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HomeMy WebLinkAboutBuilding Permit #693-16 - 255 BLUE RIDGE ROAD 12/7/2015S�,q���✓G-� /of -ic -/,.5 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#0 3 - Date Issued: � ' IMPORTANT: Applical *---- Date Received must complete all items on this page ar S ruc ure dyes ®G�,O93Yp-8 p" KS LED /��•yd� ;�• 9.. ,rte•_ '_ 86 .o� TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ AP ition Iteration ane family ❑ Two or more family No. of units: ❑ Industrial ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition jpt ,epticl �®�iNell ° gj"`�; Y - ❑ Other _ 3�'✓J i ♦tT!, t0 Floodplain " !®;Wetlandw w i"".i'°,.X:'y�Y`iy R :t--! ?0 Ullatersh, ed ®istr�ct� a DESGRIPTIUN UI- IIIIUKK 1 u tit: r trsrumiviMi. iCZ dv. e k 1 -cc -0-W ryte,11,► C- a 3 C'(z -J'-J-V-(�r s e- F 1 o a r 13, Identification - Please Type or Print Clearly Q� OWNER: Name: {- 1 Phone: Address: J one 's 1� Y:ti ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT.' $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COSTr BASED ON $925.00 PER S.F. Total Project Cost: $ s si ao Q FEE: $ / Z Check No.: Receipt No.: NOTE: so�e� co cect' !g with unregistered contractor o not have a� to the guaranty fund gnature_f_Agerf/Ovvner Si na ure of�contractok_':= -i Location J No. �" Date Check # TOWN OF NORTH ANDOMPI Certificate of Occupancy $ �— Building/Frame Permit Fee $��t/ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector 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 e U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed On Signature Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Manning Board Decision: Conservation Decision: Comments Comm Fater & Sewer Connection/Si nature &pate Driveway Permit DPW Town Engineer: Signature: FIREfDEPAf .Located atti124'. b FiretDep:�rti Y,� rtf COMMENTS rt O Street c ocafied 384 Osgood tree MENTi;=,iTerripgtDumpster onsite yes �ri�signature%date = t 4 Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, avast or .service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.s100-$1000 fine NOTES and DATA -- (For department use) ® Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 No The followings is a list of the required forms to be filled out for the appropriate permit to he 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 DTE: 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) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products )TE: 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 )TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit n all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals hat 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: Bnilding Permit Revised 2014 Enter construction cost for fee cal - North Andover Fee Cakulation Construction Cost 85po.00 m $ - $ 1,020.00 Plumbing Fee $ 127.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 127.50 Total fees collected $ 1,375.00 255 Blue Ridge Road 693-16 on 12/7/2015 Remodel Kitchen v C � N 0 0 p n Z N CD CL CL O v(ID Q Cr (ti m O o° cn CLO N• S, = I � v N C 0 O O CID 10 Cl) C O v'a O �' _ O v _.c Dco C: 0D O 0 .� r.L f! Z o =— —0 O in � — U) OHO -Q. 0 Fn CD a -MON WCD"O N 2 3 CL C G n Q O rt O WO =rCD n � O D CD qW (C• � C' � N. O- CD 0 N co O z CD O 0 Cr r+ SOu N _Q N C CL 0 <C. — CD CDO CL O O O CD �• N W �D N fl1 NCD 0 O #** 0 rt A^ cD O o a: C : y a� � 1 Or O = C. S S : (D CD Nrt CD CD o O -h - _O rt CD C O fit O • L O (D N rDD rD — OZ Z m v V 3 T 5, Z7 O Drq m Cl) 0� T >' O T /'ZA V+ = ;orn cn • 0 (� :T 7 ,T7 O S T C 7 Q rr O :3 C 3 r z vZi m O a V1 'LS = n ,G cn0 03 D v o 2 m D x —� ZZ Cl) C O v'a O �' _ O v _.c Dco C: 0D O 0 .� r.L f! Z o =— —0 O in � — U) OHO -Q. 0 Fn CD a -MON WCD"O N 2 3 CL C G n Q O rt O WO =rCD n � O D CD qW (C• � C' � N. O- CD 0 N co O z CD O 0 Cr r+ SOu N _Q N C CL 0 <C. — CD CDO CL O O O CD �• N W �D N fl1 NCD 0 O #** 0 rt A^ cD O o a: C : y a� � 1 Or O = C. S S : (D CD Nrt CD CD o O -h - _O rt CD C O fit O • L O (D N rDD rD — OZ W C ((D m v V 3 T 5, Z7 O Drq m D N m T >' (n (D n N :)oT O m S m m � n Z D j cu A O DEQ S C 3 z p M T 7 (� :T 7 ,T7 O S T C 7 Q rr O :3 C 3 r z vZi m O a V1 'LS = n ,G T O O_ rr 03 D v o 2 m D x 0 • Building and Remodeling 2016 5 APPLETON STREET NORTH ANDOVER, MA 01845 11/19/15 (978) 682 2023 6/8/16 Proposal Submitted To: Lisa and Paul Ciesielski 255joP@mftz:ftd lawtr: �.ge- 'ZZ. North Andover, MA 01845 Job: Remodel kitchen Obtain building permit Start date January 4th Finish date March 1st 2016 HIC Lic. 120296 Expires A I % q I 1--i- CSL Lic. CS 54718 Expires Cold/G Proposal Revised October 31, 2015 i Phone: (978) 886-0681 Complete removal of all demolition and construction materials Generated by Testa Building and Remodeling and its subcontractors. DEMOLITION: Remove all cabinets, counter tops, appliances, tile floor and underlayment, walls, ceiling V And remove all insulation. V. CONSTRUCTION: Remove bump out bay and frame a wall straight across in the same plane as the foundation. Patch the cedar clap board and trim outside. Move the door opening that goes into the old dining room into the new dining room. Patch the wall to match the existing room. Remove the existing window and frame a larger opening to receive a new Anderson 400 series Casement. PLUMBING: Kitchen sinks to stay in same general location. Hook up the rest of the kitchen plumbing fixtures. Hook up the gas cook top. Vent the hood over the cook top. (May need to be exposed in some cabinets) Note: There is no allowances for plumbing fixtures ELECTRICAL: Add new circuits in the kitchen area where needed. Rewire kitchen to code. Supply and install 12 recessed lights. Wire all new appliances. Wire and supply two angle plug strips on the island 'Wire and install two plug strips to the left and right of the cook top up under the upper cabinets'. Install under cabinet light' 3 pendants over the island. Once the electrician is on site he will determine if a new panel is needed. Note: There is no allowances for light fixture other than the Recessed. INSULATION Insulate the walls and the ceiling to code.t� PLASTER: Hang '/z blue board and plaster all walls and ceiling. CARPENTRY: Install all the kitchen cabinets and molding as per the designers drawings. Install new trim in the kitchen around the windows and doors to match the existing trim in the house°' Installation of all kitchen appliances. Install wainscoting on the center partition that will match the back of the peninsula. Note: Th6 is no allowance for cabinets and or countertops. b04*'- 7 j C C FLOOR: Installation of 2'/4 inch oak flooring to match the flooring in the rest of the house. Weave the floor for approximately 6 feet. Sand and apply three coats of finish. -,/ Install tile along the back splash. Labor and adhesive supplied by contractor. d/ Note: There is no allowance for tile or grout. PAINTING: Prime and paint the ceiling, walls, and new trim in the kitchen, eating area, and the old dining room. MUDROOM: Remove the wall that was creating the closet. Insulate where necessary and hang blue board and plaster. Build a bench add Bead board back with a hooks above. o Ahd Wgbk jraN �aw[ First floor half bath Remodel. Remove vanity, top and toilet. Remove and replace the file floor in the bathroom and the mudroom. Paint bathroom. Add an additional $ 3473 Note: There is no allowance for plumbing fixtures, vanity, top or tile ITEMS YOU NEED TO SUPPLY: Kitchen Cabinet Granite -' Appliances Lighting such as: Pendants for island l Under cabinet lights,-, Plumbing fixtures such as: Sink l Faucet Disposal ' Tile for backsplash l Grout 1 Bathroom Vanity / Vanity top`s Sink V Faucet,/ Toilet\/ Mirror V Light fixture,/ Floor tile j Grout .J,, A finance charge of 11/2% per month (18% per year) will apply to all accounts over 30 days past due. hi the event collection activity is required the customer shall be responsible for all costs associated with collection, including reasonable attorney's fees. I propose hereby to furnish material and labor complete in accordance with above specifications, for the sum of: $56,593 Fifty Six Thousand Five Hundred Ninety Three Dollars One- third to start, one-third after rough inspection, one- third upon completion. Authorized signature -��--� I reserve the right to cancel this contract 4ot accepted in 30_ days Signature Signature DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES This form satisfies all basic requirements of the state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of "A Massachusetts Consumer Guide to Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work. MGL chapter 142A.) Express Warranty - Is an express warranty being provided by the contractor? a No 11 Yes (all terms of the warranty must be attached to the contract) Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement. Contract Acceptance -.Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear. ®Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757. [5[!]Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to see a copy of a "proof of insurance" document. Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed 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 sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM Two identical co i Ahe" '° act must be completed and signed. One copy ould go to the homeowner. The other copy should be kept by the con Homeownerignature Contractor's Signature / 3/�,� Date Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Busines ation and the consumer shall be required to submit to such arbitration as rovided Wsaebusoqs General Laws, chapter 142A. Ho meo er's Signature Contractor's Signature NOTICE: he signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer protection laws (i.e. MGL chapter 43A) may not be waived in any way, even by agreement. However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold in Massachusetts cavy an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself to be financially insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at http://www.mass.gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at http://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeimprovement/licenseelist.as For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800, 508-755-2548 or 413-734-3114 Version 2.1-11/22/201 NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR OBLIGATION, WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE, AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU CANCELLATION NOTICE, AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELED., IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED, ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION, YOU MAY RETAIN OR DESPISE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO, THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO [Name of Seller], AT [Address of Seller's Place of Business] NOT LATER THAN MIDNIGHT OF (date). I HEREBY CAyNCEL THIS TRANSACTION. Date: Buyer's Signature: The Commonwealth of Massqchusefts Department oflndustriaZAceldents I Congress Street, Suite 100 Boston, MA. 02114-2017 �.� www mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERN,QTTING AUTHORITY. Applicant Information jj Please Print Let=ibly Name (Business/Orgar&ation/individual): Address: I?i � �► ^' � � City/State/Zip: Ny Ar4Jo''-,-r Are you au employer? Check the appropriate box: (A 14 of Vy Shone #: c k 6 43 -%'' X 0 �t 3 L❑ I am.a. employer with___._employees (full and/or part-time).' 2. kJ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ lam a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6.FJ We are a corporation and ifs offigers have exercised their right of exemption per MGL c. 152, § 1(4), and Nye have no, employees. [No workers' comp. insurance required.] Type of project (Ie4uired): 7. [] New construction 8. Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12.0 Plumbing repairs or additions 13. [] Roof repairs 14. ❑ Other 2'Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. Homeowners who subriiit 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 state whether or not those entities have . ctors have employees, &y* must provide their workers' comp. policy number. employees. If the sub-contra lam an employer that is providing workerscompensation insurance for my employees ' Below is the policy andjob site information. Insurance Company N Policy # or Self -ins, Lic. #: Expiration Date:1b7 10 f� Job Site Address: (1 /fip: � lJl N�Q � 10 0� City/State Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce?l under the pains and penalties of peg jury that the information provided above is true and correct. Phone # q Official use only. Do not write in this area, to he 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 lure, 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 enferprise, 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 !he -boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and -phone numbers) 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 foi• confirmation ofinsurance coverage. Also be sure to sign and date the affidavit. The'a£Cidavit-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 "fob 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of fndusirial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. ## 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 12/7/2015 Office of Consumer Affairs & Business Regulation - Mass -Gov The Official Website of the Office of Consumer Affairs & Business Regulation (OCABR) g Consumer Affairs and Business Regulation Home Consumer Rights and Resources Home Improvement Contracting Home Improvement Contractor Registration Lookup To search by registration number, enter the registration number in the textbox below and click the 'Search' button. Search by Registration Number 1120296 v Searc You must click the "Search Registrant" button to search by name or location. Search by Registrant Company name Search by Registrant Last name City/Town Search Registranq State F® Zip code I Click on the registration number to view complaint history. You can also view arbitration and Guaranty Fund history. The list is current as of Sunday, December 6, 2015. Search Results REGISTRANT RESPONSIBLE REGISTRATION ADDRESS EXPIRATION STATUS NAME INDIVIDUAL NUMBER DATE TESTA BUILDING & TESTA, JAMES 120296 5 APPLETON STREET 11/19/2017 Current REMODELING N.ANDOVER, MA 01845 © 2012 Commonwealth of Massachusetts. Mass.Gov® is a registered service mark of the Commonwealth of Massachusetts. � a. � u e ;)\}GO� . ` $ e A k O X \ § 2 / � 22