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Home My WebLink AboutBuilding Permit #625-2016 - 21 ASH STREET 11/19/2015SC,gwwED 11-,P3-/.S— BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION a Permit NO. too.Date Received r � '11,9 Rareo ►,�'� Date Issued: l I `"„s� IMPORTANT: Applicant must complete all items on this page LOCATION rint PROPERTY OWNER n I a V) Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village ye no V TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential I New Building I One family ❑ Addition ❑ Two or more family ❑ Industrial R-kiteration No. of units: I I Commercial epair, replacement ❑ Assessory Bldg ❑ Others: emolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands E Watershed District ❑ Water/Sewer Vc01 ON 0 Identification Please Type or Print Clearly) OWNER: Name: ` 11 P one' q%,, ,,d) U Address: CONTRACTOR Name: Phone: I ' 2,6 Address: l '� Supervisor'sConstruction Home Improvement License: Exp. Date: -, l ExD. Date. ARCH ITECT/ENGINEER _ V'C Phone: Address: Reg. No. ,(.0-41k�o FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 50, J FEE: $ Q. Check No.: Receipt No.: b NOTE: Persons contracting 'th unregistered contractors do not have access to guaranty fund Y Signature of Agen Owner Signature of contractor F I BUILDING PERMIT TOWN OF NORTH ANDOVER a APPLICATION FOR PLAN EXAMINATION Permit No#: r�At'A �SSIIP_fi' Date Received IMPORTANT: ADDlicant must complete all items on this bane ®�gtLED �646RIo� fPRO REERWRY��®1NNERd� Print3 s100,71ear�S ruct'ur � � Eyes+�[nom EMAP�PARCE'L- _ ZONING _D)STRI0T:_-, »_-4v� or€icIDistrict lyes nod 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 �4 Septics : UVe j ,loodpla'in0 �D Wetlands: ®s Waters ied Distncf++, (®W#ater/„Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly �ContractorINameJP,h7on:a Phone: ' �Su erisor�s Const"ructio_n�ILicense _ _ �Ex ti ate a ARCHITECT/ENGINEER Address: Phone: 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: $ e Check No.: Receipt No.: NOTE: ` Pey§ons contracting with unregistered contractors do not leave access to the guaranty fund Signaturexof>Agent/Ovvner rt; Signature:ofcontractor_�'�,,a�� . �a Location �� 1 45" I en No.vz,5 -2-o � ItA I Check # \ -51 L�-_; 2c*, 7b2 DatelA �)l Cl TOWN OF NORTH ANDOVER Certificate of Occupancy $- � Building/Frame Permit Fee siaw--l- Foundation Permit Fee $ Other Permit Fee TOTAL $ Building Inspector Plans Submitted ❑ Plans Waived.❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL a Public Sewer ❑ Tanning/Massage/Body Art ❑ swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE -FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS Reviewed On Signature. CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS L 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: —Located 384 Osgood Street Temp®umpster��ontsite VIM"—ENfS � t . 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 ®ANGER ZONE LITERATURE: yes MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine No Doc.Building Penroit 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 JOTS: 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/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 IOTE: 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 TOTE: 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 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ '550,000.00 m $ - $ 600.00 Plumbing Fee $ 75.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 75.00 Total fees collected $ 850.00 21 Ash Street 625-2016 on 11/19/2015 Kitchen Remodel v N 0 p n Z N D oo� �- N -� O vCD Q� M cr (D CD o CD a QO CD N- C� C � v U) o 0 o r-lok o CD0 CD 0 9 m X cn Z 0 7 _ r N=�<m O CD �: 0 O n • CD m o = -c Z G S S -a N _ICOO O O N .�+ CD N' M = W CD y r' Ln N =• �D (D : O 2 O Q 2) C O �• C 0 (O to O U)• O O 0 C1 CD N •O = +� Q p o CD 0 a y >n� = 0 < C v, O < O O rL CD7 2) < rt �D S CLN :F ND + O O .�� GAN, •� O 0 --w 5.0 o n -r Ir e•r r•f ' T n� O O G :x CD CD i r. - ��, `? CD 0 Ch � rt D CD C CD ' O su SU'; su O CL V� 3 O (D rY fD •�-' co fD T m $ Z -I 3 Dl c 3 D ZD N N0 < N c S m m M 0 z 7 N 0 c S C W GG) M m O � Dl S 7 O S C Q- O C C 0 m 0 D r' n m 3 O � 3 � O D O T D _ 4E 6*a 0 c o ®o ® McCormick Kitchens 1161 Broadway Saugus, MA 11906 (781) 231-4200 Fax (781).231-4270 www.mccormick-kitchens.com TO: ROBIN COLOMBOSIAN 21 ASH STREET NORTH ANDOVER MA 01845 PAGE 1/3 vU � I.rTw uv Chw� r3 R r � PHONE DATE 9/17/2015 JOB NAME / LOCATION (C) 978.604.0870 JOB NUMBER JOB PHONE MCCORMICK KITCHENS IS FULLY LICENSED AND INSURED: COMMONWEALTH OF MASSACHUSETTS HOME IMPROVEMENT CONTRACTOR REGISTRATION #: 131725 MASSACHUSETTS DEPARTMENT OF PUBLIC SAFETY LICENSE NUMBER: 51304 JOB START DATE: 11.23.15 1 JOB COMPLETION DATE: 01.29.16* *INSPECTIONS/PERMIT SIGN OFFS MAY EFFECT COMPLETION DATE* MCCORMICK KITCHENS TO DEMO EXISTING KITCHEN CABINETRY AND COUNTERTOPS AND PREP FOR NEW. MCCORMICK KITCHENS TO REMOVE EXISTING FLOORING IN EXISTING KITCHEN AREA AND PREP FOR HARDWOOD. MCCORMICK KITCHENS TO 04 S -VA ,l CGLtt-i'"rr -to Pi2za+�>E HARDWOOD FLOORING IN KITCHEN ONLY. CLIENT TO SAND/POLY KITCHEN FLOORING ONCE KITCHEN PROJECT IS COMPLETE. MCCORMICK KITCHENS TO REMOVE EXISTING SOFFIT ABOVE EXISTING CABIENTRY. MCCORMICK KITCHENS TO REMOVE PARTIAL WALL THAT IS COMING DOWN FROM THE CEILING WHERE THE FRIDGE IS LOCATED AND PATCH AS NECESSARY. MCCORMICK KITCHENS TO GO OVER EXISTING CEILING WITH BLUEBOARD AND PLASTER WITH SMOOTH FINISH. CLIENT'S PAINTER RESPONSIBLE FOR PREPPING FOR PAINT AND PAINTING. MCCORMICK KITCHENS TO REMOVE ANY RELATED DEBRIS FROM SITE. MCCORMICK KITCHENS TO PURCHASE, DELIVER AND INSTALL MEDALLION GOLD KITCHEN CABINETS AS DESCRIBED BELOW AND SHOWN ON PRINTS. MAKE seF- PPngE:— :;a ,� tr WOOD t, r, MLDGS Cust. Office FM 0 � 0 0 DOOR '5�- RAC -r- "3 STAIN ACCESS Cust. Office FM 0 WE PROPOSE hereby to furnish material and labor— complete in accordance with the above specifications, for the sum of: dollars ($ ). Payment to be made as follows: SEE PAYMENT SCHEDULE ON PAGE 3 All material is guaranteed to be as specified. All work to be completed in a professional qW,-1 manner according to standard practices. Any alteration or deviation from above specifications Authorized 1 i 15 involving extra costs will be executed only upon written orders, and will become an extra Signature _ charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Comer to carry fire, tornado, and other necessary insurance. Our Note: This proposal may b workers are fully covered by Workers Compensation insurance. withdrawn by s if not accept ithi days. ACCEPTANCE OF PROPOSAL —The above prices, 1 ` r _ l specifications and Conditions are satisfactory and are hereby accepted. You are Signature authorized to do the work as specified. Payment will be made as outlined above. Signature Date of Acceptance: ®v ® McCormick Kitchens 1161 Broadway Saugus., MA b1906 (781) 231-4200 Fax (781) 231-4270 www.mccormick-kitchens.com TO: ROBIN COLOMBOSIAN 21 ASH STREET NORTH ANDOVER MA 01845 PAGE 2/3 PHONE JOB NAME / LOCATION (C) 978.604.0870 JOB NUMBER DATE 9/17/2015 JOB PHONE MCCORMICK MCCORMICK KITCHENS TO PURCHASE & INSTALL CAMBRIA QUARTZ COUNTERTOPS WITH ONE OF THE (3) STANDARD NON-UPCHARGE EDGES NOTED IN CONTRACT PACKAGE. IF COUNTERTOP MATERIAL (OR) EDGE IS UPGRADED, ADDITIONAL CHARGES WILL APPLY. MCCORMICK KITCHENS INSTALL TILE BACKSPLASH. ALL TILE BACKSPLASH MATERIALS TO BE PROVIDED BY CLIENT AND ARE TO BE ON SITE WHEN COUNTERTOP IS INSTALLED. PLUMBING: MCCORMICK KITCHENS TO PLUMB KITCHEN TO CODE. MCCORMICK KITCHENS TO DISCONNECT, RELOCATE & RECONNECT SINK, DISHWASHER, FAUCET, RUN WATER LINE TO REFRIGERATOR, & DISCONNECT AND RECONNECT GAS LINE TO CAnfGE . MCCORMICK KITCHENS TO REPLACE EXISTING TOE KICK HEATER WITH A NEW ONE UNDER SINK BASE. ELECTRICAL: MCCORMICK KITCHENS TO WIRE KITCHEN TO CODE. MCCORMICK KITCHENS TO PURCHASE AND INSTALL (7) RECESS LIGHTS, PURCHASE AND INSTALL (6) UNDER CABINET LIGHTS, PURCHASE AND INSTALL (3) INTERIOR CABINET LIGHTS, AND INSTALL PENDANT LIGHTS/FIXTURE(S) ABOVE ISLAND (CLIENT TO PROVIDE). MCCORMICK KITCHENS TO INSTALL ALL APPLIANCES. :�7 NE:NT" 0-000 MAKE s4EiiE PRC,e 3 WOOD MLDGS. COSI. Office FM u DOOR seF -5 STAIN ACCESS Cust. Office FM 0 � 0 WE PROPOSE hereby to furnish material and labor —complete in accordance with the above specifications, for the sum of: dollars ($ 1. Payment to be made as follows: SEE PAYMENT SCHEDULE ON PAGE 3 All material is guaranteed to be as specified. All work to be completed in a professional manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado, and other necessary insurance. Our workers are fully covered by Workers Compensation insurance. Authorized Signature Note: This proposal may withdrawn by us..i`ot accepted wit ACCEPTANCE OF PROPOSAL —The above prices, specifications and conditions are satisfactory and are hereby accepted. You are Signature authorized to do the work as specified. Payment will be made as outlined above. Signature Date of Acceptance: 9/f -1 -SIS days. ®o ® McCormick Kitchens 1161 Broadway Saugusi, MA b1906 (781) 231-4200 Fax (781),231-4270 www.mccormick-kitchens.com TO: ROBIN COLOMBOSIAN 21 ASH STREET NORTH ANDOVER MA 01845 PAGE 3/3 PHONE JOB NAME / LOCATION (C) 978.604.0870 JOB NUMBER DATE 9/17/2015 JOB PHONE MCCORMICK KITCHENS TO PROVIDE (1) FREE STAINLESS STEEL UNDERMOUNT AMERISINK AS125 SINK, AND FREE BRUSH NICKEL STOCK KNOBS. IF CLIENT OPTS FOR DIFFERENT SINK OR KNOBS, ADDITIONAL CHARGES TO APPLY. MCCORMICK KITCHENS IS NOT RESPONSIBLE FOR: PURCHASING OF APPLIANCES, HVAC, PURCHASING OF SPECIALTY LIGHTS OR SWITCHES, REMOVING OF WALLPAPER, PAINTING, PURCHASING OF BACKSPLASH, PURCHASING OF SINK OR FAUCET, FINISHING (SANDING/POLY) OF HARDWOOD FLOORING, OR PERMIT FEES. *** ALL PAYMENTS MUST BE RECEIVED IN THE ORDER LISTED BELOW. *** PAYMENT SCHEDULE: $14,000 DEPOSIT, $8,000 DUE UPON START, $10,000 DUE UPON DELIVERY OF CABINETRY TO MCCORMICK KITCHENS, $6,000 DUE UPON ROUGH ELECTRICAL/PLUMBING, $6,000 DUE UPON FLOOR INSTALL BEING COMPLETE, $I,'�;00 DUE UPON COUNTER TOP TEMPLATE, $2,500 DUE UPON COUNTER TOP INSTALL, $1, CX)O DUE UPON COMPLETION C.tISt. Office MAKE MQAu.+oQ WOOD V"AP— 0 MLDGS. -M, P531), MaQcrzi,,� Ro Cust. Office DOOR j?Are14 (FP) Q S4AIN btvi-111 6"S -5-u. PA11T_ ACCESS nur biv,o,F_rL 1 t WE PROPOSE hereby to furnish material and labor — complete in accordance with the above specifications, for the sum of: Fifty DOLT-Aw—S A 00/100 Dollars 50, UNCI. 00 dollars ($ ). Payment to be made as follows: SEE PAYMENT SCHEDULE ABOVE All material is guaranteed to be as specified. All work to be completed in a professional manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado, and other necessary insurance. Our workers are fully covered by Workers Compensation insurance. ACCEPTANCE OF PROPOSAL —The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Authorized Signature Note: This proposal may be withdrawn by u not cc' pted within Signature Signature Date of Acceptance: `i Ifs-I,s days. 5. - MAKE WOOD NILDGS Ordcrcd by Ackn. Ckd Final d. by m Tk, P550, 0)12 o ca."► �L DOOR PAaw- PLAN FP� REC- STAM b(fJ NtrY C.Rss+C, PPnN-` Fe cl z ACCESS. c -T ACOR0 CERTIFICATE OF LIABILITY INSURANCE DATE(MMroDrvYYY) moi. 5/29/2015 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 CONTACT Amanda Stricos NAME: TGA CLO3S Insurance, Inc. PHONE FAX E.). (781) 914-1000 . yVC No): (781)224-5777 401 Edgewater Place ADDRESS: astricos@ tgacross. com Shite 220 INSURERS) AFFORDING COVERAGE NAIC0 Wakefield MA 01880 INSURERA:Employer3 Mutual Ins Co I INSURED INSURERB:H-artford Accident and Indemnity Co 22357 - — -- — - McCormick Kitchens Inc. INSURER C 1161 Broadway INSURER D PERSONAL 6 ADV INJURY $ INSURER E: _ Saugus MA 01906 1 INSURER F: I COVERAGES CERTIFICATE NUMBER:CL1551538572 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 SUBRI Y EFF POLICYPOLICY EXP TYPE OF WSURANCE IADDL LTR , POLICY NUMBER M)D i LIMITS COMMERCIAL GENERAL LABILITY EACH OCCURRENCE $ 1,000,000 A CAMS -MADE X OCCUR op)i$ PREMISE ( currerKe - 100,000 SZ30150 5/1/2015 1 5/1/2016 MED EXP (Any one person) $ 5,000 i PERSONAL 6 ADV INJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE . $ 2,000,000 L POLICY; ECT ;LOC I PRODUCTS - COMPIOP AGG_$ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY CO IatxNEDidenSINGLE LIMIT $ (EaA 1,000,000 I ANY AUTO BODILY INJURY (Per person) $ALL OWNED SCHE 5/1/2015 5/1/2016 BODILYINJURY(PeraxideM) S I AUTOS AUTOS�D5230150 �X—AUIOS IX NON -OWNED PROPERTYCIAli AGEHIREDAUTOS (Per aa9aerXj._ X UMBRELLA We OCCUR I EACH OCCURRENCE $ 1,000,000 A EXCESS UAB CLAIMS -MADE I AGGREGATE $ 1,000,000 DED X RETENTON$ 0i 15J30150 5/1/2015 i 5/1/2016 $ WORKERS COMPENSATION i I PER OTH- ;STATUTE ER TY I ' AND EMPLOYERS' LIABILITY YIN! . 'ANY PROPRIETORIPARTNERIEXECUTIVE I 'i j E.L. EACH ACCIDENT $ 1,000,000 i Obridat Ik1EM8H) EXCLUDED? N I A _ B (Mandatory in NH) I OBWEC2557MM02 5/1/2015 5/1/2016 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 f Ifyes, describe under i DE RIPTION OF OPERATIONS below I - E.L. DISEASE - POLICY LIMIT $ 1,000,000 I � DESCRIPTION OF OPERATIONS) LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Thomas Gregory/SP3 C0 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101)—..___.Y-----Th—e-ACCORD name and logo are registered marks of ACORD INS025 (201401) The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 kwl Boston, MA 02114-2017 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/ContractorslElectricians/Plumbers. TO BE FILED WITH THE PERIVMING AUTHORITY. Name (Business/orgm&ation/Individuat):. Address: I i City/State/Zip: M I V Are yon employer? Chec ppropriate box: I. , I am a employer with employees (full and/or part-time).* Phone #: �L-3f-q�A 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ lam a homeowner doing all work myself [No workers' comp. insurance required.] t 4FJ I am a homeowner and will be hiring contractors to conduct all worts on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6.Q 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): 7. ❑ Ne construction 8. [.Iodeling 9. Demolition 10 ❑ Building addition I l.QYlectrical repairs or additions 12.0-P'It tubing repairs or additions 13.E] Roof repairs 14. ❑ 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. tContractors 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 Belmv is the policy and job site information. Insurance Company Name:, Policy # or Self -ins. Lie. #: �� S� ' �+ \ ly _ Expiration Date: Job Site Address: Z � L6I City/State/Zip: 0, M�prn Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance Ido hereby c�d r'the pains and enalties of perjury that the information provided above is trne�d correct c;anafinr• bare.' 1 I r 1� —is Official use only. Do not write in this area, to be completed by city or tmvn officiat City or Town: Permit/License Issuing Authority (circle one): ; 1. Board of Health 2. Building Department 3. Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: c G� n Its` ' p cn j% DOx' -(D D C d m. O )o r- m = @ =� C> rn o o —3 c� l ?;o Nal O No j 3 M >= N -4 w Cl) !� Z f� r � H CL rye ry 70 C � O O O � d O G AQ H A 1 O C% Q� c ro m A c o. > a I o G 7 1 O 9 a a A I A n d H O C Aro to C Q I O• � 7