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HomeMy WebLinkAboutMiscellaneous - 37 COCHICHEWICK DRIVE 4/30/2018�S S r CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 825-2010 Date: April 27, 2011 THIS CERTIFIES THAT THE BUILDING LOCATED ON 37Cochichewick Drive, North Andover, MA 01845 Campion Hall MAY BE OCCUPIED AS unit IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Campion Estates, LLC 1518 Cochichewick Drive North Andover, MA 01845 Building Inspector Fee: 100.00 Receipt: 24100 This certifies that . v� c !► G^ o' 1 \ G�f��Q,,� has permission to perform .... .................... ptNi Bing in the buildings of. ' 7. ................ at ................... I ................. No Andover, Mass. Fee' '7' .. /.� Lic. No. ... ... . ....... ...... ... / /' 7 PLUMBING INS ECTOR Check # 16 0 f"d 1 JSO WASHING MACHINE CONNECTION WAT'L"Q" �HEATER ALL TYPES WATERpIPING _ OTHER INSURAKE COVERAGE: have a current liability insurance policy or its substantial equivalGht which meets the requirements of MGL Ch.142. YES Q NO [�1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE B+ECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OWNER'S INSURANCE WAIVER: I am aware that the licensee doi Massachusetts GenRral Laws, and That my siwgnature on this pern SIGNATURE OF OWNEk OR AGENT hereby certify that all of the details and information I have submitted or e and that all plumbing work and installations performed under the permit is Massachusetts State Plumbing Code and Chapter 142 of the General Lav PLUMBER'S NAME I ta�rI- rn �� MP j JP CORPORATION COMPANY NAME ADE CITY j� I��� tI ; STATE ZIP FAX _J CELL �� EMAIL INDEMNITY BOND Q of have the insurance coverage required by Chapter 142 of the pplication waives this requirement. CHECK ONE ONLY: OWNER Id AGENT d regarding this application are true and accurate to the best of my knowledge for this application will be in compliance with all Pertinent provision of the SE # SIGNATURE PD#=LLC ._i _ I TEL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY Ed MA DATE/ PERMIT # 6 1 JOBSITE ADDRESS % ti C f ` it OWNER'S NAME L ', C yj' K POWNER ADDRESS ; TEL �- —_ FAX ' J TYPE OR OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL ® RESIDENTIAL d� PRINT CLEARLY NEW: 0-_I RENOVATION: REPLACEMENT: D PLANS SUBMITTED: YES tg NO© FIXTURES 1 FLOOR—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12,'-1 13 14 BATHTUB CROSS CONNECTION DEVICE.._....__.,a K_. DEDICATED SPECIAL WASTE SYSTEM ! ___.__.I ._-____ __ _.1 __...___ . .� ( ..._.___w J I 1 DEDICATED GAS/OIL/SAND SYSTEM I ( 1 . ! .__.._I __.._....1 -- I E_771= DEDICATED GREASE SYSTEM-_--__[ = I I DEDICATED GRAY WATER SYSTEM 1 I f I _.._.I _I ► ____ ! DEDICATED WATER RECYCLE SYSTEM _ 1 ! I ( .....J __J __.._...i ! DISHWASHER__.._._# ...-.._.....__I . ___.1 ____i 1 DRINKING FOUNTAIN i _.__.....{ _._I i __...._._i ._.._-.I -_._.._. ..__. _! ._ -----i FOOD DISPOSER _I _...___{ -.____i____1 __.__.i .____�J ._____i FLOOR /AREA DRAIN _ _i � _._._. __.__._I _._ ._._._..� .___..__} _i _..._J J 1 1 I. ._._____f INTERCEPTOR INTERIOR) f __�l ___... __--__-1 ....._ _..1 { _ I _..__J .__._._f i _.._._ i � KITCHEN SINK.._..____.I _j __ . --.._I _.____I LAVATORY 1 ___...J ._.__.� I _.__....1 �_J 1 1 ROOfdDRAIN # __._.J _...___I � _.._._..._f ..__-__J .�_...__.a _.__.__1 _._ _..._.__I i SHOWER STALL ._ ! __i ._____._i ._.__� SERV CE / MOP SINK _( l _.-_-__I I .....__. � ) _ _._.J __f I s I i_. I TOILET____._.__....__._..�URINAL. _._J _.._:__.� �'_ t a. WASHING MACHINE CONNECTION WAT'L"Q" �HEATER ALL TYPES WATERpIPING _ OTHER INSURAKE COVERAGE: have a current liability insurance policy or its substantial equivalGht which meets the requirements of MGL Ch.142. YES Q NO [�1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE B+ECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OWNER'S INSURANCE WAIVER: I am aware that the licensee doi Massachusetts GenRral Laws, and That my siwgnature on this pern SIGNATURE OF OWNEk OR AGENT hereby certify that all of the details and information I have submitted or e and that all plumbing work and installations performed under the permit is Massachusetts State Plumbing Code and Chapter 142 of the General Lav PLUMBER'S NAME I ta�rI- rn �� MP j JP CORPORATION COMPANY NAME ADE CITY j� I��� tI ; STATE ZIP FAX _J CELL �� EMAIL INDEMNITY BOND Q of have the insurance coverage required by Chapter 142 of the pplication waives this requirement. CHECK ONE ONLY: OWNER Id AGENT d regarding this application are true and accurate to the best of my knowledge for this application will be in compliance with all Pertinent provision of the SE # SIGNATURE PD#=LLC ._i _ I TEL If The Commonwealth of Massachusetts Department of IndustriqlAccidints Office of Investigations 600 Washington Street Boston, MA 02111 $V wwwanass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers inii .,. D-4. T arAbl'i Name (Business/Organization/Individual): AZ 0 Address: d City/State/Zip:_rAL/�_5 -LOW #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6, El New construction part-time).* roto ees full and/or .* p Y p ) have hired the sub -contractors listed on the attached sheet. I Remodeling �' El2. I am a sole proprietor or partner - ship and'have no employees These sub -contractors have 8. ❑Demolition working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its g, [] Building addition 10.❑ Electrical repairs or additions required.] ')❑ officers have exercised their right of exemption per MGL 11. Plumbing repairs or additions 3. ❑ I am a homeowner doing all work c. 152, §1(4), and we have no 12,❑ Roof repairs myself. [No workers' comp. "+ insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] ' *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. A Homeowners who submit this affidavit indicating they aie 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. 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 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 cert fy under the pains an�nalties of'perjur that the information provided above' trug a d c�o�rrect. 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 I Contact Person; Phone a�, li COMMONWEALTH OF MASSACHUSETTS' PLUMBERS AND .GASFITTERS EIC1VStD.ASA JOURNEYMAN PLUMBER ISSUES THE ABOVE LICENSE TO: r ' I GARY A FIEL'.DING ! tit : , 1 '. 1AGIBSON Ci NORTH' ANDOVER MA O 1 -845"'4246"x ?` 2.0784 05/01/14' + ..183503 ZOS£81 h1/10/50 ZL91j , hZ� S9910, bW d3AOQN. HJ l3' NOSBI.,9"A < i JNlQl3Td V. �d � f :01 3SN3011 3AOBV 3Hl S3f1SSl �139Wn-ld m3J.SdW v Sy 03SN3oll SH311WSVE) oNd SU3d!4nld . S113S(1` SSdW dog �3M-- MNOW O4 I I 0 Date. il�X 3 ................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that............................................................................................................................ has permission to perform 1Pf t0 / u.. G� +,e ��ii ............................................................... wiring t�b 'Iding of........... G -S ami � d L'.�; N Andover, Mass. Fee -- Lic. No........................................................ .� b ............!'.................. ELE7 CAL INSPECTOR Check # SF 7Z -- f' 0 e Commonwealth of Massachusetts Office Use Only Department of Fire Services Permit No. I 30ARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 CK# 3 9 7 2 Occupancy & Fee Checked ( Rev. 11 199) (leave blank) ?PLICATION 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 IN INK OR TYPE ALL INFORMATION) DATE September 9, 2013 City or Town of North Andover To the Inspector of Wires: By this applicationthe undersigned gives notice of his or her intention to perform the electrical work described below. j Location(Street & Number)J% MCochichewick Drive Owner or Tenant Richard Kapleson BUILDING CONTRACTOR KA & EM Enterprised LLC Owner's Address 41 Cochichewick Drive CONTRACTORS ADDRESS 14 Harding Street i N. Andover, Ma Milford, Ma 01757 I Is this permit in conjunction with a building permit Yes No Building Permit no. ' Purpose of Building Residential Utility Authorization no. Existing Service 1 2 5 Amps 120/240 Volts single PHASE Overhead g ........ ..... .,,, ..4,......, „ „ , � No. of Recessed Fixtures Und rd x No. of Meters one Mast Service B No. of Lighting Outlets Syphone e New Service Amps Volts PHASE Overhead KVA Undgrd No. of Meters No. of Emergency Lighting Battery Units Mast Service e Syphone B Number of Feeders and Ampacity No. of Detection and Initiating Devices. No. of Ranges No. of Air Conditioners Total No. of Alerting Devices. Location and Nature of Proposed Electrical Work Replace wiring damaged by water in hallway and Ilvinig room Completion of tho fnlinwinn f.hlc mw he .. —d hu #h. in en1n. ni...i..... No. Hydro Massage Tubs No. of Motors Total HP Telecommunications Wiring: \ i No.of Devices or Equvalent \ OTHER: ^� Attach additional detail if desired, or as required by the Inspector of wires. 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 BOND ❑ OTHER F-1 (Specify:) (Expiration Date) Estimated Value of Electrical Work $ ( When required by municipal policy. ) Work to start: September 10, 2013 Inspection to be requested in accordance with MEC Rule 10, and upon completion. certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME Leonard Electric, Inc. LIC.NO. A10638 Licensee Signature LIC.NO. Address 154 Fletcher Street, Lowell, Ma. 01854 Bus. Tel. No. ( 978 ) 937-8620 Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the licensee DOES NOT HAVE the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner F-1 Agent (please check one) Telephone No. PERMIT FEE $ 5 5.00 (Signature of Owner or Agent) --...._.._...................... ........ ..... .,,, ..4,......, „ „ , � No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle ) Fans No. of Transformers Total KVA No. of Lighting Outlets No. of Hot Tubs Generators Total KVA No. of Lighting Fixtures Swimming Pool Abornd grnd No. of Emergency Lighting Battery Units No. cf Receptacle Outlets No. of Oil Burners FHW FHA FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners FHW FHA No. of Detection and Initiating Devices. No. of Ranges No. of Air Conditioners Total No. of Alerting Devices. Tons No. of Waste Disposers Heat Pump Number ..................... TonsW K... ...... No. of Self Contained Detection / Alerting Totals: Devices. No. of Dishwashers Space / Area Heating KW Local Municipal Other Connection M Connection No. of Dryers KW Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW No. of Signs No. of Data Wiring: Heaters Ballast's No of Devices or Equivalent No. Hydro Massage Tubs No. of Motors Total HP Telecommunications Wiring: \ i No.of Devices or Equvalent \ OTHER: ^� Attach additional detail if desired, or as required by the Inspector of wires. 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 BOND ❑ OTHER F-1 (Specify:) (Expiration Date) Estimated Value of Electrical Work $ ( When required by municipal policy. ) Work to start: September 10, 2013 Inspection to be requested in accordance with MEC Rule 10, and upon completion. certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME Leonard Electric, Inc. LIC.NO. A10638 Licensee Signature LIC.NO. Address 154 Fletcher Street, Lowell, Ma. 01854 Bus. Tel. No. ( 978 ) 937-8620 Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the licensee DOES NOT HAVE the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner F-1 Agent (please check one) Telephone No. PERMIT FEE $ 5 5.00 (Signature of Owner or Agent) .x The Commonwealth of Massachusetts lrint l orm Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Leonard Electric, Inc. Address: 154 Fletcher Street Lowell, MA 01854 Phone #: 978 937 8620 Are you an employer? Check the appropriate box: 1. ❑✓ I am -a employer with 20 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.# required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance reouired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other i *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 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 thepolicy and job site information. Insurance Company Name: SELECTIVE INS. OF S. CAROLINA Policy # or Self -ins. Lic. #:WC799386600 Job Site Address: Expiration Date: 6/30/2014 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 thepains and enaldes of perjurythat thein ormadon provided above is true and correct Phone #: 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone AC0MM0NWaLfH F M A0H I ANS "iSUES TH E -FOLLOWING J�E D MASTER , EL E CTR I CI A D ELECTRI C` `] NIC L -9Q.E TARD 1514 FLE.-TTER-f STREET x SJ 01854. 63B."" 0 ......... ......... ..."27410 This certifies that Date ....1....:........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING i ............................................................... .......-...:�........................... has permission to perform . /TWO,' !a i .. K/%/ n. o . wiring in the building of..R`.......... l o,��L, SO . .. I/ ............ ............. ............. .................... at 3.7..... .. 1.?.. .. «c........ /�.P............. North Andover, Mass. / Q Fee....'ra .. Lic. No. ...... ...�.C�S. , .6 .............. --1,,r ELECTRICAL INSPECTOR Check # Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. _ Occupancy and Fee Checked Zev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 ' (PLEASE PRINT IN HK OR TYPE ALL INFORMATION) Date: City or Town oh NORTH ANDOVER To the Inspector of Wires: By this application the undersigned ives notice of his or her intention to perform the electrical work described below., Location (Street & Number) b-1 00 RC1- - IF -1V (,-� r-1 �VL i Owner or Tenant t Ovrfner's Address SAS t3 Is this permit in conjunction with a building perm' . Purpose of Building - Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Telephone No. es nNo U (Check Appropriate Box) ilitv Authorization No. OvVheaTo Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: %qV Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA I No. of Luminaire Outlets No. of Hot Tubs Generators KVA �4P'` No. of Luminaires Swimm' Pool Above4. In o. o mergency ig tmg i " ze rnd. r d: attd ;, nits . No. of Receptacle Outlets yk ,.. x o 0i, ,uruers : > a '� ` r Fl 2E ALARMS Nko. of Zones No, of Switches No. of Gas Burners No. of Detection and j Initiating Devices II No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices t No. of Waste Disposers Heat Pump berT Numons " ' " KW ............"'"" No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KWLocal ElMunicipalConnection Other No. of Dryers Heating Applirances ► KW r. Se6brity Systems:* M V No. of Devices or E uivalent No. of Water KW No. of .. >. of 4 :. Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent . OTHER: s' tvtitQILS -,4daAWgddX6 . 1 detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: J !` `+ (CWhen quire 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 sukh coverage is in force_, and has exhibited proof of same to the permit issuing office. CHECK ONE: 1NSURAN6L 3 BOND. HER,] (Specify:) I cert! i , tinder the p-nins #nd pin 'es.ofpBr' ry, that.1he`it�for tide on this application is true and complete. FIRM NAME: `� ?`/ LTC. NO.: Licensee: ILI 656 n tur LTC. NO.: (Ifapplicable, nter "exempt" i the licen amber 'ne.) Bus. Tel. No.• Address: l 1 G � !1 w�' Alt. Tel. No.: *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 PERMIT FEE: $ Signature Telephone No. F ;A IF Date... .............. ............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING jF CHU ..... ... This certifies th lz� _. i . r:" "1 ................... ...................... has permission to erform ... .. wiring in the buildi of., .... ....oow at., . ..... ...... .... Fee....Lic. j........................ Andover, Mass. ELECTRICAL INSPECTOR Check # 53-7299/2113 122 JEAN MENEZES DBA JINO ELECTRICAL SERVICESt3 29 DAIGLE RD. LYNN, MA 01904-2109 s 55,Po Uj PAY TO T RD OF V ILI DOLLARS /K M leb rdp MEMO 25 103ISS.112 01 lb 113 ? 29CH31: The Commonwealth of Massachusetts Department of IndustriqlAccidints Office of Investigations 600 Washington Street Boston, MA. 02111 www.mass.gov/dia Workers' Compensation Insurance .Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # 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 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 construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions I L ❑ Plumbing repairs or additions 12.❑ Roofrepairs f Mr! Other � !Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. A M Homeowners who submit this affidavit indicating they Aire 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:._ L t` N SU Ka, S A l{ ery C4 f L L C Policy # or Self -ins. Lic. #: ' I `'[ tp �O ` �( Expiration Date: CS — q 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 maybe 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. Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License . 1. 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 #: and r33sN P LLi S L/I o J . "v (%T- auj N �. I 6 W • i .4b; V', w x ` 0-w w Q THE Mit STREET Ammc GRoup rrustecl NGM Insurance Company * Old Dominion Insurance Company Main Street America Assurance Company * MSA Insurance Company Information Systems and services Corporation Main Line Businessowners - Insurance Proposal Named Insured: Quote Number: 1742664-01 JEAN MENEZES DBA - JINO ELECTRICAL SERVICES 29 DAIGLE RD LYNN MA 01904-2109 Company: MAIN STREET AMERICA ASSURANCE COMPANY Policy Term: 12 months Agency Name: LEMIRE INSURANCE AGENCY LLC Address: 213 MAIN STREET STE 1 HUDSON, MA 01749 Premium —Grand Total: $ 798.00 *Including taxes, fees and assessments Liability Coverage Liability & Medical Expense —Each Occurrence Personal & Advertising Injury Limit Damage to Premises Rented to You Aggregate Limit —Products -Completed Operations Aggregate Limit —Except Products -Completed Operations Medical Expense Limit —Per Person Main Line Businessowners Enhanced Liability Features (BPM -QO2) Proposed Effective Date: 08-142013 Date Prepared: 08-14-2013 Agency Code: 201312 Phone Number: (978)568-8700 Limit Deductible $ 1,000,000 $ 1,000,000 $ 500,000 $ 2,000,000 $ 2,000,000 $ 10,000 SEE ATTACHED 4601 Touchton Road East, Suite 3400, Jacksonville, FL 32246-4486 • (800) 207-0446 QUOTE PROPOSAL COPY