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Home My WebLink AboutMiscellaneous - 30 OLD CART WAY 4/30/2018N J 0 -� W Q � q 0 i b v o D, N � b �' i o n 0 Dte . . . . . . . 0* 40RTH TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATIO�L Q. CHU CU This certifies that 4--& ... .. ......... ......... ..... has permission for gas installation in the buildings of . e-?�I. . ........... a -�.O ... QA e! .... . It Andovi t er, MaW, Fee ...... Lic. No.t.5/.3.... sp .7 cTo ASINSPECTO WHITE: Applicant CANARY: Building Dept. PINK: Treasurer I I o'- 0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMITTO DO GASFITTING (Print or Type) Al190�� Permit it CR67 0�0 Building Locatli:Cn& Ownet'shlarne-:11�56n Map:_ Lot: Zone:_ Type of Occuparicy-ges i Gr SUB-9SM7. BASEMENT I S'T F L 0 OR 2NO FLOOR 3RD FLOOR 4TH FLOOR STM FLOOR STH FLOOR ?TX FLOOR ATM FLOOR .� Ftenov2sion 0 seplacernent C3 Plans Subr-nitted: yes 7_) Ins tailing C--rnpany Name * EASTERN PRO?A.N7-7 GAS 1NC Check one: Cer.1Nc2!e Address 13 1 WATER STREET DANVERS MA 01923 f Ccrper2�cn Estima!e Value of Work: 'Partnership Business Teleph one (508) 774-1930 Fitnn /Co. Name of Licensed Plumber cr Gas Fi:,er rA� V\ —j�\ I - INSURANC5 COVEPAG S: I have acurrent liabiny irst:ranxe pc,'*cy cr i"s eq..'-1-alent whlcl� rnez- yes:a , N* :) :S *,'a req'jirer,-,e . -.*,s of MGL Ch. If you have ch.ecked ves, please indica:a type ccve.-a--e by Checking t.1je a;przpr.;e',e box. A liability insurance policy C-1her type of Bond 0 OWNER'S INSURANCE WAIVER: I ann aware 1621 t�:e licensee dces not he-v*3*.*s�a'jr."st:'ra.,ice—c*cv*e*r'-age required Chapter 1 �2 of the Mass. General Laws, and thai'my S., na"Ura on vhis pearrrut appr. :.: ... 1. .. . - ication waives this require ment Check one: Signature Of Ownar of Owniies Agent Cwner 0 . . Agent 3 I hereby mrt�, that all of ne detaiis L^4 Wotr.=604 I h2vO Submired (or entered.) in above ap;5ca6on ate true P-nd a=rale to ne bes: r. -f knOMedge and ftt all plur.1bing wzrk ag-id L-staltz1ons performed underVie permit issued for this appricalon will be in compliance 2APerlhentprovisions 01LhG VASSaaht---e--sS:a*e Gas Code and Ch2p:er 142offt Ger)eralLa yp-d W L;cei4-e. Plumber S -,;ria: -:r* of L;censed Plumber or Gas Ficer casrs.-er Ucense.V�j .ber Olt I Town Jourr-Ir.ran I'AIPPROVED (OFFICE USE ONLY)_ &-1 !2 0 U W. j A > 0 < -C = &,-) P.- 'j 13 U tj UJ z Aj Ins tailing C--rnpany Name * EASTERN PRO?A.N7-7 GAS 1NC Check one: Cer.1Nc2!e Address 13 1 WATER STREET DANVERS MA 01923 f Ccrper2�cn Estima!e Value of Work: 'Partnership Business Teleph one (508) 774-1930 Fitnn /Co. Name of Licensed Plumber cr Gas Fi:,er rA� V\ —j�\ I - INSURANC5 COVEPAG S: I have acurrent liabiny irst:ranxe pc,'*cy cr i"s eq..'-1-alent whlcl� rnez- yes:a , N* :) :S *,'a req'jirer,-,e . -.*,s of MGL Ch. If you have ch.ecked ves, please indica:a type ccve.-a--e by Checking t.1je a;przpr.;e',e box. A liability insurance policy C-1her type of Bond 0 OWNER'S INSURANCE WAIVER: I ann aware 1621 t�:e licensee dces not he-v*3*.*s�a'jr."st:'ra.,ice—c*cv*e*r'-age required Chapter 1 �2 of the Mass. General Laws, and thai'my S., na"Ura on vhis pearrrut appr. :.: ... 1. .. . - ication waives this require ment Check one: Signature Of Ownar of Owniies Agent Cwner 0 . . Agent 3 I hereby mrt�, that all of ne detaiis L^4 Wotr.=604 I h2vO Submired (or entered.) in above ap;5ca6on ate true P-nd a=rale to ne bes: r. -f knOMedge and ftt all plur.1bing wzrk ag-id L-staltz1ons performed underVie permit issued for this appricalon will be in compliance 2APerlhentprovisions 01LhG VASSaaht---e--sS:a*e Gas Code and Ch2p:er 142offt Ger)eralLa yp-d W L;cei4-e. Plumber S -,;ria: -:r* of L;censed Plumber or Gas Ficer casrs.-er Ucense.V�j .ber Olt I Town Jourr-Ir.ran I'AIPPROVED (OFFICE USE ONLY)_ 0 W. j A > Ins tailing C--rnpany Name * EASTERN PRO?A.N7-7 GAS 1NC Check one: Cer.1Nc2!e Address 13 1 WATER STREET DANVERS MA 01923 f Ccrper2�cn Estima!e Value of Work: 'Partnership Business Teleph one (508) 774-1930 Fitnn /Co. Name of Licensed Plumber cr Gas Fi:,er rA� V\ —j�\ I - INSURANC5 COVEPAG S: I have acurrent liabiny irst:ranxe pc,'*cy cr i"s eq..'-1-alent whlcl� rnez- yes:a , N* :) :S *,'a req'jirer,-,e . -.*,s of MGL Ch. If you have ch.ecked ves, please indica:a type ccve.-a--e by Checking t.1je a;przpr.;e',e box. A liability insurance policy C-1her type of Bond 0 OWNER'S INSURANCE WAIVER: I ann aware 1621 t�:e licensee dces not he-v*3*.*s�a'jr."st:'ra.,ice—c*cv*e*r'-age required Chapter 1 �2 of the Mass. General Laws, and thai'my S., na"Ura on vhis pearrrut appr. :.: ... 1. .. . - ication waives this require ment Check one: Signature Of Ownar of Owniies Agent Cwner 0 . . Agent 3 I hereby mrt�, that all of ne detaiis L^4 Wotr.=604 I h2vO Submired (or entered.) in above ap;5ca6on ate true P-nd a=rale to ne bes: r. -f knOMedge and ftt all plur.1bing wzrk ag-id L-staltz1ons performed underVie permit issued for this appricalon will be in compliance 2APerlhentprovisions 01LhG VASSaaht---e--sS:a*e Gas Code and Ch2p:er 142offt Ger)eralLa yp-d W L;cei4-e. Plumber S -,;ria: -:r* of L;censed Plumber or Gas Ficer casrs.-er Ucense.V�j .ber Olt I Town Jourr-Ir.ran I'AIPPROVED (OFFICE USE ONLY)_ Date. 0111-1. ....... '40RTjj x PE*IT ,fOR GAS INSTALLATION TOWN OIF` NORTH ANDOVER This certifies that .......................... has permission for gas installation in the buildings of .................................. ...................... North Andover, Mass. Fee. Lic. No.,��.�� ...... ..... ......... ,,GAS INSPECTOR Check # / '�"- '-' / MASSACHUSETBUNTFORMAPPUCAMN FDRPERNUTO DO GAS ffn (Type or print) , 3NG -7 NORTH ANDOVER, M SACHUSETTS Date V/X� �, /-) /,- 1, )1�1 / f / —4 Building Locations Q.&J Signature of r Permit# 3 cc/ �6w� _ Owner's Na — Amount $ Joumeyman New 0 Renovation 1-1 Replacement r -m/ Lj Plans Submitted 0 (Print or type) Name Address Business Telephone I Cf=k one: L1 Corp. Certificate Installing Company U Partner. M17;—Ir,� Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes13 NoO If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy ED Other type of indemnity 13 Bond 0 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: Signature of Owner or Owner's Agent Owner 13 Agent 13 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 underll�ermit Issfd fjor this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code ank! Cfianter 141 f P r.p.—I i — Title City/Town PPROVED (OFFICE USE ONLY) Signature of Plumber [3 G�s Fitter Master Joumeyman Q W G > z > LTW > z z z 4 U > SU B-BASEM ENT BASEMENT IIST. F L 0 0 R 2 N D . IF L 0 0 R 3 R D F L 0 0 R 4 T H F L 0 0 R 5 T H IF L 0 0 R 6 T H F L 0 0 R 7 T H IF L 0 0 R 8 T H F L 0 0 R (Print or type) Name Address Business Telephone I Cf=k one: L1 Corp. Certificate Installing Company U Partner. M17;—Ir,� Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes13 NoO If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy ED Other type of indemnity 13 Bond 0 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: Signature of Owner or Owner's Agent Owner 13 Agent 13 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 underll�ermit Issfd fjor this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code ank! Cfianter 141 f P r.p.—I i — Title City/Town PPROVED (OFFICE USE ONLY) Or Gas Fitter Signature of Plumber [3 G�s Fitter Master Joumeyman Or Gas Fitter Location:30 ()Ljr3 CART No. Date 70 8174 9= TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fe&M- $ Sewer Connection Fee $ Go CU Water Connection Fee $ FU TOTAL �D $ Building Inspector Div. Public Works PERAHT NO. m APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE I MAP +40. LOT NO. CONTR. LIC. 2 RIECORD-OF OWNERSHIP IDATE BOOK :PAGE ZONE SUB DIV. LOT NO. F LOCATION. PURPOSE OF BUILDING OWNER*S NAME NO. OF STORIES SIZE OWNER'S ADDRESS BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS POSTS DISTANCE FROM STREET DISTANCE FROM LOT LINES - SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING x IS BUILDING ADDITION MATER:AL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE I FILL OUT SECTIONS 1 3 PAGE 2 FILL OUT SECTIONS 1 12 ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE F7 F E E PERMIT GRANTED t 19 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST3 EST. BLDG. -COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY INSPECTOR OWNER TEL. # CONTR. TEL. # CONTR. LIC. H.I.C. # I OCCUPANCY SINGLE FAMILY Ao� S'ORIES MULTI. FAMILY APARTMENTS FORCED HOT AIR FURN. CONSTRUCTION 2 FOUNDATION STEAM 8 INTER It FINISH CONCRETE 3 1 2 13 CONCRETE BL K.- AIR CONDITIONING Plr' RADIANT H'T G BRICK OR STONE- HA 'DW D 7 NO. OF ROOMS I GAS PIERS PLASTER f5iRY WALL �NFIN 3 BASEMENT AREA FULL FIN, B M T AREA 1/1 '/� 1/1 FIN. ATTIC AREA t!O B M T FIRE PLACES HEAD ROOM MODERN KITCHEN 4 WALLS 9 FLOORS CLAPBOARDS ONCRETE B 1 2 3 I DROP SIDING WOOD SHINGLES EARTH ASPHALT SIDING_ HARDVJ D ASBESTOS SIDING COMMON VERT. SIDING ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR BRICK ON FRAME CONCOR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR POOR ADEQUATE H NONE 5 ROOF 10 PLUMBING GABLE I -tip BATH (3 FIX.) GAMBREL MANSARD I I TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET ASPHALT SHINGLES A-0' LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES TILE FLOOR 6 FRAMING _11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W T R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T G UNIT HEATERS 7 NO. OF ROOMS I GAS Off, � I ct crTD ir lst I 3,d 1 11 NO HEATING I I BUILDING RECORD 12 THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. A f I' - 541i P 0 Val I a i co .0 CD cm co cc C) r -L CD CO) .10 CD ICE C13 Cm coo Co on co w C* CD co CA co _rJ 93- C2, WS. 3:v CD 411� f46) C= C) s CD :a cm CD Cc CM 4.j 00 1., Go C=2 u CO2 cm CM Ca CD CD C.3 CD CD CL 40.2 CO2 CD CL 73 -,= C2 C31 CL L3,;; CD C.3 CO) C.2 ca cc COM CA C2, COD col cm, b— ml� Co C2-= CD L U- 2 F- LLJ C/) C:) C-) �M :5 Cl- 0 0 C: 0 cz u- it OD P4 4) > Qj C/5 7� 00 0 z Qd --'4 0 I a i co .0 CD cm co cc C) r -L CD CO) .10 CD ICE C13 Cm coo Co on co w C* CD co CA co _rJ 93- C2, WS. 3:v CD 411� f46) C= C) s CD :a cm CD Cc CM 4.j 00 1., Go C=2 u CO2 cm CM Ca CD CD C.3 CD CD CL 40.2 CO2 CD CL 73 -,= C2 C31 CL L3,;; CD C.3 CO) C.2 ca cc COM CA C2, COD col cm, b— ml� Co C2-= CD L U- 2 F- LLJ C/) C:) C-) �M :5 Cl- OFFICES OF: Town of 120 Main Street North Andover, ttS 0 V845 APPEALS NORTH ANDOVER Massachuge BUILDING DIVISION OF CONSERVATION HEALTH PLANNING PLANNING &COMMUNITY DEVELOPMENT KAREN H.P. NELSON, DIRECTOR In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit Number 1"S'21 is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as dcf-incd by MGL c 111, S 150A- T'he debris will be disposed of in: ' "J� :� -- 3 7 (Location of Facility) '�ignature of Permit. Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. 5d . 1 0 COMMONWEALTH OF MASSACHUSETTS EXPIRATION DATE 16(286 06/30/1993 1 17�1 RESTRICTIONS NONE SS N 010-32-8924 PHOTO t9LASTNG OPA CNILY, FEE: 100.00 pog 5� HEIGHT: ONDOB: tW, 01/17/1942 -A '41.�gl:.IINT MUST 5E CAR ON THE PERSON OTHERS RIGHT THUMB -.T OF T ' E 4OLDER WHEN ENGAG. 5D '4 'HIS OC-.L;PA-.;CN 2COM-22-87-81429 DEPAffnkiENT OF PUBM SAFETY 1010 COMMONWEALTH AVE. BOSTOK MASS- 02215 LICENSE CONSTR. SUPERVISOR EFFECTIVE DATE LIC -NO. 06130/1991 026791 'RONALD G LA10BERT 137 STEVENS ST HAVERHILL 14A 01832 NOT VAL-D M -41E:; 3' :ENSEE AND OFFICIALLY S T AM.W:) OR 51111--;E Z;F -4E COUMtSSIONER SlIGNATURE OF LICENSEE M ISSIONER M le -&-ammaxweald ol—A,&Mackaeffi IMPROVEMENT CONTRACTORS REGISTRATION ABoard of Building Regulations and Standards "0 one Ashburton Place - Room 1301 Boston, Massachusetts 02108 'HOME IMPROVEMENT CONTRACTOR Registration 104731 Expiration 07/15/96 Type - PRIVATE CORPORATION Merrimack Vall�ey-.Roofing[ Companies Ronald G—LambkL 37 Stevens�--Str-aftL--- Haverhi,11 MA--:tO18-30-� L) — 12--1 — 1<2j ENCLOSE CHECK OR MONEY ORDER FOR REQUIRED FEE, MADE PAYABLE TO "COMMISSIONER OF PUBLIC SAFETY - (DO NOT SEND CASH). P EASE NOT -E -FEE IhCREASE E FECTIVE FEB. 1 1989 MAY! IQ' Dq NOT D"Aqy<LICENSE STUB SIGN NAMVI`fIWJL1-X—QtWE SIGNATURE LINE I HOME IMPROVENENT CONTRACTOR Registration 104731 T fibTUATIC PA05AIDATTAU Iry .-Expiration 07/15196 -Agrinckjalley _-_goofing Coop Ronald S.-tambert Haverhill NA 01830 Date./ ....................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... .......... ......................................... has permission to perform . .......... . ...... wiring in the building of ....... Q 1 .................................... at.t�� .......................................... North Andover-, Mass. Fee A ............... ................................. Lic. Ncr..'.�� ....... ELEcrRicAL INspEcToR Check # 1 .4.2 Z I N Fmji Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/071 (la,e blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMA TION) Date: 00 —6 - 4>5 City or Town of. NORTH ANDOVER To the In.vpector qf'Wires: By this application the undersigned gives notice of his or her intention to perforrn the electrical work described below. Location (Street & Number) 9C) P W C A-�( Owner or Tenant -a-oo N Telephone No. Owner's Address 5)q -m Is this permit in conjunction with a building permit? Yes E] Purpose of Building Existing Service Amps Volts New Service Amps Volts Number of Feeders and Ampacity No [�J (Check Appropriate Box) Utility Authorization No. Overhead [:] Undgrd [:] Overhead D UndgrdF-1 No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: 9 0 1 ACC /TYA-t of �e-o lqo At'r Completion of thefollowing table Inay be waived by the Inspector ql'Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above 0 In- grnd. grnd. F] No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS INo. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Rancres t, No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat PumpTNumber Totals: I TonT- I I KW I I . No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local El Municip�l 0 Other Conn ction No. of Dryers Heating Appliances KW Security Systems:* No. of Devices orEquivalent No. of Water Heaters KW No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalen No: Hydromassage Bathtubs No. of Motors Total HP Telecom m un ications Wiring: No. of Devices or Equivalent -J OTHER: Attach additional detail ij'desirecl, or (is required bly the Inspector qf H'ires. Estimated Value of Electrical Work: (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 Lin less the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such covera e is in force, and has exhibited proof of same to the permit issuing office. 1 9 CHECK ONE: INSURANCE BOND n OTHER [] (Specify:) I cert?fy, uiider th ah an petrafies tifprjury, that the hiforniation on �iis application is true and conilVele. FIRM NAME:= I J,.J LOJ6,_ LIC. NO.: 4� zz .4 ,/ Licen see: Signatur( LIC.NO.:649.77 (11"113plicable, e0l, -exe t - in the licens'e b h Bus. Tel. NoA��-60-92-3-3 jj�opv-er 64.8 Of ig Alt. Tel. No.:�2�-8V�& No Address: o . An 5 . ...... *Per M.G.L c. 147, s. 57-6 1, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I arn aware that the Licensee does not have the liability insurance coverage normally required by law. By rny signature below, I hereby waive this requirement. I am the (check one) F1 owner [J owner's aaent. Owner/Agent Si -nature PERMIT FEE. 5,�,� 6 — Telephone No._ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Bostoiz, M4 02111 1 11 www-Mass.govIdia Workers' Compensation Insurance Afffidavit: Builders/Contractors/Electridians/Plumbers Name (Business/Organization/individual):L� Address: P o . i3c.-l- (ts t ov 1 "/4- city/state/zip: Po . i4roovw- P" —Phone #:. 7 k k Are you an employer? Check the appropriate box: I.El I am a employer with 4.7 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. �am a sole proprietor or partner- listed on the attached sheet 3 ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. We are a corporation and its required.] officers have exercised -their 3. 1 arn a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' . comp. insurance required.] Type of project (required): 6. New construction 7. Remodeling 8. Demolition 9. Building addition 1 0 - _5;-ETe"c_tri.caI repairs or additions I 1 .0 Plumbing repairs or additions 12.7 Roof repairs 13.0 Other ' - — � I III— WbU L111 UUL Me Section Deiow snowing their workers' compensation policy information, Hoi wowners who submi1j11ii alli-idavit indicating they art. uuin�r- &fl ;vodr. and ther, hire, outside contraciors njusi submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name ofthe sub -contractors and their workers' comp. policy information. I am an Cniployer that is providin,,-, workers'compensation i1rsurancefor my employees. Below is the policy andjob site information. Insurance Company N Policy # or Self�ins. Lic. #: Job Site Address: 130 Attacb a copy of the workers' compensation -policy Expiration Date: City/State/Zip: page (ShOwinclit�-policy number and expiration datel Failure to secure coverage as required under Section 25A M c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one -year imprisonment, as we I as-Zivil 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 hereb) u Of Periffl-31 that the information provided above is true and correct. Phone 9: 5v - F -7 R- k Official use only. Do n ot write in this area, to be completed by city or to wn official City or Town: Permit/License # Issuing Authority (circle one): el 1. Board of He alth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbinor 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. Howeverthe 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, MOL chapter 152, §25C(7) states 'Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC.or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have anv 'estion . qu s regarding the la -w or if you are required to obtain a workcrs� 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 permitflicense 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 s tamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to -thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Bost -on, MA 02111 Tel. 4 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax 4 617-727-7749 www.mass.gov/dia