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HomeMy WebLinkAboutBuilding Permit #221-15 - 178 OLD CART WAY 9/2/2014 L BUILDING PERMIT "O RT 6 TOWN OF NORTH ANDOVER 02 yt`V APPLICATION FOR PLAN EXAMINATION Permit No#: (/ Date Received 9SSACHUS�t Date Issued: �Z' C-4 IMPORTANT: Applicant must complete all items on this page LOCATION �D ~ St Print PROPERTY OWNER +E!l Y 0 6,eQ<Ll#I/1 Print 100 Year Structure yes MAP 1624 PARCEL: ZONING DISTRICT: Historic District yes o Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building A One family ❑Addition ❑Two or more family 0 Industrial ❑Alteration No. of units: ❑ Commercial fi(Repair, replacement 0 Assessory Bldg ❑ Others: ❑ Demolition 0 Other ❑ Septic ❑Well ❑ Floodplain 0 Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: :& 12 Identification- Please Type or Print Clearly OWNER: Name: . K ��M+' �A �°.Sh/�-l� Phone: 791 '99 a7y �y Address: Contractor Name: Ploy r_- Phone: 929, Address: / < j L`rn4 tk LZ-7-" 42 Supervisor's Construction License: 12a1 �D� Exp. Date: Home Improvement License: 1341 Exp. Date: ZD/ ARCHITECT/ENGINEER f 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: $ FEE: $ i Check No.: Receipt No.: - cC NOTE: Persons contracting with unregistered contractors do not have accesN to th uaran d Signature of Age-nt/Owner Signature of contractor Plans Submitted Plans Waived Cert ified Plot Plan ❑ Stam ed Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales 0 �I Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ ; THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS i CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS I Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes i Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit I DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/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) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Perinit Revised 2014 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building NN Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ 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) ❑ 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) o Copy of Contract o Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location 1 V �C✓� Cl1Q�l� No. 1 � Date Lf L -- Y . - TOWN OF NORTH ANDOVER • ... Certificate of Occupancy Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check 4t G ! � O Building Inspector From:Denise Frazier FaxID: Page 2 of 2 Date:9/2/2014 11:17 AM Page:2 of 2 PAYET-1 OP ID: DF DIYYYY) E(MMID CERTIFICATE OF LIABILITY INSURANCE F0DATE 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 NAME; Appleby Sr Wyman Ins Agency Main Street America Group-NETACT PHONE A New England Region (AIC' AIC No Ext): (AIC' AIC No): PO BOX 2027 E-MAIL msa rou .com Keene,NH 03431 ADDRESS.servicecenter Appleby&Wyman Ins Agency INSURER(S)AFFORDING COVERAGE NAIC q INSURER A:Main Street America Assurance 29939 INSURED Roger Payette dba INSURER B: Payette Construction 17 Milton Street INSURER C: Dracut, MA 01826 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. INY EXP TR TYPE OF INSURANCE INSD 1:SUt3H POLICY EFF WVD POLICY NUMBER MM/DDIYYYY MMI AUULCIYYYY LIMITS A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR MSI6540F 03/16/2014 03/16/2015 PREMISE TO RENTED ES Ea occurrence $ 50,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY ❑PES 7 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED Per accidenPROPERTY DAMAGE $ t HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? � N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE North Andover Building Dept. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 P ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St. Bldg 20,Ste 2-36 AUTHORIZED REPRESENTATIVE N.Andover„ MA 01845 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD From: <978-922-2731> To-. 19786889542 Page: 2/2 Date: 9/3/2014 2:48:21 PM ! 79/3/2014 E(MM/DDIYYYY) AcoR" CERTIFICATE OF LIABILITY INSURANCE THIS,CIERTIFICATE 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 APPLEBY&WYMAN INSURANCE AGENCY NAME: 152 CONANT STREET PHONE FAX ,AJBEVERLY, MA 01915 E--MAIL° t ac "° ADDRESS: INSURERS AFFORDING COVERAGE NAIC 9 INSURERA: LM Insurance Corporation 33600 INSURED INSURER B: ROGER PAYETTE DBA PAYETTE CONSTRUCTION CO INSURERC 17 MILTON STREET INSURERD: DRACUT MA 01826 INSURERE: INSURERF: COVERAGES CERTIFICATE NUMBER: 21459010 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 SUBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MM/DD MM/OD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMSTEDDAMAG To currrence $ MED EXP(Any one person) $ PERSONAL&ADV NJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ JECT POLICY E]PRO ❑LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ r_rDED I I RETENTION $ A WORKERS COMPENSATION WC5-31 S-368958-034 4/8/2014 418/2015 ,/ STAPJTE ERH AND EMPLOYERS'LIABILITY ANY PROFRIETOR/PARTNER/EXECUFNE Y/N E.L.EACH ACCIDENT $ 500000 OFFI CERIMEMBER EXCLUDED? FYI (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500000 If yes,describe under 500000 DESCRIPTION OF OPERAT ONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be allached if more space is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR ROGER PAYETTE. CERTIFICATE HOLDER CANCELLATION NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING DEPT ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD ST BLDG 20 STE 2-36 NORTH ANDOVER MA 01845 AUTHORIZED REPRESENTATIVE } 1 LM Insurance Corporation F ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD CERT NO.: 21459010 CLIENT CODE: 1329999 Didi Dangas 9i3/2014 2:38:07 PN (EDT) Page L of 1 r 1 %AORTFi " ve" 'o . o " . No. th ver, Mass, _q1A )JV A_ cocN�c«ew�c« 1• 7,9 q0"SATED r''0,,`,�5 S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ......... ..........MA.r.s.6 BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on ..r+.&o ..... ..... ..... . .. ... . � Rough • to be occupied as ....... .. Jn.r...�r. ... ..... 1 � Chimney provided that the person accepting this permit shall in every respect conf rm to he 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 61N T S ELECTRICAL INSPECTOR UNLESS CONSTRU RTS 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. FLOOR COVERINGS:Price includes new carpeting,pad,and labor for the entire great room. Allowance for carpeting is$65.00/sq.yd.for material and labor. Tile in foyer area to be evaluated for integrity and may be re-done at extra cost. RUBBISH REMOVAL:Builder to remove all debris generated during construction only. Rubbish containers are not for homeowner use unless otherwise agreed upon by both parties. DRIVEWAY:No driveway work is included. PAYMENT SCHEDULE: AMOUNT: PERCENT'PMT.: UPON COMPLETION OF: 5% SIGNING OF THIS AGREEMENT 1,100.00 &D 10% OBTAINING BUILDING PERMIT 2,200.00 �� ` 4 10% START OF WORK 2,200.00 DEMOLITION AND FRAME 4,400.00 20% ROUGH PLUMBING AND ELECTRICAL 4,400.00 20% INSULATION AND PLASTER 4,40000 10% FISH WORK 1,100.00 NI 5% SATISFACTORY COMPLETION 1 00.35 100% 22,100.35 AMENDMENTS:This section to be used to list any changes to this agreement. 17 , �SZI� PAYETTE CONST. CO. JOB NAME: MARSHALL SUBMITTED BY. ACCEPTED BY:_ DG R PAYETI'E DATE:1/IJ13 DATE: Z Sr PAGE:2 OF:3 6 �r PAYETTE CONSTRUCTION CO. AGREEMENT Homes&Additions of Distinction 17 Milton Street Dracut,Massachusetts 01826 OFFICE(978)454-5223 License No.021304 Reg.No.101841 www.payetteconstruction.com roperna,payetteconstruction.com TO: Alex and Jami Marshall DATE:August 18,2014 JOB NAME: Ext.trim TELEPHONE: FILE NAME: 14marshallcontract EMAIL ADDRESS: DESCRIPTION: PRICE: --------------------------------------------------------------------------------------------------------------------------------------------------------- JOB TO INCLUDE DEMOLITION: Price includes removal of all decayed trim discussed during site evaluation. SIDING: No siding work is included. Any decayed siding will be repaired at extra cost. PORCHES: Price includes changing up to 20 balusters to match existing as closely as possible. Price also includes changing 28 lin.ft.of cedar railing to match existing as closely as possible. WINDOWS AND DOORS: Great room windows will be changed at extra cost once a window option is chosen. Price includes changing the following to PVC trim wherever possible. Cedar or pine will be used where PVC is not available: 1. 14 window side trims 2. 5 sill nosings. 3. 4 pediments at the bases of the ornate corners. 5. 1 half-inch panel detail under window. 6. 2 rail sections previously discussed. 7. 32 lin ft of shadow board (1X2)on rake trims. 8. 16 lin ft of 1X8 rake board. PAINT/STAIN:No paint or stain work is included. RUBBISH REMOVAL:Builder to remove all debris generated during construction only. Rubbish containers are not for homeowner use unless otherwise agreed upon by both parties. PAYETTE CONST. CO. JOB NAME: MARSHALL SUBMITTED BY: ACCEPTED BY: ROGER PAYETTE DATE: 8/20/2014 DATE: PAGE: 1 OF: 3 i PAYMENT SCHEDULE : PAYMENT.: UPON COMPLETION OF: AMOUNT: 1/3 START OF WORK 1,750.00 1/3 APPROX. 1/2 DEMOLITION AND TRIM 1,750.00 1/3 SATISFACTORY COMPLETION 1.743.31 100% 5,243.31 AMENDMENTS: This section to be used to list any changes to this agreement. i i PAYETTE CONST. CO. JOB NAME: MARSHALL SUBMITTED BY: ACCEPTED BY: ROGER PAYETTE DATE: W0/2014 DATE: PAGE:2 OF:3 TERMS OF AGREEMENT (Not all will apply to all projects) 1. Both parties must agree to any changes. Initialing said changes shall indicate such agreement. 2. Payment for each phase of construction must be made before the start of the next phase. Such payment indicates owner's satisfaction with that phase. 3. Owner agrees to immediately notify builder of any situation that might cause a work delay or stoppage so as to minimize losses to the builder. 4. Satisfactory completion:If dispute arises over satisfactory completion,work will be determined to be satisfactory or unsatisfactoryb an impartial third a in the building trades. Such third a is to be mutually acceptable by both parties. Y P party g party 5. When a second floor is to be added to an existing home,the builder will take all reasonable precautions to prevent water damage due to rain. NO GUARANTEE,however is either expressed or implied that,if such damage occurs,repair is the responsibility of the builder. 6. The builder assumes no responsibility for any thing encountered during excavation that is beyond the builder's control,such as, BUT NOT LIMITED TO,ledge,excess concrete from other building projects,high water table or any other obstacles which would cause a work delay. 7. Unless otherwise previously stated in the specification sheet(s)the following items are NOT INCLUDED:Finished landscaping (shrubs,raking,seeding,mulch,etc.),gutters and downspouts,storm windows and doors,floor coverings(rugs,inlaid,tile etc.), dryer vents,microwave oven vents to outside,towel racks,toilet tissue holders,door stops. 8. Builder to provide proof of contractor liability and worker's compensation insurance before start of work,however,owner is responsible for providing hazard insurance for the structure as it is completed. This may be obtained as a rider to the existing homeowner's policy. 9. When remodeling or adding to an existing house,owner is to provide builder with access to the house for the purpose of resetting circuit breakers and for bathroom use. If owner wishes,arrangements could be made for electrical generators and chemical toilets to be used at the owner's expense. 10. It is understood that heavy equipment will be needed to perform different functions during construction. All reasonable precautions will be taken to prevent driveway or lawn damage,however,repair of such damage,if it occurs,is not the responsibility of the builder unless otherwise described in the specifications of this agreement. 11. When a flat or nearly flat rubber roof is installed,it is common for rain or melting snow to puddle in low spots. This is common and has no adverse effect on the roofing material and is not indicative of poor workmanship or structural flaw. 12. It is common for concrete to crack,pit or flake. This is not an indication of defective material or workmanship. Cracks will be filled if they occur within the one-year warranty period. No other consideration will be given. 13. All work is guaranteed for one year from the date of completion. Completion is defined as the date that the occupancy permit is secured,or when all final inspections are signed off. Any"punch list"items will be dealt with separately from guarantee items. 14. Extras: Any work beyond the scope of this agreement will be performed for the cost of materials and labor rates of /hr for a lead man and /hr for an assistant. PAYETTE CONST. CO. JOB NAME: SUBMTITED BY: ACCEPTED BY: ROGERPAYE= DATE: 8/20/2014 DATE: PAGE:3 OF:3 C i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington St. Boston, MA 02111 www.mass.gov/dia Worker's Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Application Information—Please-Print Legibly Name(Business/Organization/Individual/Owner: `�ArV5Vier A.4 ' Address: S City/State/Zip• �r�/./7 21 g Ti,6 Phone#: !939 Are you an employer? Are you the homeowner? Check the appropriate number: 1. VI am an employer with employees(full and/or part-time. 2. _ I am a sole proprietor or partnership& have no employees working for me in any capacity. 3. _ I am a homeowner doing all work myself. (No workers compensation insurance required.) 4. _ I am a general contractor&I have hired the sub-contractors listed on the attached sheet. (These contractors have workers comp.insurance and I have attached a copy of their ins.) 5. _ We are a corporation and its officers have exercised their right of exemption per MGL c.152§1 (4),and we have no employees.(Pio workers comp.insurance required.) • Any applicant that checks box#1 must also fill outthe section below showing their workers'comp..policy information. 0 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 attach an additional sheet showing the name of the sub-contractors and their workers' compensation policy information. Type of project(required): Check appropriate# 6._New Construction 7. Remodeling 8. Demolition 9. _Building addition 10. Electrical 11._Plumb. 12._Roof 13._Other tr1 I am an employer that is providing workers'compensation insurance for my employees. Below is the policy&job site info. Insurance company Name: 10 3 f Policy#or s elf-ins.-,Lic.# � P-D� JEx Expiration Date: .Zh/cS' Job Site Address: ` Attach a copy of worker'scompensation policy declaration page(showing the policy number and expiration urate. Failure to secure coverage as required under Section 25A of MFLc. 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 violation. 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 penalties of perjury that the information provided above is true and correct Signature: Date: Phone# Official use only: Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one) 1. Board of Health 2. Building Dept. 3._Cityfrown Clerk 4.—Electrical Insp. 5._Plumb&Gas 6.—Other Contact Person: (print) Phone# C��e rCcn�u�rrra�rtaeti�/� C��air'ac�cae//3 . Office of Consumer Affairs&Busio ess Regulation R�- ME IMPROVEMENT CONTRACTOR Type. i.egistration 701841 ( 6/2J'2D16 Private Corporatior. xpirabon ---PA-YfTTE CONSTRiICTiON CA +NG — ----- - Roger Payette 17 MILTON ST. Dracut,MA 01826 Undersecretary Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor License: CS-021304 ROGER G PAYETE 17 MILTON ST DRACUT MA 01626 ti ')i'741"s Expiration 01/20/2016 Commissioner