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HomeMy WebLinkAboutBuilding Permit #029-16 - 82 Main Street 7/6/2015 l� 1 BUILDING PERMIT o "°RrN q 'fit L60 169 TOWN OF NORTH ANDOVER 02 y: - =}' APPLICATION FOR PLAN EXAMINATION i Permit No#: Y� Date Received A� " I 7�A°R�reo�Pa` C3 /jA SSACHUSfc Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION _8r�- 6? &14\ Anhi er �cO fox 3`�3 1&4� Andooe�AA fly PROPERTY OWNER �i. 1 Na1 "1C��c tl < Print 100 Year Structure yes no MAP b 2,9 PPARCE12*5 ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family Y ❑Addition ❑ Two or more family ❑ Industrial Alteration No. of units:—H ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic 0.1Nell ❑ P'16-odplain ❑Wetlands ❑ 'Watershed District 0 Water/Sewer - DESCRIPTIO M OF WORK TO BE FORMEyD: ,�, � qq i �C� P d e tn�� W �V e!J0C_K 'Toto,L' a O+P- No 1 ecf Co, —10 6e ReMwAC entification- Please Type or Print Clearly 0)b4s OWNER: Name:Q �k S�oCt(\ E VQ, 9 90Y, 3 9 3,,lr/A / M Phone: Address: 1' P,% S [,• ?'C " ba�C oarI Lj S Contractor Name: ;Lho. e( A , !a r g l\ el ' Phone:, Email: xet ` r'+k e Address: . 1QWa�d on 6vkS, ®19,4 L( Supervisor's Construction License:CS 09 5373 Exp. Date: le ! 41 1 J� Home.Improvement License: 1777 Se, Exp. Date: I ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED C ST BASED OV65.00 PER S.F. Total Project Cost: $ � FEE: $ Check No.: l�_1 l �2(, Receipt No.: `&6 d,2� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 1 TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS i CONSERVATION Reviewed on Signature COMMENTS HES LTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments e Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit ]DP`VV Town Engineer: Signature: I Located 384 Osgood Street FIRE D�=EPARA 'LIVI -ENT emp Dujmp�ste o site Yes Located at 1P24 Main Street` ' '` �' , Fe Dep itrnen 's g `• xK . C 0111 M ESN i Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: 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.$100-$1000 fine NOTES and DATA— (For department se) ( (et �cLc i Ll i Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit o .op0 - . And/4r FDicenses / Co�Fo y of Contrac an Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) r 46 Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application -M i Doc:Building Permit Revised 2014 i R4Location .� No. Date I I . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ L TOTAL $ Check# t- Building Inspector F NORTt-� own of s E �. Andover o : - to No. _ 201 +Zt+0;NLA616 h ver, Mass, COC MICHewKK ��• s V BOARD OF HEALTH Food/Kitchen Septic System THIS CERTIFIES PEf MIT .. �.!!�....��....... BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on ..... . ...... .... �.................. �> Rough rto be occupied as ... 1.�!L . .�...��.�.. ... ....� !:1�. :...b.h:�.. :............................................. Chimney provided that the person acdepting this permR shall in every respect con r 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI TS 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. i Smoke Det. Ii f L � ropoal Page# of pages I I PROPOSAL SUBMITTED TO: QJOB NAME JOB# 6- `( C r t <- ADDRESS JOB LOCATION I DATE DATE OF PLANS PHONE# FAX# ARCHITECT V e hereby submit specifications and estimates for: L �j i _.—_......._._......-___. = ........................-....-----------__.____.......................... ._.......--.........._............................. — - -- ---------- - ...---- . ._..... -— —.............. _ --- ----- -- ro i i jVe propose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of: k U [n A c, _ Dollars, with payments to be made as follows: �f? r2G r J Any alteration or deviation from above specifications involving extra costs Respectfully ? ; will be executed only upon written order,and will become an extra charge submitted � over and above the estimate. All agreements contingent upon strikes, i accidents,or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within days. 01cceptance of Propont The above prices,specifications and conditions are satisfactory and are .- hereby accepted. You are authorized to do the work as specified. �r Payments will be made as outlined above. Signature " I Date of Acceptance Signature CZ A-NC3819/T-3850 09-11 i The Commonwealth of Massachusetts FDepartment of Industrial Accidents M Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation insurance Affidavit:Buildexs/Contxactoxs/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ' -.Please Print Legibly A ' licant Information ``t. Name(Busineejss/Oigauization/Individual): I ®+. C Address: "I /� Q�ec�o LgA P, — 1 y(IPhone#: 779 a� City/State/Zip: 0 hecktfie a ropriatebox: Type of project(required); an em 10 er.C PP Are you p Y y ,. em to ees Rill and/orpart-time).* 7. ❑New'construction 1. I am a employer with P Y ( emodea partnership and have no employees working for me m 8. g IF]I am a sole proprietor or parte P any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself~[No workers'comp.insurance required.]t 10E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole ons proprietors with no"employees. 12Tn; Plumbing repairs or addxti 5. 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 workerscomp.insurance.t 14.0 Other 6. We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees:[No workers'comp.insurance required.] *Any applicant that checks bbk#1 must also fill out the section below showing their workers'compensation policy information: dca who submit•this affidavit indicating they are doing all work and then hire outside contractors must seubmittaa now aff v inniitieti have gsuch Homeowners , .. name of the sub-contractors and stat,w , , tContractors that check this box must attached'an additional sheet showing the employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. workers'compensation insurance for my employees. ,Below is the policy and job site X am an employer tliat is providing information. � � �^ ,�n(/I �LJ� Insurance Company Name: or u /�'' ' ' l P �+ � � �� ' � r Policy#or Self ins. Lic.#: / (� ��©0 0 anon Date: / 0 C Job Site Address alp �✓ " � City/State/Zip: -. o A t 0�5CA7 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiratio 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 imprisonment,as well as civil penalties in th form of a STOP WORK ORDER and a fine of up to $250.00 a and/Orione-yearp office of Investi ations of the DIA for insurance day against the violator.A copy of this statement maybe foard ed to the Offi g coverage verification. I do herebyP 11 ertify der the . s andpenalties ofperjury that the information provided above is true and correct. Ck Date: I ts Si� ature: Phone#: 179—�93 — SOal_ 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 Phone#: Contact Person: 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 We, express or implied,oral or written." An employer is d'efnied as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enferprise,and including the legal representatives of a deceased employer,or the receivet'or tmstse of an individual,partnership,association or other legal entity,employing employees.•However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth.for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(l)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub'contractor(s)name(s),address(es)and phone number(s)along with their certificates)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 Departnent has provided;a spice at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. Xn addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write•"all locations in • (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax'number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-NUSSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia DATE(MMIDDIYYYY) AC40RO� CERTIFICATE OF LIABILITY INSURANCE 0612512015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 04963-001 CONTACT NAME: MTM Insurance Associates LLC AIC No.Ext: (978)681-5700 AIC.No.: (978)681-5777 1320 Osgood Street EMAIL North Andover,MA 01845 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURE • A.I.M. Mutual Insurance Company 133758 INSURED Jason Nault INSURER B: INSURER C: 30 Forest Street Lawrence, MA 01841 INSURER D: INSURER E: I INSURER F' COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH 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 PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD MMIDDIY MMIDDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES Ea occurrence CLAIMS-MADE 17 OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ __]POLICY ECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED AUTOS AUTOS ( )BODILY INJURY Per accident $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DEC) RETEENNTIIONN $ yy� L� TH $ V't99A;fRERYLIABILITY X TORY LIMITS OER A P T51BJ /PARTNER/EXECUTIVE Y I N E.L.EACH ACCIDENT $ 100,000.00 A oIc��M � NIA VWC-100-6018002-2014A 1216/2014 1216!2015 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000.00 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 600,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) The workers compensation policy does not provide coverage for Jason Nault II CERTIFICATE HOLDER CANCELLATION Town of North Andover 1600 Osgood Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE N Andover,MA 01846 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE C—:��l yG � ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 26(2010/06) The ACORD name and logo are registered marks of ACORD i I t NOTICE NOTICE TO r ' TO EMPLOYEESEMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that I (we) have provided payment to our injured employees under the above mentioned chapter by insuring with: A.I.M. Mutual Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY VWC-100-6018002-2014A 12/06/2014 - 12/06/2015 POLICY NUMBER EFFECTIVE DATES 1320 od Street MTM Insurance Associates LLC Nortt Ondover, MA 01845 1-5700 NAME OF INSURANCE AGENT ADDRESS (978)68 PHONE Jason Nault 30 Forest Street Lawrence, MA 01841 EMPLOYER ADDRESS 10/30/2014 DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 26158 POLICY NO. j VWC-100-6018002-2014A PRIOR N0. ! VWC-100-6018002-2013A� ITEM 1. The Insured: Jason Nault DBA: Mailing address: 30 Forest Street FEIN: **-***1111 Lawrence, MA 01841 Legal Entity Type: Sole Proprietor Other workplaces not shown above: 2. The policy period is from 12/06/2014 to 12/06/2015 12:01 a.m. standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates I Code Estimated Per$100 ( E=Annual No. i Total Annual Of i Remuneration Remuneration INTRA 1045272 i INTER SEE!CLASS CODE SCHEDULE Minimum Premium $500 Total Estimated Annual Premium $500 GOV ' GOV Deposit Premium $500 STATEiCLASS, j MA 5403 State Assessments/Surcharges $.00 x 5.8000% $ This policy, including all endorsements, is hereby countersigned by 10/30/2014 Authorized Signature Date to Service Office: MTM Insurance Associates LLC 54 Third Avenue 1320 Osgood Street Burlington MA 01803 North Andover, MA 01845 WC 00 00 01 A(7-11) Includes convriahted material of tho Natinnal r nisnrii ipom��conc�ea >/i o� a�ltzceC�a Office of Consumer Affairs&Ousiness Reg%,*%�n 11A'E PR /El1�lENT CONTRACTOR eglatrat;on7758 Type. 4 M�iFation Cq�E Individual MICHAEL A. FARELLI, MICHAEL FARELLI 9 APPLEWOOD LANES- �''` METHU.EN;MA 01-844 iUpder1ee eI's V Massachusetts - Department of Public Safety Board of Building Regulations and Standards License: CS-095373 MICHAEL A FARL 9 APPLEWOOD r"; f METHUEN MA 8184, a> Expiration , Commissioner 12/04/2016 _ESP�AS`S�ACLHgTfSE�TT'S' � � _ _i S *die },. ri. � ..I DD'7&07.2077Re40Tt1Y�Op9 . 1 � VIII.APPLICANT'S AGREEMENT By signing this application,I certify that: (I) 1 am the employer or have been authorized by the employer to complete this application on its behalf; (II) 1 have read and understand the following statements to which I agree by signing this application;and (III)All information provided in this application and on its attachments is true. In consideration of the issuance of a Notice of Assignment and subsequent policy of insurance,I hereby certify,under the pains and penalties of perjury,that: 1. 1 made a good faith effort,but failed to obtain coverage through the voluntary MA workers'compensation insurance market; 2. lam not knowingly in default of premium on any MA workers'compensation insurance policy; 3. 1 have complied and will continue to comply with all laws,orders,rules and regulations in force and effect relating to the welfare,health and safety of employees,including but not limited to: a. Allowing the carrier to make a careful inspection of my operation for the purpose of measuring the hazards,making recommendations for the health and safety of employees,and determining the rate or rates which are adequate and reasonable; b. Complying with the carriers'reasonable recommendations aimed at controlling or reducing the hazard(s)insured against; c. Keeping records of information needed to compute premium and providing the carrier with copies of those records when asked for them;and d. Fully cooperating with the carriers'attempts to conduct premium audits or inspections of the premises for loss control purposes. I understand that the employer's compliance with each of these certifications is material to the issuance of assigned risk pool coverage. Jason Nault Jason Nault Owner 12/5/2013 Title Date of Application Business Name of Applicant Signature r, Original Signature For Printed Copy: NOTICE: This insurance is being provided through the Massachusetts Workers' Compensation Assigned Risk Pool, and not through the voluntary market. e d) may,to the extent allowed by Massachusetts law,cause the carrier to initiate a mid-term employer's non-compliance with certifications 1,2 and 3 (a cancellation. FRAUD NOTICE: Massachusetts General Law,Chapter 152,Section 14(3)provides: "(A)ny person who knowingly makes any false or misleading statement,representation submission or knowingly assists,abets,solicits or conspires in the ion,or knowingly conceals or fails to disclose knowledge of the occurrence of any making of any false or misleading statement,representation or submiss event affecting the payment,coverage or other benefit for the purpose of obtaining or denying any payment,coverage or other benefit under this chapter; and any person or employer who knowingly misclassifies employees or engages in deceptive employee leasing practices for the purpose of avoiding full payment of insurance premiums...Sia!!be punished by imcrisonment in-the::ate;^son for not rrvre than five years or by imprisonment in jail for not less than six months nor more than two and one-half years or by a fine of not less than one thousand nor more than ten thousand dollars,or by both such fine and imprisonment." IX.AGENCY INFORMATION AND PRODUCER'S STATEMENT The producer hereby t all belief and that he/she made ea�under goodfaith effort to place the cove age n� aInformation thevoluntary market as required by M.G.L,C.162,Sect on 66A.edge and MTM INS iBANCE ASSOCIATES I 1 Q l Name of Agency 841723582 1832011 FEIN Producer License# 1320 OSGOOD ST. Mailing Address of Agency 978_681_57n0 NORTH ANQQVER MA 01845 City State Zip Phone PAUL J MACDONALD Producer Name Le,u J M8QQONAl D _ 12/05/2013 Signature of Producer Date Original Signature For Printed Copy: Q✓ By checking this box,I certify that I am the producer of record. Q✓ By checking this box,I certify that I have reviewed Section VIII of the application with the applicant prior to his/her signing. QBy checking this box, I hereby acknowledge the signatures to this application as original signatures. I request, on behalf of the applicant, the designation of an insurance company to provide insurance in accordance with the provisions of the Massachusetts Workers' Compensation Assigned Risk Pool,and I certify that I have reviewed the applicant's responsibilities with the applicant and will retain a copy of the completed application with the applicant's and the producer's original signatures for a period of not less than five(6)years. MASSACHUSETTS WORKERS' COMPENSATION ASSIGNED RISK POOL ONLINE APPLICATION FOR WORKERS' COMPENSATION INSURANCE Processed By: The Workers'Compensation Rating&Inspection Bureau of Massachusetts 101 Arch Street Requested Effective Date: 12/6/2013 Boston,MA 02110 617-439-9030 Employer Email: Payment for the MA Workers' Compensation Assigned Risk Pool Online Application (OAR) must be made by electronic check. Coverage will not be provided if the correct payment or deposit premium is not received within two business days from receipt of the confirmation email sent once the application has been approved and assigned. Under no circumstance will coverage be assigned if: the declination requirements are not met;there is acordnt of v a dit or in f force for inspection from entity making kiprig application; the applicant is in default of premium for prior workers' compensation coverage; or, the app' workers'compensation policy that remains incomplete due to the applicant's failure to cooperate with the prior insurer. The earliest possible date coverage can be bound is at 12:01 a.m.the day after the application is submitted to OAR. to ers'liability insurance in the voluntary market and hereby applies for compensation and em Y rs' come employers' to obtain work p The undersigned employer has failed such insurance in the Massachusetts Workers'Compensation Assignedresents that such insurance is sought in good faith. Risk Pool and expressly rep p I. GENERAL INFORMATION JASON N60 I Name of Employer(Name the sole proprietor,general partner(s)or the trustee(s)along with the trade name of the business.) SOLE PROPRIA rno inn ru nin FMPI HYPES Federal Employer Identification Number(FEIN) Total Number of MA Locations: t 1 FORESI T AWRENCE MA 01841 978-601-2250 City State Zip Phone Mailinq Address LAWRENCE MA 01841 978-501-2250 _— 31 FOREST SI City State Zip Phone Principal MA Location LAWRENCE FOREST ST city State Zip Phone Location of Records City State Zip Phone Other Massachusetts Location Legal Status: Q✓ Sole Proprietor ❑Partnership ❑corporation ❑Trust ❑Limited Partnership EJ LLC Municipality ❑LLP E]Other(Explain): II. ELIGIBILITY REQUIREMENTS To be eligible to obtain assigned risk coverage: The employer's application for voluntary Massachusetts workers'compensation coverage must have been rejected by two (2) carriers licensed to write workers compensation in Massachusetts; The employer must not be in default of premium for Massachusetts workers'compensation insurance; The employer must have complied with all laws,orders,rules and regulations in force and effect relating to the welfare, health and safety of employee and, The employer must not have an audit or inspection on a prior workers' compensation policy that remains incomplete due to the employer's failure cooperate with the insurer. 1. List the names, representatives, date(s) of discussion, and phone numbers of two insurance companies licensed to write workers' compensation in Massachusetts who have refused to write voluntary coverage for this risk in the past sixty days. Each representative named must be an employee who has authority to bind coverage for the insurance company. A failure to reach such a representative cannot be construed as a refusal to write coverage. Name of Insurance Company Full Name of Representative Declination Date Phone Travelers Insurance Joseph Arthurs 12/05/2013 800-852-6677 Hartford insurance Kristin McLaughlin 12/05/2013 800-922-8246 1 a.Has the employer's coverage,either voluntary or assigned risk,recently terminated or expired? Yes Z✓ No Note: If Yes,a copy of the cancellation or nonrenewal notice must be attached,and the reason for the cancellation or nonrenewal must be indicated or the notice. If the coverage was in the voluntary market within the past sixty days,the cancellation or nonrenewal will serve as one of the two require( declinations. Generally, coverage must be replaced in the voluntary market if voluntary coverage was cancelled or nonrenewed at the employer': request. 2. Have you received any offers of voluntary coverage? ❑Yes ❑✓ No 2a. Does the offer of coverage include multi-line,deductible,or retrospective rating terms? ❑Yes ❑No 3. Is there any unpaid workers'compensation premium due from you or any other commonly owned enterprise? ❑Yes ❑✓ No ❑Unpaid Premium [:]Premium Dispute ❑Payment Plan (Select most appropriate) If Unpaid Premium selected,provide: Entity Name Balance Policy Number(s) If Premium Dispute selected,a copy of the letter sent by the employer to the carrier disputing the premium with full explanation must be attached to this application for Bureau consideration. If Payment Plan selected,a copy of the signed payment plan agreement between the employer and the carrier must be attached to this application. 4. Does the employer have any outstanding audits or inspections on a prior workers'compensation policy? ❑Yes ❑✓ No If yes,provide the name of the insurance company and the policy number(s). Insurance Company Policy Number(s) 4a. Has an audit been scheduled? ❑Yes ❑No If yes,provide the insurance company contact name and phone number. Insurance Company Contact Name Contact Phone# III.CORPORATE OFFICERS, SOLE PROPRIETORS, PARTNERS&MEMBERS For Sole Proprietors,Partners,LLC Members and LLP Partners: List the names,titles,ownership and duties of all proprietors,partners or members, and indicate whether each is electing coverage.Sole proprietors, partners and members are not covered unless they elect coverage.To elect coverage, a letter must be attached on company letterhead in accordance with MA Regulation 452 CMR 8.07. Refer to the MA Workers' Compensation & Employers Liability Insurance Manual,to the Rates Page with Miscellaneous Values,for sole proprietors',partners'and members'basis of premium. In Section VI include the Basis of Premium for all sole proprietors,partners and members electing coverage. For Corporations: List the nam i P e, title, ownership, duties and actual sola of all officers listed in the Corporate salary p Articles of Organization and indicate whether each has chosen to exempt himself from coverage in accordance with MA Regulation 452 CMR 8.06. Corporate officers will be included unless a Form 153 has been submitted to and approved by the MA Department of Industrial Accidents.A copy of the DIA stamped and approved Form 153 must be attached to this application. Corporate officer salaries may be subject to payroll limitations; refer to the MA Workers'Compensation &Employers Liability Insurance Manual,Part One—Rule IX.In Section VI include the salary,subject to minimums and maximums,of all nonexempt corporate officers. Name I Title I%Ownershir; I Elect/Exempt i Duties Salary JASON NAULT SOLE PROPRIETOR 100 EXEMPT CONSTRUCTION 10,000 IV. INSURANCE RECORD 1. Has the applicant previously had Massachusetts workers'compensation insurance from a licensed insurance company? ❑Yes ❑✓ No 2. If Yes,complete the followinq for the most recent three Years: Insurance Company Policv Number Policv Period FPremium From To 3. If No,complete: ❑✓ New Business ❑UninsuredSelf Insurance Group Self-Insured ❑ P ❑ []Other(Explain): 4• Was the applicant self-insured within the last twelve months or was the applicant's expiring policy subject to the Premium []Yes ❑✓ No Determination Endorsement—Former Self-Insurers 1? If Yes,former self insurers who are subject to Premium Determination Endorsement—Former Self-Insurers 1 cannot submit an online application through OAR.A paper application must be submitted.Refer to the Pool Procedures for New Applications for details. Former members of self insurance groups are not subject to this endorsement. 5. Is the employer in bankruptcy? ❑Yes ❑✓ No 6. Does this entity or any other commonly owned entity have operations in states other than MA? ❑Yes ❑✓ No 7. Has there been a name change within the last five years? ❑Yes Q No 8• Has there been a merger or consolidation within the last five years? ❑Yes ❑✓ No 9. Has there been a sale,transfer or conveyance of ownership interest within the last five years? ❑Yes ❑✓ No 10.Did the applicant purchase or otherwise acquire the physical assets of another entity whose operations they took over within the last five years? ❑Yes ❑✓ No 11.Have the owners or officers ever had ownership interest in any other entity,either currently or previously existing? ❑Yes ❑✓ No V. BUSINESS OF EMPLOYER 1. Completely describe all operations of the employer.If there are multiple locations,provide a description for each. Completely describe any changes that have taken place in the last three years that might affect the classification of the operation. Li9ght carpentry work on residential properties,remodeling,etc. No employees 2. MA law provides that you,the employer,are liable for injury of employees of uninsured subcontractors.Premium will be charged in the absence of a certificate of insurance from subcontractors. Is it anticipated that subcontracted labor will be utilized during the policy term? ❑Yes ❑✓ No 3. Do you use independent contractors? []Yes ❑✓ No If Yes,you must maintain documentation which supports that they are,in fact,independent contractors. If such documentation is not available, or if the designated carrier finds evidence of an employment relationship,then premium may be charged as if the individuals were employees. 4. Is the employer a temporary help agency? []Yes ❑✓ No 5. Does the employer lease employees from another business? ❑Yes Q No 5a. Is this application for your own employees not subject to an employee leasing arrangement? ❑Yes ❑No 6. Does the employer lease employees to another business? ❑Yes Z No 6a. This application is for: []Your own employees not subject to an employee leasing arrangement. []Employees leased to a client company. Client Name Client FEIN Street City State Zip VI. MASSACHUSETTS CLASSIFICATIONS, ESTIMATED EXPOSURES, AND PREMIUM CALCULATIONS FLoclation Sift Class Code Classification Phraseology s Number of Estimated L Employees Remuneration/ Rate Premium H Exposure 645 CARPENTRY-DETACHED ONE OR TWO FAMILY8.68C'v✓ELLiNGS -651 CAE ENOC -THREE STORIES OR LESS CA8.68 9.61 Are Admiralty or FELA higher limits of liability(25,000/25,000) []Yes No Factor being quested.re � Manual Premium 0 If coverage II,voluntary compensation selection: ❑USL&H []Massachusetts Waiver of Our Riqhts-No Employers Liability 9845-Standard Limits Deductible- None VII. DEPOSIT REQUIRED: Experience/Merit Rating MA Construction Credit- 0% 1.Installment Options Standard Premium Total Estimated Installment Deposit Additional ARAP Premium Basis Factor Payments QLMP% Under$5,000 Annually 1000% None Balance To Admiralty/FEt A Minimum Premium At Least$5,000 Semi-Annually 75% One Loss Constant 50 At Least $10,000 Quarterly 50% Three Expense Constant 159 At Least$25,000 Monthly 25°/(a Nine Terrorism Premium ,03 0 2.Is premium being financed through a premium []Yes ❑✓ No Premium Subiect to Total Policy Minimum Premium 120009 finance company? Total Policy Minimum Premium 3.Any binding of coverage is conditional until the electronic funds have Total Estimated Premiumcleared. If the electronic funds requested are denied,the employer will be given ten(10)days to provide the carrier with a bank check or money orderDIA Assessment 034for the full amount of the required deposit. 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