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HomeMy WebLinkAboutBLDR-23-10008 RECEIVED ONE & TWO FAMILY ONLY- BUILDING PERMIT APR _ 023 Town of Yarmouth Building Department 1146 Route 28,South Yarmouth,MA 02664-4492 i , E N r 508-398-2231 ext. 1261 Fax 508-398-0836 ey:_ I;_i •1 Massachusetts State Building Code,780 CMR ..,_•..ti..iy.) — Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling [.1) _2 3' /WV This Section For Official Use Only r Building Permit Number: $ 2 3COp(1,15- Date Applied: Building Official(Print Name) • Signature Date SECTION 1:SITE INFORMATION . 1.1 ,,,iprto bliC tree: I a �, 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?street?yes no Map Number Parcel Number 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: Zone: _ Outside Flood Zone? Municipal 0 On site disposal system stem 0 Public 0 Private 0 Check if yes© p SECTION 2: PROPERTY OWNERSHIP' 2.1 OwUr,,�tfRe j\ W. .Pair(AB/lA� en.*,. ca&73 L�GI� 1 t�-/.l, orAina) �•t City,,State,ZIP�r` UN" t`�W (( (, I" ' D7).q's(' �1�1.ey C�,hf/d.u��^- No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing BuildingkV Owner-Occupied Repairs(s) 9, Alteration(s) 0 i Addition 0 Demolition CI Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed W rk2: 1�5'Va - r�-e Y it SECTION 4:ESTIMATED CONSTRUCTION COSTS. Estimated Costs: Official Use Only Item (Lab r mid Materi ls) I.Building $ I 0 1. Building Permit Fee:S I c.0 Indicate how fee is determined: 1p Standard City/Town Application Fee 2.Electrical $ 0 Total Project Cost3( 6)x multiplier . . x 3.Plumbing $ 2. Other Fees: $ G l *sa 7( 3,5-.0 6 List 4.Mechanical (HVAC) $ . 5.Mechanical (Fire $ Total All Fees:$ Sul iression) p Check No. Check Amount Cash Amount /+1✓ I 0 vOutstanding Balance Due: 1N5 V — 6.Total Project Cost: $ v ❑Paid inFull � SECTION 5 CONSTRUCTION SERVICES 5. Co ' n Supervisor License(CSL) I 6/7(er,3 3.5-,P-1/ te, Y n YC License Number Expiration Date Nam e of SL xo 1/�.� Li (04 CSL Type(see below) N . d Street p Type Description f ( i,� ('j J U ,0 U ( Unrestricted(Buildings up to 35,004 cu.ft.) R Restricted l 2 Family Dwelling City/To ,State,zip M Masonry i t `®' ! ivq i. e �,5 f,�C'. M RC Roofing Covering WS Window and Siding A ( '�, (� sF solid Fuel Burning Appliances' I Insulation Telephone Email address D I Demolition 5..2 l tered Home Improvement Contractor(NC) t rl I �1� en',i n'3 r }TIC Registration Number J Y Expiration Date Incypm e o fG gistraratName 11 Y •q 3 se All(e5 hfe. ot� tl 1 vv `� u i 3 c��vv Email address CityfT'own,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION I TS'URANCE AFFIDAVIT(M.G.L.c.3.52.§ 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 ........."ie No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COUPLE fist)WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PER.IVIIT I,as Owner of the subject property,hereby authorize � Lj0 l�(} to act on my behalf,in all matters relative to work authorized by this building permit application. rQtiil tfs .23 ' t Owner's Name(Electronic Signature) Date • SEC LION 7b:OWNER'OR AOTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information mate ed in this placation is true and accurate to the 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(I3IC)Program),will riot have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the I IC Program can be found at www.mass.aov/oca Information on the Construction Supervisor License can be found at www.anass.govldtns 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementtattics,<decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halftbaths Type of heating system Number of decks/porches Type of cooling system Enclosed Open L 3 "Total Project Square Footage"may be substituted for"Total Project Cost" §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-22* extA261 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 (2)(Lk' /51�& ►"� A11 conducted at 1 D J � Work Address .�-� Is to be disposed of oat the following location: Rit, (AbliCiATI`CeSp Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. I Y'dS Di3 / Sia e of Application Date s . Permit No. Page 1 of 13 CT Reg#0605216 MA Reg#146589 RI Reg 4,6463 HOME SOLUTIONS 26 Cedar St Woburn, MA 01801 800-242-9974 Federal ID#20-2625129 Luxury Contract Customer Information Laura Dell Laura cell: (617)877-9548 0 Date:04/03/2023 481 Buck Island Rd Unit 11 E Laura email: Rep: Matthew Melo W Yarmouth MA 02673 beachlover1121@yahoo.com Office#(800)242-9974 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: 481 Buck Island Rd Unit 11 E W Yarmouth MA 02673 Custom Shower Details Package Tub to Shower(Custom Acrylic/Spray Foam) Wall Color: Arctic Ice Size-Dram: 60"L x 32"W-Left Wall Style: Herringbone Impressions Base Color. White Walls To Ceiling: Yes Threshold: Single Fixtures QTY Brushed Nickel Genta Shower Trim&Valve 1 Moen QTY i Brushed Nickel Annex Rail ONLY Moen QTY Brushed Nickel Multi Function Hand Shower ONLY 1 QTY 1 Brushed Nickel 5'Straight Shower Rod QTY 1 Brushed Nickel 12"Grab Bar Liquid Accents QTY 1 Brushed Nickel 24"Grab Bar Liquid Accents leis space i€itentionally left blank Page 2 of 13 Shower Foot Rest QTY t Brushed Nickel Liquid Accents Accessories Single Tier Corner Shelf Smooth QTY 4 Arctic Ice 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. This sl)ace i tevitic rally left blank Page 3 of 13 Payment NPc Discounted Price: $16,998 Deposit $1,600 Due Upon Completion: $15,398 Payment Method: Finance Estimated Start&Completion Estimated Start: 14 to 16 weeks Estimated Completion: 2 to 5 days (Determined by Plumbing & Building Inspections) Time Management Discount (Included in NPC Discounted Price): $1,000 As always, it is our goal to exceed your expectations. We will work to do so every step of the way. We simply find ourselves not able to make firm delivery promises that we may be unable to keep due to circumstances beyond our control. Rest assured, your completed project and ultimate satisfaction is our number one goal. To express our gratitude for your patience while we navigate these conditions,we are providing you with a Time Management Discount" (see above), as a part of our NPC Discount. We know homeowners want to get the job done as quickly and efficiently as possible. We will do everything in our power to get your project over the finish line. We hope this additional savings demonstrates our commitment to you and that partnering with us will be worth the extended wait. is Laura Dell 04/03/2023 Date State MA Year Home was Built 1979 LSWP NO This space intentionally left blank Page 4 of 13 Renovate Right Pamphlet Receipt Laura Dell 481 Buck Island Rd Unit 11 E W Yarmouth MA 02673 Your family'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. Laura Dell 04/03/2023 Date Residential Exemption Clearance Form ENVIRONMENTAL PROTECTION AGENCY RENOVATION, REPAIR,AND PAINTING RULE Laura Dell 481 Buck Island Rd Unit 11 E W Yarmouth MA 02673 The type and scope of the planned remodeling project is described further herein. On behalf of Newpro,the undersigned individual hereby states that the following exemption from the Renovation,Repair,and Painting Rule is applicable to the planned remodeling project: Work Performed on Paint-Free Surface.To exempt the work area as paint-free, BOTH of the following must be completed: On behalf of Newpro,the undersigned individual has personally examined the specific areas upon which the remodeling work will be performed,as well as any adjacent or adjoining areas{interior and exterior)that are expected to be impacted by the remodeling work.Upon such examination the undersigned has determined that there is no painted surface that will be disturbed, damaged,or otherwise affected or impacted by the planned remodeling project;AND By initialing after this line,the undersigned states that to the best of his and/or her knowledge,the areas upon which the planned remodeling project will be performed do not appear to contain any painted surfaces that will be disturbed,damaged,or otherwise affected or impacted by the planned remodeling project. Customer Initials NEWPRO Representative:I certify under penalty of law that the above Information is true and complete to the best of my knowledge as of the date first written above. Matthew Melo 04/03/2023 Date This space intentionally left blank Page 2 of 2 • MA Reg#146589 CT Reg#0605216 • HOME SOLUTIONS Federal ID#20-2625129 Change Order Customer Information Laura Dell Laura cell: (617)877-9548 0 Date:04/07/2023 481 Buck Island Rd Unit 11 E Laura email: Rep: Matthew Melo W Yarmouth MA 02673 beachlover1121@yahoo.com Rep#(800)242-9974 Description of Change: Remove shave bar, add RH bench seat in arctic ice Payment Previous Contract Amount $16,998 Revised Contract Amount $18,(I08 Original Deposit: $1,� Additional Deposit: $0 Due Upon Completion: $16,408 Additional Deposit Payment Method: None Estimated Start: 14 to 16 weeks Laura b Deli Laura Dell 04/07/2023 Date Accepted:The above prices and specifications of this Change Order are satisfactory and are hereby accepted.All work to be performed under same terms and conditions as specified in original contract unless otherwise stipulated. Matthew Melo 04/07/2023 Date Page 1 of 2 Customer Information Laura Dell Laura cell: (617)877-9548 0 Date:04/07/2023 481 Buck Island Rd Unit 11 E Laura email: Rep: Matthew Melo W Yarmouth MA 02673 beachlover1121@yahoo.com Total Price: $18,008 Deposit $1,600 Balance Financed $16,408 Amount Financed $16,408 Stage 1 to be processed at order ' $8,204 L i) Stage 2 to be processed upon completion $8,204 LbD Financing terms are subject to change based upon review of customer credit history. Customer Info Last 4 Digits of Social 8041 Disclaimers By signing below,I/we,the Borrower(s): 1.Acknowledge submitting an application for a loan with a participating financial institution in the GreenSky Program; 2.Acknowledge receipt of the GreenSky loan agreement("Agreement")with the lender specified on the Agreement("Lender)and agree to be bound by the Terms and Conditions of the Agreement. 3.Authorize the payments in the schedule above subject to mutually agreed upon completion of the project stage; 4.Instruct our Lender to disburse the proceeds of the GreenSky loan to the Merchant identified above in the Amount(s)specified in the Payment Authorization Schedule. The Signature of a Borrower(s)below or the subsequent use of the GreenSky loan to make a purchase will constitute acceptance by all Borrower(s)of the Agreement and the authorization of Borrowers to process the transaction as identified in the Payment Authorization Schedule above. 1)W Matthew Melo Laura Dell 04/07/2023 04/07/2023 Date Date Page 1 of 17 CREATE A 5 STAR EXPERIENCE FOR EVERY CUSTOMER ASK FOR A REVIEWHHII HOME SOLUTIONS Luxury Work Order Customer Information Laura Dell Laura cell: (617) 877-9548 0 Date:04/20/2023 481 Buck Island Rd Unit 11 E Laura email: Rep: Matthew Melo W Yarmouth MA 02673 beachlover1121@yahoo.com Rep#(800)242-9974 Bathroom 1 of 1 Details Impressions Promo** second floor, Homeowner is aware that towel bar will need to be relocated to accommodate the wall package ceiling height is 91", picture is unclear, if necessary I can go back for pic but home is a townhouse with regular height ceilings, nothing out of the ordinary. Parking available in visitor spots, work is permitted behind the residence with easy access through backsliding door Package Includes Selected Base,3 Walls, 1 Corner Trim,3 Wail Repair,and Floor Repair if needed Shower Measurements Package Tub to Shower(Custom Acrylic/Spray Foam) Wall Color Arctic Ice Size-Drain 60"L x 32"W- Left Wall Style Herringbone Impressions Threshold Single Walls to Ceiling- Room Height Yes-91 Base Color White Left Side Wall Width 40 Opening Length x Existing Base Width 59"x 60" Left Surround Width 34 Trim Skirt YES Right Side Wall Width 34 Right Surround Width 34 Fixtures Genta Shower Trim&Valve QTY 1 Brushed Nickel Moen MT 2472-BN Annex Rail ONLY OTY 1 Brushed Nickel Moen TRM-M-3661-BN Multi Function Hand Shower ONLY QTY 1 Brushed Nickel TRM-M-4927-BN 5'Straight Shower Rod QTY 1 Brushed Nickel SRS-60-BN 12"Grab Bar QTY 1 Brushed Nickel Liquid Accents LAGB-12-BN Page 2 of 17 24"Grab Bar QTY 1 Brushed Nickel Liquid Accents LAGB-24-BN Accessories Single Tier Corner Shelf Smooth QTY 4 Arctic Ice CC-ST Al RH Bench Shower Seat Textured Top w/Smooth Sides QTY 1 Arctic Ice LBS-RH-Al Installation Instructions Left Wall Valve-Shower Fixture-Wall Repair-2 Corner Shelves Back Wall Wall Repair-24" Grab Bar Right Wall Wall Repair-2 Corner Shelves-12" Grab Bar-Bench Seat Pre-install Checklist Variance Required YES Property Type Condo/Townhouse WITH Own Shutoff Parking Options Parking Lot-Visitor Parking(Condo) Fixture Install Annex Rail Curtain Rod or Glass Doors to be Installed Straight Curtain Rod Bath Location 2nd Floor Existing Base Type Fiberglass Existing Walls Fiberglass Is there access behind wet wall or below base? NO Ceiling Panel/Soffit NO Window Within Wet Area NO Wainscoting/Accessories NO Second Full Bath NO Additional Items to be Installed None Are there any existing problems with the plumbing? NO This space intentionally left blank • Ima e: 1.1 Page 3 of 17 , • -• .43": "• 1.• r ;";:- ,foxrektren,vato . .s; - •: a ; • ,,seent•t,-;..asy -•..," _ :',..;q:,,R4Vezwqii• • 144.7e4:N•tYeg-z'-r-gAtt V-kt :- 4. -05-1444M-4-APPA*0507,274A. 10047.4 V +-'.24w4C4Vz- ti irAfg*:$*':;,7,S1MT. • -• :;_! _ . --"-' • • : • , - ; - • _ • - .; - Page 13 of 17 • Image: 1.11 ) �; I g4 II 1 t r •C I I f 1 fin' i 4 Ow tx , r , I t r -'-e' A 4 r {3 7 4. 1 4 1 ix �" =r fi F ; 4-s�T'3 ram : - Rrr ,-x ..as a al=t 3 y , • ' ... ., ..ATM r , ' • h?.. X ., A x tI f\'ci .\67\ r. V I 1 o i 1 r r i • Office of ConsumerAffairs and Business Regulation 1000 Washingtcx Street-Sucre 710 Boston,Massachusetts 02118 Home Improvement Contractor Registration 3NE4'1PRO OPE�2A7 kIG LLG � Supplement au Card ?S CEDAR ST- vvoaunN.&10180"r i UpdasAGdneas and%CUM Gera HOME ewIET ly iYPESq Card' b ixe' pira5o rda iffouduat use .RP lton Esouaegn fitGoi gamer.,date.Infotmd return ofi4ceo(£ unnarJeat-aMBafTnpcsRoyuta5nn tassea" o -pro PRO OPSRATING.I1L ;i9A r.'. - tadtlroLeSignadue l-- 11 Commonwealth of Ma Division of Occupational is '=.::ur2 Board of Building Regulations and Standards ��`�IT Cons ons visor •Y CS-110763 �- }empires:•05/05/2024 k t. .• d¢FREYFi17 64 OLD RD ,�t .� SOUTH BER IcK M o.3 es y ', 11.1.i' Lim.-V- *e x Commissioner • y ./S. if, Ut-t17•�Jss� Page 1 of 1 DATE(MM10OIYYYY) ACO CERTIFICATE OF LIABILITY INSURANCE 11/23/2022 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 endorsernent(s). PRODUCER CONTACT Joha Beam Willis Towers Watson Northeast, Inc. NAME: c/o 26 Century Blvd (NC.No.Exti: 1-877-945-7378 PHONE (NC.No): 1-888-467-2378 P.O. Box 305191 ADDRESS:AE certificates@willis.com Nashville, TN 372305191 IISA INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: North Pointe Insurance Company 27740 INSURED INSURER B: Praetorian Insurance Company 37257 NewPro Operating LLC 26 Cedar Street 7NSURERC: Starr Indemnity & Liability Company 38318 Woburn, air 01801 INSURER D: General Casualty Company of Wisconsin 24414 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER:W26742300 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 TYPE OFlNSURANCE ADDL SUBR POLICY EFF POLICY EXP LTRINSD WVD MMn POLICY NUMBER I3DIYYYY► (MMIDD!YYYY) 0 X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE; $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED 1,000,000 PREMISES(Ea occurrence) A MED EXP(Any one person) $ 20 000 171000062 11/23/2022 11/23/2023 PERSONAL&ADVINJURY $ 2,000,000 GENT.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PELT ,X LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER $ AUTOMOBILELIABIUTY COMBINED SINGLE UMIT $ 2,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED 1610007/4 11/23/2022 11/23/2023 BODILY INJURY(Per accident) $ _ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) ,S X UMBRELLALUIB X OCCUR EACH OCCURRENCE $' 5,000,000 C EXCESS LWB CLAIMS-MADE AGGREGATE $ ,1000579769221 11/23/2022 11/23/2023 S 000,000 DED RETENTIONS $ WORKERS COMPENSATION X I STATUTE ER AND EMPLOYERSLIABIUTY D ANYPROPRIETOR/PARTNERIEXECUTIVE Y N EL.EACH ACCIDENT $ 1,000,000 ,000,000 OFFICERNIEMBEREXCLUDED? Li NIA 152000448 11/23/2022 11/23/2023 (Mandatory In NH) EL.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISFASE-POLICY LIMIT $ D Building r CFE1386721. 11/23/2022 11/23/2023 Blanket Limit $26,273,652 Business Personal Prop Blanket Limit $32,049,560 Business Income 6 Extra Blanket Limit $17,008,332 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional Remarks Schedule.may be attached if more space is required) RE: HomeRenew Group Holdings, L.P. acquired NewPro Operating, LLC, NewPro Plumbing, LW and they are now under HomeRenew Group Holdings, L.P. Insurance Program, effective 0S/10/2022. 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 Gar Evidence of Coverage Q 1988-2016 ACORD CORPORATION. All rights reserved. LGyuruxtertt of irtitumnuttiecuwntJ' Office of Investigations j Lafayette City Center Nx1-,�, 2 Avenue de Lafayette, Boston,MA 02111-1750 'twist www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): NEWPRO OPERATING LLC Address:26 CEDAR STREET City/State/Zip.WOBURN, MA 01801 Phone#:781 - 933 4100 Are you an employer?Check the appropriate box: Type of project(required): 1.1 J I am a employer with 20 4. Q I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6' ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. emodeling These sub-contractors have 8 Demolition ship and have no employees working for me in any capacity. employees and have workers' 9. Building [No workers' comp.insurance comp.insurance. ❑ addition required.] 5. [] We are a corporation and its 10.0 Electrical repairs or additions 3.❑`I am a homeowner doingall work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Rooeairs f r insurance required.]t c. 152,§1(4),and we have no ❑ ' employees. [No workers' 7 I3.Q Other comp.insurance required.] *Any applicant that checks box#1 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 Iv employees. Below is the policy and job site information. Insurance Company Name: GENERAL CASUALTY COMPANY OF WISCONSIN Policyy #or Self-ins. Lie. #'152000448 Expiration Date: 11 - 23 - 2023 ,fie Jab Site Address: /1i L [a1r IL. City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration,date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day aginst 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 cert ' under its and penalties of perjury that the information provided above is true and correct Signature: Date: (I J 'dr-5 Phone#: 7 3 - 4100 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License Issuing Authority(check one): 11:3Board'of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector '6.QOther Contact Person: Phone#: