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HomeMy WebLinkAboutBuilding Permit #577-2016 - 194 OLYMPIC LANE 11/10/2015 BUILDING PERMIT Of N°Dr 6.1 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION i n O Permit No#: Date Received R°ORATED Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION L.4;,\ {. Print PROPERTY OWNER -5,grelk pec st, Print 100 Year Structure yes no MAP PARCEL&2V ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg A,Others: ❑ Demolition ❑ Other ��r''�7 �PtSeptic. INeIP �'Flo:odplainetlands+ ~� 41Natershed@1Wtnct- �® V1. ter/Sewer _ f DESCRIPTION OF WORK TO BE PERFORMED: /� G Identification- Please Type or Print Clearly OWNER: Name: SarzoG7 ieeo Phone: f4� (,F?'3333 Address t l M P" Lei Contractor Name: l��Tti t Y % ` (q gAc Phone: Email: Address: -57— Supervisor's iSupervisor's Construction License: t nGo I7 Exp. Date: /11F7-�� Home Improvement License: od ' Exp. Date. �//,X/�G ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ © 0-o D FEE: $ Check No.: Receipt No.: A NOTE: Persons contractir ith unregistered contractors do not have access to the guaranty fund -, _ - lRign k Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL E Public Sewer El F] Pools El ' Tanning/Massage/Body Art ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sa1es ❑ Private(septic tank, etc. ❑ Permanent Dumpster on Site ❑ i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS 1 CONSERVATION Reviewed on Siqnature j COMMENTS 36 HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes a Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street p.,'++„'.w'.` S+.'?A.-. ni' y.:#a 3' i ., .. � .s ..,., r ,N r. 4 f'a ti 1 t r. ,�",°r'S+'��f�@:lY'}�y'.'....,h��"�P,t�`•,....�.r FEDEP, RT,�EN7 TernDumpster onsite, yes ,st u ; 'nog �: i} Qrocated at 1pQ- Main •^Nr--t�45' ...,"r,.w.olr �;.. .. Fire .Department�ignature/date vs^t 7n+i::dot-.kr,t. V ,#{;t r L.,i 4 t� � �' ,� �+'1 'fir rra yt x,�!t �t h`.1t�+ �-.* i'Vic, .t� �,❑ v�F i 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) �I ® Notified for pickup Call Email I Date Time Contact Name Doc.Building Pennit Revised 2014 f Building Department N M 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 'E Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks I 4. Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit � Photo Copy of H.I.C. And C.S.L. Licenses 4� Copy Of Contract 4. Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) t, Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) 4, Building Permit Application 4. 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 � 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals . that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location No.r-�77-- 2—tAt, Date . • TOWN OF NORTH ANDOVER y Certificate of Occupancy $ ate:, Building/Frame Permit Fee $ - Foundation Permit Fee $ � Other Permit Fee $ r �U4 TOTAL $ Check# 296 52 f Building Inspector eusmess Regulation office of Consumer Affaus and 5170 10 Park Plaza Boston, Massachusetts10Re 6stm#On 110me ImProVement Contractor Registration: 102726 Type: DBA Tt# 2=49 Expiration: 7!212016 POLAR BEAR INSULATION CO- Vincent LeBlanc P.O. BOX 958 �qa moo for change- ANDOVER, MA 01810 Update Address and return employment [] Lost cera j Et Address Renewal J 141216 op"A1 G t Massachusetts-'Department of public Safety Board of Building Regulations and Standards construction Supersiwr Specialt} Y. License:CML_106017 PETER A LEBLAW - 2 EAST PINE STREET r Plaistow NK 0386 _ a-� Expiration 0412$I2018 commissioner NORTH Town of 2 t 771'o :.,, AndoVer 0% No. n h ver, Mass, o 1. COC NICCHI Hl w1C�[ � S V BOARD OF HEALTH Food/Kitchen Septic System PERMIT : . THIS CERTIFIES THAT ��� BUILDING INSPECTOR has permission to erect .......................... buildings on ...............` .. ...� .4 .. .,..... Foundation if L%40 Rough to be occupied as ...... ....smhn.... ......� ................................... Chimney provided that the person accepting this permiin every respect 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO STARTS 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. Federal ID#05-0405629 RISE Engineering�' RI Contractor Registration No 8186 ` MA Contractor Registration No 120979 A division of Thielsch Engineering CT Contractor Registration No 620120 60 Shawnrut,Canton,NIA 0202CONTRA t vi 339-502-5197 PAX.339-502-6345 E Page 1 PROGRAM E NGl NE E RIIN G THIS CONTRACT IS ENTERED.INTO 8E7WEUJ ME CNIA-HE'S ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIBED BELOW CUSTOMER PHONE. DATE CLIETLT9 WORK ORDER: Saran Keogh (978)689-5533 (1612412015 416737 00002 SERVICE STREET BILLING STREET 194 Olympic Laiie 194 Olympic Lane SERVICE CITY.STATE,23F BILUNG CITY,STATE,LP North Andover, MA 0 1845 i orth Andover, MA 01845 JOB DESCRIPTION Alit SEALING:Provide labor and materials to seal areas of your[ionic against wasteful,excess air leakage. This work will be performed in concert with the use of special tools and diagnostic tests to assure that your home wiU be left with a healthfullevel of air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams and other products. Primary areas for sealing include air leakage to attics,basements,,attached garages and other unheated areas(windows are not generally addressed.) This♦rill require(8)working hours. A reduction in cubic feet per minute(cfm)of air infiltration will occur,but the actual number of cfm is not guaranteed. At the completion of the weatherization work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis wide be conducted by the sub-contractor to ensure the safety of the indoor air quality. $680.00 AIR SEALING ADDER: (4)working hours. $340.00 ATflC FLAT:Provide labor and materials to install a 7"layer of R-25 Class i Ccilulosc added to(784)square feet of floured attic space. $1.403.36 DAMMiNG:Provide labor and materials to install a 12"laver of R-38 unfaced fiberglass baits to(144)square feet for damming purposes. $29520 ACfIC FLAT:Provide labor and materials to install an 8"layer of R-28 Class 1 Cellulose added to(584)square feet of open attic space. 5800.08 ATTIC ACCESS:Provide labor and materials to install(d) easily moved,insulating cover for the attic access folding-stair. A small flat surface of pl" ood will be created around the opening within the attic. This will allow the cover's integral weather-stripping to restrict air lcaka,c. $237.65 V fiN 1'11.A*I'ION:Provide labor and rnalerials to install(2)insulated exhaust hose with roof mounted flapper vent to exhaust existing bathroom fan(s). 5237.50 VE I'll-ATION:Provide labor and materials to install ventilation chutes in(66)rafter bays to maintain air flow. 5132.00 RiSf_.t neinecring will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount. Currently,for eligible measures,Columbia Gas offers 75%incentive,not to exceed$2,000 per calendar year,and an incentive of 100%for the Air Sealing measures up to the first 5680 and an additional 5340 if savings are justified by the auditor. For the safi:ty and health of your home's indoor air quality,we will be conducting a blower door diagnostic of the available air flow in your home both before the work is begun,and after the wcatherization work is complete.We will also conduct a frill assessment of the combustion safety of your heatim,system and water heater.This has;a value of$90 and is at no cost to you. Total allowahle weathcrl7.ation incentive is S3.1 IQ. $90.00 Federal ID#05-MS629 RISE Engineering RI Contractor Registration No 8186 MA Contractor Registration No 120379 A division of TlLielsch Engineering CT Contractor Registration No 620120 r" 7— A l 60 Shawmut,Canton,MA 02021 � CONT CT Q 339-502-,197 FAX 339-502-6345 PROGRAM Page z ENGINEERING THIS CONTRACT is ENTERED INTO BETWEE14 RISE CMA-HES ENGINEERING AND THE CUSTOMER FOR WORK AS DESCRIeEO BELOW CUSTOMER PHONE DATE CLIENTS WORKORDER Sarah Keogh (9713)688-5533 06(2412015 416737 00002 SERVICE STREET BILLING STREET 194 Olympic Lane 194 Olympic Lane SERVICE CITY.STATE,ZIP BTU-MG CITY,STATE,ZIP North Andover,MA 01845 North Andover,MA 01845 I JOB DESCRIPTION Total: $4,215.79 Program Incentive: $3,110;00 Customer Total: $1,105.79 I WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPWFICAT[ONS.FOR THE SUM OF ***One Thousand One Hundred Five&79/140 Dollars $1,105.79 UPON FI L SPECTION AND APPROVAL BY RISE ENGINEERING-C--STOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF 1%WILL BE CHARGED MONTHLY ON ANY UNPAID B CE AFTER IO DAYS..SEE REVERSE FOR 2 INFORMATION ON GUARANTEES.RIGHTS OF RECISION,SCHEDULING.AND CONTRACTOR REGISTRATION. DO NOT SIGN THIS CONTRACT IF THERE ARE A Y LANK SPACES AUTHORIZED ST&ATURE-RISE Engineering CUSTOMER ACCEPTANCE NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN. DATE OFACCEPTANCE ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE 30 DAYS SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORED TO DO THE WORK AS SPECIFIED.'.PAYMENT WILL BE MADE AS OUTUNED ABOVE I i 1 A 7 �• OWNER AUTHORIZATION FORM Sarah Keogh 1, (Owner's Name) owner of the property located at 194 Olympic Lane, North Andover, MA 01845 (Property Address) 194 Olympic Lane, North Andover MA 01845 (Property Address) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. Owner's Signature, Date I OP ID:SS ,4co CERTIFICATE OF LIABILITY INSURANCE °�0` U2015' `--� o3Rf13R015 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 WANED,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 endorsem s. PRODUCER COMT Durso&Jankowski Ins Agcy LLC 198 Massachusetts Avenue PHONE FAX No): North Andover,MA 01845 ADDRESSADOR Durso&Jankowski Ins.Agcy. : PNOO MER 10 s:POLAR-1 INSURERS)AFFORDING COVERAGE MAIC t INSURED Polar Bear InsulatJon Co.Inc. INSURER A:Penn America 32859 P 0 Box 958 INSURER 9:Safety Insurance Co. 33618 Andover,MA 01810 INSURER C: INSURER D: USURER 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. LTTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF LHY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY PAC7052M 03124/2015 031242016 DAMAGE TO PREMISES ocIU:U e $ ,00 CLAIMS-MADE Q OCCUR MED EXP(Arty one Person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 1,000,00 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 B ANY AUTO 2100926 01/0401015 01/04/2016 (Ea Occident) -- BODILY INJURY(Per person) $ ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY(Per=6derrq $ PROPERTY DAMAGE $ X HIRED AUTOS (PER ACCIDENT) X NON-OWNED AUTOS $ UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 1po'oix A EXCESS UAB CLAIMS-MADE PAC69O1s385 0324/2015 032401016 AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION JIMSTA TH AND EMPLOYERS'LIABBJTY YIN I I PER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,descn"be under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS J LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,N more apace M required) Insulation Work-Mlneral;Additional Ins u d for eneral liability, iiji rps is to workperfornle on their beha by thiabove nsured Is Thiel Engineering CERTIFICATE HOLDER CANCELLATION THIELS2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Thieisch Engineering THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g Columbia Gas ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD A6Z® DATE(M1iM1t�1(YYY) � CERTIFICATE OF LIAGILITY INSURANCE 12/189014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS j 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. I IMPORTAN-11 i the certificate holder Is an ADDITIONAL INSURED,the po Icy(ies)must be en orsedifSUBROGATION IS WANED,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 IAL NINE: AatOmat)c Data Processing Insurance Agency.Inc. APHONE EXa (c,w): 1 Adp 6 oulevard nmREss: Roseland,NJ 07068 INSURER6)AFFORDING COVERAGE NAIL e iNsuRER A. NorGUARO Insurance Company 31470 INSURED POLAR BEAR INS ULATION CO INC INSuRER B: - DBA:Polar Bear insulation CO Inc INSURER C: PO BOX 958 Andover,MA 01810 USURER D: INSURER E- LNSURER F COVERAGES CERTIFICATE NUMBER 291629 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOV.,HAVE.SEEN ISSUED TO THE INSURED NAMED AS OVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT.TERN OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS j CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJ ECT TO ALL THE TERM1NS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE NISO 1VVD POLICYNUNRER 0141110NYYY) (MM)>a:YYYY) LltrrS ! COM1INEROAL GENERAL UABLLnY EACH OCCURRENCE S i CLAIMS-M1inUE I OCCUR PREf.115E5(Ea c[[urtcr.[e) 5 MED EXP(Anyunepetwo 5 PERSOEa EADd B.IURY S CEWL AGGREGATE LMUT APPLIES PER. GENEMACCRECATE S POLICY aPRO-ECT M LOC PRODUCTS-CORtPAP,cc 5 ) OTHER. 5 AVIOMOBREUARILM 11a aLudent) , ANY AUTO HOMY INJURY Wet IxnonN S ALL01.1tNED SCHEDULED AUTOS AUTOS BODILY INN URY(Per zwdeGt S HIHEI)AUTOS NON-Or.TEU AUTOS tPrT a[Udel.? 5 UM1BREWILNB OCCUR EACHOCCURRENCE S i EXCESS uAll Cuu:IS-ISACCREGATE S DED RETENTION 5 S It•CMERS CO?PEMSATtM x STit ATUTE ER ANDEMPLOYERS'LBIBLLr1Y ],OOD,000 ANY PROPRIETORPARTN�ER.EXECUTII•E YNN ELEACHACU NT S A OFFICERAILIBEREXCLUDED7 Y❑N'A N PMVC660M 0110112015 01,0112016 � a6undatm m IU El -EAENI'LOYEE 5 1+ %ew DESCRIPTIONtinder 1,00 EL.D5EASE-POUCYUI.I1.00%=OESCRR MbewF 01'EINATIONS Lelus DESCRIP7=OF OPERATIONS NLOC MMS!VENUES(ACORD IOL Atut6nd Remarb Sehedure.may beattached itm seam is nqt fired) Columbia Gas massachuseus CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The)Isch Engineering,Inc. ACCORDANCE WITHTHE POLICY PROVISIONS. 19S Frances Ave I Cranston,RI 412910 AUnIORIZEDREPRESENTATNE ILL.— AV 1988-2014 ACORD CORPORATION All rights reserved. ACORD 25(2014,01) The ACORD name and logo are registered marks of ACORD I t The Connnonwealtlr of ftllassaclrusetts Departiatent of Industrial Accidt:nts Office of Investi-ations 600 lffashin ton Street Boston, AJA 02111 tvlv1u.nlass.9 ov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibl�_• Name (BusinessiOreanization/individual): 014 r A -ed r MAI K&Z�o Address: . ,� t� �} x frr� Cit}/State/Zip: pfJ f" Phone 9: Are you an employer?Check the appropriate box: Type of project(required): 1. •I am a employer with_� 4- ❑ 1 am a general contractor and I employees(full andtor part-time).* have hired the sub-contractors 6- ❑New construction 2_❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity- employees and have»workers g Building addition [No%vorkers' comp.insurance comp.insurance required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3_E3 I am a homeoi mer doing all work officers have exercised their 1 l.❑Plumbing repairs or additions myself.[-\o workers comp. right of exemption per MGL 12-0 Roof repairs insurance required.]' c_ 152.S 1(4).and we have no employees. [No workers' 1�.[ comp.insurance required.] °Any applicant that cltetks box=1 mast also an out the section haote showing their worker compcusation policy inionnation. I lomeoa7ters who submit this affidavit indicating they are doins all.volt and then yin outside ean[tattors mast submit a new affidavit indicating Sttdt. Contractor that check this box trust attached an additional sheet showinE die name of the sub-contractors and sate%rhether or not those entities have emphn-ees. if the sub-contractors have employees-they must provide their .corkers'comp.policy number. I all,an employer that is providing workers'compensation insurance for ntr employees Below is the polio'ant!job Site information. Insurance Company Name:-�t G) Policy' or Self-ins.Lic. 0 fie-6-5--�� �— Expiration Date: I i I� Job Site Address:__ C9y Gtk/1`t4 j"'t t R w Y City/State!Lip: ►�. KJ1ll/-t'r— 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 S1,500-00 and/or one-year imprisonment,as Drell as vigil penalties in die form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator_ Be advised that a copy of this statement may be forwarded to the Office of Investigations of die DIA for insurance coverage verification. Ida hereby cert j•rn der theptrins and penalties of perjun- that the information provider/above is trite and correct_ Signature: Date' Phone=: ME 1/a Official use otdr. Do riot write in this area,to be completed kr city or town official Cit•or Tower Permit/License R Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk -l. Electrical Inspector j.Plumbing Inspector 6. Other Contact Person: Phone�: