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Home My WebLink AboutMiscellaneous - 10 WALKER ROAD 4/30/2018 (9)N SENDER: I also wish to receive the ■ Complete items 1 and/or 2 for additional services. ■ Complete items 3, 4a, and 4b. f0110Win services for an g ■ Print your name and address on the reverse of this form so that we can return this extra fee): card to you. ■ Attach this form to the front of the mailpiece, or on the back if space does not 1. ❑ Addressee's Address permit. ■Write "Return Receipt Requested" on the mailpiece below the article number. 2. ❑ Restricted Delivery ■ The Return Receipt will show to whom the article was delivered and the date delivered. Consult postmaster for fee. 3. Article Addressed to: 4a. .,�ticle ,�� /�c �;�VAP V , 5 e 4b. Service Type ,,� e/(� �f1Z C (�'iLV.,9�y El Registered Bcertified /� _/ e�r �� ❑ Express Mail ❑Insured L15I / �(l �i "t [Z�-Return Receipt for Merchandise ❑ C zvf 7. Date e r 5. Received By: (Print Name) 8. Addresse 's Address (OrOf t requested and fee is paid) 6. Signat • (Addr 6. Sigor Age ' X Ps or 811, December 14'94 102595-98-B-0229 Domestic Return Receipt UNITED STATES POSTAL SERVICE First -Class Mail Postage & Fees Paid USPS Permit No. G-10 • Print your name, address, and ZIP Code in this box • KM 27 NMANMVA SENDER: ■ Complete items 1 and/or 2 for additional services. ■ Complete items 3, 4a, and 4b. ■ Print your name and address on the reverse of this form so that we can return this card to you. ■ Attach this form to the front of the mailpiece, or on the back if space does not permit. ■ Write "Return Receipt Requested" on the mailpiece below the article number. ■ The Return Receipt will show to whom the article was delivered and the date delivered. 3. Article Addressed to: 14c 9/ t11/4P6 : be4y I also wish to receive the following services (for an extra fee): 1. ❑ Addressee's Address ti 2. ❑ Restricted Delivery N Consult postmaster for fee. CL 4a. Article Number 0�4 S'c 4b. Service Type ❑ Registered ❑ Express Mail 1�leturn Receipt for 7 I c 5. Received By: (Print Name) 8. Addsess ddress (Onl) C • v i . U cland fee aid) \ 6. Signatu : (Addressee or Acrent) X PS Form 3811, Decem&W 1994 102595-9e-13-0229 Dome6tic Rei —1-010 Uk ertified ¢ ❑ Insured ❑ COD .moo w 7 0 uested Y 1 � � z UNITED STATES POSTAL SERVICE First -Class Mail Postage & Fees Paid USPS Permit No. G-10 • Print your name, address, and ZIP Code in this box • BOARD OF HEALTH 27 CHARLES STREET NORTH ANDOVER, MA 01845 Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 27 Charles Street North Andover, Massachusetts 01845 WILLIAM J. SCOTT Director (978)688-9531 LETTER OF COMPLIANCE Date: 06/03/99 TO OWNER OF RECORD Ken McGilvary, c/o Dale McGilvary Bldg. 6 Walker Road Unit 12 No. Andover, MA 01845 PROPERTY LOCATION Bldg. 10 Walker Road Unit 1 No. Andover, MA 01845 LEO Fax(978)688-9542 A Health Department ORDER LETTER dated May 3, 1999 was issued to you as owner of record of the property listed above citing violations of the State Sanitary Code, 105 CMR 410.000, Minimum Standards of Fitness for Human Habitation. A re -inspection of the property on June 2, 1999 indicated that all violations noted on the order have been corrected. A copy of this letter is being sent to the person(s) who made the complaint. If the complainant has any questions or comments concerning this determination of compliance, the Board of Health must be contacted within ten (10) days of the receipt of this letter. A Susan Y. Ford, f Health Inspector cc: Rachel Harlow & Mark Perry, Tenant Sandra Starr, Health Agent File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 NORTH ANDOVER BOARD OF HEALTH ORDER Issued under the provisions of the State Sanitary Code, Chapter II, Minimum Standards of Fitness for Human Habitation, 105 CMR 410.000. Date: May 3, 1999 TO: Property Location: Ken McGilvary, C/O Dale McGilvary Bldg. 10 Walker Rd Bldg. 6 Walker Road Unit 1 Unit 12 North Andover, MA North Andover, MA 01845 01845 An authorized inspection was made of the property at the above address by North Andover Health Department personnel on May 3,1999. This inspection revealed violations of certain regulations of the State Sanitary Code, Chapter II, as listed on the attached Violation Form. You are hereby ORDERED to correct these violations within the time allotted on the enclosed form. Failure to comply within the allotted time period may result in a criminal complaint against you in the Lawrence District Court and may result in an assessment of a fine. You have the right to request a hearing before the Board of Health if you feel this order should be modified or withdrawn. A request for said hearing must be made in writing and received by the Health Department within seven (7) days from the receipt of this order. At said hearing you will be given an opportunity to be heard and to present witness and documentary evidence as to why this order should be modified or withdrawn. All affected parties will be informed of the date, time and place of the hearing and of their right to inspect and copy all records concerning the matter to be heard. You may be represented by an attorney. You also have the right to inspect and obtain copies of all relevant records concerning the matter to be heard. Susan Ford Health Inspector VIOLATIONS TO BE CORRECTED NO LATER THAN SEVEN (7) DAYS FROM RECEIPT OF THIS ORDER LETTER: VIOLATION REGULATION REINSPECTION Living room windows/ screens - falling 410.501 out of the frame, not tight fitting, do 410.480 not lock ■ All windows must be able to be locked. All windows and screens must be fitted properly to be considered weather tight Repair or replace windows as needed Small bedroom - 410.551 screen worn and ripped ■ All screens must be in good condition Replace screen Dish machine not properly operating 410.351 ■ All owner installed equipment must be operational as its use intended. Repair or replace as needed Refrigerator - Water accumulates in 410.351 the bottom and comes out onto the floor ■ - All owner installed equipment must be operational as its use intended. Repair or replace as needed Cc: Rachel Harlow & Mark Perry, Tenant Sandra Starr, Health Agent File Date 4/16/99 Complaint Complaint# Complaintant Rachel Addresss Walker Road #10 S y. Moved into apartment condo in July. Lardlord promised he'd do some things. They are in the basement apartment. The windows won't lock, she's afraid of being robbed. She can't leave them open , they won't stay open. They have red ants, they have been bit. Action Dishwasher leaks, refrigerator is broke, they have to throw food away, etc. They have a small child. Owner of Property I They held Feb's rent, landlord mowed out of state but his daughter is taking over, she promised to fix things, she paid rent. Withheld April's rent now Owner's Address 1 Phone# OL Sent ❑ R r-- i w S P w i .., c� o y yw - �w-K t r ct `' � � ��%/1`��!/�/ILS � J�_ Y1�!Ls3/�� /�:JI�__`"—' Iii NORTH ANDOVER HEALTH DEPARTMENT 120 Main Street • North Andover, MA 01845 Telephone (508) 682-6483, Ext. 32 Housing Inspection Report COMPLAINT # J /J1J COMPLAINANT ADDRESS OF PREMISES OCCUPANT OWNER Ze,4, 111C 4 i ` OWNER'S ADDRESS x /�'>l ��-� DATE OF INSPECTION HOUR 3 R0nMS/VI0LATI0N- INSPECTOR Form #HIR -1 Action Press 6857000 Town of North Andover RTH 14, OFFICE OF �? Of 6. o0 COMMUNITY DEVELOPMENT AND SERVICES ° . 27 Charles StreetQQvP h: North Andover, Massachusetts 01845 WILLIAM J. SCOTT SSACHUSE Director (978) 688-9531 Fax (978) 688-9542 Certified #P205969487 NORTH ANDOVER BOARD OF HEALTH ORDER Issued under the provisions of the State Sanitary Code, Chapter ll, Minimum Standards of Fitness for Human Habitation, 105 CMR 410.000. Date: May 3, 1999 TO: Property Location: Ken McGilvary, C/O Dale McGilvary Bldg. 10 Walker Rd Bldg. 6 Walker Road Unit 1 Unit 12 North Andover, MA North Andover, MA 01845 01845 An authorized inspection was made of the property at the above address by North Andover Health Department personnel on May 3,1999. This inspection revealed violations of certain regulations of the State Sanitary Code, Chapter II, as listed on the attached Violation Form. You are hereby ORDERED to correct these violations within the time allotted on the enclosed form. Failure to comply within the allotted time period may result in a criminal complaint against you in the Lawrence District Court and may result in an assessment of a fine. You have the right to request a hearing before the Board of Health if you feel this order should be modified or withdrawn. A request for said hearing must be made in writing and received by the Health Department within seven (7) days from the receipt of this order. At said hearing you will be given an opportunity to be heard and to present witness and documentary evidence as to why this order should be modified or withdrawn. All affected parties will be informed of the date, time and place of the hearing and of their right to inspect and copy all records concerning the matter to be heard. You may be represented by an attorney. You also have the right to inspect and obtain copies of all relevant records„concerning the matter to be heard. Susan Ford Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 VIOLATIONS TO BE CORRECTED NO LATER THAN SEVEN (7) DAYS FROM RECEIPT OF THIS ORDER LETTER: VIOLATION REGULATION REINSPECTION Living room windows/ screens - falling 410.501 out of the frame, not tight fitting, do 410.480 not lock ■ All windows must be able to be locked. All windows and screens must be fitted properly to be considered weather tight Repair or replace windows as needed Small bedroom - 410.551 screen worn and ripped ■ All screens must be in good condition Replace screen Dish machine not properly operating 410.351 ■ All owner installed equipment must be operational as its use intended. Repair or replace as needed Refrigerator - Water accumulates in 410.351 the bottom and comes out onto the floor ■ - All owner installed equipment must be operational as its use intended. Repair or replace as needed Cc: Rachel Harlow & Mark Perry, Tenant Sandra Starr, Health Agent File a L •aolAaaS;dlaoaa uiniaa 6ulsn ao; nog( Nueyl r—T-0-W {7OF NORTH OARD OF R �VLI>� 1 MAY9 Y ry U m c .6 O O O N 0 m 6 m m N O i m m N a) U ill T 00 CO) ILL ( CL Cn rn .Q a O O 00 0 LL rn a P 205 969 487 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse Sent to /V'L Street &'Number Post 0111ke, State, & ZIP Code Postage $ 3 Certified Fee e Special Delivery Fee Restricted Delivery Fee Return Receipt Showing to Whom & Date Delivered Return Receipt Showing to Whom, Date. & Addressee's Address TOTAL Postage & Fees $ 2 ¢ � c O a� ° n o a - � 00El a- .� U N U) a) a) f ) d U c E W a c s a m 0 v1 V1 a Z, Q tZ CL O U) 0 C ❑❑ o \" °baa) r N O D a) _ o � a Q� U E,r) cca >fem N 'Q Z F- a) C U Cn N a) Q a) N U o C ro C a) Q) a a) a) a s o F ro O C CU a0 U _N 3m CWL c `-m M-0 � QX N E U ro � 3� °� o`aro N C U 3 -.s O N T Z 75 o � ° 0 0 E r Q ro a 3 O Z 0 —� �J p �� [[ z Q) C 45 Nam ` mN W y �Rro ci a) m a y �- •-M C,o ro.� N T Q a)U EE CC 00 I ,DEE w Wlu N (D 717 a) i` U ' U C CL CL >,O= ooc�zm`ta —¢ l Q >C WUUa u<aH0 �J �■■■ ■ ■■ MLC) CO Lapis asjanaJ ay; uo pajaldwoo MON ino/ Nu 13a r—T-0-W {7OF NORTH OARD OF R �VLI>� 1 MAY9 Y ry U m c .6 O O O N 0 m 6 m m N O i m m N a) U ill T 00 CO) ILL ( CL Cn rn .Q a O O 00 0 LL rn a P 205 969 487 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse Sent to /V'L Street &'Number Post 0111ke, State, & ZIP Code Postage $ 3 Certified Fee e Special Delivery Fee Restricted Delivery Fee Return Receipt Showing to Whom & Date Delivered Return Receipt Showing to Whom, Date. & Addressee's Address TOTAL Postage & Fees $ P 205 969 487 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION m 1. Permit No#• `l'� ly° Date Received ySSgrFD CHUS��S Date Issued: 1- Il5 IMPORTANT: Applicant must complete all items on this page LOCATtIOIV'- PROPER,TY OWNI-R Pnn , 10o Year Structure qes rq,, p. MAP' 1 ___ _PARCEL -:D2 -1Q_ _- ZONING DISTRICT: Historic Distri yes Machine Sh°op) Vi.11�a�gve: yes; TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family [I Addition El Two or more family 11 Industrial teration No. of units: ❑ Commercial epair, replacement El Bldg [I Others: Demolition ❑ Other ❑ 1Nell Jn�.`Septie ❑ FI"oodpla n d Wetlands: q .1lVatershed( istrict _0'Wate/.Sewer DESCRIPTIUN UI- WUMM I U b1z rtKrUruvicu: TA --+;C-+- _ OWNER: Name: Address: /0 ' ontraCtor Name _ . y ��✓ ` ll nne: " _l -2-21,31, -� Sr 4 Address:. Supervisor's, ConstructioriE License:i��' .-_Exp. ®ate: lbfZ _mom �. Home 1' 1. License:: - G ____ __._Exp. Date:_ /v%4 / __ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $92.00 PER $1000.00 OF THE WTAL ESTIMATED COST BASED ON $125.00 PER S.F. ..- 4'T EDTotal Project Cost: $`� d FEE: $ Check No.: Receipt N .. 2�� I NOTE: Persons contracting with unregistered co; aft do note guaranty fund 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/Cross Section/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 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application o Certified Proposed Plot Plan Li 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 40TE: 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 Clerics 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 2014 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 PLANNING & DEVELOPMENT COMMENTS Reviewed On Signature, CONSERVATION Reviewed on Signature COMMENTS HEALTH r ,COMMENTS, Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes 1$ Planning Board Decision: Comme Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osqood Street iPjKtfDEPARRTMENM - TemDumpster on;tsite Locatedlaf 124slMain�S__trW - �FrexDep�artment signature/date__- Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, roast or service drop requires approval of Electrical Inspector Yes No ®ANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine Doc.Building Pen -nit Revised 2014 r 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/Cross Section/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 VOTE: 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 ❑ 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 VOTE: 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 Clerics 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 2014 6�WAIwE0 /l- /4a BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: 3 —!—� 1y Date Received Date Issued: 11115 IMPORTANT: Applicant must complete all items on this page KO ION! P-ROPERTY OWNER P`.,rm 100 Year Structure. yes ,MAP'"3 _.PAR CEL.D��.o_ ZONING DISTRICT, __.:Historic Distn,ct yes Machine Shoo Villaae ves,. rIg no i TYPE OF IMPROVEMENT PROPOSED USE . Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial YAlteration No. of units: ❑ Commercial Tepair, replacement ElAssessory Bldg ❑ Others: emolition ❑ Other ❑. Septic p'Well ❑ Floodplain. d�Wetlands " V1latershed� strict nWater/Sewer DESCRIPTION OF WORK TO BE PERFOKMEU: Tr�antifiratinn _ OWNER: Name: Address: /0 Contractor Address: -u.. /4;; _ r� T W:p lel//__ Supervisor s Gonsfruction� License: ��7�'9- � . - Ex r: Date: 1 Ex ®ate:,4 Horne Improvement License: - G_�' r. _-______ p': ly�6 4�II ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THETAL ESTIMATED COSTBASED ON $125.00 PER S.F. Total Project Cost: FEE: $ 41-W Check No.: Receipt N NOTE: Persons contracting with unregistered contractors do not guaranty fund �i`nnatiire�cif A'aent%Owner _ igriafur cont'r c r A Loc(ati�onLet- P� No. �l26 6 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $�"�-'� Foundation Permit Fee $ Other Permit Fee $ e^ TOTAL $ Check #3313 29 6 7 9 Building Inspector \l `l(c 1�� 1 �� L�.�r--� �j�. x- < 00 -I 0 0 2 r0 N='cm C 25 CL 0 ZC F� H rt 0�0 �$ cn mm N 00 -- CD CD 0 �-� U) CD 0 2 O Q s1 D 1 O 0 O U) n O (D CD C CD FLown O 6 to CO *N• .-r )IW/ .=. CD C 0 U - to y+ y 0 o 0 -9 Cr O Crt N Q N 0 n�:� �. < 0-0 N 2. O< CCDL CL CD Cn CD (/1 Q 13 y (� 2 o :: CD (D p a Mir (D CD O 0 O =r` C D CD m '0 - CD @ 0 v o 0 � o �CL N 3 O ((D (D In - fD z O W C 7 (D o MH D -mZi T S. �o O C S G) N � T j fu v ; O C S m m A A r m 0 T j N 7O O C S M C W Gln m T �' y (� 3 7 (p K Z7 O C 3 T O C Q v j C C Z V m O VI m 'O n N 3 T O O n (D O O m D x C � CD CL r rn a� m =r N � CL S. to N 0—I �► C) 0 -0 O 1 Z x vCD �� cD Q o CL = C 'm cn � iU A, � Z CD Oa' CTD O W CD e� Z C -� o N'lz Co CD V� N O o0 O O 0 r+ z O CD z co: O M: O O < 00 -I 0 0 2 r0 N='cm C 25 CL 0 ZC F� H rt 0�0 �$ cn mm N 00 -- CD CD 0 �-� U) CD 0 2 O Q s1 D 1 O 0 O U) n O (D CD C CD FLown O 6 to CO *N• .-r )IW/ .=. CD C 0 U - to y+ y 0 o 0 -9 Cr O Crt N Q N 0 n�:� �. < 0-0 N 2. O< CCDL CL CD Cn CD (/1 Q 13 y (� 2 o :: CD (D p a Mir (D CD O 0 O =r` C D CD m '0 - CD @ 0 v o 0 � o �CL N 3 O ((D (D In - fD z O W C 7 (D o MH D -mZi T S. �o O C S G) N � T j fu V7 M N ; O C S m m A A r m 0 T j N 7O O C S M C W Gln m T �' y (� 3 7 (p K Z7 O C 3 T O C Q v j C C Z V m O VI m 'O n N 3 T O O n (D O O m D x * 6S DLM Remodeling Steve Ventola Dave Merrifield 154 Boardman ave, Melrose, Ma. 02176 781-2236629 781-789-8827 Marissa Cerasuolo 10 Walker rd, M North Andover, Ma H -781-944-2949 C-617-697-6933 Estimate Work to be performed as follows: Windows: -Remove existing metal window -Inspect for and repair any minor rot -Prep opening for new window installation -Install (4) Harvey Slim line Series white vinyl Double Hung replacement windows with grids between the glass. Windows to be Energy Star rated with low E and Argon Glazing. Window in bathroom to have tempered glass per building code -Insulate around window with expandable foam insulation and seal with approved sealant. -Install interior and exterior trim as needed -Remove all debris upon completion of work -Prices includes all labor and material -Lifetime warrantee on windows Patio door: Remove existing door. Inspect for and replace any rot. Prep opening for door. Install Jeld Wen sliding patio door. White interior and exterior. Insulate and seal. Install interior and exterior trim as needed to complete project. Screen door included. Total investment - $3,950* Respectfully SubmittedU/k% Y.�-�'a Date: August 11, 2015 The Commonwealth of Massa chusetts Department of IndustrialAccidents Y I Congress Street, Suite 100 E y Boston, MA 02114-.2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERIV.IITTING AUTHOR)iry. Name (Business/Orga�niizzation/Individual): Address: % �- f City/State/Zip: (0 M P�k10ne #: Are a an employer? Check the appiopriate box: Type of project (required)' 1. am a employer with : employees (full and/orpari-time).* 7. ew construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. modeling any capacity. [No workers' comp. insurance required.] 9. Demolition 3..Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 10 ❑Building addition 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions proprietors with no employees. 12. Q Plumbing repairs or additions S. F1 I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13. Roof repairs These sub -contractors have employees and have workers' comp. insurance.t 6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14. [J Other 152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submif '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, &y 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. #: d �d � Expiration Date. fob Site Address:,V bt-,�� • ��r� City/State/Zip: Attach a copy of the workers' compensatio policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required GL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as w ci '1 penalties in the a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy o his eine orwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under t ties of perjury that the information provided above :s tru and�•rect. Signature: ate: ( / Phone #: ✓ �'� 2 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 hire, 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 b6 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-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 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. Anew 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 ��e ipo�avnw�ruu `� �acJ,, Office of Consumer Affairs & Business Regulati��, f = OME IMPROVEMENT CONTRACTOR y R Registration: 163.597_ Type: a Expiration: 1.0%ZJ/2016 Individua) STEPHEN VENTOLA STEPHEN VENTOL�A 154 BOARDMAN AVE. _ MELROSE, MA 02176�y Undersecretary '.� Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS -092687 Construction Supervisor j STEPHEN M VENTOLA 154 BOARDMAWAVE"T, MELROSE MA 02176 t Expiration: l commissioner 10/02/2017