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11 CEDARCREST AVE - BPA-5-1074 IOSA, IL The Commonwealth of Massachusetts RECEIVED �— Board of Building Regulations and Stand"arodsCTIONAL SEZY CES CITY O SALEM Massachusetts State Building Code, 780 CMR Revised Mar 2011 .n Building Permit Application To Construct, Repair, ReJULFUD 161P a2z 3 8 One-or Two-Family Dwelling This Section For Official Use Only v / Building Permit Number: Date `ed: q Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION , ' 1.1 Prop ert Address: 1.2 Assessors Map&Parcel Numbers I Cet�cccreS _ Al 1.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❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: .roe loevtla qoiNemAAlk CAOCIO Name(Print) City,State,ZIP 1\ GI71-(so-LOW, No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2,(check 0 that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 21 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': Cbt 1F csce &1e SECTION 4: ESTIMATED CONSTRUCTION COSTS .. Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 1, 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier _ x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $. - (� / Check No. Check Amount: Cash Amount: 6.Total Project Cost: .$ l k �A LI ❑Paid in Full ❑Outstanding Balance Due: S-1JT I r\1 51� Io( g - SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) (S-cS (�tt;,.t _APVcy\� I V t( \bd License Number ` — Expiration Date Narne of CSI_Holder List CSL'Type(see below)_ W No.and Street Type Description (� ,1 j` \�\ _ �� �x p ��� U Unrestricted(Buildings u el ing cu.fl.) JV' kY '\�✓l 'V'V. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding _ Si' Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered HomeImprovement Contractor(HIC \ 1 ( ( / Pam . j `�I�CY\Y' 1CCr11���1 HIC IRegistration Number ExpiratiioonDtate HIC Company Name or HIC Registrant Name as0\ 01C. No.and Street Email address Ci /Town,State.ZIP Telephone SECTION 6:MORKERS'COMPENSATION INSURANCE AFFIDAVIT.(M.G.L.c:'152.i§,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 applicatioon./, f/ cl&✓ Print Owner's Name(Electronic Signature) Date _AEC,,7VN 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering m qapp el ve, hereby attest under the pains and penalties of perjury that all of the information contained in that n true and accurate to the best of my knowledge and understanding. AA q/aS/IS Print Owner's or Auth Ag t anre(Eleemmic Signature) - Date x 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 can be found at m .mass.eov/oca Information on the Construction Supervisor License can be found at wvw.mass.gov/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 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" Project 31-66854- Signed Sales Agreement https://nitro.powerhrg.com/projec"Ocmnents/6151657?pages=l c Roject 31-66854-9gned Sales Agreement DJP Gp.69MB.24480264) Device:iNd5.4 NATIONAL HEADOUARrERS Joe wd Meaesa Devito 2501 5&Vw D*C Ch"M 19013� 31-88354 888-REMODEL r f CUSTOM REMODELING AND IMPROVEMENT AGREEMENT tawte �'aaReY ka«rrlla,ma oww,ppu,of Rw PIopwr. Pro)ea Nutmer:3168 Auer m,2MS AM Do & o`s I Man&Dv to N171RM«MombdO 11 Coaeraer Aw dote rill otm) 1 8010M1 MA,eta70 C-.Wv.-ERaw .ems° NweeYkRIM arN ew+rNH alisw to putawes the owe.www ewvbesd Pbaer Hates♦1w,b0elY,&�oW S ('camauw9lneaomenoewanr,eabaewwD.awvweaR,mbspe�amanwaenanwPrDeua � �P 1ods nd" "Ge" orvareEeD ea pan a m.AaaamwR(ooNaeNNN.INs•Agreerlww7. TNe Aoreearerl[ra0•eeeNn a re6n . goods"of SM B. 9UYwfuaaaesb o therata 0ta000dsam awvbM pwtlwMdee aeealoed ttwan,rogwdlesed 0ndtg or t101Roveiaarry Mwr,Gg Buyer(s)bry aeelCiw their ptaohaM. c Purchey Pnw: VIABLY? PM kwk*RHMDomDe4a: �"'" y"re^t JO.OD w,.we anrr tom.. Balance Dw do N11AM.7f Ettlmabd .6 to weeks swstenRm CoaplMen: Eatltnate- �.1. Moftd Paymm Caw out mlwvow,a➢. .e ' mrIammpwindw oo. a Rw .wn.nry. enralnaa+a"awe.e�„rn.e`o.wo,r.sroraaa1.;en"ca,atg,d Buyers)Irereoy W=WAdMI rwxp Of a ODW It d,e WeWttw.'Ihe LAadBaN CWMW GNda 10 Hwvmte ROM',IrromYno t sayer{s)of De PaenOo risk of bid Nkwd eNwewa from ranovwIM wANky to he pwbmw0ln or at Buyer(q property:at Der address wrfttw,mole.BUyaf(e)HIDOW Rlw PwnPW w fM doe of Nee AorewmM,bob e wmrwlaenwm a ask. `Y Beyer(s),b1seM. This Agreemwt wngNNas Nw wRb sgrewwd wM wberwwldtghsi%wrt V.pwUae,e,w oft Agewn«tregewe enyaMm ? prior naootMtbro,rapr«wdYona.aR�awnwW,aWtw+Mlken ororol. No emwllYr,111. Xlw on or I,~of d*Agrw t shall be valid or eHadke Wass in wdmg wd s4«d by Dom DarOw SWIN(e)hW%bY WWOWedp«tlwt Buyer(•)1)has reW Ore wore Aprew,wa and h«rwwhed a wulplaW,WPW,era demo copy Of Mb AOMnwd,k,tludirg the too aww,lpwylno Nww W Cenpwlatlon bare,an me dMs tkw aYlNen aw,e sad 2)was grapy mbrmad Of NOWTwo 10 Cwroal No tlawecum FF Buyers)also aWW Wd,el'IMISWIM Irp ItSuyer(e)Nltertcss desow Wwa tNNywV,�the WIMTS a OW finwtarg will be & wmeUwd on sepwam dO=W$s,kKluarg srry lktsrtoa drrya. , 'Future pronatbro not appkW-4* 1 y { 00 Mar SIGN TNN AGREBENT F THERE ARE ANY SLAW SPACES. mar" Iltoerawand I « nawatN.eP.p.lmwr«a, Groat/ ► l tr. �. 15 S29A o- 15 {[ CwGmup, Signature salute Dar"NINIkN Joe Drift YDU,THE SUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TRIE PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY, AFTER THE WE OF TINS TRANSACTION. SEE THE ATTACHED NONCE OF CANCELLATION FORM FOR AN.EXPLANATIO14 OF '+THIS RIONT. Auous129,201515W ;� I , Pages 0IS I of 1 9/25/2015 4:07 PM NATIONAL HEADQUARTERS -.E - Joe and Melissa Devito 2501 Seaport Drive,Chester,PA 19013�xg �v _ PpWER: 31-ssssa August 29,2015 888-REMODEL .. .. ... MA HIC#166616 PRODUCT SPECIFICATIONS Buyer(s)'Information and Description of the Property: Project Number: 31-66854 August 29,2015 Joe Devito Oateo/Agreement Melissa Devito (617)650.6098(Joe's Cell) jdevito@mit.edu 11 Cedamrest Ave (978)594-1914(Home) E-Mail AA..f Salem,MA,01970 County:Essex Township: Buyer(s)listed above hereby jointly and severally agrees to purchase the goods and/or services listed on the accompanying specification sheets, in accordance with the prices and terms described in the Custom Remodeling and Improvement and the Product Specifications (collectively,this"Agreement"). Pre Installation Inspection Date:Your pre installation inspection is tentatively scheduled for Tue 9/15 between 9:00a and 10:00a. Windows-SL 2700 Inclusions: Includes metal reinforced meeting rails and nighttime safety locks on double hung windows only,welded corners,foam injected frames,Sashlite technology, Heatshield, Duraglass,exterior custom capping, installation,clean up and haul away of all job related debris. It is agreed and understood by and between the parties that the Product Specifications,along with the Custom Remodeling and Improvement Agreement,constitutes the entire understanding between the parties,and replace any and all priornegotiations, representations,or agreements,either written or oral. The Product Specifications may not be changed, modified,or varied in any way unless such changes are in writing and signed by both Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read the Product Specifications. I have read and received each page of this 4 page agreement. Power Home Remodeling Group Buyer(s) Buyer(s) /08/29/15 /08/29/15 /08/29/15 Signature of Remodeling Consultant Signature Signature Daniel Martini Joe Devito Melissa Devito YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. August 29, 2015 15:04 IIIIIIIIIIII IIIIIIIII IIIII IIIIIIIIIIIIIIII IIIIII Page 1 of 4 _ NATIONAL HEADOl1ARTERS ^ Joe and Melissa Devito 2501 Seaport Drive,Chester, PA 19013 31-66854 August 29,2015 888-REMODEL .. .. ... MA HIC#768676 Project Specifications Windows: Living Room 1 29.0"x53.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: Both Sashes: Colonial: Contour i Removal Wood i Additional Details None Windows: Living Room 1 29.0"x53.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: Both Sashes: Colonial: Contour I Removal Wood i Additional Details None Windows: Living Room 1 29.0"x53.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: Both Sashes: Colonial: Contour I Removal Wood i Additional Details None Windows: Dining Room 1 29.0"x53.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: Both Sashes: Colonial: Contour i Removal Wood i Additional Details None Windows: Bathroom 1 29.0"x53.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color While/White: Grid Pattern.: Both Sashes: Colonial: Contour I Removal Wood I Additional Details None Windows: Stairs 1 23.0"x21.0" WINDOWS: Models SL 2700 Styles Slider Types 2-Lite Configs None OPTIONS: Color White/White: Grid Pattern: None I Removal Wood i Additional Details None August 29,2015 15:04 IIII III II II III IIII IIIIIIIIIIII I I IIIII Page 2 of 4 NATIONAL HEADOUARTERS Joe and Melissa Devito 2501 Seaport Drive,Chester,PA 19013 'POWER 31-66654 .1'",,"°^- -^�^. t August 29,2015 888-REMODEL - MA HICH 169616 Project Specifications Windows: Hallway 1 29.5"x46.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None rM OPTIONS: Color White/White: Grid Pattern: Both Sashes: Colonial: Contour I Removal WoodFM Additional Details None - Windows: Bathroom 1 29.5"x46.0" WINDOWS: Models SL 2700 Sty/es.Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: Both Sashes: Colonial: Contour i Removal Wood I Additional Details None Windows: Bedroom 1 29.0"x46.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: Both Sashes: Colonial: Contour i Removal Wood I Additional Details None Windows: Bedroom 1 29.0"x46.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: Both Sashes: Colonial: Contour Removal Wood Additional Details None Windows: Spare Room 1 29.0"x46.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: Both Sashes: Colonial: Contour Removal Wood _ Additional Details None - Windows: Spare Room 1 29.0"x46.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: Both Sashes Colonial: Contour Removal Wood i Additional Details None August 29, 2015 15:04 IIIIIIII II IIIIIIIII I I IIII IIII I IIIIII IIII Page 3 of 4 _ NATIONAL HEADOUARTERS Joe and Melissa Devito 2501 Seaport Drive,Chesler,PA 19013, .� - "`�01X/E%Z 31-66854 August 29,2015 888-REMODEL .. . .a •o* MA HIC#168616 Project Specifications Windows: Spare Room 1 29.0"x46.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: Both Sashes: Colonial: Contour Removal Wood I Additional Details None 0 Windows: Bedroom 1 29.0"x46.0" WINDOWS: Models SL 270o Styles Double Hung.Types None Configs None rM OPTIONS: Color White/White: Grid Pattern: Both Sashes: Colonial: Contour Removal Wood I Additional Details None 11111 Windows: Bedroom 1 29.0"x46.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None w OPTIONS: Color White/While: Grid Pattern: Both Sashes: Colonial: Contour Removal Wood I Additional Details None August29,zols 15:04 IIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIII Page 4 of 4 POWER-1 OP ID: EL ACoao" CERTIFICATE OF LIABILITY INSURANCE DATE 1/2 014 YI osnvzola 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 endorsements. PRODUCER CONTACT NAME: Lacher&Associates Ins Agency PHONE FAX Lacher Insurance Group A/c No E>R:215-723-4378 Imc,No: 215-723-8604 632 E Broad St P O Box 64398 E-MAIL Souderton,PA 18964 ADDRESS: Chad Lacher INSURER(S)AFFORDING COVERAGE NAIC p INSURER A:Harleysville Preferred Ins.Co 35696 INSURED Power Home Remodeling Group, INSURER B:Harleysville Worcester Ins Co 26182 LLC INSURER C:Nationwide Mutual Ins Company 23787 2601 Seaport Drive,Suite B110 Chester, PA 19013 INSURERD:Pennsylvania Manufacturers 12262 INSURER E NSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL WU POLICY NUMBER MM/ODY EFF/YYYY MNU CY EXP LTR ID WYl UMns A X COMMERCIAL GENERAL WIBILDY EACH OCCURRENCE S 1,000,00 CLAIMS-MADEI—XI OCCUR MPA00000089793N 10101I2014 10I01/2015 PREMISES Ee occurrelce $ 1,000,00 N ED EXP(Any one person) $ 15,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY JEa LOG PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER' $ AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT $ 1,000,00 Ea..dern B IANY AUTO BA 00000089796N 10/01/2014 10/01/2015 BODILY INJURY(For person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNEDPeOr PERT rnDAMAGE $ UMBRELLA LIMB X OCCUR EACH OCCURRENCE $ 10,000,00 C X EXCESS LIAR CLAIMS-MADE CMB00000089794N 10/01/2014 10101/2015 AGGREGATE $ 10,000,00 LIED RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERT LMBILF Y STATUTE ER D ANY PROPRIETOR/PARTNEREXECUTIVE YIN 2014006620967 10/01/2014 1010112015 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MMBER EXCLUDED? NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 1,00D,00 I/yes,desmbe under DESCRIPTION OF OPERATIONS he. EL.DISEASE-POLICY UMIT $ 1,000,00 B Mass Auto BA 00000018227P 10101/2014 1010112015 Auto Liab 1,000,00 B NY Auto BA 0000007484SR 10/01/2014 10101/2015 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD/01,Addidonel Remarks Schedule,may be attached If more apace is required) CERTIFICATE HOLDER CANCELLATION SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Salem 3rd Floor AUTH/O//R7��IZED REPRESENTATIVES 120 Washington St 4C40C/\' Salem,MA 01970 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD � � �ie rOanz m�rr2��l�o�'C�J��rronor�aaiae(Ca i . Mee of Consumer Affairs&Business Regulation License or registration valid for individul use only - OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration:,-168616: - Typl —. i 10 Par Plaza-Suite 5170 Expiration 3/18/20 ,1. Supplemeni ;ard Zt 16 POWER HOME REMODELING.GROUP LLC. MARK MORDINI 2,501 SEAPORT DRIVE STE-B1'10 - j CHESTER,PA 19013 Undersecreta ry, lid without signature i Massachusetts Department of Public Safety `j Board.of Building Regulations and Standards License:CS-057645 Construction Supervisor MARK E MORDINV +i 18 NEWELL DR N ATTLEBORO i Expiration: Commissioner 09/18/2017 e A51 ACH��TTS�----"' -E > +.D�CENS- Y �— llVal uSe-�saEaon awm>a:a� &i7�' s 7828t09781966'- � x pier w sel 4i1�1 B 4: ' 18 NE6 LL DR �7� - NATTLEBOROUGH UA 02760?525 +_ '\ The Commonwealth of Massachusetts Deparment oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02II4-20I7 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Priot Legibly Name(Business/Organizationdndividual): emo (ZL Address:_ 2S'®! ,rf}//p/Lr L21Vr? City/State/Zip:C f I EK 104 0613 Phone#: 508- Z 8D— D t S6 Are you an employe?Check the appropriate box: 1. I am a empbyer wnh 5 [8. ype of project(required): employees(tuu and/orpazt-t®e).• . ❑N construction 2.❑Ism a sole proprietor m parmemhip and have an employees working forme in eIDOdelin airy cepaciTy.[No workers'comp.;nt,,.nnr. roquired.] g3. Iam a homeowner doin all work ❑Demolition ❑ g myself.[Naworkers'comp.insurancerequired.]ta. I am a homeowner aad will be 0❑Building addition ❑ kirivg contractors m conduct all work on my Property. 1 wln ensure that all contractors either have workers'compensation imurmce in we sole I I.❑Electrical repairs or additions proprietors with m employees. 5.❑I am a general contractor and I havehired the sub-contracrors listed on the attached sheet, 12.❑Plumbing repairs or additions i These subcontractors have employees and have workers'comp,assurance.3 - 13.❑Roof repairs 6.❑We are a corporation and its officer,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 fin one the section below showingtheir workers'co t Homeowners who submit this affidavit indicating � contractors policy bait a Lion they are do' all work and then hire outside contacors must submit a new affidavit indicating such. =Connectors that check this box most attached an additional sheet showing the name of the subcontractors and stare whdtff or not those entities have employees. If the sub-contactors have employees,they roust provide their workerrs'comp.policy ntanber. lam an employer that isproviding workers'compettsadon insurancefor my employees Below is thepolicy and job site information. Insurance Company Name:Aatti,f V I ll(z �L j C(ZS T f rL- lI i&tt AAi z �//1_p Policy#or Self-ins.Lic.#: 701 q p0. 101001 Expiration Date:_ ' '! '20 f S Job Site Address: I t C'ekfcy-e-sy /`PVC_ City/StateMp: �2�(V� AAA 0 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 veri I do hereby rtf the pains and penalties ofperjury that the information provided .a�boove/is true and correct v1 Si mature' p Date: /o-Y s Phone#: 5,08�-zet)-01 Sh FFOther only. Do not write in this area,to be completed by city or town q)ykW Town: Permit/License# ority(circle one): ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector on' Phone#: Batch ID: j0rdeT 8/Line H U-Factor(U.S.I t-P) Solar Heal Gain Coefficient 1 ' � . • Visible Transmittance Condensation Resistance I r.. i E -f�M.fie4 t a b l M ¢.IJ%.vw—�'�r I'iS.4 r 74�� 4L. R 1 •��r q� .S�y�'• _.� �. .0 � ^il� Y ra,! n �X� � i� •a3E i k I c.... ,5�.�.•1 .J3L i, d is r{gE } ll.a�s_ >S37 yV rf 4 c� �