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Home My WebLink AboutBuilding Permit #346-11 - 672 MASSACHUSETTS AVENUE 10/25/2010 BUILDING PERMIT oF��NORORTy TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION � o e Permit NO: 3qAp- Date Received ?•• Date Issued: IMPORTANT:A plicant must complete all items on this page LOCATION:.: :.. 22- - /�'C-S L.e .. Print .. PROPERTY.OINNER. 19�Yy.� Print` MAP 210PARCEL ZONING'DISTRICT:-_ Historic District yes. o Machine Sp.Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other O'Septic Well D Floodplain ` d Wetlands b`Watershed Districi. ❑Water/Sewer. DESCRIPTION OF WORK TO BE PERFORMED: /2 X/,' / 3 seIAS oa0 /24qr,,� PZ 4< /Z"X/k IS ec g, R-041 1,J /7;Z 6 W1 d'e-,e z,-v,a d 3 0 i ow-.I` SSP d Identification Please Type or Print Clearly) OWNER: Name: Phone: 5P 2P f7S-622 9 Address: CONTRACTOR Name: -C11PV' �P3 /fit-_PVS: 7 Address: 9- S741 T S,¢Lf -T,1 Supervisor's Construction License: 0�-7` �9 Exp: Dafe `:.7- Home;Improvement License: �fJ _ Exp. Dater ".21 ARCHITECT/ENGINEER Phone: Address: Reg. No. FRE SCHEDULE:RULDINGs PERMIT'$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST EASED ON $925.00 PER S.F. Total Project Cost: $ 3 yD� �o FEE: $_ Check No.: ;L t �L Receipt No.: 0e\-;5q NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Q 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 Si nature COMMENTS _ .0 z) HEALTH Reviewed on Signature COMMENTS 0 Zoning R2.ard 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 signatureldate COMMENTS. Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Motor 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.$1oo-$1000 fine NOTES and DATA— For department use ® Notified for pickup - Date Doc.Building Permit Revised 2010/October Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers -Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Yn all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording Must be submitted with the building application Doc:Building Permit Revised 2008 Location/,,1g2- 4-49,0 XJ No. Date �� a^Th TOWN OF NORTH ANDOVER Oit �•n .•,h0 _ F e A Certificate of Occupancy $ Mus Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �r Check # 23J.i9 Building Inspector NORTH 0VM of - 6 Andove LAK A K dover, Mass., COCMICMEVVICK AdRATED rp` �� S U BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT . ... .(tip`........ ! .N. c...t�............................ .............................. """"" Foundation has permission to erect.................:...................... buildings on .... ............... . . ................................ Rough to be occupied as......1:D...X..13...... D ..... t7 Chimney ......... e.................................................................. res provided that the person accepting this permit shall in everypect conform to the terms 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 f PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS::CONSTR C O S TS Rough .......................................................................:..: ._ ................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. North Andover MIMAP October 22, 2010 1 0 r �4,.. ti•�r �Jn� 1. 7 ,i 9 s9 Interstates —Interstate MaJor Roads Horizontal Datum:MA Staleplane Coordinate System,Datum NAD83, Roads Meters Data Sources:The data for this map was produced by Merrimack t gORTM q Valley Planning Commission(MVPC)using date provided by the Town of r Easements "so �, North Andover.Additional data provided by the Executive Office of 0 MVPC Boundary ? at a�o�� Environmental Affalrs/MassGIS.The Information depicted on this map Is L]Parcels 3 L for planning purposes only.It may not be adequate for legal boundary F •-• p definition or regulatory Interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING ♦ >♦ THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION ss�cNuse 1"=122 ft ^�° �s r� n�M. 1 O LOCUS N d' N OF SSS PROPOSED �� JOHN 9cyG D CKPROPOF ' ADDI OND MWUiLKIN.JR• g W. 36 � ! � 28-31 �ss�oaat Lah�� 13.7' #11 PHILLIPS COMMON MAP 58 PARCEL 31 1.5 STY � #678 MASS. AVE AN, MAP 59 1DWELLING� MAP 59 PARCEL 66 PARCEL 5 #.? AREA=28,600 SFt -- PLAN OF LAND 672 MASSACHUSETTS AVE. NO. ANDOVER, MA 01845 SCALE: 1"=40' 249.4' 1 DATE: OCT. 21, 2010 PREPARED FOR: -- JAYNE LANNAN TO OSGOOD ST. 672 MASSACHUSETTS AVE. MASSACHUSETTS AVENUE NORTH ANDOVER, MA. 01845 PREPARED BY: NOTES: JM Associates 325 Main Street 1. TITLE REFERENCE BOOK 11787 PAGE 293 N.E.R.D. North Reading, MA 01864 2. REFERENCE TOWN OF NORTH ANDOVER 978-664-6668 ASSESSORS MAP 59 PARCEL 5F ;"� 4 ',, www.jmassociateseng.com 1 i I I Brockway-Smith Company ' www.brosco.com vt Nt:! s { r E i { 4 t 1 ! ` f r IF .. .T { ` E { , � � I 4 f a v , r. FF —.—. x f F i _-_�. . t q ._._ _ _..`.. + ! «�.�..... 111 �> } ......�.,........�...�.�.»....... ._... _.._...1��...... ',. .....«.� { ..�..._}..........� { , f f t i 1 { i Y i 1-4 � E 1 ANDOVER, MA 01810 COXSACKIE, NY 12051 HATFIELD, MA 01038 PORTLAND, ME 04103 146 Dascomb Road Hudson Valley Commercial Park 125 Chestnut Street 203 Read Street 1-800-222-7981 1-800-222-7303 1-800-922-0191 1-800-442-6734 Fax: 1-800-242-4533 Fax: 1-800-222-7304 Fax: 1-800-922-0296 Fax: 1-800-443-0331 i I ( Brockway-Smith Company FrA www.brosco.com 1 ; ,0 ttt I74 1 . . L ._ w._ _ _ , 4 17F i I , ` _ k t Y 1 t it 7 _ _�_. _ t � t f.A .... l 1{1111 ��v.... .�....._..._ ,._.. J , Q-1 J-7 Y w 1 -_§ V � V � p� y^� i t s Y ANDOVER, MA 01810 COXSACKIE, NY 12051 HATFIELD, MA 01038 PORTLAND, ME 04103 146 Dascomb Road Hudson Valley Commercial Park 125 Chestnut Street 203 Read Street 1-800-222-7981 1-800-222-7303 1-800-922-0191 1-800-442-6734 Fax: 1-800-242-4533 Fax: 1-800-222-7304 Fax: 1-800-922-0296 Fax: 1-800-443-0331 Brockway-Smith Company www.brosco.com T { i t Y 1` , { V I s v') ilc-' 077P 3 r r r t lij t 01 t ....a._.�...._ i + i f ii. . t - i ff 1 4 \ —�— e `v I G ` e _ k , + E t 1 ! i r ! r ANDOVER, MA 01810 COXSACKIE, NY 12051 HATFIELD, MA 01038 PORTLAND, ME 04103 146 Dascomb Road Hudson Valley Commercial Park 125 Chestnut Street 203 Read Street 1-800-222-7981 1-800-222-7303 1-800-922-0191 1-800-442-6734 Fax: 1-800-242-4533 Fax: 1-800-222-7304 Fax: 1-800-922-0296 Fax: 1-800-443-0331 r i I I Brockway-Smith Company ' www.brosco.com d _3___........... I3 ... ' I ----------- s c t { 9 t • [ i , , [ i v. _ _ __ _ ,� _. ` f LE , _ _ 00 it ! i i e f � i s �y 4 Y [ { 3 1 e lj [ 1 t ANDOVER, MA 01810 COXSACKIE, NY 12051 HATFIELD, MA 01038 PORTLAND, ME 04103 146 Dascomb Road Hudson Valley Commercial Park 125 Chestnut Street 203 Read Street 1-800-222-7981 1-800-222-7303 1-800-922-0191 1-800-442-6734 Fax: 1-800-242-4533 Fax: 1-800-222-7304 Fax: 1-800-922-0296 Fax: 1-800-443-0331 LE 1 ( I Brockway-Smith Company ' www.brosco.com i 1 1 1 6 ! 4 ( � � _ T s t E I k � � �• q ; t 4 _N_ k r 9 d � ti i r _ � 1 � _ _. _. e 1 F ANDOVER MA 01810 COXSACKIE, NY 12051 HATFIELD, MA 01038 PORTLAND, ME 04103 146 Das mb Road Hudson Valley Commercial Park 125 Chestnut Street 203 Read Street 1-800- 22-7981 1-800-222-7303 1-800-922-0191 1-800-442-6734 Fax: 1-8 0-242-4533 Fax: 1-800-222-7304 Fax: 1-800-922-0296 Fax: 1-800-443-0331 i I I Brockway-Smith Company www.brosco.com < { ! 1 P _ } _ { I _ t l � t — ! � 1 1 y t 1 E r t 1 , l i l i j 1 1 " ° f I i 3 1 1 t }} 1 r < ! m , r Y .4- ------ t r fIt t p t i —r d t k " I T 4 �\ \r i ! d � { r } k x ANDOVER, MA 01810 COXSACKIE, NY 12051 HATFIELD, MA 01038 PORTLAND, ME 04103 146 Dascomb Road Hudson Valley Commercial Park 125 Chestnut Street 203 Read Street 1-800-222-7981 1-800-222-7303 1-800-922-0191 1-800-442-6734 Fax: 1-800-242-4533 Fax: 1-800-222-7304 Fax: 1-800-922-0296 Fax: 1-800-443-0331 i,� Office of Consumer Affairs&B siness egulaU�o� . z HOME IMPROVEMENT CONTRACTOR Registration: ,101846 Type: Expiration: 601912012 Individual STEPHEN M.KEISE:6NG Stephen Keisling 9 NINTH STREET SALISBURY,MA 01952,{ Undersecretary Massachusetts- Department of Puhlic Safet" Soard'of Building Regulations and Standards '} Construction Supervisor License License: CS 27489 _ �- Restricted to: 00 STEPHEN M KEISLING 9 9TH STREET 01952 ST SALISBURY,MA Expiration 711612011 Tr#: 18542 ('ununisioncr i FARM FAMILY CASUALTY INSURANCE COMPANY Issuing Office - P.O. Box 656 • Albany, New York 12201-0656 CONTRACTORS ADVANTAGE BOP000916905 ® DECLARATION PAGE Policy Number: 2005XO431 Agent No: 3485 Agent Phone: 978-887-8304 UGO.NE JOHNSON INSURANCE AGENCY , IN 7 GROVE ST STE 201 Name and Mailing Address of First Named Insured: TOPSFIELD MA 01983-1862 STEPHEN KEISLING 9 9TH ST W SALISBURY MA 01952-1702 The Insured is: INDIVIDUAL Transaction Type: RENEWAL Transaction Effective: 03/21/2010 Policy Period: From 03/21/2010 To 03/21/2011 12:01 A.M. Standard Time Business Description: CARPENTRY Total Limit of Liability Term ADDL/RTN Premium Premium Business Property Coverages Buildings Business Personal Property $5,000 $22.00 Business Income and Extra Expense Actual Loss Sustained Not Exceeding 12 Months Other Endorsements SEE SCHEDULE BUSINESSOWNERS LIABILITY Except for Fire Legal Liability, each paid claim for the following coverages reduces the amount of insurance we provide during the applicable annual period. Business Liability Limits of Insurance Bodily Injury/Property Damage $500,000 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 AGGREGATE FOR PRODUCTS/COMPLETED OPERATIONS HAZARD Medical Expenses $5,000 EACH PERSON Fire Legal Liability $50,000 ANY ONE FIRE OR EXPLOSION Other Endorsements SEE SCHEDULE POLICY SUBJECT TO ANNUAL AUDIT: YES TOTAL PREMIUM The Declarations, Schedules and These Forms and Endorsements Make Up Your Compmty-r u zy: 8P00021299 BP00060197 8P00090197 BPO4170196 BP04190689 SP04961001 BP06140103 8P07010197 BP10040498 SF30061103 OF40380902 BF40390303 BF41090204 BF41321008 F199020108 ..• {uuuaaunilcgaauuaatcIc ullelltelltbOlUleStatelin.omeimprovementUontractorLaw(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning]tome improvements should first obtain a copy of"a ; Massachusetts consumer guide to home improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the w„ 4 Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8797 or 1=888-283-3757. Homeowner Information Contractor Information Name ompmy arae Street:Address(do not use a Post Office Box address) ontntbto Salesperson/OwnerNtime 72 4 ve S'T�Of��,� �efSL�•�� Cityfrown State Zip Code 3usiness Address(must include a street address) �i ANc�te . �� o ids ys" Daytime Pbone Evening Phone Vityfrown State Zip Code 9V3 if-SYs Mailing Address 01 different from above) 3usiness Phone 3k-- Jyj ed oral Employer Il)err S.S.Number Law requires that most timid bn- p .I Home provementcontractor Reg.Number Exphationdne mwmeat muaaetors have a and.giztmtj.n moots The Contractor agrees to do the following work for the Homeo ner: e co UeVall me co 10 comp e e sPeLlIM911 Meets I re� i tg /2 X S'PfFSOnJ /Ata i W /7-;( Sde c{P� o N Ar- G-�t4i e }rt�d e.L,tli6l��a d. �6 v G� ��'x s' ep Nc�jj C Required.Permits-The followinh*+building permits are required Proposed Start and Completion'Schedule-The following schedule will and vyill be secured by the contractor as the homeownees agent, be adhered to unless circumstances beyond the conItractoes control arise (owners who secure their own permits will be excluded from the Guarant3i Fund provisions of �1�"�10 Date when contractor will begi.n contracted work. MGL chapter 142A.) Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule � The Contractor agrees to perform the work,famish the material and labor specified above for the total sum of.- .3/, 5�S/O, O Payments will be made accordin to the following schedule: g g $ '[aU upon signing contract(not to exceed 1/3 of the•total contract price err the cost of special order items,whichever is greater) t� 711091 S / by /�/� or upon completionof so/O O- z 'x /,p $1t',.S410 by _/_/^ or upon completion of A ec` 4 L4::t —7b7,-4- L' �PleQeC ./ $ upon completion of the contract. (Law forbids demanding;full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for= _ �,® ordered before the contracted work-'begins in order S-- to be paid forI d9 to meet the completion schedule.(**) NOTES: Including all finance charges(•+)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the tote]contract price or(b)the actual cost of any special equipment or custom made material which must be special oideredin advance to meet the completion schedule. Express Warranty-Is gn express warrnpty helne provided by the contractor? _No Yes fall terms of the warranty must be attached to the contrectl Subcontractors-Ther'contrector agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for matetials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract 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 cautionsand notices carefully before signing this contract. • Don't be pressured into signing the contract Take tinto to read and fully understand it. Ask questions if something is unclear. • ' Make sure the contractor hes a valid Home Improvement Contractor R.etristtatiop The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Itnprovement Contractor Registration. You may inquire about contractor registration by:writing to the Director at One Ashburton Place,Room 1301,Boston,MA 02108 or by calling 617-727-3200 or 1-800-223-0933. • Does the contractor have insurance? Check to see that your contractor is properly insured. • Know your rights and responsibilities. Read the Important Informstion on the reverse side of this form and get a copy of die Consumer Guide to the Home-Improvement Contractor p Law. You may cancel this agreement if it has been signed at a place other than the contractor's,normal place of business,provided you notify the contractor in writing at his/her main office or branch office 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 force for an explanation of dtis right. P DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!I Two identical copies of the-contract must be completed and signed. One copy should go to,the homeowner.The other copy should be kept by the contractor. - A . 2 omelvner's Signature 11Contractor ;ignatture % ate Date %-UlMacturAruitration The Home Improvement Contractor Law provides homeowners with-the right to initiate an arbitration action(as an . alternative to-court action)if they have a dispute with a contractor. The same right is not automatically afforded to a4 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 firm which has been approved.by the Secretary.of the-Executive Office.of Consumer Affairs and Business Regulation and the consumer shall.be required to submit to such arbitration as provided In Massachusetts General Laws,chapter 142A. Homeowner's Signature Contractor's Signature NOTICE:The signatures of the parties above apply only to the agreement of the parties.to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights 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,.eV6h 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 ra or provides an express warranty for workmif the contractorguantees or warranties anship or materials. In addition to guarantees ed,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 ars they do not restrict a homeowner's basic consumer rights. If you have questions about Your consumer/homeowner rights,contact the Consumer lnformatioin Hotline(listed below). Execution of Contract ,. The contract must be executed in du —_plicate and should not fbe signed until.a copy of all exhibits and referenced documents have been.attached. Parties are-also advised nqt to sign the document until all blank sections have been be given gi in or marked as'yoid,deleted,or not applicable. One original signed copy of the contract with attachments is to- the to the deleted, the other kept by the contractor. Any modification and agreed to by both parties. Contracted work may not begin until both parties oh have received a fully executed e opy of the contract, and the three day recission period has expired. Accelerated Payinents A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. Fiowever in instances to be financial) nces whe msecu re a con Y re,the contractor may require that 1be balance of funds not yet due be placed iindeems a oint esc escrow account as a prerequisite to continuing the contracted worlL Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional info consumer rights,or1f you wish to obtain a free copy about the Home Improvement Contractor Law or other Law,"contact: py of "A Consumer Guide,to the Home Improvement Contractor • Consumer Information Hotline Office of Consumer Affairs and Business'kegulatioa .10 Park Plaza,Room 5170,Boston,MA 02116 (617)973-9787or 1-.(888)2833757 x If you want to verify the registration of a co nntractor or if you have questions or need additional information specifically about the Cotractor registration component of-the Home Improvement Contractor La ' w,contact: Director of Home Improvement Contractor Registration Bureau of Building Regulations and Standards One-Ashburton' Place, Room-1301,Boston,MA 02108 (617) 727-3200 or 1-800-223-0933 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 AND/OR Better Business Bureau (508)652-4800 .(508)755-2548 (4111'7 zd_'A 1 1 A Page No. of Pages Proposal STEPHEN M. KE ESLING Building & Romadding 9 9th Street West Salisbury, MASSACHUSETTS 01952 MA Uc. 027489 Hama lmpv. 101846 Phono (978) 682.2072 o (978) 465.4712 PROPOSAL SUBMITTED TO PHONE DATE is! STREET JOB NAME (0 7 2- �r� ; /�} /2 � A.) CITY,STATE and ZIP CODE JOB LOCATION O X -� 0420 12'-4t"P C /C ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: ,. 2 Xo&2 41Z �. w Bit propQSr hereby to furnish material and labor—complete in accordance with above specifications, for the sum of: dollars($ 3y Payment to be made as follows ao .S Q d All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from above specifications Authorized involving extra costs will be executed only upon written orders, and will become an extra Signature charge over and above the estimate. All agreements contingent upon strikes, accidents f ��jordelays beyond our control.Owner to carry fire,tornado and other necessary insurance. Note:This proposal may be r workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within days. �1CtP�JtttntF of proposal —The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature �. to do the work as specified. Payment will be made as outlined above. Date of Acceptance: v 2VIU Signature The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations it U 600 Washington Street •1�. 1111 tS M11, ; Boston,MA 02111 l s Y s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please PrintLegibly Name (Business/Organization/Individual): PIJ xet N(,-- Address: 9 7-.4S�'t P e City/State/Zip: S4 Z s X&"e 144 Phone#: 4 7 cP 31Y—(P'1,5- 7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. 0 New construction art-time) employees full and/or .* have hired the sub-contractors ( p listed on the attached sheet. � 7• E] Remodeling 2.0 I am a sole proprietor or partner- 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 repairs or additions required.] officers have exercised their ht of exemption per MGL 11.❑ Plumbing repairs or additions 3.F1ri I am a homeowner doing all work g p p myself.[No workers'comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.] employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors acid 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 Self-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 a as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a F g q 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 hereby certify under thep ins and enalties of eijury that the information provided above is true and correct Si ature: Date: P S' Phone#. d" 3 Official use only. Do not write in this area,to be completed by city or town offciaL City or Town: Permit/License# 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 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 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-contractors)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 confinnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the 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 sur&that the affidavit is complete and printed legibly. The Department has provided a space at the bottom tact you regarding the applicant. of the affidavit for you to fill out m the event the Office of Investigations has to con y g g pp Please be sure to fill in the pen-nit/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 600 Washington Street Boston}MA 02111 Tel.#a`617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.govldia