Loading...
HomeMy WebLinkAboutMiscellaneous - 340 SUMMER STREET 4/30/2018 (2)N Date- —1 . . . 114 ....... ..................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......................................................... ............................ has permission to perform ........................................................................ ................................ wiring in the building of....... o L" C; . at .... ��SLA VYN�� ....... ... . h-... ............... .......................... 2. ......................... . Pfqrt -Andover, Ma Fee.5� ............... Lic. No. ................. ............... ... . . ...... ... ELEM AL PINSPECTOR c .) Check # 12149 e, Commonwealth of Massachusetts Official Userev Department of Fire Services Permit No. Occupancy and Fee Checked ,M BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NIEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of"his soor her intention to perform the electrical work described below. Location (Street & Number) %d Owner or Tenant Telephone No.�0 Owner's Address S--w--ze Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 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 Nature of Proposed Electrical Work: Completion of the following 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 5 Swimming Pool Above ❑ In- Elo. o mergency Lighting rnd. 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. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number TonsKW " ' ...... ' 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 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 WYres. Estimated Value of Electrical Work: (When required by municipal policy.) r 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 cover ge is in force, and has exhibited proof of same to the permit issuing office. UR CHECK ONE: INSANCB,KBOND ❑ OTHER ❑ (Specify:) I certify, under the painsand enalties of perjury, that the information on this application is true and complete FIRM NAM/E:. /Lt c LIC. NO.• ���� Licensee: `�c Signature �'�� l— - LIC. NO.: (If applicable, enter "exem in th license number line.) J Bus. Tel. No. • Address: /�/1. 2w < r7 Alt. Tel. No.: *Per M.G.L C. 147, s. 57-61, security work requires Department of Public Safety "S" Li nse: 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 PERMIT FEE: $ Signature Telephone No. 57-7 ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: hi accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed ` on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an 1 electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass [fl Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass IN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSP CT ON: Pass Ifl Y Failed Re- Inspection Required ($.) ❑ Inspectors Commen : Inspectors Signature: Date: u DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com l The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street .Boston, MA 02111 UV www.mass gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): , Address: &Oen- City/State/Zip:AleW /46yt'5 e 3o Z/ Phone #: LG'�� —S Are you an employer? Check the appropriate box: 1. [l I am a employer with 4. ❑ I am a general contractor and I mployees (full and/or part-time).* have hired the sub -contractors 2/ aa sole proprietor or partner- listed on the attached sheet. shmip and'haveno employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New contraction 7. F1 Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions ILEI Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other 4 *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 a're doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lie. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of 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 ce^rtto under the pains and penalties of perju ormation provided ab ve is /rind correct. SiQnatur2: \ Date: i 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 #: Informati®n 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 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 Commonwealth of Mo ssachp seis Department of Industrial Accidents Office of Investigations 600 WashiVon Streot Boston} M4, 02111 Tel, # 617-727-4900 ext 406 or 1-877,MASSA.FB Revised 5-26-05 Fax # 617"727-7749 �w�vaxzass,g¢v�dla 9 Date ...*17 /13...... 11312 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...� /P.(l.ot v ......... .... 4� d .......................................................................... has permission to perform ....... ....:.................................................... plumbing in the buildings of .... .��..f��.-✓— at ....— 44q...le..!�►.t s................................A......., North Andover, Mass. Fee Sat. Y.. Lic. No: i4r/ 1.. PLUMBING INSPECTOR `y Check # l d w ij MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK U CITY d W O v MA DATE L -/ i i PERMIT # f JOBSITE ADDRESS OWNER'S NAME"COL LQC DOf s�`� 2 POWNER ADDRESS — TELL._ TYPE OR OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: © RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES7'I NO2/ FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 , 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM i E! I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER f �— _ 1 _ I 1 DRINKING FOUNTAIN _ ! _ ! J FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR INTERIOR J- �— _ ! .1 KITCHEN SINK— LAVATORY 2 i ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET ! I URINAL , WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I WATER PIPING OTHER '5777 Fq u c -e INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ® NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE: APPROPRIATE BOX BELOW LIABILITY 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ® AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance With all Pe inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE # ZYSJ6 SIGNATURE MP® JPz CORPORATION®# PARTNERSHIP[]# LLC ®# COMPANY NAME ULT i' H ADDRESS 3, e S A/ CITY Lo STATE ® ZIP I v/ TEL 5-0 JP- FAX I SIS/ -VS l j CELL EMAIL_ I r fi n �z'f I�LR�55� loodY Location _1No. � Date TOWN OF NORTH ANDOVER a , • Certificate of Occupancy $ �'s''••°•E<�' Building/Frame Permit Fee $ f�CMUs Foundation Permit Fee $ Other Permit Fee $ TOTAL $ lor Check # 1961f 1 &4:3 8 i Building InspeWr TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: J� SIGNATURE: Date I SF.CTION 1- SITFF, INFORMATION I 1.1 Property Address: 1.2 Assessors Map and Parcel I07,1,9 Map Number Number: �/6! Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage R 1.6 BUILDING SETBACKS ft Signature Telephone Front Yard Side Yard 2.2 Owner of Record: Rear Yard Required Provide ReqWred Provided ReqWred Provided Si natureTelephone SECTION'3 - CONSTRUCTION SERVICES 1.7 Water Supply M.G.L.C.40. 54) Public 0 Private ❑ Zone 1.5. Flood Zone Information: Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System 0 SI'iiCTION 2/- PROPERTY OWNERSHIP/AUTHORIZED AGENT 1 flim ju uibifiCT: YeS NO 2.1' Own of Record a ry Name (Print) Address for Service Cz Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Si natureTelephone SECTION'3 - CONSTRUCTION SERVICES 3.1_Licen'sed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: 6/ .3 Number iLicense Z fI r",3 P.f.lo u j Address ,2 e,4 Z2 /It F Old' g Expiration Date SiTelephone 3.2 Bred Home Improvement Contfictor Not Applicable ❑ Regi n %/���J?%crib sr, of R'G�'1T'r C Gef -z "f L o /0/ p Company Name f Registration Number � ��— i3ar� i_./„2 —fG /-r, - r���i Iry {., Address i`st -c� (1zYC � / ;-77 0 -� Ef S� F Expiration Date Si nature = Telephone SECTION 4 - WORKERS COMPENSATION (M_G 1. V tet R 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 buildin rmit. Signed affidavit Attached Yes ....... No ....... ❑ SECTION 5 Description of Proposed Work check alta ucable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: ; . L /A .t i SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to LkIL4U Completed b ermit ap2licant a Building Permit Fee 1. Building �J j r Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (e) (H-VAC) 4 Mechanical 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION --a' i �'�'"'� f' �� & v 1 t G � ] � ,as O er�onzedf subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief '2".-? Y:-,� & '-e ,7 t%/ -i �► (' 1 rr rte` �� Print N r Si afore o er/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS PT 2 RD 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDA'T'ION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE aM\ Department of Indus&W Accidents "gim Office of Investigations ir 600 Washington Street Boston, MA 02111 www.massgov%die Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers Aaalicaut Information Please Print Leeibly Name (Business/orpmatioDu ividual):_%YC'"7i�� c ➢ :� ",7,0l4e," U f.1 o- —2 T -- Address: °/J i3 ,,-, `�t;�i City/State/Zip: o, i ,, ,/ Phone #: 9,�7 7_ 6' Fr3 V.- J t Are you -employer? Check the- appropriate box: 1. [ -1 am a employer with _ - 4. ❑ I am a general contractor and I employee's (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet: t ship and have no employees . These sub -contractors have working for me in any capacity. workers' comp. insurance. (No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing an work right of exemption per MGL myself. (No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. (No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition 100 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ other -nny awncmi umi cmcaa ooa tv i mum mso mi Ow we secuon oemw atwwtas thele wodws'.compmsation policy information t Homeowners wbo submit this at8devit indicating they are doing ell work and thea hire outside coutracton must submit a new stM&vg isdicetirra such tContrsctors that check this box most attached an additional sheet sbowing dw none of the cab-vontmdon and their women' comp. polity Wt'armetiaa I am an employer that Is providing workers' compensation insurance for my employees. Blow is the poMa and, job site informatlon. Insurance Company Name: Policy # or Self -ins. Lic. M. C 1 r*a ) 3. A Expiration Date: Job Site Address: City/StatelZip:i(% ,/9,,, n a ze-.� v" / �- Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requirl 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-yearbiprisonment, 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 certt�y under the palms andpcnahies of perjury that the Information provided above is arae .wd carrwez C Phone #: 9 F x - ,F 2 44�- F- QS7cial use only. Do not write In thk area, to be completed by efty or town opkiaL City or Town: Permk/Liceuse 0 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Cky/Town Clerk 6. Other J -- 4. Electrical Inspector S. Plumbing Inspector Contact Person: Phone 0: iniormatiun anu iuibui m -ti vita Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employee=s. Pursuant to this statute, an employee is defined as ` ...every person in the service of another under any contract of hire, R 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 comrnomealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), addresses) 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 sip 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 CwWanies should enter their self-insurance license member 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 permittlicense 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 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 mast 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406'or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 wwwmm.gov/dia ',•,.. RAYMOND E. DAMPROUSSE, Be AND SONS ROOFING CO -9 INC. BOX 431 LAWRENCE P.O. MA. CONSTRUCTION LAWRENCE. MA 01842 SUPERVISOR LIC. #048636 TEL: (978) 683-4588 HOME IMPROVEMENT REG. #101862 ROOFING - SIDING -,INSULATION Date From: /1J=? < !� ,n t�S / , / J � --' �-7 ,-,-V%- (Noma) (AWresq To: UTNIOD E MillIG N, JN, ='31n 181FM6 CO,, OC., BOX 431 LAWRENCE P.O., LAWRENCE, MASSACHUSETTS 01842 I (we) hereby authorize the Coffiact'or t rnish all materials, and labor necessary to Install, construct and place the . Improvements described below In -on building located at No. / c' cil� !n'j �2 Street, City , �f�-� <F l ;42'1 LL'Ll State in accordance with the following specifications: 'a�/ C) �z'7 v I'1 ii vj'J /`i (� / i ��' � �f �% � 9 ^r � r�/!'f / ^'�/.✓ �� rr� I -'l ; -✓ y.- /�,,,/ �� .( r f f! ✓�c� T f"7 ? �l". :" '7 ..:.� ? �',c7("'; 'X <) -7 tr br�✓�' v" ��f- / -7_lt/��'ilZ /�"�t/ C✓` )�� �rr'r�1'7f!' (..-1/1r=!7/2,2r-,:a - �/zy Z/.1= i / i .?f/i,',t (,� !fin/3(-) ..... r -T �1-� 7 , c . All of the above work to be done in a good and workman -like E! / ! {_ r1�•, =- X15 C3 manne_•_ .1 All men and equipment Insured. Premises to be left clean upon completion of work: �' ,O For the total sum of dollars. Entire Sum to be paid immediately upon completion In accordance with plan as shown below. TOTAL CASH SELLING PRICE .........d9 O� �s U -v DOWN PAYMENT IN CASH ............. DEFERRED BALANCE UPON COMPLETION .................. The undersigned agrees to keep property mentioned in this agreement properly Insured against 1033 by fire including the Contractor's interest therein. This agreement shall become binding only upon the written acceptance hereof by said Contractor, and upon such acceptance this shall constitute the entire contract and be binding upon the parties hereto, there being no covenants, promises or agreements, written or oral except as herein set forth. It is the Intention of the parties hereto that this contract shall be binding upon their respective heirs, executors, administrators, successors and assigns. Customer agrees to pay a reasonable sum as attorney's fees and Court Costs if placed In hands of attorney for collection. The owner further agrees that in event of cancellation of This contract after acceptance by the contractor and before the work is commenced the OWNER agrees to pay 20% of the total consideration herein named as liquidated damages for breach of contract. Said contractor shall not be responsible for damage or delay due to strikes, fires, accidents, or other causes beyond his reasonable control. We, the undersigned, certify that we are the sole owners of the property herein described on which said work or repairs are to be performed. IN WITNESS WHEREOF, the undersigned has (have) hereunto set his (their) hand(s) and seal(s) the day and year written above. Accepted By Husband RAYMOND E. DAMPHOUSSE, JR. AND SONS CO., INC. (Signature and tie of Official) Wife Mail Address (it different from above)