` i1.lassachusetts- Department of Puhlic S.tfetN Board of Buildim„ Regulations and Standards Construction Supervisor -License License: CS 27489 STEPHEN M KEISLING -9 9TH STREET WEST SALISBURY, MA 01952 �--G - —� Expiration: 7/16/2013 ('ummiscioncr Tr#: 19624 �ro�asitl Page No. of Pages STEPHEN M. KEISLING Building, & Remodeling 9 9th Street West Salisbury, MASSACHUSETTS 01952 MA Uc. 027489 Home Impv. 101846 Phone (978) 682-2072 * (978) 465-4712 PROPOSAL suBMRT DjoPHONE DATE / STREET Ad JOB NAME CITY. STATE and ZIP CODEJOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: ............_ ...._d/J.+irr..8.✓�....471,4_06�a --.._/C-,_G..x_T ..._�"'.—'"...._03Y------------- -�--- --..-o---_. i . !! /_ ......... a�i�.... _..__. ...a��...................... �z...✓..: y-.-_ . •-_ � ... 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Ile propfil! hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: dollars ($ ). Payment to be made as follows: All material is guaranteed to be as specified. All work to be completed in a workmanlike r manner according to standard practices. Any alteration or deviation from above specifications Authorized Signature LIL -� involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Note: Thispr t ay be n,,. ,.,, k. ., rnvn. — fi,uA kv w. ,k—.,'. r-—.6— 1--n— withdrawn by us if not cceIt within / / days. ArrePtonre O1 FrO1100al —The above prices, specifications /v v and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified. PaFymPe t will a made as outlined above. Date of Acceptance: (l Signature y �J Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard Language to protect homeowners Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of "A Massachusetts Consumer Guide to Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. 11V111Guri nCr lnturinution Contractor Information Name / tl I / /_ tQci ��,-Q_'/ /{��PiJI1.J t 1: -_ Company Name s Ode. Shied Address Address (do not use a Post !Mice Box address) Ad Contractor/ Salesperson/ Owner Name % 33 zo B,et 9f S % 2pe-1 Citylfown State Zip Code Business Address (must include a street address) o 15i-A;�V tIF2 #7 * a S'� Z"4 BAR A,lf- aid'vs" Daytime Phone Evening Phone Citylrown State Zip Code 9�d'"s92ss 11917? 399- 9f'p q Mailing Address (it different from above) Business Pham lFederal Employer ID or S.S. Number [ay negdrrs Nat �ti Oame Home In --W Contractor Reg. Nmnbc Elmet -dee Y /a/ C/� G - 2 1 he Contractor agrees to do the following work for the Ilomeowner. (Describe in detail the work to completed, specifying the type, brand, and grade of materials to be used, use ad tmal sh -f nec ) 6 v( Id 2 u y W1+ ! /C err, 2 /1ecMe.-,i s�.r,e,�i ?d .r,.9 o O f Pir-e AXP A Ate- "vl�P AXUzl /_ , tt.sW1Att, wit LC/P(.ts�2� s' eoccad Z1,9ATCA-n-,r 9 t" 0 v ; &V 73 P 6i.x &,+se 40A R- Q/ Required Permits - The following building permits are required Proposed Start and Completion Schedule- The following schedule will and will be secured by the contractor as the homeowners agent:- be adhered to unless circumstances beyond the contractors control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of Dom' Date when contractor will begin contracted work MGL chapter 142A.) JAS < Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule pp The Contractor agrees to perform the work, famish the material and labor snecified ahnve for the tntal vpn of �S % �! Payments will be made according to the following schedule: $ S-30'0 upon signing contract (not to exceed 1/3 of the total contract price or the cost of �r;ial order items, whichever is greater) $S300 by / /_ or upon completion of -- So yC v M/v le % !o, 1-P W A -U -C $ E3 ®D by / /_ or upon completion of 00 r10 4t Lp /P 1� $ upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(i•) $ to be paid for NOTES: (*) Including all finance charges (**) Law requires that any deposit or 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 schedule. Express warranty - Is an express wamuty being provided by the eootradoe ® No ❑ Ya (SH terms of the warranty most be attached to the contract) Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor trader this agreement Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza, Roan 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you pre confirm coverage, or ask to see a copy of a "proof of insurance" document • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. [�=�-W,Iitti-g s agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the at his/her main office or branch office by ordinary mail posted, try telegram sent delivery,notlater than midnight of the business day following the signing of this agreement. See the attached notice of cancellab rm r an explanation of ' 'ght. DO NOT SIGN THIS CONTRACT IF THERE ARE BAN ACE . . Twv idea iwt copies of thc comract must be completed and sig3ed Ouc copy shoved to b the vee nh COPY by mmcror. omcown 's Signature ��' L�--� Contr clot' ignaut D late n .e 4 Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. Thecontract d the homeowner hereby mutually agree in advance that in the event the contractor has a dispute cone . s ntract, the con"4r may submit the dispute to a private arbitration fine which has been approved by the S the E cutive Z of Consumer Affairs and Business Regulation and the consumer shall be required to su ch asded In Massachusetts General Laws, chaplet 142A. Hcfi*wner'e;SfglaSture \ N Contractor's Sign NOTICE: The signatures of the ft -ties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not the Homeowner's Rights A homeowner's rights under the Home improvement Contractor Law (MGL chapter 142A) and other consumer protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is. to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/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 of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at littp://w",.,xv.mass.gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at littp://ww%v.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: liqp://db.state.ma.us/honieimprovement/licenseelist.ast) For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800, 508-755-2548 or 413-734-3114 Version 2.1 - 11/22/2010 The Commonwealth ofMassachusetts Department oflndustrial Accidents Of"ce oflnvestigations° 600 Washington Street Boston, MA 021-11 yY www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers m licaut Information Name (Business/Organization/Individual): Sle ti'e E, _ .� iJ' L,.� 6�: Address: %' 9 S�7 e 7 — City/State/Zip: S� Li1 �3icr�. 9if} p /9.s Phone #: Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I 2.Y employees (full and/or part-time).* have hired the sub -contractors I am a sole proprietor or partner- '' listed on the attached sheget. I// ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing .officers have exercised their all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] T employees. [No workers' comp, insurance required j , -P Type of project (required): 6. ❑ New construction 7. 0 Remodeling 8. [) Demolition 9. [] Building addition 10.0 Electrical repairs or additions 11. El Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy inforrnation. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providingworkers' compensation insurance for my employees. Below is the policy anti job site information. Insurance Company Policy # or Self -ins. Lie. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL 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 certif r the p his4ndpenalties ofperjury that the information provided above is true and correct. 7d0 3i% �ys7 "JJ -'"a[ use only. Do not Write in this area, to be completed by city or town official. City or Toxon: PermitMeense # Issuing Authority (circle one): I. 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 apartinents 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 Iicense 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 -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 confumatioa 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 NOTrequired 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: Tue C0-- ,-1orcwc- ilial Of .Massadfa setts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston; 114-. 02111 Tel. # 61.7-727-•4900 ext 406 ox 1 -877 -MASSA E Revised 5-26-05 Fax # 617-727-7749 www massjz-ov/dia ------------- U11 1 "111 Brockway -Smith Company www.brosco.com ANDOVER, MA 01810 COXSACKIE, NY 12051 HATFIELD, MA 01038 146 Dascomb Road Hudson Valley Commercial Park 125 Chestnut Street 1-800-222-7981 1-800-222-7303 1-800-922-0191 Fax: 1-800-242-4533 Fax: 1-800-222-7304 Fax: 1-800-922-0296 PORTLAND, ME 04103 203 Read Street 1-800-442-6734 Fax: 1-800-443-0331 3 3 3 i 1 i _ r it i m..11Z(.,.__.,.,.... v _ » �....�..�.t i a f 3 d k (F i 1 j i t I i k t tt F ^4' l ANDOVER, MA 01810 COXSACKIE, NY 12051 HATFIELD, MA 01038 146 Dascomb Road Hudson Valley Commercial Park 125 Chestnut Street 1-800-222-7981 1-800-222-7303 1-800-922-0191 Fax: 1-800-242-4533 Fax: 1-800-222-7304 Fax: 1-800-922-0296 PORTLAND, ME 04103 203 Read Street 1-800-442-6734 Fax: 1-800-443-0331