HomeMy WebLinkAboutBuilding Permit # 9/12/2016 'sb BUILDING PERMIT 3r g°',` .•.'',°G TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN-EXAMINATAPN I; . ; e Permit NO: Date Received Ll Ii I:' Date Issued ' 1 s SsZ.ffcaus� I h4iPOI2TA�Tc�piicant must eom�lete ali items on tluspa+te ii �1 RSL � C}13N II RIS F[ittri Ltistl yesift helPte tp tfilta ..'Id' ; ``'' TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential New Building One family A,-'Addition Two or more fa m(y Industrial 3 Alteration 1 No.of units: - 'te Commercial Repair,replacement Assessory Bldg Others: 7 Demolition Other I '0 ( Identification Please Type or Print Clearly) OWNER: Name: , t Fc i c/r _= C I s s Phone: –` F a Address: C f r ARCH ITECTtENGINEER Phone: Address: Reg.No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost:$ 2 f t , 10 >_ FEE:$ Check No.:— Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the uara tv fun, ' � icgr#atisre of Agentt w er igna una of contractor ` Town of 2 k "°RT" 6 Andover No. ver,Mass, BOARD OF HEALTH Food/Kitchen PER IT T ILD Septic System V* THIS CERTIFIES THAT...................j BUILDING INSPECTOR Foundation has permission to erect..........................buildings on 9... . .. .. ............ Rough to be occupied as Oft.FPAWAP.:J..� ...... Chimney provided that the person accepting this permit shall in every respect conform to e 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 MONT S ELECTRICAL INSPECTOR UNLESS CONS ION Rough Service .. ....... ....... Final BUILDING INS CTO GAS INSPECTOR Occul!ajicy Perittit Required to Occupv Buildhig 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. Plans Submitted❑ Plans Waived Cl Certified Plot Plan ❑ Stamped Plans ❑ Iny OF SMWERr1GE DISP O I Public Sewer Tanningimassage/P,odyArt ❑ S�� .g Pools F]Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. [j Permanent Dmnpster oa Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM /PLANNING&DEVELOPMENT Reviewed On COMMEN-TS --------------------- ®NSERVATION Reviewed an/C _rv,� b Snature ` COMMENTS V\-o HEALTH rr��Reviewed on Signature COMMENTS—___P'T rZ.n,ngBoard of Appeals:Variance Petition No: 00'; Zoning Decision/r ceipf submitted yes Planning Board Decision: _Comments Conservation Decision:_ ___,Comments Water&Sewer Connection/signature&,Date __._._.—.____ Driveway Permit DPW Town Engineer: Located 3&4 Osgood Street FIRE DCPART:,MEN� -.Temp Dumpster on site :yes no Located at 124 Main Street Y Fire Dpartrrient signature/date TOWN OF NORTH ZONING BOARD OF APPEALS NAME �l or1�< P comet=rep.j) A,4p &03EA.; A CL - � �� r ADDRESS OF APPEAL Q11 ca .43VVIcK s Ne, Art,)o-,1 ,V4A 0I6�f` Tam,CierkTimeslam :rPrOCi!aa,.lrW ,_// //rr an Application for a Special Permit Twelve(12)copies of the following information must be STEP 6:SCHED&.iUNG OF HEARING AND submitted thirty CLO)days prior to the first public hearing. PREPARATION OF LEGAL NOTICE: Failure to submit the required information within the The Office of the Zoning Board of Appeals schedules time periods prescribed may result in a dismissal by the the applicant for a hearing date and prepares the legal Zoning Board of an application as incomplete. notice for mailing to the parties in interest(abutters)and The information herein is an abstract of more specific for publication in the newspaper. The petitioner is requirements listed in the Zoning Board Rules and notified that the legal notice has been prepared and the Regulations and is not meant to supersede them.The cost of the Party in interest fee. patltioner will complete Items that are underlined STEP 7:DELIVERY OF LEGAL NODTiCE TO STEP 1:ADMINISTRATOR PERMIT DENIAL. NEWSPAPER The petitioner appiies for a Building Permit and The petitioner packs up the legal notice from the Office receivers a Zoning Bylaw Denial form completed by the of the Zoning Board of Appeals and delivers the legal Building Commissioner. notice to the local newspaper for publication. STEP 2: SPECAL,PERMIT APPLICATION FORiV6 STEP 8: PUBLIC HEARING BEFORE THE ZONING Petitioner completes an application fort to petition the BOARD OF APPEALS: Board of Appeals for a Special Permit. All information The petitioner should appear in his/her behalf,or be as required in tems 1 through and including 11 shalt be represented by an agent or attorney. In the absence of completed, any appearance without due cause on behalf of the petition,the Board shall decide on the matter by using STEP 3: Pi_AN PREPARATION- the information it has received to date. Petitioner submits all of the required plan information as cited in Section 10 page 4 of this form. STEP 9: DECISION: After the hearing,a copy of the Board's decision will be STEP 4: LIST OF PARTIES Ihi INTEREST• sent to all parties in interest. Any appeal of the Board's The petitioner requests the Assessors Office to compile decision may be made pursuant to Massachusetts a certified list of Parties in interest(abutters). General Law ch.40A sec.17,within twenty(20)days after the decision is filed with the Town Clerk. STEPS: SUBMIT APPLICATION: Petitioner submits one(1)original and 11 Xerox copies STEP 10: RECORDING THE DECISION AND PLANS. of all the required information to the Town Clerk's Office The petitioner is responsible for recording certification of to be certified by the Town Clerk with the time and date the decision,Mylar,and any accompanying plans at the of filing. The original v dH be left at the Town Clerk's Essex County forth Registry of Deeds,354 Merrimack Office,and the 11 Xerox copies will be lett with the St.,Lawrence NAA 01843,and shall complete the Zoning Board of Appeals secretary. Certification of Recording foam and forward it to the Zoning Board of Appeals and the Bustling Departmemi. P�7�rr/�/if'!U rfY"y Jll��r7�'/,;%�' .�r...,v/Hdd ✓1/' _!/ry vile%lf/ /I/"�",.". 7risr7�r / y .. 0 r 978-688-9533 Office of Community Dev.&Services Town Hall 1600 Osgood Street 120 Main Street Building 20,Suite 2035 /North Andover,Massachusetts 01845 978-688-9542 fax for Community Development offices 978-688-9501 Town Cleric's Office 978-688-9545 Building Department 978-688-9566 Assessor's Office 978.688-9541 Zoning Board of Appeals Office PAGE I of 4 PAGE 2 OF 4 Date&Time Stamp Application aSPECIAL PERMIT North ANDOVER ZONING BOARD OF APPEALS OEM 1.Petitioner: Name,address and telephone number. -jH0MAS F. CLIr'i--cKP, II CHAIWicK S"TKCf2� J0, 4N7�_.0VM MA 018,45; 69--5) Lt-49 -2-0 ss 'The petitioner shall be entered on the legal notice and the decision as entered above. 2. Owners of Land: Name, Address and Telephone number and number of years under this ownership: KoGEKyA AE CWf-r-ofJ AND THOMAS F- G�IFtyRD 15 CW4,PWICK ,S-1-R C� T— rloa.-rti MA 01,245 cci-l4j) y'--q -205.5- Years Owned Land: 1- 3. Location of Property: a. Street: 19 C14AITWIC-K ST, Zoning District b. Assessors:Map number &G Lot Number: 3z- c. zc. Registry of Deeds: Book Number (203 0 page Number: 2i3q 4.By-Law Sections under which the petition for the Special Permit is made. 5-ECr1oN H.17-2., ILA -P (K-LA -D15rRIcr C,,l44 Asior1 -;- -rwc r- i4-'Y� 'Refer to the Permit Denial and Zoning By-Law Plan Review as supplied by the Building Commissioner. 5. Describe the Special Permit request: fZEQvGsi Fold A S- ECJAL ?CPMc7- -T-C' corms- gvcr" ACJ 11DI-rior'] TD A4 SiNC i-e F-�gMi Lly HON1d-5� 7o in/C,wDE TI-tf A3PiT-/oN Or- c}�Jyr7t � Dwct U ,J(s UNi� CaryYcf - ''rF/E 1-I O PAG' T-;> A —1\40 y./0 FA^n l L�j bw C L L"'I'( I hl wi 11-1 Hfi gYLA\W, 'The above description shall be used for the purpose of the legal notice and decision. A more detailed description is required pursuant to the Zoning Board Rules and Regulations as cited on page 4 of this application, Rage 3 of 4 NORTH ANDOVER ZONING BOARD OF APPEALS application for a SPECIAL PERMIT 6A. Existing Lot(s): Lot Area Open Space Percent Lot Frontage Parking Minimum Lot Setback Sq.Ft. Sq.Ft, Coverage Feet Spaces Front Side A Side B Rear e� itt27C NA NA % 9O ; 26_9 (8.'33 23.51 XM,SS 6B. Proposed Lot(s): Lot Area Open Space Percent Lot Frontage Parking Minimum Lot Setback Sq.FL Sq.Ft. Coverage Feet Spaces Front Side Side B Rear o� i1,2So rtA NA / qQ y 2 .a iS, 3 23.51 30.35' 6C. Required Lot: (As required by Zoning Bylaws&Table 2)) Lot Area Open Space Percent Lot Frontage Parking Minimum Lot Setback Sq.Ft. Sq.Ft. Coverage Feet Spaces Front Side Side B Rear t Z.Sob ,-A Ntt % IDo 44 30 yo i5 30 7A. Existing Building(s): Ground Floor Number of Total Use of Number Square feet Floors Sq.feet Building" of Units— t35q 2_ 2761 5r1,4 e't.e 1=/-N\I Lt `f IwEe e iA[& t *Reference Uses from the Zoning Bylaws&Table 1. —State number of units in building. 7B. Proposed Building(s): Ground Floor Number of Total Use of Number Square feet Floors Sq.feet Building` of Units- 1967 Z 4031 Two- P-4MtJy 1b1„!i~ L.sVCt Z Reference Uses from the Zoning Bylaws&Table 1. —State number of units in building. 3. Petitioner and Landowner signature(s): Every application for a Special Permit shall be made on this form,which is the official forth of the Zoning Board of Appeals. Every application shall be filled with the Town Clerks Office. It shall be the responsibility of the petitioner to furnish all supporting documentation with this application. The dated copy of this application received by the Town Clerk or the Zoning Board of Appeals does not absolve the applicant from this responsibility. The petitioner shall be responsible for all expenses for filing and legal notification. Failure to comply with application requirements,as cited herein and in the Zoning Board Rules and Regulations may result in a dismissal by t}he ning Board of this application as incomplete. Signature /V' - 4 Type above name(s)here 6R141J ATry Fo,2 ?tioMa-s A cL�IH=oP-o ANS ltcg<'/LTFJ f}, GLt�r�p� PAGE 4 OF A SPECIAL PERMIT 9' iIVRITTEN DOCUMENTATION zz) One(1)Mylar,with one block for Registry use Application for a Special Permit must be supported by a Only,and one block for five(5)ZBA signatures and legibly written or typed memorandum setting forth in date. detail all facts relied upon. When requesting a Special M Plan shall be prepared,stamped and certified by Permit from the requirements or MGLA ch.40A,and the a Registered Professional Land Surveyor. Please North Andover Zoning By-laws,all dimensional note that plans by a Registered Professional Engineer, requirements shall be clearly identified and factually Registered Architect,and/or a Registered Landscape supported. All points,1-8,are required to be Architect may be required for Major Projects. addressed with this application. *10 C. *Required Features On Plan: 1.The particular use proposed for the land or structure. � m north poientation shad include: 2.The specific site is an appropriate location for such 2- zoning district(s) use,structure or condition. 3. names of streets 3.There will be no nuisance or serious hazard to 4. wetlands(if applicable) vehicles or pedestrians. 5. abutters of roe within 300'radius 4.Adequate and appropriate facilities will be provided 6. locations of Property, dings on adjacent properties for the proper operation of the proposed use. within 50'from applicants proposed structure S.The use is in harmony with the purpose and intent of t 7. deed restrictions,easements. Zoning Bylaw. II) Legend 8 Graphic Aids shall include: 6.Speck reference and response to the criteria 1. Proposed features in solid lines&outlined in red required bythe particular Special Permit for which 2. Existing features to be removed in dashed lines this application is made(Le.the Earth Removal 3. Graphic Scales Special Permit has unique criteria and submittal 4. Date of Plan requirements.). S. Title of Plan 6. Names addresses and phone numbers of the 10. PLAN OF LAND applicant,owner of record,and land surveyor. Each application to the Zoning Board of Appeals shall 7. Locus' be accompanied by the following described plan. Plans must be submitted with this application to the Town 10 D. Minor Projects Clerk's Office and ZBA secretary at least thirty(30)days Minor projects,such as decks,sheds,and garages, prior to the public hearing before the Zoning Board of scall require only the plan information as indicated with appeals• an.asterisks(). In some cases further information may be required A set of building elevation plans by a Registered Architect may be required when the application 11. APPLICATION FILING FEES involves new constnrction/a conversion!and/or a A Notification fees:Applicant shall provide a Proposed change in use. check or money order to:"Town of North Andover"for the cost of first class,certified,return receipt x#of 10 A.Major Projects all parties in interest identified in MGLA ch.40A§11 Major projects are those,which involve one of the on the abutter's list for the legal notice check.Also, following whether existing or proposed: the applicant shall supply first class postage stamps I)five or more padding spaces, for each address listed on the abutter's list,plus an lit)three(3)or more dwelling units, additional 2 for the decision mailing. IQ}2000 square fleet of building area. B. Mailing labels:Applicant shall provide four(4) sets of mailing labels no largerthan 1'72-518'(3 copies Major Pro ecfs shall for the Legal marT,ng and one copy for the Decision al 1 require that in addition to the above mailing). features,plans must show detailed utilities,soils,and topographic information. C. See 2005 Revised Fee Schedule. * ®L6 A Special Permit once granted by the ZBA will *'10.B.*Plan Specifications: lapse in 2(two)years if not exercised and a new I) Size of plan: Ten(10)paper copies of a plan not petition must be submitted.©LT to exceed 11°x'17",preferred scale of 111=401 Massachusetts Home Improvement Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary.Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617.973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Roberta and Steve Clifford Kevin Smith 19 Chadwick Street 37 Linden Avenue North Andover,MA 01845 North Andover,MA 01845 Phone: 978-479-2055 Phone:978-337-2986 Licenses: HIC# 108511 Exp.8/19/2018 Const Supervisor# 102589 Exp. 3/5/2017 The Contractor agrees to do the followingwork for the Homeowner: Furnish all labor,materials,and equipment necessary to construct the two family addition shown on drawings prepared by Mr.Stephen Foster dated 8/29/2016 with structural design by Mr.Larry Ogden. Structural drawings D-1,D-2,D-3,and D-4 also included. Smith Construction Company estimate dated 6 September 2016 is included in this agreement. Start/Completion Dates Start Date: 9/12/2016 Substantial Completion Date: 1/6/2017 Required Permits—The following permits are required and will be secured by the contractor: Building Permit Electrical Permit • Plumbing and HVAC Permits to be obtained by Owner's contractors. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: $ 216,800.00. Payments will be made according to the following schedule: 15% Upon signing contract 20% Foundation Completion 35% Frame/Roof Completion 15% Blueboard/Plastering Completion 10% Flooring Completed 5% Building Inspector Final Sign-off Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless-of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Horne Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283- 3757. Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form,for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of the contract must be completed and signed. One copy should go to the homeowner. The other copy should be kept by the contractor. Homeowner's Signature Contractor's Signature f1 4t Date Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration provided In.Massachusetts General Laws,chap 142 . Q.L LoAzi;wner's Signature Co actor's re NOTICE:The signatures of the parties above apply only to the agreement of the ies to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/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 of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of"A Massachusetts Consumer Guide to Horne Improvement' contact: Consumer Information Hotline Office of Consumer Affairs and.Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at ht n:%hoti ca.mass.zav/ocabri If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 51.70,Boston,MA 02116 617-973-8787,88$-283-3757 or visit the HIC website at i tp:Uta�i.y.tr ass.zav/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: ht .i/db state iva u&/homeiiiil2roveanent/licenseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 Version 2.1•Y 122/2010 NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION,WITHOUT PENALTY OR OBLIGATION,WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU CANCELLATION NOTICE,AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL,YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE,IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED,ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE;OR YOU MAY,IF YOU WISH,COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION,YOU MAY RETAIN OR DESPOSE 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 SELLER AND FAIL T'0 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[Name of Seller],AT[Address of Seller's Place of Business]NOT LATER THAN MIDNIGHT OF (date).I HEREBY CANCEL THIS TRANSACTION. Date: Buyer's Signature: '\ The Commonwealth of Massachusetts Department of XndustrialAecidents X Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricions/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. AlanlicantInformation Please Print Legibly Name(Business//OrganizatioMndividual): e r/I y ✓t Address; J/ City/State/Zip: ,. &-,,j&,-A�4' 0/61/5 Phone#:=,�6, I=70"­� Are ymi an employer?Check the appropriate box: Type of project(required): 1.❑I ant a employer with employees(fire and/or pert-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working forme in S, []Remodeling any capacity.[No workers'comp.insurance required.] 9. I am a homcownmr dein ell wwk m smlf. y 9. ❑Demolition ❑ g y [No workers'camp.immanmm roquhed.j 4.❑I am a homeowner and willbe hiring contractors to conduct all work on my property.twill IO rABuilding addition ensure that all contractors either have workers'compensation memento or are sole 11.❑Electrical repairs or additions proprietors with no employees. ,..t, 12.❑Plumbing repairs or additions S.ry ll em a general contractor and I have hired the sub-contractors listed on the attached shout. 13,❑Roofrepairs hese sub-contractors have employees and have workers'comp.inemence.Y b.❑we area maparation and its officers have exercised theirright ofexemption per MGL c. 14.❑Other 152,§1(4),and we have no employees,[No workers'comp.insurance required.] *Any applicant that ohecks b-#1 must also fill out the section below slowing tho'nworkmrs'compensation policy vnfnmration t Homeowners who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a now affidavit indicating such. )Contractors that check this box most attached an additional sheet slowing the name of the subcontractors and state whether or not those entities have employees.If the subwontractors have employees,they must provide their workers'comp,policy number. I, I am an employer that is providing)porkers'compensation insurancefor my employees.Belmv is the policy and job site Information. _ Insurance Company Name: d G Policy#or Self-ins.Lic.#: �G fJ 717 J`�5 7-7.0 f j�E piretion Date:��lLZt -4/, /b� Job Site Address: ,4GruhC'k-'�h• City/State/Zip. Na- 6r +.`hn''�`l 01F34/:i' '- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MOL c.152,§25A is a criminal violation punishable by 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 fate ofup to$250.00 a day against the violator.A copy of this statement maybe forwarded Co the Office of Investigations of the DTA for insurance coverage verification. Ida hereby c f y an the ins d penalties ofperjury Heat the information provided above is true and correct. $,i.,g_aftKaL Phone 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#: Massachusetts-Department of Public Safety Board of Building Regulations and S a. ris License:CS402689 KEVINJSAfM =~ - 63 IN GLEW;i;niTF4W 17 North Andover ll A 0 �..f:.+ J .�rrrr�•`� ,..Expiration'� Commissioner .:03/0912017 4-i Office of Consumer Affairs&Bus fnessftegolafibu HOME IMPROVEMENT CONTRACTOR fa Registratiom 108511 Type: g rY Expiration:-8/79/2018 DBA SMITH CONSTRUCTION.CO Kevin Smith 37 LINDEN AVE _ NORTH ANDOVER,MA 01845 Undersecretary