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HomeMy WebLinkAboutBuilding Permit # 11/8/2016 TOWN Ori NORTii AI-4DOVER APPLICATION FOR PLAN EXAMINATIONof,T „b'g 0 F'2 a 0 35 Permit NO: f / DateReceived 11— p ` " �9SS1Ci4U5��4� Date issued: 1000 EVWORTANT,Anniicant must complete all items on this Daze LOCATION_ l? $ ( CC' l,`.--I Print PROPERTY OWNER 6( f l C,,`$ /`0 C1 Pr p r Print MAP NO.: _ PARCEL: 0 1 1o ,BONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building XOne family 0 Addition ❑Two or more family ❑Industrial Alteration No.of units: ❑Repair,replacement ❑Assessory Bldg ❑Commercial Demolition ❑Moving relocation► ❑Other ❑ Others: ❑Foundation only DESCRIPTION OF WORK TO BE PREFORMED Identification Please Type or Print Clearly) OWNER: Name: p tA c�4 iV1r ter. • J Phone: Address: 12 � AV,tItIL4� CONTRACTOR Name: 11C , Phone:__ P - 3'73 -2 3C2 Address: � r r a ` _ � � r i t G C: /13 Supervisor's Construction License: 3 S�-T Exp. Date: ��C/l,' :Home improvement License: l 6 � Exp. Date: ' �r 7 ARCHITECT/ENGINEER Name: Phone: Address: Reg, No. FEE SCHEDULE:BULDING PERMIT:$12,00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost xl2.00=.FEE:$ Check No Receipt No.: :3/ 1 .. ° Page I of 4 TYPE OF SEWERAGE DISPOSAL Swimming Pools 1i Tanning/Massage/Body Art ❑ Public Sewer Tobacco Sales ❑ Food Packaging/Sales ❑ Well ❑ ❑ Permanent Dumpster on Site Private(septic tank,etc. ❑ Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guaranty!frtad Signature of Agent/Owner I A116f Signature of contractor Plans Submitted � Plans Waived El Certified Plot Plan ❑ Stamped Plans El THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM DATE REJECTED DATE APPROVED PLANNING &DEVELOPMENT ❑ ❑ ❑Water Stied Special Permit ❑ Site Plan Special Permit ❑ Other COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals:Variance,Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water&Sewer connection/Signature&Date _ Driveway Permit Temp Dumpster on site yes—no— Fire Department signature/date W®RT}1 Town of 2 LLAndover No. i,. ioii iWi - LAI h ver, Mass, // g • 0/ SQA coc Hoc Hlw�[K,y1' 04ATED 0"r U BOARD OF HEALTH Food/Kitchen PERMIT . T L D Septic System THIS CERTIFIES THAT .......&.1...Ff 9A+.....cor%$41....�..,.....vp OL....t 4 tot, �i,......., BUILDING INSPECTOR ... . has permission to erect .. ...... buildings on Ax...... ,�,�,�, Foundation I Y Rough to be occupied as ........ ..C#., OCAM......!.`,........ ......................... ....... chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Fina] 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 CONSTRUCT I ST T Rauh Service ......... .... .. ... .................................................. Fina BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occuoy 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. G, 1,3 r o fl t C S trtwt ion, hic. 38 Whittier St. Haverhill, MA 01830 978-373-2302 Agreement between Client and Contractor. Client information: Bill and Maureen Collins 12 Alcot Way N.Andover,MA 01845 Contractor information: G. Profit Construction, Inc. Gurney Profit 38 Whittier St. Haverhill,MA 01830 978-373-2302 Federal Employer ID# 20-3892904 Home Improvement Contractor registration # 156781-8/06/17 Construction Supervisor's license# 73895-3/06/18 Agreement date: 10/24/16. Proposed start and completion schedule.The following will be adhered to unless circumstances beyond the contractor's control arises. Start date: 10/31/16. Finish date: 12/2/16 (when contracted work will be substantially completed). The following building permits are required and will be secured by the contractor: Building,electrical and plumbing. Total contract sum: $39,910.00.The contractor agrees to perform the work,furnish the materials and labor as specified on the scope of work page except where noted. Any alteration or deviation from the specifications involving extra costs will be executed only upon written orders. The change order will become an extra charge over and above the contract. All change orders must be in writing and signed by both Bill and Maureen Collins and G. Profit Construction, Inc.The change order will be charged an hourly rate of $125.00 plus any additional materials. The cost of the change order will be due upon completion of the change order. Building ancl Rej.,no(Jelhig fesi(Jential 1:1, tsofit Constrtiction, ltw, IQHE I � A 38 Whit-ber St. Haveli.-I'dill, MA 01,830 978-37'3-2,',302 The contractor's labor warranty is 1 year after the completion date. Subject to normal use. Manufacturer's warranty where applicable. There is no warranty on products not provided by the contractor. The contractor is not responsible for materials that are reused. The contractor is not responsible for unforeseen issues uncovered during the remodeling process. The contractor will remove all of his construction debris from the site and adequately keep the property safe and clean.All work shall be completed in a professional manner and in compliance with all building codes and applicable laws.The contractor shall adequately protect the work, adjacent property and the public. .0 The contractor agrees to be solely responsible for the 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. Payments will be made according to the following schedule: $13,000.00 first day of the project. $8,000.00 upon completion of the framing, insulation and rough electrical. $4,000.00 upon completion of the blue board and the plaster. $4,000.00 upon completion of the flooring. $4,000.00 upon completion of the finish carpentry. $4,000.00 upon completion of the painting. $ 2,910.00 upon completion of the contract. i. Building and Rernodehrig CORIIIIEHrdal and Rc�sidentia.) G.1 1)rafit Construction, In.c. 38 Whittier St, Haverhill, M'A 01830 978-373-2302 The scope of the project is as follows: Project prep. Install plastic sheeting, around the work areas to control the dust during the project. Demo. Remove the interior trim from the patio door and the transom window. Remove the baseboard in the family room, kitchen, master bedroom, master bathroom and the quest bathroom. Remove the toe kicks from the kitchen cabinets and the master bedroom cabinets. Remove the crown in the dining room, front hall and the second floor hall. Remove the fireplace. Remove the drywall on the back wall of the family room, the ceiling above the family room, the fireplace chimney enclosure,knee wall at the end of the second floor hall and as necessary to construct the floor of the new room. Remove the insulation from the back wall of the family room and the ceiling. Remove the framing of the chimney enclosure and the knee wall at the end of the second floor hall. Remove the hardwood floor in the family room, the the floors in the kitchen,master bathroom and the quest bath and the carpeting in the master bedroom. Framing. Construct a floor using 2 x 10 lumber for the floor joists and'-1/4" Advantech plywood for the subfloor that extends from the second floor hall to the exterior wall of the family room. Construct two closets in the new room. Install I x 3 strapping on the new ceiling in the family room. Enlarge the opening leading to the master bathroom. Install joist hangers on all of the joist ends. Electrical. Remove the ceiling fan in the new room and install it in the quest bedroom. Lighting-install six 6" recessed lights in the new ceiling of the family room, three 6"recessed lights in the new room, six 6"recessed lights in the master bedroom and two 6"recessed lights in the master baihroom. II BUilding and Remodeling (-,onimercial arid R.esi(Jej."itial Uct' arl, h1cm G,. N"ofit (111,onstr i '38 Wtuttier St. Haverhi,11., MA 01.830 978-373-2302 Provide outlets along the walls of the new room. Relocate the switches and outlet in the knee wall of the second floor hall. Provide and install an exhaust fan in the master bathroom and the quest bath and connect to the existing ductwork. Provide an outlet and cable for the TV in the family room. Provide electrical connections for the new appliances. HVAC. Relocate the supply ductwork in the hall. Plumbing. Install a sink, faucet and toilet in the guest bathroom and the master bathroom. Rework the drain under the kitchen sink. Provide plumbing connections for the new appliances. Insulation. Insulate the bays of the open portion of the back wall of the family room and the open portion of the ceiling of the new room with spray foam insulation. Wall and ceiling finish. Install 1/2" blue board on the back wall of the family room,ceiling of the new room and the two new closets. Patch all walls and ceilings that were disturbed to access plumbing,electrical. HVAC and framing. Apply a plaster finish to all of the new blue board and patched areas and blend into the existing finishes. Flooring. Install hardwood flooring in the kitchen, family room, new room, master bedroom and master closet. Sand and finish all new hardwood as well as the flooring in the second floor hall. Bttflding ,'�'ind F�&!'Yiode.hng Corni,nercial and Residential G. Profit Const'n.wti(M., fti'c. 38 Whittier St. .Haverhill, MA 01,830 978-373-2302 Install cement board over the existing subfloors of the guest bathroom and master bathroom. The cement board will be installed over a layer of thinset mortar and screwed down. Install a ceramic the floor and grout the tile. Finish carpentry. Install a door on each new closet. Install trim around the patio door and the transom. Install a vanity in the quest bathroom. Install baseboard in the kitchen, family room, new room, master bedroom, master closet,master bathroom and the quest bathroom. Install crown moulding in the dining room,family room, first floor hall and the second floor hall. Re-install the toe kicks in the kitchen and master bedroom. inclose the pole under the peninsula with pine trim boards and baseboard. Install open wire shelving in the two new closets. Install a TV on the wall. Install the new kitchen appliances. Painting. Paint the walls, ceiling and trim of the dining room,family room, front hall,second floor hall,new room, master bedroom and the quest bedroom. Paint the baseboard in the kitchen, master bathroom, master closet and the quest bathroom. Paint the support column under the peninsula. Stain the two handrails on the stairs. As discussed the following items will be provided by the homeowner-wood flooring for the kitchen and the master bedroom, crown moulding, appliances,cabinetry,plumbing fixtures and countertops. If the kitchen requires a new subfloor, it will be at an additional cost to the estimate given. E3utilding and Rernodeliri,g Cotnrriercial and Residential k 11"I t C Ot'll C mn 38 WI-di'lier St. H;,tvej,'-hjII, MA 018.34) 9 78,-37 2 3 0 2 Upon signing,this document becomes a binding contract under law. You may cancel this agreement provided you notify the contractor in writing at his main office no later than midnight of the third business day following the signing of this agreement Do not sign this contract if there are ally blank spacVs. T Client/1-10V1 COW lei /J' C I '71, I Contractor. Date- I look forward to working with you on this project. Sit ely, ✓ G"tirney P'rZfit 1,-0 '1 "'38 Whit'lier St. [Li,werhill, MA 0183() 978-37.�`�-2302 The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration(as an alternative to court action) if they have a dispute with a contractor.Tile same right is not automatically afforded to the contractor,however.The contractor will have to resolve any dispute be 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 the homeowner by the Home Improvement Law. The contractor and homeowner hereby mutually agree In advance that In the event the contractor has a dispute concerning this contract,the contractor may submit this dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulations and the consumer shall be required to submit to such arbitration as provided in Massachusqts General Laws,chapter 142A. Client/ 0:""' W" Coil tracto ,-,-. The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor.The homeowner may initiate alternative dispute resolution even where the parties do not separately sign this section. 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 a warranty for workmanship or materials. In addition to guarantees and 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 consumers rights.If you have questions about your consumers/homeowners rights contact the Consumer Information Hotline listed below. Bctfldinfra.ral Renaod,(,,.flJr1jV FZeskicnitial Profit Canstructiati, Inc. 38 'Whittier St. Haver-liffl, MA 01,.83,0 978­373-2302 The contract must be executed in duplicate and should not be signed until all 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 contract with attachments is to be given to the owner and the other to be kept by the contractor.Any modification to the original contract must be in writing and agreed 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. A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems himself/herself financially insecure. However,in instances where a contractor deems himself to be financially insecure,the contractor may require that the balance of the funds notyet due to 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. 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 Guide to Home Improvement" contact: Consumer Affairs Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-0787, 808-283-3757 or visit the OCABR website at littp://wwwmass.gov/ocabr/ 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 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at http://www.mass.gov/ocabr/ Bt.dlding and Reniodelin.g C"orninervial alid FlIkesidential. G', fit Construction, Inc. 38 Whittier St. flavei-hill, MA 01,830 978-373-2302 Go online to view the status of a Home Improvement Contractor Registration: V �! Mt n' 1-silI-f rughn --Ln ! / .. T-1- 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 508-652-4000, 508-755-2548,413-734-3114 ffi,filding arid R.erriodeling Conu-nei-cial and RE�Sid�mtial v ro..mm....... �.. n gg f; a N f PV t � r b i I PARKING LICENSE AGREEMENT This Parking License Agreement(this "Agreement") is made, dated and effective as of 201 , by and among EDGEWOOD RETIREMENT COMMUNITY, INC., a Massachusetts not-for-profit corporation having an address of 575 Osgood Street, North Andover, Massachusetts ("Edgewood") and THE TOWN OF NORTH ANDOVER, a body politic, having an address of 120 Main Street, North Andover, Massachusetts 01845 (the "Town"). WITNESSETH: WHEREAS, Edgewood is the owner of certain parcels of land commonly known as 575 Osgood Street, which are located in the Town of North Andover, Commonwealth of Massachusetts, and legally described on Exhibit A attached hereto and incorporated herein by reference (the "Edgewood Property"); and WHEREAS, the Town desires to obtain a license for the use of five (5) parking spaces located on the Edgewood Property and more particularly depicted on the plan attached hereto as Exhibit A and incorporated herein by reference (the"Designated Half Mile Hill Spaces"); and WHEREAS, Edgewood is willing to grant such a license to the Town, specifically to permit members of the public desiring access Half Mile Hill ("Authorized Parkers") the use of parking spaces in connection with such access to Half Mile Hill, all on the terms and conditions set forth herein; and NOW THEREFORE, in consideration of the promises, the covenants contained herein, and for good and valuable consideration, the sufficiency and receipt of which are hereby acknowledged,the parties do hereby agree as follows: 1. Recitals. The foregoing recitals are incorporated herein and made a part hereof. 2. Grant of License; Relocation. Edgewood hereby grants to the Town, the perpetual right, privilege and license to park passenger automobiles, but specifically excluding, however, trucks, commercial vehicles and campers in excess of one ton capacity or possessing more than four (4) wheels (each, an "Automobile"), in the Designated Half Mile Hill Spaces for the use by the public in connection with the use of Half Mile Hill, all in accordance with all of the provisions of this Agreement (the "Parking Rights"). The parties covenant and agree that throughout the term of this Agreement, Edgewood shall have the right, from time to time, in its sole and absolute discretion, to relocate the Designated Half Mile Hill Spaces within the Edgewood Property upon written notice to the Town. 3. License Fee. There shall be no fee charged for the Town's proper exercise of its Parking Rights pursuant to the provisions of this Agreement. The Town's sole right under this Agreement is to allow Authorized Parkers to park Automobiles in the Designated Half Mile Hill Spaces, in accordance with the provisions of this Agreement, No other rights are granted. -1- � 56189099 vl It is intended that any such Estoppel Certificate delivered pursuant hereto may be relied upon by others with whom Edgewood may be dealing. 11. Assi ng meat. This Agreement and the Parking Rights granted hereunder shall not be assigned or sublet by the Town. Any such attempted assignment or subletting by the Town shall be null void and of no effect. 12. Limitation. This Agreement grants a license only, revocable or terminable under the terms and conditions herein, and does not grant any lease, easement or other interest in real estate. 13. Remedies on Default. If the Town fails to perform any of its obligations hereunder and such default shall continue for a period of 30 days following written notice of the same from Edgewood, then in such event, Edgewood shall have the right to terminate this License effective upon written notice of termination to the Town. Such termination by Edgewood shall be deemed effective on the date stated in such notice. Termination of this License by Edgewood as aforesaid shall not prejudice any other remedies which might be available to Edgewood under this License or at law or in equity. [SIGNATURES APPEAR ON FOLLOWING PAGE] -3- 56189099 v] ! EXHIBIT A Edgewood Property (to be provided) -5- 56189099 v1 i I -� 10/25/2015 5 : 17 : 30 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE rDATE(MM/DDIYYYYI T KTIFICATE"IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY DR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE=A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER CONTACT NAME; CHASE&LUNT,LLC PHONE FAX 65 PARKER STREET (A/C,No,Ext): (AX,No): E-MAIL NEWBURYPORT,MA 01950 ADDRESS: 722MF INSURERS)AFFORDING COVERAGE i NAIC# INSURED INSURER A: CONTMENTAL CASUALTY COMPANY G PROFIT CONSTRUCTION INC INSURER B, INSURER C: INSURER D, 38 WHITTIER ST INSURER Ew: HAVERHILL,MA 01830 ENSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER, THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MJRDDIYYYY) (MlADD4YYYY) LIMITS GENERAL LIABILITY ACM OCCURRENCE $ COMMERCIAL GENERAL LIABILITY pAMAGE TO RENTED $ CLAIMS MADE F__1 OCCUR. PREMISES(Ea occurrence) MED FXP(Any one person) $ PERSONAL&ADV INJURY $ GENT-AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROJECT LOC PRODUCTS-COMPIOP AGG S AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) UME3RELLALIAB OCCUR EACHOCCURRENCE $ EXCESS LIAR LJ CLAIMS-MADE AGGREGATE S DEDUCTIBLE RETENTION $ $ A WORKER'S COMPENSATION AND x We STATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-9ROSM018-16 06!0212016 06/0212017 1 LIMITS ANY PROPER ITOWPARTNERIEXECUTIVE Y NIA ! .LEACH ACCIDENT $ OFFICEWMEM9ER1=XCLIDED7 0 100,000 (MandaloryM NH) E.L.DISEASE-EA EMPLOYEE S 100,0a{} If yes,dawc be under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONSILOCATIONSIVE;HICLESIRESTRICTIONSISPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF N.ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED V t 600 OSGOOD S I BEFORE THF-EXPIRATION DATE THEREOF,.NOTICE WILL BE DELIVERED IN ACCORD E WITH THE POLICY PRO N AVTHO ER ESENTATIVE ? N. ANDOVER,MA 0184.5 - Fwd�,r t;-: : ...• ° F. ICOR❑25(2810105) The ACORD name and logo are registered marks of ACORD 1888-2010 ACORD CORPORATION. All rig reserved. I i 3 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Please Print Name: "t V r 0 e LO I_oca ion: t 2 A r Ca° b+Jr- Cit A), 6 Phone 27P am a homeowner performing all work myself. F-1I am a sole proprietor and have no one working in any capacity FUJ I am an employer providing workers'compensation for my employees working on this job. Com an name: `� v n (00 5 r-ve`:h c .11.1 c' Address '38, t.)tk r f 't' ST, Cil,, 14-c Ver"tt r l( q l O! J, 3 7 0 Phone#: `! ! P :3 G2 Insurance Co. CIV14 Potic # Company name: Address City: Phone#: Insurance Co. Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.04 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. r understand that a copy of this statement may be forwarded to the Office of investigations of the DIA for coverage verification. I do herby certify u er the pales and penalties of perjury that the information provided above is true and correct. �i Signature_ j Date �-7 a Print name G U rri if /�in/-- i l / —Phone# 2 C 1 Official use only do not write in this area to be completed by city or town official' ❑ Building Dept ❑Check if immediate response Is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone#: © Health Department ❑ Other FORM WORKMAN'S COMPENSATION i Board Of SrrrGrturr kir rCr l ricrrrta and Stindardv, LA ease: -0173895 i rGURNEY PROFIT ° y�> m 38 WHITTIER STREET HAV RHILL MA 01330 arr°r °6flSiV"��`�,PN 0310612018 i (cense or registration valid for inrfivic9ul use wily dy9"i`rrc I)3 C t7P° 'of✓eo a l`YYft rr re.rrrz°fit"r,�Pr�4 1')rsysraCac aC tr.rtu Iaeforc t✓rc expirattr�n et.rteo ffr:oulsrl r~eturn ta: ICdNf I�IPPRt3VI3NT CC7iVTaCTCf! Office of Consumer Affairs and Business Regulation � rsfrotion: 10 'n k�PIRVI-Suite 51`0 v,r 156781 T Boston,MA 02116 ` xpiration: 8/6!20117 Privsf5 Cc C.PROFIT CONST RUCMN INC;. r ,?" GURNEY PROFIT Not N, lid without signature HAVERHILL,PV1A 01830 L�tet�r.vte r fit .. r: