HomeMy WebLinkAboutBuilding Permit # 8/16/2016 - NORT}{
BUILDING PERMIT o�A,
TOWNOF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Permit No#. �SSaCwus���5
Date Issued:
Y ORTANT: Applicant must complete all items on this page
LOCATION ;
Print
PROPERTY OWNER _ �_A If Dkv.
— -� Pr€ t 100 Year Structure yes
MAP L_PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
__Re_
esidential Non- Residential
❑ New Building One family
❑ Addition ❑Two or more family ❑ Industrial
❑ Alteration No. of units: ❑ Commercial
Repair, replacement - ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
aWatei�sahed`astr�ct
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DESC IPTION OF WORK T B PERFORMED:
dentification- Please Type or Print Clearly
OWNER: Name: 04 v f ip Phone:
Address:
Contractor Name: � 1� - - Phone: _ b� r
Email: A-4 C.
Address:
Supervisor's Construction License: C) Exp. Date: '
Home Improvement License: 3 Exp. Date- �' x
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL.ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $ �°� ____ _---
Check No.: � Receipt No.:
NOTE: Peraus contracting with unregistered contractors do not have ac el to the ual fund
ttORTH q
s
Town of �� 6Andover
O M
No.
� h ver, Mass
LAKSC OANu#_ks+ 1� a
CNICHEWIC II Y
CRATED
is U
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
k9A.7... .. ...THIS CERTIFIES THAT ........................: .,,,,,. BUILDING INSPECTOR
has permission to erect .......................... buildings on ... 3 ! � Li �e- Foundation
... ..fte .....................
:qke .....,.^�++.i ., Rough
to be occupied as .... .�. .......... ..... Chimney
provided that the person accepting this permit shall in every respect 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
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS C® S TI® Rough
Service
L=
a.... ...... Final
BUILDING IN ECTO
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildin 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.
AGREEMENT FOR SERVICES
This CONTRACT satisfies all basic requirements of the State's Home Improvement Contractor
Law(M.G.L.c. 142A), but does not preclude parties from adding language to protect their specific interests.
Seek legal advice if necessary. Before agreeing to any home improvement work on your residence you
should obtain a free copy of"Consumer Guide to Home Improvement Contractor Law"by tailing the
Office of Consumer Affairs and Business Regulation's Information Hotline at 617-973-8787.
You may cancel this Agreement if is has been signed by a party thereto at a place other than an
address of K&R Contractors, Inc.,which may be its main office or branch thereof,provided you notify K
&R Contractors,Inc., in writing at its main office or branch by ordinary mail posted,by Telegram sent or
by delivery,not later than midnight of the third business day following the signing of the Agreement.
See Attached Notice Of Cancellation For An Explanation Of This Right.
Homeowner Information Contractor/Owner Name:
Kathy Murphy Kenneth Roy, President
33 Wentworth Ave Business Street Address
North Andover, MA K&R Contractors, Inc.
I Campbell Road
North Andover, MA 01845
Business Phone: 978.726.5062
Federal Employer ID:000961723
a Salesperson(s): Kenneth Roy, President
Contractor Registration: 80721 Exp.Date:4129117
MA Sup. License: 137557
WORK TO BE PERFORMED AND MATERIALS TO BE USED
I
i.
Contractor Agrees To Do The Following Work For Homeowner: Replace rear deck with same size one
is
Remove front deck and replace with similar size one with Island Oak grey decking,white pvc trim around
frame, white vinyl lattice around base,Railings will be white Timber Tech Radiance Rail.New stairs will
face pool
The following schedule will be adhered to unless circumstances beyond the contractor's control arise*
Work Scheduled To Begin: 8116116
Expected Date Of Completion : 8131/16
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
The Contractor agrees to perform the work,furnish the material and labor specified above for the
SUM OF$10500
Payments will be made to the following SCHEDULE:
$3000 upon signing of this contract
$4500 due upon completion of frame
$3000 due upon completion of project
Law requires that any deposit or down payment required by the contractor before work begins may not
exceed the greater of:
(a)one-third of the total contract price or
(b.)the actual cost of any special equipment or custom made material which must be special ordered in
advance to meet the completion schedule*)No final payment shall be demanded until the contract is
completed to the satisfaction of the parties thereto.
OTHER IMPORTANT PROVISIONS
You are dealing with a Registered Home Improvement Contractor and are entitled to certain rights under
the provisions of 780 CMR R6 and M.G.L.c.
142A.
Payments: If payment is not received as per the Contract,then the Owner shall be responsible for all
attorneys' fees,court costs, and other costs incurred by the Contractor and enforcing Contractor's rights
hereunder.
Pets: Homeowner agrees to keep all pets out of the work area and take whatever steps are necessary to
safeguard them from any harm that may come to them as a result of the work being performed under this
Contract, including but not limited to injury on or outside the Premises or ingestion or inhalation of,or
contact with,hazardous substances. Company assumes no responsibility for any harm to the pets as a result
of the work performed under this Contract. Further,Homeowner shall take all steps necessary to protect
Contractor, its agents, servants,contractors and employees, from any harm as a result of contact with said
pets.
Characteristics of wood: Wood is a hygroscopic material. Wood swells and/or shrinks in relation to the
humidity, temperature and environmental conditions of its surrounding. Generally,wood flooring is
expected to shrink in any conditions and expand when exposed to moist conditions.
Natural wood also contains variations of graining,texture,hardness and/or knots,depending on the wood
chosen. Contractor cannot be responsible for the natural features of the wood chosen. Contractor is not
responsible for shrinkage,checking,swelling, or other conditions which are the normal condition of wood
or the result of household or environmental humidity,heat,cold,or other conditions,
Colors: You may choose colors and finishes for the parts being used in
your remodeling project. It is important to remember that a color or finish you see at the store or in a
showroom may not look the same in your home,especially after all of the different colors and finishes are
brought together upon the completion of a project. In addition, one manufacturer's named color is not the
same as another manufacturer's named color. The Contractor cannot be responsible for the appearance or
lack of coverage from Homeowner/chosen paints and/or stains and finishes.
Building Officials: Any additional costs incurred by Contractor as a result of decisions made by Building
Officials will be the responsibility of the Homeowner. The costs of additional work will be calculated as
follows: cost of materials plus an hourly rate of$45 per man hour.
Liens: In the event of non justifiable non-payment, Homeowner's residence or property may be subject to
a Mechanic's Lien as a consequence of signing this Contract.
Utilities: The Contractor will use reasonable efforts to notify the Homeowner in advance of any
interruption of utility services. However,there may be instances where the Contractor must shut down
these services without advanced notice. Homeowner must arrange for emergency backup service for any
utility critical equipment such as medical devices and computers. The Homeowner must also notify the
Contractor at the start of the work day if you will be engaged in any utility critical activities in that the
Contractor makes a notification in writing in the daily log book or otherwise.
Additional work: Any additional work requested by the Homeowner which is beyond the scope of the
work to be performed as set forth in this Agreement,shall be the subject of a separate agreement, and/or if
not,subject to the same terms and conditions as set forth in this Agreement and billed oil a time plus cost of
materials basis at Contractor's normal hourly rate.
Contractor's normal hourly rate per man hour is$45.
In the event that additional work is to be performed on an hourly Plus cost of materials basis,the
Homeowner shall be required to execute a Change Order which shall include Contractor's best estimate as
to the time required,together with the cost of labor as well as the type and cost of materials necessary.
Delays: Contractor is not responsible for delays attributable to
Homeowner initiated modifications or additions,or for delays incurred due to the actions or inactions of
city/town officials,strikes,acts of God,unfulfilled customer obligations, vendor delays, interference by
other tradespersons, customer supplied items or other delays beyond Contractor's reasonable control.
Contractor will use reasonable efforts to stay on each job until substantial completion by allotting specific
time periods to each Homeowner to complete each job in as timely a manner as possible. In the event that
Homeowner does not allow Contractor and/or his employees or sub-contractors access to the residence or
property so as to allow Conti-actor to perform his obligations and/or to complete the scope of work in as
timely a manner as possible,other than for reasons of safety or other reasons mutually agreed to between
Homeowner and Contractor,then the Homeowner shall be responsible to pay Contractor the sum of
$500.00 per day,on a pro rata basis,to covet,the costs of delay. Contractor reserves the right to suspend
work and/or delivery of materials in the event of unjustified non-payment. In such event,the Contractor
shall have no liability to the Homeowner for alleged delays or damages due to said suspension,
Punch-list Items: The Homeowner agrees that routine"punch-list"or repair items after substantial
completion are Outside the agreed scope of services, and covered by Conti-actor's warranty obligation and
will be completed as soon as practicable and according to Contractor's and Homeowner's mutual
availability. Homeowner agrees that it shall use his/her best efforts to make hiniself/herself available to
observe and/or sign off on the completion of any such punch-list Items,and that the approval of one
Homeowner regarding the completion of any such punch-list items,as well as change orders shall be
binding upon all Homeowners.
Unforeseen Condition s/Circumstances: Contractor shall not be responsible for any changes at the request
of the Building Inspector. Contractor shall also not be responsible for any unforeseen bedrock/ledge or
latent defects such as structural and/or dry rot or insect damage to the existing structure, or for preexisting
faulty or inadequate wiring or plumbing.
Contractor shall also not be responsible for any pre-existing code violations or responsible for correcting
contiguous work completed by others not under the Contractor's authority.
Insurance: Homeowner agrees to carry fire, theft,vandalism, liability and all other necessary insurances to
protect their personal property while construction is in progress. Contractor will carry all required and
necessary insurances including worker's compensation insurance. Contractor will ensure that all personnel
including sub-contractors will be covered by all required and necessary insurance including worker's
compensation insurance.
Homeowner's Cancellation Rights: In addition to the rights the Homeowner has,as set forth in the
attached Notice of Cancellation,the Homeowner may have rights under other Massachusetts Statutes,
including M.G.L. c. 93 §48,M.G.L. c. 140D, § 10 and M.G.L. c.255D § 14.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Identical copies of the
contract should go to the homeowner and the contractor.
Homeowner's Signature: k "e e"
--- -----
Date:
4' --
Contractor' Signature K&R Contractors, Inc.:
Date: "
By: K nneth Roy
Its; President
You may cancel.this agreement if it has been signed by a party thereto at a place other than an address of
the seller, which may be his main office or branch thereof,provided you notify the seller in writing at his
main office or branch by ordinary mail posted,by telegram sent or by delivery,not later than midnight of
the third business day following the signing of the agreement.
See attached notice of cancellation for an explanation of this right.
NO WORK WILL BEGIN UNTIL BOTH PARTIES SIGN THE CONTRACT AND THE OWNER
RECEIVES A COPY
REQUIRED PERMITS
The following building permits are required. It is the obligation of the contractor to secure such as the
homeowners agent:
Electrical rough and finish
Plumbing rough and finish
Insulation
Framing insp.
Finish and occupancy
NOTE: Owners who secure their own permits or deal with unregistered contractors are excluded from the
Guaranty Fund provisions of MGL c. 142A.
EXPRESS WARRANTY
All workmanship and materials to be free of material defect for a period of one(1)year. During the
Warranty period,the Company may,at its option,either repair or replace products or workmanship which
prove to be defective. This Warranty shall not apply to defects or damage arising from improper or
inadequate maintenance by the customer,customer's applied products,unauthorized modification or
misuse,damage incurred as a result of acts of God or civil strife,or normal characteristics of the materials
such as wood shrinking, expanding and otherwise reacting to moisture or environmental conditions. The
Company's liability is limited to the repair or replacement,at its option, set forth herein and Company shall
not be liable for any consequential, sequential, incidental or other damages not set forth herein. The
Warranty set forth herein is exclusive,and no other Warranty,whether written or oral, is expressed or
implied. Company specifically disclaims the implied Warranties of Merchantability and Fitness for a
Particular Purpose.
NOTE: All home improvement contractors and subcontractors shall be registered and any inquires about a
contractor subcontractor relating to a registration should he directed to:
Director,Home Improvement Contractor Registration One Ashburton Place,Room 1301 Boston,MA
02108
617-727-8598
Unless otherwise noted within this document,the contract shall not imply that any lien or other security
interest has been placed on the residence,
ARBITRATION
The contractor and the homeowner hereby mutually agree in advance that in the even the contractor has a
dispute concerning this contract,the contractor may submit such dispute to a private arbitration service
which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business
Regulations and the consumer shall he required to submit to such arbitration as provided in M,G,L.c.142A.
Contractor: Date:—... A
... 611 D
Homeowner:
L; ate:
NOTICE: THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF
THE PARTIES TO ALTERNATIVE DISPUTE SETFLEMENTINITIATED BY THE CONTRACTOR.
THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS
SECTION IS NoTSEPARATELY SIGNED BY THE PARTIES.
ACCELERATION OF PAYMENT
Homeowner's Financial Insecurity-A Contractor may not demand payments in advance of the dates
specified on the payment schedule in cases where the homeowner deems hint/herself to be financially
insecure.
Contractor's Financial Insecurity-In instances where a contractor deems himself/herself to be financially
insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work. Withdrawal from said account would require
the signatures of both parties,
Homeowner agrees to allow reasonable access to allow Contractor to reasonably attempt to rernedy any
outstanding uncompleted,disputed or non-satisfactory item.
If you have general questions or need additional information about The Home Improvement Contractor
Law,contact:
Consumer Information Hotline
Commonwealth of Massachusetts
Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170 Boston, MA 02116
617-973-8787
If you have questions about Contractor Registration, contact:
Director of Home Improvement Contractor Registration Board of Building Regulations and Standards One
Ashburton Place,Room 1301 Boston,MA 02108 617-727-3700,x25205
NOTICE OF CANCELLATION
YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR OBLIGATION,WITHIN
THREE
(3) BUSINESS DAYS FROM THE ABOVE DATE.
IF YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENT'S MADE BY YOU UNDER THE
CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE
RETURNED WITHIN TEN(10)BUSINESS DAYS FOLLOWING RECEIPT BY THE CONTRACTOR
OF YOUR CANCELLATION NOTICE, AND ANY SECURITY INTEREST ARISING OUT OF THE
TRANSACTION WILL BE CANCELLED.
IF YOU CANCEL,YOU MUST MAKE AVAILABLE TO THE CONTRACTOR AT YOUR
RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED,ANY GOODS
DELIVERED TO YOU UNDER THIS CONTRACT;OR YOU MAY, IF YOU WISH,COMPLY WITH
THE INSTRUCTIONS OF THE CONTRACTOR REGARDING THE RETURN SHIPMENT OF THE
GOODS AT THE SELLER'S EXPENSE AND RISK.
IF YOU DO MAKE THE GOODS AVAILABLE TO THE CONTRACTOR AND THE CONTRACTOR
DOES NOT PICK THEM UP WITHIN TWENTY(20)DAYS OF THE DATE OF CANCELLATION,
YOU MAY RETAIN OR DISPOSE OF THE GOODS WITHOUT"ANY FURTHER OBLIGATION. IF
YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER,OR IF YOU AGREE TO
RETURN THE GOODS TO THE CONTRACTOR AND FAIL TO DO SO,THEN YOU REMAIN
LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT.
TO CANCEL .THIS TRANSACTION,MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS
CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO
K& R Contractors, Inc.
1 Campbell Road,North Andover, MA 01845
NOT LATER THAN MIDNIGHT OF TBD.
I HEREBY CANCEL THIS TRANSACTION,
Date:
Buyer's Signature:
Received:
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PLAN OF PROPOSED PAUL LOCATION
ON
PROPERTY LOCATED AT
33 WE'NTWORTH AVENUE
NORTH ANDOVER,MA
Prepared for James and Judy Murphy
Y t
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Proposed
16 x 32 Pool
Week, _79 ,
Existing
fl0 181/2 Story Wood Garage
4
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WENTWORTH AVENUE
Date: August 3, 2006 19 �
Scale: 1"=20'
Engineers: Henry R. Himber &WOLOME0
Dante Bartolomeo NO.153OG
Ref- N.E.R.D.--Deed Book 6056 Page 122 & Plan#0358 Las
4cjEjtWXFX3Mli ]FL.,QT IPX d A W
.00roperty Located At
33 Wentworth Avenue,North Andover,MA 01845-
Prepared For James&Judy Murphy .
Bate; October 22,2003 Scale-111=401
H&B Survey Service
219 Salem Street
Andover,MA 01810
978-475-8232
lC'•.
sro y il'.W f E>I�]i Jhl QD
A
Wi'N-rWORT" H .. AVE.
j y T hereby c that the struCtam shown on this
plan are located as shown and that they conformed
g o� DAME G,,, to the Zoning By-Laws of the town of North Andover
when co11StTl3C
8ARYEOMEO
�ECISTE4�Ca
Ref: N.•B.R.U.—Aeed Book 6056 page 122 &Plan#0358
North Andover MIMAP August 16, 2016
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L7 MVPC Bo Zoning Overlay Zoning
[j Municipal Boundary Adult Entertainment Dlstric Busing.s 3 District
[)Machine Shop Village Ove .0 Busine.s 2 District Horizontal Datum:MA Sialoplane Coordinate System,Datum NAD83,
Rail Line AL3 Watershed Protection Dist D 8usine.s 3 Ddstrirct Maters Data Sources:The data for rias map was produced by Merrimack
Inlers,atos El Historic Mill Area R Busing s 4 Dfalydct taORTN Valley Planning Com mission(MVPC)using data provided by the Town of
I R;`]Medical Marijuana R Garver Business District Of tt�au rb q�O North Andover.Additional data provided by the Execulive Office of
.,._S,, Downtown Overlay District Rtl Planno Commercial Dev �, t b O Enviranmo'ntal AffairslMassGIS.The information depicted on this map Is
Historic District Conido Development Dist ,} '� (, for planning purposes only.It may not be adequate for legal boundary
Roads Osgood Smart GrwAh(44 Corrido Devalopment Dist O -. "" M definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER
p"r Easements klydrographlc Features NIl Cord Development Dist f" MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
Industri 17 District i THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
❑Parcels Streams Industn 12 District rw i ^ * OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
Wetlands Industn 13 District sr, oa4 s�* ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
III fndustn I S District THIS INFORMATION
Exempt Lands Reside ce 1 District 'lI p4+AYrd��aa4•ly
Reside co2District 1TpAGmus
Reside ce 3 District
de ce 4 Dist ct
1"=41 f# da se 5 Diatde't
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Interstates Horizontal Datum:MA Slateplane Coordinate System,Datum NAD83,
Meters Data Sources:The data for this map was produced by Merrimack
SR F1.b RTH Valley Planning Commission(MVPC)using data provided by Ilia Town of
Roads Ot "Ito 'qa North Andover.Additional data provided by the Executive Office of
+i ry Y O Environmental Affairs/MassGIS.The information depicted an(his map is
q.. Easements +t p4 A Q
Parcels ,+ (, for planning purposes only.It may not be adequate for legal boundary
�4 •-• definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER
MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
{I * THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
�F 0a ' w... ��* ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
po�Ar�v r.Yp�`n;Yi THIS INFORMATION
SAC HUS��
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XThe Commonwealth of.lV asggehasetts
z. z Depaptment ofindustrialAceidents
F I Congress Street, Suite 100
.Seaton,M4 02114-2017 ,
www.mass.golvfdia
. 141
Woxltexs'CompelasationIsuranceAffidavit:Euildexs/Cout�ractOrs/Eiectrxc�iansl�.'trmbexs.
TO BE MFD ggTfC THG PERiVFI:TMVG AUTHORITY.
Ap icautwormation 1 1 1Pl�asel'xJnt Le 'bl
Name (Business/Orgamzatioz�)h&vidual): `'
Address:
City/state/zip: / 1 A Phone#: � A 7 z ��O Z
Areyon err employer? CIA Ck&'B app'zopriaie box: Tne of project(Tecl't red):
i. I am a employer Witla employees(full and/or part time}. 7-1Q Now ca struotion
2, I am'a sole proprietor or partnership and Dave no employees working for ane in 8. Remo deag
any capacity.tNo workers'comp.insurance required.] . M Demolition
3 Q S am a hameewnex doirrgall warkmysel£1No workers'comp..iusurame required.I t 10 ❑Buil(y g addition
4.F1 jam a homeowner and will he hiring contractors to conduct alt work on my property. Twill
ensure that all contractors either have workers'compensation insurance,orate sole 11.[ Eleotrical repairs or.additions
proprietors with no employees. 12:0 Plumbing repairs or additions
5.❑I am a general contractor and I h&ybhiredthe sub-contractors listed on the attached sheet. 13_ Ro0'frap airs
These sub-contractorsiiave Binployees and haveworkcrs'comp.insluance� 14.El Offer
6.E]We are a coxporation and its of�Crcers have exercised#heir right of exemption per MGI,c, n
andvzehavenq,einployees,j,Noworkers'comp.insuranceregairedJ
Any applicautthat ohwkks hr xWl must also til out the saetionbelowshowing theirworkers'compensation policy information
i Ilaaneownars 4vho stirliiif;tvs af6 davit indicating they are doing all work and tlaera hire outside contractors mast sizbmit a next aftidavrl indicating such
TContractars that check this box must'attachod an additional sheet showing the name of the sub-contractors and state whether orllot those entities have
employees. If Etre sub cnntrarozs have empIoyeas,�Iieymust provide tbeiz workers'comp.policy number.
.pain an employer tlzatispToUIdir�gworkers'compensation insuranceforrny ernpl6yees.'.Below is tliepalicy andjob site
inf'arrnation.
fusuxanco Company Naim:
Policy#or Self-ins.1i G.#: ++ E�rirationDate: ,--
�y„i City/State/Zip: !1-��+C3 �
Sob Site Addross-�_ ..-- .
Attach a copy offfiewVkers' catupe:Ma-'onPolicy declaration page(showing thepoReYaumberand expzxat!01Ldaie)-
Failure to secure coverage as required imder MGL c. 152, §25A is a cximival ylolation pvnishabla by a fme up to$1.,500.00
and/or one-year impriso-Ument,as well as civil penalties in the forms of a STOP WORK ORDER.and a fine of up to$250.00 a
day against the-violator.A,copy of this statement may be forwarded to tla.e Office of Investigations of too DSA for insaranoe
co'verago verifloadon.
S do hereby certify, u er Aie pains d ties ofpe1jary that the informationprovid'ed above is true and correct.
,Si aturo- Date: '
Phone#_ 7�s sU Z-
Officialrase only. Do riot write in this area,to lie completed by city or town official.
City or Town:
Issuing Authority(circle one): i
1.Board of llealtya 2.Buiidiug Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing fuspector
6.Other
Contact Person,: Phone#:
Information and Instructions
Massachusetts General Laws chapter 1.52 requires aj employers to provide workers'compensation fortbek employees.
Pursuant to this statute,an employee is defined as"...every person in the service of aaother under any contract 6-9re,
expxess or implied, oral or written."
An employer is defied as"an incllvidual,partucrshrp,association,corporation or otb.er legal entity,of 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 otan individual,partnership,association or other legal entity,employing ewV16yces. However tbo
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 sack 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 consft uct buildings in the common7olth,for any
applicant who Lias riot produced acceptable evidence of compliance with the insurance coverage required.'.'
Additionally,MGL chapter 152,§25C(7)states`Neither the commoawealth nor any of its political subdivisions shall_
enter into any contract tar 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 fih'out•the workers' compensation affidavit completely,by checking�fie boxes that apply to your situation and,if
necessary,supply sub=contractor(s)name(s),address(es)audThone numbers)along with their certii'cate(s)of
ansmance. Limited Liability Companies(11C)or Limited Liability Partnerships(LLP)with no ernployeos'othorthan the,
members or p artaers,are not required to oany 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 Depatt ent of•lndustrxal
Accidents fol-ow)fwration ofinsurance covurago. Also be sure to sign and date the aidavit. The affidavit should
be return-ed to the city or town,that the application,for the permit or license is being requested,not the Department of
lndustrial Accidents. Should you have any questions regarding the law or ifyou'are rega'ixed to obtain a workers'
compensatioA policy,please call the.Department at the number listed below. Self in'suxe_d companies shoukrenter their
self✓insurarico license number on the appropriate line.
City or Town.Officials
Please be sure that the afdavitis complete and printed legibly. The Deparfm ent has,provided a space at the bottom
of the affidavit for you to fill out in the event the Office of luvestigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as areference number. l€r addition,an applicant
that must subruit multiple perraitClicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"fob Site Address"the applicant should write"all locafions in (city or
town)_"A copy ofthe affidavit that has been.off Gially stamped or marked by the city or towamay be provided to the
applicant as proof that a valid affidavit is on file for f€rture perurits or licenses. A new affidavit must be filled out each
year.Where a home omnor or citizen is obtaining a license or permit not related to any business or corn moreial venture
(i.o.a dog license or permit to bum leaves etc.)said person,is NOT requixed to complete this affidavit.
The Department's address,telephone and fax number-
The Commonwealth of Massachusetts
Department of lmd-astrlal Accidents
1 Congress Stteet, Suite 100
Boston,MA 02114-2017
TeX. # 617-727-4900 ext.7406 or 1877•-MASSAFE
Fax# 617-727•-7749
Revised 02-23-1.5 www.mass.gov/dia
✓dam,:,"'/wem
-�L\ Office of Consumer Affairs&B siness Regulation License or registration valid for individuI use only
W HOME # before the expiration date. if found return to:
t4I1PROV1 MENT CONTRACTOR
- ] Registration: �62�23 Type: Office of Consumer Affairs and Business Regulation
�= Expiration: 1/2012017 Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
K& CONTRACTORS lNC
KENNETH ROY
1 CAMPBELL RD �
N.ANDOVER, MA 01845 Undersecretary Not valid, ithout signature
41
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Super-sloi
License: CS-080721
I
KENNETH R ROS`
1 CAWBELL
North Andover WX 0
r
Expiration
04/2912017
a Commissioner
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