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Home My WebLink AboutBuilding Permit #442-15 - 52 RUSSELL STREET 11/6/2014 ORT BUILDING PERMIT o�N��D 6 TOWN OF NORTH ANDOVER 032 APPLICATION FOR PLAN EXAMINATION •moo Permit No#: {�1r.1 �r/j Date Received �DR gSSAC HU`�� Date Issued: �� es IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER { Print lob Year Structure. yesAnno MAP�_ "�0PARCEL: I ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 0 One family 0 Addition 0 Two or more family 0 Industrial 0 Alteration No. of units: ❑ Commercial 0 Repair, replacement 0 Assessory Bldg 0 Others: 0 Demolition 0 Other 0 Septic 0 Well ❑ Floodplain ❑Wetlands ❑ Watershed District 0 Water/Sewer ��DESCRIPTION OF WORK TOBE,,PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: 9 Address: Contractor Name bINL Q Phone: Address: AOU _9!Y 6 7 :2 AXE ' Supervisor's Construction License: .�J �' Exp. Date: Home Improvement License: A / 3 Exp. Date: r/7 7&/_ 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: $ 6 goo FEE: $ ` Z�YD Check No.: ��i`1� Receipt No.: �� + NOTE: Persons contractin wit unregto coa ors do not have access to the guaranty fund Lignature of Agent/O Signature of contractor 'z I Plans Submitted ❑ Plans Waived 0. 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 Signature_ COMMENTS CONSERVATION Reviewed on Signature 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 FIRE DEPARTMENT - Temp 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 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 NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name 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 u Building Permit Application u Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract a 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 a Building Permit Application u Certified Surveyed Plot Plan a Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Mass check Energy Compliance Report (If Applicable) Li 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) Li Building Permit Application Li Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses u Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Copy of Contract Li Mass check Energy Compliance Report u Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 f. Location 52— F SS 1( i No. 1 Date t r t i . - TOWN OF NORTH ANDOVER . z i s Certificate of Occupancy $ 4 Building/Frame Permit Fee $��•� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# � � r 2 8j 2 3 4 Building Inspector NORTH Town of 2 �. : : 1� Andover 01 No. h ver Mass 9 ��ve y T O 4 LAN! coc"Ic M!WIc K' aT V BOARD OF HEALTH Food/Kitchen PERMIT T L__D Septic System THIS CERTIFIES THAT � At .... BUILDING INSPECTOR ........... �i�&+ ........... .., Foundation has-permission to erect ......... ................ buildings on ........1z............. .... .....L�........ ... ..... ' b � Rough tobe occupied as ........... ...... .......... ......... ................................................................................ Chimney !!iprovided that the person accepting t is permit shall in every respect conform to the terms of the application Final on file in 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 ONT ELECTRICAL INSPECTOR UNLESS CONSTRU 'f5 S S 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. Smoke Det. VHIS /2014 10:16 FAX 781 942 2226 GILBERT IN01 CERTIFICATE 4F LIABILITY INSURANCE OATE(MANDD/Y4j 11/6/20].4ERTIFICATE 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(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 N0.ME Barbara McDonough Gilbert Insurance Agency, Inc. PHONE (781)942-2225 FAX (7e1)942-2226 137 Main Street EMAIL bmcdonough@gilbertinsurance.coml INSURER(S)AFFORDING COVERAGE NAIC# Reading MA 01967-3922 INSURER A=Har/ svill® Nationwide 26182 INSURED iNsuRrPa.P1vmouth Rock Assurance CO 004154 Duval Roofing, LLC. INSURERC;Travelers Ins. Co. 0031 P.O. BOX 637 INSURER D: INSURER E North Reading MA 01964 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1411601329 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 POLICY EFF POLICY EDLP LTR TYPE OF INSURANCE lmqp WVn P L cY NUMBER MM/0DNYV MM/DD/YYYY LIMIT$ GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 XCOMMERCIAL GENERAL LIABDAMAE TO RILITY a ocw reS 100,000 A CLAIMS-MADE FZ OCCUR L0000006415BG 10/23/2014 0/23/2015 MED EXP(Any one person) S 5,000 PERSONAL E.ADV INJURY S 1,000,000 GENERAL AGGREGATE $ 21000,000 t3EN'LAGGREGATELIMIT APPLIES PER'. PRODUCTS-COMP/OPAOG' S 2,000,000 X POLICY PRO-JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S001000 B ANY AUTO BODILY INJURY(Per person) S ALL OWNEDr:;;-?71 SCHEDULED PRC00001003799 10/23/20140/23/2015 AUTOS AUTOS BODILY INJURY(Por arcldeny S X HIRED AUTOS X NON-OWNED C147 DAMAGE S AUTOS Uninsured molcrlBL BI a III Ilmll S 100,000 UMBRELLA LIAR OCCUR EACH OCCURRENCE I $ EXCESS LIAB. CLAIMS-MADE AGGREGATE Is DED I I RETENTIONS I $ C WORKERS COMPENSATION To Be Provided directly VAC STATU- OTH11 AND EMPLOYERS'UABILJTYTORY LIMITS ANY PROPRIETOR(PARTNER/EXECUTIVE Y/N the worker'e E.L.EACH ACCIDENT S 1001000 OFFICER/MEMBER EXCLUDED? N/A (ManHamryInNN) ompen"ation carrier. 3/11/2014 /11/2015 E.L.DISEASE-EAEMPLOYE $ 100 000 Ir yes,ljoswDe unser DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 I OE$CRIPTION OF OPERATION$/LOCATIONS r VEHICLES (Attach ACORD 101,Addlllonal RemerWa Schedule,If more space Is required) Evidence of Coverage CERTIFICATE HOLDER CANCELLATION 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. 1600 Osgood Street North Andover, NA 01845 AUTHORIZED REPRESENTATIVE M Gilbert, CIC/BARRASt ACORD 25(2010/05) ®1988-2010 ACORD CORPORATION- All rights reserved. INS025 poiow).o1 The ACORD name and logo are registered marks of ACORD IOld % Page No. of Pages f 7�{rviyosa� Builders License # 58443 Home Construction Reg. # 167338 DuvaJAL RoofingLLC (781)944-1994 (978)664-2557 READING NORTH READING P.O. Box 637, North Reading, MA 01864 Please visit us at www.duvaIroofing.com PROPOSAL SUBMITTED TO PHONE DATE STREET { CITY,STATE AND ZIP CODE I f kf0t We hereby submit specifications and estimates for: , ' t,' 1 A (. G f f i 0 Rip&Remove all existing roof related debris from roof as well as job site with our own disposal truck. NO DRIVEWAY DUMPSTERS 11 layer of existing roof shingles 0 2 layers of existing roof shingles ❑3 layers or more of existing roof shingles Replace any damaged roof decking; not to exceed 32sq.ft. (additional at$1.70 per sq.ft.) 0 Install 8"Aluminum Drip-edge/Rake-edge along entire perimeter(Choice kite, rown or Mill) 0/Install ICE&WATER UNDERLAYMENT on all horizontal eaves, sidewalls, skylights,chimney flashing and valley areas 0 Install a premium base sheet underlaymeni,#eit)##tat is in compliance with the asphalt shingle manufacturer chosen by the homeowner r 0 Install The Homeowner's Choice of the selected Tamko/IKO or GAF Limited Lifetime Architectural Roof Shingles See individual manufacturer's warrantylor specific details or please call us with any questions OrReplace all existing bathroom louver and/or exhaust pipe(s)with new aluminum flanges Chimney(s) -counter-flash and re-step existing flashing ❑Cut&Install new lead flashing CS Install a continuous low profile Ridge-Vent on all ridge lines ❑Soffit-Vents _. ...❑,Reof=Louver-Vu-nts' "— ❑Seamless Aluminum Gutters-Custom fabricated on site with our own gutter machine ❑ Downspouts at additional - ❑Leaf Guards 0 Other j,., U 1j_/0 r .l•i r � G!� l iii �7�i ' (.,i(I '� 1t L. �•�7 eL, F,''I �f•'tI �1`•)! 4 (`i 't E` r�/C /� 1 Cry' ' li r� — ✓ �, �..�i ❑Roof Insulation-Increase existing R.value to R.value archk i e J U hfi'1 i` O.ut.)4Pf" Pic JJropose hereby to furnish material and labor-.complete in accordance with above specifications,for the sum of: 1776 -�- Total price not including options. dollars($ Payment to be made as follows: 30%deposit required before ordering materials.Balance due in full upon day of completion. Please make all payments out to Kenneth Duval, mailed to: P.O. Box 637, No. Reading, MA 01864 Final Payment is due upon day of completion and is subject to the Authorized supplemented Terms&Condition sheet when scheduling. Signature THIS PROPOSAL IS VALID FOR DAYS DUE TO FLUCTUATIONS IN MATERIAL&DISPOSAL PRICES. Massachusetts Home Improvement Sam We nn le Conti F, „ t ! •f This form satisfies all basic requirements of the state's Hahne Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners Seek legal advice if necessary. Any parson planning home improvements should fust obtain a copy of' f"A Massachusetts Consumer Guide to Hams Improvement,,before agreeing to any work on your residence.You may obtain a free copy by calling the Office ofConsumer Affairs and Business Regulations Consumer Information Hotline at 617.973-8787 or 1-888.283-3757 or on our website. Homeowner Information Contractor Information Company Name Street A_d (do not use a Past Office x a�dtfts Contracted SalesperamY parome er Na -i U va t ity(rows State 'p Code Business Address(must inc tude a street address) t )Qiso 63-7 14 o Daytime onO� s - � eityffown score zip Code `� Malting Address(it different from above) Business PhoneFederal Em loyerlp or S.S.Number soot lmpmVemmd Camnamaeg.Y her a�hnrion date t,ur ngefrw tDat tort Dome `��j 3 Lt�J(('� fmpranmeat common hon I -7 V a and reghnatlaa anmDer The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,ase additional sheets if ee a ary Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner`s agent: be adhered to unless circumstances beyond the contractor's control wise (Owners who secure their own permits win be excluded from the Guaranty Fund provisions of Glance.coconua for will begun contracted work. MGL chapter 142A.) UI 11) Qt.�O j d D to w n contras work wi be substantially completed. DY1. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of., SIN U V /Payments will be made according to the following schedule: l� S 116 upon stgnmg carr nd(not to exceed 1/3 of the total conttactprlce(q the cost of special order items,whichever is greater) $ by�/ 1 or upon completion of (� by =l / or upon completion of (/ V� ✓ � _j__]__upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) _ The following mateaaVcquipment mnstba special ; to be paid for ordered before the contacted wads beg=in order A to meat the Completion scbeurns.n g to bepatd for DOTES:(e)Including all finance charges(v`)Law rwMms that any deposit or down-Payment required by the connector before work begins may not exceed the granter of(a)oritthird of the total contract price or(b)the actual cost of any special equipment or Custom made material which must be special ordered in advance to meet the completion scbeduk. 110ress w n rovid o t =of the warranti,must be allachad to the contracO Subcontractors-The contractor agrees m be solely responsible for completion of the work described regardless of the anions of any third patty/subcontractor utilized by the carmadnr..The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor trader this ainaenwnt Contract Acceptance-Upon signing,this document becomes abinding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placation the residents. Review the following cautions and notices carefully before signing this contras. • Don't be pressured into signing the contract,Take time to read and filly understand it. Ask questions if something is unclear. • Make sure thecontract r ha a i:rid}lime Immo=e t Contra=RgW=titm The law requires most home improvement contactors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of inatnmtce"dtwlmtxnt • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to th a Improvement connector Law. You may can 1 this a eement if it has been signed at a place other than the comtrttetor's normal place of business,provided you notify the contractor in "ting 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 f owl the signing of this agreement. Seethe attached notice of cancellation form for an explanation of this rig)t. KO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM -2 copies oftbe roman mut be cna>platadsad signed.Oce copy should go to the homeowner.The other copy shmsd he kept by it*contractor. wner's Signature C ctor's Signal,- '? Date Date—I i r Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is haautomatically contractor,however. The contractor would have to resolve any dispute he/she has witha homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerninlscontract,the contractor may submit the dispute to a private arbitration Cum which has been approved by the Se of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to subtr4tjdsuch arbitration as aaachusetts General Laws,chapter 142A. H ineo er s ignature t Contractors Signature N E:The signatures of the patties above apply only to the agreement of the parties to altemative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement.Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. .Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manna. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree maybe added to the terms of the contract as long as they do not restrict a homeowner's basic consumer righrg. if you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in du .and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both partics.Coed work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired Accelerated Payments A contractor may not demand payments in advance of the does specified on the payment schedule in cases where the homeowner deans hirnlherself to be financially immecure. However,in instances where a contractor deems him/herself to be financially insecure,the conhaetorntay 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. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Raza,Room 5170,Boston,MA 02116 617-973-8787,888- 283-3757 or visit the OCABR website at Irtth:'; If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at ham_:;«v;ti.masa�.�i�r:cicatlir..' Go online to view the status of a Home Improvement Contractor's Registration: 1t(tn:iitib,�iat ni t us homeinmr�� ,�u:.nt licrnsc�eti�t r,rrz For assistance with informal mediation of disputes or to register formal complaints against a business,can: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-6524800,508-755-2548 or 413-734-3114 ocelot 11-11122=10 NOTICE OF CANCELLATION 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 YOU 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 SHUPMENT 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 DESPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER,OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO,THEN YOU REMAIN LIABLE FOR 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 WRITTEN NOTICE, OR SEND A TELEGRAM TO [Name of Seller],AT [Address of Seller's Place of Business]NOT LATER THAN MIDNIGHT OF (date). I HEREBY CANCEL THIS TRANSACTION. Date: Buyer's Signature: AL The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly Name (Business/Organization/Individual): Duval Rooifng, LLC Address: P.O. Box 637 City/State/Zip: North Reading, MA 01864 Phone#:978-664-2557 Are you an employer? Check the appropriate box: Type of project(required): 1.IN I am a employer with 8 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors b. F]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. $ 9. �Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.[]-Plumbing repairs or additions myself. ' right of exemption MGL y �o workerscomp. on per 12.11011 Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑Other employees. [No workers' comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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 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:Travelers Policy#or Self-ins. Lic.#:7PJub-0230N91-14 Expiration Date:3/11/15 Job Site Address: Ltd� 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 WORD 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 certi a pains and penalties of perjury that the information provided above is true and correct Siam atare: t Date- Phone#: 978-664-255 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#: s — Office of Consumer Affairs and Business Regulation s` 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 167338 Type: LLC Expiration: 9/10/2016 Tr# 256221 DUVAL ROOFING LLC. KENNETH DUVAL - - P.O. BOX 637 \ a t NO. READING, MA 01864 a Update Address and return card.Mark reason for change. SCA 1 .;j 20M-05/11 Address Renewal ❑ Employment Lost Card iauoiss1ww00 5 60Z/0 WZ L uoj4ejidx3 '� t98T(Y�OAIIQd��N ` is lu'aom ZL A Obi XOR Oa l £yb890 asuaat� -so -y^� ►osl.u;)dnS uo{t:)n.clsuoa splepue}s P" suo{;e{n6ab 6ulp{in8 to p1e08 /{;ales allgnd 10 juaw:peda4- s}tasnyaesseW NOTICE N NOTICE TO TO V a EMPLOYEES EMPLOYEES y �W ♦ V The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21,22&30,this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY (7PJUB-023ON91-9-14) 03-11-14 TO 03-11-15 POLICY NUMBER EFFECTIVE DATES GILBERT INS AGCY 137 MAIN ST READING MA 01867 NAME OF INSURANCE AGENT ADDRESS PHONE# a- DUVAL ROOFING LLC 184 PARK STREET 0 o� NORTH READING MA 01864 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE ^ MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably '— connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL EMPLOYER j � ADDRESS •� 004315 W20PIG02 TO BE POSTED BY ■ MPLO i ER