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Miscellaneous - 60 Water Street (3)
goo waka s4� "w-ti r**v o 5 �z��jt� � i � ��"turn�--,�. C° r---- -_-__�----�-�_ ` �"-- ��- � � [ ��� � ��� � � � .� � ti,�� -, ���� G��,r�. � - 1 Date.4,7..... .. .................... . a OF r►ORTly,� TOWN OF NORTH ANDOVER 0 ��,, 9 PERMIT FOR WIRING s`SgCNUS� c 4ch e._ (�)be P c . Thiscertifies that ............................................(..-......................................_...... ............................... has permission to perform �'': .e '#"'i_ ��...... �T ............................. wiring in the building of....... �� ........L--�-- .......................:... ........................................ Pbbc- at ......... ....: �............ .................. ...........:...............,North Andover,Mass. A? lgz,-/� Fee. 31.....""......Lic.No. .�y...�.. e ELECTRICAL INSPECTOR c Check# 61 i Commonwealth of Massachusetts Of se Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ev. 11/991 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: June 01,2015 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number)4 HIGH STREET Owner or Tenant RGC-LLC Telephone No. 617-625-8315 Owner's Address 17 IVALOO ST SOMERVILLE Is this permit in conjunction with a building permit? Yes ❑✓ No ❑ (Check Appropriate Box) Purpose of Building DWELLINGS Utility Authorization No. NIA Existing Service 3000 Amps 480 /277 Volts Overhead❑ Undgrd ✓❑ No.of Meters 1 New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity 2-400A&17-150A Location and Nature of Proposed Electrical Work: Completion of the followin table may be waived by the Ins for of Wires. No.of Recessed Fixtures No.of )Fans Paddle Ceil.-Sus . No.of Total p ( Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures 160 Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting 12 rnd. grud. Battery Units No.of Receptacle Outlets 309 No.of Oil Burners FIRE ALARMS No.of Zones of No.of Switches 85 No.of Gas Burners No.InDetection and 26 Initiatin Devices No.of Ran es 17 No.of Air Cond. Total No.of Alerting Devices 28 g Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Detection/Alerting Self-Contained 51 Totals: 17 Devices 1! No.of Dishwashers 17 Space/Area Heating KW Local El Municipal ✓❑ Other Systems: Connection No.of Dryers Heating Appliances KW SecurityNo..of Devices or Equivalent No.of Watero.of No.of Data Wiring: Heaters 17 KW 2.4 Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: 17 No.of Devices or Equwaient OTHER: Attach addmonal detail if desired or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND Q OTHER ❑ (Specify.) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) f Work to Start:06/15 Inspections to be requested in accordance with MEC Rule 10,and upon completion. I cerWfy,under the pains and penalties ofperjury,that the information on this application is true and comp FIRM NAME: PHOENIX ELECTRICAL CONTRACTORS,INC. LIC.N&;A1 6 Licensee: MICHAEL COVEL SR. Signature LIC.NO.:33486 (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:97as94-w9 Address:210 ANDOVER STREET SUITE#22 WILMINGTON,MA 01887 Alt.Tel.No.:978{949030 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $3 3 i i Signature Telephone No. t �. '� c/ �� >� �� �f���� --�� -moo � �� ����� _SI�'-.� �.'��� �''� 710 01.E- PHOENIX ELECTRICAL CONTRACTORS INC. 210 Andover Street Suite#22 Michael Covel Wilmington, MA 01887 Office-978-694-9949 mcovel@phoenix-elec360-.co 1 Fax-978-694-9030 978-360-2431 phoenix-electrical.com ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): p—A 0 e-Alf)( e c—Yr-, "C,i L 4fe .� f 1A C'�'v!r 7 C_ Address: ;2 fy A,doyle— Vt City/State/Zip:VV lwl,eiy4® J /A 9-0 i Phone #: Are y _ !y-an employer?Check the appropriate box: Type of project(required): 1.Nrl am a employer with 15 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. # ©modeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑ Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit,indicating such. +Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. / Insurance Company Name: Policy#or Self-ins.Lic.#: VV C D 9-Z 57// 4 Expiration Date: -71-2-7115, ''`` &/, A 1 '?s ve Job Site Address: y Hr City/State/Zip: ,1VW A 0/k4/ 75 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u the pains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: Phone#: 9-7 P q c j el 9 of Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i F ti �4 High Street 17 Condos ,Address;,. w Building Electical; " Plumbing/,,.6 Notes r` F� 1 Rough e .,.. . . Final 2 Rough Final 3 Rough . °. Final 4 Rough Finala x z5 Rough Final 6 Rough Firal 7Rough. .. Final 3: 8 Rough Final Final 10 Rough Find {, 11 Rough ' . Final 12 Rough Final 13 Rough Q as �. � ,x Final 14 Rough sv Final � _ . 151:R6 ug h Final Building . tea„ Electricaly. Plumbing/Gas Notes 16 Rough Final - „17 Rough Final t F v q WKn, Immw r K � h.e c ter" Date./,. 11159 of"opT"'tie TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING g$AC14U This certifies that..............`A4 Vf 1j has permission to perform...... ...... ...................... ........... ............ ....... plumbing in the buildings of.... AS 4-0 at...............I................ ........ h* Andover, Mass. ' F031740 L ...... ........................ ..................Lic. No. PLUMBING INSPECTOR Check I p 3-/1qo r� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY ofZ - c% _ MA DATE11PERMIT# JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ED ATIONAL © SIDENTIAL PRINT CLEARLY NEW: Rf RENOVATION:El REPLACEMENT: LANS SUBMITTED: YES® N0© FIXTURES Z FLOOR- BSM 1 2 3 5 6 7 1 8,A 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM _—k -f_ k —k __. ( A € DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM -_--,._._I ___._( _._ __,i if -_......_f DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER k ..__._._.1 ._ ._._ F-4-,--1 E :1 FLOOR IAREA DRAIN r __--..�-__.1 ._-[---i INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE MOP SINK TOILET €I �I URINAL ___-_._k ___._._f WASHING MACHINE CONNECTION WATER HEATER ALL TYPES t7vd ,'c ==Mj= WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES B""NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY [] BOND D OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT IE SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my k wledge. and that all plumbing work and installations performed under the permit issued for this application will be in compliance withA] rt! n vis! f the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMELICENSE# -SIGN TURF IMP JP�k CORPORATION # _(PARTNERSHIP _I#®LLC COMPANY NAME ,,/�� �F / �; ADDRESS CITY l.�n� `. . t STATE /tel _ ZIP �j'.� �` -� _ ^fl TEL ?Cc FAX o?fs' 6 CELL , EMAIL _._c31_.79c ..__i ROUGH PLUMBING INSPECTION NOTESW NOTEBELOW FOR OFFICE USE ONLY FINAL INSP CTIONAfoTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ '77 FEE: PERMIT# PLAN REVIEW NOTES z g . s m w 1 4 tea. 7 R� The Commonwealth of Massachusetts M Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERIVHTTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): �j���/ps� � Address: City/State/Zip: Phone (Ppo 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. Q 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.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑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. I .0 Roof repairs These sub-contractors have employees and have workers'comp.insurance. LJ 6. -a 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. A i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,'they must provide their workers'comp.policy number. fain an employer that is pioviding workers'compensation insurance for my employees.'Below is thepolicy and job site information. Insurance Company Name:.. /4 Policy#or Self-ins.Lie.#: ��Q 33 5-3 Expiration Date:�fJ Job Site Address: �/ 1115,17C5-1 V A ,R c ams 4_' City/State/Zip: /4�4 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. Ido hereby certify under the pains and penalt'esof pe cry that the information provided abov-e-lis true and correct. Signature: Date: 5� /' Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract'of lure, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of 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(7)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 certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents foi confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In 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 oran ermit not related to business or commercial venture p Y (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-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia fy� ♦Ju MONW kid EALTH pF MASSACIp!( S ETT$ A R.0;, i ♦ <. PLUMBERS. ' GASFITTER ISSUES THE FOLLOWI Cd:G L t"CENSE i L It" ENSEt) AS A ,MA-. TER PLU E� � =1 MICHAEL J SAINOON"' PAGE f.. RTE l 1 o N;H 03848 3444 <COMMONWEAi-TH OF M°ASSAGI-NS.EICT 0 $ � ®. '�Il 11114WBOAfta Of PLI;MBEFtS A1�1D G1aSF1TT�L4� � , h ISSUES .L'iCFi�SC VA '; f S t1�16.i1Y"c R?, r Rrsl STR1+0 AA P Lr �l Mt?1AtL J SA I NDQN : cls fM1o757 ICU)ME ' t PAGE AT: 4 1 �� 03848 3444 4°t NGSY'ON 2 14 2 2 0 01. l.fi CERTIFICATE OF LIABILITY INSURANCE F DATE 6/4/2015YYY) 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 CONTACT Lori Rotonnelli NAME: FAX Noyes Insurance Agency Inc PHONE AIC, . (603)536-1735 A/C No:(603)536-4298 P.O. Box 420 ADDRESS:lrotonnelli@noyesins.com 63 Main Street INSURERS AFFORDING COVERAGE NAIC# Plymouth NH 03264 INSURERAESSex Insurance Company INSURED INSURERB:PeerleSS Insurance Company 4198 Kingston Mechanical, Inc. INSURERC: One Page Road, Rte 111 INSURER D: INSURER E Kingston NH 03848 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1411703695 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 EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DDNYYY MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A CLAIMS-MADE r X1 OCCUR 3DT3553 10/1/2014 10/1/2015 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO LOC $ MBINED AUTOMOBILE LIABILITY COSINGLE LIMIT Ea accident 1,000,000 ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED CBP8997364 10/1/2014 10/1/2015 BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ X HIRED AUTOS Ix AUTOS D Peraccident X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000 DED I I RETENTION$ PXS00003274 10/1/2014 10/1/2015 $ B WORKERS COMPENSATION WC STATU-Ts OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE[1] E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A C8994353 10/1/2014 10/1/2015 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Michael Sandoin and Thomas J. Troy Jr. are listed as excluded under Workers Compensation Coverage State: NH CERTIFICATE HOLDER CANCELLATION (978)688-9556 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Water & Sewer Dept. 120 Main Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 Lori Rotonnelli/LAR ory ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 rgninn.F)ni Tho Art')Pn nnmc nnrl Innn arc rcnicfcrcfl marlrc of Arr)pn 4 High Street 17 Condos Address; Building. � ,','Electica Plu b Gas"� 1\1'6_tbs. R'640gA Final 2 Rough Final-- I Rough Final S4 4 Rough F*j I _ 5, O'Ug h Final 6 Rough 14 Fiba'l v 7Rough ough Final 8 Rough Final .9 ROUg Final 10 Rough Final" , " 11 Rough Final 4 3 12.Rough inal 1-3 Roug, 2,' Final 14 Rough Final 15[Rough Final �r. .� BuildinElectrical: rs .n Plumsl?ing/Gas' Notes �.. 16 Rough Final 17 .Rqugfi �> Final - w r r w � £ rA� T✓ 3 uro Y a w Date.... ..�I ...1...�............. OF Nowrh,� t; TOWN OF NORTH ANDOVER o s PERMIT FOR WIRING s3�CHU9E f ...... ....... .�............ . Chis certi£es that .... ...... ... . .... � , ............................... has permission to�erform ........................................ �u /� p/ Q wiring in the building of........l t .0..S-..... f/(S ............................................................... at ..........., �../ .. J� ,�Na h Andover,Mass. {.. ............................. ......... Fee ..,.......L c.No. I/EP K� ..... .................................................................. f{ / ELECTRICAL INSPECTOR Check 4t 12951 -/ elmmonwea&of Wamachujet foci I tJs Only Acc�� Permit No. partment ol5ire Sewicej Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/07] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC ,52 MMR 12.00 (PLEASE PRINT IN INK OR TYPE LL INFORMATION) Date: / p /S City or Town of: TYPE 411gie! To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street&Number) ,?�,,?•� -- Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building RE'.S'Ide,Eh l Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 6VJlAS4VII A46+ 2 fb01 t f f 62 Completion of the,following table inay be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ _No__.of Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pum Number Tons KW No.of Self-Contained Totals Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers. Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of WaterK� No.of No.of Data Wiring: Heaters Signs Ballasts I No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP TelecommunicationsWiring: No.of Devices or Equivalent OTHER: Attach additional detail ifdesired,or as required by the Inspector of Wires. Estimated Value of EI ctri at Work: 00 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: M48donp, ' LIC.NO.: l l Licensee: 6 � ' )� Signature LIC.NO.: ),O fO r (If applicable,enter xempt"in the license number line.) Bus.Tel.No.:710-1y2^2727 Address: / kQn ,14A 021510 Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Department c Public Safety"S"License: Lie.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑ owner's a ent. Owner/Agent PERMIT FEE: $ . LIM ' 00 Signature Telephone No. o ►����-1�5 12-P (rA bJ rrv,l The Commonwealth of Massachusetts PrintForm Department of Industrial Accidents Office of Investigations „ ki 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyibly Name (Business/OrganizatiorAndividual):NARDONE ELECTRICAL CORP. Address:100 WINCHESTER ST. City/State/Zip:MEDFORD, MA 02155 Phone #:781-391-2727 Are you an employer? Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 100 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' Y p Ty• 9. E] Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10. ✓❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other 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. 2Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees;they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ABC MASS WORKERS COMP SELF-INSURED Policy#or Self-ins.Lic.#:ABCMA00104815 Expiration Date:01/01/1.6 Job Site Address: HIGH ST. City/State/Zip. ANDOVER, MA Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the gains and enalties o er'ur that the in ormatton provided above is true and correct. Si nature: —. ��"�`�' r -- - a Date: Z _ Phone#:781-391-2727 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#: r Please visit our web site at http://www.mass.gov/dpI/boards/EL �a NARDONE ELECTRICAL CORPORATION STEPHEN J NARDONE (EL) 100 WINCHESTER STREET MEDF.ORD MA 02155-6451 Fold,Then Detach Along All Perforations w. COMMONWEALTH OF.;MASSACNUSETTS BflARD'QF ELECTRI:GIANS 11.'SSUES THE, FOLLOWING L1 CENSE AS R04SRED ,MA TIESTER ELECTRICIAN .�' NARDONE EL.ECTR1CAL. COR'PORAT'ION STEPHEN J NARDIONE :W 100. WINCHESTER STREET iU t1E,600 MA 02155-6451 11691 A o7%31/lb 81221 r Please visit our web site at http://www.mass.gov/dpl/boards/EL STEPHEN J NARDONE (E L) 100 WINCHESTER STREET MEDFORD MA 02155-6451 Fold,Then Detach Along All Perforations es COMMONWEALTH OF AMASSACHIJSETTS BOARD OF EL:ECTRIC`IANS ISSUES THE FOLLOWING I .iCENSE ' AS A k'iG JOURNEYMAN ELECTR ICIA STEPH.EN ,J NARDONE 100 WINCHESTER STREET �r1 o MEDFOR`D Ma oz155-6451 z5390 E 07`/31116 81222 o ,. Client#: 1009426 NARDOELEI ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)12/29/2014 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 NAME: Kathy Wagner USI Insurance Solutions, LLC PHONE 413-750-4222 FAX 610-537-9481 AIC,No Ext: AIC,No 123 Interstate Drive E-MAIL ADDRESS: ywa kath ner usi.biz g West Springfield,MA 01089-3600 INSURER(S)AFFORDING COVERAGE NAIC# 855 874-0123 INSURER A:ABC Mass Workers Comp SIG 99999 INSURED INSURER B: Nardone Electrical Corporation INSURERC: 100 Winchester Street INSURER D: Medford,MA 02155 INSURER E 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 CONTRACTOR 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 EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISESOEa occurrence $ CLAIMS-MADE 7 OCCUR MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY JECT LOC $ MBINED SINGLE LIMIT AUTOMOBILE LIABILITY (CO, Eaccident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION ABCMA00104815 1/01/2015 01/01/2016 X WCSTATLIMIT OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1000000 OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Proof of MA Workers'Compensation Coverage CERTIFICATE HOLDER CANCELLATION North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 124 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S14008587/M13900047 GZYZP ACCO 111/5/CERTIFICATE OF LIABILITY INSURANCE D /5/ 'DD'Y2015 5 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 6ERTIFICATE 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 CONTACT Michael Bonacorso NAME: Bonacorso Insurance Agency, Inc. PHONE (781)937-3200 a/c No:(781)937-3202 10 Cedar Street E-MAIL ADDRESS:michael@bonacorsoins.com Unit # 32 INSURERS AFFORDING COVERAGE NAIC# Woburn MA 01801 INSURERA:Travelers Indemnity Co. 25658 INSURED ID 613875 INSURERS Travelers Property Casualty Co. Nardone Electrical Corporation INSURERC: 100 Winchester Street -INSURER D: INSURER E: Medford MA 02155 INSURER F: COVERAGES CERTIFICATE NUMBER:15 / 16 Master 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 MM/DDPOLICYIYYYY MEFF MIDDYLICY EXP LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO X COMMERCIAL GENERAL LIABILITY - PREMISES Ea oc u RENTED $ 300,000 A CLAIMS-MADE FX OCCUR T-CO-1063P565-IND-15 0/31/2015 0/31/2016 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 X CONTRACTUAL LIABILITY GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO LOC $ AUTOMOBILE LIABILITY Ee aBINEDISINGLE LIMIT 1,000,000 B X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED T-810-1070P833-COF-15 0/31/2015 0/31/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X AUUTNOSWNED Parracad ntDAMAGE $ $ I X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I X I RETENTION$ 10,00 TSM-CUP-1718P630-TIL-15 0/31/2015 0/31/2016 $ B WORKERS COMPENSATION The WC Policy Below is X I WCSTATU- 0TH- AND EMPLOYERS'LIABILITY DRY LIMITS I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN - or locations outside MA. E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? NIA rNUB8DO9344615 0/31/2015 0/31/2016(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If Yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 A Leased/Rented EquipmentDT-CO-1063P565-IND-15 0/31/2015 0/31/2016 LIMIT $250,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF NORTH ANDOVER 124 MAIN ST. N Andover, MA 01845 AUTHORIZED REPRESENTATIVE Michael J. Bonacorso ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INSn25 i9n1nns)m Tho A(inPn nnma and Inn^aro ranictararl manta of ArC)I Il '�..�,.:s minx:.."s►a+e�!O - J// _ _•_ _`�-iM.-'-..�.t.:�'nFit�'-M.!«cr-,.-.-iTew.;r,as��..r- 1-Y.w. Location No. Date . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# <, -: Buiing Inspector Commonwealth of Massachusetts Sheet Metal Permit Date: z "I Permit# Estimated Job Cost: $ M73-0010 Permit Fee: $ Plans Submitted: YES NO Plans Reviewed: YES NO Business License# Applicant License# Business Inform4tion: Property Owner/Job Location Information: Name ,,c .C�yp� �iy '/kms ' Name: 411111. Street:�/�� Il'�jp'„� -;rw �'J� irNw �� Street• City/Town: r�,+ a - /;? (9/f'4?1 City/Town:/,/hr Telephone: �e' C� Telephone: Photo I.D.required/Copy of Photo I.D. attached: YES X NO Staff Initial J-1 /M-1-unrestricted license J-2/M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft./2-stories or less Residential: 1-2 family Multi-family Condo/Townhouses_Zt� Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: Renovation: HVAC 7V—. Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: s INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yest No❑ If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A liability insurance policy-kl Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Ch ck One Only f 1� Owner Agent ❑ r Sigture of Owner or Owner's Agent By checking this box❑,I hereby certify that all of the details and information I have submitted for entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Progress Inspections Date Comments Final Inspection Date Comments Type of License: By ❑Master zz ,Z::::, Title ❑ Master-Restricted 041 4, Citylrown ❑Joumeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: Fee$ ❑ Check at www.mass.gov/dpl Inspector Signature of Permit Approval f ' II I mASSAC'H_USE.TTS DRIVER'S •,_ LICENSE O6S) 4."Da END 4d NUMBER ' "MmO4,2e�14k NONE. S22194651"'I IXp� -�Lo1-8 3 DDB' 1,F .,..„�,.VA—.qp.-1VQ,- 1 . 08-18-J9 0, ISM g 1ssoXMy1711 s LAND WILLIAM C III 615 CLEVELAND AVE WILMINGTON,MA 01867.4316 5 DD 01.06.2014 Rev 07.15-2008 COMMONWEALTH OF MASSACHUSETTS A � o o • o o BOARD OF SHEET/METAL WORKERS [ ISSUES THE FOLLOWING LICENSE ASA" BUSINESS WILLIAM C.GOODLAND CONSTANT TEMPERATURE SYSTEMS INC 13 ALEXANDER'ROAD .. BILLERICA,MA 01821 588 06/04/2017 1113 • e o:COMMONWEALTH OF MASSACHUSETTS I ...c3u,MINDo • • o o 13GAR©OF SHEET METAL WORKERS { ISSUES THE FOLLOWING LICENSE' ` AS .A `MASTER UNRESTRICTED W1 L`LJ AM C GOODLAND 15 CLEVELAND AVE J �, .wiLMINGTON. .. MA 01887-4316 t The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Avolicant Information Please Print Le ibl Name (Business/Organization/Individual): c z� �inr' /-�-{, j/� J f C� tom/ Address: l ",Old' delc�Ji �D City/StatelZip: �z'fT Z� Phone#: r�� r ;�"TV Are you an employer?Check the appropriate box: Type of project(required): 1.M I am a employer with t employees(full and/or part-time).* 7. ❑New construction 2..``❑]I am a sole proprietor or partnership and have no employees working for me in $,Memodeling any capacity.[No workers'comp.insurance required.] 3_❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.E]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.t 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. ;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 1/6 Policy#or Self-ins.Lie.#: 16,Q�. /:�/')'!��� Expiration Date: 0(64-10 Job Site Address: `T /7`Ir'F'� v�� � 1/ - ''4� City/State/Zip: /(?y�ywJi/tet!f 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. Ido hereby cer fy unndder the sins andpenalties ofpeijury that the information provided above is true and correct. Si afore v '/✓-�`'� Date: Phone#• 9 lf_ J 7 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#: