Loading...
HomeMy WebLinkAboutBuilding Permit #712 - 85 LACONIA CIRCLE 6/4/2008BUILDING PERMIT 0`,Nuc i M 4.0.6° 16,q'yo TOWN OF NORTH ANDOVER °A APPLICATION FOR PLAN EXAMINATION -400-0, +L _ ^^ j a Permit NO: / Date Received Date Issued: _ —U`b �- IMPORTANT: Applicant must complete all items on this page LOCATIO,N-5�,�L/,/;0.0,f4J/4 O/K Print PROPERTY OWNER !U Print MAP NO PARCEL:A%:5f-- ZONING DISTRICT:. Historic District yes o Machine Shop Vr`Ilage yes TYPE OF IMPROVEMENT PROPOSED USE Reside Non- Residential New BuildingOne fa Addition Two or more family Industrial Alteration No. of units: Commercial Others: epair, replacement Assessory Bldg D olition Other Well Wat Floodplain etlan s Watershed District -- Ut5 'KIPTION OF WORK TO BE PREFORMED: ZIL)C ��� �A ori Identification lease Type or Print Clearly) OWNER: Name: Phone: Address: 9,5- AC6lut 4 OONTRACTOR Name: Phone: t, , Address:. Peta 512-7 e. Supervisor's,Construction ,License: - ?�� -Exp. Date: Home Improvement License: Exp. 'Date. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING RMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $9,<00 FEE: $__ Check No.: 2�.- D- Receipt No.:� •(� 9 NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund �natfare of Agent/Owner" ,5. '' Signature ©f contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools 1 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 t 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: uocatea 664 USgood Street FIRE DEPARTMENT - Temp Durnpster on site yes a no Located at 1:24 Main Street .Fiire 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) 1/0 I r N i nee �f LVL ❑ 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 ❑ 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 Location No. 7 Date C,% Check # /+ 2207 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ / Cj z ! D;L OP Building Inspector 1� I O co o LE V3 .a cn cz 0 w O C w° a�' U w 0 w C7 a w�' w x a W 'G_ _r �i O N _ w O 'Cnu 0 w w �. W Cv G z cn . i O V) LLJ zCL • Qi• . c o CD c y cts :. O ` O N C.2 CJ :•p,o CL C dwj6 A O : m c Q o CD CD Ea O ID: 0 Q C 4D E CL O L c CO N N O � h 'o m C4 C • N 0 --EmCD aC.L) N m m O .OZ m S:cC o a N CR c = OC `A v) o O N aw c ca W :5 *•' .N H • C41 E = y=.+O C 2 •N w .0 z O W CO CDE cm H a _ m� o1 m O y O c =4-a�m-0 9 E �! L V Z CD CL O CO) C C I Ccm C !w p .— W Q A 0) �E mCD 0 co m CL I.- co �3 03Q CL O m C _CL M c Q co C c ev V 0. 0 CD C Z ts CD C.� ND � C C c C40 LU vI U) LU W U) 1 llLl-9Z9(L19):Xel - OOLL-9Z9(LL9):euoyd 44LZO VW'epw8woS - JOE 9l!nS'le9J3S eno)0 84 `ouioeaaenE) ig awoo�j Sa33NION31Van-ona1S WOd1SEM b4N11 X31118 731D ONIIW83d ' 3SVHd LD3fOad 350 -LO a38WnN 1D3fOad VW'd3n04NV -N '31Dd1D VINODV98 3DN341S3d WOd1SON3 3WVN DXOad S310N 1V83N30 a SNVld iNd ONIWVdJ 31.U1 ONVAVtlG prys pue aowa5 )o sluawMsul aenntlsd� nayl )o vaumo Pue sgipne ay1 Pawaap aq Heys stunynsuoo s,u6,isap'luiotl'e pue u61raP'luod-e w2fosd siyl of Uadsai LAW paps asn ml aowaS )o sluauNlsul am qugnsuoo s,uS!.p lupd'e pug w �J z 40 80'66 SO SN3WnD0011Wd3d EO 80'6 L' LO NOIS30 011VW3HOS 30 'U 09L 5L NOIS341d3DNOD LO 31V0 NOIldIaOS34 5g7W W z.-. O M 3DNVnSSI llLl-9Z9(L19):Xel - OOLL-9Z9(LL9):euoyd 44LZO VW'epw8woS - JOE 9l!nS'le9J3S eno)0 84 `ouioeaaenE) ig awoo�j Sa33NION31Van-ona1S WOd1SEM b4N11 X31118 731D ONIIW83d ' 3SVHd LD3fOad 350 -LO a38WnN 1D3fOad VW'd3n04NV -N '31Dd1D VINODV98 3DN341S3d WOd1SON3 3WVN DXOad S310N 1V83N30 a SNVld iNd ONIWVdJ 31.U1 ONVAVtlG prys pue aowa5 )o sluawMsul aenntlsd� nayl )o vaumo Pue sgipne ay1 Pawaap aq Heys stunynsuoo s,u6,isap'luiotl'e pue u61raP'luod-e w2fosd siyl of Uadsai LAW paps asn ml aowaS )o sluauNlsul am qugnsuoo s,uS!.p lupd'e pug w �J z o Ha a w q FC H q M M o F I 0 w H q 14 z a W z I I W z.-. O M Q 0.H', c �XZIZ i zQ AD u.. O 0 H U p 0! O U W O m.-1 z H a\ W UJ () p�-'=O M w E. Q M z0 Z(naZU� Ux) O w H m m W Hp M a U O M H z W W 1d'j zaz a'H'3 A Y HFHM 49 ••H a�HFC OzC9 W z 0DD El N �I W Hw>+zC4 MM DH z>1HFC H a, O M z I --I W M I Hz 3 p W M A M H O W O M H O M H z Q x O D q F H A H a N v� W �0 X M O HF� U) H U W vH) U U Uri z " M W W 0 W z a 3 M W QHOO W H H M: N a HFC\HN I U H rUr�� CO .Y. x H M F H F 9 W O U M H H Q z D a FC 0)z0 4Ma(V z y H N M H M DU' Qr)H O D M M M~ U H M z O z H M FC O M a F U M W O H U 3 M - Ux2 w O7kz -z. MWEl 30�w� awH wW z XWx U) FC�0�Qa100 H U I.] 4O H UUHaO 3O 11F z F 41' UxH H 11 p y HAWH >1 W p HH ZO DHa M W O � W M O H x M z a D Ll M H a U 4 z H 3 H z z M z 0 fM0 x H Q U W OI F U • H I H W z h' x U) a: x A H M A H H W FC O z O EH a g M H M W H U H z 0 z W W H W U O ',� M x A H z to yO M O a : H z H O a a uO M W z W co z O U x z O M M RC W O y' M H a" H M H F I Q" O H H U) H N H 4 a W H H ul A H X4 a H CD x %H H W z �' W C9 H W D a o H H 4 a v) d w� M H o z a C21w O H M 3 a D h x U a H z W U) O H ZO H H u w El W7. y z� U U D O M z U) W d w w z W z z u m o w H W Da A H oa w Q Hc, O H H x W M Ma'HWCu Fpzw ',� o 11 M M N 3� a F x W a W o aw" aFCZHMw M w w o w x W a H M M H MMM M U< W HD 0 x w r� z H O O H M U H W a wx OH W H H U) H W M D M c9 F H M 4 O z W H H z H �o a C9 W z W M U O F M z z W H S F D U H a U U r.0 U 4 M U x M U) H H 0 wr� X U z 0< a • H U) a D x z O O U N M F,H C4 04 pF II o M O x W z 0 W F+ FCS H a m a x m p z A H x z N M o x z H O 9 M HH z W M M paa --Ma z ry'F zFC zp�y D WI -z OQFMx 3OFC Mµ' M HOOzH W El OO a U El U) O O W MH zHOM z z O H OW 30M O Q W MHMAH O H W O M F M M z : p x U H a O U) e 0 O a U M H E -H O Cr II r -C F d' FC 3P H N x a U) a y'HMOZF W A r -C U 0 H W HH Hz H H w O 0 H 0 Z H [u U FC x • M W O N w FCM H Lu x M W W C.Y. X 3 H M W M M 0 M F4 z W H Q M D H y' x H U D z U 5y' M U M x H z D Q w W Q z H W a ,�," ,5 H M g W a F W W M $., W y' F W U) H M a z Q x O a U' H z U) Q H z M H a q M a H W z H H U) OFAHM0 z O z 0 W Q W O a MFC U OD Uµ'£z x M W W O a II M e q ry' y' W FG F W ZaMHD F U a z U O TI M ry' H W U y' rt, z W W 0 O x W U z FC H W r1, H M z x L'+ W O .'� W W 'Zi 3 a H W H H H ND U W M a M U ?I O \ Q �+ Ha F. UHCh'H MzOU W z U) U yy' M Q Z' O a a ry' m a 3 H x F W t9 x z H W H W a H H h W H M z M z z O W z W M M M H O N H z H W h H Q W O H H x OD Mzz H U x C9 A H a' A N H az M�zmaz O O O MaHM WQH y' H0U)3 HHHXHDH W O F Q M zHMµ'H H U H FC H Ua U z a FC H a "" W U FC O r1 4 0 M z x H W D H x O U) U' a H a z U a W 1 0 a x H O W U' z D M a W H a M H H: M Q M ',L O H 3 W H z H M g U H H N a W W C9 D W z M W O aU a Cmv H J W H H F m w x UzUFCFC 0 H z H } a H FIi o U) FC 0 O z H HU)�-a fpm a� Awxw O a W U' z FC, FP• 0 U) a M Q H H M FC -W a wzMFC xFCwDm0i.9z F V) zDODzazUMH�A�- 0CY"M O w42: 0H3 FC FC W FCMa\wC9MxFa3M H E aoxz CC xz z`",HH W HW zwEl a OHFCaO zHm z FCMzaO M 3 F FC H z H 'f., H H R H W H W H z H Waaa014 F40 V)FCD w }„ W H M x W J.i- x M H z r� F.�woH Ha,'xa Hoath Q U x U) H Q O F M FC M W z F x F W W M A x M M a U) z Z M y' O Q M z H M O x Q a H a' z Q M a M W O M H H H U) (4 X U F(; H x w w U M$ M M O N H W FCO U U z U x `-' U H a M R O H M H D W W X a O O Ga 49 x z a H 0 a W 4 O FC W O W H H O Z W H W H O H F E a' z M O t9 H W H r.,; 'J z Q 3 z M W W x O o w x U M 0 M 0 a H t.. -i M P: O IZ R1 U G, O a W a M 5. a Ln O a W W H a H w 'jam U 3 4 F4' a 0 V) z O W M H O Q W H Y4 H pH 3 x H x O a A U (QW H H W z z H O O ', H 0 U)m M r o M M M W M 3 M FC D 7-I z H O W LWaj ai a' p a H H z W W $', U W H� H 0.'i W z Q H 3 0 z a H� W H W H a s M M Q a A a a' z $+ H z W W M z: a O M a W A H O M u 3 H a a a W 3 O a H a A W Q Hp r4 FUr�S H K4 W H H UD) H W3 R H a H C7 a G H F� y a W O H U M M W U U U' a M" O II II O a a D M W H H M w z a a $.' q M M a' z M N M M M H a H M M H W a x z 3 H w FC H X M D 3 0 W H M H z 3 z M a H N H D z 9 0 M H 2 H W M a a ,Q S] a o o O �" 0 H Q O 0 H w o W 'J '� F U H H M a' x z D U r� a U' U a FC 0 H W Q M a D A z z w Q w � w O U G H H z U w H H W W: U' H H H W a M FC C*+ w FC U U x H o M U H z H H W x M M Og w a z a w z o M H F�- Z4 z w M �' N o w N w Q faaw H H D W W a7 M Q $, ',� M M �.," W M 3 W z X W HFC El 44 r1l H z H x S+ z O O U F H H H x FCO � H W H w M W W Lu X U M O w a H Ly ,7 U 0 a MpU F4' WQMM',� U HH Qz M O HA}",� H a F z X W OaUM E W z y' w M 3 PQ W 3>zaa,,z0 3 GW+ W L9 ry'W F UUD H Iz-100 H O,'� � H W C9 N Cl) V) .H N M d' Ul ID [szW I o � I I CD p U) m I xi I I I I N I w 0 J z J Z � U) �:W LL 0 Wz2zr)(n ZO3'aOz Q U) C/)Z =WWoU) od W W cl) W J I— LL. LL. Z) Q Q Z UwIxcAQ W Tl - x N N N V z_ � J F--- W W LL. U > U o Z 0 F- W �N= O N Q F- W CA wU Jz Z m JZ Q0 000 �0� x Q x _ N W N N 2 rrnn V z 75 U Q Z 00 ry (- N LL. N LL. X� W Oaf WW O F- W U)ix J 0 w W F- X 0 -X0 W0 w a QW U� D � U)ZU W F- 0 od 3: 0 O O Iz0OU)o J Z U 00 W�- — N C J X O J N Z Q Z w�ZwF-_0. �z�QT- 'uw) onmq�ala ul asoyt � o � I CD p U) m I xi I I I I N I �XZIZ i i U I—_ --- I I — I 0! I UJ () p�-'=O w o I Z(naZU� IN w 0 J z J Z � U) �:W LL 0 Wz2zr)(n ZO3'aOz Q U) C/)Z =WWoU) od W W cl) W J I— LL. LL. Z) Q Q Z UwIxcAQ W Tl - x N N N V z_ � J F--- W W LL. U > U o Z 0 F- W �N= O N Q F- W CA wU Jz Z m JZ Q0 000 �0� x Q x _ N W N N 2 rrnn V z 75 U Q Z 00 ry (- N LL. N LL. X� W Oaf WW O F- W U)ix J 0 w W F- X 0 -X0 W0 w a QW U� D � U)ZU W F- 0 od 3: 0 O O Iz0OU)o J Z U 00 W�- — N C J X O J N Z Q Z w�ZwF-_0. �z�QT- 'uw) onmq�ala ul asoyt � o � \. W U) m C) LLJ ----�---- 0 � U) � O \ N � 0 o CO N Q0 �a� x 3:OpU UJ () p�-'=O w i-JQ N Z(naZU� m m � W A Y �I DI JTw D V luawn�op rz�•po Pue %mn� pads •s£uwRq Boob - LOOS ® )FF MFdo3 3Dg 1 3NHDoa I z Drs of \. W U) U�Q� 0 C) LLJ ----�---- Na � U) � O \ N � J� CO N I z Drs of U) W 1-Z J U�Q� 0 W Z W w C) � U) � O J� CO N Q0 �a� x 3:OpU UJ () p�-'=O w i-JQ N Z(naZU� 04 20 Q U �w0 z= �z4 co 0 N W -, cl)p Z W LL O Ww C� U Z_ _o C/) 00 x — X J W N N U N m o T1. �oanimoouuea�t� a��ac�zuae%ia Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registrations '103636 ExpiratJon 719/2008 Tr# 127528 O'BRIEN CONSTRUG' Ey` John O'Brien Jr. 3 WALKER AVE.° ANDOVER, MA 01810 Administrator s and Standards License 10 Tr# 4452 --I ss io ter ,r.:'"'P+,•d-^•• lfcew�s:ed tFJ1530 J11bN3101 '35bWDFOdd ^ F1 s g 'NMMN 1J3fOU K \fp) S�iuuc18 Puc VW �3AOONV'N �n DMNMVI SIR 8 - 80'6CLO N9630 Juw.3HJ5 ��;;^,I ^ L ,h' 3JN341538 WON159N3 qui ugisaP • }uiod • e \ LO'OL'3L L0'9L'R N915301d3JNOJ LO �'- � '3NMN 1J3fOtld O.rSdV 31V0 NOILdILJs30 7tl- �. 'iN3fD '3W19tJ�MYd0 v @ WONiSDN3 VON11131119 N750dM) 35Nds51 .»�.aw.mc,:��oaas.m..�,��.n,a:.:�.n:.�:w.nao»�nsA:.��.pe..:aaw.,,.,bP..aw.n•.:e»Aw.�.:�+w .�.e.r.o:e�r.Q,..,s,«�m.�::o w�A:o,,..�sam:.�.,�,..o:.m�w�,..o:».w�,w��.a�.®r�:a�4vw:..*w:s:,.r�w.�ov..>.���.,�m,..w.,�, 1 ii la i 4; .. 1j :I o , .. i 1 11' i K v• s � I� rcn / \ 1` of Ca 1 z d w r:. i Il. I o a fi .. ,R!.,pn.d..... E(ro w('r[d •� N91S30J WEEDS :3S"ONOW 'dMMN 03rOdd ,. 4�►. -C �Co;. \ S°Immcld Puv onr�o oalya�c VW �3AOONY'N �'DD MNODH1 38 8R6R0 N91S30)IIYMHJSDN341538 WONLSON3 °, . }LI10a 2 ;: •JUI UglgQ • • [0' U 1.11 l N71530 W3�N0) LO a� P -\ • 03roae W onwd 31Y0 NOLLdIei$30 a�avw W07llSON3 VONIIHIIIB � SN01040)OM1FA 3JFMIS51 ';.' � 1N3N ' 37L1' VAVtlO o a4.m, W+ra..nw pa r.�„awn.moron'.x:..u:.nw�wwnt�.a..+s'ors:n,.w=.i:oan,wFl+a,.ou..ov.�er.:n+v zlrvr.:!w.a�oecw uc.a�wwnm. oawwmwao:w r'+p I �sws�.�...ssam.o+vba+amoo-.rra�.wnrhm.Na wna..wm.%+•o wr.a•. n..w...rv.n."...y�+e...� I I .S2la.P,i H O i I is..,,,....... I ::.:. .. O ! I �1 t ' I ! sl I . Yid i .. Z j I I!a I t k i .A .... . i.. ii '. ;' ......... a� ., Z z o Q I a a_ z Z O F o W z <°o FL 0 � Z z H J p 9 r ' j tll y LA w x r: f o IE #k. -T .r1 ,1 vr�>. z'hm3R3 "4 r. ...T i.Si { . 3 h AI....... ..... m Al w QII�IIp,� � 3y: �III49'llllll o Q i ... L > I m rc N I !wp 0�o �. Z s - 1 Lu r�y W _I < w n m t o < ;i z tti z a mo F_ x < vi m I W K w m W v.2 Lo co F3 -------------------------------------------------------------------------------- --- W-------------------------------------------- Zil = ----------------------------- �V Q O Cc W a a F4 \'. V W U W0 w Wcr Q U 5 Ir 3 � � V Ilk �� w W CL W -� '� a CI- � 1 a W 0 ¢ 0 w ° cr J m w W ¢ U) >: U o. U) U Lo co F3 on tLf 7D tL Vi 07, 5 1 zi 77V tLI to lu '11' 1 1 7r,-- 11, 11, ID . lu SIG i V*1 tii 0( -3 lu 11 on tLf 7D tL zi tLI to lu on tLf 7D tL tLI to 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 ortrustee 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,opera'te.-a business or to construct buildings in the commonwealth for any ' applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "'Neither the commonwealth nor any of its political subdivisions shall enter into any contract for, the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe 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 02.111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 11-22-06 www.mass.gov/dia The Commonwealth of Massachusetts Department of Industrial Accidents W Office of Investigations r ' d 600 Washington Street veldt Boston, MA 02111 ,. www.mass.gov/dia 5� Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Address:_- City/State/Zip:,rV�o./C Al9 Phone.#: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with ' 4. ❑ I am a general contractor and I ,employees (full an 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. employees and have workers' [No workers' comp, insurance comp, insurance.$ required.] 5. ❑ We are a corporation and its 3. ❑ 1 am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' insurance Type of project (required):, 6. ❑ New construction 7. j Remodeling & ❑ Demolition 9. ❑ Building addition 10. ❑ 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 then hire outside contractors must submit a new affidavit indicating such. t'-ontractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. pohcy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ST T Policy # or Self -ins. Lic. #: ' I7 AC_ tP Expiration Date: Job Site Address: K57- G/q Co I-jr'4 ` City/State/Zip: /U Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). oYs� 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 I do hereby the plains and penalties of perjury that the information provided above is true and correct one #: U �� �/ al O �v Official use only. Do not write in this area, to City or Town: or town official. Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other 67—_I3.r,oS:�-- Contact .Person: Phone #: STATE FARM CERTIFICATE OF INSURANCE This certifies that ❑ STATE FARM FIRE AND CASUALTY COMPANY, Bloomington, Illinois ❑ STATE FARM GENERAL INSURANCE COMPANY, Bloomington, Illinois ' '` ❑ STATE FARM FIRE AND CASUALTY COMPANY, Aurora, Ontario ❑ STATE FARM FLORIDA INSURANCE COMPANY, Winter Haven, Florida 0 STATE FARM LLOYDS, Dallas, Texas insures the following policyholder for the coverages indicated below: Policyholder John O'Brien D/B/A O'Brien Construction Address of policyholder Location of operations Description of operations 4 Don Roulston Drive Salem, New Hampshire 03079-1884 The policies listed below have been issued to the policyholder for the policy periods shown. The insurance described in these policies is subject to all the terms, exclusions, and conditions of those policies. The limits of liability shown may have been reduced by any paid claims. POLICY NUMBER TYPE OF INSURANCE POLICY PERIOD Effective Date Expiration Date LIMITS OF LIABILITY (at beginning of policy period) 94 -BIC -6869 4 Comprehensive 09/15/2007 09/15/2008 BODILY INJURY AND --------- ------------------- Business Liability---- PROPERTY DAMAGE This insurance includes: ---- ----- ----------' ---- --- - -- ® Products - Completed Operations ® Contractual Liability Each Occurrence $ 500000 ® Personal Injury ® Advertising Injury General Aggregate $1000000 ❑ Products - Completed $ 1000000 ❑ Operations Aggregate EXCESS LIABILITY POLICY PERIOD Effective Date Expiration Date BODILY INJURY AND PROPERTY DAMAGE (Combined Single Limit) ❑ Umbrella Each Occurrence $ ❑ Other Aggregate $ POLICY PERIOD Part I - Workers Compensation - Statutory Effective Date Expiration Date Workers' Compensation Part II - Employers Liability and Employers Liability Each Accident $ Disease - Each Employee $ Disease - Policy Limit $ POLICY NUMBER TYPE OF INSURANCE POLICY PERIOD Effective Date ; Expiration Date LIMITS OF LIABILITY (at beginning of policy period) THE CERTIFICATE OF INSURANCE IS NOT A CONTRACT OF INSURANCE AND NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR ALTERS THE COVERAGE APPROVED BY ANY POLICY DESCRIBED HEREIN. Name and Address of Certificate Holder Bill Engstrom 85 Laconia Circle N. Andover, MA 01845 558-994 a.6 Printed in U.S.A. Rev. 05-09-2006 If any of the described policies are canceled before their expiration date, State Farm will try to mail a written notice to the certificate holder 30 days before cancellation. If however, we fail to mail, such notice, no obli n or liability willliimposed'ohS�te Farm or its ge s or repr qp_ t' es:-*.�A S; igma-tu-ne"UMMINAIR resentative. Agent 05/14/08 Title Date Brian M. Bosies Agent Name Telephone Number (603) 898-5220 Agent's Code Stamp Agent Code 2038 AFO Code