HomeMy WebLinkAboutBuilding Permit #200-15 - 5-9 Alcott Way 8/25/2014 t%ORTH
BUILDING PERMIT "�o
TOWN OF NORTH ANDOVER 02 '° °Z.
/ APPLICATION FOR PLAN EXAMINATION ~
Permit No#: �� Date Received
�9SSac►+us���y
Date Issued:
I O TANT:Applicant must complete all items on this page
LOCATION
PROPERTY OWNER
Print 100 Year Structure yes Ono
MAP PARCEL: ZONING DISTRICT: Historic District yesMachine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family !
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
denti cation- Please Type or Prin Clearly
OWNER: Nam Phone. k.3 1;?;?0/Irlf
Address:
Contractor Name 'Phone:
Address�4s f, za;1 i? /z, r�/��—/✓�� a� ��
Supervisor's Construction License: 4 Exp. Date:
Home Improvement License: l Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST
ffBASED N$125.00 PER S.F.
Total Project Cost: $ � FEE:
Check No.: 540a— Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the gua anty fund
Signature of Agent/Owner _ Signature of contractor
Location4
v W U
No. Date
i
. • TOWN OF NORTH ANDOVER .
od
Certificate of Occupancy $
Building/Frame Permit Fee $ �
Foundation Permit Fee
Other Permit Fee $
TOTAL $
Check#
Z
r
t'.
Bu`iIdTKg Inspector
E
I
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans El
T-YP_E OE.SE_VZERA.GE DISPOSAL—
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑
I
I
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
i
HEALTH Reviewed on Signature
COMMENTS I
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
f
Planning Board Decision: Comments
I
Conservation Decision: Comments
Water & Sewer Con nection/Sinnature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signatureldate
COMMENTS
i
�Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL. Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
i
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA—(For department use) j
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
it
E
Building Department f
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
u Building Permit Application
❑ Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
o Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
o Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
Li Copy Of Contract
❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
o Building Permit Application
o Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
u Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc:Building Permit Revised 2014
a+,�.,.a�:�:Y;:sE .- _ >^.-�r'+�,�.�$Qdf�.�•�lS1tL;<1tTC}��I�flt'�a?S•�1 •�5�fl��tfi:#�= - ..�.., - ,._
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CS-078130
-
RICHARD J LA*J$=T
-- 265 vwn=s=RET` s
Haverhill MA 01M { '
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�# Office.of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 149221
TVPe: Private Corporation
T.G.L.R.0 dba Lambert Roofing Company Expiration: 12!6/2015 TO 246813
RICHARD LAMBERT
265 WINTER STREET
HAVERHILL, MA 01830
Update Address and return card_Mark reason for change,
E] Address ❑ Renewal Employment
Q _ [] Lost Card
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EIN#51-05033313 - Aiio
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MA Reg.HIC#121981 19W
MA Lic #UCS 078130Rfin9 BBB
Single-Ply Lic.#1711
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We are. *Licensed AInsured 4-Factory Trained 4Factory 4Certified Installers
August 20,2014
Brian Ouellett in care of Alcott Village
440 Alcott Way
North Andover,MA 01845
Attn: Brian
Re: Roof Replacement building 5-9 all garages and over all doorways and all shed roofs 16 sq.
Building 10-15 all garages and over all doorways and all shed roofs 19sq. Building 17(1)
doorway and(1)shed 2sq. F
As requested,we have prepared an estimate for the following above named project.The
following is a general scope of work to be performed at the above-mentioned address.
1) A pre-roof walk around will be executed to observe and document any pre-existing
conditions and or any special considerations.
2) Ensure landscaping and dwelling is and will remain properly protected.
3) - Prepare for re-roofing by ensuring all safety measures are taken in accordance with
OSHA and CMR Standards.
4) Remove existing layers of shingles down to the wood roof decking and properly
dispose of debris from the jobsite. T.G.L.R.C.,INC.will arrange for disposal.
5) Inspect wood roof decking,if we discover any rotted wood,removal and replacement
will be performed at an additional cost of-
$65.00
f$65.00 per sheet of CDX Plywood removed and replaced.
Any siding and or general carpentry will be performed by others.
If we discover any pre existing conditions-we-will notify-ownerfor approval-No work will be
started without notification and owner approval: If wood roof decking and trim is sound, we
will re-attach any loose wood to the rafters,sweep deck and prepare for installation.
6) Attach aluminum F8 drip edge to all leading edges. Color(White)
7) Apply a premium ice and water shield to the leading edges 6'up and all roof to walls,
-chimneys and penetrations. Cover the balance of the roof deck with synthetic felt paper.
Page 1
� r _
L .._.. .;
st&ndard;a hurricane nailing system recommended in:northeast
regions 'This means, we in's'tall six(6)nails per shingle to reduce the risk o shin les .
I , g mm
6eiiag damaged by high winds and the weather changes iVe encounter. "'Ma
9) Install a new Certainteed limited lifetime architectural style shingle roof system. Color:
Char. Blk
I
10) All debris generated by TGLRC Inc.dba Lambert Roofing Company will be
cleaned up on a daily basis and properly disposed of from the jobsite.
Roofing Warranties:
UPON COMPLETION AND PAYMENT IN FULL A TEN YEAR NON PRO-RATED
GAURANTEE ON ALL WORKMANSHIP WILL BE HONERED AND ISSUED BY
"T.G.L.R.C.INC". A LIMITED LIFETIME PRO-RATED WARRANTY WILL BE ISSUED
ON SHINGLES BY MANUFACTURER.
-TGLRC Inc, dba Lambert Roofing Company agrees to:
__.c Commence the described work on or about August 2014
• The described work will be completed in about(2)working days per Building
• Shall not be held liable for delays due to circumstances beyond our control
• Shall not be held liable for any damages to landscape, attics and or fixtures due to
circumstances beyond our control
• Shall not be held liable and roofs are not covered under the workmanship warranty,
for pre-existing conditions including but not limited to:
o Mold and or wood rot
o Defective,faulty,rotted or worn building counterparts such as,but not limited to:
siding,gutters,masonry,plumbing and windows,all of which may jeopardize the
watertight integrity of the structure if not in sound condition
• Unless otherwise noted within this document,the contract shall not imply that any
lien or other security interest has been placed on the residence
Required Permits
A building and dumpster permit may be required to remove and replace your roof. It is
our obligation to secure these-permits if required as the homeowner's agent: - - -- - - --
Note:Homeowners who secure their own permits or deal with unregistered contractors are excluded
from the Guaranty Fund provisions of MGL c.142A
Paget P
t = zAdditional-Attached Documents,Agreements or Provisions
• Insurance Documentation if not already provided
• Arbitration Agreement - - -
• Contractor Registration Information
• Notice of Cancellation Form
This contract is the complete contract unless a signed Change Order has been executed between
TGLRC Inc.dba Lambert Roofing Company and the Homeowner -
Twelve Thousand Nine Hundred Fifty Cost of roof replacement: $12,950.00
Very Truly Yours, -
Rich ert
Rich rt ,...
F} pre , of
ert
In E Pproval igna d",Y/ 13
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'CFR�ATE il(>L b�R
e.
- SHOU1:0 ANY OF 7HE RBOYE t)E8CR1$ED$POUMS BE.CANt:ELLEt}BEFORE...: -
THE EXPIRATION DATE .T�w;
M ,kNLI $E�DEtPl�iED_IN._
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Nsoa5lzo,a�tm - ®1988=ZpiDAPM fit !; AN rrghta reseived
m.� _ 1'ie AC�Rp narAe`and logo are red Marft of ACMD - -
Do Commonwealth oflblasssachusetts
DepaY�rnen�of��ac��s�rc�lAcc�r�e���
Of,lice o,flnvestigations
600 Washington Nfteet
Boston,.A 02111
U1 www mass gov/ciia
wor�kexs,Compensation imurance.Aff�idarit:Builders/Cont°ac orc l icc xiczansl'Iiu�tbex
A,pp�(eant 7nfornz�tzon PXease,Print Le it' X
Name(8nsiness(Organizat!Duftndxvidaal):
Aftegs:_ C9
Ci.1:y/State/Z.P_
,Axe yotx an eraployer?Check the appropriate box: Type of project(required):
4. Z am a general contractor and I `
1.0l am a employer with�_ g S. []Now cbnstr+zO'don
employees(5211and/orpaxttime)* have likedthesu�b-contractors
2. 1 lama sole proprietor ox pattner
listed on.the attached sheet, 7. El Remodeling
ship and'haveno.eznployees 'hese sub-contractorshcve S. [[Demolition.
aci workers'comp.insurance, g, Building addition
woxlfing forme in.any cap ty.
pTo workers'comp.,insurance S. 0 We axe a corporatioa and its 10.0 Electricalrepairs or additions
required.] officers have exexcis4their
light of exemption or MOL 1Q]Plumbingxeparrs or additions
3.[.J X am a homeov�nex doing au work c 152 14 and myself:[No workers comp. a§ ()� 12.❑Roofxepairs
ixtsuraucerecluired]i employees.[No Workers' 13.0 Other
comp.insurance required.]
Auyapplicantthatchecksbox#xmusEalsoftllouEthesecd belowshowingtheirvlorkers'compensationpolicyinformation.
Homeowners who submitthis affidavitindicating ey ale dying dworlcand then hire outside contractors mustmbmit a neat affidavit indica ffig such.
ation.
�contraetcrs that checkthis bob zanstatfached M adcT�fional shoot showingthe name ofthe suh conisaetors andtheuworkers'comp.policyinfomi
XazclryemproysNtriatzsptovicXingworkers,coinpeitsationinsuraneefot't.�ye�rpl'oyees i3eloH�istheolicyanrijabsite
infarmation.
Insurance CompanyName;. 0, leaw .
a 2F
irationDate� ����1
Policy#or S eZz ins.7 LIG.#; ' A.
rob Site.A.ddress,' -1 �6 l'/ 6"77—ujl�j
Attach.a copy (showing•the policy number and expirations date).
Failure to secure coverage as xequixed.under Section 23A.ofM(31,o.152 can lead to the imposition.of exhilaA Penalties of a
fine up to$1,50 0.00 andlor one-year imprisonment,as well as oivil.penalties in the form ata STOP-WORK OR172 atxd a fin e
ofup to$25o.c o a day against the violator. Be advised that a copy of this statem out m.ay be,fox waxded to the Ofi7ce of
Investigations of:the DTA for insurance coverage verification.
ado Hereby eeit�wjdert7iepains andyena1ae.s of perjury t�iattrte ir2forntationprovidecZabove is flue and eorteet,
Srgynature �I
Date:
Plsone#:
Oficial ase aidy, Do not faille in this afea,to be comyleted by city or toren 0 rel 1.
I
City or Town: Perm1Mfcense#
Issuing Authority(circle ORP):
1.Board ofHealth?.BuildingDDepaxtment 3.Citylxown Clerk 4.Electrical Inspector 5.PlambingIuspector
f.Other - - -
NORTH
Town of4ndover
O -
No. �
ADO--- 105
�` i " ver, Mass S- III
o
1p S R{'rep
U BOARD OF HEALTH
Food/Kitchen
PERMIT D I�. Septic System
Ale.6 R o� BUILDING INSPECTOR
THISCERTIFIES THAT . ............................................ .......................... ................... .....................
has permission to erect buildings on ...... .... ' d Foundation
Rough
wN �/��I
to be occupied as . Q ok..rU ...4416fof , ... ...... �0��: .111 Ch mney
provided that the person accepting this permit shall in every rct conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
r. PERMIT EXPIRES IN6 NTHS ELECTRICAL INSPECTOR
o • UNLESS CONSTRUCT T S Rough
Service
................ :. ..................................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
Information and Instructions
Massachusetts General Laws chapter 152 xequires all employers toprovideworkers'compensation.fox-ffieir employees,
Pursuant to this staiaxfe,an employee is dei7ued as"...every person iri the service of another under any confract ogre,•
' egpxess ozimplzed,Dial ox'wrsfEen:' I
An.emplayWls defined as"an iadividual,partnership,association,corporation o4 otherlegal entity,ox anytwo oxxnoxe.
Oftlteiora' g engaged g g p
g q gaged in a joint enterprise,and includin thele al re xesentatives of a deceased employer,.or the
receiver ox tnistee of an individual,partnership,association or oter legal enfity,employing employees. S`owevex tna
owner o:a dwelling houseliavingxtotmore than three apartments andwho resides therein,oxthe occupant ofthe
dweltinghouse of another who employs persons to do maintenance,construction orxepair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such,employm.out be deemed to be an employes."
MGL chapter 152,§25C(6)also states that"every state or loyal lic-eusing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth-fon'any
applicant mho has not pro duced.acceptable evidence of compliance with the insurance coverage requi
w 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,thetill
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-ofWires abandoned_and_invalid if he, _
or she has determined that the aufhorized 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: A/ Note:Reapply for new permit M�-
❑Permit Extension Act—Permit/Date Closed: ��
4
Date..l/
�.
O�NORTH��O
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
,sSACMUS�
This certifies that ..........., .................................
' 441.-6,17.-.. Sar/5
has permission to perform ............... , ................... .. .................
wrong in the building ...... .....:........
at., �..<.aIF.114.,—? ........4..............................North Andover,Mass.
k —mo
Fee..,?..... "... Lic.No.q,.55*24f .................. �.�..
ELECTR�CAI INSPECTOR
Check #
8417
Commonwealth of Massachusetts official Use Only
��/
Department of Fire Services Permit No, 7
BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07] (leave blank
I
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 W INK OR TYPE ALL INFORMATION) Date:
City or Town of: NORTH ANDOVER To the Inspector of Wires.•'`
By this application the undersigned gives notice of his or her intention to perform.the electrical work described below.
Location(Street&Number) Z a a 7-7-
Owner
TOwner or Tenant C • °j- .�,L � se/Telephone No.
Owner's Address yyf
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Boz)
Purpose of Building 1 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 i
± Location and Nature of Proposed Electrical Work:
Completion of the followin table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp. (Paddle)Fans o•of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- E] o.o Emergency tg g
rnd• d. t Battery Units
No.of Receptacle Outlets No.of Oil Burners '
FIRE ALARMS No.of sones
No.of SwitchesNo.of.Gas Burners No.of Detection and
Initiating Devices
No.of RangesTotal
No.of Air Cond. Tons No.of Alerting Devices
No.of Waste Disposers eat Pump Number Tons KW _ No.of Self-Contained
Totals: Detecfion/Alerting Devices
No.of Dishwashers Heating S ace/Area ncial
{ p ' KW II'O�❑ uConnection ❑ Other
0 No.of Dryers Heating Appliances , Security Systems:*
No.of Water No.of Devices or Equivalent
KW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total gp Telecommunications Wiring:
OTHER: No.of Devices or Equivalent
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical'Work: (When required by municipal policy.) j
Work to Start: /G- , Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE OVERAGE: 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 ce?Wfy, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: LIC.NO.:
Licensee: � j�i4j� B eRu ge, Signature LIC.NO.: Y'��7 F
(If applicable,enter"ex mpt I in the icense number line-) Bus.Tel.No.:
Address: ®,�iQfC e e R, S/yVC�JJ AX/I. o3a 7 Alt.Tel.No. .y sg a 11A6
*Per M.G.L c. 147,s. 57-61,security work requires Department 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
Signature Telephone No. PERMIT FEE:S
j The Commonwealth of Massachusetts
l Department of Industrial Accidents
`', ► . Office of Investigations
"` t' 600 Washington Street
Boston
, MA 02111
www_nzass.gov/dia
Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leoibly
Name(Business/Organizabon/lndividual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box:
1.❑ employer with 4. Type of project(required):
I am a em
p y ❑ 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.x 2• ❑ 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. ❑ We are a corporation and its 9• ❑ Building addition
required.] officers have exercised-their 10:❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself.[No workers'comp. C. 1.52, §IM,and we have no
insurance required.) i employees. [No workers' 12.0Roof repairs
comp. insurance required.] 1.3.[] Other
*Any applicant that checks box#t must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit:dhis affidavit indicating Uiey ate doi:ic ail Kori-st�cf ihen hire onside ccn ra furs nfust submit a new arndavir 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.
V I am ann emplover that is providing workers'compensation insurance for np employees. Below is the policy and job site
information.
Insurance Company Name:
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 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 I'
Sio-nature:
Date:
Phone#:
Official use only_ Do not write in this area,to be completed by cite or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Gerk 4. Electrical Inspector S. Plumbing Inspector 4
6.Other
Contact Person: Phone#
I
I
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 inciudiing 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
1.
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 afficlavit 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*stions reg
ardin_the law or if you are rA.quired to obtain a worker '
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 pertnitliieense 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 w
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 burrs 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