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Home My WebLink AboutBuilding Permit #252-13 - 67 SHERWOOD DRIVE 10/1/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION t Permit NO: �� Date Received Date Issued: /,P// g— Ewod IMPORTANT:Applicant must complete all items on this page LOCATIONI s Lj� ' �Frint' 100�Year OldiStructure.� yes:, no' - 3 MAP-'NO; �� ARCEL ZONING DISaTRIC_ T H.istonc Distract r yes raol MachineShop�Villagep y_esno' TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ,POne family ❑Addition ❑Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial M Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septiei ,❑Well 0!Floodplainl Eh 1Netla.nds, ❑ V1/atershedlDistrict� - pESCRIPTION OF TO BE PERFORMED: i Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CQNTRACTO:Rr Name -_- � Phone: l .�5 +-Addressy"1 Supervise.r.'s,CorstructiornLrcense: � _ fid_ Exp Date: Homed Improvement License>° C - _ Expo Date - ' _ r_ _ . F 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 Co FEE: $ oc? IWO Check - heck No.. Recei No.. NOTE: Persons contracting withnrQgistered contractors Flo not h epos to thW ar�i ty f d Sign tan ure ofrA`gent/®vvner _ '� ' V S gnature of&&bhctorry- sU 1 Plans Submitted`' Plans Waived 11Certified Plot Plan El '.S e`1 mpJdt Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Swimming Pools El Art ❑ 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 Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Con nection/Signature& Date Driveway Permit DPW Town]Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT = Temp Dumpster onsite yes no Located at:124,Main Street Fire ®ep6itment signatiareldate .COMMENTS i 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 i II I I i I � I I I i I D Notified for pickup - Date l I Doc.Building Permit Revised 2010 I Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. i Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application Li Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses Li Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application L3 Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Crossection/EI evation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New.Construction (Single and Two Family) L Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o 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 2012 Locationca -7 1 0--)0/hl7f " No. a_ ? Date ' TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee _ Foundation Permit Fee $ Other Permit Fee $ TOTAL Check# 25767 Buil nfj Inspector Enter construction cost for fee cal- North Andover Fee Cakulation Construction Cost 251:0100100 m $ - $ 300.00 Plumbing Fee $ 37.50 Gas Fee 100 comm. ! $ 100.00 Electrical Fee $ 37.50 Total fees collected $ 475.00 67 Sherwood Drive 252-13 on 10/1/12 Bathroom remodel Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost i 255;00.10.:00 m $ - $ 300.00 Plumbing Fee $ 37.50 Gas Fee 100 comm. Electrical Fee $ 37.50 Total fees collected $ 475.00 67 Sherwood Drive Permit 252-13 on 10/1/12 Bathroom Remodel NORTH own Of E sAndover No. A6 t - h ti vee . ss- ' LAN! , �/- COC NICNlWICK V - S U BOARD OF HEALTH Food/Kitchen PERM .IT T LD Septic System THIS CERTIFIES THAT IPZ. �%.:�:`.:'..... (! � � BUILDING INSPECTOR has permission to erect ...... buildings on7.... ...... ,,,�/„',,,, ........................ Foundation . .... .......... Rough Afi ..Af—M-7'440'eto be occupied as .................... ............. ... ........................................................................ Chimney provided that the person accepting 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION SARTS RoughServe ................................. Final ........................... 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. SEE REVERSE SIDE SEP-26-2012 09: 14 Latanzi Insurance Agency 17812894451 P.002 CERTIFICATE OF LIABILITY INSURANCE DATE(M/M8D�/2 YY) 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 CONTACT NAME: LATTANZI INSURANCE AGENCY PHONE 781 284.8783 FAx 166 WINTHROP AVE E-MAIL E A1C Ne:781-289-4451 ADDRESS: KIM@ LATTANZIINSURANCE,COM REVERE, MA 02151 INSURERS AFFORDING COVERAGE NAIC M INSURERA:VERMONT MUTUAL INSURED ATS CONSTRUCTION CORP INSURERS: 22 MOUNT VERNON ST INSURERC: INSURER D: SAUGUS MA 01906 INSURERE: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TOCERTIt•Y IHAI 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 O IHER 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 I ADDL SUBR — LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP MM/DD/YYYY MM/DD/YYYY LIMITS A GENERAL LIABILITY BP17014914 11/30/11 11/30/12 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIA81LITY D A R NT D PREMISES Ea occurrence $ CLAIMS-MADE �OCCUR MED EXP(Any one person) $ PERSONAL&AOV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN.L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- F LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) $ UMBRELLA UAB H OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS MADE AGGREGATE $ OED RETENTION$ $ WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E,L.EACH ACCIDENT S (Mandatory in NH) If yes,describe under E L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS be E L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) SUBJECT TO THE TERMS AND CONDITIONS OF THE POLICY IN FORCE BY THE INSURANCE CO LISTED WORKERS COMP CERT TO BE SENT DIRECTLY FROM LIBERTY MUTUAL CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 1600 OSGOOD ST ACCORDANCE EXPIRATION THTHE POLICY PRATE OVIS PROVISIONS. WILL BE DELIVERED IN NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE J ' 10 0 AC D CORPORATION. All rights reserved. ACORD 26(2010/06) The ACORD name and logo are rogiotered mark- of AOORD SEP-28-2012 09:15 Latanzi Insurance Agency 17812894451 P.003 ,.1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Liberty AR INFORMATION PAGE mutuml. Liberty Mutual Group 175 Berkeley Street Boston,MA 02117 Issued by LM INSURANCE CORPORATION 27243 Policy Number WC5-31S-368932-012 Issuing Office 181 RENEWAL OF: WC2-31S=368932-011 Issue Date 08-21-12 Account Number 1-368932 Sub Account 0000 SEP-28-2012 09:20 Latanzi Insurance Agency 17812894451 P.003/003 .r. WORKERS COMPENSA71 ION AND EMPLOYERS LIABILITY INSURANCE POLICY Liberty AR INFORMATION PAGE mutug-_. Liberty Mutual Group 175 Berkeley Street Boston,MA 02117 Issued by LM INSURANCE CORPORATION 27243 Policy Number WCS-31S-368932-012 Issuing Office 181 RENEWAL OF: WC2-31S-368932-011 Issue Date 08-21-12 Account Number 1-368932 Sub Account 0000 1. Insured and Mailing Address FEIN 043215808. ATS CONSTRUCTION CORP RISK ID 774798 22 MOUNT VERNON STREET SAUGUS,MA 01906 Status 03 - CORPORATION Other workplaces not shown above: SEE ITEM 4. PREMIUM-EXTENSION OF INFORMATION PAGE 2. Policy Period:The policy period is from 09-13-2012 to 09-13-2013 12:01 A.M. standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500, 000 policy limit Bodily Injury by Disease $ 100, 000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06A D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate per$100 Estimated Annual Classifications Number Estimated Annual Remuneration of Remuneration Premium See Extension of Information Page Minimum Premium $ 500 (MA) Total Estimated Annual Premium $ 3, 986 Premium will be billed ANNUAL Producer 0004-073935 PETER LATTANZI INSURANCE AGENCY INC 166 WINTHROP AVE REVERE MA 02151 Sales Representative 3000 Sales Office Name WESTON 01987 National Council on Compensation Insurance,lnc. WC 00 00 01 A All Rights Reserved Ed. 07/01/2011 Broker Copy TOTAL P.003 S Zip Code Business Address(must 1 de a sttuet address) t/ - e.gh= Evening Phone City o State Zip Code � 3"s..iIIg Address differentfrom above) .. - Business Phone Federal Employer]D;2 S.S.Number. : - Bnmermprove eu Cmtmrdor11e Harbor icariondate ymy ims9mtmosthome - tmprovemcnt eantrndors bove a v end regishation number ?.. The Coutractor agrees to do the following work for the Homeowner: Me3cInbe m detail the w.orkto completed;specifyingft type,brand,and grade of materials to be used,rise additional sheets ifnecessarx) Required Permits-The;followingbuilding-perniiis;are xequaed .Proposed Start and Completion Schedule-The following schedule will and will be secured by theonlsactor asthe homeowner's agent:. .be unle s circunnst<mces beyond the contractor's control arise (C))vn eTs who,secure their.own-perMits'vvM be e cluded from the Guaranty FC and provisions of C-,2-> 'Daft when contractor will begin contractedwork. - I�J[G]Lchapter 142..), , ate when contracted work will be substantially completed. Total ContractPrice and Payment Schedule The Contractor agrees to perform.the work,famish the material and labor specified above for the total ram ofi Payments will,.be made according to the following schedule; $ p 6s--' upon signing contract(porta exceed 1/3 of the total contract price or the cost of special.order items,whichever is greater) by/0 /7 /1c%? or upon completion of01i f/ $ �cyr<�` by/C11 / or upon completion of $Z,Ct?G7. 'L upon completion of the contract. (Law forbids demfanding fall payor #until contract is completed to boli party's satisLation) - TbfollowingmatodW.equip"mentmustbe special $ to'b paiiY r ordered before the contracted work begins-in order, ` r to meetthe compiedon'seheduie.(") $ be d for, NOTES:(t-)Including all finance charges(n Law requires that any deposit or down paymentrequired by the contractor beforewoikbegins may not exceed the greater of(a)one third of the total co&art price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the,completion schedule, T;xaress Warrantro Is an exuress warmnfv borne provided by the conixactor'► No Yes(all terms of the warranty mast be attached fo the eonfrac Subcontractors='fife contractor agrees to be solely resp owible for completion of the vaoric described regardless of the actions of aay third Party/subcontractor utilized by the.contractor. The contractor further a�ees to be solely responsible for all pay=men`ts to all s:hcontractors for materials and labor and this ag- ement Contract Acceptance-Upon signing,this doament becomes abinding,contract under law. Unless othervrise noted wsth ntlns document,the contract shall not imply that any lien or other security interest has been:placed.on the residence. Review the following caztions and notices carefallybefore signing this contract. Don't be pressiued into signing the contract.Take time to read and fiiliy understand it. Ask questions i£something is unclear, o Make sure the cantracter has a valid HcmeTn}P,rovement Contractor R e?istration. The law requires most home improvement contractors and Subcontract to be registered v ith tho Director of Hoare improvement Contractor Reggistration You may inquire about contractor regisaionby waitingto"ieDirector at•Yt?Park Plaza,l2ooniS370s Boston;MA 02116 or bg -ig 617-973-87&7 or 888-283-3757, o Does the coutract r.have ms1,zance? Ad,,ihe.Contractor for has iw ur;nce eomparwy information sot yo�.r can corfi—coverage,or ask--,0 see a copy of a"proof of insurance"cocument. o Know your rights and resp,misibilities. head the Import=Information onthe a reverse side of firs form and get a copy of the Consumer Guide to the Home Improvement Contractor Law; You mai cancel this agreement if it has been signed ata place other than.the contractor`s normal place of business,provided you notify the y contractor in.waiting at his/her main office or branch ofECce by ordinary mail Posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement See the attached notice of cancellation form for an exp1 i*' on of phi s right _ xrn;?g,tir t. n;Ps n{fl+r�n�tr rmt,sFhe senstnieterltind ssed Atte cony slotho Fn d,eltouncz T6yet',zyt;c�opystodb^ cept`n%dee c ' ofc. r` Homeowner's Si Contracto�rlsigre`' �j fig`�a� d �, �'I!•�� ATS CONSTRUCTION CORPORATION. 22,Mt. Vernon St -Saugus—ML 01906. Phone(61783:=1358. fax(781)-233-0378' Lic.#CS61710 Home Imp.reg#126850 Homeowntr Ifo tion Con'ttacfor Iff6ra "tin`'' Name ComparyNAll L StccfAddress(do not use x�ost Office ContrgLc;W Salesperson/OwnerName t mov n St wn lip Code Bpsiaess Address(must include a street address) DhylimePhona BgeningPhme City State Zip Code 1vlaHmg Address Q1 drent frena above) Business Pliant' ifli / S Federal Employer ID or S.S.Number g—,IMFrUV=tMcCa ria -NR.* )bqimnon ate 7erwreani>tistlutttaaatlmaw , imj>tovairwtcaatrac0�siarva - a vaud reghtraflan mmher The Contractor agrees to do We following work for the Homeowner. (Aescrai-be in detadthe world ca mPLIed,specifyingthe type,brand,and grade of u denials to be used,u=additional sbests ifnecea�atV,) 'Regniarecl Permits-The.followingbui7ding.perimts:.ate required Proposed Stairt and Completion Schedule-The following schedule will and will be secured by..the coutractor as�Me homeowner's agent: be Wunless ckcarnstances beyond the conttwbor's control arise (Oymers^veto secure#heir own peiiRni is wi'Il be excluded. Ilie.Guaranty A+'ututd provisions oi'- �` Data when c�ntrsctor will begin contracted work MGG rihapte;<X42A,)::.. . . r A i when contracted work wM be mftt=WIy completed. Total ContractPrice and Payateat Schedule The Conttgctor agms to per£Oam$e work,fuznishthe material,and labor specifed abova£or the total son o Payments w4be.made.accordmg.to the following schedule. upOul sign .contract(notto®creed 1/3 o£the total ooabract price or 'Fbte cost of special .order iUems,whichever is greater) $�c�0,; —' by A� / °/�� or upon Completion of 04,1,14'V 1 � .. .byf"?orupon,completionOf.S 13�'r` upon compieaton ofthe contxack (Law,forbids dez=fig frill payment uuM cWrtit:t is competed to bobs pattir's saiis>gction) 7befioRowingmwwiwicquipmentmustbespedal oiduedbrforethe:contraetedwo;kbegins.taorder. 4be to mect-ft t6mppaid XOTTS:M Including all fiataaea.charges(n Law requires that any depositor down papnm9 requited by the contractor before workbegins may not exceed Hie ges*r of(a)one,--third ofthe total contract price or(b)the actual cost of any special equipment or ous6om made mat mal which mast be special ordered is advance to meet the compledon schadule. Z-=r-ess"G h"MITfv-Is an exnrem warmnty Misr provided by H°te contmdor? O No r,'Yes fall terms of the zimmft must be attrtehed o the contract) f Subcontractors i.The eomracbor agrees to h6&solely responsible dor completion of the work described _ regardless ofthe actions ofany third party/subcontractor ut*W=cl by the contractor. The comsactor star agrees to be solely zesponslble for all payments to all subcontmetors fm matsrialS and labor under tbis ammornemt Contract Acceptance-Upon signing,this documaut becomes abindingcomraetuader law. Unless oib.Crwise noixd witbiu.this document thej contract shall not imply that nay lien or other security interest has been placed on the residence. Review the following cautions and notices carcfbUy before si ging this contract n Don't be pressured into signing the contaot.Take time to read and fully undea.•st^and it. Aslc questions iE something is unclear, C Make sac the ccirtractorhas a.v id HomeTmprayementCoafasrtorRe Thelaw=quiresmosthomeimprovememcontractorsfmd subcontractors to be rued with the Director ofRome Stnprogeauent Contractor Registratioue Y -u .may acquire about contractor registxatianby w to,tb 1]irector at 01'arlcl ;' oom 5174;Boston;R11�s.02116-or.by catling 61.7-973-8787 or 888`-283-3757. Does the toutackor have insurance? Ask•the Contractor for his insurance company ftlforxnatiion so•bd y5u can Oona-M C•ovcrrr.,ga,or aslczv Svc a copy of a"11rOOf o:Ciustuanee"domment_ P u S r ` tttttt ` 1 ,sceas� t411 l!,-) ;; 1 tnvt[ia�,t' :u ►t�c accf. t '` �<►-r trf tal�n� €•Y�l�tt€ , =n! 4e� c�'art�� ,,>Mil N . � . .. 1 License �S 6i 710 , :11 I z'�* z .a» .� ANDREW T SHEEHAN1 .. 22 lU1T VERNON ST � tub, SAUOUS,iW}A 01906 _ - - a'"�s " cam_ y---- , � x z3� n: 10/1/2013. - - � , 7. nw. -� r "Jyd w -�,, 0 a f. �J� Offis�r�i bn+amer Affairs&T . .,r hr :' : � Rt3VEMENT PORIr i -1.:�r VA 0Zstt 126$30 ° .,: r3fa bP�_ kiti� ; . 22'PJIT : _^ TAN ' -• " .� 5lCJGU� r 5, �-. .i i,n ,ersec elan: _ `.� ` .k3 - 1. F <;: ._ .- A ' The Commonwealth of Massachusetts Department of IndustrialAccidents Office of In vestigations 600 Washington Street Boston,HA 02111 www-ma Workers' Compensation Insurance Affidavit: Builders/Contractors/]Electricians/Plumbers A licant Information r--� nt Le ibl Name(Business/organizadon/Individual): Please PH Address: a� /W-� t u City/State/Zip: phone#: Are you an employer? Check the appropriate box: 1A- i I am a employer with 4. [l I am a general contractor and I Type of project(required): 2.❑ employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have working for me in any capacity. employees and have workers' 8' El Demolition [No workers'comp.insurance comp.insurance.t 9. ❑Building addition required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their Myself[No workers'comp. right of exemption per MGL l L❑Plumbing repairs or additions insurance required.]t c. 152,§1(4),and we have no 12•0 Roof repairs employees. [No workers' 13.❑Other comp.insurance required.] Any applicant that checks box#1 must also fill 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 anew affidavit indicating such Contractors that checkthis box must attached an additional sheet showing the name of the sub contractors and state whether employees. If the sub-contractors have employees,theymust ether or not those g provide their workers'comp.policy number. entities have am off or►,nl � •t --an w.W ye that rsPrnvtautg workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: f�. -1 6 / '_ ,7��'T� f Expiration Date: Job Site Address:j�7 Jh�✓�u�i�di7 � City/State/Zip:�� 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 DIA for insurance coverage verification. I do hereby c fy nde- e p and aloes ofpedury that the information provided above ' true a d correct Si afore: `K I Phone#: �l r5 f Date: l �'— S� Official use only. Do not write in this area,to be completed by city or town official City or Town: Issuing Authority(circle one): Permit/License# 1,Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#• CON 4 F'7, vt': -- 3i�D _t� 72t1 5 — 3 lo fff �'. _ i4-- �^ p n 4 44 rac 471 3 f _j 4 2. - z _ (Loll ALL DIMENSIONS AND DESIGN PLANS ARE PROVIDED FOR THE FAIR DESIGNED FOR BY BY SCALE DWG SIZE DESIGNATIONSUSE BY THE CLIENT OR HIS AGENT IN r NO. GIVEN ARE SUBJECT TO COMPLETING THE PRDJECTASLISTEDWATHIN �2—(-` T � --- VERIFICATION ON JOB THIS CONTRACT.DESIGN PLANS REMAIN THE �� `��-� - - ._.-. "• ••` � F SITE AND ADJUSTMENT TO PROPERTY OF THIS FIRM AND CAN NOT BE 4 FIT JOB CONDITIONS. National Kitchen & Bath Association USED OR REUSED WITHOUT PERMISSION. N 154259.6002 G7 `E 12,1 �1t ! 1 r � J, 4 € } t N- -- i ALL DIMENSIONS AND n+ DESIGN PLANS ARE PROVIDED FOR THE FAIR DESIGNED FOR BY BY SCALE DWG SIZE DESIGNATIONS ` USE BY THE CLIENT OR HIS AGENT IN — /] "" ry """�'" 140.GIVEN ARE SUBJECT TO COMPLETING THE PROJECT AS LISTED MRTHIN - V E R I F I C AT1 O N ON JOB THIS CONTRACT.DESIGN PLANS REMAIN THE ✓ �� 2(:- SITE AND ADJUSTMENT TO _` PROPERTY OF THIS FIRM AND CAN NOT BE FIT JOB CONDITIONS. National Kitchen & Bath Association USED OR REUSED WITHOUT PERMISSION. N164259.8002 ♦ V 4 v VZ nlr.l e f iib - w • -�-- ---X14 -:._ gam: FIT 41" 'EM ALL DIMENSIONS AND �+ DESIGN PLANS ARE PROVIDED FOR THE FAIR DESIGNED FOR BY BY SCALE DWG •SIZE DESIGNATIONS USE BY THE CLIENT OR HIS AGENT IN a ' NO. GIVEN ARE SUBJECT TO COMPLETING THE PROJECT AS LISTED WITHIN ��"�"� '� VERIFICATION ON JOB THIS CONTRACT.DESIGN PLANS REMAIN THE �o S - ��^ 314 SITE AND ADJUSTMENT TO PROPERTY OF THIS FIRM AND CAN NOT BE FIT JOB CONDITIONS. National Kitchen & Bath Association USED OR REUSED wnmUT PERMISSION. ..�_-.tet:T. . I� ...Q�. PEI ZZI '`J N1,54259.6002 p S s z i f i f�f v Cq f z Ilt ii i I F 0 .ALL D I M E N S 1.O N S AND n+ DESIGN PLANS ARE PROVIDED FOR THE FAIR DESIGNED`FOR 811 BY SCALE DMIG SIZE DESIGNATIONS USE BY THE CLIENT OR HIS AGENT IN NO. GIVEN ARE SUBJECT TO COMPLETING THE PROJECT AS LISTED WITHIN V E R iF I C ATIO.N ON JOB THIS CONTRACT.DESIGN PLANS REMAIN THE SITE AND ADJUSTMENT TO PROPERTY OF THIS FIRM AND CAN NOT BE � FIT JOB CONDITIONS. National Kitchen& Bath Association USED OR REUSED WnWOUT PERMISSION. N154269-6002