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HomeMy WebLinkAboutBuilding Permit #772-2017 - 60 RUSSELL STREET 2/15/2017TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: / � - � / Date Received 1-7 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑Industrial ❑ Alteration No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ' �Wet_la_nds� Water%Sewer DESCRIPTION OF VVUXK I O tjt rtKruKivitu: �'•�iS%/-ill /�/ i��P�/-�«/��'i�-f- !��/lO��t Identification Please Type or Print Clearly) OWNER: Name: Melt- kBc,-P1Ft -Ar ` Phone: 9�79-22- Address: 462 ,PU.5;5 71 5T t6c'60 ACTOR Nance .:Cp:Tz_�.1._ _ L! -5S .Address: X8.0 &t iiso_r's Const�ucf ori;L cense G -Home lmn.roVArbEflt L'icerise�. r//2.5� ARCHITECT/ENGINEER Phone: + 3 Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F. Total Project Cost: $ 7,lo ° °• — FEE: $ Check No.: �5-9 U — Receipt No.: 2� NOTE: Persons contracting wit registered contractors do not have acAtoyarantyfund ure of.Q ent/O''her'�>oritract ... �S e._of..c ..... Plans Submitted El Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Plann-ing Board Decision: Comments r t Conservation Decision: Comments Water & Sewer Connection/signature & Date Driveway Permit DPW Tower Engineer: Signature: Located 384 Osgood Street FIRE DEPAKTMENT` - Temp Dumpster on site yes no Located -at'124 Mair.,' Street Fire Departmer-it signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions - Total land area, sq. ft.: ELECTRICAL: Movement of Dieter 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.$10041000 fine NOTES and DATA =- (For department use El Notified for pickup - Date Doe.Building Permit Revised 2010 Building Department Tine fohowing 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 DOTE: 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 DOTE: 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 TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all ceis,�s if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apn,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must boz- submitted with the building application Doc: Doc.Bubding Permit Revised 2012 Location (D � g v S S -P L La No.(7 74) — 20 %% Check # L; q, 0 �-, ;:) 16 2 4 Date 9 ` I~ a `? TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $�� Foundation Permit Fee $ Other Permit Fee $3 TOTAL $ / L C/ Building Inspector Or=� < � y CD, m 0 � CD C7 N' O CL_ m Z c s CO) -q ca: -n C a1 rt O O "r Q �• 177 .�. �D W-- 0 0 rt Cl) N C C �D ; 70 Cl) CD 2 Q o CL c �► y n to coo�A p fi �•=r0 cD o0 3 CDCD CD O�• Z -0 Q• --1 c - c� r.. CL o D co U CL 0 CD c <CL <� O Z -4M 0- (D c `1) ;, cD Q�• CD cc Q CD a CDCD CD U r�o3 �Z a)� L C Cl) rz D=,-� N b > c ;� !®r -,,, Q cn � :r .-r -� U) Z Z • oo A CD C CD 3 � fcD z CD VQ 0 co n@ CD r m = a• CD O o � v � C 3 O Z O N -r z O 7 fD A� S T 7 N < n N - O C a. T Dl X O C GQ T j Ol S a) •G O C as S O C 7 N CD -O = O O CL T m 'az D -i '�' I m r m r- C W z G)O M O O C r 2 -a m (D 3 S fD W O > v m z 700 = C J J N C A� ow O C O 1 Home Improvement Contract * Gary Liss, General Contractor 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 an work on your residence. You may obtain a free copy by call the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1 -888 -282 - Homeowner Information Contractor Information Name : Nicholas Bordeianu Company Name: Gary Liss General Contractor Street Address: 62 Russell St Contractor/ Salesperson/ Owner Name: Gary Liss City/Town: North Andover Business Address (must include a street address: 13 Stonewall Terracre Daytime Phone 978.223.5287 Evening Phone City /I'own:Atkinson State: NH zip code:0381 I same Mailing Address (If different from above) Business Phone 603.362.5185 Federal Employer ID Number: 020386673 Lowrequiresrhasmorhomc impmvemmt cDtft o a Homelmpro ton Coo,,,dw Reg.Nuoiber onshucdw supervisor =1o. hove a valid registretiw comber 112595 license Number CS -053506 The Contractor agrees to do the following work for the Homeowner: Supply and install 14 Harvey vinyl double hung "Classic "replacement windows Required Permits - The following building permits are Proposed Start and Completion Schedule - The following schedule will be required and will be secured by the contractor as the adhered to unless circumstances beyond the contractor's control arise homeowner's agent (Owners who secure their own permits MGL —2/16/2017 Date when contactor will begin contracted work will be excluded from the Guaranty Fund provisions of chapter 142A.) Will be completed within 6 months of start date (Describe in detail the work to be completed, specifying the type, brand, and grade of materials to be used, use additional sheets if necessary) 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 $7,600.00 Payments will be made according to the following schedule: $ 7,600.00 due upon completion of installation. (Law forbids demanding full payment until contract is completed to both party's satisfaction) NOTES: M Including all finance charges (fe) Law requires that any deposit or down -payment nxprimd by theconhactor before wadt beginsmay not exceed the greater of(a)onethirdofthe total contract price or(b) the actual cost ofanyspecialequipmentor oncustommadematerial which must be special ordered in advance to meet the completion schedule. Express Warranty- Is an express warranty beta provided by the contractor? nNo OYes (All arms ofthe warrarmty must he attached to the contract) Subcontractors -The contactor agrees to be solely responsible for completion ofthe work described regardless ofthe actions of any third parry/ subcontractor utilized by the contactor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance - Upon signing, this document becomes a binding contact 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 writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757. subcontractors to be registered with the Director of Home Improvement Contactor Registration. You may inquire about contractor registration by • Does the contactor 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 ofthis form and get a copy ofthe Consumer Guide to the Home Improvement Contactor Law. You may cancel this agreement if it has been signed at a place &Neer than the contractor's normal place of business, provided you notify the contactor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight ofthe third business day following the signing of this agreement See the attached notice of cancellation form for an explanation of this tight DO NOT SIGN THIS CONTRACT IF THERE AREC � BLANK SPACES! wpics ofthe compo mutt be wmpimed and signed, one copy sbould go to the M;:] Grf`�11Homeowners Signatttre cts Date: 2/6/17 Date: 2/6/17 Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an altemative 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 contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration fmn which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be requirIt to such arbitration as provided In Massachusetts General Laws, chapter 142A. Homeowner's SignatureContractor's Siature NOTICE: The signatures of the parties above apply only to the agreement of the parties to altemative dispute resolution initiated by the contractor. Tire homeowner may initiate altemative dispute resolution even where this section is not separately signed by the parties. nomeowners "nts 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/bomeowner 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 exlnbits 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 hi cases where the homeowner deems Mm/herselfto be financially insecure. However, in instances where a contractor deems himtherselfto 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 ifyou 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 bttoJ/www.mass.eov/ocabr/ If you want to verify the registration of 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 617-973-8787,889-283-3757 or visit the HIC website at httpJ/avvw.mass.eov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.usthomeimDrovement/licenseelist 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 ARID/OR Better Business Bureau 508-652.4800, 508-755-2548 or 413-7343114 Version 2.1-1122/2010 Insurance Solutions Corporation - Paige 1 of 1 CERTIFICA►,TE OF' LIABILITY INSURANCE dATE(MINIdDlYYY1�a/15/2017 ERTIFICATE lS 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 IVH 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 pollcy(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 NA aN CT Linda nogdanowicz Insurance Solutions Corporation PHONEN. p., (603) 382-4600 FAX • (603) 382-2034 60 Westville Rd E A 1andab@iso-insurance,com INSURER ($) AFFORDING COVERAGE NAIC # EACH OCCURRENCE$ 1,000,000 INSURERANMG Insurance CoMani 15997 Plaistow NH 03865 INSURED NR Rf R ®:NOrGt1ARD tngUranCa,,COMPany31470 INSURER c ; GARY LISS INSURERD: DBA GARY LISS GENERAL CONTRACT AUTOMOBILE X 13 STONEWALL TER ATKINSON NFT 03811-2148 INSURER F: COVERAGES CERTIFICATE Nl1MRFR-CL1662827670 RFV1C1nN fit IMRPDI THIS IS TO CL`-RTIPY THAT THI= POLICIES OF INSURANCE LIS'T'ED EILLOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE rOR 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 DE$CRI5EQ HEREIN IS $USJECT TO AU. THE TERMS, EXCLUSIONS ANIS CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN RE;DUCCD BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICYM®ER I Y LIMITS 71, X COMMERCIAL GENERAL LIABILITY C;LAIMS.MADE X OCCUR SC12244770 5/15/2016 5/15/2017 EACH OCCURRENCE$ 1,000,000 G>AMA(AE 7' ] EN"ED 250,000 M<GIMP Anyone rRrzgn $ 51000 PERSONAL & ADV INJURY $ 1,000,000 GEN`L AGGREGATE LIMIT APPLIES PER: .1POLICYEl FRU: JSCT (-.UG rl OTHER: GENERAL AGGREGATE $ 2,000,000 PROf)UGTS • COMPIpP ACG $ 2,000,000 AS09X S AUTOMOBILE X LIABILITY ANY A()TG) ALL OWNED xSCAUTOS HEDULED AUTOS NON -OWNED HIRED AUTOS Atyros TCA12244770 5/15/2016 5/15/2017 COM N^ N 4 1 S 11000,000 BODILY INJURY (Per porsvn) S BODILY INJURY (Per mmidant) S PROPERTY DAMAGE $ Mulfi )oli, cradil $ UMBRELLA LIAR EXCESS LIAR (aCi UR CLAIMS -WADE EACH OCCURRENCE $ AGGREGATE $ f FD RFT' :N't'ION 8 $ WORKERS COMPENSATIONPCR AND EMPLOYERS' LIABILITY YIN ANY FIrOhIiIfTOItiP'AItMtrLlXr.r,UrlvF OFFICER/MEMBER EXCLUDE07 ENI (Mandatory In NH) If If yyez, dq*rriba undrr OF OPERATIONS bPlow A GAWC788434 NH 5 MA limtad in 3A 6/1.5/2016 6/15/2017 UTH- A 'UTE E.L. EACH ACCIDENT $ 100,000 F.I,. C)l.SEA$F • FA F.,MP1,.OYE $ 100 000 E.L. DISEASE • POLICY LIMIT S 300 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may bo attached It more spaco is roquirod) (979)6$8-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of N Andover MA. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main 5t ACCORDANCE WITH THE POLICY PROVISIONS. N Andover, MA 01845 AMORIZIED REPRESENTATIVE t Ye::l'Ch Lyag.l. l aI 7F3 ••-,--�;.., ,.... ,....,, ,:....,....., 41988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 oriianrn A� EP CERTIFICATE OF LIABILITY INSURANCE DTE (MWD INSR L o 16 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(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 NAME: ONTACT Linda Bogdanowlcz Insurance Solutions Corporation PHONE.Extl: (603)382-9600 AIC NO:(603)362-2034 60 Westville Rd E-MAIL ADDRESS:lindab@isc-insurance.com INSURERS AFFORDING COVERAGE NAIC # INSURERAMG Insurance C2La2aRy 15997 Plaistow NH 03865 INSURED INSURER B NorGUARD Insurance Company 31470 INSURERC: GARY LISS DBA GARY LISS GENERAL CONTRACT INSURER D: 13 STONEWALL TER INSURER E: ATKINSON NH 03811-2148 INSURER F: ---------------- 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 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR L TYPE OF INSURANCEJ= ADDL SUER ima POLICY NUMBER POLICY EFF MMIDD POLICY EXP MMIDD LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGE TO RE TE 250,000 PREMISES Ea occunence$ MED EXP (Any one person)$ 5,000 SC12244770 5/15/2016 5/15/2017 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑ jEa FILOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMP/OPAGG $ 2,000,000 ASBBX $ OTHER: AUTOMOBILE LIABILITY Ea Maid D SINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ A ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS KA12244770 5/15/2016 5/15/2017 BODILY INJURY Per accident $ ( ) X HIRED AUTOS R NON -OWNED AUTOS PROPERTY DAMAGE Per accident $ Multipolicy credit $ UMBRELLA LIABOCCUR HCLAIMS-MADE EACH OCCURRENCE S EXCESS LIAR AGGREGATE $ DED I I RETENTIONS $ B WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY YIN ANY PROPRIEfOR/PARTNER/EXECUTIVEE.L. OFFICERIMEMBER EXCLUDED? ❑Y (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below A NIA GAWC788434 6/15/2016 6/15/2017 PER OTH- STATUTEI ER EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE S 100,000 E.L. DISEASE - POLICY LIMIT S 500 000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Keith Maglia/LJB ©1988-2014 ACORD CORPORATION- All rinhic rasprvpri ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS02512014n1I Fite Commorrrvealth of A9arssachuselts ur'jr'riamemr ref 1111drrstt'iarl / cchlettis Office of ,trivestigartiott s 600 ii'ashingtoit ,Strcet Roston, MA 02111 U9 imilw mass govIdia Wfjl'I<kW Compbtt flott Instfrance Affi(lavit: i3ttiklcrs/�:tttttra(:tors/l?lectrieiattslfiltteaalbers At)blicattl Please Print tLegibly Naitic (Business/organizatioti/tnttividual). Address: /-,F % e ,Pt?r- C.E City/Stale/Zip:>/wISG�r /M 034`// 111011C if: 3G2/��'�� Ate yoo -,fit r•ftioiiyjtW dikkk boa: 1. a! rein ddlipfoytit with 2. 4. ❑ I ami, general contractor and i etnployees (lull ad/ori pat( -tune).' have hired the sub -contractors 2. ❑ 1 am a sole [troprietot of partner- listed on the attached :heel. 1 ship and have no employees These sub -contractors have working tot file in any capacity. workers' comp. insurance. [No tvoikets' comp. insiftailce 5. ❑ We area corporation and its requited. officers have exercised Iheir 3'. ❑ 1 ani a hotfleowtiet doing all work right of exetnption per MGL ittyself. tlo *Iitkets' Whip. c. 152, § 1(4), and we have no insurance touired.J t employees. [No workers' c011i1). insurance raluiml.J *Any nlrl,licnnt that checks twit fit must also rill out the C t—1 Type of project (requiried): 6. El New constructioil 7- El Remodeling 8. ElDcnmlition 9. El Buildingaddition 10.❑ Electrical repaits or additions 1 1.❑ plumbing repairs or additions 12-ElRoofrepairs 13.['1 Other Ay/.1iVo 4-,,S sec roil ow showing (herr workers annpen:arhon policy infornmtion: f Ilomeowncrt who sutiinii this attidevit 1tnticaling they Are doing all work and then hire outside contractors must suinnit n new nnidnvit indicnt lig such. (Contractors (lint eliiA hies 6x taus( iil(6ched en additional sheet showing the name of the sulrconttnctors and their workers' corttp. policy inrorttrnlion. I atrr an enrpPoyci• Hili( is pt•oi�idhig ►tlorkees' compettsatiort instararrce for rrrp rnyrlt►Pces. 13cloty is the polirh arras'joli site dnjor rrrarioti. Insurance C01110 fy Name: M:G46, %4-f2 Policy It of Seii ihr . k.1c. #: 6A!yC'2PP.93F t xpir,tion Dale: -- Job Site Address:*/.Z �l1SS GL S�City/sWelZip:/1/�,rlODilG��-� Aft iich a coley bt (lit' wt1Fl{iri-s' E"Vensation policy declaration page (showing the policy rluntber and expiration date). railute to secure c0crage a5 tcgttired under Section 25A of MGL c. 152 can lead to the imposition of criminal petl:tlties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil pe►raitics in the Rtrrn of a STOP WORK 01tUE IZ and a floc of up to $250.00 d day against die violator. Be advised that a copy of this statement play be forwarded to the Office of Investigations oftlfc btA Cot insurance coverage verification. 1 do hel-eby reiiijr Ute rttid!,rnalties of petjttly that the irrrol-nrafiolr provided above is tr►re and cnrr-ect: Phone #: - e'e0 3 36 Z 5,l $ S"11 VfTlcial use vial�k Do irot it-i•ite in tris area, to he completed lyy rirj• or- torrlr ofTrial. City or,rilwf ., Pct—mit/license if Issuing XvIt tothy (clinic obit): 1. [lont•d bi tletiittt 2. hilliding Depnrtment 3. City/Cown Clerk G. Otter 4. i?lectrical inspector- 5. 1'11111tlrinR 1«spector Contazl i'ei-solt: thane t1� 6/a (Comweoiewea l?, o�C�il/�crrarrc�ccarl�2 \ _ Office of Consumer Affairs & Business Regulation (,�iOME IMPROVEMENT CONTRACTOR _tegistration: .".1.)2595 Type: Expiration : -_:-'4F9!201:7`_ Individual GARY E. LISS GARY. LISS _ f3 STONEWALL TER ATKINSON, NH 03811 Undersecretary Massachusetts - Department of Public Safety Hoard of Building „eguiations and Standards License: C"53506 GARY E LISS = :, 13 STONEWALL -TE ,xK' Atkinson NH 03811 �� • Expiration Commissioner 03/30/2017