43-167 (3) 428 WESTHAMPTON RD BP-2017-0413
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:43- 167 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:window replaced BUILDING PERMIT
Permit# BP-2017-0413
Project# JS-2017-000687
Est.Cost:$1145.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
use Grouo HOME DEPOT AT HOME SERVICES 99209
Lot Size(sq.ft.): 93218.40 Owner: BERLIN STEVE
Zoning: Applicant: HOME DEPOT AT HOME SERVICES
AT: 428 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCERI02908 ISSUED ON.:9/27/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 1 CASEMENT WINDOW FOR
REPLACEMENT
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 9/27/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
F,_ , City of Northampton Status of Permit:
—1 Building Department Curb Cut/Driveway Permit
SEP 2 7 2616 .12 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Oft ampton, MA 01060 Two Sets of Structural Plans
DEPT
oomrAN�roNN•li VPI 3-'17-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
�2i / f� rte ''; Map Lot Unit
U/ I/// Pk
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: i/
iiimi-i
Name(Print) a-znent�MMai in Atltl ;s/ to laez
'c/ri , eri -telephone
Signature
2.2 Autho S ent: �� "
1720
Name(Ptl j Curren MailingAd ress'
, �1z `
0/�z4
Signa Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building //'-Jl (c bp
(a)Building Permit Fee
2. Electrical ( (b)Estimated Total Cost of
Construction tom(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection /�n ] o41
6. Total=(1 +2+3+4+5) l�Lic. o Check Number / c 38i 40
This Section For Official Use Only
Building Permit Number: / Date
/ Issued:
y��— S/
Signature: ./
i
Building .mmissi. = Inspector of Buildings Date
Section 4. ZONING Ail Information Must Be Completed.Permit Can Be Denied Due Te Incomplete Information
Existing Proposed Required by Zoning
Thiscol uns to be fined in by
Building Depanmem
Lot Size
Frontage
•
Setbacks Front
Side L: R: I,: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
Lot area minus bidg 3 paved
parkinv)
#of Parking SpacesBaiiinie ire Location,
_....
Pitt
A. Has a Special Permit/Variance/Finding ever been issuedfo'�r/on the site?
NO 0 DONT KNOW O YES 0
IF YES, date Issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and Location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E, Will the construction activity disturb(d acing,grading,excavation,or filling)over I acre or is it part of a common plan
that will disturb over 1 acre? YES NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ I Addition ❑ Replacement indows Alteration(s) IL Roofing Q
Or Doors )Z`1.�
Accessory Bldg. ❑ Demolition ❑ New Signs [C] Decks [0 Siding[D) Other[p)
Description of Pro os ,Y- "�
Brief 67721/Work. l � m l cup ( to 1` 4/0 a ki
Alteration of existing bedroom Yes Y No Adding new bedroom Yes No "Z
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Rolf -Sheet
Sa.if New house and or addition to existing housing,complete the following:
a. Use of building:One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
I, Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
It Type of construction_,
i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr, floodplain Yes_No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
J
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR
APPLIES FOR BUILDING PERMIT
I, (J7 j0-zg-bAj .as Owner of the subject
property �}/`"f^� j��jq(/L I
hereby authorize '•.+"to act on my behalf,in all matters relative to work a t ' d by this building permit application
Signature of Owner Date
t, T?Lo of ,as OwnertAu€hodzed
Agent hereby declare t at the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the rfl s a penalti- of p I y.
r A hLJLfi /
11 a
-Print Name
;r er
Q- 771(
Signature of Owner!':=nt �. ' Date
•
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: j�..j)'��j��){�///C/ Not ApplicableA/ ❑�)(g/� /{
Name M License Holder: P/14 aI 3:- kV(.GrVl1 _ L55L~ ` Z % L"tlg
License Number r
! 1A// � � //J—12 - 7
Adde Expiration Date
Nlu1m&e- blU3l
Signae lephone
4W— .Q3 J35�
9,Registered Home Impr.vement Contractor: Not Applicable 0
lit r i G t/ ( c 93
on,.a ;ue , Registration Number
4°P "at 7litl' -
Addres �'�r, Cap' ion Date
,��/I/�j/
f-v �_ /r U/ /5 lePhone 7U —�,A/.' /0 2—
_
SECTION 10-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 issue +. , ' i(a"in permit.
Signed Affidavit Attac -. Yes 0 No 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(-'„)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
AS supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends In reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official that he/she shalt be
responsible for all such work performed ender the building permit.
As acting Construction Supervisor your presence on the job site will be required from lime to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
youhire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code.City of
Northampton Ordinances,State and Local Zoning laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as definednby MGL c 111, S 150k
Address of the work: Ivo W /�!A)/ 4/4c" f A,-
The debris will be transported by: S hYr7 )7774JY
The debris will be received by: Lafcai i:7
Building permit number:
ii��
Name of Permit Applican I l g117D I(Zoo A'
Q-27/4 op/a
Date Signature of Permit Applicant
Job CA'.Macts Saturday,September 24,2016
Comments Lead: 19578035 Go Advanced Search 2:11 PM
MWUPdatas' Homeowner bm$pttnslIen Job Information
Commissions Homeowner MUM steve berlin Sale Amount $1,14500 Balance Due: $80000
Homeowner2 Mrs.Valerie Lavender Product Andersen Windows(8%)
Costs Job Site Address 428 west hampton rd. Status Sale/Material Ordered
FLORENCE,MA 01062 Branch Boston North
Documents
Measure# 78540853
Sched Measure County HAMPSHIRE Sales
Homeowner Billing Address 428 west hampton rd. Commission Rate
FLORENCE,MA 01062 Consultant Name Term Date Spit Comp Plan
Job Issues Timothy Drost 100.00%Straight Commission
Labor Update Primary Phone (413)320-8455
Work Phone Ext. B-Back: No Cross Ref# 1-8530817622 Siebel Ord... 116520
Order Detail Cell Phone Key Dates
Order Entry Work Phone 2 Sale Date 9/19/2016 FUP Date
Cell Phone 2 Credit Date 9/19/2016 FPD-Customer
Payments Email stev0Qmac.com RTP Date 9/192016 Post Install Date
Cross Street Start Date FPD-Home Depot
Permits
Marketing Inspection
PO Referral Store 8452-HADLEY Job Indicators
Result Combo Base Store 8452-HADLEY Lead Paint: No Test-LSWP Not Req I k.)Services Lead Source 0080 Store Associate-OLS
Show Map
TouchPoints
Update Job ,User Dale - 7me IStates —.. Kort. Appt.pate Appt Time IConsWhr 1 .__. 1
Erikka M Lewis 9/24/20161 8:14 AM:Material Ordered No 9/19/2016 8:00 AM:Timothy Drost
Work Orders DErikka avid M Lewis
s • 9/24/2016': 8:14 AM,Order Received-PSG No 9/19/2016 8:00 AM:Timothy Drost I
Richter
!
' 922/2016 5:35 PM Measure Complete No 9/19/2016 8 00 AM Timothy Drost -
1
�CylhinaRaglm '1 9/19/2016 5:23 PM1Released to Production No 9/19/2016 800 AM Timothy Drost
Cythina Raglin 1 9/19/2016, 5:22 PMOrder Entry No 9/19/2016 8:00 AM Timothy Drost
rTimothy Drost I 9/19/20161 - 8:29 AMiCredit Pending No 9/19/2016 8:00 AM.Timothy Drost
(Timothy Drost • 9/19/2016 8:29 AM1S
, ale Pending No 9/19/2016 8:00 AM Timothy Drost
Dayend Dayend 9/18/2016 904 PM Sent to the Field No 9/19/2016 8:00 AM Timothy Drost
ASHLEY B LITTLE 9/18/20161 9:09 AM:Confirmed-Customer No 9/19/2016 8:00 AM Timothy Drost
Internet Lead 9/17/2016 . 9'58AMiPre-Book _ No 9/19/2016 8:OO AM Timothy Drost
Internet Lead !! 9/17/2016 9:58 AMILead Entered No
•
Dom I Print
,
Home Depot Contractor License Numbers:
MA Home Improvement Contractor Reg. # 126894
Salesperson Name and Registration Number:
Timothy Drost : HIS 0553710, R-R-073-15-00005
Home Improvement Agreement
THD AT- HOME SERVICES, INC ("Home Depot") or Service Provider named below will furnish, install
and/or service the equipment listed below at the price, terms and conditions as outlined on this form.
Customer Information:
steve berlin 9578035
First Name lest Name Branch Name Lead a
428 west hampton rd. FLORENCE MA 01062
Customer Address City Slate Zip
(413) 320-8455
Home Phones Work Phone 1 Cell Phone#
stev0@mac.com
Customer E-mail Address
NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR
OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT:
908 Boston Turnpike Unit 1 Shrewsbury MA 01545
Address City State Zip
or Email CustomerCancellationNorthEast@homedepot.com
BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE
SUPPLEMENT PROVIDES A different CANCELLATION PERIOD. THE STATE SUPPLEMENT
CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE.
YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME
DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME
DEPOT OR PROFESSIONAL, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME
CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU.
OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT
HOME DEPOT'S EXPENSE.
THE LAW REQUIRES THAT THE CONTRACTOR GIVE YOU A NOTICE EXPLAINING YOUR RIGHT
TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL
AND WRITTEN NOTICE OF YOUR RIGHT TO CANCEL.
Acknowledged by:
X 09/19/2016
cyst ner.senaw,. Dale
1
Distribution:White-Home Depot Yellow-Customer Copy
•
Andersen Wood SPEC SHEET SC: Timothy DrosE Meeeuee Tech: INSTALLER:
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ACORO O CERTIFICATE OF LIABILITY INSURANCE DATE fros 'r'�
u
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. N SUBROGATION IS WANED, subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer fights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
MARSH USA.INC. NA NE;
PHONE 'FAX
TWO ALLIANCE CENTER LAIC No.Em_ - I IMO,No):
3560 LENOX ROAD.SUITE 24C0 EMAIL
.ATLANTA.GA 3032fi ADDRESS/
INSURE/OS)AFFORDING COVERAGE NAIC3
lO04924-1OniBD-GA'N"-10-17 MSURER A:SIeal:hst NISU2MC Company 1126710]
INSURED &SURER B:Zurich Madcap Insurance Co 116535
DID AT-HOME SERVICES,INC
ODA THE HOME DEPOT AT-HOME SERVICES MSORER C:NEW Hampshire Ins Co 1123841
2590 CUMBERLAND PARKWAY.SUITE 300 tesuimR 0:Minis NaBMIN Insurance Company 2381]
ATLANTA,GA 30339
INSURER E:
• INSURERF:
COVERAGES CERTIFICATE NUMBER: ATL-I303745646-14 REVISION NUMBER:8
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
iYPEOFINSURANLE A—OTQ;AaaR: IMN
POLICY EFF I POUCTtXF 1 LAWS
{n'.yaw POLICY NUMBER IMOMIYYI.INWDMWYI
A X •COMMERCIAL GENERALLWSIUTY •0L04681114-05 1030111216 :0a101i2017 I EACH OCCURRENCE IS 9.000-003
I DAMAGE TO RENTED I
CLAIMS-MADE J OCCUR PREMISES(Ea oane0rnl • 1�` '�
'LIMITS OF POJCV XS MED EXPIAnY one P&mnl III T EXCLUDED
-OF SIR:SIM PER QCC • PERSONAL&ADV INJURY IS 9000'100
OEM.AGGREGATE LIMIT APPUES PER 1 GENERAL AGGREGATE EOM.=
X POLICY . LOC PRODUCTS.COMSTOP AGG 5 9000,00
_ PROG _
OTHER: •
9 AUTOMOBILE LIABILITY BAP 2938863-i3 430112016 .034310317 i,COM�aeeSINGLE OMIT ' S 1.000.003
• X ANY AUTO •
I BODILY IWURY{Per person). I5
--ALL OWHEO SCHEDULED SELF INSURED AUTO PHY DEG RODLY INJURY IPef acNaenO-SAU
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UMBRELLA OAS OCCUR I EACH OCCURRENCE I5
- EXCESS LIAB CLAMS:nADE I AGGREGATE iS _-
DED RETENTIONS 1 S
C WORKERS COMPENSATION IWC015519215(AOS) 03101/2016 ;031911201] 1 X 'I PERTurE I 1 EH-
!AND EMPLOYERS'LIABILITY 0310112%fi 03/012017 1,BU.BM
C OPRIETOPRMTuDffD'ECVr1VE YIN IWC01551921](A1(NY,NH,NJ,VI) I EL EACH ACCIDENT IS
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EXCLUDED') TI ''.NIA. WC015519216 OL0112016 031010017 1,000.007
IManEtlory•in XX) (EL) TEL DISEASE-FA FMPLoy;,4
If yet mamma urn& 1,000,000
'DESCRIPTION OF OPERAI1ONS neIuw ICwImued on ABEIMnal Page TEL DISEASE-POLICY LIMIT S
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DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACORD lotAMMAnai Remarks Schedule,maybe anions If more space is regsre
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
iHD AT-HOME SERVICES.INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
DEM THE HOME DEPOT AT-HOME SEANCES THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA,GA 30339
AUTHORIZED RFPRESONTAIWE
Of Marsh USA Inc.
Manashi Mukhedee MawmkL ...1414-4.4e-e4.4.4%A"4-
C1988-2014 ACORD CORPORATION. All rights resolved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home 'improvement Contractor Registration
Registration: 126893
Type: Supplement Card
Expiration: 8/3/2018
THD AT HOME SERVICES, INC.
RICHARD TROIA
2455 PACES FERRY ROAD, HSC C-11
ATLANTA, GA 30339
Update Address and return card. Mart;reason for change.
I Address Renewal Employment I Lost Card
Office of Consumer Affairs R: Business Regulation License or registration valid for individual use only
HOME IMPROVEMENT CONTRACTOR radon the expiration date. if found return to:
Office of Consumer Affairs and Business Regulation
Registration: 126893 Type: 19 'ark Plaza -Suite 5170
Expiration: 8/3/2016 Supplement Card Rostov MA ;12116
THD AT HOME SERVICES, INC.
THE HOME DEPOT AT HOME SERVICES I
RICHARD TROIAe/
2455 PACES FERRY ROAD, HSC - - /ry��
1"
ATLANTA, GA 30339
'Lilian seerCm 1 C \ �-i�:L
ry i of valid without signature
�\ The Commonwealth of Massachusetts
-gill= Department of Industrial Accidents
1 Congress Street,Suite 100
'_
_
Roston,MI 02114-20 I?
d www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/EiectrkianstPlumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY_
Applicant Information � Please Print/1.717-12:10a.4
Legibly YY/
Name(Business/Organization/Individduual). f ,,...,�c ,;-//b%� p-- 1. <".717-12:10 ..4
Address: Z7g? C ' I 1-3174/14–
City/State/Zip� r iso j;40 ''j Tho 0/594hone#: cfrb—/ZiZ-67/.12_
Areyou enemployer?Check the appropriate box:
Type of project(required):
LU I am a employer with employees(full and/or pan-tmc)*
7. 0 New construction
2.0 1 ant a sole proprietor 0'pannership and have no employees working for Me'in
any capacity [No workers comp.insurance required.]
8. E] Remodeling
3 I are a homeowner solo all work myself No workers'compinsurancerequired9. ❑Demolition
❑ e > ! .]' 10 0 Building addition
CI am a homeowner and will be hiring mrri[actors10 conduct all work on my properly I will
ensure that all contractors either have workers compensation insurance or are sole I In Electrical repairs or additions
proprietors with no employees
I 2.1]Plumbing repairs or additions
))X1ri am a general contractor and I have hired the sub-contractors listed on the attached sheet. 73 �R frepairs
These subcontractors have employees and have workers'comp.Insurance //
6 We ore am and is officers have exercised melr right ofexem wet14. ther �l� S ._
-❑ and
g perMei c. I
I5Z.klIfeb and we have no employees.{No workers'comp insurance requlmdl
Any applicant that checks box al must also fid the on showing thew workers'compensation
mues ibn
f Homeowners who submit this affidavit idalng they are dome all wand then hire outside contractors must submit a new
affidavit indicating such h
:Contractors t cckthsba%muatelecheiyo sheet showing the of the sub-contractorsapd5lato whethermopt Iho9C entities have
employeesIf the sub-contractors have employees,they mos;pcovdP their coot%e[5 comppolicy nItIMber
I am on employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. tt
Insurance Company Name: (VI 40 r �j�''0" l/. .f,., j + Co - �2 i_
Policy#or Self-ins.Lie.
N � t ;L..-,' ' -�j" 'f J Expiration D '�'A yid' /1�!m 1 *Oil( q
Job Site Address: !''i/ /,fr�f��//yA I 4' City/State/Zi ti/'L4fl'(,.N� //✓//IVQL/
Attach a copy of the workers'compensation pa/cy 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 51,500,00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up le$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 verification.
Ida It ery certi it.de t-- -.Ape a ties of perjury that the information provided above is true
and
correct.
Signature' 2"- F O="Yeti a^ )plc: J -2Y J I
Phone#: 6-4b2_--1,4/12---
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Official use(mei Do not write in this area,to be completed by city or town official (t
City or Town: Permit/License if
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#:
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