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HomeMy WebLinkAboutBuilding Permit #670-15 - 26 RICHARDSON AVENUE 2/25/2015NOR ' �9 BUILDING PERMIT { L 0 �tIED 1'O TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: l.' Date Received ADAA7ED ,,PPS .�5 C �SSACHUS Date Issued:?, 7, I J IMPORTANT: Applicant must complete all items on this pate LOCATION - ' VC y1Q,t'Aal) E� N tCit"Y1C7J/PaQ_ //lit. UI ' 5 n, _ c�I P PROPERTY OWNERrint _ �� rye, Print 100 Year Structure yes no MAP PARCEL ZONING DISTRICT: Historic District yes no Machine Shop Villaqe ves , 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 ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Please Type or Print Clearly OWNER: Name: rol hone: Supervisor's Con`sirruction License: ,/� 31 f Exp. Date: q11 (� Home Improvement License: /G aJJ J Exp. Date: l//4. //� ARCHITECT/ENGINEER Address: Phone: Reg. No FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $ ED Check No.: `C-� Receipt No.: 25s��K NOTE: Persons contracting with Z -is contractors do not have access to the n f nd Signature of Agent/Owner ignature of contractor <. Plans Submitted ❑ 1.,, I z Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanningimassage/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 PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature CONSERVATION Reviewed on Signature HEALTH COMMENTS Reviewed o Sianature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Dumpster on site yes_ Located at 124 Main Street Locatea Jd4 Usgooa Street no Fire Department signature/date -,� }rte: •� 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 — (1 -or department use ❑ Notified for pickup Call Ema Date Time Contact Name 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 ❑ 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 Li 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 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 o 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 2& No. Date,-�2-5-j I Check # (, C) � 6Y] w TOWN OF NORTH ANDOVER Certificate of Occupancy $- Building/Frame Permit Fee $ Foundation Permit Fee $- Other Permit Fee $ TOTAL $ Building Inspector b r 9 O H WJ S LLZ 0Vr � O m = Nm u \ O LL 41 N U N V) d H Z C O m 'O C O LL -C O d' N C Ew t U O LL O� OW N z Z z J n L O K O LL 0 z d H Z Q U W J W L to O w U 'L N V) mto O LL 0 U a Z h C7 L O c O • LL W CC G a LLLI 0 ui w LL. i CO Z ++ �, V) N N ld 0 E V) / o y c t y O = o0 L Q Q. a) • '0 y O -p CD F- v O O 2 O Q O .O co " O N m W_ _ +�•O O LU cx=:E 0 9= U) IT -C; N C LU E 0 (D.__� v Q 0-0 cn Qom= F- t � CLOU E O a T) t d1 b1 O O w c m O CD C .O O N N t O Z O a J O 2 Z m cc Z W w CLX LUG W a. O a Z CD Z 0 ro m H Q H U Z V U) J w N 5 a� O � L O Z CL ca O �, N ci O o CL CL �a o r (Q Cc .CL O }0 CL /` W V c CL U) �• O O b �o " 0 •� L O. m ma o O +_� y C.1 Y rn 0 o E c, o � U) m Cc • �J a �.. > c M O N y O O y — � : O>0 Z_y 4 a t t E%1 0 o O (D y Z / o y c t y O = o0 L Q Q. a) • '0 y O -p CD F- v O O 2 O Q O .O co " O N m W_ _ +�•O O LU cx=:E 0 9= U) IT -C; N C LU E 0 (D.__� v Q 0-0 cn Qom= F- t � CLOU E O a T) t d1 b1 O O w c m O CD C .O O N N t O Z O a J O 2 Z m cc Z W w CLX LUG W a. O a Z CD Z 0 ro m H Q H U Z V U) J w N 5 a� O � L O Z CL ca O �, N ci O o CL CL �a o r (Q Cc .CL O }0 CL /` W V c CL U) 0 next,Lno) step Living,," home energy solutions This agreement Is made by and among Next Step Living, Inc. ("NSL") Christine Duci 21 Drydock Avenue, 2nd floor Ave Boston, MA 02210 ;�eRicharclson " 1 phone: (866) 867-8729 North Andover, MA 01845 Site ID: A583377 11 -Dec -14 1. )ESCRIPTION OF WORK TO BE PERFORMED NSL will perform or cause to be performed the following work on the customer's address above, in a professional manner and in accordance with the terns of this Contract, including the attached recommendations/work order describing the work in detail (the ' Work") which are incorporated herein by reference: w , t Work Location: Attic Flat Perform Air Sealing at Estimated 62.5 CFM50 Per Hour 2 $75.00 Hr $150.00 — • • a • 8 � " �" ut ae�. �` baa " 3 J' � �'� 'k :! � �#x �i " . � `..' � n ♦ 1 � Work Location: Foundation Insulate Rim Joist with 6.25" Fiberglass Batting 164 $1.75 Lnft $287.00 Work Location: Doors Door: Thermal Barrier Polyiso 2" (Attic) 1 $73.91 Each $73.91 100% Airsealing Incentive up to Program Max $150.00 75 % Weatherization Incentive up to Program Max $270.68. Estimated Annual Energy Savings from the Above Improvements $64.00 2. 1AYMENT: CUSTOMER agrees to pay NSL for the work as follows: Payment #1: $90.23 -Credit Card or E -check deposit is due at the time the Work is scheduled. Required payment information will be collected over the phone by a customer service representative at the time of scheduling. Deposit is not to exceed 1/3 of the total retail costs. (Note: Mastercard, Visa, and Discover accepted) Additional Payments and Final Invoice: $0.00 -Additional payments for the Work shall be due upon completion of the Work. If the final invoice is being paid by check, credit card information will still be required at the time of scheduling. Notify the customer service representative that you are paying by check and your card will not be charged unless we fail to receive payment within 5 days of invoice. �- chriz,firle dud (Dec 11.2014) Dec 11, 2014 Customer Signature Date 2)e,0111(41 FIzze 701, DetK:reh Fune;ton (Dec 11, 2014) 11 Dec 2014 NSL Signature Date DeborgbrWIMORnuIder Name of NSL Representative The Terms of this Agreement are contained on both sides of this page Next Step Living - 21 Drydock Avenue 2nd floor - Boston, MA 02210 (866) 867-8729 inquiry@nextsteplivinginc.com www.nextstepliving.com TERMS OF AGREEMENT 3. PROPOSED START DATE AND COMPLETION SCHEDULE NSL will contact customer to schedule the Work at a mutually agreeable time, subject to the availability of subcontractors or materials, or to delays attributable to the weather or other events beyond NSL's control. 4. CONTRACTOR REGISTRATION Massachusetts law requires 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 Office of Consumer Affairs and Business Regulation, Ten Park Plaza, Suite 5170, Boston, MA 02116.617.973.8700. 5. PERMITS NSL will obtain any necessary permits as the Customer's agent Customers who secure their own permits or deal with an unregistered contractor will be excluded from the Guaranty Fund provisions of the Home Improvement Contractor Law. 6. PERFORMANCE OF THE WORK AND CHANGES. 6.1 NSL will not commence the Work prior to signing this Agreement and transmittal of a copy of Agreement to the Customer 6.2 This Agreement may be supplemented, amended, or modified only by the mutual agreement of the parties. No supplement, amendment, or modification of this Agreement shall be binding unless it is in writing and signed by all parties. 6.3 At times, our weatherization team discovers situations in the structure during the course of the Work that indicates a risk for a health or safety concern for residents. Such concerns can include but are not limited to ventilation, potentially hazardous materials such as mold or asbestos, or structural concerns. In the case of health or safety concerns being identified, NSL reserves the right, per section 9.2 of this contract, to communicate concerns to the Customer and halt work until such concerns have been addressed. 6.4 The rebates and incentives available from the Mass Save@ Home Energy Services Program and amounts due from the Customer are based on the best estimate of the situation in the structure by the NSL home energy advisor. However, at times our weatherization team discovers situations in the home during the course of the Work that impact the availability of rebates and incentives from the Mass Save Program. In such situations, NSL will communicate such changes to the Customer, including any impact on amount the Customer would be expected to pay for the Work. The Customer will have the option to remove from the Contract the work elements that need adjustment, or set up a separate contract for performing the adjusted work. 6.5 NSL represents and warrants to the Customer that (a) the materials and equipment furnished under this Agreement will be of good quality and new, (b) that the Work will be free from defects, and (c) that the Work will conform with the description of the Work described in Paragraph 1. 7. INSURANCE AND REGISTRATION NSL represents and warrants to the Customer that it has a valid Home Improvement Contractor Registration (No: 162111) and the necessary insurance required by applicable law and normally maintained by prudent contractors in NSL's field, including, but not limited to, Workers Compensation Insurance for all employees who will perform the Work. 8. QUALITY OF WORK. NSL agrees that the Work will be performed in a good and workmanlike manner, and that NSL will repair and replace, at its own expense, and promptly upon Customer's request, any defects in workmanship and materials provided by NSL which appear up to (1) year after completion of the Work or within any longer period as permitted or required under applicable law, provided NSL has received final payment as provided herein. 9. PRE-EXISTING CONDITIONS & PROPERTY PROTECTION 9.1 NSL shall not be responsible for any damages as a consequence of the Work performed in the home due to preexisting conditions. These conditions include but are not limited to poorly fastened or broken drywall, moisture damage, non- ode construction, cracked or fragile siding or shingles, old pipes and fittings, rotting wood, etc. 9.2 NSL reserves the right not to perform Work upon the discovery of asbestos, mold, or any other potential health risk to the Customer. In this event, the Customer is responsible for remedying the at -risk situation, including any necessary removal of hazardous materials and all bills for services to date shall be paid immediately. Work cannot resume until remediation is complete. 9.3 While NSL will make best efforts to protect any property of the Customer, it is the Customer's responsibility to remove or protect, including dust protection, any personal property including the home itself. NSL will not be responsible for damages to or losses of any of the above mentioned property not property protected prior to the commencement of the Work. 10. GENERAL PROVISIONS. 10.1 NSL reserves the right, the extent permitted by applicable law, to have, file or maintain a mechanic's or material men's lien, or to file a notice of intention to lien, and to take any other steps to perfect and enforce such a lien, if Customer fails to pay NSL as provided herein. 10.2 This Agreement shall be construed in accordance with the laws of the Commonwealth of Massachusetts. 10.3 This Agreement fortes the complete integrated agreement between NSL and Customer. The parties represent and warrant that in executing this Agreement, they are not relying on any representations, warranties or terms other than as expressly contained herein. This Agreement supersedes all prior agreements between the Customer and Contractor and may not be altered absent a subsequent written agreement signed by both parties. You may cancel this Agreement if it has been signed at a place other than the NSL's normal place of business, provided you notify NSL in writing at its 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 forth for an explanation of this right 11. ENERGY BENEFITS. The Sponsoring Utility Company (the Utility) is entitled to 100% of the energy benefits associated with all Energy Conservation Measures, excluding the value of energy cost savings by the Customer, but including all rights to all associated ISO -NE Energy, Capacity and Reserves Products. NSL agrees to provide the Utility with such further documentation as the Utility may request to confirm the Utility's ownership of such benefits and Products. 12. NOTICE CONCERNING SPONSORSHIP. Customer understands and acknowledges that NSL is not an agent, vendor or sub -vendor of The Sponsoring Utility Company (the Utility) with respect to the installation of an energy efficiency measures. In the event of the failure of an energy conservation device to perform as expected, Customer's sole recourse is to Contractor and not to Conservation Services Group (CSG) or to the Utility. The Utility and its operating companies shall not maintain, remove or perform any work whatsoever on the energy conservation measures installed. Customer understands and acknowledges that their participation in the Mass Save Home Energy Services Program is voluntary and that they have consented for Contractor to install the proposed energy conservation measures. Customer agrees that it shall not hold CSG, the Utility, their affiliates or operating companies liable for Contractor's to perform its obligations under this agreement, for failure of the energy conservation measures to function, for any damage to Customer's Premises caused by Contractor or for any and all damages to property or injury to persons caused by the energy conservation measures. 13. LIMITED TIME OFFER. The prices and incentive offered in this Contract are subject to change in accordance with The Sponsoring Utility Company Mass Save Home Energy Services Program offers. 14. CONTRACT CANCELLATION Under Massachusetts law, you may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller, which may be his main office or a branch thereof, provided you notify the seller in writing at his main office or branch 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. Planview Diagram customer _VIS(iYu— ca.Gi Advisor Name: Address 1-7 1i4416d iW AV -C Advisor Phone #: l o ti Town N6014 AAdovtr 01 M5 Any limitations to access by truck? Site ID u����5� �l1�IE7 NOTES Any work scoped outside of Best Practices? Approved by: ib I in rZ5 it Q�' -05Du0 �- . 2 P puur+ - N R Massachusetts Department of Pubitc Safety Board of Building Regulat.,, s a,id Standards Construction Super%mir Special(N Tfl^sc CSSL- 0281 . ROGIER A OVEL ETT 55 S 1T ®IE �jWvEfTdcRKRjI I NaidUadd To: CSSL OC e insuhYduan ContrraCt'Lorr � Ajjp rat, u/,, If 3120 Faiiure to possess a currem cadition ou the Massachuse2ts Plate Building Cede is cause for revocation of this Hcanseo For BPS UCPnSIn OGS'?OrMF ZVOn VNftI. 4riif 'YYCY!'ltl.YC.Gtt4'�G��'Tlfa O- � ce t'( ro ��erriL d Business Re g u I a t i o n Suite 5170 10 Park Plaza Bostton9 Massachusetts 02116 Home Improvement Contractor Registration NE)KT STEP LIVING INC. ROGER OUELLETTE 21 ®RY®®�p\C❑� K AVE. 2 i H FL BOSTON, M 02210 Office on Consumer Affffairs & Business Regulation HOME IMPROV/ MEWT coNTRACTOR Registration: 962111 Type: EYpieati0n: 1/94/2017 Supplement Card NEXT STEP LIVING INC. ROGER OUELLETTE 2-1 DRYDOCK AVE. 2TH FL — BOSTON, MA 02210 �¢adersecreiare Registration: 162119 Type: Supplement Card Expiration: 1/14/2017 Update Address and return card. Mart, reason ffor change. Address F-] Renewal F-] lEmppoyment [] Lost card License or registration vapid for individul use only before the expiration date. lff found return to, Office of Consumer Affairs and Business Regulation 110 Park Plaza - Suite 5170 Boston, MIA 02116 Not valid without signature NEXTS-1 OP IDS EL p 9— 9—RIC " #%_� CERTIFICATE OF LIABILITY INSURANCE DATE (MMMDNYM GENERAL AGGREGATE 10/01/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFER41 NO FtIGHT§ UPON Pig cgRTIFIGATP 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), 4"T"ORIZ.gp ROPIPSENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poflcy(ies) must be endorsed. If SUBROGATION 1q, W,.6jyg-5Wq'4hR1 1i the terms and conditions of the policy, certain POlicle'S relay require an endorsement. A statement on this certificate does not confer rights to 'tj1 certificate holder in lieu of such endorsement(s). PRODUCER I surance Agency 828 Lynn felp, Parkway Melrose, MA 02176 John E. McLaughlin Jr. ACT AW" Erin Lyons NAME PHONE _L�1� I., Ell): 781.665-2775 -F( C No 781-6W02Rfi. EMAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIL BODILY INJURY (Per accident) INSURER A: Nautilus Insurance PROPERTY DAMAGE Per accident) INSURED Next Stop �Iving, Inc. 1 Drydock Avenue, 2nd Floor B 2 , ton osMA 02210 iwsuReR a: Commerce Insurance Company 34704 fwsuRERc:A.0X Mutual Insurance Co. INSURER U: AXIS Insurance Company INSURER E: INSURER F: -1 ...W—. � KLVIZSIUN INUMBIER, THIS 18 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY R9R;QP INDICATED. NOT WITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH IS 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 LTP TYPE OF INSURANCE POLCY FF POLICY af�' I 1—.— — _ A COMMERCIAL GENERAL LIABILITY . ........ ....... I— ...... LIMITS EACH OCCURRENCE 1 $ CLAIMS -MADE r_x1 OCCUR 091301201 9/30/2016 DAMAGES (Ea occurrence) MED PIM IA.,-. --i It GEN'L AGGREGATE LIMIT APPLIES PER: POLICY F-1 PRO- JECT ❑F LOC OTHER: AUTOMOBILE LIABILITY ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS lx� AUTOS UMBRELLA LIAR K OCCUR D HEXCESS LIA 1� CLAIMS -MADE AND EMPLOYERS, C ANYPROPRIETOR! 09/3012014109/3012010 20110 1 09/30/201't I 091,N/201 a IAJ ITO BE BRU E-0 BY CARRIER 109/,0/20'04 10�/3012015 PERSONAL & ADV INJURY GENERAL AGGREGATE PRODUCTS - COMP/OP AGG COMBINED SINGLE LINWIT Me accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE Per accident) EACH OCCURRENCE E.L. EACH ACCIDENT E.L. DISEASE EA EM F I nlqrA.RF: Pni ir" DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, [Additional Pornarks Schedule, may be attached If more space is required) FOR X"OpfflATZON ONLY FNFO-91 SHOULD ANY Or THr ABOVE DESCRIBED POLICING BE CANCELLC-HD BErORN For Information Oniy THE EXPIRA700M DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCURLAANGi� WFCr7 —u ejE POL)C_if Pa0VIZIUM3. ©1900 201A. ACCORD CNO ACOR-n 25 (20141pl)A,�,oACOR!1�1 art.. Date. V �. /.. ez ........ ,ORTH TOWN OF NORTH DOVER , Iw'wwAw G '$0hz-z-� x * PERMIT FOR AS INSTALLATION This certifies that . . T-04we'u.- ...................... has permission for gas installation A'ew"-:'- � - -n ............ in the buildings of .... D. 0. C,. (' ............................... at . . k. /?.(, ............ North Andover, Mass. Fee. �-j'77. Lic. No.. ? ... .... L—L) %GSINSPECTOR Check # c,!r 5, ( 1 56,,4 MASSACHUSETTS UNIFORM APPLICATION FOR' PERMIT TO 00 GASFITTING��-/^� (Print or ype) 1 ( Mass. Date 20 Permit 6 Building oca on �' is N Q Type of Occupancy Installing C Address New Renovation ❑ Replacements Plans Submitted: Yes ❑ No ❑ V Business Telephone Name of Licensed Plumber or Cas Fitter )V�(— Check one: Certificate &*,.O-,rporation ❑ Partnership INSURANCE COVERAGE: I have a current 11 111ty Insurance policy or its substantial equivalent, which meets the requirements of MCL Ch. 142. Yes No p If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability Insurance policy la� Other type of indemnity ❑ Bond n OWNERS INSURNACE WAIVER: 1 am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on tits perml lication waives this requirement S Ignature of owner or Owner's Agent Check one: Owner ❑ Agent ❑ 1 hereby certify that all of the details and Information 1 have submitted for entered)Sze cation a true and accurate to the best of my knovNedga and that 211 plumbing work and Installations performed under the pethis ,cation will b ln compliance with ail pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Type of License lAo,.4,w.A A7 By ❑ Plumber sed Plumber or Gas if r Tian ❑ Gasfitter Gity/Town ter License Number (J APPROVED (OFFICE USE ONLY) ❑ Journeyman i i . • �MMMMMMMMMMMMM®M®o .. • mmmmmMMMMMMMMMMMMMM ..•MMMMMMMmmmmmmmmmmmm .. • mmmmmmw�mmmmmWm� V Business Telephone Name of Licensed Plumber or Cas Fitter )V�(— Check one: Certificate &*,.O-,rporation ❑ Partnership INSURANCE COVERAGE: I have a current 11 111ty Insurance policy or its substantial equivalent, which meets the requirements of MCL Ch. 142. Yes No p If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability Insurance policy la� Other type of indemnity ❑ Bond n OWNERS INSURNACE WAIVER: 1 am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on tits perml lication waives this requirement S Ignature of owner or Owner's Agent Check one: Owner ❑ Agent ❑ 1 hereby certify that all of the details and Information 1 have submitted for entered)Sze cation a true and accurate to the best of my knovNedga and that 211 plumbing work and Installations performed under the pethis ,cation will b ln compliance with ail pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Type of License lAo,.4,w.A A7 By ❑ Plumber sed Plumber or Gas if r Tian ❑ Gasfitter Gity/Town ter License Number (J APPROVED (OFFICE USE ONLY) ❑ Journeyman The Commonwealth of°Massachuselts Department of Industrial Accidents W ®ice of Investigations a d I Congress Street, Suite 100 W ti Boston, MA 02114-2017 wews.massgovldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please P_,rint Legibly Name (Business/Organization/individual): Next Step Living Address: 21 ®rydock Ave . Boston, MA 02210 Phone #: (866)867-6720 Are you an employer? Check the appropriate box: 1. n I am a employer with 850 4. ® I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2.0 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.t required.] 5. ® We are a corporation and its 3.0 1 am a homco,-Amcr doing all wor1� officers have exercised their myself. [No workers' comp. right of exemption per Io/IGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' insurance Type of project (required): 6. C] New construction 7. ® Remodeling S. E] Demolition 9. ® Building addition 10.n Electrical repairs or additions 11.0 Plumbing repairs or additions 12.® Roof repairs 13.H Other Insulation *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 aflidw it indicating such. tf'oatmeters that check this box mmt attached an additional sheet showing the name of the sub -contractors and state whether or sioi thole Entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer Pkat is providing workers' compensadon insurance for my employees. Below is the policy and f ole site informadon. Insurance Company Name: A.LM Mutual Insurance Company Policy # or Self -ins. Lie. #: AWC-400-7030025-2014A Expiration lute: 9/30/15 Job Site Address:_. City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the polucy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can Head to the imposition of criminal penalties of a fine up to $1,500.00 and/or one -yeas imprisonment, as well as civil penalties in the form of a STOIC 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 IIIA for insurance coverage it % 99tion. Z do hereby certify under the pains and p45iagl s fierjuxJs that the irz,�`®rMadonpr®rsialeol above is true and correct,Signature: Phone # 8tolo) -7 -9-7aq Official use only. Do not write in this area, to be completed by city or town of�ciaL City or Town: PermitfUcense Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clei°Is: 4. Eleetrical Inspector 5. Plumbing Inspector 6. Other Contact Person: