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HomeMy WebLinkAboutBuilding Permit #647 - 595 SALEM STREET 4/26/2010BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: (l' Date Issued: [- -ry IMPORTANT: Date Received must complete all items on this 4 N'' 70M., WrmwlzA MAP e PARCEL S3 ZONING: MabbirtaShoo 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 Others: Demolition Other Septic Well = Floodplain Wetlands Watershed District Water/Sewer". DESCRIPTION OF WORK TO BE PREFORMED: OWNER: Name: 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: $ jai[` FEE: $ Check No.: �0 Receipt No.:� ��- NOTE: Persons contractin with registered contractors do not have acc"e� the aran and �� � _ � gl� tJ'.f Building Department The following is a list of the required forms to be filled out for the appropriate permit to be. obtained. Roofing, Siding, 'Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2008 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS -HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Planning Board Decision: Comments Conservation Decision: Comments Zoning Decision/receipt submitted yes Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Locateo su4 Us o0o Street `FIRE DEPARTMENT - Temp Dumpster on site yes L no Located at 124Main Street Y Fire Department signatur0date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location,,mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No . MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — For department use ❑ Notified for pickup - Date I Doc.Building Permit Revised 2010 Location 1 -Cf —14o, sf77-7 N Id No. Date TOWN OF NORTH ANDOVER 1 .4 - - & Certificate of Occupancy $ Building/Frame Permit Fee $ MU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# /0 22964 Building Inspector FIELD REPORT ABERJONA ENGINEERING INC. One Mt. Vernon St. Winchester, MA 01890 Ph: 781-729-6188Fax: 781-729-7960 TO: Meridian Contracting Ltd. 9 Old County Road Sudbury, MA 01776 Attn: Win Mallett C Page 1 DATE JOB NO. 4/27/10 101027 PROJECT ornblatt Resi e LOCATION 1070 Salem St., Nort Andover, MA OWNER TCONTRACrOR hn Cornblatt WEATHER TEMP Cloudy 50 "AT 10:00 AM PRESENT AT SITE Win Mallett/Meridian Michelle Duguay/Buttaro Jeffrey Cornblatt/Owner Alan A. Vitukevich/AEI THE FOLLOWING WAS NOTED: Visited the site to review completed framing for renovation for conformance to Permit/Construction Documents. SECOND FLOOR FRAMING (REF. DWG. A -1.1A) • Existing beams adjacent to Stairway installed as 4-1 % x 9 Y2 LVL with proper hangers. New LVL beam, 4-1 3/ x 9 Y2, installed from existing header at Stairway to existing post at Entry. Existing post 6x6 with 2 new 1 % x 5 Y2 LVL added to support new 9 Y2 LVL. Existing 8x10 beam remains in place from post to front Entry. Refer to attached drawing A -1.1A with as -built framing sizes for reference. ROOF FRAMING Ccs SIDE ENTRY (REF. TO DWG. A-1.2) • New 2x10 rafters and 1 3/+ x 11 7/8 LVL valley members installed as required. Existing header beam is 3-1 '/ x 11 7/8 LVL. Major valley connected to header beam with bent plate and 3-3/4" diameter lags as required. Minor valley connected to major valley with 3-3/4" diameter lags instead of 3-%2" diameter lags as indicated on drawings. This is acceptable. L70 clips added at rafters as required. FIELD REPORT Page The comments in this field report are a record of transactions that occurred at the site between those present. if there are any errors or omissions please notify Aberjona Engineering in writing or all comments and directives shall be considered factual and acceptable by all parties. Copy: Michelle Duguay/Buttaro Enclosure 0 oF�,� ALAN A. o VITUKEVICH STRUCTURAL ,9 N0.2S882 C TEP�` SUBMITTED: Alan A. Vitukevich, P.E. It Vice President X §g M Z � � z EEC 6�11 5 ........... I .......... 1st Floor Plan T�^i'�ne+e —' � � lfr OplEY Ferny N,n M�Oe.,r, W a 9 Old cMY Pnad ArAry W 01T76 :av 4 7616 YF- ,wu F+W 56 v caw h. C� 35A 6019 4 . " The Rameys From: Sent: To: Subject: Excerpt for mey-248 CMR 288 Thank you, Sam SultanFood [sultanfood@verizon.net] Friday, April 23, 2010 9:59 AM 'The Rameys' FW: Variance SuTt 1 � *(978)-361-5103 * SultanFood@verizon.net The information in this email and subsequent attachments may contain confidential information that is intended solely for the attention and use of the named addressee(s). This message or any part thereof must not be disclosed, copied, distributed or retained by any person without authorization from the addressee. P Please consider the environment before printing this e-mail -----Original Message ----- From: Medeiros, David C (DPL)[mailto: David. Medeiros@state.ma. us] Sent: Friday, April 23, 2010 9:30 AM To: 'sultanfood@verizon.net' Subject: RE: Variance Mr. Ramey Based on the information you provided in your email a variance is not required to install a unisex handicap restroom accessible to employees and the public. Please find attached an excerpt from 248 CMR 10.10 (18) (2) c. that clearly defines what is required. You must contact the Local Plumbing Inspector and advise him of this communication and you are to provide a copy to the inspector, if required. Finally, this reply is based solely on the information you provided to this office regarding the questions I posed to you in a prior email (included herein). If you are in need of further assistance, please do not hesitate to contact me, Respectfully; David C. Medeiros -----Original Message ----- From: SultanFood [mailto:sultanfood@verizon.net] Sent: Friday, April 23, 2010 8:48 AM d , 'J To: 'Medeiros, David C (DPL)' Subject: RE: Variance Hello Mr. Medeiros, The 1182 S/F is the total gross area. We have a comer unit and the measurements are from the center of the demising wall to the outside wall (29'4") and from the 2 remaining outside walls (40'). Thank you, Sam "(978)-361-5103 * SultanFood@verizon.net The information in this email and subsequent attachments may contain confidential information that is intended solely for the attention and use of the named addressee(s). This message or any part thereof must not be disclosed, copied, distributed or retained by any person without authorization from the addressee. P Please consider the environment before printing this e-mail -----Original Message ----- From: Medeiros, David C (DPL)[mailto: David. Medeiros@state.ma.us] Sent: Friday, April 23, 2010 5:55 AM To: 'sultanfood@verizon.net' Cc: Peluso, Joseph A (DPL); Thomas, Wayne E (DPL) Subject: Variance Mr. Ramey: In your variance you state the restaurant is 1,182 square feet. Question`. Does the figure above represent the total gross square footage of the restaurant? This would include the following: 1. Patron accessible area 2. Kitchen area 3. Storage areas 4. Existing/Proposed restroom area 5. Office area 6. Closet(s) 7. Janitor Room area 8. Any other area(s) I will call at approximately 10:00 am, if I do not receive a reply by then. Respectfully; David Medeiros Discipline Coordinator (Email) David. C.Medeiros@MassMail.State. MA. US (Office) 617-727-0801 (Mobile) 857-334-4733 M This email and any files transmitted with it may be confidential, the disclosure of which is governed by applicable law, and is intended solely for the use of the recipients to whom this email is addressed. If you are not one of the intended recipients you are notified that disclosing, copying, distributing or taking any other action in reliance on the contents of this email or any attachments is strictly prohibited. In a separate email, please notify the sender immediately if you have received this e-mail by error and delete the original email from your system. http://www.mass.gov/dpl PLEASE NOTE: We have moved. Our Boston address is now: Division of Professional Licensure 1000 Washington Street, Suite 710 Boston, MA 02118 - 6100 Mail will be forwarded for a short period of time if it is sent to our old address. 248 CMR 288 10.10: Plumbing Fixtures (18) Minimum Facilities for Building Occupancy Other Than Residential. 2. Assembly (Dedicated). a. All places of worship, arenas, stadiums, theaters, cinemas, restaurants, pubs, and nightclubs shall be classified as dedicated places of assembly and toilet facilities for each sex male and female shall be provided in the amount specified in 248 CMR 10.10(18): Table I for dedicated assembly. b. Where the capacity is more than 2,000 persons, the number of toilets for the first 2,000 persons shall be calculated using the ratios in 248 CMR 10.10(18): Table 1. For the number of persons in excess of 2,000, the number of toilets shall be calculated at ratio of one per 100 for women and one per 200 for men. c. In restaurants, pubs and nightclubs where the total combined number of employees and patrons that can be accommodated at any one time is less than 20 individuals and the total gross space is less than 1,200 square feet, one unisex, handicapped accessible toilet facility for use by both employees and the patrons shall meet the minimum fixture requirements of 248 CMR. 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Office of Consumer Affairs andBusiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration — = - Registration: 149813 a Type: DBA ti71 Expiration: 2/9/2012 LANDLINE CONSTRUCTION TODD LIVINGSTONE 21 NORTHVIEW AVENUE CHELMSFORD, MA 01824 )PS-CA1 Co 50M -04/04-G101216 �/ze T�anr�szonurea� o�✓�%aaaac/ucaelta Office of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR Registration;_ -".149813 ExpirationF/9/2012 Tr# 292893 LANDLINE CONSTRUGTfON TODD LIVINGSTQNEf-1--' { 21 NORTHVIEW X . Nf7E CHELMSFORD, MA 01824`' Undersecretary Tr# 292893 late Address and return card. Mark reason for change. u Address ❑ Renewal F-1 Employment ❑ Lost Card License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid without signature . . .22 ƒ @ _/ m � < \ _< $ -n \ . c / . . \ o m m� / / o / e .G 0 a \ \. . . , From Tonry Northwest Fri 23 Apr 2010 02:10:30 PM EDT Page 3 of 4 ACORU®DATE CERTIFICATE OF LIABILITY INSURANCE (MMOD/ "In 4/23/2010 PRODUCER ('181)861-1800 FAX: (781) 861-1804 Tony Northwest Insurance Agency, Inc. 238 Bedford Street Lexington MA 02420 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED - Todd J. Livingstone, DBA: Landline 21 Northview Avenue Chelmsf rd MA 01824 INSURERANDM Insurance Company 1A�88 INSURER Ek INSURER C: INSURER D: INSURER E: rnVFaerca THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'1 TYPEOFINSURANCE POLICY NUM BER POLICYEFFECTNE POUCYEXPRATION111L LIMBS GENERAL LIABILITY EACH OCCURRENCE $ 500,000 X COMMERCIAL GENERAL LIABILITY DA P M SESOEa ocNcu�rtenoe $ 500,000 O A CLAIMS MADE OCCUR mps9384G 1/5/2010 1/5/2011 MED EXP (Any are person) $ 10,0 PERSONAL & ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000 X I POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) BODILY INJURY ALL OWNED AUTOS SCHEDULED AUTOS (P- Pew) $ BODILY INJURY HIRED AUTOS NON -OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EAACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR FICLAIMS MADE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION WC STATU- I OTK AND EMPLOYERS' LIABLRY Y I N E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNFR/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ E.L. DISEASE - EA EMPLOYE $ (Mandatory In wt) If yes, describe under E.L. DISEASE- POLICY LIMIT $ SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS (978)323-9146 25 (2009101) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 90 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE L Tonry Jr./CMATTH ©1988-2009 ACORD CORPORATION. All rights reserved. IMOULD(zoosal) The ACORD name and logo are registered marks of ACORD 4/23/2010 2:30:08 PM 8975 ® 02/02 CERTIFICATE OF LIABILITY INSURANCE DTE (MWDDtYYY) A 04/23/2010 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 TEE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, 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 Tonry Northwest Insurance Agency Inc 238 Bedford Street #6 Lexington, MA 02420- CONTACT PHONE PAX (AjC. No. Ext): IANC. No): DADDRESS: CUST MER IDN. IIISURED(S) AFFORDINO COVERAGE MAIC N INSURED Todd J Livingston . dba Land Line Construction 21 Northview Ave Chelmsford, MA 01824-3775 INSURER A: A.I.M. Mutual Insurance Co IxSVAER B: INSURE„ C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIrY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. N07WXTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LDNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. r"er POLICY NUMBER POLICY EFF POLICY ESP L324M Ae: TYPE OF INSURANCE <nMNm, GDIMMTT, GENERAL LIABILITY EACH OCCURANCE 6 ❑C—..e IAL Ge NERAL LIABILITY DAMAGE TO RENTED PNMIISESIX..000arrenae) S F-111-- MADE ❑ OCCUR 1Q;D EXP (Ay one pezaon) S ❑ PERSoxAL 6 ADV INJURY S ❑ GEN'L AGGREGATE LIMIT APPLIES ER: OMRAL AOGAEOATE $ PRODUCTS - COAT/OP ROD 6 ❑PCL ❑PROJECT ❑LOC ICY 6 � AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT lea eocident8 S ❑I.NY AUTO BODILY INJURY (per pe—)6 ❑ALL OAP YO AUTOS BODILY INJURY(Per accident) 6 ❑SCHEDULED AUTOS PROPERTY (per acoiaDMGOE ent) 6 ❑HIRED AUTOS ❑NON-OWRED AUTOS S ❑ 6 ❑VMBAELLA I.-. ❑ OCCUR EACH OCCURRENCE 6 ❑EXCESS LIAB ❑ CLAIMS MADE AGGREGATE S ❑DEDUCTIBLE 6 ❑RETE)rTION 4 6 WORKERS COMPENSATION AND EMPLOYEES LIABILITY ®oTx- TDNr LDOTS Ep E.L. eAcx AcclDexr S PDD, UDD THE PROPRIETOR/PARTNERS/ EXECUTIVE OFFICERS ARE A ❑ incl ® excl 702293601201003/22/2010 E.L. DISEASE -EA EMPLOYEE 6 500,000 03/22/2011 E.L. DISEASE - EA EMPLOYEE 6 5()0,000 CONTENTS I DESCRIPTION OF OPERATIONS OR LOCATIONS: TODD J LIVINGSTON IS NOT COVERED BY THE WORKERSICOMPENSATION POLICY. CERTIFICATE HOLDER CANCELLATION MICHAEL 6 KAREN CARTER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE 595 SALEM ROAD POLICY PROVISIONS. NORTH ANDOVER, MA 01844 AUTHORIYED REPRESENTATIVE C--` 3931 HP Photosmart C6100 All-in-One series, Faz Log for TJ 978 323-9146 Apr 07 2010 4:50PM NOTE: Blocked calls are not displayed on this report. For more information, see Junk Fax Report and the Caller ID Report. Last Transaction Date Time Type Apr 7 4:50PM Received Station ID Duration Pages Result Caller ID 0:44 0 No fax 8662076903 OF The Commonwealth of Massachusetts Department o f industrial Accidents Office of Investigations 600 Washington Street Boston, M4 02111 www rnasS.gov/dia Workers' Compensation Insurance Affidavit: Binders/Contractors/Electricians/Plumbers :Ppdicant Information Name (Business/Orgmization/,�Ind�ivi�dual):L Address/ lt)oe-11ljl'% g�..s° - i i7r , � p i M Phone #: A�Tean employer? Check the appropriate boa: 1. LJ i am a.employer with , 4.. ❑ I am a general tor employees (full and/or part—time).* 2. ❑ I am a sole and I have hired the ub- ontractors proprietor or partner- listed on the attached sheet $ ship and have no employees These sub -contractors have working for mein any capaciti3�. [No workers' camp. inau,ranee workers' comp, insurance. . 5. ❑ We are :a. corporation and,ita required ]. 3. I am'a homeowner doing all officers have exercised their right work jmyself. [No workers ° comp. of exemption per MGL c. I52, § I (4), and we have inar*>ce required ] t no employees. [No workers' comp, insurance -;—A Type of project (required): 6. 0 New construction 7. Q Remodeling 8 Demolition . 9• Q Building addition 10:0 Electrical repairs or additions 1:1.0 Plumbing repairs or additions 12.0 Roof reps, qurre ] 13.[] Other S' ny agaircant that check bov #1 must also ED out the section 'oelow shoxna^ _ �__:_z I�omeowners who stiomit this affidavit indicatingthey are doing aL' work and m�hire ouutside ontractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub contractors and their workers' affidavit policy "information. I am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site information. Lnsurance Company Name: 1 04 %�,P)V / hi 'L�4.. / _ e— _ _ Policy # or Self -ins. Lie. #: r� �ij (�,Z-0/ Expiration Date: Job Site Address -1 Lo Oil �i. n� ` ,i / Attach a copy of the workers' compensation policy declaration page (`ahoy CityJState/Zip:�_�� Failure to secure coverage as required under Section 25A of MGL c. 152 can (showing to ththe e ira os olicy number Hoof and expiration date). fine up t$ $1,500a d and/or one-year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine P criminal penalties of a of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification I do here nder pains and penalties of perjury t Signhrtt the for mation provided above is true and correct ature: Phone #: -- Official use only. Dc not write in this area, to be completed by city or town offcm( City or Town: Permifir . ense # lssui� Authority (circle one): L Board of Health 2. Building Department 3. City/Tow). Clerk 4. Electrical Inspector 5. Piumbin� 6. Othera Inspector Contact Person: Phone #: Information an- d 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 peon 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 threes apartoz tints and who resides therein, or the occupant of the dwelling house of another who employs persons to do malate 3:1amce; constructon or repair work on such dwelling -house or on the grounds 6r building appurtenant thereto shall not because of such: employment be deemed to be ap. employer." MGL chapter 152; §2506) .also, states that "every;state or 10,4r-81 licensingagency..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 coampliance 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 unitil acceptable evidence of comP fiance with the insurance requirements of this chapter have been presented to the contractin authority.- _ g ornr Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation: and,.if_ necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along 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 cQTY 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 stare 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 .=J.engi ertt of Industrial Accidents. Should you.have any question.; regardii g 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 theyr self-insurance license number m the appropriate line: City or Town Officials 1 Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit f6r 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 provided to the applicant as proof that a valid affidavit is on file for future perznits 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 than 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 Commonwealths of Massachusetts Dcpartment of Industrial Accidents Office of Investibations 640 Washington Street Basten, MA 02 111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax 4 617-7?7-7749 vrvrwmass.-gov/dia C I 1 0,NS. f_ C `IJi F T.J. Livingstone Chelmsford, MA (978) 835-6063 Land Line Construction Co. will supply customer With General Liability & Workers Compensation Insurance Certificate Name: Michel & Karen Carpenter Date: 04-23-10 Address: 1 Den Quarry Rd, Lynn Ma. Phone: 978-835-5112 ROOFING PROCEDURES ➢ Clear the area of any breakable items that would obstruct the job site ➢ Install tarps from the roof fascia to the ground to prevent any damage to the Property ➢ Completely remove any existing layers of asphalt shingles and dispose of in container provided by Land Line Construction Construction. ($ Price will vary based on number of layers on roof, which must be stripped off) 2 Layers (Incl. in Price $$) ➢ Completely de -nail roof and re -nail roofing boards as needed, completing a full inspection of the Substrate. (Hurricane Nail if Nessessary) ➢ Replace any rotted wood at $2.50per board foot/or $50.00 for every 4x8 sheet of plywood, with customers approval. Apply Grace ice & Water Sheild, or Certain teed Winter Guard or Gaf Storm Guard to eaves of roof and 3 feet to all valleys, sidewalls, chimneys and flange pipes. Apply 151b felt paper to the remainder of exposed roof deck, (GAF Deck Armor or Grace Tri -Flex can be used for an optional under -laminate) Price will valiglily ➢ Install New 8" Drip edge around perimeter of House ➢ Apply New shingles in the style and color of your choice (Ex. Architect, Three tab) 30yr Architect. i Re- flash chimney with Ice & Water Shield on all sides of chimney, next install aluminum step flashing along sides of chimney, last apply New lead in front and back pan grinding four sides of chimney to insert lead, weaving it in with new shingles. (New Lead Only if needed, bring to customers attention) $ Additional /Charge ($300-600 per chimney(] ❑ himneys) New Lead Incl. ➢ All new flange pipes will be replaced ➢ Land Line Construction is not responsible for debris that may have fallen from roof into any attic space; it is the homeowner's responsibility to cover any personal belongings from being damaged. ➢ Land Line Construction is not responsible for the prevention of Ice Damns. We will however Guaranty that we can reduce those risks by using the very Best Under - laminate and Install that under -laminate the correct way. There are other precautionary measures that should be taken for the prevention of Ice -Damns, a. Proper Insulation, b. Proper Ventilation, c. Clean Gutters and Downspouts. ➢ Any variations from project will be drawn up on a separate contract and signed by both parties, (Change Order) ➢ Completely clear debris and dispose of in waste container provided by Land Line Construction Total Cost: $10,500 Payment Pricing: 1/3 due at signing of contract 1/3 upon start of job 1/3 due upon completion of job Any changes or add-ons in contract will be drawn up and signed by both parties Acceptance of Contract The above process, specifications and conditions are satisfactory and hereby accepted. You are authorized to do the work specified. Payment will be outlined above Date or Authorized Signature -/ S THANK YOU FOR CHOOSING LANDLINE COSTRUCTION