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HomeMy WebLinkAboutMiscellaneous - 114 CHADWICK STREET 4/30/2018 CHADWICK STREET U-1 2101074.0-0038-0001.0 I r' OF NORTy, q BUILDING PERMIT TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION ~ ' p <ocrrc«ewa. 1• Permit No#: Date Received �9ssgrgoCHU19? �5 Date Issued: - IMPORTANT: Applicant must complete,all items on this page LOCATION. Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial 11 Alteration No. of units: ❑ Commercial ❑ Repair, replacement- ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic 0 Well 0 Floodplain " 0 Wetlands ❑ Watershed District„ 0 Water/Sewer _ '• DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date:- ARCH ITECT/ENGI NEER ate:-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: $ FEE: $ Check No.: Receipt No.: NOTE: ,Persons contracting with unregistered contractors do not have access to the guaranty fund �� — -- - - r � `4ORT" 4�I BUILDING PERMIT tt4tD ,b��oL 1 we TOWN OF NORTH ANDOVER o � nn APPLICATION FOR PLAN EXAMINA N Permit NO: l��t Date Received 1 Date Issued: SSACHUSE IMPORTANT:Applicant must complete all items on this page LOCATION e — PROPERTY OWNEJ4 W -1 Ir R __&jU Tt- /,� Print MAP NO:V PARCEL ZONING DISTRICT: Historic District yesrno Machine Shop Village ye TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ifr6ne family ❑Addipim ❑ Two or more family ❑ Industrial ❑ Aii4ration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic Well Floodplain [_ Wetlands _; Watershed District Water/Sewer a . 10.1 q" r,� Identification Please Type or Print Clearly) OWNER: Name: 10 7WI) Phone:920 950 U.K0(4 Address: 114 CONTRACTOR Name: Phone: Address: / Supervisor's Construction Lic nse. Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: 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: $ t h FEE: $ 1 cZ Check No.: t�1-Sqt f Receipt No.:- to Id-i NOTE: Persons contracting.with unregistered contractors do not have access th gu anty fund signature of Agent/Owner ignature of contrac _ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SE RAGE DISPOSAL Public Sewer ❑ Tanniug/MassageBody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales Private(septic tanF] Food Packaging/Sales ❑ k, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTER®EP,4RTMENTAL SIGN ®FF � U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt su-bmitted yes �°tanning Board Decision. Comments Conservation Decision: Comments 'Fater& Sewer Connection/signature c�nafiure&Date Driveway Permit ID]PW Town engineer: Signature: FIRE DEPART1j0HT _ Temp Dumpster onsite yes Located 384 Osgood Street Weated at 12.4 Main Street no . . Fire Department signatureldate COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, wast or service drop requires approval of Electrical Inspector lies No DANGER ZONE LITERATURE_ Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department apse) EJ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit 4- 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 OTE: 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) �6 Mass check Energy Compliance Report (If Applicable) 16 Engineering Affidavits for Engineered products OTE: 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 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg.'Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doe:Building Permit Revised 2014 Location No. Date xx���. , TOWN OF NORTH ANDOVER s� _ ��� >.. � Certificate of Occupancy $ • Building/Frame Permit Fee $_� Foundation Permit Fee �_ Other Permit Fee TOTAL $-, $_._ Check# Building Inspector NORTII�•r Town Of 2 t _ Andover 0 No. &91%2z T = - 1 � z - o h 4 ver, Mass, SA COC LAKG ICN y1. �11,gS°R�rEo �Pa��S V BOARD OF HEALTH Food/Kitchen PERMIT LD Septic System THIS CERTIFIES THAT .........+.fr .. . . . . . BUILDING INSPECTOR. . ...... . Foundation . buildings on IVA C !!'�.has permission to erect ...................... g ... ..... .... .......... ..................... Rough to be occupied as .......... .... . ............ ............ .... ..� ..................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST TION S Rough Service ...... .... ...... ............ Final BUILD SPECT 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. HOME IMPROVEMENT CONTRACT PLEASE READ THIS Branch Name:New England Date:Zl�/� Sold,Furnished and Installed by: THD At-Home Services,Inc. Branch Number: 31 d/b/a The Home Depot At-Home Services 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll -3768 Federal 1D#75-2698460;ME Lic#C 02439;RI Co t7Licee #16427 Installation Address: CT Lic#H1C.0565522;MA Home Improvement Contractor Reg.#126893 [i�i^R2dGUtlkC. ,��. sq City State Zip Purchaser(s): Work Phone: Home Phone: Cell Phone: ft]Rr- oto [ ] [ ] Home Address: (If different from Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): ❑I DO NOT wish to receive any marketing emaiis from The Home Depot Prpject Information: Undersigned ("Customer") the owners of the property located at the above installation address,agrees to buy, and THD At-Home Services, Inc. ("The Home Depot")agrees to furnish, deliver and arrange for the installation ("Installation") of all materials described on the below and on the referenced Spec Sheet(s), all of which are incorporated into this Contract by this reference, along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders (collectively, "Contract'): ,lob#: {tnternat Rcrercmcc.) oducts: Sec Sbeet(s)#: Project Amount Roofing Siding Windows Insulation ) �y �/ Cc /Covers ntry Doors ❑ ��I / t 7��� $ J /� Rooting Siding / t V Windows Insulation. ❑Gutters/Covers ❑Entry Doors ❑ $ -7 Roofing Siding Windows Insulation r ❑Gutters/Covers ❑Entry Doors❑ $ Roofing Siding Windows Insulation ❑Gutters/Covers ❑Entry Doors ❑ $ Mnimum 25%Deposit of Contract Amount due upon execution of this contract Maine Purchasers may not deposit more than one-third of the Contract Amount Total Contract Amount $ 10 . 160 Customer agrees that, immediately upon completion of the work for each Product, Customer will execute a Completion Certificate (one for each Product as defined by an individual Spec Sheet) and pay any balance due. As applicable, each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem with the home,environmental hazarLis such as mold, asbestos or lead paint, other safety concerns, pricing errors or because work required to complete the job was not included in the Contract. Payment Summary: The Payment Summary # 1 t o 0 ! / t as part of th Contract amount and payments required for the deposits and final payments by Prod incluc ted d (s applicable),s Contract, sets forth the total NOTICE TO You are entitled to a completely filled-in copy of the Contract the time you sign. Do not sign a Completion Certificate(note: there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product is complete. In the event of termination of this Contract, Customer agrees to pay The Home Depot the costs of materials, labor,expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination, plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THD:HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. :acceptance and Authorization: Custorner agrees and understands that this Agreement is the entire agreement between Customer and The Home Depot with regard to the Products and.Installation services and supersedes all prior discussions and agreements, either oral or written,relating to said Products and Installation. This Agreement cannot be assigned or amended except by a writing signed by Custorner and The Home Depot. Customer acknowledges and agrees that Customer has read,understands, voluntarily accepts the tertius of and has received a copy of this Agreement. A epted by. r Submitted by: X ,� .,-1-'n ._ a_ /L I _. Work area will be contained s- Pre-Renovation Form pate: jNAT-19276 This form is used to document compliance with the requirements of the P Federal Lead-Based Paint Renovation,Repair and Painting Program after April 2010. Customer Address s Job Number(s) Dust will be minimized --�t� � _ i 1• OCCUPANT CONFIRMATION - ,; � Pamphlet Receipt 1 have received a copy of the lead hazard information pamphlet informing me of the potential risk of the lead hazard exposure from renovation activity to be performed in my dwelling unit. I received this pamphlet 34M ( before work began. Home Year Built _ f Enter the year my home was built. 9 Al P / ?, If the year your home was built is Pre-1978,all work will be done following lead safe work practices. W- ork area will be cleaned up P •.,,eo,�"�" "' .`�-- rinted Name of Ower-occupant thoroughly �o ignat ire w t�v ' Sig lure of Certi g Lead Pamphlet Delivery S - kF I SEE STATE SPECIFIC FORMS ON REVERSE SIDE yk � 011 �il The Commonwealth of;Massachusetts ' Department of Industrial Accidents Office of investigations J' 1 Conb�ress Street,Suite 100 M Boston, 194 02114-2017 www.mass.gov/die Workers' Compensation Insurance Af€idavit: Bulilders;Contractors/Ele leasan riot Ley A heant Information Please Print L ;,. i L\arae (Business/Or-anizahOn/Tnikiival): � �i nn �C !'l� Phone#: 5�� Axe you an employer? Check the ag ropriate box: Type of project(required): 1.F1 I am a employer with i 4. 1 am a general contractor and I 6 New construction 'P ❑ employees(full and/or part-time)•* have hired the sub-contractors Remodeling 2.❑ I am a sole proprietor or partner- Theseon the attached sheet ❑� Remob These sub-contractors have g, ❑Demolition ship and have no employees employees and have workers' addition worldng for me in any capacity. 9. ❑Building comp. insurance.; I NO workers' comp.insurance • We ars a corporation and its [�10, Electrical repairs or additions � required.] , officers have exercised their 11.0 Pltmmbing repair or additions { 3.❑ I am a homeoweer doing all wars right of exzm tion per MGL myself. [No workers' comp. P P 124 Rio aa� c. 152, §1(4),and we have no insurance required.] t 13. Other i employees. [NO works' comp. insurance required.] .:01j appiicant hat becks box'1 must also fill out the section below showing thew workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing aIl work and then hire outside contractors must submit a new affidavit ndicating,acb ;Contractors that check this box must attached an additional sheet showing the name of the sub-cowactors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp,policy number. ;I I am an employer that is providing workers'compensation insrtrance for my employees. Below is the policy and job site information. — li surance Company Name: a4s 5 ' Policy#or Self-ins.Lic.#: 15 Expiration Date: Job Site Address: City/State/Zip: r� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL e. 152 can lead eto the imposition OP VJO�ORDER and a fine fine l penalties of a up to$1,500.00 and/or one-year imprisonment, as well as civil,penalties 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. I do her y ce t poi d p -41 es of perj th the information provided above is true and correct: Date: Si e: Phone#: 08 6 Official use only. Do not write in this area,to be completed by city or town offi:dal. II permit(License # City or Town: i Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person: i i i ACOP O CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) 02/242016 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(ies)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 CONTACT MARSH USA,INC. NAME: TWO ALLIANCE CENTER PHONE FAX No): 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# 100492-HomeD-GAW'-16-17 INSURER A:Steadfast Insurance Company 26387 INSURED THE HOME DEPOT,INC. INSURER B:Zurich American Insurance Co 16535 HOME DEPOT U.S.A.,INC. INSURER C:New Hampshire Ins Co 23841 2455 PACES FERRY ROAD,NW BUILDING D:Illinois National Insurance Company 23817 BUILDING C-20 ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003741310-08 REVISION NUMBER:O 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. INSR ADDL SUBR LTR TYPE OF INSURANCE POLICY NUMBER POLICY DIIYEYW POLICY LIMITS A X COMMERCIAL GENERAL LIABILITY GL04887714-06 03/01/2016 03/012017 EACH OCCURRENCE $ 9,000,000 CLAIMS-MADE MOCCUR DAMAGE PREMISE occurrDence $ 1,000,000 LIMITS OF POLICY XS MED EXP(Any one person) $ EXCLUDED OF SIR:$1M PER OCC PERSONAL&ADV INJURY $ 9,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 9,000,000 X POLICY JPRO- FILOC PRODUCTS-COMP/OP AGG $ 9,000,000 OTHER: $ B AUTOMOBILE LIABILITY BAP 2938863-13 03/012016 03/012017 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY Per accident $ AUTOS AUTOS ( ) HIREDAUTOS NON-OWNED PROPERTYDAMAGE AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ C WORKERS COMPENSATION WC01 5519215(AOS) 03/012016 03/01/2017X PER FOE AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE WC015519217(AK,KY,NH,NJ,VT) 03/012016 03/01/2017 D OFFICER/MEMBER EXCLUDED? a N/A E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) WC01 5519216(FL) 03/01/2016 03/012017 E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under Continued on Additional Pa e DESCRIPTION OF OPERATIONS below 9 E.L.DISEASE-POLICY LIMIT 1$ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 16000SGOODST. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee - ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD i i Aco O CERTIFICATE OF LIABILITY INSURANCE F111 111.� 07/21/20161 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.TIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED OY THE POLKWS BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURE S), AUTHO D REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. N SUBROGATION IS AIMED,subjto the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not orlfer rights to certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME Maryellen Goodwin DAVID E.ZELLER INSURANCE AGENCY INC PHONE (781 595-2071 AI Ne E.MUUL maryelien@davidzeller.com 370 LYNNWAY INSURER(S)AFFORDING COVERAGE • LYNN MA 01901 INSURERA: TRAVELERS INDEMNITY CO OFAMERICAI 25916 INSURED INSURERS: ROBICCO INC INSURERC: INSURER D: 172 WHALERS LANE INSURER E: SALEM MA 01970 1 INSURERF: COVERAGES CERTIFICATE NUMBER: 70815 REVISION NUMBER: i i THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR.HE POLICY PEFOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RES CT TO WHICH HIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT 110 ALL THE TEF S, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR OF:INSURANCE ADD SUB POLICY NUMBER POLICY EFF M LICY EXP LTR TYPECOMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s3E TO RENTED _ CLAIMS-MADE M OCCUR PREMISES Me occurrence s MED EXP(Any one person) E N/A PERSONAL SADV INJURY I L GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE Hs i POLICY❑�a 7 LOC PRODUCTS-COMP/OP AGG $ OTHER: Is AUTOMOBILE LIABILITY 881eDISINGLE LIMIT s i ANY AUTO BODILY INJURY(Per person)I s rl ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per acddenl $ _ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ � AUTOS Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE Hs EXCESS LIAR HCLAIMS-MADE N/A AGGREGATE 11s DED RETENTION ds WORKERS COMPENSATION X I STATUTE OR AND EMPLOYERS'LIABILITY YIN ER ANYPROPRIETORIPARTNERIEXECUTIVEE.L.EACH ACCIDENT 1I$ 1,000,000 1 A OFFICERIMEMBEREXCLUDED7 N/A WA NIA 6HUB5B37400216 07/23/2016 07/23/2017 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE z1$ 1,000,000 K describe under DESCRIPTION OF OP RATIONS below E.L.DISEASE-POLICY LIM $ 1,000,029'' I t N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Rom*s Schedule,may be attached It mora epee is requved) I Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to path claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of MassaMusetts. I This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above#Iolicy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwdtworkers-wmpensabonriinvesUgaUorts/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE NCELLED SEP�RE THE EXPIRATION DATE THEREOF, NOTICE WILL I BE DELIVERREEC IN THD At-Home Services Inc and The Home Depot ACCORDANCE WITH THE I:OLICYPROVISIONS. 269 Cumberland Parkway AUTHORIIEDREPRESENTATIVE K �_/. (� Atlanta GA 30339 Daniel M.Croy,CPCU,Vice President—Residual rket—WCRIB ©1988-2014 ACORD CORPORATIO All rights remidirved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD { t i I ;SSL-099699 ROBERT POCZOBU 172 WHALERS LANE SALEM MA 01970 02/08/2018 Ho ` n L,�T;�LI1Vl'11:V1L1�: 'v.'�ii� L1� 1111 _�-- __ - ,_, Ragis�la;ian: 1?�393 .� =zcir��icn: 31;1`'0li kND ATLANTA, GA 30339 --_ =�'� n d•�(ir't r�asoo or ehaa;s. —a.-' t;odat��ddrss and taut .ar ^ --- ;J :t•idr�ss J �enetivat ;� ;rm?lo'/ment i_ Lost Card [2_ ]i -JilJII71�C 1t:`'1:Ci s�:�1iiaC53 .-x'111=i]1 License )r-�;is ra�lol v2 id or:adi?ldll�l.i'-)Zl ia.e, if found r:tlirl :a: . �lfain Sad 3RSiaass Rzp'ia 7)1 ELM (}il�0)i .J1ill313' gis:scion:_9'1_o"Saam - _ 101vlc 0E 0I A r:{OLIESrmR- 0 CU�LIBcRLAu jo ??,r?.r".f`A-y 3 �; ,GA 30399 Cndzrseentary riot��iid without ai;aature JU r Date:!. . '. ...��...... b f ,ORTN TOWN OF NORTH ANDOVER 3? °a PERMIT FOR GAS INSTALLATION �,SSACMUSEt This certifies that . . . . . ... . .'!. . . . :: : . . . �u�: . . . . . . . . has permission for gas installation- . 4� . . . . . . . . . . . ... .:. .. . . . . . in the buildings of :`.`. .. . . . . . . . . . . . . . . . . . . . .. . . at ... . . . . . . ...�`!:'� :��. � North Andover, Mass. Fee..:,. . . . Lic. No.,.'/ v� �• GAS INSPECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO FITTING tPritit or Type) �1 t. !t/r02Tf! ,L/n/acryd',� 'Mass. Date-2—1 G 19r� P 3/0 Buldit vocation_ l/l -l�3 c Du��C�C �� Owner's Name 6 U�-- Type of Occupancy �1 dSiAA- vel New Re civation ❑ Replacement ❑ Plans Submitted: Yesp NO a a W h is z C a 3 M yt • .. Z a x c fh } _ 'z o a C a t7 W < _ _ �• q 0 �W lot `[ is C W Z 044 = a a W < C a a h t � p '� Yr H V J yaj < C .• r" a t O 0 z cc 0 fit s C 'i o a 1 0 o' � o .a u C > a d r o SUB—asYT. BASEMENT a 1ST FLOOR IND FLOOR 3RD FLOOR 4TN FLOOR STN FLOOR GTN FLOOR TTN FLOOR GTN FLOOR /� install ft Company Name lLl�/U %���-�f -P�.�//G iris Chuck one: Cer fume Addn3as Pd-'Corporation ❑ Partnership euadrtess Taephone �l �.? o �s'-c� ❑ Firm/Co. Name d Licensed Plumber or Gas Fitter i INSURANCE COVERAGE: I have a CWIL "Ity Insurancovoticv or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ulk- No If you have checked yes, please indicate the type coverage by checking the appropriate box A IiaNky Insurance policy Other type of indemnity❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General laws. and that my signature on this permit application waives this requirement. CheoK one: Signature of Owner or Owner's Agent I OwneFCJ Agent ❑ 1 hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knoMedge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. BY T of se ` umber S� at re o nsed umber or Gas rtter Tolle fit u Aer license Number r�jtvRr,W„ ---- Dater"'--!�.'���.".!✓ .= 3913 T.��o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SS us • This certifies that has permission to perform .�,�.. {. . . . . . . . . plumbing in the build'ngs of . .z!5: . + . . . . . . . . . . . . . . . . . . . . . d at �...T. . . . , North Andover, Mass. Fees '!. . . .Lic. N�� . . . . �!�--•-. . PLUMBING INSPECTOR 02/23/99 11:01 30.04 PA WHITE: Applicant CANARY: Building Dept. PINK:Treasurer �U MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT T O PLUMBING (Type or Print) /✓oxrq 4W'00V4e- ,Mass. Date. �-' leo' �y Building vocation Il- /3 allA.0g,1144 Permit Owners Name New Renovation Replacement Q Plans ubmitted Q FI XTURE-5- Z z x � a, o z z W W 3P.1 0 in o z w a, dc m m Q = z e» 4 m h o W '� va, = aL z ¢ o a H H Ad q 0 � W aa. a O• W o d = < W = .m a s a , a 0: W h r W a J eC I- 4 �G k ac W = 4 = 3 O Z x 54CLO O 4 W x W I.- V Y 1- O Z a M W z 0 0 x ILL F. O O Z d r < < s p'. aJ 4 '� O < J J d tr tC trr 4 O 4 1- 3 o SUB--BS MT. BASEMENT 1ST FLOOR 2ND FLOOR A qj_ 3RDFLOOR 4TH FLOOR STH FLOOR 6TH FLOOR TTHFLOOR STH FLOOR (Print or•Type) Check one: Certificate Installing Company Name Corp- v2/®p �" L Address -+ Partner. l ���' d/��� Firm/Co. Business Telephone 7 52k Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy �A _t•her type of indemnity 7 Bond Q Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owneriagent of property Owner LI Agent 1 hereby octtify Thal all of die details and inforniation 1 have submitted for entered)in above application are true and accurate to die best of my, knowledge and that all Plumbing work and installations performed under Permit issued for(his application will be in compliance with all pertinent pro. visions of the Mauachusetts State Plumbing Code and Cluptcr 142 of the General Laws. By Title Signature of Licensed Plumber Type Of Plumbing License City/Town: /0 S--/a APPROVED (OFFICE USE ONLY) License Number ®Master 0 Journeyman Date 3 TOWN OF NORTH ANDOVER • PERMIT FOR PLUMBING This certifies that . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . ...4. fir. . . . . . . . . . . . . . . ... . . . . . . . . Jr plumbing in the buildings of. . . . . . . . . . . . . . . . . . . . . . at . . . . . . . .//Y. . oh�•�t.1:1-47. North Andover, Mass. Fee . .5-0 . . Lic. No. . /—PO- / . . . . . . . . . . . . ..P . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check 9 &d(19 5- 1 K ` RM PLUMBING WOR pPERM�SO PERPO �v�\ P►PP�ICpj1ON POR PERMIT# 13 H�SE�S VNIPORM MA DATE 8I2tiRSNAME CORRIGpN FAX . Mpsspc OWNS TES , ✓ NORTH ANDOVER ADWWCKST RESIDENTIAI.� D. YESQ NOQ 1 CITY ADDRESS 114 OA pDCAZ1ONPL PINS S 30'.5f 12 13 14 JOgSWTE PLO E 9 10 11 1 ADDRESS SAME ERC1a 1Z OWNER NCY TYPE COMM CEMENT.® s 41 REPS 1 E OOCCDPA RENOVATION'.© 3 4 5 R P 2 pRINj Y NEW:© BSM 1 CLEAR F\,OOR FIXTURES Z 3 BATHTDB NNECTION DEV TE SYSTEM SS CO WA�WPS 0 SYS �pWCATEp SAES OWUSAND pEp1CAZEp SESYgTE pEp1CPTEp GREA WATERSYS TEM �' pEpWCATEp GWZATERRECYCWrESYS WA pEDWCATEp � , WASHER DISH UNTPIN FO fOOOD0 SPOSER REAp F\-00R I A IN�RIOR) 1 PTpR 1" WTERCE SINK 1 KITCHEN ` WpvA�DRp,1N ROO R STp1.1. SNOWS OP SINK SERVICE I M T011.ET CTION 1 CHINE CONNE ._ pRINP1. YES® NO WASHING R p11rPES MG�Ch.141- \N KNIT ev 42WATER WATERPIPINGis N E the RACE. of CAVE re4urrements C gEtOW E APPROPRI�`TE BOX OTHER INSV� tcXt mee b antral Na1ent a tet 142 of Oe or its su BY CHEC�NGTM BONA Q 'red by Ch P ce policy vERP`GE e requr t uran �PEOP1NpEMN1�0 Co�era9 AGENT 1 ins THETYPEOF CO 1 1 have a cuRentliabil CEASE INDICATE T\A the issue his eol, nt' ave NER CKED YES P ICY 1:•r 0 is n des na Plication Waw-' r CHECK ONE ON`s Owo the�St°f S ori of the d9e IE YOU CHE 1NSU�NCE P0� I a ,aware a u`Ion his d P e aria ac,a;Pe �rierit�o� �WABIUTY W AVER' at my sign licaiori ace mpliarir-e*0 OWNER'%%51s�neral%ClEl ave and te9ata{n9 this on X11 be SaCh AGENT �binmed o�ssued°r this applicat s►GNA� Mas 14 OR on I have S the Pe�'� SIGNATURE 0F,O aria 1010—an ea�riaet Genets 50 LL et{°rin {the c' SE# 133 Geta s p ° L1C IP®# cert►{y�`at a110{ theria iris aa'd GhaPte�142 EN P ARTNERSH 110 that all e Sta a ing Pig bin9 a #Q TIONfl ST Massa�{,�s NAME JOSEPH OUT" CORPORA DpRE$S 121 PONIARD TEL 87 2 220 P`HMgER S A JP©1 SOW_UTIONS ZIP p1862 QUATIC MP� E pDT1lE'S P STATE MA nv-S GOO COMPANY NAM JOE@DU ICRA EMA11. CITY N g1�1.E 1 FAX f 17 r l - i� i s.. r� r r i �7e i A CERTIFICATE OF LIABILITY INSURANCE 3/14/2013� ' THIS CERTIIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGKM UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMAXPALY OR NEGATIVELY AIME D, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTMM A CONTRACT BETWEEN THE ISSUING INSURER(Sh AUTHOR® REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: 9 the cert a holder is an ADDITIONAL.INSURED,the po6c un)must be fid. 9 SUBROGATION LR WANED,subjea to the berms and eondMons of the pormy,corlem pokies may reyuha an endow A ,ft Iet on this ce+rtfricele does not confer rights to the certlEicate holder In lieu of such mss). PRODUCER Coffmm Del3crea (whert Merrimack Valley Insurance Agency Inc PRIzesE (978)667-2541 Falc (srls)sn-asXa 655 Boston Road, Suite 1A OGi3bert@mains.00� -011SUPOWAFFORONG904ERAGE Nm4 � Billerica MA 01821 INsuRECA Rational Grange MutualIns.Ca. 6182 � Q wswme Xational Grange Mutual Ins. C0__ 582 Joseph P Ductile, DBA: Dutlle-s Acuatic msuteecc3Tat Tonal Grange Mutual Ing. CC. 4788 121 Pollard St a- MSURER:- N Billerica MA 01862 HdSURERF- COVERAGES CERT FICATE NUMBER:2013-14 liab. arc. - t:, 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. NOTWITHSTANDM 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 AFFORDW By THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TOM. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES_LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS um TYPEOFO Af E PQLiCYEFF Pauff w L6Em GENERALLiABOdrY EACH OCCDRRENM S 500,000 COMMERCIAL GENERAL LIAKIIY - s loQ,aaO A CIAB'dS MADE OCCUR ELLE /12/2013 !22/2014 imami&mD Ew a►e S 5,000 PERSONALaAmuwRY S 500,000 GEIGA LAGGREGATE S 1,000,000. GEWL AGGREGATE UMITAPPLIES PER: PRODUCTS-COMPraPAGG s 1,000,000 X POLICY LOC S AtIAatLrIY ' �oddstxl s 500,000 A ANYAUTO eooarnrnmYlPg�or►} s AUTOS DNLTtED X 911E J12l2013 /12f2014 BOD9.YOLWRY(Peraaad" S XHIREDAUFTDS mommmm AUTOS s 500,000 PRP-Basic S UMSRELLALIAB OCCUR SICHOCCURRSICE s. EncessLIAR CLA94SrraaE AGGREGATE s aee re=rarncxcs E A ANRIUMCOMPEmTm AND PLOYHRS'LIABU iY SFATii OTEI AW A OFFICERNBUIER EXCLtMO? Q NIA !12/2014 EJ-�IACCIDW s (Marmatuffy in mg /12/2oi3 9Yyeess ELDS -E500 Ofl0 500,000 DESC OP&tAT10t4S Neto r > - I:c DL�Ease-PottcYlnstr s 500',000 P1 iJN1BERS A1`1U GA.SFI77 TTERS _ 11 EMSEFI AS A MASTER PLU PLUMBER -:-: : 0SEPH P DUTILE ]` 1- 016LI-013 SS Aja IEFRiCA KA tll8ti2=�3ltt -_?.35fl 1?2ti11- CANCELLATION 05/02/14 ='i_ si r _^= SHOULD ANY OF THE ABOVE D POLE BE CANCMLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE MjVEMD IN Joseph Dutile ACCORDAIWE WITH THE POLICY PROVISIONS. 121 Pollard Street Billerica, MA 01862 AcrA�IVE Lucacio% Amea�' 0490(06) 15100 Nor 90 0 ACORD CO!!Pt)RAT ids All r�hffi r rv�. 1N0m).01 TM ACORD LIN*and 16pam rimed I mim etACM The Commonwealth of Massachusetts Department of Industrial Accidents Offwe of Investigations ' d 1 Congress Street, Suite 100 Boston,MA 02114-2017 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): DUTILE'S AQUATIC SOLUTIONS Address: 121 POLLARD ST City/State/Zip: N.BILLERICA MA 01862 Phone#:978-423-8220 Are you an employer? Check the appropriate box: Type of project(required): 1.X I am a employer with 2 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. Buildingaddition [No workers' comp. insurance comp. insurance.t ❑ required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.n Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:NATIONAL GRANGE MUTUAL Policy#or Self-ins. Lic. #:WCT29911'H\ Expiration Date:3/12/14 Job Site Address: l 1 q (f1 rj4� jjl� 57 City/State/Zip: Iva 71� Attach a copy of the workers' compensation policy declaration page(showing 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 criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct~ Si at -� Date: Phone#: 9784238220 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#• i Q `J GJ' 8 Date..... . .�... �. �aORTM �?Oe'.P�ao"atippL TOWN OF NORTH ANDOVER PERMIT FOR WIRING ��Ss�cNusf� This certifies that .............. ...............,.�.v..�j�JI'll........................... has permission to perform .........Aft . ..A ............................. wiring in the building of.............)......CY..... .......................................... at...... ....... ............... S ,North Andover,Mass. . Fee..:-�........... ... ... Lic.No..............� ......... ELECTRICALINSN CTOR s Check # Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 3S` p Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(M , 77 CMR 12.00 IN (PLEASE PRTININK OR TYPE ALL INFORWTIOl9 Date: 1 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned ives noticef hist orher intention to perform the electrical work described below. Location(Street&Number) a U c,(, Owner or Tenant Wo n ��G�j U/ 7 Telephone No. Owner's Address 11 � C �c c C6,I S7 Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps It-o' l L40 Volts Overhead K3-- Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: �e0lu ce -e C Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:SusoFans No.of Total `' p•(Paddle)T� Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting nd. rnd. Battery Units -- No.of Receptacle Outlets No,of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.-of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Disposers Heat Pum Number Tons KW No.of Self-Contained p Totalp -.-.. .. ....... ............ - Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection No.of Dryers Heating Appliances KW Security Systems:* rY No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts. No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: (} Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 17 dt (When required by municipal policy.) Work to Start: /6)/(C) Inspections to be requested in accordance with MEG Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the,permit issuing office. CHECK ONE: INSURANCE 0 BOND ❑ OTHER ❑ (Specify:) I certify,under the pa as and penalties of erjury,that the information on this application is true and complete. FIRM NAM : r,6>C)/\ r� 4Z LIC.NO.: 20 Licensee: �� �j✓� 1°w✓� Signature LIC.NO.: (If applicable, nter"exempt"in the license number line. Bus.Tel.No.•g'? j f 7 Address: ct o� lS�� v' / �`ft( CI/i�,v Alt.Tel.No.: *Per M.G.L c. 147,s. 5 -61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner 'El owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. r^� The Commonwealth of Massachusetts ' ' ! Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.nzass gov/dia . 'Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/Individual): Address: City/State/Zip: Phone#: . employer?Check.the appropriate box: [,Are employer with 4. ❑ I am a general contractor and IFE0JRemodel'ing ject(required): yees(full and/or part-time),* have hired the sub-contractorsconstruction . .sole proprietor.or partner- listed on.the attached sheet.1 ship and.have no employees These su&contractors have S. ❑Demolition working for me.in any capacity, workers' comp.insurance. [No workers'comp,insurance 5. ❑ We are a corporation and its 9' ❑Building addition o required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I l.❑ Plumbing repairs or additions myself.[No•workers'comp. c. 1.52, §1(4),and we have no 12.[]Roof repairs insurance required.]t employees. [No workers' comp. insurance required.] 13.❑.Other 'Any applicant that checks boy'#t must also flit out thesection below showing their workers'compensation policy information. t homeowners who submit this affidavit indicating they are daring all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workere comp,policy information. I am an employer that is.providing:workers'compensation insurance for my employees: Below is the policy andyob site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'.compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Sign ire: Date- Phone#: Official use only. Do not write in this area,to be conrleted 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.Oth6'r Contact Person: Phone#: The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston,MA. 02111 SY www mass govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant Information Please Print Legibly Name(Business/organizatioiAndividual): tecila-d SCi r Il�cr) 7_- -P- Address: City/State/Zip:_ p,�� ���/1'l� d/�jG Phone#: ?'s 1 Are you an employer?Check the appropriate box: .l.❑ I am a employer with 4. r7. pe of project(required): ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors ❑New construction •L! 1 am a sole proprietor or partner- listed on the attached shget. t ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers'comp.insurance. 8. ❑Demblition [No workers comp.insurance 5. 9• ❑Building addition ' p ❑ We are a corporation and its �-,� required.) -officers have exercised their 10. 1 electrical repairs or additions 3.❑ I 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 insurance required.]t employees.[No workers' 12.El Roof repairs comp,insurance required.] 13.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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. dnsurance Company Name: T�licy#or Self-ins.Lic.#: • Expiration Date: Job Site Address: , City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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 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. fP J r1' Ido Izereby cerci uncle the apps an enaltie� er'u tliat the information provident ab Vel i true and correct. S i nature: a`cj—� Date: ��'z '�/� . Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Is Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r Information and Instructions Massachusetts General Laws chapter 1,52 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 be doemed 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." r Additionally,MGL chapter 152, §25C(7)states"Neither the.commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." t 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 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 r Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current Policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been'officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum 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: The Col-luuoxxwealth of Ylassachusetts Depaftent of Industrial Accidents Office of Investigation$ _ 600 Washington Street Boston;MA- 42111 Tel.4 61.7-727-,4900 ext 406 or 1.-877-MA.SS•AFE Revised 5-26-05 Fax 4 61.7"727-7749 www.nnass.gov/dia