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HomeMy WebLinkAboutBuilding Permit #Exception - 575 OSGOOD STREET 5/1/2018 (9) i. y BUILDING PERMIT oNo oT e'�tio TOWN OF NORTH ANDOVER0 . APPLICATION FOR PLAN EXAMINATION * _ . I'm Permit No#: Date Received �,'"1.ArED gSSACHus�t Date Issued: IMPORTANT: Applicant must complete all items on this page i LOCATION Print PROPERTY OWNER �Print 100Year Stju.cture �yes no MAP' _ PARCEL- _ ZONING 'DISTRICT: Historic District` yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial j ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain 0 Wetlands D UVatershed District p Water/Sewer, _ DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name _ :Phone:: Email: _ - Address: Supervisor's Construction License: _ s Exp. Date._ Home Improvement License: _ ._ -__ Exp. pate:.— ARCH ate:. ._. - _ ARCHITECT/ENGINEER Phone: S Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracying with unregistered contractors do not have access to the guaranty fuald S gnatur..e of AgenVOwner _._.,. ._ Signafure of contractor: -F 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 L3 Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit ! Addition Or Decks o Building Permit Application L3 Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) L3 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) o Building Permit Application Li Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract L3 Mass check Energy Compliance Report o Engineering Affidavits for Engineered products VOTE: 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 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 - U FORM ' PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature r COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments e c Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: .I --'—E _ `FIRE�DEPARTMENT = Te psi m _ 84 t N I rn ®u p ter 60 site: yes� _ �ir o Located OsgoodStreet S iLocatedat 12MamSfreet �Fire�LZepz1Jnent,signature[date "OP RS i 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) i I i i ❑ Notified for pickup Call Email i _Date Time Contact Name i Doc.Building Permit Revised 2014 i viLocation 6-7 C'�Y No. _ Date } {U . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $�6 Foundation Permit Fee $ Other Permit Fee � TOTAL $ Check 915 /Building Inspector NORTH own of ? E ndover o - .:.. 1 to No. _ 2 * ?. � ver, Mass, �� o�K CoCNIClWICK A°4Areo 0P�`,��(5 S U - BOARD OF HEALTH Food/Kitchen PERMIT D Septic System THIS CERTIFIES THAT ......! ` V+0A � w! µ� BUILDING INSPECTOR .. .. .� ......... .... .., .. ,.. Foundation has permission to erect .......................... builW' izA ..51.Q. .... .. . ......... g Rou h to be occupied as .. .. . ...A.Y.00as... �. .�....................... Chimney provided that the person acc pting this permit shall in every resct conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO TARTS Rough Service ............. .... .. . .................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy.BuRough 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. Old School Roofing 297 Littleton R& ® Chelmsford, MA 01824 978-251-7663 (Office) 978-251-7664 (Fax) © 4 Www.oldschoolgroup.com CS?1�TI��IALLY TRAINED�_D�ER'�FIED BY A1�YERI��i�LAR�E�T�tQQFING M�Al!IJ���_U_RER� Edgewood Retirement Community Proposal September 11, 2015 575 Osgood Street North Andover, MA 01845-1935 Phone: (978) 725-3300 Attn: Bob Copolla 1. Job Specifications: Buildings 1000 and 2000(including rubber porch roofs on Bldg 1000) 2. Job Preparation. *Set up job site and insure attention to your particular concerns. Installing tarps around the areas being worked on to prevent damage to siding,plantings and any landscaping. 3. Remove Old Roof.- #We will remove the existing layer of roofing. This allows for inspection of the roof decking,and repair any damaged boards. NOTE: We will replace any damaged or rotted plywood at$2.00 per square foot for 1/2 C®X plywood, $2.25 for 518 CCX plywood and$3.00 per lineal foot for deck boards 4. Install teak Barrier. *Install full cover ice and water barrier. *This for extra protection against"ice damming"-as recommended by manufacturers, I 3' of hi-temperature ice and water shield feet up the valleys underneath the new copper valleys. 5. Flashing Details: *Install new 8"aluminum drip edge to all rakes and eaves,and pipe flashings.All side walls will be removed and ice and water installed with new step flashings. 6. Shingle Application: *Install a Lifetime Architectural Shingle,CertainTeed Landmarke Colonial Slate. 7. Ventilation: *Install a new ridge vent on all dormers. We use a ridged vinyl baffle vent which allows for the best ridge ventilation. 8. Hip 8 Ridge Shingles: *Install new hip and cap shingles, this provides protection of the ridge vent and a finished look to the roof line. 9. Roof Warranty: ♦Limited Lifetime Manufactures Warranty.(40yrs Commercial) 10 Year Workmanship. 10. Chian-upUsposak *Old School Roofing supplies the dumpster.Our disposal costs are based on recycling of the asphalt shingles. Please do not throw any household trash or foreign materials into the dumpster. We will thoroughly dean up and dispose of all materials and debris associated with the job. *Protection and clean-up of the property are one of our biggest concerns. 11. Permits: *Old School Roofing will be responsible for obtaining any and all necessary permits to insure the work is performed legally. 1 Scheduling: *We do our best to stay within stated scheduling, estimated Job completion 12-14 days. However, Mother Nature and emergencies can lead to delays. We will do our best to limit those delays. We will contact you within 48 hours before installing your new roof and work will not be commenced until you are contacted first If more time is necessary to accommodate your schedule,kindly let us know. Job Cost: $91,420.00 Payments shall be made as follows: '/:deposit due before scheduling work, balance due upon completion of the work. QUOTE GOOD FOR 10 DAYS ONLY. All applicable discounts applied. SIGNING INDICATES ACCEPTANCE OF THE PRICES AND SPECIFICATIONS SET FORTH HEREIN ANIS ACCEPTANCE OF THE TERMS AND CONDITIONS OF THIS CONTRACT. Old So I oofing: Prope Manager: ) Date i Date 11 {l f Authoriz presentative All rubber porch roofs wi//be done with.060 EPDM.adhered to Y2 Insulation Boated Additional Worklnc/uded.- Removing sidino on downers to Inst a//ice and watershield and newstep flashing Ifnewsidina needed an additional cost wou/dapp/y Full inspecWon of the main rubber roof. Too include-Inspection of a//penetrations 6apprrox 74)clean and sea/any/iftina sgwms.Inspection of a//robber/agm1join>Isr clean andsealas needed. Any serious issues discovered wi//be wrMen yp and discussed prior to any wo&startedl Please feel f-ee to call me wiM any aueWbim Thankou, Tony Dowd-978-251-7663 CSZ8099649 HICAf157447 2 �•� OP ID: MH ACORU° F DATE(MM/DD/YYYY) `.� CERTIFICATE OF LIABILITY INSURANCE 1012612015 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). PRODUCER CONTACT Segreve&Hall Insur.ASSOC.Inc NAME: E FAX 305 North Main St. A/CNNo.Ext): A/C No): Andover,MA 01810 E-MAIL Lawrence J.Hall ADDRESS: PRODUCER OLDSC-1 CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED Old School Group Inc INSURER A:Travelers Ins.Co. 25658 dba Old School Roofing INSURER B:Arbella Protection Ins.Co. 41360 297 Littleton Rd.Unit 1 Chelmsford,MA 01824 INSURER C:Northland Insurance INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY 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 DD UB Y EFF POLICY EXP LTR POLICY NUMBER MMIDD/YYYY MM DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 C X COMMERCIAL GENERAL LIABILITY WS232756 12/16/2014 12/16/2015 DAMAGE TO RENTED PREMISES Ea occurrence $ 100,00 CLAIMS-MADE I—XI OCCUR MED EXP(Any one person) $ 1,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY PRJECO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE B X HIREDAUTOS 1020000245 06/0l/2015 06/01/2016 (PER ACCIDENT) $ X NON-OWNED AUTOS $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y IN TORY LIMITS ER A ANY PROPRIETOR/PARTNER/EXECUTIVE❑NNIA E.L.EACH ACCIDENT $ 100,00 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) TBI 10/21/2015 10/21/2016 E.L.DISEASE-EA EMPLOYEE $ 100,00 If yes•describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) 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 ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street Building 20,Ste 2035 North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD OP ID: MH ACORN" F DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 10126/2015 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). PRODUCER CONTACT Segreve&Hall Insur.Assoc.Inc NAME: FAX 305 North Main St. A/c Nr o Ext): (,C, AIC No): Andover,MA 01810 E-MAIL Lawrence J.Hall ADDRESS: PRODUCER OLDSC-1 CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED Old School Group Inc INSURER A:Travelers Ins.Co. 25658 dba Old School Roofing INSURERB:Arbella Protection Ins.Co. 41360 297 Littleton Rd. Unit 1 Chelmsford, MA 01824 INSURER C:Northland Insurance INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY 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. /NSR ADDTYPE OF INSURANCE L B R POLICY EFF POLICY EXP LTR POLICY NUMBER MM DDIYYYY MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 AMAUF TO R1:N E: C X COMMERCIAL GENERAL LIABILITY WS232756 12/16/2014 12116/2015 PREMISES Ea occurrence $ 100,000 CLAIMS-MADE FXI OCCUR MED EXP(Any one person) $ 1,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY PRO- JECT RO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1 000 000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE B X HIREDA TOS 1020000245 06/01/2015 06/01/2016 (PER ACCIDENT) $ X NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER A ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? ❑N N/A (Mandatory In NH) TBI 10/21/2015 10/21/2016 E.L.DISEASE-EA EMPLOYE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) 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 1600 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. Building 20,Ste 2035 AUTHORIZED REPRESENTATIVE North Andover,MA 01845 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD o The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia WWorkers Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TBE PERMITTING AUTHORITY. Applicant Information /, Please Print Lel=_ibly NaMe(Business/Organization/Individual): 0(X? 56 4�, �jWw . 'Il✓ Address: 7 il 029l t���n (rt 11 ' 3 City/State/Zip: '` �Alrltdrd 04E 610 Z}� Phone#: 9T y- 76(�3 Are you an employer?Check the appropriate box: r Type of project(required): Ldl am a employer with J employees(fall and/or part-time).• 7. ❑New construction 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 g doin all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.n I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sub-oontractors have employees and have workers'camp.insurance.= 6. We are a corporation and its officers have exercised their right of'exem tion per MGL c. 14.[J Other ❑ rpP 152,§1(4),and we have no employees.[No workers'comp.insurance required] 'Any applicant that checks box#1 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing ivorkers'compensation insurance for my employees Be1mv is the policy and job site i information. j i 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(showin the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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 e violator.A co of his statement may be forwarded to the Office of Investigations of the DIA for insurance da against th vt 1 t Y g PY Y g coverage verification. Ido hereby c ti under thepains andpenalties ofperjury that the informationprovided above is trite and correct Si ature: Date: Phone#: -Z.V — 7461 Official use only. Do not write in this area,to be completed by city or tmvn official City or Town: Permit/License# Issuing Authority(circle one): ; 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector S.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-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 indicatingcurrent " policy information(if necessary)and under Job Site Address the applicant should write all locations' PP m ci or „ ( tY town . A copy of the affidavit that has been officially stamped p or marked b the city or town may be provided to the Y t3' Y applicant as roof that pp p t a valid affidavit is on file for futureermits or licenses. Anew affidavit must ust 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. i i 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 www.mass.gov/dia Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor Sp4cialty -` License: CSSL-099649 ANTHONY N D0'WD 9 DIGITAL DR#2'02 Nashua NH 03062 I f Expiration -Cbmmissioner 02/28/2016 ,_._._.. __.�_ "fie�(ioo�z�uaxureall�a��'`a39¢cJlu6(!lfQ .�...�.'�...�.�••..�. I. License or registration vaor nvuuse —__ Office oYConm*�rAtl'airs&Business Regulationlid fidiidl only WExpiratIon:'-'_-.f012/-2Q1'1 OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration• ;157447 TypeOffice of Consumer Affairs and Business Regulation Private Corporation 10 Park Plaza-Suite 5170 - Boston,MA 02116 OLD SCHOOL GROUP- INC.'_ ANTHONY DOWD 297 LITTLETON RD �_•�, ,^ CHELMSFORD,MA 01824 Undersecretary Not valid without signature