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HomeMy WebLinkAboutBuilding Permit #579-2015 - 53 CEDAR LANE 11/10/2015 ° BUILDING PERMIT NORTF� w- ��t TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit No#: J (� Date Received �R"CRATED "c5 gSSACNV`-'�� Date Issued: 1 IMPORTANT: Applicant must complete all items on this page LOCATIONr- -� ,pint - PROPERTY OWNER I o K346-, 5 1e"1 Print 100 Year Structure yes On MAP (4 PARCEL:_ZONING DISTRICT:`Historic District yes. AlpP Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial $Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other , ❑ Septic ❑Well 0 Floodplain ❑Wetlands ❑ Watershed`Distnct Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: re 0c-�c f 7- t �; d Lu S Identification- Please Type or Print Clearly OWNER: Name: aSle� Phone: Address: 5-3 ,, 0rGV 1- 2r(15 ContractorName: J&e4 l cy5 4tV d 1 cA (c� Phone: Email e5 - Address: Supervisor's Construction License: C.-O" " C� 7 6,91 Exp. Date:(ALZ_ .. Home Improvement License: Exp. Date: 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: $ 1 Z`+ 0 FEE: $ 71°� Check No.: �(� Receipt No.: (P"1► NOTE: Persons contracting with unregistered contractors do not have access to th a n and ignature of Agent/OwnerSignature-of contractor �' ,P'6WA0-En 11-12 Tly BUILDING PERMIT of p10R0R , TOWN OF NORTH ANDOVER6'` ° 0 APPLICATION FOR PLAN EXAMINATION r0 Permit No#: J �� Date ReceivedR -- � ArED �SS�ICHU`''���5 Date Issued: IMPORTANT: Applicant must complete all items on this page f ROPERW EOWN.ER .._ r►'l - re,-? t Pr'nt 1=0 eaFStru: ure. .` Q— ZOIND1MAPepPACE =LLAO iMachin-sS'h'op Villa; TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial P Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other p - r p�Se_.tic ❑;i1Nel_ ." b Flood lain Wetl�an0 atershetl 5CE trict +�`yWaterlSewer ` DESCRIPTION OF WORK TO BE PERFORMED: re P C-�Ce z c L/-f Identification- Please Type or Print Clearly OWNER: Name: M�� �a S e Phone: Address: 5-3 Cfec G r- L1*17 Iq.4 c1c)vAe/- v!S(/5 Coro tractorIt a0 e4: rrcwt aPhone�- 5 T - �- 77 - 3dress 9 - _ i $uTp,**e _J 1G�.o�n�strucfi®n±'L�ri e se: C �: 2 ;Hoe-,,I'rr® .ue etll dLicense R' r ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ �/ `L�} 0 FEE: $- 2-1 ) Check No.: �(� � Receipt No.:_em NOTE: Persons contracting with unregistered contractors do not have access to th a n and �SgnaturofrEAgenu Ouuner_ ' . . �Signateof'contracto_r, r; .: .' . . .-': . - .. .. _. _ l f , _ _.,... .- :- -_....: .. ... ..... a r . .. - .-._. :.._._.-. ..-:. :.. - - E _ - a -., - r-H �` _ -. �.. --:y •• _ __ ___ _ __ N 'A'eNw'.Yw"Rk9wYxiYi��-•ri`W _N" •,' _ .... .%Vwltiy.y.- _ v. R.V.'-} z., �til";. " . - .� — . _ - :. . 3 .L- . - - Location ` No. —G� Date \k \U \7 • . TOWN OF NORTH ANDOVER' xn s • c� t ars - �. Certificate of Occupancy $ r . . r Building/Frame Permit Fee $ '� ;� Foundation Permit Fee $ } k Other Permit Fee . ' . . TOTAL r ` $ -. x . 4 -j Check#P* L Fr - r. 9 6 4 J. Building nSpector - Y �c y f .>.. - _ _ .... ..... ... - - . - _ _. .;. -' . .. - ._. ...:.:. : is _ .. ':Ic. ,x. -.;..... .. . .. _.,. :: :`.... _:.n .:._.... —._ ._._ _.,-. _a,.. - k �. :'-c r a :. - .; .. --'- . ... .. ._ . - .': :. ... .. _ , r .... _ ... ..._ .. .. 3 . ...;r .- .. _ ___ _ �'.,- a .ri.^: ... -... -- ..._-. J' 9 `.. ... I d' _ n .. ..... ..rv. .. - .. . t t . ,S -.,F - ♦ . J 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 Dwnpster 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 C k COMMENTS i Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes � t Planning Board Decision: Comments t Conservation Decision: Comments Water& Sewer Connection/signature& Date Driveway Permit DPW Town Engineer Signature FJRE DEPARTMENT Temp lU mpster on site yeses _ _ Located384 Osgoo Street �._ Y T nox_ 0cated:at 24 Main Sheet Fire Departmena signature/date LO QMMFLN-T$. 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 Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature is COMMENTS ZoningBoard of Appeals: Variance Petition pp No: —Zoning Decision/receipt submitted yes Planning Board Decision: Comments x, ;'Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgoo .Street Ff yE D =PAI �iTM�E=-N�IT' Te�rnpt Du Aster on sit �L Y o '�Matn FQ a Departrn.nta swig d a; u e/d�a e 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 o Electrical Inspector Yes pP f No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 section 21A—F and G min.$1oo-si000 fine I NOTES and DATA— (For department use) w I I i ❑ Notified for pickup Call Email _Date y_ Time Contact Name Doc.Building Pennit Revised 2014 r-- 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 I Date Time Contact Name 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 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 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 Li Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ 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 ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses L, 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 o 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 o 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 NORTH own o E ndover 0 - 10 h V h verMass, AIV15601�'!w o , COC MICNtwicK �1• 7,9 A°RArEo 0p,��(5 S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THATT ,... .s�. BUILDING INSPECTOR .................. .. ... ........ ......... .. .......................... Foundation has permission to erect .......................... buildings on .. .... ..... .+Tlr!. .............. Rough to be occupied as ..... A........ ►..1!!.. ................................:........................................ Chimney provided that the person accepting this 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION7RTTS Rough Service ................... . . .,vr.r.......................... 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. � F eEnnc�ueunc SPECl/aC1STS 978—.69't-S20"t KeenConstructionCo.com Beasley,Tom 53 Cedar Ln. N.Andover, MA 01845 Contract#5561;Appendix A October 15,2015 New windows: • Supply& install twelve standard sized double hung windows, eight over-sized double hung windows and one double wide casement window • All windows to be new construction Harvey Classic vinyl windows with six over six grid pattern (grids between the glass, larger windows will be different but proportional grid pattern), energy star rated glass,with half screens on second floor,full screens on first floor • Supply& install new interior and exterior casing(integrated with window,908 brick mold style) to match existing • Dispose of all construction related debris Total Prices do not include cost of permits, painting or repairs to any unusual, unsafe or non-code compliant existing conditions not addressed in this quote. Total Price: $18,240(eighteen thousand two hundred forty dollars) Payment Schedule:$1000 due upon signing contract $4000 due when windows are ordered (approx. November 2) $4000 due the first day of work(plus permit fee) $4500 due when nine windows are installed $4740 due at completion of contracted work �— Customer Robert A. Keen L41 /0A1 911� Date Date PO Box 935 Page 1 of 1 P: 978-691-5201 N. Andover, MA 01845 F: 978-682-3231 CSL#076691 Sales@KeenConstructionCo.com HIC#108383 556 ; KEEN CONSTRUCTION CO. PC PROPOSAL NORTH ANDOVER;MA 01845 All home improvement contractors and subcontractors Tel: (978)691-5201 engaged in home improvement contracting, unless Fax:(978)682-3231 specifically exempt from registration by Provisions of Chapter 142A of the general laws, must be registered Submitted —�-- / with the Commonwealth of Massachusetts. Inquiries To:_T� �_ �r . I� about registration and status should be made to the Director,Home Improvement Contract Registration,10 Park Plaza, Room 5170, Boston, MA 02116 617-973- 8787 Owners who secure their own construction related permits or deal with unregistered contractors will be excluded from the Guaranty Fund Provision of MGL c.142A. PHONE DATE REGISTRATION NO. N0. (11 �sI � `�� MA. H.I.C. 1083837416–3783401 > C/S=Customer Supplied S+I=Supply+Install I�'See Attached Appendix A We hereby submit specifications and estimates for work to be performed and materials to be used. A > Construction related permits: ............................................................._................................................................,............_....................................................,.,...........__.............._..._.......................................... .._..�_._____......__..____._.______........._._.........._. _ WORK SCHEDULE ..........._............................ Contractor tui I not in the work or order the materials before the third day following the signing of this Agreement,unless specified hre in wr ing. C ntractor will begin the work on or about (date). Barring delay caused by circumstances beyond Contractors control,the work will be completed bye (date). The Owner hereby acknowledg s an agr s that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be corsid re s violations of this Agreement. WARRANTY The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of IeC44 C following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials,or damage caused by the Cont act r,his subcontractors,employees or agents,is discovered within one year after completion of any job,including cleanup,the Contractor shall,at his own expense,forthwith remedy,repair,correct,replace,or cause to be remedied, repaired,or replaced,such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of FT Payment be made as follows: d011arS($ T —% ($ ) upon signing Contract; �ROERT A_ KEEN Name of Contractor/Designated Registrant —% ($ ) upon completion '� 1175 TURNPIKE ST. I Street Adtlress % ($ p. e pretion of N.1 ANDOVER,.MA 01845 CiN"/State shIIade forthwith upon (978)691-5201 (978)682-3231 completion of work under this contract. Phon Fax Notice: No agreement for home improvement contracting work shall require a >down payment(advance deposit)of more than one-third of the total contract price Name les an or the total amount of all deposits or payments which the contractor must make,in 1 ✓ advance,to order and/or otherwise obtain delivery of special order materials and Author Ign re equipment,whichever amount is greater. Note:This proposal may be withdrawn by us it not accepted within days. Acceptance Of Proposal-I have read both sides of this document and all attached documents and accept the prices,specifications and conditions stated. I understand that upon signing,this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. You,the Buyer,may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.Cancellation must be done in writing. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Signature l < Data V d` '— Signature Dale IMPORTANT INFORMATION ON BACK ► ACD O® CERTIFICATE OF LIABILITY INSURANCE DATE �� 10/223/20153/2015 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). PRODUCERTAC Barbara McDonough Gilbert Insurance Agency, Inc. PHONE (781)942-2225 F�No:(781)962-2226 137 Main Street ADDE-MARESS:bmcdonough@giThertinsurance.com INSURER(S)AFFORDING COVERAGE NAIC 0 Reading MA 01867-3922 INSURERA Norfolk 6 Dedham Insurance 23965 INSURED INSURERB:Safety Insurance Company 39454 Keen Construction Company INSURER C Travelers Ins. Co. 0031 483 Chickering Road INSURERD: INSURER E: North Andover MA 01845 INSURER F: COVERAGES CERTIFICATE NUMBERCL1552101779 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. /NSR TYPE OF INSURANCEADOL POLICY EFF POLICY EXP LTR POLICY NUMBER LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE FX CCCUR PREMISES a oc=nce $ 100,000, ND-P-010078/000 3/13/2015 3/13/2016 MED EXP(Any onePerson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEHL AGGREGATE LIMIT APPLES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JE O LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SIG IT eeccMent $ 1,000,000 B ANY AUTO BODILYINJURY(Pe r person) $ ALLOWNEOX SCHEDULED 6228807 COM 01 5/23/2015 5/23/2016 BODILY INJURY AUTOS AUTOS (Per accloenq $ X HIRED AUTOS X AUTO ED PROPERTY $ Undemrsured natodst $ 100,000 UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LWB CLAIMS-MADE AGGREGATE $ DED RETE NTON $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ) ANY PROPRIETOR/PPRTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 C OFFICERIMEMBER EXCLUDED? NIA (Mandatory In NH) 6HUB-9991M58-2-15 10/8/2015 10/8/2016 E.L.DISEASE-EA EMPLOYEE $ 100,000 0 es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addifi—al Remarks Schedule,may be attached I more space Is required) CERTIFICATE HOLDER CANCELLATION (978)623-8320 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE M Gilbert, CIC/BARBAR ©1988-2014ACORD,CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS0251201401) ON 140 luri mm=�11=1=1. Z . . The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia SJ• Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PEFMTTING AUTHORITY. Applicant Information Please Print Legibly Name: (Business/Organization/Individual): t(P_&1r1 O 5 ou � cy-N C7 Address: City/State/Zip: �� I�`rl SCJ�;�i�tC t G� P one#: 9?Z— �,7, 4 �Z0 Are you an employer?Check the appropriate box: Type of project(required): 1.21 I am a employer with 2- employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp,insurance required.] 9, ❑Demolition 3.FJ I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insuranceJ 14. Other 6.F1 We are a corporation and its officers,have exercised their right of'exemption per MGL a ❑ 152,§1(4),and we have no 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workerscomp.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: ve- e r5 105 — Policy#or Self-ins.Lic. L) 99 5) 1 N5<9-2___ Expiration Date: 1 6 Job Site Address:,3 CeC'�G-r Ln City/State/Zip: k; Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un r th pains and penalties of perjury that the in provided above is true and correct. Signature: Date: l d 2 9 Phone# 9:2.17 — �9 — 5-210 C. 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 of Public Safety Board of Building Regulations and Standards 1.11 t1�L11I1111111 JUIICI Y1�1/1 - License: CS-076691 ROBERT A KEEN-: 12 12 E WATER STI North Andover AfA 0 r __,Y__A4 .-w10 Expiration Commissioner 08/16/2017 �}� C1�>�ie rpo�nvrraaau�s o�C�aacf cu�ell� 'lA- Office of Consumer Affairs&Business Regulation reg ME IMPROVEMENT CONTRACTOR istration: ;;108383 Type: piration 8118/2016 DBA KEEN CONSTRUCTION 00 I = Kenneth Keen 1175 TURNPIKE ST NO.ANDOVER, MA 01845 Undersecretary i