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Home My WebLink AboutBuilding Permit #597-14 - 15 BRADSTREET ROAD 2/14/2014 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: - _` Ll Date Received Date Issued:l `1 �. IMPORTANT:Applicant must complete all items on this page-- § .• a €n 5 S cd x"s$A»l;a ;t }a '�' s - � e�.k, • t ��'.i+-s�' >:` g-y`�.i � 5 '6�° 5 x c:. 3�-;. ..saw � �..c�,.- �ry t PR:OPERTI' ®UV _ .f"f,� f't`LI3rrmar` . �100 +ea00-.Q , cryefureS Mes (�(,MA_I? N®°y- �,�� ' PARCEL� Z®N`ING ®IST=RIOT -�3Historic ®isfirict +� * � TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial PT%le-pair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 58 p c -®tWel 'J ❑ Floodplainr. .N.Wetlands sMer. �� ,��, �1NaDist ct ;pWater/Sewer � r .— � ° -�''; DESCRIPT ON OF WORK TO BE PERFORMED: nee hu'r-m-tv. A Od-V 3 .YL�ff7�^cx�r-� barb rte, rah secawd f�oc�✓` Identification Please Type or Print Clearly) OWNER: Name: Px,�,i&k 8,zAe-.,, Phone: Address: S- -k)0iInAs ^*rte ,,.d, -.�v + * a^r r? 's`-'ice-X• .-�•. .= r - -. *er5dr' AA r '^ �� u � a �`� ryu Cta�• r � kyr k skt CONT GL OR�N ....s h > fF'o Cao . LLQ, phone , 6d3 3 9' 6';�c3 9` Q k� lSS fv[�ror.- .� vI, d �Y v�a�. w t h o f YYc ra tz a n t � �..t� �`�`,.. ,-� � ,�,�� " .��'�T��'' `_ a , . - - Su ervisor s C°onstrucion License � '0 14 p s� �y7q�9 Exp Date��,3 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: $ '7 7, as FEE: $ SOCL Check No.: Receipt No.:--,3� d 1, NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted LJ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ d-sL T Location` No. � ? Date Ql • ' TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 2r ' :7 J 03 Building Inspector M - i i I i i l i - . - Plans Submitted ❑ PlanslVaived ❑ Certified Plot Plan ❑ Starnped Plans ❑ TYPE_OF;SEWERAGEDISP.OSAL - Public Sewer ❑ Tanning/MassageBodyArt ❑. . . Swimming Pools ❑ <a Well ❑ Tobacco.Sales ❑ Food Packaging/Sales' ❑ Private:(septic tank,etc.- permaneint Dempster on:, ite ❑ -THE-FOLLOWING SECTIONS FOR OFFICE USE..ONLY INTERDEPARTMENTAL SIGN OFF - U FORM _ DATE REJECTED: DATEAPPROVED PLANNING & DEVELOPMENT" ❑ - ❑ COMMENTS CONSERVATION Reviewed on Signature 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 r . DPW Tow;2 Engineer: Sign�tiike: Located 384 Osgood Street FIRE DEPARTMEN.t.:-z.-Temp Dum ' 'ti"r on site n es o y Located'at 124iMair,.Street Fire Departine►it signature/date" COMMENTS NTS --DimensiGn Number of Stories: Total square feet of floor area, based on Exterior dimensions. .Total-land area, sq. ft.: r ELECTRICAL: Movementof Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER. ®NE LITERATURE: Yes No MGL-.Chapter-166 Section 21A.=F and G min.$10041000:fine NOTES and DATA— For department use B Notified for pickup Date Doc.Building Permit Revised 2010 Building Department the r'oh swing is'a list of-the requited.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/O'(C.S.L Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineeredp roducts 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 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 o 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 apur?al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.+.ted with the building application Doc: Doc.Bui!ding permit Revised 2012 Massachusetts Home Imurovement SMP—le Contract This formsatisksallbasion phmtmtsoftha=e Ma meO-uBcwI.aw(MMdhpUs142AXbutdoetuethwhidedandud to prefect boseowaera.Sed` adv"if hVptave mals should first obtain a cW Of A �Cons�cGm'detoAooa:l� �yt>��Bhome' . bdne tDanywmkonymmttsideamYOU mayobtain afrocopy bycdmgthe OT=ofOmsmerAfiimsaadB Regula mtCoammwh onHodmeat617-973-8787or1-888-283-3757aronomvabsite. Homeowner Information Contl2clorinfa matron Name Co r>eax C�- A' Q�n f D �r LLC. SnaAddnse(dotmtmeaPamOfiteB=addtess) Caottaetml3datpasadthvaerl�aeee Cityfr— State ZpCO& Eo Addicts(oastincbedeasuettadd=) A6A ;LI 11 A r Ch no Daytime PIlRl tStyA'owe State zip Code - MBtling Address(ft dim fi0m above) Padad Fmployw 1DarsS�liutabv .. Aomet remr&gltmnLadffi ter�n�sllmRl.�e • at10d.07 6 3v i TbeCoiahx6oragra sto do fie following wmlttortheHovaewner- �e mnndaml thewak m osopkoed,speeifyhg�tYpe.b��tt�+d> m 6ensed,�addir6teet shesaifesenseev) d`Z 1 12CPi& erAe,44 �tnc�ows ?-na Poor— 6o,4,,cw,- rtrio,;W RegdredP=ft-TlwMowiagbmldmgpem'- —required A'oposed3fas -dGmpW-S -Thef000vviogmhemcwm and wffl be secured by the contactor as the hanteownes agent be adheeod to nabna eirr131811M bead the conuactoft control arise (Owners who secare their own pawift wiQ be eacladed from the Guaranty Fund providens of Date whey contractor wM begin emuamd week. MQ,cbspter 142A.) Date when coubataed we*YM be sabsiaatially Comptek& TOW CasteaetPUMund PaymcetS&edWIe Thocaouactoraptxstopaduaodowo'kfomsbdometeWand laborspecified abave5orthemialSam of l�aymeodswiD bemadea000nimgtothefollowing srl edolc $ aponSigning CQUb t(DOtoOweedWOfthethlamt®dFixX tacastafgeriallenter em%whicb waisWeatw') S l ��by /_�or apon otmpled-of L j,r)d o,,, /`tS k& then S , by / -upon—upldiaaof S —opo$ ofthenomad (LawfotbidsdemandingMpWucwtmulcantedis completed to both patty's satisiactioa) Tbeibitowiva—amYaquOts mintnespeoet s tobepaafor oedaodbdaeeb0000aae- vwekbtgiosismfor atoeettbeampietm (++) S tobepaWftw NOTZ&(hbdWbga8faamoaI g (-)latrtegaieestlatstydWcaft rdoanj"meot bsdeeasweacowbdoeav+akbegitem� deem WIbegnadaof(a)ooWhitdofdmtottdo numpdmor(b)tLeammlaostofmyqmcweqok=Mdorwstom�demsetiai wleb�mmtbeapccid alae I is advmeetomoct accompleem sehea to • 13snreuwarrashr-H�emrs�warraolvbti�otev➢drAhvfAem�+ �No�Yes/.11tensnr»...�......e rr - Sabtontradota-The earagtas to be solely mgmsflk forcomptehon ofthe welt described reguallm ofere US=afanytbkd IML3461b.prmilarin auliaedbytheemuacoor.TlmaottttacmrfmtlidragmatobesadytespUMVCSoranpaymmisInall mbooMUmsfor Vials and under this ameem®t CoetreetAeopftu--Upaasgomg,tasdammmcotheoomesabazdmgaoa>,actmederlaw, i)ntessOdmWisenowwithmtbisdaaameat the oomtactshaQ�imgelythetmryTienaaothaaamityiatetesthasbam�aatueteadence.R�aviewtlm catamnybefwesigoe�teiscwuais_ foIIowuegcaotwsandtmtioes • Doftbepoasmnediatoslagamgtheoo TADdmetoreadaodfoflytmderslanik Ask ga ifsooielbmgisoadeaz • Maltese ACMtarmrbasavAdAomebmmwwotCoeeuaraor a.:d.ee:m The IawmosthoutchgNWAMOge®uadmsand gibcoubwwmtobomwdemdvn&ftDu=WofllmmhapwvammnCookactaRegmkgwm you maymgmeaboq*eonuacbN tegisti mbywdrtogtatheDaectmatlOPOkFhw4Rmm517O Boston,MAM116arbyca➢mg617-973.8787orU&283-3757. Dots the aanuaetwhave insunt oe7 Ask theCoubactor forhis b mane cougmy hmxteaden so That you eaa ooafum eovQag�ar askta see a copy afa'poofafiasosmx'dowmmt Knowyawrighwandregn asbtftm Readdief I I -TOfOundmonftmvc=sWcoftbisfmmamdgaaaWafftckmsmmw Glade to Ste Rome Imptavemmt Law. Youmaycmtoeltbisareconaatifithas baatapcdataplawotbwdmtheaonuactofsav®aipfaoeaf6a ,piavidedypunalify>)m QQUUacIQrjQVffftIthWbWAWM0ffiWQr' mall II&byWlqpm SWarbydchvcty,ntlawthantmdoightofthe dwdbummd2wh&ywmgdosowgofduswam3mL See&eaKbcdmbwcfcmccibibmbmformncwboadmofddsrot I DO NOT SIGN TffiS CONTRACT IF THERE ARE ANY BLANK SPAMMI TWOide6dogPesofaecoNaetm=bocwW Udmdz%pA Owco ysbaddgoetmctbmooaoec Tbeaateoapyd=NbcIxptb9®eoomcWL Homeowneessignauite cent's Sigoetme Data Dane Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 25,767.00 m $ - $ 309.20 Plumbing Fee $ 38.65 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 38.65 Total fees collected $ 486.51 15 Bradstreet Road 597-14 on 2/14/14 21 Replacement Windows and Remodel bath on second floor I NORTf•� Town ofAndover� , 0 �" - 0% No. ' z ver, Mass A � o A_ COCHICMIWICK I". RATE0 S U BOARD OF HEALTH PER Food/Kitchen Septic System D THIS CERTIFIES THAT ............ .... ... .•• .........................IT T L............. BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on ..1.45... f ..... 1 , � Rough tobe occupied as r�1hOs' WV 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 M/ THS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO _ 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 D.ryall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner - Street No. Smoke Det. SEE REVERSE SIDE Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to midate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically affordedto a contractor,however. The contractor would have to resolve any dispute he/she has 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 t%_ mit to such arbitration as provided In Massachusetts General Laws,dh, ter 142A Homeowner's Signaturet' s Signature NOTICE:The signatures if the parties above apply only to the agrecineilfofthe 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 homeownces rights under the Home Improvement 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 exchrded 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 workmantilm 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 wan-antics provided by the contractor,all goods sold in Massachusetts eery an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree maybe 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!�hcatr and should not be signed until a copy of all exhibits and referenced doemietits have been attached Parties are also advised not to sign the document until all blank sections have been filled in or madwd 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 original 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 rescission 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/hemIf to be financially insecure. However,m instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of fiords not yet due be placed in a joint escrow account as a pc vequisite to continuing the contracted work Withdrawal of fiords 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 Massachusetts Consumer Guide to Home Improvesnene contact Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at lion;/lav«�r.inass.ao�/ocabr' 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 Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at http:/,x%Aviti•.mass uov!twcabr! Go online to view the status of a Home Improvement Contractor's Registration: litto://db.state.nia.usAiomeiml2ro-.,cmcniAiccnseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 version 2.1-1 IlZ9J1010 ,john Moran construction, G.G.0 BuiWing andRemodefing 21 Evergreen Drive phone 603-329-6209 Hampstead,NH 03841 fax 603-329-6209 January 27,2014 Patrick Bateman 15 Bradstreet Rd. No.Andover,MA 01845 Dear Patrick: This is the proposal to replace 21 windows at 15 Bradstreet Rd. as follows: 1. Remove existing sash and storm windows. 2. Remove window weights and fill cavities with insulation. 3. Install new Andersen Woodwright replacement windows. White interior and exterior finishes with applied grills .The U-factor is 0.31 The cost per window is$975.00 for window and labor. 4. I will apply for permit. Cost: $20,905.00 Respectfully submitted, John Horan- Stateof Massachusetts Home Improvement Contractor License#102071 Page 1 t .EF14 State of Massachusetts Construction Supervisor License#47989 NAT-2:839-1 John Moran Construction, L.L.C. Buifding and g?fmodefing 21 Evergreen Drive phone 603-329-6209 Hampstead,NH 03841 fax 603-329-6209 December 16, 2013 Patrick Bateman 15 Bradstreet Rd. No. Andover, MA 01845 Dear Patrick: This is an estimate for second floor hallway bathroom as follows: 1. Remove vanity,medicine cabinet,tile on walls and flooring. 2. Install a new drywall ceiling; taped and sanded finish. 3. Install cement board on floor. 4. Tile floor allowance of$5 per sq. ft. Approximately 36 s . ft. PP Y q 5. Patch walls. 6. Install a vanity 30"x22" and top. Allowance of$500.00 including faucet. 7. Reinstall existing toilet. 8. Install ceiling exhaust fan and light. 9. Disposal of debris included. 10.No painting included. 11.No tub or wall tile refinishing included. Cost:$4,862.00 Respectfully submitted, i John Horan I ' State of Massachusetts Home Improvement Contractor License#102071 Page 1 %SEFA ° State of Massachusetts Construction Supervisor License#47989 NAT-24839.1 I� 11M Massachmsef s-Department.of Pub io Safet Board of Building Reguiations an#- tad ds License: CS-047989 JOHN V HORA- ?. 21 EVERGREEN DR Hampstead NH 03841 r Expi-ation i C�srrarissiane* 03/02/2014 (_.%/�c �•o�r2»r-avtraerr�l�r�!?.7�r1Jn-cltrt.,�llF�. �"� Office of Consumer Affairs&Busidess Regulation � . ME IMPROVEMENT CONTRACTOR Registration: 102071 Type: xpiration:.. 6l3012014-, DBA JOHN V.HORAN CONSTRUCTION : s John Horan 21 EVERGREEN DRIVE HAMPSTEAD,NH 03841Undersecretary License or registration valid for individul.use only before tlit:eXpiration date If found return to: Officerap�an'sumt f-h ffaiii+s aiid l;usiness:Regulatiou 2(i Lu� ►lalra Surte$170 Boston 1VI 0 •4 '" �': Nd valid withoutsignatd&1vt CIA 'T ClienW.490547 JOHNHORA 11 ACORD. CERTIFICATE OF LIABILITY INSURANCE 1! 5/30/2013 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 j IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the pollcy(ios)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 1'MNu of such endorsement(s). PRODUCER WEtWr USI Insurance Services LLC " .603 625-1100 Ne PO Box 6360 ADWDRESS: Manchester,NH 03108-6360 INSU AFFORDING COVERAGE MAIC A 603625-1100 INSUREtA:Maine Mutual Group Insurance Co 15997 INSURED INsuREt13:EastGuard Insurance Company 14702 John Horan Construction LLC INSURER C. 21 Evergreen Dr. INSURER 0: Hampstead,NH 03841 INSURER E: INSURER F. !i 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 CONTRACTOR 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 R POLICY NUMBER POLICY EFF POLICY EXP j LIMITS A GENERAL LIABILITY SCI 0955638 0112013 0410112014 EACH ovcuRAENCE $1,000,000 X COMMERCIAL.GENERAL LIABILITY 1 Ee_ s250,000 CLAMS411AM Q OCCUIR MED EXP( "pen=) $6,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GEM.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $2,000,000 POLICY PRO LOC $ A AUTOMOBILE LIABILITY KA10955638 D410112013 0410112014 cOMNIGLE LIMIT $1,000,000 IX AMY AUTOBODILY INJURY(Per person) $ ALLL O ED SSUTOS �ULED BODILY INJURI mer acted) $ MRE)AUTOS X A (Ps P= TYDAMAGE $ $ A' X ummw:uALIae OCCUR KtN0955638 0112013 04101/201 EACHOCCURRENCE s1 000000 otcras LIABCLAIppE AGGREGATE 1` $1.000,000 DED RETENTION$ $ B WORKERS COMPS NsanOM JOWC443891 D410112013 0410112014 X Y&STATUI 10,gTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/DECUTIVEY/N NTA E-LEACHACCIDENT $500000 OFFICt72JMEEL EXCLUDED! (Manddory in NH) E.L.DISEASE-!"EA EMPLOYEE $500 000 If yes.describe do DESCRIPTION O OF below EL DISEASE<`.POLICY LIMIT $500,000 i( ii DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEMCLES(Attach ACORD 101,Addl WW Ra mfa Schedule,If more space Is required) This certificate covers all operations usual and customary to the Insur+ed's business. t i CERTIFICATE HOLDER CANCELLATION '"For Information Purposes on SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOWE WILL BE DELIVERED .M ACCORDANCE WITH THE POLICY PROVISIONS. si AUTHORMED REPRESENTATIVE f f...e• it O 1988-200 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) 1 of 1 The ACORD name and logo are regbtwW matt of ACORD #S97878081M978"82 LCACA The Commonwealth of Massachusetts Department of IndustrialAccidints ` Office of Investigations 600 Washington Street Boston,MA. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/OrgmizatiorAndividual): 7tAn )4ofar, �nS Tr✓tit/ovt L� Address: ll 9u�e,QjPry Ue City/State/Zip: AarrwsJy�pkj D384/1 Phone#: 60.3 3Is a2� Are you an employer?Check the appropriate box: Type of project(required): 1.RN—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.❑ 1 am a sole proprietor or partner- listed on the attached sheet.# remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. EJ Building addition [No workers' comp.insurance 5. El 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' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors 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:. GCS 1(,Utt1rG( t v r(u►C e_ 60#112" Y Policy#or Self-ins.Lic.#: n I)C 7,1? Expiration Date: Job Site Address:. L4� ,8ra)S4re_e_+ 12x1, , —,City/State/Zip:�dr AAIO&e - 04 i 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 cer u der the p i s and penalties ofperjury that the information provided above is true and correct Simature: Date: Phone#: 03 3oZ 5 -616 q Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." �l Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply our 1 to situation and if Y , necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, lease call the Department at t p p Y�P he number listed below. Self-insured urel compames should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Conmonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston.,NIA 02111 Tel,#617-7274900 ext 406 or 1-877 MA.SSAFE Revised 5-26-05 Fax#617-727;7749 wWW mass,govfdia