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HomeMy WebLinkAboutBuilding Permit #359 - 49 PADDOCK LANE 11/25/2008 BUILDING PERMIT °* NORTH q TOWN OF NORTH ANDOVER ?`', ''- =+" °p APPLICATION FOR PLAN EXAMINATION Permit NO: J Date Received 0' Date Issued: CHUS IMPORTANT:Applicant must complete all items on this page LO.`CATI;Q:t �L/ ,d L icrt ... Ptin PRC�PEITY 01�1C (EF Jam' ' E�rff V. - S Pant q M;4P NO: {PARCELZ01�11`l D STRL,CT _. .t-1rs#onc Des#rrct Vires rr lUtachirre Shap VilfaJe fives. TYPE OF IMPROVEMENT PROPOSED USE Resi Non- Residential New Building One family Addition Tw a family Industrial Alteration No. of units: Commercial 'repair, replacement Assessory Bldg Others: Demolition Other Septi:` il1/e11 FiaodZla]rr U1lapds _ ulfateried District `W-aterZSewer DESCRIPTION OF WORK TO BE PREFORMED: c �%r E ovz�2 Identification Please Type or Print Clearly) OWNER: Name: LAupA A MDULSa-n/ Phone: gae-as&- 3 Address: ,Y QoeK COITRACO1ae ;ut t1 Phone Andress; Sliperwsbt%C:o str t-%on ices '": Epp Date. „:-► Home lmproVer"Je'n tic- Wise: _w _ .. cp Dste, : 1-c 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. Total Project Cost: $ ,�� 7 — FEE: $ � Check No.: 4/ l� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Si 'nature of A ent/QaNner � �� �..��" M .� �--' _ignaure of contractor , — _ 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 Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature s COMMENTS 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: Located 384 Osgood Street :FIRE DEARTIENT Tette Duapster on site ye r rro I-ocat d.at 24,Main Street t=ire.:Department s�gnatareltlate§ COMMENTS �a 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 requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine I i NOTES and DATA— (For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 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/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 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 DEPARTMENTMFORM07 Revised 2.2008 Location Ste.y No. Dated Uy MORTry TOWN OF NORTH ANDOVER O ll siowai • : Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 7 (/ 2 ► + 5 Building Inspector NORTH Town of And 0 LAKE O 1 dover, Mass., `o I� COCMICHEWICK 7��oRATED i?�\ �C V BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System �'' r : BUILDING INSPECTOR THIS CERTIFIES THAT....................................................... G .r......l� �... .........�................... ...................... Foundation has permission to erect........................................ buildings on ..... ..:p...... ...A^� / ........� ............. Rough to be occupied as....../.......... ....... ....G!!! �.T. k......a 410............................................................................. Chimney provided that the person accept! this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final '' PERMIT EXPIRES IN. 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Contract Pella Windows&Doors,Inc. 45 FONDI ROAD ® HAVERHILL MA 01832 ��� Phone: 800-866-9886 Fax: 978-373-7274 Customer Project/Ship-To Order MOULSON LAURA MOULSON-NORTH ANDOVER Date 00/00/00 Quote No. MOULSON 49 PADDOCK LN 49 PADDOCK LN Order No. Need Date 00/00/00, N ANDOVER,MA 01845 N ANDOVER,MA 01845 Sales Rep.Name Gould,Rick/WME ESSEX ESSEX Prepared by Payment Terms Deposit/C.O.D. Owner: LAURA MOULSON Architect Bus.Phone: (978)258-5463 Bus.Phone: Jamb Depth Bus.Fax:( ) - Home Phone:(978)258-5463 P.O.No. Cellular( ) _ Branch Order No. Home Phone: ( ) - Order Type Installed Sales Order Glazing Design 20.00 psf. Pressure Branch Name Pella Windows&Doors,Inc. Branch Address 45 FONDI ROAD Phone 800-866-9886 City HAVERH 9,L Fax 978-373-7274 1 State MA 01832 Comments: Customer has paid$2,413.36 deposit(50%of contract Total) Customer has paid using a(credit Card) The Remaining$2,413.36(Final 50%)will be paid upon substantial Completion of installation- Customer nstallationCustomer will be paying balance with(credit Card For information regarding the finishing,maintenance, service, and warranty for all Pella products,visit the Pella Website at www.i)ella.com. Printed 10/30/08 Contract-Page 1 of 3 • Project: MOULSON-NORTH ANDOVER Order No.: Contract for Customer MOULSON LAURA J �mm D , ri tion UnitPrice Extended Price_ Outside View Item No. Otv —�-j-F Item#15 Qty: 1 36 x(80 to 81)Interchangeable Storm Door,Opening:36 X 81: 700.27 700.27 Location: Entry Systems,Clad,Fullview,Model 1 , 1-5/8"Extruded,Hartford RO.3'0" X 6'9" Green(PR0104),Plain Glass/Clear,Brass Handle,With Hinges,4601- STD 1-5/8"Ext FV Plain Glass Value Added Items: Storm Door-Qty 1 Notes: Outside View Item No. Off'- Summ n Description Unit Price Extended Price Item#20 Qty: 1 Hardware:Door,Keylock,Keyed Alike,Stainless Steel 13.63 13.63 Location: Notes: Sammary Description U� Extended Price Outside View Item No. �- ll-- 3,893.98 3,893.98 Item#25 Qty: 1 4 Panel Classic w/Full Sidelight Location: A: 110"x 6'6"Fixed-used with In-swing Entry Door Sidelight, 0 RO:5'5-1/4" X 61811 Clad,Full Lite Frame: X 79-1/2:Entry Systems, Model 2, WallCond•4-9/16" White,Smooth-Grain Fiberglass, 1/2"InsulShld Temp IG-SDL ®il I Glazing,Ext.Hartford Green/Interior White,7/8"SDL Traditional Grille(Grille Lites Wide=01,Grille Lites High=05),Golden Oak Stain,Brass Anodized Sill w/Adj Oak Threshold,Fins(per design) B:3'0"X 6'6"Left Hinge In-swing Entry Door,Frame:37-1/2 X 79-1/2:Entry Systems,Clad,4 Panel Classic,Model 2,White, Smooth-Grain Fiberglass,Ext.Hartford Green/Interior White,Latch Bore with Deadbolt,2-3/4"Backset,Brasstone Zinc Dichromate Hinge,Golden Oak Stain,Brass Anodized Sill w/Adj Oak Threshold, Fins(per design) C: 1'0"x 6'6"Fixed-used with In-swing Entry Door Sidelight, Frame:13-1/2 X 79-1/2:Entry Systems,Clad,Full Lite,Model 2, White, Smooth-Grain Fiberglass, 1/2"InsulShld Temp IG-SDL Glazing,Ext.Hartford Green/Interior White,7/8"SDL Traditional Grille(Grille Lites Wide=01,Grille Lites High=05),Golden Oak For information regarding the finishing,maintenance, service, and warranty for all Pella products,visit the Pella Website at www.pella.com. Contract-Page 2 of 3 Contract for Customer MOULSON LAURA Project: MOULSON-NORTH ANDOVER Order No.: Stain,Brass Anodized Sill w/Adj Oak Threshold,Fins(per design) Notes: Thank You Forrchasing5P Ila Products Z4��� Taxable Subtotal $4,376.88 Customer Signature Pella Sales Representative Signature Sales Tax at 5.0000% 218.84 //; Non-taxable Subtotal 231.00 �V `— G' ` a Total $4,826.72 Date Date Deposit Received $2,413.36 Remaining Balance $2,413.36 I I WARRANTY: Pella products are covered by Pella's limited warranties in effect at the time of sale. All applicable product warranties are incorporated into and become a part of this contract. Please see the warranties for complete details, taking special note of the two important notice sections regarding installation of Pella products and proper management of moisture within the wall system. Neither Pella Corporation nor Pella Windows&Doors,Inc. will be bound by any other warranty unless specifically set out in this contract. However, Pella Corporation will not be liable for branch warranties which create obligations in addition to or obligations which are inconsistent with Pella written warranties. Clear opening(egress) information does not take into consideration the addition of a Rolscreen[or any other accessory] to the product. You should consult your local building code to ensure your Pella products meet local egress requirements. Per the manufacturer's limited warranty, unfinished mahogany exterior windows and doors must be finished upon receipt prior to installing and refinished annually, thereafter. Variations in wood grain, color,texture or natural characteristics are not covered under the limited warranty. For information regarding the finishing,maintenance, service, and warranty for all Pella products,visit the Pella Website at www.lpella.com. Contract-Page 3 of 3 PELLA WINDOWS AND DOORS CONTRACT 7. PAYMENTS 1. TERMS AND CONDITIONS Pella shall be entitled to stop the Work upon written notice to Owner for any material default or failure by Owner,including but not limited to,the Owner's These Terms and Conditions are an integral part of the contract set forth on the failure to pay Pella the amount due within seven days after the date payment is Product Order(the"Contract")between New England Window and Door LLC due. dba Pella Windows&Doors,Inc.("Pella")and the person(s)identified on the Product Order("Owner")to supply the products(the"Products"),and perform 8 CORRECTION OF WORK the work(the"Work")described or referred to in such Contract. For Product Only purchases,a signed"Product Only Addendum"is a required part of the Pella shall correct installation Work not in conformance with the requirements contract. of the Contract,if notified in writing by the Owner within two years after the Completion Date or,if earlier,the date on which the Work is substantially 2. OWNER completed and payment of the Purchase Price made subject to a holdback as provided above.Correction of Work as herein provided shall be Owner's sole Pella is not responsible for any existing security systems.Owner shall remove remedy for defective workmanship,and is provided in lieu of any and all other all shades;verticals,blinds,curtains,drapes or window mounted air remedies.Pella's obligation to correct Work is conditioned on Pella's prior conditioners,prior to the installation of the Products.Pella's installers are not receipt of all payments then due. responsible for the removal or installation of these types of items. Pella is not responsible for pre-existing window coverings fitting on newly installed Pella 9. LIMITED PRODUCT WARRANTY windows. Pella shall warrant all Pella products,but only in accordance with the Pella The Owner shall provide complete access to the work site between the hours Windows&Doors Limited Warranty.THIS LIMITED WARRANTY SHALL of 7:00 a.m.and 6:00 p.m.(Monday through Friday)for Pella's installers to BE THE SOLE WARRANTY WITH RESPECT TO THE PRODUCTS AND deliver the Products and perform the Work. PELLA SPECIFICALLY DISCLAIMS ALL OTHER WARRANTIES, EXPRESS OR IMPLIED, WRITTEN OR ORAL(INCLUDING WITHOUT 3. PELLA LIMITATION ANY WARRANTY OF MERCHANTABILITY OR FITNESS Pella will be responsible for and have control over construction means, FOR A PARTICULAR PURPOSE). methods,techniques,sequences and procedures and for coordinating all portions of the Work.Pella will be responsible for the Work of its Pella 10. NO CONSEQUENTIAL DAMAGES Contractors who will install the Products. UNDER NO CIRCUMSTANCES SHALL PELLA BE LIABLE FOR Unless provided otherwise in the Work description,Pella will provide and pay CONSEQUENTIAL,INCIDENTAL,INDIRECT,OR SPECIAL DAMAGES, for all labor,materials,equipment,tools and machinery,transportation,and WHETHER FORESEEN OR UNFORESEEN. other facilities and services necessary for the proper execution and completion of the Work. 11. HOME IMPROVEMENT CONTRACTORS The materials and equipment famished under the Contract will be good quality All home improvement contractors and subcontractors shall be registered with and new unless otherwise required or permitted,the Work will be free from the director of the Home Improvement Contractor Registration Program defects not inherent in the quality required or permitted,and the Work administered the Board of Building Regulations and Standards. Pella and conform with the requirements of this Contract.Pella shall not be responsible any of its subcontractors identified in this agreement have been registered. for damages or defects caused by abuse,modifications not executed by Pella, Any inquires about Pella or any of its subcontractors relating tregistration improper or insufficient maintenance,improper operation or normal wear and should be directed Director,Home Improvement Contractorr Registration, tear. Pella will keep the premises and surrounding area free from One Ashburton Place,Boston,MA 02108,617-727-8598 accumulation of waste materials or rubbish caused by performance of the 12. PERMITS(MA customers only) Work. o Pel is obl'g e to and will obtain the following permits for this project: 4. CHANGES 44. � Homeowners who secure their own permits will be excluded from thc:46aranty fund provisions of Massachusetts General Laws, The Owner may order in writing changes in the Work consisting of additions, chapter 142A. deletions,or modifications("Change Order"). Any Change Order shall include an adjustment to the Price and the Substantial Completion Date,as In addition to the rights and warranties enumerated in this agreement,you may determined by Pella. Pella reserves the right to approve or disapprove any have additional rights under Massachusetts General Laws,chapter 142A and Change Order and any such Change Order must be signed by both Owner and 780 Code of Massachusetts Regulations R6. Pella to be effective. 13. NOTICE OF CANCELLATION 5. SUBSTANTIAL COMPLETION You may cancel this agreement if it has been signed by a party Owner understands and agrees that the Substantial Completion Date is an thereto at a place other than an address of the seller,which estimate only and that the actual date on which the Work is completed may be may be his main office or branch thereof,provided you notify extended to allow for Change Orders requested by Owner or if the time to complete the Work is affected by conduct of the Owner,weather,labor the seller in writing at his main office or branch by ordinary disputes,availability of subcontractors,acts of God,fire or other causes mail posted,by telegram sent or by delivery,not later than reasonably beyond Pella's control.If for any reason the Work is not fully midnight of the third business day following the signing of this completed by the Substantial Completion Date(including any extensions agreement. contemplated above),but is substantially completed by such date,i.e.,the Product has been installed,but minor parts or components are missing or need See the attached Notice of Cancellation for an explanation of to be replaced or repaired,a hold back proportionate to the cost of remaining parts or work to be completed is acceptable.However,the holdback will not this right. exceed the amount of the completion costs or 10%of the remaining unpaid balance of the Price,whichever is less. Do not sign this contract if there are any blank spaces. 6. FINANCING If payment of the Price is financed with a financial institution through Pella,all financing paperwork must be completed upon signing of this Contract and the requisite approvals and authorizations for the full amount of the requested financing shall have been received from the financial institution. Customer signaturdi Date Date Of transa ftransa ND�jCE O ctlOn. F CAN Y° O. CELLATjo day o yl cancel this Ifyou a above dQnsaction and an cancel a ate. wit foil, negotiab,' rOPQrt y t slag ou o f ejPt by the stamen acted in, a qty°r°bllgatio goo ou tante the tr�sac ionseller°fyo uteri by YOU meets'Nde wlthln�'ee b YOU rnan a yndition a°u dus Wst m will be ca4cellar X111 be rd y you under nd business hrPment ft°u �,Isb- ten reotot V a vailable 1 ed nOtl ce, an k'itlun tet a agree me Ifyoi0iu d° he goods at nt Ply W. anygo�°the abe sellerayour aloYsecurityntelness days of then twee(I the good e sellers xPe sect°ns erect, resldenc rest seller goods ays°f s a Vail nse and Of 0 You and e,In Sub liable' or iffOrPe you m'tbOut ani'e dateof yo o e sell nsk seller regathislagr agree stant1 1y as TO c agreecel t0 re cher 4e - * Otice tio of and the s g the return or nOtjc°ran is Hansa ofall°bl tgatOOds to 72* If yhe o fallconcellatl Viler do not fella tiVi y other written'mail 0 °ns under the ller and f ake t4 410d n Ick dem P u ndo ws and D n notice o sli ver a sl contract arl tO d0 0o the a vailab�sPose ie not later °Ors' at end a telegra gnedand date n you relnai to the transacOn bo dnight 4SFOndi R m to d copy of t4is c n an Iherebycant vel. °f �. d kaverhill cellation Ap el tns tr�sacti <three business 1832 (ba. °n. slness days fro In thedateOf <8uyer's ure)signat f DISPUTES > Job Name / �7D41 107 Date ZGe!- 3,!::� - o (w THE CONTRACTOR AND THE HOMEOWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT PELLA HAS A DISPUTE CONCERNING THIS CONTRACT, PELLA MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE CONSUMER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN M.G.L.c. 142A Aw Contractor omeo er NOTICE: THE SIGNATURE OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE SETTLEMENT INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES. ala„arhu,rtt, Drlrutnunt rat ['uhlic Nafct� 13foard fit Buildin, Re-_,ulation, and standard, Construction Supervisor License License CS 89853 Restricted to. 00 WILLIAM R NICHOLS t 57 PEARTREE RD w” HAVERH ILL, MA 01830 �--�- �yi Expiration: 10/26/2010 t mnn..i.m Tr_ 5196 �lt' -�%anz»za�unvct`��. t�� G[tr.tuir�ude�a Y i Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR - Registration: 129774 Expiration: 11/2/2009 Type: Supplement Card PELLA WINDOWS AND DOORS WILLIAM NICHOLS 45 FONDI RD. u HAVERHILL,MA 01832 or Administrator CER FOCA4E O `I LOABOLOY ONSUR. AMC' = 0/OZUB11:42 " . PRODUCER ,' ` 1(800)22S-1865 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION FndC,chmcb,be. ONLY AND CONFRRS NO RIGHTS UPON THE CERTIFICATE 41 WbllmenSlfeat HOLDER. THIS CEIMFICATE DOES NOT'AMEND, EXTEND OR 41 a gmanS1eet ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 800.2.25-1865 - INSURERS AFFORDING COVERAGE. - NAIC#. DISum INSURERA- Cift=b"=eGC0MPWdAuid a, XmBq;mdVwdow&poorLLCI INSURERS: HenoYerlDSlDf�ncaCofDPWY 45 Fon&RoVA RavefL%MIL 01832-1302 INSURER* Me>:sech=#s&,Ylas m@e OLmmo: 29459 of dURE COVERAGES ' THE POLICIES OF INSURANCE LISTED BELOW'HAVE BEEN ISSUEDTO THE INSURED NAMED ABOVE FORTFIE POLICY PERIOD INDICATED.NOTWITHSTANDIAG 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 BYTHE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALLTHE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREOATELONTTS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS. POLN:Y U18R POLiCYNU!'AUER POLICYEiMIR11T10M U W. � GEKERIY.fIAOMY EACHODCURMCE R CaINMERCGENERMUNILIIY $50000 CWMSMAOE ®OCCUR sl opo 7A ZM8161407 7n4008 7/14009 PMON&AMMINEY i 000000 GENETW.AGGREQATE a, 000 GENT.AGGREGATEUMRAPPUESPER: PRODUCTS-COMP AGO i��.� POLICY o' Loc AUiOROMMUABIUTY (E�000fd�llq eIGLEUMrc $1,000,000 R AWNW , Au.ONRiE0AUT08 PAIN w ' •$ C SCHEDUMDAVTOS ADNB162169 7/14008 7/14009 X HIREOAVTOS• WR.Y $ R NON."MAVTOS P40�DAMAGE� s et N.' i. kR•' . . ;�. ti' :is (�► • OIWAGEUNNLrcY% _,' AVTOORLY-EAACCENT S AWAUTO OTHERTHAN EAACC AVTOCrr. AGO i UABKY EACHOCCURRENCE s 9 •X OCCUR ❑•CLAIMSMAOE AGGREGATE $9.000+0m IS tJfIN8i67305 7/14008" 7/14009' 3• Rx DEDUMLE PATEN(a s i WORIO nscoMPENSAm"MR ][ WC EMPLOTERS'LiASUfY Ed-EAOHACGDERT s 500.000 D gKPcRE PRIETORi&(LmuERIEXECuTFAE 08VAK4 5742 7/112008. 7/14009 OFFlCERfrdEMSERExC1UDE04E.L.oISFA F ffAEMPL0fE S0Q000 ft deeaihe unSdor ' _ F.i.o1SEAm POUGV uMrc sbdow OTHER F ' �ERATIONS1LOC IMSIVEHICLESISCOLUSIONSADDEONYENDORSISIO EMERrISPECIALPROYNS OFtO fOFP CERTIFICATE HOLDERCANGELLATION Gw Edglond Winduw&DoorLL0 . SHOdLOANYOPIMEMOVEDESCIUeEISI+GLICIESBECANCELMOEFORETNEEI NIMH Fondi Road DATE THEREOF,iNE ISSUING INSURER WILL ENDEAVOR TO MNL 30 DAYS WWW aV8r1ii11,MA 01830 lioneETo"ECERi aATEHOUIERNomirOTHELEFT.BUTPAIMATODosoimL MUIOSM NO G U bAMW OR LMMM of ANY IOND UPON THE INSURER,RS AGENTS OF ' fUD'fU�ENTA7IVES. . 1 fL"oN=REPRESERTATNE�' �. .•. +• ,, .. :'."' Client# 2960 Mat# Amo ©ACORD CORPORATION 190 ' AcoRo zs(2oo1/os os-a9 oz,00,w� cert# The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant InformationI // Please Print Legibly Name (Business/Organization/Individual): ?e l tC( W�,A4•l W S CL k4 �o rs 1 AC . Address: q s, pD,4% U City/State/Zip: }- aVer k'111 MA 0(93-1 Are you an employer? Check the appropriate box: Type of project(required): 1.R I am a employer with 2.S 4. El am a general contractor and I * have hired the sub-contractors 6. ❑New construction employees(full and/or part-time). 2.El am a sole proprietor or partner- listed on the attached sheet. E] Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition workingfor me in an capacity. workers' comp. insurance. Y p tY• 9. E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.E] Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their wbikers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: V''e OI C . G k V r a k Policy#or Self-ins.Lic. #: Q'S w G N L 57q 2 Expiration Date: 7h L2.00 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:6f this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: iI/� Date: Phone#: c(79. 2-6.5--?2.55 Official use only. Do not write in this area,to be completed by city or town offu;iaL 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#: