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HomeMy WebLinkAboutBuilding Permit #275-15 - 99 SUGARCANE LANE 9/17/2014 BUILDING PERMIT TOWN OF NORTH ANDOVER 3? � ''`- �-�- 6 °� APPLICATION FOR PLAN EXAMINATION ee '� _ * .:`• e Permit NO: Date Received �SSACHU`��� Date Issued: I P RTANT:Applicant must complete all items on this page "` "= . -14 LCATOON Suc . r,Go.�'r� �-c��G -�; z= . PROPERTYOVI/NR � r � � 3 ,z � �.4 .� Print4.4 .., rMAPN® +U SPARC°EL . , : NIN`G ®ISTRICT _ ���Hi_st'onc District b `es� rio .�� �.. :.r2ak.r�-,esd.,...s �s....a's;.�-ams�' �i..u,.:4.:... ..�--�sr•.,.-c.�Frw�'Ly,.a3��. -cf_�-'...GP ,.�9 e �J;.m.aL� ti,�. �' : TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building 12 nefamiI Addition Two or more family Industrial Alteration No. of units: Commercial air,_Lep Iacemen Assessory Bldg Others: Demolition Other Flood lam ~ V tlan s `- `W I �w4' i Watershed® istnct . 1NateP/Sewer 3 .. 4. ,�. � �� _ .4 DESCRIPTION OF WORK TO BE PREFORMED: B.t S2xA�.nc. } `V����v E�O✓ Identification Please Type or Print Clearly) OWNER: Name: &A W, ex - Phone: 611 -9IQ-99 '7 Address: q 5 r A�AnverM 01945 C®NTRACTa®RNarne�Gx'� 5rt-.t UvINt� trn Adtlress�k rat Iii� TO�i!_/H / 57 771? - tAN11dR1` Rl� ��nJf}Rtv1ck,`i�,� � . `Supervis©r' Construct on License .:l;p Z�1J� -,��' Eg pii ®ate;--q - !Hornelmpr, ®dement License.: .t._•, 1._(�Z,11 ' �a n =Expo ®ate ., w�Jy .aS . . ARCHITECT/ENGINEER 4114 Phone: /vIAddress: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ V101 FEE: $ Check No.: C7 c� Receipt No.: 094 NOTE: Persons contracting with U� isi4contractors do not have access to the guaranty d SignafureofAgent/Ownerr ignaturefofcontraetor '`Y '' Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Taming/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 a COMMENTS I CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Clonservation Decision: Comments Water& Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIREDISR,AMENTTrempDurripsteronsiteyes � rno 450-66t4at 124 MainStreet Fre Dep ment-signature/date Me 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 i Doc.Building Permit Revised 2008 i 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location No. I Date e TOWN OF NORTH ANDOVER D e ,. Certificate of Occupancy $ Building/Frame Permit Fee s/v�' ` i� Foundation Permit Fee $ E Other Permit Fee $ TOTAL $ j f Check# 28028r Building ector NORTII Town of ndover . 0 No. i - 06 L KE h ver, Mass, CONIC Hl WICK X1,95 R�reo �PP��S U BOARD OF HEALTH Food/Kitchen LPERMIT T �' • Septic System THIS CERTIFIES THAT ........ ............................... BUILDING INSPECTOR has permission to erect .......................... buildings on ........j.. Foundation......a?�tS.. .�. .... ..� �- t Rough to be occupied as .......... *....... .................... chimney provided that the person accepting this permit shall in every respect conform to the terms oM application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final �! PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR +� • • UNLESS CONSTRUCT02 ST TS 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. Smoke Det. ' ��zulzo�y Next. Steg Living, Inc. HOME IMPROVEMENT - ' - - next step living ri Date of Contracts Friday,June 20,2014 home energy solutions 21 Drydock Avenue,2nd Floor,Boston,Massachusetts 02210 Telephone:866-867-8729•www.nextstepliving.com Customer Name:Jennifer Fiocchi Customer Street Address: 99 Sugarcane Lane City: North Andover State: MA ZIP: 01845 Site ID:A426183 Customer Preferred Phone#: b 17 c(io-9,ti 17 Customer jointly and severally agrees to purchase the products and/or services of Next Step Living,Inc.("Contractor")in accordance with the terms and conditions described on the front and reverse of this Home Improvement Agreement("Agreement')and the attached specification sheet(s).Customer hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. TOTAL COST of HOME IMPROVEMENTS: $5,701.32 TOTAL INCENTIVES applied to HOME IMPROVEMENTS: $2,600.00 CUSTOMER COST for HOME WROVEMENTS: $3,101.32 PAYMENT METHOD: (select one option) CashCredit Card DOWN PAYMENT: $100.00 Check HFinancing ADDITIONAL PAYMENT at FINAL INVOICE: $3,001.32 A credit card of E-check down payment is required at the time the home improvements are scheduled. Down payment is not to exceed 1/3 of the total cost of home improvements. Additional payment for the home improvements shall be due upon completion of the work If the final invoice is being paid by check,credit card information may still be required at the time of scheduling. Please notify the customer representative that you are paying by check and your card will not be charged unless we fail to receive payment within 5 days of invoice. Customer agrees and understands that thisgr Agreement constitutes the entire understanding between the parties,and that there are no verbal understandings changing any of the terms of this Agreement.Customer acknowledges that Customer has read this Agreement, understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. NEXT STEP LIVING,INC. Print Name Signature Date CUSTO R Print Name Sig re Date Planview Diagram Customer -110Ini Advisor Name: Address ° _ Advisor Phone #: °I 3 ' Town Ad � Any limitations to access by truck? Site ID NOTES Any work scoped outside of Best Practices?6e4 L �� 1 Approved by: tt �- 0� C 0 rA / 45 C./ett) w Z0S t'S Li - n I vew4-- (�1 lJ ti. 1 t�l �5 �L - v � -V; Planview Diagram Customer �c,Fi Advisor Name: o, Address ��` Advisor Phone #:lqlq -c77 Town N1-9 ,'0�/C� Any limitations to access by truck? Site ID NOTES Any work scoped outside of Best Practices? Approved by: 1" —7 d5 l �z Cl TERNOFAGREEMM 3. PROPOSED START DATE AND nnacs c PIONDULE - NSL wail le to the wealh ar r then a le ds beyond ata L:s cony ale time subject to the avaifabidy of subcontractors or materieb,or to delays 'f Attributable b the weather or other everts beyond NSL's control. '. 4. CONTRA OR REGISTRATI� MassachuSeftlawrequIfes home Impmvemr ntcorma*rs andsubombacf tO be registered with the Director of Home Improvems'nrt Comtaidar Registration.You may inquirebout acontractior regtsMon by writing to�icaof Consumer ARabs and 1jushr R9guPation,Tontt C Pmaa,Suite 59p0,®oston, 02195.697�Y3�l�. 5. PERMITS NSL vdii be responsible for obfainfng any new PermitsastheCusloiWsagent,Crrstorirers wiro seairetireir coir pemrils a deal writit an unMWW conlrstorwid be excluded from the Guaranty Fund provbbns ofths Home Improvement Contreclor Lawn. 6. ERF CEDFTHEWORKANDCHAN,E�, ::A '.::<•: .. . • . 6.1 NSL will frog the Work Pdorto string this Agreemant and banarribi of a copy ofAgreersentto the Customer 6.2 ThIsAgreemeanyhasupplxmnted,amanded ormod0iedaMYbythamvgraf modification of thisAgreemortshap be binding unless ft is In agresmerd otitis parties.No suppbmrt;afien�inent or 6.3.At flmes,ourweatlreri�atiori team discovers sihra6orre ink by all parties. forneskWis.such concernscanincludebuteranotIfinkedthherdlatiorr 64thecourseofthe WodcthatMicalesariskforeh laiotsa Ryconoirii' concerns.in She case of health orsetatynoems� ,Pbaily hazardous riraberbis such as mold oP risbesto§;or stnac9ural being identified,NSL MMM the right,Per WM 92 of this coirt3Gt!to_0ommunic*ifancrsrns th the Customarand haft vrodc unbT such m=ms have been addressed. 6.4 The rebates and ktceirlim aveibbia from the MW Save@ Home Ensigy Servkes Progrern and amounts due groin flys Cus(Omarare on the best eslbnals afthe stbatiumtn fie shchireby the NSL home anergy advisor.However,at limas ourweatheftft foam discovers sftuations in the home during the course of the WO*got impact the availability of rebates and inoerdf les from the Save Progrem. In such situations,NSL inti communk"ate such chaigesbSfireCu*W'h*orgair,imWOrramomdtheCusbmerwwtdbe to payfortheWA VA WA have the oplton to iamove from the Conbactthe txork elW MTM that n ead adJustment or set up a separate eomractfor performing the adjusted wiork. 6.5 NSL represents and waemmrLs to the Customer6rat(a) @)that ttre the mebriais and WOO fumMW underthis Agreement wdii be of good Quality and new, Work oil be frac tram defects,and(c)fhatthe Work will cordomrwith the description of the Work desmW In Paragraph 1. 7. INS'JRd�Iri:A%9-_1_S TION NSL represents and wrananis tD the Cusbw that lilies a valid Horrra•ititpmMmt ConWebr Regbhtior(No:162f91)and the necewrylkidiaila red by applicabie law and nomsally mgInIalned bypmdmd OOnlracbrs in NSL's field,Including,but notilift to,,Workers-Cc : "for.-alt empby�s who will Pedonn the Watt, , npinsurarroe R u sure Workwill partorrr m a good and worbrianiRce manner,and that NSL wdil repairand►apiece,at Its,own exporse,and prom* request any defect In Workmanship and maMab proves by NSL which appear up m are yearaftarcompletbn offhe Work of within any longer Period as permitted or required Ander apptiabis law,provided NSL has received final Paymentas provided herein. 9. PRE EXISTING COtdDiTIONS>L PROPER rY ParsTECTiON 9.1 NSL shall not be resportaWe forany damages sea consequence of the Work peffomred iii the home due to pre•01sting conditions.These conditions indude ares not Bmded to poorly fastened or broken drywall moisture damage non-Oode consbuciion,cracked orfraglle siding orshingles,Of pipes and9ffiftnNSL �therigPerform�htnottoWoric upon the discovery of asbesbs,mokf,or any other pobmiaf hesNh rak tc the Customer.In this®vent the Cusbnrer is responsible for romedyhaJ the at rbic sf oWn,indudiig any necessary removal of heisrdous materbis and aU bids forservkres IDdate shall be paid lmmedbtaly. Work cannot resume until remediation is ODOVIeth. 9.3 While NSL-wdl make bestetfors to protea arty pmpTty cf the Cusbrrrer,fib the Customer's nespDnsibidy to remove urprotect includhg dust Prot may,an i piD ,thdudirg the,home heel.NSL will not be res wsible for damages to or losses of any of the above mentioned property not pdortothe commerroemantofThe Work 10. • GENEi?®I PROVISIONS ntB NSL reserves the fightake the extent perm by aPPIk0bl8 law,to have,file Or maintain a macharic's or material men's lien,orto file a Police of iribntion to tail,and to take airyothetalaps to Perfect and enforce such a den,if Customerfads to pay NSL as provided herein. ,102 Thb Agreement sham construed In accordance withthe lavas Otto Cemrtorrweelth of itassachuseft.. _ 10.3 This Agreement foms the complete Ifti fed agreement between NSL and Customer.The parties represent and warrant that in exearting this Agreement,they are not relying on any rapresentadons,warranties ortarma other than as expressly Wye, hereto, This Ag supersedes all prior resmertts batrvaerrUle CustQM0r-nit Conbacloranm may not be altered mut a subsequent written agisemerd signed by bothPartin 11. ANERGY @ENEFITS The SIMM"Ufnlly Corrpariy(fie Utilftq)b entiasd to 100%ofthe energy banafls assoclatedwith all Energy Cons®roadon Nlessures,excluding the Testis of energy oostsa ft by the Custoider,but inMi g•ad rights to ad associated IME Energy,Capacity and Reserves products.NSL agr�s to Provide the Ulldly with such flirlherdocum entation as the.Utility may request to confirm the Utidty's ownership of such benefits and Produce. 92. NOTICE CONCERrvicvr�ONSORSHIP 12nespect 1 Cuto the stomerlefstanatimof ae acknowledges that NSL is not an agent;vandor oreub ver�of The Sponsoring WHY Company(the Ufidy)with with)efikiency measures.In tha event Of#19 failure of an energy conservation device to perform as expected, Customer's sole recouise is to Contractor and not to Conservation Services Group(CSG)or W the Uti . ,r�veOr work ) illy.The Utility and ha oparathg companies shat not 922 � adnatsaerreron tPre energy conservation measures installed. . Customer understands and admowiadgas that their paiticipelim in the Mw Save Home E consanted farConoa n�gySen�icres Program a Tokio and that have caor b Instal the hay y Pod coruservefkn mea 12,3 Customeragrees that 11311811 not hold CSG,ft Utidf r,their afidistes or opar�g companies liable for Condacfor s to perform ds obligations under this agresrruentforfaftureofthe erierfgyoonsentalbnmeasuiesbfun�n for any dam ptoCustorer'sPrambascaused byCmtr�Ororforanyand all darn to Property or Injury to persons roused by the energy oonsenvadoi measures. 93. LIMITED TIIV�OFFER The pikes acrdOff rs.offered in toes Contract are subject to diange Services Program oilers. in accordance with The Sponsoring utility Company A bss Save Hoare Energy 14. C0MTRACT QMM ATIDN Underbe ach&�t 1 � whkPo May bac hale 01"n dice or a branch the this P Tided You nnoo*the been se Ined WillingWilling at his wain a theft at a PofOeo or branch by ordinary no lace oft than an.UMMSS oftira cal b , y fax,orby a•�rail santor by deft-M,not lathrtlren mWn%M Of the&Wtnrsiness day f011owh4 on signing of Gris agia"WL it � I'(,P IIL�GZ I��IG�7?�Lf1ECC /LI;G . UWE Office ®f Consumer Affairs d Business(5Regulation 10 Park Plaza e Suite 5170 Boston, Massachusetts 021. 16 Home Improvement Contractor Registration Registration: 162111 Type: Supplement Card NEXT STEP LIVING INC. _ _Expiration: 1/14/2015 ROGER OUELLETTE 21 ®RY®OCK AVE. 2TH PL BOSTON, MA 02210 Update Address and return card.Mark reason for change. Sc.4, 0 20M-05);, Address 0 Renewal R Employment Lost Card ::/fr fr.rr,rucrzrr:err�/�r lir.;.;ur�lerr:;e&t 0ffece 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: 162111 Type. Office of Consumefairs and Business Regulation T 10 Park Plaza-Suite 5170 Expiration:. 1%14%2015 Supplement Card �4 Boston,AVIA 011 6 NEXT STEP LIVING INC.. 0 ROGER OUELLETTE f � 21 DRYDOCIG AVE.2TH FL BOSTON,MA 02210 " Undersecretary of valid without signature i dJ A Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor 5Perialh License: CSSL-102811 55 STANMORE�)i7vF Wandck RI 02899 Expi ration Cornmissionet- Restricted To: c5SL 0C e insulation Contractor Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license; For®PS Licensing information visit: www-Mass,GoV/DPS NEXT84 OF ID,ISS .� �►Dr��,y CERTIFICATE OF LIABILITY INSURANCE F oATEgaaelD®„ 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 ceetiRcalre holder is an ADDITIONAL INSURED,the policy(in)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 rdghM to the certificate holder in lieu of such endomeme s. PRODUCER InsuranceAgemcy Phone:71;°15 2775 828 Lynn MW, Melrose MA 02Pa y Face 78°1465-0295 fAr—NmP"O"E N®e John E.WiLaughldn Jr. 106: INSUREM)AFFORDING COVERAGE "ABC@ 0=REIRA:Nautilus Insurance INS rm Neg Step Living,Inc. wwRERs:Commerce Insurance Company 34754 Jeff Lisaacls 2I Dryd®ck Avenue,2nd Floor IweIURERc.Indian ii�larl�,Ir Insurance�®tn . 3 Boston,MA 02210 wsumD.A.I.M.MuWal Insurance Co. IMRER E' P: COVERA CERTIFICATE NUMBER-. 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. NOTWTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NTH RESPECT TO WHICH T"M CER71FICATE 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 NAME BEEN REDUCED BY PAID SMS, ROM OR rm w a9SBDRADIrCE BIaHrffi GENERAL LIABILM, EACHOCCURRENCE $ �, a A X COMmERCIALG�ENERALUABILITY BOUND ��Bd I9i°� ON301`4 IBES Oe�glBitrs � �c a CLAIMS-MADEFM OCCUR NED EXP(ArM omFAD $ 10,0 PERSONAL&ADV INJURY $ `I,01110,00 GENCRAL AGGREGATE GENIL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMMOP AGOPRO POLICY = LOC S AUTOMOBILE LIAMOLM, Ea LEU IT ANY AUTO BOUND d101w m1114 SCDILYINJURY(Perpeml � ��D AUTO�® BODILY INJURY(Perecalerd) $ X IIIR€DAUTOS N VNED parr vDa GE — c X UMBRELLA LAB OCCUR EACH OCCURRENCE C EMESSoIM CLAIMS-LADE BOUND me`Iinj 13011 AGGREGATE $ = I x IRETENTION $ t COMPENSATION I!�STATU ANDIPL UAB O YON ® ANY F DFRIETCRlPA13gNERiE2(CCUME ®AWC702515M2012 1i�i a`I°im w30,44 E.L.EACH ACCIDENT � Skim— MIA OFFICERWEMBEREJSCLUDED? on Rai) E.L.DISEASE-EA EMPLOYES $ elIMI, Ryye Cloacae a r DESL�RIFTI F PE TIONS E.L.DISEASE-POLICY LIMIT $ 5K E Mobil Float ®®111,111,1111121"03 111110a3 11/11014 90MR so, E Lossed Equipment R00081,1UNWIl 11011013 110110'64 limit 1�,® oPoFERAeao��sTalDaseeVE�a,EsgAa�I�es. `a®a,Alas�eAsa� e�nas�a� g CERTIFICATE HOLDER CANCELLATION INFO-01 —ANSHOULD Y OF THE ABOVE DRSCRRWED POLICIES BE CANCELLED BEFORE For Ieaf®rmaatl®ra Only A CDATE HE Nel BE I�E� IN NHOMS A 0 REPRESWA71W ®INS-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010005) The ACORD mane and logo are registered marks of ACORD Departreent of Industriaf Accidents Office of Investigations I Congress Street, Suites 100 V J� Boston,MA 02114-2017 wB2yw massog®vldia Workers' Compensation Insurance Affidavit.-davit.- Bunlder s/Co ntractors/Electnlelans/Plii nbers ILI Neer Step Living Address: 21 DyDock Ave City/State/Zip_Boston, MA 02210_ phone#o (866)867-8729 Are your an employen°? Check the appir®prlate.lbom. Type® project Qrealnrire�lD: 1.N 1I am a employer with 750 4. ® 1 am general contractor and 1 _ employees (full and/or part-time).* have hired the sub-contractors 6. El New construction 2.El 1 am a sole proprietor or partner- listed on the attached sheet. 7. E]Remodeling ship and have no employees These sub-contractors have 8. []Demolition working for me in any capacity. employees and have workers' coo insunrance. 9° ®Bunilding addition [110 workers' comp. insurance lD° � required.] 5• ® We are a corporation and its 1®.0 Electrical repairs or additions 3.® 1 anis a homeowner doing all work officers have exercised their 11.E]Plumbing repairs or additions myself ilio workers' comp. right of exemption per MGL 12.E]Roof repairs insurance required.] f c. 152, §1(4),and we have no employees. [No workers' 13.a Other lnsulation comp. insurance required.] xray applseant that checks bo<,l-1 must also fill oast the section below showing their workers'compensation policy information. Homeowners who submit S:his affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. , fi,r,i.'(,.E ::•. employees. if the sub-contractors have employees,they mai3t provide their workers'comp.policy number. lain an employer ithag ispropiding workers'coo peaasmadom nnswr ancefor myy employees. Bellow us She pv®li Y mlRdjo5,()lE'e aaa,�®rr�ml�s®uao Insurance Company Name. AIM Mutual lnsurance Cowpony Policy/f or Self-ins. lLic. AWC70251530120 2 ]Expiration Date: 09/30/14 Job Site Address: City/State/Zip: _ Attach a copy of the workers' compensation p®iley&ccllar°atiOrn page(shoa rani g the policy number and expuraflonn date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the foram 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 fTnmarded to the Office of Investigations of the DIA for insurance cove�a e verification. do hereby c¢nfi��air m7¢a° baa , e mslaa�s of�a�n�a��y9�lamap�6a�lna�cmn°uaama dnu�u u al�mZ mil�an Bs�u^aj�maaaal sena°u°ice Si , ture: '' :,fir., ' `�` Date:. Phone OffMaml/rise only. Do mob wr ige in this area,to be completed by elapy or i•or"a o acdmrL -- _- ---- Duty®r'Town. Permitil/ILucegase 0 lssuning,Authority(circue Orae)- A.Board of Health 2.BrrUffiRS Deperrtrmemt 3°City,/Town CReryk 4.EIectlEdcal fnspectorr S.?Run,MIME;lmispectwr 6.Other°