HomeMy WebLinkAboutBuilding Permit #058-13 - 38 GREEN HILL AVENUE 7/24/2012 BUILDING PERMIT °� "°RrH q
ttylD C6
TOWN OF NORTH ANDOVER 2 h�'`` - ,, °
3
APPLICATION FOR PLAN EXAMINATION _
Permit NQ Date Received
� � � .SSAGHUSE
Date Issued:
ORTANT:Applicant must complete all items on this page
} x. .t + C t c i,,.+, tes ( pct t ,_ n. � lx.-:5-, s t j x � r,� a '- �♦
# LOCATIONgi�
PROPERT�YtOWNER 'y a x
.r MAP�NO �.����ARGEL��� � ZONING D STRICT: Historic Distnct� ,_ yes._ no ,
rw gF k
TYPE OF IMPROVEMENT PROPOSED USE
ReM- y
Non- Residential
New Building
Addition Industrial
era ion No, of units: Commercial
pair, replacemen - Assessory Bldg Others:
Demo i ion Other
Wetlantls `x�Watershed.District
"h
at.f/
f � f nr�r •c.� t''�(F�� ��f ..
WSewe_rE< F ,- „ �` t
DESCRIPTION OF WORK TO BE PREFORMED:
Q'J/ for LLQ 2oa rs
dgntiation Please Type or Print Clearly) �� �
OWNER: Name: IIIT_ f}AA 21/1 L Phone: /7
Address: f < < AOL
r r ggac S~+�i� e �J�, f r s��
iJ �_ '` =1 •..t..,t.s. .!� a '3\ "`CZ
�""' x:'� r -xaay. . -�
r., b c i r
r`
CONTR-AG-T®R Name t a
ME,
'a.tx : .dress �.�-.'�� � ��'�3� � ;� ._ T �
' .. ,! f t p € *a _WPM
Mi
' �.p '{
't [CJS � ¢ „t,A'. b+- ; ,yF�+t --^, .+� > r� ':
`S •�. -4 ., r#4` �,.tF + ' i" 5•,,",s v ? +t«,Ar >- �- �,.
upervisorts Construction Licensees Exp�Date �!
� `¢ '' ,t. 'R-?=�t -
1-'�-.3'.S.-�,�rad �.�" t►,."i'��',4-e�S��'�� �i i� .d �rs t d S'`v i,+4 t F ��: � - `, T.���1'�•`� *'u *{". y.g s!. ; �"
.L�.'`''�°
Home Improvement License
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $ 2te;7 . 54D
Check No.: t� 0114 Receipt No.: C)
NOTE: Persons con acting with un r gister ntractor s do not have access to the uaranty fund
Signature.of A ent/Owne� - I nature of contractor
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
MOTE: 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
I' NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
I' New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan i
❑ 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
❑ Engineering Affidavits for Engineered products
MOTE: 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
l
that the appeal period is over. The applicant must then.get this recorded at the Registry of Deeds. One copy and proof of recording
1
must be submitted with the building application
Doc:INSPECTIONAL SERVICES DEPARTMENTMFORM07 1
Revised 2.2008
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/BodyArt Swimming Pools
Well Tobacco Sales Food Packaging/Sales
Private(septic tank,etc. Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
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
t
Cgnservation Decision: Comments
Water & Sewer Connection/Signature &Date- Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
-FIRE DEPARTMENT 'Temp`Dumpster on site yes
•. rr ,r.•� r;—: # s'3'.-:got-I— X"•i' : i} .et• E . i ,�'Y £rxF-. *.4
Located at 124=Main=StreetiN
' :
`Fire Depart
men t,signatureldat�. �" � � � � �
- t q,✓y{ { t p'T x'fi'd -�+'�. 't.�` fi 4 9..f;� 9.` a#, v C,5 we` ,f,u
*l :z v e' aft �ri > 'fi s shyl�,ry{k t i 't •�'"i.:� a,,,$,." l .{
COMMENTS "_ t m_ . � t r Y� l
..:�� '�
i
i
Dimension
Number of Stories: Totals square feet of floor area based on Exterior dimensions.
ions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA—(For department use)
I
Ll Notified for pickup - Date
I -
I
Doc.Building Permit Revised 2008
Location Gf le 0-Ilk,A k P
No. ��'C�` ,� Date 4
' 'tt TOWN OF NORTH ANDOVER
Certificate of Occupancy $
• Building/Frame Permit Fee $ �
Foundation Permit Fee $
Other Permit Fee $ .
TOTAL $ "=
iY
Check# IW
4
- 25537 Building Inspector
i4
r 1 NORTii� ,*
O
LAK, h ver, Mass, Af
cocrocnewIcw y4'
A0
4.4tED r.P�,`'�5
S U LD
BOARD OF HEALTH
Food/Kitchen
. PERM Septic System
THIS CERTIFIES THATY BUILDING INSPECTOR
has permission to erect ba.. �. � •,,��,,., ... Foundation
p ...................... buildings on ... ..... .....
Rough
tobe occupied as ......18.............~.................... '.... 1. :..!....... .............1!��.! ............ Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the 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 CONSTRUCS TS Rough
Service
............LS
.........................................................
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
.TTreenl i�afBuildin and remodeling
511 Lowell st. Lynnfield ma. 01940
Mass lie#cs083846 Don Cell-(781) 249-6747
Mass lic#cs092635 Steve Cell-(781) 913-6411 �+
Mass Hic lic# 143204 Fully Insured
Date: 7/3/12
Customer: Matt and Katie Barnett Home#: 978-682-1946
Street: 38 Greenhill Ave. Cell#: Matt-617-999-7270
City/State/Zip: North Andover, Ma. Work#: Katie- 781-883-9797
Greenleaf building and remodeling proposes to furnish all listed material and labor necessary for the
completion of the following job specifications:
Repairs to 38 Greenhill Ave. detailed in Design 1 job specification .This invoice and all accompanying
documents are part of the overall contract. By signing this contract,we are assuming that you have read and
approved all of the attached documents that have been sent electronically.
Greenleaf Building and remodeling proposes to complete above stated specifications for the sum of:
Revised 6/13/12
Changes since last pricing on October 2011.
Door selections per Matt
For main front entry, model 814, divided lites for 6 pane effect
For breezeway front entry, model 684,divided lites for 9 pane effect
• We are adding larger window on back,which will require two windows
• 2 Windows on front
• Pocket door additional
• Door styles have added small charges. Original estimate included standard 6 panel door.
o This estimate includes the front door replacement and includes the storm door. ,
• Larger stairs/landing in back(minimal cost change)
• Additional electrical to accommodate four switches,cable outlets,etc.
• Ceiling configuration has changed to tray like ceiling to accommodate fan.
**If you go with electric heat in the breezeway,you can save approximately$1000 on the cost of the
job.**
f
't_ I "C5 bail
s tl� ' Ij 7�. m r a#�om p �' .Lx
'a: _ 5i tai>il r"tr_'ti sli, i!: ..,r.� :It'� , �.., ay _
•°'�.7 'atrJs����1�%�.�. 'lii ✓! t:'�Ii�. T �. r 11` 4..i •TJ ..
[' 5 ,I•. tM'!a '47°�: ti;;i; .,.;}j3 , 1F cal r r. ;1W r La -v � . :t1f'r"t.",3"� SL
SO :f is va `/L7 a-t'_o '1 z.':
"�11M.1:'i�1�f�..'1:7 i.�. ;1:°{�}i,.i .5{1 it i.' !Y. f"�...:�'�. 4... fes. .,t.i. !r'Y �. tJ. .S_•.1<<.1�.1
�i s � w X11:'1 •s}r}
1
1
+"Sl] k:J -0013101 psi O..IW f r• .. 7 fm non A x. .
:1 n TO all Nil!11110M srgf_t. ,1t3 IT"m
fin € }1;.
w 'g
ZY4;. _ •t� :.life + { i P. ' i�:1 i:!"I �tt��".{l l\. :t•51: SS 9 ne 'e tt.{' ° r6" ".'J' �E
} t
'!: 1,51-(a%r "tit [?i '.;3l hya `Aq •tcv 0 lymifbd^• r,MI s`•dif!1;'i:7•,.,A an "M 3
d w1 °µ8'd€ qc _ va "L3 an rutg M, out t+1 01;0
Y t.
I. Add forced hot water baseboard as needed with separate zone and thermostat in breezeway. Our
assumption is that the existing heating unit appears adequate enough to handle this new add on.Any
needed upgrades to existing equipment aren't included.
Miscellaneous:
Locksets will be matching for front breezeway door and main front door and garage door.
Not included and to be provided by homeowner:
• Ceiling fan
• Surface mounted lighting fixtures(exterior, any wall mounted inside)
• No painting is figured into this estimate.
*****Unexpected upgraded to electrical,building or plumbing due to code requirements are not included.None
are expected but sometimes these situation arise. Any additional costs will be discussed prior to any work being
done.****
GreenleafBuildin and remodelin
g
511 Lowell st. Lynnfield, ma. 01940
........................................($22,260) plus permit costs
Payments will be split into three payments. 1/3 down for materials, 1/3 after inspection, and 1/3 plus permit
costs at job completion. Each payment is $7420 at each interval plus permit costs at the last interval.
All change orders must be approved and paid for at time of approval.
All material is guaranteed to be as specified and the work will'be completed in a workmanlike manner in accordance to specifications.
Any and all alterations or deviations from the stated specifications involving extra costs and materials will be executed only upon written
orders.These changes tum into an extra charge,over and above the estimate.All agreements are contingent upon accidents or delays
beyond contractor's control.Our workers are fully covered by Workmen's Compensation Insurance. If either party commences legal
action to enforce its rights pursuant to this agreement,the prevailing party in said legal action shall be entitled to recover its reasonable
attorney's fees and costs of litigation relating to said legal action,as determined by a court of competent jurisdiction.
Submitted by: Steven Greenleaf/Mike Kirtland
This ro osal may be withdrawn if not accepted within 14 days.
Acceptance of Proposal
As stated in the above specifications. The costs, materials, and specifications are
satisfactory and are hereby accepted. 1 authorized the contractor to perform the work
+ Qt.i."'`i1. .. !
.�•i *C. .:i)C"•. Yj, .J.: .' +~'-rrx l.I.1'=�C �€ _, _ 't, .. �' -
t
y tt'. Jlt'�w";:?r.; ..:i�,• , _ k!'..'_f} .'.i •� r'I �' '�,. ,b=C� t;�?�. i ^'
��` ,•,�t�C .:4 �.� � til '.;+''7z k(:el)j' +�J �y,t:4 y � :�: ut114'- .. ?+ . a 'i .. ti'u
._ i M M 1^ 1L _L' t;r� :} , � �,ir:�... (il^•%ii.f ,sd -U �,d• �or!.. ,� , u is- • CL - r lob.,
F.. .;r..J `i. - .f, '1•'S f+IS.. '�' . J1`.t it: C•i n. !•+ - _. _ :e F -1 cc. � . - <� fQs'!
!J:C:`U 6*2 e. 1 (;:*i ..4'3JONG is i`fC WUL .i �•�,. .AGO C3::..%V!
.':-('.C. IV , ; . 't:", b/t^ mit;• � h'_ l.. •i"1
:..r• ,3't.s�," ,r `s � �`.s+,..i 6°'`U 14c W s F �+. to .� r• y' 4 nor %i3�eTY� 1 s,
s'1 -
, 4
,c t
r.• t
rM. .,sof• r"c 6 Et.' 1 > -j .i", 3 `. LjJ C, a iZ&; S1, it.30 'j;cc'J'3j
;`33.ti.li. 1.7 `.i.);'s .; �_ .t 1` �:' Sii .k., •� !�v 4
...,�,; ,'''.i'•. -.yam,;.e—.p£3,� 1..`7,( t A;h o ! a C?.i:.;,f c'a �
r
re r
,:'_ �:'r.'f.��C� ^r;. r..•t... :-�1..? p�_�r *'jrx.-fr 7l f(.i x tr a ,f :f C'r ;p .,dr?! .' �t' �.'• +'3f'+.Cr ?tu'� '.i �!i �<1 �E �. �:hl tr r �6tl i,
}•7 rr •r S + s s r !!
L
�iu, ':}',tl, .,i�E. tj , .�t t' jki1 ..'ia (... 1.+jt,"a: 1..•- „(!" .P)Cj' t';'iCf' ii;lif: UO' {. s
r. b !-,rr(;• J �^'r`1r �.t C4f fll! , .twat-•
s'
1�l '1 1}1. ,qC^ I ^.d(.} i?!(:f7i y;
4'`i;':r;!cs ym P 'f,iJi'if 1 1.0.t'i , ACV ;. r: ,t,. . . U il!
,
i,''C;Ct%q tsUi,I qr.'j(r 'iliS:�':E '!l i,``l t °•` .+ 'i C t
ii�xtf! i�f' .+^: 1Ii. �� Mitt-. .+ :1�- .i ii•. .$
E i.'il!: i p RME+. i j):;CC�
71 `,.C�{t %e"
• p'
a
We will provide outlets,switches,etc.We will provide:recessed lighting with trim. Homeowner to provide
all surface mounted fixtures.
Electrical for existing outside floods in back is not figured but may be able to be done along with this
depending on how it is run.
Walls and ceiling will be sheetrock with plaster/joint compound finish.
Trim will be standard casing painted grade.
Doors and windows will be from Harvey Building products and have allowances for standard fiberglass doors
and vinyl windows.
This estimate is based on the assumption that the foundation that exists in adequate enough to build on.
The estimate doesn't include building permit costs(which are assessed by the town)and any unforeseen code
updates that may be required by the building inspector.
Permit costs are expected to be$600-$800 and will include costs for applying for and procuring the permits.
Construction
1. Remove existing front and back walls. Frame per code and insulate and sheetrock.
2. Add white vinyl siding to match existing
3. Add front exterior door.Add storm door.
4. Add sliding patio door to rear. Center on wall
5. Windows. Add I double hung windows on back wall. Add 2-double hung on front wall. Trim to match
existing house windows,wrapped with aluminum.
6. Insulate and sheetrock as needed.
7. Insulate garage side abutting wall. Sheetrock with 5/8" if code requires:
8. Replace door to garage with 6 panel fiberglass per code(not sure if it needs fire rating)
9. Remove kitchen door.Replace with framed/cased opening with pocket door.
10.New stairs front and back. We will do this minimally for now. Small stairs with railing. Composite
decking with fir posts/balusters. Finished with white primed boards for risers/skirt boards.
11. Install new front entry door with storm.
Oak hardwood flooring is figured in this estimate.
Electrical-Switching of lighting to be determined. See pictures of electrical box.
1. Add outlets as needed per code
2. Add cable/internet to walls as needed
3. Add recessed lighting in ceiling. 4 cans with dimmer
4. Add switched outside lights at front of breezeway. Lighting to be provided by homeowner.
5. Add ceiling fan at ridge
Heating/plumbing.
"to +'t ail }; i •1,'ow.' 1 Aamq NO _ .r
'1u;Q lu" rl .ii eT°,i t,�t . '? f.4
ovw e;;I
t •i' r >+ f '7 � t' i+; !( t .�'.:� F � J"1' '. +. irr. i! 1' ,
r�. .t.. .t! :)'+,LtL4i,1C';' :••Jt"!{ I _ Fri. 1 - ;ii�. y t 1
?0 11 :-'.if} f; '3�r1 (.S. �' _ �i ir�(ir j •r �.
A'>n wn 01 KA,;1;l. Ar ly A" 1
•it... .1 .`I(. tt 1Ji1:, I. 'i`l Jti j�. ?i7�, ;% ;t ,.j.}.�iit 'ii"' {.
OWN ,.. � "' `" � - •J jisl J(`
1+t�J i
!
brin {,t <'xl Jii!liz {
no
Edi) -+f,'(' ow, u .. i.}:,F .?ii,d' h:33i!'! r jean ON
" i.i`,!T _` , ! s�`��• `'ii,lr ^i:;rii :,` ,,� rJ ,7 1lj�}.r.�: ,F .s ;,I:�+ ,.�
i3 OWL ;— jfy�4�'ji{ • , !°..P �i. .•t �"( a � ��.. y u
ts,=' r t.,'}t+ ,.... 'a !s`�`."tr Aa;.an. tJ.J;y _
! , 0 +U' . i d . �s,(fSS
1 t t-
=,+, t,^1 ,'•1 i ;tCili,tM rfi e ` ?. i;:,i!.", i Arldlirf93'iN Cil{i �f� tj
,P ,7
1
C „j? rfs'' °t''* ix, �.
to '_•tt wiq . .;t: Italian A) Y yaw
All l l ' t - r'.r• is a !J!, • I
v 01w
_ Tl rri.rVb tt1S.r -• i,'i tifilil:: r { �,t±�� FJ• " +moi t 1:1 •'
.I'd' 1 .,i1 •}'I(� :1`, s)t ._t'(S•. t .: �..I � II', tt 1' �e i ''J` ..
("1fi}it1 I rt JI
as specified and payments will be made as summarize above.
Customer Signature: Date: �-- 9 /Z
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
,Y www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information (� Please Print Legibly 1
Name (Business/Organization/Individual):��(�(,�f�'L 6 Ec7Z-`�' b eX k7�_
Address: S11 L o UJ e 11 s t, Lu 1A l&C. i d AAA , 01 efg O
City/State/Zip: MA 61�?Y l) Phone#: 1513—6w —
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
_ p*oyees(full and/or part-time).* have hired the sub-contractors
2.®/am a sole proprietor or partner- listed on the attached sheet.I remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9• ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑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.] employees. [No workers' 13.❑Other
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 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:
�
a + City/State/Zip: i Q � U--..
Job Site Address: � �����N � � /�U�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 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 r�PqIte ains and pen !fp erju ry that the information provided above zy true and orrec�
Si nature: Date: 9
Phone#: '- l5 T
Official itse 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#:
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-contractor(s)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 burn 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 Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
� Revised 5-26-05 r
www.mass.gov/dia
_ - Office o � -
f Consumer Affairs and Business Regulation
.�, 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
- Registration: 143204
....:� t Type: DBA
- Expiration: 6/22/2014 Tr# 228945
GREENLEAF EXTERIORS
STEVEN GREENLEAF
511 LOWELL ST
c4�
LYNNFIELD, MA 01940 `'
A�
A i' , y-r Update Address and return card.Mark reason for change.
SCA 1 .^: 20M-05/11 `- Address 0 Renewal [:] Employment Lost Card
,
"-T� ��e �P�vm,�u�ea���o�C�/faaaac�ccoeG�
\ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
— --, ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
s egistration: .,1-43204 Type: Office of Consumer Affairs and Business Regulation
xpiration: . 6/22/26:14,, DBA 10 Park Plaza-Suite 5170
GREENLEAF EXTERIbRS:ry.:j-= ;=1•
Boston,MA 02116
STEVEN GREENLEAF' %�__ -
511 LOWELL ST ,
LYNNFIELD, MA 01940 4 �,
Undersecretary Not valid without signature
Massachusetts -Department of public Safety
AM
Board of Building Res ulations and Standards
Construction Supcn isur
License-CS-083846
STEVEN S GRNLEAF
511
LYNNFIELIa%MA 01940
o -
a ~ Expiration
Commissioner
04/25/2014