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HomeMy WebLinkAboutBuilding Permit #527-15 - 304 CHESTNUT STREET 12/5/2014i Permit No#: Date Issued: 1 LOCATION. BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 1. L IMPORTANT: Applicant must complete all items on this Dave A PROPERTY OWNER__,.C.. Print 100 Year Structurg MAP PARCEL: ZONING'DISTRICT.�Historic.District yes g yes no :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 ❑ Septic ❑ Well ❑ Floodplain El Wetlands ❑Watershed District ❑ Water/Sewer DESCRIPTION, -WORK TO BE PERFORMED: 09 E / Identification - Please Type r Print Clearly OWNER: Name: [ aiZL - .4-et,7 r �l,� Phone: %)9 %75,, ,, �cf Address:_ �i C_A e 5 th l S fr -ee f -1-706Contractor NameT�Aat_ _ Phone: - _ �l % r •� 3 , L Address"/ �IG�� Italf. C< I r1 ��! t Supervisor's Construction License: ©5f_6 % Exp. pate-. 06 - - Home -Improvement License:2f ._ 6 'Exp 'Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BAff SED ON $125.00 PER S.F. Total Project Cost: $ 000 FEE: $ �lp Check No.: Zc'e� Receipt No.- ? i NOTE: Persons contract', with unregistered ccoontractors do not have access to the ZZ u anty fund Signature ofAgent/Owner-ature of contrac o4 _ Location 1 6UAIU4-56-42+ No. 617, Date 4 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee vV�''� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # U 0 Building Inspector Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Sw"'uning Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature_ CONSERVATION Reviewed on Signature COMMENTS L 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 6M usgooci street FIRE DEPARTMENT - Temp ,Dumpster on site yes no Located at 124 Main Street Fire' Department signature/date COMMENTS Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. 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 Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ 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 Li 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 0 oS 0 0 a i r vii=<m 6 to 0 CD 0 � CD C) m O .�'� M Q- C.)3 N• Z p =r =r N —1 p NdF FD y �I C rt p 0 CL m =r `C 23 CD W N -a y p -� _ N CD = o Q � D O �. O a 0 --4to C7 '° two a► O o B 30 O oo = (Dco CD cD O� Z� Q. --lomov .r-• rrn � aF)T. _? n.f O : CD p O CL �• c0 c z �' cue rt- P 4, 0C/CL 0 to ) c0 p OQ. N CL CD rn N 7�(D CL Q �q * ? Er �CD CD O 3 n VJ CD -I- 00 -ro _ :DcZ' Z '_' C CD 2 U3 --1 Cl) moo' .« CQ CD (A CDs. C O CD �D Z r may,. 0 rt - O CD c� n CD CD z �� r - c : :. O m: d� m : = �• CD a« p m p C S.' N o ro NO z P W C (D „ v 0 rri Z T 7 A O an S N v' n 7O0 T 7 N fD f1 `° m O 00 S m m > H A T j' O 00 S c W G) H A 3 3 O c S O 7 Q w r' b - c ° In H T 0 N n „ 3 O Q \ s O O O S rn 2 E 4E r�;v sr Page # of pages J 5 PROPOSAL SOBMrM TO: JOB NAME JOB # LADDRESS � JOB LOCATiOj� � DATE DATE OF PLANS . � < 6 �` 2C211' It ARCHfrECT fIlle hereby submit specifications and estimates for: I Y /Ve.propose hereby to furnish material and labor — complete in acro�ance withthe above specifications for the sum of:. U V1 with payments to be made as follows: / Any attention or deviation from above specifications involving extra costs Respectfully will be executed only upon written order, and will become an extra charge submitted .over and above the estimate. All agreements contingent upon strikes, \accidents, or delays beyond our control. Note — this proposal may be withdrawn by us ff not accepted within f _ 01crepiance of Propool r The above prices, specifications and conditions are safisfactory and are — hereby accepted: You are authorized to do the work as specified. Payments will be made as outlined above. Signature Date of Acceptance Signature A aILX. a A-NC3M9/T.3850 09-11 A-NC3819 /T-3850 - 3 -part carbonless contractors proposal Page # of pages ��Ip1F'7' S 1 PROPOSAL SUBMITTED TO: JOB NAME JOB # / v ADDRESS C t eS 0 JOB LOCATIZ A 0 C� )Cl J � DATE BATE of PLANS PHONE # FAX# ARCHITECT Ve hereby submit specifications and estimates for: oil tames � �- �, C,G C4 to AZrI i, 1,710 r Ich14 1 ` X` e f e propose hereby to furnish material and labor — complete in $ � Llon c) with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs will be executed only upon written order, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, \accidents, or delays beyond our control. ante with the above specifications for the su/mof:1 f mile 7 o oq(��'/U I� `@dit� Respectfully submitted Note—this proposal may be withdrawn by us if not accepted within days. 00, cceptance of Vroponl C16 . The above prices, specifications and condig are satisfactory and are _ hereby accepted. You are autho*d�o as specified. Payments will be made as outlined above. Signature Date of Acceptance Signature (� Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the 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 Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Name �v C,=anJy Name y/ vl f' V �'(1(►�� Street Address (do not use a Post Office Box address) 3051 C4' 4sf�t, f Contractor/ Sales on/ Owner Name ao O e Lit e- 104 Cityffown State Zip Code I)O- r,e►- u, 0Fg Business Address (must include a street address) % Daytime Phone Evening Phone City rn State Zip Code Mailing Address (It different from above) Business Phone Federal Employer M or S.S. Number Lary requires that moll home Home lmprovemrnt ContractorR�. NumW Expiration dote Improvement contnrtan have -lid registntion number 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 bed pse additional sheets if necessary.) 2e�nav�e �cKtSIt oL,p,Wault XpZ9hg 595 apa 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 contractors control arise (Owners who secure their own permits will be �l excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work. MGL chapter 142A.) �� `1-7_ Y-,9atc when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work, fitmish the material and labor specified above for the total sum of Payments will be made according to the following schedule: $ 060 upon signing contract (not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater) $__77 by _/_/ or upon completion of $ I& _ by / / or upon completion of $-Y'060' upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following materiallequipment 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 of the 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 of the work described regardless of the actions of any third party/snbcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and laborunder this apreement 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 hnorovement Contractor Registration. 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 ofthis form and get a copy of due 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 of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Tsve identical copies ofthe contract.must he completed and signed. One copy should go to the home— er. The other copy should be kept by the contractor. 0AX H meo e Vo ractor's Signature 2- Z 0'QZ Date FDate 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 hnprovement 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 is not 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 du licate 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 IniMierself 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 littp://Nv%vNv.niass.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 lid://wvvw.niass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.nia.us/homeiinproveinent/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 • 11122/2010 ® DATE(MMIDD/YYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE 1 12/02/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THI CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIE BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE 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 t the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to th certificate holder in lieu of such endorsement(s). PRODUCER - CONTACT A.I.I. Insurance Brokerage of Mass., Inc. NAME: PHONE FAX 183 Davis Street A lair No: E-MAIL P.O. Box 1139 ADDRESS: PRODUCER Douglas MA 01516 INSURED Johnny's Carpentry 37 Canton Street Lowell MA 01852 ATLANTIC CASUALTY INS CO INSURER B: D: oco. GCVICIAW NI IMRPR• 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. IPOLICYEFF LTR TYPE OF INSURANCE ADOL SUER POLICY NUMBER MMIDD/YYYY POLICY EXP MM/DDIYY Y LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY L117001658 01/21/2014 01/21/2015 EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence I $ 1OO,DDO MED EXP (Any one person) $ 5,000 CLAIMS -MADE O OCCUR PERSONAL& ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 $ X I POLICY PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) S ANYAUTO ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS HIRED AUTOS PROPERTY DAMAGE $ (Per accident) $ NON -OWNED AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE S EXCESS LIAR CLAIMSMACE _ DEDUCTIBLE $ - RETENTION S WORKERS COMPENSATION TWCSTATU- OTH- RY$ (fAII� AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEJ i S OFFICERIMEMBER EXCLUDED? (Mandatory in NH) NIA E.L. DISEASE- POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if mom space is required) Contractor SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Laureen Fuller THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 304 Chestnut Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover MA 01845 AUTHORIZED REPRESENTATIVE W 11100-LUUN AW.VRIJ%.vRr Vrw i ry IV. nu,Iynw rW-1VVv. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD Page # of pages �e hereby submit specifications and estimates for Cj CA I ►n S' �'� � i� C � �-- CSU Gl 'P � Y VA vl / Op Zile propose hereby to furnish material and labor — complete in $<� v with payments to be made as follows: with the above specifications for the sum of: 1Z/I) (/ v 0 O vIp r, Any alteration or deviation from above specdications involving extra costs Respectfully will be executed only upon written order, and will become an extra charge submitted over and above the estimate. All agreemerds contingent upon strikes, ,laccidents, or delays beyond our control. Note — this proposal may be withdrawn by us if notaccepted within days. Al Rcceptance of proposal The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Signature 4?ZZCV —6 Date of Acceptance A-NC3W9/T-3M 0311 I . All work shall be completed in a professional manner and in compliance with all building codes and other applicable laws. 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 Tesponsible for the proper completion of this Contract. 4. Contractor shall furnish Owner 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 and/or Additional Work Authorizations shall be in writing and signed by both Owner and Contractor. 6. Contractor warrants it is adequately insured for injury to its employees and other 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 remove all debris and leave the premises in broom -clean condition. 9. In the event Owner shall,fail to pay any periodic or installment paymaent due hereunder, Contractor may cease work without breach pending payment or resolution of any dispute. Failure to make payment within days from the due date of payment Shall be deemed a material breach of this contract. 10. All disputes hereunder shall be resolved by binding arbitration in accordance with the rules of the American Arbitration Association., 11. Contractor shall not be liable for any delay due to circumstances beyond its control including strikes, casualty or general unavailability of materials. 12. Contractor warrants all work for a period of days following completion. Note: This form is not a substitute for the advice of an attorney. Legal advice of any nature should be sought from competent, independent, legal counsel in the relevant jurisdiction. Absolutely no warranties are made regarding the suitability of this form for any particular purpose. hk .Tisa Comla2onwe#th of Massac/itesetts - Departmentof-' dostriglAccid&N Office of Invesfigations 600 Washington Street Boston, MA 02111 -www.mass:gov/dia Workers, Compensation Insurance A ridavit: Builders/Contraeiors/EXvr�ra awIPlumberg Name (Business/organizadon/individud): Address• Ciiv/Siate/Zip: L6e fl Z l ( 10 4., , SA Phone ,AXeou an employer? Check the appropTiate box: 4 ° I a general contractor and I 1. 1 am a employer with �— employees (fall and/or par- time)•* have liixedthe sub -contractors listed on the attached sheet. 3 2.0 I am a sole proprietor orpariner� ship and'have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myselfi [No workers' comp. insurancerequired.] i These sub -contractors have workers' comp. insurance. 5. 0 We are a corporation and its officers have exercised&air right of exemption per MGL c. 152, §I(4),and wehave no employees. Lao workers' comp. insurance required.] Type orproject (required): 6. 0 New construction 7. [] Remodeling 8. 0 Demolition 9. [] Building addition 10.0 Electrical xe*s or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other -Any applicant that checks box41 must also fill outthe section below showing their workers' compensation policy information. -Homeowners who submit this affidavit indicating they Rdoing allworlc end then hire outside contractors must submit a new affidavit indicating such. ?Contractors that checkthis box must attached an additional sheet showingthe name o£the sub contraefors and Their workers' comp, policy information. X aryl an employe? that isproviding worlters' compensation insurance for° my en2ployees:.Belo» is the policy and job site information. f / / / - h Inswaucc Cam policy Policy # orS�lf ins. Lic. #: W S J s J O 5;4-0 Expiration Date: 61 Job Site A/� ddress: Attach. a copy of the workers' cornpensationlpolicy declaration page (showing the policy number and expiration date). Failure to secure coverage as required -under Section 25A, of MGL o. 152 can lead to the imposition of criminal penalties of a s wellas oivil penalties ha the form of a STOP WORK ORDER and a fine fie up to $1,500.00 and/or one=year imprisonment, a Of up to $250.00 a day against the violator. Be advised that a copy of this statement: maybe foiwaxdedto the Office" of Investigations of the DIA for insurance coverage verification. Ido hereby certify Un!&- the pain/Js and penalties Of/perjury that file information provided aboveais true /wand correck off eial use only. Do not Write in this area, to be completedby city or town off tial. City or Town: Permit/License Issuing A.uthtority (circle one): 3. City/Town Clerk 4. Electrical Inspector 5. Plutmbinglnspector 1. Board of Health 2. Building Department 6. Other Phone Contact Person: 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 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 wdeceased 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 snore than three apartments and who resides therein, or the occupant of ilio 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 p ermit to operate a business or to construct buildings is 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 itspolitical 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 phone numbers) along with their certificates) 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, apolicyisrequired. De advised that this affidavit may be submitted to the Department of Industrial Accidents for confumation 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 for you to fill out in the event the Office of lnvwtigatlons has to contact you regarding the applicant. Please be sure to fill in the permitTcense number which will be used as a reference number. In addition, an applicant that must s ubmit multiple permit/licama applications in any given year, need only submit one affidavit indicating current policy information (ifnecessmy) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamp ed or marked by the city or town may be provided to the applicant as pro of that a valid of idavit is or file for future p ermits or licenses. A new affidavit must be fWgd out each year. 'Where a home owner or citizen is obtaining a license oz permit not related to any business or commercial venture (Le. a dog license orpermit to burn leaves etc.) said person is NOTrequired to complete this affidavit. The Office of Investigations would like to thankyou in advance for your cooperation and shpuld you have any questions, please do nothesitaieto give us a call. The Department's address, telephone anal faxnumber: �'ho �oxl?�oa��vealt� of�assa�huSP�;` . - Wputmentciff dmWal AccldenL% Moe ofI estigWo>rts 6.0 1 asl p p. SJxe,�,t Boston, MA 021. It TeJ. # 61.7.72,' -49QQ axf 40,6 or 1 -8,77 -MA SSAFE Revised 5-26-05 Fax # 617"727"7749 ; � . -'b t: s . o %.o } �M \ \ } «.$w°® ®. ¢ \\?\f���/ g�■q4 \§/��. o §\ ( .) 2 2 y`\01r1:1 , } m *y # 2 � nJ® 2 /\ . §2 f. ;= ƒ E . §ƒ ƒJ 4m / ; � . -'b t: s . o %.o } �M \ \ } «.$w°® ®. . C6 0' � \\?\f���/ o EE7 , m *y nJ® 2 / � . � zr • 12/3/2014 8:54:05 AM PST (GMT -8) FROM: 100005 -TO: 19784411282 Page: 2 of 2 0 A o CERTIFICATE OF LIABILITY INSURANCE O? E (MMIDD/YYYY) 71202014 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 terns 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 endorsements . PRODUCER MONICA INS AGENCY 19 MILL STREET LOWELL, MA 01852 CONTACT NAME: PHONE N Nn: EMAIL ADDRESS: INSURERS) AFFORDING COVERAGE NAIC #600 INSURERA : LibertyMutual Fire Insurance 33 INSURED JOAO BATISTA DE ALMEIDA DBA JOHNNY'S CARPENTRY 37 CANTON STREET, FLOOR 2 LOWELL MA 01852 INSURER B : INSURERC: 04SURERD: INSURER E: MSURER .. VVYCKAVCJ v�r�urrvr.i�nv....�..• cwww, 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 REDUCEDBY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUER WVD POLICY NUMBER POUCY EFF MMIDDIYYYY1MM1DUIYYYy11 POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY Liberty Mutual Fire Insurance f All,[ III --d EACH OCCURRENCE $ DAMAGE r $ CLAIMS MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY IS GEN'LAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ PRODUCTS - COMP/OP AGG $ POLICY PRO LOC P O- $ OTHER: LIMIT AUTOMOBILE UABLITY Gui SINGLE Ea ac c idem $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHFOULFD BODILY INJURY (Per accidenl) $ AUTOS AUTOS NOWCWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Feridenl $ acc $ UMBRELLA LIAB OCGUU R EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB FIDED CLAIMS -i A RETENTION_ WORKERS COMPENSATION � WC2-31 S-373064-014 5/16/2014 5/16/2015 .� STATUTE ERH E.L. EACH ACCIDENT $ AND EMPLOYERS' LIABILITY Y / N1000000 ANY PROPRiETOR/PARTNER/ XECUTWE OFFICERlMEMBER EXCLUDED? ❑Y (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA E.I.. DISEASE EA EMPLOYE $ 1000000 E.L. DISEASE - POLICY LIMIT $ 1000000 DESCRIPTION Of OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space le required) Workers compensation Insurance coverage applies only to the workers compensation laws of the slate MA. THE WORKERS' COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR JOAO BATISTA DE ALMEIDA. This certificate cancels and supersedes all previously issued certificates, Only as they relate to workers' compensation coverage. GtKIII*i1t MULVtK ORATION — SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE LAUREEN FULLER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 304 CHESTNUT STREET ACCORDANCE WITHTHE POLICY PROVISIONS. NORTH ANDOVER MA 01845 AUTHORIZED REPRESENTATIVE 1� Liberty Mutual Fire Insurance f All,[ III --d ©1988-2014 ACORD CORP V ACORD 25 (2014!01) The ACORD name and logo are registered marks of ACORD CERT NO.: 21525201 CLIENT CODE: 1402264 Lucy Garfield 12/?/2014 11:50:14 AM (EST) Page I of 1