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HomeMy WebLinkAboutBuilding Permit #173-13 - 11 FOXHILL ROAD 8/30/2012 ii NORT1y BUILDING PERMIT O��gLED Ib qtr TOWN OF NORTH ANDOVER 32 h °°� APPLICATION FOR PLAN EXAMINATION 70 ry Permit 140: Date Received �� ey A-9 y. 7,4 A�RATEo SSACHUS�� Date Issued: IMPORTANT: Applicant must complete all items on this page rn 4 PR©FERT�Y®WNER !'l �'' -_{��CAr!�! �OCJ I�PP�/f�/ 10y0Year' Sfructur yeses fl9 ;: MAP 2h10PARCEL �3t ZONING DISTRICT }Historic ®ist it ct es3 no k' d .MachineShop,Villa9e rt.Yes!;,, no wry TYPE OF IMPROVEMENT PROPOSED USE Reside tial Non- Residential ❑ New Building 2<ne family ❑Addition ❑Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other .EEISe tic '®Welly f ❑JFlood Iain ®Wetlandssy 3 #� "' '}'` p.� r p _ , ❑-,Watershed District iW, Z DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: . -_ -3��r t`-i' �*, S.}. � : 7s ' ;�+'.^..�. _�`v��ri' ,.;..I+..^.y°P` -- `c • q..-m z ,' � ex -ro' v � c. a � ' �- i��p a ay .i`fa ,,J�. .- a�s" - ^� � �♦ t ^� f�� T{�c'- � ECONTIRACTOR Named27-,, CL = ' Phone %r tet' �.. w Address � 77 ev /�! Oh T! , Exp?, T+T'^j, t n+ Home Improvementllhcense 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 i Project Cost: ZSR FEE: I Check No.: Receipt No.: 2t�� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund I Signature�ofYAgent/Qvvnerf _ s T. Signatureof contractor Location }" No. 3— Date 1 v2012 TOWN OF NORTH ANDOVER e Certificate of Occupancy $ Building/Frame Permit Fee $ 159-00 Foundation Permit Fee $ Other Permit Fee $ t TOTAL $ Check# 25668 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS f HEALTH Reviewed on Signature COMMENTS f 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 ®EPARTMENl TeDum sten onsite :yes ' r 4w 9 t { mp „ +: LXocated pat�124�Main�Street? � �Ea` �S � �, i�4i � i� hr(.x iit.t`r ,y • ..;sr^2-tia� '.r'xr�' ar..p. Sy'.e" s3" fylx ro 4•Fire;Department signature/dates �f) ��.ar �' yus` ,rsx x, r , s a' k �. r ��ro rt1" � t} 1 � _ xt 3' J .n X'2+'�+rsF�F.;."4- •'.n'S��"'g 't3'�s.t!'"��� ^ b (. .ro�,. � .:.v r k) *e -r "1 � '':" t'•` rF 6 .P 't' t� '�fi` ,i .t,r�}-v. ^t,p{,'�`i . " •'l§• ' r i }.x... 4 F „'t.::5 v � rofi .' �` xv r � }" a �G0MMENT4S x-3.�-^�t z..n..:s't tr.. 1.,*�r,'' _..s. .r. �..,ro � w.xt•. .rr. {" r.-r .�,. ..F,� �i.� .,�".E,#�:�wFae�_.t Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, roast 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 i ® Notified for pickup - Date I Doc.Building Permit Revised 2010 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 MOTE: 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/Crossection/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 MOTE. 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) Li Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 10TEo 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 2008 �• NORTH W, -c ve,. . O "� y.• r No. h ver, Mass �Q t0c«1c«ewrcK 1JAW 1_ 26 1� leS�q�ltED APp`,`'�y U BOARD OF HEALTH Food/Kitchen PERMIT .. T D Septic System • THIS CERTIFIES THAT ...11� 4, BUILDING IN ...... SPECTOR has permission to erect ........................... buildings on Foundation .... g �. .... ..�. .... . .L.I,.....R�. !. ...... Rough to be occupied as ....... �" , , �, �� . , 6h .. .. .............. .... ..... .. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on.file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Final 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 &-, ONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU TS Rough Service ... ....... ................ ................................ BUILDING INSPECTOR Final 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. IF SEE REVERSE SIDE Smoke Det. Malcolm Winfield and Helaine Posnick 11 Fox Hill Rd North Andover MA 01845 P: (978) 681-9956 Project: Basement Level Storage Area Remodel Date: August 10, 2012 Dear Malcolm and Helaine, I have attached a standard contract to remodel your basement storage area as discussed previously. Included with the contract is Exhibit A describing the scope of work. Please review and verify I have documented your requirements fully and if acceptable,please print and sign two copies of the contract. I look forward to working with you on this project. Sincerely, 7� Ted Kelley TMK Remodeling CS Lic# 105086 214 Sutton Hill Rd North Andover MA 01845 978 852-4491 www.tmkremodeling.com L TMK Remodeling CS# 105086,WC Lic# 165887,RRP#LR000106 214 Sutton Hill Rd North Andover MA 01845 9788524491 CONTRACTOR AGREEMENT THIS AGREEMENT made this 20JUy and between Theodore Kelley dba TMK Remodeling, Construction Supervisor License'# 10 86,214 Sutton Hill Rd,North Andover MA 01845 hereinafter called the Contractor,and Malcolm Winfield and Helaine Posnick,hereinafter called the Owner. WITNESSETH,that the Contractor and the Owner for the consideration named herein agree as follows: ARTICLE 1. SCOPE OF THE WORK The Contractor shall perform all of the work described in the specifications entitled Exhibit A,as annexed hereto as it pertains to work to be performed on property located at: 11 Fox Hill Rd,North Andover MA 01845. ARTICLE 2. TIME OF COMPLETION The work to be performed under this Contract shall be commenced on or before August 27,2012 and shall be substantially completed on or before September 15,2012. ARTICLE 3. THE CONTRACT PRICE The owner shall pay the Contractor for the labor and materials to be performed and supplied under the Contract the sum of Thirteen Thousand Two Hundred FiftDollars($13,250),subject to additions and deductions pursuant to authorized change orders. The contract price includes One Thousand Seven Hundred Fift Dollars($1,750)in allowances for flooring materials.The final invoice will reflect actual and approved costs for the flooring materials. ARTICLE 4. PROGRESS PAYMENTS Payments of the Contract price shall be paid in the following manner from the Owner to the Contractor: 33%upon contract acceptance and signature 331i upon rough-in completion and rough inspections 33%upon final completion and inspection ARTICLE 5. GENERAL PROVISIONS 1.All work shall be completed in a workmanship like manner and in compliance with all building codes and other applicable laws. 2.To the extent required by law all work shall be performed by individuals duly licensed and authorized by law to perform said work. 3.Contractor may at its discretion engage subcontractors to perform work hereunder,provided Contractor-shall fully pay said subcontractor and in all instances remain responsible for the proper completion of this Contract. 4.Contractor shall furnish Owner appropriate releases or waivers of lien for all work performed or materials provided at the time the next periodic payment shall be due. Initials �P <i//�/1� Page 2 � I I TMK Remodeling CS# 105086,MC Lic# 165887,RRP#LR000106 214 Sutton Hill Rd North Andover MA 01845 9788524491 5.All change orders shall be in writing and signed by both Owner and Contractor. 6.Contractor warrants it is adequately insured for injury to its employees and others incurring loss or injury as a result of the acts of Contractor or its employees and subcontractors. 7.Contractor shall at its own expense obtain all permits necessary for the work to be performed. 8.Contractor agrees to place all debris in an on-site trash receptacle(dumpster)and leave the premises in broom clean condition. 9.In the event Owner shall fail to pay any periodic or installment payment due hereunder,Contractor may cease work without breach pending payment or resolution of any dispute. 10.The Contractor and the Owner hereby mutually agree in advance that in the event that the Contractor and Owner has a dispute concerning this contract,the Contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and the Contractor and Owner shall be required to submit to such arbitration as provided in MGL c 142A. 11.Contractor shall not be liable for any delay due to circumstances beyond its control including strikes,casualty or general unavailability of materials,or inclement weather. 12.Contractor warrants all work forariod of 12 months following g co mpletion. 13.Contractor may post small signage(18x24")on property advertising services during the duration of the project. 14.The Contractor and subcontractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Office of Consumer Affairs and Business Regulation Ten Park Plaza,Suite 5170 Boston,MA 02116 Phone:(617)973-8700 ARTICLE 6. OTHER TERMS Initials 12W� / 1°i`�ci/�Z Page 3 I TMK Remodeling CS# 105086,HIC Lic# 165887,RRP#LR000106 214 Sutton Hill Rd North Andover MA 01845 9788524491 ARTICLE 7. ACCEPTANCE Signed this /Oday o 20 �! i Contractor NOTICE. The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by the contractor. The owner may initiate alternative dispute resolution even where this section is not signed separately by the parties. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES i i Initials / Page 4 TMK Remodeling CS# 105086,HIC Lic# 165887,RRP#LR000106 214 Sutton Hill Rd North Andover MA 01845 978 852-4491 Exhibit A - Statement of Work Project Scope: Remodel existing basement level storage area. 1.00 Demolition 1.01 All items to be removed to be placed in dumpster on site 1.02 Remove existing 2x2 ceiling tiles and grid in both rooms (approx 550 SF) 1.03 Remove existing carpet tack strips on floor 1.04 Remove existing drywall 24" AFF in primary seating area(approx 20 SF) 1.05 Remove carpet,pad, and tack trips on stairs (approx 30 SF) 2.00 Construction 2.01 Rough In 2.02 Construct soffit to enclose mechanical chase and along ceiling perimeter at wall transitions in 4 locations 2.03 Install 2x2 ceiling grid(approx 550 SF) in both rooms to 7' ceiling height 2.04 Rough Inspection 2.05 Finish 2.06 Install 2x2 gyp board ceiling tiles(approx 550 SF) 2.07 Install 1/2" gyp board on walls and soffits,patch and paint 2.08 Install new engineered plank wood floor over vapor barrier/pad(approx 350 SF) 2.09 Install new 4 1/4"baseboards (approx 100 LF) 2.10 Prime and paint walls, doors and trim 2.11 Final Inspection 3.00 HVAC 3.01 N/A 4.00 Electrical 4.01 Rough In 4.02 Install 8 6" recessed light fixtures in ceiling grid on existing switches 4.03 Relocate receptacles, cable,tel outlets to 18" AFF 4.04 Install additional receptacles in seating area 4.05 Rough Inspection 4.05 Finish 4.06 Install finish trims,plates and switches 4.07 Final Inspection 5.00 Plumbing 5.01 Rough In 5.02 Install supply and waste lines for slop sink in storage room 5.03 Rough Inspection 5.03 Finish 5.04 Install slop sink, faucet, connect to supply and waste lines 5.05 Final Inspection Initials / � ��� Page 5 i RightFax C3-2 6/26/2012 12 : 22 : 50 PM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) Ir—rig" 080612012 TM1&aE1lkrTIFICATE 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PHLINE ALLMASS FERNEKEES INS FAX (A/C,No,Ext: AIC 95 MAIN ST PRODUCER READING,MA 01867 CUSTOMER ID#: 77RCB INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: HARTFORD UNDERWRITERS INSURANCE COMPANY KELLEY,THEODORE DBA TMK REMODELING INSURER B: INSURER C: INSURER D: 214 SUTTON HILL RD INSURER E: 4- NORTH ANDOVER,MA 01845 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 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 ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMtDDIYYYY) (MM%DD%YYYY) LIMITS GENERAL LIABILITY ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE F__1 OCCUR. REMISES(Ea occurrence) ED EXP(Any one person) $ ERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY [:]PROJECT a LOC DRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY OMBINED SINGLE $ ANY AUTO -IMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS Per person) HIRED AUTOS $ cINJURY Peerr accident)accident) NON-OWNED AUTOS DROPERTY DAMAGE $ Per accident) UMBRELLA LIAB OCCUR ACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X WC STATUTORY OTHER EMPLOYER'S LIABILITY YM UB-4184P88A-12 04/02/2012 04/02/2013 LIMITS ANY PROPER ITOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 Ifyes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR KELLEY,THEODORE. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER BUILDING INSPECTOR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED ATTN:BUILDING INSPECTOR IN ACCORDANCE WITH THE POLICY PROVISIOt e_._,.,_. 16OSGOOD ST AUTHORIZED REPRESENTATIVE NORTH ANDOVER,MA 01845 ACORD 25(2009109) 1988-2009 ACORD CORP T ` is reserved. Malcolm Winfield and Helaine Posnick 11 Fox Hill Rd North Andover MA 01845 P: (978) 681-9956 Project: Basement Level Remodel Date: August 10, 2012 Dear Malcolm and Helaine, I have attached a standard contract to remodel your basement as discussed previously. Included with the contract is Exhibit A describing the scope of work. Please review and verify I have documented your requirements fully and if acceptable, please print and sign two copies of the contract. I look forward to working with you on this project. Sincerely, Ted Kelley TMK Remodeling CS Lic# 105086 214 Sutton Hill Rd North Andover MA 01845 978 852-4491 www.tn*remodeling.com I i - Massachusetts- Departincnt of Public SJetV Board of Buildinlg Regulations and Standards Construction Supervisor License License: CS 105086 THEODORE KELLEY g: 214 SUTTON HILL RD NORTH ANDOVER, MA 01845 -Expiration: 10/8/2013 Commissioner Tr#: 105086 ✓fie vanviirzaozureczlC� o�.-/f/raaaacfivaelta Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR — Registration: x-165887 Type: Expiration: A-/5 /2014 DBA TMK"REMODELING THEODORE KELLEY -'s, e 214 SUTTON HILL NORTHANDOVER,MA.01845: Undersecretary I i i ; f 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 a shall withhold the issuance or Y 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 olic is required. Be advised policy q 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 an business . P or commercial venture Y (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: 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 evised 5-26-OS Fax#617-727-7749 www,mass.gov/dia i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 U&S www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): o,Cc Address: f �v�� ��zGG 1VJ, i H k,90y6c JV,4 mef City/State/Zip: Phone#: ?7X 95-2 ��& Are on an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. El am a general contractor and I 6. ❑ w construction Are (full and/or part-time).* have hired the sub-contractors 2.E] I am a sole proprietor or partner- listed on the attached sheet. ? 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.F1 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑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.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 1& NO j�1',46�� Policy#or Self-ins.Lic.#: (/� � ��v l�� /Z Expiration Date: Z _ fob Site Address: 111a, ev City/State/Zip: W1M 44,Av 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 Tule 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 if 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 verification. do hereby certify under the pains and penalties f perj_ y that the information provided above is true and correct. ii nature: Date: 8 Z 'hone#• 7,? u S—Z 4T /PI 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#: