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HomeMy WebLinkAboutBuilding Permit #247 - 25 HARWOOD STREET 9/23/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:. Date Received Date lssued:q—,�-�—// IMPORTANT:Applicant must complete all items on this page LOCATION Print, PROPERTY OWNER Gam- / L Unit# Print MAP NO:=PARCELZONING DISTRICT: Historic District ye no Machine Shop Village y s no 100 year-old structure s no 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 Septic _❑!Well' ❑Floodplain Wetl'_ands` ❑ WatershedDistnct, 4 ®Water/Sewer•-, - - -1 .- .. ., . DESCRIPTION OF WORK TO BE PERFORMED: (Identification Please Type or Print Clearly) OWNER: Name: Ie l/i Phone: Address:_ �C CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.•$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST ASED ON$125.00 PER S.F. Total Project Cost: $ 4906l9 FEE: $ Check No.: / 3 ) y Receipt Nb:- NOTE: Persons contracting with unre scontrrii toffs do nog.hav c ess to the guaranty fund �S�anature ofAdent/Owner._ Signature of:cont�actor I 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 El 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 CONSERVA T ION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS i Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comment-- Conservation ommentsConservation Decision: Comments I Water & Sewer Connection/Signature&Dafie Driveway Permit ti a DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes L . no_ Located at 1.24 Main Street Fire Deparbnent signature/dafe COMMENTS 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 ® Notified for pickup - Date Dor,%Building Permit Revised 2011 June/mi Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products 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 MOTE: 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 2008mi Location � ��� No� Date r.7L / NORTH TOWN OF NORTH ANDOVER f w A }�o Certificate of Occupancy $ scMus Building/Frame Permit Fee $ 1 Foundation Permit Fee $ I Other Permit Fee $ TOTAL $ Check #� 2 4 6 0 Building Inspector NORTH TO" of V% 0 . ' 'M -- -_ ' C, o , dover, 1VMass., • Q LAKE /fess C)CKICMEWICK RATED PP l V BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR a }• raa� ..... THIS CERTIFIES THAT.. .... ........... .... .... ....................................I.... . . Foundation . .. ........ .... .......... has permission to erect............:........................... buildings on .... .. ...... .......................................... Rough t0 b8 occupied as...... ! ......... ...."..! 0 ... Chimney ................... provided that the pe on opting this permit shall in every respect conf to the terms of the application In Final this office, and to the provisions of the Codes and By-Laws relating to the nspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 THS UNLESS CONSTRUCTI S ELECTRICAL INSPECTOR V 1�l LESS Rough .................. ................................................................4%..................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough . Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE.DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. 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 Name(Business/Organization/Individual): e0,11,0ej t/ 0 C Address: City/State/Zip: ✓��� ` �C /�Phone Are you an employer?Check the appropriate box: Type of project(required): I IZ l am a employer with_ 4. ❑ I am a general coritractor and I 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 sh%et. t 7• ❑ 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.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.0 Other 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 7 7/ 7 C Expiration Date: — Job Site Address:_ ��� ;e�„,,, City/State/Zip: /� ��fl�" 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 cer/ am -and penalties ofperjury that the information provided above is true and correct. Sianature: 1 1 _ Date: �- •� Phone#: 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 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. 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 burn 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 Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia T EIN#51-050-3313 Haverhill MA 978.374.9224 MA Reg.HIC#149221 am Lawrence MA 978.687.7339 MA Lic.UCS#78130Hampton NH 603.929.9224 BBB_ Single-Ply License#1711 F4 Hampstead NH 603.329.8200 SCVX4=e-J932 Co. Toll Free 1.888.SOS.ROOF i 265 Winter Street Haverhill MA 01830 *Licensed *Insured ;.Factory Trained *Factory Certified Name: Date:- Telephone: Alt.Telephone: E-Mail: L Billing Address: s a�, g3� i i V ob Address: %�= <f Scope of Work and Re-roof ❑Re-roof Approximate Roof Area: CYare for re-roofing by ensuring all safety measures in accordance with OSHA standard regulations and landscape is properly protected. remove existing layers of shingles down to roof deck and dispose of in a legal fashion from the job site. 4-1 n-spect wood deck,if we discover any rotted wood,replacement will will performed at*$ .-�s� per LF for roof deck boards.If substantial deck rot is discovered,re-sheathing of roof deck can be performed at*$—Z6'----6' per SF. If individual sheets are found to be. rotted/or de-laminated, removal, disposal and replacement will be performed at*$ per sheet.If any trim boards are rotted, replacement will be performed at*$--,Z-- --per LF for new pre-primed pine. Inspect siding at roof line and all flashing behind siding,if we discover any damaged flashing or siding at the roof line,replacement will be performed at*$ r` . - a . If wood deck,siding,and jasking is sound,we will re-nail any loose wood to rafters,sweep deck,and prepare for roofing. 17 Inst 18"drip edge to all rakes and eaves. Color. t­Xpply ice&water shield UNDERLAYMENT as er manufacturers'specifications and/or ' ,.I�AVp—ly premium(UNDERLAYMENT)to the balance of the exposed wood deck. �R:e=flash all plumbing stack pipes,and any roof penetrations as required and dictated by good roof practice to ensure water tightness. ,0-ff-upan-inspection,we discover chimney lead to be worn or deteriorated,replace nt will be performed at *$ Install a new: t Year ❑ Traditional Oral ❑ Designer ,,­N�'Furnish.and Install a new shingle over style ridge vent system ❑Soffit vent system*$ '.0"Ti debris generated by Lambert Roofing Co.,Inc.will be cleaned up and disposed of from the job site in a legal fashion.Under no circumstances will the watertight integrity of the building be compromised. Special Notes (ke,, e-'. C/O I , wl UPON COMPLETION AND PAYMENT IN FULL, R06F SHALL HAVE A WORKMANSHIP GUARANTEE FOR A PERIOD OF YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY AND0YEARS HONORED AND ISSUED BY THE SHINGLE MANUFACTURER. ❑MANUFACTURER UPGRADE *$ *Denotes potential additional costs above the total estimated price. TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE - The Contractor agrees to perform the work,furni the m,enalssaad labor specified above for the total sum of:$ i° t �.T (*) r (Dollars) Payment will�'e made according to the following work schedule: e(u5 / e'� ie; tom + 14���; $ r �` . /--C'`deposit upon signing contract . S by_/_/_or upon completion of `may upon completion of contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) 1 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 main office or branch office by ordinary mail posted,by telegram or by delivery,not later than midnight of the third business day following the signing of this agreement. See attached notice of cancellation for for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES Acceptance of the Contract Proposal f Home Owner(s) Signature(s): _ Date: / 10 /� �,..%"`fes Contractors Signature: f " . g - Date: www-lamhnrtrnnfinrr nr..,, ,,., . _ . DATE(MMQD/YYI A-CO-RD. CERTIFICATE OF LIABILITY INSURANCE 09/06/2011 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ALLAN INSURANCE AGENCY INC. HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 63 1/2 Jefferson Avenue 2nd F ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. BOX 511 COMPANIES AFFORDING COVERAGE SALEM MA 01970-0511 I COMPANY A Seneca Insurance Company ................- ..............- EN5U QED COMPANY Safety Insurance Group TGLRC INC dba Lambert Roofing ........................... ................................. 265 WINTER STREET COMPANY C Landmark Insurance Company HAVERHILL MA 01830- ... .... ......... ....... ................. . ...................... C.OMPANY D National Union Fire Insurance COVERAGES P-11S IS TO CERI'IFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOrv'VITHSTANDING ANY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO%-14HICH THIS 11 ,LRTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS S0Bj--CT TO ALL TIIE TERMu EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS .............. I-- - I --,1111 -.111-1---.1.---- ................. ..............- - -........................... CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MMIDDIYY) DATE(MMIDD/YY) BODILY INJURY OCC 110001000 GENERAL LIABILITY 11/12/2011 .......................---................ .................-- X COMPREHENSIVE FORM SGL3000422 �11/12/2010 P,2DILY MJURY AGG, 2,000,000 X PREMISESIiOPERAI FONS PROPER TY DAWAGE OCC 000 A 'UNIARGR0UND43R0PLR'ry D GE Aug 2,.004,OWO .......... I EAP I68,iON&COLLAPSF HA7JRD PRODUCTSICLIMPLETED OPER 91&PD COMBINEDOirC Is BI&P0 COMBINED AGG S X CONTRAG T UAL ............ ............... .......... NDFPENDFINT CONTRACTORS 1,000,000 ............ ........... X BROAD F ORN PRO—FiRTY ONAAGE Medical Payment 5,000 .......... .................- .................---------- ?L.l PERSONAL INJURY AUTOMOBILE LIABILITY I BODILY INJURY ANY AiP.0 (Per owmaw -wate P"� X All 004;ED AUTOS(P, 16203819 BODILY INUR' ALL OWNED AUTOS �'Per acxmdenI) (O!h&than Pnvat4 Passeng elf) X I I IR F D AU T 0.,; 07/16/2011 07/16/2012 PROPERTY DAMAGE I X NON OWNED A9T0 .............. .............. BODILY INJURY GARAGE LIABILITY PROPERTY 0A.MAGE S 11000,000 ."CESS LIABILITY............... COM BNED OCCURREWF $ 5,000,000 C X 1UMBRELL;0:ORM LHA054597 11/12/2010 11/12/2011 $ 5,000,000 OTHER THAN UMBRELLA FORM I�ACC T TU I WORKERS COMPENSATION AND SLA � x Ofi TH D EMPLOYERV LIABILITY 009934145 FL EACH ACCIDEN_T $ 1-000,000 'I HE PROPME1 OR" i X I INCL EL DISEASE POLICY LIMIT 1,000,000 PARTNERSiEkECUTIVE MA, NH 08/28/2011 08/28/2012 1-- .. .............. ................ -................................... EXCL EL DISEASE EA EMPLOYEE 11000,000 --�FFICFRS—ARF r. OTHER .......... ........ ..................... .................................. ......................................... .................. DESCRIPTION OF OPERA'nONSILOCA'nONSNEHICLES?SPECIAL ITEMS CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Lambert Roofing Co. EXPIRATION DATE THEROF,THE ISSUING COMPANY WILL ENDEAVOR 10 MAIL 3() DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 265 Winter St. OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES, Haverhill MA 01830- AQTHORIZEj6 WRESENTATIVE i IA- ACORD 25-N(1195) 4 ORD CORPORATION 1988 �`I__ ,-- r - bm_ of Affairs and us Pak Plaza m Ste, 5 70 improvement ING c� r O , C.v�.J 1t',7�2 �—�.��. ��tic 1�i '•�—�--�.'��.•� t��. ET C3e7� '`"� a-e •-� '--_'-�--._- _. ��. updow--Addrm and Address i. Pa�Q�rz ' 2icsScICd33?; iSE'�3a as €'3� Tel C �'�`"`.�.^ :'•s�ate,aa3ix`ssa�` roc�ci$' cc . �icF�SQ: CS 78330 PICHARD.J LAMSERT -9A PQt"_©UDI f'fir RD HAMPSTEAD, NH 03841 =XPFatio j: 6C 20,12 r FUMICELL® ` S CARPENTRY & HOME IMPROVEMENTS Wayne Fumicello 781-6974329-cell WayfumQyahoo.com Date:8/16/2012 Work performed for: Williams Residence North Andover DESCRIPTION OF WORK: Demo:$4.650.00(to be done RRP Lead safe) • Demo of Kitchen ceiling,walls and floor • Demo of proposed bathroom area Chimney:$2.100.00 • Removal of chimney from basement through roof • Removal of all debris Electrical:$9.525.00 • Service upgrade • Supplying outlets to code • (15)5" recessed lights • Switches as discussed • Closet light • Outside light • Electrical for light above dining room table • New dedicated circuit for AC in bedroom • Electrical for proposed new bath Plumbing:$9775 • Supply power vent for existing boiler and water heater • Move gas pipes for stove • Plumbing for master bath and kitchen • First floor heat Beams for Kitchen&Bath: $2.840.00 • Install beams in both kitchen and bath ceilings as described in engineered plans Framing:$3,875.00 • New kitchen closet • New walk-in closet • New bathroom opening • French door opening • Close in side door • New bathroom framing • Sub-floor work • Move front door • Patch roof Siding:(vinyl)$820.00 • Fill in front door • Fill in French foors • Patch old door opening • Replace 3 rows on side Cabinet Install &Appliance Hook-ups:$3.200.00 Doors&Trim:(Install for Kitchen&Bath)$2.960.00 • Windows&doors • Baseboards Doors:(Budget) • 5 interior doors$1,200.00 • 1 double closet door$300.00 • Front Door$500.00 • Double French Doors$1,500.00 • Hardware$350.00 Insulation:(ceiling and exterior walls)$575.00 • Provide firestop as needed • Insulation in Kitchen and bath ceiling for sound • Insulate exterior walls Blueboard&Plaster(walls&ceiling)$3,500.00 • Kitchen, bathroom and new closet Dumpster&Trash Removal:$600.00 Tile Budget: $3.500.00 Permits. Drawings and engineered plans budget•$700.00 TOTAL COST.$52.470 Payment Schedule To Be As Followed $18,000.00 at start of job $11,100.00 at start of rough plumbing and electrical $11,100.00 after plaster $11,100.00 after cabinets and trim are installed $1147.00 Rnal payment PLEASE NOTE ANY UNFORSEEN WORK&EXTRAS WILL BE DISCUSSED PRIOR AND WILL BE MADE INTO A CHANGE ORDER Thank You! Client Date ayne Fumiceilo e -- `7113��Z Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor I &2 Family License: CSFA-105990 , iI. W AYNE W FUMIf!ELLO__ 81 WINTHROP Sim'I Waltham MA 02d`53 Expiration Commissioner 05/12/2016 ✓�' Truer Alfa rs& a�.-/�aaaac�uvelra Office of Consumer Affairs&B sines Regulation HOME IMPROVEMENT CONTRACTOR Registration: 171118 Type: Expiration: 12I5L2013 Individual VW!kE UMICELLO WAYNE FUMICELLO - 81 WINTHROP ST i WALTHAM, MA 02453 Undersecretary 1 t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly Name (Business/Organization/Individual):�y (/J��,C(//f`�/ G e ZZ a Address: O l z1ZI/Alf"o ,s City/State/Zip: &IX 1f16M, All. O�V,0 Phone#:(2kZ) 60 7/3 "Z 9 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.�1 am a sole proprietor or partner- listed on the attached sheet.$ UKRemodeling 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 1 l.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]i employees. [No workers' comp.insurance required.] 1311 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site Information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: fob Site Address: 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 Me 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 if 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. do hereby certify under the pain ndpenalties ofperjury that the information provided above is true and correct. ii nature: / Date: 2z ZZ 'hone#: 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 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. 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 burn 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 revised 5-26-05 Fax#617-727-7749 www,mass.gov/dia �r�r y7�✓a�� /�aN II yOUIi��VJG4G4—1 R I It - 1 is 0 C� I o IO o /i~15th 126 ! N i N t Q c- - CN 12tt 1 tt 3 tt ! f w 3614 130-21" '; �G fI plan --- 'Im O --. Q n Q� CV 8 IM j ! co CV N 1 Wit; i C.0 �— , p Q lj W a I v _' ` CO li N j Q� II j j t Ci- I t0 NU iN wl fIL . ILI 4 126 C ` ! %' Otic ! N I - i I MBD24 ' M. I 1 ---- ! fiE�,CD N 1 co ---- SB30-1 /1 ros JV c rn . Nlu 615-R ` ------ — ,! 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