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HomeMy WebLinkAboutBuilding Permit #631 - 468 WOOD LANE 1/30/201509 NORTH Z(/ BUILDING PERMIT o��t�eD;6��o TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 3 �z Permit No#: i/ Date Received TED v �SSACHUS�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 7.e F &Ayio PROPERTY OWNER�4 rl 1) /IJ�'S�1Mf.vtGti l _ - - _ - Print, 100 Year StructWe yes no MAP �a _ PARCEL: ZONING DISTRICT: _ _ _. _ _ Historic District yes no - _ Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building XOne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial XRepair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District Water/Sewer At,) elaeo-) Re, rv41C-2 Roo -F l OWNER: Name: Address: 6 DESCRIPTION OF WORK i O tit FhK1-UK1V1r-U: uhp 4 e �d l h OG. /G e,d, Ms zye e-) 1--Itele l�t DO M. — ;eS . Re 'v-4 rce ktf�tie Ceilr'� Ol le- 7NhfXej t ation Pleas Type or Print Clearly Phone: E, ,X o / 1 ru , N , m4a Contractor Name-.;rPhone':Co`� Address: \"3 Wit¢r�t N 4 M Cy1Q�4 Supervisor's Construction License:(f C, o1C _ -_ _ Exp. Date: VA 2-- )S . 'Home Improvement License: _ . tib_-_ _ "Exp.,. Date:._I_ ARCHITECT/ENGINEER r Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTRASED ON $125.00 PER S.F. Total Project Cost: $ J10, 00 0 FEE: $ Check No.: l Receipt No.: NOTE: Persons contracting with ccnregistered contractors do not have access to the guarafty fund r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPB�OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ 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 PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed On _ Signature Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature & Date Driveway Permit DPW Town Engineer: Signature: m = — , -- - Located 384 Osgood Street FIRE DEPARTMENT - Temp Du'- ter on site es y no Located at 124 -Main Street _ _ _ — -- Fire'Departmen`t signature%date --- Dimension 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:re . quires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes -No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ 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 ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) L3 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 o 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 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: Building Permit Revised 2014 Location 4(f RMW( kwl— Date No.(ANC . _,I . 1�15 TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee VE— Other Permit Fee TOTAL Check *1 n2� 28 4 62 Building Insp-ec M®r Enter construction cost for fee cal - North Andover Fee Cakulation Construction Cost $ 40,000.00 m $ - $ 480.00 Plumbing Fee $ 60.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 60.00 Total fees collected $ 700.00 468 Wood Lane 631-15 on 1/30/2015 New Kitchen, Update 2 Bathrooms, Update Basement n J W u=. OJ u Y \ O LL w n N u"6 O_ (n 00 (LLI � d Z Z D co O 7 LL t DD K C -E V m C LL 0 LU yaj Z Z mm C t O W m C LL 0 oc W !A Z V V LU t cr N u N C LL O u a Z Q (7 t O d' M C LL Z WC C °C LU 0 W 5 N m O z {% N N LU 13M O O O CLa. as �a 0.2 .o, 0 V r L L (A '.0. _ O U) 4 Q � J d L ` m CD -a > Cc_ (D qo.E � o o 0 .= r'MU .a ;gel o E m oz CL _ .- �t •2 c o~ L Q. Q U ' Cc .N tm _ _ L i R CD O 0 N CL O V m _ -0� O O C .!R% N = MO) O +�+ it V V L- 0 •= i G1 O •a d �, o.o O•�a= _ O t . 0.00 Li. 0 LU U) z 0 m //�/ Cl) V/ O G^ z 'W Z V W U) x W OU H cn W LLJ -i a Z X'he Commonwealth ofMasssachuselts - Deparhnent o, f lndus€rigl Accidents Off "ice of lnvestigadons 600 Washington. ,S`tr'eet .Boston, MA 02111 www.mass.gov/ciia Workers' Compensation Insurance Affidavit: Builders/Contrac Name Address: ��,�_A City/State[Zip: L -\e\ Phone #' Are you an exnployer? Check the appropriate box: 1. ❑ I am a employer with _ 4. E]I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors listed on the attached sheet 2. ❑ I am a sole proprietor or partner ship and'have no.employees These sub -contractors have working forme in any capacity. workers' comp. insurance. 5. ❑ We area corporation and its [No workDls' comp. insurance officers have exeressed.their required.] 3. ❑ I am a homeowner doing all work right of exemption per MGL Myself [No workers' comp. t c• 152, §1(4), and we have no employees. [No workers' ins„rancerequired.] comp. insurance required.] Type of project (required): 6. ❑ New cOnstraction f 7.modeling 8. [] Demolition 9. ❑ Building addition 1011Electrical repairs or additions ILL] Plumbing, repairs or additions 12.❑ Roofrepairs 13.0 Other -Any applicautthat checks box#1 must also fill out the section bel6w showingtheir wbrkers' compensationpoHc;y information. �'Horneowners who submit this affidavit indicatingthey are doing all work and then hire outside contractors must subinit anew affidavit indicating such. tContxaetors that chakthis box must attached as additional sheet showing the name oi:the sub -contractors and their workers' comp. policy information. X am an emyloyer that is providing worketrs' cornperasation insurance for my employees. Below is the polley imd joh site in, formation. Insurance Company Name% Policy # or S elf ins. Dic. Expiration Date; Job Site Address: City/StatelZip: cy declaration page (showing the policy number and expiration date) Attach a copy of fire workers' comp ensatiozi poli . palure-to. secure coverage -as requiredunder Section 25A ofMGL o. 152 can lead to the imposition of criminal penalises of a _— - %e up to $1,500.00 andfnx one-year x7nprisornneiti",-mss well id 0- l lsenalties gni he form rof a STOP WORK ORDERand adna- of up to $250.()o a day against the violator. Be advised that a copy of this statement maybe forwarded io the Office of Investigations of the DIA- for insurance coverage versfication. X d0 hereby ce fy Under th.nd penaltles of perju y that fit information provided above is true and correct - .�1 na+P• \ •1--o' zp _11 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 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 int 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 ati individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having notmore 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: &elliug house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employes." MGL chapter 152, §25C(6) also states that "every, state or local licensing agency shall withhold the issuance or renewal of a license or p ermit to op erate 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 ofpublic work until acceptable evidence of compliance with the insurance requirements ofthis chapter have b con 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 cerecate(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 Li C or LLP does have employees, a policy is required. B a advised thatthis affidavit maybe 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 peanut 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 andprinted 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 fall in the permit/license number whichwill be used as a reference number. In addition, an applicant that must submit multiple permit/licame applications im anygiven year, need only submit one. aftzdavit indicating current Policy information (if necessary) and under "lob Site Address" the applicant should write "all locations in (city or towza)." A' copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as pr.0ofthat a valid affidavitis on file for future permits or licenses..A. new affidavit must be.Plled out each _ year Whereahoaneownerorcati2enxsobtaanmgahcenseorpeamitnoffae ted�to=auybusinessox_comnercial�verii e� T - —.._ -- — (ke.-edbg Hanse orpermit to burn leaves eta.) 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.iuesgons, please do not hesitate to give us a call. The Department's address, telephone and fax number: Tho 4`QwonwalthofA1'assac vsetE,q Depaximmt dfhdu al A,coldmtst Qfte dwo ugattow do Wasbiugtm Stich TO. # 617.7.247-4900 at 406 or 1 -87 -7 -MAS Revised 5-26-05 Fax # 617-727-7749 www.�ass,g�.v�clxa. �� 3G �� i %� REALESTAT2 ACORINSURANCE BINDERDATE COVERAGEIFORMS DEDUCTIBLE 12/29/14 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM. PRODUCER PHONE g78-657-5100 AIC No Ext COMPANY BINDER# AU IZED REPRESENT TIS VE (AIC No)m 866-685-0347 Acadia Insurance Company APP1903590 HUB International New England EFFECTIVE DAMAGE $ RENTED PREMISES EXPIRATION g DATE TIME DATE I TIME GENERAL AGGREGATE $ X AM AUTOMOBILE X 12:01 AM 299 Ballardvale St 12/29/14 12:01 BODILY INJURY (Per accident) $ 01/29/14 MEDICAL PAYMENTS $ Wilmington, MA 01887 PERSONAL INJURY PROT $ UNINSURED MOTORIST $ PM AUTO PHYSICAL DAMAGE DEDUCTIBLE COLLISION: OTHER THAN COL: NOON ACTUAL CASH VALUE STATED AMOUNT $ OTHER THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY PER EXPIRING POLICY #: CODE: SUB CODE: AGENCY 4866$ CUSTOMER ID: DESCRIPTION OF OPERATIONSIVEHICLESIPROPERTY (Including Location) Loc#1: 468 Wood Lane, North Andover, INSURED Real Estate Investments 8r Equity, LLC; Paul Cammarata MA 01845 8 Jewel Dr. RETRO DATE FOR CLAIMS MADE: Wilmington, MA 01887 AGGREGATE $ COVERAGES LIMITS TYPE OF INSURANCE COVERAGEIFORMS DEDUCTIBLE COINS % AMOUNT PROPERTY CAUSES OF LOSS BASIC E1BROAD X� SPEC Builders Risk -existing structure bldg materials 5,000 5,000 273,000 60,000 Reading, MA 01867 AU IZED REPRESENT TIS VE GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE F OCCUR RETRO DATE FOR CLAIMS MADE: EACH OCCURRENCE $ DAMAGE $ RENTED PREMISES MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ } MEDICAL PAYMENTS $ PERSONAL INJURY PROT $ UNINSURED MOTORIST $ AUTO PHYSICAL DAMAGE DEDUCTIBLE COLLISION: OTHER THAN COL: ALL VEHICLES SCHEDULED VEHICLES ACTUAL CASH VALUE STATED AMOUNT $ OTHER GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY UMBRELLA FORM OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: EACH OCCURRENCE $ AGGREGATE $ SELF-INSURED RETENTION $ WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY WC STATUTORY LIMITS E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ SPECIAL OTTHER ONS/ Job Specific: COVERAGES See attached Spec Conditions/Other Covs page. FEES $ TAXES $ ESTIMATED TOTAL PREMIUM $ NAME & ADDRESS Reading Cooperative Bank ISAOA/ATIMA X X MORTGAGEE LOSS PAYEE ADDITIONAL INSURED LOAN # 180 Haven Street Reading, MA 01867 AU IZED REPRESENT TIS VE ACORD 75 (2001/01) 1 of 3 #114204 NOTE: IMPORTANT STATE INFORMATION ON REVERSE SIDE DV001 © ACORD CORPORATION 1993 1� rlipntik ARRRB: RFALFSTAT2 ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE (MWDD/YYYY) 12/29/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 HUB International New EnglandPHONE CONTACT NAME: g78 657-5100 FAX (AfC, No Ext : ac, No): 866-475-7959 299 Ballardvale St Wilmington, MA 01887 978 657-5100 IL ADDRESS: nee.certificates@hubintemational.com INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: Underwriters at Lloyds, London INSURED Real Estate Investments INSURER B: 12/2912015 & Equity, LLC; Paul Cammarata 8 Jewel Dr. INSURER C: INSURER D Wilmington, MA 01887 INSURER E: 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 CONTRACTOR 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 ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD LIMITS A GENERAL LIABILITY QML1338245 12/29/2014 12/2912015 EACH OCCURRENCE $110001000 X COMMERCIAL GENERAL LIABILITY PREMISES RENTED $50,000 CLAIMS -MADE F -I OCCUR MED EXP (Any one person) $1,000 PERSONAL & ADV INJURY $1,000,000 X BI/PD Ded:250 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ $ PRO- LOC X POLICY AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ WORKERS COMPENSATIONWC STATIJIMIjS OTH- AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F N / A E.L. EACH ACCIDENT $ (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Holder is listed as add'I insured mtgee. Loc# 2 - 468 Wood Lane; North Andover, MA Reading Cooperative Bank ISAOA ATIMA 180 Haven Street Reading, MA 01867 ACORD 25 (2010/05) 1 of 1 #S1276746/M1276745 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 lV 19tItI-Zulu AL UKv LUKrUKA I IUIV. All rlgncs reserves. The ACORD name and logo are registered marks of ACORD DV001 CONDITIONS This Company binds the kind(s) of insurance stipulated on the reverse side. The Insurance is subject to the terms, conditions and limitations of the policy(ies) in current use by the Company. This binder may be cancelled by the Insured by surrender of this binder or by written notice to the Company stating when cancellation will be effective. This binder may be cancelled by the Company by notice to the Insured in accordance with the policy conditions. This binder is cancelled when replaced by a policy. If this binder is not replaced by a policy, the Company is entitled to charge a premium for the binder according to the Rules and Rates in use by the Company. Applicable in California When this form is used to provide insurance in the amount of one million dollars ($1,000,000) or more, the title of the form is changed from 'Insurance Binder" to "Cover Note". Applicable in Delaware The mortgagee or Obligee of any mortgage or other instrument given for the purpose of creating a lien on real property shall accept as evidence of insurance a written binder issued by an authorized insurer or its agent if the binder includes or is accompanied by: the name and address of the borrower; the name and address of the lender as loss payee; a description of the insured real property; a provision that the binder may not be canceled within the term of the binder unless the lender and the insured borrower receive written notice of the cancel- lation at least ten (10) days prior to the cancellation; except in the case of a renewal of a policy subsequent to the closing of the loan, a paid receipt of the full amount of the applicable premium, and the amount of insurance coverage. Chapter 21 Title 25 Paragraph 2119 Applicable in Florida Except for Auto Insurance coverage, no notice of cancellation or nonrenewal of a binder is required unless the duration of the binder exceeds 60 days. For auto insurance, the insurer must give 5 days prior notice, unless the binder is replaced by a policy or another binder in the same company. Applicable in Nevada Any person who refuses to accept a binder which provides coverage of less than $1,000,000.00 when proof is required: (A) Shall be fined not more than $500.00, and (B) is liable to the parry presenting the binder as proof of insurance for actual damages sustained therefrom. ACORD 75 (2001/01) 2 of 3 #114204 SPECIAL CONDITIONS/OTHER COVERAGES (Cont. from page 1) 1 Location Limit: $273,000 Temp Loc Limit: $30,000 Transit Limit: $30,000 Max Per Loss: $333,000 Desc: Sewer Backup Limit: $25,000 Desc: Existing Building - Stated Value Basis Limit: $273,000 Ded: $5,000 Desc: Building Materials -RC Limit: $60,000 Ded: $5,000 Desc: Expediting Expenses Limit: $25,000 I AMS 75.4 (2001/01) 3 of 3 #114204 1 U'he commonwealth of .Massachusetts Depaxtmmnt ofindg9higl Aceldints �, face of Investigations 600 Washington Sheet Boston, AIA 0211.1 ky www mass gov/dia orkex,q' Com ensationbsurance.A�f�'ida' t: Bufdens/ContractorsLElectx e-iaw]Pl mbers P Please Print LeAR CitylfttelZip: X44 1 C ,M oI9b y �a Phone #: Are your an employer? Check the appropriate box: 4. ❑ Z am a general contractor and Z 1. [[ 1 am a employer with _ ______ employees (full. and/ox paw Vie)• have liiredthe, sub -contractors T 2. [] 1 am a sole proprietor Orpartner meted on the attached sheet. These sub-contiactors have ship an d'have no employees working forme in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its [No workers' comp. insurance officers have exercised their required.] 1 a homeowner doing all work right of exempiionper MGL3. am ai. we have no c. 152, §1(4),n myself [No workers comp. insuraacerequired.] i employees. Ego workers' comp. insurance required.] Type of project (required): 6. [] New construction F '7, VRemodeling 8. [] Demolition 9. [] Building addition 10N Electrical repairs or additions 11.0 Plumbing.repairs or additions 1211 Roofxepairs 13.0 Other xAny applicantffiat checks box#1 mustalsofdl outthe section below showingthdr workers' compensation policy information. Homeowners who snWttlus affidavit iudicatingthey sre doing all wont and then hire outside contractors must submit a new affidavit indicating such. T-Jromacton; that checkihis bo- must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. X am ars employer' that ispYoviciing workers' compensation insufanee foT MY employees; Bel" is the pokey and job site information. ;Insurance Company policy 6 or Self. -ins. Lic. #: ExpirationDate City/State/Zip: J'oh Site Address: ensation�policy declaration. page (showing the policy number and expiration date). Attach a copy of the workers' comp Failure to secure coverage as required undas of a er Sec s5wA fimposition Of "hinal Penalt' as mop. e�� es in tthde forto m f a STOP WORK ORDBR and a time fine up to $1,500.00 and/or one-year imprisonm ? of up to $250.00 a dap against the violator. Be advisell ed that a copy of this statement may be foxwarded to the Ofdca o£ 7nyesiigations of the DIA for insurance coverage verification. ^ Xdo liere7ay cert ur2cter tliepains ancipenaltles 0 lverjury tllcat the are formatzonprovrcieciaboYe e and�r'ec �� (� ' Date• � 6 20 Phone #: Official use ©nly. Do not write in this aret; to he eoYnpleted by city or town official. Cly or Town: Permit/License # Issuing Authority (circle one): X. Board of HeaIth ?. BuildingDepariment 3. City/Town. Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone #: Information and Instructimns Massachusetts General Laws chapter X52 requires all employers to provide workers' compensation fort their employees. Pursuant to this statute, an employee is defrted as "...every person in the service of another under any contract of hire,. express orimplK oral or.writien?, An eYnployei is defined as "an individual, partnership, association, corporation or other legal entity, or any two ox more of the _foreg=60,ok engaged in a joint enterprise; and including the legalrepresentatives of a deceased employer, or the receiver or an individual, partnership, assn ciaiion or other legal enfity, 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 person&to .dd a .aintonanoe, consixuctzgn ox repair work on suchdwelling house or on the grounds or building appurtenant thereto shall not because of such employment be doemed to be an employer! MGL chapter 152, §25C(6) also states that "every state or looal,4"nsing agency shalt withhold the 1sftkce or renewal of a license or perm&lo operate a business or to construct bu ddiugs in the commonwealth..for any applicant who has not produced•acceptable evidence of compliance with the -insurance covexAge re'quiired Additionally, MGL chapter 152, §25C(7) states "Neitherthe 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 chapterhave beenpresentedtathe contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking ilia boxes that apply to your situation and, if necessary, supply sub-contractor(s) nmo(s), addresses) and phonenumber(s) along with their certificate(s) of insurance. Limited Liability Companies (GLC) 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, apolicyis required. Do advised that this affidavitmay be submitted to the Department of Industrial Accidents for confumat'ton of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the *or town that the application for the permit or license is being requested, not the Department of IudusWal Accidents. Should you have any questions regarding the law or if you are required to obtain a workeis' 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 andpriated legibly. The Deparimenthas provided a space atthe 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 periitTeense number whiehwM be used as a reference number Tim addition, m applicant that must submitmultiple permit/license applications in any given year, need only submit one of Udavit indicating current policy information (lfnecessary) and under "Job Site Address" the applicant shouldwrite "alllocations 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 fature permits or licenses. Anew affidavit roust be filled out each Year. More a home owner or citizen is obtaining a license ox hermit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves etc) said person is N'OTrequired to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any gaestions, please do not hesitate to give us a call. The Department's address, telephone anal fax number: Depaximmt Qfkduad lAccldetts 4fte of fAvedtigWoa �QQ Was i gw est: Bostw., M.A: 02111 617.727_4900 est 406 ox- 1-877,MMSAM Revised 5-26-05 Fax # 617"727"7749 Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supen=isor License: CS -062014 MARC A COOPE#STEII�I 133 Colonial Avenue. North Andover WA 018-451 11 Yy `. Expiration Commissioner 11/12/2015 __9911, 237 3 754 -39"-- All dimensions _size designations given are subject to verification on job site and adjustment to fat job conditions. DESIGNER JEN�1 DUSSAULT CAROLE KITCHEN; BATH 21; SALEM STREET WOBURN MA 01870 781-933-3339 66-V -- - VS636 ----_-J N N F330 VSB30 This is an original design and nnist not be released or copied Curless applicable 'fee has been paid or job order placed. Designed: 12/17/2014 Printed: 1/8/20J5 carnnan over3 All Dra,ti,ng 4: 1 Scale : 0 5!1(i' _ )'