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HomeMy WebLinkAboutBuilding Permit #740 - 237 CARLTON LANE 4/22/2014Permit NO:- I I U BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received Date Issued: !�[ I IMPOkTANT: Applicant must complete all items on this page tot i -k x -ATI-0 Print 1RROPRERT,Y-'NWNEFt. �T-D lt!h L) AP NO ltd LP-AikC-E-LAiD�),],,-�.2bNING'iDISTRI�, dt es' no -Village-Jp§ , TYPE OF IMPROVEMENT PROPOSED USE ResidendaL— Non- Residential New Building<�n ef �am i I � Addition, Two or more family Industrial Alteratio No. of units: Commercial Others: c� 'Repair, replacement--) Assessory Bldg Demolition Other juga. , i� SIepflq, .Floodplain btland"`-,, Watershed Wates- ewer U1=bL;K11- I IYN Or WORK TO BE PREFORMED: - Identification Please Type or Print Clearly) OWNER: Name. Phone:q9?-')qq- N4 Address:�39 N7 C -TO RIN. a-- n' rRtACho .4 1A L c. 41 h6ne.:-.79J K Address '7 isupe�N 1 'is6r'w§,�.Cb n -s rup ionLicense ,;, q Eio. D,t i&. s juga. , i� -7 a oomelm Date: ARCH 1�ECT/ENG I NEER 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: $4- )0; 400, 00 FEE: $ Check No.: 01 Receipt No.: _47 4 NOTE: Persons contracting with unregistered contractors do not have access to the fund f uaranty lyu�� tor Signature of Adent/Owne" r 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 6 i HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Com Water & Sewer Connection/signature & Date Driveway Permit DPW Town Engineer: Signature: 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.$1o0-$1000 fine 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 �o Building Permit Application �o Workers Comp Affidavit �❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building'Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then.get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 c H � O N '� �N N�� ��� m �N .0 N t` 19 aL�LazEr`-cin 04-0 Q1' co O WY O 4T On Zm coyv V Iwo = tj Z co Qj ` Q Z Q io � Q a g �0 o > co)�r 0 Wp V1 � n 4 g e LL OC a) v€ W z aLU `1 $ Q c ,. f O Af�e LU Z W o o 0Co H (� ■ oLnMag o � _ T�xz`4 t, o On Pm. o���r zLEI ' V E$�e '� a1n ut rA 5M �1 Q _ _ O _ 0cc z w LL O0 OZ Q OJ m c U1 Q1 d LA Z _ m c O LLJ N Z Z m = J a LU CL Lf) Z J U oc W J NJ O ~ w N Z C^ Q (D w G a W o W oC LL \ O LL A N U O_ N +> -0 7 LL L 7 d' > ccC C U fD c LL t j K (0 LL t 7 d' U N a LL .c j K 5 c LL L m O z O1 L N N O N r�1 0 • .Q L .c Q Eoo E a L U) • ECL ai C3 U) el L m (Df- > _ro CDL: 0U)m ►: j.Eoo _-a�' c moo= rt a G1 y Z L 1 w:�=ate � � 0 L : � (� CL CD 9) M W _ '0— 0 0 LL N d N ce- v • U 0 o-0 CD Ah Z y 004-= � � o � AZ 0-00 O W CL z z 0 m 2 o� Z U W 0 c x Z LLJ U W c W J az m 0 0 N m 4- 0 O O 'N "I 07. w W 0 CD O O O O. � Q M Cc J -0 O Z AQ Ch 'Any tHonl ��fof'1114 Insul�anc Policy # o Joh Site Ao ! Attach a co Failul-e to sec fne up to $1,: I° ves f U to $250. ( tigations 11 I do hereh .Y cerli Si nature; �' pb_ �.I rflClRl use ozrly, City or To _ Issuing Attthorit 6 0 �e d of $eai h I 1/6/2019 10:02 AM FROM: Fax TO: 17819320860 PAGE: 001 OF 001 Y ACO Dr -CERTIFICATE OF LIABILITY INSURANCE_ D6/2IDD/YWV) 1//6/204 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 Mackintire Insurance Agency Inc 11 West Main Street Westborough MA 01581-1931 CONTACT Melissa Pflug PHONE (508) 366-6161 AIC No: (508)366-5202 ILADDRESS.melissap@mackintire.com INSURER(S) AFFORDING COVERAGE NAIC i INSURERA:Peerleas Insurance Co. 24198 INSURED Newpro operating LLC 26 Cedar St. Woburn MA 01901 INSURER Acadia Insurance Co. INSURER C : INSURERO: INSURER E INSURER F yr LW ICU- OCLLJVV rIAVC OCcly I.iiUCU Iu rnt IINJUKtU NAMtU AtsUVt ?-UK IHt JJULIUY NtKIUU INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO "'RICH 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. S � TYPE OF INSURANCE D POLICY NUMBER POLICY EFF MM/DD/YVYV POLICY EXP MMIDDIYYVV LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE EZOCCUR CBP 8589577 2/31/2013 2/31/2014 PR 11 ce $ 100,000 MED EXP (Any oneperson) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 I GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PROT- LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY . W• COMBINED SINGLEM T-� -.. 1 OOQ 000 6fiuILY !NJ k •i (Per p.. gin) $ BODILY CdJU31'(Peracl ant) $ A ANY AUTO ,. ,- -. ALL OWNEDSCHEDULED AUTOS1. AUTOS � -- - 8584174 2/31/2013{].2/31/201:ii X X NON -OWNED Hl.ctL). OTOS X AUTOS UMBRELLA LIAR X OCCUk R �TA 1A - Pe c $ Uninsured motorlst BI split limit $ 250 000 EACH OCCURRENCE $ 5 , 000 , 000 A - EXCESS LIAB - CLAIMS -MADE , AGGREGATE $ 5,000,000 DEDTX RETENTION 10,000 _ $ U 8582578 2/31/2013 2/31/2014 H WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under N / A -20-20-003506-01 /1/2013 /1/2019 I VAC STATU- OTH- O Y I ,' ER E.L. EACH. ACCIDENT $ 500 OOO E.L. DISEASE - FA EMPLOYE $ 500,000 - E.L. DISEASE POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TO Whom It May Concern ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE T Moynagh/MARIAN Co AVUKLJ LO (LUTU/U*) ©1988.2010 ACORD CORPORATION. All rights reserved. ntact person. INS025 (201005).01 The ACORD name and logo are registered marks of ACORD i IN From Our Home to Yours... JOB #: Windows, Siding andtMore Page of CUSTOMER t`1() t? h CCD) CiU Y�1� DATE L4 - 5- ,A ADDRESS __2 J (:Ia o L n CITY, STATE N V ('{ �1}�1 I IfIP 1 5 PRODUCT SPECIALIST T(�' � o� TOTAL # OF # OF BOW/BAY/ 'EXTERIOR WINDOWS LEAD PAINT STATUS Yr Built: 5 LSWP: ONE MUST EXEMPT: '>C BESELECTED n E-MAIL ONT 0�,fj ` C. �GS 0 -130 HOME PHONE WORK/CELL PHONE BEST DAY TO INSTALL: M T TH F (circle one) ESTIMATED START DATE ���•••���+++ 5 - '5-19 GRID COLOR GARDEN CLADDING # OF DOORS (Inside/Outside) CAP COLOR Bay' Bow'— IWhite I S torm Ea y� . O 1� MFG: NAPCO ! Norandex / Garden_ Shelf our9\\V,l �►j Other Roof or Soffit Painted'�Y 111��� e (circle one) Locks & Keepers (circle one): h AAlmond Bronze Brass Satin Nickel Diamond PVC c Smooth (circle one) circle one) Handles & Night Latches (circle all that apply): White Almond Bronze Satin Nickel Brass No Bottom Handles Night Latches Inside Color:hit Natural Oak London Walnut Colonial Cherry Barrister Oak Outside Color:kite • VfBasi�c Brown Almond Forest Green Tuxedo Gray Claystone Mocha Bronze Winterberry Wedgewood Blue Window Model: �i (-&, N )( Initials Date Special Crew Size Needed Time Fr me to complete job Capping Type WE MMM MMM MM Fa W, va MMM MMM M E M iiiiiiaaN M��iii M MMM MMM N WMEW Initials Date Special Crew Size Needed Time Fr me to complete job Capping Type MA Reg #146589 CT Reg #0605216 O Contract # RI Reg #26463 Energyszvin xemefm mve nh Federal ID # 20-2625129 9 p me Corporate Headquarters, 26 Cedar St, Woburn, MA, (P) 800-342-2211 (F) 781-933-9626, www.newpro.com THIS CONTRACT MADE THE 5 day of —AC 20� between _ I"(vi I � t ..T(1 l 't n n M A l I. U '1 ,7it WWNAXVMIMTASTNIMM��A on (Address) (City) the "Owner" and NEWPRO Operating, LLC, "NEWPRO". Phone) 65701 I (State) (Zip) S c5. (E -Mail) for pr6prietary use only NEWPRO hereby agrees that it will for the consideration hereinafter mentioned, furnish all labor and material necessary to install the following described wo at the premises located at: (Job Address) Drt a¢ '7 ElThe job address is a condominium. TOTAL # <NEWPRO WINDOWS Window Color QTY Int: IAML MInt: Ext: SERIES# tim Window Color QTY Ext: ❑ WINDOW OPTIONS Grids: ES LJ NO KONTOUR LJSDL LJEUR8LJMAMOND OBS I TMP: (Location) []TOP []BOTTOM Screens: (Exterior color Full Screen Standard) ALF []FULL Vent Latches: ❑ YES RTNO Capping Color: DOORS MODEL QTY Please Initial: Customer understands that NEWPRO® does not do any y painting or staining. (ie: when removing or replacing interior stops or trim). NEWPRO® is not respon- sible for conditions or circumstances be - yond its control including condensation result - ing from or due to pre-existing conditions. PVC LJ Smooth LJ NoMar No Capping iding Glass Door MODEL NAME MODEL # QTY C'6J.r In: Out: Double Hung Acti : Left Center Ri h 2 Lite Slider 757 HDWR: SN BE WH GE 3 Lite Slider (1/4,112,114) 753 Entry DAlir Style 3 Lite Slider (113, 113, 113) 756 Color In: Out: Casement (Hinged Right) 851 Fiberg ss Ste Casement (Hinged Left) _852 HDWR: SN B AGB AB ORB Twin Casement 853 -- Sidelite Style (circle one): CASH Balance paid to ins er at completion FINANCE Bank completion form signed at installation Stationary Casement 856 color In: Aut. Triple Casement om, 1/2,1/4) 859 Storm Door Style Triple Casement (113, 113, 113) 860 color Picture Window 751 HDWR: SN BE AGB AB Sash Only 752 Left H14e Right Inge Hopper _491 Entry Door tyle Awning _351 color I out: TOTAL CASH PRICE. t Q 4 00 t , f Garden Window 798 — Aberglass steel Bay Window (Roof I soffit) HDW SN BE , AGB AB RB Bow Window (Roof I Soffit) Otttir Door I DEPOSIT WITH ORDER �lO Other �. for In: out: Other I HDWR: DESCRIBE WORK & PROMOTIONS APPL D: TOTAL DUE AT o0 IM I rea WINSTALL skid Est. Start Date: 5.15' Est. Comp. Date: 5''�_ Customer understands this is an "estimated date" Owner has read and agrees to the terms and conditions on the front and the reverse of this Agreement. Owner specifically agrees to the (1) Total Cash Price; (2) work being performed; and (3) work not being performed. Owner understands that this Agreement and any attachments contain all of the promises made by NEWPRO. Owner has been orally advised of his right to cancel this transaction at any time prior to midnight of the third business day after the date of this transaction and Owner was provided with two (2) copies of a cancellation form explaining this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. (Rhode Island Sales Only): Notice to buyer: (1) Do not sign this Agreement if any of the spaces intended for the agreed terms to the extent of then available information are left blank. (2) You are entitled to a copy of this Agreement at the time you sign it. (3) You may at any time pay off the full unpaid balance due under this Agreement, and in so doing you may be entitled to receive a partial rebate of the finance and insurance charges. (4) The seller has no right to unlawfully enter your premises or commit any breach of the peace to repossess goods purchased under this Agreement. (5) You may cancel this Agreement if it has not been at the main office or branch office of the seller in the Agreement by registered or certified mail, which shall be posted not later than midnight of the third calendar day after the day on which the buyer signs the Agreement, excluding Sunday and any holiday on which regular mail deliveries are not made. See the accompanying notice of cancellation form for an explanation of buyer's rights. (Rhode Island Sales Only): Owner acknowledges receipt of required Contractor's Registration and Licensing Board consumer education materials. F—] Owner's initials By: JSMA 16 M O&D V1 EIN# Signed: l> ��r�N✓ � (�it f/jIi/1i Product Specialist (Printed Name) I Owner By: Signe C' NEWPRO Op ing, (Signature) Owner WHITE: Branch Copy YELLOW: Customer's Copy PINK: File Copy GOLD: Finance Copy US -15 1/6/2019 10:02 AM FROM: Fax TO: 17819320860 PAGE: 001 OF 001 A AIR ® CE iTIFICATE OF LIABUTY DATE(MMfD01WYV) INSURANCE .1/6i'2014 THIS. CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE rCERTIFICATE 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 KAM Melissa Pflug Mackintire Insurance Agency Inc (508)366-6161 FA(508)366-5211 West Main Street AIC No: melissapftackintire.com - r.a.u•ao w�ctcwut Westborough MA OIS81-1931 INSURERA;PeerleSs Insurance Co. INSURED NeWpro Operating LLC INSURERB Acadia Insurance Co. 26 Cedar St. INSURERC; Woburn MA 01801- I INSURER F "'IAT- I�AUCENIIFY IHAI IHt NULICrtS6ST'rNtZi�4961! rS'16b"tiFLMH)(QCtF'CN ISSUtU IU IHt INSUKL-.'DT ilr8LV�96%1rLPK IHt POLICY PLINIUU 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. NSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF MMIODmYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY P R EM 2/31/2013 2/31/2019 SEL(F84 0 $ 100,00 A CLAIMS -MADE iOCCUR BP 8589577 MED EXP (Any one person) $ 5—,00 IPERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 21000, 000' X PRO- POLICY LOC AUTOMOBILE LIABILITY- -• N I L M—` '"•" 1,000,00 A ANYAUTO _ ALL OWNED SCHeDU:.ECr AUTOS AUTOS• ALTOS 8584174 2/31/201317.2/31!2015 EGUIL'f!NJ f:s -,'(Perp, n) $ - .--� X - X MIED I BODILY INJURY (Per ai:;cent) $ HI+:tU:4UTOS AUTOS P A�... Uninsured motorist BI split limit $ 250,000 X UMBRELLA LIAR X OCCUk EXr•1=�SS LfAS EACH OCCURRENCE $ 5,000,000 A CLAIMS -MADE - AGGREGATE $ 5,000,000 DED X RETENTION 10,000 U 8582578 2/31/2013 2/31/2014 B WORKERS COMPENSATION $ AND EMPLOYERS' LIABILITY V� STATU- OTH- v r N ANY PROPRIETOR/PARTNER/EXECUTIVE 1/1/2014 I ,IT _ ER E.L. EACH ACCIDENT 500,000 $ OFFICER/MEMBER EXCLUDED? � N /A (Mandatory in NH) -20-20-003506-01[1/1/2013 L. V10—OE-7:H rMI-LUTGI L. DISEASE- POLICY LIMIT OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN To Whom It May Concern ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE IT Moynagh/MARIAN ACORn 95 iinintri '2TUUU-ZUTU ACURO CORPORATION. All rights reserved. INS025 (2oloos).o1 The ACORD name and logo are registered marks of ACORD 1_ The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 U www.niass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le�><bly Name (Business/organization/Individual): 1 t M LL L Address: oil, 0 f S— J City/State/Zip:_ (.A rn 1h A C:)/ nor Phone #: il, q a, Are you an employer? Check the appropriate box: l . ] I am a employer with .5 0 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole have hired the sub -contractors listed proprietor or partner- ship and have no employees on the attached sheet. I These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t ❑ 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): 6. ❑ New construction 7. Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other — R. MUM also nn out me section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and IC then hire outside contractors must submit a new affidavit indicating such. ontractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. Iain an employer that is providing workers' compensation insitrattce for »ty employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Uc - 'g o -.AC' - ddb ��E �.� Expiration Date --i::)— — Job Site Address: (S 3"_) N G 1+b n City/State/Zip: k Ar),� oy er t 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. Ido hereby certify under the pains and penalties ofneriury that tbra infnv.. i, , ....-.,:,,_., _L i t, c LO 'a P o cu M cn v m .a U) Cc G, c a N ~ °o W m of 7 Q ^f m a eo � � a � ca m M f'V h Un w ~ 00 0 C LIJ toz co J L 6 w Lo ._., > I oo o z i m 4 i Q u w N X W u W d O O t, c LO 'a o cu M cn v ON�i .a U) C 7 W of 7 Q ^f 00 acs OE" E ca m M f'V