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HomeMy WebLinkAboutBuilding Permit #007-12 - 72 STAGE COACH ROAD 7/1/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION , Permit NO: �0�7_�2 Date Received Date Issued: -7 , ' � IMF RTANT:Applicant must complete all items on this page LOCATION �7 2 S ,e � Ch Print PROPERTY OWNER kM 0 n e_ 4 6�rAA41t� Print MAP NO: 0"5PARCEL: .r ' ZONING DISTRICT: Historic District yes n Machine Shop Village yes n 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 0lSeptcyWell_ '_piloo_dplai�0 Wetlan Lds v4~ []_� WatersliedlD_i'strictK DESCRIPTION OF WORK TO BE PERFORMED: , t i swb� (Identification Please'Type or Print Clearly) e nr ry OWNER: Name vn e �- Lt LR ,�0.1 �J Phone: f7 �' � Address: 13- Ca a, h1wia Vv4n I CONTRACTOR Name: w1 rt, Vi t"! Phone: G�-?�� 43a ?e �► Address: Ute .� �-� ��., / s` tI(/�, t�f Supervisor's Construction License: 5(0:13Exp. Date: O�- 1 ©i (f Home Improvement License: t' ' 26` Exp. Date: 3- i a t ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Tota! Project Cost: $ 0qa FEE: $ Z-77— Check No.: /�8� Receipt No.: 7 � E NOTE: Persons contractin with unregistered contractors do not have access to the guaranty fund _�� _ Si nature)of A ent/Own i nature -„ - _g.„ ._ � ��' g. . Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed.Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application 1 ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan_Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Y) ❑ 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: Doc.Building Permit Revised 2008mi 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 7—/ — Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zo"ning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA - For department use i ---- -----.-------- ---- -- ------------------ ® Notified for pickup - Date Doc:.Building Permit Revised 2008mi Location No. Date f NORM TOWN OF NORTH ANDOVER 41 s ° a Certificate,of Occupancy $ ;�J''•°'Eta' Building/Frame Permit Fee $ �cmus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # f v v 24340 Building Inspector NORTH To'" of 0 OA No. off . �•X 0 o , dover, Mass., C OCHICHEWICK �,95°RA TE D U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........ --"Y/V6 �G Foundation has permission to erect........................................ buildings on...7.a.... �. ..�.. ........ ............. ....................... Rough 77T t0 b8 OCCUpled as................. ................................ M..:. ..i.'oo.-�/.. ...... ..... 0. ..................................................... Chimney provided that the person accepting this permit shall in eviry respect c nform to the erms 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 MONS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ,RTS Rough r� ........... Service BUILD PECTOR Final Occupancy Permit Required to Occupy 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. Clienfa'R: 53642 --- . 1-1 �v.r&U 1 r I UJ:10101"LIC?'9 UO-U:3 � FAMILYPOOLI ACORD- CERTIFICATE OF LIABILITY INSURANCE DTE(MM2011YY) THIS CERTIFICATE IS ISSUED AS A MAT OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AIMEN'D,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE?GLICIZS BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE BOLDER. IMP3RTANT:It thocartificate holder Is an A e poi cyfigs)must be en orsed- IV su ject 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 endorsoment(s). PRODUCER N HUB International Now England HONE P ----- 233 Ballarrlvale St ti!c N ,,,:978 657-5100 :,A!^ N�. 866-475-7959 $?IANC -_—_..__...__.__..—__..___..__________.__ Wilmington, MA 01887 ADDRESS: — 978 657-5100 CUSTOMER ID 0, INSURERS)AFFORDING COVERAGE NAIL t INSURED Nautilus Ins Co Family POO S&Patios Inc. INSURERA: INSURER s Technology Insurance Ca Bill 8,Cindi Gianopoulos (� 70 S.Broadway NSURERC:Acadia Insurance Company 131325 Lawrence, MA 01843 INSURER D,Safety Insurance Cc -- -- i INSURER E: !NSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A.EOVE FGR THE POLICY PERIOD INDICATED.NOT"'ITHSTANCING ANY REtZUIREMENT.,TERM OR CONo/'ION OF a.NY CONTRACT OR OTHER DOCUUENT'N17H RESPECT TC WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFCRDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTC ALL T",E TERPAS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIia11TS aHCWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE Or:INSURANCE POLICY NUMBER MP CD?EFF 1' IPo�Mf•'DrYYY'fLtMtTS A GENERAL LIABILITY NN036497 911912010 0911912011'�Eac��l t�1 000 000 Al QMA!ERCIAL GE.!E.-gAI.LIAMI I Y u',1trI' � PRE6d'SE S{Ea acc.rnan�r $100,000 1:L.A'540!v .DE i "I OCCUR —' �MED EXP(hoy a,e N rsrn) $�_ 0 �XJ�BVPD Ded.2,500 FeRsoN Le..aD'.'sNJURY 000000 -- XI XCLi InCIGENE'tAL A GGREaATE_ $2.000,0013 GEWL A•3GREGATE LIMP APPLIES?ER: 2,000,000 oQ_ICY r'RG- LOC F'RQDUCTti_rYJlfp,rPrSr c -- $ )] AUTOMOBILE LIABILITY 3947232 1213112010 12/31120111 COMEt'NEJ Slt!GLE J&8T ico ac"tea"'t' _11_000,000 ANY AUTO ALjBODILY!NJUPY,- ar cA X•SCHEDULEDAU7CS I i ISiJDIL:•'if.JURYi'e•aaldent) S PROPERTYDAMAGE $ HiRcC AUTOS 1;Per acrid.=,nll XI NON-QWNEP,AJTOS $ UMBRELLA LIAB $ EXCESS LIAB �I EACH OCCURRcNCF $ C'_AIMS-MADE AGGREGATE $ DEDUCTIBLE - $ RETENTION B WORKERS COMPENSATION $ Y _ N/A y S_ .07H_ 03259514 21311201012131/2011'— JWC STATJ AND EMPLOYERS'UASILI7Y ',•IA11T ANYPROPRiETuR,PARTNER:EX-'L!'-IVE --- OFFIr:ERIMEMBCR EYCL;!O-D? L.EACH ACCIDENT NT $100,000 1Marttlatpry in NH) K 7a4 da .ritx.imd<r F L DISEASE A EN•R OYFE $100,000 DESCRIPTION GF OPERATIONS below 'E.L.DISEASE POLICY Llf'1- 1$500,000 C Property P rtY CF A018008414 391191201D 0911912011, vrs fimiL a vrs lots JS2m Form Re ICost ed$1000 DESCRIPTION CF OPERATIONS!LOCATIONS'VERtCLES(Attach ACORD 101,Additional Remark$Sehedute,if more apace is require.) CERTIFICATE HOLDER CANCELLATION JD Days for-Non-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 3E CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED RCPRESSEE14TATIVE 01988.2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009!09) 1 0 f 1 The ACORD name and logo are registered marks of ACORD #484444 EH002 :1'larsachti ctts Departtncnt of Public Safet} ti Boanl of Builtlino Re-ulations and , tantJard Y--+ Construction Supervisor License License: CS 10330 Restricted to: 00 Ry WILLIAM C POULOS 70 S BROADWAY ` LAWRENCE, MA 01843 Expiration: 7/19/2011 t unmissl!ner Tr-#: 1306 .'111"jjucfuaeA License or registration valid for individul use only ��e Uiarrvrraaruueca�t� Regulation before the expiration date. If found return touhtion sines,Office of Consumer Affairs ONTRACTORg 70 IMPROVEMENT C Office of Consumer Affairs and Business Reg K HOMEType: 10 Park Plaza-Suite 5 istration:. 418204 Private Corporation MA 02116 ��= Reg' Boston, Expiration: 21/312013 w. FAMILY POOLS&PATIOS INC i WILLIAM GIANOPOULUS � gam- Not valid without signature 70 S.BROADWAY Undersecretary LAWRENCE,MA 01.843 i ae i 10.8' WON Pkm Paneb o t. I-VPbd Pond 8�1-014 a ¢2'NRa Cu xrs 4Eb1-017 21RAD. 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RamYa�.K.dd.R mmr.Fo.dk a+ck,ik�pdbm:d.µadr 1 +uw.w�mina.+aa..i,,,.drnemm:s.ma�+alos nuv�d - fONfFW1'KElW{Sy QK `8ia aJtdsgPPen1a90° ,'e1o�Jarlais IJSPI CYPB if ,��;," �odm"md e��•a�exka ? NG wtfiesL a tsA � , .k�€W.LI�..a.n®b,,a..,mwmgy,...akJ.e+a;.°ia�°.d� fJ�500tbf•6IYl �..W.w+'uJ A..n.l � u...esta®Rwec,.,.m,e„y b+Rk9nK.1ma9.r°ir:.a`- •a.Bk:n 0 1 ..4+km°nd as rom5e 1. ro hw A1GOrCfi 9.B.u..dieaa ear d"n 'b .e9 iM°aad.oem,w9dra�i.d.y.p,e.��..,a nvur ueaf ��(�� ,-��,�” v� t.tvp.xw°{'�lahaa n.awdrq FSI..,kkad.ks�E on�kd - e 6"+v�w�Fv o-t.:E�aR�w•.�m�ss.ak�.oas wneJ ,ma }���t�y ewea�� .am aaoad.c..a„,� �"" Jw�fa'� raawnstasa Y R'E{TAKWR��AE31US { r ..�i�ntttamJ...R...;"w.,�,�xiat�M•""re.s.,l ORi y ✓Klly llk.GrlJGu U/lU lrla"rGU www.familypoolsonline.com �A_C 1-3 4rName f" ' y Date " Address �� ^U City State Zip O r 8 Home Phone - g3 7 3 Work Phone Cell ?2S /' K0 1 Add'I# Cross Street/Directions _ 1�n n .t� C Estimated Start Date Estimated Completion Date frZ Q, We propose to furnish and install one ,in _ gunite 3(aswimming pool for the sum of$ ( s-b ,I— THIS PRICE INCLUDES: �Y •Normal Excavation up to 8 hours on day of dig •Manual vacuum cleaner kit •Waterline Tile(6•) •Backfill and Sub-Grade up to 3 hours •3-Step stainless ladder •Liner Chace -7 A! •Underwater Whit6ttl;ht+2&Vofi•Rope and floats •Test Kit •Steel Reinforcing per Engineered Plans for gunite •Initial balancing chemicals •Surface skimmer(s) Z- •Steel Structure per Engineered Plans for vinyl •8 to 12 Wk supply of maintenance chemicals •Dual Main Dr?'y •Over-Flo Line for added protection (supply depends on pool size) •Coping- --��- - •Pressure testing of plumbing during construction •Leaf net •Steps •Ten Year Plumbing Guarantee(see specifications) •Wall brush •Handrails •Transferable Lifetime Structural Warranty •Extension pole •Filter Tl� _ (plumbed no more than)58 from pool) •Pump&motor THIS PRICE DOES NOT INCLUDE: •Any plumbing over 25ft from pool.Additional runs are not recommended but would be at a cost of$ -Z'S' '� per foot per line. •Machine time in excess of that specified above.Additional machine time to be billed at$ 16'5— including machine,operator,and laborer,due with second pod payment. •All hours of trucking will be charged at$ :If per hour per truck due with second pool payment. •Any dumping costs incurred for disposal of ledge,large rocks,garbage,stumps buried or otherwise,building materials,unsuitable or nonstructural soils,or any unforeseen material that must be removed. a •Removal of ledge or large rocks by way of a Starr bit,chipper,or blasting. •Additional fill,if necessary,for proper backfill or reshaping of hole,supply or spreading of loam,reseeding of grass. •Patio,fence,retaining wall,or any accessory items other than noted on contract. •Electrical wiring,fuel connections,heater venting,fuel storage tanks or permits. •Repair or replacement of sprinkler systems or any buried items such as well lines,drywells,leach fields,electrical lines,cables,etc.that are damaged during construction. •Costs due to water or soil conditions(ex.clay,peat,live sand,excessive rock,etc.)requiring a stone pack of the hole.The stone pack will be at an extra charge of$ minimum to $_ql maximum and at the discretion of the job supervisor.Additional machine time and/or materials necessary to rectify such a condition will be at a cost over an above the stone pack and will be quoted by the job supervisor. •Water to fill pod. Initials CUSTOMERS MUST SUPPLY: •Access for all trucks and equipment •Building and Electrical Permits or assume the costs necessary to obtain such permits. •Water and electric necessary for construction of pool •Customer must water cure Gunite shell for 7 to 10 days If applicable. •Water to fill pool immediatelyuponinterior finish I l L / ( L 1 l �( NOTES: 6 l al _ d C1 171 cvlej I G� 4a c fit e-G,�r�. �,k ( S) ('. • —c-r4-c� Ib F,o>M 'e CIO L-4 OPTIONS: TOTALS: Diving Board Solar Cover ) /.X-y Basic Pod Price $ a Additional Pool Lighting �( ,UP2(UJ ) Options $ TZ ZJ Heater 000 ( ) Environpool Plus,8 hd+2 surface ( ) SU OTAL $ °Z 3a 7d Additional Floor Heads ( ) —brfkSalesTax $ Polaris Vac-Sweep ( ) � Polaris retrofit only ( ) TOTAL $ cP-3-79 1 Swimout/Bench ( ) Interior Finish ( ) — Less 10%Deposit r Spa Automated Control System Salt Chlorine Generator (t•'`�j ` �, _ Other n.vueetTc....-,tf-%t-,y AVAT10N . ....., 113 BACKFILL'+F EXTRAS 113 SYSTEM START-UP UU IOIII-Vu. Removal of ledge or large rocks by way of a Starr bit,chipper,or blasting. Additional fill,if necessary,f0sproper backfill or reshaping of hole,supply or spreading of loam,reseeding of grass. Patio,fence,retainLrig-wall,or any accessory items other than noted on contract Electrical wiring,fuel connections,heater venting,fuel storage tanks or permits. Repair or replacement of sprinkler systems or any buried items such as well lines,drywells,leach fields,electrical lines,cables,etc.that are damaged during c struction. minimum to Costs due to water or soil conditions(ex.clay,peat,live sand,excessive rock,etc.)requiring a stone pads of the hole.The stone pack will be at an extra charge of i $_�maximum and at the discretion of the job supervisor.Additional machine time and/or materials necessary to rectify such a condition will be at a cost over an above the stone pack and will be quoted by the job supervisor. •Water to fill pod. _Initials CUSTOMERS MUST SUPPLY: •Access for all trucks and equipment •Building and Electrical Permits or assume the costs necessary to obtain such permits. •Water and electric necessary for construction of pod •Customer must water cure Gunite shell for 7 to 10 days H applicable. •Water to fill pool immediately upon interior finish L n ( NOTES: f1 c�6 - r 1 6'V�r?J( ( A c vi e e_66-J, IJ OPTIONS: TOTALS: .._ Diving Board ( �� I ( ) / Basic Pool Price $ Solar Cover / ,, ''n / ) 5Z7 t) Additional Pod Lighting ��4 LA Nom"C ) Options $ Heater U ( ) — W SU TOTAL $ a 30 70 - Environpool Plus,8 hd+2 surface ( ) ii 12-1 Additional Floor Heads ( ) Sales Tax $ 7 I Polaris Vac-Sweep ( ) '��' TOTAL $ Polaris retrofit only ( ) Swimkwt/Bench ( ) _ Less 10%Deposit $ �>LI� Interior Finish Spa - 1 Balance of Contract $ Automated Control System ( ) a / Sall Chlorine Generator ( �r ) w �' l� � `i Other PAYMENTS: 113 EXCAVATION 113 BACKFILL+EXTRAS 113 SYSTEM STARTUP The buyer hereby agrees to pay, in full,the total amount of this transaction upon start-up of the installed pool.Your salesman or job supervisor will meet with you prior to excavation at which time all decisions including pool size,shape,elevation,liner print,and all options must be final.Changes after this date will be subject to extra charges,where applicable,and will result in unavoidable delays.You,the Buyer,may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.Credit card payments not accepted on con act amount. �wBUYER date l� ILA- SELLER date CO-BUYER date The Commonwealth ofMassachusetts ,,• � I Department oflndustrialAccidents Ii Offtce of investigations 600 Washington Street Boston,MA 02111 L . www.rnass:gov1dia Workers' Compensation Insurance Affidavit:Builders/Contractors/FIecfriciaus]Plumbers Applicant Information yy^^ Pease Prinf:Legibly Name(Business/Organizati-on/Individual): Address: �0 City/State/Zip: � . Q( kYPhone '7 - [EIT n employer?Check the appropriate box: Type of project(required): a employer with �— 4. ❑ I am a general contractor and I T New construction loyees(full and/or part-time).* have hired the sub-contractors a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling and have no employees These sub-contractors have 8. ❑Demolifion ing forme in any capacity. workers'comp.insurance. 9. Building addition workers comp.insurance 5. ❑ We are a corporation and its ❑ g ired.] officers have exercised their 10.❑Electrical repairs or additions a homeowner doing all work right ofexemption per MGL - ILfPlumbing repairs or additions lf.[No workers'comp, c. 152,§1(4),and we have no 12.[]Roofrepairsance required] employees.[No workers' 13.0Other comp..i nsur ce an re u' ie • rd p q .] *Any applicant that checks box#I must also fli l out the section below showing their workers'compensation policy information. Idomeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors acid their workers'comp.policy information. X am an employer that is providing workers'compensation insurance for my employees. Below is gie policy and job site information. Insurance Company Name: �s Policy#or Self-ins.Lic.#: 12-i S'_(, Expiration Date: Job Site Address: ' �% C-O c%�"� ��(,C �� City/Sfate/Zip: !1�1 (�16 ' "'� . Attach a copy of the workers'co pensation policy declaration page(showing the policy number and expiration date) Syr 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby ceitify under the pains and enadties ofpefjuiy that the infor madon provided above is true and coli ect.' Si ature: Date: Phone#: Offeiad 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): X. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person• Phone#: Information and Inst uct'iOns 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 Iicensing 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 ofpublic work until acceptable evidence of compliance with the insurance requirements ofthis chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation'affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any.questions regarding the law or ifyou 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 pennit/lieense number which will be used as a reference number. Irl addition,an applicant that must submit multiple�permitllicense 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 pennit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOTrequired 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 C'olnm011Ww a1th of Massachusetts 1)eVartMQ111 of Industrial Aeoidws Office of Investigations 600 Washington Street Boston,MIA.02111 Tel.#617-72,7-4900 406 or 1-87.7 MhA.SSAFE Revised 5-26-05 Fax#61?-72'-7749' w.mass.govldia