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HomeMy WebLinkAboutMiscellaneous - 695 MASSACHUSETTS AVENUE 4/30/2018 695 MASSACHUSETTS AVENUE 210/059.0-0044-0000.0 NLocationk� _ No. ' .� Date NORTH TOWN OF NORTH ANDOVER G ,. Certificate of Occup' anby- -'s: 41n Building/Frame'Permit fte $ ' P 'r1 ��no•A�.�! r �ss�cMustc Foundation,P4, trtF,e!Co� $ Other Permit Fee Q. I� Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector ector 10936 Div. Public Works 111T No. APPLICATION FOR -PERMIT TO BUILD NORTH AN , MASS. PAGIC _ MAP 4-40. LOT NO. 2 RECORD OF OWNERSHIP JDATE BOOK 'PAGE ZONE SUB DIV. LOT NO. I — LOCATION i9 4tr ,i z IOU I POSE OF BUILDING OWNER'S NAME N Of STORIES, SIZE C Gni a OWNER'9..ADDRESS:.. . D EMENT OR GLAD ARCHITECT'S NAMC f E OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME AN DISTANCE TO NEAREST BUILDING \ _ IMENSIONS OF SILLS _ DISTANCE FROM STREET ! - POSTS . DISTANCE FROM LOT LINES— SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION - THICKNESS IS BUILDING NEW SIZE OF FOOTING - x 19 BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION - IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUI NW OFC IS BUILDING CONNECTED TO TOWN WATER COIR BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER If BUILDING CONNECTED TO NATURAL GAB LINE a INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES - EBT. BLDG. COST i®61 ' PAGE I FILL OUT SEC7ION9 I - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS I - I2 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPG MUST BE ON OUTSIDE OF BUILDING. 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE R GULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING I SPECTOR DATE FILED ��/ ol q q fff BUILDING INBPKCTOR. A URE OFsOWNE R AUT119JLLZM AGENT F E E WNER TEL/ A;7 PERMIT GRANTED CONTR. L j CONTR.LIC.0 0 3 L ` H.I.C.0 ly 13 3 1 BUILDING RECORD 1 OCCUPANCY 12— SINGLE AMITYSCOrr1E5 THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT' DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- ' APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES_PLOT PLAN. CONSTRUCTION 2 FOUNDATION 6 INTERIOR FINISH CONCRETE _ d 1 2 13 CONCRETE BUK. PINE BRICK OR STONE HARDW O PIERS PLASTER - - _ DRY WALL - UNFIN. - -- _ 3 BASEMENT Ti AREA FULL FIN. B M'T' AREA _ 1/4 1/1 �/. FIN. ATTIC AREA NO BMT FIRE PLACES - HEAD ROOM MODERN KITCHEN 4 -µ WARS 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH ASPHALT SIDING HARDW0 ASBESTOS SIDING COMMCN VERT. SIDING ASPH. TILE STUCCO ON MASONRY _ STUCCO ON FRAME ATTIC STRS. b FLOOR _ BRICK ON FRAME I CONC.OR CINDER BLK. a STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR I_4 POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I I HIP BATH 13 FIX.) _ GAMBREL MANSARD TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR 8 GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING i 1 HEATING - - WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. g. TIMBER BMS. 3 COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR } W000 RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT.HEATERS 7 NO. OF ROOMS OZGI IL B'M'T ( 2-dELECTRIC Tit 3rd if NO HEATING 5.:-.L�7.r.... S •',..'Y ,A3--....r. .. ..3�" ... =y�.��y. �""',"" 1� •`•a:, �., ..���.�'j..- s/"� �M z>3"..tea,. ! .'v F'_ �{..-.-•y4t� �•`�'i 'd' _ � _4�v e.�X1�':L� x M�1:' _ Ay "liver pig 71 - over, Mas . 4COCMICNEMICx f 19 0 L/ '9s AA TE o APA may. PER BOARD OF HEALTH Food/Kitchen ' Septic System THIS CERTIFIES THAT ...... BUILDING INSPECTOR . ... ... s has permission to jwea.... Foundation n •.... f••• ..... �........... Rough to be occupied as gh ........................................ . Provided that the arson accepting. ...•.... •• •••-•-"""'"" ication on e in Chimney P pti g this permits II in eve re •••" o th.e..ter•••• of.t " this office, and to the provisions f the Codes.and By-Laws relating to th nspect on, Alteration ahe nd Construction of / Buildings`In the Town of North Andover. Final VIOLATION of the Zoning or Building Regulations Voids this Permit. PLUMBING INSPECTOR Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION ST S ELECTRICAL INSPECTOR Rough ........................... ... Service . ... .... ... .............................. €€ I DING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove R°` f Final No Lathing or Dry Wall To Be Done nal f f Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. Smoke Det. N2 9681 Date. . . . . . . . s "oWT„ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING . ._ ssACMUs� c This certifies that . . . . . . . . t�� .. . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . plumbing in thebuildin s of . . . . '�^i0. . . . . . . . . . . . . . . . . . . . . . . . at. . . . h . e�-. . . . . . . ., North Andover, Mass. t. c� Fee—$.1/ .Lic. No 1bo. . . . t"t . . . . . . . . . . . . . . . . . . . . . . . . . . �Zt7Z.��(t PLUMBING INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK:Treasurer ,,.....r.'.: ��ice:...: ��....;._ �: �.'..... .,.4.,..x< ..: ...._..�. '•_y_ _. y...>.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ` CITY _1 _ $ MA DATE ' 2 PERMIT# 24N JOBSITE ADDRESS (� OWNER'S NAME P OWNER ADDRESS _ i TEL NAME[_ OWNER f TYPE OR OCCUPANCY TYPE COMMERCIAL E( EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: ©I, RENOVATION:2- REPLACEMENT:® PLANS SUBMITTED: YES E0 NODI FIXTURES 7 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE �_( __.r._..--f I :_._..__,_ _ E ___.___: _,_.._I _..,___.. •_.._._S ._.-_.__.i ____-i ..__ f M—f DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM !. ..I I ► _...J .. _.-..._l _ _{ ,.___•_ I-___J __-___-� DEDICATED GREASE SYSTEM _1 f f J: _._._.._._ ..._..._.l ( -- 1 -.-_---__1' .._.....---I _--.--___! _.__-f _-...._._.I _.__f �{ DEDICATED GRAY WATER SYSTEM I I { _-f ...__. I 1I ..___J __( _J f ... DEDICATED WATER RECYCLE SYSTEM ...._..... .._! DISHWASHER _._._.j _____ DRINKING FOUNTAIN FOOD DISPOSER1 _ ( .....__l FLOOR IAREA DRAIN INJ,ERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY -_.--.__J ___...-._.1 __-__{ _._.._...__I I _J R65F DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL _1 � ....____.1 .---..._.__► _..._.__ _-_J ...._.._.._._! WASHING MACHINE CONNECTION ---____l _- f _. ._ f WATERHEATER ALL TYPES f y( ! i i ! _ Ii ... ..._i --, ! _.--..._J � ._. ._-! _ -( _-_._-- WATER PIPING Tl _ OTHER __-.__ __. __.___ _�._ _._ rJ _ I __l ..---...._i ..............I _�__) _i .--_-.._....i ._.__.._..•i ....___..._! ___i .____.__._I F777117771 F INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO r IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ed OTHER TYPE OF INDEMNITY Ej BOND I OWNER'S INSURAN WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts G eral Laws,and that my signature on this permit application waives this requirement. 4 SIG URE OF OWNER OR AGENT ��. i CHECK ONE ONLY: OWNER AGENT � I hereby certify that 0of the details and information I have submitted or entered regarding this application are true and accurpw to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in c n with a inept provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ LICENSE# MP JP CORPORATION Q# i PARTNERSHIP D# i LLC COMPANY NAME L ; ADDRESS �-� `- — CITY -Tse 1 STATE ZIP _d1TEL FAX L _ CELL[___ EMAIL 1 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ �, `l� ��/� FEE: $ PERMIT PLAN REVIEW NOTES ��/ r 1 i..r ' �-� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UV 600 Washington Street Boston,MA 02111 www mass.gov/dia I Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: L❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required): 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.E] I am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. [No workers' comp.insurance 5. El We are a corporation and its 9 ❑Building addition required.] officers have exercised their 10.F1 Electrical repairs or additions 3. ] 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp, c. 152, §1(4),and we have no insurance required.]t 12.[]Roof repairs q ] employees. [No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#I 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. kContractors 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: ?olicy#or Self-ins.Lic.#: Expiration Date: `ob Site Address: City/State/Zip: kttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 if up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. i nature: Date: hone#: 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. 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-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have 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 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 ` ��AMl�rl0 "AL F MA"S -RU T -'. � . 0LUM-`8EQ!3 AND,GASFIT'fERSk : LICENSED A J0URNEYFI PLUMBERi ISSUES THE ABOVE LICENSE TO i , MARK D 0L•E010 r. 2 CLAYTON. .A%'.E' METHU N 'MA 0 1844 2710 18833 )5/01/14 164493 `` ` Ford,Then betach Along All Perforations CONTROL# H37-2917 IMPORTANT If this license is lost or destroyed, notify your Board at the: Division of Professional Licensure, 1000 Washington St., Suite 710,•Boston,MA 02118-6100. If your name or address shown is changed, notify your board of correct name or address to insure proper mailing of next Renewal Application. Always refer to your license number. This license is subject to the provisions of the General Laws as amended. It is a personal privilege,and must not be loaned or assigned to any other person. Keep this license on your person or posted as required by law. WrJntll;-V—ff:X; .•t E,di,`' ;=.f,"JRUY FEATURES t — -Fold,Then Detach-Along AII-Perforations ; f I J I J 1 Date �. ^ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . . .Ui . � �t�� has permission for gas installation . .� .?�. ." . . . . . . . . . . . . . in the buildings of. . 01 P '—i. o : . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . ,North Andover, Mass. . . GASINSPECTOR Check# 8461 A MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ---;t CITY _ _ II MA DATE 2 3ZJ1 PERMIT# p JOBSITE ADDRESS� � —I{OWNER'S NAME E GOWNER ADDRESS TEL _�_IIFAX TYPE OR OCCUPANCY TYPE COMMERCIAL -.I EDUCATIONAL PRINT L ® RESIDENTIAL CLEARLY NEW:[ RENOVATION:Er REPLACEMENT:0 PLANS SUBMITTED: YES F-] NO F APPLIANCES Z FLOORS BSM 1 1 2 3 1 4 5 6 7 8 1 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER . FIREPLACE � �L 1 _ I �_. ( . I"RYOLATOR FURNACE .:GENERATOR INFRARED HEATER LABORATORY COCKSf MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ._ I -. .__J � -Al ROOF TOP UNIT (-. 4 .1 TEST _.._l L— 1 (----- UNIT HEATER UNVENTED ROOM HEATER T�� 1 �((--`� r�--- WATER HEATER --- I OTHER , INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES IF-11 NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [- OTHER TYPE INDEMNITY 0 BOND OWNER'S INSURANC• IVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts Ger 6ral L ws,and that my signature on this permit application waives this requirement: / CHECK ONE ONLY: OWNER D-I AGENT SIG URE OF OWNER OR AGENT hereby certify that alVbf 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 complia with 4=the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASF ITTER NAMELICENSE# SITNATURE MP0 MGF E--] J PFZJGF LPGI E] CORPORATION E]#=PARTNERSHIP(_�]f#=LLC D# COMPANY NAME: _. _._. ADDRESS[-01 CITY t !�_..._..- - -._.._.._ ......._. �� STATE CAjjZIPP\5'TEL FAXJI CELL "AILLLL �w- W - -- - - ---- --- - - - I ROUGH GAS INSPECTION NOTES TRIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ 1 /� /� FEE: $ PERMIT# PLAN REVIEW NOTES i it I y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: 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 employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. [No workers' comp.insurance 5. El We are a corporation and its 9 ❑Building addition required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 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 contractorsmust 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. t 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.#: Expiration Date: lob Site Address: City/State/Zip: tttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ,ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 &up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. d2nature: Date 'hone#: 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#: CJJ/w}' i V Ir r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. 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-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have 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 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 Revised 5-26-05 Fax# 617-727-7749 www,mass.gov/dia