HomeMy WebLinkAboutMiscellaneous - 22 SAUNDERS STREET 4/30/2018 22SAUNDERS STREET
210/029.0-00040000.0
Town of North Andover VIORTH
F?.o���oo,•,yOO!
Office of the Zoning Board of Appeals
Community Development and Services Division 1
27 Charles StreetToo
North Andover,Massachusetts 01845 'ss„C,K,se�
D. Robert Nicetta Telephone(978)688-9541
Building Commissioner Fax(978)688-9542
Any appeal shall be filed Notice of Decision
within(20)days after the Year 2004
date of filing of this notice
in the office of the Town Clerk. Pro at:22-24 Saunders Street
NAME: Vasil y Molls HEARING(S): July 13&September 21,2004
ADDRESS: 22-24 Saunders Street ' PETITION: 2004-015
North Andover,MA 01845 TYPING DATE: September 24,2004
The North Andover Board of Appeals held a public hearing at its regular meeting on Tuesday,September 21,
2004 at 7:30 PM m' the Senior Center, 120R Main Street,North Andover,Massachusetts upon the application of
Vasiliy Molls,22-24 Saunders Street,North Andover,requesting a dimensional Variance from Section 7,
Paragraph 7.3 and Table 2 for relief of the rear setback in order to construct an attached 2-story 2-car garage and
apartment,and a Special Permit from Section 9,Paragraph 9.2 and Table 1 of the Zoning Bylaw to extend and
alter a pre-existing structure and use on a pre-existing,non-conforming lot. The said premise affected is property
with frontage on the East side of Saunders Street within the I-S zoning district. The legal notice was published in
the Eagle Tribune on June 28&July 5,2004.
The following voting members were present: John M.Pallone,Ellen P.McIntyre,Joseph D.LaGrasse,and
Richard J.Byers. The following non-voting members were present: Thomas D.Ippolito,Richard M.
Vaillancourt,and David R.Webster.
Upon a motion made by John M.Pallone and 2nd by Joseph D.LaGrasse,the Board voted to GRANT the
applicant's request that the Variance and Special Permit petitions be WITHDRAWN WITHOUT PREJUDICE.
Voting in favor:John M.Pallone,Ellen P.McIntyre,Joseph D.LaGrasse,and Richard J.Byers.
Town of North Andover
Zoning Board of Appeals,
en P.McIntyre,Vice
Decision2004-015.
M29P4.
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Board of Appeals 978-688-9541 Building 978-688-9545 Conservation 978-688-9530 Health 978-688-9540 Planning 978-688-9535
Town of North Andover °fH
ORT
Office of the Zoning Board of Appeals F? • ' °°�
Community Development and Services Division
27 Charles Street
North Andover,Massachusetts 01845
D. Robert Nicetta Telephone(978)688-9541
Building Commissioner Fax(978)688-9542
Any appeal shall be filed Notice of Decision
within(20)days after the Year 2004
date of filing of this notice
in the office of the Town Clerk. Pro at:22-24 Saunders Street
NAME: Vasily Molla HEARING(S): July 13&September 21,2004
ADDRESS: 22-24 Saunders Street PETITION: 2004-015
North Andover,MA 01845 TYPING DATE: September 24,2004
The North Andover Board of Appeals held a public hearing at its regular meeting on Tuesday, September 21,
2004 at 7:30 PM in the Senior Center, 120R Main Street,North Andover,Massachusetts upon the application of
Vasiliy Molla,22-24 Saunders Street,North Andover,requesting a dimensional Variance from Section 7,
Paragraph 7.3 and Table 2 for relief of the rear setback in order to construct an attached 2-story 2-car garage and
apartment,and a Special Permit from Section 9,Paragraph 9.2 and Table 1 of the Zoning Bylaw to extend and
al pre-existing ter a pre-e st g structure and use on a pre-existing,non-conforming lot. The said premise affected is property
with frontage on the East side of Saunders Street within the I-S zoning district. The legal notice was published in
the Eagle Tribune on June 28&July 5,2004.
The following voting members were present: John M.Pallone,Ellen P.McIntyre,Joseph D.LaGrasse,and
Richard J.Byers. The following non-voting members were present: Thomas D.Ippolito,Richard M.
Vaillancourt,and David R.Webster.
Upon a motion made by John M.Pallone and 2°d by Joseph D.LaGrasse,the Board voted to GRANT the
applicant's request that the Variance and Special Permit petitions be WITHDRAWN WITHOUT PREJUDICE.
Voting in favor:John M.Pallone,Ellen P.McIntyre,Joseph D.LaGrasse,and Richard J.Byers.
Town of North Andover
Zoning Board of Appeals,
,4
Ellen P.McIntyre,Vice
Decision2W4-015.
M29P4.
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Board of Appeals 978-688-9541 Building 978-688-9545 Conservation 978-688-9530 Health 978-688-9540 Planning 978-688-9535
, MORTGAGE INSPECTION FLAN
NORTHERN ASSOCIATES, INC.
342 m MAIN STREET ANDOVER MA 01810 TEL: '(978) 474-4410 FAX., (978) 474-5067
MORTGAGOR: PAOLi.A, VAS ILY AAJO •W0011LA DEED REF: Q8110 PG: AKI
LOCATION: 22--Z4 SAV/VWIZS SMEET PLAN REF: oo/kip
CI'I'Y,S`1'A`I'E:_AJ AAhWM )MA JOB# : 9$0512U
DATE: tp/w./� SCALE: =y0�
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CERTIFIED TO: MPL.E-) �RI'FA66 SAVIN125 f3AN1L
NOTE: This mor[gaga inspection was prepared This mortyage inspection was prepared In accordance
specifically for mortgage purposes only and w1Lh the Technicul Standards fur Hortyage Loan
is not to be relied upon as a land or property 1H OF M LispecLions as adopted by the flassachusetts Board of
line survey, used for recording, preparing deed QQ�. ofp� Negiutrution of Professional Engineurs and Land
descriptions, or construction. No corners were �y1 "Y� Surveyors 250 Q111 605.
set. Building location and offsets are o CARME yG 1 further state that In my professional opinion that
approximately located on the ground and �. the structures shown conform with the local zoning horizonta
are shown specifically for zoning determination -. dimensional setbuck requirements at the time of construction
only and are not to be used to establish property are exempt under provisions of H.G.L. C11. 40-A Sec. 7.
lines. The matters shown hereon are based on
client-furnished intormation and may be subject 67 apQ 16I.Property/house is not in a Flood hazard.
to further out-sales, takings, easements and rights .r�, qF �Q 4, E12.1'roperty/ilouse is in a Flood Hazard Area.
of way, and other matters of record and prescriptive J0►STER JQJ (]3.Information is insufficient to determine
or other rights. Northern Associates, Inc. assumes no S
responsibility herein to the land owner or occupant, ONgi LAW3 Flood Hazard.
accepts no responsibility for damages resulting from said Flood Hazard determined from Intest Federal Fin-
reliance by anyone other than the said mortgagee and its assigns �2'i 98 Insurance R to Hap Panel ZOad
In connection with Its proposed mortgage tinancing to said mortgago . Date.------ �-Z ZA�
4` Zone >G— -�►'1',
Date. ..
of No pTti :` T01 OF NORTH ANDOVER
A OJ PFS IT FOR GAS INSTALLATION
�9SSACHUSEt
/• 1, .
This certifies that
has permission for gas installation '� '.'ter . .',�'. 7 . .�..f;..f
K.-
in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
at Nbrth Andover, Mass.
Fee. .';�. . Lic. No.. . . . 1 : 'i . . . . . . . . . . . . . . . . . . . . . . . . . .
1 GAS INSPECTOR
WHITE:Applic&2�—' CANARY: Building Dept. PINK:Treasurer GOLD: File
4-� wip55AL` SETTS UNIFORM APPLICATION FPR PERMIT TO DO QASFITTINQ
(Print or Type) J
NORTH ANDOVER, , Mass. Date i 1)g—q, l/
y� "71
/ 5
Building ��� S �i Permit #_ Z�(r� Z
Location - a- Sy ry
Owner's C
Name _�n
New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yea p No ❑
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O -) � W I- �, d s K
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SUQ—aSMt.
BASEMENT
1ST FLOOR
=NO,FLOOR I
SADFLOOR
4TH FLOOR
STH FLOOR }
STH FLOOR `
7THFLOOR !
STN FLOOR
�.
Check one: Cednicate
Installing Company Name Corp.
Address- /31)V Ve Z l [j Partnership
❑ Firm/Co.
Business Telephone �76 0 g 2--o
Name of Licensed Plumber or Gas Fitter_- go
INSURANCE COVERAGE: Check on_*—
I have a current liability Insurance policy or its substantial equivalent. ' Yes [T No ❑
If you have checked yea, please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy 19< .. 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 Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
%nature of Owner or Owner's Agent Owner 11 Agent❑
(Hereby certify that all of the details and Information I have submitted(or entered)M above application are true and accurate to the best of my
knowledge and that all plumbing work and Installations performed under the permit I ad this applicat on will be In compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of tha ws
Type 91 license:
umber urs o cense Plumber or as er
Title Gasntter
aster Ucense NumberU
Ctty/Town D Journeyman
AP1110NE0(OFFICE USE ONLY)
BELOW FOR OFFICE USE ONLY
FINAL INSPECTION SKETCHES
PROGRESS INSPECTION
FEE
N0.
APPLICATION FOR PERMIT TO DO GASFITTING
NAME A TYPE OF BUILDING
LOCATION OF BUILDING
PLUMBER OR GASFITTER
LIG NO.
PERMIT GRANTED
DATE 19
GAS INSPECTOR
�or+rk
Zoning Bylaw Review Form
F Town Of North Andover Building Department
27 Charles St. North Andover MA. 01845
Phone 978-688-9545 Fax 978-688-9542
Street:
Map/Lot: 2 Cl
Applicant: UA S Y4
Request: 1 .2 G > -/o i-/- 401d� d'-i Ivr Ga f,74e
Date: 1 S is a od
Please be advised that after review of your Application and Plans that your Application is
DENIED for the following Zoning Bylaw reasons:
Zoning y S <:5-0,000 a ,sa rNvty zo- at, -a o
Item Notes Item Notes
A Lot Area F Frontage
1 Lot area Insufficient 1 Frontage Insufficient
2 Lot Area Preexisting y S 2 Frontage Complies
3 1 Lot Area Complies 3 Preexisting frontage y c 5
4 Insufficient Information 4 Insufficient Information
B use 5 No access over Frontage
1 Allowed G Contiguous Building Area N A
2 Not Allowed 1 Insufficient Area
3 Use Preexisting !S 2 Complies
4 Special Permit Required y s 3 Preexisting CBA
5 Insufficient Information 4 Insufficient Information
C Setback H Building Height
1 All setbacks comply 1 Height Exceeds Maximum
2 Front Insufficient 2 Complies
3 Left Side Insufficient 3 Preexisting Height y,e,5
4. Right Side Insufficient 4 Insufficient Information
5 Rear Insufficient I Building Coverage N�
6 Preexisting setback(s) y 1 Coverage exceeds maximum
T. Insufficient Information 2 Coverage Complies
D Watershed 3 Coverage Preexisting
1 Not in Watershed H S 4 Insufficient Information
2 In Watershed Sign IV
3 Lot prior to 10/24/94 1 Sign not allowed
4 Zone to be Determined 2 Sign Complies
5 Insufficient Information 3 Insufficient Information
E Historic District K Parking
1 In District review required 1 More Parking Required
2 Not in district V e-5 2 Parking Complies
3 Insufficient Information 13 Insufficient Information c g
4 Pre-existingParkin
Remedy for the above is checked below.
Item # Special Permits Planning Board Item # Variance
Site Plan Review S ecial Permit C Setback Variance
Access other than Frontage Special Permit t-3 ? Parking Variance.
Frontage Exception Lot Special Permit Lot Area Variance
Common Driveway Special Permit Height Variance
Congregate Housing Special Permit Variance for Si n
Continuing Care Retirement Special Permit Special Permits Zoning Board
Independent E__Iderly Housin Special Permit Special Permit Non-ConforminUse ZBA
Large Estate Condo Special Permit Earth Removal Special Permit ZBA
Planned Development District Special Permit Special Permit Use not Listed but Similar
Planned Residential Special Permit Special Permit for Sign
R-6 Density Special Permit _ Special permit for preexisting
Watershed S ecial Permit nonconforming
The above review and attached explanation of such is based on the plans and information submitted. No definitive review and
or advice shall be based on verbal explanations by the applicant nor shall such verbal explanations by the applicant serve to
provide definitive answers to the above reasons for Any inaccuracies,misleading information,or other subsequent
changes to the information submitted by the applicant shall be grounds for this review to be voided at the discretion of the
Building Department.The attached document titled"Plan Review Narrative"shall be attached hereto and incorporated herein
by reference. The building department will retain all plans and documentation for the above file.You must file a new permit
application form and begin the permitting process.
- /Y (� c3 i o o ly
Building epartment Official Signatyf�e Application Received Application Denied
f
Plan Review Narrative
The following narrative is provided to further explain the reasons for DENIAL for the
APPLICATION for the property indicated on the reverse side:
t�,gal x t
.�,�b, fs s t e Z
c5 PS c
—`� (/,42/ANCti 14::;!" Q r,42
A
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InPGfrl�npJcp a/VW ��Ly, /� � rS 5 A
S e,G 7-!O , /�
p f U,P,k 07 Lo A.)
S/�ACYS Per wa//,tiy UNc4-
5 L5
� �cb��Ng o'Jw� l/�tiy �ti, 5 a �� p,�rs 4 .
AOA
Referred To:
Fire Health
Police tonin Board
Conservation DPlann' e artment of Public
Other Works
thern Historical Commission
OBuildin Department
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED:
aawas
SIGNATURE:
Building Commissioner/I for of Buildings Date
SECTION 1-SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
�; q Map Number Par Number
1.3 Zoning Information:Ovv" 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(so Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide Required Provided Required Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public ❑ Private 0 Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT [Oi-IC LiStriCt: Yes p M
2.1 Owner of Record
ame Print) Address for Service
` 7g- Zig- ??'3
Signature f Telephone
2.2 Owner of Record:
0
Name Print Address for Service:
M
Signature Telephone
SECTION 3-CONSTRUCTION SERVICES DIP- htE!fi
3.1 Licensed Construction Supervisor: Not Applicable ❑ 9
r-�
Licensed Construction Supervisor: '✓
License Number
Address
Expiration Date ic
Signature Telephone
3:2 Registered Home Improvement Contractor Not Applicable ❑
Company Name 0 r o
Registration Number
Address
Expiration Date
Signature Telephone
1
SECTION 4-WORKERS COMPENSATION(nG.L. C 152 § 25c(6),
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes.......❑ No.......❑
SECTION 5 Description of Proposed Work check all a livable _
New Construction Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition 0
Accessory Bldg. 0 Demolition ❑ Other 0 Specify
Brief Description of Proposed Work:
ri
0,-6,l X2 1-9`1 FK'gOlo11 it, [: k t'-,I(")I
z C,-- r !����J�
�1 A(J�Cl�l� d✓� Zed FICC/ CD✓1�d1/"1 S to ZSI Gress
0-F M1 t , ✓--e
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be £;ffICIALC USEONLY
Completed by permit applicant
1. Building O Co (a) Building Permit Fee
Multiplier
2 Electrical (b) Estimated Total Cost of
43% O�iO Construction
3 Plumbing DG o Building Permit fee(e) X (b)
4 Mechanical HVAC
5 Fire Protection &&0
6 Total 1+2+3+4+5 C-C cy I Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, VA ;'t' L V ILI 0 �C�— as Owner/Authorized Agent of subject property
Hereby authorize_ to act on
My behalf,in all matte relative to work authorized by is building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUT ORIZED AGENT DECLARATION
1, as Owner/Authorized Agent of subject
property
Hereby declare thaf the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief
Print Name
Signature of Owner/A ent Date
ilium
NO. OF STORIES 3 SIZE `
BASEMENT OR SLAB
SIZE OF FLOOR M4BERS 15 2' ) 3RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
DIGHT OF FOUNDATION _ THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FIT—LED LAND _
IS BUILDING CONNECTED TO NATTJRAL,GAS LINE
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Date.!/ .A5�.9........
f HORTM 1
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATIO
�,SSACHU$
This certifies that . .� y.!�2.t,! . . . .� . . . . . . . . . . . . . . . . . . .
has permission for gas installation . . /.7.4;P. :.,lX . . . . . . . . .
in the buildings of (.66. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
at . . . . . . . . . . .. North Andover, Mass.
Fee. �. . . . . Lic. No..?6 '? �
3. !. �. . �i�-v. . . . . . .
AS INSPECTOR
Check#
f2-
6 Uri
MASSA(liUSEM UNIFORMAPPUCA'PONFORPERWrTp
(Type or print) GASG
NORTH ANDOVER, MASSACHUSETTS Date O .
Building Logations � < S 0�� /
S l jY Permit# 7
ners Nrame Amount$
a!40W
New❑ Renovation ❑ Replacement
❑ Plans Submitted ❑
� a
y W
z o u � x �.
y , I , E W p O z O Z w
a o w o F
z a x a y F o a > e
F � W
Z Q tra W W F q U
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W
S ,
SUB -BAT O
> C C < G G Z S F• w
SEM EN + O
_ BASEMENT
] ST. FL00R
2ND , FLOOR
3RD , FLOOR
4TH . FLOOR
TH . FLOOR
6TH . FLOOR
7TH , FLOOR.
8TH . FLOOR
(Pmznt or type) 5
Name Check one: Certificate Ins Ling Com an
❑ Corp, P Y
Addree . C�i� 7 �` �/�
ElPartner.
usmess e ep one
Name Of Licensed Pfum ❑ Firm/Co.ber'orGas Fitter /
INSURANCE COVERAGE
I have a current liability Insurance•poficy or it's substantial equivalent, Check one:
If you have checked yes,please indicate the a cove Yes ❑ No
Liability insurance policy rage by checking the appropriate box,
❑ Other type of indemnity ❑
Bond 13Owner's Insurance Waiver. I am aware that the licensee does n_ u
Mass. General Laws,and that my sih� Y the Insurance coverage required b Chapter 142 of the
gnature on this application waives this requirement.
Signature of Owner or Owner's Agent Check one:
wner
1 hereby certify that all of the details and information t have submitted(or entered)in Agent13
Best of my knowledge and that all plumbing work and instal}ations performed under Permit Issued for this lice
compliance with all pertinent provisions of the Massachusetts State G e and accurate to the
Gas Code and Chapter.l 42 of the General Laws.on will be in
By Signature of Licensed
Title ❑ Plumberm'er,Or Gas pier
City/T_61 ❑ Gas Fitter /
icense um er
rl Master
_ APPROVED(OFFICE USE ONLY) Journeyman
�I
De artment ofweea ofJuassachusetts
P Industrizd Accidents
' '
Office o
i
� r��' ,f Investigations
600 W
ashin,°rton Street
..�
Boston Mt102111
r .
wwrc+.rrz�s,�go z�/dig
Workers' Co;<npensatian Insurance•A�davit: guilders/Contractors/EI
An Leant Information ectridians/Piumbers
n Please Print Legibly
N31Ile ($usirtess/Organization/Individuai): �� Y
Address:
Clty/State/Zip:
FAEreyou anemployer?Check the appropriate hoz:
amaemp}oyer with 4• Typeofprujecf(required❑ 1 azo a i;eneral contractor and[ )mpioyees(fall and/or part-time).* have hired the sub-contractor; 6 ❑ �1ew construction
•,�am a sole proprietor or partner-
s
artner- listed sh' and have °t? the attached shut x 7. [� RemodeIing.
workingTh-
for me in any specify. work=, have
g• ❑ Demolition
(No workers'comp. insurance 5. ❑ We� � comp. insurance. 9•
re
a corporation and its ❑ $uiiding addition
r ofncem have exercised.thetr 10:❑ Electrical repairs or additions
3.7 I am a homeowner doing all work right of ex
myself. [No.workers' oom , c. 152 ern tion
p c. 15 , e 1(4)�and w�have no 11'❑ Plumbing repairs or additions
insurance required.] t 12,
Y .s. [No.workers ❑ Roof repairs
comp. insurance required.] 13•Q Other
'Any appficant.that cheeks box#I.must also�fill out the section below showing
'Homcownen;wito submii.fhis affljdavit indiceting il�e-are duir••E?utCrrlC th—ir workers'compensation policy mionnation.
1Cont�tors Thal check this box. ru Encu nits o
must a=hed an additional sheet showing the utsidE contracture roust submit a new am[iav
name of the sub-Dorn=tots and th ii indi ing arch,
I am an enrplo}�e'dh�:is providtrto workers'cor. eus m*r workers'comp.potic3,imonnation.
atioez er^-
infor�ration n / ° " wurance for ng,employees. Below is the poficj'and job site
Insurance Company Name: J � Com/ � r, ��C ��
Policy#or Self-.ins. Lit.#:
Expiration Date:
Job-Sit`Address
Attach s copy of the workers, compensation tic decia City/S�/Zip:
.Failure to secure coverage as required under Section 25A of tion page(showiQ'the Policy number and expiration date
fine up to 31,500.00 and/or one-year imprisonment,as well MGL c. 152 can lead to the imposition of es of a
as civil penalties in the form of a STOP WDRK ORDER and a fine
of up to.5250.00 a day against the violator. Be advised that a
Investigations of.the DIA for insurance coverage verificati.ori•copy°f this statement may be forwarded to the Officeof
I do hereby certif under the painc and p=ajdw ofperjurJl �the ffor matron provided above is true and correct
Signature:
Phone P: Date:
Official use nnl P. Do not write in this area, to be completed bj, j,or town ofJccial
City or Town:
Issuing Author' Permit/License#
Issuing (circle one):
1. Board of Health 2. &uiiding Department 3. CitylTown
fi. Other Clerk 4. Electrical Inspector S. Piumbirtu I
b rtspector
Contact Person:
Phonefh
1111V1 L1IQLIVII acC=.jju lust]uciions
Massachusetts General.Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined.as P P
r-y person in the service of another under any contract of h ire
' express or implied_oral or written."
An employer is defined as`pan individual,partnership;association, corporation or other legal amity,or any two or more
of the foregoing engaged in a joint enterprise,and inclucii ng 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 horise.having not more them.three ap:aximents and who msides therein,or the occupant of the
dwelling house of another who employs persons to do mintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be d,-erred to be an employes."
MGL chapter 152, §25C(6)also states that"every state o r local licensing agenc} shall withhold the iissuanceor
renewal of a license or permit,to operate a business or- to conamat buildings in the commonwealth for-any
applicant who has not produced acceptable evidence o f 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 worms ra Tdl acceptable evidence of compliance with the insurance
requirements ofthis chapter have been presented to the cl<�nt=ting authority,".
Applicants
Please fill out the workers'compensation affidavit compi•etely,by checking the boxes that apply to your situation:and, if
necessary,supply sub-contractors)name(s), address(es) and phone nurnber(s)along with their certifimte(s)of
insurarico. Limited Liability Companies (LLC) or Limited. Liability Partnerships(LLP)with no employees other than the
member's or,partners,are not required.to carry.Workers'comp��on insurance. If an LLC or LLP does have..
employees, a policy is required.. Be advised.that this.afffic$.a.vit maybe,sued to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the af*tidavit Theaffidavitshould
_ be returned to the city or town that the application for the p�.n or license is being requested,not the Department of
Industrial Accidents. Should you have any questions re_aixding the.iam,or.if you are required to obtain a workers'
compensation policy;please call the Department. t the nuanber.lisFwd below. Self-insured mr, auies should enter their
self-insurance license number on the appropriate line.
City or Town Ofuciais
Please be sure fat the affidavit.is complete and printed le-gibiy. The Department has
ep provided a space at the bottom
of the.affidavit foryou to fill out in theevent the Office of Investigations has to contact you regarding the applicant:
Please be sure to fill in the p:imifAicense number which will be used as a reference number. In addition, an applicant
-that must submit multiple,permit/license applications in arty given yew,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 furtuuet permits or licenses. A new affidavit must be filled out each
year. Vrrh= a home owner ar citizen is obtaining a Iicens- or permit not related to any buusiness or commercial ventu rt
(i.e. a dog license a permit to burnleaves etc.)said pers011 is NOT required to complete this affidavit.
The Office of Investigations would like t6thank you in advance for your cooperation and should you have any questions, .
please do net hesitate to give us a call.
The Department's address,telephone and fay,numbs:
The Cornrnonwtadth of Massachusetts
Department of badustrial Accidents.
Office of r avestigations
600 Was}o ington St-t:.
Boston; MA 02111
Tel. 4 617-727-45x00 apt 406 or 1-8?7-MASSAFE
Revised 5-2645 Fax 4 61 7-72.7-7749
VAWMasS.gov/diff