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HomeMy WebLinkAboutBuilding Permit #679-2017 - 1 WALKER ROAD 12/29/2016 V, ,/ 4 y ' 1 ' TOWN OF NORTH ANDOVER } i �� APPLICATION FOR PLAN CI "ORT" N EXAMINATION ti s °o 9 Permit N0: Date Received I g19`T 3^C NU P�S�S Date Issued: & s IMPORTANT: Applicant must complete all items on this page LOCATION- /�,4 IXR_p, IZ- U �� #4-/Q 6'�• a9'JG�d�/l'2 PROPERTY OWNER ,Print-14 Print MAP NO.:_PARC EL: v ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑New Building 'One family Addition ❑ Two or more family ❑Industrial ❑ aeration No. of units: Repair, replacement ❑Assessory Bldg 11 Commercial ❑Demolition ❑Moving(relocation) ❑ Other ❑ Others: ❑Foundation onl DESCRIPTION OF WORK TO BE PREFORMED Identification Please Type or Print Clearly) OWNER: Name: W A 5•h , Phone Address:_. / jt/g/i"ePI' moi+ /�j ,fin V^ CONTRACTOR Name F :� 1 , n S V2z NA-eG11 1 0 Phone: 70 /- 35Z-1110 Address: 1-7 C. /, .1�11 54 (/-fig-- k-4- a t 1- Supervisor's Construction License: $ - ®"7 5 7'3 Exp. Date: Home Improvement License:_ I Z �'� 73 Exp. Date: 3/3 / /-7 ARCHITECT/ENGINEER Name: Phone: i Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.•$12.00 P1 -$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S F. Total Project Cost :$ 3 L( S x12.00=FEE:$_ _ heck No.: Receipt No.: J� e lof4 lahei/ I NORTy BUILDING PERMIT OF�tLEu TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received �,yA�R CHU K ^ SSacHus�� Date Issued: EVRORTANT:Applicant must complete all items on this page I PROPERTYOWNER ruu tPnnt , 1DYear Stctre�a, M ,fY�s' no jAP ~ ' ` rPARCEL`;�_.�__ xZON MING�DISTRICT .t Htstart�cDistnctyes ;ro - - y_ _ ._ ; Machtne.Shx Ila TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ElRepair, replacement 0 Assessory Bldg ❑ Others: ❑Demolition ❑ Other -- Se='tic V1/ell �.Floodplain 0 Wetlands 1Naterslied D'i"sf�ict pti 181 �_INa_ter/-Sevver.. - DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contactor Name` .. • Phone: _ - tk Exp D Supervisors Construction License _z= = t :; . Home,,Ii7n, rrient License:: __ Exp; ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F, i----,Total Project Cost: $ FEE: $ V t. Receipt No,, L`~ Check No.: P NOTE: Persons contracting with unregistered contractors do not have.access to the guaranty fund �inriafirIi-P>rif-ArientFn--6A iPr Signature of contractor l Plans Submitted ❑ Plans Waived El Certified Plot Plan ❑ Stamped Plans ❑ TTyPE 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 INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature COMMENTS ` Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes } Pla-nning Board Decision: Comments Conservation Decision: Comments Water & Sewer Con nec#ion/Signature Date Driveway Permit DPW Town.Engineer: Signature: Located 384 Osgood Street FIRE DEPAI;TIVIENT -.Temp Dumpster on site yes no Located at i2ZIVlain Street --,'' Fire Department signature/date COMMENTS -)imension 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 dropyrequires approval of Electrical Inspector Yes Ido - ®ANGER 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 ate Time Contact Name - ------------------ Doc.Buildin�Permit Revised 2014 ,. _. Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. r 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 ❑ Workers Comp Affidavit o 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) o 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) a Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit ❑ 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 o Engineering Affidavits for Engineered products DOTE: 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:B0dingPermitRe-4sed 2014 Location No. n 79 .7o/ 7 Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# S� "' Building Inspector � NORTiI� own of E ndover No. '07b ' * - ,� % h ver, Mass, ;1b cocNictiew�cw 1' �4qo P`� ,4 R�1TEo �p •(5 U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ........ktr4 ... . ,... BUILDING INSPECTOR . ... Foundation has permission to erect .......................... buildings on ... ..... .A. .�4.!�I .......V4.4............/� Rough to be occupied as ........ ........9fYMM.ICAWI ...A�. W A.0w s y 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 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO RTS Rough . Service .......... .......... .. ... ... ............... BUILDING INSPECTOR Final GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. CONTRACT# 00120351 MASSACHUSETTS SERVICES SOLUTIONS INSTALLED SALES CONTRACT LOWE'S AUTHORIZED REPRESENTATIVE IINUMBER CUSTOMER STORE NO. STREET ADDRESS STREET ADDRESS CITY STATE zip CITY STATE ZIP �c1i TELEPHONE ? THLEP ONE . .. CZ' DAT LOWE'S HOME CENTERS,LC'S MA HIC NO.: 148688REG I ( � ' FEIN:56-0748358 CHARGE `tom [� u This is only a quote.for the merchandise andservices printed below. This becomes an agreement upon Upon payment,the entire agreement,including the specifically completed pages of this document,the Terms and Conditions included with this document and any other addenda and attachments hereto,shall be referred to herein as this"Contract." PLEASE READ ALL TERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS PAGE AND FOLLOWING PAGES BEFORE SIGNING. INSTALLATION STREET ADDRESS CITY STATE ZIP "N Ivi- � r _ t l ids C.Gpp, NOTICE TO CUSTOMER—PRICE CALCULATIONS: In order to properly perform the installation of certain Goods,the Contract Price may include more Goods than actually will be installed based on the measured square footage of the Project Area. As a result, the parties agree that the lump-sum Price stated in this Contract is calculated upon both the value of estimated Goods required to fulfill the Contract(including waste),which may exceed the actual square footage of the Project Area,and the labor which may be estimated based on the amount of Goods required to fulfill the Contract(including waste). By signing this Contract below,Customer acknowledges receipt of this notice and agrees and understands that the Price includes these costs which may not be refunded once the Installation Services are performed. Contract Total Are permits required for this installation Yes [ ] No applicable tax included NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamplet Renovate Right. By signing this Contract, Customer acknowledges having received a copy of this pamphlet before work began informing Customer of the potential risk of the lead hazard exposure from renovation activity to be performed in Customer's dwelling unit. NOTE: If rotted wood is discovered during installation additional char a ou will be given a quote and a change order must be completed and signed by the customer for any additional ch sA�an Customer must initial. *Any work or material not specified is not included in this contract.Any changes or additions will onal charge for the material and labor. PHOTO RELEASE:Customer grants to Lowe's and Lowe's employees and independent contractors the right to take photographs of the Premises where Installation Services will be performed and all work performed at the Premises related to this Contract, and irrevocably grants to Lowe's all right,title and interest in and to the photographs for use in all markets and media,worldwide, in perpetuity.Customer authorizes Lowe's to copyright, use and publish the photographs in print and/or electronically,and agrees that Lowe's may use such photographs for any lawful purpose,including,but not limited to,marketing, advertising, publicity, illustration,training and Web content. By initialing here,Customer agrees to the foregoing. [Customer to initial to the left]. o11k is t corn!1re upon reasonable availability of Contractor and/or any specialo e• u to er made Good(s)which is anticipated to be T � [fill in date]. Estimated completion date is I I [fill in date]. Said estimated substantial completion date is not of the essence. A statement of any Contingencies that would materially change said estimated substantial completion date is as follows: (if applicable, insert a statement of such contingencies). IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full. COVPLETE THIS SE 0 Y WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00: pt Cb4Customer to Pay Full; [ ]Customer to use the following payment schedule: 1)Dep 't $ to paid upon signing contract. Deposit should be 1/3 the total contract price;and (2)Payment of $ to be paid anytime after this Contract is signed and before commencement of installation,I/We authorize Lowe's to do one of the following(check appropriate box below): [ ]Charge mylour credit card for the amount of the payment indicated above anytime after the date this Contract is signed; or [ ]Deposit my/our check for the amount of the payment indicated above anytime after the date this Contract is signed;and (3)Final payment of$100.00 to be paid upon completion of the installation and both parties'satisfaction. NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L.c.142A LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT,THAT LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUT- OFFIC ER FAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION BS ID 2 Date: ` squdfe IVutdge ui um;rIVECUt MIGC,dnu LIM iauVI vvi m.n n,ap uc vao v.,.,,.,an,.,..,...., .+•+.,...+��y..,,.... ...•.-11•.1..•.. ..........-• •^-•-•�•••a ••��•�i• Byesigning this Contract below,Customer acknowledges receipt of this notice and agrees and understands that the Price includes these costs which may not be refunded once the Installation Services are performed. Contract Total ble �J Are permits required for this installation Yes [ ] No *appllca tax included 123 NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamplet Renovate Right. By signing this Contract, Customer acknowledges having received a copy of this pamphlet before work began informing Customer of the potential risk of the lead hazard exposure from renovation activity to be performed in Customer's dwelling unit. NOTE: if rotted wood is discovered during installation additional chara You will be given a quote and a change order must be completed and signed by the customer for any additional ch S . Customer must initial. 'Any work or material not specified is not included in this contract.Any changes or additions will be additional charge for the material and labor. PHOTO RELEASE: Customer grants to Lowe's and Lowe's employees and independent contractors the right to take photographs of the Premises where Installation Services will be performed and all work performed at the Premises related to this Contract,and irrevocably grants to Lowe's all right,title and interest in and to the photographs for use in all markets and media,worldwide, in perpetuity.Customer authorizes Lowe's to copyright, use and publish the photographs in print and/or electronically,and agrees that Lowe's may use such photographs for any lawful purpose,including,but not limited to,marketing, advertising, publicity, illustration,training and Web content. By initialing here, Customer agrees to the foregoing. [Customer to initial to the left]. o k is t com ce upon reasonable availability of Contractor and/or any specialore ru to er made Good(s)which is anticipated to be � [fill in date].Estimated completion date is I [fill in date]. Said estimated substantial completion date is not of the essence.A statement of any contingencies that would materially change said estimated substantial completion date is as follows: (if applicable, insert a statement of such contingencies). IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full. C PLETE THIS SE O Y WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00: Customer to Pay Customer to use the following payment schedule: 1)Dep 't $ to paid upon signing contract. Deposit should be 1/3 the total contract price;and (2)Payment of $ to be paid anytime after this Contract is signed and before commencement of installation,I/We authorize Lowe's to do one of the following(check appropriate box below): [ J Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed; or [ ]Deposit my/our check for the amount of the payment indicated above anytime after the date this Contract is signed;and (3)Final payment of$100.00 to be paid upon completion of the installation and both parties'satisfaction. NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L.c.142A LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT,THAT LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUT- OFFIC R AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS ID 142 . t i •� ' t B Date: s om. Cen L q Date: Owne ignat THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY LOWE'S PURSUANT TO M.G.L.c.142A.THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THE SECTION ABOVE IS NOT SEPARATELY SIGNED BY THE PARTIES. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT. BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT. YOU ARE ENTITLED TO A C P THIS C N,RAC AT THE TIME OF RE. WITNE OUR HAND(S) SEAL(S)BELOW THIS DAY OF Low 's Holne_Centers, L tf owe's Authorized Rep . ,tive �wner Co-owner or Witness Customer acknowledges recd1pjdf a true copy of this contract which was completely filled in prior to Customer's execution hereof.You,the buyer,ma: cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.See the attached notice of cancellation form for an explanation of this right. © CUSTOMER COPY 2004 Lowe's.ra Lowe's and the gable design 55102 REV. 12/13 are registered stered trademarks of LF Corporation. I i i i Massachusetts 1'1'ie Commonwealth of 1Y1 Accidents�e t Demxdaial pt �5tie YConb' ess Street, 017 M d Boston,MM 02114-2 c www.massgo-v/dia ensationXrxsuxanceAfxaadt:BuildeOX-ontxactorsf�+,leetriciabsl lmnbers. �7Qakexs' Comp G AUTOB '. TO BE MED' ' H PMMM Elease Pr mt Le 'h, A licantTiafoxmation 0 Namo(Business/Ozga�aizonllndividual): ��, \JzC Address: �� �-C; �— - r City/State/zip: Type of project(requixetl)= Axepou an empioper?gLeclttlie appxopriatebox: , emgloye es full.and/or part time).* 7. ❑I�&constr' dion 1.❑I am a employer with__— ees�aorlang forme in $. ❑]Zeillo de]Ii7g I am.a sole proprietcr Orpa ctaarshtg andhage no employ 9 []Demolition any capacity.[Noworkers'comp.insurance required] elf o workers'comp.insurancerequired]t 10❑Building addition 3.�I am ahomeowner doing allwoxkmys � ro IwriIl Q_❑I am a homeowner and will be hiring contractors to conduct aIl work onmy r Pte' II-ElElectrical repairs or additions ensurefihat all contractors eitherhave workers'compensation insurance or are sole Pl�bing repairs or additions t. ees. 12; proprietors withno emgioy 13•.0 Roof repairs 5.❑I am ageneral contractor and Ihav eaeedth su-contras romp ched sheet These sib-contractors have employ 14.0 Other. (,❑We are a corporation.ands offices have exercisedtheir rigbt of'exeraion per Md c. 152,§1(4),and yre kava no employees_(No workers'comp.insurance required] apPhcanithat checks box#1 mist also fill ontthe seciionbelow show>Dg �w orkers'coup ensationpoist minim wsach affidavrt indicatingthey are doing all work andthenhire outside contractors must submit a new affidavit indicating ye, i Ilomeowners wha submit-tT?s,, the name of the sub-contactors and staie whether or notfhose.entities have tContractors that checktlus lion must attached an additional sh r-V hde their workers_'comp-policy number. employees. Ifthesub-cordzactorshaveemployees,theymus pern to ees $clo7v t/ierolieyaizdJohsite X am an employe tlicrt is pYovzdzng7vo7�eNs'eorrrpensation iv�sraxacz�ccefor'my P 7' informadon. - S' Xnsiirance Company Name; acv\ L ExpiratienDatez Policy#or Self-ins. elf ins. P 0 `or � 16 City/State/Zip:i) lob Site Address: Wi the olio number and expiration date). Attach a cope o£theworl�exs' compensationpolicy declaration page(shoWmg p y to$1,500-00 Failure to secure coverage as required under MGL c•152,§2form of STOP WORg.ORDMD'and a fie oi£up to $250.00 a and/or one-year imprisonment;as-well as civil p enaldcs in thef day against the violator.A copy ofthis statement znay be forwarded to the Office of Investigations of the DSA fox irisuxance coverage VeldfCcation. tli ai penalties o erjury tTiat the inforvnation pr ovided above s tr ue and correct I do li cex�tifOt 1 Date: Si Phone#: 1 OffiezctZ zcse only. Do yzot-tvrite in this area,to be corrnpleted by city ox town official Perinxt/License# City or To-Wn.' issuing Authority(circle one): ector 5.Plumbing bsPector 1.Board of Eealth 2,Building D epartm.ent 3.CztylTovvn ClexI� �,Electrical Xnsp 6.Other Phone#_ Contact Person: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their can Ib ees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of kite, express or implied,oral or writtea>~" An employer is'd'efiued as"an individual,partnership,assn ciation,corporation or other legal entity,or any two or more Of the foregoing engaged in a joint entexprhq,and including the legal representatives of a deceased employer,or the receivbr'or trustde Qfan individual,partnership,association or other legal entity, employing emplbyees.,However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling or on the grounds or building appurtenant thereto shall not because of such employment b6 deemed to be an emp oyer', MGL chapter 152, §25C(6)also states that"every state or Iocal licensing agency shall withhold the issuance or ,renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicantwhd Ras not produced acceptable evidence of compliance with the hasurance coverage rec died." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements ofthi chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supplysd'contractor(s)name(s),address(es)and phonenumber(s)along with theircertifcate(s)of insurance. Limited-Liability Companies(LLC)or Limited Liability Partnerships(LLP)withno employees otherthan the members or partners,are not required to carry workers'compensation insurance. If an LLC ox LLP d6e's have employees,a policy is required. Be advised'that this affidavit may be submitted to the Department of Industrial Accidents for confirmation ofinsurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a yvorkers' compensationi policy,please call the Department at the number listed below. Self-insured companies should enter their self insurance license number onthe appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space atthe bottom of the affixdavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to Min the p ermit/license numb ex which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current Policy information(ifnecessary)and under"lob Site Address"the applicant should write•"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for futureermits or licenses. P Anew affidavit must be filled out each year.Where ahome owner or citizen a" s obtaining a license or permit notrelated to any business or commercial venture (i.e. a dog license or permit to burn leaves etc)said person is NOT required to complete this affidavit. The Department's address,telephone and fax numb ex: The Commonwealth of Massachusetts Department of Industrial.Accidents I Congress Street, Suite 100 Boston,MA 02114.2017 Tel.#617-727-4900 ext.7406 or 1-877 MNSSAFE Fax# 617--727-7749 Revised 02-23-I5 wwwm.ass.gov/dia Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-072573 Construction Supervisor `y PHILLIP,i VERNACCHIO,III 4 17 CLIFTON ST REVERE MA 02151 �M L/L-- Expiration: iration: Commissioner 04/27/2018 Office of Consumer Affairs&Business Regui at c)n f (HOME IMPROVEMENT CONTRACTOR i Registration: 129273 Type,. Expiration 8/3/2017. Individual t Philip,i Vernacchio III ' } philip Vernacchio \� 17 Clifton St. ;:.r Revere, MA 02151 Undersecretary. d /2812G1'1 02: 14 PIA FAX No, CERTIFICATE _ oa1t:(�IMtOumYYy 3 OF LIABILITY' INSURANCE ���28/2416 THIS CERTIFICATE IS ISSUED AS A MATTER Of INFORMATION ONLY AND CONFERS NO RIGHTS'UPON THE CERTIFICATE BOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR, NROATIVELY AMEND, EtITEN'O OR ALTER THE COVERAGE AFFORDED ICY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT 09TIMEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE'OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT- If the certificate holder Is an ADDITIONAL INSURED,the poIloy(Ias)rntmi be endorseq M$tlf�R50ATION 16 WAIVED,subject to this tarns and conditions of the Policy,certain policies may require an endorumant A statemrent on this cArMcato'does not confer rights to the certificate holdor In ilau of such endorsement(s),, PrlcFouCEB Patagia" Mrraah John E- Biagio Insurance AgencyC (617)846-0600 � I6171e46-ev2e 399 Winthrop Street caw mbl�bfggacrltss�xra o .c Winthrop MA 02152 tTEP At'rtultllNr,G1I1t1FtA€iiE_Y____ _ . A , FNBURER A-Ha $Ville Insns an o pan:r rNsulzsn _ FNsuttE>R a rlil Zvi lie Pref�rxe�ci � I?Isilip J Vernaaehics, III INSURER C:Not RD Insuran � 17 #Cl7.ft9n St r tv, INSUR6Et 0 Revere, M42151 INSURER S: INsurt�x 1?; COVERAGES CER'T'IFICATE NUMBER CL144900625 REV[SIUNNUMBER, a THIS IS TO CERTIFY THAT TH!^POL CIE$OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURE=D NAMED Ash KA THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY kEQUIREMEN7,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH t KCrt TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEPFIN IS SLIWECT TO ALL TPX-- TE-Ar&, EXCLUSIONS AND CON©mONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. SR ADDL SU LNTYPE OF IN3URAN6A p4tt Yr F1 POLICY E(I7 CY NUM 3ER IuM/6tS d£►IMLt1AMUTY EACHOCCUKgENCE # I,Ot30,CIbd X CAMMEPOALGENERAL LIACkM DAWAGE E� W s 31iU,GsOfl A, O-AP>I;;4mm Lxl QCC LIR 5PP00000050861L 2/1512016 2/15/2017 NED EXP w1*gele,44x 5,Qt3tI PERSONAiDLt y T � 1,000,00G GENEI°tfel.PskafiilE IT1: 1 2,OrS{3rrl€III a OENLAt EGATEUWT APPLMS FV pgQpRjC7g. J6 G: 5 2ft3tlf},(7iitf JFrT AlITOYOaIIX LUMLIT"/.. COIABINEO U1.E LILY : 1000 0015 AW AUTO BOCsILYINJVRY"(P«c ) # A 4 tI r3 ASCMEDLqm JtFOt)tt€I74ar5 6118/2016 /1812017 BoDayirattdreY(PerM # X HMD AUTOS � n!#I`{14 ._ w s UMBRM.LA u EACH OGuca I# EXCESS UAS CwI S oce�t TE g LJ tiETE�3 _ s 13 Woma AS COMPENt+ATI4H Y. R t! Ht ElrFWY`Vt5't1A44JVY --- ANY P90PtRtETCNUPARTi#t)w(:amVE YEN e.L.EACH ACCIDE"rS bC 'QDO OF I tG6FIna 01 E�It�I � N t A' iN + +Y1+NRi 595710 4/3/2016 /3/2011 EL DISEASE•EA EMPLOYEE s Soo 000 titsit� D II# TIO IW fc L=QkSE-POLICY LANT i 5pb -bbb D RIPTION OF ORMTi 10"I0CAT)fts 1 HIGLES(Ad cr,ACOAD 04,A"dand Rema)ta 3611etlu19,It more$pans Is re"Ulnut) I CERTIFICATE HQLOI= CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of orth Andover ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street AUTHDfu=R�RESENTATIVE North Andover, MA t3�.$45' p