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HomeMy WebLinkAboutBuilding Permit # 6/4/2015 '?'(WAN OF NORTH R � taoRvey APPLICATION FOR PLAN EXAMINATION gtio O � Permit NO: Date Received �gA1t0 'Pp``'Q5 u® 9SSAGHU'�4 Date Issued: IMPORTANT:Applicant must com Tete all items on this page LOCATION // Print AT PROPERTY OWNER 1W6Z �'&� / 0(J1Z Iq N J Print MAP NO.: ' PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Resid ntial Non-Residential ❑New Building One family ❑Addition ❑Two or more family ❑Industrial er Alteration No. of units: ❑Repair,replacement ❑Assessory Bldg ❑Commercial ❑Demolition ❑Moving (relocation) ❑Other ❑ Others: ❑Foundation only DESCRIPTION OF WORK TO BE PREFORMED r n/'r.S'� ,f�r3-.S�✓�7('�I T� � s'3- � �f9 .�e'� rs� - J�'�i� Identification Please Type or Print Clearly) ,/ OWNER: Name: Phone: - ,60'7-8&C13 Address: CONTRACTOR Name: U 6) Phone: Address: X V✓iu �� /� 5 o$U Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.•$1 ER$1000.00 OF THE TOTAL ESTIAIATED COST BASED ON,S125.00 PER S.F. Total Project Cost :$ x 12.00=FEE:$ , � �v Check No.: Receipt No.: Page Iof 4 Dimension e Number of Stories: Tonal square feet of floor area, based on Exterior dimensions. Total land area, sq. fit.: ELECTRIGA,L: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE. Yes -- No MGL Chapter 166 Section 21A—F and G min.$1oo-$1oo0 fine NOTES and DATA.-- (For department use) 4 LJ Notified for pickup Call Email Date Time Contact Name ................. ii Doc.Building Permit Revised 2014 I i t%ORTH own of AndOlver ® No. h ver, Mass, a �� COC NIG NE WICK RATE[) U BOARD OF HEALTH PER I Food/Kitchen L D Septic System THIS CERTIFIES THAT ........... jAr 11, lie. � %a tAro. BUILDING INSPECTOR lie. ................... .. . ............................ 1 Foundation has permission to erect ....................... buildings on ....1. ...... ... Qr.... T..&....&.• • Rough tobe occupied as ....... . . 1' ...�0.. r. .. ...... . . .............................. 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 N ELECTRICAL INSPECTOR LESS COSTRUC S T Rough Service ............... .. ........ ............,.................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building - Rough Islay 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. 1 Margate N., rulover,Mass 5/11115 Final budget Caroline Matzoura c&O Contracting.Plaistow,NH 9 15 hanges Allowances- 19 selectw 603-235-8160/cocontraetngglive.com ion needed by home one, JA Mat'l Labor Other .Lec-fiou Description Tokal 1.00 Design/layout[budget(town fees will be direct billed) S 0,00 S 225.00 S 0.0;'S 225.00 2.00 Permits 0.00 $ 100.00 $ Om $ 100.00 a.Building $ 0.00 $ 50.00 S 0.00 $ 50.00 b.Plumbing $ 0.00 $ 100.00 $ 0.00 $ 100.00 c.Electrical S 0.00 S 250.00-S 0.00 S 250.00 Sub total 2.0 3.00 Demo ''....$ Om $250,00 $550.00 $800.00 a-Basement contents]old flooring/ceiling $ 35.00 $ 550.00 $ 125M $710.00 b.BatWoorn(open slab for sewer ejected trenches-shower/WO $450.00 $450.00 c.Remove oil tank(pump and disposal) 350.00 $350.00 d.Remove old oil burner fitrunce Sub total 3.0 S 35.00 S 800.00 S1,475.00 $2,310.00 4.00 Framing $240.00 $ 850.00 $ 0.00 $1,090.00 a.frame 70 LF exterior wall for insulation R-13 $ 105-00 $450.00 $ 0.00 $555.00 b.Bathroom 8x8 $405�00 $300.00 $ 63.00 $76&00 c.Laundry/closel/Bathroom door 405.00 125.00 $ 550AD $ 0.00 $675.00 d,Rocoofigurestami $ 25�00 $ 125.00 $ 0.00 $ 150.00 e,Re Joe 1st floor closet to gain head mom on stairs $425.00 $575.00 $ 159.00 $1,159m f,Now windows(Anderson series 70 gliders 3-33X24) $485.00 $325�00 $ 21.00 $831.00 g.New ext door walkout(fliermal True/DbI bore Fanlight) $ 185.00 $ 100.00 $ 21-00 $306.00 It.New interior walk out(SC molded smooth/flat) $ 45.00 $ 105.00 $ 0.00 $ 150.00 1.Closet-linen with shelving j.Niche under stairs with book Me Subtotal 4.0 $2,040.00 53,380.00 S 264.00 $5,694.00, 5.00 Rough electrical $ 105.00 $325.00 S 0.00 430.00 a.15 duplex outlets Basement $432.00 $ 71100 $1,144.00b.8/5"recessed cans with LED Trims $ 15.00 $ 35.00 $ 0.00 $ 50.00 c.Cable TV jack $ 35.00 $ 100.()0 S 12.00 $ 147.00 d.1.20 AMP home run bathroom vanity/GFGCl outlet $ 12.00 $ 40.00 S 25.00 $ 77.00 e.Vanity lights/SW $ 198�00 $ 185.0 $ 0.00 $383.00 f.Exhaust fall/light(110 CFM-ducted to outside) $ 50.00 $ 100.00 $ 0.00 $ 150.00 g.Sewer ejector $847.00 51,497.00 S 37.00 52,381.00 Sub total 5.0 6.00 Rough plumbing $440M $350.00 0.00 790m a.Sewer ejector/vent 925.00 $ 550.00 25.00 $1,500.00 b.4-PC alcove shower/Valve with 2"drain 35,00 $220.00 0,00 $255,00 c,vanity waste and water 75.00 $290.00 $ 0.00 S 365.00 d,Water closet waste and water(3"flange) 189.00 $450.00 $ 0.00 $639.00 e.Gas piping for furnace and thankless $1,664.00 $1,960.00 S25.00 53,549.00 Sub total 6.0 7.00 fusulationR-13240C (480 SI) S 390.00 S 295.00 S 12.00 S 6917.00 8.00 Drywall � $380.00 $ 580.00 S 25.00 S 985.00 a.Basement(480 SF)4x8xl 2 reg gyp $ 145.00 $ 175.00 $ 0.00 $320.00 b.Bathroom(225 SF)4x8x8 MR Gyp $ 60.00 $350.00 $ 0.00 S 410.00 c.Mud and tape(753 SF) S-985.00 S1,105.00 S 25.00 $1,715.00 Sub total&0 - 9.00 Prime and paint walls 700 SIT by others S 0.00 S 0.00 S 0.00 $ 0.00 10.00 Flooring $1,290.00 $1,100.00 S 75-00 $2,465.00 u.Basement floor(lament/3MM-float)-600 SF $330.00 $350.00 $ 21.00 $701.00 b.Bathroom floor(70 SF 16x16 porcelain file) Sub total 10.0 51,620.00 51,450.00 S 96.00 53,166.00 11.00 Trim package(100LIF 5.25 speed base/100 LF 2.5 colonial PFJ) S 398.00 S 175.00 $ 12.00 S 595.00 12.00 Bathroom finishes(allowance for vanity/medicine,faucets,shower) $ 138.00 $ 75.00 $ 0�001 $213.00 a.Shower trim BN koWer Forte b.Vanity base( unper-16") S 670.00 S 95.00 $ 0.00 765.00 c.Vanity top/; egral v Re under mount sink $425.00 $ 95.00 $ 0.00 520.00 d.Lav fauc-',,,'wide spread BN Kolher-) $350.00 $ 105.00 $ OJ)O 455.00 e.AVaterclosett soft close seat-white Kolher-12"RO $290.00 $ 125,00 $ 3&00 $453.00 - Sub total 12.0 $1,973.00 S 495.00 S 38.00 $2,406.00 13.00 Suspended ceiling(600 SF)4x2 pattellulitte rail $1,410.00 S 850,00 S 12.00 52,272.00 14-00 Fintsit stairs a,Red oak Mix 36 trends/US pine risers $450.00 $MOO S 12.00 $987.00 It.,Newel pant limit ratting/turned balusters $190.00 $350.00 $ 0,00 S 540.00 c.Seal trends,pod and hand nit S 42.00 S MOO 3 0100 $167.0 d.Pahat risers and balusters S 38A S 190.00 S 0.00 $228.00 Sub total 14.0 720.00 $1,190.Otl $ MOO $1,922.00 Total bathroom and basement remodel -- 52,0118.00 $27,162.00 14.00 New 60,000 BTU Trans gas fired furnace/new feeds appropriately sized Mat'l Libor other Total Includes removing and disposal ofall unit Connection togas meter Need supply sized for each room $6,960.00 $2,440M $ 98.00 $9,498.00 Control wiring F14A furnace and one T-Stat $ 21.00 S 350M $ 0.00 $371.00 Timis 4TX-CCHl EFF cooling end Timis 2 ton XK-16 compressor(compressor,pod line sets)2399.001100OA0 S OM S 0.00 $ 0.00 S OM De(koateeirptfit/HRwhit(fiscomect/mittotwiring]89,00/3,90.00 $ Oml S 0-001 $ 0.00 S 0.00 Sub-t.-1al 14.0 1 $6,981.001 $2,790.001 -$ 98.00 $9,869.00 15.001 New gas main from street(by others-Colunibia Gas) 1 1.101 1 0.00 0.001 $ 0.00 16.00 30 circuit service panel 150 AMP(,are findt circuit as per code) $659.00 $375MI $ 0.00 $1,034.00 17.001 Tarts-less water heater-(NavienNPE-2405-NG) $1,434MI $835.00I $ 75.00 $2,344.00 18.00 tate rfor French T..t,.M.PPump(wt.,I.p-mm-tL") a.Demo slab.trenolt 140 LF 12"wide slab cut andAren7h S 0.00 $2257 T 600.00 S 825.00 b,lostall 140 LFdruin pipe to new surop pump Incificat, $360,00 $1.50.00 $ 0.00 $510.00 c.Install settled sump pump housing/112 H11 sump pump $200M $103.00 $ 90,00 S 395,00 it.Two Exterior discharge pipe-2"PVC $ 56.04 $190.00 S 0,00 S 246M e,Back All,and concrete trenelfs 140LF $240,00 S 400.00 $ 0,00 $640.00 f Addsecond varrelfbe witergency 41sclo arge)PIM 2 Accloarge S 914 09 $105.0 $ 0.69 $199.00 g-Ad,(ZWt-ybac*ltpforsititippllilq) $291001 S qs.00l ""90 &Ao Pfloo,d1anit $ 7S, $ 95.1 17000 W "", DO Sub total 18.0 $1,320.1 $,11"1 �10-10 $3,375M Total all sections $21,976.00 $18,937.00 $2,871.00 $43,784.00 Overhead $1,098.80 $568.11 $ 143.55 $1,810.46 Profit $ 692.24 $585.15 $ 90,44 $1,367.83 Grand total 523,767,04 520,09016 $3,104." S46,96119 Foot notes and conditions L This agmentent is defined#i description column.Any deviation to this scope requires a change ot-der agreed and signed by bode parties. 2 C&O Conh acting is),espoiniblefor all applicable per7)iiis ant coordination ofiough and final inspections. 3.Please not,any borne itower wpm pulls there own permits is not reliable for clahns against the HICstatefund 4.Schedule-tentative start date week of May 15,2015-Projected completion is week of 26,2015 5.Gas main is not included in the able schedule-Columbia Gas is handling the gas line from the street to meter. 6.Items Ingli lighted in purple are allowances,once final selections have been made budget to be adjusted. 7.Payments are based on initial deposit for long lead and special order materials-balance will be progress payments as work is completed. 8.Warranty on workmanship-6 months frain dated completed,manufactures warranty implied for all materials. 9.Contractor and home owner agree to independent arbitration to resolve scope of work and financial disputes. 10.C&O ContriefingTax ID number 020524775 11.Insurance certificate available upon request-we carry 2 Million h1bdity. 12.Heat is budget based on Natural Gas Trans FHA system-60K BTU wills manual registers locate in the basement.System will.include coil for future A/C system. 13.Interior French drainto sumppamp-limited to 140 LF with discharge at front of the home. Add second discharge vessel for over flow situafions with separate 2"discharge 14.All deposits s 1i be held for 3-days/during Oiis period all funds are 100 percent refundable to the home ownerup to day 3 of the grace period, Hoene Date 5�-,31 LJ J Contracts[ Date '4�1(3 2,CVS // Mk, �, `L.� (,o,tea pev.cy Su,011"a4y /. ;?Q,l�®V'S' ass G q 0 41k - _64Se,-ne � t . �e l AIS 3. 1 ws7-ALL. GAs lyct 1.j - 6,4s c he,,c �` aT w��e a k A14vte�l Ta,ulc%ss -,A16 K K Su_ ��+ � �Z N, ' F/a�r7� ,<e Arc/i D geLlA'l Add 31$1 of Ate , -- (kooe/u 8-Atc:/� Load Short Form Job: Date: May 14,2015 Entire douse By: Custom Climates HVAC For: Bob Ouellette 14 North Margate, North Andover, MA MIMIIt w Htg CIg Infiltration Outside db(°F) 9 88 Method Simplified Inside db(°F) 68 75 Construction quality Average Design TD (°F) 59 13 Fireplaces 0 Daily range - M Inside humidity(%) 50 50 Moisture difference(grAb) 44 31 HEATING EQUIPMENT COOLING EQUIPMENT Make Make Trade Trade Model Cond AHRI ref Coil AHRI ref Efficiency 80 AFUE Efficiency 0 SEER Heating input 0 Btuh Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 OF Total cooling 0 Btuh Actual air flow 919 cfm Actual air flow 919 cfm Air flow factor 0.026 cfm/Btuh Air flow factor 0.042 cfm/Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat Load sensible heat ratio 0.88 ROOM NAME Area Htg load Cig load Htg AVF CIg AVF (ftz) (Btuh) (Btuh) (cfm) (cfm) basement C 5(o® SF V�ea+ed 1080 12707 3729 335 157 IC tD5 R,,n 2 120 3284 2145 87 90 ele5et4 atfi ro,> v\ 48 781 384 21 16 kitchen 196 4608 4469 121 188 kids room 4 1 140 1907 1396 50 59 master 196 4070 3374 107 142 t-1%j w�5 ZOO n, 380 7537 6395 199 269 Entire House d 2160 34896 21890 919 919 Other equip loads 0 0 Equip. @ 0.93 RSM 20314 Latent cooling 2908 TOTALS I 2160 34896 23222 I 919 919 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. 2015-May-1419:11:03 wrightso Right-Suitc@ Universal 2013 13.0.13 RSU16206 Page#Oetk Project1.rup Calc=MJ8 Front Door faces: E Load Short Form Job: Date: May 74,2015 Entire louse By: Custom Climates HVAC For: Bob Ouellette 14 North Margate, North Andover, MA Htg Clg Infiltration Outside db(°F) 9 88 Method Simplified Inside db (°F) 68 75 Construction quality Average Design TD ('F) 59 13 Fireplaces 0 Daily range - M Inside humidity(%) 50 50 Moisture difference(grit) 44 31 HEATING EQUIPMENT COOLING EQUIPMENT Make Make Trade Trade Model Cond AHRI ref Coil AHRI ref Efficiency 80 AFUE Efficiency 0 SEER Heating input 0 Btuh Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 'F Total cooling 0 Btuh Actual air flow 919 cfm Actual air flow 919 cfm Air flow factor 0.026 cfm/Btuh Air flow factor 0.042 cfm/Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat Load sensible heat ratio 0.88 ROOM NAME Area Htg load Clg load Htg AVF Clg AVF (W) (Btuh) (Btuh) (cfm) (cfm) basement C 54,0 SF �kM+vd 1080 12707 3729 335 157 (&;#WtS tDs RM *2- 120 3284 2145 87 90 clew#-1 4+�`rh rodyy\ 48 781 384 21 16 kitchen 196 4608 4469 121 188 kids room i 1 140 1907 1396 50 59 master 196 4070 3374 107 142 Reomg-t•- Q xv.5 Roo rh 380 7537 6395 199 269 Entire House d 2160 34896 21890 919 919 Other equip loads 0 0 Equip.@ 0.93 RSM 20314 Latent cooling 2908 TOTALS 2160 34896 i 23222 1 919 1 919 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. htsoft 2015-May-1419:11:03 wrl g Right-Suites Universal 201313.0.13 RSU16206 Page 1 Pr*.t1..P Calc=MJ8 Front Doorfaces: E Level 1 ,,rr basement ent f OEM i I 1 Job#: Custom Climates HVAC Scale: 1 : 60 Performed for: Page 1 Bob Ouellette Rig ht-SuiteO Universal 2013 M-North North Andover,MA 4t ty "� 13.0.13 RSU ,� 2015-May-14 19:11:9:11: 39 I Project1.rup 4t 1011- Level 1 � Se Q basement Job#: Custom Climates HVAC Scale: 1 : 60 Performed for: Page 1 Bob Ouellette Right-SuiteCa7 Universal 2013 14 North Margate 13.0.13 RSU16206 North Andover,MA 2015-May-1419:11:39 Project1.rup Project Summar Job: y Date: May 14,2015 Entire House By: Custom Climates HVAC For: Bob Ouellette 14 North Margate, North Andover, MA Notes: Weather: Lawrence Muni, MA, US Winter Design Conditions Summer Design Conditions Outside db 9 OF Outside db 88 OF Inside db 68 OF Inside db 75 OF Design TD 59 OF Design TD 13 OF Daily range M Relative humidity 50 % Moisture difference 31 gr/Ib Heating Summary Sensible Cooling Equipment Load Sizing Structure 27028 Btuh Structure 15548 Btuh Ducts 7867 Btuh Ducts 6343 Btuh Central vent(0 cfm) 0 Btuh Central vent(0 cfm) 0 Btuh Humidification 0 Btuh Blower 0 Btuh Piping 0 Btuh Equipment load 34896 Btuh Use manufacturer's data n Rate/swing multiplier 0.93 Infiltration Equipment sensible load 20314 Btuh Method Simplified Latent Cooling Equipment Load Sizing Construction quality Average Fireplaces 0 Structure 1882 Btuh Ducts 1027 Btuh Heating Cooling Central vent(0 cfm) 0 Btuh Area(ft2) 2160 2160 Equipment latent load 2908 Btuh Volume(ft3) 15660 15660 Air changes/hour 0.32 0.16 Equipment total load 23222 Btuh Equiv.AVF(cfm) 84 42 Req. total capacity at 0.70 SHR 2.4 ton Heating Equipment Summary Cooling Equipment Summary Make Make Trade Trade Model Cond AHRI ref Coil AHRI ref Efficiency 80 AFUE Efficiency 0 SEER Heating input 0 Btuh Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 OF Total cooling 0 Btuh Actual air flow 919 cfm Actual air flow 919 cfm Air flow factor 0.026 cfm/Btuh Air flow factor 0.042 cfm/Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat Load sensible heat ratio 0.88 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. W ri htso 2015-May-14 19:11:03 IPoght-Suitdil Universal 201313.0.13 RSU16206 Page 1 Proied1.rup Calc=MJ8 Front Door faces: E | � � LJob:Job:~~=~" ~~~^�^ ~ Form Date: May 14,2015 � Entire House By: Custom Climates HVAC MENEM= MEN= For: Bob Ouellette 14North Margate, North Andover, MA � Htg Clg Infiltration Outside db("F) Q 88 Method Simplified � � Inside db('F) 68 75 Construction quality Average � Design TD ('F) 59 13 Fireplaces O � Daily range - Nl Inside humidity(96) 50 50 Moisture difference(gr/|b) 44 31 HEATING EQUIPMENT COOLING EQUIPMENT Make Make Trade Trade Model Cond AHR\ ref Coil AHRl ref Efficiency 80AFUE Efficiency 8GEER Heating input O Btuh Sensible cooling O Btuh Heating output O 8(uh Latent cooling D 8tuh Temperature rise O OF Total cooling O 8tuh Actual air flow 019 cfm Actual air flow 919 cfm Air flow factor 0.028 cfm/Btuh Air flow factor 0.042 ofm/Btuh Static pressure O in H20 Static pressure O in H2O Space thermostat Load sensible heat ratio 0.88 ROOM NAME Area Htg load CIg load Htg AVF Cig AVF basement 1—kft�4�vck 1080 12707 3729 335 157 paaloy ikAtz,vv, 120 3284 2145 87 90 0696H 1 48 781 384 21 16 kitchen 196 4608 4469 121 188 kids room 140 1907 1396 50 59 master 196 4070 3374 107 142 R09W& 380 7537 6395 199 269 Entire House d 2160 34896 21890 919 919 Other equip loads 0 0 Equip. @ 0.93 RSM 20314 Latent cooling 2908 TOTALS 1 2160 34896 23222 919 919 Calculations approved byACCAtomeet all requirements ofManual J8th Ed. .�, 2015-May-1419:11:03-��- ��ri��htso8�' wum-Sumaoowemm2Ol3l3.0.13nau1620Page I �~+�� pm1oalmv no/o~mm Front Door faces: s Level MON= Mao master r p S room (x kilt"',e Job#: Custom Climates HVAC Scale: 1 : 60 Performed for: Page 2 Bob Ouellette Rig ht-Suke@ Unive rsal 2013 "�' �( �M j""€, cri 13.0.13 RSU16206 North Andover,MA 7 2015-May-14 19:11:39 Projectl.rup C'oC7�' 'i,�lg@,C,aed Call I dF w � w r 6 YY �'� �� ' =�_ s,,. -..� `� "•�` m, fi �' ��� k� .,,��z gym' ¢ �� c�i.a v # �, ' 63 LF Wwi i' G i ' kr !i LIP i � r .......... Andz-,v 7111 cooNt ci(,7, Wit ai jf, Co r R evu,C'. J I L S F) I A R35 rnxq e v,�- vw, 7 6E,�vAq—� �ecfvr V/Z 2 5hwf- Con c r e --�m: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia lj'orkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNIITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organizatiov/Individual): �� (�m� 2/ �iiycr Address: /©2 L,y.1V 1,A1 do City/State/Zip: A1191SI-6Phone M 2Sd.3 �5`=c9/6'69 Are you an employer?Check the appropriate box: Type of project(required): I. I am a employer with employees(full and/or part-time).* 7. E]New construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3,E]I am a homeowner doing all work myself[No workers'comp,insurance required.]t 9. El Demolition 4. I am a homeowner and will be hiring contractors to conduct all work on m 10 ❑Building addition ❑ g y property. I will ensure that all contractors either have workers'compensation insurance or are sole 1 I.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 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.l 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required:] *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. rContractors 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 ani an employer that is providing workers'compensation insurancefor 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 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. I do hereby cerfify under the pains and penalties of"perjury that the information provided above is true and correct. Si na e; Date: ar—/2� f Phone#: , 2 3r P/6 o 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#: SdG/Aog•sseWmmm :11slA umlewiolul Sulsua3l,SdG Joj •asua311 s14110 uotleaonaj j01 asne3 si apo Rulpttne a1e1s suasn4oessevy 94110 uotltpa tuaJjn:)a ssassod o;ajnite j i -aovds pasolouo JO(JU166)1aaj oigno GOO`S£uEt{�ssol U!Muoo gonlm dnoj2 osn Auu3o s9inpng-pai3ij;saaun vJie royuynowiveall�o��GJ�l�afrac�tatclt Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR egistration: 123742 Type: Expiration: 4/3/2017 Individual Stephen M.Rothwell Stephen Rothwell / 3 SCOTTSDALE RD. Lam.---- ATKINSON,NH 03811 Undersecretary Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-043475 STEPHEN M ROTJ4WELL 3 SCOTTSDALERD Atkinson NH 03811 _ Expiration Commissioner 07/24/2016 Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(99IM)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. j For DPS Licensing information visit: www.Mass.Gov/DPS