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4 LARKIN LN - BUILDING INSPECTION -7 t�j1� ga The Commonwealth of Massachusetts &4g Board of Building Regulations and Standards FOR j Massachusetts State Building Code, 780 C 7`�edition MUNICIPALITY Building Permit Application To Construct, v,Renovate Or Demolish a Revised January One- or Two- :y Dwelling I,2008 ectionFor Official-Use-.Ohly Building Permit N ber. D Applied: Signature: n / rof Bldui ding Co r ings SECTION 1:SITE INFORMATION 1.1 Pro rty re 1.2 Assessors Map&Parcel Numbers n l.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(it) 1.5 Building Setbacks(it) 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 dis osal rem ❑ Check if yes❑ Pa P SECTION 2: PROPERTY OWNERSDIPi 2.1 07rr of Record• r Name(Print) Address for Service: OK�-,k N 51-)� - -) y V- 39/c . Signature Telephone SECTION 3:DESCRIPTION OFPROPOSED WORK=(check an.that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify: i Brief Description of Proposed Work 2: Uc a,-,.�__ c1,5�cSc e�I��� s /{S// �/ , 1 5 Fn-// 90 l 2 ka 0 - �l�14�. Cs U'If�/S /JO'W/1 Fbr.fS SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials F 1.Building $ 1. Building Permit Eee:$ Indicate how fec is Actemtined: 2.Electrical $ ❑Standard City/Towa Application Fee ❑Total ProjectCose(Item 6)x-multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire Su ression $ Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 2ODD. OD ❑Paid in Full 13 Outstanding Balance Dues SECTIONS C0 STRUCTIQN,SERYICES . 5.1 Construction Supervisor License(CSL) )577 > 3 77i— License Number Expiration Date Name of CSL Holder y.,: w Pam � List CSL Type(see below) No.and Street .mow" tmet - TYpe D'esoriptlon :. U Unrestricted(Buildings up to 35,000 cu.ft _ Stem MA 01970 R Restricted l&2 Family Dwelling City/Town,State,ZIP M Masoru RC Rooftg Covering WS Window and Siding SF Solid Fuel Burning Appliances 4) V 7 I I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) _ % q 2.0 I?q HIC Registration Number Expiration Date HIC Compmy Name"HIC [I L3H AVCI[Ue No.and Street Salan MA 01970 9 7 r 7 yY b/y Email address City/Town,State ZIP Tele hone SECTION G. i 9RI k;S'C01VlpEl ISATft1N INSURANCE AELzii AV 4C L.e.152 i( 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 of1he building permit. Signed Affidavit Attached? Yes—........ No...........❑ SE) LIO1Y7a:O�'SrjYERAAM.HQRIZAnON,TC1 BE COMPLETED FVi EN WJIER SAGENTpR.C.CIh�TItkcCORA1sI'1(IlE O 9xOR$YITLDIIVGPERMIT . .. 1,as Owner of the subject property,hereby authorize Cc, to act on my behalf,in all matters relative to work authorized by this building permit application. Al&', � N n ODY-& � r'Print Ownes Name(Electronic Signature) y9 Date ,, ;..SECTIQN:76 OWNER'ORAUTSORIZED 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 tothe best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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&Lt 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¢ov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns 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" i Massac Iusetts Home Improvement Sample Contract This form satisfies all basic requir'ements ofthe slate's Home Improvement Contractor Law(MGL chapter 142A),but does not include standi language to protect homeowners,I jSeelc legal advice if necessary. Any person planning home improvements should feat obtain a copy of"A Massachusetts Consumer Guide td Home Improvement"before agreeing to my work on your residence.You may obtain a free copyliy calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617.973-8787 or 1-888-283-3757 or on am websitt Homeowner Information Contractor Information it Name li Company Name Ah,,j � tutl( Sneer AddressFCana[use a Post Office•Box address) Contractor/SalespenoN Ovmer `• `f t ar�. C, A cf. , /�a( 61'RJe Cityllmvn State Zip Code Business Address(armt include a� atreefad 4gsasYYe3F1 J m MA 01970 Daytime Phoae venlvg Phone Chytrown State Zip Code Mailing Address (It dill ent form abode) Business Phone Federal EmplayarID air s.S.Number " Lmrt mlLnl mmrhome �"m MpmwmN Cvnlnctw Rey Numea ,Pvminuev tlYe Imamvem anuncbn4nw was nemm,xon�mwer ' The Contractor agrees to do the following work for the Homeowner: (Describe i(nnddetail the work to completed,specifying the type,broad,and grade of materials to be used,as,additional thecto'£ y�) 15 ,f�2 Required Permits-Thefollowingjbudding permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the centractoi as the homeowner's agent: be adhered to unless chmum Lances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of 1C)/ Dace whet centractorvdll begin contracted work MGL chapter 142A.) ��Dace when contracted work will be substantially completed. Total Contract Price and Payment;Schedule The Contractor agrees to perform the worlS furnish the material and labor specified above for the total sum 2 of: ;m Q- �d (•) Payments will be made according to t to following schedule: cZ�06 G� a upon vgnmg con}racf(riot to exceed"173'oYth`e total cdntEa�ce pS'the con tifs'peciel'oideritems whictieGer is grealef)—'—--- - by /_/ or upon completion of -. . by or upon completion of MJL k )V')(0 $ y,za upon completion�'I f the contract. (Law forbids demanding Cull paymentuntil contract is completed to both parry's satisfaction) The following ma[odwacted work must be special $ to be paid for Th ego befog the cdntmcted obat begins in order to meet the completion schedule,'(.*) $ to be paid for i NOTES:(•)Including ell oven.cha iges(+•)Law requires that any deposit or down-payment required by the contractor befog work begins may act exceed the greater of!(a)one-third Of the total contract price or(b)the actual cost crony special equipment m oustam made material which must be special ordered in advance to meat the completion schedule. Fxoress Warrnnty-Is an u '� tvM1' n.,,.;d db tM1 t 40N ❑Y (III RM1 N ba armhdf tl ....... Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless ofthe ambons of any third party/subcontractor utilized by the Contractor. The contractor further agrees to be solelynesponsible for all payments to all subcontractors for mAerislsmdiaborwderthis t Contract Acceptance-Upon signing,this document becomes a binding coconut under law. Unless otherwise noted within this douumenq the contract shall not imply that any liev or other security interest has been placed an the residence. Review the following cautions and notices carefully before signing this centreitl , • Duct be pressured into signing the contract Take time to read and fully andemtand it. Ask questions ifsomething is unclear. • Make sure the contractor has evalid3orneLipprovement Contractor Recistration. The law requires mosthome improvement contractor,and subcontractors ce be mgrstsmd'Iwhh the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director 910 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617.973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his imamate company information so that you can confirm coverage,or ask to see a copy of a"proof ofmsureuce"document • Kcow yaw rights and responsibilities. Read the Important kmfonnation on the reverse side ofthis form and get a copy ofthe Consmoer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place ofbusiness,provided you notify the contractor in writing at his/hermainjoffice or branch office by ordinary mail posted,by telegram sent or by delivery,not leter thm midvight of the third business day following the signing ofthis agreement Seethe attached notice of cancellation form for an explanation ofthis right DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM Twe itlentical cvpiea orWe wntivct mua[be wmplReC mW ai®,e6 One copyfioWtl gv W the Mmevwnu.The vWercopy ebwlC be keptty a,e cavhvctm. Homeowner's Signiftim, Contractor's Signature 4; Data Date it Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate anlarbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless -both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor bas a dispute concerning this contiact''the,contractor may submit the dispute to a private arbitration firms' hich has been approved by the SeCretary� kilie`Uecmi;e Office of Consumer Affairs and Business Regulation and theTonsumer shall be required to dubpaiSQotsucB:ar i"tratiprovided In Massachusetts General Laws,chapter 142A. Homeowner's Signature Contractor's Signature NOTICE:The signatures of the parties above apply only to the agreement of the parties t alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A),and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreemem.1 However,homeowners. may be excluded from certain rights if the contractor they choose is not properly registereq as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the;work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to li=antees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular limpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract - The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,.or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original_contract musstbs i avTiting and agreed to by both parties:Contracted worlCtnay hot begin until both parties have recmived a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment sehedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet duel be placed in a joint escrow account as a preregdisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home hnprovemcn'l Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation �- 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at http://www.mass.pov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additiIrod information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 0. 617-973-8787,888-283-3757 or visit the HIC website at hM,//www.mass.Rov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: hM-//db,state.ma.us/homeimprovementflicenseelist.asl2 For assistance with informal mediation of disputes or to register formal complaints againsl a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 Version 2.1-11/12 2 01 0 Rightfax C3-2 3/11/2013 4 : 45 : 54 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATE YYYYI TWL&CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE OLDER. T S 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 certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: EASTERN TINS GROUP LLC PHONE FAX 233 WEST CENTRAL ST WC,No,EXt): (AID,No): E-MAIL NATICK,MA 01760 ADDRESS: 22ML W INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A. AMERICAN ZURICH INSURANCE COMPANY ATLANTIC WEATHERIZATION LLC INSURER B: INSURER C: -Jr INSURER D: 61 REAR JEFFERSON AVE INSURER E: SALEM, MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 15 TO CERTIFY AT THE OLICI S D RANG BELOWHAVEBEEN 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 MY 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. LIMITSSHDWNMAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MNTDD\YYW) (MMrDD\YYYY) LIMITS GENERAL LIABILITY ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE E]OCCUR. REMISES(Ea occurrence) MED EXP(Arty one person) $ ERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER ENERAL AGGREGATE $ POLICY E::]PROJECT 0 LOC PRODUCTS-COMP/OP AGO $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULE AUTOS HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB R OCCR EACH OCCURRENCE $ EXCESS LIAB CLAIMUS-MADE AGGREGATE $ DEDUCTIBLE RETENTION IS A WORKER'S COMPENSATION AND wCSTATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-5B270'I21-13 032020'13 03/202014 X uMITs ANY PROPERITOR/PARTNER/EXECUTIVE rN7 N/A E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 Il yes,desonte under EL.DISEASE-POLICY LIMIT $ 500.000 DESCRIPTION OFOPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUEI)TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION CITY OF SALEM SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED 93 WASHNTON ST IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED SALEM,MA 01970 - �....'�..;t.a. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. ' h CERTIFICATE OF LIABILITY INSURANCE U1111'/DD/Y3 �� 3/11/2013 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 C AME:N ACT Construction Eastern Insurance Group LLC PHONE . (SOB)651-7700 FAX c 1 233 West Central Street - IL INSURE 3 AFFORDING COVERAGE NAIC# Natick MA 01760 INSURERAArbella Protection Ins. Co. 41360 INSURED INSURERBArbella Indemnity Ins Co. 10017 Atlantic Weatherization INSURERCNaut-ilus Insurance Cc 61 Rear Jefferson Avenue INSURER D: INSURER E Salem MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBERM STER 2013 REVISIONNUMBER: 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. INT PO R TYPE OF INSURANCE POLICY NUMBER pCY EFF POLICY EXP LIMITS GENERAL UABIDTY EACH OCCURRENCE $ 1,000,000 }C COMMERCIAL GENERAL LABILITY PREMISES Ee o a ce $ 50,000 A CLAIMS-MADE aOCCUR 8500042816 /20/2013 /20/2014 MED EXP(Any one person) $ 5,000 PERSONAL S ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE UMIT APPLES PER: PRODUCTS-COMP/OP AGO $ 2,000,000 POLICY X PRO LOG $ AUTOMOBILE LIABIUTY EOaE¢I IEeDtSINGLE LIMIT 11000,00 B ANY AUTO BODILY INJURY(Per person) $NJURYPer accident ALL OWNED X. SCHEDULED 020015871 /20/2013 /20/2014 BODILY I $ AUTOS AUTOS ( ) X HIRED AUTOS X. NON-OWNED PROPERTY DAMAGE $ IAUTOS Per accident PIP-Basic $ X UMBRELLA LIAR ){ OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED 1 RETENTION 600047820 /20/2013 /20/2014 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/NCRY ANY PROPRIETOR/PARTNER/EXECUTWE E.L.EACH ACCIDENT $ OPFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ B yea,aeacdba undaz DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C POLLOTION LIABILITY PL2003786001 0/1/2012 0/1/2013 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,AddiOanal Remade Schedule,If mere 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 CITY OF SALEM ACCORDANCE WITH THE POLICY PROVISIONS. 93 WASHINGTON STREET SALEM, MA 01970 AUTHORIZED REPRESENTATIVE Rosemary EUlham/Pt9L ✓^^a�'8'� ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 nn+msm nee Arrnwn n„ne and Innn ere rarieforarr mark.of Ar:nRn The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Atlantic Weatherization,LLC 61 R Jefferson Avenue Address: Salem MA 01970 City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' Y P tY� 9. ❑ Building addition [No workers' comp. insurance comp. insurance.1 required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] Any applicant that checks box kl must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: n V4 C 1 Policy#or Self-ins. Lic.#: /+_7 176 24 Expiration Date: Job Site Address: La-r' 17 C— /y City/State/Zip: 4 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 WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties oofperjury that the information provided abov Ls true and correct. Sienature: /<w� Date: � G 6—) Phone#: 9 S2 —tiY7 Official use only. Do not write in this area,to be completed by city or town ofj.ciaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hue, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and.who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the,commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cant'workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia UnresWcted-Buildings Of Buy use group which t Massachuserts -Dsp_ar¢marn of Public—Sava' contain less than 35,000 cubic feet(991m)of Board of Building Regulations and Standards 113ibiCGl'Ei11 r.?_ ai iNl±' } enclosed space. � LICERSE:CSa187977 ERIC W PALM-' 3 HILTON ST SALEMMA-01970 R Failure to possess a current edition of the Massachusetts - State Building Code is cause for revocation of this license. Far OPSucensrngil6o don WS1t- w -Mass_Gov/OPS co..=mssioner 04/23/2094 valid for individul use only ✓ �, " License orregistry-bon - 0MCe o nsamermr,—ss kio°a`, A ou before the aspiration data If found retain to: Office of Consumer Affairs and Business Regulation HOME IMPROVEMENT CONTRACTOR T { lOParkPlaza-Suite5170 Registra8on .142089 YPe j Boston,pi -Su - Expiration 3/1=014 Ltd Liability Corpor i! a i . �YIC WEATHERIZAMON LLC. tI t _ ERIC PALM - ? _ 61R JEFFERSON Not valid wtthout srgoa a SALEM,MA 01970 - Undersecretar9 yy