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HomeMy WebLinkAboutMiscellaneous - 530 TURNPIKE STREET 4/30/2018 (7)4 �a t1 J 0 IS v 0 Ir V a Z \ i o � � W 0 = G0 � V LL o� r 0 O w 0 z O Q � � A r LL Z V OJ 611 !i• _� 0 IS v 0 v � CL Q vp vz o� H w a L� CO-, 1\ LL o w 0 V � LL A w a ��w rrw ,y Location x. O--A� 4-�, No. �' G'�� Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee - $ �36 TOTAL $ &0 .�- Check # d 90 18643 //'I— 8643'I— Building Insped 0 L' A M W Z > O O Q � U Z Q J _ 0. CL F - z LL W O o. z� z O � H N N• m ZL d 0 1L C O O N O` Q W O O -0 o «. �'��� CC o `0 ( )2 0-0 mJm I E�J U a ca(6 m >+ Z. 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JI Tau f I-aoo-SICN {7aaol �r .r � r r DL:PARIMIJYI'UPTUBLIUMPCI Y Permit No. BOARD 0FMEPREVEW0NREGMT10AN 7CVfRIZW �-- Occupancy &Fees Checked , APPUCATTONFOR PERNff TO PERFORMELECTRMCAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACIiUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Datq ?� Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) -71MAKIUPJ�� Owner or Tenant Owner's Address S-30 Is this permit in conjunction with a building permit: Yes [ZJ No [::] (Check Appropriate Box) Purpose of Building >Fi 'TN15FS 3 C&V %;/a Fir—U)"' Utility Authorization No. Existing Service Amps�Volts Overhead aUnderground No. of Meters �w New Service ° AmpsVohs �� nr� +erhead!�� Underground 's No. of Meter"sk'. ra, Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work &MA:- SS C -&1v`7&21- f`T- P No. of Lighting Outlets No. of Hot Tuba No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pod Above 0 Below Generators KVA 7 and ground No. of Receptacle Outlets ZiGn No. of Oil Burners No. of Emergency Lighting Battery Units /-3 No. of Switch Outlets 9 No. of Gas Burners �/�j ;/ V6- FIRE ALARMS { No. of Zones No. of Ranges No. of Air Coad. Total Tons a�• No. of Detection and No. of Disposals No. of Heat Total Total Pump Tons KW Initiating Devices No. of Sounding Devices �— No. of Dishwashers Space Area Heating KW No. of Self Contained Detectic dSounding Devices Locala Municipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP oTIIE 3 — 9- ;-O* 3 /4go BV 19- S040W+S %,VU1viNiT t3ootff s insuatoeCae�dg� bthetequierta�atll�td>tlsdla Ilmeahn tadvaWprcdcfsarebtle0ffm YES © NO ' [:n* >M a OMM a WorkbSlat 7 8--C)s Ir15pe[" D*Re*zod Skmi undEm ptnallial a4miuy. I FIRMNAME L190TY 6a-fr—T- Lioa3>9ee U� Comw jeQissteovalant YES NO E3 "j If}(nimedod®BYES pimenicwdietAe(ifoaeWbycaaiglhe (Pleasespaofy) /1 os- 111"mD FsknatedVakvafEkdilalWakS Rao FYW 4Al C 1'�4r-�-�—. L;mwNa � Ti _ L;rwNo 31�11a5-E Bus=Td1,h b b 3 - $S'R'- bd AkTdNa &03-199S---222 {�'� aod�etmysig�re�ernl�spa�'teppic�imw�esthisragcaarlat - _ l✓ (Please check one) Owner a Agent Telephone No. PERMIT FEES`�'� 0 Mol 7 q 0 Mol - �$- - 0 ,:5- Date ..77 ....... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING. This certifies that .... I - has permission to perform .. ........... to ................ :q�A"f- plumbing in the buildings of . A ............... at. . North/Andover, Mass. Fee..4/PA'..Lic.No. 4??8. A4. PLUMBING' INSPECTOR -7 '1 Check # / 6522 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS /Date 5— 05— Building Location of 3 Z7 / v (. r`1ffc- Owners Name VO &44 _�, /L W'- S5 t� ermit IF Amount Type of Occupancy New Renovation 12/ Replacement 0 Plans Submitted Yes 0 No FIXTURES (Print or type)o // "s �� * � Check one: Certificate Installing Company Name C Ul � Corp. Address / ® 6 Partner. AF ,'+-1-74- Business Telephone TV Frm/Co. Name of Licensed Plumber. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy/ Other type of indemnity 0 Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner D Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. // 7'r By: SignmrC of Ewenscam bing License Title � City/Towni e um Master Journeyman ❑ y APPROVED (OFFICE USE ONLY 9--a -'4%. V10 Date ....1.'.i. 6`y........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING j �ej' This certifies that ... ............................................................... ............. . C 1 9- has permission to perform -1 .......................................... wiring in the building of ' ...('� � ...-......................................... "�& ............ at.S?. -v ..... ........ . North Andover, Mass. Fee.�A? ........ Lic. No. ELECTRICAL INSPECYOR Check # 5 b S 8 ^ DFPARTMENTOFPUBLICS4FM Permit No. BOARD 0FFIREPREVF.IW0NRWUl.AT10AN527CI1R 12-M occupancy sc Fees Checked 6 `� UV,4TUCAMNFOR PERMITTO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat Town of North Andover To the Ins ector of Wires: Af The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) j 3� Owner or Tenant Owner's Address S-30 7-996669:C -- Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building Fi'TiV1'S C49vZ�op— 1eir 0'0 Utility Authorization No. Existing Service Amps / Volts Overhead 0 Underground M No. of Meters New Service Amps /� Volts Overhead r --J Underground Q No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures / Swimming Pool Above [71Below Generators KVA and ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units /3 No. of Switch Outlets 9 ` No. of Gas Burners FIRE ALARMS No. of Zones _ No. of Ranges No. of Air Cond.Total e �� ✓ Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local a Municipal a Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER 31 2-.�Ofi- 3 ¢ /�O�aaBy !°/�'✓� �R72.%i.S , �6 '- /�I�'tri�S. Si rs 2 iibvN��& 8001#S IharewbmiiiedmMpto*fsanebtheOfoc YES M NO Vpq NRRANCE c7j' BOND a OHiER a Y WcrktoSw -7-4'6,5- hspec iasD*RgpmWd SgtadundaTieP a P*y-.0-%� 1�c1 E�-��-� FIRMNAME georitssi>slatlialewhdat YES NO 7 (fy uhmedrdmdYES,pleas m&mthetMxofwxWbydakirtgthe 0-5-- D* Est m*dVakrdTJeitlxW tWak $ Parra Rough �� 1 n LxenseNo. �y�f _ Iioa�eNo 3 Wa-�E Bts¢IesTd.Na 6,412-951'- &O� — Ak7eLNa OWNER'SINSURANMWAIVER;IamawatethatmeUaensedmmtnaremeastraloem► a�su�eategtaw�r�mra�atn+uYr� ��'�'� a�d>hatmysigsahaernfhispean[app�a��vai�esth's last (Please check one) Owner Agent Telephone No. PERMIT FEE $ '��� �� �3� d� � U�� -- v a� E r r N is Location—S ,,, Pr ice- No. q 0( a Date d r HpRTM TOWN OF NORTH ANDOVER 0 IWO 9 ' Certificate of Occupancy $ • i # -TS „CHUS <� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ a f? l D ,t J t Check # .?'Z I { f �834U Building Inspector i The Commonwealth of Massachu-setts GJ..� `t` 1.2 As©ssors Map and Parcel Number: State Board of Building Regulations and �„ TOWN OF NORTH ANDOVER Standards ©o6µ BUILDING DEPARTMENT Massachusetts State Building code Parcel Number 13 Zoning information: G 780 CMR 1.4 Pro ny Dimensions: S 3 o APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OF OCCUPANCY OF, OR DEIOLISII ANY BUILDING OTHER THAN A ONE OR Two FA\LILY DWELLING Building Permit Number: Date Issued. Proposed Use Signature: Building Commissioner6s ector of Buildin s Date SF( 1-TnN I_ SITE rNF(1RMATMN LI P ty;rty Add eta GJ..� `t` 1.2 As©ssors Map and Parcel Number: t`7i wok&, `". �„ ; Name print) o 4 ©o6µ r� IU : An.P.ot,,-r MR owz- Map Number Parcel Number 13 Zoning information: G Grate 13� �:. -` 1.4 Pro ny Dimensions: S 3 o Name (Print Address Lot Area (sq) Frontage(ft) Zonine District Proposed Use Address 1.6 Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided 107 XV ate' supply 9M.G.L.C.40.[::�14b 1.5. Flood Zonc Information: 1.8 Se%%erage Disposal System: Public Private Zone Outside Flood Zone Municipal On Site Disposal System 2.1 Owner of Record Not Applicable ❑ t`7i wok&, `". Licensed Construction Supervisor: yb/ A 9t Klo.Atn,6 -c MA Name print) o 4 Address: 978 SignatureTelephone DateCL > �} 2.2 Auth izAgent mq Name (Print Address Signature Telephone Registration Number 'i ('()NSTRI�(�Ti(1N SFR VI(`FS F(1R PR(1IGf'TS 7 FCC TURN ie nnn rr IRrIrc rr nr rN`-r neon en• roc 3.1 Licensed Construction Supervisor: FT6s my D Not Applicable ❑ Licensed Construction Supervisor: License Number AddressExpiration a- DateCL ?-� I D Signature 1A A Telepho 3.2 Registered Home Improvement Contractor: mq Not Applicable Company Nan:e Registration Number Address Expiration Date Signantre Telephone Revised 1997 ]MC SECTION 6 - DESCRIPTION OF PROPOSED WORK check all applicable) New Construction ❑ Existing Building Repairs ❑ 1Alteration(s) Addition ❑ Accessory Bld . ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed { ► oW�- e� IO+Sap -" oftiesii A-2 A-5 A-3 hereby authorize 49 CMAM oiwa::/,,L-977— to act on SECTION 7 - USE GROUP AND CONSTRUCTION TYPE USE GROUP Check as applicable) BUILDING AREA Existing if applicable) Proposed Number of Floors or stories include basement levels �• CONSTRUCTION TYPE A Assembly A-1 A-4 A-2 A-5 A-3 hereby authorize 49 CMAM oiwa::/,,L-977— to act on I 1B ❑ ❑ B Business 2A 2B 2C 10 ❑ ❑ E Educational ❑ F Facto ❑ F -I F-2 H High Hazard ❑ 3A 3B ❑ ❑ I Institutional ❑ I-1 I-2 I-3 M Mercantile ❑ 4 Cl R Residential ❑ R-1 R-2 R-3 5A 513 ❑ ❑ S Storage ❑ S-1 S-2 U utility ❑ S eci : M Mixed Use ❑ Specify: S Special ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS. ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Existing Hazard Index (780 CMR 34) Proposed Use Group: Proposed Hazard Index 780 CMR 34) SECTION 8 - Building Height and Area BUILDING AREA Existing if applicable) Proposed Number of Floors or stories include basement levels �• SECTION 10a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN Floor Area per Floor (sf) Q , c 1370 z Total Area (sf) 4. 4,10 hereby authorize 49 CMAM oiwa::/,,L-977— to act on Total Height (ft) 2,11 0" SECTION 9 - STRUCTURAL PEER REVIEW 780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes ❑ No ❑ SECTION 10a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT J I, ohn l GZS r , As Owner of subject property hereby authorize 49 CMAM oiwa::/,,L-977— to act on my behalf, i 11 matters rel ive to work authorized by this building permit application. Sig rre of,6wner D to revised bldg form/state JMC SECTION 4 WORKERS' COMPENSATION INSURANCE AFFIDAVIT IM.G.L. c. 152 § 25C(6)I Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached l'es No SECTION 5- PROFFESSIONAL DESIGN AND CONSTRUCTION SERVICES -FOR BUILDING AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CNIR 116 (CONTAININGMORE THAN 35,000 C.F.OF ENCLOSED SPACE 5.1 Registered Architect: No Applicable Name (Registrant): Address Registration Number Signature Telephone Expiration Date 5.2 Registered Professional En ineer s NameArea Lj, berg Cle.c riC T,)c. of Responsibility Address SD vrfhW fern br. c.lem H ino?9 Registration Number /3590 6,03 -Ne -60,13 Signature !Mt Tele hone Expiration Date 7^31-.0 Name): l�•� l � Area of Responsibility K� lE 1= `Mer-�u'+.�,� cn.` Address Registration Number L Signature Telephone M- 30'3 Expiration Date a 12 G a Natne P(/la �JL T ij Area of Responsibi ty UW1 `oLH Address►---� Q X OL� �d/ �/° "� (Al7 /� Registration Number'O Signature 0,3 -- Telephone g-� Expiration Date / / 106, Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 5.3 General Contractor r Company Name: Not Applicable 0 Responsible in Charge of Construction r Address Signature A, 4t -Telephone v (90 3' 06 -las? �'iY:Ynr:a7� � r+..-�.-,-.kyr.: y;•• -a,. :,r - sa �,.r �'�.._ - . Workers Compensation lnsarance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the ' issuance ofthe building it Sinned affidavit Attached Yea ......A No ...... D 5.1 r nO \< No. 4871 3 GLADVIME, 02 PA. a Company Name: Responsible in Charge of Construction Not Applicable ❑ Area of Responsibility - Registration Number Expiration Date Name: Address: Signature Tale1 Not applicable ❑ Registration Number. Expiration Date Name: Address ,.Signature Telephone Area of Responsibility Registration Number Expiration Date 'Name Address . Signature Telephone Area of Responsibility Registration Number Expiration Date Name — Address Signature Telephone Company Name: Responsible in Charge of Construction Not Applicable ❑ SECTION 10b - OWNER/AUTHORIZED AGENT DECLARATION I� I, 0 as Owner/.czzft hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. ' Signed under the pains and penalties of perjury. Print Name i Zi SECTION 1 1 - ESTIMATED CONSTRI JCTION COSTS Item Estimated Cost (Dollars) to Official Use Only be completed b permit applicant 1. Building(a) Building Permit Fee A Q ODr 2. Electrical SW -Multiplier (b) Estimated Total Cost of / Construction from 6) 3. Plumbing 3015-00 Building Permit Fee (a)x(b) 4. Mechanical (HVAC) QQ 5. Fire Protection QQ 6. Total = 1+2+3+4+5) U 10-100 Check Number T .`.. OFFICE OF BUILDING INSPECTOR TOWN OF NORTH ANDOVER r` CONSTRUCTION CONTROL PROJECT NUMBER: PROJECT TITLE: PROJECT LOCATION: NAME OF BUILDING: NATURE OF PROJECT: IN ACCORDANCE WITH ARTJCLE 116 OF THE MASSACHUSETTS STATE BUIL91,N CODE, I, j O)I T D 4W REGISTRATION NO. `7' BEING A REGISTERED PROFESSIONAL 41&qd1K9WARCHITECjrHEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING: ENTIRE PROJECT • FIRE PROTECTION • 4 RCHITECTURAL STRUCTURAL • MECHANICAL • ELECTRICAL • OTHER (SPECIFY) FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEGE, SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRATICES. AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND B EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0 1. Review, for conformance to the design concept, shop drawings, samples and other submittals which are submitted by the contractor in accordance with the requirements of the construction documents. 2. Review and approval of the quality control procedures for all code -required controlled materials. 3. Be present at intervals appropriate to the stage of construction to become, generally familiar with6the progress and quality of the work and to determine, in general, if the work is being performed in a manner consistent with the construction documents. PURSUANT TO SECTION 116.2 .2 1 SHALL SUBMIT WEEKLY, A PROGRESS REPORT TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING INSPECTOR. UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FO C PANC . G ATURE 1 �w SIBS D SWORM TO BEFORE ME THIS 2I DAY OF J Al a OS ., COMMONWEALTH OF PENNSYLVANIA _ NOTARIAL SEAL a NOT BLIC MY COMMISSION EXPIRESTHOMAS P BAGLIVO, Nota Public My 61p bila. Wounty My Commission Expires November 15, 2008 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT :LCs l v Cy (� h PHONE LOCATION: Assessor's Map Number PARCEL SUBDIVISION ��---- LOT (S) STREET `�%� 1 �z -�/" ST. NUMBER OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS DATE APPROVED DATE REJECTED COMMENTS A/2 4�' FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT - DUMPSTER PERMIT RECEIVED BY BUILDING INSPECTOR DATE FORM U - Revised 6.05 JMC 4?1UI0�- NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I OA. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant Fire Department Sign off Dumpster Permit Date I he G'ommonwealth of Massachusetts Department of Industrial Accidents 131 I -T 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):—R—&., Faru A#3Tin1. A' / 1 .o, Address: :9R GD&,Q - City/State/Zip: ;tb n3 0 ? ej Phone Are you an employer? Check the appropriate box: 1. ❑ I am a employer with �_ 4. ® I am a general contractor and I employee's (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.] ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t officers have exercised their Tight of exemption per MGL C. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10-DElectrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other _., -FF-- •==a=..uc " wA n, MUM Ulbu nu out me 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. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy inforrnation. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company N Policy # or Self -ins. Lic. #: Expiration Date:_ u j Job Site Address: SIN n Tl i?i�a T City/State/Zip: /�1 V��:����� aur 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'tmprisonment, 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 nder the and penalties of perjury that the information provided above is true and correct Oficial 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 6. Other Contact Person: .'p 4. Electrical Inspector 5. Plumbing Inspector Phone #• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers, compensation any contracemployees e. Pursuant to this statute, an employee is defined as "...every person m the service oanother 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 au 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 supply sub-contractor(s) name(s), address(es) and phone nu necessary, mbers) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial ge. Also be sure to sign and date the affidavit. The affidavit should Accidents for confirmation of insurance covera be returned to the city or town that the application for the permit or license is being requested, not the Department of ave any questions regarding the law or if you are required to obtain a workers' Industrial Accidents. Should you h 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 r Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant of the a Please ff 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 affidavit is on file for future permits or licenses. A new affidavit must be filled out each applicant as proof that a valid year. Where a home owner citizen is obtaining a license or permit not related to any business or commercial venture Or (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address; telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia ✓1Ee �aninw�a�veaoc�u BOARD OF BUILDING REGULATION _ Ucense: CONSTRUCTION SUPERVISOR 3 ! 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