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HomeMy WebLinkAboutBuilding Permit #871-14 - 1132 SALEM STREET 6/2/2014 f Tot BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINA N i Permit NO: ! J Date Received +r � 9SS Date Issued: Z 1 '+CHus IMPORTANT:Applicant.must complete all items on this page "� y . 5yy��;,.� .E :, iz. °"'F �'�{,� s #�' .F7' ..t i?7rt'^4 i �# .^ �'` "�Y trvrk° rt.$•.. .ysr'iN,,7Y ;` �r7� `� ��».: art v,- ,�:,y, �°� •��-.# � E�� w 4.� � .v � �"' -�,�.. w„t'�'i'�"��.': 't��y�r�5 �t'p$rxt- ��.yk. ,ci a s s'i95e MIMI` to 'vkt. 4r flit Z &,.,�Jrt� � gg�� �1����S��I�]�'C 9F'� � _..�h TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑ New Building $(One family ❑Addition ❑Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑Other `❑Se tic " p � elly r A—' `❑:Wetlars =per; ❑ Watersliecl��strict� ` Y ❑WateriSewer � s.,, t ,. i r\: A A a 10 One- o i e J Identification Please Type or Print Clearly) OWNER: Name: rT�u ,� {� - �a y„ Phone: 'SCR-309- Address: ' CONTRACTOR Name: pl�o►ae Me-- , i s ess Ar dd SupervlsOrf$�+ Dt�StrGt4i�77 n LIS$ < ^�'' ��( � ,Lat�e 'H .�u d¢ y }iome,lrnpro.vbmer�t':License,;� 1`xp data �� SII `kr, y h Y e ._•��'u^ $F �, �.;. .T. �.fz. �.Faa t+� # t+ .��- _.,�Y.� � 9 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ` -::F C) FEE: $_ 7-?,0z Check No.: 4Z a 2 Receipt No.: 4 z�: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received a Date Issued: IMPORTANT: Applicant must complete all items on this age Paint_ PROPERTY OWNER ---- Pring 100 Year 1 Structure = yes' r o ° MAP NO` .-_�_.._. :PARCEL:_M__. ..._ZONING'DFSTRI:CT. -- '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 M Septic Q Well a, 0•Floodplair ,�, o We 0 Watershed E)istrlct 0.Wate_r/Sewer. _ - DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: ° CONTRACTOR Name: _~ .. Phone.: _ f 'A ddress: .. e ...___� .....r• ..«....�. - -- - - - -• - - Supervisor's Construction License:- _ _ _ _._� _� ExP. Oate:�=� Home Im.provement�License; - -_ Exp Date:._ Y 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. I Total Project Cost: $ FEE: $ __ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Stgn_ature�of;AgentlOwner' _ __ Sig,�iaturek=of#contractor, Plans Submitted Fj Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ I Building Department rhe following is a-list of the:required.forms,to be filled out for:the appropriate.permit to be obtained. Roofivg, Siding, Interior Rehabilitation Permits ' Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And%O'r C.S.-L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals + that the apw,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Building Permit Revised 2012 . : 'Plans Submitted ❑ Plans Waived ❑: -..Certified Plot Plan ❑ Stamped Plans El _T -PE_OP:SEWERAGEDiSPOSAL public Sewer ❑ Tanning/Massage/Body Art ❑. . _Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private.se tic tank etc._ . Private(se Peiznarient Dinpster on-site ❑ THE-FOLLOWING SECTIONS FOR OFFICE USE ONLY ' INTERDEPARTMENTAL SIGN OFF - U FORM DATE, REJECTED DATE:APPR=OVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS QI onhed 64, Su4v, Ian :CONSERVATION Reviewed on 1 Si nature \ COMMENTS C� CN—ON c� OL�-L -- 6 aS1�c� C- _rZA 0 � tw•-. a."-A )�`HEALTH Reviewed on SO 620 Signature Q • T R; COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments C-onservation Decision: Comments. `,Hater& Suver Connection/Si nature& Date Driveway Permit DPW To-td;! Fnglneer: Signature: � Located 384 Osgood Street f FIRE DEPAR�fIl iT., Temp Dumpster on site yes no Located at l24-Mair Street Fire De artme� signa p rt `5 • S C0MM.ENTS_" ;. Dimension- v Number of Stories:_ Total square feet of floor area, based on Exterior dimensions._, -Total land area, sq. ft.: ----------- ..'ELECTRICAL.:Movement of.Meter, Meter,Iocatlbn, mast Electrical Inspector � Yes or service o chop requires s a pproval of i DANGER. ®NE LITE RATURE. Yes MGL.CFiapter166.section 21A and G min.$1oo=$loon fine No ------------ NOTES and DATA— For department use z1 L 5� �-- �j 6y�wtje4,z, � V 4a a x, �s . P I i 1 b El Notified for pickup - Date )oc.Building Permit Revised 2010 Location 11 _ No. - /C�, Date t0 Z• i TOWN OF NORTH ANDOVM Certificate of Occupancy $ Building/Frame Permit Fee $ da j Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# "'l� 27635 t Building Inspector �Town of QIi NORTndover o ,. ,. , No. —1 * _ yah ver, Mass, Lot1 'QA [O[HI(H�WKM`y7� U►.PP�,(`� S N BOARD OF HEALTH 0 0 Food/Kitchen j) N PER T T Septic System 0? D z6A4& THIS CERTIFIES THAT......... ....... .. ............ ................... ..................P...... Asp Qsl BUILDING INSPECTOR V1. S Foundation has permission to erect ..........................buildings on .... ... ... ............! . �.. ...�. Rough to be occupied as ....,��,��.....�....Pinvevery.1.� Chimney provided that the erson acceptin this ermit shares ect confor the terms of theapplication P 8 p P 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 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT ON STARTS Rough �� Service ........... ...rte zt•Cr .:(„J/:rren................................... I BUILDING INSPECTOR Final GAS INSPECTOR Occrigancy Permit Required to Occupy Br►ildh 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 N Street No- CD ct Smoke Det. 0 c Enter construction cost for fee cal - North Andover Fee Cakulation Construction Cost $ 391,380..00 m $ - $ 472.56 Plumbing Fee $ 59.07 Gas Fee 100 comm. $1 100.00. Electrical Fee $ 59.07 Total fees collected $ 690.70 1132 Salem Street 871-14 on 6/2/2014 12x26 One Piece Fiberglass Pool - Inground i Sia 1132 ���� � r10RTF� Town of A No. sli C, T h ver Mass Al (A&W G a o > > A- COC �'►• 7� �R�tTEO rPP��S S U BOARD OF HEALTH Food/Kitchen PERT T LD Septic System THIS CERTIFIES THAT ........ Av.. ..-. .. lar BUILDING INSPECTOR . ............m4....... . ... ................ .............. ... . . ..... ........ Foundation has,permission to erect .......................... buildings on .... 94 L............ ... .. .............! p ....1a. 1 .... ,�. . ,. Rough t0 be occupied as .r .; Chimney provided that the person accepting this permit shalfin -f-0 eve res ect confor the terms of thea licationp p p g pevery p application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT ON STARTS Rough Service ............ ...c: .��Sr�. ................................ Final BUILDING INSPECTOR 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. LCHERRY HILL CONSTRUCTION CORP CfIERRY 722 Washington Street P.O.Box 6 POOL AND SPA- North Pembroke,MA 02358 THE FIBERGLASS POOL COMPANY Ph: (781)826-6886/Fax:781-829-1002 MA Construction Supervisors License No. 80888/MA Home Improvement Contractor License No. 135607 CONTRACT AGREEMENT This Contract is made as of the date set forth below by and between the undersigned Glen Aspeslagh (hereinafter referred to as the"Owner")and Cherry Hill Construction Corp.(hereinafter referred to as the"Contractor")for the installation described below,at the price,terms and conditions hereinafter set forth. This contract represents the entire agreement between the parties hereto and supersedes all prior negotiations,representations or agreements, either oral or written. 1132 Salem Street N.Andover MA 01845 Street Address City State ZIP 508-369-1000 len(a)ecamm.com Home Phone Cell Phone Email Address The Owner herein agrees to purchase and the Contractor herein agrees to sell and install a Swimming Pool on the Owner's property.The approximate outside dimensions to be: 12 feet 0 inches in width, 26 feet inches in length,and a depth of 3 feet 5 inchesto 5 feet 5 inches. Detailed Construction Specifications: Owner Responsibility: Pool location,building permits,all electrical work and all gas work,water delivery,removal of known obstacles, removal of unknown obstacles and access to property,locate and expose any septic lines and water lines. Any additional fill needed to be hauled in or excess debris or fill to be hauled out will be charged$500.00 per 10 wheeler truck load. i Contractor Responsibility: Excavation of pool,dig safe properly,deliver and set pool,backfill pool,supply and install 40 yards of sand,pump, ! filter and all necessary plumbing and pipes,pad for equipment,rough grade all area disturbed by pool installation. Detailed Pool Specifications: Pool Options: Shell: Color: Granite Model: Bermuda ■In-stock Bermuda $27,380 min-floor cleaning included $ Filter: Model:Hayward Size: ■Waterline tile $1,500 ■2 LED Lights $1,800 Pump: Model:Hayward HP ■Salt Generator $ 1,900 :Delivery comfort heat pump $4,800 Maintenance Kit: ■Vacuum ■ Skimmer Pole ■Delivery $2,000 ■Hose ■Brush ■ $ ■ $ Contract Price: In consideration for the performance of the work and materials as outlined above,and subject to additions and deductions as provided for in change orders below,Owner shall pay Cherry Hill a lump sum price of $ 39,380.00 Dollars,including taxes,to be paid as follows: 50%due upon the signing of this agreement: $19,690 40%of the total balance is due when the pool arrives at the job site or storage if receipt is delayed $15,752 7%of the total balance is due when the pool plumbing is complete; $2,756.60 3%of the total balance is due when backfill,grading and clean-up is complete. $1,181.40 Owner Initials,-,:2LCHPS Initials: AVV% ��� CHERRY HILL CONSTRUCTION CORP CIIERRYL 722 Washington Street P.O.Box 6 POOL AND SPA— North Pembroke,MA 02358 THE FIBERGLASS POOL COMPANY Ph: (781)826-6886/Fax: 781-829-1002 MA Construction Supervisors License No.80888/MA Home Improvement Contractor License No. 135607 Any payments not received within ten(10)days of the due date shall incur a$50.00 late fee and any payments not received within thirty(30)days of the due date will incur a 1 '/2 per month interest charge. All payments must be received prior to the installation of the concrete footing and pool start-up. Construction and Design Standards: Where appropriate,equipment shall comply with or exceed the standards of the National Spa&Pool Institute and the National Sanitation Foundation. The Design shall comply with current standards of the National Spa&Pool Institute,Consumer Product Safety Commission,the City and State in which the pool is to be installed. Right to Cancel: The Owner may cancel this agreement if it has been signed by the Owner at a place other than the address of Contractor which may be at its main office or a branch thereof,provided that the owner notifies the contractor in writing at its main office or branch by ordinary mail,not later than midnight on the third business day following the execution of the agreement. Terms and Conditions: The Owner and Contractor hereby agree and incorporate herein by reference,the Terms and Conditions appended hereto and Owner hereby acknowledges that he/she has read all of the terms and conditions and understands same. The Owner is advised that the Owner is not to sign the within agreement before the agreement has been read by the Owner and unless and until all blank sections have been filled in or marked as void,deleted or not applicable and until all exhibits and related or referenced documents that are incorporated herein are attached hereto. Witness our hands and seals on the date set forth below. Date:Ih 5—/ / , r 4Cherry' l Construction Corp Authorized Representative Date: 5/15/14 Owner TERMS AND CONDITIONS 1. CONTRACTOR RESPONSIBILITIES AND DISCLAIMERS a.Contractor shall pay Federal and State levies for its employees,and shall carry Public Liability and Property Damage insurance in such amount as may be determined by Contractor. Should Owner desire coverage for himself or additional coverage,he shall make his own arrangements therefore. b.Contractor shall not be responsible for damage to any part of the pool structure,equipment or Installation resulting from natural causes or an act of God,including,but not limited to,earthquake,ground swells,inundation,ground and/or hillside motion,landslide or natural or accidental cause of peril resulting from storms,flood,war or riot nor is the Contractor liable for damages caused by surface drainage around the pool. The Contractor also shall not be liable for damage caused by the Owner or his Agents. c.Contractor shall not be liable for delays caused by strikes,war,acts of God,weather,other contractors,delays caused by owner or delays caused by suppliers,which are beyond the control of this Contractor. Contractor shall with due diligence proceed to complete the project in a timely manner. d.Contractor is not responsible for damage to patios,driveways,lawns,trees,plants,shrubs,fences,sprinkler systems or sewers which result from normal ingress and egress to the job site by trucks and equipment. e.Contractor shall not be responsible or liable for work performed or equipment and materials supplied by any sub-contractor or other party who has not been contracted with by Contractor. f.Contractor shall not be liable for staining or blemishes caused by abnormalities,either in the water used for filling the pool or, by poor pool maintenance or by die in bricks,tile,stone or deck coatings. Owner InitialsIZLI(_ CHPS Initials i y � Commonwealth of 4assacnuset s Je Qartment Of->Ut)IIC Jafgt�:- •r:,rntt _Icense: HE-131256 ; .JAMES A.M�C(GFU,,r, P0 BOX 26/722-sVA5w@N-TOI`t. North Pemhroke-11,11A. ..O(nfYY155r OtY B' -X J''ai{Dn 0/130/2015 I I t i Massacttusetts-Department of Duohc Satety SOA' " 20M-05/11 Board of Building Regulations and Standards r/— id.:rir�rir _Icense: CS X3$0888 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR JAMES A MCGILL ia. registration: g, 135607 Type: P®BOA J.6%/22 .nl3ugOT®�; `Expiration: 4/23/2016 Private Corporation North Pembroke 1,A, 0235p a^:tet:._:` CHERRY HILL CONSTRUCTION CORP. James McGill �ommrc 5lnnp, 95130120, 722 WASHINGTON ST. N. PEMBROKE, MA 02358 Undersecretary '4� 4//TE(MMCERTIFICATE OF LIABILITY INSURANCE DATE 16/20144 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(les)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 CONNAMTACT Northborough Construct West Eastern Insurance Group LLC PHONE (508)393-7744 FAX 155B Otis Streeto'E INSURERS AFFORDING COVERAGE NAIC 0 Northborough MA 01532 INSURER A.Continental Ins Co 35289 INSURED INSURER B:Travelers Indeninity Company Cherry Hill Construction Corp,Cherry HIll Pool INSURER C: & Spa;The Townsend Co;Yankee Fiberglass Pools INSURER D: BOX 6 INSURER E: North Pembroke MA 02358 INSURER F: COVERAGES CERTIFICATE NUMBER:2014 Cert 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. 'NSR I ADDLSUBR POLICY EFF POLICY EXP TR TYPE OF INSURANCE POLICY NUMBER MM MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITYASESO R NTPREoccurrence $ 100,000 A CLAIMS-MADE OCCUR 083129319 /11/2019 /11/2015 MEDEXP(Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 11000,000 AIx ANY AUTO BODILY INJURY(Per person) $ ALL AUTOS }{ AUTOSULED 083129353 /11/2014 /11/2015 BODILY INJURY(Per accident) $ HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident) $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ l'000,000 A EXCESS LU18 CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION 083129336 /11/2014 /11/2015 $ B WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N XLIMIT ANY PROPRIETOR/PARTNER/EXECUTIVE N/A OFFICERIMEMBER EXCLUDE.L.EACH ACCIDENT $ 500,000 ED? N❑ (Mandatory In NH) 4069T738 /18/2019 /18/2015 E.L.DISEASE-EA EMPLOYE4$ 500,000 es,describe under H DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) A CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Ronald Cleaves/CLUl �/ c -��— ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. k INSn2519n1nnF1 n1 The a(`nRrl name Jnr)Innn srn rnnic4urnA mer4c of arnon E Form The Commonwealth of Massachusetts Print_ Department of Industrial Accidents Office of Investigations x I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Auplicant Information Please Print Legibly Name (Business/Organization/Individual): 6 <YS4 tk0 k! C.0016AVIX;�d00 Address: '70Q ��,; Von 13 City/State/Zip: nobrCkgo (\)A OagfjS Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with t ff' 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance. 1 ❑ required.] 5. EJWe are a corporation and its 10.E] Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I ani an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: cc- n VQ,k �,� Policy#or Self-ins. Lic. #:y(,- t4 n L,9_T` ry , Expiration Date: Job Site Address: 19 3Q 5C A.r,rn !: 4 EV A nAr-,ye C: City/State/Zip: �- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.0.0 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. I do hereby certify under the pains and enalties ofperjuiy that the information provided above is true and correct. - Date: . >Y 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#: 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 - Date Doc.Building Permit Revised 2012 j 9 NI/I 1yIn6f3yfNd , d r {Zc 3SYd t7![NGOY C=Otto= Ed go w1d aaNm 3)NYI MDW IDM NTNS� m lym AAM i unit MWE-mun ALWW=0 cpm 3 r01J1�D i O Unum ADEM VA&) ram 10 HL1� J89YL mtm MAt A tgFa93.UVSON Tian T . _ ... - �3plE .stlrjpq,NOM!'N1NL mamm im TM a mo sI 4L ti0J N7tOJ: t i 3"Y") ALS L �• r r {t t 91,Mad d"SMS82M+ ] ilYtl1/!-IIOBY YN�7llAll q �d tl3A00N11 NLNON %03gONddV ^L'Y71.3,h .zia+7 Lmm Ott{ YYYJ rM"m 7`. i NMA orae aoijD 'T4M� L2�� __ -r eau �`=� w" voo�evri�snoss�sr M mvd Mowmm � ` •`� r'l o" poc-A- POS CALL C '- �r�,r.v4, lv� �+� 1�v� ��e ��c�► C®y-n a� I