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HomeMy WebLinkAboutBuilding Permit #628-2017 - 5 STONEWEDGE CIRCLE 12/9/2016BUILDING PERMIT of NoF a T0 WN OF NORTH ANDOVER o� `� APPLICATION FOR PLAN EXAMINATION �0 P ermit No#: (D — Date Received o RATE S ACI k Date Issued: I)- -- °t �' 1 LUPORTANT`:Appliccanntt must complete all -items -4 - this page to a. 10D Year'Structu—re , Pnnt IUI�AP�10'�ARCEL�d.L,�' ZOIVINGDISTRICT�'`Histo�ic District �y est. -Yy F no TYPE OF IMPROVEMENT J.PROPOSED USE Residential Non- Residential ❑ New Building XOne family ❑ Addition ❑ Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic 1Nell ❑Floodplain ❑ Wetlands b Watershed District t O Water/Sew rr..,<.:r,A DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly . OWNER: Name:�j 1��cr Phone: 9�� eQ3'1 Address L � Pho_ rie: Contractor Name �3rd�1��-o�02 S�1 .y'.. .'::-`•1' . r� • _ .+. .;P �p _ - is - a .- _ •. a. �.e,-+c<is..w x"+sT; `31+t`-"F•-y�..�wr..t't"aa�� �_ .. .y".�"+s.,;'- F:.-lv+siS-- .: > ,+F.., Supervisors.Constr"uction` License �Q�/��Exp''Date�Q�`1�' <i� sx^ * �."„ s�t� i,r . ������ "-•r-E F;3`firf}f"..� r ^^a r7 � 1 � :�c.;',•'.Y"' a ,��' «''� r .r+• --a-� to �, t �w.l.,,'�` �' � ,;, '`„�'"".-. «,'�`Da e� �r �Home;IrnprovementLicense ARCHITECT/ENGINEER /1�/ Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. .Total Project Cost: $ FEE: $���� Check No.: 7 Receipt No.- --3 / NOTE: Persons co c .n itla unr g' ted contractors do not have: access to the guaranty fund Si "riatu�e of_Ag tLl Signature of contractor ._ .........__ ._._ _..._. i i Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ Typl3bF SEWERAGE DISPOSAL Public Sewer ❑ Tanuing/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 Reviewed On COMMENTS Signature_ CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Sianature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments_ f'onservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located �3M Usgood Street FIRE DEPARTMENT -,Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date / COMMENTS limension 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 ®ANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine M I 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) ❑ 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 40TE: 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 S 5TVPJf UJ'odC7-e Cr /C Date /,*W/ t No. le;X( )�-vl 7 Check # 7 /f 2 0 TOWN OF NORTH ANDOVER Certificate of Occupancy $- Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee TOTAL $ Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost I 14,000.00 m $ - $ 168.00 Plumbing Fee $ 21.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 21.00 Total fees collected $ 310.00 5 Stonewedge Circle 628-2017 on 12/9/2016 room in basement �\ 1 a 'V q so I CN rA O J 2 LL p Q pF' m O LL N u Q V1 p U ta/f Z Z m c a C: 0 LL 7 Q' c E-Fu_to U (0 LL O vaf Z _Z J d t j c LL Waif Z0. J V U LUZ t j d' v L o fO LL O W Vf Z Q C7 t .3 d' _ f0 LL Z y� a W � LL L a L m - N N 41 O au O N O R R O a4) O O �, N V E d L Q in qw' 0 O �• E L C: =• O V N CM Q R N J d ' c - N O i0 O s 'a O = N d Q � .E 0c as ° z � N c ° t 'y =. CO F- L Q CD r ci �+ _ R 0 'N ED r _ = as d CLai O v m LUW = -a Z o o LL •N d R N c � N CL�ww w E 0�.5� U (o� N c m cc;►- 0c I— � 0-Ov 01 U :a U) z ' m V O E L.L O �F+ Z Q O 0 -- CD N Q M� co 'E W W CL c O �+ > V 0 O Q a CL � Q O V J � CL 0 CD W O U c !c _ ca U) 0 NORTH SHORE BUILDING SERVICES LLC 1 Westward Circle North Reading, MA 01864 1-800-564-4016 Licensed: CS -060149, HIC-165538, RRP lead Certified ,•, PROPOSAL ,*r , 1. t 0(� Revised: November 26, 2016 October 28; 2016 F 9 Mike tuzzo 5 Stonewedge Circle North Andover, MA 01810 Email: Michael.a.luzzo@fmr.com 617=947-6234 We hereby submit specifications and estimate for: Finished Basement Room. SCOPE OF WORK: • Framing — interior partition walls and closets per home owner's layout. • Frame in under stairway for door. • Electrical — Install plugs and switches to Massachusetts code, install ten recessed lights, install fluorescent lights in closets in finished room and under stairway closet. • install insulation to Massachusetts code. • Install %" 'blue board on walls and skim coat plaster, smooth finish. c Install doors, trim and baseboard in finished room and under stairway. • Install acoustical ceiling in finished room. • Apply two finished coats of paint on walls, doors, trim and base board. • Install existing HVAC lines in acoustical ceiling. • install closet shelfing in finished room closet and in closet under stairs. • install flooring in finished room, flooring to be supplied by home owner. • Contractor to obtain all necessary permits_ • Contractor to dispose of all debris. Total: $20,000.00 We hereby propose all materials and labor — complete in accordance with the above specifications, for the sum of: $20,000 Twenty Thousand Dollars Payment to be made as follows: 1. 50% at midpoint. 2. 50% upon job completion. Acceptance of proposal—The above prices, specifications, and conditions are satisfactory and hereby accepted. You are authorized yo do thqr work as specified. Payment will be made as outlined above. acceptances (Customer's Signature) (Contractor's Signature) All work is 100`Yo guaranteed for one year on all craftsmanship. All other warrantees are through the manufacturer. All warrantees will be null and void if job is not paid in full. Thank you for letting us serve you! North Shore Building Services LLC DHW 45( lit Pl1w X Y1 it /-evzz d Tcr ACORO® CERTIFICATE OF LIABILITY INSURANCE `.� FDATE(MWDD/YYYY) 11/29/2016 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 terns 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 CONTACT House OIISe Linnane Insurance Agency, Inc. 280 Main St. #101 arc°NNo (978) 664-2000 AA/C No: (978)664-0160 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # 8/28/2016 INSURER A: Commerce Group CIG001 N. Reading MA 01864 INSURED INSURER B NORTHSHORE BUILDING SERVICES LLC INSURERC: PO BOX 663 INSURER 0: INSURER E: $ N Reading MA 01864 INSURER F: COVERAGES CERTIFICATE NUMBERCL1510601069 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 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MWDD/YYYY POLICY EXP MMIDD LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑R OCCUR BGRJRR 8/28/2016 8/28/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ MED EXP (Any one person) $ 5,000 PERSONAL& ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ JET LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Peracadent $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNERlEXECUTIVEE.L. OFFICERIMEMBEREXCLUDED? F-1 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA PER OTH- STATUTE I I ER EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) t;LK 111 -ICA I t HULUtK CANCELLATION bleathe@townofnorthandover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Dept ACCORDANCE WITH THE POLICY PROVISIONS- - 1600 Osgood St Bldg 20 Ste2035 North Andover, MA 01845 AUTHORIZED REPRESENTATIVE M Linnane/LINRPI ACORD 25 (2014/01) INS025 Ontaml ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACC:)RV CERTIFICATE OF LIABILITY INSURANCE FDATE A E(MMI2016 ) 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 CONTACT NAME: Town Of Andover BYETTE INSURANCE AGENCY INC. He No W : (978) 851-6678 AIC, No COMMERCIAL GENERAL LIABILITY E-MAIL ADDRESS: nicole@akfowledns.com INSURERS AFFORDING COVERAGE NAIC # 200 Park St. INSURERA : ACE AMERICAN INSURANCE CO 22667 North Reading MA 01864 INSURED INSURER B: INSURERC: BARBAGALLO PETER DBA NORTH SHORE BUILDING SERVICES INSURER D: INSURER E: PO BOX 663 INSURERF: NORTH READING MA 01864 COVERAGES CERTIFICATE NUMBER: 108124 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 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 LTR TYpE OF INSURANCE ADDL SUBR POLICYNUMBER POLICY EFF MM/DD POLICY EXP MM/DD LIMITS North Andover MA 01845 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL &ADV INJURY $ N/A GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO ❑LOC JECT GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE N/A DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? NIA NIA NIA 6S62UB2E30048516 07/02/2016 07/02/2017 SPER TATUTE ETH X1 E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT I $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at www.mass.gov/lwd/Workers-compensabonAnvesbgations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCFLLATION ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main St. AUTHORIZED REPRESENTATIVE nn �" C North Andover MA 01845 Daniel M. Crcyey, CPCU, Vice President— Residual Market — WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massaebusetts ,Department of l-ndustrialAccidents M = r X Congress Street, Strife 100 " w d021X4 20X7 _ - - Boston, MA ,1 I www rnassgov/dia °M SVsv Q(ta kers' Compensationlnsurance,A.fftdadt-B10Uders/Conic ictorsfElectrici:ansMlWbers. TO BE FILED WITHTHEpIIxNGATJTtOItI7'Y. AP' licant Intormamou Name (Business/Ora bization/indivi&A: Address: �1��`i Phone #: city/state/zip: Check the appropriate box: / Type of project (required); Are you an employer? e to ees fuIl and/or part time). Y 7. ElN&Wv donstraoiion 1.❑ I am a employer with mP 2.[] I am a sole proprietor or partnership and have no employees Worlang :forme in 8. Remo del%iig any capacity. [Noworkers' comp. insurance required_] insurance required.] ' 9. ❑ Demo]ition 3.E] I am a homeowner doing all work myself. [No workers' comp. 10 [:1 Building addition 4.F]I am a homeowner and will be hiring contractors to conduct all work on my property. I will insurance or are sole 11 [] Electrical repairs or additions ensure that all contractnis either have workers' compensation ��'- Plumbic airs or additions 12 ' g r proprietors with no employees. Lel` 554I am a general contractor �d I have hired the sub -contractors listed onthe attached sheet. insurance t 13% Ej Roof repairs These sub contractors have employees andhave workers' comp. 14 n pier b. ❑We are a corporatio4 and its, offices have exercised their right of exemption per MGL c. insuuance required ] 152 employees. [No worker' comp. Plm andWahaxbr� applicant utthosectionbelowshowing thefrworkers'compensationpoficyinformation ` `Any PP ilia are doing all walk andthen hire outside contractors must submit a new affidavit indicating snob i Homeowners who submit•this affidavit indicating Y !Contractors that check this box must attached an additional sheet r showing thewe namerhe& of amp policy nnmbe and state whq her or not (hose entities have employees. If the sub -co, , , , ors have employees, they mist p ce for my employees 8elo7v is flue policy and job site X am an employer that is providing-workeys' compensation insuran information. Insurance Company Name: �D ExpirationDate: Policy # or Self -ins. Lic. #: t Job Site Address-.) �� City/State/zip: 0.. vte�'� 0��/l Attach a copy of the workers' compensatio�olicy declaration page (shown -g the policynumber and expo atzon date . Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation. punishable by a ab up to $1,500.00 WORK oRDIR and/or one-year imprisonment, as well as civil p enalti s f the foxed to the office of Inv� 0 a of the DIA for irlsuran day against the violator. A copy of this statement may coverage verification. X do Hereby certify undeptliepains an pena� es ofpe j ' that the information provided move w true and correct: i 7 'Ii> //-- official use only. Do not -write in tliis area, to be cor,2pleted by city or town official. City or Town: PerwRiLicense #. Issuing Authority (circle one): I 1. Board of Health 2. Building Department 3. CitylTowa Clerk 4. Electrical Inspector 5. Plumbing Inspector b. Other Phone #: Contact :f Q 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 in 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 enfeiprise, and including the legal representatives of a deceased employer, or the receiveFor trustde ofan individual, partnership, association or other legal entity, 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 persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment b6 deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local Licensing ageney shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage i4dred." Additionally, MGL chapter 152, §25C(7) states "Neither the 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 chapter have been presented to the contracting authority." Applicants Pleasb 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 certificate(s) of insurance. Limited -Liability Companies (LLC) or Limited Liability Partnerships (ILP) 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, a policy is requixed. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The of davit should be returned to the city or town that the application for the permit 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 and printed 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 fill in the permit/liceme number which will be used as a reference number. In addition, an applicant that must submit multiple pernit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) and under "fob site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamp ed or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filed out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i. e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617•-727-4900 ext. 7406 or 1-877•-MASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia &xe (60141mw4w�:111 ' Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration _ Registration: 165538 Type: Corporation Expiration: 2/1/2018 Tr# 419291 C.J. & B CONSTRUCTION CORP. PETER BARBAGALLO = P.O. BOX 663 NO.READING, MA 01864 Update Address and return card. Mark reason for change. Address F -]Renewal F] Employment R Lost Card SCA 1 s; 20M-05/11 `-, _Office of Consumer Affairs & Business Regulation OME IMPROVEMENT CONTRACTOR -- _ Jp9� Re istration: 165538 Type: `?Expiration: _::211/2018. Corporation C.J. 8 B CONSTRUCTION CORP:;: ' PETER BARBAGALLO 1 WESTWARD CIRCLE' NO.READING, MA 01864 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid without signature t Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS -060149 Construction SupervisorAa ' PETER J BARBAGALLO +F- 1 WESTWARD CIR N READING MA 01864 r,---jzCK Expiration: Commissioner 10/31/2018