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HomeMy WebLinkAboutBuilding Permit #795 - 92 HEATH ROAD 5/3/2012L BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0:-2Date Received > Identification PIease Type or Print Clearly) OWNER: Name: Phone: r' ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $__ �L0, 6,S-,2. Qy FEE: $_ (9 T Check No.:�Z Receipt No.: 0 NOTE: Persons contracting with unregistered contractors do not have access toAhe guargnty.fund 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 0 Nil 11 LVII E N T S 'HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street 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.Suilding Permit Revised 2010 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 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 ❑C..brie, 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: Building Permit Revised 2008 Location No. Date oz - Check # )-- 25260 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector Massachusetts Home Improvement Sample Contract This form satisfies an basic ngmmnwft of the swe's Hine Improvement Co L-iw (MGL chapter 142A� but does not include standard mogmge to ptrobeet honeotraera. Seek kgal advice if neotssary. Any prion planning home improvements should fast obtain a copy of -A Massadtautls CmsumerGuideto Home Im)aovmunr before agteeing to anywodton ymQreddence. You may obtain afieecopy by calling the Office ofCAnsionerAffairs and BminessRegnlahon's Consumar Information Hoilme id6l7-973-9797 or 148&283-3757 or on our website. Homeowner Information Contractor Information Name COY Name --T-nocr,cs Lrnrr+sor, k.,c-an L.LG ShoetAddres (do not use aPost Office Box add=) CorttracMdSalespersorJ OwtreName Ci a eta. Cityfroam - state zip Code BasmemAddrest (must include asiedaddress) (lO. Rc.3nM V '19 al EvergC--cry Oc . Daytime Phone Evaong lthorre CiWT— Stele Zip Code !-lrX n,?S+e"Ld Q )i -t 03 F 14 l MadigAddress(ft dittandfamabove) BnsnesPhoae Uo3 aalEmployer IDorsSNumber raw,e11 Qd end tutu H=cImpmrma ce OWWRea.NMher r*ndiandue The Coutratxoragrees to do the finowingwork fo?iheHomeowner. (Desaibemdamlthewwktocomphftd speofyingthetypSbraad,andgmdeof materiatstobeused, amaddidonalsheetsifnecessaiv) Required Permits -The following building permits are required Proposed Start and Completion Schedule -The fallowing schedule will and will be secured by the contractor as the homeowner's ageW. be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work MGL chapter 142A.) Date when contracted work vAH be substantially completed The Contractor agrees to putbrin the work, tmmsh the maul and labor specified above for the total sum of Oc uT(2 S at, , U U,(') Payments v nit be made according to the fonowiog schedule: $6.000 upon signing contract (not to exceed 1/3 of the ental contract price g the ocet ofspedat order items, whichever is greater) S -5 COO by �_� or upon cemplelion of �3E'ek ,f S by or upon completion of $k upon completion of the contract. (lawforbids demanding fall payment until contract is completed to both party s satisfaction) The following mffiesiaVesptipramt must be sperdal s to be paid for ordered before thecomtacted work begins in aux to meet the eemplefmasebeddn(Ph S to be paid for NOTES: (h lean finWW eharga4 (*') lawregain s that any deposit or dcm°-Payincat requi;d by the conuactorbefwa work begins may not .dtheVeamof(a)ooe4hvdoftbetaalo prices(b)theaeoWc tofmyspeciatagtupaumora�ammademater l which must be special ordered inadvaffietomeatthe conWedanschedule, Smrets Warrant. - provided by the cantrachm? 0 No © Yes (alt tevim of the viarranty mast be aged to the contreca Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless oftbe actions of any third partyfsubcuntractar unlined by the coatrastor. The conttadorfiather agrees to be solely responsible for all payments to all subcontractors for materials and labor tides this agreement CoatmdAcceptance-Upon signingthis ddiammtbe==abmdmgeontractunder law . Unless otherwise noted within this document, the contract Shan not imply #an any lien or other security interest has been placed on the residence Review the following cautions and notices carefirny before signing this contract Don't be pressured into signing the conham Take time to read and fultyunderstand it Ask questions if something is unclear. • b tea sure the conhador boa valid Home Immovement Cel Registration- The law requires most home improvement contradors and subcontractors to be registered with the Director of Home improvement ContractorRegstrafion. You may inquire about conawor registration by writing to the Director at 10 Park Flan, Roam 5170, Boston, MA 02116 or by caning 617-973-8787 or 888-283-3757. • Does the contractor have insuraxc7 Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to see a copy of a "proof ofiosarancte dormant • Know yarn rights and responsibilities. Read the important Information on the reverse side of this form and get a copy ofthe Consumer Guide to the Home improvement Conttranmorlaw You may caacd this agmement!fit has bum signed at aplace other than the contcaoWs normal place ofbusiaes%providsd you notify the c'auira=m wn1mgathislltettonin office or branch office byordinary M1 posted, by telegram snot or by dchvmy, not tate than midnight of die third basmess dayfonowmg the sig mg ofdas agremient. Seethe attached noticeof cancellsiiar form for an explanation ofthis right DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Twoidanficatoapp`sof wovpetmatbopinedandsipc& ooecopys—Hiptedcbmmwoec ihtadwcopy d—Mbelxptby0tooaaaet� Homeowner's Si Con 's Signature f'rG/Pi I , of 0 •_j/:3 /acct � Dame Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to sAarbUrdtion, as provided In Massachusetts General Laws, er 142 Homeowner's CODYactor's Signature NOTICE: es of the parties above apply only to the agreement ofthe parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer protection laws (i.e. MGL chapter 93A) may' not be waived in anyway, 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 sewre their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold m Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfiilly agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). Execution of Contract The contract must be executed in dunlicate and should not be signed until a copy of all exhibits and referenced documents have been attached Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day rescission period has expired- Accelerated xpiredAccelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself to be financially insecure, the contractor may require that the balance of fimds 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 flee copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at hitp:;/�t��«.mass.�o�;ocahr! If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at 11ttn:ir'�i�� �c.mass.eowbcabr! Go online to view the status of a Home Improvement Contractor's Registration: htto•,'idb state.ma_us/homeimprovement/licenseelist.asp For assistance with informal mediation of disputes or to register formai complaints against a business, call: Consumer Complaint Section Office of the Attorney General 617-72748400 AND/OR Better Business Bureau 508-652-4800, 508-755-2548 or 413-734-3114 version 2.1 - 11/22/2010 John Yforan Construction, L.L.C. (Bu_i{,dii q rind ertiodefing 21 Evergreen Drive Hampstead, NH 03841 April 25, 2012 Thomas Lamson 92 Heath Rd. No. Andover, MA 01845 Dear Dr. Lamson: Specifications for contract to reshingle roof as follows: 1. Strip existing wood shingles. 2. Add a layer of '/2" CDX plywood over existing boards. 3. Install new white drip edge on leading edges and rakes. 4. 6'-0" of Grace Ice & Water shield on roof edges and in valleys. 5. 15 lb. felt on remaining roof. 6. Install Certainteed Landmark Black onyx asphalt shingles. 7. New flashings where needed. 8. Reshingle cupola roof to match. 9. Disposal of debris included. 10. I will apply for permit. Cost: $20,652.00 Respectfully submitted, John Horan a- State of Massachusetts Home ;Improvement Contractor License #102071 State of Massachusetts Construction Supervisor License 447989 hF?-2<&34.5 phone 603-329-6209 fax 603-329-6209 Page 1 Massachusetts . OePartment o€ F sb4io safety " Board of Building. Re rations n0,Standard.s f �rnstlui€}tsar �<.t�=�:i4t,fr - License: CS -047989 JOHN V HORAN '� z 21 EVERGREEN DR. r Hampstead Nji 03841' ®� tw Expiration commissioner 03/02/2014 ���e C�c��znzciiulca�(f a%�C-/�ji�s:sac�usel(J 2� Office of Consumer Affairs & Busibess Regulation j— OME IMPROVEMENT CONTRACTOR Type: N Registration. T02071 DBA �/7�`xpiration 6/30/2014 y JOHN V. HORAN CONSTRUCTION John Horan 21 EVERGREEN DRIVE g� HAMPSTEAD, NH 03841 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 q i� -_ Not valid without signature Client#: 490547 JOHNHORA ACORD. CERTIFICATE OF LIABILITY INSURANCE uraic lmmruurrrrrl 4/24/2012 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 iholder its an ADDITIONAL IINSURED, the policy(!es) mustbe endorsed. Ilf'SUBROGATIO.N IIS'' 111A'IVBD, sUb'ject 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'COO',fNTA4CT USI Insurance Svcs of NE, Inc."N PO Box 6360 Manchester, NH 03108-6360 603 625-1100 GENERAL LIABILITY X COMMERCIALGENERAL LIABILITY CLAIMS -MADE � OCCUR I 60362541,00 FAx E-MAILmac' .ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Maine Mutual Group Insurance Co 15997 INSURED John Horan Construction LLC INSURER B: EastGuard Insurance Company 14702 i :DA'MAGE TO RENTED i �PREMISES� Ea�occErence :$2501000 y 21 Evergreen Dr. Hampstead, NH 03841 � INSURER C : INSURER D 4 INSURER E INSURER IF:: $ 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 CONTRACTOR 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. INSRI LTR TYPE OF INSURANCE �ADDL INSR UBR WVD POLICY NUMBER IPOLICYIEFF , MM/DD' , t IP.OLICYIEXP ;_ MM/DO, ,- ,j LIMITS A 1 GENERAL LIABILITY X COMMERCIALGENERAL LIABILITY CLAIMS -MADE � OCCUR SC10955638 4N0112012 1041,011201' EACH OCCURRENCE •$'1;1000,1000 j :DA'MAGE TO RENTED i �PREMISES� Ea�occErence :$2501000 y MED EXP (Any one person) :$.5, IOOO PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'LAGGREGATELIMITAPPLIESPER: POLICY ;jE Q LOC PRODUCTS-COMP/OPAGG $2,000,000 $ A AUTOMOBILE X X LIABILITY, ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS X AUTOS ! I KA10955638 4�0�,42012 041011.201}. ,COMBINED.`SINGL`EfCIM1T 1000; OOO Ea accident 1s , BODILY INJURY (Per person) $ IBODICYfINJURY;(Peraccident) $ IPROPERTYDAMA'GE P.eraccident $ $ I A X UMBRELLA LIAB EXCESS LIAB OCCUR (CLAIMS'.MADE. KU10955638 041011.2012 ON0112013 EACH OCCURRENCE $1,000 000 x000 AGGREGATE :$1,00 0,000 DEDRETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A JOWC225195 4N01J201,2 04/0112.01' WC.STATU- "0TH-' .X T.PR E.L. EACH ACCIDENT '$500.'000 iEJL.;DISEASE-!EAiEMPL'OYEE x$500,000 pp E.L. DISEASE - POLICY LIMIT $500,000 B DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) This Certificate covers all operations usual and customary to the insured's business. I i I I For Information Purposes Only SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD ICORPORATIION_ All] Irieh'tc Ir,PnPrvPd ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S7173249/M7173245 LCACA The Commonwealth ofMassachusetis - Department oflndustriglAccidents Office oflnvestigations 600 Washington Street Boston, MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/ContractorsfElectricians!Plumbers Applicant Information Please Print Lep-ibly NaMC (Business/Organization/Individual): `��y y� f j G ct:!�nC ��c.�iaD.� 4.G.C. Address:_-- - _ A) LUCjr- ` Tc -erg �r, Ue City/State/Zip:_ 11 t s� ee ak AM Phone #: 603 III "Gi-0 T Are yo n employer? Check the appropriate box: Type of project (required): 1. I am a employer with Z 4. ❑ l am a general contractor and I 6. Now construction ' employees (full and/orpart-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet, z 7• ❑ Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for mein any capacity. workers' comp. insurance. g, F1 Building addition [No workers' comp. insurance 5. F1 We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing. repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' _13.0 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 ere doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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% � �S � (j c�cc✓'O( 2A SV ri6,/, ,e _ —Sb v � Policy # or S elf ins. Lic. #: S D (,J G 2,2 S_ 11 5 Expiration Date: � / O Job Site Address: �'/ dea, k 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 requiredunder Section 25A of MGL o. 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 civilpenalties 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. for insurance coverage verification. I do hereby cer#A Oder 17y pains andpenalfies ofperjury that the information provided above is true and correct. r& Phone #: V e� n 3 34-7 - lv 461 Official use only. Do not write in this area, to be completed by city or town official. City or Town:. Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone Information and Instructi®n8 . 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 ofhire, 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 Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current Policy information (ifnecessary) 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 ofMpssachvsetts Department of Jndustrial Accidents Office of Investigations 6.00 WasWVoa Street Boston, MA. 02111 TO, # 617-727,4900 err; 406 or 1-877,MA.SSAF13 Revised 5-26-05 Fay, # 617"727-7 749 www-mass,gevIdia CO) m X C m CO) CO) mm D CO) .O C � O CO2 CO) =. O CD a z v) o.O '0. r c d = y 70-1 aO CD CD O CLQ "dCD CDo CD C CD y CD S. O � to CD I y O CD z 0 � CD CD O CD 0 :l It r� rn^ V ) n Ocn� cn n� rn O� z O z cn C 0 Wall = _. ;;.C,..,' Q. y »mC2 m CA v, o cic 3. 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