15 BRADFORD ST - BUILDING APPS a� The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
:yd Revised Mar 2011
Building Permit Application"ro Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only O - 27"
Building Permit Number: Date Ap d:
—": ,
Building Official(Prim Name) Signature Date
SECTION I: SITE INFORMATION
1.1 Proper A rlss^ 1.2 Assessors Map&c Parcel Numbers
I.I a is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq h) Frontage(ft)
L5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2. caner'of Reco}I:
_ e Jv e )
Name(I,', q City,�Slate,,ZZIP
�g _
Ism /s rJ 1� �2tR-q'2 2s77S
No.and Street l'elepl one Ismail Address
Q SECTION 3: DESCRIPTION OF PROPOSED WORK'(chec all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Id I Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': 1.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ LaC) I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard Cit flown Application Fee
2. Electrical $ 6)� ❑Total Project Cost'(Item 6)x multiplier x
CIA3. Plumbing $ U v, 2. Other Fees: $
( ���•�
4. Mechanical I IVAC) S List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
/'L Check No. Check Amount: Cash Amount:
1 ' 6. Total Project Cost: $ Q V�j ❑ Paid in Full ❑Outstanding Balance Due:
i:, ,)L-L 0 M C Qt,-'!rq�--A G -D e, S 12�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor 1 ic�ense(CSL) q�`�G
/y,q��'� lL.icense Number L F pimtio Date
Tonne of CSL f older t��r
����� r7 � List CSL Type(see below) (i
No.and Street TYPe Description Unrestricted(Buildings up to 35,000 cu. ft.
do ✓ /I/ l/ / / of Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
n WS Window and Siding
im a /y6 SF Solid Fuel Burning Appliances
Insulation
Telephone Email ad ess I Demolition
5.2 Reg
istered dome Ira rove/m�ent Contractor(HIC) �0 6 9
i( HIC Registration Number F,x ration Dale
f IIC Co pary Name or HlC Jthgis r.�tl�ame � � � / �� / C /y
k reet Emmil address
✓J �' sad'
Cit City/Town State, IP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issua nee of the building permit.
Signed Affidavit Attached? Yes .......... 01 No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
/ rr
A?d� 0:✓ r On/<'
Print Owner's Name(Flecuonic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, i hereby attest under the pains and penaltids of perjury that all of the information
Wconin this application is true and accurate to the best o kn ied understanding13
/ G �. �n S o' ?r's or Authorized Agent's Name('Fleciromc Signatu ate
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.nmss.Cov/oca Information on the Construction Supervisor License can be found at www.ntass.eov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.)_ Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number ofhalf/baths
Type of heating system_ Number of decks/porches
Type ofcooling system _ Enclosed Open
3. "Total Project Square Footage"may be substituted I or"Total Project Cost"
CITY OF S.UL Em AG S&. CHUSETTS
BCILDLNG DEP:1MLENT
120 WASHNGTON STREET, YO FLOOR
Tt.L (973) 745-9595
F.LX(978) 740-9844
KI1tDERLEY DItlSCOLL
N LAYOit T lgo.%tU ST.PmjM
DIRECTOR OF Puxx PROPERTY/aL:MDLN(;C010115SIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CmR section l 11.5
Debris, and the provisions of NIGL c 40, S 54;
Building Permit !t is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by ,NIGL c
l 11, S 150A.
The debris will/be transported by:
(name o auler)
The debris will be disposed of in
(nano t'acdity)
l d
(aJJrass of taeili y)
!ynarure u(permit applicant
aCITY OF SM-EM, NL- SSACHUSETTS
BUILDING DEPARTNI INT
120 \' ASHLNGTON STREET, 3'a FLOOR
TEL (978) 745-9595
F.kX(978) 740-9846
KINBERLEY DRISCOL-L
IVLAYOR THO6IAS ST.MuE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONNISSIONER
Worlcers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Informatinn A I Please Print Legibly
V81nc tiiusinessorganizatiom'I fivi(tual): G
Address: Ike-
city/state/zip: / /�/67//l✓�� Phonelt:_
Are you an employer?Check the appropriate box: 'type of project(required):
I.❑ 1 a a employer with 4, ❑ I am a general contractor and 1 6. ❑New construction
upinyees(full and/or pan-time).• have hired the subcontractors
I atn a sole proprietor or partner- listed on the auachcd sheet.t 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity, workers'camp. insurance. y, ❑ Building addition
INo workers' comp. insurance 5. ❑ We are a corporation mid its
required.) officer have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 ram a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. [\o workers' comp. C. 152, §1(4),and we have no 12,❑ Roof repairs
insurance required.) t empluyees. (No workers' i3,[I Other
camp. insurance required.)
•Any applicant nut chvvks bus Y I must alsu all out thu section below showing their worken'curn"nuoun puticy intlrrnnatiun.
'I fomeown r who submit this affidavit indicating they am doing all work and then hire outside contractors most auhmit a new o r.davil indicting such.
:Pomnwwn shut cheek this bus must anachd an addidurui sheet showing ow name of the sub.contncton sod their worken'Gump.pulley infumtmien.
I ran can employer drat is praviding workers'carupetssadan insurance for my eaployees. Below Is die policy and fob site
information.
Insurance
Policy g or Srlf-inei, Lic, N: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expirarlon 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 S1,500.00 and/or one-year imprisonment,as%veil as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S23000 a day against the violator. Ile advised that a copy of this statement may Ix:I-urwarded to the Of Lice of
I nvtst igat ions offhe DIA for insurance coverage vcri ficatiun. -
i du brreby err in or a pa is rat no irs of perfury that the infurrnadna provided ahhuva is rue and correct
at
Phone rJ:
o/licial use only. Do not wrile in this area, tube conspleted by city ur town ofJFciaL
City or l'usvn: _._ __ Pcrmit/Llccnsc N
Issuing Aulhurity (circle one): -�—
I. hoard of Ilealth 2. Building I)epartutent 3.Citylrowu Clerk 4. Flectricai lospecltr 5. Plumbing Inspecror
6. Oilier -
Contact Person:____. Phone
"'��Yrwi.•ww�w. vd;y� L-cw�56."eM1Xii:[, xx
V/te�rnwmantue�e�to�C�/l�,(rWac�adelL1 'f '
Office of Consumer Affairs&Business Regulation {
VC
ME IMPROVEMENT CONTRACTOR
gistration 118039' Type,
piration /-1/20/2166 Individual.
MICHAEL G. HONAN
MICHAEL HONAN
47 SHERWOOD AVE
DANVERS,MA 01923 Undersecretary-,' dersecretary',,
VMassachuseits -Department of Public Safety
V Board of Building Regulations and Standards
Construction Supervisor
License: CS-083668
MICHAEL G HOI�XN
47 SHERWOOD AVEJ c
DANVERS MA 019231
r.• _ J�,,, � � '� "'�� Expiration,'
Commissioner 07/23f2014,
r,
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
`' I G m Wilbraham y Massachusetts State Building Code, 780 CMR, 7 edition
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One- or Two-Family Dwelling Ext 118
This Section For Official Use Only
Building Permit Nuinb Date Applied:
Signature: 10 ' O
Building ommissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
�l3ex)n fee 0 �,eyeJ _
I.Ia Is this an accepted street?yes no I Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use. - Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
pD •P4taa'� Poo/e cs � la� (oR� S S�h�, mr� o iG7n
Nam P intT Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ I Existing Building W'Owner-Occupied 2l Repairs(s) ❑ Alteration(s) &I Addition ❑
Demolition Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:_
Brief Description of Proposed Work': Pnl(S r R i-f y)4 f i i -�C he A/
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical g 3 ❑Standard City/Town Application Fee
ozYJ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $,5 rrJ� 2. Other Fees: $
4. Mechanical (HVAC) $ List: r
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $� a�7 0paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) f`
License Number Expiration Dale
Name of CSL-Holder List CSL Type(see below)
Type Description
Address U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted I&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address ---- --
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
1, /( y j"(O0 / -e- ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf. ( /
16OJc ---
Print N-me
Signature of O r or Authorized Agent Date 7 0
(Signed under the pains and penalties of perjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
Cr p
�f� L�1p1f�1/6�1}N�1fp6*�`jB�/E�� /� g� NO OVER BY T44E
d'' dl+Yilr'�."J.iM7 I` YyA F .F7dr+�•1a GRANTED
ED r .:
1 CITY OF SM.EM
No.\1 `1 k V Data J a
Is Property Located in Location of No Historic District? Yas_No " saiTding is Rrm%' MI!IT'
It Property located In
Ure conservation Area? Yes_No�...
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair eplace, Other: �os�ins
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name Mari N00%
i tiakbf� s /8 , 0 37
A�ress & Phone
Architect's Name
Address & Phone L )
Mechanics Name Ella! e
Address & Phone I/ )W,dj/z RI efe44,J >f/& (gig )
' h«7
What Is Una purpose of b MbV? s 7=�e /�s,�e•�c� ; �.
tilatedal of Ixrlldbq? I a dw@&V,for how many Inman?
WN txr kIM cordomt to law? Asbestos?
Eatimated cost. aN Umm r N A state tkarrae'o 01A6 770 .
Homo Improvement
Signature of Applicant
SIGNED UNDER THE P6#*ft
OF PERJURY
DESCRIPTION OF•WORK TO BE DONE lIJ
`: RZ,po,/rS OH GX157//!L7'�r�Yles ill=yearJ�ae Gn�d/rins', r� �!� /Ty�i�.rntr �� I
1
i nll�il �I �I �
t _
� M �
I I
MAIL PERMIT TO: 0 ti'n '� �wl��attt,
No
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
t/ O�c9 Lf Zd9 �
APP FD
G
INSPECTOR OF BUILDINGS
MR
� The Commonwealth of Massachusetts
/ CITY OF
�. Board of Building Regulations and Standards
Massachusetts State Building Code, 730 CMR SALEb(
'`. I� � Revised iLfar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelling
Ch s Szction;For'Official Usti Only.
Building Permit Number; Oafehed Z'
Building Official(Print Name) Signa re Date
SECTION L SITE INFO VIA
1.1 Pa ss r y 1.2 Assessors t ap 3c Parcel Numbers
I.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION2:, PROPERTY'OWNERSHIPL
2.1f�wg er of ecor
/t o � VW/Grt/ Alwe sal M af/9/ 9 C)
Noma(Print) Z A�,-Z 'r7'-, City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WOR V check all that.apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': o P
SECTION 4: ESTINLaTED CONSTRUCTION COSTS
Item Estimated Costs: Official Use 11 Only
Labor and Materials
L Building IS d 1. Building Permit Fee S indicate how fee is determined:
Electrical j ❑ Standard.City/Town Application Fee.
2. ❑Total Project Cost]_(Item 6)x multiplier x
3. Plumbing 3 2. Other Fees: $
i. Mechanical (HVAQ S List:
5. Mechanical (Fire 5
Suppression) _ Total All Fees: .S
Check No. Check A1110t1nt: Cash Amounti
G. Total Project Cost
tJ Paul in Pull 0 Outstanding 13oLutce Duo:
L
SECTION 5: CONSTRUCTION SERVICES
5.1 onstrt 'tion Supervisor License(CSL) /� � 0 6 g ,a,l
•G Gt 'M License Number_ Expiration Date
Name of CSL I[older
List CSL Type(see below)
No Street TY a Description
Unrestricted(Buildings up to 35,000 cu. 11.)
Restricted lac? Flantly Dwelling
Citylfown, State,ZIP iI Nlasonr
RC Roofing Coverin
_ WS Winslow and Siding
r 9s SF Solid Fuel Burning Appliances
JDIP—t� t1-/ 2836 A/v�Oi tg� I Insulation
I'cle hone —. Email address U Demolition
5.2 Regissttered HomeeIIntprov tttent Contractor(HIC)
t'(!" (� ( / H2//C1?70/1
gistratti-o/n Number Exp' anon Uate
I�IC 'om a y Namz or 111c'�Rzgts rant Name
5�� ��P�` � r�zY - 1 h, 195L9,&L,Gd
nd Street --z Email address
City/Town, State, " IP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan a of the building permit.
Signed Affidavit Attached? Yes .......... 91 No ...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDIN�G7�P,ERNIIT
!G
I, as Owner of the subject property,hereby authorize A Qe Z 6" /?% /q
to act on my behalf, in all matters relative to work aut prized by this building permit application.
Pi J I /0L e- .7 13
Print Owner's Name(Electronic Signature Date
SECTION 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and enalties of perjury that all of the information
cunt fined i i this application is true and accurate to t sI of y kn led a and understanding.
111 not Owner's or Autlwritzd:\gznt's Namz(Electronic St natu c) Due
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on file FIIC Program can be found at
www.mass.gov%oca Information on the Construction Supervisor License can be found at trww.ntass. :o�'tIL
2. When substantial work is planned, provide the information below:
Total floor area(sq. 11.) _ _(including garage, finished basement/atticS, decks or porch)
(7ross living;ura(Sq. d.) Habitable room Count
Nnmberof fireplaces_-- Number ofbedroums -- ------_--
Number of bathrooms _-----____-- Number of half'baths --
I'cpe Of he:uing system
f\pe of cooling sy;tcmt ___--_--- Fnclosed- ._ _ Open --
i. I'nryeCt lgwira Foot t e" uery be sub,fimit"d Project Cunt" - _- .----- - -- --- _ _---
I
5
^� CITY OF SOU EM2 NLUSACHUSETTS
7: t fi BL:LWL\G DEPAR•IMtENT
` r 120 WASHNGTON STREET, 3w FLOOR
TEL (978) 735-9595
x1.NrBFx1EY Dtuscou
F.U.r(978) 740-9M
.%UYOR Tg0-%G sST.PIERRs
DIRECTOR OF FLOUC PROPER7y/8VjM ZG CC-NNISSIONER
Construction Debris Disposal Affidavit -
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 1 l 1.5
Debris, and the provisions of tb1GL c 40, S 54;
Building Permit/# is issued with the condition that the debris resulting from
this work shall be disposcd of in a properly licensed waste disposal facility as defined by 1WGL c
l 11, S 150A.
The debris will be transported by:
(nam Chauler)
The debris will be disposed of in
(name facility)
(adJress o 'tScility)
'"'natureofpermitVi,
3 �
Jatc --
i�
CITY OF &U.Em, NLkSSACHliSETTS
BUILDING DEPAIMIENT
120 WASNLIIGTON STREET, 3'o FLOOR
Tti:L (978)745-9595
FAIL(978) 740-9844
Kl,,BERt RY DRlSCOLL
MAYORTHObtAS ST.PtERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING COA6NISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A i slicant Information A Please Print Legibly
Name(BusioessOrpsnizati nAndividual): t. Q N'
Address: 17
City/State/Zip: Phone H:
Are you an employer?Check the appropriate box: rype of project(required):
1.VEI m a employer with 4. Q I am a general contractor and Iployes(tLll and/or part-time).• have himd the subcontrctor6. ❑New construction
2. m a sole proprietor or partner. listed on the attached sheet t 7• ❑Remodeling
ship and have no employees These subcontractors have tt. 0 Demolition
working for me in any capacity. workers'comp.Insurance. 9, 0 Building addition
[No workers'comp.insurance 5. 0 We are a corporation and its
required.) officer have exercised their
10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL I I.❑ umbing repairs or additions
myself.(No workers'comp. c. 152,$1(4),and we have no 12.✓ Roof rapairs
insurance required.)t employees.LNo workers' 13.0 Other
comp.insurance required.)
;Any apptic:un that chasks box e l must also rill uut the A'etim blow showing their warkm'companndun poery into matiom
I h"euwm"who suhmis this affidavit indicating they ant doing all work and ihm him omaideconimetm most submit a naw anidavil indicating such.
:Contmiant that chalk this box must adachad an addidumd short showing the name of the suttointractan and their workm'comp.policy intotmaeon.
I.
1 um an employer that Lr providing workers'compenradon hnurance for my employees: Below is the poflcy and fah site
iajorrnutlon.
Insurance Company Name:
Policy Nor Sclf--its.Lic. N: Expiration Date-
Job Site Address: City/State/2ip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to xcuru coverage as required under Section 23A of MGL e. 152 can lead to the imposition of criminal penalties of a
rine.upro S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form Ufa STOP WORK ORDER and a line
of up to S250A0 a Jay against the violator. lie advised that a copy of this statement may be forwarded to the OI'lica of
Investigations ul'thc DIA fur insurance coverage verification.
/du hereby cer dap t u s p t s ujper/ury Ihuf rhI brjurnruNmr provided abu k i7s are b uad corree6
,. .j' t Uat • j
IO/]idol use only. Do not write in rlrh arenas to bs camp/ered by city or town afJlelu! I
Cityarl'uwn: Permit/Llcensefl
Issuing Aulhorily(cirelo one):
1. hoard of health 2. Building Department J.Cilylfown Clerk 4. Electrical Inspector 5. Plunnbing Inspector
6.Other _._.
Contact Person: _ _ _ _____ _ Phone N•
_ - Nja p
� �'/ee Panvneanweald oy✓Glamac�irtoel�d ,
Office of Consumer Affairs&Bu mess Regulation �
WELMIC
HOME IMPROVEMENT CONTRACTOR..Registration Cy-018039 Type:
Expiration 1/2012014' Individual
G HONAI,`Fc
€ ,;I
MICHAEL HONAN.r�F—p_'3'�
47 SHERWOOD'AVE .
DANVERS;MA 01923 �-, Undersecretary
t
i xsas
)q1 Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-083888 c
MICHAEL G HO1gAN ---
47 SHERW OOD AVEI _
DANVERS MA M923�
Expiration
Commissioner 07/23/2014