HomeMy WebLinkAboutBuilding Permit #684-12 - 325 GREAT POND ROAD 3/29/2012TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received I✓�
Date Issued:
IMPORTANT: Applicant must complete all items on this paize
LOCATION 3
C f 0
PJ
i1 Qi
Residential
PROPERTY OWNER
In rl
`-Pr t
U�
I Unit #
❑ Addition
❑ Two or more family
Print
❑ Alteration
MAP NO: U'47 I PARCEL -V V ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
100 year-old structure 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
�� Septi ell- ,.
tom,: ,�etlands
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DESCRIPTION OF WORK TO BE PERFORMED:
Y , "o Y A" Yt 14 c e -e-)-e L.tx:a ..i ( A V-
Ladentification Please Type or Print Clearly)
OWNER: Name: v-\ 0 Phone:
Address: 3 L)(,e-,,J
CONTRACTOR Name: Phone:
Address: A
\..I 94--d
Supervisor's Construction License: Exp. Date:_
Home Improvement License: i@W 13240�ZQ Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ a , FEE: $.Crib
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access)6*e guaraily fund
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. ❑
PermanentDumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION
11
COMMENTS
f
HEALTH
COMMENTS
Reviewed on Signature
Reviewed on Signature
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:
FIRE DEPARTMENT - Temp Dumpster on site yes.
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Located 384 Osgood Street
no
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 servicedroprequires approval of
Electrical Inspector Yes
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 - Date
Doc:.Building Permit Revised 2011 June/mi
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
(VOTE: 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
MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
Location GST �OhG� /-2900"'
No. 6 S Date���
Check # // 0
25141
TOWN OF NORTH ANDOVER
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Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
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office of Cons,, rr Affairs &Adi�m��m�uHOME IMPROVEMENT CONTRACTORRegistration: .,1.37640 Type:'1�- -1/2012 Private CorporaboExpiration: JIANNA CURRAO67 LOWELL BLVDMETHUEN, MA 01844 Undersecretary
-Department of'PublicConstruction Supervisor LicenseLicense: cS 93041
ANNA CURRAO
G7LOVVELLBLVD `
METHU2N MA 01844
'
Expiration: 2n12013
S
This form satisfies all basic requires
language to protect homeowners
Massachusetts Consumer Guide to! I
Office of Consumer Affairs and Bus
Homeowner II>if
Name
Street Address (do not use a Post Office j
City/Town State : I
Daytime Phone
Address (It different from
ome Improvement
of the state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard
legal advice if necessary. Any person planning home improvements should first obtain a copy of "A
Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the
Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. .
address)
�,&
Zip Code
Phone
Contractor Information
Contractor/ Salesperson/ Owner Name
D"Smess Aaaress (must include a street address)
Business Phone
Late requires that most home
improvement contractors have
a valid registration number
U *.-
State Zip Code
C)
1 eaeral
er ID or S. S. Number
Reg. Number IEx
The Contractor agrees to do the following work for the Homeowner:
(Describe in detail the work to completed, ,sp�ecc'ifying the type, brand, and grade of materials to be used, use additional sheets if necessa
LA)
� � r , � c:: �1' S %1 � � ✓J�r G , `J r f Y 2 Y
r m (ivy CL (W n S j.
p%i6n)CkinvC. 0 ins%I,C%
n (01:7 v� 1c9,wc.ler 5h;¢eclNs
;p ed &c eft' rob U 5,r�CJ Ceriu�rte-cY.14 a,CLA 4'C�':'c
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 control arise
(Owners who secure their oven permits will be
excluded from the Guaraniy fund provisions of a D
MGL chapter 142A.) ate when contractor will begin contracted work
! q Date when contracted work willbe substantially completed.
i
Total Contract Price and Payment! Schedule
The Contractor agrees to perform tel work, fiunish the material and labor specified above for the total sum of:
Payments will be made according to;the following schedule:
$ 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
$ U� by / j, or or upon completion of
$ALA upon completion 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 work begins in order
to meet the completion schedule ('k*) $ 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 l (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.
1';x ress Warranty - Is an exress warran bels rovided b the contractor.
❑ No ❑ Yes all terms of the warran v 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/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 agreement
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�
e Don't be pressured into si I
going the contract. Take time to read and fully understand it. Ask questions if something is unclear.
• Make sure the contractor has alvalid Home Improvement Contractor Registration. The law requires most home improvement contractors and
subcontractors to be registered1with the Director of Home Improvement Contractor Registration. You may inquire about contractor
registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757.
• Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to
see a copy of a "proof of insurance" document.
• Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy 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 main) of�xce 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 ARF �y BLANK t l
Two identical copies ofthe contract must be completed and signed. One copy should go to the homeowner. The other copy shouldept by the
e
,Ho downer'sZSigrtatu�re� j
Date
C actor's Signatu e
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 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.
H�Aieowner`s Signa e ontractor'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 sijzned by the barties. i
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 anyway, 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 con&ct 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 receii 'ed a fully executed copy of
tine contract, and the three day rescission period has expired.
Accelerated Payments
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the
homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself
to be financially insecure, the contractor may require that the balance of fiends not yet duel 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 ! j
10 Park Plaza, Room 5170, Boston, MA 02116 j
617-973-8787, 888-283-3757 or visit the OCABR website at lam://wwtiv.m'ass.izov/ocabr/
If you want to verify the registration of a contractor or if you have questions or need addiiip nal information specifically
about the contractor registration component of the Home Improvement Contractor Law, contact:
Director of Home Improvement Contractor Registration I
Office of Consuumer Affairs and Business Regulation
10 Park Plaza, Room 5170, Boston, MA 02116 1
617-973-8787, 888-283-3757 or visit the HIC website at http://www.mass. ov/ocabr/
Go online to view the status of a Home Improvement Contractor's Registration: I
h-Ltp:Hdb.state.ma.us/homeimprovement/licenseelist.asp
For assistance with informal mediation of disputes or to register formal complaints against a business, call:
Consumer Complaint Section
Office of the Attorney General
617-727-8400
AND/OR
Better Business Bureau
508-652-4800, 508-755-2548 or 413-734-3114
Version 2.1-11/22/2010
••L ••`' %.#r -r% i itmok%i c yr LimQ,L-,
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Hasbany Insurance Agency
236 Pleasant Street
Methuen, MA 01844
CONTACT
NAME: Jansen
PHONE (978) 685-3188 FAX N ; (ass) 685-9460
ADDRESS: eric@hasbany.com
PRODUCERR2520
INSURE PAS) AFFORDING COVERAGE NAIC 9
INSURERA:CT — Western World
_
INSURED
INSURERS:MA - W C - Travelers
Julien Dupont
INSURER C:
DBA Julien Dupont Construction
INSURER D: 1
20 May Lane Drive
INSURER E:
Salem, NH 03079
INSURER F: 1
PRODUCTS - COMPIOPAGG 1 S 2,000,000
v♦ nv�aua-��.
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 ANDCONDITIONS OF SUCH POLICIES. LIMITS SHO"44 MAY HAVE BEEN REDUCED BY PAID CLAIMS. _
INSRj jAODL�SUBR POLICY EFF POLICY EXP
LTR I TYPEOFINSURANCE j i i POUCY NUMBER I MIDDIY MMIDUYYWY i UMTS
1 GENERALUAe1LITY
AIfC,ERCIALGENERAL LIABILITY
IAWfSASADE OCCUR
'
INPP1167773
7/13/11
I
7/13/12
I
EACH OCCURRENCE 1 S 1,000 000
D"AGE TO RENTED 1S 50,000
P EMiSU-tEa occ mencet
MED EXP (Ary one person) I $ 5 000
PERSONAL BADV INJURY S 1,000,000
GENERAL AGGREG1 ATE I S 2 000-! 000
+I GENTAGGREGATELIMITAPPUESPER
I X !POLICY JECT t I LOr,
I
I
PRODUCTS - COMPIOPAGG 1 S 2,000,000
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
ANY AUTO
I ALLOVJNEOAUTOS
SCHEDULEDAUTOS
I
(Esaccidert) I S
I BODILY INJURY (Per person) S
I BODILY INJURY (Per axiden[)1 5
PROPERTY DAMAGE S
I (Peraccid-nt)
HIREDAUTOS
NONmOWNED AUTOS
1 S
j:
UMBRELLA LIAB
I EXCESSUAB
OCCUR
CLAIMS-MADEI
I
I
EACH OCCURRENCE S
AGGREGATE S
f�
1 DEDUCTIBLE
I S
I
I
S
N RETENTION S
I
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y f N
ANY PRRMEN ORlPACLUDEEXECUTNE
OFFICERMEk13ER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N / A�
'
9889M298 UB
8/20/11
8/20/121
V,1C STATU• OTH-
I X I FR I
_
E.L. EACH ACCIDENT I S 1,000,000
DISEASE DISEASE -EA EMPLOYEE', S 1,000,000
I� E.L. DISEASE -POLICY LIMIT S 1 , 000 000
I
DESCRIPTION OF OPERATIONS f LOCATIONS /VEHICLES (Attach ACORD 101, Additional Renarks Schedule, if more space is reguired)
v [zoo -AV V-HLvfcU UUKt KAIIQN. All rights reserved.
ACORD 26 (2009/09) The ACORD name and logo are registered marks AC0RD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Eric Jansen
v [zoo -AV V-HLvfcU UUKt KAIIQN. All rights reserved.
ACORD 26 (2009/09) The ACORD name and logo are registered marks AC0RD
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 certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may 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 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 (if necessary) 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. A new 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 NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwoalth, of Massachuse
tts
Department of ludustriai .Accidents
office of Investigations
600 Washington Street
Boston, MA 02111
`del, # 617-727-4900 ext 406 or 1-877:MASSAFB
Revised 5-26-05 Fax # 617 727-7749
w4vwmass,govfdia
The Commonwealth of Massachusetts
Department of IndustriqlAccidents
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: G I'C rn �1- (') D��I Phone #:
Are/fou an employer? Chec t propriate box:
I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have Hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. E] Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roofrepairs
13. ❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. //', ��
Insurance Company Name:. rr 1i - �Gl /If A U t It r s
Policy # or Self -ins. Lie. #: 1(GRq Maq e �% _ Expiration Date: O J
Job Site Address: 3� % l i� U i' �(� ��y City/State/Zip:, P/j 41 (ft IV4
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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided abo a is tru and correct. -
Signature: Date:
Phone #: V "
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 4. Electrical Inspector 5. Plumbing Inspector
6. Other - -
Contact Person: Phone