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HomeMy WebLinkAboutBuilding Permit #109-14 - 661 OSGOOD STREET 7/31/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION i Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION' ' =• ,- Pnnt - PROPER'TY, OWNER - _ - Punt _ 100 Year OId,Structuce yes 'Ia MAP NO= PARCEL _ ZONING DIS�TRI;CT Historic _istrict" _ , ryes a, Machine Shop Village YeS _ o _ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Co ercial ❑ Repair, replacement ❑Assessory Bldg thers: ❑ Demolition ❑ Other 11 Septic: ❑Well ❑ Floodplain 0 Wetland's. ❑: Watershed District- _ 11 Water/Sewer. DESCRIPTION OF WORK TO BE P�ERFO MED: s �-- Tentification Please Type or Print Clearly) OWNER: Name: %Tv-o Phone: - a Address: aV. CONTRACTOR N_ame: _ Y , Phone- - _ 2 Address:� 0- 1 1� Z ( I Supervisor's Construction License. 'Exp 'Date: Home lmprovement'License: Exp, Date: Z 2_o I LY ARCHITECT/ENGINEER Phone: g Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BAS ON$125.00 PER S.F. Total Project Cost: $ �� �� FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to th g n and Signature of�Agent/Owner� Sig nature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE-.OF--SEWERAGE DiSP.OSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco.Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ I i j 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 COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes P, anning Board Decision: Comments a Conservation Decision: Comments Water & Seaver Connection/Signature& Date Driveway Permit DPW Tow;; Engineer: Signature: Located 384 Osgood Street FIRE.DEPARTMENT Temp Dumpster on site yes no Located at 124 Mair, Street Fire Departrnerit signature/date COMMENTS i f - 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 z it ® Notified for pickup - Date Doc.Building Permit Revised 2010 f i Building Department The fohowing is-a list of the required forms to be filled out for the appropriate permit to be obtained. Roofiv,g, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses a Copy of Contract o Floor Plan Or Proposed Interior Work a Engineering Affidavits for Engineered products MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application {i 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) a 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 1 New Construction (Single and Two Family) ❑ Building Permit Application o Certified Proposed Plot Plan a Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit 7 o 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 apw-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.fted with the building application Doc: Doc.Bufiding Permit Revised 2012 _ I Location l i' No. Date 77 -47 • - TOWN OF NORTH ANDOVE`r1 Certificate of Occupancy $ Building/Frame Permit Fee $ , ,? Foundation Permit Fee $ Other Permit Fee $ � TOTAL $ Check# Q, v 6 t b 8 9 Building Inspector 9/1/2013 12:39:08 PM PST (GMT-8) FROM: 100005-TO: 19786889542 Page: 2 of 2 A� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 8/1/2013 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 PLANRIGHT INSURANCE & FINANCIAL LLC CONTACT NAME: 224 MAIN STREET STE 3C PHONE C o Exl AX A1C No SALEM, NH 03079 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: INSURED INSURERS: EDMUNDS GENERAL CONTRACTING LLC PO BOX 2214 INSURERC: SALEM NH 03079 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 17176799 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 EFF POLICY EXP LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES ERENTED occur ante $ CLAIMS-MADE D OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) AUTOS AUTOS $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS Peraccidenq $ UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS MADE AGGREGATE $ DED "RETENTIONS $ A WORKERS COMPENSATION WC5-31 S-369752-023 1/26/2013 1/26/20141 WC Cffk- AND EMPLOYERS'LIABILITY Y/N _ J I TORY LIMITS ANY PROPRIETOR/PARTNER/EXECUTIVE E .EACH ACCIDENT $ 100000 OFFICER/MEMBER EXCLUDED? ❑Y .L NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if mon:space is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF NORTH ANDOVER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATTN: BRIAN LEATHERS ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD ST BLDG 20 STE 2035 NORTH ANDOVER MA 01845 AUTHORIZED REPRESENTATIVE 1 Jeff Eldridge F! ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD C R7 NO.: 17317 799 CLIENT C OE: 1338660 Oidi angas g/1/2013,12:36.�34 PM Pag 1 of 1, TFfis certiT _cate cance�s and supersecPes ALL previously issue certificates. EuMUN-1 VI'IV No DATE(MM/DDI(YYY) CERTIFICATE OF LIABILITY INSURANCE 0713112013 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 pollcy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an engorlsremmit. A ataLumvilt or,this oordfiooto dooQ not confar rLghtst to the certificate holder in lieu of such endorsemen s. PRODUCER Phone:603-590-6439 NAM E:CT lanright In9urdn ®S Calem PHONE PP la Main Street Suite l Fax:603-890-6521 AJarc No+ L Salem,NH 03079 ADDRES = James A Santo INSURERS AFFORDING COVERAGE NAIC 0 INSURER A:St Paul Surplus Lines Ins Co INSURED Edmunds General INsumn u:River ort Insurance CoTppany 36684 Contractor LLC INSURER C: PO.Sox 2214 Salem,NH 03079 INSURER O INSURER F: INSURER f COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUE[)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. ,LTR TYPE OF INSURANCE POLICY NUMBER MMI EFF MM 'YY P LIMITS GENERAL.LIABILITY EACH OCCURRENCEAQE TO-RENTED 9 1,000,OOI A X COMMERCIAL GENERAL LIABILITY WS165946 1111112012 11111/2013 PRE SEs occur nrm $ 50,001 CLAIMS-MADE �OCCUR MED EXP(Any ono person) $ 5,00, PERSONAL&ADV INJURY $ 1,000,00, GENERAL AGGREGATE $ 2,000,00' GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000a00, X POLICY1:1 PRO LOC $ C ED SINGLEMIT AUTOMOBILE LIABILITY Ea accldenl BODILY INJURY(Per Person) $ ANY AUTO ALL OWNEDSCHEDULED BODILY INJURY(Per acdcle l) $ AUTOS AUTOS PERTY DA E $ NON-OWNED Per accident HIRED AUTOS AUTOS 83 UMBRELLA LIAB OCCUR EACH OCCURRENCE �+ D=RETENTION CLAIMS-MADE AGGREGATE $ $ $ we STATU. I I OTH- WORKERB COMPENSATION Y AND EMPLOYERS'LIABILITY 100 OC B ANY PROPRIETOR/PARTWRIEXECUTIVE YIN G26B300042bOt3 0410312013 04/03!2014 E.L.EACH ACCIDENT $ OFFICE RIMEM13r EXCLUDI D? �Y NIA 3A: NH E.L,DISEASE-EA EMPLOYEE S 1OO,OC (Mandatory In NH) If"s,describe under E,L•DISEASE-POLICY LIMIT S 600,0( DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If mQU space Is requtred) David. Edmunds is excluded from Workers Compensation coverage. Confirmation of coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover, MA Attn: Brian Loathe AUTHORIZED REPRESENTATIVE Osgood St, 2Ste 20_J5 North North Andover,MAA 01845 5 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010106) The ACORD name and logo are registered marks of ACORD pORTH Town of ndover No. O y _ ' _ - jr`O�A At,� LAN. h .y ver, Mass, O ' COC.NICMl WICK S �y V BOARD OF HEALTH Food/Kitchen PER hT LD Septic System THIS CERTIFIES THAT ..Tlcoax00.;� BUILDING INSPECTOR has permission to erect buildings on 6(of O Foundation Rough to be occupied as .............•rr�•... .........:.�......... �yQ ..........--�"................ Chimney provided that the person accepting s permit shall in every respect confor 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 M NTH ELECTRICAL INSPECTOR UNLESS CONSTRUCTIOUT S Rough. Service .................. . ........................................................ Final BUILDING 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 ;l Fully Licensed and Insured • Member of MA Better Business Bureau Member of NH Better Business Bureau FFS. Broadway GAF Cert.ME#20212HIC Reg#166661 ens Corning Preferred Contractor#212828 MA CSL#104728 HA 30 Hour Construction Safety Training EPA Lead Safe Certified General Contracting, LLc #2214 Salem, NH 03079 (603) 890-0084 110 Stevens Street#141 Andover, MA 01810 (978)475-0095 D TO PHONE DATE ,5;7 STREET E-MAIL s (. ; as A;� CITY,STATE,AND ZIP CODE JOB LOCATION Completely protect the home with tarps to catch falling debris. Respect and protect shrubbery and flower beds. Strip off I layers of roofing material down to the bare roof deck. Inspect the roof deck for structural defects. Determine the condition of the underlying plywood or boards, and repair and replace as necessary*. Inspect roof ridge for proper 11/2" spacing on either side of ridge for maximum exhaust ventilation. Cut in if necessary. Install new heavy gauge/U t'I I ri J i 5ILI (color) drip edge at roof eaves. Install 7l".cj_414cwt4 +ck ice and water shield to meet manufacturer's specifications (i.e. 6 feet from roof edge, 3 feet centered in valleys, around all skylights, chimney bases, roof penetrations and at all sidewall transitions). Install Deck Xuem f7' breathable roof deckle protection to remainder of the roof deck. Install new heavy gauge A,' Il E. 5L''1 (color) Afh,rAirvt_s drip edge at roof rakes. Install P-0 — �`� c�i § starter strip at roof eaves and rakes. Install F ! ct'(� r Z 11r 1 i rnf 141) desired color. � (color) Install new flashings to meet manufacturer's specifications. (i.e. sidewalls, chimneys, skylights and roof penetrations). C Install 166 (feet) of_ Oil 5 / ridge vent at roof ridge to allow maximum ventilation. Hand nail to ensure proper astening. Install J(/®(feet) of /11 d51e('4-elc distinctive hip and ridge cap. Hand nail to ensure proper fastening. Thoroughly clean up and dispose of all roofing debris on property. Magnetically sweep property for nails. Notes: kkl!AC4 ec, C i f 74C 1-tic �_'Oafc, Edmunds General Contracting will: • Obtain all necessary construction-related permits to complete this project. • Perform work as efficiently as possible without sacrificing quality. • Furnish and install all necessary materials to complete the project. • Provide a thorough clean-up and disposal of all debris generated during project. Edmunds General Contracting LLC agrees to commenfe work on/or about-7/;z(?/¢S and described work will be completed in about L days. Product Upgrade 1: Product Upgrade 2: Contractor's employees are fully covered by workmen's compensation and liability It is further agreed that this contract may be assigned by the contractor,and also insurance. that the obligations hereof shall bind and apply to their heirs,successors or estates of the parties. Upon completion of the above work,all undersigned agree to execute and deliver to the contractor,their joint note in accordance with his(their)above obligations as EdJn ds Generaf Contracting LLC guarantees all workmanship performed for requested by contractor.Upon refusal to do so,contractor may at its option declare 2years. the entire contract price or so much as then remains unpaid,immediately due and payable.It is agreed that,if permitted by law,contractor shall be paid by the We will register ,Y/.� �� 1 l_C factory enhanced warranty owner(s)all reasonable costs,attorney fees,and expenses,in addition to the providing 13P ff;�, years of material defect coverage andyears of amount due and unpaid,that shall be incurred in enforcing the terms and conditions workmanship defect coverage through tr 4 F for: of the contract and/or any lien in connection herewith. 0—el no charge the additional cost of Y Edmunds General Contracting LLC will provide the materials,labor and disposal to replace up to 64 sqft.of ro f decking and 20 ft of fascia at no additional cost. Any additional materials including labor and disposal will be replaced at per sheet or+ ��3b linear foot. (Edmunds General Contracting, LLC agrees to furnish the material and All material is guaranteed as specified.All work to he completed in a workmanlike manner according to standard practice.Any alteration or deviation from above specifications involving extra costs will be executed only upon written aborrccompllete in accordance with the above specifications,for the sum orders,and will become an extra charge over and above the stated contract price.Contractor is not responsible for Of "� ,.T /V C.l?�',�'• // ,�/� damage due to high winds,tornadoes,hurricanes,fire or other hazards.Owner(s)agree to carry lire tornado and other t dollars($ ts+, e�CJ/t(��necessary insurance.Contractor is considerate of owner's landscaping and but due to the nature of the roofing installation some damage may occur.We attempt to minimize any damage,and will not be held responsible if any p1,,,J� i�f^rj �''"�� � ,,.0 — damage occurs. Contractor Is not responsible for any damage to the Interior of property,including pre-existing Payment Terms: conditions(i.e.water stains,crumbling plaster,exposed nails)or conditions resulting from application of materials as specified above.Items in the attic may need to be covered by the owner.Contractor Is not responsible for damage • A deposit of (not to exceed 1/3 of the total contract)is caused by ice dam build-up.All agreem:72/0`k ntingent upon strikes,accidents,or delays beyond our control. due upon start of work.The balance of4/�(�is due when work Authorized Signature: d.G� (, is completed to the satisfaction of all parties! Edmunds General Contracting LLC • A finance charge of 1.5% per month (18% per year)will be charged on Note: This proposal may be withdrawn by us if not accepted within past due accounts over 30 days days. 01[CCeptance of J)ropOj5af -The above prices,specifications,and DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANKSPACES. conditions are satisfactory and are hereby accepted.You are authorized to do the work as specified.Payment will be made as outlined above. Authorized Signature: 1/1_ _ r Date of acceptance: s ( � r Authorized Signature: All home improvement contractors shall be registered.Any inquiries about a contractor or subcontractor relating to a registration should be directed to:Office of Consumer Affairs and Business Regulation,10 Park Plaza,Suite 5170,Boston,MA 02116(Phone:617-973-8700). Owners who secure their own construction—related permits or deal with unregistered contractors shall be excluded from access to the Guarantee Fund provisions of MGL.c.142A The owner will receive a signed copy of this contract before work will commence.The owner has three(3)business days to cancel this contract and incur no penalty.Correspondence should be directed to Edmunds General Contracting LLC al the above address. Rev.01/13 Brr:u'cl u1' Dclru'trtrcnt of Ntr 'tty-$af Supervisor RcL'ui;rtir�n, ; Construction Su andSt Builclin� :inrhu c4, sor License License: CS 104728 DAVID EDMUNDS ... k. P•O. BOX 2214 SALEM, NH 03079 s C"nunl, Expiration: 10/3/2013 Tru: 104728 %�c �a�rzeirarrrorcrl(�r�r>t��ri;nc�u.;e/Li i Office of Consumer Affairs&Busrhess Regulation OME IMPROVEMENT CONTRACTOR egistration: 166661 Type: xpiratio n: 6/2172014 Corporation EDMUNDS GENERAL CONTRACTING, LLC. . DAVID EDMUNDS .18 ASHFORD RD 4 % � HAMPSTEAD, NH 03841 Undersecretary i 2 The Commonwealth of Massachusetts - Department of lndustriqlAccWnts Office of Investigations 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit:Builders/ContractorsAElectricians/Plumbers Applicant Information Please Print Le0bly Name(Business/Organization/Individual): E)VIAA J �j �N �� r tom, t Address: 1 ` c� �,70,�1 � b�jC��G1 City/State/Zip: j��h /f C) 'gH hone#: (D)-) —3(Ze'; --72Z Are ou an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 'L 4. El am a general contractor and I ` � have hired the sub-contractors 6. ❑New construction employees(full and/or part-time). 2.El am a sole proprietor or partner- listed on the attached sheet. E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition 5 We are a corporation and[No workers comp.insurance ❑ � id it10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. o workers' comp. c. 152,§1 4),and we have no ( 12. Roofre airs Y CN p ❑ p insurance required.]t employees.[No workers' comp.insurance required.] 13.[i 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 Lire 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 am an employer that is providing workers'compensation insurance formy employees. Below is the policy and job site information. r Insurance Company Name:. L. .sW b Policy#or Self-ins.Lie.#: �J c, ? '� 1 c C_ `1�Z Expiration Date: 2 Z c�13 Job Site Address: VD C)Sf,- aeQJ SV-Y- City/State/Zip: d ��j Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 Izereby e pains andpenalties ofperjury that the information provided above is true and correct. Signature/'7mDate: ( A 7 - Phone#: U (o 0`J-3 Ce S— '7 7 -7— Official Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone M Information and Instruction'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 of hire, express or implied,oral or.written." An employeiis 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 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 beingrequested,not the Department q � p nt 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-coin lete-and rinted le ibl . The"De artmenfhas rovided a s ace at the bottom p P g y p P-- — —p- -- 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. Anew 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 Commonwealth of Massav�hus-tts Department of Industrial.Accidents Office of Intvestigatious 604 Washington.Street Boston,MA 02111. ;[`el.,#61.7-72.7-4900 ext 406 or-1-877�,MASSAFB Revised 5-26-05 Fax##617-727-7749 '�wur.zrtass,gavfdia