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HomeMy WebLinkAboutVINYL SIDING ON FRONT OF BUILDING t%oRTJ1 BUILDING PERMIT ,,FD 16 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION 4 Permit No#: Date Received ArEv SSAC Date Issued: fo" IMPORTANT: Applicant must complete all items on this page LOCATION /04\ Andcier Print, '3 Alocy, Andw4,018 PROPERTY OWNER 9,0. 3 c) Print 100 Year Structure yes no MAP PARCEL ZONING ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building [I One family 11 Addition [I Two or more family 11 Industrial N"Alteration No. of units: H [I Commercial FAepair, replacement 11 Assessory Bldg Li Others: 0 Demolition Li Other "S, E, ,01,111 1-MMI,11/11112 101, 8 ' �01 IN% mlva DESCRIPTIOOF WORK TO BE MVORMED: k) Er C(Vi o qA (Iu ,0h WAV o'i L ent fication- Ple e Type or Print Clearly i, OWNER: Name: hone: Address: Anciiac AA, c) )Lt Contractor Name: C xv( rTLc -qJ\ 'J Phone: mail:1. 6 Em (1114) ohca-�+k lye--t- Address: C) Affl-(Wadd LnnE - ,t1 e, S-, <D I P 4 q Supervisor's Construction License:CG 09 S3-73 Exp. Date: Home Improvement License: Exp. Date: ARCH ITECT/ENGI NEER Phone: Address: Reg. No. FEE SCHEDULE.,BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATEDXC ST BASED 01fl U 5.00 PER S.F. ("o , Total Project Cost: $ FEE o ac) Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund W,W/ 7 W. 1W -Z tkoRTH -w% dA--&ver town of - e :..7" An u ® t� O. _ 2m r0 LAKEWICK 11 ver ass' I� COCHICNC • ADQ•4TED S u mor— BOARD OF HEALTH AW IM Food/Kitchen P E I T L D Septic System m1i BUILDING INSPECTOR THIS CERTIFIES THAT .... .. Oill.... ........................... Foundation has permission to erect buildings on .............. ....................... ..... ... Mal.. ..... Rough p /� e—' to be occupied as ... Ul.l!1. . . ....l..u.. ... ...... ... ....f4 ... .ti�.. .............................................. Chimney provided that the person aepting this perm shall in every respect conr 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 E I ® TS ELECTRICAL INSPECTOR LESS CONSTRUCTI TS TS Rough Service .............. I. .... ......... ........................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Requiredto OecupV 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 Approvedthe Building Inspector. Burner Street No. Smoke Det. vnub w. Page# at pages 41 PROPOSAL SDRiatrtTED TO,, !JOR�NA:ME JOB# JOB LOCATION W DATE DATE Of PLANS PHONE If FAX# ARCNITEGT r Me hereby submit specifications and estimates for: ..... _ i d ,.�,,,_..,, �,,...,........................_. .. .,....._..,., _........: ., ,......,.,..�,., I w _ f ..._ l: fi n ._,-e propose hereby to lfurni h material and labor—complete in accordance with the above specifications for the sum of,,, M� p e ....... with payments to be made as follows: _ �tk � ,', , �w._... _ �, F tt I' Any alteration of deviation from above specifications ipuoM np extra coats Respectfully will be executed only upon written order,and will become an extra charge _- � 4-__...�__._ quer and above the nstiinete. All apreenrents usentingent ngpn strikes,kas„, accldents or dpi,,,s begond our 000#01 Note dbis proposal may be Withdrawn by us if not accepted within— clays. The above-prices,specifications and ttondihons are satisfactory and are hereby accepted, You are authorized to du the work asspecified, � Payments will be made as outlined above, gateof/cnePtanr�e_._..:. ._ Signature.w;,. IIr �J _ __ _ The Commonwealth of Massachusetts Department of IndustrialAceldents I Congress Street,Site 100 20X7 - d Boston,MA 021X9 r www•mass.gov7dia compensation Affidavit:Builders/Conti:actors/Electricians/Plumbers. ' Compens �i TING AUTbfOEI�'�Y. wpl kers To BE FILED WITH rHE FERMI ,Please Print Le 'bl A licant Information Name(Business/Organic ation/lndividual): i Address: - t (�„ S y`l Phone#: .. .; ,. 1 r 1 V Tape of project(xecluire]additiolas City/State/Zip: . you an employer?Checictiie appropriate box: 7. �]eva'coristruction Are y e employees(ut and/or part-til )' 8. emo deling 1,❑I am a employer with�- 2❑I azn a sole proprietor or partnership and have no employees working for me in 9 Demolition any capacity.IN oworkers'comp.insurance required.] p,insurance required.]" 10❑Building addition 3,E1 I am a homeowner doing all work myself.[No workers'coin be hiring contractors to conduct all work on my property. I will 11.❑Electrical gegaixs 4❑I am a homeowner and will 12M1L—�P1b jng repairsor ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. /� 13•,�Roof repairs 5 VT an a general contractpr and I ploy,, oe ed have workersetcomp{ulSurance ed oil the#ached sheet. 14 Other These sub-contractors have emp Y 6.❑We are a corporation and its.officers have o workes �comp their right required.tiOn Per]MGh o 152,§1(4),and employees.(N ensationpolicyinformation. their workers'comp *Any applicant that checks bbx#1 davit indicating th ysare domgiow showing hen of the sub-contractors and state whether or not those entities have out the all work and then hue outside contractors must submit anew affidavit indicating such. i Homeowners who submit•this affi the name, to ees,the must rovide their workerscomp.policy number. tContractors that check this box must attached an additional sheet showing em to ees. eloiv is the policy and job site employees. If the sub-contractors have emp S X am an employer that is providing-worers'compensation insurance for MY p y information. X y an Name: Insurance Comp Y 0 ° — - ration Date: ® — ` � Policy#or Self-ins.Lic.#: i C � A5 City/State/Zip: t otic number and expiratio date. 8 a e showing the p Y Job Site Address: , ensation policy declaration p g ( P a fine u to$1,500.00 Attach a copy of the workers comp 25A is a criminal violation unishable by P e as required under MGL C.152,§ Failure to secure covexag as sell as civil penalties in the form of a STOP WORK OR and a fine of up to $250-00a and/or one-year imprisonment, be forwarded to the Offica of Investigations of the DIA for insurance day against the violatox.A copy of this statement may coverage verification. e�.uj• that the informationprovided above is true and correct. der the sand penalties of p I @ y X do hereby ertify Date: Si afore: 3 � 140 Phone#: completed by city or town official. Official use only. Do not write in this area,to be PermitlLicense# City or Town: circle one): lt 4•Electrical Inspector 5.Plumbing Inspec or Issuing Authority( e artment 3.City/Town Cler 1.Board of p(ealth 2•Building D P 6.Other Phone#: Contact Person: �ecoRv0 CERTIFICATE OF LIABILITY INSURANCE 70T E61125(20MM/2015 'YYYY' 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). ACT PRODUCER 04963-001 NAME: MTM Insurance Associates LLC PaHic°Nrio,Ext; (978)681-5700 A/C.No.: (978)681-5777 1320 Osgood Street EMAIL North Andover,MA 01845 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURERA: A•I•M,Mutual Insurance Company 33758 INSURED INSURER B, Jason Nault INSURERC: 30 Forest Street INSURER D: Lawrence, MA 01841 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 CONTRACT OR OTHER DOCUMENT VV1TH 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. IMM TYPE OF INSURANCE "NSR SW�p POLICY NUMBER —POLICY—EFF MM/DD�YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMI ESESS( RENTED $ '.. PREMIEa occurrence CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL R ADV INJURY $ '.. GENERAL AGGREGATE I$ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG I$ OLICY ECT OC AUTOMOBILE LIABILITYEaIEDSINGLE LIMIT accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OV�i lED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS �_l NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ I UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ yyp I KDDEEERDgg ooMM�P1 RETENTION $ TH $ AND EMPLOYWT ABILITY X TORY LAMITS OER AWy PRkPR�E�p�/PARTNER/ ECUTIVE YIN E.L.EACH ACCIDENT $ 100,000.00 A oFFICERlNTIV ER EXCLUDED N/A VWC-100-6018002-2014A 12/6/2014 12/6(2015 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000.00 DESCRIPTION under below E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) The workers compensation policy does not provide coverage for Jason Nault CERTIFICATE HOLDER CANCELLATION Town of North Andover 1600 Osgood Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE N Andover,MA 01845 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 26(2010/06) The ACORD name and logo are registered marks of ACORD NOTICE INOTICE TO TO EMPLOYEES EMPLOYEES The Com monwealth 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 4O7O Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY VWC-1 00-6018002-2014A 12/06/2014- 12/06/2015 POLICY NUMBER EFFECTIVE DATES 1320 Osgood Street (978)681-5700 MTM Insurance Associates LLC North Andover, MA 01845 PHONE NAME OF INSURANCE AGENT ADDRESS 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 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. VWC-100-6018002-2014k PRIOR NO. VWC-100-6018002-2013Ai 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 ana 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 Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration j Premium II 1 INTRA 1045272 INTER SEE,CLASS CODE SCHEDULE j j Minimum Premium $500 Total Estimated Annual Premium $500 GOV GOV Deposit Premium $500 STATE CLASS MA 5403 State Assessments/Surcharges $.00 x 5.8000% $ This policy, including all endorsements, is hereby countersigned by 10/30/2014 Authorized Signature Date 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) , ��ie Lpan:rtt2�uuetz��Q�i?�Jrzc�iuJeC�d Office of Consumer Affairs&c puniness Regula j ME IflAPRPvENT CONTRACTOR e iatration g a 5, Type: �777 $ xpiration LQS Individual MICHAEL A. FARELLI MICHAEL FARELLI 9 APPLEWOO.V LANE METHUEN MA 01844 iUrd�rseci rarY Massachusetts - Department of Public Safety Board of Building Regulations and Standards License: CS-095373 %t MICHAEL A FARM. 9 APPLEWOOD METHUEN MA 8184 . x Expiration Commissioner 12/04/2016 M4 e s SPR �� oa 16D 12.03.20P'WD7 j 70A9 VIII, APPLICANT'S AGREEMENT application on its behalf; application,I certify that: to complete this app By signing this app� the employerlication;and (I) I am the employer or have been authorized by i I have read and understand the following statements to which I agree by signing this app ranee,I hereby certify,under the pains (i) of ints is true. nsu (III) All Information provided rg issuances of apNotice of Assignment and subsequent policy compensation in market; In consideration Of u that: h the voluntary MA workers'comp and penalties of perjury,rY MA workers'compensation insurance policy; health and 1. 1 made a good faith effort,but failed to obtain coverage through he m default of premium on any 2. lam not knowingly comply with all laws,orders,rules and regulations in force and effect relating t0 t eirecommendations for t I have complied and will continbut not limited to: ur ose of measuring the hazards,making safety of empi°Pees,including inspection of my operation for the purpose insured against; a. Allowing the carrier to make a carefuland determining the rate or rates which are adequate and reasonable; the health and safety of employees, providing the carrier with copies of those records when asked for them;and in with the carriers'reasonable recommendation um and pt vidin controlling or reducing the hazards s control purposes. b. Complying compute rem remises for los c. Keeping records of information needed to comp P premium audits or inspections of the p Pool coverage. d. Fully cooperating with the carriers'attempts to conduct p 12/5/2013 er's compliance with each of these certifications is material the issuance of assigned risk a of Application i understand that the employ Dat r Jason Nauit Title Jason Nauit Signature Business Name of Applicant t Original Signature For Printed Copy: In market. The NOTICE: the Massachusetts Workers' Compensation AssigneedaRissk Pool and not throug se the calmer to int ate a mid-term This insurance is being provided through2 and 3(a-d)may,to the extent allowed by employer's non-compliance with certifications 1, cancellation. FRAUD NOTICE: Section 14(3)provides: assists,abets,solicits or conspires of any in the Massachusetts General Law,Chapter 152, statement,representation or submission or fails to is false or misleading conceals ora amen dCovefage oor other benefit under this e of the `chapter; "(A)ny person who knowingly makes any resentation or submission,or knowingly age Des for the purpose of avoiding full purpose of obtaining or denYemployee leasing p imprisonment in jail for not less making of any false or misleading statement,rep to ees or engages in deceptiveboth such fine event affecting the payment,coverage or other misclassifies�assifies ehmp ye e_.,Iso;j for not mare ti an five years or by P and any person or employer who knowing e punished by impr:sonm�nt in th^-::Ut " be a fine of not less than one thousand nor more than ten thousand dollars,or y payment of insurance prem,u"" " than six months nor more than two and one half years or by and imprisonment:' that all information provided is true M G.L.the bC.162,Section 65A.ast of hlslher edge and IX.AGENCY INFORMATION AND PRODUCES STATEMENT peg ryEN market as required by The producer hereby certifies,under the pains and penalties belief and that helshe made a good faith effort to place the coverage m the voluntary Name of Agency 2Producer License if FEIN Mailing Address of Agencv Zip Phone NORTH State City PAUL J MACDONALD Producer Name Date Signature of Producer Original Signature For Printed COPY: 1 certify that I am the producer of record, applicant prior to his/her signing. licant,the Q By checking this box, application,with the app I certify that I have reviewed Section VIII of the app nal signs of the Massachusetts Workers Compensation Q By checking this box, lication as original signatures. I request, on behalf of the ap completed acknowledge the signatures to this app of the comp By checking this box, I hereby an to provide insurance in accordance with the p years designation of an insurance company is ori final signatures for a period of not less than five(5)y Risk Pool,and I certify that I have reviewed the agpplicant's responsibilities with the applicant and will retain a cop Assigned ircant's and the produce appiication with the app MASSACHUSETSURANC TS WORKERS' COMPENSATION ASSIGNEDRISKPOOL ONLINE APPLICATIONFORWORKERS Bureau of Massachusetts � COMPENSATION Processed By: The Workers compensation 101 Arch Street Requested Effective Date: 12/612013 Boston,MA 02110 Employer Email: 617-439-9030 electronic check. Coverage will not be Compensation Assigned Risk Pool Online Application OAR) must be made by application ass premium(s not received within two business days from receipt of the confirmation email sent once the Payment for the MA WOf payment or dep P e in force for the entity making provided if the correct pay prior has been approved and assigned. or, the applicant has an audit or inspection from a coverage be assigned if: the declination requirements coverage; there is a record o cove Under no circumst cantvis lin defaut of premium for prior workersapplicants failure to cooperate with the prior Insurer. application; the app incomplete due to the app workers'compensation policy that remains incomp after the application is submitted to OAR, applies for market and hereby pP represents that such insurance is sought in good faith. compensation and employers' liability insurance in the voluntary The earliest possible date coverage can be bound is at 12:01 a.m.the a The undersigned employer has failed to obtain workers' such insurance in the Massachusetts Workers'Compensation Assigned Risk Pooi and express y p I. GENERAL INFORMATION Name of Employ r Name the sole proprietor,general partners)or the trustees)along with the trade name of the business.) EMPLO Total Number of MA Locations: 111-01220— Federal Employer Identification Number(FEIN) Phone State ZIP City =Principal ress Phone State Zip City - 2 A Location City State Zip Phone Location of RecordsPhone State ZIP City Other Massachusetts Location Corporation Trust E]Limited Partnership ❑LLC Legal Status: Q✓ Sole Proprietor ❑Partnership [] ❑ []Other(Explain): Municipality LLP II. ELIGIBILITY REQUIREMENTS two (2) carriers licensed to To be eligible to obtain assigned risk coverage:assachusetts workers' compensation coverage must have been rejected by •The employer's application for voluntary io ee write workers compensation in Massachusetts; .The employer must not be in default of premium for Massachusetts workers'compensation insurance; lied with all laws,orders,rules and regulations in force and effect relating to the welfare,health and safety o emp rior workers' compensation policy that remains incomplete due to the employer's failure t .The employer must have comp and, inspection on a p compensation in .The employer must not have an audit or cooperate with the insurer. of discussion, and phone numbers of two insurance companies licensed to write workers' J. List the names,representatives, date(s) A failure to reach such a who has authority to bind coverage for the insurance company. Massachusetts who have refused to write voluntary coverage for this risk in the past sixty days. Each representative named must be an employeetion Date Phone Declination representative cannot be construed as a refusal to write coverage Full Name of Representative 800-852-6677 Name of insurance company 1210512013 Joseph Arthurs 1210512013 800-922-8246 Travelers Insurance Kristin McLaughlin []Yes ❑J No Hartford Insurance expired? 1 a.Has the employer's coverage,either voluntary or assigned risk,recently terminated or exp to er. da s,the cancellation or nonrenewal agar nonrenewed at the employee cancellation or nonrenewal notice must be attached,y,t the reason for the cancellation it nonrenewal must be indicate or Note:If Yes,a copy of the cant market within the past Y coverage was can the notice.If the coverage was in the vol untarylaced in the voluntary market if voluntary declinations. Generally, coverage must be rep request. F]yes ❑✓ No 2. Have you received any offers of voluntary coverage? Dyes ❑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? ❑Unpaid Premium ❑Premium Dispute ❑Payment Plan (Select most appropriate) If Unpaid Premium selected,provide: Balance Policy Number(s) Entity Name 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. ❑Yes ❑✓ No 4. Does the employer have any outstanding audits or inspections on a prior workers'compensation policy? If yes,provide the name of the insurance company and the policy number(s). Policy Number(s) Insurance Company ❑Yes ONO 4a. Has an audit been scheduled? If yes,provide the insurance company contact name and phone number. Contact Phone# Insurance Company Contact Name III.CORPORATE OFFICERS, SOLE PROPRIETORS, PARTNERS&MEMBERS ership and duties of all ,partners or members, For Sole Proprietorsees,t ng o e age.Sole rs,LLC Members and ILLP epi a Partons parList thand membel esa are not cove ed unless theypelect coverage.To elect coverage,a and indicate whether each s letter must su ante Ma ual,to the R tes Page with M scel aneous Val es,Rforgsolel proprietors'part ers and members'basis of prem upm nln Sect on V P Dyers Liability In include the Basis of Premium for all sole proprietors,partners and members electing coverage. rate Articles of For her eachihas chosenthe t exmpttitle, himselfownership, covduties erage n accordance with MA Regulation d actual salary of all listed 452 CMR 8.06 oCorporate officesOrganization beincluded unless ea whet .A copy of the DIA roved Form 153 must be Form 153 has application.ned to and approvd by the MA Department of Industrial Accidents Co porate officer salaries ies may be subject to payroll Imitations; refer to the MA Workers'pCompensaed and tion &Employee Liability attached to this Insurance Manual,Part One—Rule IX.In Section VI include the salary,subject to minimums and maximums,of all nonexempt corporate officers. Duties � Salary I 7iti, i%Ov:nersh:p I Electf Exempt 10,000 JASON NAULT SOLE PROPRIETOR 100 EXEMPT CONSTRUCTION IV. INSURANCE RECORD []Yes ✓ No 1. Has the applicant previously had Massachusetts workers'compensation insurance from a licensed insurance company? 2. If Yes,complete the following for the most recent three Years: Policy Period premium Insurance Company Policy Number From To 3. If No,complete: ✓❑New Business ❑Uninsured ❑Self Insurance Group ❑Self-Insured ❑Other(Explain): ❑Yes ❑✓ No 4. Was the applicant self-insured within the last twelve months or was the applicant's expiring policy subject to the Premium Endorsement— Determination Endorsement—Former Self-Insurers 1? If Yes,former self insurers who are subject t emi m Determination e Refer to the PoolrProcedumer fres forNew Applications rs I cannot lfor n online application through OAR.A paper application details. Former members of self insurance groups are not subject to this endorsement. ❑Yes Q No 5. Is the employer in bankruptcy? ❑Yes n,/ No 8. 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 F,/]No 8. Has there been a merger or consolidation within the last five years? ❑Yes Z No 9. Has there been a sale,transfer or conveyance of ownership interest within the last five years? 10.Did the applicant purchase or otherwise acquire the physical assets of another entity whose operations they took over within the last []Yes ❑✓ No five years? ❑ ❑No 11.Have the owners or officers ever had ownership interest in any other entity,either currently or previously existing? Yes 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? ❑YesJQ 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 n 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 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 Location Shift Class Code Classification Phraseology s Number of Estimated L Employees Remuneration/ Rate Premium H Exposure 1 1 5645 CARPENTRY-DETACHED ONE OR TWO FAMILY DVvELLiNGS 8.68 1 1 5651 CARPENTRY-DWELLINGS-THREE STORIES OR LESS 8.68 1 1 5403 CARPENTRY NOC 9.61 Are Admiralty or FELA higher limits of liability(25,000/25,000) ❑Yes ❑No Factor being requested? Manual Premium 0 If coverage II,voluntary compensation selection: []USL&H []Massachusetts Waiver of Our Rights-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 100% None Balance To Admiralty/FELA 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$25,000Monthly 25% Nine Terrorism Premium .03 0 2.Is premium being financed through a premium ❑Yes [�]✓ No Premium Subiect to Total Policy Minimum Premium 209 finance company? Total Policy Minimum Premium 500 3.Any binding of coverage is conditional until the electronic funds have Total Estimated Premium 500 cleared. 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 order DIA Assessment .034 0 for the full amount of the required deposit. Only if sufficient funds are Total Estimated Premium Plus DIA Assessment 500 received by the carrier on a timely basis,will coverage be effective as of the tentative binding date on the Notice of Assignment issued by the Bureau. Deposit Premium- Annual 100% 500 r 7y.�.KmdAv.P-cr..KmmRvr911m+tNrr3rs �� � ARS Restoration Specialist {: ly �` 38 Crafts Street Newton, MA 02458 z Phone (617) 969-1119, Fax (617) 244-1115 F Certificate of Attendance & Successful Completion Lead Safe Renovator Supervisor - Refresher Per 454 CMR 22.00 Michael Farelli 9 Applewood Lane Matthuen, MA 01844 -- Certificate Number:'R-R-48693-15-00053 Course Date: 04/22/15 Examination Date: 04/22/2015 Expiration Date: 04/22/2020 �V L—1'2 L ask. r Training Manager/ Principal Instructor Date r y