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HomeMy WebLinkAboutBuilding Permit #429-15 - 67 STONECLEAVE ROAD 11/3/2014 NORTy BUILDING PERMIT o�tt`Eo ,6A4N TOWN OF NORTH ANDOVER o� h;ti - "`:° ' APPLICATION FOR PLAN EXAMINATION 3� I1 -� �( Permit No#: Date Received � � Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION . - _ 3 Pr PROPER Y OWNER___.'. .:- vPrint 100 Year Structure yes - - - MAP _PARCE ZONING-DISTRICT: _ m _ Historic District yes Y _ �-- Machine.`Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ,eOne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic ❑Well t ❑ Floodpl� in ❑,Weil rids ❑ Watershedj-strict;_ El Water/Sewer, e 0 DESCRIPTION OF ORK TO BE PERFORMED: a Identification- Please,�pe or Print Clearly OWN R: Name: � �T�T,�./t Phone: g-;7(p- Address: Cp rt Contractor€Name Phone: _ Su ervisor's Construction,License Date Home Imp" rovement.License �'.. �..,� � ARCHITECT/ENGINEER Af 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: $ /�V-O©d FEE: $ �Q , Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the gua anty fund Signa uret of Agent/Own r Signature of contracts- - = Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL A c 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature 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 e Water & Sewer Connection/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 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 Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products 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 m ust be submitted with the building application Doc:Building Permit Revised 2014 Location 67 No. �GDate a • TOWN OF NORTH ANDOVER o 4 Certificate of Occupancy $ G Building/Frame Permit Fee $fd 0-0 Foundation Permit Fee $ Other Permit Fee $ ,'��,���•�;i,te�x TOTAL $ Check# 23219 1 ` ' Building Inspector NRT Oh Town of �. _ .�. 6 ndover h ver, Mass, c)4e ,,6er cocHicnew�cw �1• A�RwrEo S tJ BOARD O�HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT re:5!A:........PeL4.e .................................................................. BUILDING INSPECTOR has permission to erect .......................... buildings on JV—.1...5 Vie:... Q0.ie. : Foundation ..................... ................... Rough ...w .l , tf 1�► 1�.� `t� 1� (r�.�_ V��rfd*"' i Chimney to be occupied as provided that the person accepting this permit shall in evbry 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 CONSTRUCTIO S Rough Service ................. ............... ............................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz Rough Display in a Conspicuous Place on the Premises — Do Not Remove Fina' No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Rightfax N2-1 11/4/2014 6 : 01 : 30 AM PAGE 2/002 Fax server CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/041?n 14 N&MR11FICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: DOHERTY INS AGENCY INC PHONE FAX PO BOX 1985 (AIC,No,Ext): (A/C,No): 21 ELM STREET E-MAIL ANDOVER,MA 01810 ADDRESS: 22YMX INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: HARTFORD UNDERWRITERS INSURANCE COMPANY HUYNH MARK REMODELING INC&M&S LANDSCAPING INC INSURER B: INSURER C: INSURER D: 43 HIGH STREET INSURER E: ANDOVER,MA 01810 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY 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 ADDSUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MM1DD\YYYY) (MNI DDIYYVY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE [::]OCCUR. PREMISES(Ea occurrence) ED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: 3ENERAL AGGREGATE $ POLICY F]PROJECT LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINEDSINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAROCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ A WORKER'S COMPENSATION ANDX P WC STATUTORY OTHER EMPLOYER'S LIABILITY YM UB-2E11194A-14 03/07/2014 03107/2015 LIMITS ANY PROPERITOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE EA EMPLOYEE $ 500,000 (Mandatory in NH) Ityes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERA-(ONS/LOCA710NS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED 1600 OSGOOD ST.,BLDG 20 IN ACCORDANCE WITH THE POLICY PROVISIOyB:__; AUTHORIZED REPRESENTATIVE NORTH ANDOVER,MA 01845 ------------ ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPf9fAgP `i4T7�`PjFits reserved. Rightfax C1-2 4/25/2014 7:15:26 AM PACE 3/004 Fax Server .4c R& CERTIFICATE OF LIABILITY INS�N — RANCE a.:z�.201 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS ORIGHTS UPON THE CES-2014 TE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND TS ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW: THIS CERTIflCATE OF INSURANCE DOES NOT CONSTIIVTE 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 policypes) O sub)ect to the terms and conditions of the poky, licy,certain policies may require aSUBROGATION IS WANED, n endorsement A statmust be endorsed, If SUBRement O not confer rights to the c ttcate holder in 1W of such endorsemsM431. this 000cate does FNDOVER. CONTACT ENCY INC NAME: PHONE FAX 810F'I r E A/All IHSURERISIAFFORDING COVERAOE NAIC• INSURED INSURE ►wRTFC wUmUERWRITERSIMSURANWCp 'Al HUYNH MARK REMODELING INC. INSURER e: M&S LANDSCAPING INC INSURER C: 43 HIGH STREET INSURER D ANDOVER,MAO%IO INSURER E: e INSURER V C Ft REVI 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 CONDRION 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. go— LTA TYPE OF INSURANCE W R WEE MaYD POIICr NUTAHER y�CY EFF PCUCY EXP of 5MR LIABRITY LIMITS COMMERCL�I GENERAL LwegITY EACH OCCURRE]tCE S OCCUR O�AIAAMOE TO RENTED S Jim n MEDEXP( nnepcaon) S PERSONAL a ADV tNJURY S GENT AGGAGG®ITAPPLIES PER GENERAL AGGREGATE S POLICY I I JECT LOC PRCOUCTS•COMMCP AUG S MOS LE L.IABM" 7- -ANY AUTO MSINEOSnAE LIWT S ALLAUTY D SCHEOJUR ULED SCOILYINYObr"..j S NONOWNEO SOMLYINAIRY(Peraoppgnq S HIREOAUTOSP AUTOS AIIMGE S S UMSRELLALIAB OOGIR EXCESSLIAa CLAIM34AAOE EACH OCCURRENCE S DEO RETENTIONS AGGREGATE S 10110 ERSCOMPOMTON S AND EWLOYERW LIASUW X WCSTAUU. T ANY PROPRIETORIPARTNEI EXE TORY ER GFFtCE rymNH)HEREXCLUDEDV Y NIA (Melasalrory m N6S60UB 03AC 07-2014 03.07.2015 EL.EHACCtOENr 15500.000 D rm ftw6e uraw 2E11194A EL.OIS:ASE-EA EMPLOYEE $500.000 T E L.OISEASE•POLI Y LIMIT IS500.000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(Autbu ACORD 101,AdMoAM Romab Scha4Wa.N mole opaflp q ToOtd TOWN OF ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES B 34 BARTLETT ST CANCELLED BEFORE THE EXPIRATION DATE THEREOF, ANOOVER,MA 01810 NOTICE WILL BE DELIVERED IN ACCORDANCE WITH TH POLICY PROVISIONS. AUTHORIZIED REPRESENTATME G ACORD 2512010105) The ACORD name and logo are registered ma off ACORO ORPORATION.All Fights rt setvod. Client#:13099 HUYNH1 ACORDN CERTIFICATE OF LIABILITY INSURANCEDATE"` '"rn 1312014 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Doherty Insurance Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O.Box 1985 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 21 Elm Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Andover,MA 01810 INSURERS AFFORDING COVERAGE NAIL# INSURED INSURER A. Travelers Huynh Mark Remodeling,Inc.& INSURER 8: M&S Landscaping Inc. INSURER C: 43 High Street INSURER D: Andover,MA 01810 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REOUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUMBER POLICY CTIYE POLICY EXPIRATION LIMITS A GENERAL LIABILITY 680839SM2151342 11121/13 11/21/14 EACHOCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED Hicel $300,000 CLAIMS MADE M OCCUR MED EXP(Any one penes) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE s2.000.000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 4,000,000 X1 POLICY PRO- r-1 RO LOC AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT $ ANY AUTO (Ea acadenI) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (per person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Por aeddenq PROPERTY DAMAGE $ (Per aceidenq GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN FA ACC $ AUTO ONLY: AGG $ EXCESWUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION S S WORKERS COMPENSATION AND WR LIMIT FR EMPLOYERS'UABILITY ANY PROPRIETOWPARTNEWEXECUTIVE E.L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If M.dewAW under SPECIAL PROVISIONS below E.L.DISEASE•POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS Covering operations usual to Huynh Mark Remodeling Inc.and M&S Landscaping Inc... CERTIFICATE HOLDER CANCELLATION IODaVsforNon-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of North Andover DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL ,.0_ DAYS WRRTEN 1600 Osgood Street,Bldg 20 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO DO SO SHALL North Andover,MA 01846 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR REPRESENTA71VE3. AUTHOSIZE9 REPRESENTATIVE r ACORD 25(2001108)1 Of 2 #S311611M30395 D L 0 ACORD CORPORATION 1988 The Commonwealth of Massachusetts - Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): Address: City/State/Zip:� N (�l�rna tel �-i Phone#: q aim 2 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. El am a general contractor and 1 6. E]New construction f employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. 7. E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for mein any capacity. workers'comp.insurance. g ❑Building addition (No workers' comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.F1 Electrical repairs or additions 3. 1 am a homeowner doing all work right of exemption per MGL 11.E]Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12T]Roof repairs insurance required.]i employees.[No workers' 13. Other !E3 (1( Jv 6, 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 lice doing all work and then hire outside contractors must submit anew affidavit indicating such. !Contractors 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:. Policy#or S elf-ins.Lic.#: Expiration Date: Job Site Address: 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 requiredunder 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 rine 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. X do hereby cert under thepains and hies of perjury that the information provided above is true and correct. Signature: Date: l Phone#: — — Officiad use only. Do not write in this area,to be completer)by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing 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 j oint enterprise,and including the legal representatives of a-deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employes." 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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. he affidavit should be.returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill.out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(ifnecessary)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.fillgd 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 CQMMOjjW0ajth Of �ttq Department of Industrial Aeddonts Office o£Tn'vestigatxon& 6.00 Wa$bington.Street Boston,MA 02111 Tel,#617-727=4900 at.406 ox 1-877-MASSAFE Revised 5-26-05 Fax 0 617-727-7749 wt�t�.�.ass,govfdia I Huynh Mark Remodeling Fully Insured Minh Huynh H.I.0 Lic#152811 43 High St Andover MA 01810 978-407-9336 Proposal Submit to Teresa Address: 67 Stonecleave Rd North Andover 01845 Job Location: Same Date of Plans: Fall 2014 We hereby submit specifications and estimates for: To strip and vinyl side a single family house with approximately 2800 sq ft of exterior coverage. Job Includes: Apply full trim coverage throughout the house and tape seams, where necessary. Full trim coverage such as, soffits, fascia, windows, and rake boards. We propose hereby to furnish material and labor-complete in accordance with above specifications, for the sum of: fifteen thousand even..............amount: $15,000 Payment Terms: $7500 when job is start and remaining balance of$7500 when job is complete. Authorized Signature: Homeowner Signature: l �C Date: October 20 2014 Date: October 20 2014