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HomeMy WebLinkAboutBuilding Permit #310-14 - 1264 SALEM STREET 10/2/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: v Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION ► 2 A.) n u X12_ .,:. Print- PROPERTY OWNER ru k J.I✓ SSL_ MAP NO/ Print 100 Year Old Structure yes no -PARCVL4"ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building cekOne family ❑Addition ❑Two or more family ❑ Industrial 9.Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands 0 Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: 4Zi Phone:2 E_( - OCA) Address: 12611 5�9L,E-H al-IR H1 H 04L45 CONTRACTOR Name: f on tjo ljsrSA Phone: .;tuft S20,S so 2.C" Address: I. M aro �� o f o,�;�_,a„p� n A -0 Supervisor's Construction License: S d Exp. Date: 3 Home Improvement License: 1 -75-413-7 Exp. Date: s-1,3 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 Project Cost: $ f 3 S D D . FEE: $ Check No.: Receipt No.: L NOTE: Persons contr6eting with unregiste^Atractors do not have access to the guaranty fund Signatureof Agerit/Owner e Signature_of contractor Plans Submitted 0 Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 DATEAPPROVED PLANNING & DEVELOPMENT' ❑ ❑ COMMENTS -CONSERVATION Reviewed on Signature 0 �UOMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes- .- Planning es -Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW T ow;2 Engineer: Signature: Located 384 Osgood Street FIRE DEPAftTMf_NT - Temp Dumpster on life yes.. . no Located-at 124 Mair, Street - Fire Departinentsignature/date`' 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, 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 El Notified for pickup - Date Doe.Building Permit Revised 2010 Building Department The fol�,3wing 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 Li 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 a Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o 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 o 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 submAted with the building application Doc: Doc.Buiiding permit Revised 2012 Location �� No. Date • - TOWN OF NORTH ANDOVER • rt Fb6�� aCertificate of Occupancy $ + pry= z Building/Frame Permit Fee $ '� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ i Check# Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 13500.00 m $ - $ 162.00 Plumbing Fee $ 20.25 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 20.25 Total fees collected $ 302.50 1264 Salem Street 310-14 on 10/3/2013 Bath Remodel NORTfy Town of Andover o No. ILV - 10L i h ver' Mass T O LAME ' COC HIC NE WICK S U BOARD OF HEALTH Food/Kitchen Septic System PERMIT T LD THIS CERTIFIES THAT ........................ �............... .fe. f' .41mv...................................... BUILDING INSPECTOR 1 Foundation has permission to erectg 1 �. .......................... buildings ..... .. .. .......24 . ..... .............. Rough to be occupied as .......... ...................... ..®......................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final l 6OIL PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR l UNLESS CONSTRUCTI AR Rough Service .................. ............................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE 10/01/2013 12:40 FAX a 003 TE C,LIP CERTIFICATE OF LIABILITY INSURANCE DA091MMIDDIYYYY)3012013 - 091 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 pollcy(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). PRopuceR 04213-001 5QMcT SuzanneRibeiro Brooklawn Insurance Agency Inc &W EX,! (608)886.8861 1W.No.: (609)886.4047 596 Ashley 1910 osl New Bedford,MA 02745 A.I.M.Mutual Insurance Company 33758 INSURED INSURERS JBM GnierPrise Ina 11 Margin Street New Bedford,MA 02744 1 INSURER E, I 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.LIMIT$BHOVMI MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN TYPE OF INSURANCE POLICY NUMBER MM)I SMY AMI LIMITS GENERAL LIABILITY EACH OCCURRENCE i COMMERCIAL GENERAL LIABILITY i PREMISES rronas CLAIMS-MADE F-]OCCVR MED D(P(Any one person) 3 PERSONAL b ADV INJURY i GENERAL AGGREGATE I EN'LAGGREOA15LIMIT APPLIES PER; PRODUCTS-COMP/OPAGO J ucY o FILOC AUTOMOBILE LIABILITY GTE Cf1S11T-- S---^��-•-•— ANY AUTO 60DILY INJURY(Fn pawn) s ALL OWNED SCHEDULED BODILY INJURY Per ecciden! $ AUTOS AUTOS ( > HIRED AUTOS NON-OMED PROPERTY DAMAGEi AUTOS ipor 009i Intl UMBRELLA LIAROCCUR - - EACH OCCURRENCE i EXCESS LIAR CLAIMS MADE AGGREGATE b DED RETENTION f E A (MandYInNH) FCE-u"vr 7 NIA AWC-400.7024687-2013A 8/18/2013 8/18/2014 E.L.EACH ACCIDENT i $001000,00 I(/'Mandaaft��ocrylAneNunHd)er �l hV'�J E.L.01$EA$E-EA EMPLOYEE f $00,000.00 6ERIP710N Of OPERATION6 below E.L.DISEASE-POLICY LIMIT i 600,000.00 OHSCRIPTION OF OPERATIONS I LOCATIONS I VEHICLI?6(Atmch ACORD 101,Additional Remarks Schedule,If mon apace Is required) CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER BUILDING DEPARTMENT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1600 OSGOOD STREET THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED IN NORTH ANDOVER,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPREBENTATIVB l 1988-2010 r g is reserved. ACORD 26(2010/06) The ACORD name and logo are registered marks of ACORD 10/01/2013 12:39 FAX 0001 CERTIFICATE OF INSURANCE This certificate Is Issued as a matter of Information only and confers no rights upon the certificate holder. This certificate does not amend, extend, or alter the coverage, terms, exclusions and conditions afforded by the policy or policies referenced herein. It certifies that the policies listed In this document have been Issued to the Named Insured. Coverage is subject to the provisions of the policies, Including any exclusions or conditions, regardless of the provisions of any other contract, such as between the certificate holder and the Named Insured. The limits shown below are the limits provided at the policy inception. Subsequent paid claims may reduce these limits. General Agent: Named Insured: A.I.I. Insurance Brokerage OT MA, Inc. Jihad B Moussa & JBM Enterpriae Inc 183 Davie Street East Douglas, MA 01516 11 Margin Street New Bedford MA 02744- Agency No: 02002 - 00 General Liability Insurer Name: Nautilus insurance Company Policy Number:NN364238 Type of Coverage: ® Occurrence ❑Claims-made Retroactive Date (if claims-made): Policy Effective Date. 08/03/2013 Policy Expiration Date: 08/03/2014 $ 2,000, 000 General Aggregate Limits $ 2,000, 000 Products/Completed Operations Aggregate of $ 1,000,000 Personal And Advertising Injury(Any one person or organization) Insurance $ 1,000,000 Each Occurrence $ 100, 000 Damage To Premises Rented To You(Any one premises) $ 5,000 Medical Expense (Any one person) General Aggregate Limit applies per: F9 Policy ❑ Project ❑ Location Automobile Liability Insurer Name: Policy Number: ❑ 1 -Any Auto ❑ 2.Owned Autos Only ❑ 3-Owned Priv. Pass.Autos Only ❑ 4-Owned Autos Other Than Prly. ❑ 5-Owned Autos Subject to No ❑ 6-Owned Autos Subject to a Pass.Autos Only Fault Compulsory UM Law ❑ 7-Specifically Described Autos ❑ 8-Hired Autos Only ❑ 9- Nonowned Autos Only Policy Effective Date: Policy Expiration Date: Limits of $ Combined Single Limit(each accident) Insurance $ BI Per Person $ BI Per Accident $ PD Per Accident Umbrella Liability Insurer Name: Policy Number: Type of Coverage: ❑ Occurrence ❑Claims-made Retroactive Date(if claims-made): Policy Effective Date: Policy Expiration Date: Deductible: Self-Insured Retention: Limits $ Each Occurrence of Personal And Advertising Injury(Any one person or organization) Insurance General Aggregate(other than a covered auto) 5948(01/12) Includes copyrighted material of Insurance services Office,Inc.,with its permission. Page 1 of 2 10/01/2013 12:39 FAX 0 002 Excess Liability Insurer Name: Policy Number: Self-Insurance: Type of Coverage: ❑ Occurrence ❑Claims-made Retroactive Date (if claims-made): Policy Effective Date: Policy Expiration Date: Limits of $ Each Occurrence Insurance $ Aggregate Professional Liability Insurer Name: Description Of Coverage: Policy Number: Type of Coverage: ❑ Occurrence CI Claims-made Retroactive Date (if claims-made): Policy Effective Date: Policy Expiration Date: Limits of $ Each Claim Insurance $ Aggregate Other Insurer Name: Policy Number: Policy Effective Date: Policy Expiration Date: Description of 0 erationa/LocationsNehicies/Endorsements/S ecial Provisions Carpentry Contractor Additional Insured Status ❑General Liability ❑Automobile Liability ❑ Umbrella Liability ❑ Excess Liability Ll Professional Liability ❑Other THIS CERTIFICATE DOES NOT GRANT ANY COVERAGE OR RIGHTS TO THE CERTIFICATE HOLDER. IF THIS CERTIFICATE INDICATES THAT THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED, THE POLICY(IES)MUST EITHER BE ENDORSED OR CONTAIN SPECIFIC LANGUAGE PROVIDING THE CERTIFICATE HOLDER WITH ADDITIONAL INSURED STATUS, THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED ONLY TO THE EXTENT INDICATED IN SUCH POLICY LANGUAGE OR ENDORSEMENT. Cartiflcate Holder: Town of North Andover Building Department 1600 Osgood Street North Andover MA 01845- Authorized Representative: Date: 09/30/2013 S948(01/12) Includes copyrighted material of Insurance Services Office,Inc.,with Its permission, Page 2 of 2 Ho mie Tmjurovemenf Rq ' �Le Co>mtnict This foam,satisfies all basicrecluirements of the skate's Home Improvement Contractor Law(MGL chapter 142A),but does not' language to protect homeowners. Seek legal advice if ne e'm Auome iaelude standard Massachusetts Consumer Criiide to Home Improvement"before agreeingto Person oxlc on your residence.You may obtainOvcments should s free copy by calling e Office of Con mer andBusin.ess R,egulation's Consumer InformationHotline at 6.17-973-8787 or 1-888-283-3'157 or on ourwebsite.g ' HomeoWner Wou9l�.at,7lold. K V' S S L. Contractor JC f®rmatxOil Name Company Name b �F 0� LC M Sr • :j--�!`1 � Street•A.ddress(do not use aPost Office Box address) Ir Con OwnerName �v VES M� © ! � � • City/Town State Zip Code Bpsiness Address(muss include.a street address) Abfi- DaytunePhone BvenangPhone P175 City/Town State y� Zip Code Mailing Address(It=erentfromabove) rd M m D Zr Lr Business Phone I7ederal>;mpIoyer ID or S.S.Number I S11iri4 Homeimprovement'Contmctorlteg:Nomber Expiration date T' xawregnirestbatmoathomc improvement contractors have _ I valid registraL'on numvar -7 S- The Contractor agrees to do the following worIt for the Homeowner: T 3 5 (Describe in detail the worlcto completed,specifyingtbe type,brand,and grade of materials to be used,use additional sheets ifnecessa ).e,rn o C I'/ aI ' Required Permits-The following building pmm3.ts are xegiaired Proposed Start an•d Completion,Schedule-The following schedule and will be secured by the contractor as•the homeowner's agent: be adhered to unless circumstances beyond the contractor' control arise (Owners who secure their own Permits�Vi1X be excluded from the Guaranty Fund provisions of -MGL chapter 142A.) /J—Date when contractorWill.begin conixactedwozlc. Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform tlae wozlc,:Cmmishthe material and labor specified above fox the total sum of: `— Payments will be made according to the following schedule: � 0 ------------ $ 3D 0 a upon signing contract(not to exceed 1/3 bf the total,contract price or the cost of special order items,whichever ise 3 by Z / or upon completion of Rn C.1ater) w�, 2 4 I AJ $-------by — / / or upon completion of .m j9 ,�vupon completion of the contract, (Law forbids demanding full.payment until contract is completed to both parVs satisfaction) The following material/equipment mustbespecial ' ordered before the contractedwork begins in order to be paid for to meetthe completion schedule.('m) _ to be paidfor NOTES:(")Including all finance charges(°t°i°)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 which must be special ordered in advance to meet the completion schedule. special equipment or custom made material x ress Warren -Is an ex ress warren bein rovi ded b the contractor? Subcontractors-The contractor agrees to he solelyxesponsible for completion of the work described regardless ofth actions efed io the contract partersals and actorbor utilized l ythe contractor. The contractor fi rther agrees to be solei responsible for all a a ytb>rd materials and aborundertliis a cement y p payments to all subcontractors for Contract Acceptance-•U'poai 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 be 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. ° ASIC questions if something is unclear, suu Make sbcontractors to be registeredwisure the contractor has a valid Home xovement Contra tractor Re 'stration. The law requires most home improvement contractors and tb the Director ofHome Improvement Contractor Registration. You may an quire about contractor registration by writing to the•Director at 10 parlcPlaza,Room 5170,l3oston,MA.02116 or by calling.617--973 8787 or 888-28actor . ° Does the contractor have insurance? Aslc the Contractor for his insurance eompaary information so that you can confnai coverage,or aslc to see a copy of a"proof of insurance"document. ° Twice your eights and responsibilities. Read the important Info>xnation on.the reverse side of this form.and get a copy of the Consumer Guide to the Dome Improvement Contractor Law; You may cancel this 4.greementifithas been signed at aplace other than the contractor's nortaaalplace of business,provided you contractor es writing at his/her main office or branch of6.ce by ordinary mail,posted,by telegram sent or by delivery,not later than midnight of the third business day following the sr gr y notify the g going oftbis agreement. See the attached notice of cancellation form for an explanation of this right, Do I+OT'SIGN TMS CONTRACT]I+'T73ERE Two"d' tical copies of tale contractmast be pleted and signed. One copy should go to the h E �-SLA �SPACE'S��actor. I I ona.eownef s Signature Wac-4tor's nature .nate Cottnraefor Arbitr4on The Home Improvement Contractor ctor Law provides homeowners with the right to initiate an arbitration action(as an alternative to Courtactio 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 disputte he/she has with a homeowner.in court unless both parde�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 the Law. g The contractor and the homeowner hereby i aataa7ly 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 film which has been approved by the Secretary of the Executive Of ice of Consumer Affairs and Business Regulation and the consumer shall be required to submit tsu h arbitration as. ovide Massachusetts General Laws, chapter 142A. Homeowners Si atwe tractor`s Signature NOTICE:The signatures of the parties above apply onlyto the agreement of the parties to alternative dispute resolution initiated by the contractor: The homeowner may initiate alternative dispute resolution even where thi section is not separately signed by the parties. s Homeowner's Rights A homeowner's rights under the 7:Iome Improvement Contractor Law(MGL chapter 14.2A)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 te contractor they choose is not properly registered.as prescribed by law. Homeowners who secure their own building permits axe automatically excluded-from,all Guuaranty Fumd provisions of the Home Improvement Contractor-Law. The contractor ig responsible for completing the world 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 worlauanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold-in Massachusetts caray an implied warranty of merchantability and fitness for a particular purpose. An entiuueration 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 resi.Tict a homeowner's basic consumer rights. Zf you have questions about your eonsumer/b.omeomer rights, contact the Consumer 7itiEormation IZotline(listed below). Execution of Contract The contract must be executed in chin licate and should not be signed until a copy of all e�ddbits and referenced documents have been-attached. Parties ate.also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One briginal signed copy of the contract with attachm6nts is to be given to the owner anal the other kept by the contractor. Any modification to the,original contract must be in writing and agreed to by both parties. Contracted world may not begin until both,parties have received a fu71y executed copy of -the contract, and the three day rescission period has expired. A.ecelerated Payma nts A contractor may not demand payments in advance of the dates specified on Clue 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 fin=cially insecure,the contractor may require that the balance of funds not yet due be placed in a j ob t escrow account as a prerequisite to continuing the contracted work. Withdrawal of feuds signaturesCrow said account would require the of both parties. Additional 7Cnfo:rmation ,If you have general,quiestions or need additional in:forniation about the Igoxue Improvement Contractor Law or other consact er rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer knform.ation Hotline Office of Consumer Affairs and Business Regulation 617-973-8787; 888-283-3757 ox"vxisitttile OCABRwebsiteatat02116%6wwtiv.rnass. o g v/ocabr/ If You want to very the registration of a contractor or if you.have questions or need additionalinforxnatxon about the contractor registration component of the Horne Improvement Contractor Law, contact: sped[ically Director of Home Improvement Contractor Registration, OrFce of Consumer Affairs and.Busiuess Regulation Id ParkPlaza,Room 5170,Boston,MA 02116 617-973-8787-, 888-283-3757 or visit the HCC we at 11ttb://wv mass troy/�C��,; Go online to view the status of a Home 7mprovemelt Contractor's Regi.sixation: 11tt7r//db.state.ma.t2s/hoz•neimoroyeir�ent/liaenseeTist as ror assistance with informal mediatzou of disputes or tor,gister formal complaints s a aini a business,usiness, calx: Consumer Complaint Section Of EMP of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4.800,508-755 254.8 or 4.13-734-3114. The Commonwealth of Massachusetts - Department of IndustriglAccitlents Office of Investigations 600 Washington. Street Boston,MA.02111 www.mas.s govIdia Workers' Compensation Insurance Affidavit:Builders/Contractors/Eleletrricians/Plumbers Applicant Information PIease Print Legibly Name(Business/Orgmization/Individual): ✓ 6 1 n !Q r e r I 1-,e- �- C- ° Address: / A"J o•I City/State/Zip: IJ c�. d� 0 2.-7hone Are you an employer?Check the appropriate box: - Type of project(required): 1.❑ I am a employer with 4. n I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.NI 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, El We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ X 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.]► employees.[No workers' ME]Other comp.insurance required.] 'Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they ke doing all work and then hire outside contractors must submit anew 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:_ /4' • S , M Policy#or Self-ins.Lic.#: A-ti (' '7 DZ q V 7 a 1 ZD 13 Expiration Date: — �'� — y Job Site Address:1ZSA'L em- S4 N•&&2)Oa-CGS City/State/Zip: A • A ,J J>D L)EEC K4 0 1 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certio under the pains andpenalties ofperjury that the information provided above is true and correct. Signafore• Date: - a Phone# bC�g ) SD9 - 3b2J Official use only. Do not write in this area,to be completed by city or town of Mal City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other - - Information and Instructiolms 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 lie-ensing agency shall withhold the issuance or renewal of a Iicense 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 ofits political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)andphononumber(s)alongwiththeir certificates)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 isrequired. 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 permithicense 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. Anew 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 Goavwnwealth of Mfassarhv.:setis l_3epa ,ent of fadust dat Accidents (?flee ofJAVOS igatlo- 60 Wasbhtgtoxt Stxeet Boston?MA.Q2X X Z TQJ,#617-727-4.900 ext406 ax 1-877 UA.SSAUF, Revised 5-26-05 Faze,#617^727-7749 s JBuois,s1wWoo . 5 LOZ10£l£0 r uolte�ldx3 % bbLZOI Nolpag Mau 12ta-dT S Nt'ga At 11 ;*Ssfiow S CVVW s l,65990-SD :asua31 .tostvadns uotpn.iasu03 s e Pue1S pue suotj,%nBaa 6utpltn8 10 Weo8 P A1a1eS oilgnd 10}uawlaedaa - s}lasnyoessejN t Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 a, - Boston, Massachusetts 02116 Home Improvement Contractor Registration . 'Registration: 175437' ' Type: Individual Expiration: 5/13/2015 Tr# 240267 JIHAD MOUSSA JIHAD MOUSSA 11 MARGIN ST NEWBEDFORD, MA 02744 Update Address and return card.Mark reason for change. ❑ Address ❑ Renewal F—] Employment ❑ Lost Card SCA 1 0 20M-05/11 •