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Home My WebLink AboutBuilding Permit #407 - 266 LACY STREET 12/31/2008 NORTH BUILDING PERMIT 0*".tutu TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit NO: L10-? Date Received Id- '31 Date Issued: voe- A Hus IMPORTANT: Applicant must complete all items on this page V" PR PER.TY-OW. 7� , , . rnn v MAPodrA GE -ZONINGDISR RIGT .7 7*;�, ru yes. . � OpIMllage TYPE OF IMPROVEMENT PROPOSED USE Residen Non- Residential New Building 11 ne family ,r T _ wo 0� m Addition woo more family Industrial Alteration No. of units: Commercial air Assessory Bldg Others: Demolition Other . . . . -an S.-.. Y 'Sep 777fG16d1pJam- WY-eff d 4'� titers reit D�stt�t 1laLaterlSe,w—er, DESCRIPTION OF WORK-TO BE PREFORMED: A=~Afir_7- oz.5e I 4§;Z4dF—0114-Art Vi 1000< Identification Please Type or Print Clearly) OWNER: Name: Phone: !27k-49ki-kY.7-1 Address: 2 LA o_ Ph -4, R D .. .... U;_p"& iseTI; on Lens - Epp z#.Lrdibi L b -e- ry "Horne thr -et:e-nt lqEqi 4te ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. :11!1 Total Project Cost: $ FEE: $ loa Check No.: �/ Receipt No.: e;7-/ 7 2,6/ NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund gnatu _7v� Signature,� r re'6fr 0 6 _n t/1 wher- ._ _._ 1corrtractor 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 HEALTH Reviewed on Signature COMMENTS 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: Located 384 Osgood Street ?FIRE DE ?A T]I ENT" - Teraip Da psteroil- :Located: t°1;,24 a Marn Street Erre Departrr�en#s� naturitdate3 O1111/IEN SZt .i 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 ❑ Notified for pickup - Date 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 ❑ 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 ConstructionSin le and Two Family) � 9 Y) ❑ 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 Location a�� QC S- No. Date ,�. NORTH TOWN OF NORTH ANDOVER • s . : . Certificate of Occupancy $ E<� Building/Frame Permit Fee $ sACMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2 u t � r 2r 'i 'rv � Building Inspector c N0RTH '9 Town of No. 40 � C' - �A O dower, Mass., Z-10 COCMICMEWICK ADRATED P'? C BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System �J BUILDING INSPECTOR THIS CERTIFIES THAT.............. h. . :'. .l...C...................................................................................... Foundation has permission to erect........................................ buildings on....... ....Z4..G. ......:S,1217.............t............... Rough to be occupied as l.... , ..... :a. r.. .T / ....� �• G� .d' ��/ ........ ......., ..... �� .. . ..l ...C7.G.r/` Chimney provided that the person accepting this permit shall in every respect conform to the terms of the appi!' ation on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, 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 MONTHS UNLESS CONSTRUCTION ST TELECTRICAL INSPECTORS � Rough .................... ............ . . �. Service BUILD 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. Contract �� lc.J o a3� Pella Windows&Doors,Inc. 45 FONDI ROAD ® HAVERHILL MA 01832 HIC# 129774/Tax ID#26-1413183 Phone: 800-866-9886 Fax:978-373-7274 Customer Project/Ship-To Order Rennie,George&Joanne Rennie WME North Andover Date 00/00/00 Quote No. RENNIE 266 Lacy Street 266 Lacy Street Order No. Need Date 00/00/00 NORTH ANDOVER,MA 01845 NORTH ANDOVER,MA 01845 Sales Rep.Name Keating,Linda/WE ESSEX ESSEX Prepared by Payment Terms Wells Fargo Owner: George&Joanne Rennie Architect Bus.Phone:( ) - Bus.Phone: Jamb Depth Bus.Fax:( ) - Home Phone:(978)688-8421 Branch Order No. Cellular:( ) - Home Phone:(978)688-8421 Order Type Installed Sales Order Glazing Design 20.00 psf. Pressure Branch Name Pella Windows&Doors,Inc. Branch Address 45 FONDI ROAD Phone 800-866-9886 City HAVERHILL MA 01832 Fax 978-373-7274 State HIC# 129774/Tax ID#26-1413183 Comments: Customer has paid$2,459.26 deposit(50%of contract total) Customer has paid using Wells Fargo The remaining$2,459.25(final 50%)will be paid upon substantial completion of installation Permit Fee is$60 For information regarding the finishing,maintenance,service,and warranty for all Pella products,visit the Pella Website at www.pelia.com. Printed 11/18/08 Contract-Page 1 of 4 Contract for Customer Rennie,George&Joanne Project: Rennie WME North Andover Order No.: Outside View Item No. Otv. Summary Desefl to ion Unit Price Extended Price Item#10 Qty: 1 Vent/Fixed XO Sliding Window,Frame:46 X 42:Pella Impervia, Location:kitchen Alternative Material,Model 1 ,Brown, 11/16"InsulShld IG Glazing, R.O:T10-1/2" X 3'6-1/2" Half Screen,Brown Hardware,3/4"6-Lite Prairie GBG(muntin ° WallCond: 1 11/16"(Fin to Roomside) pattern:2W011),Brown,Block Frame w/Std Fin Value Added Items:Impervia Full Frame-Qty 1 Disposal per Unit-Qty 1 Notes: Outside View I+em No. OIL �i�mmary Description Unit Price Extended Price Item#15 Qty: 1 310"x 618"Right Hinge In-swing Entry Door,Frame:37-1/2 X 81- Location:front door 1/2:Entry Systems,Clad,Craftsman,Model 2,Brown,3/4"InsulShld R.O:3'2-1/4" X 6' 10" Temp IG w/Argon Glazing,Craftsman-Grain Fiberglass,Ext.Brick WallCond:4-9/16" Red/Int.Dark Mahogany Stain*,Latch Bore with Deadbolt,2-3/4" Backset, 1-1/8" SDL Traditional Grille(Grille Lites Wide=03,Grille Lites High=02),Polished Brass Hinge,Brown Paint,Milbrook Hd1Set Sgl Cyl w/Glenham Levr Brass,Bronze Anodized Sill w/Adj Oak Threshold,Fins(single unit per design) Value Added Items: Single Entry Door-Qty 1 Disposal per Unit-Qty I Notes: i i For information regarding the finishing,maintenance,service,and warranty for all Pella products,visit the Pella Website at -tvww.Pella.com. Contract-Page 2 of 4 Contract for Customer Rennie,George&Joanne Project: Rennie WME North Andover Order No.: Outside View Item No. Otv. 'Rummaa Descri2j4on Unit Price ExtendedPrice Item#20 Qty: 1 36 x(80 to 81)Interchangeable Storm Door,Opening:36 X 81: Location:front door Entry Systems,Clad,Fullview,Model 1 , 1-5/8"Extruded,Brown, ILO: 3'0" X 6'9" Plain Glass/Clear,Brass Handle,With Hinges,4601-STD 1-5/8"Ext FV Plain Glass Value Added Items:Storm Door-Qty 1 Notes: Thank You For Purchasing Pella Products Taxable Subtotal $3,008.10 stomer Signatur P a ales Repres five Signature Sales Tax at 5.0000% 150.41 Non-taxable Subtotal 1,760.00 // / Total $4,918.51 Date Date Deposit Received $2,459.26 Balance Due $2,459.25 WARRANTY: Pella products are covered by Pella's limited warranties in effect at the time of sale. All applicable product warranties are incorporated into and become a part of this contract. Please see the warranties for complete details,taking special note of the two important notice sections regarding installation of Pella products and proper management of moisture within the wall system.Neither Pella Corporation nor Pella Windows&Doors,Inc.will be bound by any other warranty unless specifically set out in this contract. However,Pella Corporation will not be liable for branch warranties which create obligations in addition to or obligations which are inconsistent with Pella written warranties. Clear opening(egress)information does not take into consideration the addition of a Rolscreen[or any other accessory] to the product. You should consult your local building code to ensure your Pella products meet local egress requirements. For information regarding the finishing,maintenance, service, and warranty for all Pella products,visit the Pella Website at www.pella.com. Contract-Page 3 of 4 P Contract for Customer Rennie,George&Joanne Project: Rennie WME North Andover Order No.: Per the manufacturer's limited warranty,unfinished mahogany exterior windows and doors must be finished upon receipt prior to installing and refinished annually,thereafter. Variations in wood grain,color,texture or natural characteristics are not covered under the limited warranty. Contract-Page 4 of 4 PELLA WINDOWS AND DOORS CONTRACT 7. PAYMENTS 1. TERMS AND CONDITIONS Pella shall be entitled to stop the Work upon written notice to Owner for any material default or failure by Owner,including but not limited to,the Owner's These Terms and Conditions are an integral part of the contract set forth on the failure to pay Pella the amount due within seven days after the date payment is Product Order(the"Contract")between New England Window and Door LLC due. dba Pella Windows&Doors,Inc.("Pella")and the person(s)identified on the Product Order("Owner")to supply the products(the"Products"),and perform 8 CORRECTION OF WORK the work(the"Work")described or referred to in such Contract. For Product Only purchases,a signed"Product Only Addendum"is a required part of the Pella shall correct installation Work not in conformance with the requirements contract. of the Contract,if notified in writing by the Owner within two years after the Completion Date or,if earlier,the date on which the Work is substantially 2. OWNER completed and payment of the Purchase Price made subject to a holdback as provided above.Correction of Work as herein provided shall be Owner's sole Pella is not responsible for any existing security systems.Owner shall remove remedy for defective workmanship,and is provided in lieu of any and all other all shades;verticals,blinds,curtains,drapes or window mounted air remedies.Pella's obligation to correct Work is conditioned on Pella's prior conditioners,prior to the installation of the Products.Pella's installers are not receipt of all payments then due. responsible for the removal or installation of these types of items. Pella is not responsible for pre-existing window coverings fitting on newly installed Pella 9. LIMITED PRODUCT WARRANTY windows. Pella shall warrant all Pella products,but only in accordance with the Pella The Owner shall provide complete access to the work site between the hours Windows&Doors Limited Warranty.THIS LIMITED WARRANTY SHALL of 7:00 a.m.and 6:00 p.m.(Monday through Friday)for Pella's installers to BE THE SOLE WARRANTY WITH RESPECT TO THE PRODUCTS AND deliver the Products and perform the Work. PELLA SPECIFICALLY DISCLAIMS ALL OTHER WARRANTIES, EXPRESS OR IMPLIED, WRITTEN OR ORAL(INCLUDING WITHOUT 3. PELLA LIMITATION ANY WARRANTY OF MERCHANTABILITY OR FITNESS Pella will be responsible for and have control over construction means, FOR A PARTICULAR PURPOSE). methods,techniques,sequences and procedures and for coordinating all portions of the Work.Pella will be responsible for the Work of its Pella 10. NO CONSEQUENTIAL DAMAGES Contractors who will install the Products. UNDER NO CIRCUMSTANCES SHALL PELLA BE LIABLE FOR Unless provided otherwise in the Work description,Pella will provide and pay CONSEQUENTIAL,INCIDENTAL,INDIRECT,OR SPECIAL DAMAGES, for all labor,materials,equipment,tools and machinery,transportation,and WHETHER FORESEEN OR UNFORESEEN. other facilities and services necessary for the proper execution and completion of the Work. 11. HOME IMPROVEMENT CONTRACTORS The materials and equipment famished under the Contract will be good quality All home improvement contractors and subcontractors shall be registered with and new unless otherwise required or permitted,the Work will be free from the director of the Home Improvement Contractor Registration Program defects not inherent in the quality required or permitted,and the Work administered the Board of Building Regulations and Standards. Pella and conform with the requirements of this Contract.Pella shall not be responsible any of its subcontractors identified in this agreement have been registered. An for damages or defects caused by abuse,modifications not executed by Pella, �Y inquires about Pella or any of its subcontractors relating tregistration improper or insufficient maintenance,improper operation or normal wear and should be directed Director,Home Improvement Contractorr Registration, tear. Pella will keep the premises and surrounding area free from One Ashburton Place, ,Boston,MA 02108,617-727-8598 accumulation of waste materials or rubbish caused by performance of the 12. PERMITS(MA customers only) Work. Pzga4sobli aced to and will obtain the following permits for this project: 4. CHANGES 'Ex 'V e, Homeowners who secure their own permits will be excluded from theIguaranty fund provisions of Massachusetts General Laws, The Owner may order in writing changes in the Work consisting of additions, chapter 142A. deletions,or modifications("Change Order"). Any Change Order shall include an adjustment to the Price and the Substantial Completion Date,as In addition to the rights and warranties enumerated in this agreement,you may determined by Pella. Pella reserves the right to approve or disapprove any have additional rights under Massachusetts General Laws,chapter 142A and Change Order and any such Change Order must be signed by both Owner and 780 Code of Massachusetts Regulations R6. Pella to be effective. 13. NOTICE OF CANCELLATION 5. SUBSTANTIAL COMPLETION You may cancel this agreement if it has been signed by a party Owner understands and agrees that the Substantial Completion Date is an thereto at a place other than an address of the seller, which estimate only and that the actual date on which the Work is completed may be may be his main office or branch thereof,provided you notify extended to allow for Change Orders requested by Owner or if the time to complete the Work is affected by conduct of the Owner,weather,labor the seller in writing at his main office or branch by ordinary disputes,availability of subcontractors,acts of God,fire or other causes mail posted,by telegram sent or by delivery,not later than reasonably beyond Pella's control.If for any reason the Work is not fully midnight of the third business day following the signing of this completed by the Substantial Completion Date(including any extensions agreement. contemplated above),but is substantially completed by such date,i.e.,the Product has been installed,but minor parts or components are missing or need See the attached Notice of Cancellation for an explanation of to be ning parts or work to be aced or completed iaired,a s acceptable.However,theback proportionate to eholdback wicost of ll not this right. exceed the amount of the completion costs or 10%of the remaining unpaid balance of the Price,whichever is less. Do not sign this contract if there are any blank spaces. 6. FINANCING If payment of the Price is financed with a financial institution through Pella,all financing paperwork must be completed upon signing of this Contract and the requisite approvals and authorizations for the full amount of the requested �C financing shall have been received from the financial institution. Cu mer signature x /// /S toy Date 4 NOTICE OF CANCELLATION Customer Name: I `2n n ( lc_ (Pleaseprint) Date of transaction: I l 16-Lo S You may cancel this transaction,without any 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 agreement, and any negotiable instrument executed by you will be returned within ten business days following receipt by the seller of your cancellation notice,and any security interest arising out of the transaction will be cancelled. 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 agreement; 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 your notice of cancellation, you may retain or dispose 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 Pella Windows and Doors, at 45 Fondi Rd.,Haverhill, MA 01.832 not later than midnight of I O L (three business days from the date of transaction above). I hereby cancel this transaction. (Date) (Buyer's signature) e DISPUTES Job Namee2n►'-)t Date I k- /I 16 9- r THE CONTRACTOR AND THE HOMEOWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT PELLA HAS A DISPUTE CONCERNING THIS CONTRACT,PELLA MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE CONSUMER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN M.G.L.c. 142A 4t,��L -K 6;'i"-r' ctor i Homeowner NOTICE: THE SIGNATURE OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE SETTLEMENT INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES. �la,.arhu.rtt. - Department of Public �afet� Board of Buildim- Re,ulations and standarth Construction Supervisor License License: CS 89853 Restricted to: 00 WILLIAM R NICHOLS 57 PEARTREE RD HAVERHILL, MA 01830 Expiration: 10/26/2010 c unmi i•nee Tri: 5196 +� �fe %�amnzvn�uealt� a�,��farvcu,�uaelj, Board of Building Regulations and Standards -_ HOME IMPROVEMENT CONTRACTOR Registration: 129774 Expiration: 11/2/2009 Type: Supplement Card PELLA WINDOWS AND DOORS WILLIAM NICHOLS 45 FOND[RD. HAVERHILL,MA 01832 Administrator l4�>a. CER u FOLATE OF,LOQ B OLOW ON UO AN 07 81 . (80285-18� THIS CERTIFICA IS ISSUERS A MATTER OF INFORMATION PRooucER FmdQCbarob,bc, ONLY AND CON KS NO HTS UPON THE CERnRCATE 41 Weltman3lLeat HOLDER.THIS ICATE DOES NOT'711MID EXTEND OR LOWeILMA01851 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 800�Z5-1865 .. .. .• INSURERS AFFORDINGCOVERAGE - NAIL 0. Newer�d Window�,DaoPLT.0 DIEuaERA: C'tiseastns mr&CmVgyofAmu= 45FonrffRoad INBURERB: HanovertBaueanceCampmy lkveMI,MA 018321362 IR7UIiERC: MacmchllseilaB�plaslDatDce uts ML. TvilaCivsketosuamce. 29459 • INBUIiERE COVERAGES THE POLICIES OP INSURANCE USTED BELOW'HAVEBEEN ISWWTOTHEINSURED NAMEDABOVEFORTIIEPOLICYPERIOD INDICATED.NO7WITHSTANDING ANY REQUIREMENT.TERM'OR CONDITION OF ANY CONTRACTOR OTMER.D000MENT WITH RESPECT TO WHICH THIS CENFIFICATE.MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREON 19 SUNECTTO ALLTHE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATELINITSSHOWN MAY HAVEBEEN REDUCED BYPAI)CLAIMS. DISK POUGYNUI'ABEB T(ON MORS GENERALUABILRY EAtR1a000RRENCE $1,00moo X COMMERCIALGENIMLU1B11.I1Y HAN OLNMBMAOE ® N OCCUR D _ �0 AH� ZON8161407 71111008 7/112009 PERSOMI.&ADVINIURY 0 GENERALAGGREGATE _ GEN'LAGGRINIATEUWAPPLUMPER: PAODUCTG-COMpIDPAGG I:Pew. POLICY LOC . L'1a81LELIABLIVY 0 INGIEUMIT ANYAM ' ALLOIVNWAVICS BODY D AW R eIREOAUR7a C MOULEDAUTOB ADN8162169 71111008 7/1!1009 R NON•OWNEDAUTOS • . • IBPe�rA S • GMAGELWBILISY%• " AUTOONI.Y-EAACCIDI:NT S •' ANVAUTOOIHERTNAN EAAGC I AM I p(CE9SN!!�BRE"UABILRY SM CE S MOM •7L OCCUR DIIAIMSL9AOE _ AGGREO!w S 9,ao0�au B T)lUSi8f67305 7/12008" 7/1/1009 DEDUCTIBLE s • X fUZZENTM7N s s . tlYORNERsaO11PENS11ilaNAND g I Wo STS El:IPLOVERS'UASM FULBACHACGDENT ssam D ANYPROPRIEroPAMRINE IDIRCUiIVE 08WBNM42 7112008 7/12009 aFFICEIYMEMBEREXCL RIVOT EL.oISEA�EaEAEN O S 500,000 . SS—,rm PROVIBbN wwws ` EL.oISEAgE:P�OLIacuMIT S ER OW _ OESCRIPRON OF OPERA7IONB/LOCA7IONSIVENICLE9/.MMUMIONSADDEDBYRMMGBMENTISPECL4LPRONSIONS P[GOFOflLLLLR11IBnCD • r CERTIFICATE FOLDER CMCKILATION L Few EuglandVrmdow&Door LLO a adLDANrormEABOVEDESCEUBEdt6UMtsBECANCECLEDO ONE711EEMPMUCB PS FondlRoad oA7E SNEREdR INE ISSUING INSURER WILL ENDEAVOR TO MAL 30 DAYS VIRM SYeIhil1,MAI 01830 NURGETOINBCERIIEICAIENOWERNA{SEDTOTNEWIF BUTFAIWRE'IODOSOSNALL • a57POSE t10 OBuliATNlN OR LIA8ILIIY OF ANY tOND,UPON THE DISUREif,R8 AGENSS OP ' REPRESEITAWM A111RammPEPRESERAI VII6• ...'••:'•:::••: "• e......... , ACORD26(2001108)'Client#2960 Mst# 0 6400-WC� Cert# ®ACORDCORPORATiON188 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aonlicant Information Please Print Legibly Name(Business/Organization/Individual): U,,&a•l w S Q✓ld Dbo rS 1 AC . Address: q ar->aio\c U Ci y/State/Zip: �•VeCklI 4D(9 1 'Pl'ib� d#:.� 7 �`2E��•`7�. q � Are you an employer?Check the appropriate box: Type of project(required): 1.X I am a employer with 2 Jr 4. ❑ I am a general contractor and I have hired the sub-contractors 6. E]New construction employees(full and/or part-time).* 2.❑ I am a sole proprietor or partner- listed on the attached sheet. �• 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 10F1 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.[1Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing th&VoilWfi' 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: fir-'�oI C�V'r'�v1 Policy#or Self-ins.Lie.#: ®$ W 9 Al L- 571-12. Expiration Date: Job 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 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 dais statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si fore• , Date: �3l 08' Phone#• 265'72-55 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#: