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HomeMy WebLinkAboutBuilding Permit #1346-2016 - 54 HEATH ROAD 6/28/2016 L)r( �y BUILDING PERMIT O� �O"FID �H TOWN OF NORTH AN®®VER -�� ���?,•� .�f`46 0 APPLICATION FOR PLAN EXAMINATION ~ '� �o m" Permit No#: / `�`ZV�� Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION' L He4 fh • Rd Print PROPERTY OWNER ;F `P nt 100 Year,Structure yes no MAP. AP PARCEL ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resi ential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑bAteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other - =. ©Sep 1t1t ❑Well' i y} f ^❑rFloodplftWetlands{ 1lVatershed k sfrrct E , DESCRIPTION OF WORK TO BE PERFORMED: N1� /Q F re�G(ac..2 Ska SF,t o ruLL- roof; 4(ea Sz See a #acAed d Q.h,d ej, pro p oscx,� 'r-0o )!I —� Identification- Please Type or Print Clearly OWNER: Name: j Phone: L Address: eq Contractor Name: ,_SC04 Ir 11 Q��J- Phone: 9 7�-68 )UL/7 Ema11; ri kA rn��1,, aw Address; r s� o v ►�-�/-! 4 i�'y S` Supervisor''s Co h§trudtibn,License• CS- %0ab63 Exp:. Date: 0.8T�o1�a0l'7 Home Improvement License: 13 g 56 Exp: Date: I y .04 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: $ L'7©d. 00 FEE: $ 3(i Check No.: Receipt No.: Y NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund S34W�7_ - - - --- — r 1 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 & DEVELOPMENT Reviewed On Signature_ i COMMENTS I CONSERVATION Reviewed on Signature COMMENTS I HEALTH Reviewed ori Signature I COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes ',Planning Board Decision: Comments Conservation Decision: Comments j Water& Sewer Connection/Signature Date Driveway Permit DPW Town Engineer: Signature: FIRE D.. �M EaN Located e 384 Osgood d Street EP,A ��Tem ump,seer on�site�y sg� �`u y no _ ll- co ated at 1P24 Mam S reet� �`"'""�"`� M'�M Er-�N��=S .�:,, 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-reclJoires approvral 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) f k ® Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 r 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 46 Floor Plan Or Proposed Interior Work 4. Engineering Affidavits for Engineered products OTE: 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/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) r 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) I � Copy of Contract 2012 IECC Energy code i Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location No. \ �`' Zv� Date 7 � • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ T Other Permit Fee $ TOTAL $ Check# � � j n Bu l"ding Inspggctor NORTiy Town of O ' No. q4_ 7 �� h4* verass> 2ai o coc"IcNewa« y1• RATED 0`P�`�,(5 U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ...... ..�. ... ... .. ... .. ....................... . . .. . . M .... . .... ... . ... .... Foundation has permission to erect ............. buildings on Rough to be occupied as .... �- !V--. k..... . ... .Fve;v .............................................................. Chimney provided that the person accepting this permit shall inrespect 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS TIO Rough Service .. .... . ....... .. Final UILDIN EC R 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. WRIGHT GUTTERS 350 Berry Street No,Andover,Me 01545 Homeowner information Contractor Information Companyla S'•estAM-Cas(do rotuseapcstoheceBo f dires5) V Co.:tra o•/Setesp1 .JO'...e-tiz.,:e C! Tov.n S:z!a ZipCc'_e 3:>' e=sA?d:zss( tircLf as:-e ?res) Al. lqi1doVac Mtj 0 r8Y5- i 5 Q �Re rr,4- Sf — — Da}'ir:epncne f Fsr'cr 3Phere Ci arc:ct atate Zip Code th 4rCLO V2r Mdq 0/3y5- 9 tta: ngAdd:ass(itdihefeatEMT,a,07-) Bu;ir�sp:7reQ � AFedtTr_ otcfrMorS.S.;3usbtr�()- Ia,�rci�:rsCE:tr..wttc�e (./ ),rip n -;.srcrnrflcn Lc,e :a,� •. y/�J�rJFV3 cry:id re;•atn:1n:F;a a.-}rr J The Contractor agrces to do the following work for the Homeowner: ('De;uib:sndetaiit:e c'stoeee;pletzd,s eci:jir$tFe yge,b;aad,,asd zdaof r:tei s!abeeszd,u_ex ditio-al�'heesifr4-naer+.) �gw,.oJQ E V-q(ckcz s(�, eT rt�bbe voe� ��_ct�i� Sett �A Required Permits-naio:lowing bttildingpent3ts are ragnired Proposed start and Completion schedule.a.-sollov,ing schedula Mil and vvi11 be sec!uel�y rico con`rac:0r as cite how:co:vrars agent. be adaered to ;Messc:rctuni%ncesbeyoad tlnecontiactoiscrntriarse (Owners Who secure their own perinits will be excluded from lite Guaranty Fund provisions o£ D 'c�'r ::2 CvniiuCTGr 1'i!ll begin connected,;cr c. \IGL chapter 142A_) J f1 l6 Datav:iieacon tac!eIvicr wi11basubs tan?ia)lycompleted. L Total Contract Price and Payment schedule c o�8*n 2 The Contractor agrees to perform the work,f!unish the material and Iabor specified above for the total sunt of _ Pay�renu will be made according to tae foLo',viag schezu':e: upon;igrinsce::tract(:ottGexceedl/Sof*he:utlr, tz:tpccgKul ;.-tof;peciieA eus,',vhicL,ever isgrea!en, S _--of ( l�ertzp .rca•-p.eitcnof �__ S by i( / or upon completion.of S_i �}ylQpoa completion ofihe canrct. (Law forbids demanding allpayment until conxactis completed to both pity's satisl'zc�oa) iJ iT.:et:t _Z!L•J(}•)J _�...to NOTES;(')lri di::ga.ltinz�tae saes("")Lawu:;.iitSf`zteaydepcs.'e:du:t1- =}'venire,uifedby23CGnLat:Grb°:C:e1iJrtberin;ay 1.0.ex (a)one'h?rdoft'roto!alecnuaGtprc.arjb)nez ulcosta£zryspzriz]egap: zntcrc stealtnade:r,zter7l LxrresS�V�rrinf. lsanexLre.>}r'trrnntvbeingpro•9dtdbvthe^antrxtcr? \odYe'(�ilterntsafthe tarnnty7lustbeatt=chcdt.atheter'r�'tl Subcontractors-T.eccntmctcrag'eest a basole'.yre;pansible ocompie-;onoft.hawork described regardlessofthe actlonsofaaythird DiS�y�S!IbC07t'fiC:Or r u'ize3by irs cen�actor. the contractor fiudter ag­ees to be solely resporsbla for all eey;;.ca!s to all s!�c0ctac:0r fur )naferials and labor tender,11:5 zme=ert Contract Acceptance-Uport slgninzgl this document becomes a binding contract,undzr law. Jessothenvisenoted wiVathiaCocialent, :e contact s!la1l net amply that any lien Cr r,011.,Security I temst has beea placed ca tae rside:0e. Zevia.;'tita fo110;`.lag cauu0ns and 1:0 ice; carefullybefore.;8dng Us contract. • Don'tbepresscredinto si )gthacontact.Take timetaiezdacdfully unde:s:audit. Ask;nes•.ie^sicscmeddngistmc?er. • ),Us sure 7lalawreyuirestr:esthcxeimprovanzntcoitrzctcrSr d subc intractors to be registered with the Director ofHome Improvement Contractor Registration. You may inguiraabout contractor registration by vvrir.'ng to the Director at 10 Park PIaza,Room 5170,Boston,MA 02116 or by calling 617-973.8787 or b 88.233375;. • D09i the COGCaCtGi Nati'P.1GSCi2nCCT Ask ilio CG71'S'aCtOr fOr1115Iri5:7ra;:CC CCmp'w"iy iltfOtID:.t10:a 50 ii:att`01 Cs»Cvn i:Rll CG}'e:a,°�a,0:iiti ii. Sea a COjiy Of a"prCCZ Of in5llra nCe-'C;OC+1'7efii. • Know your:&tits and resacnsibilides. Read tLelmportent Infornai140n on the reverse side of tars form,rd get a copy oft;:e Ce_s�aocr �nil'.o to tL-01'.01:e impro�:ernent Co:.aac!ar La,t. You 1il is agreement ifithas teenstguedataplace other thanOre cortractersnormalplace ofbus mess,provided younotifytela conttactor in writing at hiller main osca or btanc'a once by or&a ymail posted,by telegram sent or by delivery,not Ia!ar than mienieltt ofthe brdbusinessday fo'llowing1liesigniogofthis agreement. See tl!eattached notice ofcancellatioaform for mexplaaationofti!isrigl V DO NNOT SIGN THIS CONTRACT IF THERE ARE A-W, BLANK SPACES! `. 130r:tao,vrcr's Signa: a ` 'Cea:rrot's Sio,:arura v E struction FREE ESTIMATES PROPOSAL Lie-4 CS 02663isor ` FULLY INSURED H.I.C. Reg,# 138569 GT ROOFING-GUTTERS AND HO E"ROVEMIENT All Types of Roofimg& Gutters 350 BERRY STREET © NORTH ANDOVER, MA 41845 TELEPHONE: 978-687—2247 47 PROPOSAL SUBMITTED TO PHONE DATE Z"Z; STREET JOB NAME/LOCATION L/ Cirf,STATE AND ZIP CODE JOSSTART DATE `l /I o of .�`�Q ,Xts !�`► IS ,�� I�l�[ �� Il' ((F9i..ai� d,0-C, �ttIt F"�(( i�,� dlQt'1t��T ' Cu_ CS. til V1 C� rt C lhliY Vi t Uri-C�. 1 t S"�--a!?�-u � �� � � - Ic" d�i (1GLsfta dE`a�j. t i� pL't Se�a�ta ��i1�Oj ieArSC '�a'rr1 CL--- 00, 10 We Propose h o furnish material and labor-T7completein aordancewith above specifications,for the sum of:$Payment to b ade as fall w /� ^/ � \�4 1 et cv clic ,17,rE t� '�'t► All material is guar to be as specified.All work to in a substantial workmanlike AUth6rlZed manner according to specifics o r s andard practices.Any alteration or deviation from s above specifications involving extra costs will be executed only upon written orders,and will become an Signatu extra charge overand above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry fire,tornado and other necessary insurance.Our workers are fully NOTE: This proposal may be covered by Workmen's Compensation Insurance.Non payment by agreed party may result in litigation withdrawn by us if not accepted wit6m days. with penalties including court cost and compensation both real and punitive. Acceptance of Proposal - The above prices, specifications and conditions are satisfactory and are hereby accepted,making this a valid contract. Signature s f' Ca 9 You are authorized to do the wort,as specified.Payment will be made as outlined. i Date ofAcceptance: � Signature i i The Commonwealth of Massachusetts Department of Industrial Accidents _ F 1 Congress Street,Suite 100 Boston,MA 02114-2017 F www mass.gov/dia • Affidavit:Builders/Contractors/Eleetricians/Plumbers. Workers'Compensation Insurance Af TO BE PILED WITH THE PERMITTING AUTHORlt' - PleasePrint Ledb A lican:Information Name(Business/Organization/Individud): W f t h U` Address: SO Ci /State/Zi A� nc& U P� M [ yS Phone 4: 9 7 8-6 87 a `/ City/State/Zi P / Are you an employer?Check the appropriate box: rject(required); em toe full orpart-time).* construction 1.�t am a employer with') P y 2.❑I am a sole proprietor or partnership and have no employees Working for me in deling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition <1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole 12,0 Plumbing repairs or additions proprietors with no employees. 5.❑I am a general contractor and I have hired he sub-contractors listed on the attached sheet. 13, %Rof re�pjairs These sub-contractors have employees and have workers'comp.insurance.# 14. er IC C>M 0 V2 E' 2An�Q�Q 6.Q We are a corporation and its.officers have exercised their right of exemption per MGL c. Q/ ;r o o T WA 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicantthat checks box 4l must also fill out the section below showing their workers'compensation policy information. fi Homeowners who submit this this s musstt art indicating they are attached an additional sheet all work and then hire outside contractors must showing owing h name of the sub contractors and state whetht a er or new not hose entities have such. #Contractors that employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. Yam an employer that is providing workers'compensation insurance for my employees. Below is the policy and fob site information. Insurance Company Name: a Policy#or Self-ins.Lic.#: l i t(' 5-31S-3 8'118 7-O1 S _ Expiration Date: ' 3 0 d�/6 / ' a A f�l� �A�,Q,�r� ►I/Dnp M w4 City/State/Zip:g, An doy� ��' ©/��s Job Site Address: 5�� �i Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25the f is a faSTOviolation V ORKp RDER and a fine of up to $250.00 a and/or one-year imprisonment,as well as y a fine up to$1,500-00 civil penalties in the form o day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. e F do hereby certify n er the airs and p ltiesQfP jtuy th ?he information provided above is true and correct. Si ature: —-- - Phone#: 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 Phone#• Contact Person: /15/2015 7:37 :05 AM PST (GMT-8) FROM: 100005-TO: 19786889542 Page: 2 of 2 ACS CERTIFICATE OF LIABILITY INSURANCE DATE`MM/DD„YYY' 10/15/2015 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 terms 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). CONTACT PRODUCER T A SULLIVAN INSURANCE AGENCY INC NAME: 135 MERRIMACK ST PHONE FAX METHUEN, MA 01844 E-MAIL /uc "° ADDRESS: INSURERS AFFORDING COVERAGE NAIC A WSURERA: LM Insurance Corporation 33600 INSUREDINSURER B SCOTT UNRIGHT DBA WRIGHT GUTTERS INSURERC: 350 BERRY ST INSURERD: NORTH ANDOVER MA 01845 INSURERE: INSURER F COVERAGES CERTIFICATE NUMBER: 26936592 -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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTR INSD D POLICY NUMBER MMIDD/YYYY MM/DD/YYYY .. COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAG RENTED CLAIMS-MADE FIOCCUR PREM SESO a oc." nce $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER; GENERAL AGGREGATE $ POLICY❑PRO LOC PRODUCTS-COMP/OP AGG $ JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED l MIT $ Ea aaident ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peraccident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED RETENTION $ A WORKERS COMPENSATION WC5-31 S-387187-015 9/30/2015 9/30/2016 ,/ STATUTE ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N N/A E.L.EACH ACCIDENT $ 100000 OFFICERIMEMBEREXCLUDED? rY (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. THE WORKER'S COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR SCOTT WRIGHT. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF NORTH ANDOVER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATTN: LOCAL BUILDING INSPECTOR ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET NORTH ANDOVER MA 01845 AUTHORIZED REPRESENTATIVE f LM Insurance Corporation ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 936592 1-387187 15-16 WC shankar.gadale@Libertymutual.com LO/15/2015 7:34:59 AM (PDT) Paqe 1 of 1 &Iassachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-102663 Construction Supervisor i SCOTT w WRIG"T 350 BERRY ST . NORTH ANDOVER PAA 011945, (,A '-� Expiration: Commissioner 08/12/2017 Unrestricted-Bufldin�s of any use,group iv1►ic b contain less than 35,000 cubic feet (991 M)of enclosed space. Failure to possess a current edition of the Massachusetts _ State Building Code is cause for revocation of this license. For DPS Licensing information visit: www,Mass.Gov/0PS ' Office of Consumer Affairs&Business Regulation c ;40ME IMPROVEMENT CONTRACTOR p !Registration: -138569 Type: . Expiration: 4/14/2017 DBA WRIGHT GUTTERS SCOTT WRIGHT 350 BERRY ST, NO.ANDOVER,MA 01845 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza,Suite 5170 Boston,MA 02116 Not valid wlthout gnature 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited d 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 bum 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-MASSA-FE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia