Loading...
HomeMy WebLinkAboutMiscellaneous - 193 ANDOVER STREET 4/30/2018 2101046._0-0012-0000.0 I f ° M I i 11 North Andover Board of Assessors Public Access d Page 1 of 1 NORTH North Andover B4r'A.rd of Assessors t i I roperty Record Card Click Sea]To Retum Parcel ID:2101046.0-0012-0000.0 FY:2013 Community:North Andover SKETCH PHOTO Click on Sketch to Enlarge Click.on Photo tis l alar>e Search for Parcels Search for Sales I Summary t .. Residence : l Detached Structure Condo '.. 0 Commercial - Location: 193 ANDOVER STREET Owner Name: KILPATRICK,MARY S CARA D MARSHALL Owner Address: 193 ANDOVER STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood:5-5 Land Area: 0.31 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1581 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 317,000 301,000 Building Value: 149,200 128,500 Land Value: 167,800 172,500 t arket Land Value: 167,800 hapter Land Value: LATEST SALE Sale Price: 1 Sale 11/09/2001 Date: S le Cns odeLength F-NO-CONVNIENT Grantor:KILPATRICK/MARSHALL Cert Doc: Book: 06469 Page: 0237 �I I http://csc-ma.us/PROPAPP/display.do?linkld=2253081&town=NandoverPubAcc 3/26/2013 Residential Property Record Card PARCEL ID:210/046.0-0012-0000.0 MAP:046.0 BLOCK:0012 LOT:0000.0 PARCEL ADDRESSA93 ANDOVER STREET FY:2013 PARCEL INFORMATION Use-Code: 101 Sale Price: 1 Book: 06469 Road Type: T Inspect Date: 05/27/2010 i Tax Class: T Sale Date: 11/09/01 Page 0237 Rd Condition: P Meas Date: 05/27/201_0 Owner: r._ .- -Cert/D----- --_ ------ - Tot Fin Area: 1581 Sale Type: P oc: Traffc. M Entrance: "� C" KILPATRICK,MARY S Tot Land Area: 0.31 Sale Valid: F Water: Collect Id: RRC CARR D MARSHALL Address: Grantor: KILPATRICK/MARSHALL Sewer: Inspect Reas: M 193 ANDOVER STREET Exempt-B/L% / Resid-B/L% 100/100 Comm-B/12/0 Indust-B/L% I Open Sp-B/L% / NORTH ANDOVER MA 01845 RESIDENCE INFORMATION LAND INFORMATION Style: CO Tot Rooms: 6 Main Fn Area: 1266 Attic: NBHD CODE: 5 NBHD CLASS: 5 ZONE: R3 - code-m-__.- - — -------. . ... Story Height: 1.50 Bedrooms: 3 Up Fn Area: 315 Bsmt Area: 1155 Seg Type Code Method VSq-Ft T Acres s Influ-Y/N Value Class -- -- Bsmt - —"- 1 P 101 S 13500 0.310 167,805 Roof: G FuII Baths. T 2 Add Fn"Area: Fn Bsmt Area: Ext Wall: FB Half Baths: 1 Unfin Area: Bsmt Grade: DETACHED STRUCTURE INFORMATION ` Masonry Trim: Ext Bath Fix: 0 Tot Fin Area: 15.81 Foundation: ST Bath Qual: T RCNLD: 148222 Str Unit Msr-1 Msr-2 E-YR-Blt Grade Con0_d %Good PIF/E/R Cost Class l<itcfi Qu"al: TEff Yr-Built: 1970 Mkt Adj: SE C 144 0.00 1988 A A /1185 11000 Heat Type: ST Ext Kitch_: Year Built: 1900 Sound Value:_ VALUATION INFORMATION Fuel Type: 0 Grade: A Cost Bldg: 148,200 Current Total: 317,000 Bldg: 149,200 Land: 167,800 MktLnd: 167,800 Fireplace: 1 Bsmt Gar Cap: Condition: _ A T Att Str Val 1: : _ Prior Total: 301,000 Bldg: 128,500 Land: 172,500 MktLnd: 172,500 Central AC:,_. N Bsmt Gar SF: Pct Complete: Att Str Va12: Att Gar SF: %Good P/F/E/R: W75 i Porch Type Porch Area Porch Grade Factor P 192 E 235 SKETCH PHOTO 13 E 235 Sq: 9 FM/8 6 15 525 Sq.Ft 15 Ftp 7 4 FU"0.50/11Fh10/B 18 630 Sq.Ft 14 P $ 192 Sq.Ft Parcel ID:210/046.0-0012-0000.0 as of 3/26/13 Page 1 of 1 I Date.................. ...................... TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING Thiscertifies that ........................................................................................................................... YZ e vy,CJ41 L,-kr A has permission to perform ................................................................................................ wirinLAn the build of M&*N**—***(*�,**A--* at ........ .................... lorth Andover,las. Fee ..........Lic.No7C(;A>— .................... ............... ELECTRICAL INSPECTOR Check 4 Commonwealth of Massachusetts Official Use Only Department of Fire Services PernutNo. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07j (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CodeC),52 CMR 12.00 (PLEA SE PRINTWINKORYTP EALL,INFORMATIOA9 Date: 212-V)/ Y 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) 1 ,,y�p�pi S� Owner or Tenant � ✓� l'(t`L p �dcJi Telephone No. Owner's Address Is this permit in conjunction with a buildi g permit? Yes No ❑ (Check Appropriate Box) Purpose of Building �t%rc ke►-� �b,`,td, /&,l-\ Utility Authorization No. j Existing Service i00 Amps /Z /2-y° Volts Overhead 2– Undgrd❑ No.of Meters \r New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: if 1•�u �� � �����, . ill to In, /Cx�h� Qao/o �} Lc{fivtfl✓�I �mr�M Completion of thefbllowintable may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total Transformers KVA / No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool c--- Above In- o.o mergency ig ting rnd. rnd. ❑ Battery Units No.of Receptacle Outlets 2Y No.of Oil Burners FIRE ALARMS No.of Zones No.`uf Switches Y No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: • I"......•""""'""'"'"""""""""' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KWLocal❑ Municipal El Other 3 Connection No..of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: He Signs Ballasts No.of Devices or Equivalent Ncy 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 Value of lectr' al Work: (When required by municipal policy.) Work to Start: Z /Lf 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:) Icertify,under thep`ains andpenalties o perjury,that the information on this application is true and complete. FIRM NAME: _ GYU o2o��di Cil vtr•1 LIC.NO.:;4:5;0 I Licensee: te,-nora r-x-. Signature LIC.NO.: (Ifapplicable,e ter "exempt"in the license number line.) Bus.Tel.No.:IQ�12712K?1� Address: L t �g ve. ,t t ,�I Or�SSd 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 F���FEE.-$ 4 Signature Telephone No. 2— I ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the 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 -y ' electrical permit shall be issued to the person,firm or corporation stated on the permit application.Such entity shall be responsible for the f 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 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 R Failed❑' Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTI Pass 0 Failed Re-Inspection Required($.)❑ ' Inspectors Comments Inspectors Signature: Date: FINAL INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comment4./\, Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com y The Commonwealth ofMasssachusetts - Departmant of1ndifsh*1 Aecid&fs Office of. Investigations 600 Washington Street Boston,MA 02111 'tvww.mass gov/riza Workexs'Compensation.Insurance Affidavit:Builders/Conal°actors/Electrieians/l.'lrilnnber�s Appliea.nt Information Please Print LegibXy Name(Businessiorganizaaonftdividuat): ���"tY�C� U II L,4", Address: 39 ( `1 Qy%cc t""7,u City/State/Zip: Al B 1 Phone#: Are you an.employer?Check the ailpropriate box: Type of project(required): 1.❑ T am a employer with 4. ❑I am a general contractor and I 6. ❑New construction Vrp'TP-11oyees(fall and/or Par-fime)* have Hired the sub-contractors 2. 1 am a sole proprietor or partner listed on the attached sheet.x 7• Remodeling ship and'haveno.employees These sub-contractors have S. [(Demolition working forme in any capacity. workers'comp.insurance. g, El Building addition [No workers'comp.insurance 5. ❑We area corporation and its 10.�lectr i Information and Instructions Massachusetts General Laws chapter 152.regi*es all employers to provide vioxkers'compensation fox their employees. Pursuant to this statute,an eYr�ployeeis defined as°°...every person in the service of another under any contract ofhire,- express or implied,oral or written" An employeris defined as"an individual,partnership,association,corporation or other legal entity,or any two or rnore of the foregoing engaged in a j oint enterprise,and including the legal represcntatives 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 notmore than three apartments and who resides therek or the ocoupant 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 bean employes." 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 beenpresentedto the cgntracting authority." Applicants Please fU out the workers'compens aiion affidavit completely,by checking the b oxes that apply to your situation and,if xiecegsary,supply sub-contractors)name(s),address(es)andphonenumber(s)along with theireertifcate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,axe notrequired to carry workers'compensation insurance. If an LLC or LLP does have employees,apolicyisxeq*od. Be advised that tbisaffidavit maybe submittedtothe Department of Industrial Accidents for confirmation of insurance coverage, Also be sure to sign and date the affidavit. �'he affidavit should be returned to the city or town thatthe application for thepermit 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 OfFacials Please be sure that the affidavit is complete and pxiuted 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 thatmust submitmultiple permit/license applications in any given year,need only submit one affidavit indicating current Policy information(if necessary)and under"lob Site Address"the applicant shouldwrite"all locations in (city or tow.0.".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-lion 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 orpermitto burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: `z'he,Gos ouwoaltho;FMassachvsPtt� Depaftent dfndusWal Accidents Offi`tee offs mdtigWons 00 Washir an Stzee-t Bostan,MA 021.It 7Ed.#617-7-27-4900 eA 406 ax 1-57MVWS.F.B Devised 5-26-05 Fax#617-727-7749 www_maSa govldla i a� Ono M. wo Not � I� r IN O , 1 J 1 I i i I Date.... pF j4QRT#j TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Thiscertifies that.....................................I......................... ..........................3. ........... has permission to perform................. .............................. ......................... ......... ......... �L. M-Y2(elL plumbing in the buildings of ........................................... at.....) C1 -1-�-&,,/eA North Andover, Mass. . .... ... .. ..I..... ... ........ Fee ,�a Lic. No. �)Z PLUMBING INSPECTOR Check# C12-11 � ����� OA i11L, ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATEV1 � �(� ( PERMIT# JOSSITE ADDRESS OWNER'S NAME P OWNER ADDRESS TEL - JFAX TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL El RESIDENTIAL ZO PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:Q PLANS SUBMITTED: YES Q NO© FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM I DEDICATED GASIOILISAND SYSTEM f ! __.1 DEDICATED GREASE SYSTEM I DEDICATED GRAY WATER SYSTEM_= _ f DEDICATED WATER RECYCLE SYSTEM DISHWASHERI=== DRINKING FOUNTAIN FOOD DISPOSER i _---_.l --__1 --__f FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK I F-17 LAVATORY ROOF DRAIN SHOWER STALL ( ____J_-J I SERVICE I MOP SINK ._.._,..1 TOILET .___f { .----- --J URINAL - f I _._ __. I I i..w..--- f � _4 ....... ) .....__._1 T-i WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER -., ` INSURANCE COVERAGE: 1 ha` e a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[& NO k IF YM CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY X OTHER TYPE OF INDEMNITY 0 BOND Q 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. p CHECK ONE ONLY: OWNER Q AGENT 10 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 oLmy knowledge I and that all plumbing work and installations performed under the permit issued for this application will in comp' nce with all ttnnent ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME d SeP. _ 1"L4 _ _ `��-` LICENSE# 'F7- I STGNATUPE Mpg JP CORPORATION M# PARTNERSHIP -19 LLC COMPANY NAME v16-o� k ADDRESS CITY V 3 --��..- --- - _!STATE ZIP O/��� 1 TEL `• 9771 FAX _ ( CELL r ROUGH PLUMBING INSPACTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION TOTES SSS 7tl Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r ! "_$ �� Date.............I....... ...................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION I This certifies that ��........................................ ...... has permission for gas installation ..... in the buildings of....... i.?P.. .................................................................. ........ . .... ........... .. at........ ...... S.A,(U.4.......North Andover, Mass. . .... .... ............................ ........................ Fee... Lic. No. ,t32... ..Pjh.r.................................................... ............... GAS INSPECTOR Check# 9767 6zc —OcS L� \-2_ISlIq MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE PE.' q_ 01 JOBSITE ADDRESS � OWNER'S NAME GOWNERADDRESS 11 TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ] RESIDENTIAL Rj PRINT CLEARLY NEW: RENOVATION:Rj- REPLACEMENT:® PLANS SUBMITTED: YES N0Zj APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13'' 14 BOILER I L BOOSTER r _ _LD CONVERSION BURNER COOK STOVE — DIRECT VENT HEATER DRYER _ I-- .,_ V 0=F-- FIREPLACE FRYOLATOR FURNACE GENERATOR -- GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER 'J _ ROOFTOP UNIT [ - TEST - UNIT HEATER UNVENTED ROOM HEATER WATER HEATER _ OTHER � INSURANCE COVERAGE I have�a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [SNO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and apcurate to the b - of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in mpliance ith a rtinent vision o€the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME —P Cry cEEILICENSE# SIGNATURE MP D,MGF 0 JP® JGF LPGI© CORPORATION©#=PARTN SHIP®#©LLC[I# COMPANY NAME: -- O tJ�a-� - - ADDRESS._-__:a CITY _ �r t������ STATE ZIP (��l ZE TEL 71 11 FAX EMAIL _ 17 t OUGH/GAS INSP+ T N NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES l h ' The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Orgmization/Individual): Address: 33 GU e Ck�.2- City/State/Zip:�W a-z�,k\ '�'� © t 1!3 a' Phone#: T 7 7'c "" -97 Are you an employer?Check the appropriate box: Type of project(required): J.❑ I am a employer with 4. El am a general contractor and I 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.? � �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 10. Electrical repairs or additions 3111 am a homeowner doing all work right of exemption per MGL 11.USPIumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill outthe section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they hie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 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: 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 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 certify under the pains and pe lfies 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.EIectrical 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 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 requjred." 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),addresses)and phone number(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 an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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. 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 (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Coag monweaJ&of Massachwetts Depaftetzt of J ndusWal Accidents Office ofWestigatjo� 600 Washiugto>n.Street Boston,MA 42111 TeX.#617-727-4900 eat 406 or 1-877rMASSAFE Revised 5-26-05 Fax#617-727;7749 www-mass.gov/dia $S _ . Y AW'TL i tl ' ` ? ;-, 0 1 h �y V Y a €I I � • x a k h