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HomeMy WebLinkAboutBuilding Permit #577-14 - 97 LOST POND LANE 2/5/2014 TOWN OF NORTH ANDOVER �APPLICATION FOR PLAN EXAMINATION Permit N0: 1 \ Date Received Date Issued: I PORTANT:Applicant must complete all items on this page = LOCATION. - _- nn Print PROPERTY OWNER Print 100`Yea Old Structure yes no - MAP NO:Ibq 6 PARCEL;.ZONING DISTRICT: Historic District ye no :Machine Shop Village ye_ no .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 ri Septjc ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District. 1JWater/Sewer /?)E§C�IPTION OF WORK TO BE PERFORMED. Identific tion Please Type or Print Clearly) OWNER: Name: (9 .�'ti r�-���r s5 e Phone: 9�� �-?o�3 Address: CONTRACTOR' Name:._. inr��._, r fir(' Rhone: ? � 7"_- Y 1 Address: Sup.ervisofis�Constructlon.License: -.. __-_- 'Exp Date: Home Improvement License: _ __ _ _ . _._ Exp. Date_ 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: $ oy FEE: $ 2i!� Check No.: �� Receipt No.: Qcl�+ C)� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Slgnatureof=Agent/Owner _ _ T._ Sigature,of contractor Plans Submitted E Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ f a Building Department --The fol;1wing is=a=list of the required-forms to be filled out for the.appropriate.permit to`be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Btaildin Permit Application g ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L.- Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o 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 cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apnaal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Builling permit Revised 2012 Plans Submitted ❑ Plans Waived"❑ .Certified Plot Plan ❑ Stamped Plans ❑ TYPEOF-.SEWEIZAGED3SPO.SAL Public Sewer ❑ Tanning/Massage/BodyArt ❑. . _Swimming Pools ❑ well ❑ Tobacco.Sales ❑ Food Packaging/Sales ❑. -Private(septic tank,etc... ❑ -Permanent Dempster on Site ❑ THE.FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM - -::-,DATE REJECTED DATE:APPR-OVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS .CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature b COMMr;NTS L- Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comments Conservation Decision: Comments Nater & Sewer Connection/Signature& Date Driveway Permit DPW To`vo Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMEN' . -"Temp Dump`ster on site .yes no Located at 124 Ma Street = Fire"Departmeit�signature/date '~� "' ^`' - ' �`°'•` �f '' � `' ' �` ';'' - '' '' ''• g 15 COMMENTS '� , . � " . . • - . • ,.. . , b. a_,- , ; I, + Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ C _ :Total land-area, sq. ft.: ELECTRICAL: Movement of Meter.location, mast or service drop requires approval of Electrical Inspector Yes No DANGER.Z®NE LITERATURE: Yes No MGL-Chapter-166 Section 21A-F and G min.$10041000.fine +I NOTES and DATA— For department use El Notified for pickup - Date Doc.Building Permit Revised 2010 Location Date �:1 TOWN OF NORTH ANDOVER D P Certificate of Occupancy $_� << Building/Frame Permit Fee $ � Foundation Permit Fee $ "*1 Other Permit Fee $ ` TOTAL $ Check# 27275 Building Inspector Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost MOWN m $ - $ 960.00 Plumbing Fee $ 120.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 120.00 Total fees collected $ 1,300.00 97 Lost Pond Lane 577-14 on 2/5/2014 Kitchen Remodel ........................... .................. .. .....__ _ Ill 1Y E , _._........... : ts( i�fE. 3 �1 a , t i( _ .. _.._.. M. k .. iri4.. ,.... �--'�---_.^--._^ I Sr_ ;•—r - ,... . a :.E =.a 1 gqp i i ID l_ 1 g'' j E 4,)it3f_:t\ALCONTKAC:Cl OCI;4IL;1 Cl.3T<3 EP DATE Note:This drativing is an artistic Designed: 16/5/2Q13I interpretation of the general (' Printed: 10/17/2013 appearance of the design.. It is v not meant to be an exact rendition. i � r E' ?Daubresse corner pantry_kit �A11 drav4in #: 1 Tiny 'N nn ent Sai. ' e �[ Co1mtzriet This forst Satisfies all basic requirements of the state's Language to protect homeowners. Seely Home Improvement Contractor Law(MGL chapter 142A),but does not Include Iegal advice if necessary. Any person planning home irapxovements shouldirstobtain a copy oA standard Massachusetts Consumer Gilide to Home Improvement"before agreeingto any worlc on your residence.Xou may obtain a ixee copyby cahhing•the OfEtce of ConsumerAffairs and Business Regulation's Consumer Infor mationHothine at 6.17-973-8787 or 1-888-283-3757 or on ourwebsite. Homeowner hfo>rma.><,no>l> 'Corl.t)NaCtOS')Cnf6JI'J110:�.'�'Jt01]• Nam p Company Name Street.A•ddresso not use ost Office B )ox address n � Contr for/Salesperson/OwnerName I o . -y/Town L-p� State �GWL45 Zip Coodde Business Address(must includ�e.a s%eet address) D'aytimePhone BveningPhone City/Town /r� Zip Code Mailing Address(It different from above) 6q/ siness Phone I~ederal>;mpIoyerIDNumber Homeimprovement'Contmctorlteg:Number 2xpiradondate • xaw imp rovemregnientres tflntmostlmme contractors itave n va]id registration nttmTtcr The Contractor agrees to do the following work for the Homeowner: (Descn'be in detaiithe worltto completed,specii�dngthe ,brand, Land d grade of materials to be/used use additional sheets ii'necessa ,) �!/� (.✓�.--wC.d w �., (�--U ��TG`t^.�-r. .e�.t—rJQ I'i2-�Y✓/ _ /�{,c.J /V�r�_�'z�f/'�(,.oc�• ��.�.•- f ��-g�.r /tri C-r;�l`.�v`3 .ti`e-�-� �Z-ta=...t:... Required Permits .The foliowingbuildiagpermits are xequired Proposed Start and Completion:Schedule-The following schedule . and will be secured by the contractor as-the h.omeow.ner's agent: be adhered to unless circumstances beyond,the contxactofs control arise (Owners who secure their o-Wnn per wits wi]X Me e�eluded fxon� the GU' MGL P rOVisions of �J G L chapter 142A.) Data when contractor will begin contracted worlc. �L/�/Ylxte when contracted work will be substantially completed, Tat al ContractPrice and Pa'Ment Schedule p The Contractor agrees to perform•the worts,furnish the material and labor specM-ed above for the total sum of- Payments WM bemade according to the following schedule: (�) $ � upon signing contract(not to exceed 1/3'of the total,contract price or the cost of special order items,whichever $-167,`)&z' by ! / !� orupon completion of ��--s °4-r e- w >s gleatex) jD r6Z+-7 by 3 l !� Y er upon completion of $ 7 upon,completion of the contract, (Law forbids demanding full payment until contract is The Completed both parVs satisfaction) . followingu�afierial/equipmentmustbespecial � /L,n-�• • orderedbefore the contracted work begins in order -- to be paid for to meetthe completion schedule.(°r°) to be paid for • I'T®TLS;("`)Including all ftnance charges a::r. requires . not exceed the greater of(a)one-third ofthe totalthat contract ri a or(b)the ctual costo any spec al equ pmeut ohe contractor b or custommades may 'which must be special ordered in advauce to meet the completion schedule. material Bx ress Warran -Is an e, resswarrant bein rovided b the contractor. .SubcontractorstYlsora ••'rhe contractor agrees to be solelyresponsiblefor completion of the woxlc described regardless ofthe actions o 1Vo J.❑•'Yes all terms o�the warran mast be attached•Eo the contract partylsubcontractorutilized7iythe contractor, Tie contractor�eragreestobesheWor desciedrega a fanyt Td materials and abor under this a Bement p Payments to an subcontractors for ConL'actSAccep�t mPlythatMYlienothis rsecurntbecomesabiudingconfractMUMlaw. Unless Otherwisenotedwithinthisdocumen e ' contract shall net i ring ibis wp lien or other security interest has been,placed on the residence. Review the followin cautions carefully before signing this contract, t'�• g ns and notices ° Don't be pressured into signing the contract.Take time to read and fully understand it. Aslt questions if something is ° Make sure the contractor has a valid Tome Tin rove>yent COritr trfnr R pm ,-+ unclear,• subcontractors to be registered vdth the Director of23ome Improvement Contractor Re The law requires most home improvement contractors and registration bywrildngto the Director at 10 Parlcl'Iaza,Room 5170,Boston,MA.02716 or by calliug,61�973 87e o t contractor . Registration. You may inqui about contractor c Does the contractor have insuxanee? see a co of a" „ Aslcthe Contractor fox Iris insurance company information so that you can,conf*m coverage,or ask to XnOWPY pxoofofinsurance document. ° Guide t oth rights and xespon erri tines. Read the Important Information on.the reverse side of this form,and get a copy ofthe Consumer Guide to the rTome Impxovemenh:Contractor Law: c oumay eaneeithis at his signed ataplaee otherthauthe contractor's nontnalplace ofbusiuess,pro third contractor in writing at his/ier main ofdice or branch office by ordinary mail Posted,b tele third business day followin the si gr p you nmid the g going ofthis agreement. Seethe attached notic of by n deli� Iaroationtofthisanlight. t ofttZa ®lT�T' x�fil '7[' ]fS C®NT.tACT IF TDEJE Two identical copies ofthe contractmust be completed and signed, One CApy should go to t1m ho�mepwn�er &ep $ ` T T T 5 onU tlto contractor. tato . Contractor's Si' Date Colmi ractor Arbi ref ion The Home Inpa:ovement Contractor Law provides homeowners with tTae right to initiate an arbitration action as an 'alternative to co'ut action)if they have a dispute with a contractor. The same right-'snot automatically afforded to a contractor,however, The contractor would have to resolve any dispute he/she has With a hoxueowner.in,eo•arE unless both pari ies agree to the®ptianal clause provided below. This clause*O-ad give the contractor the same ri htt arbitration as is worded to the homeovw.n,er by1a exome improvement Contractor Law. g The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute conee T g s contract;the contractor may subxnitthe dispute to a private arbitration: j;which has been approved b the Secretary of the Executive Office of Consumer Affairs and Business RegLaatjon and the cons has=er shall be required to submit tosuo bitratio;n as•provided Tn Massachusetts General.Laws, chapter 14.2.&,• � Homeowner's SagaatLue ®TIContractor' Signature The signatures ofthe parties above apply only-to the agreement of the pardes to alternative dispute resolution initiated by the contractor: The homeowner may initiate alteinative dispZ•Lte resolution even where this section is not separately signed by the parues. Ehomeowner's Rights A hom:eowner's rights under the Home Iia provement Contractor Law(MGL chapter 14.2A) 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 root properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excht.ded`h;om OZ Guaranty Fund provisions of the Rome Improvement Contractor-Law. The contractor is responsible for completing the work as described,in a timely and worlcmanlilce mimer, Homeowners maybe entitled to other specific legal rights if the contractor guarantees or provides an express warranty for worlanansEi .%or materials, In addition to antees Or Warranties providedbythe contractor, all goods sold-in Massachusetts carry an implied,warranty 01finerchanta:bility and fitness for a pai[icadded the purpose. the enrimcontract as n n other matters onwhich the homeowner and contractor lawfully agree maybe added to the terms of the contract as long as'they do not restrict a homeowner's basic consumer rights, 7f you have questions about your eonsumer/homeowaer rights, contact the Consumer 7uform.ation Hotline(listed below). Execution of Contract; The contract must be executed in du licate 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 maxlced as void,deleted, or not applicable., One original signed copy of the contract with attachments zs to be gi�ten to the owner and the other kept by the contractor. Any modification to the,original contract must be in writing and agreed to by both parities. Contracted wOrlc may not begin until both pardes have received a fully executed copy of -the contract,and the three day rescission period has expired. .A.ccelefrateci J?ayments A contractor may not demand payments in advance oftb e dates specified on the a hoaneowner deems him/herself to be anancially insecure, However,in instances Where a contxac o deems azt schedule in cases hihim/hexsehf to be financially insecure,the contractor may require that the balance of funds not yet due be'laced in a j oint escrow signatmes of both parties. account as a prerequisite to continuing the contracted work. Withdrawal of=ds Crow said aecoi t would require the Additional Wormation If you have general questions or need additional in_oriroation about the Home ltnprovemeat Contractor Law or other consluuer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home l pf ovement" contact: Consumer information Hotline Office of Consumer Affairs and Business Regalation 10 PadcPlazai�ROOM 617-973-8787, 888-283-3757 or"visittthe OCABR•w byte aA 021 16c v _ mass:gov/ocabj If you want to verify the registration of a contract about the contractor registration compor or iFyou have questions or need additional idormalion specificall onent of the Home lmprovement Contractor Law, contact: y Director of Home Improvement Contractor Registration Office of Consumer Affairs and-Business Regulation lb Room 5170,BostonM& 617-973-8787, 888 283 3757 ora s ttheEUC website, att 02126 __-'�.1�•//Vi�VJGV1?12SS �'OV/OCa'bTI Go ardine to view the status of a Home Mmprovemelt Contractor's Registration: , htt7x//db.state•�ala>.2G/11o7neimtrovelr�ent/licenseelist.as , For assistance with informal mediation of disputes or to regi.sler formal complaints agairost a business call: �,. ,. Consumer Complaint Section OMce Of the Attoiney General 617-727-8400 AND/OR Better Business Bureau 508-6S2-4800,508-77:55-2548 or413-734-3114. Andover O `..y." �.4 •� 0 No. h , ver, Mass, 1 COC MIC„lWICK U BOARD OF HEALTH PE R T Food/Kitchen LD Septic System .......D THIS CERTIFIES THAT .......... . .....M. ........ !��,,, ,r � BUILDING INSPECTOR has permission to erect yid, Foundation .......................... buildings on .....�`......... . �...�j.... ....�. Rough to be occupied as .........<0.1401.w4A.... .......................ry.....pi................................................................ Chmn ey provided that the person accepting this permit shall in eve respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6THS ELECTRICAL INSPECTOR UNLESS CONSTRUCT TA Rough Service ....... ........ ......................... 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. SEE REVERSE SIDE Smoke Det. I A� CERTIFICATE OF LIABILITY INSURANCE DIDDIYYYY) 2//4/24/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONT NAME:CT Linda Gallant EA Stevens Company, Inc. PHONE(Air N, Fxti- (781)322-2324 FAX (781)397-7672 389 Main St. AIL ADDRESS:lindag@eastevensins.com P. 0. BOX 188 INSURERS AFFORDING COVERAGE NAIC# Malden MA 02148 INSURERA:Nautilus Insurance INSURED !NSURERB:Safety Indemnity Company 3618 Brian Nolan, DBA: Omni Construction Corp INSURERC: 8 Pyburn Road INSURER D: INSURER E: L nnfield MA 01940 INSURER F: COVERAGES I CERTIFICATE NUMBER:2013-2014 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I�7R TYPE OF INSURANCE DDL UBR POLICY EFF POLICY EXP POLICY NUMBER MM/DD/YYYY1 (MM/DDIYYYYJ LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 }{ COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 50,000 A CLAIMS-MADE a OCCUR NN397287 0/2/2013 0/2/2014 MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- JFCT F-1 LOC $ AUTOMOBILE LIABILITY EOMaBINEDtSINGLE LIMIT 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 054060 0/28/2013 0/28/2014 AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS N NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ Waive Collision Deductible $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION Worker's CompensationWC STATUM OTH- AND EMPLOYERS'LIABILITY LIMITS I I FR ANY PROPRIETOR/PARTNER/EXECUTIVE Y 1 N certificate to be issued E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? ❑ N I A (Mandatory In NH) directly by insurance E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below company. E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) Job location: 97 Lost Pond Lane, North Andover, MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Gary & Louse Daubresse ACCORDANCE WITH THE POLICY PROVISIONS. 97 Lost Pond Lane North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Thomas Cares, Jr/WV f/-sd•""""� ® �'ri1 �✓,. ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INSn25 oninnri n1 Tho Arnion nnma=net Innn nro roniefornrl marls of Annion The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Iudividual): Oft n . C-n^� Address: City/State/Zip: 4iY -7 Ao-U 44116 Phone#• Y y Areyouan employer?Check the appropriate box: Type of project(required): 1.[I 1 am a employer with 4. ❑ I am a general contractor and I 6. ❑Ne construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• .modeling ship and'have no employees These sub-contractors have 8. F1Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 1011 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roofrepairs insurance .re uiredemployees.[No workers' required.] 13.❑Other comp,insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i'Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. n �+ Insurance Company Name:. Policy#or Selfin.s.Lic.#: 3 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 requiredunder Section 25A of o. 152 can lead to the imposition of criminal penalties of a flue up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do Hereby cert under thepains and alt' ofperjury that the information provided above is true an�./d correct. - Sinature: Date: Phone#: Official use only. Do not write in this area,to he 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 hire,• express orimplied,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 shallnot because of such employment be deemed to be an employer." 1 s 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'com enation affidavit com letel P p y,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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their sell-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 yoli'regarding the applicant. Please be-sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one,affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in .(city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho Common�vealth of Massac hvsP�s Uopartment ofJudwWal.Accidents Office ofIuvestigaitiom 600 Washington.Street Boston}MA 02111 T01,#617-727-4900 est 406 ox 1-877 MASSAFB Revised 5-26-05 Fax#617-727-7749 www-mass.govfd s 6;�e 43) 02 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 4�. Home Improvement Contractor Registration Registration: 168261 -s Type: LLC �' -•`::f'T Expiration: 1/24/2015 Tr# 235201 PAULS HOME SERVICES LLC. _ i. - PAUL SHAPLEIGH 7 STROUT AVE. .LYNNFIELD, MA 01940 ' F 1 pdate Address and return card.Mark reason for change. - ' iCA 1 ie 20M-05/11 Address E] Renewal ❑ Employment E] Lost Card ,per ��e ipanunw�r��uP,a,C�a�C%liGaaoacfutaeL� -\ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 46 $261 Type: Office of Consumer Affairs and Business Regulation xpiration:-12412o-1;5 LLC 10 Park Plaza-Suite 5170 -;r Boston,MA 02116 'AULS HOME SERVICES-LLC- z---, 'AUL SHAPLEIGH ,:i 7 STROUT AVE. _YNNFIELD,MA 01940 Undersecretary Not valid without si4naturt Massachusetts -Qepartment of Public Safety Board of Building Regulations and ` g g Standards Construction Supervisor j License: CS-105174 PAUL S SHAPLEtdH �' { 7 STROUT AVE Uj LYNNFIELD MA 01 `. 2� Expiration Commissioner 11/20/2015