HomeMy WebLinkAboutBuilding Permit #786 - 445 BOSTON STREET 6/1/2007Permit NO:
Date Issued: e , % O
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
I - IMPORTANT: Applicant must complete all items on this page
LOCATION .41 �— ,50,5Td 1V 57-1?e e= T
PROPERTY OWNER 7110,W46- <24 ?W L V
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Villaae ves no
TYPE OF IMPROVEMENT
0
Residential
Non- Residential
❑ New Building
,p
1.
PROPERTY OWNER 7110,W46- <24 ?W L V
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Villaae ves no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
XOne family
❑ Addition
❑ Two or more family
❑ Industrial
Alteration
No. of units:
❑ Commercial
Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
0 Septic ❑ Well
❑ Floodplain 0 Wetlands
0 Watershed District
❑ Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
��viiv� 2ao� %o y �r!a-aXioh'er�Pe�z /e,! rVatlpf 3 ,/ V-170'IfO49 J-
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Address: g0S1--0h/ "/,,g OIP-Y5_
CONTRACTOR Name: g Phone: �?%Q 0 0 fRt�F
Address: vim/ "DD(/n2
Supervisor's Construction License: L r��� �% Exp. Date: 0,-/Z0
Home Improvement License:
. Date:
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.
7
Total Project Cost: $ /4 ���• o� FEE: $
Check No.: `L �7 Receipt No.: (20dS —
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner � Signature of contractor
Location '�fN�� �r7
No. --2,04 Date
N�RTN TOWN OF NORTH ANDOVER
3?� ..SOL
Certificate of Occupancy $
�'� s'••'°' Eta
Nus Building/Frame Permit Fee $
nc
Foundation Permit Fee $
Other Permit Fee $ r
TOTAL $
Check # i
20+254
Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales Ch.
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED DATE APPROVED
❑ ❑
0
DATE REJECTED
DATE APPROVED
DATE REJECTED DATE APPROVED
❑ ❑
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
Located at 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street /
Fire Department signature/date
COMMENTS
Dimension
i
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
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
❑ Notified for pickup - Date
Doc.Building Permit Revised 2007
� r -
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
o 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
o 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
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
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
o 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 appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2007
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The Commonwealth ®f Massachusetts
North Andover
( Cityof Town )
Department of Fire Services
Office of the State Fire Marshal
R O. Boz 1025 State Road, Stow, MA 01775
PERMIT
Permit No
( If Applicable )
In accordance with the provisions of M. G.L 14 8 Chapter_j_(Z as provided in section 5 7 7 (; MR 34
This Permit is granted to: z ,S';�* Wi 17-C Z. _
Date: !, 2,-_
Dig Saafffe/N�um er
Start Date
Full name of person, Firm or Corporation
Permissionto locate dumpster for construction/renovation/demolition of building
Corrtments: dumpster must be. 25' from structure if unable to place with "required
Restrictions:
clear ance dumpster must be covered with plywood or tarp end of work -day
at
( Give location by street and no., or describe in h manner as to provied adequate identification of location )
Fee Paid 50.00 Fire Chief
This Perrhit will expire�� (Sigtu
nare of o tcal granting permit ) 0 ical granting pennit (Title)
U06-4 /o/
A CONTRACTOR'S COPY
QRESIDENTIAL CONTRACTING AGREEMENT
O Read this agreement and make sure you understand it before signing it. This Agreement has legal
force and effect binds those who sign it.
Notice:
All home improvement / general contractors and subcontractors engaged in home improvement
contracting, unless specifically exempt from registration by provisions of Chapter 142a of the
general laws, must be registered with the Commonwealth of Massachusetts. Inquiries about
registration and status should be made to the Director, Home Improvement Contract Registration,
One Ashburton, Place, Room 1301, Boston, MA 02108.
Designated Registrant's Name: Roger J. Ratte', Inc.
Salesperson's Name: Joseph R. Ratte'
Registration Number: 100294
License Number: 015004
This agreement is made on May 18, 2007 between Roger. J. Ratte', Inc.
DBA R. Joseph Ratte', Inc. of 10 Main Street North Andover, MA 01845 Ph. (978)-688-8839
hereinafter called "Contractor" and Thomas & Maureen Connolly of 445 Boston Road
North Andover, MA 01845 Ph. (978)-975-7694 hereinafter called "Owner".
I. DETAILED DESCRIPTION OF WORK TO BE PERFORMED
Contractor agrees to perform in a good and workmanlike manner all work detailed below. Such
work consists of the following: Renovation of kitchen and three bathrooms as per attached
specifications and allowances.
DETAILED DESCRIPTION OF MATERIALS TO BE USED
Materials to be used in performing the above described work consist of the following:
As per attached specifications and allowances.
II. PRICE
Contractor agrees to do all work described in Section I for the total price of: $43,460.00
Forty three thousand four hundred sixty dollars.
HIDDEN CONDITIONS AND NECESSARY ADDITIONAL WORK:
Hidden conditions or additional work may require adjustment in the overall price for the
necessary work related to this contract. In such case the Contractor shall inform the Homeowner
of such conditions forthwith and where necessary a written amendment of this Contract will be
negotiated and executed by the Parties. Additional work beyond the scope of this contract will be
billed at an hourly rate of $65.00 per man hour for carpentry and $85.00 per man hour for
plumbing. Additional material and subcontract work will be billed at direct cost plus a 25%
General Contracting fee.
(978) 688-8839 • 340 Mt.Vernon Street • Lawrence, MA 01843 • Fax (978) 688-7476
III. PAYMENT
Payment will be made as follows:
S4p"MV"osit with signed contract
$ 8,000.00 At start of job.
$10,000.00 Completion of kitchen cabinet installation.
$ 5,000.00 Completion of half bath.
$ 5,000.00 Completion of main bath.
$ 5,000.00 Completion of master bath.
$ 2,460.00 Completion of job as per specifications.
Payments as provided above shall be made when due. Any payments that are delayed shall be
subject to a finance charge of 1.5% per month.
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 or the total amount of all
deposits or payments which the contractor must make, in advance, to order and/or otherwise
obtain delivery of special order materials and equipment, whichever amount is greater.
IV. COMMENCEMENT AND COMPLETION OF WORK
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 June 4, 2007. Barring delay caused by circumstances beyond Contractor's
control, the work will be completed on or about July 20, 2007. 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.
V. NO ACCELERATION OF PAYMENTS BUT ESCROWING ALLOWED
The Contractor may not require payments to be made in advance of the time specified in Section
III (Payment) above for the reason that he deems himself or the payments to be insecure.
If, however, he deems himself to be insecure, he may require, as a prerequisite to continuing the
work described herein, that the balance of the payments under this contract that are in the control
of the Owner, shall be placed in a joint escrow account that requires the signature of both the
Contractor and the Owner for withdrawal.
VI. INSURANCE
Contractor will be responsible to Owner or any third party for any property damage or bodily
injury caused by himself, his employees or his subcontractors in the performance of, or as a
result of, the work under this Agreement. Contractor agrees to carry insurance to cover such
damage or injury.
(978) 688-8839 • 340 Mt. Vernon Street • Lawrence, MA 01843 • Fax (978) 688-7476
VII SUBCONTRACTING
Contractor agrees that, notwithstanding any agreement for materials and/or labor between
Contractor and a third party, Contractor is responsible to Owner for completion of all work
described in a timely and workmanlike manner.
VIII CONSTRUCTION -RELATED PERMITS
The following construction related permits will be necessary in order to complete the scope of
work included in this contract and are the responsibility of the Contractor:
(mark X where applicable)
Building X Demolition
Plumbing X Electrical X
The Contractor under provisions of Chapter 142A of the General Laws is required to apply for
and obtain all construction related permits. Home improvement work (i.e.. additions, garages,
porches, etc.) may require other permits including but not limited to Variances and Special
Permits under Zoning by-laws through the Board of Appeals, Board of Health Permits for
expansion of sewage disposal systems, Conservation Commission for an Order of Conditions, etc.
Such permits which may require non -construction related, engineering, technical or legal
representation of the Homeowner, shall be the responsibility of the Homeowner.
Notice:
If the homeowner obtains his own construction -related permits for the work described under this
agreement, the homeowner is hereby advised that in the event of a dispute, judgment and
nonpayment of the Contractor, the homeowner will not be entitled to make a claim to or
collect from the guarantee fund established by Chapter 142A, M.G.L.
IX. MODIFICATION
This Agreement, including the provisions relating to price and payment schedule cannot be
changed except by a written statement signed by both Contractor and Owner. However,
cancellation by Owner is allowed in accordance with the Notice of Cancellation (annexed).
X. WARRANTIES
The Contractor warrants that the work furnished hereunder shall be free from defects in materials
and workmanship for a period of one year following completion and shall comply with the
requirements of this Agreement. In the event any defect in workmanship or materials, or
damage caused by 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, or 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-
(978)
ork
(978) 688-8839 - 340 Mt.Vernon Street - Lawrence, MA 01843 - Fax (978) 688-7476
All warranties for equipment supplied by the Contractor under this Agreement shall be those
given by the manufacturers of such equipment, which shall be and are hereby passed through
directly to the Owner. Under such manufacturers' warranties, the Owner may be required to
register or mail in a warranty card or other evidence of ownership and use of such equipment in
order to activate such warranties. The Owner's failure to mail in or register such documentation,
which failure voids the mamdacturer's warranty, shall not create any responsibility for the
Contractor to warranty such equipment.
M. COMPLETENESS OF AGREEMENT FOR EXECUTION
The.Owner is hereby advised that he should not sign this Agreement unless and until all blank
sections have been filled in or marked as void, deleted or not applicable, and until all exhibits
and related or referenced documents that are incorporated herein are attached hereto.
XII. COPY OF AGREEMENT TO BE GIVEN TO OWNER
This Agreement is governed by the Laws of Massachusetts. It must be executed in duplicate, and
an original signed copy hereof given to the Owner at the time of execution. No work
under the Agreement shall begin prior to the signing of the Agreement and transmittal to the
owner of a copy thereof.
RIGHTS TO CANCEL
The owner may cancel this agreement if it has been signed by the owner at a place other than
an address of the contractor which may be his main office or branch thereof, provided that
the owner notifies the contractor in writing at his main office or branch 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 attached Notice of Cancellation.
HOMEOWNER DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
s/zz`a7
Owner's Signature Da a Signed
o'
ntractot's Signature Date Signed
(978) 688-8839 • 340 Mt.Vernon Street • Lawrence, MA 01843 • Fax (978) 688-7476
Specifications
May 18, 2007
Mr. & Mrs. Thomas Connolly
445 Boston Street
North Andover, MA 01845
FIRST FLOOR HALF BATH
PRELIMINARY: Submit specifications and obtain all necessary permits.
DEMOLITION: Remove all existing plumbing fixtures, cabinets, floor tile, and underlayment,
Dispose of all debris.
PLUMBING / FIX TURES: Install new stops for vanity. Install new toilet, sink, and faucet, as
selected by owner. Allowance for fixtures: $425.00
ELECTRICAL: Replace existing light fixture.
PLASTER / DRYWALL: Repair all disturbed areas in preparation for painting.
CABINETS / COUNTERTOP: Install new vanity and countertop as selected by owner.
Allowance for cabinet & countertop: $800.00
INTERIOR TRIM: Repair baseboard as needed, and adjust entrance door to close and lock
properly -
TILE / UNDERLAYMENT: Install 1/2" underlayment over subfloor and secure as needed.
Install ceramic tile to main floor as selected by owner. Allowance for tile materials: $200.00.
PAINTING: Prime and paint bathroom as required. Allowance for painting: $650.00
HARDWARE: Install bath hardware provided by owner.
Complete clean up and removal of all debris.
Total cost as described above: $5,350.00
MAIN BATH SECOND FLOOR
PRELMNARY: Submit specifications and obtain all necessary permits.
DEMOLITION: Remove all existing plumbing fixtures (excludes tub), countertop, floor tile, and
underlayment. Dispose of all debris
PLUMBING / FIX TURES: Install new stops for double vanity. Install new toilet, 2 sinks, 2
faucets, and new shower trim as selected by owner. Allowance for fixtures: $750.00
Refinish existing shower module in place.
ELECTRICAL: Replace existing light fixture, install new fixture in shower, and install new
exhaust fan.
(978) 688-8839 • 340 Mt.Vernon Street • Lawrence, MA 01843 • Fax (978) 688-7476
PLASTER / DRYWALL: Repair all disturbed areas in preparation for painting.
CABINETS / COUNTERTOP: Install new granite countertop on existing vanity, and install
medicine cabinet or mirror as selected by owner. Allowance for countertop and mirror.
$1,000.00
INTERIOR TRIM: Repair baseboard as needed.
TILE / UNDERLAYMENT: Install 1/2" underiayment over subfloor and segue as needed.
Install ceramic tile to main floor as selected by owner. Allowance for tile materials; $320.00.
PAINTING: Prime and paint bathroom as required. Allowance for painting: $800.00
HARDWARE: Install bath hardware and shower door as selected by owner.
Allowance for shower door and installation: $500.00
Complete clean up and removal of all debris.
Total cost as described above: $8,725.00
MASTER BATH SECOND FLOOR
PRELIlVIINARY: Submit specifications and obtain all necessary permits.
DEMOLITION: Remove all existing plumbing fixtures, cabinets, floor tile, and undedayment.
PLUMBING / FI3ams: Install new stops for vanity. Install new toilet, sink, and faucet, as
selected by owner. Allowance for fixtures: $500.00
Refinish existing shower module in place.
ELECTRICAL: Replace existing light fixture, install new fixture in shower, and install new
exhaust fan.
PLASTER / DRYWALL: Repair all disturbed areas in preparation for painting.
CABINETS / COUNTERTOP: Install new vanity and countertop as selected by owner.
Allowance for cabinet & countertop: $800.00
INTERIOR TRIM: Repair baseboard as needed.
TILE / UNDERLAYMENT: Install 1/2" underlayment over subfloor and secure as needed.
Install ceramic tile to main floor as selected by owner. Allowance for tile materials; $160.00.
PAINTING: Prime and paint bathroom as required. Allowance for painting: $500.00
HARDWARE: Install bath hardware and shower door as selected by owner.
Allowance for shower door and installation: $500.00
Complete clean up and removal of all debris.
Total cost as described above: $7,850.00
(978) 688-8839 • 340 Mt.Vernon Street • Lawrence, MA 01843 • Fax (978) 688-7476
DOORS / WINDOWS
Replace existing slider to porch, and kitchen window. install new interior trim.
Dispose of all debris. Allowance for both units: $1,700.00 Total cost: $3,685.00
KITCHEN WORK
Disconnect and remove existing appliances and kitchen sink & faucet.
Remove and dispose of existing cabinets, countertops, floor covering and wWalayment
Alter existing closet to accept proposed cabinet
Frame new opening in bearing wall to living room approximately 4' wide.
Install 6 new recessed light lures in ceiling and associated switches.
Upgrade electrical in kitchen per code and as directed by owner.
Allowance for electrical and Sxtures: $2,000.00
Repair plaster ceiling and walls as needed.
Install new cabinets and trim as per plan provided by Jackson Lumber.
All cabinets and countertops are to be supplied by owner.
Granite countertops shall be installed by fabricator.
Upon completion of countertops, install new sink and faucet provided by owner.
Trim out new opening to living room and install miscellaneous trim as needed.
Install new '/s" underlayment on floor and ceramic the as selected by owner.
Allowance for tile material and installation: $1,600.00.
Upon completion of floor, install all appliances supplied by owner.
Stain new woodwork, and paint ceiling and walls as directed.
Allowance for painting: $1,500.00
Total cost as described above: $17,850.00
We are licensed, registered, and fully insured.
License #015004 Registration #100294
(978) 688-8839 • 340 Mt.Vernon Street • Lawrence, MA 01843 • Fax (978) 688-7476
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Reg, No.
Ap licant
Street
City
State
lExpirationj
ROGER J.
340 Mt.
tette'
6/15/2008
100294
RATTE, INC.
Vernon St 1
Lawrence
MA
01843
esident
0
Total of 1
Records
matched.
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 015004
Birthdate: 0812711958
Expires: 08/27/2007 Tr. no: 15942
Restricted: 0.0 -
JOSEPH R RATTE f
340 MT VERNON ST
LAWRENCE, MA 01843 -
Commissioner
1P a
�^--------------✓ite -Vantmza�twea�t a�./�aaaaciuceekd
j Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 100294
Expiration: 6/15/2006
Type: Private Corporation
ROGER J. RATTE, INC.
Joseph Ratte
340 Mt. Vernon St
Lawrence, MA 01843
Administrator ,
ACQRQ.
CERTIFICATE OF LIABILITY INSURANCE
Michaud, Rowe And Ruscak Ins.
198 Massachusetts Ave
North Andover MA 01845
Phone: 978 688 8829 Fax: 972 557 2130
Roger J. ROttO, Inc_
10 MAin street
North xndover D& 01945
a 'M lmMAaD ffm
ONLY AND CONFERS NO RIGHT i UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOOM NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORD ED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE: NAIC ##_
INSURER A: ANW12 P4otaetion Ins. Co. y 41360
INSURER B: safe xn$urar ce Coufpa�ny 33619
NSURERC: American Intez aat_ional COS
INSURER D: _.
INSURER E: _
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NI (WITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANT CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERYIFICATE MAY Of ISSUED OR
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND COND '-EONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
SR LTR NS YYPE OF INSURANCE POLICY NUMBER DA MMfD DATE LIMITS
DATE T"eimw, THE ISSUNG INSURER IMI L ENDEAVOR TO MAIL _ DAYS WRIMN
GENERAL LIABILITY
wpow No OBLIGATION on LwKm or,;NY IOND UPON THE UM&(RER. ITS AGENTS OR
EAC IOCCURRENCE
$ 1000000
PREP R I
x50000
.s .w.�.nn wnenne�w nna� Joao
COMMERCIAL GENERALLL49ILFTY
8500033367
1 CLAIMS MADE RQ OCCUR
MEC EXP ww one pwm)
$
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51000000
A
X BuLsine 5 Owners
03/28/07
03/28/08
Pm-:;ONALBADV INJURY
GENI:RALAGOREGAYE
s20000 0 -
t
PRCI)UCTO-COMPIOPAGG
$`1000000
-
t3EMLAGGREGATE UMITAPPLiESPER:
POLICY PJEC 7 LOC
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
B
ANYAUTO
1500030
01/16/07
01/16/08
ALL OWNED AUTOS
BOC LY INJURY
$ 100000
leer sarsonf
X
SCHEDULED AUTOS
_ -
X
HIREDAUTOS
BOE LY INJURY
$ 300000
(Pet weldent)
R
NON -OWNED AUYO$ '
- .._ . _ ..
PR( °ERTYDAMAGE
$ 100000
(Pei wditd)
i
GARAGE LIABILITY
(7 ONLY - EA ACCIDENT
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EA ACC
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AGG
$
EXCE89lUMBRELLA1.L4811RY
EAC iOCCURRENCE
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OCCUR CLAIMS MADE
AGc;REGATE
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8 —
$
DEDUCTIBLE
_..
—
$
_ RETENTION S
WORKERS COMPENSATION AND
TORY LI ITS , ER_
MPLOYERS LIABILITY
WCO944334
04/23/07
04/23/08
E.L:ACHACCiDENT
$100000
)ISEASE-GA EMPLOYEE
ANY PROPRIETORIPARTNE XECUTIVE
$ 100000
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$ 500000
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D PTIQN OF OIPERATIONB I LOCATIONS I V6IIIDLI:B / EOCLUSIONS ADDED BY GMBOMBMS T I SMAI PROVISIONS
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RATTEC2
SHOULD ANY OF THE ABOVE DESCRIBED 'OLWIES eE CANCELLED 96FORE THE EXPIRAY,ON
DATE T"eimw, THE ISSUNG INSURER IMI L ENDEAVOR TO MAIL _ DAYS WRIMN
NOTICE TO THE CERTIFICATE HOLDER NA tED TO THE LEFT, BUT FAIW RF TO 00 80 SMALL
wpow No OBLIGATION on LwKm or,;NY IOND UPON THE UM&(RER. ITS AGENTS OR
REPRESENTATIVES.
AUTHO REPRESEM'1'A n
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ACORD 26 (200901)
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
d 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information — Please Print L,e_y
V'ibl
�/
Name (Business/Organization/Individual): A9061 -el? �C d L � /
Address: Aa 6_7'
City/State/Zip:PN 0&r—Phone #: % ��` �00� -��
Are you an employer? Check the appropriate box:
1. I am a employer with 3 4. ❑ I 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. I
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance 5 El
required.]
3. ❑ I am a homeowner doing all work
myself [No workers' comp.
insurance required.] t
These sub -contractors have
workers' comp. insurance.
We are 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.]
Type of project (required):
6. ❑ New construction
7. Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs oT additions
11.0 Plumbing repairs or additions
12.0 Roof repairs
131-1 Other_
*Ariy 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.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
1 an: 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. #:� 7 Expiration Date:
Job Site Address: i l ;E 02 5� City/State/Zip:�%� /���/g7 .�
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.
1 do hereby certify under the pains an penalti f peijul tat to information provided above is true and correct
Signature Date: �O i
Phnne # / �c �/ O 0. 00 /
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 #: