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HomeMy WebLinkAboutBuilding Permit #1024-15 - 45 HERRICK ROAD 4/8/2015 BUILDING PERMIT NORTH OF�t�ED ;'. ., �gga Q'O CN TOWN OF NORTH ANDOVER 3� y .a�.' i APPLICATION FOR PLAN EXAMINATION JK Date Received �RA-ArED 0 Permit No#. �SSACHUS Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION P PROPERTY OWNER .1,/ l�f Print 100 Year Structure yesOno MAP 0/57PARCEL:�s� ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Resid ntial Non- Residential ❑ New Building ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District Water/Sewer _- - DESCRIPTION OF WORK TO BE PERFORMED: ` X4C/C al Ile /4-1,*e D/! lwP x Qlnl ly`/d x 3 Identification- Ple, e Type or Print Clearly OWNER: Name: y �fd��Q�✓f r Phone: I'dV Address: � ��✓�� �A� i Contractor Name: Phone: Email: Address: Supervisor's Construction License- Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.10 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cos FEE: Check No.: b-�, Receipt No.: -� NOTE: Persons contracting wi nregter d ontractors do not have access to the guaranty fund 1 {J j Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & D,EVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on ,S Si natur COMMENTS HEALTH Reviewed on Signature COMMENTS 1 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments "Conservation Decision: Comments t: Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: 1 _ - Located84 O 'FIRE�,DEPAfR i N urn 3 Osgood Street t� to nlF sife iloo ` D"epa; j tsignaur�e/date ��F�ire�L� rfinen C`®MMEN�TS� r 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 ap royal of Electrical Inspector yes p No DANGER ZONE LITERATURE: yes MGL Chapter 166 Section 21A—F andG min.$1oo-$1000 fine NO NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date 3._ Time Contact Name Doc.130ding permit Revised 2014 - r I 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 I 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit 4 Addition Or Decks f 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/Cross Section/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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) 6 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 2012 I ECC Energy code 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 this recorded at he Registry of Deedsown Clerks office must stamp the . sion from the Board of Onecopy and proof of recording peals that the appeal period is over. The applicant mus g must be submitted with,the building application Doc:Building Permit Revised 2014 Location 4CD No. Date I� • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $GL+.dD Foundation Permit Fee $ - Other Permit Fee $_,_ TOTAL $ Check#--762- 2 Building Inspector i 2'O i - I i I I r' i • a > ' w NORTH Town Of . � E ndover O - 0 J/- 0h ver, Mass, &. 06 COC NSC Nl w.0 16 A?A C7 S t] - BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System hkoTHIS CERTIFIES THAT d5CaDvesBUILDING INSPECTOR ................... ................ ....... . ..... .... ...... ............. 16 . .. . .. . .. .. ... ... has permission to erect .......... buildings on P.41 Foundation Rough to be occupied as .......... ... .... ..... ........ .... ................................ Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN k6MONT ELECTRICAL INSPECTOR t5 UNLESS CONSTRUCTRough Service .............. ............................................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display 1n-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. The Commonwealth of Massachusetts F Department of IndustrialAccidents r I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation insurance Affidavit:Builders/Contractors/)llectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Le 'bl A' licant Information I, Name(Business/Organization/Individual): /✓/. �� F Address: Z A �lf� XV City/State/Zip: /� .�/ Dt��� �� 1/,f-11r Phone Are you an employer?Check the appropriate box: Type of project(required): em to ees(fill and/or part 7. ❑New'constraWon 1.❑I am a employer,with P y 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10[]Building'addition 4.lam a homeowner and will be hiring contractors to conduct all work on my property. I will 0 11. Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole •. proprietors with no employees. 12_[]Plumbing repairs or additions 5.❑I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.Q Roof rep airs These sub-contractors have employees and have workers'comp.insurance.t 14.[]Other 6.Q We are a co oration and its.officers have exercised their right of exemption per MGL c. 152,§1(4),andive have no employees:[No workers'comp.insurance required.] *Arty applicant that checks box.#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: I. Expiration Date' Policy#or Self-ins.Lic.#: City/State/Zip:/y/ �� �� Job Site Address: �,P,P�� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). violation punish by a fine up to$1,500.00 52 25A is a criminal viol p Failure to secure coverage as required under MGL c.152,§ ORDER and a fine of up to$250.00 a and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby certify and t e pains andpe ties o jury that the informationpNovidedahove is true and,correct. Date: Si ature: A9/ _ / Phone#: �� 7'�� o Off tial use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authoirity(circle one): 1.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 defi ied 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,§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 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 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 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 NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia ;� - TOWS'O �TO�.'�.'�[. "Opt - 0-1,11 .�4b ae� OFFICE OF • ' x�o ,,� 1600 Dsgooa WeetB0&g20 •Sujte 2 36 7•gS R C8Jul l •Noith ,.ndovex,Massachuset�!01845 SA � Gerald A.Brown •' Teleplxone(978)688955 Inslractor ofBuildings _ Fax (978)689-9542 ,., .. �C�It�EOW:NER:LICENSE ESE . M.PTIO N 8 1 1 PFWWT.T'PLXO.ATION pleaseyrinf . DATE. SOB LOC. TION: tls' • • Aze->irl . Number StreetAddress . • Map)Zot % -UOM�O MR ' ' yalK Name. StAe- . HozneP3�one1ork 'llone �p Cods The cuzxent exemption for"•homeow_n-ers"was extenaod to:nolude ownex occupied divelin�s to tiva units o ;- nr o a71o�stac,��?omPo.rei� � - a� SSS I to e�z ave a „ �' 6-11gase n ara�lzaual•forzre ono d e . • does�.ot055eS5 a�CenSe provided 1� that the o e acts as u wn r s pazvisor}. S,�.te3u?ldzug (CodeSect?onZ�8.3.5.�) . DE'Mr ZON OFROMEOVMP, , Pe rson(s )wlzo_wns a parceloflandon betuhiclzlze"shere sides or intends to reside,on which there is,or is intended to ,a one or two fanaAy sfuefures. .A.person Wha aoz>strmts mo eth considered z atAzxe home xn.a tea yearperiod shalt not be ahozrteo ne The uzzdersigned` omeoVVn(-,r"'assumesresponsibilityf0raonT1iances with the StateBuilding Codeand other .Applicable codes,by lags,rules and-xegulations. The undersigned`hozaeowne 'cezfifesthat he/sheunderstandstheTowuofNorlh.Anaover)3uildingDepmtment Min ixninspecfionproceduresand repirementsand that lZelshe. '� mplyWitlz;saidproceduresand rec�irernezxts, -U0AM0W BR.S SIGNATURE A1'P ,OVAL OF BMDWG G � OFFzcML Reyiseti 9.209 y ' FomaTlozneownersExempiion <Y $OARD OFAPP.EATS-689-9541 1 CONTSBRVAUON 699-9534 - HEALTk1688-954U P��.T7N1NG 688-9335 ao2o Herr« _ jnfl org4 - 30 U-10 y. iG, Para :5 P- k 4 ,X 12 7 �r a W -- ,.3 ,3+ep . �4 . - PC : l� Kid-" ger v , Aeckm ale Oro 4X-4 x RT ( h • �Ibs rem c . a el f Ito fie_. 12. ' t gg i }} 14T— s Apma c*t r ALL s{Z't 1 Ply rs euer)ly vV, + t.' R TW r l f , � �-#� # ♦#Y �.p" s 'r � � Cir ¢f ! . wA,4 1 vi , 2 } w� IrP ��. DC7' Mr �` y (• ��'��� r ;' �� 17 s • �RY a5 ^�' 'iia :t�* } `,�r'��• #,� v � �.�p. • • •,SAY�ftTif t . N •t J � ; 'A{ S4.Jrytj 4 �,�.^�. •'..'i,""`a. •:f `� sI'S.ldb p i F y?j 1 t � • R �+ 4 IR 7n a ,,tt..r.,,w :�' t .�� � t. ' �«" �4 ,:� .•�f i ���^ •.��; ��`f�.`` �tr �• . '1'.•i � � 'u, �'��' .elf ^'a � '� _l�f, + � ' »k r S h It AL 3 North Andover MIMAP June 8, 2015 IVA 7 �w � •O �4"Syt ve A • 4 f �y �"s O {r » �t .�d < . a � a k s s u : Interstates - - I —SR Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, --Roads - Meters Data Sources:The data for this map was produced by Merrimack Valley Planning Commission(MVPC)using data provided by the Town of Easements af' s �/7a North Andover.Additional data provided by the Executive Office of Q MVPC Boundary �s ��O Environmental Affairs/MassGIS.The information depicted on this map is ❑ ParcelsL for planning purposes only.It may not be adequate for legal boundary } tp definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING # • THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY i e OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT - i of ;i ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION sswcwusE 1"=32ft /f f �, " a �# *'' r has �•. a i ��. / kyr • 3 a � 1 ------------ 71, dff ff .: [r t" '-,77 Horizontal Datura:MA Stateplane Coordinate Syste Meters Data Sources: The data for this map was p VkOR Valley Planning Commission(MVPC)using data pr( O 'gq%.1LV ,� $r North Andover. Additional data provided by the EXE 's �0 Environmental Affairs/MassGIS. The information dE — for planning purposes only. It may not be adequate IF- definition or regulatory interpretation. THE TOWN( MAKES NO WARRANTIES,EXPRESSED OR IMPI �1 THE ACCURACY,COMPLETENESS,RELIABILIT) _ OF THESE DATA.THE TOWN OF NORTH ANDD% n 0� yc,. # ASSUME ANY LIABILITY ASSOCIATED WITH THE THI.0 1N1Pr)PhAATnnn1 North Andover MIMAP June 8, 2015 �� o� so 0059 0 '��c01 bti �015v0-0058 Nk 53-f MK 1035 0-.0049: I y ;015:0=0057 04 — f � R4` 015'0-0:055 ,*-HERRICKIRD' �. r Ip "015 0=005',4_ .�V i �� 41 HERRICK�',RD 11 YOUNG.`{RD. 015:0-00 56 �:O6:0=0005' �0�16a0=0004: ^y 1 S"YOUNG MR oa6o.=0006 ;01650=0003 I Rail Line 4 Wetlands Zoning Interstates 0 Exempt Lands t, Busine s 1 District —I - 0 Busine s 2 District Hodzontal Datum:MA Stateplane Coordinate System,Datum NAD83, —SR O Busine s 3 District Meters Data Sources:The data for this map was produced by Merrimack 8 Busine s 4 District 140RTi� Valley Planning Commission(MVPC)using data provided by the Town of — Roads ■Genera Business District Ot aD qy - North Andover.Additional data provided by the Executive Office of Easements 0 Plannei I Commercial Dev :`••�� r•�•00 Environmental AHairslMassGIS.The information depicted on this map is r Corrido Development Dist ,�. L for planning purposes only.It may not be adequate for legal boundary E3 MVPC Boundary 0 Corrido Development Dist O • definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER E3 Municipal Boundary 0 Corrido Development Dist 9 MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING Zoning Overlay Industri 11 District 1A ; THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY ti Industd 12 DisMct 8 Adult Entertainment • "s „� +� - OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT 0 Industd 13 District �Downtown Overlay District * o �. i ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF 0 Industd I S District • ©Historic District 'b���Go��.� THIS INFORMATION Reside ce 1 District �l 0 Water Pro C1 Reside ce2District ,S$wCNUstit ❑Parcels. G Reside ce 3 District. 6 Hydrographic Featuresde ce 4 District —Streams 1"=32 ft de ce5 Distdct ede ce 6 Distdct -'--g. esidential District 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After apermit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the 9 notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of.ongoing construction activity,and maybe-deemed-by the Tnspector_of_Wires abandoned-and-invalid-if he—. ._ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or-the installing entity stated on the permit application. The Permit Extension Act was created by Section 173 of Chapter 24D of the Acts of 2010 and extended by 8ections.74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence'during the qualifying period beginning on August 15,2008 and extending through August 15,2012. • ule 8—Permit/Date Closed: / ***Note:R ply for new permit irz/Permit Extension Act—Permit/Date Closed: Date.e.-../69...(.,.?....... 40RTH ,,,to '6. - 0 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING �sSAcmU This certifies that `7.�.:' t......... .............................................. .. ..................... kas permission to perform......'..:..!?;? wiring in the building of at... ............. ................. .................................S... ...... North Andover, fx� ,r4( Lic.No........... ELECTRICAL INSPECTOR Check # 896 � {'#. Commonwealth of MassachusettsOfficial Use Only Department Of Fire Services Permit No. 9G119 ' [ .5 o� BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked ' _ Rev. 1/07] eavebiani- ' ` ^ APPLICATION FOR PERMIT TO PERFORM ELECTRICAL `A' All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 2 000 WORK (PLEASE PA NTININK OR TYPE ALL INFORMATION) Date: / d City or Town oh NORTH ANDOVER By this application the undersigned gives notice of his or hr intent�,on to perform the electrical wof rk described below. Location(Street&Number) �! �-�—� Cwner:)br Tenant /�f":1--Cps CjTJ,1 CQlVes Owner's Address Telephone No. Is this permit in conjunction with a building permit? yes . NO ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / _Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: e��ice �,-,� Completion o the ollowin table m be waived by the Inspector o Wires. No.of Recessed Luminaires No.of Ceil.-Sus No.of Total . p.(Paddle)Fans Transformersp� No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires �_ Swimming Pool Above ❑ In_ o.o mergency ig g I'd, rnd. ❑ Batte Units No.of Receptacle Outlets / No.of oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.-of Detection and No.of Ranges Na.of Air Cond. Total Initiating Devices Tons No.of Alerting Devices -p No.of Waste Disposers Heat Pump NumberTons KW No.of Self-Contained Totals: ___..._.__....__.... _. Detection/AlertingDevices No.of Dishwashers Space/Area Heating KWLocal L] Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems: �E No.of Water KW No.of No.of Devices or E uivalent Heaters ° °f Data Wiring: Signs Ballasts. No.of Devices or E uivalent No.Hydromassage BathtubsNo.of Motors Total gp Telecommunications Wiring: OTHER: No.of Devices or E uivalent ` Attach additional detail 111 desired, or as required by the Inspector of Wires. Estimated Value of ectrica Work: (When required by municipal policy.) Work to Start: g /5` a i Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO "VEE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liabilityg"completed „ insurance includin com feted operation coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE R BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: ae 11C Signatul a �� (If applicable, enter�` gmpt' in the 1' e e num er n .) � LIC.NO.: 6 �� Address: ==1 t!c / j(` t QGi'r�1 ( g(Q its.TeL No.: Co/ 6. l � Per M.G.L c. 147,s. 57-61,security work requires D Alt.Tel.No.: ! )5 , epartrnent of ublic Safety"S"Lice e: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement I am the(check Owner/Agent one) ❑owner ❑ owner's agent. Signature Telephone No. PERMIT FEE. S?�(c Y The CoMmonwealth of Massachusetts kj 1! Department of Industrial Accidents t ! Office of Investigations 600 Nlashington Street is Boston, MA 02111 www_masxgov/dia . Workers' Compensation Insurance Affidavit: Builders!Contractors/Electricians/Pinmbers Applicant-Information Please Print Legibl NarI a (Business/Organization/Individual): G Address: City/State/Zip:/e)) in /[c�MPhone #: . Are you an employer?Check.the appropriate box: T of project YI►e I. P 1 (required): I ❑ am a employer with 4, (] 1 am a general contractor and I employees(full and/or part-time),* have Dred the sub-contractors b ❑New construction 2.(� I am.a:sole proprietor or partner_ Iisted on the attached sheet.t 7• ❑Remodeling ship and have no employees These sins-contractors have 8. 0 Demolition working for me in any capacity, workers' comp.insurance. [No workers corn . insurance 5. 9• ❑Building addition P ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 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. Roof insurance required.]t employees. ❑ repairs r [No workers' 13.Q.Other COMP, insurance required_] •Any applicant that checks bov 1 must also fiat out the seotion below showing their workers'compensation policy i ilbr oration. t homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such =Contractors diet check this box must attached an additional sheer showing the name of the sub-contractors and their workers'camp.policy information. I am an employer that is providing workers'compensation insuanefor meployeeeowitinformation. policy andjob site . Insurance Company Name: r- Policy#or Self-ins. Lie.#: Expiration Date: Sob Site Address_ G �C G City/State/Z' • �a l`� Attach'a copy of the workers' cora natio . } Pe n policy declar- ation page(showing the policy number and expiration date). Failure to secure coverage as required under 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 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 certify u eirtlie p and p o r Mat r f lurJ' the info motion provided above ' true and orrect Si tore: � f � Phone#: Date: 1 �3 Official ase only. Do not write in this area,to be completed bycity or town ofciaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building ntlding Department 3.City/3 own Clerk 4.Electrical Inspector 5. Plu 6.Other mb31nsperltor Contact Person: Phone#: i Information and Instructions Massachusetts General Laws chapter 152 requires all emp I overs 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 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 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 applicant who has not produced acceptable evidence..of compliance with the insurance'coverage required" Additionally, MOL 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 4 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 submit multiple perniMicense 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 f rtrrre permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT.required to complete this affidavit The 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 as a call. The Deparmnent's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel.# 617-727-4900 Ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia