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0013B GRISWOLD DRIVE - BPA-15-172 Cr R ' RECEIVED � The Commonwealth of Mas 10 Board of Building Regulations and�Standards CITY OF Massachusetts State Building Codel7ffl I q b: 50 SALEM Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling s Section For Official Use Only l Bmldmg"Permit Number, t ; I n Date A lied F }? Bwldmg OBiicial(Print Name) 4 f � i� - -Signature - SECTION 1:SITE INFORMATION, 1.1 Property Address: ' 1.2 Assessors Map&Parcel Numbers l.l a Is this an accepted street? W pQ/CGI � `�a -O 1 e's Ye _ no Map Number Parcel Number Zoning Information• _ 1. Property Dimensions: Zoning District Proposed Us---e— Lot 1.5 Building Setbacks Area(sq ft) Frontage(ft) (ft) Front Yard Side Yards Required ---- _. Rear Yard 9 Provided Required Provided - Required Provided - 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: Public❑ Private❑ - Zone: Outside Flood Zone? 1.8 Sewage Disposal System: Check if yes[] Municipal❑ On site disposal system ❑ SECTION 2; PROPERTY OWNERSHIP'. _7 _ p2.1 Owner'of Record: Nariie Print) �; ') City,State,Zli' No.and Street �/ 1 r `" 1��-- �•� D Telephone Email Address FECTiON 3 DESCRIPTION OF PROPOSED WORKZ N (check all thaf.apply) . ew Construction❑ ExishngBuifrling❑ Owner-Occupied ❑ Repairs( Alteration(s) ❑ Addition ❑N Demolition ❑ Accessory Bldg. ❑ Number of Units Brief Description of Proposed Work2: Other ❑ Specify: ) � } . n SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials ,, � It `_Official Use Only � � � _ 1. Building $ 1 Buddin PermitFue $ < g Indwate how fee rs determined: 2.Electrical $ ❑Standards City/Totvn Appbdatlon Fee° • ' 3.Plumbing______$ _ ❑Total protect Cost'(Item 6)x mulhpher _ x ten'' Otfier Fees $ T -- --- 4.Mechanical (HVAC) $ List• _ .5.Mechanical (Fire Su ression) $ Total All Fees $ Check No.' Ch 17 6. Total Project Cost: $ q DD,OD eck Amount: Cash Amount :aid in Full ❑Outstanding Balance Due. SEK)-r SECTION S:g CONSTRUCTION SERVICES r s r 5.1 Construction Supervisor License(CSL) n /1 Name of CSL Holder License N ber Expiration Date _ List CSL Type(see below) U No.and Street _ De tioe� �' `• ' ` P , W Q y�_ 6,A(n l l ' '� U Unrestricted(Buildin s u to 35,000 cu.ft.) ' I Famil Dwellin City/Town,State,Zip Restricted I&2 - M Maso RC Roofin Covenri WS Window and Sidin - - ii rr-- SF Solid Fuel Burning Appliances cle I Do "1"D rriTuX Dr1(d r)CV3,fJf1.> c) I Insulation - Tele hone Email address D Demolition 5.2 Registered Home Improvement Ot%tractor(HIC) _ .. v u - — I HI tion9 Number - Expir C'C i any Name r HIC.Registr Name L Date 12_ (r1, CXa LVo.and S reet 7 rrl bi)(/1 d'J-)ya Z>I S177) I_g ) 'G�_,�3-yl� Email add ss Ci /Town,State,ZIP Tele hone SECTION 6::WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GiL 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 1.0 BE COMPLETED WHEN -OWNEWS.AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT",.i I,as Owner of the subject property,hereby authorize rn ] Lc, to act on my behalf,in all matters relative to work authorized by this building permit applUtion. Sty Z L'ay11y Print Owner's Name(Electronic Signature) Date "-r SECTION 7b: OWNERr OR AUTHOItIZED:AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. _-' }os�2A s Oar •c� 3 t�159 Print Owner's or Authorized Agent's Nam IecL'onic Signature Date 1. An Owner who obtains a building permit to do his/her own work,or an owner who hiresan 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.mass eov/oca Information on the Construction Supervisor License can be found at www mass uov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) ---— - --Gums livf- -area(sq ft.-)===_-- -- - --=-Habitable m-courit--- ---- — -- ---_- Number o£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" 9 MA Reg#146589 v Contract# CT Reg#0605216 Federal ID#20-2625129 RI Reg#,26463 - "Home Improvemarn Solutions 70182 - Corporate Headquarters,26 Cedar St,Woburn,MA,(P)800-342-2211 IF)781-933-9626,www.newpro.conn . THIS CONTRACT MADE THE t alI 5i- day of �Q� 20 15 between "�efr ���/ lJ✓?tUfl S7g-?45 -o1R3 (Rome Owners) ` (Home Phone) (RUS/C607Phone) Of 13 (r� sttivl� ±x yr;� 1� SG.�eV� U 19Id (Address) , (City) (state) (Zip) _ the"Owner"and NEWPRO Operating, LLC, "NEWPRO". (E-Afa//JforprooMetary use only NEWPRO hereby agrees that it will for the consideration hereinafter mentioned,furnish all labor and material necessary to install.the following - described work at the premises located at: Sw�P ❑ The job address is a condominium. (Job Address) TOTAL# EWPRt7 WIND OPTIONS: WINDOWS - SERIES Grids:J YES J NO ❑CONTOUR LJSDL JEURO DIAMOND Window color QTY I Window color CITY OBSITMP:(Location) r❑, ❑TOP BOTTOM Ext: Ext - Vent latches erior color FulbScr en 1 i Z Standard) 1�1,YES ❑ NO L Capping Color: DOORS MODEL QTY Please tn/t/ak PVC J Smooth NoMar LA No Cappindj Sliding Glass Door MODELNAME MODEL# CITY Color In: Out: Doi le Hung Active: eft Center Right Customer understands that NEWPRO® 2 Lite 'der HDWR: SN BB BGE H does outdo any painting orstaining. 3 Lite Slide�, (1/4,112,1/4) Entry Door Style (fie:when removing or replacing interior 3 Lite Slider (v3.1/3.113) Color In: Out: stops ortrim). NEWPRO®is not respo- Casement(Hinge fight) Fiberglass - Steel nsible forconditions orcircumstances bey- Casement(Hinged LeT HDWR: SN Be AGB AB ORB and its control including condensation resu- Twin Casement Sideli_tes Style Iting from or due to pre-exi ing conditions Stationary Casement Colon" In: Out: (drcieone): Triple Casement 1114,112,114) Storm Door S le CASH Triple Casement (113,113,11 Color In: Out: Balance paid to installer at completion Picture Window HDWR: SN BB AGB AB Sash Only Left Hinge Right Hinge FINANCE " Hopper I Entry Door Style Bank completion form signed at installation Awning JColor In: Out: Garden Wi dow Fiberglass Steel TOTAL - Bay Win Ow(Roof/soft) HDWR SN BB AGB AB ORB CASH Bow endow(Roof/Soffit) Other Door Style PRICE I Othdr Color " In: Out: '' DEPOSIT Ot er HDWR: WITH DESCRIBE WORK&PROMOT/ONSAPPL(ED: lZe`Mc).P- OI G.� r2 ('. ORDER W � d5 5 , T kk- a1 Pic:5 . e- -e _ TOTAL / yx;AACV4 Cvsaak^ LFn 04,- o2 s DUEAT INSTALL VVv Est Start Date: q / 17 115 Est Camp.Date: j S Customer understands this is an"estimated date" Owner has read and agrees to the terms and conditions on the front and the`reverse of this Agreement. Owner specifically agrees to the(1)Total Cash Price; (2)work being performed; and(3)work not being,performed. Owner understands that this Agreement and any attachments contain all of the promises made by NEWPRO. Owner has been orally advised of his right to cancel this transaction at any time prior to midnight of the third business day after the date of this transaction and Owner was provided with two(2)copies of a cancellation form explaining this right. .. - DO NOT SIGN THIS CONTRACT IF THERE ARkANY BLANK SPACES. m (Rhode Island Sales Only): Notice to buyer: (1) Do not sign this Agreement If any of the spaces intended for the agreed terms to the extent of then available information are left blank. (2)You are entitled to a copy of this Agreement at the time you sign it. (3)You may at any time pay off the full unpaid balance due under this Agreement, and in so doing you may be entitled to receive a partial rebate of the finance and Insurance charges. (4)The seller has no right to unlawfully enter your premises or commit any breach of the peace to`repossess goods purchased under this Agreement._(5)You may cancel this Agreement if it has not been signed at the main office or branch office of the seller, provided you notify the seller at his'orher main office or branch office shown in the Agreement by registered or certified mail, which shall be posted not later than midnight of the third"calendar day aker the day on which the buyer signs the Agreement, excluding Sunday and any holiday on which regular mail deliverles,are not made. See the accompanying notice of cancellation form for an explanation of buyer's rights. (Rhode Island Sales Only): Owner acknowledges receipt of required Contractor's Registration and Licensing Board consumer education materials. (Owner's Initials) By:�f r!Yn\) ( utow-C-) EIN# - Signed: Product/Sppeseccialllls{f/PdnWlyame) _ ►,//vJ� /7 p r�� /Owner ,y-�^ / By: ✓�'. ( Signed: 8-e- v�uT-f � f ft{T.<.%l/ NEWPRO Operating,LLC(StgnBtere) / Owner US-15 WHITE: Branch Copy YELLOW: Customers Copy PINK: File Copy GOLD: Finance Copy R0714 ADDITIONAL TERMS AND CONDITIONS Warranties: Any product warranties are provided by the manufacturers of the products that Owner is purchasing. NEWPRO is also providing Owner with a labor warranty, which covers NEWPRO's labor. Owner understands that Owner should read all the written warranties for complete details of warranty coverage and that warranties are available for complete review before signing this Agreement. Late Cancellation: Owner understands that Owner has three (3) business days to cancel this Agreement. Owner understands that if Owner wants to cancel this Agreement after those three (3) days, NEWPRO does not have to allow that. Owner understands that if NEWPRO does let Owner cancel, however, that Owner will have to pay to NEWPRO a late cancellation fee equal to 33.3% of the purchase price in order to cover NEWPRO's labor,administrative,and material costs. Delay/Unknown Conditions/Damages: Owner understands that if NEWPRO determines within thirty(30)days of the date of this Agreement that it cannot perform the work according to NEWPRO's professional standards,NEWPRO can cancel this Agreement,notify Owner of cancellation,and promptly return Owner's money. Owner understands that issues that may cause NEWPRO to cancel this Agreement include incorrect pricing or unknown pre-existing conditions to the property. Owner understands that NEWPRO is not responsible for structural or other defects in the property,and that NEWPRO's products do not cure these problems. Owner understands that the work could be delayed by events that NEWPRO does not control. Owner understands that NEWPRO is,not responsible for(a) damages due to causes beyond NEWPRO's control,(b)damages arising from a delay in NEWPRO performing under this Agreement,or (c)unintentional damage to Owner's personal property, it being understood that it is Owner's responsibility to remove/secure his personal property prior to commencement of work. When Money Is Due: Owner agrees that when the work is"substantially complete", Owner will pay the balance due on this Agreement. Owner understands that "substantially complete" means the work has.been materially finished, functional as intended, and a final inspection,permit,or occupancy certificate, if required,has been obtained. Owner agrees that once Owner has paid the purchase price, if Owner believes any of the work performed by NEWPRO is defective or incomplete, NEWPRO will inspect the work and perform any service Owner is entitled to under this Agreement and/or any warranty. Owner agrees that if Owner does not pay any of the money when it is due,Owner can be charged a late fee of 1.5%on the amount owed for each month the money is not paid. Owner agrees that if Owner defaults on any promises under this Agreement, and NEWPRO hires an attorney to enforce this Agreement, Owner will pay NEWPRO its reasonable legal fees and related costs or expenses,as long as it is legal for Owner to do that. Other Understandings: Owner agrees that Owner will assert a dispute,claim,or controversy(hereafter referred to as a "Claim") arising under or relating to this Agreement only on behalf of Owner's own self and that Owner will not assert a Claim on behalf of,or as a member of,a class or group in either an arbitration proceeding,a private attorney general action or in any other forum or action. If a court determines that this specific paragraph is not fully enforceable, the court's determination shall be subject to appeal. This paragraph does not apply to any lawsuit or administrative proceeding filed against NEWPRO by a state or federal government agency even when such agency is seeking relief on behalf of a class of buyers. Owner agrees and understand'that if Owner finances the work, Owner's separately provided financing documents will include the number of monthly payments and the amount of each payment, including any finance charge. Owner promises that he will provide NEWPRO with access to the work area, including access to electrical "outlets. Owner understands that this Agreement and any attachments make up the entire understanding between the parties. Owner agrees that any change to this Agreement must be in writing and signed by both parties. (Massachusetts Sales Only):All contractors and subcontractors must be registered by the administrator of the Board of Building Regulations and Standards and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Office of Consumer Affairs and Business Regulation,Ten Park Plaza,Suite 5170,Boston,Massachusetts 02116 Telephone: (617)973-8700, It shall be the obligation of NEWPRO to obtain any and all permits necessary under this agreement,as the Owner's Agent.NEWPRO shall advise Owner of any necessary permits. The Owners who secure their own construction-related permits or deal with unregistered Contractors will be excluded from the guaranty"fund provisions of MGLC, 142A. ,Any deposit required under this Agreement to be paid in advance of the commencement of work shall not exceed the greater of one-third of the total contract price or the actual cost of any material's or equipment of a special order or custom-made nature,which must be ordered in advance of the commencement of work,in order to assure that the project will proceed on schedule.No final payment shall be demanded until the contract is completed to the satisfaction of the parties. (Rhode Island Sales Only): THIS IS A NON-NEGOTIABLE CONSUMER NOTE.During the term of this Agreement,NEWPRO shall maintain public liability and property damage insurance covering the work of not less than$500,600 combined single limit,bodily injury and property damage and workers'compensation insurance as required under chapter 29 of title 28_NEWPRO and/or subcontractors or material persons may file a lien in accordance with Rhode Island Mechanics Lien Act,chapter 28 of title 34. (Maine .Sales Only): Consumers are strongly advised to visit the Attorney General's publicly accessible website (www.maine.gov/ag) to gather current information on how to enforce their rights when constructing or repairing their homes. The Attorney General can be contacted by telephone at 207-626-8800. Any alteration or deviation from the above contractual specifications that results in a revision of the contract price will be executed only upon the parties entering into a written change order. t l In addition to any additional warranties agreed to by the parties, NEWPRO warrants that the work will be free from faulty materials; constructed according to the standards of the building code applicable for this location; constructed in a skillful manner and fit for habitation or appropriate use. The warranty rights and remedies set forth in the Maine Uniform Commercial Code apply to this Agreement. If a dispute arises concerning the provisions of this contract or the performance by the parties that may not be resolved through a small claims action, then the parties agree to settle this dispute by jointly paying for one of the following: ❑ Binding arbitration as regulated by the Maine Uniform Arbitration Act, with the parties agreeing to accept as final the arbitrator's decision;❑ Nonbinding arbitration, with the parties free to not accept the arbitrator's decision and to seek satisfaction through other means, including a lawsuit; or ❑x Mediation, with the parties agreeing to enter into good faith negotiations through a neutral mediator in order to attempt to resolve their differences. (Connecticut Sales Only): THIS INSTRUMENT IS BASED UPON A HOME SOLICITATION SALE, WHICH SALE IS SUBJECT TO THE PROVISIONS OF THE HOME SOLICITATION SALES ACT.THIS INSTRUMENT IS NOT NEGOTIABLE. The owner(s) of NEWPRO is or has been a shareholder, member, partner, or owner of the following corporations, limited liability companies, partnerships, sole proprietorships or other legal entities that have been a home improvement contractor during the previous five years:NONE Jlcf��l �Lkcre�o _. �Db#: — Product"S e�ialisf-- _---" C) Home Improvement Solutions Page of Date 26 Cedar St•Woburn,MA•01801 1 78IX4100•newpro.com Lead Paint Status Homeowner m (s) \, \� C)G Yr Built LSWP One Must 13 �J f.SI CI,C � Vf� �C`�V✓1 -MA ollu O Exempt X Be Selected Address City State Zip M T W TH F ) Phone Email ciW/eone) Est.Start Date TOTAL#OF #OF BOW/BAY/ `EXTERIOR GRID COLOR WINDOWS GARDEN CLADDING #OF DOORS (inside/Outside) CAP COLOR Bay*_ Dowlf— White Storm_ m S" MFe: NAPCO / Norandez/ Gartlen Shelf Steel Contour Other E:1 IFool or Soffit Painted Patio Pralde Y\•lC. (cir6le one) Diamond PVC Smooth Locks 8 Keepers(circle one): Whit Almond Bronze Brass Satin Nickel (circle one) drele one 3 6f — . Handles 8 Night Latches(circle all that apply): White Almond Bronze Satin N ck I Brass No Bottom Handles Night Latches Inside Color. Whi Natural Oak Colonial Cherry Banister Oak Outside Color: White Basic Brown CT Beige Forest Green Tuxedo Gray Claystone Terra Brown Bronze Winterbeny Wedgewood Blue Window Model OPENING SIZE STOPS N0. I MODEL -1WxH U.L LOCATION GyRIID SCR IN OUT CONV ADDITIONS OPENING CUT 10l 1(�Z'� O X o %U. , . x x x x x i � l z/.��� s '74 r z x x x x x s x x VD&IL IA- 4r&e& - x x x 1' f 'o"t r^ b� x x x x x ' G T"(' x x 145 L. x x x x Measuremam ., IrRials Date Crew Size Needed; Time Frame to complete job Capping Type Special Installatiop Instructio s: ;r// J j 44p + r r /Ul1l.�� GLdC m „, /�CQ® GATE(MMIDDIVYYY) CERTIFICATE OF LIABILITY INSURANCE 1/6/2015 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 Melissa Pflug NAME Mackintire Insurance Agency Inc PHONEINC No 1 (508)366-6161 FAX No: (508)366-5202 11 West Main Street ADDRESS:melissap@mackintire.com INSURERS AFFORDING COVERAGE NAICk Westborough MA 01581-1931 INSURER A Netherlands 24171 INSURED INSURER B.Libi Mutual/Peerless 24198 Newpro Operating LLC INSURERCAcadia Insurance Co. 26 Cedar St. INSURER D: INSURER E: Woburn MA 01801 INSURER F: COVERAGES CERTIFICATE NUMBER Master 14-15 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 LTR TYPE OF INSURANCE UBR POLICY NUMBER MM/DDV� MM/DDVfYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Eaoccurrence $ 100,000 A CLAIMS MADEOCCUR CBP 8589577 12/31/201412/31/2015 MED EXP(Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENE AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- AUTOMOBILE $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 A ANY AUTO HOD ILLY I NJURV(Per person) $ ALL OWNED X SCHEDULED 8584174 2/31/2014 2/31/2015 BODILY INJURY Per accitlent $ AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE H HIRED AUTOS X AUTOS Per accitlent $ Uninsured motorist 815lit limit $ 250 000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DEC X RETENTION IS 10,00C PU 6582578 12/31/2014 12/31/2015 $ C WORKERS COMPENSATION I WC STATU- OTH- ANDEMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNEWEXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? Lj NIA (Mandatory in Ni -20-20-003506-02 05/01/2014 05/01/2015 E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under _ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 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 To Whom It May Concern ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE T Moynagh/KRISTI ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS026 oni m Th. ArIni in.one aierl I�nr. moe4e of Arni The Commonwealth of Massachusetts ' Department oflndustrial Accidents Office of Investigations Uf 600 Washington Street Boston,MA 02111 www.n:ass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Nanle (Business/Organization/Individual): � Address: me", occa.r f S— City/State/Zip: � )0hu ro t 00.q l a of Phone #: Are you an employer? Check the appropriate box: F (required): 1.E I am a employer with SO 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors struction2.❑ I am a sole proprietor or partner- listed on the attached sheet. t ingship and have no employees These sub-contractors have nworking for me in any capacity. workers'comp.insurance. addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their ME]Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.El 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.] 13.0 Other 'Any applicant that checks box#1 must also t fill out tile licye section below showing their workers'compensation po infomration. 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 pry employees. Below is the policy and job site information. Insurance Company Name: b )acJsjr)b e, J_a.Strr-in rnnC Policy#or Self-ins. Lic. �// "�3cxoE ' Expiration Date: Job Site Address ��I5 u�o J ( l tsl I City/State/Zip: h 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 a 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. signature: Date: Phone#: [[6. ficial use only. Do not write in this area, to be completed by city or town official ty or Town: Permit/License# uing Authority(circle one): Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 571nspector Other ntact Person: Phone#: ,q rJ�r f[Yq/NrnvrrnCn���r/r'�((rJJn('�uL��J � . ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only �PME IMPROVEMENT CONTRACTOR I � — before the expiration date. If found return to: .;;Registration: 146589 Office of Consumer Affairs and Business Regulation en v Type' 10 Park Plaza-Suite 5170 Expiration: 5/5/2615 Supplement ;ard NEWPRO OPERATING, LLC. - Boston,MA 02116 THOMAS FOXON - 26 CEDAR ST. WOBURN, MA 01801 — ���N1t-.hd,.thout,.g Undersecretary q lure - Massachusetts Department of Public Safety Board of Building Regulations and Standards Con.tt uinnn Supcn'isur _icense CS-029090 THOMASPFO%ON 230 WALNUT ST '�r. - READING MA 61867 ' 4 _�.ui;atiori 00mmtssioner 11/19/2015 f FEB-25-2015 12:13 FROM; T0:17913339626 P.2/2 dq S AiA d nl 6t46'itt.amuM Iiu�•Oteot 781.995+t90a•.newptamm. Auglor(�gcntio-ReftmfWork �� ! For tlotaeowroKIS ' . 1 r. MAL Coe have aeon.s wod ft sampb of Nto NEY PRO Q� -M:V.md";�uj have; �d Entoho•e►1d after phbmg hs I urldgPpmna Un f eEy{� • • my aitneouns to'be++6panded w81 rom®in'ets aarna(I.e:deublb�hting m i�auble hang,•olldar�o iMar; mt y Tio•U6ftr and e>detior ash and mitlsr Rpr til sgll . . be whltd'�n aoblr. , . .Nlhan roPlae�1'0 a .waod.wwow the e*rlof Win wigm(flon� ;reWao� r window the extadar•'a livoran Go le duo to the dMhronee In ftMO $126 bohvW ,t► non�tlatell V/ doih sad thq exim6g motel vA t&w.�t i,• ' C 4i v.•• 770 Hoar• I '� 1 M Muli T00[n SEIIVS oHdAaN LTLOCCOTBLT XVd L6:TT STOZ/TT/CO 03/11/2015 11:47 FAX 17819330717 NEWPRO SALES 0 002 vim I' PYe,ugtesu: 4M0 a uw",B4OlddM iN ig a Pug moi Biblt Dry as a ous,pute"uugltu %No ppr ur r u �loda+d�xp iuby ettgrp, " a MW nq'aW g 0 jtt �° t®71WUOM dra11 OIM Oydq N, # ��B!. 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