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HomeMy WebLinkAboutBuilding Permit #600-2016 - 30 BUCKLIN ROAD 11/16/2015 BUILDING PERMIT "oRrH q ED 16' tiO TOWN OF NORTH ANDOVER 3� h 6 °� APPLICATION FOR PLAN EXAMINATION * 'z Permit No#: 66 Date Received �gSSACHU i Date Issued: I f IMPORTANT: Applicant must complete all items on this page IR i €'-, H :•a-33. --` M F. '{ "sem . .. n: 1 +t ` - 3 �0ROPERTY'3;. -naE'R � f o t t�NAM,,F ONY.ear S OMuret esu` -ayes ,�#y o Mf�F� P�ARCEL IZONINGICTi _�'� � � ,esu Enos �_ His oric Disfr`ict �y '¢i-_-•',•- �.• ,_3 � ri �� � � -� � --� � ,- � � ach:ine�S:ho Villa e� es,, ono;, 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 r0 S ptic W Id {V �Floodplain ❑ ds t �❑ Watershetl District Water/Sewers .. DESCRIPTION OF WORK TO BE PERFORMED: t �ri Identification- Please Type or Print Clearly OWNER: Name: Z t Phone: Address `b-r)dl(-� 01 xp- f r.. OLS "G.o'nt�actor MT Address? t b w pi a " ra j a rr3 a �tP _ - `e4Syuper1vte`a� > �� nstruc�tioi.License /( � Exp ®ate � Q v� 4 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. Total Project Cost: $ c�� FEE: $ 43 Check No.: 0y s!J Receipt No.: � NOTE: Persons contracting wit r t red contractors do not have access to th a and 5i natu er ofA#�ent%Owner ' _ g ' f `1 natrureofc onfractor . <„ No.to�U Date f /lp • TOWN OF NORTH ANDOVEFI Certificate of Occupancy $ = Building/Frame Permit Fee - Foundation Permit.Fee $ Other Permit Fee $ f J TOTAL $ r� Check# 2q(; 29 wilding Inspec or Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ ElPermanent 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 N 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 pse � Zl- on 4Ws Located at 124 Main S ree« � . Fire De artrnen�si. R ,# r � ,. hd p � � gnature/dRems _ � <� � � :s �MMENTS j ,.vls�i" '�' ''�F'� �t.rs c t �+` ds���r � ,4 ' �„.rrtt��'�F "k ^�� �� *+:S s` 4�r`Y�,«�•r Y`r-� T'�"+Y`e�'f,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.$10o-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doe-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 PP Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o 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 o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract a Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) a 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 o 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 NORTH own of . � E �� . Andover o - h ver, Mass01/lewbw COC MIC„!WICK y1. ORATED S U , BOARD OF HEALTH Food/Kitchen PER L T LD Septic System THIS CERTIFIES THAT L v#*a BUILDING INSPECTOR ............. ............ .................... ....... �!!. !.. ................... ............... Foundation has permission to erect .......................... buildings on ... �i .. 14�.w. .... .!.`t�.............. �............. • Rough to be occupied as ....... .. �..' ... ......� w ...................................... Chimney provided that the person accepting this permit sh4 in every respect conform to the terms of the application Final on file in 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 NT ELECTRICAL INSPECTOR UNLESS CONSTRUCTI A , Rough Service ............ .................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. next step living® home energy solutions r This agreement is made by and among Sarah Jennings Next Step Living, Inc.("NSL') 21 Drydock Avenue,2nd floor 30 Bucklin Rd Boston,MA 02210 North Andover, MA 01845 phone: (866)867-8729 Site ID: 424020 08-Oct-15 1. DESCRIPTION OF WORK TO BE PERFORMED NSL will perform or cause to be performed the following work pr};the customers address above,in a professional manner and in accordance with the terms of this Contract, Including the attached recommendations/work order descdbin ,V"' Gvork in detail(the"Work")which are incorporated herein by reference.Pricing reflected below maybe subject to adjustments in program pricing and offerings and Is 9lirlite'ed for 30 days from the date the Contract Is printed.. Work Location: + Perform Air Sealing at Estimated 62.5 CFM50 Per Hour 12 $85.00 Hr $1,020.00 Work Location: + Damming 84 $2.05 Lnft $172.20 Uert bath fan to roof flapper 2 �11$�75 Each $237 50 Hatch Thermal Barrier Polyiso 2 inch (Attic) 2 $60.00 Each $120.00 Prop vent 2'or 4' 57 . $2.00 Each $114 00 Attic Floor Open Blow Cellulose 11 p 528.: . .. $1.51, sgft.. .., $797.28 Attic Floor Open Olow Cellulose 11" � `� � 210 $1.��a1 sgft $31710 UVo`Fk Location Knae Wall t , Kneewall Floor Enclosed Cellulose Dense Pack 10" 56 ,'1.9 5 sft $ q $109.20 - R Instill 2 Thermal Barrter`f?olytso on Kneeuvall = 14 :. $3::50 sgft < t $49 00 Install 2"Thermal Barrier Polyiso on Kneewall 10 $3.50 sgft $35.00 � Install 2"Thermal Ba�rlt3r polylso on Kn�ew�ll � � F 4� 70 X3`:50 sgft r. 5 00 Work Location: Misc Sheathing Access 1 $31.31 Each $31.31 • ,� 1 � �,,�t1'.00%,Alrse�llrtg Indgntive upto PrGgram Max `$1,Q20 00 ' t 75°/a`Weathertzatlot� fnc�ntly�up,to Program Max X1,670 68 t` estimated Anntaa� �rergy S�ving�from the�bpve Ifnprbvements $569 00 Id I C o Signatur Da 191, 8 Oct 2015 Edward Yaracz NSL Signature Date Name of NSL Representative P A1277645 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 o inquiry@nextsteplivinginc.com•www.nextstepliving.com next step living® home energy solutions This agreement is made by and among Sarah Jennings Next Step Living, Inc.("NSL") 21 Drydock Avenue,2nd floor 30 Bucklin Rd Boston,MA 02210 North Andover, MA 01845 phone: (866)867-8729 Site ID: 424020 08-Oct-15 1. DESCRIPTION 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 terms of this Contract, Including the attached recommendations/work order describing the work in detail(the"Work")which are incorporated herein by reference.Pricing reflected below may be subject to adjustments In program pricing and offerings and is guaranteed for 30 days from the date the Contract is printed.. Work Location: + Recessed Light Cover,(Not Rebate Eligible) 10 $31.25 Each $312.50 Estlmat�d Annual Energy S�Whgs from the Abc�e Improvements $46 00 2. PAYMENT: CUSTOMER agrees to pay NSL for the work as follows: Payment#1: $50.00 Additional Payments and Final Invoice: $262.50 Custo r Sig ate 8 Oct 2015 Edward Yaracz NSL Signature Date Name of NSL Representative A1277645 The Terms of this Agreement are contained on both sides of this page 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 be responsible for obtaining 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. r>;:?•: r' r 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,NSL's weatherization team discovers situations in the structure during the course of the Work that indicates a r*1br 6 health;br'safetyj•.;: concern for residents.Such concerns can include but are not limited to ventlation,potentially hazardous materials such as mold or:asbestos,.ar structyral. concerns. In the rase of health or safety concerns being identified,NSL reserves the right,per section 9.2 of this oc�ntraot to comrpun.cate con rns 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 torn 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 setup 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. 6.6 NSL may determine in the course of pre-installation Technical Review that modifications are necessary to the scope of Work in order to ensure professional quality of the installation. In the event,of such modifications,:NSL will request a written modification of the Agreement to be signed by all,:_;:;. parties.In the event that Customer and NSL.cannot agreg on the modification,the Agreement maybe terminated.by'erther party. .. 7• INSURANCE AND REGISTRATION ;•,,: NSL represents and warrants to the Customer that it hasp valid Home Improvement Contractor Registration(No:162111)and.the,necessary insurance.•.,,;:; ..required b a applicable I wand normal) maintained b prudent contractors in NSL's field including,but not limited to Workers Com,nsation Insurance Y PP Y Y p 9. Pe for all employees who WII pedoim the Work.. . 8. QUALITY OF WORK.• , :. : . , NSL agrees that the Work Will be o mad h 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 one year atter 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 pre-existing conditions. These conditions include but are not limited to poorly fastened or broken drywall,moisture damage;non-code 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 properly 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. 103 This Agreemenj omtsthe'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. 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, 12.1 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. 12.2 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. 12.3 Customeragrees 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 fax,or by e-mail sent or by delivery,not later than midnight of the third business day following the signing of this agreement. J Plainview Diagram Customer Advisor Name: Address Advisor Phone #: X5-1 Town m Pr,4•+rec Any limitations to access by truck? Site ID 411A o°yo No- NOTES Any work scoped outside of Best PrNtices i3 K L .�c�� I D Approved by: Cl)[I of �w1 P44W, �In jf1 P� "fcas 14° It, y MIA 'Z" P0\ ICS 10 51..e��1,c�� Rc�ieSS lo- 6F0 � G revel a5S a 08 1H i}opG 1 � o ro NEXTS-1 OP ID: EL ACORO® F DATE(MM/DD/YYY() CERTIFICATE OF LIABILITY INSURANCE 09/30/2015 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(les) 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 CONTACT NAME: McLaughlin Insurance Agency PHONE FAX 828 Lynn Fells Parkway (A/C.No Extl:781-665-2775 1 (A/C,,.): 781-665-0295 Melrose,MA 02176 E-MAIL John E.McLaughlin Jr. ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Nautilus Insurance Company 17370 INSURED Next Step Living, Inc. INSURERB:A.I.M.Mutual Insurance Co. 21 Drydock Avenue,2nd Floor Boston, MA 02210 INSURER C:Commerce Insurance Company 34754 INSURER D:AXIS U.S.Insurance Company 15610 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 TYPE OF INSURANCE L BR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD MMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE FKIOCCUR ECP2010198-13 09/30/2015 09/30/2016 EU PREMISES Ea occurrence)urrence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY D PRO ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT OTHER: 1$ AUTOMOBILE LIABILITY CEa accOMBINED SINGLE LIMITident $ 1,000,000 C ANY AUTO 15MMBGKKDM 09/30/2015 09/30/2016 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident X Comp$1000 X Coll$1000 $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 D EXCESS LIAB CLAIMS-MADE ELU783547101/2015 09/30/2015 09/3012016 AGGREGATE $ 5,000,000 DED RETENTION $ WORKERS COMPENSATIONX STATUTE ETH AND EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/NO BE ISSUED BY CARRIER 09/30/2015 09/30/2016 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A` (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) FOR INFORMATION ONLY CERTIFICATE HOLDER CANCELLATION INFO-01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Information Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD r The Commonwealth of Massachusetts Department oflndustrialAccidents UVwww. I Congress Street, Suite 100 Boston, MA 02114-2017 mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers- TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Next Step Living Address: 21 Drydock Ave City/State/Zip: Boston MA 02210 Phone#: (866)867-8729 Are you an employer?Check the appropriate box: Type of project(required): I.Q✓ I am a employer with 850 employees(full and/or part-time).* 7. E]New construction In I am a sole proprietor or partnership and have no employees working for me in g. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. F1 Demolition 3.[]I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 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.t 14.�✓ Other Weatherizatipn 6.F1we 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.] *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 affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or 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 providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: A.I.M Mutual Insurance Company Policy#or Self-ins.Lic.#: AWC-400-7030025 Expiration Date: 9/30/16 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 MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this stat me may be forwarded to the Office.of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains dp aloes ofperjury that the informationprovided above is true and correct Signature: Date: I O Phone#: (866)867-8729 F only. Do not write in this area,to be completed by city or town official n: Permit/License# hority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: I J/leOfofipcewo"f"C4onns&um*ear/A6f4fai and Business Regulation 10 Park Plaza e Suite 5170 w Bost®n9 Massachusetts 02116 Home Impr®verr ent Contract®r Registrati®n Registfation: 162111 Type: Supplement Card - _ - - -- Expiration: 1/14/2017 NEXT STEP LIVING INC. _ . ROGER OUELLETTE - 21 DRYDOCK AVE. 2TH FL : BOSTON, MA 02210 ^ 'b Update Address and return card.Mark reason for change. F] Address F-1 Renewal F� Employment )Lost Card OPS-CA1 0 SOM-04104-GIM16 92. oomxasza�zawa&i a .AW'W'l"V .:. Office of Consumer Affairs&Business Regulation License or registration valid for individul use only -_ before the expiration date. If found return to. (-''HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration -_162111 Type: 10 Park Plaza-Su*te 5190 ` Expiration 17:1412017 Supplement Card Foston,NIA 02116 NEXT STEP LIVING)NG" f_ 4 ROGER OUELLETTE.a 21 DRYDOCK AVE:'„2TH`FL BOSTON,MA 02210 Undersecretary f�'9t alid without signature Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor Speciaglt} h , License: CSSL-102811 55 STA ®RE iL ) Wandck RI 028 i Exp(ration Cornnussroner 0911 92016 �I Restvicted To: CSSL¢0c e lnsuation Contractor I Failure to possess a current edition of the Massachusetts State building Code is cause for revocation of thus license. For DPS Licensing information visit: wwvv.Mass.Gov/DPS