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HomeMy WebLinkAboutBuilding Permit #856-16 - 135 JOHNNY CAKE STREET 2/3/2016 AAA/ MORTk 9 11 BUILDING PERMIT `' �/frK� 3�°� TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION i ea mit N0: Date Received C • Date Issued: �9SSACHUS IMPORTANT:Applicant must complete all items on this page �}- LOCATION I1\J' int PROPERTY OWNER I®t�'1 }-- (`e�l� .� 6i✓r'1 ef`:TC3�G : ,; .MAP NO-,/ :/ PARCEL: 6 ZONING DISTRICT. Historic District yes ` no Machine Sh' Viliage yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑ New Building P<ne family ❑Addition ❑Two or more family ❑ Industrial *'Alleration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other .11 Septic ❑Well Floodplain e[I Wetlands V1%a#er'shed Distract IiAlater/Sewer L 6U C� Gv � L fc f Identification Please Type or Print Clearly) OWNER: Name: J_C.7M COOAt" Phone: g7�"' (O�d7� 02 0 Address: � a�N ree-t A). Avid ov-e-e IRA, CONTRACTOR Name. n Phone: �. a O Address �.�c�t �e P Icy. iIv ��LL Supervisor's Construe ion.License ` Exp Date: Home ImproGement Licerse �{ Ex Date 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: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contractiWak unregistered contractors do not have ac s a Signature of Agent/Own_er ~signature of contracf _ F f 4 v OORTH q yED BUILDING PERMIT _ O t + TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION * ,� . ry M M1 Permit No#: Date Received �gssgcHus���5 Date Issued: IMPORTANT: Applicant must complete all items on this page i LOCATION Print PROPERTY OWNER 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 ❑tSeptic ®Well � Flootl ala` i�n :5 nds, ®a WFater�shetl ®strct DESCRIPTION OF WORK TO BE PERFORMED: I � f Identification- Please Type or Print Clearly I OWNER: Name: Phone: I Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: 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: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund MAf r,- � `-—1"c ' r e ... r`__-,.__.,,..,„ -- �_._. _- --_ ... ... _..... Plans Submnitted ❑ 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 I PLANNING DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature i f I'> COMMENTS , HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes iPlanning Board Decision: Comments r i t Conservation Decision: Comments Water& Sewer Connection/signature pate Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEP R MEIVT - , rx, c. t �x4f � xk 4 Temp Dumpster ontsitetN yes' ino r Located at 1x24.Main Street° "` r` ,a � " t ��- • Fire Department signature/date ,, ` COMMENTS : W • '- ; f s41 �...+.ri..s. �cM,�<.•a�• .. - ,a,. ..`� � s , r . ;3 is �F; L i Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: C ELECTRICAL: Movement of Meter location, mast or service drop requires approval of li Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10041000 fine i NOTES and DATA— (For department use) �I I r I �i 6 LI Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 4� Building Permit Application 4. Workers Comp Affidavit 4, Photo Copy Of H.I.C. And/Or C.S.L. Licenses I � Copy of Contract 4. Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: 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 . OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application 4 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 2012 IECC Energy code 4� Engineering Affidavits for Engineered products OTE: 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 Doc:Building Permit Revised 2014 Location CA _ No. 'e`_ Date ,Jrp • - TOWN OF NORTH ANDOVER � .. , Certificate of Occupancy $ x Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee I TOTAL $ Check -A6 i 29.98-3 ceding Inspector r NORTH . _ .. : .c . . veA 0 Nov o h ver, Mass, - ISO OEM_ ___ U BOARD OF HEALTH Food/Kitchen PERMIT T LD t Septic System THIS CERTIFIES THAT ® WN BUILDING INSPECTOR ....... ........ ...... ...... ........... ..... .... ... .... Foundation has permission to erect .. ......... buildings on .....L. .r. ..�i%. .. ............... ....... ... . ... Rough to be occupied,as .........W.A.Wla...IA&....... .1 �..........� ...... .. . ..... . Chimney provided that the person accepting this permit shall in every respect conform to the terms 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO AR . Rough Service ................... .. . ............................. 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. i Smoke Det. A. F. Watson General Contracting Estimate 3 Edgemont Street Derry,NH 03038 DATE ESTIMATE# Tel. 603-661-5360 10/11/2015 1622 Cell#603-661.-5360 NAME/ADDRESS Tom&Brenda Comerford 135 Jolmy Cake St. N.Andover,MA 01845 TERMS PROJECT Due on receipt Master Bed Rm.Closet ITEM DESCRIPTION QTY COST TOTAL 21/4"oak Flooring Allowance 9 70.00 630.00 Plastering Plastering Allowance 1,600.00 1,600.00 Electrical Electrical work allowance 1,000.00 1,000.00 Subtotal labor&Materials 12,715.43 Cont.fee Contractors 10%Fee profit+overhead 10.00% 1,271.54 TO AL Y"986.97 SIGNATURE OWNERS SIGNATURE Page 2 A. F.Watson General Contracting Estimate 3 Edgemont Street Derry,NH 03038 DATE ESTIMATE# Tel. 603-661-5360 Cell#603-661-5360 10/11/2015 1622 NAME/ADDRESS Tom&Brenda Comerford 135 Johny Cake St. N.Andover,MA 01845 TERMS PROJECT Due on receipt Master Bed Rm.Closet ITEM DESCRIPTION QTY COST TOTAL Engineering Engineering Allowance 800.00 800.00 labor Carpenter's labor Allowance 104 45.00 4,680.00 1.Install Beam,support post with new header and jack supports at door way in garage ceiling to support floor of closet. 2.Add 2"to floor joist to match floor heights. 3.Install 3/4"sub floor per plan. 4.Sister in rafters as needed to frame two Skylite 5.Frame perimeter walls and doorway per plan. 6.Add framing to sloped portion of roof to allow for insulation. 7.Install ceiling joist,and strapping as needed. 8 Install blue board walls and ceiling. 9 Install door,flooring,and baseboards. LVL 1 3/4"x 18"x 24'-0"LVL 3 367.01 1,101.03 Materials Materials for posting down under beam allowance 200.00 200.00 2x6x 18 2"X 6"X 18'-0"KD 10 11.24 112.40 avantech TX 8' X 3/4"T&G Subfloor 12 26.95 323.40 2x6x10KD 2"x 6"x 10'-0"KD Spruce 40 4.90 196.00 lx3xl6strapin 1"x 3"x 16-0"Strapping 24 2.70 64.80 B1ueBd. 4'x 8'x 1/2"Blue Board 30 17.13 513.90 R-21 R-21 6.5 X 15 Kraft Face Insulation 3 60.15 180.45 R-38 R-38 Kraft faced 15"x 48"bats 5 42.69 213.45 2'-6"PreHung 2'-6"x 6-6"x 13/8"Six Panel Prehung Pine Door Unit 200.00 200.00 Skylite Skylite 2 350.00 700.00 2-8 9 Lite Insulated door unit 200.00 200.00 TOTAL SIGNATURE Page 1 Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A .Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information N � / Comp nyN_.e �/4;50ju (��Vj CCjJ(-ZdA) Street Address(o not use a P ee Box address) Co or/ alesperson/Owner N7At,5 J35'Jo n ie. r U r o rt) City/Town 11 Stat Zip Code Business Addres (must include a str t address) =s, me Phone E mg Phone _City con State Zio Code Mailing Address(It different from above) Business Ph deral Employer ID or S.S.Number Home haprovemeot Contractor Re rego ,,g.Nwnbc Fap'vetioa date law i—tbnt—thome im 11d mens matnbeve /1 _ ad registration 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.) 5C'.e eSt r VKte, 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 u ass circumstances beyond the contractor's control arise (Owners who secure their own permits will be t!+ ' excluded from the Guaranty Fund provisions of h ate when contractor will begin contracted work. MGL chapter 142A.) Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule ��Q p/; The Contractor agrees to perform the work,famish the material and labor specified above for the total sum of: 7 IS C� (*) Payments will be made according to the following schedule: $��.upon signing contract(not to exceed 1/3 of the total contract price or"thee cost of special order items,whichever is greater) $ ` . by a or upon completion of f ou�/r I y—J spl/C��ptU $ yQ/ �/by ,B/ or upon completion of $ !Ub-t (upon completion of the contract. (Law forbids demanding fiill 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 l to meet the completion schedule.(**) $ r r JNOTES:(*)Including all finance charges(**)law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty being provided by the contractor? No Q Yes fall terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this=cement 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 j carefully before signing this contract. j • 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 j subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor j registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram t or by delivery,not I ater than midnight of the third business day following the signing of this agreement. See the attached notice of cancellatio form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THE A BLANK SPACES!!! Two identical copies of the contract most be completed and signed.One copy should go the horn er copy sh Id be k t by the contra or. Homeowner' ature Contractor's Signature r Date Date PRMSSlOW Ti l.T r Sn.UJCT^4L EMNEEMG 0.0._BOX 958 .OESIGN.UWCES OqF e HAMPSTEAD.NH 03826 :(GM 329-456Q FAX(MM.320440 �. STRUCTURAL H No.3= TITLEEST Jos? c 3 SUBJECT � � ' SHEET Ea, DESIGNED Sy DATE CHECEBD BY RATE TAW " V-61 `, ,'� .-�' �� � �S'i'd.► i�"C��1�9 Ac % y w AVS J� i 1 /40J. ......... JOS F PROFESSIONAL ii�' t7 i• STRUCnjRAL E"NE> RING R.O.Box8 QSS DESIGN SERVICES E,HAMPSTEAQ,NH SACVA�bR , til MOCCIA w FAX.(=63 REMENTWO •SIAL y` , 1!to.33d$7 TITLE .090 Ft'ySTERq � EST. ' , JOB SUBJECT .. •7P � a SHEET 50. DESIGpED BY ✓:.DAT E CEECEED AY DATE......... -- s �wj - P, rue - -- -- el OV 43 614. 4y) ' a .." er ` r prem *. I ► lT qiUC flJ NEEMNS VA DEMN SERVICES 0.0.90X g58 M 8 ' Moq F_KAmPSTEAD.:N sRkjZ!TU fAY,(M 3294" RMMOMAL.0 kA $ i . . . EST TITLE .101 JOB � S0. SUBJECT DESYG tEI? $Y DATE CREGLED 8Y DATE.......... VA 01D C600 Ok . . ro � 44 PUP) IVA tN � i Q ° . SV em Ai �` ► M ------------ I, w 3a�a as a-s133aO -3zva xe oS ,OR las z� reas t or R�TON ���N UV a��, rr azzz ".. lyli . 90r9"6�X7081 XYZ bla3pyy gW WN 4dy3LSdW1/H �2A!vs Ko X©8 Tai. Sir, -ftWUarWg T4,s,�e�� 1"otc PFKWE $TONAL.. �'�i Ntfl1JC.'TURAk.E�II�G DESCiN SEFINM P-0.BOX on o� E WIMPSIEAD,NN 036 �"Al A7aRE J, OOCIARESIDGI L o ,. IST TITLE J08 No I HDBJECT SHEET NO. _. DESZG148D BY DATE S-cszCLED -BY DATE ...�� -?-- -- I'I Su w 1 IL10IN rl N4. OA i ACORO® DATE(MM/DDMIYY) � CERTIFICATE OF LIABILITY INSURANCE 02/02/2016 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 CONTACT NAME: Gregory Porziella PAUL T. MURPHY INSURANCE AGENCY INC. n/CONN Ext; (781)321-9700 ac No: E-MAIL ADDRESS: greg@ptminsurance.com 628 BROADWAY INSURERS AFFORDING COVERAGE NAIC# MALDEN MA 02148 INSURER A: LM INS CORP 33600 INSURED INSURER B: ARTHUR WATSON INSURERC: DBA AF WATSON GENERAL CONTRACTING -INSURER D: 3 EDGEMONT STREET INSURER E: DERRY NH 03038 INSURER F: ,COVERAGES CERTIFICATE NUMBER: 28417 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. (LTRR TYPE OF INSURANCE ADDL SUER POLICPOLICY NUMBER MM/DDY EFF Y EXP MM1DDLIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PRO ❑LOC PRODUCTS-COMP/OP AGG $ IEC OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIABOCCUR EACH OCCURRENCE_ $ EXCESS LIAB___HCLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X1 SPER TATUTE ETH AND EMPLOYERS'LIABILITY Y t N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICERIMEMBEREXCLUDED? NIA NIA NIA WC531.S6012..78016 0.1/14/20.16_ 0.1/14/2_0.1.7 (Mandatory in Nfl) E.L.DISEASE-EA EMPLOYEN$ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 [:EN/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured'hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. Soleproprietor has.not elected_coverage. CERTIFICATE HOLDER CANCELLATION -SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Andover 36 Bart(et St ACCORDANCE WITH THE POLICY PROVISIONS. Job Loc 135 Johny Cake St .AUTHORREDREPRESENTATIVE . North Andover MA 01845 �)_� C Daniel M.Cro ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25.(2014/01) The ACORD name and logo are registered marks of ACORD Yhe Commonwealth ofMassmchasefts Y)epc��tmenf of YndustrialAceldents X Congress Street,Suite 100 << Boston,MA 02114-2017 , www.mass.gov1d1a . 5V� Workers'Compensaiionlnsurantce.Affzdavit:JBudlders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE JPRRMiTTING A.UT'(ORXTX. Applicant Information Please Print Ledb f .cc Sd-zv Name(Business/Organization/Individual): !' Address: F,�4•e. 7 City/State/Zip: C�N /l/ f 'hone#: CP G 3 Are you a employer?Checkth.e appropriate box: Type of project(Teq cored): 1. I am a employer with .: employees(full and/or parE time).' 7. Ne�W construction 2.[l I am a sole proprietor or partnership and have no employees working for me in 8. M4emodelitig any capacity.[No workers'comp_insurance required.] 9. ❑Demolition 3.❑lam a homeowner doing all work myself[No workers'comp.insurance required.]t 10 13uTlding addition 4.❑lam a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions ._._ . proprretors�with.no employees. . _ -- -•-•-]:2:E]3'lum:bing-xepau'S-or_additions.,-,_.._ ,.•n...._ 5.❑I am a general contractor and I have hired the sub-cofitractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 14.❑Other 6.F1 Weare a corporation and its offigers have exercised their right of exemption per MGL c. 152,§1(4),and we have nueroyegs.[No workers'comp.insurance required.] - TO '.Any applicant that checks box 41 must also ffd out the section below showing their workers'compensation policy information. t Homeowners who subaf this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have . employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. X am an employer that is piovid6hg workers'compensation insurance for my employees.'.below is the policy and jolt site information. / Insurance Company Name: / Policy#or Self-ins,Lic.#: WG j S(0 G 12 7 36 ' Expiration 'a�"t"e��: l` � � AUr Al�(Q� 5 rob Site Address: l�5 � City/State/Zip: a/F�} Attach a copy olFthe workers' compens tion policy declaration page(showing the policy cumber and expiration date). Failure to secure coverage as required under MGL o. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification X do lie:eby c der the p`an s andp nalties of pea;juP that the information provided above is true and correct. Si nature: `\ Date: 2--Z--16 .-.3 Phone#• (Po l> A 6G 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#: i Information and Instructions Massachusetts General Laws chapter 1.52 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 Bite, 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 b6 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 fll•out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractox(s)name(s),address(es)and-phone number(s)along with their certi$cate(s)of insurance:-Limited.-Liability-Companies-(L-LC)-ox Limited-L-iability Putwrshi�(LL-Pyv-th no employees o eran 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 ofinsurance coverage. Also be sure to sign and date the affidavit. The'afCxdavifshould 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 yo'u'are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-ihr ured companies should'entertheir self insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as areference 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(ifnecessary)and under"fob 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 TeX.#617•-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-•727-7749 Revised 02-23-15 www.mass.gov/dia 0 l � f .`� - Vfze dnvrrio�ruuecr��a�Gaa�aeCt�. �a Office of Consumer ss Regulation' Ok IMPROVEMENT CONI RAGTOR b egistration'� a g848 T Ype' Expiation 4/28120f1 DBA " A F WATSON GEN ON, 'GT.ING±� H ARTHUR WATSON i 3,, DG ST t k DE.RRY;, NH 03038 - Undersecretar"y' y,« Mai§A;lii"&- pBt6Ttil ULt c. ` fL 14 r Sciard ofStfijajng� 64- "flan Conitruttion Super4isor i h'i'2 k.w'im! Licenge'. CSFA-063168 ' i • _ �ter,t�.� ,�� - '�.. ARTHUR F WAT§O,N 3 EDGEMUNT ST :DERRY NH 030A r p -Expiration t 1 Commissioner` 02/12/2016