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HomeMy WebLinkAboutBuilding Permit #789-13 - 157 HIGH STREET 5/20/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued:. IMPORTANT:Applicant must complete all items on this page LOCATION / ��j4 y Print PROPERTX OWNERia .cs y Pnnt MAP NO: W] PARCE ZONING DISTRICT'.' Historic District yes n . Machine Shap 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 Septic Well Floodplain Wetlands Watershed District Water/Sewer 121 DE RIPTIOkOF WORK TO BE PERFORMED: • Identification Please Type or Print Clearly) OWNER: Name: / - Phone: Address: � 7 i f �/�. V,- CONTRA CTOR v CONTRACTOR Name: e./ Phone: p r Address: Supervisor's Construction License: , c Home Improvement-License: " )= p. Dater ✓ ®s 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: $_ 6-cs 16D FEE: $ Check No.: It I— Receipt No.: `l NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 17 Signature of Agent/Owner Signature of contractor Building Department The following is a list of the required forms to be filled but for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008 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 FOR OFFICE USE ONLY . INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED 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 ' DPW Town Engineer: Signature: Located 384 Osgood Street + FIRE DEPARTMENT Temp:Dumpster on site yes no Located at 124 Main Street Fire Department signatureldate _ COMMENTS 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 i_._......_....-.........................._._....._._...._._._......-..........._..........-.....-_.............._....----._........................---.............._. _.-_._.......... Doc:.Building Permit Revised 2008 Location No. J Date LID e - TOWN OF NORTH ANDOVER' �t e � Certificate of Occupancy $ Building/Frame Permit Fee $ ' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ M1 Check# 0 ; 26418 'building Inspector NORTH own of _ Andover G o to No. t T _ it 10 �.T h ver, Mass, coc"Ic"twic.c �1. p0RATED S U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System - i �N l�N BUILDING INSPECTOR THIS CERTIFIES THAT ........�..C!�.O�.... ... ............ ....................$ip ..................................................... Foundation has permission to erect .......................... buildings on ....�, �.......:. sem ............................ Rough Rough tobe occupied as ...............5..1 .. ..4 ....�.. .....:..... ........ . ..... .....4.................................................... Chimney provided that the person accepting this permit shall In every res ct 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 MONTHS�6ELECTRICAL INSPECTOR- UNLESS CONSTRUCTION STA 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. SEE REVERSE SIDE HOME IMPROVEMENT CONTRACT TERMS AND CONDITIONS(M.G.L.142A) 1.WORK:Provided the Homeowner performs under this agreement,the Contractor shall perform the work on the Property as specified Proposal,attached incorporated herein.The work does not include extraordinary conditions of which the Contractor could not reasonably be aware.If such conditions are encountered,this shall be an additional cost to the Homeowner.Materials selected by Homeowner may have to be ordered or custom made,which items are specified in the Proposal.The Contractor is not obligated to agree to any modifications,extras or change orders unless such items are agreed to in writing by the Contractor.All extras and changes shall be at an additional cost to the Homeowner.Contractor shall perform the work in a good and workmanlike manner using materials consistent with this contract.Lawn or Driveway may be damaged by dumpster or equipment.Due to material shortages Contractor may substitute materials of equivalent grade. 2. PERMITS:If a building permit is required for the work,the Contractor shall obtain same as Homeowners agent.Contractor is not responsible for any other permits that may be required for the Work,and Homeowner is responsible to determine whether any zoning,planning or wetland related permits or approvals are necessary.Homeowners who secure their own permits or deal with unregistered contractors will not have access to the Guaranty Fund. j 3. COMMENCEMENT AND COMPLETION:Homeowner.acknowledges the:commencement.date of the work is fluid,and is subject to numerous factors such as scheduling other contractors,delivery of materials and weather.Contractor and Homeowner shall determine the commencement date of the Work when a more definite determination can be made and shall execute a written acknowledgment of same.The Work shall be substantially completed within 7 days of commencement,except for longer periods as may apply to particular projects as Contractor shall notify Homeowner in the Proposal,and subject to delays for circumstances beyond Contractors control.Notwithstanding,the commencement date and substantial completion date may be extended,and the Contractor will not be liable for delays caused by,labor or material shortages,delays in delivery of items selected by the Homeowner,governmental action, and unforeseen events beyond the Contractor's control,including but not limited to weather,strikes,war,the acts of third persons or the acts of the Homeowner.The Homeowner recognizes that the commencement date may be delayed due to scheduling or the completion of Contractor's other jobs. 4. PAYMENTS:Contractor agrees to perform the Work and to furnish the.materials and labor specified in the Proposal for the amount as stated in the Proposal.Thirty percent(30%)of the total is to be paid as a deposit with the signing of this contract.Upon cancellation prior to commencement of the Work,any remaining deposit will be returned less the costs for materials ordered for which Contractorwas unable to cancel.Final payment shall be due upon completion of the Work and Homeowner agrees it may not hold any retainage.Late fees.may applied for late payments.Homeowner shall pay Contractor's reasonable costs of collection,including attorney's fees and costs.Time is of the essence hereof. 5. WARRANTY:For a period of lyear after substantial completion of..the Work the roof will be free of leaks caused by defects in workmanship, but not those caused by ice backing-up or extraordinary weather events,including blizzards,tornadoes,hurricanes or storms of greater than a twenty-five year duration or intensity.Contractor gives no warranties with reference to any materials or equipment installed in the Premises,passes any such warranties directly to Homeowner,and Homeowner agrees to look only to the manufacturer with reference thereto.This limited warranty extends to the Homeowner only and is not transferable to succeeding Homeowners.This Limited Warranty specifically excludes(i)all consequential and incidental damages;(ii) damage due to ordinary wear and tear,abusive use,misuse,or lack of proper maintenance;(iii)defects which are the result of characteristics common to materials used;(iv)defects in items installed or supplied by anyone other than Contractor;(v)work done by anyone other than by Contractor;and(vi)loss or injury due to the elements.There are no other expressed or implied warranties or representations made or given. 6. ENTIRE AGREEMENT:This contract and all documents referenced herein constitute the complete and final agreement between the parties.In the event that any of the.provisions of this contract shall be held to be invalid,the remainder of the provisions of this contract shall remain in full force and effect.Two identical copies of this contract have been completed and signed.Homeowner acknowledges receipt of a completed contract signed by the Contractor. 7. HOME IMPROVEMENT REGISTRATION:In accordance with M.G.L.c.142 A,§9;Contractor is registered with the Bureau of Building Regulations and Standards Registration No:174377 Homeowner may verify by contacting the Director a[.(617)727-3200,ext.25205.A Homeowner's rights under the Home Improvement Law(M.G.L.c.142A)and other consumer protection laws may not be waived in any way.Homeowner acknowledges receipt of a copy of 780 CMR R6 and Massachusetts General Laws chapter 142A,and which are available online at www.mass.gov.Questions may be directed to the Consumer Information Hotline,(617)727-7780_ 8. ARBITRATION: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 such dispute to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulations and the consumer shall be required to submit to such arbitration as provided in M.G.L.c. 142A.No lien or security interest is imposed on the Property as a consequence of this contract,but Contractor has the right to record this contract or a notice of this contract,or seek a lien if the Homeowner breaches this Contract. 9. HOMEOWNER COVENANTS:The Homeowner agrees,represents and warrants that(a)the,Homeowner grants permission to the Contractor to enter the, Property to perform the work as covered by this contract;(b)the Homeowner has funds available to make full payment under this contract to the Contractor upon completion;(c)the Homeowner understands that construction as contemplated by this agreement creates a dangerous condition,and agrees not to enter portions of the Property under construction until the Contractor advises the Homeowner that the construction is completed;(d)Contractor may need use landscaped areas of the yard during the Work and Homeowner is responsible to provide protection for landscaping and(e)that code requirements may result in roofing nails penetrating through roof decking and will be visible on the underside of some surfaces.The Homeowner indemnifies,exonerates and holds harmless the Contractor from any loss,damage,claim,liability or expense(including reasonable attorney's fees,deposition costs and court costs)resulting from a breach of this provision.Contractor is not responsible for in e to landscaping that will grow back during the next growing season. 10.CANCELLATION:Homeowner may canoe i agreeme ov' ed Homeowner notifies the Contractor in writing at the address listed in the Proposal not later than midnight of the thir st ss day f ow' g the si g of is agreement. HOMEOWNER DATE: �3 Shingle: NO C f"4��4 DEPOSIT: Proposal 1 HIC#174377 Damph®usse Roofing uP A trusted name since 1938 Roofing •Siding •Windows 87 Belmont Street• North Andover, MA 01845 P: 978-683-4588 • F: 978-685-7446 NAME OF OWNER G��F`'' f ✓a sfi S.: ADRESS OF JOB 2 /V/d-Af Y7— A/, o/J-Yj— TEL. �7�p �/�f'/� MS'S ��I DATE: 1 "' Z}'--2 13 We will remove all roof shingles off total roof area, up to two layers. Replace any boards or sheathing at additional cost. A new 8" white aluminum drip edge applied on all edges.Approx. 6ft of ice and water membrane applied on eaves, 3ft in valleys, strips around skylights, along chimney flashing and sidewall junctions. Existing step flashings to remain. A new base sheet applied. A 30yr architectural roof shingle installed. Install new vent pipe boot flashings. Waterpr000ff existing chimney flashing and remove de'b'ri/s..iy�/�j Shingle Color: K C�/ ��r�%la6-C" Cc:s Z_un ' 1�O"7``�_ Ridge Vent Upgrade $8.00 per ft. Wood Sheathinq Repair$8.00 per ft. All Aft,'' 1'71 41h,` V0 &/v1'S' u !71,- We 71,"We Propose herby to furnish material and labor-complete in accordance with above specifications,for the sum of: dollars($ �' O• ). Payment to be made as follows D d U �� 0J, Cad 0. %/ ev✓ hAuthorized rte" Signature NOTE:This proposal may be withdrawn by us if not accepted with in_days Acceptance of Proposal - The above prices, specifications and conditions are satisfactory and are herby accepted.You are authorized to do the work as specified.Payment will be made as outlined above. ' Signature u Date of Acceptance: ��Z�,, / Signature 4/23/2013 8 : 32 : 27 AM 8935 ® 03/03 TE CERTIFICATE OF LIABILITY INSURANCE DA041231D0IYYYY) 04!2312013 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). ACT PRODUCER 00474-001 NAMEN: Doherty Insurance Agency Inc rAHIC.No.Ext): (978)475-0260 PO Box 1985 EMAIL Andover,MA 01810 ADDR SS: INSURER(Sl AFFORDING COVERAGE NAIC t INSURER : A.I.M.Mutual Insurance Company 33758 INSURED INSURERS Damphousse NS RBDamphousse Roofing LLP lNsuRERc: 87 Belmont Street INSURE-RD: North Andover,MA 01845 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, ggEXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED D�yyB�pYppppPAID CLAIMS. ILTR TYPE OF INSURANCE INSR'WU POLICY NUMBER MMILDIDJYYYY PM/LDIDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ ANIAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ee occurrence $ CLAIMS-MADE ❑OCC1JR MED EXP(Arty one person) $ PERSONAL 3 ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ OLICY CT OC AUTOMOBILE LIABILITY Ee se dEentSINGLE LIMB $ ANY AUTO BODILY INJURY(Per person) $ 1 ALL OWNED SCHEDULED 80DILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE HIRED AUTOS NON-0NMED $AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED I I RETENTION $ $ VyypRKERS COMMPS SATIp N ER N!C STATu- OTH- ANDEMPLOYERS'IT X TORY LIMITS AN PRpPRIETOR/Pq{�TNER/E��CUTIVEYlIV E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUQED? [N NIA AWC-400-7028774-2013A 4117/2013 4/17/2014 E.L.DISEASE-EA EMPLOYEE $ 500,000 (�Myaanddrry atonin NH) DESsCRIPi ION L0 OPERATIONS beton E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) No partners are covered by the workers compensation policy. CERTIFICATE HOLDER CANCELLATION Town of North Andover 1600 Osgood Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE North Andover,MA 01845 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 4454 APR-22-2013 MON 12;24 PM FAX N0, 9784750303 P. 03 l �I Client#:14415 _� � OAMPHOUSSE II ACORDIa CERTIFICATE O� LIABlLtTIY INSURANCE FDATE { PRODUCER 04/22/13 Doherty Insurance ggen_y.Inc. THI CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ON AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O.Box 1985 HOL ER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 21 Elm Street ALTER THE COVERAGE AFFORDED BV THE POLICIES BELOW. Andover,MA 01810 INSURED INSURPRS AFFORDING COVERAGE NAIC it Damphousse Roofing LLP INSUR'1 A ain Specialty Insurance Company 87 Belmont St North Andover,MA 01845 COVERAGES THE POLICIES OF IN.I.IRANCC LIS rEr1 BELOW HAVE OEEN I$$IJEU TO THE IN&IIRED NAME,ADUVL;FOR THE POLICY PERIAr)INUICATEU.NOTW1 rHSTANUING, ANY REUUIREMENT,TERM OR LOND111UN OF ANY CONTRACT OR OTHER DCLUMEN r WITF RESPECr TO WHICIA THIS CERTIFICATE MAY EE i SUED or, MAY PERTAIN,THE INSURANCE AF'rQRDEU[LV THE POLICIES DESCRIBED HEREIN I.^• UB-)-CT 1O ALL THE TERMS.EXCLUf•ION,;ANO CUNnITIONS OF SU0I POLIC,,IES.AGCREGATE LIMIT;SHOWN MAY HAVE BEEN DEDUCED BY LAID CLAIMS LTR NSR TYPE OF INSURANCE POLICY NUMBER POu[Y EFFE TIVE t'OLICY e0-1RA71ON - - DATA MMID Y -DAT. EIM!gRLVVI LIMITS A GENERALLIABILITY CIP169387 04/12/13 04112/14 EACHOCCt11:RENGh $1000,000 X COMMENCIAL GImNERAL I IABILITY 1 unMAGf m RCNTF.II CLAIMS MAUI i'I.Y;-�r�Lrtn 11.•ri $100,000 nCCUk i MtU FXf(Airy on Ilernn) $rj 0{10 X BUPD Ded:1,000 1 --- - PERSCINAL s AUV INAIkY $1 00(),000 OCN6HAlAGGr.Frnr1 s2-,000, C-FN'L A[trR[GAIF LIMIT APPLIF_S PER: rRo• rRouuClg-Ci1MPA?F n(u: 82 000 OOp q0 0 X p01ICY .rFC7 F IOC �AUTOMOBILE LIABILITY LIABILITY -- ANY AUTO I COMDIWA)SINGI F LIMIT (En arrutagU S Al 1.OWNI.O AUTO:, 1 9CHEDUL ED Au TOS i 80011 Y INJURY (per pare,nJ 3 HIRED AIITOS 1 NON OWNF D At 1105 1 001111 Y INJURY I (Pit ictid:�nq $ r I _- PROFFRTY DAMAGE (fr.I:Irr rtrnQ S GARAGE LIABILITY A2TC7 l7N1V-Cn A(:CIBC•NI b ANY AilIO 1 OTHER I'HAN EAAC1 s ALITOONIY EXCCSSRIMORELI.A LIABILrTY _ 1 E:AGltirrrltRgkN(:F } OCCUR D CLAIMS MADE 8 BRETE..'O. WORKERS COMPENSATION AND I „ YVC'•:rnTU OTI•I FMPLOYFRS'LIABILITY 7C1RY tiMj'P. _ ANYrHrtrRir.TbHIPARTNEItIEXEI:lIT1VC E.L.L-ACHAC(auFNT g - OrFIGFRIMEMMERCx(:LUr�ED? _ _ If vn.,.. t O uilllCf E.L.LIISEA I7 I:A FMFLIrvFL' r 2-ptrIAL PROVISIONS Nim "-`-'"- •-- OTNER _2r rnIICYLIMIi i I OESCnIPT10N OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED elY ENOORSEMENT I SPECIAL P(i0Y1SIONS - Covering operations usual to Damphousse Roofing LLP... CERTIFICATE HOLDER CANCELLATION SHOULD ANV F THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of North Andover DATE 7HEPE I .THE ISSUIN(t,INSURER WILL ENDEAVOR TO MAIL -- 0- DAYS WRITTEN 1600 Osgood Street NOTICE70 THCERTIFICATE HOLDER NAMED TO THE LEFT.OUT FAILURE TO DO So SHALL North Andover,MA 01845 IMPOSE NOOO1IGATION OR I.IADILIIYOF ANY KIND UPON THE INSURER.ITS AGENTS OR REPRESENTAT ES. NTI AUTHORIZED PRr;6Ev .-.--.- i l\ ?Z' ACORD 25(2001108)1 of 2 #S29121/M29119 DM ¢ AC CORPORATION 1988 til.iic1 Useits.-Departaltent i�f Puni c S.>Ief} cl'nf Built€ins Rt ut Etii)m.lnti ..t.tn�iai-il. -- iifiSL U"tic Li Sc1'1 ;;tfsoF 'LlGei3SF License: CS 67560 I ..SHAUN:M TWOMEY 61.PATRO{T.ST ,..` N ANDOVER, MA 01845 ' �--G- Expiratiisn. 10/25/2013 t3,umussiart�rr' Tf-`'4913 Massaci itsLiS -O€ Tat T4E tc 01 3'i1C oP Board of.*—S JiiGin-Regulations and Stanrdafd..:' ' ��insirnctit�n Superr�isnr -:ces se: CS-055108 .-L r DOUGLAS J LEG2E 79 GARY AVE HAVERH1LL-MA 01830 r r 1 c _ - ^i' x: Qi 5'.3itiSS't€SnL:' 0910212014. . ------------- V/ae Cpa��2��za�zcaeaCfl o���LcaJ6cc�u�e%�� C—\ Office of Consumer Affairs&Business Regulation = ME IMPROVEMENT CONTRACTOR egistration: 174377 Type: ;cxpiration: : 2/4/2015,:- LLP DAMPHOUSSE ROOFING.L•LP- SHAUN TWOMEY 87 BELMONT ST N.ANDOVER,MA 01845 Undersecretary i I • The Commonwealth ofMassachusetts Department of Industrial Accidents Office of£nvestigations -. 660 If fishin in Street Best©n,'AL4 6.2ZII : www massgov/dia - Workers' Compensation Insurance Af€.davx : Bnilders/Contractors/ Iecfnciaas/P untbPrs Apmlicant Information Please Printleggi . i�ame(Btrstrtess/Or�aatzation/lnd�vtdual):' % Address 7. City/statelZip Ate=,01� Phone L�I onasyer?Check the appropriate"bowType of project(required).am a employer with 4_ ❑ I, a o . (� =eneral contractor and I 6. Q"Nein construction employees(full and/or part-time).* have bind the sub-contraxtors 2:❑ I am a sole proprietor or partner listed on the attached sheet:"1 7., D Remodeling , ship.and have no employees These stib-contractors have ,. 8. []Demolition working form in any capacity. Workers' comp.insurance : 5. 1 Building addition [No workers'comp.insurance 5. VJe are a corporation and its: required.] officers haveexercised their 10.0 Electrical repairs or additions 3.F I.am a homeownerdoing all work sight.of exezalption:per MGL • I LD Plumbing repairs or additions myself[No arork�rs'comp: c. 157§I(4);and we-have no 12 Pfoof repairs : incurance d t employees- [Tlo workers' 13.171 Other` comp:insurance required *per.EPPEnf etio bo .~l melte sit?as:fnc s dies OFOPR" r ��, ^:c:man- 'Who I orvcowa�s"who submit this of idavit indicating the} ary dckg all wart:and thea'hire,outside-contractors.must submit a new a�navit"inni�ting such: !Contractors that ch,'.' this box musCatiached"an additional sheet sho a th name of fie sub contractors and the[]workers'comp.:policy information. lam an employer that is providing workers'compensation insurance for my employees Below is the police and job site informer ion.. Insurance Company Name: Policy.#or Self-ins."L,ie Job site Address C l irationI?ate: Attach a copy of the workersco enation policy declaration.page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL.c. 152 can�lead to the imposition"df ciitninal penalties of a fine up t1.o S 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 tip to 5250.00 a.daq aeains'i the violator: Be advised that a copy of this stat„-meat maybe forwarded to:the.Office of" Investigations of the DIA.for insurance.coverage verification I do hereby certify. er the pains and penalfies of perjury that the information provided above is true"and correct Signature: Date:.- - Phone;t Official use only.-Do not write in this area,to be completed bj:cit),or toNmt officiaL City or Town: Permit:Ucense# Issuing Ruth - Authority(circle on..j. 1.Board of Health .2.Building Department 3.City/Town Clerk 4.Electrical Inspector az.Plumbing Inspector 6. Other Contact Person: Phone;;.