HomeMy WebLinkAboutBuilding Permit #080-2017 - 73 LANCASTER ROAD 7/25/2016 s
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✓�IJ�1� AA 4 TOWN OF NORTH ANDOVER
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APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
�9SSACNUS��
Date Issued:QR 25 Lolh
IMPORTANT: Applicant must complete all items on this page
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LOCATION l AOC-ASl els ROA NOR,114 4jo�1VE1,
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PROPERTY OWNER S1H J- AIPL.E& Votr-OAK
Print
MAP NO.: PARCEL: ZONING DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DISTRICT YES
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non-Residential
❑New Building ❑ One family
0 Addition ❑ Two or more family ❑Industrial
❑Alteration No. of units:
Repair,replacement ❑Assessory Bldg ❑Commercial
0 Demolition
0 Moving relocation ❑ Other ❑ Others:
0 Foundation only
DES RIPTION OF WORK TO BE PREFORMED 2,Vftak
r¢ ace M *- ct� -,W\ Ch. ew
Identification Please Type or Yrint Clearly)
OWNER: Name: G� 1�✓I ( ' bV 1C/�U��-- Phone.-
dress:
CONTRACTOR
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CONTRACTOR Name: hl_ �iCG�S Phone: 781 7 60 2031
Address:
W064 (\
Supervisor's Construction License: Exp. Date:
Home Improvement License: ` CS' 6 I Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED $125.0B-ELR S.F.
Total Project Cost :$ 25, DI 5 " x12.00=FEE:$
Check No.:--.6w Receipt No.:
Page 1 of 4
Location
No. Z01-
TOWN
vtTOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $L�
Foundation Permit Fee $
Other Permit Fee
TOTAL $ •
Y
Check#�42
1
3 U 6 S 9 �` Building Inspector
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NORTH,
BUILDING PERMIT ' °F �`Eo rbgtio
TOWN OF NORTH ANDOVER o
APPLICATION FOR PLAN EXAMINATION 4
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Permit No#: Date Received ��sS CHUS���S
Date Issued:
IMPORTANT:Applicant must complete.all items on this page
LOCATION.
Print
PROPERTY OWNER
Print 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential f
❑ New Building ❑ One family
11 Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement- ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
O'ySeptic' ❑,Well: =r❑Floodplain, ;�Wetlands'`' ,, ,❑ Watersheist�ict
y
,..`s `4 ��,,. c ...h - .�G ,r' r- 1 ^ ; a,r, �„} -•" 1r 't
L`®:Water/Sewer-- -- -?: '� S" '- s _< _..ire�,� ,�..'�k �
_DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License: Exp. Date:
i
Home Improvement License: Exp. Date:
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: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Vol
Signa PrP of AaPnt/Owner Signature of contractor
— - ------- s -- —--- '
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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 Permit
Building Permit Application
4. 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
OTE: All durnpster 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 of H.I.C. And C.S.L. Licenses
Copy Of Contract
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable) I
Mass check Energy Compliance Report (If Applicable)
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Depa-tment prior to issuance of Bldg Permit
New Construction (Single and Two Family)
Building Permit Application
Certified Proposed Plot Plan
T Photo of H.I.C. And C.S.L. Licenses
Workers Comp Affidavit
I
Two Sets of Building Plans (One To Be Retu ned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Copy of Contract
2012 IECC Energy code
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Depament prior to issuance of Bldg. Permit 7
I
In all cases if a variance or special permit was required the Town Clerks office ust stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the egistry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc:Building Permit Revised 2014 I
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 Dunipster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
i
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
v
Planning Board Decision: Comments
CcInservation Decision: Comments
Water & Sewer Connection Driveway Permit
DPW Towyn Engineer: Si na
� Signature:
Located 384 Osgood Street
FIRE DEPAR-TMENT - Temp Dumpster on site yes. . . no. .
Located at 124 Main Street
Fire Department signature/date
COMMENT _
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 I No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department arse)
I
f
® Notified for pickup Call II mail
Date _ Time Contact Name
Doc.Buildinab Permit Revised 2014
Enter construction cost for fee cal- North Andover Fee Calculation
Construction Cost
$ 25,015.00 m
$ - $ 300.18
Plumbing Fee $ 37.52
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 37.52
Total fees collected $ 475.23
73 Lancaster Road
080-2017 on 7/25/20116
Mater Bath Remodel
NORTki
own of 2 ndover
O - 0
Z
LAKE
o h � ver, Mass, 04 f��► W��
COCHICNI WICK
A�RATEO I•P��.(�
S U BOARD OF HEALTH
PERMIT T Food/Kitchen
LD Septic System
THIS CERTIFIES THAT .. �•• ��t... �! �.��. ......... BUILDING INSPECTOR
Foundation
has permission to erect .......................... buildings on ... ....G,+�l'�1/..rr Tom,/ •••• •• •••-•.• • ougn
to be occupied as
to.;056.. Chimney
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provided that the person accepting this permit shall in every respect conform to the terms of the applicationCA& Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration an
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERM17 EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTR ION S Rough
Service
.. .. .. ... .... ....... Final
BUILDING PE OR
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.
Page 1 of 6
Nexus II Carpentry and
Construction Design
P.O. Box 2823
Woburn,MA 01888
781 760 2031
Fax 978 975 1263
marknnextisearpentry.eom
wvww.nexusearpentrv.com
CS#-073991
MC#129177
Contract
This is a contract between James and Kathleen Yonchak of 73 Lancaster Road,North
Andover MA 01845 (Hereafter referred to as the "owners"or"owner") and Nexus II
Services (hereafter referred to as "Nexus") dated June 8th 2016.
i
GENERAL SCOPE OF WORK DESCRIPTION
WE HEREBY SUBMIT SPECIFICATIONS AND CONTRACT FOR: work as stated
below for bathroom and basement work
Scope of work:
General details
♦ Meet with local building official and apply for permits
e All work will be in accordance with local building code regulations and will be
inspected by local officials prior to continuing with the next phase—Nexus will be
responsible for arranging and being available for all inspections
♦ All work will be coordinated directly between"owners", architect if required and
Nexus
♦ Nexus confirms that it is licensed, insured as required and ensures any sub-
contractors utilized on this site will have the appropriate insurance coverage
♦ Nexus will be responsible for the safe storage of all its property and any materials to
be used on the site. Any items left on site will be covered under Nexus insurances
Owner is responsible for removal and return where necessary of all items within the
work area and their safe storage prior to our work commencing
e Owner will then be responsible for returning all items to the area after completion of
the scope of work
SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND
PROJECT MANAGEMENT
Page 2 of 6
♦ Nexus will remove all trash associated with this project into a Nexus supplied
dumpster and arrange for safe disposal in to a registered site—if required
♦ Nexus will contact Dig Safe" and confirm all utilities location—if required
Scope of work- master bathroom;
e Provide onsite dumpster for the duration of the project
♦ Remove and trash the existing light in cathedral ceiling,tile floor, tile from walls
around existing tub, 2 wall units, existing shower stall, 2 sinks with faucets and 1
counter top
e Remove and SAVE existing toilet
NOTE: existing vanity cabinet to remain in place
NOTE: New counter top to be templated and installed by "others"
♦ Furnish and install framing to create a new shower stall approximately NOTE: frame
a seat into the shower stall
♦ Furnish and install rubber pan to base of shower
e Furnish and install plumbing to code inclusive of shower "head", and a hand held
shower spray NOTE: fixtures including valve to be supplied by "owners"
♦ Furnish and install 1 vapor barrier light over new shower stall
♦ Install (one) customer supplied light fixture into the existing feed in cathedral ceiling
e Install tile and grout supplied by owners to the floor of the new shower and the walls
of the new shower NOTE: we recommend a piece of granite is used as the top of the
new seat in the shower-this should be supplied and installed by your granite
company and should be installedP rior to the tile walls being installed
♦ Install threshold supplied by customer to entry to shower
♦ Install tile and grout supplied by the customer to area around the existing tub
♦ Make compound repairs to the wall above the vanity
e Install sinks, faucets,toilets and fixtures supplied by owners
e Prep then paint the existing vanity cabinetry- exterior only NOTE: no painting
included for the interior of the cabinet box NOTE 2: the door and drawer fronts will
be painted "all sides"
♦ Prep, inclusive of removing the wallpaper,then paint the walls, ceiling and existing
trim to colors advised by owners
♦ Proposed cost including materials and labor as noted above is $15, 550.00
Scope of work-full bathroom;
p ,
NOTE: New counter top to be templated and installed by"others"
e Remove counter top, sink and faucet
♦ Install sink and faucet provided by "owners"
♦ Prep then paint the existing vanity cabinetry- exterior only NOTE: no painting
included for the interior of the cabinet box NOTE 2: the door and drawer fronts will
be painted "all sides"
♦ Proposed cost including materials and labor as noted above is $490.00 including
materials and labor
SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND
PROJECT MANAGEMENT
Page 3 of 6
Basement protects
♦ Bedroom;
♦ Paint walls,trim and doors to colors chosen by customer- $800.00
♦ Ceiling tile swap to Armstrong#1205 utilizing existing 2'x 2' ceiling grid - $990.00
♦' Bathroom;
♦ Primer,then paint walls,trim and doors to colors chosen by customer- $630.00
♦ Ceiling tile swap to Armstrong#1205 utilizing existing 2'x 2' ceiling grid - $410.00
♦ Living area including hall to stairs;
♦ Remove existing ceiling grid system and install framing to box in duct work
♦ Furnish and install strapping to accept new sheetrock ceiling system choosing highest
elevation around existing pipes etc.
♦ Furnish and install sheetrock with smooth plaster finish to strapping and new
framing- $2, 670.00 for these 3 items above
♦ Remove existing light box and install 2 x 5'recessed cans on existing switch-
$450.00
e Furnish and install blocking to wall to support TV bracket, install an outlet and cable
outlet- $465.00
♦ Primer, then paint ceiling,paint walls, trim and doors to colors chosen by customer-
$2, 000.00
e - Staircase;
♦ Primer, then paint walls and trim to colors chosen by customer- $560.00
The above quotation does not include the cost of any of the following and in some
cases where stated allowances have been given to assist you in selection. If
requested,we would be happy to provide any costs on items listed below, if not here
stated;
Permit costs (these are repairs so there should not be permit fees), unseen conditions,
and architect or engineering costs
Painting or staining or prep work beyond specifically noted in the scope of work above
Upgrades to existing utility conditions or structure
moving of personal property
Asbestos remediation of any kind
Fixtures and fittings including shower heads and valves,
Granite counters,
...Tile and grout,
Glass shower doors,
upgrades to any existing utilities,
changing out any existing trim pieces of the existing tub(you were going to show
Diane at PeabodySupply aphotograph to see if this can e
pp Y b done?)
SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND
PROJECT MANAGEMENT
Page 4 of 6
All material is guaranteed to be as specified.All work to be completed in a workmanlike manner according to standard practices.Any
alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an
extra 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 insurance.Our workers are fully covered by Workman's Compensation Insurance.
PERMITS
"Nexus"has accepted the responsibility to obtain the necessary building permits."Nexus"will act as a GC and work in
accordance with fair and reasonable practices,and cooperate fully and under the guidance of the"Owners"and
authorized parties.
Standard Exclusions:
Unless specifically included in the"General Scope of Work"section above;this agreement does not include labor or
materials for the following work(any Exclusions in this paragraph which have been lined out and initialed by the
parties do not apply to this Agreement): Removal and disposal of any materials containing asbestos or any other
hazardous material as defined by the EPA. Custom milling of any wood for use in project. Moving"Owners"property
around the site. Labor or materials required repairing or replacing any"Owners"-supplied materials. Repair of
concealed underground utilities not located on prints or physically staked out by"Owners",which are damaged during
construction. Surveying that may be required to establish accurate property boundaries for setback purposes(fences
and old stakes may not be located on actual property lines). Final construction cleaning("Nexus"will leave site in
"broom swept'condition). Landscaping and irrigation work of any kind. Temporary sanitation,power,or fencing.
Removal of soils under house in order to obtain 18 inches(or code-required height)of clear space between bottom of
joists and soil. Removal of filled ground or rock or any other materials not removable by ordinary hand tools(unless
heavy equipment is specified in scope of work section above),correction of existing out-of-plumb or out-of-level
conditions in existing structure. Correction of concealed substandard framing. Removal and replacement of existing
rot or insect infestation. Construction of a continuously level foundation around structure(if lot is sloped more than 6
inches from front to back or side to side,"Nexus"step the foundation in accordance with the slope of the lot). Exact
matching of existing finishes. Repair of damage to roadways,sidewalks,or driveways that could occur when
construction equipment and vehicles are being used in the normal course of construction.The"Owner'is to enter into
contracts for all of the above-mentioned services and provide direct payment to"Nexus"for a]I of the services we are
to provide."Nexus"will be responsible for removing all components and all construction materials relevant to the
"scope of work"in this contract.
Dumosters,trailers and signs
"Nexus'will provide as included in the cost of this project,a dumpster for the sole purpose of the removal of trash
associated with this project.This dumpster should not be used by any persons for any other waste items or for any
purpose outside of the specific use under the scope of work,unless authorization is received from"Nexus".Nexus may
have on site for part,or the whole of the project,a trailer containing materials and tools belonging to"Nexus'.This
trailer will be parked in a position agreed to in coordination with the"Owners"and will be covered under the
insurances of'Nexus"at all times."Nexus"will have on site,a sign,with our contact details,in the event that anyone,
including your neighbors,has a need to contact us directly.
Photographs
"Nexus''reserves the right to,from time to time,take.photographs of the contracted work for use in its general
marketing or for production on its web site.At no time will"Nexus"share any personal contact details of the"owner'
for any photographs that it may use without seeking authorization from the"owner".
Warranties
All the components supplied by"Nexus"as part of the original order are covered under the warranty exercised by
"Nexus"and supported by the vendors or sub-contractors.All labor and materials purchased from other suppliers to
achieve completion of contract are warranted(1)one year from completion of the construction.
Owner appointed sub contractors
From time to time an"owner"may request that we incorporate a sub-contractor of the"owners"choosing on a project.
"Nexus"will facilitate this request provided the assigned sub-contractor is connected directly with"Nexus"for all
scheduling requirements and"nexus"will manage this sub-contractor in a fashion comparable with any other sub-
contractor.All sub-contractors must be licensed and insured in accordance with State law."Nexus"will meet with
these sub-contractors and will ask them to submit a written proposal of all the work that will be included which
Nexus"will then confirm with the"owner"."Nexus"will oversee this scope of work and ensure that it is completed in
a professional manner but the sub-contractor will be responsible for any future warranty issues directly with the
"owners".All sub-contractors are responsible for the safe and clean upkeep of the working environment and will be
responsible to remove their associated trash on a daily basis.
SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND
PROJECT MANAGEMENT
Page 5 of 6
Deliveries
"Nexus"will be responsible for the safe arrival to site of all materials required for construction purposes for items
contained within the scope of work.The"owners"shall be responsible for the safe arrival to site of other items outside
of construction materials,however,should"owners"require"Nexus"to collect and bring to site,any of these items,
"Nexus"will accommodate as able and add a minimal cost to cover time and fuel to a change order.
Weather Delays
Nexus has made provision to attend the site throughout the project,and as weather allows—any changes to this
schedule will be advised to the client as appropriate.Inclement weather,inclusive of hurricanes,tomado's,snow storms
and other events,will affect the ability of Nexus to attend the site,and will therefore affect the ability of Nexus to
perform those tasks assigned within this contract.In the event of an unplanned weather event,it is the responsibility of
the"owner'to ensure that access to the site is maintained,so as to allow for work to recommence as soon as possible.
Personal Property,Pets and Children
"Nexus"will be respectful at all times,of the personal property of the"owners''but does ask that all personal items be
removed by the"owners prior to commencement of the scope of work and not returned to the area until the scope of
work is complete.It is the responsibility of the"owners'to make alternative arrangements for the safety of any pets
that dwell in the residence or facility,and"Nexus"will not be responsible for the care of these pets,or other live
animals,during the duration of the scope of work.Children living in the residence or facility,should be advised by the
"owners"of the dangers connected with construction projects and the need to stay clear of the areas being worked
upon,as well as away from any tools that will be on site.
Allowances with the contract cost
Within the cost structure of this contract,certain cost allowances may have been given for the"owners"to purchase
items chosen by them—these allowances will be noted above with the amount allowed clearly noted.If the"owners"
do not spend the full allowance in an area,this amount will be credited back to the customer and not included in the
final contracted amount.If the"owners'spend beyond the allowance noted,then the"owners"shall be responsible for
this balance and a payment made to cover this amount either to the vendor,the sub-contractor or to"Nexus'
Expiration of this Agreement:
This Agreement will expire 30 days after the date at the top of page one of this agreement if not accepted in writing by
"Owners"and returned to"Nexus"along with the necessary deposits within that time frame.
People Authorized to Sign Change Orders:
Q g
The following people are authorized to sign Change Orders:
"Nexus": Mark Gotobed or Ged White
"Owner/Owners": Jamdor Kathleen Yonchak
Concealed Conditions:
This Agreement is based solely on the observations"Nexus"was able to make with the area in its current
condition at the time this Agreement was bid. if additional Concealed Conditions are discovered once
work has commenced which were not visible at the time this proposal was bid,"Nexus"will stop work and
point out these unforeseen Concealed Conditions to"Owners"so that"Owners"and"Nexus"can execute a
Change Order for any Additional Work.
SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND
PROJECT MANAGEMENT
i
Page 6 of 6
Changes in the Work:
During the course of the project,"Owners"may order changes in the work(both additions and deletions).
"Nexus"will determine the cost of these changes and the cost of this additional work will be added to
"Nexus"profit and overhead.
Schedule of work
It is agreed by both parties that this work will be coordinated with the"Owners"and"Nexus"to be
undertaken in various stages to avoid complete disruption of the home environment."Nexus"will
give"Owners"no less than 2 days notice prior to arriving on site for commencement of any of the
agreed stages of work to allow"Owners"to prepare."Owners"commits to have sites identified for
construction work available for start at the beginning of the scheduled day so as to avoid any
unnecessary delays.
Contract Cost and Payment Schedule: tJ3 �
Total cost of work description and materials included in the proposal(except
materials/work stated) - $25 015.00(Twenty Five thousand,zero dollars and zero
cents)
G
PAYMENT SCHEDULE
1st Payment due upon signing this contract 1
TOTA $7, 500.00
2nd Payment due upon Installation of framing
TOTAL $7, 500.00
3rd Payment due upon Installation of ceilings
TOTAL$7,500.00
Final payment due upon completion of scope of work
TOTAL $2,515.00
Amount due upon signing this contra .500.00 J
\o
I have read and understand, and I agree to, all the terms and conditions contained
in the proposal above.
Date1 .!'6........ "Nexus"Authorization.................
.� . .................F..............
Date... �. JQ JJY......... "Owner/Owners"Authorization..1-aa�'`'� ' . °.. ........
AND/OR
Date............................... "Owner/Owners"Authorization.....................................................
SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND
PROJECT MANAGEMENT
The Commonwealth of Massachusetts
Department ofI><dustrialAccidents
I Congress Street,Suite 100
d Boston,MA 02114-2017
www.mass.gov/dia
Workers,Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FMED WITH THE PERMITTING AUTHORITY-
APPMeant Information Please Print Legib
Name(Business/Organizationffndividual): IBX
Address: 3 C:rL&OAtZ Dpi vt *49es MA 01"k 3
City/State/Zip: Phone#: �� 9 Ito - 203 D
Are you an employer?Checktlie appropriate box: Type of project(required):
1.❑I am a employerwith ! employees(full and/or part-time).* 7.. 0 New constiuetion
I
am'a sole proprietor or partnership and have no employees working for mein Remodeling
any capacity.[No workers'comp.insurance required.] ,
9. Demolition
3.FJ I am a homeowner doing all work myself[No workers'comp.-insurance required.]
Building addition
4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole1. Electrical repairs or.additions
proprietors with no employees. 12. Plumbing repairs or additions
5111 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.'0 RObf repairs
These sub-contractorshave employees and have workers'comp.insurance.t
' ' 14.[]Other
6.FJ We are a corporation and ip officers have exercised their right of exemption per MGL c.
re
152,§1(4),and we have no,employees.V9 workers,comp.p insurance required-]
] ,
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who suliiaif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that checkthis box must•attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees.'1f the sub-contractors fiave employees,rliey must provide their workers'comp.policy number.•
I-am an employer that ispiovidingworkers'compensation insuranceformy employees.'Beloiv is thepoN4 andjob site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: 1'PT '�`�0 �b(Z1 Expiration Date:
Job Site Address:
3 L ACAS l€� � City/State/Zip: NY-1 H 440�
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance
coverage verification.
Ido hereby certify un thepa" d p -'e erjury that the information provided above is true and correct
Signature: Date: 2,5 4
Phone#
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): i
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector
6.Other
Contact Person: Phone#:
i
IuformMion and Instructions '
Massachusetts General Laws chapter 152lrequires 4 employers to provide workers'compensation forthei�employees.
L
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 enferprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnjrship,association or other legal entity,employing employees. However the
owner of a dwelling house having not mofe 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 commonvXealth 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)names),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 cry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. B e advised that this affidavit may be submitted to the Department of•Iindustrial
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 apjlication for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law ox 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 eveTnt 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. Iu 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 unde'•"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 ob�aining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Dgpartment of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA.02114-2017
Tel. # 617-727-4900 ext.7406 or 1-877-AIASSAFE
Fax#617•-727-7749
Revised 02-23-15 www.mass.gov/dia
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TYPE OF SEWERAGE DISPOSAL Swimming Pools ❑
Public Sewer
F1Tanning/Massage/Body Art ❑ g
Well F1Tobacco Sales ❑ Food Packaging/Sales [I
Permanent Dumpster on Site F1Private(septic tank,etc. F1 Permanent
Meter location to
project
NOTE: Persons contracting with unregistered con actors do not have access to the guaranty fund
Signature of Agent/Owner ignature of contractor l
Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF-U FORM
DATE REJECTED DATE APPROVED
PLANNING&DEVELOPMENT ❑ ❑
[]Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
COMMENTS
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DATE REJECTED DATE APPROVED
CONSERVATION ❑ ❑
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑
COMMENTS
Zoning Board of Appeals:Variance,Petition No:
Zoning Decision/receipt submitted yes
j Planning Board Decision: Comments
Conservation Decision: Comments
Water&Sewer connection/Signature&Date Driveway Permit
Temp Dumpster on site yes—no— Fire Department signature/date
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