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HomeMy WebLinkAboutBuilding Permit #538-16 - 147 HIGH STREET 10/30/2015 L�9/rr/✓E"D ��^S' �S� pORT11 O`�t�av bq�0 BUILDING PERMIT �.? g, _ °.•:a o� <sTOWN OF NORTH ANDOVER ° p APPLICATION FOR PLAN EXAMINATION Permit NO: ��/ Date Received 0 " �9SSACHU`����y Date Issued: ►t " IMPORTANT: Applicant must complete all items on this page ,�� 1 LOCATION �"l 1 1 - O T 111 A 01 S Print PROPERTY OWNER } C� -"�t � ' Print MAP NC _�PAPCEL- ZONING (IISTRICT: 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 El Septic ❑Well 0 Floodplain 0 Wetlands ❑ Watershed District El Water/Sewer a se tymn,+ F� Identification Please Type or Print Clearly) p QG OWNER: Name: [ /y 0 0-hA S _ l Phone: q � � 11) Address: 1 1 L 614 3- "1– P_Tu A&b0VFKM 618#5- CONTRACTOR Name: Phone: 0 _zj �l peb CJ ALM (-,)I Address: Supervisor's Construction License: Exp,. Date: , C I s- 1,201 -7 Home Improvement License: Exp. Date: 0i 1 () )wlco ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project C st: $�3� GO �O FEE: $ Check No.: S Z 3 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access.to`the gua�ranry fipd ignature of Agent/Owner Signature o of contrac r ¢' r i � I i Location/ 0- Aih No. Date% . - TOWN OF NORTH ANDOVER f X Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ i Check#�� Z 2960 Building Inspector pORTH BUILDING PERMIT O.11 F f TOWN OF NORTH ANDOVER 32 1E,0 APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received gs01?ArL1 Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION _. - Print PROPERTY OWNER__ xririt 1 DO Year Structure yes, n'o MAP' _ _..,_PARCEL: ZONINGDISTRICT: _ Historic District yes, no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building ❑ One family 0 Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial 0 Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic 0 Well 0 Floodplain 0 Wetlands 0 Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: r - II Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: • Contractor Name: _.___ _ . _ ___ __--Phone Email::,- Address.:, ., mail:Address.: Supervisor's Construction. License: __ ___ n s_Ex_ : Date: p _. Home improvement License:,,._ _ _.Exp Vate - - - - - , I 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 w Signature of Agent/Owner _ _ . _ Signature of contractor 1 F 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan j ❑ 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 VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doe:Building Permit Revised 2014 f Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stampeck Plans ❑ f TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dtunpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature i COMMENTS 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: . -- IFIRE SIJ PARyTMENi Temp DuP-, r ons siteTEyes � ._ 3no�Y Located Osgood Street - _ F=;re�Departments:gnature/d`ate— f aCOMME.14% Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: i ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No I 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 E �I h I { ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 i Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 433005.00 m $ - $ 516.06 Plumbing Fee $ 64.51 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 64.51 Total fees collected $ 745.08 147 High Street 538-2016 on 10/30/2015 Basement Remodel "Yown of ndover No. h , ver, Mass, ( a 1,36 1 S' COCHICNtwtCtt 4ArE0 BOARD OF HEALTH Food/Kitchen PERMIT T LIJ Septic System h THIS CERTIFIES THAT .Il. l.(! ......V11. ....................... BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on 1. �:"..... s.k1 � .... .. .. ... ................................... Rough tobe occupied as ........640Y4......... .......... .................................................................................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and ' r Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR s. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR ; UNLESS CONSTRUCTION STARTS Rough Service ................................................................................ Final 3 BUILDING INSPECTOR GAS INSPECTOR i D ®ccyR ancE Permit Required t® ®ccugy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final llY No Lathing or Dry all To Be Done FIRE DEPARTMENT = n Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. � NORT1y Town of 2 : � E �. ndover 0 . Ilk ' h ver, Mass, I COC MIC"t W$CK �•4 A°RATen P-P�,��(5 S U BOARD OF HEALTH Food/Kitchen PERMIT T LD 1- Septic System THIS CERTIFIES THAT .U. ?.1.!!:...... I.'?.... :- `............................................ BUILDING INSPECTOR has permission to erect ... g ......1R..... ,,�, 1;5,}x,,, Foundation ....................... buildings .......................:....... Rough tobe occupied as ........ ,J�.......... .......... ................................................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration'and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS 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. Professional Building Services Estimate ® . ' 9 Olde Woode Rd Salem NH 03079 www.professionalbuildingservices.com Date Estimate# info@professionalbuildingservices.com WM ' 603-898-2977 / 781-995-2335 9/30/2015 2902 Exp. Date 10/21/15 Name!Address Robin Morgansen 147 High St North Andover MA 01845 Description Qt Rate 'Total P Y Scope:Basement remodel Building Permit-Administration Fee 1 375.00 375.00 Home owner can pull building permit themselves. If customer wishes Professional Building Services to pull permit, please add $375. ** Customer to reimburse Professional Building Services cost of permit fee paid to Town/City.** Building Permit Fee paid to Town/City-TBD 0.00 0.00 This fee to be reimbursed to Professional Building Services or customer can pay directly to municipality Framing: 1 3,000.00 3,000.00 Construct 2x4 walls around perimeter and interior walls All doorway and window boxes Pressure treated sills Strap ceiling with 10 strapping.2 ring nails per code Thank You. We look forward to working with you ! Total Page 1 M Professional Building Services Estimate ®`` "�� 9 Olde Woode Rd Salem NH 03079 www.professionalbuildingservices.com Date Estimate# � infoCLDprofessionalbuildingservices.com ' 603-898-2977 / 781-995-2335 9/30/2015 2902 Exp. Date 10/21/15 Name/Address Robin Morgansen 147 High St North Andover MA 01845 Description at Rate Total P Y Electric Allowance 1 10,292.50 10,292.50 SCOPE The proposed electrical work is limited to the following: Secure electrical permit from North Andover Inspectional Services. Change existing service to 200-Amp with 40-circuit panel.Relocate wires where necessary. Reconfigure switching as needed. Wire for new receptacle outlets to code. Furnish and install 12 recess fixtures. Change(2)existing smoke detectors to combination Carbon Monoxide/Smoke units.Add(1)new smoke detector at boiler utility room. Wire for(1)CATV. Wire the washer and dryer for new location. Wire for sewer ejector pump. Provide and install electric baseboard heat at laundry,bathroom and open space.Provide and install(1)Panasonic bathroom exhaust fan, vent by others. Plumbing Allowance: 1 7,187.50 7,187.50 Saniflo 3/4 Install new 1/2 bathroom in basement to include.Liberty macerating pump with white elongated toilet and seat.One white 24"vanity with top and 4"chrome faucet.($250 allowance on sink,faucet and cabinet.) Move washing machine and laundry sink over 5'from present location. Move gas dryer over 5'from present location. Tie new pump drain to existing 2"cast iron drain line.Tie into 2" PVC existing vent stubbed into basement. New PEX water lines for washer and new 1/2 bath. Permits and inspections Plumbing Allowance: Move furnace back to wall 1 1,200.00 1,200.00 Move furnace back to wall allowance Thank You. We look forward to working with you ! Total Page 2 M Professional Building Services Estimate 9 Olde Woode Rd Salem NH 03079 www.professionalbuildingservices.com Date Estimate# info@professionalbuildingservices.com 603-898-2977 / 781-995-2335 9/30/2015 2902 Exp.Date 10/21/15 Name/Address Robin Morgansen 147 High St North Andover MA 01845 Description oty Rate Total Sump pump: 1 2,400.00 2,400.00 Cut concrete Dig out and remove soil to grade Fill with stone and bucket Install sump pump Pipe to outside **Concealed conditions apply **Can not determine what is beneath the basement floor so if we hit an obstruction,additional fees may apply*** Excavation Allowance: 1 0.00 0.00 ** NOT INCLUDED IN THIS ESTIMATE ** **Bulk head and basement doors by others and not included in this estimate** Flooring Allowance: 1 0.00 0.00 FLOORING AND SUBFLOORING BY OTHERS Thank You. We look forward to working with you ! Total Page 3 Professional Building Services Estimate B rY,. 9 Olde Woode Rd Salem NH 03079 www.professionalbuiIdingservices.com Date Estimate# info@professionalbuildingservices.com 603-898-2977 / 781-995-2335 9/30/2015 2902 Exp:Date 10/21/15 Name/Address Robin Morgansen 147 High St North Andover MA 01845 Description Qty Rate Total DRICORE SUBFLOOR: 1 3,100.00 3,100.00 There is 730 square feet of flooring and we should have approx 10% waste.For 800 square feet of DRICORE. Each tile is$5.47 201 tile @$5.47=$1099.47 10 packs composite shims ]0 x$1.85=$18.50 Glue,nails,etc.$78.50 Materials: $1196.47 Tax:$74.78 Delivery:$100 Materials Subtotal:$1,371.25 We mark up 15%to handle and manage but just do it on the materials(no tax nor delivery)of$179.47 Materials Total:$1550.72 Labor to install discounted$1550.72 $3100 Electric baseboard Heating 1 2,500.00 2,500.00 Insulation to meet code 1 2,400.00 2,400.00 Drywall,Ceilings&Coverings 1 4,200.00 4,200.00 Paint-prime and paint all ceilings,walls,doors and trim 1 2,400.00 2,400.00 1 coat Ben Moore Ceiling White 1 coat Ben Moore linen white eggshell finish on walls I coat Ben Moore White semi-gloss on all trim Darker paint colors will be subject to upcharges if applicable as additional coats may be required with darker colors. Multiple paint colors will be subject to upcharges if applicable as additional set up/clean up times may be required with multiple colors. Thank You. We look forward to working with you ! Total Page 4 w Professional Building Services Estimate 9 Olde Woode Rd Salem NH 03079 www.professionalbuiIdingservices.com Date Estimate# info@professionalbuildingservices.com 603-898-2977 / 781-995-2335 9/30/2015 2902 Exp.Date 10/21/15 Name/Address Robin Morgansen 147 High St North Andover MA 01845 Description Qty Rate Total Doors&Trim- 6 panel doors with hardware installed 2 450.00 900.00 Bathroom door Furnace door Doors&Trim-6 panel bifold door with hardware installed 2 850.00 1,700.00 Bifold door for storage area.Slightly more because needs to be cut down to size ** doors in front of washer/dryer**** Windows&Trim-box out 4 basement windows 4 150.00 600.00 Speedbase trim 1 750.00 750.00 CONCEALED CONDITIONS:This Agreement is based solely on 0.00 0.00 the observations Contractor was able to make with the structure in its current condition at the time this Agreement was bid.If additional concealed conditions are discovered once work has commenced which were not visible at the time the proposal was bid, Contractor will stop work and point out these unforeseen concealed conditions to Owner so that Owner and Contractor can execute a Change Order for any Additional Work. Thank You. We look forward to working with you ! Total $43,005.00 Page 5 3'-711 7'-7 5/8" 7'-8" Id HWTank Cn Boiler 3'-6" N � � M M O 00 r S v V4�rvt. '0 rp 5'-8" 5'-8" 32'-6" ACC) CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) `� 1 10/20/2015 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 Patricia Blais NAME: Financial Insurance Services Inc PHONE . (603)432-6414 FAX AIC No (603)432-3852 PO Box 950 E-MAIL ADDRESS:Pblais@fisins.com INSURERS AFFORDING COVERAGE NAIC# Derry NH 03038 INSURERANational Grange Insurance Co 14788 INSURED INSURER B:Hartford Insurance Company Professional Building Services by PMC LLC INSURER C: 9 Olde Woode Road INSURER D: INSURER E: Salem NH 03079 INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 500 000 PREMISES Ea occurrence $ r A CLAIMS-MADE Fx_1 OCCUR KPT1630H /5/2015 /5/2016 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY JrCT PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 ANY AUTO BODILY INJURY(Per person) $ A ALL OWNEDSCHEDULED B1T1630H /5/2015 /5/2016 AUTOS X AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X $ AUTOS Per accident Medical payments $ 5,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ B WORKERS COMPENSATION WC STATU- DTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMIT, ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? [::i N/A (Mandatory in NH) 04WECLB1809 8/5/2015 8/5/2016 E.L.DISEASE-EA EMPLOYE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover MA ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Sam Fragala/PAT � - ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INSOZril7 1n 51 n1 Tho ernRn name nnrl Innn orn reniefureA mnrlrc of Arr)Pr) The Qfttvlltlnj!'tajgf Ti- 0=4 "tc€,' Uta rj5tdla#>r 0 M4-2017 W.In clss.go v1dia 14*ork .ars" Cjmpejjsatj(')jj insurance. Cdr avi ; "'t-ase Print Leggib1% 0a) *•y �. F t-, i « .w Aes ��° �, ,i t ( . _ qn employer?CiYtctr Oic x3pproi3rl;aie)vrx. 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C .3Tsacterrs t�Z�t x boy,tt wo c aclrtiti{cm,e idi`t^I'1 Am st ,awg Me On=, il:to lathe wb�omrlctm'h .vmpd,Y.cxs�tt Y� tiiu�t•prv;§��I}ct. cite ctrnp.txzlt �itu,nttcr t am aft f'#1ph )-er that is prolidlll""rr'ork r;c'etbJ1ipensati n itisuras# ct fi#t n3 sx`f?ftD�'t'Y. Bulow i.s the polh,1"tlttd,$ob iii& r3i?t;zticC'Company rtT)c: LLUJob POW! #or selr-ttts. 1-ic. ;';': O."'S .t ,y�2dt'r;Jkasc 1,,,. Att idi .i 01100l theIvarkers' c+)limp t"ltiMl V01 iCY de€aratio 1 i age(shotving,dtie poli-c. k�ti•rttht r inl4 e.�;trt;ttriakt cistts ). Fntilurc to scctrr CON CI ge as g#" uin`L ullder Section :. i�, (`f t�.i c ") � lead he col c t �w �- � L P ...�to kt r tIYC�:,F.S,.�l c'} Il}2i1�� t7 ,., i';y f1f:� 6111 Up to J i.-T0¢t 00£ndkir onspar tt31 rj,r)Drr?"Il., Is ac!] SiL,,# J; TLii .* att: Jit2 OtCTJ' VV3l ORDER, t 1R,z?t ( :! fSP,•_ ofup A 5250 Oto day <, c. 1 , . ,, f(#�;t�Cr. Be i3Ci't'3;�c, l' � t FT ., � _ � �. OT I. i. tar..-.,�,..I[ r.t k.�, ,Cri i4.?C4�s+., .. ,�1C 5�.:.`�: o�. Fit Gtr T.' •1 c c , .,r � �t ,� ;,.� c., f ('Y IYit kgritYmm od t DIA.ices insuran-ce co\cva C T tlrt herr,yrr"Wer the pai#2,t and penoWs n f 1,ef:WrC Him I s. ;it�cyr a,?t It;�z�itr,r°tJ�ca t€hr%t"is Ir ue and cuvc.r. t t itwr,ZI -4-L-Ahlym a ldt t t1/O t� filklol It'v fr Ul" .0o not "41c in this arca,to be complt,le 1 t7 ;, i�� t € Y c, 11)it`rt s rc•irri tr'4'OS""rt")YY n: t IS*Sttilt; rltthority (cir'clerjjv); l HO.rid of ti'Cakh 1 HuMng C) par tme m I �""at�i�'aYir>(:`i<r� 4, Llc# �:Wic.i! tta%p ctov . . Plumbing trtsitt for6. other ` Contact Phone The Commonwealth ofmassacIlusetts Deparltnentof 1'n ustrialAceidents Off ee of Investigations 1 Congress Street,Shite loo Boslvnlf J19A 07114-2,017 www.mass.govIdia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ApRficant Information Please'Print lr.,e ibly 3vi3Tlae (Business/t)rgfltaa7atioritlnd.izidual): Address: Cityy/State/Zip: � d ? ( Phone 4: Are you an employer?Check the appropriate box: ,. 1. 1 am a employer with ��) 4. 1 am a general contractor and I Type of project(required): euaployces (Fu11 and/or part-tihay=e fired the sub-contractors f'. New cons ruction 2.0 1 aiaa a sole.proprietoror partner listed on the attached sheet. 7. J emodelitag ship and have no employees These stab-contractors have ;�. Demolition work-Ing for sate in any capacity. einploy�ees and have workers' lNto workcrs` comp,insurance camp. insurance.1" 9. wilding addition required,; 5. We are a corporation and its 1.[l.®Electrical repairs or additions 3.0 1 am a hoineoxvner doing all %vork officers have exercised.their I I II Plumbing repairs tir additions myself: [No workers" comp, right:ofexemption per MOL insurance required.] t c. 152, l( ),atad ��c laa�^e no 12.0 Roof repairs employees. [to workers" 13.[3 Other comp. insurance.reguired.I *Ani'applicant that checks box#1 must 31st?fill ot1t the section belotiv shop+ing their A+orkers`cornrpcusasti<nts polio inf<annation. 'l�fomeow hers who submit this allidavit indicating they are doing all cvotk and then hint outside contractors must submit a ncnc a€fidavit indicative such. =Contractors that check ibis box must attached an Additional slnc t shouting tine nanle of the sub-contractors,and state whether or not those entities Lve e+npl11 oVees If the scab-contractors tiaveemp#r��^rxss.they must provide their W-kcnrs'comp.polieN number. Ian?all enzpllrrer that is provhfing workers,Compensation insurance for nil,emp1mw&. 13crloiv is tlte�ttolic�t ant/joh sifc� its ortmation. In urance Company Naisae: + � : IV]J fa 1i L�� tnce-, Omm # `. Policy#or Self-ins. Lic. 4: { CP 1`t_ F ...... _ Expiration Date r Job Site Address: Att:adi a copy of the trorkers' mlaensatian policy declaration page(Showing the policy number and expiration date). Failure to seetire coverage as required ander Section 25A of MGL c. 1.52 can lead to the imposition ofcrinnnal penalties of a fine up to$.1.500,00 and/or one-wear imprisonment.as-well as civil penaltics.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 cope^of this stateinetat mm, be forwarded to the Office of Investigations of the blA for insurance coverage verification. I do hereby.ce under the pains and penalties of perjury that the itifortnation provided above is trite and correct. Si attire, P aonc#: Official use only. Do not ivrite in this area,to be completed by city or toivn gffacual. City or Towm: Permit/License# Issuing Authority (circle one): I. Board of Health 2.Building Department 3.City/Town Cleric d.Electrical Inspector 'S.Plumbing Inspector 6.Other - Contact.Person; Phone#: lie�p rr�orccae�aCf�aC�/�L�u��aciccJefta w` Office ofCons uul Affairs&,BusinessRegulat\ond. +, 1 ME IMPROVEMENT CONTRACTOR` egistration: :170870 Type: xpiration: 1/10/2016. DBA PROFESSIONAL BUILDING SERVICES INC. PETER CIARALDI 9 OLDE WOODE RD 4 ` SALEM, NH 03079 Undersecretary Massachusetts Department of Public Safety Board ofBuilding Regulations and Standards License: CS-097650 Construction Supervisor C!lv PETER M CIARALDI9 OLDE WOODE.RDSALEM NH 03079I fir,-"jZ;7K CA__ Expiration: Commissioner 07/03/2017