Loading...
HomeMy WebLinkAboutBuilding Permit #725-13 - 10 MILK STREET 5/2/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION_/Q S71- Print PROPERTY OWNER_ S cg44 Print 100 Year Old Structure yes no MAP NO: PARCEL: ZONING DISTRICT: Historic District yes (�b Machine Shop Village yes 4Uo TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑Addition ❑Two or more family ❑ Industrial C,Iteration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer lzl- DES RIPTION OF WORK TO BE PERFORMED: ty e Lcn Identification Please Type or Print Clearly) OWNER: Name: CSQ Phone: Address: CONTRACTOR Name:��Q,�,xs �rP�c'� ,� PhoneLq?o 6e-T-a 9G Address: 35U � f�„� �,�cf� �GL ,��,,r�v, �cJ-.L/• G 30 3�' Supervisor's Construction License: c3658 >U Exp. Date: /d//�//y Home Improvement License: 1.?6Exp. Date: 7/S ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. oa Total Project Cost: $1,7yoGG FEE: 0- $ , Check No.: o���i�" Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner Signature of contract Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans 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 Permit 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 Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And 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 Permit 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 case if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the app;al 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.Bui!ding Permit Revised 2012 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. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature 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 DPVV Towp_ ]Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Mair Street Fire Departmerit signatureldate COMMENTS ; Dimension Number of Stories:r , Total square feet of floor area, based on Exterior dimensions.y S ,, Pn5 Total land area, sq. ft.: ELECTRICAL: Movement of Meter 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 2010 Location No. 1 Date l 12 7Xf • TOWN OF NORTH ANDOVER • y Certificate of Occupancy $ Building/Frame 9/Frame Permit Fee $ �. Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# `� 26347 Bu Inspector tAORTH oven of � � E ndover No. 3 � iAll5 S� o h ver, Mass, COCNIc"RWICK y1. _ S U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System + BUILDING RYSPECTOR THIS CERTIFIES THAT ........ ..... . �� ......�...................................................�� Foundation has permission to erect .......................... buildings on .: Rough to be occupied as , 6 eo ................ /�/ ...........................�................................................................... 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service :j4 e ' . T. .R+w...................................• ........ .., .. .... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough �• � Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. IL SEE REVERSE SIDE ,t- ���� PREMI-3 OP ID: SG A�C."-- Rp, CERTIFICATE OF LIABILITY INSURANCE D ATE(MM/DDIYYYY) 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 Phone:603-890-6439 CONTACT Planright Insurance-Salem Fax:603-890-6521 PHONE FAX 224 Main Street Suite 3C aC No Ext): ac No Salem,NH 03079 EMAIL James A Santo ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A:Western World Insurance Co INSURED Premier Roofing&Painting INSURER B:Travelers Indemnity Company 25658 Jonathan N Lee dba 215 South Broadway Box 145 INSURER C: Salem, NH 03079 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEbLLSBUED 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 I SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MM/DD/YYW LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 DAMAGE TO RENTEU_ A X COMMERCIAL GENERAL LIABILITY NPP8098090 05/24/2012 05/24/2013 PREMISES Ea occurrence $ 50,00 CLAIMS-MADEa OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,00 X POLICY IPECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NONNOSWNED PROPERTY DAMAGE $ Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY X T RY LIMIT ER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 6KUB465OP25512 05/25/2012 05/25/2013 E.L.EACH ACCIDENT $ 100,00 OFFICER/MEMBER EXCLUDED? F—Y] N/A (Mandatory in NH) 3A NH E.L.DISEASE-EA EMPLOYEE $ 100,00 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Roofing-Residential Only. Jonathan Lee is excluded from worker compensation coverage. fax 978-688-4165 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Charles Construction ACCORDANCE WITH THE POLICY PROVISIONS. 200 Sutton Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Massae ,usetts Home Imurovement Sample 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 ISeek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to!I RIome Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and BLliness Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website.. Homeowner Idformation Contractor Information Name Company Name 4 er) i + . Street Address(do not use a Post Office Box address) Contractor/Salesperson/Owner Na City/TownState ' I Zi Code if S e�IC L p Business Address(must include a street address) D ( 941�' Daytime Phone vening Phone City/Town State i I p Code 38—bS7o^l; Perc )i-H H . 6 3o3a Mailing Address(It different from above) Business hon f(0031R35-5712-1 Federal Employer ID or S.S.Number Home Improvement contractor Reg.Number Low inquires that most home Expiration date improvement contractorshave •7/� YPY n valid registration number • O(.b The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if nececsarv.) S+rVI r 00 o ' a � kyer Of Qsphl1+ sh;n` )e �n5 q l) CF�+44" ,n8, Lqr c) ac k I i TC 4`rnc w, 4x�i -ecl,UcCL Required Permits-The followinglbuilding permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor:as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty]Fund provisions of Date when contractor will begin contracted work- MGL chapter 142A.) i Date when contracted work will be substantially completed. Total Contract Price and Paymerit!Schedule The Contractor agrees to perform the wor15 furnish the material and labor specified above for the total sum of: (�) Payments will be made according to;the following schedule: Upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ by / or upon completion of LIt OT *hl $ by / or upon completion of upon completion 6f the contract. (Law forbids demanding Rill payment until contract is completed to both party's satisfaction) ! ! The following material/equipment must be special $ _to be paid for ordered before the contracted work begins in order to meet the completion schedule to be paid for NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of I(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. Express Warran -Is an ex ress warran born rovided b the contractor? Subcontractors-The contractor agrees to be solely responsible for completir]on of the work described regardless of the actionNo YYes 6111 terms of the wirl,11 n must be s of any tthird he contract 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 a eement 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 lieii'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 alvatid Home Ira rovement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registeredwith the Director of Home Improvement Co intractor 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 Cons Guide to the Home Improvement*Contractor Law. umer 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 maimoffice 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. Seethe attached notice of cancellation form for an explanation of this right. DO NOT SIG) THIS CONTRACT IF THERE ARF NK oTwoidenitioalcopithe contract must he completed and signed. One copy should go to the homeowner. The other copy shouldSpACESept by the ontractor. t e actor's Signature D e Daiti, I Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate anlarbitration 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 contra Ictor 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)which has been approved by the Secretary of the Exec tive Office of Consumer Affairs and Business Regulation and the consumer shall be required to su t to such itr on as provided In Massachusetts General Laws,chapter 142A. ; Z Mil, S eontractor's SiE:The ignattures of the parties above apply only to the agre ent of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resoIbition 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 142A3,and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way, even by agreement.i 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 iwork 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 exl ibits 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 coritract 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 receiii d a fully executed copy of diL:.yu'`.a aim' hare period has etiyired. 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 ,a to be financially insecure,'the contractor may require that the balance of fiords not yet duel placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of fiunds 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 Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation ! I 10 Park Plaza.,Room 5170,Boston,MA 02116 j 617-973-8787, 888-283-3757 or visit the OCABR website at h=://vm�,v.mass.Rov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additi�nal information specifically about the contractor registration component of the Home Improvement Contractor Law,clontact: 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.Rov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: I http://db.state.ma.Lis/holneimprovement/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 I 508-652-4800,508-755-2548 or 413-734-3114 j Version 2.1-11/22/2010 ii Ri.ghtfax C1-1 3/15/2013 5:39:26 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE =DATEIMMWIDID/YYYY).1 TIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICAT 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 he terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to he certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PLANRIGHT INS&FIN PHONE FAX 224 MAIN ST STE 2A (A/C,No,Ext): (A/C,No): EMAIL SALEM,NH 03079-3192 ADDRESS: 76HMH INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: ACE AMERICAN INSURANCE COMPANY LEE,JONATHAN N DBA PREMIER ROOFING&PAINTING INSURER B: INSURER C: INSURER D: 215 SOUTH BROADWAY BOX 145 INSURER E: SALEM,NH 03074 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: I G IMUKANGE LISTED BELOW HAVEBEEN ISSUEOTO 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, NSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (I'MMYYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE E]OCCUR. EMISES(Ea occurrence) ED EXP(Arty one person) $ RSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER ENERAL AGGREGATE $ POLICY E]PROJECT❑LOC ODUCTS-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 $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB 0 OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND XWe STATUTORY OTHER EMPLOYER'S LIABILITY Y/N UB-4777P487-12 07/302012 07/30/2013 LIMITS ANY PROPER ITORIPARTNER/EXECUTNE OFFICERIMEMBER EXCLUDED? NIA E.L.EACH ACCIDENT $ 100,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,desaibe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIRESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR LEE,JONATHAN N- CERTIFICATE HOLDER CANCELLATION CHARLES CONSTRUCTION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 200 SUTTON ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL B DEL IN ACCORDANCE WITH THE POLICY PRO NANDOVER,MA 01845 AUTHORIZED REPRESENTATIVE ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPO Flo 3 t served. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address:,S6 City/State/Zip: f c-r(V /U.4 O 3 p 31 Phone#:65 NO 6 Are you an employer?Check the appropriate box: Type of project(required): 1.R26 am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. E]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. F1 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11. umbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.ff Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they ire 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:.Ae- Ac�✓t�Qn 2-5-S Policy#or Self-ins.Lic.#:��j - �/� 7 7/�y d`7-tea Expiration Date: &.?0 /3 Job Site Address: /O Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of 'Investigations of the DIA-for insurance coverage verification. Ido hereby certlo under thepams andpenalties ofperjury that the information provided above is true and correct. r Si atur Date: 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#: Information and Instructiois Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employeiis defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Gommonwoalth of Massachuseitts Departmmt of fadustrial Accidents Office QUAVestiga}tions 600 Washington Street Boston,M..A,02111 Tel,#617-7274900 ext 406 or 1-877�,MASS.A.k'.B Revised 5-26-05 Fax 4 617-727-7749 Wvw.Mass,goufdia Page No of Pages J&i Specializing in all types of MA 978-683-2968 ROOFING Carpentry - - 8 Roofing - Ventilation NH 603898105 PROPOSAL SUBMITTED TO PHONE DATE C II �r4r (`17,-) a C,V- U STREET JOB NAME CITY,STATE&ZIP CODE JOB LOCATION 11 •r j ARCHITECT DATE OF PLANS _ JOB PHONE We hereby submit specifications and estimate for: /+ r t �n �+fr r+ S-i-tn irr f 0t Ori IeAvprr, I �rA ; r. r y ref! I ^ r r k---,ror f' !( C,rrf c f'� r 0 .7' S t 1 r r r V ) C r rS T _ 'Q - r -r *In + + ;h +- '� r } fnr, l C t S > r1 Pit r% !r f r}� I t a^ �t I u C ,• r r L+ f , /r'/GG Lr /? �'/�' /37-r' G r/ /' �� <-i r Gi0' 1. 4Z ♦� i �i •r�,r I.. �/]��t �/ �r - �('i// /rC�' " f•/I G/CJS +'r�./i /f ^L O " r- , G7r We Propose hereby to furnish material and labor- complete in accordance with above specifications,for the sum of: n , - �,r! Dollars($ - 7 :'i 1 G L ). Payment to be made as follows: + All material is guaranteed to be as specified.All work to be completed in a workmanlike �• �^ manner according to standard practices.any alteration or deviation from above specifica- Authorised C- /f tions involving extra costs will be executed only upon written orders,and will become an Signature extra charge over and above the estimate.all agreements contingent upon strikes,accidents or delays beyond our control.owner to carry fire,tornado and any other necessary insurance. Note:This proposal may be Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within tet; Days. ArreptanrP of t1r11}100d The above prices,specifications / and conditions are satisfactory and are hereby accepted.You are authorized Signature to do the work as specified.Payyyme will a made as outlined above. Date of Acceptance: / � Signature Vroposat Page No of Pages &j Specializing in all types of MA 978-683-2968 Roofing - Ventilation NH 603-898-1058 ROOFING Carpentry PROPOSAL SUBMITTED TO PHONE DATE STREET JOB NAME i CITY,STATE&ZIP CODE JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimate for: I i We Propose hereby to furnish material and labor - complete in accordance with above specifications, for the sum of: Dollars($ ). Payment to be made as follows: All material is guaranteed to be as specified.All work to be completed in a workmanlike Authorised manner according to standard practices.any alteration or deviation from above speciflca- Signature tions involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.all agreements contingent upon strikes,accidents or delays beyond our control.owner to carry fire,tornado and any other necessary insurance. Note:This proposal may be Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within Days. Pxrgxtanrr of Proposal The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized Signature to do the work as specified.Payment will be made as outlined above. Date of Acceptance: Signature Massachusetts -Department of Public Safety Board of Building Regulations ulations and Standards Construction Supers isor License: CS-065870 JAMES P FREDEf4CK 352 ISLAND POPW RD DERRY NH 030A r, A j4' Expiratior Commissioner 12/17/201 + Vfie�panz7raa�acuetrl��'o�C��tr2Jtrcfccee Office of Consumer Affairs&Business Reg.elAtior. gaOME IMPROVEMENT CONTRACTOR egistration: 126777 Type: xpiration:.::..7/19/2014. Individual JAMES P.FREDERICK_:::: i, JAMES FREDERICK 352 ISLAND POND RD` _ DERRY, NH 03038 Undersecretary i,,. r: .q i r' c 1 t Massachusetts -Department of Public Safety �f Board of Building Regulations and Standards Construction Supen-isor License: CS-065870 i JAMES P FREDEOICK 352 ISLAND POND RD - DERRY NH 030A )1141\ Expiratior Commissioner 12/17/201, ,p� �e�pa�a�uaietaca���o�C�/��c:raacfu�e O£f ex of Consumer Affairs&Business Reg Zation _ ; = OME IMPROVEMENT CONTRACTOR i - _ , eglstration: -126777 Type: ' I xpiration: 7/19/2014 Individual JAMES P.FREDERICK.= i. JAMES FREDERICK, 352 ISLAND POND RD, g � DERRY, NH 03038 Undersecretary i•. 4 roz I i i