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HomeMy WebLinkAboutBuilding Permit #219-2011 - 50 PETERS STREET 9/14/2010 N H t9 BUILDING PERMIT F ORT o "ED TOWN OF NORTH ANDOVER o2 � �`'..•�,`�' rtb °� APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received � �� � ���°-�-K• °' � V • ��SSACHU`����� Date Issued: _ IMPORTANT:Applicant must complete all items on this page },7r'�Y,E7;!_'ysi;9i=::ii •F,':=•_`';1e4'R:,]Y,..+:�_4v.., ;.r�.;it:k,.,. �_�.<,:;- 3�I:-5' _ _ 'L%$r'='_i••i:.Y4:i�_ - .s'.:i._7_'^au_•` .a=le:i•'i':^.n:. .if.,�. - :�;�•.:r _ _ •.NS's:..s_,..,.M•._.i:-r,....._�- ,^y= �•-....tr a.l"..:f•.- ::r'f :�a.lii - ..a�:1qq':,6^n-.. - .Tt� `i•5?:, •1r� - ,:4 :�• ��-`y�.".i_�.''jK'"?".;y.���i.r.^v-r�"-nA�•rr�r.:�x.�'�.��.'�,n...Q.�--f:Ir�.i.�r-_s..y.._-;,'j�.'r�`--:v+��'t.n,ii�.�•�'�s.ss:•-S_xc'a.-",�r.n`r.+.^�:w�,-,'•_..�',..le..�;.r=t.W'Ye�v�r.•vr=R:__„x'_u.-.f.,.fVi[ti.li._�-:.p�-�,:'-7.5D-.fi_..`,s>5'v- -. 9 rrr_"a.'rE.?•?V`•"_r�.rin=_.�_.,.-'-�Fc_-_t•t_z r•:_-S.•{L.:_`�i5.�-.a+::���'nti_'"�--a-_.4..lyo=_rrT�-y aJ�-F.CF:-Pi-E.0,'d�t,:I.ti�;.�S.i:i�i{vk•7�W-dt-_7.•nr•�'..:"''.�',.,r�L•�..,_�"'2�v''r1r�:."=-._.d i.�-rt-�'w:-`--.-;�'.-:r�_-'-.1�'-.�ir'';�,-r3-.:r._s.- �=�,'y+�.:.-'::i�:"-,';_':�.z>.r'z.<�.l�vy.-=__�a__-_-:S.�:��..��_p.•�e��:��c.7..�-_�.�5-„,-,:i+.•,a"si"�.-'��_y,"c ;.�h=aJ.!I,:,L%-'5f.�°:!::�r':�i�_i::T.',S�.er?.ii9.�.._w::":`l,ti�','�om.�='y�-:-'��';�_.:rz F"--:....-.��,./-.z,?f.'..:.r,':RkJy-'fiIE`.-'•-..�.ram__:: d:_� S'LF!= `aN�rh:n,rn VER. 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'. �•s 5. �, .rx�4r'-�-h�Y-V:�`_ "`•' _.� :�, .......�.�?r, 'kms e'�:a R.`_ F� � �@ � 4.°L-f:F_Kt- '-«.:3-'n-. y �•:�r:::Irn�_r.�.lrf'li...r.,.+a•-N"1k.:vt^.r"-�e�-_'-1.�i��, r:^T��It�'�w�^+;rf4�,.•�i:::n5;�{r�`_'.L�^�...,r..�r�'L,'�-,t;..:�F:. �'- ��a:���°,� :'I': �?.:vG-� �-ry:!:F� I TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family r Addition Two or more.family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other ARM,- Identification M,s'z'S �.,o� a � r'i-• s - „ _..,,� f . �'`' -�1�-"ep��U�- f' ,�•^ v-,'r,,,-a r1• �`. � ry _ r, ,��p .{. ,y to � �.7(r r ,y.:.r;5�"_`•9.r` - ,r_;,, �......_. t m ";.,`zr•+�:i:'sST:x.�' ? �r`�'��� ''..- ..�q' '� °1a��''� ••a'*�-�"{Y��1L�� U��"�-'Fj:���'r� '�+-v.,f t .}� cam-�S 2t',: L r -ft SZ.vi .�� v�''>,��'"�..�`:ra'•`'l�ly-F,�7 ���"�� �t7.g. f`��,�,��'���.'7,r�x•.�,s'n"..E• s. �-^�„�_t_r��.rE ��.�,��•���,lsl��a��r����.`�'��-•�`.�4-'°N."'�_. li r � ,,�1� �'+'E= >+•.i ,�'y z-3u: '`�+'-»pPt'ry,.2-"2. �•�''' R'E^ r�,.�y�- "�� rte¢ +a -a�!..n ✓1�����[eliL � T.l1"-rte. •��V=F�.J'y,! �Cr�y�.. ��%�F!-� 9`r'rr `i�f�"�4 [vwlra�..ti��•'�F����"T_��.1.��yT�+3'�T�}zx7-��j,14��Cv.}��`S�z,3 Sy,,'�'-Y' 4 �c._:,:._...'..__.,......�._s •�.Ri_..r �� .._ .+.:t?F_� 3X .?!.r.� �.::{.�.-'yh�:efr..'...$�.d,_µ`:i.g=w/�"G...:!fY.e'•L{r..,dll':<�'s�� J_.��'�- 1�+'F�Y r;'1-�� �I DESCRIPTION OF WORK TO BE PREFORMED: i Handicap• ramp - t Identification PIease Type or Print CLearIy) OWNER: Name: HORIZON 'K NAGEMENT Phone: 781-407-7799 ' I� Address: 990 Washington St, Suite 110, Dedham, MA 02026 - - - i, mry'.'y� �:r' 1"s5 r� -s-�•$ �r Tri: °^e-. 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ARCHITECT/ENGINEER Dana Perkins, Inc. Phone: 978-858-0680 8 0680 r } Address: 1049 East St, Tewksbury,• MA 01876 Reg. No. 29763 _ E � FEE SCHEDUL E.BULD/NG PERMIT:$12.00 PER$9000,00 OF THE TOTAL ESTIMATED COST BASED ON$125,00 PER S.F. Total Project Cost: $ inn nn FEE: $ 6o i `� 3 Gfc� I Check No.: ��� Receipt No.. ' NOTE: Persons contracting wi nregistered contractors do not have access to e aranty fund afur• o: gsrfilOarunernatured , Pians Submitted Plans Waived Certified Plot:Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer 4 Tanning/Massage/Body Art Swimming Pools 'Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE.USE ONLY INTERDEPARTMENTAL SIGN OFF -U FORM DATE REJECTED DATE APPROVED- PLANNING & DEVELOPMENT COMMENTS I ' CONSERVATION Reviewed on )/,O___ Signature .'O"Wi•��ENI O 1 VI.JIVIIVICIV �S 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 Connection/Signature&Date Driveway Permit DPW Town Engineer: Signatiire: Located 384 Osgood Street '".4. --•:f - .r'N: r1.:LR+w'-%i}�-�:� r�4..-_ve:ne!4_:w-_.:v".^,:= rr�V :F, - - T�e:` -:.-r - ::�`.: - .:L_ :=.-?%S?v."5..�Qr^u`:c:g..am.��� .yd::�'�dr^..r�Fi'^'�:r-r- r-;yy";"n',-.-:::.rrte.t•om"-!•.'!:::,-,.+..-. 't-"inn-..0,t• t... -- ...,.w ,..:. _.... .ti..-. .. Fd ,.,..7. ..,:..._..q_�.r ...,�.. :F..:•.:„ ._ .. - -- :-dy::• .�:_4x' •'":a,:;r:ti,;��.,� :: S t,} r.,- a... - _ - L- afreel>, sic. - - ' _ - bA F. .aP. .vr. ..... .t....1F... ".... :—._......_ ._... _ ..__ _r.-............._:....._.. _CJS. }::1 - - - l;._ !•..,..._.....:...._.1.: x..ter.... ... ..�..,•..�...- - a. ]+ .IIT 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 p DANGER ZONE LITERATURE: Yes No j MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine h i NOTES and DATA— (For department use) ❑ Notified for pickup - Date \ . f 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 aWorkers Comp Affidavit o%'Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract a-- Floor Plan Or Proposed Interior Work .a- 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 o 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 --.i--New Construction (Single and Two Family) ❑ Building Permit Application ❑ U I Lill�U r-roposed r�oE Tran. [3 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 I I� Location No. 2/5 — '?0/% Date NORTH TOWN OF NORTH ANDOVER F? •. _ • 0AL 9 + Certificate of Occupancy $ c MuEck' Building/Frame Permit Fee $ 6 s+ s Foundation Permit Fee $ Other Permit Fee $ E TOTAL $ Check # 234 - uilding Inspector - NORT►y And T0VM Of over No. T () LAKE O dove ' ' COCHICMEWICK ^ Of? SSS qre� PP���S BOARD OF HEALTH Food/Kitchen Septic System PtRM 'IT T BUILDING INSPECTOR //0/1/1Z- �/V Awa"�1-' -^,��I ��*� THISCERTIFIES THAT............................................................... ............................................................................................... Foundation `, has permission to erect........................................ buildings on .............................................................................................. Rough &Ivy-611- to be occupied as............... �..�.<�.. .... �!Z ...... .... ...... �..i: Cc/te' l!:��`1a..... L Chimney provided that the person accepting this permit shall in every respect nform 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. .S�l�CcS lve!!�,-- P/Cze--c' PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations-Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO STARTS Rough .. Service BUILDING Final Occupancy Permit Required t0 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. Smoke Det. SEE REVERSE SIDE Aug 24 10 11:31a 978-475-3102 p.1 Serving Andover and Vicinity Since 1947 PROPOSAL PROPOSAL SUBMITTED TO PHONE DATE Andover Electric 978-423-8350 08/11/10 STREET JOB NAME 206 Andover Street Proposed Handicap Ramp-Revision CITY,STATE.ZIP CODE JOB LOCATION Andover, MA 01810 50-66 Peters Street,North.Andover ATTN: Bob We hereby submit specifications and estimates for: Proposed Handicap Ramp 1. Call Digsafe. 2. Saw Cut Hot Top and Cement. 3. Excavate out Hot Top and Cement;Remove from Property. 4. Prep Area for Handicap Ramps. 5. Form and Pour Ramp. 6. Prep and Pave Area in Front of Ramp. We Propose hereby to furnish material and labor—complete in accordance with above specifications,for the sum of$3,300.00(PRICE GOOD FOR 45 DAYS). Not Included A. Permits B. Police Detail C. Signage D. Striping E. Engineering NOTE: Any change in plans price will be subject to change. Any change from proposal could result in price change. Price does not include any work with ledge or unsuitable material. Price does not include any work with buried debris(trees,stumps,large boulders,etc,). Price.does not include any work with existing underground utilities. All paving prices are based on asphalt prices as of 08/11/10 and are subject to change.Final payment is duc within 30 days upon completion of job. In the event that you do not make the payment,when due,you will be responsible for Aur costs of collection, including our reasonable attorney fees and costs. In 11 ion,you will be charged interest on any outstanding amount at the rate of 18%per year(1.5%per month)from date which it is due. All material is guaranteed to be as specifies.All work to be completed in a workmanlike • ` r' �,� manner according to standard practices.Any alteration or deviation from above specifications h- Aulh / aF involving extra costs will be executed only upon written orders,and will become an extra Si t e charge over and above the estimate.ALI agreements contingent upon sttikes,accidents or delays-beyond our control-Owner to carry fire,tornado,and other necessary insurance. Our workers are fully covered by Workman's Compensation Insurance. ; ACCEPTANCE OF PROPOSAL The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized a# - w.....r.p•���,�y to do the work as specified-Payment will be ma a as outlined above. I Date of Acceptance: Si 2:)f6 Andover Street • Suite 11 • Andover, Massachu s 01810 • : 97 -X75-12 : r)- e-mail: fpreillya sons@comcast. 't pP012t e-T- S• rZ,4^lc-.0$1, NORTH TO" of Ove 0 AI �. Q LAKE O dover, Mass., 45 2 COC MIC NE WICK -/ \ d AERATED P'P�,`�� S$ BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......... ..................................................�1.................................................................................................. � Foundation has permission to erect..............:......................... buildings on ............ ... ..................' .........`.�.................... ......... Rough to be occupied as.............../.. t'' .G .G...l� h.. ..... !L�J��p......0 ... .��..fi...//.........�..� ..... L r� Final y C 7Cc/tI'GG'' e provided that the person accepting this permit shall in every respect 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. .SIvae_rs pe%i- PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS - ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO STARTS Rough Service ............................................................................................................... BUILDING INSPECTOR 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. Smoke Det. SEE REVERSE SIDE v.y .. ' M<<S4;►chusetts DE �t e n t of P — 1 B°�trd of'Buildin(, Re, ubiic, , Construction Super~�1`ltions S ttct� III(, Standar-cis License: cS pervisor License Restricted to: 00 92721 K`3 ,dvrl✓`t ROBERTd 46 CUT BRANCq 1 LER;R F ANDOVER ,°MA 01810 ' t (�°nui�issiroer Expiration:: 10/30/2011 Tr#: 6866 K. r Boa - �Am fLELT II- E¢���65 SH �2'NTS ACORD' DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 08/27/2010 PRODUCER Phone: (978)474-0810 Fax: (978)474-0890 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION JONATHAN M SAMEL CIC LIA ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE SAMEL INSURANCE AGENCY,INC. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 15 CENTRAL STREET HE COVERAGE AFFORDED-BY THE POLICIES BELOW- ANDOVER MA 01810 LINSURER URERS AFFORDING COVERAGE NAIC# INSURED A: Maryland Casualty Company 19356 ANDOVER ELECTRIC SERVICES INC RERB: Citation Insurance Company 40274 PO BOX 629 RER C: National Union Fire Ins Co of Pittsburgh PA ANDOVER MA 01810RER D: AIG Insurance Group INSURER E: F7 COVERAGES 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 CONTRACT OR 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR INSR DATE MM/DDIYY DATE MM/DD/YY LIMITS GENERAL LIABILITY CFP016027733 03/23/10 03/23/11 EACH OCCURRENCE $ 1.000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES Ea occurence CLAIMS MADEM OCCUR MED.EXP(Any one person) $ 10,000 A 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 PRO- LOC $ AUTOMOBILE LIABILITY KW7918 03/23/10 03/23/11 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ B X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EBU015812434 03/01/10 03/01/11 EACH OCCURRENCE $ 2,000,000 X OCCUR a CLAIMS MADE AGGREGATE $ 2,000,000 C Prod-Comp Ops Aggr $ 2000000 RDEDUCTIBLE Crisis Response $ 250000 RETENTION$ Excess Cas Crisis $ 50000 WORKERS COMPENSATION AND WC6765754 04/28/10 04/28/11 X I TORY LMITS OTHER EMPLOYERS'LIABILITY YIN D ANY PROPRIETOR/PARTNERIEXECUTIVEE.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 5 ,0 0 „000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER I DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Operations typical to commercial and residential electrical contractor. Project Name:Rocky's Plaza Handicapped Ramp CERTIFICATE HOLDER A ELLA ON Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 120 Main Street EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO North Andover MA 01845 DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,IT'S AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Attention: Jonathan M.Samel ACORD 25(2009/01) Certificate# 29107 ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwetzlth of Massachusetts Department o f Industrial Accidents Office OfTnvestigations 600 WashineQtort Street Boston, M14 02111 Workers' Com ensation Insurance oda WWW.Mas�b ovidaa ' P Affidavit: Builders/Contractors/Electricians/Plumbers An Iicant Information PIease Print Lembiy Name (Business/organization/if,dividual): Andover ElectricServices; Inc. Address: 19 Dale St, Andover, MA 01810 City/State/Zip; Andover Phone#: 978-475-499.5 Are.you an employer?Check the appropriate boa: I•® I am a employer with_6___ 4. ❑ I am a general contractor and I Type of project(required): ?.❑ employees(full and/orpart-time).* 6. ❑Near construction I am a sole proprietor or partner- lstedh ned the sub-contractors ship and haveno employees These sub-e attached sheet x 7• ❑Remodeling contractors have ❑ -- working 8. Demolition for me in any capacity. workers' comp•insurance. required) are comp:insurance 5. ❑ We are a corporation and its 9. Building addition officers hake exercised their 3.0.I am a homeowner doing all work riQ 10•❑Electrical repairs or additions Lht of exemption per MGL 11. myself. [No workers'comp, c. 152 ❑Plumbing repairs or additions insurance required.] t 1�4)�and we have no employees. 1 ❑Roof repairs [No workers comp,insurance required• 13 ❑ Other =- V wp?icant that ch—l"bo:. i.n,s a?_so fu cet Cat Be--6m J f3omeown ce)o�•s nv W.+: - + ers who submit this afFdaVIt tndl^atmg the��Z_�doing � a ��.a•ora.ers coin,-_, �o�r-i•�•^•�.�.r, Contractors that cbec)c this bo*must attached an addition)sheets owing thea mea hire o>Aside coin°to 4u''t'u�'it a new amidavit indi=ting such. name of the sub-contractors and their workers'comp.policy intormahon. I am an employer that uProviding workers'compensation insurance for my employees Below is the oli information, P cy and job site Insurance Company Name: AIG Insurance Group Policy#or Self-ins.Lic.#: Expiration Date: 4/28/11 Sob Site Address: So _� (p ,e,T�Rf• S T Attach a copy of the workers' co pensation policy declaration page(sho •City/State/Zip: �} •/� Failure to secure coves �'� a policy numb coverage as required Y er and expiration q und.�r Secti � dat Section_5A of e). fine u to$15 L c. 152 c p 00.00 and/or one-year an lead to the ' ar im osi • Y pnsonment,as well as civil 'mP tion of criminal penalties of a Of up to$250.00 a day ag ' e violator. Se advised that a c penalties m the form of a STOP WORKO�gZ a fine Investigations of the D copy of this statement may forwaand rded Re coverage v ded enficatron, to the Office of I do hereby certify aims and penalties o fPerl�y that formation provided Signature: above is true and correct '.Phone - 5-4995 Date- 9.- v aI use only. Do not write in this area, to be completed by city.or town o;ficraL City or Town: permit/License# Issuing,Authority(circle one): 1: Board of Health Z.Building Department 3. city/Town Clerk 4.Electrical 6. Other Inspector S.PIumbin" b Inspector Contact Person: Phone : Information am d Instructions Massachusetts General Laws chapter 152 requires all employs to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every pt✓rson in the service of another under any contract of hire, express or implied,oral or wntten." An employer is defined as"an individual,partnership,associaition, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise;and including t3h legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association ox-other legal entity,employing employees. However the owner of a dwelling house having not more than three apartnZ ents and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintemance,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 lir in agency shall withhold the issuance or renewal of a license or permit to operate a business or to(--enstruct buildings in the commonwealth for any applicant who has not produced acceptable evidence of comupliance 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=--til acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please a 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships U-.2)with no employees other than the members or partners,.are not required to carry workers' comp a nsation insrrr,,nce. 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 svire to sign and date the affidavit The affidavit should by ivt'uiued t0 the vitt' r tC1wTi that the Rp pllCd`uOri for the pmt or licerise us being requtAs4d,nat the L'epaTL:,--nt.of Industrial Accidents.. Should you have.any questions regard:ri g the lair or if you are—j-i:ired to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license nurriber 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 pmmit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit'Iiceme 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 Office of Investigations would I&e to than 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.,faxnumber._._... The Commonwealth of Massachusetts Depa�ent of lndustrial Accident Qflirce Gf Im estiaat ons 600 Washm tan Street Boston,M-A 02111 Tel. # 617-72-7-4900 ext 406 or 1-8 777-MASS.FE Revised 5-26-05 Fw. # 6.17-72.7-7749 vmrv,.Ina&a.aov/dia.