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HomeMy WebLinkAboutBuilding Permit #416-13 - 167 DUNCAN DRIVE 11/26/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: o Date Received Date Issued: — ' IMPORTANT: Applicant must complete all items on this page LOCATION �f �i11'/ ��1'� Print PROPERTY OWNER ^, 67r;1-9'./-V V- - �int 100 Year Old Structure yes no Q MAP NO: 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 ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) YP OWNER: Name: Identi /�q t= S F�J-� Phone: 9 � ' Address: "/" /"' ,,q 4 CONTRACTOR Name:T $l Phone: L 100 3J? Address: { f Supervisor's Construction License: IQ;21-23 Exp. Date:�e�� Home Improvement License: Exp. Date: 17-4111 , 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: $��`�/0 ov FEE: $ Check No.: / U "r— Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guars ty and i Signature of_Agent/Owner Signature of contractor Plans Submitted 11 Plans Waived ❑ Certified Plot Plan ❑ S mped Plans ❑ Locational l!J7), ACom/eq No. "7! — Date TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Fee $ 1k Foundation Permit Fee $ ' Other Permit Fee $ r TOTAL $-- Check# 105-1 25974 Bu`i ding Inspector 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 i COMMENTS HEALTH Reviewed on Signature i 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 i DPW Tow,]Engineer: Signature: Located 384 Os ood 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 El Notified for pickup - Date Doc.Building Permit Revised 2010 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 PI I OTE: 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 o 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 MOTE: 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 a 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 subm:fted with the building application Doc: Doc.Building Permit Revised 2012 RightFax C2-2 2/14/2012 5 :40 : 13 AM PAGE 3/003 Fax Server E RTIPIArTE of INSI� NCE' ISSUE DAT 2/14/2012 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 MARKETING ASSOC INS AGCY NAME: 150 WELLS AVE,#1 PHONE FAX (AlC,No,Ext): INC,No): NEWTON,MA 02459 E-MAIL ADDRESS: PRODUCER CUSTOMER ID INSURED INSURER(S) AFFORDING COVERAGE NAIC# VALDEZ,WILSON DBA MASTER ROOF INSURER A ACE AMERICAN INSURANCE COMPANY &UNIENVIOUS-MA INSURER B PO BOX 83 MILFORD,MA 01757 INSURER C INSURER D 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,TERMOR 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 SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD QQMD/YYYY) 0,9MD/YYYY) GENERAL LL&BI ITY EACH OCCURRENCE $ .DAMAGE TO RENTED $ 0 COMMERCIAL GENERAL LIABILITY PREMISES(Each occurrence O CLAIMS MADE 0 OCCUR bIED.EXPENSE(Any one $ person 0 PERSONAL&ADV. $ INJURY 0 GENERALAGGREGATE $ GEN'L AGGREGATE LII41T APPLIES PER: PRODUCTS-COMP/OP $ 0 POLICY 0PROJECT 0 LOC AGG AUTOMOBILE LIABILITY COMBINED SINGLE $ LIMIT (Each accident 0 ANY AUTO BODILYINJURY $ _ (Per Person) 0 ALL OWNED AUTOS BODILYINJURY $ (Per Accident) 0 SCHEDULED AUTOS PROPERTY DAMAGE $ (Per accident) 0 HIRED AUTOS - 11 NON-OWNEDAUTOS $ 0 0 UMBRELLALIAB 0OCCUR EACH OCCURRENCE $ 0 EXCESS LIAB 0 CLAIMS-MADE AGGREGATE $ 0 DEDUCTIBLE $ 0 RETENTION$ S WORKERS'COMPENSATION WC A AND EMPLOYERS LIABILITY NIA STATUTORY Y/N LIMITS ANY PROPRIETOR/PARTNER/ EXECUTIVE OFFICER/MEMBER Y N/A 6S62UB4505P574 03/15/12 03/15/13 E.L.EACH ACCIDENT $100,000 EXCLUDED? (MANDATORY IN NH) E.L.DISEASE—EACH $100,000 EMPLOYEE If yes,describe under DESCRIPTION OF E.L.DISEASE-POLICY $500,000 OPERATIONS below LRIIIT DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR VALDEZ,WILSON THE INSURED'S MA WORKERS COMPENSATION POLICY AND TTS LIMTIED OTHER STATES INSURANCE ENDORSEMENT AUTHORIZES THE PAYMENT OF BENEFITS FOR CLAIMS MADE BY THE INSURED' EMPLOYEES IN STATES OTHER THAN MA NO AUTHORIZATION IS GIVEN TO PAY CLAIMS FOR BENEFITS IN ANY STATE OTHER THAN MA IF THE INSURED=S,OR HAS HIRED,EMPLOYEES OUTSIDE THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE E)tIVICATE.R()IsAE CAIVGI I Lt#TTO}y LOWE'S COMPANIES INC ATTN:IS INSURANCE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PO BOX 1111 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. N.WILKESBORO,NC 28656 AUTHORIZED REPRESENTATIVE �Pl.adti MG.(.L6GiA'V ACCORT325 28091Q4. .. ; ... ? L�s19S8.20.0 ,ACORI3COI2P61tA1bN All ow, 02/14/2012 6: 42AM 12-11-26 10:01 Lowes #2382 ISO 6036814226 >> P 1/1 CONTRACT# 0 2 3 0 9 9 3 EXTERIOR SOLUTIONS INSTALLED SALES CONTRACT INSTALLED SALES SPECIALIST; NUMBER: CUSTOMER e STORE NO, STREETADDRESS aTREETADDRESS �� 1 AV CITY STATE ZIP CITY STATE ZtP TELEPHONE TELEPHONE L4 11 I�K GATE LOwI:S CONTRACTOR LICENSE NUMBER cArIM �Ro Boa ana-7 I ( This Is only a Quoto for de merchandise and servlras printed below,This becomes an agreement upon payment Upon payment,the entire agreement,Including the spocl0ralty completed pages of this document,the Timms and Conditions Included with this document and any other addenda and attachments harsto,shall be referred to heroin as thin'Contract.' PLEASE READ ALLTERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS PAGE AND FOLLOWING PAGES BEFORE SIGNING. INSTALLATIONSTREETADRESS CITY STATE ZIP UQ A I /: v f5cu U. (� 05-7, 13 L-A- to • 1-! J Tom ' �� u� o ► - �12 P C' h I C r r1 +00 Contract Total "applicable taxes included NOTICE TO CUSTOMER: Fadoral law requlros Lowe's to provide you with the pamphlet Renovate Right. By signing this Contract, Customer aoknowlodgas having rocolvod a copy of this pamphlet before work began Informing Customer of the potential risk of the load hazard exposure from ronovatlon activity to be performed In Customor's dwolling unit. PHOTO RELEASE:Customor grants to Lowe's and Lowe's employees the tight to take photographs of all work performed at the Premises rolated to this Contract,and Irrovocably grants to Lowe's all right,title and Interest In and to tho photographs for use In all markots and modia,worldwldo.In porpotulty. Customor authorizes Lowe's to copyright, use and publish the photographs In print and/or oloctronlcally, and agroos that Lowo's may use such photographs for any lawful purposo, including,but not Ilmilod to,marketing, advertising, publicity, illustration, training and Web content. By Initialing here,Customer agroos to tho foregoing. (Customer to Initial to the left]. Work Is to commonco upon reasonable availability of Contractor and/or any special qqlu or customor mado Goods)which Is anticipated to be 'z O�r V,�, +�4- Ifllla In data].Estlmatod complotion date Is +,.I— [fill In date]. Sold ostimotod substantial completion dato Is not of tho ossonco, A statement of any contingencies that would materially change said estimated substantial completion date is as follows: (if applicablo,Insort a statmont of such conlingonclos). This Contract provides that all claims by Customor or Lowe's will be resolved by BINDING ARBITRATION.Customor and Lowe's GIVE UP THE RIGHT TO GO TO COURT to enforce,this Contract(EXCEPT for matters that may be taken to SMALL CLAIMS COURT).Lowe's and Customer's rights will be determined by a NEUTRAL ARBITRATOR and NOT a Judge or.Jury, Lowe's and Customor aro entitled to a FAIR HEARING, But the arbitration procedures aro SIMPLER AND MORE LIMITED THAN RULES APPLICABLE IN COURT.Arbitrator docislons aro as enforceable as any court order and aro subject to VERY LIMITED REVIEW BY A COURT: FOR MORE DETAILS,Rovlow tho soctlon tltlod ARBITRATION AGREEMENT,WAIVER OF JURY TRIAL AND WAIVER OF CLASS ACTION ADJUDICATION found In the Torms and Conditions of this Contract, DO NOT SIGN THIS CONTRACT UNTIL COMPLETE AND YOU HAVE READ THE TERMS AND CONDITIONS CONTAINED ON ALL PAGES OF THIS CONTRACT.BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ,UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH ON ALL PAGES OF THIS CONTRACT,YOU ARE ENTITLED TO A�M PAGES OF THIS CONYRACT.BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDERSTAND �., AND AGREE TO THE TERMS AND CONDITIONS SET FORTH ON ALL PAGES OF THIS CONTRACT.YOU ARE ENTITLED TO A�2 COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE. WITNESS OUR HAND(S)AND SEAL(S)BELOW TWIS �DAY OF Lowe's Home Centers, Inc. Owner Spoclallst or Above Co-owner or Witness Customer acknowledges receipt of a true copy of this contract which was completely fitted In prior to Customer's execution hereof.You,the buyer,may cancel this transaction at any time prior to midnight of tho third business day after the data of this transaction.Soo the attached notice of cancellation form for an explanation of this right. 0 2004 by Owo'%A Lowe's and the Pablo design 1090794 (Rev.12110) FILE COPY are replelered trademarks or LF Corporallon. i NORTH Town of s EAndover 0 9W.M.8 No. �� - h ver, Mass, �I • I� COCMICKfwICK A. 7,9 A'DRATED 1"P���(5 S U BOARD OF HEALTH PERMIT LD , Food/Kitchen Septic System THIS CERTIFIES THAT f r.C ...�t6 �. .. BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on ..... I..C. .......V..Qfklj�................... Rough to be occupied as ..............:..�.. .......:.'}......./..�,.1!4�t,0. ................................................. .. Chimney provided that the person accepting is permit shall in every respect co rm 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 EXPIRE MO THS ELECTRICAL INSPECTOR UNLESS CONST CT ARTS 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. I Smoke Det. SEE REVERSE SIDE 12-11 -26 10:03 Lowes #2382 ISO 6036814226 >> P 1/1 `J '— 0 a U_ -I t 0 �v Un s ,P -4 I r' F I C r h �p aa •i r I 0 ° L I , n}, r I L4 Y r r ()C) e0 e, Contract Totalrn/� *applicable taxes included J NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamphlet Renovate Right By signing this Contr. acknowledges having received a copy of this pamphlet before work began Informing Customer of the potential risk of the load ha: from renovation octivlty-to be performed in Customer's dwelling unit. PHOTO RELEASE:Customer grants to Lowe's and Lowe's employees tho right to tako photographs of all work performed at tho Promises Contract,and Irrovocably grants to Lowo's all right,title and interest In and to the photographs for use In all markets and media,worldwldo Customor authorizes Lowe's to copyright, use and publish the photographs in print and/or oloctronically, and agrees that Lowe's photographs for any lawful purpose, Including,but not Ilmltod to,markoting, advertising, publicity, Illustration, training and Web content here,Customer agrees to the foregoing. [Customer to Initial to tho loft]. Work Is to commonco upon reasonable availability of Contractor and/or any specialor or customer made Good(s)which Is ant ~2 rs v 4- � [flllo In data].Estimated completion date la 11� [fill In data). Said ostimotdd substantial complotlon dato Is not of the essence. A statement of any contingencies thaf would materially change sald estirr completion date Is as follows: (If applicable,insert a slatment of such contingencies This Contract provides that all claims by Customer or Lowe's will be resolved by BINDING ARBITRATION,Customer and Lowe's G TO GO TO COURT to enforce this Contract(EXCEPT for matters that may be taken to SMALL CLAIMS COURT).Lowe's and Custoi determined by a NEUTRAL ARBITRATOR and NOT a Judge or,Jury. Lowe's and Customer aro ontltiod to a FAIR HEARING. procedures aro SIMPLER AND MORE LIMITED THAN RULES APPLICABLE IN COURT.Arbitrator decisions aro as enforceable as a aro subject to VERY LIMITED REVIEW BY A COURT. FOR MORE DETAILS:Review the section titlod ARBITRATION AGREEMENT TRIAL AND WAIVER OF CLASS ACTION ADJUDICATION found In the Terms and Conditions of this Contract. DO NOT SIGN THIS CONTRACT UNTIL COMPLETE AND YOU HAVE READ THE TERMS AND CONDITIONS CONTAIP PAGES OF THIS CONTRACT,BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ,UNDERS AND AGREE TO THE TERMS AND CONDITIONS SET FORTH ON ALL PAGES OF THIS CONTRACT.YOU ARE ENTIT COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE. WITNESS OUR HAND(S)AND SEAL(S)BELOW THIS DAY OF�)tz e ,6P..•r- Lowe's Home Centers, Inc. Owner Specialist or Above Co-owner or Witness Customer acknowledges rocolpt of a true copy of this contract which was completely filled In prior to Customer's execution horool cancol this transaction at any time prior to midnight of the third business day after the date of this transaction.Seo the attached nc form for an explanation of this right, ®2004 by LowdD.®Lowo's and Iho #90794 (Rov,12/10) FILE COPY aro reglelored Iradomarks of LF C RightFax C2-2 2/14/2012 5:40: 13 AM PAGE 3/003 Fax Server ©� / �FI'\SV� 1l�E ISSUE DATE JLi tr L` 111 Il 2/14/2012 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:Ifthe 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 MARKETING ASSOC INS AGCY NAME: 150 WELLS AVE,#1 PHONE FAX (A1C,No,Ext): (A(C,No): NEWTON,MA 02459 E-MAIL ADDRESS: PRODUCER CUSTOMER ID A INSURED INSURER(S) AFFORDING COVERAGE NAIC# VALDEZ,WILSON DBA MASTER ROOF INSURER A ACE AMERICAN INSURANCE COMPANY &UNIENVIOUS-MA INSURER B PO BOX 83 INSURER C MILFORD,MA 01757 INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD DNYY� (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ .DAMAGE TO RENTED $ COMMERCIAL GENERAL LIABILITY PREMISES(Each occurrence MED.EXPENSE(Any one S 0 CLAIMS MADE 0 OCCUR. person PERSONAL&ADV. S INJURY GENERAL AGGREGAT; $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP $ 0 POLICY 0 PROJECT 0 LOC AGG AUTOMOBILE LIABII.ITY COMBINED SINGLE $ LIMIT (Eachaccident) 0 ANY AUTO BODILYINJURY $ (Per Person) 0 ALL OWNED AUTOS BODILYINJURY $ (Per Accident) 0 SCHEDULED AUTOS PROPERTY DAMAGE $ (Per accident) 0 HIRED AUTOS $ 0 NON-OWNED AUTOS $ 0 0 uNmRELLALIAB DOCCUR EACH OCCURRENCE $ 0 EXCESS LiAB 0 CLAIMS-MADE AGGREGATE $ 0 DEDUCTIBLE $ 1) RETENTION$ S WORKERS'COMPENSATION WC A AND EMPLOYERS LIABILITY NIA STATUTORY YIN LIMITS ANY PROPRIETOR/PARTNERI EXECUTIVEOFFICERIMENIBER Y N/A 6S62UB-4505P574 03/15/12 03/15/13 E.L.EACH ACCIDENT $100,000 EXCLUDED? (MANDATORY IN NIT) E.L.DISEASE—EACH $ EMPLOYEE 100,000 If yes,describe under DESCRIPTION OF E.L. EASE-POLICY $500,000 OPERATIONS below LIId1T DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR VALDEZ,WILSON THE INSURED'S MA WORKERS COMPENSATION POLICY AND ITS LIMITED OTHER STATES INSURANCE ENDORSEMENT AUTHORIZES THE PAYMENT OF BENEFITS FOR CLAIMS MADE BY THE INSURED EMPLOYEES IN STATES OTHER THAN MA NO AUTHORIZATION IS GIVEN TO PAY CLAIMS FOR BENEFITS IN ANY STATE OTHER THAN MA IF THE INSURED HIRES,OR HAS HIRED,EMPLOYEES OUTSIDE THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE CERTIF.I CNCT IATTON LOWE'S COMPANIES INC ATTN:IS INSURANCE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PO BOX 1111 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. N.WILKESBORO,NC 28656 AUTHORIZED REPRESENTATIVE "13Yi.G7.f'V MGT.CLELT.YV '.ACOR?25 2004tU9L)19$$3tt09 ACORII CORP(7RATIOII Alli ht5 rCSCt fed:: 02/14/2012 6: 42AM The Commonwealth of Massachusetts Department of Industrial Accidents 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/Organization/Individual):T 2(//Prl 0900/, Address:: City/State/Zip: 1 Phone#: Are an employer?Check the appropriate box: Type of project(required): L - I am a employer with— V 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.E] I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.E] 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.F,+Koof repairs insurance required.]1 employees.[No workers' 13.❑Other comp.insurance required.] kny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. Lsurance Company Name: :)licy#or Self-ins.Lic. [�Q2,5 e, 7Y Expiration Date: l� ►b Site Address:� City/State/Zip: �t� L/ ' ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). tilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ie 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for insurance coverage verification. to hereby certify unde the pans n penalties of perjury that the information provided above is true and correct. nature: r Date: I Lone#: Official use only. Do not write in this area,to be completer)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." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if 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,please call the Department at the number listed below. Self-insured companies 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1--877-MASSAFE Fax#617-727-7749 evised 5-26-05 v ww_ma.q.q.uovldia Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-102403 WILSON R VALDEZ f - i 1$1 MAIN STREET M11YORD MA 07$7 �� r rs Expiration Commissioner 11/20/2014 arrz7>za�zwecz� a Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration: ,,-150577 Type: Expiration: •4!11/2014 DBA MA ERROOF = _ WILSON VALDEZ 151 MAIN ST MILFORD, MA Undersecretary r %r j j f