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HomeMy WebLinkAboutBuilding Permit #301-15 - 57 MAPLE AVENUE 9/24/2014 NORTH BUILDING PERMIT o�ct`eD ,b TOWN OF NORTH ANDOVER �2 h '''`- '° ° APPLICATION FOR PLAN EXAMINATION Permit No#. Date Received 7,9 °NAre Date Issued: 1 SSACHUSE IMPORTANT: Applicant must complete all items on this page LOCATION 5 j� __ m Ople. �- NQA-41% - M d Ins ��1'`s�►�i � 1�Print PROPERTY OWNER_._ c� Print 100 Year structure es MAP lJ PARCEL Z(7NING DISTRICT: _ Historic Distract yes no ` Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition Cil Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septic ❑Well E"Floodplain ❑Wetlands q Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Viky� ��*d wok i 1 WV" � ,�� ('T A _. Identification- Please Type or Print Clearly OWNER: Name: i � \ulna h Phone: Address: �� 5^°) bo2 unnA ,. vj,.) M\AV b r Contractor Name Phone: --. _ D � _ Address: /�'') G� `,I /.C � C�'/Z/� Supervisor's Construction License: _ CS Exp. Date: Home Improvement License:- . T 354 Exp. Date:_____a�.-_/� �- X 1-6 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: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unre tered contractors do not have access to th g aranty fund Signature of Agent/Owner - Signature of contractor i i Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Sidinn , Interior Rehabilitation Permits Building Permit Application o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o 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 Li 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:Building Permit Revised 2014 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 I DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use) { ❑ Notified for pickup Call Email Date Time Contact Name ------------- Doc.Building Permit Revised 2014 Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ TYPE"OF SEWERAGE DISPOSAL n ❑ Public Sewer. ❑ Tanning/MassageBody Art E] Swimm�ig Pools Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ I Private(septic tank, etc. ❑ Permanent Dumpster on Site ❑ I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS i CONSERVATION Reviewed on Signature I COMMENTS HEALTH Reviewed on Siqnature COMMENTS i 'h Zoning Board of Appeals: Variance, Petition No: Zoning Y Decision/receipt submitted es i Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Os ood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Location No. U Date 112 44 • - TOWN OF NORTH ANDOVER • ��,'fbT QED t;�y6` . • Y �,, a� Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ w Other Permit Fee $ a TOTAL $ Check# 28054 Building Inspector e (par���wrau�eal oaduaeC7 'WOffice of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR e! istration: 67346Type?iration: 9/10/20=96 Individual . ++� SANTIAGO PEREZ SANTIAGO PEREZ 4 PRESCOTT ST FITCH, MA 01420 Undersecretary 4_ Massachusetts -Department of Public Safety Board of Building Regulations 9 ions and Standards Construction Supen•isor License: CS-036735 SANTIAGOJPERZ r,---i 4 PRESCOTT STS Fitchburg MA 01420 L� f .Expiration Commissioner 03/13/2016 - Required Contract Terms Page 1 of 2 The Official Website of the Office of ConsumerAffairs&Business Regulation(OCABR) Mass.Gov Consumer Affairs and Business Regulation Home>Consumer?Home Improvement Contracting> _.._ _..._......__ _.._............... ........ Required Contract Terms �•; _,L, 4-- bContracts-all contracts over$1,000(OneThousand Dollars)must be in writing. NEWS&UPDATES M The law requires the following FOURTEEN items to be included in any contract between a homeowner and a registered OCA Survey Finds One in Five g home improvement eme t c p v n contractor for home improvement work subject to MGL 0.142A: Home Improvement Contractor � 1. The complete agreement between the contractor and the owner and a clear description of any other documents Advertisements Placed by which are part of the agreement. Unregistered Entity 2. The full names,federal T.D.number(if applicable),addresses(NOT P.O.Box numbers),of the parties,the More... contractors registration number,the name(s)of the salesperson(s)involved,if any and the date the contract was executed by the parties. Subscribe Learn more 3. The date on which the work is scheduled to begin and the date the work is scheduled to be substantially completed. RELATED LINKS^ 4. A detailed description of the work to be done and the materials to be used. Yon Gid Konsomati; 5. The total amount agreed to be paid for the work to be performed under the contract. Massachusetts you Reparasyon 6. A time schedule of payments to be made tinder the contract and the amount of each payment stated in dollars, nan Kay including any finance charges.Any deposit required to be paid in advance ofthestart ofthe work SHALLNOT 0000000000000 exceed one-third of the total contract price or the actual cost of any material or equipment of a special order or customGmiia para e1 Consamidor de made nature,which must be ordered in advance of the start of the work to assure that the project will proceed on Massachusetts para Mejoras en schedule. No final payment shall be demanded until the contract is completed to the satisfaction of all parties. el ssach ogar 7. All parties must sign the contract. Gula para el Constimidor de 8. A clear and conspicuous notice stating. Massachusetts para Mejoras en I el Hogar a.That all home improvement contractors and subcontractors shall be registered and that an inquiries about. y to contractor or subcontractor a t' 9 r 1a in to aregistration should be directed Office of Consumer Affairs and Business Regulation Ten ParkPlaza,Suite 5170 Boston,MA.02116. Phone:(617)973-8700 b.The c _ ontractor's registration number must be on the first page of the contract. c.The homeowner's three da cancellation rights under MG c • Y g L 93 s 48• MGL c 140D s 10 or MGL c 255D s 14 as maybe applicable. d.All warranties on the owner's rights under theprovisions of and MGL c.142A. e.In ten point bold type or larger,directly above the space provided for the signature,the following statement: il. D 0 NOT SIGN THIS CONTRACT 1F THERE ARE ANY BLANK SPACES. f Whether any lien or security interest is on the residence as a consequence of the contract. 9. An enumeration ofsuch other matters upon which the owner and contractor may lawfidly agree. 10. Any other provisions otherwise required by the applicable laws ofthe Commonwealth. 11. Permit Notice:Every contract shall contain a clause informing the owner of the following: a.any and all necessary construction-related permits; b.that it shall be the obligation of the contractor to obtain such permits. c,that owners who secure their own construction-related permits or deal with unregistered contractors shall be excluded from access to the Guarantee Fund. Required Contract Terms Page 2 of 2 12. Acceleration ofpayment.No contract shall contain an acceleration clause under which any part or all of the balance not yet due maybe declared due and payable because the holder deems himselfto be insecure. However, where the contractor deems himself to be insecure he may require as a prerequisite to continuing said work that the balance of funds due under the contract,which are in possession of the owner,shall be placed in a joint escrow account requiring the signatures ofthe home improvement contractor and the owner for withdrawal. 13. No work shall begin prior to the signing of the contraot and transmittal to the owner of a copy of such contract. 14. Arbitration: If the contractor determines that in the event of a dispute,the contractor wishes the dispute to be settled by arbitration,this fact must be signified on the contract and both the contractor and owner shall sign this clause separately. The following format isacceptable(in 10point type orlarger); 'The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this contract,the contractor may submit such distpute to aprivate arbitration service which has been approved by the Ofye of ConsumerAffairs andBusiness.8egulation andthe consumer shall he required to submit to such itr 1 asprDvided in MGL c I42A. Owner: Contractor: NOTICE. The signatures of th parties above apply only to the agreement of the parties to alternate dispute resolution initiated by the contractor. The owner may initiate alternative dispute resolution even where this section is notsi edseparatedvtheparties." ©2011 Commonwealth of Massachusetts t%ORTH Town Of .. I _E : ,,, ndover O No. � , � Z00h - n o;;N ver, Mass, COCHICHRW.[M 1• apo� ATE pt TE O p.P S U BOARD OF HEALTH Food/Kitchen PERMIT D Septic System THIS CERTIFIES THAT ... .................. BUILDING INSPECTOR . Foundation has permission to erect .......................... buildings on .... .. ... ... ......(01O.V4. .�/`..... p Rough to be occupied as �,.VV �...........C.d. ....... ............. ..... .. ........................................................ Chimney provided that the person accepting t4) permit shall in every respect nform 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 MO THS ELECTRICAL INSPECTOR UNLESS CONSTR IO ARTS Rough Service .... ... ....... ..... ................................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Name Company NameOF Street Address(do not use a Post Office Box address) Contractor/Salesperson/ er Name City/Town State Zip Code Business Addre mdP/` ust inc treet regs) - � Daytime Phone Evening Phone City/T �il�l'�` StatZip Code (,jj-663-jiay e 6 I 1,� Mailing Address(It different from above) Business Phone Federal Employer M or S.S.Number Home Improvement CanhactorRea. mGon Number Eapidate Ian requires that most home improvement contractors have arolid—&tradon number / 9,-10 2,6/4 The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to runless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of ate when contractor will begin contracted work. MGL chapter 142A.) 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. M Payments will be made according to the following schedule: upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ by / / or upon completion of $ by / / or upon completion of $ upon completion ofthe contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be paid for NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(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 ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty being provided by the contractor? ❑No VYes fall terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor fuuther agrees to be solely responsible for all payments to all subcontractors for materials and labor tinder 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 Contractor Registration. 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 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not I ater than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two Iden' 1 copies ntract must be completed and signed.One copy should go to the haigq should be kept by the contractor. Homeowner's Sig a on �(a3Ir�H g_z> - �Y Date Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractoi has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws,chapter 142A. Homeowner's Signature Contractor's Signature NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at llttp://www.mass.gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at http://wvvw.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeimprovement/Iicenseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 Version 2.1-11/22/2010 -- • , aflee offmayfigafeons �'Q'0�as�ir��ox�aS'ixee;~• Hoston,HA 02111 VPPIrrnassgo-p1d a arc exp ' om�exwafionYusuranceMUM: 72!o�na�on 'Name(Busitess(Orgau%zation&dvzdurA): Cit fSta efZi Phow#:^ 7 &B YOU M era)Ploper?CheAtbo app ropriatehox,. Type ofPx0ject(regYdre�}' 1,a I ave.a employer with 4• []jam a general.contractor andl S 6. New 06118txuctiov. employees( land(orpart✓time�T have li odthegab-contractors 2.[l I am a sale proTrietor or parblex~ listed on the attached sheet° `�. E.emodelv�.g ship and`haveno.employees 'these sut7 coatxactoxshave S. �{Demolition woffing forme fm any capacity. woxkors'comp.insurance. 9. Building addition PTO wukoxs'comp.jsuraumce 5. Q We axe a corporation and N' j0.r]Electricalxepaixs a additions xec zixecl.] officers have exercisedtbeir 3.E] Z ave,a homeowner doing all work right of.exemption per MGB It[]Plumbingxepairs or additions myseL. !o workeYs'comp. o.152,§1(4),andwehavano 12,p Roofxepais i�urancarecpzixed.1 employees.[No workers, 13,1 Other comp.insnxancexe�aired.� . Any applicanttfiaz ctieoksbo 11mtrsta�so llauitheseci�onheldwshov�ingtheirwozkers'eompensatiozlpolicyinfozmafiou. 4 omeowu.rswho submstti2isawdaVRkdicatingi(teybtedoing AworlVandtben.hireoutsidecontractorsmust.subm tanewafddayitindicatiizgsize&. xConiracfors;�atcbecktiusbo�mt�statfached�uadditiona�sheetshovringthenameofthesul�-coup'acforsandtheiFworkers'co�p.�olicyinfomiatzon, I ign an em��oy�N t�itat z���avic�ir2g 1�or�te�s*Cornpeat�atior�znsr��ar�ee formy Xoyees, �3eXot�a��lie�a�iey�r2c�jo�,�t'e i�,fp;�.mutior2. 1 i h. swance CompanyName:. 'olicy or e Ins. 1c:#. Pr �'8 _,2 / /� nt Expiration Date: 3'Z `" b�5— fob ite Addxess� S-/- A4 4f 4-0 S`� � u�1w�'CitylState/Z%p.; ' r AffaoA a copy az �iewnxSre s'eompwe atioxwTolieycleclara-do)ipage,(showlug-MepolicynumTberand agkaffou date). Yaxturetosee�zre<coverageasxequixec�tutcler eetzon25Aof G ,c.152caaleadtotheimpositionofeximiva115enaltzesofa RAO up to$1,500.00 andlox ow-Fear xtn.Priso�?mert-t,.as well as cbApenaltzes in ce fom of a STOP-WORK ORDER avid a.ante afuP to$250.00 a.day against thu,violator. Be advised that a copy of M19 statemontmay be foxwardedto the Office-of vestigatlons of the DTA.fox iii arance coverage vexiticatzon. 7n t o Xie e y ce rici' die icai�t to ld vericaZtieg o�ve jur trial Ate z ortr�tcrrionprovidec al7ove fs ftzra and comee. Si attire: Data: - 2.-3 - l A0120 0. offf,ezal use altzy. V o not vvile in 61s area,tube eomwfefed ry cAP or town of cinf Ot9'or TowTown: 'erxaztl icezzse# Dol-agAnthorIlY(circle one): Z.Board off fealth 2.BuildJugDepaxtment I City17[OM Clerk 4.Blectrzcd l':ugeetor 5.NuunabinghsPector• f.Quiet - - - Information and Instructions Massacbsetfs General Laws chapter 152 mcptires an employers to pxTovide workers'compensation for titer emplo ees. . Pursuant to this sfaiufe �� y ,ane�e,proyeeisdeffiedas ,.,evexypexsaxtiitheserviceofanotherunderanyconfractoj4 -a ,, ' express oxim 114 oral orwxitLen." .Azt defluod as"an.individual,partaexshi ,associatio co oxatio . •. ,. � n, � other le a. old � � gal entity,o�any�ro oxmoxe ofthexoxe o�.n engaged e gag gag x ntexpxise,andincludin. thele alxe xesea ' g g to ves of a deceased eln 1p�ex,.Or the, xe�eivex otrustee of andividual,parfaexshi ,as§ociation ox otherle al entity, l Omerr p g ty,employing employees, however she wxtexotadwe]Iingb,ousehavivgxtotntaxe'dzarzthxeea e fs paxhn n ar�.dvrhaxesxdes�,exez�,oxthe occupautot't7ie dweZtingbause o�'anotlkex who empXoys pexsous to da anainfenance,constntotion oxxepair woxlz o�x such,dweltingbouse or onthegrounds oxbuiXding appuzLenantthereto shallnotbecause ofsuch employ mOnt be deemedtabe an employez;" MGL chapter 152,§25C(6)also states that"every sfate or Ideal Rmnsla a enc ha 't . g g y s 11 wz�hhold the ox renewal oz a license or pexanit to opexate a business or to constxrxet hnildings zu the commonwealth for wadi applimt who has)tot produced•accepfable evidence of compliance YOL the Insurance coverage required;' Additionally,MGL chapter 152,§25C(7)states"Nezther the eommonwealth nor any oi:its poR&.al subdzvj`szons shall enter into any contract foxtha,performance ofpublicwo&untzl acceptable evzdence of co)nplrapce witlZ the insurance requirements of this chapfexhave b eenpxesexted to the cgntracting authority,, Applicants PleasofIll out the waxkexs'compensai on affidavit completely,by cheeping the boxes that apply to your situation and,if necessary,supplysub-contractox(s)name(s),addxess(es)andhonenumbex{s)alongwiththeir cextificate(s)of insurance; LiinitedVabilityCompanies(LLC)orUmitedLiabifitypartnexsbips(f, )withno employees otlierthatzthe members orpartnexs,axenotxe9*6dto carryworkem'compensationirfsuranCe. SfanLLGorMP doeshave employees,a olicy is xecluixed, Be advisedthattbi a davitzuay be submitiedto theDeaztmeut of hi ustr' " p d zal Acoiden zoo confirmation ofinsurance coverage. Ako be sure to,sign,and date the amdavi: lze afredavit should bexet�u'n.ed-Eatb,eciiyoxtow.z�.tllattheapplication=ortb.epermzEorlicerasexsbeingxeclue�-Eecl,�to�f7�,eDepaxtmen-tDx" . kdustralAccidenfs. Shouldyouhaveamyguestiensxegaxdingthelaw orifyonarexeg*et to obtain•a.*oxkexs' �Dm pensation otic leasecaltthe e a p y,p D p xbnent at�h�mmlbex hsfed below: Self znstrxed companies should enter their • self-insurance license number on the appxopxiate lane. QY or Tom MIA . be sure ghat z$e azfidavz�zs com e' pl ie andpxintecilegibly, `T$eDeparknentbaspxovidedaspaceatthebotLom ofthe a�RdavitfoxyoutoM outin.the event the Office ofWestigaamshasto contactyomregarftthe applilicaat Please be-sure to iM in tha peamit/Recuse number whlo .wM be used as a xezexence number, Ih.addition,an applicant thatmust submitxnultiple p ezmit/license applications la any givenyear,need only submit one affidavit indicating Curt'ent policy infarmaiion(Znecessary)and under"M Site Address"the applicant shoWdwxite `all locations (city or town)"t copyoitlieaftidavitthatbasbeanoffiolallystaimpedOXmarke.dbyt ocity ortown.maybapxo-ddedtoMa app7iCantasproof'thaEa�raliclaf'r"zdavit•zsonfrlei~oxi�ttu'epexmifsorucenses. ,fi.neWai�davitmust7�e�11edouteach, Yom Whexe ahoxne owner orCztz�extxs obtaiuingalicense oxpexmitnotxelatedto anybtzshtess ox comYnexcial venture (Le.a dogllcense orliermitto bum leaves etc)saidpexsoxtis�TOz`xequiredta Ca�nplete this affidavit. Tho offeaofI'nvestigatio-"0V1dMetothakyeninadvancefox Irouxcooperation and shquidyqukava anyquestions, please do not hesitate to give us a Call. The.77epaxEm.ent's address,telephone aitd faxnumbex: 6.0mb: gtoa xe � €�atan,MA 02111 JM CONSTRUCTION PROPOSAL JM CONSTRUCTION 1 181 SUMMER ST I LUNENBURG,MA 01462 978-235-1586 1 JUANNEGR057@YAHOO.COM CUSTOMER DESCRIPTION Shahid ESTIMATE NO JM-039 _ Install isolation on existing siding --- _ — - - DATE Verify for any damage wood and replace it withnew wood if needed sti 9/19/2014 Install plac siding lifetime(client will ch -colo r) Install soffit around house ADDRESS - - Trash disposal 57 Maple St. Seal house foundation around house CITY/STATE/ZIP N.Andover PHONE E-MAIL khan1172(d)amazon.com CONSTRUCTOR---_ - r __ -- - - - —- - ._ _• Juan Marrero PROJECT siding ---- - - LICENSE: - 172203 - — - - — Page 1 _ THIS PROPOSAL INCLUDES THE CONDITIONS NOTED: Permits are included. 50% needed when starting project and 50% when is finish. - -- Labor&Materials $14,000.00 Total $14,000.00 ign Here to ccept Quote: �-22 tractor Date Client i 4 l M k �i