Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Building Permit #797 - 71 OLYMPIC LANE 5/31/2011
r BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Issued: IMPORTANT: LOCATION � OL Applicant must con 44 tj Date Received all items on this PROPERTY OWNER Print MAP NO: /OG IO PARCEL /�O - ZONING DISTRICT: Historic District Machine Shop Vi yes V ett�.eo '616 no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ane family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic El Well ❑ Floodplain ❑ Wetlands E Watershedbist�ict ❑ Water/Sewer OWNER: Name: DESCRIPTION OF WORK TO BE PREFORMED: 7 r__ 0 dJ— Fa ti�on�lease Type or Print Clearly) - Phone L y / Z Z -A) CONTRACTOR Name: i Ari 2i� 9%�' '%S-3 CONTRACTOR ) dh �G� Phone: ` l Address: -,•-w► -4 Supervisor's Construction License: % f 2 © _ . _. - Exp: Date: Home Improvement 0 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 Cost: $� S� - y Q FEE: $ 1 -- Check No.: J Receipt No.: NOTE: Persons contracting with unr istere contractors do not have access to the g ranty fund J� ;Signafure 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 ❑ • C T' _ Food Packaging/Saieg¢ Q Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY • INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED PLANNING & DEVELOPMENT COMMENTS DATE APPROVED CONSERVATION Reviewed on Signature COMMENTS HEAD-TH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comme Conservation Decision: Comme Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer! Signature: it t Located 384 Osgood Street FIRE DEPA - M`ENT Temp Dumpster on site yes no Located at 124 Main Street Fire`Departmentsignature/date COMMENTS e - Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 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 o Workers Comp Affidavit a Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work a Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks a Building Permit Application a Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses • Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Li 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) a Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o 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 o 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location 11 D/4L ,/l�fl't✓ No. Date MORTIS �• TOWN OF NORTH AN®OVER Certificate of Occupancy $ J�CNus `1 Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # X33 Building Inspector m m m m Y/ m y mm l v 0 z M ro C � b y L' . � d CrJ F5 GO �? w CD Czy '0 CD O � C' r 0 z C) C d = CO) � O 0 � CD Cl CD o cr CD CD CD 0o ao C CD C/! L CO) CO O I CD CO) O CDCD O A O CCD O F FA C y 0 Go = doSm H oap®Q m n C CO m Z CD =r= N 0 .r .,r CD y. �1 �d.�d. o -4 O O y O y O m CD 2 N > > D G A O o ZS.wn. 1 oCC 0 H �CD col CL �. �. o ��: O H c CL -1 • CD CIO V N vOi fl. m Q : c o C= c "C CL CO) CD to CD H N H CD CD CD m � N O� 9 ate: J o OcSa )CON .� CD rr^^ m ; VJ CD TT .� NCD = d CD d Q - : C7 C� y CA c o moo: w CD cn 0 z M ro = o aGn b y L' . c �. o � CrJ F5 GO �? w 0 Z ro :vn w � � � n1 0 � z C) cn C b 91 o o Q d O i� M rA 0 0 H 0 9 0 c invoice date will carry interest at the rate of 1.5% per month and further agrees to pay all costs incurred in Page 1 of 1 5/25/2011 4:02.04PM ' Ccin*tMCWP 8wpervtstar LA061 l 0 Urt sa: CS 69170 Restricted to: 00 JOHN W LANZ.AFAME 30 TEMFoLE DR METHU£N, MA 01844 E"rrA I et— 4r3WW TrA 13KS Office of Consumer Affairs and flusiness Regulation 10 Park Plaza - Suite 5 170 Boston, Massachusetts 02116 Horne Improvement C„ox�lrWtor Registration ALL UNDER ONE ROOF JOHN LANZA,FAME 166 A MERRIMACK ST. METHEUN, MA 01844 Uue: RepistraWn. 1370f T TvRe: DBA E)078�: 10/2/2012 Trt1 2 +02 , Update Address and retorts carts. Mark reason for change. Address Renewal i•;mploytnrnt t,nst Carp ptlisr eat t Bamrr /�ff{aits ifs 8a License or nrgtat.Ytion rslid for itidivodtli ase tntt, HOME 1MP14OVE1M E -NT CONTRACTOR be#=tt the tt;*Wtion Mete. ff hWW rosea to. Re9lotrotloti: 137,057 Typo: Of1ist afCoommiodr Affi;rs and Rosiness R"Wat�:Vn Expiration: 3i1QM , 2 DBA 10 Pratt Pram - wase 317® pit UNDER ONE ROOF Boson' MA 02116 +tWN LAN%AFAME . MERRIMACK ST! "gMHEUN. MA 01844 t )nderwetreMarr Not Valid srhAnpt�� ! From:PERRY INSURANCE AGENCY 9786870149 12/20/2010 15:26 #272 P.002/002 ..-�- nn 0-9'%'Wa ft ala air Aft, OW 0 2 a was mamA• aw a a�wt� 'X Massachusetts uopie�i �r�trement Sample • A 0ntract This Form satisfies all basic iequirements of the state's Name itnprovemeuit'Contractor Law language to protect homeowners. Seek legal advice if necessary. An (MGL chapter 142A), but does 'not 'include skhndnrd Offirp ofC tts consumer guide to home imprpvemen's before agr eing to a y work on y ur r silence. You mayrovements should obtain uwfree copy by calling flee office ofConsttmer Affairs and Business Regulation's Constunerinfonasatiun Hotline at 617-973-8767 or 1 -may obtain a . r of"a �• $o eo uer nformation j P, IL Contractor information ame . C�l-�/%y►� rZ. L� ompanv ame Street,Address (da not use a Post Office Box address ' n , ) Contractrp / Sale arson/ O er�N�ame CityFfowa f� ��+��`-' I 'State Zip Code usiness Address (must include a street address) DaytitaePhon i EveuinaPhone� ltyPrown State Zip Code C� -t'T '�7 j Hi d Mailing Address (It different fiom above) Business Phone ederal EmployerIDarS•S,Number OactitcanincmartaveIL - name pmvaa=kc0auactor C and molt matractots have t I • x�l cr fixpintion date The Contractor agrees to do tlre'followiu �uaRyt`e`a°°°° °,ta ,�f �, g worlt for the Romeo der: ' j (� 'm a to e w r- o comp e e ectJ ,/ �I sP g e_1111q ran , J1UU Lrano all ae o atiCfl IICP 9]T�RT.�hTi_ - _ Regtiired,'liermlts - The followingbuildingpermits arc required rrflptosed Start and Complet[oni Schedule - The following schedule will and �yyip he seeured by the contractor as the homeowner`s agent, be adhered to unless circumstances beyond the contractors control arise (Ov�ners vvlto secure their oven permits will be exelildedfrom ,the Guarant3iFund provisions- of S�e2,atcwhencanlraatorwillbeginconiractedworkMGL chapter 142A.)'�"ate when contracted work will be substantially completed. Total Contract Pr1ce'aud Payment Schedule The Contractor agrees to perform the wort,. fiimish the material and labor specified above for the total sum of Paytt}eitts will be made according to the following schedule: (*) Upon signing•contmet (not to exceed 111 ofthe'total contract price or the cost of'special order items, whichever is • — /+ greater) by' �/ or upon campledonnf fp�•'�1,s'1 L ic, ' 5--- - - by -or upon completion of Lz ° � upon completion of the conizaat (Law forbids demanding full pay mentuntil contract is completed to both a p party's satisfaction) Tho following material/equipment must be special $ � . ordered before the contracted wotl'begins in order to be paid for ' to meet the completion schedule,(**) to be paid for NOTES: (*) Including all finance ch not exceed the charges (** ) Taw requires that any deposit or down -payment required by the contractor before work may of (a) ane -third of the total contract price or (b) the actual cast bogies which must he special aFdeced'in advance to meet the completion schedule, of any special equipment or custom made material I'D y '91, terms of thew '-- "—P - z ne"Contractnr agrees to be solelyresponsible for cotnpletioa of the work described must be Utta the action °f any t rd paity%subcontractor utilized by the contractor. The contractor further a ee ateria s and labor underthis a Bement €•t S to be solelyrespttnsible for all a contract Acceptance - Upon signing, this documentbreomes abinding contract under law. Unless otherwise n ted withinOnts to all ubcontractors for care ll shall not imply that any ]len or other security into reAhas been placed on the residence, Review the following cautithis and notices carefully before signing this contrack this document, the • • Don't be pressured into si • , fining the contract Take time to reac(Id and fully understand it Ask questions if something is unclear, Flake sure the contractor has a . olid Home T sub contractor, to be registered with the Director ofHotrte Improvement Contractor RegislratiotL you may inquire about contractor ctristration The law requires most home improvmrtent contractors and registration by,vvridngto the Director at One Ashburton Place, Room 1301, Bostp ]:800:223-0933, n, MA 02]08 orb calling quir • Does the contractor have insurance? ` Y g 727-3200 or Check to see that your contractor is properly insured. Gude tYour che Ham and responsibilities. $earl the Important Inforntatialo on the reverse side of this farm and gets co of the Guide to the flame Improvement Contractor Law. PY Consumer Ethiru ay cancel this agreement if it has been signed at �ilatie atKer• than Ute contractor's normal place ofbusiness r ctorin writing at his/hermain office or branch a$icl cr ordinarymail' ontusiness day foIlowing'the signing of this ovi 8greemenk See the atutc_hcd notice of cancellation form for de iVery, not later you notify the P d, by telegram sent orby de]jde expla DO NOT SIGN' T - ry, not later than midnight of the Twa identical espies ofthe enntrai tmus�St be CO d1 1 signed.and 'CT IF TJEWRE t � E °f illis righk One wpyshouldan to thb lWhIeowaQ Y Thee S" A ES r! Thea crcopys6auldhekept6ythecon tractor. Homeowner's Signature r• C ctor's E e Date Date t Contractor Arbitration The Home Improvement ContractorLaw provides homeowners� alternative to -court action)•if they have a dispute•with a Conti ctor. The same right initiate no automatically tration action affordeqs to a' contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court rless ies agree to the otional clause provid both partped below. Thus clause would give the contractor the same right to arbitration as'is afforded tb the h6meowtter by the Hdme 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 toa private arbitration f rm which has been apprpved.by the Secretary, of the. Executive Office -of Consumer Affairs and Business Regulation and the consumer shall. be rl qulred to submit to such arbitration•as provided In Massachusetts General Laws, chapter 142 H'omeowner's Signature 4 Co actor's Signature NOTICE: The signatures of the parties above apply only to the agreem n , 4 of the parties. to al tnative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by tLte parties, - Homeowner's Rights : + , ' •.A. homeowner's rights vender 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, .even by agreement. However; homeowners may be excluded from certain rights if the contractor they choose is no.t properly registered gs prescribed by law. iiomeowiaere who secure their own building permits are automatically excluded from all Guaranty. Fund provisions of 'thd Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in s timely and warkmanlaX a manner. Homeowners may be entitled'to other speci�c 1pgal rights if the contractor guarantees or provides an express warranty for workmanship or nnaterials. In addition to guarantees or warranties providediby the contractor, all goods sold in Massachusetts carry an ituphed warranty of inerchantability and fitness for a particlar purpose; An enumeration of other matters -on which the homeowner and contractor lawfully agree may be adder to the term's of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions'abbut Your c6nsum6r/hcmeowner rights, contact the Consumer Informatioir Hotline (listed below). Executions of Contract u The contract must be executed in dulieate and should nol be signed until•a copy of all exhibits and referenced documents havd been.attached. Parties are.also advised not to sign the document until all'blank sections have been filled-in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachmentsis to, be given to the owner'and the other keptby the contractor. Any modification to the original contract must be in writing and agreed to by both' arties. Contracted work may not lbegin uxitil both parties have received. a fully executed copy of the contract,- and the three day recission period has expire Accelerated Payments 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 fuiancially insecure. However; in instances where a contractor deems lumfiierself -to be financially insecure, the contractor may require that the balance of funds not yet due be placed iri a joint escrow account as a pretequisite to continuing the contracted woslc., Withdrawal of funds front said account would require the signatures ofboth: parties, Additional Information If you have genu questions or need additional info rination about the Home Improvement Contractor Law or of er consumer ro rights, or tFyou wish to obtain a free copy .of ,�, Consumer Guide to the Home Improvement Contract�Or Law," contact: ' Cdnsumer Information Hotline ° Office of Consumier Affairs and Business'$egulatioa .10 Park Plaza, Room 5170, Boston;• MA 02116 (617) 973-8787'or 1(8.88) 2833757 "z If -you want to verify the registration of a contractor or if you haveuestionts or need adfional i, about the contractor registration component of the Home'Improvem nt Gontractvr LawdContact nfoimatlon speet#'tcally Director of Home Improve:menf Contractor Registration Bureau olBuilding Regulations and Standards One' Ashburtoii place, Room.1301, Boston, MA 02108 ' (617) 727-3200 ror 1-800-223-0933. For assistance with informal mediation of disputes* or to register formal complaints a ainst a bus' g mess, call: Consumer Complaint Section Office of the Attorney General r (617) 727-8400 AND/OR Otter Business Bureau (508)652-4800 .(508) 75*5-2548 (413) 734-3114 CERTIFICATE OF L#ABimy thL4l lDAfd *l: TPfQ POLICIES OF I NSURAAtCEUMO BELOW "M BEEN D TO TIME 046VMD NAMEDMAIE FOR TWE FKiLXy P�Eltoo Ml0"TEO. ANY REOUIREMENT: TOM OR CONDMON OF ANY CONTRACT OR 0TmER OOCCAMEW VWT" RES'PEGT PERTAIN, THE INSURANCEAFFO"ED BY Tim POLIK—S DESCRIBED F f tS —SUBJECT TC) THE TEAIuRS. EXCLUSKNiSC� ARID ONDITO POE. Mi. AGGREGATE UTAITS SHOWN MAY bMAVF uccu oenew�=n na. �� �SUEO OR MAY OF ^-"r-64 IIATe(mWmy YY) R erry tNWrance Agency �2 Ghfck0fing Road NthAndover, MA 01S45 12/20/2010 TW COMRCIME MON � 8 UPON Tw HOCDEft THM CEKV* LATE DOU NOT AVEND,Oyu ALTER TW cue sv TFtE t+OLICi BEL OWt. pyo, "stw4m AFFORONG COVERAGE MAIC 0 JOHN LANZAFAME DBA ALL UNMR ONE ROOF I"WFmt& ATLANTIC CASUALTY INSURANCE a AN ffatllaEec: 30 TEMPLE DR fNsuREa d. MET HUEN. MA 01844 0GURER E TPfQ POLICIES OF I NSURAAtCEUMO BELOW "M BEEN D TO TIME 046VMD NAMEDMAIE FOR TWE FKiLXy P�Eltoo Ml0"TEO. ANY REOUIREMENT: TOM OR CONDMON OF ANY CONTRACT OR 0TmER OOCCAMEW VWT" RES'PEGT PERTAIN, THE INSURANCEAFFO"ED BY Tim POLIK—S DESCRIBED F f tS —SUBJECT TC) THE TEAIuRS. EXCLUSKNiSC� ARID ONDITO POE. Mi. AGGREGATE UTAITS SHOWN MAY bMAVF uccu oenew�=n na. �� �SUEO OR MAY OF ^-"r-64 af'lO"ANY OF TME ADOVE 065CROMPOUCES 6E C^0MLLE0 GOVORG THE EXPIRATUM DATE WEREDF, TIM OMJM VML VaWAVCIIC TO MAIL 10 DAYS WPO TYU NOTWE TO TIE GEftTM 4M "OLDER YAWW TO TIME LE 'T, OUT H1i AME TO 00 So BSMAt4. ------------------ Tyft C1F " caMwERcfAL GENERAL au�efLm O CLA"As h1AM ® OCCUR Ca£Nl. AQGREEiATE LMIAF APPLIES PER.' POLICY PR0IECT LOC taruCY L.118000227 Mom amirloto 9m1r2oi1 kfYlta EACH OCCURRENCE s aoa.aoc ao n �wictl s 50 00000 �— MED EXP «.t E ZWO00 PERSONAL L AVV WURY S 300.000.00 t�1Et1 MPALAOGae"T s GMAOa00 SWOOO 00 P#taOttCT & • c aMMwoP waG s ASR [ tJIkNU Y ANY AUTO ALLOWNEDAUTOS SCHeML£O AUTOS HIREOAUTOS NON -OWNED AUTOS F11gS:tG1.E LtMR s C ILS RY s _y– Og i MaOfAl�fiF a AUTO ONLY. EAACC4'NT _,,....�......_,,,^ .. GARAGE LtA[#fLtTY ANYAUTO MV EAACC i LY AGG s ET�LA M.M116tLCfY OCCUR ® CLAIMS MADE OEOUCTMIMLE RETENTION S WORKo cor�Mto ANY PROPRIETORIPI't1ERXECUTtYE OFFECEAVgaWR EXCLU©EO� SPfCtAL PKMSKM Gslaw OTftER AWC7009464012010 1110912010 Ifl09)2011 EACtf OCCURRF rWX s AGi3Rt:GATE s t f. I. EACHACC=GFDCT E 100,0U000 _ _ E L OtsEAik . EA FRPlOYFk ig 100,04004 E L CNSEASE - PCXICY LtwT tS SM -000 00 af'lO"ANY OF TME ADOVE 065CROMPOUCES 6E C^0MLLE0 GOVORG THE EXPIRATUM DATE WEREDF, TIM OMJM VML VaWAVCIIC TO MAIL 10 DAYS WPO TYU NOTWE TO TIE GEftTM 4M "OLDER YAWW TO TIME LE 'T, OUT H1i AME TO 00 So BSMAt4. 3rof canstretcteop suns '.. i aceinse bcentse: CS 6912D Rest*tcted to: 00 JOHN W LANZAFAML= 30 TEMPLE DR METHt1W MA 010+44 E xp+rat ton. 4181017 Tro 13449 V Office of Consumer Affairs and Business Regulation LM . - Suite S 170 14 Park Raza Boston, MassacbUsetts 02116 Horne Improvement Cggc ttraFtor Registration Re4istration: 1370E 7 TyDe: DBA ALL UNDER ONE ROOF Expiration: 10!2/2012 Trp 204021 JOHN! i ANZAFAME 166 A ERRIMACK ST, METH UN, MA 01844 AG3�uae!�a•ua-�3 W illy UIRcetlfCOgaq rt Alt iss WA HOM8111111PIROVEN4ENT CONTRACTAR Registration: 137057 Type: 2' Expiration: 1(}aM12 DSA 4LC UNDER ONE ROOF JOHN LANZAFAME <66 A MERRIMACK ST':, MF-tA UN. MA 01844 t iaderxeretary Elpdate Address and return card. Mark reason for chanNe, Address Renewal i ' Employment Lost C2rt1 Lirea:se or r tration valid for indivedul use on I, before 16t expiration date. If tbmW return to: 47 W -t of C-09umer AfFairs and $asinrss Rt�ntat on 28 Park ?U=- Suite 5278 8011m MAA2tl6 f # Not valid writbtmt The Commonwealth of Massachusetts Department of IndustrialAccidems Office of Investigations 600 Washington Street Boston, MM 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganizatiorAndividual): _Ta4-1 I Address: 3 0/�/1 City/State/Zip: phone #: 91? —'Y V,5-- Are you an employer? Check the appropriate box: 1 • Iam a employer with s� 4. El am a general contractor and I employees (full and/or part-time).* 2..❑ la m a sole proprietor or have hired the sub -contractors listed partner- on the attached sheget. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. E] I am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showin +11 Type of project (required): 6. E]New construction 7. ElRemodeling8. El Demolition 9. E]Building addition 10-ElElectrical repairs or additions 1 l.❑ Plumbing repairs or additions 12.[]Roof repair 13-ElOtherP1a Homeowners who submit this affidavit indicating they are doing all work and then hire routside ontrac ors must submit information.new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' omp, 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: 0 Policy # or Self -ins. Lic. #: �–� iZt� ��.�j� cs ��p `� Expiration Date: [ I Job Site Address:_ / � O Li ,4A Arr— L_ AJ City/State/Zip: A44 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify undo thep� is andpety/ ies ofperjury that the information provided above is true and correct. // .111"" I �s 3 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): I. Board of Health 2. Building Department 3. City/Town Clerk 6. Other Contact Person 4. Electrical Inspector 5. Plumbing Inspector 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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign 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 sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum 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, MAA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia C as t $ o� cU � REED All ` yjm Of rrcl E' rx Masonry € r 1 aS coil V 4 .*Pv° Y sEa s'FS 5r .e sn F. $;e 1'S.Pa` ° t SYd."tee t" z n `4 3 v7-�'X':"'l.%i” a+sie,#'$'`Y,olt jg ; i '' �•" Tom" rpt,, " to Proposal To: Chris & Andrea Hanle Date 5/10/2011 Street: 71 Olympic Lane 978-258-7628 N. Andover, MA Roof proposal vanhanle@comcast.net 1. Protect house exterior and landscaping as best as possible. (tarps etc.) Total cost: $ 6,500.00 2. Strip all shingles from entire main roof. 3. Inspect and re– nail any loose or lifted plywood. 4. Any compromised plywood will be replaced at an Balance due upon completion �� 5. Install heavy gauge 8" aluminum drip edge to all Referrals available upon request eaves and rakes. 7Z Highly rated member of the accredited BBB and shield along all eaves, wall connections and top to „ /� ¢�ENO GdF �y('� 35`s4"•' Thank you! ,oar )�� �il9 tY 3 E, , ; , r�✓� �� n .a $ sheathing up to the ridge. C 10. Install IKO Cambridge Limited Lifetime architec- tural shingles to entire main roof. Mfg. warranty •t a S FRooflon A 0' ' 12. Counter -flash chimney with ice and water shield, 711 `. 14. Building permit included. 15. Removal of all work related debris. C as t $ o� cU � REED All ` yjm Of rrcl E' rx Masonry € r 1 aS coil V 4 .*Pv° Y sEa s'FS 5r .e sn F. $;e 1'S.Pa` ° t SYd."tee t" z n `4 3 v7-�'X':"'l.%i” a+sie,#'$'`Y,olt jg ; i '' �•" Tom" rpt,, " to Proposal To: Chris & Andrea Hanle Date 5/10/2011 Street: 71 Olympic Lane 978-258-7628 N. Andover, MA Roof proposal vanhanle@comcast.net 1. Protect house exterior and landscaping as best as possible. (tarps etc.) Total cost: $ 6,500.00 2. Strip all shingles from entire main roof. 3. Inspect and re– nail any loose or lifted plywood. 4. Any compromised plywood will be replaced at an Balance due upon completion additional cost of $50.00 per sheet of 1/2" cdx fir 5. Install heavy gauge 8" aluminum drip edge to all Referrals available upon request eaves and rakes. 6. Install 6' of IKO Armourguard ice and water Highly rated member of the accredited BBB and shield along all eaves, wall connections and top to Angies' List bottom in all valleys. Full coverage on rear lower addition. 6'MA state code. Thank you! 7. Install all new pipe boots. 8. Above the ice and water shield, install Typar Sur- E, , ; , r�✓� �� n round synthetic underlayment to the remaining sheathing up to the ridge. 9. Install IKO Leading Edge starter shingles 10. Install IKO Cambridge Limited Lifetime architec- tural shingles to entire main roof. Mfg. warranty Pro rated after 15 years to original owner. 11. Install new GAF Cobra ridge vents. 12. Counter -flash chimney with ice and water shield, re -seal and tie into new roof. 13. Seal rear gutter 14. Building permit included. 15. Removal of all work related debris. 16. Contractor workmanship warranty =10 years un- der normal wind and rain conditions. Acceptance of Proposal—The above prices, specificz tions and conditions are satisfactory and are herby ac- cepted. You are authorized to do the wor s specifie Payment will be m e as fined above. Date of Acceptance:5/ ��,1 Signature: