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HomeMy WebLinkAboutBuilding Permit #374-13 - 103 MILLPOND 11/6/2012 { } TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION j Permit NO: �� Date Received Date Issued: "-- - ", IMPORTANT:Applicant must complete all items on this page o � . WCATIONA(��j _M%\\ , Print PROPERTY QWNER Print 100 YearOld Structure) yes no; MAP NO: - PA_RCEL: Z0NING'DIST€RIOT: HistoricUstrict, yes no- MachineaShop�Village, yes, no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial Ysoteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septic. flWell' D Floodplain: q V.Mlands, ❑ Watershedi0istrict, I]Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type orri t Clearly) OWNER: Name: Phone: q —Co&Co—qGM Address: l N\;k\plc CONTRACTOR NameY (\ CSc� Address: { .. Supervisor's-Construction Licenser Home Improvement,License: \ L-�_ _ Exp: Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ��. _75KA" , �(� FEE: $ Check No.: Receipt No.: NOTE: Persons contractin with unre istered contractors do not have acce a uara PL*�_ Si nature of A ent/Ow _ Si naturefof contracto { 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 o Building Permit Application o Workers Comp Affidavit u Photo Copy Of H.I.C. And/Or C.S.L. Licenses Li Copy of Contract a Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: 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 o Copy Of Contract a Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Mass check Energy Compliance Report (If Applicable) o 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) a Building Permit Application o Certified Proposed Plot Plan a Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report Li 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 2012 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ I 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 i INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS I i I Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Wates & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Os ood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at'124:Main'Street Fire Depa'r#inent-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 DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10041000 fine NOTES and DATA— (For department use El Notified for pickup - Date Doc.Building Permit Revised 2010 Location/��_ �� No. Date — • - TOWN OF NORTH ANDOVER x O "gym Certificate of Occupancy $ Building/Frame Permit Fee �l F Foundation Permit Fee $ Other Permit Fee $ ; TOTAL $ r Check 4- 25914 Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost j $ 15,789.00 m $ - $ 189.47 Plumbing Fee $ 23.68 Gas Fee 100 comm. $- 1100.00: Electrical Fee $ 23.68 Total fees collected $ 336.84 103 Mill Pond Road 374-13 on 11/6/12 Bathroom Remodel 10/24/2012 7:42:08 AM PST (GMT-8) FROM: 100005-TO: 16034376134 Page: 2 of 2 �1 ® CERTIFICATE OF LIABILITY INSURANCE 710/24/2012 (MM/OD/YYYY) a�orra 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 PAUL T MURPHY INSURANCE AGENCY INC CONTACT NAME: 628 BROADWAY PHONE A1C No Ext: 781 321-9700 F A1C No: 81 324-42 3 MALDEN, MA 02148 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC if INSURERA: INSURED INSURERS: ARTHUR WATSON DBA AF WATSON GENERAL CONTRACTING INSURER(: 3 EDGEMONT ST 14SURERD: DERRY NH 03038 NSURERE: NSURERF: COVERAGES CERTIFICATE NUMBER: 14504882 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MMIDDIYYY MMIDDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE F-1 OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY F PRO- LOC $ OMBINED SINGLE AUTOMOBILE LIABILITY EIMIT a accident) L $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED F7SCHEDULED BODILY INJURY(Per accident) AUTOS AUTOS $ HIRED AUTOS AUTOS (PRO aERd�tDAMAGE $ $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ $ $ A WORKERS COMPENSATION WC5-31 S-384095-012 1/5/2012 1/5/2013WC STATU. AND EMPLOYERS'LIABILITY YIN J TORY LIMITS ANY PROPRIETORIPARTNER/EXECUTNE E.L.EACH ACCIDENT $ 100000 OFFICERIMEMBER EXCLUDED? ❑Y NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR ARTHUR WATSON. Workers compensation insurance coverage applies only to the workers compensation laws of the state MA. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE KAREN HALEY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 103 MILL POND ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER MA 01845 AUTHORIZED REPRESENTATIVE t y J A Jeff Eldridge ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD CERT No.: 14504882 CLIENT CODE: 1578924 Katherine Nicholo5 10/24/2012 7:38:01 AM Page 1 of 1 This cecti ficate cancels and supersedes ALL previously issued certificates. From:JOHN OBREY Fax:(866)295-1921 To: 16034376134@rcfax.cc Fax: +1 603437 61 34 Page 2 of 5 10124/2012 3:55 AIS D' CERTIFICATE OF LIABILITY INSURANCE DATE(rbaBDDmrv) PRODUCER f 0124012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ObreylmuNra eeAgenCy,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1E Commons Drive Ung 27 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Larmlanderry NH 00063 INSURERS AFFORDING COVERAGE INSURED Af Watson General Ccrlb no INNAIL 9 SUAEp MAIN 3 Edgemont81 INSU R Derry NH 03OW [INISURERC; INSU EA D: COVERAGES INSURER E: TANY HEPOLICI ESOFINSURANCELISTEDBELOWHAVESEEN ISSUEOTOTHE INSUREDNAMEDABOVEFORTHEPOLICYPERIODINDICATED.NOTWITHSTANDING MAYPERTAIN,ITHEIIV URm OR RANCEAFFOITION RDEDB THHEPOLIGESDE CRIBEDHERRACT OR OTHER�EINISSUBJECUMENT T OALETHETERMS.EXTH'CLUSITO WHICH EQTRI�,SFgNDCONDTONSOFSUCM POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TWO D' POLICYNUMBER CYEFFECTIVE LIC1fEXPIRATION GENERAL LuWUTY LJMRS A X COMMERCIAL GENE LIABtIITY MPT4730C EACH OCCU -NCE 1 DDD 000 1012112012 101219913 oAMAGE TO RENTED 100 CUAIMSMADE X OOCUR MED EXP An $5,000 PE NAL d AOV INJURY S 1 000 ODD 7-COMpinp ATE S 100 ODD GPM AGGREGA LIMIT APPLIES PER: POLICY PRO- LOC -PRODUCTSPA7P G S 100 000 AUTOMOBILE LIABILITY A ANY auto B1T5304C 10121PZ01Z 1Q►2112013 LfMrr 51,ODD()DoALL OWNED AUTOSX SCHEDULED AUTOS X) HIRED AUTOS X NON-OWNEDAUTOS BODILYINJURY (Per awdenU) S PROPERTY DAMAGE $ (Per accwrr7) GARAGE LIABILITY ANY AUTO UTO ONLY-EA CID OTHERTHAN EA ACC AUTO Zr AGG S E)OCESS/UMBRELLA UABILRY Uq EAtItOCCURRENCE S CLAIMSMADE AGG T S DEDUCTIBLE 5 RETENTION S S WORKERSCOMPENSATION S AND EMPLOYERS'UABRRY r�N WC STATU OTH- ANY PROPRI ETORIPARTNERM.XECVTwa—I OFFICERIMEMBER EXCLUDED? E L.EACH ACG S (Mmrdatory In NH) II ea I describe ander E.L.DISEASE•EA EMP OYE 5 I OTHER E.L.DISEASE-POLICY LIMrr DESCRIPTION OF OPERATIONS/LoCATI0NS1 VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER JAUTHOflIZEDREPRESENTATryEd LD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 103 MILL POND THEREOF,THE ISSUING INSURER WILL ENDEAVOR To MAUL X30~ DAYS WRITTEN CE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUr FAILURE TO 00 SO SHALL NORTH ANDOVER,MA DIN$ SE NO OBLIGATION OR UAB&HY OF ANY KIND UPON THE INSURER.ITS AGENTS OR ESENT TIVES. 9 1= <JO> ACORD 25(2009/01) ®198844 ACORD CORPO ON. All rights reserved. The ACORD name and logo are registered marks of ACORD - NORTH Town ofover T ® � 4 zh ver, Mass (40 • C% LAKE COCHIC Kl MACK y1 `r U BOARD OF HEALTH LDFood/Kitchen Septic System PLERM T BUILDING INSPECTOR THIS CERTIFIES THAT �«••• • • •• � ••'• •' "' "' ""' ............ ..................... . /�1 •. Foundation 1.0..M......... ,11......... .. ... ..t................. has permission to erect.......................... buildings on . Rough Chimney to be occupied as .... .0....... ........ .. .. ............. ..... .. .. ... e 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 PLUMBING INSPECTOR Construction of Buildings in the Town of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU6ON4RTS Rough Service ..... Final BUILDING INS ECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Final Display in a Conspicuous Place on the Premises — Qo Not Remove FIRE DEPARTMENT No Lathing or Dry Wall To Be Done Burner Until Inspected and Approved by the Building Inspector. Street No. Smoke Det. SEE REVERSE SIDE NORTH Town ofs_� ., over O 0 A- I A In h ver, Mass, COC MIC Nl weCM ��ADR�7ED AP�,t�CS S V BOARD OF HEALTH I PERMIT LD Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT �'� ' �.. ........... ........� ... . .. ........ ................................. Foundation has permission to erect .......................... buildings on .1.03........ 111......... .. ... •-V.................... Rough tobe occupied as .... ................ ........ .. .. ... ......... ..................................... 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 CONSTRU ON RTS Rough Service ......... .. ................. ....... .............. Final _ _ BUILDING INS E C T 0 R 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. IF SEE REVERSE SIDE ® ® — F1 sBaen3a SB703826 LIVING AREA 720 sq ft A � eOffice of onsumer airs mess ego h{OME JMPROVEtiI�ENT GOtj fRA)CTOR Type: Registration 1.18848 Expiration: 412812013 . DBA IA. ATSON GEN€QF kTRACT{NG< ARTHUR WATSOk r 3 EDGEMONT ST t DERRY,NH 03038 . Undersecretary Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supenisor I &2 Family License: CSFA-063168 ARTHUR F WASONP t 3 EDGEM0114 STm DERRY NH X3038 Expiration , Commissioner 02/12/2014 1' A. F. Watson General Contracting Estimate 3 Edgemont Street Derry,NH 03038 DATE ESTIMATE# Tel. 603-437-6134 Cell#603-661-5360 9/18/2012 1509 NAME/ADDRESS Karen Paterson.Haley 103 Millpond North Andover,Ma 01845 TERMS PROJECT 10%Deposit@start Master Bath ITEM DESCRIPTION QTY COST TOTAL labor Carpenter's labor Demo walls,ceiling,and floor per plan 24 42.00 1,008.00 labor Carpenter's labor 84 42.00 3,528.00 1.Open floor as needed for plumbing to be added for new tub. 2.Install plywood sub floor and tile backer for floor tile. 3.Install blueboard walls&ceiling as needed. 4.Install new vanity cabinet 5.Install ceramic tile floor and shower walls 24SPRUCE 2"x 4"x 8'Spruce stud 6 2.84 17.04 3/4plywood under... 4'x 8'x 3/4 Plywood underlayment 3 30.91 92.73 4x8xxl/4ply 4'x 8'x 1/4"Plywood underlayment 4 16.99 67.96 BlueBd. 4'x 8'x 1/2"Blue Board 5 8.99 44.95 cement board Tx 5'x 1/2"Cement Board the backer 4 13.75 55.00 Miscellaneous Miscellaneous screws,&nails 60.00 60.00 Thinset Thin set cement 3 27.58 82.74 Plastering patching and repair 350.00 350.00 Plumbing Plumbing:Allowance 1,600.00 1,600.00 Electrical Electrical work allowance 1,000.00 1,000.00 Tile Tile Allowance Floor 120 5.00 600.00 Tile Tile Allowance Shower walls 64 5.00 320.00 Subtotal labor&Materials 8_,826.42 Cont.fee Contractors 10%Fee profit+overhead 10.00% 882.64 Fixtures Plumbing fixtures 3,000.00 .3,000.00 Doors Custom Glass shower door Allowance 2,000.00 2,000.00 Painting Painting Allowance 700.00 700.00 Dumping Charg Disposal Fees 200.00 200.00 Permit Town of N.Andover building permit fee 180.00 180.00 THANK-YOU A.F.WATSON TOTA $1 ,789.06 SIGNATURE OWNERS SIGNAT Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the states Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Hore Infor ation Contractor information Name nCompany Name Street Address(do not use a Post Office Box address) ontractor/Salesperson/Owner Name J lo Citylrown State Zip Code Business Address(must include a street address) M Daytime Phone Evening Phone Cityfrown State Zip Code -G,6&-146SU o U3 Mailing Address(It different from above) usiness Phon Federal Employer ID or S.S.Number Nome hap —errem cornraclor Reg.Numher Extritawn date Lm mgatns that most home tmn d.gd•t w.... .bare 1` s 13 ra.rgtslratioa•amber 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 necessary.) Q(�5'nCAe\*1 nc y"�Zr Ix-coWi"a") i,,v eco Required Permits-The following building 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 contractors control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of (� � P Date when contractor will begin contracted work. MGL chapter 142A.) Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule ^� The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: �` t / o p (•) Payments will be made according to the following schedule: $ 78R,pco upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) 64C420 by�l/PV or upon completion of _ i �),30rk $ lJ IO byWR/_or upon completion of MMYlCA $rn, upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) "J The following material/equipment must be special $�1_ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $��to be paid for NOTES:(a)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(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must he special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty being provided by the contractor?aO No❑Yes(all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for complefio4ofthe work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement 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. 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 a valid Home Improvement Contractor Registration. The law requires most 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 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 Consumer Guide to the Home Improvement Contractor Law. 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 main office or branch office by ordinary mail posted,by telegram sent or by delivery,not I ater than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation orm for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE RE ANK SP ES!!! Two identical m i of the contract must be completed and signed.One copy should go to a ho r. other should be t by the contractor. 0 owner's Signature It or s Si re Date Date i The Commonwealth of Massachusetts fn 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:3 c) C City/State/Zip: Phone#: l 7aa2 Q) Are you an employer?Check the appropriate box: Type of project(required): 1am 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 Z.ElI am a sole proprietor or partner- listed on the attached sheet.t ? 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.El Electrical repairs or additions 3.F] I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.❑Other comp.insurance required.] kny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. tsurance Company Name:1-,1 tCEA'i AA olicy#or Self-ins.Lic.#: Expiration Date: ►b Site Address_10. iMi 1N PCJYNd City/State/Zip: N ,/V\\ ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). _�•J iilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ae 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for insurance coverage verification. �o hereby er pains a d pe try that the information provided above is trate and correct. nature: Date: tone#: Official atse only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i Information and Instructions 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 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 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 number(s)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(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. 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 do license or permit to burn leaves etc. said person is NOT required to complete this affidavit. g ) p P q P 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE -vised 5-26-05 Fax# 617-727-7749._.