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HomeMy WebLinkAboutBuilding Permit #1207-2016 - 345 CANDLESTICK ROAD 5/17/2016 J Wei� t � �10RTF� q -.1 (� L BUILDING PERMIT O* TOWN OF NORTH ANDOVER 3 APPLICATION FOR PLAN EXAMINATION ~ Permit No#: Date Received �4'°°R..TE° gSSHCHU5�4 Date Issued: tI —OR—TANT: Applicant must complete all items on this page LOCATION � 5 C.�o d l p, �.C-k i��i P int PROPERTY OWNER R rTT �OL �-� Print,.. 100 Year Structure yes MAP 106 PARCEL: 7-3 ZONING DISTRICT: Historic District yes o' Machine Shop Village yes. no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Two or more family El Industrial El Addition Y ❑Alteration No. of units: ❑ Commercial 9PRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ Septic ❑UVell i �Ulr F oodpl'a n Wetlands s- - D WatersFied D stncf - ll DESCRIPTION OF WOI�TO BE PERFORMED: f V-- cl e-C- i ✓ice G✓l �9 Identification- Please Type or Print Clearly 'r t OWNER: Name: ` �J �f Phone: 20 " 98S- q'I�g Address: 34 5 4GA CG vlolleJ? 1-c�, A4d& e Contractor Name: 5 R, D. Phone: -�9-5.2e Email:. 6,,te S P row c✓' e cow Address: 0 K 93 o S Supervisor's Construction License: G5 - .d7(��9/ Exp.. Date: Th6 b7 Home Improvement License; /b 8 363 Exp. Date: ill 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. P Total Project Cost: $ `� 90 FEE: $ 1 Check No.: 111-3 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to tha fund hgr .. . . .. .. ..,... . .. .. : .. _- ... - - '� '.. :4 - d i s 4. a..� .. _ . .'. .. .11 _.:. .... ..... .- .., . .._.-._... .-.. .... .... - _ - '_ .�. -:, .. ... .. 1. _ 1 1. . _. .. ..:_ .... __ 1 �' y7. M1^ ..,: r N," -� ,. .r. J� 4 '� • i tN0 .� «C��� Location #1� .l i No. 2..GI` _ Date I a . - TOWN OF NORTH ANDOVER • . . . . Certificate of Occupancy $ Building/Frame Permit Fee $�i j Foundation Permit Fee. $ .; f` 1. Other Permit Fee . $ TOTAL $ cf� S x ' ... - ,:. :. . . � � � Check# ; �..J (f I .,.,,,,;�,-��--�--,:,,,�,�..---,--��-.,4:�-��..��--�2�����%L.��.-��..�-�!�..� . � � -1 . � / . 1.� -1, .V Building Inspector _ S, Id 4. .-. k - - { % vw - - :. - I-L3 0 --1 . - I I I - '. X, }.. 11S :.. . -. �k.... - -' _-__' - - - - _ .::. .y.. _ . ... - .. o„. - .. - - ___ 1. .:._.. _-.._. ._. ... , - -. - a..: u... _ .._... 1. ::'. -. :..'. v c rr..> . . ..- I. �. ..r-_. _ .:-..... ... -. ._ . . . 11� .. .>-.... " - . .. .... .. .. ., , L:{ -. .. ... ._. ... - S' .. .. s - - y r.�: - ,i1 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanuing/Massage/Sody Art ❑ Swinnning Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF o U FORM PLANNING DEVELOPMENT Reviewed On `'�l?,��1(o Signature_' COMMENTS P1.Q,>&t CONSERVATION Reviewed on to Signature.—I-11 (C'11-- COMMENTSS i`^a,« [lc-c�� i (�1(–d , /ki HEALTH Reviewed on ''( Z Signature COMMENTS S�D �L t� �J�1 �� �� 1 Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes PWnning Board Decision: Comments Conservation Decision: Comments t ° Water& Sewer Connection/SIgnature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEP`A N' Temp D Aster ontsiteno ?' Located at 1y2,4 Main Streets Fire De - `' partment si.gn�„ ature/date it Dimension Number of Stories: Total square feet of floor area, based:ori Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drrop: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) ❑ gel- Notified for pickup Call Email Date Time Contact Name I 3 Doc.Building Pennit Revised 2014 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 14, Photo Copy Of H.I.C. And/Or C.S.L. Licenses 4 Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: 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/Cross Section/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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) r-- Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 in ust be submitted with the building application Doc:Building Permit Revised 2014 NORTH own of 0 0 soh ver, Mass, cocNicHewaw y1. d(A4 _ SJ?ATE O L) BOARD OF HEALTH Food/Kitchen PER T L D Septic System THIS CERTIFIES THAT ...Cr... �� �Q '` .... BUILDING INSPECTOR .............. ........ ...`. . ... ...... ...... ....... .... ... .. Foundation haspermission to erect ......... ................ buildings on`.�... 'S.. . .. . ... ... ................ Rough to be occupied as ........ G �1c�....Cels. .....anky.... .... :.�. ... .. .... c n him e provided that the person accepting this permit shall in eve respect conform to the terms of the applic n 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 CONSTRUCTIO ARTS Rough Service .................... ..:G:... ... ................ """"""" BUILDING INSPECTOR Final GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. PIAN 'LIOIV,4 71--10 07- 147.00, / f w � Y 14 �\� � . �' WFA� -.._ � � I; I _�.__ I�43.6 <,, �_A.B. �- i 1 1 ! ----___ -----_ -�_- N & #21 CONNQLLY as-e�iCIAPE N� WFA 1ID lNGs MELA P3.6 `OP � A.B.�4s.3 KENNEP4 #11216 50 of A.B. z� - \ , RIP— Ap 1H:1 WFA2 Z AS—BU/L T ! il1c Z Q POOL NS AS—Bux T Q• `0 J �O \/ POOL DECKCD qq 49.3 ,_ 43.4 cz� _ I #1 �AIE f b A.B. j 4\`F pry f TE 0 48 garJ� I 4 11 NYRE GE =Z OPTCROP J/ 11 m N AC 2 STORY / WOOD W60D WOOD FRAME STEPS !� DWELLING O /�ECK / WFA Q� , { 45.8 � //• � / f A.B. 43.8 � -LOT m Ep F�OpR �p WALL , A.B. o F,��A �RESHOj 2' HIGH WFA6 AREA= 479,35-t- S f; z ME 53�9 N 10-- ACRES? o ¢ 7HIKOIRY / x I0 IL f { y o � 11 WFA 7 �. TRE `G O i E�IN `a r t E �� I LA'vVN _� S—Bull- WFA8 , MARSHALL l RAC i ARY SAND �vl jal4d�CaP/14(::z7 & M 23 ��ad �, �RISrON LOT 1121s LA PLAN # North Andover MIMAP April 21, 2016 106.A-010 106.A-0105 106.A-019-4- 106.A-0104 SF 11 106.A-0103 Y63 CANDLESTICK RD 214' 106.A-0102 370 CANDLESTICK RD 175 CANDLESTICK RD 106.A-0228 106.A-0207 106.A-0206 106.A-0227 365 CANDLESTICK RD 106.A-0205 114' 357 CANDLESTICK RD 106.A-0229 ..... == 295 CANDLESTICK RD 106.A-0233 271 CANDLESTICK RD 106.A-0226 "Z 106.A-0235 345 CANDLESTICK RD 106.A-0230 R1 10 IS& 2:0 3 106.A-0010 42 JERAD PL 106.A-0009 106.A-0231 Q`ace, a& 333 CANDLESTICK RD -0234 106.A ......... 285 CANDLESTICK RD 106 2421 25 3ERAD PL 336 CANDLESTICK RD3 15 CANDLESTICK RM 106.A-0214 106.A-0250 --- ----- (0 139 70, 326 CANDLESTICK RD , 66 122 -�Po 106.A-0249 . . ........ 106.A-0246106.A-0245 3LO6.A-O:i4 A-0248 106 292 CANDLESTICK RD 4?- A-03.11=:::-- ------ ----------- C11 MVPC B. Zoning Overlay Zoning 13 Municipal Boundary 13 Adult Entertainment Distric r Businei s 1 District 0 Machine Shop Village Ova 0 Bu:inne!s 2 District Horizontal Datum:MA Statelplare Coordinate System,Datum NAD83, — Rail Line Watershed Protection Dist 0 Bu i a s3Ds Meters Data Sources:The data for this map was produced by Merrimack i 0 Historic Mill Area 1 District Interstates 13 Busine!s 4 District nct Valley Planning Commission(MVPC)using data provided by the Town of 13 Medical Marijuana 0 Genera Business District North Andover.Additional data provided by the Executive Office of SR 13 Downtown Overlay Co ,"So Environmental Affaim/MassGIS.The information depicted on this map is District M Planne,I Commercial ev 0 Historic District C Corrido Development 's • forplanningpurposes only.It may not be adequate for legal boundary Roads U Osgood Smart Growth(40 0 Corrido Development definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER q7t Easements 13 Hydrographic Features 0 Corrido Development Dist MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING I :ndustri it 1 District El Parcels --St.— t' rujustri 12 District THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY ♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF Wetlands :ndustri it 3 District OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT rdustri it S District 91 Exempt Lands Re idle�ce 1 District THIS INFORMATION Reside ce 2 District SSACMUset P—id:c.3 District d ce 4 District 1"=125 ftde ce 5 District do ce 6 District "ge esidential District 55` KEEN CONSTRUCTION CO. ���®S� ° 1175 TURNPIKE STREET NORTH ANDOVER, MA 01845 All home improvement contractors and subcontractors Tel: (978)691-5201 engaged in home improvement contracting, unless Fax:(978)682-3231 specifically exempt from registration by Provisions of I Chapter 142A of the general laws, must be registered Submitted �i� { �� 1 J� , ; �fl.� with the Commonwealth of Massachusetts. Inquiries To: It about registration and status should be made to the t—J y, Director,Home Improvement Contract Registration,10 C1 Park Plaza, Room 5170, Boston, MA 02116 617-973- (�n ` 8787 Owners who secure their own construction G C4 5 related permits or deal with unregistered contractors will be excluded from the Guaranty Fund Provision of MGL c.142A. PHONE �l D�E/I� � REGISTRATION NO. EIN N0. (� MA. H.I.C. 108383 46–3783401 C/S=Customer Supplied S+I=Supply+Install C See Attached Appendix A We hereby submit specifications and estimates for work to be performed and materials to be used: 6-t1 ' 8 decd Construction related permits: E .. --__..._......................._.................... .. ......._......_......._....._....._............._........._........................................................................................_.........,.........._.............................................._..........................__......_............-.......__......_..__...................... WORK SCHEDUL Contractor will not begin the work or order the materials before the third day following the signing of this Agreement,unless specified here in writing. Contractor will begin the work on or about (date). Barring delay caused by circumstances beyond Contractor's control,the work will be completed by (date). The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement. WARRANTY The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of &Cl. I following completion and shall comply with the requirements of this Agreement. In the event any detect in workmanship or materials,or damage caused by the Contractor,his subcontractors,employees or agents,is discovered within one year after completion of any job,including cleanup,the Contractor shall,at his own expense,forthwith remedy,repair,correct,replace,of cause to be remedied. repaired,or replaced,such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. We Propose hereby to furnish material and labor-complete in acc(orrddance`with above specifications,for the sum of 10_ fill f1Q ��tl/t�YY�� ZV� -- -_ pp 9�, Payment to be made as follows: dollars($ J� ), —% ($ ) upon sig Ing Contract; ! ROBERT A. KEEN � Name of Contractor/Designated Registrant ($ ) I. Iii etjoh of 1175 TURNPIKE ST. 1 Street Address $ -; Pon completion,of _ N. ANDOVER, MA 01845 _ _.. � � qty/Stale o ($ ) shall be made forthwith upon (978)691-5201 (978)682-3231 completion of work under this contract. iAuth &Sgha Fax Notice: No agreement for home improvement contracting work shall require a '>down payment(advance deposit)of more than one-third of the total contract price lestraor the total amount of all deposits or payments which the contractor must make,inadvance,to order and/or otherwise obtain delivery of special order materials and re equipment,whichever amount Is greater. Note:This proposal may be withdrawn by us if not accepted within days. Acceptance Of Proposal-I have read both sides of this document and all attached documents and accept the prices,specifications and conditions stated. I understand that upon signing,this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. You,the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.Cancellation must be done in writing. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Signature -�l�"-^ Date � /- �l- Signature Date IMPORTANT INFORMATION ON BACK'00- t -- Construction Co: t:rmooE�_�nc. s�•rc�n�ts-rs 9.78-697-5207 Kee nConstructionCo.com DiNatale, Brett&Christy 345 Candlestick Ln. N.Andover, Ma 01845 Contract#5575; Appendix A April 14, 2016 Rebuild deck: • Repair water damaged sheathing and framing of house, inclusive to visible damage only. Repairs to house include 8 man hours' labor and$200 materials. All other repairs will be charged separately at$90/man hour plus additional materials. • Dig eight holes for cement footings • Supply&install pre-cast footings as needed • Supply& install deck framing to code to match existing footprint(16'x 21' lower deck&9'x 19' upper deck, less 2'x 7'jog)and 4"x 4" posts where needed. Existing posts will be used as needed and credited to customer. • Supply& install landing and stair stringers from upper deck to lower,and single steps at doors on upper deck to code, including temporary treads • Supply& install metal connectors as needed per code requirements • Supply& install flashing against house to code and siding to match existing Total Price: $9908(nine thousand nine hundred eight dollars) Price does not include cost of permits, decking, rails or repairs to any unusual, unsafe or non-code compliant existing conditions not addressed in this quote. Payment Schedule: $1000 due upon signing contract $3000 due the first day of work(plus permit fee) $3000 due when repairs are done and footings are in talle $2908 due at completion of contracted work J. V Customer Robert A Keen A5 /I Date Date PO Box 935 Page 1 of 1 P: 978-691-5201 N. Andover, MA 01845 F: 978-682-3231 CSL#076691 Sales@KeenConstructionCo.com HIC#108383 Massachusetts-Department of Public Safety Board of Building Regulations and Standards . n___`____.:__ s � 1.1111�L1 U1L11111 JU�1C1 YI\i11 License: CS-076691 ROBERT A KEE1j-` 12 E WATER ST IAF North Andover AfA 0 r J �/r.�L •�r��. ` Expiration Commissioner 08/16/2017 c< �?��n. (po-�rrr»R»-rc,ea���c��vhac�ieateC�i tee of Consumer Affairs&Business Regulation E IMPROVEMENT CONTRACTOR eistration:<- 9 108383 Type: Expirationl�8tg1$ pifi Supplement Ca;' KEEN CONSTRUCTION ROBERT KEEN 1175 TURNPIKE ST NO.ANDOVER, MA 01845 Undersecretary ACO® DATE(M�NDDIYYYY( CERTIFICATE OF LIABILITY INSURANCE 10/23/2015 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 Pol(cy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Cq e:o Barbara McDonough Gilbert Insurance Agency, Inc. PHONE (781)942-2225 FAXNo:(781)942-2226 137 Main Street ADDRIESS:bmcdonough@gilbertinsurance.com —INSURER(S)AFFORDING COVERAGE NAIC A Reading MA 01867-3922 INSURERA 24orfolk 6 Dedham Insurance 23965 INSURED INSURERB:Safety Insurance Company 39454 Keen Construction Company INSURER C.Travelers Ins. Co. 0031 483 Chickering Road INSURER D: INSURER E: North Andover MA 01845 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1552101779 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. ILTR NSR TYPE OF INSURANCEPOLICY EFF POLICY EXP LIMITS POLICY NUMBER X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE XX OCCUR P E ISES a currence $ 100,000 LID-P-010078/000 3/13/2015- 3/13/2016 'MED EXP(Any onePerson) $ 5,000 PERSONAL 6 ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY O PROJEC- f]LOO PRODUCTS•COMP/OP AGO $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT a enl $ 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OS X SCHEDULED 6228807 COM O1 5 23/2015 5/23/2016 BODILY INJURY Per amide $ No AUTOS AUTOS / ( n0 X HIRED AUTOS X NO AUTOS ED PROPERTY DAMAGE(Per accideni $ Underinsured motodsl $ 100,000 UMBRELLA LU18 HOCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE g DED I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN OTH- ANY PROPRIEfORIPARTNERIEXECUTIVERIME.L.EACH ACCIDENT $ 100,000 C OFFICEEMBER EXCLUDED? O NIA A (Mandatory In NH) 6MM-9991MSO-2-15 10/8/2015 10/8/2016 E.L.DISEASE-EA EMPLOYEE $ 100,000 It Yes,dewdbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AdditI.-I Remarks Schedule,maybe attached If-space Is required) CERTIFICATE HOLDER CANCELLATION (978)623-8320 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. AUTHORRED REPRESENTATIVE M Gilbert, CIC/BARBAR ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS02512014011 i The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print. Leeibly Name(Business/Organization/Individual): i Address: - , 5 n + City/State/Zip: I�� ��� �C)'� .�f C G f$P one#: Are you an employer?Check the appropriate box: Type of project(required); 1. am a employer with 2 employees(full and/or part-time).* 7. ❑New construction I 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. V]Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.E]Electrical repairs or additions proprietors with no employees. 12..❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14. Other 6.F-1Weare a corporation and its officers.have exercised their right of'exemption per MGL c. ❑ 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *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 are 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. j Insurance Company Name: -1 rc,tee. e r5 / n 5 // Policy#or Self-ins.Lic.#:6; 14 l) IJ �-9,92 1 NU'Z _ �� Expiration Date: � 5U Job Site Address: 3'1 �l� PS4 i G k r! 1 City/State/Zip: ✓l Cmc— 0/�T� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u e the ains and penalties of perjury that the information provided above is true and correct. Si nature: Date: Phone# Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# i 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#: