HomeMy WebLinkAboutBuilding Permit #396 - 83 BUCKINGHAM ROAD 11/4/2011 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received
Date Issued: /
IMPORTANT:Applicant must complete all items on this page
LOCATION P-2, uC .�ufJ�✓►
Pint
PROPERTY OWNER C ZitlAe. We'1 19 A.2n.�7 Unit#
// Print
MAP NO: / PARCEL: Z ZONING DISTRICT: Historic District yes
Machine Shop Village yes6
100 year-old structure yes no
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
T:-�� ,n°'�&`:�`,Jf'im�' ^'"`*M va gut -"^F-.l€� r$ { ,<-o.€-��^`T` "+'.�,�-w �.',e;,y.o ,F•'s;z x•�""°�'�"s_:;i x `7 ate;-.. .+ » -- as
Se tic ❑Well 7 ¢�., � �. �. F �,. �:
p � t .,❑Flood lain ❑Wetlands ,.�
. =�u wed Dishy cwt
x 7-
{ a
DESCRIPTION OF WORK TO BE PERFORMED:
eqenz ve x�SiiNG c��d,�� S/.>,��les sic 0 L.44lL z'.usi�LL �e,erA.viP�a�
_yitivL s;�l�u� EaTrlee NIOL4e. ReP/4ce 7_lARae �i,�d�ycys cufTti l�A.�P/trPNGn�I�s
(Identification Please Type or Print Clearly)
OWNER: Name: C C/9 Ile e 14P A m ANN Phone:
Address: V. KlNRA19rn 4)0-d
CONTRACTOR Name: ,fie fS �,.; 6::- Phone: 9 gid'
Address:
Supervisor's Construction License: ? 51(p Exp. Date: 7-%0-2c i3
Home Improvement License: /a/IF 5/6 Exp. Date: 6-2�P,,-zoi2
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.,BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ 00�
FLEE: $ 9Y
Check No.
M1.
-Recei �-'
pt No.
NOTE: Persons contracting with unregistered contractors do.not have access to the g my fund
Signature of Agent/OiNner r ._ Signature of contractor :'
Location e � °
No. Date
of NORTp TOWN OF NORTH ANDOVER 'S
F A
Certificate of Occupancy $
717�°+•sus•�,�'�
Ss+CHUS Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
�TOTAL $
Check # ljrL/
r,
2471
to Building Inspector
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
,1
Conservation Decision: Comments
Water& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Ter fjUD—um—psTe—r,s`iite- yes- " no
Located at 124 Main Street
Fire Department signature/d,to
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
U Notified for pickup - Date
Doc:.Building Permit Revised 2011 June/mi
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
MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Perm
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/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)
❑ 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
NORTH
Town of _ Andover. .
No. 3 CP b
"to/.Z _
To , over, Mass-J1 ,q4
1" Q t- LAKE
�A COCHICHE ICK
ORATED DQ tl�Cl
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT..............�..�..�'s '�'.M'�'.�!1► 1! •••••••
.......................... ..................:.... .................................................... Foundation
has permission to erect........................................ buildings on ....�3.......... .!!M ..................... Roujh
to be occupied as.... .' 'r .....�'�'O�.Y�.�... '..... 1!^ �. .1 ..... �I.... ......
provided that the person accepting this permit shall in every respect conform to the terms of Ell
plicion 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 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTI ARM'S Rough
.................................................................................................
Service
BUILDING INSPECTOR
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.
Smoke Det.
SEE REVERSE SLOE
i
'I sli
sniner Affairs&BJsiuess e911120�011
HOME IMPROVEMENT CONTRACTOR
Registration: 1101846 Type:
— Expiration: -6729!2012 Individual
S EN M.KEISLING ' ;4
Stephen,Keisling -_' xr
9 NINTH STREET
SALISBURY,MA 01952 Undersecretary
N9assachusetts- Department of Public Safety
Board of Buildim-,Re-ulations and Standards
Construction Supervisor License
License: CS 27489 .— ---�
STEPHEN M KEISLING
9 9TH STREET WEST
SALISBURY, MA 01952 �.
Expiration: 7/16/2013
Commissioner Tr#: 19624
FARM FAMILY CASUALTY INSURANCE COMPANY
Issuing Office - P.O. Box 656 • Albany, New York 12201-0656
CONTRACTORS ADVANTAGE BOP000slssos
® DECLARATION PAGE
Policy Number: 2005XO431 Agent No: 3485 Agent Phone: 978-887-8304
UGONE JOHNSON INSURANCE AGENCY . IN
7 GROVE ST STE 201
TOPSFIELD MA 01983-1862
Name and Mailing Address of First Named Insured:
STEPHEN KEISLING
99TH STW
SALISBURY MA 01952-1702
The Insured is: INDIVIDUAL
Transaction Type: RENEWAL Transaction Effective: 03/21/2011
Policy Period: From 03/21/2011 To 03/21/2012 12:01 A.M. Standard Time
Business Description: CARPENTRY
Total Limit of Liability Term ADDL/RTN
Premium Premium
Business Property Coverages -
Buildings
Business Personal Property $5,000 $22.00
Business Income and Extra Expense Actual Loss Sustained Not
Exceeding 12 Months
Other Endorsements SEE SCHEDULE
BUSINESSOWNERS LIABILITY
Except for Fire Legal Liability, each paid claim for the following coverages reduces the amount of insurance we
provide during the applicable annual period. .
Business Liability Limits of Insurance
Bodily Injury/Property Damage $500,000 EACH OCCURRENCE
$1,000,000 AGGREGATE
$1,000,000 AGGREGATE FOR
PRODUCTS/COMPLETED
OPERATIONS HAZARD
Medical Expenses $5,000 EACH PERSON
Fire Legal Liability $50,000 ANY ONE FIRE OR EXPLOSION
Other Endorsements SEE SCHEDULE
POLICY SUBJECT TO ANNUAL AUDIT: YES TOTAL PREMIUM
The Declarations, Schedules and These Forms and Endorsements Make Up Your Complete Policy:
BP00021299 SP00060197 BP00090197 BP04170196 SP04190689 BP04961001 BP05140103 BP07010197
BP10040498 BF30061103 BF40380902 BF40390303 BF40861010 BF40910708 BF40921010 SF41090204
SF41321008 F199020108
Countersigned By
Page: 1 of 2
Authorized Representative
ANx-3190 INSURED COPY Processed Date: 02/15/2011
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 cant unless
loth patties agree to the optional clause provided below. This clause would give the contractor the same right m
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 submittoto such arbitration as provided In Massachusetts General Laws,chapter 1�42A...� p
Homeowner's Signature $igoaptre
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 Rlgbts
A homeownces rights under the Home]mprovement Contactor Law(MGL chapter 142A)and other consumer
protection laws(ie.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 Horne 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 contactor
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 c onsumuerrights. If you have
questions about your consumer/bomeowner rights,contact the Consumer Information Hotline(listed below).
Execution of Contract
i The contact must be executed in duplicate and should not be signed until a copy of all exhibits and referenced
I 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 contact 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 bin/herself to be financially insecum However,in instances where a contractor deems hirniherself
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 five 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
617-973-8787,988-293-3757 or visit the OCABR visite at httn:/hv%%m.mass.eov/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 Paris Plaza,Room 5170,Boston,MA 02116
617-973-8787,888-283-3757 or visit the MC website at htto://-,,.,%%:%N.mass.eov/ocabr/
Go online to view the status of a Home Improvement Contractor's Registration:
htt,p://db.state.ma.us/honieimprovenient/ficenseelist.a.sp
For assistance with informal mediation of disputes or to register formal complaints against a business,call:
Consumer Complaint Section
Office ofthe Attorney General
617 7274MM
AND/OR
Better Business Bureau
508-6524800,508-755-2548 or 413-734-3114
v«imerr-hrr2 mho
Massachusetts Home Improvement Sample Contract
This form satisfies all basic ralahemeals ofthe stales Home Impmvtazmt Cotmactor tzw(MGI,chapter 142AX but does not include standard
langoagrto prated homeowners.Seehieggl advice ifuecessary.Anype+son planning home inipmenients should fig obtain aoapyof"A
Massadlusetts Corstener Guide to Home liuln-e scar beforeag—Stu anywide onyourvmdcnm You mayobtain a five copy bycallmglbe
Office ofCons neer Affairs and Business Regutatiotes coaromerInfonuation Hotr v 617A73-8717 or 1-Mg-2g3-3757 Oro,ourw+ebft
Homeowner Information Contractor Information
trema Compauufr
�-
sbct Addnsa(do not use a PW Office Box address) O p
e�3 (�vr/6/A✓f/Q,1* k'-d
cwr— ZiP C•de auk Addnw(mass an; de a sued )
AV, �' %.l -C&,e7"
Dayi ne Phi livening Phone Citq rower Uft ZiP Cod
' ?39 IPM RP/-72.5�, 110V.-4a/v-5-Z
Mailing Address(h difTeseat from above) stain=s plmam
Federal FwPioger m or S.S.lrmmbts•
. _ _ ��aeue•at�c n.meiq�cammeeoraeg.liwea Fiyamonams
The Contractoragrees to do Poe fof ffft wodc fortheHomwwmx;
(Describe to detail the Werk to completed,spedfAM the VM bmA aM grade of ata to be mend,use additimud ifaruMa.v)
lee
/h.9i,t..sT�re=T vy,-y[ s�d.,t.� . rc r .�� :¢4:1 c-2,,d w, i-A a e--x t—41 7e t4PA o
wiK claw E>Li�a�oic .t rn e �vp��cP�u�T vvn>,-L &;�4 A d
/'v2 Sl c{/.rz G ikp lice /3tia/w '�� ��ivQ/OGrls''
Regais>ed P -The fonerrriog btuldm9 permits we required Proposed Start and ComPleflon Schedule-The Mlowing sdnedula Wall
and will be segued by the mar as the homeownefs agent be adhered to Mess stances beyond the oontrncws cm*W arise
(Owners who secure their own permits will be
excluded from the Guaranty Fund provisions of Date when oentractor will begin contracted work.
MGL chapter 142A.)
LI-42"/ DDate whey cOntaftd vmkk win be-billy c-Vldc&
Total Contract rdecand Payment Schedule
The Contractor agrees to pafomt the wink,famish the material and labor specified above for the tont sum Of tsj
Payments will be made according to the following sclic le:
S Wan signing www(not to eceeed(/3 of the total t>oahaet
pries ffi the o>ost of sptxia!oM items,wbicliever is greateir
$ S/ by^_/i_cur upon compW.D of �P4 vP�iy a 7 ice.¢7P'1,-1,4 e
oruponcompietionof SO/O Coo? e io--v
i upn cOmPletian ofthe con(rai t. (Law'fmbids dmtandatg fn payment urul txatrast is convicted d to both
partyts satistaGitm
The fotiowmg mint—yequipment must be speciet S to be paid for
ordered before the eonuacted wmb begins in order
to meet the comptation sdhedula(") S to be paid for
NOTES'-(h blArding all fnence ••
cbaB�( )Low requizesdiataaydepmitmrdosm-paymmtna4uuadbytheooaI'Mbefaraworkbeetas may
no rxarod lima terof(a)onathird ofthe tow voouaa wive or(b)the auraw cost ofany spcciot eupuuiptnemt or crustaun made roataial
vMch must be specW ordered in advMM to.axes the oompleem se(tedule.
FaeorMwi"WIr-ramieairmweryaatvbdea' a.- 13 r4-13 Y. ..e,.w..�....w- -.._�._.
Subcontractors-Miccontractor agrees tobesolely responsible for tampleuonofthewinkdescribedregardlessofthonsofanyd
Pmylsmboantractor utilized by the contractor.The contractor further agrees to be solely responsible for a payments to ad
an sutbomtractors for
Mals and labor under is aaeement
ContraetAeoeptance-Upon signing;iris doarment bocames a binding oontrac under law. Unless otherwise noted Within this dowmmt,the
ontract shall not imply that any liw or oMerseaa*interest has been placed an the residence.Review the following cautious and notices
IY befiim sifpng this contras_
• Dons be pry into signing the contract Take thne to read and felly undastand iL Ask questions if something is endear.
• Make sure the the lavnxlnites most home improvenmt oentcadors and
mbaonftacws to be registered with the Director oflloure improvement Cmmac for Re&testi,, Yeo
regigrmion by writing to the Director at to Park Plaze,Room 5170, °n!'f°gr'na abeam oatttactcr
• Does bite contractor have insurance?Ask the Cantracor for his tttsu�ce pHA 02116 or 6y tailing 617 973.1717 or888-283-3757.
ser a copy of a`*roof of iosnrance docani at. conpatuy mforntatiaas so that you can confirm rbvaage,or ask to
• Know your rights and responsibt7it-Read the hVintant lafatanation on the averse side ofthis form and geta copy ofthe co n,Wtmer
Guide to the Hone imprtweaaent Contracot Lau,
You may cancel this aveement if it has been signed at a place otter than the eontmctoes Maul place of business,provided you notify the
contractorin writing at hislhermain office or Windt office by rxdinaryma0 posted,by telegtainseat or by delivery,not iatertban midnight osfthe
third business day Mowing the signing of obis See the Winched notice ofeanci llurion foto for an laention of this right
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM
TmvidMtapiesofduuwmractamstbeoom�dandsi�ed.Qcea�shoddgumaehomwm»a theomereopy�odd6efmpbgdceuxmtr�oc
FGbR�SlgaabIIe �TMR�I+.� Sd �� � 1
D Can wactuesSigesoate.
oma/27 20//
Date Date
T��i�S�tl ftF l+lo. of
SnPHEW M. KEISUNG
ng&
9 9th Street Wei
Sa't my, MASSACHUSERS 01952 .
MA Lit. 027489 Home !mpv. 101846
Phone (978) 682.2072 a (978)465.4712
PROPOSAL SUBMITTEDTO PHONE 09M
sTI*Er Cor JOB NPAM
s
MY.STATE and MP CODE Oe tACAT10N
?Zit ')17
ARCWTBCT DATEOFPLANS
JOBPNONE
We hereby submit ins and estimates for.
coV-fir.-Gtr /tio_ Xie 615W� � Y.P
u � � �-�-
Bit PrOPOW- hereby to furnish material and labor—complete in accordance with above specifications,for the sum of:
PaymeM to be madeMfdUwA%: dollars($ )_
AD rrmtmial is grrmmdad m be as specfed•A9 vrork ID be campteted in a wodemanow
mamw a000 t to s'ndard pradioes.Any meream or dearm m tmm above qw0jcaftr, Authodzed
kwdv g extra costs wM be awaited 0*upw waft n orders,ad wM become an extra
etmW over arrd above the earmrahL Ad agreements corrtaWm upon straw%aaadaft
or dekys beyond arr=dmL termer to carry rue.tomado and other necommy mawx,- Note:This proposal may bg
our wodaefs are irmy covered by wortanaft Compema@on haurmm withdrawn by us d not accepted WWdn d�
=Zthevork
o$ roposat—The above Prices,specifications
atisfactory and are hereby accepted. You are a rihorized somhrre - �Q/yi yi�jyriy.
ecified. Payment wdl be made as mftied above.I6/a7�%
The Commonwealth of Massachusetts
Department oflndustriad Accidents
Office of Investigationg
600 Washington Street
Boston,AM 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
_Applicant Information
Please Print Leg>!bly
�.,
Name(Business/Organization/lndividual): Zi,cl
Address:---
.City/State/Zip:
ddress:.City/State/Zip: s 1141,e Phone#: '�'7,P ' QV—d"S-S_7
Fship
employer?Check the appropriate box:
employer with 4. ❑ I am a general contractor and I Type of project(required): -
ees(full and/or part-time).* have hired the sub-contractors6 ❑New construction
sole proprietor or partner- listed on the attached sheget.# 7• ❑Remodeling
d have no employees These sub-contractors have 8. ❑Demolition
g for me in any capacity. workers'comp,insurance.
rkers'comp.insurance 5. ❑ We are a corpozation and its 9. ❑Building addition
d.] ,officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11-El Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no
12.0 Roof repairs
insurance required.]t employees.
[No workers'
comp,insurance required.] 13.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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.
lam 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.Lie.#:
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 ofthis statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
fP J ry `
I do hereby certify under tIt pains andpenalties o er'u that the informationprovided above is true and correct.
Signature-
' ;�� Bate:
Mone#: 9 7 3 IV- d'Y S'7
Fffi-cialonly. Do not Write in this area,to be completed by city or town official.
n: Permit/License#
hority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electric
6.Other al inspector 5.Plumbing Inspector
Contact Person:
Phone#:
Information and Instructions
uctions
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 ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants ----------------
PIease 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 numbers)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,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 Iicense 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 referencd 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. Anew 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 is 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-Cor► ` ORIMa a of Afj assae'oasetts
Department of ladustrial Accidents
®dice of Investigations
600 Washington Street
B oston}�,02111
Tel.#61.7-727-4900 ext 406 ox 1-877-11ASSAFE
Revised 5-26-05
Fax#617-727-7749
tw.mass.govfdia