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HomeMy WebLinkAboutBuilding Permit #Exception - 62 CARLTON LANE 5/1/2018 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION is Permit NO: 4�J Date Received Date Issued:L 21 a IMPORTANT:Applicant must complete all items on this page LOCATION ! Print PROPERTY OWNER TZ�1�-� ti r Z � N Print MAP NO: PARCEL:Z1 ENING DISTRICT: Historic District yes An CpOD'o Machine Shap Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Buildingne fami Addition Two or more family Industrial Alteratio No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: I, Iden 'fication Please Type or Print Clearly) OWNER: Name: 12oA LIZ- reAJ6 Phone: 9 -697__0 %P Address: CONTRACTOR Name: Phone: -lf -2�b Address: ;5Pie 2-04C610 4 5 -tea Supervisor's Construction License: 5 )03 b1(40 Exp. Date: Home Improvement .License 1C01 Exp. 'Date.- Zz l ;H9-&CT/ENGINEER/7L5/6�& - C-2A4GCU LYPIOPhone:�� 7-75�� ,�� � [otilpt)1110��'� Address: 4� offla f) V(�a/ "DR A)If Reg. No. FEE SCHEDULE:BLiDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. / 0 �- �- Total Project Cost: $ 3 (e FEE: $ / Check No.: �4 03 Receipt No.: � NOTE: Persons contracting with unregistered contractors do not have access to the g a- fund Signature of Agent%Owne .F PSignature of contractor 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 u 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 o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) u 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: Doc.Building Permit Revised 2008 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Pu�Se Tanning/Massage/Body Art Swimming Pools 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 1• L Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department 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 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 Doc:.Building Permit Revised 2008 Location Z Cg�Z (�U�✓ C No. G,/g Date of r°oT: TOWN OF NORTH ANPI .. 9 Certificate of Occupancy $ ♦ orb+,��A`.• ♦ /� � � NusttA Building/Frame Permit Fee $ V Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 22761 Building Inspector NORTH Town of _t 4Andover L No. 1 LAKEover, Mass., ' COCHICHE WICK y^' ADRATE D S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......... ....ad.....7......... .EZ,,,,,,,, N d . .......... ....1 .............................................................................. Foundation has permission to erect.................... buildings �— f� son . .. ................ 2 Grl.........L,v Rough ............................ to be occupied as.. . .. ♦ .......... . . + Chimney. &oii�-io/-`t/e4teAr*mrsprovided that the person accepting this permit shall in every respect c of the application on file in Final 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU ON STARTS Rough . ....................................::..:.:.:....::...... .:.................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to OCcljpy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. f Burner Street No. SEE REVERSE SIDE Smoke Det. w BQARDWALK 2 Division of Data Industries,Inc. (for office use only) 24 Orchard View Drive Office ................... Londonderry,NH 03053 Order NO................. TEL(603)437-2500 Checked by .............. me - m FH boardwalknorth.com Purchase Agreement Name of Purchaser(s) RON&LIZ FORTINO Phone No. Daytime Phone No. Address 62 CARLTON LN NORTH ANDOVER MA (His or Me B) 01845 (No.) (Streeq (CRY) (Slate) (Lp) Mailing Address if different SAME Email 97R-6R2-0196 WORK SPECIFICATIONS We will furnish and install the REMODELING PROJECT PAGE 1 OF 4 as specified below: REMODEL TIM PXTCTTWC:'TZTTrT-TPW KITCHEN REMODEI:OVERVIEW 1.REMODEL THE EXISTING KITCHEN,LOCATED AND ST7F.D PER THE CONCEPTI TAI./CONSTRTICTION DRAWINGS DATED DECEMBER,2009. THE PROPOSED KITCHEN REMODELING PROJECT TO TN I.T TDF.-CABINETS, COUNTERTOPS.ROUGH AND FINISH PLUMBING.ROUGH AND FINISH ELECTRICAL,WINDOW,FLOORING, DRYWALL(MUD,TAPED,&SANDED AND READY FOR PRIMING).RANDOM SWIRL.SOFT TEXTURED.SAND FINISHED CEILINGS(OR SIMILAR TO EXISTING),AND ALL THE NECESSARY INTERIOR FINISH CARPENTRY.ALSO INCLUDES MODIFYING INTERIOR WALLS TO INCLUDE:PATCHING DRYWALL AND CEILINGS WHERE NECESSARY AS A RESULT OF THE REMODELING EFFORT,AND REMOVAL AND RELOCATION OF ANY EXISTING 110V OUTLETS AS DEEMED NECESSARY BY THE COMPANY. KITCHEN REMODEL: DEMOLITION I 2.REMOVE EXISTING KITCHEN CABINETS,COUNTERTOPS,FLOORING,SINK,FAUCET AND APPLIANCES,TO j SUPPORT THE PROPOSED REMODELING EFFORT,PER THE CONCEPTUAL/CONSTRUCTION DRAWINGS DATED DECEMBER,2009. KITCHEN:CABINETS 3.PROVIDE AND INSTALL NEW"GEPPETTO BRAND"(OR SIMILAR IN PRICE)"SHAKER STYLE"KITCHEN WALL AND BASE CABINETS,LOCATED AND SIZED PER THE CONCEPTUAL/CONSTRUCTION DRAWINGS DATED DECEMBER, 2009(SEE ALLOWANCE SCHEDULE). Remarks: This contract supersedes all conversations, statements and Price and Payment— agreements expressed or implied,between the parties,their agents Cash price....................................$ 83,936.00 and representatives. Payments to be made as the work progresses as per the Payment Schedule Purchaser(s) authorize Boardwalk North to Investigate credit which Is attached and made part of this Contract: / worthiness. Date All work started above to be completed In a workmanlike manner Owner according to the floor plan,job specifications and terms and con- ditions as stated on the back of this form. Date nor 12/30/2009 By: Date Boardwalk North Representative BOARDWALK A Division of Data Industries, Inc. (for office use only) 24 Orchard View Drive Office ................... Londonderry,NH 03053 Order NO...... H TEL(603)437.2500 Checked by .............. NMiboardwalknorth.com Purchase Agreement Name of Purchaser(s) RON&LIZ FORTINO Phone No. Daytime Phone No. Address 62 CARLTO_N LN NORTH ANDOVER MA (Hrs orHB16) 01845 (No.) (street) (City) (state) (Zip) Mailing Address ff different SAME Email 978-682-0196 WORK SPECIFICATIONS We will furnish and install the REMODELING PROJECT PAGE 2 OF 4 as specified below: KITCHEN-rOIJNTFRTOPS 4.PROVIDE AND INSTALL NEW GRANITF.C01 NTERTOPS(OR -,Rv i.AR IN PR TICE),WITH A Q ASS MOSAIC BACKSPLASH.LOCATED AND SIZED PER THE CONCEPTUAL/CONSTRUCTION DRAWINGS DECEMBER 2009(�SF>~ THE ALLOWANCE SCHEDULE). KITCHEN:CABINET HARDWARE 5. PROVIDE AND INSTALL KITCHEN CABINET HARDWARE LOCATED AND SIZED PER THE CONCEPTUAL/ CONSTRUCTION DRAWINGS DATED DECEMBER,2009(SEE ALLOWANCE SCHEDULE). KITCHEN:PLUMBING 6. PROVIDE AND INSTALL A NEW DOUBLE-BOWL KITCHEN SINK AND A FAUCET WITH A PULL-OUT SPRAYER, PER THE CONCEPTUAL/CONSTRUCTION DRAWINGS DATED DECEMBER,2009(SEE ALLOWANCE SCHEDULE). KITCHEN:ELECTRICAL 7.PROVIDE AND INSTALL LIGHT FIXTURES TO INCLUDE:(12)RECESSED LIGHT FIXTURES,TIED INTO A THREE-WAY SWITCH,WITH ONE OF THE SWITCHES BEING A DIMMER CONTROL UNIT,UNDER CABINET LIGHTING,TIED INTO A SINGLE POLE SWITCH,AND NEW 110V OUTLETS,AS DEEMED NECESSARY BY THE COMPANY,THROUGHOUT THE PROPOSED KITCHEN.ALL NEW WIRING TO BE TIED INTO THE EXISTING ELECTRIC PANEL(SEE ALLOWANCE SCHEDULE). KITCHEN:APPLIANCES 8.PROVIDE AND INSTALL A NEW REFRIGERATOR,SLIDE IN STOVE,DISHWASHER,AND MICROWAVE.(SEE ALLOWANCE SCHEDULE) Remarks: This contract supersedes all conversations, statements and Price and Payment— agreements expressed or Implied,between the parties,their agents Cash price....................................$ 83,936.00 and representatives. Payments to be made as the work progresses as per the Payment Schedule Purchaser(s) authorize Boardwalk North to Investigate credit which Is attached and made pal of this Contract: • worthiness. Date 3v O All work started above to be completed in a workmanlike manner Owner according to the floor plan,Job specifications and terms and con- �f� ditions as stated on the back of this form. a Date Owner 12/30/2009 By: Date Boardwalk North Representative BOARDWALKA Division of Data Industries, Inc. (for office use only) 24 Orchard View Drive Office ................... mHLondonderry,NH 03053 Order NO................. TEL(603)437-2500 Checked by .............. boardwalknorth.com Purchase Agreement Name of Purchaser(s) RON&LIZ FORTINO Phone No. Daytime Phone No. Address 62 CARLTON LN NORTHANDOVER (His or Here) (No.) (Street) (City) MA (State) Mailing Address if different CAMF. Email 978-682-0196 (zip) WORK SPECIFICATIONS We will furnish and install the REMODELING PROJECT PAGE 3 OF 4 as specified below: KITCHEN. FLOORLN(; 9.PROVIDE AND INSTALL NEW CFRAMTC FLOOR TILE THROL GHOTIT TRI PROPOSFD KTT('HEtlMSTAi T t~n OVFR .THE EXISTING S1 JB F LOOK,OR AS DETERMINED BY THE CompANy (SFF Al I OWA- (.F S('>F,'rDI IT F) KITCHEN: WINDOW 10. PROVIDE AND INSTALL A 3-PANE BOW WINDOW WITH TWO OPERATING PANES,PER THF rnNCEPTU / CONSTRUCTION DRAWINGS DATED DECEMBER.2009 KITCHEN:OFFICE AND DESK AREA 11.REMOVE AND RELOCATE THE EXISTING WALL BETWEEN THE KITCHEN AND THE DEN AND PROVIDE AND INSTALL A DESK AREA IN THE PROPOSED KITCHEN PER THE CONCEPTUAL/CONSTRUCTION DRAWINGS DATED DECEMBER,2009. REMODELING:DRYWALL 12.PROVIDE AND INSTALL NEW 1/2"GYPSUM WALLBOARD(DRYWALL)ON THE INTERIOR CEILING AND WALLS (AS NECESSARY)OF THE PROPOSED KITCHEN,TO INCLUDE:PATCHING AS NECESSARY RESULTING FROM THE REMODELING EFFORT.ALL DRYWALL TO BE FILLED,SANDED AND FINISHED TO A PRRAE-READY STATE. KITCHEN:MILLWORK AND TRIM MOLDING(INTERIOR) 13. INTERIOR WINDOW AND DOOR MOLDINGS TO BE 2-1/2"INCH,PRE-PRIMED,FINGER JOINTED,COLONIAL STYLE. INTERIOR BASEBOARD MOLDINGS TO BE 3-1/2"INCH,PRE-PRIMED,FINGER JOINTED,COLONIAL STYLE. PAINTING 14.ALL PRIMING,PAINTING,STAINING AND/OR PREPARATION THEREOF TO BE COMPLETED BY THE CUSTOMER OR WILL BE QUOTED SEPARATELY UPON REQUEST. Remarks: This contract supersedes all conversations, statements and Price and Payment— agreements expressed or Implied,between the parties,their agents Cash price.................................... 5 83,936.00 and representatives. Payments to be made as the work progresses as per the Payment Schedule Purchaser(s) authorize Boardwalk North to Investigate credit which Is attached and made part of pis Contract: worthiness. Date 1 Z 3c o All work started above to be completed In a workmanlike manner Owner according to the floor plan,lob specifications and terms and con- ditions as stated on the back of this form. Date �J 12/30/2009 By: Date oardwalk North Representative BOARDWALK A Division of Data Industries,Inc. (for office use only) 24 Orchard View Drive Office ................... Londonderry,NH 03053 Order NO................. xHTEL(603)437-2500 Checked by .. ............ boardwalknorth.com Purchase Agreement Name of Purchaser($) RON&LIZ FORTINO Phone No, Daytime Phone No. Address 62 CARLTON LN NORTH ANDOVER MA (Nm or Her's) Olga (No) (SIM69 (City) (State) (ZIP) Mailing Address if different SAW, Email 97R-6R2-0196 WORK SPECIFICATIONS We will fumish and install the REMODELING PROJECT PAGE 4 OF 4 as specified below: PLANS 15_FINAL CONSTRUCTION DRAY ING9,ENDORSED)TNFRF N 4IIPFR4FnF Ali CONCEPTUAL DRAWmMC:4 GENERATED DURING THE T)ESIGN PRO S4 DEBRIS REMOVAL 16.INCLUDES REMOVAL OF ALL DEBRIS NOTE:THE NEED FOR ANY ENGINEERING REPORTS SUCH AS PLOT PLANS OR VARIANCE-REQUIRED PLANS AND/OR STUDIES DUE TO EXISTING CONDITIONS,WILL BE QUOTED SEPARATELY UPON REQUEST BUILDING PERMITS 17.INCLUDES ALL THE NECESSARY BUILDING PERMITS,BUILDING PERMIT FEES AND APPLICATION THEREOF EXCEPT AS NOTED. NOTE:SURVEY AND/OR CERTIFIED PLOT PLANS,ZONING BOARD,AND/OR CONSERVATION COMMISSION APPLICATION(S)EFFORT TO BE QUOTED SEPARATELY UPON REQUEST. IItJ�GG ;�/n/ Aff-) 1rV 10 AeZa9A&Z4r- Remarks: 7b . This contract supersedes all conversations, statements and Price and Payment— agreements expressed or Implied,between the parties,their agents Cash price....................................$ 83,936.00 and representatives. Payments to be made as the work progresses as per the Payment Schedule Purchaser(s) authorize Boardwalk North to investigate credit which Is attached and made part qj this Contract: worthiness. ] Date All work started above to be completed In a workmanlike manner Owner according to the floor plan,Job specifications and terms and con- ditions as stated on the back of this form. Date O r 12/30/2009 By: Date Boa alk North Representative r X �WO)nl = Bord o ga ulalonsan tan ar One Ashburton Place - Room 1301 Boston, Massachusetts 02108. OCT" t Home Improvement Contractor Registration .. .. w Registration: 161542 i Type: Private Corporation .. "` Expiration: 10/27/2010 Tr# 276787 DATA INDUSTRIES, INC. EDWARD STEWART 24 ORCHARD VIEW-DR.---- LONDERRY, NH 03053 Update Address and return card.Mark reason for change. - ❑ Address F-] Renewal ❑ Employment ❑ Lost Card )PS-CA1 0 50M-07/07=PC8490 A. Board of Building Regulations and Standards License or registration valid for individul use only =—HOME IMPROVEMENT CONTRACTOR before the expiration date.-If found return to: 't11 Board of Building Regulations and Standards RegistrattoA 161542 One Ashburton Place Rm 1301 EX011 iari 0/27/2010 Tr# 276787 .-� ` Boston,Ma.02108 Tpe Rnw,ate Corporation DATA INDUSTR SRN, a I EdWARD STEW `r QRGHARD VIEi"_K LONDERRY,NH 03053' Administrator Aot4tsignature i i.iassacnusetts- uepartment of rublic SafctN Board of Building Regulations and Standards Construction Supervisor License License: CS 103316 .BRIAN L�RI3 '' .,IR MORD IDE DRIVE DERRY,NF 1.10038:..', � -—d i�►.E Expiration: 3/14(2013 Commlashwer• Tr#: 103316 Restricted to: 00 00- Unrestricted 14-1 2 Family Homes i Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Refer to: WWW.MaSLCrov/DPS t��.vrru ULK I INUA I L OF LIABILITY INSURANCE .1""'T��2009 .06/01/2009 RODUC R (603)432-3666 FAX (603)432-6076 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Lakeside Insurance Agency, Inc. & C&G Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE One Wall Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Windham, NH 03087 INSURERS AFFORDING COVERAGE NAIC# .SURED Data Industries, Inc. , INSURERA: Peerless Insurance 24198 dba Boardwalk North INSURERS: Excelsior Ins. Co. 11045 24 Orchard View Drive INSURER C: Londonderry, NH 03053 INSURER D: INSURER E: OVERAGES 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. ALT R DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATEIMMIDDan GENERAL LIABILITY CBP8445959 06/01/2009 06/01/2010 EACH OCCURRENCE $ 1 OOO 1 OO X COMMERCIAL GENERAL LIABILITY - DAMAGE TO RENTED $PRFMIRFA(F. 100,00 CLAIMS MADE FX OCCUR MED EXP(Any one person) $ 1S,0011 A PERSONAL&ADV INJURY $ 1 000,00( GENERAL AGGREGATE $ 2,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00( POLICY JET MLOC AUTOMOBILE LIABILITY BA8446559 06/01/2009 06/01/2010 COMM 11D SINGLE LIMIT X ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ A HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY CU8446959 06/01/2009 06/01/2010 EACH OCCURRENCE $ 2,000,00 X OCCUR FICLAIMS MADE AGGREGATE $ 2,000,000 A $ HDEDUCTIBLE $ X RETENTION $ 10,000 $ WORKERS COMPENSATION AND WC84463 59 06/01/2009 06/01/2010 X WC S I ATU- OTHIMITR FR - EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 100 OO B ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE1$ 100,00( SPEs,describe under CIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$ 500 00 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS overing residential carpentry and related operations to be performed by the named insured during the olicy period. orker's Compensation statutory coverage is provided for New Hampshire. Executive Officers have lected to be excluded from Worker's Compensation coverage. CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MNL lO_DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MNL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. For Information Only AUTHORIZED REPRESENTATIVE .d4 Edwin Duvall LYNN ACORD 25(2001/08) ©ACORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street looston, MA-02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): &9,4 ,VpW2,21 AADIY-1 Address: Z City/State/Zip: 4DA1'DfP(Z'/i A/14 05D53 Phone#:43�Lf3 7-71500 Are you an employer?Check the appropriate bog: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or.partner- listed on the attached sheet.1 7• �,Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp, insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. Electrical re required.] officers have exercised their ❑ pairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp.insurance required.] *.;,,y appl:'cant that checks.box fl; _-Iso fill out the section below showing their workers'compensation policy information. fi Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractor;that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 48k0lDr /,AJ,14RA Z. t ,SN( Policy#or Self-ins.Lic.#: UX! C�q qtg 5 ` Expiration Date: (a, o Job Site Address: �P 0 Gzg9 ao-A) Lo City/State/Zip:_ V. AA46W 72 A 4-0t945 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead 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 STOP WORK ORDER and a fine 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 verification. I do herebyrtify an en of perjury that the information provided ab ve is true and correct Simature: Date: `/` f� Phone#: (O05 3 U/ Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitUcense# 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 apartrnents 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 commonwealth 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 acceptable evidence of compliance with the insurance 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-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)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 anddate the affidavit. .The affidavit should be rei=ned 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 Office of Investigations would like to thank 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 640 Washington Street Briton,NIA 0.21.11 Tel.# 617-7274900 ext 4.06 or 1-877-MASSAFE Revised 5-26-05 Fax 4 617-727-7749 vwvw7.mass.gov/dia 4'-0"x 3'9'• 5,-B" IL DW OPTIONAL BUTCHER n BLOCK ISLAND O cn4-ANG PROP05ED KITCHEN MESSAGE AREA PANTRY RE 8_1p11 } HEADERS RELOCATED WALL PObTb F-� THIS DRAWING IS THE PROPERTY OF BOARDWALK NORTH REVISIONS CLIENT FORTINO TITLE CONCEPTUAL AND ANY USE OF SAME WITHOUT THE EXPRESS WRITTEN THESE DRAWINGS REPRESENT AN OVERALL DESIGN CONCEPT. THEY ARE PREPARED APPROVAL OF BOARDWALK NORTH SHALL SUBJECT WITH THE INTENT TO DEMONSTRATE THE OVERALL DESIGN ARRANGEMENT AND METHBOARDWALKOD FLOOR PL�4N THE USER TO A RILL COMMISSION. OF ASSEMBLY TO THE VARIOU5 COMPONENTS. THE DRAWINGS DO NOT INDICATE vERIFY ALL H 62 CARLTON LANE EXTENSIvE DETAILS. BOARDWALK NORTH HAS REVIEWED THESE PLANS,SEEN THE EXISTING NORTH ANDOVER, MA COPYRIGHT © ZOOS BOARDWALK NORTH SUBJECT PROPERTY AND 15 CAPABLE OF EXECUTING TLE DETAIL WORK NECESSARY CONDITIONS SCALE: 1/4".1' PAGE. /�—O� TO ACHIEVE THE INTENDED RESULT IN A MANNER CONSISTENT WITH DUALITY IN FIELD A OESIGN/YUILD COMPANY /V_ THIS DRAWING 15 COPYRIGHTED BY WORKMANSHIP STANDARDS,COMMENSURATE WITH THE"RESIDENTIAL CONSTRUCTION BK: PG. MAP: LOT: 102 DATE: 19/29/p9 BOARDWALK NORTH. UNAUTHORIZED PERFORMANCE GUIDELINES",PRODUCED IN COOPERATION WITH THE YYMIY6WNDMALKNORTMAOY APPROVAL, OF: USE 18 A VIOLATION OF FEDERAL LAW NATIONAL A550CIATION OF HOME BUILDERS. DRAWN BY: GJD