HomeMy WebLinkAboutBuilding Permit #639 - 94 PETERS STREET 4/21/2010-3®ho 4,'� YC)6 3S"0 -0q9(
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:. 6� � I Date Received
Date Issued: V — Z( — / 0)
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One ami ry-)
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Others:
Repair, replacement
Assessory Bldg
Demolition
Other
S0 06 Well "
Wetlands F166 6180 Wi
tla
Watershed District
VVaterSewer
Ut:bk;K1F I 1UN OF WORK To BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: CV; /(,'am of,/,/
Phone:?26 (71' o?S S",6
Address: J peJ,2 IS lz-
Phone
', -�5' " 3" ,
a
'CONT-RAQT0k-
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: $ A FEE:
Check No.: 12 S� Receipt No.: C52d
NOTE: Persons contractingwith unregistered contractors do not have —
access to the guaranty fund
Plans Submitted
Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales'
Private (septic tank, etc.
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
.ti
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:
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 2010
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ - Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Building Permit Revised 2008
--,I�,;,,9dsuj buippq
c
S 36 Z Z
/g 6 / # 13OL40
IVIOI
99=1 I!WJGd J9410
99J I!WJ,9d uoilepuno4
$ 89A I!WJGd 9wejj/butpj!nj3
$ Aouedn000 jo
alempliao
IF-
U3AoaNV HIUON .10
NMOI
ale(]
'ON
UOjjBoOj
E
Q
m .
O Ju Q �.
o E c
�Q ,0 m
N y0
CD
klzvc
� m � N
.m O
CAGo
O O
O
O O
av m
® y CD m
C3
c,cr �
m ca m
cj y O p
O0Z
O .... Cf
ICJD
r Q [ '04 O C •O
v = m m� o N
a
M a
,✓/ W wit
r c
�. .y d O C Z
W
m
o
CLy
m
d
0. CS
O
x
U
=��CM.-o
m r 3
x
w
C—L
x
w
c
O
w
4�
1�
c `
O y
z
U
G
x
a
a°'
c
w
W
Cd
E:cc
W
90
U)
o
cn
Q
m .
O Ju Q �.
o E c
�Q ,0 m
N y0
CD
klzvc
� m � N
.m O
CAGo
O O
O
O O
av m
® y CD m
C3
c,cr �
m ca m
cj y O p
O0Z
O .... Cf
ICJD
r Q [ '04 O C •O
v = m m� o N
a
M a
,✓/ W wit
r c
�. .y d O C Z
W
m
o
CLy
m
d
0. CS
O
g
=��CM.-o
m r 3
z
C—L
�m
c
4�
1�
c `
O y
to CJ
.nom
E:cc
W
m c
�
S
o
Q
m .
O Ju Q �.
o E c
�Q ,0 m
N y0
CD
klzvc
� m � N
.m O
CAGo
O O
O
O O
av m
® y CD m
C3
c,cr �
m ca m
cj y O p
O0Z
O .... Cf
ICJD
r Q [ '04 O C •O
v = m m� o N
a
M a
,✓/ W wit
r c
�. .y d O C Z
W
m
o
CLy
m
d
0. CS
O
g
=��CM.-o
m r 3
z
C—L
CD
O
CD ■
L
O
V
Z v.
O y
0 C
I C C
CO2 Q -0
.CO2CD
CD
m m
0 CD
CL
CD O�
�3
CD
O O
civ o a
CL CM<
ca
cc
CL
O. O •Or
CODC Z C3
C, CO)
� C
c—
■a �
CO)
0
LLI
ch
NINEN
0
19
W
W
12
LLIW
U)
F
'aJnjonJgs u n000 04 JO!Jd paJ!n aJ Aouedn000 10 aleoyrPoo
(ApeaH a8) 00.0£$ - eel uo!loadsu!-ell
•uotpodsu! Jol pa.nnbei sJ!eiS tieJodwal
aJnpnJls 6uiAdn000 o} Joud paJmbei huedn000 Jo aleouiliaO
•alaldwoo 6u!peJ6 Joualx3
•sJnels Jellao uado ap!s6uole paJnnbaJ sl!eJpJenO
;sod llemou/glean o; pauJnjoi slteJpueH :HSINIJ
•aseq Jlels le ped •ouo0 'wgq umop s6u!lool Ja!d
•slleJ pue s}sod lle Bel
•6u!oeJq leJalel/an sisod gxg asn 'apeJ6 anoge ,g JanO
Jaluao uo „g coeds xew Jalsnle8 '4614 n 9£ •u!w sl!ea
•6ul4seg ap!noJd 'asno4 o; Bel :SX03(l
•isngwoo @ pllos „g 'slulof ueop '6u!6Jed 41oowS
4s1u!d - Jagwe40 a)IowS - 6u1lood le suollOadsul
•paJ!nbei 1!wJad aleJedaS :S30V1d3Ul=l
a6eJols Jol pasn 1! mels Japun opooeii j
•sluan 96pp paJmbei pue p4os '.luau JadoJd. - sooeds ollle luau
•Joop Jo mopulm ssaJ6a t�ZxOZ u1w paJ!nbei swooJpaB
algeuedo aq 11e4s 6u!zel6 paJ!nbei jo %
•eaJe Joon to %9 of lenbe 14611 leJnleN
:aneH isnyy wooly elgel!geH AJan3 Jo eppe4oS mopu!M
sanols V seoeldeig eoueJeolo ,0. to aweJl poom u/S apooaJld
•(;,l;os u! lou) Jo!Jam of lonp lelaw 9ne4 of sue; isne4xa 41ee
(gZxgl, u!w) •ssaooe coeds ImeJO
•(anoge wooJpea4 .£/m OcXZZ •u!w) ssamv 0174V
sweaq Japun 'sAemjiels - saoueJeolo wooJpea4 NOa40
-Ole sweee/sJapeaH Jog lioddns 6u!Jeaq p!IoS
sassnJl s,71A71/sweae Jog pannbaJsuo!lelnOleO pa!;!ia0
•spue le 6uloeJq leJale71
•slallood uo!lepunol ui sep!s le coeds Jne � y
suo!lepunol le 6wJeaq aleld laals Jo Nouq p!los - siJ!O
leas II!s/m (1d 6) 9XZ-Z saleld II!S
•sl!eu Ja6ue4 /aa pel!eu AlInl - sJa6ue4 is!or
•lioddns lea4 pue sino 4olem - sJa6u!Jis nelS
•aleld of oil �sdgo aueopinH. asn pue suo!loauuo0 JadoJd apinoJd sJalleJ loot leJpa4le0
•suogOauuoo JadoJd ap!noJd - d!H 19 a6p!lr
•sllem le 6uueaq plem - sJalleJ AelleA pue d!H
-%no Jane, le 6u!Jeaq Ilnl ap!noJd of o6pp az!S
•suo!plied 6ulJeaq Jaluao pue sJauJoo aoeJgpu!M
•sisfimiis J!els le slleM
•ola 'oala 'lea4 '6ulgwnid Jo} suo!leJlauad
is!of Joog uaaNeq saleld/siJ!6 JOAO - NoolgaJ! j :3WVad
'Wipouuo0 lallno pue Janoopollij ougel/auols/ad!d - uieJp uo!lepunod
6ugooJdweQ
sdeils Jo siloq Jo40uV
pej!nbei se Jegaa :NOI1VGNf10d
suwnloo Jo!Jalui Jog s6wlool cluls snonu!luo0
AemAe>l tixZ link snonu!luo0 :SJNIlOOd
•leu! j 'uollelnsui `aweJd 'uo!lepunod '6u!lood ' uo!leneox3 (wnw!u!w) :SN01103dSN1
suoipadsui ou JO 010 AdOO) Iffi l3d (INV 'SS3Haav 'Stl3GvynN 107111V 1SOd
M013EI SIN311 01 4311W171 ION -ISlIN03HO/S31ON JNIOline 71VU3N3J
o
R
n
SIII
>,
L
y
�
v
a
a
u
N
�I;
J
;J) W
p
04
O
00
�
Z
U
0,
UJ
N a
r ,n, i°
-
W
i E
w,.
�n H
�!
�o
o
#
�.
r «
O
W gyp...
w O
u
11J
w
W 2 LL
p
=o
02
W O
o
oQ�gLU
rn
Q
P=m=
V o
W w
Z 0
N Q
n
SIII
N
�I;
J
;J) W
p
04
O
00
a
0,
c L
O
.� (a
o
#
r <, o.
D
o
. o
rn
o
rn
Q
V o
W w
i
Lci'
MO
J�
i.
a
ZQit v
=
w
r•.
7) 't
U�
r1icnfli- 17RAZO
UINI I C
ACORDTM CERTIFICATE OF LIABILITY INSURANCE
LTR
INSRE
0DATE 8/12/09D)
PRODUCER
Herlihy Insurance Agency, Inc.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
51 Pullman Street
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Worcester, MA 01606
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE a OCCUR
508 756-5159
04/15/09
04/15/10
INSURERS AFFORDING COVERAGE NAIC #
INSURED
United Painting Company, Inc.
INSURER A: Acadia Insurance Company
INSURER B:
200 Butterfield Drive, Unit I
INSURER C:
Ashland, MA 01721
INSURER D:
INSURER E:
rnvGoer_ce
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TWADM
LTR
INSRE
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE MMIDDIYY
POLICY EXPIRATION
DATE (MMIDDfYYI
LIMITS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE a OCCUR
CPA011338715
04/15/09
04/15/10
EACH OCCURRENCE $1 OOO OOO
PREMISES RfEa RENTED $250,000
MED EXP (Any one person) $5,000
PERSONAL & ADV INJURY $1.000,000
GENERAL AGGREGATE $2 OOO 000
GEN'L AGGREGATE LIMIT APPLIES PER: PROF�
POLICY EC
J ECT LOC
PRODUCTS - COMP/OP AGG. s2,000,000
A
AUTOMOBILE
LIABILITY
ANY AUTO
MAA011338815
04/15/09
04/15/10
COMBINED SINGLE LIMIT
(Ea accident) $1,000,000
ALL OWNED AUTOS
X
SCHEDULED AUTOS
BODILY INJURY
(Per person) $
X
HIRED AUTOS
X
NON -OWNED AUTOS
BODILY INJURY
(Per accident) $
n2rive
Other Car
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
ANY AUTO
AUTO ONLY - EA ACCIDENT $
A
EXCESS/UMBRELLA LIABILITY
X OCCUR FICLAIMS MADE
CUA011339114
04/15/09
04/15/10
OTHER THAN EA ACC $
AUTO ONLY:
qGG $
EACH OCCURRENCE s4,000,000
AGGREGATE s41000,000
DEDUCTIBLE
X RETENTION $ O
$
A WORKERS COMPENSATION AND WCA026478911
EMPLOYERS' LIABILITY
08/15/09 08/15/10 X WC STATU- 0,
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
E.L. EACH ACCIDENT $500,000
If yes, describe under
E.L. DISEASE - EA EMPLOYEE $500,000
SPECIAL PROVISIONS below
OTHER
E.L. DISEASE -POLICY LIMIT $SOO,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
United Painting Company, Inc.
United Painting Company, Inc. dba United Home Experts
CERTIFICATE HOLDER
CANCELLATION
United Painting Company, Inc.
200 Butterfield Drive, Unit 1
Ashland, MA 01721
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 0_ DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
ACORD 25 (2001/08) 1 of 2 #S38752/M38751
REPRESENTATIVE
e
RLK 0 ACORD CORPORATION 1988
x
w
O
o
co
o
w2
cn
a'
cn
Uv
�
z
A
Or.
LV
w°
U
w
0
0.
®
w
a
W
a
W
W
a
cn
_ro.
w
a
p°G
co
w
W
a
a
a
w
rA
2
cn
v
D
o
cn
{ c� i : h r -
%�a y a
i o m c
CD 20
QV �W l m
f a Q y e: 0 O
O CD
10.
`N10� AQP v p
r �
c
CD vi No
14 a
y■■�
3
O N
CO
y
m o
y A o
:29 H
nc.3 m
o cm
o w
Po m
.� C3 = Z c
eo?
ocm
CL. o
c
_ ® CD
:coo N
0
co
N •dam C LaiZ
m •E
CJ..oo
LU ICL�o�o�6 a
00 a zCLS 11,
g
z
0
U
az
7
4
O
co ■
L
O
Z °D
d
O y
� C
CO2'O cm
Q
O
�LA co
m m
a) O.CD
CD
tv �
O 0 O
L
Q�a
c
eA
cc
COQ
O■, O ♦O■,
C Z CD
V CO)CL
O C
cc _.
h
LLI
N
uj
U)
19
W
cz
ujW
N
05
®
o
�c v
W
C y
con
.a' c
Cgo
WONE
R R • (Q
c
't
o o
S
�
o CD
o
{ c� i : h r -
%�a y a
i o m c
CD 20
QV �W l m
f a Q y e: 0 O
O CD
10.
`N10� AQP v p
r �
c
CD vi No
14 a
y■■�
3
O N
CO
y
m o
y A o
:29 H
nc.3 m
o cm
o w
Po m
.� C3 = Z c
eo?
ocm
CL. o
c
_ ® CD
:coo N
0
co
N •dam C LaiZ
m •E
CJ..oo
LU ICL�o�o�6 a
00 a zCLS 11,
g
z
0
U
az
7
4
O
co ■
L
O
Z °D
d
O y
� C
CO2'O cm
Q
O
�LA co
m m
a) O.CD
CD
tv �
O 0 O
L
Q�a
c
eA
cc
COQ
O■, O ♦O■,
C Z CD
V CO)CL
O C
cc _.
h
LLI
N
uj
U)
19
W
cz
ujW
N
requtred ]
aIicznt that chi bo�.41 must »t.3Q fill out the secdon beiov shorti .
a I30meowners who submit this affidavit indicating they are do' a., work and their W06 -•s' oora _sa'roc Y "c, � "ho'u
�� ulme of t outside contractors must submit a new affidavit indicating such.
`+Contracton; that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' come,Pouc3' information.
I am an employer that is providing workers' compensation insurance Y e or m
information. ,t f - . . mPLOYeM Below is the policy. and job site
Insurance Company Name
Policy #. or Self:ms Lic:
Expiration Date:;
-Job Site Address:
Attach a,rP:
copy of the workers' compensation policy declaration age sho City/State/Zip:
p s ( wing 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
fine up to $1,500:00 and/or one-year imprisonment, as well as civil P criminal penalties of a
of up to $250:00 a day against the violator. Be advised that a co penalties in the form of a STOP WORK ORDER and a fine
Investigations of the DIA for insurance coverage verification. PY of statement may be- forwarded to the Office of
I do hereby cer4ify under the pains and penalties ofPcriury that the information. provided above is true and correct.
i
Si afore:
- A -
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Iss
Permit/License #
A
►ung uthor-nty (circle one):
1. Board of Health 2. Building Department 3. City/Town CIerk
6. Other
Contact Person:
4. Electrical Inspector 5. PIumbing Inspector
Phone fir:
The Commonwealth of Massachusetts
Department o f £ndustrial Accidents
Office of£nvestigations
600 Washington Street
Boston, MA 02111
www.m4fzss9or1&a
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrici
Applicant Infomation
ans/Plumbe rs
Please Print Leaibl
Name (Business/Organization/lndividual):
Address:
,
City/State/Zip:
Phone
#:.
an employer? Check the appropriate boa;
Arl
1 • m a employer with
4. ❑ I am a general contractor and
pe of project (required):
employees( p ) *
full and/or. art -trine ,
2. ❑ I am a sole
have hired the sub=contractors
Nevv c
❑ onstruction.
F7.
proprietor or partner-
ship and have no employees
listed on the attached sheet t
These sub -contractors have
❑ Remodeling
working . for me in any capacity,
[No workers' com .
p insurance
workers com . insurance.8
� P
5. ❑ We are a corporation and its
• ❑ Demolition
9. ❑ Building addition
3: ❑required.]`'
I am a homeowner doing all
officers have exercised their
10 ❑ Electrical repairs or additions
work
myself. [No workers' comp.
right of exemption per MGL
C. 152, § 1'( ), 4 , and have
11.❑Plumbing repairs or additions
insurance re uired t
4 ]
no
employees. [No workers,
112.[] Roof repairs .
comp. insuz-once
13.7 Other
requtred ]
aIicznt that chi bo�.41 must »t.3Q fill out the secdon beiov shorti .
a I30meowners who submit this affidavit indicating they are do' a., work and their W06 -•s' oora _sa'roc Y "c, � "ho'u
�� ulme of t outside contractors must submit a new affidavit indicating such.
`+Contracton; that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' come,Pouc3' information.
I am an employer that is providing workers' compensation insurance Y e or m
information. ,t f - . . mPLOYeM Below is the policy. and job site
Insurance Company Name
Policy #. or Self:ms Lic:
Expiration Date:;
-Job Site Address:
Attach a,rP:
copy of the workers' compensation policy declaration age sho City/State/Zip:
p s ( wing 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
fine up to $1,500:00 and/or one-year imprisonment, as well as civil P criminal penalties of a
of up to $250:00 a day against the violator. Be advised that a co penalties in the form of a STOP WORK ORDER and a fine
Investigations of the DIA for insurance coverage verification. PY of statement may be- forwarded to the Office of
I do hereby cer4ify under the pains and penalties ofPcriury that the information. provided above is true and correct.
i
Si afore:
- A -
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Iss
Permit/License #
A
►ung uthor-nty (circle one):
1. Board of Health 2. Building Department 3. City/Town CIerk
6. Other
Contact Person:
4. Electrical Inspector 5. PIumbing Inspector
Phone fir:
Information an- d Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute an employee "
p ogee is defined as ...every person in the service of another under
any contract of him,
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 ox- other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartm..ents and who resides therein, or the occupant of the
dwelling house of another who employs persons to do mainte3aance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of suchemployment 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 orpermit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of co:antpliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the'eommonwealth nor any of its political subdivisions shall'
enter into any contract for the. performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants ;
Please fill out. the workers' compensation affidavit completely, by checking the boxes that apply to.your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability partnerships (LLP) with no employees other than the
members or partners,are not required to carry workers' compensation inaurance. If an LLC or LLP does have
employees, a policy is required Be advised that this affidavit may submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. .Also be swre to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the perit or ficense is being r eauestz d, aeQt the .TJepartment. of
Industrial Accidents. Should -you have any questions regarditxg the law or if you are required to obtain a workers'
compensation policy, please call the Department at the .numbmr listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Imvestigations 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 penrnits 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 bum leaves etc.) said person is NOT required to complete this affidavit
The Office of Investigations would Ifice to than you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address, telephoneandhx.numbez_. _._ .
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of lav-estibaiions
600 Washington Street
Boston, MA 02111.
Tel. # 617-72.7-4900 enxt 406 or 1-877-MASSAFE
Revised 5-26-05
Fu: 4 617-72.7-7749
m Vrm,-mass..°ov/dla
Massachusetts Home Improvement Sample Contract
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 617-973-8797 or 1488-283-3757.
Homeowner Information Contractor Information
W Illicern _ lL:r,fa_E_
Name
ompany Mae
Street Ad ass (do not use a Post Office Box address)
Contractor/ Salesperson/ OwnerQName '
Cityown State Zip Code
usmess Address (must incluse a street address)
01221
Daytime Phone Evening Phone
.ityfrown State Zip Code
S:oaV
Mailing Address (]t different from above)
Business Phone - ederal Employer ID or S.S. Number
•
taw requires that most home im- Home haproverneat Contractor Reg. NumberExpiration
date
. '
pmvemeot contractors have a
-
The Contractor agrees to do the following work for the Homeo
alidmgistration nmoha .y/ ✓ 0 �
Her: /s rr
I
Me worg o
TT�t�r rrrrs�tt�rrttr-nrsr�-sato t-aEaa t
Required Permits - The following building permits are required
and will be secured by the contractor as the homeowner's agent,
(Owners who secure their own permits will be
excluded from, the Guaranty Fund provisions of
MGL chapter 142A.)
Proposed Start and Completion Schedule - The following schedule will
be adhered to unless circumstances beyond the contractor's control arise
ly
At, when contractor will begin contracted work.
� / - /%Date when contracted work will be substantially completed.
The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of:
Payrm�ents will be made according to the following schedule:
$ d G A upon signing contract (not to exceed 1/3 of the total contract price or the cost of special order items, whichever is.greater)
$9(e 3 by 6-f. /gq%U or upon completion -.of
by q / IL0 _ or upon completion of - �Ci(%
$ upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction)
The following material/equipment must be special Sto be paid for
ordered before the contracted work begins in order S _ to be paid for
to meet the completion schedule.(**)
NOTES: (•) Including all finance charges ('•) Law 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.
aaan�u u u erre con[r ci
Subcontractors - Thertontractor agrces to be solely responsible for completion of the work described regardless of the actions of any third
party(subcontractor utilized by the contractor. Tie contractor further agrees to be solely responsible for all payments to all subcontractors for
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 One Ashburton Place, Room 1301, Boston, MA 02108 or by calling 617-727-3200 or
1-800-223-0933.
• Does the contractor have insurance? Check to see that your contractor is properly insured.
• Know your rights and responsibilities. Read the Important Information on the reverse side of this 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 of business, 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 right.
DO NOT SIGN THIS CONTRACT II: THERE ARE ANY BLANK SPACESM
Two identical copies of thecontract must be completed and signed. One copy should go to. the homeowner. The other copy should be kept by the contractor.
Homeowner's Signature
2IL/ Con actor's Signature
2C)
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 ar 'tration as provided In Massachusetts General Laws, chapter 142A.
Homeowner's Snature Contractor's Signature
NOTICE: ThAig`natures 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 iby the
contractor, all goods sold in Massachusetts cavy 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 questionsiabout
your consumer/homeowner rights, contact the Consumer Information Hotline (listed below).
Execution of Contract
The contract must be executed in duplica 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 keptby 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 recission 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, e contractor may require that the balance of funds not yet due be placed in a joint escrow
the
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, ortf you wish to obtain a free copy of "A Consumer Guide to the Home Improvement Contractor
Law," contact;
Consumer Information Hotline
Office of Consumer Affairs and Business Regulation
10 Park Plaza, Room 5170, Boston, MA 02116
(617).973-8787 or 1-(888) 2833757
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
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, call:
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