HomeMy WebLinkAboutBuilding Permit #789-14 - 175 MAIN STREET 5/5/2014TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:)PS _ Date Received
Date Issued:
M ORTANT: Applicant must complete all items on this page
LOCATION r.
PROPERTY OWNER I(- 6�,e-x
Print 100 Year Old Structure yes no
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
.TYPE OF IMPROVEMENT
PROPOSED USE
S7Dt2/44A1\,
/4- del
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
XRepair, 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)
OWNER: Name: Phone:
Address:
CONTRACTOR Name:
V
Address: 0757-67nI�tlsE � 2Er'7—
S7Dt2/44A1\,
/4- del
Supervisor's Construction License:
U
! 5 a
Exp. Date: �" �P Gov Ll
Home Improvement License:_
ARCHITECT/ENGINEER
Address:
WTOMl
Reg. No
r g0
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ A, a FEE:
Check No.: o� v 3 Receipt No.: 3
NOTE: Persons contracting with unre istered contractors deo notbrave access to the uaranty fund
Signature of Agent/Ovvne ure of contractor
Plans Submitted Li. ansaived ❑ Certified Plot Plan ❑ Stamped Plans ❑
Plans -Submitted ❑ Plans -Waived ❑ r -Certified Plot Plan ❑ Stamped Plans ❑
TYPE -OP S) WERAGEDISP.OSAL
Public Sewer ❑
Tanning/MassageBodyArt ❑ ..
_Swimming Pools ❑
Well ❑
Tobacco.Sales
--Food Packaging/Sales ❑
-Private (septic tank, etc-
Permanent D' nmpster 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
COMMENTS
Reviewed on Signature
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 To`r-: Engineer: Signature:
Located 384 Osgood Street
_FIRE DEPARTMIENT - Temp Dumps#er on site yes no
Located -at 124 Mair; Street
- Fire Departinel it sighatu"r`eldate"-
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; n ast-or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: =Yes No
MGL-.Chapter166.Section 21A -F and G min.$100-$1000:fine
NU 1 is anti UA I A — p -or aepartment use
I
® Notified for pickup - Date
Doe.Building Permit Revised 2010
Building Department
The following is'a list of:the r0uired.forms to be filled out for the appropriate permit to .be obtained.
Roofiig, Siding, Interior Rehabilitation Permits
Building Permit Application
❑
Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Gr 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 apodal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submJted with the building application
Doc: Doc.Building Permit Revised 2012
Location �� AA Ill
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ it
Building/Frame Permit Fee $,2 ---'—
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # Iq O ' V3"t Q 7 s�
4
Building Inspector
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CONTRACTOR/CONSTRUCTION CONTRACT
THIS AGREEMENT, by and between DeviwNuzzi DrAn & Builders PONTRACT0% and
_Larcdurnont Malt LLC with an address of 78 Lardhmont Road, M&M MA
02176 (OWNER).
PRELIMINARY STATEMENT
The CONTRACTOR has responsibility for wcxlc at the "OvAng described P OpedY.
Property Name: Sturixidae Arms
Street Address: 175 Main Shed Unit 5 CityfStaw Noon Ardyw MAA
OWNER desires to lure CONTRACTOR to supply certain servicers with respeet to the lgperty aril the CONTRACTOR desim ID
provide said services for the consideration Mein expressed:
tt is agreed that CONTRACTOR shan perionn the neceSsay to =Mqft the WA de9cot8d hos 90 fespect ID
the Property, all in accordance with the condiftions contained herein, incl ding the 0whed gerneral wdftrk, 0wh One
CONTRACTOR ackncnedges that ft has read and with which is agrees to cx ►.
THE WORK: CONTRACTOR agrees to famish all IaW and equipment do perform the g wok P
X In a =xdaroe with the provisions of Exhibit A - Scope of SerAces, Exhibit B —Genual Cotnd66ars, E—Tads
Completed and Payment Scinedule.
X As described hereirn:
TIME: CONTRACTOR agrees to begin worts on or about May 1, 2014„ and to conlPkie the Vftk on or before Jule 1. 2M4
as such date may be adeunded by the number of days CONTRACTOR is delayed from complebm of the Work tr weasons try
beyond the control of CONTRACTOR. if CONTRACTOR does not complete the Work wam such time, any l;s ffwmd by
OWNER resulting therefrom will be charged to CONTRACTOR and deducted from final payment. Purnch I'd its sb i be
completed by CONTRACTOR within ten (10) days after the scheduled completion date. TIME IS OF THE ESSENCE IN THE
PERFORMANCE OF THIS AGREEMENT
PAYMENT: OWNER small pay CONTRACTOR for the performance of the Work the sun of $ 851400 as modifived by 1t
changes approved in writing by the OWNER subseguent.to this Agreement; payable in 1 payment FK4L PAYMENT sha0 be
made within ttrlrty (30) days after the OWNER cerbiies substantial impletion and acceptance of the mak shall be coriffuned
upon compllarice with the provisbm of this cornual and CONTRACTOR twfthing a release of lien, in a ton awepWe to
OWNER for itself, the GENERAL CONTRACTOR and its subcontractors and SuppLIM
CONTRACTOR:
By:
ADDRESS:
S7aA&W4r( /h4 O?JP
OWNER: � �� � �1�"rl LL --C.
ADDRESS:
n,e�Sjo-- Vr\ ca t�
Exhibit A
SCOPE OF WORK
Contractor to provide labor for the items specified herein as Exhibit A and agrees to provide this labor
for a total contract price of o -•n
1, �+ arpri P2�vmeirts
Material cost born by the Contractor will be paid by the Owner at a rate of cost plus 2004 All,
material receipts must be provided with the material payment submitted.
2. tabor 1e:�ts
Payments for labor will be made weekly according to the flowing procedure. Each Saturday
Contractor will provide owner with a listing of completed work and related hours for work in
place in a form as shown in ExhibitContractor for whw&er indicate if
ork submitted on
the labor provided for the tasks completed is within budget. Payment
Saturday will be paid the following Wednesday.
3. mineral Conditions
Contractor is responsible for the following general conditions as described below as they relate
to this project,
a. Obtain permits for work described herein if required.
b. Work with electrician and plumber to complete project as described herein
c. Patching & Painting: contractor is responsible for patching and painting of walls, ceilings,
floors, as they are required to accommodate the plumber and electrician.
d. Deliveries: owner will notify contractor of all deliveries and contractor will be available to
receive those deliveries during the term of this contract Owner will provide 24 hours notice of
all deliveries with a 2-4 hour delivery time window.
4, DISgos.l of Materials
All construction debris is to be broken down and removed by contractor.
1. remove and dispose of carpet in living room and hall way
2. remove linoleum floor in kitchen
3. level the floor with floor leveler
4. install Allure flooring product in living room, hallway and kitchen
S. install 2 door jams in entrance to each bedroom
6. remove and dispose of existing kitchen cabinetry and kitchen sink
7. install new kitchen cabinetry according to floor plan
B. remove all existing closet doors - 5 doors total
9. hang new closet doors and install door knobs -, 5 doors total
10. install new lock set in main front door
11. install crown molding in the living room, kitchen and bath areas
12. remove and dispose of all wall tile and window frame in the bathroom
13. install new tile in the bath area only, frame in the window 12x24 vertical
14. install granite slab to window sill area
15, remove and dispose of existing vanity and medicine cabinet in the bathroom
16. prepare bath wail for paint
17. install new bath vanity with top and r back and side splash
18. install new flush mounted medicine cabinet
19. install a new the floor over existing bath floor -12x12 diagonal
20. install new file base molding in bath
21. install new bath door jam if necessary due to floor height
22. assist with installation of kitchen appliances if required
23. install file backsplash from kitchen countertop to bottom of cabinets -6 -diagonal
24. install new shower rod
25. install all kitchen and bath hardware as supplied by the owner
26. install closet systems in both bedrooms as supplied by owner
27. assist with coordination of kitchen countertop installer as required
HL PIVEAM
1. Coordinate with and assist plumber as required to install existing disposal, install new fad in
kitchen and bath, install new shower control in bath, replace toilet metal tubing and install new
dishwasher.
1. Coordinate with and assist electrician as required to remove and install new kitchen, bedroom and
bath lights. Move outlet in bath. Place kitchen light on a timer. install new kitchen appliances - stove.
microwave and dishwasher. Install new outlets and some under cabinet lighting.
1. paint living room walls, ceiling, trim, crown molding and interior of main door
2. paint kitchen walls above the cabinets, side wall, ceiling and crown molding
3. paint both bedroom walls, ceiling, closet doors and woodwork
4. paint bathroom walls, ceiling, crown molding, woodwork and closet door
S. paint all closets - 4 total - this includes the shelving in the bath linen closet
6. stain and polyurethane (3 coats) the 2 door jams entering bedrooms
1. Price of painting to include all prep work required, caulking, patching, sanding, cleaning priming as
required.
2. All paint and stain is supplied by home owner
3. Painting price is for one coat of paint. Wali that need touch up after the first coat will be done on a
time and :materials basis as instructed by owner.
4. All flooring and or new material are to be protected by contractor during painting.
S. Any unforeseen work will be at a rate of $30.04 per hours with home owner approval.
6. Unit will left clean upon completion of project. This includes windows, sills, woodwork, countertops,
tub and floors. Floors should be Swiffer dean or equivalent.
Total Carpentry cost? $7,110
Total Painting cost: $1,400
Total Price $81510
Contract issues•
1. Payments made emery week on a Wednesday providing the week's labor completed.
2. Change Orders must be approved in writing by Owner before work t proceed.
3. Work submitted every Saturday - Contractor to submit weekly requisitions with work completed
based on cost breakdown in scope of work above withWednesday- owner to review with
Contractor
the following Monday and payment to be made by ch h list's completed to owner
4. Holdback - a 10% holdback will be retained by the Owner U- i the Pune
satisfaction.
S. Contractor not responsible for electrical or plumbing work.
CO form nee of Work
All material, work and construction means and methods to be in confoOance with the Mass tate
Building Code, 2013 edition.
GRUMMAll work performed by Contractor and/or its subcontractors t actors be guaranteed for a period o one year
from the date all punch items are completed an P by
the Owner-
Annr+avai of Work
owner must approve all work
Contractor may make a request for payment at the end of each week. in each case less a retainage of
10% of the contract amount will be held by the Owner. Retainage will be released when all punch list
items are completed and accepted by Owner, Architect and Building Inspector as evidenced by a
Certificate of occupancy.
kJI site
No product shall be installed unless it meets manufacturer's specifications or air temperature,
conditions or ventilation requirements including but not limited to any type of caulking, joint
compound, sealants, paint, polyurethane, vinyl flooring and carpet.
EXHIBIT B
THE FOLLOWING GENERAL CONDITIONS APPLY:
tawr► tlAichaet Hoffman (� ag+� to defend, indemnify
1. IDEMNIFICATION and HOLD HARMLESS: TO the extent } �,ageft � � �, and against any and
and hold harmless Lachmont Mamagermhent LI-C(awnerj including 3� fees and casts Wag in Wo* or in pari
all claims, suits, liens, judgments. damages, lasses and expenses ' performance of any wok by � ^ its
and in any mariner from acts, omissions, breach or defa<dt of oontracW, in connection *film pe
offices, directors, agents employees and subnontractors• .
bfe for the wood and emery Part ftnereof, and al Wok of
2. 1'tESPONSIBifITY OF CONTRACTOR: GQNTRACTOR sh�l be r+esPons+ m cx ri sA�
whether by CONTRACTOR, its employees, subcontract ate•
every description done or used in connection herewith or injury
u from � cause � y or person used spwlc* and dsbnmfflly assume and does so assume ail risks of damage j rY ore or
from die t property or peons used a any"adon or
or employed on or in connection with the work, arid all damage or injutY wherever iodated, resufting from
in connection with the Work and of all damage or injury to any Pew of property t tett and defend ARCHITECT and
operation under this Contract or in connection with the Work, and undertake aero pmviori, protect
fees, on Mme t of any such
OWNER from and against all claims, Ides and expenses, � without lknitadion, aorrneys
damage or It".
CONTRACTOR will be held resporisiblB for C0mPM9 tte Work in accordanoe with the few, � �°
harge, all kicider" RM
any drawings whand ol
ich may have been connection herewith.�, good reason for ming th the use d
required as a pact of the Work even though not particularly speedt OWNER and
any ma tedai, appliance or method of diction as stho wn or steed, it shall make teport of such vbj +
obtair
proper written adpsbrment before the Contract Is made.
3. MATERIALS AND WORMANSHIP: Unless otherwise speed, all materials shall be new, and CONTRACTOR sM provide arc
pay for all labor, royalties and all tools and a quirpment, scaffolding and q0ances necessary to do the Work. Ail materials am
workmanship shad be of good quafrty commensurate with the type and class of construction, and in keeping wrTh 90 intended uses
and shah be at all tines subject t approval or moctiorn fa' W cause by OWNER and ARCHITECT. Whenever equo nent o
materials are specified as definite "or equal" substifntions for the afire spndtetf must have the wmlften approval of ft OWNER.
4. ORDINANCES, LAWS AND PERMITS: AN pits and floes necessary far the PMMM" of the Work Shan be seed and pail
for by the CONTRACTOR and reimbursed by OWNER, unless otherwise specified in 9. CONTRACTOR shall give all notices
and comply with ail lawns, ordinances, nties aero re901110M bearing on the conduct of the Work as dawn and specn6ed. ff Contract
perfomrns any Work knowing it to be contrary to any of such ins, ordin , uncles and re � � made um►IaT the notice,Contractor otdin
bear all costs and damages arising therefrom or in connection therewith. Final payment
a Certificate of Occupancy from the Town of North Andover, MA Ruiidirng lnspecW'
5. ROYALTIES AND PATENTS: CONTRACTOR shall pay all royalties and lige fees. It shad defend all suds or claims R
infringement of any patent rights and shaft save the OWNER, harmless from loss on account thereof.
S. INSPECTIONS AND ACCEPTANCE OF WORK: OWNER or ARCHITECT and its fePM ntallm sia at all limes have access t
the Work wherever ft is in preparation or progress and the CONTRACTOR shall provide facilities for such aces and Inspection. A
materials and workmanship shaft be subject to inspection and acceptance by OWNER or ARCHITECT. Upon reques
CONTRACTOR shalt furnish OWNER or ARCHiTef T with a fist of the Materials to be used and the maWW homm from WIMM'th
materials for the Work mentioned in this Contract tare been purchased, and no payment will be made on acoount of the Work don
until after Inspectim and acceptance of the Watt done. Should CONTRACTOR fait to cant out any part of this Contract or if th
Work is not done to OWNER or ARCHrrECrs satisfaction, or any work requited for payment is not completed or h cormclive a*
by the co ntractor is not made in a timely fashion or corrections made, owner may deduct the cost thereof from the amount awed t
the CONTRACTOR hereunder or otherwise
7. CORRECTION OF WORK AFTER FINAL PAYMENT: Nettfter final Payment nor any other PtO4siOn In the CMVWshad retie~
CONTRACTOR of responsb1ity for faulty materials or workman* and, unless othenwie specIlled, it shah remedy any defects dt
thereto and pay for any damage to other work resuitirig therefrom, which shall appear within a period of one year fmm the date
final completion, as evidenced by Final payment of retainage. OWNER or ARCHITECT shad give node of observed dekft hwi
reasonable promptness.
Mwvied In
for c orders will be allowed only when work is by OWNER filled � aEra e � �N
g EE 13igs hangs
by the OWNER before work commences. Ail extra work outside the scope of aan sur to be and ntbish shall be
g. RESTORATION OF THE PREMISES: Before teavinq the
6 as completed,
all surplus materials. core
removed from the premises and the house shag be left clean and ready for occuPMstr be free iron
herein, CONTRACTOR guar that a# Work m be
1l}. GUARANTEE: Unless clti�erwise sperm without east � OWNER, or their' �
defects and workmanship fora with the delle of cyear and such hi be P� 0 � Ma Paynient Of any MMkW
and assigns. The one year will snag be undertaken by owWs
funds. At owners' option, any defect in work not covered by within 3Q days notice
selected contractor and billed to contractor. or
d of
1. TITLE: CONTRACTOR shall ensure that OWNER shall have to tree and clear f � p completed
1 to and stored at said lab site which Wads at the job site and to all materlats delivered
st
worts and covered by this Contract.
12. TAXES: CONTRACTOR shall pay all sales, use and other taxes of every kind, appkJ* to the peffionnairoe of this order:
13. ASSIGNMENT: CONTRACTOR shall not assign this Contract or any monies to became due hereunder
WMW the pd"
written
consent of GENERAL CONTRACTOR.
14. TERMINATION: This Contract may be terminated by OWNER without notice upon non-perfon by CONTRACTOR, wit"
reason, or by giving contractor twenty four (24) hours notxe in writing or email in which event all rights, tables and, ObI41111"
t "Mparties hereto shag fofty i �, and CONTRACTOR shag his fo&with removie any and all of equipment and
premises and shag thereafter have no further right to enter upon ft Prop * wfilrout permission of owner- in addition, this COMM
is automatically cancelled upon sale of the Property.
15. EXHIBITS OR ATTACHMENTS: 9 the provisions of any Exhibit or Attachment to this Contract are in conW with the
WASIM
the pians and specifications, the provisions of this contract shall prevall.
16. SUBCONTRACTS: CONTRACTOR, as soon as practicable atter the award of this Contract, shag famish to Owner in t
names of all subcontractors to be used. CONTRACTOR shall not employ any ntractor to whom OWNER has made a time)
objection. AN subcontracts shy tie subioct to this Contract.
17. OTHER WORK: OWNER reserves the right to perform other Work on the Pmperhl by itsel or by othe+< oaf
18. LIEN RELEASE: CONTRACTOR to execute a final wanner of lien upon mutual acc9ptarlm of final payment and retease of retamagto the undersigned, the completion of all punch list &MFurihemmore, for aril in consideration of PAID IN FULL paid
whereof is hereby aikro+uledged, the undersigned does Y n � for tabor' amdMlem and �mater€a€, gerre:ai nquish any and � of ��tlorr �
whk
the undersigned may now have upon the premises above
alteration and/or otherwise.
19. REQUIiTIONS AND ACCEPTANCE OF WORK: requisitions for paymenls must be provided to the owner on no Weir than Saturd:
at 5:00pm for the week of work proc:eedimrg that Saturday. Work in place will be Inspected on the blowing Monday Owner
withhold payment on any worts not to owners' satisfaction or if in the owners opinion the work being billed In the r+equrisition is not
place.
20. SCHEDULING: CONTRACTOR to provide a schedule which deur when the scope of work Indentifiet! in paragraphs, it and III
exhibit A (scope of work).
29 . REtIAOVAL OF WASTE: Contractor will remove all waste by using a 'p truek or O#w vehicle in a timely fashion.
22. PAINTING. CONTRACTOR to make best effort to avoid getting paint on new materials andlor final finishes, CAxilracfar is responsil
for removal of aR paint from any final finished surface It is not intended for. Arry finish material that meds to be replaced as a r+esull
paint stains will be at contractors' sole expense.
23. ON SITE PRESENCE: CONTRACTOR (Michael Hoffman) pledges to be on site 75% of the time during the life of ft =#a% i
. ,_m........,..w...,.,^�.vvwa f w nil wArk oral f;wm rzmaleted by veople in his employee 0 subc0rM3CM Or agents paid dimly
Contract AINSMS
payments made every week on a Wednesday � g* s f
1 •in writing by Owner before work to proceed
used on oast l clown
2, Change Orders —must 6e approvedG� to summit fly with Monday � � � be made
3. W0fk submitted every SaEturdaY-the following
in scope
Of wodC above with �� ��. �M � review � Cantra�r
by check on Wednesday. completed to �staetion.
4. Holdback — A 100% holdback will be retained by the until the punch lSt is comp
5. Conte notresponsible for electrical or plumbing
Conformaooe of VNorkState Bulling Code, 24!13
materials, wank and �n means and methods to be in c onfo mom' the ��sa�huseds
All mat
Ethilon.
Guaranteendlor its subcontractors vnll be guxxbed for a period of one year from the date all punch list
AN work � by Contractor
items are completed and accepted by the Omer.
AooM of Work
Owner must approve of all work.
p and Retainage In each case less a retainage of 10% of the
�r may make a request for payment atm be � when all punch first items are completed and as by ,
amount will be held by the Owner.,
Architect and Building inspector as evidence by a Cer"cate of OccupancY.
Adherence to oroduci manufacture MIS s WWkakons or air temperature, site ca4W or ve 4a*m
14o product shall be installed unless it caulking, joint end, wants, paint, polyurethane, vinyl tb xft,
and
requirements including but not limited to any type Of
carpet.
1 Massachusetts - Department of Public Safety
Board of Building Regulations and
Standards
Construction Supervisor
License: CS 101958`,/
KENNETH J DEVJTCE _
88 CONVERSE STREET n s
STONEHAM Mk 02180 R'
Expiration
Commissioner
07/06f,2014
CJ/ce `�ori�,��zcvr�,coea�/� o�'C'�lcc�s�ir�u�c<(/r
Office of Consumer Affairs & Business Regulation
_jOME IMPROVEMENT CONTRACTOR
? =
Type:
eegistration: 174822
xpiration: 3/20/2015 LLC
DEVIN-NUZZI DESIGN &`BUILDERS, LLC.
KENNETH DEVINVENT
88 CONVERSE STREET
STONEHAM, MA 02180
Undersecretary
The Commonwealth of MassachusettsSLX -
_Department of XndlusMa1 Accid&ts
40 Office offnvesiigafions
600 Washington Street
Poston, ltfA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Cont°actors/.Elec£xxczansfPliunbers
Applieant Information Please Print Lem
'Na]be(Businesslorganizationitndividual): 7:gNgUZ21 CNSrfzVCTlonl
Address: IS: ('nZsT 11Awr&J be q
City/State/Zip: �3.,,z1,�c� ;oma, A o �o Phone #:
Are you an. employer? Check the appropriate box:
Type of project (required):
1. [( I am a employer with
4. ❑ I am a general contractor and I
6• r] New construction.
employees (M and/or pax- time) *
2. �� I am a sole proprietor or paitnex
have Hired the sub -contractors
listed on the attached sheet.
7• ❑ Remodeling
'§hip and'have no -employees
These sub -contractors have
8. [(Demolition
working for mein any capacity.
workers' comp. insurance.
g• Building addition
[No workers' comp. insurance
5. ❑ We area corporation and its
ME] Electrical repairs or additions
required.]
3. [( I am a homeowner doing all work
officers have exexcised.their
right of exemption per MGL
-
11. ❑ Plumbing repairs or additions
myself: [No workers' comp.
c. 152, §1(4), andwe have no
12.0Roofrepairs
insurancerequixed.] i
employees. [No workers'
13.[] Other
comp. insurance required.]
Mny applicantthat checks box#f must also fill out the section below showingtheir workers' compensationpolicy information.
T'Homeowners who submit this affidavit indicaiingthey kdoing all work and then hire outside contractors must submit anew affidavit indicating such.
TContractors that checkthis box must attached an additional sheet showingthe name ofthe sub -contractors and their workers' comp. policy information.
I
am an employer that is providing workers' compensation insurance for my employees Below is thepolley andjob site
information.
Insurance Company
Policy /# or Sell Ins. Lic. #: Expiration Date:
lob Site .A-ddress: 05- 5- M N ! Tf�-F J W IT City/State/Zip: DO UL
Attach a copy of the workers' compensaiionpolley declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A ofMGL o.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.
Mo HerebyQQder Mepains and fenalties ofperjury Mat Me information provided above is true and correct.
Signature: 77ALAJ� C Date: 3-I l / / -4
Phone#• I %F— V-5-
Official
S
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permialcense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other -
Contact Pers
Phone #: