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Home My WebLink AboutBuilding Permit #14-13 - 50 PHILLIPS COURT 7/9/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: A ) IMPORTANT: Applicant must com lete all items on this page LOCATION o? �h I //(,p J (20 Li✓� Print PROPERTY OWNER //FN&Y (5us/5.d /I/ZM lTi9 G Unit# Print MAP NO:�PARCEL:�ZONING DISTRICT: Historic District yes no Machine Shop Villages no qs- ` 10 year-old structure (`.J no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building X One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Well .° ' ®Flood lain ® Wetlands � ® �VVat re shD�istnct P - + - - —•�- , , r.OWater/Sewers . n _ DESCRIPTION OF WORK TO BE PERFORMED: RLL o v F kt tAJ i a� /��.4:L a` /�tj LJJ (Identification Please Type or Print Clearly) OWNER: Name: AE,& ,g /rc�.l�,�1 f!2r1 t c, Phone: M 794 63 V �d Address:_ ,g a T)h ll� &,.�r� Nd rah Andover HA o/kYJ- r, . CONTRACTO 2oori R Name. �S rt2l C oN� l �/�- g Phone. q7� b 3 3 YAG Address: c:21 ,3 f R Su Na n 5' recj c3 A Iv6,4. An 4 D ve,. AIA 6 1 YS r Supervisor's Construction License: 9,35 Exp. Date: ( 0- 113 Home Improvement License: q S(0 9 Exp. Date: 7 t L/ f� ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.•$9200 PER900 $ 0.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $_ Sy k 6,0 0 FEE: $_ Check No.: �'�� - 1 Receipt No.:,��' �--' NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ,Signature of,Agent/Ovvner,�.{. x .�: -. .,, , �, _ Signature of�contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans TYPE OF SEWERAGE DISPOSAL �1 { Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑' ° Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ I Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE. ONLY INTERDEPARTMENTAL SIGN OFF - U FORM`; G• $' DATE REJECTED �, '-DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS K-EALTH Reviewed on Signature f Q6MMENTS 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 DEPARTMENT -Te'm'p Dumpster on site yes no Located at 124 Main Street• Fire Department signature/date COMMENTS `` 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 servicedroprequires approval of Electrical Inspector Yes DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine i NOTES and DATA— For department use I El I Notified for pickup - Date I Doc:.Building Permit Revised 2011 June/mi i 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: Doc.Building Permit Revised 2008mi 1 _ Location 0— 2 F, No. I Date s • • TOWN OF NORTH ANDOVER •:; Certificate of Occupancy $ Building/Frame Permit Fee { Foundation Permit Fee $ v Other Permit Fee $ TOTAL $ s Check#��tf 25487 Building Inspector OORTH -o=wn- o � t _ Andover No. 7 �O LANE h " ver, Mass, • • Helm. -CoCMICNEWICK y1' �d A04ATEv S u LD BOARD OF HEALTH ' T Food/Kitchen PER Septic System 0 ........... BUILDING INSPECTOR THIS CERTIFIES THAT ........... ... .: ........ ............. .:.. ...��.f.......... .... ..� ................... � Foundation 60&0� has permission to erect .......................... buildings on ....... .... ... ..P. ........CF.+..*........ ,..� Rough to be occupied as ... .. ........! ..... .. .... .. ..*. ..: .�:— ............................. Chimney provided that the perWepting this permit shall in every respect on m to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws lating 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 CONSTRUC TS Rough Service ............... .. ....... ..... .. ---- :. .................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. A�Co,.RH CERTIFICATE OF LIABILITY INSURANCE DA's`""' 9/9/201111 THIS CERTIFICATE 16 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 holier is an ADDITIONAL INSURED, the policy(les)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 endorsemen s. PRODUCER 00hrTACY NAME. Willows InsurasLao Agcy o l: 978 475 3414 ., j� No);,- S1 Cochichewik Dr E-MAIL ---"' PR OMCERMA OMER IQ I. - -.. North Andover HA 01845 INUMER(S)AFFORDING COVERAGE MAIC r _ NAIC, INSURED INaURERAMaiden 9t>ocialty Ina Co I Rea e; DAVID CASTRICONE ROOFING 6 SIDING INC INSURERC i _— _._. 200 Sutton St Suite 226 INeURlR D: - - I NORTH ANDOVER MA O1ANSURER E; d5 ' INSURER F COVERAGES CERTIFICATE NUMBER:CL119906255 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. - - - - — .. 'DTSUeN . .-._...__., )LTSRA' TYPE OF INSURANCEAIM WvDPOLICY NUMBER P EFF PID� LIMITS Y NE ---- - --—•—• GERAL L1A8Iln'I' EACH OCCURRENCE ES 1000000 X COMMERCIAL GENERAL LIABILITY MUCEMPREM i OCCUR 4�5KMThU e +rra� 500- 00 _J44a _ SA I 7 MED EXP An one en S 1000 _...—_.... - - "' "' -'-"-' '•` _PER.40NAL d ADV INJURY t 1000000 GENERAL AGGREGATE S 200000_0 GEKL AGGREGATERO. APPUE3 PER PRO PRODUC- T.S-.CDMPOP AGG_ 5 1 OOOOOO - . . .. .. . .S POUCY LOC .' . AUTOMWILE LIABIU'fY - COMBINED SINGLE LIMIT S ANY AUTO (FJ K-0dent) ALL OWNED AUTOS BODILY INJURY(Per Damn) S SCHEDULED AUTOS BODILY INJURY(Per ecadetl) $ HIRED AUTOS PROPERTY DAMAGE s (Pw eccloent) I NON-OWNED AUTO$ S UMBRELLA UAB OCCUR - .. ... S . It EE5 LIAe EACH OCCURRENCE S CLAIMS MADE DEDUCTIBLE AGGREGATE S RETENTION WORKM COMPENSATION s AND EMPLOYERS'UABILftY WCSTATU- IDTI+ ANY PROPRIETORMARTNERIEXECLIT Y f N• _ .. TRAY,LIMITS..._�_ OFF CERMEMBER OCCLUDED? NIA E.L.EA ACCIDENT s (Mendetory In NN) tt des describe�^dw E.L.DISEASE•EA EMPLOYE S DESCRIPTION OF OPERATIONS bdwv - F.l.nISEASE.POLICY UMrr i DISC RIPTION OOP OPERATIONa I LOCATIONS I VEHICLES (Attuh ACORD 101,Addklonel Remsno 9cheoul/,M men Spec!k mqu)Md) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN David CastricOne Roofing & Siding Inc ACCORDANCE W)TH THE POLICY PROVISIONS. Castricone Roofing 200 Sutton Street Suite 226 AUTHOWn0-PRaaaMTATTVE N Andover, MA 01845 ACORD 25(2009109) INS025(2WW9) The ACORD name and logo are r9gistened marks�of 0 ORD CORPORATION. qn rights reserved, DAVID CASTRICONE CASTRICONE ROOFING& SIDING INC. ROOFING,SIDING&REMODELING REPLACEMENT WINDOWS HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 200 SUTTON STREET,SUITE 226,NO.ANDOVER,MA 01845 In North Andover 978-683-3420 In Boxford 978-887-6147 In HaverhX 978-374-7314 I/we the owner(s)of the premises mentioned below,hereby contract with and authorize you as contractor,to furnish all necessary materials,labor and workmanship,to install,construct and place the improvements according to the following specifications,terms and conditions,on premises below described: i y� Owner's Name........ tr PN.......k .l tYl.i..lN�.? .................................................T�phone#....2p.1.(�..-..0 �j,3 1..1.3...... Job Address....t.. a' ,.......�z.L1Lt 5......� .....................City.. State.... .Z ....... Specifications: ...........................................................................................:. ........................................................................................................ ................. ,-5frip existing shingles.( .Apply new drip edge to all edges. ✓Apply_feet ice and water shield membrane to bottom edges of house. 3 feet ice and water shield membrane in valleys and bottom edges of any unheated areas of house. ............................................................................................................ ...... ..... Apply felt paper underlayment. vlmstall ridge vent to n p..... T......41 / 16 carP,r� �fc, ................. ....T...... ....................��, ...�....................................................... .Reroof u shingles with a+s:i.�0 year warranty. ........... Ct.�(C.. ......................................................................................................................... Counterflash chimney. 'Wew vent pipe flashing. ?egal disposal of all debris. .......................................................................................................................................... ......... .............................................................. Area(s)to be worked on: /..Y.a. J...t^..r,. t'..4?.a.. ..........................................L..� J ........�J......�tr a a /.. 1'�..... 6'I. ....s; �ne.......%s ........... .P.............. . .... ,�t�v ........................ ................................................................. .................... . Roof board replacement if necessary @ Gb /sheet o;Y.P°/foot. .............................................................................................................................................................. .............................. Two Year Workmanship Warranty(Not Transferable) Kanufacturer's Warranty as sped 1 by man facture The c tractor agr es to 1.rform the work d sh the materials specified above for the SUM $... { .......... .. >�!r � Payable....11 i'1........on.. xv.1................ Payable.............................on...........-- .................Balance payable on completion of job Owner or Owners are not responsible for Property Damage or Liability while jo is to operation. Contractor is not responsible for any damage to the interior of property,including pre-existing conditions(i.e.water stains,crumbling plaster,exposed nails)or conditions resulting from application of materials specified above(i.e.objects coming loose from walls,crumbling plaster,exposed nails,dust in attic or other living spaces).Items in attic may need to be covered by homeowner.All materials arc property of contractor. Any dumpster placed by contractor is for his use only.Upon completion of above work,all undersigned agree to execute and deliver to contractor,their joint note in accordance with his(their)above obligation as requested by contractor. Upon refusal to do so,contractor may at its option declare the entire contract price or so much as then remains unpaid,immediately due and payable. It is agreed that,if permitted by law,contractor shall be paid by the owner(s)all reasonable costs,attorney fees and expenses,in addition to the amount due and unpaid,that shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith.It is further agreed that this contract maybe assigned by contractor,and also that the obligations hereof shall bind and apply to their heirs,successors or estates of the parties.The undersigned warrant(s)that he is(they are) the owners(s)of the above mentioned premises and that legal title thereto stands of record in his(their)names(s).There are no representations,guaranties or warranties,except such as may be herein incorporated,if any,nor any agreements collateral hereto,nor is the contract dependent upon or subject to any conditions not herein stated.Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties. All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to:Director,Home Improvement Contractor Registration, One Ashburton Place, Room 1301,Boston,MA 02108 Tel:617-727-8598 Any and all necessary construction-related permits shall be obtained by the Contractor. Any Owner who secures his own construction- related permit or deals with unregistered contractors is excluded from the Guaranty Fund provisions of MGL c.142A. Approximate starting date of work................................................ Completion date......................................................... Receipt of a copy of this contact is hereby acknowledged,and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Owner has three business days to cancel this contract and incur no penalty (see notice of cancellation). / IN WITNESS WHEREOF,the parties have hereunto signed their names this.�4.. s..day of..ti/.f. ?.ew........20../,a� Accepted: -' >eSigned , lt�.(i? G{:. 7.. ?1L_ ` ................. Owner Caa�__ Signed............................................................................. Owner ................................................................... David Castricone,President CERTIFICATE OF LIABILITY INSURANCEF9/23/2011 DATE(MMlDDIYYVV) AC�� 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(Sy, AUTHORIZED nArAr\ITATI\Ir AA AA A1111A rA •\IA Tl Ir/�rl'\TI r1/ •Tr I IAI nrn IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)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 N AME: Eastern Insurance Group LLC - Main PHONE(AicFAX 233 West Central Street - - A/c No: -653-8089 EMAIL Natick MA 01760 ADDRES INSURERS AFFORDING COVERAGE NAIC B b' INS-URERA:COMMerCe Insurance Company 34754 INSURED 31969 INSURER S:CHARTTS David Castricone Roofing & Siding Inc INSURER C: 200 Sutton Street #226 INSURER D: North Andover MA 01845 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2141633407 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 ADDL SUBRI �u l vumocn gg8SYrEFF NIWliL/rEXP n GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITYPREMISES aoccurrence): $ CLAIMS-MADE F7 OCCUR MED EXP(Any one arson) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ POLICY PRP LOC $ A AUTOMOBILE LIABILITY SCNGCV /1/2011 /1/2012 (LEx,'M,."'%raS'NGLE LIMIT 1000000 ANY AUTO BODILY INJURY(Per person) $20000 ALL OWNED SCHEDULED AUTOS Ix AUTOS BODILY INJURY(Peracctlenl) $40000 X HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS Peraccidenl $ 1 UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ g WORKERS COMPENSATION 0003989723 /23/2011 9/23/2012 X WCSTATU- O - AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOWPARTNERIEXECUTIVE E.L.EACH ACCIDENT $100000 _ OFFICERIMEMBEREXCLUDED? N!A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $100000 If yes,descrlbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMB 1$500000 i I DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION Castricone Roofln & Sidin SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE g g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN I' Suite 226 ACCORDANCE WITH THE POLICY PROVISIONS. 200 Sutton Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 01988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD �1 1��arI)tuct(' - DC lid I-T111c•t1t ul Pl11111c 1:1fct1 BOAT(I i)t Builtlitt F2c,ul,ttiurl. antl $t:lnrl;rrtl '`— Construction Supervisor Specialt y License License: CS SL 99358 Restricted to: RF,WS DAVID CASTRICONE 31 COURT STREET NORTH ANDOVER, MA 01845 �s --'$- �� Expiration: 12/16/2013 ( inuii..inrr Tr%;: 7924 SCA 1 is 20M-05/11 ?. Office of Consumer Affairs&Busi/ess Regufat on/ - HOME IMPROVEMENT CONTRACTOR I —Negistration: 104569 C G xpiration: 7/14/2014 Torpo Private Corporation DAVID CASTRICONE ROOFING, SIDING 8 David Castricone 200 SUTTON ST SUITE 226 _ NORTH ANDOVER, MA 01845 — Undersecretary I i Town of North Andover NnkYN o Building Department o ' 27 Charles Street ti13 North Andover, Massachusetts 01845 -� r (978) 688-9545 Fax (978) 688-9542 p 7 4�R�reo Apr``(r� �SHcHu5e DEBRIS DISPOSAL FORM In accordance with therovisi p ons of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work sliall be disposed of in a properly licensed solid waste disposal facility , P y as defined by MGL c,l 1, s1S0a. The debris will be disposed of in/at: e, — L Facility location Signature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project tluoug.h the Office of the Building Inspector, 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 Information CPlease Print Legibly Name (Business/Organization/Individual): CA6-78166de X10 0 F/N k Address: 2,31 R Ju T' Tb N STRUT ,3A City/State/Zip: N o. An b oV 6R HA 6 MS Phone #: 9 U - W '3 Q 0 Are you an employer? Check the appropriate box: Type of project (required): LW I am a employer with 7 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet $ El Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.El 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' 13.0 Other comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.- Homeowners nformation.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. ram an employer that is providing workers'compensation insurance for my employees. Below is the.policy andjob site 'nformatiom nsurance Company Name: V� A(Z r1,S ?olicy#or Self-ins. Lic. #: co a 3 19170113 Expiration Date: Q• a3 -1� ll11 I'I lob Site Address: Jt �hl (1 t('S Coyr� Ci ri/State/Zi p: fib. An d d vv Yd 6 t q-) kttach 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 me 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 )f 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 coveragq verification. do hereby certify under th ins and p nalties of perjury that the information provided above is true and correct Signature: Date: ?hone#: 9 7 E W _:3 q A o Oficial 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#: