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24A-108 (2) 36 PROSPECT AVE BP-2017-0406 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24A- 108 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv: Bath reno BUILDING PERMIT Permit# BP-2017-0406 Project# JS-2017-000673 Est.Cost: $19000.00 Fee: $124.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 101342 Lot Size(su. ft.): 9888.12 Owner: SAVARESE MARY L&JEAN B Zoning:URA(l00)/ Applicant HOME DEPOT AT HOME SERVICES AT: 36 PROSPECT AVE Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVIDENCERI02908 ISSUED ON:9/27/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:BATHROOM RENO 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 ti Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: O1: 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 $124.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-0406 APPLICANT/CONTACT PERSON HOME DEPOT AT HOME SERVICES ADDRESS/PHONE 24 SUNRISE DR PROVIDENCE PROPERTY LOCATION 36 PROSPECT AVE MAP 24A PARCEL 108 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST 4"7-K, ENCI,OSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid / Building Permit Filled gut6/91 / Fee Paid _,,...•/ Tvoeof Construction: BATHROOM RENO New Construction Nun_Structural interior renovations Addition to Existing Accessory Structure Buildinp,Plans Included: Owner/Statement or License 101342 3 sets of Plans/ Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: pproved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Nan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay Sign ure o' uildin. ficial Date Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. Department use only --— --- City of Northampton Status of Permit L.....______ -- _- -. Building Department Curb Cut/Driveway Permit n �ifi 212 Main Street Sewer/Septic Availability L Room 100 Water/Well Availability ` orthampton, MA 01060 Two Sets of Structural Plans l7rm Or MOLDING iNsf !lib 41c-587-1240 Fax 413-587-1272 Plot/Site Plans .4FThAMPt0N MA 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 96 f?a r„ - Map Lot Unit ly `.lYyttVF(L. Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2 Own: of R:cord: /��,, �yy� / /��{,�/ �/ ', /� ;-' vir/. r��" . 3IP ' W tJiY' /V % �l, 1 A, h /°1' . Name(Print) Current Man Address: O rw bo ' Sf, V/n(_ e'l Telephone. Signelure 2.2 Auth•dzed A'i t: A Name(Pent) � ._. / Current MathngAddress y© :A-Z.3 a At r Signature *' Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building J4 Thy } p- iv (a)Building Permit Fee 2. Electricall U F' !J (b)Estimated Total Cost of Construction from(6) 3. Numbing Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection 6. Total a (1 +2+3+4+5) �t� S ri ' _ Check Number _f 7 n This Section For Official Use Only Date Building Permit Number ,,,,, issued: Signature: Building Camrnissionedlnspector of Buildings Date Section 4. ZONING Ati Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to bo filled in by Building Depanmeni Lot Size _ Frontage I _ Setbacks Front Side L: R: h: R: Rear Building Height Bldg.Squaro Footage ,o Open Space Footage dot am minu%LIdg&paced parknid e of Parkin,Sines Fill: (vcolumn&LL<ahoni A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES 0 IF YES: enter Book Page andf or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES fl 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 © NO O IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over I acre or is it part of a common plan that will disturb over 1 acre? YES O 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 Addition Replacement Windows Alteration(s) ❑ Roofing Q Or Doors 0 Accessory Bldg, Demolition ❑ New Signs [O] Decks [I] Siding[0] •t [O( _ , rLbs._ / T,^z"/ DYQ" Brief D.f5,c9'ption of ProJ7osed v CC 3n-ttrtv 47 -2 AlX /7 k '1. ' Work: 1//I-'/Y!l)Bin LI !/✓/i .,. Iu�YCr�/1 1 1 "r3� r/, r�/U- GfreD 5kin l .�. cvnt- Ilia . r (1i-1- P1 -ct rn+-2C/t& )A1£KTf-tm2, w: Alteration of existing bedroom Yes No Adding new bedroom Yes _ No aezVs, fli3 An; - Attached Narrative Renovating unfinished basement Yes No , Plans Attached Roil -Sheet C. 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? it. Proposed Square footage of new construction._ Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. 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 Is Will building conform to the Building and Zoning regulations? Yes No I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENTOR SCONTTRACTORyA�PPLIES FOR BUILDING PERMIT GE y(S„'___ 64.141 g5 c ,as Owner of the subject property hereby authorize 121 �{�'9 �?�>t 61 1 1p*vi to act on my behalf, in all matters relative to work authorized by this building permit application. 6t (irl Cr 1-23-li Signature of Owner Date ? Ali) -ram ,as OwnerfAuthorizod Agent hereby deo:re that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under;,: pair s and penalties ofx. •erjur fe aid / Print Name Signature : Owns'Agent Date • • SECTION S-CONSTRUCTION SERVICES S.1 Licensed Construclion'^Supervisor: 1••//f}} 4 Not Applicablele�C❑ V y j—y Name of Licenae Holder: Vic_ J^ 1 ?( (�� ioa7'G^` License Number 1/0 F n _._.yam g� ........_ Adtlr s Expiration Date z [b w67 rim-- 0/2.3D Signature Telephone Lin 523 133 2- 0.Registered Home ho ovement Co otor: Not Applicable 0 -1-wf l rnq `� i ` i2L -3 Company Name Registration Number 1184 eoO `rig, '3 15- Ad s /� /'�, �) /�'7 Expiration Date ! ���'/// f/ IV Telephone�U/ 33 4 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 issuance of building permit. Signed Affidavit AttaaK es 0 Na 0 11. - `Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) or two(2)families and to allow such homeowner to engage an individual for hire who dues not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.51 Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to 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 thin one home in a two-vvar period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official that heishe shall be responsible for all such wart performed under the buildino permit. At acting Construction Supervisor your presence on the job site will be required from time 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) you hire to perform work for you under this permit. The undersigned"homeowner'certifies and assumes responsibility for compliance with the Slate 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 defined by MGL c 111, S 150A. Address of the work: 96 fizeohr The debris will be transported by: Wim? /Y1-61 �� The debris will be received by: 1/0272C-ca /7 Building permit number: Name of Permit Applicant )2andt) eVi.e/. 1 as -.2 If At . Date Signature of Permit Applicant `,7 FINAL INSTALLATION QUOTE ,nem r Name, Jean Upstairs bathroom Rev,6/2316 06/26/16Flnel Deayml 'S Ln /ego sitc7— +T✓g' Nbonrih,„2/77"r7 f 0/060 Pp: 6£420230 OIL TO FINAL Pre-Construction,Demolition,Removal,and Haul Away WAWA° Rall any requited floor nd site wolecion Octrear .own walls,shower base la\epa existing 'i floor Gut alls.0 Remove bathroomall job-related debris from 5oe Per Box Cabinet Melallallon g7m00 mitaII vanity Electrical 111111250 Remove lg fixture W electrical and carpentry ieedHN[nremove yM $7730] star aKlouvepslWas reqm2dentrynwig need ntnrew line panel $S3000 instal,new light fixture:intlu][s<rpm[rybmeto mount newtling or nil ba $I5]-EO Plumbing 43,231.25 Disconnect toilet and anity p u mMny Demme totn,vanitytoo and venny; s avefw re-installation uisew shower un ing d stal l new nabPiobe.valvenll dpdPlismbnew bathtub tana plameman install and plumb vanity Flooring and Baa splash Installation sl,a nAo Install new ceramic tile naso Drywall Work A Painting $2,735114 stalrew moisture iniroomdn Inducting all Pa'm f applaud trim in room,indudllrgdoor and heater Additional Charges(lfeconcreteleable) S5,351.20 Install new rete boardat d tub walls, Installconcretewall to at ore walls.Include soap nide Tile bathroom tub bwa s ceiling Install ne mediun ns newInstall medinne cabinet Reinstall trim Perin de Plumbing Building WOO Lead Sale Work Practices WOO Asnemos may oe present in a Jwme oust onween awe ano naw and inc rant may ce present in a none Dmu before 1978. Additional charges may occur (the customer does not dispose of product per Federal Mandate of lead i\ Sane Practices. General Notes on the Propel ON RARE OCCASIONS,AODfI!ONAL WORK IS DISCOVERED AFTER A PROJECT HAS STARTED,THE CU5'OMER AGREES THATTH6 ESTMATE IS VALID ONLY FOR THE WORK LISTED AND THAT ANY AGDrOONAL WORK THAT IS DISCOVERED AFTER THE PROJECT HAS BEGUN THAT WAS EITHER MISSED ON THE OR]NAL BID OR ARISES DUE TO UNFORESEEN CIRCUMSTANCES WLL RESULT N ADDITIONAL CHARGES THAT MUST BE PAID FOR BEFORE THE WORK CAN BE COMPLETED. 316.823.19 -/ _ l/l�_ \elz:Af. Kitchen MAN T7`}` ice 6".91..._ //G cierf GC 6lpngva: New: By onNorthampton Building Department ` cd /do�Eo9- *>A PlanReview 212 Main Street Northampton,MA 01060 CH -Vanes from 78"to 91" SCOPE: (see pies) -Replace toilet, vanity.sink-faucet,bathtub, and shower valve. CL-sink-33 1!2 from L CL Toilet- 15 1/2"from L -Install new the on floor, and shower walls. h8 -Replace insulation in exterior wall with -15 fiberglass 1"15 ° 4RScR( (( 1 v � 2t3 X1ar' . tc1� a e rd1S egat5 1 cm b �r TC4LET-I t -11 . MN I I cul N Iw r I = 1 r1 SH OWER • ,A#Y"� 50 " 58}" Jean Savarese 36 Prospect Ave Northampton MA 01060 646-285 4151 POk 52420230 • ,4CO/z� CERTIFICATE OF LIABILITY INSURANCE DATE YY) 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 WANED,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 MARSH USA,INC. NAME: MVO ALLIANCE Nuic ITER xxEu_.EML— Imo.Not: 3560 LENOX ROAD.SUITE 24C0 E-MAIL .ATLANTA,GA 30326 IOORE6: INSURERISI AFFORDING COVERAGE 1 NAICa 10G92-HOMEDGAW-16-17 INSURER A:SNRCIESI Insurance CamPallY ;266387 INSURED N5uRERB:Line MieIlcan Insuran Do 116535 THDAT-HOME SERVICES,INC. I DEA THE HOME DEPOT AT-HOME SERVICES INSURER C:NEW HMIp91ae his Co .233041 2690 CUMBERLAND PARKWAY.SUITE 300 INSURER 0:MIxa Nalional Insurance Company 2917 ATLANTA,GA 30339 ' INSURER E: INSURER F: 1 COVERAGES CERTIFICATE NUMBER: ATL-00374664814 REVISION NUMBER:B 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. ANSR LN TYPE OF INSURANCE 'm p.W V R— posy rJUMaER I IMPxWTOYMf I IP DTYYSY)I LIMITS A X .COMMERCIAL GENERALJABIUTY GLO48$7714-E6 CG101/2016 103/01i2(117 Bpor OCCURRENCE IS 9.030.000 CLAIMS-MACE X OCCUR I I DAMAGE To RECIDb IS 1.000,0011 PREMLSFSIER oft _—__ —_ • LIMITS OFPWCY XS MEC EXP IAn/me poor) • EXCLUDED :OF SIR 31M PER sec 'PERSONALS ADV INJURY IRS 9,000F00 ;ENL AGGREGATE LIMIT APPLIES PER' I • I GENERAL AGGREGATE I S 9,000,1100 X POLICY JECT — LOC - , PRODUCTS-WMPICP AGO 15 9,000.000 OTHER. _ S B AUTOMOBILE UA¢RITY . BAP 2930-13 .03101/2016 03101,12017 I COMBINED SINGLE LIMIT •s 1C00000 •(Ea=quill) X .ANY AUTO .BODILY IWURY(Per person) 5 •—AU_JWNEJ SCHEDULED SELF INSURED AUTO PRY DMB • BODILY INJURY(Per xndenO':S AUTO_InREO AUTOS —TON-OWNED PROPERTY DAMAGE 5 _ _.AUTOS �(Pe gFAeml I L$ :UMBRELLA JAB OCCUR I EACHOCCURRENCE I5 EXCESS UAR CLAMSMADE ' - I AGGREGATE i 5 ' DED RETENTION s S C WORKERS COMPENSATION !WC81551921$AOS ' 1/2016 03101/2017 X STAPER AER 0TW .AND EMPLOYERS'LIABILITYBILT' 1 I I 03NIE Cvlx Y PROPRETORIPARTNERFENECUT/E ' .WC015519217(AK,KY,NH,N4.VT) 03/018016 03MtR0IT ISL EACH ACCIDENT S 1,000.000 D (Or Mandatory in NH)EXCLUDED-, �',xIA µg1551921803101/2016 103101120IT ',IMandal0ry in NH) (FL) EL DISEASE-EA EMPLOYEES 1.003,000 It yes descnbe under iconiu,ue8 on MdibonNP1,000,000 'DESCRIPTION OF OPERATIONS below1 I EL DISEASE-POLICY LIMA s •I .. • DESCRIPTION OF OPERATIONS I LOCATIONS IVEXICLE41ACORD 101.Additional XeniaPS SetlMNe,may be anartheri R ode space:mMNldd) EVIDENCE OF INSURANCE • CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES.INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DEA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WTO.THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE or Marsh USA Inc. Manashi Mukh_. _M>...mL 3d�/aaA4-cL- 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014401) The ACORD name and logo are registered marks of ACORD • LLLL. • rk [ V ! 1l ri Sy i Ti " I� I • yMh io t Yi"Y 2 1 I .I� III 4{ Y iv IdPg 11 1 } s � s sit (y I.,. t;dl • iU >;� .- ,g 8 sH .w,w ,CrAtt Y W 'I� ,-;:.-1r. " ; Lit '4• 4q'o .ty 1 c,' in s, l Litt i'o `;Y 3 µi: 2i ' .y Jr �, MU • {• "R cry,, } L Itt i_ ul t� �i+ i; ,c r� ,B ,,, p i —r' f [Y`—pY hit 2r f Pa yr r� aima .ii, 14 au ? * 4 rJ�I Ir. Ii 11,ii; mct4 say t � ; 'rnw ryj W Fl }F O ren �:i ti ei ire .._- �1y4..1 .. i.Y r 111 {V ,i r. 44141.4. i fl e.•ul .L U let � ,,' U (,m 'a . .rt ! is " ;'fir 1: ii1 i•J a• � i q/"; tt to W ti di :I e� dA yl is i. �' 1' N ki tI(lIYI •r7���iy •:� [:'cf .tI IIL ijk f rl „d J { i. %:7 I .is ' iI 1 ;S I! F 141�j Vik ,}'it uq o-,1 1 U� 0: kii ifl :1 AA kt fi7 _r Al, -, i jfl II I ,�iiLL± ) I t;¢ 7ratit I tXl��f r � 'k4h 1 i` G rI I {ji if f " a) Office of Consumer Affairs and Business Regulation 10 Park P:':aza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 126893 Type: Supplement Card THD AT HOME SERVICES, INC. Expiration: 8/3/2018 RICHARD TROIA 2455 PACES FERRY ROAD, HSC C-11 ATLANTA, GA 30339 Update Address and return card. Mark reason for change. Address Renewal Employment Lost Card Office of Consumer Affairs& Business Regulation License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration: 126893 Type: 19 fart:Plaza - Suite 5170 Expiration: 8/3/2018 Supplement Card Boston. MA 02116 THD AT HOME SERVICES, INC. THE HOME DEPOT AT HOME SERVICES RICHARD TROIA / - 2455 PACES FERRY ROAD, HSC - -- r J ATLANTA, GA 30339 �~� � �, ,Z'L lied crsecreta ry 1 1 ot va id without si nafture ".=-` The Commonwealth of Massachusetts --------"1417-4 Department of Industrial Accidents I Congress Street,Suite 100 oct www.mass.gov/rlia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO RE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): 9'�;jc 1)f Pel , T }-}r; e- i� ;2V)C2S Address: fy',�f11.qq.�� ( C _� ' A (/}?' ,P ._. City/State/Zip 2 ( ii i; P)f^C)InYlfhone#: i2._12j2_ Are you an employer?Check the appropriate box: �'L_�J Type of project(required): I.❑I am a employer with employees(full and/or pan-time)' 7. 0 New construction 2fJ'ama sole propnetor or pannership and have no employees'vorking for me in $, ❑Remodeling any capacity [No workers comp.insurance required] 3.0lamahomeowner doing all work myself[No workers'comp insurance required-1' 9. ❑Demphtlon a Iamenomeowmer and will be hiring109 Building addition -� contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions ;XI am a general contractor and I have hired the sub-contractors II sled on the attached sheet 13 Roof repass These sub-contractors have employees and have workers comp.insurance: 6.❑We arc a corporation and its officers have exercised their right or exemption per MGL c 14Other 152.21(4).and we have no employees.[No workers compinsurance required.) YTTN'Vfi..h097 0-71.5'Any applicant that checks box 21 must also fill ow the section below showing their workers compensation policy information.� '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 state whether or not those entities have employees. !lithe sub-contractors have employees,they must provide their workers'romp.policy number. l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job,site information. f, ..{{�..))77--��}}��,, �f���.[99 / ti�fa r/o/>/1 7ibr - --/`�-7 72 Insurance CompanyName: �f^ ) Policy#or Self-ins.Lie.#: �pL.'V jI717Qt_—l6' Expiration Dale: 3 .. I r L Job Site Address: '3/(1 p/t�� 1 IF[j City/State/Zip: %/ Liar,. #49/9-- Attach b Attach a copy of the workers'Eompensation policy eclaration page(showing the policy number and expir.t ion date),/oko Failure to secure coverage as required under MGL C. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to S250.00 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. I do h= ebycertifa-de t —.B1� ' am pena lies of perjure that ore information provided above is true and correct. Si_namre: �^ 2 - Date: �� Phone#: '1ry/nS 11 I�%y// Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 9. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: CS 101342 S Ry y :, �Y._kpu Y O FU S 1 RE El ‘13. 01230 • .,; tY r 08111?2016