HomeMy WebLinkAboutBuilding Permit #0722-2017 - 336 CANDLESTICK ROAD 1/18/2017 GG 6/' ORT"
L�-, BUILDING PERMIT ` OF"�eD
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TOWN OF NORTH ANDOVER -
#- 9
APPLICATION FOR PLAN EXAMINATION #
Permit NO-OW-71120p— ^D
Date Received
�SSACHU5�t
Date Issued:01 /9 2®
IMPORTANT:Applicant must complete all items on this page
LOCATION. .. ; �e C'AMbedl o--c- Print
PROPERTY OWNERIC'J�
MAP 210 PARCEL: ZON-ING`DISTRICT: Histone District yes no
Machine Shop Village .yesno
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One famil
Addition Two or more family Industrial
Alteration No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
Septic ' . Wel] - Floodpiain Wetlands 1Natershed District
Water/Sewer: { .
DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: :Jxg. MA-DDeA Phone:
Address:_33 C&O(.6 STI Cl-.. 2I7 . ll� AAJOy i &,
CONTRACTOR Name: bAlUCk' / ,4(-�T/tiO Phone. ' - (72 3
360_
Address: 'yam . �(lary y � , ETIu�.v
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Su.pervisor'sConstruction=_Licenseti, ��3. � _}Exp_ .:Date: - :177 .
yr
Home`Im rovem6htticense. _ p, ;Date:: .
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: $ <a7/ -706 LL- FEE: $ /���
Check No.: Receipt No.: 31
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of,Agent/Owrier° - • _ �Sigrature of contractor =���%/f'�,�=!i
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Location
- 1.1. 1. j No. 0��Zo/ Date 41 /8 W17
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. - TOWN OF NORTH ANDOVER
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1. Certificate of Occupancy $
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{ Building/Frame Permit Fee $ I J56
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Foundation Permit Fee $ '
Other Permit Fee $ �, ,
TOTAL $ 3
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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
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
a
Panning Board Decision: Comments
r
t.
Conservation Decision: Comments
Water& Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FiRE-DEPARTMENT Ternp Dum`psteron site yes. no
Locatod'�at 1:24-�Main Street
'Fire Departmentsignature/date a
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 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
w✓Workers Comp Affidavit
T4/,Photo Copy.Of H.I;C. And/Or C.S.L. Licenses
v/ opy of Contract
loor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the 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 2008
Enter construction cost for fee cal - North Andover Fee Calculation
Construction Cost
$ 873700.00 m
$ - $ 1,052.40
Plumbing Fee $ 131.55
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 131.55
Total fees collected $ 1,415.50
Foundation 100
336 Candlestick Road
722-2017 on 1/18/2017
Kitchen Remodel
NORTll
Town of 6 ndover
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a a417 z
4i*_. '0h ver, Mass,LAKI
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BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT ............ ....44,.M .... BUILDING INSPECTOR
....... ..... .
�.. .. .. ,� .... Foundation
has permission to erect .......................... buildings on ..�3. ....... 4'l���.t +< .
Rough
tobe occupied as ..j",I.. ... .. �00 ................................................................................. 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
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONST ION- Rough
Service
... .. . .. ...... ........ ............. .............. ......
Final
BUILDING INSP OR
GAS INSPECTOR
Occupancv 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.
DM
Construction
Building with the QUALITY and Character of yestery =
44 Addison Ave Ext.
Methuen, MA 01844
(978) 685-3037
Estimate Submitted To:
Jack&Mary Ellen Madden Construction Supervisors License 66342
336 Candlestick Rd. Home Improvement Registration 124961
N.Andover,MA
We hereby purpose to furnish the materials indicated and perform the labor necessary for the
completion of:
Kitchen renovation(See specifications sheet)
All material is guaranteed to be as specified, and the above work to be performed in accordance
with the drawings and specifications submitted for above work and completion in a substantial
workmanlike manner in the sum of: i �ty-seven thousand seven hundred dollars-87,70006
Payments to be made as follows:
$ 1,000.00 Upon'execution of contract.
$15,000.00 When work begins.
Remaining payments as work progresses.
Respectfully submitted: Darren Martino
Any alteration or deviation from thea ove specifications involving extra costs will be executed
only upon written order, and will become an extra charge over and above the estimate. All
agreements contingent upon accidents, or delays beyond our control.
Note-This proposal may be
withdrawn if not accepted within 10 days.
Proposal Date 10/04/16
ACCEPTANCE OF PROPOSAL
The above prices, specifications, and conditions are satisfactory and are hereby accepted. You
are authorized to do the.work as specified. Payments will be made as outlined above.
Date: /2 I
Signature: q_-
Date: Signatuf 77)-: 2
DO NOT SIGN`THIS CONTRACT IF THE ARE ANY BLANK SPACES
BUILDING DEPT. COPY
i
MADDEN RESIDENCE
SSoecifications Sheet
GENERAL SCOPE OF WORK
Renovation of kitchen including, but not limited to, new cabinets, counters, appliances,
window, etc.
PERMITTING
DM Construction will file all necessary paper work to obtain electrical, o
the llowin
building, plumbing, f gpermits.
P g, gas, and debris removal. The c
necessary is not included in this estimate and wost ofall permits and ees
ill be billed se irately.
SITE PREP
In an effort to limit the dust generated from the renovation process. Doorways and
openings to other areas of the house will be sealed off within reason with plastic or drop clothes.
DEBRIS REMOVAL
DM Construction is responsible for all debris generated. A container will be placed on
site to ensure a clean work site. The container is for debris generated by DM Construction only,
it is not intended for homeowner use.
DEMOLITION
Kitchen-Demolition offixtures, cabinets, counters, drywall, appliances, insulation,
flooring, etc. Take down the knee wall between the kitchen and living room. Back hallway—
Remove existing the and subfloor.
FRAMING
Framing for new kitchen window. Framing of walls as necessary for new kitchen layout.
To ensure proper fastening, solid blocking will be install behind all cabinetry.
WINDOWS UNITS
Frame and install new kitchen window. The cost of all the windows, screens, hardware,
grills, etc is covered under an allowance.
SIDINGIEXTERIOR TRIM
Patch in siding where existing window will be removed. Patch in siding and install trim
as necessary around new window unit.
INSULATION
The exterior kitchen wall will receive new insulation.
DRYWALL
Installation of Y2" blue board on all walls, ceilings, or other areas where drywall has
been removed or disturbed. A skim coat ofplaster will be installed on all new blue board. All
new ceilings will receive a smooth finish.
i
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i
MADDEN RESIDENCE
FINISH WORK
Specifications Sheet
'
Installation of new trim around the new kitchen window. Square off and installation of
new trim around the opening to the living room. Installation of new baseboard as deemed
necessary. New window trim and baseboard will match the existing conditions. Installation of
recessed panel wainscoting of the wall opposite the sink.
CABINET INSTALLATION
DM Construction is responsible for installation of all cabinetry*and their associated
moldings and hardware. Solid blocking will be installed to assure proper securing of all
cabinetry. The cost of the cabinets and their associated moldings and hardware is covered
under the Cabinetry Allowance.
*This estimate is subject to receiving and reviewing a anal cabin
reserves the right to adjust the price of the contract upon final receipt of this plan struction
APPLL4NCE INSTALLATION
DM Construction will install the following appliances: refrigerator, beverage
refrigerator, dishwasher, range, exhaust fan, microwave, trash compactor, and garbage
disposal.
The cost and de very o thea liances is not included in this contract and is
rest')nsiballty ofthe homeowner the
*This estimate is subject to receiving and reviewing a final appliance schedule. DM
Construction reserves the right to adjust the price of the contract upon final recei t o this
plan. p f
PAINTING
This proposal does not include any interior or exterior painting.
HVAC
Relocate AC vents as necessary for the new kitchen layout.
Provide the necessary ventilation for the hood exhaust. If the hood selected requires
make up air, this will incur extra cost.
TILE SETTING
Back hallway: Installation of new subflooring. Installation of the floor. The cost of the
tile is covered under an allowance.
II
I
MADDENRESIDENCE
SLeci(1cations Sheet
PLUMBINGIGASIHEATING
Plumbin /G
- g as
Demolition-Disconnect and remove all plumbing fixtures and appliances in the kitchen.
Kitchen-Provisions for and installation of the following fixtures: one main sink, one
garbage disposal(on an air switch), one dishwasher, and a recessed box for the refrigerator ice
maker with a no burst hose. Gas piping as necessary for one gas range.
Heating
Demolition-Remove the following sections of baseboard heat: under the existing desk on
the knee wall to be removed, and on the wall opposite the breakfast nook bumpout.
New baseboard-Installation of new base board heat in the kitchen as deemed
The exactd necessary.
amount of baseboard and location to bed y'
determined.
All plumbigr txtures including, sinks I faucets, etc. are covere
d under the dumbing
Fixtures Allowance
ELECTRICAL
Demolition-Demolition ofall wiring, receptacles, switches, and fixtures necessary.
Remove, reroute, and relocate wiring as necessary.
y
General-Provide standard white receptacles and GFCI receptacles as required by the
code in all new areas and all areas to be renovated.
Appliances-Provisions for the following appliances: refrigerator, beverage refrigerator,
dishwasher, gas range, exhaust fan, microwave, garbage disposal, and trash compactor. All
new appliances to be GFCI/AFCI protected as required. p
Kitchen- Provide GFCI receptacles on the countertops, and island as required by code.
Switching for any recess lighting,pendant lighting, under counter lighting, incabinet lighting,
etc.
Miscellaneous-All circuits will be tied into the existing panel. If the circuits required
do not fit in the existing panel, a subpanel will be installed at a location to be determined.
This estimate does not include an work on are rotection Smokes CO2 etc
NOTE: The costo all recessli titin endant li h '
accent la tits ceilin trn vanityli tits under cabinet in cabinet
xtures ex
haust ans
coach la tits etc is covered under an allowance.
MADDEN RESIDENCE
I,
ALLOWANCES
The following allowances are included in this estimate. The allowances exist to cover the
purchase of materials only, unless otherwise specified. Any amount spent in excess of an
allowance will incur extra cost. Any amount less than the allowance will warrant a credit.
Upon completion of the project any extra cost or credits will be issued.
CABINETRY-$30,000.00
This allowance covers the cost of all cabinetry and their associated moldings, glass,
shelving, accessories, and hardware.
n
Uj l L COUNTERTOPS-$7,500.00
f et's
costs. This allowance covers the cost of all countertops and their associated template and installation
V
PLUMBING FIXTURES-$1,S00.00
This allowance covers the cost of all plumbing fixtures including but not limited to: sinks,
faucets, soap dispensers, accessories, etc.
LIGHT FIXTURES-$2,500.00
This allowance covers the cost of all light fixtures. This allowance covers the cost of labor and
materials for recess lighting, under cabinet lighting, in-cabinet lighting, and any specialty faxtures,
including timers, dimmers, etc.
Example: S"LED Recess light w/air tight trim, white baffle, and LED bulb-$200.00 Complete
Example: S"Recess light w/air tight trim, white baffle, and Halogen bulb-$160.00 Complete
WINDOWS UNITS-$2,000.00
This allowance covers the cost of all window units and their associated grills, hardware, screens,
and extension jambs.
TILE BACKSPLASH-$1,500.00
This allowance covers the cost of all tile, materials, and labor associated with installing,
grouting, and sealing a tile backsplash.
FLOORING- $5,000.00
This allowance covers the cost of the for the back hallway. This allowances covers the cost of
materials and labor for installation, staining, and refinishing of any new or existinghardwoodflooring.
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MADDEN RESIDENCE
MISCELLANEOUS
This contract does not include any interior or exterior painting.
This contract is subject to review upon receipt of the final cabinet plan and final appliance
schedule. DM Construction reserves the right to adjust the price of the contract after
reviewing these. Cost could increase if any changes had an impact on plumbing, venting,
structural work, change of framing plans,more cabinetry, additional appliances, etc..
Note: Due to the nature of wood and the drastic temperature and humidity changes in our
region,you may notice the movement and shrinking of the flooring and exterior and interior
trim. This is typical of the region and is not due to defective installation.
Change Orders Any changes from the existing plans or increased scope of work involving
extra costs will become an extra charge over and above the contract price. Change order
agreements must be signed before any work commences.
The following schedule will be adhered to, unless circumstances beyond our control arise:
Time frame for completion: When demolition begins to completion .1-I3 weeks*
*Subject to delays beyond our control.
(ie. delays associated with delivery of products, customer change orders, etc.)
All work to be done Monday-Friday between the hours of 7.00 am—6:00 pm.
If deemed necessary to work any other times, the homeowner will be consulted first.
MEMBER OF THE BETTER BUSINESS BUREAU
HOME IMPROVEMENT CONTRACTOR: 124961
CONST RUCTIONSUPERVISOR LICENSE:CS 066342
All home improvement contractors and subcontractors shall be registered. Any inquiries
about a contractor or subcontractor relating to registration shall be directed to:
Office of Consumer Affairs and Business Regulation
Ten Park Plaza,Suite 5170 ',.
Boston,MA 02113
Phone: (617) 973-8700
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FILLER FASCIA -
DM Construction
Building with the QUALITY and Character of yestetyean
44 Addison Ave Ext.
Methuen, MA 01844
(978) 685-3037
i
NOTICE OF CANCELLATION
October 4,2016
You may cancel this transaction, without any penalty or obligation, within three business days
from the above date.
If you cancel, any property traded in, any payments made by you under the agreement, and any
negotiable instrument executed by you will be returned within ten business days following receipt by
the seller ofyour cancellation notice, and any security interest arising out of transaction will be
cancelled
I
If you cancel,you must make available to the seller at your residence,in substantially as good
condition as when received,any goods delivered to you under this agreement;or you may if you wish,
comply with the instructions of the seller regarding the return shipment of the goods at the seller's
expense and risk.
If you do make the goods available to the seller and the seller does not pick them up within
twenty days of the date of your notice of cancellation,you may retain or dispose of the goods without
any further obligation. If you fail to make the goods availableto the seller,or if you agree to return
the contract.
the goods to the seller and fail to do so,then you remain liable for performance of all obligations under
To cancel this transaction,mail or deliver a signed and dated copy of this cancellation notice
or any other written notice to:
NAME OF SELLER: DARRENAMRTINO
ADDRESS: 44 ADDISONA VE EXT METHUEN,MA 01844
NOT LATER THANMIDNIG VT OF.• October 7 2016
I HEREBY CANCEL THIS TRANSCATION
Date.-
Buyer's
ate.Buyer's Signature:
I(we each)acknowledge receipt of two copies of this form.
Buyer.
Buyer:
4 --
DM Construction119=i6
Building with the QUALITY and Character of yesteryear.
44 Addison Ave Ext.
Methuen, MA 01844
(978) 685-3037
CONTRACTOR ARBITRATAION AGREEMENT
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.
The Contractor(Darren Martino) and the Homeowners (Jack& Mary Ellen Madden)
hereby mutually agree in advance that in the event the contractor has a dispute concerning
this contract,the contractor may submit the dispute to t
p o a private arbitration
been approved by the Secretary of the Executive firm which has
ive Office of
Consumer Affairs
Regulation and the consumer shall be required to submit t rs and Business
Massachusetts General Laws, chapter 142A. o such arbitration as provided In
P
lomeg�ner—ls Signature
C to igna e
o owner s Signature
L
k* Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-066342
Construction Supervisor
DARREN MARTINO� ,�
44 ADDISON AVE EXToY
METHUEN MA 0'1844 v
"M l� Expiration:
Commissioner 08/16/2017
c lretf'o»2w10)1weal/ll of 911�r1J(-rcl[rse/6
Office of Consumer Affairs&Business Regulation
rOME IMPROVEMENT CONTRACTOR
egistration: 124961 Type:
xpiration: 9/17/2017 Individual
DARREN MARTINO
Darren MARTINO
44 ADDISON AVE.EXT.
METHUEN,MA 01844 Undersecretary
i
ry The Commonwealth oftllassachusetts
Department ofIndustrialAceldiks
Office of Investigations
600 Washington.Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:BuildersfContractors/Electricians/Plumbers
Applicant Information Please Print Ledbiy
Name(Business/OrganizatiorAndividual): pAkale A
Address: L/ 4b0lfaN ^t� X91 -
City/State/Zip: e 1(I l, YK O l f i/V Phone#: 9 79- (FS-3 0?7
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
mployees(full and/or part-time).* have hired the sub-contractors
2I am a sole proprietor or partner- listed on the attached sheet.z t 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 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.F1 Plumbing repairs or additions
myself. [No workers' comp. c.152,§1(4),and we have no 12.❑Roof repairs
insurance required.] employees.[No workers' 13.❑Other
comp,insurance required]
'Any applicant that checks box#1 must also fill outthe section below showing their workers'compensation policy information.
T Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit a new affidavit indicating such.
?Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
.t am an employer th at is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:.
- -- -- - .. . .. - - - . . .. ...... . .. . .. . .. ....... .. _. .. _...__..----------
Policy 4 or Self-ins.Lic.#: 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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one=year imprisonment,as well.as civil penalties in the forin of a STOP WORK ORDER and a fine
of up to$250.0 0 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.
.l do hereby cert under tthhe pains andpenalties ofperjury that the information provided above is true and correct.
Date: Z V-7-1-7
Phone 0: 11 3
Official use only. Dig not write in this area,to be cornpleted by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CitylTown CIerk 4.Electrical Inspector 5.PIumbing Inspector
6.Other - - -
Contact Person: Phone#:
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 ofhire,•
express or implied,oral or.written."
An employeY is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
Of the foregoing engaged in a j oint 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 Ideal 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 producedacceptable 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 ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapterhave 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),addresses)and phone number(s)along with their certificates)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-andprintecl legibly: The D epait�rierit leas 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 oz permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
`Z'hoozxoz� �aXti o �1?assa.,cl�v.:sPtts -
Dep.axtmez�t offadu�Wal,accidents
offiice of lave'stigatio.'lls.
600 Wasbiugtou Sft,ed
DOAQn}NIDA.02111
Tel,#61.7-727,4.900 0A 406 ox 1-577-MASSME
Revised 5-26-05 FaY,#617-727-7749