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HomeMy WebLinkAboutMiscellaneous - 197 BERKELEY ROAD 4/30/2018 197 BERKELEY ROAD 210/047.0-0051-0000.0 73 0 Date..��/./A!. ...... '40 TH TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Sq USEt This certifies that . . . . . . . . z. . .. . . . . . . . . . has permission for gas installation . . . oye. ... . ... . . . . . . . . . in the buildings of . . f1..1 It- ... . .. . .. . .. . . . .. . . .. . . . .. . . . . at . . ` .1. . . .P n ,f. :/.. . .. . . . . . ,, North Andover, Mass. Fee. :-?U. . . . Lic. Nol.5.�. �. .. , :.. . .. . GAS INSPECTOR Check# C �� MASSACHUSETTS UNIFORM APPLICATION FO PERMIT TO DO GASFITTING A Atobouol Mass. Date 20 l6 Permit# Building Location Owner's Name CAS4LE 17 Re*C-L`( Type of Occupancy C- I/ New ❑ Renovation ❑ Replacement l- Plans Submitted: Yes❑ No❑ � ro U Ui rA F- C7 W 00 U F p; E• M cn F ¢ p O O H Z �j A zw Z a ¢ w a y N a H Uww W U� rn z 0 :40 : 04-<-< 0 0 x 0 0 �<-c 0 U SUB-BASEMENT BASEMENT i FIRST 1 ST FLOOR SECOND 2ND FLOOR THIRD 3RD FLOOR 4 FOURTH 4TH FLOOR FIFTH 5TH FLOOR SIXTH(6TH)FLOOR SEVENTH TT FLOOR EIGHTH 8T FLOOR Installing Company Name }� T Address q/ - N Check one: Certificate 0 OvaEreorporation �d Business Telephone 7 ❑ Partnership Name of Licensed Plumber or Gasfitter - w C k ❑ Firm/Co. INSURANCE COVERAGE:. I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes 0-- No❑ R you have checked ;please indicate,the type of coverage by checking the appropriate box. A liability insurance policy 0- Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the MGL,and that my,signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Mis4ach tts State Gas Code and Chapter 142 of the General Laws. By 'type of License:, Title ®-Plumber 5-Master Signa a icensed Plumber/Gasfitter City/Town ❑ Gasfiuer ❑ Joumeyman License Number APPROVED OFFICE USE ONLY i Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec 3B To: Building Commissioner or Inspector of Buildings City Hall FFCF ED N. Andover,MA 01845 MNY 2 4 2007 RE: Insured: Boris&Dvora Bel TOWN OF Pti`..,:.i;,;r; Ntq LTO Property Address: 197 Berkley Road,N. Andover,MA 01 5 Cause of Loss/Date: Windstorm Loss of 4/16/2007 File or Claim No: BOSO44728 Claim has been made involving loss, damage or destruction of the above captioned property,which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Mark Randall Adjuster On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. R, Signature Date NEW ENGLAND CLAIMS SERVICE,INC. 100 CONIFER HILL DRIVE,SUITE 308 DANVERS,MA 01923 Phone:f978)777-9900 FAX:{978}774-9296 Location / r,14 No. G/ Date /0 TOWN OF NORTH ANDOVER F41 9 Certificate of Occupancy $ CMUs�� Building/Frame Permit Fee $ Foundation Permit Fee $ s Other Permit Fee $ TOTAL $ Check A / 20687 Building Inspector TOWN OF NORTH ANDOVER NORTH APPLICATION FOR PLAN EXAMINATION 0 -(Uto 1O p Permit NO: Date Received U a \moi v ��SSACHII`����9 Date Issued: J IMPORTANT: Applicant must complete all items on this page LOCATION 7 Pb Irk kl M i/' d2 rint PROPERTY OWNER_ G /3 I3%.L �=1 Print MAP NO.: C? PARCEL: z © ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building ane family ❑Addition ❑Two or more family ❑Industrial FL.,40teration No. of units: LF"kepair,replacement ❑Assessory Bldg ❑Commercial ❑Demolition ' ❑Moving(relocation) ❑Other ❑ Others: ❑Foundation only DESCRIPTION OF WORK TO BE PREFORMED P c&A,,-/t Z A-J/ r d2oa/=yheg� l7L/ovwl. S ol,I2 x'/s d�A-,� Y&rt l0/�' )eal)r imp Identification Please Type or Print Clearly) OWNER: Name: 60 / 5 6/1.- z- Phone: ?�•e if Address: / P17 /ii5.,A 1,'Lly 9_,,)/ 'I CONTRACTOR Name: U, /Z Cl>,S/CJ1✓a Atr-5Jait/ Phone' Address:a�-C I-O w I U s / �Z L. A24 Supervisor's Construction License: O O go Exp. Date: Home Improvement License: I O'l 4 6 ,7 Exp. Date: ARCHITECTIENGINEER �— Name: Phone: Address: Reg. No. --- FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST B SED ON$125.00 PER S.F. Total Project Cost :$ /D.�'` x12.00=FEE:$ Check No.: O�f Receipt No.: go.�0 Page lol'4 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application ❑ Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) ❑ Building Permit Application o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans(One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DE,PARTME.NT:RPEORNIIIS P;wp 4 44 i TYPE OF SEWERAGE DISPOSAL Swimming Pools ❑ 11Tanning/Massage/Body Art E]Public Sewer Tobacco Sales ❑ Food Packaging/Sales 11Well ❑ F1Permanent Dumpster on Site Private(septic tank,etc. ❑ Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Plans Submitted ❑ Plans Waived Ll Certified Plot Plan F1Stampe laps ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM DATE REJECTED DATE APPROVED PLANNING& DEVELOPMENT ❑ ❑ ❑Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ COMMENTS Zoning Board of Appeals:Variance,Petition No: Zoning.Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water&Sewer connection/Signature&Date Driveway Permit Temp Dumpster on site yesno_ Fire Department signature/date Building Setback( Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area,based on Exterior dimensions. Total land area,sq.ft.: NOTES and DATA—(For department use) Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARI'MFNTI3PFORM05 0 eased 1MC..fan'006 NORTH Town of 86 _ 41L /_6 X10 dover, Mass. 1. COCHICHEWICK �k� 7ADRATED qS BOARD OF HEALTH Food/Kitchen PERM. 1 D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..........10.01,5............. ..................... .. .............................................. Foundation 111W has permission to ere44A-&- ................................ buildings on ../f.1.........oige LI�w.�ir�i'...... ........... Rough to be occupied as....... .........../..........L. .. ...I�i/Rww ......................................................................... Chimney Ch' provided that the person accepting th permit shall in eve respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Void_s this Permit. Rough Final 6 3 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS- CONSTR T�. ART Rough ............................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building - GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing cW Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. - - _ Burner Street No. SEE REVERSE SIDE Smoke Det. t-KUIrI : r'anason i c F HX aY5 I EM PHONE NO. : Mar. 14 2007 09:,3Atl P1 OR IC] K DATE(MMIDOIYYYY) AC080, CERTIFICATE OF LIABILITY INSURANCE NEWEV-i 03/20/07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFUP.N:ATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE xi.lgore InSuranCe Agency HOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 33 centennial Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Peabody MA 01.960 Phone'. 973-531-6550 Fax:"578=531-9442 INSURERS AFFORDING COVERAGE NAIL# — ...._—_....—.. INSURED .------ INSURER A: Western World Insurance _ om an � INSURER B: Safety Insurance CompanV 39454 _ Now England Custom Design INSURER C: TraVelers Pro Ext & Casual � Ron Weinberg & Val Lan a _ . '�..... —� 2;6 Lowell Street / [Tri t B4-•A INSURER D:. - Wilmington ESA 01857 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISBUEQ TO THEIN8URED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFOROF_D BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED 6Y PAID CLAIMS.' DD DAT�YIUMlDE POT M D YY LIMITS LTR,7 MS TYPIC OF INSURANCE POLICY NUMBER I GE14ERALLJABIUTY EACH OCCURRENCE $1000000• "VA( $50004.. A X COMMERCIAL GENERAI,LIABILITY NPP101164 9 03/14/07 03/14/08 PREMtSES ISS occurence)� CLAI`IS MADEOCCUR ( I MED EXP(Any One pemonl $2500 --J I PERSONAL d.ADV INJURY $1000000 ' �— —� I GENERAL AGGRECATE $'1000000 i PRODUCTS-COM PIOPAGG $1000000 GEN'L ACGREGATE LIMIT APPLIES PER: kPOLICY _ j10T Y LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 04/05/06 04/05/07 (I'eOcdenq $ AN'rAUTo 0462853 -... .. ALL UWNEDAUTO$ BODILY INJURY $250000 (Per person) i }( SCHEDULED AUTOS HIREDAUTOS BODILY INJURY $500000 (Per n6dent) NON.O'WNEO AUTOS PROPERTY DAMAGE $x.00000 (Per hCddent) GARAGE LIABILITY I i AUTO ONLY•IEA ACCIDE"IT $ ANY AUTO j i OYHERTHAN +ACI S ! AUTO ONLY: AGG $ EACH OCCURRENCE $ EXCES$IUMBRELLA LIABILITY OCCUR u CLAIMS MADE AGGREGATE OEDUCTIBI.E 1 RETENTION. 5 WORKERS COMPENSATIONAidD X TORY LIMITS ER 8 E nOYERS'LIASILITY 7PJLT8503K108707 03/14/07 03/14/08 E.L.EACH ACCIDENT $1.00000 ANY PROPRIETORlPARTNER/EYECUTWE i E.L.DISEASE-EA EMPLOYE $10 0'000 OFFICER/MEMBER EXCLUDED? !-fy�e,descnbnunder I E.L.DISEASE-POLICYLIMR $5500000 WEaIAL PROVISENA Gelaw OTHER i i I DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES/EY"CLUSIONS ADDCD BY ENDORSEMENT 15PECUlI PROVISIONS CERTIFICATE HOLDER CANCELLATION NEW�i'NCru SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 8E CANCELLED 8£FORB TWE EXPIPATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS Oft REPRES TINES. AUTHOR1 ED EP ES TIV rel ArnRn CORPORATION 1988 NEW ENGLAND CUSTOM DESIGN, INC. 226 LOWELL STREET WILMINGTON, MA 01887 #978-658-0881 Home Improvement Contract Registration No. 102467 ROOFING AND SIDING AGREEMENT ,' This is a legally binding contract. Make sure you read this Agreement and understand it before signing,it. Do not sign this contract if there are any blank spaces. NOTICE: All home improvement contractors and subcontractors, unless specifically exempted by Massachusetts Law, must be registered with the Commonwealth of Massachusetts. All inquiries about registration should be directed to; DIRECTOR-HOME MPROVEMENTCONTRACTORREGISTRATION One Ashburton Place,Room 1301 Boston,Massachusetts 02108 Telephone:#617 727-8598 This Agreement is made on y&�/ ,20 0'2 and between New England Custom Design,Inc.(herinafter, "Contractor")and owner l 0/S P/{ (hereinafter, "Owner"), of City/Town A/, h/[LeaV"k State 11)12e, Zip HPhone j7)t'� Job Address ("The Premises") /�P-",d�p}A-/, �(� // WPhone 7r� - New England Custom Design, Inc. Salesperson v ....... . ... ......"� �![ J"tlRoomg will be a li nl on l aroo urfaces below,over present roofing shingles unless specified underREM z ?9HnK0..../ ....... ................... ...... .....� Co]o ..A19} V . tfC Main Roof : 6..............Ba Windows..... lN:( Extensions � .......................... lt Porches:Front...A/P...........Side...../•t1G?sY'.0.............. Rear....e'.2h'.iti: .....................Other Roofs..... CDX r�.................... NOTE:Roofboard Replacement Cost — per foot OR — per 4'x 8'sheet of ---- inch Plywood. REMARKS/EXTRAS: Missing or defective lumber is not included in any category of work unless specified under REMARKS. 1YI .....���r./ ..C�'� ...?v....G..�< .. '..Y..��.. `..yt4/rGS...,.......f!�tG�rrr.�t:-�................ .:......................................................................................................................... .........................................................................................................................................................................................................I...................... ................................................................................................................................................................................................................................ n .........:.............................................:....................................................... r ,.1:>.....G4r �� c .l......0 ?r` ... ...... a:.....c.................................................................................................. The Contractor agrees to perform in a good and workmanlike manner all work detailed above. OG' CASHPRICE $...... NOTE: All Roofing Customers ....................- DOWN;PAYMENT $...........r `0...._o....................:.... New England Custom Design,Inc.will not be held. PAYABLE ON START OF WORK $.....0� �>Or..• •.••.•.. ........... responsible for dust and debris falling inattic area PAYABLEONCOMPLETION $.....o?.S �fJ.:.......... .rfl�??r...s during roof installation. [� Please remove or cover valuables. DATE:........../... /..l`�.. ........20.............. I � RIGHT TO CANCEL CThe Owner may cancel this agreement if it has been signed by the Owner at a place other than the address of the Contractor,which may be his main office or branch thereof,provided that the Owner notifies the Contractor in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery,not later than midnight of the third business day following the signing of this Agreement. See attached Notice of Cancellation. A cancellation fee representing 30%of the contract price will be in effect if cancellation is requested after the legally allotted time has elapsed. The Owner hereby certifies that he has read this Agreement,that the terms and conditions and the meaning thereof have been explained to him, and that he fully understands them and that there is no understanding between the parties,verbal or otherwise,than that which is contained in this Agreement,and agrees that the said Contractor is not responsible nor bound by any representations not contained in this Agreement,made by any of its agents,unless the same be reduced to writing and signed by the C ac o. ATTENTION HOMEOW R: DO NOT SIGN THIS CONTRACT IF T ANY BLANK SPACES. Owner's Signature Date England Custom Design,In Date Owner's Signature Date i Depa;.rtment of Public Safety Board of Building egula q s One Ashburton Place, Pm 1 :01 Boston, Ma.02108-1618 License: CONSTRUCTION SUPERVISOR LICENSE Birthdate: 04/20/1951 Number: CS 008828 Expires: 04/20/2008`. Restricted To: 00 VAL J LANZA } L Tr.no: 2 1457 Keep top for r$celpt and change of address notification. )PS•CAI 0 5OM-04/05-PC8698 Boar_ d of Building Regulations and Standards One Ashburton Place - Room 1301 Boston. Mas5p,4usetts 02108 Home Improvement Qttractor Registration Registration: 102467 Type: Private Corporation 'r' Expiration: 7/2/2008 NEW ENGLAND CUSTOM DESIG ', G J Val Lanza 226 LOWELL ST. WILMINGTON, MA 01887 ='• .' ' ` == ';; ,�y:. `'�-�.�,-:,.� is c;• Update Address and return card.Mark feason for change. (I Address E Renewal 7 Employment Lost Card 'PS-CAI 0 50M•05/06•PC8490 I i The Commonwealth of Massachusetts Department of Industrial Accidents office of Investigations . Z 600 Washington Street Boston,MA 02111 ,M www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant Information Please Print Le-ibly Name (Business/Organization/Individual): Address: City/State/Zip:1;,)', %0A 10 V1 Phone #: Are you an employer? Check the appropriate box: Type of project(required): �- 4. ❑ I am a general contractor and I 6. New construction I.'tom., : am a crrlployer with�_ ❑ employees (full and/or part-tune).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet $ �� Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capaci /. workers' comp. insurance. 9. ❑ Building addition o workers' comp.insurance 5. ❑ We are a corporation and its officers have.exercised their 10.E] Electrical repairs or additions required.] 11. Plumbing repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL ❑ g myself. [No workers' comp. c. 152,§1(4), and we have no 12.0 Roof repairs employees.ployees. [No workers' insurance required.] 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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. zContractors that check this box must dtiached-an additional sheet showing the name of the sub-contractors and their work 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:___�C'CA\�C%`C(-� Policy#or Self-ins.Lic. #: 7 , U B�f7 aJ� Expirarion Date: 1 Job Site Address: 1 ! 7 lei a kL l�y tz- City/State/Zip: A/ 4 t400144 '724- 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,cad to the imposition of criminal pena 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 n-,2.y be forwarded to the Office of lnvestigations of the DIA for insurance coverage verification. I do hereby certify under th pains and penalties of perjury that the information provided above is trite and correct Si afore: %r f'/ ✓ -� Date: ry `7 i Phone#: Official use only. Do not write in this area,to be completed by city.or town official. City or Town: Permit/License# i Issuing Authority(circle one): I. 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 hue, 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 havebeen 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(Oalong with their certificate(s)of insurance. Linuted Liability Companies. (LLC)or Limited Liability Parto.crships(LLP)with no employees;other than the members or partners, are not required to carry workers'compensatio,,r insurance. If an LLC or LLP does have employees,a policy is required..ae advised that.this affidavit may be submitted to the Department of.In 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 Accident`s:,,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 perrnidlicense number which will rye used as a reference number. In addition,an applicant that mast submit multiple permit/license applications in arty 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 'moi um)-" copy of the affidavit that has been officially stamped or marked by the city or townmay be provided to the applicant as pro h valid affidavit is on file for future permits or Iicenses. Anew affidavit must be filled out each year. Where a home owner or citizen is ol?'.aming a license or permit not related to any business or commercial venture (Le. a dog license or permit to bum le ✓es etc.)said person is NOT required to complete this affidavit. The Office of InvesrigationG 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. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia