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HomeMy WebLinkAboutBuilding Permit #479-2017 - 1060 OSGOOD STREET 11/7/2016 �an,s N t: NORTy BUILDING PERMIT (� TOWN OF NORTH ANDOVER r APPLICATION FOR PLAN EXAMINATION t,,� /1 ?/�-01.Permit No#: (�GI ' �f 7 Date Received � ADR�TED 9SSac HusE� Date Issued: IMPORTANT:Applicant must complete all items on this page +-0C Tl 4 0 0 - M-AAJ„f3 t Print PROPERTY OWNER __ - r Pnnt: T*89ar Sfructure yes no MAF PARCEL:.00 kZONING DISTRICT' Historic Distract yes no Mae�f me Shop,Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family V<ddition ❑Two or more family El II ustrial ❑Alteration No. of units: �Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ Septic Well J 1] Floodplain >]Wetlands Watershed District ti WaterlSewer , DESCRIPTION OF WORK TO BE PERFORMED: Up - 1 / erns ,,�`n,e zZA ,a 6b J ec Identification- Please e r rant Clearly OWNER: Name: KS �' r4 Phone: Address: t v /Z � Contractor-'Name: Phone Supervisor's Construction.L-icense © 6� 2._ - EXp} Date: ��n 16 - �_ d bq - Exp Date:, Horner mprovernent License:. � - ARCHITECT/ENGINEER %�'�_ Phone: Address: 4 ?Gn/-n �� � Af Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$1250.F. Total Project Cost: $ �� �� t9'� FEE: $ (P (//Io o Check No.: a-"1 Receipt No.: L //y 49^ NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund -- _ .. - --- - -- -- w1 Signature of Agent/Owner Signature of contractor (� I 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 ❑ I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On ZQ Signature_ aj--� COMMENTS O )1v - CONSERVATION Reviewed on 'a h Signature.. Litt- MMENTS HEALTH Reviewed on Siqnature r l OMMENTS t7 (�S��L�tiln� �+'�-► � V 9�5� to f Zonina-'3oard of Appeals: Variance, Petition No: Zoning Decision/receipt submittedY es Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: �._.._ Located 38 -- 4 Osgood Street FIRE DEPAR+TMENT ,,Temp+Dumpste�.on site yes 4;Located,at 124iMa :_ '' _ -. i '" _ x Y inoA Y �. in�St�eet� . � t ��`� � Fife'Departmentisignature/date COMMENTS. Y Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. i 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) N I i II Ilf III ❑ 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 pp 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 VBuilding 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) a 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 Doe:Building Permit Revised 2014 Location C) d No. 7 e7 _ 0:1(j0 Date ► / � /�C), v � • • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $kv LP 0' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 1 `I '2 Building Inspector J i Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 5'55'5,000.00 m $ - $ 660.00 Plumbing Fee $ 82.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 82.50 Total fees collected $ 925.00 1060 Osgood Street 479-2017 on 11/7/2016 Wax Room and and Employee Room at Nail Salon NORTH Town of �.. , Andover No. 71-o ?otl 4 4 z o�h , ver, Mass, // 7 /�•I NICNtW1CN%V1' 7,95 R�TE0 PPa��S U BOARD OF HEALTH Food/Kitchen PERMIT . T. LD Septic System THIS CERTIFIES THAT rs.. ..*. v�. !$# BUILDING INSPECTOR has permission to erect buildings on Foundation .......................... ......�. .4�.......Q•. . .�+..�.. .. to be occupied as ...A... ' Chimney � Rough p ��........ ....,..... e............. .... � e Y 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR V UNLESS CONSTRUCTION UAFTS Rough Service .'..,..... Final It BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required 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. 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 it Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans TYPE OF SEWERAGE DISPOSAL, Public Sewer ❑ Tanning/Massage/Body Art Swimnnmg 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 PLANNING & DEVELOPMENT Reviewed On 1 ZN ) Signature_ C A-/� COMMENTS O � t �ItA 0)I (&Irn CONSERVATION Reviewed on I to Si nature MMENTS _ q HEALTH Reviewed on Signature OMMENTS Zoninac,3oard of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planninb Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature& Date Driveway Permit DPW Town Engineer: Signature: FIRED , Located e 384 Osgood Street er1psteron site- ENT yes . Located at f124 Main tStreet Fre�D -�-_ .� -�--- epartment,signature/date COMMENTS ' through facility) Fast Food 15.0 per ksf GFA Fast Food with-drive through facility) 12.0 per ksf GFA Office and Business Services Data Processing/Telemarketing/Operations 6.0 per ksf GFA Medical Offices (multi-tenant) 4.5 per ksf GFA Clinic (medical offices with outpatient treatment: no 5.5 per ksf GFA overnight stays) Veterinary Establishment,Kennel or Pet Shop or 0.3 per ksf GFA Similar Establishments Bank Branch with Drive-in 5.5 per ksf GFA Funeral or Undertaking Establishment 0.05 per ksf GFA Other Business or Office Uses Not Otherwise Listed 3.0 per ksf GFA Above Industrial R&D establishment,manufacturing, industrial 0 g per ksf GFA services, or extractive industry Industrial 2.0 per ksf GFA Manufacturing/Light Industrial (Single-Use) 1.5 per ksf GFA Industrial Park(Multi-tenant or mix of service, 2.0 per ksf GFA warehouse) Warehouse 0.7 per ksf GFA Storage 0.25 per ksf GFA Other Industrial and Transportation Uses Not As determined by the Planning Board,but Otherwise Listed not less than 0.25 per ksf GFA Governmental and Educational Elementary, and Secondary Schools 0.35 per student;plus 1 per 2 employees College University Determined by parking study specific to subject institution i CulturaURecreational/Entertainment Public Assembly 0.25 per person in permitted capacity Museum 1.5 per 1,000 annual visitors Library 4.5 per ksf GFA Religious Centers 0.6 per seat Cinemas Single-Screen: 0.5 per seat; Up to 5 screens: 0.33 per seat; 5 to 10 screens: 0.3 per seat Theaters(liveperformance) 0.4 per seat Arenas and Stadiums 0.33 per seat 50 per nine (holes); plus the parking Golf Course or Country Club requirements for food or beverage uses described above Health Clubs and Recreational Facilities 2 per player or 1 per 3 persons permitted ca acity 90 I , � '.V Iry%L�47'✓ q /'' S 1� ► /�b2E l M As n/ .41 A-) ? 527kcg 3900 Dr.Greaves Rd.,Kansas MY,MO 64030 (816)761-7476•Fax(816)765-8955•Email.•ruskin@ruskin.com 11/3/2016 1060 Osgood St-Google Maps Google Maps 1060 Osgood St f t , f ,z4 . e OD 6 y f Imagery©2016 Google,Map data©2016 Google 50 ft e� z ME w sy K=y 1060 Osgood St North Andover,MA 01845 LA � . f At this location hftps://www.google.com/maps/place/1060+Osgood+St,+N orth+Andover,+MA+01845/@42.7147605,-71.1172796,120m/data=!3m 1!1 e3!4m5!3m4!1 sOx89e30692.. 1/3 1 Important BERKSHIRE HATHAWAY ' InformationG IJARD INSURANCE ' COMPANIES i A 398 Insured RICHARD S00 H00 INSURANCE AGENCY, INC. H & BROTHERS CONSTRUCTION INC 1148 Washington Street 118 RUSSELL PARK Boston, MA 02118 QUINCY, MA 02169 Changes to Your Workers' Compensation Policy with AmGUARD Insurance Company Policy Number R2WC525224 Polky Period From December 4, 2014 to December 4, 2015, 12:01 AM, standard time at the insured's mailing address. Party Requesting the Change and Type of Endorsement Deleted Forms effective 12/04/2014 WC 000421C - CATASTROPHE(OTHER THAN CERT ACTS OF TERR Premium change: n/a This endorsement changes the Policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below Is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective See Above Policy No. R2WC525224 Endorsement No. Insured H&BROTHERS CONSTRUCTION INC ' Premium N/A Insurance Company Countersigned by AmGUARD Insurance Company Thank You Again for Choosing Berkshire Hathaway GUARD Insurance Companies! Call Customer Service at 800-673-2465 with any questions. i Endorsement DZU CONSTRUCTION, INC. 20 Labadine Street Quincy, MA 02170 Tel: (617) 719-6192 License #: CS-086642 Registration #: 180409 Contract Home Owner Name: Yen Hai Tran Location: 1060 Osgood Street North Andover, MA 10845 Description of work performed: 1)Add a waxroom 2) Add an employee room 3) Add blueboard, sheetrock and paint where agreed upon 4) Add new flooring We Propose hereby to furnish material and labor complete in accordance with the above specifications, for the sum of FIFTY-FIVE THOUSAND dollars ($55.000.00) Payment Terms will be as followed: 1 st Payment: Deposit of $18,000.00 prior to work being done. 2nd Payment: Payment of$18,000.00 Upon passing rough inspection. 3rd Payment: Balance due of $19,000.00 prior to calling for final inspection. Date of Acceptance: Home Owner Signature:. Date of Acceptance: Contractor Signature: r i ,4co OR CERTIFICATE OF LIABILITY INSURANCE r ATE(MM/DD/WYY) 10/27/2016 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 endorsement(s). PRODUCER CONTACT NAME: Carol Chin RICHARD SOO HOO INSURANCE AGENCY PHCN o (617)338-8168 n/C No: ADDRESS: carolchin@soohooinsurance.com 1148 WASHINGTON ST. INSURERS AFFORDING COVERAGE NAIC# BOSTON MA 02118 INSURER A: AMGUARD INSURANCE CO 42390 INSURED INSURER B H &BROTHERS CONSTRUCTION INC INSURER C: INSURER D: 118 RUSSELL PARK INSURER E: QUINCY MA 02169 INSURER F: COVERAGES CERTIFICATE NUMBER: 97881 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 LTR POLICY NUMBER MMIDDNYYY) (MMIDD/YYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY DJE� LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY Per accident $ AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION �/ PER OTH- AND EMPLOYERS'LIABILITY YIN X STATUTE I ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A R2WC653020 12/04/2015 12/04/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of N. Andover ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main St. AUTHORIZED REPRESENTATIVE N.Andover MA 01845 'D_0 Daniel M.Crony,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of jyzdustrialACcidents r I Congress Street,Suite 100 F Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance,A,ffiidavit:Builders/Contractors/FIectxicians/Plunabers. TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Le 'bl A '�Bean-information Name(Business/Organza'on/Individual): SC) /� V �'4��OL - Address: �' �'- City/State/Zip: C`�� 14A- 0-?-��Phone f� •��� G �� Z-,*' , Are you an employer?Checktlie appropriate box: Type of project(required); ( em to ees full anP and/or a1ttime).* 7. ElNeVit`d6nstCil'ction 1.❑I am a employer with P y 2.❑I am a sole proprietor or partnership and have no employees Working for me in 8. R emo deliiig any capacity.[Noworkers'comp.insurance required.] 9, ❑Demolition 3•❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10E]Building addition 4.[]I am a homeowner and will be,hiring contractors to conduct all work on my property. I will e e that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions oprietors with no le 6ye6s. 12,[]Plumbing repairs or additions s. I am a general contractor and T have hired the sub-contractors listed on the attached sheet. 13..0 R TEpa7SS These sub-contractors have employees and have workers'comp.insurance.' 14. ., Other 6.Q We are a corporation and its,officers have exercised their right of bxemption per MGL c. 152,§1(4),and vwe have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. davit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such Homeowners who submit this affi 'Contractors that check this boat must attached an additional sheet showing the name of the sub-contractors and state whether or not fhose entities,have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurancefor my employees. Below is tliepolicy and lob site information. % 1�1,( !e/C�_ Insurance Company Name: ;0_6 �/�fT�lJ,d ? Expiration Date:. It �L_q401'6 Policy#or Self-ins.Lic.#: ��L�1�� lob Site Address: �O 60 City/State/Zip: /U fl'� a � Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration.date). Failure to secure coverage as requited under MGL c.152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. c v hereby certify under the airs andpenalties ofperiury that the information provided above is true and correct Si afore: a'u Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town- Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and 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'd'efuied 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 b6 deemed to be an employee, 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 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=contractors)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 IndustrialAccidenis. 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 dog license or permit to burry leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia �-� ✓v r�r�� o.S Massachusetts -Department of Publ?C Safety1 Board Of Building Regulations and Standards / l IIr{Sl1 U1�11%II JL�IC!V'1�1/1. ''- License: CS-086642 SO V CHAU O`�t �j^ - V .J 20 LABARDM ST 9 p QUINCY MA 0270 r Expiration Commissioner 06/16/2017 • Office of Consumer Affairs&Bisiness Regulation i �'JQME IMPROVEMENT CONTRACTOR Type. I 3gistration: 1804D9 Corporation X6piration: --11112/2016, rP DZU CONSTRUCTION, INC. SO VAN CHAU 1 20 LABADINE ST QUINCY,MA 02170 Undersecretary i a Y . AA4 —v �' or✓ �Yg p .42E /M a•�(c t�f �'Ti�T�Jr✓ i 3900 Dr.Greaves Rd.,Kansas Co,MO 64030 (816)761-7476•Fax(816)765-8955•Email:ruskin@ruskin.com