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HomeMy WebLinkAboutBuilding Permit #401 - 855 SALEM STREET 11/27/2007 r4ORTH BUILDING PERMIT o���,60 TOWN OF NORTH ANDOVER 9 APPLICATION FOR PLAN EXAMINATION nO Permit NO: Date Received SSACHus� Date Issued: 'Z) IMPORTANT:Applicant must complete all items on this page LOCATION t , (V\ "i I`.t t -C"` 4:: V { „ Print PROPERTY OWNER �.. -- _`n- -- pdnt MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village 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 Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIP I N OF WORK TO BE PREFORMED: Die s LdQ S 0 Identificatiop Please Type Print Cleay) s� OWNER: Name: i(��li 4�T �kof Phone: Address: WA� CONTRACTOR Name: �raC,Ati'-A�1— �' I� Phone: / ` Address: It ds ktsSupervisor's Construction License: ic Exp. Date: 1 e / ! I z Home Improvement License: /02 Exp. Date. ARCHITECT/ENGINEER Phone: i Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$ 000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 36 FEE: $ 0 Recei t No:: 0 -2Z-, II Check No.: p NOTE: Persons contrac 'ng ith nre 's red cont r ctors do not have access to the gua my f d ignature of Agen#lOwne S ature of contractor 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 o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ 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 ❑ 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 o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o 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 r Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 i Revised 2.2007 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 DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH COMG�IENTS r o� 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 Located at 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on' site yes no Located at 124 Main Street _ _ Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 Location 0 ��IC 61r No. © Date0.1 �D NORTH TOWN OF NORTH ANDOVER favow9 Certificate of Occupancy $ �'�S'•^°•E��' Building/Frame Permit Fee $ � s�cMus f Foundation Permit Fee $ ry Other Permit Fee $ TOTAL $ d Check # 20622 __......� Building Inspector r.NOV.26.2007 14:45 rt Il 11P: • .n,,..,.,,._ly.� '-Ilei.YAI.1.r.,.;. .)'::�.i y.{'•�i:{�r ':,•;' ��•ry'��� �. h:4r'' �A"� a..L �+ ).� :::J�S.•.1. :(�:�� �1. I ��1•,,, .17r' 1.'a • �,r �.. rG.t.,rnl,rr ��;I"!r Pr •1:".(n�1;IM1'PN!il�a-M. •I. I , .)�r. :�y•••�I.•.,. �7pr�. I npp1 �! f�q./ .�.r; .:7 .,,>,�rr;I ;j�l 1ji'. :).l. �':.!lifl'�:L' I:. w1�.•'1'••I�. 1 If�'�'., 1p'•'.R.,'� l"'l•,1!:i:��"��i: '•d•':"�„ ::.J:„:::-;-���:( ..ii�w,�`��f;�r. a wl.!'I e�rr f.;ya '{fit.,• .t'iY'' -.I 1� �YIA 1� A ' ;�f ; t •;.E'7, 1. 4,, ,6M..•1 n 1. _K!� - � .'7..A. .•i.:f a..• _•:J:::,;,. •••;1'{•C�l•L'ar:,'II''1;o1"is ii;F�,•gg�/„11;'r,:.a'�V P. ,., �„ �f.�•a,l},',: 'a ��il^•'�•;I;:g='i^ •.df.• �I 7 ;.n•• ;.y.��.:1:"1 '.rrl ..'�:: •f� �, I.iti ;:'1'•'1;;,1 .1. I ..li.: I' •.�•:• 9^1'�a.!7.', 'Yr,'' '' 16;d•_ .:'ION i'� AS A MATTER OF INFORMATION THIS CERTIFICATE IS'ISSUEO PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE T AMEND EXTEND OR Armand P Michaud Ina Agency Inc ALTER T.THIS VERAGICA AFFORDED BE DOES OY THE Po CI S BELOW 105 Haverhill St ALTER THE COVERAGE AF Methuen,MA 01844 PANILS AFFORDING INSURANCE COMPANY A GRANITE STATE INSURANCE COMPANY INSURED Samuel 8 Luxes Nome Improvement corp 91 High St Lawrence.MA 01841 p� •'JrM,..;;f,{7. I•';ttlT,!:+!.'•17,(�� 1:.:•r" �nJ� ,,37$(rY.;a ,1•.:.•:i:*,'''4.- •'�" :.i."lii�f•. .!�;,•:�,�.;c,J!tSM!}��N; i'�•ti cpmIw CC ::.. ••••, .Iy� Iay7VR�n,•,�;I' ..�..� •I�r�.,.I,r.•r•,�I•':.�:f"•r.,,• I I_. �..,•,.•i d:, ,,.,, '.;�:•a• THIS IS TO CERTWy THAT 1,H E POLICIES OF INSURANCELISTEDBELOW HAVE SEEN ISSUED TO THE INSURaO NAMED ABOVE FOR ANY CONTRACT OR OTHER 1"E POLICY PERIOD 1NOIGAT.0,NOT WITHSTANDING ANY REQUIREMENT,TERM OR CONDITION DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED THE POLICIES DESCRIBED HEREIN IS SUBJECT To ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEIJ REDUCED BY PAID CLAIMS. lY TYP P Y POU NYM9 ► FIE AT PO4 ;STA o ME PROPNIE1QRlINKERIE 1,tmvERV L MITEC Group 8/29/2007 8l;r r^:; : -p.100,00GIPENT POLKY LTAIT EACN EMPLOYEE 100 0 ESCItIPTION OF OPERATIONSNENiCL00EC1AL ITEM CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER MAanOU1DAWOFTHE AOOV%OR9CM=POLICIESINECANCKtEoKFOReTML 1600 OSGOOp 9T ExPIIIATIDN QATE TKFEPF.THL IswING COMPANY YPLL ENDEAvbR TO MAIL 12 NORTH ANDOVER,MA 01PS DAYS WRITTEN NOTICE To IME CUITM\ICATe HOLDERNAMED TO THE kiFl,BUT PAIIURE YO W4L SUCH NOTICE 6MALL IMPOSR NO ODUGATION OF LIABIUTY OF ANY KIND UPON YH$COMPANY,RS AOENTS OR R"IsfIiT"S' AUTHORIZED REPRESENTATIVE aNOV.26.2009 19:95 NMI 1358t-0000 WC 636-20-71 GRANITE STATE INSURANCE COMPANY _____________..____ ..._._._.________________ 13102 013-66-0807-00 PENNSYLVANIA SAMUEL 6 LUCAS HOME IMPROVEMENT CORPORATION Member Companies of 9g1 HIGH ST 01M 'American International Group T.AWRENCE, MA 01841-0000 EXECU nVE OFFICES: 70 PLANE STREET, NEW YORK. N.Y- 10270 SEE NAME AND ADDRESS SCHEDULE - WC990610 1.0# MA uli A 'P MICHAUD INS AGCY WORKERS COMPENSATION AND EMPLOYERS 105 HAVERH.I LL ST LIABILITY POLICY INFORMATION PAGE METHUEN, MA 01844-4274 —" PREV OU I 6 POLICY NUMEIM INSUREDI CORP QRA ION NEW OTHER WORKPLACES NOT SHOWNOA VB Ei S11 NAME AND ADDRESS SCHEDULE - wcg§o610 ITEM 2 POLICY PERIOD 12;01 A.M. Vine e at the Insured-a nfalangaddress FROM 0$/�9/07 To o8/29/o$ ITEM 2 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Lew of the states listed hero: MA B. Employers uabuity Insurance: Part Two of the policy applies to the work In each shite listed in item 3A. The limits of our liability under Part Two are- Bodily Injury by Accident S 100,000 each accident Bodily Injury by Disease S 500.000 policy limit Bodily Injury by Disease S 100,000, each employee C. Other States Insurance: Part Three of the policy applies to the states, If any, listed here- SEE ENDORSEMENT - WC200306A ITEM4 The premium for this policy will be determined by.our Manuals of Rules, ClasslflcatlenS. Rates and Rating Plans. All Information required below is subject to verification and change by audit. Eettmeled Total Rete Per Eetlmetetl Classifications Code NumbW Remuntion itaa Of Re- Premium OAnnYal 3 Year mune�ratlon X Annuml 3 Year SEE EXTENSION OF INFORMATION PAGE - WC7754 . TAXES/ASSESSMENTS/SURCHARGES . $280 RXPENSE CONSTANT(EXCEPT WHERE APPLICABLE By STAT!) 2 4 MA MINIMUM PREMIUM $_500 MA TOTAL ESTIMATED PREMIUM S5.384 If Indicated WOW, Interim adjurtmemle of premium shall be made:. Semi Annually tlumnarty monthly DEPOSIT PREMIUM_ ENDORSEMENTS(FORM NUMaER) SEE ATTACHED FORM -SCHEDULE - WC990612 09/27/07 ASSIGNED RISK 66 C. tache Date Issuing OKicc Auth6dwd Ropresentiativo wC 00 Oo of anger Boa7-roBg Regula ons and Standards One Ashburton Place - Room 1 301 �~ Boston, Massachusetts 02108 Construction Supervisor Licen<e License CS: 53524 Restriction: 00 E:::piration: 10/8/2009 Tr# 7796 MICHAEL P KENDALL PO BOX 1153 ---- -- -------- GARDNER, MA 01440 Update Addre.xs and return card.Mark reason for chane Address Renewal Lost Card DPS-CA1 ca 50M-05/06-PC8490 ' � J�.G' �Oli7/I72dI'LLIiP.CL�� c�'✓,�Zcr�.tvace'2.w.�b - - Board of Building Regulations and Standard., Imo' HOME IMPROVEMENT CONTRACTOR z Registration: 109725 Expiration: 9/24/2008 Tr# 12839:. Type: DBA KENDALL HOME MAINTANCE MICHAEL KENDALL 165 BAKER ST GARDNER,MA 01440 Admiui iratoi "� � ✓s�ie �om�meaiu,�rea�i � �/e� rhlac�ucde/6 Board of Building Regulations andGcStandards Construction Supervisor License License: CS 53524 Expiration .10/8/2009 Tr# 7796 Restriction. 00 MICHAEL P KENDALL PO BOX 1153 ��— GARDNER,MA 01440 Commissioner NpRTIy 0 144M ToAndover 'SVT O o. T 4` �, _ o dower, Ma SS. - o ISO COCMIC EWICK y1 7d ADRATED PC `r BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System 0 BUILDING .INSPECTOR THIS CERTIFIES THAT................ T......A/..�..-!............, �/.. ../..r,... 1.... ...•..................................... �V Foundation has permission to erect........................................ buildings on ... .....s. .�Cv.I.W.......,, :f........ Rough Chimney to be occupied as..J�► .... ................ .. .............. ........�!"....... y provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRU Rough ........ .. ................ Service BUILDING INS R Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. 1 1b , � 5o . � a ------------ ------------- --- ------ ------- ...... - - ------------- .............-----—-------------------------- ....... 2-- 1R, :36* 5"- 54- -------------- 15" .30" 19 34" ------------- 6,1 ................ — 57 ---6 ------ .... ...............t'--,-18" -4, 12" 3-7 21 ---------30 18-- -------- 30" 5G15 -71 -------- .......................;, .............. ( VV1536y 1536 W3015 W- 1 536Ri VVR361 8 WFl3. .r P P1224j P90 21 Z Fj BF k 5R.2FVV.T -------------------- Customer:Mike&JUlie 855 Salem Street North Andover, MA 01810 C --- Designer:Rick Epstein Manufacturer:Kraftmaid Style:Deveron Cherry Square 11 _ //(n Finish: Honey Spice Countertop:TBD Upgrades Options "All Plywood Construction- "DBBRFX Ultimate Runner System" 36"Wall cabinets aligned to 90"+/- D SHW. All trim.filler, mouldings,toekick.and panels P11 to be trimmed by installer. ALL and 177 -4/0 c __� - ARE APPROVED BYMEASUREMENTsM HOEOWLAYOUTNER INSTALLER. X/ki.-, Yl 7% - -----80 PLEASE NOTE.THIS IS A SPECIAL ORDER AND IS NOT RETURNABLE Yj.52490R490L.45OT 49 ... ........ 15 .151. 151, ------ ------ 218+ ------------ -----------------—-------- 46- + -----------100-1-------------- 264 -------------------------------------------------.........------------------ —------ ----------- ----------- --------- All dimensions size desi n<jtioijs given arc This is an original design and i-nLISt Ilot bC _—ned: 10,,22/2007 SUbjeCt to verification oii job site and Alhh� released or copied L1111CSS "IppliC:IbIC fee Printed: 10,122/2007 --------------------- adjustillent to tit job Conditions. has been paid oi-joh order placed. is ;---------- R'tilflai-idMike IZE\,'ISFD RE0 ,)2907.ki All 474: 1 ------ ..................... -------....... -----------— ....... ---------- ---------- - ------------------------------ CONTRACTORS INVOICE WORK PERFORMED AT: TO r DATE YOUR WORK ORDER N0. OUR BID N0. i OE grill � mr 0 0 • � 0 0 1 � � i a r c t — I 1 � V All Material is guaranteed to be as specified, and the above rk was performed in accordance with the drawings and specifications provide or the above rk and was coe'Zmplex d in a substa ial workmanlike manner for the agreed sum of The -- Dollars($ --). This is a ❑ Partial ❑ Full invoice due and payable by: Month Day Year in accordance with our NIAgreement ❑ Proposal No. Dated Month Day Year NC3822 CONTRACTORS INVOICE .a�tV ()SA lu C=-tq luc6: ;;p R:1L p c` awsui 1 b1^.b02sj f0. ----— Ds cG s F- bVILI�4i 11 LfQ iunC qr.e suq bulapp p,'%.- 27 , 2' ''`B' ;.1. G1ct•'t JTflji�.S VIl q 0... ..�J,�' .:.5a �sRli'.i'.,=} '1 :COI '.I.C' �a•�• �i�. .�' Jae !!J �I a... 1 nlr J 1 � I � 11 f � i I ' s � }r i I 1 i r r ' ' r ACSF l bLH' 'L ti CONTRACTORS INVOICE' WORK PERFORMED AT: TO. "-Q�A-k 4AAso i a J DATE YOUR WORK ORDER NO. OUR BID NO. DESCRIPTIONOF •-K PERFORM ,l i� s XVI G All Material is guaranteed to be as specified, and the abovew rk was performed in accordance with the drawings and specifications provide or the above rk and was compd in a substa ial workmanlike manner for the agreed sum of Dollars($ op O ). This is a ❑ Partial ❑ Full,invoic e and payable by: '# ` Z— Month Day Year in accordance with our NAgreement ❑ Proposal No. Dated 11ro() — Month Day Tear NC3822 CONTRACTORS INVOICE + r 1 i -- - --- -- _ • - Yrs ! _ -"la• Y L 11 'Ja 11011:4q �r.w Ah %— 9 a- 0 36" -f . ,J9.liy;,:: 2'_ 3LJ p 76 Aj 1011=J.lre— nPloa,7i10e,' .GI 176fC':itc S n` Liv PrC`5 . . .' bna .1 r "IIs': F .I•.� F 7 1...}. -. - - - - - - :�c sit;_,... b: t� °�.o �.. _ ,, ;9 JEU J0 r,_'.1 f•: . _ ni 979534/NC3822 CVT 8198 carbonless °d°"" " NC3822' "' ' 3 PART CONTRACTORS INVOICEX * l WORK PERFORMED AT: Ilk 4 A T0: -� 'C; + S i r DATE. .. YOUR WORK ORDER NO. OUR BID N0. _ In 2 9r DESCRIPTIONOF ••K PERFORM t r f 4-A -R aA 04._ QkA C C a �--- All Material is guaranteed to be as specified, and the above wk was performed in accordance with the drawings and specifications provideor the above rk and was comple 2d in a substan/,all workmanlike manner for the agreed sum of / Dollars($ This is a ❑ Partial ❑ Full invoiced a and payable by: Month Day Year in accordance with our 6 Agreement ❑ Proposal No. Dated O Month Day Year NC3822 CONTRACTORS INVOICE The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a a 600 Washington Street <W Boston,MA 02111 7 OW &M It www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ] (� 1 Please Print Legibly Name(Business/Organization/Individual): (�' l �� r L. i' f�� �1z 44./L Address: 11111 L ©` i o City/State/Zi Phone.#: g Are,you an employer? Check the apprI opriate 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. 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-corttractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp.insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised.their 11.F1 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.[1 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 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.#: 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 may be forwarded to the Office of Investigations of the DIA f ce coverage verification. I do hereby cern ju the pat # penaltie o per' t t e information provided above is true and correct. Sienatu Date: v 1 Phone#: !t� Offlcial.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#: f I ' 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." i 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 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-NIASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia 240" ' 16" 36" 15" 54" 15" , 30" 15" 56 4" 61 n" 5 4" 8i" 18" 12" 3 i" 21" 30" 18" 15" 3 15" 56„" Z 00 W153 1536L W3015 bN1536R WR3618 W PP1224 O90f21.2.F BF 18R.2FB1 5L.2RA 615R.2FWT v N [O O ._ _. ---------------------------- .. .... " BEPr r r ,0 r W N 0 23 „.17a" 88"•, 15" 30" 35 a" ------------ ----- 80„". 1 524 90 84 90E ROT 24L BFRIDIG 1536RW2418BUTT 1536 j �y " 15s” 15"-�15" - 15" 15" 71" 46" 464" - 196" 15"—,/ 24"—#-15"—#-14"—// 264" All dimensions_size designations given are This is an original design and must not be Designed: 10/22/2007 subject to verification on job site and released or copied unless applicable fee Printed: 10/30/2007 adjustment to fit job conditions. has been paid or job order placed. d RuhlandMike REVISED RE092907_ki All Drawing#: 1