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Miscellaneous - 7 ABBY LANE 4/30/2018
North Andover Board of Assessors Public Access Page 1 of 1 NORTH North Andover Beard. of Assessors S- roperty Record Card Click Seal To Return Parcel ID:210/065.0-0284-0000.0 FY:2013 Community :North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge r- j Search for Parcels Search for Sales , Summary = Residence " Detached Structure Condo 7 ABBY LANE Commercial Location: 7 ABBY LANE Owner Name: NORTH ANDOVER REALTY CORP C/O RICARDO J.DUBE Owner Address: 7 ABBY LANE City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 10-10 Land Area: 0.63 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 4480 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 974,100 808,700 Building Value: 718,300 514,900 Land Value: 255,800 293,800 Market Land Value: 255,800 Chapter Land Value: LATEST SALE Sale Price: 3,200,000 Sale Date: 07/08/2005 Arms Length Sale G-NO-PARTIAL Grantor: JOHN KOZDRAS Code: Cert Doc: Book: 09631 Page: 0118 http://csc-ma.us/PROPAPP/display.do?linkld=2254800&town=NandoverPubAcc 3/18/2013 Residential Property Record Card PARCEL ID:210/065.0-0284-0000.0 MAP:065.0 BLOCK:0284 LOT:0000.0 PARCEL ADDRESS:7 ABBY LANE FY:2013 PARCEL INFORMATION Use-Code: 101 '` -Sale Price: 3,200,000 Book: 09631 RoadType: T Inspect Date 04/27/2011 Owner: Tax Class: T Sale Date: 07/08/05 Page: 0118 Rd Condition. P Meas Date: 04/_27_1_2.0.11 NORTH ANDOVER REALTY CORP Tot Fin Area 448O--Sale Type: L" --_Cert/Doc: Traffic: m,_ ___ M -Entrance. C NO NO TH AJ. DOBE Tot Land Area: 0.63 3 Sale Valid: G Water. Collect Id. C/ODO SGC Address: _ Grantor: JOHN KOZDRAS Sewer: Inspect Rea§ `M 7 ABBY LANE Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-131% / Open Sp-B/L% / NORTH ANDOVER MA 01845 RESIDENCE INFORMATION LAND INFORMATION Style: CL Tot Rooms: 10 Main Fn Area: 2240 Attic: NBHD CODE: 10 NBHD CLASS. 10 ZONE: R2 —.__......,..— _--,. _M -_ .....� Story Height: 2.00 Bedrooms- 4 Up Fn Area: 2240 Bsmt Area: 2240 Seg Type Code ethod Sq Ft Acres Influ-Y/N Value Class _-_.- ____ . _,�. S-- _._ __.__ 1 P 101 S 27550 0.632 _ 255,779 .Roof: G'- Full Baths: 3'F'Add'Fn Area_: � _ Fn BsmtArea: _ _ Half Baths: _,1 Unfin Area: _ _ .. Bsmt Grade:, Masons Foundation:— nm. 28 Ext Bath Fix: 2 Tot Fin Area: -4480 _ r_ . VALUATION INFORMATION Ext Wall: FB Bath Qual: L 4 RCNLD: 718303 Current Total: 974,100 Bldg: 718,300 Land: 255,800 MktLnd: 255,800 - � Prior Total: 808,700 Bldg: 514,900 Land: 293,800 MktLnd: 293,800 Kitcli Qual: �L`m EfFYr'Bulf:Y" �"2008��Mkt`Adj:`� Heat Type: FA Ext Kitch: Year Built: 2011 Sound Value: Fuel Type-—G-- `'' `-'�` Grade: � _VE'-"Cost Bldg: 7 8,300 Fireplace: 3 Bsmt Gar Cap: 3 Condition: E Aft Str Val 1: Central AC._ -Y Brsmt GaSF: "� I'ct Complete: _- .. ✓Atf Str Val2 _ Aft Gar SF: %Good P/F/E/R: ///100 Porch Type Porch Area Porch Grade Factor S 120 W 240 SKETCH PHOTO 2a in . ¢r. s 12 240 SgJFt 1320 sy At2 4M 10 24 �a 2240 sgrT 32 36 M 71ABBY LANE M Parcel ID:210/065.0-0284-0000.0 as of 3/18/13 Page 1 Of 1 MATCH LINE _ DEP FILE#242-1296 �.ISI ,r .RAM SEE SHEET 2 I I>I I ®,O OMN,o I wvM;WfM NN1NN0 /® i mx / III ,mdj l BN,YOUFm10,0jCp01, caNmaauMRp LOT 12A u, -----------_--- 81 NUO- imRIM.xOSOB 1MEB VANOEL° q }� � A IJ �'� I•• Rrv,rollr.BHn 4b E B B B R +a� AB1X N, 1aA JT A1� tj b� LOT11 _ r0 STORAGE AREAS:DETENTION POND#i I '0 p - �� wpi b / / F N0�0 GOOF EATON( .)06 GN SURGACEME 0.SBU Li SURF CE Rw tq LOCUS MAP Vf NE_CC NO]E.]HEIMY RPEAI(B4ORAGEEIEVATPJN-1]&,FTO� LEGEND n /u //1 , i„m �i I RG XEAOYIIIL O]ONE WALL e®IrkxrAO]rrt // E44 i1/p lApBNH N,F -011-01F ORARNMANHaP ACCEEO, LOT 10 w<x ¢ oRAINA°EPn>E NO zt , FwanEN°�.•„°NawPnAs 'd=.. n l I I� I I „m 7 I I i RFrLnco�. W SF FmEmvxAxr A.\ m ili��i�IJI m„ Iili 3 LOT LOT WATER NANBOA]EVA.VE /I I I '��77 ELATION O BauN]tiCN .pm SSA- T J k POND11 ONRlsr°vNERwxOOEM B sNA I��e EwERrulx '.A-0 I; .RAP %i I it LOT 9 E,oO„No �r, E>omlNma, —— oA.rnwn z, a 11 1 y1 SB II WFJR I l 111 NOUSE HOU,EmS N° � LOT 3 ' \ 1 1 1d I(1 Ijl, Q �/I 01 MgmmfiWREW9 � � Pte' -arv- uImE0.GR°lN°EtEO°iICrtF1IDHONEKAOIENLO�' � � A\\\31\+i�,Av - I�� TOPB 0. � B� w 6�B BORATE) �ffi5] 06N0/MENUR PFAL]YIfNBT ® D04IINGEOGEOFPAVEMEIIT III BEOIROR 1lII . i b/ 11 1\7\I\� R Fox>:BAx n',II HY°RA'^ w 'BF rPLCBEWm --,e°-- Ewemly EaEVAnON CONI`OM x,' \\\1 \ ,Tm I'll IX9TM0 -p_.- WERINO FlAOAIID EOpE OFBOROEWNO _GE_ NOuus 1x9 Y£OEIA]ED WENNO ,+MOFFfrvP.l mP�® LaROF,oCBIRv .NE � � �\\�, � ,r acv oRAm -®- umoFEV XOauwzoxE -srnx z .� \\\ \\�\\i \ ile�ia•aP-tna, LOT 8 —.F.--- -------- .F.XO-019NIB— xecPP Oxux FNO. Pw-z°xn EP piRp\1'0�d__9 AI 0I WORPIO(F JJI-\5�1 �<I;�r" °NMVHB3#A9R•iO"IIMfFU•`1].OPES P RINMV,-Yxa.t] 1.+ CaIINNtBvNY],g•TxRa0-1artAl-1,.,O0xA9 PAVENENi(IYP.7 ea ..9.^/F . XOnUI6BO T 2 E� O EEEOF y�OFS sEoRaOwFNrn9nRaK MLLP10-111— p —AREA +cxNrRae\Rrum +]A'� � � e j Orae CBx R,OL OMTET � / I PAVEPB F]0310p MV�NINOb xAivM,OOVF.BOA,R LOT 7 on iiwr�imttoBn A _ smrrlMrANm F,re �L rRa A /b NOO 0191UPB / � I BAT1M0 PrtCXINn PBA-x00-00 MVITOIR•Ra]9 WAIEIi NAM b d ZONE UMROF,oO I BroNE BOPDE0. 9AfH INV tY OUT•100.m � I w.+m I .-w /�/ euFF]-],mNE cPP CRAa INv,Y.m.RRI®1J Ew01M0 LOT 1 I ,,. OPEN SPACE 11 Xo,uE 8 I _SR MV,r OIR-RI.N 9 Yl NF / OPEN SPACE I °X°°u�E Mv,rwmm % Rrow000uBE PLAN LOT6 rx Brv,rour.,mA. tet+ +] Ha• o an ea I Ha0.P10 ]OP ,YRGOftUN M9PMT Q RfdA Q®o 1 SCALE:1'=4U / EAeE'Mwr I I oNdx rxrooxur, ucxRlsru s unsER I ...E CRANB RIM•xoAm Iwi,vM;r'w'm mxxmMHn -1—:109.H °„ODNN'7 ' CONSERVATION AS-BUILT PLAN SHEET 1 OF 2 EA9FNENT I °MX, Nr,TM-,m.m B.a00 PN,r xA,TM.1,5.,,(<x1) °R R°FE„ION. I ----- --------------------- oN,rM•,m30 N.NX]7 OUF•,0,x, ExawEER "AUTUMN CHASE" 8 ow2Co0f•tav,Sl F___ _____cROSSCONNRRY GRAIN C____ ,r ORPORa1H �- / I xroRANr RM•,nm °f'/isaR•tw ffi FA91E&NF A W”rov'm� r r�P w. aRAE NORTH ANDOVER,MASS. '� 1 r /I NUN Mv+z art•,wx, t .,mm '� y10R�'\N•A-'' mzn NORTH ANDOVER REALTY CORPORATION EMI+ 15.OPPOMIN (;RO^.,✓OO- '' ;r OUF•,A09B SO,PR,NO H,LL xOAO,NOR,H AxOWER,xA Of0,5 MX SUMMER STREET ��2ta1s IA NS EERsauNP6v,_M �•+� CHRISTpANSEN&SERGI INC. Bry iim:im.v5t�e) RM-a-M TS_ W`x`wMC„o"F."x wv,ra,rr-,eBn Mv,r Dur-,mm R.cax Location 7 No.��3—�� Date/ : TOWN OF NORTH ANDOVER s . ° Certificate of Occupancy $ r : Building/Frame Permit Fee $ - 0 Aal � Foundation Permit Fee $ �A Other Permit Fee $ TOTAL $ Check#-, s17 r 26334 /Bui ding Inspector Building Department TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION The fol owing is a list of the required forms to be filled out for the appropriate permit to be obtained. Permit NO: Date Received VMS Roofirig, Siding, Interior Rehabilitation Permits Date Issued: OG IMPORTANT: Applicant must.om lete all items on this page ❑ Building Permit Application ❑ Workers Comp Affidavit LOCATION h . 41 u Photo Copy Of H.I.C. And/Or C.S.L. Licenses (Print PROPERTY OWNER 1?%C KL 4- PAti11.� ❑ Copy of Contract Print 100 Year Old Structure yes ❑ Floor Plan Or Proposed Interior Work MAP NO�PARCEIL ZONING DISTRICT: _ Historic District yes LiEngineering Affidavits for Engineered products Machine shop village yes NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential Addition Or Decks ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑ Building Permit Application ❑Alteration No. of units: ❑ Commercial ❑ Certified Surveyed Plot Plan ❑ Repair, replacement ElAssessory Bldg K Others: J P� ❑ Workers Comp Affidavit ❑ Demolition El Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑ Photo Copy of H.I.C. And C.S.L. Licenses oWater/Sewer ❑ Copy Of Contract DESCRIPTION OF WORK TO BE PERFORMED: ❑ Floer/Cressectien/Elevation Plan Of Proposed Work With Sprinkler Plan And J n zz- ,- 44 Hydraulic Calculations (If Applicable) �t � J ❑ Mass check Energy Compliance Report (If Applicable) —o o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Idennfication Please Type or Print Clearly) OWNER: Name: &- r-rAUj -Q- �>Vdue� Phone: New Construction (Single and Two Family) Address: 1Joyz-ice Andd4e-rM,4-- x . ZZ ❑ Building Permit Application CONTRACTOR Name: I (� S Phone: �� -ly $-' � ` o Certified Proposed Plot Plan � ❑ Photo of H.I.C. And C.S.L. Licenses Address: D �o C� ��q� (_A u1Rl��, ©I �'� � ❑ Workers Comp AffidavitSupervisor's Construction License: 0/0,Z0. Exp. Date: a , ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And l G1 t 3 Hydraulic Calculations (If Applicable) Home Improvement License: kso I Exp. Date: Z - 3 - I Y' ❑ Copy of Contract ❑ Mass check Energy Compliance Report ARCHITECT/ENGINEER Phone: ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. 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 app;,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording Total Project Cost: $ Y�SD FEE: must be subm'Ated with the building application Check No.: 7 Receipt No.: Doc: Doc.Building Permit Revised 2012 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner QG ` �%ignature of contractor Q Plans Submitted Plans Waived ❑ Certified Plot Plan [9-`� Stamped Plans Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISROSAL Dimension Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Number of Stories: Total square feet of floor area, based on Exterior dimensions. Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ 11 Permanent land area, Sq. ft.: Private(septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY ELECTRICAL: Movement of Meter location, mast or service drop requires approval of INTERDEPARTMENTAL SIGN OFF - U FORM �= _� Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No DATE REJECTED DATE PPROVED MGL Chapter 166 Section 21A—F and G min.$10041000 fine PLANNING & DEVELOPMENT NOTES and DATA— (For department use COMMENTS ro ner�ti ��hQ CONSERVATION Reviewed on Signature r COMMENTS V_ 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 Ll Notified for pickup - Date DPW T'owo )Engineer: Signature: Located 384 Osgood Street FIRE=DEPARTME=NT -Temp Dumpster on site yes no Doc.Building Permit Revised 2010 Located at'124 MainStreet Fire Departinerat signature/date COMMENTS Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 349050.00 m $ - $ 408.60 Plumbing Fee $ 51.08 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 51.08 Total fees collected $ 610.75 7 Abbey Lane 713-13 on 4/30/2013 In round Pool t10RTf Town of . t b ndover O No. o h ver, Mass, COc NICKl WICK �,p A�RwTED r'Pa,`�5 S U BOARD OF HEALTH PERMI� T T LD Food/Kitchen Septic System / BUILDING INSPECTOR THISCERTIFIES THAT .Ap��. ! ...� ...........:.............................................................................. ......... buildings on ...��. .h.��l Foundation has permission to erect ................. .......................................... /7 Rough tobe occupied as ...................I.........a. ..k..y................................................................................ Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough ...... Service .......... ............ ..... jK3c�2�� .......... .. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in 'a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE E 20 0 20 40 FT SCALE: 1"=40' 49.38, A�, �eY cil LOT 1 9s AREA 27,550 S.F. �8� Q` h �J EXSTING HOUSE 87' PROPOSED ti SWIMMING POOL 28' LOT 2 \ 51' OF s 8� oy �s G m .28895 PLOT PLAN FOR PROPOSED ALENSWIMMING POOL AT 7 ABBY LANE ` IN F "f� NORTH ANDOVER, MASS. MlCHA L Gyp PREPARED FOR ci I a RICHARD DUBE N 01. DATE:APRIL 17,2013 9 3S S PROFESSIONAL ENGINEERS&LAND SURVEYORS csCHRISTIANSEN& SERGI, INC. l 160 SUMMER ST. HAVERHILL,MA:01830 WWW.CSI-ENGR.COM 7EL.978-373-0310 FAX.978-372-3960 COPYR/GHT2013 DWG.NO.97066012 t� 20 0 20 .40 FT E SCALE: V=40' 49.39, co LOT I AREA=27,550 S.F. h �b' �J EXSTING HOUSE � 87' N� 22' ry 4� PROPOSED WIMMING POOL 28' LOT 2 51' �S1i OF S cPb, G R+ .28895 H Fclsh�� � Y PLOT PLAN FOR PROPOSED �SIONALtiN�' SWIMMING POOL AT 7 ABBY LANE IN OF 14 ' NORTH ANDOVER, MASS. MI Lr�� PREPARED FOR I RICHARD DUBE N DATE:APRIL 17,2013 s PROFESSIONAL ENGINEERS&LAND SURVEYORS ' CHRISTIANSEN& SERGI, INC. 160 SUMMER ST. HAVERHILL,MA.01830 WWW.CSI-ENGR.COM 7EL.978-373-0310 FAX 978,372-3960 COPYRIGHT2013 DWG.NO.97066012 k 20 0 20 40 FT � SCALE: V=40' 4 9.39. 4� LOT AREA 27,550 S.F. B� h EXSTING HOUSE it \ 8T o� I ry O `V PROPOSED 22' HVIMMING POOL LOT 2 28' ` 51' OF S �� `y s G m .28895 sT£aE° `z Y PLOT PLAN FOR PROPOSED ssrONAI SWIMMING POOL AT 7 ABBY LANE A IN QJF \; NORTH ANDOVER, MASS. MICHA L t PREPARED FOR I RICHARD DUBE N ' DATE:APRIL 17,2013 csAMA PROFESSIONAL ENGINEERS&LAND SURVEYORS CHRISTIANSEN& SERGI, INC. l 1617SUMMER ST. HAVERHILL,MA.01830 WMCS/-ENGR.COM M.978-373-0310 FAX.978-3723960 COPYPJGHT2013 DWG.NO.97066012 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations j 600 Washington Street Boston,MA 02111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): tL PO-41 � I Address: r7p So Zn A o of P� City/State/Zip: A-vlf 2&4-u_ r ,4, O 1��3 Phone T7 kre you an employer?Check the appropriate box: Type of project(required): am a employer with Z," 4. ❑I am a general contractor and I 6. [A New construction employees(full and/or part-time).* have hired the sub-contractors ❑ I am a sole proprietor or partner- listed on the attached sheet.# ? EJ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers'comp.insurance. 9 Y p ty FJ Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.R Electrical 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.152,§1(4),and we have no 12.❑Roof repairs ] �/ insurance required.]i employees.[No workers' 13.[Other t/D> da comp.insurance required.] ty applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. :)meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. Baan employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site Jrmation. urance Company Name: hJ RLVT1 Lyti f - icy#or Self-ins.Lid.#: ��n/L 33 3 5-0 a(o Expiration Date: 12," U 1 ['3 Site Address:_F7 /K 6q k", - KJJ,(_4 `l Jy,,-� City/State/Zip: M ach a copy of the workers,compensation policy declaration page(showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 Lp to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of estigations of the DIA for insurance coverage verification. hereby certify under the pains and penalties ofperjitry that the information provided above is true and correct iature: i Date: 2 )S ne#: - p )fficial use only. Do not write in this area,to be completed by city or town official. �ity or Town: Permit/License# ' ssuing Authority(circle one): .Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Other 'nnfarf parenn. PhnnP# Informati®n and Instructions ' Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house ' or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-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 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 burn 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, .3lease do not hesitate to give us a call. 'he Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fav V 6,17_7?7_.7749 m:Eileen P. Hart, AAI -Hub International New Engl To:COI & req: NC Andover ( 16033' 10011 & L;36q?/G7/1L3 EST Pg 6-6 FAMILYPOICIL1 ACC►RDr,., CERTIFICATE OF LIABILIW INSURANCE DATE(Mf&Dn1YVYY) 3,'0712013 THIS CERTIFICA''E IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RRSHTS UPON THE CERTIMC:A.TE HOLDER,THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR 14EGA71VELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY T412 POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT SETVVEEN THE ISSUING INSUREF.{S).AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT':It the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be ondorsa-d.If SUSROGA?ION IS 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 Ileu of such endorsament(s). PRODUCER NAME:� HUB International New England 866-475-7S59 299 .475-7559 299 Ballardvale St ti : - Acl;cZ — Wilmington,NA 01887 ADDRESS: v--^- ---------- __-- 978 657-51 DOIN3URERIS)APFORUING COVrRAGE I NA!C e _ INSURERA:NaUIiIUS Ins Co -- ---�-- INSURED Family Pools&Patios Inc. INSURER a:Technology Insurance Co INSURER C:Acadia Insurance Company --131325 INaURER D:Safety Insurance Co 70 S.Broadway -- Lawrence,MA 01843 INSURER E ENSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED N;JAEC ABO`,''E FOR THE POI.ICY PERIOC INDICATED, NOTWITHSTANDING AIN REQUIREMENT,TERM OR COMDI'ICN OF ANY CONTRACT OR OTHER DOC-UMEN7 W1 H RESPECT-0 bVHiCH THIS CERTIFICATE MAY BE ISSUED OR MAY PER74!N, THE 114SURANOF AFFORDED 3Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITION$ OF SUCH POLICIES. LItvITs SHOWN NIA" HAVE BEEN REDUCED by FAJD CLAIMS. INSINSK 46t5i FOUC FF PO ICYEXP i - ----- TYPs:OF:Nri:RANCE .0JCYNUr�AEE9 M*UD(YY1'Y rdM(DDfYYYY" LIMITS LTR TINS` '"� -_.- A GERERALLIAB;U7Y �KN138379 5911912012 0$/'19/201 EEA H,')CClURR_NCET_$i 0001000 'QMNRRCIALGENERAL LIABILIY4' � PkEP.9��T EpE^N+'c.�rfn^e' S100� L�00 t- CLAIMS-MADE I-^I OCCUR I MED EXP(Any_ena pe-on) $5,000 -_ X 131/PD Ded:2,500 PERSONAL,%ADY'NJURY 1110-0-0-00-0- GENERAL AGGPEGATE 0GENERALAGGREGATE s2,000,000 GEMLAGGRFGA�LIM1-APPPLIES'�ER' i PRODUC::S-coup;cpAG'G x2,000,000 FOLK'!17 gpi F7!LOC _ I ' $AUTOMOBILE LIABILITY D115'NED SINGLE_III D I ,94723?. 213112012 12/31/201 Eaacdoent__—_--_---$1,000,000—_-- TII ANYAUTO 'aODILY INJURY(per e9's7n1 $ ---- - i ---- .4LI OWNED X SOHE U- AUTOS AUTOi 80011?'iNINJURY(?er acciden;) $ „ NONLWN PRUPEFtTY DAMAGE $ X HIFEDAUTO X 411705 'a-arr+an[1 UMBRELLA LIAR _ r• - - I OCCUR I EACH„t7GJRR__N E EXCESB-LI7AB— i I_;A;Mv%lhj E AO3rtEGA-E $ _ DEDREI TENTION3 ------ - --- B WORKERS COMPENBATtON TWC3335006 x213112012 12/31,2013 ii;Ry�Am Ts EkH AND EMPLOYERS'LIABILITY Y,N ANY oROPRIETOR;DAR'NER,'E.XECI!TrdEI E L E•^H ,!'-!OEVr OFFICERIMEMBEREXCLUDEi I Nj N/A I x500.000 (Mandatory In NHj I EL DISEASE-E4`:Vi�'LOYcE $500,O+�Q I'Yes,beserbs undue DESC.r�IIPTIOPi_DF OPEI'rA?tONS Uklx! _ E.L.DIgEASE.PnLIC''_Qll' :sJQ0,0'0d C Property CF'AO18U08416 v/19f2012 09119/2/�vrs limits Spec Form Repl Cost ed 81000 I DESCRIPTION OF OPERATIONS:LOCATIONS!VEHICLES lAttach ACORD 101,Additbnal Remarks Schedule,it more space In requires') re:Rick&Paula Dube,7 Abbey Large,No.Andover MA 01845, CERTIFICATE HOLDER CANCELLATION TOWn Of North Andover THE ANY OF THE ABOVE DESCRIBED POLICIES 3E CANCELLED BEFORE THE EXPIRATION DATE E THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,WA 01845 AUTHOR=REPRESENTATIVE '-VC .�^��� �C. V.,... ©1988-2010 ACORD CORPORATION.All rights raserva d. ACORD 25(201:0105) 1 O$1 The ACORD name and logo are registered marks of ACORD SM22191M834981 EH402 Ucense: CS 10330 WILLIAM C POULOS 70 3 BROADWAY as M;,A 01843 .. ......... =u,. 7/19/2013 Tr_ 20%8 .A' r 7 Office Of Consumer Affairs And' usiness Regulation 1-0 Park Plaza - Suite 5170 Boston., Massachusetts 02116 Home Improvement Conti-actor Registration Registration: 118204 Type. Supplement Card FAMILY POOLS & PATIOS INC Expiration: 2/13/2015 GLEN WIGGIN 70 S. BROADWAY LAWRENCE, MA 01843 11-1pdate Address and return card.Mark reason for change. SGA I POM-D511 Address '--i Renewal Employment Lost Card Y, ©trice orCowsuincr,affair,&Business Regidation License or registration valid for indivioul use only ,J.QME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: J" Office of Consumer Affairs and Business Regulation Registration: 118204 Type I@ Park Plaza-Suite 5170 Expiration: 2/1312015 Supplement -ard Boston—NIA.02116 FAMILY POOLS&PATIOS INC GLEN WIGGIN 70 S. BROADWAY LAWRENCE,MA 01843 Not valid without sign,I (j., STEEL WALL POOL SYSTEM - -- 22' X 44' MOUNTAIN LAKE 4.f 141 WH DWG#: GS-1094 DATE: 2/13/2008 1 REV:A PAGE 2 GP 3 TURNBUCKLE BRACE til ;Ili(ulu(1l±) f 4B- CRE ST-24009OR ST-72010ORR i, ANEL ST-720111 R LE ' E3'-4" ST-720111 RR10'-O' Z"POOLRASE4'-0„ TYP ST-36011ORR11'-0"AKE t io 25-7 1/8 ST-720111 RL `1111 EMBEDDED NUT BRACE 1 2'-0., 22'•0" _ R7'-0" bo CLIP io �a EMBEOOEO NNT - STEEL no"PANE y' ST-720111R 1001CRETE FLIOTER ,E,_O„ rT rT-O POOL �- RJ f 04 11' AA i ST-720111 R ST-72 10!l(Ilt(t ' ST-720111R? S ANf ST-24011 OR DECK SUPPORT(OPTIONAL) A4. {j Al I 'f 3' 41j a a 4,-0„ 6'-0" DIVING MAY THIS DOCUMENT IS FOR ILLUSTRATIVE PURPOSES ONLY, RESULT IN SERIOUS MAY Alpha 3 Mfg.makes only those representations which are stated in its written warranty.Any other representations,statements,or contracts mada by the dealer/rnnnucr n In Thur nndinia,rnllanliEto oily I attributable to the dealer/contractor only.The dealer or contractor who sells or installs your pool is an indepandant contractor and is not an agent or Knnpluyuu of Alplm:r I Iw r anon w.wnr mrijahfi tlpl3lr No MWING INJURY OR DEATH. to normal ground conditions.There may be additional precautions and/or methods of construction.The responsibility is the contractor's.-A safety inn,with buoys.I-i m tw wrnuuranir attar bar I'It' r n I v ILFI. Signage must be permanently attached around the change.-Different methods and precautions may be dictated by various ground conditions.This is to be determined by and is the responsibility of tire contractor who w nor an ngnnr ni Ihw rnnnbfge:iur�r r be done in accordance with all federal,state and local building codes,as well as A.N.S.I./N.S.P.I.suggested standards.-BOTTOM SPECIFICAI IONS MLIS I MEE I(II!I%(:I E II A N I IN'1 f^t/A 1�h r' i$I+ - - perimeter Of the pool. signage must be permanently attached to the entire perimeter of the pool.See instructions with signage.-17 IS NOT RECOMMENDED TO USE DIVING ANO/011[t1 I IINII @I)t)IF'MkNt(IN FIIl airm 43'-10 5/8" 2 OF 3 ST-36009OR ST-72010088 ST-2400908 ST-720091R ST-720111 R 8' 0" ST-4800 ST-72009ORR —3'-4" ST-720111 R R10'-0" R9'-D" ST-42076OR TYP ^ 9 ST-4807608 ST-3601108 I o M i e R9' 0" R11'-0 17 ENTER LINE 00 ` R7'-6" 25'-71/8" 22'-0ST-720111 RL " — —. — — I FS-9694RBW* R7'-0" {O7 1P ^ ry N N M Q _ ST-720111R R9'-0" ST-4207608 R4'-0" 153 ,� ST-36076OR ST-720111R ST-72009ORR ST-720090RR ST-720111R ST-72004OR ST-240110R RACES &DECK SUPPORTS AT PANEL JOINTS AS SHOWN 73��4" T-4., 4'0" 6'-0" 14'-0" 19'-10 5/8„ THIS DOCUMENT IS FOR ILLUSTRATIVE PURPOSES ONLY. Alpha 3 Mfg.makes only those representations which are stated in its written warranty.Any other representations,statements,or contracts made by the dealer/contractor to the customer regarding any components produced by Alpha 3 are f at«Ibutable to the dealer/contractor only.The dealer or contractor who sells or installs your pool is an independent contractor and is not an agent or employee of Alpha 3.The construction methods illustrated here are suggestions and apply only p".to normal ground conditions.There may be additional precautions and/or methods of construction.The responsibility is the contractor's.-A safety line,with buoys,is to be permanently attached V-0'to the shallow side of the point of first slopechange. Different methods and precautions may be dictated by various ground conditions.This is to be determined by and is the responsibility of the contractor who is not an agent of the manufacturer of the component parts.-Installation is tohe done in accordance w'dh all federal,state and local building codes,as well as A.N.S.L/N.S.P.I.suggested standards.-BOTTOM SPECIFICATIONS MUST MEET OR EXCEED A.N.S.I./N.S.F.I./A.F.S.P.RECOMMENDED STANDARDS'NO DIVING'siynaye roust be permanently attached to[he entire perimeter of the pool.See instructions with signage.-IT IS NOT REC011MENDED TO USE DIVING ANO/OR SLIDING EgU1PMENT ON RESIDENTIAL POOLS. h1C'tUYINp'C011P.° 70 South Broadway45 Route 125 Lawrence,NfA 01843 Kingston,NH 03848 Tel:978-688-8307 laid?' C) le t Tel:603-642-9909 Fax: 978-688-1.949 SrNCF»7A Fax:603-642-9906 providing a full line of services and supplies fully licensed and insured www.familypoolsonline.com � ( 71�1�1 6,Name (C..tt��� ---- I Q Q. Date & Il.(C, f Z.)1-3 Address ? A � OL, 41 City • f�y1�aV� State M4• Zip U l 914 Home Phone 91 R- 109F—rl00 Work Phone Cell g " �" I PZ I Add'I# Cross Street/Directions ofr MoN �L)_ �ner ,4- Sim r 1 -t",l Estimated Start Date Estimated Completion Date ` =F �^... •�.�.-:- :":-...... pool We propose to furnish and install on vinyl unite G-W ` Nor' rte,. swlmmtng pool for the sum of$ daSw' 1lsP end THIS PRICE INCLUDES: •Normal Excavation up to 8 hours on day of dig •Manual vacuum cleaner kit •Waterline Tile(6•) •Backfill and Sub-Grade up to 3 hours 3-Step stainless ladder •Liner Choice Ti�� 7,of 28124"11,f •Underwater White Lightt• •Rope and floats •Test Kit •Steel Reinforcing per Engineered Plans for gunite •Initial balancing chemicals •Surface skimmer(s) •Steel Structure per Engineered Plans for vinyl 8 to 12 Wk supply of maintenance chemicals •Dual Main Drains •Over-Flo Line for added protection • (supply depends on pool size) Coping Pressure testing of plumbing during construction Leaf net Steps� i�f^Y_• ^ r r 11 •Ten Year Plumbing Guarantee(see specifications) Wall brush •Handrails 4r. •Transferable Lifetime Structural Warranty •Extension pole •FilterC'r-VL._ (plumbed no more than 25ftfrom pool) •Pump&motor f �L THIS PRICE DOES NOT INCLUDE: •Any plumbing over 251t from pool.Additional runs are not recommended but would be at a cost of$._. per foot per line. •Machine time in excess of that specified above.Additional machine time to be billed at$ 1(e:S� including machine,operator,and laborer,due with second pool payment. •All hours of trucking will be charged at$ %I) per hour per truck due with second pool payment. •Any dumping costs incurred for disposal of ledge,large rocks,garbage,stumps buried or otherwise,building materials,unsuitable or nonstructural soils,or any unforeseen material that must be removed. •Removal of ledge or large rocks by way of a Starr bit,chipper,or blasting. •Additional fill,if necessary,for proper backfill or reshaping of hole,supply or spreading of loam,reseeding of grass. •Patio,fence,retaining wall,or any accessory items other than noted on contract. •Electrical wiring,fuel connections,heater venting,fuel storage tanks or permits. •Repair or replacement of sprinkler systems or any buried items such as well lines,drywells,leach fields,electrical lines,cables,etc.that are damaged during construction. •Costs due to water or soil conditions(ex.clay,peat,live sand,excessive rock,etc.)requiring a stone pack of the hole.The stone pack will be at an extra charge of i minimum to S' J"" maximum and at-the'discretion-of ti,ejob supervisor.Additional machine.time,andfor materials necessary to,rectq such a.condifion will be at a costoverar above the stone pack and will be quoted by the job supervisor. •Water to fill pool. Initials CUSTOMERS MUST SUPPLY: •Access for all trucks and equipment •Building and Electrical Permits or assume the costs necessary to obtain such permits. Water and electric necessary for construction of pool •Customer must water cure Gunite shell for 7 to 10 days if applicable. Water to fill pool immediately upon interior finish o / NOTES: � A(.( �< .► "f�}�� Vt a. p. — �.c t t 1-.Q S c7.n 7 E Sit '7-Q n V"0s I� C..A--Q-o� rc,� t-&Ul R 0..h a -e-e-67 e-`t OPTIONS: TOTALS: Diving Board Solar Cover ( ) -- Basic Pool Price $ Additional Pool Lighting s r e t7 ) �^^-�•- Options $ Heater �t"v -T Environpool Plus,8 hd+2 surface SUBTOTAL $ 4"©QJ— Additional Floor Heads "' Polaris Vac-Sweep ( -ri„c, f►•Z 5%Sales Tax/ 3 $ Polaris retrofit only TOTAL '`' $ Swimouq en �+�"fCt✓,a v�wi.f eew-ereh)f 110-0 Interior Finish ( } —_ Less 10%Deposit � 1t,(J� $ Spa ( ) Balance of Contract '�W $ Automated Control System ( } ^ Salt Chlorine Generator (Mae Other 4' .ar �T`�Q�` ) \✓✓ Oct-� -&-t S� �tA t#ru PAYMENTS: 1i3 EXCAVATION 1l3 BACKFILL+EXTRAS 1l3 SYSTEM START-UP The buyer hereby agrees to pay,in full,the total amount of this transaction upon start-up of the installed pool.Your salesman or job supervisor will meet with you prior to excavation at which time all decisions including pool size,shape,elevation,liner print,and all options must be final.Changes after this date will be subject to extra charges,where applicable,and will result in unavoidable delays.You,the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.Credit card payments not accepted on contract amount. b t. r! BUYER date 6)/ ELLER ' date'Z� CO-BUYER /' 11JA �'� dateJ—&, ? 9 8 b i Date..L ZZ--&........ NOR71{ 3=o;t;``°:•�"oo� TOWN OF NORTH ANDOVER 0 -Swift. .00 PERMIT FOR WIRING AU S This certifies that ......................Li O . ................................... has permission to perform ....(V.e(,(; �.......................................... wiring in the building of.. ' .e��.�<L ��S at............ .P... y..../:W...............L D.T 7..........,North Andover,Mass. h Fee&9.0 Z Lic.No. 3 12-................ ELEcnucAL lmrEcroRF ',.;heck # �✓ 2 S Commonwealth oto Massachusetts Official Use Only Department of Fire Serviceq PermitNo.— t BOARD OF FIRE PREVENTION UV REGULATIONS Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORD All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORAW TION) Date. City or Town of: WA To the Inspector of Wires: By this application the undersi ed gives not' e of his or her it tion to perform the electrical work described below. Location(Street c&Number)_ /,ty t/ At -7 Owner or Tenant Cd' Real/ OW5y,r C- Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes 2 No ❑ BLDG PERMIT# Purpose of Building '''yip nye Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service 300 Amps /--I' /� y Volts Overhead — ❑ Undgrd © No.of Meters / Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Gv y�,,v6 „dam Completion of the following table may be waived by the kupector of Wires. No.of Recessed Luminaires ,,20 No.of Ceil:Susp.(Paddle)Fans No.of Total, Transformers KVA, No.of Luminaire Outlets No.of Hot Tubs / Generators KVA No.of Luminaires Swimming Pool A ove mergency ig m rnd. El oto rn . BtUnis No.of Receptacle Outlets fV No.of Oil Burners FIRE ALARMS No.of Zones No. of Switches No.of Gas Burners 3 No.of Detection and initiatin Devices No. of Ranges / No.of Air Cond. l Tons No.of Alerting Devices No. of Waste Disposers f Heat Pump Nuer .Tons KW No.of Self-Contained Totals: "..... .. ..' Detection/AlertiniT Devices No. of Dishwashers / Space/Area Heating KW Local[] Municipal Connection E] other No. of Dryers / Heating Appliances KW Security Systems:* No. of WaterNo.of Devices or E uivalen No.of No.of Heaters KW t Data Wiring: Sim Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: tlttach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by 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 such cove ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) d cert,under thep/aiins and penalties ofperjury,that the informado on this application is true and complete- FIRM NAMER E: /5 / % /,4? LIC.NO.:o9 �— Licensee: Signature LIC.NO.:,9oC 9 Z (If applicable, enter "exempt"in the license number line.) Address: �4 j /JU6cl �aL Bus.Tel.No.:*I- fl /1-9-1 *Per M.G.L. c.147,s.57-61,security work requires Alt.Tel.No.: Departm t of Public Safety"S"Licen LIC.NO.: -2 - 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 Signature Telephone No. PERMIT FEE: $ s ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL 1.ROUGH SPECTION: Passed— Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-n nitial`s) Date 2.FINAL IN PECTION: Passed–[ Failed–[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-no i tials) Date 3. UNDER GROUND INSPECTION: Passed–[ ] Failed–[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no initials) Date / 4.INSPECTION–SERVICE: DATE CALLED NATIONAL GRID: — – / NAME: Passed–[ Failed–[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: v G (Inspectors'Signature-no initials) Date F5.INSPECTION-OTHER: ssed–[ ] Failed–[ ] Re-inspection required($50.00)-spectors' comments: s (Inspectors'Signature-no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED. The Commonwealth of Massachusetts ti Department of Industrial Accidents Office ofInvestigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insuranee Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Na1Tle(B.usiness/OrganizatiorAndividual): Address: Glo nA_k4>i(::*pb U City/Stateizip: _yMLgeao Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction. ,employees(full and/or part-time).* have hired the sub-contractors 2.[✓f 1 am a sole proprietor or partner- listed on the attached sheet.z 7• E]Remodeling . ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑B rung addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10. Electrical repairs or additions 3.❑ 1 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.❑Roof repairs insurance required.]i employees.[No workers' 1311 other comp.insurance required.] *Any applicant that checks box#1 nmst 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 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 ofthis statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. do Hereby certify under thepains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: Phone#: L only. Do not write in this area,to be completed by city or town official n: Permit/License#hority(circle one):Health 2.Building Department 3.CiWTown Clerk 4.Electrical Inspector 5.PIumbingfuspector son: Phone#: