HomeMy WebLinkAboutMiscellaneous - 671 MASSACHUSETTS AVENUE 4/30/2018 (2)Permit NO:
w
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
TYPE OF IMPROVEMENT
PROPOSED USE
OWNER: Name: Ll, a r'Al i,
d 1-ff wry.
Residential
Non- Residential
New Buildingne
family.
Addition
woor more family
Industrial
Alteration ---.No.
of units:
Commercial
R6 air
Assessory Bldg
Others:
Demolition
Other
r 'Septic .x Well
Floodplain: '�"' Wetlar ds'
° Watershed District
'Water/Sewer.
DESCRIPTION OF WORK TOB PERFORMED:
Identification Please Type or Print Clearly)
711- � 6 Z - gSG y
OWNER: Name: Ll, a r'Al i,
d 1-ff wry.
Phone:
Address: (W1 f. M 4 57
CONTRACTOR`= Name:_ t ��
Phone:
Address: �rh
-, nes?
l S 7
So- r��sot, Construetion�L cens � �
Exp.
Date:
Home;lmprovement License:
'?
Exp.
Date: 211 C) -
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: $ 2-) FEE: $ �S g
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
v'
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
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 Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ 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 cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Doc.Building Permit Revised 2008
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
HEALTH Reviewed on Signature
COMMENTS
4
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 Town Engineer: Signature:
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 2 1 A —F and G min.$100-$1000 fine
NOTES and DATA — For department use
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2008
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use
❑ Notified for pickup - Date
. . ......... . . . . . . . . ............... . . ...... . . ................ . .. . . .................... . . .................. . . . ............... . . . ............... . . . . . .................... . . . . . ..................... . ..... . . . . . . .................. . . . . . ...........
Doc:.Building Permit Revised 2008
It
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
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 Town Engineer: Signature:
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit.
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
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 Construction (Single and Two Family)
❑ Building Permit Application.
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ 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 cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Doc.Building Permit Revised 2008
Permit NO:
.
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Buildingr
e family
Addition
wo or more family
Industrial
Alteration ----.No.
of units:
Commercial
Re air re la
Assessory Bldg
Others:
Demolition
Other
1 ` DESCRIPTION OF WORK TO BF PERFORMED:
Identification Please Type or Print Clearly) W I - 76 -7--
OWNER:
-OWNER: Name:Phone:
ARCHITECT/ENGINEER
Phone:
Address: Reg. N
FEE SCHEDULE. BOLDING PERMIT: $12.00 PER Z $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
��
Total Project Cost: $ � , � FEE: $ �s
Check No.: Receipt No.: 2 z4-1 s�
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Location
No. Date
NORTH TOWN OF NORTH ANDOVER
•. O0
Certificate of Occupancy $
Building/Frame Permit Fee $
sncMust
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ C;zs "T
Check #
22815
Building Inspector
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02/24/2010 WED 9:16 FAX
X001/001
AC -ORD -CERTIFICATE OF LIABILITY INSURANCE PID $
Ha�ol
DATEIMMIODM10
oz 24 to
PRODUCER
Benevento Ing. Agency, Inc.
497 Humphrey Street
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOGS NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
Swampscott, MAL 01907 -
phone: 7.81-599-3411 fax:781-581-7200
INSURERS AFFORDING COVERAGE
NAIC 8
INSURER A: patrons Mutual Ina. coo""
. _Y
INSURED -
INOVAER B:
{RSR D ••.... —••--- ....,.......................... POI ICY EFF VE POL'ICYEXPIRATI60
LTR NS TYPE OF INSURANCE POLICY NUMBER DATE MMM DATE MMlO
LIMITS
egG;
_........ _ _.._-_-.... ,.:...._
EACH OCCURRENCE
M'chael Teheen
dba TeheeennCConstruction
X COMMERCIALWNERALLIASIIIYY CTR0006987 07/29/09 07/29/10PREMISES
BALM MA Uly7�D
INSURER D:
INSURER E.
CLAIMS MADE F OCCUR
bVYCRNV W
'-----
SHOULD ANY OF THE ABOVE DESM13ED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DIE 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
Town of North Andover
MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS
OF SUCH
POLICIES, AGGREGATE LIMIT$ SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
REPRESENTATNES.
{RSR D ••.... —••--- ....,.......................... POI ICY EFF VE POL'ICYEXPIRATI60
LTR NS TYPE OF INSURANCE POLICY NUMBER DATE MMM DATE MMlO
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$1,000,000
X COMMERCIALWNERALLIASIIIYY CTR0006987 07/29/09 07/29/10PREMISES
Eaoceurenee
$50,000
CLAIMS MADE F OCCUR
MED. EXP (Any Ons person)
$5,000
-'� 1
PERSONALLAOVINJURY
:l,aaa,OQa
GENERAL AGGREGATE
s2,000,000
CEN'LAGGREGATELIMIT APPLIES PER-
PRODUCTS -COMPIOPAUG
$1,000,000
POLICY jeL47 Loc
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
(Ea aeddem)
ANY AUTO
ALL OWNED AUTOS
BODILY INJURY
s
(per meson)
SCHEDULED AUTOS
HIREDAUTOS
BODILY INJURY
f
(Pa acddam)
NON•ONINED AUTOS
PROPERTY DAMAGE
s
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GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
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OTHER THAN EA ACC
ANY AUTO
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GAc4iOCCURRENCE _
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DEDUCTIBLE
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WORKERS GOMPFTISAYION AND
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EMPWYERV LIABILITY
ANY PROPRNEI'ORIPARTNERIEMCUTIVE
OFFtCERIMENOER EXCLUDED?
G.L. DISEASE • EA EMPLOYE!_S
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E.L. DISEASE •POLICY LIMIT
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SPECIAL PROVISIONS below
s
OTHER
5fS- PYKIN OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
Noimm
'-----
SHOULD ANY OF THE ABOVE DESM13ED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO OO $O SMALL
Town of North Andover
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Town Hall
REPRESENTATNES.
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The Commonwealth of Massachusetts
LX Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA -02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lezibly
Name (Business/Organization/Individual): —1 e- C�s/� S n
Address: f *; 1(\
City/State/Zip:. 5 G 1 Ms ChN70 . Phone #: c % `ic- �9 -3 a -6 M'2
Are you an employer? Check the appropriate bog:
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
2ZI am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for 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
11.❑ Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
DOX tri ui:TL 8:a^o iaj} out Me seCUon below st1owmg their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tcontractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that isproviding workers' compensation insurance for my employees Below is thepolicy and job site
information.
Insurance Company Name:
Policy # or Self4ris. 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 required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalfies of perjury that the information provided above is true and correct.
Phone #: 67 �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 #:
Iaformation 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 apar rnents 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 Iicensing 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-contractor(s) 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 cant' 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 anddate 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 Iike 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 0.2111
Tel. # 617-7274900 ext 406 or 1-877-,MASSAFE
Revised 5-26-05
Fax # 617-72.7-7749
www.mass.gov/dia
Information and Instructions
Massachusetts General :Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apart rnents 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 Massachusetts
Department of Industrial Accidents
Office of Inves6 tions
600 Washington Street
Boston, MA 0.211.1
Tel. 4 617-7274900 ext 406 or 1-877-MASSAFE
Fax 4 617-72.7-7749
Revised 5 -26 -OS v,-masS.govfdia
The Commonwealth of Massachusetts
Department of Industrial Accidents
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):� Ca��
Address: f "'; 1(\�a'
City/State/Zip: 5, lo -vi . M, d? 9'7c) Phone #:cl Ti36-67,015
Are you an employer? Check the appropriate bog:
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2Z am a sole proprietor or partner-
ship and have no employees
working for in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t .
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
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
t1f,u11:-.::::: uuu C:uGGGS Dui: tri uus- aisv 1-111 out me sectlon below showmg 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 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 required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Phone #: 'I Z i� - �9 56 - C 7C I
Official use only. Do not write in this area, to becompleted by city or town offwiaL
City or Town:
Permit/License #
'7`—�
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 #:
I a
This CONTRACT (the "Contract") satisfies all basic requirements of the
states Home Improvement Contractor Law (MGL c. 142A), but does not
preclude parties from adding language to protect their specific interests.
Homeowner Information:
Mike & Debbie O'Hara (collectively, the "Owner")
671 Mass Ave.
North Andover, Ma 01907
781-704-8957
moharal7@yahoo.com
Contractor Information:
Teheen Construction (The "Contractor")
13 Intervale Road
Salem, Ma 01970
1-978-836-6969
Michael Teheen
Ma Lic. CS 089623 exp. 6/29/2012
HIC Reg. 149787 exp. 2/9/2012
WORK TO BE PERFORMED AND MATERIALS TO BE USED:
Contractor Agrees To Do The Following Work the "Work') For Owner:
Bathroom remodel with a new shower. See attached estimate dated 1/17/10
for details
The Work shall be performed by Contractor in a good and workmanlike
manner in accordance with the Contract Documents (the "Contract
Documents" are defined as this Contract, the cost estimate (the "Estimate")
and inclusions, all of which are appended hereto and made a part hereof)..
Materials Expected To Be Used:
Materials required for completion of the Work include, but are not limited
to:
Insulation, drywall and plaster, wood trim and tile setting materials
SCHEDULE:
The following schedule will be adhered to unless circumstances beyond the
Contractor's control arise:
Work Scheduled To Begin: 2/24/10
Expected Date of Completion: 3/31/10 (due to special order items)
INDEMNITY:
Contractor shall indemnify, defend and hold harmless Owner from any
claims or mechanic's liens brought against Owner or against the Project as a
result of the failure of Contractor, or those for whose acts it is responsible, to
pay for any services, materials, labor, equipment, taxes or other items or
obligations furnished or incurred for or in connection with the Work. Within
three (3) days of receiving written notice from Owner that such a claim or
mechanic's lien has been filed, Contractor shall commence to take the steps
necessary to discharge said claim or lien, including, if necessary, the
furnishing of a mechanic's lien bond. If Contractor fails to do so, Owner will
have the right to discharge the claim or lien and hold Contractor liable for
costs and expenses incurred, including attorneys' fees.
Contractor, to the fullest extent permitted by law, shall indemnify, hold
harmless and defend Owner, its officers, directors, employees and agents
from and against claims, losses, damages, liabilities, including attorneys'
fees and expenses, for bodily injury, sickness or death, and property damage
or destruction including loss of use and damage to the Work itself to the
extent resulting from the negligent acts or omissions of Contractor, its
design consultants, Subcontractors, or anyone employed directly or
indirectly by any of them or anyone for whose acts any of them may be
liable.
If an employee of Contractor, or of any of Contractor's design
consultants, subcontractors, or anyone employed directly or indirectly by
any of them or anyone for whose acts any of them may be liable, has a claim
against Owner, its officers, directors, employees, or agents, Contractor's
indemnity obligation set forth in this Contract shall not be limited by any
limitation on the amount of damages, compensation or benefits payable by
or for Contractor, or of Contractor's design consultants, subcontractors, or
other entity under any employee benefit acts, including workers'
compensation or disability acts.
INSURANCE:
Before commencing the Work, Contractor shall furnish Owner with an
insurance certificate showing at least the following coverage, listing the
Owner as an Additional Primary Insured on a Non -Contributory Basis:
Commercial General Liability: Bodily Injury - $1,000,000/$2,000,000
Property Damage,- $1,000,000/$2,000,000
Contractor shall obtain and maintain the insurance at its expense for the
duration of its Work.
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE:
The Contractor agrees to perform the Work, furnish the material and labor
specified above for the SUM of. $19,635.00.
Owner shall pay to Contractor for the satisfactory performance and
completion of the Work and all the duties, obligations and responsibilities of
Contractor under this Contract, the sum set forth above as the Price which
shall be deemed to include all Contractor's costs for the performance of the
Work. The Price includes sales and use taxes except as otherwise noted.
Payments will be made according to the following SCHEDULE:
• $7,000.00 upon the start of work
• $7,000.00 upon completion of rough plumbing, electrical, framing and
insulation sign offs
• $4,635.00 upon completion of contract less vanity install
• $1,000.00 upon completion of the vanity
4
Homeowner's Signage Date
Contractor's Signature Date
No work shall begin until both parties sign the contract and the owner has a
copy of the contract.
ASSIGNMENT:
Contractor shall not assign this Contract without the prior written consent of
Owner. Contractor shall not be relived of its duties and obligations
hereunder by any such assignment. Contractor consents to assignment of this
Contract to Owner's lender(s) and affiliates, and agrees to execute
documents reasonably necessary to effectuate any, such assignment.
ARBITRATION:
The Contractor and the Owner hereby mutually agree in advance that in the
event'the contractor has a dispute concerning this contract, the Contractor
may submit such dispute to a private arbitration service which has been
approved by the Secretary of
The Executive Office of Consumer Affairs and Business Regulations and the
consumer shall be required to submit to such arbitration as provided in
M.G.L.c.142A. Neither party waives the right to a trial by jury in any
Massachusetts court of competent jurisdiction involving any dispute arising
from the Work and/or under this agreement.
Contractor:
Date: �' Z i-1— ` C
c
Owner:
Date:
REQUIRED PERMITS:
The following permits are required: Building, Plumbing and Electrical
The Contractor shall, at its own expense, and as the Owner's agent, obtain
all necessary licenses, permits, and approvals pertaining to the Work and
comply with all statutes, codes, ordinance, rules, regulations and orders of
any governmental or quasi -governmental authority having jurisdiction over
the Work or the performance thereof.
Safety:
Contractor shall establish and implement safety measures, policies and
standards conforming to'those required, or recommended by governmental.
and quasi -governmental authorities having jurisdiction and by Owner.
Cleaning up:
P
Contractor shall at all times keep the Project Site free from, and shall
promptly cause to be removed from the Project Site, any accumulation of
waste material or debris arising out of the operations or Work of Contractor.
Contractor shall remove daily all trash, rubbish and debris caused by its
Work.
Warranty:
Contractor warrants that the Work shall be in accordance with the Contract
Documents and shall be free of defects in material and workmanship for a
period of one (1) year from the date of completion This warranty is in
addition to any other right of owner under the Contract Documents or law.
Default:
Should Contractor at any time: (a) fail to supply the labor, materials,
equipment, supervision and other things required of it in sufficient quantity
to perform the Work with the skill, conformity, promptness, and diligence
required hereunder, (b) cause stoppage or unreasonable delay of or
interference with the Work, (c) become insolvent, or (d) materially fail in the
performance or observance of any of the covenants, conditions, or other
terms of this Contract, then in any such event, each which shall constitute a
default hereunder by the Contractor, Owner shall, after giving contractor
notice of default and seven (7) days within which to cure, have the right to
remedy the default by whatever means Owner may deemed necessary or
appropriate. Should Owner shall fail to pay Contractor within seven (7) days
of the date payment is due, Contractor shall have the right to stop work upon
and additional seven (7) days written notice and Owner's failure to cure.
during such additional seven (7) days. If such payment is not then received
within thirty (30) additional days, Contractor shall have the right to declare
the Owner in breach and terminate this Agreement.
NOTICE OF CANCELLATION
YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR
OBLIGATION, WITHIN THREE BUSINESS DAYS FROM THE ABOVE
DATE. 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:
No work may
begin until this
time expires.
TEHEEN CONSTRUCTION
DESIGN BUILD ♦ FINE FINISH CARPENTRY ♦ KITCHENS ♦ BATHS ♦ REMODELING
January 17, 2010
Mike Ohara
781-704-8957
mohara@yahoo.com
671 Mass.Ave.
North Andover
ESTIMATE
DESCRIPTION
This estimate is for the renovations in your upstairs bath. The following services are
included:
• Removal of existing Jacuzzi tub
• Removal of Bidet
• Removal and patch of door to 2nd bedroom
• Removal of existing floor tile
• Removal of all drywall and fixtures
• Construction of a new 36"x72" shower (tiled base) with a seat
• Installation of a moisture barrier on shower walls
• Installation of new tile backer on shower walls and bathroom floor
• Installation of new floor tiles
• Installation of new shower tiles
• Installation of a new 3 piece custom shower door
• Installation and plastering of a new ceiling and walls
• Repair of effected sidewall in bedroom
• Installation of a new door
• Installation of a new toilet
• Re -flash skylight
• Install a new fan vented to outside
• Install new recessed lighting, GFI and vanity lighting
•" Install a cable feed
13 INTERVALE ROAD ♦ SALEM, MA 01970
OFFICE/FAX: (978) 741-3980 ♦ E-MAIL: TEHEENCONSTRUCTION@YAHOO.COM
CONTRACTORS LICENSE #: CS89623 + HIC REG: 149787
TEHEEN CONSTRUCTION
DESIGN BUILD ♦ FINE FINISH CARPENTRY ♦ KITCHENS ♦ BATHS ♦ REMODELING
Insulation: (assuming the current insulation is not to code)
Ceiling: (icenyne) $600.00
Wall: (exterior) $100.00
Total: $700.00
Plumbing: (see notes) $2,000.00
Electrical: (see notes) $2,600.00
Plaster: $1,125.00
Labor:
Vent fan to outside
Construct shower
Install tile -backer and water -proofing
Where required
Install and grout all tile
Install vanity
Construct shelving in front of chimney
Install new medicine chest
Install new window and door trim
Total Labor: $8,000.00
Shower door:
New three piece frameless shower
Door (3/8") with chrome hardware: $2,400.00
Fixtures:
Shower base Tile Redi base and niche $670.00
Toilet American standard champion 4 $300.00
Total: $970.00
Vanity:
2 24" Bertch Osage vanities, custom center shelf and tray. Top: $1,640.00
Total: $19,435.00+ Building permit fee est. $200.00
This estimate assumes the following items will be customer supplied:
Vanity & top
Sink faucet(s)
Shower valve
Medecine chest
13 INTERVALE ROAD ♦ SALEM, MA 01 970
OFFICE/FAX: (978) 741-3980 ♦ E-MAIL: TEHEENCONSTRUCTION@YAHOO.COM
CONTRACTORS LICENSE #: CS89623 + HIC REG: 149787
TEH>~EN CONSTRUCTION
DESIGN BUILD ♦ FINE FINISH CARPENTRY ♦ KITCHENS ♦ BATHS ♦ REMODELING
Notes:
This estimate assumes no unforeseen structural or water damage issues
Plumbing charges include the following: remove fixture supplies and drains, remove
bidet plumbing, rough in sink plumbing for a double vanity, install a 2" shower drain and
a new shower valve, pull a plumbing permit and complete a rough and final inspection.
The plumbing charges assume no unforeseen circumstances and do not account for work
required by the inspector outside of the bathroom.
Electrical charges include a super quiet Panasonic fan only unit, 6 recessed lights, 2 new
vanity sconce light boxes (fixtures by owner) all required GFCI circuits, updating or
elimination of sub. panel and extra switches behind door, a cable feed and outlet for a TV
as well as an electrical permit and a rough and final inspection. Electrical charges assume
no unforeseen circumstances and do not account for work required by the inspector
outside of the bathroom.
Insulation estimate assumes the existing insulation, if present is un -useable. Should it be
found there is. insulation in the ceiling and wall that it is code compliant it can remain.
Re -flashing of the existing skylight is included assuming the surrounding roof shingles
are in acceptable condition
Labor for tile installation assumes tile no smaller than 3/a" square on mats and no larger
than 18" square solid tiles. Increased labor charges may be incurred for irregular, glass
or exceptionally large or small tile and specialty, layouts.
Please let us know if we can assist you in the selection of your products or if you need us
to modify this estimate in any way. We look forward to working with you on this project
and others in the future.
Regards,
TEHEEN CONSTRUCTION
MICHAEL TEHEEN
(978) 836-6969
JOHN TEHEEN
(617) 872-0548
13 INTERVALE ROAD ♦ SALEM, MA 0197.0
OFFICE/FAX: (978) 741-3980 ♦ E-MAIL: TEHEENCONSTRUCTION@YAHOO.COM
CONTRACTORS LICENSE #: CS89623 ♦ HIC REG: 149787
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