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HomeMy WebLinkAboutMiscellaneous - 55 MIFFLIN DRIVE 4/30/2018 55 MIFFLIN DRIVE 210/021.0-0027 --0000.0 Date........................1....................... NORTry p• "Ica , TOWN OF NORTH ANDOVER �, ""= = : PERMIT FOR GAS INSTALLATION 4 This certifies that �J �'l �c y 4-L�,'� ' ✓� =�'u .........................................................`.................;................................... has permission for gas installation ....... .��. ....;: r..�.' :.....'�....� .....,�. ` r d, in the toldings of..., :-,t.: , ...a .:. .......................................................:...... at..... .7....... ...i....]!. - :.. .................................... North Andover, Mass. Lic. No. GASINSPECTOR Check MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - CITY North Andover MA DATE[/1/2014 I PERMIT# JOBSITE ADDRESS 55 Mifflin Rd OWNER'S NAME ►'V OWNER ADDRESS I Same1 TE IFAXF— � TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONALE] RESIDENTIAL❑ PRINT CLEARLY NEW:® RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER - BOOSTER CONVERSION BURNER ! . o COOK STOVE y DIRECT VENT HEATER ' DRYER - FIREPLACE �. 1 - FRYOLATOR a. FURNACE GENERATOR ) ' ;-- -' GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT r— OVEN POOL HEATER ROOM/SPACE HEATER 3 ROOF TOP UNIT e TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHERav MF::�Aj _ INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO Ej I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE 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 c pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Joseph Marino LICENSE# 8736 S N RE MP ED MGF❑ JP❑ JGF❑ LPGI© CORPORATION Q# 3285C PART SHIP❑#0 LLC❑#� COMPANY NAME:LRH White Construction Co =ADDRESS 41 Central St CITY I Auburn I STATEDDZIP1 01501 TEL 508)832-3295 FAXI 508-926-4347 j CELL 508-832-4614 EMAIL JMarino@RHWhite.com - t ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# -� /�LO PLAN REVIEW NOTES i . ;COlj1MYNWEALTH OF MASSAGUi' ' ; . - =PLUIUjBERS i4NE1 OASFfTlE.RS". `' - fSUE S TANSE D NA-R.I N.O `:3. 'FA `RINGTON ST : w C""E`ST`ER MA 0 x� 05/01/14 ::_GOiIlillllUNWEALTH OF MASS/*C`fc#•#1S:E'I iS=' P`USU1SERS AND GA5FI1"( AS A J ,; 1('CEiVvSED DU.RNEYMA-W---?L*(jmr�{ `ISSUES THE ABdVL LICENSE TO --- "FAR:R_i-' GTON fb e% STE R MA 0 1 G 05/01/14 7U31:8 s�- Draw 04/03/2014 14:04 5088326751 RH WHITE CONSTRUCT PAGE 02/02 ACCORDCERTIFICATE OF LIABILITY INSURAN DATE(MIV/2013 CE Page i of x OB/2g/2013 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certaln policies may require an endorsement.A statement on this certifleate does not confer rights to the Certificate holder in lieu of such endorsement(s). PRODUCER CONTACT willim of Massachusotte, Inc. AIMOAL NE c/o 29 co-Atury Blvd. NO,.Exl 877-945-7378 P CO). 188-46'T-2378 P. 0. Box 805191 p cc; pwillia.00m Nanhville, TN 37230-5191 INSURERS AFFORDING COVERAGE NAIC0 INSURED INSURERA: The Charter Oak Fire ineuranag Company 25615-001 R. B. White ConstriAction Company, Inc. INSURERS:TraVOIArS Property Casualty Conhpany of Ant 25674-003 41 Casntra2 Street INSURERC:National Union Fire) Insuranao Company o£ 1 7.9445-001 P. 0. Box 257 Auburn, MA 01501 INSURER D;Travelers indemnity Company 25658-001 INSURER F; INSURF,R F. COVERAGES CERTIFICATE NUMBER:20287680 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,LIM17S SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DD SUB POLICY NUMBER POLICY EFF POLICY EXP LIMITS A GENERAL LIABILITY VTC2000 977X9948-13 9/7./2013 '9/1/2014 EACMOCC,URRENCE F_ 2,000,000 X COMMFRCIALGENERAL LIABILITY pqq TORENTF,D PR8(Eeoeourancr) 5 300,000 CLAIMS-MADE OCCUR MED EXP(Any one person F 10"000 PERSONAL&ADV INJURY S 2 0UQ,000 GENERAL AGGREGATE $ 41 000 000 GEN'LAGGREGATELIMITAPPUESPER; PRODUCTS-COMPIOPAGO $ 4,000,000 POLICY PR0. LOC $ AUTQMOBILELIABILITY vTJCAP 977R955A-13 9/1/2013 9/1/2014 ? BIreDISINGLE LIMIT S 2,000,000 X ANYAUTO BODILY INJURY(Perpemon) S ALLOWNED SCHEDULED BODILY INJURY Peraocldsnt $ AUTOS AUTOS ( ) X HIREDAUTOS X NON-OWNED X Co Defl X Cv118Ded eraccldent $ S C UMBRELLALIAB X OCCUR BE8766140 9/7./2013 9/1/2014 EACHOCcURRENCF $ 5,000,000 X EXCESS LIAR CLAIMS-MAGE AOGREGATE 1-5,000,000 DED I $ IRETENTIONS 10,000 D WORKERS COMPENSATION VTRKUB 11205A185-13 9/1/2013 9/1/2014 X O AND EMPLOYER8'LIABILITY Y T.ORY1,1, 1) ANY PROPRIETORIPARTNFRIEXECUTIVEI.; NIA VTC2xuB 8203A71A-13 9/7,/2013 9/1/3014 E.L.EACHACCIDENT s 1,000 000 OFFICERrMEMBEREXCLUDED7 LTJ fMandatogInNM) E.L.DISEASE-EAEMPI,OYEE S 1,000,000 iyee,deedrlbs dndnr UEv KIIlIIUNUFOPURATIONSbelow E.L,DISEASE-POLICYLIMIT S 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach Acord 101,Addltonpl Remarks Schadula,If more sp eco In raqulrod) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THERC-OF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Evidence of Inaurance colt-:4197604 Tp1:1694012 Cert:202676$0 ®1988-2010ACORDCORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD • NOR7q �r��.,�'°.;•_',"oo� TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING SSACMUS� /j/� J U This certifies that . . . . . . !. ' . !? 1. . . !1.C-- has permission to perform . . . up, plumbing in the buildings of at,,. . D.�. . . . t . . ��`�'�. . . .�.'i . . . . . . .. Vort A�V�v Mass. Fee Lic. NO..8.0.5,Z . . . . . . . . 7PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING x City/Town:ALA MA. Date: ��?O�( Permit# Building Location:__ j f—pkti Owners Name: s$ ILUl�1 Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ ResidentialIg New:❑ Alteration:❑ Renovation:M Replacement:0 Plans Submitted: Yes❑ Nom FIXTURES DEDICATED W Z SYSTEMS Z z in W N O =) z LnH d C Z FQ Y Q fA V F O a CC H W p G C Q m V1 d: I- Ln W Q N Y C 0 2 = Q 0: F w o a' o: H h 0 Q N 3 p O Q N Q Z a ul O Z LU N t3 Zin -j U a W S .� Q w U F=- = a O 3 z Z Q O 3 a Y Q = w w w CC o2f O in 3 W a Q H o o > > o = o a a a a = u Ln a a m m e o LL x s: g s m H � � 3 3 3 o Qt7 3 •SUB BSMT. < c� BASEMENT 1ST FLOOR 2"D FLOOR 3RD FLOOR 4T"FLOOR 5T"FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR Installing Company Name: ( n/rn P P4-9 `. Check One Only Certificate# �yd Dr. 19 Corporation 331 3 Address:_ A y City/Town: �QiY State: N�N j� ❑ Business TeL _ Partnership � ax � y- 7(E,Q7 ❑Firm/Company Name of Licensed Plumber: CA-as ?g,. 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 have checked Yes,please indicate the.type of coverage by checking the appropriate box below. A 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 Signature of Owner or Owners Agent Owner ❑ 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 Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title Plumber Signature o�Licen�se City/Town Master a9 APPROVED OFFICE USE ONLY) Journeyman License Number: Lx32— r' COMMONWEALTH OF MASSACHUSETTSIMPLUMU \� =:,• aM �I "'~ �• LICENSED ASA MASTER PLUMBER j ISSUES THIS LICENSE TO 'i I CHAD MICHAEL PERRY ma , 26 JUDY DR LONDONDERRY NH 03053-2918 ; . 13032 05/01/12 756537 � . CONTROL IpgpORTANT notify your Board at the: If this license is lost or destroyed, Causeway St., Division of profess 02114Censure, 239 Boston, nofity your board 5th Floor, shown is changed ailing of next If your name or address Yess to insure proper�Icense number• of correct name .. Always refer to General Laws Renewal Application. provisions of the is subject to the p , and must not be loaned -This license It is a personal privilege. this license on your as amended. other perso' Keep I or assigned t0 any required by person or posted as r r 05/20/2011 07:54 19783883101 RC BRIGGS PAGE 01/01 DATE(M D NYM 65Z* CERTIFICATE OF LIABILITY INSURANCE OP ID RE�r 05/20/1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTAN :I the cert Icate,ho er Is an ITIONAL SURED,t e poliey(ies)must be en orsed. If SUER GATIONTS WAIVED,subJect to the terms and Conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER NAM-E_' Linda Reifke -PHONEarc No,Ext)_ 978--388-0019 jpic,Nol___.979-388-310 R.C. Briggs Xnsuranee Agency I TbffA c �. DRESS: �.nda@rCbxXggains_Com 103 Main Street: AD _...... Dom--1 -- Amesbury NA 01913 CUSTOMERIDO: _HILLA--J Phone:978-388^0019 Fax:978-388-3101 INSURER(S)AFFORDING COVERAGE, NAIL# INSURW INSURERA: Chnrcar Oak ri.rn Inauranao Co - ........ •••-- , ..........-___ Hillard Plumbing & Heating, In INSURER 8; Paychex Insuranc ... ..... 225 Stedman Street INSURER C: _..__..._-._. -_...._.........Lowell MA. 01851 IN$URER D: INSURER E; __......_._..._--.. INSURER F: COVERAGES CERTIFICATE NUMBER: 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 WI•IICH THIS CERTIFICATE MAY 9E ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIDED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANDCONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, .... - ....._. __... __. ((gy�pp — .. )ETR TYPE OF INSURANCE INSR WV POLICY NUMBER (MMIDD/YY1 Y MM/DpIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1"..0.00,000 "UAMAVETb RENTEV_____. .. A X C_OMMF,RCIALGENER_ALLIABILITY 680-7349060-A-09 11/09/10 1,1/09/11 _P_R_EMISE fLI • occurrenee) 1.300,000 _ - CLAIMS-MADE I X] OCCUR MED EXP(Any ens person) - $ 5,000 _-- PERSONAL&ADV INJURY 5 1,000,000 GENERAL AGGREGATE ;2,000,1000 GCN'LA-0 GAT REE LIMIT APPLIES PFR: . PRODUCTS•COMP/0P AGG A2,000,000 POLICY — jRo- I.oC COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (ESaceldent) $ 1,000,000 A ANY AUTO BA07903CO1 11/09/10 11/09/11 `--- " ---' -" BODILY INJURY(Perrp person) :F ALL OWNED AUTOS -----,•-• —._.._._..__,_...__. _ BODILY INJURY(Pgr�cddenl) S X SCHEDULCD AUTOS --.---.•.••.• •• PROPERTY DAMAGE � -- X HIRED AUTOS (Per socl.cal X NON-OWNED AUTOS �.._..--_--.. _... UMBRELLA LIAO OCCUR EACH OCCURRENCE "n EXCESS LIAR I _CLAIMS-MADE AGGREC�ATF S DEDUCTIBI,F R RETENTION $ B WORKERS COMPENSATION 7 -WE x1,6298 08/15/10 08/15/11 - 70RYI,IMITS H. AND EMPI.OYERS'LIABIUTYYIN -- - -- - ANY PROPRIFTORIPARTNER/F.XECVTIVF ►A E.L.EACH ACCIDENT $ 100 OFFICERIMFMDER EXCLUDED? .._._.. H (Mandatory In NN) F.,L,DISRASE-EA EM_PLO_YEE F )'000 Ifrs dr;.crrlM:under F,t DISEASE-POLIGYLIi41T .T 500 000 D3LIRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schadula,If more space Is rodulred) I usual to plumbing fax 978-688-9542 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVURP-D IN ACCORDANCE WITH THE POLICY PROVISIONS, Town of North Andover AUTHORr7);D REPRESENTATIVE 1600 Osgood Street North Andover MA 01845 ®1988-2009 ACORD CORPORATION- All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD l 0 t 1 A. Date..5............................. f NORTH 1 3?°•`;�``°-{'�."�� TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACNUS� This certifies that ��'`' T S f .................................f.......... ............................. has permission to perform .... �{.�`::... ........... ..................�.......... wiring in the building of.... , .... . . . . . ...........1�at. x.3....... ............. . ............ North Andover, s. t � Q Fee... . .-. ....... Lic.No.�� /oe, :. r..... .. .. .y:.�,. / ELE (CALINSPECfOR 'Check # ��o� Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. /0 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked Rev. 1/07] ----=- ' APPLICATION FOR PERMIT ��-- PERFORM �� CC C +cleavebla+nk All work to be performed in accordance with the OMassachusetts rO�ea iC ELECTRICAL WORK (PLEASE PRIM flVINK OR 7T TE ALL flWO Io� (MEC),527 CMR 12.00 City or Town of: NORTH ANDOVE�2Date: By this application the undersigned gives notice of his or her intention to perform the the Inspector of des:below . Location(Street&Number) ss /�/�t ��n Owner or Tenant t? t Owner's Address (/ Telephone No. Is this permit in conjunction with a building permit? Purpose of Building e,� Yes No ❑ (Check Appropriate Bog) t & Utility Authorization No. Existing Service 12! (O Amps 't(d Volts Overhead Amps ts P�Undgrd New_ Service Vol ❑ No.of Meters Number of Feeders and.Ampacity Overhead❑ Undgrd❑ No.of Meters Location and Nature of Proposed Electrical Work: Com letion of the followin table maybe waived by the Ins ector of Wires. No.of-Recessed Luminaires � No.of Ceil:Sus No.of p.(Paddle)Fans Total No.of Luminaire Outlets Transformers KVA � � No,of Hot Tubs No.of Luminaires S Generators IZVA bAove �_ Swimming Pool o, No.of Oil BurnBurnerso mergency ig g --, No.of Receptacle Outlets d rnd. Battery Units E i c . No.of Switches Q ALARA No•:af 'nes 0 No,of Gas Burners No..of Detection and No.of Ranges Imha6n Devices . No.of Air Cond. Total Tons No.of Alerting Devices Pump Number _T No.of Waste Disposers / Heat Pum ons KW No.of Self-Contained Totals: _._.....__......... No.of Dishwashers f Detection/Ale rtin Devices ` Space/Area Heating KW Local.❑ Municipal No.of Dryers gestin Connection ❑ Other Heating A ppliances ICVV Security Systems:* No.of Water ' No.of ' No.of Devices or Equivalent HeatersNo.of Data Wiring: Suns Ballasts. Na.Hydromassage Bathtubs No.of Dvices or E uivalent No.of Motors Telecommunications Wiring; Total HP / OTHER; No.of Devices or E uivalent Estimated Value of Electrical Work: Attach additional detail if desired,or as required by the Inspector of Wires. Work to Start: (When required by municipal policy.) 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 cRONDE] a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OTHER I Certify, under the pains and penalties o er u that the innformation on this application is true and complete FIRM NAME: le,L Z- ,E CE G p d rY, L p Licensee: ,�/t/� S K E I E/(�j/� LIC.NO.: 1(/� 1 applicable 'E-•s Signature (f pp 'cable,enter empt i th/ nse n ber li .). LIC.NO.: ��E� Address: Bus.Tel.No.:4 7-�f1(e-S?p0 o *Per M.G. c. 147,s.57-61,security work re uires D f / Alt:Tel.No.: OWNER'S INSURANCE W q ent of Public Safety"S"License: Lic.No. WAIVER: I am aware that the Licensee does not have the liabili ty ins required by law. By my signature below,I hereby waive this requirement. I am the(check one) E]owner coverage gent. Owner/Agent Signature Telephone No. PERMIT FEE:$ f/,j� ELECTRICAL PEpMT N®. INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL I.ROUGH]NSP TION: Passed—[ Failed—[ ] Re-inspection required($50.00) Inspectors'comments: (Inspectors'Signature-no initials) Date 2.FINAL INSPECTION; Passed—[ Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors Signature o initial Date ' F ER GROUND INSPECTION: —[ ] Failed—[ j Re-inspection required($50.00)-[ors' comments: (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: DATE CALLED NATIONAL,GRID: NSE: Passed—[ ] Failed—[ j Re-inspection required($50.00)-[ ] Inspectors'comments: (fnspectors'Signature-no initials) Date 5.INSPECTION-OTHER.: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ j Inspectors' comments: 1 (Inspectors'Signature-no initials) Date D0OA.TAC.g ARE TO SE FILLED OUT AND LEFT ON SITE IF TRE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED. The Commonwealth of Massachusetts • w Department of Industrial Accidents Office ofInvestigations ..600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Llectricians/Plumbers Applicant Information Please Print Legibl Dame (Business/organization/Individual Address:_. n gn'S 7W City/State/Zip: � lj t f Phone#:_ Armee you an employer?Check the appropriate box: 1•ffl- am a employer with 1 q.• Type of project(required):' __ ❑ I am'a general contractor and I employees(full and/or part time).* have hired the sub-contractors 6• ❑N construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 1 7• Remodeling ship and have no employees These sub=contractors have working for me in any capacity. workers' comp.insurance. 8' ❑Demolition [No workers'comp. insurance 5. ❑ We are a corporation and its 9• ❑Building addition 3.❑ required.] officers have exercised their 10-ElElectrical repairs or additions I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. C. 1521 1(4),( ),and N;re have no 12.0 Roof insurmce required.] t emplcyees. [No t=✓orkers' rQpL-irs comp.insurance required.] 13.❑ Other 3 applicant that checks s box ul must also fill cut the section beio,R,she•,: ��f' t _ Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submoit 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. Iain an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:_�j1-�tQ� rZ?U.S-G�/t[4ytl �ar Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address:_�S Attach a copy of the workers' t compensation policy declaration page(showing the Policy number and expiration�1, Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimil 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 cern nder the pai d pen s of perjury that the information provided above is true and correct Si a Phon # G l 7 Oficial 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#: