The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #448-13 - 72 PEACH TREE LANE 12/5/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: / O Date Received Date Issued: 2 'IMPORTANT:Applicant must complete all items on this page t 1 f c LOCATIONt PRO'PERTtI( OWNER _ � No W i Prant� '00'YeatiOld Strudure) yes'4 0 MAPN® ,?_-t O PARCEL Cil P-ZONINGDISTRICT Histo�ictDastrtctyes Machine?Shop::Ulllage yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building kOne family ❑Addition ❑Two or more family ❑ Industrial } B'Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ ❑ Septic3 OWelll' O'Floodplam# ❑1Netlards ❑ WatershedDistrct 1 ❑;Water/Sewer, DESCRIPTION OF WORK TO BE PERFORMED: I Identification Please Type or Print Clearly) OWNER: Name: P/-)OL- Phone: 91 S-VSs-3111 Address: CCT ONTRAOR4cName `> _ Plone -_ T # N , Address '� Superviso�Ps�Co�lstrucfion�Llcense __ �_- _ _ Expo Date . _ f � _ ARCHITECT/ENGINEER M2o 02 Phone: -181-21"1 - yyy -. 4390 Address: 2- rloaiy-A-c- AW, 5�W %� 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: $ yS OOb FEE: $ Sy0 . O O Check No.: O Receipt No.: 04 NOTE: Persons contracting 'th egistered contractors do not have access to the guarantyfund `..:.cr,aea-er-^..--I' »,z.:g -'��••,�,d. - .+Eaam..w.r �y '° -.;.w -:w-.., _r.+.� .n v �a r s*., aR' th �` ^4,. e:,. SignatureofrAgent/Owner�V _ e :Slgnaturehnof contractors kt Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS " HEALTH Reviewed on Signature i 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 DPW 7Cowo Engineer: signature: Located 384 Os ood Street FIRE DEPARTMENT = Temp Dumpster on site yes no L_o.cated at 124,Main'Street Fire Depa lmentsignature/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 t i i i II U Notified for pickup - Date E E Doc.Building Permit Revised 2010 I r 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 , NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building permit Revised 2012 Location 2 /l lnce-'o No. �/�•�—/ 3 Date • - TOWN OF NORTH ANDOVER O .: Certificate of Occupancy $ �a Building/Frame Permit Fee ' Foundation Permit Fee $ Other Permit Fee $ � TOTAL $ Check# 26012 Buildaiiig Inspector 4 The MZO GROUP T � We in rta.r&NJ.cT K NH.Ott DESIGNERS a ARCS 1TEC-TS PLANNERS J�J:Cumin 1s.A1,1. W THEL MIQUELLE TRADMON imrlhrarlev U.in W.NNE.T c6u&Ft.M*dk . - Satiart&IeeBaQr January 17,201.3 Mr.Paut Wise ; 72 Peachtree Lane North Andover,MA 01845 Re Kitchen Renovation 72 Peachtree Lane Dear Paul, ° g I visited your home on Jan. 1 G,2013 to review the work done to ` - remove the wall between the Kitchen and the Dining Room: The 1 work has been done in accordance with the architectural plans and the steel beam is installed,properly and with good workmanship. The support is as called for on the architectural.plans and prt�perly implemented. The work is accepted and ready for close-in. Andrew T.Z A.I.A. President,The MZG GROUP ` '_ - x KA%V.\Coressp.xfuccAW*e-Sue fruit 01-15-13doc.doc 92 Montvale Avenue;Suite 4350 Stoneham.MA 02180 a Voice 781•279.4446 i Fam 781.279.4448 E-Mail•Emo@mzogroup.com Web-VvivW mzogtoup.com Enter construction cost for fee cal - North Andover Fee Cakulation Construction Cost $ _ $ 540.00 Plumbing Fee $ 67.50 Gas Fee 100 comm. $ 1'001 ..0.:0 Electrical Fee $ 67.50 Total fees collected $ 775.00 72 Peachtree Lane 448-13 on 12/5/2012 Kitchen Remodel NRTH O Town of E 6Andover No. 144f Y _ . . h ver, Mass, coc N1c Nl WKK TED S U BOARD OF HEALTH LD PERMIT T Food/Kitchen Septic System ........... BUILDING INSPECTOR THISCERTIFIES THAT ........ i �l..FI..F........ ..............................................................:.... 7a2 ® Ce �FL foundation has permission to erect .......................... buildings on .................... r.......:.....�1!...................................... Rough to be occupied as ....................1."i..ri. l ,<......l�r.. .�t.�ir�........................................................ Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIONS ARTS Rough Service ............ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final _ No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE O ' NEW:CABINETS LIMITOF : BY OTHERS NEW 2X6 TUD NA �F I: I DINING �O:QM Ol .... .. D WIOxI BEAM.ABOVE i. I.. I.NEW ISLAND - ( BY B OTHERS ' : w .. : _ I REMOVE Gf�EAT ROOI�{1 POST . S LID POS I G 8'_41. D - - - - - ------ - . . _ . EMOVE POST.; O I � I - ,' DASHED WALLS TO AUND. BE REM VED l° II r- CC x� LINE. OF.LOFT 41 X ABOVE 1 :I� �0 2 --.— -- —� SOLID° O - - _ .. POSTING a �ti O 10' 8� Q 16'-811 ,' 3. 6' _ - � 611 - - 4 ' 10 z . qw L . LAV. I KITCHEN ni _.. 9 9-3 .: o - +^- °,� U D R II ..LINE OF LOFT ----- ... .. - I I � I i2> 2o:X ABOVE ------- J +' I I I, I , - -4 4'-5" I 1 n �\. ....._-.- -._. ... North Andover November 20, 2012 The MZO GROUP . ES1O ■ARC}11TEC-M 0,!'1.ANNERS FOYER . .... .... .... .... �� .... I_I `I'v -• to oN I U- h��//EH.S ""�� .. II1L�a{(p/fys'1714D]'ll ..:.. .. ... .. .... .. .... .. .... .. 92 ■1.x 781-279-4448f.WM IN MonrvakAqS.e 4310■ S chain,Slass h ms M180 Va]NI.2"/VJi1( ml �(r�1m>narcwp, rcn - ---- B� AIV1 SCN � DUI E - fVIARK;:. TYPE. THICK NOTE 29 LVL/MICROLLAM (4)I 3/4'` X 9 I/2" 7 FLUSH W/ FL: 1148 30 STEEL _ WIO X 17 4„ BELOW LVL LIMIT OF N WORK L 14 -- - - - - _ . - 0 ST . - .. . OVE E G BE T BE 30 . FRAMING. NOTES: R M - PROVIDE SOLID.. BLOCKING TO FOUNDATION. AT ALL BEARING POSTS14C - 11MICROLLAM" "PARALLAM" AND ''TJI/PRO SERIES" ARE REGISTERED TRAD MARKS i i ANY SUB'STITUTI'ONS OF, OTHER BRAND BEAMS -MUST BE CHECKED AND VERIFIED BY SUPPL:LER. ExsT'G POSTi – o - – S A A ION: MUS E FO Ol%JED ------------ REMOVEDASF. s _.. I,. TO E : : . iii. � MANUFACTURERS S:PEC:IFICATIONS: REGARDING :I:N T LL T _ T B FOR ALL.. "ENGINEERED. WOOD PRODUCTS." _- I O BELOW: r - I I FRAMING NOTE ' - - THIS DRAWING IS . A .GRAPHI'C REPRESENTATIO OF THE FRAMING FOR THIS STRUCTURE } CONTRACTOR SHALL NOT SCALE THIS :DRANIII i — — — — — — _.. FOR THE LOCATION OF FRAMING MEMBERS I ? - - REFER TO THE PLANS/ ELEVATIONS; AND SEG IONS ' E XST'G FLOOR RAM:ING TO REMAI . : FOR DIMENSIONS AND NEIGPTS. AL - q . SECOND F LOI� AMINE CO - q. :: .I/4"=I:'"0" qn - r se1R-es ellee.. .. - _ ver, M _ 20, 20 1 i North Ando a November 2 I MZO GROUP _. .. If I . .. ITE('Tti I : : 13 :The 1 Tii4DITIONpw • ''' 92 Mommlc T<nuq Sitc 4330 Sibielum,}liy hscus 02180 ... .... .. .... .. .... -. .... .. .... .. .. .. .... .. .... .. VA781.2m/JN(.1-781-279-IWM .' Page 2 of 3 I: J " - (4). q 1./2u 1 3/4u X LVL SEE DETAIL-4: CONNECTION DIAGRAM EAT RAFTER -": JOIST RANGE t 4'-81/7... ...27-10 3/4' I7-4'3/4' .. ... .. V41 .X 17 BELOW ...HAND RAIL I� WALL. BETWEEN KITCHEN ib 11 RISERS @'7 5/8 +/- pppp�� II. AND LIVING..ROOM TO BE 15 TREADS10P :r N05E (3)2X12 5TRINGERS �1 it�I rED ... ... ... ... .. .. REMOVED II T' II D EAI � C� NEN BEAi"l ABOVE ISLAND 2 I 1/81I 11 Du :SIMPSON. STRONG—TIE :: SECTIO T[- R000 KITCHEN _ .... .. rl -- I SDW22�34=R50 1/811 = 11-011 !STRUCTURAL SCREWS _. .. i2 . . Z : N 2> 0' 4. ! — 1-11W MIN 7. _. I �o o 1. . - CONNECTION DIAGRAI"1 I II II c-.-� I. II I .... _.. .. _.. .. (4) 1 :3/4" X q 1/211 L JM T II . .. .. .. .. CO - L -:JL- -JL-— .. .. -. _... .. tpq -------- DETAIL C� NEN BEA1 l I .. .... .. 1/ 4 I II II I I I I GREAT ROOM . b I - 4 mise ]R-esidence .... b : : I I'I I m 3 .. T North And Ma. November 20, 2012 - GROUP -- - - Ei"M .... .... .. .. .. q : - The O �ts,�h�. �� YLA\INt:ItS .. In'1'Nli. '1 .. .. SECTION TNROU P ID F,00l"f ilux N1.27Y R.P.A1 E G C� 92M.—n A c,5 i 4350• Sim 1vnS Vimexh s021� - a V �N1-2>Y�.flf � � sl .... .. .... .- ... -... .... . .. .. - .... .. .. - - Page3 of:3 . 04 °oT a�ti TOWN OF NORTH ANDOVER 0} %, a TM OFFICE OF BUILDING DEPARTMENT o . ,�°" :.1600 Osgood Street Building 20,-Suite 2-36 �7�55 cHus� NOrth,Andover,Massachusetts 01845 Gerald A.Brown Inspector of Buildings Telephone(97$)688-9545 HOMEOWNER-LICENSE EXENlpTION Fax (978) 688-9542 BUIDING PERMIT APPLICATION Please print DATE:-- a 5 1 JOB LOCATION: 7 • P�ac�,�re� �h� Number Street Address r10MEOVVNER Wise- Cl-1 S-Coss-�9 87 5Ce -31 1-ga93 Name Home Phone Work Phone PRESENT MAILING ADDRESS sGrr 1� W014k And over— M A 018145 State. Zip Code The current exemption for"•homeowners"was extended to include owner-occupied or less and to allow such hoTneot.,l ers to engage an;1cividual.for hire who does not dwellings to two units possess a license,provided that the owner acts as supervisor). State DO, ding (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Persons)who Qwns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two farc�ily structures. A person who constructs more that one home in a which there O shall not e considered a homeowner. be The undersigned"homeowner"assumes responsibility for compliances with the State Building Co Applicable codes,by-laws,rules andregulations, de and other The undersigned`lomeowner"certifies that he/she understands the Town of Forth Andover Building Department minimum inspection procedures and requirements and that he/she will comply with,said procedures and requirements, � ' HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption 'EOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): �� t d'W Address: 7i be" City/State/Zip: 1�, }}�t-�8� MA7 Di$ Phone#: 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(full and/or part-time).* have hired the sub-contractors Z.E] I am a sole proprietor or partner- listed on the attached sheet.t ?• [✓]Remodeling 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 ;oquired.] officers have exercised their 10.El Electrical repairs or additions 3. I am a homeowner doing all work right of exemption per MGL 1.1.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.❑Other comp.insurance required.] kny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information, am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. isurance Company Name: :)licy#or Self-ins.Lic.#: Expiration Date: ib Site Address: City/State/Zip: ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). tilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a .-ie up to$1,500.00 or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine up to$250.00 a y ag ' st the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of th DIA r insurance coverage verification. to hereby certify a de 1 pains and penalties of perjury that the information provided above is true and correct. gnature: Date: 4 L13 ltz--- Lone #: 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#: 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 z- or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an empYoyer." ` MGL chapter 152, §25C(6)also states tliat"'every state oi'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 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 `' t Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 evised 5-26-05 www.m a sS.unv/cl i a j� 3 i I mm I � 1 I I HIM zt 10 i Nate: This drawing is an artistic a Designed: 11/6/2012 interpretation of the generalI ` a Printed: 11/15/2012 appearance of the design. it is �' �I; ....... not meant to be an exact rendition. CROLE KITCHEN ARD BATH DESIGN t 1 s _.. .................. 301;" 139" ®. =48 24Ll 2' 2 24"—... 4-a" 15' 7:„ 5 04-1" 1 z 15 3 z 5 ................ 7 ...__._ " 4,,. 7," 1 , , ." 57 M�® 3® --r�` 4' 33 �---•3� 36 ,�'94 15 � 20 ,��• 15 38�1 W4238 W9021BUTT _ r,..% 2438HUT'W1238L W1230OB •..:p 15i W9515- I �•� =ia 618E O 630tYU ` dE 48REF-8I U2424906UTTA0C33r4906UTT 838.2D _.... @ =3, B30 W3745 - B302D QFn1S-1 Fb1fr, ...... .. o ....... .........._ ; TP3 'SEP KL 1 ' r , I -4 N W i ------------------ wN _N V , li r l a^� ............. : 9544Fr 4.D16HW.3Q(2)APSBE38 '830.?D 1542 �. LW30,908UTT Waz30 W8030BUTT 1.✓ d 9 ----------------- 7 J-36"— 0 15 2a` e20e"— 1in 20,_. 21 s3,1 i" i ---- —— .................. 11 dimensions size designations This is an original design and must Designed: 11/15/2012 given are subject to verification on ^" not be released or copied unless Printed: 11/15/2012 job site and adjustment to fi#job s '-'1 applicable fee has beenJ or aid job p ;conditions. order placed. MOLE KITCHEN AND BATH DESIGN �.... ....... ........ ...... InI i i r• . i i { i i • i Q �l Note: This drawing isan artistic Designed: 11/15/2012 interpretation of the general Printed: 1.1/1512012 appearance of the design. It is ! '� not meant to be an exact rendition. CROLE KITCHEN ANp BATH DESIGN r I i i I L-4 I .. ........- e � I f -- f a Note: This drawing is an artistic ! Designed: 11/15/2012 interpretation of the general I k�rinted: 11/15/2012 appearance of the design. It is "�I not meant to be an.exact rendition. CAROLE KITCHEN AND BATH DES! i i } -__ lul OM Note: This drawing is an artistic r Designed: 11115/2012 interpretation of the general printed: 11/15/2012 appearance of the design. It is not meant to be an exact rendition. CROLE .......... 1<ITCH1 W 6AII(11S1b1 4ti>•__ .. a __ '� G i i 3 3-- I' Note:This drawing is an artistic Designed: 11/6/2012 IALA interpretation of the general Printed: 11/15/2012 ffs-,a n appearance of the design. It is ............... !S LJ+X Lay not meant to be an exact rendition_ MOLE ........ ................ ....... K1TCHEA ANQ BATN DESIGN I { 3 E I i T g I�esign.ed: 11/6/2012 Note: This drawing is an artistic u i -� interpretation.of the general e r Printeri: 11/15/2012 appearance of the design. It is � � � not meant to be an exact rendition. MOLE KP'PCHEk 4N0 BATH 6tFSiGH The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): �� t Address: '�2e-- City/State/Zip: � City/State/Zip: }01\rZE MA7 &M Phone 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. ❑New construction employees(full and/or part-time).* have hired the sub-contractors .E] I am a sole proprietor or partner- listed on the attached sheet.$ ? Remodeling 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 quired.] officers have exercised their 10.❑Electrical repairs or additions 3. I am a homeowner doing all work right of exemption per MGL 1.111 Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.R Other Uy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.poliey information. am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site formation. isurance Company Name: Aicy#or Self-ins.Lia#: Expiration Date: ►b.Site Address: City/State/Zip: ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). iilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ae up to$1,500.00 or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine up to$250.00 a y ag ' st the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of th DIA tr insurance coverage verification. Yo hereby certify u. de pains and penalties ofperjury that the information provided above is true and correct. mature: Date: 6 Z_ 3 t tone#: Official itse 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 M