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HomeMy WebLinkAboutBuilding Permit #Exception - 88 CARLTON LANE 5/1/2018 TOWN OF NORTH ANDOVER C� APPLICATION FOR PLAN EXAMINATION Permit NO: l Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION & 9", Print PROPERTY OWNER L�.� , Print MAP NO: PARCEL. ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building neIa Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: i Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: 2,211r2 Phone: 0('`17133 7 3 6 Address: / ,,o Supervisor's Construction License: Exp. Date: ( �f f - Exp. Home Improvement License::. OffDate: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT:$12.40 PER$1000.00 OF THE TOTAL ESTIMATED COSIRASED ON$125.00 PER S.F. Total Project Cost: $ L(00, FEE: $ C/1) �� Check No.: (� 7 7 Receipt No.: 2 Z o�S- NOTE: Persons contracting with unregistered contractors do not have accessth uaranty fund ignature of Agent/Owner Signature of contracto Plans Submitted Plans Waived Certified Plot Plan St ed Plans 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 o 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 o Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008 TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/MassagcBody 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: Comments Conservation Decision: Comments Water& Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department sgnatureldate COMMENTS 1 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008 Location9k C�, ►'� �� No. o Date NORTIy TOWN OF NORTH ANDOVER ."O. f s Certificate of Occupancy $ — Building/Frame Permit Fee $ 0 Q 3 CHus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # � 3 � 226bz- Building Inspector - NORT►y Town of And dover, Mass., T O - LAKE I� COCHICMEWICK %d�oRATED 7 V BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR l�&G... 2,ac .. ;k .. THISCERTIFIES THAT......... ..... ............ ..........................L................................................... Foundation has permission to erect............................. ......... buildin son..... ....Jcomlw+w1 .......�..=................... Rough tobe occupied as.. T......... ............ 0. ..................................... ..................................................... chimney provided that the person adapting this permit shall in ery respect conform to the terms of the application on file in Final 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU TARTS Rough ...... ... Service .. .... . ...... ... ................... BUILDING CTOR D Final Occupancy Permit ,Required t0 Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. ... °„a,u «.,e...a-, ...,._. � ,,. •J.. ., -�.�, .. s..,.�.1. „. . .._r's.�r. a ... y � x .. r � ., w.+.� ... _ ,'x r` . Pogo No. of P ASCO ROOFING .& CONSTRUCTION CO. CONTRACT LOWELL, MA 01852 HIC#108424 a Super Contractor License#092469 978-937-5840 or 978-475-7544 7�7z7'.2 PROPOSl SUBINITTE TO PHO �^ ��� DATE o Of STREET Ir JOB.NAME CITU, 1STAT, -AND ZIP-CQDE JOB LOCATION ARCHITECT E OF L 4S)Ly/ JOB PMONf �We hereby, submit sp/eyd�ficat�i`ons,.and estimates for: ` ov., C4 ('60 a4a-1a G � e. r ; 'SOOr We P6ro*e hereby to fur is,motorial nd la r co4laite in accordance with o4ove spedficat' ns, for the euro of: r-'Lff Ccs !�a " —dollars :($ Payment"'to be made as follows / r S() v c� i t All material is guaranteed to be as spscNiad. All work to be completad,ifi a workman. like monner occarding to standard praNicea. Any olterotion or dlri on.from Dhow Authorized specHkotione involving extra tests will be..executed only upon written ordan, and Signaturq , will become an extra charge over and•above the estimate. All ogreeinents contingent / upon strikes, occident% or. :delays,beyond our control. Owner tocarry fire, tornado `Not Thproposal maybe ° and other necessary insurance. Our workers are fully covered byWorkmen's Com- withdrawn by us iff/not.oecepted within days. penwtion Insurance. Ac imptanee of Proposal -The above prices. specificatlona and conditions are satisfoctory and ore:hereby accepted You are authorized to do the work,as specified. Payment will be mode as outlined above. Signature Data of Acceptance 'Y' Signature, massachusetts Home Int rovement Snm le Contract • =Mussuachusetts s all basic requirements of the state's Home Improvement Contractor law(MGL chapter 142A),bat does not include standard ect homeowners. Seek legal advice if neceniingy. Any person.piamnng home improvements should first Obtain a copy of"a nsume guide m horns improvement"before eto arty work on_vaur residence.You may obteina free copy by calling theer Affe rs and Business Regulation's Consunforntat9on Hotline ar617-S73,8187 or]-885-283-3157. ��HH'omen gr lnf�a6on Contractor Information Name l.C!V l7✓v mpan Street Addrm(do e a Post ce Box.address) u' m/Salespcsoa/0 erN . ..Ciry/I'own( Smtc _Zip Code - /`C .- -usinesSAd/dres must MCI ii t p a Daytime Phone _/ LI/u • , /.. G ,t � Evening Phone iryl A nwn stat Zip Code Meiling Address(It diflereat from above) , usiness Phone eduel Emnlover ID ar S.S.Number. Lw*rquircs ober soostame� Hone -I��®rat mnvenars eevee •� >ml•o�mrnrCanaador)rst.)'tomeer I iiw,`on aeC The Contractor agrees to do the foliowing work for the Romeo aerasa��u�nnv�a C,�4.L e5 C m e q ,-P e YP" au Required Permits-The contras builrling,permits are reguirrd Proposed Start and Completion Schedule-The following schedule will. and will be secured by the contrnctoras the homeowner's agent be adh (Owners who secure,their own permits will be coed m unless circumstances beyond the contractor's control arise excluded from the Guaranty Fund provisions of MGL chapter 142A.) �t rr Due when contractor will begin contracted work. S Dam when coatmcred work will be substantially completed. Tata .Contract Price and Pavment Schedule The Contractor egrets m perform the work,famish thematerial and labor specified above for the.total sum of ' OOI Payments will be made according (�) to the following schedule: - s Upon.siguing connect(not to exceed 1/3 of the tom)contract . price or the cast of special older items,whichever is greater) $---_ b3 _/_/ arupon completion of S_ b3'_/_�or upon compietion of $ upon completion of the contract, (law forbids demon ditag.frill payment until contract is completed to both party's satisfaction) The following matedaliequipmemmust-bespecial s. L- ordereil'oefoethecontradedwmik. to be Paid for ' begins in order f paid ( �^ to meet the completion schetltile.{*+) to be C NOTES:(•j Includingall fi=m charges(+•)law requires thatany - _ -- nor exceed the deposit or down-payment required the cm (//.' greatnr of(a)onathirci ofihe roti)conttact.price a(b)the actual �a°r bdfare wont bepns may . . which must be special ordered m advance to meet the completion scbedtde: cost of any special egiripment'or custom made material Exprass Warranty-is an express wa-M=bei rnvidetl.h the.covtrattor? Na ya e11 sof a warrimm must be atuechedm he contract Subcontractors-The contractor agrees to be solely iessponsible fast co t party/subcdnnactor utilized by the contractor. The contractor further ap croon of the work described regardless of the actions of any third serials and labor under this a etas nts to solely responsible for all payments to all subcontractors for Contract Acceptance-Upon signing,this document becomes a binding act _ jsc no contract shall not imply that any lien or other security interest has been pia�ed on the�resaden Review the following cautious ted within tiohi and���the carefully before signing this contract Don't be pressured into signing the contract Take time to read andf tU • Make sure the contractor has a valid Home Improvement Co y coedit. Ask questions if something is unclear. 1113clor The subconhncters to be registered with the Director of H me improvem nt Contractor Re law requires most home improvement contractors and registration by writing to the Director at Doe Ashburton Place,Room 13(11,Boston Mq p 108 or by calling inquire ui a about c o�ctor 1-8 0D-223-0933. • Does the contractor have insurance? Cheek to see that your contractor is properly insured • Know your rights and responsibilities. Read tbe-important information on the reverse,sid Guide.to the Home Improvee of this form and gets copy afffie Consumer Improvement Contractor law. ElZbi-rld cancel this agreement if it has been signed ata place other than the contractor's normal place of�&Jivey, ss,provided you notify th r in writing.at his/ber main office or branch office by ordinary mail Posted.b iness day following the signingof a Po d,y telegram sent or by not later then midnight of�the greement See the attached notice of cancellation form foplanation of this right DO NOT SIGN THIS CONTRACT IF TIES ARF A ,y BL tit T�wjro iiddenozl copies Of the�antna amat6 complacd and sign&Orr ropy should go ro�e ha"memme.r � tSPACES.- lK/ kept f/hcncJonnanor. Homeowners signature Contractor s i at Date ItAR- 12 _og 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 i not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in courtunless both parties agree to the optional clause provided below. 'Phis clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractorl,aw. 71e: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 Laws,chapter 142A, Homeowner's Signature Connectors Signature Nt)F7 CE: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 cb000se'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 lmprovemeot CContractorLaw, The contractor is.responsible for completing the work as descnbed,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,fora 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 arc 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. Amy 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 cont-act,and the three day recission period has expired. Accelerated Payments A contractor may not demand payments in advance of fhe dates specified on the payment schedule in cases where the em homeowner des hinr/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 consumerrights,or if you wisb to obtain a free copy of"A Consumer Guide.to the Home ImprovementContractorLaw,"contact: Consumer Information Hotline, Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 (617)973-8787 or 14886)2833757 If you want to verify the registration of a contractor or if yon have questions orneed additional information specifically 'about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home,lmprovement Contractor Registration Bureau of Building Regulations and Standards One Ashburton Place,Room 1301,Boston,.MA 02108 (617)727-3200 or 1-800.223-0933 For assistance with informal mediation of disputes or to register formal complaints against a business,.can: . Consumer Complaint Section Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755-2548 .(413)734-3114 11u..a=,hu rtt� - i)clr<utntrnt of,i liblic Safett 7 Board id 80ildiW-' Rc�I'ttlatinns .11](I Standard � -- Construction Supervisor License License: CS 92469 A Restricted to: 00 JOSEPHJ GYS 10 MEGHANN LANE LOWELL, MA 01852 Expiration: 9/27/2011 t mumi—i"wr Tr»: 3108 /zv ooay�vi�zonucz! al' Z' r, �( Officc of Consumer Affairs&Busmess�2eg%wz t HOME IMPROVEMENT CONTRACTOR Registration: 108424 Expiration: 8/18/2011 Tr# 286780 Type: DBA ABCO ROOFING&CONSTRUCTION Joseph Gys 10 MEGHANN LANE LOWELL, MA 01852 Undersecretary RightFax N2-2 4/23/2009 6 : 06 : 36 AM PAGE 2/002 Fax Server ACORD. CERTIFICATE OF INSURANCE DATE(MM\DD\YY) 04-23-09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE FRED C CHURCH INC HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR PO BOX 1565 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE L0\\ELI—.%,IA O1,\531\6 COMPANY 291-15J A IL\RTFORD CROUP INSURED COMPANY B GYS .JOSEPH DBA ABCO C0NS IRUCTION COMPANY 10 NIEGHANN LANE C LOWELL,MA 01552 COMPANY D COVERAGE THIS 19 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, CO POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER DATE(Mh1tDD.YY) DATE LIMITS GENERAL LIABILITY GENERAL AGGREGATE S COMMERCIAL GENERAL PRODUCTS-COMP%OPAGG. S CLAIMS MADE OCCUR. PERSONAL&&ADV.INJURY $ OWNER'S&&CONTRACTOR'S PROT. EACH OCCURRENCE S FIRE DAMAGE(Anyone lire) S MED.EXPENSE(Anyone parson) $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIN117 S ALLOW NED AUTOS BODILY INJURY(Per Person) $ SCHEDULE AUTOS BODILY INJURY(Per Accident) S HIRED AUTOS PROPERTY DAMAGE S NON-OWNED AUTOS GARAGE LIABILITY ANY AUTOS AUTO ONLY-EA ACCIDENT S OTHER THAN AUTO ONLY: EACH ACCIDENT S AGREGATE $ EXCESS LIABILITY UMBRELLA FORM EACH OCCURRENCE S OTHER THAN UMBRELLA FORM AGGREGATE $ / WORKER'S COMPENSATION AND A EMPOLYER'S LIABILITY UB-0448N539-09 05-01-09 05-01-10 STATUTORY LIMITS X THE PROPRIETOR; EACH ACCIDENT S 100,000 PART NERSIEXECUTIVE INCL DISEASE-POLICY LIMIT $ 5002000 OFFICERS ARE: X EXCL DISEASE-EACH EMPLOYEE S 100,000 OTHER DESCRIPTION OF 0 PERATIONS/LOCATIONS/VEHICLES/RESTRICTIONSISPECIAL ITEMS THIS REPLACES A\Y PRIOR CURTIFICATE ISSUED TO T1IE CERTIi�ICATE HOLDER AfiTCTINO WORKERS COMP COVERAGE THF WORK[-RS'CO\,IPGNSA-I.10N POLICY DOES`0"r PROVIDE COVERAGE E'OR GYS JOSEPH. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CAIJCELLED BEFORE THE CITY OF L.OWELL EXPIRATION DATE THEREOF,THE ISSUING COMPANlY Vvlt-ENDEAVOR TO MAIL IO DAYS 1'v RITTEN NOTICE TO THE CERTIFICATE HOLDER!jAUED TO THE LEFT,BUT 375 MERREMAC.I\SI-REIT' FAILURE TO!RAIL SUCH NOTICE SHALL iK1POSE NO OBLIGATION OR LIABILITY OF ANY KIND JPON THE C01.1PANY.ITS AGENTS OR REPRESFOTATiVFS LOWELL,MA 01852 AUTHORIZED REPRESENTATIVE ACORD 25.5(3/93) Ramani Ayer FPX 'o- : m ACORD,m CERTIFICATE OF LIABILITY INSURANCE °ATE I, C ,yy"' PRODUCER f,S90) THIS CERTIFICATE 19 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE red C Church.Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR -11 WcIlmml Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, S00-125-IF6; INSURERS AFFORDING COVERAGE NAIC INSURED Aloco Con�tlllcuon 7 lqlmim Lane Low-cILMA 'JW' COVERAGES THE POLICIES OF INSURANCE LISTED BELOVV HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TOALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. —ROUICY�YPIRATION [NSR ADD'!. NUMBER PDoALTlCY?EVFAFJDED7Yl`VjE DATE VAIM�QDNY) LIMITS LTR INSRO TYPE OF INSURANCE POLICY GENERAL LIABILITY X x A CCP82;18(13 426'2o ':26,2010 09 500.000 1,000,000 GE "IT ES��F Ea., F AUTOMOBILE LIABILITY s;;; TC 3-�4 ,-i GARAGELIABILITY z'-EA EA Acc EXCESSIUMBRELLA LABILITY E WORKERS COMPENSATION AND EMPLOYERS LIABILITY L AL z•E.Hp: q 'El OTHER DESCRIPTION OF OPERATIONS I LOCATICNSI VEHICLES I EXCLUSIONS ADDED BY ENCORSEIAENTI SPECIAL PROVISIONS Faxt`1-9,S-446--103 CERTIFICATE HOLDER CANCELLATION (-it%-iot,Lowell SHOULD ANY OF THE ABOVE O5SCR!BED PO'!C!ES BE CANCELLEC BE'FORE THE EXPIRATION lcrrinlac�St 37.� �IATE THEREOF,THE SSW]N'13 INSURER WILL ENDEAVOR TO V�Ail- DAYS WRITTEN � NOTICE TO THE CERTIFICATE HOLDER NA�MEO TO THE LEFT.BUT FAILLRE TO 00 GO SHALL Lo-o,-ell, MA IMPOSE NO OBLIGATION OR LIABILITY OF ANY;<;:Jll UPON THE INSURER,ITS %;FNTS GR REPRESEHTAT�VES. AUTHORZEDREPRESENTATiVE ACORD25(20W08) 0 ACORD CORPORATION 1988 r•••t 1_uffmnamwea&k of Massachiae&S De►artmerzt of Industrial Accue is 6 mice of ImpesV afions 600 Mras)iin.ton Street y� / b Boston, MA OZlll Workers' Compensation Insicranee -�»�ss:gov/dig A �Mt W rffia�ion A.ff davit~ $ui�ers/Coafractors/Eieetciciaas/Piam6ers Pl ' t LeQibi ame(ZUsiness/Cr MizafioMndividuW); Address., • City/,State/gyp. - Phone#:• �-/''��3 3 .��(S` Are - a employer? $PPmPriinte-box: am a I. employer wiflr 4. TYPe of ro'ect 1 mn a general contractor and I .. P 3 (regairedj;. 2•� employees(fun and/or part_time.* have .' 6. ❑'New coristi-r�cdofi . I sm.a.sole" � hued the sutr-comzact�s proprietor or partner• listed ern the attached sheet t 7. ❑Pimodeiia S4 and have no employeM . These sub-contractors have g working forme in any rape�y, work 8. Q Demolition (No work='com h ' comp.insurarfzw. P °�� ra)tm'ed.] $ VJe am a corporation and its 9. ❑Bw Iding addition o��'s have exercised their 10. 3.❑ I sin a homeowner doing all work ri ' of ❑ =Irical repairs oradditians. ellc � exemption per MGL 11. mys- [No workers cramp. c ZS Plumbing t'epairs"rr additions insc¢attce.r��&I t ?, §1(4)',and�we have no 12. . .•FnP1oYee-L[No work=' ❑Poof'rcpairs comp. irtsuranee required.) I3.[].O�e `�"3 appticarRtimr tbecks bob#I mast etso fl t outf=section 6efow ----------- t riomeourrtdrs who submit this ewidsvk indieaitttg slay arz °boy"mB theirworhard aotnP-Mte ti D. Caatratyars ffiet cherae dila box roust dMog an�"Mt end th.hh outside aanasctora infomution at>solyd an adcF.�tioast shestdwq',r�•the ntunc ofthe mL- submit a sew afndavh iodiotria;such.' I Qe:�sn et�sioyer tira�isornuin'.urd:►�ark_--:� ������O� `�`�'F`":ic�i*foa. to h'•..•e vo - ¢>zd'ni Ingtrartec Company Name: n ! policy 4 or Set=ins.Lie.9: r/�t 7AA. Job Site Address: 51/0 Attach a copy of the workers'•coon Peosation Policy daeiara&n Per(showing the policy Dumber and e Failure to secru�e coverage as required under Section 25A of xpirsfioa ifate}. fine up to$450Q00 and/or one-year iznPd=Se MC1L C. 152 can lead m the imposition of criminal Of up to$250.00 a ;as wail as civil penettim in the farm of a 57l'JP WORK �of a �3 against the violatrn. Be advised that a copy.of this statement ORDER�a line invwfigations of the DIA-for insurance coverage venoicE6CM, may be forwarded to the 0{nct of I do hereby certi%y u the assts pl Pcrlwy�fim the infarmadan provided above is true Si aorrr Phone ieicl use an y, do not wale in this arra,m be er►mptetrd by dj or town.off"i"L City or Tows: Issuing,4,utho •y(cPertait/License# r[fircle one): 1. Board of Ofber Seattb 2 BuMi,-Department 3.City/Tcrwn Clerk 4.Electrical luspeetor 3.PiDmbiDg Irrsl�r 6 Contact Person: Phone# Information aL jnd Instructions Massachusetts General Laws.chaptar 152 mquim all emp]a__Ts to provide workers' compensation for their employees. Pursuant to this stage,an euutployee is defined as"..:every person in the service of another under any contract ofhire, express or implied,oral or wriftnn," ' An ennftoyer is defined as"an individual?partnership,ass,aciation,catporstion or other legal entity,or any two ormore of tiro foregoing engaged in a joint entz*se,and including the legal representatives of a deceased employer,orihe receiver ortr»stee•of an individual,partnership,association or other legal entity,employing employees.'Howcmthe owner•of a dwelling house having not more that three apartments and who resides therein,or the occupant of the dwelling house of another who empioys persons to do mazmte mac,contraction or repay w&k m such dweifthouse or on tate grounds or building appurtenant thereto shall not br..cause,of s.=b employment be deemed to be an employe.." MGL chapiti:r 152,923C(6)also states that"every stats o.s-heal licensing agency shall withhold the isseancear renewal of a license or permit is operate a business or ergo construct buildings is the commonwealth for any applicant who has out produced acceptable cvideQce o comprmce with the.iusumuce'coverage required." Additionally,MGL chapter 152,925CM states"Neither the commmenwea*nor arty of its political subdivisions shall enter into,any contract for the perfamaince of public worle until aaeepiabit evidence of compliance with tic insimc:e tsquirernertls.of tiffs cdrapter have been presented Lathe ear dmct rig indic;rity." Applicants Piease fill out the workers'compensation.aStdavit completely,by checking tate boxes that apply to.your situation and,if necessary,supply sub or(s)rrsme(4 adtiress(es):acid phone number(s)along with their cartifica*s)of insurance. LimitedUabiiky Companies(LLC)or Limited umbuity.Pwtn=diips(LLP)with no employees otherfhan the mariners or.priners,are notregcmed,to carry workers'ctarnpensaiaon inswas= Ifan LLC orLLP does have empioyees,a policy is required. Be advised that this affud-m-&may be submitted to the Depanfinenl of lndu=w Accidents for amf rmation of insurance coverage.. Ala'Eye sure to sign and date:the affidavit The affrdavh should be returned to the city or town that the application for the permit or license is being requested,not1he Departmtem of Industrial Accidents. Should you have any questions raga ruling the law or if you are inquired to obtain a workcmr oompensataon policy,pleasecall the Departuarent at tate nurxtbar.listed below. Self-insured companies should enter their self-insmzncc license number of t#to PPMpriate line. City or Town Officials Please be sure tat affidavit is complete and printed le:g-ibly. The Depw merit has provided a space at the bottom of the affidavit for you to full out in the event the.Office of Investigations has to contae you regarding tiro applicant Please be sum toifll in time perrnit/liconse naunberwhich w-M be used as a reference number. in addition,an appk= that must submit multiple permit/liconse applicatibm in any given year,need only submit one affidavit indicating cm i m policy:information(af necessary)and under"lob Site Addr-ems"the applicant shouuld write"all locations in (city or tAwn)."A Dopy of'fbe affidavit that has been offuciaily stamped or marked by the city or town may be prowled 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 lirensc'or permit not related to any business or commercial venture (i.e. a dog license w permit to bum leaves etc.)said pmm&n is NOT.required to-complete this afitdaviL Tic Office, of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do ot hesitate to give us it call Tfzr Departmam is address,telophonc and fax numb=. The CommonwoaLlth of Mamachusetts D_ artincat of Eadust aig A=deat Mce of Env'Ut gations 600 Washington Stye-t Bosfvi, MA fl2111 TeL 9 617-7274900 in 406 or 1-977-MASSA;FE Revised 5-2b-05 Fax;9#61 7-727-7741 www.mass.;ov{dia ellv Page 1 of 2 The Oficial Website of the Executive Office of Public Safety and Security(EOPSS) Mass.Gov .Public Safety '- sr _crisinc->:;ens.' =by SLISinr�'E;Area o i cto > y c> ieme in croverer,i Home improvement Co€Itra„lror Reg;atratloll Program Contracts-all contracts over$1,000(one Thousand Dollars)must be in writing. The law requires the following FOURTEEN items to be included in any contract between the homeowner and registered home improvement contractor in al contracts for home improvement work subject to MGL c I42A I. The complete agreement between the contractor and the owner and a cleat-description of which are part of the agreeany other documents ment 2. The full names,federal I.D.number(if applicable),addresses(NOT P.O. Box numbers),of the;patties,the contractors registration number,the name(s)of the salespetson(s)involved;if any and the date the contract was executed by the parties: 3. The date on which the work is scheduled to begin and the date the wort:is scheduled to be substantially completed. 4. A-detailed description of the work to be don-,and the materials to be used. 5. The total amount agreed to be paid for the work to be performed under the contract 6. A time schedule of payments to be.made under the contract and the amount of each payment state in dollars. including all finance charges,'if any.Any deposit required to be paid in advance of the start of the work SHALL NOT EXCEED one-third of the total contract price or the actual cost of any mat custom made nature,which must be ordered erial or equipment of a special order or in advance of the start of the work to assure that the project will proceed on schedule. No final payment shall be demanded until the contract is completed to the satisfaction of all parties. 7. All parties must sign the, 8. There shall be a clear and conspicuous notice stating; a.That all home improvement contractor and subcontractors shall be registered and that any inquiries about a contractor or subcontractor relating to a registration should be directed to; Registration Divison,Program Coordinator One Ashburton Place Room I30.1 Boston,Ma 02108 Tel:(617)727-3206 ext.25239 b.The contractors registration number must be on the first page of the contract c, the homeowners three day cancellation rights under MGL c 93 s 46; MGL c 140D s 10 or MGL c 255D s 14 as may be applicable. d. All warranties on the owner's rights under the provisions of 780 CMR R6 and MGL c 142A C. In ten point bold type or larger,dimcth,above the space provided.for the signature,the following statement; DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. f Whether any lien or security interest is on the residence as a consequence of the contract 9. An enumeration of such other matters upon which the Owner and contractor may lawfully agree. 10. Any other provisions otherwise required by the applicable laws of the Commonwealth. 11. Permit Notice:Every contract shall contain a clause informing.the owner of the following; a.any and all necessary construction-related permits; b.that it shall be the obligation of the contractor to obtain such permits a the owner's agent c.that owner's who secure their own Construction obtain perrnM or deal with unregistered contractors shall be excluded from access to the Guarantee Fund. 12. Acceleration of payment: No contract shall contain ar,acceleration clause under which anv part or all of the http://www.mass."ov/?pa6eID=eopsterminal&L=4&LO=I Iome&LI=Consumer+protection... 12/5/2008 rage of l V balance not yet due may be deciared due and payable because the holder deems himself to be insecure. However, where the contractor deems himself to be insecure he may require as a prereq uisite to continuing said work that the balance of funds due under the contract which are in possession of the owner,shall be placed in a joint escrow account requiring the signatures of the home improvement contractor and the owner for withdrawal 13. No worl:shall begin prior to the signing of the contract and transmittal to the owner of a cop),of such contract 14. Arbitration: If the contractor determines that in the event of a dispute,the contractor wishes the dispute to be settled by arbitration.this fact must be signified on the contract and both the contractor and owner shall sign this clause separately. The following format is acceptable(in 10 point type or lar=cr); r "The contractor and the hamcowner hereby mutuaUl,agree in adva rice that in the event that the contractor has a dispute concerting dais contract,the contractor mziy submit such dispute to a private arbitration service which has been approved bt,the Office of'Consumer Affairs and Busitaess Regulation and the consumer shall be required to submit to such arbitration "ovided in MGL c 142A. c Owner: Contractor: NOTICE: The ig 'ores of the parnes above appit'aaly to the agreement ojthe parties to alternate dispute resolution inia ed ht-the contractor. The owner may initiate alternative dispute resolution even where this section is not signed separately by the parties." ©2006 Commonwealth of Massachusetts Ili I http-.//WWw.mass.(Yov/?pageID=COpStcrminal&L.4&LO=HomeL-LI=Consumer+protection... 12/512008