HomeMy WebLinkAboutBuilding Permit #594 - 55 PRESCOTT STREET 3/12/2007 %►ORTF/
BUILDING PERMIT °�t'``° '°A�°
TOWN OF NORTH ANDOVER 0 _
APPLICATION FOR PLAN EXAMINATION
Date Received Z`Q 'Is9'�Rwrso�P `49
— 9 <
Permit NO: ' SSACHUSE
Date Issued:
IMPORTANT• Applicant must complete all items on this page
Al
Awri
Wl
'k ov
.,�
PROPER7YC}WIE5 �
p
_ NIN .L ISTRICT r. ,
�}-IDSTRI`FCT Xie
�A? � _ . . �;FCE�
�� � .. _ ._ ,�, . � .IPIMPF
TYPE OF IMPROVEMENT PROPOSED USE
j Residential Non- Residential
❑ New Building :One family
❑ Addition ❑ Two or more family [I Industrial
El Alteration No. of units: El Commercial
epair, replacement ❑ Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
iters eCIC�
tkds A
&
�
.:
a
DESCRIPTION OF WORK TO BE PREFORMED:
i
i
n Identification Please Type or Print Clearly)
t� � t 250 5-"- Phone:
OWNER: Name:
Address: 15 r
a
VONTAA � Nar k L
ru,
i • �
� ate `�' �•,
1pe is � on�r�acto tee: pq
xW
3 F �
M
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$100Q00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $I
. FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access t t e guara fund
Signature og
f A ent/Owner Signature of contractor �
i
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be
obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
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
i
And Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
a ❑ 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
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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2007
i
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF- U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
I
DATE REJECTED DATE APPROVED
CONSERVATION
Fl-
COMMENTS COMMENTS
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑
COMMENTS
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 ❑
Q
I Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Si nature& Date Drivewa Permit
Located at 384 Osgood Street
{
F
7 77
S'DEPAR'TME "` = m Dur �s�tel�,ot ated at 12M in t e# ` �� a � Ulu 'areDepartmensignatureldat� � ��
� �
. 1_
41
��
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
................................................................................. .................... .................................................................................... .............. ............................................................................................................................................
+ ...................................
Doe.Building Permit Revised 2007
1
Locaiion
No. Date
NORTH TOWN OF NORTH ANDOVER
` Certificate of Occupancy $
a ,n°•t Buildin
swcNus glFrame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ ��
Check #
�f
200 � -
�f�' Building Inspec or
NORTH
Ove Of �' : � 4 L Andover
No.
dover, Mass., & -40'7A4
T 0 - LAKE �• i
COC MICHE WICK V
�d A0RATED P`Pa` �C ,
7`T BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT..........C z Irl........ ... 2..�............................. ...........
.... ...................................:: Foundation
has permission to erect........................................ buildings on......Gr........PA ...5......f.................. Rough
to be occupied as S�. d 3 Chimney
�...' ..... .......... ........................ ................................................................. y
provided that the person accepting this permit shall in eve respect conform o 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
PERMIT EXPIRES IN 6 MONTHS Final
ELECTRICAL INSPECTOR
UNLESS CONSTRU . ... .:7A%s
Rough
...... ............................................... Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Ocmpy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal
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.
J -\
The commonwealth of Massachusetts
Department of Fire Services
Office of the State Fire Marshal
P.0.Box 1025 State Road,
S
7t
-ow,NLA,01775
PERMIT Date: 3—/.t
North Andover Permit No Dig Safe Num er
(Cityof Town) (if Applicable)
Ea accordance with the provisions of MG.L 14 8 Cbapter 1 0 as provided in section S 2 7 (MR 34
F
Date
This Permit is granted to:
Full name of person,Firm or Corporation
Permissionto locate dumpster for' ..construction/renovation/demolition of building.
Comments: dumpster must be . 25 ` from structure if unable to place with required
Restrictions:clearance dumpster must be covered with plywood or tarp end of work -day
at
(Give location by street and no.,or describe is such manner as/to 'v ed adequate identification of location)
Fee Paid$ 50.00 � h ham' Fire Chief
This Permit will expire Signature of offical granting permit) Offical granting permit (Title)
`nMs�e, done today w/tti
>
rw ^ www.ctbasldin androofln .cote
•li • •Rclocofigg
J�
,!1 II1 t!R
269 Main StreetI!
Office(508)473-2774
Milford,MA 01757
Toll Free(877)266-2074
Fax(508)473-2883
ROOFING AGREEMENT 11/10/06
Z
Mr. & Mrs. Tokars 55 Prescott Street N. Andover, Ma (978) 682-6661
• THE ENTIRE ROOF OF YOUR HOME TO BE STRIPPED OF EXISTING SHINGLES
• CTBA WILL ADD 3' OF ICE AND WATER BARRIER ON THE EVES AND VALLIES THE REST
OF THE ROOF DECKING WILL BE COVERED WITH A #15 FELT.
• CTBA WILL PLACE A TIMBERLINE 30 YAR ARCHITE URAL S INGLE ON YOUR HOME
(COLOR TO BE DETERMINED)*CTBD* _:Ll 91VLIZ t Zc-
• A *CTBD* 8" DRIP EDGE WILL BE INS r . LLED ON THE EN� PERIMETER OF YOUR
ROOF.
• CTBA WILL INSTALL A COBRA RIDGE VENT AND COLOR MATCHING CAPS ON THE
PEAKS OF YOUR HOME
0 ALL VENT BOOTS WILL BE REPLACED AND STATIC VENTS WILL BE REPLACED.
• YOUR UTMOST SATISFACTION, BY WORKING DAILY UNTIL COMPLETION; TAKING INTO
ACCOUNT WEATHER OR UNFORSEEN PROBLEMS.
• DUMPSTER AND MATERIALSWILL BE SUPPLIED BY CTBA SIDING AND ROOFING AND
REMOVED WITHIN 24 HOURS OF ]OB COMPLETION
• CTBA WILL CLEAN ALL WORK AREAS, MAGNETICALLY SWEEP YOUR DRIVWAYS,
WALKWAYS AND LAWN FOR NAILS
• All CTBA EMPLOYEES WILL CONDUCT THEMSELVES IN A PROFESSIONAL MANNER AND
RESPECT THE HOME OWNERS PROPERTY.
EXTRAS
a IF THERE IS ANY UNSEEN DAMAGE TO THE ROOF DECKING OR FASCIA THERE WILL BE
AN ADDITIONAL CHARGE OF $60.00 PER SHEET FOR 1/2 CDX PLYWOOD, AND $4.75 PER
LINEAR FOOT FOR REPLACEMENT PRE-PRIMED PINE FASCIA OR LEDGE BOARD
• AFTER INSPECTION, IF CHIMNEY FLASHING NEEDS TO BE REPLACED, THERE WILL BE A
$350.00 CHARGE PER CHIMNEY TO HAVE A 12" LEAD INSTALLED ON YOUR CHIMNEY.
• CTBA WILL COMMENCE WORK ON OR BEFORE *** AND WILL COMPLETE THIS ]OB TO
• 10- YEAR WARRANTY ON WORKMANSHIP
TOTAL ROOFING COST $13,860.00 OR $277.20 PER MONTH*
*After the 12-month No Interest No Payment Program
Signature below constitutes acceptance of this proposal as written above and authorizes CTBA to perform the work as specified.
(Home Owner)
(CTBA Representative) -
Spe
a Re onsi 'ity
VISA integrity -
Terms of Agreement:
Payment:
CTBA accepts Visa and MasterCard, Cash, Bank check or Financing through a third party.
Credit cards, cash and Bank checks require a deposit of 1/3 of the contract price. 1/3 of the contract price is due
halfway through completion of the project with the final balance (including extras) due at the completion of the
project.
CTBA will be responsible for pulling all permits.
Homeowner is responsible for payment of all permits and fees applicable to this project.
Proiect Schedule:
The Scheduled start of the project is an approximation. Ctba will show good faith to meet all agreed deadlines but
can not be held responsible for delays caused by Weather, material shortages, asbestos abatement, hidden
damages, building inspections or officials, accidents or Acts of God.
Chance Orders:
During an improvement project, damages, defects or prior substandard construction practices can be discovered.
CTBA wilt make every effort to contact the homeowner to notify them of the issues if the homeowner cannot be
contacted, CTBA wilt use its discretion to protect the homeowner's property and residence from the elements.
CTBA will photograph the damage, and the repair. The homeowner agrees to pay for the materials and labor
necessary for such repairs as listed on the contract.
General Terms:
CTBA will leave the outside work areas rake clean and magnetically swept. Walkways, patios and decks will be left
broom clean. CTBA will not be responsible for debris and dust falling into the attic nor the cleaning of attics or
storage spaces. We suggest you cover all contents of your attic prior to the commencement of work. This contract
does not include the moving of the homeowners property around the site, painting, any hazardous material
removal, lawn, landscaping or asphalt repair due to site equipment. CTBA will not be responsible for the
repositioning of any satellite dishes should it be necessary. CTBA is not responsible for existing skylights or solar
panels due to age and or seal failures. CTBA will not be responsible for automobile tires damager by errant nails
either BEFORE or AFTER a magnetic sweep has been performed.
Contract Acceptance:
Upon the acceptance of this agreement by CTBA this contact and all work described herein will constitute the
entire agreement between CTBA Siding B Roofing and the homeowner.
In the event of a breach of this contract, the buyer, by signing where indicated agrees to pay all applicable
attorney fees in connection to litigation or collection activities necessary to recover the written amount for the
work described and preformed by CTBA. Upon Signing the Customer agrees to uphold the findings of an impartial
arbitrator for resolution of any dispute.
Warranty:
CTBA agrees to correct any work that fails to conform with the contract or workmanship at NO CHARGE to the
homeowner. The Homeowner agrees to notify CTBA specifying the nature of any workmanship defect,
immediately. No warranty is provided for ordinary wear and tear, fading, abuse, neglect or minor
cracking/shrinking of concrete, plaster, grout or caulking. No warranty is provided due to ice dams or freeze backs
caused by extreme winter weather, materials NOT supplied by CTBA, re-work or work done by others.
This agreement may be voided without penalty within 72 hours of signing by either party
for any reason.
spe
t'%` Re nsi 'ity
VISAintegrity
btMfWM�bn our 6idnws 0
✓lae �'ammauoealt/z o�,�/laoaac�u�aed` `Y
Board of Building Regulations and Standards
License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR
before the expiration date. If found return to:
Registration: 151030 Board of Building Regulations and Standards
Expiration: 5/12/2008 One Ashburton Place Rm 1301
Type: DBA Boston,Ma.02108
CTBA SIDING&ROOFING
ANDERSON CASTRO`
KELLEY RD.
NO
_NORTHBRIDGE,MA 01534 Deputy Administrator No alid without signature
7
�C-0-AD. CERTIFICATE OF LIABILITY :INSURANCE0DATE(mmmal'
CT87P1S-1 Y"Y)06 20 06
I;r=-CER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO R10IITS UPON THE CERTIFICATE
Tttcmuta 3 Woods Insurance Agcy HOLDER.THIS CERTIFICATE DOES NOT AMEND.EXTEND OR
P.O. Sox 2940 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Worcester KIL 01613
Phcme:508-788-5944 Pax:608-791-9841 INSURERSAFFORDING COVERAGE NAIC0
INSURED INsuRERA Connecticut Underwriter-s
CTHA Siding & Rooting INSURER e:
erSOII KASURERC:
Z90 KCi�atr0 AHA
elly Road
RortAbr a MA 01534-1137 WSUIRERO:
INSURER E.
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEO 70 THE INSURED NAMEO A8DVE.FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REOIIIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOMMENT WITH RESPECT TO W HICUM THIS CERTIFICATE MAY ISSUED OR
MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TD ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED By PAID CLAIMS.
LTR WRCTYPE OF INSURANICE POLNCY NMIIBEJI OATIVE TE' LWTS,
GEMEROA.LMaRLITY - - - - EACH OCCURRENCE ' *2000000
A X cOMIWRCIM_GENERAL LIABILITY MPPI036764 06/07/06 06/07/07 vREnas s E° ce $50000
I I CtAtMSMAOE OCCUR MED EXP(Any OnepdrNtfe) $5000
'
PERSONAL BADV INJURY $1000000
GENERAL AGGREGATE $2000000
GWLAGGREGATE LIMIT APPLIES PEP PRODUCTS-CDMPJOpAGG $1000000�~
POLICY �T LOC,
Atrrow StLE LIABFLfiY
I ANY AUTO (.t O SINGLE LIMIT $ -
I HL e acftwt)
ALL OWNED AUTOS
� fTODILYINJtIftY
} SGHEDUIEDAUTOS 1 (Aerpemm)
I HIRED AUTOS I
( BODILY INJURY
E NON•OWNEO AUTOS S (Per OCCA 0 $
!Ii f
PROPERTY DAMAGE. S
GARAGE LIABILITY _ ONLY-EA ACCIDENT S
I ANYAUTO II AUTOy
OEA ACC S
1 ASONLY!
Y• AGG s —
jFEXCE8t3NtJ A LJABILTiY ccH occuRRaNc£ $
j f OCCUR CLAIMS MADE j AGGREGATE ••��- '3
lfir—t i 1 '$
1 t DEDUCTIBLE t- -
s
RETENTION -
WORKE•RS COMPENSATION AND I � .. TORY LIMITS ER
EMPLOYERS'LIABILITY f
ANY PROPRBETORIPARTNEWEXECUTNE i SEE NOTE BELOW ! I E.L.EACH ACCtMNT S __
OFFFyFICERVEMBER EXCLUDED?
E. DISEASE-EA EMPL-OY� s
SPECIAL PROVISIONS Oetaw _
£J..DISEASE•POLICY LIMIT S
?OTHER
VaSCRIOTIOMOF OPERATIONS/LOCATIONS I VEHICLES I E r r"j iIQNS ADDED SY E:iMRSEMEIR t SPECIAC<PROV1S1pNg
WORKERS COMPENSATION COVERAGE INFORMATION WILL BE PROVIDED UNDER SEPARATE
COVER BY THE ASSIGRED RISK CARRIER.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
CTBA OFFICE USE DATE THEREOF,THE ISSUING NASLOER WILL ENDEAVOR TO MNL 1.0 DAYSVRRTEN
FOR PRESENTATION USE ONLY NOTICE TO THE CERWICAT9,HOLDER KMAEDTO THE LEFT.BUT FAiLURETODOSOSMALL
WPOSE NO OBLIGATION OR LIAWLI TY OF ANY OUND UPON THE INSURER.ITS AGENTS OR
REPRESENTATIVES:
ASJTHOROED REPRESENTATIVE
Walter M. Conlin, Jr. CPCIT
ACORD 25(2004108) 0 ACORO CORPORATION 1888
RightFax Hartford 6/21/2006 1: 16 PAGE 006/006 rax berver'
. ��• DAiE(MHnomrr,
mmitb. ,CERTI.FICATE OF- tN.SURAN.CE , .
MATTER Of IMF
PRODUCER ONLY fift
THIS AND CONFE�RqS NO RIGHTffnFICATE 0 ISSUED AS S UPON THE CERTIFICATE
THtOMAs WOODS las Ac HOLDER. THIS c WnFICATE DOES NOT AMEND �D OR
ALTER TH£COVERAGE AFFORDED BY THE POLICIES BELOW.
20 PARK AVE
PO BOX 2940 COMPANIES AFFORDING COVERAGE
WORCESTER MA 0161.3 COMPANY
A
INSURED
COMPANY
CASTRO, ANDERSON B
DBA C T B A SIDING 6 GUTTERS COMPANY
290 KELLY ROAD C
NORTHBRIDGE VIA 01534-1137 COMPANY
D
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW NAVE 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 CONDIT)ONS OF SUCH POLICIES,LIMITS SMOMMAY HAYS BEEN REDUCED BY PAID CLAIMS.
CO TYPE Of INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EYPtRATI LIMNS
LIA DATE(A MGOMYY) DATE(MWM%YY)
GENERA.UANUTY CENERAL AOCREGATE f
COMMERCIAL GENERAL LOIKOY PRODUCTS•IOMPIOP AGG :
CLAWS MADE QOCCUR PERS(INALAArNftrjRr f
OWNERS a CONTRACTORS FROT EACK OCCURRENCE f
FIRE DAMAGE("one nreN $
MED EA'PENSE(Any ons person)i
AUTOMOBILEUABIUTY CQYBINEDSINGLE t.
ANY AUTO Lglfr
ALLOWNEDAtlTOS BODILY twjRY a
(Pa POISON
SCHEDULED AUTOS
HIED AUTOS BODILY JKWRY :
NON-OWNED AUTOS (Per AceA M)
PROPERTY DAMAGE f
"PAGE LIABILITY AUTO ONLY EA ACCIDENT t
OTHER TkM AUTO ONLY '.. .. .
ANY AUTO
EACH ACCIDENT 5
AGGREGATE i
EXCESSUAtUTI EACHOCCURRENCE f
UM8nLAFORM AGWGA'E f
OTHER THAN UMSRCI:A FORM
WORKEWSCOMPENSATION AND (IIIc•648X701 !-w 03-02-06 0:3-02-07 STa;uT01?!Lwgs N/A'
A EMPLOYERS UAWLITV EACtr AG=CNT t ^—I
70E PROPRIETOR/ ,, DISEASE-FOLIC'OMIT I
FARTNEHSIE%ECU?IVE
OFFICERS ARE
EXCL DIS"SASE^FACT)EAU'LOYEE f
3INSILOCATIVIIINVUMLEVReSTRICTIONOMPNMAL ITEMS
IIS Y K Ok :'RTtFiC ll ':O THE CLRItt iCA'E tiU UE' AFF "T NG WORKES ' CMP C ERAGF
" .
CEIT
TCA "E CANLkA
SHOULD ANY OF THE ASOVE DESCRIBED POLICIES Be CANCELLED BEFORE THE
EXplRATlON DAZE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
CTBA OFFICE USE 10GAYS WIMEN NOTICE TO THE CEIMI'MATEHOLDER NAMEDTOTHE
FOR PRESENTATION ONLY LEFT'BST FAILURE TO IAWALL SUCH NOTICE ALL IMPOSE NO OBLIGATION OR
LimuT1 OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES,
AUTHORIZED REPAESENTAT(VE
ACORD 23.8 JM \ 893
wl CERTIFICATE OF INSURANCE DATE(AgIWOtYY,
n
I CERTIFICATE ISSUED AS A IN .- N
PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Tt30MAS : WOODS INS AG ALTER
THIS CERTIFICATE DOES NOT AMEND EXTENT? OR
ALTER THE COVERAGE AFFORDED BY THE POLL-ITEds BELOW.
20 PARK AVE
P0 BOX 2940 COMPANIES AFFORDING COVERAGE
WORCESTER MA. 316:3 «.t?AW
A v
INSURED COMPANY
C ASTR.O, ANDERSON B
DBA C T B A SIDING S CUTTL"aS COMF'AAIY
290 KELLY ROAD C
NORTHBRIDGE. !4vl 01534_11'13'' COMPANY - r
D
COVERAGES
T141S IS TQ CERTIFY THAT THE POLICtES OF WSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY.PERtOD
INDICATED, NOTWITHSTANDING ANY REOWREMEW. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE MSUED OR MAY PERTAIN, THE INSURANCE: AFFORDED BY THE POLICIES DESCRI13ED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY.HAVE SEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXF RATION LIM(T5
LIA DATE(MWOMYY) OATF JMW O%YY)
GENERAL UMALITY GENERAL A0GRECATE $
COMME'RCM,GENERAL LtA&"-ITY PRODUCTS•COMPrOP AGG
C,NMS MEADS ?CC'a:; ilf RSONAL 8 A17V MIURY
OWNER'S A MNTRACTC+R'S PROT EACH OCCURRENCE y
Rt,DAMAGE(Any one tre{ $
MED EXPENSE Any ane person) $
AUTOMOBILE LIABILITY CONIMNED SINGLE
y
AN'AUTO EMIT
ALL OWNEDALTvS BODILY INJ!iRY
SCxECULEO AUTOS (r'b Persant $
HIRED AUTOS goolLY a'aiRY $
NON-CAN YEII AJ US
i
Per AcCaderi)
PROPERTYDAMAGE $
GARAGE UAWLITY AV70 ONLY"EA ACCIDENT $
ANY AJ'O DITHER THAN AUTO ONLY
EACH ACCIDENT y
AGGREGATE $
EXCESS UAOtUTY EACH OCCURRENCE $
UMBREiLAFORM AGOnFGA:E _ $
OTHER THAN VML MEI.LA H RM
WORKE,R'SCOMPENSATIONAND S-A:U70PYtrWRB _ NIA
A EMPLOYERS LIABILITY '(UB 848X701-1-061) 03-02-07 03-02-08 � A u ACCO,-:N, $ luunw
TIl.EPROPR*TtYI D!BFASE-.?G±.C� LVIT $ - -.1
PARTNEH`"+IEXECu'tYEFA -- ----
0FFICE9SARE ext 015'r'ASF—EA:I,EMPLOYE:
OTHER
7DESC1THIS
RI ONOFOPF.RA IO LOCATI N"s t 7tCLEI. O 5S.E At..tTEM55 REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE
1
CERTIFICA E WDER CANCELLATMN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
CTBA OFFICE USE WRITTEN NOTICE TOTHECERTIFICATEHOLDERNAMED TOTME
FOR PRESENTATION ONLY LEFT,.BUT FAILURE TO MNL .SUCH NOTICE $HALL IMFOSE NO OSUGATION OR
LIAWLITY'OF ANY KIND UPON THE COMPANY,ITS AGfNTSOR REPRESENTATIVES,
AUTHORIZED REPRESENTATIVE
ACORD 2$•8(3193), � � 893
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
UT
600 Washington Street
Boston,MA 02111
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name(Business/Organization/Individual):
Address: .
City/State/Zip: (\b�-��Z tom:(��) C ; AA-4 Phone#: �iOg ��6
Are yo"u employer?Check the appropriate box: Type of project(required):,
I. I am a employer with—_ 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6 ❑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'
insurance,# 9• ❑Building addition
co
[No workers'comp.insurance mP•
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doingall work officers have exercised their
11.❑ ing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12. oof repairs
insurance required.]t c. 152,§1(4),and we have no
employees.[No workers' 13.❑Other
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 nam of the sub-contractors and state whether or not those entities have
employees. If the sub-contractor:have employees,they must provide their worker;'comp.policy number.
I am an employer that isproviding workers'compensation insurance for my employees Below is thepolicy and job site
information.
Insurance Company Name ! rc•c�n�C �l�l. ray,1.-3r, ,
Policy#or Self-ins.Lic.M 12t3 - <64i 4 )0(—(` 0 6 1 Expiration Date: (7 3-02-O c -
Job Site Address: h5 PCPSCO Tr Z�)_t City/State/Zip:�. Aa�n�2,2��
Attach a copy of the workers'compensation policy declaration page(showing the policy number and .expiration date).
)
Failure to secure cove quired under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500. and/or on -year imprisonment,as well as civil penalties m the form of a STOP WORK ORDER and a fine
of up to$250.00 day aga' the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of a DIA r insurana coverage 4rification.
I do hereby cerci un theins and pen s ofperjury that the information provided above is true and correct
Si lure: ��
Phone#: - p
Offlcia 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 employdrs 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'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-conttactor(s)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 carry 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 permit 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 can the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on thea ro nate 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 permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permittlicense 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:.727-4900 ext.406 or 1-877-MASSAFE
Fax#617427-7749-- - _
Revised 11-22-06 www.mass.gov/dia