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HomeMy WebLinkAboutBuilding Permit #207-2017 - 163 HIGH STREET 8/29/2016 BUILDING PERMIT NORrH O�,t�eo 646 TOWN OF NORTH ANDOVER '�� � _' <..•. 0 APPLICATION FOR PLAN EXAMINATION H n0M ^O Permit No#: 01 Date Received co—C., Hu�Pp 4y �� gSSNCHu Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER L ri&14 7- Pr t 100 Year Structure yes no MAP PARCEL: ZONING.DISTRICT: 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 0 Septic ❑Well ❑ Floodplain. D Wetlands ❑ Watershed District D Water/Sewer DEpSCRIPTION OF WORK TO BE PERFORMED: rt-5eiftnq '19 i �9S�rvirw% Cr:/�� L� !h/ pe)vr7-4ylrnt .�v1 � ��l ��*WAC►�.% (->r`O v r� Identification- Please Type or Print Clearly OWNER: Name: QorA-xgtI 1-VAJr,1 Phone: o5;;L.5- Address: 6 S�' ✓�� ��° '� Contractor Name. I Peter Leblanc Phone: pill Email: Address: P a13 OW • 978-407-76,38 Supervisors Construction License:. to O !� Exp.. Date:. ��� Home Improvement License: Exp. Date: 2 / 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: $ a 3©©• a a FEE: $ d Check No.: —*00 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 4, Building Permit Application Certified Surveyed Plot Plan 4. Workers Comp Affidavit 4 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) :aMass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) 4 Building Permit Application 4 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 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 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 m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature f COMMENTS KK a stP a Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes t Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 3 o 11111 FIRE DEPART�� hemp Dempster O�s t' Sj'_ ri �oOsgood ,90 s d Street Vit_ co ated at 1a2 Main Stree r , � Fire De artment s p gnatu a date ek Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email 1 Date Time Contact Name . __._........ ._.__._.____._..___.._ ___-----.--.-_—_--- _ Doc.Building Permit Revised 2014 Location � � '�T r No. Gam' V �` Y Date • - TOWN OF-NORTH ANDOVER . Certificate of Occupancy $ Building/Frame Permit Fee $ � f` Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#:910 J� 3 0 6 02 V Building Inspector NORTH Town ofnd over O dal- 2.& No. 0"'P. h ver, Mass, as Z46 ZWA6 C O[NtCNl WK.t 1� �A `V 0R%TEO NPa��S S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System Mumma THIS CERTIFIES THAT 01401IN 600 BUILDING INSPECTOR . . ....�l .. .. .. .................................. . ........................ . . . Foundation has permission to erect .......................... buildings on ...'. ..... ...... 14 . . ... ..... ........... Rough to be occupied asArR ... .... ..,. + ... A . .. .� Chimney provided that the person acce tin thi ermit shall il4�%*Iespe tL� - Nfor� "t� np p p g �Q� 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 CONST 10 Rough Service ........ ...... ..... Final BUILDING I PECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Federal 113005-0406629 RISE Engineering RI Contractor Registration No 8186 MAContractor Registration No 120979 A division of7ltielsch Engineering RISE ING Company Address,City,NIA 00000ENG 401-1CONTRACT FAX401-123-1234 L N Page 1 PROGRAM CNIA-HES eEmawec E°Ha��IMCUSIDr,�MD D(10 nw�"atWORK�AS DESCAMED BELOW CUSIMER - "aw DAV CUErrd WORK ORDER Norman Lundquist (978)687-0525 08/09/2016 406832 00004 SERViCE STIEET a "o swMET 163 High Street 163 High Street SERVICE 0T(,3 VVE.aP ww"Ctl'r,cAlc,aP North Andover,MA 01845 North Andover,MA 01845 JOB DESC'RWnON HEALTH&SAFETY:DIRT CRAWL, $0.00 AIR SEALING:provide labor and materials to seal areas ofyour home against ArastcfLd,excess air leakage. This rrork aril)be performed in concert rrith the use of special tools and diagnostic tests to assure that your home Kill be left mith a hcdlthful level of air exchange and indoor air quality.Materials to be used to seal your home can include pinks,foamsand other products. primary areas for sealing include air leakage to attics,basements,attached garages and other unheated arca s(%Aindoes are not generally addressed.) This will require(6)murk g;hours.A reduction in cubic feet per minute(cfm)of air infiltration Milt occur,but the actual number of cEm isnot guaranteed. At the completionoft he Heatherization rwrk,and at no additional cost to the homeo%ner,a final blo%%cr door andror combustion safety analysis will be conducted by the s&contractor to ensure the safety of the indoor air quality. $510.00 CRAWLSPACE:Provide labor and materials to install(3 12)square feet ofR-19 faced fiberglass insulation to the craWspace ceiling. $911.36 CRAWLSPACE:Provide labor and materials to install(1092)square feet of 6 rat polyethylene over open ground in designated craWspacelcarthen basement areas $840,84 1NCENTI VE:Rl SE Engineering will apply all applicable,eligible incentives tothis contract. You mill only be billed the Net amount. Currently,for eligible measures,Columbia as offers an incentiveof 75°/q not to exceed$2,000 per calendar year,and an incentive of 100%for the Air Sealing measures up to S 1,020 FORA LIMITED TIME:Columbia Gas uill also offer an additional$100 incentive to%%ards the meatherization vwrk outlined in this proposal.This special Stmimer]ncentive is available to homeowners who have had their Columbia Gas home energy audit before August 31,2016. A signed proposal for�uatherizuton needs to be submitted by September 9,2016 and�rork must be completed by September 30,2016. For the safety and health of yotar home's indoor air quality,etc trill be conduct ing a blower door diagnostic of 1 he available airflow in your home both before the cork is begun;and after the%watherization rrori,is complete.We Hill also conduct a full assessment of the combustion safety of your heating system and triter heater.This has a value of S90 and is at no cost to you The maximum allowable inccni ive for all measures,including air scaling,is$3,210 The Permit mill be secured by the insulation contractor,at no additional cost.It is the homcorrner's responsibility to close out this permit by contacting their municipality at the completion of this work. 590.00 t_I AUG 1 0 2016 Federal ID 0 06.0905629 RISE Engineering R1 Contractor Registration No 6166 AtiiT3sionof7liiclschFagiaeering tAAContraetor Registration No 120979 ��� R I S E ENGINEERINGCompanyAddress,City,NIA 00000 VQWRACT 901-123-1239 FA.K401-123-1234 Page 2 PROGRAM CMA-HES AMIKECUS NWMD IMM�WOMAS oEscR®EOBEt1Tw CU3ISI�ER PNW(E DAE cumNT0 WOFMRIDER Nomlan Lundquist (m8)687-0525 08109/2016 406832 00004 SERVICE s tEET BIWNo SWEET 163 Hieh Street 163 High Street SERVICE.MY.SUrE.23P sum CnY.S91TF„21P . North Andover,MA 01845 North Andover.MA 01845 JOB DESCRIPTION Total: $2,352.20 Program incentive: $2,014.15 Customer Total: $338.03 W EAGREE HERESY TO FURNISH SMVICES•COMM W ACCORDANCE W irH ABOVESPECiFiCATiONS FOR THE SUM OF **'Three Hundred Thirty-Eight&051100[collars $338.05 ItFONiiNAttImPEC�tArtDAPPBCNI�BY RCiE E�MQIHEERM4 W93YEA ARfEE6 IDREMAICUNTMIE nl AfLL YI]MMSTCFt%YlFllrlECHARMMS1iLYeNANY UPWAD)SAtAt10E AT1ER 30 D14Y8:SEE REVERSE FOR. 10NON CUARANEED.RX*M OP RECdION.GCHEOUIN06 AND CCNWC}%t REMS4TAIN. SIGNTHtSCONTRACT IFTHERE ARE ANY t3LANK,SPACES ' j ✓ AUitORl�DtilOtlA1TRE RAE TOlE3tA NCE:1415 OW tAOTIMY BE WrWRAWN BY US WKWEXECOM WTM DATECFACCEP90CE . �CF CClIRA<.T-11E*COVE PFDCES,$PECIF7CAlCitS ANDCQmIfOlt3 ARE 30 DAYS:. SAISFA=R'YIOUs ANDARE HEREBY ACCEPTETL YOUARE Atr110AME0 10001MWOM AS SPECUtM.PAYNENTWILLEE ME AS ODUNED ASM V ._------rte RISL' 60 Shawtnut Road Unit 21 Canton MA 02021 1339.502.6335 ENGINEERING www.RISEengineering.com OWNER AUTHORIZATION FORM 1, Noetkc o L 0pl s vfsT (Owner's Name) owner of the property located at: l _. AUG p X416 (Property Address) (Property Address) hereby authorize � R kr Subcontractor an authorized subcontractor for'RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property.This form is only valid with a signed contract. Owner` Sign re Date 132 c97,e Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 102726 Type: DBA t z v' Expiration: 7/2/2018 Tr# 419291 POLAR BEAR INSULATION CO. Vincent LeBlanc i P.O. BOX 958 ANDOVER, MA 01810 e { C/ Update Address and return card.Mark reason for change. SCA 1 0 204/-05/11 Address [] Renewal Employment Lost Card VJre�naneorz�uuet�lG�o���ataacfuuet Office of Consumer Affairs&Business Regulation License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:'t�102726 Type: Office of Consumer Affairs and Business Regulation -" 10 Park Plaza-Suite 5170 ;y Expiration 7/2/2018 DBA Boston,MA 02116 (( .I �� �� POLAR BEAR INS[1,LATIQN.CO. l., Vincent LeBlanc 51 SO.CANAL ST.#SAz —� .E.s.., .­ �_ LAWRENCE,MA 01841 Undersecretary Not valid without signature } Massachusetts -'Department of Public Safety Board of Building Regulations and Standards Construction Supen icor Specialty License: CSSL-106017 PETERALEBLAI$C 2 EAST PINE STREET Plaistow NH 03865 0.4— �111�[ ""' Expiration Commissioner 04/28/2018 A1`.� r CCOREP CERTIFICATE OF LIABILITY INSURANCE D./.0/20.. /10 0 Y6 Y) 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 endorsemen s. PRODUCER CONTACT Linda BO daaowicz NAME: g Insurance Solutions Corporation PHONE (603)382-4600 Fy No;(603)382-2034 60 Westville RdE-MAIL ADDRESS:liadab@isc-iasuraace.com INSURERS AFFORDING COVERAGE NAIC# Plaistow NH 03865 INSURER A:Western World INSURED INSURER B Nautilus Insurance Group Polar Bear Insulation Company Inc INSURERC: PO BOX 958 INSURER D: INSURER E: Andover MA 01810 INSURER F; COVERAGES CERTIFICATE NUMBERCL1632326134 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. IXP LTR TYPE OF INSURANCE A SBR POLICY NUMBER M POLICY YYF MM POLICY Y LIMITS R COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ ❑R OCCUR PREMI IMAGE TO A CLAIMS-MADE 0 PREMISES Ea Occurrence) ccurrence $ 100, 00 NPP8274967 3/24/2016 3/24/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 S POLICY 1:1 JE F1 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN TATUTE R E ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F-1N/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St, Ste 2032 ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Reith Maglia/SJA @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 0(114n1) 611012016 Preview:Certificates of Insurance A`oRU® CERTIFICATE OF LIABILITY INSURANCE DA1'6 ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed.if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: FAl(Automatic Data Processing Insurance Agency,Inc. PAtCNNo.E:t: 1wC Not 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE KAKI INSURER A: NorGUARD Insurance Company 31470 INSURED INSURER e: POLAR BEAR INSULATION CO INC PO BOX 958 INSURER C: Andover,MA 01810 INSURER 0: INSURER E: INSURER F: ' COVERAGES CERTIFICATE NUMBER: 503587 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 EXP LTR) TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDDI EFF POLICY YYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE S CLAIMS-MADE FIOCrUR PREMISES(Ea occurrence) S MED EXP(Any one person) S PERSONALE ADV INJURY S GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S tf'�'PRO- POLICY LF JECT F LOC PRODUCTS-COMP)OP AGG S OTHER: is AUTOMOBILE LIABILITY S I S (Ea auidenll ANY AUTO BODILY INJURY fear Person) s ALL OVrNEDSCHTOS EDULED AUTOS AUBODILY INJURY War accident) S hIO"VINED Y HIRED AUTOS AUTOS S IPn accidenil 5 UMBRELLA LIAO OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE Is DED RETENTIONS S WORKERS COMPENSATION AND EMPLOYERS'UABiLITY YIN X STATUTE ERH ANY PROPRIETOR'PARTNER•EXECUTIVE E1.EACH ACCIDENT S 1,000,000 A OFFICERIMEMBEREXCLUDED? Y❑NIA N POWC772258 01/0112016 01!0112017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000 It yes,describe undo DESCRIPTION OF OPERATIONS bc.ow E.L.DISEASE•POLICY UTAIT5 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached N morospam 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 ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St I suite 2035 North Andover,MA 01845 AUTHORIZED REPRESENTATIVE It..)k-- A©1988.2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD https:lladpia.adp.comficertcf/#/run/preview/503587/900012975 1/1 it The Commonwealth of Massachusetts Department of IndustrialAccidents - Office of Investigations 1 Congress Street,Suite 100 Boston,JVA 02114-2017 www mass.g ov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information —pp - Please Print Legibly Name(Business/Organization/Individual): 11 AR RF,pR 1NS11 AiiCM6 PO BOX 958 Address: ANDbYER,MA 01810 City/State/Zip: Phone#: 5l P� GAG' �iks _ Are you an employer?Check the appropriate box: Type of project(required": � 1.0 I am a employer with 4. 1 am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6• ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any acit employees and have workers' I y ca p y # 9. ❑Building addition [No workers' comp.insurance comp. insurance. required.] 5. [, We are a corporation and its 10. Electrical repairs or additions 3.0 1 am a hcmeowaer doing all work officers have exercised their 11.0 Plumbing repairs airs or additions I myself. [No workers right comp. � of exemption p on per MGL � 12.E]Roof repair; insurance required.]t c. 152, §1(4),and we have no ' employees. [No workers' 13.F I Other j comp.insurance required.] *Any applicant that checks box I I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing al!work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this Fox?rust attached zn additional sheet showing the r_sme of the sub-contractors and s"!ste rrhethe:or not those entities have empioyees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an empll?ver that is pr o1Ming wor-k-em0cankpIensafier.hisnrance j or isny employees. Below is'the policy and job site information. Insurance Company Name: i1 O ('6,u h k a� Zn S"y (-4 tore o W►QQ t2 Y _ Policy#or Sclf-ins.Lic.#: ?OAC Expiration Date: ot AJ lea o job Sitc Address: )i'o � �t q {� Si City,Stat;!Zip:___Y1. 13 Attach a copy of the workers'compensation policy declaration page(sh3wirg the poliey 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&y against the vioiatcr. Be advised that a copy of thi.statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ., do hereby certi under the anis and enattie: 'o er'u the e in or nation provided above is true and correct Signature: Phone#: C( V- Ye)- 7& 3 6 Of rciai use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# I Issuirug 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#: 'I