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HomeMy WebLinkAboutBLD-23-001122 ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department :off.'."y • _ 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 j� 1- ,.;.,t' ` Massachusetts State Building Code,780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: BL-b�- 12,-2— Date Applied: Building Official(Print Name) • Signature �Da`ts f-, C E I V E SECTION 1:SITE INFORMATION I F Li Pr arrif ress:(poodu i1Mapi AU 3 2 9 2022 �Q(( rss. `�✓ 1.2 Assessors &Parcel Numbers 1.1 a Is this an accepted street?yes no Map Number Parcel Number T i'l_DING DEPARTMENT 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required I 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 0 Private 0 Zone: Outside Flood Zone? — Municipal 0 On site disposal system 0 Check if yes❑ f� r,,j(�/_y�SEECTTIION 2: PROPERTY OWNERSHIP` Thríneir O1ord `k �b L` Vcifixintie -- in 64€� Name(Pr, ) City,Ste,ZIP c21- ...pazinpooll, Rek _, /53 0.0.1ckhglyieficZ9nuAt,CAP-i' No.and Street Telephonl Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 I Existing Building 0 Owner-Occupied C}� I Repairs(s) 7 Alteration(s) 0 I Addition 0 Demolition ❑ Accessory Bldg. 0 Number of Units �(! Other 0 Specify: Brief De tion of Proposed Work'scr�5-46\, r`. �(Ai 4.1.14) big' tali. GliCaS (:U (Y/C. 0 r tSairr" " r SLr'CTION 4:ESTIMAT�STRUCTION COSTS. • Item Estimated Costs: Official Use Only (Labor and Materials) 1.BuiIding $ I S S 0 1. Building Permit Fee:$ SO Indicate how fee is determined: 2.Electrical $ El Standard City/Town Application Fee 0 Total Project Costa Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ C-#. 4S09 . 4.Mechanical (HVAC) $ Ltst: 5.Mechanical (Fire $ . . • Suppression) Total All Fees:$ �� 1 Check No. Check Amount Cash Amo 6.Total Project Cost: $ V 0 Paid in Full El Outstanding Balance Due: ' MIII e ki4'J 1d q///ate SECTION 5: CONSTRUCTION SERVICES 5.2 Cos nMors ct" n Supervisor License(CSL) I1 ��3 ssaV Name of CSL Ho r License Number Expiration Date (act V i i d , ek List CSL Type(see below) SNo.td:Street � Type 1 Description �'(pLci C. ► ' e., In Cl,0 U ( Unrestricted(Buildings up to 35,000 cu.ft City/To ,State,ZIP R Restricted l&2 Family Dwelling ) (1 1 M ��'�A l ��� se„r ca(i f.. t/", RC Roofing Covering - WS Window and Siding I Joi. 6A tb-6 SF Solid Fuel Burning Appliances I Insulation Telephone Email address • D i Demolition 5.2 A. ggistered Home Improvement Contractor(HIC) f II(#<$C n' HI�j(',pm e o gistrant Name' HIC Registration Number Expiration Date '( 1\1y"G�e1 th, ' ek o t D O1 I • "13�•((G�}� Emaildd •t �- City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(II.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 U . SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTORIl APPLIES FOR BUILDING PERl%IIT I,as Owner of the subject property,hereby authorize N)."eh f i Cb I)Y)OY to act on my behalf,in a matters relative to work authorized by this building permit application. l�1A. y.)s- ?_,� rant Owner's Name(Electronic Signature) Date • SECTION 7b: OWNER'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 plication is true and accurate to the best of nay knowledge and understanding. j-elfii h.noYS t '')-S i?/) Print Owner's or Authorized Agent'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 program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program can be found at www.mass.nov/oca Information on the Construction Supervisor License can be found at www.mass.aov/dps 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 halflbaths 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" §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22311 ext..1261 Fax 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4. I hereby certify that the debris resulting from the proposed work/demolition to be conducted at 02 k rcut,r o CS(// Rik/ Work Address Is to be disposed of oat the following location: (', (/ �O h Vtilt Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. Si a re of Application Date Permit No. Page 1 of 13 CT Reg#0606216 MA Reg#146689 RI Peg#26463 i .s1�1Seg�t ■■ : s b +: HOME SOLUTIONS 26 Cedar St Woburn, MA 01801 800-242-9974 Federal ID # 20-2625129 Luxury Contract Customer Information Michael Beckner Mike Cell: 508-776-7653 Date: 07/05/2022 Susan Beckner Home Phone: 508-398-3906 Rep: Jason Santos 28 Fairwood Rd mikebeckner1955@gmail.com Office# 800-242-9974 South Yarmouth MA 02664 Location Agreement NEWPRO hereby agrees that it will, for the consideration hereinafter mentioned, furnish all labor and material necessary to install the goods purchased by Owner in accordance with the terms described on the following pages of this agreement (collectively, this "Agreement") at the premises located at: 28 Fairwood Rd South Yarmouth MA 02664 J SV v Custom Shower Details / Package: Tub to Shower(Custom Acrylic/Spray Foam) Wall Color: White Size - Drain: 60"L x 32"W - Left Wall Style: Smooth Base Color: White Walls To Ceiling: Yes Threshold: Single Fixtures Shower Trim&Valve w/4-Function Shower Head QTY 1 Chrome Liquid Accents 12" Grab Bar QTY 1 Chrome Liquid Accents 24" Grab Bar QTY 1 Chrome Liquid Accents Accessories Single Tier Corner Shelf Smooth QTY 4 White Labor Full Tile Removal(Wet Walls Only) QTY 3 Remove Cast Iron or Steel Tub QTY 1 Tub will NOT be removed in one piece Sliding Glass Door Details 5'Platinum Riviera Euro Series (Semi-Frameless) Bathroom 1 Door Height: 75 3/4" Finish: Chrome Glass: 5/16" Clear w/C-10 EZ-Clean Coating Handles: Towel Bar with Pull Knob This space intentionally left blank Page 2 of 13 Installation&Promotion Details Newpro will remove any demoed or installation debris from the property in relation to this contract. All promotions were applied at the time of purchase and can not be combined with any future offers. Discounts Destination Motivation Payment Total Price: $15,850 Deposit: $0 Due Upon Completion: $15,850 Payment Method: Finance Estimated Start&Completion Estimated Start: 14 to 16 weeks Estimated Completion: 1 to 3 days Customer understands they will be contacted to set a firm installation date once all product is received. State MA Year Home was Built 1960 LSWP YES This space intentionally left biasin Page 3 of 13 a -s FIE Renovate Ri•ht Pam•hlet Recei.t Michael Beckner Susan Beckner 28 Fairwood Rd South Yarmouth MA 02664 Your family's health and safety is our top priority! I hereby acknowledge receipt of the pamphlet, "Renovate Right." This pamphlet informs me of the potential risk of lead hazard exposure from renovation activity to be performed in my home. I confirm that I have received this pamphlet before any work began on my home. 117 -42 Michael Beckner Susan Beckner 07/05/2022 07/05/2022 Date Date This space intentionally left blank Page 1 of 19 CREATE A 5 STAR EXPERIENCE FOR EVERY CUSTOMER ASK FOR A REVIEWffim WARD HOME SOLUTIONS Luxury Work Order Customer Information Michael Beckner Mike Cell: 508-776-7653 Date: 07/07/2022 Susan Beckner Home Phone: 508-398-3906 Rep: Jason Santos 28 Fairwood Rd mikebecKner1955@gmail.com Rep# 800-242-9974 South Yarmouth MA 02664 Bathroom 1 Details First floor easy Access to plumbing below.. this is a second home for them as they live out of state. Package Includes Selected Base, 3 Walls, 1 Corner Trim, Floor Repair if needed Shower Measurements Package Tub to Shower(Custom Acrylic/Spray Foam) Wall Color White Size - Drain 60"L x 32"W Left Wall Style Smooth Threshold Single Walls to Ceiling - Room Height Yes- 87 Base Color White Left Side Wall Width 36 Opening Length x Existing Base Width 60" x 32" Left Surround Width 34 Trim Skirt YES Right Side Wall Width 36 Right Surround Width 34 Fixtures Shower Trim&Valve w/4-Function Shower Head QTY 1 Chrome Liquid Accents LA-S12419-C 12" Grab Bar QTY 1 Chrome Liquid Accents LAGB-12-C 24" Grab Bar QTY 1 Chrome Liquid Accents LAGB-24-C Accessories Single Tier Corner Shelf Smooth QTY 4 White CC-ST W Labor Full Tile Removal(Wet Walls Only) QTY 3 Remove Cast Iron or Steel Tub QTY 1 Tub will NOT be removed in one piece Sliding Glass Door Details 5'Platinum Riviera Euro Series (Semi-Frameless) Bathroom 1 Eras space intentionally left blank Page 2 of 19 Door Height: 75 3/4" Finish: Chrome Class: 5/16" Clear w/C-10 EZ-Clean Coating Handles: Towel Bar with Pull Knob Installation Instructions Left Wall Valve - Shower Fixture- Wall Repair- Full Tile Removal - 1 Corner Shelf Back Wall Full Tile Removal - Partial Tile Removal -24" Grab Bar Right Wall Wall Repair- Full Tile Removal - 2 Corner Shelves - 12" Grab Bar Pre-install Checklist Variance Required NO Property Type Single Family Parking Options Street-Small Driveway Fixture Install Shower Head Only Curtain Rod or Glass Doors to be Installed Glass Door Bath Location 1st Floor Existing Base Type Cast Iron /Steel Existing Walls Tile Is there access behind wet wall or below base? YES Below Base Ceiling Panel/Soffit NO Window Within Wet Area NO Wainscoting /Accessories NO Second Full Bath YES Additional Items to be Installed None Are there any existing problems with the plumbing? NO This space intentionally left blank Page 3 of 19 Ima.e: 1.1 fir _ .� x: C a �_ �qa•' .'$ asn parr ,: r7 fi+F's 3% y - �.S y ,` ?c -S �i Y k w- .,, ,r' s,,�.fi' yie'r d . "�x .^��",. i, Jt - x v A ' • Page 9 of 19 Image: 1.7 4 . t. i` g° ' a S�"..a phi = r: 7• r , L r. a ,,,".\.:.,. (.Y 4 V x T SSs, s`P } - .y S"FCC�.., b•w -i Ya$ .K,. ... N . 1 t } Il !/ - . 4..:4'..,,,,. .. _ ,;,' k , t "- ) ,. 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Commonwealth at Mar- • Division of Occupational i... •,,,ure Board of Building Rmlations and Standards C 0 n Artrai. 1445es visor -...'" .F. .• . . . . CS-110763 :-; - pires:05/0512024..-. JEFFREY C0j\INORS .. 64 OLD FLEA RD 1 .,. . —_ . 4.. .,. • SOUTH BERWJCK ME 03909 4...- : -, 4.- t --,. It..0•+,- .1.? ' )1.1,ii A.1- ., - .. •-• -A: , • Commissioner .nt_ ti. Ve.f17Ct.'a.,• 0 •. . • ®A c D s CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 1zr3o/zo21 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 have ADDITIONAL INSURED provisions or 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 452EaeT Melissa Pflug The Hilb Group of New England PHONE EXtI (508)366-6161 FAX 120 Turnpike Rd.Ste 300 EMAIL (AIC.No): ADDRESS: Melissap@mackin6re.wm INSURER(S)AFFORDING COVERAGE NAIL fR Southborough MA 01772 wsuRERA: Employers Mutual Casualty Co 21415 INSURED INSURER a: Newpro Operating LLC INSURER C: 26 Cedar St. INSURER D: INSURER E: Woburn MA 01801 INSURERF: COVERAGES CERTIFICATE NUMBER: 21-22 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AUUL EIIt POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s 1,000,000 CLAIMS-MADE I"I OCCUR DAMAGE TO RENTED 500,000 PREMISES(Ea occurrence) S MED EXP(Any one person) S 10,000 A 6015090 12/3112021 12131/2022 PERSONAL&ADVINJURY g 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE ' $ 3,000,000 POLICY n F 0. n LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: EMPLOYEE BENEFITS $ 1,000,000 AUTOMOBILE LIABILITY GOMBINE9SINGkELIMIP., s 1,000,000 (Ea acddent) ANY AUTO BODILYINJURY(Perperson) S A OWNED SCHEDULED 6Z15090 AUTOS ONLY /X AUTOS 12/31/2021 12/31/2022 BODILY INJURY(Per accident) S X HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY X AUTOS ONLY (Per accident) S Uninsured motorist BI $ 250,000 X UMBRELLA LIAB OCCUR fir,...,C . 5,000,000 EACH OCCURRENCE S A EXCESS LIAB CLAIMS-MADE 6J15090 12/31/2021 12/31/2022 AGGREGATE $ 5,000,000 DEO X RETENTIONS 0 S WORKERS COMPENSATION _ AND EMPLOYERS'LIABILITY YIN X STATUTE 111- ER ANY PROPRIETOR/PARTNER/EXECUTIVE '4 N OFFICER/MEMBER EXCLUDED? N IA EL.EACH ACCIDENT $ 500,000 (Mandatory In NH) EL.DISEASE-EA EMPLOYEE S 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 91000 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Contractor/Carpentry/Siding Install CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE r-. - /ter- I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ACc RD . CERTIFICATE OF LIABILITY INSURANCE 0DATE(M61/0 5/30/20 D ) 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Marsh Affinity PHONE FAX Marsh Affinity (A/C,No,Ext): 866-237-4079 (A/C,No): a division of Marsh USA Inc. E-MAIL D ADDRESS: ADPTotalSource@marsh.com PO Box 14404 Des Moines,IA 50306.9686 INSURER(S)AFFORDING COVERAGE NAIC s INSURER A: New Hampshire Insurance Co. 23841 INSURED INSURER S: ADP TotalSource CO XXII,Inc. INSURER C: 5800 Windward Parkway INSURER 0' Alpharetta,GA 30005 Alternate Employer: INSURER E: Newpro Operating LLC INSURER F: 26 CEDAR ST Wobum,MA 018010000 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD IYYYY) (MM1DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS-MADE OCCUR DAMAGE TPREMISES CEa oau ence) MED EXP(Any one person) S PERSONAL&ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S PRO POLICY JECT LOC PRODUCTS-COMP/OP AGG S OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S (Ea accident) ANY AUTO BODILY INJURY(Per person) S OWNED ^SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) S HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY ,AUTOS ONLY (Per accident) S S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S BED RETENTIONS S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S 2,000.000 OFFICER/MEMBE EXCLUDED/ N/A WC 024509800 MA A (Mandatory in NH}R 07/01/2022 07/01/2023 E.L.DISEASE-EA EMPLOYEE S 2,000,000 f yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) All worksite employees working for NEWPRO OPERATING LLC.paid under ADP TOTALSOURCE,INC.'s payroll.are covered under the above stated policy.NEWPRO OPERATING LLC is an alternate employer under this policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Newpro Operating LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 26 Cedar St Woburn,MA 01801 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) NQ ©1988-2015 ACORD CORPO ION. All rights reserved. The ACORD name and logo are registered marks of ACORD \ i !Departmentof IIndu. tr iabC Accidents Zx _e:j-'') I I Office o1f+'Investigations .i) Lafayette City Center `1- 2 Aveni e de Lafayette., B isto � NJ�� 02 11—a 750 _il Workers' Compensation insurance E`t ai£ avii: I uHi ers/Contr?cto"s/! eciuicians/P be's A milicant if-i f olt'r' ation Please Print Legibly Name (Business/Organization/Individual): NEWPRO OPERATING LLC A ddress:26 CEDAR S T rlity/State/Zip:WOBURN, MA 01801 _ phone ft: 781-933-1 100 Are you an employer? Check the appropriate box: _ 1 =.i'oe of project(u•equ?ier.). l.n I am a employer with 20 4. H i am a general contractor and.I - employees (full and/or part-time).': have hired the sub-contractors 6. p New construction 2.7 I am a sole proprietor or pathier- listed on the attached sheet 7. Remodeling ship and have no employees These sub-contractors have 00. Demolition working for me in any capacity. employees and have workers' 9. 1 Building addition [No workers' comp. insurance _ comp.insurance.= required l 5. I ; We are a corporation and its 10.H Electrical repairs or additions 3officers have exercised their 1 Plumbing repairs or additions T am a homeowner doing all work -•�! Plumbing myself_ [No workers' comp. right of exemption per IvIGL 12.1 ( Roof repairs insurance required.] c. 152, §l(-'•),and we have.no employees. [No workers' 1. . Other comp. insurance required..] `Any applicant that checks box-.must also fill out 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 indication-such. =Coatlactors 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'come_policy number. I am.an employer that is providing workers'corr2pensatioi2 iP2SI Tahee ei'my employees. Below is the policy a.nd job site information. Insurance Company Name: NEW HAMPSHIRE INSURANCE CO — Policy 0 or Seli ins. Lie. ft• tA1C 024266477MA Expiration Date:0 -0 -2023 Job Site Address: t, V ra i r��ea" leol City/State/Zip: (4.1,\) + ' SY-0./(01-kLpi'iL Da��1 :-mach a copy of the workers'kers' compensation'policy declaration nage(showing the policy number and e:pii ation date). Failure to secure coverage as required under Section 25t_of NMGL 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DLA for insurance coverage verification. ao fzereby cep- i i d L 'a :p�naitiies of en wy;.`flat tze Lego,- provided above?s ride amid con,ecL. Signature 7 t h -' Date: U i2...--- V Phone#: 7 3'i-933'?i 00 Official iiSe OY2LJ_ Do not write in this area,to be cai.apJe/ed by city OF cowiE of fiCiaL City or Town: Permit/License# nssuing Authority(check one): DEoard of Health 20 Built7ag Department 30C y/Town catrik. 4i..+Electrical inspector SDPiumb nae Luspec_or 6.DOtiier . Contact?erson: ?'sae e 0: !i