HomeMy WebLinkAboutBuilding Permit #694-2017 - 35 PENNI LANE 1/5/2017Permit No#: tog 4 — 91.0
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION '
Date Received
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TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
X One family
❑ Addition
❑ Two or more family
❑ Industrial
;Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
Ej Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
- Se tic V1/e11
q Floodplain O et ands
Waterstiec! ®►sf�ic
.Water/Sewer<:
DESCRIPTION OF WORK TO BE PERFORMED:
Identification - Please Type or Print Clearly -
OWNER: Name: Q ac tea. L��c �t\ cx t n Phone: q7�b �� `� 5
Address:��\N
-Contiacfor Narne--,T7w�,. C_ I- k -A Phone: G1.2 -- - C .... i.9-(a�-
Address:�-
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Date .1 i.
5upeivisors Construction License
77
Ex Date.:. _`��:`=c --- - -
HnmP Imnro�ement. L=icense.:.._ \. �_ .prP . -
ARCH ITECTIE NG IN EER
ARCHITECTIENGINEER CSA PT Phone:
Address: Reg. No..
FEE SCHEDULE. BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
_ ,Total Project Cost: $t_wo of9t FEE: $ V
Check No.: f l y Receipt No:: 3 r Y D
1'e�sons e t�acting �vitii un�egiste�ed contractors do not have: access, to the gu aranty fund
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
o 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)
o Mass check Energy Compliance Report (If Applicable)
o Engineering Affidavits for Engineered products
VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
o Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
• Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
o 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
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 PermiYRevised2014
Plans Submitted ❑
Plans Waived Q Certified Plot Plan ❑ Stamped Plans ❑
'TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/MassageBody Art ❑
S` haA—dng'pools ❑
Well ❑❑
Tobacco Sales
}ac',,4 .-
Food Pkaging%Sales ❑
Private (septic tang etc. AL
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
Signature
CONSERVATION Reviewed on Sianature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
,Zoning Board of Appeals: Variance, Petition No: Zoning Decisionfreceipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Con nectionlsignature , Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT* -.Temp Dumpster on site yes no
Located at 124 MainStreet
Fire Department signatureldate
`Nmension
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 lies No
®ANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$10D-$1000 fine
Doc.Building Permit Revised 2014
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
I 30,000.00
m
$ -
$
360.00
Plumbing Fee
$
45.00
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
45.00
Total fees collected
$
550.00
35 Penni Lane
694-2017 on 1/5/2017
bathroom remodel - 2
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CONTRACTOR:
ADDRESS:
EIN# : 36-4736058
PHONE: (978) 500 - 9960
CS# CS073793
Standard Form of Agreement/Contract
TINKHAM BUILDING &FREMODELING
17 SALVATORE CIRCLE
DANVERS, MA 01923
Property Owner(s): Anthony and Norma Lochman
ADDRESS: 35 Penni Lane
North Andover, MA
December 31, 2016
I. PARTIES
This contract (hereinafter referred to as "Agreement") is made and entered into on this
December 31, 2016, by and between Anthony and Norma Lochman (hereinafter
referred to as "Owner"); and Tinkham Building & Remodeling (hereinafter referred to
as "Contractor"). In consideration of the mutual promises contained herein, Contractor
agrees to perform the following work: Remodel two bathrooms.
Il. GENERAL SCOPE OF WORK DESCRIPTION
The Contractor proposes to construct and supply all materials for....
Division 1- General Conditions, Building Permit,
Trash/Debris removal,FD Inspection
$4,000.00
Division 2- Carpentry Labor
$11,300.00
Division 3- Electrical
$4,500.00
Division 4- Mechanical Systems, Plumbing
$9,950.00
Division 5- Allowances
$300.00
LUMP SUM PRICE FOR ALL WORK ABOVE: $30,050.00
III. GENERAL CONDITIONS FOR THE AGREEMENT ABOVE
A. EXCLUSIONS
This Agreement does not include labor or materials or the following work:
STANDARD EXCLUSIONS: Unless specifically included in the "General Scope of Work"
section above, this Agreement does not include labor and materials for the following
work: Engineering fees, or governmental permits and fees of any kind. Testing, removal
and disposal of any materials containing asbestos (or any other hazardous material as
defined by the EPA). Custom milling of any wood for use in project. Moving Owner's
property around site. Labor or materials required to repair or replace any Owner -
supplied materials. Repair of concealed underground utilities not located on prints or
physically staked out by Owner which is damaged during construction. Surveying that
may be required to establish accurate property boundaries for setback purposes (fences
and old stakes may not be located on actual property lines). Final construction cleaning
(Contractor will leave site in "broom swept condition). Landscaping and irrigation work of
any kind. Temporary sanitation, power or fencing. Correction of concealed substandard
framing, correction of existing out -of -plumb or out -of -level conditions in existing
structure. Rerouting/removal of vents, pipes, ducts, structural members, wiring or
conduits, steel mesh which may be discovered in the removal of walls or the cutting of
openings in walls. Removal or replacement of existing rot or insect infestation. Failure of
surrounding part of existing structure, despite Contractor's good faith efforts to minimize
damage, such as plaster or drywall cracking and popped nails in adjacent rooms, or
blockage of pipes or plumbing fixtures caused by loosened rust within pipes. Exact
matching of existing finishes. Public or private utility connection fees. Repair of damage
to roadways, driveways, or sidewalks that could occur when construction equipment
and vehicles are being used in the normal course of construction.
B. DATE OF WORK COMMENCEMENT AND SUBSTANTIAL COMPLETION
Commence work on, or before January 16, 2017. Construction time through substantial
completion: Approximately SIX WEEKS, not including delays and adjustments for
delays 'caused by: inclement weather, accidents, additional time required for
performance of Additional Work Order Authorization work (as specified in each
Additional Work Order Authorization), delays caused by owner, and other delays
unavoidable or beyond the control of the Contractor. Delays caused by Owner, resulting
in Contractor pulling off the job due to Contractor's ability to perform the work under this
Agreement may be charged a re -mobilization fee based upon the discretionary decision
of Contractor.
C. EXPIRATION OF THIS AGREEMENT
This Agreement will expire 10 days after the date at the top of page one of this
Agreement if not accepted in writing by Owner and returned to Contractor within that
time.
D. ADDITIONAL WORK ORDER AUTHORIZATIONS: CONCEALED CONDITIONS,
ADDITIONAL WORK, AND CHANGES IN THE WORK
1. CONCEALED CONDITIONS: This Agreement is based solely on the
observations Contractor was able to make with the structure in its current
condition at the time this Agreement was bid. If additional concealed conditions
are discovered once work has commenced which were not visible at the time
2
this proposal was bid, Contractor will stop work and point out these unforeseen
concealed conditions to Owner so that Owner and Contractor can execute an
Additional Work Order Authorization for any Additional Work.
2. CHANGES IN THE WORK: During the course of the project, Owner may order
changes in the work (both additions and deletions). Contractor will determine the
cost of these changes and the additional cost of this Additional Work will be
added to this Agreement. The cost is established by adding a 20% gross profit
margin onto materials, equipment and subcontractor costs and at the following
Tinkham Building & Remodeling labor rates: Lead Carpenter $70/hr, Laborer-
$30/hr.
3. DEVIATION FROM SCOPE OF WORK: Any alteration or deviation from the
Scope of Work referred to in the Contract Documents involving extra costs of
materials or labor (including any overage on Allowance work) will be executed
upon a written Additional Work Order Authorization issued by Contractor and
should be signed by Contractor and Owner prior to the commencement of
Additional Work by the Contractor. This Additional Work Order Authorization will
become an extra charge over and above the Lump Sum Price referred to at the
beginning of this Agreement.
4. CHANGES REQUIRED BY PLAN CHECKERS OR FIELD INSPECTORS: Any
increase in the Scope of Work set forth in these Contract Documents which is
required by plan checkers or field inspectors with the city, town or county
building/planning departments will be treated as Additional Work to this Agreement
for which the Contractor will issue an Additional Work Order Authorization.
E. PAYMENT SCHEDULE AND PAYMENT TERMS
1. PAYMENT SCHEDULE:
First Payment: Deposit is due when Agreement is signed
and returned to Contractor.
Second Payment: Due upon completion of demolition
Third Payment: Due upon rough inspection
Fourth Payment: Due upon installation of tile
Fifth Payment: Due upon installation of plumbing fixtures
Sixth Payment: Due upon substantial completion
Total Payments:
3
$6,000.00
$6,000.00
$6,000.00
$6,000.00
$3,000.00
$3,050.00
$30,050.00
v
2. SUBSTANTIAL COMPLETION PAYMENT: Substantial completion is defined as the
Contractor having substantially completed the scope of work as contracted, which will
allow the Owner to inhabit the property for its intended use. The Contractor shall
notify the Owner that the Contractor has substantially completed the project and a
final walk through of the project will be scheduled. A punch list of "incomplete" or
"repair" items shall be compiled during the final walk through and a dollar value
assigned to each item. This dollar value can be deducted from the `Substantial
Completion' payment and is due payable to Contractor at the start of completing each
`punch list' item. The 'Substantial Completion' payment is due promptly after final
walk through.
3. PAYMENT OF ADDITIONAL WORK ORDER AUTHORIZATION: Payment for each
Additional Work Order Authorization is due upon completion of Additional Work Order
Authorization work and submission of invoice by Contractor.
4. ADDITIONAL PAYMENTS FOR ALLOWANCE WORK AND RELATED CREDITS:
Payments for work designated in the Agreement as ALLOWANCE work has been
initially factored into the Lump Sum Price and Payment Schedule set forth in this
Agreement. If the actual cost of the ALLOWANCE work exceeds the line item
ALLOWANCE amount in the Agreement, the difference between the cost and the
line item ALLOWANCE amount stated in the Agreement will be written up by
Contractor as an Additional Work Order Authorization subject to Contractor's profit
and overhead.
If the cost of the ALLOWANCE work is less than the ALLOWANCE line item amount
listed in the Agreement, a credit will be issued to Owner after all billings related it this
particular line item ALLOWANCE work have been received by Contractor. This credit
will be applied toward the final payment owing under the Agreement. Contractor profit
and overhead and any supervisory labor will not be credited back to Owner for
ALLOWANCE work.
F. WARRANTY
Contractor provides a limited warranty on all Contractor- and Subcontractor -supplied
labor and materials used on this project for a period of one year following substantial
completion of all work.
No warranty is 'provided by Contractor on any materials furnished by the Owner for
installation. No warranty is provided on any existing materials that are moved and/or
reinstalled by the Contractor within the dwelling (including any warranty that
existing/used materials will not be damaged during the removal and reinstallation
process). One year after substantial completion of the project, the Owner's sole remedy
(for materials and labor) on all materials that are covered by a manufacturesVs warranty
is strictly with the manufacturer, not with the Contractor.
Repair of the following items is specifically excluded from Contractor's warranty:
4
Damages resulting from lack of , Owner maintenance; damages resulting from Owner
abuse or ordinary wear and tear; deviations that arise such as the minor cracking of
concrete, stucco and plaster; minor stress fractures in drywall due to the curing of
lumber; warping and deflection of wood; shrinkage/cracking of grouts and caulking;
fading of paints and finishes exposed to sunlight.
THE EXPRESS WARRANTIES CONTAINED HERIN ARE IN LIEU OF ALL OTHER
WARRANTIES, EXPRESS OR IMPLIED, INCLUDING ANY WARRANTIES OF
MERCHANTABILITY, HABITABILITY, OR FITNESS FOR A PARTICULAR USE OR
PURPOSE. THIS LIMITED WARRANTY EXCLUDES CONSEQUENTIAL AND
INCIDENTAL DAMAGES AND LIMITS THE DURATION OF IMPLIED WARRANTIES
TO THE FULLEST EXTENT PERMISSIBLE UNDER STATE AND FEDERAL LAW.
G. CONFLICT OF DOCUMENTS
If any conflict should arise between the plans, specifications, addenda to plans, and this
Agreement, then the terms and conditions of this Agreement shall be controlling and
binding upon the parties to this Agreement.
H. MATCHING EXISTING FINISHES
Where Contractor's work involves the "matching of existing finishes or material"
Contractor will use reasonable efforts to match existing finishes and material. However,
Contractor does not guarantee an exact match due to such factors as discoloration due
to the aging process, difference in dye lots and difficulty of exactly matching certain
finishes, colors and planes.
I. WORK STOPPAGE, TERMINATION OF CONTRACT FOR DEFAULT, AND
INTEREST
Contractor shall have the right to stop all work on the project and keep the job idle if
payments are not made to Contractor in accordance with the Payment Schedule in this
Agreement, or if Owner repeatedly fails or refuses to furnish Contractor with access to
the job site and/or product selections or information necessary for the advancement of
Contractor's work. Simultaneous with stopping work on the project, the Contractor must
give Owner written notice of the nature of Owner's default and must also give the Owner
a 14- day period in which to cure this default.
If work is stopped due to any of the above reasons (or for any other material breach of
contract by Owner) for a period of 14 days, and the Owner has failed to take significant
steps to cure his default, then Contractor may, without prejudicing any other remedies
Contractor may have, give written notice of termination of the Agreement to Owner and
demand payment for all completed work and material ordered through the date of work
stoppage, and any other loss sustained by Contractor, including Contractor's Profit and
Overhead on the balance of the incomplete work under the Agreement. Thereafter,
Contractor is relieved from all other contractual duties, including all Punch List and
warranty work.
J. DISPUTE RESOLUTION AND ATTORNEY'S FEES
E
F
Any controversy or claim arising out of or related to this Agreement involving an amount
of less than $5,000 (or the maximum limit of the court) must be heard in the Small
Claims Division of the Municipal Court in the county where the Contractor's office is
located. Any controversy or claim arising out of or related to this Agreement which is
over the dollar limit of the Small Claims Court must be settled by binding arbitration
administered by the American Arbitration Association in accordance with the
Construction Industry Arbitration Rules. Judgment upon the award may be entered in
any Court having jurisdiction thereof.
The prevailing party in any legal proceeding related to this Agreement shall be entitled
to payment of reasonable attorney's fees, costs, and expenses.
K. ENTIRE AGREEMENT, SEVERABILITY, AND MODIFICATION
This Agreement represents and contains, the entire agreement between the parties.
Prior discussions or verbal representations by the parties that are not contained in this
Agreement are not a part of this Agreement. In the event that any provision of this
Agreement is at any time held by a Court to be invalid or unenforceable, the parties
agree that all other provisions of this Agreement will remain in full force and effect. Any
future modification of this Agreement must be executed in writing in order to be valid
and binding upon the parties.
I. Insurance
Owner shall pay for and maintain "Course of Construction" or "Builders Risk" or any
other insurance that provides the same type of coverage to the Contractor's work in
progress during the course of the project. It is Owner's express responsibility to ensure
dwelling and all work in progress against all damage caused by fire and Acts of God
such as earthquakes, floods, etc.
The Contractor represents that it has purchased and agrees that it will keep in force for
the duration of the performance of the work or for such longer term as may be required
by this Agreement, in a company or companies lawfully authorized to do business in the
State of Massachusetts, such insurance as will protect Owner and the owner of the site,
if the site is not owned by Anthony and Norma Lochman from claims for loss or injury
which rise out of a result from Contractor's operations under this project, whether such
operations by the Contractor or by subcontractor or its subcontractors.
The Contractor represents and agrees that said insurance is written for and shall be
maintained in an amount not less than the limits of the liability specified below or
required by law, whichever coverage is greater. The Contractor certifies that coverage
written on a "claim made" form will be maintained without interruption from the
commencement of work until expiration of all applicable statutes of limitation.
1) Commercial General Liability with limits of not less than $1,000.000.00 per
occurrence.
M. LICENSES
6
r
All work shall be completed in a workman -like manner and in compliance with all
building codes and other applicable laws. To the extent required by law all work shall be
performed by individuals dully licensed and authorized by law to perform said work. The
Contractor and its subcontractor's shall be registered, and that any inquiries about the
Contractor or Subcontractor relating to a registration should be directed to:
Director, Home improvement Contractor Registration, One Ashburton Place, Room
1301, Boston, MA 02108. Telephone # (617) 727-8598.
N. ADDITIONAL TERMS AND CONDITION§
See pages (s) attached:. Yes No
have read and understood, and I agree to, all the terms and conditions contained in
the Agreement above.
\1�4W_--
Date
�- 311 Lo 1
Date
Tinkham Building & Remodeling David Tinkham
X �= ez-�i� w� ate-✓
01/05/2017 00:33 9787778415
PAGE 01
CERTIFICATE OF LIABILITY INSURANCE DATEXiWDD1YYM
CHIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THS/5/�o17
NERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER TRE COVERAGE AFFORDED 8Y TME POLICIES
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,
FLOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUiN(i INSURER(S), AUTHORIZED
IMPORTANT: If the Certificate holder la an AD V1I1URAL INSURED, the pollcy(la)
the bnris and conditions'"Uskoe endorsed It SU®RQt3ATION 18 WANED, subject to
of the P011Cy, certain pollClea may require an endoraemant A statement on this cerilScate doea not confer rights to the
CerNAwts holder In Ileu of such endOMoment(s).
COUNTY INSURANCE AGENCY INC INAM
123 Sylvan St PH : (978)774-2463 N,•(978)777-8415
Danvers, MA 01923 DRE
nouRa,�(a) ArraeplNG covwpa NAM
AMUREDTinkhant, David INSURER A : C012MrCe
INSURER B ; Travelers
Tinkham Building & Mmodeling INSURER C:
17 Salvatore Circle
Danvers, Ma 01923 INSURER D :
INSURER E
""r -^^"r -Q CERTIFICATE NUMBER;
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAW(EpIoAB NUMBER:
RTHE POLICY PERIOD
INpICATED, NOTWITIiSTANDING 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 Lc Al 141 ICPT IPA
EXCLUSIONS ANn cnMnl'rinue ne _.. _
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TYPE OF INSURANCE
GENERAL LIABILITY
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AUDWYA
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X COMMERCIAL GENERAL LIABILITY
PREM gE6 Ee ocau ranee i so 000
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CLAIMS MApEX OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
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AUTOMOBILE LIABILITY
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PERSONAL 6 ADV INJURY
GENERAL AGGREGATE $ 1,000 000
PRODUCTS - COMP/OP AGG $ 11000,000
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DCRIPTION OF OPERATIONS below
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5/27/165/27/17—E.L.
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EACH ACCIDENT i 100 000
E.L. DISEASE - EA EMPLOYEI $ 100,000
E.L. DISEASE -POLICY LIMIT $ .500 000
ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101. Add'diomi Rvnark s Sohadule, H more maca Is required)
larpentry ops
TE HOLDER
Town of North Andover
ATT: Paul Hutchins
North Andover, MA 01645
,CORD 25 (2010/05)
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 REPRE�
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0 1 988-201 0 ACORD COR'
The ACORD name and logo are reglstered marks of ACORD
TION. All rights reserved.
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De Commonwealth of Massachusetts
_ Department of ndustrialAccidents
H 1 Congress Street, Suite 100
d .8osto.a MA 02114 -2017
www mass.goPMa
•p•/b�M - ��v
Warkexs' Compensation Tnswrauce?' BSOMffrMs,'ciax�s/'lmnbexs.
TQ BE MEDvTPn ce Print ]
NaMo(Businessloiganizaiionllndividual) \ LL
1
Address:.
City/Siate'/ZiP: ' \')
Axe you an employer" Cb ecl the appropriate box:
1.❑ I am a employer with_ — _�MPloyees (fuIl and/or parttime).
2,R I am a sole proprietor or partacohiP andhage no employees Working forme iu
any capacity. [Noworkers' comp. insurance required]
3-[] I am ahomeownez doing all workmyself [No workers' comp. insurancerequired] i
4.n I am ahomeowner and will be biting coI to conduct all work onmy prop61tY- I v0
ensurethat all contractb3s eitherhave workers' compensation insurance or are sole
proprietors witi�-no employees.
s.FjI am a general contractor and Ihave haedthe sob -contactors listed ontbe attached sheet
These sub -contractors have employees andhavew-k-1r5' comp. insurance.
6.❑ We are a corporation and *, offcoers have exercisedtheirrigbt of'exeDTdonper MGL c.
' Irava no employes. jNo workers' comp. insurance required]
\rC VC
Phone 4: C( %
CT) RC(Gic)
Type oi<pro7ect (Tegrfted)=
7. ❑ Nei 6nst dd"on
8. ® Remodelm"g
9. ❑ Demolti077.
10 r] Building addition
ll.[] Electrical repairs or a.dditiops
12�[(:Plumbing repairs or additions
11 [] Roofrepairs
14. [] Other
152, §1(4), andwe -_
a hcantthatchecksbbX#lmusiaisofllo ihesectionbelourshowmgth�R'orkers'compensat[onpolicymfomration
;�� PP they are doing all work andthenhire outside contractors muss submit a new affidavit indite—raa such
I Homeowners who submit this ai$davrt indicating eY the name of the sub -contractors and state whether or notihose entities: have
?Contactors that checkthis 136j: nest attached an additional sheet showing co olic number.
emplcyeas. ifthesub-coutractorshaveemployees,theymustprogidetheir workers' mp.P Y
X am an em Zoyer that isproPidrng�'orlcer�s' compensation insurancefor my employees Below is tlzeporicy arzd jo�i site
p
information.
Insurance CompanyName:.
F,%piration Wo' 5J 2D f
Policy # or se1'f-ins. Lic. #:. `
Tob Site Address: 3� �G�� \ �� CiiT/State/Zip:
Attach a copy of the fvorkexs' co. mpensatiou policy, deelaxation page (sh�°y�pa ati n poems&a by a fi�ue up to $1,5 0 00 iration .
Failure to secure coverage as required under MGL c-1-52, §25A is a crlmul p,t25 0.
and/or one-year imprisonment; as -well as civil penalties in the form of a STOP WORK ORDER and a fine DIAof UP
to saran 0 a
day against the violator. A copy of this statement may be forwarded to the Of$ce oflnvestigations ofthe DIA foxmanCe
X do kere/iy certify under tlzeTdns anclpenalties ofperjury t%at the informotioB provz e
--�� Date: -t
,�1 atur Q L �3 �j
Phntte_
Of use only. Do not write ire this area, to be corrcpleter� by city or to�Yn offidaL
• Pexmit/Lieense #
City or Town'
fSsuingAnthoxity (circle one):eetox
,.Board of Eealth 2. Building Department 3. CitylTown. Clerk 4. ElecixiealXnspectox �. Plumbing �
6. Other
Phone
Contact Person,
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 ormore
Of the foregoing engaged in a joint eniexprise, and including the legal representatives of a deceased employer, or the
xeceiver'or, trasiee pf an individual, partnership, association or other legal entity, employing emplbyeeg.. 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 dwellvig house
or on the grounds or building appurtenant thereto shall not because of such employment b6 deemed to be an employer."
MGT., 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
applicaintwlid bras not produced -acceptable evidence of compliancewith the insurance coverage required."
Additionally, MGL chapter 152, §25CM states `Weithex 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 ofthi 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 sab=contractors) name(s), addresses) and phone number(s) along with their certiftcate(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 orLLP d6es have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation ofinsurance 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
Iudusixial-Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensatiori.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 p ermit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given pear, need only submit one affidavit indicating current
PORGY 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 b eon officially stamp ed or marked by the city or town. may b e provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filed out each
year_ Where ahome owner or citizen is obtaining alicense or permit notrelated to any business or commercial venture
(i. e. a dog license or permit to burn leaves etc) said person is NOT requited to complete this affidavit.
The Department's address, telephone and fax number_
The Commonwealth of Massachusetts
Department of lndusirial.Accidents
1 Congress Street, Suite 1.00
.Basion, MA 02114-2017
Tel. # 617.727-4900 ext. 7406 or 1-877 MASSAFE
Fax # 617-727-7749
Revised 02-23-15 wwwma8s.gov1dia
Commissioner
i
c pi ratio W.
03107/2018