HomeMy WebLinkAboutBuilding Permit #249-11 - 101 CROSSBOW LANE 9/24/2010 BUILDING-PERMIT of "°?
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: r Date Receiveds
Date Issued: �SSgCmut ti�
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TYPE.OF IMPROVEMENT IPRQRQSFD USE
esidentia Non- Residential
New BuildingAJne family
Addition Two or more.family Industrial
Alteration No. of units: Commercial
Repair, replacement- Assessory Bldg Others:
Demolition _ Other
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DESCRIPTIOf�OF WORK TO BE PREFORMED:
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Identification Please Type or Print Clearly)
OWNER: Name: ,/ Phone:
Address:
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$9000,00 OF THE TOTAL ESTIMATE COST BASED ON$125.00 PER S.F.
Total Project Cost: $ 60 -Y 2- �Q00FEE:
Check No.: ' l Receipt No.:
NOTE: Persons contracting with unregistered conte actors do not have access to the guaranty fund
_�_�9� r..� =' lana: areco :'r °° •�_ �J
Location
No. Date
�pRTh TOWN OF NORTH ANDOVER
A
Certificate of Occupancy $
s,CNUstt� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # ! I
._s
234
Building Inspector
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/MassageBodyAjFoodPackaging/Sales Pools
Well Tobacco Sales
Private se ticp tank,etc. Permanent Dumpster on Si
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THE FOLLOWING SECTIONS.FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED'
PLANNING &:DEVELOPMENT
COMMENTS
I
CONSERVATION Reviewed on Signature
CO M M E- T S
HEALTH Reviewed on Signature
COMMENTS
r' •
ming Board of Appeals;`Variance, Petition No: Zoning Decision/receipt submitted yes
Planniri,r,. aoard Decision: Comments
Conservation Decision: Comments
Wafer& Sewer Connection/Signature&Date Driveway Permit
DPW Town Engineer: Signature:
_ _ �' + i'Located` 384 Osgood Streefi
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��;•5�."���I�see��'t"af��?rtix_ - �:z,: •.�::.,x�.<-_x.,.n;��.x••x'•r.:: '' - __ �•'i-'rk�••`-.`._.:
m:��••�'�•ytn .�� -__ -.'t7. �'�.. _.�z' - _sax.--'.�.r.::r:' ..r�:t-:r..- -:r _��'t;7: ��;F::qx,'^..".,,_ �7=::.C'av;�,:
_ _ ..rx�l •u.�A 34x. ..l-�. __ ".Y]�1.�=h;:=i��`o '.A••1 S'L:;ra•�-u�'__"' 3:� _T-I'.-.r�.xY.ntYsyr:i'.a yT.
ca;r y.� !=^�._`=`.x-e:': =:r_•:xt3 - - _i.:- ya~� _ _ —•tom ii:__..
- ..ty.-`:� - •-!•^fir.: _ _ :'•G-'_�-^��' _ _
- llG�T•-Z^!:'it•'e:_. _ __ _ - '..1.'. _ ...-f-i _._.S,•axCi'CS:".a,!•:r"+•'a x• - _
aJ3:..3_ r..�-�::/'c"• uL_JA ...r�•.Ji -- -�j"'"_ -'_'t.:�.'T,-.:.-...- -
_
-
- -
P - ry:]�:�:: •:t.at• :'•tit__,_::�+` �� -
-r'ly.. - :�`Tr - - - f:!:�yc:..�j^: ••4.i�_Y::.in L::x..a _ � _ _ �•
_ _ - - .-,:..isr:.:,y:1rr^:-1pc:`w.;7•ar�•i=;;�.r^'l:{fi`:r:a
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)
i
❑ Notified for pickup- Date
I
Doe-Building Femut Revised 2010
i
Building Department .�
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
I
Roofing, Siding, Interior Rehabilitation Permits G
h
❑ Building Permit Application
o Workers Comp Affidavit !I
❑ 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
Y .
o Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/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
❑ Cle.,Ll.ied r'r... pl%)sed 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)
o Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
MOTE: 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 2008
Location,/01
No. '"' Date
�10RT1y TOWN OF NORTH ANDOVER
? ,_ • C
w w
s
Certificate of Occupancy $
s CHCS Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 3,-
23478
CBuilding Inspector
T0VMr t ORTH
of
No. -
A K E O dower, Mass., •
O
COCHICHEVVICK
7,p�OOATE D
lel ` BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT �
. ••"•"•••••"'•'•""•"""" Foundation
has permission to erect.......... buildings on ..J.. .L. `
...... .. � .............................
Rough
to be occupied as } �. Chimney
provided that the person accepting his permit shall in every respect nform to the terms of the application on file in Final
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 CONSTRURough
... .........................................................................................................
.
BUILDING INSPECTOR Service
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
1
NERAL BUILDING NOTES/CHECKLIST-
GE U GNOT LIMITED TO ITEMS BELOW
POST ALL LOT NUMBERS,ADDRESS, AND PERMIT(COPY 0K)..or no inspections
INSPECTIONS: (Minimum) Excavation , Footing, Foundation, Frame, Insulation, Final.
FOOTINGS: Continuous Full 2x4 Keyway
Continuous strip footings for interior columns
FOUNDATION: Rebar as required
Anchor bolts or straps -
Damproofing
Foundation drain-pipe/stone/fabric filter/cover and outlet connection.
FRAME:Fireblock-over girts/plates between floor joist i
Penetrations for plumbing, heat, elec, etc.
Walls at stair stringers.
Windbrace corners and center bearing partitions.
Size ridge to provide full bearing at rafter cuts.
Hip and Valley rafters-watch bearing at walls.
Ridge&Hip-Provide proper connections.
Cathedral roof rafters provide proper connections and use"Hurricane Clips"tie to plate.
Stair stringers-watch cuts and heal support.
Joist hangers-fully nailed w/hanger nails.
Sill plates 2-2X6(1 PT)w/sill seal.
Girls-solid brick or steel plate bearing at foundations
'/"air space at sides in foundation pockets.
Lateral bracing at ends.
Certified calculations. required for Beams/LVL's Trusses.
Solid bearing support for Headers/Beams etc.
Check headroom clearances-stairways, under beams
Attic Access. (min. 22x30 w/3'headroom above).
Crawl space access. (min. 18x24).
Bath exhaust fans to have metal duct to exterior(not in soffit).
Firecode S/R wood frame of"0"clearance fireplaces&stoves
Window Schedule or Every Habitable Room Must Have:
Natural light equal to 8%of floor area.
of required glazing shall be openable.
Bedrooms required min.20x24 egress window or door.
Vent attic spaces-"proper vent", soffit and required ridge vents.
Firecode under stairs if used for storage
FIREPLACES: Separate permit required.
Inspections at Footing-Smoke Chamber-Finish
Smooth parging, clean joints, 8"solid @ combust.
DECKS: Lag to house, provide flashing.
Rails min. 36"high, Baluster max space 5"on center.
Over 8' above grade, use 6x6 posts w/lateral bracing.
Lag all posts and rails.
Pier footings down 48", Conc. pad at stair base.
FINISH: Handrails returned to wall/newall post.
Guardrails required alongside open cellar stags.
Exterior grading complete.
Certificate or occupancy required prior to occupying structure.
Temporary Stairs required for inspection.
Re-inspection fee- $30.00(Be Ready).
Certificate of occupancy required prior to occupying structure.
i
�.1ORTH
ToVVn of
0
� Q s
o dover, Mass., -t O
'7` = LAK
A- COCMICMEWICK �t
0RATED p '`C
7 BOARD OF HEALTH
Food/Kitchen
, .PERMIT T D Septic System
O BUILDING INSPECTOR
THIS CERTIFIES THAT...................1...�IM........ .............. ........ .... ......................:..
Foundation
........................ buildings has permission to erect................ g .. .. ..I.........�..�.�s',b6.0.0:.:..........,............... Rough
A.. 1� Chimney
to be occupied as.................. .. . .. ....................�inevery
.�..... ..............................................................................
provided that the person accepting his permit shall respect nform to the terms of the application on file in Final
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 CONSTRU Rough
Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
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. Bumer
Street No.
SEE REVERSE SIDE smoke Det.
Mass;t'hus tts D p trtmcnt ut• Public Safct�
i
p Board of 13161(lin�g.Regulations and Standards
3 Construction Supervisor Specialty License '.
License: CS SL 102129
{ Restricted to: RF
DENNIS SHURTLEFF
._'9 HADLEY..RD
l _ VESTFORD, MA 018$6
Exiration: 1/13/2013
GL�tmrii,nrr.- Y` '''7Y#: 102129
l
i
CERTIFICATE OF LIABILITY INSURANCE apse DS OFF,
09 z2 10
THIS TE 4 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFRRMATNELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELO.1f THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING MLSURER(8�AUTHORIr3eD
RESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER.
en 1 must to
the tames ad e=Wm s d the P ft certain Pdides may rsyuis an adoR wnm t A statement on thea Ixrtlicate does nal confer riots to the
oardllssita hMder it lieu d such mss}
PRODUCER
NM:
litestford Insurance Agency Ne
224 Littleton Rd P.O. Box 308
Westford M& 01886- wMranERD1: SRtM_D2
Phone:978-692-3073 Fax:978-692-0429 WXXtEFt(2)AFFOROM C*VWtAQE Nuc1
Ral♦REO NSUR ERA: Central Insurance panany
p�a Shurtleff NSUREt B:
or �l01886 WOURBRC:
NSURER D
NSUM E:
NBURF.RF
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
T419 10 TO FYTHHAT THE POLICIES OF MANUUCE LISTM BELOW WAVE BEEN T-6THE WORD NAMED ABOVE FOR THE POUCY PEP30D
INDICATED.NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIK THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 13 SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TWI TYPE OF a1SURANCF NSR POLICY NUME6t LIMRa
o ILUAerm
EA01 OCCL"eCE S1000000
A : C0144RCIALGEOMLIASIUTY 7867502 03/15/10 03/15/11 PRENSES(Eaoelctawn $100000
CLAI ®OCCUR MED EAP(Any one oww) $5000
PERSOW H:ADV INJURY $1000000
GeAERAL AGGREGATE s2000000
GM AGGREGATEUWTAPPLIES PM PRODUCTS-COMPOPACG $3000000
pMC.( PRO-JECT Loc f $
AUIT011109 PLIASM CONONlEDSINGLEUNT =
ANN AUTO Ee-dam
ALL OWNED A M OWLY IKOJRY(Pet P 9m) $
AUTOS BODILY I1,4ARY(Per atddeM) $
PROPERTY DAMAGE
HIED AUTOS Fw ettld*4 S
NIONNOW*Z AUIIDS =
t
tlMMWLA Lin. oC EACH OCCUIVMME s
IDtCEaeLL1B CLAIMSMADE AGGREGATE
DEDUCTIBLE S
RETENTION SW41 amw cow%mv=W-- 20 Us =
AND 0111PIA" tai LMe$RrY YIN $ TORI'L
AW PM)PP4ETOP4PAR7t*3VEXECUTIVE BY n1eVaAMM CARR=
OFFXXPJMEMgR EXCLUDED? i A E.L.EACH ACCIDENT S
E.L.DISEASE-EASOPLOM S
� OFCPERAnONSw" E.L.DISEASE-POLICY LIMT S
Osumi OF OPEftATI M I LOCATiote r vEl 0ml CAlheh AIDRD tat Adtlt W Rewft whet*nears pan is r"%*"
Mr a0tR-coaatructioa of reaideatfa property not ®xCwediug three stoCies
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THIN ANOVE DE$CFJM POLICE$NE CANCD.LW BEFORE
TIM[NXPOMION DATE TH EIMOP.NOTICE WILL NE DELIVERED a
ACCORDANCE WRN TM POLICY PROVNNON S.
%Mm Of North Andover IUIrNNORIM TA
1600 Os 3
treat
N. Andover Wh 01845
Aitay-F e
Ma reserved.
mm 23(20M") The ACORD name and logo are registered marks of ACORD
RightFax C3-2 9/23/2010 5:49:44 AM PAGE 2/002 Fax Server
i
ACORD. ` CERTIFICATE OF LIABILITY INSURANCE DATE(mwWYYYY) oel no,i0
THIS,CERi1FlCATE M ISSUED ASA NATTER OF INFORMATION ONLY AND CONFERS NO ROM UPON TME CERTNRCATE HOLDER. TNBS
CkT1TIPeAU GOES NOT AFFIRNATIYELY OR NEOMNVELY AMEND,Eam OR ALTIGt THE COVERAGE AFFORDED BY THE POUCso BELOW.
� THIN COMFICATE OF INSURANCE DOES NOT CONSMM A CONTRACT BETWEl"TME INIBUNG I R(Sh AUTHORRED REPRESENTATIVE
OR PRODI1C. &AND THE NMMAcATE HOLDER.
MPORTANT:N the cwtikets hoMw is an ADDITIONAL INSURED,IIe potloT(Isa)mast be srwforssd.if SUBROGATION IS WAIVED.N*Jact to the
Is and eomilbom of In poky,wbin POldes mar requim and sadorswoft A Wom wd on this ow"ftate doss not confer doff to IIs
carNfleats how"In Nu of such ondsraosr*(
PRODUCER ODNTACT
NAME:
PHOIIE FAX
WES7FORD TNS AGCY INC (Ale,No.EIIQ: FAX
P O BOX 308 (AIC.No):
E.11111L
ADDRESS:
PRODUCER
WES7FORD.MA 01866 CUSTOMER IN is
28W5B. INSURERM)AFFORDING CWVERAGE NAICI
INSURED INSURER A: CONTl MIMAL CASUALTY COMPANY
INSURER N
SHURTLEFF DENNIS DBA SHURTIBF'F ROOFING INSURER Q
INSURER D.-
9 HADLEY ROAD INSURER E:
WESTFORD,MA 01886 INSURER F:
0MIRRA011S CERTMATE NUMM: REVISION NUMBER:
THSISTOCERrNFY TMTTNNEPON.ICEESOF MNSURANCE LASTED BELOW HAVE BEEN MUED TOJW mtWMNANEO ABOVE FOR TIE POLICY PEWADNOMTED,
NOTMIINSTANDNSANY REWIREMIT,TEIOEORCdIDTIOHOFANYCONTRACTOROTHERtOMWEENTWITHRESPECTTOW"ICHTIISCO FICAIEBAYBEIBBUEt)
OR MAY PW,ML TIM NlURMCE AFFORDED BY THE POUOES DESCRMED HERB419 9=ECTTO ALL THE TERIIN,EXCLUIIONS ANDCOt IMM OF SOC!!POLICIES.
UMS SI MM BAYRAVE BEEN REDUCED INTI PAM CLAUL
am ADDLSUBR POLICY EFF DATE POLICY ETP DATE
LTR
TYPE OP OSURANCE tMSR T1VD POLICY NUMBER (MBaDDIYYTY) PMssD V"V) UNITSi
GENERALUABLnY EACHOCCURRENCE $
COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED $
i CLAIMS MADE OCCUR. PREMISES(Ea owmenoe)
MED EXP(Any ons parson) S
PERSONAL 68 ADV AWRY S
GENLAGGREOAIE LIMIT APPLIES PER: GENERAL AGGREGATE E
POLICY PROJECT LOC PRODUCTS•CONAPIOP AGO S
AUTOMOBNLE UABLTY COM BNED SINGLE $
ANYAUTO LIMIT(Ea ao kWill
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Per Pn)
HMO AUTOS BODILY INJURY $
1 (Per axidant)
NON<OWNED AUTOS PROPERTY DAMAGE $
(Per acddmQ
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS UAB CLANS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION$ $
WC STATUTORY LIMITS OVER
WORKE7!'S COIFENSATION AND
EMPLOYER'S UABS.ITY YM U6-0206M502-10 071232010 07/23/201 t E.L EACH ACCIDENT $ 104000
ANY PROPERITORIPARTNEWEXECUTNE Y E.L.DISEASE•EA EMPLOYEES 100,000
OFFICERILMEMBER EXCLUDED?
~ E.L.DISEASE•POLICY LIMIT $ 500,000
aym dewOen
DESCRIPTION OFOPERATIO M bdw
DESCRIPTION OFOPERAMONSILOCATNONSIVE ACLES UTRIC O N81SPWAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE LERrMA7E HOU)B AITWI NO WORKERS COMP COVIIRAGR
TRT:WORKMT COMPENSAIRW POLICY DOES NOT PROVIDC•WVM AGE FOR SHORTLEFT DEM.
CERTIRUTE HOLDER CANCELLATION
TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRMED POLICIES 8E CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE
1600 OSGOOD STREET WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
NORTH ANDOVER,MA 01645 Dennis Chookaszis
ACORD 25 C 11188-211109 ACM CORPORATION. All rights reserved.
I
The Commonwe¢lth o Nlassac
J� husetts
Department of Industria1.4ccidents
Office of investigations
600 Washington Street
Bostorz, M4 02111
Workers' CompensationInsurance H "w- rzssb ova&a
An licant Information Affidavit: Builders/Contractors/Electricians/Plumbers
Please Print Legibly
Name(Business/Orgmiza6ondndividual): }1 n '
Address: In
City/State/Zip: w
Phone#: 07 j `0
Are yo 'an employer?Check the appropriate boa:
l.
am a employer V I Vith— — 4. ❑ I am a general contractor and I2. Type of project(required);
r7employees(full andlorpart-time).* have hired the sub-contractors 6. ❑New contraction
I am a sole proprietor or partner- listed on the attached sheet x �• ❑RemodeIin
ship and have no employees These sub-contractors have emolition
working for me in any capacity. workers gain . ' 8. ❑D
[No workers'camp. p insurance.
p insurance 5. ❑ We are a corporation and its 9. []Building addition
required.] officers have exercised their 10-13Electrical
3.❑ I am a homeowner doing all work right of ex �or additions
rep
myself. [No workers'comp. c. ht emption per MGL 1 I.❑Plumbing repairs or additio
,§14 ns
insurance required.] t � ),and we have no 12,7 Roof �
employees. [No workers' ��
comp.ins ce red.] I3.❑ Other
`tiny}mH-ut that checks box�, musi aso r ��
I3onieowners who submit ou:the sectio`eeiop•shev;r�*rs war
this affidavit indi ting they a, doing all'work and Y c�.: oa
+Contractors that check tris box must attached an additional sheet showing hire outside c°n+sactor Acis.submit a new affidavit indicating such.
o the name of the suh-conuactors and their world'co
I am an employer that is prove workers'compensation insurance for my employees. B �'policy information
information. Below is the policy and job site
Insurance Company Name:
-� or
Policy'#or Self-ins.Lic.0.
Expiration Date:
Job Site Address: Cr,
City/State/Zip:
Attach,a copy of the workers' compensation policy declaration aQ
Failure to secure coverage as required p ne(showing,he policy number-and expiration
q under Section 25A of C. 152 can lead to the imposition of criminal date).
fine up to$1,500.00 and/or one-year imprisonment,as well as civil
Of up to'$250.00 a day against the violator. Be advised that a co aminal penalties of a
Penalties in the form of a STOP WORK ORDER and a fine
Investigations of the DIA for insurance coverage verification. Py of this.,statement maybe forwarded to the Office of
I do hereby certify under ns and
penalties o.fP !er
my thQt the information.provided above is true and correct
SiQuature: /
�l.l.)..Y.�to..
Phone#, i �`
O
O fficidl use only. Do not write in this area, to be completed by city or town q "Cial
Cita or Town
' Permit/L,icense#
lssuin�g Authority(circle one):
I. Board of Healtb 2.Building Department 3.
6. Other• City/Town Clerk 4.Electrical Inspector 5.Plumbiab Inspector
Contact,Person: .
Yhone :
PROPOSAL
i
DENNIS SHURTLEFF ROOFING g Hadley Road PROPOSAL NO.
Residential / Commercial Westford, MA 01886
Specializing in SHEET NO.
Rubber • Shingles • Tar and Gravel Dennis Shurtleff
Chimneys • Strips #(978)692-5082 DATE
Fully Insured
PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT:
NAME ADDRESS
ADDRESS
o/ dross bow k ne..
9 n j 0 V e r. M5 . DATE OF PLANS
PHONE NO. ARCHITECT
We hereby propose to fumish the materials and perform the labor necessary for the completion of
II . .
(" !f c
e 1 ce an � o
le
C- c r r C- v>7 C, M de r o Po 0
r c i ( Ti
i .
U .
w911 9nr e q d.
o I e ee 9 He f0 r S
o
All material is guaranteed to.be as specified, and the above work to be performed in accordance with the drawings and specifications
submitted for above wP�k and completed in a substantial workmanlike manner for the sum of
•/�/ L j h D u S Q C1 A . Dollars ($
with payments to be made as follows:
Respectfully submitted
Any aneratbn or deviation from above spions ntwMing 9&a costs wiA be
emdeedonly upon wdaenon*w.and will beodneanetaradtatpaaer and above tlte
estimate.As agreementscontipantuponsnikes.accidents,ordelays beyond our Per
control.
Note-This proposal may be withdrawn
by us if not accepted within days
oe
ACCEPTANCE OF PROPOSAL
The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the works ecified.
Payments will be made as outlined above. Pis
Signature
Datei
Signature
WESTFORD INSURANCE Fax:978-692-0429 Sep 23 2010 09:06am--P002/002„- 1
�-� CERTIFICATE OF LIABILITY INSURANCE OP ID Ds '
o�122110
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 CE I;TIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(SJ AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT. If the certifmate holder is an ADDITIONAL INSURED,the po Les m m- a e-hdomed. If SUBROGATION is WAIVED,subject to
the derma and cond-dions of the pofrcy,certab,POIir:Ies may require an endorsement. A statement on this certificate does not confer rights to the
certiFj:40 holder in fieu of such endorsemetu(s)L
PRODUCIER
NAW:
-PRURE-- FAX
ftstforx Tn$urance Agency C No CA;
C No:
224 Littleton Rd P.O. Box 308 ADDRESS:
Westford HA 01886- PRODUCER
CERlDa; SHUR-D2
Phone:97d3-692-6073 Eax:978-692-0429 CLISTOINSURER(S)AFFORDING COVERAGE NAICa
IN oENSURERA: Central insurance convany
Dennis Shurtleff
9 Hadleeyy Road INSURER B
Wastfora mA 01886 INSURERC:
INSURER D
INSURER I;
IN8URERf:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TH£INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REOUIRPMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W ITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
IRXCIUSiONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE INSR WVD POLICYNUMBOR (NIMID A (MhUD LIMITS
GENERALLIABILnY EACH OCCURRENCE $ 1000000
A 8 COW&RCIALGENERALLIABILITY 7867502 03/15/10 03/15/11 PREwSE$ E®occurrencm) $ 100000
CLAIMS MADE ®OCCUR MED EXP(Any one person) $5000
PERSONAL&ADV INJURY $ 1000000
GENERAL AGOREOAIE s2000000
GEHL AGGREGATE LIMIT APPLIES PER; PRODUCTS-COMP/OP ACG $3000000
POLIO JECT LOC $
AUTOMOBILE LIABILfrY COMBINED SINGLE LIMIT $
ANY AUTO (Ea eccldent)
BODILY INJURY(Per person) 3
ALL OWNED ALROS
BODILY INJURY(Per ecciderrn $
SCI-EDULED AUTOS
PROPERTY DAMAGE
HIRED AUTOS
(PBretG108nt) I s
NON,0WWD AUTOS S
UMBRELLA UAB. OCCUR EACH OCC"ENCE S
I(� CLAIMS-MAM AGGREGATE $
DEDUCTIBLE $
RETENTION $ S
>Arottla=RS COMMMATION TO HE ISSUED
AND EA&PLOYERV LIABILrIY Y/N TORY J ll'
AT$ ER
ANY PROPF4ETOWARTNER/EXECUTIVE ❑ 1 A BY XHOURtNCE CMUQ= E.L.EACH ACCIDENT S
QFFICE RINEMtSER EMt UDED?
(M"idaryIn INK E.L.DISEASE-EA EMPLOYEE S
Ues,describe under
SCR{PTI ON OF OPERATIOM below E.L.DISEASE-POLICY U 4 T S
DE8CRIPTION OF 0KRATEONs I LOCATIONS I VGWCL E8 (Attach ACORD 101,Additional Remarks Schedule,if more space is required)
caentry-constructionof residential property not axaeeding three stories
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE 01160RIDED FOLICIEs BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE VIALL BE ORLNEM0 IN
ACCORDANCE WITH THE POLICY PROVISIONS,
Town of North Andover AUTHQRMD Rr=PREeENTA'TrYE
1600 OLsgood Street
N. Andover 2Q. 01845
1'980--20MCM0=RP0WCW AIPIrights reserved.
ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD
WESTFORD INSURANCE Fax 978-692-0429 -Sep 231610 09 06am WO
ACORD:; CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 09/2a/2010
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO R10HTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAOE AFFORDED BY THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE I55UIN0 INSURER(S),AUTHORIZED REPRESENTATIVE
OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the cortHieate holdet is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION 19 WAIVED,ottb*t to the
tertrls and condition*of the policy,certain Policies may require and endor*ement A abatement on this certlfIca te doea not confer rlghtS t0 the
c"VfiicM holder In MU of*och endoreement(a).
PRODUCER CONTACT
NAME:
WESTFORD INS AGCY INC PHONE FAX
No,EXt): FAX
P 0 BOX 308 F-MAIL (A,C,No)'
ADDRESS:
C PRODUCER
WESTFORD,MA, 01886 CUSTOMER ID$:
28W513$ INSURER(S)ACFOR DING COVERAGE MAIC#
INSURED INSURER A: CONfIMNTAL CASUALTY COMPANY
SHURTLEFF DENNIS DBA,SrTURTLF.FINSURER B:F ROOFING INSURER C:
INSURER D:
9 HADLEY ROAD INSURER E:
WESTFORD,MA, 01886 INSURER F:
COVERAGES CERTIFICATE NUMBER:
REVISION NUMBER:
TIPS 19 To CERTIFY Tkg7 THE POLICIES OF DURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREP NAMED ABOVE FOR THE POLICY PERIOD INDICATED,
NOT*TrRSTANbWC ANY REQUIREMENT,TERM OR CONDrsw of ANY CONTRACT OR OTHER DOCUG1E1d'r ATN RESPECT TO WHICH THS CERTIRCATE MAY BE ISSUED
OR*IAY PERTAIN.THE INSURANCE AFFORDEb BY THE POUCIES DESCRIBEb HEREIN 19 SUBJECT TO ALL THE TERMS,ExcLU9ipNg AND CONDITIONS OF SUCH POI la)g,
EDUCED BY PAID CLAIM.
LBIRT9 SHOWN MAY NAYS SEW R
INBR ADDLBUSR POI,ICvEFF DATE POLICY EXP DATE
LTA TYPE OF INSURANCE POLICY NUMER (M"D%YVYY) (NlRQDDIVy
MR WYD YY) UNITS
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED $
CLAIMS MADE OCCUR. PREMISES(Es occurrence.
MED EXP(Any one pgrgon) S
GEMLAGGREGATE LIMIT APPLIES PER: PERSONAL&&ADV INJURY S
GENERALAOGREGATE S
POLICY PROJECT LOC PROOUCTS-COMPrOP AGG S
AUTOMOBILE LIABILrTY COMBINED SINGLE $
ANY AUTO LIMIT(Es aocldenr,
ALL OWNED AUTOS
SCHEDULE AUTOS (Per 600 IlvJURY $
INLY IN)
HIRED AUTOS BODILY INJURY $
(Pel accident)
NON-OWNED'AUTpS PROPERTYDAMAGE $
(Per aocidan0
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAR Ca_41MS•MADE AGORE,GATE $
DEDUCTIBLE; $
RETENTION S'
INC STATUTORY LIMITS OTHi=k
WORKER'S COMPENSATION AND
EMPLOYER'S LIABILITY YIN US-OPSOM502-10 07/23/2010 07/Z?20I1 E.L.EACH ACCIDENT $ 100,000
ANY PROPERITO.%P,a.RT:JER/EXECUTIVE Y E.L.DISEASE-EA EMPLO`/EE $ 100,000
OrFI0ER/M9kISER EXCINDED?
O&M.da=ib Mm
and E,L.DISEASE-POLICY LIMIT $ 5001000
11 yes.dec2ibp under
DESCRIPYIOFI OF OPERATIONS bblow
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
T395 REPLACES ANY PRIOR CERTIFICATE ISSULD TO THt-CZRRTrnCATE,NOLDEI.AFPWTN.G WORKERS COMP COVER&OG
THE WORKERS'COMPUNSATION POLICY DOES NOT PROVIDE COVERAGE FOR SHURTLEFF DENNIS.
CERTIFICATE HOLDER CANCELLATION
TOWN OF NORTH A IDo'vTsR SHOULD ANY OF TIRE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE F.J(PIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE
1600 OSGOOD STREET WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
NORTH ANDOVER,MA 01845 Dennis Chookaszis
ACORD 25(2009109) 1988-2009 ACORD CORPORATION. All rights reserved,