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HomeMy WebLinkAboutBuilding Permit #384-2016 - 88 ADAMS AVENUE 9/24/2015 BUILDING PERMIT 0RNORTH TOWN OF NORTH ANDOVER 02 APPLICATION FOR PLAN EXAMINATION Permit No#: O - D/( Date Received 4 4DRA7fD �SSRCHUS�� Date Issued: �! IMPORTANT:Applicant must complete all i ems on this page LOCATION PROPERTY OWNER l rbqc� Print 100 Year Structure yes no MAP PARCEL: ��Z ZONING DISTRICT: Historic District yes no Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSFD USE Resiorrial Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑AI ion No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ---n\ ._- _ __ ._ . _ __ __ __A ___ . ❑ Septic1Nkl,, 11 Floodplain Wetlands ❑ 1NatersF ed�_®istnctz ❑V1/aterlSewer; ' DI I TON OF WORK TO BE PERFORMED: I entificati - lease Type or Print Clearly Q� OWNER: Name: Phone: Q Af� Address: ' PCkq,,NS- Avi. h oz G- 40 Contractor N me: n )?hone: Email: f Address: me j � I Supervisor's Construction License: `J n Exp. Date: 1 Home Improvement License: �3 Exp. Date: l - , l ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDIN6 PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $�► , FEE: $ ��0 00 Check No.: S`J7oc:;'- Receipt No.: 9�//2 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Sian p - Location 6'Cf C°rz"'r sf Date • • TOWN OF NORTH ANDOVER • Certificate of Occupancy $ �ry Building/Frame Permit Fee , KZ 7 Foundation Permit Fee $ Other Permit Fee $ Afi TOTAL $ Check li Building Inspector. Jr i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ElPrivate(septic tank,etc. E] Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF ® U FORM � PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Si nature COMMENTS i HEALTH Reviewed on Signature COMMENTS A- I Zoning Board of Appeals:variance, Petition No: Zoning Decision/receipt submitted yes i Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/signature Date Driveway Permit DPW Town Engineer: Signature: 2 ° Located 384 Osgood Street {FIRED >� ���.-ME�N,T T�emp�Dumpsfer onsite es •r ,' �` �- '- �`N"�•r=--a�.�; �- 4iLocated at 124�MainFSt_feet, , � k t �y5 �--d. , F E ' Fire©apartment signature/date 'COMMENTS°, . •;,;. , . . R .. 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 Call Email Date Time Contact Name Doc.Building Permit Revised 2014 J 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 4. Building Permit Application 4. Workers Comp Affidavit I Photo Copy Of H.I.C. And/Or C.S.L. Licenses I Copy of Contract I 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 4� 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) 4. Mass check Energy Compliance Report (If Applicable) i& 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) 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 66 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 { Doe:Building Permit Revised 2014 E r 1t%ORT1l w: � EAuc . : ve: No. * o�hn ver, Mass, �Y /S" A- COCHIC"RWICK ��' 7,9 q�'ggTED APp,��(y S U BOARD OF HEALTH Food/Kitchen PERMIT T LD /�j Septic System THIS CERTIFIES THAT ...... /G ...(/'O.r4/(.:�f................ ................. ............................... BUILDING INSPECTOR has permission to erect......................... buildings on ... .aolc- vee ......................... Foundation Rough to be occupied as ............. ..��i�?...�... .. �6Zp 1.................................................................... 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 STARTS 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. PROPOSAL L.E. Morgan Construction Company we Accept: 86 Billerica Avenue,Unit#1 =SA # �t N. Billerica,MA 01862 �� ascc var Office: (978)670-4747/Fax: (978)670-6477 PROPOSAL SUBMITTED O PHONE DATE ffie- D�ems 7?-6P6-7©-PP STREET Jr JOB NAME 8 S v Pi CITY,STATE AND ZIP CODE JOB LOCATION A) Aucl uor !`?A CONTACT CELL PHONE OTHER JOB PHONE �p a73 34aa Strip down to the wood deck, layers of shingles, dispose of debris to a licensed recycling facility: Install &' ice and water shield at the gutters feet of ice and water shield in valleys. Install synthetic underiayment on the remainder of the wood decking. Install 8" aluminum drip edge on'all perimeters, color choices: A White, ❑ Mill, ❑ Brown, ❑ Copper. Installs' ayear G ro architectural asphalt shingles, and hurricane nail. Install ridge vent manufactured by _� �ti4 to all ridges and dormers. Install new skylight flashing kits manufactured by N,1,4 Flash all cheek walls, pipes, skylights, and penetrations to manufactures specifications. Remove existing lead flashing /oolD New -00 '�6 chimneys and install new lead flashing. Install matching cap shingles to all ridges, hips and dormers. WE PROPOSE hereby to furnish material and labor-complete in accordance with above specifications,for the sum of- krz I!,a Re w�a n. `tea h I-••,t �: dollars($/013 ). All material is guaranteed to be as specified.All work to be completed in a workmanlike Authorized Signatur eC manner according to standard practices.Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.Our workers are fully covered Note:This proposal may be withdrawn Q by workmen's Compensation Insurance and Liability Insurance. by us if not accepted within / b days. [he�rCEPTED AS A CONTRACT-The above prices, Date of acceptance: ec�by ifications and conditions are satisfactory and are _,,Leuthorizea Signature: r accepted.You are authorized to do the work as ✓� ecified.Payment will be made as outlined above. Anthor;zea signature: Additional Remarks: INGLE COLOR— l4,)(. e f G`. c PPC* e-.j1-1G-S J a .`.C1 ✓tie. moi` �% '� �' THANK YOU FOR CHOOSING L.E. MORGAN CONSTRUCTION CERTIFICATE OF LIABILITY INSURANCE DATE Q7117119(MM//9015 Y) TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: BALDWINIVVELSH PARKER INS PHONE FAX 131 COOLIDGE ST,SUITE 4100 (AIC,No,Ext): (A/C,No): HUDSON;MA 01749 E-MAILADDRESS: 27KLD INSURER(S)AFFORDING COVERAGE NAIC# INSURED I INSURERA: AMERICAN ZURICH INSURANCE COMPANY L E MORGAN CONSTRUCTION INC INSURER B: INSURER C: PO BOX 75 INSURER D: NORTH BILLERICA_MA 01862 INSURER E:INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE IS COMMERCIAL GENERAL LIABILITY CLAIMS MADE r7 OCCUR. DAMAGE TO RENTED S PREMISES(Ea occurrence) MED EXP(Any one person) $ PERSONAL&ADV INJURY S GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY PROJECT LOC PRODUCTS-COMP/OP AGG S AUTOMOBILE LIABILITY COMBINED SINGLE I$ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA UAB []OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIM&MADE AGGREGATE g DEDUCTIBLE $ RETENTION S I$ A WORKER'S COMPENSATION AND XWC STATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-58738312-14 12/14/2014 12/14/2015 LIMITS ANY PROPERITOR/PXCLUDEIEXECUTIVE OFFICER/MEMBER EXCLUDED? O NIA E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS belo1v E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS CERTIFICATE HOLDER CANCELLATION TO\NRNT OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD ST;BLDG 20,STE 2035 BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRTA ( — NORTH ANDOVER,MA 01845 f- � ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved- LEMORGA-01 BBOYER A�R� CERTIFICATE OF LIABILITY INSURANCE DATE DI5 7/712015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Welsh 8 Parker Insurance Agency,Inc.I Hudson Office PHONE 978)562-5652 aJc No:(978)552-7120 131 Coolidge Street,Suite 100 Alc No Hudson,MA 01749 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Western World Insurance Company INSURED INSURER B:Safety LE Morgan Construction Inc INSURERc:Scottsdale Insurance PO BOX 75 INSURER D: Billerica,MA 01821 INSURERS: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE INSD WVO POLICY NUMBER MM/DDY EFF MMIO EXP LIMITS A X COMMERCIAL GENERAL UABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE F—xl OCCUR NPP8237995 0411312015 04/13/2016 DAMAGE TO RENTED PREMISES Ea occurrenceS 100,000 X Contractual Liabilit MED EXP(Any one person) 5 5,000 PERSONAL BADVINJURY 5 1,000,000 GEITL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 5 2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE OMIT (Ea accident) S 1,000,000 B ANY AUTO COM6230688 1011312014 10/13/2015 BODILY INJURY(Per person) s ALL OWNEALUIASX HEDULED AUTOSTOS BODILY INJURY(Peraccident) S HIRED AUTN OWNED PROPERTY DAMAGE TOS P "den11 S 5 UMBRELLAOCCUR EACH OCCURRENCE 5 5,000,000 C X EXCESS UCLAIMS-MADE XLS0096729 04/13/2015 04/1312016 AGGREGATE $ 5,000,000 DED I I RETENTIONS $ WORKERS COMPENSATION PEROTH- AND EMPLOYERS'UABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT 5 OFFICERIMEMBEREXCLUDED? N/A yes.d y be and E.L DISEASE-EA EMPLOYE 5 1 If yes,dzscribe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I S DESCRIPTION OF OPERATIONS i LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached B more space is required) Proof of Workers Compensation coverage will be sent directly by the carrier. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street,Bldg 20,Suite 2035 ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD .. -- -- Massachusetts-Department of Public Safety --- —--: :ioard of 0-Wiciln^y R_^g iations and Standards Jin i%04?bP1L�^aegq�//,� df - Office Ofy�OnSnrDerAl['�ns4n� J'uness egTation HOME IMPROVEMENT J CONTRACTOR License: CS-079476 L' `-Registration• 137913 � Type: Expiration: 1/27/2017 LAWRENCE E M�R. IndividJa! 86 BILLEffiCA ASE € LAWRENCE E.MORGAN JR. N BMLERICA MA 0186 ra f 0`40-7 LAWRENCE MORGAN JR. 86 BILLERICA AVE UNIT 1 ` Expiration N.BILLERiCA,MA 01862 Commissioner 06!03/2017 Undersecretary 0 - saroer�idsnartri - - J � AMtS.VC'JpS . - y,,}f� n Z e S dY This card acknowledges that the recipient,has successfully completed a S•>'e.w trnenc of a c 30-hour Qc+upafionat Safely and Health Training Course in DccvPationat Safety and Fear,!! Construction Saiety,and Health I L A R R� MO &AtQ R A/1!,j!g, Je i '21.Successfully completed a!G-`:cur O;;cup3[:Crtal Safety and:Health Training Course in i Construction Safery 8 Health (Trainer name—printortype) 1 L6U1 S RCNDS&.1J 0.5AU&69 — (Course end date) ' (rztnep (Da,e? ROOF TOP RECYCLING Recyclers of Asphalt Shingles SEAN ANESTIs PRESIDENT&CEO 369 CODMAN HIT f ROAD TEL 978-263-1899 BoxBORouGH,MA FAX_ 978-263-1879 EMAM ROOFroP1CVE1uzON.NET CELL 508-726-5341 t i I f I 1 e Com ealth of assachusetls De artmkhttflndustr4idAecidents I Con) e s Street,,S ite 100 i BoAk n,MA 02119:2017 144 1W mass govMa Workers'Compensation Insurance-l{ fi avit:Builders/Contractors/Electricians/Plumbers. TO BEFILED THE PERMITTING AUTHORITY. Applicant Information I A I I A. Please Print Le ' 1 Name(Business/Organization/individual):I ,E, r �1Address: City/State/Zip: ri, Phone#: Are yon a oyer?Chcck tb appropriate boa: Type of project(required): 1. am a employer with employees(full and/or part I 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees rkitrg forme in any capacity.[No workers'comp.insurance 8. []Remodeling 3. I am a homeowner doing all work m sel£ { 9. ❑Demolition ❑ g y [Nonworkers'comp, ce required.]t { 10[]Building addition 4.Q I am a homeowner and will be hiring contractors to conduct a1. voi k on my prope . I will ensure that all contractors either have workers'compensati'oince or are sole' 11.Q Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors Id on the attached bhcet. These sub-contractors have employees and have workers'come I, in urance.$ l 13.E]Ro S 6.r]We are a corporation and its officers have exercised ised their righ of emption pen•MGL c.l 14. Other 152,§1(4),and we have noemployees.[No workers'comp.fi >radce required.] Any applicant that checks box#1 must also fill out the section belowblnovring their worke s'compensation policy information Homeowners who submit this affidavit indicating they are doing all Terk d then hire outside'contractors must submit anew affidavit indicating such Contractors that check this box must attached an additional sheet sho ge name of thejsub-contractors and state whether or not those entities have employees. If the sub-contactors have employees,They must provide ti it(workeis'comp_`policy number. I am an employer that is pi o iding workers+'compensatz' n 8nsurance employees.'Below is the policy and job site information. �r Insurance Company Name: I � Policy#or Self-ins.Lic.#: V 5 159 5)Id1 Expiration Date: o? )LQ-01A )S G6(/v m Job Site Address: City/State/Zip-N. 1� n `�J Attach a copy of the workers'compensation Q n policy d i i lar page 'showing the policy number and expiration date). Failure to secure coverage as required under NIGL C.15Z § {, 2 5A is a crinunal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties i a the'form of a S tOP WORK ORDER and a fine of up to$250.00 a day againste iolator.A copy of this statement may be If bn Varded to the Office of Investigations of the DIA for insurance coverage voififation. Ido here c tify under the pains n p it' fperjat at the i �Madon provided ove is true and correct 4 Si a Date: odd' S Phon #: ff0fciase only. Do not write in this area,to be cone et�d by city or!fown official own: I I (Permit/License# Issuing Authority(circle one): 1.Board of Health Z.Building Department 3.City Mtn Clerk 4.ii{electrical Inspector S.Plumbing Inspector b.Other Contact Person: Ph one 4: Information ind I tructions Massachusetts General Laws chapter 152 requires all employers to )v i I 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,a 3sociation,c rp .ition or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal rer sentativesof a deceased employer,or the receiver or trustee of an individual,partnership,association or other I ag 1entity,employing employees. However the owner of a dwelling house having not more than three apartments an li6 resides therein,or the occupant of the dwelling house of another who employs persons to do aintenance, on st 'ction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall 6t because o stic i employment be deemed to be an employer." I MGL chapter 152,§25C(6)also states that"every state or local lice s' I agency shall withhold the issuance or renewal of a license or permit to operate a business to contra t ii J14ings in tie commonwealth for any applicant who has not produced acceptable evidence of complian e i th the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commo wa Ith nor any flits political subdivisions shall. enter into any contract for the performance of public wolk until ac.! 1 evidence of compliance with the insurance requirements of this chapter have been presented to the Contracting a A I ity." Applicants (� Please fill-out the workers'compensation affidavit completely,by c ec g the boxe that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)�andphone .ir(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited LiabilityPar n,,r6ips(LLP)with no employees other than the members or partners,are not required to carry workers'61ompensation s rance. If ah LLC or LLP does have employees,a policy is required. Be advised that this afffidavit may b sl `tted to the Department of Industrial Accidents foi•confirmation of insurance coverage. AlsQI'be sure to,si nd date the affidavit. The affidavit should be returned to the city or town that the application for the permit or liceis being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law if you are required to obtain a workers' compensation'policy,please call the Department at the number listed be o 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 111gibly. The De p I art I ment has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigat on as to contact you regarding the applicant. Please be sure to fill in the permit/license number which twill be usedas z eference number. In addition,an applicant that must submit multiple permit/license applications m' any given year,nil ea only sulimit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the a p c t should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or m k11310 y the city�or town maybe provided to the applicant as proof that a valid affidavit is on file for fu 'e permits o, li I ses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit o�r lated to business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said per,on is NOT r q 'i d to complbte this affidavit. The Department's address,telephone and fax number: G r i The Common health of M a& chusetts Department of Industria A idents 1 Congress Street, Siit 00 Boston,NIA 02114 20 Tel.#617-727-4900 it.7406 oi 18 7-MASSAFE Fax# 17-727-749 # Revised 02-23-15 www�masS.g0 is