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Home My WebLink AboutBuilding Permit #467 - 677 SALEM STREET 11/16/2012Permit NO:6 Date Issued://,/// /2_ TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received I / / IMPORTANT: ADDlicant must complete all items on this Date I LOCATION' 1PROPERTY OWNER\A,4 Nl._11-0 MAP NO:PARCEL:. ZON Print •100 Year Old Structure yes(no, o IN G DIS_ TRICT `.Historic3Distdct - yeso Machine.Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residen ' I Non- Residential ❑ New Building a family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other p Septic ❑aWell ❑ Floodplain 0 Wetlands ❑ Watershe&District. El Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: .AN LC <- ; AA -4 Address SA- I{.,•� S's Improvement License: Exp 'z-- 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: $ 'r 3 ", �)- L9,0 d $ FEE: $ 2 E .-- Check Check No.:_ 1 �'�1 Receipt No.: NOTE: Persons contracting with unregistered contractors do not haven ccess to the guaranty fund Slgnatureof�Agent/Owner' �� Signature of con Tactor? Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan Stamp ,Plans ❑ 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 o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o 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 ofH.I.C. And C.S.L. Licenses ❑ Copy Of Contract o 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) ❑ Building Permit Application ❑ Certified Proposed Plot Plan o 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) o Copy of Contract o 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: Doc.Building Permit Revised 2012 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMME CONSERVATION COMMENTS HEALTH A- 60MMENTS DATE REJECTED DATE APPROVED ❑ ❑ Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comm Conservation Decision: Com Water & Sewer Connection/Signature & Date Driveway Permit DPW 'Towp- Engineer: Signa Locatea 5b4 us ooa Jueei FIRE DEPARTMENT - Temp Dumpster on site yes no Located at ,124 Main Street - Fire Departmentsignature/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 21A —F and G min.$100-$1000 fine NOTES and DATA — For department use ® Notified for pickup - Date Doc.Building Permit Revised 2010 Location r a'-�-0 No. 6 Date i Check J4 25957 TOWN OF NORTH -ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee $ '� Other Permit Fee $ TOTAL $ Building Inspector IN~— r - 00 0 Z Z> 0 M W W o > -n U) 0 0 0 G) :3 (n (D m x < S 0 YA O (D :7 0 C) CO) M, m m y m < 0 0 0 °' _ O � N 0-00 O C) O O r+�c) 3 ; Vi• , Z O :s O• cn• -•I "a O O y affgyQp' in T �, r► O• .+ Oh O Fn CD W O - O —1 N =. I to 2 �• O CLO @ : m D y Q •O O _ .. cD cc e�•F O Z N C W CD 7a �D Z -o- CL o•'o r m to= :E o `� Cl) ONS Q c to z C �• cn C7 rt 0 0 _ �. n c� -• O O v�N �- �- • �► C7 `� Z < CL O 0 O N CCLD aC O Zm CL C Cl) CL CD C7 -0 moo CD m O CD OCD CL CD It cn -pw CD z _- CO CD�_ Cl) .. Z CD CD 0 ID W cn CD o_ n 0 v o 4 � 0 O c� : C C 7%y CD -CD :0a O m <o CD -i : 0: a)CL o rA InrN' O7 T ;a -n U .Z7 T DC7 T n Z7 T (n T 0) ° CL rD (Dfu o 3 w Z m m o, N K m V =3 m m 'PI W A C H W > o H n a C' 0 n H H M m Z 0 70 A n O 0 V S THOMAS DEFUSCO, LLC DBA - Tom DeFusco - General Contracting 23 Dutton Rd. Pelham, NH 03076 H.I. Reg. #11.7756 - Constr. Lic. #071037 PROPOSAL SUBMITTED TO: ll� G 5A I, -e WE HEREBY SUBMIT SPECIFICATIONS AND ESTIMATES FOR: r�rzo�osA� Page No. -of 7 Pages DESCRIPTION OF JOB ARCHITECT DATE OF PLANS JOB ADDRESS GIN STATE ZIP PHONE DATE M e, ✓-i S' L/ /-- ( T��. 4+/1✓ SCC .; `tom, Ci cJ • �✓ j T a.. 't� 5 [ ( S l ales c)�.L.,.� -. S ��,�� J✓/w. �C'�. y LCA 3G s//�%r Z_ We hereby propose to furnish material and labor, complete in accordance with above specifications, for the sum of / 1l nc �I hourA_.j w- c,"") �W _ – dollars (S .2616 -,— with payment to be made as follows: 6 ad All material is guaranteed to be as specified. All work is to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from specifications Authorized involving extra costs will be executed upon written orders, and will become an extra Signature charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary Note: This proposal may be withdrawn by us if not accepted insurance. Our workers are fully covered by Workers Compensation Insurance. withinjLCL days. Acceptance of Proposal - The above prices, specifications and condi- tions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Signature Date of Acceptance:' --4v �_41� Signature _ BERRFRI OP ID: KN A` CORD, 1�.►� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYY'n 1 08/28/12 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(les) 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 hoider.in lieu of such endorsement(s). PRODUCER 978-683-4700 T. A. Sullivan Ins. Agcy, Inc. 344 S. Union St Lawrence„ MA 01843 NNAMNEEa' PHONE FAX Arc No Ext : arc No AADDDD TRESS: INSURER(S) AFFORDING COVERAGE NAIC A X COMMERCIAL GENERAL LIABILITY INSURER A: Risk Placement .Services INSURED JFB Vinyl Siding INSURER 6: INSURER c Frank & James Berry DiBIA Frank & Sons DBW Frank & Son Contracting INSURER D: INSURER E: 45 Windbrook Drive Epping, NH 03042 - - INSURER F 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 GENERAL LIABILITYEACH A D S B POLICY NUMBER M/D EFF YYY1 POLICY EXP IM LIMITS OCCURRENCE $ 1,0d0,OO A E REN ED PREMISES ' R occurrence $ A X COMMERCIAL GENERAL LIABILITY Pelham, NH 03076 3DC9470 04/30112 04/30113 MED EXP (Any one person) $ CLAIMS -MADE Fx] OCCUR X Owner/Cont Prot. - - PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2+000,00 $ OMBINED LIMIT $ Ea (Ea POLICY PRO- LOC AUTOMOBILE LIABILITY BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) S ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ Per accident $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS UAB CLAIMS -MADE DED I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE WC $ STATU- O R T IMf R DR E.L- EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ OFFICEWMEMBER EXCLUDED? ❑ (Mandatory in NH) N / A E.L. DISEASE -POLICY LIMB S If yes, describe under DESCRIPTION OF OPERATIONS below A Commercial Applica 3DC9470 04130112 04130/13 DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, K more space is required) Vinyl siding installation and roofingvinyl siding installation, minor car pentry, residential home painting and roofing rAurCr I A'Tr W V 7'JirO-LUTU ALIJKU LVRrVR/a11Vn. eau nynu rwer.ev. ACORD 25 (2010105) 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 Tom Defusco ACCORDANCE WITH THE POLICY PROVISIONS. General Contractor LLC 23 Dutton Road AUTHORIZED REPRESENTATIVE Pelham, NH 03076 V 7'JirO-LUTU ALIJKU LVRrVR/a11Vn. eau nynu rwer.ev. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Rightfax C3-1 9/28/2012 6:03:16 AM PAGE Z/00z Fax Server CERTIFICATE OF LIABILITY INSURANCE DATE (MM112012 Y) FICATE'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 policV(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to he terms and conditions of the policy, certain policies may require and endorsement. A statement on this certificate does not confer rights to he certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PHONE FAX DAVID E ZELLER INS AGCY 370 LYNNWAY (AIC, No, Fwd): IANC. No): E4WL LYNN, MA 01901 ADDRESS: 25D6D INSU RERM AFFORDING COVERAGE NAIL q INSURER A: ACE AMERICAN INSURANCE COMPANY INSURED INSURER B: BERRY, FRANK & BERRY, JAMES DBA FRANK & SONS INSURER Q INSURER D: 45 WINDBROOK DR INSURER E EPPING, NH 03042 INSURER P COVERAGES CERTIFICATE NUMBER: REVISION NUMBER-. —THIS IS TO CEHTIFY Wir WE POLRWsoFlHsURAHcE LISTED smovir HAVE BEEN ISSUED TO THE UMMED NAIAD ABOVE FOR THEPOUCY PERIOD INDICATED. NOTWnHSTANDNG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTBICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRB® HEREIN 6 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICES. LNUS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS. NSR ADD SUBPOLICYEEFF DATE POLICYEXP OATS LTR TYPE OF INSURANCE L R POLICY NUMBER (MM MYYY11) (NWMDDW YYY) - LIMITS GENERAL LIABILITY ACH OCCU>IRRENCE s COMMERCIAL GENERAL LIABILITY DAMAGE $ CLAIMS MADE a OCCUR. MISES (Ea occurrence) IMED EXP (Any one person) S INJURYGEHL AGGREGATE LIMIT APPLIES PER: AGGREGATE S POLICY Q PROJECT a LOC S - COMPIOP AGG S AUTOMOBNFLIABILITY DSINGLE S ANYAUTO rRALLADV ccident) ALL OWNED AUTOS JURYSCHEDULE ) AUTOS JURYHIRED AUTOS n0NO"WNED AUTOS Y DAMAGEnt) UMBRELLA LIABOCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS -MAD NGGREGATE $ . S DEDUCTIBLE RETENTION S S A WORKER'S COMPENSATION AND X I WC STATUTORY OTHER EMPLOYER'SLIABfl1TY YM UB -089P89342 07Q212012 07r22n '13 UMITS ANY PROPERITORPARTNERIEXECUrIHE 0 NIA E L EACH ACCIDENT S 100,000 OFRCERIMEMBER EXCLUOEO? EL DISEASE - EA EMPLOYEE S 100,000 (Mandatory In Ni If yes, describe under EL DISEASE - POLICY LIMIT S 500,000 OESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONSJLOCATIONSNB RCLESIRESTFJCTIONSISPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE THE INSUREDS MA WORKERS COMPENSATION POLICY AND IT S LIMITED OTHER STATES ENDORSEMENT AUTHORIZES THE PAYMENT OF BENEFITS FOR CLAIMS MADE BY THE INSUREDS MA EMPLOYEES IN STATES OTHER THAN MA NO AUTHORIZATION IS GIVEN TO PAY CLAIMS FOR BENEFITS IN STATES OTHER THAN MA IF THE INSURED HIRES, OR HAS HIRED EMPLOYEES OUTSIDE OF MA. THIS POLICY DOES NOT PROVIDE COVERAGE FOR ANY STATE OTHER THAN MA NO PARTNERS ARE COVERED BY THE WORKERS' COMPENSATION POLICY_ THE POLICY DESIGNATED ABOVE IS CANCELED EFFECTIVE 10-09-2012 CERTIFICATE HOLDER CANCELLATION TOM DEFUSCO GENERAL CONTRACTOR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EVIRATION DATE THEREOF, NOTICE WIL D ATTN: TOM DEFUSCO INACCORDANCE WITH THE POLICY PRO 23 DUTTON ROAD AUTHORIZED REPRESENTATIVE PELHAM, NJ 03076 ACORD 25 (2010/05) I Re ACORU name an0 logo are reglsreren marNs or fn_uitu 7=W-LUlU NwrtU %'4JKrurva r rvn. M1 rryrna 1c _ vw. From: 10/02/2012 09:02 #083 P.001/001 04 YYM CERTIFICATE OF LIABILITY INSURANCE 10/2` 012 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 cert'fiicate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WANED, 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 endorsenm s). PRODUCER coir Rose _Munoz Wilson Insurance Agency PHONE (781) 665-1034 FAz (761)662-0301 109 West Foster Street INSURERfs)AFFORDING COVERAGE MAIC0 Melrose MA 02176 rimsumm ERA:Scottsdale Insurance Co. INSURED ER e - Tom De Fusco, LLC, DBA: Tom De Fusco General EtC: PO Box 1012 ERD: ER E Methuen KA 01844 RF: s nn%naww 111111A000• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN MSUED 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• MSR LTR TYPE OF INSURANCEPMDL SU POLICY NUMSE R POLICY EFF POLICY EXP LINT'S AUy1LORwm REPREsENTATIVE GEIERALLUSHM Reith Bowden/ROSS EACH OCCURRENCE S 1.000,000 DAMAG Ea�D g 50,000 8 COMM�IALGENERALUABILITY MED EKP Aar orm pemn) g 5,000 A CL VMS4=E ® OCCUR rPS1595412 /3/2012 /3/2013 SAOVINJURY g 1,000,000 -PERSONAL GENERAL AGGREGATE 3 2,000,000 GEPyLaGGREG11TEtIMRAPPLIESPEt PRODUCTS-COMMOPAGG f 110001000 g PROX POLICY jec LOC AUTOMOBILE LIABILITY COMBINEDLuffy aedde 6ODILY INJURY (Perpemw) i ANY AUTO BOMKNRY (PW ea3dwo S ALL owNED H SCIMOUL.ED AUTOS AUTO NOpI{IyyN® - - PRDP(3iTY DhTAAGE g _ HIRED AUTOS AUTOS . E UMBRELLA UAB OCCUR EACH OCCURRENCE 4 AGGREGATE g EXCESS LIAR CLAWSMADE DED RETENTION g yYOR1(ERSCOMPENSATION U OTH- WCSTATEEL AND EMPLOYERS' LIMUTY Y f N ANY PROPRIETOR/PARTNERIEXECUTIVE F1 EACH ACCIDENT S . E.L DISEASE - EA EMPLOYEE $ - OFRCERIMEMBER EXCL IDED? [:]NIA (My>etlsM� am+r in NN) EL DISEASE -POLICY LIMITg DESCRIPTION OF OPERATIONS belay DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES (Alach ACORD 101. AddManA Remarla Sdrodde. Nmo,e space is n mPfire* FOR INFORMATIONAL PURPOSES ONLY ACORD Z5 (2010105) w vaoo-w cv:� vv,� v...+...+....... .n ................. INS025 (2moos).oi 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 ACCORDANCE WITH THE POLICY PROYLSIONS. AUy1LORwm REPREsENTATIVE Reith Bowden/ROSS ACORD Z5 (2010105) w vaoo-w cv:� vv,� v...+...+....... .n ................. INS025 (2moos).oi The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ,Y www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): `��M L S Address: Q �!, �) ,., City/State/Zip: c✓ 1,4— el > u 7 ! Phone #: G `G 3 G 3 &—,s G / '", Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 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 additions 11. F1 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. I Homeowners who submit this affidavit indicating they are 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. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: ,,& j,A6-/� vu i -1 f Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under 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. I do he ti under the pains and penalties of perjury that the information provided above is tree and correct. a.c�. i Z v nate- le Official tcse 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 #: 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-contractor(s) 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. 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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5 -26 -OS „n,.., m _ _-IA:_