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Building Permit #712 - 85 FLAGSHIP DRIVE 6/2/2008
BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date I IMPORTANT: Applicant must complete all items on this -Daae LOCATI Print PROPERTY OWNER $ .' S t ' f, t, GGE>'r`� Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village ves no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alter 1OrT No. of units: Commercial Others: Repair, replacement Assessory Bldg Demolition Other Septic Well floodplain Wetlands Watershed District Water/Sewer OWNER: Name:_ z -b6 -A Address: 12 loot CONTRACTOR Name: Address: I Pz DESCRiNnON OF WORK TO BE PREFORMED: M , LiGwrS Identification Please Type or Print Clearly) t- k -C Phone: '97? -3374-6630 R t> fLL Hio,Vi50 i4t L.€, MA W rt- -t A -m '-ii P -C � 1-69 --- <v P4 R Supervisors Construction License: C 04-15�963 Exp. Home Improvement Licen RCHITECT ENGINEER 9 ©GH P Address: Date: 1-141—Df Date: ►,�l t Ctl Mh Req. No. 15'b 56 o 19 35'' - FEE SCHEDULE:; BOLDING PERMIT T: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ / �i ° �v FEE: $ a Check No.: Z 0 -� / Receipt No.: /) NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund :Si�_. gnature of A ent/Owner -- _d. • Signature of contractor BUILDING PERMIT o� ""' , TOWN OF NORTH ANDOVER t�eD APPLICATION FOR PLAN EXAMINATION 1 Permit NO: Date Received ��gogAro 'pP�y Date Issued: 096 -M. "- IMPORTANT: Applicant must complete all items on this page LOCATION IP Print PROPERTY OWNER $ar IFLrG54 L -L -G t ���T`�'' RwS •�"� Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE t �.', t� . Phone: Residential Non- Residential New Building One family Addition Two or more family Industrial Alter ion._ No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: 6TV6 'A:+{t'TL rM ©pV-7NLKC5 rJ-rt:W6 C14'A-PGT OWNER: Name: - f '604 Address: 12 966 Identification � �LAr�SH �GA�f�fj "!^fev P4 R m R p Please Type or Print Clearly) P . 1-- i. -C, Phone: HA-V E-e,y 1LL . WIA- r;>I 9.15 - CONTRACTOR Name: `J4&jc-t- Cvr45'T" t �.', t� . Phone: Address: I PZ- W 1t,- W A-mGyp R. c it R •-- U PSR Supervisor's Construction License: C.5 o 45'#263 ` Exp. Home Improvement License: Exp. RCHITECT ENGINEER 90C,H Address: Date: I —1 q -- D q Phone:��'� ,rJ C/4 Mh Reg. No. !0b 5Z 01136" FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ / 2 ds—v FEE: $ d Check No.: (% 1 Receipt No.:� /J G% NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor r Location No. -7le?-_ Date 6• 0? " (jcr— NOR,h TOWN OF NORTH ANDOVER OL 9 Certificate of Occupancy $ + I.�J'•ry°' E<� s�CHus Building/Frame Permit Fee $ Foundation Permit Fee $ " Other Permit Fee $ TOTAL $ Check # IC)� 2�t99 Building Inspector k 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 PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS DATE REJECTED DATE APPROVED Reviewed on Signature HEALTH - Reviewed on Signature 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 Town Engineer: Signature: Locatea %4 usgooa street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS 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 COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 USgood Street FIRE DEPARTMENT -'Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA – (For department use 0 Notified for pickup - Date ._......._._..—._ ................... _—_...._............. .................... ................................. __................................. ............................... _._............... _... _.......... _................... ---..... _.................. _... _.... _............................... _..._._........................... __.......... .......... Doc.Building Permit Revised 2008 +r 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 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 Im. 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 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 ❑ 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 i Statement of Project Completion Project: 85 FLAGSHIP DRIVE Project Number: Interior Improvements to UNIT E North Andover MA Date: July 03, 2008 rCrt[It ivurrluer: f72 In accordance with 780 CMR (Commonwealth of Massachusetts Building Code) Section 116.0 Construction Control, and specifically Sections 116.2.2 Architect's / Engineer's Responsibilities during Construction, I. ............................................................Architectural Registration No............. ....... being a registered architect, have monitored the construction and provided the following tasks and documents during this construction process: 1. Reviewed for conformance to the design concept: shop drawings, samples and other materials which were submitted by the contractor in accordance with the requirements of the construction documents. 2. Reviewed and approved the quality control procedures for all code -required controlled materials. 3. Was present at intervals appropriate to the stages of construction, generally familiar with the progress and quality of the work and determined, in general, that the work was being performed in a manner consistent with the construction documents. 4. Was present at the construction site on a regular basis or as outlined in the initial inspection schedule, and/or I have sent other appropriately qualified design professionals, to determine that the work was proceeding in accordance with the documents submitted with the building permit application and the applicable provisions of the Commonwealth of Massachusetts Building Code. 5. Provided the building inspector with an original, stamped report for each site visit, scheduled or otherwise. Please accept this statement in consideration for the issue of a CERTIFICATE OF OCCUPANCY for the above referenced project / work. Signed and Sealed: Attachments: uisirmution: 38 Essex Road, Ipswich, Massachusetts 01938 - 2532 electronic: kocharchitects@verizon.net telephone: 1.978.356.5065 facsimile: 1.978.356.6056 Building Department Client Architect Contractor / Pield OO -1 O\U�p xiN��! y NE cr O y N O c. T •� two Q= On VQ ,^ O iA 'y0 O ;0 rn b m Yn :�% N 6 ^" "d 'b r N to 0 G - N N N e fu A m as a �, m a .7. n� ?; O a 2 r1 0 O0 a iG ' p' H• 0 8� V N 2 N o pOj A 2• w C d "�00 O O. = H 7 7 y 0 7 c�^o O p, T7 ": °;, -r O m w H? W n _ to fan oo ° E _ O n ta < c o y f �b y 3 om co _. 0 -J., O 7d O �o y b Y 0 0 0 m to o p, � CD cr fD m 0 O 0 T-EA vi m O J N U .� •-• N ••• N r 'A N U O C C O U O D U O :e .d V U O O O O 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 O O G N O m O O O O G O O 0 0 0 0 0 0 0 0 0 0 0 0 ym. O Cni O d a m n m a � O o =` pr _ o O•� o rt o, n m. EL . m O o y Oe<0n c ' a ° c- om 7 a vi ,O m m m Er N A N• a .m. O' w i�D o a O m vi 0 3 = y O H a 9 2 o i X03°�� co oB ^ O F EL CL 1-4 m O O m n H M o n K m 00 0 °o v o 0 � goo �- m�,•a 7 m w n C O O7 m p y 0 3 a C O 0 � 7 m 5 O- C, w n m m o c a T O E 0 0 m 7/- -0�2 WARD OF I Licens N N u M 6"f CT-19N."'8UPERVISORR' (-I, , 568 Wef: 22 PRrce :-0 WILLIA§ 861%9 33.SOUTH RIVER\; HAVERHILL, 'MA �0'1'8m Commissioner 00 .35,000 cf enclosed space (MGL C.112 S.60L) ,�' tea' 1A - Masonry Drily, * '. AG 1, 2 Famil)l or es, ^ f. Failure to'possess a -current edition of the '.Massachusetts State Building Code is cause for, revocation of this license: s It `4 DIGySAFE CALL CENTER: (888).344-7233 n r I` , 06/02/2008 08:44 FAX 19786833147 M.P.ROBERTS INSURANCE A0MW CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDO/YYYY) 6/2/2008 PRODUCER M.P. ROBERTS INS AGCY INC 1060 Osgood Street North Andover, MA 01845 (978)683-8'073 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED SCOTT CONSTRUCTION CO . , INC. SCOTT COMPANIES 12 ROGERS ROAD HAVERHILL, MA 01835-6925 INSURER A; GEMINI INSURANCE INSURER B: COVER INSURANCE CO INSURER C; INSURER D: ,AIM MUTUAL INS CO INSURER E: UAHMR INSURANCE COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 8E ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, ILTfi NERD POLICY NUMBER D I Y EFFECTIVE pq /YY POLI Y A I N DATE MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ �, 000,000 PREMISES Eaoccuronco $ 50,000 COMMERCIAL GENERAL LIABILITY CLAIMSMADE CI OCCUR MED EXP(Anyonaperson) $ 5 ORO PERSONAL SAOV INJURY S 1,000,000 A 621983706002 09/01/07 09/01/08 GENERAL AGGREGATE $ 2,Q00,000 GEN'LAGGREGATELIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 29000,000 PROT LOC POLICYFI AUTOMOBILE LIABILITY ANYAUTO COMBINED SINGLE LIMIT (Em accident) $ 11000,000 BODILY INJURY (Per person) $ x ALL OWNED AUTOS SCHEDULED AUTOS BODILYINJURY (Pereccldent) $ B g X HIRED AUTOS NON4WNEDAUTOS AHN-8005020-01 12/01/07 12/01/08 PROPERTY DAMAGE (Pereccident) S GARAGE LIABILITY AUTO ONLY- EAACCIDENT $ OTHERTHAN EAACC AGG $ ANYAUTO HAUTOONLY: $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE t AGGREGATE $ OCCUR CLAIMS MADE $ $ DEDUCTIBLE $ RETENTION $ D WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY ' ANYPROEBxo ECUTIVE ANY E�uDE WMZ8005435012007 03/06/08 03/06/09 —1–TwoctRYLIMITS I X I ER E,L.EACHACCIDENY $ 110 0 0 000 E.L. DISEASE . EA CMPLOYE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 16000,000 Ifyyea, describsunder SPECIAL PROVISIONSbwlpw OTHER SCHED D:*255FIGO E INLAND MARINE INH8390989 11/20/07 11/20/08 EQUIPMENT LEASED OR RENTED: $25,000 LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES/ EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS TORN OF'NORTH ANDOVER, MA BUILDING DEPARTMENT 1600 OSGOOD STREET NORTH ANDOVER, MA 01845 ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED CORPORATION 1988 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Avolicant Information Please Print Legibly Name (Business/Organization/Individual): C6 Address: 1101 OG ,m, City/State/Zip: V1Hlelt"vl-i, Mk ©1,9 Phone #: iS 7sr-31ILN, 0034 Are yo'u an employer? Check the appropriate box: The Commonwealth of Massachusetts -4 Department of Industrial Accidents ' 1 t- 4..I-jj •' Office of Investigations '`' 600 Washington Street u P-' Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Avolicant Information Please Print Legibly Name (Business/Organization/Individual): C6 Address: 1101 OG ,m, City/State/Zip: V1Hlelt"vl-i, Mk ©1,9 Phone #: iS 7sr-31ILN, 0034 Are yo'u an employer? Check the appropriate box: I. ❑ I am a employer with 4. N, I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1. am a sole proprietor or partner- listed on the attached sheet. 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.] officers have exercised their 3. ❑ I atin a homeowner doing 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.] Type of project (required): 6. ❑ New construction 7. % Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 1 l.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box # I must also FII 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. :Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site . information:, /� Insurance Company Name: A moi-( - M m u? i,t,orl. 37Ij$ V.�c c, Policy # or Self -ins. Lic. #: LJ m -z- R'Oas g3Sf3 ! aoo Expiration Date: Job Site Address:�-S ��A6s�4,P� ;yam la.Nil City/State/Zip: A/o, ki 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. I do hereby certify Ander thelpainWnd p4alties of perjury that the information provided above is true and correct. r4z ... Phone #: 17 U—, 3 6 A -- 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): 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-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 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia O y � 5 0 �m c •• O O y O. �CJ av t R m c 3 w i' EQ L, O x d t • CD CE W m 0. :.r � �i E c . r; O `► 11. co o .N t3` 1 Q w O ** s c O y y O O y m t m O cm CD y mCD �Z •c O Cf coa O acs IS V� V y O O Z .r .coo CL c a a m mc c = m ms„ 3 D m LJJ COD O •tyA CL IU I.- c 2 = Ijmv� O W E v�vO • ii m Ow�� c H d m O'O _ cgo c J2O a O4- CLO - O w P-4 91 CDO � •. O v Z CL. O CO) Q C CD •rte caCD Q A 'E m m 12 CL !— �3 ii CDca L Mo a CL ca caccV as c Z CD V h cc c _c CL. y D w O W N W w U) O O U w •' a co A )co o L� 0 w° 0.N. V) w° aG U w O O y � 5 0 �m c •• O O y O. �CJ av t R m c 3 w i' EQ L, O x d t • CD CE W m 0. :.r � �i E c . r; O `► 11. co o .N t3` 1 Q w O ** s c O y y O O y m t m O cm CD y mCD �Z •c O Cf coa O acs IS V� V y O O Z .r .coo CL c a a m mc c = m ms„ 3 D m LJJ COD O •tyA CL IU I.- c 2 = Ijmv� O W E v�vO • ii m Ow�� c H d m O'O _ cgo c J2O a O4- CLO - O w P-4 91 CDO � •. O v Z CL. O CO) Q C CD •rte caCD Q A 'E m m 12 CL !— �3 ii CDca L Mo a CL ca caccV as c Z CD V h cc c _c CL. y D w O W N W w U) A Date.... ........................ This certifies that ........../� TOWN OF NORTH ANDOVER PERMIT FOR WIRING has permission to perform ............ ---f: ..... �/'dpf, wiring in the building of ........... S'4i ................ at .... 2a.. ....... North Andover, Mass. Fee..!.?���'. Lic.NoN;?74 ............ . . .. ... ... ........ ..... ........ LE R1 ALI S R Check# 8214 A I A N RON . .. . •.•••''•• "' r-aa5sacnusLaffsLO7ccupancy Official Use Only Department of Fire Services O.''� BOARD OF FIRE PREVENTION REGULATIONS and Fee Checked APPLICATION FOR PERMiT Tp p AP(leave AD work to be performed in accordance with the M ERFORMELECTRICAL WORK (PLEASE PAWN RX OR TYPE ALL INFOR11C4no . mtrical CW), CMR 12.00 Date: City or Town of. NORTH ANDOVER By this application the undersigned gives notice of his or her ' To the Inspector of Wires. Location (Street & Number)intention to perf°rm the electrical work described below. Owner or Tenant . tk- Cys Owner's Address to RG Qt S R ATelephone Naq 1$ -3�y _ pQ3tt k k . Is this permit in conjunction with a building permit? Purpose of Building C o.w•� ec cc o, l W wr Yes No ❑ (Check Appropriate Boz) e �o Se Utility Authorization No. Existing Service Amps_Volts' Overhead ❑ Undgrd No.- of Meters New Service Amps /_._Volts . Number of Feeders and Ampaciiy Overhead Undgr d ❑ No. of Meters Location (and N tature of Proposed Electrical Work: ew.er ew` U�,+c No. of Co letion o the followin •table may 1 Recessed Luminaires No. of Cert. -S r be waived the ector o f Wires. No. of Luminaire outlets No, of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No, of Dishwashers No. of Dryers No. of ater Heaters- IOW No. Hydromassage Bathtubs usp. (Paddle) Fans io. of Hot Tubs wimming Pool Above o. of OR Burners o. of Gas Boxners o. of Air Cond, ,-•o Space/Area lRe$ting KW Heating Appliances KW No. of n. of Suns Ballasts of Motors . Total HP i • n.rsrormers KyA Generators KVA EDo, o mergen—cymwaii 0. Units FIItE ALARMS No, of Zones o, of erection and ' Devices No. of Alerting Devices o, of Self -Contained Detection/Ale Devices Local [] Mnuicip Connection ❑ Other Security Systems: Na of Devices or Equivalent Data Wiring: No, of Devices or E &alent Telecommunications No, of Devices or EauP,.+ Estimated Value of Electrical Work: l RC1 (,G Attach additional detail if desiret� oras required by the Inspector of Wires. Work to Start' 'a4c �. -(When required by municipal policy.). Inspections to be requested in accordance with MEC Rule 10, and upon.completiorL INSURANCE COVERAGE: Unless waived by the the licensee provides proof of liability insurance includin owner, no permit for the performance of electrical work may issue .unless undersigned certifies that such coo h a is in force, and g completed operation" coverage or its substantial equivalent The as exhrbited proof of same to the CHECK ONE: INSURANCE 0- BOND ❑. p Permit issuing office.. I certify, under the pains and penalties. o er u (Specify:) FIRM Np ! ry, that the irtfornradon on this application is true and complete -A W�� c c ��C rC� Licensee: Mc,% S LIC. NO.: Wapplicable, enter "exempt" in the lice a number lin ,) Suture LIC. NO: Address: S 311-1-1 F c acv L-�u.VJQr 1nt`( 0A C, Bus. Tel.Nc.:F1SrE3'►�-54"t� *Per M.G. c. 147, S. 57-61, security work requires Departxaent ofPublrc Safety "S" License:Alt. Tel. No.: so -9892 OWNER'S INSURANCE WAIVER: I am aware that theLic. No. required by law. By my signatureLrcensee does not have the liability insurance coverage normally below, I hereby waive this re Owner/Agent quirement I am the (check one) oWDer ❑ owner's agent Sis�natare Telephone No. PERMIT FEE: $ h �' �. � �% i. 1 �' +' 9 y W The Commonwealth of Massachusetts u j Department of industrial Accidents Off "tee of Investigations ,a ti rj . 600 W=Izin�ion Street Boston, MA 02111 Workers' Com easaiion inseu'anee www massgov/din . P Affidavit~ Builders/Contractors/VectriciaaslP� A Iicant Information umbers ` Please print Leeibiv Na me: fBt iness/Qrgsiratioraindviduat 2 Yh Address:: b S A fC I CItyGSt ale/zip: �� c ��•, � � t4V�c. Phone n employer? Cheep the appropriate boz: ` a employer f Z 'rype.of with loyees (full and/or 4, ❑ I am a project( nt general contractor and i p ,a ole P etor or ,..have lured the s d)- 6. Q how construction partner- have no em '1 ees Fh iistadand on t}re shaet ! 7• ❑ Remodelmg These suis -contactors haveay ing for me in an c capacity. comp, insurance work 8. Q Demolitionorkers' 5. ers comp. insurance.❑ We are a corporation and 9' ❑ Bwiding addition ed.] hOmI*wner doing alt work ifs .: officers have exercised their 1Q•Q Electrical repairs or additions right of exemption MGL myself.. [No -workers' Comp, per I 1.(] Plumbing c.. 2:52; § I el 'and we have � TzP� or addition, Insurer �d j t.- no 12.[] Roof .anployees, [No work=$ • repairs 'AnYePPticamthar ebnnuualso COMP. instu eme required ]: t3:0.0ther eeks bob#it fit! out the section blow showing theirworicers' bornpenaatiori •' t Homeowaen; who en6mitthia e$ policy inforntalion IConoactow that chink this box mastada ummng fey nw h=ruring an work and thea hhe onside eonuactors s ohed an edditiaaei sheershowirrg �e tmrne of the �+� must submit a new afrdevit indi � �iL , . rf.. arm 9 c7 iS-- ��«rs comP. Policy in%nnetion. irtfotneadon. '° ing:workersc' cornPo smioft i�urmIce for nth,. CM10 YZM Below is. Me policy mid sitL insurance Company Mama: ' Policy # or Self -ins. Iiia #: Job Site Address.;_ S(Opiration Date: Attach a copy of the .workers' coat' peasation policy diaration page (showing the policy number and expira6oa da Failure to secure coverage as requinxt under Section 25A of fine up to $1,500:00 and/or one-year imprisonment,MGL e. 152 can lead to the imposition of cmMinal Of up to $250.00 a Y r.Beadvise a well ss civil penalties in the form of a STOP WORK ORDER and of i �3' against the violator. Be advised that a copy of this statement may be fares RDER and a fine Investigations of the DIA for ' Y arded to the O msreranr� coverage vccificaticsn, (rice of . •�• cazu)y nder the pains and penalties ofpeJary that the irrfnrma ign Provided above is d1?te Si and corm Phone #: 7 3 2 ('�. Date -'4 Official=--. fficialasr Ono. Do not.►nrrle in .this area, to Ae completed or townoffiria[ . City or Tows: issuitt A Permitli.icence # g ndwrity (circle one): I. Board otHealtb Z Bn k5ug Department 3. Cityaown Clerk 4 Electrical Ins Other pector S. Plumbing inspector Contact Person: Phone #: Information a nd 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 empinper is defined as "an individual, partnership, ussbciation, corporation or other legal entity, or any: two or more ofthe'foregoing engaged in a joint erutcrpr e, and ineludirn the legal represerrtatives of a deceased employer, or the receiver ortnsster-of an individual; partnership, associatioru or other legal entity, employing employees. '1•ioweverthe ownerof a dwelling house having not more than diver apartments and who resides therein, or the occupant of the dwelling house of another who employs persons, to do maintenance, oonstruction or repair work on such dwelling house or on the grounds or building appurten= thereto shall not because of such employment be dearned to be an employer." MGL chapter 152, §25C(6) also states that "every state aa- local ficeinsiag 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 appiicaat who has not produced acceptable evideuce.of compliance with the insurance coverage required." Additionally, MOL chapter 152, §25C(7) states "Neither the commonwealth nor any of its -political subdivisions shalt enter into any contract for the permanence of public wor c umil acceptable evidence of compliance with the insumce Tequurements 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 s6b-contractors) name(A address(es) artd phone number(s) along with their cordficate(s)' of insurance. Limited Liability Companies .(LLC) or Limited Liability Partnerships (LLP) with no,employeos otherthm the members or partners, are not required to cavy workers' cDrnPmuation insuran= if an LLC. or LLP does have employees, a .policy is required. Be advised.that this affidmv.it.may be submitted to the Deparknmt of industrial Accidents for confirmation of insurance coverage.. Also'he sure to sign. and date the affidavit The affidavit should be returned to the city or town that the application far the pemit or license is being requested, not line Depmtrnam of Industrial Accidents, .Should you have any questions rega3-ding the law or if you.are Tmpiured to obtain a workerst oompensation policy,:pleme-call the Department at the -nusnber.lked below. Self-insured companies should entertheir self-insurance icanse number on t'nc'appropriafe hear. City or Town Officials Please be sure that the afadavh is complete and printed lesgibiy. The Departrnmit has provided'a space at the bottom of the affidavit for you to full 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 applicsat that.muLstsubmit multiple permit/iicanse applications in any given year, need only submit one -affidavit indicating•euurent policy'infonmafion (if necessary) and umder "Job Site Address" the applicant should write "all iocabons in (city or town)." A copy ofibe affidavit that has been officially stumped or marked by the city or town may be. provided to the applicant as proof that a valid -affudmit is on file for fahm 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 ventm (i.e..a dog Iicense or permit to burn leaves eta.) said person. is NOT required to-.complcte this affidavit The Office of Investigations would Iike to: thank you in advance for your cooperation and should you have any questions, please do not. hesitate to give us a call. The Depav=ent's address, telephone and fax number: Tine Commonwealth of Massachusetts DeparE nt of Iadustdal Accidents office of'- Investigations " 600 Washington Street Boston, MA 62111 TeL # 617-7274960 ext 466 or 1-x.77-MASSAF£ R-evised 5-26-05 Fax # 617-727-7744 www-3nzm.gov/dia Kp' Information a nd 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 impiied,. oral or -written." An employer'is defined as "an individual, partnership, association, corporation or other legal entity, or any two ormore ofthelburping engaged in a joint enterprise, and includi"S the legal repre =td:ives of a deceased employer, or ffie receiver orbustee-of an individual; partnership, mociatioi . or other legal entity, employing empioyees. '1•ioweverthe 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 ma.intmumce, construction or repair work on such dweifinghouse 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 it business or .to construct buildings in the commonwealth for any appficaat *be has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, WGL chapter I52, §25C(7) states "Neither the commonwealth neer any of its -political subdivisions shall aster into any contncet for the performance of public woe% tmtil-acceptablc evidence of compliance with t_he insurance requi =mts 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-contractar(s) name(s), address(es) aisd phone number(s) along with fi wir certificaie(s)' of insurance. Limited Liability Companies.(LLC) or Limited Liability Partnerships (LLP) with no. employees otherthan the members or partners, are not required to carry y workers' carnpensation insuran= if an LLC. or LLP does have employees, a .policy is requiredBe advised.that this afficlavii.may be submitted to the Department of Industrial Accidents for confitmatian' of insurance coverage.. Ain be sure to sign. and state the affiidavit. The affidavit should be rettaaed to the city, or to= 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 requited to obtain a workers' compensation poiicy,:pleasecail the Deparimemt at the -nurnber.listed below. Self-insured companies should entwrthefr self-insenam=e ..ficanac number on fine appropriate RM 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 tine event the Office of Investigations has to contact you regarding the applicant Please be ore to fill in the permit/liocnae number which wiiII be used as a mference number.. in addition, an applicant that. must submit multiple permit/iicense 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 ofibe affidavit that his 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. Anew affidavit must be filled out each year. When a home owner or citizen is obtaining a license or permit not related to any businm or commercial valbue (i.e. a dog license of permit to bum leaves air.) said person is NOT required io-,campiete this affidavit The Office of investigations would 15 m. to. thank you in advance for your cooperation and should you have any questions, please do not. hesitate to give as a call. The Department's address, teiephonc and fax number. The Commonwealth of Mawachusetts Dcpart=nt oflndustrial Accidents Office Qf•Inveqk-atians 600 Washington Street Basion, IIIA 0211.1 Tel. fr 6I7-7274900 ext 406 or I - 977-MASSAFE !L -viand s-26-05 Fax fi 617-727-7749 www.raass.govldia The Gommarx wealth Of MATSirchise&r Departure of .industrial Accidents Off -we of Investigations . 600 )Washinon street Bositori, MA 62111 Workers' Compeusafion Les' w>W, �Mgnv/dia A Iicant Infuafian uranee A$davit; Builders/contractus's/Eiectricia/i'iQmbera NamePlease Print Lm-- m s/Otganira6otAndividual); AYVIG cr b Address: b S J� City/State/71p; .Are you an employerPhone #: ? Cheat the PProP�te-box: 1•�'1°am a employer with f Z employtxs {full andlor 4' 1 am a general contractor and 1 Type -of Project (nq°i*: 2 I am:s.so}e proprietor. opart-dme) havc hired tate sttb- 6 New con oh partner- listed e0 structi ship and have no employees on the attached sheet t 7. Remodeling working forme in 7besc Sub -co 13 have [No workers' cum P ts', warkers� imp insurance, 8. Q Demolition` p insurance $. a co oration .required.] ❑ We are tP and its . _ 9. ❑ Building addition 3• fain a homeowner doing all work ffi� have exercised their 10.[]Electrical repairs right of exein or additions myseI£. [No -workers coni . Pticm per MGL 11. . insurance regetired p a LS2, § 1(4),'and we have no Plumbing repairs. or additions 12•❑ Roof emplioyee& [No work=? repairs "AnYapplicnntther checks burp#I enact also fill outtlm camp. imt�nce required_j: I3.[].Othcr t liott+eowaeta wbo nnbmit this section blow echo 3Cm*'84 ors that eh cdavrt u►d>Qeang they are doing all wos �g their workers' ooiapensation policy atfommti0 eek this box ►oustattaehed an addihanW shGtshow' and then hve•outsidc g the MM of the sub• cow must submit a new affidavit indics* a,IL nfo' MR*� that.isinrotttt tg:workers' contperrsafian irrsrn.Qnee for cans aged the,r work=' comp, poEicy in%�melion. °�''1PbJ'ees: Below is. the poficy mrd job site lnsuranee Company Mame: ' Policy # or Self -ins. Lic. #: Job Site Address: ExPuaiion Date: Atiat:h a copy ofthe.workers' cont,Pensatioa decl Uny/Sta�-lp: n� Q Failure to i*lT Luratioa page (Showing the secure coverage as requited under Section 25A of g Policy number and expiration date}. fine up to $1,500,00 and/or one- MGL c. 152 can lead to the imposition of Of up to 5250.00 a Yew imprisonment, Be advise as well as civil penalties in the form of a carinal p 4es of a Investigations' �sinstthe violator. Be advised that s c STOP WC) ORDER of the DIA for insurance coverage opY of this Sitrrtsent nay be forwarded td the O and a fine erage verification, Office of I do hereby comfy nder the pours and penattfes 'Pw'wy the the o Si rmr�ion pmvia(ed olxave is trrtE and corm °hone#: 9%�- 3�Z—.�c�1.� Dat16 x''.Z�- bd 1 Ofj`tcirtl rrsr only, Do not wale.this area, to be conpptexed hY ' or town rtffiria( Cry or Town: Issuing Authority'Permit/Licease # 1. Board of Hearth( Bu'[di one�. � ti Other De rfiaeat 3. City/Town Clerk 4. Eiectrical Inspector S. Piambiag laspectar Contact Person. Phone #; Date..... 6...... /S -,v 7 TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that..........02....�/.............0............. has permission to perform ....... cl`............................. �'`�� T o0 wiring in the building of ............� ��'� G C` FG...........;r.................. at ............. ��5..�`%�� 4W......... , North Andover, Mass. o© r Fee..?" ......... Llc.Noe*s.-:?� ....................1... ' ELECTRICAL INSPECTOR Check # 7462 �! Commonwealth of Massachusetts w Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. % 7 6 Z. Occupancy and Fee Checked [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 0, S �s�. i p p(. U r,, k Owner or Tenant 1� P LL Owner's Address Is this permit in conjunction with a building permit? Yes Purpose,of Building Telephone No., 6(1%- 314'0e1y No ❑ (Check Appropriate Box) Utility Authorization No. Existing !Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd ❑ No. of Meters d kUOv)�Ir0CJ✓vtCA�✓�e�e Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires I No. of Ceil: Susp. (Paddle) Fans No. o Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires ')L Swimming Pool Above ❑In- ❑ rnd. rnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches a No. of Gas Burners No. or -Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers HeatPumpNumber Tons KW No. oSelf-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Munic'pal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water Kms, Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications firing: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: *SSU, C o (When required by municipal policy.) Work to Start: 6- td • c�7 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless " the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE []r BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: A torr- FX«Ar;c Zn c LIC. NO.: Licensee! Pcly1 au, � Signature LIC. NO.: 3\131 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.• CL-1g-312'SSh Address: �S Avcu ,(t'11--1 l ( Alt. Tel. No.: SO'd 0 --i9i2 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $\A�- 00 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): �� Moco- L K , C_ Address: ' � S A fcc) � cl VVlC,, . City/State/Zip:<<^< < < .ASG - CAM Phone #: Areyouan employer? Check the appropriate box: 1. 1 am a employer with 4. ❑ I am a general contractor and I employees, (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. $ ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] f These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. Q emodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *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 than hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name ofthe sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. i Insurance Company Name Policy # or Self -ins. Lic. #: . vi�E� 40,c k cAwECNLbC0q/o8 Expiration Date: b l<� - 09 Job Site Address:_ City/State/Zip: N A&, -ac, ✓Q r . Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). I 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. I do hereby certify lunger the pains and penalties of perjury that the information provided above is true and correct. o '� r 3c,�'---� i 12 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # -I-S-v-� 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 #: