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HomeMy WebLinkAboutBuilding Permit #331-14 - 334 WAVERLY ROAD 10/7/2014 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: / l Date Received Date Issued: A IMPORTANT:Applicant must complete all items on this page LOCATION .01 eze6 • Pin PROPERTY OWNER ' Tint MAP NO: pAR.CEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Imine family ❑Addition ❑Two or more family ❑ Industrial ❑Alt ation No. of units: ❑Commercial epair, replacement [I[IAssessory Bid g 11 Others: Other ❑ Demolition K Flo _ z"' — ' pawellwn, ❑ odplan ©Wetlnds ' ' ® WatershedkDstrict�I ,� t DESCRIPTION OF WORK TO BE PERFORMED: Q % , Identification YJease Type or Print Clearly) OWNER: Name: Ph e , Address: Phone: CONTRACTOR Name: ✓L' Address: ff—f 6p Z Exp. Date: Supervisor's Construction License: l Home Improvement License: /, � Exp. Date: f ARCHITECT/ENGINEER �`�'a'� Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$72.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ FEE: $ /,__9 O� Check No.: /.� � Receipt No.: 7�� NOTE: Persons contracting with unregistered contractors do not havr,access to uar fund i ___ __--- - --- __ __-__ _-___max_.._>.--+1^ _ a•::.t^ _ -- _ _- -- --------- --- - ;: o ra co`tc i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ FWe]I WERAGE DISPOSAL ❑ Tann ng/MassageBody Art ❑ Swimming pools ❑ j ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ c tank,etc. ❑ ❑ Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS 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 ConneGition/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 COAIMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. t.: 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 fne NOTES and DATA-- For department use ® Notified for pickup - Date Doc:.Building Permit Revised 2008 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 ConstructionSin � gle and rw® 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) ❑ Co of Contract ntract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products . OTE: All dumpster permits require sign off from Bldg Permit q g m Fire Department prior to issuance of B g all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals it the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording is be submitted with the building application Doc: Doc.Building permit Revised 2008mi Location No. 34-f� Date o - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Fee $fl Foundation Permit Fee $ Other Permit Fee $ A r VI)Nh TOTAL $ Check# Ile 26966 Building Inspector Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 93700.00 m $ - $ 116.40 Plumbing Fee $ 14.55 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 14.55 Total fees collected $ 245.50 334 Waverley Road 331-14 on 10/7/13 1/2 bath remodel r -1 - NORTH - w: : E o No. — - �w�, h ," ver, Mass, /o12% c oc"ic Nl w1c. S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT BUILDING INSPECTOR .... .. ........ has permission to erect .......................... buildings on Foundation .. .��...�,�...... . ..4.L�E�:/.,V............................... Rough to be occupied as ..........Ae'1074�,t//14 ... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the app&Z.�;........................................................'......lication Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT 0 STAf/RTS Rough � Lf Service ................................................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE TWO EY & LEGARE CONTRACTING INC . "Couldn't your home use a little TLC?" Specializing in residential additions 87 Belmont Street, North Andover, NIA 01845 HIC #136779 North Andover- 987.685.7447 Facsimile- 978.685.7446 EXI IIBIT B Proposal/Specification Homeowner: Scott Hyzdu Contractor Twomey&Legare Contracting Inc 334 Waverly Road 87 Belmont Street No. Andover, MA North Andover, MA 01845 978-305-2652 (978) 685-7447 The following is a description of work as discussed. • Renovation of new Bath 1. Demo-strip drywall from walls in bath areas,needed for proper pluming/electrical and inspections.Rip up floor to sub floor. Reframe shower wall. Strip tile in shower and cement board. 2. Owner to supply all fixtures and tile with grout. 3. Insulate areas around shower walls.. 4. Electrical to be completed by contractors electrician. 5. Existing plumbing to remain in same location.Install new shot offs to sink and toilet. Plumber to correct plumbing to code. 6. Fir walls as needed in shower area. 7. Blue board and piaster on areas where walls are stripped. 8. Contractor to vent bath fan. 9. All painting by contractor.Paint walls ceiling and trim.. 10.Match all new interior trim as close as possible,add chair rail in toilet area. 11.Install tile on floor and walls above tub area over cement board. 12.Install new baseboard cover. 12. Contractor responsible for all permits and inspections. Sign Date �� Allowance Page Plumber & Electrical $25000.00 Painting $600.00 Tile labor $950.00 Includes cement board and thinset. Permit $200.00 Bath fixtures By owner 1. Sink and faucet. 2. Tub with drain assembly. 3. Shower valve. 4. Toilet and seat. 5. Towel bars, TY holder. 6. Mirror. 7. Tile for floor, and tile for shower& grout. Customer has fixture list. I i 1�Ir®j ect Total and Payment schedule Exhibit D Job Total $9,700.00 Balance 1st signing of contract $11,000.00 $8,700.00 2nd The day work starts $3,000.00 $5,700.00 3rd Completion of plumbing Electrical roughs $4,000.00 $1,700.00 4th Substantial completion of project and final sign off. $1,700.00 Sign Date ' HOME IMPROVEMENT CONTRACT TERMS AND CONDITIONS(MGL 142A) 1.WORK:Provided the Homeowner performs under this agreement,the Contractor shall perform the work on the Property as specified Proposal,attached incorporated herein.The work does not include extraordinary conditions of which the Contractor could not reasonably be aware.If such conditions are encountered,this shall be an additional cost to the Homeowner.Materials selected by Homeowner may have to be ordered or custom made,which items are specified in the Proposal.The Contractor is not obligated to agree to any modifications,extras or change orders unless such items are agreed to in writing-by the Contractor.All extras and changes shall be at an additional cost to the Homeowner.Contractor shall perform the work in a good and workmanlike manner- using materials consistent with this contract.Lawn or Driveway may be damaged by dumpster or equipment.Due to material shortages Contractor may substitute materials of equivalent grade. 2. PERMITS:If a building permit is required for the work,the Contractor shall obtain same as Homeowner's agent.Contractor isnot responsible for any other permits that may be required for the Work,and Homeowner is responsible to determine whether any zoning,planning or wetland related permits or approvals are necessary.Homeowners who secure their own permits or deal with unregistered contractors will not have access to the Guaranty Fund. 3. COMMENCEMENT AND COMPLETION:Homeowner acknowledges the commencement date of the work is fluid,and is subject to numerous factors such as scheduling other contractors,delivery of materials and weather.Contractor and Homeowner shall determine the commencement date of the Work when a more definite determination can be made and shall execute a written acknowledgment of same.The Work shall be substantially completed within 7 days of commencement,except for longer periods as may apply to particular projects as Contractor shall notify Homeowner in the Proposal,and subject to delays for circumstances beyond Contractor's control.Notwithstanding,the commencement date and substantial completion date may be extended,and the Contractor will not be liable for delays caused by,labor or material shortages,delays in delivery of items selected by the Homeowner,governmental action, and unforeseen events beyond the Contractor's control,including but not limited to weather,strikes,war,the acts of third persons or the acts of the Homeowner.The Homeowner recognizes that the commencement date may be delayed due to scheduling or the completion of Contractor's other jobs. 4. PAYMENTS:Contractor agrees to perform the Work and to furnish the materials and labor specified in the Proposal for the amount as stated in the Proposal.Thirty percent(30%)of the total is to be paid as a deposit with the signing of this contract.Upon cancellation prior to commencement of the Work,any remaining deposit will be returned less the costs for materials ordered for which Contractor was unable to cancel.Final payment shall be due upon completion of the Work and Homeowner agrees it may not hold any retainage.Late fees may be applied for late payments.Homeowner shall pay Contractor's reasonable costs of collection,including attorney's fees and costs.Time is of the essence hereof. 5. WARRANTY:For a period of Iyear after substantial completion of the Work the roof will be free of leaks caused by defects in workmanship, but not those caused by ice backing-up or extraordinary weather events,including blizzards,tornadoes,hurricanes or storms of greater than a twenty-five year duration or intensity.Contractor gives no warranties with reference to any materials or equipment installed in the Premises,passes any such warranties directly to Homeowner,and Homeowner agrees to look only to the manufacturer with reference thereto.This limited warranty extends to the Homeowner only and is not transferable to succeeding Homeowners.This Limited Warranty specifically excludes(i)all consequential and incidental damages;(ii) damage due to ordinary wear and tear,abusive use,misuse,or lack of proper maintenance;(iii)defects which are the result of characteristics common to materials used;(iv)defects in items installed or supplied by anyone other than Contractor;(v)work done by anyone other than by Contractor;and(vi)loss or injury due to the elements.There are no other expressed or implied warranties or representations made or given. 6. ENTIRE AGREEMENT:This contract and all documents referenced herein constitute the complete and final agreement between the parties.In the event that any of the provisions of this contract shall be held to be invalid,the remainder of the provisions of this contract shall remain in full force and effect.Two identical copies of this contract have been completed and GISsigned.Homeowner acknowledges receipt of a completed contract signed by the Contractor. >�3 6"�V7 7. HOME IMPROVEMENT R TRA I N:In accordance with M.G.L.c. 142 A,§9,Contractor is registered with the Bureau of Building Regulations and Standards Registration No: Homeowner may verify by contacting the Director at(617)727-3200,ext.25205.A Homeowner's rights under the Home Improvement Law(M.G.L.c. 142A)and other consumer protection laws may not be waived in any way:Homeowner acknowledges receipt of a copy of 780 CMR R6 and Massachusetts General Laws chapter 142A,and which are available online at www.mas*s.gov.Questions may be directed to the Consumer Information Hotline,(617)727-7780. 8. ARBITRATION: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 such dispute to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulations and the consumer shall be required to submit to such arbitration as provided in M.G.L.c. 142A.No lien or security interest is imposed on the Property as a consequence of this contract,but Contractor has the right to record this contract or a notice of this contract,or seek a lien if the Homeowner breaches this Contract. 9_ HOMEOWNER COVENANTS:The Homeowner agrees,represents and warrants that(a)the Homeowner grants permission to the Contractor to enter the Property to perform the work as covered by this contract;(b)the Homeowner has funds available to make full payment under this contract to the Contractor upon completion;(c)the Homeowner understands that construction as contemplated by this agreement creates a dangerous condition,and agrees not to enter portions of the Property under construction until the Contractor advises the Homeowner that the construction is completed;(d)Contractor may need use landscaped areas of the yard during the Work and Homeowner is responsible to provide protection for landscaping and(e)that code requirements may result in roofing nails penetratingthrou hkoof decking and will be visible on the underside of some surfaces.The Homeowner indemnifies,exonerates and holds harmless the Contractor from any damage,loss, g ,claim liability or expense(including reasonable attorney's fees,deposition costs and court costs)resulting from a breach of this provision.Contractor is not responsible for damage to landscaping that will grow back during the next growing season. 10.CANCELLATION:Hom wn cancel this agreement provided Homeowner notifies the Contractor in writing at the address listed in the Proposal not later than midnight of the thi d business ay fo lowi the signing of this agreement. HOMEOWNER: DATE: /d '7 KI DEPOSIT: Kightfax C3-1 9/19/2013 5 : 15:55 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATEIMM/DU/YYY)n 19/2013 RTIFICATE 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 PRODUCER. E 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 and endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), PRODUCER ndorsement s- PRODUCER CONTACT NAME: DOHERTY INS AGENCY INC PHONE FAX PO BOX 1985 (A1C,No,EXQ: (A1C,No): E-MAIL ANDOVER,MA 01810 ADDRESS: 22YMX INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: TRAVELERS INDEMNITY COMPANY OF AMERICA TWOMEY&LEGARE CONTRACTING INC INSURER B: INSURER C: INSURER D: PO BOX 366 INSURER E: NORTH ANDOVER,MA 01845 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: RED N ANDM UCY E ' TIG ANYREWRBWW,TERMORO"7MCFANYCaORACroR01HMD0 Y4RHRESPECTTOMICHTMSCERr:rATEMAyBER JEDORMAYPERTAKTWIdSURAN(E AFFORDED BYTHE POLICIES DESCRIBED FER9N ISSIUBJECFTOALLTHETEII NS,D(CLUSICNSANDO0NDnX EBCF SUCH POLICIES t PXrS S 4aM MAY HAVE BEEN REDUCED BY PAID CLAIMS MR ADD SUB POUCY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY MA WR (MIAMYYYY) (MM DDA""M LIMITS GENERAL UABIUTY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE AMAGE TO RENTED $ OCCUR. REMISES(Ea occmence) UPIED EXP(Anyone person) $ ERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICYE]PROJECT❑ ENERALAGGREGATE $ LOC RODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINEDSINGLE $ ANY AUTO LIMIT(Ea accident) ALLOWNEDAUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Peraccident) UMBRELLA LIAB 0 OCCUR EACH OCCURRENCE $ EXCESS URB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND WC SiATUrORY OILER i EMPLOYER'S UABIUTY YIN UB-029OW94-13 09/1812013 09/1812014 X UNM f ANY PROPER11ORPARTNE80 ECUTIVE Q NIA E.L EACH ACCIDENT $ 500,000 OFRCEPA43MBER D(CLIIDED? N-igoryinNl'I) E.L.DISEASE-EA EMPLOYEE $ 500,000 K yes,describe order DESCRIPTICN OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHCLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD S1REEf BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DEUVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENT"YE A NORTH ANDOVER,MA 01845 fC ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1986.2010 ACORD CORPORATION. All rights reserved. JUN-20-2013 THU 04.06 PM FAX N0. 9784750303 P. 14/17 • Client#:13298 T OMEY8 A QRLX. CERTIFICATE OF LIABILITY INSURANCECATE(MWDONYYY) 06/20/2013 PRODUCER THIS CE iTIFICATE IS ISSUED AS A MATTER OF INFORMATION Doherty Insurance Agency,Inc. ONLY A ID CONFERS NO RIGHTS UPON THE CERTIFICATE P.O.BOX 1985 HOLDS .THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 21 Elm Street ALTER HE COVERAGE AFFORDED BY THE POLICIES BELOW. Andover,MA 01810 INSURER AFFORDING COVERAGE NAIC# INSURED INSURER A' krbella Protection Ins Company Twomey&Legare Contracting,Inc. PO Box 366 INSURER B: North Andover,MA 01845 INSURER C: INSURER 0: INSUHER Z. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED AE OVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RE SPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED DY THE POLICIES DESCRIBER HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED SY PAID CLAIMS. ED I fim TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTO EFFECTE POUH UMTS A GENERAL LIABILITY 8500043255 06/22113 06/22114 EACH OCCURRENCE s1 00 .000 X COMMERCIAL GENERAL LIABILITY OA AGF O RENTED x900 Dao CLAIMS MaOEX OCCUR MED EXP(any IXr9 oorson) $5000 PERSONAL 6 ADV INJURY 31 000 000 GENERALAGGREGATE $2 000 000 GEN'L AGGREGATE LIMIT APPLIES PEA; PRODUCTS-COMP/OP AGG S2 000 000 X POLICY PRO- LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT S (EP BCCiUdM) ALL OWNED AUTOS SCHEOULEDAUTOS SODILYINJURY S (Per Down) HIRED AUTOS INJURY NO"WNED AUTOS BODILY(PBeIraccidend) CCiq PROPERTY DAMAGE $ (Pat ccggant) GARAGE LIABILITY AU)0 ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC S AUTOONLY: AGO S EXCESSNMBRELW LIABILITY EACH OCCURREryCf g OCCUR F CLAIMS MADE AGGREGATE S DEDUCTIBLE S RETENTION $ S WORKERS COMPENSATION AND WCSTATU- 0TH. EMPLOYERS'LIASILIP/ _11ORILIMITS ,I ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT g OFFICERIMEMBER EXCLUDED7 dyes.Deenre,e under F.L.DISEASE-EA EMPLOYEE S SPECIAL PROVISIONS bega. E.L.DISIFASF,-POUCY LIMIT S OTHER OESCRIPTION OF OPERATIONS J LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PF OYISION5 Covering operations usual to Twomey&Legare Contracting,Inc... CERTIFICATE HOLDER CANCEL LA ION 10 Days for Non-Pa ment SHOULD ANY O 7 THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _.JJL_ DAYB WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO DO 80 SHALL IMPOSk NO OB KiATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATI WFS. AUTHORIZED R 5PRESENT ACORD 25(2001108)1 of 2 #S29374/M29371 PML TION 1988 O CORP CO F - $�'•= 11assachusetts- Department of Public S det., TvBoard of Buddin., Rc�ulittulns and Standards Cfli?SiP 3s tf•3I1 ?3.tyl /fa3i icense License: CS 67560 A OF SHAUN M,TWOMEY `. 61 PATRO(T ST N ANDOVER, MA 01845 r .. Expiration: 10/25/2013 t',rrtuni�s e,rrer Tr-: 4913 1 SMassachuseDcs; -Departrneri '1, '113fc S y ' Construction Sup re-isor License: CS-055108 .L DOUGLAS J LEGARE ..- 79 GARY AVE HAVERHIL:L MA 0183E1 Cn s issi ne= 09/02/2014 - - �/1LT�C771:T7[G97CfrCrl�1/t C� •l(f�'S3f///1�/SC��3 Oflice of Consumer Affairs S.Business Regulation .. :_ OME IMPROVEMENT CONTRACTOR Type: ffilP;i=liegistration: 136779 }-' Partnership � :Expiration: -P261201 — 14 TWOMEY+LEGARE.GONTRACTING INC. SHAWN TWOMEY 87 BELMONT ST. — N.ANDOVER,MA 01845 Undersecretary The Commonwealth of Massachusetts Department of Industrial Accidents J Office of Investigations . 600 Washington Street Boston, NIA 02111 www.in assa ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/21umbers Applicant Information Please Print Leelbly Name (Business/Organization/Individual): J tooYI? g-`!' T [ l}�-film fi/ Address: cz107 City/State/Zip: IV #AV o�lz- IMI Phone#: 9 7,e_ 6�i'��'7 el V 7 Are yjm an employer? Check the-appropriate box: Type of project(required): 1. I am a employer with t:2-- 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).T have hired the sub-contractors 2.F-1I am a sole proprietor or partner- listed on the attached sheet $ E] Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. F-1 Building addition [No workers'.comp. insurance 5. ❑ We•are a corporation and its required.] officers have exercised their 10.0 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.❑ Roof-repairs insurance required.] t employees. [No workers' 13.❑ Other comp.insurance required.] `Any applicant that checlm box#1 must also fill out the section below showinglheir workers'compensation policy information.' t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContracton that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am all employer that is providing foorkers'compensation insurance for my employees. Below is the.policy and job.site information. Insurance Company Name: Policy#or Self-ins.Lic.#: L1,6— 6 ,,;29 b M 177'q q / 'I— Expiration Date: Job Site Address: City/State/Zip Attach a copy of the workers' compensation P/Iicy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under 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 againstthe violator-.-Be advised that a copy of this statement may be forwarded to the Office of Investigations•of the DIA for insuzance coveragt.verification. I do hereby cer ify er lie pains and penalties of peijury that the information provided above is true and correct Si- -attire: Date: Z /� Phone Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitlLicense# 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#: