HomeMy WebLinkAboutBuilding Permit #222-2011 - 47 EMPIRE DRIVE 9/10/2010 BUILDING PERMIT vF r1ORTy
TOWN OF NORTH ANDOVER •.-
APPLICATION FOR PLAN EXAMINATION '-
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Permit N0: e414 "
Date Received
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Date Issued: CHUS
4IMORTANT:
Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Resid Non- Residential
New Building One family
Ad ition Two or more.family Industrial
Alteration No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
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DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: _ Ag'.n 0i(-f 4/-C Phone:� 2
Addres - G,tl11 11,111
I e Fajen -Dlg
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ARCHITECT/ENGINEER , �(' � - Phone:?;7a4)-,5s2-�'3/�
Address � M�i� �� ed� �{l 3 Reg. No. 6,�;—
FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
'Total Project Cost: $ ,/,2 FEE: $ 3 / 7- 50
Check No.: (� / Receipt No.: �-1411
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
SI nature�o�A ent/Oar✓ne - - `�'� �, .
Location 4/7 Alii F 1'
No ^ Roll Date
M011TIy TOWN OF NORTH ANDOVER
9
• • /0,9+ Certificate of Occupancy $
Building/Frame Permit Fee $ 3/7,<.'U
sACMus
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ 7
Check #i � v l
r
ilding Inspector
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
J
TYPE OF SEWERAGE DISPOSAL
ublic 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 44�
COMMENTS 4J /�0 � y 5�� wlq
�o
i
CONSERVATI-ON Reviewed on /t}
Si nature
l.��JIVIIVIrz Is �V�S7� �- �jZ'
HEALTH Reviewed on Si nature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comment
Water & Sewer Connection/Si nat at
Drivewa Permit
DPW Town Engineer: Signature:
1="1RE E ")IJI N3 �e ate d 384 Os ood Str t
y ripsterr� �te ` 4
-
Ftr s5 an�Itreirda�e
COMIE1afT ;
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)
a
❑ Notified for pickup - Date
L
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
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or.Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
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
❑ Cel ifieu 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
LAWRENCE H. OGDEN,P.E.
198 EAST MAIN STREET
GEORGETOWN,MA 01833
978-352-8318 fax 978—352-2858
cell: 978-502-5921
November 6,2010
Mr. Robert Messina
Orchard Village LLC.
Empire Drive
North Andover,Ma 01845
RE: THE WILLOW GB# 6213
Lot 25 Empire Drive,North Andover,Ma. 01845
Dear Mr. Messina
As you requested I visited the site 11/4/10 to review the installation of the
Engineered Materials consisting of LVLs and Engineered Joist utilized in the framing
of the above project. These are shown on plans prepared by G.J. Bruno and Associates A-
1 to A-5 Dated 7/30/09 with the framing sheets certified by me 6/15/10.
The following items require additional work.
1. Insure that the 3-16d nails from the plate to between the studs as shown on the
Braced Wall Additional Connection Detail are in place. As I discussed with
Jeff Horne this nailing should be from the plate to the rim board.
2. Add additional studs under the LVLs at the Breakfast Area to insure the
number of studs required match the plan. Review post at all other locations.
3. Note the Rough Plumbing,Electric and HVAC was not complete at the time
of this visit.
Based on the above site visit and based on what I could visibly see provided the
above additional work is completed I can certify that to the best of my knowledge the
LVLs members and Engineered Joist utilized in the framing as shown on the drawings
are installed properly and meet the loading conditions of the Massachusetts State
Building Code for 1&2 Family Residences. This certification assumes that all other
framing requirements of the drawings and code, including but not limited to materials,
nailing schedules, blocking, connections and other details were properly complied
by the licensed construction supervisor responsible for the project. va�P�W °F4
Should you have any questions please do not hesitate to call. �VRENCE
Yours truly, o N
U :N
-1
27765 ti
O
Lawrence H. Ogden P.E. Structural 27765
Cc: Mr. Gerry Bruno
Copy mailed to Mr. Robert Messina, 44 Great Pond Road,Boxford,Ma. 01921
lb
M�TN Ap
�S j
c�Ket
CERTIFICATE OF USE & OCCUPANCY
'OWN OF NORTH ANDOVER
Building Permit Number 222-2011 Date: January 21, 2011
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 47 Empire Drive, Lot 425, North Andover,
MA 01845
MAY BE OCCUPIED AS single-family IN ACCORDANCE WITH THE PROVISIONS
OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS
AS MAY APPLY.
Certificate Issued to: Orchard Village LLC
44 Great Pond Drive
Boxford,MA 01921
Building Inspector
Fee: 100.00 previously paid
Receipt: 23441
� �10RTF1 1 -
� � M
n
APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION
Buildinal Permit#
ADDRESS/LOCATION OF PROPERTY : 45 7 t�----m Pl ,Qt/v c
Map LD 7G Parcel /2 4#21 Lot Number a
SUBDIVISION
DATE REQUESTED FILED/READY FOR INSPECTION
CLOSING DATE ON PROPERTY: I — 1/
FIVE(5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED
ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE-
INSPECTION FEE OF TWENTY DOLLARS$20.00)WILL BE CHARGED IF THE STRUCTURE
DOES NOT MEET ALL APPLICABLE CODES.
�'
11�r^r5'h ECGIIwJ-lwiV. O .F�
ns-9A 1 a..�L8 `�
1 GI 11tIAA.IGY .
Address - 0 E-0 R0 114A 0
SIGNED
ROUTING
i
CONSERVATION
PLANNING I /fi'I
DPW.-.WATER METER
SEWERIWATER CONNECTION
NOTE
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST
Signature
3 y Y I Fite: Application for OC form revised Jan 2007
ORTH
T0VM of Andover
No. _
ti - -
Q LAK_ O dower, Mass., J�
COC MI CMEWICK
ADRATED
S ` BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic S ste
/ LDI INSP . R
THIS CERTIFIES THAT O� O'�il�Gl' �. ��. f..... .. �`�� c '�'�' `�
f .............................
Fo ndation �r�
has permission to erect........................................ buildings on .... `% 7 ����` :.............................. ou ri/s X11 2
tobe occupied as.................. / 1. .....1 « .r...... .......................................................................................... y
provided that the person accepting thio permit shall in everyr4pect conform to the terms of the application on file inl/.�/ l/
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.
F O lc-
PERMIT EXPIRES IN 6 MONTHS
UNLESS CONSTRUCTIONr.T4-.
TS ELECTRICAL INSPECTOR
Q/ Dough � ��,� �j LG pp,
...... Service
BUILDING G�INSPECTOR
ZGASINSPE
Occupancy Permit Required to Occupy Building TOR
617Display in a Conspicuous Place on the- Premises — Do Not Remove
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No:
SEE REVERSE SIDE Smoke Det. �, -
F
� t
Oj4n.�1
81ACIMK4
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 222-2011 Date: January 21, 2011
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 47 Empire Drive, Lot #25,North Andover,
MA 01845
MAY BE OCCUPIED AS single-family IN ACCORDANCE WITH THE PROVISIONS
OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS
AS MAY APPLY.
Certificate Issued to: Orchard Village LLC
44 Great Pond Drive
Boxford,MA 01921
Building Inspector
Fee: 100.00 previously paid
Receipt: 23441
ORT1y
Town of
over
_; LAK' dover, Mass., �/�A
COCMICMEWICK I.
ORAT E D F'P5
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
J
THIS CERTIFIES THAT......... BUILDING INSPECTOR
0'.�%....Gr'GI I/f,,�� F..... ,�
�..
Foundation
has permission to erect......................... `7 / � 2)
P buildings on .............. .....---........ .-' .....`.............................................. Rough
to be occupied as.................. 11._l.....255 z. ................................... Chimney
y
provided that the person accepting thh(permit shall in every rdspect conform to the terms of the application on file in Final
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 CONSTRUCTION T TS Rough
/_� B
LDIN'G`INSPECTOR Service
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
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.
SEE REVERSE SIDE Smoke Det.
\\ \ 20.6'
\
EXISTING FND. \\\
TOF=271.2
F
10.5' \
\
\\ i
254. LOT25
11�
58.6' - L j"OF4tqS19
MIC L 9
EMP/RE DR. 0 S J
0 No
P'v
co
<q4 S ?e Q(
FOUNDATION L OCA TION /CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS
TO THE HORIZONTAL SETBACK REQUIREMENTS OF THE LOCAL
APPLICABLE ZONING BY-LAWS EFFECT WHEN CONSTRUCTED
CLIENT. ORCHARD VILLAGE, LLC .
(THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER
RESTRICTIONS SUCHAS COVENANTS,WETLANDS,EASEMENTS,
THIS CERTIFICATION/S MADE AND LIMITED TO THE ABOVE CLIENT ORDERS OF CONDITIONS,ETC.)THIS DRAWING SHALL NOT BE
LOCA TION:NORTH ANDOVER,MA. USED BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT
OUTLINED ABOVE,EXCEPT WITH THE WRITTEN PERMISSION OF
DATE. 10/1/10 SCALE.1"=30' CHRISTIANSEN&SERGI INC FURTHERMORE THIS DRAWING IS
THECOPYRIGHTED PROPERTYOFCHR/STIANSEN&SERGI INC.
AND ANY UNAUTHORIZED USE/S PROHIBITED.CHRISTIANSEN&
SERGI TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE
OF THIS DRAW/NG OR ANY 1NFOR-MATION CONTAINED HEREON.
PROFESSIONAL ENGINEERS& LAND SURVEYORS
CHRIS T/ANSEN & SERGI, INC.
160 SUMMER STREET, HAVERHILL, MASSACHUSETTS 01830
WWW.CSI-ENGR.COM TEL. 978-373-0310 FAX 978-372-3960
D WG.NO.:06029.001.047
► I
MAScheck COMPLIANCE REPORT I i
Massachusetts Energy Code ► Permit # I
MAScheck Software Version 2.01 Release 2 I I
I I
I Checked by/Date ►
► I
CITY: North Andover
STATE: Massachusetts
HDD: 6322
CONSTRUCTION TYPE: 1 or 2 Family, Detached
HEATING SYSTEM TYPE: Other (Non-Electric Resistance)
DATE: 8-27-2010
DATE OF PLANS: 7/30/09
TITLE: The Willow
PROJECT INFORMATION:
Orchard Village, Empire Drive
COMPANY INFORMATION:
Orchard Village, LLC
COMPLIANCE: PASSES
Required UA = 450
Your Home = 233
Area or Cavity Cont. Glazing/Door
Perimeter R-Value R-Value U-Value UA
-------------------------------------------------------------------------------
CEILINGS 1258 38 .0 0. 0 38
WALLS: Wood Frame, 16" O.C. 2115 21.0 0.0 121
BSMT: Conc. 8 .0' ht/7. 0 ' bg/0. 0' insul 0 0.0 0.0 0
GLAZING: Windows or Doors 140 0.350 49
DOORS 79 0.000 0
FLOORS: Over Unconditioned Space 768 30.0 0. 0 25
HVAC EQUIPMENT: Furnace, 96.0 AFUE
HVAC EQUIPMENT: Air Conditioner, 13. 0 SEER
-----------------------------------------------------------------------
COMPLIANCE STATEMENT: The proposed building design described here is
consistent with the building plans, specifications, and other calculations
submitted with the permit application. The proposed building has been
designed to meet the requirements of the Massachusetts Energy Code.
The heating load for this building, and the cooling load if appropriate,
has been determined using the applicable Standard Design Conditions found
in the Code. The HVAC equipment selected to heat or cool the building
shall be no greater than 125% of the design load as specified in
Sections 780CMR 1310 and J4. 4 .
Builder/Designer Date
MAScheck INSPECTION CHECKLIST
Massachusetts Energy Code
MAScheck Software Version 2 .01 Release 2
The Willow
DATE: 8-27-2010
Bld�. l
Dept. l
Use I
I
I CEILINGS:
[ ] l 1. R-38
i Comments/Location
I
I WALLS:
[ ] I 1. Wood Frame, 16" O.C. , R-21
I Comments/Location
I
I BASEMENT WALLS:
[ ] I 1 . Conc. 8. 0' ht/7. 0' bg/0.0' insul, R-0 (uninsulated)
I) Comments/Location
I
I WINDOWS AND GLASS DOORS:
[ ] l 1 . U-value: 0.35
I For windows without labeled U-values, describe features:
I # Panes Frame Type Thermal Break? [ ] Yes [ ] No
l Comments/Location
I
I DOORS:
[ ] I 1. U-value: 0
I Comments/Location
I
I FLOORS:
[ ] i 1. Over Unconditioned Space, R-30
I Comments/Location
I
I HVAC EQUIPMENT:
[ ] l 1. Furnace, 96.0 AFUE or higher
I Make and Model Number
[ ] 1 2. Air Conditioner, 13.0 SEER or higher
Make and Model Number
i
I AIR LEAKAGE:
[ ] I Joints, penetrations, and all other such openings in the building
envelope that are sources of air leakage must be sealed. When
I installed in the building envelope, recessed lighting fixtures
I shall meet one of the following requirements:
l 1 . Type IC rated, manufactured with no penetrations between the
I inside of the recessed fixture and ceiling cavity and sealed or
I gasketed to prevent air leakage into the unconditioned space.
I 2 . Type IC rated, in accordance with Standard ASTM E 283, with no
I more than 2 .0 cfm (0. 944 L/s) air movement from the the
I conditioned space to the ceiling cavity. The lighting fixture
I shall have been tested at 75 PA or 1.57 lbs/ft2 pressure
I difference and shall be labeled.
I
VAPOR RETARDER:
[ ] I Required on the warm-in-winter side of all non-vented framed
I ceilings, walls, and floors .
I
MATERIALS IDENTIFICATION:
[ ] I Materials and equipment must be identified so that compliance can
I be determined. Manufacturer manuals for all installed heating
I and cooling equipment and service water heating equipment must be
I provided. Insulation R-values, glazing U-values, and heating and
I cooling equipment efficiency must be clearly marked on the building
I plans or specifications.
I
DUCT INSULATION:
[ ] I Ducts shall be insulated per Table J4. 4 .7. 1 .
I
DUCT CONSTRUCTION:
[ ] I All accessible joints, seams, and connections of supply and return
I ductwork located outside conditioned space, including stud bays or
I joist cavities/spaces used to transport air, shall be sealed
I using mastic and fibrous backing tape installed according to the
I manufacturer' s installation instructions. Mesh tape may be
omitted where gaps are less than 1/8 inch. Duct tape is not
I permitted. The HVAC system must provide a means for balancing
I air and water systems.
I
TEMPERATURE CONTROLS:
[ ] I Thermostats are required for each separate HVAC system. A manual
or automatic means to partially restrict or shut off the heating
I and/or cooling input to each zone or floor shall be provided.
I
I HVAC EQUIPMENT SIZING:
[ ] I Rated output capacity of the heating/cooling system is
I not greater than 125% of the design load as specified
in Sections 780CMR 1310 and J4. 4.
I
SWIMMING POOLS:
[ ] I All heated swimming pools must have an on/off heater switch and
i require a cover unless over 20% of the heating energy is from
I non-depletable sources. Pool pumps require a time clock.
I
HVAC PIPING INSULATION:
[ ] I HVAC piping conveying fluids above 120 F or chilled fluids
I below 55 F must be insulated to the following levels (in. ) :
I
I PIPE SIZES (in. )
HEATING SYSTEMS: TEMP (F) 2" RUNOUTS 0-1" 1.25-2" 2 .5-4"
I Low pressure/temp. 201-250 1.0 1.5 1 . 5 2 . 0
I Low temperature 120-200 0.5 1.0 1 .0 1 . 5
I Steam condensate any 1.0 1.0 1 . 5 2 . 0
COOLING SYSTEMS:
Chilled water or 40-55 0.5 0.5 0.75 1 . 0
I refrigerant below 40 1.0 1.0 1. 5 1 . 5
I
CIRCULATING HOT WATER SYSTEMS:
[ ] I Insulate circulating hot water pipes to the following levels (in. ) :
I
PIPE SIZES (in. )
NON-CIRCULATING CIRCULATING MAINS & RUNOUTS
HEATED WATER TEMP (F) : RUNOUTS 0-1" I 0-1.25" 1.5-2.0" 2 ._0+"
170-180 0.5 1. 0 1.5 2 .0
140-160 0.5 0. 5 1. 0 1.5
100-130 0.5 I 0.5 0. 5 1. 0
I
----NOTES TO FIELD (Building Department Use Only) -------------------------
The Commonwealth of Massachusetts
Department of Industrial Accidents
` MT;, Office of Investigations
•; U ,` 600 Washington Street
Boston,MA 02111
www.mass.g ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual):a--�
Address: -//I Gpiqwp iorlye
City/State/ZipJt3jj(rdep AAJJ OH21 Phone #: �f'-ofd-5102--
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I atn a general contractor and I 6. R Newconstruction
employees(full and/or part-time).* have hired the sub-contractors
2.[ I am a sole proprietor or partner- listed on the attached sheet. $ ❑ 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 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t 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 workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#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 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�under the
�pains and penalties of perjury that the information provided above is true and correct.
Signature: (� D�'J� ► YlQ ('(/(�(�C� Date:
Phone#: g 9If— F0 7— 316 2
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.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three 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-contractor(s)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 pen-nit 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 pen-nit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pen-nit/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 pen-nits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or pen-nit 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 Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia