Loading...
HomeMy WebLinkAboutBuilding Permit #789-2016 - 140 ACADEMY ROAD 1/7/2016 & IkORTH a 1 BUILDING PERMIT ® RtL ED �. TOWN OF NORTH ANDOVER 4a APPLICATION FOR PLAN EXAMINATION S Permit No#: Date Received AC Lis Date Issued: ( , ORTANT:Applicant must complete all items on this page Pr-no 4F'RO+RTY ®UUNE'R Pri 1.00 PYea Strove if yes no EMAP f�RCEL � 7nNING ©IS�TiRI,CT.' Fits o is ®istrict e o - , 777 Machine Shop Village yes o x, 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 .9 Others: ❑ Demolition ❑ Other -Z tlSv I S't i o Septic# . ❑ w�Elli, r- � g q Fes- .'bf Lm _ Y ® Flood lairiOWetlan ®1 Vl/atersh'ed D'strl t i Water/S DESCRIPTION OF WORK TO BE PERFO DIED: ... i SQA�f T/r T h - i'v&L 7-0 Identification- Please Type or Print Clearly OWNER: Name: � Ja c1 lne('& CA" k*►tea Al Phone: Yep-;>63? Address: I q u ry >, N 'bo fraug Narne, f= �� ..�e Phone a :EOLA .iEAR1N �- � r Address` _AA 4.,t�. A Home Impro,errm;ent )Adense. � 1 �-f� �.. E ®ate; 3 F ARCHITECT/ENGINEER Phone: Address: Reg. No. p FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000,00 OF THE TOTAL ESTIMATED COST BASED ON$125,00 PER S.F. Total Project Cost: $ 92!0(0-0 b FEE: $ Check No,: Receipt No.: 2G(^169 3 DOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ignature'of Agent/Owne_r. Signafiure'of,confiractor- Location i nC A- Lev. �• No. _ u Date . - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Fee $. _ Foundation Permit Fee $ *� Other Permit Fee $ TOTAL $ s Check 4t 2.0- J i 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 ❑ !, Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS POET OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments s Conserrfation Decision: Comments !Nater=A Sewer Connection lSi�nature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street aFIRE DERAR�TMENT +T'emp�Dum s 'fr� f;.� - -------- 3 -�-. ,.•, orrsite� es > �v �,� �.1.� p ter ny k►.�,_�.. Located at1�24 MaStre �,+ co;#+ ,• r v; y ,1rKw .:r . t- � k5 re lie rtmentsignature/dale:; +}Z.l✓ '}, , Sy11 � ZT },�Y 5 c•a• r ar�.. '�`L�..`�a.�"�y�s���'i.X`�tq� .�yl �-� i •+ l•`1�;; �'tt�:i(R�k.l�t " 3 t x*-,i�t �1 �Us� , i'j raj , ,�'.�t +c�f I ---------------------------------------- II COMMENI,'S; � .�_. �`� ...,f s�,��.• � .- .,.., -f .-,Ix - �.��;:;�r��.� _� �, ' � � �;i a Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ® 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 ❑ Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Intefior 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 u 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 ®TE: 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 ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) u Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products :)TE: 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 � NORTH Town of ndover O t++ No. z o h ver, Mass coc IC M.WIcM y1. �iq q�R'�TED �Pp��S s V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT tVN�,lA1rJ.... BUILDING INSPECTOR Foundation has permission to erect..............I ........ . buildings on ... ....................... .�" ...................... Rough to be occupied as ....... �.. �.. 4 ...� .i............................ Chimney provided that the person accepting this perlrhall 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 CONSTRUCTIOA S 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. Smoke Det. Federal ID At 06-0405829 RISE Engineering M CordmetwReghdrallon 11108166 MA contractor Reglstrallon No 140879 A division of Thlelxh Eogtaeering CT Cardratxar Registration No=120 69 Shawmat,crater,IYIA o20:1 CONTRACT 339502-5197 FAX339-SOZ 6345 Page 1 © PROGRAM tnescarreAcrnarsvraeeemronnersratame CMA-MSMan ow CUM# 01tolau— wstoreswnawwcns c Bradford Wakeman (508)328-4630 07/10/2015 418421 00002 SERVICE grlc=v 140 Academy Road C= 140 Academy Road 0 is North Andover,MA 01845 North Andover,MA 01845 OB DESCRIPTION PHASE ONE-Proposal for this calendaryear. $0.00 Alt SEALING:Provide labor and materials to seal areas ofyour home aping wasteful,excess air leakage. This work will be perforated in concert with the use of special tools and diagnostic tests to assure slat your home will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can include caulla,foams and other products. Primary arcs for sealing include air lealcap to attics,basements,attached garaps and other unheated meas(windows are not generally addressed)This will require(8)working hours. A reduction in cubic feet per mutate(cf n)of air infiltration will occur,but the actual number of of n is not guaranteed. At the completion of the weatherintion work and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-contractor to ensure the safety ofthe indoor air quality. $680.00 ARt SEALING ADDER: (4)working hours. $340.00 ATTIC FLAT.Provide labor and materials to install an 8"layer of R 28 Class I Cellulose added to(1440)square feet of floored attic spate. $2,592.00 DAMMING:Provide labor and materials to install a 12"layer of R-38 unlaced fiberglass belts to(38)square feet for damming purposes. $77.90 ATTIC FLAT:Provide labra and materials to install a 10"layer of R-35 Class 1 Cellulose added to(176)square feet of open attic space. $258.72 COMMON WALL:Provide labor and materials to install R-19 unfazed fiberglass to 72 square feet of common wail, Then imlell 2"rigid board insulation that meets Hue sections R-316.5.4 and 316.6 requirements ofbu ilding code. Seal all seems with FSK tape. $28224 CRAWLSPACE:Provide labor and materials to hstall(740)square feet of 6 ml polyethylene over open ground in designated cmvAspacelearthen basement areas. $569.80 RISE Engineering will apply all applicable,eligible incentives to this contract You will only be billed the Net amount Currently,for eligible measures,Columbia Gas offers 75%incentive,not to exceed$2,000 per calendar year,and an incentive of 100%for the Air Sealing measures up to the first$680 and an additional$340 if savings are justified by the auditor. Forthe safety and health of your home's indoor air quality,we will be conducting a blower door diagrios is of the available air flow in yaw home both before the work is begun,and after the weatherimtion work is complete.We will also conduct a full assessment of the combustion safety of your beating system and water heater.This has a value of$90 and is at no cost to you Total ellowdble weatherimtion incentive is$3,110. $90.00 I / Federal i0#06-0MBS629 RISE Engineering Rt Contractor Rogistratton No SIBS r' MA Contractor Registration No 120978 A division offlik uh Engineering Cr Contractor Regia Aon No 820120 60 Shawmat,Canton,MA 02021 339-502-5197 FAX 339.5024M CONTRACT Page 2 PROGRAM TxeeoNrRAerTeENn�oaoeasva�aTasn CMA_EESEMODUMMANDnoCUM010 tFORWORRAS Bradford Wakeman (508)328-4630 07/10/2015 418421 00002 140 Academy Road 140 Academy Road North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION Total: $4,890.66 Program Incentive: $3,020.01 Customer Total: $1,870.65 WE AOREE HERMYTO FUra,BH SWMCFS-CGN PLM[N ACCOROAUM W FH ABOVE SPEC MTIONS.FOR 7HE SUM of "'One Thousand Eight Hundred Seventy&651100 Dollars $1,870.65 =jAeALCAN LANCEAFT®tm AinwRrsaiNra°owaea N,era�°uiam,AmIrnnAet°oaaFantraAv 7�sos. DO NOT SM THIS CONTRACT IF THERE ARE ANY BLANK SPACES -- M,a"�Tr,dem cAa 21..!,5 Signature: Age .toe B. Walte ora,. ASIR6[ Bradford B.Wakeman(Jrd 17,2o15) Email: bwakeman@williams.edu '.. NOTE TMS CONTRACT WAY 9E,YTTOMM aY USIP ROT EXECUTED RAnM aATEaFACCEPTANCE tev TOAlm ®PACCePTED AUM071WDAK 30 DAYS. ABSPECMM:LPAYMWV"BEYMASOMUNWABM /'N OWNER AUTHORIZATION FORM Bradford Wakeman (Owner's Name) owner of the property located at 140 Academy Road, North Andover MA 01845 (Properly Addrm) 140 Academy Road, North Andover MA 01845 (Properly Address) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. ees ginatu Date 1/4/2016 Preview:Certificates of Insurance AcoRO® -CERTIFICATE OF LIABILITY INSURANCE DATE(MM ODlYYYY) 01/0412016 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 CONTACr NAME: PHONE Automatic Data Processing Insurance Agency,Inc. AIC.No.E.1): (A1C.N.Y 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC Y INSURERA: NorGUARD Insurance Company 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 Andover,MA 01810 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 429703 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 REOUIREMENT.TERN?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. LTR TYPE OF INSURANCE INSD WVO POLICY NUMBER LI IMIW'DDNYYY (MGUDDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 CLAIMS-MAGE D OCCUR PREMISES iEa occurrence) S MED EXP!A-,.!one Person) S PERSOIJ.L S ADV INJURY S GENL AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE S JECI'POLICY U PRO- F LOC PRODUCTS-COLIR'OP AGG S OTHER: _ S . AUTOMOBILE LIABILITY GO' SftF" I` S IEa.-,cadent) ANY AUTO BODILY INJURY IPu-w,rs t S ALL%YNED SCHEDULED AUTOS AUTOS BODILY INJURY IPa acadenti S NUN-OVlNEDE Ji S HIREDAUTOS AUal TOS iters adml)„ S U-RELLAL_ OCCUR EACH OCCURRENCE S EXCESS UAB H CLAIh1S-LIADE AGGREGATE S DED RETENTIONS S WORKERS COMPENSATION X R U AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR++PARTNER+EXECUTIVE YIN E.L.EACH ACCIDENT" S 1,000,000 A OFFICER330'JBErEXCLUDED? NIA N POWC772258 O1/01120i6 07/01/2017 (Mandatary in NH) E.L.DISEASE-EA EMPLOYE'S 1.000,000 If v .dcscnbc undo 1,000,000 CESCRIPTION OF OPERATIONS belay: E.L.DISEASE-POUCYLIMIT 5 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional Remarks ScheduM.may be attached H mora space is requirM) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TheilSch Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 195 Frances Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE tit. IL.— A@ 1988-2014 L...A©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 2S(2014101) The ACORD name and logo are registered marks of ACORD POLABEA-01 JONEILL '4CORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 1/6/2016 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(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 NAME: _ Durso&Jankowski Insurance Agency PHONE — --- FAX 11 Saunders Street (aC No Ext);(978)688-7000 _ _ ac, (978)688-7001 North Andover,MA 01845 E-MAIL aooREss: INSURER(S)AFFORDING COVERAGE NAIC 9" INSURER A:Nautilus Insurance Co. 17370' INSURED INSURER a;Safety in_s_urance Company^ 33618_ Polar Bear Insulation Co.Inc. INSURER C: Peter Leblanc&Steven Leblanc - —_-�- - P O BOX 958 INSURER D: Andover,MA 01810 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ INSR TYPE OF INSURANCE ADDL StfBR� POLICY EFF POLICY EXP LIMITS LTR I IVSD WVD POLICY NUMBER MIWD MM/D� A X COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE Is 1,000,000 CLAIMS-MADE OCCUR (NN538691 03/24/2015 03/24/2016 A –RIER L) PREMISES Ea occurrence l-$ 50,000 j O _ _.,_ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 — - --- $ GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 X POLICY F JECPRO1 J LOC PRODUCTS-COMP/OPAGG $ 1,000,000 JECT �--__ _ OTHER: i $ AUTOMOBILE LIABILITY I I COMBINED SINGLE LIMIT $ 1,000,000 qx _(Ea accident) BANY AUTO 2100926 101/04/2016 01/04/2017 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED X BODILY INJURY(Per accident) $ AUTOS —AUTOS I --.------..--- I NON OWNED PROPEF2TY DAMAGE $ .HIRED AUTOS ��AUTOS j (peraccide�.�—, ._ ... _. ..__.. I $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE 1AN019284 1 03`2412015!03/24/2016 AGGREGATE $ DED I RETENTION$ _ I $ WORKERS COMPENSATION PER I OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXEW.WE Y/N i E.LEACH ACCIDENT $ OFFICERIMEMBEREXCLUDED? NIAI — (Mandatory in NH) it E.L.DISEASE-EA EMPLOYEE $ It yes,describe under i DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached it more space Is required) Insulation Work-Mineral Insulation Work-Mineral;Additional insured for general liability per blanket additional insured endorsement with respects to work performed on their behalf by the above insured is Thielsch Engineering CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thielsch Engineering Columbia Gas THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 9 195 Francis Ave ACCORDANCE WITH THE POLICY PROVISIONS. Cranston,Rl 02910 AUTHORIZED REPRESENTATIVE 4l-4600 12n4A Ar-/10n r+/100nDAT1/1AI All..,.�.a,..,.,.,...,,.,a The Commonwealth of Massachusetts Department of IndustrialAccidents r l Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/iiia Workers'Compensation Insurance Affidavit.Builders/Contractors/Electricians/plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. . A_ nulicant Information } f Please Print Let*ibly Name (BusincsslOrganizatioo/Individual): Address: V X 'q'j`J� City/State/Zip: u--t F fn � �Lt7 Phone#: Are you an employer?Chcck the appropriate box: Type of project(required): 1. 1 am a employerwith _employees(fun and/or part—time)—* 7- ❑New construction 201 am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No wo&— comp-insurance required-) 9. ❑Demolition 3-E]1 am a horn.doing all work my.IE[No workers•comp.insurance required.)t 10 Q Building addition 4-[]l am a homeowner and will be hiring contractors to conduct all work on my property. (wilt ensure that all contractors either have workers'compensation insurance or are sole I I.[]Electrical repairs or additions proprietors with no empkryoes 5�1 am a general contractor and 1 have hired the subcontractors ontrtors listed on the attached sheet 12. Plumbing repairs or additions Tbcse sub-contractors have employees and have workers*coop( instaaneet 13.❑Roof repairs 6.Q We arc a corporation and its oil-ioer-have exercised their right ofacamption per MGL c_ 14. Other 152,§1(41 and we have no employees[No workers'comp.insurance required.] *Any applicant that checks box#1 must also Sri out the section below showing their workers'mmpmsation policy information- t Homeowners who submit this affidavit indicating they are doing all work and thea hire outside 000uaetors must submit a new 2M&vit indicating suuch lCont actors that check this box must attar_bed an additional-beet sbowing the name of Ibesubcontractors.aod state whether or not those entities have employees. If the sub-contractors have employees„they must provide their workers'comp-policy number_ l am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name-- p 3j- Policy#or Self-ins.Lic.M I 0(fJG ���don Expiration Date: d/ r'/1.-20/7 Job Site Address: l '4-b P-e-A C City/StatdZiJj N-(f Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500-00 ind/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a lay against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance ;overage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct ;iznature: ? t..et—/ - '"�/- ---- --vi Date 'hone Official use only. Do not write in this area,to be completed by city or town gf'tciat City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health L Building Department 3.City/Town Clerk 4.Electrical Inspector 5 Plumbing Inspector 6-Other Contact Person: Phone#: i &Wessand gelation Office of Consumer Ams 5170 10 Pazkplaza-Suite 02 0 116 Boston,Massachusetts Massachusetts for mon HOIIie� COZlt :�v R� ratian- 102726 - -=:_ TYPE_ DBA Tr# 232M E�cpration 7/2f2Q16 POLAR BEAR tNSULpATtON CO- Vincent LeBlanc _ = - _ P.O,BOX 95B _ = reason for dmar- ANDOVER, MA 04890 = UnAdaressand `�`, �►��°t ❑ cam -� Address 0 0pS4004 sw � pq G 101216 M,SssG 9 � i515flafCls Board 0 Bui::ding R uta ;ons afSd�=. C»n,erucdun Supersir-r Sperialr+ nasi 106017 pgM A UB 2 4v pug SMET Plaistow PIH QHS _ =xaarnr,�r Camrziss:anei