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HomeMy WebLinkAboutBuilding Permit #523-13 - 31 PHILLIPS COURT 1/22/2013BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 3 — I 1 A+6- Date Received Nun In Qf ttLED 16 q4C T % TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition [moo or more family. 0 Industrial g -Alteration No. of units: C7 Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: 0 Demolition u_ .� ©Se tic1�Ilelt� X�© f"�a�#. F ±phi=. N`P�1y. ��� ❑ Other �. k�V1liter IodIp�aanFaU/etlads.� PTIG `��."Xl--,. K # �•+ he ®Itici�r� s � %�17 a �"3•.Sk�e S�^.M y�,,�yl,.Z ,� ^�,,�R+`��' ;' 9�, M i wi. �1� �+A 'k❑S.W /�GwG�4' 'C,F^t�Fbi �. �}"" S`{�' .�^� h Lro :r. t!�t���l��aG-. �gi�'"� '�'y� �o: "�.i� -� 1 t ?�' t d �A 't N�' z. r i'L'T� §�> tt �'N' .f- �l ` ��i � 1 "vi^3 t.. C�' f�� l j'a X 'c"C ^X y �T x'Pr �' P' S l t:.. �.d. .Fw� �..�F�. 2J,..Kr,.�3....•a.._.. .. l.+.fa'v..�+.1i,...c.. �i*�'�Y"{ al'. _DE5(;KIF I JUN UI- VVUKM I U 6C rRr-rUr% . OWNER: Name: A _, J !'1UU 1 GJJ. ARCHITECT/ENGINEER Address: Type or Print Clearly) q .�'(� � Phone: l � �� � Phone: Reg. No. _- FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ �'� ��' FEE: $ 1G Check No.:� Receipt No.: 0 NOTE: Persons contracting with unregistered contractors do not have access to thenty fund 41 a t Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/MassageBody Art ❑ w / r _ rica Swimming Pools ❑ Well ❑ Tobacco Sales ❑ I Z S- t 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 ❑ COMMENTS CONSERVATION ❑ COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED N] DATE REJECTED DATE APPROVED ❑ ❑ Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer-Connection/Si nature & Date Driveway Permit Located at 384 Osgood Street Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine Doc.Building Permit Revised 2007 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract - ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location 33 P16111?,5' 61 No. �d3 -13-4- .5a3-13-3 -4- 6-,23-13-3 A Date aoz TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL Check# 26102 Building Inspector LAWRENCE H. OGDEN, P.E. 198 EAST MAIN STREET GEORGETOWN, MA 01833 978-352-8318 fax 978 —352-2858 cell: 978-502-5921 March 23, 2013 Mr. Mike Rodden 47 Prescott Street North Andover, Ma. 01845 RE: 31-33 Phillips Court, North Andover, Ma. 01845 Dear Mr..Rodden As you requested I visited the site 3/22/13 to review the installation of the Engineered Materials consisting of LVLs and Lally Columns utilized in the framing of the above project. These are shown on plans S-1 & S-2 prepared by me dated 2/3/13 and certified by me 2/18/13. Based on the above site visit and based on what I could visibly see. I can certify that to the best of my knowledge the LVLs members utilized in the framing as shown on the drawings are installed properly and meet the loading conditions of the 8th Edition of the Massachusetts State Building Code for 1 &2 Family Residences. All other framing requirements of the drawings and code, including but not limited to materials, nailing schedules, blocking, connections, manufacturers installation requirements and other details are the responsibility of the licensed construction supervisor responsible for the project. Should you have any questions please do not hesitate to call. Yours truly, thencde H. Ogden P.E. Structural 27765 ;.w iaw LO`y 3 �2 3/13 o r, YO�v - Enter construction cost for fee cal - - North Andover -Fee Calculation Construction Cost 601000.00 m $ - $ 720.00 Plumbiri Fee $ 90.00- 0.00-Gas GasFee 100 comm. $ 1'00.00 Electrical Fee $ 90.00 Total fees collected $ 1,000.00 31-33 Phillips Court 523-13 on 1/22/2013 Two kitchen renovations l Enter construction cost for fee cal - North Andover Fe@ Cakulaflon Construction Cost $ 609000.00 m $ - $ 720.00 Plumbing Fee $ 90.00 Gas Fee 100 comm. $ 100.0.0 Electrical Fee $ 90.00 Total fees collected $ 1,000.00 31-33 Phillips Court 523-13 on 1/22/2013 Two Kitchen Renovations ` rk� f a� 0 It a O o o LA. O a m O LL E v u (. N Z - c7 o c b 7 LL t 7 K c E U C U: Z m d O7 LL' G LL Z Q � L 0.0 O _U VI LL O W Z �^ L C LL W a a LU LU y ` co Z i., v N u O VI n O C O W :a a� cc :Llz �E * � O•��:co :o r S� E Q. CD �s J C ••:Ecm =� l oIVA �,Q P � •�; � o � Z 'o �. m E O. CL . y Lu y H- o o _ a� moo= > a� e. 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Sox 1023 State Road, Stow, MA 01775 PERMIT LGl North Andover Permit No ( City of Town) (Lf Applicable.) D. in accordance with the provisions of M. G.L l 4 8 Chap.ter_LL as provided in section- S 2 7 (M R 3 4 Start Date This Permit is granted to: Full name of person, Firm or Corporation Permissionto locate dumpster for construction/renovation/demolition of buildi Comments dumpster must be.25' from structure if unable to place with required Restrictions: clearance/dumpster must be covered with plywood or tarp end of 'work -day at ( Give location by streetand no., or des in such manner as to provied adequate identification of location ) Fee Paid s 5 0.0 0 F h y:... ire Chief This Permit will cxpire• —/ ( S igna ical grantirig"perYnit) Offical granting pern it ( Title ) . Massac ,usetts Home Improvement Sam �e Contract 'I 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 toy Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and 1A iness Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283.3757 or on our website. . Homeowner Formation Contractor Information Name Company Name -Street Address(doh(notuseaP�o`stOffic�e�Bo(x`address) Contractor/ Salesperson/ Owner Name City/TownStat '7! Zip Code J Business Address (must include a street address) AW Q\1 tAR1 �e�c k �k Daytime Phone Evening Phone City own State Zip Code Mailing Address (It different from above) Business Phone IPederal Employer ID or S.S.Number Home Improvement Contractor Law requires that most tomo improvement contractors have J/�C a valid registration number V I 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.) Q�_ IIal -lei Required Permits -The followinglbuilding 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 cool arise (Owners who secure their 6Wn permits will be ntr excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work MGL chapter 142A.) i Date when contracted work will be substantially completed. Total Contract Price and Paymerat!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 tothe following schedule: it upon signing contract (not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater) $ by /_; or upon completion of ------- by or upon completion of 'i $ upon completion i i the 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 rSock begins in order to meet the completion schedule i(**) $ to be paid for NOTES: (*) Including all finance charges (**) Law requires that any deposit or down -payment worgins may not exceed the greater of j (a) one-third of the total contract price or (b) the actual cost of any special equipment oor re custom made material which must be special ordered in advance to meet the completion schedule. 1 x resswarran - Is an ex ress warran beinz rovided by the contractor. N. Subcontractors -The contractor agrees to be solely responsible for completion of he workd scr bed regardless of the actio s of any thud ontract 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 a eement 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! I • Don't be pressured into signing� the contract. Take time to read and fully understand it. Ask questions if something is unclear. o Malce sure the contractor has alvalid Home Ira rovement Contractor Re'stration- The law requires most home improvement contractors and subcontractors to be registerediwith 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. o Does the contractor have insurance? Ask the Contractor for his insurance company infor�iation so that you can confirm coverage, or ask to see a copy of a "proof of insurance" document. o Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the 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 maim 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 si9*19 of this agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT SIG'N',TEAS CONTRACT IF THERE ARE ANY BI,SPACES!!! Two identical copies ofthe contract must be completed and signed. One copy should go to the homeowner oUt oA h acontractor. ept by the H e Amer's Signature Contractor's Signature Date 2) i > Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate aniarbitration 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 firml 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 toe alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolli tion even where this section is not separately sinned by the Darties. 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. i 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 receiMed 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 hin-/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 duel be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of fiends from said account would require the signatures of both parties. Additional Information 1 If you have general questions or need additional information about the Home Improvements Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: I I Consumer Information Hotline Office of Consumer Affairs and Business Regulation ! j 10 Park Plaza, Room 5170, Boston, MA 02116 j 617-973-8787, 888-283-3757 or visit the OCABR website at littp://www.Lnass.E ov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additi� nal information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: I Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 i 617-973-8787, 888-283-3757 or visit the HIC website at http://www.lnass.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 j 508-652-4800, 508-755-2548 or 413-734-3114 j Version 2.1-11/22/2010 Page I_ of I RODDEN CONSTRUCTION License #28538 47 Prescott St. Expires: 09/05/2013 N. Andover, Ma. 01845 978 687 2934 PROPOSAL TODAY'S DATE 1/21/13 JOB NAME Kenneth Elliot DATE OF PLANS/PAGE #'S JOB LOCATION 31 - 33 Ct., North Andover, Ma. 01845 -Phillips We propose hereby to furnish material and labor necessary for the completion of: Supply materials and labor for total kitchen renovations in both unit 31 and 33 Phillips Ct. Remove all cabinets, counters, int. trim, flooring and plaster walls and ceilings. Electrical will include relocating some existing circuits and adding additional circuits including lighting and also connecting the new appliances. Plumbing will include rerouting some existing heat, water and drain lines and also connections to the new appliances. Insulate all exposed ext. walls using fiberglass batts and poly vapor barrier. New walls and ceilings will be 1/2 " blueboard and plaster skimcoat. New int. trim to match existing. New flooring to be ceramic the over plywood underlayment. Work will be done on a time and material basis with carpentry rates of 49.00 per hour. Any additional labor will be billed accordingly. All subcontractors and all materials will be billed at cost with no markup. Invoices are payable upon receipt. No painting is included in this estimated cost. Allowances are as follows: Kitchen cabinets, counters, and appliances ( each side 12,500.00) = 25000.00 Electrical materials and labor= 10000.00 Plumbing materials and labor= 6000.00 Flooring materials and labor = 4500.00 We propose hereby to furnish material and labor - complete in accordance with above specifications for the sum of: Estimated cost of sixty thousand dollars ( $ 60.000.00 ) Payment as follows: Invoices payable upon recent All material is guaranteed to be as specified. All work to be completed in a substantial workmanlike manner according to specifications submitted, per standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our workers are fully covered by Workmen's Compensation Insurance. If either party commences legal action to enforce its rights pursuant to this agreement, the prevailing party in said legal action shall be entitled to recover its reasonable attorney's fees and costs of litigation relating to said legal action, as determined by aye-__nfpetent jurisdiction. Authorized Note: this proposal may be withdrawn by us Aw Signature if not accepted within 30 dais. ACCEPTANCE OF PROPOSAL The above prices, SignaturefVkjj 1 14 id specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Signature Payment will be made as outlined above. Date of Acceptance WWW.THECONTRACTORSGROUP.COM & Diane Dennis Enterpnses 0 2004 PROP-001.pdf Rev 10-04 ACORN® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDYYYY) 01/22/2013 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 08 NORTH ANDOVER INSURANCE AGENCY, INC. CONTACT NAME: PHO AIC'.0, Ext: (978) 686-2266 ja/c, No): (978) 686-6410 ADDRESS: cfernandez@nafins.com M.J. FOSTER INSURANCE SERVICES 163 MAIN STREET CUSTOMER ID aRODDEN CARPENTRY INSURERS AFFORDING COVERAGE NAIC # NORTH ANDOVER MA 01845-2508 INSURED INSURER A :MERCHANTS INSURANCE GROUP 23329 INSURER B :TECHNOLOGY INSURANCE CO RODDEN CARPENTRY INSURER C 47 PRESCOTT ST INSURER D / / INSURER E DAMAGE TO RENTED 500000 INSURER F NORTH ANDOVER MA 01845— 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 LTR TYPE OF INSURANCE A O INSR S BR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DDIYYYY) LIMITS A GENERAL LIABILITY Y OPI054995 02/01/2012 2/01/2013 EACH OCCURRENCE $ 1,000,000 / / / / DAMAGE TO RENTED 500000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ r CLAIMS -MADE a OCCUR / / / / MED EXP (Any one person) $ 15,000 PERSONAL E ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: / / / / PRODUCTS - COMP/OP AGG $ 2,000,000 $ X POLICY PRO LOC JECT / / / / A AUTOMOBILE LIABILITY MCA7015515 7/16/2012 07/16/2013 COMBINED SINGLE LIMIT $ 1,000,000 / / / / (Ea accident) BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED AUTOS X / / / / PROPERTY DAMAGE SCHEDULED AUTOS X HIRED AUTOS / / / / $ (Per accident) $ X NON -OWNED AUTOS / / / / UMBRELLA UAB HCLAIMS-MADE OCCUR / / / / EACH OCCURRENCE $ AGGREGATE $ EXCESS LAB / / / / DEDUCTIBLE $ / / / / $ RETENTION $ / / / / B WORKERS COMPENSATION TWC3341295 01/01/2013 1/01/2014 XWC STATU- OTH- AND EMPLOYERS' LIABILITY ( Y / N / / / / ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 100,000 OFFICEWMEMBER EXCLUDED? N / A / / / / (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ 100,000 If yes, describe under / / / / I DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space is required) CERTIFICATE HOLDER CANCELLATION ACORD 25 (2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025 (200909) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF NORTH ANDOVER 120 MAIN STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845- ACORD 25 (2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025 (200909) The ACORD name and logo are registered marks of ACORD M The Commonwealth of Massachusetts - Department of1ndustr1g1 Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):����� Address:_' City/State/Zip:� Phone Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with I 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors ,.._,/ 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t �• L� Kemodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance.g• ❑Building addition [No workers' comp. insurance 5. [J We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roofrepairs insurance required.] i employees. [No workers' .13.[j Other comp. insurance required.] 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they Aire doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy anal job site information. Insurance Company Policy # or Self -ins. Lie. #: i'� 1 e(5 Expiration Date: Job Site Address: — L �r 0 �� �� �_� 4 L 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 requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA. for insurance coverage verification. Ido hereby certto under tla ains 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: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other - - 4. Electrical Inspector 5. Plumbing Inspector 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 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 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 three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be, deemed to be. an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) 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 an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of 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 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 is on file for future permits or licenses. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOTrequired to complete this affidavit. The Office of Investigations would like to thank you in advance. for your cooperation and should you haveany questions, please do not hesitate to give us a call. • The Department's address, telephone anal fax number: The Compaonwealth of Ma ssa.o v..sotts Depadment of Wdustrlal Accidents office OfInvestigati ms. 600 Wasbi Won Street Boston, MA 021 It Tel, # 61.7-727-4900 at 406 or I-877;NI.ASS.A.FB Revised 5-26-05 Fax # 617^727-7749 WVVw.t7 ass,gov/dia