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HomeMy WebLinkAboutBuilding Permit #378-15 - 85 MAPLE AVENUE 10/21/2014 NORTH BUILDING PERMIT 0 ,,,_EU ,,n,I o TOWN OF NORTH ANDOVER 02ty� O APPLICATION FOR PLAN EXAMINATION y _ T � h Permit No#: �4" Date Received � q °R,TEo,.P SSACHUS� Date Issued: `� � IMPORTANT: Applicant must complete all items on this page LOCATION C — / Print PROPERTY OWNER: T�2_ri � _ - 3� IPrint 100 Year Structure, ' no MAP PARCEL: ZONING DISTRICT Historic District yes Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 0 ne family [I Addition trwo or more family ❑ Industrial ❑Alteration No. of units: 2 ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic Q Well ❑ Floodplain El Wetlands_ ❑ Watershed District Water/Sewer DESCRIPTIONOF WORK TO BE PERFORMED: cw- ,-Alt Identification- Please Type or Print Clearly OWNER: Name: Ve,-F 4-,e s a Phone: Z79>0 7-/V 7y Address: s s t Gyp- Q AT� v-e- Contractor Name: Addxess -7-1 -- - t Supervisor's Construction License: _ ,.�� ...� Exp. Date: Home Improvement License:_ 1 73,3 _Exp. Date.: 0 /U r ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ l0, sd FEE: $ I a-7-b-0 ,,,Check No.: .1%J Receipt No.: '7,b (�p NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner i nature of contract Z 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 i ❑ 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/Cross Section/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) i ❑ 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:Building Permit Revised 2014 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 ❑ I IIS THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes PlanningBoard Decision: Comments a Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Ternp'Dumpster on site yes no L-ocated,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— de a For ( department use) ❑ Notified for pickup Call Email i Date Time Contact Name Doc.Building Permit Revised 2014 4 i Location-�1 No. I r`j Date 0;?kill 'S ° - TOWN OF NORTH ANDOVER ♦ �_ Certificate of Occupancy14 $ Building/Frame Permit Fee $ N2-1 s Foundation Permit Fee $ Other Permit Fee $ :. TOTAL $ Check# 28161 Building Inspector VAIS 1/2014 09:11 FAX 781 942 2226 GILBERT 1@001 DATE( MWDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE -12/4/2013 ERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and Conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONT PRODUCER ACT Barbara McDonough Gilbert Insurance Agency, Inc. pHONE . (701)942 2225 PAXNoli (701)s42-2226 137 Main Street E.pAIE .bmedonough@gilbertineurancA.com INSURERM)AFFORDING COVERAGE NAIc a Reading MA 01867-3922 INSURERA:HARLEYSVILLE ORCES'TER INS CO. 26182 INSURED INSURER B:TraVelArs Ins. Co. 0 031 Duval Roofing, LLC. INSURER C: P.O. Box 637 INSURER D! INSURERE: North Reading MPA 01864 INSURER F: COVERAGES CERTIFICATE NUMBER-CL1331100142 REVISION NUMBER: THIS IS TO CERTIFY THAT 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 BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR IYDL SUOR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER /DD YW GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMA NTED 100 000 F Es eeeu S , II A CLAIMS-MADE I X I OCCUR GL641500 10/23/2013 10/23/2014 MED EXP(Any one perwnS 5,000) L6415BG 20/23/201410/23/2015 PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN1 AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AM $ 2,000,000 POLICY PRD- LOC S X COMBINED SINGLE LIMIT U AUTOMOBILE LIABILITY fFaacddenl 500 000 ANY AUTO BODILY INJURY(Per person) S A ALL OWNED X SCHEDULED 64456G 10/23/201310/23/2014 BODILYINJURY(Perecclaranl) $ AUTOS AUTOS NON-OWNED PROP RTY DAMAGE g X HIRED AUTOS X AUTOS P r' nl Uninsured molorMel50111 IIMII 3 100 000 UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCE55 LIA13 CLAIMS-MADE AGGREGATE $ i � S DED RETENTIONS $ WORKERS COMPENSATION o be provided directly OR MMMT 0TH- AND EMPLOYERS'LIABWTYis Travolera Snvurance E.L.EACHACCIDENT $ 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N OFFICER/MEMPPREXCLUDED9 El NIA /11/2014 /11/2015 E.L.DISEASE-EA EMPLOYE S 100,000 (Mandatory In NH) Ir - describe undor E.L.DISEASE-POLICY LIM17 5 500 000 DESCRIPTION OF OPERATIONS balaw DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD'1al,AddlUonal Ramarke Schadura,it more apacc is required) Evidence of Coverage CERTIFICATE HOLDER CANCELLATION (9-79)688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 9E CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover 1.600 Osgood street AUTHORREDREPRESENTATIVE North Andover, MA M Gilbert, CIC/SARBAR ACORD 25(2010105) ®1988-2010 ACORD CORPORATION. All rights reserved. 1FJQn9S on,nng%m The ACORD name and logo are registered marks of ACORD NORT#1 Town Of . t _E nd- over No. t = , ver, Mass, . 2 �a Coc«it«[w.cw �4S R�7Eo P'PP,`'�5 U BOARD OF HEALTH Food/Kitchen PER IL D Septic System MOITHIS CERTIFIES THAT , t ......... ... BUILDING INSPECTOR ...................................�......... ....... ........ ........ ... ........ . .. ..... . . f has permission to erect buildings on Foundation Rough to be occupied as .............� ..... ...... "f.............................................................. Chimney provided that the person accepting As 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 \ VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONT ELECTRICAL INSPECTOR UNLESS CONSTRUCT S S Rough Service ............ . ....... ................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. i Page No. of Pages Builders License # 58443 Home Construction Reg. # 167338 0 Tel CD D G@Cglo W) • a"`d_c-c . MA (781)944-1994 (978)664-2557 READING NORTH READING P.O. Box 637, North Reading, MA 01864 Please visit us at www.duvalroofing.com PROPOS UBMIuT a - .` DATE STR.1 CITY,STATE AND ZIP CODE We hereby submit specifications and estimates for: ! �t t1TC ��0C" �_ eft �'!tl`�1 � �f•/`7��� f'`�t LC<� f' 1 f Cc Ri,p�&'Remove all existing roof related debris from roof as well as job site with our own disposal truck. NO DRIVEWAY DUMPSTERS rU' 1 layer of existing roof shingles ❑2 layers of existing roof shingles ❑3 layers or more of existing roof shingles Replace any damaged roof decking; not to exceed 32sq.ft. (additional at$1.70 per sq.ft.) U I.stall 8"Aluminum Drip-edge/Rake-edge along entire perimeter(Choice o hite, Brown or Mill) " stall ICE&WATER UNDERLAYMENT on all horizontal eaves, sidewalls, skylights,chimney flashing and valley areas stall a premium base sheet underlayment(felt)that is in compliance with the asphalt shingle manufacturer chosen by the homeowner id Install The Homeowner's Choice of the selected Tamko/IKO or GAF Limited Lifetime Architectural Roof Shingles See individual manufacturer's warranty for specific details or please call us with any questions Replace all existing bathroom louver and/or exhaust pipe(s)with new aluminum flanges ©fChimney(s)-counter-flash and re-step existing flashing ❑Cut& Install new lead flashing Install a continuous low profile Ridge-Vent on all.ddge lines ❑Soffit-Vents UdRoof Louver-Vents Crair;c c c r,li F7 ❑Seamless Aluminum Gutters-Custom fabricated on site with our own gutter machine ❑Downspouts at additional ❑Leaf Guards ®Other r i T4 7i" //fA / ,I( C�i7i[ ' C� fir ttr1 t / pt , f ❑Roof Insulation- Increase existing R.value to R.value /yakk. o/-1 �o urG �'4 ;�c( C � 101ed roof /Ot/L;Pr //ll e JUraposr hereby to furnish material and labor-complete in accordance with above specifications,for the sum of: 3�V U - Total price not including options. dollars($ ` C%, 6 ). Payment to be made as follows: 30%deposit required before ordering materials. Balance due in full upon day of completion. Please make all payments out to Kenneth Duval, mailed to: P.O. Box 637, No. Reading, MA 01864 Final Payment is due upon day of completion and is subject to the Authorized "_ r� supplemented Terms&Condition sheet when scheduling. Signature ✓� ► THIS PROPOSAL IS VALID FOR 1Y < DAYS DUE TO FLUCTUATIONS IN MATERIAL&DISPOSAL PRICES. Massachusetts Home Improvement Sample Contract t:, This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Namempany Name 1 C� Street Address(do not use a Post Otlice Box dyes) ntractor/Salesperson/OwnN er ame 02�, /?,V,; Sal 7 ©e Cityflown State 44�ip Cod f�s� Bus' ess Address-(muft include a street ad s) Daytime Phone�j Evening Phone ity/Town G State/ Gr�Zip C e Mai' g Address(It different from above) Business Phone lFederal Employer ID or S.S.Number Homekmpmvemeal Camragor Reg.Number Expirefiondge r..w resmrer m.t m.n home Improvement eeatndonhave � 3F� holl .retia regttrr*ton number The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and gmde of materials to be used,use additional sheets if uecessarv.) ,✓t,���- ori,�e� Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be r�/ 3w� �` excluded from the Guaranty Fund provisions of 6 1 _Date when contractor will begin contracted work. MGL chapter 142A.) UV t��;,,�D cl o it a e w en contracted work wi a substantially completed. Total Contract Price and Payment Schedule �j 9 The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum oP./ Payments will be made according to the following schedule: S:q!;W.upon signing contract(not to exceed 1/3 of the total contract price ar the cost of special order items,whichever is greater) $ by—/—! or upon completion of $ by —/ / or upon completion of A — mP $—7 095��pon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following matchal/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be paid for NOTES:(*)Including all finance charges(**)Caw requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express warranty-Is an express warranty being provided by the contractor? ❑No Wes(all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important Information on the reverse side ofthis form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place ofbusiness,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. Seethe attached notice of cancellation form for an explanation of this rigbt. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM Two idemical copies of the contract must be completed and signed.One copy should go to the homeowner.The other copy should be kept by the contactor. Homeowner's Signature Contractor's Signature Date Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Lhapter 142A. /aws � Homeowner's Signature/ Contractor's Signature 7 NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at http://www.mass.gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at http://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: hLtl2://db.state.ma.us/homeimprovement/licenseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 Version 2.1-11/22/2010 The Commonwealth of Massachusetts Department oflndustrialAccidents h Office of Investigations J ' d I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Duval Rooifng, LLC Address: P.O. Box 637 City/State/Zip: North Reading, MA 01864 Phone#:978-664-2557 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 8 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. 9. E]Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12,X Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Travelers Policy#or Self-ins. Lic.#:7PJub-0230N91-14 Expiration Date:3/11/15 Job Site Address: City/State/Zip: A)d Attach a copy of the workers' comp sation 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 he pains and penalties of perjury that the information provided above is true and corre t Date: Phone#: 978-664-255 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#: i NOTICE N NOTICE TO ., a TO EMPLOYEES AF EMPLOYEES �AV The Commonwealth f ea o Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As r uired by Massachusetts General Law, Chapter 152,Sections 21,22&30 this will give you notice that P � g II we) have provided for payment to our injured employees under the above mentioned chapter b insuring Y I g with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY (7PJUB-023ON91 -9-14) 03-11 -14 TO 03-1 1 -15 POLICY NUMBER EFFECTIVE DATES GILBERT INS AGCY 137 MAIN ST READING MA 01867 �= NAME OF INSURANCE AGENT ADDRESS PHONE# a_ DUVAL ROOFING LLC 184 PARK STREET o. o� _ NORTH READING MA 01864 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably '— connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 004315 W20MG02 TO BE POSTED BY EMPLOYER SLOZ/OL/ZL Jauuo1ss�s1wuioo3 uo4ejidx3ck i 9N 98Ibt VWVWI([da2I N " IS MHON ZL 061 X09 Od 0,5 H1 aNNII :asu £tif►850-� 831-1 ._... s .10si.Uadns uoU3n1;su0j spiepuets pue suogein6aN 6uipiine jo paeog RtajeS oilgnd;o 1.uaw;jeda(i-s:49sn4oesseVy r -_ Office of Consumer Affairs and Business Regulation d t` 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 a Home Improvement Contractor Registration gtration SE Registration: 167338 3 � y , Type: LLC s t� Expiration: 9/10/2016 Tr# 256221 DUVAL ROOFING LLC. KENNETH DUVAL i ' T.. P.O. BOX 637 NO. READING, MA 01884 Update Address and return card.Mark reason for change. �r Address Renewal E] Employment Lost Card SCA 1 Cs 20M-05111 i