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HomeMy WebLinkAboutMiscellaneous - 507 JOHNSON STREET 4/30/2018 507 JOHNSON STREET 210/098.A-0016-0000.0 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION PermitNO: Date Received Date Issued: 41PnRTANT:A plicant must complete all items on this page LOCATION__ 50 -7 ' Print PROPERTY OWNER��I/>')'1 Print 100 Year Old Structure yes o MAP NO: LN PARCEL:a*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 ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: c1 � Identification Please Type or Print Clearly) s OWNER: Name: ►v�17 [ -P� Phone: Address: 50-7 d)J vl-ro 'i - CONTRACTOR Nam;.7\ Phone: yGJ Address: Supervisor's Construction License: 5E,414-l.3-Exp. Date: 110 Home Improvement License: 16 -7339"" Exp. Date: �� I 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: $ �o?S FEE: $ •� Check No.: Ill t Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner ig�ature of contra Plans Submitted [J-- Ians Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE-OF:SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco.Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc.. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS 1 HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Toiv � Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Mair Street Fire Department signature/date D COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A=F and G m1n.$100-$1000 fine NOTES and DATA — (For department use El Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The fol-awing is"a list of the required forms to be filled out for the appropriate permit to be obtained. Roofivg, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New ConstructionSin le and Two Family) � 9 Y) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all casts if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm-tted with the building application Doc: Doc.Bui?ding Permit Revised 2012 Location f5bl To I,--j 'J No. 1 l Date 12-j(, • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee TOTAL $ Check# �; Building Inspector r , NORTH - . w1. . . 0. .c . . ve: Page No. of Pages Builders License # 58443 IAL Home Construction Reg. # 167338 Duva 00 �ngLLC (781)944-1994 (978)664-2557 READING NORTH READING P.O. Box 637, North Reading, MA 01864 Please visit us at www.duvalroofing.com PROPOS LSUBMITTEDTO NONE DATE STREETCITY,STATE AND ZIP CODE VV ti We hereby submit specifications and estimates for: F! L94p& Remove all existing roof related debris from roof as well as job site with our own disposal truck. NO DRIVEWAY DUMPSTERS 14' [Mayer of existing roof shingles ❑2 layers of existing roof shingles ❑3 layers or more of existing roof shingles Uk6eplace any damaged roof decking; not to exceed 32sq.ft. (additional at$1.70 per sq.ft.) Install 8"Aluminum Drip-edge/Rake-edge along entire perimeter(Choice of White, Brown or Mill) a nstall ICE&WATER UNDERLAYMENT on all horizontal eaves, sidewalls,skylights and chimney flashing nstall a premium base sheet underlayment(felt)that is in compliance with the asphalt shingle manufacturer chosen by the homeowner Install The Homeowner's Choice of the selected Tamko/IKO or GAF Limited Lifetime Architectural Roof Shingles "See individual manufacturer's warranty for specific details C14eplace all existing bathroom louver and/or exhaust pipe(s)with new aluminum flanges Chimney(s)-counter-flash and re-step existing flashing ❑Cut& Install new lead flashing urfnstall a continuous low profile Ridge-Vent on all ridge lines ❑Soffit-Vents ❑Roof Louver-Vents ❑Seamless Aluminum Gutters-Custom fabricated on site with•our own gutter machine ❑Downspouts at additional ❑Leaf Guards L�16ther 1 '' �J ( t I I *Please Note:All items in roof attic should be removed or covered due to falling roof particles, at time of roof tear-off Price includes all items above that are checked only/others may be priced separately upon request. Pe Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of: Total price not including options. dollars($ Payment to be made as follows: 30%deposit required before ordering materials.Balance due in full upon day of completion. I Please make all payments out to Kenneth Duval, mailed to: P.O. Box 637, No. Reading, MA 01864 Final Payment is due upon day of completion and is subject to the Authorized supplemented Terms&Condition sheet when scheduling. Signature- THIS PROPOSAL IS VALID FOR 2 1 DAYS DUE TO FLUCTUATIONS IN MATERIAL&DISPOSAL PRICES. " Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Name Company Name �� k v Street Address(do not use a Post OfficeBox address) Contractor/Salesperson/Owner Name lj o"1 �c 11 ��, N� 63 City/Town State Zip Cade Business (must include a street address) C)Ik6 Daytime Phone Evening Phone City/Iown utate Zip Code Mailing Address(It different from above) Business Phone Federal Employer ID or S.S.Number Homelmpmeemenl Cantrector Reg.Numbar Expiration date Law reII.lrea that most home atnmrober —73.3 � 7116LI y �asregistration••tuber ! The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used use additional sheets i ecess .) V%t j c, u - � � est,AAZo, I I w-ff 1 Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be 3(,(KZ4t9 excluded from the Guaranty Fund provisions of 0M30 Date when contractor will begin contracted work MGL chapter 142A.) �p J Dat when contracted work will be sulisfaitially completed. Total Contract Price and Payment Schedule � The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: (9 (*) Payments will be made according to the following schedule: $ upon igning contract(not to exceed 1/3 of the total contract price pr the cost of special order items,whichever is greater) $ by_/ / or upon completion of $ by_/_/_or upon completion of IF $/ upon completion of the contract. (Law forbids demanding full payment until contract is completed to both parry's satisfaction) The following material/equipm®t most be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be paid for_ NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty being provided by the contractor? ❑No flErYes(all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important Information on the reverse side ofthis form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. Seethe attached notice of cancellation form for an explanation of this rigbt. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! �­djmlettic.picsoftheco ctmut be comp!ed and signed.Om copy should go to the homeowner.The other copy should be kept by the contractor. Homeo r s$i a Contractor's Signature t r i/ lay l3 Date Date ���CA, " Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to su mit to such bitratio as pro 'ded In Massachusetts General Laws,chapter 142A. C H eowner's SignatureContractor's Signature res, The signatures of the parties above apply only to the agreement of the parties to alternative dispute es,lution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. 1 Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at http://www.mass.Rov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at htt]2://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: htip://db.state.ma.us/homeimprovement/licenseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 Version 2.1-11/22/2010 NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR OBLIGATION,WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU CANCELLATION NOTICE,AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL,YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE,IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED,ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY,IF YOU WISH,COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION, YOU MAY RETAIN OR DESPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO, THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION,MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO [Name of Seller],AT [Address of Seller's Place of Business]NOT LATER THAN MIDNIGHT OF (date). I HEREBY CANCEL THIS TRANSACTION. Date: Buyer's Signature: CERTIFICATE OF LIABILITY INSURANCE , i2/4/2a13 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXPEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICA'T'E OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT, N the eartiffcate holder Is an ADDITIONAL INSURED,the poilcy(iss)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and condttbns of the policy,certain policies may require an endorsement. A statement on this carMcate does not confer rights to the fcartIficate holder in Hou of such endomeme"s. PRODUCER I tr RAM Barbara McDonough � Gilbert Insurance Agei%Gy, Inc. { PMQNE (781)842-2225 IPAx cies> -S2ze 137 Main Street ESL .bmcdonwgh@gi,l.beztiLnlauranea.a m ! INSURERS AFFO OING COVERAGE f NAIC 6 Reading MA 01867-3922 WSUMRA-ELS.RLEYSV-ILLS WORCESTER. INS CO. 26182 INSURED mulfata:Travelers las. Co. 0031 Duval Roofing, LLC. elsuRmc: P.O. Box 637 INSURER D INSURER E North RaadingrMA 01864 { nysuRERI=: COVERAGES CERTIFICATE NUMBER-CL1331300142 REVISION NUMBER, THIS is TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY,HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE CY NUk8ER EppPOLICY EAP ums GENERAL LIAEIL(iY EACH OCCURRENCE _ S 1,000,000 RCNnO X COMMERCIAL GENERAL LIABILITY PREM[g§DAMAGtTo $ 100,000 A CLAIMS-MADE rx]OCCUR 64158G 10/23/201310/2312014 MED Exit'(Any Ona nemw) $ 5,000 PERSONAL A ADV INJURY S 1,000,DOO GENERAL AG RELATE S 2,000,000 GENLAGGREGATB IJMrr APPLIES PER: PRODUCT$-COMPIOP AGG f 2,000,000 X POLICY JECT [7 Pfd LOC S AUToNOWLsuAIRUTY , Nardn i LIMIT rd) 1 000 A ANY AUTO BODILY INJURY(I�Pg�) $ ALLOWNEC XSCHEDULEv BA64456G 0/23/2013 0/2312014 gppiLY1NJURY(Pae uddentl S AUTOS AUTOS NON-OWNED A DPP GE S WNED X HIRED AU'OS x AL, $ UnI<slredmofarhtBie NLIM11 $ 100,000 UMBRELLA LIA9 pCGUR EACH QGCURRENCE 8 EXCESS UAe CLAIMS-t 96 { AGGREGATE I S _ DEQRETENTIONS $ $ WORKERS WMPENSATION To be provided 'directly 4VCSTATU- qSw AND EItFLOYERS'14"ILITY Y t N i ANY FROPRIETORIPARTNERIEXEC'MVEN!A is Travelers insurance E.L.EACH ACCIDENT 3 100,000 OFRCERIMEMBER ED(CLUDE07 /11/2013 /11/x014 (ftuiftey In NH) Mfg DIMSE-EA EMPLOY . 3 100,000 ff yas describe under DE641RM'*N OF OPERATIONS babW EL OIWASE-POLICY LIMIT s 500,000 095OMPTIQN OF OPERATTC"S t LOCATIONS I VEf9cLE9(Attach ACORD 104,Addldmaf Rmtefks Setwdula,trmarn space is rsgodrod) Evidence of Coverage CERTIFICATE HOLDER CANCELLATION (978)688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL !BE DELIVERED IN Town Of North Andover ACCORDANCE WITH THE POLICY PROVISIONS, 2600 Olsgood, Street North Andover, MA AUTHORIZED R9FASSENfATWE Gilbert, CICIRAMMR ACORD 25(2010f(I5) 01988-2010 ACORD CORPORATION. All rights reserved. iufxn3s rornnnm M The ACORD name and loco are rwistered marks of ACORD The Commonwealth of Massachusetts - Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston,MA.02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/plumbers Applicant Information Please Print Le;;ibXY Duval Roofing, LLC Name(Business/Organizationgndividual): PC BOX 637 Address: No. Reading, MA 01864 " City/State/Zip: Phone#: q79- 'I/c:256 7 Are ygtt an employer?Check the appropriate box: - Type of project(required): 1. I am a employer with Ir 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2111 am a sole proprietor or partner- listed on the attached sheet. �• El Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ElBuilding addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.[]Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.�oof repairs required.]insurance re employees.[No workers' j� oyees13.❑Other 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 hire doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that checkthis 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.#: v a 30 A)y Expiration Date: c Job Site Address: 5J 0 -7 City/state/Zip: N� 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. Ido hereby Date: /� zz�z c under thepains an ofperjury that the information providedabove is true andcorrect. Signature: J , 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - ry 4 ------ -Phnnn#- __' b9glOdW'ONiad3� ON i �aa�aaaasaap°[I is HlaON ZL 1,q Ma H13NN3�1 �d a 01-1JNI4pO�j _ otjea►d 3 �i.OZI0yl6 .uot�eaaStBa�! �__.. '.001 a010,4tiNO3 IS.aim. �3wnsaoD 30331310 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supenisor License: CS-058443 KENNETH P DIIVA PO BOX 190 - 4 72 NORTH ST N READING MA,91864` w Expiration 12/10/2015 Commissioner NOTICE N NOTICE TO .. a TO EMPLOYEES �� EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-7274900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152,Sections 21,22&30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P .O. BOX 1450 MIDDLEBORO MA 02344-1450 ADDRESS OF INSURANCE COMPANY (7PJUB-0230N91 -9-13) 03-11 -13 TO 03-11 -14 POLICY NUMBER EFFECTIVE DATES ^ GILBERT INS AGCY 137 MAIN ST READING MA 01 867 NAME OF INSURANCE AGENT ADDRESS PHONE# o. DUVAL ROOFING LLC 184 PARK STREET oma. 0 NORTH READING MA 01 864 EMPLOYER ADDRESS '— EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE o= MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordancewith the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 001907 W20P1G02 TO BE POSTED BY EMPLOYER