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HomeMy WebLinkAboutBuilding Permit #452-16 - 94 FOXHILL ROAD 10/8/2015 BUILDING PERMIT of NORT" � TOWN OF NORTH ANDOVER A�PLICATION FOR PLAN EXAMINATION10 Permit No#: Date Received "reo�Pa�•(5 / �SSACHUS Date Issued: - IMPORTANT: Applicant must complete all items on this page 1 '-TY'�,.t.s o�y. j S z �e" sF' ' ',g= -".�.�,' t.:a� r,,sr�?' t'3a.' a. "".3�' •";�"1- azr rx ter- ryu�: a ':i' Y�.'' s+r L 6 n t 'E• .:.{r k}«. k vi' K g ":p i+ '�. �Sg ry `.+r' .7 ,•a £._ ,y'^$ sr.',`.�n .":.. y s. r.. r k 4 #¢- •p rcpt � P +�Y �A R' nr �'�, W-4 ^ r h � t� 3LOCA�TION � �gb� ,�l w � s .. tk' tenr > •t'-' tz• «�-ei s" n 4 s,vw. n• .s e �S ,2, is - t F L s, s� �• q•Punt �: r •..sy �:-P Z°.i,tc # •'x �`�y � ' �,. =".-z...-Y1tti.�a1.5 a�. r•+��F. a� (/y� ( .•F f ! 9,.� L nSa a '�u` k �: r;rta �s �a sxr.;.,k>': F 3ii S �' -\ Y� ,r"g�1 �� c+• .F{ s r� ' x °• k`.3�' x z> ,PROPERTY OWNER }�.- ; a m, ' ` Pnntr Is *. X100 YearjStFucture�'- "* YeS ,IVIAP'r K! ( PARCEL t.` �s" ZOIVING'DISTRICThy {��� � Historic� rictpf °yes .. no% S ...� M S r... Y a7 .,,2ca.,*,,:'-:'�-�'� .� .t`�. ,+X•,-y.,x`r».,.�• Hr*�.: -� ..r,...�_ Ye TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑:Septic❑VVellA ' ❑ Floodplain T ❑WbtlandsT f " {'A"k❑ 1Nate shednQ.istrict TMr :xx ar "-fwY. +4•lr p aZ 1 � .# 7' k t�.1r'0 s i. 7a• ca rt fc t`'�4� w�. �"'��t jk'i�`t' ,+Yait 4� S'�" ;ir ...� : :.. , ,Water/Sewera ; ,..k .,i�•-7.`_ t v w r aEs _�k._..:iis ,..+..?,S� r".a...... ..':,.h—e...rc;-:m..a �, .:..a.. 1.�.....„j;: DESCRIPTION OF WORK TO BE PERFORMED: �s I( � I� bath - ,Mtl� �/cif roar. d,p��x► r���l� sD Identificatiop- Please Type or Print Clearly OWNER: Name: I.s5� �1- C I`r,� 1� n I Cc> Phone: '7 I q q =-�� 7-� Address: '� q F n Hill c� �aor-)r1A Aa 8,� �" *Y. 6 .�,. _ .P :- -- r e � s �x: � ,.s',�4� x:�• � .rte' xJ i� q'•�'4 " ,t ��•+� �. 1 s Fi J ...r a 4 �Sx�kw � a a ?��" z tk S ContractortNameonedS '� . z r*a �.. +�- wFyt T x r �, w --a«.a�. �� �• -y' +� ,� rr �ry t r T� i CJ ,fitto yry t3"' s v -Y n t.:.• Y r tis" it A .v",x, V}ewv t^.•+..w..A X vi S; " t � t� ""+` t'� r•t� R S #�rx ids ti S*�.. � � �,� s'. pervisor,sConstuctionryLicense �C'St b5"�'��' Expo ®ate HomeImprovementzLice se s /� �` ©��?r. 3 k° ;ExpDate 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: $ '36 , /6 6 ' 00 FEE: $ �� f Check No.: ` � Receipt No.: , NOTE: Persons contracting with unregistered contractors do not have acc ss u fy d Signature of Agent/Ow. ner Signature of contractor Location IItt No. Date V f . - TOWN OF NORTH ANDOV4ER J '9 Certificate of Occupancy $ o _ / Building/Frame Permit Fee $ _ Foundation Permit Fee $ Other Permit Fee $ :i TOTAL s Check ti f. 2949 4 Building Inspector 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. ❑ Pennanent Dwnpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS 0 A HEALTH Reviewed on Siqnature COMMENTS ZoningBoard of Appeals:Variance pp Petition No: Zoning Decision/receipt submitted yes � Planning Board Decision: Comments Conservation Decision: Comments Water &c Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 tF wn�.3Os tsr zg-oyo� d aStreet FREDEARTtsTre ;n T� N Dm P eo : ryecdfa�24ainSfet �;Fire+Department,�ignature/date m b .n} ha.- c 1 y r6' ^'i. 2 .' ,a'..t3"' '�•1�d`a".�.s tf (". y h"":'x a.�C`y"-'° C, rw- -.tom ,t.®MMENTS,# '.y _� f yk � �tt }• 1 —� - #�: '; _ rs 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 No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) I LI i Notified for pickup Call Email Date Time Contact Name Doc.Build' mg Penmt Revised 2014 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 o Building Permit Application ❑ Workers Comp Affidavit j ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work Li 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 Li 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) o 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 1 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 Doe:Building Permit Revised 2014 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 36,100.00 m $ - $ 433.20 Plumbing Fee $ 54.15 Gas Fee 100 comm. $ 100:00 Electrical Fee $ 54.15 Total fees collected $ 641.50 94 Fox Hill Road .452-2016 on 10/8/15 Install 1/2 bath, family room r 1 NORTH �- .. ver OAIL ;- h ver, Iass,4O O �C- ) , coc N1CNlwococ 1' RA'rED I,P S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ............ . .[..S, �t„ .....rk:...... .�!�/..4..,5......... ... ..I�/V�l.��7...,.,.,,,.,.. BUILDING INSPECTOR / has permission to erect .....:.................... buildings on /. ....... .......,..........,......,.,, Foundation �j Rough to be occupied as .....1640l.N"',�.................................. ...... .L.... .�il .. --................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the,Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final V3 2, PERMIT EXPIRES IN 6 MO THS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI ST S Rough Service ..............011....... .............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by-the Building Inspector. Burner Street No. Smoke Det. l . ----------------------- -------------------------------- _ AUD Al lERNAiE SCOPE ---- I IIIIIIJIIllIl/lIII1011IIJIII_IJplllllplllllJllJllllppllJplplllplllp��Ill1011ll6pll11110111(I!I/I!!I!!O�//llOplIJJIJpIIJI r--___.._._..—_ ___.._—__. - - <2'<L«"�JIIIIIIllllpJ!llll�lIIIIO ------ — Ex SiDR 01, iiAl , , SloftnCE, I 'SrORAGE --- //� rDS) _-- u I i REF iFJ I II Aot� a ' I 1!.IJlJIJIIIJIJI!/IJpIIIJOIIlIIOJJIIJlIJI JlJJJIJlIJIIJjIO!!!/JDl/I?/l/!I// l!- - - -------- OA ISSUE WE MARCH 26 2015 __.. -_ _ OJFCI NAM!PR - -....._._.. DRAWN DY --- --- SHEEI IIILf: —_ DIMINICO RESIDENCE-BASEMENT RENOVATI HEEL NUMOEir REVISIONS _ PROJECT ADDRESS --- ------- ------ -------- -- .._..—_._ ._ HASEMENT CONSTRUCTION PLAN yn FOX HILL ROAD --- - A-101 NORTH ANDOVER,MA 07&15 �� i X44 BUILDING & REMODELING, INC. 26 Fairfax Street Burlington, MA 01803 Direct: 781-775-5820 E-mail: brian@bcmbuilding.com www.bcmbuilding.com Building License#CSFA-055372 STANDARD AGREEMENT BETWEEN OWNER AND CONTRACTOR I. Parties This agreement is made and entered into on the �' y day of October, 2015 between Chris and Melissa DiMinico, located at 94 Fox Hill Road, North Andover, MA. 01845 and BCM Building& Remodeling Inc., located at 26 Fairfax Street, Burlington, MA 01803 ("Contractor"). II. The Contract Documents The Contract Documents consist of this Agreement, Proposal of Work, Conditions of the Contract (General,Supplementary and other Conditions), Drawings, Specifications, Addenda issued prior to execution of this Agreement, other documents listed in this Agreement and Change Orders issued after execution of this Agreement, all of which for the Contract, and are as fully a part of the Contract as if attached to this Agreement or repeated herein. The Contract represents the entire and integrated agreement between the parties hereto and supersedes prior negotiations, representations or agreements, either written or oral. If anything in the other Contract Documents, other than a Change Order, is inconsistent with this Agreement, this Agreement shall govern. III. Scope of Work Contractor shall fully execute the work described in the Contract Documents, except as specifically indicated in the Contract Documents to be the responsibility of!others which is reasonably inferable from the drawings, as they currently exist, shall be the Contractor's responsibility. Page 1 of 8 Owner promptly agrees to furnish Contractor with all details and decisions about unspecified g construction finishes, and to consent to or deny changes in the Scope of Work that may arise so as not to delay the progress of the Work. IV. Date of Commencement (and Substantial Completion) The date of commencement of the Work shall be the date of this Agreement unless a different date is stated below or provision;is made for the date to be fixed in a notice to proceed issued by the Owner. Date of commencement, shall be within 7 days of obtaining the building permit. The Contractor shall achieve Substantial Completion of the entire work not later than 45 business days from the start of framing, subject to adjustments of this date as provided in the Contract Documents. "Reduction of scope previously approved, whether in Change jOrder or initial contract, will incur additional costs(20%J on returned or declined scope of work. V. Change Orders Any Change Orders to the Contract Documents involving adjustments to the Contract Price due to extra costs must be in writing. All Change Orders must be in writing and signed by owners, or their authorized representatives, regardless of whether that authority is actual, apparent, or implied. The Owners agree that Change Orders resulting in the furnishing of additional labor and/or materials will be paid for in full, prior to the commencement of the extra work, unless otherwise agreed to by the parties in writing. Keeping in mind that a change order may lengthen the amount of time it takes to get to substantial completion. Any owner supplied items that need to be picked up by Contractor,will incur a $75.00 per hour fee,with a minimum fee of$75.00. VI. Permits, Licenses and Approvals i i j Page 2 of 8 Contractor will obtain local building and construction permits, and will obtain and pay the fees for the governmental inspections that are necessary for the construction as outlined in the Scope of Work provided, except as otherwise provided in this contract. The owners will secure and pay for any zoning changes, necessary modifications of restrictive covenants, or other hazardous material permits/removals, and/or surveys as required by the Town, etc. VII. Insurance and Risk of Loss Contractor agrees to maintain workers' compensation insurance and liability insurance to protect the Owner from liability claims for damages because of bodily injury including death, and from liability for damages to property, due to injury or damage caused in the course of Contractor's performance of the Scope of Work. Owner agrees to maintain proper insurance coverage to protect Owner from claims resulting from anything outside the Scope of Work. It is the responsibility of the Owner to maintain proper insurance, in amount and type, on the property located at 94 Fox Hill Road, North Andover, MA 01845. VIII. Access Owner will allow free access to work areas for workers and vehicles between the hours of 7:00 am and 6:00 pm Monday through Friday unless otherwise agreed to by both parties in advance. Owner shall also allow areas for the storage of materials and debris. Driveways and parking areas will be kept clear for the movement of vehicles during work hours. Contractor will make reasonable efforts to protect driveways, access doors, lawns, shrubs and other vegetation, but will not be responsible for any damage incurred due to constant access that may occur during project duration; such as wear and tear on lawn, etc. Free access to the building will be required for delivery of materials. IX. Activities Related to Architecture, Design or Engineering The Contractor is not the Architect, Engineer, or Designer. Contractor is not being hired or compensated to perform any of these services.To the extent that the Contractor makes any suggestions in these areas, Owner acknowledges and agrees that Contractor's suggestions are merely options that Owner may want to review with the appropriate design professional for consideration. Contractor's suggestions are not a substitute for professional engineering, architectural, or design services, and are not to be relied on as such by Owner. Contractor is not responsible for ascertaining whether details in Owner's plans conform to all applicable building and planning codes. Contractor is not responsible for the cost of correcting errors and omissions by Owner's design professionals and separate contractors. I Page 3 of 8 X.. Site and Concealed Conditions Owner acknowledges that the Contract Documents are based upon Contractor's observations of conditions and review of all drawings and the Agreement,together with the Contract Documents, is based solely on the observations Contractor was able to make with the structure in its current condition at the time project was bid. Conditions which could not be known by a reasonable inspection, such as, but not inclusive of,termite damage,water damage, code violations, not level, not plumb or other concealed conditions, may require extra labor or materials,which by this reference, are specifically excluded from the Scope of Work. If such conditions are discovered,the Contractor will promptly notify the Owner to make a Change Order to the Contract Documents to address the work necessary to alleviate the condition(s). Contractor will leave site in "broom swept" condition. (Precautions will be taken to minimize dust; however, some dust will migrate to other locations in the home. Contractor does not guarantee 100% dust removal.) XI: Exclusions Unless specifically included in the Contract Documents, this Agreement does not include labor or materials for the following work: removal and disposal of any materials containing asbestos or any other hazardous material as defined by the EPA, custom milling pf any material for use in this project; moving Owner's property around the interior or exterior of the site; labor or materials required to repair or replace any Owner-supplied items and/or materials; correction of existing out-of-plumb or out-of- level conditions in existing structure or fixtures; correction of concealed substandard framing;or removal and/or replacement of existing rot or insect infestation. Contractor is not responsible for incomplete plan details or omissions in plan specifications. XII. Payment Contract Price/Sum The Owner shall pay the Contractor the Contract Sum for the Contractor's performance of the Contract. The Contract Sum is$36,100.00 excluding the cost of Change Orders. Page 4 of 8 Payment Schedule Payments for the work are as specified on the proposal dated 9-.18-15: 3 equal payments of$10,830.00 and a final payment of$3,610.00. If payments due to BCM Building and Remodeling, Inc. are not paid within 5 days in accordance with the payment schedule in this Contract, the Contractor will suspend work until the scheduled payment is made. If further action is needed beyond this statement, then the dispute resolution clause will be instituted unless otherwise agreed to in writing by all parties. Owner shall make progress payments on the Contract Price to the Contractor as provided below and elsewhere in the Contract Documents. $10,830.00 upon signing. $10,830.00 upon sign off of rough inspections. $10,830.00 upon substantial completion, $3,610.00 upon completion of any punch list. All payments shall be due and payable on their respective due dates, unless extended by the parties due to a Change Order or by other provision of the Contract Documents. XIII. Final inspections Upon notification by the Contractor of substantial completion of the work, Owner and the Contractor will inspect the work performed, and at that time Owner will prepare a punch list that identifies any incomplete work or deficiencies in workmanship or materials. The Owner may retain the value of the punch list work from the final payment until punch list items are complete. Completion of the punch list items must be made within 12 Business days from the date of the punch list preparation, unless otherwise noted on said punch list. When the punch list items are completed,the Owner will pay the Contractor the balance of the contract price within 5 business days. XIV. Limited Warranty Contractor guarantees the work will meet trade standards of good workmanship. Contractor will make every effort to blend existing textures, colors, and planes, but exact duplication is not guaranteed. Contractor warrants that materials of goad quality will be selected. Contractor will maintain all manufacturers' warranties only on material purchased by the Contractor. Owner is limited to the I I Page 5 of 8. manufacturers' warranties for defects in the manufacture of the materials. All Contractors' warranties are limited to a period of no more than one year from final inspection sign off. The Contractor's warranties are limited to the cost of labor and materials only, and exclude ordinary wear or tear or abuse by others. Contractor guarantees that the Work will.be constructed in a good and workmanlike manner and it will guarantee the Work against defects in workmanship and materials for a period of one (1)year from the date of its completion. Warranty work will be completed within 45 days from the date of receipt of written request from the Owner. Please note that this Limited Warranty specifically excludes consequential damages. The warranty is extended to the Owner. Contractor hereby passes through and assigns to the Owner any and all manufacturers'warranties on all materials and equipment supplied by Contractor in the project. Contractor specifically does not assume responsibility for an of the following items each of which is p Y Y g , specifically excluded from this Limited Warranty: 1. Defects in materials are covered by the manufacturers' warranties which are hereby assigned directly to the Owner. Each manufacturer's warranty claim procedure must be followed where a defect appears in any of those items. 2. 'Damage due to ordinary wear and tear,abusive use, misuse, or lack of proper maintenance of the project location or its component parts or systems. 3. Defects which are not caused by the negligence of Contractor and or its subcontractors, but the result of characteristics common to the materials used such as but not limited to; a) warping or deflection of wood; b) fading, chalking and checking of paint or stain due to sunlight; c) cracks in concrete due to drying and curing of concrete plaster, brick or masonry; and d) Drying, shrinking and cracking of caulking and weather stripping. e) Where Contractor's work involves the matching of existing finishes or materials, Contractor will use his best efforts to match existing finishes and materials. However, Contractor does not guarantee an exact match due to such factors as discoloration due to the aging process, difference in dye lots, and difficulty of exactly matching certain finishes, colors;and planes. 4. Defects in items installed by the Owner or anyone other than the Contractor or its subcontractors at Contractor's order. S. Work done by the Owner or anyone other than the Contractor or its subcontractors at Contractor's order. 6. Defects in items supplied by the Owner. 7. Loss or injury due to the elements not caused by the negligence of Contractor and its subcontractors. 8. Conditions not caused by Contractor and or its subcontractors resulting from condensation on, or contraction of materials. 9. Paint applied over newly plastered walls unless applied by the Contractor or its subcontractors. Page 6 of 8 10. Consequential damages. All implied warranties including, but not limited to, warranties of merchantability and fitness for a particular purpose, are limited to the one{1)year warranty period as set forth above. This Limited Warranty is the only expressed warranty given. In the event that any of the provisions of the Limited Warranty shall be held invalid, the remainder of the provisions of the Limited Warranty shall remain in full force and effect. XV. Dispute Resolution The parties will cooperate with each other to resolve conflicts informally. In the event that this is not possible, all claims and disputes arising under or relating to this Agreement are to be settled by binding arbitration in the state where the project is located or another location mutually agreeable to the parties. The arbitration shall be conducted on a confidential basis pursuant to the Commercial Arbitration Rules of the American Arbitration Association. Any decision or award as a result of any such arbitration proceeding shall be in writing and shall provide an explanation for all conclusions of law and fact and shall include the assessment of costs, expenses, and reasonable attorneys' fees. Any such arbitration shall be conducted by an arbitrator experienced with the Construction Industry Rules of the American Arbitration Association and shall include a written record of the arbitration hearing. The parties reserve the right to object to any individual who shall be employed by or affiliated with a competing organization or entity. An award of arbitration may be confirmed in a court of competent jurisdiction. The Contractor and the Owner 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 ha ieen approved:by the Secretary of the Executive Office of Consumer Affairs and Business Wuland the c sumer shall be required to submit to such arbitration as provided in etts Gen al Laws, chapter 142A. gnatur —Contractor's Signature NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the Contractor. The Owner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Page 7 of 8 XVI. Work Performed by Owner or Owner's Separate Subcontractors Any labor or materials provided by the Owner or Owner's separate subcontractors while Contractor is still working on project must be supervised by Contractor and an overhead rate of 20%will be charged on all labor and materials;provided by Owner's or Owner's separate subcontractors. Contractor has the right to qualify and approve Owner's subcontractors and require evidence of work experience, proper licensing, and insurance. Owner may avoid paying Contractor's profit and overhead per this section, only by allowing its separate subcontractors access to the project before or after Contractor has performed all of his work unless agreed to in writing by both parties prior to start of any work by Contractor. i I i XVII. Signatures We,the undersigned, have read and understood this entire Contract, including documents which may be attached by reference. We acknowledge that these documents constitute the entire agreement between the parties. This contract is binding once signed by Contractor and the Owner Brian C. MacDonald, Contractor Date BCM Building& Remodeling, Inc. Contractor, License#55372 Home Improvement License# 129781 n Owner Date Owner Date Page 8 of 8 N)U A!([RNA(F. SCOP! IUll/UO/UUIlU/Il7l//7IIJIUIlIII//pill/GIJJIIUII/UUlIJUpll2l//JU/IIUIIUIUIUIIIUU/IUIU/IIUIIUUIIU/I/`7II//TUU/l7lll/I/UUIIUIIUIIlUUI Ex sroR r t ; r � � r (o I U I 1 II ;---- -----; - - U ami izi�ari�Jrao� r 1 r SlOkaf;f. I � ;$IORAGF. MOR I I A�Y�fS}iKfffffY •'",.��r-•.•_ •._i I I I i :IIO1zIzll I 1 - ,.•. �i rit iiil/..'ll/UI!/lIL%�%�%i�i:o3%l,:Or%/I// j I I i IINAA) I OA 11, j12Cll )6 7Q1`� If?gWN RY INN I !11!! i1i11 �!rL�n 510NS i)IMINICO f T WYNCE-RAS[-M[,,i I2f:i+JOVA iO,fv i i`.111!I mimilf!? f 1'Rp.l!Cl null!?I HAM-MI NI CONST f2UM 1ON PIAN ! I b, IHAOX I N.! )VL.WUAR A-101 NOk i,ti ANDC7 VL.1?.MA 111fA1!i / I I i The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 ` Boston,MA 02114-2017 ",yfyyt www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): ('�o�� t� ��y%, ` Address: 9/1Z, Fai rx rrs ��. 0151 d City/State/Zip:N S 5 Phone#: 7T 1 — -2.�"7 Z - 13 Z-3 Are you an employer?Check the appropriate box: Type Of project(required): 1. I am a employer with_`:`` employees(full and/or part-time).* . 7. El New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.] 3.FJI am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition 4.F]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs Thre es ub-contractors have employees and have workers'comp.insurance.$ 6. a are corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. i 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: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby certify nder t to pains d pe'nal�' of pei jury that the information provided above is true and correct. Si nature: Cj 1 )ate: 7 41> q Phone#: 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 lure, 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-ft sur6d 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.# 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 - www.mass.gov/dia i V 12P� ((.'0�I7'til9't,0)2LlICCI.GUIZ O�C%I�GA.JJA.CfICCJP�Q ffice of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR gistration: 177008 Type: xpiration: v=I0I211205 Corporation BCM BUILDING&REMODELING INC: BRIAN MACDONALD,, 26 FAIRFAX STREET .M BURLINGTON,MA 01803 Undersecretary I' I , Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor I & 2 Family License: CSFA-055372 BRIAN C MACD(,1AuD,-- 26 Fairfax Street j Burlington MA 09803 _ i N\ Expiration Commissioner 03/19/2016 I