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HomeMy WebLinkAboutMiscellaneous - 17 HALIFAX STREET 4/30/2018 17 HALIFAX STREET U-B 210-X022,0-0119-0000.6 \ �. / i i i Y ..Dat ........ .... ............... Date s 't NORT/1 °� "" '•�� TOWN OF NORTH ANDOVER o n PERMIT FOR WIRING �,ss�CHU5��4 Thiscertifies that 11.........................../............../............................................................................... has permission to perform ....)c..L4-4^.i........ .P7*1..e-.r..::��..�).......................... wiring in the building of.......... 2....................................................................... a,j.-7�14.//,h? ... '2 ..................>No An over,Mass. M F,re..... .:...........Lic.No. /. ............... ....... ............ r; ELECTRIC INSPECTOR Check# 9 7,M1hLb 27?bl i 710-/5 rk 41'16 JE'-�7�r-cY ,e ` A Commonwealth of Massachusetts Official Use Only Permit No. `�!6 7 Department of Fire Services 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 CodeC),f27 CMR 12.00 (PLEASE PRINT IN HK OR TYPE ALL INFORMATION) Date: ,3 T/7 A.S 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) /—] I-OLJFt 1, &T, Owner or Tenant L VFR L Y s j-01q f Telephone No. Owner's Address S/It-1D Is this permit in conjunction with building permit? Yes M. No El (Check Appropriate Box) Purpose of Building HOW Utility Authorization No. - Existing Service /00 Amps 120 -1 YO Volts Overhead. Undgrd❑ No.of Meters 1 New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: /40D Lj qtl J Fy- H19w,FAH ` / G t=1 F{ire C-t4A146,r 00 F+ tc Dl:vocts Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires f No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA AboveIn- o.o mergency ig ting No.of Luminaires Swimming Pool rnd. ❑ rnd. Battery Units No.of Receptacle Outlets I No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: .--I.... """"""' "'"'"' 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 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 E uivalent OTHER: n w Attach additional detail if desired,or as required by the Inspector of 07res. Estimated Value of Electrical Work: is 0 0 (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 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,cinder the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: _ LIC.NO.: Licensee: /-12/ -lt jMP!V 0 Signature_ LIC.NO.: /�S S_� (If applicable_enter "exempt"in the license number line.) L--� Bus.Tel.No.: 97F-6 70 Address: 0. L70 Y as F p/HINuRj j J-7A. U/P&(s Alt.Tel.No..Sd 109 a M? *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 IPERMITFEE-$ 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 a 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(] Failed IN Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass c q Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed ❑' Re-Inspection Required($.)❑ Inspectors Comments: 14 Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com j The Commonwealth of Massachusetts , - Department of IndustricclAceldii is Office Oflnvestigadons 600 Washington Street .Boston,.MA 02111 -www.mass gov1d1a Workers'Compensation Insurance Affidavit:Builders/Contractors/Electr ic�ians/�''liimbersgib Anplieant Xnfornoatxon Please Print Lely Name(Business/Organiizationl.Cndividual): 12d 11/, l�/fP�'U ya Address: P 0 • l2O,-, d City/State/Zip: Pr/QC/1u/(J1_ /7/7 o/F(O C Phone#: 7?r 6 70 - AA-11 ou an employer?Check the appropriate box: Type of project(required): I am a em to er with / 4• ❑ I am a general contractor and I ` p 6, ❑New construction employeesd/orpart time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner listed on the attached sheet, 7• Remodeling ship and•have no employees These sub-contractors have 8. []Demolition working forme in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑We are a corporation and its 1011 Electrical repairs or additions required.] officers have exercised.their 3.0 1 am a homeowner doing all work right of exemption per MGL MEI Plumbing repairs or additions myself.[No workers' comp. c.152,§1(4),and we have no p 12. Roofre airs insurancererluired.]? employees.[No workers' 13.[]Other comp.insurance required.] xAny applicantthat checks box#1 must also fill outthe section beldw showingtheir workers'compensationpolicy information. t-Homeowners who submit Phis affidavit indicatingthey dre doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that cheAthis box must attached as additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that isproviding workers'compensation insurance for my employees Below is the policy and joh site infomation. Insurance Company Name% 711C y5WTR110 Policy#or Sel£ins.Lic.#: Expiration Date: Job Site Address: 17 !/moi AV J City/State/Zip:/-c Attach a copy o#the workers'compensation-poliey declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25.A ofMGL o.152 can lead to the imposition of criminal penalties of a :Q up to$1,500.00 andfor one=year imprisonment,as well.as civil penalties in the foram.of a STOP WORD ORDER and a fine of-up to$250.00 a day against the violator. Be advised that a copy of this statementmay 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 that the information provided ove•s true and eorreet, - Si store• Date: _ 7 /S Phone#• 77r-6 70 - o/&3 Official use ortly. .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.C41Town.Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other - - Contact Person: Phone#: k. Information and Instructio _ � ns Massachusetts General Laws chapter 152 requires all employers to provide workers'c Pursuant to this statute,an employee is defined as OMP ensation for their employees. express orimplied,oral ox wxitten." . "...every person in the service of another under any contract ofhixe,• An employeis 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 nts and who resides therein,or the occupant of the owner of a dwelling house having notmore Chau three apartme dwelling house of another who employs persons to do maintenance,construction or repair worts 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 pro duced.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 p ffi avit completely,by chocking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)andphonenumber(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers,compensation insurance. If au LLC orLLP does have f employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial v Accidents for connrmation 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 obtaia 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 Towns Officials Please be sure that the affidavit is complete andprinted 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-ore,to fdl in the permit/license number which will be used as a reference number. 1haddition an applicant thatmust 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 dor future permits or licenses. Anew 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 S (i.e.ad og license or permit to burn leaves eta.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and shQuld you have any questions, please do not:hesitate to give us a call. The Department's address,telephone and fax number: The cax onwcaTthofZVl uar'hv efts A-Taximai t ofZndustxial Accldex4% Oflee of IRVestigAtim 6bG WashiWQn free Boston,MA021If TO,#6I M-2-7^4900 QA406 or 1-8,77 �MFE Revised 5-26-05 `ay, 617-727-7749 _ _WWW.Mass,9Q-V1`a Division of Professional Licensure: License Search Page 1 of 1 The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES ......................................................................................................................-............................................................................................................................... Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency LICENSEE More... Name: FRANCIS J. DEPTULA REFERENCES& PINEHURST,MA RELATED INFO NEW SEARCH Disclaimer Regarding Website License Searches Licensing Board: ELECTRICIANS Glossary of License Status Codes License Type: JOURNEYMAN ELECTRICIAN TYPE CLASS: E More... License Number: 31255 Status: CURRENT Expiration Date: 7/31/2016 Issue Date: 9/28/1987 Exam Date: 8/1/1987 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. ` The page above has been generated by the Division of Professional Licensure web server on Wednesday,March 18,2015 at 10:12:38 AM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us/public/pubLicenseQ.asp?board_Code=EL&type_class= E&li... 3/18/2015 Date:31,11.0/1.5........ I I C LIS G, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that....�C� k— ................................................................................................. has permission to perform...!...... !.. L ./....jjr . ✓ve-v-, "J'-A ............................................................. . ......... plumbing in the buildings of... .... ............................................................................. at.....1:1...... ....... ............. North Andover, Mass. �n. \t Fee.tZ.........Lic. No. .......c....... ....0.1,e .............................................................. PLUMBING INSPECTOR Check# Vr1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK � b � IlV.�.r 1. "r. PERMIT# CITY��_ r_n�5. ���r _.. .. hub MA DATE �-.L - F JOBSITE ADDRESS E OWNER'S NAME r -_ btv OWNER ADDRESS TEL Ir FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL E] RESIDENTIAL[� PRINT CLEARLY NEW:I RENOVATION:Q REPLACEMENT:Ej PLANS SUBMITTED: YES NO[] FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 77 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM 0 DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN 0� FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) 0 KITCHEN SINK LAVATORY 00 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK 0 TOILET URINAL 0 WASHING MACHINE CONNECTION 0 WATER HEATER ALL TYPES WATER PIPING OTHER 0 0 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY[Z OTHER TYPE OF INDEMNITY n BOND 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 F-1 AGENT [] 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 complia a with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. a PLUMBER'S NAME =Air& _ LICENSE# _ .}� SIGNATURE MPa?/ JPR CORPORATIONO#F _ PARTNERSHIP # LLCD#�� COMPANY NAME - < '. ADDRESS sem, CITY STATE ZIP TEL - -- FAX -- tier . CELL EMAIL �' (.CA � �o r ti The Commonwealth of Massachusetts �✓' Z3 l j^ "O l� Department of Industrial Accidents 1. Office Investigations ice o �41 www.mass.gov/dia , 600 Washington Street 1 Boston, MA 02111 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1. 0 I am an employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2. ❑ I am sole proprietor or partner- listed on the attached sheet. $ 7. ❑ 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 10. ❑ Electrical repairs or additions required.] 5. ❑ We are a corporation and its 11. ❑ Plumbing repairs or additions 3. ❑ 1 am a homeowner doing all work officers have exercised their 12. ❑ Roof repairs myself. [No workers' comp. right of exemption per MGL 13. ❑ Other insurance required.]t c. 152, § 1 (4),and we have no employees. [No workers' comp 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 that 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 workers'comp.policy information. r 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. License# Expiration Date: Job 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 required under Section 25 A of MGL 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$250.00 day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Phone# Official use only Do not write in this area,to be competed by city or town official City or town: TOWN OF ACTON Contact Person: FRANK RAMSBOTTOM Phone#: 978-264-9632 I • -rte .. - � -. � _ .. —� t,., . - v r -- �.�. Date.... .............. ................. F NORTH o�' TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 4 S$'�CHUSfa This certifies that ........�'�:,.......�L.e� I Q-'LP ........................................................ has permission for gas4istallation ! : '� Z..,.,.......................................... in the buildings of........ 2_.. at...............�.1 --�' c �.�t�9� ....... ............., North Andover, Mass. Fee.�QQ.... Lic. No.-�..JA.�....... _ "................................................. GAS INSPECTOR Check# U n/ V MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY t`lIC r MA DATE PERMIT# (' JOBSITE ADDRESS �� --5 �=- OWNER'S NAME GOWNER ADDRESS J TEL — iFAXI -) -TYPE OR PRINT COMMERCIAL[] F]OCCUPANCYTYPE COMMERCIALEDUCATIONAL RESIATIk — 211"CLEARLY NEW:[] RENOVATION:2 REPLACEMENT:❑ PLANS SUBMITTED: YES[] NOM APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 1 11 12 13 14 BOILER BOOSTER CONVERSION BURNERjj COOK STOVE - - DIRECT VENT HEATER DRYER - FIREPLACE 'FRYOLATOR - FURNACEx'- - _ GENERATOR GRILLE INFRARED HEATER e ' _ LABORATORY COCKS MAKEUP AIR UNIT I , `a 1 OVEN POOL HEATER _ _ a _ 1 _ III ROOM I SPACE HEATER h I ROOF TOP UNIT s TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER ' tI= , , INSURANCE COVERAGE 'f I have a current liabil' insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Cj�NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABILITY INSURANCE POLICY NjP"" OTHER TYPE INDEMNITY ❑ BOND 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 ❑ AGENT El 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 complian with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �-fir 01i��_ PLUMBER-GASFITTER NAME I Paul Kelleher I LICENSE#Lj;� SIGNATURE MP[ZrMGF❑ JP 0 JGF❑ LPGI❑ CORPORATION❑#®PARTNERSHIP❑# LLC❑#� COMPANY NAME:j Paul C.Kelleher Plumbing&Heating,Inc ADDRESS 16 Ledge Rock Way Unit 2 CITY I Acton 1 STATE®ZIP 01720 TEL 978-263-3356 FAX 978-264-4015 CELL 978-815-5604 EMAIL PCKelleher@vedzon.net l�� f ass � 2z ��' The Commonwealth of Massachusetts Department of Industrial Accidents M 1 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 Legibly Name (Business/Organization/Individual): PAL/L, Address: G, LL(o t>;a tvct (aJ&q UIy, a City/State/Zip: JACA /�, ��/,j�(� 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 8. /Remodeling any capacity.[No workers'comp.insurance required.] 9. F1 Demolition 1F]I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F1 Roof repairs These sub-contractors have employees and have workers'comp.insurance.x 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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 submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: A G- -/ Policy#or Self-ins.Lie.#: 0 U — b�l 0 D,K�15 Expiration Date: 11y (j Job Site Address: {-1 �ha[_b &X g.-T City/State/Zip: N p "O>o V 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 under the pains and penalties of perjury that 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#• 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." N 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 our 1 to situation and if Y , necessary, supply sub-contractors names address es and hone numbers along with their( ) ( )�address(es) P ( ) g ear certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit.' The affidavit should be returned to the city or town that the application for the permit or license is being requested,notthe 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 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. # 6 - 17 727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia S� r Pt �¢ JAMM ,},, ' X ! x V i KELLER �., - L `v ,1:Y �'S � 'I... 1. N� # � :t e' r � tf ♦: '�✓� LEO G Wwi r ^ Y1 j a s }e >< Y � � t. - �rt ,^' t r.. .;,-¢ r aa:: ".t• r�v.,icam'.,rr"...'. `r Date ' Town of North Andover Your permit has been sent back to you for the following reasons: 1) Check amount incorrect 2) No copy of current license ov�1 3) Insurance Binder not on file or expired la te ``'e— '- 5 �� 4) No Workers'Compensation Insurance Affadavit Form � .e doc7z l Please call with any questions 978-688-9545. Fax 978-688-9542 Workers'Compensation Form and Schedule of Fees can be found on the Town of North Andover Website under Building Department. Mailing Address: 1600 Osgood Street, Building 20,Suite 2035, North Andover, MA 01845