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HomeMy WebLinkAboutBuilding Permit #738 - 64 SECOND STREET 4/16/2012BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: --40 Date Issued: t1./ J r t 12-- Date Received 4?V-tt�e° �e�e O\ 3 '� '` °t °; 0 IMPORTANT: Applicant must complete all items on this naize I LOCATION i Print PROPERTY OWNER J� ,•i !� y .� t✓�rY' Print MAP 210 PARCEL: ZONING DISTRICT: Historic District -7--- Machine Shop Villaae yes no 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 Repair, replacement Assessory Bldg Others: Demolition Other ,• Septic Well Floodplain Wetlands Watershed istrict Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: A-, s �a // 06 / a) A) - � � C' � /4<ds C .'.0 A /-A L � Identi cation Pleas Type or Print Clearly) OWNER: Name: Phone: 7 • 7,Y'7 Address: e r CONTRACTOR Name: 041" ,L 5U/-4Af aPhone: Address: ..'U ZdA2At'14 -/ 0-2 41C4 J� 54 *� 4)-& Supervisor's Construction License: 9 7G / Y Exp. Date: Home Improvement License: I Exp. Date: 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: $ -7 0 -7d . 7.5 FEE: $ I --- Check No.: �),g- GReceipt No.: aSt Lz> NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner/Xj,�,yOM/��Signature of contractorx"J-0,&,, 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Locatea oo4 usgooa street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS. 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 2 1 A —F and G min.$100-$1000 fine NOTES and DATA — (For department use ❑ Notified for pickup- Date Doc.Building Permit Revised 2010 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance. Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ 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) ❑ 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 Location v �/ y n ol �/ Check '4S5— 25190 Date K TOWN OF NORTH ANDOVER i ---- Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 6E� �\L—� BuildInspector • E N. o L2 a ci) 0 og w° w°' a U w a 0, a�- w a 0 w w W C2 co w w�' w Ea w a w a4 o z cn A o Un E N. 1 L 4 W O CD O o cs CD d O y � C I O "0 CD 'FE mCD C3 co m 93- �— = CD O � � O CD L m 0 d Coo o C cc O co C CD V V� � C C C C. 0 c � m C O c� O L O y is C O .2 V •d'O ac ea W 3o o c Ea w-. v G VJ 4mi �o m c V O rr Ju C" RE y R E Lm co a C1 O y m O y C c y O E m -: y O m 5 - _ Z O Qf c o a �. - ftz HZ m �C1 O r.+ . i c I O i O C C •p Q = m :00 N H. CD y coLU m t ` dt O ma •CL C o:r o.v� fO� N CO2 O� O� CD H R .0. CL 1 L 4 W O CD O o cs CD d O y � C I O "0 CD 'FE mCD C3 co m 93- �— = CD O � � O CD L m 0 d Coo o C cc O co C CD V V� � C C C C. 0 Job Number 1.WEATHERSTRIPPINGJCAULKING Door Kits Q -Lon or Equiv. Door Sweeps (Regular) Door Sweeps (Automatic) Reglaze Windows /ln.inch Window.Weathstr Schlegel per side Tenmat Recessed Can Cover Attic/Basement bypass sealing man/hr Attic sealing with 2 -part foam man/hr SUBTOTALS 2A.INFILTRATION / INSULATION Domestic pipe Hot Water Tank 1 st 6' Sill Insulation R-19 CF Sill Two Part Foam w/ Fiberglass Batt Drape Perimeter R-5 Anch. Sq, ft, Perimeter 2" T-max or equivalent foam board sq. R. Drape DOOR R-5 or T-max or equivalent on door. Tape Joints (Alums Grip only) per hr. Duct Insulation & Tape sq. ft. R-5 Rigid Foam Board Anch. 1" per board Hydronic pipe insulation to 1" R-5 Hydronic pipe ins.1.25"-1.5" R-5 Steampipe Ins, tol.25" iron pipe R-5 Steampipe ins. 1.5"- 2" iron pipe R-5 Steampipe Ins. 3" iron pipe R-5 Air Conditioner Meeting Rail Air Conditioner Cover Air Conditioner Cover Special Order 4216 Client address city / town contractor QUANTITY 5 3 1 0 0 0 5.5 0 1 61 0 0 0 1 0 0 0 0 0 138 43 0 0 0 0 :DATE 9 -Apr -12 SHIRLEY STARR 978-682-1757 64 SECOND STREET NORTH ANDOVER MA 01845 CAREONNEAU TOTAL 227.50 47.25 23.00 0.00 0.00 0.00 330.00 0.00 627.75 15,78 96.38 0.00 0.00 0.00 51.00 0.00 0.00 0.00 0.00 0.00 760.38 273.05 0.00 0.00 0.00 0.00 SUBTOTALS 1196.59 2B. INSULATION Open Unrestricted R 49 0 0.00 Open Unrestricted R 38 246 361.62 Open Unrestricted R 30 200 274.00 Open Unrestricted R 20 252 325.08 Open Unrestricted R 10 0 0.00 Restrict FUSloped R 30 264 390.72 Restricted FUSloped R 20 0 0.00 Restrict FUSloped R 10 0 0.00 R-19 FGB open rafters/wails/kneewalls 0 0.00 R-11 FGB open rafters/walls/kneewalls 0 0.00 Attic Stairs(stairweil & common wall) 0 0.00 Cover Pull Down Stairs Thermadome 0 0.00 Site built pull down stairs 2" foam box 0 0.00 AUDITOR NOTES SEE SPECIFIC NOTES AUDITOR NOTES I iMAIN BASEMENT I COPPER STEAM USE FIBERGLASS COPPER STEAM USE FIBERGLASS AUDITOR NOTES SEE NOTES!lIIII M!Illl!l M UNDER OLD ROOF p c( ? /�.'i Attic / Kneewal Floor Transition. Dense pack cellulose W.S. Hatch Q -Lon or equal W.S. & bat Hatch R-30 /Q -Lon or = Kneewall R-12 cell behind Per.Memb Open Rafter R-20 Cell. /w poly Open Rafter R-30 Cell. AN poly Basement Overhead R-19 fiberglass Basement, Overhead R-30 fiberglass Crawlpace Overhead < 4' high R19 Crawlpace Overhead <4' high R30 Garage Ceiling cavity filled w/ cellulose Wood, Shake, Clapboard, Shingles Vinyl Asbestos (single nail) /Asphalt Asbestos (doub. Nall)/ Aluminum Brick/Stucco Vinyl over Asbestos Multi -layered 3 or more layers Drill rough plaster or finish wood plug Drill finish plaster Test Drill Walls (all 4 ) SUBTOTALS 2. INSULATION TOTAL 2A.+2B. 3. STORM WINDOWS / DEADLITES Plexiglass up to 88 u. I. Additional per UI over 88" Other (Negotiated Price) SUBTOTALS 5. OTHER MATERIAL Ridge vent In ft. Vents Gable rectangular Varipitch Vent Vent Roof 135 (1 sq ft NFV) Large Vent Roof 865 (A sq ft NFV) Small Vent Soffit Rectangular Turbine Vents All Stack Vent Propa Vent Permable House Wrap Vapor barrier Energy Star R-4 Rigid Vinyl Rep] 94-101 U. 1. SUBTOTALS 6J7. E.C. MATERIALILABOR 8a. HEALTH & SAFETY 0 0 1 0 0 135 0 0 0 240 0 1246 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 4 4 0 0 4 0 0 0 0.00 0.00 33.50 0.00 0.00 276.75 0.00 0.00 0.00 470.40 0.00 2230.34 0.00 0.00 0.00 0.00 0.00 0.00 0.00 60.00 4422.41 5619.00 AUDITOR NOTES I ICALL ME WITH RESULTS AUDITOR NOTES 0.00 0.00 0.00 0.00 0.00 92.00 0.00 0.00 320.00 108.00 0.00 0.00 16.00 0.00 0.00 0.00 536.00 6782.75 I AUDITOR NOTES I 18 X 16 FRONT OF MAIN HOUSE I DO NOT CHANGE 4X16 Page 3 AUDITOR NOTES Vent Bath / Kitchen Fan Dryer vent w/ exhaust duct Heartland Dryer Transition Duct only Blower Door Test Pre Post - SUBTOTALS 8b. REPAIR MATERIALJLABOR Basement outside door only Basement outside door w/ jambs Door Repl pre hung 32-36" Steel`* w / Lite Door Repl interior solid care 2837' Door Rep[ pre hung 32-36" wood' w / Lite Window Replacement w/ SIR less than 1 Basement Window Rep[. Awning/ Hopper Basement Window Rep]. With a frame Lockset ( door) Schlage or equal Repair / Refit Door Replace Side Stop Replace Casing Glass Replacement to 64 u. i, Glass Replacement per u.i. over 64 Sash Sidelock /Top Replacement Threshold (Wood) Threshold (Aluminum) Slide Bolts Plug Plate Cover Cut / finish attic-kneewall access Cut / close attio-kneewali access Labor Rate Hours Permits / Fees (Wap only) SUBTOTALS TOTAL_ REPAIR+ HEALTH & SAFETY 89.00 . 1 89.00 0 0.00 0 0.00 NO! 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 4 1 0 178.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0,00 50.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 60.00 0.00 110.00 288.00 GRAND TOTAL WORK ORDER # (A) 4226 7070.75 SHIRLEY STARR 978382-1757 64 SECOND STREET NORTH ANDOVER MA 01845 Any alterations or deviations from the above specifications involving extra costs must be cleared in writing before installation. The Work Order must be complete within 15 working days from acceptance date below: I AUDITOR NOTES IBASEMENT TO OUT I BATH CRANK OUT I CONTRACTOR/COMPANY: XR= ACCEPTANCE: Company/Contractor AUTHORIZED SIGNATURE: AGENCY APPROVALS: CTI Authorized Signature: T r, S14 iv- - o,-, LLC Date H- l l a Date GLCAC Authorized Signature: Date A6�R—�'® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 3/22/12 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 Appletree Insurance 216 Central St. Hudson, NH 03051 CONTACT NAME: PHONE N Edi- 603 881-9900 FAX No; (603) 594-9840 E-MAIL ADDRESS: PRODUCER 1648 INSURERS) AFFORDING COVERAGE NAIC# INSURED CARBONNEAU INSULATION LLC. 21 LENNY LANE HUDSON, NH 03051 INSURERA: HANOVER INSURANCE INSURER B: TECHNOLOGY INSURANCE COMPANY INSURER C: 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 LTR TYPE OF INSURANCE AML SUBR POLICY NUMBER POLICY EFF MMIDDIY POLICY EXP MM/DD/YYYY LIMITS A GENERALLIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1_x7 OCCUR OHV6430533 4/5/12 4/5/13 EACH OCCURRENCE $ 1, 00,000 DAM4GETO RENTED P LMISES(Eaoccurrence) $ 300,000 MED EXP (Anyone person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENTAGGREGATE LIMITAPPLIES PER PROT LOC POLICY El PRODUCTS - COMP/OP AGG $ 2,000,000 $ A AUTOMOBILE X LIABILITY c ANY AUTO ALL 0 WNE D AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS OHV6430533 4/5/12 4/5/13 COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Per accident) $ A X UMBRELLA LIAB EXCESSLIAB I X OCCUR CLAIMS -MADE OHV6430533 4/5/12 4/5/13 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 DEDUCTIBLE RETENTION $ $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTVE YIN OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If ES describe under DESCRIPTION OF OPERATIONS below N I A TWC3279006 6/2/11 6/2/12 WCSTATu- X oTH- E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE -EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 r DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is regui red) CERTIFICATE HOLDFR CANCELLATION © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN FOR THE BENEFIT OF THE INSURED ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE PATRICK J. CONWAY © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD '=: ala suchucctt> - Department of Public S'afc.t� Board of Building Re,_mlations anti :5taatlards License: CS 97614 NORMAN CARBONNEAU 4 CARRIER ST LONDONDERRY, NH 03053 C U91fl11>�lullt't' Expiration: 1/19/2013 Trm: 10243 ho;41chasetts - Depa tIment of Pula is Safety ,. Board of Building lter_1ttl itiou* and Stan(LAI S Construction S€tt 3rvisor specialty License Liceose: CSSL 10216$, Re§tricted 3o: IC . MICHEAL CARBONNEAU x 21A LENNY LANE . HUDSON, NH 03051 Expiration: 11/10/2012 :,;�srn;•, „�a, . Trr: 102168 ✓> VOOtLlJddJL Aea"1L o� ✓l/laaaac�ivaefta Office of Consumer Affairs & B siness Regulation HOME IMPROVEMENT CONTRACTOR Registration: �A.62729 Type: > Expiration: A1612013 LLP CARBONNEAU uppu"a k „IF- If MICHAEL CARBONNEAU;r=`` is 2 LENNY LANE HUDSON, NH 03051", ; — 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 7_AJ Not valid wi#dout signature Date. .� . � I - - TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ..Z—.(�X�(Ae-V-e jA4ZA has permission for gas i�nNtallation ................ in the buildings of ... . ............................ Fee :30 ..... Lic. No.aro... R GAS .... .... A ..... Check# INSPECTOR 8223 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY^J'" ~� MA DATE PERMIT # JOBSITE ADDRESS 2 OWNER'S NAMEjjgle G _ OWNER ADDRESS ... TEL[ TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL RESIDENTIAL CLEARLY NEW: Q RENOVATION: El REPLACEMENT: PLANS SUBMITTED: YESF-1 NO Q APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER ICE: COOK STOVE r. I _ .. 1 _. . _. DIRECT VENT HEATER�T DRYER �. .� _.. FIREPLACE FRYOLATOR— FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS- MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ' r— ROOF TOP UNIT TEST II UNIT HEATER__... UNVENTED ROOM HEATER C_ _ _1 _ !i _. r i— WATER HEATER OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ,] NO 0 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY]_I OTHER TYPE INDEMNITY © BOND jC] OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 01 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc rate to the bes f my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com liance II Pertinent ovi ' n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME T �y{_._ _ _-_� LICENSE #a (. SI N kfURE MP\ I. I] MGF JP n JGF LPG] ] CORPORATION �# ( PARTNERSHIP 0#=LLC # " COMPANY NAME: _.;_ _._ ADDRESS CITY STATEZIP�TEL FAX CELL F- ASO EMAIL { __ - The Commonwealth of Massachusetts 07 Department of IndustriqlAccidints Office of Investigations UV 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (B, Address: City/State/Zip:Z &V& ate, %�%g. Q/�fy� Phone#: Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have Hired the sub -contractors 2. MI am a sole proprietor or partner- listed on the attached sheet. t ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additidns 11. El Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *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 &ie doing all work and then hire outside contractors must submit a new 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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. (_ 1n / ^ , " __— Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: CQ �f" ��L° [�DtIJ d City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requireclunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. Ido hereby cert ur r thepains andWalties ofperjury that the information provided above is tfue anti correct. v7e -6 ob, Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # G/a7// " Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -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 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 like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commouwealth, of Massachusetts Department of Zndustdai Accidents Office of Investigations 600 Washington Street Boston? MA. 0211 t TTL # 61.7-727=4900 ext 406 or 1.-877�,MASSAFB Revised 5-26-05 Fax # 617-727-7749 wWwMass,gov/dia