HomeMy WebLinkAboutBuilding Permit # t%O R TPI
BUILDING PERMIT 16"6
TOWN OF NORTH ANDOVER 0 -
APPLICATION FOR PLAN EXAMINATION
� <o....
Permit No#e Date Received OOATED �R�S
Date Issued:
IMPORTAX Applicant must complete all items on this page
LOCATION
., Prin
PROPERTY OWNER
0CA � � Print 100 Year Structure yes no
MAP I" S PARCEL:_ZONING DISTRICT: Historic Districtes no
Machine Shop Village Oyes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
11 Addition ❑Two or more family ❑ Industrial
El Alteration No, of units: [i Commercial
[IRepair, replacement 11Assessory Bldg A Others:
Demolition 11 Other � r ✓ (
�„
s ❑ Wate,rshed Distract
/ ❑:.Wetland
ai
r, F ood I n
is ❑ /
ill/
i
r/%Wa�er/S,ewer/f
TO BE PERFORMED:
DESCRIPTION OF WORK
A) � L
DI 0 V)6 A7
~ ; fi L c I kL
Identification- Please Type or Print Clearly
OWNER: Name: °a 6 "" f`V ~
Phone: / 8 S/5
Address: Z 2
�.
Contractor Name:'?-DC
Email: > .02L . uc "
Address: �' e ` v " / k
Supervisor's Construction License: C 5Exp. Date: /P
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER q' t 'r' ' l ' Phone: 9s � �
.�
Address: = cmc, t' Reg. No. STs/
FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ / FEE: $ g
� -
Check No.: Receipt No.-
NOTE: Persons contracting with unregistered contractors do not have access to the guaralzty fund
'- ---
t4®RTH
Town ofAm-% dover ll .
2 _E. .:..1,,
® .ti.. 0%
sh h &.
- �- ver, ass,
O L^KG 1
C oCMIc"t WICK
0RATE D ► �5
t1 BOARD OF HEALTH
PERMIT T LLJ Food/Kitchen
Septic System
THIS CERTIFIES THAT .. .Ct. . ......... .........a. . . BUILDING INSPECTOR
.... ....... ... ...... ...................6.1 .
haspermission ................ Foundation
p n to erect .......................... buildings on ........ ... . .`�'.k....��. .�......................
Rough
to be occupied as ......... �. PP — ...,
p ..... .�'. ..... . ........'� 'r^rr.... .... ��i?......................... Chimney
provided that the person accepting this permit shall in every respect conform t the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
607-3 2, UNLESS CONSTRUCT STS Rough
�f 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.
T"oWn'of North Andover ® �O T1�
Building Department ��rt-ED,,. .16
1600 Osgood Street
North Andover MA 01845
Tel: 978-688-9545 Fax: 978-688-9542
D CocMiCHEwicec yR'
DEMOLITION OF EUILDING AFFIDAVIT �,9 A044TED
CHUSE
DATE 611--71116-
OWNER'S
11-°-7 ( i`6-OWNER'S NAME &ADDRESS U-)e_4- tAA kN k—UG
GIS
LOCATION OF PROPERTY TO DEMOLISH ; ( t� In �c �} ra C;iLi �
DESCRIPTION
CONTRACTOR'S NAME &ADDRESS
DEPAR% T SN-OFFS,
DEPT.'OF PUBLIC WORKS -WATE SEWER: f
DEPT OF CONSERVATIOKJ.�� HEALTH DEPT: Septic We �/o �
HISTORI COMMISSION
GAS
ELECTRIC _ vc�. il�� J t�/�t �3 � �_�Z--ice
TELEPHONE
CABLE
TAXES
POLICE
q FIRE i Vii° yr
EXTERMINATOR
DUMPSTER—ON/OFF STREET oFF ST-
DIG SAFE NUMBER
DATE REC'D BLDG. INSPECTOR
Doc.form demolition of building affidavit
°ToWn'of North Andover 0
uildin Department ��Ky�° ;6 W'
1600 Osgood Street
North Andover MA 01645
Tel: 976-685-9545 Fax: 978-6$8-9542 �.
o cocaic 1 It" �
DEMOLITION OF BUILDING AFFIDAVIT �,9504,%rED "�¢.�"6�'
SAC HuS�
DATE t ..
�.. " ..
OWNER'S NAME &ADDRESS � ^� � ��'� P � U k..
S-..
LOCATION OF PROPERTY TO DEMOLISH
DESCRIPTION. ?if ell 2- AAOA ,.e c
CONTRACTOR'S NAME &'ADDRESS �UC'� �-- �U������� �l..,J�„ J'd
DEPARTMENT S N- )FFs�, .Z l
DEPT.'OF PUBLIC WORKS -WATER SEWER:
DEPT OF CONSERVATION -( � HEALTH DEPT: Septic Well C "
HISTORI ,COMMISSION/
ELECTRIC � E7 A IV 114 J5 r t
TELEPHONE /
CABLE
TAXES
POLICE Z.,-'7
�I-P
q FIRE
EXTERMINATOR
DUMPSTER-ON/OFF STREET °"
DIG SAFE NUMBER it- I w C
DATE REC'D BLDG. INSPECTOR
Doc.form demolition of building affidavit
September 25, 2015 RCG LLC
17 Ivaloo Street
Suite 100
VJ Tocci Somerville, MA 02143
Tocci Building Companies T 617 625 8315
660 Main Street F 617 625 8345
Woburn, MA 01801 www.RCG-LLC.com
NOTICE TO PROCEED
Dear VJ,
On behalf of the Owner, RCG West Mill NA LLC, I hereby authorize Tocci Building Companies to proceed
on Phase I of the West Mill Building 37 Demolition project. Phase I includes the demolition of Building
37, as further defined in the contract documents, for a total construction cost of$560,136.
Sincerely,
Da . _Steinbergh
Manager
RCG LLC, acting as agent for RCG West Mill NA LLC
1
OF�yQR7;t4
Town of North Andover
Machine Shop Village Neighborhood Conservation District Commission
1600 Osgood Street dol tIt W(101•cr, MA 01845
�SRfH1Y4E�
A lication For Certificate to Alter
Instructions: bill out the form below and submit to the Machine Shop Village NCD Comm*ssion
Chairperson(contact info below). The goal of this application is to protide a clear understanding;
of the proposed alterations,and host-thec N-ary from the existing conditions. Your application
must include photos or plans of the existing conditions,and plans or draicings of the propr>scd
changes_ Include product&material descriptions for both existing and proposed conditions.
Discussions with the Building Dept.or mI V NCI)Co
application. Mn ion are not a substitute for filing an
Date' >; .i , = J 2— t
Contact game&Address:
I Ric
t i
t✓'L
proicct Address:
•-v
I)roicct Description(attach additional pages,if needed):
t c c. {
C! 2- (�iii u'��C{ i.•,
Information proE-ided_
PllorofDr"awing Of Existing Conditions f r-nn! , -
Photo/Drawing of Proposed Conditions -
Description of Existing Materials
Description/Catalog Cuts of Proposed Materials to be used
Other Infonnation(describe):
MSV lVCDC Cnm nt Chair:Liz Fennessy,77 Elm Street,lizettafennessvCvahoo.com.978-688-291
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Tocci Building Companies
LETTER OF INTENT-Agreement 914501.002
This agreement is made this,by and between Tocci Building Corporation Inc.AND
SMS Services Inc
55 Equestrian Drive
North Andover,Massachusetts 01845
Phone:978.683.1166 Fax: 978.883-9771
Shawn Slattery
West Mill Parking
M.
Tocci Building Corporation Inc.Job No. 14501
Tocci Building Corporation Inc. has entered into negotiations for a written agreement with SMS
Services,Inc.("SMS")for construction management services in connection with the above-referenced
Project and has Tocci's authorization to proceed with the performance of certain preliminary services while
Tocci and SMS negotiate the Agreement. The preliminary services covered by this LOI shall be limited to bid
`v scoping, start design-assist process,develop logistics,site mobilization activities,permitting and municipal
s g xn rt approvals,including demolition permit and ten-day notice for demolition. This acceptance is conditional
h 4 x upon the execution of a written trade contractor agreement and your proof of ability to conform with
applicable insurance and bonding requirements. Tocci and SMS agree to exert commercially reasonable
efforts to expedite negotiation and execution of the Agreement by or before September 4,2015.
You are authorized to proceed with the preliminary steps required for the execution of your work and,in
r accordance with the bid plans and specifications,the following specific work items:Shop Drawings,Product
Data,Samples,Coordination.Prior to starting work,a Certificate of Insurance naming Tocci
Building Corporation Inc.as an'additional insured'must be delivered to Tocci Building
660 Moon g,,&Di Corporation Inc.by you or you will not be permitted on the site. To the fullest extent permitted
Woburn,MA 0 180 1 by law,you shall indemnify,defend and hold Tocci Building Corporation Inc.and the Owner harmless for any
r 781.936.55011
€781.935,180 and all claims,liability or damages arising out of or caused by your negligence,or those for whom you are
etww.focci.e°m responsible,whether caused in whole or in part by a party indemnified hereunder.
It is anticipated that a trade contractor agreement shall be executed as soon as practical.In the event a trade
contractor agreement is not executed within twenty-one days due to the inability of the parties to agree upon
terms or conditions,this agreement will terminate and both parties agree to waive any cost incurred up to an
Including the date of such termination.
Please acknowledge your agreement to the above by faxing and/or emailing an executed copy of this Letter
of Intent to Tocci Building Corporation Inc.at 781-935-5744 or jpickard0toccl.com within 48 hours of your
receipt of this notice. If we do not receive your reply within that time,our acceptance of your price quote will
expire. We will deem the facsimile as an original counterpart.You should retain your
executed original in your file.
i
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coof calve constructed
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Tocci Building Companies
In witness whereof,the said parties have hereunto set their hands and seals the day and year written below.
Tocc;BuWildin Cor or io c SMS Services Inc.
By: ` By:
Title:
Date: 1q1 20I Date:
r.Aqs tiati
uHA-'ss
t,
d of•5 '..
660 Main Ssrent
Woburn,MA 01801
,781.93S.5500
f78).935.181313
lWn4.focai.pon,
coat calm constructed
er S,
PROJECT: West Mill Redevelopment
LOCATION: North Andover, MA.
DATE: June 29, 2015
TO: Tocci Building Companies
ATT'N V J Tocci
PHONE: 781.218.5706
FAX: 781.935.1888
E-MAIL: vtocci@tocci.com
Gentlemen;
The below listed proposal has been prepared for the above stated project along with a list of conditions. If we to
Enter into a Sub Contract;these conditions would become part of that agreement.
SCOPE:
Demolition and Removal/Disposal of the entire existing brick structures, identified as the Schneider Bldg.
Demolition parameters are as identified, Foundation plans S-1&S-2; Framing plans 5-7&S-8; Slab plans S-5 &
S-6.
PRICE..............................................................................................................................................................$ 290,500 LS
INCLUDES:
• P E STAMP Demolition plan foundation removal for potential UG utilities - assume 50'
• ADD for Concrete Fd Removal $150 per/If allowance =$7,500
• Removal of Roof Structure, Exterior Brick Walls&Loading Docks
• Removal of all interior walls,flooring,ceilings,fixtures and MEP'S
• Removal of concrete slab on grade.
• Concrete Slab to remain over Existing Culvert.Approx 25ft x 200f 1500 CY Crush concrete to 6"minus and leave on-site
• T&D of painted block and brickTruck & Dump painted block at rear of building37
• Protect adjacent buildings
• Separations from the existingbuildings to remain Dust & Debris Blankets
• Perimeter foundation removal to 1'below existing grade Will be brought to Same level
• Pile caps and Interior footings removed to slab removal grade
• All work to be performed Non Union
• All work to be performed in strict accordance of all Local,State and Federal Safety Regulations
• Demolition debris will be recycled/disposed of at approved facilties
• One Mobilization
Very truly yours,
Sal Tecce
SMS Services, Inc.
Saltecce@ gmail.com
781.835.5135 cell
cc: Shawn Slattery SMS
55 Equestrian Drive,North Andover,MA.01845 Office 978.683.1166 Fax 978.683.9771
® S'
NOTE: See Next Page for List of Exclusions
PROJECT: West Mill Redevelopment
LOCATION: North Andover, MA.
DATE: June 29, 2015
TO: Tocci Building Companies
ATT'N V J Tocci
PHONE: 781.218.5706
FAX: 781.935.1888
E-MAIL: vtocci@tocci.com
EXCLUSIONS:
• We exclude any and all costs associated with Testing, Processing, Removal and Disposal of ACM and other
Hazardous Material.
• No Pest control
• No Pre or post demolition surveys
• No Vibration/seismic monitoring
• No Temporary fencing
• No Site security
• No Air monitoring
• No Police and/or Fire Details
• No Backfill Material
• No Permits/Air Monitoring
• No Cut&Caps of utilities < Cut & Cap of underground utilities to be by
• No Relocating/restacking or resetting items Site contractor
• No Traffic controls, barricades and/or signs
• No Erosion control/Tree protection
• No Shoring /shielding/SOE
• Dif Safe by GC
• Salvage Value to SMS Services
• GC to mark Layouts and Engineering
• No Water for dust control
• No removal of AST/UST
• Street sweeping
• No Weather protection
• No Dust barriers/curtains
• Retainage released 15 days from completion
• Quote valid for 30 days.
55 Equestrian Drive,North Andover,MA.01845 Office 978.683.1166 Fax 978.683.9771
NORTHEAST
1 I CLIFF AVF, Suite 13, HAMPTON, NII. 0')842-36 0
September 9. 201
Mr. 14auricio Ferreira
Infinity Abatement Set-vices. Inc.
91 Farnham Street
Lawrence, MA 0I 843
Re: Post Asbestos Abatement Visual Inspection: 4 1 ligh Street
No. Andover, MA 01810
Dear Mr, Ferreira.
This letter may be considered a certificate of completion of the asbestos abatement pro?ject at the site
stated above. The visual inspection was conducted by John A. Bachand (AM 0313 19) on
September 4, 2015. Pursuant to the ASTM Designation E1368-05, `*Standard Practice for Visual
Inspection of Asbestos Abatement Projects' the fundamental criterion for completion of removal and
cleanup is the absence of visible residue,dust and debris. This standard Inas been adequately met and no
further action is recommended at this tin-tc
If'you have any questions or comments, please do not hesitate to call me at (978) 618-0064.
Respectfully.
John A. Bachand.. I sq.
Industrial Hygienist
AAOOO 153
AM 031,319
Al 030160
i
SMS SERVICES , INC
WEST MILL REDEVELOPMENT
DEMOLITION WORK PLAN SUMMARY
1.0 INTRODUCTION
SMS SERVICES, INC. (SMS) has prepared this Demolition and Removal Plan, hereafter referred
to as the "Work Plan", for the purpose of providing a detailed description of demolition and
removal procedures, which SMS will be implementing during the on-site activities at the WEST
MILL REDEVELOPMENT
1.2 SITE LOCATION AND DESCRIPTION
The WEST MILL REDEVELOPMENT is located at 4 HIGH ST,NORTH ANDOVER,MA.
Demolition includes total takedown of existing BUILDING NO 37
1.3 GENERAL WORK ACTIVITY OVERVIEW
The work covered under this Work Plan will be conducted in a sequential manner, with some
activities being conducted concurrently with others. Demolition work will be performed in
accordance with all Federal, State and Local regulations. Depending upon site and other unknown
conditions, SMS's general sequence of demolition activities may require alteration at any given
time. A summary of the general sequence for the work activities is outlined as follows:
Pre-construction activities and site mobilization
Verification of utility disconnects,shut offs and isolations by others
Obtain all required DEP permits from authorities
ACM will be removed
Any RTU/AC FREON will be purged
Windows along BLDG 5 to be covered with plywood
Pedestrian /Vehicular traffic controls installed (BY OTHERS)
Submit plans, procedures and sequence for demolition work
Demolition of existing structure
Haul off of all building components to proper off site facilities
1.4 PERSONNEL HEALTH& SAFETY
SMS considers safety and the prevention of accidents an integral part of its operation. Under
Federal, State and local laws, SMS is responsible to provide a safe working environment, to protect
life, health and safety of its employees and subcontractors personnel. Although providing safe
working conditions is primarily a management responsibility,safety and accident prevention can be
accomplished only through coordinated efforts of all employees and subcontractor personnel. It is
the policy of SMS for this project as with all of our projects, that if the task or service being
undertaken cannot be done safely, that work is to be stopped until proper controls can be
established.
55 EQUESTRIAN DRIVE—NORTH ANDOVER,MA 01845-- 978.683.1166
SMS SERVICES , INC
2.0 DEMOLITION ACTIVITIES
Prior to commencement of building demolition, a thorough walk thru and evaluation of the
structure will be conducted to confirm that all appropriate measures have been completed to
ensure that the area is ready for commencement of demolition activities.
In general, tasks will include a wide variety of procedures. The most important aspect in the
development of these procedures will be the safe conduct of the work. SMS's procedures will limit
the use of labor to the most controlled and safe conditions and rely upon mechanized means of
removal wherever possible. Excavators equipped with concrete hammers, grapples and other
modern hydraulic demolition tools and attachments will be utilized.
General building/structure demolition will be conducted in a manner that does not interfere with or
encroach upon the surrounding pedestrian and vehicular traffic during normal activities. TOCCI
Construction Inc. has provided fencing around the project site and SMS will work within the
confines of the site fencing. However, depending upon site conditions, alternative methods of
demolition and alternative types of equipment may be used to ensure the safest and most efficient
means of operation. This may involve modification of the site,fencing from time to time in order to
complete the demolition activities. This will always be coordinated with TOCCI in advance. It is
anticipated that trucks/trailers for disposal operations will exit Left onto High St. and take Sutton
Street to route 495 either North or South.
Prior to any torch cutting operations, a permit, if required, will be obtained by SMS.
During any torch cutting, the surrounding vegetation will be removed to reduce the risk of
fire. Two fire extinguishers will be located in the vicinity ready for use in case of fire.
2.1 EQUIPMENT TO BE UTILIZED AND AVAILABLE:
Cat 349 Exc.
Cat 336 Exc.
Cat 329 Exc..
Cat 980 Ldr.
Mini Exc.
Cat D8N Dozer
Bobcat, Manlift, Scissor Lift and Pumps
End Dumps/Tri Axels
LaBounty Shears
Hydraulic Hammers, Grapples, Concrete Muncher, Concrete Pulveriser.
2.2 GENERAL STRUCTURE DEMOLITION
Interior demolition will be pulled down into building,work to be performed with lifts, skid steers ,
bobcats and/or a CAT 301.5 Mini Excavator. A hole shall be made into the exterior wall at Col.
Lines 11-12 and A-B to allow the Equipment to enter the building.Windows on the west side(rear)
will be pushed in and garage doors opened or removed for ventilation during interior work. Debris
as it is generated will also be transported through this opening and loaded into trailers to be
disposed of at an approved recycling/disposal facility(s).
55 EQUESTRIAN DRIVE—NORTH ANDOVER, MA 01845-- 978.683.1166
SMS SERVICES , INC
Next, roof separations at buildings 5 & 38 will be done by laborers with saws, cutting roof material
and truss connections. Then excavators will begin by lowering the Roofing Material into the
interior. Roofing debris will be cleared with excavators, loaded onto dump trailers and transported
to a recycling facility.
Following roof material removals, utilizing excavators (Cat 349 /Cat 336) with grapples and/or
shears the structural steel framing, metal roofing and trusses will be lowered to the interior,
allowing the exterior walls to stand. Metals to be prepared for Recycling.
As the roof removal progresses the block and brick walls will be demolished/pulled inward allowing
the block and brick to fall into the building footprint. Block and brick will be downsized by
excavators,loaded onto trucks and transported to a recycling facility.
Concrete slabs, any foundations and interior column footings will be removed to existing grade, by
excavators with hydraulic hammers and/or munchers. Steel rebar will be removed and concrete
sized to 6" minus and left on site.
2.3 FERROUS AND NON-FERROUS METALS RECYCLING
During demolition of the existing building structure, SMS will process the demolition debris to
recycle as much metal material as possible. Structural steel framing, metal roofing and siding,
reinforcing steel in concrete, copper tubing, electrical gear, controls etc.,will be separated prior to
the demolition as much as possible. These materials will be hauled to recycling facilities: These
facilities are well aware of the potential lead on various metal components.
2.4 DEMOLITION DEBRIS DISPOSAL
All demolition debris/block and brick that will not be recycled by SMS will be loaded into a 100 CY
Trailers and hauled to a disposal facility for further recycling or landfill. Demolition debris may be
hauled to the following disposal facilities:
• Charles George Companies
A.K.S.Recycling,Inc.
209 Nashua Rd.
Londonderry,NH 03053
CL NOONAN
415 West Street
West Bridgewater,MA 02379
Casella Waste systems
4 Chennel Dr.
Concord,NH 03301
2.5 DUST CONTROL
Dust control will be considered an important part of the overall project. When needed, SMS will
utilize a fire hose attached to a local hydrant during demolition operations. SMS will direct a water
spray to the source of demolition activities, as required, thereby reducing airborne dust particles.
To minimize the run-off of water, the water supply will only be used when necessary.
55 EQUESTRIAN DRIVE—NORTH ANDOVER,MA 01845-- 978.683.1166
UNCLE
Post-End, Inc.
/ 15 Pelham Street P.O. Box 185
Methuen, MA 01844 Plaistow, NH 03865
(978) 794-4321 Fax(978)688-8344 (603)382-9644 Fax(603)382-9525
pestendinc.com pestendina.com
RODENT CONTROL REPORT
BAITING PRIOR TO DEMOLITION
Date: September 16, 2015
Property Address: 1 HIGH STREET NORTH ANDOVER, MA 01845
Commercial: Yes 11� No
Residential: Yes No
Property Treated With Check One or More
First Strike Soft Bait EPA#7173-258 Difethialone
Contrac All Weather Blox EPA#12455-79 Bromadiolone
Final All Weather Blox EPA#12455-89 Brodifacoum
Areas Baited:
Interior Baiting
Exterior Baiting
Dumpster
Planter's
Other
Area(s) Clean Yes No
Activity Seen Yes No
Mice Rats
Comments from Technician ����e e,S .
Technician Name: BRANDON LEE
Signature: License #39615
Date: Z-7// I Tj
U CLE
est-End, Inc.
15 Pelham Street P.O. Box 185
Methuen, MA 01844 Plaistow, NH 03865
(978)794-4321 Fax(978)688-8344 (603)382-9644 Fax(603)382-9525
pestendinc.com pestendinc.com
Date: September 16, 2015
Property Address: RCG LLC 1 HIGH STREET NORTH ANDOVER,MA 01845
The above address has been inspected by our company. The inspection has been done by
a licensed technician for rodent activity. The rodent control report provides information on
the technician and chemical that may have been used if evidence was found.
Please call our office if you have any questions 978-794-4321.
Thank you,
Pest End Exterminators and Pro Tech Lawn Care.
pe Commonwealth of'Massachusetis
Department oflndusta"r~al Aceidents
X Congress,S`tt'eet,Suite 100..
. Boston,M.A.02-U4-2017
4 www.mass go-v/dta
Workers,Compensation)basuxa)oiceAff'idavit:Builders/ContractorsfBlgctricians/Plixmbers.
TO BEFffAD WITH TEE PERWHr TATGA*UTRORT.TY-
7icant fMormiatio /+ Please Print Le 'bl
Name(Business/organization/lndividual): 7-61 I. 1 a!L •�4 r o1 J
Address: G a M41AI srkccf'
City/State/Zip: �a�yKr�l MA- 19 / Phone#: W o
Areyou an employer?ChecktUee aplizopriatebox: Type of project(Tgquired)•
1.MIamaemployerwith SC, employees(full and/or part•time).* 7. ❑Now construction
2.Q I am a sole proprietor or partnership and have no employees working forme in 8. FJ Remodeling
any capacity.(Noworkers'comp.insurance required.] 9. VDemolition
3.Q I am a homeowner doing all work myself;(No workers'comp.insurance required.]t 10[(Building addition
4.E]I am a homeowner andwill 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 or additions
proprietors with no employees. 12.EJ Plumbing repairs or additions
5.❑I am a general contractor and I have hiredthe sub-contractors listed on the attached sheet. 13.Q Roof repairs
These sub-contractors hale employees and have workerscomp.fnsruance.
6.[]We area corporation pnd its cfficem have exercisedth*right of'exemption perMOL c.
14.❑Other
152,§1(4),and we havenq,empl""y s.[Noworkers'comp,insmUcerequired.] +•
*Any applicant that checks box#1 must also fill out the section below showingtheirworkers'compensation policy information.
i Homeowners who submit#his afAdavit indicating they are doing all work andthea hire outside contractors must 4bmlt anew affidavit indicating such.
tConfractors that aheckthis box must attached an additional sheat showing thename,of the sub-contractors and state whether or notthosa entities have .
employees. If the sub-eonlrac4ors five employees,4liey muit provide their workers'comp.policy number.'
lam an employer tfzat ispi'ovidtng workers'compensation insurance for my en2ployees.'Below s the policy and job site
information. �; �- /
Insurance Company Name: -rhe O✓el rrd sago kl mr► t^ M t'�t a
Policy#or Self ins.UG.#: H L S Y 5'8 (y Expiration Date: 0 21 201 S
Sob Site Address: 4 440 ` (c cl City/State/Zip. k 01
Attach,a copy of the workers'coxnpepsation•policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL o.152,§25.A.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 WORIC ORDER and a fine of up to$250.00 a
day against the violator. y o this statement may be forwarded to the Office of Investigations of the DIA.for insurance
coverage verlf cation
f do hereby eert* under•the ins a pe tie ofperjury tliat the informadonprovided above is true and correct.
Si nature: Date:
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.CWJTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
1 Massachusetts -Departme , c e'--
gca• !
Of Bi.i.id'nu Reciuiat Drs a Sar
Cnnetruction Super.'ian
_;cense: CS-048220
ROBERT F TIERNEY JR
7 FARRELL DR
FORESTDALE NIA 02644
9,21 02/03/2016
�ss