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HomeMy WebLinkAboutBuilding Permit # 4/19/2016 %AORTH BUILDING PERMIT TOWN OF NORTH ANDOVER #0 APPLICATION FOR PLAN EXAMINATION 41000.1 Permit No#: Date Received Are() CHU5 Date Issued: IMPORTANT: Applicant must complete all items on this page --'r- LOCATION LO MA) ZAJ l L16e IdA Print PROPERTY OWNER dMC,,qA Se-077- Print 100 Year Structure yes MAP _JlPARCEL:_O IQZONING DISTRICT: v Historic District yes ra Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential---- 11 New Building family 0 Addition [I Two or more family 11 Industrial "Iteration No. of units: El Commercial El Repair, replacement El Assessory Bldg 11 Others: demolition E1 Other R PJ,R/ [A V;V,/ t," "I' o DESCRIPTION OF WORK TO BE PERFORMED. ewa A� dz�s vae e, &,re.14eAJ (2AOIIA�-tY "— dop up 7o- 6V,6. Identification- Please Type or Print Clearly 15 OWNER: Name: i r4 � e.C NAL Phone: 9,20f-1,62- 413�i 9, J TA-Jr,_qc Zz=z I Address: 341,�;- �hIL>_,o6z. Contractor Name:, .77,.ffui k6'ZMA-A) Phone: Email: 6, , Address: ` ow s_ ' 0 V, Supervisor's Construction License: 67, e3 4; j` 91�V Exp. Date:0,; 2e� Home Improvement License: `12 Exp. Date:6;?­/3 '2017 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. r Total Project Cost: $ � 7 FEE: $ Check Na.: ' 3 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to t. guarantyfund ------------ 646 gnat_ rialure-of-rmtra r ! NORTH Town of W * =� Andover ® ver, Mass 41 %,z� o A- cocNicnewic.c �1' 7ieS OATEO U BOARD OF HEALTH Food/Kitchen �PERMIT T . LD Septic System �' hP F THIS CERTIFIES THAT BUILDING INSPECTOR ...............:..................................................... ....................................... �� �... Foundation has permission to erect .......................... buildings on ..................... .C:.... ...��.. ........ ...................... Rough to be occupied as .......... �..�?.!.�:°:<-. ... .71. ' .��.F.:!................................................................ Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough MONTHS PERMIT EXPIRES I V c MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTI STARTS Rough ............ Service ........... .... � .... ................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Ruildin Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Eastern Construction. PO Box 1266 .--...,., Saugus,MA 01906 US Invoice (781)233-5333 i `'I eastemconstruction@comcast.net' east ernconstruction.net (. C7 iii S T R lC T I G) \ BILL TO Marcia and Scott Lane _,35419aleigh Tavern Lane North Andover,MA Marcia:978.609-4345 Scott:978-578-5329 INVOICE#d, DATE� -. TQ`CAL DUE y ENCLOSED 1589 12/17/2015 $32,170.00 DESCRIPTION OF WORK AMOUNT 1---Remove existing kitchen appliances,cabinets,sink,flooring,and door leading to rear screened in porch area 2--.Remove existing wall coverings down to wall studs 3---Remove existing insulation 4---Install new framing as needed to make opening where sliding door was removed smaller to accommodate a new door. 'exact size to be determined 5---Install new door in new framing 6---Seal new door as needed using Geocel Tripolymer Sealant 7—Install temporary supports as needed to support house where wall is to be removed between kitchen and dining room and opening is to be made wider between kitchen and hallway 8---Remove existing wall separating kitchen and dining room and wall separating kitchen and hallway 9---install new LVL beams or equivalent as needed to support house where wall in kitchen was removed separating kitchen and dining room 10--Install new LVL beams or equivalent as needed to support house where opening between kitchen and hallway was made wider 11--Install new wiring as needed for appliances and 7 recessed lights in new kitchen 12--Install new plumbing as needed for a new sink and garbage disposal new sink is to be located in peninsula between kitchen and dining room 13--Install new plumbing as needed for a new water line for refrigerator 14--Install new insulation between exposed wall studs to code 15--Install new blueb4ard over all walls and ceilings in kitchen area and in porch area where door was changed 16--Apply a new skim coat of smooth plaster over new blueb4ard 17--Install new 7 recessed lights in kitchen ceiling 18--Install now electric outlets in kitchen area to code 19--Install new light switches 20--install new homeowner supplied kitchen cabinets and crown moldings `includes drawer pulls,cabinet knobs,etc,.. 21--Install new Durock Wonder Board on floor and on back splash of wall behind stove 22--Install new homeowner supplied ceramic or porcelain tiles on kitchen floor and back splash of wall behind stove *additional charges may apply if tiles are not ceramic or porcelain or if accent pieces are to be installed with tiles 23--Apply new homeowner supplied grout to new tiles 24--Install new electric toe kick heat 24--Remove excess grout 25--Install homeowner supplied appliances 26--install new misc trim in new kitchen as needed baseboards,door casings,etc... 27--Prime and paint new walls,ceilings,and trim 28--Remove all job related debris V (/ DESCRIPTION OF WORK AMOUNT "'This estimate has an allowance of$600.00 to purchase a new door —This estimate has an allowance of$2,800.00 for pluming,not including fixtures which the homeowner is to supply —This estimate has an allowance of$4,650.00 for electrical; including 7 recessed light fixtures,switches.outlets,plates,and electric toe kick heat —This estimate does not include repairs if necessary to the dining room ceiling. —Additional charges may apply if repairs are necessary to the dining room ceiling —Add$230.00 to this estimate for each LED under counter lights "'Add$2,400.00 to this estimate for electric radiant heat,a thermostat,wiring,and installation 33,170.00 All materials are guaranteed by the manufacturer. All work is to be completed in a professional manner according to standard practices. Any hidden conditions.alterations,or deviations from above specifications involving extra costs will be executed upon written orders,and will become an extra charge over and above the original contracted price. All agreements are contingent upon weather andior delays beyond the control of Eastern Construction. An initial deposit Is to be Paid.:pon proposal acceptance. 'Add 3%for Mastercard,Visa,and American Express transactions TOTAL 33.170.00 'All estimates are based on current product pricing and are subject to change without notice DEPOSIT 1.000.00 'Any changes,variations,or alterations to this estimate will result in BALANCE DUE $32,17®.00 additional charges ��77G n DESCRIPTION OF WORK AMOUNT ***This estimate has an allowance of$600.00 to purchase a new door —This estimate has an allowance of$2,800.00 for pluming,not including fixtures which the homeowner is to supply —This estimate has an allowance of$4,650.00 for electrical; including 7 recessed light fixtures,switches,outlets,plates,and electric toe kick heat —This estimate does not include repairs if necessary to the dining room ceiling. —Additional charges may apply if repairs are necessary to the dining room ceiling **Add$230.00 to this estimate for each LED under counter lights ***Add$2,400.00 to this estimate for electric radiant heat,a thermostat,wiring,and installation 33,170.00 All materials are guaranteed by the manufacturer. All work is to be completed in a professional manner according to standard practices. Any hidden conditions,alterations,or deviations from above specifications involving extra costs will be executed upon written orders,and will become an extra charge over and above the original contracted price. All agreements are contingent upon weather and/or delays beyond the control of Eastern Construction. An initial deaosit is to be paid upon propcsal acceptance. *Add 3%for Mastercard,Visa,and American Express transactions TOTAL 33,170.00 *All estimates are based on current product pricing and are subject to DEPOSIT 1,000.00 change without notice *Any changes,variations.or alterations to this estimate will result in BALANCE DUE additional charges I -C>L2 � Li Note: This drawing is an artistic NORTHEAST KITCHENS Designed: 12/3/2015 interpretation of the general 206 SOUTH MAIN Printed:1/22/2016 appearance of the design. It is NUDDLETON, MA 01949 not meant to be an exact rendition. 978-774-8001 SUSAN SHALKOSKI, C.K.D i .3s� b L�.A c fR5 Pte' �1spe-f2. UF S zk 3'iL r DIn1 � p O i { 24 IF HA Note: This drawing is an artistic NORTHEAST KITCHENS Designed: 12/3/2015 interpretation of the general 206 SOUTH MAIN Printed: 1/22/2016 appearance of the design.'It is MIDDLETON,MA 01949 not meant to be ar exact rendition. 978-774-8001 S�L SUSAN SHALKOSKI, C.K.D 1 -022- Northeast-.Lane-Kalman;< All` Drawing#: 1 14943., T139-0-1-1 W3036 W3015 =A3036 N W361824 _ _I j po { 6F 2D624 PB920TPWW 3DB30 " I 0189024 330 30,-- —i TEP249OWD CABINETRY:SCHROCK APC _ Ap DOOR STYLE: PARKER - ' WOOD SPECIES: CHERRY I FINISH: C Odt-,likMoM DRAWER: MATCHING 5PC 4 n SB27 _ _ 4DE1 N BWB18 DWT50ORWW w =X O IU- NEW 9 w _LO FLOORING V ISBS 1 I_/ � HIGH WALL BUILT Y CONTRACTOR 90;" i dimensions -size designation's NORTHEAST KITCHENS This is an original design and must Designed: 12/3/2015 :n are subject to verification on 206 SOUTH MAIN not be released or copied unless ,4 Printed: 1/22/2016 site and adjustment to fit job MIDDLETON, MA 01949 applicable fee has been paid or job j iitions. 978-774-8001 order placed. SPL SUSAN SHALKOSKI, C.K.D -a�- 0 -heast-Lane-Kalman All Drawing #: 1 3 4 V, S y i RRA", 1 at , M O L-b j, LG J P QZ S CS. ti« LLEVE iq 9- v TO7 0 o k , � o 0 . �D P��11✓C. �g P4M' J r - i U75 Note This drawing is an artistic NORTHEAST KITCHENS Designed: 12/3/2015 interpretation of the general 206 SOUTH MAIN Printed: 1/22/2016 appearance of the design. It is MIDDLETON,MA 01949 �L �. : not meant to be an exact rendition. 978-774-8001 SUSAN SHALKOSKI,C.K.D Northeast Lane-Kalman All # 1 f m- Drawing M'.�,'^. t . 4 T ,' BOMBARDIER cr=� ,SPI N a'° fit-) -ak°§ STRUCTURAL ENGINEERING S Bombardier Structural Engineering 131 Lincoln Street,Abington,MA 02351 ' - - Tel:508-631-3332 ww w.KW Htl D¢19 n.ne, KWhtl¢¢IAn.l, April 12,2016 Ketlh LEED AP BD*0 apt PO BOX5164 4 BOSTON, 07205 (81'✓)813-47171 4LEED AP BD+C k¢mn®ewna¢¢icn. Keith Hinman, �t KWH Design,Inc. ww«.KWHtl¢dvn.n¢, PO BOX 51544 gpMBARDIER Boston,MA 02205 STRUCTURAL ENGINEERING Re: Structural Review (508)6313332 VOICE 345 Raleigh Tavern Road,North Andover,MA. e,)e„-2oe2FAx 345 RALEIGH TAVERN LANE Dear Mr.Hinzman: Per your request,I have reviewed your drawings for 345 Raleigh Tavern Road,North Andover,MA. I dated April 10,2016. The new door header for the opening to the kitchen is correctly sized.One section of the main beam, four 2x10's,supporting the first floor is sistered with an additional 2x10.This is an acceptable solution to increase load capacity where the existing header post and the two new posts at the doorway header load the beam. it is important that all posts are blocked solid to the beam with like sized material.The new 2x10 should be fastened to the adjacent member with 2 rows at 6 inches on center of'/+"diameter by 3''/d'long SDS screws. In my opinion,the drawings are structurally adequate. Sincerely, OF Mgy.�c 9G o= LEON A. m BOMBARDIER ,p No.27616 o e 01 T 70 ° 345 RALEIGH TAVERN ROAD Leon A.Bombardier,PE COVERSHEET Structural Engineer p�p,nome., Pml¢ct Numbat Dem 2018-04-12 e�,w Author ,.e Ch¢ch¢r —CCS 3 J Q i ua1Hof ....SIGH www.KWHde s lOn.net KWH de¢12`Ins. Kelth Hinz—,LEED AP BD+C PO BO%51844 BOSTON,MA 02205 (617)013-4714 kelth®kwhdssl0n.net ——_—___ �1 -t -- /\^J\— STRUCTURAL ENGINEERING (508)6313332 VOICE (787)871-2062 FAX II iI EXISTING(4)9110 CARRYING BEAM ABOVE �Iue. w..n en 'NEW � / ..—.. II �2st0 SISTERBD ABOVEABOVE liI I SI6TEREO BEAM NOTE: it ALL PGSTS TO BE BLOCKED SOLID TO THE BEAMWENT MEMBERITH UKEWITH2 ROWS MATERIAL,TIE NEWTER �! OF 114 LIN CH DIAMETER BY 3THEA .7121NIA LONG SOS SCREWS, ROWS ATBINCHES ON CENTER _ _—_--_ _—— ____ __-- --- _—_— �—�^ - ---- ^— STEPS �( 345 RALEIGH TAVERN ROAD BASEMENT FLOOR 8 P„ti�1��m,,, Pr�leaN�meer zo1s-04-1z A0hcr �yaM Checker A1.01 =_ 1 BASEMENT i!4"•1'-0" TRUE HALFSIZE SET il4"•1'-0" Hogs www.KWHdeelgn.net KWH design.Inc. Keith Hln—,LEED AP BO*C PO BOX 51w BOSTON,W 02205 (SM 9134714 kelthQ"l,deeign.mt BMBAMER STRUCTURAL ENGINEERING EXISTING THREE E%ISTIN m SEASON PORCH (50B)6313332 VOICE DECK 0 (781)871-2062 FAX NO HEADER--s1L-—REM OVE REQUIRED II EXISTING q II NON-BEARING I WALL I s - d H-.�P�A. ...RENOVATED p E%19TiN0gTCHEN BEDROOM NEW NEW NEW POST, POST, POS7, pO PO PO POST, 23 EXISTING STAIR NOT SHOWN ----------- 345 -----_ 345 RALEIGH TAVERN ROAD 1ST FLOOR 8 vmMn ouMw� Protect Number 2016-04.12 .wnW Author x.ea Chockar � A1.02 1 1ST FLOOR 2 1/4"m 1'-0" TRUE HALFSIZE SET 114"m 1'-0" � z ,SIGN -- _ ATTR —_—_— __—_—_—_____—___—_—_—___—_ _ _-1Twww.xwxaeelpn.nml demlpn0lnc.` I Kelth Hlnzm n,TEED Al BD*C PO BOX 51844 ' — , BOSTON,A4A 02205 (817)pia-4714 kelth®kwhdemlpn.net 1STFO------7- R_�� wmv.KWxdeelpn.ne! BONEIMEMER SPLIT -- --- _--_- -- 71— 4 STRUCENGINEERING (53332 VOICE (781)871-2062 FAX BASE M &r-9 1 BD114mn"�1'-0" TRUE HALFSIZE SET QE D CQ � QB A E3 I I i I ,. No. Damen ien Dm I I I I �T FLo, _ I 6PLIT ______ _____ 4 345 RALEIGH _ I TAVERN ROAD A ______ __—___ _ _ __BS'S-MENTA i EXTERIOR J IELEVATIONS FmpetnumCm, Proleet Number 2018-0412 W AWhor Mmaw Checker � ,wen A201 TRUE HALFSQE SEI' ---------_ --_ �,,. www.KW Hdsal9 n.net Fk.IthQkhd..lp n.lna on TEED AP BD*C 644 A 07205 —————— _ _ _ -- 75T FLOOR 714 deelp0.net Sv ssip��n,sat��������pp _———_—_—— SPLIT B M E LA�f E R STRUCTURAL ENGINEERING (508)631332 VOICE ———— — — ——————_ _ _ _ _ BASEMENT (7811871-2082 FAX �Nodh tl4 i-P TRUE HALFSRE SET A I I I I o.d it K_ -------- _ ATlIC I I I I -------- —..-------�— ------ --.... -----._1STFLOOR _. _. 9'— ————_—_——I _—___— - 345 RALEIGH -I TAVERN ROAD ---- ----- ---- - ------- ASFMNETn EXTERIOR ELEVATIONS ar°p°rn—, Pmleat Number 201!1-0412 ..*w Author Checker I r Eoat A202 il4 1-0'TRUE HALFSIZE SET 1l4"=i'-0" i I I I I �SfGN I I ------------ www.KWHdeOiBn.net �— A C NO HEADER REQUIRED KWH j deslpnonnc.Kellh Hlh LEED AP BD-C PO BOX 51644 BOSTON,MA 02205 1617)913-4714 1 Wthakwhdulpn.nel wmv.KWHdoslpn.nef _ _ _. 1 ST F 1300__ n pVMo/Y'•Y� G/l ——————— ————— �� _ _ SPLITS'��V STRUCTURAENGINEERING (508)631-32 VOICE (7131)871-2062 FAX I Fr 2 n SHORTSECTION 1/4 1-0 TRVE HALFSIZE BET TRUE HALFSIZE SET 7ED BEAM NOTE: STS TO BE BLOCKED SOLD TO THE BEAM WITH LIKE SIZED MATERIAL.THE NEW 2X10 D BE FASTENED TO THEADJACENTMEMBER WITH2ROW5 AT 61NCHE5 ON CENTERNCH DIAMETER BY 3-1/21NCH LO NG SOS SCREWS, A—iHDOi TO P21 I . ) DBL EXISTING HEADER ABOVE,r NEW KITCHEN �� - q OPENING P25 �-- P21 P22 ��—P2J 16T FI OOR 8- i.d" I�370s —EXISTING(4)210n DROP-FRAMED BEAM —P——_ P2 .�-P3 •e----P4... PS _PLO—f ———— 345 RALEIGH COINC,FN&EXSTINGClP TD EXI6TIN0 BEAM �'i WALLS TAVERN ROAD EXISTING LALLY COLUMNS--� _ _ ASEM NT SECTIONS -0" 9''" 7'd" 7'-0" 10'-7" 9'.10•• vmp�i Duma., ProIect Number 9'•10" 7'd" 7'-0" 70'-7" 10'-2" 2015-0412 DBO1 D802 DB03µ,-0„ OB04 D806 Author °eW Checkor � n LONG SECTIONScow ` A301 3 1l4 1-0 TRUE HALFSIZE SET ¢ 1!4"•1'4y' 9 l ePR-05-2016 TUE 05; 10 PM P. 001 DATE(MMIDI YYYYY) cam T'IFI AT F LIABILITY INSURANCE4 516 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,Ute pollcy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to tha terms And conditions of the policy,certain policies may require an endorsement. A statemont on this certificate does not confer rights to the certificate holder in lieu of such sndorsement(s). CONTACT PRODUCER NAME: Joan Spears Joseph O Danca Jr Ina Agcy Inc PHONE , (781 322-1322 A N (791) 322-9778 182A Highland Avenue ADDRESSI oan@danaainaurance.com Malden, Nh 02148 INSURE a APPORGING COVERAGE NAIC# INSURER A:Northland Tna INSURED INSURER B; AA & K Construction Ina INSURERO: C/O Steven Kalman INSu D' P.O. Box 1266 INSURERS: Saugus, MA 01906 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN I55UED 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 OP SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_ - ADDL SUER POLICY EFF P LIMITS L R TYPEOFINSURANCE POLICYNUMBQR MM/DD/YYW MM/DD A OENURALLIABILITY N N W8253980 6/2/15 6/2/16 DAMAGE TO RENTED $1 OOO 00� COMMERCIAL GENERAL LIABILITY $ 50,000 X CLAIMS MADE F—I OCCUR MED @XP(Anyona pencn) $ EXCLUDED PERSONAL&ADV INJURY 1$ 1,000,000 GENERAL AGGREGATE $ 2,000,000 $ r CLUDED GEN' AGGREGATE LIMITAPPLIEB PER R PRODUCTS-COMP/OP AGG $ POLICY PRO, LOC CDeNBINED SINGLE LIMIT 8 AUTOMOBILE LIABILITY BODILY INJURY(Per pe:eon) & ANY AUTO ALLOWWD SCHEDULED BODILY INJURY(Pereccldenl) $ AUTOS AUTOS $ NON-OWNEO PPereccl ent HIRED AUTOS _ AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESSI_IAB CLAIMS-MADE AGGREGATE $ DED RETENTION WC STATU- 0TH- VVORKERS COMPENSATION AND EMPLOYERS'LIABILITY E.L.EACH ACCIDENT S ANY CE PMEMBER FXCL W EDECUTNE Y� N/A EX, (fAandamry In NM) PIS -EA Etv1PLOYEE It es toryunder E,L.DISEASE.POLICYLIMrT S D SbRIPTID N OF OPERATIONS Detow DESCRIPTION OF OPERATION&/LOCATIONS/VEHICLES (Attach ACORD 101,Addldonal Rvnnrka$chedule,if more epece to re qU red) CONTRACTOR : JOB LOCATION 345 RALEIGH TAMERN LANE, NO ANDOVER MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 114 TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 120 MAIN ST NO ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE Joan 9 earth 0 19882010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: (978) 688-9542 E-Mail: %OPR-05-2016 TUE 01 : 19 PM P. 001 ® q INSURANCE DATE(MMIDDIYYYYI fico CERTIFICATE ®F LIABILITY INSURANCE 04/05/2016 LDER o�ATE DOES NOT AFFIRMATIVELY EOR NEGATIVELY AMEND,R OF INFORMATION ( TEND OR AND RAL ERNO RTHS TCOVERAGE AFFORDED S UPON THE ABY THE. FOLIC ETE HOLDER. IS BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ust be endorsed. If SUBROGATION IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(lee)mment on this certificate does not WAIVED,t confer rlghtasubject to the terms and conditionB of the policy,certain policies may require an endorsement. A statettoo the cerllflcAte holder In lieu of such andomement e. ONTACT Joan S ears PRODUCER NAME: JR. INSURANCE AGENCY INC. PHONE 7gi)322-1322 AIC No: JOSEPH O. DANCA, AD•MAIL k1 LE oan dancaineuranca.com C INSURER(S)AFFORDING CQVERAO NAIC U 162A HIGHLAND AVENUE, 25874 MALDEN MA 02148 NSURER A; TRAM LERS PROPERTY CAS CO OF AM INSURER B: IN6URED A A&K CONSTRUCTION INC ODA EASTERN CONSTRUCTION CO INSURER C: INSURER D: INSURER E: PO BOX 1266 SAUGUS MA 01908 INeu ERP: COVERAGES CERTIFICATE NUMBER: 42186 aEVISiON NUMBER: THIS 15 TO THAT THENDICATED.CNOTTWITHSTANDINGOLICIES ANY REQUIREMENT.TERM OOF INSURANCE R CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WIHAVE BEEN ISSUED TO THE INSURED NAMEDDTH RES ECT TOLW ICHTIHIS 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 REDUCEoL CY a BY P PICLAIMS. POLIC L:mlTe ILSR TYPEOFINSURANCE POLICYNUaeBER tnMIDD/YYYY EACH OCCURRENCE 3 COMMERCIAL GENERAL LIABILITY $ PREMISES(En occults CLAIMS-MADE Ej OCCUR MED EXP(Airy one arson S WA PERSONAL&ADV INJURY S GENERALAOOREGATE S GEN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS-COMPIOP AGG $ POLICY E]JECT D LOC 9 OTHER: Co nedd D) g AUTOMOBILE LIABILITY BODILY INJURY(Per person) S ANY AUTO BODILY INJURY(Per scddenl) S AUTOS OWNED SCHEDAUTOSULEO N/A PROPERTY DAMA $ NON•OWNED Per ec HIR50AUTOS AUTOS $ EACHOCCURRENCE S UMBRELLA LIAR OCCUR EXCEee LIAR CLAIMS-MADE N/A AGGREGATE S S DEO RETENTION$ " DTH- /\ ATUTE ER WORKERS COh1PEN9ATION AND EMPLOYERW LIABILITY Y/N EL.EACH ACCIDENT S 1,000,000 ANYPROPRIRTOR/PAWfNER/EXECUTIVE NIA NIA NIA 7PJUB2E27247015 05/2212015 05/22/2016 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 A OFFICFRIMrMOFR In NH)EXCLUDED? (man atonydo$Cin NH) E.L.DISEASE-POLICY LIMIT $ 1,000,000 If DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS/I.00ATIONS/VEHICLES(ACORD lot,Additional Remarks Schedule,MAY bo attnahed If more epRGe is requlrod) Workers'Compensation benefits will be paid to MaeaaChUSattS employees only.Pursuant to Endorsement WC 20 o306 B,no authorization is given to pay claims for bene0ts to employeea in states-other than Massachusetts If the Insured hires,or has hired those employees outside of Massachusetts, This certlficate of insurance shows the policy In force on the date that this ebrtlfimonitoredte wee s issuedily by mess th eexp ration Proof of Coverage date on the above policy Ve cedes anon e Issue date of this certificate of insurance). The status of this coveragecan Search tool at www.mass.gov/lwd/workers-compensation/Investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRI13ED POLICIES BE CANCELLED OF-FORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of No Andover 120 Main St AUTHORIZED REPRESENTATIVE C MA 01845 `l C No Andover Daniel M.Crqey,CPCU,Vice President—Residual Market—WCRIBMA ©1988.2014 ACORD CORPORATION, All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD �. Yhe Commonwealth of assachuSeits Department ofindastrialA.celdents x _ . 1 Congress Street,Suite 100 Boston,MA.02114-2017 t ~ www.mass:gov/dia Wavkexs'Compensation Insuranlce Affidavit:l�uiXdexslCozltxactoxs/Electrczczans/PXumbexs. TO Bri I:ffRj)WITH THE PERMITTING AUTHORITY. Please Print I,e 'bl A licant Information uGTi®� Name(Busin.ess/0rgan1zat1or1&d vidual): .Address: �oL,6 i 2• X T City/State/Zip: ,t2/4 Type of'project(required): ,. CdS Are you an employer,?6eckfl ap'roprlate box: L __em toy ees full.andlor part time).' 7. E]New construction 1, am a amployerwith P Fa 2. $.I am a sole proprietor or partnership and have no employees Working for me in Remo dlirig any capacity.[No workers'comp.insurance required.] 9, v[ Bmolitlon am.a homeowner doing all work myself[No wozkerej omp.nisurance required.]' j0 E]Building addition 4.E]I am a homeowner andwill be hiring contractors to conduct all work onmy property. Twill ILEI Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole T 12:E]P] bing re7airs-oadditzol?s— --_ —'–propiietors withno employees 5.E]I am a general contractor and l hage hired the sub-contractors listed on the attached sheet. ]g,Ej R,o Of 4airs 'These sub-contractors lige employees and haveworkers'comp.insurance x 14. Qtj1ex 6.❑We are a corporation and ifs of ftrs have exercised their right of exemption per MGI G. 152,§1(4),and we have nq employees.[No workers'comp.insurance required.] YL pensation policy 0 do *Any applicant that checks Elus4a1 Must indicating they are d°mgcut the section lall work andthen hire outside cow showing their-workers' m ntractors must siubmi aanew af"davit indicating such. Homeowners who subrm . tcontrotozs that check this box mustattached an additional sheet showing the name of the sub contractors and state whether or not(hose entities have employees. 7fthe sub-contractors Have employees,they must provide their,workers'comp.policy number. X am an erriployer that is prdpzdzngworlcers'compensation insurance for my employees'Below is the policy ar�d jolt site information. Insurance Company Name: V / S Policy#or Self-ins,Lie.#: J�$�Z 2 Y '®' Expiration Data: .S ��/� City/State/Zip:_,/ ®�fH fob Site Address: Attach.a copy Of the Workers' compensation policy declaration page(showing the policy number,and expiration date). unishable by a fmo up to$1,500-00 Failure to secure coverage as required undertM en Hies in 152,§he fbrs a xm of a S OPal IWO1on RKpORDER.and ftn.e ofup to$250.00 a and/or,one-year imprisonment,as�v p day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. l do lzerehy cert der thepa' andpenalties ofper jure that the information pr ovided above is true and correct. Date: Si nature: Phone#: • Offtcial use only. Do not write in this area,to he completed by City ar'town offlczar Permit/License# City or Town: Issuing Authority(circle one): i 1.)3oa:rd of Ifealth 2.Building Department 3.City/'Town Clerk 4.Electrical inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person• ............... .... ..____._.............. Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-075948 STEVEN R lKAL [N PO BOX 1266 t� SAUGUS MA 01906-L _ . a `` ` °✓J..�,, .11.6cy� " Iil Expiration Commissioner 03/06/2017 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Cbl ' tor Registration <. ,_ Registration: 182642 Type: Corporation z Expiration: 7/13/2017 Tr# 268344 AA & K CONSTRUCTION CO, INC. -- ` STEVEN KALMAN P.O. BOX 1266 = ° SAUGUS, MA 01906 J(��'�,� ✓t,`�wUpdate Address and return card.Mark reason for change. i..- scn i G 20M-05/11 ❑ Address Renewal Ej Employment E], Lost Card u'e