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Miscellaneous - 4 HIGH STREET 4/30/2018 (3)
TOWN OF NORTH ANDOVER NORTF/ Office of the Building Department O� q ttLED ,6 q, Community Development and Services 1600 Osgood Street, Bldg. 20, Suite 2035 70 North Andover, MA 01845 978-688-9545 Gerald Brown, Building Inspector April 8, 2014 To: John T. Smolak, Esq. Fr: Gerald Brown Re: West Mill Complex, Four High Street Zoning Determination Dear Attorney Smolak, I have received and reviewed your April 7, 2014 letter to me requesting an interpretation of the interplay between the Downtown Overlay District (Article 18) and the underlying Industrial S Zoning District. Most of the site is located within the Industrial S Zoning District, as defined under Section 4.135, although other portions of the site, including the parking area on Water Street is located within the General Business (GB) District (Section 4.131) as well as the Downtown Overlay District (Article 18) of the Zoning Bylaw of the Town of North Andover (the "Zoning Bylaw"). As you know, another portion of West Mill is located within the Residence (R-4) Zoning District (Section 4.122) but is not located within the Downtown Zoning Overlay District. For the purposes of this letter, I interpret your letter as requesting clarification of the portion of the site located within the Industrial S Zoning District. Accordingly, I have determined the following: 1. The provisions of the Downtown Overlay District, and the underlying I -S Zoning District (as well as other applicable provisions of the Zoning Bylaw) are to be read together, so an applicant requesting approval under Section 18 would also need to comply with other applicable provisions of the Zoning Bylaw, including the provisions of the I -S Zoning District. 2. An applicant may obtain approval of a use and/or structure in the Industrial S Zoning District (and apply the Industrial S Dimensional standards) for that use, or alternatively, may request approval under the provisions of the Downtown Overlay District under Article 18. 3. An owner of a parcel can request approval for uses and structures under the Industrial S Zoning District for one portion of a parcel, and also obtain approval of a use and/or structures under Article 18 for a separate portion of the same parcel. Please contact me should you have any questions concerning this matter. Sincerely, Gerald Brown Building Inspector ATTORNEYS AT LAW April 9, 2014 John T. Smolak, Esq. Smolak & Vaughan LLP, East Mill 21 High Street, Suite 301 North Andover, Massachusetts 01845 Re: West Mill Complex, Four High Street Zoning Determination Dear Attorney Smolak: John T. Smolak, Esq. T: 978-327-5215 1 F: 978-327-5219 jsmolak@smolakvaughan.com I have received and reviewed your April 7, 2014 letter to me requesting an interpretation of the interplay between the Downtown Overlay District (Article 18) and the underlying Industrial S Zoning District. Most of the site is located within the Industrial S Zoning District, as defined under Section 4.135, although other portions of the site, including the parking area on Water Street in located within the General Business (GB) District (Section 4.131) as well as the Downtown Overlay District (Article 18) of the Zoning Bylaw of the Town of North Andover (the "Zoning Bylaw"). As you know, another portion of West Mill is located within the Residence 4 (R-4) Zoning District (Section 4.122) but is not located within the Downtown Zoning Overlay District. For purposes of this letter, I interpret your letter as requesting clarification of the portion of the site located within the Industrial S Zoning District. Accordingly, I have determined the following: 1. The provisions of the Downtown Overlay District, and the underlying I -S Zoning District (as well as other applicable provisions of the Zoning Bylaw) are to be read together, so an applicant requesting approval under Section 18 would also need to comply with other applicable provisions of the Zoning Bylaw, including the provisions of the I -S Zoning District. 2. An applicant may obtain approval of a use and/or structure in the Industrial S Zoning District (and apply the Industrial S Dimensional standards) for that use, or alternatively, may request approval under the provisions of the Downtown Overlay District under Article 18. 3. An owner of a parcel can request approval for uses and structures under the Industrial S Zoning District for one portion of a parcel, and also obtain approval of a use and/or structures under Article 18 for a separate portion of the same parcel. Please contact me should you have any questions concerning this matter. Sincerely, Gerald Brown Building Inspector {00078271;v1}East Mill, 21 High Street, Suite 301, North Andover, MA 01845 W W W.SMOLAKVAUGHAN.COM SMOLAK & VAUGHAN ATTORNEYS AT LAW VIA EMAIL AND BY HAND Gerald Brown Building Commissioner Building Department Town of North Andover 1600 Osgood Street North Andover, Massachusetts 01845 Re: West Mill Complex, Four High Street (Assessors Map 54, Lot 1)(9.57 ac)(the "Property") Request for Zoning Determination Dear Mr. Brown: John T. Smolak, Esq. T: 978-327-5215 1 F: 978-327-5219 jsmolak@smolakvaughan.com April 7, 2014 This firm represents RCG West Mill NA LLC ("RCG West"), the owner of the property located at One High Street. In accordance with Section 7 of M.G.L. c.40A, RCG West is requesting clarification concerning the interplay between the Downtown Overlay District (Article 18) and the underlying zoning districts at West Mill. The entire site as described above is located within the Industrial S Zoning District, as defined under Section 4.135, although other portions of the site, including a 0.3 -acre parking area on Water Street in located within the General Business (GB) District (Section 4.131) as well as the Downtown Overlay District (Article 18) of the Zoning Bylaw of the Town of North Andover (the "Zoning Bylaw"). As you know, another portion of West Mill is located on a separate 6.8 - acre lot is located within the Residence 4 (R-4) Zoning District (Section 4.122) and is not located within the Downtown Zoning Overlay District. For purposes of this letter, we are requesting clarification for the portion of the site located within the Industrial S Zoning District. Specifically, the Property is located both entirely within both the Industrial S Zoning District, as defined under Section 4.135, as well as the Downtown Overlay District (Article 18) of the Zoning Bylaw of the Town of North Andover (the "Zoning Bylaw"). While some of the uses permitted in the Industrial S and Downtown Overlay District are the same (i.e., banks, professional offices), there are some East Mill, 21 High Street, Suite 301, North Andover, MA 01845 WWW.SMOLAKVAUGHAN.COM SMOLAK & VAUGHAN LLP Gerald Brown Building Commissioner April 7, 2014 uses within the Industrial S District (i.e., light manufacturing) which are not permitted within the Downtown Overlay District. We note, however, that Section 18.0 of Article 18 states that "[t]his bylaw is intended to be used in conjunction with the existing zoning and other regulations as adopted by the town,..." We interpret this provision to mean that if an applicant sought approval under Article 18, then the dimensional and other provisions of the underlying Industrial S District are intended to be applied unless expressly stated otherwise in, or would be inconsistent with, the provisions of Article 18. On the other hand, it appears that Article 18 would not preclude an applicant from applying for and obtaining approval of uses allowed in an Industrial S Zoning District (and applying the applicable dimensional standards within the Industrial S District) to premises without consideration of the standards under Article 18. Moreover, it would appear that there is nothing in the Zoning Bylaws which would preclude an owner of a parcel from seeking approval under the Industrial S Zoning District and Article 18, if such uses were location on separate portions of the parcel. Accordingly, we respectfully request that you confirm the following: If an applicant sought approval under Article 18, then the dimensional and other provisions of the underlying Industrial S District are intended to be applied unless expressly stated otherwise in Article 18, or would be inconsistent with the provisions of Article 18. 2. For a parcel within the Industrial S and Downtown Overlay Districts, an applicant may obtain approval of a use in the underlying Industrial S Zoning District (and apply the Industrial S Dimensional standards) for that use, and the provisions of the Downtown Overlay District under Article 18. 3. There is no provision within the Zoning Bylaws that would preclude an owner of a parcel from seeking approval for uses under the Industrial S Zoning District for one portion of a parcel, and also obtaining approval of a use under Article 18 for a separate portion of the same parcel. 17 SMOLAK & VAUGHAN LLP Gerald Brown Building Commissioner April 7, 2014 Please contact me should you have any questions concerning this matter. Sincerely, `John T. Smolak JTS/ Enclosure(s) Date..7/ TOWN OF NORTH ANDOVER PERMIT FOR WIRING /"1 k- //,, V This certifies that t<- .................. has permission to perform ..... ...... wiring in the building of �j Q-4— at ..................... C.) ...................................................................... North Andover, Mass. Fee/J�—� ........ Lic. No . ............... 1,21'' .......... ......................... ELECTRICAL INSPECTOR Check # 12542-/ I -IA- i Fr, " 4 Commonwealth of Massachusetts Officialc�Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (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 ININK OR TYPE ALL INFORMATION) Date: 7 36 ("-- City or Town of. NORTH ANDOVER To the Inspector f 'res: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Y %fii'�!� S"r Owner or Tenant / or;m A-•%J6irr►z As Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ Purpose of Building - Existing Service Amps / Volts New Service Amps I Volts Number of Feeders and Ampacity (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Location and Nature of Proposed Electrical Work:j^ © t� f {;rs,• ��;A Comnletion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA .No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. grnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection andInitiating Devices No. of Ranges Tot No. of Air Cond. Tons No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Dis osers P Totals: Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances KW SecN . o Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications No. of Devices or E u valent OTHER: Attach additional detail if desired, or as required by the inspector qj wires. 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 unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME:. A a I t LTC. NO.: Licensee: -Q„ tL �}��,j c Signatu 4LTC. NO.: 1310127 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: Address: _�g.f-�X o� /Ld cf Ol;.?-i7 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security ork requires Depart&nt of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ �. S 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 ofthe Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending -through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: i Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass IN Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPE ION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com v 0: The Commonwealth of Massachusetts Department of IndustrialAccidents I congress Street, Suite 100 Boston, MA. 02114-2017 y��•'v`° www mass.gov/dia ��J• Wol:kers' Compensation Insurance Affidavit: Builder$/Contractors/Electricians/Piwmbers. TO BE FILED WITH THE PERMTTING AUTHORITY. ,1--b—+ 1 Ov`L C IV,,* -L I -LC_ Name (Business/Oiganization4ndividual): Address:�-�- City/State/Zip: d�J �� Phone #: Are you an employer? Cbeck the appropriate box: 1,❑ I am a employer with employees (Aill and/or part-time).* 2.F] I am a sole proprietor or partnership and have no employees Working forme in any capacity. (No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself,. [No workers' comp. insurance required.] t <1 I am a homeowner and will be hiring contractors to conduct all work on my property. ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. Type of project (required): 7. ❑ Nev d6nstruction 8. [] RemodellAg 9. ❑ Demolition 10 [] Building addition I will 11.❑ Electrical repairs or additions 12. D plumbing repairs or additions I am a general corrOcto : and 1 have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. Q We are a corporation and its, officers have exercised their right of oxemption per MGL c. 152, § 1(4), and'we have no employees. [No workers' comp. insurance required.] *Any applicant that check's box #1 must also fill out the section below showing their workers' compensation policy information. rs must submit a i Homeowners who submis k pd s min` st it chid an additional doing all showing the name of the then hire contractortside os and state whether or not those new ffidavit ent ties have such. tContractors that check tlu 1IM— �„b-contractors have employees, they must provide their workers' comp. policy number. 13,.[] Ro6f repairs 14.[] other- . --5.F] workers compensation insurance fol° my employees. am an employer that is providing information. insurance Company Name: policy # or Self -ins. Lic. #:• Below is thepolicy andyob 81-10 Expiration Date; City/State/Zip: fob Site Address: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). aS by a ffib up to $1,500-00 Failure to secure coverage as required undercivil enaltieszin the form of aSnviolation TOP WORK ORDER and a fine of p to $250.00 a and/or one-year imprisonment, as well a p day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA £or insurance coverage verification. X do hereby certifydlie pains and penalties of perjury that the information provided v� is true and correct. official use only. Do not write in this area, to be completed by city or town official' Permit/License # City or Town- Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone #- Contact Person: 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 receivet'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 ofthe 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'notproduced -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 certificates) of insurance. Limited Viability 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 IndustrialAccidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self insurance license number on the appropriate line. - City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple perm-it/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. 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 9. 113 ii. S Date .... T.('311 ...... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that.-��-414 ... . ........ ............................................... has permission to perform ... be.A.'o .. . .... ......... plumbing in the buildings of ......... at.. Fe ... Lic. No. 07.6—P.-. Check # ...................... rth dover, Mass. ............... ................... P-O-MBI�&; OE M 6 Pc� K M g MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY .N O Y` tl A N WM 9 MA. DATE 13 I r 5 PERMIT # JOBSITE ADDRESS 610& *37 /-' / ( h :St OWNER'S NAME /� C & ` C- PP OWNER ADDRESS a Ii/A&V &a. I NTE�)1'�1 _ TEL 6 r 7 ~ g 70- 6 736FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL 91 EDUCATIONAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO [] FIXTURES 7 FLOOR-- BSMT 1 2 3 1 4 5 6 7 8 9 10 1 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIUSAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL .. WASHING MACHINE CONNECTION WATER HEATER ALL TYPES lNATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which, meets the requirements of MGL Ch. 142. Yes %] No ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [4 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE BOX ONLY: OWNER ❑ AGENT ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1 PLUMBER NAME M (� g a SIGNATURE LIC # 1.515 � MP W1 JP ❑ CORPORATION ❑ # PARTNERSHIP41 # LLC ❑ # / COMPANY NAME j4klel Gl f gill i I'TIf yy ADDRESS: 7V CITY 54/e STATE I*'/ � ZIP 0367 � EMAIL /'"I %e 3 3 Ce �6 TEL CELL 7?I yo�3 y ��' g'V FAX The Commonwealth of1Vlassachusetts Department of IndustrialAceldents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass gov/dla s Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE, FLED WITH THE PERMITTING AUTECORITY. AAplilicant Information Please Print Lei Mb Name (Business/Organization/1'n.dividual): t 4 /✓l,o (��"f I!1 Address:y 1:5-5 City/State/Zip:IV /1 Al Axeyou an employer? Checkttie appropriate box: 9 Phone 1. ❑ I am a employer withemployees (full and/or Part-time)-* 2.I am a sole proprietor or partnership 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 4. a I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.E] I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.T 6.[] 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.] V Type of project ()Vequired): 7. ❑ New construction 3. [1 Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions lip Plumbing repairs or additions 13.0 Roofrepairs 14. [] Other 'Any applicant that checks Box#1 must also sill out the section below showing their workers' compensation policy information. T Homeowners who subn if this affidavit indicating they are doing all work andthen hire outside contractors must submit anew affidavit indicating such. ?Contractors that check this box must -attached an additional sheet showing them m of the sub -contractors and state whether or not those entities have employees. lfthe sub-c6n6d6rs have employees, they must provide their workers' comp. policy number. I am an employer that is pidpiding7vorkers' compensation insurance for my employees ' Below is the policy and job site information. Insurance Company Policy # or Self ins, Lie. Expiration Date: Job Site Address: City/State/Zip: Attach. a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MCTL o.152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a S'T'OP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certify ur er thepains and penalties 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): i 1. Board of health 2. Building Department 3. City/Town Cleric 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." Air employer is dewed as "an individual, partnership, association, corporation or other legal entity, ox 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 commonwealths 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) and -phone numbers) 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 maybe submitted to the Department of IMustrial Accidents foi.• confirmation of insurance coverage. Also be sure to sign and date the ajudavit. 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 yoifare 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 Tovvn 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 permi�illicense 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. 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 Department's address, telephone and fax number: \ The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, AM 02114-2017 � Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Date .... ?//Z� ............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...................... .................................................... has permission to perform .... A. ,/� ......................... Z............................ wiring in the building] of ......................... ( t ................................................................ at y / -�-- ............................ a ...................................................................... . North Andover, Mass. FeeAR-5 ............. Lic. No. IJ�2(P-5 .................................................................................. ELECTRICAL INSPECTOR Check # V Occupancy and Fee Checked p �, W:) �?,',4;Q,D Or FIRE F REVENTION REGULATIONS [Rev. t/071 (Ieave blank) APPLICATION11 FOR PERMIT TO PERFORM ELSE TRiCAL WORK H fI work to be perfoz fined ir_ accordance rN th the Massachusetts Electrical Code (MEC), 527 Cts 12.00 (PL E'ASE PF,ofTi EArK oi? 1 —, o-Rm Trop 2� , �i �o City or Town of N - n � e-Aie l �o t'ne Inspector of Wires: By this application the uadersibmed gives notice of hyo cr her intention'to perform the electrical work described below. Location (Street Number-) Owner or Tenant L�;� r)d 4' f a 11C JYIJ Lh m� � l2 � �p `d'elephone l�Ta�. 1 Owner's Address Is this permit in cou uRctiod with a ti ding pert? 'des ❑ Loo 0 (Check Appropriate Box) p� Purpose of BuRding ll i�� Authorization No- Y existing Service Auras / Volts Overhead ❑ Undgrd ❑ No. of Deters New Service fps / Molts l rerhead ❑ Undgr d ❑ No- of Meters Number of Feeders and Amiaacty Location and Nature of Proposed Electrrtcaa Work � I� �)'��� 1 � � 'Ir�� C. � h Gnri S s C'cmpletion of the foTZo�ring tools may be waived Znj the I ecto of ltiires. y [1 o. of Recessed Luwn mires lNo- of CCeil.-Susp. 1, add3e) VarusIIN a s1 rmxs VRa - JI o. of La-minairre Outlets I—No- of Hot Tubs (Generators KVA � o- of L8fl>T�ivai,res swim ate¢ P0od F�i➢o�e --- r33- ivar. vx mux '� Urn, .�IIl2 - �t�2 units IXo. of Receptacle Oudets l�ko'� e-,03-1 Burlie'n, ' � ALAR YIS INo. of Zd�iu. es '�,( rn + y, 1 7 :/ 2L"3b'e.�J 79I l +�_ oa wa s B.,H; _w�.x s No. of Det}ec xoa� and Y�i'L�°.'L48 Devices Yo, o, of Ranges No. of AJ-- Wand. Total � oras No. of Alerting Devices �To, of rite �saosers Heat t crap Number otadsa 'Irons ff KW Noe of Self -Contained I DetecdonWert nZ Devices iNo. of Dishwashers _ L�/fuaracrpal Space/Area Hea g K �occ� [_i Cmnnecdon I I �s'ti�eA �� lNe. of Dryers Hea a� pUan es � ` �� l Sj, em.o S; eitice e -o I°=Tu. fl���"rl£es rsr Eqi.,ftBleat No. of Water KV No- of I°�o. of Data Wiring: Beaters Si,—s Ballasts I?nTo. ofDe,ylces or -Equivalent 1�Ta. dJydromassage Bathtubs IST®. of Motors elecs�a Ideations �INarSie a- 'do. I IIS No. of Deices ass- aaiv; eat -tee Attach additional detail f desired, or as required by die Inspector- of Wires_ Estimated Value of Electrical work: $200.00 (When required by municipal policy.) Work to Start: baspections to be requested in accordance with i/iEC Rule 10, and upon completion. EXSURANCE C'OT-E.UJE: Unless waived by the o,%rner, no permit for the performance of electrical work may issue LMIess tb jvdicensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The andersigned certifies hat such coverage is in force, and has exhibited proof of same to the permit issuing office. CI ,CK ONE: 1WSURATTCE Q BO-I\TD ❑ OTHER ❑ (Specify:) c?r'!i�/, vender thopains and pe,7taiaies of u,,rju,y, t'b t the i fof atio a o this app_1acQtzo�s is true and co;npleie P- M I°TAME: DIPIETRO HEATING & COOLING s - SC, Nro:Al 8265 License ERIX PIERMATTEI Sn;za,ature °7f applicable, enter "erernpt" sn the license ntimber (fine) gus. Tel_ No.: 978-372-4111 Address: 5 SOUTH SUiViMEF,, ST BRADFORD MA 01835 Alt. Tel. No_- 978-994-0725 `Per nit.G.L. c. 147, s- 57-61, security work requires Department of Public Safety -`S" License: Lic. No. D'Y'41 ER'S Ti fSITRAPrCE WAIVER: C am aware that the Licensee does not lzave the Liability insurarice coverage normally equred by !a,,v. By c_y si:mature betow, 'hereby his cequireznent, f am. the (check one% ❑ ozrraer ❑downer's )WTI ei'/A-?n:i:t tU ro . 9-7 ,T' �' t k -d =e comma weaftfs of Afassackwseffs L= Deparonento Allay& adAc e�ts Vesd Office of _In arts 600 Washington ,street -� Boston, MA 02111 Workers' Compensation Insurance Affidavit-- dersiContr,%,ctorsMectricians/Piumbers Appea�t [afoi�taea Prasre pyinti Leib,% Nae (Business/or�anirdonadividuai): i `' Q l Address: sjYif�- i''.lty/State/ i T n�� f> �..�- I x'1'1 �1 11 t� 'hone #: Are you an enaplayer? Check the appropwiate box: ' � Tfi;"New f proj (req - L I am a employer with 4_ Q I am a general contractor and Q � 5_ constrttction M (full and/or part-time)_* have wed the sub-caztzactors listed orie axtacfzed sheet_ l 7. Q Remodeling, 2- Q I am a sole proprietor or partner f ship and have no employees Mese sub -contractors have a g. Q Demolition: working for me in any capacity_ employees and have worl��s' g_ Q 3uilding adrlitiort [No workers' comp- insurance comp. instarauce. required_] 5. Q We are a corporation and its l0-��lec%ricai repairs or additions 3. Q 1 am a homeowner daing aT work officers have exercised their l 1. Q Plumbing repairs or additions myse#L [No workers' comp_ right of exemption per MGL l2_Q Roof repairs insurance required.] c. lit, § 1(4), and we have no employees.[No workers' 13_Q mer corms. bsurance required.] g 'Any applicant that checks bon # < est also MI out the section 6elova shoring thei wrs'orke--pensatiw policy Edbrnlald— iomeowners who submit this affidavit indicating they are doing ail werk anal then hire outside comactors must submit a acw affidavit indicating such- tContractors that check this box Lunt attained an additional sheet showing the narne o= rhe sarb-contractors .and state vrhether or not those eatitics wave employees_ If the sub-cowractws have employees, they must provide their workers' comp policy rurrnber_ I aria ag employer ifiat is,pmvie ng• warkm, ctrjn���'le� ��fn�w is fhePvtasy an4d O :sake anfrs�� Insurance Conanmy Name: n f Vie l l (� l"L U � sem` � �� 1 ' aLn ( o Policy # or Self -ins. Lic. #: DO as I?M I, ' Expiration Bate_ fob Site Address: H t I q Y) accc� Gty�'State/Zip, Att2ch a copy of The workers compegsatIOB po&y declara.MR page (sldsswinn d_xd poffey aambes- Md mpirat.101t dave) Failure to secure coverage as required under Section 25A of MGL c_ 152 can lead to the imposition of criminal penalties of a FMe up to $1,500.00 and/or one-year imprisonment, as well as civil penalties ha 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 ice of Investigations of the DIA for insurance coverage verification. I do herehr it j i er the pains and pa Aglties ofper}ury that the information provided above is true and correct Official use only. Do not write ira this area, to be completed Em di 7 or town official. City, or Town. Fermlt,Ucense 9 L,smiug Authority (eirde oue); 1. Board of f alth Z_ Building Departmeat 3. Cat-y/Towna Clerk 4_ Vectricai .luspector 5. Plumbim; IUspeetor 6> other Contact Person: Phone #: t3i1��1�1E3%E►L; Q lltilhiiil�...} • •MV8• •0 ruin EkETI? :�.:i 7. iSSlJES THE FOLLOWI G LI CftJSL � �� �PMD MAST-ER.- �.LfC,FR,I..ti�ryFA pS H 'A D P 1 ETRO HEAT1 NG' 25„ 'BE E CFt't UM D R .. ft EST, _59. 982r suoi�e�n6aa jo/pue mei Aq paainbai se palsod ao uosaad anoA uo asueoil siyl das>j -mei jo Igleued aapun Aplue ao uosaad Cue oi peuftse ao jual aq louueo pue `a6ajinud a si asueoil .in% -suoileln6a.i pue sorrel leaaua!D s4asnyoesseW o} joefgns si asueop, siu -eouepuodseuoo aay10 AUS pue uopoijddy jemauaH anoA �o 6utipw aado,id aye 9-ensue of suoi}on.ilsui aol odp/no6•ssew le aps gaAt ino lism `palDaaaoo aq of speau ao :ajeanooeui si 'palo4sap ao pa6ewep `�soj si asueop inoA 1.1 .LNVJLUOd11V9 b'sb U ';W moi.✓ fes,. �i January 12, 2015 John T. Smolak, Esq. Smolak & Vaughan LLP, East Mill 21 High Street, Suite 301 North Andover, Massachusetts 01845 Re: West Mill CompleiCjour High Street Zoning Determination Dear Attorney Smolak: You have requested an interpretation of specific uses for property located both within the Downtown Overlay District (Article 18) and the underlying Industrial S Zoning District (Section 4.135). As you had explained to me, the proposed use would include office use which is allowed by right as "Business, professional and other offices" as defined under Section 4.135.2 of the Zoning Bylaw. You have also informed me that the property would be used as a vivarium which you described to me as a lab or facility used for keeping living animals for observation, research and study. I would classify the vivarium use as "research and development facilities" as defined under Section 4.135.1 of the Zoning Bylaw. The property is also located within the Downtown Overlay District under Article 18 of the Zoning Bylaws, as most recently amended at the May 2014 Annual Town Meeting. Section 18.2 lists uses permitted by right within this District, and Subparagraph 22 of Section 18.2 provides that "all uses allowed in the underlying zoning district are allowed by right." Accordingly, both uses as you have described them to me are allowed within both the Industrial S Zoning District as well as the Downtown Overlay District. Please contact me should you have any questions concerning this matter. Sincerely, Gerald Brown Building Inspector Date ...... ... I . . ........ ((..� ............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING �o I Aiv HLAI�— This certifies that .................. .......... 3./H .................................................... ....... has pennission to perforrn ............ ........... . .. . .................. .................................. if . . . ......... ldi C -e \e e 0 ") winngin the Pui ing oi. ...... ......................................................................... ... .. . orth Andover, Ma at ................................... ............. Fee ..... 1213 Lic. No. . ..... M.K. ........ ......................... ... .. EL CTR�ICAL INSPECTOR Check# � % 7 '7� - &f:>4 44<�4�o-,- llkoH Commonwealth of Massachusetts Department of Fire Services a BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. la 3 3 Occupancy and Fee Checked ,[Rev- 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 52 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: % ?r y / G! City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives potice�of his or her kitNtion to perform the electrical work described below. Location (Street & Number) /(jy7 Owner or Tenant ha L i,6 R O N Owner's Address E/') r/ V /L/ Telephone No. Is this permit in conjunction with a building permit? Yes 0 No ❑ (Check Appropriate Box) Purpose of Building coo/3 &:P Q f 1�'L— Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion o fthe following table may be waived by the Inspector of 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 ❑ In- Elo. o mergency Lighting ` / rnd. rnd. Battery Units No. of Receptacle Outlets f �j 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 No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number ""' Tons "' """' ' """'""""' KW """'" No. of Self -Contained Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Y1— Attach additional detail if desired, or as required by the Inspector of 07res. F, 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 unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) rcertify, under thepai%��s��nd enalties ofper,�ury, th t tl e infor atcon on this application is true and complete. FIRM NAME:. "rt%GiA1 � %!;/t ���/ LIC. NO.: Licensee: /,�p0� l///�Signature LIC. NO.: (If applicable, enter "exem t" in th 1' s atmbe l' e.) Bus. Tel. No.: Address: GOA AlipAlt. Tel. No.:— *Per M.G.L c. 7, s. 57-61, security work requires Department of lic Safety "S" License: Lic. No. � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. � i ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the J o 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 this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed ❑' Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass IE V Failed IN Re- Inspection Required ($.) ❑ Inspectors C ents: r Inspectors Signature: Date: FINAL INSPECTION: Pass M V Failed Re- Inspection Required ($.) ❑ Inspectors Co ents: Inspector Signature: Date: L� DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Invesilgations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/individual): Address: /Z/ bLoy eln (/pU, City/State/Zip: a419 LI / /�� 4�e e/, jione #: Are,you an employer? Check the appropriate box: 1. 1 am a employer with 4. El 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. I 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. ❑ Remodeling 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 2te 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 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/ ,�j#:` /f Expiration Date: Job Site Address: % y/ (se U 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. Ido hereby cert& under the pains a / en�altie o ry that the information provided aboveis true and correct Rio n-hiriv // bate' 411 __17-/1l Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: t 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 employeiis 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 an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials .., Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. 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 tax number: The Commonwealth of Massachusetts Departapent,of Industrial Accidents Office-oIntestigations 600 Washington Street Bostoi?-MA 02111 Tel # 617-727-4900 ext 406 or 1-877:MASSAFE Revised 5-26-05 Fax # 617-727-7749 __www-mass,gov%dla Rei I