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HomeMy WebLinkAboutBuilding Permit #051-13 - 21 EVERGREEN DRIVE 7/23/2012 NORTH BUILDING PERMIT OFtt,�o ,bgti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Zj 0cqrEo Pa``,�y �SSAc"U`-+�� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION 0_1 C cye e�ri° �_ . d, r hf tlQly- . . tint. PROPERTY 01NNER'.: u*� a t*S MAP-NQ' a ��ARCEL: ZON6ING D.ISTRICTsHistonc District yes rho= - e' _,2ys� °11/IachneShop Vtllage , ,no TYPE OF IMPROVEMENT PROPOSED USE Reside Non- Residential j New Building One famil i Addition Two or more family Industrial Alteration No. of units: Commercial ;! Repair, replacement Assessory Bldg Others: Demolition Other Sepfic ell Floodplain . Wetlands E Watersliedt®istrl`_ ` 1NateUSewery.. � x # „ DESCRIPTION OF WORK TO BE PREFORMED: , �Q V-0 of C �' CQ tr- � " Identification Please Type or Print Clearly) OWNER: Name: PCILUA Phone: 687-4.Id3 Address: ( seg- r 18 LIS-. NTRACTORT NA-ine `P ��'i ���� �- S £;.: a�S� dd CQ . r- 8 Address'.;35o a ��-�, -_�5+, l� �Q�,1pc�r Nt A .0 y� Su.pervisor's Con stDate �d Home Im rovement.License.,-�,_ }; ,...I? - f:3956?-f xp Date / 203 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 7,5-6 0.00 FEE: $ Check No.: / Dp Receipt No.: NOTE: Persons contracting with unregistered contractor's do not have access to he guaranty fund Signature of Agent/Ovvner .. f�. Signature of contractor' Location No. X50 Date e ' TOWN OF NORTH ANDOVER 4 e Certificate of Occupancy $ Building/Frame Permit Fee $ -- a Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# k, 25531Building Inspector l 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS 'i HEALTH Reviewed on Signature COMMENTS s Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments PWater & Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street fIREDEPARTMENT` `Temp Dumpster on site yesesono ',Fi 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 i4 I �I II ❑ 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 d 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 Colrlp 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 1 NORTHve" 'o- w: .. . -c No. r! ver, Mass, s3 /_-- COCNICNl WICK---_ol. 1 q�OArED S V i BOARD OF HEALTH Food/Kitchen (� Septic System k THIS CERTIFIES THAT PERF41T ..���=:�. ..... ....... ... ................. BUILDING INSPECTOR .................. ... .. ... . . ...... .......... ............ ... T ................ has permission to erect .......................... buildings on , ., v� '�' !.../.................................. Foundation Rough � to be occupied as ............... W.--. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final i 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 i VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR 1 UNLESS CONSTRUCTIONS ARTS 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 D Wall To Be Done FIRE DEPARTMENT Dry Until Inspected and: Approved by the Building Inspector. Burner Street No. r i Smoke Det. SEE REVERSE SIDE i 41It - 4" This(form satisfies all:basic requirements of the state's Home Improvement Contractor Law(MGL chapter.1412A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"a Massachusetts consumer guide to home improvement"before agreeing to any work on your residence.You may"obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8797 or 1488-283-3757. Homeowner Information Contractor Information Name omji'my Name PQu 'NI vt�s Wrt`al►f .. rk'R2M_T F Con-d uc�)10r2 StreetrAddress(do not use a Post Office Box address) ContractoW Salesperson/Owner Nafne � I �✓e:r eeh` 4An �'cd� l,�rttta��' - Cityrrown State Zip Code hisiness Address(must i Jude a street-address) Dr n' Je MA 0/Sy-5- 3HO Be-,r�ry Sf, A16rflt "ve; Mt9 0/,?(19. Daytime Phone Evening Phone .ity/Town State Zip Code x:711-'A,�B- ��7'7 q g•..b8`7-y�r�i3 '7f�-68�-��y7 Mailing Address(It different from above) Business Phone ederal Employer ID or S.S.Number Law requires that moll borne im- name vemeol Coabaetor Het.Number Expiation date prnvr tcoatraetonbavea . ' aad,egistsatios eumbe I 3 y� 6 6 9 �� �O/- . The Contractor agrees to do the following work for the Homeowner: C) I 7/ /// 3 1° mP a e, -ano,anagraticol-JUMMIsloneu 11F0 $�rrp Stz 2 Iro spl�al¢ sl.t S r'kw(QC_ W'A 30 , ti%4 " (,tx;raK 64F. 0� �s alit 0_r kJ c: ill 7_1111A berL>7e kD P c e S . ice s weer S1r, iQ en a!/tu roes v�11 a;�t,� - t "� r �� ><`as�ed a " A,c er 1 C(,,,n.ney, �rMcQ t (C2F � ,� )4-�ape,r .r�,�a G�r� lio rtiPN wth�l r2�tr, . (,ts� c(ut.•psre� �ro rid of d�b,�ls �o tees, ram 1c�tot 'u, !1 aid 2a QS W ':n _ r �. P rtrlG.'�t?✓' tS�trQ�� 0 d �D rne'•f o , a oM rocsT vP,'+ �d+ 'c� rr an l eavt?9 J7tke Required.Permits-The following building permits are required Proposed Start and Completion Schedule-The fol owing schedule will and will be secured by the contractor as the homeowners agent, be adhered to unless circumstances beyond the contractors control arise (Owners who secure their own permits will be excluded from.the Guaranty Fund provisions of ,2 /, Date when contractor will begin contracted work. MGL chapter 142A.) 17/d7//4 Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule (� The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of- t`f' 7500,00 Payments will be made according to the following schedule: $,A 000,00 upon signing contract(riot to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) S by _/_/__or upon completion of $ X4,00,, upon completion of the contract. (Law forbids demanding full payment until contract is completed to both patty's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work"begins in order S to be paid for to meet the completion schedule.(**) NOTES:(*)Including all finance charges(•*)Law requires that any deposit or down-payment required by the contractor before work begins not exceed the eater of a ane-third of the o ge may greater O total contract price or(b)the actual cost of m special y alequipment or costo Pm made material anal which must be special ordered in advance to meet the completion schedule, Exaress Warranty-Is an express warranty beige arovided by a contractor? No Yes (all terms of�g warranty mu t be attarhed to the a, ar Subcontractors; ThdVontractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontructor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement _ Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. ; • Don't be pressured into signing the contract Take time to read and fully understand it. Ask questions if something is unclear. • Mako sure the contractor has a valid Ugme Improysment Contracigr Reeistration The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvcment Contractor Registration. You may inquire about contractor registration by:writing to the Director at One Ashburton Place,Room 1301,Boston,MA 02108 or by calling 617-727-3200 or 1-800-223-0933. 'tr Does the contractor have insurance? Check to see that your contractor is properly insured. • Know your rights and responsibilities..Read the Important Information on the reverse side of this form and get a copy of the Consumer. Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed ata place other than the contractors normal place of business,provided you notify the contractor in writing"et his/her main office or branch office b 'ordinary . mai Y ry I posted,b .tele m sent or b Y firm delive third business da follows Y delivery,not Teter than ighL ht of the n .the signing g n of this Y g gn g agreement. See the attached notice of cancellation form for an explanation of this right DO NOT SIGN THIS CONTRACT IF TIEIERE ARE A_ NY.BLANIC_SP-ACAS!!!- -• --� -- - -— Two identical copies of the contract must.be completed zad signed.ane copy should 9.to the hoi awncr. The other mp y should be kept by the contractor. Homeowner's Signature ontractor's Si nature 6 1 i8Date bo, Date • r i v Contractor Arbitratin �� The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an . alternative to-court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with_a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration`as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor,may submit the dispute to a private arbitration firm which has been approved by the Secretary,of the'Executive Office of Consumer Affairs and Business Regulation and the consumer shall.be required to submit to such arbitration as provided In Massachusetts General Laws, chapter 142A. Homeowner's Signature onrat c tot's Si n NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this separately is stiction is not of signed P b th Y g e arties. . Y P _ Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer t. protection laws(i.e.MGL chapter 93A)may not be waived in-'any way, even by°agreement. However;homeowners M may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits,arer automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractorls responsible for completing the worLas described, in a titnely and workmanlike manner. Homeowners may be entitled to other specific regal rights if the contractor guarantees or provides an'express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied'warranty of merchantability and fitness for a particular purpose, An enumeration of other matters on which the hotneowner.and contractor lawfully agree may be added to the term's of the contract as long as they do not restrict a bomeowner's basic consumer rights. If you have questions about your co nsumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract ". The contract mus[be executed in d irate and should not:be signed until.a copy of all exhibits and referenced documents have been.attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner'and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of -the°contract,.and the three day recission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the 4 homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure, the contractor may require that:the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of fu signatures o rids: � f both parties. from said account P would require the Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or'tfyou wish to obtain a free copy of "A Cons Law,"contact: umer Guide.to the Home Improvement Contractor Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Bostan, MA 02116 (617)973-8787 or 1-(888)2833757 If.you want t Y o verify the registration gtstration of a contractor or if . . you have about Y questions o e contra � 9 ns or ne contractor registration component of die Home Improvement Contractor Law,lctontact,nfotmation specifically Director of Home Improvement Cont Registration tactor Re istra 'on Bureau of Building.Regulations and Standards One Ashburton Place, Room 1301,Boston, MA 02168 (617) 727-3200 or 1'-800-223-0933 For assistance with informal mediation of disputes or to register formal complaints against a business call =cs ,,. Consumer Complaint Section - Office of the Attorney General (617)727-8400 AND/OR - Better Business Bureau (508)652-4800 (508)755-2548 (413) 734-3114 j I fiu fi Oftice�&0mer airsi heAshAveg a HOME IMPROVEMENT CONTRACTOR R Registration: X138569 Type: + Expiration 4l4/-2013 DBA j T GUTTERS' z SCOTT WRIGHT .� s,i 350 BERRY ST i . NO.ANDOVER,MA`b18 5 Undersecretary •. 1 Massachusetts- Qcliar trncnt of Puhlic Safet�1 Board of Building Regulations and Standards Construction Supervisor License License: CS 102663 :'� — —= k: t krF ' Rt SCOTT WRIGHT i 350 BERRY.'$T NORTH ANDOVER,MA 01845 Ito" o-- �'�" Expiration: 8/12/2013.. C1mmissiunei Tr#` 3384 i i WRIGSC2 OP ID: MO ACORO" DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 07/19/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATEDOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 978-683-4700 CONTACT T.A.Sullivan Ins.'Agcy,Inc.. NAME: 344 S.Union St: PHONE FAX AIC No Ext): A/C No): Lawrence„MA 01843 EMAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A:Worcester Insurance Company INSURED Scott&Gma Wright INSURER B: 350 Berry St N.Andover, MA 01845 INSURER C: 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 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 - =SUER LTR TYPE OF INSURANCE POLICY EFF POLICY EXP POLICY NUMBER MMIDD MM/DD LIMITS GENERAL LIABILITY' EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY SPP0000004226L 12/01/11 12/01/12 DAMAGE TO RENTED PREMISES Ea occurrence $ 300,00 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 50,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY171,,EcT L1 PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ - $ UMBRELLA LIAB ''. OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU0TH- AND EMPLOYERS'LIABILITY YIN Y L M T- ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/M EMBEREXCLUDE1 N/A Mandato in NH (Mand. cr ) E.L. A A EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) i CERTIFICATE HOLDER CANCELLATION I -- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Paul Davis THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 21 Evergreen Dr ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 A RD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and lo4gistered marks of ACORD ' f iH.IS CERTIFICATE IS ISSUEDI ASA MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE ERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED Y THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN HE ISSUING INSURERS AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. Ln8 PORTANT: If the Certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION WAIVED, subject to the terms and conditions of the policy, certain policies may require and endorsement A statement this certificate does not confer ri hts to the certificate holder in lieu of such endorsement PRODUCER T A Sullivan Insurance Inc 344 S Union St Lawrence, MA 1843 COMPANIES AFFORDING INSURANCE INSURED COMPANY A GRANITE STATE INSURANCE COMPANY i Scott Wright 350 Berry Street North Andover,MA 01845-0000 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOT WITHSTANDING 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 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. Co LTR 1YPI OF INSURANCE POLICY NUMBER FOLICYIPPECTTVE DATE POLICY 101RATION DAT! A WORKERSCOMPENSATION ND EMPLOYERS'L LABILITY THE PROPRIETOR/ 7i- CtwerapAp�leatoMAOperdqnsOnly. S PARTNERSIMCUTIVE OFFICERSARE: INCL❑EXCL❑ 9942804 9/30/2011 9/30/2012 ATUTORY LIMITS OTHER CN ACCIDENT $ 100,00 ISEASE POLICY LIMIT $ 500,00 DEBCRIPTION,OF OPERATIONSIVEHICLl;L8//BPECIAL ITEMS ISEASE EACH EMPLOYEE 100,00( HE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR SCOTT WRIGHT CERTIFICATE HOLDER CANCELLATION PAUL DAVIS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.NOTICE WILL BE DELIVERED IN ACCORDANCE 29 EVERGREEN DR. WHTE THE POL ICY PROVISIONS. NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE 'Tilw The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly `` ,, 11 � � r r. Name (Business/Organization/Individual): W r t, 1n. (p 16 i•1 ci p 4 Address: 350 B eVrN S • City/State/Zip: /lr o4-f-k 1kc6o U' /y1A 0 iSKPhone#: 9 Y-6 87-d1Y 7 AVI an employer?Check the appropriate box: Type of project(required): 1. am a employer with oti 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ f repairs insurance required.]t employees. [No workers 13. Other ..�"�,,p c`r�ac�e troof S�►�l�Qed comp.insurance required.] , *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. II -- Insurance Company Name: V*k AP- S y u rte,,CQ C'O rn A Policy#or Self-ins.Lic.#: C19 y i eQ C/ Expiration Date: Q D Job Site Address:,)] Eyey-a cng fir- City/State/Zip:_( lam- A4 Ole S- 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. T do hereby certify der lie pains and penalties o -that the information provided above is true and correct. Sig i nature: Date: 71d�Z12— Phone 41 # 9 :2L (c62 LW 7 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.City/Town 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 Pies 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 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. g 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 bum 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 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 www.mass.gov/dia