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HomeMy WebLinkAboutBuilding Permit #54-15 - 32 DUFTON COURT 7/16/2014BUILDING PERMIT O� tLeD bq\ TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received ls�ADRTED IPP,�9/ Date Issued: I I IMPORTANT: Applicant must complete all items on this page I LOC PRC MAP iviaur nr is a[ iup v w me -10, W-10— r6--� TYPE OF IMPROVEMENT PROPOSED USE Resi ntial Non- Residential ❑ New Building Wbne family 0 Addition 0 Two or more family 0 Industrial 0 Alteration No. of units: 0 Commercial ❑ Repair, replacement 0 Assessory Bldg 0 Oth 0 Demolition 0 Other ;qq 0 Septic 0 Well 0 Floodplain 0 Wetlands 0 Watershed DisVct 0 Water/Sewer -Jdentification - P e Typepr Print Clearly OWNER: Name: /-A /q .7—o n Address: Contractor Name: Address: Supervisor's Construction License: b.©� Exp Home Improvement License: / ? /S Exp T 041'- 14Z � Date:;%�/�, Date: ARCHITECT/ENGINEER a6/%C© Phone: !-?2 5'? i Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $ tpz� v� Check No.: Receipt No.:�� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ;Signature of Agent/Owner signature of contractorIle Location 7Z 1 C -r— No. Date Check # C/ 2//U; TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fe,� $ TOTAL $ Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS R 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 FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS r Dimension Number of Stories:_ Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use ❑ Notified for pickup Call Email Date Time Contact Name 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. Roofin , Siding, Interior Rehabilitation Permits lading Permit Application 7hrkers Comp Affidavit oto Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract a Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan a Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) a Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application Li Certified Proposed Plot Plan a Photo of H.I.C. And C.S.L. Licenses Li Workers Comp Affidavit Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) a Copy of Contract a Mass check Energy Compliance Report o 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 JUL-16-2014(WED) 13:14 (FHX)9785572130 P.001/001 SAABM-1 OP ID: JY CERTIFICATE OF LIABILITY INSURANCE DATEIMMIODNYYY) 07/16/14 1 WIS 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($), 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 statoment on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone: 978 688 8829 Michaud, Rowe And Ruscak Ins. Fax: 978 557 2130 P.O. Box 188 North Andover, MA 01845 Mark S. Rowe, CIC CONTACT AMM PHONE - SAX _UVc,.Na.EI:D:_._.. _. _71 Q, Nor: EMAIL - -- ADDRESS:.,,,,_-_ AUTHORIZED REPRESENTATIVE I EACH OCCURRENCE INSURERS) AFFORDING COVERAGE NAIC N INSURER A:Travelers insurance Comp Dy - INSURER 8: INSURER C: _ ____ COMMERCIAL GENERAL_ LIABILITY CLAIMS -MADE I OCCUR INSURED Mitchell Saab 57B 57B Bridge St. Salem, NH 03079 INSURER 0: 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. Ih1SR TYPE OF INSURANCE POLICY NUMBER MM �DNYri POLICY MID NEYYY LIMITS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN GENERAL LIABILITY 384 Osgood Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE I EACH OCCURRENCE S PRGMISr:^ Faocru onto MED EXP (lulY One person) COMMERCIAL GENERAL_ LIABILITY CLAIMS -MADE I OCCUR $ $ „•, _—__• PCRSONAL & ADV INJURY $ $ GENERAL AGGREGATE CtML AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP ACC S POLICY 7 PRO LOC $ - AUTOMOBILE UANUTY COMBINED SINGLE LIMIT ANY AUTO BODILY INJURY (Per person) S ALL OWNED AUTOS SCHEDULED AUTOS HIRFD AUTOS NON -OWNED AUTOS BODILY INJURY (r'er ecddenl) _ POOPERIY-UAMA'E Per secide l $ $ UMBRELLA LIAR OCCUR EACH OCCUR .ENCS $ EXCESS UAB CI.AIMS-MADE AGGREGATE $ DED RETENTION S $ WORKERS COMPENSATIONWC STATU. o -m - A AND EMPLOYERS' LIABILITY ANYPROPRIF,TOR/PARTNER/FXECUI•IVE YIN OFFICENIMEMBEH EXCLUDED? N / A 6KU556666127-13 10/23/13 10/23114 E.L. EACH ACCIDENT S 100,000 _-•. E.L. DISCASE -EA EMPLOYr:F (Mandalory In NH) Us% describe under DESCRIPTION OF OPERATIONS brlow $ 100,000 •--- F 1• DISEASE - POLICY LIMIT S 500.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Atteeh ACORD 101, Additional Remarks Schedule, N more space Is required) CERTIFICATE HOLDER CANCF1 I ATTIM NORTH13 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 384 Osgood Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE I ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD E J W x LL C' 0 m O N t u Y \ O E N U O- O C. z Z _ �I m C O N "O 3 t =) N C _ O W H Z Z C G J d L m. ..� O 0. Hu Z V J W t m u •� 0 a Ln H Q (7 t N W F. �. 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Q .Q O .4+ Z O U U) c N D � rJ �C l%67)LIItCJl[!C(l�f� (��•([CI+.iClC�IGiCI>!3 Office of Consumer Affairs & Business Regulation Ri ME IMPROVEMENT CONTRACTOR istration:171835 Type: piration::.4/24(2016 DBA MITCHELL SAAB GENERAL CONTRACTOR MITCHELL SAAB 57 BRIDGE ST 4� SALEM, NH 03079 Undersecretary t - i#araif?gYa - • :S`Yaaai•73eaiEh - - NITCHEtt --A -ked' s- - -+f Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor { License: CS -0208.64 MiTCEIELL L SAO 57 BRIDGE ST =` SALEM NH 0301 == a MAN" Expiration Commissioner 07/23/2015 �- '�''� CER /ATE OF LUABlL11Y INSURANCE I - Tllls CEKIIRM M IS ISSUED ASA MMER OF NERNMUM ONLY AND COMMSO FdMM WON IRE tEitlVICATE MBEIL IM t R78Rt:KiE DOES mw M MMIP ..Y OR 188SI IVELY AMJD; EMMID OR ALTER IEE CMUMM AIVOR ED BY TIE POLICES . 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F ....... .,.......... ................ .:................ ATTN..........................:............. ... ....... ............ DATE: .............................:............................................... Typeof work ............ a .................................................. PROPERTY ................ ..... LOCATION We propose to furnish all necessary labor, material, and equipment (except as noted below) to perform the following work in First Class workmanlike manner. Roof maintenance is required annually. Not responsible for water back up caused by snow and ice. Scope of work........_:.,.....:....:. ., ..............:. ,,...:... ................ _ _....._...........: ................................... ,. .., ....... ,.. ,, T , ... ._ ............c ........................................... ...,.....................•............................ r............. ................ F. .f............ a ............. .........a. ........... ...................r....... .................... .. ........................ •1 ......�f.:........ .....,'............................................. F .. •............ .'.J.......................... _.............. ................ .f •........................ ......................�.. .................. x... n .... .i. ..............,................................ r ................................................................. f r..... ...F. . a .. .. .. .n, .. .r. .... ...,................................. ...... ................... ..... ................ ........V............t.................v................... 1. r ... '............. w. ., ,_................................................ For the Sum of ..: ...... ......:... ............................................... Signedby............................................................................... "� c u V taction) i ft they h Law provides Jlomeowners with the right to initiate an arbitration action (as are ar'temative to court action) if thephave a disputa with a contractor. The same right is not as automatically afforded to a contractor, however. The contractor would have to resolve ay dispute he/she hwith aomeowner in court unless h ' , r both parties agree to the optional clause provided below. Tnhis clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The erning this and the homeowner her may I dally agree in advance that in the event the contractor has a dispute concerningthis contract; the contractor may submit the dispute to aprivate 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 afib it to such arbpration as provided In Mam-khusetts General laws, chapter 142A (__ f — '17 _ .—6ua�uin - v / Contractoz's Signature IaI®TIC>v: ne signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The hoin ownermay initiate alternative dispute resolution even where this section is not separately signed by the narFiac Hormeowner's Rights A homeowner q rights under the Home Improvement Contractor Law (MGL chapter Protection laws (ice. MQ chapter 93A) 142A) and other consumer may not be waived in any way, even by agreement. However, homeowners maybe excluded from certain rights if the contractor they choose is not properly registered as prescribed by Iaw. 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. The may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship ormate provided by the contractor, all goods sold in Massachusetts rials, In addition to guarantees or warranties y an implied warranty of merchantability and fitness for a Particular purposeAn enumeration of other matters on which the homeowner and contractor lawfull added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If e bmay e . questions about your consumer/homeov er 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 do cement until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with aiiachmants is to be given to the owner and the other kept by the contractor. Any modification to the original contract must m in writing and agreed to by both parties. rescission Contracn work may not begin until both parties have received a fully executed copy of the contract, and the three day rescissionperiod has expired. Accelerated )Payments A contractor may not demand payments in advance of the dates specified on the payment schedule incases where the homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself to be financially insecure, the contractor may require that the balance of fiends not yet due be placed in a join{ escrow account as a prerequisite to continuing the contracted work Withdrawal of fiords from said account would require the signatures of both parties. Additional information Ifyou have general questions or need additional in#bmlation about the Home Improvement Contractor Law or other contact: consumer rights, or if you Wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" Consumer Information Hotline Office of Consumer Affairs and Business Regulation a, Room 5170, Boston, 2116 617-973-8787 88g-283-3757 or ParkPlvisitt the OCABR websitehat 1 Ott//v,�i w mass c�ov/ocabr/ If you want to verify the registration of a contractor orif you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Rome Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 ParkPlaza, Room 5170, Boston, MA 02116 617-973-8787, 888 283 3757 or visit the HIC website at http://weary mass I-IncaN Go online to view the status of a Home Improvement Contractor's Registration: NUPI/db.state ma us/homeimproyementnjcenseelist acn For assistance with informal mediation of disputes or to register formal complaints against a business, tali: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800, 509-,755-254g or 413-734-3114 VmSfOn 21-11122/2010 This form satisfies all basic requirements ofthe state's Homelmprovement CentractorLaw (MGL chapter 142A) but does notiarIude standard + Ianguagetoproteethomeowners. SeeItlegal advice ifnecessary. Anypetsonplanning home improvementsshonldfustobtainacogypf A Massachusetts Consumer Guide to Home Improvement" before agreeing to any work on yourresidence. You may obtain a free copy by calling the + Office of consumerAffairs andBusincss Regulation's Con erWoimatioa Hotline at 617-973-8787 or I-888 283-3757 or on our website+ 38(OFneownerinformation . Goutrac.orTmforimation, e CompanyWame S etAddnss(do not use, Post Officr reC dress) Contractor/STalespersonlOwnerName Cityffawa State Tip Code BusinessAddress (must moludeastreetaddress) DaytimePhone Evening Phone 10wrown Z-- ran rcgnirev tLut m ost 5mae Impmremeut coatmdo:s Lure amtld rV5fr Con number The Contractor agrees to do thefollowingworltfor the Homeowner. (Describe in detail the workto completed, specifying the IyT , brand, and grade of materials to be used, Mr additional sbeets ifnecessa_ .) Required Permits -Ile following building permits arerequired and wIll be secured by the contractor as thelromeownees agent (Owners who secure thele oven Permits will be excluded from she Guaranty.11 nd provisions of MGL chapter I42A,.) wort Pavm onf C..T,oi,.t., Proposed Startand Completion Schedule - The followingschedole will be adhered to unless Circumstances beyond the contractofs control arise Date when contractor will begin contracted work Dais when eentmcted Work will be substantially completed. The Contractor agrees to perform the work, firnish the material and labor specified above for the total sum of: Payments will be made according to the following schedule: $ upon siguing contract (not to exceed 113 ofthe total contract price or the cost of special order items, whichever is greater) $ by / / or upon completion of $ by or upon completion of $ upon completion ofthe contract. (Law forbids demanding fim payment until contract is coamleted to bothp 's "sfaction) The following materiaVequipmeat must be special $ to be paid for ordered before the contracted work begins in order to meet the completionschedulm(Se) � to be paid for NOTES: (p) Including all finance charges ('N') Law requires that any deposit or down-paymeotregvired by tfie contractor before work begins may not exceed the greater of (a) ---third oftha total contract price or (b) the actual cost ofany special equipment or custom made material which must be special ordered in advance to meet the completion schedule. a esswarranty-tsaneruresswarrantvbeingRrovidedbythecontractor? UN UY(alifermsofthewarrantvmustbeattachedto ontra_ctl Subconfractors -The contractor agrees to be solelyresponslble for completion ofthe work described regardless ofthe actions of any third party/subcontraefor utilized by the contractor. The contractor further agrees to be soIelyresponsible for all payments to all subcontractors for materials andlabor under this agreement Contract Acceptance -Upon signing this document becomes a binding contract underlaw. Unless otherwise notedv&bdn this document, the coniractshallnotimpIythatanylianorothersecurityinteresthasbeenplacedontheresidence. 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. o I fv aka sure the contractor bas a valid Home Imurovement Contractor Reeistration. T1te Iaw requires most home improvement contractors and subcontractors to be registered with the Director ofHome 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 catling 617-973-8787 or 888-283-3757, o Does the contractorhave 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 e now your rights and responsibilities. Read the important Information on the reverse side of this form and get a copy ofthe Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the contractor is vziting at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight ofthe third business day following the signing of this agreement Seethe attached notice of cancellation fora for an explanation ofthis right. DO NOT SIGN TMS CONTRACT IF TmR�.4IdE ANY BLANK �i'?aC JSI!1 Two ideotieaicopiesoflheconhactmu5 ecompietrdandsigned. Oneccpyshoeldgototheh==mer. The othercopy slmutdhekeptbyf cc"bector. U/5 � 1 Homeowmees Signature Contractor's Signature Date Data Required Contract Terms . The Official Website of the Office of Consumer Affairs & Business Regulation (OCABR) Mass.Gov Consumer Affairs and Business Regulation Page 1 of 2 Home > Consumer> Home improvement Contracting > - { Required Contract Terms4-- W� •', �..;. i i Contracts - all contracts over $1,000 (One Thousand Dollars) must be in writing. NEWS & UPDATES r-• The law requires the following FOURTEEN items to be included in any contract between a homeowner and a OCA Survey Finds One Five registered home improvement contractor for home improvement work subject to MGL c. 142A: g p p � t � HomelmprovementContractor 1. The complete agreement between the contractor and the owner and a clear description of any other documents € Advertisements Placed by Unregistered Entity which are part of the agreement. i 2. The full names, federal I.D.pumber Cif applicable), addresses (NOT P.O. Box numbers), of the parties, the i More... contractors registration number, the names) of the salesperson(s) involved, if any and the date the contract was Subscribe I Learn more executed by the -parties. - 3. The date on which the work is scheduled to begin and the date the work is scheduled to be substantially completed. RELATED LINKS 4. A detailed description of the work to be done and the materials to be used. 1 Yon Gid Konsomate 5. The total amount agreed to be paid for the work to be performed under the contract. r Massachusetts you Reparasyon nan Kay 6. A time schedule of payments to be made under the contract and the amount of eachpayment stated in dollars, including any finance charges. Any deposit required to be paid in advance of the start of the work SHALL exceed one-third of the total contract price or the actual cost of any material or equipment of a special order or custom made nature, which must be ordered in advance of the start of the work to assure that the project will proceed Gufa para el Consumidor de on schedule. No final payment• shall be demanded until the contract is completed to the satisfaction of all parties. Massachusetts para M joras en el Hogar 7. All parties must sign the contract. 1 Gufa para el Consumidor de 8. A clear and conspicuous notice stating: Massachusetts para Mejoras en . a. That all home improvement contractors and subcontractors shall be registered and that any inquiries about a i et Hogaz contractor or subcontractor relating to a registration should be directed to: Office of Consumer Affairs and Business Regulation Ten Park Plaza, Suite 5170 Boston, MA 02116 Phone: (617) 973-8700 b. The contractor's registration number must be on the first page of the contract. c. The homeowner's three day cancellation rights under MGL c 93 s 48; MGL c 140D s 10 or MGL c 255D s 14 as may be applicable. d. All warranties on the owner's rights under the provisions of and MGL c. 142A. e. In ten point bold type or larger, directly above the space provided for the signature, the following statement: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. f. Whether any lien or security interest is on the residence as a consequence of the contract. 9. An enumeration of such other matters upon which the owner and contractor may lawfully agree. 10. Any other provisions otherwise required by the applicable laws of the Commonwealth. 11. Permit Notice: Every contract shall contain a clause informing the owner of the following: a. any and all necessary construction -related permits; b. that it shall be the obligation of the contractor to obtain such permits. . c. that owners who secure their own construction -related permits or deal with unregistered contractors shall be ex lu from access to the Guarantee Fund. 12. Acceleration of payment: No contract shall contain an acceleration clause.under which any part or all of the li"-//www:ma..Rs. aev/7naQelD=ocaterminal&L=3&LO=Home&L1=Consumer&L2=H•ome+,.. 9/1/2011 Page 2 of 2 balance not yet due may be declared due and payable because the holder deems himself to be insecure. However, where the contractor deems himself to be insecure he may require as a prerequisite to continuing said work that the balance of funds due under the'contr-t, which are in possession of the owner,shall be placed in a joint escrow account requiring the signatures of the home improvement contractor and the owner for withdrawal. 13. No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract. 14. Arbitration: If the contractor determines that in the event of a dispute, the contractor wishes the dispute to be settled by arbitration, this fact must be signified on the contract and both the contractor and owner shall sign this clause separately. The following format is acceptable (in 10 point type or larger); i "The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this contract' the contractor may submit such dispute to aprivate arbitration service which has been approved by the Office of Consumer Affairs and Busines Regulation and the consumer shall be required to it to such arbi at F is as rovided in MGL c 142,41f Owner: Contractor: NOTICE. The signatures of theParties above apply only to the agreement of theparties to alternate dispute resolution initidted by the contractor. The owner may initiate alternative dispute resolution even where this section is not signed separately by the artier. " © 2011 Commonwealth of Massachusetts http://vwvw.mass.gov/?pageID=ocatermin.al&L=3&LO=Home&L1=Consumer&L2 Home+... 9/1/2011 MAN The Commonwealth of M'assaiOusetfs - Department ofindus%iql-Accidiinis Office of ffivestigatroas 664 Washington Street Boston, .MA 62111 www.mass gov/clia i7iTnrrYzeYc� iyomnensationlfo ranceAffidav�it: Bader, Phone Phone #: 4U,�.��.. Are you an. employer? Check the appropriate box: Type of project (required): r 1. LK I am a employer with �,� 4- El am a general contractor and I 6. New construction. employees (fullandloxaa have hired the sub -contractors listed on the attached sheet: t 7• ❑Remodeling 2.E1 I am a sole proprietor or partn.ex ship and`havena.employees These sub -contractors have 8. E] Demolition working forme in any capacity. workers' comp. insurance. 5. ❑ We are a corpora] on and its 9. [] Building addition tN'o worlrers' Pomp. jnsurance officers have exercised 10.[] Electrical repairs or additions I required.] 3. ElZ am a homeowner king all work -their right of exemption per MGL 11.[] Plumbing, repairs or additions Myself Voworkers' comp. c• 152, §1(4), andwehaveno 12,[] Roofrepairs insuranceregalred.] employees. jNoworkers' comp. insurance required.] 13.[] Other xAny applicant that checks box#I must also fi11 outthe section below showingtheir workers' compensation policy information. :Homeowners who submit !big affidavitindlcatnjtfiey k4 doing allworKand then hire outside contractors must submit a new affidavit indicating such. lContractors that checktbis box must attached an additional sheet showingthe name ofthe sub. -contractors and their workers' comp. policy information. I am an employer that it providifcg woPkeJV cofnpef�sation irzsr�Pance foP fry employees Bat W is the policy M111 h site info,�fnatioft. �, � Insurance Company Policy ## or Selz ks.Lic. #: r �3 Ys� Expirat onDa%: Tob Site Address' ��'�on rCity/State/�ip:�s�iQG{D!1'�i t'' /� ✓at.� Attach a copy of t�e workers' comp ensation-policy declaration page (showing the p olicy number and expiration! date). Failure to secure coverage as requireduunder Section 25A of MGL o. 152 can lead to the imposition of criminalpenalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil. penalties in the form of a STOP WORD ORDER and a fate ofup to $250.00 a day against the violator. Be advised that a copy of this statement may ba forwarded to the Office of Investigations ofthe DTA. for insurance coverage verification. t do IiePeby cert y under tZ p/a�ms and enaZtae of pePjzcPy t}Zat irZe in OPfnatiOn pPOVided a700' rs iP�u d eoPxeet. Phone #: Off eial use 0111y. Do not write in this area, to be cojgfeted by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. BuildingDepartmeut 3. CitylTowa Clerk 4.Electrical Inspector 5. Plumbznglnspector 6. Other - - - Information andInstructions Massachusetts General Laws chapter 152 requires alt employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person thi the service o£another under any contract ofhixe, express or implied, oral ovwritten!, An employe is defined as "an individual, partnership, association., corporation or otherlegal entity, or anytwo oxxnore Of the foregoing engaged in a joint enterprise, and includingthe, legal representatives of wdeceased employex,.or the receiver ortrdstee of'an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having notm.ore than three apartments and who resides therein, or the occupant ofthe 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 bean employer." MOL 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 fox a)ay applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chaptex 152, §25C(7) states "Neither the commonwealth nor any of its political subdtvhons shall enter into any contract for the performance ofpublic work until acceptable evidence of coprpliance with the insurance requirements of this chapter have beenpresentedto the contracting authority.." Appucants Please fill out the workers' compensation affidavit completely, by checking ilia boxes that apply to your situation and, if iiecessat% supply sub -contractors) name(s), address(es) andphonenumber(s) along with their cerecate(s) of insurance, Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notrequired to carry workers' compensation insuramce. IfamLLC oxLLP doeshave employees, apolicy is required. Be advisedthatthis affidavitmay be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. .Also be sure to sign and date the affidavit. the affidavit should be returuadto the city or town that the application for thepennit or license is being requested, xtot the Department of industrial Accidents. Should you have any questions regarding the law or if you are xequired to obtain a yTorkexs' compensationpoltay, please call the Departmentatthe number listed below Self-ir s red companies should enter their J self-insurance license number on the appropriate line. City or Town Officials -" Please be sure that the affidavit is complete andprinted legibly. The Department has provided a space at the bottom of the affidavit foryou to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be -sure to fill in the permit/11cense number whichwill 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 (if necessary) and under "Yob Site Address" the applicant shouldwrite "all locations in (city or townn)" .A` copy o£the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proofthat a valid affidavit is on file for future permits or licenses. A new affidavit must be idled out each Year. Where a liome owner or citizen is obtaining a license ox permit not related to any business or commercial venture j (i.e. a dog license orpermit to burn leaves eta.) said person is NOT required to complete this affidavit. The Office of fhvest gations would like to thank you iu advance for your cooperation and should you have any quewons, please do not hesitate to give us a call. The Department's address, telephone aitd faxnumber: The Ca on-w:eaMofMu-saokwefts - �?opa�xre�l; Office offAvostigAvo.na 6b Wasbhj on 8�:eet Bmton,UA02111 T01# 67.7-72'4-4900 o A 406 or. z~87.7, �'�i Revised 5 -26 -os Fax # U M27 7749 ' w�w•za�a�s,gov�dia