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HomeMy WebLinkAboutBuilding Permit #560-11 - 141 CORTLAND DRIVE 5/1/2018 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO.---/,2— O: �67 — / Date Received Date Issued: DHORTANT:Applicant must complete all items on this page j LOCATION Cort r%y y I p Print M PROPERTY OWNER R obtr� rAKd Lost a^ Print MAP NO: 104. c PARCEL: 0 r ZONING DISTRICT: Historic District yes no Machine Shop Village yes not TYPE OF IMPROVEMENT SED USE 1 identia Non- Residential 1 ❑ New Building ❑ One family ❑Addition ❑Two or more family 0 Industrial E(Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition 0 Other 11V` � 0� `` d`1" d ! '❑ t Idd D strr DSeptic �DAWell�> _ Floo p am= f 01xWetlan s Wa ers _�i ict �y L�Water/Sewer• -- ...._�iMvb-.tavuac..,.. DESCRIPTION OF WORK TO BE PERFORMED: • dd btit�rvolh �h �4Ser�ent � dentification Please Type or Print Clearly) I � OWNER: Name: �ob e and Lort{j'ti �ddl e�-o►, Phone: Address: 1 Car �►Kd pr;yc I CONTRACTOR Name: K S1'enerSvh Cohstr��t�vti LLC Phone: Address: co03g6 1 - � Supervisor's Construction License: 8 5' 311 -Exp. Date: 1) 7z j x Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: I Address: Reg. No. I FEE SCHEDULE:BULDIPERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ 1 _FEE: Check No.: ( /021 Receipt No.: NOTE: 'Persons contracting'with unregistered contractors do not have access to the guaranty fund ,.,:. x -:�;z •. :_,:=may.:•-E,._,.:...,. .•-.� --.,. Signature;o_f,�A�ent%O.wn_ .:_.-- of;contractor-�::.::_.::.:°:=. :.-• . I TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: �"— / Date Received Date Issued: IlMORTANT:Applicant must complete all items on this page LOCATION yage Cortl Hv►d V r 1 a 01f?--fi,1460VSe- co,��ohjl - Print PROPERTY OWNER R`b't`t GnJ Loft ff ZfvM Print MAP NO: ION. C PARCEL: Oo)-8 ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT SED USE identia Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial E(Alteration No. of units: ❑ Commercial ❑Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Watershed�Distnct' =# ;DEWater/Sewer.. - __�:.,_� �._�.�_v�:_ ... --•----- ----- . _..,..,- - - - - -- - -- DESCRIPTION OF WORK TO BE PERFORMED: Add b,A�flrom %h p(4semtnt Identification Please Type or Print Clearly) � OWNER: Name: Q�L rpt an�1 Lortt�ti �ddl��-oh Phone: + Address: 1 l C rated p r i ve, CONTRACTOR Name: Si'enerS�n >hs�'r��fio� LL C Phone: Address: �d Sk�� I��hage 03 q6 1 - Supervisor's Construction License: __Exp. Date: 11 Y�'p! Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERN/r,$92.00 PER'$'1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $—Z/ FEE: $ l Check No. / 2 Z -� Receipt No. NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Q contractor; S Location Z/z 6.,y No. 5��- Date � TOWN OF NORTH ANDOVER 3? • '_ O FO. � 9 t �o ,; ; Certificate of Occupancy $ CMUst<�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Y(j) Z ^Z-- 2380 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools ❑ Well r ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank etc. ; ❑ r i ` w PernaiientDumpster on'Site ❑ . ► ` , THE FOLLOWING SECTIONS FOR OFFICE USE ONLY i BIGN OFF -1J�FORM INTERDEPARTMENTAL . DATE REJECTED DATE APPROVED- PLANNING & DEVELOPMENT ❑ __ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS y HEALTH " Reviewed on Signature J o,t-i j ,- COMMENTS- Zoning .COMMENTSZoning 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 signature/date I COAIN4ENTS Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Swimming Pools ❑ Tanning/MassageBody Art ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF -1J FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS F HEALTH Reviewed on Signature " COMMENTS 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 signature/date COMIVMNTS 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 - Date Doc:.Buildiug Permit Revised 2008 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ff.: I 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 I NOTES and DATA— For department use I U Notified for pickup - Date Doc:.Building Permit Revised 2008 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 g Bering 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 D . 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 DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit I all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording !ust be submitted with the building application Doc: Doc.Buifding permit Revised 2008mi 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 o Photo COPYof 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 o 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 o Engineering Affidavits for Engineered products DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit n all cases if a variance or special permit was required the Town clerks office must stamp the decision from the Board of Appeals iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording !ust be submitted with the building application Doc: Doc.Building permit Revised 2008mi NORTH o � 6 over 64 /pD�., 0 00 — 7 ,_.�.•.�rn �F . . over, Mass.,, CO C N I C NE WICK A0RATED P ,�5 ` `S BOARD OF HEALTH Food/Kitchen Septic System . PERMI,,T T D BUILDING INSPECTOR `THI&CERTIFIES THAT ......... .... .............�.......�1�.,.���.��a.�............................................................................. Foundation has permission to erect...... ...... buildings on .... ...... .........D"..) Rough .} to be.occupied as �4s �!!1. ... Io l 1...' -ac7i/V ...................... Chimneys pros e ;thiat tl a person ccepti6o this„permit shall in every respect.conform to the terms of the application on file in Fi�;� f this office, ani to the progisions orthe Codes.and By-Laves relating to the Inspection; Alteration and Construction of. Buildings iri.the Town of,North AndoVBrr PLUMBING INSPECTOR VIOi ho!Il of-thel2oning or�Beilding Regulaiiont Voids this Permit. Rough Final 3 PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUC N TARTS ELECTRICAL INSPECTOR Rough ............. ..................................................... ................... .................. Service BUILDING INSPECTOR Final Occupancy Pemit 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 BeDone FIRE DEPARTMENT: Until. inspected and Approved by the Building Inspector. Burner — —— Street No. 'SEE REVERSE SIDE Smoke Det. Feb 09 2011 9: 41AM Mountain Vieux Kitchens 6039995017 p. 1 lCL, stenersen Proposal ConstruCtfon LLC date Estimate# 109 SHAW HILL ROAD RR4DGE,NH 03461 218/20 s►3 Name/Address Bob & Loretta Middleton 141 Cortland Drive North Andover,MA 01845 Terms See Below Quantity Desc eiption Rate Total Addendum to Proposal#507 to add a batluoom with sink,toilet,and shower/tub unit(see 0.00 0.00 revised plan) • 600.00 600.00 Flooring Allowance(tile) Cabinet and Countertop Allowance 300.00 300.00 Bathroom with raised floor and Jet pump(not recommended by phmtber) 7,800.00 7,800.00 Baftoom all at one level with plumbing Jade ttmnrnered into the floor and a larger in 0.00 0.00 ground pump(add 2500.00) bc ,wtme«sris��.a�eentobeasnpe�ea i►u.r«t.wn� �ame..�rr� ar.+smaw•a; �w.i�.ma .a�.en.. «v.comw;n �,ua aWy WW"ttm ordw;end w M bwme W a=c1o aa ood.bone the amam*set Jordi ebo" Wo shalt not be nepawible fw Aeleys mmd by SdJGM=p&wtk««Lar caerioge—b"WA oar d-Wol. Owner to carr Sq tornado,sm Durr nectefrr mamas oar Hort«.nal eoverad br woAomena Cou4emedne trnatax ACCEPTANCE Abe above prams. am terms mad oaa itiars am satisfactory and arc humby aoot ptc& NOTE:This proposal may be witbdrwm if not Yau*m mathocixed to NWPbr itis app MStWW and daft yolk Waffled.Paymatd will be apee}ted within 30 days. OF PROPOSAL made as oWbwd t bcw. BECOMES SIGNATURE DATE CONTRACT Phone E-ff%A Total 58,700.00 603.520.6672 kstenersen Isom 11 M N X w qu CO Box Out C for closet Desk Area Ca M 'Ma -X. 0-A C 3 Ct Itt Closet Ct w ........:..::,.,:.., /' 7 7: --t77,77= am out 3 for STAIRS Television IM 511 Storage t�,t"ttli C a a U U All dimensions-size designations This is an original design and must Designed: 2/8/2011 given are subject to vcrifiCutiOn On not be released or copied unless Printed;2/8/2011 job site and adjustment to fit job applicable fee has been paid or job conditions. order placed. Massachusetts- Depai-tMent of Public Safety Board of Building Regulations and Standards Construction Supervisor License License: CS 85388 '" I 71, ., KENTON, L STENERSEN m , *QQ'BOX 408, RINDGE, NH 03461 Expiration: 11/17/2012 Commissioner Tr#: 8149 Policy Number: Date Entered: 1/11/2011 ® DATE(MMIDD/YYYY) ACORO CERTIFICATE OF LIABILITY INSURANCE 1/19/2011 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. i 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). j PRODUCER CONTACT D.W. MUGHMAW INSURANCE AGENCY NAME: I 1032 RTE 119 nIc°No Ext: (603)899-3231 A No: (603)720 7985 E-MAIL DAVID@ RINDGEINSURANCE.COM SEPCO BLDG ADDRESS: I INSURERS AFFORDING COVERAGE NAIC# RINDGE, NH 03461 TRAVELERS INSURER A INSURED K L STENERSEN INSURER B: KENTON STENERSEN INSURER C: I 109 SHAW HILL ROAD INSURER D: RINDGE, NH 03461 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 SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $1,000,000 ACOMMERCIAL GENERAL LIABILITY 680373M2038-ACJ-10 0/26/2010 0/26/2011 DAMAGE 0 EN D 300 000 PREMISES Ea TE_ $ r CLAIMS-MADE ® OCCUR MED EXP(Any one person) $5,000 I —PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $2,000,000 POLICY E� LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ I ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ + 1 HIRED AUTOS NON-OWNED FTEROPERTY DAMAGE $ t AUTOS Per accident $ ++I UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1 EXCESS LIAB HCLAIMS-MADE AGGREGATE $ i DED I I RETENTION$ $ WORKERS COMPENSATION TOW TAT RY L MIT OTR AND EMPLOYERS'LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $100,000 OFFICER/MEMBEREXCLUDED? ❑ NIA 373M165-6-10 0/26/2010 0/26/2011 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under 100 000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $. r I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION ROBERT AND LORETTA MIDDLETON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 141 CORTLAND DRIVE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. N ANDOVER, MA 01845 I AUTHORIZED REPRESENTATIVE I - AVID MUGBMAW ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD I Produced using Forms Boss Plus software.www.FormsBoss.com:Impressive Publishino 800-208-1977 µoerH TOWN OF NORTH ANDOVER aH0 . OFFICE OF BUILDING DEPARTMENT . 1600 Osgood Street Building 20, Suite 2-36 ��s°�•no s�p �c5 North Andover,Massachusetts 01845 SgcHu Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print ` DATE: JOB LOCATION: Number Street Address Map/Lot HOMEOWNER 19d�irr Name Home Phone Work Phone PRESENT MAILING ADDRESS , moi ve- An�(jver- 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 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 requirements and that he/she will comply with said procedures and requirements. - �'��� r HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption I BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts Department of Industrial.Accicients Office of Investigations 600 Washington Street Boston,MA. 02111 UV www.mass gov1dia 'workers' Compensation Insurance Affidavit: Biii-ldexs/Conttractvors/BlectlriciansIplumbers Applicant Information y Please Print Legibly Na 1rie(B.usiness/Organization/Individual): ��(' b-�y t I' ` 14 d I tfo In Address: l X11 �� �` l nc� 0, ve_ City/State/Zip: Abrik &4,cr ! ���y —Phone#: q 7F--�- TT 9 Are you an employer?Check the appropriate box: Type of project(required): I.❑ I am a employer with 4. ❑ I am a general contractor and 1 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.x 7. ❑Remodeling . ship and have no employees These sub-contractors have 8. ❑Demolition i working for me in any capacity. workers'comp.insurance. g, ❑Building addition. [No workers'comp.insurance 5. ❑ We are a corporation and its r .] 10.❑Electrical repairs or additions required .] officers have exercised their � 3. 1 am a homeowner doing all work right of exemption per MGL 11.F1 Plumbing repairs or additions myself. [No workers'comp. c.152,§1(4),and we have no 12.❑Roofrepairs insurance required.]i employees.[No workers' 1311 Other comp.insurance required] *Any applicant that checks box#l.must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and joh site ` information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: fob Site Address: City/State/Zip: 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 eerti � cler t;a pains apd enalfies�ofperjury that the information provided above is true and cont eet. r Si ature: '�' t/ z r` r Date: vZ 1I Phone#• 9 7 T_6 $5f�(� [ i FL only. Do not write in this area,to be completed by city or town official wn: PermitUcense# hority(circle one): ! E[ealth 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector rson: Phone#: The Commonwealth of Massachusetts Department oflndustrial.Accidents Office of Investigations 600 Washington Street Boston,MA 02111 u9p. www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/FIectricia>ns/JPluxnbers Applicant Information Please Print Legibly Name(B.usiness/Organization/Individual): Address: /09 Alit pct., City/State/Zip: IVY , 03'/61 Phone#: 6o3 S'z o 6 t i Z- Are you an employer?Check the appropriate box: Type ofpxoject(required): .I-0 I am a employer 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.1 7. Remodeling . ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑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 12.0 Roofrepairs insurance ]uired re . employees.[No workers' q � 13.❑Other comp.insurance required] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners 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: /r ve fe,S Policy#or Self-ins.Lic.#: 6003 7 M 2039 k J--1 d• Expiration Date: I01-42di! i Sob Site Address: City/State/Zip: N0,lti ;4�,�J __, 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 tine �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. 'do hereby certify under the pains and penalties of erjury that the information provided above is true and'corr ect. Si afore: Date: Phone#: S ZA TZ F- ae only. Do not write in this area,to be completed by city or town official. wn: Permit/License# .Issuing Authority.(circle one): 1.Board ofHealth 2.Building Department 3.City/Town Clerk 4.EIectricaI Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: