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Building Permit #272-15 - 1 Morkeski Drive 9/14/2014
Of 0ORTN A BUILDING PERMIT 3? 6`�tlo '6�6�OOL TOWN OF NORTH ANDOVER •�' APPLICATION FOR PLAN EXAMINATION Permit NO r Date Received Date Issued: 9SSwc►+us'�� IMPORTANT:Applicant must complete all items on this page LOCATION �eynows Print PROPERTY OWNER lV• /�n�y�vf.•- /�y s; y f�r.> ra��y Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes nn Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition V Two or more family ❑ Industrial ❑Alteration No. of units: to o ❑ Commercial )tRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Cl Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer IrL Identification Please Type or Print Clearly) OWNER: Name: NogrH AVI✓IX A"5,.-vw�*;6 Phone: Address: ^4 Krs,ws A~0 evs A"O'" CONTRACTOR Name: Phone: PPs _�/hBs ot�� tcy Address: 1 k 3 S'a �i nt�7asc f��� ��• �i2'4L✓/� *4. O/8J G Supervisor's Construction License: Exp. Date: Home Improvement License: 52>,? Exp. Date: 7 ai ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 11040, o o FEE: $ `yk. 701- Check No.: /�1 j 2 Receipt No.: r �0��' / NOTE: Persons contracting with unregistered contractors do not have access to th uaranty nd Signature of Agent/Owner Signature of contractor v i' Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 1 TYPE'OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY j INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS d Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments dWater& Sewer Connection/signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no f, Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast 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) ❑ Notified for pickup Call Email 3 t Date Time Contact Name Doc.Building Pen-nit Revised 2014 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 NOTE: 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 o 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: 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 Doc:Building Permit Revised 2014 Location / No. — Date . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ►—r" Check#—�` -4L Building Inspector %AORTIy Town of 2 s E ndover No. n0;N.*"h ver, Mass, qI-0 .Q COC LAKII HICHEWIC« 1' A°,#A re o S U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT .........No...M> ' BUILDING INSPECTOR /... .. . ..... �. has permission to erect .......................... buildings on Or or .....� Foundation p� stwo". , .... �. Roughyt0 be OCCU led as ......C.��.:........ ...... ............................................. Chimney provided that the person accepting this permit shall in ery 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 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT RRTS 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. HAMMERTIME CONSTRUCTION HOME IMPROVEMENT CONTRACT HOMEOWNER INFORMATION CONTRACTOR INFORMATION . ._.._.....=�,_c.��=a.':.=_-::_?�:—a::.a-•-••..a..r..._:_.^•f.-�._—:ac»�'�`_ `��' r=s�--..ia=•..W..�.._;,s., i�'_^.-+r"i=G•z6:�::-�L�'�:ME:ti :. .CO:M:PANY-NAME� NO. ANDOVER HOUSING AUTHORITY HAMMERTIME CONSTRUCTION _ r�•G L y:..-SCT•.•�:.����::.''L,-r,r i��^J:}. :: :�T� » ^.STz REETr..�•:S..�..•.D...:Df.....:,..�E...S. S..,,c..Ti,b.�...a-�:.�=r.�•„.-_=—�:.•_r;_a.�•----=�....r.:�:f.�_�rn:.,�:._:..a:--,.�'�.-3..�.01NN_ E.R�NA(1�..E. ..�:..e�x.:�..r.:;i;>i�_~•;..�.^_;..��.�;i^,_�t'--a;. _3-�^ Fn.�� 1 MORESKI MEADOWS JAMES GODFROY a: _ :i. .:f::t� '- ' •»,.-=-:r.�Wit"•:'a- ....r--f,�.... .. .�.�_.`�s. .... _ - ..-7iG-.s�.cr-��-::,T`cL•:�nu=-n'••;^:iaFs•;e:;.:�:• =GITY/T4�lVN � : .SrtATE : �wZ[P—':_ :BUSS:NESS��0DR .=S5. - IMMUNE�L= _::: NO. ANDOVER IMA 01810 _382 PRIMROSE HILL RD DAYTI. A wd U' ` ._.i,...-: 5' .-"•L.. ...xrsn :.:..-�:._-• �: .c...ii,a_-.:lu_-.kM1.'•-.f. a_:i ��y s�f.. .:n,xr.t=.`a iii y k•a. r:? .:ai:-•••'i:.�`••r•-:''�?."�nr�.- "3? ME'.HOPI.E.���•�.—_��,:,f�_.����.:�w.�-��:��.CITY�/LTO.WN�..:�::,��ST�4l�. �:21P:.-.�.._.��.�:a�,.��r,: ��. 978-682-3932 EXT. 11 DRACUT MA 01826_ l .•-wt.�.}...�.... _ i_-_�, ::a^"su j=':. wry_ "g`�fy._ Vn' %.�j: ...i.:.. •�:;i �i!Y^m;�i a:_:.� IT—V I MOP H011i w.:',_^��-=;-=.. T?[i Yr:; ill sc.:-: ^ti:.4.!c y. {h„ r �iF. _......_. _..........r_E. :_t z. .,.�.,.�.,._...._...t;:ENAII,=_ ; �' '� , -�. _PHDNE# .�,._ VICSDAD@COMCAST.NET 978-995-1898 .. _ t::: ; �i .f:..,-.. ..,mt. .'..'1'- -5 .,..._ �.r�...,.ill '. .:.' �.:' , ���. F MA1 L)NG , ESS i D FFE � RMTRA ° �:Gr�;=: a ... .. ,A0,1... .... --�..IF__,L..L...... ..I z.. --NTr 4_..T� .i .H..i... .�R�G~� P.lRA;TfiO;N 139503 7/21/2015 ` :�.i; t�=�i r;E��;l;�a�!js��=_;'r:Lt�.;��-=:�ir=rf.;'�"�'Is`tcr;.x;�;�r�.:t�E;:I€=��.��r.";• „��.-.rs;�__._.,Y -- -:`E;'..'�'' '�=-- - k.:' =:,f:a,�r: : •W_• ;;- _f4_�.�,.... .i_.r,._._.coNsT..s...P 8 ISoaR Ll_0.-_#_,P. I I A ION; icomerford@northandoverha.com CS92065 3/28/2015 HAMMERTIME CONSTRUCTION AGREES TO DO THE FOLLOWING WORK FOR THE HOMEOWNER: The following work to be performed at Housing Complex in Moreski Meadows. Remove and dispose of two(2)existing sliding glass patio doors. Supply and install two(2) new white vinyl Anderson Permashield sliding glass patio doors with screens and brass hardware. Any drywall damage during the installation will be repaired and painted to match as close as possible. All labor, materials and disposal for the sum of($4060.00)four thousand sixty dollars REQUIRED PERMITS (REQUIRED AND PROPOSED START AND COMPLETION SCHEDULE . SECURED BY HAMMERTIME CONSTRUCTION (THE FOLLOWING SCHEDULE WILL BE ADHERED Ti ACTING AS THE PROPERTYAGEN7): UNLESS CIRCUMSTANCES BEYOND THE CONTRACTORS CONTROL ARISE): Construction Permit to be provided by Hammertime Construction DATE WHEN CONTRACTED WORK WILL BEGIN: 91112014 DATE WHEN CONTRACTED WORK WILL BE SUBSTANTIALLY COMPLETED: 9/30/2014 TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE: HAMMERTIME CONSTRUCTION AGREES TO PERFORM THE WORK, FURNISH ALL MATERIALS AND LABOR SPECIFIED ABOVE FOR THE SUM OF: $4,060.00 (*) PAYMENTS WILL BE MADE ACCORDING TO THE FOLLOWING SCHEDULE: $2000`00 —upon signing contract(not exceeding 113 of the total price OR the cost of special order items, whichever isgreater) Y . a HAMMERTIME CONSTRUCTION HOME IMPROVEMENT CONTRACT upon delivery of materials and start of work upon completion of the contract and sign off of permit The following material/equipment €$ , '� ;to be paid for must be special ordered before the contracted work begins in orderf$�Ato be paid for to meet the completion schedule ('*} NOTES: (*} 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- X YES NO (All warranty terms will be attached if needed) SUBCONTRACTORS-HAMMERTIME CONSTRUCTION agrees to be solely responsible for the completion of the work described regardless of the actions of any third party/subcontractor utilized by HAMMERTIME CONSTRUCTION.HAMMERTIME CONSTRUCTION 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 any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract 1. Don't be pressured into signing the contract Take time to read and fully understand it. 2. Make sure the contractor has a valid Home Contractor Registration. 3.Ask the contractor for insurance information so you can confirm coverage. 4. Know your rights and responsibilities. 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 attached notice of cancellation form for an -explanation of this fight. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACEStilt HO EOWNER �I,NATURE: CONT CT 7eATURE: Ail Af 9 �y ATE: E: y HAMMERTIME CONSTRUCTION HOME IMPROVEMENT CONTRACT 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 disputes 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 Regulation and the consumer shall be required to submit to such arbitration as provided in Massachusetts General Laws, chapter 142A. HO EOWNERSNATURE: CONT O IGNATURE: 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 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 workas 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 provide by the contractor,all goods sold in Massachusetts carried 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 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 unti 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 voided, 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. HAMMERTIME CONSTRUCTION HOME IMPROVEMENT CONTRACT ADDITIONAL INFORMATION-If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you with 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: http://www.mass.-gov/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: http://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeimprovementilicenseelist.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 HAMMERTIME CONSTRUCTION HOME IMPROVEMENT CONTRACT NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR OBLIGATION, WITF THREE BUSINESS DAYS FROM THE ABOVE DATE. 1F YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE, AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOUR CANCELLATION NOTICE, AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED, ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLERS EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION, YOU MAY RETAIN OR DISPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO, THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO JAMES GODFROY(HAMMERTIME CONSTRUCTION), AT 382 PRIMROSE HILL RD, DRACUT, MA 01826, NOT LATER THAN MIDNIGHT OF (DATE). I HEREBY CANCEL THIS TRANSACTION. DATE: BUYER'S SIGNATURE: Massachusetts-Dertt of?utitic Safefi ward 6f Building Regulatt?ns'i3rcf- it# a � €r;nstruction pe�isnr License CS-092065 ` 382 pgn MOSF- ffiLLRD _ Dracut MA 018M = ' r � i ExpiratiOn 03/2812015 r_oinmissioner Unrestricted-Buildings of any use group which . `�tahrless than 35,000 cubic feet(991m)of`_` enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www.Mass.Gov/DPS e` a�n�no�rtueulii v [ �urdz«sett i icense or reg On v$hd for wdWal-un only- e oGossamer-Affsns&-Beset Regelslsoa 5efo>re the e�[p�ca4ion dates:i fir° ' — MEIl111PRflVfMENI'COhtTRACCE)1{ i ir��f Gaas� AffairsioRuda a Regulation YP �Q_: on_ 139503 i�ParkPiaza 5me 5i70 ration 1!2112015 ' - D13A Boston,MA-02116 HAMMER TIME CONSTRl3CnO t 8i t2EMODELIN JAMES GODFROY 382 PRIMROSE HILI RD gas--,_ ►� _ . DRAGlfT, fid-- :re MA-01826 Undersecretary V 3 7 u Depar est Ot Occupatioirai wetyandHikh.Adnlmstratrorr :James GodNr t nas t letea a lfo-titna oc«patronai safety ana t eahnf t �Trami2�G`otnsein- _ construcson &`Realm �" CERTIFICATE OF LIABILITY INSURANCE DATE IMM//2 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 PRODUCER. E CERTIFICATE 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: FRANCIS E PROVENCHER INS PHONE FAX 530 ROGERS STREET (AUC,No,Ext): (A/C,No): E-MAIL LOWELL,MA 01852 ADDRESS: 26F9G INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: HARTFORD UNDERWRITERS INSURANCE COMPANY GODFROY,JAMES DBA HAMMERTIME CONSTRUCTION INSURER B: INSURER C: 382 PRIMROSE HILL ROAD INSURER D:INSURER E: DRACUT,MA 01826 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 (MMI)DIYYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE ❑OCCUR. DAMAGE TO RENTED $ REMISES(Ea occurrence) MED EXP(Anyone person) $ GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL&ADV INJURY $ ENERALAGGREGATE $ 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 $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAR M OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND WC STATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-4305P306.14 07/22/2014 07/22/2015 X LIMITS ANY PROPERITOR/PARTNER/EXECUTIVEy NIA OFFICERIMEMBER EXCLUDED? ❑ E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR GODFROY,JAMES. CERTIFICATE HOLDER CANCELLATION NORTH ANDOVER HOUSING SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1 MORESKI MEADOWS BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIO"— AUTHORIZED REPRESENTATIVE1 N.ANDOVER,MA 01843 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORP � `ANW§Tits reserved. GODFJA1 OP ID: BW CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDIYYYY) 03/11/14 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). CONTACT PRODUCER Phone:978459-8681 NAME: Francis Provencher Insurance Fax:978-454-9343 PHO,AICNEEXJ� ac No Agency, Inc. E-MAIL 530 Rogers Street ADDRESS: Lowell, MA 01852 Mike Provencher INSURERS AFFORDING COVERAGE NAIC u INSURERA:Preferred Mutual Insurance Co. 15024 INSURED James Godfroy INSURER B: dba Ham m erti m e Construction 382 Primrose Hill Road INSURER C: Dracut,MA 01826 INSURER D: INSURER E: 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 rypE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP POLICY NUMBER affd==affamac= LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 500,0001 A X COMMERCIAL GENERAL LIABILITY CPP0160592482 09/13/13 09/13/14 DAMAGE TO RENTEIT_ PREMISES occurrence $ 50,00 CLAIMS-MADE FX]OCCUR MED EXP(Anyone person) $ 5,00 PERSONAL&ADV INJURY $ 500,00 GENERAL AGGREGATE $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,00 POLICY PROT F1 LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY t $DAMAGE HIRED AUTOS AUTOS er acciden $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMBSI ER ANY PROPRIETOR/PARTNER/EXECUTNE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) **CERTIFICATE FOR WORKERS' COMP COVERAGE WILL BE ISSUED DIRECTLY FROM THE COMPANY WITHIN 2 BUSINESS DAYS** CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN N.Andover Housing Authority ACCORDANCE WITH THE POLICY PROVISIONS. 1 Moreski Meadows N.Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations ' I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): *f 5o11) to ¢,rs 4ieti 111 see Ay'rAa Address: 1?9; Zz;et5•r,s City/State/Zip: e,d� G Phone #: Arejou an employer? Check the appropriate box: Type of project(required): 1I am a employer with .3 4. ❑ I am a general contractor and I employees(full and/or part-time). * have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. 9. E] Building addition required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions ] 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' 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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ,,// ` Insurance Company Name: /%)fi¢T��yz� f�nt.L+e c ac;fieizs 5r.i1✓4-4vee- &i ,O�vx Policy#or Self-ins.Lic.#: 116 -/y Expiration Date: Job Site Address: '22o�e r�'S4cs *~P w: /V /f�.oevs City/State/Zip: /1/•�iryev EA-oe *10, 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 certify undepains and penalties oferju that thein ormation provided above is true and correct Si afore: Phone#: 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#: