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Home My WebLink AboutMiscellaneous - 81 LINDEN AVENUE 4/30/2018N , 9764 Samoa, 'For, Date ...... 1.1-12-,-.12 .. ..... ......... .. .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................ :.:rP8 .... ko.cv.lvz*� ............................ .... .. ..... ..... . . has permission to perform ..................................................... wiring in the building of ............ ........................................... at ..... ;? / , Z- ...... ? ......................... ... .......... . North Andover, Mass. .......... V .............. Fee..3� Lic. No. L;?A .. ..... ;i ELECMIcAL I.Ospecro Check # r It Commonwealth of Massachusetts Official Use only FE Department of Fire Services Permit No. g 74 1% Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 11- Aa - l 0 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 3/ `1 t)Je,g tj ue Owner or Tenant —JaA PJ f - ('"�! L�M Telephone No. Owner's Address Am rp Is this permit in conjunction with a building permit? Yes [�J' No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Ren ov&$-e k 1-c(, e Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires 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 Above ❑In- ❑ rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pum Totals: Num............r � � Tons ........... KW """""......."" No. of Self -Contained Detection/Alerting Devices No. of DishwashersSpace/Area !1 Heating KW Local ❑ Municipal Connection El other No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of WaterKW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work:J0-00 (When required by municipal policy.) Work to Start: i 1- 0 /0 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 age is in force, and has exhibited proof of same to the permit issuing office. NCE ? CHECK ONE: INSURABOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: ow A 1,A4 N LIC. NO.: Licensee: Sn Signature L=QLIC. NO.: 37 v1 11 E (If applicable, enter "exempt" in thelicen^number line.) Bus. Tel. No.: 70/ 7S3 670 6")9 .S Address: on,WW0J1 ler- )4At/1son /I/ LgR/1 Alt. Tel.No.:6Q3366) 6570 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. 37 6) / / E 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 a ent. Owner/Agent PERMIT FEE. $ Signature Telephone No. m p � Q o k � d 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): Address: � Slinewo.l Ier v City/State/Zip: A-J,�, ns0 n AN 039ll Phone #: X - X53 - v-70 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I mployees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.1 required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t ❑ 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 *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they 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 -contractors 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: Policy # or Self -ins. Lic. #: Job Site Address: Expiration Date: 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 herebX certify der the pains and penalties of perjury that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: t .8770 Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...�., . ,1, , , , o' has permission to perform .... P 5� / .U. y,w s . plumbing in the buildings of ...Cry." . ,..t . , , , , , , , �r at.. . �. d ", .? -_ .. , North Andover; Mass. Fee. y?..... Lic. No.. ...... o. �L- ^.... ......... . PLUMBING INSPECTOR Check # A5 5) a -tl--\ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING CitYRown:_,NoC�rh MA. Date: i 0�10 Permit# BuildingLocation: ' (� Owners Name: _k j C (1 Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: 0 Plans Submitted: Yes ❑ No tZ FIXTURES z z w 0 tY N W Q N >- J = hy. W Z a W z 1. Z qa N fn Q 0 w o m z a z n O m tzif a� a W m} W Y m 0 a x o a a � a _z fn y t� U a LL a Y= 9 0 0 1— s: = a f G W y W J z it J � � IY Q a N N O V) . ! >> 0 Q O Z Z fA F H= i Y g g °� v=, n 3 3 3 o SUB BSMT. BASEMENT 1 FLOOR 2NO FLOOR --S'FLOOR 4 FLOOR 5 FLOOR WN FLOOR 7 FLOOR 8 FLOOR LOW Installing Company Name: � e (ly T � , r Check One only Certificate # Address:QV � �3 Ci /Town: 1'r�U4 gCorporation - � �State: �Business Tel:q) Partnership i �G �,_ Fax: 1 Name of Licensed Plumber: �bW ❑Firm/Company INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes -Z No ❑ If you have checked Yes. please indicate the type of coverage by checking the appropriate box below. A liability insurance policy '® Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: 1 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 Si nature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be In compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ❑ Plumber Signature of Licensed tuber City(rown ❑ Master APPROVED OFFICE USE ONLY ❑Joumeyman License Number: �C Date.6 . � ........ NORTH ANDOVER FOR GAS INSTALLATION This certifies that . .� -,.'.( 14.11 -- has permission for gas installation ............................ in the buildings of ........................................... at ..... 9, z . 1..!. t % . �. . . . 1,e. North Andover, Mass. Fee. .k. !r-' . Lic. No.......... . Check # 56U9 • MASSACHUSETTS UNIFORM APPUCATON FOR PERNIIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations 8� Z% toy ��- f�%��/� Owner's Name New11Renovation 11Renovation LIZJ Date Plans Submitted ❑ Permit # _ Amount $ (Print or type) hec one: Certificate Installing Company Name T W4 G L Or/ -q r✓ Corp. Address f. d - 13 G X S 7 °Z ❑ Partner. 4,4Aj4eni« 14 P aid y�L Business Telephone 97 j' 6 b(5' 9 50 Y ❑ Firm/CO. Name of Licensed Plumber or Gas Fitter 7�4),-i ats ! L} //c, eq t" l INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ® No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy ® Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: 1 am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: ❑ Signature of Owner or Owner's Agent Owner ❑ Agent i hereby certify that all of the details and mtormation 1 have submitted (or enterea) in anove appucanon are true ana accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State GasCode anfl Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ® Plumber a2 Y � 33 ❑ Gas Fitter License Number ❑ Master ® Journeyman k' • UWAKS FLOOR _------_---------__S_ (Print or type) hec one: Certificate Installing Company Name T W4 G L Or/ -q r✓ Corp. Address f. d - 13 G X S 7 °Z ❑ Partner. 4,4Aj4eni« 14 P aid y�L Business Telephone 97 j' 6 b(5' 9 50 Y ❑ Firm/CO. Name of Licensed Plumber or Gas Fitter 7�4),-i ats ! L} //c, eq t" l INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ® No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy ® Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: 1 am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: ❑ Signature of Owner or Owner's Agent Owner ❑ Agent i hereby certify that all of the details and mtormation 1 have submitted (or enterea) in anove appucanon are true ana accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State GasCode anfl Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ® Plumber a2 Y � 33 ❑ Gas Fitter License Number ❑ Master ® Journeyman M MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS a , Date Building Location L//y,9eA 4✓W. Owners Name Al— r*eo Ed?—/Gv-14 Permit # Type of Occupancy 4 jA1e11." A1 y Amount New 0 Renovation 0 Replacement W Plans Submitted Yes 1:1 No (Print or type) Check one: Certificate Installing Company Name _//4'%!D/2Corp. Address /00 eox 57-4— Partner. & 4 Polly R.4- usmess Telephone G X 3e `t Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy El Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbic Code and Chapter 142 of the General Laws. 113y: City/Town APPROVED (OFFICE USE ONLY Type of Plumbing License a yY.?3 tcense lNum5er Master ❑ Journeyman 1B 1' / ` i I:` I .--.M...-M.-..--.-.-- MM ' ..-.-.M.. M .............-. ��' ..-..M-..-..M-W-M.-M.-.-. wjek,lort--t.-ammmmmmmmmmmmmmmmmmmmmmmm. .,1 c o.' .-.-.-.m.-m..m.-...-----. � MM-MMMM.M-MMMMMMMMMM.-M®- ��:' ....---.MM..-.-M-.M--M.-- W I -i' mmmmmmmmmmmmmmmmmmmmm MMM 5MMMMMMMMMMMMMMMMMMMMM MM (Print or type) Check one: Certificate Installing Company Name _//4'%!D/2Corp. Address /00 eox 57-4— Partner. & 4 Polly R.4- usmess Telephone G X 3e `t Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy El Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbic Code and Chapter 142 of the General Laws. 113y: City/Town APPROVED (OFFICE USE ONLY Type of Plumbing License a yY.?3 tcense lNum5er Master ❑ Journeyman 1B Location - No. Lig Date '� S TOWN OF NORTH ANDOVER h p Certificate of Occupancy $ �'�s''••° • E<�' Building/Frame Permit Fee $ s�cwus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 'ld f1 184U2 Building In4iktor t TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMTr NUMBER: Jy� DATE ISSUED: y SIGNATURE:,v Building Commissioner/InWector of Buildings Date — / T 0Z SECTION i- SITE INFORMATION 1.1 Property Address: mo_ &--/Z a- ZA �, If 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING 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: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner 'off Record Name (Print) Address for Service 0 Signature Telephone 2.2 Owner of Record: t Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 �L*czned Construction Supervisor: i nsed Construe on uperyisor: por Address ��j /,O� gn�it% Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Con for � r t 7C�mpName� ®� Not Applicable ❑ �o 7 Registration Number Address i ture Telephone Expiration Date O z M 90 O on M _r z 0 r 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. Signed affidavit Attached Yes .......0 No ....... ❑ SECTION 5 Description of Proposed Work check all appUcable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work. - Al 'fl ork:Alli I II SECTION 6 - ESTIMATED CONSTRUCTION COCTR Item Estimated Cost (Dollar) to be Com leted by permit applicant OFFICIAL USE ONLY - 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) % 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number Jr.l,11V1'4/a VW1NLKAUlnUKILAl1V1N 1Ubh UVMNLE'1E) WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNUT I, 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 SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION Date t, 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 8 Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TITVIBERS 1ST2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE REPAIRS CASTRICONE CONSTRUCTION LLC FREE ESTIMATES CASTRICONE ROOFING & SIDING CO. ` Telephone: (978) 682-4266 Fax: (978) 794-0910 MARIO CASTRICONE DAVID MICAL P.O. Box 441, North Andover, Mass. 01845 I/we, the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms, and conditions, on premises below described: I��e=,e;t� W i Owner's Name. I 6 4e,............... .. .. ........... . Job Address ..61. ............... City � . /� State SPECIFICATIONS ........... ......... .........................IL ...................................... .................... . . . . . . . . . ....................... ......................................................................... Materials and labor to cost $ .1 . ea ... Payable .... ... .... on . . . . . . . . . . . and balance in . . .. .. . monthly installments of $ ." '.�Q.eo , each, payable on ........ day of each and every month thereafter until paid 16o d in full (. . . . . . % charge per gear is to be added to above cost of labor and materials and is included in monthly payments.) Contractor will do all of said work in a good workmanlike manner. Workmanship is warranted for one year. Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation and a completion as requested by the contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid immediately due and payable. It is agreed that if permitted by law, contractor shall be paid by the owner(s), all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of this contract and/or any lien in connection therewith. It is further agreed that this contract may be assigned by contractor; and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties. The undersigned warrant(s) that he is (they are) the owner(s) of the above mentioned premises and that legal title thereto stands of record in his (their) name(s). PROVISO: This contract shall be void and of no effort if credit approved of owner(s) is refused. There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is this contract dependent upon or subject to any. conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties. Cover attic storage cleaning not included. Not responsible for ice back up, Not responsible for broken plants or rip-offs. Receipt of a copy of this contract is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. Owner or Owners are not responsible for Property Damage or Liability while job is in operation. IN WITNESS WHEREOF, the parties have hereunto signed their names this . . . /Z , , , , , day of , 20 a 5� , Accepted: Siginerd .. .... �!... . caner (OWNER HAS 3 DAYS IN WHICH TO CANCEL CONTRACT) Per. . . . . . . . . Represen e Signed.............................. Owner Signed.............................. REPAIRS CASTRICONE CONSTRUCTION LLC FREE ESTIMATES CASTRICONE ROOFING & SIDING CO. i Telephone: (978) 682-4266 Fax: (978) 794-0910 MARIO CASTRICONE • DAVID MICAL P.O. Box 441, North Andover, Mass. 01845 I/we, the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms, and conditions, on premises below described: Owner's Name. , .:� ................. .. .. ............ �, r /�./ Job Address. �. , , , , , , , , , , , , , , , City . /.`�� State rQ. SPECIFICATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... . . . . . . . . . . . V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Materials and labor to cost $ .A . mo ... Payable ... . .. .... . on . . . .. . . . . . . and balance in .. . . .. . monthly installments of $ each, payable on ....:... day of each and every month thereafter until paid 66 a in full (. . . . . . % charge per year is to be added to above cost of labor and materials and is included in monthly payments.) Contractor will do all of said work in a good workmanlike manner. Workmanship is warranted for one year. Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation and a completion as requested by the contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid immediately due and payable. It is agreed that if permitted by law, contractor shall be paid by the owner(s), all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of this contract and/or any lien in connection therewith. It is further agreed that this contract may be assigned by contractor; and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties. The undersigned warrant(s) that he is (they are) the owner(s) of the above mentioned premises and that legal title thereto stands of record in his (their) name(s). PROVISO: This contract shall be void and of no effort if credit approved of owner(s) is refused. There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is this contract dependent upon or subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties. Cover attic storage cleaning not included. Not responsible for ice back up, Not responsible for broken plants or rip-offs. Receipt of a copy of this contract is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. Owner or Owners are not responsible for Property Damage or Liability while job Is in operation. IN WITNESS WHEREOF, the parties have hereunto signed their names this , , , /,9 , , , , , day of , 20 en 5 Accepted: Signed . .. ... . . . . . , l•!' , , caner (OWNER HAS 3 DAYS IN WHICH TO CANCEL CONMACn Signed . . . . , , , . , , , ,, , , , , , , , , , , , , _ _ Owner Per .. (C�i, �=G� • ....... Signed . .. ... .. ... ..... .. .. . . Represon e Z 0 � , ?/ e a , ��2■ �� 0 j �,� \� = 0 _ ■EF, % 2 ■ n 0 > m x �■E e ® f p2 °. \z ~\ ■ j.I � § »:9� \\z\: § .0 2 k \ 0 z / . \o 0 ( ■ LL \ ■o■£t- o _ • e a , ��2■ �� ,� �g■� � � ■EF, �_ �■E \ ■ .w a U"Orrfvnwrus[n UJ /YLassacnuseas 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 (B, Address: City/State/Zip: Are you an employer? Check the appropriate cti box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employee's (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me 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.] 'Any applicant that checks box #1 must also fill out th bel Type of project (required): 6. [1 New construction 7. El Remodeling 8. EJ Demolition 9. E] Building addition 10.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13�OtherZol p ' e se on ow 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 tContractors that check this box must attached an additional sheet showing the name of the sub-contnictors 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. el -N _ Insurance Company N Policy # or Self -ins. Lic. #: /Z/5' Expiration Date: 9 Job Site Address:/ (/ S' ` City/State/Zip: o/ &&, 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-yeariinprisonment, 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 painsand penplties of perjury that the information provided above is true and correct 1117 1 e- � Ze.�- Offieial use only. Do not write in this area, to be completed by city or town official, ficial, 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 #: 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•; li en." 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 all individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than � � apartments a r �e�ts encdonstructionresides orthrepa�ir work on suchoccupant dwelling House dwelling house of another who employs persons 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 not produced acceptable evidence of compliance with the insurance coverage required." applicant who has "Neither the commonwealth nor any of its political subdivisions shall Additionally, MGL chapter 152, §25C(7) states 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 er which will be used as a reference number. In addition, an applicant Please be sure to fill in the permit/license numb that must submit multiple permittlicense 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 I(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 bumleaves 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 Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia