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Home My WebLink AboutBuilding Permit #350 - 34 Camden Street 10/31/2006 V TOWN OF NORTH ANDOVER NORTH APPLICATION FOR PLAN EXAMINATION oft.��° �a''a 0?*a�;:r._ ,. '• � 070 i Pernlit NO: �� Date Received� ab Date (ssued:/6}-3/—c1 �,SSACHUSEt�� IMPORTANT: Applicant must complete all items on this page LOCATION _5�61 Cam /-i��i?�Ie,T- Y°t Z ,f PROPERTY OWNER f� j, C 6t t 5�_Print C�, l Print MAP NO.: PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES 0 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑New Building ❑O cfamily. 0 Addition eT wo or more family ❑ Industrial 0 Alt-Qration No.of units: Repair, replacement 0 Assessory Bldg 0 Commercial Demolition Moving(relocation) ❑Other ❑ Others: ❑ Foundation only DE ION OF WORK TO BE PREFORMED l Ty- R e ) ee �P2Gj ;�e�toUz Dei � i Identification Please Type or Print Clearly) OWNER: Name: 11A Ch `t�l 54— Phone: �l 3 Z S5 Address: -� DC' 5 � 1q e V M :\. CONTRACTOR Name:— `2 �� 1Glwile q cz 6"r7� Phone: Address:_ Supervisor's Construction License: Exp. Date: J6 P p Home Improvement License: /3 7� y3 Exp. Date: ARCHITECUENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT. $11.00 PER$1000S.F. . OF THE TOTAL EST/MATED COST BASED ON 5115.00 PER S Total Project Cost :$ /J�; 35C� /6Q X FEE:$ z Check No.: _l� Receipt No.: Page lof4 Location Date AL-2/-64- TOWN L'2/-tomTOWN OF NORTH ANDOVER O 41 R 9 4 Certificate of Occupancy $ Ss�cMusE` Building/Frame Permit Fee $ Foundation Permit Fee $ k Other Permit Fee $ TOTAL $ ' Check # . 19751 'Building Inspec or TYPE OF SEWERAGE DISPOSAL Tanning/Massage/Body Art Swimming Pools L Public Sewer Tobacco Sales 1--J Food Packaging/Sales i_! Well Permanent Dumpster on Site Private(septic tank, etc. i Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor,%'—, � Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS FIRE DEPARTMENT - Temp Dumpster on si yes no Fire Department signature/date COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water&Sewer connection/Signature& Date Driveway Permit Building Setback ( Front Yard Side Yard Rear Yard Re wired Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA—(For department use) Page 3 ufi Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Cremes JMC.Jan.2006 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 Addition Or Decks ❑ Building Permit Application ❑ 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) 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 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 DEPAR'rN1EN'r:8PF0R11II5 Page 4 of 4 10/31/2006 12:07 617 796 0110 -� 19786889542 NO.469 P002 .AG' RD� CERTIFICATE OF LIABILITY INSURANCE REFLECT Bio 3�061 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Corkin Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 180 Wells Avenue HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Suite 301a ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Newton Center HA 02459 Phone: 617-796-0111 Fax:617-796-0110 INSURERS AFFORDING COVERAGE NAIC s INSURED INSURER ST PAUL/TRAVELERS INSURER B: Zurich Insuranee Eerviocs, Inc Lawrence Burn$ d/� a INSURER C: 2 REFLECTION COI;M'RArrT NG Ventura Drive INSURER D: Raymond NH 03077 -• INSURER E: COVERAGES TILE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TUE POLICY PERIOD INDICATED,NDTVOTNSTANDING ANY REAUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFPORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONOITIONS OF SUCH POLICIES.AGGREGATE LIMITS SMO`A N MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER PATE M TE H GENERAL LIABILITY EACH OCCURRENCE 7s- COMMERCIAL COMMERCIAL GENERAL LIABILITY PREMISES(acGxeneel S CLAIMS MADE J OCCUR MED EXP(Any One pmm) 1 S PERSONAL Q ADV INJURY i I GENERALAGGREGATE f GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPIOP AGO f POLICY PROCT El LOC JE AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S iANY AUTO (Ea BCCidenl) ALL OWNED AUTOS BODILY INJURY I SCHEDULED AUTOS (Per person) S HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (FW adaern) i PROPERTY DAMAGE : (Per eoadent) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG 9 EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE I OCCUR F CLAIMS MADE AGGREGATE Z I S DEDUCTIBLE S RETENTION S S WORKERS COMPENSATION AND X I TORYLIMITS I I ER EMPLOYER BANY PROPRIETOROPARTHEREXECUTIME 6ZZUB 0493B15-5-06 02/09/06 02/09/07 E.L. C"ACCIDENT_ 3100000 - OFFICERIMEMBER EXCLUDED? 1.DISEASE.FA EMPLOYEE $100000 I w.,IAL PROVISIONS below 1 do�bo uNor �/J. E.L.DISEASE-POLICYLIMIT {500000 SPEC OTHER DESCRIPTION OF OPERATIONS I LOCATIONS;VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS JOB SITE: 34 CAMEN STREET, NORTH ANDOVER, HA I i ! CERTIFICATE HOLDER CANCELLATION TONNSRI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 8E CANCELLED BEFORE THE EXPIRATION TOWN OF ANDOVER DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRRTEN BUILDING DEPARTMENT NOTICE TO THE CERTIFICATE HOLDER NAILED TO THE LEFT.WT FAILURE TO DO$O SHALL ATTN. OF BRIAN LEATHE IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR AIMVER I m .978-688-9542 REPRESENTATIVES. OQ AUTHORIZED REPRESENTATIVE ACORD 25(2001/08) ®ACORD CORPORATION 1988 i I i 10/31/2006 11:17 9786671018 BRAI NERD PAGE 02 DATE(MNVD0M" 7A=DTM. CERTIFICATE 4F LIABILITY flNURANCE 1or�1,2o06 ODUCER PNM: (1178)07-9031FaM:eTt s7.1DIs 6Nlt� ANO CONFERS NO RIGHTS UPON TT CERTITHl CERTIFICATE F,G SON BRAINERD INSURANCE,INC. HOL R. TNI9 CERTIFICATE DOES NOT AN�ND, EXTEND OR 11 A ANDOVER RD AL R THE COVERAGE AFFORDED 9Y CLICIES BELOW. P O BOX 1042 91LLERICA MA 01521-0742 TNAIC# INSl1RERS>�FFORDING COVERAGE Aped — INSURER_A:—iTravelers Service Center INSURED REFLECTION EXTERIOR CONTRACTING INSURER[4: CIO LAWRENCE L BURNS INSURER -- PO BOX 27 INSUF,ER 6)_ —_.. •• NORTH BILLERICA MA 01662 -- INSURER 1;: COVERAGES THE POLICIES OF ANY REO IREMF•NTNSTERM OR CONDITION OF ANY CONTRACT OR 01HER DTo THE OCUMENnWITFI RE�PFCT OFOR TWHICH THISPCERriFICATE MAY Bt ISSUED 4 DrVO MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 19 BIJBJE-T .D A"0 ALL THE TEAMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGOREOATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS- —• -- — - ... .. ... - .. POLICY NUMBER POLIC. EFFft POLICVOWIRAIM LIMITS Nen MoD TYPEOFINSURAHCE ! 1,000.00 LTR IENCLEACH OC—CURRENCE �OENERALLIABILITY 1x680-907HS073-TCT•0 09,01146 09101!07 OwAQETDRENIEO E 500,000 X COMMERCIAL GENERAL LIABILITY PREMBE6(s.oenm..et ,„ MED.EXP(Any"peroorll E 51000 -, CLAIMS MADE Il, OCCUR PERSONAL A ADV INJURY 4 1,000 000 A GENERALAGGREOATE ! 2,000x000 pEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS_•COMy/oP AOG ! 2x000,000 .•• I POLICY I EC 1 LOC AUTOMOBILE VABILITY ; COMBINED SINGLE LIMIT = (Ea eeeaent) ANY AUTO I BODILY INJURY 6 J ALL OWNED AUTOS I (Per Dpraan) SCHEDULED AUTOS j HIREDAUTOS BODILY INJURY ! - I (Per eccldent) NON-OWNED AUTO 1 (P ' _ ...— PROPERTY DAMAGE S I c;ARaGE LlaeluTY AUTO ONLY•EA ACCIDENT ANY AUTO AUTO THAN _EAACC S AGG Il EACH OCCURRENCE ! ERCESS I UMBRELLA LIABILITY OCCUR I CLAVAS MADE — E DEDUCTIBLE --' - - E RETENTION S ATU MITI; WORKERS COMPENSATION AND roRY u EMPLOYERS.LIABILITY F-,L.EACH ACCIDENT - ! - ANY PROPMETORMARITI®UEMECUTNE ,E.L,DISEASE•EA EMPLOYEE ! _ •OFFICERIMEMBER CULLMIM7 .• - try".desn I E.L.DISEASE-POLICY LIMIT ePECIAL PROVISIONS S edv.r OTMER, = DESCRIPTION OF OPERATIONS,LOCAT10N8ryEH)CLESIEXCLUSION9 ADO i D BY ENDORSEMENTI SPECIAL PROVISIONS CARPENTRY CERTIFICATE HOLDER CA CELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIPe BE CANCELLED BFPORETHE EXPiR*TION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTf=N NOTICE TD THE CERTIF1t:ATE HOLDER NAMED TO THE LEFT,BUT FAILURE TFl 00 0 SHALL IMPOSE NO OBLLGATION OR LIABILITY OF ANY KIND UPON THE INSURER, WS ACI'FNTS OR REPRESENTATIVES. TOWN OF NORTH ANDOVER 1600 OSGOOD ST p41T us REPRESF•NTATIVE N ANDOVER,MA 016454G Attention: BRIAN LEATHE-BLDG DEPT. Gordon C Bralnerd Jr,President ACORD 26(2001!08) Certificate 0 2076 0 ACORD CORPORATION 1966 WORTH_ Town Of .... . Andover 0 0 No. `3'� _ _ _ dover, Mass. cam COCMICMEWICK RATED D C2 Is BOARD OF HEALTH Food/Kitchen PERMIT . T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..............957.09............. ......... .......... ........ ........... .................................. ......... ........... ... Foundation 00ig 00440*0 .......... has permission to erect........................................ buildings on .? ......... .............. ......... Rough . ........... to be occupied as .......... ..... .... ... ......... Chimney provided that the person accept this permit shall In every respect conform to the terms of the application on file in � iso Final this office, and to the provisl of the Codes and By-Laws relating to the Inspection, Alteration and Construction of )th Buildings In the Town of No Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONS CT10N STAR 2 ELECTRICAL INSPECTOR Rough .. ............41 1 0.0 .......................— ................. ...... A�ce B Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Der. The Commonwealth of Massachusetts Department of Fire Services Office of the State Fire Marshal P.O.Box 1025 Stats Road,Stow,MA 01775 PERMIT Date: North Andover Permit No Dig Safe Num er (City of Town) (If Applicable) In accordance with the provisions of M.G.L.l 4 g Cha ter_ 0 as provided in section 5 7 7 G MR 3 4 Start Date This Permit is granted to: �� /1 �'� "L' Full name of person,Firm or Corporation Permissionto locate dumpster for construction/renovation/demolition of building. 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 street and no.,or describe in such manner as to provied adequate identification of location) Fee Paid$ 50.00 C/ r �/ � Fire Chief This Permit will expire 0-3-0(6 (Signature of offical granting permit) Offical granting pemut (Title) i r i 10/31/2006 13:58 9786671018 BRAINERD PAGE 02 DATE(MMMDNM) ACORD CERTIFICATE OF LIABILITY I SURANCE 1or31l2008 PRODUCER Phone: (97oml-4031 FOR ;7a-W7.1010 tHIA CERTIFICATE 19 ISSUED A8 A MATTER OF INFORMATION BRAINERD INSURANCE,INC. ONLIY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1 A ANDOVER RD HO ER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P O BOX 1042 ALTEER THE COVERARE AFFORDED BY THE POLICIES BELOW. BILLERICA MA 01821-0742 INSURERS AFFORDING COVERAGE MAIC# INSURED INSUP.ER r�,J Travelers Senrlee Center _„ _•,., ..— REFLECTION EXTERIOR CONTRACTING INSURER H: C/0 LAWRENCE L BURNS INSURER i:- PO BOX 27 INSURER Il: NORTH BILLERICA MA 01862 ---- "- 1 INSURER COVERAGES ' H POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEO TO THE INSURED NAMETI ABPVE FOR THE POLICY PE 100 INDICATED,NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OP ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT�O ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, - R AD TYPE OF INSURANCE POLICY NUMBER - PoUtYBIKft POI ICYexpmAl1ON LIMITS LTR INIq GENERAL LIABILITY i-880-907H6073-TCT-0 09/01196 ; 09101107 EACh1-OCCURRENCE„ .—�-- - 1,000,OQO _ DAMAOE TO RENTED 300,000 X COMMERCK GENERAL LIABILITY PREMIBrt p-Lw-a02Ka) CLAIMS MADE! OCCUR MED.EXP(AnY Dnb P�eorl) >< 5,000 A PF,RSONAL T,ADV INJURY 1 1,000,000 QENERALAGGREGATE t 2,000,000 GEN'L AGGREGATE LOOT APPLIES PER PRODUCTS.C6IVPlOP AGG, S 2,000,000 PRO- _- POLICY 7 0CT LOC AUTOMOBILE LIAe1LITY COMBINED SINGLE LIMIT S (Ea awdenq ANY AUTO ALL OWNED AUTOS (perPBODILY INJURY (Per pproon) 3 SCHEDULED AUTOS •••• -- '"- HIREO AUTOS BODILY INJURY L (Per@WdgM) MON-OWN PROPERTY DAMAGE R — -- par owiden GARAGE LIABILITY I AUTO ONLY-EAACCIDENT ANY AUTO OTHER THAN EA ACC ,x ... _ AUTO ONLY: AGG II EACH OCCURRENCE S EXCESSIUMBRELLA LIABIUTY .. - ... . OCCUR n CLAIMS MADE AGGREGATE .. 7 .. .. Z DEDUCTIBLE r7" RETENTION$ Ml IITUTw orllEq WORKERS COMPENSATION AND —TORY LIM1Tg - , EMPLOYERS'UABIUTY E.L.EACH ACCIDENT $ ANY PIR)PRIETORMARTFEwEIEcutroE E.L.DISEASE-EA EMPLOYEE A OFFICOW11MBER E710LUDED7 g�y.aaaauartbaandlr E.L.DISEASE•POLICYLIMIT E gpEgAL PROIRSIDNa brow OTHER: DESCRIPTION OF OPERATIONSrLOCATiONSIVEHICLESIEXCLUSIONS AbD t3Y ENDORSEMENT!SPECIAL PROVISIONS CARPENTRY i CERTIFICATE HOLDER CANCELLATION 6W)UL 6 ANY OF THE ABOVE OESCRIBCD POLICIES BE CANCELLED BEFORETHE 134 �_and EXPB2A';ION DATE THEREOF.THE ISSUING INSURER ED To DEE OR LEFT. MAIL N L DAYS Gf S NAFITTEISNONOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TODD SHALL IMPOSE NO OBLIGATION OR LIMILITY OF ANY IOND UPON THE INSURER, TOWN OF NORTH ANDOVER TI'AGENTS OR REPRESENTATIVES, 1600 OSGOOD ST —ATI-00Z—ZD REPRESENTATIVE N ANDOVER,MA 01845 Attention: BRIAN LEATHE-BLDG DEPT. Gordon C Bralnerd,Jr,President ACORD 26(2001106) Certificate# 2075 0 ACORD CORPORATION 1998 S ti Board d Baildiae ReS.hU�.sY' sed Staedards' License or registration valid for indWidal use only HOMEHAPROVEMENT CONTRACTOR before the expiration data If found retara to. ,. Board of BaU iag RsguatMes and Standards Registratkn ' 13760';' 41One Ashbarian Pace Rm 1361 1ZJ13I2Q06 Boston,Ms.02168 TvM: butAfiraL LAWRENCE L.BURNS LAWRENCE BURNS =>: . 5-7 WILSON ST. !'a _�/✓t"" 1_5,e ,- BILLERICA.MA 01862 —t -- - at e .��"' Administrator Not valid without signature LAWRENCE BURNS A REFLECTION OF PERFECTION Rt tkz 11 z &Exteriors Contracting,LLC P.O. BOX 27 N. BILLERICA, MA 01862 PAINTING GUTTERS*PLOWING BUS: 978/663-5840 CELL: 978/833-6025 TOLL FREE: 1-877-PRO-ROOF(776-7663) VISIT OUR WEB: WWW.REFLECnONROOFING.COM Date Customer Quote# Ter ms 8/42006 E62606b 30 Days** ITEM DESSCRIP71ON 3-Tab ARCH Roof: 1 Layer strip and disposal,replacement,ridge venting, 24 Sq. complete paper underiayment,Vice&water shield,drip N/A $9,500.00 edge. Installation of shingle color(oust.choice) Disposal: Thorough cleanup-(Dumpster use is restricted to roofing materials;if customer includes additional waste,the customer shall incur all above weight limit and/or improper Inc. Inc. material disposal charges at the additional expense) Go over installs dumpster not necessary. To Include: Reflashing all walls,fixing rubber roof MISC. appropriately. Also install rubber on flat section on side of WA Inc. home 10 Sq. Patio&Garage on side of yard: 2-3 layer strip and install as $3,850.00 / above t On all new roof installation: Labor Guarantee-4 years 30ar Shingle Guarantee-25,30 or 40 year as provided by vendor Total $13,350M Additional boards-$4.00An.ft.plywood$65/sheet -Less 1/3* ($4,450.00 Will tryto protect all surrounding landscaping,but can not be help responsible for any incidental cental Not responsible Total �D•O for any minor debri in attic I y Payment 113 down,113 due upon mid-completion,final 113 due upon completion and customer satisfaction in compliance with this contract.(*12 deposits due for 2 or less days est.completion) 'Oil price increases cost of materials,so materials only could be subject to increase in quote prior to actual contract signing. All discounts/coupons are only valid when presented at contract signing not at a later date,one per customer. Deposit non refundable. Start dates are weather permissible. 1. Enter this contract in accordance with the prices,terms,methods , And specifications listed above. FULLY INSURED. MA Lie#137643 COLOR CHOICE:A X/ySi ek,41# 2. Send all correspondence payable to: Customer Comments: Start Date: 0 — LAWRENCE BURNS Mrs.Edith Cti R e s t DBA/Reflection Exteriors Contracting, LLC 34 Camden St. P.O.Box 27 N.Andover,MA 01845 North Billerica, MA 01862 P: 978/682-3255 c:978/686-0034 __/6 I�AA �Qkn7�� ers Confirmation Signature Date Authorization Clients Signature ate The Commonwealth of Massachusetts r l Department of Industrial Accidents 1�61 L 'l` Office of Investigations 600 Washington Street Boston MA 02111 www.mass.gov/dia t , Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): a°F1�G %U�t �Of27�rGtC 1 `2 f Address: S— 7 6,ull 50,7 ST . City/State/Zip: Utl�>al C°? /I'l� Ol�(� Phone #: 77 �F556o 2,5 Aj?l employer?Check the appropriate box: Type of project(required): 1. am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction * have hired the sub-conte employees(full and/or part-time). actors 2. t am a sole proprietor or partner- listed on the attached sheet. + E] Remodeling ❑ P P ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. q, E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑ Electrical repairs or additions required.] 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#I must also till out the section below showing their 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. *Contractors that check this box most 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: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: 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 required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine 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. /do hereby cer 'y under the pains and penalties of perjury that the information provided ab ei true and correct l0(3! /J Si=nature: �� Date: O Phone#: 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#: