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HomeMy WebLinkAboutBuilding Permit #744-15 - 103 JOHNNY CAKE STREET 3/30/2015 BUILDING PERMIT NORTH qti TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit No#: '" Date Received Q°R�TED�Paq9 gSSACHU`��� Date Issued: MPORTANT: Applicant must complete all items on this page LOCATION 0 Print PROPERTY OWNER , _ Print 100 Year Structure yes no MAP,ID 2 PARCEL: ZONING DISTRICT: Historic District yes no + Machine Shop Village yes o j TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: G Identification- Pleas Type or Print Clearly OWNER: Name: 11(� �(�P�1�� Phone: Address: uk CAK4> /v r � v Contractor Name Phone: 7 Address: Q� Supervisor's Construction License: % �� Exp. Date: Home Improvement License: ZZ26�?l�1 Exp. Date: J/7 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. Total Project Cost: ` 7 l FEE: $ b 0 Check No.: Receipt No.: d-46Tq��: NOTE: Persons contracting with a ' ere ntractors do not have access to the r Aund Signature of Agent/Owner y;s ignature of contractor r Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Swim-ming Pools ` , y . ❑ Tanning/Massage/Body Art ❑ , 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 PLANNING & DEVELOPMENT Reviewed On Signature_ 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 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. 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 Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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/Cross Section/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 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:Building Permit Revised 2014 Location /Sv ' An CA"`.6 No. Date • - TOWN OF NORTH ANDOVER . Certificate of Occupancy $72j�;F -- Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ rt TOTAL $ Check# Building Inspector i I r 1 NORTH - _ _ . w: .. . � s � c . . ver No. o K4 ver, Mass, CO[HICHl WKH y1' V BOARD OF HEALTH Food/Kitchen PERM- IT T LD Septic System THIS CERTIFIES THAT �6 ,J �� 'Cot BUILDING INSPECTOR ................................ .....................�............................................................ ..,. has permission to erect .......................... buildings on ...�. .......�. �?.. ...4��i 4,•r.Qr.... -..' Foundation Rough to be occupied as ......... �Y ......- -. Svl.. .... ... 1................................... Chimney provided that the person accepting this permit3'fiall 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION 7 Rough Service ................................................................................ Final BUILDING INSPECTOR GAS INSPECTOR OccupancyPermit Reuired to Occupy BuildinPermit Reuired to Occupy Buildinz 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. This agreement is made by and among Next Step Living, Inc.("NSL") John Breiland 21 Drydock Avenue,2nd floor 103 Johnny Cake St Boston,MA 02210 phone: (866)867-8729 North Andover, MA 01845 A905137 10-Mar-15 1. DESCRIPTION OF WORK TO BE PERFORMED NSL will perform or cause to be performed the following work on the customer's address above,in a professional manner and in accordance with the terms of this Contract,including the attached recommendations/work order describing the work in detail(the"Work")which are incorporated herein by reference: ',�f'�x-r•�rIF�j�Y��AAFIAP e o a�.i� .e Q 0,6 b Attic Flat Perform Air Sealing 150.00 at Estimated 62.5 CFM50 Per Hour 0 85 00 8 Vey 7 Attic Flat Whole house fan box:Thermal Barrier Polyiso 2"(Attic) 1 $209.21 Each $209.21 Attic Stair Cover Thermal Barrier with Carpentry 1 $237.65 Each $237.65 Propavent 2'or 4' 100 $2.00 Each $200.00 - _.,--- Knee Wall — -- -- --- ---- -- - ------------ ------------- - ----- ----- ------- --- --- -- Install 2"Thermal Barrier Polyiso on Kneewall 54 $3.50 sqft $189.00 -- ------------------------------------------- ---------- -- -- ---- Misc Insulation Removal 184 $0.75 sqft $138.00 _• is : Foundation -- - - - ---------- - ----------------------------------------------------- --------- Insulate Rim Joist With 2"Thermal Barrier Polyiso 184 $3.52 sqft $647.68 i. �alm� $ 100%Airsealing Incentive up to Program Max $850.00 75%Weatherization Incentive up to Program Max $1,216.16 Estimated Annual Energy Savings from the Above Improvements $178.00 Customer Signature Date 10 Mar 2015 Elizabeth Venuti NSL Signature Date Name of NSL Representative A905137 The Terms of this Agreement are contained on both sides of this page Next Step Living"21 Drydock Avenue"2nd floor"Boston,MA 02210"(866)867-8729"inquiry@nextsteplivinginc.com"www.nextstepliving.com TERMS OF AGREEMENT A905137 3.PROPOSED START DATE AND COMPLETION SCHEDULE NSL will contact customer to schedule the Work at a mutually agreeable time.subject to the availability of subcontractors or materials,or to delays attributable to the weather or other events beyond NSL's control. 4.CONTRACTOR REGISTRATION Massachusetts law requires home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to: Office of Consumer Affairs and Business Regulation,Ten Park Plaza,Suite 5170,Boston,MA 02116.617.973.8700. 5.PERMITS NSL will obtain any necessary permits as the Customer's agent. Customers who secure their own permits or deal with an unregistered contractor will be excluded from the Guaranty Fund provisions of the Home Improvement Contractor Law. 6.PERFORMANCE OF THE WORK AND CHANGES 6.1 NSL will not commence the Work prior to signing this Agreement and transmittal of a copy of Agreement to the Customer 6.2 This Agreement may be supplemented,amended,or modified only by the mutual agreement of the parties.No supplement,amendment,or modification of this Agreement shall be binding unless it is in writing and signed by all parties. 6.3 At times,our weatherization team discovers situations in the structure during the course of the Work that indicates a risk for a health or safety concern for residents.Such concerns can include but are not limited to ventilation,potentially hazardous materials such as mold or asbestos,or structural concerns. In the case of health or safety concerns being identified, NSL reserves the right,per section 9.2 of this contract,to communicate concerns to the Customer and halt work until such concerns have been addressed. 6.4 The rebates and incentives available from the Mass Save@ Home Energy Services Program and amounts due from the Customer are based on the best estimate of the situation in the structure by the NSL home energy advisor. However,at times our weatherization team discovers situations in the home during the course of the Work that impact the availability of rebates and incentives from the Mass Save Program. In such situations,NSL will communicate such changes to the Customer,including any impact on amount the Customer would be expected to pay for the Work. The Customer will have the option to remove from the Contract the work elements that need adjustment,or set up a separate contract for performing the adjusted work. 6.5 NSL represents and warrants to the Customer that(a)the materials and equipment furnished under this Agreement will be of good quality and new,(b)that the Work will be free from defects,and(c)that the Work will conform with the description of the Work described in Paragraph 1. 7.INSURANCE AND REGISTRATION NSL represents and warrants to the Customer that it has a valid Home Improvement Contractor Registration(No:162111)and the necessary insurance required by applicable law and normally maintained by prudent contractors in NSL's field,including,but not limited to,Workers Compensafion Insurance for all employees who will perform the Work. 8.QUALITY OF WORK NSL agrees that the Work will be performed in a good and workmanlike manner,and that NSL will repair and replace,at its own expense,and promptly upon Customer's request,any defects in workmanship and materials provided by NSL which appear up to(1)year after completion of the Work or within any longer period as permitted or required under applicable law,provided NSL has received final payment as provided herein. 9.PRE-EXISTING CONDITIONS&PROPERTY PROTECTION 9.1 NSL shall not be responsible for any damages as a consequence of the Work performed in the home due to pre-existing conditions. These conditions include but are not limited to poorly fastened or broken drywall,moisture damage,non-code construction,cracked or fragile siding or shingles,old pipes and fittings,rotting wood,etc. 9.2 NSL reserves the right not to perform Work upon the discovery of asbestos,mold,or any other potential health risk to the Customer. In this event,the Customer is responsible for remedying the at-risk situation,including any necessary removal of hazardous materials and all bills for services to date shall be paid immediately. Work cannot resume until remediation is complete. 9.3 While NSL will make best efforts to protect any property of the Customer, it is the Customer's responsibility to remove or protect,including dust protection,any personal property including the home itself. NSL will not be responsible for damages to or losses of any of the above mentioned property not properly protected prior to the commencement of the Work. 10.GENERAL PROVISIONS. 10.1 NSL reserves the right, the extent permitted by applicable law,to have,file or maintain a mechanic's or material men's lien,or to file a notice of intention to lien,and to take any other steps to perfect and enforce such a lien,if Customer fails to pay NSL as provided herein. 10.2 This Agreement shall be construed in accordance with the laws of the Commonwealth of Massachusetts. 10.3 This Agreement forms the complete integrated agreement between NSL and Customer. The parties represent and warrant that in executing this Agreement,they are not relying on any representations,warranties or terms other than as expressly contained herein. This Agreement supersedes ail prior agreements between the Customer and Contractor and may not be altered absent a subsequent written agreement signed by both parties. You may cancel this Agreement if it has been signed at a place other than the NSL's normal place of business,provided you notify NSL in writing at its main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this Agreement. See the attached notice of cancellation form for an explanation of this right. 11.ENERGY BENEFITS. The Sponsoring Utility Company(the Utility)is entitled to 100%of the energy benefits associated with all Energy Conservation Measures,excluding the value of energy cost savings by the Customer,but including all rights to all associated ISO-NE Energy,Capacity and Reserves Products.NSL agrees to provide the Utility with such further documentation as the Utility may request to confirm the Ufilq's ownership of such benefits and Products. 12.NOTICE CONCERNING SPONSORSHIP. Customer understands and acknowledges that NSL is not an agent,vendor or sub-vendor of The Sponsoring Utility Company(the Utility)with respect to the installation of an energy efficiency measures.In the event of the failure of an energy conservation device to perform as expected,Customer's sole recourse is to Contractor and not to RISE Engineering(RISE) or to the Utility.The Utility and its operating companies shall not maintain,remove or perform any work whatsoever on the energy conservation measures installed. Customer understands and acknowledges that their participation in the Mass Save Home Energy Services Program is voluntary and that they have consented for Contractor to install the proposed energy conservation measures. Customer agrees that it shall not hold RISE,the Utility,their affiliates or operating companies liable for Contractor's to perform its obligations under this agreement,for failure of the energy conservation measures to function,for any damage to Customer's Premises caused by Contractor or for any and all damages to property or injury to persons caused by the energy conservation measures. 13.LIMITED TIME OFFER. The prices and incentive offered in this Contract are subject to change in accordance with The Sponsoring Utility Company Mass Save Home Energy Services Program offers. 14.CONTRACT CANCELLATION Under Massachusetts law,you may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller,which may be his main office or a branch thereof,provided you notify the seller in writing at his main office or branch 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. Mass Save Planview Diagram Customer . ,Jbq� aElt arga Advisor Name: j�c,12}jmgq yr- Address b3 jbHnllJN_ ctivE 27 Advisor Number: Town moew kinoybe— Any limitations to access by truck? Site ID /401DS13"� SCh NOTES v H IS,:O AIC, ►frnLr-L, (t,ou* to ares : ('�wu� covcrL, grI 1 k lZ S C 14 H/ � (DT-Cum 6, QT' I ©PV 0FRVevts, Q1,1 IDo t ®I StoLL 2" WOW oiq Sry LI6rW WR LL. ASN�J v'WSULanall V2LYMVISL (YL7"-F&-) I` i0 Q wsuu4,-E e4T IIS z„POW • I�Af t'E12S I b o� 1�' Wume uotwc-a At-feAny NwtS ILL CAvC�S y� U 3� S1LN ' lwN�� 10 12' L' r r e 3� 0 ti� v y 38' Srt I /o,� 5.5-5 fir � � I�I��t v!'•I.1 L dee ®f Consumer Affairs and Business Regulation t._ 10 Park Plaza o Suite 5170 Bost®n9 Massachusetts 02116 Home Improvement Contract®r Registration Registration: 962911 Type: Supplement Carol NEXT STEP LIVING INC, Expiration: 9�1��2097 ROGER OUELLETTE 21 ®RY®®CK AVE. 2TH FL l BOSTON, MA 02210 Update Address and return card.Mark reason for change. E] Address 0 Renewal ❑ Employment E] Lost Card _. office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. Ilf found return to: Office of Consumer Affairs and Business Regulation Registration: 162111 Type: 10 Park Plaza-Saute 517D Expiration: 1f1412017 Supplement Card Boston,ISA 02116 NEXT STEP LIVING INC. ROGER OUELLETTE 21 DR(DOCK AVE.2TH FLS ; BOSTON.MA 02210 3lndersecretarg Not valid without signature Massachusetts Uepartme,11 or Public Safety Board of Building Regulah. a ld Standards Construction 'Super%imor Speciah,% t q N r+s f- C SK-1®8111 55 STANMORE RO AW vvaffw,nck lii 02w) 0911-312018 Re,s eted To: CSSWC e Msuhfelon Contractor Fa-ijure to posssess a current edition OT the Muss chose= Stale Building Coe is c,-,we for re vo atloon a this license. �oG���L,VtC�?�Si9r�9�9PdU®PPVB�I'6'ad�l�Ff9a0�e �9�,^s�^,r,6���se�c��sQ®E�� 14EKT6 I _ OP 10.EL CERTIFICATE_ OF LIABILITY INSURANCE_ D0/Y1Y4 YY) iOi0`I12 AT THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONSy AND CONFER$ NO KIGHTJ UPON 1Hg G911'FiFIGATP HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGAIIVELV AMEND, E0ENU Ok AI I'ER IHE COVERAGE AFFUkUEU HY 'i'HE POLICIES B3ELOVIf. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHOR14D ROR FSENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the gertificate holder is an ADDITIONAL INSURED,flee policy(les)must be endorsed. If SUBROGATION Iq `i1141La�$�g the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to ghR certificate holder in lieu of such endorsement(s). PRODUCER --- CONTACT - MgLaugh irl i 1570 a00CU Agency NAME: EI'Ifl Lyal,nS f 6 y AlaNN E,,t:781.665.2775 AIC No:781-665.02 828 Lynn¢eIN<s Rarktppy Melrose,MA 02176 E-MAIL John E.McLaughlin Jr. ADDRESS: iMSURER(SI AFFORDING COVERAGE NAIL 9 INSURER A:14811MIUS Insurance INSURED 21 D Step�ck Aven Inc, INSURER B:Commerce Insurance Company 34754 B1 ton,MA 02210e,end Floor INsuRERc:A.I.M.Mutual Insurance Co. Boston,MA 02210 INSURERD:AXIS Insurance Company 15610 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI©P INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHITHIS 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. ILTR TYPE OF INSURANCE D BR POLICY NUMBER MMILDDY EFF MMIDDY EkP LIMIT S A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ®OCCUR ECP2010198-12 09/30/2014 09130/2015 DAMAGETO S _R FN7 Dnce $ 190,00 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1, r00 GEN'!_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ $4010 PRO- POLICY❑JECT M LOC -PRODUCTS-COMP/OPAGG $ ?IQ041000 LE OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ —" Ea accident 1, 05,011 ANY AUTO 14MMBGKKOM 09/30/2014 09/30013 BODILY INJURY(Per person) $ ALL OWNED y SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS x AUTOS Per accident $ $ UMBRELLA LIAB X OCCUREACH OCCURRENCE $ 6,000 00 EXCESS LIAR CLAIMS-MADE ElrU783547012014 09/30/2014 09/30/2015 AGGREGATE $ ,bIO.,QQ DED RETENTION$ _ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE Ya TO BE ISSUED BY CARRIER 09/80/2014 00/30/2013 E.L.EACH ACCIDENT $ 500,01® OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 9D1,Additional Remarks Schedule,may be attached If more space is raquired) FOR INFOYdNATION ONLY I I CERTIFICATE HOLDER CANCELLATION � INFO-01 ISHOULD ANY OF THr ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Information Only THE EXPIP.ATION DATE THEREOF, NOTICE WILL BE DELIVERED IN y ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ,ACORD 25(2014191) TN 1469RP°IOMR lo9F9% Qqf ACORq. �y The Commonweulth t1filIussuc:hu:Yetirs Department of Industrial Accidents Office of In Pestigations I Congress,Street, Suite]00 v,,Wh Boston,M4 02114-2 017 ,M WW.Mass ga-v1dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �. Please Print Legibly NdI21@ (13usirtess/®rganizati®n&dividual)e Next Step Living Address° 21 Drydock Ave ,Cit,/State/Zips Boston, MA 02210 Phone#:(866)867-8729 Are you an employer?Check the appropriate bozo a Type of project(required): 1.0 1 am a employer with 850 4. ® I am a general contractor and 1 employees(full and/or part-time). have hired the sub-contractors 6. ®New construction 2.® 1 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. employees and have workers' 9. E]Building addition [No workers' camp. insurance comp,insurance.t required.] 5. We are a corporation and its 10.E1 Electrical repairs or additions 3.0 1 am a homeowner doing all work officers have exercised their 11.®Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.®Roof repairs insurance required.] t c. 152, §1(4),and we have no Insulation employees. (No workers' 13.§Other _ comp. insurance required.) g t ' Any applicant that checks box#1 must also fill out the section below showing their workers compensation policy information. Ilomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must,submit a new aflxda"it indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not 103e entities,have employees. If sub-contractors have employees,they must provide their workers' comp.policy number. I aman employer that is providing workers'compensation insurance,por my employees. Below is the policy aaftd lob site information. A.I.M Mutual Insurance Company insurance Company Name. p y __.. Policy#or Self-ins. Lie.#:AWC"400-7030025-2014A Expiration Date: 9/30!15 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 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 v fi tion. I do hereby certify under the pains andpen es fperlury that the information provided above is true and correct Signature: /. Date: 10/ 11 /1 11 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 M.