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HomeMy WebLinkAboutMiscellaneous - 125 Main Street (3) a k fi s b ' c a � A j r r-1 Location No. Date / • - TOWN OF NORTH ANDOVER �. Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee ->iy^' $ TOTAL $ I Check# / r f 1 BLilding Inspector ttORTH Q4�SLEc 161, 0 TOWN OF NORTH ANDOVER ATESIGN PERMIT �Ro APP �(5 �SSACHUS�� DATE: February 1, 2016 PERMIT: 014-2016 THIS CERTIFIES THAT Michael Charron has permission to erect a sign on 125 Main Street — 90" Lon 14"High — "Cosmos" and 74" Long by 5" High Organic Nails & Spa" provide that the person accepting this Permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Sign Regulations in the Town of North Andover. Violation of the Zoning of Sign Regulations, Section #6, Voids this Permit. t INTERNALLY ILLUMINATED SIGNS ARE PROHIBITED Inspector of Buildings Amount Paid:$30.00 Check 1373 Receipt 29973 SIGN PERMIT APPLICATION 1600 Osgood Street—Building 20,Suite 2035 TOWN OF NORTH ANDOVER Map Parcel DATE SUBMITTED Site Owner lY), _wAj CkaCYUn Applicant_ �I� STS(�10�lG�h �l �1QC�►'1 Tel Site Address ha 5 Main 9 k&k Aftdawr MA Size of Proposed Sign aa� A INTERNALLY ILLUMIloTATED SIGNPROHIBITED How attached: aQ4gaaust the wall b)Roof Illumination: aQNot illuminated c) Ground b)Externally illuminated d) Other �i �" Materials: �� X90" 010& PVC J f kr r�►�n �a CJ�( 8 Proposed Colors: Background--nN--e r Lettering Coo _ASAW-solm rtn Co_ . 5")s tri N(L L PVC (p44rcs ( � Border drJ�L Q old Col'NYA iq wwonUm '-a U, Required Attachments: Photographs of building Note: No permanent/temporary sign shall be erected, or enlarged until an Material sample application on the appropriate form fiumished by the Sign Office has been Color sample filed with the Sign Officer containing such information including Site or Plot Plan(Required for all free-standing signs) photographs,plans and scale drawings, as he may require, and a permit Drawings of proposed sign for such erection, alteration, or enlargement has been issued by him. Other, specify Such permit shall be issued only of the Sign Officer determines that the sign complies or will comply with all applicable provisions of the By- Law. Will sign overhang any public road or walkway Yes ( ) No ( ) If Yes,Name of Agency who will provide liability insurance: AN INCOMPLETE APPLICATION WDLL NOT BE ACCEPTED DATE FILED: SI FAP ICANT THE�� MEG C O M P A N I E S I R 1s A L L S 7' A 'I' G i\t r\ N A G E 117 E N T A N U C O N S U L 7' I N G January 29, 2016 Hang Pham and Dinh Pham 15 New York Street Lowell, MA 01854 Re: Sign Approval 125 Main Street, Unit 2,North Andover, MA Deal'Hang and Dinh, i I am writing to inform you that the landlord has approved your sign design for the above l mentioned location. You may proceed with obtaining municipal permit and installation at your convenience. Sincerely, MEG ASSET MANAGEMENT,INC. Michael Charron Director of Property Management 25 ORCHARD VIEW DRIVE LONDONDERRY, NH 03053-3376 (603) 434-6700 FAX (603) 434-0214 MFG ASSET MANAGEMENT,INC.DBA THE MEG COMPANIES REAL ESTATE MANAGEMENT AND CONSULTING i COSMOS NAILS&SPA. BEFORE AFTER Name 125 MAIN STREET IAddress JIM e N.ANDOVER,MA cdamot ORGANIC NAILS 8 SPA n J �.� - —'� •:fit Approval Signature of sign layout plan and permission to install sign as proposed Landlord I Property Manager Date MA Lic#G-15 820402-RI Lic#33835-UL Lic#W168403 Copyright 2015 Art Studio Sign & Neon.All Rights Reserved. A R T S T U D I O Design, design concept, and color combination may not be copied, reproduced, or transmitted without prior written consent be • Art Studio Sign & Neon. 90„ COSMOS NAILS&SPA Name 125 MAIN STREET Address 14" N.ANDOVER,MA 22" 4" PA 96" a) 14"x 90" Black PVC Letters with Gold Colored Aluminum Face ( COSMOS AND LOGO) b) 5"x 74" Black PVC Letters with Gold Colored Aluminum Face (ORGANIC NAILS & SPA) Approval Signature of sign layout plan and permission to install sign as proposed Landlord I Property Manager Date MA Lic#G-15 B20402 -RI Lic#33835 -UL Lic#W168403 Copyright 2015 Art Studio Sign & Neon.All Rights Reserved. A R T S T U D I O Design, design concept, and color combination may not be copied, reproduced, or transmitted without prior written consent be .. .. Art Studio Sign & Neon. l ' COSMOS NAILS&SPA BEFORE AFTER Name 125 MAIN STREET Address iggN.ANDOVER,MA csmot° •" ORGANIC HAIL$8 3PA Jo ,�. '_ ._ • Of it A >,p Approval Signature of sign layout plan and permission to install sign as proposed Landlord I Property Manager Date MA Lic#G-15 B20402-RI Lic#33835-UL Lic#W168403 Copyright 2015 Art Studio Sign & Neon.All Rights Reserved. A R T S T U D I O Design, design concept, and color combination may not be copied, • • reproduced, or transmitted without prior written consent be . , Art Studio Sign &Neon. 90IV COSMOS NAILS&SPA Name 125 MAIN STREET Address 14VIN.ANDOVER,MA 22" 4" Arm1:�j QU '�-j dL`0 96" a) 14"x 90" Black PVC Letters with Gold Colored Aluminum Face ( COSMOS AND LOGO) b) 5"x 74" Black PVC Letters with Gold Colored Aluminum Face (ORGANIC NAILS & SPA) Approval Signature of sign layout plan and permission to install sign as proposed Landlord I Property Manager Date MA Lic#G-15 620402-RI Lic#33835- UL Lic#Hf168403 Copyright 2015 Art Studio Sign & Neon.All Rights Reserved. A R T S T U D I O Design,design concept, and color combination may not be copied, reproduced, or transmitted without prior written consent be . Art Studio Sign & Neon. Date/v/' /.5........... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that.... ........... .........I....... .......................................... has permission to perform...-7.... ........L7.0... plumbing in the(buildings of at.J.0.7......./-/ North Andover, Mass. Fee .......Lic. No. /.55.7a. ................................................................................. & PLUMBING INSPECTOR Check* (tI� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY ___I MA DATE�/-/ ( PERMIT# JOBSITE ADDRESS O — � � OWNER'S NAME _ POWNER ADDRESS 1 /5 EI_ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ] EDUCATIONAL © RESIDENTIAL O PRINT CLEARLY NEW: RENOVATION:8 REPLACEMENT:Q PLANS SUBMITTED: YES® NO 01 FIXTURES 7. FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 1 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE yi _.I I _ ._ _ _..._.___.1. _...__ _ _ ; _w I I DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ! _.__. i ,_. _t —.{ -_ _i _I __- _ _. _1 ( 1' a .1 _. ._1 _ i DEDICATED GREASE SYSTEM _._1 _ I _.___._..1 DEDICATED GRAY WATER SYSTEM 4 _ ( _.E � I .- I E_j ( ___( I ___.. i 1 1 DEDICATED WATER RECYCLE SYSTEM { 1 .._-_.._.._I I � ..__. r k __....! ._...__I _ __I DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER - I . J I ._..___i ( .—_..I � --_--._-I � __1 _---_I __1 i __-_..I FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 l -- ..- -__.�l ____ ___.___I ___.� .__._ ____{ _______1 .._..__.._- _-_._- I LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET _—..I .___ URINAL Ll WASHING MACHINE CONNECTION/ i _ _! .._._- ` ____ __! WATEP,HEATER ALL TYPES WATER PIPING ( ► __...__.I _..... _-I .__...__I 1 ___. 1. I i OTHER _ . _ ! I _i _. i ._.----__1 _--_.__1 _ __I t _--._i ._..__.__I ....__.__J ► .---...__I —i _I ----__.I _ I - _I _.____i _.__._..._t I _.___I __---i ---.. _._I ...__1 _f W INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO Ell IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY DI BOND M OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER —1 AGENT (0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I LICENSE MPX' JP Q CORPORATIONJ#©PARTNERSHIPS# __� s LLC COMPANY NAME ADDRESS i CITY STATE /t-_ ZIP a ,^—� TEL - FAX ( CELL��EMAIL I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSrECTIONNOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES l I The Commonwealth of Massa chusetts M Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): f (� Address: City/State/Zip: 7 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with (.. . employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in g. Remodeling any capacity.[No workers'comp.insurance required.] 3.F1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 1 F1 Demolition 10 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑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 listed on the attached sheet. ❑ - 13.FJ Roof repairs These sub-contractors have employees and have workers'comp.insurance.1 6.F-1We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[J Other 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. I Homeowners who submif 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: �O/��( �j�P/y Attach a copy oft a workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury Haat the information provided above is true and correct. Signature- Date: 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 Contact Person: Phone#: 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." 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 cant'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 foi 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' compensatioii 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 bum 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 �a�x COMMONW ....-�.�. EALTH OF MASSAICHUSETTS> PLUMBER..§; ',A�Nt?' GASF:.1 T; <: . ISSUES -T-R THE FOLLOWII' ++ L I C� IS'Ei` AS q ENSE 1 ! MA.STER�PLUMBR TSI NGUYEN 12 DEVINE RO' �S lt€DOLPHr to 02368-387 ! ! SS > : '`> 0: :: 221669 q + Date......... ......... .. ............. �NORTM TOWN OF NORTH ANDOVER s PERMIT FOR WIRING CHU �1 71- �f 4"This certifies that ....................................................................... has permission to perform ........ ........ ......CSvrt.t 5.../...a.... wiring in the buildi g of......... -rSS �4 .......................... .................................................. /w. r at ....f. .��..............................,.. 7 ................:................North Andover,Mass. Fee.!C??� ........Lic.No. -!..iIJ. .................................................................................... / 2 ELECTRICAL INSPECTOR/// Check# /do 3 1 Official Use Only y -C111\ Commonwealth of Massachusetts Permit No. Department of Fire Services ' Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: -- [ {O City or Town of: NORTH.ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intentio o erform the electrical work described below. Location(Street&Number) rj / ' 1 Owner or Tenant C o s m a s tj 66L— �P Telephone No� Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: LAJi/ Completion o the following table may be waived by the Inspector of Wires. V No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA i No.of Luminaire Outlets No.of Hot Tubs Generators IVA AboveIn- o.o mergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Detection and �— No.of Switches No.of Gas Burners Initiating DevicesTot No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Ner Tons KW No.of Self-Contained P Totals: ........................... "...........".I....................... Detection/Alertin Devices Space/Area Heating KW Local --I Municipal El Other No.of Dishwashers S P g Connection Dryers Heating Appliances KW Security Systems:' No.of Dr y No.of Devices or Equivalent No.of Wateri KW No.of No.of Data Wiring: Heaters l Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Valu of Electrical Work: l L.) -(When required by municipal policy.) Work to Start Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The t undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. fit CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) 1• I certify,under thed p realtieserjury,lit at tl tion on a' application is true and complet 1 FIRM NAME: . rnzad (/1LIC.NO.: L)-- Licensee: Signature LTC.NO. G}T//06 (If applica a t�erl"exec t"i a icense nztm�line r � �� Tel.No.� / t�U Address: =1 '{/f�_ � 1 1 ,Tel.No.• *Per M.G. c. 147,s.57-61,security work requires Department of Public Safe "S"License: Lic.No.• OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the liability insurance coverage normally 1 required by law. By my signature below,I hereby waive this requirement. 1 am the(check one)[]owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature — Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the r . s permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, §32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed IN Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: a SERVICE INSPECTION: Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: PassM Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com t The Commonwealth of Massachusetts £ Department of IndustrialAccidents r d 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia sy'y Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name(Business/OrganizLndndividual):•Address: S � City/State/Zip: Fd o 7 G-I Phone#:_77V—c) Are you an employer?Check the appropriate box: Type of project(required): 1.Q I am a employer with employees(full and/or part-time).* 7. ❑New construction am a sole proprietor or partnership and have no employees working forme in $. 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.Q I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]Other 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] *Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit 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-coniraciors 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.Lie.#: Expiration Date: 0 Job Site Address:) City/State/Zip: /I`'" A�'✓�G�/ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and s andpenalties ofperjury that the information provided above is true and correct. Signature: C)-- r/ Date :&—.3 6�2 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 1 Contact Person: Phone#: r f 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 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 be submitted to the Department of Industrial Accidents fok 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 permiVlicense 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-MASSA-FE Fax#617-727-7749 Revised 02-23-15 www.Mass.gov/dia � �.��V'1Y•r i"'-.ww.'�J.#w-s 4-�wx._.T .J':..x,.,,.„ -. - .. �dLl@lMAW :kfUETTS� c BGARD wr . 1 SSUES THE FOLLOW N[; tFCENSE � 4 AS A` FFGOURNfYMAN;ELE ' ro PkfET PHOUTHAUONG -( iQ 32�+ PURI: AS 175 ( 78(Q• ' ,2.68 6. tt