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HomeMy WebLinkAboutBuilding Permit #376-2017 - 28 MARBLERIDGE ROAD 10/7/2016 j7)A� S'CAniAl BUILDING PERMIT °� z`E° '6Atio TOWN OF NORTH ANDOVER - - • . APPLICATION FOR PLAN EXAMINATION /0 > -7 • ,:PL®t g 7(w- Date Received— Permit No#: "°R�rEo cy gSSACHus�t Date Issued: IMPORTANT: Applicant must complete all items on this page_ s L®:CA�T1LkF_ �`Y ®VUNER ;R r r PR®PE Pant' Pnn#s 1DDrYe tuctu% �s o. , a ON ftO) r Z®N']�I��G DIS�TRI�CTIHist°oric�D�strct �� NMA.P PAXRSCEL _ a �— --i{` Machine.Sp�Villag Ye., ALL TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition [I Two or more family ❑ Industrial eAlteration No. of units: [i Commercial ❑ Repair, replacement [IAssessory Bldg ❑ Others: ❑ Demolition ❑ Other �_ - ❑F oodplain # ®' ,etla'mds; ❑`Septic. ❑rV119N], g Watershetl°District -. -� 1 - - " r aterlSewe -_�:_,_ . -- DESCRIPTION OF WORK TO BE PERFORMED: V:,/lit tAlr_n 0't C ' t116,1cC Z- 2-444 19c� Identification- Please Type or Print Clearly OWNER: Name: ��/ Lv6�/4r�-� XGA Sf- CIC Phone: Z 77 Address: Contra t r'Name - - 11.21 Ala L x r x ructi®n:Lovement.Lice',sey_ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 41FEE: $ �� 10A7 _ Check No.: 9-39 L/ Receipt No.: 3 l d 1 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fun i naturefofcontractor., - Signattare_ofA en Ownert i 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/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 ❑ 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 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature 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: F RE DEP RAT EMS NT Tm'p ®umpsr .n� ees, V 3noOsgood Street Located o s Located dyc2,,4jMainStreet< FrefDrepsa�rtments g atiare/date, :. - a + � � CµOMM M 3S k f "` 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 Call Email Date Time Contact Name Doe.Building Pennit Revised 2014 Location g V4 A461 t 6't P No..-374, . go 1 '2 Date `Q_ 0,01 • - TOWN OF NORTH ANDOVER z Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#2 y 31010 � Building Inspector r 1 - NORTH _ w: 1 . c . ve. . O .� No. MV 514 lL4 h ver, Mass .Q coC"IcNeWIC" �.9SDR�TED I►PPN'_ �.�S V PERMIT. - T BOARD OF HEALTH Food/Kitchen ..,..,... Septic System THIS CERTIFIES THAT .......n14j.' 01.64tt. ........................ BUILDING INSPECTOR has permission to erect .......................... buildings on ....... Foundation R� �. Foundation to be occupied as Rough .......... ...V�..Ade-le..... provided that the person accepting this permit shall in every respect conform to the terms of the application Chimney on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Final 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 ELECTRICAL INSPECTOR UNLESS CONSTRUCTJQN 4STRTS RoughService .......... BUILDING INSPECTOR. Final GAS INSPECTOR Occupancy Permit Required to Occupy Buildine 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. Smoke Det. Sales: 800.448.3636 Phone: 804.271.2363 J04CSF NEXT GENERATION Fax: 804.743.7779 LET'S GET IT DONE STORMWATER MANAGEMENT SOLUTIONS acfenvironmental.com Site Development and Retrofit . Low Impact Development . Green Infrastructure FOCALPOINT(high flow biofiltration) - R-TANK(modular subsurface storage) - PAVE DRAIN(paving,drainage,storage) - FABCO(decentralized treatment) 1 i i f/ 1 t i f 214 Sutton Hill Rd 6A Contract North Andover MA 01845 1[NMLuciano_28_Marble_Ridge_Bedroom—R2 978 852-4491 www.TMKremodeling.com REMODELING CONTRACTOR AGREEMENT THIS AGREEMENT made this &L 1 20`4y and between TMK Remodeling, LLC Construction Supervisor License#105086, 214 Sutton Hill Rd, North Andover MA 01845 hereinafter called the Contractor, and Judi Luciano&Brian Seigel hereinafter called the Homeowner. WITNESSETH, that the Contractor and the Homeowner for the consideration named herein agree as follows: ARTICLE 1.SCOPE OF THE WORK The Contractor shall perform all of the work described in the specifications entitled Exhibit A—Statement of Work, as annexed hereto as it pertains to work to be performed on property located at 28 Marbleridge Rd North Andover MA 01856. Work Scope Summary:Remodel first floor bedroom approx.280 SF in existing footprint. Remove existing window. Install new Marvin clad window and transom units provided by Owner, flashed,trimmed and painted. Replace exterior clapboard siding from window to corners. Furnish and install 6 recessed halogen light fixtures on new switch. Paint walls, ceilings and trim. Install 2 surface mounted light fixtures at garage supplied by Owner. Replace 2 exterior lamp posts w/lights. Lamp posts supplied by Owner. Replace exterior garage door trim and side jambs. Install door gaskets. ARTICLE 2.TIME OF COMPLETION The work to be performed under this Contract shall be commenced on or before October 03,2016 and shall be substantially completed on or before October 14,2016 ARTICLE 3.THE CONTRACT PRICE The Homeowner shall pay the Contractor for the labor and materials to be performed and supplied under the Contract the estimated sum of Seventeen Thousand Seven Hundred Twenty Six Dollars and No Cents ($17,726.00), subject to additions and deductions pursuant to authorized change orders. The contract price Fixed cost of Sixteen Thousand One Hundred Forty Three Dollars and No Cents($16,143.00) for the building materials and construction labor as specified in Exhibits A and B. Variable cost of One Thousand Five Hundred Eighty Three Dollars and No Cents($1,583.00)for the allowance items listed in Exhibit B Allowances and will be 110%of the actual invoice price paid by the Contractor to his suppliers. Exhibit B lists the allowance items and budget costs the Contractor will purchase for the Homeowner. Sales tax and freight are not inlcuded in allowance budget. Contractor will furnish and install all building materials,fixtures and finish items unless noted otherwise. Any Homeowner supplied materials will be charged a 15% handling and coordination fee based on actual invoice. ARTICLE 4. PROGRESS PAYMENTS Payments of the Contract price shall be paid in the following manner from the Homeowner to the Contractor: Payment 1: 33% upon contract acceptance and signature; $5,908.67 Payment 2: 33% upon rough building inspection;$5,908.67 Payment 3: 33% upon final building inspection and 90%completion of finish; $4,325.67 plus the actual contract price for allowance items as defined in Article 3; Budget:$1,583.00 The contract cost for mutually agreed to change orders will be paid 50%at time of change order signature and 50%after completion and Homeowner sign-off. ARTICLE 5.GENERAL PROVISIONS 1.All work shall be completed in a workmanship like manner and in compliance with all building codes and other applicable laws. P Copyright TMK Remodeling, LLC Initials All Rights Reserved Page 1 214 Sutton Hill Rd 4l.IA Contract North Andover MA 01845K�r Luciano-28—Marble—Ridge—Bedroom—R2 978 852-4491 www.TMKremodeling.com REMODELING 2.To the extent required by law all work shall be performed by individuals duly licensed and authorized by law to perform said work. 3. Contractor may at its discretion engage subcontractors to perform work hereunder, provided Contractor shall fully pay said subcontractor and in all instances remain responsible for the proper completion of this 4. Contractor shall furnish Homeowner appropriate releases or waivers of lien for all work performed or materials provided at the time the next periodic payment shall be due. 5.All change orders shall be in writing and signed by both Homeowner and Contractor. The cost for mutually agreed to additional work, required due to.unknown conditions or substantive change orders,will based on the current bill rates for the actual time used.Additional materials will be billed at contractor cost.All change orders subject to 15% markup for overhead. 6. Contractor warrants it is adequately insured for injury to its employees and others incurring loss or injury as a result of the acts of Contractor or its employees and subcontractors. 7. Contractor shall at its own expense obtain all permits necessary for the work to be performed. 8. Contractor agrees to place all debris in an on-site trash receptacle(dumpster)and leave the premises in broom clean condition. 9. In the event Homeowner shall fail to pay any periodic or installment payment due hereunder, Contractor may cease work without breach pending payment or resolution of any dispute. 10. The Contractor and the Homeowner hereby mutually agree in advance that in the event that the Contractor has a dispute concerning this contract, the Contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and the Homeowner shall a required to s oto such arbitration as provided in MGL c 142A. Homeo er Date: G / Contractor Date: Notice: The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by the Contractor. The Homeowner may initiate alternative dispute resolution even where this section is not signed by the parties. 11. Contractor shall not be liable for any delay due to circumstances beyond its control including strikes, casualty or general unavailability of materials, or inclement weather. 12. Contractor warrants all work for a period of 12 months following completion. 13. Contractor may post small signage(36x36°) on property advertising services during the duration of the project. 14. The Contractor and subcontractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Office of Consumer Affairs and Business Regulation Ten Park Plaza, Suite 5170 Copyright TMK Remodeling, LLC Initials ' All Rights Reserved Page 2 f-9/G/�` 'U�(9 w 214 Sutton Hill Rd Contract North Andover MA 01845 Luciano_28_Marble_Ridge_Bedroom_R2 978 852-4491 TRE www.TMKremodeling.com REMODELING Boston, MA 02116 Phone: (617) 973-8700 15. The Contractor or Homeowner may terminate this contract at any time for any reason by giving 3 days notice in writing to the other party. If either party terminates the contract as provided herein, then the contractor will be paid for work (labor and materials)completed as of the date of termination plus any materials or equipment that are backordered and not delivered. Payment is defined as actual job costs for the project plus 15% overhead charge. The contractor will provide a written report detailing actual job costs plus overhead for payment. The Contractor will refund any funds paid by the Homeowner that are a remaining balance for the labor and materials used as of the date of termination, plus any materials or equipment that are backordered and not delivered, plus 15%overhead charge. The Contractor will make arrangements for the backordered items to be delivered to the Homeowner. 16.The Homeowner is responsible for maintaining adequate access to the property including snow removal, personal property storage, and working doorways, stairways and walkways. In the event the contractor is required to provide access or repair to the doorways, stairways and walkways,then the Contractor will bill the Homeowner at the hourly bill rate for same. ARTICLE 6.OTHER TERMS ARTICLE 7.ACCEPTANCE Signed this day of 20_L(L. Homeowner C ntractor 67- NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by the contractor. The Homeowner may initiate alternative dispute resolution even where this section is not signed separately by the parties. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Copyright TMK Remodeling, LLC Initials S%A) . All Rights Reserved Page 3 214 Sutton Hill Rd _ Exhibit A-Statement of Work North Andover MA 01845 Luciano 28 Marble Ridge_Bedroom_R2 978 852-4491 www.TMKremodeling.com RENTODELING A B C D E F 1 Owner: G I 2 Judi Luciano&Brian Seigel Estimate: 2016-034.1 Estimate valid for 30 days 3 iudmar1Ccilaol.com Estimate Date: 09/25/16 Expiration Date:10/25/2016 4 28 Marbleridge Rd 5 North Andover MA 01856 6 978 655-1277 7 8 Scope of Work Remodel first floor bedroom approx.280 SF in existing footprint.Remove existing window. Install new Marvin clad window and transom units provided by Owner,flashed,trimmed and painted.Replace exterior clapboard siding from window to corners.Furnish and install 6 recessed halogen light fixtures on new switch.Paint walls,ceilings and trim. Install 2 surface mounted light fixtures at garage supplied by Owner. 9 Replace 2 exterior lamp posts w/lights.Lamp posts supplied by Owner.Replace exterior garage door trim and side jambs. Install door gaskets. 10 Notes: 11 Pricing includes labor and materials to install finished item+allowances. EA=Each LF=Lineal Feet SF=Square Feet 12 EA LF SF Total Cost 13 Quantity Cost Quantity Cost Quantity Cost 14 1:0 Administration . 14 .$4,400. 54,400 15 01 Pians and Permits:01.2 Building Permits 2 $399 $399 16 01.0 06an -Building I $324 $324 17 02.0 Permit-Electrical 1 $75 $75 18 01 Plans and Rermits:01.3•Building"Inspections 4 $260 $260 1906.0 Rough Inspection-Electrical 1 $65 $65 20 08.0 Rough Inspection-Building 1. $65 :$65 21 09.0 Final Inspection-Electrical 1 $65 $65 _. - 22 11:0 Finat'Inspection Building .' 1 $65 $65 23 02 Site Work 7 $1,402 $1,402 24 15,Yd Dumpster 1 $545.. : $545 25 Adjacent spaces to be protected by temporary barriers from dust infiltration 1 $132 $132 9 ._ 26 Ali floor coverin s and,hand rails the work area and primary entrance to be:covered withprotective coveringmaterial 1 $171 '$171 27 Erect temporary staging.Remove at end of job 2 $450 $450 28 Owner responsibie,for storing.any items to.re i $0 $0 29 Work area to be vented during demolition and construction to minimize dust_infiltration 1 $105 $105 30 31'Oyerfisad 8 Expenses _. p 1 :$2,336 $2,339 31 Overhead and project administration 1 $2,339 $2,339 32 1st FldMaster Bedroom 280 SF 72 $7,316 456 $2,064 1048-_ $3,945 513,326 33 02 Site Work:02.10 Demo 6 $575 108 $157 $731 34 Disconnect and remove electrical fixture 1 '$52 $52 35 Disconnect and remove trim materials 108 $157 $157 36 Disconnect and remove window;frame and molding _ 5. $523 $523 37 10 Exterior Trim&Decks 160 1 493 3 201 56 $712 108 $996 $ , 38 Furnish and install cedar ciapttioard,siding oveFvapor barrier,primed and painted to match•existing, 160 $1,493 $.1-,493. 39 Furnish and install PVC trim board 108 $996 $996 40 install garage docir:gaskets "' 54 $162 $162 41 Replace lamp post in concrete base,reconnect existing electrical connection.Lampost supplied by Owner 2 $550 $550 42 13 Windows 8 Trlm 1 $2,500 $2,600 43 Install Marvin clad window and transom units approx 112x96".Window supplied by Owner 1 $2,500 $2,500 44 16 Electrical B Lighting 8 $1,947. $1,947 45 Furnish and install 4"halogen recessed fixture on new switch 6 $1,470 $1,470 ©Copyright TMK Remodeling,LLC All Rights Reserved Page-4 Unlawful to distribute without permission �o Nor Sutton Hill Rd North Exhibit A-Statement of Work h Andover MA 01845 Luciano 28_Marble Ridge_Bedroom R2 978 852-4491 — — _ www.TMKremodeling.com REMODELING A B C D E I F G I 46 Install surface mounted fixture on existing switch.Fixture supplied by Owner 2 $477 $477 47 18 Interior Walls 48 1"side wall finish:'1!2"plasterbase'blue board,plaster skim coat - 240 $912 608 $1,766 $_2,678 49 Prep,Prime(1 coat)and Paint(1 coats)trim 64 43 50 Pre Prime 1 coat and"Paint.2 coats walls 240 $912 _ , $912 $2 . 51 19 Ceilings&Cover 544 $1,523 $1-1523. 280 686 $686 52 Painted Ceiling;primer and 1-finish coat - � - -- .._ - _ _ 53 33 Allowances - ..280 $686 $686 1 $1,583 $1,583 54 Fee for installing.owner supplied materials 15%of invoice.Budget _- $1 563 1 $1,583 _ _. _� ._ 55 Grand Total 86 $11,716 456 $2,064 1048 $3,945 $17,726 ©Copyright TMK Remodeling,LLC All Rights Reserved Page-5 Unlawful to distribute without permission ! t .,.The Commonwealth of Massachusetts Department of industrialAceidents I Congress Street,Suite 100 _ - Boston,HA o2114_2017 o` www.mass.gov/dla 'Id�M SV�V yWaikers'CompensationlnsuxanceAfftdavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERM4UTM'A _gOR1TY. Please Paint Le 'bl A ''licant Information Name(Business/Organizationftdividual): Address: O�/ S / �(�� M4— Phone#: City/State/Zip: Are you an employer?Check the appropriate box: Type ofproject(required): am a crop loyer with m ( eto full and/or part tone).* 7. ❑Nevi'donstrucfOn 1�I P yees 2.❑I am a sole proprietor or partnership and have no employees Working for me in 8 emo delii7 g any capacity.[No workers'comp.insurance required.] 9. Demolition 3.❑I am a homeowner doing all work myself[No comp.insurance required.]� 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work ce or property. I will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole 12 [f Plumbing repairs or additions proprietors with no employees. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13% Roof repairs These sub-contractors have employees and have workers'comp.insurance-* 14. Other 6.❑We are a corporation and its.officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp,insurance required.] *tiny applicant that checks bbic#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit•..affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such i o Homeowners that check this box must attached an additional sheet showing the name of the sub-contractors and state whether oz not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providingworkers'compensation insurance for my employees. Below is the policy and jot site information. Insurance Company Nance: --Z.1Gr,4) ExpirationDate: Policy#or Self-ins.Lic.#: %��ll � �l City/State/Zip: Job Site Address: 71c'? age(showing the policy number and expiration Attach a copy of the workers'compensation policy declaration pate). lation by a fiftb up to$1,500.00 Failure to secure coverage as requited under MGL c. 152, the form criminal aSnal vioOP RK ORDER punishable nd a fine of up to $250.00 a and/or one-year'imprisonment,as well as i Penalties day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. Ido liereby certify nder thepains andpenal es o erjury that the informatiorrect. n provided above is true and co Date: Si afore: Phone#: . 74 official use only. Do not write in tliis area,to be completed by city or town official. Permit/License City or Town- # Issuing Authority(circle one): LLB:ardealth 2.Building Department3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Phone#• on• 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 deft ied 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 receiv6for trusted 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=contractors)name(s),address(es)and hone numbers along with their certificate ('s)() g sof insurance. Limited LiabilityCompanies paine s( LC)or Limited Liability Partnerships s(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 IndustrialAccidents. 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(ifnecessary)and under"fob Site Address"the applicaht should write"all locations in Q (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 burnt leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone qnd fax number: The Commonwealth of Massachusetts Department of Industrial Accidents ,rte 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext.7406 or 1-877-AIASSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia �a . tporrvr�aoraauecclt� f0 Office Office of Consumer Affairs&Business Regulation _ —, HOME IMPROVEMENT CONTRACTOR Registration: 165887 Type: Expiration,�4/56.1-8 DBA r TMK REMODELING THEODORE KELLEY 214 SUTTON HILL RD:'> NORTH ANDOVER, MA 01845`- —sem Undersecretary LI0Zl80l01 Jauolsslww_o0 � :uoi;ejldx3 i � l W W 2§AOONV NIHON ;;fl[H N011f1S KZ -NT A31-1m W 3NO003H1 JosinJadnS uoi;oni;suo0 980906-SO :asuaorl I sWepue;S Pue suopIn6aa 6uippn8;o pjeo8 A;a;eS oilgnd 10;uawjjedad s4asn43esseW �$