43 IRVING ST - BUILDING INSPECTION a�U The Commonwealth of n4assachusetts
Board of Building Regulations and Standards CITY SALEOI
Massachusetts State Building Code, 730 C�IR;, Revised Mar 2011
.,ti, i
Building Permit Application To Construct, Repair, Renovate OrDemolish a
One-or Two-Family Divelling • .
This Section For Official Use Only.
Building Permit Number; Date pplw r`
-Building Official(Print Name):. -Signature Data
SECTION I: SITE INFORMATION.
1.1 Property Address: L2 Assessors Map& Parcel Numbers
�13 -J_Ttj.�� 5 >-
I.1a Is this an accepted street?yes_ no Nfap Number, .Parcel Number
1.3 Zoning Information: 1.4 PropertyDlmepsions:.ii
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: (iM.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 yesE3
SECTION!, PROPERTY'OWNERSHIP�
2.1 OwnprlofRed: Ka 5/� YK 2 d cr 1 c r z- S �Uvt r/a
Name(Print) City,State,ZIP
`A :Z2 s 97�-7YY-m
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WOR.W(check all that apply)
New Construction ❑ Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other Cl Specify:
B >/foDensc ripticn �f4Pr(oOpXosedVork': r — 2 Sh, (
w
cja(I ee- 3
., Ge-( �✓ /- — / Sic. 6d/
SECTION 4: EST EVLa D CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only%
Labor and b[atcrials
I Building S I. Building Permit Fee:S Indicate how fee is determined:
2. Elceirical S ❑Standard.City/CownApplication Fee
❑'CotalProjectCost3(Item6)xmultiplier x
3. Plumbing S 2. Other Fees: S
t. ,Mechanical (IIVAC) S List:
i. Mechanical (Fire $
�np cession) _ Total All Fees: S_
Check No. . Check Amount: Cash Amount:
n fntal 1'1•0ject Coif S 6 000 0 Paid,,
id in Pull, - _ _ ❑ OuLshuuliny l3alnncc Du;;: ----- -- _
SECTION 5: coNSTRUCrION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Gepirttion Date
Name of CSL Iloldcr �-
HfltDn St!'ftt List CSL Type(see below)
Ty Description
No. and Street
U Unrestricted(Buildings u to 35,000 cu. tt.
Restricted 1&2 Family Dwelling
City/lro%vn, State, ZIP �L Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Futt Burning Appliances
qlr I Insulation
felt honell Email address D Demolition
5.2 Registered Home Improvement Contractor(11IC) Y-)�o�-y �>1-1 jy
At1--'Zt1S`let.'.°a"16 'At19n,LLC HIC Registration Number Expiration Date
I IIC Company N:une or I W .�SwA,;muC r e CC -yt�
No.and Street w Email address
�/7� 7V -fr/Y7
City/Town,State, ZIP 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 FORK BUILDING PERMIT
I, as Owner of the subject property,hereby authorize Ell( C t " (`tom
to act on my behalf, in all matters relative to work authorized by this building permit application.
f�FLLl h kG '�/ t`z-� �
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 penalties of perjury that all of the information
contained in this application is true and accurate the best of my knowledge and understanding.
g-l� C- � %� --64
Print Owner's or Antllorized:\.gent's Name(Electronic Signature) Date
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
progr in or guaranty find under M.G.L. c. I42A. Other important information on the HIC Program can be found at
www.tn as ."uv/oca Information on the Construction Supervisor License can be found at www.ntass.'ni L)a
2. When substantial work is planned, provide the information below:
-road floor area(Ski. R.) _(including garage, finished basement/attics,decks or porch)
tiro;; living ;tea('(I ft.l -- — Ilabintble room count --
Number of tit rpl.icc,_--_----- Number of lic(frooins _-------_
Number of bathroonis
f 'pe of Mating -_ - Number off dlmlfk b/uhs
,ysleln -h------- -------
-
r tipeofcanlimg ;yacut --_-_ _-- (fncloscd _ t)pcn -------_, -___---
1, l ot'll 11101a(3 Syu.ira Prnit i uiav h,: ;ub;titut I ti)i I„t it I rojM ( oX,
Massachusetts Home Improvement Sample Contract tea.
I;
r2ma�chuLsetts
orm satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard
- erotect homeowner& Seek legal advice if necessary. Any person planning home improvemenmshould fast obtain a copy of"A
Container Guide tdI Home bnprovemrnt"before agreeing to any work on your residence:You may obtaw a free copyby calling the
frmmer Affairs and 132mess Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website.
Homeowner Information Contractor Information
Na�me^ Company Name
GiTip
Ste:a Atldress(do net use�ra�cORmb�Box address). Coamcror/SapersoN OwuerN
Ciryrfown Sm[e ' Zi Code Business Address(must include canter no Avmue
SA lGv) d1CS&Wm NIA 01970
Daytime Phone EvFryng Phone Citylfown State Zip Code
Mailing Addresa(It different Gam abode) Business Phone PedemlBmploymmor S.S.Number
' - Iary�e9u:v Nat meq Lom• FbRna^N.vrnmt Carvkkr Reg M11,M Emimion tlne
ImpmRmenl tonhneloR LpR
4 rnlla rtpl•hn con nnmbu y�L �<+ _ .
The Contractor agrees to do the following workfor the Homeowner: /
(Describe in domit the weds on completed,specifying the type,brand,and guide of materials to be used,nee additiannl abed,'f newm,,.)
��ow1 CC.(;(n—IO _ c)u_115 Q—IS �lq-fire 6nn y., -gyp
RequiredPermits-'he foilowingjbuildin permits are required Proposed Start and Completion Schedule-The following schedule Ivill
and will be secured by the contractor as the homeowners went: be a hered to unless circumstances beyond the contractor's control arise
(Owners who secure their own permits will be
excluded from the Guaranty Fund provisions of (� /3 Date when contractor will begin contracted work r.
MGL chapter 142A.)
al' Date when contracted work will be substantially completed.
Tom]Conti act Price and PaymedtlSchedule eiJ
he Contractor agrees to perform the worlq furnish the material and labor specified above for the total sum of.. /0 �d(] (•)
Payments be made according to the following scheskile:
$�E
�f•� upon signing contracC(iiot to exceed 1/3 of the totel conCact price-/Qr'the oosT'ofspeciai order iiem"s;wiiictiever is greater)-
$ pip by / /_ or upon completion of -
S �No�-°D by / / '/�t J1t or upon completion of -� UU(1
$ Dll.r/6d upon completion a£the contract. (Law forbids demanding full payment until ontract is completed to bath parry's setisf'aetion)
The falldwing material/equipment most be special $ to be paid for
ordered before the conramted'lmYk begins in order
to meet the completion schedul'e.(••) $ 0be paid for
NOTES:(*)Including all finance charges(**)Law re oltes that any deposit or down-payment required by the co"=,before work begins may
not exceed the greater oft(a)ono-third of Me total c.at mer price or(b)the arNW cost of any special equipment ureustom made material
which must be special oracred in advance to meet the eompledom schedule. -
Lhoress WnrmnN-ds an exorvss con" IVM1 I id db 1h t t Y ❑N ❑Y (all terms fth /v mustb as h d in the
Subcontractors-the contractor agrees to be solely responsible for completion of the work described regardless ofthe actions of any third
party/subcomractor utilized by the d.dntraetor. The contractor further agrees to be solely responsible for all payments to all subcontractors for
materials sad labor under this t
Contract.4cceptance-Upon signing,this document becomes a trading contract under law. Unless otherwise noted within this document the
contract shall not imply that any lien'or other security interest has been placed on the residence. Review the following cautions and notices
Cmefully before signing this commit!
I'.
• Doa't be pressured into signing the Contract.Take time to read and fully understand it. Ask quesdons ifsomething is unclear.
• M•tc the tre t has aYPI'AHsnner t Contractor Registration. The law requires most home improvement contractors and
subcontractors to be registeredlwith the Director of Home Improvement Contractor Registration. You may inquire about contractor
registration by writing to the Director at 10 ParkPlam,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888.283-3757.
• Does the contractor have insumdce7 Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to
see a copy of a"proof of insurance"document.
• Enowyom rights and responsibilities. Read the Important Information on the reverse side ofthis form and get a copy of the Consumer .
Guide b the Home Improvement Connector Law.
You my cancei this agreement if it has been signed at a place other dim the cominco es normal place of business,provided you notify the
contractor in writing at his/her main allice,or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight ofthe
third business day following the signing ofthis agreement Seethe h ch d ti f ell ti { farm explamatontofthistight.
DO NOT SIG'' THIS CONTRACT IF TIIERE ARE ANY BLANK SPACES!!!
ter' r`xo idJe�nt'val<opW o[tbe wntrac[mmt be wmpkxd andsigned.Ouc copyshoWtlgato rhebomwwna.its olheraopy ahoWd be ke➢tby thecwtrneror.
Hon wnc Signah a Conhactor's Ss ¢tore
� 4� 3
Date Date /
1�
600tractor Arbitration
The Home Improvement Contractor Law provides homeowners alternative to court action)if they have a dis with the right to initiate anjarbitration action(as an
pute with a contractor. The same right is D-01 automatically afforded to a
contractor,however. The contractor would have to resolve any dispute he/she has with a Homeowner in cote;
both parties agree to the optional clause provided below. This clause would give the contr actor the same ri t to
arbitration as is afforded to the homeowner by the Home Improvementtto
The contractor and the homeowner hereby mumall er, agree Contractor Law.
l
'��c � � �lth �p,¢trhJgr may submit the disputeto a prvance thvate arbitrat oa fivent contractor has a dispute
t Secretary o,' at in the e
the eont'ye,�ftice of cons umer Affairs and Business to rmI
M'stlbu&t to sac&: p }}vvhick has been aipproved by
lzfliittation'�aslProvided In Massachusetts General Laws,chailatton and thejconsumer shall ye required
142A.
Homeowners Signature —
NQ4YCE;The signatures Ofove Contractors Signature resolution initiated by the on
tor.The homeowner may initiate alternative dispute resgl�ttion even where this
PP Y oN to the agreement of the parties toy j]ternaflve dispute
section is not separately signed by the parties.
Homeowner's Rights
A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A' !
protection laws(i.e.MGL chapter 93A)may not be waived in any Way,even b a
may be excluded from certain fights' ), d other consumer
gh if the contractor they choose is not properly registered as prescribed byeIs,,.-
Homeowners who secure their own building permits are automatically excluded from all Guaranty the Home Im rovement Contractor Law. The contractor is Pes onsible for completing the Umel and workmanlike as Fund provisions of,"
Y provides
manner. Homeowners may be entitled to other p g p if
e described,in a
gulirantees or provides an express warranty for workmanshipSpecific legal rights if the contractor
Provided by the contractor,atl goods sold in Massachusetts or materials. In addition to
a particular arry an implied warranty L merchantability or warranties
purpose. An enumeration of other matters on which the homeowner an contr4�torfu a re fitness efor
added totlte terms of the contract w long as they do not restrict a homeowner's basic consiuner rights. If you have
questions about your consumer/homeowner rights,
i is Y agree may be
gh ,contact the Consumer Information Hotline(listed below).
Wxecntion of Contract
The eetytt'act must be executed in du licate and should not be signed until a copy of all extibits and referenced
have been attached. Parties are also advised not to si
filled in or marked as void,deleted,or not apAlicable. One original gn signed he document anti]all plank sections have been
be giyento the owner and the other kept by the contractor. Any modification to the on ' _
copy of the contract with attachments is to
- and agreed.to-byboth parties,Eonnacted Wotkln—tv-tiegin unn botri`pazhes h- rec�eiul d y fjjlly e executed co
the contract,and the three day rescission period has expired. r' lY uSc-bed copyting._._
le copy of
Accelerated Payments
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the
homeowner deems him/herself to be financially insecur ie. However,in instances where a contractor deems
to be financially insecure,the contractor may require that the balance of funds not yet due e
account as a prerequisite to continuing the contracted work. Withdrawal of funds from said nt escrow
�d placed in would
re escrow signatures of both parties. d account would require the
Additional Information
If you have general questions or need additional information about the Home Improvemer��
consumer rights,or if you wish to obtainContractor Law or other
contact: a free copy of "A Massachusetts Consumer Guide to Home Improvement"
i
Consumer Information Hotline r -
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston,MA 02116
611-973-8787,888-283-3757 or visit the OCABR website at htto•//ww, maser ov/ �/
If you Want to verify the registration of a contractor or if you have questions or need information specifically
i addif
about the contractor registration component of the Home hnprovement Contractor Law,c�Onta i�nal
Director of Home Improvement Contractor Registration
Office of Consumer Affars and Business Regulation
10 Park Plaza,Room 5170,Boston,MA 02116
617-973-8787,888-283-3757 or visit the HIC website at h W26wW W m.us ov/ocabr/
Go online to view status of a Home Improvement Contractor's Registration:
httn•//d state ma athe.Mo imorovement/licenseehst as
�j
For assistance with informal mediation of disputes or to register forma]complaints again a business,call:
consumer Complaint Section j
Office of the Attorney General
617-727-8400
AND/OR
Better Business Bureau
508-652-4800,508-755-2548 or 413-734-3114
Version 2.1-11l12I2010
A`i CERTIFICATE OF LIABILITY INSURANCE 3%1i/201133
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 C ME COAetrUotion
Eastern Insurance Group LLC PHONE - (SOB)651-7700 - FAX
233 West Central Street E-MAIL
ADDRESS-
INSURE S AFFORDING COVERAGE NAICM
Natick MA 01760 INsuRERAArbella Protection Ins. Co. 41360
INSURED INSURERBArbella IndeannIty Ins Co. 10017
Atlantic Weatherization e1SURER C Nautilus Insurance Cc
61 Rear Jefferson Avenue INSURER D:
NSURER E
Salem MA 01970 INSURER F:
COVERAGES CERTIFICATENUMBER3•mSTER 2013 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.
I ADDL SUB
L R TYPE OF INSURANCE POLICY NU BER POLICY EFFF— M LICYEXP LIMITS
GENERAL LIAmUTY EACH OCCURRENCE E 1,000,000
X COMMERCIAL GENERAL LIABILITY E Q
EMI Rocco $ 50,000
A CLAIMS-MADE ❑X OCCUR 8500042816 /20/2013 /20/2014 MED EXP Any one person) E 5,000
PERSONAL B ACV INJURY Ns; 2,000,000
1000,000
GENERAL AGGREGATE GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPK)PAGG ,000,000POLICY X PRO- LOC AUTOMOBILE LIABILITY EOa BINaccidEDt SINGL OMIT 000 000 ANY AUTO BODILY INJURY(Per person)ALLOWNED X SCHEDULED 020015871 /20/2013 /20/201d ( )AUTOS AUTOS BODILY INJURY Pereccitlent XHIRED AUTOS X NON-OWNED P PERTYDAMAGE
AUTOS Peraccl ord
X UMBRELLA LIAB X PIP-Basic E -
OCCUR EACH OCCURRENCE E 1,000,000 4
A EXCESS UAB CLAIMS-MADE AGGREGATE E 1,000,000
"
DED 1 600047820 /20/2013 /20/2014 S
WORKERS COMPENSATION STA U- OTH-
ANDEMPLOYERS'LIABILfTY YIN
ANY.PROPRIETOR/PARTNEIVEXECUTIVE E.L.EACH ACCIDENT E
OFFICER/MEMBER E%CLUDEDT NIA
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE E
II ye
DESs,desrnbe under CRIPTION OF OPERATIONS MOW E.L.DISEASE-POLICY LIMIT E
C POLLUTION LIABILITY PL2003786001 O/1/2012 O/1/2013 GENERAL AGGREGATE $1,000,000
EA POLLUTION CONDITION $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more apace Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY OF RAT M ACCORDANCE WITH THE POLICY PROVISIONS.
93 WASHINGTON STREET
SALEM, MA 01970 AUTHORIZED REPRESENTATIVE
Rosemary Elilham/PMA 'CJ'e',
ACORD 25(2010105) 01988-2010 ACORD CORPORATION. All rights reserved.
INS025 ramm,rm Tl.a Ar(1R11 nansa anA Innn aw.anialn.nA ma.Ia of Al:rTGn
Rightfax C3-2 3/11/2013 4 : 4-5 : 54 ,AM PAGE 2/'002 Fax Server
'R CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
T IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICAT O R. 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 and endorsement. A statement on this certificate does not confer rights to
the certiflcate holder In lieu of such endorsements .
PRODUCER CONTACT
NAME:
EASTERN INS GROUP LLC PHONE FAX
233 WEST CENTRAL ST A/C,No,Ext); (A/C,No):
E-MAIL
j NATICK,NIA 01760 ADDRESS:
Yr. 22MLW INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURER A: AMERICAN ZURICH INSURANCE COMPANY
ATLANTIC WEATHERIZATION LLC INSURER B;
INSURER C:
INSURER D:
61 REAR JEFFERSON AVE INSURER E;
SALEM,NIA 01970
INSURER F: '
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
HIS is 10 CERTIFY THAT THE POLICIESOF INSURANCE LISTEDB TO THEINSURED 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. LIMITSSHOWNMAY
HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MMOD\YYYY) (MMOUWYYY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE
MMERCIAL GENERAL LIABILITY $CO
DAMAGE TO RENTED $
CLAIMS MADE OCCUR. REMISES lEa occurrence)
MED EXP(Any one person) $
ERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER'.
ENERAL AGGREGATE $
POLICY =PROJECT =LOC RODUCTS-COMP/OPAGG $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT(Ea accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULEAUTOS - (Perperson)
HIRED AUTOS BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE Is
RETENTION $ I IS
A WORKER'S COMPENSATION AND WC STATUTORY OTHER
h EMPLOYER'S LIABILITY Y/N US.5B270121-13 03202013 03202014 LIMITS
ANY PROPERITOR/PAR XTNEWEXECUTIVE
OFFICERNEMSER EXCLUDED' a N/A E.L. EACH ACCIDENT $ 500,000
(MenEatory In NH) E.L.DISEASE-EA EMPLOYEE S 500,000
IT yes,describe untler
DESCRIPTION nF OPERATIONS below E.L..DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE LMUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE:
CERTIFICATE HOLDER CANCELLATION
CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
93 WASHINTON ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
SALEM,MA 01970 AUTHORIZED REPR TAT}CVE 'rkF?•.,. �l_�e 7�;;:r 4.:.�""'
1VUd-2010 ACORD CORPORATION. All rights reserved.
ACORp 25(2010/05) The ACORD name and logo are registered marks of)
The Commonwealth ofMassachusetts
Department ofludustrial Accidents
Office oflnvestigations
600 Washington Street
Boston, MA 0211.1 y
wjvW.inass.gov1dia
Workers' Compensation Insurance Affidavit: Bu Iders/Contractors/Electricians/Plumbers
AIieant Inforr 011
Name (Business/organizationMdividual : Please Print Le Ibl
> ATLANTIC WEATHERIZATION, LLC
Address: 61R J FF R
SALEM, MA 01970
City/State/Zip: FAX VIM) 745.2200
Phone#:
Are you-an employer?Check the a 1
s 1• I am a employer with vZ�• — pprop 4- E box:
employees(full and/or part-time).* 4 ❑ trauma hired the sub a a generalctor and
Type of project(required):
2•❑ Lam a sole proprietor or partner- 6. ❑New constmcdon
ship and have no employees listed on the attached sheet t 7• Remodeling
working for me in any capacity. These sub-contractors have
workers'comp. insurance.
8. ❑Demolition
'
[No workers comp, workers'
5. ❑ We are a corporation and its 9• ❑Building addition
e
❑ required.] officers have exercised their, 10.0 Electrical repairs or additions
3• I am a homeowner doing all work right of exemption per MGL I [�plumbing repairs or additions
myself. (No workers'comp. c. 152, 14
insurance required.] t § ( ),and we have no
employees.[No workers' 12.❑Roof repairs
t Ho npplicant that checks box#1 must also fill out these 7— below scompj, insurance required.] I3.0 Other
t Homeowners who submit this affidavit indimfin the 8 their workers'coin
pemutiou
g Y ate doing all work and then hire outside contractors must sucy bmit a new affidavit indicating such.
Contmetors that check this box must attached an additional sheet showing the name of the sub-contactom=it the
I am an employer that isproviding workers'compensation insurance for my employees Below is the policy and job site
Policy information.
information
Insurance Company Name:
Policy#or Self-iris.Lic. #: .t6 -�L �tj
Job Site Address:,y�j 1, ExPn'ation Date: ' 20 �•y
City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP V✓ORI{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 a
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the Pains and na/ties ofp¢rjury that the information provided above it true and correct
Sienature:��
Phone# 2 �2 y St-
Official use only. Do not write in this area,to be completed by city or town off
cial
City or Town
Permit/License#
Issuing Authority(circle one): ;
1.Board of Health 2.Building Department 3.
6. Other City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
Contact Person:
Phone#:
VMassachusetts_-Department of Public Safety.
Board of Building Regulations and Standards
Comiru=lion Supen i.�r �f""';_ Unrestricted-Buildings ofany,use group which
License:CS-0879TT _ contain.less than 35,000 cubic feet(991 m')of
I,--' ' " ,),_. enclosed space.
ERIC W PAIM - F LILL
3 HILTON S'F n es t4
SALEM MA-01970t a
Expiration Failure to possess a current edition of the Massachusetts
Commissioner 04/23/2014 -State Building Code is cause for revocation of this license:
For 0P5 UceruingiMumiation visit:-,w .Mass.Gov/0P5
SHOMEIMPROVEMENTCONTRACTOR _ License or registration valid for individut use only
Registration h142089 Type• - i ? before the expiration date. If found returnto
Expiration: 311211014 Ltd Liability Corpor i i :Office of Consumer Affairs and Business Regubtion
O
WEATHERt2ATlONk:1.:C. _ !+ 10 Park Plaza-Suite 5170 i
_ t Boston,MA 02116
ERIC PALM
61R JEFFERSON
SALEK MA 01970. Undersecretary ;•.� III � ��
�Not validtwi[tiout signature
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