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HomeMy WebLinkAboutBuilding Permit #767-15 - 58 PHEASANT BROOK ROAD 4/8/2015BUILDING PERMIT TOWN OF NORTH ANDOVER n APPLICATION FOR PLAN EXAMINATION Permit No#: `"' Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION _ Pint PROPERTY OWNER _ __ _. Print 900 Year Structure MAP . ._� PARCEL:.__ ZONING DISTRICT:--.. _: Historic District - Machine Shoe Villan.P NO R TF/� OF<t`-eo �bgti0 yes o yesno ves (no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg 0 Others: ❑ Demolition ❑ Other Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed, District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Ail' Identification - Please Type or Print Clearly OWNER: Name.0' iV�@ rw('�L- Phone: Address:('-. Nm LAVV01 Contractor Name hone: Address: Supervisor's Cons ruction License: ��� _ Exp. Date: Horne Improvement License: __ I rr i�l - _ _ _ Exp. Date: e, L 41h 7 , 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: $ �490o� FEE: $ 5-z?' &V Check No.: �d M1 Receipt No.: NOTE: Persons contracting with 's re tractors do not have access to the a ty Sig�ature of Agent/Owner signature of contractor 1' 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 o Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses a Copy of Contract Li Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks u Building Permit Application a Certified Surveyed Plot Plan o Workers Comp Affidavit Li Photo Copy of H.I.C. And C.S.L. Licenses Li Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application o Certified Proposed Plot Plan o 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) Li Copy of Contract o Mass check Energy Compliance Report Li 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 Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Signature_ Reviewed on Signature Reviewed on _ Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes hPlanning Board Decision: Comments f .Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT Temp Dumpster on site Located, 1.24 MainStreet Fir parttment signature/date COMM Locatea M4 usgooa atreet no Dimension Number of Stories Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. 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 NU 1 tJ ana UA 1 A— —wor a ❑ Notified for pickup Ca rtment use Emai Date Time Contact Name Doc.Building Permit Revised 2014 Location � -e CA No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # /Ituilding Inspector .a 0 Z o �r C. n co O 00 CD CLc CD 0 00 00 �CD 0- o moi• CD PP -1• O AWA U) O F C a cn n CD Pt CD CD3 CO)• CD U) iv Z ATF N cfl O CD r2 0 Z rn cn 0 7�v 0 O Z C z m O D O z 0 CD to to CD U3 O Vl C 0 Q• V1 S cn o�10 � __ N - < CO) cn . co CL 0CD CD o s �-0 3 T Ln O O r+ O. 0 T ~' -' (D 01e -f W U) O CL au N CD CD D =o 0 --� ca CLr' U) rt i � rt n rt S lD S O jS CD O O O ,} O 0 y -ef y CID n CD CL 00 y s Q O 0 � O y CD <D O y CD CL-CCD -D� �. `r ry ;or / O •� CD =� COo 0 .f O O CD `° CD . V/ y CD O 0 D� CL v v m ;v N O C m rD p Ln N - a0 co 7 m -Zj T pOq s N H m T =� N < ,C7 O GQ s m n Z T 70 O pCq 0 C W Li Z N T (") _S m �1 O W s T O 3 a 3 C p z _M z N m m --I' 0 V7 M 0 o T O 0 O- r) s co =3 O > v O ^ m m D 2 O J CIO y E 00 next step Living home energy solutions This agreement is made by and among Suzanne McCormick 58 Pheasant Brook Rd North Andover, MA 01845 Site ID: A851429 Next Step Living, Inc. ("NSU) 21 Drydock Avenue, 2nd floor Boston, MA 02210 phone: (866) 867-8729 05 -Mar -15 1. DESCRIPTION OF WORK TO BE PERFORMED NSL will perforin or cause to be performed the following work on the customer's address above, in a professional manner and in accordance with the terms of this Contract, including the attached recommendationstwork order describing the work in detail (the "Work") which are incorporated herein by reference: )escription Quantity Investment fir Sealing Recommendations $1 360.00 vvorh Location: Attic Flat Perform Air Sealing at Estimated 62.5 CFM50 Per Hour 16 $85.00 Hr $1,360.00 .. M Komi Work Location: Attic Flat Install 3.5" Fiberglass Batting In Open Attic Floor Hatch: Thermal Barrier Polyiso 2 inch (Attic) Damming Propavent 2' or 4' Attic Floor Open Blow Cellulose 4" 75 1 117 45 414 $1.32 sqft $60.00 Each $2.05 Lnft $2.00 Each $1.13 sqft $99.00 $60.00 $239.85 $90.00 $4.67.82 Work Location: Knee Wall _ Install 2" Thermal Barrier Polyiso on Open Kneewall Slope Install 2" Thermal Barrier Polyiso on Kneewall Kneewall Floor Open Blow Cellulose 4" _ 179 148 164 $3.31 sqft $3.50 sqft $1.11 sqft $592.49 $518.00 $182.04 Work Location: Misc _ Insulation Removal _ 100 $0.75 sqft $_75.00 Work Location: Foundation Insulate Rim Joist With 2" Thermal Barrier Polyiso 100 $3.52 sqft $352.00 Um 100% Airsealing Incentive up to Program Max 75 % Weatherization Incentive up to Program Max $1,020.00 $2,000.00 %Uft Estimated Annual Energy Savings from the Above Improvements $223.00 �'- 3-15.1 Date 5 Mar 2015 Date Edward Yaracz Name of NSL Representative A851429 The Terms of this Agreement are contained on both sides of this page Next Step Living . 21 Drydock Avenue " 2nd floor " Boston, MA 02210 " (866) 867-8729 . inquiry@nextsteplivinginc.com . www.nextsteplivina.com t I r 1 i r! 00 iiext step hiving® home energy solutions This agreement is made by and among i Suzanne McCormick Next Step Living, Inc. ("NSL") 21 Drydock Avenue, 2nd floor 58 Pheasant Brook Rd Boston, MA 02210 North Andover, MA 01845 phone: (866) 867-8729 Site ID: A851429 05 -Mar -15 1. DESCRIPTION OF WORK TO BE PERFORMED , r )ascription Quantity Investment ether Recommendations $866.13 vvorK Location: AUIC Hat Attic Flat 4" + any MS cellulose work (Not Rebate Eligible) 578 $0.69 sqft $397.38 Recessed light boxing (Not Rebate Eligible) 15 $31.25 Each $468.75 Not Rebate Eligible $0.00 F— R092MM Estimated Annual Energy Savings from the Above Improvements $67.00 2. PAYMENT: CUSTOMER agrees to pay NSL for the work as follows: Payment #1: $50.00 Additional Payments and Final Invoice: $816.13 -Additional Payments for the Work shall be due upon comoleUon of the Work —5 IS Date Mar 2015 Date Edward Yaracz Name of NSL Representative A851429 i ne Terms of this Agreement are contained on both sides of this page TERMS OF AGREEMENT 3. PROPOSED START DATE AND COMPLETION SCHEDULE NSL will contact customer to schedule the Work at a mutually agreeable time, subject to the availability of subcontractors or materials, or to delays attributable to the weather or other events beyond NSL's control. 4. CONTRACTOR REGISTRATION Massachusetts law requires 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 Office of Consumer Affairs and Business Regulation, Ten Paris Plaza, Suite 5170, Boston, MA 02116.617.973-8700. 5. PERMITS NSL will be responsible for obtaining any necessary permits as the Customer's agent. Customers who secure their own permits ordeal with an unregistered contractor will be excluded from the Guaranty Fund provisions of the Home Improvement Contractor Law. 6. PERFORMANCE OF THE WORK AND CHANGES. 6.1 NSL will not commence the Work prior to signing this Agreement and transmittal of a copy of Agreement to the Customer 6.2 This Agreement may be supplemented, amended, or modified only by the mutual agreement of the parties. No supplement, amendment, or modification of this Agreement shall be binding unless it is in writing and signed by all parties. 6.3 At times, our weatherization team discovers situations in the structure during the course of the Work that indicates a risk for a health or safety concem for residents. Such concerns can include but are not limited to ventilation, potentially hazardous materials such as mold or asbestos, or structural concerns. In the case of health or safety concerns being identified, NSL reserves the right, per section 9.2 of this contract, to communicate concerns to the Customer and halt work until such concerns have been addressed. 6.4 The rebates and incentives available from the Mass Save@ Home Energy Services Program and amounts due from the Customer are based on the best estimate of the situation in the structure by the NSL home energy advisor. However, at times our weatherization team discovers situations in the home during the course of the Work that impact the availability of rebates and incentives from the Mass Save Program. In such situations, NSL will communicate such changes to the Customer, including any impact on amount the Customer would be expected to pay for the Work. The Customer will have the option to remove from the Contract the work elements that need adjustment, or set up a separate contract for performing the adjusted work 6.5 NSL represents and warrants to the Customer that (a) the materials and equipment furnished under this Agreement will be of good quality and new, (b) that the Work will be free from defects, and (c) that the Work will conform with the description of the Work described In Paragraph 1. 7. INSURANCE AND REGISTRATION NSL represents and warrants to the Customer that it has a valid Home Improvement Contractor Registration (No: 162111) and the necessary insurance required by applicable law and normally maintained by prudent contractors in NSL's field, including, but not limited to, Workers Compensation Insurance for all employees who will perform the Work. 8. QUALITY OF WORK. NSL agrees that the Work will be performed in a good and workmanlike manner, and that NSL will repair and replace, at its own expense, and promptly upon Customer's request, any defects in workmanship and materials provided by NSL which appear up to one year after completion of the Work or within any longer period as permitted or required under applicable law, provided NSL has received final payment as provided herein. 9. PRE-EXISTING CONDITIONS 8 PROPERTY PROTECTION 9.1 NSL shall not be responsible for any damages as a consequence of the Work performed in the home due to pre-existing conditions. These conditions include but are not limited to poorly fastened or broken drywall, moisture damage, non -code construction, cracked or fragile siding or shingles, old pipes and fittings, rotting wood, etc. 9.2 NSL reserves the right not to perform Work upon the discovery of asbestos, mold, or any other potential health risk to the Customer. In this event, the Customer is responsible for remedying the at -risk situation, including any necessary removal of hazardous materials and all bills for services to date shall be paid immediately. Work cannot resume until remediation is complete. 9.3 While NSL will make best efforts to protect any property of the Customer, it is the Customer's responsibility to remove or protect, including dust protection, any personal property including the home itself. NSL will not be responsible for damages to or losses of any of the above mentioned property not property protected prior to the commencement of the Work. 10. GENERAL PROVISIONS. 10.1 NSL reserves the right, the extent permitted by applicable law, to have, file or maintain a mechanic's or material men's lien, or to file a notice of intention to lien, and to take any other steps to perfect and enforce such a lien, if Customer fails to pay NSL as provided herein. 10.2 This Agreement shall be construed in accordance with the laws of the Commonwealth of Massachusetts. 10.3 This Agreement forms the complete integrated agreement between NSL and Customer. The parties represent and warrant that in executing this Agreement, they are not relying on any representations, warranfies or terms other than as expressly contained herein. This Agreement supersedes alt prior agreements between the Customer and Contractor and may not be altered absent a subsequent written agreement signed by both parties. 11. ENERGY BENEFITS. The Sponsoring Utility Company (the Utility) is entitled to 100% of the energy benefits associated with all Energy Conservation Measures, excluding the value of energy cost savings by the Customer, but including all rights to all associated ISO -NE Energy, Capacity and Reserves Products. NSL agrees to provide the Utility with such further documentation as the Utility may request to confirm the Utility's ownership of such benefits and Products. 12. NOTICE CONCERNING SPONSORSHIP. 12.1 Customer understands and acknowledges that NSL is not an agent, vendor or sub -vendor of The Sponsoring Utility Company (the Utility) with respect to the installation of an energy efficiency measures. In the event of the failure of an energy conservation device to perform as expected, Customer's sole recourse is to Contractor and not to Conservation Services Group (CSG) or to the Utility. The Utility and its operating companies shall not maintain, remove or perform any work whatsoever on the energy conservation measures installed. 12.2 Customer understands and acknowledges that their participation in the Mass Save Home Energy Services Program is voluntary and that they have consented for Contractor to install the proposed energy conservation measures. 12.3 Customer agrees that it shall not hold CSG, the Utility, their affiliates or operating companies liable for Contractor's to perform its obligations under this agreement, for failure of the energy conservation measures to function, for any damage to Customer's Premises caused by Contractor or for any and all damages to property or injury to persons caused by the energy conservation measures. 13. LIMITED TIME OFFER. The prices and incentive offered in this Contract are subject to change in accordance with The Sponsoring Utility Company Mass Save Home Energy Services Program offers. 14. CONTRACT CANCELLATION Under Massachusetts law, you may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller, which may be his main office or a branch thereof, provided you notify the seller in writing at his main office or branch by ordinary mail posted, by fax, or by e-mail sent or by delivery, not later than midnight of the third business day following the signing of this agreement. 0 a fA . / � d r � 6e r ti s1.oPe ?3 \J No At - 5S g � �° L . 2 R E ly` PL1\1 r3 �1t t� s LoeE �L11, r a Mass Save Planview Diagram Customer. S:A-ag�„e, GG�f�,,�ls Advisor Name: Address S$ VVt s,6� Advisor Number: >'p Town (V 64V,R-r Any limitations to access by truck? Site ID —Nn— NOTES $ �(�,ce11 i<W F ► 6y 0 g±S fj�� � � �� � R5 1 , �f:S �a rF{,(j�( Re,.,I.l ��r� 1 �►� ��e7G .SiPr14r �.J {yy n\� l\i_ 5 P ,q-,OA15 GS,t� r ! ►� "� i 0 a fA . / � d r � 6e r ti s1.oPe ?3 \J No At - 5S g � �° L . 2 R E ly` PL1\1 r3 �1t t� s LoeE �L11, r a Affairs s amid Business Regulation 10 Park Plaza e Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration NE®Cly STEP LIVING INC. ROGER OUELLETTE 21 ®RY®®CKAVE. 2` H FL BOSTON, MA 02210 ?- i' :AFM M od 1�-'::' 7Z, • / l�I..rr /ratetle Office of Consumer Affairs dpi Business Regulation HOME IMPROVEMENT CONTRACTOR yrw Registration: 162111 Type: Expiration: 111412017 Suppiemeni Card NEXT STEP LIVING INC. ROGER OUELLETTE 21 DR`(DOCK AVE. 2TN FL BOSTON. MA 02210 Undersecretary Registration: 162111 Type: Supplement Caro] Expiration: 1/14/2017 Update Address and return card. Dark reason for change. ❑ Address F-1 Renewal F] (Employment F� Lost Card License or registration valid for i naiividuE use only before the empiratioan date. IIT found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 517D Boston, MA 02 IR R6 Not valid wittaotat signature m. AWIL IMI Massachusetts Department of Public Safety WI Board of Building Regulatlo•is and Standards Construction Super+isor Spech dtN eAN [.!cense GUST -10281 ROGZR A ©VZ-FLLX C ll 55 STlAWORE �O vqmff,7&k Kit 02M) .Uo11SSIII! W Rcrg;i keds To: CSS C-(IRSUhMIGn COoM801Or '- xpiratlol, ©WI NNI S Fafl nre to possess a current edition ofthe Mi assachusetts Stage Building Cade is cause for ravocaVon ofthis licensee I'r,�rr oPS (sue�r�a6W� ovuuoP��"euo� erus6e.o �:�ers�,^�,63,���s,�oerOD�S NEX`)`S-i OP 0. EL DATC(LIMIDDYYCERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MA TER OF INFORMATION 0%y A140 CONFER$ NO RIG"Ti UPON TH9 CgRTiFIGAITP HOLDER. THES CERTIFICATE DOES NOT AF'FiRZMAT111E1>eY OR NEGA'HVELY AMEND, EXTENta OR A�ER u'HE CUVERAGE AFFCbidl7EU BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE WANG INSUIRER($), AUTHORMP 014R PSENTATRVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IIP RTANT: If the gertifecate holde, is are ADDITIONAL INSURED, the po icY(les) must be and©r.sed.I�f SU[BROCKTiON 11 P�p6�0��q gy0jei;j 9 the terms and conditions of the policy, certain policies may require all endorsement. A statement on this certificate does not confer rights tai �hq certificate holder in lieu of such endorsement(s). _ _ PRODUCER -- _ MCLaao boli I sus araea araC 03 V ( Par(wpy Melrose, IA 02376 John E. McLaughlin Jr. CONTACT NAME:a Erin �a�aDoa u I e E>d : 781-065-2775 Ar =065-02 AIM E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE MAIC 9 X COMMERCIAL OE6EPAL LIABILITY CLAIMS -MADE ® OCCUR INSURER A: NaQ1JtR us Insurance ECP2910198-12 INSURED Next Steil ¢ ivinq, lnc. 21 Drydock Avenue, 2nd Floor Boston, ISA 0221® INSURER B.Cvar MS11*ce InSUrcance CD[ lPffly 34754 INstIRERc:A.I.�fI, Mutual Insurance Co. MED EXP (Any one person) INSURERD:AMS PrIsurance Company 15010 GEN'- AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO- JECT F-1 LOC OTHER: INSURER E PRODUCTS -COMPIOPAGG $ INSURER F: AUTOMOBILE LIASIMTV ANY AUTO ALL OWNEDSCHEDULED AUTOS AUTOS vNON-OWNED HIRED AUTOS AUTOS COVERAGES CERTIFICATE NUMBER: REVIISROM MUMR2R_- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PffRO INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH T}. IS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ITR TYPE OF INSURANCE D L BUSH POLICY NUMBER POLICY -M FF POLICY M UD EXP LIMITS A I j X COMMERCIAL OE6EPAL LIABILITY CLAIMS -MADE ® OCCUR ECP2910198-12 0913012014 08/8012015 EACH OCCURRENCE $ 1,000,000 PREMISES Eeoccurrence) $ 190,000 MED EXP (Any one person) PERSONAL E ADV INJURY $ �, GEN'- AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO- JECT F-1 LOC OTHER: GENERAL AGGREGATE $ pa,QQ®rWAR PRODUCTS -COMPIOPAGG $ AUTOMOBILE LIASIMTV ANY AUTO ALL OWNEDSCHEDULED AUTOS AUTOS vNON-OWNED HIRED AUTOS AUTOS 14MMBGKKOM 09/30/2014 TM 09/S012015 _ Ea aocd.ntSINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) PROPERTY DAMAGE $ Per accident $ ® UPABRELLA LIAR EXCESS LIAR x I "CCUR 11 CLAIMS -MADE r=0783547012014 09130/2014 00/3a 012013 EACH OCCURRENCE $ �. 8,000p AGGREGATE $ IA, O, nQpQ DED RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY OFFICERMIEMBER EXCLUDED? ECUTIVE Y� (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below I N / A I I TO BE ISSUED BY CARRIER 00180/2014 0 /8®/2015 I _ x PER � ERH E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,00 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 909, Additional P.emar'as Schodulo, may be attached if more space is raquirad) POR IMFORVATZON ONLY For Wormation Only SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLM- BEFORE THE EXPIPATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-20"14 ACORD CORPORATION. AIR chats r®serrvpd ®R®25 (2014/Wa) Top ARt [ P q&M0 ova pm % are r9qog¢ �� ACORR, ��, TThw Commonweultlt ��fl%!us°,gachuseta,s' Department of Indusir'ialAccid'ents Office of In i7estigattons 1 Congress Street. Sulte .i00 Boston, MA #2114.2017 SAD v 6� }rflnw :mass.goit1dia Workers' Compensation Insurance Affidavit: Bu lders/Contr actor's/Electrreians/Plumbelrs Applicant Information Please Print Legibly Name, (Busiraess/Organizatioa/Iradividaal)e Text Step Living Address: 21 Drydock Ave Boston, MA 02210 Pb®rte #: (666)667-43729 Are you an employer? Check the appropriate box: 1. N I ane a employer with 360 4. ® I am a general contractor and I employees (full and/or part-time),* have hired the sub -contractors 2.0 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp, insurance required.] comp. nnsurance.1 5. We are a corporation and its 3. I am a homeowner doing all work officers have exercised their myself, [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. (No workers' comp. insurance required.] Type of project (required): 6. 0 New construction 7. ® Remodeling 8. Demolition 9. ® Building addition 10.El Electrical repairs or additions I LE] Plumbing repairs or additions 12.0 Roof repairs 13.§ Other Insulation 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f I lomeowners whe submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affiidal it indicating such. (Contractors that check this box merit attached an additional sheet showing the name of the sub -contractors and state whether or vo9 t1103c entitift have employees. if the sub -contractors have employees, they must provide their workers' comp. policy number. Ian an employer that is providing workers' compensation insuran¢cefor may employees. Below is the policy and lob site uniform atom. Insurance Company Name: A.I.M Mutual Insurance Company Policy # or Self -ins. Lie. #: AWC-400-7030026-2014A Expiration Date: 9/30/16 Job Site Address: City/State/Zip: Attach a copy of the workers9 compensation policy declaration page (showing the policy mummer and expiration date). Failure to secure coverage as required under Section 25A of 1@1iGL c. 152 can Iead 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 STOIC WORD ORDER and a fins of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage vifition. I do hereby certify sander the pains and. that the inforsmation provided above is true and correct Sip ature: Date: 101 61/I Phone #:l' tolo) &_7_ 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 S. Plumbing Inspector 6. Other Contact Persona Phone #.