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HomeMy WebLinkAboutBuilding Permit #300-2017 - 105 PEACH TREE LANE 5/1/2018 NoRTH t� BUILDING PERMIT Allly J44` TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION V AV o ey F . Permit No#: 00 �� Date Received a-!/ / �q°°A TE° SSACHUS� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION o rs�h '+re l�h e Print PROPERTY OWNER 04q pCird'/S— 6700 W"to Print 100 Year Structure yes no MAP 65T PARCEL: 1 a- ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 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 -�J nSVf 0-ie V �.Se tie a,WN :. ❑ Floodplain Wetlands [�. 1NaterShed� strict', DESCRIPTION OF WORK TO BE PERFORMED: nn � �a SIS� ✓�i A'T'?`t*C l�/1SY�k�%1 N -ro K-4 r1 yen-,r f oT o 0 6 Identification- Please Type or Print Clearly OWNER: Name: L,,Aa. g`duS- Goy lKeAll Phone: 5>,F- Gf'1­LJ soy' Address: 10b f(grhrP{c 1-tile Contractor Name: ►?r*e r t d 1k r C Phone: Sok t{r2-7«fl Email: Address: j 1RS7 lilt Si Supervisor's Construction License: t6 Go t7 Exp. Date: yhF�/8 Home Improvement License: Jo 27i G 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: $ LICoo-6 v FEE: $ Check No.: a Receipt No.: 36Y NOTE: Persons contracting ith unre istered contractors do not have access to the guaranty fund 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 Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF -.0 FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature IC30MMENTS HEALTH . 14 Reviewed on Signature COMMENTS Zoning Board of AppeaIs:.Variance, Petition No: Zoning.Decision/receipt submitted yes 1• S Planning Board Decision: Comments ' Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street T,FIRE DEPARTMENT"'Temp D°umpster�onzsite, Yyesi �}' ; Located at.1F24 Main Street + t r..Flrte�®epartment signatureldate„ ' ..-. _ r �14Y .{r� .'!A.a'1 c}:fir, •1 =r n n +�?4 ". r.• 3r4�^.:� -'t k r -` ! . Sr"r ; v�S"§-{�,a�,,} rat GQMMENTS , ._ pp, a= u ..s s , ,, sxEIF�io _. s � a., 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 i DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) I ® Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 i 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 OTE: 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 OTE: 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 iL 2012 I ECC Energy code 4 Engineering Affidavits for Engineered products 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:Building Permit Revised 2014 p �> Location No. 300 Date-q--,O�'a` -ipa/� a • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ IIS Check# Buildin6,lnspectov 30920 - � F NORTH own o s _ ndover O h ver, Mass,COC o 11�K. 1, S U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System �C. . Ce 8..� �" BUILDING INSPECTOR THIS CERTIFIES THAT ....... �o ��.`...... �14C�►.. .....da/.1/.t Foundation has permission to erect .......................... buildings on .... . .. ............ Rough to be occupied as .......... ............ .......... .....1WA Chimney provided that the person accepting this permit shn 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 CONST TIO Rough Service .... .... ... BUIL.. INSPECTOR..... ............ Final 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. Federal 10#F 05-0405529 RISE Engineering RI Contractor Registration No 8186 MA Contractor Registration No 120979 A division of Thicisch Engineering CT Contractor Registration No 520120 ENGINEERING 60 Shawmut,Canton,MA 02021 CONTRACT 339-502-5197 rA 1539-502-6x345 Page 4 PROGRAM THIS CONTRACT IS ENTERED INTO BETWEEN RISE CMA-HES ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED MOW CUSTOMER PHONE - DATE - CUENT® - WORK ORDER Linda Pardus-Goodman wIva (978)682-4900 0210812016 427360 00002 SERVICE STREET its BILUNG STREET 1.08 Peachtree Lane 108 Peachtree Lane t s t t SERVICE CITY,STATE,ZIP BIWNG CITY,STATE,ZIP North Andover,MA 01845 UUU North.Andover,MA 018 DESCRIPTION PHASE ONE-Proposal for this calendar year. $0.00 AiR SEALING:Provide labor and materials to sea]areas of your home against wasteful,excess air leakage. This work;will be perfonned in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams and other products, Primary areas for sealing include air leakage to attics,basements;attached garages and other unheated areas(windows are not generally addressed.) This will.require(8)working hours. A reduction in cubic feet per minute(cfm)of air infiltration will occur,but the actual number of c1m is not guaranteed. At the completion of the weatheri7Ation work,and at.no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-contractor to ensure the safety orthe indoor air quality: $680.00 AIR SEALING.ADDER: (4)working hours. $340.00 DAMMING:Provide labor and materials to install a 12"layer of R-38 unlaced fiberglass halts to(96)square feet for damming purposes. $1.96.80 ATTIC FLAT:Provide labor and materials to install a 10"layer or R-35 Class t Cellulose added to(1976)square feet of opcn attic space. $2,904,72 ATTIC ACCESS:Provide labor and materials to insulate the:back of(l)attic hatch with 2"rigid Thermax board.Weatherstrip'the perimeter. $60.00 VENTILATION:Provide labor and materials to install(1)insulated exhaust hose with gable wall mounted(tapper vent to exhaust existing bathroom fan(s). $118.75 VENTILATION:Provide labor and materials to install(1)insulated exhaust hose with soffit mounted flapper vent to exhaust existing. bathroom fan(s). $118.75 VENTILATION:Provide labor and materials to install ventilation chutes in(90)rafter bays to maintain air flow. $180.00 RISE Engineering will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount. Currently,for eligible measures,Columbia Gas offers 751/o incentive,not to exceed$2,000 per calendar year,and an incentive of'1001/6 for the Air Scaling measures up to the first$680 and an additional$340 if savings are justified by the auditor. For the safety and health ofyour home's indoor air quality,.we will be conducting a blower door diagnostic of the available air flow in your home both before the work is begun,and alter lite w•eatherization work is complete.We will also conduct a full assessment of the combustion safety of your heating system and water heater.This has a value or$90 and is tit no cost to you. Total allowable wcatherization incentive is:$3.]l 0. $90.00 { i Federal ID#05-0405629 ME Engineering RI Contractor Registration No 8186 MA Contractor Registration No 120979 A division of 7hietseh Engineering CT Contractor Registration No 620120 RISE ENGINEERING 60 Shawmnt;Canton,MA 02021 CONTRACT 339-502-5197 FAX 339-502-6345 Page 2 PROGRAM THIS CONTRACT IS ENTERED INTO BETWEEN RISE CMA-HES ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRISEDBELOW. - CUSTOMER PHONE - - DATE CLIENT 9 WORK ORDER Linda Pardus-Goodman (978)682-4909 02/08120.16 427360 00002 ..SERVICE STREET BILLING STREET 108 Peachtree Lane 108 Peachtree Lane SERVICE CITY;STATE,ZIP BILLING CITY,STATE,LP North Andover,MA 01845 North Andover, MA 01845 JOB DESCRIPTION Total: $4,689,02 Program incentive: $3;020.01 Customer Total: $1,669.02 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUNT OF ***One Thousand Six Hundred Sixty-Nine&02/100 Dollars $1,669.02 UPO FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING:CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL-INTEREST OF 1%WILL BE CHARGED MONTHLY ON ANY UNP. BALANCE AFTER 30 DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION, DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES '! UTHOR S LURE-RISE Engineering CUS�ANCE �— NOM THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED VATHIN DATE OF ACCEPTANCE I LR ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPEC.FICATIONSAND CONDITIONS ARE 30 SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORMED TO DO THE WGRK GAYS. AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE I I i r RISE60 Shawmut Road,Unit 21 Canton,MA 020211339-602-6336 ENGINEERING www.RISEengineering.com afi:irrcy Eng.rSi:ac. OWNER AUTHORIZATION FORM I Linda Pardus-Goodman (Owners Name) owner of the property located at: 108 Peachtree Lane, N. Andover, MA 01845 (Property Address) (Property Address) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property.This form is only valid with a signed contract. 1�c towners-Stg6nature :IJ361 L Date ,A6oZo CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 6/10/2016 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 endomemen s. PRODUCER COANTACT LiNME: nda BogdanowicZ Insurance Solutions Corporation PHONE (603)382-4600 No):(603)382-2034 60 Westville RdE-MAIL ADDRESS:lindab@isc-insurance.corn INSURERS AFFORDING COVERAGE NAIC/t Plaistow MR 03865 INSURERA:Western World INSURED INSURERB:Hautilus Insurance Group Polar Bear Insulation Company Inc INSURER C: PO Box 958 INSURER D: INSURER E: Andover MA 01810 INSURER F: COVERAGES CERTIFICATE NUMBER-CL1632326134 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 S B POLICY EFF POLICY EXP LT POLICY NUMBER MM/D YY M/DD/YYY LIMITS R COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE ❑R OCCUR DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ � NPP8274967 3/24/2016 3/24/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER, GENERAL AGGREGATE $ 2,000,000 X POLICY❑PRO- ❑LOC JECT PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ R UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS MADE AGGREGATE $ 1,000,000 DED I RETENTION AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION PER ITH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICEWMEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Add@lonal Remarks Schedule,may be attached H more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St, Ste 2032 ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Reith Maglia/SJA - ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(701401) 6/10/2016 Preview:Certificates of Insurance ) ACC>R& CERTIFICATE OF LIABILITY INSURANCE DATE A s(wYMIDON ) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS j CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES I BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED j REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER E3 IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the pollcy(les)must be endorsed.If SUBROGATION IS WANED,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). 1 PRODUCER CONTACT # NAME: PHONE Automatic Data Processing Insurance Agency,Inc. AIC No Eat: ac,No 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC 9 INSURER A: NorGUARO Insurance Compsrry 31470 i 3 INSURED INSURERS: POLAR BEAR INSULATION CO INC PO BOX 958 INSURER C. Andover,MA 01810 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 503587 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 LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD MIDDI EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE OCCUR __JUKtRitU PREMISES(Ea occurrence) S MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ECOT LOC PRODUCTS-COMPIOP AGG S OTHER: $ i AUTOMOBILE LIABILITY S II (Ea MdeH ANY AUTO BODILY INJURY(Per person) $ ALLOWAUTOS NED SCHEDAUTOS BODILY BODILY INJURY(Par acciderd) $ AMAGE HIRED AUTOS AUTOS -Per aodtlea $ $ j UMBRELLA LIAROCCUR EACH OCCURRENCE $ 1t EXCESS/JAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN x STATUTEANY ER A O FICERRIME BERPEXCLUDED?ECUTIUE NIA N POWC772258 01/01/2016 01/01/2017 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NN) Ifes E.L.DISEASE-FA EMPLOYE $ 1,000,000 ydescribe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ 1,000;000 i I 1 DESCRIPTION OF OPERATIONS I DATIONS 1 VEHICLES(ACORD WI,Additional Remarks Schedule,may be attached H more space Is required) $ ( i ( � i I i t # CERTIFICATE HOLDER CANCELLATION 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE j THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN i Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood st I suite 2035 i 1 North Andover,MA 01845 AUTHORIZED REPRESENTATIVE p A©1988-2014 ACORD CORPORATION.All rights reserved. 1 ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 1` �I https://adpia.adp.com/icertcf/#/run/preview/503587/900012975 t/t 1 The Commonwealth of Massachuse#s Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 Boston,JIM 02114-2017 ,T www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information _Please Print Legibly Name(Business/Organization/Individual): F&4%2��V�p� �.dd:ess: .PO BOX 958 �Nt�VER MA fl181 fl City/State/Zip: Phone#: Are you an employer?Check the appropriate box: —_ . .— TJ-pe of project(required.): .required�. 1.0 I am a employer with_ _ 4• ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors `o E]New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. j' i. ❑Remodeling ship and have no employees These sub-conuactors hve 8. EJ Demolition working for me in any capaci-ty. employees and have workers' I insurance.# 4. EJ Building addition comp.[No workers'comp.insurance P• required.j 5. ❑ We are a corporation and its 10. l Electrical rspairs-or additions 1 ❑ I am a homeowner doing all work officers have exercised their i .1.❑Plumbing repair or additions myself.[No workers'comp. right of exemption per MGL 12.❑Roof repair insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 1311-1 Other comp.insurance required.] *Any applicant that checks box Rl trust also fill out time section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing ail work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this Mx must attached zn addittioral sheet showing the rAme of the sub-con tracor.and sate whether or not thos;entities have empioyees. If the sub-contractors have employees,they must provide their workers'comp.policy number. F am an empl�ver th_a:is prof%diaig uorke:s'cr_-.:nusnsaticn��sz�rance for my z pinyees. Belot: is the policy and job site information. Insurance Company Name-,--n=6 V h A -: n ro ('4 y.re ® M�4 VJ_ Policy#or Sclf ins.Lic.#: ?p\„JC Expiration Date: o/A) /aa Job Site Address: City;Btata!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 Lmprisonment,as well as civil penalties in the form of a STOP WOM ORDER and a fine of up to$250.00 a day against the violator. Be advised that a cozy of this staten� ient may be forwarded to hta Office of Lrivestigations of the DIA for insurance coverage verification. do hereby cern under the alas and eraltiat ofer u that lite in orinatian provided above is tru.a and correct. Si�-ia� : °DateJ Phone#: yo)- 7& 3 6 Official use only. Do not write in this area,to he completed by city or town officiaL Cit Town:Y or 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#• _= Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 102726 Type: DBA Expiration: 7/2/2018 Tr# 419291 POLAR BEAR INSULATION CO. Vincent LeBlanc P.O. BOX 958 ANDOVER MA 01810 Update Address and return card.Mark reason for change. - SCA 1 u 20M-05/11 Address ❑ Renewal F] Employment E] Lost Card .----- _ _ `--. �J�C TGQ777.71Ia/7RK'(r��I o��-'/('�(TS.JQ'C�tI1CIlS 4 Office of Consumer Affairs&Business Regulation License or registration valid for individual use only expiration date. If found return to: before the es HOME IMPROVEMENT CONTRACTOR p Registration:-': 102726 Type: Office of Consumer Affairs and Business Regulation y Expiration 7/2/2018 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 POLAR BEAR INSULATION CO Vincent LeBlanc "ZI " 51 SO.CANAL ST.#5A>.':; :•-,tl;; .�_:- _•._._,: :tea.:-_t. LAWRENCE,MA 01841 Undersecretary WCNoKtva-- Massachusefts -'Department of Public Safety Board of Building Regulations and Standards Construction Super%kor Specialty License: CSSL 106017 °� >T PETER A LEBLANC r 2 EAST PINE STREET 1 a. Plaistow NH 03865 Expiration Commissioner 04/28/2018