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HomeMy WebLinkAboutBuilding Permit #631-2017 - 21 SILSBEE ROAD 12/9/2016Permit No#: (61 - a01-7 Date Received la, ` 9-0 TYPE OF IMPROVEMENT PROPOSED USE �r BUILDING PERMIT Residential Non- Residential ❑ New Building TOWN OF NORTH ANDOVER ❑ Addition ❑ Two or more family APPLICATION FOR PLAN EXAMINATION Permit No#: (61 - a01-7 Date Received la, ` 9-0 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 ®,�IVeI � x� " ;�.�.��..� ¢�{Floodp-rgim ❑Wetlands X a �❑YSept�c � :,� DESCRIPTION OF WORK TO BE PERFORMED: CQ 1 t 1 'LCY-YL I n C—t C Identification - Please Type or Print Clearly OWNER: Name: An(f-P-W Phone: q)8 -&Q 1 'SgaZ4 ARCHITECT/ENGINEE Address: Phone: No FEE SCHEDULE: BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $ n Check No.: , R "n C) Receipt No.: 3( 3 a_ NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund nati irP of Anent/Owner Si nature 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. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On COMMENTS CONSERVATION COMMENTS HEALTH ,COMMENTS Signature, Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes_ Planning Board Decision: Comments v Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: LUI.d ICU 004 FFIRE DEPAR1TMENT-,ifT,�em�Dumpster on site- Mfocated at 124311%lain Street �'lh.r3se'S;+MCt""`-"''$.t-^t�.;ns51"�. COMMENTS Street 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 Doc.Building Permit 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 o 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/Cross Section/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) ❑ Building Permit Application o Certified Proposed Plot Plan o 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 o 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: Building Permit Revised 2014 Location :� ( No. 63 / - c9 017 115L,ee 4z�- Check# -Roto) Date / g A, 1,;�o I (. TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL AO Building Inspector v .a C � V� C7 O CD O n Z N CD O CL CL �• N 10CD Q� cr _ CD CCD O MIS a CD _. O' O N CD � v O Z CD 0 � O CDO CD Z � mm cn - prn Z aCl)i � m cn O Z �g Z cn ti � v z M: 0 O :3-%O 2) _ < CD y O > �. p CD n • z CD � n O O °; c� A , ii (6 .+ O O =r Q L. i17 4 0 S CD O r p CD 'a N J C CD C7 Nto .-r ODJ �3 W ��� cknew c� 0 < rNWO C. CD c U2 h v> co OD'" 0 CD N N p =�. Qo_ <� cn CL N =• : o -% as < ice. O Z03 pt +� FL y io y �. c *** G c � _� O 4r�' :A C �* '' { it � , � U) CD CD 5wcn CD CD C CD o �+ Q C/2 v 9 0 9 mow W T.Z7 N .o T T 3 1 C 7 O _T O O j O S O O rD O F 77 (D (D 00 M Oro QAC 7 Q_ (Drr rD S S 7 S d n \ Z m m K N 7Z O K m 0 (D m r, W m T m C C 3 m W W v N p z m Z D z Z p D�' m O •� n tZi+ CAL m z z n 0 0 0 x 9 0 9 mow I DUFnSK r Federal ID / 05-0405629 RISE Engineering RI Contractor Registration No 8186 MA Contractor Registration No 120979 % CT Contractor , Registration No620120 RISE60 Sh a wm u t Road, C a n ton, MA 02021 ENGINEERING" CONTRACT 339-502-6335 FAX 339-502-6345 Page 1 r PROGRAM ., `[..�t� '•1, MCOWMCT1SENXKDaRD80WEENFUSE CMA-HFS DESCRIBEDDELOW CU9�AIERti7RWOfiNA8 CUSX MER PHONE Me CUENTo WORK OMYER Andrew Dufresne ���� (978)821-5924 11/29/2016 442048 23902 r? SERVICE STREET U�V LUNO STREET 21 Silsbee Road 1 Silsbee Road SEmnCE crtt, 8mIE, Z BU"W ON, am1E, IIP North Andover, MA 01 North Andover, MA 01845 JOB DE, SCRWnON AiR SEALING: Provide labor and materials to seal areas of your home against wasteful, excess air leakage. Phis %%ork will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left %kith a healthful level of air exchange and indoor air quality. Materials to be used to seal your home can include caulks, foams and other products. Primary areas for sealing include air leakage to attics, basements, attached garages and other unheated areas (windows arc not generally addressed.) This will require (8) working hours. A reduction in cubic feet per minute (cfm) of air infiltration will occur, but the actual number of cfm is not guaranteed. At the completion of thea%eatherization work, and at no additional cost to the homco%%ner, a final blower door and/or combustion safety analysis will be conducted by the subcontractor to ensure the safety of the indoor air quality. $680.00 DAMMING: Provide labor and materials to install a 12" layer of R-38 unfaced fiberglass batts to (50) square feet for damming purposes. $102.50 ATTIC FLAT: Provide labor and materials to install a 7" layer of R-26 Class 1 Cellulose added to (720) square feet of open attic space. $936.00 ATTIC ACCESS: Provide labor and materials to install (1) easily moved, insulating cover for the attic access folding stair. A small fiat surface of plywood -,Nil] be created around the opening within the attic. This will allow the cover's integral %%cather- stripping to restrict air leakage. $237.65 VENTILATION: Provide labor and materials to install (2)insulated exhaust hose width gable wall mounted flapper vent to exhaust existing bathroom fan(s). $237.50 VENTILATION: Provide labor and materials to install ventilation chutes in (42) rafter bays to maintain air flow. S84.00 RiSE Engineering will apply all applicable, eligible incentives to this contract. You will only be billed the Net amount. Currently, for eligible measures, Columbia Gas offers 75% incentive, not to exceed $2,000 per calendar year, and an incentive of 100% for the Air Sealing measures up to the first $680 and an additional $340 if savings are justified by the auditor. For the safety and health of your home's indoor air quality, we will be conducting a bio%%er door diagnostic of the available air flow in your home both before the work is begun, and aflcr the wcatherization work is complete. We will also conduct a full assessment of the combustion safety of your heating system and %%ater heater. This has a value; of $90 and is at no cost to you. Total allowable weatherization incentive is $3.110. The ;Permit will be secured by the insulation contractor, at no additional cost. It is the homcounces responsibility to close out this permit by contacting their municipality at the completion of this work. to Federal 10 It 05.0405629 RISE Engineering RI Contractor Registration No 8186 L MA Contractor Registration No 120979 Contractor Registration No620120 RISECT ENGINEERING" 60 Shaw•mut Road, Canton, NIA 02021 CONTRM4T 339-502-6335 rA\339-502-6345 Page 2 PROGRAM CMA -HIES EENNMEEERIRiNGANDWCCUSIMERBEFOORRWORKISAS DESCRIBED BELOW CUSTOMER PHONE DALE CUENTN WORK ORDER Andrew Dufresne (978)821-5924 11/29/2016 442448 23902 SERVICE STREET BILLING STREET 21 Silsbee Road 21 Silsbee Road SERVICE Crit, SAW, ZIP BILLING CIT/, S1A1E, YIP North Andover, MA 41845 North Andover, MA 01845 JOB DESCRIMON $90.00 4 2 201b p�C _ Total: $2,367.66 Program Incentive: $1,668.24 Customer Total: $399.41 WE AGREE HEREBY TO FURNISH SERVICES -COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS. FOR THE SUM OF ***Three Hundred Ninety -Nine & 41/100 Dollars $399.41 UPON RNALINSPE UNPAID BALANC R D APPROVAL BY RISE ENG"MERINQ CUSIOAER AGREES IOREMTAMMWOVE IN FULL. D ERESTOF 1% W W.BE CHARGED MONILLY ON ANY AYS. SEE REVEVt FOR "OR ANTINFM"IKM ON WARANEES, RKUITS aF RECtSION, SCHEDULING. AND CONIiRACIOR RE=jRAIiCN. A DSIDNA -fl SIGN THIS CONTRACT IF THERE ARE ANY BLANK PACES erorovig RkCCEPWNCE NaIE: IFUS CCNIRACTFNY BE WI'HDRAWN BY US IF NarFXECUED WITHIN RATE OF ACCEPTANCE 30 DAYS. ACCEP1RNCE OF CONTRACT-IKE ABOVE PRICES, SPECIRCARONS AND CONDIIONS ARE IOUs AUTIORIZED W OO1tE WORK WILL BE MADE AS SPECIFIED. AYYNIE As LMNED ABOVE RISE60 Shawmut Road, Unit 2 ( Canton, MA 020211339-502-6335 ENGINEERING www.RISEengineering.com . OWNER AUTHORIZATION FORM I }�C04e, Q2& 0 (Owner's Name) Name) owner of the property located at: (Property Address) (Property Address) u " Merrimack valley Insulation 23A Sullivan Rd hereby authorize Billerica. MA 01862 (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. Own is Signatur Date 6.2016 MERRVAL-03 WEJE DATEl1A?=DNYYY) �- CERTIFICATE OF LIABILITY INSURANCE 6/1312016 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 polity, certain policiesm _ ay require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME Automatic Data Processing Insurance Agency,lnc PHONE FAX 1 ADP BoulevardINC,No Ext :(,,.No). A1C. No . E-MAIL - Roseland, NJ 07068 ADDRESS: tNSURED Merrimack Valley Insulation Corp 23a Sullivan Rd North Billerica, MA 01862 INSURER(S) AFFORDING COVERAGE I NAIC V _ INSURERA:SStar V3 AAIC American Alternative insuran. INSURERC: ! INSURERF- 1 1 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: i THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE- LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUGY 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 RFFN RFnI]rM RY PAID M AlIVIR itNSR� LTR TYPEOFINSURANCE ADDLSUBRt MSR 4WD f POLICY NUPdBER 167lNDDiYYW PCLtCYEFF � POLICY tr1R71DD1YYYY� -- LIPo7RS I GENERAL LIABILITY I I EACH OCCURRENCE 15 " i C_O?R.IERCWLGENERAL U4BILITY u OCCUR 4 1 AMA ttuRFIAIS=E .N1x' ancel iSLA%.iS-IAADE P.,ED EXP (Any one person) i S --- i ! — --- - PERSONALSAOVINJURY --IS GENERAL AGGREGATE S GEMLAGGREGATE ULIrrAPPLIES PPR: PRC- I POLICY i ( Ick LOC I ! 1 I i j i _ PRODUCTS -CONIPIOPAGG S ---- -- S AUTOMOBILE LIABILITY 1 j i COPIBINEOSINGLE WAIT tea accidentl S BODILY INJURY (Per person) IS j ANY AUTO ; i 1 ALL OWNED SCHEDULED AUTOS AUTOS i i i ---"-- - - -- _.__.—_ -' -------_--- -- ; BODILY INJURY (Per accident) S { NON-0WNEO KtRED AUTOS AUTOS ! 1 !f f PROPERTY DALAAGE 1 rjj (Peraocident) S . — ULIHRELLA UASOCCUR ; 1 EACH OCCURRENCE 5 EXCESS UABP1 CLAIMS-MADEI I AGGREGATE S DEO RETENTION S __ _ _ — S Ijj j ! WORKERSCONWENSATION i.ANDEIAPLOYERS'UABIUTY YIN A # my PROPP.IETORIPARTNERIEXECUTME OFFICERAIEtABEP. EXCLUDED? Y NIA 9WC749118 IV 6118/2016 f 66812017 x WCSTATU- OTH- TORY LIMITS EP. E.L EACH ACCIDENT S_ 1,000,00 _— — E.LDISEASE -EAELAPLO S 1,DDD,OO� 1 (Mandatory in NH) If Xes, describe under I 0 RIPTtON OF OPERATIONS meow i it E.L DISEASE- POLICY MOT 5 1,000,00 1 I I i s I DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if tnom space is required) I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEL I D.BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover, Massachusetts ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andover, MA 01845 THORIZED REPRESENTATIVE I ©1988 2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered: marks of ACORD /116. D CERTIFICATE OF LIABILITY INSURANCE FDAT1E1/(0)20 6 ) 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 poHcy(es) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED, subject to the terms and conditions of the pol'Lcy, 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 Charles J Coughlin Insurance 14 DinleyStreet P. O. Box 10 Dracut, MA 01826 CONTACT Carolyn A Coughlin PHONE (g78) 957-3588 fAX AIC No: ADDRESS: Carolyn@coughlinins.com INSU SAFFORDINGCOVERAGE NAIC# INSURERA: Northland Insurance Company 24015 INSURED Merrimack Valley Insulation Corporation Joseph A. Ryan, Jr. 23A Sullivan Road N. Billerica, MA 01862 INSURER B: Safety Standard 39454 INSURER c: Torus Specialty Insurance Company A0159 INSURER D: INSURER E INSURER F . L.UVCKALitJ Cbl! I IFKATF IMI IMRFR• OCtAe1nBI Ku IMO= 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICYEFF D POUCYE MJDD v UMTS A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F -\—A OCCIR WS274182 01/21/2016 01/21/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE TORENfED 100,000 PREMISES Ea occurrence $ MED EXP (Any one person) S 5,000 PERSONAL & ADV INJURY S 1,000,000 GENL AGGREGATE LIMIT APPLIES PER POLICY ❑ jEa LOC GENERAL AGGREGATE S 2,000,000 PRODUCTS - COMP/OP AGG S 2,000,000 I S OTHER B AUTOMOBILE LIABILITY ANY AUTO 6205006 11/25/2015 11/25/2016 COMBINEDntSINGLEUMT S 1,000,000 Ea accide BODILY INJURY (Per person) S OWNED / AUTOSSCHEDULED AUTOS ONLY V AUTOS BODILYINJIRY (Per S ( �U fHIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident S $ C UMBRELLAUAB HCLAIMS-MADE OCCUR 87593L161AU 01/2112016 01/21/2017 EACH OCCURRENCE S 1,000,000 EXCESS LIAB AGGREGATE S 1,000,000 1 DED 1 1 RETENTION S 0 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILrrY YIN ANY PROPRIETOR/PARTNERIEXECUTNE OFFICER/MEMBER EXCLUDED? ❑ N / A PER DTH• STATUTE ER E.L.EACHACCIDENi S _ E..L DISEASE -EA EMPLOYEE S (Mandatory in If yes, describe under un EL DISEASE - POLICY UMIT S DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Insulation installation Town of North Andover, Massachusetts 120 Main Street North Andover, MA 01845 ACORD 25 (2016103) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WrrH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE W -1V00-BUTS AGUKU GUKPUKATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 3 = Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvemeiit Contractor Registration Type: Corporation t -�= '• _F Registration: 180506 Merrimack Valley Insulation Corp> " Expiration 11/23/2018 23 A Sullivan Rd Billerica, MA 01862 Update Address and return card. Mark reason for change SCA 1 G 2OM-05111 J le 54 m`r .; , and card t('PTJ7TT7072(tlCfll�lL O�� �TCISSQCfICIJC� nL��Il(' l }= office of Consumer Affairs & Business Regulation HOME IMPROVEMENT y1 CONTRACTOR Type: Corporation "Registration Expiration 180506 11/23/2018 Merrimack Valley Insulation Corp Joseph Ryan 23 A Sullivan Rd Billerica, MA 01862 Rsneie.a1 i_I_FEpl . m-ePt. I_I ! n,i !`aM Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 7 Undersecretary // Not v id iihout signature �YaassG use--' - i>epa..w.0--' J le 54 m`r .; , and card -;= nse: CS -07.554.1 JOSEPH RYAN,,:-' 200 -- Rail Dr_.Apt 21D1 3ainfield MA 013+40 02/072017 The Commonwealth ofMassachusetts ` Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AM 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ApWicant Information Please Print Legibly Name (Business/Organization/Individual): Merrimack Valley Insulation Corp. Address: 23 A Sullivan Rd. Phone #: 978-888-3495 Are you an employer? Check the appropriate bog: 1. FT i am a employer with 18 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 3. ❑ 1 am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. 0 Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 1351 Other Insulation *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. r Homeowners who submit this affida-6t 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 wit an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 5Star V3 AAIC American Alternative Insurance Policy # or Self -ins. Lie. #: V9WC749118 Job Site Address: Expiration Date: 6/18/2017 City/State/Zip: 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 certify wider the pains 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 official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone #•