HomeMy WebLinkAboutBuilding Permit #535-13 - 21 MOODY STREET 1/24/2013BUILDING PERMIT
TOWN OF NORTH ANDOVER ° _
APPLICATION FOR PLAN EXAMINATIOV
Permit NO:
Date Received � pA .. •
cAAT.. •'�y.(5
Date Issued:
9SSACHUS
IMPORTANT: Applicant must complete all items on this
LOCATION_ IOOV>Y �T
Print
PROPERTY OWNER -1-irn 1 �F w� MAR 1 M i
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes(no
o
Machine Shop Villaqe ves
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
XOne family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
O'Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
f I Septic f .I Well
I I Floodplain ❑ Wetlands
❑ Watershed District
X Water/Sewer
IIC,W6,M J�£MhR-) FL NEW 0A_RtWfFT-1, , �L�CTI�►c
Identification Please Type or Print Clearly)
OWNER: Name: J am -p5 6'. Phone: 5_2��l aq
Address: _
CONTRACTOR Name: Br', C-0 %0 LID Phone: CJ -7$
Address:
X1111�IAv P�_y IZD 00KTH AQ-Ln-ove_ MR o►gtis
Supervisor's Construction License: 1 oyLA.2$ Exp. Date: 1 2
Home Improvement License: WR 512
Exp. Date: 1 1 I
ARCHITECT/ENGINEER Phone:
Address: Reg. No
FEE SCHEDULE.- BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST PASED ON $125.00 PER S.F.
Total Project Cost: $ QH , S60.0(3 FEE: $ � ot/
Check No.: Receipt No.:
NOTE: Persons con with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner cur•y A4^--u—Signature of contractor.
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
HEALTH ,
n
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision:
Commen
Water & Severer Connection/Signature � Date Driveway Permit
DPW 'TowL Engineer: Signature:
FIRE DEPARTMENT _ Temp Dumpster on site yes
Located at 124 MainkStreet -
Fire Departinerit-signatureldate
COMMENTS
Located 384 Osgood Street
no
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
El Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
Building Permit Application
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Li Copy of Contract
u Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
Li Certified Surveyed Plot Plan
o Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
Li Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
o 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)
Li Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
Li 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: Doc.Building permit Revised 2012
Location
No. ?j Date
Check 7 1
26117
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $�
Foundation Permit Fee $
Other Permit Fee $
TOTAL rr $
2-(--1
Building Inspector
Enter construction cost for fee cal -
North Andover Fee Calculaf/O11
Construction Cost
$ 249860.00
m
$ -
$
298.32
Plumbing Fee
$
37,29
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
37,29
Total fees collected
$
472.90
21 Moody Street
535-13 on 1/25/2013
Kitchen Remodel, New Cabinets,
Electric and Plumbing
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�This form satisfies all basic =Tents of the state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard
language to protect hommwners� ISeelr legal advice if necessary. Any person planning home improvements should fust obtain a copy o£ "A
Ma4saehusetts Consumer U}tide to He= TmptovaueaY before agreeing to any work on your residence. You may obtain a fico copy by calling the
OffiCOOfOOWUMCrAffliliMandBicneecR� tel r ..r«� _a_.,---. V --- ----
Homeowner 10ormation Contractor Information
iTame
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CompatryName
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Street Address (do not use a Pus[ Offic1c
8ox address)
Contractor/ Salesperson/ owner Name
1 MOOby
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City/town State ' Zip Code
Business Address (must include a street address)
N vE
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DaythaePhone
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Cityfrown State Zip Code
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AN DoVrg MA
01$y j
Mailing Address (It different from abode)
Business Phone Federal Employer ID or S.S. Number
Ire mgmres amt most 6amo
'��Cowarmraeg Nun6er
api®tioo date
®piwemmtr•atrastms here
n.srd regtehane*"mnaer
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(Desraihe is detail the workto completed,, spwifying the type, brand, and guide of materials to be used, use additional sheets if necess
RMOZj�I �XIS'i�N6 kITCN ,
NEW �t-EC�:►C, 3'Lvn�81NG
Required Permits -The followi ziouilding Fem are rcgaired proposed Start and Completion Schedule -The following schedule will
and will be secured by the eontraebbi as the homeowners agent: be adhered to unless circumstances beyond the contractor's control arise
(Owners who secure their own permits will be j
excluded from the Guaranty; Fund provisions of d I Date when contractor vpill begin contracted work.
MGL chapter 142A.)
I I 1 Date when contracted workwill be substantially completed.
Total Contract Price and Paymci4Sebedule
The Contractor agrees to Petfmm the work famish the mat-1—el rah,.' e.,o,.:aea .,>,....� r_-.� _ ._._, ___ _ « J l,1 ri I A
Payments will be made according to;the following schedule:
upon signing contract (not to exceed 1/3 of thetotal contract price or the cost of special order items, whichever is greater)
$10!)00 by / !_orup. completion of 4]c)I�j�tNC t�iK'M\� AtitD (Q^IYL1F� nr�vs
by __L_/_f or upon completion of_G0.t2(N�T rW na r
$ t I 6 0 upon completioni i the contract. (Law forbids demanding full Payment until contract is completed to both party s satisfaction)
The following materiallequipmi:dtmust bespecial $ to be paid for
ordered before the contracted work begins in order
to meet the completion schedule.,(**) $ to be paid for
VOTES: («)lncluding all finance cbn gen Cts Lawragoires that any deposit or dowa-payment required by the contractor before work begins m
ay
not exceed the greater of i (a) One-third of the total contract price or (b) the actual cost of
which must be any special equipment or custom made material
special cederte in advance meet the completion schedule.
Subcontractors -The contractor t
Party/subcontractor utilized by the
materials and labor under this
Contract Acceptance - Upon sign
contract shall not imply that any h,
carefully before signing this conte
s to be solely responsible for completion ofthe wotkc .destmbed regardless ofthe actions of any third nnrrnr
tractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for
nt
this document becomes a binding contractunder law. Unless otherwise noted within this document, the
other security interest has been placed on the residence. Review the following cautions and notices
Don't be presswedinto signing the contract Take time to read and fully understand it Ask questions if something is unclear.
• Make —the contractor has alvalid Home Imarovement f2gotactor Registration. The law requires most home improvement contractors and
subcontractors to bereostered'with the Director of Home
Improvement Contractor Registration. You may inquire about contractor
registration by writing to the Dpecmr at 10 ParlcPlaza, Room 5170, Boston, MA 02116 or by catling 617-973-8787 or 888-283-3757.
* Does the contractor have msmimce? Ask the Contractor forhisinsurance company information so that you can
see a copy of a confirm coverage or ask to
` proof of insur'an'ce" document.
• Know your rights and responsibilities. Read the Important Infoimation on the reverse side ofthis form and get a copy ofthe Consumer
Guide to the Home Improvement Contractor Law.
You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the
contractor in writing at his/her mainjoffice or branch office by ordinary mail posted, by telegram sent orb delis
third business day following the sigding of this agreement See the attached notice of cancellation farm for an �' not later than midnight of the
explanation ofthis right
DO NOT SIGIjT THLS CONTRACT IF THERE ARE ANY BLANK SPACESM
Two idendcel capia offfie oonaactr®st bec..A,*d and a
@.& oro nnPYabnn)d Cn m dse ls>mew.aR- Tee e"• _ �,py rtwrd lm rapeuy am aanGnamr.
Flom er's Signature tore
wuuactu s J�
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Date Date 1 O
01/25/2013 10:33 _ 9787945409 N GREENWOOD INS PAGE 01/01
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[DD!ATE0(MMIDDIYYYY)
-' CERTIFICATE OF LIABILITY INSURANCE/0919.0-12IS
T Y IFICATE IS ISSUED ASA
VE YEOR NEGATIVELY AMENpYEXTEND OR ALTER THE OVERAGE AFFORDED 13Y THE POLICIES CIES BELOW.
CERTIFICATE DOES NOT AFF/
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
P
SE TI 0 RO C AND E TIF CA H DE
IMPORTANT: It the teottheol ers an ADDITIONAL
A I YUequlrehalld endorsement• A statemebe nt on his certificate does olt confer hright!; to
the terms and conditionspolicy,
s_ —dNislw hnid ar in lieu of Such endarsemen S . _ ____
PRODUCERONE PPROI3UCER
FAX
NANCY ORBENWOOD SMITH 1N ,IL
I HAVHR14ILL ST
#:
MpTHTJHN, MA 01844 CUSTOMER ID NAIC #
INSURERS) AFFORDING COVERAGE
726KN
INSURER A: TItAVTdLflR3 FPOPflR'CY CA•4UALTY COMPANY OF AMERICA—
INSURED INSURER B:
BRi.C,O BIJILDI14G & REMODELING} LLC INSURER C:
INSURER D:
417 WAVIIRLEY RD INS RVR E:
N ANDOVER, MA 01845 INSURER F:
REVISION NUMBER,.
;P14MAVE
VERAGES CERTIFICATE NUMBER:
' IF 7 G T O HAVE SEEN ISSUED 70 THEINSURED NAMED AgOVEFORTNEPOLICY PF,RIOD1 ICATEU,
NOTWRHSTANDINB ANY RyQI11REN{ENT, TERM OR CONDRION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WNCOICH THIS NS opIC/1TE MAYBE ISSUED SS MAY
moTWIT . TRE QNSURANCE AFFORDED BY THE POLICIES ITIONDESO 1AN HERON IS SUBJECTTOALLTRETERMS,EXCLUSION3ANDCONDRIONS OF SUCH POLICIES. LIMITS SHOWN MAY
BEEN RmUCLD RY PAID CLAIMS. IDATE
TYPE OF INSURANCE
:RAL LIABILITY
COMMERCIAL GENERAL LIABILITY
—1 CLAIMS MADE a OCCUR,
GEUL AGGREGATE LIMIT APPLIES PER:
p01_ICY M PROJECT ❑ LOC
AUTOMOBILE LIABILITY
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ALL OWNED AUTOS
SCHEDUIJ2 AUTOS
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NON -OWNED AUTOS
UMBRELLA LIAB "OCCUR
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POLICY vir-F GATE POLICY —
POLICYNUMBER I (MM MYYYY) I (MQNmDIYYYY)
LIMITS
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EXP (Any one person) $.
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A WORKER'S COMPENSATION AND UB-431OP507-12 0411912012 04/19/2013 LIMITS OTHQR
EMPLOYERS LIABILITY YIN
ANY pROPERCTORIPARTNERIEXECUnVEQ E. L. EACH ACCIDENT' $ 100 000
OFFICERrMEMBER EXCWDE09 -E. L. DISEASE - EA EMPLOYEE :$ 100,000
(MAndnlory In NH)
Irye/, descxii5n under E.L. DISEASE - POLICY LIMIT $ 500,000
DESCRIFTION OF OPERATIONS below
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/RESTRICTIONSISPECIAL ITEMS
THI3 RERt.ACBS ANY PRIOR CERTIFICATE ISSUED TO THE CUFTIFICATE I•IOLDER AFFECTINO WORKERS COMP COVIRRAOE.
TOWN OF NORTH ANDOVER
1600 OSOOOD ST
N ANDOVER, MA 01845
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE VMLL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS, 4 I
UTHORIZED REPRESENTATIVE P'%^
01/24/2013 15:09 9787945409 N GREENWOOD INS PAGE 01/01
CCORv� CERTIFICATE OF LIABILITY INSURANCE
°�'�`�"1/24"'
1 24 13
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CER11FICATE 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($), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMFO ANT: 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 endorsemen s).
PRODUCER
Nancy Greenwood Ins. Agency
11 Haverhill StreetJ9aaU
Methucan, MA 01844
CONTACT
NAME:
PHONE
978 6B3-7676 A N ; (978) 794-5409
i'�hss: Nancy@Nano Greenwood. com
EACH OCCURRENCE_
NA MCI 0 —
MED Cerny one Pereon�M
] ,000,000
$ l00 OQO
INSURER($ AFFORDING COVERAGE„-
NAIC;#
INSUR2R A : Northland Inaurance
INSURER B :
INSURED
Adam J Brien
8RICO Building & Remodeling
417 Waverley Rd
N Andover, MA 01845
INSURER C :
S 1 000 000
INSURER o:
91 2.000.000
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER.
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN (REDUCED BY PAID CLAIMS.
INSRAWL UBR ....... ,. ...........„ „_..._....-.........._...._....__.-----
LTR TYPE OF INSURANCE POUCY NUMBER (MMIDI)NMMIDD/YYYY UNITS
A
GENERAL
X
LIABILITY
COMMERCIAL GENERAL LIASIUTY
CLAIM5�NIADF � OCCUR
North Andover, Ma 01845
AUTHORIZED REPRESENTATIVE
WS142992
4/13/1.
_
4/13/13
EACH OCCURRENCE_
NA MCI 0 —
MED Cerny one Pereon�M
] ,000,000
$ l00 OQO
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S 1 000 000
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WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORIPARTNERIEXECUTME
OFFICE RMIEMBER EXCLUDED?
(Mendefory In NH)
If Ea4eeerl0e
ORPTIONOeOPRATIONS below
N I A
WC STATU• I I OTH•
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DESCRIPTION OF OPERATIONS I LOCATIONS IVERC= (AMnch ACORD 101,Addlaonnl R(,rmrka Schodule, It mom epaco lm requrnd)
CER I IFICAI E HOLDER rAMMZI I A-rrnu
Q9 1988.2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (201 0108) The ACORD name and logo are registered marks of ACORD
Phone: Fax: (978) 689--8300 E -Mail: - -
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of North Andover
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
1600 Osgood St.
North Andover, Ma 01845
AUTHORIZED REPRESENTATIVE
Ronald Bri a
Q9 1988.2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (201 0108) The ACORD name and logo are registered marks of ACORD
Phone: Fax: (978) 689--8300 E -Mail: - -
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This is an original design and must
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24.Dt:
21 Moody St.
8
., 305„
8
W4830-3
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TECHNOLOGIES Lim
This is an original design and must
not be released or copied unless
applicable fee has been paid or job
order placed_
Designed: 12/12/2012
Printed: 12/12/2012
CV.)
Matt Seed Marini -tat All Drawing #: 1 No Scale.
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36"--18;6'
961'"
All dimensions -size designations�O
given are subject to verification on
job site and adjustment to fit job
conditions.
-p-,` II
TECHNOLOGIES Lim
This is an original design and must
not be released or copied unless
applicable fee has been paid or job
order placed_
Designed: 12/12/2012
Printed: 12/12/2012
Matt Seed Marini -tat All Drawing #: 1 No Scale.
All sub -contractors contracted to perform work must carry appropriate
licensing and insurance to work in Massachusetts.
The contractor and owner may agree to extra services and work, but any
such extras must be set out and agreed in writing by both contractor and owner.
BriCo building and remodeling is a fully licensed and insured LLC
company in the state of Massachusetts. License numbers are provided in the
header above and current insurance documentation upon request.
Dated:
Signature of Owner:
i
Signature of Contr tor:
Total Estimated Cost $24,860.00 Leighton Maple Cabinets
BriCo Building and Remodeling is a fully licensed and insured LLC
company in the state of Massachusetts. License numbers are provided in
the header above and current insurance documentation upon request. We
would like to thank you for the opportunity to bid on your project and would
look forward for the opportunity to work with you.
• 1 Dining room light
• Recessed light trims included, pendants and any other lights to be
purchased by homeowner
• New light switch locations
• Kitchen to be wired to code
• All plugs and switches to be white
• Dishwasher, garbage disposal and microwave wired
• New feed for toe kick heater
Plumbing work will consist of:
• Plumbing of new sink, dishwasher and garbage disposal
• Garbage disposal, sink and faucet provided by homeowner
• Baseboard heat on pantry wall to be removed and replaced with toe kick
heater.
Items with a given allowance is an estimated cost if the cost of any allowance is
not met a credit will be given on the final invoice. If the cost is exceeded the
homeowner would be responsible for the difference.
The contractor agrees to perform this work in a competent and skillful
manner according to standard industry practices, and all work performed shall
be subject to final approval by Owner. All work to be done incompliance with
Massachusetts building code. BriCo takes on full responsibility of all necessary
inspections.
The Owner agrees to pay BriCo Building and Remodeling $24860.00, for
doing the work outlined above. The following payments will be paid to the
contractor in the following manner:
Deposit of $10000.00 is due when permit is granted and cabinets are
ready to be ordered.
Second payment, $10000.00 due after demolition, electrical rough and
new ceiling is installed and granite countertop selection and beginning of
cabinet installation.
Final payment, $4,860.00 at completion of contract.
Any unforeseen work or necessary repairs found during this project to be
brought to the owner's attention as soon as possible. Any extra work resulting
from unforeseen problems will be priced accordingly on site and be done with
written approval. BriCo is not responsible for anything that occurs on site that is
not directly involved with the construction of this project. BriCo warranties all
workmanship for 2 years.
3rl*Co.
Building & Remodeling
Adam Brien
CSL 104428
417 Waverly Rd.
HIC 168512
North Andover, MA 01845
LLC
978-479-1526
01/16/12
adambrico@gmail
CONTRACT
Jim, Jen Marini
21 Moody St
N. Andover MA
Job Description: Kitchen Remodel
• Demolition of existing cabinets, countertop, kitchen ceiling
• Removal of old appliance to be reused
• Floors will be protected to be saved and cleaned at the end of job
• Removal of existing wall partition between kitchen and dining room,
making smooth transitions at all point.
• New Armstrong cabinets installed per planned, style and color noted
below
• Cabinet knobs or pulls installed knobs and or pulls purchased by
homeowner
• Counter -tops to be granite an allowance of $3300 is included
• Disturbed drywall, and ceiling areas to be re hung and plastered
• Baseboard and chair rail blended to match in disturbed areas
• Electric range and over the range microwave allowance $1100
• Microwave installed
• All permits and inspections included
• Paint not included
• All debris to be removed to an off-site facility
Electric work will consist of:
• 5 New recessed cans to be installed
• 3 Pendants, 1 over sink and 2 over peninsula
Massachusetts - Department of Public Safety
Board -of Buildinll Rclnilations and Standards
Construction Supervisor License
License: CS 104428
ADAM BRIEN
417 WAVERLY ROAD
NORTH ANDOVER, MA 01845
(,unmi..innrr
Expiration: 5/12/2014
Tr#: 104428
✓iie i�ammwnurea� o�✓`iaaoa�iueelia
Ofr.. of Consumer Affairs & B mess Regulation
T
HOME IMPROVEMENT CONTRACTOR
Registration: - 168512 Type:
Expiration: 3/1/20 13 LLC
ILDING AND REMODELING LLC
ADAM BRIEN
417 WAVERLY RD
NORTH ANDOVER, MA 01845
a
Undersecretary
The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information _ Please Print Legibly
Name (Business/Organization/Indivi dual):
Address: 417 tis A VE, K L y
Sl!_D1A)G Ig,b S?£MODF(
IN`AbArA Zk1fN�
City/State/Zip: ,RNDoCf_g
01 t Phone #: 9 7 $
111 } S 2
Are you an employer? Check the appropriate box:
Type of project (required):
1. 0 I am a employer with 1
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
6. E] New construction
!. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
7. Remodeling
ship and have no employees
These sub -contractors have
g. ❑ Demolition
working for me in any capacity.
employees and have workers'
9. E] Building addition
[No workers' comp. insurance
required.]
comp. insurance.
5. ❑ We are a corporation and its
10.❑ Electrical repairs or additions
S. ❑ I am a homeowner doing all work
officers have exercised their
11.0 Plumbing repairs or additions
myself. [No workers' comp.
right of exemption per MGL
12. ❑ Roof repairs
insurance required.] t
c. 152, § 1(4), and we have no
131-1 Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. /
Insurance Company Name:TR AVf_ 161; / K N C 7 C72KEF: MW <k'M S M 11 14
Policy # or Self -ins. Lic. #:I F, V i3 ' 6 I $ "-)p - -7 - \ \ Expiration Date: LA I
Job Site Address: Z M061)y .,57—% City/State/Zip: )JtlgYN AN DOVE g t Mp1 0 JtAS
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ce!Ak under the and penalties of perjury that the information provided above is true and correct.
Official use only. Do not write in this area, to be completed by city or town of
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 #:
