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HomeMy WebLinkAboutBuilding Permit #661-14 - 28 PLEASANT STREET 3/27/2014i P QCT YD��Gp q -5-C( 4- cnt 77A.14 ® � 4 OWle_ — S ov 11 _ seas >Mlrg � w� Identification Please Type or Print Clearly) OWNER: Name: 'DAUO 6A,4E 5 ,S®A Phone: 778 — -Ve, — b78Z-- R ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ `�"���n 00 FEE: $ 1H, Check No.: Receipt No.: NOTE: Persons con 'ng w.t/k uneegistered_oontractors do not have acc` s to d. TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received - Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION _ Print. PROPERTY OWNER,: --- _ _ — - Print _ 1'00 Old Structure yes no Year MAP NQ �. PARCEL_ _ ZONING ,1S-T,.RIG Histonc,District yes no r..n Machine Shop Village.; yes 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 q $eptic ❑ 1Nell ❑Floodplain O Wetland's Watershed ,®istnct _,_,Cl Water/Sewer DESCRIPTION OF WUKM I U tit rtKrUKivitU: Identification Please Type or -Print Clearly) OWNER: Name: Phone: ARCHITECT/ENGINEER Phone: t S Address: 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: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund r t--,...,....-°fig...-�•—r-,a^•,�.,.�,. _ ^,` _ 4�i• :hafure of�A ent/Owner��.,.:. _ : - �_ _ , . ' S�g�afureof�cont�actorr .:: T t - - ���:'� Plans Submitted E Plans Waived ❑ Certified Plot Plan 0 Stamped Plans ❑ Building Department rhe fol�w ng is a list of the required -forms to be filled outfor.:the appropriate. permit to .be obtained. Roofivg, Siding, Interior Rehabilitation Permits ❑ ' Btailding Permit Application ❑ Workers Comp -Affidavit ❑ -P- � v -C py Of H-.I.C. And/Or G.S.L.Licenses, _E1 Copy of Contract ` ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 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 apuaal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doe: Doc.Bui?ding Permit Revised 2012 Plans -Submitted ❑ Plans -Waived ❑ .: Certified Plot Plan ❑ Stamped Plant 'TYP,E_OF': SEW,ERAGEDtSFDSAL" Public Sewer ❑ Tanning/Massage/Body Art ❑ .. Swimming Pools ❑ Well ❑ Tobacco.Sales El Food Packaging/Sales ❑ Private (septic tank, etc._ Permanent Dumpster on -Site ❑ 1HE_FO-LLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM "DATE. REJECTED . PLANNING & DEVELOPMENT ❑ COMMENTS _CONSERVATION COMMENTS HEALTH COMMENTS DATE:APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW To` o Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMr NT = Ternp Dumpsier on site ..yes no Located at u124¢Mairr Street a f. Fire D'partine►�tsaturelddig COMMENTS :Dimension Number of Stories: Total land -area; sq. ft.: Total square feet of floor area, based on Exterior dimensions. ELECTRICAL: Movement of. Meter.locatfan-, mast or service drop requires approval of :Electrical Inspector Yes No DANGER..Z®NE LITERATURE: -Yes No MGL -Chapter 166. Section 21A -F and G min.$100-$1000:fine NO I tg and UA I A — (dor cileparfinent use ® Notified for pickup - Date Doc.Building Permit Revised 2010 Locationc;6 P No. -4 Date TOWN OF NORTH ANDOVER L Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL Check # (4 2,(f 27384 Building Inspector Cion c _ U)=' < CD N Q 0 CD Q. o 3 � -o a. O o +CL 0 m N � N O CD CD 2 _Q 2) y C = = O n to o. rt O .+(CD (D 0 �o v o to :L oou, '•� h -a CD o 0, Cr c D CD = o. CM) CL ` 0 C < CDCD O looul Com 0'1 cD • 0 �CD U) ♦• n i O Co � O = _ lD U CD y o0 D(D CD -0 0 h Q j N W TZJ T V1 :7 T A T C� .Z7 T V) T p 3• p (D p p S O O fD O O (D Z D) 2 < Dl 'a N 0 a UQ OQ CD = i1 m -m ? n S S O S N O n Ln � o y n n to O n C C =_ -0 Z Z O 0)m s a -@-o 'b Cl) CD �- co O N * fD cQ -� o 3 Z N o v� T < m C C W CL C Cl)cr S co 0 Z N CD m y CD oCD O p cn ,Z Vi _ p CO c/i CQ CD Cl) - �+ D C � CD 0 v 3 T 0 70 c z (46 � y < . 0 CD M O m Cion c _ U)=' < CD N Q 0 CD Q. o 3 � -o a. O o +CL 0 m N � N O CD CD 2 _Q 2) y C = = O n to o. rt O .+(CD (D 0 �o v o to :L oou, '•� h -a CD o 0, Cr c D CD = o. CM) CL ` 0 C < CDCD O looul Com 0'1 cD • 0 �CD U) ♦• n i O Co � O = _ lD U CD y o0 D(D CD -0 0 h Q j N W TZJ T V1 :7 T A T C� .Z7 T V) T p 3• p (D p p S O O fD O O (D D D) 2 < Dl N a UQ OQ � = i1 m -m ? n S S O S N n Ln � O n (D O N s O * fD S fD 3 O T m C C W m y W p D � T �zif S M m m A A z 0 0 2 At Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements ofthe 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 Constuner Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Name -pAVC- GH,4 t 5.5-00 Company Name WT O.l Street Address (do not use a Post Office Box address) Contractor/ Salesperson/ Owner Name 4,2-s— 1J Wr" 5 Y D r,,,,. /4 City/Town State Zip Code Business Address (must include a street address) /p� l V 'IT�%0�, o ( �y� � !_- t, / 0 - Daytime Phone Evening Phone 7'7,Y— - -© Cityfrown State Zip Code V T (e " 34-+`t 64-302.CIV1 Mailing Address (It different from above) Business Phone I Federal Employer ID or S.S. Number Loa requires that most home Nome Improvement Contractor Reg. Number Espmniondete Improvementcontnumb have valid regbtrntion number ` © l( 41F � r The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed, specifying the type, brand, and grade of materials to be used, use additional sheets if necessary.) 5te---9- P/Loro5 i-- A-.rr&re_-H(F3) Required Permits - The following building permits are required Proposed Start and Completion Schedule - The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (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.) Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of: Payments will be made according to the following schedule: $Ivy t upon signing contract (not to exceed 1/3 ofthe total contract price or the cost of special order items, whichever is greater) $ by //_ or upon completion of $ by /_/ or upon completion of $ 3 `A)upon completion ofthe contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be paid for NOTES: (*) Including all finance charges (**) Law requires that any deposit or down -payment required by the contractor before work begins may not exceed the greater of (a) one-third ofthe total contract price or (b) the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty - Is an express warranty being provided by the contractor? ❑ No ❑ Yes (all terms of the warranty must be attached to the contract) Subcontractors - The contractor agrees to be solely responsible for completion ofthe work described regardless ofthe 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 affeement 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 Reeistration. 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. • 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 ofthe 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 ofthe third business day following the signing of this agreement. See the attached notice of cancellation fort for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of the contract must be completed and signed. One copy should go to the homeowner. The other copy should be kept by the contractor. Homeowner's Signature Date Contractor's Ignature 3% / A4,. Date 4 S_e - vj�- 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 Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws, chapter 142A. Homeowner's Signature Contractor's Signature NOTICE: The 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 isnot 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 93A) 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 carry 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 llttp://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.asp 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 - 11/22/2010 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 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 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 DESPOSE 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 CANCEL THIS TRANSACTION. Date: Buyer's Signature: Description: We Shall Provide Material, And Labor To Do The Following: 1. Roof Leak Over Kitchen • Remove Siding on Two Walls Up to 18" Above Roof Line • Strip & Re -Roof Entire Back Porch of Approx. 18'x 8' 2. Repair Handrails on Rear Deck • Add Two Posts • Add Bracing & Anchor Bolts Below to All Existing Posts as Needed to Firm Up Handrail. 3. Remove and Replace Rotted Fascia Board on Front of Building with New 1x6 Board 4. Haul Away Job Trash and Clean -Up 5. Permit From Town of Andover Included in this Proposal up to $100.00 6. Total Cost $ 4100.00 Notes: • We Provide Our Own Necessary Licenses & Insurance • This Contract May be Rescinded by Customer Within Three Days of Signing, Provided Work Has Not Begun. <<� Acceptance: Date: ZIP 0-7/�f 3/27/2014 9:18 AM FROM: HOWE INSURANCE AGY HOWE INSURANCE AGENCY TO: 978-688-9542 PAGE: 002 OF 002 ACORLY CERTIFICATE OF LIABILITY INSURANCE DATE (M/201 YYY) 03/27/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 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), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the'terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Phone: (978)475-0400 Fax: (978)475-2171 THE HOWE INSURANCE AGENCY 4 PUNCHARD AVE ANDOVER MA 01810 CONTACT Tina Grange NAME — .. I'o Ext : (978) 475-0400 Fac No : (978) 475-2171 ADDReSS: tgrange@howeins.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA : National Grange Mutual INSURED WILLIAM J ZANNONI INC INSURER B : Liberty Mutual INSURER C 806 SALEM ROAD DRACUT MA 01826 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMHFR• 7U/'h3 RFVISIr]N NIIMRFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS 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 LTR TYPE OF INSURANCE ADUL INSR SUER vwD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY E%P MM/DDIYYYY LIMITS A GENERAL LIABILITY MPB39171 02/26/14 02/26/15 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR DAMAGE TO RENTED $ 500,000 PREMISES (Ea occurence MED. EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 4000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 PRO - $ POLICY JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per person) $ BODILY INJURY Per accident $ ( ) HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ era UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR Id CLAIMS -MADE AGGREGATE $ DED I RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WC231S384548-014 01/14/14 01/14/15 X I WCSTATU- OTH TORY LIMITS ER $ E.L. EACH ACCIDENT $ 1,00„000 ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N OFFICER/MEMBER EXCLUDED? FNJ (Mandatory in NH) N/A E.L. DISEASE -EA EMPLOYEE $ 1,00"000 It describe DESCO DESCRIPTION OFFOPERATIONS below E.L. DISEASE -POLICY LIMIT $ 5,00,,000 DESCRIPTION OF OPERATIONS / LOCATIONS ! VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) �"I\ I Ir K.n I Q nvwor% I.ANI.tLLA I ION TOWN OF NORTH ANDOVER BUILDING DEPARTMEN Attention: FAX #978-688-9542 ACORD 25 (2010/05) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ne ACUKu name and logo are registered marks of ACORD RD COR Christine J. Grange The Commonwealth of Massachusetts - Department of IndushiglAccitlents Office of Investigations 600 Washington Street Boston, MA. 02111 www.massgov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Orgadzation/fndividual): W 0, (A A A _,-E �- Address: SVLP City/State/Zip: �.� Phone q,lj Are you an employer? Check the appropriate box: Type of project (required): 1. 1 am a em 7i ttoer with employer 4. ❑ I am a general contractor and T 6. F1 Now construction ` employees (fall and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7• El Remodeling ship and'have no employees These sub -contractors have 8. E] Demolition worldng forme in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ 1 am a homeowner doing all work officers have exercised their right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12, Roofrepairs insurance required.] i employees. [No workers' 13.0 Other l�l/AJ®r"L i �2i ►M �'O,4ir7 comp. insurance required.] 'Any applicantthat checks box#1 must also filloutthe section below showingtheir workers' compensation policy information. i -Homeowners who submit this affidavit indicating they aiie doing all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. / it l Insurance Company Name% V lkL.- Policy # or Self ins. Lic. #: W C L3 Expiration Date: j Job Site Address: l'>' Q S 5�. City/State/Zip: A -r, l ey1 e( ; -- 0C8, Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL o. 152 can lead to the imposition of criminal penalties of a :Fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations ofthe DIA for insurance coverage verification. I do Hereby cert& under A pi s and penalties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitMeense # --L-7 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,• express or implied, oral or written." An employd is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a•deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than tliree apartments and who resides;eherein, or the occupant of the flnI. dwelling house of atlother who em- p- logs person's td do maihtenanc6, construction: or repair work on such dwelling house or on the grounds or building appurtenant thereto shallnot because of such employment be deemed to be an employes." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall-wvithhold the issuance or renewal of a license or peirmit io'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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If au LLC or LLP does have employees, apolicyis,required. Be advised that thisaffidavit maybe submitted tothe Department of Industrial Accidents fox confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit foryou 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 "Job Site Address" the applicant should write "all locations in _ . (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit lion file for future permits or licenses. Anew affidavit must be filled out each year. Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: ; ; ,� ^ ,•� _ ; T'he Common -wealth of M-assachweW9 _ Departmelit o fadustrial .Accidexits Ofte ofIavatigationa 600 Washivon Street Boston.,MA 02111 ETOL # 617-727-4900 W 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass,gov/dia 4. J, N Massachusetts- Department of ftblid-Saif0t y, frice-ofConsumer-AffairsAte3s�Regk1I4#oA Board bUBuilding ReqWatiotis,dnd,,Stat)dards '.k 'Construction Supervisor ME IMPROVEMENT CONTRACTOR .4, j� 4)5b2B1, egistration, Type:q License: CS pirati6n--.- L 14 Private Corporatio WHXL4kM J WILLIAM �J.-ZANNOKI Q 'BW SALEM DRACM:MA 0 qM L William.Zannoni 806 Salem Road A - Dracut, MA 01826 Undersecretary .1 Expiration 1011512014 Commissioner 'MEMCALSKAMMEWS CEFMRCME I cerffy OWI have axaml'JedIn %ft the .Federal Motor --&-Y Rook— (49 CFA 30141-M.49) old wth womedge,0 sm. 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