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HomeMy WebLinkAboutBuilding Permit #282-15 - 13 WALKER ROAD 9/19/2014 BUILDING PERMIT NO Q�tTLED .r hb • '"n,16 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION t tl T Date Received o�RNT SPP" 5 Permit No#: q Eo � SSACHUS Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION / 7N�`'� -pn' *&O'c+ LJ/Li not - PROPERTY OWNER ` n Print 100 Year structure yes (no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition )(Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: nAerr� ,e;, 70� Identification- Please Type or Print Clearly OWNER: Name: HU i &1 Phone: Address: Contractor Name: Phone: to2,2(Z) Address: I g0tk l Ixe Ra OLE () a Supervisor's Construction License: (14522. Exp. Date: r Home Improvement License: _ Exp. Date: 3/(o/)h 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. / r Total Project Cost: $ SIO 00 �� CJ FEE: $ (6DO � �1 �ti Check No.: I=1 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner /. �' 4 ignature of contractor_ I J 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS n 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 - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signatureldate COMMENTS L Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: I ELECTRICAL: Movement of Meter location, mast or service drop requires approval of j 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) II II i ❑ Notified for pickup Call Email i Date Time Contact Name Doc.Building Permit Revised 2014 r 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 pp 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the 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 Doe:Building Permit Revised 2014 Location I� Ille rz UI�A -- Date I t No. ' . - TOWN.OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee I� $4"` TOTAL J, ,t $ Check# All U1, wilding inspector 9/22/2014 8:05:06 AM PST (GMT-8) FROM: 100005-TO: 19786889542 Page: 2 of 2 ACCW"® CERTIFICATE OF LIABILITY INSURANCE F DATE(MM/DD/YYYY) 9/22/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(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). PRODUCER PRESCOTT&SON INSURANCE AGENCY INC NCONTACT AME: 963 EASTERN AVENUE PHONE F,y MALDEN, MA 02148 A/c Ext), ac No E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC p INSURERA: Liberty Mutual Fire Insurance 23035 INSURED ANDREW DABBS INSURERB: DBA AD BUILDERS INSURERC: 180 SHAWSHEEN ROAD INSURER D: ANDOVER MA 01810 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 21676168 REVISION NUMBER: i 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD YYY WVD POLICY NUMBER MM/DD/YMM/DDNM LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE r_1 OCCUR DAMAGE TO RENT D PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY[71 PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOSAUTOS BODILY INJURY(Per accident) $ HIRED AUTOS AUTOS NON-OWNED PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ A WORKERS COMPENSATION WC2-31 S-386080-024 6/14/2014 6/14/2015 PER orH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ® N/A E.L.EACH ACCIDENT $ 100000 (Mandatory in If yes,describe under E.L.DISEASE-EA EMPLOYEE[$ 100000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR ANDREW DABBS CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 OSGOOD STREET, BUILDING 20, SUITE 2035 ANDOVER MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE t Liberty Mutual Fire Insurance ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD CERT NO.: 21676168 CLIENT CODE: 1779833 Lucy Garfield 9/22/2014 11:02:27 AM (EDT) Page 1 of 1 0911912014 09:32 Prescott&Son Insurance Agency (FAX)7813333278 P.0011001 Ca CERTIFICATE OF LIABILITY INSURANCE I 9DATE/19/201NYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Commercial Lines NAME, Prescott and Son Insurance Agency,Inc. PHONE . (761)322-2350A�C No:781-397-0115 963 Eastern Avenue E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# Malden MA 02148 INSURERA:Arbella Protection Ins Co 41360 INSURED INSURER B: Andrew Dabbs INSURER C: 180 Shawsheen Rd INSURER D: INSURER E: Andover MA 01810 INSURER F: COVERAGES CERTIFICATE NUMBER CL1491919342 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMfDD MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100 000 REMISES Ea occurrence $ r A CLAIMS-MADE a OCCUR 8500062348 /21/2019 /21/2015 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATIONNIC STA-UR S1 OTH- LIM,ANDEMPLOYERS'LIABILITY Y/N FR ANY PROPRIETOR/PARTNER/EXECUTIVEF—] E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) i CERTIFICATE HOLDER CANCELLATION (978)688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St. AUTHORIZED REPRESENTATIVE Bulding 20 , Stuite 2035 Andover, MA 01845 J S Scholnick/WRF ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD t%ORTH Town of s E : ,, Andover o No. o > h ver, Mass, COC LAK WI[R ��• 044 TIE U BOARD OF HEALTH Food/Kitchen PERMI. T T LD Septic System THIS CERTIFIES THAT A**=A..... paOT BUILDING INSPECTOR .. 4 . . ... ..... .... .... Foundation , has permission to erect ..................... ... buildings on .�. .. .. ... ....UM ...... Rough tobe occupied as ... ... .. .. ... .... .... .. . ................. .,�,.........S.40.4*.......................................... 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S ARTS Rough Service ...... ... ... ... t........................ 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. i i Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-094522 ANDREW J DAB% ' ter. 180 SHAWSHEEN RD: Andover MA 01810 " l� Expiration i Commissioner 08/19/2015 ,}� ��e cpoa���aaiuuecrlGf 4�a�ur�eC�ii -\ Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR egistration: 1,71308 Type: xpiration: --.3/6/2016 DBA A. D.BUILDERS i ANDREW DABBS 180 SHAWSHEEN RD. ' ANDOVER, MA 01810 gam= Undersecretary I II i Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. MA R� Ho eownnerInformation Contra for Il ormation Name ! Company Name 13 W441<i-r V­,J 6 Street Address(do not use a Post Office Box address) Contractor/Salesperson/Owner Name Not* Ai JoW, Mn 0 f 8 V-S CityfFown State Zip Code Business Address(must include a street address) Daytime Phone Evening Phone CityTOZ State Zip Code 31 PrP-3vA nr. 14""4 e. 1� r -7 2,20f 6220 m E042- Mailing Address(It different from above) Business Phone I Federal Employer W or S.S.Number He improvement Contactor Rea.Number DTT ntim dale .lid reties tbi ...be, 9`612016`61201 6 tmprovement cantroctors have LN/1 a enlid reglstrotian number The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) ins1&l AA-0/ &-i/4C�f iM MIZ k:I&X" Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of I ��" Date when contractor will begin contracted work. MGL chapter 142A. 10110.) Date when contracted work will be substantially completed. ji Total Contract Price and Payment Schedule 11 The Contractor agrees to perform the work,famish 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) $l 3 by 9 14/ 14 or upon completion of $ by / / or upon completion of aahl 4 $ upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be paid for NOTES:(*)Including all finance charges(**)Lawrequires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty being provided by the contractor? Ko❑Yes(all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor tinder this agreement Contract Acceptance-Upon signing,this doctiment becomes a binding contract tinder law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with tate Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important Information on the reverse side ofthis fort and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. Seethe attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of the contract must be completed and signed.One copy should go to the homeowner.The other copy should be kept by the contactor. /-/- A-- a, " D Homeowner's Signature Contractor's Signature Date Date i Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws,chapter 142A. Homeowner's Signature Contractor's Signature NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in du lip Cate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at littp://www.mass.gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at http://mvw.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http•//db.state.ma.us/homeiinprovementilicenseelist asp For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800 508-755-2548 or 413-734-3114 Version 2.1-11/22/2010 yhe Commonwealth Qf ffassachuseus t.. . be aPt.�n • , Office of Invesfigafions 6`00 Washfgfon Street Roston,.A 02111 WIPIP- msygovfiiza Wgrke:c0i eoxnpematioubsurance Affidadt: erg .A.pp �a� omWoz� PX€ase.Print bxy Namo(BusiaosldrganizafionI.t'n hidual): nnaj aA) On Ad&ess: Igo at Phone lk V12,2 0 Ar orxau employer?Cheek. appropriatehox: Type ofproleet(re gm'red) 1,71 am a employer with 2-- _ 4. 111 ant a general contractor and 1 S. ❑New cOnstmetion. employees( xUand(oxpa time)T havenedth.e sub-confractors 2.El l am a sale proprietor or partner~ listed on the attached sheet. 7• ]i' emadeling These Ship and`7�aveno.employees salt-contxaetorshave 8. �l?emolztion working for me in any capacity. workers'comp.insurance, g, 11 Building addition [No wortkers'comp.Jrtsurance 5, Elo ffi area corporation audits 101]Electrical repairs ox additlons regt7ired.] ofncers have exercised.theix right o 3. l am a homaowxtex doing all workoftexemption.per M% 11..[]P1um�bing,repdrs or additions myself.�lowgrkerS2 comp. c.152,§1(4),andwehaveno 12.Q XUDfxepairA em loyees.[No workers' 7 p 'e insusaxtcerequared.� 13.[�0th r comp.insurance required.] eAnyapplicanfthac cheoks box#S mnsEalsoIlouithesectionbel6grshovingtheirwbrkers'compensation polio infozmafion. 7 IfOMOoW.nCr8 wha submitthis aiftdaYifindicatingihey 're dging a1lwork andfhen Sin a outside contractors must suBmif a new of tdapif indicating sizoh. xContracfors'iha�cheekthis bo�musf attached an.additional sbeetshowingtha name oi:the sub-coufractors andtizeirworkars'camp.po8cy informaiion. t� ax2 eznptoyer.tB(d is•prDviding 1po.,kersl eomperisadon i saran fo�Yr�y er loyees. i3etow a lie D�licy arar��o:�,�t'e iT2f0�'.YlZatlD72. . ksumance CornpanyName". 'Policy#ox Sa:I Im.YID.#: — d — 42 Expiratzon Date: �o�/ 1 l'ob bite Addresq: Czty/State/Zip: .tit tae ,a copy Df thewoxkers'comp ensatron-policy declaration gage(sizowing•tlte policy umnber and expiration date. p'ailure to secure coverage as xequzxerlundex Sectzon 251 of G1,c.152 can lead to the imposition of erhAdIpemlties of a faze up to$1,510,11 andlox ones-year implisopment as well.ao chApenalties in the foam ofa Sq OP�!OR1 ORDand a dine ofup to$250.00 a day againstthe violator Be advised that:a copy ofthis statementmayhe forwardedto the Office of ) vestigatlons of the WA for ib=ance coverage verification. X do hereby cor fy under tIicyaifis cytj•penarties of�rer�r�y triad arie ire fo�rtatz©r�provlded ai`ioYe is true and eorrect, S�anafure /� / � rJ Date: Q I ci Thone 4. OjrIciaZ uS,_Mly. Do not Ivrite in triis area,to be eo7?Wreted by city or togm official. CRY or TOW= Perm tILIcen5e# SssuingAnthorfly(circle 6ue); Z.$aaxd of ealth 2.Building7�epartme�zd 3.CxtylToym Clerk 4.Electrical inspector 5 B mbingbspector f.Outer ~ ~ information and instructions MassaChusefs General Laws chapter 152 requires all employers to provide workers'compensation for Eck employees. Pursuanto this sfat�ate,an e�r�,ployee is defined as" xyp erson iri'die service of another under any contract ob3xe,, express orhapllod oral orwxiftee Ars era lave is defined as"atL individual,partnership,association,corporation or.other legal entity,or any io oxxrtoxe. . Of the foregoing engaged in a joint extterpxise,andancludingtbe legalxepresentatives ofa•deceased einplpyex,.or the receiver o ttzistee of�an ind%vzdual,parinexsldp,assoolatzon or otherlegal entity,employing employees. nSovreverfhe owner of a dwelfing house having notmore than three apartments and who resides therein,or the o ccupant ofthe dwelling house of another who employs,poisons to do MAten.ance,construction or repair world on.such,dwelling house or onthegrounds orbuildhg appuxtenmtthereto shallnotbecause ofsuch employmentbe)deemed to be an employer:" MGL chapter 7.52,§25C(6)also states that"every state or jocaj 1ZceRs149 agency s7xall Withhold the Issuance or renewal of a license or permit to operate a business or to construct buildings&the commonwealth for any applicant who has not produced.acceptable evidence of compliance with.the fusuran.ce coverage reN reed" Additionally,MOL chapter 152,§25C(7)states"Mitherthe commonwealth nor any of its political sub d-Alons shall eutexinto any contractfordie performabce ofpubhowork Until acceptable evidence of compliance with the insurance requirements of tids chapterhave beenpresented to the contracting authority," .Applicants fleas.fi11 out the workers'compensation affidavit completely,by cftecking the bores that apply to your sifaation anl,if A6cedsary,supply sub-confractor(s)name(s),addresses)andphone numbex(s)along with their certifzcafe(s)of iasuxance, limited Vability Companies(LLC)orL7miteMbilitypartnerships(fU)withno employees othertbumthe Mambers oxpartnexs,arenotxequixeclfo carryworkers'compensationiusuxance, Si an LLC orELP does have employees,apolicy is xeq*ed. De advised thatibis afdavitrnay be submittedto theDepartmert of Industrial Accident.-fox coniitmation ofiusurance coverage, Also be luxe to sip and date the azdavz: The affidavit should b e refuxnedto the city or town that the application fox fhoporadt. or license is being reclaested,not the Dopattment of W-Usfrial accidents. Shouldyou have any questions regarding the law or ii you are reRn-ked to obtain a*orkers' comp eisafioapolicy,Please call theDepartmentatthemmberAtedbelow: Selfinsuxedcompaniesshouldentexfheir • sel£inswMee license number on the appxopxiate line. ' City or Town Melals 'leasebesuxethafthea fitdavitiscomplefeandpxintedlegzbly, The Department has provided a space attheloitom oz"thea clayif for you to filj o at zn fTie event the Office of f vestigafions has to contactyouxegar ft the applicant. i'leasebesuxefanllinttl�epemzif/Izcensenumbexwh7ebwillbeusedasaxezexencenwnber, Inaddition,anappllcant fhatxnust submitiaTAIple permit/license applications iz any givenyear,need only submit one affidavit indicating current PORGY infonnation(Nnecessaxy)and under"lob,Site Address"the applicant should wxife"all locations in (city ox town)"A copyo tlieafidavitthathasbeon.ofhciallystw4adormarked bythe city oxfowumaybepxovidedtothe applicant as ptbo f that a valid affidavit is on file f or fatoxe p ermiis orlicenses< Anew afddavitxnust b e filled out each Year.sere ahome owmerorcitizen is obtaitfingalicense oxpermitnotxelatedto anybminess or commercialventuxe (x.e.a dog license orpermit to burn leaves etc)said person is N0Txecpured to complete this afjida'vi t The Office of Investigations'would like to fhank you in advance fox your,cooperation and should you have any questions, please do not hesitate to give us a call, The Department's address,telephone ahc1 faxnMber. �"h�CQ�4x�1��a�t�o�M�.S�ac,7����� • 6WWAVI Solan 02111 o � 617"72�4900 81,40,6 or 1-87-7- '� Devised 5 2605