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HomeMy WebLinkAboutBuilding Permit #534-16 - 5 ROSEDALE AVENUE 10/29/2015,�l t BUILDING PERMIT .. TOWN OF NORTH ANDOVER re7-4�% APPLICATION FOR PLAN EXAMINATION Permit NO: 4 Date Received Date Issued• LOORN TANT: Applicant must complete all items on this naize LOCA 4-r VA Print PROPERTY OWNER C ",- fZ L G -7 Print MAP N� / PARCEL;% ZONING DISTRICT: Historic District yes no Machine Shop Village ves no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential I I New Building I family n Addition ri Two or more family ❑ Industrial I I Alteration No. of units: ❑ Commercial impair, replacement I I Assessory Bldg I I Others: ❑ Demolition ❑ Other ❑ Septic 7 Well I-] Floodplain Wetlands ❑ Watershed District ❑ Water/Sewer -f - Q Greif w Identification Please Type or Print Clearly) OWNER: Name: C /-`/,g i'?_ Z Address: Phone: 0 3 of M CONTRACTOR Name: Phone: q z� Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $9000,00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ r � J' 76- - 0 FEE: $ 0/4— Check No.:Receipt No.: NOTE: Persons dn7rhellng with unregistered contractors do not have a ss t t re guaranty fund Signature of Agent/Owner Signature of contraCtrsF''f---�----- 4 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 PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature CONSERVATION Reviewed on Signature y COMMENTS HEALTH Reviewed on Signature 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 FIRS DEPARTMENT -Temp Dump ster on site yes _ no Located at 124 Main Street Fire Departmentsignature/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 requires 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 o Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o 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) ❑ 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) o 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) o Copy of Contract o Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products VOTE: 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 No. Date Check�� TOWN OF NORTH ANDOVER Q Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $-- TOTAL 1TOTAL $ W "(L,�� Building Inspector CD � . Z CD O Cr SU Q 2. >to �O O v CD C cr CD O LWJ O U) 0' 0 U) cfl CD U) O 0 O CD O n n OP Z O 0 n Z1 G): Z N m O • Z� rnm �� c )M Z x � rn C Cn I Z 00-0 0=-% z r -DCD -I - CL • (DD 0 n O.0, �O � O o. 0 f/l� rtN TI N� rt 0�0 sQ m C W � a, y c� 0 __lN c. CD 'V . CD 2 CD O Q OCD D (Q N O W =rOcDCA CD.0 -� 0 oco� o 0 0 = 0CD 0, '�• rt O N Ir CD N = C-). 0-0 O O 0= Q < C 0 cn CD U) N �Q -� D CD Y'H 9. r -o * CD O 0 ��1 O7Nt rt y D� 0 0 r! CD `. CD CD rt <D C) �=r ym CD O O _rt a) O O O CL , VI O ((D'•'" (D N � N z Co C (Dr) �+ V D m z T.Z7 QC z N p T 2 VI (DS. (D � Oq S mVrD m D M 0 T �o m S C z m 0 T n 7 (D < 7J UO S T =3 Q O C GZi m 0 V7 Ll. n L 3 T Q \ N = W v O D x .WAIM 0 e LeClair Roofing & Weatherproofing Inc. 830 Livingston Street #13 Tewksbury MA, 01876 (978) 851-8304 FAX (978) 851-98 PROPOSAL Proposal Submitted To: Phone: Date: Charlene Lian 339 298-0198 October 12,2015 Street Address: Salesman: Contact Person: 6 Burnham Road Gerard Nolan Charlene Lian City, State and Zip Code Job Location Andover MA,01810 5 Rosedale Avenue, North Andover MA Massachusetts Home Improvement Contractors Registration Number: 121050 Expiration Date April 1, 2016 Federal Identification Number 04-314-1810 We hereby propose to furnish labor and materials to install new shingle roof to manufacturer's specifications by the following: This estimate covers the following roof areas: Upper Main roof and Lower garage Roof Preparation: • Tarp the building for the removal process. • Protect all shrubbery as required • Remove the existing One (1) layer of asphalt shingles and felt down to the wood sheathing. • Leave any existing ice and water shield in place. • Remove the existing static vents and board in roof. • Cut a new opening in the existing sheathing for the new ridge vent. • Reuse the existing ridge vent opening. • Inspect for and replace any broken, rotted, or missing roof sheathing. Any sheathing replacement cost depends on the type of sheathing. Any ledger board sheathing replacement will be installed at an additional $6.00 per linear foot and any plywood sheathing will be installed at an additional $75.00 for replacement of %a inch CDX plywood per partial or full 4 foot x 8 foot sheet. We will try to match the existing sheathing as closely as possible. Installation: • Install new White, Premium Brown or 8 inch aluminum drip edge along all eaves and rakes. • Install Ice & Water Shield 6 feet along the eaves of the roof. • Install Ice & Water Shield 18 inches .around all penetrations. • Install Ice & Water Shield at flush to the wall at all roof and wall junctures. • Cover the balance of the roof with 15 lb. Felt. • Install a starter course on all eaves. • The shingles will be installed using roofing nails by pneumatic roofing tools.. • The shingles that will be used are GAF Timberline HD (Architectural). Your choice of standard manufacturer colors: Page,1 of • Install a new Cobra Ridge Vent at the ridge openings. • Install Seal A Ridge cap shingles on all ridges. • Install new vent pipe flashing up to 4 inches. Any larger will be properly sealed. • Re -use and seal the existing sidewall flashing. Any new step flashing replacement may require siding removal. This would result in an additional cost to the contract. • Inspect and reseal the existing chimney flashing and counter flashing. • Clean and re -secure existing gutters. Our Proposal Includes The Following: • Clean and legally remove 99.9% of outside job-related debris. The jobsite will be cleaned daily. • We will require space for a dumpster. The placement area will be agreed upon before placement. • Provide standard GAF Limited Lifetime shingle manufacturer's warranty. • Provide standard LeClair Roofing & Weatherproofing Inc. (2) year workmanship warranty. • Carry all necessary workers' compensation and liability insurance. Contract Requirements: • We will require electrical power in close proximity to the work site. Unit Pricing for Unforeseen Conditions: • Any sidewall flashing will be at $25.00 per linear foot. Additional Labor and Material Costs for Unforeseen Conditions if there is NO CHAGE ORDER: • A signed change order with a description of the work and the proposed cost will be provided before the work is started. If there is no signed change order any additional work beyond the above scope of work will be done at a rate of $75.00 per man per hour for roofing and $80.00 per man per hour for sheet metal and carpentry (rates subject to change), plus materials, portal to portal and $.58 per mile travel expense and any per diem charges UNDER NO CIRCUMSTANCES SHALL ANY ADDITIONAL WORK TAKE PLACE WITHOUT THE OWNER'S AUTHORIZATION Contact Notes: • This proposal is subject to change unless acceptance is made within 30 days of the date of issue. • All Massachusetts Sales taxes are included in our proposal. • Subject to manufacturer's price increases as they occur. • All work will be performed per OSHA safety standards. Required Permits: • Our proposal covers the cost of any required permits and will be secured by the contractor as the homeowner's agent. (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of MGL chapter 142A.) 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 lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. Page 2 of 6 Estimated Start Date: Estimated Completion Date: The Start Dates Given Are Weather Dependant And Will Be Decided Upon Acceptance Of The Proposal. We propose hereby to furnish materials and labor, complete in accordance with above specifications, or the sum o Eight Thousand Seventy Five Dollars ($8,075.00) Payment terms are to be as follows: *1/3 Deposit $ 27691.00 *1/3 At Start $ 21692.00 *Balance Upon Completion $ 2,692.00 *Total Payments $ 8,075.00 Estimated Start Date: Estimated Completion Date: The Start Dates Given Are Weather Dependant And Will Be Decided Upon Acceptance Of The Proposal LeClair Authorized Signature Sign Here Date: October 12,2015 Date Here 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 lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. DO NOT SIGN THIS PROPOSAL IF THERE ARE ANY BLANK SPACES ACCEPTANCE OF PROPOSAL — The above prices, specifications, conditions and additional terms are satisfactory and are hereby accepted. You are authorized to do the work asspeci d. Payment will be made as outlineabove. �� Date of Acceptance 010-17,&19" Signature: ,�% Date Here Sign Here Signature: Here Please Make Checks Payable To Steve LeClair Page.3 of 6 Contract Arbitration 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 142A. Homed er s Signature Contractor's Signature Sign Here Sign Here 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. Additional Proposal Conditions Proposal Contingencies • All agreements are contingent upon strikes, floods, accidents, fires and other delays beyond the control of the roofing contractor. LeClair Roofing & Weatherproofing Inc. maintains required levels of Workers Compensation and General Liability Insurance. • It is agreed that all payments will be made when due. Warranties will be void if full payment is not received. It is further agreed that the customer will pay all costs of collections incurred by LeClair Roofing & Weatherproofing Inc. including but not limited to attorney fees, any cost associated with recording liens, and any other associated charges. It is also agreed that any late payments will accrue finance charges a 1.5% per month finance charge will be added to all invoices on the 31S` day. All legal and/or collection fees will be paid by Buyer. • Any alteration or deviation from the plans and specifications involving extra costs not specified in the contract will be agreed upon in verbal or written format prior to performance of additional work: • All materials to be as specified (or equal to or superior in performance). • All work to be conducted in a workmanlike manner. • This proposal MAY NOT be used for any legal or lawsuit cases unless approved by LeClair Roofing & Weatherproofing Inc in advance and any costs approved in advance. • Although the execution of this contract doeg not initiate the filing of a lien, LeClair Roofing & Weatherproofing Inc. reserves the right to file liens for non-payment as allowed by law. Structural Concerns • Contractor is not responsible for structural soundness and shall have no liability whatsoever for the supporting structure to support men, materials, equipment, ice, snow or water. This clause shall apply regardless of the timing between the occurrence and the performance of the work. • Contractor is not responsible for interior damages resulting from structural deficiencies as outlined above. • There are no -hidden utilities under the roof sheathing that would be damaged or broken by the roof installation. Exclusions • Contractor's scope of work shall not include the detection, abatement, encapsulation or removal of asbestos or similar hazardous substances. The contractor has the right to discontinue work if and when hazardous materials are discovered. Contractor shall be entitled to receive compensation for changes in the scope of work or length delays encountered as a result of hazardous materials as detailed above. • Bonds, snow removal, painting and cleaning of dust and or particles in attic after roof removal, acts of nature, winter conditions and snow shoveling. Page.4 of 6 Warranty Information • All warrantees will be issued after payment has been received in full. • All warranties will be null and void if any work such as snow removal and ice removal, satellite dish or antenna installation, electrical heat tape, guide wires, gutter work, or any work requiring roof traffic or construction takes place on the roof in any way. Any work on the roof should only be done after consulting with LeClair Roofing & Weatherproofing Inc. to make sure the work will not void the warranty or guaranty. • All warranties on materials and workmanship are with the original owner and may be transferred to the next owner with permission from LeClair Roofing.& Weatherproofing Inc. • The warranties mentioned above shall have no effect on the owner's rights under the provisions of MGL c. 142A. Other Information • In some communities all property taxes must be paid in full or the permit may be denied. • If LeClair Roofing allows the owner to place any additional debris in the dumpster There will be NOIIAZARDOS WASTE AMTREIALSALL 0WED! Homeowner's Rights LeClair Roofing & Weatherproofing Inc is registered Home Improvement Contractor with the Commonwealth of Massachusetts. Should you need to make any inquiries about LeClair Roofing & Weatherproofing Inc (or any other contractor or subcontractor) relating to' a registration, they should be directed to: Office of Consumer Affairs and Business Regulation Ten Park Plaza, Suite 5170 Boston, MA 02116 Phone: (617) 973-8700 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 contractor 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. Page 5 of 6 r Cancellation: Under sections, MGL c 93 s 48; MGL c 140D s 10 or MGL c 255D s 14 as may be applicable, 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 "Notice of Cancellation Form" as well as the "Waiver of Right to Cancel Form" below for additional information. SIGN THIS NOTICE ONLY IF YOU WANT TO CANCEL THE CONTRACT NOTICE OF CANCELLATION REQUIRED BY FEDERAL and STATE LAW Date of Transaction You may cancel this transaction without penalty or obligation, within three business days from the above date. If you cancel, any property traded in, any payments made by you under the contract or sale, and any negotiable instruments executed by you will be returned within ten business days following receipt by the seller of your cancellation notice, and any security interest arising out of the transaction will be cancelled. If you cancel, you must make available to the seller at your residence, in substantially as good condition as when received, any goods delivered to you under this contract or sale; or you may, if you wish, comply with the instructions of the seller regarding the return shipment of the goods at the seller's expense and risk. If you do make the goods available to the seller and the seller does not pick them up within twenty days of the date of cancellation, you may retain or dispose of the goods without any further obligation. If you fail to make the goods available to the seller or you agree to return the goods to the seller and fail to do so, then you remain liable for the performance of all obligations under the contract. To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other any other written notice, or send a telegram to: LeClair Roofing & Weatherproofing Inc. 830 Livingston Street Tewksbury MA, 01876 Not later than midnight of I hereby cancel this transaction. Date: upaatea Y-io-i3 Page 6 of 6 Buyer's Signature: (date). LeClair Roofing & Weatherproofing Inc 830 Livingston Street #13 Tewksbury MA, 01876 (978) 851-8304 FAX (978) 851-9884 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S54, a condition of Building Permit Number: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. The debris will be disposed of in: LUS Watewood 87Watewood Road Salem NH Dumpster Company Signature of Permit Applicant Date Charles George Company P.O. Box857Londonderry NH, 03053 OP ID: AT AR1:X CERTIFICATE OF LIABILITY INSURANCE OAT 1 DOCUMENT WITH RESPECT TO 01/141/YYYY) 01114115 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 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 Phone: 781-935-8480 NAME: DeSanctis insurance Agcy, Inc. Fax: 781-933-5645 100 Unicorn Park Drive PHONE FAX A4tC, tio, F.t1: Woburn, MA 01801 E-MAIL CLAIMS -MADE X__ OCCUR AQORESS: 5,00 PRODUCER CUSTOMER ID #: ECLA_1�_-- -__._ INsuREo LeClair Roofing & —___- INSURERISIAFFORDING COVERAGE NAIC INSURER A:Acadia insurance Company 31325 Weatherproofing, Inc. �— INSURER a: Star Insurance Company .012245 830 Livingston Street _— �� — - --- -- .-- _.. _ ____�_ _ Tewksbury, MA 01876 INSURERc: - - _ .. — INSURER 0: 2,000,00 INSURER E: _ PRODUCTS - COMPlOP AGG 5 INSURER F: COVERAGES CERTIFIC:ATF NIIMRFR. 0Ct1101rNK1 w11111IMOM. � Iwnlu�r�. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR'.--'______ .__ ._ ._ -- ._. __-- :A°DL_(TBR. --_ -- --`_ ____._ p0_L_ICY LTR TYPE OF INSURANCE WSR YAIO POLICY NUMBER MM1DD1YY)T MMIDD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE f S 1,000,00 A Xl COMMERCIAL GENERAL LIABILITY CPA50T7662 01/01/15 01/01/16 — —� -- DAiA0.G� i(7 RNT£Q --- 5._.—^ 250,00 CLAIMS -MADE X__ OCCUR _PREMISE§(Ea occurreocej MED Exp (Any ore person) S 5,00 X BlktContractual --_ _._._ PERSONAL&ADV INJURY S 11000,00 X XCU Hazards — _-- _ . AGGREGATE 5 2,000,00 GEN_ 'L AGGREGATE LIMIT APPLIES PER: T 'PRO. _ PRODUCTS - COMPlOP AGG 5 —2,000,00 7— POLICY X LOC — --- --- •-` ---- -- AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT A (Ea accident) $ 1,000,00 ANY AUTO `BODILY ALL OWNED AUTOS INJURY (Per person) 'S �. A 'X SCHEDULED AUTOS CAA507766412 01/01/15 01/01/16 .BODILY INJURY (Paraccident)5 — A X HIRED AUTOS PROPERTY DAMAGE S (Per accrcden!) A X 1 NON-OWN£DAUTOS _ S X :UMBRELLA LiA6 X OCCUR EACH OCCURRENCE S 5,000,00 'EXCESS UAB CLAIt1iS-MADE A _._ . ...-; CUA5077665 01/01/15 01101/16 YAGGREGATE_ - S 5,000,00 -- DEDUCTIBLE X RETENTION S NONE WORKERS COMPENSATION AND EMPLOYERS' STA C U- T WSTATU-0TH-' LIABILITY Y t N B X T_OC ANY PROPRIETORIPARTNER/EXECUTIVE WC0707947 01/01/15 01/01/16 OFFICERIMEMBER EXCLUDED N NIA. E.L_EA_CH ACCIDENT S — 11000,00 (Mandatory in NH) MA NH If es, describe under ' . E L. DISEASE - EA EMPLOYEE, S 1,000,00( , DESCRIPTION OF OPERATIONS befaw E.L. DISEASE -POLICY LIMIT , 5 — _ 1,000,00 A installation Float CPA5077662 . 01/01115 01/01/16 Limit 100,00 'Stored Materials iDeduct S0 DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) ILLUSTRATION OF COVERAGE r�COTICFI�ATc uA1 nt-,-� G1 ILLUS -1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ILLUSTRATION OF COVERAGE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Print Form� Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): LeClair Roofing & Weatherproofing Inc. Address:830 Livingston Street Unit 13 City/State/Zip:Tewksbury MA, 01876 Phone #:(978) 851-8304 Are you an employer? Check the appropriate box: Type of project (required): 1. [D I am a employer with 25 4. [] I am a general contractor and I 6. El New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g• Demolition workingfor me in an capacity. y p n'• employees and have workers' comp. insurance.: 9. ❑Building addition [No workers' comp. insurance required.] 5. E] We are a corporation and its l0.[] Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their I LEJ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.F/ Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.0 Other employees. [No workers' comp. insurance reouired.] *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 such. 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. Below is the policy and job site information. Insurance Company Name: Star Insurance Company Policy # or Self -ins. Lic. #:WC0707947 Expiration Date:1/01/16 Job Site Address: 614/_ �4 � �Lf" City/State/Zip: 1�aw 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correc4 (978) 851-8304 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 #: Massachusetts - department or Punlic Sarety Board of Building Regulations and Standards Construction Supervisor License: CS -079509 STEPHEN P LEC 38 BRETT ClR PEUUM NH 03076 1 Expiration Commissioner 09/27/2016 �' .U/re �o»ontfur�ter�/flr n�� Office of Consumer Affairs & Busi ess Regulation s ME IMPROVEMENT CONTRACTOR i egistration: 121050 i'ype: 1K- kPiration: 4/112016- Private Corporatic LECLAIIRR ROOFING & WEATHERPR INC STEVE LECL•AIR 830 LIVINGSTdN ST TEWKSBURY, MA 01876 U- "�ry ;. i iiitii�f-secrefa 4