Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 314 REA STREET 4/30/2018
�! d Date....3-' ..`-./.. ...... . NORT/y TOWN OF NORTH ANDOVER o�? s PERMIT FOR WIRING 7��+nm•'P'L 8`QACHUg� This certifies that ...... ,� d N�� ..... .. . .... ........... . ........................................................ has permission to perform ....... � �C.F � ...... ....................................... ......... wiring in the building of......................... .. .� '`t' S� at ......: L ..lf ......�............................................North Andover,Mass. Fee....................` ......Lic.No. ................. ... .......................... ...... /�.. ' ELE AL INSPE&O Check# a / Commonwealth ol aaaachuje Official Use Onnlly---� •- Permit No. PIN`` ` `I` �J Apartment o f Sire Seruicei BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION. FOR PERMITTO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1113 - City or Town.of: I` � And e L&— . To the In pector.of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant P C / 9el CZ � (1 a-5 Q Telephone No. Owner's Address -Q)t- M• F7 Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building R—e j j d ea re, Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and atur of Proposed Ele trical Work: 0^e la Completion o the ollowin table.maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.,of Luminaires. SwimmingPool Above In- . , .o.o mergency Lighting N .. .. _ rnd. rnd. E]?. Batte Units No.,of Receptacle Outlets o.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. Total No.of-Alerting Devices v Tons g No.of Waste Disposers Heat Pump Number Tons KW No.,of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating .KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water K`,1, 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 c OTHER: 1�5 ^� Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: V (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVE GE: 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 cove age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ND ❑ OTHER ❑ (Specify:) 1?���/ �S�(/''G'vIC� I certify,under the pains and enaldes ofperjury,that the information on this afflfication is true and complete FIRM NAME: Q V4004, / LIC.NO.: Licensee: Signature LIC.NO.: (If applicable,enter " em t"i the license u ber line.) / Bus.Tel.No.•G' e &Z2 Address: Alt.Tel.No.: � *Per M.G.L.c. f47,s.57-61,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 ❑owner's a ent. Owner/Agent Signature Telephone No. --FPERMIT FEE: $ LID Jim Leonard 9782088171 p,3 The Commonwealth of Massachusetts I Print Form ` Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: R eS Address: IL City/State/Zip: '- � /"� 61f 5/gone#: 0 'S 7- 7-5 3 Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2 I am a sole proprietor or partnership and have no 7. ❑ Office andlor Sales(incl. real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] g• Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12_❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers compensation insurance for my employees Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. # Expiration Date: 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 ofpedwy that the information provided above is true and correct. Si atwe: �.i Date: -3/S//--) Phone# S 7 OJ)7cial use only. Do not write in this area,to be completed by city or town official City or Town: PermitlLicense# Issuing Authority (circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia Jim Leonard 9782088171 p.2 __.. C011�i Of 11YEALTH OF MASISAC-lriUSErrS - OF ELECTRICIANS AS-A REG JOURNEYMAN-ELECTRICIAN (SSUES IHE 200E UCENISE 7': .. JAMES .M LEONARD SR A) r` 1 DEXTER STREET ME.THUEN MA 01844;5419 3819.7 E 07/31/13 81-4975 a Date.... AI\5............ TOWN OF NORTH ANDOVER 1 0 PERMIT FOR WIRING �SACHU This certifies that ......................................() has permission to perform ........ ..... . . ..... ............. .A..;�.............. C.......................................... .......... wiring in the building;of at ....3................................. .. .......................................................North Andover,Mass. Fee . .......Lic.No .............f.•...................... ,---*"*"*''* **-**'*hLECTRICALINSPECTOR Check# v� Izn4115 a Commomlea&o f Mas&.. utb Official Use Only Apa,Emenl of Sire S ftlice3 Permit No. Z I Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: 16),- City 'C'City or Town of. s �r iceTo the Inspector of Wires: By this application the undersigned gives noti a of his or her intention to perform the electrical work described below. Location(Street&Number) J,,/ V 440h Owner or Tenant //4-i1/ei4/Z aJ-41 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes P-011 No ❑ (Check Appropriate Box) , Purpose of BuildingIrvr'� 1��' Utility Authorization No. 3 Existing Service 0d Amps /10/ ;Wt-Volts Overhead 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: ,V,'5-?! 4 77/ :�-- A?Fez�9 .,,�. 1 ��l �s•� Com letion of the followingtable may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators K-VA No.of Luminaires Swimming Pool Above El El -o Emergency Lighting rnd. rnd. Baotte 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 Initiatin Devices No.of Ranges No.of Air Cond. .TTotal No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: �� "�`���""�" Detection/Alerting Devices � No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances Kms, Security Systems: 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: -5- Avttr"L- <'�� n 5/44',wl` Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC 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 Covera is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and enalties of perjury,that the information on this application is true and complete FIRM NAME: -7LIC.NO.: Licensee: / 4"-;111-S �j� >�� Signature /� LIC.NO.: (If applicable,enter "exempt"in the license number line) Bus.Tel.No.•97h' `)70 /592 Address: �S�'S%�'.i✓�FJOz�/��E ,r�R �]fZF7C'r�7- 4?, pf�,'Z Alt.Tel.No.:-Z-7-,0 'S 7 S 3;r6/ *Per M.G.L.c. 147,s.57-61,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 ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ J The Commonwealth of Massachusetts G Department oflndustrialAccidents 1 Congress Street, Suite 100 v Boston,PM 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le0b Name(Business/Organization/Individual): Address: City/State/Zip: ( -j,4 6119 Phone#: J` b `375'--- 3 7 Are you an employer?Check the appropriate box: Type of project(required): L❑lain aeLnployerwith employees(full and/or part time).* 7. New construction 2.a am a sole proprietor or partnership and have no employees working for me in 8. 0 Remo delirig any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1-will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. ' 12.E]Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.0 Roof repairs • These sub-contractors have employees and have workers'comp.instuance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGI;c. 14.❑Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 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. 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,kheq must provide their workers'comp.policy number. !am an employer that is pYovidin workers'compensation insurance for my employees.• .Below is the policy and job site information. Insurance Company Names � � Cl J`�7 i` r Expiration Date: Policy#or Self-ins,Lic.#: G �� �/�'17�7 7 / p l 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this st e ent may be forwarded to the Office of Investigations of the DLA for insurance coverage verification. , X do hereby:y�cerIifA der the pains and penalae �petjury that the information provided above is true and correct. Signature: Date: / Phone#: G_. / - • 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 liire, 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 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-contractors)name(s),address(es)aud-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 bottoni 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 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 COMMONWEALTH OF MASSACHUSETTS: ELECT0 CI ANS . ISSUES THE FOLLOWING L1,CEN5E AS A R:EGtSTERED MASTER E;LECTRI:QFAN ` I � . THOMAS. J SPR I NGFORD .. j 158 STONEBRI DGS DRACUT MA o1826 266n 20336A of/3.1/16 39124 >.... COMMONWEALTH OF MASSAOHUSETT EtEC�`R I C I ANS I CENSE FOLLOWING 1 I SSUES THE ELECTRI 'IfA ' RE:G 'JOURNEYMAN < r, r, z ti J _SPR INGEORD X58 STONEBI�IDGE DR.." bt, { A 01826 260 X25 RAcu 0 /3 / 6 . 39 I 34145. •' — Date. l. .°.v o'.".°R'"'�o TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING SSA�MUS� This certifies that " has permission to perform . . . . . . . . . . . . . . . plumbing in the buildings of . .` .ri?� at. . ..�`.� . . . J'"-. . . . . . .. . . . . . . . . . . . . . . North AndoveC, Mass. Fee . `.y. . .Lic. No.. S r? �`- .r. . . � -�.,� ` ,y' y J . /,' �PIUMBING'INSPECTOR Check # el v U 5293 ;J MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING �. (Print or Type) l �ttK mass. Ua te.-.- .._. .-. ----..-.._.._. ---•- e City, Town r^ CE P6rndt Building _ Owner ' -- -----~-- + . AT: Location _ Naine oke ie s•.:,, VY TyPe of i New ❑ Renovation Replacement: ❑ ,1 l s FIXTURES subli ❑ ulmti,t 1:ed: YPti ❑ No X fA 11 N Z Y < .It h N N N O Z Li W Y J N �' V < M. O W N Z N < cc W = ~ Z O = Yl d y j H W N 1- W lA F V W H us LL Z Z 1, IC Y < Z r r:.- L L a :� x �j ic W O O W < H _ < W N ® cc -1 Z C 4 G O LL ��. l- V t Y 0 d Z ._ �c 4 O IP- Y Y < W LL 11: W ;jt .. < 1 < j = y N ` Q Z O O 0 W 1' O U Y < J J < ac at 4'i < O < F- ;�� o < 3 ac m o I sus=sSMT. — — BASEMENT - — °i ` 1ST FLOOR i! 2ND FLOOR 3RD FLOOR 'i 4TN FLOOR 51 6TH FLOOR 6TH FLOOR 1.. G :t 7TH FLOOR STH FLOOR (Print or Type) Chcck0orp. Ccrtifiaite Installing Company Name _ Address ,�. . . \ ❑ Partnership 44 -�-- ❑ Firm/Company _ r' Na;ac of Licensed I'lunibcr 01'G sI t'ef I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best ofmy y ti -:knowlcdge and that all plumbing work and installations perforated under I'erinit issued for this application will he in compliance with all pertinent provisi low of the Massuchusetis Stoic Gas Cllde and Chapter 102 of the(icncral I aws. Fis l hove informed the owner or his agent that 1 do not have liability insurance including completed upelations coverage, 1 lulvc a current linhility insurance policy to include complctcel operations cavclagc. ❑ By ----- ---- Signature of Licensed I'luntl r 'I itic —_ I City/'Town — 'type of Plunlbit I tcensc C APPROVED (OFFICE USE ONLY) - I_i � Alastc ❑ Journeyman c,nsc Ntimhcr « 41 {. 3.t s Fcxtm 1240 HonHn a WA1114E4.INr; 1989 - 1 Location a S No. -� ,3 `� Date f MORTM TOWN OF NORTH ANDOVER 0 x Y • � ; , Certificate of Occupancy $ 'i Building/Frame/Frame Permit Fee $ s�cHuse 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ `3 Check # 3afo 15467 � Building Inspector I TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. a DATE ISSUED: y _� SIGNATURE: Building Commissioner/ingwor of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number Zoning Information: 1.4 Property Dimensions: Zoning District Proposed LTsc Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWred Provided Required Provided ,3�1 v 1.7 Water S ly M.G.L.C.40. 1.5. ood a Infomution: 1.8 Sewerage Disposal System: PublicPrivate ❑ ;Zone Outside Flood Zone Municipal On Site Disposal System 0 SEC IO 2-P,ROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Ow r of Record J— alvel 074)4,0 ,, ,,�,(I%/ r" Av 5 /-�"O 6Pf -3 Nan t) 14� Address for Service r Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z rn Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Li sed Construction Supervisor: Not Applicable ❑ 6C �119« VJ s 673201 License&Construction Supervisor: 7 i) Ql�9 q 7"' S J License Number Addres T / "n O b - 7e 5- Expiration Date ic Signa Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name Registration Number r Address _r Expiration Date /� Signature Telephone V SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the bpilding permit. Signed affidavit Attached Yes...... No.......❑ SECTION 5 Descri tion of Pro osed Work check all applicable)— New ConstructiomX Existing Building ❑ Repair(s) ❑ TAlIerations(s) 7Z ition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Descrip on of Proposed Work: /� f ) r SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building yds O d v (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of 3 CJ Construction 3 Plumbing 0 0 0 Building Permit fee(a) X(b) 4 Mechanical(HVAC O 5 Fire Protection &--d 0 6 Total 1+2+3+4+5 D U Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize ����'s l�,o �`� s�'"/-��� v S to act on My behalf,in all matters relative to work authorized by this building pennit application. G Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, �, i s%a p ��C �� ��-✓�S ,as Owner/Authorized Agent of subject property Herebv declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief 4, -F!r't1 e S Print Name - 1 Signature of Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TITVMERS 1 2ND 3 SPAN DIMENSIONS OF SILLS DM ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHININEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE TOWN OF NORTH ANDOVER f ttORTH Of-rice of the.Building Department Community Development and Services ° 27 Charles Street North Andmer,Massachusetts 01845 �ySS-AP. CK0 D. Rolm-,Nieetta, Telephone(978)688-9545 Budding Commissioner FAX(978)688-9542 DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and as a condition of building permit # the debris resulting from the work shall be disposed of in a properly licensed.solid waste disposal facility as defined by MGL c 11, s 150x. The debris will be disposed of at/in: /e) (Site location) y zz v Z Signa4-.e, permit applicant Date Michael McGuire,Local Building Inspector James Decola,Electrical Inspector JamesDiozzi,Gas/Plumbing Inspector t Tile�oomi�nan+uea�c°�✓�' ioeC�d�y; t BOARD OF BUILDING REGULATIONS ' License: CONSTRUCTION SUPERVISOR s*AS_ Numbtt073901 Birthdate° 03/1q)1971 Pis:'03/11 t0$4 Tr.no: 17738 R�strN 0 3 r CHRISTOPHER IRNIACENA8 '? 70 PLEASANT ST'2N� L I N ANDOVER, MA Administrator The Commonwealth of Massachusetts ' Department of Industrial Accidents I Office of Investigations Boston, Mass. 02191 Workers'Compensation Insurance Affidavit t- Please Print Name: foo �� rl,✓ d��IZ i `�0 .�� S" Location: / lej-4 City • e' Phone ( L Ls-,5- am a homeowner performing all work myself. 01 am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for my employees working on this job. Company name: 1r o allot S Address AD City: /�/ /i N D Odr Phone Insurance . _o. C/e- t,/ / 1/9 P 6 Z-r-?</3 7de:� Compgny name: Address City: Phone# Insurance Co. Folicv# Pailure to secure coverage as required under section 25A or MG1.152 can lead to the imposition of criminal penalties.of a fine up to$1,500.00 and/or one years'imp. t as well as civil penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. I understand that a c statement may be fo to the Office of Investigations of the DLA for coverage verification. I do herby certify n penalties that the information provided above is true and correct Signature at r Z d L Print name C e' 4e C, /�•q<<�✓qs . Phone# e( Official use only do not write in this area to be completed by city or town official' ❑ Building Dept ❑Check if immediate response is required Building Dept ❑ Licensing Board Contact person: Phone# El Selectman's ice ❑ Health Department ❑ 0fher RM WORKMAN'S COMPENSATION wir TAU RIM 0TVIM , OfE Andover No.4S3 ift ab T O _�_- LA E o dover, Mass., COCMICKEWICK ADRATE D 5 S BOARD OF HEALTH PERMIT T Food/Kitchen Septic System N to S BUILDING INSPECTOR THIS CERTIFIES THAT.. orevleow0 0 V 4I/My lwo..... ....................... % '........................ .... ....�... ............................ Foundation has permission to erect../ ' � ..buildings on .j a ' Rough .. �. ...............�........ ... ..... .. .. t0 be Occupied as �iJ1 Po....... ,fil a w....�t.��%�V!�V S..,�� '6 I rte, Chimney . ..... /. .. .. . .. 1 . ........................ provided that the person accepting this permit shall in every respect conform to the terms lthe application on file in Final this office, and to the provisions of the Codes and By-La s relating to-the Ins action, Alteration and Construction of Buildings in the Town of North Andover. f� / J73 �j/ PLUMBING INSPECTOR VIOLATION of the Zoning or Building.;$,Aegulations Voids this Permit. v Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION T ELECTRICAL INSPECTOR TS Rough C ........ ... Service ............... . ... . . .. ..... ...... BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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 1 Street No. SEE REVERSE SIDE Smoke Det. +� NORTH Aw— BUILDING PERMIT O�It%.* ,6 64e, a I TOWN OF NORTH ANDOVER � APPLICATION FOR PLAN EXAMINATION Z, w . Permit No#: b 1 Date Received �,ys R,TED ` � SiCHUs Date Issued: Z� K IMPORTANT: Applicant must complete all items on this page LOCATION 31Y ST Print PROPERTY OWNER AMS' 6TANCX49-t sn Print 100 Year Structure yes no MAP L02_PARCEL: ©/23 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 CR"Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic 0 Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: l AI-k (9P AMC- WTLL AE FZADM&� AND M#DE SDI m A �LA V Identification- Please Type or Print Clearly OWNER: Name: Am Phone: Address: 3 Jq K61 57, NaAN&um AJA Contractor Name: kF� A �Kuw Phone: X81 -(.-7o - 05« Email: K 2 Knls conRsr�eUcT.ro�yu C CO-7 Address: fie sr Sr w z c Supervisor's Construction License: CS - /ogoi� Exp. Date: ( If/T x Home Improvement License: /86`/2 Exp. Date: Jl 17 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: $ 254 gf3 so FEE: $ 3/0. 42 Check No.: y5 7-D Receipt No.: NOTE: Persons contractin ith un istered contractors do not have access to the guaranty�fuunnd Sia - — I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ f TYPE OF SEWERAGE DISPOSAL ! Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ i COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature . C MMENTImS >r Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes ^Planning Board Decision: Comments s A.. Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRED PARITMENT Temp Durnpster on site ;yes,_ Q Loc_atediat -12:4 Mam>ISteet. 4 ^1. Fire{Dgepartment sgnature/date; '`COMMENTS, } . _ 1 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 j NOTES and DATA— (For department use) i I ❑ Notified for pickup Call Email Date Time Contact Name Doc.Bnilding 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 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) Mass check Energy Compliance Report (If Applicable) 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 Doc:Building Permit Revised 2014 Location No. I , "�5 Date • - TOWN OF NORTH ANDOVER . JOY , ' . Certificate of Occupancy $ Building/Frame Permit Fee $ /U. Foundation Permit Fee $ r J Other Permit Fee $_ ` TOTAL $ _ Check# 2 C, G � Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 25,843.00 m $ - $ 310.12 Plumbing Fee $ 38.76 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 38.76 Total fees collected $ 487.65 314 Rea Street 1093-15 on 6/24/2015 ATTIC TO Playroom � NORTI� Town o .. t E �. Andover o to 01).- 115 * 0 . h ver, Mass, p� �/- cocH�cHew�cK y1' 7,9 q��'�TEO ►`P�,`�(5 S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .po.s.OT ......., , .! 1, ! .Q................................. BUILDING INSPECTOR Foundation has permission to erect ........................ buildin s on ..34. ...... .............. ......................... Rough to be occupied as ...... .............................. . . 40............................................................................. Chimney JA 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 � O UNLESS CONSTRUCTIO 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. NORTH own Of E ndover o *.� No. o R�Ah , ver, Mass, p� .� ».WICK 1 � A �v Q ,R-1TE6 I'Qa�,�y S U BOARD OF HEALTH • PERMIT T Septic System � � UI DING INPECTOR� THIS CERTIFIES THAT ............. .... . .... .. .. .. a�. .�1 �S.Ia................................ ........... ..... Foundation .... build' s on ...�. . has permission to erect,.................... t. ...... .............. ......................... � R'o h tobe occupied as ...... ............................ . . L*............................................................................. ��'cn provided that the person accepting this permit shall in every respect conform to the terms of the application Fi on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and L__ — All Construction of Buildings in the Town of North Andover. PLUMBING INSPECTO Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR O. UNLESS CONSTRUCTIO __]- Rough " Service .................... ..... .......................... J .................... Final ����1,< 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.S �� KMS Construction,LLC Kevin Schuh (781) 670-0517 Kevingkm sconstuctionllc.com 60 Forest St. Wakefield, MA Proposal For: Amy Cianciaruso 314 Rea St. Attic Work North Andover, MA Protect Scope: Project Preparation: • All belongings will be moved to alternative location. • Objects that cannot be moved (duct work, etc.)will be covered with plastic for protection. Construction: 0 Sister all floor joists with true (2x8) lumber to meet the floor joist requirement for a live load occupancy. • Replace collar ties so they are able to support drywall ceiling. Frame knee- walls for room. Finished room will be approximately 384 sq. ft. All walls and ceiling will be insulate with spray foam insulation which will provide sufficient insulation and air sealant rating to reach code. Larger window will be installed on both gable-end walls for secondary egress requirements. • Baseboard will be installed on finished walls and trim will be installed around windows. • Electrical work is included for outlets installed to meet code and for one TV/XBOX hookup with necessary cables. Painting of entire area is included as well. Items not included: material needed for stair treads/risers/handrail (however labor is included), cost of cork flooring, and HVAC vents for air conditioning. Estimate: MATERIAL LABOR TOTAL $16,270.50 $9,573 $25,843.50 Terms: 50% Payment upon project start Project start to finish: 22 Days 50% Payment upon project completion �y .y` C O N S T R U C T I O N L L C. Article 6—Subcontracts 10.1 A Subcontractor is a person who has a contract to perform any of the Work at the site. 10.2 Contracts between the Contractor and the Subcontractor shall be in accordance with the terms of this Agreement and shall include the General Conditions of this Agreement insofar as applicable. Article 11—Payments 11.1 Payments shall be made as provided in Article 3 of this Contract. 11.2 Final payment shall not be due or paid until:the Contractor has finished the Work;the Homeowner has inspected and approved the Work as complying with the Contract; any manufacturer or supplier warranties,equipment literature,and any as-built plans required are deliver to Homeowner;Contractor has complied with all requirements for Final Settlement. 11.3 Payment of final settlement is acceptance of Work in Agreement. Homeowner: By: Date: Printed Name: O Contractor: By: �� Date: OIE; Printed Name: *ov Scat,/A? }/ Page 3 yy I C O N S T R U C T I O N L L C. Article 4—Contract Documents 4.1 The Contract Documents Include: • Construction Contract • Project Estimate • Blueprints provided by Contractor and any applicable drawings • Notice to Proceed • Project Special Provisions, if applicable • Change Orders, if applicable 4.2 The aforementioned documents form the Contract.The intention of the Contract Documents is to include all labor, materials, equipment and other items necessary for the proper execution and completion of the Work and the terms and conditions of payments therefore. 4.3 Contract shall be signed by both the Homeowner and the Contractor. By executing the Contract, the Contractor represents that he has visited the site and familiarized himself with the local conditions under which the work is to be performed. 4.4 The term Work as used in the Contract Documents includes c udes all labor necessary to produce the construction required by the Construction Documents and all materials and equipment qu pment incorporated or to be incorporated in such construction. Article 5— The Contractor 5.1 The Contractor shall perform the work as a General Contractor pursuant to this agreement. 5.2 The Contractor shall supervise and direct the Work, using Contractor's best skill and attention. The Contractor shall be solely responsible for all construction means, methods, and techniques for coordinating all portions of the Work under the Contract. 5.3 The Contractor warrants to the Homeownerh t at all materials and equipment incorporated in the Work will be new unless otherwise specified, and that all Work will be of good quality,free from faults and defects and in conformance with the Contract Documents. All Work not so conforming to these standards may be considered defective. 5.4 The Contractor at all times shall keep the premises free from accumulation of waste materials and debris caused by Contractor's operations.This provision is imperative. At the completion of the Work, Contractor shall leave the Project site in a neat and orderly condition. Page 2 �r Y t; F'r rt C O N S T R U C T I O N L L C. THIS AGREEMENT is made and entered into this I jAclay of 7AA , 2015, by and between KMS Construction, LLC(hereinafter called "Contractor")and Amy Cz4Nex wsn (hereinafter called "Client" or"Homeowner"). The Homeowner and Contractor agree as follows: Article 1—The Work The contractor shall complete all of the work on the TNrep ftcnQ, J97r as specified in the Scope of Work on the included estimate,which is incorporated herein.The Work is generally described as oprr PtAy Rain AfdB4 Article 2—Time of Commencement and Completion 2.1 The Work performed under this Contract shall be scheduled to commence upon receipt of acceptance of attached estimate.Start date is anticipated to be on or about Barring any delay or additional work requested, project work is expected to have a duration of A3 days. 2.2 Except as otherwise required for the safety or protection of persons or the Work or property at the Work Site or adjacent thereto, all Work at the Site shall be performed between the hours of 7 AM and 5:30 PM, Monday through Friday, unless otherwise provided in writing by Homeowner, such consent not to be unreasonably withheld. Article 3—Contract Amount and Basis 3.1 The Homeowner shall pay the Contractor the amount of$ a5,8'13.50 for the performance of the Work,subject to additions and deductions by change orders to the provided estimate. 3.2 The terms for payment are as outlined on the attached estimate. completion project Upon the p p remaining balance is due to the contractor, which is inclusive of any and all change orders generated. Page 1 Kevin Schuh From: Cianciaruso, Amy <Amy.Cianciaruso@crl.com> Sent: Sunday, May 31, 2015 9:34 PM To: Kevin Schuh Subject: RE: Updated square footage AWESOME-- let's do it. Please keep this moving along. Once you are ready to start, let's discuss getting the dumpster so I can clear that area. So excited--thank you! Are you still thinking second week of June? Thanks. -----Original Message----- From: Kevin Schuh [mailto:Kevin@kmsconstructionllc.com] Sent:Sunday, May 31, 2015 2:40 PM To: Cianciaruso,Amy Subject: RE: Updated square footage Hi Amy, I have attached the estimate for finishing the attic.You will notice an increase over the most recent basement quote of about$2,500.The reason for the increase in price is due to the larger finished area, since this room will be over twice the size of the basement there are more materials needed. We will also need to put down additional plywood on the floor in order to make the subfloor adequate for the cork flooring. I have included the cost of replacing one of the gable-end windows to meet egress requirements and planned to leave the other window as is, so we do not increase the price any further.The costs for painting and electrical work have been included with this figure as well. The only things that have not been included are the cork flooring, material for stair treads and risers(since we have not discussed), and HVAC vents for AC. Please let me know if you have any questions or concerns. Once we decide to go ahead with this, I will meet with the building inspector to go over the construction plans and to obtain the building permit. Once we have this we will be able to start as soon as possible. Hope you are enjoying your weekend. Thanks, Kevin Kevin Schuh 781.670.0517 Kevin@KMSConstructionllc.com -----Original Message----- From: Cianciaruso,Amy [mailto:Amy.Cianciaruso@cri.com] Sent:Thursday, May 28, 2015 8:37 PM 1 -- ��I�pow __ IIT 1 T I 1 I l - I I f -- - - _I- I 1�1�. _i- NL-\-jl I� I I I_� _1 1 --1_ I_ IA I -1 1 _ I� 1 ;ail, rT-I_J �� i ���_1_"I_;_...I_" � �_._I-i __i- -� - - 1_-1_- 3�i - - - - �- � - TI_I_ 1 _ STA R _I _;_ _1 1 ISI IT I I I I IIT I�TI f l I- I�T _I--- I- ---iW � l_-- 1_ I T 1 T I { l i I ! I�i IT T�I�TI� 1�5;-1--1- TI { i�I_I_IT r I II } IaII I II T t�iah,e%ac�`Ir u�o The Commonwealth of Massachusetts F Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia . 7'-IM SJ•V Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY.A hcant Information _ Please Print Legibly Name(Business/Organization/Individual): KmS CO3vsr#&cUQaV-� Address: Cofimar !Sr City/State/Zip: Otero Phone#: 8/ 6,60 - 0514 Are you an employer?Check the appropriate box: Type of project(required); 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New'construction 2. ]I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling 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 11.0 Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no Employees. 12,0 Plumbing repairs or additions 5.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 14.❑Other, 6.n We area corporation and its,officers have exercised their right of'exemption per MGL c. 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. 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: uu � � ✓ Policy#or Self-ins.Lie.#: G2UF� E9tIBtK`Q" �— Expiration Date: 02 -t3f Job Site Address: 3111 �EA .Sf City/State/Zip: Nonni- 14ril Lez IIIA 018yS Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. provided above is true and.correct. hereby certify under thepains and penalties of perjury that the information Idoher y fy P ,�� S Signature _ zeWu Date: Phone#: $/' LLse only. Do not write in this area,to be completed by city or town official. n• Permit/I icense# hority(circle one):Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: 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 be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license 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-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 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 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 O VDAC ace group WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6S62UB-2E72805-9-15) NEW-15 INSURER: ACE AMERICAN INSURANCE COMPANY 1. NCCI CO CODE: 12165 INSURED: PRODUCER: KMS CONSTRUCTION LLC RSC INSURANCE BROKERAGE 60 FOREST STREET 15 PACELLA PARK DR WAKEFIELD MA 01880 RANDOLPH MA 02368 Insured is A LIMITED LIABILITY COMPANY Other work places and Identification numbers are shown in the schedule(s) attached. 2. The policy period Is from 02-13-15 to 02-13-16 12:01 A.M. at the Insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in �:.. item 3.A. The limits of our liability under Part Two are: .dam --- Bodily Injury by Accident: $ 1100000 Each Accident Bodily Injury by Disease:' $ 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee o� B . C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any,listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A ` D. This policy includes these endorsements and schedules: moi= '- o� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE '—' 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 03-05-15 PD ST ASSIGN: MA OFFICE: ORLANDO DA ACE 24M PRODUCER: RSC INSURANCE BROKERAGE 27K4T 014131 c Cnin„+oiru�rrr�//cyr'.1/nJJrrP�trJr//J License or registration valid for individul use only Office of Consumer Affairs&Business Regulation $ Y G�3 F1OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: registration: 180427 Type: Office of Consumer Affairs and Business Regulation 5 1 xpiration: 11/17/2016 LLC 10 Park Plaza-Suite 5170 Boston,MA 02116 KMS CONSTRUCTION,LLC. KEVIN SCHUH 60 FOREST ST � � WAKEFIELD,MA 01880 p Undersecretary Not valid without signature I Massachilsetts -Department of Public Safety Board of Building Regulations and Standards Construction Supersi%or O _ License: CS-108016 KEVIN SCHUH 60 FOREST STREET _ Wakefield MA 01880 CXpiratint. �+C-ommissionner' 06/0612018 Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991m3)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing Information visit: www.Mass.Gov/DPS