Loading...
HomeMy WebLinkAboutBuilding Permit #1005-15 - 79 GLENNCREST DRIVE 6/3/2015 JJ4 1 ` BUILDING PERMIT NORTy O�ts0R ,6A'YO TOWN OF NORTH ANDOVER �� yt APPLICATION FOR PLAN EXAMINATION �V � `` X04 ey J M ^` Permit No#: Date Received � (15-/` � QDRg7ED I'PP '�� �SSAC HUS�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION -79 CA e.j e c*5} '::),r M . N Print PROPERTY OWNER ` -lad --�_`' r-ON 5 Print 100 Year Structure yes o MAP J C PARCEL: ar`'( ZONING DISTRICT: Historic District yes o Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 90ne family ❑Addition ❑ Two or more family ❑ Industrial ;!�-Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg 0 Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Wat /Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: c Contractor Name: Phone: 9"7-5— Email: i tc t Address: 5' (fin 1 e-+Q..J 5+rcc.I- Pao r Supervisor's Construction License: y'i I Exp. Date: Home Improvement License: oZ `� Exp. Date: tt , 1 q I I S- 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: $ f `( l� S FEE: $_� ' Check No.: dT Receipt No.: �� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Location :2 G,�Gi-cam No./v�� ' Date �J • - TOWN OF NORTH ANDOVER . Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $__ } Other Permit Fee $ TOTAL $ Check r� 15 Building Inspec r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOS Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY � INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed OnC�/6— Signature COMMENTSA�4���� jfp CONSERVATION Reviewed on Sic nature /:�j COMMENTS W,L- HEALTH Reviewed on Si nature COMMENTSG; &(Z— 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 SIRE DEPARTMENT Temp bumpster on site yes no Located at 124 Main Street Fire Department signature/date .COMIVIENffS 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 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 Call Email Date Time Contact Name Doc.Building Permit Revised 2014 I 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 a. Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract :r< Floor/Cross Section/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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) 4; 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 # 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 1 1 Doc:Building Permit Revised 2014 t%ORTH own of ? E ndover Q " - ' 0 No. �oLAKI h ver, Mass, qA COCHIC«ew.cw 0RATEO ►PP,`'�y S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System PolIC,t. CI.I?� .. BUILDING INSPECTOR THIS CERTIFIES THAT ......... ........... .... !.5................................................................. . Foundation has permission to erect .......................... buildings on ..�..... /.'.IG� T�....................... Rough tobe occupied as ..... ..............................:.............................................. chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in.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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO T S Rough Service ................................................................................ Final BUILDING INSPECTOR 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. TES TA Building and Remodeling Start date 6/15115 5 APPLETON STREET Finish date 6/30/15 NORTH ANDOVER, MA 01845 HIC Lic. 120296 Expires 11/19/15 (978) 682 2023 CSL Lic. CS 54718 Expires 618116 Proposal May 28,2015 Proposal Submitted To: Paul Tanglis Cell Phone: (978)390-1153 79 Glencrest Drive North Andover MA 01845 Job: New Deck 13x16 with a set of stairs Obtain building permit Complete removal of all demolition and construction materials generated By Testa Building and Remodeling and its subcontractors. DEMOLITION: Remove the current deck. CONSTRUCTION: Dig 3 holes and pour footings 4 feet deep. Remove siding where deck will be attached to the house. Properly flash the house. Frame a deck approximately 13'x16'. Attaching the deck to the house. Frame the deck with 2x10 and 4x4 posts. The decking will be River rock using the hidden fasteners. The railings will be white Radiance railing system. A landing and a set of stairs will come down along the side of the deck. A finance charge of V/2%per month(18%per year)will apply to all accounts over 30 days past due. In the event collection activity is required the customer shall be responsible for all costs associated with collection,including reasonable attorney's fees. I propose hereby to furnish material and labor complete in accordance with above specifications, for the sum of- -$ 14,508 Fourteen Thousand Five Hundred eight Dollars One-third to start, one-third after rough inspection, one-third upon completion. Authorized signature _g,,, I reserve the right to cancel this contract if not accepted in 30_days Signature 11 Signature DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES 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. (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work. MGL chapter 142A.) Expfess Warranty-Is an express warranty being provided by the contractor? No Yes(all terms of the warranty must 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 all payments to all subcontractors for materials and labor under this agreement. 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. •Don't be pressured into signing the contract.Take time to read and fully understand it.Ask questions if something is unclear. •Make 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 of Home Improvement Contractor Registration.You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. •Does the contractor have insurance?Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. •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 of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identic ies of th must be completed and signed.One copy should go to the eowner.The other cop ould be kept by the contractor. Homeowner's Signa Contractor's Signature Date Date Contractor Arbitration 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 concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provife Massachusetts General Laws,chapter 142A.�� Homeowner's Sign re Contractor's Signature NOTICE: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 any way,even by agreement.However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by 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 workmanlike 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 lawfully 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 documents have been attached.Parties are also advised not to sign the document until all blank sections have been 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 the original 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 funds 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 Improvement" 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 OCABR website at http://www.mass.gov/ocabr/ 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 Home 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 HIC website at http://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeimprovement/licenseelist.as For assistance with informal mediation of disputes or to register formal complaints against a business,call: 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 2.1-11/22/201 NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR OBLIGATION,WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU CANCELLATION NOTICE,AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELED. IF YOU CANCEL,YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED,ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY, IF YOU WISH,COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION,YOU MAY RETAIN OR DESPISE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO,THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO [Name of Seller],AT [Address of Seller's Place of Business]NOT LATER THAN MIDNIGHT OF (date). I HEREBY CANCEL THIS TRANSACTION. '"'s Date: Buyer's i y s S gn atur e. North Andover MIMAP May 29, 2015 10 4.0-00 45 104.C-0038 10.4.0-0039 104A 052 104:C-0097 ,04.C=004- 0,053/ 67 GLENNCREST DR 104.0-0096 104:C=0095 104.0-0054 79 GLENNCREST/DR R1 / 68 GLENNCREST D ater % 104 C�0061� WProtection � 20 SO.UTH,BRADFORD ST 8.7 GLENNCREST/DR 104:6-0060 104.0-0055 104.0-0•l0Y 100,GLENNCREST/DR 104.0-0056 99 GLENNCKr-ST DR104..0-005 104:0-0057 Rail Line t Wetlands Zoning Interstates O Exempt Lands Busine s 1 District— O Businw.s 2 DistrictHodzontal Datum:MA Stateplane Coordinate System,Datum NAD83, I — ■ Busine s 3 District Meters Data Sources:The data for this map was produced by Merrimack ■ Busine s 4 District NORTH Valley Planning Commission(MVPC)using data provided by the Town of Roads ■Gene Business District Ot ° �� North Andover.Additional data provided by the Executive Office of U Planner Commercial Dev +« �• O %7,Easements ? �� •� O Environmental Affairs/MessGIS.The information depicted on This map is O Cordd Development Dlst 3 _ L for planning purposes only.It may not be adequate for legal boundary MVPC Boundary O Condo Development Dist O definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER Municipal Boundary ■Cortido Development is h A MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING Industri I 1 Districts Zoning Overlay • ♦ THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY D Industd 12 District e Adult Entertainment • i y � ♦ OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT o C Industd 13 District Downtown Overlay Distinct �► o .K i ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF ©Historic District ■IndusM S District 0 Water Protection Reside ce 1 District tit�O�•.�o r•�t.(y THIS INFORMATION n Residei ca 2 District SSA�HUS� ❑Parcels o Roside ce 3 Distdd O Hydrographic Features de ce 4 Distdd 80 ft de ce5 Dist —Suaams 1"= dd de ca District .e a esidential Distdd North Andover MIMAP June 1, 2015 Nl eJ Its • I'ill .•e: �e � 5 i Interstates —I —SR Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, Roads Meters Data Sources:The data for this map was produced by Merrimack IkORTN Valley Planning Commission(MVPC)using data provided by the T—n of f Easements Or c �� North Andover.Additional data provided by the Executive Office of C)MVPC Boundary ? r��`CO Environmental Affairs/MassGIS.The infarmatiou depicted on this map is Parcels 3 _ L 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 # >f THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY • s ,± .� OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOF a► oma+ �� ♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION CMUSEt 1"=60ft -� r MORTGAGE INSPECTION PLAN LOCATION: 79 GLENCREST DRIVE 13-08622 CITY,STATE' NORTH AV Dlo jq,MA BOSTON APPLICANT' TANGUS B PAIS cFRnt=1�o ro. SURVEY, INC scAL��Inch= ubdmw so rear PREPARED: 07-20-2013 aA aox2mmMARLESroft VA 1 1 t: Rr12i W6.1 _ 116 ' t ap LOT 11 45,470 SF+f- DWK 18TORY 979 i , t t�Q GC�NcR'FST�RIV F FLOOD DBTHRMt MIMN gw P a. DEEDICER7' 10868a2 ppe on ensp ayabm �+ PLAN RE€: #4261 So]V X turn 1a,u��..�a,b.�r.v�c� ecmqlolompc- O4'�EFFBc�DA �N3 a4laasoo�ca�a4F anfC�LjrappW�°FH)mr.yaC.f_rf=tft[xrrdarui*Id Lr as/1LaKt'UO.rtfBottdorRerM+do°°D+o •ua �'N �atAvyu�aal+trolu31rod 3hhv� s.PL3 i i 00 4 Im � dk* r i The Commonwealth of Massachusetts F Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 e^M SJ. www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERAUTTING AUTHORITY. Please Print LeSibly Applicant Information q Name(Business/Organization/Individual): e'T 5 Address: le�� {� do y r /Y1 a o1By'phone 4: R Z V ^ G 9 City/State/Zip: No ti e Are you an employer?Check the appropriate box: Type of project(required); 1.Q I am a employer with employees(full and/or part-time).* 7. EJNew'construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. ®Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11. Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.0 Plumbing repairs or additions 5.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 14.❑Other-- 6,.F1 ther6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. homeowners who submit this affidavit indicating they aze 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Expiration Date: Policy#or Self-ins.Lic.#: 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 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. coverage certi under the painssaan'd penalties of perjury that the information provided above is true and correct Ido signature: �o-� Date: Phone#: (s Z 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-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 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"fob 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.)saiderson is NOT required p q d to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia _pepartment Of Public Safe" ! ' bus sul of buat-!ons and Standard's ilding Reg taard Sa en=isor Construction P License CS-054718/'Y JAMES M TESTA; SAPPLETON Sr" Ol$ ` ANDDVR . .� ey 'pirgdJon y�5 IiA 0610812016 Co"Unissioner ��c�+�7L717a97{U(fClflYl,a���,7rddcr,�ttdr�✓.I.� �ce�f��onsumet A'('f`a�r3�&'Bus�ness R�gul`a�ibn NIPRO� ENT�CsQ�1TR�C�Q�3 gigs tion: I 296 T1!Pe zFation; 11 0 5' CUBA TEES .` � i&` Afi71ffiS SaT Nj",-WJ7 i A1Q,I'846 finder ecret ry