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HomeMy WebLinkAboutBuilding Permit #72 - 198 DALE STREET 7/29/2007Permit NO: Date Issued: / BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this page LOCATION 1 J V— Print PROPERTYOWNER ,9//'/ / �; t>.�.4�°L �"�1c4L i9/ "� �� Print 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 Floodplain Wetlands Watershed District oel Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: `�+ J Pr r U S Identification le se T o not Cleary OWNER: Name: 4 Phone: %�- �f� ��s Address: CONTRACTOR Name:ro.0�- Phone: Address:�i''�_ %t• zz� '41 /01,0 Supervisor's Construction License:. � Exp. Date:_�,a Home improvement License: 46�xj:� Exp. Date: s' 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: $ 02 ���� FEE: $ Check No.: 7jAV Receipt No.: � �p NOTE: Persons contracting with unregistered contractors do not have access to the aranty f d 6ign—at u -re of Agent/Owner Stgnature. of contract LocationL �•L �� No, 0 2-- Date �oRT� TOWN OF NORTH ANDOVER F 9 • ; ; Certificate of Occupancy $ NUS •Building/Frame Permit Fee $ �C t Foundation Permit Fee $ 49' Other Permit Fee $ TOTAL $ Check # 30A)� 2 , 56/ Building Inspector 31 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewe Tanning/Massage/Body Art Swimming Pools i Well Tobacco Sales Food Packaging/S06g 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 Reviewed on DATE REJECTED DATE APPROVED Sianature 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 Town Engineer: Signature: t.ocatea 6ts4 usg000 Street FIRE DEPARTMENT Temp Dumpster on site yes no .. `'• Located at 124 Main Street.. -' Fire Department signatureidate COM 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 2 1 A —F and G min.$100-$1000 fine NOTES and DATA — For department use -e c L ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 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 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 submitted with the building application Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 U) m m m mm CO) CD. Z CD O ar �d CL. )::NCO CD v Q� cr CD 0 COD d 0 C O C , y d t7 CD EL - O to O CD S CA CD sz O 7 CCD O CCD C O c?� o 0 m N 2 d Z dN O C7 = m m N C m SOY N m d � °� O m .O c ' ?-w N M tz z V n' < .+�wQ O d TI N 'O O : ten-► CD M� Ocl Mn y Wim: OO N OCD y �1 0 �.0 0 co CD o m _ O S. Cl) CD ca v C o =r CD m N CL CD m Ngo = N cn ^ Zw O CL d: d W C1 ° ?y ?� C m n � °� O m =m: 7 M O � C CL '7 tz z V n' < O o\. rz- O d CD N 'O O : Ocl Wim: C y w C: o m _ m m nom: C-) CY c o = co: cn :Y cn ^ Zw O m n d ?7 7O Vl ?y ?� cn a- n � °� RL 7 M O � C CL '7 tz z V n' < O o\. rz- O d E5 H 0 0 c • CONTRACT TO INSTALL BASEMENT LIVING SYSTEM Liquacoat, Inc., d/b/a Affordable Basements Solutions, of New England, LLC (the contractor) hereby submits this proposal to sell and install the Basement Living System and related items as described herein at the residential premises set forth below. This proposal shall not become a binding commitment until it has been signed by both the Contractor and the Customer. Contractor: Date: Liquacoat, Inc d/b/a Affordable Basements Solutions, of New England, LLC ^1 48 Main Street, Plantsville, CT 06479 lephone # 800-738-3387 860=620-0014 Fax: 860-620-0182 ederal Tax ID # 20 - 8881017 Mass. Home Improvement Contractor Reg. # 153747 CT HIC # 600725 Customer: Customer � Street Addr City, State, Telephone This is a contract between the Contractor and the above named Customer to sell and install the Basement Living System and related items specified herein at the Customer's residential premises identified above. Scope of Work: All Sketches and/or specification sheets must be attached ! Are sheets attached? ( es-() No *All attachments are incorporated into and b om a p rt of this cit Description of Work/Specifications: S W a 'i+ ,\ � v / 11t u 1'c', L k) 40-3 dru.iWA. SYN,G K W k S h A1— - Th —Awork schedule is a roximate and sub'ect to Phan e) ,�. rl"^+ e I " or c e u e. ( e prop pp � g Approximate Start Date: -0d5'iApproximate Completion Date: 6L>u Contract Price: Total Contract Price: $ Deposit With Order: $ Z�(y S ( ) Cash heck # LA Balance Due: $-T 1. Terms: (ash O Finance (Cash terms are 10% deposit, 10% at tech measure, 50% on commencement, 20% end first week, 10% final) Due At: $ (Measure) $ I C} �'� (Start) $—(Ist week) $`� �' ' (Final) DO NOT SIGN THIS CONTRACT UNTIL ALL APPLICABLE BLANKS ARE COMPLETELY FILLED IN AND UNTIL YOU FIRST READ AND UNDERSTAND THE ENTIRE CONTRACT, INCLUDING ANY ADDENDUM ATTACHED HERETO, AS WELL AS ANY ATTACHED SKETCHES, MATERIAL LISTS OR THE LIKE, AND THE TERMS AND CONDITIONS ON THE BACK OF THIS CONTRACT DOCUMENT. YOU ARE ENTITLED TO A COMPLETE, FULLY EXECUTED COPY OF THIS CONTRACT AT THE TIME OF EXECUTION. Witness our hand(s) and seal(s) below on this day of IV Contrac Autho ' Repr tat e: L� Signature,and Title Custbmer*** F /✓,L/� 1/41. G CL Customer Signature Custom r Signature I Contractor.may have certain lien rights in the premises until the price is paid in full. You have the right to cancel this contract, without any penalty or obligation, at any time prior to midnight of the third business day after the date you signed this contract. (Sat. Inc) See the notice of cancellation for an explanation of this right. ***Customer acknowledges receipt of a true copy of this contract which was completely filled in prior to customer's execution hereof. Affordable Basements --- White Copy Homeowner --- Pink Copy Quality Control Manager -- Yellow Copy TERMS and CONDITIONS GENERAL DESCRIPTION: By this contract, Customer agrees to purchase and Contractor agrees to sell and install the Basement Living System and related items identified on the first page of this contract in the above identified premises, for the stated total contract price and according to the specifications and other provisions of the contract documents including (a) this contract form, (b) the Addendum, if and to the extent applicable, (c) any attached sketches, materials lists, floor plans, and/or specification sheets. SCOPE OF WORK: Contractor shall be responsible to Customer to supply the Basement Living System and related products and for the performance of the installation services as required by the contract. All drywall, wood or other paintable surfaces shall be primed and ready for final touch up and paint. Painting, staining or decorating are not a part of this contract unless otherwise noted. PRICE: The Price owed by the Customer is a lump -sum, tum key price, covering the Basement Living System and the labor necessary to install it. The Price assumes sound existing substructures, superstructures and points of attachments. The Price shall not include the cost and reasonable profit, as determined by contractor, of having to provide (1) additional products or installation services as a result of defective substructures, superstructures, or points of attachments, and (2) any additional goods or installation services beyond those originally specified in the contract which are requested or approved by the Customer and reflected in a change order signed by the customer and the contractor. PAYMENT: Payment of the price by Customer is due in full upon the terms set forth in this contract, but in no event later than completion of the work. In the event that the Contractor declares the project completed but the customer still has some reasonable "punch -list" items, it is agreed that the Customer may be entitled to withhold 5% of the total contract price until such items are completed. ENTIRE AGREEMENT/CHANGES: This contract accurately states the entire agreement between Customer and Contractor concerning the Basement System and the work. This replaces and supersedes all prior agreements and understandings relating thereto, both oral and written. Any additions or changes to this contract must be in writing signed by both the Customer and the Contractor. WARRANTY: Customer will receive the product warranty provided by the manufacturer for the Basement System as well as any other product warranties provided by a manufacturer of other goods and/or products comprising as part of the Basement System installed under this contract. Contractor will provide Customer with any such manufacturer consumer warranty information. Contractor warrants that the work will be performed by Contractor in a workmanlike manner. Contractor's warranty for the work shall extend for a period of two (2) years from the date the work was completed or for such greater period as may be required by applicable law governing consumer warranties for workmanship. Customer must give Contractor written notice within the warranty period of any warranty claim relating to the work. Customer agrees that its sole and exclusive remedy against Contractor for a period of any warranty claim is for installation in a good and workmanlike manner, including the repair or replacement of any goods or product if and to the extent reasonably necessary to correct the defective work. Customer shall have no other remedy against Contractor for a Warranty Claim, including without limitation remedy for toss or damage caused by normal wear and tear, loss or damage which has not been reasonably mitigated, loss or damage caused by intentional or negligent acts, loss or damage caused by acts of God, incidental or consequential damages for lost profits, sales, injuries to persons or property, or any other incidental or consequential damages. LICENSES, PERMITS, CODES, ORDINANCES AND OTHER LAWS: Contractor will be responsible to Customer for assuring that any and all licenses and/or building permits are obtained. If Customer obtains permits on his own, Customer will be precluded from claiming against certain state guaranty funds relating to home improvements. Contractor shall also be responsible to Customer that the contract shall be performed in compliance with all applicable safety rules and all existing building codes, ordinances and other laws. If a change occurs to any applicable safety rule, building code, ordinance or other law which required additional goods, products or installation services to perform the contract, Customer agrees to pay the cost and reasonable profit for such additional items and to execute a resulting change order or new replacement Contract as requested by Contractor. CUSTOMER'S WARRANTY AGAINST VIOLATION OF THIRD PARTY RIGHTS, EASEMENTS OR COVENANTS: Customer warrants that performance of this contract by Contractor will not violate any existing real property easements, covenants, or rights of third parties holding an interest in the real property being improved. UNDISCLOSED CONDITIONS IN PREMISES: Customer represents and warrants that any defect or weakness in premises' structure, substructure, superstructure or points of attachment that might affect performance by Contractor has been specifically and fully disclosed and described in this contract. If any undisclosed defect or weakness is later discovered after performance of this contract has commenced and such defect or weakness makes additional goods, products or installation services necessary, Customer agrees to pay the cost and reasonable profit for such additional items and to execute a resulting change order or new replacement contract as requested by Contractor. ARBITRATION: Any and all disputes or claims between Customer and Contractor arising from this contract that cannot be resolved informally, shall be resolved by binding arbitration, conducted by one arbitrator under the auspices, rules and procedures of the American Arbitration Association. This arbitration shall be held in the city or county where the premises are located or in such other location mutually agreed upon. No discovery shall be allowed except as may be agreed to in writing by the parties. Either party may demand arbitration. Arbitrator's final award shall be issued within ninety (90) days after the service of the arbitration demand on the other party. It is agreed that all arbitration costs shall be borne by the party that does not prevail. REMEDY FOR BREACH: If Customer breaches this contract, Contractor shall be entitled to recover the greater of liquidated damages in the amount of 20% of the total contract price or such actual damages as the contractor may prove. Also, if Customer fails to pay the total price in accordance with this contract, Contractor shall be entitled to recover its legal costs, including reasonable attorney's fees, in connection with arbitrating, obtaining judgment on an arbitration award, or otherwise pursuing Customer for collection. In the event that the Contractor cancels this contract, a written notice will be sent within 30 days of contract date and all deposits or monies on account will be promptly refunded to the Customer. UNAVOIDABLE DELAY OR FAILURE IN PERFORMANCE EXCUSED: Any delay or failure by Contractor in performing this contract because of strike, fire, floods, acts of God, inability to obtain goods, or any other causes beyond the reasonable control of the Contractor shall be excused and shall not be breaches of this contract. MISCELLANEOUS: The contract shall be Interpreted under and governed by the law of the state where the premises are located, without reference to its choice of law provisions. If any provision of this contract is contrary to any law to which it is subject, such lawful provision shall be ineffective without invalidating the other provisions which shall remain in full force and affect. All home improvement contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director, Home Improvement Contractor Registration One Ashburton Place, Room 1301 Boston, MA 02108 Tel. (617) 727-8598 MOLD RESISTANCE: Customer acknowledges that although the Basement Finishing Components are designed to resist the development of mold, they are not capable of preventing mold if the conditions for mold growth otherwise exist in the basement. Customer further understands that viflually all basements require dehumidification in order to maintain an appropriate humidity level, and that a failure to dehumidify could result in mold or mildew development in the completed area and upon the contents. By initialing here customer acjt edges that they have reviewed and understand the terms and conditions of this contract. Customer1 . Customer _�; 7116/200B 1:44 PN FROM: Petruzelo Petruzelo To: 1-960-62n-n1R7 PAaF: nn? AF n01 �, CERTIFICATE OF LIABILITY INSURANCE of/16/2008 PRODUCER (203) 269-3551 FAX (203) 269-7588 Pet ruzel o Insurance Agency, Inc. 4 Research Parkway P.O. Box 5050 Wallingford, CT 06492-7550 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIL # INSURED Liquacoat, Inc PO BOX 434 MILLDALE, CT 06467 INSIRERA National Grange Mutual Ins. 14788 INsmmB: Acadia Insurance Co. INSIRERC: INSURER D: INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE 07/07/2008 POLICY EXPIRATION UMTS GENERAL LIABILITY M5597060 07/07/2009 EAcHocamENCE S ODO COMMERCIAL GENERAL LIABILITY OHMAGE TO RENTEID S SOO , O CLAIMS AMIDE El OCCUR MED DIP (Any ane Person) $ 10,00( A PERSONAL a ADV wJURY S 2,000,00( GENERAL AGGREGATE $ 4,000,00( GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COApIOP AGG $ 4. ON, OO POLICY JMEC LOC AUTOMOBILE LIABILITY ANY AUTO 61597060 07/07/2008 07/O7/2009 COMBINED SINGLE LIMIT (Ee eccidart) $ 1,000, ON BODILY INJURY $ (Per Per ) A ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY $ (Per ft-ddwt) HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE _ (Per eccidert) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER TRWEA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITYCLJS97060 OCCUR FICLAMS MADE 07/07/2008 07/07/2009 EACH ocojwNCE $ 1.000,000 AGGREGATE $ A $ $ HDEDUCTIBLE X RETENTION $ 10 ,000 $ WORKERS COMPENSATION AND WC STATUL OTH- TORY I IMITS FR EMPLOYERS' LIABILrTY E.L. EACH ACCIDENT $ ANY PROPRIETOWPARTNER/h7EClJTIVE OFFICER/MEMBER D(C.UDEO? I yes. describe under E.L. DISEASE - EAEMPLOYEE1 S E.L. DISEASE - POLICY LIMIT I S SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS) VEMCLES 1 EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAL 10 DAYS WRITTEN NOTICE To THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABLRY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATNES. AUTHORIZED REPRESENTATIVE -- n /9 - ACORD 25 (2001/08) UACORD CORPORATION 1988 SCOPE OF WORK FOR Daniel & Joan Takasian 198 Dale Street N. Andover, MA 01845 978-688-1354 BUILD WALLS WHERE NOTED: 1. PRESSURE TREATED SHOE 2. METAL STUDS 3. MOLD FREE DRYWALL: (BLUE BOARD) PUT IN DROP CEILING: 450 sq. ft need grid & ceiling tiles ELECTRICAL: 1. 19 RECESS LIGHTS 2. 10 OUTLETS ON NEW WALL 3. 3 DIMMERS 4. 1 CABLE JACKS 5. 2 SMOKE DETECTOR 6. 1 SWITCH 7. 1 Telephone Jack 8. Circuit breaker of Sub Panel (if necessary) HEADER & COLUMNS: 1. WINDOWS & DOORS: PANELS: CEILING: 1. INSTALL 4 WINDOWS AND TRIM OUT AS SPECIFIED 2. ONE (1) NEW DOOR 1. INSTALL 43 (4'x8') R-13.8 PANELS ON OUTSIDE WALLS 1. CEILING HEIGHT 7'2" CARPET: INSTALL BERBER CARPET ON FLOOR, LANDING & STAIRS BLUE BOARD: 22 LINEAR FEET OF BLUE BOARD (6) ADDENDUM TO PERMIT APPLICATION OWNER AUTHORIZATION FOR AGENT OR CONTRACTOR: I,___ _�._ n k_ _ _ _IaKc,� c , as owner of the subject property hereby authorize Liquacoat, Inc. to act on my behalf, in all matters relative to work authorized by this building_ permit application. As owner of the subject property located at I further acknowledge and accept the Town of auth rity inspect the work pe ormed by the agent/contractor. Sidra ure -of Owner Date TO BE PART OF THE PERMIT APPLICATION WORKERS CO MPEN 3ATION AND EMPLOYERS LIALILI I Y INZiUKHtVT,#G rvLf'* r Asi$cy POLICY NO. AWC 70i24b20920t1tf i SCR NO. I AWC 7012452012007 - if !i YiF �-1 ai v= � iv�}f y1 f�tL'—` £i:[!�i_�1i4F? d�FHzf ]•!� x:F. Mailing Address: 25 Cheryl Drive ® Indw dua€ ❑ PertnerMp © CWPW--bm 0 O#w (11her woflctsltce* not shown abate: ct_-yi_3-Cr Mate Z� case EEIN 01-4662425 2 The Odic`, - - -- - --- .. _ 3. A. Worker - MA S. Employers UabiUty Insurer.: Part T%v of the policy applies to wnrFlc in ea&, star = The Umits of our i€Mityunder Part Two are: 80d Iy ir4uty by Amort $ ! , q20, 00 G ead4accident Bodily "urybyDisease S 1, 000, 000 poficyfimit Bodily Injury by Disease Y — _ - a+ -F _ yF each employee 1, Other States Insurance: Covera Repla*d Day Endoresnent 2t) 43 06F D. This poky €ndudes gwee, endorsenvmts and schedules: SEE SCHEDULE 4. The pnffn€um for this pdt y wiH be determined by our Manuals of Rules, Class€Frcafions. Rates and Rating mans. eti ;*,wmatinn reau€red below is subled to vGdfcat€on and gangs by eucrd' Classifications _ - - - _ clede• TtAW;."Asi G ArjwW rdu. Re1wneraH o Rennaleratim Plasmon • t INTRA 058573 Si=t +ONOF INFO tATICN PAGE I Minimum premium $ 600.00 Totes Lwnjawo prlrnlai r'iernlum a .,,,,.v., iF be sit Premium $ 5-15.00 As lndiCateds lilt6nTri adjustiElrris Of 'i5srrtiiluin SI`•.3Fa vc, made'D` [� Annually Q Semi Annually ❑ Quar" El Morrthly MJ'S P#SsewsYfil�rti C119. �- 07JIX 0 Th -.,S poUcy, €nduding an end=--ernsnts, €s t' --"Y cGLF.lt P d by GOV GOV KIND? Qi ACJfHJG. C AIM , NAME , SAFE tY STATE CLASS AUDIT OFFIGF- OFF -ICE t;ii�at � GfiUW F Atlantic irl�rasrce tit�tap T01 Agency Inc MA 5403 -- 530 Adams Sires WC 0D 00 01 A (11-88) Milton, MA 02185 lnd d. mpyF «i Fi lttisl of the Cia>iGn al CMA -XU m u=*wthiwPss =- MUTUAL POLICY CONDITIONS ENDORSEMENT MASSACHUSETTS WORKERS COMPENSATION ASSIGNED RISK POOL This policy is issued by Associated Industries of Massachusetts Mutual Insurance Company as a designated insurance carrier of the Massachusetts Workers Compensation Assigned Risk Pool. The Massachusetts Workers Compensation Assigned Risk Pool was created by statute to provide a means for Massachusetts employers who could not obtain coverage in the voluntary market to satisfy their obligations under Massachusetts General Law (M.G.L.) Chapter 152. The Workers Compensation Rating and Inspection Bureau of Massachusetts has been designated by the Commissioner of Insurance, in accordance with Sections 65A and 65C of M.G.L. Chapter 152, to administer the Pool. This policy is issued utilizing forms and in consideration of premiums, additional fees (if any) and charges as prescribed by the Pool Administrator and approved by the Commonwealth of Massachusetts. It is understood and agreed that the "Mutual Policy Conditions" of this policy jacket are amended as follows: MUTUAL POLICY CONDITIONS THIS POLICY IS NON -ASSESSABLE. NO PERSON OR ORGANIZATION WHICH IS AN INSURED NAMED IN THIS POLICY SHALL BE A MEMBER OF THE ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY (THE CORPORATION) OR BE ENTITLED TO ANY OF THE RIGHTS OR BENEFITS OF MEMBERSHIP IN THE CORPORATION. SUCH INSURED ALSO NEED NOT BE A MEMBER IN GOOD STANDING OF ASSOCIATED INDUSTRIES OF MASSACHUSETTS. IN WITNESS WHEREOF, the issuing Company has caused this policy to be signed by its president at Burlington, Massachusetts, and countersigned on the Information Page by a duly authorized representative of the Company. This endorsement is attacMd to the PMWY more = www arw w -- --' -....o ..o.n .,R.... .....__. _..-- - - -----• - at the address of the Insured as described in the information page. Policy No. Group Expiration Date of Policy Effective Date of Endorsemen AWC 7012452012008 03/21/2103/21/2008 ditional Premium Issued to r Paul J 9 Toole dba Milltown Contracting ISSUED BY: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY Authorized Representative AIM -2 6/ 96 RA KT0C: m ocuz> DOtn0 �rD M nwm--I *O o Fn -n rn D .p N rn 4 r r n Elg as EL � a H L1. (A Q A r H C a. c T m e ❑A w CrJ a. 3 t V to 0Is x o E 0 o IT A aro m a A a iyllllilkllitl� II��I�� -c�min��'ullUl. � y �.I11118U��lilllllfi��� `t o CCD 0 0 p O " cn O O �:F'` C 0 ru C O (q. cn 5 CD cn cn CCD o. pd N 5 ^�^� CD M m 7r? pip W C f-+• e-* fl; -I fl, �-+ ►j o D o �+ . cnn0i � a iv r -4 �•�' O 01 cr V co n 0 1010 G) 0 c Cl N ' The Commonwealth of Massachusetts Department of Industrial Accidents Offwe ofInvestigadons 600 Washlingion Street Boston, MA 02111 www mas&gov1dia. Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciam Plumbers pRUSAMi Information Please Print Leebly Name (Buss ims/omnizatontbdividuat): / ,2Z (97DOle Address:_ City/State/zip: aW 4; Phone #: ��% 4 l • F-111 Are you an employer? Check the appropriate box: 1.0 I am a employer wig 4. - ❑ I am a general contractor. and I employees (fix and/or part time)." have hired the sub-cauhract ns 2. ❑ I am a sole proprietor or partner-. listed on the attached sheet # . ship and lave no employees These sub -Contactors have working far me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I sm a homeowner doing all work right of exemption per MGL myself [No workers' comp. c. 152, j1(4), and we have no insurance required J # employees. [No worlocrs' comp. insurance required.] Type of projed(regnired): 6. ❑ New conshucticm 7. ❑ Remodeft 8. [] Demolition 9. ❑ Binding addition -1 BE Electricalrepairs or additions 11:0 Plumbinglepairs or additions 12.❑ Roof repairs 13 Other Ag', 94 `Any applicant that dteeks bmc #1 must also fill out the section below showing their workers' compensation policy information. t Fiotneowness who acbadt this affidavit indicating they ate doing all work and finer him outside couftactors trust submit anew aff&m indicating such. #Commcfots that dmk this box must atteched.an additional sheet showing the namo of fie sub-coaftaetots and 6w workers' comppolicy mfnniahm I am an employer that is providing workers' compensation insurance for my employeex Below is the policy and job rite information. Insurance Company i q Policy # or Self ins. Lic. 4zj2 ?fit .-O?,QOUrr- Expiration Date: •1� l ob Site Address: �y �i9/� ��_ City/State/Zip:,� i/t!,�i9 D ft�yr Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Fails re to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of m molal penalties of a fine up to $1,500.00 and/or one-year imprisomomnt, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00a day against the violator. Be.advised.that a copy of this statement maybe forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do hereby cert& ujukr the pains ana s ofpedury liar the information provided above is truepid correct Official use only. Do not -write in this area, to be completed by city or town ofju *WL Town: PermitUcense # issuing AnthWRY�2.uilding k-o1. Board of BDeparfxnent City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person• Phone#: �te �Jt/19tOOZGffe L . Board of Building Regulations and Standards HOME IMPROVEMENT CONTRAC IyOR Registration: 123626 Expiration: 3119/2009 Tr# 127254 Type: individual Paul J. O"foole - Paul O'Toole 25 CHERYL DR. MILTON, MA 02186 Administrator ✓tie TOayst��tonule� �`�[`"""'"""'�� BOARD OF BUILDING REGULATIONS Ucense: CONSTRUCTION SUPERVISOR Number. CS 078157 Birthdatb: 10/30/1968 Expires: 10/.3012008 Tr. no: 3228.0 Restricted: 00 PAUL) OTOOIF CHERYL 25 CHERYL DR MILTON, MA 02186 Commissioner