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HomeMy WebLinkAboutBuilding Permit #749 - 181 BERKELEY ROAD 5/13/2013gT�ac , 9 BUILDING PERMIT 3r yeti:,, ,,,.,°+6hoL•,i/ TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 41 Permit N0: + Date Received Date Issued: J 1 1 �1SSwcuu4 tc`' IMPORTANT: Applicant must complete all items on this LOCATION i8i J&rke1f V Print PROPERTY OWNER L-,vc � Print MAP N0: �PARCEL:� ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE v Residential Non- Residential ❑ New Building WOne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Others: N'Repair, replacement ❑ Assessory Bldg ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑ Water/Sewer & trace Aeek JOCQ i, Identification Please Type or Print Clearly) OWNER: Name: A&;ke Macuo,. Phone Address: i `i(ke ee CONTRACTOR Name: Phone: 778 -787 -30C, -z Address: t6Ci c. 1Zo c� k4 Ole %I Supervisor's Construe ion License: Exp. Date: lel 2-o%4 I 2-o%4Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULD/NG PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBAON $12M0 PER S.F. Total Project Cost: $oo, FEE: $ l Check No.: 2 Receipt No.: NOTE: Persons ..ontracting with un egist red contractors do not have access to the guaranty fund i ignature of Agent/Owne Signature of contractor J• TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LQCATION? Printi PROPERTY OWNER- _ Print 100 Year 01d Structure yes, no, MAP NO: PARCEL:. ZONING DISTRICT: Historic District yes no. Machine. Shop Village ves 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: ❑ Floodplaih; ❑ Wetlands ❑ Watershed,Dlstrict? o Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: AddrPs-,: hone: 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- $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/ her, Signaturejof contractor ^. Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ iWA a M Locationj�� /gfGt `Sr No. Date Check #( 3 -Z ; 26376 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ f Foundation Permit Fee $ Other Permit Fee $ TOTAL $ fgrtLs2, Building 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 PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comme Conservation Decision: Comme Water & Sewe.r Connection/Signature & Date Driveway Permit DPW Touo ]Engineer: Signature: Located 384 Osgood Stjjet FIREDEPARTMENT - 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 — (dor 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 u Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract u 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 appeal 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.Building permit Revised 2012 O J W s LL 0z o co C Lm y o O. LI E V) U a ai V) W O d z �_ D m a > O LL c > o OC w c E f U m S LL Cc O z a z J a s O O m W. O z J V LY W O M a) �_ v V) m iz Q H Z IA a to t O o CL m S IL w a W O 25 LL y O :3+� ca Z + v VI v O E VI M17 uj am C oV 'Q R CLcnZ cua �r �Q L M tai ° o E cm Z o za Q M � U cCDH ea G1 o =_ c> > -0o U) 0-0 E o o z O a c .� �.7 N O O U Mn 3 � > o �>0 Cl) cic tm CL �= m � 0 c oM Q L L {a f- 0 y N V m W a o o u. 2 N ! O W E u d c i co CL d > c H w M o Z .o CLOV O W CLcnZ Z in ~ Z za � U � U) W d O LJ O U Cl) cic tm W� az m � 0 tm c .O N �.. m w 0 Z O H ROUSS-1 OP ID: NB CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/Y1 105109120133 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). PRODUCER Phone: 603-890-6439 Planright Insurance -Salem Fax: 603-890-6521 224 Main Street Suite 3C Salem, NH 03079 Jason M Mlocek NNpME CT PHONE FAX AIC No): AIC No Ext): (AIC' E-MAIL ADDRESS: INSURERS) AFFORDING COVERAGE NAIC # __ INSURER A: Acadia Insurance 31325 INSURED Rousseau Carpentry Jeffrey Rousseau DBA 18 Coventry Atkinson, NH 03811 INSURER B: Utica National Insurance Group 25976 INSURERC: 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 LTR TYPE OF INSURANCE DDL POLICY NUMBER POLICY EFF MM/DD POLICY EXP MWDD LIMITS North Andover, MA 01845 GENERAL LIABILITY EACH OCCURRENCE $ 1,00D,00 PREMISES Ea occurrence $ 50,00 A X COMMERCIAL GENERAL LIABILITY BOA5054873 06/2212012 06/22/2013 CLAIMS -MADE O OCCUR MED EXP (Any one person) $ 5,00 PERSONAL &ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,00 $ PRO LOC POLICY 7 IF AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per acddent) $ PROPERTY DAMAGE $ Per accident NON -OWNED HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE: $ AGGREGATE $ EXCESS LIAR _ _J CLAIMS -MADE $ DED RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY IN ANY PROPRIETORIPARTNER/EXECUTIVE Y OFFICER/MEMBER EXCLUDED? (Mandatory in NH) NIA 4519493 03/13/2012 03113/2013 WC STATU- OTH- TORY LIMITS X ER _ E.L. EACH ACCIDENT $ 100,00 E.L. DISEASE -EA EMPLOYE $ 100,00 E.L. DISEASE -POLICY LIMIT $ 500,00 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) C 3A NH, MA - Jeffrey Rousseau has elected to be excluded RE: McKay, 181 Berkley Road, North Andover, MA 01845 CFRTIFICATF HninFR CANCELLATION ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover Building Department AUTHORIZED REPRESENTATIVE 1600 Osgood Street North Andover, MA 01845 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Jeff Rousseau Carpentry Proposal 18 Coventry Road. Atkinson,NH 03811 CSL#05947, C 150905 Printed Date: 3/19/2013 For: Mike Mackay 181 Berkeley Street North Andover MA 01845 This Agreement For Professional Services is entered into by and between Jeff Rousseau Carpentry hereinafter called Jeff Rousseau or "Contractor', and the party signing below, hereinafter called "Owner", governing work to be performed on the property and building located at 181 Berkeley Street, North Andover MA 01845 FOR: Replacing decking and railings on existing back deck Jeff Rousseau shall furnish all labor and materials to perform the work described in the following specifications, and incorporated by reference as part of this Contract and any Addendum attached hereto. It is understood and agreed by and between the parties to this agreement, that the work included in this Contract is to be done under the direction of Jeff Rousseau , and that owner's decision as to the selection of materials and, method of construction and meaning of the specifications shall be final. At the completion of the demolition work, Jeff Rousseau will make sure there is no aditional framing,flashing,or fasteren necessary to be completed project. Owner will at that time have the option to choose the necessary repairs if any Jeff Rousseau will make. Owner understands and agrees that Jeff Rousseau has not figured or included any permits in this proposal unless specifically mentioned elsewhere in this agreement. Owner understands and agrees that Jeff Rousseau will remove all wet rot damaged materials and repair the damaged areas as specifically outlined in this agreement. No other work of this kind, including any damage done by insect infestation is figured or included on this job. Jeff Rousseau will remove approximately 215 square feet of existing deck, and haul away debris from the job site. Jeff Rousseau will tearout and remove the existing porch railings structure, and haul away debris from the job site. Any sub standard framing, flashing found will only be repaired or replaced through a CHANGE WORK ORDER. Jeff Rousseau will furnish and install 215 square feet of new Fiberon Horizon composite decking color Ipe, laid flat with hidden fastems spacing between boards.The edge of the deck will have a border with surface screws. Jeff Rousseau will furnish and install 62 lineal feet of new Fiberon Horizon white railing with a mission profile hand railing, 36" in height.All railing post to have pvc post sleve with skirt molding trim at the bottom and a post cap.White pvc privacy lattice will be installed around the under side of the deck on all three sides and trimed out with versatex pvc trim boards. This Contract between Jeff Rousseau and the Owner has been entered into in the State of Massachusett. The parties agree that Jurisdiction in the State of Massachusett with , shall be utilized in construing this Contract and in enforcing the rights and remedies of the parties. Jeff Rousseau assumes no code violation work will be required except as noted in this Contract. All hidden, concealed, or unforeseeable conditions, including code violations, that must be repaired, corrected, replaced, or overcome, shall result in a change order to the work. Jeff Rousseau will make it's best effort to discover any hidden conditions that exist.. These conditions include, but are not limited to code violations, structural, mechanical, electrical or plumbing defects, insect or rodent damage, buried objects, or any other matters that might impede the progress of this job. Any conditions that are not reasonably discoverable prior to job start, which in any way interfere with the safe and satisfactory completion of this job will be corrected by an additional work order and at Owner's expense. If hidden conditions are found, the work will stop, Jeff Rousseau will prepare an additional work order along with the cost estimate for the repairs and present it to the Owner for signature and payment prior to resuming the contracted job. Jeff Rousseau shall, from time to time, as is reasonable, or in the interest of safety, remove accumulated debris and waste/salvaged materials from the premises specified in this Contract. Additionally, Jeff Rousseau will remove and haul away all construction debris from the job site at the completion of this job, and leave the job site in a broom clean condition. All material removed in the course of alterations shall be disposed of by Jeff Rousseau except those items designated by Owner in writing prior to job start. . SUBSTANTIAL COMPLETION: The date when construction is sufficiently complete in accordance with the contract plans and documents so that the Owner(s) can occupy or utilize the work or designated portion thereof, for the use for which it is intended. Some work may remain at SUBSTANTIAL COMPLETION, Le.. special order parts that are late or unavailable, defective or broken parts, scheduling problems, weather problems, etc. Owner and Jeff Rousseau will mutually agree on any amount that may be reserved from final payment until the entire job has been completed as per this agreement. This construction Contract is entered into on March 17,2013, by and between Jeff Rousseau Carpentry, hereinafter called Contractor or Jeff Rousseau , and the party signing below, hereinafter called Owner. The above specifications, conditions, and job material selection sheets are satisfactory and are hereby accepted. You are authorized to purchase materials and proceed with this job as specified in this proposal. Jeff Rousseau shall f imish all labor and materials to do the work described in the above specifications and Owner agrees to pay Jeff Rousseau as follows: CONTRACT PRICE 9,500.00 TOTAL CONTRACT PRICE 9,500.00 DOWN PAYMENT 3,000.00 PROGRESS PAYMENT #13,000.00 PROGRESS PAYMENT #2 2,000.00 DUE ON DAY OF SUBSTANTIAL COMPLETION OF THIS JOB 1,500.00 ATTENTION: Jeff Rousseau will do only that work which is written in the above specifications for the above agreed amount. The terms and conditions as stated are part of this Contract. Please be advised that your signature is formal acceptance of the terms and conditions of this agreement and your failure to comply with the terms stated herein will be considered a breech of the contract. You, the buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. See the attached notice of cancellation form for an explanation of this right. (Owner's signature) (Owner's signature) Own ) acknowledge receipt of a copy of this Contract, and that they have read and understand the terms of th' n act and the payment schedule for this job. lia lr3 (Je ousseau Carpentry) Lic#05947 HIC#150905 NOTICE OF RIGHT OF CANCELLATION Notice of Cancellation Date / / You may cancel this transaction, without any penalty or obligation, within three business days from the above date. If you cancel, any property traded in, any payments made by you under the contract or sale, and any negotiable instrument executed by you will be returned within 10 business days following receipt by the seller of your cancellation notice, and any security interest arising out of the transaction will be cancelled. If you cancel, you must make available to the seller at your residence, in substantially as good condition as when received, and goods delivered to you under this contract or sale; or you may if you wish, comply with the instructions of the seller regarding the return shipment of the goods at the seller's expense and risk. If you do not agree to return the goods to the seller or if the seller does not pick them up within 20 days of the date of your notice of cancellation, you may retain or dispose of the goods without any further obligation. To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written notice, or send a email to: jeffrousseaucarpentry@gmail.com Jeff Rousseau Carpentry, 18 Coventry Road, Atkinson NH, 03811 Not later than midnight of / / I hereby cancel this transaction: (Buyer's signature) The Commonwealth of Massachusetts Print Form Department of Industrial Accidents UIPOffice of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): _�cW'Rous cuu Address: nS�� . IJ N o33�1 Phone #: & c 3- arca -(.3w3 o-, I) 9>8-987 - Are you an employer? Check the appropriate box: 1. [:11 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. LITI am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance required.] 5. ❑ 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t employees and have workers' comp. insurance.$ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *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: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: 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 penalties of perjury that the information provided above is true and correct Phone #: q7 FIS, -Q5`(-?0067 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Cityfl'own 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 ppropriateline.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 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 7-2010 Fax # 617-727-7749 www.mass.gov/dia ,tom Mae �Oarnmuvrr2uea�� o�V4Lcr69aciutaeC�a �\ Office of Consumer Affairs & Business Regulation WI ME IMPROVEMENT CONTRACTOR istration: 150905 Type: piratio n:;:=;5/5%2014_._ _. Individual JEFF ROUSSEAU JEFF ROUSSEAU 36B COGSWELL ST. g a HAVERHILL, MA 01832 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170. Boston, MA 02116 ` Not valid without signature Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor License: CS -059647.7, Aj' '�. JEFFREY S ROUSSEAU 18 COVENTRY RiD ATKINSON NH 713811„ Expiration Commissioner 10/01/2014