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HomeMy WebLinkAboutBuilding Permit #806-12 - 1020 SALEM STREET 5/8/2012 0RTJJ BUILDING PERMIT t%%.F.D ,6 qNA TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit NO: Date ReceivedA r1r:ED) Date Issued: CHUS IMPORTANT:Applicant must complete all items on this page x f: 5 :` � TT 4 " .4z A ,.R@P RERY., OWNERh : biSt yrs ,, .t T. .0 AT nP TYPE OF IMPROVEMENT PROPOSED USE -ResUential Non- Residential 7- El New Building V One family El Industrial 0 Addition [I Two or more family Iteration No. of units: El Commercial D Repair, replacement 0 Assessory Bldg El Others: [I Demolition E❑I Other ZMg_ T ' , ❑SotiwelNal MITFWE, h0 District Wc ; DESCRIPTION OF WORK TO BE PREFORMED: LA.3 --/O(AJ Identification Please Type or Print Clearly) OWNER: Name:_ L� v3x AP-00 Phone:(etl Address: 10 Ngime. ,-0tNTKAG*T_ L 't d d reg�! M Li e?Lhge14__nR;z '0 byr, ViW:CQ#,n._ ('60oln Lie P - a ARCHITECT/ENGINEER & Phone: Address: Reg. No. FEE SCHEDULE:B ULDING PERMIT:M 00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ -7 3 U-7 FEE: $ 7-00 Check No., A Receipt No.: NOTE: rso s ontracti th unregistered contractors do not have access to the guaranty fund 1 ''K 'bt. 1g. Life. 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 o Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑- Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass'check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products V®TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit of Building Plans One To Be Returned) to Include Sprinkler Plan And o Two Sets ( 9 Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report D Engineering Affidavits for Engineered products N OTE: 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 I Revised 2.2008 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 DPW Town Engineer: Signature: Located 384 Os ood Street iF�l_RE DEPARTMENT a Temp Dumpster ori site ' _ 'Locate at 124 Man,ca et '4,� -,*"+R, +, f Fay-r� ►t y � * + ,.. .. !] C7xr <4.1 ._. f + d y � y t i 5i�" �F'ire�Department�ignature/date�z ���' �,'�� #�'*-°�t�= -����� �d �s �- � ,a�.:. �_� s���'� �� � �• t � '. ,t�.i,:S a.�t7'„°? j-,�jSY1', {i+S�,yyQ:'�.'*, ; '.het-.++ 'i `x" iY+' "t. ' ,�. ,'t ♦ y, +"may ��S`� Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. 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.$10041000 fine NOTES and DATA— For department use i i ® Notified for pickup - Date Doc.Building Permit Revised 2008 Location No. 4 ©C —�2- Date /2 ® • TOWN OF NORTH ANDOVER e r a� Certificate of Occupancy $ Building/Frame Permit Fee $ 37�G Foundation Permit Fee $ Other Permit Fee $ 1 y TOTAL $ Check# �� 25279 Buhing Inspector NORTH 0VM Of er LAK0 E o , dower, 1Vlass., `COC MIC HE WICK ��. AD11:?A T E D P9 S U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System �r' / BUILDING INSPECTOR CHIS CERTIFIES THAT.........�7`�4 .................. .. ..... .................................................................... Foundation las permission to erect............::.......................... buildings on ./ ,2.0.....Sale-- 7, 7 Sl ................... Rough ................ .......... o be occupied as........ fUr7 .. �c�.,f �'e ��'` ....-...../r�G�/ /' �, j .�IVt��1a11 Chimney irovided that the person accepting this permit shall in every respect conform to the erms of the application on file in Final his office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of 3uildings in the Town of North Andover. �g�i7 6e>f;.��pW PLUMBING INSPECTOR IIOLATION of the Zoning or Building Regulations Voids this Permit. / Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO TARTS Rough . ............... ........ .......................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry wall To Be Done FIRE-DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE11 Smoke Det. t, L cv � I AIA Document A105 t�ndud Form of A.. reem�ntp Between Ownera' nd 6ontraptor for a Small Project where the Basis of Payment is a STIPULATED SUM 1993 SMALL PROJECTS EDITION i Bc,catwx.,this document has important legal consequences, we encourage you td consult with an attorney before signing it, Some states mandate a cancellation period oi ul�e other spec 'c disclosurex includit warnings for home improvement contracts, u►hen a docurraq�rrt sawb a.c this will be used for Word on the owner's personal residence. Your attorney should insert aif Ian iuWe required by state or local law to be included in this dement.Such statements may be entero In the$pace provided below, or(f required by law,above the signatures of the parties, I t �b This AGREEMENT is made: MA-V 2 O[Z iOrr,a, BETWEEN the Owner: Aun4o-n1 L;,Arre,iv I 1t^20 SaL� ST I Rri 4 and the Contractor: 0 A6C- po80..4 111)6Rt14 for the following Project: 2 FLooR L_Aja.z�Ry GLo_sLvr $A5 1`►� 8A N 2eios-i t 5 i Ong AGC 900&4 The Architect Is: GJJA. . F enrA C-z-tractr_%r 90MOP PA fhll )w4. of APchlterlA, !?3S New Vork Avenue.N.W..Washington.U.G..t1111ifi.4292 ll4prt1tltt�tlofl of tht n►utt r1a1 hsrt:ln N ItlJIC e @9[:t►Itgrt�tht ly91 tip Phe Aflterisafl Int vioams the vo iot tuns elf Ihta t:nits.al atatts and will sul►l«r Iht %iolator to or ouhxtantlal tltmtntltrn e►f Its pruvLK�nns withtsut tha written l>�tmixslan uP thr a1A l►? I Ittlull l�rcmrv►uttt►�t, i a AIA DOCUMENT A105•o"11R.CONTRACTOR AUKEFf:•tUNT-"MA6t,PHOJUL143 e,xMA 0 ►tttr AMNtiIf.A,`IN..Srrr 115 of ARt:HJ111 ..1735 NRW YORK r INE CO ACr Oi CUMEM ��a11���tttt,1e���ti>o`1��n���t �� �c COMM�7ncsimeni8,��alnt�lit- Tbz Garb'n,olty 'ncd by sbu owper and Conimrm, . cumern aMW Condhionn of lie Conta�ct:fforConstrucaion Fifa Small Paxa WI I'mr-M cliti ; �3ae�ra�vJrig �n�l Spec;flt�ticc�na {aumd b.. ch st ,slaacsl s and en mnemied as MIMM: :orzring& AT-rA G Hz 5 doo*ms; A'rTAC,Nt--7D „ d by the AnbltCct as l0l10 ; PJ f/.� .5 nen;change�Cer�ter fr olnoir chengeS 3n the wodt usued Ater udon of d-dlls Agreement; and .6 otbordocumem,.Ifswy�identML-d"f011 : l nttr-- �t Alit Wsoe .? s . _.. . xe»r�s�ra ewe elm AND SUNTAMAL COMPLEM VAl,re SAF CO vlow. 11. SAU"I'M ly ibun AS SocAJ In 20tubimem by CbIl,'W'OnIL'f- allwo-file ACT SUM -I-be CmIlrAct Sum Tjc"ry O�dvr, 3,1 SubjeAMOM �AJe 'pa 111la5, wol"k, 12 For PUMOM Of Paymem j�ecvflmct sum indudw.1-bef'o'llowIng ftram*IWO& The sum sba AGM Wrr-'Whl�TUW-= Al ill ARTICIA 4 PA -necL the Oars sball 11Vunmriol3 e "s f"MMS, , ling JCC al.1bap ,Cantrac,j,)ocumcnts shall beat intemst fr .,Of be pjAa*t. C2 ,,V,Ments djL .1bereof, trete P aleAW InIOW-13 'Orin*e gbsenLe tracts►r's��cltprcacat�gl�rr.�tn��trrrh�ru q3 .1 ALS INSURMICE pjxMoeCon ffwcWs WbIlftyand err Insure 08 Muws; 5.1 The Contmew A �,2 nCrl5taa11�3]��ide�+s1Cs°'�f1it1���-��'SCK Sj I fit tXjjtf,,,jk:Wj:njufll uAm-- Commut-fort"Ohs"ON-In P.,Uvgmpl-,3..12 iof.AM n"'Umem tj')nTMenCC111VJnI Of ,of Inslimnm shat bg pmvjdcd by each PaMsb'-')vdn,9"beer 1'4$P`�Ov:ct'YL' SA CxYTIRM198 the vot AM DOCUUM AIDD um,Vf M, ARTICLE 6 OTNER TERMS AND CONDITIONS Klldlrlar<t►runup.) : I f Irrav M rttti ndin r frnox or twif i This Agreement entered into as of the clay and year first written above, i rdlrvxrd► !n las;brruri turtr�lirtdlart pvtiarl dfsclost►rus or odour•tranrUrg starterarantsadratva rlw stgna►rrrift) f OWNS l CONT RACrOR A_ A t � _ <►�NAS t�'�"e A � — (Al"ted name,tideland addrea) (l;rFnted name,title and addnerso �t�2c� ��tC1 ST 1NJA6C 0. &K 13Z- LICENSE NO. G� lUmsDICTiON CAUTION: You should eign en original AIA document which has this caution printed In red. An original essuros that changes will not be obscured as may occur when documents are reproduced- See Instruction sheet for Limited Licence for Reproduction of thie document. AIA DOCUNIM'I'A108•OWNgR.CONTRACTOR AGRUDIENT—SMALL PROJECTS I WMor,i 0 AW.01"3.3718 AMOCAN INnTM OF AKHnB n,1735 NEW YORK ».werou�tfrJlt•llMdnrrt�dt�RIItOBQ11Milt� I 11'Inarlti�i:1< s `'1.tssachusetts-'Deja .trtlnent of Yt11t1ic�afrt: Board of.Btiildira+g, Re!!tiiations ind Sta 1t1.ird f . Construction Supervisor License , ^q License: CS 162616 44 Restrictled7to: 00 r JOAN R LEEMAN JR 70 PILLON ROAD r MILTON, MA 02166 Expiration: 6/16/2012 j!!! --('oijuuis.ir+er Tr##: 27393 t i Office of Consumer Affairs andusiness Regulation 10 Park Plaza - Suite 5170 �M Boston, Massachusetts 02116 Dome Improvement Cdactor Registration Registration: 137552 - Type; Private Corporation =- Expiration; 11/26/2012 TO 205622 NORTH ANDOVER BUILDING CORP JOHN LEEMAN is P.O. BOX 132 N. ANDOVER, MA 01845 F�Jpdate Address and return card,Nark reason for change. Address Renewal Employment Lost Card DPS-CA1 Co 50M-04/04-G101216 I C I I CERTIFICATE/0- ��� MNLlD OF LIABILITY INSURANCE ' °w" /THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UP@N THE CERTIFICATE HOLDER, THIS 11/15/2011 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 13ETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an AQOITIONAL INSUR€D,the pollcy(iss)moot be endorsed. II?SUBROGATI@N 1�WAIVED,a�ehjoct� the terms and erInlieu conditions of the policy,certain Policies may require an ondorsomenL A statement on this cero%#%po dodo not confer rights to the certificate holder!n Ilou of such endorsomon s, urray PRODUCER 1N 2naurance Associatesinda Al681-5 575 Chickering R$ law, (9T®3661-5700 I?79)691=5777 lisdaa6etaSss e.COM North Andover MA6 01845 �Y�oa Neon INSURED A3lautilus Insurance C John Leeman, ASA: North Andover Building Corp ° FO BOX 132 0° 8 AndMr Uh 01845 COVEROWN �1lCJ4T1E MU1t11 :11-12 Iatsr List V TwwTHAt 'nLF'06JC=CFlNSLft CE LIST® ttA1 8I 1. L IONNUMBER: TYN7l1STANDINti Mill�;TS TE CONDITIBELOW HA E EE TK ! �TIE PMOU&AY BE ISMAED OR MAY�TIE INSURA[�AFf4RDW SY AOR OTIC aWMT TO v RNIB DCONDI NS OF 1IIlAfFS SHOIAI I MAP 14AVE limit FAY P"CtsLSTO Att.THE TERdtS;ISM AtQVdK tUA8UrV fi" S 1,000,0 S-VDE �O=M S 100, 1?3/20=a ani 0 S. R CNALS ASN MjtMy ! 2,000,004 A 1TE tlltll APPt!!* P GORMAL ATE b 2,000 ab Z PQt(CY �' � PROOUC7S�L'ONRR4RAiRS � 1,$0Q,00 AirrOrlOdLdl f RfiY At1rO! ASU MOWNED @QriIEY SiA1RY(�r'Pwer+nl f HIRIEDAU,06 Alrr 9O9lLY IKJURY(Psr I f uN'aRnLA11AD QCeuR s �uND EACHs s ANY M0FRVMRWaVIM >w�&ALUMsra ELUCQAOClI 6EL : -PC=LOOT s ollRltT101UIfLOCA IOfISrY�1lG� k11ac4lAE:Dl�40t, 1!!Ib[IbR�rt s A�Ie,PalArsspew ls,�q card Matas hold= as list A� CERTIT>E! CANCE"T" 11Jf1OMPANIfOP1WA P gEC TMTtOfl DATE Tm9wor, MMM ®.L as ow4aw as JL5 ti THEPOLMPRS 1y 1'\ti: ` bhCOODUM C W,, CSC ACM lfl'6Q3Rt�!!! BI16ACO€$AZ AI 1lbw reew��rl lra�ss�w ,VIVA"of SAWVM .r VA, J< A1. 1 d. 1 . V1d 1 III V41V4 CERTIFICATEOF LIABILITY INSURANCE _"A!Hii;iHiVu'�,;i .._: ..� JlC ;'MIITtYtCA�'l9+Yd t�tlllE�®tiff 11 IIA'6"PtlR I?P�ffitlCQti�lAmfOM ONLY IND UO!!f�np NO �tt;a!!4't<t UOON �'tl� tD!1mSSSCAT� NOG9pbt�'�NSIF C&P'>`!q'tG�T��'��') r016 ROT AMPIRtlATIVDLY OR 080"IVMLY A1111110, NXTOND 08 AbTeR TNe COVDR;A09 ArrORD09 BY T!!R FOLICICD UOLON, TRIO VERTIFIVATU Of 'YNCURANCM 0000 NOT CONUTITU'i'L A CONTRACT DCII HN T-111 11JCUt11% INIlURORM, AUTHOR11110 1%VP 990TATFVM OR PROUVOMA, A110 T110 ,euCl.OIiwCRuTO..RI.T.:AwtCiTA..TaH.HOLDNe A1 IuYVhwO ii-`ea..h•«O�leii . w or ADDITIONAL TNDUEDB, the Deilayl@rK12aarn,dw ObNwr.oH.§,.•.wS«:fis.wO...UtrBmRa.OEe.Ot,T.�vSsV:.NF.s�S:..i: wdaSVr19, oub�scC bo bile terms And candibione of bila policy, cerbein policies my require all endereement. A etaWntnt eft this cortilivete 4009 1101 'r Dontar rights to tile Offbificete holder_in lieu of ouch end oNaelnent r , COMM - MTTd UsUranac Afidoeint©n LLC 9NID1 878 Chiakori -rtp�111 rAw n� �tid n!r ne North Andom, MA 01048 rDBtlem9 10q ._.m.. .x� �- North Andovor Building Corp u19s9Yo Al EW. Mutual Insurance Co �._..,_. _ 37 5 0 _. 70 Fillon Road ' PntuN�e, Milton, MA 029100 lt1Au9L8 0l r IN9UDL'9 UI ".'_'_----•--•—- - �. .--- -........�..:..r..---_ _.......-_.._...... INNUNP'N f'1 - .,, .rr - COViC1iA0fCB CIRTIRCATZ NUHH11i RNVIBION NUMMRt 1 �4it"S'a" iNi 'tETiE' [iAT Y4it i `i'br"fth`trs17 �' t D A'g�, "Ili V"walTIiam"0"�tt.�"�iitUil'yti�!t� I NDTNSTNtlTANDItlU ANY 1MQUSILiMr, "IN On CONDITION OP ANY CONTRACT 01 MIS DvOVt'A!NT WITH RESHOT W PTCH THSr OIBTITIOATr NAY MM S961110 01 MAY PIRTASH, TNM iNSUNANUM AYfO1DMD By 49111 POLSCSII DMSOISDMO 1111DSN IN HUM TO ALL Till TUBS, NNOLUS9901 AND CONDITIONS of SUCH UOLI0IMN1 WHITI slim ' MAY IIAVM DUN 1NDUCID DY PAID OLAILir, i1�1PPOLICY NVHSU ., rOLSOY IPP rOLSOY MNI TYPI Or INSUTA - NOM ,WlmArrrrl I9N!cllrrrrrl LSHITI - t1�ItiRllSfi 4iMlt _..,...., �<........... a.w..............._.<.. „�._.,,..a:a.,......... ...�w.....s<.�.�.,�..,.c�>.�,� .:�.z.,.....�r.�,.,._.�,�._ rAtt!NrruxAtlero � t� 1j1:Cig1YNCJAL UAUNAAL 6WILP'tY UN.F1tlaD9!Da,arupSir so � q 1113cLA11011011 ®�rcop IIID G9p (Any Dna petlnt),� gL��LtY,ny, - UGN9UN01 A AW11h_PY,� ! ,,.,...,.«............._........._ 09 N'L 01140011 LIHIf A(ThINd PAI 9D99UNAUllA9VAP9 .... ., . �Pn6PdY ®}'AhdN54�Lnr IgUIDIIPiN-r1Uln�l!p AItU t ®ANY AUYn (e+A feerldenP! q �. ....,. .a ALL naa6U AUI'rr1 VUOILY 1161UNY IOaP IIEPMlNII ! �tIIANh AVY�u `T!t(iGi:ItfY"L`NtXFiN•"•.;"`•>•.'"•`�••".�-._.,...._......__.,�.,. Iptr meldrn0 1311611,400 AMA ~��NdAA9LLA LthD �v!1.'UIIA�..r....... e.,.....w..��.�...,.......,.-.. ....-- :_._...._. �..........,..,_,......... yM'N OrCU99119r9 �...,._.w.. .�.�......W.....a«....._....w.....<... ®NmewAl DIAD ® a6AIM 1N1,N MIUAGOAtH � q. - h96Ur41 AGAR..�..,...._,._.._._......u.... :.._.....,,,.,.._�_.......:...__,._.. ...,........_�..,...__.<.,.........._ f ._.`...!tOdtlrNl`�3'fdtlNltiTll�tl"..__ � PaNw 4utee AND "LOY1Mr LSAMILITY �MR C}tP hlt�iPhtH H/PAIa791gHb/ 9,L, I O nrrM9Ns q ........�: 100y000 C3 7023207012019D.L. 0189699 .r1.0cy I.Init 1 500,000 11/11/2011 11./11/2012 .„.�,y.b.,,,, _...�.�...�. :<._.......�..�.....�.....�..._.- 11.1'! 01811689.11.4 9nnLr.YDe q 100,000 ION RHO= ANY or "ll ADOV1 D[Rt'1IDrA POLL It g DN CAA0 iDW-0 (IA'pORM 4'It6 >rkpltlATY'0N DnTN 491NpKGf, NO!CIOD tlIt1L PRB6LIVe11N9 in A0O19A1iD4 uI241 191r nabc po box 132 n andover,ma 01845 978-869-9616 mr and mrs warren division description total_ -general conditions $ 760.00 permit included plans/engineering owner project manager included layout included dumpster included tools included equipment included heat, light.Power by owner toilet by owner water by owner demolition $ 432.00 site building included sitework $ 504.00 excavation for plumb excavate egress driveway concrete $ 1,224.00 floor patch plumb foundation slab cutting egress masonry chimney $ - walls steel beams $ - decking rough carpentry $ 3,577.00 framing bath,window, laundry roofing rubber roofing siding windows egress sky lights fire door exterior doors nabc po box 132 n andover,ma 01845 garage doors 978-869-9616 trim finish carpentry $ 2,404.00 ' base/trim included doors 3 included stairs ceiling tiles kitchen cabinets 500 allowance bathroom vanity counter tops other cabinetry Insulation $ - flooring $ 750.00 wood the 750 allowance carpet clean other finishes $ 1,940.00 drywall included plaster paint exterior paint interior bath,laundry,dinning wallpaper hvac $ 225.00 heat reg in bath air conditioning plumbing $ 5,800.00 1000 allow fixtures sprinkler electrical $ 2,120.00 bath,dryer,washer $ 19,736.00 nabc overhead $ 2,763.04 nabc profit $ - diane k total $ 22,499.04 qualifications no unforeseen conditions no hazardous materials rTfl ry The Commonwealth ofMassachusetts . - Department ofl-ndustriglAccidents Office Of Investigations 600 Washington Street .Foston,MA 02111 www.massgov/dia 'workers'Compensation Insurance Affidavit:Builders/Contractors/ElectriciansfPlumbers ,Applicant Information Please Print Legibiy Name(Business/Organization4ndividual): Address: Q $fit City/State/Zip: K) , 1Aq Phone#: q`t) 1�GI, �L AU=ma mployer?Check the appropriate box: Type of project(required): 1. mployer with 4. ❑ I am a general contractor and T 6. ❑New construction employees(full and/orpart-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.x 7• modeling ship and' El no employees These sub-contractors have 8. Demolition working for me in any capacity. workers'comp.insurance. g, ❑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 homeowner doing all work right of exemption per MGL l l.❑Plumbing repairs or additions myself.[No workers'comp. c.152,§l(4),and we have no 12,❑Roofrepairs insurance required.]i 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. T Homeowners who submit this affidavit indicating they 6re doing all work and then hire outside contractors must submit a new affidavit indicating such. tOontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that is providing workers'compensation insurance for my employees Below is thepolicy and f ob site information. Insurance Company Name:. AokA Policy#or Self-ins.Lfc.#: s162 Tj'LS'JO Z Expiration Date: Job Site Address: City/State/Zip:_ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o.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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereb cert!under thepains andpenalties ofperjury that the information provided above is true and'correct - Si ature: Date: IV Phone#: qI L Official use only. Do not write in this area,to he completed by city or town official. City or Town: . Permit/fAcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employeeis defined as"...everyperson in the service of another under any contract ofhire,- express or implied,oral or written" An employer is 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 shallnot 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 orpermit 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 ofpublic 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 number(s)along with their certificates)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 maybe submitted to the Department of Industrial Accidents fox 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 ifyou 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 vrhichwill 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(if necessary)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. Anew affidavit must be filled out each year.More a homeowner or citizen is obtaining a license or perniit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT xequired 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: Tho Commonwealth o Massarizv.:setts - Z3epaxtrnent o�7x�dustrial.A..ccldemts OfAee of Yuwestigatiom 6.00 Waftgoll ft7r t Boston?MA 02111 Tol,#6177 727-4900 ext 406 4r 1-87T MA.SS.AFE Revised 5-26-05 BaY,#617"727^7749 W wanass,govaa w•v1 vraavaa�a YY 111UV W VVQ11 13y0L%.,111 1311ew window wefts wont well wtm " pour4n-place foundation I ws. Consists of side panels and step panels that snap together After the window buck is fns led and on site.Step design cart be landscaped with your favorite _ the foundation has cured,the well is flowers or plants for further visual enhancement. ! anchored to the buck or foun{lation i wall.The bottom of the well 11s filled with crushed stone and the area is back-filled to complete the installation. l.. (ScapeWEL model shown) Remodeling Project Bilco window wells can be installed on.exiating homes to transform a basement into code compliant living SeapeWEL®Dome Cover space.After the location of+window well area clean of snow,leaves and debris.Constructed has been determined,the"must be o Epolycarbonate,this high impact cover is W-resistant and excavated and foundation sad cut to igned for durability and long-life. your a window and.the well.To find d:syour nearest Bilco certified itistaller logon to www.bilco.com. Features: x • Step design aids emergency Additional Blleo Products egress and can be landscaped gylco Basement Doors with plants or flowers for added visual enhancement (: High-density polyethylene molded construction will never rust,rot,or change color and is t Available,in high- UV-stabilized igh- UV stabilized for long life density polyethylene • Attractive driftwood color Heavy duty molded panels and steel construction complements basement interior feature a structural foam SeapeWELO Metal Grate Cover and blends with any architecture core for added strength ps well area clean of leaves and debris while providing • Easily cleaned with standard and ugh' imum ventilation.Cover grate is constructed of steel and household cleaners Basement doors provide tected with a baked on primer finish. • Reversible aluminum mounting flanges mount easily to a convenient direct access to foundation wall or window buck basement areas.The large • Available in a number of sizes to accommodate virtually opening is ideal for moving ';,.. tom-=•— any foundation height large items in and out of the basement and meets building code requirements for emergency egress. i Imagine... What Silco can do for your basements stakWELO Dome Cover well area clean of snow,leaves and debris.Constructed P.O.Box 1203 polycarbonate,this high impact cover is UV-resistant andNew Haven,CT 06505 (800)854-9724 www.blico.com igned for durability and long-life. i ®2010 The Bike,Company,All rights reserved,Printed in"U.SJ ! WWW PV/ t w-Luuuiar w maow well Step 1:Measure or calculate dimension System consists of individual modules that simply slide OA as shown in the detail on the right Building together for fast and easy installation.This flexible system based on the site's grade conditions and Line Window well side Oaras must allows modules to be stacked to accommodate virtually any foundation height. extend 4in.abovede level. foundation depth and provides an economical solution for Grade must be slog:away building code compliance. Ste 2:Determine the from well.OowrI uts must also Step required window be directed away from the well.' well side panel height by performing this =!. simple calculation: Required Side wmd°w — Dimension AO+7'/z" Dimension A StakWEL° or ' Maswretnxn SeapeWEL° From the first column in the table below, bonom of window s'° tDgradetavel Window'Well select the closest side panel height that System will meet the site conditions. Step 3:Once the side panel height has •3-1/2 in. �'( ree draining Use 3/4 in.clean j been determined,read across and select rock or A6 stone Features: the desired window width.With the 44 in.Maximum ,S• � � at least 12 in.in from floor to window Y s kith around all M ndow Modular system provides ys p �. Iw W1ndOW size sal sin �:+ sides of the well. corrosion resistant erformance S acted,read across to a to meat egress ill to depth of p "' code requirements u at"steel-like"prices select the proper window well and cover. :r' foundation High-density polyethylene NOTE:Both stakWEL®and SeapeWEL® oting.,,:, „.•; ': molded construction will never •Wens can be in lied tower models satisfy building code requirements •.�'r;,;;•; than the nd rust,rot,or change color and is ad 3-1/2 In. •''.:"s..*'• to he recomrr UV-stabilized for long life for emergency egress. lP meet grade conditions Unique"Grip/Step"des Features high-density j Tie rode fill into polyethylene molded inserts perimeter drain ff"table features convenient handle and which add strength and gusseted step to meet emergency rigidity to withstand adverse egress requirements freeze/thaw and settling Neutral driftwood color and conditions while simplifying the backfilling process. pebbled interior finish will Standard Sizes and Model Numbers complement the interior of any home Overlappingribs and tabbed inserts lock modules together stakWElO Window Well ScapeWELs Window Well to form a cohesive assembly Side Vtlintdow Modular system can be used on foundations of ten foot Heim Width Modal #of inside Projection n Optional model#S No. [,aide PrDome Of Width ojection Optional Cover and greater in depth p„chs./ til # Modules (-�) Fouon Well Ext. Tiers tautwl Foundation j Panel (Inches) Dome Grate 38 4048.42 X 2 42 41 40420 CG1 48 48 sliand48 3 49%z 40Y. stiand48D �;.. 404854 . X 2 54 41 40r34C CG2 60 X X X X X 4048$6. X 2 66 41 40Bt1C C433 " 36 48624862-42stkwF4B 4 49'/ 40/. 4 " X 3 42 49 CG4 62 48 sIMnM1�18D 486254 X 3 54 49 48540 CGS 60 X X X X X 4862 W X 3 66 49 C CG6 4862-42 301942 3. 42 49 2C CG4 81 4g sno�A•AS 5 49'/s 40'/, stlonM148D 486254 301954 3 54 49 CG5 60 1 X X 1 X X X 4862.66 3019 3 66 49 48§6C CG6 •Window Buck extensions are available to accommodate foundations greater than 10 laches in tlnidmess contact Bilco for more information. X-Not Available