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HomeMy WebLinkAboutBuilding Permit # 2/26/2015 "ORTH BUILDING IT O TOWN OF NORTH ANDOVER ( APPLICATION FOR PLAN EXAMtNATtil , Permit SIO. 1 Date Received p�RaTso►�`�q- Date Issued: �L411 w sg^CHUS� fKTPORTANT:A licant must complete all items on this 2age LOCATION i"°It r Pant PROPERTY W ER Y° 5 j - u Print MAPNO PARCEL; ZONING DISTRICT: Historic;District yes �'no no .Mac ehm Sho Villa a es Shop g y TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building , One family ❑Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ,`Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic ❑Well ❑ Floodplain 11 Wetlands ❑ Watershed District ❑Water/Sewer 7 Identification Please Type or Print Clearly) OWNER: Name: Pulhr also Phone: V- � Address: Lhwaleol� 4 _ CONTRACTOR Name:,5 Phone: &6 Address:.. r tl � J I t ' I elm r Supervisor's Construction License: Exp. Date: Is Home Improvement License: Exp. Date: /if 0(fes3 , 7 1 ARCHITECT/ENGINEER , G qA -, fl % � Phone: Z-a Address: Reg. No. . ,.' FEE SCHEDULE:BULDING PERMIT:MOO PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost:$-�1 FEE: $ �� Check No.: Receipt No.: NOTE: Persons contracting with a is bred contractors do not have access1k,Aa ua anty fund Signature of Agent/Owner Signature of contractor ;� NORTH Town o Andover O 0 '4" No. ' ,-c- _ T INow rO LAKE h verb ass, coc"Iclow#CK �•�t ADRATED I`4a�"♦5 S BOARD OF HEALTH PER T Food/Kitchen Septic System . �. IS CERTIFIES THAT ....... BUILDING INSPECTOR • 1606.4k �4k Foundation . 14 has permission to erect ...................... buildings on53 . �/ ...^11? ................ ' Rough to be occupied as XX ­4­....4404-. .4.0aObI••••• 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final 1 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC ST Rough Service .... 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. � _ ., _.........,... 3 Patriots Lane Estimate ' } Nottingham,NH 03290 Phone/Fax:(603)734-2464 symmetryconstruction.com (4 Contacts:John&Bill Cantwell CUSTOMER Patrick&Sari Walsh 11C 53 Bridges Lane e , North Andover,MA 01845 DATE ESTIMATE# (781)929-3878 mobile 2/25/2015 1354c ITEM DESCRIPTION TOTAL Description Provide construction services for customer owned single family dwelling located at 53 Bridges Lane North Andover,MA. Symmetry Construction to supply materials and labor to perform work as outlined below. Scope of Work Modifications of existing dwelling as per conceptual design discussed with homeowner. Contractor agrees to perform in a good and workmanlike manner all work detailed below. Such work consists of the following: General Requirements Building Permits All applicable building,demolition and tradesman permits to be obtained by contractor and issued by the town of North Andover,MA. ($850.00 allowance) Dumpster Waste debris container to be on job site during construction. Bathroom 1 st Floor Bathroom 14,652.00 Remove all existing cabinets,bathroom fixtures,plumbing fixtures and electrical fixtures. Remove all existing tile and flooring. Remove all existing wallboard from walls and ceiling. Complete bathroom demolition back to wall studs and subfloor. Insulation to be installed as required for exterior wall. 1/2" concrete board to be installed on subfloor. 1/2"blueboard installed on walls and ceiling and plaster skimcoat to be applied. New the and grout installed for floor. Install new cabinets,bathroom fixtures,plumbing fixtures and electrical fixtures. All electrical and plumbing to be installed as per code. Existing washing machine/dryer to be stacked.Customer to supply hardware. Thank you for the opportunity to submit this estimate. Total Page 1 3 Patriots Lane Estimate Nottingham,NII 03290 Phone/Fax:(603)734-2464 symmetryconstru cti on.com Contacts:John&Bill Cantwell CUSTOMER Patrick&Sari Walsh tl.0 53 Bridges Lane North Andover,MA 0184 � °, '� (781)929-3878 mobile DATE ESTIMATE# 2/25/2015 1354c -- — - - ITEM DESCRIPTION TOTAL Kitchen Kitchen Renovation 21,852.00 Removal of all existing cabinets and countertops. Removal of wallboard to studs for walls and ceiling. Removal of existing flooring to subfloor. Complete removal of all demolition and construction materials. Installation of new framing required for new window sizing/kitchen design. Re-work existing wiring as required and removal of existing unusable wiring. Install all required electrical as per code. Installation of recessed ceiling mount cans(6),pendant light at sink&general room lighting. Install all required switches and GFCI outlets. Dedicated wiring for new appliances. Customer to choose lighting fixtures. Install all required plumbing as per code. Rework existing sink water feeds and drains. Install water feed and drain for new dishwasher. Install water feed for new refrigerator. Installation of all fixtures. Installation of new exhaust for cooktop. Customer to choose plumbing fixtures. Replace insulation for exterior walls as required by code. Installation of firestop for all floor penetrations. Walls and ceiling to have 1/2 inch blueboard installed with a smooth plaster skimcoat applied. New customer provided kitchen cabinets and trims to be installed as per design provided to Symmetry Construction. New baseboard to be installed. New window casings to be installed. Installation of tile and grout for back splash area. Appliances provided by customer. Interior Rework Dining/Kitchen.Wall 5,966.00 Removal of dividing wall for kitchen/dining room. Installation of an approximate 1211 LVL header beam to accommodate weight load for upper floor. Rework existing electrical wiring. Rework existing plumbing for heat. Patch wallboard for ceiling and walls and wallboard exposed beam. Thank you for the opportunity to submit this estimate. Total Page 2 3 Patriots Lane w �'�.yy Nottingham,NFI 03290 - ,,1 ate Phone/Fax:(603)734-2464 ,.w .., symmetiyconstruction.com Contacts:John&Bill Cantwell _._....__.......__... ........ CUSTOMER Patrick&Sari Walsh tl. 53 Bridges Lane North Andover,MA 01845 ` Vt � ' '"�' E DATE ESTIMATE# (781)929-3878 mobile 2/25/2015 1354c ITEM DESCRIPTION TOTAL Floor Coverings Hardwood Flooring 14,305.00 1st Floor(Great Room) Removal of existing carpeting and installation of 495 square ft.of prefinished hardwood flooring. 1st Floor(Dining,Front Entry,Hallway,Porch) Removal of existing flooring and installation of 430 square ft. of prefinished hardwood flooring. I st Floor Kitchen Installation of 175 square ft. of prefinished hardwood flooring. Allowances $4,950.00 1,100 square ft.Hardwood flooring $490.50 109 square ft.Tile&Grout-Bathroom Flooring/kitchen backsplash $550.00 Plumbing Fixtures $250.00 Electrical Fixtures/Lighting $450.00 Window(Kitchen) $1,500.00 Exterior Door $8,190.50 Total Allowances Customer to provide kitchen/bathroom cabinetry and countertops. Painting not included as part of this estimate. --jThank you for the opportunity to submit this estimate. Total Page 3 3 Patriots Lane Nottingham,NH 03290 '' ��� '�' Estimate Phone/Fax:(603)734-2464 symmetryconstruction.corn Contacts:John&Bill Cantwell CUSTOMER " Patrick&Sari Walsh LLC 53 Bridges Lane North Andover,MA 01845 (781)929-3878 mobile DATE ESTIMATE# 2/25/2015 1354c ITEM DESCRIPTION TOTAL Warranties The Contractor warrants that work furnished hereunder shall be free from defects in materials and workmanship for a period of one year following completion and shall comply with requirements of this Agreement. In the event any defect in workmanship or materials,or damage caused by the Contractor,his subcontractors,employees or agents,is discovered within one year after completion of any job, including cleanup,the Contractor shall,at his own expense,forthwith remedy,repair,correct,replace,or cause to be remedied,repaired or replaced,such damage defect in materials or workmanship. The foregoing warranties shall survive any inspection performed in connection with the agreed upon work. All warranties for equipment supplied by the Contractor under this Agreement shall be those given by the manufacturers of such equipment,which shall be and are hereby passed through directly to the Owner. Under such manufacturers'warranties,the Owner may be required to register or mail in warranty card or other evidence of ownership and use of such equipment in order to activate such warranties. The Owner's failure to mail in or register such documentation, which failure voids manufacturer's warranty,shall not create any responsibility to the Contractor to warranty such equipment. The Warranty gives the Owner specific legal rights,and Owner may also have other rights which vary from state to state. Terms and Conditions Payment terms to be 25%initial first payment and remaining amount progress payments to be paid on approximate 2 week intervals as per invoice detail worksheet as percentage of work complete. Change orders to be written as separate estimates with payment terms to be 25%initial first payment and remaining amount progress payments to be paid on approximate 2 week intervals as per change order invoice detail worksheet as percentage of work complete. All material is guaranteed to be as set forth.All work to be completed in a workmanlike manner according to standard practices.Any changes to above specifications involving additional costs, will be made only by request in writing,and will be an additional charge.All agreements contingent upon strikes,accidents or Acts of God.Owner to carry fire and other necessary insurance. Our workers are fully co e ed by Workmen's Compensation and Liability Insurance. This proposal may be withdrawn r bjec c ccepted within 30 days. Authorized Signature Acceptance of Proposal The above prices,specifications and conditions are satisfactory and are hereby accepted.You are hereby authorized to d e work specified. ay nt will be ad s outlined above. Acceptance Signature ` Thank you for the opportunity to submit this estimate. Total $56,775.00 Page 4 re ,_ 5 S GN FOR PRESENT °r is CUS TOM :CER iED kis kSURPOENTS ALL.Mks .«URS N S . u'• TSE aR€FILE AND FINAL DRAVVINGS SIGNED 5ErCIE PURCHASE ,t -; z_- �mo-"+.-.�:., .,"�.>��;��•�®.- t��� .�s�D €TO ENSURE T HE ACCURACY OF PHYSICAL FINAL DE-S!G-N qMUSTE 's SUSB -i;}TED FOR FORMAL v 733-1139, 2020 Y re 1290--3941.fit , . „• . €. - -------------------------------------------------- }Crestal v _a _ »� - _ r _ Fu-. a Pec'R oto ''=_ sla- tae irc-ipoEnds Dc=�o Doors or islandof n Height:90.AFF Glass NONE —op Mc-Una � . a Top s nment: ,. LG Vialcra Se ar Or fd n r s 't -,_ .— yra for I,. IELLvMO,`__3 Z;7L'-- U.�d. G._3 L,�<<� ------------------------------------------------------------ --torl .c. New cab-nee! 3youl . €€. not `dtc-i !cola: Keep '' or. „c..€ cin floc-ringh cknecs of now,iatzsna!'� E - f -3 PL..., •FBI.�`�-, E€.,�€-sem=t�:�.a-s. _=-'�D_�.,-�R`�:�'=..C-,�.�a-E-RLjNFS WERE NC.'T P V :,---:D. .. All dimensions sire desi-nest ons \\~\`\ This as an cit€€gin al design and must i Designed: ? 1 01.3 iti-cai arc st€ +ject tv verification on not be released or copied unless Printed: 2 1_' 414 fob stile rind adiustrimil to litob \ \ ~ ! � �� � ti�� applicable l'cc has bcett said err fob ccru€titious_ \\\ ` carder 1 laced. 12c)dl3941 1 DC E)csa n Drawing L.: 1 No Scab;. i I I 81 �� I i i i I � I i f 1 I i i-� 1 � I I ! o IN 1 HN HP a $ I 1 lit I ii �I tit I AH r { ,r /r10 J au FI IJ i . .�.�r- ii Nom.ua.rnunsL•nernluTeoGUMneR earn. tt➢tteRCNceNores � __ ---';�ko ��"` ALL LUMIRA MATtNW StIAU.M PRLiSI Y,UP.ATRO A14lNWb MTRR1ALbNALL)>n S1ANpAAp I-'!1888 b0.AWD+U9411ALI bY.USP.OWOONII.'NCnON - wATFiUDMTRIAiMQft Sp .dM4IIA Me3TOC1(,(IAAtl➢Nn.3OHdRlTCIl4Al•INf4, WITFI'JIAUCCVPAL DIV.WIN05,9HtlY PRAtVWSl9 C _a uOTea __ v"MRN Y➢LLOW PINE ORSrmk,HAt M AND SPPCD'ICATIONS. 0AT9 _ L AMW@NMAovL TDLS:rI➢fln.ow I.AMPIMUMALI.OWA➢LH7'IBPJ[STR➢9SWAANDWO EgUAi.TOOK ORfvATAP TitAN:tT t00.t PSt 3,ALL DN3➢NSIONSAND CONDITIONS MU➢T➢➢VPAVI➢T3 P-0UAL'4'O pR OAHATBR THAN: M TH8 PmD AND ANv pJ%CRIRC(tP]'A`1G9fi33HA31 bR I AMPPDLI)A OP IIASTICITI'F(}UAt'IT30IX(IAYATRR DRPVU➢9'ToR a ATT@RION arzo S3A[cmm L. 2 AO3G➢IILIlS DP 0.ABTICITY➢QUAL TDPAOARATP3l TH.W:C�1.t00v999 PSI LLNNTKB AFRCrRD PARTOFTHEFORB19tOCD6pM0 , THAN:R-I,i00p00Ps1 WISIf TFN APPPCIBU PARTOPTHC tVTJAIC I YS 1 I W ! � S i � 1 i i I 1 3 I i i Nil �3 Hill �i jjjl111Ljjj � �L �i !•i �� _� "a li 1-26-15 R ® S E B U R G 2:20pm le 1 of I CS Beam4.604 {miB*=Eggine 4.6.1.0 Materialg rUfa taso 1476 Member Data Description: Member Type:Beam Application:Floor Top Lateral Bracing:Continuous Bottom Lateral Bracing:Continuous Standard Load: Moisture Condition:Dry Building Code:IBCARC Live Load: 40 PLF Deflection Criteria: U360 live,0240 total Dead Load: 10 PLF Deck Connection:Nailed Member Weight 10.4 PLF Filename:Beam1 Other Loads Type Trib. Other bead (Description) Side Begin End Width start End start End Category Replacement Uniform(PSF) Top 0' 0.00" 12' 6.00" 13' 6.00" 30 10 Live Additional Uniform S ToD 0' 0.001, 12' 6,00" 13' 6,00" 20 10 Live 12 60 /m ® , 12 60 Bearings and Reactions Input Min Gravity Gravity Location Type Material Length Required Reaction Uplift 1 0' 0,000" Wall SPF Plate(425psi) 5.500" 3.767" 5603# — 2 12' 6.000" Wall SPF Plate 425 sl 5.500" 3.767" 5603# Maximum Load Case Reactions Lked forapplying point toads(ortine loads)to carrying members Live Dead 1 3959# 1844# 2 3959# 1844# ' Design spans 11' 8.7W' Product: 2.0 Rigldl-am LVL 1-3/4 x 11-7/8 2 ply PASSES DESIGN CHECKS Connect members with 2 rows of 18d common nails at 12.0"oc Design assures continuous lateral bracing along the top chord. Design assumes continuous lateral bracing along the bottom chord Allowable Stress Design Actual Allowabie Capacity Location Loading Positive Moment 16430.'# 19905.'# 82% 6.25' Total Load D+L Shear 4658.# 78974 58% 0.4' Total Load D+L Max.Reaction 56034 81811 68% 0' Total Load D+L TL Deflection 0.4165" 0.5865" U337 6.25' Total Load D+L LL Deflection 0.2943" 0.3910" U478 6.25' Total Load L Control: Positive Moment DOLS: Live=100% Snow=116% Roof=125% Wind=1600/o H Of r IL S CIA UCTURAL No.332J14 /ST 87 Fss�aNAL All product names are trademarks of their respective owners r Copyright(C)2013 by Simpson StronliMe Company tnaALL RIGHTS RESERVED. —Passing Is defined as when the member,floor joist,beam orgirdeg shown on thisdrawing meets applicable design criteria for loads,Loading Conditions,and Spans listed on this sheet. The design mud be reviewed by a quannad designer or design professional as required for approval.This design assumes product installation according to the manufacturer's tlerations wj &a"4 PROFESWNAL ` .�.' ' -6TRUCtURAL ENt3iNEF.RiNG P.O.@OX 958 DESIGN SERVICES F-HAMPSTW.NH OM FAX( U%4406 TITLE ; .F = __.. �� g , EST•� N0. �,..;�.�......_ .TOB 3 SUBJECT 1 t Y- ,( lZVO \u--L4,iHEET No• DESIGNED WAO BY : z"DATE _2.CHECLED BY DATE r _�ZIv g i p IV, s s % I _ ' r T.. ----------------- 3 } Ac", LV3 V. PROFESSIONAL. STRUCTURAL ENGINEERING P.O.BOX 958 i `r� DESIGN SERVICES IM HAMPSTEAD,NH 03826 (603)3294W RL FAX(603)32948" RESIDENTIAL. COMMERCLAL• 3 WM, \ ,- TITLE . OB SUBJECT-L] ��� � � -- a � 5 =sHEET NO. DESIGNED BY DATE 2/! �� C$ECEED BY DATE Vv, Lo �., T tE derl r_., r7 Massachusetts - Department at Public Safety Board of Building Regulations and Standards Construction Supemisor „ License: CS-081956 JOHN D CANME LL 3 PATRIOTS LN ' NOTTINGHAM SH Q32 0 Commissioner 08/05/2015 ✓z Uouzozzau �lac�a�tes Office ofi-onsumer A airs B smess egulahon , HOME IMPROVEMENT CONTRACTOR Type: + Registration: 180883 {' Expiration: 1/23/2017 LLC SYMMETRY CONSTRUCTION LLC. JOHN CANTWELL 3 PATRIOTS LANE C�- � - NOTTINGHAM,NH 03290 Undersecretary 02/26/2015 10:27 6034329822 BENWAY JOHNSTON INS PAGE 01/01 OP ID:PC DATE(MMIDD1YYYY) l CERTIFICATE OF LIABILITY INSURANCE 0212612015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND OR ALTER THECOVERAGECOVERAGE AFFORDED GHTS UPON THE ABY THE POLICIES TE HOLDER, CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. t be endorsed. it IMPORTANT_ c the conditionsofthe policy,certainpDITIONAL po lrA09 may require,the an endorsement.A statement n this Certificate doses noticonferOrights to the us the terms and condo p certificate holder In lieu of such endorsement 9. coNrAcr PRODUCER NAME: Senway-Johnston Insurance Inc. PHONE FAX PO Box Box 750,35 Crystal Ave E-MAIL — Derry,NH 03038 ADORE99: Benway-Johnston Ins.,Inc. �6Ro��'-� SYMME-1 cusx�eR ID ems. LINSURPR IN9URERRSLAFFORD.1NGCOVERAGE NAIC# INSURED Symmetry Construction LLC Merchants Mutual Ins.Co. 23329 John Cantwell RiV®rpolnt Insurance Co. — 3 Patriots lane Nottingham,NH 03290 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: INDICATED, NOTWITHSTANDING ANYIES REQU REMEOF N, TERM OR COND TION OF ANY CONTNCE LISTED ELOHAVE SEENERACT OR OTHER DOCUMENT WITH RETO THE INSURED NAMED ASOVEO SPECT TOIWHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAPID CLAIMS. - LIMITS T R TYPE OF INSURANCE POLICY NUMBER MMIDDIYYY MM/DD YYY 1,000,001 EACH OccURRFNCE a GENERAL LIABILITYAGt 10 = 600,001 '.. BOP1045129 01/12/2015 01/12/2016 PREM/ ES S(Eaau orrence). S A x COMMERCIAL GENERAL LIABILITY MED EXP Any ono_peraon) S 6,001 CLAIMS-MADE OCCUR1,000 001 PERSONAL&ADV INJURY a GENERAL AGGREGATE $ 2,000,001 PRODUCTS-COMPIOP AGO a 2,000,001 GF-N'L AGGRFOATE LIMIT APPLIES PER: $ POLICY PRO LOC COMBINED SINGLE LIMIT 9 AUTOM091LE LIASILITY (Ea accident) _ ANY AUTO BODILY INJURY(Per Pnomn) $ ALL OWNED AUTOS BODILY INJURY(Per aecldent) S SCHEDULED AUTOS PROPERTY DAMAGE S (PER ACCIDENT) HIRED AUTOS 1F NON-OWNF,D AUTOS S EACH OCCURRENCE S U MBRELLA AGGREGATE a S a" WC STATU- OTH- WORKERS COMPENSATION TOSNIIT H 100 0( AND EMPLOYERS'LIABILITY WC-28-83002887-06 01/1912015 01119/201 S E,L EACH ACCIDENT a , 8 ANY PROPRIFTOR/PARTNERIEXECUTIVE Y� NIAE100,0( OPFICERIMEMBER EXCLUDED? .L,DISUSE-EA BMPLOYSE $ (Mandntery In NN) E.L.DISEASE-POLICY LIMIT S 500,01 ifre daactiee under DESUIR(PTION OF OP RATIONS below DEDSPDENTIAL CARPENTRY LOCATIONS/VEHICLES (Akneh ACORD 101,Addlkonel Remnrke Schodule,Irmorn ipaeo Is mgolrod) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL. BE OCLIVSRED IN Town of No Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St. Bldg,20 Suite 2035 AUTHORIZED REPRESENTATNE No Andover, MA 01845 Benway-Johnston Ins.,Inc. ®1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents i o 1 Congress Street, Suite 100 Boston,MA 021142017 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNHTTING AUTHORITY. Applicant Information Please Print Le ibl J Name (Business/Organization/Individual): ®il /^U Q " ®Vlvl Ca // Address: City/State/Zip: t� �77 C ® Phone#: 03 Are you an employer?Check the appropriate box: Type of project(required): 1.&I am a employer with employees(full and/or part-time).* 7. El New construction 2.F1 I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.F_1 m I aa homeowner doing all work myself.[No workers'comp,insurance required.]t 10 D Building addition 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 11.❑Electrical repairs of additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.F1 Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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. f Insurance Company Name: /Ur'd'//d//� l��5'Ud'A C (, f Policy#or Self-ins.Lic.#: `- ��� -C�� S� Expiration Date: Job Site Address: iG4 City/State/Zip: / we)fj t� Aj� O� 1 Attach a copy of the workers' c mpensation policy declaration page(showing the policy number and expiration ate). 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 WORD 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. I do hereby certify r theair and penalties of perjury that the information provided above is true and correct. Signature: try Date: Phone#: Q . z/—0 • 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#: