No preview available
HomeMy WebLinkAboutBuilding Permit #611 - 125 BRIDGES LANE 4/16/2008 BUILDING PERMIT °`"��T 6;�tio TOWN OF NORTH ANDOVER 02t4 :;. .•_ op APPLICATION FOR PLAN EXAMINATION * ,� H Permit NO: Date Received0""""`�`P",� ��SSACHUSE� 5 Date Issued: IMPORTANT: Applicant must complete all items on this page � . . LOCATION I �, PROPERTY OWNER 1'rli �-� v =� nn7 . MAP NOF,�� PARCEL. ZONING DISTRICT `Y Historic District yes no j Machine Shop Village `yes nod; TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial epair, eplacement Assessory Bldg Others: on Other Septic VJlell' r Floodplain f tWetlands Watershed District water/Sewer DESCRIPTION OF W RK TOBIn PREFORMED: OCT -- 1 L P.lin c3y e *F 5. . ;- -,-j-C J .�,� 1 �`��c�11 3 G'� Iden ification Please Type or Print Clearly) r OWNER: Name: Phone./a, , 0 Address: ' z , CONTRACTONam R e ,� 77 Supervisor's ConstructionLicense �' ; "w V ExpXDate. , t Vlj Home lmproyementLicense . . _ Date d� --_� ARCHITECT/ENGINEER A Phone: i Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED CST BASED ON$125.00 PER S.F. Total Project Cost: $ ,��� 1f` FEE: $ Check No.: Flo J qc-> Receipt No.: �O NOTE: Persons contracting with unregistered contractors do not have a ess to a guaranty fund S Si nature ofA ent/Owner r ' g ignature Of contracto Location LI-4No. Date r r l NpRTq TOWN OF NORTH ANDOVER ' Certificate of Occupancy $ --- Building/Frame Permit Fee $ c►wst� T� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # ru! ` 21 090 7Building 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 HEALTH Reviewed on Signature COMMENTS l t 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 DEPARTMENT t TempDumpster on site yes �- Located.at124 Main Street` Fire Department-signature/date t COMMENTS.- s }. � Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: v ELECTRICAL: M o ement 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.s100-s1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 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 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 o 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 mast 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 NORTIy Town of And 0 No. * � L • 0 LAKE o` dower, Mass., COCMICKEWICK y1. Ids RATED 7 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING .INSPECTOR THIS CERTIFIES THAT.....FA'<Gl.......... .........:.:...................................... """"""""""'.""'Foundation has permission to ere ....................................... buildings on ...ld.�........49.44d�......./Ao.*w............... ..... Rough to be occupied as.... .. e..o.. ...........� ......Sr ........ � . .A .I ... .........,............................ Chimney y h' provided that the person acc ting this permit shall in every respect confoFm.to the terms of the application on file in Final 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 1 & PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR_ UNLESS CONSTRU ARTS Rough .............. ............................................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy' Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/In for of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWredProvided Re 'red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT IScorIC !Strict: Yes--NO M 2.1 Owner of Record / ,L /� �`, /�, / �,, �y /Z3 C J/`/fiCl/h� z"'7 , /V • /,7(!/� , L[ik Name(Print) Address for ServiW. 07 ' ,30 Signature Telephone �I 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number P© .M -277) �5!�LCI A t I AAA ©12024 � i Address I /DGEM )�Q� 1e9 U `7f1�1l. Expiration Date signature Telephone SECTION 4-WORKERS COMPENSATION(n G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attach Yes ... No.......❑ SECTION 5 Description of Proposed Work Lheck all a Vcabte New Construction ❑ Existing Building ❑ s) Alterations(s) 0 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other 0 Specify Brief Description of Proposed Work: RL tm dlr e &a6h h a .-5h i moo, ,AA d Zl--26 196Vf yp�rlf- SECTION 6-ESTIlVIATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to beFICIAIL.><TSE Ol4iLY , a N ^lf Com feted by permit applicant aY. saw ° �, . � Ile y •- 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 -- Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Ounier/Authorized Agent of subject property Hereby authorize_ to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION /r�JaL(,2r le �n,4 11�� '//Y ,as Owne uthorized Agent o bject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Si ature of Owner/A ent Daae �r NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS i s 2 3 RD SPAN DIMENSIONS OF SILLS DIN ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL,GAS LINE i CONTRACTORS �RA " ffladuffmL s Ma­sfer Elite user ' ® r SflfCT 0 SHINGLE ROOFER' CeEtairi�ed® INDUSTRIES, INC. c�wun n,mrc ranaccmw wroun� ROOFING CONTRACT Sales Rep: This ROOFING CONTRACT(this"Contract")between contractor(the"Contractor")and owner(the"Owner")named below OWNER CONTRACTOR Name: !'iiC) (:n&'-c,l'3`c' SUPERIOR INDUSTRIES,INC. Address: ��? ✓,C��°a 33 Great Road f City: y e-- Shirley,MA 01464 State: 100,14 Zip: 4:�' e!C 888-618-7663/ Ext: Mailing address(if different): i q 7,T) y LCA'?i If Cell Number Address: PI Registration#: 144428 Exp.10-4-06 City: R Federal Tax ID#:043518271 State: 6 Zip: ;E G✓� // f Day: o t03) Evening: 197'P/ � . -3('Gi� Alt: We propose hereby to furnish material and labor—complete in accordance with specifications below. ` Existing Roof consists of#of // Comp layers 1 __#of Wood layers Ridge to install l� 7Roo o Install: Manufacture Ce e4e,%i -c e,d T e ,AZO�cJ.�C a'°. �' 3J ,Y�P,�(�� I Color M, Drip Edge ❑ Vented Drip Edge (Color) )I/ I Re-lead Chimney ❑ Soffit Vents (4"X16")Approx.Quantity This contract is dated2,// (L (Month/Day/Year). The work under the Contract is scheduled to begin s on or about. �• � f (Month/Day/Year)and is scheduled to be substantially completed on or about ✓��f/���aY (Month/Day/Year); provided, however(i)such scheduled dates of beginning and completion are subject to change due to unforeseen circumstances,and(ii)the Contractor shall have no obligation to begin.work until the Owner has paid the Initial Advance(as hereinafter defined). The scheduled dates for beginning and completion are estimates only,and the Contractor shall have no responsibility or liability for reasonable delays in beginning and completing the work hereunder. In addition,the Contractor shall have no responsibility or liability for any delays arising from permitting requirements,the Owner's loan approval and funding,loan disbursement,acts of God, weather,strikes,lockouts,boycotts,or other local labor union activities,job changes requested by the Owner,inability to secure materials,labor shortages, failure of the Owner to makea ments when due delays caused P Y y sed by inspections,changes caused b ins delays 9 Y inspectors, e ays by the Owner in making selections,or any other cause beyond the Contractor's control. / ��r aa �j '/ y�'! The work described below is to be performed at the following property(the"Property"): l� Ajr,d ,I �y 4."6 ; The following is a detailed description of the work to be performed and the materials to be used in the performance,6f this Contract:Refer to attached estimate. Such work and materials are hereinafter referred to as the"Work." This Contract shall not be construed as requiring the Contractor to perform any work or to install any items or materials except expressly set forth above. in the event that the Contractor determines that certain materials are not readily available,the Contractor reserves the right to substitute materials of equal or greater value. / Prior to the Contractor beginning the Work,the Owner shall pay to the Contractor the sum of$ 50 C - �(()(.l (the"Initial Payment")in advance,which amount(if this Contract is for Residential Contracting)shall not exceed the greater of ork-thircr of the total contract price or the actual cost of any materials or equipment of a special order or custom made nature,which must be ordered in advance of the commencement to the Work. Thereafter,the Owner shall make progress payments to the Contractor as follows: 1/3 Deposit—1/3 Middle Payment—1/3 Final Payment. I The owner is signing below to acknowledge that the Owner has been advised of this cancellation right described in detail on the back of this Contract and also on the notice of cancellation form. I OWNER: Print Name: tC'4' 1..o� y S S G Print Name: ALTERNATIVE DISPUTE RESOLUTION (SEE BACK SIDE OF CONTRACT,NUMBER 29,FOR DETAILED DESCRIPTION) THE CONTRACTOR AND THE HOMEOWNER MUTUALLY AGREE THAT IN THE EVENT THE CONTRACTOR HAS A DISPUTE CONCERNING THIS CONTRACT,THE CONTRACTOR MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION THROUGH ANY PRIVATE ARBITRATION SERVICES APPROVED BY THE DIRECTOR OF CONSUMER AFFAIRS AND BUSINESS REGULATION,UNDER PARAGRAPHS(a)TO(6),INCLUSIVE,OF SECTION FOUR OF'THE HOME IMPROVEMENT CONTRACTOR LAW. RO CONTRACTOR:SUPE IOR/ }STRIES,INC.By: =—c�s — /,' Date: OWNER: N CcPrint Name: Date: OWNER: Print Name: Date: BY SIGNING THIS CONTRACT YOU ARE ACCEPTING ALL TERMS AND CONDITIONS DO,NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. L CONTRACTORE 10 N STRIES,INC.By: , Date: /��/ OWNER: � 1t f�,,Uv`L`�S Print Name/: Date: OWNER: Print Name: Date: Z � ti VISA BB- 7 MEMBER 1 f �iFe�ow.,no.ruea/,hC o�.�aaaau4e� Board of Building Regulations and Standards License or registration valid for individul use only HOME IMF.ROVEMENT CONTRACTOR before the expiration date. u found return to: RegistraiioAs 144428 Board of Building Regulations and Standards xPi�Ma- 7--_7Ig12008 Out Ashburton Place Rm 1301 ' Boston,Ma.02108 PnVale Corporation SUPERIOR INDEJ$ ES+$tr SEANGREEN 33 GREAT RD 'k SHIRLEY,MA 01464 Deputy Administrator Not valid without signature 12. All shingles will be fastened with 1 %4'to 1 %"hand nails. 13. Apply a Certainteed 30 year Architectural Shingle. Color: TBD 14. Step-flash and Re-Lead Chimney(s) Yes, back chimney only 15. Install an Air Vent Shingle Vent II ridge vent on house for proper ventilation. 16. Install 4"x 16"rectangular under eave soffit vents?No, existing 17. Work site will be cleaned during the daily operations, and all areas gone over with a magnet to pick up any nails. 18. Superior Industries will supply customer with any and all permits pertaining to the job. 19. Superior Industries will furnish a Certainteed Surestart factory enhanced Warranty that entitles the homeowner 15 year of non-prorated coverage including labor, materials, workmanship, and disposal costs. 20. Superior Industries will supply the customer with a liability $2 000 000.00 and worker's compensation PP Y , t3'( P ($1,000,000.00)insurance certificate. (All workers are employees,not subcontractors.) Massachusetts License#144428. Better Business Bureau#83356. 21. Any alteration or deviation from the above specifications involving extra costs will be executed only upon written Change Order and will become an extra charge over and above the estimate. 22. Payment to be made as follows: 1/3 deposit due upon signing, 1/3 due halfway through the job and the balance due upon completion of the job. 23. Any carpentry work that presents itself as a result of the roof replacement, or not included in this proposal will not be started until the roof is completed and paid in full. All Jobs to be started approximately 20 days after contract is signed& deposit is paid (Pending Weather) Job Cost $ 7,600.00 Complete Roofing System 500.00 Re-lead chimney -700.00 Homeshow/Winter Discount(sign up by 3/15) $ 7,400.00 Total Investment Comments: Please Feel Free to contact me at 978-490-9118 Thank You Ryan Dolan S INDUSTRIES, INC. ROOFING GUTTERS COPPER RUBBER ROOFS SIDING WINDOWS Fred Calarusso February 22, 2008 125 Bridges Ln North Andover, MA ROOF WILL BE HAND NAILED ONLY 1. Description of work area to be completed. Entire House 2. First detail is to install a tarp, or tarps from eaves of roof to prevent damage to house, landscape, plantings and lawn. 3. Next, remove existing layer of Asphalt Shingles and dispose of into a dumpster. 4. Completely de-nail roof, and re-nail roof sheathing to assure deck is properly fastened. 5. Replace any rotted or broken roofing boards at NO cost up to 100 linear feet for boards, or 100 square feet for plywood. Additional linear feet will be installed at$4.00 per foot and$2.25 per square foot for %2" CDX plywood. (5/8" will be at$2.50, and%at $2.75 a square foot.) 6. Apply six feet of Certainteed Winterguard to all eaves of roof,three feet along sidewalls, three feet around chimneys and pipes,three feet in all valleys, and three feet along all rakes. Wrap ice and water shield under drip edge and down fascia. 7. Next, apply Certainteed Roofers Select high performance, fiberglass re-enforced felt to the remainder of exposed roofing area. 8. All wall flashing will be inspected and replaced as needed. Any rotted or damaged siding that requires removal to replace flashings will need a Master Carpenter and Apprentice to rebuild/replace additional to roofing costs. This will be done on a time and materials basis if completed by Superior Industries, Inc. Any copper or lead counter flashing will be inspected and replaced as needed at an additional charge. 9. Apply a chalk line every five inches to assure proper exposure and straight courses. 10.Install eight-inch aluminum drip edge to all eaves and rakes. 11. Install new pipe flanges on all plumbing vents. 1-888-618-ROOF (7663) 978-425-0812 Fax 33 Great Road •Shirley, MA 01464 — Serving New England i FROM FAX NO. Mar. 14 2008 03:42PM P3 CERTIFICATE NO./DATE A�Ww CERTIFICATE OF LIABILITY INSURANCE Ai:I1H-120017.0).'45.3 FM 63116/7.00H G1:53 PRODUCER THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION Jli.ghpoilit [tisk RorviUos LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 14160 Dallafl Parkway #500 HOLDER..THIS CERTIFICATE DOES NOT AMEND,EXTEND OR oul I as, TX 75254 ALT THE COVERAGE FORD BY THE POLICIES BELOW. (Ban) 632-5094 (972) '/1.5 •0959 INSURERS AFFORDING COVERAGE Fax: (9'/2) 404-4450 NAL TSURANCr GU IANX INSURED; ' .d nAFinCf A SUPERIOR TNDIISTRIRS, INC INSURER II: 33 GREAT TID f,'HIRI,r•,Y, MA 01464 INSURER C; (9.18) 425-0808 Fax: 19'/13) 425-0A'12 INSURER D: INSURER r-.- POVERAGEI 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 HERRIN 19 SUBJECT tO.ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AOGREOATE LIMITS SHOWN MAY HAVE BEENIREDUCED BY PAID CLAIM. N R TH Ty.PR OP INSURANCE POLICY NUMBER LIMITS MEMOEACH OCCURRENCE S GONERAL LIABILITY COWERCIAL GENERAL LIABILITY FIRE DAMAGE(Ally One Flrb). 6 CLAIMS MAPF gCCUR MED EXP(Any one peron) S PFABONAL 8 ADV INJURY S GENE-RAI,AGGREGATE $ OEN'L AGGREOATt LIMIT APPLIES PER; PRODUCTS,COMP/OP Atit9 b POLICY MT' LOC AUTOMOBILE LIABILITY COMDINED gINOLE LIMIT S (Ea acaldent) ANY AUTO ALL OWNED AUTOS DODILY INJURY $ (Per Perron) SCHED!ILEO AUTOS HIRED A[nOS BODILY INURY $ (Per ocoldent) NON-OW NED AUTn9 PROPERTY DAMAGE S (Por acaklent) GARAOE LIABILITY AUTO ONLY•EA ACCIDFN r $ ANY AUTO OTHER TI IAN EA ACC S AUTO ONLY: AGG $ EXCESS LIABILITY FAC"OCCURRENOE 8 r)CCUR CLAIMS MADE AGGREGATE 3 S . DEDUCTI(+I,F t RETENTION $ S C ST X OT EMPLOY RS'LiA BUTT )NAND DWc.02000504P 03/1.4/2000 06/20/2008 " � EbWLOYERB'LIABILITY F.1-.EACHACCIDFNT S 1000000 A F.L.DISEASE-FAEMPLOYEF 1 1000000 E.L.DISEASE-POLICY LIMIT S 11100000 OTHER LINKS i LIMITS b DC9CRIPTION OF OPERAYIONBILOCATION"Fti C eVEXCLUBIONS ADDED BY ENDORSFMENT/SPECIAL PROVISIONB `t . 'L'hiI4 CertifiCat-.e raiftalns in effect, provided the d1lont's &ccount i in quod (standing with AM,S 53taf:t Leaj.jng. CLIvc:!rage is not provided Lor any c:mp7.oyec for whil:ll the olia1]t i8 Ilor. rep0:rt.1,Tlg Wdgfjo to AMS Staff 1,ua:Sing- Applies to 100% of the eingloyeeS of AMS ;staff L08aing loaned to WPERIOR TNDUSTRIRS. INC, rffectivo 03/3.4/'2000 2. J,rojort IllfCjrmation; COURTYARD CONDOS 360 L,iTTLETON ROAD (-J.IEMSPORD MA3. Ijat:ured is 19f£orded Workers Compensation & EMP1OyefS liabill.ry as A cc-emD.)oyer under the policy for emplvynoA 1eai;4;wj from AMS SI%aff Lyasing, Inc, RTIFIC HOLD ADDITIONAL INSURED;INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL sNDEAVOR TO MAIL 30 DAYA WRITTEN NOTICE TO THP-CERTIFICATE HOLDER NAMED Tn THE LEFY, BUT FAILURE TO DO SO$HALL IMPOSE.NO 06LI0ATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR MPRESENTAYIYE3— ORIZEQ REPRESENTATIVE ACORD 25-S(7107) 0 ACORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations c. =' 600 Washington.Street a' Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 6VPGk'.lop 1Aj15TZ'J�_5 _ Address: '43 66EAT ,Eat City/State/Zip: J A�lej 4jA &4Utl Phone#: (?VQ> 6W1 - 70t,,,P3 Are you an employer?Check the appropriate box: Type of project(required): 1.91 I am a employer.with J_ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. E] We are a corporation and its 10.❑ 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.M Roof repairs insurance required.] t c. 152, §1(4), and we have no 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. $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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �LLQ3 10g7zd-Ae< L Policy#or Self-ins. Lic. #: Expiration Date: 62Z&1e9­' Job Site Address: 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 $250.00 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Sijznature: �_ _JL� Date: Phone#: 0� -62/0 —76,n44 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 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 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-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 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 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 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 Fax# 617-727-7749 Revised 4-24-07 www.mass.gov/dia.