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HomeMy WebLinkAboutBuilding Permit #669-14 - 115 WEYLAND CIRCLE 3/31/2014 TOWN OF NORTH ANDOVER PPLICATION FOR PLAN EXAMINATION Permit N0: r Date Received C Date Issued: I O ANT:Applicant must complete all items on this page LOCATION ! O /8 Print. PROPERTY WNER �' O U , L Z WE Z Print 100 Year Old Structure yes no •° MAP NO: � PARCEL:ZONING DISTRICT: Historic District yes no Machine Shop Village ye no TYPE OF IMPROVEMENT, PROPOSED USE Residential Non- Residential ❑ New Building �(One family ❑Addition El Two or more family 11 Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ ❑ Septic ❑Well, ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: 2PO . L IINFL Phone: Address: ll.f- I�✓ �'h`L(,e QI��-fi G �'►�-v��' �.� CONTRACTOR Name: Phone: 6� SL f�cP Dw - o! 7;)' Address: ZS - t.- �`- aze uz eloj MAO Supervisor's Construction License: Of j?6x � .. Exp. Date: !' 7 �' Ex Date: sV ` Home Improvement License: p. ARCHITECT/ENGINEER Phone: ddres - _ --- - - - - - - - - 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: $ 01f—> d © 6 �° FEE: $ �00 -- Check No.: / 0 v Receipt No.: � NOTE: Pe sons contracting with unregistered contractors do not have access to the guaranty fund � r Signatureof�Agent/Owner. Sig-nature of contractor _ Plans Submitted [] Plans Waived ❑ Certified Plot Plan 11 tamp lans ❑ Plans Submifted ❑ Plans Waived ❑ ..._Certified Plot Plan ❑ Stamped Plans ❑ TYPE Q"EWERAGEDISPDSAL- Public Sewer ❑ Tanning/Massage/Body Art ❑. . Swimming Pools ❑ Well ❑ . ..Tobacco.Sales •Food Packaging/Sales ❑ Private{septic tank,etcEl❑ Permanent Dempster on-site THE-FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM ..DATE REJECTED DATE:APPR-OVED PLANNING & DEVELOPMENT Fl- COMMENTS COMMENTS ,CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature . COMMENTS 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 Todv.! Engineer: Signature: Located 384 Osgood Street FIRE-DEPART,RN�T: .,Tehip Dumpster on site yes no Located"at124,mair`Street _ Fire" D f epa"rtme►it signature/elate aY :;° 4 COMMENTS ; ;-Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ :Total land-area, sq. ft.; ELECTRICAL: Movement of Meter location-, niast-or service drop requires approval of Electrical Inspector Yes No DANGER.Z®NE LITERATURE: Yes No MGL-.Chapter-166.Section 21AµF and G min.$100=$1000,fine NOTES and DATA— (For department use i El Notified for pickup - Date E Doe.Building Permit Revised 2010 Building Department rhe fol owing is-'a list of-the required-forms to befilled out'for:the appropriate.permit to`.be obtained. R.00fivg, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/O•r G.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 o Issuance 6f-B1dg 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 apu 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--ted with the building application Doc: Doc.Building Permit Revised 2012 Location L No. Date . - TOWN OF NORTH ANDOVER s F,° . Certificate of Occupancy $ • Building/Frame Permit Fees O 1t � r Foundation Permit Fee $ a Other Permit Fee $ TOTAL $ Check# 2 7 ,375 3 Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 2553000.00 m $ - $ 300.00 Plumbing Fee $ 37.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 37.50 Total fees collected $ 475.00 I 115Weyland Circle 669-14 on 4/1/2014 2 Bedrooms and 1 Bath in Basement i NORTII Town of , E ,, Andover _ IF No. Iq * • t = - �� zh ver, Mass A°R�{TE1) S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System BUILDING INSPECTOR THISCERTIFIES THAT ......... -1�1,� ..........I&A,..40.. ....................................................................... �•�. '�•• 144 f. /,�• .... Foundation has permission to erect .......................... buildings on ... ...... �••� j/(� ••l�.L • •••••••••••••• .............. _ o Rough to be occupied as .Ce� ....&e&n, - -......,�Gt. ►r.^.!ll?.... ` ... Chimney e provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and PLUMBING INSPECTOR Construction of Buildings in the Town of North Andover. L-1 1 lj� � �, ._... / _ Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI T RTS Rough Service ................. ........ ..... ................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancv Permit Required to Occupy Building Rough Final Display in a Conspicuous Place on the Premises — Do Not Remove No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information N Company Name vJ k t Zorn_ L-Tz 4"Z4 i � Street Address(do not use a Post Office Box address) Contractor/Salesperson/Owner Name i (� I/✓ (,cwt d f�AXJf-F r=f 40 City/Town State Zip Code Business Address(must include a street address) aA id6u� c J S— i .r 3 5`�M st. aytimePhone Evening Phone City/Town State Zip Code 11lw?^a�'�`A^rt? ailing Address at different from above) Business Phone I Federal Employer ID or S.S.Number Home Improvement Contractor Reg.Number Expiration date � � s Lon requires that most home / '{, ((`� - tn f Improvement contractors have 7 y / i[ W�'.l v` ^'l `�e J a valid reglstmdan number //y�� 8/6 ' The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractors control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of ,- I- ate when contractor will begin contracted work. MGL chapter 142A.) ate when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: (*) Payments will be made according to the following schedule: $ upon signing contract(not to exceed 1/3 ofthe total contract price or the cost of special order items,whichever is greater) $ ��'� f by /_/_ or upon completion ofoe «� $ by_/ /_or upon completion of $ O G�D e ipon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be paid for NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty being provided by the contractor? ❑No Yes fall terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signint ofthis agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT SIG THIS CVNTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical espies of the co ct must be corn eted and signed.One copy should go to the homeorvner.The other copy should be kept by the contractor. Homeowner's Sign ft re Colt!) o actor' Signature Date Date Y Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws,chapter 142A. Homeowner's Signature Contractor's Signature NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at http://www.mass.gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at http://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeimprovement/licenseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 Version 2,1-11/22/2010 1 ' NOTICE OF CANCELLATION U MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR FYO. 2� R OBLIGATION, WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU CANCELLATION NOTICE,AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL,YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED,ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION, YOU MAY RETAIN OR DESPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO, THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION,MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO [Name of Seller],AT [Address of Seller's Place of Business]NOT LATER THAN MIDNIGHT OF (date). I HEREBY CANCEL THIS TRANSACTION. Date: Buyer's Signature: 979534/NC3822 CVT 8/98 carbonless NC3822 3 PART Tom , CONTRACTORS 0 NVOICE pkv �S3 S S WORK PERFORMED AT: TO J� e DATE YOUR WORK ORDER NO. OUR BID NO. i6N6F-W6Rk PERFORMtb, 3 . ory r All Material is guaranteed to be as specified, and the above work was performed in accordance with the drawings and specifications provided for the above work and was completed in a substantial workmanlike manner for the agreed sum of Dollars ($ ), This is a ❑Partial ❑Full invoice due and payable by: Month Day Year in accordance with our ❑Agreement ❑Proposal No. Dated Month Day Year NC3822 CONTRACTORS INVOICE 03/31/2014 12:42 6174827318 WALTER KWAN INS PAGE 01/01 ACORD CERTIFICATE OF LIABILITY INSURANCEDATFIMM'DDIYYYY) 03/31/2014 ODUceR 617-964-5340 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION SURPLUS SERVICES/MARKETING ASSOC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 150 WELLS AVENUE ' HOLDEN. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR NEWTON, MA 02459-3302 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW_ INSURERS AFFORDING COVERAGE NAIC# INSURED [INSURER NSURERA: NAUTILUS INS. CO. L T Z CONSTRUCTION COMPANY JIA XIANG ZHAO NSURER B: 253 SEA STREET, C:QUINCY, MA 02169 NSURER D: COVERAGES INSURER E: THE POLICIES OP INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO 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.AGGREGATE LIMITS SHOWN MAY HAVE;EIEEN REDUCED BY PAID CLAIMS. INSR DD'L POLICY EFFECTIVE POLICYEXPIRATION POLICY NUMBER IMMLDDNYk LIMITS GEN ERALLIABILITY EACHOCCURRENCE $ 1,000,000x X X COMUE,RCIALGENERALLIABIUTY NN362431 8/28/2013 8/28/2014 PREMISES EsoCCUlence $ 501000 CLAIMS MADE a OCCUR MEDEXP(Anyanaperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEMLAGGREGATELIMIT APPLISSPER: PRODUCTS w COMIVOP AGG INCLUDED POLICY PRO' LOC CT F AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANYAUTO (Eaacctaanp $ ALLOWNEO AUTOS SCHEDULEDAU (Porperean)YOS e9 rOere HIREDAUTOS BODILY INJURY S NON+OWNED AUTOS (Per aaoldanl) PROPSRTYOAMAGE $ (Peraccident) GARAGP LIABILITY AUTO ONLY IEAACCIDENT S ANY AUTO OTHER THAN EA ACC E AUTOONLY: AGG $ EXCESSIUMBRELLA LIABILITY PACH OCCURRENCE $ OCCUR FICLAIMS MADE AGGREGATE $ 8 DEDUCTIBLE S RETENTION S S WORKERS COMPENSATION AND I WCSTATU> DTH) EMPLOYERS'LIABILITY TORY LIMI ANY PROPRIETORIPARTNERIE%ECUTIVE E.L.EACH ACCIDENT $ CFFICI;RIMEMBER EXCLUDED? If yes,describe under E.L.DISEASE EA EMPLOYEE $ SPECIAL PROVISIONS be1Dw E.L,,DISEASE>POLICY LIMIT $ OTHER CONTRACTOR LIABILITY $500 BI&$500 PD DEDUCTIBLE DHSCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES/P XCLU$IONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS JOB START 04/06/2014 JOB SITE; 115 WAYLAND CIRCLE, NORTH ANDOVER,MA 01855 WILL BE UPDATING 2 BEDROOMS AND 1 BATHROOM CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF TNF A130VF DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CITY OF NORTH ANDOVER DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN BUILDING DEPARTMENT NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 1600 OSGOOD STREET IMPOSE NO OBLIOATION OR LIABILITY OF ANY KIND UPON THE INSURER,IT6 AGENTS OR NORTH ANDOVER,MA 01855 REPRESENTATIVES. FAX#,,978-688-9542 AUTHORIZED REPRESENTATIVE Elizabeth Beauchamp/We-Walker Kwan Ins.Agency, Inc ACORD28(2001/08) WORD CORPO TI 9 d6 -fy ai t f T/ At w �,� ►vim' J' m L-J0 i Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a•deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employingemployees. However the owner of a dwelling house having not more than three apartments and who resides therein,oe 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 enato e " p Y �'. MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required:' Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-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 au LLC ox LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be-sure to fill.in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. .A.new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a 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 shquld you have anyquestions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Coaunoawealtho;fM-assachusotts Depaxtnent Qf fadustdal.Accidents Q.ffiiee of lovestigation,% 600 Wmbiu&n Street Boston,MA 02111 TO,#6XM-2.7 4900 ext 406 or 1-877 MASSAF Revised 5-26-05 Fax 0 617-727-7749 wwwaw.,govldia The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations quo 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizationadividual): Z 7—Z Address: City/State/Zip: oil��/� �/rhone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ T am a employer with 4• ❑ I am a general contractor and T 6. ❑New construction employees(full and/or part-time).* have liiredthe sub-contractors 2�Tam a sole proprietor or partner- listed on the attached sheet. �• F1 Remodeling shipand'haveno.employees These sub-contractors have 8. E]Demolition working fox me in any capacity. workers'comp.insurance. 9, []Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10[]Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL ILEI Plumbing repairs or additions myself.[No worke_rs'comp. c. 152,§1(4),and we have no 12.❑Roofrepairs insurancere ired.]t employees.[No workers' comp.insurance required.] 1311 other !Any applicant that checks box 41 must also fill out the section beldw showing their workers'compensation policy information. 7'Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit a new affidavit indicating such. l'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. co Policy#or Self-ins.Lic.#: 3 / Expiration Date: 2 Job Site Address: /1P W at6, City/State/Zip: d th kAwp7•�2-I'_D a P-, Attach a copy of the workers'compensation p olicy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL o. 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$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the AIA for insurance coverage verification. X do hereby cert under the pains and pe s ofperjury that the information provided above is true and correct. - Si afore: Date: 3 Phone#: / 7 fib' °/ / ?3 O / Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 9: CONTRACTORS INVOICE �7-' /Pej0 1---"P3 Sea S74 WORK PERFORMED AT: Qk �n ev , InA 0 a.6, p /7 T0: M of a�gJ,4jo DATE YOUR WORK ORDER NO. OUR BID NO. DESCRIPTIONOF •-K PERFORMED t zl'A' - y J7a , �='-r�-r%! �<.:-4 c� CTYut ,7�' •�v�r (VI r A xj All Material is guaranteed to be as specified, and the above work was performed in accordance with the drawings and specifications provided for the above work and was completed in a substantial workmanlike manner for the agreed sum of Dollars ($ ). This is a ❑Partial Ej Full invoice due and payable by: Month Day Year in accordance with our ❑Agreement ❑Proposal No. Dated Month Day Year Nc3822 CONTRACTORS INVOICE 03/31/2014 09:17 6174827318 WALTER KWAN INS PAGE 01/01 ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDlYYYY) 10/07/2013 ooucER 617-964-5340FALTER CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION SURPLUS SERVICES/MARKETING ASSOC Y AND CONFERS NO RIGHTS UPON THE CERTIFICATE 150 WELLS AVENUE DER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR THE COVERAGE AFFORDED BY THE POLICIES BELOW. NEWTON, MA 02459-3302 INSURERS AFFORDING COVERAGE NAIC# INSURED .._.._.._ .. �... ...__._ ........._.. L T Z CONSTRUCTION COMPANY •IysuRERA; NAUTILUS INS. CO. JIA XIANG ZHAO INSURER B: 253 SEA STREET, INSURER C: I QUINCY, MA 02169 Nsua�RD: __.... __._.. INSURER E: COVERAGES' 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 SOF SUCH POLICIES.AGGREGATE LIMITS SHOWN-- HO MAY HAVE BEEN REDUCED By PAID CLAIMS. NC POLICYNUMBER POL(CYEFI"LjE•"PDATE(MW1DDfYYLm. OLYEXPIRATIOJLTR N I LIMITS II ' X ; R AL LIABILITY ) I EACH OCCURRENCE $ 1,000,000 X III GENEMMERCIALQENERALLIABILITY 1 NN362431 8/28/2013 I 8/28/2014 I UKfNAGETORE'NTED--' -- PRMISEs Eaoccurence s 50,000 CLAIMS MADE XOCCUR I I I`MED...... -.:Y.... 5,000 PERSONAL&AOVINJURY S - 1,0001000 I GENERALAGGREGATE�.. .........-----.. .. s __2,000,000.. . GEN'LAGGREGATELIMIT APPLIESPER: i .... ;••„„•_FRODUCTB)coM?/OPAGc $ INCLUDEID POLICY PRO)JECT LOC AUTOMOBILE LIABILITY } A14YAUTOI COMBINED SINGLE LIMIT $ I (Es accident) ALLOWNEDAUTOS ! I _----... BODILY INJURY e SCHEDULEDAUTOS j (Perperson) HIRFDAUTOS I• i i BOOILYINJURY NON>OWNEDAUTOS i (Peraccident) $ PROPERTYDAMAGE (Per oc6loont) ,$ GARAGELIABILITY AUTO ONLY IEAACO Ipf NT S ANYAUTO I F —.__..... ........._.I........._.....---..... OTHERTHAN• EA ACC $ _ AUTO ONLY: AGO! EXCESS/UMBRELLA LIABILITY I EACHOCCURRENCE $ OCCUR CLAIMS MADE (----,.._....,,,.. ..--._.... .._........... _...._._..._.. ---• j AGGREGATE g I ; DEDUCTIBLE i RETENTION I I I WORKERS COMPENSATION AND ; WCSTA7U) OTM EMPLOYERS'LIAOILITY ! I I ;,TORYLIMIT$I•,,, ;,_�R- __••,•, ,.._..... ANY PRO PRI ETO RIPARTN ERIEXECUTIVE °E.L.EACH ACCIDENT $ _.._.._-_._._..... _.. ......... ---------- __ OFFICER/MEMBER EXCLUDBDI E.L.DISEASE)EAEMPLOYEE $ If yes.describe under ,... ._._...__...........EMPL......... ........... ....... SPECIAL PROVISIONS below OTHER E.L.DISEASE)POLICY LIMIT IS CONTRACTOR LIABILITY I I $500 BI &$500 PD DEDUCTIBLE DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS BATHROOM& BASEMENET JOB START 10/07/2013 rOR 1 FAMILY LOCATION: 116 ELEANOR DRIVE, BRAINTREE.MA 02184 , NgR;- IE YUN TEL.: 617-283-10 CERT ICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION C Y OF B INTREE DATE THEREOF,THE ISSUINO INSURER WILL ENDEAVOR TO MAIL 10 PAYS WRITTEN BU DIN EPT. FAX: 781-794-8022 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 90 SHALL 90 P STREET IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR BR EE MA 02184 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Elizabeth Beauchamp/la-Walter Kwan Ins.Agency, Inc AC 5(200110 -ACORD CORPORATION 1988 FA.YF0 0i PICT M3 ............. i ��ze�porwrn�aarea"141 waclaaeM Office of Consumer Affairs&BusifYicss Regulation OME IMPROVEMENT CONTRACTOR ! egistration: 172854 Type: 1 xpiration:..,816`/201.4 Individual JIAXI G ZHAO 1 w" JIAXIANG ZHAO 253 SEA ST QUINCY,MA 02169 Undersecret ry Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor License: CS-098627 JIAXIANG ZHAO 253 SEA STREET Quincy MA 02165 -ww"' Expiration Commissioner 02/06/2016 I