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HomeMy WebLinkAboutMiscellaneous - 36 FOSS ROAD 4/30/2018r. i Th7s certifies that ........ � � has permission to perform . ... ....�� W!o�� ! ....... . plumbing in the buildings of . ..�✓ at .....5. ....,... , ., , North Andover, Mass. Fee . P�D . Lic. No..125�M4-... ................ .. . PLUMBING INSPECTOR Check #—. ORM MBItI443 NNumr% Viwlft TO �PE�F-f PERMIT To Ts %Woiim—�PAIPPLICpT�P�,J PERMIT MASSA Mp, cot/ 0,VNmSNPME FAX , . .......... CIT L --V -` TEL ......... . JOBSkTE ADDRESS _ RESIDENTIAL -- ------ COMMERCIAL CI EDUCATIONAL PLANS SUBMITTED. OWNER ADDRESS YES 11 12 13 .rypp 0 y TYPE .0 9 14 _ R OCCUPANCY RENOVATION: REPLACEMENT 7 a pRJt4T RF -14 CLEARLY Ew-. 3 Fl)(JURES SRO wpSTE SYSTE--- _- - �CD r. SAND SYS SE01III SPF-cl I)Eglep,IED GAS SYSTEM DEDICh,IED GREASEATER SYST DEDICATED G CLE S11 A -T VV D TERRE DISH pSHER DRINKING FOUNo AIN I SINK URINAL MACHINE rNNF 0NNE RALL I It Ep ,PIPING OTHER C 3 Ch. 'YES KI requirements 0i MGL CU INSURANCE meets the Id lid.- ------- its substantial equivalent which -11jF APPROPRIATE SO), BOND ELOW it -Insurance P01ICV or OV E MG rr- By CHECKING current lia—billm )ICA IF _TtiFTYPEOpC "I have a PLfASf-I1U Emtzy tea by chapter 142 01 he ti OF lt4o .veragO required F-CKrr.D YF -69 OT"ERTYPF 3av 0 the Insurance , ent. 11 Y0,1 ""' N,UMt4rE POU Agmnpin waives this Mqulrem OWNER oxaloy aware that the licensee d R 0 AGENT OWNER'S INSURANCE WAIVER. I am MY signature on this permit applicatlo".— CII ONE ONLY: 0" o MY n 0% and that urate to the S� ion Massachusetts Gone"' d BOPerlin P mas n are true In OOMPII8 SU u au OWNER ;��Mitted�r� I.I.,p-pticau RE red regarding OFI n I BV( PJ U SIGNATURE d to jet the Permit issued or 101 the details 8n n e 0 e UP the General Laws' I hereby certity, U and Instsil ri be ter i of C Plumbing 'NO cod LLC and 081211 plumbing Massachusetts JP ART t4 E R SR P CI#L-- PLUMBER'S NAME CORPORA ADDRESSMPd JPC3 LwDi ..__ _ _ . - ` TEL Z - ----- .--- Old-- COMPANY NPIME - -- 0 ZIP STATE - --- --- CITY MAIL VO FAY, ---------------- CELL The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street q1 Boston, MA 02111 ." www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Name (Business/Organization/Individual): J O �/I >, Address: / ,� % S 0/1 J � �✓//•��, A�„ /State/Zin: Wv%M,its/_a,-► 1914 OMX2Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees working for me in any capacity. [No workers' comp. insurance . required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have employees and have workers' comp. insurance.1 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] (0 sd e Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *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. *Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities -have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. 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. Lic. #: Job Site Address: Expiration Date: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 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 ur thetins and penalties of peurat the information provided above istrue and correct. #: v / �1`_ Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other. Contact Person: Phone #: t .COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS LICENSED AS qMASTER ISSUES THE ABOVE AS EER NSE PLUMBER E JOHN J NYTYCH JR 18 DOBSON -STREET WILMINGTON NA 01887-1814 s 12583 05/01/14 ,.,_, 172709 Date.. 5........ ...z... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that.............1.......................................................................................................... is permission to perform ............................ ...�' ..?` ` -firing in the building of ........ �t ...r t.........Z.................................... ............................... at ........7..W/ / 1�5� � J -, North AndoveroMass. .............. ;.............................. Fee ...... lJ.....J! t ...... Lic. No /ZY3a' /�7 f /I 11616 CTRTCAL INSPECTOR Check #2-06 K S , I 11616 a Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank 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 INMK OR TYPE ALL INFORMATION) Date: 2;- 1.3 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned ives notice of his or her intention toper rm the electrical work described below. Location (Street & Number) Fc,;, -&-S xoe{ Owner or Tenant Owner's Address e moo! d /YIrS 1 *' o -e, s Telephone No. Is this permit in conju ion with a b ing per it? Yes ©� No ❑ (Check Appropriate Box) Purpose of Building i -47.1 /a ^tt f� Utility Authorization No. - Existing ServicaC O Amps j!') /cava' a Volts Overhead ❑ Undgrd IS No. of Meters / New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: /1Z -4—v l/eti ,' F, e-7 ,t3�Tzf Completion ofthe followina tahle may he waivad by tha rn.snector of Wires. No. of Recessed Luminaires aa• No. of Ceil.-Susp. (Paddle) Fans V No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. grnd. o. of Emergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No, of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g / Total No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers / HeatPump Totals: Number ......................._................................. ���'� ' Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or E uivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total 11P Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. x , Estimated Value of Electrical Work: lj yoo (When required by municipal policy.) Work to Start: S- d 9 - l 3 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: 1NSUIRANCE LM. BOND ❑ OTHER ❑ (Specify:) I certify, under the ins and pert�Ities�fipe�jury/th tlzq� Drina ion on a�lication is true and complete. FIRM NAME:. N /�f/ r ,(�`+ iG: LIC. NO.: Of /ak Licensee: S4n-Y Signature LTC. NO.: 4.3/03 S (Ifapplccable, enter exempt n the Incense numbe line.) / � Bus. Tel. No.• Cn f/ Address: �� �J� �✓ G'/tee �E+ � y � d jl /�Z/a O �° i��s Alt. Tel. No.: S. *Per M.G.L c 147, s. 57-61, security work requires Department o Public Safety "S" License: Lic. No. o� C 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 PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose. of,fhis act is to pibmote 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 N Pass 0 Failed ❑' Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass ❑' Failed'❑ Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass I Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FIS INSPECTION: Pass 0 X. " Failed 0 ' t \ Re `In p`ection Required ($.) ❑ Inspectors Comments:. Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth ofYlassachusetts Department oflndustrigl Accidents Office of Investigations qV 600 Washington Street Boston, MA. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address:�yod he.,- co -C, City/State/Zip k'd"' °4 IV'# d/ f-0 Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction mployees (full and/or part-time).* have hired the sub -contractors listed on the attached sheet. ?• ❑Remodeling 2. I am a sole proprietor or partner- 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. El We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c.152, §1(4), and wehave no 12.❑ Roofrepairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicatingthey a -re doing all work and then hire outside contractors must submit anew 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 em ployee3: Below is the policy andjob, site information. Insurance Company >o�'�yhS XA-S i Policy # or Self -ins. Lie. #: � s �l ��% �' Expiration Date: ,/�� Job Site Address: , ?to A S S 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 xequiredunder Section 25A of MGL o. 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido herebyerti un r ins and na ies erjury that the information provided aboveis true and correct. SianafirrPw /� .� Date: S� —:),R— /_17 Phone #: Sa Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/I,icense Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector 6. Other - - Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, - express or implied, oral or written." 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 legatentity, 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, constrlictiorr or repair work on such dwelling house or on the grounds,or building appurtenant thereto shall not because of such employment be deemed to be an employer" MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) andphone 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 LL C 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 hds provided dspace atthe 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'tb fill'in'tho pernilthicense number which will be used as a reference number: In addition, an apphcatrt that must submit multiple permit/license applications in any given year, need only -'submit one affidavit indicating current policy information (ifnecessaty) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The 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, OfMassachuseat4 ., Department ofl;ndustrial ,Accidents pff%ce of1"estigations 600 Washington Street BosfuMA02111 ` QL ## 617-727-4900 oA 406 or 1-877-MASSAFF, Revised 5-26-05 Faze## 617-727-7749 ------- --------Fy`- Deems, Maura From: Dena Paris [dlparis8@gmail.com] Sent: Saturday, May 18, 2013 6:49 AM To: Deems, Maura Subject: building permit transfer This email is intended to inform the North Andover Building Inspector's Office that we, Matthew & Dena Paris of 36 Foss Road, have changed contractors from Red Apple Construction to Double Z Construction Services, Inc. Please let me know if you have any questions or need additional information. Thank you, Matt & Dena Paris Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: hftp://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. -4-vss v�ze ipao�urrzo�aureatcia a� vt2�cusricsucael.G� \ Office of Consumer Affairs & Business Regulation EM 1� OME IMPROVEMENT CONTRACTOR - = _ egistration: .172957 Type: xpiration:-.:.;8/,20120:14; LLC DOUBLE Z CONSTRUCTION SERVICES LLC. CAROLYN ZIPETO 27 PLEASANT ST ANDOVER, MA 01810 - Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid without signature `li ic. a�rz�ua�r�aea !✓ �l Office=of Consumer Affair's S Business IRegwafiofi _ IOMyEMENT CONTRACTOR E I-MPROType. registration: 172105, Individual Expiration V2212014.. i206ER1 ISBELL t- ROBERT ISBELL 20 OAK K NOLL RD. METHUEN, MA 01844 Underseereta"Y Massachusetts - Depatrtment of Puiiiic Safety Board of Building Regoulations and Standards Construction Supervisor License. License: CS 81684' ROBERT E ISBELL •' 20 OAK KNOLL RD METHUEN, MA 01844 ..` cam_ may!` Expiration: 10/9/2013 Commissioner- Tr#: 7822 The Commonwealth of Massachusetts Department oflndustrialAccidents 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/Organization/Individual): 2— C--k)A �►` 1LQ .� Address: 'D�-"l �4 l.2 " a..J' C=a,,� City/State/Zip: OAA AsR rE�� Phone # Are you an employer? Check the appropriate box: - 1. Erl am a employer with k 4. ❑ I am a general contractor and I employees (fall and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t 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. ❑ I am 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. [-Modeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they hire 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 woYkers' compensation insurance for my employees Below is the policy and jab site information. Insurance Company Name:. Policy # or Self -ins. Lie. r'"1 ct Aa�f, Expiration Date: oS� I Job Site Address: ��to �aS �-G! 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 sof Investigations of the DIA for insurance coverage verification. I do hereby cert under the pains and en_ rides ofperjury that the information provided above is true and correct. 11�;,• ► 3 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other - - Contact Person: Phone #• Information and Instruction' -s 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 ofhire, - 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 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), 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 cant' 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 liroyided 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 (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to 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 Massaftsetts , Depadment of Industrial Accidents Office ofIavestigatlow 600 Washingtoa Street Boston} MA 02111 Tel, # 617-72.7-4900 ext 406 or. 1-877-MASSAFB Revised 5-26-05 Fax # 617-727-7749 tzttxxcxrmaeo RATTfilio �J>ze tprnn�r�zrnuoeccccia a� UVGrca3rcciuc6ec,Gs Office of Consumer Affairs & Business Regulation �:. OME IMPROVEMENT CONTRACTOR egistration: 172957 Type: xpiration:. ;;8720!2014; LLC DOUBLE Z CONSTRUCTION SERVICES LLC. CAROLYN ZIPETO 27 PLEASANT ST 4� e� ANDOVER, MA 01810 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid without signature i c��C�1!'��SCtC�IIQel�3 ; fi Office of Consumer Affairs & Business Tiegutafio OME IMPROVEMENT CONTRACTOR Type: - egistration: -.'172105. - Individual Expiration 5/2y2014 . ROBERT ISBELL ROBERT ISBELL = � 20 OAK iC NOLL RD METHUEWMA 01844 - Undersecretary NI.tssachuse s - Depae-tment (if Puitlic Safetc Board of Building Regulations and Standards Construction Supervisor License. License: CS 81684 --- - j ROBERT E ISBELL 20 OAK KNOLL RD METHUEN, MA 01844 �--�-- -�! Expiration: 10/9/2013 Commissioner Tr#: 7822 , 'DRIWI�-'S�JCENSE� -- :;; } 'F UMBER4� . 48984062EXP 008 ': I °10-0"9-2014 1 Q-09-19 'AfASS �,7 REST HGT SEX t.4 m 'S 'ISBELL cj3 ROBERT E �A* 20 OAK KNOLL RD Q 0 METHUEN,`MA `1018444936 t ! FV The Commonwealth of Massachusetts - Department of IndustriqlAccidints Office of Investigations IV 600 Washington Street Boston, MA 02111 www.mass govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PleasePrintLegibly Name (Business/Organization/Individual):a>1=1` Z Q�oAs�`�'� Address: '-'t _4 lz "a.4,� CZVk- City/State/Zip: OvL Ss!\ % V Phone #: Are you an employer? Check the appropriate box: 1. Erl am a employer with k 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- ship and'have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t listed on the attached sheet. These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Typo of project (required): 6. ❑ New construction 7. P IGmodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *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 ire doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. 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. Lic. #: vAF3 Expiration Date: os� 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 maybe forwarded to the Office sof 'Investigations of the DIA for insurance coverage verification. Ido hereby certio under the pains andeni�lties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Phone #• Information and Instruction' -s 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 required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) 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 anLLC 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 f rovided 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 Commonwealth ofMassachusPtts D_ epaftent of Industrial Accidents office of Investigations 600 WashiWon Street Boston} MA 021 1, X Tel. # 61.7-727-4900 ext 406 or 1.-877�,MASSAFE Revised 5-26-05 Bax# 617-727-7749 WWW_mace am'-filin