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Miscellaneous - 1600 OSGOOD STREET 4/30/2018 (18)
i . I E �� i i t I +I� 1 I i •� I T I I 1 t I �oo ��I �.. �„r,,b • �� ti DateZ . ..2.7�.g. 7. NORTFI TOWN OF NORTH ANDOVER PERMIT FOR WIRING �7SgACHUSEt This certifies that . L�- L z�2` c �N C- ....................:�.... .............................................. has permission to perform ......... .. v P ... ........ .................................... wiring in the building of 0Z Z e �`� L�9/v/rJ ........Z Z. a.'.............. JNorth Andover,Mass. Fee. s � Lic.No.t (!75-.03,4 �/ .......... .....................1�,.r�!............�.. ELECTRICAL INSPECTOR Check # — 7Bu3 Lommonweairn or massacnusetts utncial Use unl f -7Department of Fire Services Permit No. Is Occupancy and Fee Checked kv BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/051 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 12 2 4 City or Town of. NORTH ANDOVER To theIn pec or of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street& Number) 1600 aS 0oA Ef. 6u'i Edi,o 1 Z0 2c,,A R_61j � Owner or Tenant KX N60a s+, L.LZ QZZ t j � � r�''L'(1y ,�tJc�,l-crl,t�t,� Telephone No. "'4'6` '1 Owner's Address 1606 D5 , 6�U.N 30 ZPJL FL.ao r( Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building aiiq'GC �P,f-o c/ t Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps T?-- / Volts Overhead ❑ Und rd g ❑ No. of Meters Number of Feeders and Ampacity ) Jobb l4 12-6/Z.06 ud jl- F'epd,r-i / Location and Nature of Proposed Electrical Work: 1600 OS OjDd cSf , vi ddtA- Zd ti F-Loo�L — $f 000 SI P. 6 ice c Completion of the ollowing table ma be waived by the Ins ector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans o.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ n- ❑ o.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.o etectoon an Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers eatum o.oSelf-Contained Totals umer, ons KDetection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.o KW o.o o.o Data Wiring: r Heeaa ters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Te—le—communications Wiring: 1 No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work. 2500 — (When required by municipal policy.) Work to Start:l2 U a Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVE AGE: 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 undersigned certifies that such co rage is in force,and has exhibited proof of same to the permit issuing office. RANCE CHECK ONE: INSUBOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that floe information on this application is true and complete. FIRM NAME: iLrL. 1r�,pt,'�y�� .ie-, _ LIC. NO.: Licensee:Wwgtn( W.Snr res Signature 0, LIC. NO.: 503 (If applicable enter "exempt"to the lice se number h e.) Bus.Tel. No. d - 4`� Address: (1! �3t^��,, 6�u�, �a�ex t 14 R, p30p Alt.Tel. No.: *Security System Contractor License required for this work; if applicable,enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. TEN - ��� s ���-2 The Comertonwealth of Massachusetts x 1 Department of Industrial Accidents Office of Invesdgations . 600 AWashmgton Street Boston, MA 02111 c www mass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Elecfricians/Piumbers Alinlicant Information Please Print Legibly NAMe(Business/Oqg mization4ndividual):�,1 LL `e C C U, Address:_ City/.State/Zip:_ �.��1 �3� f Phone#•_D0 ' 7b s— q7J 2 — Arern an employer?Cheek a appropriate box- Type of Project(required): I am a employer with 4. ❑ I am a general contractor and I 6. New * ❑ construction employees full and/or time have hired�e sub-contractors ( part-time).* 2.0 I am.asole proprietor or partner- listed on the attached sheet.3 1. ❑Remodeling ' ship and have no employees These sub-contractors have 8. 0 Demolition- working for me.in any capacity. workers' comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10❑Electrical or required.] officers have exercised their repairs additions 3.❑ I aim a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself~[No-workers'comp, c. 152, §1(4),'and we have no 12.0 Roof repairs insurance required.]-t -employees.[No workers' comp.insurance required-.] I3'O Other •Any applicant that cheeks bon(#I must also fill out the section below showieg Hair workers'covhpensatioe policy information. t Homeownerp who submit this affidavit indicating they ars doing an wotk end then hire outside comractors must submit a new affidavit indim ting such. lContmetors that check this box must mu*jed an additional sheetshowing the name of the sub-conusetors and their wofkcrs'comp.policy infmmnation. I am an employer that is provid,ng:workers I contpensadon hzwrance for MY en ployem, Below is the policy and job site information. II Insurance Company Nam • 'U e rc e ALts-(��^Y` N SCP Comp", / Policy#or Self-ins.Lic.#: W C Expirstion Date—J402_ ©13 -$2-*0Io`fi--oo 1-Unt4't t►>.,do�on Job Sim Address-.MV43 - lWL)( ,syoaa% bAQi us ?b,2-1 FIS W41, CitylStaheJZip:�St�Sk,ls��T d`gct5 Attach a copy of the workers'.compensation policy declaration page(showing the policy number and expiration date Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance overage verification. I do hereby'cpert,fy under the pains and penalties of perjury that the information provided above is true and correct Si Phone#: 3- 7657170.2 O•fjfcifft use only. Do not write in this area,to he completed by City or town o•f uid City or Town: Permit/License# Issuing Authority(circle one): t.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: TOWN OF NORTH ANDOVER Construction Control Affidavit Project Number: 0710129 Project Title: F.H. Cann Call Center. Tenant Fit-up Project Location: 1600 Osgood Street— 2nd Floor— Building 20 Name of Building: Osgood Landing Building 20 Nature of Project: Office Renovation for Tenant Fit-up., new exitway In accordance with Section 116.0 Registered Architectural and Professional Engineering Services-Construction Control of the Massachusetts State Building Code, I, Gregory Smith Registration No. 8688 being a Registered Pfflfessiena4 €ngineeF/Architect, HEREBY CERTIFY that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: Entire Project Architectural )OOOOIX Structural Mechanical Fire Protection Electrical Other(specify) FOR THE ABOVE-NAMED PROJECT AND THAT SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE 780 CMR MASSACHUSETTS STATE BUILDING CODE. ALL ACCEPTABLE ENGINEERING PRACTICES AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.2.2 1. Review, for conformance to the design concept, shop drawings, samples and other submittals which are submitted by the contractor in accordance with the requirements of the construction documents. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the state of construction to become, generally familiar with the progress and quality of the work and to determine, in general, if the work is being performed in a manner consistent with the construction documents. UNDER SECTION 116.4, I SHALL PERIODICALLY SUBMIT A PROGRESS REPORT, TOGETHER WITH PERTINENT COMMENTS, TO THE BUILDING INSPECTOR UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION AND READINE ROJECT FOR OCCUPANCY. D ARC Signature and Stamp(no facsimile) Ry P. �Q No.8688 % NORTH ANDOVER, DAA. SUBSCRIBED AND SWORN TO BEFORE ME THISo-eh DAY OF 2007 "\ MY COMMISSION EXMES SUN M. MOFFETr NOTARY PUBLIC * Plotarq Public Commonwe-v th ;.F Massachusetts My Commission Expires March 7, 2014 GSD Associates, LLC TO 148 Main Street, Building A, North Andover MA 01845 Tel: 978 688 5422 Fax: 978 688 5717 Web:www.gsd-assoc.com 4P Computer Aided Design • Architecture • Planning • Interiors • Development Consulting TO: DATE: 1 ' 41'&V9 JOB NAME AND #: l . #, CA", TIME START: jt: TEMP: •WEATHER: 150Hr!j LOCATIONA" 105y"D ST. Opt) F-(-l2 TIME END: Na✓tti l f AL ,t,p---7 i5c G Zo SITE OBSERVATION/PROJECT MEETING REPORT ........... i !�!> C�!✓ ,_ GD ?ZC2ekec M I I /A�..4 !i / ! V.._..J...i l.L.�4a��•��., �: I i i i I ... i ... I .. i _ i i :� ! i 1 I Z 1 �1 ZW61c _, i w r t f , , &X7' s; •cps 1�,c b w �Y✓ U3 E 1 1 E � 1 3 1 1 , , f i 1 1 3 1 I 1 E 3 res r ? l i I t 3 � 1 � I 1 i f tba,.f10nl_i sXM-I!, I f 1 f 3 —1�- /0V Tp, 7 J ~f* 1-f R01'n;5, } 1 1 3 1 E I 3 i t :. ... .....4...... i .. ..d..... ..d _... ..i... .....d._....._.i _ ....:... ..........e 3..... ....V .._,....._. .4... .._.t..... t..... ..4. ....... .... .......... ..._ ... d _. ... I 3 t i I t 1 1 I 1 1 i 1 ....1......1. . ....1...... 3 ......i.... ...1...........! .... ... _.....__. i_._._. 1. ....l.... ......i _.t.. ._...f ......t..... 5. .. ..i.. _.. .i......... .... ... .. 1 ......i..... ... .... k I i ....I........ I .......E_.- t ._.,i'- t _.._._{ .. .. .. .. ..... ... .......F t__. ..9 .... ...i......... I.........t...... _ _.... .. .. .. ... 3 , I ! k i . f 1 3 i 3 3 3 3 I '..I... .'........L .........1._ .. L..._. _i.... ..t...... ...I ..... ........: .. ..I....__..t.. .3...........A ...3_.... I........€....... .1......_... ...... .... ..... ..i..... t .._ .... ... ... t 1 ! I I I 1 1 F F i I i t i i i I 1 1 = f t t 1 1 1 1 1 I 1 1 1 I '.� ....i.. ....I. .. ....i .._. __. '..... .I......... .i ;...........1 ..L. _..._1... ..._.1._. _._. _.:.._._. ............ ..... .. .......I..._. 1 __.._E._ E _. .. ..f ...... ... Reviewed by Page Nod / f Date . . {.—.3.-. . TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . . . . . . . . .l�. . . . . .4y7 � . . . . . . . . . . . . has permission to perform . . . . C; ,Gf !Ge C . . . . . . . . . . . . . . . . . . . OZ Ped wiring in the building of . . . . . . . . .P,/, , . . . . !`1 .�t/��!!�. . . . . . . . ' . . . . . . . . . . . . . .T�iq, h Andover, Mass. Fee )2.'o" . . Lic. No. 7-tel��. . . . . . f ,� . �1�� J� ELECTRICAL INSPECTOR r . Check# 10 9 'i -J ;` 30 r Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked ° BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: ( F r City or Town of: NORTH ANDOVER To the Inspe for of Wires: By this application the undersigned gives notice of his or he intention to perform the electrical work escribed below. a Location,(Street&Number) f p © t) +o` ` ud 'I Owner or Tenant Telephone No. A —i Owner's Address 5 d Is this permit in conjunction with Wbuilding 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: Completion of the following table may be waived by the Inspector of Wires. No.of Recessed.Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA J No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- Elo.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS ]No' o. of Zones of No.of Switches No.of Gas Burners No. InDetection and Initiatin Devices No.of Ranges- No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Connection No.of Dryers Heating Appliances KW Security Systems:* Y No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Bathtubs No.of Motors Total HP Telecommunications Wiring: No.Hydromassage No.of Devices or Equivalent OTHER: r(�, C-( rU f h r� Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: y� t/D O (When required by municipal policy.) Work to Start: f 94nspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVE-RAGE: 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 undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE` INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on thisap lication is true and complete. q FIRM NAME` 5 t 2 C LIC.NO.: 1 30 Licensee: -N-A A �Q-e^ Signature � LIC.NO.: (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.: Address: Alt.Tel.No.: *Per M.G.L c. 147, s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insuDance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. i ' �JUJ6Jll.r.l..R�-.1.•v�j���/�'.�+�.L�-LfJ-ti.*.�•�(®�� D^�j �]'f'�•� •.'-+.►F7JL.L•IUJil.�..1 �®J.�.+.i . oar reCO D2�sset�---•I � --�'aiiefl-•j' 7 �e-inspec�Zoz��'equzxec�(��OAD)�( � tors'co 3nspecpnrtexts: - (r'nspeetore Signature-no:IPitials) •_ date _ �'assec�- aiTe�--I ate-3nspectiouxetnixe ($ 0.00}- [ lujiector c encs: (rinpectors'gzgnatare•-.ao tnztials) date ' Passed—[ � �ia�Iecl—I � �e�fnspectzo�xec�ui�retl(��0.00)�[ ] inspectors'comments. (Inspectors'signature- o?M als) Wfe ATM,CA rLEW N a+ON's Off,l : NAME: assecl--[ azlecl•-Ie-nspectionxequirecl050.00)�( ' tspectbxs'commeph: (�xtspeetors'�iguatuxe-Jao jnztials) Date rse�--I ) �'aileof�•[ )- 'ate�nsp ectioxt ze0uix'ed($50.OD)-•[ � pectoxs'cozixmients: _ . _ 0418y ectors'Minat-oxe no initials) Date ' 3)OR TAUS.ASE TO 13B ITMED PDT alb UFT ON RITE N TM.AP'XA TO BE INSRECTUD XO NOT t The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): e—c+ LL C Address: 15.1 W+Cs 'jc i City/State/Zip: 0�/ A) Phone#.(60 351 —,9/ Are you an employer?Check the appropriate box: Type of project(required): 179,I am a employer with I Sy b 4. ❑ I am a general contractor and I ` 6. F1 New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet,# E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9• ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.t3,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 j myself. [No workers' comp. c. 152,§1(4),and we have no 12.0 Roofrepairs \ insurance required.]t employees.[No workers' 13.❑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 ace 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and' b sit information. Insurance Company Name:. y('M I IhS v r ct rt Policy#or Self-ins.Lic.#: Expiration Date: "lob Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' under the pains and penalties of perjury that the information provided above is true and correct. Simature: .— Date: cLIV str,,� Phone 4- _ .2— Official 2Official 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#: e 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 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 of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." 4 An 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 confumation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum 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 ofMassachusetts Department of Industrial Accidents Office of Investigations 600'Washington Street Boston}MA 02111 TO,#617-7274900 ext 406 or 1-877-MASSAFB Revised 5-26-05 Fax#617-727-7749 wwwmmass.govaa i M ws&B 1 2 3 VF 36 .,.a. � 31 32 37 3 2 1 b < __j ^ ^ WS 4 5 6 7 p , .m ^�"� n�i. s "`;--a _ L._. -' BF - - ....... ... -- WS, BF WS 33 10 r- r Ws&BF i—a !—a '—^ 29 30„ WS E > R- 6 y34 35 �" 5 4 8 9 10 11 b b b ^ s 23 24 27 28 Ws ws 13d18 15 ��� ^ — "Ib. �I.. i — — , g Imo; WS&BF = L L_ � !---- ZO - -- & F WS 2526 6 17 v 19 2114-1 22 b b WS&BF=Wall Start&Base Feed FH Cann PP&BF=Power Pole&Base Feed WS =Base Feed Final 7/2/12 i Date . . . lom TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . �.� Z j, . . . . . / [i. . . ., 7,v4� has permission to perform . . .7 .Z,. .�, .% wiring in the building of j�tn-1�,�/. . .F, /, .14AA . , . . . at . as ! ��—. . �34- . • • • • • , . . , North Andover, Mass. Fee . No. . .A/4. . . . . . . . . . . . . ELECPRICAL INSPECTOR �Check# �r�� 10939 Commonwealth of Massachusetts Official Use Only Permit No. 0 l � Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned givesnotice or her intention to perform the electrical work described below. Location Street&Number n Owner or Tenant r c' Telephone No. 750 — Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No M (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: Completion of the following table may be waived by the Inspector of Wires. of No.of Recessed Luminaires No.of Ceil: TransSusp.(Paddle)Fans Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o Emergency Lighting + No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Dis osers Heat Pump Number Tons J.KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal El Other P g Connection No.of Dryers Heating Appliances KW SecuritNo.of De ices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: �© GtJ � � G �' �S� I e Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: cn9 l- cO (When required by municipal policy.) Work to Start: 71'3L( -, 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 undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE k BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: . P S P� Cco t.Q 9 t0s t4)C LIC.NO.: IV Licensee: Signature LIC.NO.: (If applicable,enter "exempt"in the license number-lin ) Bus.Tel.No.: Address: ,P ct, /'3oX S � W.,c xe7,&S k�G) Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. r y; 3'ns,�ectoz's'co�te�ats: - ' 't it• � �• ' {?tnspecfioxsyzgeatuxe"no (tiaTs) Pate. 3?asset +afle --� - ate-ns ectioaroaniuec�($�OAO)� [ � xnvecto exits: (Mss ectoxs'mgna -no ixutials) date 3,TTN AR GROUND MROCTZON. w �'assett'-j j �+'azlec�--j � �teans�ectZo�xe4uirec�050.40)�[ � Tnspectozs'comments: , (lnspectozs' ignatoxe� o vitals) ]ate r assert—[ 7 valled--j a rhe-nspectionxequire ( 50A0) [ ts�pectbxs'eoJmmextfs: " (f4spectoxs'olgaature«Ρio initials) 17ate WSPACrTION--( PI:' , 'seri- ailer--[ - tenspeetionxer�uixer�( 50.00)�[ pectors'com.xn.ents: _ , S ' �t�,sp eetoxs'Ezgnataxe••no liMals) Date 3 OR TAAQ,5 ARF,TO 13B FMUD 9-UTANDMT ON SITE M TM A'XA TO 3E WRECTUD Xg NOT J The Commonwealth of Massachusetts Department ofIndustrigl Accidents Office of Investigations UV 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legib NaTnP,(Business/Organization/Individual): le 3.5,f V-L), y/ Address: �' S 70 City/State/Zip: �� S ir� Phone#: `1'7 C7'� ��r Are you an employer?Check the appropriate box: Type of project(required): 1.WI am a employer with�3 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. �• E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 1012113lectrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.EJ 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' comp.insurance required.] ME]*other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they aie 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. 42,-�,o Insurance Company Name:. Policy#or Self-ins.Lic.#: J D �0 Expiration Date: l2 _ Job Site Address:,/,6 CJ d OS Oo j City/State/Zip: )f 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 c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby under t pa* a penalties ofperjury that the information provided above is true and correct. Signa re: CDate: 3 Phone#: / 4 S of-5-0 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 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(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 4' (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston,M.A,02111 Tel,#617-727-_4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax##617-727-7749 wvvw.mass,gov/dia � p Date..... .'". NORTI♦ °!t�`'°:•�"° TOWN OF NORTH ANDOVER PERMIT FOR WIRING SS/1CMUSEt This certifies that L T ►L L, .J,4-,c ...................................... . ................................................. Sv has permission to perform•.. .... ...... ....•....�G21t!!!i1~F(� ......... wiring in the building of... ::�1.'� XC-. 'y •� �1/ . ................................................. at.±.bV.' .ST........ Z DA ................. .... .,1,North Andover,Mass. . .... ....... ....... ......... ao — Fee.. . ......... Lic.No.�6, ..a..3! .............. .�....... 1. .......,yyy'''..... 1 LECTRICAL INSPECTO�t Check # < �� 80 ,11 Commonwealth of Massachusetts Official Use Only i Department of Fire Services Permit No. [O 12 / �Vj Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC�09 ,527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: 2�ZS City or Town of: NORTH ANDOVER To the Insp ce or of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) I f000 Psi O`,',',,'JI &A . Owner or Tenant F 14- CMN Telephone No. Owner's Address/ S ;X r 2441 Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building g Utility Authorization No. y I 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: �- 2b, 2MA. F., NO 4-ft, _ ipsf'R I _ IdOs>6+t� 9 j gWt*f gut pave( amA Feed a ct tort.,,4-v 2C- A Completion o the ollowin table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators K-VA No.of Luminaires Swimming Pool Above ❑ In- 11is o.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and TotInitiatin Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number I Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or E uivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Dvices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: _I No.of Devices or Equivalent OTHER: b 6y�/� Attach additional detail if desired, or as required by the Inspector of Wires Estimated Value of Electrical Work: �!w(/ (When required by municipal policy.) Work to Start:it 1$ Inspections to be requested in accordance with MEC Rule 10,and upon completion. i INSURANCE O RAGE: 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 undersigned certifies that such coy rage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE F BOND ❑ OTHER ❑ (Specify:) I certify,under thepains andpenalties of perjury, that the information on this application is true and complete. FIRM NAME:M;Lt— SLic ic Cp. X)VG . LIC.NO.Joo34 Licensee: 4yw W. splits Signature _ LIC.NO.: G 5,0 C34 (If applicable, en er"exempt" 'n the li n e number line Bus.Tel.No.603 Address: 381' t1 Aytr. �j lex lV 03671 Alt.Tel.No.: *Per M.G.L c. 147,s. 7-61,security work 6quires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ 1 5 yZe_f i `'' �L 6,-2;.�tti�;t�.ta + )^' a:�•' -,},!; . ('- ' l 14 �7'ai - t + �.�.'y,ti:,=� •� !el iJ�oi", ..3�i • w S-.4�s �!$; .j''mti ` a r . yJ c a iy '��u K y yt•j ` t� r Date.................................. NORTH TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that ....f..?'.�` 66 M. ..... T�z. r has permission to perform ................................ ...�"'T.............................. wiring in the building of..... .. �... �n/ti 4��e' .... .................................................... �� 6_5r4� S .,-North Andover, Mass. _ '00Fee.....Z 5.......... Lic.No. '1 .................... ............. .............. ELECTRICAL INSPECTOR / Check # l � /`7� 7M w z' Commonwealth of Massachusetts OfficialUseOnly Department of Fire Services Permit No. ! ' BOARD OF FIRE PREVENTION REGULATIONS [1WOcpancy e .17and Fee Checked (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: fEg , 7 alb B City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 1600 o''G©ao �t(57 &1uZ t,v(, Do Owner or Tenant A,SSoC,1 A,-Te" Telephone No.877 7SQ-9800 Owner's Address ((p00 6S6 WO S7V--tX7 Is this permit'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: w Completion o,",-followingtable maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA j No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency ig g nd. grnd. Battery Units No.of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones r No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers .Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KWLocal❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* N No.of Water No.of No.of o.of Devices or Equivalent Heaters KW Signs Ballasts Data Wiring: I'llNo.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications firing: �' No.of Devices or E uivalent Y Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start:�Ib 7 c�003 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 undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: , /i 6t9/f)m till/- ��j�? LIC.NO.: Licensee: Signature LIC.NO.: (If applicable, enter"exem..t"in license number line.) Q� Bus.Tel.No.: Address: `f�'�/�/ f T /C(S/�pfjl'j e Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ I i . The Commonwealth of Massachusetts k� �, ! Department of Industrial Accidents # Icd Office of Investigations 600 Washington Street r" � Boston, MA 02111 www.nZass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ArpCGcant Information n Please Print Le-vibly Name(Business/Organization/individual): NWCQ NN Cn M1� Address: City/State/Zip:_�ILLSAo'2o Phone#: . Are y an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with 4. ❑ I am a general contractor and 1 6. []New construction employees(full and/or part-time).* have hired the sub-contractors ,�� 2.❑ 1 am a.sole proprietor or partner listed on the attached sheet.I L`� Kemodeling ship and have no employees These sub-contractors have 8. []Demolition working for mein any capacity. workers' comp. insurance. g, ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and.its 10.❑Electrical repairs or additions required.] officers have exercised teir eP 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[Nonworkers'comp. c. 1.52, §I(4),and we have no 12.[] Roof repairs j insurance required.]t employees. [No workers' comp. insurance required..] 1311 Other *Any applicant that checks bo) I must also fill out the section below showing their workers'compensation poiicy 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 their-work-ers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees: Below isthe policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: Ugoo 06660 Mtc at-0(� Zo City/State/Zip:_, Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. 4 I do hereby ce if under the pains an penalties of perjury that the information provided above is true and correct Signafore: //� / j / Date: � o�(di yj Phone#: 6 0 3-- �G 4'"l— LI(d o o 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 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 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-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 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 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 dine. 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. When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture i.e. a do license or permit to bum leaves etc. said erson is NOT (' g p ) p required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call.. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4400 ext 406 or 1-11.77-MASSAFE Revised 5-26-05 Fax 4 617-727-7744 www.mass.gov/dia