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Home My WebLink AboutBuilding Permit #268-14 - 169 LACY STREET 9/23/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: " IMPORTANT:A licant must complete all items on this age r CATION / /' /�► t-�� COY8` 3 Lo rint R . PROPERTY OWNER e�/ Q o Print 100 Year Old Structure yes no MAP NO;1UYt PARCEL: NING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resid ial Non- Residential ❑ New Building Udne family ❑ Industrial 11Addition ❑Two or more family El Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: 0 Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer WO K TO BE PE FORMED:?ESCRIPTIOI�-QF ?C �X c� /It CJ�! Z-A P�2 �� .tel eyz Zo �'/ I'Cler i Identification Ple Type or Print Clearly) ��2 6� OWNER: Name: :___Z2 ��hJ(`�, , /c / Phone: Address: 0V (U��FA Phone: .5�,266066 65ONTRACTOR Name: ivl2 �� -dress: Supervisor's Construction License: 1D( D Exp. Date: Home Improvement License: �� 66t'D Exp. Date: ` 20> ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASF ON$125.00 PER S.F. Total Project Cost: � FEE: � Check No.: Receipt No.: NOTE: Persons con actang with unregistere retractors do not have access to the gua anty fu� Signature of Agent/Owner Signature of contractor Plans Submitted 0 Plans Waived ❑ Certified Plot Plan ❑ tamped Plans ❑ J Plans Submitted❑ Plans Waived'❑ Certified Plot Plan ❑ Stamped Plans ❑ .-TY-PE OF':SEW-ERAGE:DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑. . Swimming Pools ❑ Well ❑ . .Tobacco.Sales .❑ Food Packaging/Sales 0 Private(septic tank, etc.. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED: DATEAPPROVED PLANNING & DEVELOPMENT' ❑ ❑ COMMENTS 1 .CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Bosj-d of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning 6'3ard Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Tow;; Engineer: Signature: Located 384 Osgood Street FIRE DEPAE"NT =Temp Dumpster on site yes no Located-at 124 Mair Street Fire'Departmerit-signatil'rb/date"' 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 EI Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The fol�;�wing is---a-list of the required forms to be filled out for theappropriate permit to be obtained. Roofir;,g, Siding, Interior Rehabilitation Permits A ❑ 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 o 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 o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract Li 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 apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Bui!ding Permit Revised 2012 Location No. Date J 13 i C . - TOWN OF NORTH ANDOVER i • y . Certificate of Occupancy $ (, Building/Frame Permit Fee $ _: Foundation Permit Fee $ ' Other Permit Fee $ TOTAL $ K for Check# t 26896 Building Inspector 4. ;' F_ O ; �� _ _ . w: 1 . � 1 � � c . . ver 5- 0 ;� ,�.. %,"1 2,(oS- iq0 _ h ver, Mass, a3 COCMIc.1-IC c V A41 DR�TED S V BOARD OF HEALTH Food/Kitchen Septic System THIS CERTIFIES THAT .....PERMIT .�..G�k ,........ ..V.r. ..l .................................................... BUILDING INSPECTOR has permission to erect .......................... buildings onl G ....Lao)........cin.............................. Foundation .................... Rough tobe occupied as .... ... ..^. ...........G*...... '.�.� . ......................................... Chimney provided that the person accep Ing this permit shall in every re 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 ONTHS ELECTRICAL INSPECTOR O)Q& UNLESS CONSTRUCTSTA 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 CD 11,1&16 2013 WORK ORDER � Lifetime Roofing corm:GEN-00-20U81 w CUSTOMER NAME: rl'v )� cU(�"� 17 3 AMOUNT TO BE COLLECTED ON COMPLETION: $ _ w w INSTALLATION ADDRESS: b -�� S�(" TELEPHONE (RES.) � b'Z- (BUS.) _ CITY/STATE/PROV: 1jb2-- [, A7,;' 6V4(L fw POSTAL CODE 04FCK LIST DIAGRAM 0 LlPICTURES YES LlNO Q CD1 ❑Fascia Board 2r ll k �V ❑Fascia Cover Color i t ' -Z ��k V& ��c ❑Roof Type ❑Roof Color LA1(e�+5 t LAyza.. � t ❑ Pitch of Roof 15f tZ ........----.__._— LJ Present Roof p6 4L� K l�Ar4iL`( as rA N�k ❑No. of Layers ❑ Air Vents ❑Ridge Vents ❑No, of Skylights 1 9D ❑No, of Chimneys � � � � �� l � IJ 4'a `� Svf v S ,� o 'Ice&Water o ❑ Snow Guards _ ❑Valley Footagc J� ❑Endwall Footage �y� SPECIAL INSTRUCTIONS: ❑Height 1-2-3 Storey ❑ l Sign for JobZ.._�`(�N C) N A,{.,�4c�, t MQ. U ( rte (U1��J fL r( i /�nIT g S 1 of A mr,/bM(57tF 6"h4 J `�s- Pa4 A??eAf2- {v ort- Ve,.,,I r%.a 6 Sep 16 13 08:34a interlock industries 978-281-8040 p.4 e dsbestroo .corn IN K G INTERLOCK INDUSTRIES, INC. SEP 162013 Unit 7,25 Walpole Park South,Walpole, MA 02081 ( lifetime Roofing Systems' Massachusetts Home Improvement Contractor Registration#139640 1` \ 1. BY---------------------- FEIN 43479096 �_41 Name i � l.?(2-{Lt ("Buyer SsrL>a DFe-4, Job"Address t�� `� 5� G � C'Premises") _ city[Town /J ' "T YV Aike Zip Code Mailing Address E-Mail Work Phone { ) Home Phone (uu )(y�2"�-ZY�- Cell Phone The Buyer is the registered owner of the Premises and hereby contracts with Interlock Industries, Inc. (the "Contractor") authorizing the Contractor to furnish all necessary materials and labor to install, construct and place the improvements according to the Fallowing specifications, terms and conditions (the"Specifications")on or at the Premises: SPECIFICATIONS tcirdeoney: SHINGL SLATE IB LOCATION OF SHIPMENT: �� Color: YES NO ROOFING MATERIAL YES NO OWNER WILL __�W Flash Skylights# 42 ✓ Supply adequate electrical power. — Flash Vents _A kt I %/ Be responsible for all rot damage and other necessary roof _ Underlayment;7tt1-,-,0)o-A {' 11C'Z < wA:4ef:- repairs ie: roof decking,fascia boards,etc.at a cost mutually Snow Guards# - agreed upon in advance. Ridge Vent PROPO ED START AND COMPLETION SCHEDULE: _ ROOF REMOVAL Start Dat Q Ujo4a Substantial Completion DateZUQ Strip existing roof(circle one): 1 2 3 layers O�. t�- FVOX _ Supply%z"plywood REQUIRED PERMITS:The following permits are required and Haul away roof debris and pay refuse fees. will be secured by the Cr as the homeowner's agent: LOCATION FOR BIN: --t>& Owners who secure their own permits will be excluded from the Guaranty Fund provision MGL chapter 142A. l�� t� IZa.I� S�5 e,•t f Al C,� c�.scl.y Doh ,�-(,� �,b�ri �� PD Dc¢�.�•�.�-E3 , A-r.it� �,�,,�.z.a� � t4ia 1� ! �t ��' Ir� >�� 3 Cf c-�- �Lc.1(,� l��-I 4A,01 �o S I THIS CONTRACT INCLUDE ( �f!t. � LIFETIME LIMITED WARRANTY,TRAN� BLE, 4��RORATEQ FOR�A TALS MANUFACTURED BY INTERLOCK ROOFING LTD. PLUS 10-YEAR LIMITED LABOR WARRANTY PROVIDED BY INTERLOCK INDUSTRIES,INC. SEETHE WEBSITE FOR WARRANTY TERMS. LIFETIME LIMITED MATERIAL WARRANTY FOR IB ROOFING,PROVIDED BY IB ROOFING SYSTEMS. Financing Requested Yes No Sales Price $ �,��. Sales Tax $ Interest Rate: 11.9%to 14.9% n Total Contract Price $ Down Payment (not to exceed 1/3 $ a of total contract price) Payment not to exceed$ Total Balance on Completion $ i Zt673 O.A.C.(on approved credit) MAKE ALL CHECKS PAYABLE TO: INTERLOCK INDUSTRIES, INC. You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller,which may be his main office or branch thereof, provided you notify the seller in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. IN WITNESS WHEREOF,the Buyer and Contractor have hereunto signed their names this ay of e" 24 k3. Do Not Sign This Cont There A ny Blank Spaces 1 INTERCO I DU I S, INC. Signed Per: Buyer (Print name) Signed Unit 7, 25 Walpole Park South Buyer Walpole, MA 02081 HIC#f139640 This Agreement is a binding agreement and contract between the parties. This is not a credit transaction and will not be financed by the Contractor. If financing is required,the Buyer hereby authorizes the Contractor to obtain credit information and the Buyer hereby agrees to provide and sign all necessary documents required by any third party financial institution to complete the financing, immediately on request. The Buyer hereby acknowledges receipt of this Agreement. See reverse of Agreement for additional terms and conditions. All surplus material is the property of the Contractor.CRSC MA 0811 <LIN P tQ0/YI'UI9?iC��Z�fJPf,?/G�l2.fY� �/ Office of Consumer- Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home;Improvement Contractor Registration -- Registration: 139640 = =- Type: Supplement Card Expiration: 7/28/2015 INTERLOCK INDUSTRIES INC NICK TERLETSITY . #7-25 WALPOLE PARK SOUTH - WALPOLE, -MA 02081 =' Update Address and return card.Mark reason for change. SGA 1 '0 2OM-05/11 Q Address F-1 Renewal E] Employment E] Lost Card �e ((Ju7nfr�zorrtueal!/o��Q/ll fdJCF.0/cuaclG,t ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration:, j 396.4.0 Type 10 Park Plaza-Suite 5170 i= - Expiratiori:;;7/28720:1`5;' Supplement Card Boston,MA 02116 INTERLOCK INDUSTRIES INC:-.-i�, NICK TERLETSITY':'., #7-25 WALPOLE'PARK SOUTH WALPOLE,MA 02081 Undersecretary id out s►gna re Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor Specialty I License: CSSL-101285 NICK TERLE:r4kw 41 EDGEW06D AyE Providence Rj 029`05 Expiration Commissioner 02/11/2014 Mi 1 , f �J ACORD" CERTIFICATE OF LIABILITY INSURANCE DATE(MM20'13YY) 2/1/2014 1/28/2013 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. 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). CONTACT PRODUCER LOCKTON COMPANIES,LLC-1 KANSAS CITY NAME: 444 W.47TH STREET,SUITE 900 IACNNO, Ext): A/C No): KANSAS CITY MO 64112-1906 E-MAIL (816)960-9000 ADDRESS: INSURER(Sl AFFORDINGCOVERAGE NAIC# INSURER A: National Union Fire Ins Co Pittsburgh PA 19445 INSURED INTERLOCK INDUSTRIES INC. INSURER B: 1333138 A MASSACHUSETTS CORPORATION INSURER C: UNIT 7,25 WALPOLE PARK SOUTH WALPOLE MA 02081 INSURER D INSURER E: INSURER F: COVERAGES INTIN18 CERTIFICATE NUMBER: 11152803 REVISION NUMBER: XXXXXXX 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE SR WVD POLICY NUMBER MID (MMIDDIYYYY1 LIMITS A GENERAL LIABILITY N N GL5836199 2/1/2013 2/1/2014 EACH OCCURRENCE 2,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occcu encs 500,000 CLAIMS-MADE 7 OCCUR MED EXP(Any oneperson) 50,000 PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY JERCOT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ XXXXXXX ANY AUTO NOT APPLICABLE BODILY INJURY(Per person) $ XXXXXXX AUTOS OWNED SCHEDULED BODILY INJURY(Per accident $ XXXXXXX - HIRED AUTOS NON-0OWNED PROPERTY aceidenDAMAGE $ XXXXXXX UMBRELLA LIAB OCCUR EACH OCCURRENCE $ XXXXXXX EXCESS LIAB CLAIMS-MADE NOT APPLICABLE AGGREGATE $ XXXXXXX DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N NOT APPLICABLE TORY LIMITS V V ANY PROPRIMS R/PXCLUDE/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ XXXXXXX OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L DISEASE-EA EMPLOYEE XXXXXXX If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POI CY LIMIT XXXXXXX DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 11152803 AUTHORIZED REPRESENTATIVE TO WHOM IT MAY CONCERN ACORD 25(2010/05) © 9 8-2010 ACC#fDJt0RP0RATI0N.All rights reserved The ACORD name and logo are registered marks of ACORD i - n CUMFICATE OF LIABILITY INSURANCE °ATE`MM'oo,YYYY; 01/28/20"13 THIS CERTIFICATE18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIC,HTS 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'poficy(ies)must be endorsed. 0 SUBROGATION:IS WAIVED;subject to the terms and conditions of.the policy,,,certain pafi.cies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). OhobudER.. CONTACT - -... NAME Connie HanSon BFL CANADA Insurance Services Inc. PHONE Fax /C No.Ext), - 461 fAIC Nol'6(}4 FiR' 4'�1 tj. 1177 West Hastings Street,Suife,200 E-MAIL Vancouver,BC V6E 2ff3' ADDRESS: -QAWAQA.ca' INSUAER(Sj AFFORDING COVERAGE NAIL# INSURER A:Liberty-Mutual Insurance Company 3043 INSURED INSURER B Interlock Industries Inc. -- _-. Unit 7.-25 Walpole Park South INSURER C Walpole,MA 62081 INSURER D: INSURER E: INSURER F.i- COVERAGES. CERTIFICATE NUMBERWC-32 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: ILTR TYPE OFINSURAN¢E A L S BR - FOLICYEFF -.POLICY EXP. - .. I S D NO MM/DD. .MM/DD/YS!YY LIMITS GENERAL -.. GENERALLIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY G O NT -PREMISES Ea occurrence S _ CLAIMS-MADE OCCUR �' _ MED EXP.(Any one person) -S PERSONAL&:ADV INJURY $ GENERALAGGREGATE $: .GEN`L AGGREGATE LIMIT ARPLIES PER: PRODUCTS-COMPIOP AGG $ POLICY PRO= J E7 LOC AUTOMOBILE LIABILITY (� COMBINED SINGLETIMIT - - - L Ea a.,de8t. $ ANY AUTO BODILY INJURY(Per Person) $- ALL OWNED -SCHEDULED .. AUTOS AUTOS BODILY INJURY(Per accident) $ NON=OWN.ED _ HIRED AUTOS AUTOS I PROPERTY DAMAGE $ Par accident $ UMBRELLA GAB .00CUR F7 EACH OCCURRENCE: $ ' EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS$ $ ISI WORKERS COMPENSATION - WCSTATU- OTH- AND EMPLOYERS LIABILITY X TORY Ll ITS. ER. ANY PROPRIETORIPARTNER/EXECUTIVE Y N A OFFICE/MEMBER EXCLUDED? N/A�__' WC1-671-072231-053 2(1/2013- 2/1,!20,14 E L"EACH ACCIDENT $1,000000 (Mandatoryin'.NH) E.L.DISEASE-EA EMPLOYE S J,Q60,�000 Lryes,descdbe under ... E.L.DISEASE,POLICYLIMIT $1.,000,000 1 DESCRIPTION OF OPERATIONS I LOCATIONS-I VEHICLES.(Attach ACORD 109,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN To Whom It May Concem ACCORDANCE WITH THE POLICY PROVISIONS. AUTIiO O REPRESENTATIVE 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD f'lal aJ1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.g ov /daa Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Naive (Business/Organization/Individual): Interlock Industries,Inc. Address: 25 Walpole Park South, Unit 7 City/State/Zip: Walpole, MA 02081 Phone #: 508-660-6665 Are you an employer? Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 9 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6 El New construction 2.❑ 1 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 capacity. employees and have workers' comp. insurance.t 9. ❑ Building addition [No workers' comp. insurance p• required.] 5. F-1 We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their ILEI tubing repairs or additions myself. [No workers' comp. right of exemption per MGL 12., Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.❑ Other employees. [No workers' comp. insurance required.] *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 are 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: BFL Canada Insurance Agency-Liberty Mutual Insurance Company Policy#or Self-ins.Lic.#: WC1-1371-072231-053 Expiration Date: 02/01/2014 Job Site Address: zl( ,S� City/State/Zip: N H/klshi 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 certify under the pains and�ee_s oerjur that the information provided above is true and correct. Signature: Phone#: Ofjtcial use only. Do not write in this area,to be completed by city or town of iciat 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#: