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HomeMy WebLinkAboutBuilding Permit #152-11 - 644 SALEM STREET 8/23/2010 i BUILDING PERMIT of "°ROTH�ti TOWN OF NORTH ANDOVER �� 4`tP._ `_,°•6 0 O APPLICATION FOR PLAN EXAMINATION I * _ Permit NO• Date Received e� �Qq cecwKwrKu y1` Date Issued: 2 �SSACHUS IMPORTANT Applicant must complete all items on this page ENVs�i r 4-,� .}5�f�,. .t ' n10Y F ylu 3n"FS". Yt b` u` "a$�`��� ,�.;aki',"c,�cT JJ`r,.dEc j _ .� ;YT '.�. - _ ..•L,u'.•y� ,z�x~�}f�, i Hr:,'<-r t 4 �i �-. "�r{� r lhi� i�G&55�<<s °"c"—�c'��,�..�crf"` = r-�C^.`i�, "- �a7A�I�CTgm 'sz-�a Opa"I",sl�.i �� F���� ��`r�,�-rn� f ry �°��rti'a`�':` �-. h5 Vti r-z;� �'�i t•yp '�".�� '�- + y��tgkyl-.+•.�Yr?NKc.� ��rri,'�t �',`�-�1`q,�"'�,rt.� w 'f •s s q 4�T".''.i$fr.X s+u-- •'�,-ct k �{ � JJ�1�+�y'� �p FFFyyy a y1v�-� ,�SCrrL.�.lm,��x.?�+t3l+.l: h9� cs 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 �'c�.-.��� f��'���,3• `�,�x'3�-."�5 ;�,F�h� �. "c� �L���i�1 '�"�`'�� �+ �- �-;�. y.,,rte,,,- v-t t;:,,� r SS- _ r� _�Z . ext ami , F�r-'� '4 DESCRIPTION OF WORK ~~ _.,•.,r+ ._,�.... Grp... :t TO BE PREFORMED: S7P-T Identiification Please Type or Print Clearly) OWNER: Name: `Tc-gAab Aw z- -<.01/ Phone r A ddress�n f y1: �-•�.�. Sc4!�r A.cr._-r��ilµ�f 'Er : nz muL $;��lt 5h',n..'S"��`'zra'u, -�'`Yy'{€"-..G' -`Ms.:a��?-'} N +r✓.-yryx-' ya +.,.+ {,` r _..,s- fr.Y.'=yn�-i.'..t. -i r �� t[�°�-es' ,t,r"�'� 'TTn.a.•-�— � �, Z�':. ; �����1�%�..5 -r � .� � �-z� L P ,�� s �• k l.t�, m���, ±eakeatfiS � ..: rti � �� �eslu 3'y�y'�-� � '�aw�!'������ � ����'f A�„ �` •ic � ��'.'v 7gGi'��p'�i ,�, t5t' ,Iri}sy,�nwum py5a .t,:n:, 3 f � F xw _. >��!sk�>:gsrsrt'y'W�'xd j 1'(t''��`i . '� -e? '$e•e .t;flc Z�+y;:. 'k a� t �;f """e�43„..�� r, �Yr y!r� A ct- t„7'����� ,�`�Y��,'t:r' -}�sr r ;t r .n}{^ sy�,yr�',r��T �^{-L}�?�,.'•'��;a { F } 'at Y `~A "��`1�yv,•�t'tl'%Y<`?:1%r'.�,�.z'l.N•.J 1�1n+t��5Gr�.y'4"p i r -_.IJ. � .. } itk�.6' �� r�1 -YAA�y_��`�im�"G� '0S�' �J 1 � ;A'���� rte• y;, -. rP '� "fip .!- A� < d 1 `r c't '. ,��`��_ s iu � 'f 'r'..s7 T �-•``I`{".lV`'`'r����.sx"�s r��4=i'>.-i�^r'fx"`_,�.->: 3" �a��:ar{"�'4 par{�.��.t„r;•'�•,C,'�7,� �-�` J 11t t � R TY- � } f 'U �F� •4: htr' � � e '��'� 1��111'S�*��x� �� ° "'t '�� •,i � � �-,� v •� -.ate:� G-�"s,'� tri�� AY i 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: $_ cJ�jFEE: $ �� Check No.: Receipt No.: 3 L NOTE: Persons contracting with unregistered contractors do not have access to the 'a ty Si naureofA ent/Owner - Sagnaturerof$cat i 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 i 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 /Grossection/Elevation Plan Of Proposed Work With Sprinklerrink) er Plan And Hydraulic Calculations (If Applicable) PP ) A L3 Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit -.,i,-New Construction (Single and Two Family) ❑ Building Permit Application ❑ 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 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 Reviewed on Signature CQMMENTS a Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water $ Sewer Connection/ Driveway Permit DPW Town Engineer: Signature: Osgood od St Located 384 reet F�N�taE3P �3T�VlfNTf erDuipserra-ST te des' s { ray r , � gL> cain S#rest h -t 5 � l ire�3e, are s� naireldae u, } ` F CO: iMEIq;T :::: 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) a ❑ Notified for pickup - Date i Doc.Building Pernut Revised 2010 Locatiod ZZ-s- s; te� L No. Date "ORT} TOWN OF NORTH ANDOVER F S Certificate of Occupancy $ cMusE�� Building/Frame Permit Fee $ 96 . r Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 253E$ 4 Building Inspector NORTH Tovm of 6 Andover 0 No. =_ �t. dower, Mass.,- Z ? L 0 COCHICHEWICK 1 RATED PP�`"`� BOARD OF HEALTH Pr. RMIT T Food/Kitchen Septic System _ rBUILDING INSPECTOR THIS CERTIFIES THAT....................... .......... .:�:.4.rr!.... ...........................................:.......... Foundation C6 - has permission to erect........................................ buildings on..j 2 z J...........S1'f. ........ ........:....................... Rough tobe occupied.as...........t>)..�!''' .....:y'...............a4.0.. ....r............................................................................................ Chimney provided that the person accepting this permit shall in ev respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC STARTS Rough ............................. Service BUILDING SPECTOR Final Occupancy Permit Required to Ocatpy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing .or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved .by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Aug 19 10 11:36a Richard Anderson 978-683-2023 P.1 Fax:978-251-2907 Office:978-256-2333 DATE OF PROPOSAL 419/2010 r r PROPOSAL VAr£ r& lir-rt&t-10 £y I etz of o www.expressrooier.com rn*e(&exaressroof_er.eorn HOME IMPROVEMENT CONTRACTORS LICENSE#108126 00" PROPOSAL SUBMITTED TO: • • WORK TO BE PERFORMED AT: N"AE RICHARD ANDERSON aooaess 1225 SALEM ST ADDRESS 1225 SALEM ST IN ANDOVER N ANDOVER °M"''" 978683 2023 We hereby propose to furnish materials and perform the labor necessary for the completion of: STRIP ALL SHINGLES OFF ROOF CLEAN UP AND HAUL AWAY TARP OFF HOUSE TO HELP PREVENT DAMAGE TO HOUSE AND LAWN AREA COMPLETELY DE-NAIL ROOF AND RE-NAIL ROOFING BOARDS AS NEEDED ALL WALL FLASHING WILL BE INSPECTED AND REPLACED AS NEEDED Install: GAF Weather Watch 6'up from the bottom eves GAF Weather Watch in valleys GAF Weather Watch around vent pipes GAF Weather Watch under chimney lead and Y down on roof GAF Weather Watch on roof where roof meets house by pulIngtrim off Felt paper over roof boards GAF Starter strip on all roof decking edges 110 Mile wind warranty) GAF 30 year Timberline Architectural shingles 110 Mile wind warranty) 30 Year GAF Timber Tex caps 110 Mile wind warranty) 8"drip edge along all outer roof edges WHITE--BROWN---SILVER New pipe flange's over vent pipes 4"Pi es; All shin les will be fastened using 1 '/4"-1 '/i'roofinq nails Take out . . chimney lead and install new chimney lead . .. into new shingles 2 New bathroom vent box on roof. no inside work ROLL MAGNETS OUT TO PICK NAILS OFF LAWN AREA FOR FINAL CLEANUP ALL ABOVE . ROOFING MATERIALS ARE -•- OF ROOFING `."Sr,LUZTS:oL'_ LAt3 R AND P§ATERIALS FOR THE ABOVE AND ROOFING PERMIT '.'E: tii'•.iG:�:.'':'E3 _-SSP �sW7,ED AND 30 _:is+'TED YEAR G:AF SK GL= ;1: ,�Rj'�'t?iY Note:No warranty on probbMS caused byre backups No Ylarranly ba Wd Skyignts All material is guaranteed to be as specified,and the work to be performed in accordance with the drawings and OctWcations . submitted for above work and completed in a substantial workmanlike manner for the sum of. $8,695.00 S NO MONEYDOLWN$ PAYMENT IN FULL AT COMPLEA TION OF JOB WITH WITH CASH OR BANK CHECK �I 1G 'vCi.:7 MADE OUT/N THE NAME OF 17 -99-5 Call Toll Free Respectfully submitted -� 1-888-210-ROOF o.o Noie-This proposal may be withdrawn by us it not accepted by: BBB 4/16/2010 All workers fully insured ACCEPTANCE OF PROPOSAL The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specirred.Payments will be made as outdned above.Any additional work than the above will be an extra charge. ) / f Signature Date `�'f=�zG r C SHINGLE COLOR —Note ary roof boards that reed replacement will be an extra charge of$4.00 lineal foot "Note any pywood replacement will be an extra S60.00 per Axa sheet-labor&materials included Massachusetts Rome Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"s Massachusetts consumer guide to home improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8797 or 1488-283-3757. Homeowner Information Contractor Information (4 a, �kPrrEsS tz �' Name omp;my Name t S .s L -f �19/- Street.Address(do not use a Post Office Box address) Contractor/Salesperson/Owner Name Mit . A- uti vets R c� . City/Town State Zip Code lusiness Address(must include a street address) WEST BD42 Ss Daytime Phone Evening Phone .ity/Town State Zip Code a Z - - � Mailing Address(li different from above) usiness Phone b ederal 5 0 Employer ID or S.S.Number Law requires that most home im-1 namepmvemeot Contractor Reg.Number lixpbalion date Pro—cut wutraetora have a ' ad mgistratioo Dumber The Contractor agrees to do the following work for the Homeom vner.(besEhn e m detalt me worr to CompletrEl, g me PAe, ran , em n s o e e n ace STtz` � + A49 1604 f/'E,N7_S 61 Required.Permits-The followingbuilding permits are required Proposed Start old Completion Sch ule-The following schedule will and vYill be secured by the contractor as the homeowners agent, be adhered to unless circumstances beyond the contractors control arise (Owners who secure their own permits will be excluded from.the Guarant}i Fund provisions of *�A atewhen contractor will begin contracted work. MGL chapter 142A.) Q D 4;14iDate when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: (s) Payments will be made according to the following schedule: S ;0 upon signing contract(riot to exceed 1/3 of the'total contract price or the cost of special order items,whichever is greater) 4 S Y b /' / or completion-of �— � P S by j1,3 /Q.or upon completion of ^— upon completion of the contract. (Law forbids demanding full payment until contract completed to both party's satisfaction) The following material/equipment must be special S to be paid for ordered before the contracted work-'begins in order S to be paid for to meet the completion schedule.(**) NOTES. Includin all finance O g charges( )Law requires that any deposit or down-payment r aired b eq y the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule, Expre'ss Warrants'-Is an express warr•ar.r bean provided by die contractor? _No Yes fall terms of the warranty meet 6 •trached to theca tractl Subebotractors-Th6tontractor agrees to be solely responsible for completion of the work described regardless of the actions of any third paity/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for 1171111gdals and labor under this agEgement Contract Acceptance-Upon,signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration The law requires most home improvement contractors and subcontractors to be registered with the Director ofHome Improvement Contractor Registration. You may inquire about contractor registration by;writing to the Director at One Ashburton Place,Room 1301,Boston,MA 02108 or by calling 617-727-3200 or 1-800-223-0933. • Does the contractor have insurance? Check to see that your contractor is properly insured. • Know your rights and responsibilities. Read the Important information on the reverse side of this form and get a copy of the Consumer Guide to the Home.Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than Ilre contractor's normal place ofbusiness,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following.the signing of this agreement Seethe attached notice of cancellation form for an explanation of this right DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!I .— Two identical copies of the.conin ct must be completed and signed. One copy should go to.the hoincowner- The other copy should b kept a contra i Homeowner' Signature Contractor's iitnature ' g D, a Date Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an . alternative to-court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/sire has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved.by the Secretary,of the.Executive Office.of Consumer Affairs and Business Regulation and the consumer shall.be 'required to su it to such arbitration as provided In Massachusetts General Laws,chapter 142A. 1 Homeowner's Signature Contractor's Signature NOTICE: The signatures of the parties above apply only fo the agreement of the parties.to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this sr ction i'not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A).may not be waived in any way,.even by agreement'. However;homeowners may be excluded;from certain rights if the contractor they choose is not properly registered as prescribed by law: Homeowners who secure their own building permits are automatically excluded from all GuarantyFund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided,by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose, An enumeration of other matters on which the homeo terms of the contract as long as they do wrier and contractor lawfully agree may be added to the not restrict a homeowner's basic consumer rights. If you have questions about Your consu.mer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been.attached. Parties are-also advised not to sign the document until all blank sections have been filled in or marked as'yoid,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner"and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day recission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,orIfyou wish to obtain a free copy.of "A Cons Law,"contact: umer Guide.to the Home Improvement Contractor Consumer Information Hotline Office of Consumer Affairs and Business Regulation. .10 Park Plaza,Room 5170,Boston,MA 02116 (6I7)973-8787 or l-(888)2833757 i If you want to verify the registration of a contractor or if you have questions or need additional info about the contractor registration component of the Home'Improvement Contractor Law,contact: rulatlOn specifically Director of Home Improvement Contractor Registration Bureau of Building Regulations and Standards One Ashburton Place, Room.1301,Boston,MA 02108 (617)727-3200 or 1-800-223-0933 For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney Genera_l ' (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)7.34-3114 The Commonwe,Qlth of Massachusetts -Department o f fndustraal Accidents Office of r"Veslio ations . 600 Washington Street Boston, X,4 0 111 Workers' Compensation Insurance Affidavit: g��rs/C Applicant Informaiion ontractors/Electricians/Plumbers Please Print Lembly Name (Busines/O srganization/Individual): Address: 12 City/State/Zip: Phone#: Are you an employer?Check the appropriate boxc 1.❑ I am a employer with 4. 111 am a Fpe of project(required): general contractor and I oyees(full andlorpart-time).* have hired the sub-contractors ❑Neu]construction am a sole proprietor or parer- listed on the attached sheet x ❑Remodeling ship and have no employees Theseb-contractors havworking for me m an ca e ❑Demolition Y P�itY. workers' comp.insurance.[No workers' comp. insurance 5. ❑ We are a corporation and its ❑Building additionrequired] offcenhave exercised their ❑Electrical repairs or additions 3•❑ I am a homeowner doing all work right of ex myself P emption Per MGL 11. Plumbing repairs or additions Y [No workers comp. C. 152,§1(4),and we have no insurance required.] t employees. jNo workers 12•7 Roof repairs Pomp.insurance required,] 13.7 Other �--ny 2PPIieaat that checks bo:. 1 must also fi'a out these_ "ticm Q-'Qw`-avv;"-`g th^ VVCrwwS'CQtnr•„.�`QC....i:.... C homeowners who stiomiftiiis affidavit indicating they+?--,z dcing 01 air. and Policy z ti +Contractors that check this box must attached an additional sheet showing the mea hire outside contactor �=submit a new affidavit indicating such. Game of the sub-contactors and their workers'comp.noiicy information I am an employer that is providing workers'compensation insurance for my e 1 ees Below,is the off information, mP°J' Policy and job site Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: Attach a copy of the workers' compensation policydeclaration sore(showing City/State/Zip: Failure to secure coverage as required under Section 25A ofM P ( vying the policy number-and expiration date). c. 152 fine up to$1,500.00 and/or one-year imprisonment as well as Gtr Penalties in the lead form oimposition f a STOP WORK ORDS and a a of up to $250.00 a day against the violator. Be advised that a co penalties of i ne Investigations of the DIA for insurance coverage verification copy of this statement may be forwarded to the Office of I do hereby certify under the pains and penalties of perjury th4rr the informationprovided above rs true and correct Simiature- Date,:._... ._ Phone#: Official use only. Do not write in this area, to be completed b,c , J itJ or town ofjzciaL City or Town: PermitUcense# Issuing Authority(circle one): 1. Board of Health 2.Builainb Department 3. City/Town Clerk 4. Electric al Inspector 5.PIumbiaR 6. Other b Inspector Contact Person: Phone',-. Information an- d 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,associi xtion, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including t1he legal representatives of a deceased em . ,. 'P IovAr, or the P �� > receiver or trustee of an individual,partnership, association or other legal entity,employing employees.to ees. However the owner of a dwelling house having not more than three apairtni eats 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 be:cause 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 a onstruct 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 uMVE acceptable evidence of compliance with the insurame 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 cerdficate(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'comp enation 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 stu-e to sign and date the affidavit. The affidavit should be returned to the city or tow n that the ap'ullcadon for the pertor license!S being."eauested,not the.Department of Industrial Accidents. Should you have.any questions regard•in.,the law, or;,f you are r•�iiired to obtain a workers' compensation policy,please call the Department at the number lid 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/liccnse n=ber 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 faxmumben_._. The Commonwealtl2 oflvfassachusexts Dc art=t of Industrial Accidents Office of lnrestivatioas 600 Washington Stmt Boston,M-A 0.2111 Tel. # 617-72.7-4900 ea.-t 406 or 1-8 7-NLASSAFE Revised 5-26-05 Fax It 617-72.7-7749 vm v,.mass-aov/dia.