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HomeMy WebLinkAboutBuilding Permit #886-14 - 691 JOHNSON STREET 6/5/2014TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: 0 Commercial IN Repair, replacement ❑ Assessory Bldg ❑ Others: 9 Demolition ❑Other 11 Septic ❑ W 11 ❑ Floodplain = ❑ Wetlands " ❑ Watershed District. Water/Sewer THE APPLICATION IS FORA REMOVAL OF EXISTING GUYED TOWER AND CONSTRUCTION OFA REPLACEMENT TOWER WITHIN THE EXISTING TOWER COMPOUND. ARCHITECT/ENGINEER JAMES DARREN HOLT, PhD., P.E. Phone: (919)755-1092 Address: 6529 MERIDIENDRIVE, RALEIGH, NC27616 Reg. No. 47696 FEE SCHEDULE. BULDING PERMIT. • $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 100 000 FEE: $ 1,200 Check No.: Receipt No.: 2 CoS x— NOTE: Persons contracting with unre isle ed contractors do not have access to thin Signature of Agent/Ownerignatdre of -contractor r- J TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family', - 0 Industriat---— 0 Alteration No. of units: 0 Commercial IM Repair, replacement ❑ Assessory Bldg ❑ Others: 19 Demolition ❑ Other 11 Septic ❑ We.1.1i El Floodplain D -Wetlands ❑ Watershed District 0 Water/Sewer. THE APPLICATION IS FOR A REMOVAL OF EXISTING GUYED TOWER AND CONSTRUCTION OFA REPLACEMENT TOWER WITHIN THE EXISTING TOWER COMPOUND. Identification Please Type or Print Clearly) OWNER: Name: CTI TOWERS, INC. Phone: (732)6875521 Address: 38 POND STREET, SUITE 305 FRANKLIN, MA 02038 ^ CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License:. Exp. Date: eT 'FG//lwafo , /y- 36 2 --5-��' ARCHITECT/ENGINEER JAMES DARREN HOLT, PhD., P.E. Phone: (919)755-1012 Address: 6521 MERIDIEN DRIVE, RALEIGH, NC 27616 Reg. No. 47696 FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 100,000 FEE: $ 1,20o Check No.: Receipt No.: NOTE: Persons contracting with nnre is,(e ed contractors do not have access to the guaranty fund Signature of -Ac ent/Owrier f Signature of contractor Plans Submitted Plans Waived ❑ I V Certified Plot Plan 0 Stamped Plans ❑x TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body All ❑ 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 ❑ a JT p%/� COMENTS A Plain; rOMMENTS NSERVATION I I HEALTH COMMENTS DATE REJECTED DATE APPROVED ❑ ❑ 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 Located at 384 Osgood Street Plans Submitte& ❑ PlansWaived-0 F -Certified Plot Plan ❑ Stamped Plans ❑ :TW- - OF SEWERAGEDiSPO AL ` Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco.Sales ❑ -Food Packaging/Sales ❑ -Private:(septic tank, etc.. - . Permanent Dmnpster on Site ❑ THE- FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM - DATE REJECTED DATE: A_PPR-OVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed on Sionature Reviewed on Signature Zoning Board of Appeals: Variance, Petition N Planning Board Decision: Comme Zoning Decision/receipt submitted yes Conservation Decision: Comments Water & Sewer Connection Driveway Permit DPW Tows Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -, Temp Dumpster on site yes no Locatedat'124 Mair Street:- - Fire Departme►�t 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, niast 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 usel Doc.Building Permit Revised 2010 go -4y lD �P 1` Ne Q --O 4? „f Z L- j- C;, 1►9,� El Notified for pickup - Date i Doc.Building Permit Revised 2010 Building Department -The fol�-;)wing -W'-A list of the required -forms to be filled out for the appropriate. permit to .be obtained. Roofing, Siding, Interior Rehabilitation Permits o ` Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And7Or C.S.L.Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application `:... a Certified Surveyed Plot Plan • Workers Comp Affidavit • Photo Copy of H.I.C. And C.S.L. Licenses a Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) • 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) a Building Permit Application Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses L3 Workers Comp Affidavit L3 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 bP subm.tted with the building application Doc: Doc.Bui!ding Permit Revised 2012 � 0� I Location No. SS6—li Date 1% TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee TOTAL $ �()Jc, I - Ch eck # 0-T Buildind inspector 4064 VL— -e2 ov Q ftj c North Andover Board of Assessors Public Access OF ,AO oTM41 1 # s ^ 9SSwCHus¢t Click Seal To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial Page 1 of 1 roperty Record Card Parcel ID :210/038.0-0029-0000.0 FY:2014 Community: North Andover SKETCH PHOTO No Picture Available Location: 0 JOHNSON STREET Owner Name: CTI TOWERS INC Owner Address: 38 POND STREETSUITE 305 City: FRANKLIN State: MA Zip: 02038 Neighborhood: 5 - 5 Land Area: 16.88 acres Use Code: 431 -RELAY -TOWER Total Finished Area: 0 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 401,800 401,800 Building Value: 85,800 85,800 Land Value: 316,000 316,000 Market Land Value: 316,000 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkld=2433933&amp;town=NandoverPubAcc 6/9/2014 North Andover MIMAP Interstates I SR Roads C'. Easements 0 MVPC Boundary f I Parcels 1"=713ft June 9, 2014 Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, Meters Data Sources: The data for this map was produced by Merrimack NORTH Valley Planning Commission (MVPC) using data provided by the Town of Ot o r• q� North Andover. Additional data provided by the Executive Office of ,+`� +p 00 Environmental Affairs/MassGIS. The information depicted on this map is e� G for planning purposes only. It may not be adequate for legal boundary • F definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT o _ 4 ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION T D n m Ir 0 N O 0 W O 0 O O N lD O O O O 0 D 0 w O O r O C) O O N O r- 0 O 0 0 o� o° CD CD D� ;u CD n0 0 m° r C- oCL m C- 0 m z Cl) O z m m m = a O mL.CL0 Grp zoo -, o r -v Z m D o m Z W o n m Z n O M D O z X O O N CO CD ^' X CD N 2106 T 7 : N O � aDN a D m CD o m � 01' W 0 co CD cn �mmmm S< ov r n m m 0 CD0 CD � c� c cn N) Cl)z O m--1 Ca = A N X1 CD 5' a C) C) cn c O r �o 00 D O o o ' ;uv - 0 O Q) 0) -- m 0 Z CDv0 r" -ro -� m !T 000� 3 n a0 0 AAn al 3 m 0� jo ww �Q z o o0 0o 000� 000� m CD z Dcog _ N' m CD o =0 c Z -4 D Co Co Co G �m0 '8 ��000X m a r cQCQ rD" , . o c o�v, Ny "� DDD" � , "'v c CD 0) Qo OD 00 O c o.. �Z � dna 00 00 Z m n -� co n O a `< oo DDDo C �o� �� =. 5R r r O 7 m o C:) z 7. r"� Qa y Z 4��* i WC CD O ? 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Z H M m --1 0 =' O m S C 3 W G� N m 0 =3_? r O GQ S O =3Q N p =3 W C p z H m O (D N rD 3 O n s fD :3 00 O = m D x CD N XN 6s MOWN.-, 0 e North Andover MIMAP June 9, 2014 o� -R3 as 4 O qez N •.-- .. :�I .; '... ., rill ^y)f,({ .: ':::: -, -..1V!/. .... ..;:.. ...... aur. _.. :�U;r-;- • ' ;:��: �;: �_� _. •:.�u-:: - btu".:_�. -: , J :_..• :_.. CD2 N . y ,.I": .J . 114 eS9Tive ::� � ,t. :::: � = I1 - -- tet• u 114 Valu �O O�iS' We - �as�a�9 I.1 • ; � _ Ff -:• - _ — Rail Line `w Wetlands Zoning Interstates ..Exempt Lands _ I Busine Busine s 1 District s 2 District Horimntal Datum: MA Stateplane Coordinate System, Datum NAD83, — SR O Busine Busine s 3 District s 4 District AORTN Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of Roads r Easements Gene IO Planne - Corrido Business DistrictOt o 'qy Commercial De ��, r�• O ? bt ! O Development Dist 3' North Andover. Additional data provided by the Executive Office of Environmental Affairs/MassGIS. The information depicted on this map is ❑ MVPC Boundary C3 Municipal Boundary O Comido 10 Corrido _ L Development Dist p ._.. IN Development Dist for planning purposes only. It may not be adequate for legal boundary definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING Zoning Overlay 0 Adult Entertainment Indust, G; Indust, I 1 District • t{ I2 District THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT 3 Downtown Overlay District Q Indust, 1 3 District r` •+ ♦ * o' ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF Historic District Water Protection ©Indust, Reside Reside _ ...r. I S District ce1 District 'Zl +°++*�o ��t cc 2 DisMct ,S THIS INFORMATION 0 Parcels = Ronde m 3 District SACHU`+e C1 Hydrographic Features 1" = 713 ft de de ede ce 4 District - 5 District – Streams ce 6 District age a idential District '`✓ BoardMassachusettsBuilding - Department o..._..._. f Public Safety ding Regulations and Standards ( un%truction Supra kor License. CS -064485 JEFFREY R GOLD 953 PUTNAM PIKE Chepachet RI 02514 Expiration Commissioner 10/03/2014 AD- WESTCOM-01 CHANDRANVI 14`4coRo°CERTIFICATE OF LIABILITY INSURANCE ATEYYYY) r6/14/201412014 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 Willis of Alabama, Inc. c/o 26 Century Blvd(AIC,No P.O. Box 305191 Nashville, TN 37230-5191 CONTNAME: certificates@willis.com PHONE 877 945-7378 FAX /c No): (888) 467-2378 Ext): ) AJC, E-MAIL ADDRESS: 20 ECS QUO527 I 12/31/2013 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Hartford Fire Insurance Company 19682 DAMAGE TO RENTED 300 000 PREMISES Ea occurrence $ , INSURED INSURER B: Commerce & Industry Insurance Company 19410 INSURER C : WesTOwer Communications Inc. INSURER D: 2460 Sand Lake Road Orlando, FL 32809 INSURER E: INSURER F: AUTOMOBILE X 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 ADDL BR POLICY NUMBER POLICY EFF POLICMM/DDY EXP LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1XI OCCUR X I 20 ECS QUO527 I 12/31/2013 12/31/2014 EACH OCCURRENCE $ 1,000,00 DAMAGE TO RENTED 300 000 PREMISES Ea occurrence $ , MED EXP (Any one person) $ 10,000 PERSONAL &ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X PRO - POLICY LOC PRODUCTS - COMP/OP AGG $ 2,000,000 PROD COMP OPER $ 1,000,000 A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON-OWNEDPROPERTY HIRED AUTOS AUTOS 20 LIEN QUO520 12/31/2013 12/31/2014 Ea aBINEDtSINGLE LIMIT $ 1,000,00 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ DAMAGE Per accident $ B X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 15805686 12/31/2013 12/31/2014 EACH OCCURRENCE $ 10,000,00 AGGREGATE $ 10,000,000 DED X RETENTION $ 10,000 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE20 OFFICER/MEMBER EXCLUDED? � (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WN QU0523 12/31/2013 12/31/2014 X I WC STATU- OTH- TORY LIMITSI ER E.L. EACH ACCIDENT $ 1,000,00 E.L. DISEASE - EA EMPLOYEE $ 1,000,00 E.L. DISEASE -POLICY LIMIT $ 1,000,000 A Equipment Floater 21 UUM TW6241 12/31/2013 ::nSEE ATTACHED , DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Re: Work performed at 693 Johnson Street, North Andover, MA 01845 Town of North Andover, Mass is included as an Additional Insured as respects to General Liability. Town of North Andover, Mass 1600 Osgood St. 011d1CLo1R14AG\1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE k, )f�, ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ADDITIONAL COVERAGE SCHEDULE COVERAGE LIMITS Contractors Equipment $500,000 Leased/Rented Equipment POLICY TYPE: Equipment Floater $10,000 Ded All other Equipment CARRIER: Hartford Fire Insurance Company $25,000 Ded Crane POLICY TERM: 12/31/2013-12/31/2014 The Equipment Policy is written on a Special Form POLICY NUMBER: 21UUMTW6241 including theft subject to policy terms, conditions, exclusions and limitations From: (919) 367-5027 Charity Dunn FDH Engineering 6521 Meridien Drive Suite 107 Raleigh, NC 27616 SHIP TO: (978) 688-9545 Maura Deems Origin ID: RZZA 1600 Osgood Street Building 20, Ste. 2035 NORTH ANDOVER, MA 01845 Fedk. Express E A4101312270326 BILL SENDER Page 1 -of 1 ( i Ship Date: 12FEB14 6 ActWgt 1.0 LB CAD: 104898477ANET3490 Delivery Address Bar Code III IIIIIIIIIIIIIIIIIIIIIII I IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII� Ref # 1900 Invoice # PO # Dept # THU-13 FEB AA TRK# 7978 9722 6127 STANDARD OVERNIGHT 0201 01845 NB MXGA MA -US Bas 11111111111111111111 111111111 1111111111 111111111111 After printing this label: 1. Use the'Print' button on this page to print your label to your laser or inkjet printer. 2. Fold the printed page along the horizontal line. 3. Place label in shipping pouch and affix it to your shipment so that the barcode portion of the label can be read and scanned. Warning: Use only the printed original label for shipping. Using a photocopy of this label for shipping purposes is fraudulent and could result in additional billing charges, along with the cancellation of your FedEx account number. Use of this system constitutes your agreement to the service conditions in the current FedEx Service Guide, available on fedex.com.FedEx will not be responsible for any claim in excess of $100 per package, whether the result of loss, damage, delay, non- delivery, misdelivery, or misinformation, unless you declare a higher value, pay an additional charge, document your actual loss and file a timely claim. Limitations found in the current FedEx Service Guide apply. Your right to recover from FedEx for any loss, including intrinsic value of the package, loss of sales, income interest, profit, attorney's fees, costs, and other forms of damage whether direct, incidental,consequential, or special is limited to the greater of $100 or the authorized declared value. Recovery cannot exceed actual documented Ioss.Maximum for items of extraordinary value is $1,000, e.g. jewelry, precious metals, negotiable instruments and other items listed in our ServiceGuide. Written claims must be filed within strict time limits, see current FedEx Service Guide. https://www.fedex.com/shipping/html/en//PrintIFrame.html 2/12/2014 ANTHONY'S BUILDING CO., INC. GENERAL CONTRACTORS 953 PUTNAM PIKE CHEPACHET, RI 02814 PH. (401) 567-0600 FAX (401) 567-9354 June 4, 2014 Town of North Andover, MA Department of Licenses/Inspections North Andover, MA Project: 693 Johnson Street, North Andover, MA 01845 To Whom It May Concern: This letter is to serve as authorization for Kevin Znuj of WesTower Communications to transfer my signature affixed to this document in filing for the building permit under the Major Contractor Registration # MCO.0900617, for the above-mentioned project. If you have any questions, please feel free to contact me. Sincerely, Jeffrey R. Gold President The Commonwealth of Massachusetts SNN Department of lndustrialAccid%nts Office oflnvesttgations 640 Washington Street .Boston, MA 02111 www.mass gov/ciza WQrkexs' Compensation insurance Affidavit: Builders/Contractors)Electricians/PIrimber.s Appl�ieant lnforznation Please Print Led 'Name (Businesslorgauization&dividual): Address: City/State/Zip: c s� 13nS-`1 Phone#: 31S (-132-'z 7. Are you an employer? Check the appropriate box: Type of project (required): 1. $ I am a employer with 11D 4• ❑ I am a general contractor and I 6. E] New construction _ employees (full and/or part-time).* 2. El am a sole proprietor or partner- have biredthe sub -contractors listed on the attached sheet. 7• ❑Remodeling ship and1aveno.employees worldng forme in. anycapacity. These sub -contractors have workers' comp. insurance. S. ❑ Demolition �, Building addition [No workers' comp. insurance 5. ❑ We area corporation and its 10.E] Electrical repairs or additions required.] 3.El I am a homeowner doing all work officers have exerelsed.their right of exemption per MGL I I. [l Plumbing. repairs or additions myself [No workers' comp. c. 152, §I(4), and wehaveno 12.❑ Roofrepairs in.surancere ed.a employees. [No workers' 13.[�Other �wea we comp. insurance required. xAny applicant that checks box#I must also fill out the section below showing their workers' compensationpolicy information. i Homeowners who submitthis affidavit indicating they bre doing all work and then hire outside contractors must submit anew affidavit indicating such. Untractors that checktbis box must attached an additional sheet showingthe name ofthe sub. -contractors and their workers' camp. policy information. I am an emy foyer that is providing WOTIfex.s' compensation insurance for my efnployees BeloW is the policy andJoh site information. Insurance Company Name;. Policy ## ox Self ins. Lic. ff: b U t; tJ City 0 S20 ExpitationDate: 12/ 31 4014 lob Site Address, �e� Z1^^'y S� �"1� jCiiy/State/Zip: Attach a copy of tie workers' comp ensation-policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL o. 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 ofup 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. X do hereby CeT0 u eii anrenalties of perjury tYiat tree in, formation provided above is true and correct. Phone #: t of S 2— l 3 4 Oficial use only. Do not write in this area, to be completeri by city or tort official. City or Town: PermitlLicense Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - r Coatact 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 tri the service of another under any coi Tact of hire,. express orimplied, oral orwritien." An employers defined as "an individual, partnership, association, corporation ox other legal entity, or any two oxmore of the foregoing engaged in a j oint enterprise, and including the legal representatives of wdeceased 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 notm"ore 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 bean 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 fox any applicant who has not produced"acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have b con presented to the contracting authority." Applicants Please fill out the workers' compensailon affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) andphone numbers) 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, apolicy is required. Be advisedthattbis affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be, returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensationpolicy, 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 ba sure that the affidavit is complete andprinted legibly. The Department has provided a space at the bottom of the affidavit fox you to fill out in the event the Office of Iuvestigations has to contact you regarding the applicant. Please be -sura to fill in the pen it/license number which will be used as a reference number. In addition, an applicant that must submitmultiple permit/license applications is any given year, need only submit one affidavit iudica&g cutrent policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town) ".A: copy ofthe 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. ii on. file for future p ermits or licenses, .A, new affidavit must b e filled out each year. Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves eta.) 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 aiid fax number: Tho Coxr_mom-ealt1t of M—usu'Ausetts Depaxt�xrant Q.iZ�.dus�xzaX ,A,ccXi�cxlis Office ofTAve9Rga.-0oxw - 6,0 WasRagtonSjxe,�,t Boston, 0.2.11 T019 617.7.27_4.90Q at 406 QX- 1-877-MA.SSAFF, Revised 5-26-05 Fax 9 617-727-7749 www maS,.gQv ctia 1 V} I z Q 0 Z 0 w�oN� m rn Brn ci ^oo !t oo¢z_¢LO LJ.J z U y F rp� "� N O O b,3rc g Z I- e4i U? 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