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Home My WebLink AboutBuilding Permit #685-13 - 129 MAIN STREET 4/18/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION L Permit NO: Date Received Date Issued: Ylld-la IMPORTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER 71_CA�4 I Print 100 Year Old Structure yes no MAP NO: Q PARCEL: _ZONING DISTRICT: _ Historic District ye no Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family /Id ustrial ❑Alte ion No. of units: mmercial E-gepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic 0 Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: ,S-&JP aj, t?t_rg-/ Identification Please Type or Print Clearly) OWNER: Name: `3—ati.vw, e 1 Phone:?-'l TW- lc- 1C Address: 4 CONTRACTOR Name: J c�)ky F- QLrl xzt,� Phone: �?.1 - Z ? ` 718'/ Address: Supervisor's Construction License: / 6SS-1 Jt Exp. Date: J� I Z01 `I Home Improvement License: )4 I (3(o D Exp. Date: 7 oZ oI 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: $ 3 2- Oto. --D FEE: $ 3 o T r- /�k Check No.: Receipt No.: . NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Own ,�v///�, Signature of contracto Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Swimming Pools ❑ Tanning/Massage/Body Art ❑ 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 a HEAL�TH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments i Water & Sewer Connection/Signature& Date Driveway Permit I DPW Tower Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire DepartMerit signature/date y COMMENTS i 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 DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10041000 fine NOTES and DATA— (For department use I I ® Notified for pickup - Date Doc.Building Permit Revised 2010 V Building Department The folowing 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 o Workers Comp Affidavit Li Photo Copy Of H.I.C. And/Or C.S.L. Licenses L3 Copy of Contract o 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 o Building Permit Application a 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) o Building Permit Application o Certified Proposed Plot Plan o 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) o Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign offrom Fire Department nt 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 app;-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,4ted with the building application I Doc: Doc.Bui?ding permit Revised 2012 Location/ 5 � �1 _97 No. Datev • - TOWN OF NORTH ANDOVER e 5Y�►'Lt:�l 146: • > ;- Certificate of Occupancy $ t� Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#�C�O 26302 Building Inspector ooRTH w: t _ �. .c . : ver O No. LAK, h ver, Mass, c Oc Klc"t WICK �d A�VArso P, C S u BOARD OF HEALTH RM - T T LD Food/Kitchen .PE I Septic System THIS CERTIFIES THAT ........... ..1.....0111- �. .................................................. BUILDING INSPECTOR ................ . .... has permission to erect buildings on 15P1. .! ,, .0f....St Foundation n_ r Rough to be occupied as ....F1A.........4fteirm, ..�:...1��1'G>D�:..-.......1.��...��X.V........... Chimney provided that the person accepting 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 rel1iting to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIJM ST TS Rough Service Ti ......................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE RVEY Order Confirmation HARy,6 `STRIES WA NG PRODUCT'S (�(� 19 ATHLETIC FIELD R0 Cash Sale 122690066 WALTHAM, MA 02451 (781) 899-2880 Sale Page 1 of 1 Merchant IN 542929801332016 04/15/2013 15:25:59 Term ID: LX828160 04/15/13 15:26:20 Document Date 04/15/2013 Batchh: 000824 Inv ft: 000031 Customer Phone No. 781-894-3754 AMEX Entry Method: S Ordered By JOHN XXXXXXXXXXX100Z Job Name MCGIRL Purchase Order No. F Sea,U: 0031 Appr Code: 511851 Shipping Conditions CUSTOMER PICK-UP Total: $ 2,218.66 Clerk Name N00104 APPROVED Customer, Copy Material Description QtY Unit Price Amount 530930242 RPI SEAM TAPE PRIMER 1 GAL 1.00 GA 37.85 GA 37.85 ** Hexanes /3/ LIN 1208, 11 530930007 RPI ROOFING ADH #6504(5 GAL) 3.00 PA 91.35 PA 274.05 **Adhesives /3/UN 1133, II 530930003 RPI 10X50 .060 EPDM BLACK 3.00 RL 293.75 RL 881.25 530954810 1"X48"X96" AC FOAM II 30.00 SH 15.39 SH 461.70 530930025 GALV DECK PLATE 1.00 CT 75.00 CT 75.00 530930023 5" COATED SCREWS �` 1.00 CT 137.00 CT 137.00 200039215 RPI(PLIO) SEAM TAPE 3X100 BLACK 3.00 RL 60.50 RL 181.50 ST310OF 530970032 9" ROLLER COVER 12.00 PC 1.50 PC 18.00 530970030 9" ROLLER FRAME 4.00 PC 2.50 PC 10.00 530970031 48" WOOD HANDLE W/THREADED 4.00 PC 2.95 PC 11.80 END ----------------------------------------------------------- Subtotal 2,088.15 Sales Tax 130.51 Final Amount 2,218.66 Balance Due 2,218.66 All claims for shortage or error must be made an receipt of goods.Any material proving defective will be replaced,but no claims for labor or damage can be allowed.Prices subject to change without notice.No credit will be allowed for custom made or special order items.Purchaser agrees to pay all reasonable costs,collection fees,attorney fees,and expenses Incurred by seller In event of failure of purchaser to pay this amount when due. Signature Date Corporate Address: Harvey Industries 1400 Main St Waltham, MA 02451-1689 781-899-3500 I 1 /24/2013 5 : 32 : 04 PM 8740 ® 04/04 R[�r'0 CERTIFICATE OF LIABILITY INSURANCE DATEJM f2 ) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CEATIFICATI!HO ODER. TMS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDS) BY THE POLIWS BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHQRrMD REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WANED,Suboal to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 04331-001 NAH LACT Eastern Insurance Group LLC Ip No.Ext: (800)333-7234 F .Ne_ (908)6534OU 233 West Central Street Natick,MA 01760 AFFORDING A.I.M.Mutual Insurance Company 337,58 INSURED INSURER - John F O'BrIon Inc INSURER C; 257 Trapslo Road Waltham,MA 02462 INSURER E: j COVERAGES CERTIFICATE NUMBER: REVISION NU ER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURM NAMED ABOVE FOR TNI:PGLICY PEIR INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH ROSPt±CT TO IAWH IR 15 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I3'4I"tT TO AL.(` THE'YERtYtS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED B�YPAID pCLAIMS. IMP TYPE OF INSURANCE I POLICY NUMBER MMF� yD/YYF ppMML Y ITS GENERAL LIABILITY EACH QCCURi2tT•tM S E TO COMMERCIAL GENERAL LIABILITY PREAIS ftftEl) ydbvft CLAIMS-MADE []OCCUR MED EXP(Arlt(one, 5i 4 PERSO14AL&4,OV,M0.3RY `}j GENERAL AGAR" ;. EN AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMfiC49P�. LICY CST OC AUTOMOBILE LIABILITY COMBINED swUntg' Ea sociden ANY AUTO BODILY INJURY(Pef pdu4r# ALL OVMEO SCHEDULED AUTOS AUTOS deBODILY INJURY(Per aeant}. HIRED AUTOS AUTOSVMED O Per wd A S UMBRELLA LIAR OCCUR EACH OCCURRENCE - EXCESS LIAR CLAIMS MADE AGGREGATE } yy�RDDEEgDS p�RETENTION $ AND EMPL�YERS'LIABRRY X TORY L�MIT3 qqNyy PPRR��ppRR��TTppRR1P TNER/E�ECUTIV E.L.EA6H ACCIDF44T' E A OFFICER/MEMBER EXCLUDE07 NIA VWC6014375012011 4/21/2011 4/21/2012 IMandatory in NH) E.L.DISEASE-EA EMPLOYEE E DESCRIPTION F OPERATIONS below E.L.DISEASE-POLICY L1MR S o a—wo E r1 I 7 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(At toch ACORD 101,Additional Remarks Schedule,if more space is required) i CERTIFICATE HOLDER CANCELLATION McGurl Construction Co 11 Morrison Road SHOULD ANY OF THE ABOVE DESCRIBEd POLICIES BE CANCEW ED 91FORO' Burlington,MA 01803 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE C 1888-2010 ACORD CORPORATION.All rights r6Sery ACORD 26(2010/05) The ACORD name and logo are registered marks of ACORD 3240 Tel:781-936-4057• Fax: 781-209-0659 ROOFING P.O. Box 390945 Cambridge, MA 02139 jforoofing@msn.com b'llnc. Mcgurl Construction Proposal 11 Morrison Ave Date: 4/15/13 Burlington MA.01803 Job Address: 1A9 Main St. N Andover MA. We hereby submit estimates for: Strip rubber and insulation Install 1" insulation board Install EDPM .060 rubber fully adheared Install aluminum edging on entire perimeter Flash and terminate according to industry standards Provide dumpster Provide permit Clean out all gutters and downspout Remove all debris created by us We herby propose to furnish all materials and labor,complete in accordance to industry standards. For the sum of dollars (_$32000.00 )with payments to be made as follows One third to start,remainder upon completion. All material is guaranteed to be as specified. All work is to be completed in a workmanlike manner according to practices. Any alteration or deviation from specifications involving extra costs will be executed upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Our workers are all covered by workman's' compensation. Authorization Signa Note this proposal may be withdrawn if not keepted within 30 days Acceptance of Proposal—The above prices, specifications and conditions are herby accepted. You are authorized to the work as specified. Payment will be made as outlined above Signature • Signature: Date of acceptance: l to 13 Massachm—fts Rome Improvement Sam* pie Contract Thisage satisfies all basic requirements languageof the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard to protect homeowners. Seel Iegal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeingto any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business R,egulation`s Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Name C- CompanyNzmc ^( Street Address(do not use aPost Office Box address) Contractor/Salesperson/Owner Name City/Town State Zip Cod Business Md ess mus c'Ke a street 4NC-� address YS (OCA) UI z G D•aytimePhone BveningPhone City/Town State Zip Code 79)-- fool(f- 7Sr-2a 8- et o`-1 so 1 17 Mailing Address(It different from above) Business Phone I'ederallmployer ID or S.S.Number raw requires tbnt most homo EomeImprovementContmctorlWa.Number Expiration date • Improvement contractors have a valid registration nninber / C-/D/_(� O i z 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 ifnecessatv.) Required Permits-The follgv6g building permits are r*equired Proposed Start and Completion Schedule-'The following schedule will, and will be secured by the.contractor as-the homeowners agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will,be excluded from the Guaranty Fund)provisions of Date when contractor will begin contracted work. MGL chapter 142A.) Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to periform 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 of the total contract price or the cost of special order items,whichever is greater) $ by / / or upon completion of $ by / / or upon completion of upon completion ofthe 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:('i°)Including all finance charges Q**)Law requires that any deposit or down-payment required by the contractor before workbegins may not exceed the greater of(a)one-third ofthe 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. I';xpress Warranty-Is an express w•trranty beine provided by the coptrlctor ❑No❑Yes full terms of the warranty must be Rttached to the contract) Subcontractors The contractor agrees to be solely responsible for completion ofthe work described regardless ofthe actions of anythird party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for ate ials and laborunderthis a Bement 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 Horne Im rovement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director ofl-lome Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 ParkPlaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. c Does the contractor have insurance? AsIc the Contractor for his insurance company information so that you can confv see a copy of a"proof of insurance"document. I coverage,or ask to o Know your rights and responsibilities. Read the Important Information on the reverse side of this foam and get a copy ofthe 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 Inter thaidnightof the third business day following the signing ofthis agreement. Seethe attached notice of cancellation form for an explanation of this right. DO NOT'SIGle] TI�[S CONTRACT IF THERE ARE ANY 13LAM<SPACES!rr Two identical copies ofthe contract must be completed and signed. One copy should go to the homeowner. The other copy shouldbe Icept by the contractor. Homeowner's Signature Contractor's Signature `f r► J 1`' /1 'Date -7 ' Date 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 ame right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. 1 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 alterative 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 Gutaranty Fimd.provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and worlcmanlilce 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 ed arrant of merchantability and fitness for carr an implied w tS' provided b the contractor,all goods sold in Massachusetts y p Y P Y � a particular purpose. An enumeration of other matters on which-lie homeowner and contractor 1aw6ully 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 anti] 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 contTactor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a j oint escrow account as a prerequisite to continuing the contracted work. Withdrawal of fiunds:from said account would require the signatures of both parties. Additional Information ' If you.have general questions or need additional inormation 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 Parlcplaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the OCABRwebsite at 11_:11www.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 ParkPlaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the BIC website atl2li!//ww,,v..inass.Rov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: . ]ZtilD://db.state.ma.us/homeirnt_rovem ent/Iiaenseelist.asb For assistance with informal mediation of disputes or to reg,* er formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508455-2548 or 413-734-3114 Version 2.1-11/22/2010 Condraeforr Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an 'alternative to count action)if they have a dispute with a contractor. The same right is not automatically affordedto a contractor,however. The contractor world 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 imutaally agree in advance that in the event the contractor has a dispute concerning this cont-act,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 cons-umer 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 patties 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. B[oxmeowner'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 excludedfrom,all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and worlananlike 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 mailers 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 IuformationHofline(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. Patties 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 theoriginal contract must be in writing and agreed to by both pares. Contracted work-nay 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 fmancially insecure,the contractor may require that the balance of funds not yet due be placed in a j oint escrow account as a prerequisite to continuing the contracted work. Withdrawal of Rmds from said account would require the signatures of both parties. Additional Wormation ' If you have general questions or need additional information about the Home Improvement Contractor Law or other constiuner 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 Parlt Plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at lam://www.mass.gov/ocabr/ If you want to verify the registration of a contractor or ifyou 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 BIC website atb=://www.inass.gov/oc,-Lbr/ Go online to view the status of a Home Improvement Contractor's Registration: . ht- X//db.state.ma.us/hoineimprov ement/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 4.13-734-3114• V=ion 2.1-11/2212010 Massachusetts ]dome Improvement SaM Ile Conix-act This foam.satisfies all basic requirements of the slate's Home Improvement Contractor Law(MGL chapter 142A),but doesnot include standard Ianguage to protect homeowners. Seelc Iegal advice if necessary. Any person planning home improvements should first obtain,a copy of"A a free copy by calli Massachusetts Consumer Guide to Home Improvement"before agreeingto any work on your residence-You may obtain ng 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 formation 'Contractor Information Name Compan^yNAa�m^e Street Address(do not use aPost Office Box address) Contractor/Salesperson/OwnerTame City/Town S (W f f?e tate ZiP Code :BVsinessM�,ddress � reet addreUI `i i ()zYSz Daytime Phone Evening Phone City/Town State Zip Code ,nom p(-1 s'v I>P17 Mailing Address(lt different from ab)ve) Business Phone I'ederall;mployer ID or S.S.Number Home improvementContmctorReg:Number Expiration date • ]Law requires that most home improvement contractors hive a valid registration member / /D/_ O / 1 (P Z 26) The Contractor agrees to do the following work for the Homeowner: (Describe in detailthe workto completed,specifyingthe type,brand,and grade of materials to be used,use additional sheets if necessarv.) Required Permits-The following building permits are r'equired Proposed Start and Completion Schedule-The following schedule will and will be secured by the.contractor as-the homeowners agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits'vvill be excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work. MGL chapter 142A..) Date 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 £ �-4 (1, Payments will be made according to the following schedule: —/0 &&0 upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ by / / or upon completion of $ by or upon completion of upon completion of the contract. (Law forbids demanding fall payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to beaid for ordered before the contracted work begins in order p to meet the completion schedule.(]°°j°) $ to be paid for NOTES;(y°)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. Ex ress'Warrnn -is an expresswarran bein rovided b the contractor? ❑No❑''Yes all forms of the warran 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 fur all payments to all subcontractors for Materials and labor underthis a Bement 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. o Don't be pressured into signing the contract.Take time to read and fully understand it. Aslc questions if something is unclear., o Malce sure the contractor has a valid Home lm rovement Contractor Re 'stration. The law requires most home improvement contractors and subcontractors to be registered with the Director ofI-10me Improvement Contractor Registration. You may inquire about contractor registration by waiting to theDireetor at 10 ParlcPlaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. c Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confn7st coverage,or aslc to see a copy of a"proof of insurance"document. e Know your rights and responsibilities. Read the Important Information on the reverse side of this form andget 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 signing of this agreement. Seethe attached notice of cancellation form for an explanation of this right. DO NOYSIGN T 7[S CONTRACT IN THERE ARE ANY IB LAS K SPACES 1! Two identical copies of the contract must be completed and signed. One copy should go to the homeowner. The other copy shouldbe lcept by the contractor. Homeowner's Signature Contractor's Si afore gu Date - Date ' Office of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration - +~ Registration: 141060 Type: Private Corporation zi F i a Expiration: 1/2/2014 Tr# 220057 JOHN F. O'BRIEN INC. = = , JOHN O,BRIEN 257 TRAPELO RD. 4 WALTHAM, MA 02452 ' Update Address and return card.Mark reason for change. Address Renewal [:] Employment Lost Card )PS-CAI 0 SOM-04!04-G101216 ✓�te "C/JOo�tinza�zu+ea� ,,,,,,��✓4Gaddac�tu6¢�6 Office of Consumer Affairs&Boniness Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: ,141060 Type: Office of Consumer Affairs and Business Regulation Expiration: ,.112/2014 Private Corporation 10 Park Plaza-Suite 5170 r Boston,MA 02116 VJYOF. 'BRIEN'ING�. JOHN O,BRIEN = of 257 TRAPELO RD. WALTHAM,MA 02462'-' Undersecretary Not valid without signature i iNfassachusetts- Department of Public Safetc Board of Bui.ldinl.; Regulations incl Standards ` Construction'Supervisor License License: CS 105517 a + JOHN O'BRIEN" 257 TRAPELO.RD WALTHAM,MA 02452 Expiration: 4/7/2014 " ( nmmi.�i uicr Tx#: 105517 4/ 16/2013 12 : 34 : 39 PM 8935 ® 02/02 ACCT CERTIFICATE OF LIABILITY INSURANCE DATE(MMroDiYYW) 04116/2013 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 ADD171ONAL INSURED,the poiicy(ies)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). �p PRODUCER 04331 -001 NAME:CT Eastern Insurance Group LLC �A7c°"Ilo.Ext): (800)333-7234 FC.No.: (508)653-8089 233 West Central Street EMSS: Natick, MA 01760 INSURERS AFFORDING COVERAGE NAIC# INSURER A: A.I.M.Mutual Insurance Company 33758 INSURED INSURERS John F O'Brien Inc INSURER C 257 Trapelo Road INSURERD: Waltham,MA 02452 INSURER E COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IR TYPE OF INSURANCE I SPR U POLICY NUMBER M�n �i7YyifY LIMITS QTR GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES Ea occurrence CLAIMS-MADE F—]OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ OLICY CT OC AUTOMOBILE LIABILITY COEa MaBcddeINED SINGLE LIMITnt $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIREDAUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident) UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED RETENTION $ g �J 7H $ l( y pOoRpMY9C�RW X T YLIIMITS OER A OFFICER/MEUkr&JUSS FECUTIVEYLJ NIA VWC6014375012012 4/2112012 4/21/2013 E.L.EACH ACCIDENT $ 100,000 IN (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 DESsCRI�TIONG�F 9PERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,Ir more space Is required) WC coverage applies to MA employees only CERTIFICATE HOLDER CANCELLATION Proof of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 00000 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 0 988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 3616 The Commonwealth of Massachusetts - Department of IndustrialAccWnts Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leibly Name(Business/Organ'izatiorandividual): p—U—b V y\ F O'E r.2vi -Tyt C Address: � � City/State/Zip:_I n)c 1` A c VV 9- Phone#: _Y/ ' ZJ-f-07 3 df Are you an employer?Check the appropriate box: Typo of project(required): 1.I�J"I am a employer with G 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have]fired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. ?• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10. Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.] employees.[No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i 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 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. 1 f Insurance Company Name: a l"� �1 U�w` Policy#or Self-ins.Lic.#: V C,(o U 19,3 7 cY 0 l Z o l Z— Expiration Date: 'f,/,/Z,7 _ . Job Site Address: 4 t 14) 94— City/State/Zip: 9J, � 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 epains and penalties ofperjury that the information provided above is true anttcorrect. SignDate: 1 /l 3 Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: - Information and Instruction's ' 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 too operate a business or to construct ruct buildin . sin the corn applicant who has not produced-acceptable evidence of compliance with the insurance coverage lrequir dy 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 cavy 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 1 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 o ladustrial.Accidents Office of Investigations 604 Washington Street Boston,MA,02111 TO,#617-727-4900 ext 406 or 1-877:MASSAFE Revised 5-26-05 Fax 4 617-727-7749 Www.mass.crnv/riia i Information and Instruction's 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-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 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. g g PP 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 y given year,need only submit one affidavit indicating current policy information(ifnecessary)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 bum 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 Iavestigatious 600 Washington Street Boston,MA.02111 T01,#617-727-4.900 oxt 406 or 1-877:MASSAFB Revised 5-26-05 Fax#617-727-7749 wr w-mass,govldia The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Business/Organization/Individual): ---J—o kt,\ E O'E r,eo T_Tkt c, Address: r `� /d is City/State/Zip: (,u, (,q u w4 (/!- Phone#: -Yl ' id'--013 Fl A,rree,yo an employer?Check the appropriate box: Type of project(required): 1.L�'I am a employer with (0 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. �• E]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 required.] officers have exercised their 10.E]Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance �uired. -req employees.[No workers' 1311 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 tiie doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors 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 thepolicy and job site information. _ f Insurance Company Name: Policy#or Self-ins.Lie.#: V/ C,(0 0 L 7 cY Z Expiration Date: � Z7 :;? O b 3 i Job Site Address: 1 I M 4 t 14 94- City/State/Zip: RJ art,Lt, 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 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 maybe forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true anticorrect. Sign re: Date: 3 Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: