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BP-2005-41794 Permit No. BP-2005-41794 Map s' ,.01 rna-4:ac'''''' 9 Lot �00 . ,„ „ Spb of ? o0�s - � TOWN OF DARTMOUTH y: A�L 1'.ER.ATION Category. ` 400 Slocum Road,Dartmouth,Mk 02747 P olect i JS-2006 1142 ' z Phone: (508)910-1820 Fax: (508)910-1838 Est Cost: * 1$14658 0(} y Fee . _.: - r , ,t$5000`,r.~y �,x PERMISSION IS HEREBY GRANTED TO: „coast Class . Use Group R4 �-3§' Contractor: License: Phone#: Lot'Size,(sq ft:) , :;2,1IA 3 DANIEL WALSH 111-137943 (781)771-2742 Zoning: ` . ,'SRB Ate_. . . - := Engineer: License: Phone#: New Const - N/A h Alt Canst , 400:sq ft 4 ,,A . Applicant: Phone#: Date Typed: - , 10-2S 20U5 4 a .,,' OWENS CORNING BASEMENT FINISHING SYSTEMS (781)771-2742 OWNER: ALVES PAUL&,KIMBERLY ALVES � DATE ISSUED: // /,I'. 05 TO PERFORM THE FOLLOWING WORK: Finish existing basement walls with insulated panel system; NO STRUCTURAL CHANGES BUILDING PERMIT Project Location: 18 MEDEIROS LN Approved/Issued By: ��_�' _ /� LYNWO .COMSTOCK,LOCAL BUILDING INSPECTOR All work shall comply with 780 CMR 6TH Ed. (MGL Chap. 143) and any other applicable Mass. Laws or Codes and plans on file. POST THIS CARD SO IT IS VISIBLE FROM THE STREET SCHEDULE APPROPRIATE INSPECTIONS AS REQUIRED. UPON COMPLETION OF WORK, FINAL INSPECTION IS REQUIRED. THIS PERMIT WILL EXPIRE PER 780 CMR 111.7(NOT MORE THAN 3 EXTENSIONS WILL BE GRANTED)OR ON ISSUANCE OF A REGULAR OCCUPANCY PERMIT. I hereby certify that the proposed work is authoriz.+" y the owner of record and I have been authorized by the owner to make this tic. '! I as his ag•�'"' d to receive this permit, I further understand other agencies may have rea on t 1 ST q P WO.; f items under their jurisdiction are not met; not withstanding the issuan e O h s : lding//j ni 7..Permit. iSignature of Owner/Agent: Comments: PERMIT NUMBER REQUIRED WHEN REQUESTING INSPECTIONS RE-INSPECTION FEES MUST BE PAID BEFORE;RECEIVING ANOTHER INSPECTION "Persons contracting with unregistered contractors do not have access to the guaranty fund(as set forth in MGL c.142A)" REPLACEMENT FEE WILL BE REQUIRED FOR LOST SIGNATURE CARD TOWN OF DARTMOUTH - /,'9 42747 BUILDING RECEIPTS 4 % U ok TAX ISsu •LLICTO ,,,,, , R'S OFFICE * i , ,, Name:7' 7i /)4-<- re•erty , s'.. -:, ./ „-1( ( )7.11111 1.5-U)(/1.1-1 74 i./1 '''-') 7- ' i 'i f Date Owner: — ,- _-- Job Location: j -) 1 i / i ffL . ..'._..) i ...• 1 _„,,,-,-C' --',.--=------ S Copy-Collector's Office , ,,,,,:-_ , Plot: /If Lot ,/,. .-- T" 1.----- Yellow Copy-Customer's Receipt / / V- (_, ‘ isti t 0$1) Pink qopy-File Copy 4 ....Sireen Copy-Building Department Phone: --7 e i /_ 2 7 c , --.... , i / - t....° , Description General Ledger#'s ef.# - Amount., , License&Permits-Building 01000-44105 ,-; / ,,,, — 1 : i f --- - ) License&Permits-Building Misc. 01000-44105 -, License&Permits-Electrical 01000-44106 License&Permits-Plumbing&Gas 01000-44107 Other Department Revenue 01000-42420 I .// _ // ,1::---" ..--7,„-_ ,',.-,- ,., This is not a Permit or License for Building.Plumbing or Gas Received By:_--ic,---,'---it- it...-. c (,,---,-,..-.• #_ TOWN OF DARTMOUTH 41794 BUILDING RECEIPTS ,,, . COLLECTOR'S OFFICE i ft / ` / / J dam° { Name: ��rr J11 ' / ;, Property - ,. �' --...,.., Date: 47,` , ,r`� r :!b• I--j { _ I," '!c Owner: Job Location: / 11f"f F S •r. / i • 01 White 4 opy-Collector's Office Plot: t � Lot: �� P S7Dulf. low opy-Customer's Receipt J. L , P• C..y-File Copy No eta[ t $ �Gr en C spy-Building Department Phon TA)( ISSUES 1 NIAi13 Description General Ledger#'s ' - . Amount License&Permits-Building 01000-44105 License&Permits-Building Misc. 01000-44105 / '% ; ~- ` ) • %,-/ License&Permits Electrical 01000-44106 License&Permits-Plumbing&Gas • 01000-44107r Other Department Revenue 01000-42420 l 1 This is not a Permit or License for Building,Plumbing or Gas Received By: i .t-. z RESIDENTIAL ❑ FOUNDATIONONL Y $25.00 APPLICATION FEE IS NON-REFUNDABLE &NON-TRANSFERABLE Ta, DATE RECEIVED fmay -----, , DARTMOUTH BUILDING DEPARTMENT P I (t`. ': 400 Slocum Road, P.O. Box 79399 -,... . `D 11 Dartmouth, MA 02747 _',;,- 508-910-1820 FAX 508-910-1838 APPLICATION TO CONST•�'CT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY: I) BUILDING ii,„/A(11, ,«- ,, , DATE SENT FOR REVIEW: j NUMBER: i D E SUED: OK TO ISSUE-SIGNATURE: DATE Buildi g Official Zoning District Pr.•osed Use: _ Zone: ltd` ❑B ❑A ❑ V Outside Flood Zoneuifer Zone THE FOLLOWING A NCIES SHOULD BE NOTIFIED: ❑Board of 0 oard of ❑Con.Corn. 0 Demo 0 DPW"` ❑Elec. 0 Energy Report Appeals ealth Affidavit Card Sent: Cut Off Follow-up* 0 Fire 0 Gas ❑Planning 0 Sewer Card 0 Water Card " ❑ ..O Other Chief Cut Off Board* I Cut Off 1 Cut Off Zoning, *REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT. DEPARTMENTAL APPROVAL Zoning Review: Signature: Date: Energy Report: Signature: Date: Fire Chief: Signature: Date: Board of Health: Signature: Date: Conservation Commission: Signature: Date: Other: Signature: Date: Description of work being performed: fdJ.'-/y SECTION 1 E INFORMATION NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑yes 0 no r 1.2 Assessors Map umber: - 1.1 Property Address: I C-e , c®S Lk) Map Lot Nearest Cross Street: Subdivision Name: 1.3 Historical District 0 yes E Yho Total Land Area Sq. Ft.: Has application —been submitted to the Historic Commission? 0 yes io Date: 1.4 Water Supply(MGL c 40 § 54): 1.5 Sewage Disposal System: C:`,bldg.forms\Bldgapp.res.wpd Page 1 Rev.January 2005 1 i a,4 X. 1 1-r zraar .. SECTION 2-PROPFRTY OWNF'RSATP/AITTHORTZFI)AGENT 2.1 Owner of Record: 0() ), Na e(print) Contact Address Phony'I umber 2.2 Authorized Agent: cUl J C-(22 Ct\D ,\NscA cf (7 o i c��.� 5T � �� i .AN.2 Name(print) Cont ct Address to e Number SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: t j Not Applicable❑ censed Construction Supervisor "� License Number Address 9 o -T--0_4)42 ,6� � ti_?.97 (,-61),b? Expiration Date ; Signature / ���� Telephone tO ,C c� -.(3--) 3.2 Registered Home Improvement Contractor: C ck,4 , Not Applicable ❑ Are you a Home Improvement Contractor subject to(7S0 CMR-6)? ❑yes ❑ , no If no, go to the next section! Are you claiming exemption from the requirement? ❑yes ❑ no If yes, submit the required affidavit! Company Name t Registration Number(if none, state"none") .id.ess el iii Q c4 v*--- 6 �`, j '` )7 I Ck 3 Signature / „jiffy Telephone 7'(�777_a7L Expiration Date f ,�'"jj 9 - d 7 3.3 For Residential Remodel Work Only !! PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND: QUESTIONS OR COMPLAINTS call or write: Home Improvement Contractors Registration. One.Ashburton Place-Room 1301, Boston, M4 02108. (617) 727-8598 Owners Name(p ' L V..< l ' Signature f 1 7 by signing the above, home owner acknowledges that there will be no eli_ibiity to the Guaranty Fund Date 3.4 Homeowner Exemption -One&Two Family Only FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT 109.1.1 licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section l l 6.0,effective July 1, 19S2,no individual shall be engaged in directly supervising persons engaged in construction.reconstruction,alteration.repair.removal or demolition involving the structural elements ofbui ldings or structures,unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction Supervisors. Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section;provides that i f a Homeowner engages a persons)for hire to do such work,that such Homeowner shall act as supervisor. For the purposes of this section only,a"Homeowner"is defined as follows: Person(s)who owns 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 than one home in a two-year period shall not be considered a Homeowner. If you are applying under this section sign below: Signature: Your signature carries certain responsibilities,including but not necessarily limited to,general liability C:\bldg.forms\Bldgapp.res.wpd Page 2 Rev.January 2005 1 RESIDENTIAL NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction Supervisor,whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15) SECTION 4-WORKER'S COMPENSATION INSURANCE AFFIDAVIT(MGL C.152 §25) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit mill result in the denial of the issuance of the building permit. Signed Affidavit Attached: eyes cl, n 0 SECTION 5-DESCRIPTION OF PROPOSEDPO WORK(check all applicable) ❑ newconstruction* 0 addition ['alteration 0 repairs 0 chimney/ 0 woodstove (energy report required) (ener�gy report required) fireplace O deck 0 pool 0 accessory bldg. ❑ replacement window/door ❑ other 0 demolition (shed garage) no. of windows_doors (specify below): (specify below): * If new construction, please complete the following: Single Family: no. of bedrooms no. of baths Two Family: no. of bedrooms unit I no. of baths unit 1 no. of bedrooms unit 2 no. of baths unit 2 ❑ Furnace(hot air) - fuel gas(natural or propane), fuel oil, electricity, other(specify): ❑ Boiler(heating) - fuel gas (natural or propane), fuel oil, electricity, other(specify): ❑ HVAC (combined unit) -primary fuel, natural gas, propane, electricity, other(specify): ❑ Air conditioning-(separate unit) ❑ None of the above to be provided ❑ Hot Water: Gas Electric Fuel Oil Other Brief Description of Proposed Work:�,,,� `-rR 4 , �,� r`Yz- 1�c . C i.�,e f\is (<`�l ..irCf SECTION-6 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(S)to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total =(1 +2 +3 ±4) *Estimated Total S ) `7 ` 6 6' r 0 SECTION 7A-OWNER AUTHORIZATION (to be completed when owner's agent or contractor applies for building permit) (ple e print) _ I, V\.- �'t , as Owner of the subject property hereby authorize a..L cc(-ki;11yr, to, c in a afters relative to work authorized by this building permit application. S'gnaere ofO Tfer Date e � ,� SECTION 7r;-OWNER/ATTTITORI7En AGENT DECLARATION I. �` ` ►� 6( _ , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed n er the _ • s and nalties of perjury. Signa re of Own /Authortze,d Agent Date C:hlda.forms'Bldgapp.res.wpd Page 3 . Rev.January 2005 RESIDENTIAL SECTION 8-INSPECTOR'S REVIEW/CONINIENTS 1. Date plan reviewed: G-' 2. DENIED (see project review worksheet): Date: 3. HOLD reason: Date: 4. HOLD subject to Zoning Board of Appeals action: Date: Comments: Inspector's Signature: Date:® SECTION 9-AP LIC INit NOTIFICATION Applicant inform of fr Date: OO Time: Clerk: Comments: J SECTI V O-OFFICE\INSPECTOR'S NOTES Total Permit Fee: $ Less Application Fee: $ 25.00 Remaining Balance: $ 0 06) TOTAL FEE: 60 Gross Area-New Construction total sq. ft. Gross Area-Alteration totalto sq. ft. ����J / Permit Issued To• /'� �'6Z-5 • 6-, ( / /a���� /J/ /�l1 d�d�U///VVV GLL SECTION 11-ADDITIONAL COMMENTS/SKETCHES ✓ C:'\bldg.forms\BIdgapp.res.wpd Page 4 Rev.January 2005 permit No. BP-2005-41794 Project Location: 18 MEDEIROS LN commonwealth o Vlassacllusetts TOE O DARTMOUTH : � � -; 9 4Q6 Slocum Road,Dartmouth,'MA 02747 , , , ; Phone:($08)910-1820: Faac:(508}910-1838;. • @@ gymo ' fiffuILDE\J,.. _,.> . ,,,,,:! (' „'''':' , , ,„, -,,,,,:„'-',,:,-,:- FIELD,,.,,,,,::z:;,-„- INSPECTION,;,.: ?,-iy:, -- , ,,-:_! „..„,,„,,:,:,,:„:„,,....„„,:,:::,...,,„„:„,,,,,.„,„::,::,::,::,:,,.„.,,.„.,,,,_._,.,,,„,,.„.,„,„:„„„,„:„,„:„.,„„:„:„,,,,,„,,,,,,,,,, ''—-Contractor.; ':'', :License: '':,'-Phone#: ' ` DANIEL WALSH HI-137943 (781)771-2742 :. 7:,', Engineer: ngineer License: Phone#: x Riki i t p4 iIO Applicant: Phone#: OWENS CORNING BASEMENT FINISHING SY TE VIS (781)771-2742 OWNER: NL. ALVES PAUL &,KIMBERLY ALVES i ID DATE ISSUED: JcolpLETEL, TO PERFORM THE FOLLOWING WORK: Finish existing basement walls with insulated panel system; NO STRUCTURAL CHANGES D TE I TIME TYPE OF INSPECTION&REMARKS INITIAL jl /aici _ Ø7% tA '!_-`�=�' Board of Building Regulations and Standards s. =`E 1- One Ashburton Place-Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Reiislratiorc 137943 Type: Supplement Card Expiration: 1/29/2007 • OWENS CORNING BASEMENT FINISHING DANIEL WALSH 960 TURNPIKE ST.CANTON, MA 02021 Update Address and return card.Mark reason for chang El Address El Renewal El Employment El Lost Card besom 0 50M4034G101216 926"gtr(s ronuieal!/c 94.1 4fadaddai Board of Building Regnlafions sad Standards License or registration valid for individul use only II—NM HOME IMPROVEMENT CONTRACTOR before the cation date. If found return to: E-?• RellIstratioM 137943 Board of Building Regulations and Standards ,. °' r 2Pf2007 One Ashburton Place Rot 1301 — Boston,Ma.0210E r._`:f,Ypx=� Card OWENS CORNING BASEMEN' 1�li `-_sue 960 TURNPIKE ST. `f-`n '- . ,,ram✓ CANTON.MA02021 'J Administrator Not'valld without signature • • • • • z 1 I I I P n - - 20 . m n, • :iiiiiiiiiiii a _ ■0PF■Ri■111■■ ■■■■■■■ ■ 1 ■■■. - o T j ■ r4'1■■■■■11■�■�,1.�■■■4■■■ . n 0 33 (' ' IE '1a1■■■■N�La■ ■ ■�■■■■; m -I II immummiwpammommorliginkumagnint '7 1 ■.■ Irtniair""--N-PE7-idimra iiiliiiiiiillllllllllllllllllHI1 v . 0 c 1.„, i 1.0z 1'. r, ■■■■■....� mummemi..■■i■.■■■■■.■aG ), T'1 itEmamranmvi.■■■ ■■ ■■ 1. i= ■ . ■ 111111111FINN: m•• , _ 11111111101111111111711 ■■ _ I••••••■•■•11111J1M111mCl q i . 4,.11 1111111 IIIIIIHhIHH �IlUhlIllhlli: ■■ ■F.■■■■■.■.■■■■■■tI■■ ■■■■■■■■Er -3 ., ! 1r1111111111111ZIMMIIIlI ■ N■ ■ ■� ■■ ■y ■ . ■ ■1 ■■ ■ •: :11 i ,.., taribliblell1111111111111i !PIHHHILIIHHHHHL o co 0 :i■■■■■■.■.■■.■11•. _ 1 y p m ,). f m,. g a S �y 3 0.2 � ; C+ = r� itgII 11111111111111 ; '�li • - A ■■■ °0 61 iiiiiiiiiiiiiiiiiiIIIII1III'Ciii■.■■■■.■.■■■.■■■■■■■.■■■■■■.■■ 0) IIIjIHIHIHHIHflhhhhhflhhhhhfl: Jill5 _ J w. r N S RESIDENTIAL _ 0 FOUNDATION ONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE &NON-TRANSFERABLE ;0, :�,,� Tf, ;. :I FStcTE RECEIVED / 13� f; DARTMOUTH BUILDING DEPARTMENT f '- 400 Slocum Road, P.O. Box 79399 tV Dartmouth, MA 02747 r�' ' `, 12: 39 508-910-1820 FAX 508-910-1838 APPLICATION TO CONST',.`CT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY: BUILDING P� DATE SENT FOR REVIEW: NUMBER: �� DATE ISSUED: OK TO ISSUE-SIGNATURE: DATE Building Official Zoning District: Pr osed Use: Zone: ❑ C ❑B ❑A ❑V Outside Flood Zone❑Aquifer Zone THE FOLLOWING A NCIES SHOULD BE NOTIFIED: ❑Board of 0 oard of ❑Con.Com. 0 Demo ❑DPW Cl Elec. 0 Energy Report Appeals ealth Affidavit Card Sent: Cut Off Follow-up* ❑ Fire 0 Gas 0 Planning 0 Sewer Card 0 Water Card • ❑ 0 Other Chief Cut Off Board* /Cut Off /Cut Off Zoning *REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT. DEPARTMENTAL APPROVAL Zoning Review: Signature: Date: Energy Report: Signature: Date: Fire Chief: Signature: Date: Board of Health: Signature: r %�U'(..L �� i'�(.k..-� �, Date: /c� -2:~7( Conservation Commission: Signature: Date: Other: Signature: Dte: l C C. L S ��G� work l vet u Description of work being performed: SECTION 1- E INFORMATION NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑yes 0 no • 1.2 Assessors M a of Number: 1.1 Property Address: / rV\Pt.c.W, La..? Map Lot - Nearest Cross Street: Subdivision Name: 1.3 Historical District 0 yes Total Land Area Sq. Ft.: Has application been submitted to the Historic Commission?— ❑yes ©o Date: 1.4 Water Supply(MGL c 40 § 54): 1.5 Sewage Disposal System: C.`.bldg.forms\Bldgapp.res.wpd Page I Rev.January 2005 eanvino,luveallAot_ BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR .s Number: CS 079893 Birthdate: 10/05/1962 Expires: 10/05/2007 Tr.no: 6491.0 Restricted: 00 DANIEL F WALSH 488 KENDALL RD TEWKSBURY, CL /9/ EWKSBURY, MA 01876 Commissioner 05/28/2005 13:04 FAX 1 781 6S9 4?2S Andrew C Gordon Inc 4001 .,i coi wren 1z:zs PAGE 002/002 LW/ • • • Loerty Mutual Group • , PO Boa 7102 fr'j� Mxl Pertsu outk,NEI03802-7202 Tdepi<ase(800)653-7893 Fax(603)431-5693 May26,2005 NAUGHTON do CO 960 TURNPIKE ST CANTON,MA 02021- • RE: Certificate of Workers Cnehpehhahfssa Insurance Iashhred: OWENS CORNING FINISHED BASEMENT 960 Tt960 TURNTEKEST CANTON,MA 02021 Po&icyNu r_ WC2-3IS-344359-015 Effedivc 5Q4/2005 Fxpkatieur 5/242006 Coverage afforded under Wasters Couspensafion Law ofthe following stater(& MA Enslavers Liability: • Bo&lyIajsyByAccident S 500,000 Each Accident BodilyIa ryyDiarat= S 500,000 Each bum BodilyInjwybyDiseasc S 500,000 PoEcyLisuits As of this date;the abovereixenced policyholder is ionised byL'1>QtyMutual Fire Insurance Co wader the poEc y listed above. The insurance afforded by the fisted parley is subject to all the lan;=d tiaus and cantraionr,and is act aketed by any requirement,Leant or cc c Ii a afaay or other dour with respect 10 which this eaTilcale maybe issued. This cafhficate is issued as a der ofinformation only and confers no right apm.you,the ee 1 fiehde holder. This ccxtificateis act as inssrancepoihcyand does not amend e:;ead,ar alter the coverage afforded by the po&cy Estod above. If this poEcyis caaccfl d before the stated agics$ea date,Maly wi ladczror to nctdyyou of such caaoellateaa_ K e-agi-4 AUIHORIZED 112PRESENTAIIVE MERIT MUIIIALI S[arAlKf GROUP ThisCatermairisimerbil lerIMITMETWALINSCRAMEGIODUr.c. i.,.cme:rsisibsweesswies. cc Insured: Producer°gean& OWENS CORNING FINISHED BASEMENT ANDREW G GORDON INC 960 TURNPIKE ST P O BOX 299 CANTON,MA. 02021 NORWEL1 MA. 02061 irasrsru 05/26/2005 TRU 12:36 tTZ/RI lE0 51441 lik002 I I VIII-LVGy11 WVV CU-(WH11611Ja,UIi111611VC IdN✓.V a/I./vJJ IV I v.1lvv(11 ACORD_ CERTIFICATE OF LIABILITY INSURANCE OPID EC DATE(MMLxri BAYST-1 08/19/05 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Kaplansky Insurance Brookline HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 114 Harvard Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Brookline MA 02446 Phone:617-738-5400 Fax:617-738-8214 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER& Norfolk & Dedham Group 13943 INSURER B: g7y§fate Basement System LLC B/A Owens Corning Finishing INSU:FRc 960 Turnpike St INSURER0: Canton }O02021 • INSURER E: - COVERAGES TEE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI00 INDICATED.NOTNRTHSTANDNG ANY REOUREIENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUhENT WITH RESPECT TO,M-IICH THIS CERTIFICATE MAY BE ISSLED OR MAY PERTAML TEE INSURANCE AFFORDED BY THE POLICIES DESCRIBED IEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICES.AGGREGATE LNIII1S 9-0M1 MAY HAVE BEEN REDUCED BY PAID CLAIMS. HMK vUUL POUCYLH-EL LITE POLICY EXPIRATION LIR NSRD TYPE OF INSURANCE POLICY NUMBER DATE(MOONY) DATE R.114/DD/YY) UNITS ' GENERALLIABLITY EA HOCaEENCE s 1000000 • CO*4ERC AL GENERAL LIABILITY PRai'EisEs�REN 1«a«Ioe) $ 10000 0 D.NMS MACE •n OCCUR MED FXP(Any one Person) $ 5000 A X Business Owners R0309626 02/10/05 02/10/06 PERsoNAL&(wviiw-r $1000000 GENERAL AGGREGATE s 2000000 GEHL AGGREGATE LIMIT APPLIES PER: PRODUCTS-coMPToeADG $2000000 nPOLICY n n LOC . AUTOMOBILE LIABILITY ANY AUTO (EaCONEINED SMGLELIMIT $accident) ALL OWHEDAUTOS BODILY WURY i SCHEDULED AUTOS (Pr person) HIRED AUTOS BODILY NON-OWNED NJTOS • (Per = PROPERTY DAMAGE _ (Pareceidert) GARAGE LIABILITY - AUTO ON.Y-EA ACCIDENT f 70NYAUTO DTHfRTHAN EA ADC f AUTO ONLY: AGG f EXCESS/UMBRELLA LYLBLITY EACH ONCE f OCCUR .❑CLAIMS HAN:E AGGREGATE f • OEOUC RE $ RETENTION $ WORKERS COMPENSATION AND W.-SIAIU- OIH- EIPLOYEtS'UAB UTY TORY LIMITS ER ANY PROPRETORPARTNER)EXECUTIVE E.L.EACH ACCIDENT $ OHTICER/FEMBER EXCLUDED? - E.L.DISEASE-EA EMPLOYEE f IT yes.describe=der SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT f OTHER • DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAC, 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAM O TO THE LEFT.BUT FALURE TO DO SO SHALL POSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON TIE INSURER,ITS AGENTS OR REPRESENTATIVES. AuNgral Tu AC IMPOSE 0AXONE CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents 1 — I Office of Investigations 1 • 600 Washington Street = Boston, MA 02111 SV•�W www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information � Please Print Legibly Name (Business/Organization/Individual): 0\ Yv 7 cS j0\A Address: I'l 62 ® CU¶ c_ }-n'C u Gi City/State/Zip: Phone #: (70 7 1 ` 9 71,4) Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ri New construction employees(full and/or part-time).* have hired the sub-contractors 2. /am a sole proprietor or partner- listed on the attached sheet. + 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. [7 Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.E1 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.1-1 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: kiln (Vt'cj. Policy#or Self-ins.Lic. #: - 3 5 3< L. 35q"C3 t,5 Expiration Date: '—v2 4 - 0 Job Site Address:____4 M ik ,,'ram_ City/State/Zip: 06" 1` 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 c i under;,ins a f%`p , r ie if perjury that the information provided above is true and correct Signature: „yl, II' Date: 10 ( 8 -O cS Phone#: C Ti ) �L a "7. 'L 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 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 hire, 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 apai intents 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 carry 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 burn 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 5-26-05 www.mass.gov/dia