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HomeMy WebLinkAboutBuilding Permit #241-14 - 38 BRADSTREET ROAD 9/18/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 4 Date Received Date Issued: K�5 PORTANT:Applicant must complete all items on this page t •';c.- "+ 'y3- �1 '�lF� moi' .�' b- ,,._. - ' .+' r" � } �, - e� # �LOCATfI@. a a .i..�cs.-.T•r�`�F.'"� �.tip Y`•.� s 'i2 ear .3 x .. Frlfit�, " "k" t..l.-� �dv;wb .,F r�' -+rf.. E� '� 'a Fi._ PR®PERTY ®WNER' 1 x";r a'-� "�NIAP! r1 ®; _ = ,�1PARCEL �rsZ�®NI�NG DISTRICT' _ Historcj®ist�ict{ yes #no '' Villa9? -�kYeS °:onok TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial 2-Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other x _ � p ,i •.yl.,l. -i" z+c a f <-""h' i"'i..tris -"r° '� "�.'- , tr -Y+t`v -19 Septic --,510'11e€ ��� T; ®�F oodplainp Wetlands ; x 1 ❑ Watershed District 's .04Water/Sewer10b0j � h 6 _.r..t. -. ._.. -a.-,+:.......o��'- � r�d.'3._M1.-..s�tr-'� ...�..+na.rr-_:•+tit.-...a..+�,�..«-�+.�.r��.�a -�'tt'.'�� �""t*��-:�l�e�,t..�.:aa�`r�ac-r�rc �'..;ff3a=..`�.oa..fi��..s:.R DESCRIPTION OF WORK TO BE PERFORMED: o� Identification Please Type or Print Clearly) OWNER: Name:.. ,. IL Wd.)S k Phone: Address: f3 recAS�ree-- 2�c �•' nz *4. M. z4y,'� 's�'. .#;.'+: r w 1..sW' a.r., .� •�w;s �' 'r_ '� ,'vy+"•.': . .'➢'� ,r'' a�%;t?�.,-,k� Fa ,'s CONTTOR Name y� x Phone +F., �,, 71z �,.1,117,17M.- 3a teq"-* 'g rF' w'�] +7 Tittoa la k �•R, ��.�. .Y"�'�E.'�rgs�w�aa+ •,'�+�; 5. -r �� � � ..;�E�'�7�r., �-a. � .+ � �t��� f� r$ ,14 v ., `a,.T S � � y s..f� 7 ".�� Y� � �'`k• F Suu ervisorxs3C:onsfructionLicenseOiY �� �° r # yp 7� . - Exp �Date 3oL �3 * Horne Improvement,License� > L� /,O,ap7� , :Exp Date .��.�. x....-..;-�;•:>n..�.r.;;�,.a.....$nxw^.w:,r,.-m �;S a_�.a..s:.;iG• s> a'.t"�i.. xk,r,...� 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: $_ /1 x;69,00 FEE: $ Check No.: �C � f° Receipt No.: NOTE: .Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Sig`1ature of contractor , Plans Submitted FJ Plans Waived ❑ Certified Plot Plan ❑ St ped Plans ❑ i Location G ds4,-e� No. y Date-! z: e j • - TOWN OF NORTH ANDOVER 9 •.:5��is�D���i' Certificate of Occupancy $; p.' Building/Frame Permit Fee Foundation Permit Fee 9 Other Permit Fee $ .TOTAL $ Check#, G9 ` Building Inspector t4G 1 F Plans Submitted❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE:OF SEWERAGE:DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ _ Swimming Pools El 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 i .CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS i Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Severer Connection/Signature& Date Driveway Permit DPW Toiv;s Engineer: Signature: Located 384 Osgood Street FIRE-DEPARTMENT Temp Dumpster on site yes no Located-at 124 Mair Street.- ire ®epartmbrit 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.fiine NOTES and DATA— (For department use El Notified for pickup - Date a Doe-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. Roofiv,g, Siding, Interior Rehabilitation Permits ❑ Building Permit Application o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o 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 a Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Mass check Energy Compliance Report (If Applicable) o 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 o Certified Proposed Plot Plan , o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) a 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 cans.if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apo,-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Dac.Buil,iing permit Revised 2012 pORTH own oAndover 0 . 0 No. - LAK. h ver, Mass, �� 3 COC NI CNl WIC. �d A04ArED /`P���S S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT M .......... BUILDING INSPECTOR g Foundation has permission to erect .......................... buildings .� ..... .�.� ......... Rough - � to be occupied as .. !....... .. .. ........ .......... .�... d ..s .... .... 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 CONSTRUC TS Rough ...... Service .......... .. ...... ............ ......................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy 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. SEE REVERSE SIDE Client#:490547 JOHNHORA ACOR& CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDDlYYYY) 5/30/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terns and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 5241F-�CT USI Insurance Services LLC PHONE 603 625-1100 PO Box 6360 A/c No Et): ac,No: E-MAIL Manchester,NH 03108-6360 ADDRESS: INSURERS) It AFFORDING COVERAGE NAIC 603 625-1100 INSURER A:Maine Mutual Group Insurance Co 15997 INSURED John Horan Construction LLC INSURER a:EastGuard Insurance Company 14702 21 Evergreen Dr. INSURER C: Hampstead,NH 03841 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MR TYPE OF INSURANCE NSR NND POLICY NUMBER MMIDDAUD—L SRY EFF IYTIM MPH0 0UCY EXP LIMITS A GENERAL LIABILITY SC10955638 W0112013 0410112014 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ee owl,°Irence $250 000 CLAIMS MADE a OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY EO- LOC A AUTOMOBILE Lu►sILnYKA1095663$ 0112013 04/01/201 c eM.B11oano E LIMIT $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOSX NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ $ A X EM ESS LA LLB OCCUR KU10955638 0112013 04/011201 EACH OCCURRENCE $1,000,000 EXCESS LIAa CLAIMS-MADE AGGREGATE $1,000,000 DED RETENTION $ B WORKERS COMPENSATION JOWC443891 0112013 04/01/201 X wC sTATu- OTH- AND EMPLOYERS•LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVEEXCLUDED? YIN F-L EACH ACCIDENT $500 000 IR OFFlCERIMEMBER EXCLUDED? Y N/A I Mandatory in NH)and E.L.DISEASE-EA EMPLOYEE $500.000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,N more space is required) This certificate covers all operations usual and customary to the insured's business. CERTIFICATE HOLDER CANCELLATION "For Information Purposes only" SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S9787808/M9787782 LCACA John Moran Construction, L.L.C. (Buififing andWmodefng 21 Evergreen Drive phone 603-329-6209 Hampstead,NH 03841 fax 603-329-6209 May 2, 2013 Matt&Christen Walsh 33 Bradstreet Rd. No. Andover, MA 01845 Dear Matt and Christen: This is an estimate to install replacement windows in your house as follows: 1. Remove windows and storm windows. 2. Remove interior casings to insulatepockets and reinstall casings. 3. Install Andersen Woodwright Double-Hung windows according to specifications on your Jackson Lumber quote. Total of 22 windows. 4. Procedures to be in accordance with RRP lead safe regulations. 5. Disposal of debris is included. 6. I will apply for permit. 7. No painting included. Cost: $19,368.00 Respectfully submitted, John Horan Page 1 ' State of Massachusetts Home Improvement Contractor License#102071 State of Massachusetts Construction Supervisor License#47989 NAT-24639-1 Massachusetts Home Improvement Sample Contract This form satisfies all basic regairemeuts of the states Home Improvement Contractor Law(MOL dopter 142A but does not include standard age to Pmt hemeownem Seek legal advieeif ns ry Any Person Planninghome' Massachusetts Consumer Guide to Home Improvement"hefore 'dente You mnts ay first obtain a copy ll ng Office of Consiam Affairs and gadnea Information�' on 617-973youres-97 7 Yon may obtain a fire copy by calling the Regidffiiods CemsOmer htfomiation Hotline at 617-A73-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Namey Name StrectMaess(do not useaPda Office Bax address) C�traetodSat /p Name cilyfrown State Tip Code g• N O f .cssAfidmn(mug include a street address) � dX51 r. Evening Phone Cny awn Vstate ZIP code Mailing Address(h eliffi w 1mm above) E 3 •6 Fmpleryer W or&&Number r••,avm,a+eart�taame 7az7) 7 � -30 The Contractor agrees to do the following work for the Homeowner. / y tlesurbeinddm7die work tocompleted,specifying tlagMbrand,aadWade ofmaterials tobeused,weadditionel Required Pamirs-The fol burl and will be severed the lowing �g; Zt aro�� Proposed Start and Ceimpletron Schedule-The following schedule willby contractor as the homeowners agent: be adhered in unless circumstances beyond the contractors control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work MGL chapter 142A.) Date when Contracted work will be substantially completed. Total Contract price and Payment Schedule The Cantracturagrees to perform the weals fmmish the material and labor specified above for the total stmt oe Payments will be made according to the Mowing schednle: $ upon signing Contract(not to exceed W ofthe total contract price gI the cost of special order rtenn ' s,whichever is greater) $ by 1 J or upon completion of $ by orupon completion of $ Upon completion of the contract (Law forbids demanding fall Payment until contract is completed to both P party's satisfaction) Thefoltowingm I aVequipmemtmustbeapecial $ �to be paid for Witt�OW3 .t ]r wdavd beforethecmftacted weir begirtm order t•maeiriceeomptedM (6*) S to be paid for NOTES:(_)Including all face charges(__)law-pares that any depit or d—Taymmt-pureed by 60 connector before woik act card&egcmw of(a)ane4i d efthetoW conned price Q(b)tbeamW coat afmy special equipment er�m�- whieh mint be special ordered m eidvaseetn meet thecample5m sdhwhft waa.9...._t.a an spiv bin•n.nv:r..i t r the contraemi� ❑No�]Yet(alt r Subcontractors The oontructor agrees to be sold most ad•cted to�•eoatraett y retponsble fm compledson of the work desarbed regardless 0f the actions of any third patty/subcontractor utilmad by the contractor The oonhacxorfiutber agrees to be solelmaterials at4 this — y responsible for all payments to all subcontractors for Contract Amept m imply Upon signing i contract shall not this documea becomes a buidmg cmftadmmder im Unless otherwise noted within this doatmam,the mply that air Sen or other security interest has been placed an the residence.Review the following cantions and notices erre idly before sigomg this contra • Don't be press"red into signing the contract Take time in read and MY understand it Ask • Make scar the ceUtractor Iters a said Home„narove,naet r questions if Something 1S unclear subin be I.The law requires most home improvement contractors and registered with the Director of Home LWoveonent Contractor Registration.You may inquire about contractor registration by writing to the Director at 10 PaokPlaak Room 5170,Boston,MA 02116 or by calling 617-973.7;787 or 888-283_3757. • Dens the contiam have insurance?Ask the Cemtiaetor for his insurance company imarmation so that you can ceofirm mask o sex a copy of a']trooterf insurance?'docameat • Know yew rights and responsibilitim Read the hnpeatont In bmmtwn on the reverse side of this fmn a� Guide to the Home Improvem mt Contractor Law. get a entry erfthe Consumer You may caned this agreement ifit has been signed at a Place:othe�IFTHERF the contractees normal place of business,provided you notify the co7WacW m writing at hiVbwmam office on knack office by ordimail posted,by tel thirdbusinessdayfollowingtheelgungofdrisagreement Seethenotice of on or oneInterthanmiemightofthe DO NOT SIGN THIS CONTRACT team formiPAC of thirteARE ANY BLANKSPAtCESttr i eampiered ead�red.Oce etggsbouldgoeo�e bameoemri'mea�eopyatoaidbekepeby ere ceatraemc �4� Homeowner's Si 0r's Signature Date Z 02A I Data 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. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required lHomaeesSignature rbitration as provided In Massachusetts General Laws,chapter 142A. 1 Con toes Signature NOTICE:The signatures of the parties above apply only to the agreement f the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. 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 LhWlicate 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 fiords 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 bttn:/hv��m-.mass.eo�docabr/ 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 litlp:/h+,\v%v.inass.gov/oeabt-/ Go online to view the status of a Home Improvement Contractor's Registration: lit#n'//db state ma tis/llameimprovernent/lieenseeligt M 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 2.1-1122/2010 Massaehusefz.S--Dep"ent 4t Public Safety Boards of Bu'iiding Reguiations.i�ind Standards License: CS-047989 JOHN V HORA N { 21 EVERGMN DR ' Hampstead*1 03841 .f t s . 'd A Ex irat:0n Commissioner 03/02/2014 �(' 7��lJJrZC�trP�") Office of Consumer Affairs&Busidess Regulation ME IMPROVEMENT CONTRACTOR _ Registration 1'02071 Type. x iration:--,61-30/2014- DBA aj p _ _ _ JOHN V.HORAN CONSTRUCTION `y r' John Horan 21 EVERGREEN DRIVE HAMPSTEAD,NH 03841 Undersecretary ------------- License or registration validfor individul:use only befoi a the e7cptrafton date.. Iffound`ietufn to: icerof t?aioisumer=43Tai sand Busiit sr. egulation 1ii:L_a�1� la2rar Suttc X170 r r Not valid without signatflr�e ?T ` The Commonwealth of Massachusetts Department oflndustriglAccidents Office of Investigations 600 Washington.Street Boston,MA 02111 www.massgov1d a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0bly Name(Business/Organi'zation/Tndividual): �p�.^ Ho roue (.oh ol_ca on Address: D r i v e S City/State/Zip: �t d -nq f Phone#: 60 3 3oLii - 6,1_0 i Are you an employer?Check the appropriate box: Type of project(required): 1.[W I am a employer with —3 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.T �• modeling ship and'have no employees These sub-contractors have 8. ❑Demolition workers'com insurance. working forme in any capacity. P• 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]i employees.[No workers 13.❑Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing woYkers'compensation insurance for my employees. Below is the policy antijob site information. Insurance Company Name% l��R.S� 6 ur rJ lr%sy ou.r•ae. 6'®MQ6,4 e/ Policy#or Self-ins.Lie.#: 0 ill G Expiration Date: Job Site Address: .33 Q ruks arc,+ Pat. City/State/Zip: ASA &do w r 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 MCL 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 cerfiffy under A g pains and penaltles ofperjury that the information provided above is true anti correct - Signature: Date: Phone#: boJ 3,0 — 6 a2-D c� Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - f nnfarf PPrcnn! Phone#: Information ation 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 ofhire,- express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152 2 �° p ,§ SC(6)also states that every state or loeal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." p g q . 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 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 necessaM.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 LL C or LLP does have employees,a policy is required. De advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must sub mitmultiple ennit/license aplications' n' 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. Anew affidavit must be filled out each year.Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The 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: The Go ouwmlt� ofMassahwetts Aepartmeut ofIndusWal Accidents- Office A.ccidentsOffice of I.'ayestigafi•;oaas 600 Vias toytree S t Boston MA 021 Z Z Tel,#61.7-727-4900 ort 406 ox 1-877�MASSA.FE Fay,#617-727-7749 Revised 5-26-05 _ F,