Loading...
HomeMy WebLinkAboutBuilding Permit #230-14 - 595 CHICKERING ROAD 9/11/2013 L TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: 4 IMPORTANT: Applicant must complete all items on this page LOCATION � , ", p,-i tt ( a Print PROPERTY OWNER - -N agar Print 100 Year Old Structure yes no MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE M Residential Non- Residential ❑ New Building ❑ One family 11 Addition ❑Two or more family ❑ Industrial . ❑Alteration No. of units: Ctommercial &Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well D Floodplain ❑Wetlands ❑ Watershed District 11 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 1J a 8-Ivjcc oWcak bye, Identification f,Please Type or Print Clearly) OWNER: Name: l�,n '� ke II Phone: Address: CONTRACTOR Name: c ,Liao0f Phone: Address:154 42", g--l'��y AN Supervisor's Construction License: p Ex Date: l C _Exp. Home Improvement License: 100 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$'iv00.00 CSF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: FEE: $ �f�-O� ' Check No.: A2? Receipt No.: . ' ', NOTE: Persons contracting with unregistered contractors do not h e cess to the guar qrfiund Signature of Agerit/Owner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Location �21 No. J Date A� • - TOWN OF NORTH ANDOVER . Certificate of Occupancy Building/Frame Permit Fee $�— Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#//W ' v J Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF'::SEWERAGE:D3SPOSAL Public Sewer ❑ Tanning/MassageBodyArt ❑... . 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 1 PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS i LEALTH Reviewed on Si nature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comments - I Conservation Decision: Comments Water & Sewer Connectionlsignature& Date Driveway Permit DPW Tovv;! Engineer: Signature: _��tgd 1$r4 Osgood Street FIRS '' EPARTMie_NT =Temp Dump'ster on site es.. Located at 124 Mair, Street no Fire Departmeri't signature/date g 1� r ; COMMENTS r Dimension Number of Stories: Totals square feet of floor q 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 ® Notified for pickup - Date I Doc.Building Permit Revised 2010 r- Building Department The foil,"swing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofhig, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ,d 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 o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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 o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o 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 apu,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Bubding Permit Revised 2012 i oNo eTH'H . o 4 3SS/ICH11549 i CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 230-14 on 9/11/2013 Date: October 11, 2013 THIS CERTIFIES THAT THE BUILDING LOCATED ON 595 Chickering Road MAY BE OCCUPIED AS Legends Gymnastics _IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Legends Gymnastics 595 Chickering Road North Andover,MA 01845 :/' Building Inspector Fee: PrePaid Receipt: 26846 Check : 1003 Hudson Design Groupuc FIELD OBSERVATION REPORT NO.2 Legends Gymnasium South 595 Chickering Road North Andover, MA 01609 Date: October 1, 2013 WORK PROGRESS: The project is proceeding well. The reinforcing wall was finished at the front lobby. Both the sprinkler closet and heating equipment room were roughed; with drywall completed. The restroom area metal stud work was completed and plumbing work started. COMMENTS: 1. The diagonal reinforcement for the restroom walls was in progress. 2. B. O'Donnell provided G. Getchell with a copy of the interior wall and finish requirements for a Class C rating. 3. The carpet requirements for flame resistance were provided to Legends on August 2-th (Class 11, 0.22watts/cm2 or greater and pass the DOCFF-1 pill test). 4. Legends hopes to be ready to open in approximately one week. 5. Painting was started. REPORTED BY: Brian P. O'Donnell, AIA, LEED AP DISTRIBUTION: Glen Getchell—Legends Gym—South Gerald Brown—Inspector of Buildings, North Andover p:978.557.5553 f:978.336.5586 a:1600 Osgood Street,Building 20 North,Suite 3090,N.Andover,MA 01845 p:413.588.8139 f:413.517.0590 a: 116 Pleasant Street,Ste 302,Easthampton,MA 01027 NORTH own of ) ndover 0 V h ver, Mass, o l!/ COCNIC«.WIC« yQ• ` AERATED 9 S u BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT �.�." BUILDING INSPECTOR .,.. .... .. l��'..�....-�y�.� ��`0�0 /� Fo ation has permission to erect.......................... buildings on .v..:.............,..............'... ..... .. ......................... g Run le��ll3 ,,•�� t0 be occupied as f-e. c'.�a1'C � ...,.��..."?� ,�t�CS; . 1.=r1 ...............'.`.�., %V���? � r:C.:ar........ chimney p' �............,-.. �................. provided that the person accepting this permit shall in every respect conform to the terms of the application Final Oe faf f-/n 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 i4g4 VIOLATION of the Zoning or Building Regulations Voids this Permit. FINAL INSPECTION NOTES APERMIT EXPIRES IN 6 MONTHS '� /W UNLESS CONSTRUCTION TARTS Rough DSS' q— �_% . ............................... ina `6 ILDING INSPECTOR ©� 1��' ail GAS INSPECTOR t. 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 Smoke Det. SEE REVERSE SIDE NORTF/ Town of ndover 0 .:. r h ver, Mass 'QA COC NIC"t WICK S U BOARD OF HEALTH PERMIT T D Food/Kitchen / Septic System f/ l? BUILDING INSPECTOR THIS CERTIFIES THAT .........4 ...�............. . ... .. '�'' �' �'4�r , � Fo dation has permission to erect .......................... buildings on ..::'� .... !;l�r ��.. I .................... ..... .......�......................... g /D�l �3 to be occupied as .............r?,`�..e`�c!va C:f.�...:,.�.. L ��..�.�..:: t: .�.. 1�?.1 .............. Vi);��? ` �:3�.2 ........ Chimney � provided that the person accepting this permit shill in every respect conform to the terms of the application Final Ok' / �g'/j 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 Jaggy FINAL FINAL INSPECTIO NOTES PERMIT EXPIRES IN 6 MONTHS 1;-;r�.47- UNLESS CONSTRUCTION TARTS "R uu'gh Service `BUILDING INSPECTOR GAS INSPECTOR 5 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 Smoke Det. SEE REVERSE SIDE Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 419000.00 m $ - $ 492.00 Plumbing Fee $ 61.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 61.50 Total fees collected $ 715.00 595 Chickering Road 230-14 on 9/11/2013 Legends Gymnastics remodel Hudson Design GroupLLc FIELD OBSERVATION REPORT NO.1 Legends Gymnasium South 595 Chickering Road North Andover, MA 01609 Date: September 12, 2013 WORK PROGRESS: The existing restrooms and office were demolished. Construction was started on the new restrooms. The owner has purchased fire retardant wood studs and submitted receipts to the Building Inspector. The owner mentioned that the building permit was received earlier in the week. COMMENTS: 1. The boiler room will have an inside width of 5'-0" to allow clearance from the equipment. 2. The owner would like to build the restroom, office, boiler room and sprinkler closet and walls to a height of 8'-0" AFF. HDG provided a sketch for diagonal bracing to the corner of the walls for seismic support. 3. Ceilings must be a minimum of T-6" above the finished floor. 4. HDG provided nomenclature clarification of the metal studs to the new wall bracing at the front of the space. REPORTED BY: Brian P. O'Donnell' AIA, LEED AP DISTRIBUTION: Glen Getchell—Legends Gym —South Gerald Brown— Inspector of Buildings, North Andover p:978.557.5553 f:978.336.5586 a:1600 Osgood Street,Building 20 North,Suite 3090,N.Andover,MA 01845 p:413.588.8139 f:413.517.0590 a:116 Pleasant Street,Ste 302,Easthampton,MA 01027 NORT11 own of t E : ndover O - .:;. 1 to No. Z �� 3 ' h " ver, Mass COCHICHIWICK y1. �d A04ATED P'Pp��S .S V BOARD OF HEALTH PERMITT, L D Food/Kitchen Septic System ��N F afj '�� BUILDING INSPECTOR THISCERTIFIES THAT ......... ... ............................................................................................................ �" " C/�J'G �i"�f'/ Foundation has permission to erect .......................... buildings on . ................................... ..(T. . ............................ Rough to be occupied as , (, � -„�'?'� ,�4!cr �.zl � ......... .'.)!4�? �: .it:........ Chimney provided that the person accepting this permit sh II in every respect conform to the terms of the application Final p p p 9 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 CONSTRUCTION T RTS Rough Service ,ter,, Final N6-INSPECTOR 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. SEE REVERSE SIDE 8/30/2013 Thomas Denoi MA Lic#32701 EPA REFG.#0389243174800 HIC LIC. #173832 876 Forest Street North Andover MA, 01845 Work to be done at 595 Chickering RD.North Andover, MA 01845 (Gymnastics Studio): 1. Move One Water Closet Approx.2 inches right to comply with ADA standards. =$300.00 2. Move 2 lay. Drains,vents and water supplies,to comply with ADA standards.=$650.00 3. Install a standing Mop sink with ejector pump and barrel,along with all necessary drain vent and water supplies needed for this fixture.=$1,800.00 4. Install Two American Standard ADA Tank Type Toilets (including Material)=$9 50.00 S. Install Two ADA Lav faucets (Incl.Material)= $375.00 6. Install, Hi-Lo EZBL ADA Water Fountain (Incl. Material)= $2,100.00 7. Install, 20g1.Electric Water Heater(Incl. Material,but Not Electrical Wiring)= $600.00 Grand Total=$6775.00 *Material,Permit, Inspections Included. All above stated work will be paid for by Condo owner(50%) and Condo renter(50%). INDEPENDENT CONTRACTOR AGREEMENT This Independent Contractor Agreement (this "Agreement") is made effective as of September 05,2013, by and between Legends South Inc.,of 595 Chircking Rd.,North Andover, Massachusetts 01845, and Bill Blackwood, of 250 High Rd.,Newbury, Massachusetts 01951. In this Agreement,the party who is contracting to receive the services shall be referred to as "Legends South Inc.", and the party who will be providing the services shall be referred to as "Bill Blackwood Construction". 1.DESCRIPTION OF SERVICES.Beginning on September 05,2013,Bill Blackwood Construction will provide the following services (collectively,the "Services"): As described in the attached Exhibit Construction of all interior walls 2. PAYMENT FOR SERVICES. Legends South Inc. will pay compensation to Bill Blackwood Construction for the Services in the amount of$6,000.00.This compensation shall be payable in a lump sum upon completion of the Services. 3.TERM/TERMINATION.This Agreement shall terminate automatically on September 16, 2013. 4.RELATIONSHIP OF PARTIES. It is understood by the parties that Bill Blackwood Construction is an independent contractor with respect to Legends South Inc.,and not an employee of Legends South Inc.. Legends South Inc. will not provide fringe benefits,including health insurance benefits,paid vacation,or any other employee benefit,for the benefit of Bill Blackwood Construction. 5. WORK PRODUCT OWNERSHIP.Any copyrightable works,ideas,discoveries, inventions,patents, products,or other information (collectively,the "Work Product") developed in whole or in part by Bill Blackwood Construction in connection with the Services shall be the exclusive property of Legends South Inc.. Upon request,Bill Blackwood Construction shall sign all documents necessary to confirm or perfect the exclusive ownership of Legends South Inc. to the Work Product. 6.CONFIDENTIALITY.Bill Blackwood Construction will not at any time or in any manner, either directly or indirectly, use for the personal benefit of Bill Blackwood Construction,or divulge, disclose, or communicate in any manner any information that is proprietary to Legends South Inc.. Bill Blackwood Construction will protect such information and treat it as strictly confidential. This provision shall continue to be effective after the termination of this Agreement. Upon termination of this Agreement, Bill Blackwood Construction will return to Legends South Inc. all records, notes, documentation and other items that were used,created,or controlled by Bill Blackwood Construction during the term of this Agreement. 7.INJURIES. Bill Blackwood Construction acknowledges Bill Blackwood Construction's This is a RocketLawver.com document. F � obligation to obtain appropriate insurance coverage for the benefit of Bill Blackwood Construction (and Bill Blackwood Construction's employees, if any). Bill Blackwood Construction waives any rights to recovery from Legends South Inc. for any injuries that Bill Blackwood Construction (and/or Bill Blackwood Construction's employees) may sustain while performing services under this Agreement and that are a result of the negligence of Bill Blackwood Construction or Bill Blackwood Construction's employees. 8.INDEMNIFICATION.Bill Blackwood Construction agrees to indemnify and hold harmless Legends South Inc.from all claims, losses, expenses,fees including attorney fees, costs, and judgments that may be asserted against Legends South Inc. that result from the acts or omissions of Bill Blackwood Construction,Bill Blackwood Construction's employees,if any,and Bill Blackwood Construction's agents. 9.ENTIRE AGREEMENT.This Agreement contains the entire agreement of the parties, and there are no other promises or conditions in any other agreement whether oral or written. 10.SEVERABILITY.If any provision of this Agreement shall be held to be invalid or unenforceable for any reason,the remaining provisions shall continue to be valid and enforceable. If a court finds that any provision of this Agreement is invalid or unenforceable, but that by limiting such provision it would become valid and enforceable,then such provision shall be deemed to be written, construed,and enforced as so limited. 11.APPLICABLE LAW.This Agreement shall be governed by the laws of the State of Massachusetts. 12.SIGNATORIES.This Agreement shall be signed by Glen E. Getchell,President on behalf of Legends South Inc. and by Bill Blackwood,Owner on behalf of Bill Blackwood. This Agreement is effective as of the date first above written. This is a RocketLawver.com document. PARTY CONTRACTING SERVICES: Legends South Inc. By. Glen E. Getchell President CONTRACTOR: Bill Blackwood By: Bill Blackwood Owner 4� This is a RocketLawyer.com document. t Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Super,isor License: CS-052533 WILLIAMBLACICWOOD 250 HIGH RD ; NEW BURY MA 01951 Expiratior Commissioner 09/17/201: BLACK-3 OP ID: KQ ATE,aCORO CERTIFICATE OF LIABILITY INSURANCE D09/11/2 111/2 Y013 `--� 03 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 Phone: 978-465-5301 NAME: Arthur S Page Insurance Agency Fax:978-462-0890 PHONE FAX 57 State St. A/c No Ext): AIC, Ic No): Newbu ort,MA 01950 E-MAIL ryp None ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A:Western World Ins Co INSURED Blackwood Construction INSURER B Bill Blackwood 250 High Rd. lNsuRERc: Newbury, MA 01951 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 ADDL SUBR POLICY NUMBER MM/DD YYYY MMIDD YYYY LICY EFF POLICY EXP LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY PENDING 09111/2013 09/11/2014 DAMAGE PREMISESS( RENTED 100 000 Ea occurrence $ CLAIMS-MADE I A I OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 POLICY 7 PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOSAUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMIT ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) CARPENTRY CERTIFICATE HOLDER CANCELLATION TOWNN-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth oflilassachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit:Builders/contractors/EIectricians/Plumbers Applicant Information Please Print Legibly Name(Business/Org ani zation/Individual): end rvis, Address: R City/State/Zip: lgrth , r Pkl Mphone#: VG-57f-WoV Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6 New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.1 7. [ emodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working forme in any capacity. ,/workers'comp.insurance. 9. ❑Building addition f [No workers' comp.insurance 5. We are a corporation and its required.] officers have exercised their 10.❑EIectrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.E]Roofrepairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other 'Any applicant that checks box#1 must also fill out the section below showingtheir workers'compensation policy information. Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit anew affidavit indicating such. ?Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I aman employer that is providing workers'compensation insurance for my employees. Below is the policy and joh site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a.copy of the workers'compensationpolicy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiroclunder 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido 11erehy cert. un r Aepains andpenalties ofperjury that the information provided ahove is true and correct. - SignatureAh: Date: L 41 Phone Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown CIerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person:_-_ Phone#: Information and ffnstruefIlon's ' 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 ofhire,• 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapterhave 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 maybe 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 afidavitis-complete-and printed'legibly. The De artrrierifhas rovided a s ace of the botEom 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 homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho G`oxilmonw(- t�ofM,9ssa(,-h-u tts Aep.artmit offadustdat,A ccideats Office of 1"estigations. 6QQ Wm iiugtmi Street Bostonr 11�IA.Q2X 1.X TOL#61.7-7274900 ext 406 oar 1:-8,77-MASSAk`F Revised 5-26-05 FaY,4 617-727-7749 i i %j k -..icbiti,i - t3% 1 amen. 1 Valilly ia. '' .ttictral fii•Ut d:o- U : ttil,c , and Slaallart, .r Y :rjxtion S--r- License i a:•CS 52533 - I ' WILLIAM BLACKWOOD 250 HIGH RD NEWBUI2Y, MA 01951 Expiratian 9/17/2013 e Tr't- 601 r