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Home My WebLink AboutBuilding Permit #409-11 - 55 MILK STREET 11/15/2010 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 6� Date Received Date Issued: IMPORTANT:Applicant must complete all items on th' age LOCATION S M L(4 c Gks Print PROPERTY OWNER 13 Ayepq L O W Print MAP NO:D�PARCEL:��IZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building )4 One family ❑Addition ❑Two or more family ❑ Industrial kAlteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic ❑Well ❑Floodplain 0 Wetlands 0 Watershed District . ❑Water/,Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: &V eR { L o w Phone: L Address: 5-5' fn tV, AtN-tbue-�4 CONTRACTOR Name: Phone: -3s---70y' Address: 5!Zl�' G�y` 1iu Supervisor's Construction License: IY2 lz�`e 3 Exp. Date: Home Improvement Improvement License: _ / � /�/ Exp. Date: d /9 Z.a� ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ 1�T�6d' FEE: $ �/ f' Check No.: 15 '7 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fun Signature of Agent/Owner Signature of-contractor _ 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 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ WellElTobacco Sales� S ❑ Food Packaging/Sales ❑ Private(septic tank, C. f A^ ] El 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 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 - Date Doc:.Building Permit Revised 2008 Location No. Date NORT/l TOWN OF NORTH ANDOVER D Certificate of Occupancy $ �ssuMus E<� Building/Frame Permit Fee $ _�___ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r Check # r Ir L ' : _ JC , Building Inspector ORTH Town of Andover . 0 _�- LAKE o dover, Mass., �• 1 '� ' /� COCMICHEWICK 7d ADRATED BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT............... (.0.4 ......... BUILDING INSPECTOR . """"' Foundation ........ ........................ bull On ..... ..... 1.1. W� Rough has permission to erect. �� ........... ..........�.................... g r • t0 be OCCup18d as......... Chimney . .................. ......................................................................................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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 CONSTRUC ST S 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 Street No. SEE REVERSE SIDE Smoke Det. F R A N K FRANK HOWARD CARPENTER & BUILDER H O W A R D Barry Low 55 Milk St N. Andover,Ma Nov. 10,2010 Contract for Bath remodel: 1. Obtain Building, Electrical& Plumbing Permits 2. Demo down to studs by owner 3. Remove and replace double hung window with new vinyl awning windowRO 24 1/2x36 1/2 4. Remove and replace interior door 2'6"x6'8" 5. Install new wiring for one Nutone Fan&Lite unit vented to exterior, one GFI receptacle, , wiring for one lite over sink(fixture suplied by owner) 6. Plumbing includes installing one copper shower pan, one toilet, one sink(Fixtures supplied by owner) 7. Remove and replace existing radiator 8. Install new insulation to exterior wall and ceiling Unstall new 1/2"cement board to walls in shower area,1/z" blueboard to ceiling and walls outside shower 10. Apply 1/8" skim coat plaster to walls and ceiling, 11. Install ceramic tile to Shower floor ,walls and ceiling $4.00 sq ft allowance for tile ,tile to be supplied by owner 12.Remove all debris as necessary Labor& Materials 14,500.00 All materials guaranteed as specified. All work completed in a workmanlike manner according to standard practices. 512A MAIN STREET, BOXFORD,MASSACHUSETTS 01921 VOICE: 978.352.7604 FAX: 978.352.7604 Start Nov. 16,2010. Completion of Nov.24,2010 Payment Of 5,000.00 at start,Payment of 5,000.00 after rough inspections, Balance upon completion. You the buyer,may cancel this transdaction at any time prior to midnight of the third business day after the date of this transaction. Accceptance of Contract:The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified.Payment will be made as outlined above. Signed G. a:J Date /a16 Signed GG�� Date e Fed#27-0640325 Cell# 978-265-2308 Builders Supervisor#42443 Exp 09/03/2012 Home Improvement# 167191 Exp 08/19/2012 512A MAIN STREET, BoxFORD,MASSACHUSETTS 01921 VOICE: 978.352.7604 FAx: 978.352.7604 BEN CURRAN Ande�en ANDERSEN REPRESENTATIVE Wind_ Pe6o�� Andeirssen 76 HUNTERS VILLAGE WAY MANCHESTER, NH 03103 DATE: JOB: c 4 m • Q S �,•�ov Office o onsumer A airs fB sinesseg+., on HOME IMPROVEMENT CONTRACTOR Registration:., 167191 Type: VExpiration 8/19!2012 LLC FK OWARD C*NStFVCTION LLC FRANK HOWAR6 572 A MAIN ST. BOXFORD,MA 01921., Undersecretary Massachusetts - Department of Public Safety Board of Building Regulations anis Standards Construction Supervisor License License: CS 42443 FRANK L HOWARD 512A MAIN ST BOXFORD MA 01921 �-G- --y Expiration: 9/3!2012 (bmmis%ioner Tr#: 1979 10-12-2110 1"3:49 GUARINO INSURANCE 978777'9443 --AGE1 r OP 10:AG CERTIFICATE OF LIABILITY INSURANCE ®AT 10/11011CftN/YYY) 7110 PHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THItl ;ERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIYFLY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES 3ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDEPL _ MPOWTSNT- If the cortlficateholder I s an ADin ADOITIONAL INSURED,the pollryflesl must tr0*ndorsvd. it SUDRCOATION I WANED,subject to :he forme and condition*of the policy,coram Po`Ieio*may m1♦uilm an and+m9raont A statement on this cartificate does not confer rights to the 'Afrcate holder in lieu of such endorstMetYt(b). 00UMN 978.777.5520 xtT4T" NAMEr niel J.t3uAlrin:y Ina_A enc — �J y 978.777.944,3 PN ! PAX I Rosewood Drive Lts: _—____________.�—._.__._. �rtooucr� .. .. ._.__... . ...... nver8,MA 019231 cV$T.Wrrelc rsHUMER-1 _, _ _.—_—_M __ _..-- _ _ _ iNIURIR E�Al•POROnd3 G4��AAGE — NAIC#I MILID Humerian AnthonyI11WRIM A;Norfolk&Dadhaln Mutual Fire 12706 S Prentia>:Road 1 fes/ ,r@�rHeRa, Danvers,MA 01923 INZ�iRFIL D INSURER X )VERAGES CmirICATE NUMBER: REVISION NUMBER; THIS lS TO CERTIFY THAT r4E POLICU OF INSURANCE LISTED BELO HAVE BEEN ISSUED TO THE INSURED MA1;*0 ABOVE FOR 7HE POLICY PERIOD NDICATED NOTW17MSTANDiNG ANY REJUIREMENT, 'TERM OR COKNTION OF ANY CONTRACT OR OTHER DOCUMENT WMH rtFSPeC:ITO WH104 THIS :ERTIFIGATE MAY BF SSUEU a'J.R MAY PERTAIN, Tme INSURANCE AFFORDED BY THE POLICIES DESCRIBED HERE 14 IS SUP-1ECiT TO ALL THE TERMS, :XCLUSIONS AND CONOITEONS OF SUCH POLICIES.LII-ATS.SHAWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. R7-•__-_._.. ____..._....... .... ikW6Tg1OR,--— — P91.1 y Fr �-- �. TYPE OF INSURA406 ,VM! POLICY NUMBERIM'Al/l! _ MIrYO WaT8 — (GENERAL LIA.eUrY r f EF..H CICGURREACE A$ 6tlfl,IDO CEKRAL LIADILIIv _ CLA M.S-WDE F-1 OCCUR t I MED EXP Itvv one Person! ausingurowners ; I �R80r1AL6kAEN INJURY GENERAL AGGREG,1-rt s 1,404,D CEN'L A 0IRF.QATE LiM4T APP?JES PER' y PRODUCTS.CONWOP AW- :6 —{ X PlSL{L'YL^�I pP O- —_ LOC — AUTONWINLE WAOILRY CC 181NED SINGLE LIMIT i t(f.N BGtidgm) ANY AUTO j , � �6Qr71LYlNJUR"(Petp©te+5ni S ALL OWNEUAU7Ga' ESWILY INJJRY Mm ncciden!) 3 SCHEDULED At1TOS � PFtO♦ TY DAMAQf _ HI W AUT08 i(Pet w6dent) 0 NDN-OWNEDAUTQS li1PBRiLLA,LIAR I OL'CUci ` i EACH O(:CURRENCE S .. - E1(CFA*LIAR AGGREGATE I I 8 r A RETENTION.b WORKERC CO MMMAnON _ WC STATU- i D?'t�•� �� AND OVLOYERS'UASILITrY!N ! i I ANYPROPAMTORIPARYNMrmXECUTfE ri E.L.EACFACCIVENT d .� or'F.FRrbirmeFR E.xaLbsui I— NIA; (Menxta4o°SrinON) I P.L.DISEASE,RAEMRI-OYES 3 8 s,3aecnbe under DF&CRionON OF OFtKATIQN&trefow a ssnsc.POLICY atr WIT x 8CRIFTION OF OPERATIONS I LOCAMNS IVENIGLEU lAtUti ACORFJ 101,AJdldonal Amsrpt'SaWlure.It Mow foilim 10 r%Wetd) RTIFICATE HOLQkA _+— _. CANCELLATIC3IN �_ _I_ "OULD ANY of TME ABOVE DESCROED FOLIG&B OF CANCELLED OF-FORE HE EXPIRATION DATE THEREOF, NOTICE YML.L. BE 9FlJVERE:1� N Frank Howardr CGtSRC°ANCF YYITH THE POLICY PROVISIONS A Main Strt�ot Boxford,MA 01821 01980-2000 ACORD CORPORATION. All rights reserved, -ORD 25(2008t45} The ACORD name and logo are registered marks of ACORD DATE(MM/ODIYYYY) ACORD. CERTIFICATE OF LIABILITY INSURANCE 07/15/2010 PRODUCER 603.772.6438 FAX 603.772.6547 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Costello New Hampshire Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 37 Portsmouth Ave ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO Box 1011 Exeter, NH 03833 INSURERS AFFORDING COVERAGE NAIC# INSURED George Degranpre _ INSURER A: Merchants Insurance Group Heating ��' 3�" INSURER B: P.O. Box 464 INSURER C: Epping, NH 03042 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRDDLTR NSR TYPE OF INSURANCE FuLTCYEXPIRATION POLICY NUMBER DATE MMIDDM YY DATE MMIDD/YYYY LIMITS GENERAL LIABILITY BOP9096508 06/29/2010 06/29/2011 EACH OCCURRENCE $ 300,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea oceurrence $ S00,000) CLAIMS MADE OCCUR MED EXP(Any one person) $ 1S,000 A PERSONAL&ADV INJURY $ Included GENERAL AGGREGATE $ 600,000 KEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 600,000 POLICY JECT LOC AUTOMOBILE LIABILITY CAP8622029 05/06/2010 05/06/2011 COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO 500,000 ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) A X HIRED AUTOS BODILY INJURY (Per accident) $ X NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR EICLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ luTH WORKERS COMPENSATION TORY LIMITwc SI ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE Y I � E.L.EACH ACCIDENT $ N OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ (Mandatory In NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Frank Howard REPRESENT ES. 512 A Main Street RUTH 2 REPRESENTATI `? Bo ford, MA 01921 ACORD 25(2009/01) ©1988-2009 ACORD CO PORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 09/29/2019 13::1 978-521-5127 COSTE:L.L.O INS. PAGE 01/02' DATE(0W?DDM"yY ACORD, CERTIFICATE OF LIABILITY INSURANCE 09/29/N10 PRODUCER 9i$.374.63SZ FAX 978.521.5127 THIS CERTI LATE 13 ISSUED 4 ATATTER OF INFORMATION CASTELLO INSURANCE:174.635 AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTENT?OR 2 South Kimball St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BEL.O'W. PO Box 5248 Bradford, MA 01835 INSURERS AFFORDING COVERAGE NA1IC 4 INSURED rr—a-W Howard 5 ructi6n LL _^ INSUP4RA! National Grain Mutual Ins. Co 14788 S1ZA Main St. INSURER a: Cranite State Ins. to- ARK 13102 Boxford, KA 01921 INSURER C: INSUREI!D. _ cO-VERAQEs — -- -- --- THE POLICIES OF INSURANCE LISTED EELOW HAVE BeRN ISSUED TO TH'i INSUR E?ABOV@ FOR THE POLICY PERIOD INDICATEL`.N'QTWITHSTANDING ANY RECA PAMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHM DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 6E�SSUEJD OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRi6M1 HEPIEIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POJCIES.AGGREGATE LIMIT$SHOWN MAY HAVE SEEN REDUCED BYPrJD CLAIMS. LWK I'D TR n1 r?P6 OF INSURANCE j - POUCY NUMBER Al 41P.1 TS G6AERALLIAB�LIT1' MPM0078I 09/22/201© 09/2Z 2011 EACMOCCURRENCE $ 1,00010 X COMAtERCIA 3SNGAt UAlUi ITY PREM u i cta.+rrar; S 500 10001 CLAWS MADE L�• 1 OCCUR MED EXP(Any CM 1WZO" S .�_ A FERSOP L 6 ADV IN URV $ 1,000,000 GENERAL AGORWATE $ 2,000,000 GZ,VL AGGRIGATG LIMIT APPLIES PER cmODUCT$•COA/PlOF AGG 4 210001000 POLICY iEC�T LOC AUTOM06ILG LIABILITY COMBINED£INSLE LIMIT S (f0 oaid6ft) ANY AVTO AL'_OWNED AUTOS SONLY INJURY (P9rptttcw) SCHEDUtEI,AUTOS r IRED AUTOS sQOILY INJURY (y (Per W-Cervi) NON•OWNED AU Qrb fPROPERTY DAMAGES S ( T (Per awldoaq GAR GE LIA@IUTY � � AUTO QNLY-CA NXIDENY ! ==ANYAUTO OEA ACC3YAG,GESS 1 UM$k1 Li A LIABILITYI --- EACH OCCU MNCE OCCUR CLAIMS MA E i ( AGtfiREGATE 6 �,,,� oEDUCTi5L6 f RETENTION S WOR ltF6Rs flBiiPENSAT -' N(C009941Ei D8 69/04 2010 09/04/2011 IM AND EMPLOY@RV LJARILITY YIN i Q.L.EACH ACCIDENT 13 100,00( P.NYrROFRjORPARTNERIEX CUTIUEr-*-7 OFFICORrMEMBER EXCLUDED? I J j E.L.:lIS6ASE-EA 6161PLdwe g 100,00( (mandatory in N)ij II yea d"011) Vndw e.L,b151"sASE-POu4Y uma S ---s00'00( $PENAL PROVISIC?1S SF�ow __ OTHER { t _ C)WcPjprION TF OPERATIONS!LOCAVONS+'VEHICLE$I EXCLUb10N$ADDED VY ZND�)RSEMSNT;SPECIAL PROVISION5 CERTIFICATE HOLDER CANCELLATION _ i ---r- I SHOULD ANY op THEABOW DE$CRISED pOLlsl)F3 Be 6AN0ELLED BEFORR THE EypIRATIC DATE THEREOF,THs ISSUING IN5UREIR MLL ENDEAdOR TO MAIL 30 DAYS VAUTTEN NOTICE To IME CERTIACATE HOLDS NAMED To THE LEFT,BUT FAILURE TOO*80 SHALL III. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPREWN`A E$. ^- AUTIIOR02E6 REFR ATVE ..�- -- �19S&2009 AC RD CORPOM All rights reserve The ACORD name and loqu are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02-11.1 www.rnass:govfciia Workers' Compensation Insurance Affidavit: Builders/Contractors[Elect ricians/Plumbers Applicant Information /� `` Please Print Legibly Name(B.usiness/Organization/1'ndividual): ►e Pei �j�t� r�"�J Cf �'d`L�LGCCYL u G Address: 6'7 2 U S�� City/State/Zip: RG r �V tIA,* Phone#: ? 9 3 7600` Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. Rr I am a general contractor and I 6. ❑New construction employees(full and/or part-time).x have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.? 7. [Remodeling . ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers'comp.insurance. Y p tY 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.E]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' comp.insurance required.] 13.❑Other *Any applicant that checks box 41 must also fll out the section below showing their workers'compensation policy information. 7 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. I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenaldes of perjury that the information provided above is true and correct. Sig—nature: C Date: /I/�b Phone#: 7 3 S-7-- 76 qe 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.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: