HomeMy WebLinkAboutMiscellaneous - 73 COTUIT STREET 4/30/2018A, jw Location r13 — 1� 5 S No. 3S Date �l�av-�3 TOWN OF NORTH ANDOVER r°41 - s Certificate of Occupancy $ tt�' Building/Frame Permit Fee $ UU � sACNUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ O d Check # / Building Inspector T M 3 z O N C 1 b TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING yrs s , r n � c '� .:, .«. -•n x.:; , 'v: "- # x ( 7, a � .a,.w:». 7 . wad:" arm BUILDING PERMIT NUMBER: DATE ISSUED: � SIGNATURE: Building CommissionEL&sLxctor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 1)3 b, f J Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 WELDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record i�/�-�t•, cS y �-�� /�� G/-���s �� Cii fv� St— Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: e Signature Tele one SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ LtY U Licensed Construction Su rvisor: 6 rL oar �r� License Number yj Address �( /Z 71e / , r/G — Z 5; f ` Expirraaiion Date`e gnature Telephone 3.2 Registered Home Improvement Contractor Not Applicable 0 '= Company e Registration Number F/2 le, Z//"( Expiration Date Si nature J Telephone T M 3 z O N C 1 b SECTION 4 - WORKERS COMPENSATION (NLG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. affidavit Attached Yes .......❑ No ....... ❑ -Signed SECTION 5 Description of Proposed Work check su a licable ' New Construction ❑ Existing Building 0 Repair(s) Alterations(s) 0 Addition 0 Accessory Bldg. ❑ Demolition 0 Other ❑ Specify S fl Brief Description of Proposed Work: c f' r`�fy� A SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant ; ,OFFTCIAL,USE ONLY 1. Building p� U O F9 (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (+) x (b) -�- 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, , as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORI/Z�ED AGENT DECLARATION 1, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief \ Print Name %2��G' Signature of Owner/A it Date NO. OF STORIES SIZE BASEMENT OR SLAB SVE OF FLOOR TIMBERS 1ST 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DiMI NSIONS OF GIRDERS I Il ioI IT OF FOUNDATION THICKNESS S V L Ol� I� OOTING X MA FERIAL OF CHIMNEY IS 13tTILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE xal ' J..� f e �amman�vea`!�i aaaurciu�aelia BOARD OF BUILDING REGULATIONS Icense: CONSTRUCTION SUPERVISOR Number: CS 069951 Birthdate: 08/27/1955 f Expires: 08/27/2004 Tr, no: 288 Restricted: 00 LEE G STEPHENS 81 CHESTER RD #2 RAYMOND, NH 03077 Administrator u Tp 1 le Laanz�n4nwna�r a��t%�r,�faciu�detla Board of Building RegulAtions and Standarus HOME IMPROVEMENT CONTRACTOR Registration: 108985 Expiration: 8/28/2004 Type: DBA SYLVAIN CONTRACTING Marc Sylvain 9 PLAISTOW RD. PLAIS70W, NH 03265 Administrator 1 ) "�Ir #�. 7t! r r S, T+F ✓ :OIDUCER Serial # A16442 AON RISK SERVICES, INC, OF FLORIDA ry. DATE(MMfDMWD)YY)ACORD„ 07/22/2003 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1001 BRICKELL BAY DRIVE, SUITE #1100 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. MIAMI, FL 33131AS37 COMPANIES AFFORDING COVERAGE 800-743-8130 -- — COMPANY AMERICAN HOME ASSURANCE COMPANY A COMPANY ADP TOTALSOURCE, INC. B ----- — - - 10200 SUNSET DRIVE — ------ — ---- MIAMI, FL 33173 `ALTERNATE EMPLOYER: COMPANY C COMPANY SYLVAIN CONTRACTING LLC D !,A �Y��I�L� i . ),Kyi ? h1r S-. .^t,�yi 7 . i �ti r+ T G' >•'Ylh i�� .;: r7i 1 r y� r � P y 7 y t r,t i: ., .. 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �— TYPE OF INSURANCE 2 I POLICY NUMBER POLICYEFFECTIYE I DATE (MMIC01YY) POLICY EXPIRATION DATE WOO” LIMITS AL LIABILITY GENERAL AGGREGATE $,tERCLALGENERA��LL--IA77BILITY I iPRODUCTS- CCNPIGPAGG $ CLAIMS MADE 71 OCCUR PERSONA',. & AD`J &URY $ OWNERS & CONTRACTOR'S PROT EACHOCCJRP,ENCE $ F';REDAAAAGE (Any one fire) $ I _ ---_------------ MED EXF (AN weperson) — $ ------ AUTOMOBILE i LUIBILITY ANY AUTO COMM! NED <aNG-E LIMIT $ I BOCILYINJURY —t$ (Per Person) BODILYINJURv S 4 ALL OWNED AUTOS SCHEDULEDAUTOS HIRED AUTOS III---------��� H NON-OWNEDAUTOS rPer PRCPERTYDAIMA.GF $ -------- --- GARAGE LIABILITY AUTO ONLY - EA ACCGENT $ ANY AUTO OTHER'FHAN AUTO ONLY EAr_HACCOENT -------" AGGREGATE $ $-------- I EXCESS LIABILITY JEACH OCCURRENCE $ r UMBRELLA FORM AGGREGATE $ — JTHER THAN UMBRELLA FORM $ WORKER'S COMPENSATION AND RMWC 3476330 06/30/2003 06/30/2004 X o; EMPLOYERS'LIABILITY EL EACHACCiDEPt? $ 1,000,000 THE '- INCL EL DISEASE •PCLIC.YLIMIT Is 1,000,000 PARPCP&E1CU PFR1nER5EyCECU1rVE pPPICEF.'S aRe: EXCL EL DISEASE • EA EMPLOYEE $ 1,000,000 (OTHER .L EMPLOYEES WORKING FOR THE ABOVE NAMED CLIENT COMPANY, PAID UNDER ADP TOTALSOURCE, INC.'S PAYROLL, WILL BE COVERED \DER THE ABOVE STATED POLICY. "THE ABOVE NAMED CLIENT IS AN ALTERNATE EMPLOYER UNDER THIS POLICY. SHOULD ANY OF THE ABOVE DESCRIBED PCLICIES BE CANCELLED BEFORE THE SYLVAIN CONTRACTING LLC 9 PLAISTOW ROAD EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 34 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, PL.AISTOW, NH 03865 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTH0 D A VE is l Name The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02919 Workers' Compensation Insurance Affidavit Please Print Name: Lriri 1�jyly� f �n �-lS�`�-2pere" Locaiion: City ��� nr` P';'7--- Phone # I am a homeowner performing, all work myself. 1 am a sole proprietor and have no one woddng in any capacity �am an employer providing workers' compensation for my employees working on this job. Insurance Co. /lam �r (`cn WComet T Policy # Comoanv name. Address Phonek Folure to secure coverage as required under Section 2M or MGL tat can teed tothe Imposition of criminal perces of a fine r to �1.5i and/or one yeeW in. ll elif�(,S]AD tlO astagF e. understand that a coptr of this statement may beforwarded to the office of Investigations cf the DIA for cmefage verification. I do hereby cal* under the gabs and penalties of pMwy fleet flee k*i=flarrpmviided above is true and raarnea nate Print name L t t U -f=C /7Li t+ 3 PbDne-# Official use only do not write in this area to be completed by city or town offiaar City or, Tom. BW7Whg Dpt DCheck I ftnediate response is required RSint� j B 1 ❑ Selectmaft o Contact person_ Phone#: ❑ Health Deparit ❑ Other R: C G CD C O CIS G y O G �r O 101 C2 G-1 �: dG O A m C cp ;L O o �+ Q O p. 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C Z CD CL :..± ND O C C c CO) p i LLI uj W LLI W co North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: r'el� S4rA L�nv( rli ill z LC '41) 1W, (Location of Facility) 2 �, 0 /z 2: — - igna ure of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Sylvain Contracting. tto Date: Name: Add res City, St Home Work P 9 Pleirtow Rd. Plaistow. till 0386S Dear 14a-� Thank you for taking the time to meet with me and discuss ideas to Side your home. I would briefly like to tell you about Sylvain Contracting, LLC and why you should choose us for your remodeling project. Sylvain Contracting protects your property by covering you with $2,000,000.00 of liability insurance. Workers Compensation Insurance covers all of our employees so you are not exposed to any Liability and we are licensed and registered in Massachusetts. Our Home Improvement Contractors Registration # 108985. Construction Supervisors license # 060607. We are members of the Certified Contractors Network (CCN), Better Business Bureau (BBB), Greater Salem and Greater Haverhill Chamber of Commerce. As a legitimate end dependable siding company, we maintain these affiliations and credentials to provide you with the highest level of confidence and customer service. All of our siding mechanics and estimators are Certified CertainTeed installation experts, and attend pre -approved on-going training to keep them up to date on the latest technological advances in siding including the local building codes vinyl siding specifications. With a permanent place of business and over 15 years in the remodeling industry, we take pride in our quality workmanship and specialty services offered to our clients. Very Truly Yours, e'r�' I �' r1� S C Sylvain Contracting, LLC 58 Island Pond Rd. Atkinson, N.H. 03811 Tel. (800) 281-4995 Fax (603) 362-5836 This project has been specified in accordance with local building codes, industry standards and manufacturers specification requirements. All work will be installed by certified craftsmen to assure qualifications for the long term siding warranty. General Siding Specifications: Job Site Preparation: 1. Sylvain Contracting will protect all bushes, shrubbery, and surrounding grounds with tarps. 2. Sylvain Contracting will provide a container for disposal of existin siding. We will need to locate and prepare a convenient place for the container. � Dr- ✓Ti -1, Material Removal: We will remove all the existing siding from the home down to the Sheathing and dispose of it in an on site container. We will remove all existing accessories from the exterior walls, including shutters, light fixtures, etc. Sylvain Contracting, LLC 58 Island Pond Rd. Atkinson, N.H. 03811 Tel. (800) 281-4995 Fax (603) 362-5836 Plywood Surface Preparation: The plywood is the structural surface over which the siding will be applied. The plywood should be a smooth, solid surface, which will permit the siding to be securely fastened. The surface must be at least 3/8" thick plywood, or 7/16" thick non -veneer, or nominal 1" thick boards. The deck must be strong enough to: *Provide resistance to wind force. *Anchor the nails If you apply vinyl siding to plywood that is unacceptable to the manufacturer, and damage results, the warrantee may not be honored. The manufacturer will not take responsibility for. *Poor surface design that causes damage to siding or other parts of the house *Defects or damage caused by the materials used as an underlayment, over which the siding is applied. *Damage to the siding caused by settlement, distortion, failure, or cracking of the structural surface. *Defects, damage, or failure caused by the application of the siding not in strict adherence within written instructions of the manufacturer. *Application over wood that is not dry or which has hard projections, such as partially driven nails, which can cause damage to the siding panel or the underlayment applied above. 1. Inspect entire surface before the installation of the new siding, re -nail protruding surface nails and clean the surface to allow for a smooth surface for the installation of the insulation and new siding. 2. Replace any rotted plywood at $5.00 per square foot. (Full sheets $75.00 L & M) 3. Replace any rotted finish lumber at $10.00 per board foot. 4. Re -nail loose plywood with 8d common nails to properly secure to the house Wall Preparation: 1. We will apply 310-1 inch High Performance Insulation. Sylvain Contracting, LLC 58 Island Pond Rd. Atkinson, N.H. 03811 Tel. (800) 281-4995 Fax (603) 362-5836 Door Details: _1s We will cover the door casings as described below. *Remove the existing storm doors and frame *Scrape the old caulking and sealants from the wood casing *Fabricate PVC coated aluminum trim stock to cover the casing, joining the corners with 45 -degree angles. Color: (,v M-ZT-v-r *Extend the ears of the casing trim so as to tuck them behind the storm door frames. *Cover the jamb of the doorframes that will be exposed to the weather. *The kickboard cladding shall extend from under the bottom of the threshold to the landing. *Reinstall the storm door. Trim Details: ;/ e 5 1. Apply J -Channel to all sides of the windows and doors using an interlocking 45 -degree corner detail. 2. Fabricate new wall flashing at decks 3. Flash along unfinished edges that are visible from normal view. 4. Install sill flashing to all windows to prevent water from weeping behind the siding during rainstorms. 5. Fabricate PVC coated aluminum trim stock to cover the window casings, joining the corners with 45 -degree angles. Color: 6. Use window J -Channels to match trim. Color: 7. Use door J -Channels to match siding. Color: i 8. Use all other J -Channels to match siding Color: o (�e. r. 9. Install p!. -IP ,'v ''corner posts Color: hyh'.�i� ire.✓e Siding Panel Details:v� klQ jo 1. Install the new siding over the specified insulation: Panel specifications: %v,- , ✓�,' Color: 2. Secure the panels with special aluminum siding'nails to prevent any bleed through of rusty fasteners. Sylvain Contracting, LLC 58 Island Pond Rd. Atkinson, N.H. 03811 Tel. (800) 281-4995 Fax (603) 362-5836 Soffit and Facia Details: 411 1. Cut and fit a receiving channel for the new soffit panels and to serve as a cover strip for the fasteners holding the final row of siding. 2. Cover the soffit with a vented vinyl pa el havin a 3 -inch exposure. Panel specifications: 1,o t Color: 6, l4� t 3. Custom fabricate PVC coated aluminum trim stock to cover the Facia and rake boards. Color: ZN H �r —x- 4. Follow the existing lines of the shadow and Facia. 5. All materials shall be secured with special aluminum siding and trim nails to prevent corrosion and bleed through of rusty fasteners. A)6w 6.D F6�2 koo- a16 e- E l4y Accessories: 1. Re -install all original fixtures with special vinyl J -Type mounting blocks. 2. Replace dryer and bathroom vents with special vinyl vents made for vinyl siding applications. 3. Install special J -Type faucet blocks around all water spickets. 4. Install special J -Type outlet blocks around all electrical outlets. All of the J -Type vinyl blocks will be the color of the siding 5. Replace the existing gable end vents with vinyl gable vents Color of the new gable vents will match the siding. 1 /V Remove and reinstall existing shutters. ?f7AI s Install jjjj.,,_) vinyl shutters using special vinyl shutter locks to prevent any buckling of the new siding. Color: = �0�, st'��� e Remove and reinstall approx. LLA, feet of existing gutter and downspouts. New Install approx. /3 Feet of seamless aluminum gutter and downspouts. Color: Sylvain Contracting, LLC 58 Island Pond Rd. Atkinson, N.H. 03811 Tel. (800) 281-4995 Fax (603) 362-5836 General Details: 1. Dispose of all debris and scrap materials using an onsite container. The container will be located: ,_'%� C,l veZr.�ke--�'c' 5 1ar, �✓�t �- h 2. Work area shall be kept neat and clean on a daily basis and returned to normal upon completion of the project. 3. Materials will be delivered to tth job site in advance of job start. The location of the materials will be: J/?C/ de 4. The electrical service box shall be detached to allow the new siding and insulation to be applied behind the box. It will be secured as original upon completion of the siding job. 5. The owner shall remove all wall hangings and shelf items on the outer walls that may become loose and fall due to hammering on the outside. This would include items such as pictures, clocks, plants, dishes, figurines, etc. 6. All work shall have a ten-year workmanship warranty. 7. A written materials warranty shall be provided upon receipt of final payment. 8. All work follows existing OSHA regulations as mandated by 29 CFR 1926 for the construction industries. 9. All work will follow local building code requirements and any permits required will be obtained by Sylvain Contracting, LLC 10. We maintain a current General Liability and Workman's Compensation Insurance Policy. A copy is available upon request to verify coverage. Sylvain Contracting, LLC 58 Island Pond Rd. Atkinson, N.H. 03811 Tel. (800) 281-4995 Fax (603) 362-5836 Local and National Affiliations: Certifications: "Certified Contractors Network (CCN)" *CertainTeed Vinyl Carpentry "Greater Haverhill Chamber of Commerce" Siding Specialist "Greater Salem Chamber of Commerce" *Advanced Alside Siding Product New Hampshire Better Business Bureau (BBB)" and Installation Specialist "Energy Star Retail Partner' *Alside Window Design Specialist "National Association of Home *Authorized Sunlight Series Dealer Builders and Remodelers" *Authorized Elite Sunroom Dealer *Authorized Wolverine siding Dealer INVESTMENT TOTAL FOR SPECIFIED PROJECT proposeWe hereby . furnish all labor. materials in accordance with the above specificatiorr,.-kw-the-emm--.,5--,----,-. /moi,/�.�</;� =.. ,� �L��/es Deposit at accep ance of proposal Due at Job sta1a00 Due upon completion This proposal may be withdrawn or subject to change if not accepted within 10 days. Authorized Signature —" Date Authorized Signature �--- Date Acceptance of Proposal The above prices, specifications, and conditions are satisfactory and are hereby accepted. You are Hereby authorized to do the work as specified. Payments will be made as outlined above. In the event Sylvain Contracting, LLC finds it necessary to seek legal action in order to collect any payments that is overdue, or in order to perfect its mechanics lien, I agree to pay interest on any overdue accounts at the rate of 18% per annum (1 Ys% per month) All work to be completed in a workmanlike manner according to standard practices. Any changes from above specifications involving additional costs will be made only by request in writing, and will be an additional charge over the original proposal. All agreements contingent upon strikes, accidents, or acts of god. Owner to carry fire, hazard and liability insurance. Sylvain Contracting, LLC 58 Island Pond Rd. Atkinson, N.H. 03811 Tel. (800) 281-4995 Fax (603) 362-5836 Right of Rescission I have the right to terminate this contract within three (3) business days of signing this agreement. If I c o e t/its—Cof rminate this contract, I will contact Sylvain Contracting, LLC office on or beforeIn the event I terminate this agreement there will be no penalties, and a depo mine will be promptly returned. If the customer is a corporation or limited partnership, the undersigned, jointly, severally or individually hereby unconditionally guarantees the obligations stated herein. Signature Date Signature — Da Affidavit I, the undersigned, the owner of the property located at -�,- Hereby verify hat have authorized Sylvain Contracting, LLC to apply to the building department of t 11 to act as my agent in obtaining a building permit and'/o'r any oning requirements needed to obtaining permits. Signature Home owner at Sylvain Contracting, LLC 58 Island Pond Rd. Atkinson, N.H. 038I1 Tel. (800) 281-4995 Fax (603) 362-5836 Date 1p..UN, 5......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING U This certifies that .....�...... �n e.l..... L � " ,.o..� ........................ has permission to perform ...... !.'�. tP - ��L ...................................................... plumbing in the buildings of ........ �. d ?. P..0.......................................................... at r d `^ ..................... North Andover, Mass. Fee .2..`.�S. ... Lic. No.43ti ................................................................................ PLUMBING INSPECTOR Check # i�- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITYt-m�'e� i[ MA DATE 5_11 PERMIT# III 0 JOBSITE ADDRESS , OWNER'S NAME WQ 3 P OWNER ADDRESS 3 Ca S TEL DYE $ 11FAX TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL © RESIDENTIAL0 PRINT ��, CLEARLY NEW: !J RENOVATION: ® REPLACEMENT: © PLANS SUBMITTED: YES ® N0�]I FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER _ ._I ._._ I � I J �._� .. .- J _ ..1 _J ! DRINKING FOUNTAIN FOOD DISPOSER__.. ' FLOOR/AREA DRAIN _I � _I � J I INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK I { I I _._J ..__J ____.J __ _. I __J IF TOILET I .. J J I _.1L�j .. J URINAL ____. WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING _ _! � ! _.J i I OTHEr.' _-__J -__731 1 __._ 1 _ i _.._._I = ! ._.__! _ J ! _..__I ._._.__I _.... INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO �f IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY � OTHER TYPE OF INDEMNITY D BOND DJ 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 DI AGENT 1D 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 4o in compliance with all Pertin nt provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME [ LICENSE # 3 3j [ SIGNATURE IMPIA JP Q CORPORATION 0# PARTNERSHIP D COMPANY NAME 1[lQf���'g,� ; ADDRESS CITYt�,`14�� - -_ _.._(STATE /,/ _[ ZIP TEL FAX [ CELL a3y9/f EMAIL ° 0 F z N ❑ W cx w W LL 1 The Commonwealth ofMassachusetts Z Department oflndustrialAccidents n r 1 Congress Street, Suite 100 Boston, MA 02114-2017 :�'"t www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: City/State/Zip: Lo e�,61qQ rrff 0 Are you an employer? Check the appropria a box: 3 Phone#: (&03)a3q-91A6 1. I am a employer with ___L_employees (full and/or part-time).* 2,❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6. ❑ 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): 7. ❑ New construction S. El Remodeling 9. ❑ Demolition 10 E] Building addition 11. E] Electrical repairs or additions 12. Plumbing repairs or additions 13. F1 Roof repairs 14. [J Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub-con`traciors have employees,' they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. / Insurance Company Name: 1' 4 %L Policy # or Self -ins. Liic//. #: Job Site Address: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Expiration Date: City/State/Zip: I do hereby certify under the painsand penalties ofperjury that the information provided above is true and correct. nkwAl Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License —3F_f'S 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 #: 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 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 -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' compensatiod'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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Property Address Policy Number: Date/Cause of Loss File or Claim Number: Rita Wells 73 Cotuit Street H P3050817 10/18/2014, Water/Plumbing 30313-R Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Ryan Werner On this date, I caused copies of this Notice to be sent to the per named above at the addresses indicated above by First Class Mail. AI ,/ SignafVe and Date ANDERSON ADJVATMENT CO., INC. 50 Nashua R ad, Suite 303 PO Box 1098 Londonderry, NH 03053