HomeMy WebLinkAboutBuilding Permit #731-13 - 70 ROSEMONT DRIVE 5/6/2013TYPE OF IMPROVEMENT
PROPOSED USE
v
,(ii�-TlaY�,
Residential
Non- Residential
❑ New Building
5(One family
. a
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Others:
(Repair, replacement
❑ Assessory Bldg
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
1 '1�► ��'��c��'-". �'n�,���c.�a��n cif
r� �2�1��1s
C��,����c-
,(ii�-TlaY�,
att MY -1-706) cfMVG-(� &VF sys, 't
. a
��U�.c,
o�/yx �4U,I-e-l<
Identification Please Type or Print Clearly)
OWNER: Name: [�JhU I 6 &+i,1_1 �)j"5` Phone: Ct ieljy C aL.
Address: rT0 �DSC:It'id�fi �(� I V L f l
CONTRACTOR Name: Ph�8-ls.9-aw
&100 one: 0-AL-aW --JT
Address:
1G4914"Monf ROA,6 �))Rat,(l IYA 018,410
Supervisor's Construction License: Exp. Date.
�i_ its/ably
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ �i ��Z)1 �& FEE: $ '2� '0
Check No.: n Di4 I--- Receipt No.:
NOTE: Persons coVractitlglwith unregistered contractors do not have a ss t ts?ie guaranty fund
5i nature of A ent/Owner , �i nature of contractor
�g g
Building Department
The foh�owing 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
o 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 app:.al 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.Bui!ding permit Revised 2012
Plans Submitted.❑ "+ Plans Waived ❑
Q
Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT ❑
COMENTS
CONSERVATION
COMMENTS,
DATE REJECTED DATE APPROVED
C
DATE REJECTED DATE APPROVED
HEALTH , ❑ ❑
COMMENTS
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
Located at 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no - -,
Located at 124 Main Street
Fire Department signature/date ;:z
3r _�
COMMENTS
Plans Submitted
", Plans Waived ❑
C 14 J
Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/MassageBody 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
COMMENTS
DATE REJECTED
El
DATE APPROVED
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:
Comme
Conservation Decision: Com
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Towo ]Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTM�_RIT - Temp Dumpster on site yes no
Located at'124 MainStreet
Fire Departrnert 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
E) Notified for pickup - Date
Doe.Building Permit Revised 2010
Building Department
The fohcowing 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
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 app; al 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.Bui!ding Permit Revised 2012
Location
No.
Check #A, --m k
26353
Date /I..,?
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Flae $ �
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
0U/U l% iy '�/fl `7 Via`
Ottt)'OCt
Tom Quinn
(617) 939.1353 QUINN'S CONSTRUCTIO
(978) 265.2390 868 Mammoth Road - Dracut, MA 01826
tom@quinnsconstruction.com www.quinnsconstruction.com
Property Owner Information
Name
Street Address (N t Post
Office Box) 1 E f
?,�/ i %
v
5 7J� V f`
City/Town
State Zip Code
Homes Phone
Cell Phone Email
Mailing Address (If Different From Above)
Employer ID #
y 27-1639714
Pad e 1 of 3
J (2V - �20/
Date
./ Zvi-"/'�--. �!
Job Name
S��✓ �7f l
Job Location
z
Salesperson(s): / Contractor Registration #: CS -039732 Ex. Date: ?i
` REQUIRED PERMITS
The following bui ding permits are required. It is the obligation of the contractor to secure such permits
as the homeowner's agent: List any and all necessary construction -related permits.
Note: Owners who secure their own permits or deal with unregistered contractors are excluded
from the Guaranty Fund provisions of MGL c. 142A.
Is an EXPRESS WARRANTY being,provided by the contractor? NO YES
"All terms of the warranty must be attached to the contract"
NOTE: All home improvement contractors and subcontractors shall be registered and any inquires about a contractor or
subcontractor relating to a registration should be directed to:
Director, Home Improvement Contractor Registration
One Ashburton Place, Room 1301
Boston, MA 62108 '
617-727-8598
Unless otherwise noted within this document, the contract shall not imply
that any lien or other security interest has been placed on the residence.
ARBITRATION
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 such dispute to a private arbitration service which has been
approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulations and the consumer
shall be required to submit to such arbitration as provided in M.G.L. c.142A.
c
Contractor: „*. __e�c,� %.�-"�/Yt.�� Homeowner: V
Date: y ? r) ..J / "` J Date: i /
NOTICE: THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES
TO ALTERNATIVE DISPUTE SETTLEMENT INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE
ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE
PARTIES.
ACCELERATION OF PAYMENT
Homeowner's Financial Insecurity - 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..
Contractor's Financial Insecurity - In instances where a contractor deems him/herself to be financially insecure, the
contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to
continuing the contracted work. Withdrawal from said account would require the signatures of both parties.
THE CONTRACT MUST ALSO CONTAIN:
1. A Complete Description of any other documents which are part of the agreement;
2. A List and Description of other matters upon which the contractor and homeowner lawfully agree;
3. Any Other Provisions otherwise required by applicable laws of the Commonwealth.
Remember, the Contract must be the Complete Agreement
Between the contractor and the homeowner.
Contract
Tom Quinn QUINN'S CONSTRUCTION Employer 9 4
(617) 939.1353
(978) 265-2390 868 Mammoth Road • Dracut, MA 01826
tom@quinnsconstawtion.com www.quinnscons&wtion.com Page 2 of 3
Modifications
There shall be no modification, amendment, or change order made relative to this Construction Contract, Contractor's Work, or the
Plans and Specifications without the express mutual modification signed by Owner and Contractor.
a. Required Change Orders: The Specifications represent Contractor's best effort to be complete in detailing the scope of work to be
performed. However, this contract is based solely on observable conditions of the structure in its status at time of Contract preparation.
If additional concealed, unknown conditions are discovered in the course of construction, Contractor shall point out these conditions
to Owner so Owner and Contractor can execute a signed Change Order for any additional work. Such orders shall specify additional fees,
materials, labor and services, and become part of this contract. Additional costs, if any, shall be paid for by Owner in advance of
execution of work specified in said Change Order. Failure of Contractor to request such payments in advance shall not be deemed a
waiver of payments due. Any delays in Contractor's Work caused by required change orders shall not be deemed the responsibility of
Contractor, and shall automatically extend the time of completion. Additional time required shall be stipulated within the Change Order.
b. Additional Work Authorizations: In the event that required work cannot be priced in advance of completion of such work, (i.e.
discovery of rot needing repair), an Additional Work Authorization shall be executed. Such orders shall describe work to be completed,
and shall specify method of calculating additional fees, materials, labor and services to be charged upon completion, and become part of
this contract. Payment shall be due upon presentation of Contractor invoice. Any delays in Contractor's Work caused by required change
orders shall not be deemed the responsibility of Contractor, and shall automatically extend the time of completion. Additional time
required shall be estimated and stated within the Additional Work Authorization.
I, the Homeowner have read and understand the above mentioned modification section and agree to the terms.
Homeowner's Signature Contractor's Signature
Date Date
The following schedule will be ell
red to unless circumstances beyond the contractor's control arise:
Work Scheduled To Begin: Expected Date Of Completion: _ _ 6l 5-112
(Date Contractor will begin contracted work) '`(Date when contracted work will be substantially completed)
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
The Contractor agrees to perform the work, furnish the material and labor specified above for the SUM of: $ /C./
(*Include all finance charges in this amount*)
Payments will be made according to the following SCHEDULE:
$a..J upon signing contract (*Not to exceed 1/3 of the total contract price OR the cost of special order items,
whichever is greater*).
$ by / / or upon completion of
$ by / / or upon completion of
e upon completion of the contract (*Law forbids demanding full payment until contract is completed to
both parties' satisfaction *)
In order to meet the completion schedule, the following material/equipment must be special ordered before the contracted
work begins (*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 total contract 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*):
$ to be paid for
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Identical copies of the contract should go to the homeowner and the contractor.
Homeowner's Signature
Date
Contractor's Signature -�
Date Z
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller, which may be his main
office or branch thereof, provided you notify the seller in writing at his main office or branch by ordinary mail posted, by telegram sent or
by delivery, not later than midnight of the third business day following the signing of the agreement.
See attached notice of cancellation for an explanation of this right.
Contract
Tom Quiff ( UINN'S CONSTRUCTION. E "ployer ID27463974
(617) 939.1353 7�•G
(978) 265.2390 868 Mammoth Road • Dracut, MA 01826
tom@quinnsconsbwthm.com www.quinnsconstruction.com Page 3 of 3
WORK TO BE PERFORMED AND MATERIALS TO BE USED
Contractor Agrees To Do The Following Work For Owner: f���r _ %/"'j // lc /� / �/'✓ ✓r �. -'� fes,
S�t' i �/ ,~..r !"--C.Gr ✓ •� . './ r r. ,:✓ / -.) �/, r s.J L./^'` /iC�i �/,j/, ..i.,.,/ r J - / ¢•% )
f
i .:/ / l \. � • .//—•�.,e.+ , ,a- �.r , .� i,� /�" C I yi' �j1' - ,.� / �� / / f r � ,� / ..i S ' � l c, f f / i .. .r .�- r'
f I •� ./ / r/ �..> � .r 7 i iC..s �r"� / S \/ �r .N r' • !.' .. r !� J r / / r ✓ ✓' „� _.r . /r— r,i .� . ^ i ./..,/J
.a r� / r ` Ir !� _ jt / �r r j '✓ /(. j/CJi�C' c_ �s�/!. <', 1.7 . i/✓ ,/ r- c� liter d/y/�
W]
140
LLI
2
LL
a0
mC
t
Y
\
0
LL
E
+ai
N
• U
cu
'V1
c
CL
N
Z
Z
°_
co
C
o
-D
C
LL
L
w
v
c
U
LL
O
f -
VW
m
N
Z
Z
=J
d
t
d'
LL
O
F
9L
N
Z
J
V
u
j
W
C
d'
v
U
(A
m00
LL
O
Wa
N
Z
t
OC
LL
f-
cc
Q
IJJ
a
LL
N
L
m
Z
—
a
N
cu
O
leN
Q
N
n
O
Q d
' � O
�O CL
U)
as �,
jE _
" cc
c
0 CD
cn
m E
� 0
f
1 • N 0
�' m a
U)
cn cn N N
o •a >
_ : Q
) m c
�a y
O
E o m
O
N r- O O
_ O
c
c o�
CL
CL
as m
R•N O
CD
tm
a •o
= O CL '� N
Oy d
co O 7 O O "�
IL •V R N C O
ix
C a.+ :E 0 Z
.E v 'a a 0
W a. 0
V Q O -a d ,r
'ma= O O
F- t
0 cLOL) >
Z
O
m
CDZ
W
w
CL
W
CH
G
W
a.
0
V
.W
Z
Z
CO
H
IQ--
O .
V
H '
Z
O
J
LS
O
w
N
v
v
O
E
O
Z Q.
O N
D =
I C .-
.E m m
CL
.a., .O
O �+
v 0 O
m O m
CL
� Q
V J 0
= O +;
Z
UcCL
ca =
CL
i
U)
140
x
uai
x
c
O
mE
y
'O
LL
N
N
.F.,
i]
'Ln
O
a
Z
z
�_
m
C
C
LL
:
d'
E
U
f0
C
LL
0
U
c
z
z
co
d
to
7
O
W
N
C
LL
OI
U
N
z
J
u
J
W
7
p
M
Ln
m
C
LL
ocz
O
w
V1
Z
y
l7
W
f0
C
LJ..
UA
2
o~c
YJ
O
LLJ
5
LL
m
z
CU
N
N
o
O
Ln
U
uj
a �z
•Lv
w
ti
N
N
W
W
OL
W
U)
7•
o cC
O
o
: H
Cluj
. -
:w
:a
I
fA
Z
�Z
' 0-2
Q
C
N V
,0
E Q
" m
N
:r c
m —
CD
i/)
S o
Cf)
•o
'cEa
ZE"
0�
O
E
O
y J
�
p
Y
L m
CL
Z
•_
�' _
CA
'^
v/
N
c-0
>
U)
r-
X
Z
N 4)a
.�
E0Z
n.W'...
cm
—
CC
CO
r- p
G
N
�•
3
w
2
c'> p
c
w
J
c o t-
CL
a-
Z
4 �N
o
o
0)
_
Q
L
= _
L iO
.p
2
F-
as
Q (D '5
N
p
yV m
N
W
LL
'2
'O � O O
!yCc�
p
o• ..Z
E
O0
W
V
Q
0 d = L
0-0 d
.o"'
y
U)
0 =
-0
O
F
$ U.
o V
>
•Lv
w
ti
N
N
W
W
OL
W
U)
N• ci
n
b
N O.
rL z
t-�
04
O p
n Q''', oy
w
(D a o a
P• o'
G N ry rYr
rt
(D
p U ~ td O W+!
CD
Wo
rt n a M (n r+
w En
w � •awu4
rt N R1
N
rt
N•
o
a'
cr
b
Dq
Id
�
GI
a.
o
In
CDCD
N
�,
cFc C)
�
w
H
b
cl_
w
G
m
rt
R
C a.
n
(D
m
H
a
0-
-N
\
rL
p
.
(A
H
.
'd
rt
rp
n
�1
`�
fn
00
n •
m
rt
• �i �
°:
H
f1
m
R.
rt
G
1
rt
r7
N
ft1
P.
�
w
ri
]
w
` P
O
(D
w
O
,y
rt
•
]
L.
rt
w
N
w
rd
P
(D
(D
(D
G1
rt.
H C7
L* s
O
th
H
(D
tii
O
G '
x'
H
N• ci
n
b
N O.
rL z
t-�
04
O p
n Q''', oy
w
(D a o a
P• o'
G N ry rYr
rt
(D
p U ~ td O W+!
CD
Wo
rt n a M (n r+
w En
w � •awu4
rt N R1
N
rt
N•
o
a'
cr
b
Dq
v a
a
Office Of Consumer Affairs andBusiness Regulation
- 1-0 Park Plaza - Suite 5170
Psasion, Tvsassacuset�s 02116
Haeme ►mprotreLnent`CQn roctor Registrar oil
QUINN'S CONSTRUCTION
THOMAS QUINN.
868 [AAMMIOTH RD.
DRACUT, IUiA 01826
OPS -CAI 0 SM -0004-G195216
1fc ttcurrrrrrs.u.•eull�t`C/la��rie�aic'/G'.
Office of Consumer Affairs & Business Regulation
OME IMPROVEMENT CONTRACTOR
5 - egistration: 121604 Type:
piration: 5/24/2014 DBA
QUINN'S CONSTRUCTION
License or registration valid for individul use only
before'the expiration date. 1f found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, MA 02116
THOMAS QUINN
868 MAMMOTH RD. �3_- -- '• 01
DRACUT, MA•01826 Undersecretary Not valid without signature
/rr t�-c»rvresercea%H ct C�lla.-fsudrtscCG-•
Cf#ice of Consumer -Affairs & Busibss Regaulation
T
�1MEIMPROVEMENTCOD.ACTOR
5 �eg'wrtration: 121604 Type-
� -radon: 512412014. DBA
QUINN'S CONSTRUCTION
T NOMAS QUINN
868 MAMMO T H RD.
DRACUT, MA -01826
License or registration valid for individul use only
before the expiration date. 1f found return to:
0f -ice of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 51-70
Boston, i11A 03116
L
f i
Qom....•-_��. t _. �f �1) e"'i'►I�lr�3i,V�,.
e indersecrctarr Not valid without signature
t Massachusett's - Department of Public Ssfety
Board of Building Regulations and Standards
Construction Supcil h(W
License: C"39732
THOMAS J QUINN
r
868 MAMMaTH RD
DRACUT MA 01826
F
Jam"' �J��g•,: pirai:an
Commissioner Ex
03/2512014
UnrestfIc'ted - Bold inns Of - nY* I' -se' 91 -OUP Tv7 'ch
con aim less than 35_Q00 013bic feet (991m) of
enclosed space.
Failure to possess a current edfdon of the Massachusetts,
state Building Code is cause for revocation oc this license.
For DPS licensing info oration visit- wv t"-ivtass.Gov%OPS
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
Print Form
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ai
) S
Address: w A"m 0l'- &)P-0
Citv/State/Zip:
Or,
0I9d (P Phone #:�J-
Y AS--rP)o
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. E] New construction
employees ( nd/or part-time).*
11
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
7. ❑ Remodeling
ship and have no employees
These sub -contractors have
g, ❑ Demolition
workingfor me in an capacity.
y p ty
employees and have workers'
9. F1 Building addition
[No workers' comp. insurance
required.]
comp. insurance.:
5. ❑ We are a corporation and its
10.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work
officers have exercised their
11.[] Plumbing repairs or additions
myself. [No workers' comp.
right of exemption per MGL
12.D, Roof repairs
insurance required.] t
c. 152, §1(4), and we have no
131-1 Other
employees. [No workers'
coma. insurance reouired.]
*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 a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:��;L�ri1�
Policy # or Self -ins. Lie. f-' '70Expiration Date:l J qUl v
Job Site Address: r�y 1ye- City/State/Zip: ,�&&i . & oq
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DTA for insurance coverage verification.
I do hereby cern under e_pains and penalties ofperjury that the information provided above is true and correct.
Phone #: 16 %V—&b 066(%� C,5 -L.0 9'7X-' - a��
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
OP fD- Lc
Ovum
71413 CEPTIfEiCAi'I55 IS ISSUM AS A MA iTER OF 114FORMATIBN ONLY AND CONFER$ ND RIGHTS Upo;ii T14E CERTIFICATE HOLDER. THIS
DEFT [RdATE DOES Nor Ab`P1R:P•.t}4Ti<JELY OR t 2GATIVEI. AMEWD, F,-,TEWD OR ALTER THE COVERAGE AFFORDED BY THE PQLIGIas
22L>r W' TM"9 CERTIFICATE Ol- INSURANCE DOES NOT CONSTITU, E A CONTRACT 13ETIMM THE ISSUING INSURER(S), AUTHORIZED
REPP,ESERIPA 71VE OR PRODUCI":R, AND THE CERTIFICATE HOLDER.
Iftlif�(MANT: If tlt2 COPMOW H0dir is an ADDITIONAL INSURED, the poltgrges) MUSIC ba enda7sed. 17 SUSROZATION IS WAIVED.sub)
act w
the t�ni 7r, and a0:zditions at: the ps11W, Ceftin gVII S May requiM gn endorsent ant A stetgment on gills CBrtlffCaE2 Baas not Ccrat�r rlg�l� #0 4I�e
GWIMCM hatd f III lieu aF such �11>3oPsemsrtlsl.
C. Hall Insup AsagE.tSM ��fltii�5•� �D6
OF. Quinrl'g D!?nsfetactlafi
0@2 W217111aet-t goad
ftCIBC, NIA 09820
Ing
Co.
INDICATBO. NOTWI FFSTANDING ANY REQUIREMENT.i�TE�yj OR CONDITION OF ObLOW HAVE ANY CON?RAGT OR 0 ER DOCUIIAEIVT WlTtd RESPECT rOISSUED TO THE INSVRED NAMED ABOVE r69 TME LthMICH�TH�S
6EI�TiFICAYE tYfAY BE ISSUE OR ldL4Y PERTAIN_ THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I$ SUBJECT TO ALL THE jHS.
EXGLUSION5 AND CCINDITIONS OF SUCH POLICIES. LlnttlYS SMOVM MAY HAVE B1eEt, REDUCED BY pptD CLAIti7S.
a t'�'Pc'DrtN9ttRAN.CE Ac s GDLU:YNUt>g9� q, �
(GEIJt;F�lL u�,i;tLiS� ! Lr�IttE
L"OOMM6ROtALGEMF.t3AL ABILrrY
CIAIMSMADE [Ij OCCUR
QE TL A0GRW-A7F {,I,,%tITAPPIJES PER;
POLICYPRO- COC
AU?AL;13811,E LIABILIT'
AWAUTO
ALL OU`JMED AUTOS
sCweDULEDAVrOS
HIRED AUTOS
r4 NON -OWNED AUTOS
UNSA& 1d; uae "OCCUR
G''EE53 uAe CWMSMpc
GFOUCTIBLE
ErENTION $
WORKERS CDPdPIBtISAMN
ANO WiPLOY31WLIABIure ytt{
t A.W PRCPRIe MR/PARTVE gXEGUrW
OSFICERn EM -RIP. �GLUD'et3p etfA
r.IcnrawT to Nhy
L�S'�= doperbavndar
DESLIRiP410N DF 0)3LRATIOrdS bat.
Ii:SCRIPTIONOFOPEMTIONBILOCA .noxgrI M1CLO
VOID PropriatorThomaS QOinn is ETi09Ueled
ACORD 2E (200€3109)
09/75/93 C 07176114
06107112 1 O:i07193
ISMS 1 07119193 ' 09195174
RUra111140 Sehadut%tf v=v opmIn �Vqutr¢d)
Is
CMIDINED SINGLE LRIIT ( Sr
(Esecddtrni)
BODILY INJURY leer Damn) S
BODILY INAARY(Per gowdcm) S
{r3r c�rtdenll -. -._ i S
�itd2r(t?3C11'8�i &
Jc1111:IJ�It'Ad 1 S
sxOULD ANY 9F THE AHO'VE DESCRIBED pOLICUES BE CANCSLLED gSp:ORE
"4'i WIPATION DATE THEREOF, NOTICE WILL 9S DELIVMeb IN
ACCORDANCE VM TP rr.poUayPROVISIONS.
A1fT. ORIZED REPRUBM rATIR
1998-2009 A+CORI
Cc1e- ACORD narr:e astd 1090 are eegf &rad tlsf b Of ACORD
AD Fights resemed,