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HomeMy WebLinkAboutBuilding Permit #143 - 14 BEECH STREET 8/18/2009 BUILDING PEKMI I TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION / qq eacwm.x Permit N0: ( Date Received °.0ACHus�`�� Date Issued: IMPORTANT Applicant must complete all items on this page "smr � � �b.. y`.y F w n TYPE,OF IMPROVEMENT PROPO D USE Res,06ntial Non- Residential New Building /One family ❑ Addition ❑Two or more family ❑ Industrial ❑ Alteration No. of units: 0 Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ DESCRIPTION OF WORK TO BE PREFORMED: An Ue /Vgc� 1-r_ 4s V- <S' n ,�iDi45 I CJS) Y >k wo /2>t- Ste/- GCI S a a 0 F ! T I >,�d R� au e Rai fi- �ShIKc - /Identification t Please Type or Print Clearly) W ONER: Name: u�V �.t� 1�� Phone: Address: `- nww [?" r' a�`alG�u�r � w� y�"f,' akqx �. �a + YH�'H'.lfk'f3k r...,a.rte. ... ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THTAL ESTIMATED COST/BIASED ON$125.00 PER S.F. Total Project Cost: $ g6-60 9-WEE: Check No.: aa•t Receipt No.: :9 off. NOTE: Persons contracting with unregistered contraors do not have access to the guaranty fund Location?l No. Date 5 NORTIy TOWN OF NORTH ANDOVER 9 f i i Certificate of Occupancy $ Building/Frame Permit Fee $ —94f- CH Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 225 V Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales D 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 DATE REJECTED DATE APPROVED CONSERVATION El El COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ r ~COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments i Water & Sewer Connection/Si nature Date Located at 384 Osgood Street Drivewa Permit ^e �ra� ..�.y�.?�' " W�`�'�*�.. •:�`-Y �, e jos�,,Fm�x 3 � � ' '��,� ',�a0_ 4 - r >,x H # '� „.�...,«a , x� �`�`•� t:: z "`z.P" F,Y�.G tw A w. ,Ss� 4 J z~. K �; �'' nu'^"a't� ^t� ,rick- E g � rs � 'V. Dimension Number of Stories:_____ Total square feet of floor area, based on Exterior di mensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires a Electrical Inspector Yes q pproval of No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine No NOTES and DATA— (For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ 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 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Rcvised 2.2007 V40 R Tiq A (own, (0 ,09 Andover q3 do ver, - W LY' Mass., ' - coCHICKEWICK \y1. AD'4ATED PPS -`� pi­ R . BOARD OF HEALTH Food/Kitchen Septic System 41t11001 BUILDING INSPECTOR q'.'4Ue.j...d............. THIS CERTIFIES THAT.......... ...... lau.. ,......................................................................... Foundation has permission to er t........................................ buildings on .�. .......Q.Elm► ,..... ......................... Rough tobe occupied as..... ...... . e............. ... .1�...... ............ .... ...................................................................... Chimney provided that the person a cepting this permit shall in every resp conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS STARTS Rough Service BUILDING IIVNECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. o� rioerN ati TOWN OF NORTH ANDOVER °0 OFFICE OF 0 y BUILDING DEPARTMENT a* 1600 Osgood Street Building 20, Suite 2-36 1'9s gATfD epS�S North Andover,Massachusetts 01845 SHCHUS� Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION I Please print DATE: ' f � (0 q JOB LOCATION:_ I'7 IJ'f eC 6A. Number Street Address Map/Lot HOMEOWNER D RV' d Name Home Phone Work Phone PRESENT MAILING ADDRESS , NCOCG ��. / )6jR,, �14doOvl 0i, k�L/ City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to j be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requir men and that he/she will comply with said procedures and requirements. �A HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 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 oprovements should firsf obtain a copy of"a Massachusetts consmnerguide to home improvement"before agreeing to any work on yourresidence.You may obtain free copy by'caUing'the Office of Consumer Affairs:and Business Regulation's Consumer Information Hotline at617-9734787 or 14884283-3757. Ho - meowner Information =Contractor Information rine . Pant N ,rte Street A (do not use a Post Offi contractor/ Oxmer rine CiTy frown Zip Code less Address must include a street address) SC ef� .V/ -97 Daytime Phone Evening Phone -Ityrr State 4 Code Mailing Address(It different from above). Business Phone ederal Fmpleyer ID or S.S.Nnmtier 1•r requires tlutmat homeim- Home CmmmrRea.N®tier :axp6atiOs�dm: `- P•�oat maosoton Wvee I d �3 .�7,( �•,iaam®tia The Contractor agrees to do the following work for the Homeo ner: w-A W WMP Is dG . o /�' , / Ada r7 P�i h � L e5 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 he excluded from.the Guaranty Fund`provisions of Date when coutmctor will begin contracted work. MGL chapter 142A.): Date when contracted .work will be substantially completed. Total Contract Price and Payment Schedule , The Contractoragrees to perform the work,furnish the material and labor specified above for the total sum of. (.) Payments &ade according to the following schedule: $ o(gd uponaigning contract(not to exceed 1/3 of the total.6ontract price,gr the cost of special order items,whichever is greater) S —::—by�=or upon completion of _f-z�or upon completion of S upon completion of the connect (Law forbids demanding full payment until.contract is completed m both party's satisfaction).. d� The following material/equipment must be special S to be paid for ordered before the contracted work begins in order" S to be paid for to meet the completion schedule.(**) NOTES:(*)Including all finance charges(••)Law requires that any deposit or down-payment required by the contractor befom work begins may not exceed the greater of(a)one third of the total contract price or(b)the actual con of any speoW.equipment or custom made material which must be special ordered in advance to mat the completion schedule. Express Warranty-Is an express warranty hemi crovid•t>. e contre r+ No Yes (all terms of the waReoty at M ea bed « atraetl Subcontractors-The contractor agrees to be solely responsible for completion of the work descnbed 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 aereemen 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)w been placed on the residence. Review the following cautions and notices carefully before signing this contract • Don't be pressured into signing • -'" P suing the contract Take time to read and fully understand it Ask' if" is unclear. Make surd the contractor his a valid Home Improvement Contractor R nicrratinn The hnv requires most home improvement contractors and. subcontractors to be registered with the Director ofHome Improvement Contractor Registration. You may inquire about.wntractor registration by writing to the Director atone Ashburton Place,Room 1301,Boston,MA 02108 or by calling 617-727-3200 or 1-800.223-0933. • Does the contractor have insurance? Check to see that your contractor is properly insured • 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 Hom6Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the cofactor'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 SPACESM Two identical copies of the coonaci must be completed and signed One mprshoutd go to the hOM0071.The ocher copy should be kept by the comma r. .. Homeowner's Signature Contractor's Signature Date Contractor Arbitration .: .The Home Improvement Contractor Law provides homeowners with the right Io-initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same tight is not automatically afforded to"a. contractor,however...The contractor would have to resolve any.dispute helshe.lias.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,ch a a 142,A. Homeowner's Signdture Contractor's Signature NOTICE:'The signatures of the parties above apply only to the agreement of the parties toalive dispute lution initiated by the contractor.i The homeowner may initiate alternative dispute resolution even where this section is not separately signed'bythe parties . Homeowner's Rights A homeowner's rights unde :the Home•hnprov4ent Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be"dvaived 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 cant'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 lic 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 griginal.eontract 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 recission period has expired. Accelerated Payments A contractor mgy 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 Consumer Guide to the Home Improvement.Contractor Law,"•contact Cgnsumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 (617)973-8787 or 1-(888)2833757 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 Bureau of Building Regulations and Standards One Ashburton Place,Room 1301,Boston,MA 02108 (617)727-3200 ort-800-223-0933 For assistance with informal mediation'ofdisputes or to register formal complaints against a business,call: Consurier-Complaint Section Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)734-3114 Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGI,chapter 142A),but does not include standard language to protect homeowners. Seek legal.advice if necessary:Any person la Massachusetts consumer guide to home improvement"before a planning ho 6'4wprovements should first obtain a cagy of"a Pro 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 617-9734787 or 14&8483-375.7. Homeowner Information Contractor Information Name parry ama Street Address not use a Postce Box address) �y , )� alespetson/OwnName ass Address(moat include a atrept sd�dr '�coca O(�,� i�\f � Daytime Phone v PhQoriaQ ity/iown / state�+ p Code a i V VQ?. -7f0��t�7 Mailing (Itdifferwt fmm aboyel: Business Phone edew Employer ID or S.S.Number e `C Lne�r : n Lomemrl Homo Comaomr sea.N=b. Expmfi ndt T Contractor agreesto do the following work for the Hortre � . Required Permits.Thcfoilowing building permits are required Proposed Start and'Comple8on Schedule-The following schedule will and will be secured by the contractor as the'homeowfler's agent be adhered to`unless circumstances beyond the contractor's control arise (Owners who_aecnre their own permits will be - exeluded from the Guaranty Fund`provisions of �� Date when contractor will begin MGL chapter 142A.) gm contracted work 0 Date when contracQ .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 thetoutl sum of J 6d (•) Payments will be made according to the following schedule: S .upon-signing.contracr(not:foexceed 1/3ofthetotal:'contract price pn .Qr;the cost-of special order roams,whichever is greater) -upon completion Of S by —� or upon completion of Ja,p _upon completion of the contract (Law forbids demanding full payment until.contract is completed to bo party's satisfaction) 7be following material/equipment must be —\ apodal S W be paid for . ordered before the contracted work begins in order' S—�� to be paid for to meet the completion schedule.(**) - NOTES:(•)Including all(mance 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 con of any special.equipment or custom made material which must be special ordered in advance to mat the completion schedule. Express Warranty.is•n ""ori being.orovided by thesontnetor+ No Yea Ilterms f N, a - " Subcontractors Tho 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[hie aereemeat 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 interest7tas been placed on the.residence..Review the following cautions and notices carefully before signing this contract • Don't be pressured into sighing the contract Take time to read and frilly understand it Ask'questions if sovtething is unclear. • Make sure the contractor has a valid Home Imn�veme-•t contractor Rcidstratioji. The law requires most home' raN improvement subcontractors to be re pro connectors and. registered with the Director of Home Improvement Contractrfr Registration. You may inquire sbout.contractor registration by writing to the Director atone Ashburton Place,Room 1301,Boston,MA 02108 or.by galling 617-727-3200 or 1-800-223.0933. • Does the contractor have insurance? Check to see that your contractor is properly insured • Know your rights and responsibilities. Read the Important ln1brmaation on the reverse side of this form and get a copy of the Consumer Guide to the Home Idlprovement Contractor Law. [thiidbusiness ay cancel this agreement if it has been signed ata place other than the cofactor's normal place of business,provided you no' ate tor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or delivery, day following the signingof this a by cry,not later than midnight of the greement See the.attached.notice.of,cancellation form for an explanation of.this right DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two idenicela*esofthecommetrnuatbecoupleWendsignei paoq,xb�dd ' . /Hom er.The otic copy should be kept by the eontrsam.er's Signature Contractor's Si Date- :Date t., 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 fight:is not automatically afforded to a. contractor,however.The contractor.would have tgresolve any.dispute he/she}las 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 Busin lation andthe consuer shall be required to submit to such arbitration as provided In Massachusetts Gen ws,cha er 142Am .\ Homeowner's Signature Contractor's Signa 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 Hpmetmprovement 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 hiprovement 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 of materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts caan implied warranty of merchantability and fitness;for a particular nt' 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 d Lica a 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 contractwith attachments is to be given to the owner and the other kept by the contractor. Any modification to the griginal.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 recission 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 Consumer Guide to the Home Improvement Contractor Law, contact - Cgnsumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 " (617)973-8787 or 1{888)2833757 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 Bureau of Building Regulations and Standards One Ashburton Place,Room 1301,Boston,MA 02108 (617)727-3200 ort-800-223-0933 For assistance with informal mediation of disputes or to register formal complaints against a bUsines s,call Coiisiimet`Complaint'Section Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)734-3114 " The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Kashington Street Boston, .HA 02111 ^� www.tit ass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractor-s/Electricians/Plumbers Applicant Information Please Print Ley_ibly Name (Business/OrganizatiotVIndividual): L�/071� QN V 0 'U Address: V\ -�l s ��1 1 's City/State/Zip:� /V Pl>one #: 97� XJ7 Are you an employer? Check the appropriate box: Type of project (required): 1.❑ I am demployer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition Workingfor me in an capacity. workers' comp. insurance. Y P Y 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.] t 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: t Ilomeowners who submit 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. / Insurance Company Name: &� 2Yr 1-k. C0 Policy#or Self-his. Lic. #: 7G lel�i412-,6 6Expiration Date: ee Job Site Address: �� r /�� //TSB 0eity/State/Zip: �/q145 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 crinunal 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. 1 do hereby certif under the pains and penalties of perjury that the information provided above is true and correct Signature: O� Date: le Phone#: 9lk Oficial use only. Do not write in this arca,to be completed by city or town official. City or Town: Perrnit/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#: The Commonwealth of lllassachtrsetts Department of Industrial Accidents Office of Investigations 600 11'ashington Street Boston, .IIIA 02111 ^� iwlviv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plultnbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): wylke C(`G Address: ;`Fe r City/State/Zip:3�QArl N'I/ b B O& Plione P: (oG3-- E'3 -Y3 6C) b A;Vl ou an employer? Check the appropriate box: Type of project(required): 1. am demployer with_/V© 4. ❑ I am a general contractor and I 6. El New construction ,x mployees (full and/or part-time).* have hired the sub-contractors [ Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. t 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 • 10.El Electrical repairs or additions required.] officers have exercised their 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.] t employees. [No workers' 13.0 Other COMP. insurance required.] 'Any applicant that checks box H t must also fill out the section below showing their workers'compensation policy information: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContraclors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy inforTmtion. I am an employer that is providing workers'compensation insurance formy employees. Below is the policy and job site i►iforntatiort. �( Insurance Company Name: 0(3C)0er'G41 `/-P _:�jl C_0 , Policy n or Self-his. Lic. M f Z(D 3a19S O Y Expiration Date: /� Job Site Address: A/ bee SI/ City/Stale/Zip:b,6rA Q Q torr,t O 1 gyS 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 ce)7ify under the pains and penalties of perjury that the information provided above is true and correct Siznature'—�`/c>�tt/_� /�L1D Date: Phone#: 6 03— ci�q,3 ^ el' 3 662 Official use only. Do not write in this area,to be completed by city or toren official. City or Town: Permit/License# Issuing Authority (circle one): 1.Board of Health 2.Building Department 3.Cityrrown Clerk 4. Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#;