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HomeMy WebLinkAboutBuilding Permit #054-16 - 59 PHILLIPS COMMON 7/13/2015 NO Rli T 15� l' 9 BUILDING PERMIT of %0R 1 ' TOWN OF NORTH ANDOVER 0 2 y '`- ;"'` o APPLICATION FOR PLAN EXAMINATION X-4 n O• Permit No#: 5 Date ReceivedA 7RADR�TED •PP`y�� gSSACHUSE� Date Issued: ( IMPORTANT:Applicant must complete all items on this page Ili q ' LOCATION l ` ( ` ` s COMM6-v) Pri t PROPERTY OWNER��'aM� A`_'1' Print 100 Year Structure yesno MAP PARCEL:ZONING DISTRICT: Historic District yes n Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building P-6ne family ❑Addition ❑ Two or more family ❑ Industrial Ih ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other U;;7 Septtc ®y�1lllell .q "a; a �� F©odplan. `� etland❑ ❑W��WaterlSewera - � . .� t ., .�•td , f Y_ � "' �� � DESCRIPT119N OF WORK TQ ,FE PERFORMED: 54y a V-e- 6 I dentifica ' n- PleaseType or Print Clearly OWNER: Name: --.J Phone:91 Address: Contractor Name: ` � �-'� Phone: R��' � "'®tdc,� Email: Address: Supervisor's Construction License: 1�( Exp. Date: x r � Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.,BOLDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BAS(ED,,ON$125.00 PER S.F. Total Project Cost: $ �t FEE: $ Check No.:A 3 (0 "l Receipt No.:aCA n`t NOTE: Persons contracting with unregistered contractors do not have access t 1 t e uara ty fund - 4 A t Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swunming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS i HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes k Plan ding Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street .33!" FIRE DEPAiRTNiENT' - Tem ®urri ster ies onste y p p M no a - � � �. w�, � � •. � � �� ',� r #� ,J.�` .�� � � �TMs•" F'S.`+r,' 1 LSC' t.�; „� s#,� <g t�- �ti}#mfr* q• ��*,a.+�x. ._3« `y,T�'*,fi�- �{_91. 4-111 7f'�,+ t7�'t..i.�A'w-tk, ssl.�+r`�a'ed t ' y< .g.+. ` I F I Dimension I 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 Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 OTE: 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 OTE: 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 4. Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 4L 2012 IECC Energy code � Engineering Affidavits for Engineered products OTE: 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 I G l S ' Location No. ` Date • • TOWN OF NORTH ANDOVER Certificate of Occupancy $ • Building/Frame Permit Fee. $ ._ Foundation Permit Fee $ •* Other Permit Fee $ _ 1"1N C► ,, TOTAL $ 4 Check# i� Building Inspector .7 Town of North Andover . of N°R°Til q Office of the Zoning Board of Appeals 0� Community Development and Services Division Heidi*Griffin, Division Director =�• "° 41 27 Charles Street SSAC s� North Andover, Massachusetts 01845 978 hone l Tee D. Robert Nicetta p ( )688-9541 Building Commissioner Fax (978) 688-9542 Any appeal eal shall be filed Notice of Decision within(20)days after the Year 2002 date of filing of this notice in the office of the Town Clerk. Property at: 54-56 Phillips Court. NAME: Paula Cahow DATE: 3/22/02 ADDRESS: for property at: 54-56 Phillips Court PETITION: 2002-008 North Andover,MA 01845 HEARING(s): 3/12/02 The North Andover Zoning Board of Appeals held a public hearing at its regular meeting on Tuesday, March 12,2002 at 7:30 PM upon the application of Paula Cahow,for property at: 54-56 Phillips Court, North Andover,MA requesting Variance from Section 7,Paragraphs 7.1 &7.2 of Tablet for dimensional relief of lot area and street frontage in order to subdivide the lot into two non-conforming lots within the R- 4 zoning district. The following Board members were present: John M.Pallone,Ellen P.McIntyre,George M,Earley,& Joseph D. LaGrasse. Motion was made by Joseph D.LaGrasse and 2"d by Ellen P.McIntyre to grant a variance from the requirements of Section 7,Paragraphs 7.1&7.2 for dimensional relief of lot area and street frontage in order to subdivide the lot into two non-conforming lots. Voting in favor: John M. Pallone&Joseph D. LaGrasse. Voting in opposition: George M.Earley&Ellen P.McIntyre,therefore,the petition was DENIED. H Town of North Andover C==- Board of Appeals, CD or >`- C:)rrt c3 n-i hn WPAone,Acting Chairman < z c N D Decision2002-008 CD a- BOARD OF APPEALS 688-9541 BLTILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 NORTH own of E , Andover No. &PA— y ? � y T r Mass� h ver, 3 ° LAKE COC NIG NlWKK V S U BOARD OF HEALTH Food/Kitchen -PERMIT T L D Septic System THIS CERTIFIES THAT .......7. �.�....... , 1111. .tR. ........ BUILDING INSPECTOR /� ' has permission to erect .......................... buildings on .15A.......10. 4<.�.��. 1►..... ................~ Foundation # Rough to be occupied as .....1 ... .. ...t...... .�. ... ................................................ Chimney provided that the person acceplin�this permit shall in every respect conform 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 CONSTRUCTIO S AR Rough 11� Service .... .......................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Baystate Roofers,Inc. Proposal P.O. Box 189 North Reading,MA 01864 Date Estimate# Tel. 978-664-0668 Fax 978-664-4333 5/25/2015 16017 Name/Address HIC# 137193 Jane Bennett CSSL# 99895 59 Phillips Common North Andover,Ma.01845 Bay State Roofers Inc proposes: Remove approximately 3800 square feet of the existing asphalt shingle roof down to the wood decking. Install new ice and water shield along the 6' roof edge, valleys and around all the roof penetrations. Install new 151b felt paper throughout roof area. Install new white aluminum drip edge along the roof perimeter. A new Lifetime GAF Architectural asphalt shingle will be installed over the prepared substrate. A new ridge vent will be installed to ensure the proper roof ventilation. All roof penetrations and flashing will be installed according to manufacturers recommendation, specification and details. Install new pipe flanges. Bay State Roofers will properly dispose of all roof debris in our own waste containers. Any wood decking that needs replacement will be an additional $2.50 per lineal foot. Remove corner boards and clapboards on the section of roof above the deck to flash the sidewall propoerly and reinstall new primed pine and clapboards. Replace 3 sections of rotted rake boards with new 1x8 and 1x3 primed pine. This included in this proposal. The satellite dish will need to be re-adjusted after the new roof is installed. New Shingle Roof Authorized Signature: Tota I „ I $13,860.00 /J P"'� Waste containers supplied by Bay State Roofers, Inc. are for sole purpose of roof debris. Under no circumstance is the homeowner to use these containers for personal use. 10 Year Workmanship Warranty on all roofs. (Except Repair Jobs) CONTRACT ACCEPTANCE The specifications,prices,payment schedule are satisfactory and hereby accepted. Date: '^J Z O _6BAY STATE ROOFERS,INC.is authorized to perform work as specified. Payment will be made as previously outlined. Signature 'p All bills over 30 days are subject to 1 1/2%finance charge per month(18% annual). Color �)�� ' PROVISIONS OF THE AGREEMENT I.PROJECT PROVISIONS e. Damage to Project:Contractor will not be responsible for any a.Guideline:The Project will be constructed in strict conformance damage caused by the Owner. or other causes beyond the control of to the plans and specifications which have been examined and the Contractor.Owner will pay for any restoration work. approved by the Owner. IV.CONTRACTOR'S RIGHTS AND RESPONSIBILITIES b.Compliance:The Project will be completed in strict compliance with all laws, ordinances, rules and regulations of the applicable a. Delay: Contractor will be excused for any delay beyond his government authorities. reasonable control. These delays may include, but are not limited to c. Control:The Agreement plans and specifications are intended Acts of God,labor disputes,inclement weather,acts of public authority, to supplement each other. In case of conflict,the plans will control the acts of the Owner.or other unforeseen contingencies. specifications and the Agreement provisions will control both. b. Right to Stop Work: If any payment under this Agreement is d.Charge Orders:As directed by the Owner,construction lender, not made when due,the Contractor may suspend work on the job until public body or inspector,any alteration or deviation from the specifications such time as all payments due have been made. Any failure to make that involves extra cost(subcontract, labor, materials)will be executed payment is subject to a claim enforced against the property in only upon the parties entering into a written change order. Expense accordance with the applicable lien laws. incurred because of unusual or unanticipated conditions will be paid for c.Substitution of Materials:Contractor may substitute materials by the Owner. without notice to the Owner in order to allow work to proceed,provided e. Allowances: If the Agreement price includes allowances, and that the substituted materials are of no lesser quality than those listed the cost of performing the work is greater or less than this allowance, in the specifications. then the Agreement price will be adjusted accordingly. d.Salvage:All salvage resulting from work under this Agreement II.FINANCIAL RIGHTS AND RESPONSIBILITIES is to be retained by the Contractor unless other agreements are contained in the written specifications. a. Labor and Material: Contractor will provide and pay for all e. Insurance: Contractor will maintain workers' disability labor and materials necessary to complete the Project. Contractor is compensation insurance for his employees and comprehensive public released from this obligation for expenses incurred when the Owner is liability insurance policies. in arrears in making progress payments. b. Permits:Contractor will obtain and pay for all required building V.COMPLETION OF PROJECT permits and licenses. a. Notice: Owner agrees to sign a Notice of Completion within 5 c.Taxes,Assessments and Charges:Taxes.special assessments days after completion of the project. If project passes final inspection of all descriptions, and charges required by public bodies and utilities and the Owner does not sign the Notice,the Contractor may act as the will be paid for by the Owner. Owner's agent and sign the Notice. d. Deposit of Payments: Contractor is required to deposit all b. Clean-up: Contractor is responsible for removing debris and payments received prior to completion in an escrow account. In lieu of surplus material from the property, and leaving the property in a neat such a deposit,the Contractor may post a bond or contract of indemnity and orderly condition. with the Owner guaranteeing the return or proper application of such VI.CONFLICT PROVISIONS payments to the purposes of the contract. All advanced funds will be a. Arbitration: Any controversy or claim arising out of this deposited as indicated under Special Provisions. Monies used in Agreement that cannot be resolved, is subject to arbitration, with escrow become the property of the Contractor when they are applied an arbitrator of mutual agreement, and all parties (including according to the Agreement payment schedule, when a breach of Owner, Contractor, Architect and Sub-Contractors) are bound to contract by the Owner occurs, or when the Agreement has been this arbitration, If any party does not appear at arbitration substantially performed. proceedings, the arbitrator is empowered to decide the controversy e. Bankruptcy: It either party becomes bankrupt. the other party in accordance with whatever evidence is presented by the has the right to cancel this Agreement. party(ies)that do participate. III.OWNER'S RIGHTS AND RESPONSIBILITIES b. Attorney Fees: If either party becomes involved in litigation a. Cancellation: Owner has an unconditional right to cancel the arising out of Agreement, the Court shall award costs/expenses Agreement, without penalty or obligation, until midnight of the third including attorney fees to the party justly entitled to them. business day after the Agreement was signed. Cancellation must be c. Limitations: No action related to this Project may be made done in writing. Upon cancellation, any property traded in, any by either party against the other more than 2 years after the payments made under this Agreement, and any negotiated instrument completion of work. executed will be returned within 10 business days following receipt by VII.GENERAL PROVISIONS the Contractor of cancellation notice. b. Property Lines: Owner shall locate and point out property a. Notice:Any notice required or permitted under this Agreement lines to the Contractor.Contractor may,at his option,require the Owner may be given by certified or registered mail at the addresses contained to provide a licensed land surveyor's map of the property. in the Agreement. c. Liens: Failure to pay persons supplying materials or services b. Prohibition of Assignment: Neither party may assign this according to the terms of this Agreement may result in the filing of Agreement or payment due under this Agreement without the written mechanic's liens on the affected property. Owner has the right to ask consent of the other party. the Contractor for lien waivers from all persons supplying these c.Qualification:This document constitutes the entire agreement materials or services. In the event any mechanic's lien is filed through of the parties. No other agreements exist. This Agreement can be no fault of the Owner, then the Contractor agrees to take all steps modified only by written agreement signed by both parties. necessary for the release and discharge of such lien. d.Insurance:Owner will maintain property damage insurance at d.Governance:This Agreement shall be construed in accordance' � least equal to the Agreement price. with and governed by, the laws of the state in which the Project is located. PROVISIONS OF THE-AGREEMENT I.PROJECT PROVISIONS e. Damage to Project: Contractor will not be responsible for any a.Guideline:The Project will be constructed in strict conformance damage caused by the Owner. or other causes beyond the control of to the plans and specifications which have been examined and the Contractor.Owner will pay for any restoration work. approved by the Owner. IV.CONTRACTOR'S RIGHTS AND RESPONSIBILITIES b.Compliance:The Project will be completed in strict compliance with all laws, ordinances, rules and regulations of the applicable a. Delay: Contractor will be excused for any delay beyond his government authorities. reasonable control. These delays may include, but are not limited to c. Control:The Agreement plans and specifications are intended Acts of God,labor disputes,inclement weather,acts of public authority, to supplement each other. In case of conflict,the plans will control the acts of the Owner.or other unforeseen contingencies. specifications and the Agreement provisions will control both. b. Right to Stop Work: If any payment under this Agreement is d.Charge Orders:As directed by the Owner,construction lender, not made when due,the Contractor may suspend work on the job until public body or inspector,any alteration or deviation from the specifications such time as all payments due have been made.Any failure to make that involves extra cost(subcontract, labor, materials)will be executed payment is subject to a claim enforced against the property in only upon the parties entering into a written change order. Expense accordance with the applicable lien laws. incurred because of unusual or unanticipated conditions will be paid for c.Substitution of Materials:Contractor may substitute materials by the Owner. without notice to the Owner in order to allow work to proceed,provided e. Allowances: If the Agreement price includes allowances, and that the substituted materials are of no lesser quality than those listed the cost of performing the work is greater or less than this allowance, in the specifications. then the Agreement price will be adjusted accordingly. d.Salvage:All salvage resulting from work under this Agreement II.FINANCIAL RIGHTS AND RESPONSIBILITIES is to be retained by the Contractor unless other agreements are contained in the written specifications. a. Labor and Material: Contractor will provide and pay for all e. Insurance: Contractor will maintain workers' disability labor and materials necessary to complete the Project. Contractor is compensation insurance for his employees and comprehensive public released from this obligation for expenses incurred when the Owner is liability insurance policies. in arrears in making progress payments. b. Permits:Contractor will obtain and pay for all required building V.COMPLETION OF PROJECT permits and licenses. a. Notice: Owner agrees to sign a Notice of Completion within 5 c.Taxes,Assessments and Charges:Taxes.special assessments days after completion of the project. If project passes final inspection of all descriptions, and charges required by public bodies and utilities and the Owner does not sign the Notice,the Contractor may act as the will be paid for by the Owner. Owner's agent and sign the Notice. d. Deposit of Payments: Contractor is required to deposit all b. Clean-up: Contractor is responsible for removing debris and payments received prior to completion in an escrow account. In lieu of surplus material from the property, and leaving the property in a neat such a deposit,the Contractor may post a bond or contract of indemnity and orderly condition. with the Owner guaranteeing the return or proper application of such VI.CONFLICT PROVISIONS payments to the purposes of the contract. All advanced funds will be a. Arbitration: Any controversy or claim arising out of this deposited as indicated under Special Provisions. Monies used in Agreement that cannot be resolved, is subject to arbitration, with escrow become the property of the Contractor when they are applied AAarbitrator of mutual agreement, and all parties (including according to the Agreement payment schedule, when a breach of an contract by the Owner occurs; or when the Agreement has been Owner, Contractor, Architect and Sub Contractors) are bound to this arbitration, If any party does not appear at arbitration substantially performed. proceedings, the arbitrator is empowered to decide the controversy e. Bankruptcy: It either party becomes bankrupt. the other party in accordance with whatever evidence is presented by the has the right to ciancel this Agreement. party(ies)that do participate. III.OWNER'S RIGHTS AND RESPONSIBILITIES . b. Attorney Fees: If either party becomes involved in litigation a. Cancellation: Owner has an unconditional right to cancel the arising out of Agreement, the Court shall award costs/expenses Agreement, without penalty or obligation, until midnight of the third including attorney fees to the party justly entitled to them. business day after the Agreement was signed. Cancellation must be c. Limitations: No action related to this Project may be made done in writing. Upon cancellation, any property traded in, any by either party against the other more than 2 years after the payments made under this Agreement, and any negotiated instrument completion of work. executed will be returned within 10 business days following receipt by VII.GENERAL PROVISIONS the Contractor of cancellation notice. b. Property Lines: Owner shall locate andoint out property a. Notice:Any notice required or permitted under this Agreement p p p y may be given b certified i rt fled or registered mail at the addresses contained Y 9 Y 9 lines to the Contractor.Contractor may,at his option,require the Owner to provide a licensed land surveyor's map of the property. in the Agreement. c. Liens: Failure to pay persons supplying materials or services b. Prohibition of Assignment: Neither party may assign this according to the terms of this Agreement may result in the filing of Agreement or payment due under this Agreement without the written mechanic's liens on the affected property. Owner has the right to ask consent of the other party. the Contractor for lien waivers from all persons supplying these c.Qualification:This document constitutes the entire agreement materials or services. In the event any mechanic's lien is filed through of the parties. No other agreements exist. This Agreement can be no fault of the Owner, then the Contractor agrees to take all steps modified only by written agreement signed by both parties. necessary for the release and discharge of such lien. d.Insurance:Owner will maintain property damage insurance at d.Governance:This Agreement shall be construed in accordance least equal to the Agreement price. with and governed by, the laws of the state in which the Project is located. The Commonwealth of Massachusetts z . Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print Ley-ibl Name (Business/Organization4ndividual): Address: OL'-to &lee—k— sk City/State/Zip:. tk4 Phone#: �TC6 -b�Ii r b1, Are you an employer?Check the appropriate box: Type of project(required): 1.W!am a employer with� i employees(full and/or part-time).* 7, []New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3..Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10[]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either Have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also full 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name:—AQ Q Arn-ey tc!�A — Policy#or Self-ins.Lic.#: (�J( �- A'41-)09P62— _ Expiration Date: ` - f q R� Job Site Address: S L4 1 City/State/Zip: /y ev Attach a copy of the workers' compensate n policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificatio . I do hereby ce of un r the ai d e It of p jury that the information provided above is true and correct. Si nature: Date: i Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealths 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 coin acceptable evidence of fiance with the insurance p P 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-'contractors)name(s),address(es)and phone number( )along s with their certificates 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 call the Department at the number listed below. Self-insured companies should'enter their - self-insurance license number on the appropriate line. - City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Rfghtfax C2-2 4/15/2015 10:30:49 AM PAGE 3/004 Fax Server 1% v® CERTIFICATE OF LIABILITY INSURANCE O-IS-201$ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. if SUBROGATION IS WANED, subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: A 8 K FOWLER INS LLC PHONE FAX 200 PARK STREET AX No sI A!C No NORTH READING,MA 01864 E-MAIL INSURER(SIAFFOROING COVERAGE NAIL# INSURER A:ACE AMERICAN INSURANCE COMPANY \ INSURED INSURER 8 BAY STATE ROOFERS INC INSURER C PO BOX 189 NORTH READING,MA 01864 INSURER D INSURER E: INSURER F COVERAGES C FI 8 R REVISION NUMBER! THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE. BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT, 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. [NSR ADDLISUBPOLICY EFF POLICY EXP LTR TYPE OF INSURANCE WSR I WVD POLICY NUMBERM W IyyyYyy LIMITS GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED occurrence 5 CIAWS.MAOE PREMISES _J MED ga _ 1 MED EXP(Any one person) S PERSONAL&ADV INJURY S GENERAL AGGREGATE S GENt AGOREOATE LIMIT APPLIES PER: PRODUCTS•COMP:OP AGG 5 POLICY PEa LOC S SCHEDULED7AAUTOS MOBILELIABILITY � 8I�DISINGLELIMIT S ANYAUTO DINNED BODILY INJURY(Por persaq S AUTOS BODILY INJURY(Par aeodent) S HIRED AUTOS ANtU7T0NE0 dt�= AMAGE S S UMBRELLALLAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE 5 DED I RETENTIONS S WORKERS COMPENSATION X WCSTATU- 0TH (MamwAty M NMI AND EMPLOYERS'LIABILITY Y,N TORrUMIT- ER ANY PROPRIETORrPARTNER'EXECUTN� 0FFtCERW1M8EREXCLUOED7 1(D'N/A 6$62UB 04-12-201$ 04.12.2016 EX,EACH ACCIDENT $1,000,000 It yos.dC&"Q ander 4609PO62 E.L.DISEASE-EA EMPLOYEE $1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS)VEHICLES(ARaeh ACORD 1101,AddMonal Remake Schedule,if more spew Is requlred) BAYSTATE ROOFERS INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES B P.0 BOX 189 CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NORTH READING,MA 01864 NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AWHORIMO REPRES_ENTATM -YL-"IL, ACORD 25(201010$) The ACORD name and logo are registered rACOROCORPORATION.All r19FItS reserved. x.• Massachusetts -Department of Public Safety Board of Building Regulations and Standards* 4 Construction Supervisor Specialty License: CSSL-099895 ROBERT E OKEEFE 21 FRANCIS STREET o, NORTH READIPTG MA 01861 Expiration Commissioner 09/29/2015 Y - -��e -l/JO'IIP/IIZOOLLlICQGL�L o�./�aaaar�uaelta Office of Consumer Affairs&Business Regulation UWOME IMPROVEMENT CONTRACTOR f Registration 137193 Type'. Expiration;10/15%201,6 Supplement c BAY STATE ROOFEWIINC� W ROBERT O'KEEFE >.=<7 �� PO BOX 189 •s`- � � - N.READING, MA 01864-_ '' Undersecretary