HomeMy WebLinkAboutBuilding Permit #561-11 - 531 FOREST STREET 2/14/2011 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
TANT:AppEcant must complete all items on this page
LOCATION., 4 -7I /'&fir s-f" Al ,— 1ylo✓cT ra-
Print
PROPERTY OWNER G'
.Print
MAP NO: Z b PARCEL: l�� ZONING DISTRICT: Historic District yes no
Machine Shop Village yes
TYPE OF IMPROVEMENT �eilv SE
Non- Residential
❑ New Building
0 o more family ❑ Industrial
❑ dition ❑Two r y
Alteration No. of units: ❑Commercial
❑ Repair, replacement [IAssessory Bldg 11 Others:
❑ Demolition ❑Other
4 ❑Floodplaui ®Wetlands ' n ' � Watersh'e3d�Distr` ct� .
�s ,t
t ❑ Septi�^{/ .�[l�'Sp
y
�O�WaterS/ ewer�`� °
DESCRIPTION OF WORK TO BE PERFORMED:
C- lVeLd
T NuAl 1�-t -
Identification Please Type or Print Clearly)
OWNER: Name: -ln✓� ''��'� �~r Phone: 2
Address: �$� J��,/ s— e ��} •/��ry /,�
CONTRACTOR Name: x �%- ice � � ff'�c`tel.<1�� Phone:
Address: �
Supervisor's Construction License: GS /b Exp. Date:
Home Improvement ent 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$925.00 PER S F.
Total Project Cost: d FEE: $
Check No.: el
Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have a cess th u
r Si n - e" corof
atreof;� Si nauritraeto` =.L
—
Location 4
No. Date
�aRTM TOWN OF NORTH ANDOVER
10
9
Certificate of Occupancy $
'ss�cMust`� Building/Frame Permit Fee $ `
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # G
rlp.
r.
F'
2389
- Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Swimming Pools ❑ ti
Tanning/MassageBodyArt ❑ v
Well ETobacco Sales ❑
,-,/ Food Packaging/Sales ❑
Private(septic tank,etc. I'�' permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
MEN -
S
_ HE II
ALTH Reviewed on Siqnature
a
COMMENTS
r .
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments +
Conservation Decision: Comments
Water &Sewer onnectio11/Siqnature&Dafe 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
s'
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
is
Total land area, sq. ff.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Inspector Yes No
Ins
Efectrical p
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 section 21A—t-and G min.$100-$1000 fine
I
NOTES and DATA— For department use
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® Notified for pickup - Date
Doc:.Building Permit Revised 2008
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Building Department �I
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 ;
r �
Addition Or Decks
o Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit F
❑ Photo Copy of H.I.C. And C.S.L. Licenses '
❑ Copy Of Contract
N
o Floor/Crossection/Elevation Plan`Of.Pposed Work With Sprinklerro ` ir lan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
❑ Engineering g ng Affidavits for En ineeredroducts
require sign off from p
NOTE: All dumpster permits re {
q g f m 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
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
v Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products ,
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
i-�the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
is be submitted with the building application
Doc: Doc.Building permit Revised 2008ml
C NORT#I '9
over
Of ,.,And
/ 020
C%
o dover, Mass.,'I
0 - LAA.
COCHICHEWICK\�
ORATED PPS �y
qS �� BOARD OF HEALTH
Food/Kitchen
Septic System
E..R Ml I.T.
BUILDING INSPECTOR .
;THIS CERTIFIES THAT............C�b -..��'1�,-!-r-•�`".. r ............................................................
,.....�... ......... ...................... Foundation
has permission to erect........................................ buildings on .... 3.�......'fid- iT................... ... Rough
to be:occu ied;as:.....(.. L lm
p v�!� (w✓�i�.. _ !. ... .i, ..... Chimney
(...... �}
prpvlded than a person` c eptm`g tRis;permrt all in every respect conform to the terms of the application on file 16 Final
this.office,.and to the provisions of'the,Codes and,$y-lames relating to the Inspection, Alteration and Construction of
Buildings: in.the Town ofAortft Andover:. PLUMBING INSPECTOR:
VIoiA ON of<the Zoning or'Building Regulations Voids this Permit. Rough
Final
a(,L PERMIT EXPIRES IN 6 MONTHS
UNLESS CONSTRL�C STARTS ELECTRICAL INSPECTOR
Rough
Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
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,
r +.,. J
Street No.
Smoke Det.
SEE REVERSESIDE , 1
Contractor Arbitration
The Home Improvement Contractor Law provides homeowners witlr the right to initiate an arbitratio ` ~
. alternative to-court action)'if they have a dispute•with a contractor. The same right is not automaticall action
es to
contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court nless
both parties agree to the optional clause provided below. This clause would give the contractor the some ri ht to
arbitration as is afforded to the homeowner by the Home hnprovement Contractor Law, g
The contractor and the homeowner hereby mutually agree in.advance that in'the event the contractor has a dispute
concerning this-contract, the contractor may submit the dispute to a private arbitration ferin which has been approved.
the Secretary.of the-Executive Offrce.of Consumer Affairs and"Business Regulation and the consumer shall.be qur dy
to submit to such arbitration-at provided In Massachusetts General Laws,chapter 142A.
Homeowner's Signature
NOTICE:The signatures of the parties above apply only to the agreement of the parties. r
oalternative dispute resolution
initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not
separately signed by the parties,
Homeowners 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
maybe 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 Gu'
the Home Improvement Contractor Law. The contractor is responsible for completing the work knaass described in provisions of
timely and workmanlike manner. Homeowners may be entitled'to other specific legal rights:if the contractor�guarantees
or provides an express warraniy 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 addeei to the
Your consumer/homeowner rig
term's of the contract as long ghts,they do not restrict a homeowner's basic consumer rights. If you have questions±about
contact the Consumer Information Hotline(listed below).
Execution of Contract
The contract must be executed in du licate and should not be signed until•a copy of all exhibits and referenced
documents have been.attached. Parties are-also advised nut to sign the document until all'blank sections h
filled-in or marked as void, deleted,or not applicable. One have been
PP n original signed
lie given toed co 0
g the owner�'and the other kept'' the � PY f the contract with attachments is to-
be
agreed to b Y contractor. Any modification to the original c'
y both parties. Coatracted work may not begin until both parties have received a fully ontract executed copy o
t be in Writing
the contract;and the three day recission period has expired.
Accelerated Payments
A contractor may not demand•payments in-advance of the dates specified on the payment schedule in cases where the
homeowner deems hiim%herself to be financially insecure. Iowever,in instances where a contractor dee
-to be financially insecure,the contractor ma r uire ms hina/liersel
Y eq that 11te balance of funds not yet due be placed in a joint escrow f
.account as a prerequisite to continuing the contracted worl�, Withdrawal of
signatures of both fund
parnes. s from said account would require the
Additional;Information
If you have general questions or need additional info
consumer rights,orrmation about the Home lm ro
if you wish to obtain a frco of A Consumer Guide.to the Home Improvement C
� Law,"contact: .. �� P
vement Contractor Law or other
eePY
oriftutor
• Consumer Information Hotline
Office of Consumer Affairs and
B
usi
lop ark PIaza,Room 5170,Boston,MA 02116 on
(617)973-8787'or 1-(8'88)2833757
Ifyou want to verify theregistration of a contractor or if
about the contractor registration component of-the Home Improavement Contractor ou uestions or aw�COonal information specifically
ntrict:
Director of Home Improvement Contractor Registration
Bureau of Building Regulations and Standards
One-Ashburton Place,Roorn.1301,Boston,MA 02108
(617)727-3200 or 1-800-223-0933
For assistance with informal mediation of disputes or to register fdrmal complaints
against a_ business,call: "
Consumer Complaint Section
Office of the Attorney General
(617)727-8400
AND/OR
R
"Better Business Bureau
(508)652-4800
.(508)755-2548
(413)734-3114
i
' Massachusetts Rome I101,2vement• Sample Contract
This Form satisfies all basic requirements le the state's home Improvement'Contractor Law(MGL chapter 142A),but does not'include standard
language to protect homeowners. Seek legal advice if necessary. An}r person Planning home
Ivlussachusetts consumer guide to home improvement"before agreeing to any wok on your residence.oYou mayshouldvements first
s�free copy bcoc ilio"the
Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8797 or 1-888-283-37 Py y g '
57.
. Homeowner •
Information
y n Contractor/Information
am
ompany ame
�, c.,. S•� G'lig'1 �'S., f'�✓�1�-i, `
Street;Address(de not use a Post Office Box address) Cou_tntctorl Sale ers.Qn/Owner
.. sP Name
- DAG✓• �! GY �� —/,J� Je�s�:��-- �,� '
Ci own State Zip Code usiness Address(must include a street address)
'63 %6 442: �
Daytime P.bone Evening Phone ',iryl I own ( c
State Zip Code
Mailing Address at different from above)
usiness Phone ederal Employer ID err 5.5.Number
laru rega&tca aur mon hamf im- home pmvtsotattCotwaMor
provrauat contractors have• I •Nina aapcalion date
cad registration nmbe
The Contractor agrees to do the•following work for the Homeo mer: ( U L L
cn e in a r o com e e e/✓ / Z 1..�/
P sP� g e a ran e c n t n s o e e on
aces
Required,Permits-The followi4building permits are required Proposed Start and Completion'Schedule-The fallowing schedule will
and v(ill be secured by the contractor as the homeowner's agent, be adhered to unless circumstances beyond the contractor's control arise
(Ovdners who secure their own permits will be
exelilded from the Guaranty%Fund provisions-of `v 't Date when contractor will begin contracted work.
MGL chapter 142A.)'
r 2�Date when contracted work will be substantially completed.
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 112
a (*)
Payr4ents will be made according to the following schedule:
S upon signing'contract(motto exceed 113 of the•total contract price or the cost of'special order items,whichever is greater)
L by or upon completion of �K,, r;•� ; ��i
Z 11�J L i
S by =1 1 •or upon completion of_ C<r
i
upon completion of the contract. (Law forbids demanding full paymentuntil contract is completed to both party's satisfaction)
The following tnattrial/equipment must be special 5 Q to be paid for
ordered before the contracted worl•begins in order S C/ . to be paid for
to meet the completion schedule.(**)
NOTES:(*)Including all finance charges(**)Law requires that any deposit or dawn-payment required by the contractor before work begins may
not exceed the greater o r(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material
which must be special ofderedin advance to meet the completion schedule.
)gess
Warranty-Is an express warrnpty beta urovided by$te contractor?_ No Yes (rill terms of the warrnnty must be attac>led to the contract)
Subebntractors-7 6-contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third
party/subcontractor udlize'd by the contractor. The contractor further agrees to be solely'respDnsible for all payments to all subcontractors for
materials and labor under this agreement
Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the
contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices
carefully before signing this contract.
• Don't be pressured into signing the contract Take time to read and fully understand it. Ask questions if something is unclear.
• ' Make sure the contractor has a valid Home Improvement ContractorR.e¢istration The law requires most home improvement Contractors 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 One Ashburton Place,Room 1301,Boston,MA 02108 or by calling 617-727-3200 or
1:800-223-0933.
• Does the contractor have insurance? Check to see that your contractor is properly insured.
• Know your rights and responsibilities. Read the Important Inforinaliotn on the reverse side of this form and get a copy of the Consumer
Guide to the Home Improvement Contractor Law. +'
Youmay cancel this agreement if it has been signed at a place oilier than the contractor's normal place of business,provided you notify the
conbetor in writing at his/her main office or branch office by ordinary ma if posted,by telegram sent or by delivery,not later than midnight of the
third business day following.the signing of this agreement. Seethe attached notice o 11 f cancellation form for an explanation of this right
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES111
Two identical copies of thc•contractmust be completed and signed. one copy should go to•the hoincowner.'The other copy should he k t b the
cp y contractor.
Homeowner's Signature
on igna'fure
Date
Massachusetts- Department of Public Safety
Board-of Building Regulations and Standards
Construction Supervisor License
License: CS 104741 "
CHRISTIAN SILVE&TRI
13-15 DELAWARE DR.
SALEM, NH 03079
Expiration: 1/31/2014
('ununisviuncr. Tr#: 104741
&.. o� ��
Office of Consumer Affairs&Bu�ine s Rgw.tiuio.
HOME IMPROVEMENT CONTRACTOR
Registration: ,,x1,68350 Type:
Expiration 2181-0,13 Individual i
C TIAN SILVESTRI
CHRISTIAN SILVESTRI js4
t
13-15 DELAWAREDg .
1 SALEM, NH 03079 ! {
Undersecretary
i
01/01/2008 06:53 19785211020 COWL PAGE 01/03
1tSSR0h_dkftS$o 'e 1•aoretne�t Sam le Canhact
This ot-s ae6w gh bat iequttbmeals of We aws Rama IMI
vemuit Con
lghgt�ape to protect immeotrgeta Seale legal mdvleq If taersse mor Eaw(MaL CbVW I42U but a_not fgdude stbedgrd ;
Maaos�charrpsootyurovr�°idamReme# m1CApYpeteovplanaieeh°meimptayemep�abmddfiest°6uiaaaopy°feq
Otfiap afCatxu°ei ASa' mptOv+�oel°§yfpla atmac(bg 10 any work on year amdee¢you
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Tilt boalraceargamrstodatLe'thgossIngYorltfor the Homen eentr�e.. W.
ReQnlred'Parmtts-Tbe foO!
le.lWnrgpWmits wv mrptEred Flop°ved 6tbvr d°d Oompl�dan$ehadWe_•fLa
. agd h!be ae�urod byt)te wenaaroras ffia homttaemet'e a fallawlog edtedule Will
(0=1'1 Will 1e1�4 b�L adhmW to-Ewers° bryodd dth auaali emirs cKttd orlW
their own permits�rN be
auipded 5rou�the GumrtlW I Nnd ravislof /~,tY 11
MCL 11,p10 142A.j' �DvkwLeflChahHc�rwlllbegigcantroopcdarptl�
�LD9k when man,a uod w°dcw1U1--b.Md0Y-..,lomd.
' T•tatL'entravt!`Hceititdr•patoelScht�ttte -
71eCom—toragroci'1appr—a. .1;*.",hemato AsollUborepaillodalfor the toNlmul a_a
j paIro'mods aaaDlttlbp to&a following mbeww.
' ..S•. d' epoo dgnlgp e®mrOt(Pot to dcceed 1/3 of dx ptee!coabaet -
1 p ou Pria Ow co]t°P'Fppc{d off'I�Iga,WW0xIYerte grcpta).
• L hY�h)// // orupaacaaopkdoa;of •!.,� '
' s !w� ; � �,t'u, //.aruf+eaaompkdagof •e4.•.� r .•i ,
S t/�• bpam eemplafion a4 the c .
. O {Iawforhldt demmdiar full paymamitmGt o0nhbe(la thm Igad t°hoth
r�°rohe1i�a�ddfe9alpo°mr moo W v das s:!� p Paeh'•a aafiPf°oq°a�
rbeduathecvg•edodwbdrbgatslaaNerto"MaMPMAOM-A*"1-041 • S- r✓_mbop wfar�'rflS"'�.��• ..
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• tv�tee pr�ddCllml .
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parte abmade.m'adimd.tpdtowa6octar.Tkegmmatorlumbi%FWDmbewleima�dlva.0foroapt°mOfMYmild� '
Ykz9ba bteforallfiaymentstoetlsubemamammfoi
caattaetAoeoptegtx-Uponatgnh M thla daaumcettraaoeior•bbo
eaadetehvll not aplr dot may 16.or otbors gym;eoahact Bader law,Udeyj o9rervrinopakd ori dopa dearmtoµhe
-14*befbrasis cthis eantraa6 eemfhimmtmcbasitamtplaoedaatbatefidenre.9aviewth°folbwingaaogameande°tioea
• Dont be pravo•od tbta etVobty lira a0aaaot tglm Sma to1:11 toad and fel , • .
•' MpOes:Ogr<mr t W e,m new . 1:102!111 jijtj
Ar&— b wd�amd It Aak•94eed°getteomeartog iavablwc
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b9ae+213.0932,• n.mA.92168 or by c01%617.727-3a0ahow&a ar
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t;utde to the Heprp>m roppovsibRFdei beam lm� Fyq�d m� —. aide tbwi f°sd amd awn&I of tlL.a mmeow
ptvvomeoecouvmtat
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day foIIotrin the si ae of thio a�ee�eat Bea lire ettvelrodaottm or. m e4m arhy de116ery.not hcp d ee midal�a mill b0 No'1'51GN TFg6 CONTRAt;7'ZIt 'rtrm�a�, �t°"°ex Wood a qrtblr a
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01/01/2008 06:53 19785211020 COWL PAGE 02/03
Conkuetor Mtilhation .
718 Rome Improvement ComtractoYT aw
ettemeave tn.court action'if theyAgate's ith a c4 tz# , tlrtbe right to initiate an atbihatimt acdoh(as as.
contmulor,bowever. no conbutorwottldlq t to asp aoY dispute he/ebertor.116 damp dP�16'M antomaHcaft
both parhes aetesto the epboatpl clause provided below.ibis clause Y ttlfvtd0 to a•
Les withe homaovmerim eoutt Wd4ss
etbitreEion as is afforded tb the hdmeoer b rile Hnroe would give the eotahaOtar the Semetigbt to
Y pmvcmentCantmcmrL..
The Foottraotor oqd the bcoacovmrr h
acmacrolnthe dyseontvect,the eonhactorm m a�� advance tb at he super rile canlractor bas a disputa
tris Sac�,quy of theBxeently,Offiaa of tbn mit a dispute to a pnvete itratioat hint which has been
to sabaslt t,eu MMarAftda and 7JnsineIIa rta;talatioa ebd the ehicb b e epptpved by
bad pmtided In Ma"Itchuseto flpnarat Latus,eh9Pte1 1 rahAll he it quiipd
' FlomeotyaePa Sighettue .
NO T7C15.The signaturp of the Patties shove a co stow Sagnatvm
faitlal,N by a oontr"m- Thn hameotw PPIv vu�y to tha agreement of Ow alttgnative di
s aratelY signed the . 'as. trMy lvitiate nttemative dispute t esaln4on evm wheteihla sFcp a monk tion
gomaowner's Rights;
A bomrownees riWte ung theHoaae
Pm4Cctloa lawd'(i.e,ham t Iff 93 7mpytat be t Contrector Law(1v1t31;Citap�r,7 2A
may be excludea frons Certulat rights If�tbe ront:4u m ffi ved is arty wa. .- � )nod other eenattrrter
-Rormeowltva mho s �choose is not by agreemtyd However,bota"ers
tits�ome r ebIM their own banding ptnmils atg atitamatice7l Propotiy registered os prt�scribed by fate.
mt+raveuaaat ConttQctorIaw. The coatrHctarla.IHt Y exclttded f ank all
timalyy an corp eC m��HvtpaDa pets mel be L---Ppt other' campled g the�� d 6 o°e Of
contraator,
All goads sold r od4OaAhip orroatar€ats. 7(a addi4ou t 1 � if tL'e canttac,4rg r, ,taee
putpmre'!ta uaette an t�ph'ed w guarantees or W&Mdes Ptu idcd,by the
e�metadonofvihertnasiem—wh3vhtheha °f inQvheatabilltyandfitnesstbta
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- �4.ltooat 5170,>3oetort,7vfA
(617)973-87&702146•
or 1+(8$g)283757 .+
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about the Cotjtt9o(or reglsttati11114Di or if'
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MA 02108
Par oeeistaace wish info (6I7)721-3100 ar 1-$DI)?�3 093s
1 mediation of dtapafee or to+eBlatArfctmal '
eompiaials agalvat a business,cell:
Conequaw Coolottiot Seetiap,
Office oFthe Att*ay Gm*W a
(417)727-8400
AND/OR
13e{tcrBualnem 1 uw*a '
(sos)652.000
008)73.5-2eas
(413.)734-3114
Massachusetts- Department of public Safety
Board of Building Rculations and Standards
Construction-Supervisor License
License: CS 104741
CHRISTIAN RI ,
S
TI
SILVEsaTRI I
13-15 DELAWARE DR,
SALEM,.NH 03079,
Expiration: 1/31/2014
l.'unmiissiincr. Tr#: 104741
i r\
The Commonwealth of Massachusetts
I Department oflndustrialAccidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print']Legibly
Name(Business/Organization/Individual): rC e �e ✓��'eG X,
Address: I `- r
City/State/Zip: C �, ( e,m /f 1�" �7� f' Phone#: 6c, 'PI V 01 y
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
,Y_ 11
. I am a sole proprietor or partner- listed on the attached sheet. E]Remodeling
hip 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.] 10.❑ Electrical repairs or additions
officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.] employees.[No workers'
comp. insurance required.] 13.n Other
*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 acid their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance(Company Name:
Policy#or Self-ins. Lie.#: Expiration Date:
Job Site Address: 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 WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance'coverage verification.
I do hereby certify under the pains ancenalties of perjury that the information provided above is true and correct'
Si nature: Date:
J.- z ;>
Phone
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#:
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 enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of an 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 be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency 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 required."
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
Please fill out the workers' compensationaffidavit 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(LLP)with no employees other than the
members or partners,are not required to cavy workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the pen-nit 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 pennitllicense number which will be used as a reference number. In addition,an applicant
that must submit multiple,pennit/license applications in.any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped 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 filled 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's
address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street -
Boston,MA 02111
Tel.##617-7274900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax##617-727-7749
www.mass.gov/dia