The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #788-2017 - 44 KARA DRIVE 2/21/2017a � Aao i BUILDING PERMIT TOWN OF NORTH ANDOVER 11 APPLICATION FOR PLAN EXAMINATION Permit NO: +� Date Received Date Issued: ANT: Applicant must complete all items on this LOCATION 4q K c-' N - A►,3c v e* Print PROPERTY OWNER-rorr-, 6601\heil Print MAP NO: 6fk ZONING DISTRICT: Historic District yes Machine Shoo Villaae ves *'no) TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition ❑ Two or more family F1 Industrial Alteration No. of units: ❑ Commercial Repair, replacement I I Assessory Bldg I I Others: ❑ Demolition ❑ Other i Septic i i Well i i Floodplain i Wetlands i i Watershed District VWater/Sewer P )as1-p- 64�%oor-- rer oJel.<, Warp �u �h�t�J� h,�� Iv�ti,►�. Shoc"Prf it ►��, Gc+,l�Jlt F� ! +C IectHrL� 1 IvrA i,A( �" v Oymz'�� Y-'4�Vv�. Identification Please Type or Print Clearly) OWNER: Name: vt~ � �� tJ Ccm\di Phone: �� y � 7-1-2 Address: 44 ver` Or,�e, t\,. AJOv.•^- CONTRACTOR Name: —T6nckhc+, C' s -jt, v ct- Phone: _Soli� -Sd.3 96 3 r Address: %a. Qrcv-dehcz �(,h U , A ,Ksc}-, ru ff G3e if Supervisor's Construction License: CS-G7CtLl 3 Exp. Date: / I ? Home Improvement License: y y y Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $1200 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ --�04-7I tJ 00 FEE: $ a0— Check No. q Receipt No. =:z NOTE: Persons contracting with unregistered contracto do not have access t the guaranty fund Signature of Agent/Owner ture of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE -OF .SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well El Tobacco Sales El 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 COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submifted yes S . Planning Board Decision: Conservation Decisio Com Comments Water & Sewer Connection/Signature Date Driveway Permit DPW To-tvn Engineer: Signature: FIRE =DEPARTMENT - Temp Dumpster on site yes Located at 124 Main' Street Fire DepartmerIt signature/date COMMENTS I nratarl qPA Street Dimension Number of Stories Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions _ ELECTRICAL: Movement of Deter location, mast or service crop requires approval of Electrical Inspector Yes too DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A -F and G min.$100-$1000 fine NU I Lb and UA 1 A - wor B Notified for pickup - Date Doc.Building Permit Revised 2010 ent use No Building Department 'rine following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o 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 40TE: 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 DOTE: 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; app•,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must he- submitted with the building application Doc: Doc.Buhding Permit Revised 2012 Location W No. 7&j -,2 d / ho ff Check # o?J9 7 211 Date ;7121117 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ k TOTAL $ Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 30,710.00 m $ - $ 368.52 Plumbing Fee $ 46.07 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 46.07 Total fees collected $ 560.65 44 Kara Drive 788-2017 on 2/21/2017 master bathroom remodel E9—* x J 2 LL O O O m u Y v O U N N v a cn p V ta/f Z O Z m c O Z m a 7 tOi s ? v c U i.i O W H Z Z m J d t O i„� W H J u u NJ t u ` v N _ ro O LL O C~J to Z N s O n _ co C LL W Q w LLI 6L v m O Z +, O N ++ N 0 Y O {n I U) E n L N as � t w 0 E w D � m m O w :a C9 .Z 0 m H �C V G Q Q z � � coLLI > .� XUJ. z Wa W J az M w D � m m BUILDING & REMODELING CONTRACTOR MASSACHUSETTS HOME IMPROVEMENTS CONTRACT This form satisfies all basic requirements of the state's Home Improvement Contractor law (MGL chapter 142A), but does not include standard language to protect homeowners. Seek legal advice necessary. Any person planning home improvements should first obtain a copy of "A Massachusetts Consumer Guide to Home Improvement' before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-97341787 or 1.888-283-3157 or on our website. Homeowner Information Name Mr. & Mrs. O'Connell Tom & Jane Street Address (do not use a Post 00ice Box address) 44 Kara Drive City(Town State Zip Code North Andover, MA 01845 Daytime Phone Evening Phone 978-7944127 Email: toconnelltomi@comcast.net Mailing Address (It different from above) Contractor Information Company Name Joscon Management, Inc Contractor) Salesperson/ Owner Name Jonathan O'Sullivan Business Address (must include a street address) 185 Atlantic Avenue Cityffown State Zip Code Salisbury, MA 01952 Business Phone Federal Employer ID or S.S. Number 603.489.1568 61-1403121 Home Improvement Contractor Reg. Number 159444 Expiration date 4-30-2018 The Contractor agrees to do the following work for the Homeowner. (Describe in detail the work to complete, specifying the type, brand, and grade of materials to be used, use additional sheets if necessary.) Master Bathroom: Renovate the existing master bathroom by reconfiguring the bathroom by eliminating the soaking tub, fabricate a new custom shower approx. 6'x 4' at the soaking tub location, add a new linen closet and renovate the remaining bathroom area. Several items below have Allowance amounts provided and will be adjusted accordingly once all materials have been selected. Final shower dimensions will determine the actual tile material and labor cost. Scope of Work • Building permits per the Town of N Andover. • Temporary protection and daily cleanup throughout the remodeled areas. • Demolition work to include the following: Removal of the file flooring, shower, mirror, tub unit, vanity and fixtures. Disposal of all construction related debris. • Remove the existing sub flooring at the new plumbing locations to access plumbing for the new layout and code upgrades. • Rough carpentry to include re configurring the existing bathroom per the new layout including the new custom shower and linen closet. Minor framing adjustments in the floor for the new plumbing supply runs. Shower final dimensions and configuration TBD and pricing adjusted accordingly. • Insulate and fire caulking as needed. • Install new'' blue board on all new walls and disturbed areas. Ceiling to have a smooth finish over the existing textured plaster. Patch holes as needed. • Install homeowner purchased bathroom towel bars, robe hooks and toilet paper holder. • Plumbing work has been figured on the following: Demo old shower and cap Imes. Install new toilet, install new double vanity and install new shower with shower head and hand held spray. If we have to run more than 3' of 2' PVC to connect the shower drain, pricing will be adjusted accordingly. All work to code. Option: Relocate 3' of baseboard heat behind the toilet @ $325.00. • Plumbing fixture Allowance listed below. • Electrical work has been figured on the following: Demo unusable wiring and devises in the master bathroom. Supply and install a Panasonic 80 CFM fan only unit, using existing switching. Replace (3) existing vanity sconces with new, purchased by homeowner. Install fight in bathroom closet. Install swtrching, wiring and support for chandelier, provided by owner. Replace all existing master bathroom switches, receptacles and cover plates with new. • Carpentry work to include baseboard moldings, and install (1) new linen closet door unit. Linen closet shelving to be while metal vented shelving with 4 rows. • Install a new vanity and associated hardware. New vanity figured on an 84' double bowl unit. Vanity and countertop allowance listed below. • Install file backer board throughout the bathroom floor area, shower area. Tile materials allowance listed below. • Install new the throughout the bathroom floor and shower area. • Install a shower gloss door system. Additional specifications needed. Door allowance listed below. Final layout will determine the actual door amount. • Painting throughout the bathroom area for the walls, millwork and ceiling. • Final post construction cleaning throughout the project area. Allowances: • Plumbing work Plumbing fixtures o Toilet @ $300.00 o Vanity sink @ $100 x 2 = $200 o Vanity faucets @ $150 x 2 = $300 o Shower trim and valve @ $500 • Electrical work • Vanityincluding the top. Vanity @ $2,000 & Top @ $1,100 • Tile floor (Materials) • Tile master shower (Materials) • Custom shower glass enclosure Total for the above scope of work including the Allowance amounts: $ 30,710.00 Required Permits — Building permit (Owners who secure their own permits will be excluded from the Guarantee Fund provisions of MGL chapter 142A.) @ $2,775.00 @ $1,450.00 @ $3,100.00 @ $760.00 @ $1,310.00 @ $3,000.00 Proposed Start and Completion Schedule - The following schedule will be adhered to unless circumstances beyond the contractor's control arise. 2-27-17 Date when contractor will begin contracted work. Actual start date will be based on the building permit If being issued by the Town of N Andover 4#17 Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of $30,710.000 Payments will be made according to the following schedule: $ 4,606.50 15% Deposit Upon signing contract. (not to exceed 113 of the total contract price or the cost of special order items, whichever is greater) $ 7,677.50 25% Upon the start of the project $ 9,213.00 30% Upon the of the completion of demolition and rough in sign offs. $ 6,142.00 20% Upon the start of the file install and drywall completed. Carpentry started. $ 3,071.00 10% Upon substantial completion of the contrail (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following matedallequipment must be special $ 0 to be paid for NIA ordered before the contraded work begins in order to meet the completion schedule f) $ 0 to be paid for NIA NOTES: (I Including all finance charges ('") Law requires that any deposit or down -payment required by the contractor before work begins may not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty - Is an express warranty Wng provided by the contractor? olo o Yes (all terms of Me warranty must be attached to the contract) Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement. Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any limn or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. MDon't be pressured into signing the contract. Take time to read and fully understand it Ask questions if something is unclear. Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-9734787 or 888-283-3751. MDoes the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to see a copy of a'proof of insurane document. MI(now your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide 0 the Home Improvement Contractor law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement See the attached notice of cancellation form for an explanation of this right DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM Two identicaLlw W of the contract must be completed and signed. Onecopy sho Id go to the homeowner. The other copy should be kept by the HoA&nefs Si atu , (� ConWs Signature C .� Date Date VIZJ ZZ Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless loth parties agree to the optional clause provided below. This clause would give the contractor the same right to arb tration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws, chapter 14 meowners Signature r1ors Signature NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowners rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Hare Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and f mess for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowners basic consumer rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day rescission period has expired. Accelerated Payments 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. However, in instances where a contractor deems him/herself to be financially insecure, the contactor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at http-./hm.mass.gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration comment of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at hftp:itwww.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractors Registration: http://db.state.ma.usihomeimprovemenmicenseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800, 508-755-2548 or 413.7343114 Jan.26.2017 03:03 PM Advantage Insurance Agenc 978 794 4833 PAGE. 1/ 1 CERTIFICATE OF LIABILITY INSURANCE INDICATED, NOTWTHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH 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, [011'261'2017 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($), AUTHORIZED REPRESENTATNE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPOMNr. If the corlIftate holder is an ADDITIONAL INSURED, the pDlicy(tes) musten o su t to the teems and conditions of the policy, certain P01101as May (aqulta an endomente L A atetament on this cwUflcats does not corer fights to the certill"W holder In Ilett at such endomement(e). PRODUCER NAME: PAUL DEVIN ADVANTAGE INS. AGENCY INC .__..... 978-681-1055 ...... $I,BASANT VALTAY STMT tAr,NNbo. Ext): , ,,)078-794-4833104 - - ADDRESS! METHtUBN, MA 01844 IMURERI$HAPPORDIMCOVeRACt'. NAIL* INItMIRA:ARBELLA PROTECTION INS. CO. MURID �OSCON DlI1LBx►GEl4ICN'Y INC. INSURER B INSURER C: S 5,000 72 PROVIDIENCE RILL ROM _ INBLtRER D: ATKINSON N B 0381), MUM E! M wtuF: ._ ,... - I.h1lG'Ys. wrw %.0 r mT%m%3Ga CER t iFICA I G N UM61EK. REVISION NUMBER: THIS M TO CERTIFY THAT THE PQLICIE$ OF INSURANCE LI$TFh 13ELOW HAVE [TEEN ISSUED TO THE INSURED NAMED ABOVE- FOR THE POLICY PERIOD INDICATED, NOTWTHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH 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. �Hys- -- —---��..._._.._ .................... . LTR TYPE OF WSURANCE ROR VWD POLICY NUMaBR (MNVOOImYYY) (MNIODm" LIARS A GENERALU"ILLTY AVTHGRIa,REPR716- 85D0055ti90 05/30/201 05/30/2017 EACH OCCURRENCE 5 1,000,000 pRcM( ^G ) 3 100,000 X COMMERCIAL GENERAL LIARIUTY MED EXP IAny em WWI S 5,000 GLAIMg MADE ®OCCUR PERSONAL&ADVINJURY S 1,000,000 _ ._........_.._ ......... ....__._..._...».._.. —.-___.._........., .., . ..... flGHCRALA0011E0ATE ► 2,000,000 b 2,000,000 QF.NLAGGREGATE LIMIT APPLIES PER: PRDDLICTS-CANIPlOPAGG POLICY J—ECT--- AUTOMOMLE LIABILITY (Ee orddent RODiLYINJURY {Per person) S ANY AUTO ALL OWNED SCHEOULF0 AUTOS AUTOR BODILY INJURY (Per fPxlAvnt) I NO"WNNIRCOAIlTOS AUTOS ED -PRDPnTYDAMAdE (Por YorJdont ' 4 UMBRELLA LMf3 OCCUR EACH OCCURRENCE _ EUM UA CWMB-TdADE AGGREGATE DEO I I RETENTION S i A WORKERS COMPENsAT(oN 9121451013 10/05/201 10/05/2017MD _ TORYUNIITS g ER AEiPLDYERV LUMUTY YIN E.L. EACH ACCIDENT .............! y 1,000000 . ANY PROPRIETORIPARTNEIVEXECUTNEt��y � OPPICEWMEMBEREXCLUDED? NIA (NlmdetorrNIQ LJ ro E.I,.DISEASE -FAWFLOYEA II 1.000.000 If describea, desce Under .. _ OESCRIPTION OF OPEIiArIONS Wow E.L. DISEASE- POLICY LIMIT $ 1,000,000 OeACRII"WN OF OPAMTKM I LOCATION$ ) VEHI$LFA (Auto% AGORO /M, AddlN*eW 14- eee.duy R xwn ap c. to ngnlry,d) EVILDINO & • R$b=Z1,XNG CONTRACTOR CERTIFICATE HOLDER CANCELLATION T u Or NORTH amOVLR BUILDING DEPT. SHOULD ANT OF THE ABOVE DESCRIBED POt.UC1ES nE CANCELLED UEF'ORE THE EXPIRATION DATE THEREOF. NOTICE VML.L E6 DELfVERBD IN 120 MAIN STREET ACCORDANCE VWN THE POLICY PROVISIONS. NORTI$ ANDMR MGL 01845 AVTHGRIa,REPR716- Nit INS1114MIJ At KL) CUHF'ORATION. All ngntd reaerVed. ACORD 26 (2010M) The ACORD name and logo are reglsmred marks of ACORD The Commonwealth of Massachusetts Department of IndustrialAccidents twi I Congress Street, Suite 100 Boston, MA 02114-2017 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/organization/Individuao: Address: -7o\--,. V 11 YL3 City/State/Zip: N Ny IV( Phone #: G O 3a W - 1 SG 6 Are you an employer? Check the appropriate box: Type of project (required): 1. dam a employer with �kt`" employees (full and/or part-time).• %. ❑ construction 2.[J I am a sole proprietor or partnership and have no employees working for me in g, remodeling any capacity. [No workers' comp. insurance required.] 9. El Demolition 3.❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers' compensation insurance or are sole I l .❑ Electrical repairs or additions proprietors with no employees. 12.E] Plumbing repairs or additions 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13.E] Roof repairs These sub -contractors have employees and have workers' comp. insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. l4.FJ Other 152, § 1(4), and we have no employees. [No workers' comp. msurauce 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 suck tContractors 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 Beloty is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: -1 ) )"1 4 w G 13 Expiration Date: Job Site Address: '14 VGrG C)rti\,<, City/State/Zip: IV 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 e. 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 $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerify under the pains and penalties of perjury that the information provided above is true and correct &U,3- y�jl q - /" F Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # 11'1V) 7 Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: i �, �J/,� ��:,,,,,�f.,,«;.•.,/r! � j �' �1,�.;�,�1,.�, ire , _Office of Consumer Affairs & Business Regalatiion H, ZZHOME IMPROVEMENT CONTRACTOR Registration:159444 Type: Expiration: 4/30/2018 Private Corporation JOSCON MANAGEMENT INC. A JONATHAN . O'$ULC.IVAN 72 PROVIDENCE HILL RD. ATKINSON, NH 03811 Undersecretary } Massachusetts Department of Public Satety Board of Building Regulations and Standards License: CS -070043 Construction Supervisor ,a► JONATHAN o%ULLIVAN 186 ATLANTIC AVENUE #4 SALISBURY MA 01952 ("�,,,czCA, Expiration: Commissioner 08/26/2018