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HomeMy WebLinkAboutBuilding Permit #909-14 - 1 SCOTT CIRCLE 6/12/2014 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: �ImpcA licant must com Tete all items on this age _LOCATION Print PROPERTY OWNER �r (.� xk Unit# / Print MAP NO: PARCEL:XS' ZONING DISTRICT: Historic District yesQ-0 nit Machine Shop Village yes 100 year-old structure yes TYPE OF IMPROVEMENT PROPOSED USE Reside Non- Residential ❑ New Building ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: Industrial ElRepair, replacement ❑Assessory Bldg ❑ Others: ElDemolition 11 Other £ir't•tir Well IM F11 1 Iii U YV dLI L3 V� .1 DESCRIPTION OF WORK TO BE PERFORMED: (Identi�ation Please Type or Print Clearly) OWNER: Name: 1,rYrs Phone Address: 1SCA (� C or 4 CONTRACTOR Name: E,- C Phone: q2L2YY_1!3'/Y3 Address: iII � Sfi Supervisor's Construction License: _ 9? Exp. Date: A3 (, Home Improvement License: / Y-�_ o SI Exp. Date: / /6 ARCHITECT/ENGINEER Phone: Address: Reg. No. ; FEE SCHEDULE.BULDING PERMIT.$12.00 PER1000. $ 00 OF THE TOTALESTIMATED COST BASED ON$125.00 PER S.F. t Total Project Cost: $ 3 7--?0(0 _ 4� FEE: 4c) . Check No.:— Receipt No.: (p� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Qvvrier - - _ __ignature of contractor �2 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Penmanerit Durnpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY( INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS ��. :E.,:tm.cr`.•i: :+,ea# ��:Wi�:Lvl.t.i ii�� vi.+i�ai.ui�: COMMENTS HEALTH Reviewed on Signature r COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water &s Sewer Connection/Signature& 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 signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Tota[ [and area, sq. ft.: ELECTRICAL: Movement of deter location, mast or service drop requires approval of Electrical Inspector yes No DANGER ZONE LITERATURE: yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi Building Department 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 ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ 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 Perr Addition or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses • Copy Of Contraco. Pian 0`l' l"ropuse i vi urK vviw dpi nKier Mare Ana Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products - NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permi- New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ 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: Doc.Building Permit Revised 2008mi Location No. ! _ Date to aZ l . - TOWN OF NORTH ANDOVER F. Certificate of Occupancy $ Building/Frame Permit Fee $.410. 0il Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check 4Z� i j GBuilding Inspector NORTH Town of E : 1, Andover O ` 'y 1 to J_ C16i _ C I _ h over Mass J(Ar-)e 12 , 2biq A- COC NICNl WICK 1_ 7�A0R^TEo NPP�,�y S V BOARD OF HEALTH Food/Kitchen PER LD Septic System THIS CERTIFIES THAT kZ �' BUILDING INSPECTOR ........... .. ....... ................... ...... .... ........................................... . : .. ..... ....: rr has permission to erec .......................... buildings on ....I.....SUA .....C.lk<.�C. ............................. Foundation Rough to be occupied as ...Av.vc 6es.J...4 1 C. 3,0. Chimney provided that the person accepting this permit shall ih 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 CONSTRUCTION TARTS Rough Service .................. .....T. . ... _.s........................ 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. I Smoke Det. A CERTIFICATE OF LIABILITY INSURANCE DA TE(MM/DDIYYYY) 3/10/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR 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 an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Construction Eastern Insurance Group LLC PHONE (508)651-7700 FAC 233 West Central Street nolE INSURERS AFFORDING COVERAGE NAIC# Natick MA 01760 INSURER AArbella Protection Ins. Co. 41360 INSURED INSURER B P+rbella Indemnity Ins Co. 10017 Atlantic Weattlerization INSURER C Nautilus Insurance CO 61 Rear Jefferson Avenue INSURER D: INSURER E Salem MA 01970 INSURER F. COVERAGES CERTIFICATE NUMBER3daster 2014 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR 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 ADDL SUOR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE WVD POLICY NUMBER MMIDDIYYYY)J_MMIDD1YYYY1 LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 }I COMMERCIAL GENERAL LIABILITY ffl)— PREMISES Me occurrence $ 50,000 A CLAIMS-MADE Fx-1 OCCUR 8500042816 /20/2014 /20/2015 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAG GREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY $ JFCT PRO- LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1 000 000 B ANY AUTO BODILY INJURY(Per person) S ALL OWNEDR SCHEDULED 020015871 /20/2014 /20/2015 AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Peraccident $ PIP-Basic $ 8 000 X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 1,000,000 AXCESS LIAR CLAIMS-MADE AGGREGATE S 1,000,000 E RDED I I RETENTION$ 4600058654 /20/2014 /20/2015 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN I FIR — OFFICER/MEMBER EXCLUDED? ❑ NIA E.L.EACH ACCIDENT $ (Mandatory in NH) If yes,describe under E.L DISEASE-EA EMPLOYE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C POLLUTION LIABILITY CPL200378602^ 0/1/2013 0/1/2014 GENERAL AGGREGATE $1,000,000 z EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,ff more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE Ronald Cleaves/SMEs — ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025i2nimsim Tho Af`ARf1 namn anti Inns aro roniafanad marke of Ae non Right€ax N3-2 4/18/2014 7:54 :21 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATE(MMrDD/YYYn T. IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR 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. D THE CERTIFICATE HOLDER, IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the pollcy(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 endorsement(s). PRODUCER CONTACT NAME: EASTERN INS GROUP LLC PHONE FAX 233 WEST CENTRAL STREET (AIC,No,Ext): (AIC,No): E-MAIL NATICK,MA 01760 ADDRESS: 22MLW INSURER(S)AFFORDING COVERAGE NAIC 1t INSURED INSURER A: AMERICAN ZURICH INSURANCE COMPANY ATLANTIC WEATHERIZATION LLC INSURER B: INSURER C: INSURER D: 61 REAR JEFFERSON AVE INSURER.E: SALEM,MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 670 FY THAT THEPOLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR 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 PAD CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMIDD%YYYY) (MLWDIYYYY) LIMITS GENERAL LIABILITY ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY �- AMAGE TO RENTED $ CLAIMS MADE E]OCCUR. REMISES(Ea occurrence) ED EXP(Any one person) $ GEML AGGREGATE LIMIT APPLIES PER: ERSONAL a ADV INJURY $ ENERAL AGGREGATE $ POLICY 0 PROJECT[:]LOC RODUCTS-COMP/OP AGG $ 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) UMBRELLA LIAB M OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER';COMPENSATION AND WC STATUTORY OTHER EMPLOYERS LIABILITY YM UBb6270121-14 03/20/2014 03(20/2015 X LIMITS I ANY PROPERITORPXCLUDE/EXECUTIVE E]NIA E.L EACH ACCIDENT $ 500,000 OFFICERlMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CER7TYTCATB HOLDER AFFEC rrNG WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REFR A VE �✓ --,� N ANDOVER,MA 01845 "� ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988=2010 ACORD CORPORATION. All rights reserved. l assach�s� s �om� Im trove men( Sa � mle Contract This form satisfies all basic requirements of the states Home Improaement Contractor Law(MGL chapter 142A),but does notindndestamdnrd language ro protect homeox mgrs Seel;legal advice if necessary Any person planning home improvements should first obtain a lvlassaclwsetts Consumer Guide to Home Improvement"before a_tmeems to any work-on pour residence.You may obtain a fee copy of ng 10ffice of Consumer Affairs and Business Regulation's Consumer information Hotline at 617-973-8787 or 1-888-383-3757.or on our ebb calling e Homeowner Information Contractor Information Name ompam Name Streit Address foo not use office Boxaddras)r Canttactod e S e o'T- C( Fant. al n 61 R Jew A u Cin:?awn State Zip Code Btisiaea Address must ( Sale M! "M 970 Da)time Pitane Eaerims Phone Citp/l'owa State Zap Code Mailing Address Rt different tram aboae) BusirhessPhtme FederalEmploperIDorS.S.Number klamL—,.acz=-f Carea:tRr..tiryy: '�"�'�""�� tan+equtro nut cauhaze E�-•inl_e iaP dreira[oonc=b z�.nd rg6tntloa coact The Con tractor agrees to do the following work for the Homeowner, (Describe in detail the aamEtocompleted,specifyingthe r<7te.brand,and grade oftiwtetiattrooeats ud use zdditienalsheemirnss m) Fhe its-The following building permits are required Proposed Start and Completion Schedule-The following schedule will red by the contractor as the homeowner's neat: be adhered to unlen cimimawtxs beyond the wntrdctot's control arise secure their own permits will be m the Guaianty Fund provisions of 7r 14211.) Date aafien wrttraetotaat7l begin contracted orotic. Date when contracted work%%V be substantially completed. Tatat Contract price and Payment Schedule The Contractor aereees to perform the work,furnish the material and labor specified above for ibe total sum of 3-30 . (,) Payments will be made according to the following schedule: S �d upon signing contract(not to meed Ir of the total contract price or the cost of ecial order it sP ems,nitiehever isgreater) S by 1 or upon completion of �^ S—K=_-= or upon completion of a S _upon completion of the contract. (Law forbids demanding frill paymea until contract is completed to both patty's satisfaction) The following matorialtequipment must be special $ ordered before the contracted wank begins in order to _paid r to meet the completion scheduile("l 5 o be to; \OTES:M Including all finance charges(")Lan requires that any deposit or damn-pa}mem required to the contractor betaro cow',.begins not e.¢eed the meter of(a)one-third of tha total eontrci ria orma` wfiich atm be P @e the cast afany special equipment or custom made material special ordered in advance to meet the completion scheduda lwznress 1Farrztnrran a be'n ❑Yn --�.5a nrosided he th .v+..+ cmr� ©yam calf form orthe Iva Subcontractors The contractor ed tothemntmna agrees is b solei.responsible for completion of the wrorl.described t Blas of the actions of any third party subcontractor utilized by the contractor. The contraetorfitrtbera t al d 1 h cern r Lia to be solely responsible for all payments to all subcontractors for 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.Reaiew the following cautions and notices carefully before signing this contract a Don't be pressured into sitming the contract Take time to read and filly understand it Ask questions ifsomething is unclear. Vfake;!'! the contractor has a aalid Home hnoroaement Cantraztor ReO�trahon.The tato regtrites most home improv subcanaatxors ro be reetsteted nth the Drrectot OFHome Improvement Contractor Reaistratian You mat ingtitreemen Mttri etors and registration by writing to the Director at 10 Park Plaza,Room 5170,BOStan,MA 03116 or by calling 617-973-8737 or 888-283-3757. • Does the contractor haat insurance? the Contractor see a copy oFa'proof of insurance"docuocument for his insurance company-information so that you can confirm co%wage,or ask to a Know•your rights and responsibilities Read the Important Information on the raerse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Lan. Yon may cancel this aereement if it has been signed at a place other than the contractor's normal place of business,protided you notify the contractor in writing at hisrher main office or branch office by ordinan mail posted,by telemam sent or by delis en,not later than midnight of the third business day folloning the sighting of this agreement Ser the attached notice of cancellation form furan explanation of this right. DO Iron SIGN T IIs coN '-T IF TBERE A LRE BLANK sPACF s►T: T ar Jmju�oftEr n xc�teaapL-mi si, C�oirs `o r,Lr1 ow Tttethh:rMpys*a'it. tE eaci^src Homeoaaner s Signature Contractor's Si_ re le ` le �i l Date Date i Contractor Arbitration. The Home Improvement Contractor Law provides homeowners with the right to initiate anarbitration 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.h.•opieowner in court unless both parties agree to the optional clause provided below. This clause would give the coatraEctor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. i 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`hich has been approved by the Secretary of the Eseeutive Office of Consumer Affairs and Business Regulation and thelconsumer shall be required to submit to such i ibitratioii as p�rojvided In Massachusetts General Laws,chapter 142A. Homeowner's Signature Contractor's Signature NOTICE:The signatures of the parties above apply only to the agreement of the parties tg 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(Le.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'hotproperly registered as prescribed by law. Homeowners who secure their own building permits are automatically exciuded from all Gtiararny 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 cavy an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfWly 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 d i�licate and should not be signed until a copy of all exNbits 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 coriftct with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract musA-bsin vtdting and agreed-to by both parties-.-Contracted wofift ynotliagin iintiFUoth parties have received afully 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 s hedule 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 duelie placed in a joint escrow account as a prerequisite to continuing the contracted work Withdrawal of fiords from sail 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 Guidb to Home 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 OCABRwebsite at htlp://www.rnws.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 Horne Improvement Contractor Law,cpiitaet: Director of home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 ParkPlaza,Room 5170,Boston,MA 02116 i 617-973-8787,888-283-3757 or visit the HIC website at h=://www.m6s.eoy/6cabr/ Go.online to view the status of a Home Improvement Contractor's Registration: hMJdb state mauslhomeimprovementllicenseelist asp For assistance with informal mediation of disputes or to register formal complaints again a business,call- -Consumer Complaint Section Office ofthe Attorney General s 617-727-8400 AND/OR Better Business Bureau r 508-6524800;508-755-2548 or 413-734-3114 y i version ll-t imnolc 1 1!#G VV//i/fLV/i/YGiiiili VJ 1/.[K.70Kl./6"0GILJ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 y www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organiiadon/Individual): ATLANTIC WEATHERIZATION, LLC NUE SALEM,MA 01970 Address: (978)i 143 I-AX(918) 745-2200 City/State/Zip: Phone#: _ Are you an employer?Check the appropriate box: _ Type of project(required): 1.❑ I am a employer with 4. El am a general contractor and I * have hired the sub-contractors 6. F1 New construction employees(full and/or part-time). 2.F-1I am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeorer doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑koo epairs insurance required.]t employees. [No workers' comp.insurance required.] 13. er Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 1 am-an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: l,k f-c(;Cn Policy#or Self-ins.Lic.M 2 7 I Z I Expiration Date:� ,--- Job Site Address: / S C_ o C ` City/State/Zip: /'V a&L48, ogle 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 thata copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ` 1 do hereby certify under the pain&and penalties of perjury that the information provideed�above is true and correct. Signature: ��L / ��� Date: Phone#: .7 `—� 7 `( �� Y- 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): L Board of Health' 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i 7�A za�zcaca��a��� Office of fairs&Business RegulationCTORME IMNT CONTRA Type:gistra89 Ltd Uabil'dy COMM.pirati1.6ATICWEATHL.t.C.ERIC PALM ����/, OR JEFFERSON AVE Undersecretary t SALEM,MA 01970- Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-087977 ,i s 1%, ERIC W PALM l 3 HILTON ST fi Salem MA 01970= r Expiration Commissioner 04/23/2016