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HomeMy WebLinkAboutBuilding Permit #641-14 - 400 SHARPNERS POND ROAD 3/18/2014TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION �( 0 Permit NO: I ` Date Received l Date Issued: 1 ICI t "I WIPO TANT: Applicant must complete all items on this age LOCATION G��� • �' PROPERTY OWNER. l _ ....... q Pr' 100 Year'Old structure MAP NO: (®_ PARCEL: ZONING D1,5TRICT Historic, -District. Machine Shop Village yes no' yes no` , TYPE OF IMPROVEMENT PROPOSEp USE Resid al Non- Residential ❑ New Building be6ne family ❑ Ad ' ion ❑ Two or more family ❑ Industrial g,MeLation No. of units: ❑ Commercial OA�epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic: ❑Well{ ❑ Floodplain; ❑ Wetlands. ❑ Watershed1-pistrict.. ' 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: OWNER: Name: Mle Address:j&0 ';6a CONTRACTOR, Name - 0 Please Type or Print Clearly) ( ` - L lel✓ it, _- -- -F Address: 12.0- AN 2,(kz >-_ leo n No e) v Su ervi`sor's: Construction Licenser (i 'V& 09 N -Ex:. p _ �L� --- -_ p` Date Home Improveriment' License; / C Exp; -Lute: ARCHITECT/ENGINEER 9,70- 7 —/7?' iwG4' 01 �� I e4 Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST �BASED ^O�N $125.00 PER S.F. Total Project Cost: $ `5� 0 d o ' FEE: $ , K� v Check No.: Receipt No.:ck NOTE: Persons contracting with unregistered contractors do not have access u It"411 Signature of Agent/OvVnerSignature :of .contractor Plans Submitte� Plans Waived 11 "\Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ .TYPE OF. SEWERAGEMSPOSAL Public Sewer ❑ Tanning/MassageBodyArt ❑ - 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 PLANNING & DEVELOPMENT ❑ DATE APPROVED COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS EALTH Reviewed S ' z COMMENTS T7)``��-`' Z" Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comme Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW To-wo Engineer: Signature: Located 384 Osaood Street FIRE bEPARTME'N't Temp Dumpster on site yes Located at 124 Mair Street Fire Departinef-it signature/date COMMENTS no 1 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions _ Total land area, sq. ft.: (ELECTRICAL: Movement of (!(Teter 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 5L D Notified for pickup - Date E Doc.Building Permit Revised 2010 Building Department The fol 'Owing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products (VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses a 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 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 ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apn,?al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Buil.Jing Permit Revised 2012 Location X00 N o. Date TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Check 44*61- 27360 Building Inspector s-4-6. 0 -- s - Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 15,000.00 m $ - $ 180.00 Plumbing Fee $ 22.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 22.50 Total fees collected $ 325.00 400 Sharpners Pond Road 641-14 on 3/18/2014 Attic converted to office/playroom, add 1/2 bath 3 0 H = Q 2 LL O D Q O m a)ycu U.2 YLn0ra \ O LL E U N N 0 W N z Z m C 'O O LL L O C N C L U C LL 0 W H z Z g J d L O O C LL 0 W N z V �� U W -C to O d' O V) LL oc O V a Ln Z Q C7 t ' CC LL z C I- a W w 5 LL ` ` en Z y Ln a+ N N Y Ln 0:zi:00 O E'0 �o C z �. ..s c � H CL(D cc 0 � � E O c c Nm G> CJ m uaW O 'O w O O E: O d �' N C N .Q O LU ci O N > — v> O "" c F- .w Q 0 V O w 5 U C.� w •Q Q • 0 O y v E I � Q L N � C O N OL E • a /i. c c L 3 I�( 10 r (-J `m c � yCci O O •� O O 0-0 E'0 �o C z �. ..s c � H CL(D cc 0 � � E O c c Nm G> CJ m uaW O 'O w O O E: O d �' N C N .Q O LU ci O N > — v> O "" c F- .w Q 0 V O w 5 U C.� w assach use fs -omi.e ��p�ovema em.f sg.m Re C This false. satisfies all omen equireatents of -the skate's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard Tanguagetoproiecthomeowner. SeeIcIegaladviceifneeessary. Anypersonplanninghomeunprovementsshouldfixstobtainacopyof"A Massachusetts Consumer Chide to Home Improvement" before agreeingto any work on yourresidence, You.mah obtain afree copy by calingthe Office of Consumer Affairs and Business 1,egulation's Consumer 7nfolsnationHotline at 6.17-973-8787 or 1-888-283-3'757 or on our website. HQS]]FOwdi�r ®]C'.IIID.�.ti n 'Contractor �Jl'��III�at7OI1 y CompanyName ct, NCO tree -Ad S (o notuse. Post Office ox address Contractor) Salesperson/ OwnerN City/Town ��4.►-- v _ v"'f. � � � �� o'�. Q � �C .state Zip Code/ C �/ �� - 413s ness Address (must include.a sy'g l_ . idress) - I.L ederal>;rnpio117er or S.: inwregnurstUnEmostho:ne "116 aprovamenr[;ontm improvementcontrnctarsHavc avnlidregistnitionnninber J.ne Uontractor agrees to do the following worl' for the Homeowner: (Describe in detail.the worlcto completed, specifyingthe type, brand, and grade of materials to be used, use additional sheefs ii'necessa Jl2e4nixed Permits - Tb e following building permits are required Proposed Start and Completion; Schedule be secured by the and will -The following schedule will (owll -contractor as -the hom.eownex's agent: be adhered to ess circus Isl<ances beyond the contractor's control arise nters who secure their OwnPernl®its:WM be excInded[ from tjie Gftaraniy 7uund provisions of p MGG--hapter 142,A.) Date when contractor will begin contracted work. Date when contracted work will be substantially completed. JCotal G'Or(trzetPrice and Payment Schedule The Contractor agrees to pex:form the work, :Runishthe material, and labor specified above for the total suns. o' Payments will, be made according to the following schedule: Upon signing contract (not to exceed 1/3 bfthetotal contract �7y p a:ce ZZ the cost of special order items, w 'chever is greater) �--�. by / / or upon completion of l��1 $%�- S . by I 1 or upon completion of --�`- upon, completion ofthe contract. (Law forbids demanding fall paymentuntii contract is cam Thefollowingmaterial/equipmentmnstbespecial pletedtobotllpaxty'ssatisfaeiion). ordered before the contractedworlcbe ' to be paid for to meetthe completion schedule.(.r.°',)s m order to be paid for lT®'TBS, ('') Including all finance charges (**) Law requires that any deposit or down payment required by the contractor before wo not exceed the greater of (a) one third ofthe total cQntractprice or (b) the actual cost of any special equipment or custom made may material which must be special ordered in advande to meet the completion schedule. Subcontractors -The contractor agrees to besolelyxesponsibleTot complett�oofthe work describedregardless ofthe actions of d io the Yes all terms o£the warren must be attached to the contract party/subcontractor utilized liy the contractor. The contractor further agrees to be solely responsible for all a materials andlabor'anderthis a dement Contract Acceptance - U on si p yments to all subcontractors for p ging, this r security Omes a 0mcL ng contract under law. Unless otherwise notedwitbmthis d0cume4 the care fact shalt re s imply ring this con lien or other security interest has been. placed on, the residence. Review the following cautions and notices carefully before signing this contract. o Don.'tbe pressured into si gain g the contract. Take time to -read and ftiliy understand it. Ask questions if something is unclear., • Malce sure the contractor has a valid Home Tm xovement Contractor Re 'stration, subcontractors to be xegistexed with the Director ofl3ome improvement Contractor Registration. You may inquire about contractor The law requires most home improvement contractors and registration by vgto the•Director at 10 Parlcloiaza, Room 5170, Boston, MA .02116 ox by calliug.617--973 8'787 or 888 283-3757. o Does the contractor have insurance? Aslc the Contractor for Iiis insurance company information so that you can confam coverage, or aslc to • see a copy of a "proof of insurance" document. Gu de t oth rights and resp Omenlities. Read the Important lnfoxxnation ou the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law; , You may cancel this agreementifitbas been signed at aplace otherthanthe contractors normal place ofbusiness, provided o contractor in writing at ping t main, office th branch office by ordinary mail posted, by telegram, sent or by delivery, nut icier than midnight third business day following the signing Of this agreement. Seethe attached notice of cancellati on form for an you xiotifye ®T'JCGfi17C ofthe S C®NTRACT gi Ta3FJME ARC ANY xpianationofthisricht. Two idenfical copies ofth ntractmust be completed audsigned. One copy should gZCoactoPs tl The XO co 's ii 'Jute Date Co2mi raefoar .xbif rijion ` The Home Ixnpi ovement Contractor Law provides homeowners Wit], the right to initiate an arbitration action (as an alternative to court •action) if theyy have a dispute with a eontTactor. The sam e right is no both paries agree to the t automatically &50rdedto a contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner.in court unless optionall clause provided.below. This clause would give the contractor the same -right to arbitration as is afforded to the'homeowner by the "O'ne Improvement Contractor Law. g The contractor and the homeowner hereby inutaally agree in advance that in the event the contractor has a dis ute concem' g this contract; the contractor may submit the dispute to a private arbitration. fum which has been approved b the Secretary of the Exectatxve Office of Consumer Affairs and Business Regulation and the consumer shall be re uired to submit to 'such arbitration as -provided In. Massaehusetts,General Laws, chapter � � eownei s S at e �'®���: n a or's Signaitixre The sa attire -the,parlies above apply only -to the agxeeme o'the pax -des to alternative dispute resolution initiated by the contractor: The homeowner may initiate altea five dispute resolution even where this section is not separately signed by the •narEes. Romeowner's Rights A homeowner's rights under the J=Zome Improvement Contractor La.'w (MGL chapter 142A) and other consumer protection laws (i.e. MGL chapter 93A) may not be waived in. anyway, even, by agreement. l:Iowever, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed bylaw. Homeowaxers who secure their own bixildin.gpermits are autonmatxcally excluded.* om. all Guaranty Fund provisions of the Home Improvement Contractor -Law. The contractor is• responsible for completing the work as described, in a timely and workmanlike na.anner. Hoaneowaaers may be entitled to other specific legal rights ifthe contractor guarantees or provides an express warranty for workmanship or materials. Stn. addition to guarantees or warranties provided by the contractor, all goods sQld•in Massachusetts caray an implied'warxanty of merchantability and fitness for a parUcular purpose. An enumeration of other matters on which the homeowner and contractor lawfally agree maybe added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have gilestxons about your consuna.er/homeowner rights, contact the Consumer IlICOlTnat7 0a1 Hotline (listed below). Execution on of Contract The contract must be executed in cin licate and should not be signed until a copy of all exhibits an•d referenced documents have been -attached. Parties are, also advised not to sign. the document until all blank sections have been 'Filled in or anaxlced as void, deleted, or not applicable. Ocie, original signed copy of the contract with attachments is to be given to the owner and the other kept by the eosltractor. Any mo difieati.on. to the. original contract must be in writing and agreed to by both parties. Contracted work may not begin Haat U both parUes have received a (ally executed copy of 'the contract, anal the three day rescission period has expired. Accelerated J?aym.ex.•ts A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him)herself to be financially insecure. T-lowever,-iu instances where a contractor deems him/herself to be fnancially inseciire, the contractor may require that the balance of :Goods not yet due be placed in a j oint escrow account as a preregtusite to continuing the contracted work. Withdrawal of Ctiinds from said aecotint Would xegtixre the Sign -stares of both parties. Additional Information 'If you have general questions or deed additional. inCortnation about the Rome Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consiimer Guide to Home Improveanent" contact: Consumer In:.COnnation Hotline Ofrzce of Consumer Affairs and Business Regulation 10 ParlcPlaza; Roam 5170, Boston, MA 0211.6 '617-.973-8787,'888-283-3757 or"vi.siithe OCABRwebsite at 11 _//wwzvrnass: ov/ocabr/ If you want to veri.'Cy the registration of a contractor or ifyoii. have questions or need additional information about the contractor registration component of the Hoyn.e Improvement Contractor Law, contact: specifically ]director ofHomeImprovement Contractor Registration O: r-0 of Consumer Affairs and -Business Regulation 10 ParkPlaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visitthe I -UC website atl.1ttp:wwtv.Mass gov/ocabi/ Go online to view the status of a Flome Sanprovemebt Contractor's Registration: 11ti.7�:J/db.state.ina.t2s/ho7neimttoveir�e:nt/]icettseelist asu • `7l~ or assistance with. informal mediation of disputes or to xegisi er formal conn taints a A r` p gamst a business, calx: i Consumer Complaint section ` OfRce of the Attorney General 617-727-8400 .AND/OR Better Business Bureau 508-6S2-4800, 508-7552548 or 413-734-3114 —ACCEPTANCE OF PROPOSAL— I have read this document and all attached documents and accept the prices, specifications and conditions stated. I contract You are authorized to do the work as specified Payment will be made as outlined above_ If an attorneys signer shall be responsible to pay attorney's fee in addition to sum due. You, the Buyer, may cancel this agreement at any time prior to midnight of the third business day after the date of this Land by signing, this proposal becomes a binding is utilized in the collection of any amount due, the Cancellation must be done in writing. SKI' PHOENIX CONSTRUCTION MGT LLC General Contractors & Construction !tanagers Tel: 617.596. 1146 P-0. Box 243 Alt: 617.818. 7175 Boston, MA 02127 Email: skyphoenixgroup@yahoo.com NAME/COMPANY: &LO DATE: GL STREET: v _ PHONE: (YA P V 23V-4, CITY: STATE: mAss. ZIP CODE: —ACCEPTANCE OF PROPOSAL— I have read this document and all attached documents and accept the prices, specifications and conditions stated. I contract You are authorized to do the work as specified Payment will be made as outlined above_ If an attorneys signer shall be responsible to pay attorney's fee in addition to sum due. You, the Buyer, may cancel this agreement at any time prior to midnight of the third business day after the date of this Land by signing, this proposal becomes a binding is utilized in the collection of any amount due, the Cancellation must be done in writing. �.. ---� _� 4� �. � --� ..Y.. C O ' �-- . � �. � � E?— �, r, f�— ._._.— �-- © � �.�"' § 0 M�7 w % § §^ cL2E E�.2 Lu �) CL ?ww � [ � 2 . k~ [ )§ \k \ [ uk \o 3 CL c ` I1 o � . { ./ . E- - ems mG Z 2 § 0 M�7 w % § §^ cL2E E�.2 Lu �) CL ?ww > V)./ }9 2 . k~ /\ \k u5 uk \o 3 CL c ` , { ./ . E- � /0) i- $` \t. o . , / $ ° _\ 0 §E9 \� LOL,aW 40D S ?rtCS pDrJ, 00-f -0\ A4over. n)v4 PY -fy% )XA5 �V --Rov Y--,A-4cn, -��Pj roo-m rWo J; r6 ��z bt S� a r �snN ct�LQ� C�,xek a" a arte' %�L�t' ) 0. CERTIFICATE OF LIABILITY INSURANCE DATE(MMoorr yY) 10/17/2013 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: M the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WANED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rtyhts to the certificate holder In lieu of such endorsement(s). PRODUCER CONT NAME: MATTHEWS INSURANCE PHONE N; 508 673-2250 No:(508) 678-5320 4071 County St ,SES:rmath3081@aol.com Somerset, MA 02726 M"ERM AFFORDING COVERAGE Nacs INSURER A, ATLANTIC CASUALTY INSURANCE COMPANY INSURED SKY PHOENIX CONSTRUCTION COMPANY INSURER B P.O. BOX 243 INSURER O: BOSTON, MA 02127 ItNSURER E I INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR LTR TYPE OF INSURANCE ADM !NSR SUOR wyo POLICY NUMBER POLICY EFF M POLICY EXP MfDMYYYY) LIMBS I A GENERAL UAB(LITY X COMMERCIAL GENERAL. UABIUTY CLAIMS•MADE E OCCUR L143003602 10/1/1310/1/14 EACH OCCURRENCE $ 1,000,000 PREMISES Ea oeeurreMe i 100,000 MED EXP (Any one Person) Is 1,000 PERSONAL a ADV INJURY s 1.000,000 GENERAL AGGREGATE Is 2,000,000 GEN1- AGGREGATE LIMIT APPLIES PER POLICY M LOC PRODUCTS - COMP/OP AGG f 1,000,000 f AUTOMOBILE LIABILITY ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS AUTOS NON-OWNED(Per COMBINED SINGLE War (Ea accident) f BODILY INJURY (Per Person) i BODILY INJURY (Per aaidenfl E PROPERTY DAMAGE accident)f f UMBRELLA LIAR EXCESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE i AGGREGATE f OED RETENTION f f WORKERS COMPENSATIONCSTATU AND EMPLOYERS LIABILITY ANY PROPRIETOR/PARTNER EXECViNE Y f N OFPC£RMEMeER EXCLUDED? F-1 (teandatary In NHI I== es, describe under DESCRIPTION OF OPERATIONS below IAE.L. OTH TORY LIMITS ER EACH ACCIDENT f EL DISEASE - EA EMPLOYEE f E.L. DISEASE - POLICY LIMIT f UtSGRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101. Additional Remarks Schedule, it more space Is required) CANCELLATION SHOULD ANY OF THE AB VE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE�THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE PbbbbbbLICY PROVISIONS. AUTHORIZED REPRESENTATIVE (i�) 1988-2010 ACORD CORPORATION. All rights reserved. ACORD25(2010/05) The ACORD name and logo are registered marks of ACORD ACC )R0� CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 01/30/2014 THI�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 TIFICATE OF INSURANCE PRODUCER, AND THE DOES N TE CONSTNOT ITUTEA CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(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 02730 - 002 Matthews Insurance Agency Inc 4071 County Street Somerset, MA 02726 CONTACT NAME Ext : 08)678-8831 No.: (508)678-5320 E/io. ADD ass: LIMrcs EACH OCCURRENCE $ DAMAGE TO RENTED $ PREMISES (Ea occurrence) MED EXP (Any one person) S A.I.M. Mutual Insurance Company 33758 INSURED Michael Leung Sig Phoenix Construction P O Box 243 Boston, MA 02127 INSURER INSURER Q, . INSURER EINSURER OLICYROT- OC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS F DCVIQInkl NI IMRFR- COVERAGES GEKI II-wA I E NUMOr- c — - 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 CE- Ar -FORDED BY THE POUCIES DESCRIBED -HEREIN AS -SUBJECT -TO ALL. -THE -TERMS.. EXCLUSIONSCERTIFICATE MAY BE ISSUED OR AND CONDITIONS 0 SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F -I OCCUR I OSk UB POLICY NUMBER Mwds MPND , LIMrcs EACH OCCURRENCE $ DAMAGE TO RENTED $ PREMISES (Ea occurrence) MED EXP (Any one person) S PERSONAL &ADV INJURY S GENERAL AGGREGATE $ PRODUCTS - COMPIOP AGG $ EN'L AGGREGATE LIMIT APPLIES PER: COMBINED SINGLE LIMIT i 'Ea accident) OLICYROT- OC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per person) S BODILY INJURY (Per accident) $ PROPERTY DAMAGE _ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS MADE NIA VWC-100-60173342013A 5/6/2013 518/2014 EACH OCCURRENCE E AGGREGATE t S X TORY LIMITS OER DEDg p �RNETTEENN�TIIONN i D EMPLOYEMRS' LIABIIJTY pR�p�E7p qR7NE�/EX oF';ICER/MRFJdBER'EXCLUDED7 EcuTnrE( 1((rManda�dtory In NH) LJ D�&RIPTION99PERATIONSbe. A EL EACH ACCIDENT $ 100,000.00 E.L. DISEASE- FA EMPLOYEE $ 100,000.00 EL DISEASE -POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space Is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE r� &P—a I ©1988-2010 ACORD CORPORATION. All rights reseryed. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information b Please Print Legily Name (Business/Organization/Individual): I IJnrl.. r 4'l, Address: a ® - o- City/State/Zip: wL M , - �� �� Phone li: �, t —Sal tAre an employer? Check the appropriate box: I am a employer with 4. F1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet ship and'haveno employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. OICemodeling S. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions I L ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 7 Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. A Insurance Company Policy # or Self -ins. Lic. #: 6 0 l �e Sq 9-0 � Expiration 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 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. , Y do hereby -`tiM4---' that the information provided above, is true and correct. 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 #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retained 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 permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation' and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Dep.artmmt ofZndustdal Accidents Office ofIovestigations 6.00 Washington Street Boston, MA. 02111 Tei. # 617-727-4900 at 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 wwwanass,gov/dia 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 (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department ofladustrial .Accidents Office of Investigations 600 Washington Street Boston} MA 02111 TeX, # 617-727-4900 ext 406 or 1-877rMASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass,gov1dia 2 L. OB S N LU a O O CU rl N 41 E O L 3 X m E E O 0 c m O N N c L Y (U to c m U 4+ O c c 0 ca V Q Q. 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