Loading...
HomeMy WebLinkAboutBuilding Permit #892-15 - 1 MILLPOND 5/7/2015 tiORTFf A BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: tz� I--:), I I SS IMPURTANT:Applicant must complete all items on this page tOPEIfb t i t "'41"PPT 5, ` t,t 8 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential D New Building 0 One family D Addition 0 Two or more family 0 Industrial [I Alteration No. of units: x Commercial M Repair, replacement [I Assessory Bldg El Others: D Demolition D Other 4�4 Z IS 7,_ dp M Man 1 11w* 4, 4o V fi f'6b "mijR tig &A, I 'h"V Ab d _7 I? 8cic,-od v- fiwrs. 'RQ_poey- WZPA�S 0,ml Cf,'t1i(V'AS btj d(4 WaA i G'SA__P_(4 11 C�_\\ v �-pe_cS P1 k-" JJ-�&V-A-, r� C'!,64e Y- J Identification Please Type or Print Clearly) OWNER: Name: Sebastian Valentin Phone: (978) 490-5752 Address: —163 Woodland Street, Lawrence, MA 01841 Phone 710- "c _e'&s-"' ­ ' n Nk. _St' b w�"r reeti,L wr� 4 n ap" evisor "M : "0 5 1b.vemen1JLice Q, ARCHITECT/ENGINEER Marcos A. Devers Phone: (978) 804-7588 Address: 16 Woodland Street, Lawrence, MA 01841 —Reg. No. 33848 FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 26,000.00 FEE: $ 312.00 Check No.: Receipt No.: NOTE: Persons contracting wit nrygistered contractors do not have access- ei, ew '- 0 !r a e, i A ,.f ' � �� t►ORTH BUILDING PERMIT o16 � z .bAtio TOWN OF NORTH ANDOVER h.:'' APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received reD gSSACHU`+� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes.. no I Machine Shop Village yes. no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic ❑Well �0 Floodplain 0 Wetlands 0 Watershed, El Water/Sewer_.-- DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address: - Supervisor's Construction License`. Exp. Date: Home Improvement License: Exp. Date: 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. J Total Project Cost: $ FEE: $ y Check No.: Receipt No.: NOTE: Perr,!ns contracting with unregistered contractors do not have access to the guaranty fund ianatut nature of con ar- - Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application - Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (if Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) 4. Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses 4 Workers Comp Affidavit 4 Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (if Applicable) 4. Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products ISIOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doe:Building Permit Revised 2014 r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Starr-;pied Clans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimnning Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS I CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS A 5 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Wafter& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: .7 r Located 384 Osgood Street FIRE DEPMENT emp bumps e on s to p � Located at 1,24 Main Street. �TM Fire Department s_tiygnatur%daate i i'^G' -}�- n� .� t G 7 .q�1.4;r,��a$W .:i,�L��. �•�Y3 „4 F} e .e.-, ?, ",t l r°.,.,a `i. %.d'''• f r - 'w .COMMENTS •��• � �_ _, ° -� �• �,r�. � ,w Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, hast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) Ii LJ Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 Location Q NoS-11^ I Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ `� Building/Frame Permit Fee $ Foundation Permit Fee •,x �� Other Permit Fee $ ED TOTAL $ Check#,)A 28742 Building Inspector Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 265000.00 m $ - $ 312.00 Plumbing Fee $ 39.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 39.00 Total fees collected $ 490.00 1 Mill Pond 892-15 on 5/7/15 Repairs I � NORTH own of A No. - ,� 1 ver, Mass, , Q�RgTEO ipk*' S V BOARD OF HEALTH Food/Kitchen . PERMIT T .. LD Septic System rS y BUILDING INSPECTOR THIS CERTIFIES THAT ........................................................�....... .... ......�x... has permission to erect jljj:� buildings on I....... . ,..... Foundation Rough to be occupied as .�. ... ........ ... .... .....A,` lift•• .•••••• Chimney provided that the person accepting this permit shall in every respect che terms f 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 Final PERMIT EXPIRES IN r6^;NT ELECTRICAL INSPECTOR 3 61 UNLESS CONSTRUCT Rough Service ..................... ...... ............................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. " Homeowner Information Contractor Information Name Company Name _ S n M b C-0 Street Address(do not use a Post Office Box ad Contractor/Sal n/Owner Name l� 1 ax ��`�_-r-�� City/rown 1. State Zip Code Busmesiiddress(must include 4 street address) NA O�W Daytime Phone Evening Phone City/1'own-. State Zip Code _ Lowes ncz M A 0)`6�-�. Mailing Address different from above) Business Phone' Federal Employer ID or S.S.Number �g P ' n ^ 'S Home Improvement Contractor Reg.Number Expiration dat OV S L.I` Law requires that most home `` improvement contractors have a vatld regtstratfon number The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used se additional sheets if necessary.) 1 'C�ln'11✓1Gt O rah I CLvnG� l�00✓1 O '1V vy Qcnt �i r riao►-S rc.�lJ G1,v1cM F�1o.S'�e+r A-wfS aF 1ivi roaM, Ct_.vo. , , (� raom, bc��'I•.roor�'1 Owe r5 bCd Yc)o r"'s• ?Yt rest- U.nn, Pb'o rt}-. Czm b t OSS Pe- Cot e, 0.v o �IKCJ—P-icG1 Cs pe►- (Ode-- CkeCA.,j vp o�- Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work. MGL chapter 142A.) Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule Z�, �0 •o® The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: M Payments will be made according to the following schedule: $ upon signing contract(not to exceed 1/3 of the total contract price gr the cost of special order items,whichever is greater) $ by _/ /_ or upon completion of $ by _/_/ or upon completion of $ upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be paid for NOTES:(a)Including all finance charges("')Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty being provided by the contractor? ❑No❑Yes fall terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. 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 f rm r an explanation of this right. DO OT SIGN THIS CONTRACT IF THERE A =Opyd be pt by th coSmust be completed and signed. One copy should go to the hntractor. HomeoNAM er s Signature Contractor's Signature 5 -S_- iS Date Date , - a t j •. a'.- 'iS J � .r as f ..?. i i �i..� , ��� ` _Y. +� , ... Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regul ' d the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws, h p r Homeowner's Signature Contra Si natur NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners i may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at hu://www.mass.P-ov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at hgp://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeimprovement/licenseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800, 508-755-2548 or 413-734-3114 Version 2.1-11/22/2010 ! < •r ¢F roi3 .z t .iy `.a5 ,f ;k. 'a .. r .1 .� ,. F ie 't ' R • , S MDJ Engineering&Construction 16 Woodland St mD i Marcos A.Devers,P.E. Lawrence MA 01841 R.P.EIA 33848 C.S.L.#:47056 T:978-804-7588 978-685-5691 111121 mm��� H.LC.L.#106698 E-mail:mdjincorporated@comcast.net 3/30/2015 Building Repair Proposal Owner: Sebastian Valentin Job Site: 1 Mill Pond Address: 163 Woodland Street North Andover, MA 01845 Lawrence, MA 01841 Use:Residential Tel: (978)490-5752 Construction Type:Wood-framed Structure Job Breakdown and Cost: Materials Labor Total j & Equipment 1. Framing a. Framing on 6x6 laundry room in basement Framing Total: $300.00 $300.00 $600.00 2. Floors&Stairs a. Install hardwood floors on living room and kitchen b. Install laminated floors on the loft and 2 bedrooms c. Install commercial tiles on playroom in the basement Floors&Stairs Total: $6,600.00 $6,000.00 $12,600.00 3. Drywall/Plaster a. Install 12 sheets drywall on living room ceiling b. Install 12 sheets drywall garage ceiling c. Install 32 sheets mold resistant drywall to playroom ceiling and walls d. Repair and patch wall in Bathroom and 1 Bedroom e. Repair and patch crack on walls and ceilign in hallway Drywall/Plaster Total: $1,000.00 $2,100.00 $3,100.00 4. Painting a. Prime and Paint related surfaces and trimming under repairs Painting Total: $400.00 $800.00 $1,200.00 5. Plumbing a. Relocate and reinstall washer and dryer hookups b. Retest all water pipes for leaks and damages c.Repair and/or replace force hot air Furnace and proper hookups Plumbing Total: $2,450.00 $3,250.00 $5,700.00 6. Electrical a. Rewire and Reinstall 220 connection and plug for washer and dryer b. Install 5 reset lighting fixures in the living room area. c. Repair and/or replace electrical fixures related to Furnace Electrical Total: $650.00 $750.00 $1,400.00 7. Clean up a. Tear-out, debris removal and clean-up b. Dumpers Celan-Up Total: $600.00 $1,000.00 $1,600.00 8. Miscellaneous a. Permits Misc Total: $700.00 $700.00 Total $12,000.00 $14,900.00 $26,900.00 Total Amount to be paid for the work to be performed under the contract is $26,900.00 The Job will be completed within 30 business days. Beginning within 5 business days after the closing date and completed within 30 business days thereafter The contractor will obtain all necessary construction permits. Owners who secure their own construction-related permits or deal with unregistered contractors shall be excluded from access to the Guarantee Fund DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES The contractor and the owner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this contract,the contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer affairs and Business Regulation and the consumer shall be required to bmit to such arbitration as provided in MGL c. 142A Owners: A Al Date: Sebastian Valentin Subcontractor Date: MDJ Incorporated represented by Marcos A. Devers, P.E. All home improvement contractors and subcontractors shall be registered and any inquaries about a contractor or subcontractor relating to a j � registration should be directed to: Office of Consumer Affairs and Business Regulation Ten Park Plaza,Suite 5170 Boston,MA 012116 ---------- i ImMDJ Engineering&Construction 16 Woodland St DJ Marcos A.Devers,P.E. Lawrence Ms.01841 R.P.E.L.Ii:33848 C.S.L.#:47056 T:978-804-7588 97&685-5691 ME �I 1 H.I.C.L.#106698 E-mail:marcosdevers@gmail.com Certification on Structural Impact 3/30/15 Re: 1 Mill Pond,North Andover,MA Owner: Sebastian Valentin I hereby, certify that the existing structural building assembly and its bearing capacity will not be impacted by the new framing to be built to house a laundry as part of the repairs and improvement works at the above-captioned property. Respectfully yours, OACyUSF�� #33848 W Marcos A. Devers J. P. E. MA �, = Mass PE license AEG`' I I i i i i ., , � . • � F � � i .� �� ..$. The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,AIA 021142017 www muss gov/dta Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant infotrmation Please Print Legibly Name (Business/OrganizAtion/individual): MDJ Incorporated Address: 16 Woodland Street y City/State/Zip: Lawrence, MA 01841 Phone#: (978)804-7588 Are you an empl6yer?Check the appropriate box: Type of project(required): 1. I am a employer with 3 employees(full and/or pari-time). 7. New Construction 2.❑1 ani a si,3c prupticttn'or p uhuu:ship anti!rave uu entpluyecs tvorl ui fur ntu in $. ®Remodeling any capacity.lNo workers'comp.insurance required.] 9. ❑Demolition 3.®I tun a honueo amer doing all work myself.[No workers'comp.insurance required.]t 10[]Building addition 4..aJ-mn_a homeoAx=r-and will.be hiring uontractors.to conductali work on.my,..propedy. I vv"ill ensure that all contractors either have workers'compensation insurance or are sole 11.®Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.rl t am a general contractor and.I have hired.the sub-contractors listed on the attached sheet. 13.®Roof repairs These sub-contractors have employees and have workers'comp.insuuance.+ 14.Q Other Building Repairs 6.®We are a corporation and its officers have exercised their tight of exemption per MGL C. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t I-lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContrrtctors that.check this lox most attached an additional sheet showing the name of the sub-contractors and state whether or not these entities have employees. If the sub-oontractors have employees,they must provide their workers'comp.policy nwnber. I am an employer that is providing►vorkers'cortrpensation insurance for my=employees. Belmv is the policy and,fob site information. Insurance Company Name: Continental Casualty Company Policy#or Self-ins.Lic. #: UB-5B759670-14 Expiration Date: 11/20/2015 /1 Job Site Address: M1 �d� City/State/Zip:11,=�� PIAA Attach a copy of the workers' compensation policy declaration page(showing the policy number and expira�te). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce 1 =and1pweqq, erjury that the infornuaion provided above is true and correct! A Signature: Date: is ^/ Phone#: (978)804-75 Oficial use only. Bo not write in this area,to be conildeted by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/ own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Persons Phone#: O 0 DATE(MM/DD/YYYY). �,. CERTIFICATE OF LIABILITY INSURANCE 5.5/2015 THIS CERTIFICATE is ISSUED AS A.MATTER.OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.1141S CERTIFICATE .DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THISCERTIFICATE 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•pollcy(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 onthis certificate does not confer rldhts.to the certificate holder In lieu of such endorsement(s). PRODUCER. CON O TACT LouO AM ou Tonry Albert J. Tonry & Co. , Inc. PHONE (617)773=9200 AC.Nal (617)773-4920 - L 300 Congress Street EDMAIE D :carts@tonry.com INSU S AFFORDING COVERAGE NAIL S Quincy MA 02169INSURERA-.Endurance American specialty 41718 INSURED INSURER B NDJ., Incorporated INSURER C 16 Woodland street INSURER D: INSURER E: .Lawrence rSA 0.1841 INSURER F: COVERAGES CERTIFICATE NUMBERCL1511309745 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$E ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDIT16NS`OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADUL SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE POLICY'NUMBER LIMITS GENERAL LIABILITY' :EACH:OCCURRENCE $ 1,000,000 DAMA9F TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES`Ea occurrence $ 100,000 A I CLAIMS-MADE QOCCUR CBC10001403802 2/22/2019 2/22/2015 MED EXP Any one person) $ 5,000 PERSONAL S ADV INJURY $' 1,000'000 GENERAL AGGREGATE: $ 2,000,000 GEN'LAGGREGATELIMITAPPLIES.PER: PRODUCTS.-COMP/OP;AGG $. 2,>000,000 X POLICY` PRO- LOC AUTOMOBILE LIABILITY COMBINED:SINGLEL LIMIT Ea dent, ANY AUTO BODILY INJURY(Pet person) $ ALL OWNED SCHEDULED BODILY'INJURY(Per accident) $ AUTOS AUTOS' P I 1 1 NON-OWNED PROPERTY DAMAGE HIRED AUTOSAUTOS Peraceldent $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION I WCSTATD- OTH AND EMPLOYERS'LIABILITY -- ANY PROPRIETORWARTNERIEXECUTNE YIN EL EACH ACCIDENT $ OFRCERIMEMBER EXCLUDED? N/A (Mandatory In NH) [El-DISEASE-EA EMPLOYE $ If yes,describe udder DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS'!LOCATIONS I VEHICLES(Attach ACORD t01,Additional Remarks Schedule,If more apace Is required) Re: 1 Mill Pond, 'North Andover. Operations usual to a residential general contractor. When required by written contract executed prior to loss, the certificate holder and other parties are included as additional .nsured(s) for work performed by the named insured. CERTIFICATE HOLDER CANCELLATION (978)688-9542. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 13E CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS: Town of North Andover Building Department 1600 Osgood Street AUTHORIZED REPRESENTATIVE Building #20, Suite 2035 `North Andover, NA 01845 ----- L Tonry Jr:/KFOLAN ACORD 26.(201 0106) ©1888-2010 ACORD CORPORATION. All rights reserved. INS025 oninr %pi Tha arnan name ane4 Inn^are marls of Amon Y,83 � R CERTIFICATE OF LIABILITY INSURANCE DATE(5/06/201 YYY) T TIFICATE 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: ALBERT J TONRY&CO INC PHONE FAX 300 CONGRESS STREET (AIC,No,Ext): (AIC,No): E-MAIL QUINCY,MA 02169 ADDRESS: 2873Y INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: CONTINENTAL CASUALTY COMPANY MDJ INC INSURER B: INSURER C: INSURER D: 16 WOODLAND STREET INSURER E: LAWRENCE,MA 0184 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS: INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMIDDIYYYY) (WRDMYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE M OCCUR. REMISES(Ea occurrence) ED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY [:]PROJECT[::]LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS: (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE GGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION ANDWC STATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-5B75%70-14 11/20/2014 11/20/2015 X LIMITS ANY PROPERITOR/PARTNER/EXECUTIVE OFFICE WMEMBER EXCLUDED? FLI NIA E.L.EACH ACCIDENT $ 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESIRESTRICTIONSISPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER,BUILDING DEPT. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD STREET,BUILDING#20 SUITE 2035 BEFORE THkEXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACC ORDAN E WITH THE POLICY PRO AUTHO E SENTATNE N.ANDOVER,MA 01845 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All ri reserved. • .. r ..I1 . r. ,. r - i. ., ._ • i . '• i p �` , ., 1 _.. .... _ .. .... .. _ ., ._ I. .. .. ..a - .. .. �_ r _ _- + + . . ! � _Y � - -- - � _ k __., � .. _ _ .. Y ,_ . . _ � i i Massachusetts-t7epartment of Public Safety • • • • Board of Building Regulations and Standards t ° Gonstrtiction Supervisor E 1r :�W License: CS-047056 MARCOS A DEV"S 16 WOODLANDST MUMx - A , U ; r. LAVYRSNCE Mk 01 90 af4et ti i}r t o /� J i i 9f?`` � � w ��/ Exptratton 104.-5-1 comm ssionet 10125/2015 ax - = l 0-69 . 'dice of Consumer Ati�urs$c Bas ae8s&eguintton �r1'ix1 f~iNIP12 fV Alff:►li GC NY AIC ost ". - i11"�Or!}�»i� '��1� Pf9�8tBrp'OiHtiOt� �� .3 ���� s , t Agg MDJ.INCi. _. ` has orn{#eteda ©Hour 5#�A�t� I ii m;N" lr+ strr Marcos bevotsWile f sr 61'W66 L7 LAtd[}STFfEE i I4 VREWCE,MA 01841 - =t39 to S fl li eMCr1► fray er indt'rdecretd Y I Project Address: tA�\ k ?(:),r)cl N r+h nd over MA The above licenses are authorized for the project address stated above only. DO NOT REPLICATE. AutIs - MW Engineering& ons Marcos A.Devers J.,P.E. Lawrence,MA _' S 978-804-7588