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HomeMy WebLinkAboutBuilding Permit #248-13 - 73 LANCASTER ROAD 10/1/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION t I Permit NO: yA Date Received Date Issued: �b IMPORTANT:Applicant must complete all items on this page LOCATION} .73 PROF'ERT*OWNER :S13v4e<5 l avtGAav - P.rint' 10.0`;Y,e r,Old'Structure, yes-, no MAPINQ-., PARC:EL:-0_/7 ZONING'DIST�RICT:. :Histone Distract yes, m Machin&Shop Villages yes. no:; TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building KOne family ❑Addition ❑Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial KRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition [I Other ❑ Septic ❑1Nell p Floodplain} ' ❑1Netlandsy ❑ WatershedyDistrict' Water/.Sew,er s ` DESCRIPTION OF�O�TO BE PERFORMED: p (( e4�l�e� "/(�lwJocWS 4- Fix rca� ee� A 1 Identification Please Ty a or Print Clearly) OWNER: Name: es Phone: '',I '789 fl,� 92 Address: 73 4 wcas�mr CONTRACTOR Name: g w esYo s, :-n Phone: `�7 3 7�C�a - -n Address: !�/7 a G✓ Ai!e _ Todd 0- Su . _�$ T r Supe,rvisor's Construe#ion L'icense C S_ l} �a4736 7 Expt; Date: If 7113 Home Improve l 730 7(� 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: $ 12,000 FEE: $ ���/•®� Check No.: 62 6 Receipt No.: �2r76 2- contracting with unregistered contractors do not have access to the uaran and NOTE: Persons g g g tY.f nature:ofAgent/Ovvnei, i ~aturefof'contractor; Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ tamped 4ns 11 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 a Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or 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 o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance was ors special permit required the Town Clerks office mus t stamp the decision from the Board of Appeals P P 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 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 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 Signature COMMENTS HEALTH Reviewed on Signature COMMENTS 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 DPW Town]Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT Temp Dumpster on site yes no Located at'124,Main Street.- Fire treet:Fire Department signatu"reldate "} ' •_ < ' , COMMENTS -Y,.. ,:• I` Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: I ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No I DANGER ZONE LITERATURE: Yes No 1 MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use I i I ® Notified for pickup - Date i Doe.Building Permit Revised 2010 ..4 Location No. / Date 0 2 a • TOWN OF NORTH ANDOVER ,r Certificate of Occupancy $ Building/Frame Permit Fee $_Lo� Foundation Permit Fee $ Other Permit Fee $ - °��°�•����' TOTAL $ Check# cir� r '' 25762 Eruilding Inspector .0 NORTH own oAndover No. h ver, Mass, r� COC NIC«l W,CK 1' 0RAT E c) U BOARD OF HEALTH Food/Kitchen PERM' .1T T D Septic System THIS CERTIFIES THAT ..........t2.5?A4!I,i'„�.,,,�© ................................ ............................ BUILDING INSPECTOR has permission to erect buildings on Foundation to be occupied as ....... . � . ,,r� G��; �/;, /,, Y Rough ./ i'.R::� �. ........ s, !. ... ![ .8.,.......................... Chimney 4g provided that the person accepting this permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Final 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIONS ATS Rough Service .................. 4B1_.L=ING INSPECTOR Final 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. SEE REVERSE SIDE Smoke Det. CONCRACT 9/12/12 LYONS DEVELOPMENT CORP 261 HYATT AVE. BRADFORD MASS,01835 PHONE/FAX 978-372-0262 CELL 978-479-8730 R' MR.& MRS.JIM YONCHgCK 73 LANCASTER RD. NORTH ANDOVER MA.01845 SCOPE OF WORK: REPLACE 3 WINDOWS ON FRONT OF HOUSE AND ONE IN THE SUN ROOM. INSTALL NEW DECKING AND RAILS TO EXISTING REAR DECK. ALL MATERIAL FOR WORK LISTED ABOVE TO BE SUPPLIED BY OWNER. LYONS DEVELOPMENT WILL SUPPLY LABOR ONLY AND REMOVE ALL TRASH TO MELLO TRANSFER STATION. PRICE FOR WORK LISTED ABOVE$6265.00 94, /YONS ----------------------------- ------- -----------DEVE PMENT DATE OWNER �.`.•. V2. O�IIY/YLfT92lUP,Q.G/.lZ Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR egistration: :173076 Type: xpiratibn: :.8/3 %21114 Corporation LYONS DEVELOPMEN7IQRP.�--- t JAMES LYONS 261 HYATT AVE BRADFORD,MA 01835 Undersecretary Massachusetts-Departmept of Public Safety Board of Building Regulatioeis-and Standards Construction 5upen-isor 1&2 Famil License: CSFA-047567 2 JAMES H LYOS nr� 261 HYATT AwE BRADFORDp M 01835 =. i JJ �, i � Expiration ornrnissioner 11/07/2013 ACORQ CERTIFICATE OF LIABILITY INSURANCE 09/28/2012' PRODUCER (978)373-5623 FAX (978)521-2751 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ANTHONY & MALCOLM INSURANCE AGCY. , INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 3 S0. CENTRAL ST. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. BRADFORD, MA 01835 INSURERS AFFORDING COVERAGE NAIC# INSURED Lyons Development Corp. INSURERA: Safety Insurance Company 33618 261 .Hyatt Ave. INSURER B: Bradford, MA 01835 INSURER C: INSURER D: INSURER E: COVERAGES 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,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONLTR INSR LIMITS GENERAL LIABILITY CP00002322 10/06/2011 10/06/2012 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000 PREMISES(Ea ncnurancp� CLAIMS MADE F—] OCCUR MED EXP(Any one person) $ 10,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 1-1 POLICY PRO LOC JECT 71 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F-1 CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU- OTH- ER EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS arpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Town of North Andover BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY Rte 125 OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Frederick Malcolm Jr./JA ACORD 25(2001/08) ©ACORD CORPORATION 1988 M[assac]husetts Home Improvement Sairr pie Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Name Company Name 73 LcLotcq OhS@Ue`o Street Address(do not use a Post Office Box address) Contr ctor/Salesperson/Owner N me City/Town State Zip Code Business Address(must include a street address) Daytime Phone Evening Phone Ci�tyf/Town I r State Zip Code Mailing Address(It different from above) Business Phone 017 F.3) 6 Federal Employer ID or S.S.Number Home Improvement Contractor Reg:Number Expiration date Law requires that most home 7,3©;76 7/ improvement contractors have 6 t0 I -lid registration nnmhcr The Contractor agrees to do the g following worts;for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) S�e Co H �7 Required Permits-The following building permits are required Proposed Start and Completions Schedule-The following schedule will and will be secured by the contractor as-the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their owes permits will be excluded from the Guaranty]Fumed provisions of MGL chapter 142A.) / /3d � Date when contractor will begin contracted work.iI t 1/1z Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,Auwk4t+�e T—m-teriai and labor specified above for the total sum of: fo 3 d t7 Payments will be made according to the following schedule: $ a70 0 b upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ _Z200 byI d l 3 0 l /I or upon completion of $ by / / or upon completion of $ ��5 t a6 upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) . The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be paid for NOTE,S:(*)Including all finance charges(")Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warrqnty-Is an express warranty being provided by the contractor?�No El-Yes(111 Perms of the warranty mast be attached to the contract) Subcontractors The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for alI payments to all subcontractors for materials and Iabor under this a Bement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. C Don`t be pressured into sighing the contract.Take time to read andflliy understand it. Ask questions if something is unclear.. 0 alce sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director ofHome Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at lO ParlcPlaaa,Room 517n�Doston�T�iiA 021 16--by call ing 6 t 9731­8'?o^o oo nog �rrS•r a Does the contractor have insurance? Ask the Contractor for his insurance company information so the you can confirm coverage,or aslc to see a copy of a"proof of insurance"document. e Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation erof this right DO NOT'SIGN TICS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of the contract must be completed and signed. One copy should go to the homeowner. The othe opy sholddbe]sept by the contractor. ,.� Homeowner's Signature C actor's Signa e Z 'Date ' Date Contractor A.rbit611on The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action.(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerningthis contract;the contractor may submit the dispute to a private arbitration f r-m which has been approved by � Y the Secret'asS'of the Executive Office of Consumer Affairs and Business Regulation and the cons-Lunar shall be required to submit to such arbitration as provided In Massachusetts General Laws,chapter 142A.. Homeowner's Signature Contractor's Signature MIOTIC):The signatures of the parties above apply only-to the agreement of the parties to alternative dispute resolution initiated by the contractor: The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A) and other consumer protection laws i.e.MGL chapter 93A may not be waived in an way, even by agreement. However,homeowners i P ) Y Y p ( b may be excluded from certain rights if the contractor they choose is not properly registered as prescribed y law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and worlananlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold-in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfiilly agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced c sections have been advised not to sip the document-until all blanl documents have been attached. Pax-ties are also gn filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to theoriginal contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the.payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of fiends from said account would require the signatures of both parties. Additional Information .If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Impiovement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the OCABRwebsite athitp-://ww,,v.Triass..gov/ocbrl If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Hone Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park.Plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the BIC website at bgp://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: ht-�..)://db.state.ma.us/b.omeimprovem ent/]icenseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business, calx: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 Version 2.1-11/22/2010 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 ,Washington Street Boston,MA 02111 UT. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): t-YQ hs los 0 e/��b b �✓ Ca'r� Address: ab l bfVa City/State/Zip: Aa 01&,36— Phone#: 979 3 2a 0ai�.2- Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. We area corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 3.El I am a homeowner doing all work g exemption right of per MGL 11.[]Plumbing repairs or additions p myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they 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.P Expiration Date: Job Site Address: City/State/Zip: 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. T do hereby certify unde he pains and penalties of perjatry that the information provided above is true and correct. Si nature: Date: Phone# `17g 3 )6t0 (o Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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. A new 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 evised 5-26-05 Fax#617-727-7749