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HomeMy WebLinkAboutBuilding Permit # 11/8/2016 of BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION T y Permit Not#: Date Received aye 4a� rEp rP���� � ssac��s� Date Issued: ORTANT: Applicant must complete all items on this page LOCATION Pnnt PROPERTY OWNER 1ao:Y ' Pnnt ear Structure yes no MAPPARCEL ZONING DISTRICTHistancD�str�ct yes no Machine 5 op Village yes no .. TYPE OF IMPROVEMENT PROPOSED USE Resi ential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑ eration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others- ❑ Demolition ❑ Other ❑'Septic ❑ Well . ❑ Floodplain ❑Wetlands ❑`Watershed District WaterlSevver, DESCRIPT ON OF WORK TO BE PERFORMED: 1 IS)9-MJ- '� vwi , 7 I- It 1 fes`', ' ` Id ntification lease Type or Print Clearly' . OWNER: Name: .I L/ ( , Phone- - Address: 5 � � o' 7- /4- c e Contractor Name �SIG�b-Plone: . 1� Address,' Supervisor's Construct�on.License Exp. Dater Home Irriprove merit 1*icense.. Exp. Dater .. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDINC PERMIT.-$12.00 PER$1000,00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. ,Total Project Cost: $�� (1�} FEE: $ Check No.: Receipt No.,- NOTE: o„NOTE: Persons contracting with unregistered contractors do not have.access to the g ara nd Signature of AgenYOwnerSignature of contractor Plans Submitted ❑ Plans Waived 0 Certified Plot Pian ❑ Stamped Plans ❑ -TyP13 bF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming fools ❑ p Well ❑ Tobacco Sales ❑ Food.Packaging/Sales ❑ Private (septic tank, etc, Perinanent Dumpster on Site f 5 M X THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGNf OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature COMMENTS CONSERVATION Reviewed on Si nature COMMENTS HEALTH Reviewed on �� Si nater COMMENTS Y1 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sower Con nection/Sig nature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT` -,Temp Dumpster on site yes no Located at 124.Main Sheet Fire Department Signature/date COMMENT dimension Number of Stories: Total square feet of floor area, based oil Exterior dimensions. Total land area, sq. ft..- ELECTRICAL; Movement of Motor location, mast or service drop,irequires approval of Electrical Inspector Yes No ©ANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and a€nin.$10041000 fine NOTES and DATA--- (For department use) ❑ Notified for pickup Call Email ate Time Contact Name Doc.Building Permit Revised 2014 :. I . NORTH own of Q .. ' : ` 0 No. s h ver, Mass 'QA coc"Ic Nl Wilicoc - 'Z7.�S R�rEv r.QR,��CS U BOARD OF HEALTH Food/Kitchen PERMIT T Septic System M THIS CERTIFIES THAT ,,, . .. ..... t ...... , ��, BUILDING INSPECTOR has permission to ere t .. buildings on # .,..,1. CC ...... Foundation Go Rough tobe occupied as .., ......,.. .1 ..•........ ... .... .......,... 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. 4Q1 PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. IL ou g Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC STAR Rough ... Service ........ .. ... .. ........ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy .Permit Required to Occupy Buildin 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. DocuSign Envelope ID:657983ED-FF3F-4422-B9E5-40456ECDCCBF Home Imorovement Aereement E&C Contracting LLC 14 McGrath Hwy Somerville, MA 02145 781-526-7501 E&C Contracting LLC of 14 McGrath Hwy, Somerville, Massachusetts 02145 ("Contractor") and Karen O'Donohue of 6 Queen Street, Newburyport, Massachusetts 01950 ("Owner") enter into this agreement effective on October 1 2016, providing for certain renovations and improvements to Owner's property located at 201 Raleigh Tavern, North Andover, MA 01845 (the "House"). The parties agree as follows: 1. Contractor Information. Contractor, a Massachusetts Limited Liability Company, is licensed as a home improvement contractor by the Commonwealth of Massachusetts, Office of Consumer Affairs and Business Regulation. Contractor's Home Improvement Registration Number is 183579. Contractor's license will expire on October 26, 2017. Notice: All contractors and subcontractors must be registered by the Director of Consumer Affairs and Business Regulation. Any inquiries about a contractor or subcontractor relating to a registration should be directed to the Director. Home improvement contractors are regulated under Chapter 142A of the Massachusetts General Laws,which chapter provides certain warranties and non-waivable rights to homeowners including access to arbitration services and,where qualifying,to payments from a Guaranty f=und established to compensate owners for certain uncollectable, actual losses. 2. Ownership and Condition of the House. Owner is the owner of the House. Kitchen, bathroom, hallways, paint and flooring throughout are dated and in need of repair/replacement. 3. Start©ate and Completion Schedule. Unless circumstances beyond Contractor's control arise, Contractor will begin the contracted for work on or before October 10, 2016 (the "Scheduled Start Date") and will have substantially completed the work before November 30, 2016, 4. Description of Work. i. Interior Painting: Contractor shall paint the interior of the entire house,walls and trim work as per prior conversation; smooth all the ceilings through the house; applying the finish coats of Benjamin Moore interior paint, in colors selected by Owner,to all interior wall and ceiling surfaces of the House; [$15,800.00]; ii, Flooring Replacement in kitchen and front entrance hallway: Contractor shall (i) remove the existing floor in the kitchen and entrance hallway area, prepare subfloors for installing new hardwood floors, and (ii) purchase flooring and Install new hardwood floor (matching the living and dining room),sand and apply three coats of polyurethane; [$5,700.00]; iii. Refinishing Flooring: Contractor shall refinish the floors in the office, dining and living rooms;sanding and applying three coats of polyurethane; ($1,550.001 Page 1 of 5 i DocuSign Envelope ID:657983ED-FF3F-4422-B9E5-40456ECDCCBF iv. Repair deck and porch floor: Contractor shall replace rotten boards on the porch and deck; remove all the deck boards in the area that is sinking,fix the frame (straighten it) install boards back. Paint/Stain the entire deck and porch floor; [$1,100.001; V. Kitchen Remodel: Contractor shall (i) provide all rough material, (ii) remove all existing cabinets, counter tops and appliances, (Iii) dispose of all debris, (iv) update electrical and plumbing, and (v) install new cabinets, counter tops and appliances; [$15,000.00]; vii. Upstairs Master Bathroom Remodel• Contractor shall provide all rough materials and shall (i) demolish the existing bathroom, (ii) update plumbing, (iii) update electrical, (iv) prep subfloors, and walls, (v) install cement boards on floors and walls, (vi) install stand up shower,vanity,medicine cabinet,toilet,tile,and (vii) paint; [$1.6,000.00]; vii. Upstairs Hallway Bathroom: Contractor shall provide all rough materials and shall remove and replace double sink vanity and counter top; Replace the faucets, and plumbing fittings. Remove and replace medicine cabinet. Remove and replace toilet. Remove and replace radiator; [$2,800.00]; viii. Downstairs Half Bath: Contractor shall provide all rough materials and shall remove and replace full width vanity and counter top; replace the faucets, and plumbing fittings, remove and replace toilet; remove and replace radiator; [2,000.00]; ix. Furnace/ Hot Water: Contractor shall provide all of the materials, equipment, plumbing and electrical work and shall install a new furnace with an on demand tankless hot water system; [$6,400.00]; X. Incidentals: Contractor shall perform such incidental home improvement services as may be necessary in Contractor's sole determination and such as may be informally requested by owner, but shall not perform any such incidental services beyond those the total cost of which would exceed $2,000.00 except in accordance with the herein "Changes" provisions. xi. Completion of Contractor's work: Upon completion, Contractor shall clean up the work site removing any debris, equipment,tools, supplies, and materials. Contractor shall perform all work in a good and workman-like manner, Other than as specified herein, Contractor is not required to perform any repairs or correct any structural defects, and Contractor is not required to perform work on any other structures, including without limitation, sheds, garages, or fences. 5. Total Contract Price and Payment Schedule. Contractor shall furnish all tools, supplies, equipment, material (including without limitation, rough materials, primer and paint), labor and supervision, and shall perform the work described above for the total price of$[66,350.00} (the"Total Contract Price"). Owner shall make payments, by check or cash,to Contractor according to the following schedule: i. a deposit of$20,000.00 prior to the start of Contractor's services, ii. a progress payment of$25,000.00 by the later of the fourteenth day following the Scheduled Start Date or the day following completion of interior painting, iii. a final payment of the balance then owing on the Total Contract Price upon completion of the work. Page 2of5 1. DocuSign Envelope ID:657983ED-FF3F-4422-B9E5-40456ECDCCBF Contractor's obligations to begin and to continue any work are conditional upon receipt of the deposit and progress payments outlined above and upon Owner's performance of his or her obligations and responsibilities detailed below. Contractor understands the pricing agreed to herein is an essential term of this agreement and that Owner would not have entered into this agreement but for such pricing terms. In the event that cost overruns acceptable to Owner occur, and such cost overruns result in a final price exceeding the herein agreed upon Total Contract Price, Contractor agrees to receive the excess overrun amount from Owner upon Owner's sale of the House, and Owner agrees that Contractor may place a lien for such amount on the House. 6. Owner's Obllgation and Responsibilities. 6.1 Color Notification. No later than scheduled start date, Owner shall notify Contractor of the product number, color name, and color number of each finish paint color and the surface areas to which each specified color will be applied. 6.2 Appliances, Cabinets, Countertops. Owner shall purchase and have delivered all replacement kitchen appliances [stove, microwave, refrigerator], cabinets, and countertops. 6.3 Bathrooms. Owner shall purchase and have delivered all finishes including fixtures, vanities, toilets,tubs, medicine cabinets, and tile. {Contractor's estimates: expect to spend on finishes between $800 to$1,000 for a half bath,$1,200 to $1,700 for full bath and $2,000 to $3,000 for master bath.) 6.4 Utility Services. Owner shall provide all necessary water and electrical power to the work site while the work is on-going. 6.5 Access to Work Site. Owner shall provide 24-hour everyday access to the work site while the work is on-going. 6.6 Clear Work Area. Owner shall relocate and protect all items, including but not limited to, plants, automobiles and fixtures,that would inhibit Contractor's free access to the work area. If Owner fails to remove any items that impede the work or that may be damaged in the normal course of performance of the work, Contractor may relocate those items, without liability for damage to the items while relocating them or in the course of performance of the work. 7. Changes. If Contractor determines that the occurrence of unforeseeable circumstances, other than increases in the cost of hourly labor, or that changes requested by Owner,will require that Contractor incur greater than reasonably anticipated costs,the parties shall negotiate and enter into a written, equitable, price modification which will be incorporated into this Agreement. 8. Miscellaneous, 8.1.Access to interior of House and Facilities. Contractor shall have access to the interior of the House including bathrooms. 8.2 Permits. Contractor shall obtain all permits required for this work and for all agreed upon change orders. Where permits are required, owners who secure their ownpermits will be excluded from the Guaranty,Fund provisions of MGL chap ter 142A. I Page 3 of 5 a i i Duou8gnEnvelope ID:007983eD-FF3p-44z2-89E54O450sCaCCoF 8.3 . Contractor may subcontract ordelegate the performance of any work contemplated bythis Agreement. Contractor shall at all times be responsible for the activities and the work subcontracted or delegated. 8.4&d\me1ishl9. Contractor is entitled to display an advertising sign atthe work site beginning on the date that work starts and continuing uninterrupted until the latest of the seventh day after work is completed or the day final payment on the Total Contract Price has been received, 9. Mechanics Lien, Under the Massachusetts Mechanics Lien Statute, MGL Chapter 254, an erson perftqrmi—ng-h-ome improvement work on Owner's House, including Contractor, has the right toptqq a lien on the House if that_pgr�sqQ is not paid for work or for materials. 10, copy,two identical copies, one to the Owner and one to the Contractor, mu-stbe completed and ��d Notice: Under Chapter 93,Section 48, of Massachusetts General Laws,you may cancel this agreement if it has been signed at a place other than the Contractor's normal place of business, provided you notify the Contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this Do not sign this contract if there are any blank or incomplete spaces. E@kC Contracting LLC KarenO^Donohue o°"mw"m^y, moc°ew"w^r November Z, 20I6 | 15:56 EDT November Z^ 2016 1 16:45 EDT Page 4of5 11/3/2016 IMG_1665.PNG •0000 Verizon LTE 12:59 PM 69% W) Thread 3 of 3 - -- I . ba k f7 https://m ail.googl e.com/mai l/ca/u/O/Mnbox/1582b259584G551 a?projector=l 1�1 11/3/2016 Ful ISizeRender.jpg r—»„��"3' ✓'�' r �" �.;,T � nod� r l 1l r 7 y u � i C ✓ NY Y https://mail.google.comlmail/Ca/LdOMnbox/l582b292bd47e6eb?projector=1 111 0 DATE(MMIDDIYYYY) AC"R" CERTIFICATE OF LIABILITY INSURANCE 1011112016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS 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 NAME: Claudia Victoria AL PONTE INSURANCE AGENCY INC RCNo Ext: (617)492-7600 FAX Na: E-MAIL claudia.victoria on the te rou ADDRESS; @ P—,_ g A•com 819 CAMBRIDGE ST. _ INSURER(S)AFFORDING COVERAGE NAtC# SAUGUST MA 02141 INSURERA: ATLANTIC CHARTER INS CO 44326 INSURED INSURERS: _ E&C CONTRACTING LLC INSURERC: INSURER D'. _ 24 KINGSTON STREET INSURERE: NORTH ANDOVER MA 01845 INSURER F: COVERAGES CERTIFICATE NUMBER: 92278 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. I "06LCYEFF EXP LTR TYPE OF INSURANCE tNSD ADUL SUER POLICY NUMBER —` MMIW[YYYYI (MMIDDPOLICYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE 1-1 OCCUR PREM SES Ea occurrence $ MED EXP(Any ane person) $ NIA PERSONAL&ADV INJURY $ GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑JE PRO E LOC PRODUCTS-COMPIOP AGO $ OTHER: $ AUTOMOBILE LIABILITY COMBINED S2NGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY{Per person) $ ALL OWNED SCHEDULED NIA BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE NIA AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X STATUTEORH AND EMPLOYERS'LIABILITY ANYPROPRIETORIPARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT _ _$ 1,000,000 A OFFICER/MEMBER EXCLUDED? NIA NIA NIA WCV01260000 10/29/2015 10129/2016 (Mandatory In NE1.DISEASE•EA EMPLOYEE $ 1,000,000 It yes,describe under DESCRIPTION OF OPERATIONS below I I E.L.DISEASE-POLICY LIMIT $ 1,0110,000 NIA DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It more space Is required), Workers'Compensation benefits Witt be paid to Massachusetts employees only,Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL, BE DELIVERED IN NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845 Daniel M. 4�ey,CFCU,Vice President—Residual Market—WCRIl3MA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 0DATE(MMIDDIYYYY) ACOR" CERTIFICATE OF LIABILITY INSURANCE 9/22/16 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS 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 NAME: Al Ponte Insurance Agency PHONE 617 492_7600 __TF No: (617) 354-0401 819 Cambridge St A•D©�RESS: CLAUDIA.VICTORIA@THEPONTEGROUP.COM Cambridge, MA 02141 INSURER(S) AFFORDING COVERAGE NAEC# tNSURERA:WESTERN WORLD INSURED -INSURERS: E&C CONTRACTING LLC INSURERC: __... 24 KINGSTON STREET INSURER,0 NORTH ANDOVER, MA 01845 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 15 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 ----.-......_ IRO CYEFF POLICY EXP --_.....,..,.. ._._...,___......._-.., LTR TYPE OF INSURANCE POLI CY NUMBER MIDDN MMIDD(YYYY LIMITS A GENERAL LIABILITY NPP1427032 10/28/15 10/28/16 EACH OCCURRENCE $ 1 000 000 TO RENTED COMMERCIAL GENERAL LIABILITY DRSE ES E_ai.occ Qrtc_e $ 100,000___ CLAIMS-MADE L-1 OCCUR MED EXP(Anyone person) $ 5,000 PERSONAL&ADVINJURY $ 11000,000 GENERAL AGGREGATE $ 200,000 GEN'LAGGREGATELIMITAPPLIESPER PRODUCTS-COMPIOPAGG $ MOD 0000 �[ POLICY PRO• LOC a $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ _ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS araccids, $ UMBRELLA LIAS OCCUR EACH OCCURRENCE $ EXCESS LIAB _ CLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION WC STATU• OTH- AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETORIPARTNEMXECUTIVE " 7NfA E.L.EACH ACG DENT $ OFFICE WMEMBEREXCLUD807 J (Mandatory€n NH) E.L.DISEASE-EA EMPLOYEE If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE.-POLICY LIMIT $ DESCRIPTION OF OPERATIONS ILOCATIONS/VEHICLES (Attach ACORD 761,Addlilonal Renerks.Schedule,It more space Is regtdredi CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET NORTH ANDOVER, MAS, 01845 AUTHORIZED REPRESENTATIVE ALPONTE O 9988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: The Common-Walth of Hassachuse"N _ Depadmeut of-&dustrraZAeddefats eet Si-i 100 Soox�, A 021x42017 www mass,gav/dxa -Wp-jkexs,Compensationfusurance Affidavit:Builders/CO tr �TSORII�.�icians/pl nbers. TO BEFMEDWITHTEEPERMPI'7 N pleasel2rint Legibly A ''licant hormation Name(Business/bigaaization/lvdividiml): G >7 Address.__zPhone Ci IStatelZip: � '' rn mate bnx: `hype oft--proj eat(required); Axeynrr an exupIoyar?Checktbe app p d-W donstx>�ction 1.�aru a empinyeX wig �! ampicyees Gull and/or part time}. 8. exa.odeliii' 2.p I am asoie proprietor or partnership and bwtsno emplogees r�orking forme in 8• g aacity.[lTo�ntorlcers'comp.insurance required.] 9. ❑Demolition ny cap 3.❑I am.a Witt'.wrrez doing aIi workmyself.[No workers'comp•insurancerequired.]t JOE]Building addition 4.❑I am a•homeowner andwM be hiring coutractors to conduct ail work onmy property_ Iwil1 11.0 Electrical Ipp*s or additions ensure that all contractors either have workers'compansation.insurance or are sole +12 z Pltixubittg repairs an additiox proprietors withno enapoye6s. 5.❑I arrr a general eont;actotand Ihav-hired thasub-contractors listed on the attached sheet. 13'.Q Roof xeiiairs These sub-contractors]nave employees and have workers'camp.insurance# 14.111 Other 6,E]We area corporatioi and its,OM06rs have exercised their right of exemption per MGI a. 152,§1(4),arai we hav6 no employees.[No workers'comp.insurance regLrrred] applicant thatcheeks;bbi #l�iustalsafiliouttltoseciaonhelowshowingtherr/porkers'compensationpolicyivfarmaiion. x�ythe are doing all andth&ahire outside contractors must submit anew affidavit indicating such t Homeowners who subruit•this affidavit indi6ating y showingoet =o offhe, }Contractors that nheok this z�hava emplayeesa they mus pX videflLoir s° s'comp Spoiioy nutriberd state wireer of not those enfittes ave empleyecs. Ifthc sub-c�xtz ,aux ea enxthe sub /lief is�rrovicling_workeYs,compensation insurance for my employees Belatw is the policy alldfo i site aft infD377xafiDn. l /V o g e Insurance CompM)'Name: Q C p j LxpiratioxtDate= I Policy#or Self ins.Lic.#: L �Y City/State/Zip: `�'\ lob Site Address: 0 a showing the policy number an expiration date). Attach a copy of theWQro rkexs3 caznpensation policy decl Z5A na crimvgal violationpunishable by a fine up to$x.,500.00 S�ailure to secure co�rerage as xequ 'ed under MOL c. es i § aacVoz one-year impxisonm.ent,as well as civil pt maybe forwarded.to the Of�ice ou the form of a STOP bvesgations of the DTA.fbr hisurau 0 a day against the violator.A copy of Ibis stafieruen coverage-verification, xdo herebyceep irz an pe of rjury that the information provided wave is txve and carrect. } Date: 0 Si ature: Pham#: Offacial use only. Do not-write in this area,to be completed lit'city ortotv7�affxcial. Per:mitlL3icexx8e# City or'To-WR: issuinguthoxity(circle ane): ' p ector 1.Board of�ea3#h 2.)3nildngDepartxraeut 3.City/Town Clerk d'.Electrical.Xns ector 5.plumbing�p 6.Otb.er Phone#- Contact Person. i Masvachusetts , Departmerit of Public Safety Board of Buildiiig Regulatioris wid Staridar'ds License- CS-086122 em, I'll, FUEL A DASILYX 11 EARLY AVE A Ile MEDFORD MA 021 I 1 14% Expiration conwnissioner 1113012016 frice of Consumer Affairs Business Regulation M IMPROVEMENT CONTRACTOR E egistration: 183579 Type: f" 77- ,' -xpiration: 10/26/2017 Corporation E & C CONTRACTING LLC. ELIEL DASILVA 24 KINGSTON 14 NORTH ANDOVER, MA 01845 Undersecretary