HomeMy WebLinkAboutBuilding Permit #1070-15 - 858 GREAT POND ROAD 6/18/2015 r y-
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I BUILDING PERMITo` z,�� �b.114NNb� enIv l/ •:q 46 O
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit No#: 70 / Date Received
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Date Issued: ;6 h kr
IMPORTANT: Applicant must complete all items on this page
LOCATION (,.r-ea ®r►r R c&c�
Print
PROPERTY OWNER
Print 100 Year Structure yes no
MAP 103 PARCEL: 33 1� ZONING DISTRICT: ir A� Historic District yes
Machine Shop Village yes r
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building P<One family
XAddition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
El S:eptic `Well: ❑FFloodplain 1Netlands Watersheds District
ter/Seuver;
DESCRIPTION OF WORK TO BE PERFORMED:
II Ac- ,I brie_ roow. o4- Seco --OL A-loor 1euC1 a-6ve- e�4is-t,^4 `DInin, Atx,
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Identification- Please Type or Print Clearly
OWNER: Name: G�a! , "I r cy Phone: 9a/ -l96- 934-S'
Address: $' � G��-�w� o R c� K)c� �. CSC v ei- i
Contractor Name: Atljne
cr � `01 Phone: / d -/ 5 7
Email: f t�n2cr s F a Vii ton
Address: .k/ 14er1`i ck goQ"I'X r& HA 6192/
Supervisor's Construction License. C S?034-f-�"3 _.�, Exp.. Date: a/214,2e ".
Home Improvement License: ` / �S Exp. Date: /2Z;z z 201
ARCHITECT/ENGINEER Mp-f si e-r- keridenlid Pes Ql Phone: 97s'- 616"
Address: 4Reg. 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: $ k3 , 17,66, FEE: $ 410016 —
Check
, 0016 ,Check No.: Receipt No.: !�26P57
NO E: PeT4aus contracts g ith unr ere contractors do not have access to the guaranty fund
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Plans Submitted ff 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 X
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF m U FORM
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PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: variance, Petition No: Zoning Decision/receipt submitted yes
Pa nn�ing Board Decision: Comments
Conser(ation Decision:
Comments
Water& Sewer Connection/Signature&Date Driveway Permit _
]DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE 1 EPAR�-MENT Tern
� p Durnpster
Located'at "I P2
partment signature/data ,e +
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COMMENTS ,
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Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:_ �,gl
f
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
M Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
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MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
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NOTES and DATA— (For department use)
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® Notified for pickup Call Email
Date Time Contact Name
Doc.Building Pennit Revised 2014
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
4. 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
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
Y Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract
✓4� Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
,/ 4 Mass check Energy Compliance Report (If Applicable)
I V � Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
I 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
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
Doc:Building Permit Revised 2014
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Location Z��
No. 70 " / Date A
• • TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
t t : TOTAL $
Check#
2844
uilding Inspector
Enter construction cost for fee cal- North Andover Fee Calculation
Construction Cost
$ $3 .782.00 m
$ - $ 1,005.38
Plumbing Fee $ 125.67
Gas Fee 100 comm. $ 1:0.0,.0:0
Electrical Fee $ 125.67
Total fees collected $ 1,356.73
858 Great Pond Road
1070-15 on 6/18/2015
Addition of one room above existing dining room
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LAKI
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A�RATEO 0P�`,�'(5
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BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT ......,�, .�C.G1.I'd
BUILDING INSPECTOR
has permission to erect .......................... building on ... ...�z-..r .f...�.�.::�'.,` .:. a�
Foundation
.......... .............
j Rough
$0 be OCCUpled as .......... .M .. 1�:.� �1��;1„�;1.� ( N
d ........ . f]G�J�' ........................... Chimney
provided that the person accepting this permit shall in every respect c nform 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 CONSTRUCTION TS Rough
Service
.................. ........ .0//Qy�' � Frrrt .......................
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.
The -Co* .mmonwealth of -Massachusetts
Department
-of Fire Services
19's
Office of
the State Fire Marshal
P.0.Box 1025 SLZte'Road,.Stovi,NIA 01775
• PERMIT ' � � Date: .
North Andover JPermitNo
Ci of Town Dig Safe Num er
• ( ty. ) (If Applicable•) '
In accordanc6mith the provision NL GL.l 4 8 Chap.ter—Ij(L as provi
�d
�ed insection S 7 7 ('MR 34
7�f�1s✓/. \ Start Date
This Pcrmit is gtantcd to:. Cr-S/ /
Full name of person,Firm or Corporation
Permission to locate dumpst;er • for construction/renovation/demolition of building.
Comm Its: dumpster. must be . 25from structure if unable to place with required
Rcstrctioas:clearance dumps-ter must be covered with plywo,,
od or tarp end of 'work -day
at
(Give location by street an o. or describe in such ma as to provicd adequate identiEcation.of locatioa)
FcePaidS 50 .00 ire Chief
This Permit will expire- �� (>iNlure of o ca granting permit) Offical granting permit (Tide)
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ANNECREST BUILDING CORPORATION
P.O. BOX 290
BOXFORD, MA 01921
Office: (978) 887-4991
Fax: (978) 887-2113
BUILDING CONSTRUCTION CONTRACT
This agreement made thisday of June 2015 between David and Gay Tracy of 858 Great Pond Road, North
Andover, Massachusetts 01845 (hereinafter called "Owner") and ANNECREST BUILDING CORPORATION
(hereinafter called "Contractor").
WITNESSETH:
In consideration of the covenants and agreements herein contained, the parties hereto agree as follows:
1. Contractor agrees to construct a new addition in good workmanlike and substantial manner, upon the real
property hereinafter described,furnishing all labor, materials,tools and equipment therefor, except as
otherwise provided an addition shown on Plan entitled "Proposed Addition at 858 Great Pond Road, North
Andover, MA" Job No. 1772, dated 5/25/15 by Guy Messier Residential PI The Design g ( Plan).
2. The structure to be constructed and completed in substantial conformance with the "Plan" and attached
hereto as " "
Exhibit A and signed b the parties hereto
a copy of which
the Plan shall be filed with the Town of
North Andover Building Department.
The following items are included in the Contract Price:
1. Obtain all required permits from the Town of North Andover, MA.
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2. Provide and install all framing, roof shingles and siding similar and matching to existing house. All exterior
trim to be Azek or similar.
3. All new windows to be Eagle type,the same as existing house and shown on the "Plan".
4. Provide and install new aluminum gutters and downspouts at front and rear of new addition.-
5.
ddition:5. Provide and install all new plumbing for 24 inch fiberglass slop sink with standard faucet as located on the
"Plan".
6. Provide and install one supply and one return register connected to the existing HVAC system in attic.
7. Provide and install six duplex receptacles and two switches for future lights. Lighting to be provided by f/
Owner and not included under this Contract.
8. Provide and install closed cell insulation for roof at R-49 and exterior walls at R-21. Apply foam insulation
around exterior windows.
9. Skim coat plaster to be used over% inch blueboard. All walls and ceiling to be smooth finish and painted.
10. Interior window trim and baseboard to be similar to existing house.
11. Paint interior and exterior to match existing house.
12. Provide carpet, pad and installation at$30/yard.
A. In consideration of the covenants and agreements hereof being substantially performed and kept by
Contractor, including the supplying of all labor, materials and services required by this Contract, except as
otherwise provided herein, and the construction and completion of the structure. Owner agrees to pay the
Contractor the sum of$83,782.00 subject to additions or reductions for extras or credits arising after execution
of this Contract, in installments as set forth on the payment schedule annexed hereto as"Exhibit B", said sums
to be paid upon inspection by the Owner, but in any event within five (5) days of demand or requisition therefor.
B. The Contractor shall pay all valid bills and charges for material labor or otherwise in connection
gwith or
arising out of the construction except those expressly undertaken by the Owner and will hold the Owner of the
property free and harmless against all liens and claims of lien for labor and material, or either of them,filed
against property.
C. Payment hereunder of said improvements or any part thereof shall be constructed as acceptance of the work
done up to the time of such payment not including any punch list items.
D. Should the Owner at any time prior to or during the progress of the work request any modifications,
alterations or deviations in, additions to, or omissions from,this Contract or the plans or specifications, herein
called "extra work",they shall request in writing that the Contractor undertake such extra work. If the
Contractor shall agree to such extra work,the Contractor shall submit to the Owner an estimate as to the cost of
such extra work, and if agreeable to the Owner and the Contractor, a written change order covering such extra
work shall be signed and the Owner shall cause to be paid the full cost of such change order in advance on a cost
0
plus 20% basis. This Contract shall be held to be completed when the work is finished in accordance with the
original plans as amended or modified by such change order, whatever may be the nature or extent thereof.
The rule of practice to be observed in fulfillment of this paragraph shall be that upon the agreement of the
Owner and the Contractor, as to the character and valuation of any or all changes, omissions or extra work,such
agreement shall be fixed in writing as a change order signed by the Owner and the Contractor. Where the
alterations, deviation, additions or omissions from the "Plan" or specifications required the written approval of
the first lienholder, the Owner will secure said written approval, provided, however, that the Contractor is not
deemed to have waived his right to compensation for extra work if the same is not provided for in writing, but
shall be paid a reasonable value of such work as compensation.
E. The Contractor shall not be responsible for any damage occasioned by the Owner or the Owner's agent, acts
of God, earthquake, or other causes beyond the control of Contractor, unless otherwise herein provided or
unless he is obligated by the terms hereof to provide insurance against such hazards or hazards.
F. The time during which the Contractor is delayed in the work by (a)the acts of Owner or his agents or
employees or those claiming under agreement with or grant from Owner, including any notice to the lender to
withhold progress payments; or by(b) any acts or delays occasioned by the lender or lienholder; or by(c)the
acts of God that Contractor could not have reasonably foreseen and provided against; or by(d) stormy or
inclement weather which necessarily delays the work; or by(e)any strikes, boycotts or like obstructive actions
by employees or labor organizations and which are beyond the control of Contractor and which he cannot
reasonably overcome; or by(f) extra work requested by the Owner; or by(g)failure of Owner to promptly pay
for any extra work as authorized in Paragraph 9 or 9 hereof, shall be added to the time for completion by a fair
and reasonable allowance.
G. Completion and acceptance of the work shall entitle Contractor to receive all progress payments according to
the schedule set forth in Exhibit"B".
H. The Owner agrees to procure at their own expense and prior to the commencement of any work hereunder,
fire insurance with course of construction, all physical loss and vandalism and malicious mischief clauses
attached,such insurance to be in a sum equal to the total cost of the improvements as set forth in Paragraph 3
hereof,with loss, if any, payable to any mortgages or beneficiary, under any deed of trust, such insurance to be
written to protect the Owner and Contractor, as their interests may appear, and should the Owner fail so to do
the Contractor may procure such insurance,as agent for the Owner, but is not required to do so, and the Owner
agrees on demand to reimburse Contractor in cash for the cost thereof.
I. The Contractor shall at his own expense carry all workmen's compensation insurance and public liability
insurance necessary for the full protection of Contractor and Owner during the progress of the work.
J. As between thearti s hereto,p e e eto, alluestions as to the right and obligations q g g s arising under the terms of the
Contract, the "Plan" and specifications are subject to arbitration. In case of dispute, either party hereto may
make a demand for arbitration by filing such demand in writing with the other. One arbitrator may be agreed
upon,otherwise there shall be three, one named in writing by each party within five (5) days after demand is
given, and a third chosen by the two appointed. Should either party refuse or neglect to appoint the arbitrator
or to furnish the arbitrators with any papers or information demanded, he or they are empowered by both
parties to proceed ex parte. If there be one arbitrator, his decision shall be binding; if there be three,the
decision of any two shall be binding. Such decision shall be a condition precedent to any right of legal action,
and wherever permitted by law, it may be filed in court to carry it into effect. The arbitrators, if they deem that
the case demands it, are authorized to award to the party whose contention is upheld such sums as they shall
deem proper for the time, expense and trouble incident to the appeal and, if the appeal was taken without
reasonable cause, damages for delay. The arbitrators shall fix their own compensation, unless otherwise agreed
upon, and shall assess the costs and charges of the arbitration upon either or both parties. No one shall act as
arbitrator who is in any way financially interested in this Contract or in the business affairs of either Owner or
Contractor. The action or decisions of any arbitrators do not affect any of the rights of and are not binding upon
any first lienholder.
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K. Should either party hereto bring suit in court to enforce the terms hereof, any judgment awarded shall
include court costs and reasonable attorney's fees to the successful party.
L. Upon completion of the work, the Contractor agrees to remove all debris and surplus materials occasioned by
the construction from the building site and leave the property in a neat and clean condition.
J V'
M. The Owner is solely responsible for providing the Contractor, prior to the commencing of construction, with
the hookups for such water and electricity at the job site as may be required by Contractor to effect the
construction of the improvement covered by this Contract.
N. The Contractor shall be responsible for damage and subsequently, repairing or replacing to the Owner's
satisfaction damage to existing walks, curbs, driveways,cesspools, septic tanks, sewer lines,water or gas lines,
arches,shrubs, lawn,trees,telephone and electric lines, etc.,by an subcontractor or supplier incurred in the
performance of work or in the delivery of materials for the job.
0. Contractor has the right to subcontract any part,or all, of the work herein agreed to be performed.
P. The Owner hereby grants to Contractor the right to display signs and advertise at the building site.
Q. All utility.bills shall be paid by the Owner during construction.
R. Contractor to provide container for off site debris removal.
S. Contractor to provide job site portable lavatory.
T. Any products purchased b the
Owner that have e to be replaced after
p the initial installation are not covered
e ed
for reinstallation. Therefore,there will be an extra charge for installation.
U. Upon the signing of the Building Construction Contract b 6/16/15,and
Yassumingall the permits from p the
Town of North Andover are received, we will start the project on 7/6/15 and complete by 9/25/15.
V. The Contractor shall correct, repair or replace any defects found due to workmanship in the first year
following the date of completion. Material defects shall be addressed in accordance '
with the manufacturer's
warranty. All labor required to correct, repair or replace any defects due to manufacturer's material defects
shall be provided at no cost for the first year following completion. The following items are specifically excluded
from this warranty:
1. Cracks in.foundation walls or concrete floor slabs are not covered except for those that admit water.
These are covered for two (2)years.
2. Work performed by anyone other than the Contractor or its subcontractors at Contractors order.
3. Insect damage.
4. Damage covered by Owners or Contractors insurance.
5. Defects for which the Contractor has not received notice within the applicable warranty period.
6. This warrant is given y g e to the Owner of the premises only and is not transferable.
NOTE: Any warranty requests shall be directed to the Contractor, in writing, at:
ANNECREST BUILDING CORPORATION
P.O. BOX 290
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BOXFORD, MA 01921
Office: (978) 887-4991
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Note: The Contract Price will not be increased at any time unless changes by the Owner resulting in higher costs
to the Contractor are implemented. The Contract Price will be reduced if work is eliminated by the Owner.
Cancellation Notice:
This Contract may be cancelled within (3)three business days from the signing of this Contract.
Massachusetts
Home Improvement Contractor
Registration Number 112418
Contractor Supervisor License
CS-034453
In WITNESS WHEREOF,the parties hereunto set their hands the day of year first above written.
I — 6—f(, �S
David Tracy Date of Acceptance
ay Tracy Date of Acceptance
ANNECREST BUILDING CORPORATION `I
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By: Basil E.Constantine, President
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"Exhibit B"
WORK COMPLETED AMOUNT
Upon signing of the Building Construction Contract----------------------------------- $27,000.00
Upon completion of rough framing, windows and roofing--------------------------- $21,000.00
Upon completion of siding, rough electric/plumbing and HVAC-------------------- $18,000.00
Upon completion of insulation, inspections and plastering-------------------------- $10,000.00
Upon completion of all work per this Contract------------------------------------------ $7,782.00
Contract Price
$83,782.00
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David Tracy
1
ay Tracy
ANNECREST BUILDING CORPORATION
y: Basil E. Constantine, President
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The Commonwealth of Massachusetts
{ Department of Industrial Accidents
" 1 Congress Street,Suite 100
Boston,MA 02114-2017
www mass.govfdia
ODM Svy
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE FERAUTTING AUTHORITY. ,
.:.Please Print Legibly
AAbphcant Information
Nance(Business/Organization/Individual): I'1►'1 C E'e S t
Cil l V6A Cali A C�f rw I t�N
Address: 8` \A erri c-VL �aw�
City/State/Zip: '30 Phone 4: 9 j7k-Af7" 4 9/
Are you an employer?Checli the appropriate box: Type of project(required); -
1.❑I am a employer with employees(full and/or part-time).* 7. ❑New'construction
2.F1 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 Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
sation insurance or are sole
11.❑Electrical repairs or additions
ensure that all contractors either have workers'compen
proprietors with no'employees. 12.❑
bin repairsavrs or additionsPlun
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROOF repairs
These sub-contractors have employees and have workers'comp.insurance.: 14.❑Other
6`,g 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.
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.
lam an employer that is providing workers'compensation insurance for my employees. he'low is the policy and job site
information. nn L f /� 1
Insurance Company Name: �t T I avil I e- Char l--t `fin Sy`d✓�C P �' /
Policy#or Self-ins.Lic.#: W G I co t co 3 0 4• Expiration Date:
Job Site Address: n r e-a-- P®r4 GQ 9 City/State/Zip: nJ 0 10
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
MGL c. 152 25A is a criminal violation punishable by a fine up to$1,500.00
under ,
Failure to secure coverage as required §
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.
I do hereby certify uunder the p ins and penalties of perjury that the information provided above is true and correct.
Signature � '�� Date: to 410-61se
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Phone#:
Contact Person:
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"d'efined 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
applicaiitwhd has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(1)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 certificates)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
IndustrialAccidents. 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 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
,per T � ✓la�
aas\ Office of Consumer Affairs&B siness Regulation
11 THOME IMPROVEMENT CONTRACTOR
Registration:.-;1,112418 Type:
Expiration: >2,612016 Private Corporatio
AFCREST BUYLDING WX
BASIL CONSTANIINE
81 HERRICK RD. , E
BOXFORD,MA 01929 , Undersecretary
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Constru Ition Supenisor
Licenst CS-034453
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BASIL E CONSTAj4T ..
81 HERRICK RD �
BOXFORD MA 61921
1
1 )1111 \
Expiration
Commissioner 12/21/2015