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HomeMy WebLinkAboutMiscellaneous - 72 STAGE COACH ROAD 4/30/2018i .�.y a�,r"J, 3'� i"ldaxx�iaa. ,+'i"b-+i'cY'Yf'�'2`� •:+'Try J' ROBERT J. SWAJIAN & ASSOCIATES, INC. INSURANKE ADJUSTERS 7 A "At 1820- TURNPIKE STREET --STE. 207 MEPEWDECKNr ANDOVER,ASSOCIAT N. iADAMM TELEPHONE FAX (978) 655-3571 Info@RJSAssociates.biz FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B TO: Building Commissioner or Board of Health or Inspector of Buildings Town Hall North Andover; Ma 01845 SAME RE: Our File No: 15-30157 Insured: Jeffrey & Lynne McDonald Loss Location: 72 Stage Coach Rd Date of Loss: 2/1/15 Policy Number: BDNYSL Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss, and claim or file number. ADJUSTERS TITLE: On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Rob E. Swajian - Adjuster August 12, 2015 11'10,91 Date ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..........f' IN ....... .......... 15� ..................... has permission to perform ..........P .... ... wiring in the building of .......... ).ZC ...... ......... . ...................... at 41fell ....... &� ...... n . ....... . North Andover, Mass. Fee .:74i� .... . .... Lic. No. ........... ........... ELECTRICAL MiE *i;� 4 'Check 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 utriform 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 ofongoing construction activity, and may be.deemed-by the 7nspector-of_Wires abandoned.and.invalidifhe—. 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 entitystated 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. [ ule 8 — Permit/Date Closed: -/, 0 Permit Extension Act — Permit/Date Closed: ** Note: Reapply for new permit .I 1 -" Work to Start; (When required by municipal policy) ..y... ;U "'y cne inspector of Wires. 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 the Iicensee.provides proof of liability insurance including"completedoperation" coverage or its unle undersigned certifies that such cove ge is in force, and has exhibited prof of same to the permit ssuin substantial officeuivalent The CHECK ONE: INSURANCE BOND g I certify, under theRains and pe Ities Perjury, OTHER •(Specify:) F,�M N fP J ry, thr the inforeaa�ati®n on this application is true and complete. Licensee: Xr C LIC. NO.: (Ifapplicable, enter "exem Stgna`ure LIC. NO.: �� Address: P in the lice a numbe line.) �S Q Bus. Tel. No.: *Per M.G.L c. I47, s. 57-61, security work re es Department of Public Safety S License: OWNER'S INSURANCE W „ „ Alt. Tel. No.:, RIVER: I am aware that the Licensee does not have the liability Lic. No. � Rw--:W. � required by law. By my signature below, I hereby waive this requirement. I t the (check one insuorance coverage none Owner/Agent ) ❑ owner y Signature owners agent. Telephone No. PER HT FEE. $ Common-wealth of Afassachusetts Official Use Only Department of Fire Services VPermm'it No.BOARD OF FIRE PREVENTION REGULATIONS ncy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT To PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR12 00 WORK WL EASE PRINT. WINK OR TYPE ALL I,WORM1gTl0 City or Town oh NORTR ANDOVFn Date:- By this application the undersi ed To .the Inspector of Wares: gn gives notice of his or her intention t erfoim the electrical work described below. Location (Street &Number) ��� Owner or Tenant � Owner's Address S'% Telephone NO.,? 7— Is this permit in conjunction with a building permit?r i't� S Purpose of BuildingYes C _ Existing Service Amps _ / _Volts New Service Amps / Volts Number of Feeders and.Ampacity No 11 (Check Appropriate Box) Utility Authorization No. Overhead El Undgrd E] Overhead El Undgrd E] No. of Meters No. of Meters < ELECTRICAL PER RT No. INSPEC7['rCDN DFpnPm. h VTNT.AT b.. ...a r L � Inspectors' comments: raueu — -no 3. UNDER GROUND INSPECTION: Passed — [ 1 Failed—'[ Inspectors' comments: I s,ausycvLuxs- signature - no u �-'. INSPECTIOiV— SEItV[CE': Passed — [ 1 Failed — [ 1 Inspectors' comments: -no S. INSPECTION - OTHER: Passed —r 1 Failed — Inspectors' comments: ection required (S50.00) - rvAME: Date Date Date Date ection required (S50_0f)l - r i I— tLuspectors• LLgnature - no initials) Date DO OP, TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A REA NSPECTION OF550.00 IS TO BE CHARGED. s. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Lnvesfigations 600 Washington Street Boston, AM 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A Iicant Information Please Pram I,e ably Dame (Business/Organization/Individual): Address: City/State/Zip: Phone #: E an employer? Check the appropriate box: I. a employer with 4. ❑ I am'a general contractor and I Type of project (required):' loyees (full and/or -Part-time).* have hired the sub -contractors 6. El New construction a sole proprietor or parhier- listed on the attached sheet # 7• ❑Remodeling and have no employees These sub_contractors have king for me in any capacity. workers, comp. insurance. 8' ❑Demolition workers, comp. insurance 5. ❑ We are a corporation and its 9' ❑ Building addition ired.] officers have exercised their 10. El Electrical repairs or additions a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions elf. [Nc worlcers, comp. c. 152, §1(4), wird rxTe have no vice requu-ed.] f employees. N , 12.❑ Roof repairs No O � 7Ur�CerS comp. insurance required.] 13.❑ Other '------------- Y apY11ca t that cheers box Yl must also ,11 out the secaon f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers comolicy information. I an employer that is providing workers' compensation ip. pf infoormation. nsurance for my employees Below is the policy and job site Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: << Job Site Address: _.City/State/Zip: t Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine Of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si ature: Date.: Phone #: EE. only. Do not write in this area, to be completed by city or town official n: Permit/License # ority (circle one): Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector son: • Phone #: Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Property Address Policy Number: Date/Cause of Loss: File or Claim Number: Jeffrey & Lynne McDonald 72 Stage Coach Road BDNYSL 1/16/2014, Sewerage Back -Up 28996-R Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Ryan Werner On this date, I caused copies of this Notice to be sent to the peons named above at the /1 addresses indicated above by First Class Mail. Signaturj and Date ANDERSON ADJU,9TMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 G TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY O_ Ai'1--- 0VC4f _. MA DATEJ' - PERMIT# JOBSITE ADDRESS '�Q� _� _ 1201 - OWNER'S NAME IJaf_ G OWNER ADDRESS k%rY 1- TE FAX OCCUPANCYTYPE COMMERCIAL[] EDUCATIONAL NEW: Ej_ RENOVATION: D REPLACEMENT: _ - FLOORS- I BSM BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM 1 SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER RESIDENTIAL R' PLANS SUBMITTED: YES 13 NO� 8 1 g 10 11 12 1 13 14 Date... /.��/' ........ 10TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ....! �y� 1�..4�. �%� ...... ..c' ..... . has permission for gas installation ..... ...•/ in the buildings of .....�7.�'./ 9�!p at .... . • • • • ��-�C �?. �= . , North Andover. ., ' ass. '• • � Fee .�.. ! Q%' . Lic. No. �3°. 1 1 ..... GAS INSPECTOR Check # 8237 " , St�KKf�I�IwL'ZTokRA-G� have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL. Ch. 142 YES [�fNO Ij I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Q 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 ONLY: OWNER 0 AGENT ji OF OWNER OR 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 bece with ll Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of. the General Laws. PLUMBER-GA��.JP AMELICENSE #0SIGNATURE MP�GF � JGF LPGI© CORPORATION 1j# PARTNERSHIP[. # LLC D# - I COMPANY NAME:IGl�' l�t�.n C_ ADDRESS CITY�i STATE zip!_ TEL FAX --X/- . CELL EMAIL 757 8 Date m�/.'. ......... pORT/y TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that has permission for gas installation ........... in the buildings of ...................... at�............ North Andover, Mass. l Fee...3. �... Lic. No.... 3. Y�.'.. ..... , . .. .. � ... �.... . GAS INSPECTOR Check # (/ Location / / � .5�a q& C UQc 4 T)j No. Date °�` ` U TOWN OF NORTH ANDOVER ` Certificate of Occupancy $ Eta' Building/Frame Permit Fee $ swGMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 15672 Building Inspector } TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, REN OVAT—E,, OR DEMOLISH A ONE OR TWO FAMILY DWELLING u b" .4 ' IF-.':. 'Ay77 -377 BUILDING PERMIT NUMBER: D DATE ISSUED: SIGNATURE: Building Commissioner/In t of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: ` / Cr O4cll/���l� 1.2 Assessors Map and Parcel Number: lows— Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required I Provide Required Provided Required Provided 1760 1e" P 1.7 Water S G.L.C.40. 54) 1.5. Flood Zone Information: PublicPrivate ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage �°�1 System: Municipal On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 OwnerRecord o •gz Name (Prin jr IV -v 14Ad ress for Service vL 7u S37- 3 3 3 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: s Licensed 64struction Supervisor: I Address Signature Telephone Not Applicable 0 License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone O z M 90 O Wn r M rM r z ^^ Q SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 & 25c(6) 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 Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by penuit applicant (iFICIAi =TSEt?NLy= ... 1. Building (a) Building Permit Fee Multiplier 2 Electrical i (b) Estimated Total Cost of Construction 3 PlumbinE Building Permit fee (a) X (b) /a 4 Mechanical (HVAC) 5 Fire Protection 6 Total 1+2+3+4+5 U p Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ( 1, ` lAjvy— as Owner/Authorized Agent of subject property Hereby authorize /954//4Z.0 to act on My behalf. inAl matters relativg to mor uthorized by thds building permit applicatio ►,� (�- /i Q L:- Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and infonnation on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name r Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST2 ND3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHM4NEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U -LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary a pprovals/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*********************** *********************** ✓� � �2l APPLICANT PHONE 3 7 �— 3 3 3 7 \ LOCATION: Assessor's Map Number PARCEL SUBDIVISION ' LOT (S) STREET ° J cP, ST. NUMBER *****************************************OFFICIAL USE ONLY*********************************** RECOMMENDATIONS OF TOWN AGENTS: ,fd 27,2 -1 - CONSERVATION CO SERVATION ADMINIST //�IIO COMMENTS TOWN PLANNER COMME FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS )R DATE APPROVED A DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED 1 PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Revised M7 jm DATE 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 Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: (Location f acility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Town of North Andover Building Department �7 Charies Street North Andover, MA. 01845 D. Robert Nicetta Building Commissioner (978) 688-9545 '(978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print DATE lLy JOB LOCATION "HOMEOWNER Number Street Address Name PRESENT MAILING ADDRESS City Town Home Phone State Map / lot (1-70)�S37 - 333,7 Work 14 �- U) ) - Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individualfioc hire who does. not possess a license, provided that the owner acts as supervisor. '(State Budding Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures_ A person who constructs more than one home in a two-year period shall not be considered a homeowner The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNA APPROVAL OF BUILDING OFFICIAL it f-IPW • �JV]1400F,' 4 ()][ E K SURVEY INC ♦ HAVERHILL, MA 1 Phone 978-4M 1965 Fax 97&46a7D46 MORTGAGOR '' L lIIJ twee wo DEED REF. PG. Go ADIDRESS OF PRINCIPLE BUILDING PLAN REF. c Adr&t ", DATE OF INSPECTION SCALE: 1" _ (po �►dT'3i ( . -- fi '�'lO,d+r1 A'NgO �►1 _. _... _� �. ,.. ... _. �: _ ,�.. ;. ._ `. . ,, _ ;: ; .. .. i. � _ _J ,.. ... _. �: _ ,�.. ;. ck C/) m m U) 0 m CA CD a2c CD O CL r- � d � a� -o o C2 p CL Q " _ CD o CO) Co 0 O CD CD CO)CD C CO) n CD 0 CD 0 CO) CD CO) 0 ?� CO 0 = �o a�'em y N! O 0 CL H c CL .yym Z =� H ? o a � d mC� O O O N O Wim', ® _ > >� p3 m �. 0 O :& : O Z C07 CD p��LA C y 1 RL E ar.^►: co O9 = m yCD y a CL CAD 1 �V• d y C=. a d s. EL - H ` :OR Cf)�I o(, m o"� Z C. O CD0�: z� �. `� O .e .j,.:1 �l � .� O :4 d a:�� sm: dd CL te. ncDj� CD Cn O Cn r+ A to (D�- ?1 p? 7d rA :p w Cn (D ; 7d a Cil r Ix ?r ;* a- "� t=f x ti n x OO CL W ^ a o �yy w, FIXTURES � MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: 19V711 dh1WL1VC _ MA. Date: Z Permit# Building Location: Z__5 Owners Name: JL R0 Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES � W ui tX UJI z H N Y Q x Co:3 Q LLI Co W W x z J V ~co N W 0 m '2 O 0z N W m O ~ Q w Q 1=- = LL C W H Q Z W W W Z N W = COW O W = z W 0 > U W Z O co '� F H O m Z W J O U' z �- O N W ~ W > z W W Q O D >_ W O W W 0 a R >>> U ❑ W O x x J IW— O SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 TH FLOOR 51HFLOOR 6 FLOOR 7 1H FLOOR 8 FLOOR Installing Company Name: P /, L( Check One Only Certificate # bl yl�iGtr ll h7 0210+ L -- El Corporation Address: �5 City/Town: �� A'P. r State: ElPartnership Business Tel:Ape �) , 3 V --q IOc b Fax: [Firm/Company Name of Licensed Plumber/Gas Fitter: 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 have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy lv 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 Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checkina this box ll: I herebv certlfv that all of the details and information I have suhmitted for enteredl reaardino this annliratinn arp trim 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. Type of License: BY ❑ Plumber Title ❑ Gas Fitter Sig ture of Lice sed Plumber ❑ Master City/Town ❑Journeyman License Number: APPROVED OFFICE USE ONLY ❑ LP Installer www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Prinf Legibly Name (Business/Organization/Individual): City/State/Zip: 03053 Phone 9: Are you an employer? Check the appropriate box: The Commonwealth of Massachusetts r Department of Industrial Accidents �. a ?v r Office of Investigations 600 Washington Street ship and have no employees These sub -contractors have working for me in any capacity. workers' comp, insurance. Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Prinf Legibly Name (Business/Organization/Individual): City/State/Zip: 03053 Phone 9: Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. Electrical repairs or additions 11. Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors acid 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 Policy # or Self -ins. Lic. #: Job Site Expiration Date: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance*coverage verification. I do hkeby cert fy_rnder the pain"ndB.Oalties ofpetjury that the information provided above is true and correct 3 f/_ q Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # ,=.2 — -7 -- // 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 Are you an employer? Check the appropriate box: 1. ❑ I am'a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. # ship and have no employees 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 atn a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] 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 12.0 Roof repairs 13.❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors acid 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 Policy # or Self -ins. Lic. #: Job Site Expiration Date: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance*coverage verification. I do hkeby cert fy_rnder the pain"ndB.Oalties ofpetjury that the information provided above is true and correct 3 f/_ q Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # ,=.2 — -7 -- // 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' compensationaffidavit 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 cavy 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 confinnation 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 pennitJlicense number which will be used as a reference number. In addition, an applicant that must submit multiple,-pen-nit/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 pen -nits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pennit 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 Teal. # 617-727-4900 ext 406 or 1-117TMASSAFB Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia tommCiwwtALTH OF MASSACQ$ETTS .-. ; � ER IIID GA' pa'T F - LICENSED AS MASTER PLUMBER , ISSUES THE ABOVE LICENSE TO: ;I MANUEL S LAURENCIOt� 93 ROCKINGHAM ROAD ? LONDONDERRY NH 03053-221y3 05/01/12 78.6-41. j 13435 s CONTROL # G 018 6 4 9 IMPORTANT If this license is lost or destroyed, notify your Board at the: Division of Professional licensure, 1000 Washington St., 7th Floor, Boston, MA 02118. If your name or address shown is changed, notify your board of correct name or address to insure proper mailing of next j Renewal Application. Always refer to your license number. r This license is subject to the provisions. of the General Laws .;I as amended. It is a personal privilege, and must not bd loaned or assigned to any other person. Keep this license on your person or posted as required by law. I k)Rf'S