HomeMy WebLinkAboutBuilding Permit #556 - 104 FRENCH FARM ROAD 3/17/2010 BUILDING PERMIT Y '� o* "o ILED 1 q
TOWN OF NORTH ANDOVER
02 o�
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Arno 0,4
��SSACHUS�
Date Issued: 'C C-)
IMPORTANT: Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER �- J N `\J C 04S,8 :S
Print
MAP NO: ° PARCE : ZONING DISTRICT: Historic District yes no
3 a 3 p 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
Septic Well Floodplain Wetlands Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
4—a (z
Identification Please Type or Print Clearly)
OWNER: Name: 00 cno5 o f Phone:
Address: okk 1�
CONTRACTOR Name: �C1 � � G Phone: 'l
Address: ' �"� "� i2� J G�� r� 1-3
Supervisor's Construction License: Exp. Date: 3 ( ate
d a� u
Home Improvement License: � � � � S � Exp. Dater 0� � ��
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$112.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ (� O t� �� FEE: $ q
Check No.: ZqI Receipt No.: 260
NOTE: Persons contracting ith unrefristerel contractors do not have access to the uaranty fund
Signature of Agent/Owner /
CfLua�/Signature of contractor
x
Location /0V po'l
No. 47 Date 3,
SORT„ TOWN OF NORTH ANDOVER
0 .. A
` Certificate of Occupancy $
♦ i i
,^°'tt�+ Building/Frame Permit Fee $
J�cMus
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
Building Inspector
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
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
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT -Temp Dumpster on site yes no
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 - Date
Doc.Building Permit Revised 2008
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
❑ 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
❑ Certified Proposed Plot Plan
❑ 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
❑ 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
NORTiy
, Townof 4Andover
No.
AKE dover, Mass., 3. 1�} • 10
�A COC MIC K WICK\y�
DRATED PPP �5
`s BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THISCERTIFIES THAT...... 1 /�,i......... .................... .......................................................... Foundation
has permission to erect........................................ buildings on .........JOY.......��-!ti.�...�ll��.....�•..... Rough
-t
to be occupied as 47 ~ �d� Chimney
....... ....................... ................................................................................
provided that the person accepting t is permit shall in every pact conform 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 (,%STARTS Rough
..... ........................... ....:............................::.............................. Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
gh
Display in a Conspicuous Place on the Premises — Do Not Remove F nal
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 avc, 1 U1 L
The Official Website.of the Executive Office of Public Safety and Security(EC)PSS) I
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Ntass.Gov
Public Safety •;;`
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'10->Smnsume-DrtlisctlDG f'.Business 1"ICenslnD>L,cense pEE[).•�'LSIRgg-. Area>
::antractor> tome improvement
_..._...................................._.....................:........_......................
FtOP71e inrOEQ a t Cont,actor ........._...::_....:............_........_.......__......._...:..._...
Registration Frog, am
Contracts-all contracts over$2,000(One Thousand Dollars)must be in writing.
The law requires the following FOURTEEN items to be included in any contract between the homeowner and
registered home improvement contractor in al contracts for home improvement work subject to MGL c 142A
1. The complete agreement between the connector and the Owner and a clear description of any other documents
whieb are part of the agreement.
2. The hill names,federal I.D.number(if applicable),addresses(NOT P.O. Box numbers),of the patties,the
contractors registration number,the name(s)of the salesperson(s)involv
executed by the parties. ed if any and the date the oontraet was
3. The date on which the work is scheduled to begin and the date the work is scheduled to be substantially completed.
4. A-detailed description of the work to be'd'oiieand the in t ils to be used.
5. The total amount screed to be paid for the work to be performed under the contract
6. A time schedule of payments to be.made under the contract and the amount of each payment state in dollars,
includirig all finance charges if any.Any deposit required to be paid in advance of the start of th
EXCEED one-third Of the total contract price or the actual ce work SHALL.NOT
ost of any materia]
custom made nature, oequipment of.a special order or
which must be ordered in advance of the start of the work to assure
assure drat the project will proceed
an sebedule. No final payment shall be demanded until the contract is completed w the satisfaction of all parties.
7. All parties must,sign the contract
8• There shall be a clear and conspicuous notice stating;
a.That all home improvement contractors and subcontractors shall be registered and that any inquiries about a
contractor or subcontractor relating to a registration should be directed to•
Registration Divisor,PrO9Mm Coordinator
One Ashburton Place Room 1301
Boston,Ma 02108
TeL(617)727-3200 crt'_5239
b.The contractors registration number must be on the fust page of the cope
C. the homeowners three day cancellation rights under MGL c 93 s 48; MGL c 140D s 1.0 or MGL c 255D s 14
as may be applicable.
d All warranties on the owner's rights under the provisions of 780 CMR R6 and M.GL c 142A
C. In ten point bold type or larger,directly above the space provided for the signature,the following statement;
DO NOT S1 GN THIS CONTRACT IF THERE ARE ANY BLANK S PACES.
f Whether any lien or security interest is on the residence as a consequen ce of the contract
9. An enumeration of such other matters upon which the owner and contractor may lawfully agree.
10. Any other provisions Otherwise requiredby the applicable.laws of the Commonwealth.
11. Permit Notice:Every contract shall contain a clause informing.the owner of the following;
a.any and all necessary construction-related permits;
b.that it shall be the obligation of the contractor to obtain such permits a the owner's agent
c,that owner's who secure their own construction-related permits or deal with unregistered contractors shall be
excluded from access to the Guarantee Fund.
12. Acceleration of payment: No contract shall contain an acceleration clause under which any part or all of the
http://v1wu,.mass.gov/?pap1D=eopsterm' AalLL=4&L0=HorneLrL1=Consume]
Protect]on... 12/5/2008
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balance not yet due may be declared due and payable because the holder deems himself to be insecure. However,
where the contractor deems himself to be insecure hemay require as a prerequisite to continuing said work that the
balance of funds due under the contract,which art in possession of the owner,shall be placed in a joint escrow
account requiring the signatures of the home improvement contractor and the owner for withdrawal.
13. No worlt shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract
14. Arbitration: If the contractor determines that in the event of a dispute,the contractor wishes the dispute to be
settled by arbitration.this bet.must be signified on the contract and both the contractor and owner shall sign this
clause separately. The folloing format is acceptable(in 10 point type or iarCer);
"The contractor and the homeowner hereby muuuz4j,agree in ads)¢rice that is the event that the contractor
hac a dispute concerning this,contract,the contractor ma)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#bntd to such ayfWationas rovided in MGL c Id2A
RIM
.o�
own
4
Contractor. ..... ..
NOTICE: Th s gnatures of the parties above apply onlv to the agreement of the parties to alternate dispute
resolution initiated h1;Me contractor. The owner may initiate alternatir.e dispute resolution even.where this
section is nor signed separately by the parties."
a 2008 Commonweafth of Massachusetts
http://urvtu,.mass.gov/?pa�elD=eopsterminal&:L=4&LG=HomeLLI=Consumer+protection... 121/5/2008
This form satisfies all basic requiremmn of the s'tate's Home!m rov
p lauguagto Protect homeowners. Seek le a)advice tf recast eany Contractor Law(MQL chapter 142A) but does not include standard
p g
.� Messadhusetn consumerguide to.home improvement"before �. Any Pas°n_platmmghome improvements should first tibials a copy of"a
0mce of Consumer A$airs and Business Regttiatioa's Coasrtm Iaforrrrto tom'wade°n Your residence,You may abmin•e fru co b
at2on Hotline at617-97;1,8787 or 7-888.283-3757. � y calling tile,
Homeowner Information
erne
Contractor Information
IJ�CR /Ptany AMC
Stttxt Address(do not.use8 Post.Officc Hox.addreas) �t(. l/4_o(,n 0•�Ls �a`�J
Jt f �n Y^M i+ /L✓ t C°°tractorlySalesp-owOwnerNs=
_CityRowa � ..�<S 1't„l •Va✓)21�r>!�l�1�J✓I Z,�
State zip code usiness Address
(mast include a streLt address)
. Da}kime Passe tY/TEvCuns Phone . T
. ownZip Code
Simi;
A4ailiag Address(lt tiiffcmt tion,have)
usiaess PL®e rilcel Employer M or S.S.Numba.
L.'�»hua,oa.hamem
��.e. f �
The Contractor �ealrmt
4grees to do the followiati work for the 19CIL mer
Required Permits-The fhIItrwiag btdldiae,.permits are required Pro
and willbe secured by the cannacrores the homeowaet's n �Start and.Com{iletion S6hedule following gent be adhered to unless wing schedule will .
(Owners who-aeruM,their own permits va be circumstances beyond the contractor's control arias
excluded'from tate Guat'aaty Fund provisions
MGL tihap6er'i?t2A:) : when conaaemr will begin cbatracted work
Z J a Dart wbem eontmeted work will be aubsrtantialfy completed
Total Contract Price and Payment Sehednle
The Comactor agree to-Pcz*r f the wor7:,fttrniah the `
materiel and labor specified above far the total
8=0.
Payments will{re made according to the following schedule:: (*)
S upon signing cmuract Grotto exceed 113 of the tore]con
tract price or the cost of special order items,whichever
S or is greater)
_l-1 on )
up completion of
C
$— by /./ or upon wmpietion of
upon completion of the contactn
flaw forbids demaacling.U
T_folleaz
owmgm _VCgmpmCmmRsi. payment until coatraet is epbe E) nTictedm•both•party'ssatisfaction)
. onlaea before Wcontracted wotke spatril 5---,_ to be paid for
'bep¢s in older 4
ak Vie G
to mthe completion oo,) be paid for is
NOTES:(•)lachuirog a0 finance atarges'(••)1aw remtises that _ .
whiff be'lot esceed the stems or(a)ooedLird ofthe total�traepleti error(b)the ac tt W wrna-®by the"Mosetar before work beldns may
spatial ordand m adveace to mat the eompl xion Schedule- Y special equipmmtar custom made material
.Wartanrv-isarr '�varraury tied. .the.eantraraayr
Subbontractors-Tho contractor agrees to be stile Na Yes all sof a warranrvmnst.be etrached m can et
Party/subcdutractor utilized the cos i5
responsible for compl�oa ofthe work descnbdd ne
7s tractor. The co�acmrftutherag+zos io be sdlei responsible
gmitlas of the actions of any third
r.un er '. t Y Parable for all paYlocum to all subcontractors for
Contract Acceptance-Upon signing,this document becomes a binding
careftiliy before signing ming that anycon Gen or other security interest bas been placed on the .d Un'ess Otherwise noted wither this'doct�ent the
grins this contract rosidenee. Review the following cautions and erotica
• DonYbePressured-into signing the conuam Tike time to read and
• Nfa'ke sure the Contractor has a valid H+*ne Irm„nvemrnt Cu*+. full-y understand it Ask quatioas if son
ethibg is mtc7car.
subcontractors m be rogrstered with the Director ofHame lm n law requires most borne
registration by writingProvemoat Contractor Pe ' umprovement oontractors and
to'thc Director er One Asliburam Place,Robin 1301,Bosco guua1.08 You may mqubc'about Contractor
1-S11D-223:0933, n,MA O..IOB or by calling G 17-727.3200 or
• Does the contractor have insurance? Cheek m see that your coatmctor is properly insured.
• &sow your rights and responsibilities. Read the-
rovement Contractor law,rant Information
Guide to the Ho=brpnn tiro reverse•side of this form and get e
copy ofthe Consumer.
You may cancel this agrecment if it has peen signed-at a place other thea the
coanactor in writing.at his/her roam officc or branch office atracmYs maims]place ofbusi
•thud business day Followingthe si orb°a?3'maLE.
md, . tel ° ,Provided you notify the
griinF afthis egreanent See the attache $r°sent br'by dclivery,not later then midnight ofthe
r.a is)OU NOT S'I'GN ticc of cancellation Formforanexption of this rightS CONTRACTIF TR.E ARE AA'Y BI,
C* the cot@.e becumptaed mad siymm.Gac ANK SPACES t t t
mvr.howd go m the hommwva.Ti.Otho
curt dwld 6e,kW by the catannar.
Hotneo
's Signature
Co tar's S' vire
L
Date 44
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,bowever. The contractor would have to resolve any dispute he/she has with a homeowner in coun-unless
both parties agmen 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 Contractofl aw.
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 Secre of the Executive-Office of Consumer Affairs and Business Regulation and the consumer shall be required
to sub it such arbi on asp ided In Massachusetts•general Laws,chapter 42A.
/
v�
meowntx s Signature Co s Signature
NOTI.QE: e•signatures of the Parti above apply only to the agreem o the parties to altmnIffive dispute resolution
initiatedby the contractor. The h caner may initiate alternative disp lution even wherethis section.is not
separately signed by the parties.
Homeawnees nights
A homeowner's rights under the Home lmprovemeat Contractor Law(MOL chapter 142A)and other consumer
Protection laws(ie.MOL chapter 93A)may not be waived in any way,even by agreement However,homeowners
may be excluded fromcertain rights if the'contractor they choose is not properly registered as prescribed by law.
Homeowners-who secure their own building permits ars automatically excluded from all Guatatiiy Fuad provisions of
the Home Improvemept Ctmtractor'Law. The contraetoris responsible for completing the work as described,in,e
timely and workmanlike manner. Homeowners may be-entitled to other specific legal rights if the contractor guarantees.
or provides tin•express wattan1y for worlananship or materia I•s. In addition to guarantees or warranties provided by the
conttwtor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness.for a parficulw
purpose. An enumeration of outer matters on Which the-homeowner and contractor lawfully agree may be added to the
terns of the contract as long as they do-not restrict a homeom per's basic consumer rights. If you have questions about
m
your consumerlhoeowner rights,contact the Consumer Information Hotline(listed below).,
Execution of Contract
The contract must be executed in dUD1iCe to 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 matked as void,deleted;or not applicable. One ori•giz&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 wilting .
and agreed to by both parties.Contracted work may not b gin until both patties have received a fully executed copy of
the contact,and the three day recission period has expired.
Amelernted-Payments
A contractor may not demand payments in advance of the dates specified on the paymentsebedule in cases where the
homeowner deems him/herself to be financially.insecure. Hovvever,.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 ofboth.parties'.
Additional Information
If you have general questions at need additional information about the Home Improvement Contractor Law or other
consumeriights,or if you wish to-obtain a free copy of"A Consumer Cmide.to the Home Improvement Contractor
Law,"contact;
Consumer Information Hotline.
Office of Consumer Affairs and Business Regulation
10 Paris Plaza,Room 5170,Boston,MA 02116
(617)973-8787 or 1-(888)2833757 -
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
Bureau of Building Regulations and Standards
One Ashburton Place,Room 1301,Bostot;.MA 02108
(617)727-3200 or'1-800-223-0933
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)652-4.800
(508)755-2548
(413)734-3114
d
Massachusetts
The Commozzwea&h of
! Department of Industria!Accidents
Office of Investigations
% {4 600 Nrashington Street
Boston, MA 02111
www mass.gov/dia .
Workers' Compensation Insitrance Affidavit: Builders/Contractors/El
ectricians/Piambers
Applicant Information
Please Print Legibiv
NaM'e(Business/Orguirdfion/Individual):_ U rt Q
Address: J-z� fi t .y-r•p 0A
City/State/Zip: Phone#: . '`�� �''I��- J"3
Are you an employer?Check the appropriate box:
1.u-I am a employer with 5- 4, Type of Pref(required):
❑ I am a general contractor and T
employees(full and/or part-time).* have fired the sub-contractors b• ❑New construction
2.Q I am.a.sole proprietor or partner- listed on the attached sheet,x 7• Q Remodeling
ship and have no employees These subcontractors have
working forme.in an aci workers' comp.insurance. 8 Q Demo,
Y �'• 9. Building
[No workers'comp. insurance 5. ❑ We are a corporation and its Q addition
required.) officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1Plumbing repairs or additions
myself. [No-workers'comp. c. 152, §1(4),and we have no
insurance.re required.]t 12.[] Roof repairs
q .employees. [No workers'
comp. insurance required.] I3•�Other � �i
'Any applicant tient checks bolt I must also flit out the section beiow showing their workers'oompensation policy information
?Homeowners who submit this affidavit indicating they ars doing all work end then him outside contractors must submit a new affidavit indicating such
xCannactors that check this box_mustatteched an additional sheet showing•the none ordw sub-contractors and(heir workers'com^, ii in
r Fc•; frrmietion.
I ant an employer that iS provideng:workers'compensation insurancefor np employeesa pelpty is Pow'�job site
information.
Insurance Company Name: ,� t`1'4, o 'r k I
Policy#or Self-ins.Lie.#: t) 6
`` Expiration Date: (I 1 Q4 1 a
Job Site Address:_ �". rf..t
city/state/zip----A, ! "f
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 farm 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 under pains and penalties of perjury that the infor»tadon provided above is true and correct
Si Lure: ��~��
Phone#: `� _9 S . C3
[6.
acid use only, Do not write in this area,m be completed by city or town o ciaL
City or Town: Permit/License#
uing Authority(circle one):
Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
Otherntact Person: Phone#:
C
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an en ployee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the'foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees.'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 house
or on the grounds or building appurtenant thereto shall not because of such employment be:deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state ev local 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
applicant who has riot produced acceptable evidence-of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither t1ho 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 insurmc e
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation•affidavit complertely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s)name(s),address(es)and phone nianber(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance 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 workers'
compensation policy,please call the Department at the nurnber listed below. Self-insured companies should enter their
self insurance license number on the appropriate lino.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of lnvestigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number 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(if necessary)and under"Job Site Address"tho 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 future permits or licenses. A now affidavit must be filled out each
year. When a home owner or citizen is obtaining a license; or permit not related to any business or commercial venture
'(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give as a call.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
TeL 4 617-7274900 ext 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax 4617-727-7749
www.mass.gov/dia
10/ 13/2009 3 : 27 : 00 PM 8868 m 02/02 --- �'
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r � �+ ,4K =ISSUEE 1011312009
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
Perry Insurance Agency LLC CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE
DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
22 Chickering Rd,Rt 125 POLICIES BELOW.
oA Andover,MA 01845
COMPANIES AFFORDING COVERAGE
sURED
Under One Roof
Temple Drive COMPANY A ALM.Mutual Insurance CO
LETTER
ethuen,MA 01844
7-7
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.
LTR TYPE OF INSURANCE POLICY NUMBER PDATE(M KOD(M DATE(MMIDWYY)FFECTIVE POLICY N LIMITS
GENERAL AGGREGATE
GENERAL LIABILITY
PRODUCTS•COMPIOP AGO
COMMERCIAL GENERAL LIABILITY PERSONAL&ADV INJURY
=CLAIMS MADEQOCCUR EACH OCCURRENCE
DOWNER'S&CONTRACTOR'S PROT. FIRE DAMAGE(AnF*ft pro)
MED EXPENSE(AnTom Paton)
AUTOMOBILE LIABILITY COMBINED SINGLE
LIMIT
NANY AUTO BODILY INJURY
ALL OWNED AUTOS (Pap—)
SCHEDULED AUTOS
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Pa wakA)
GJkRAGEUABILfI`Y
PROPERTY DAMAGE
EXCEU LIABILITY EACH OCCURRENCE
.l�'-
UMBRELLA FORM AGGREGATE
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND AT LIMrr3 STATEDTIM
EMPLOYERS L ABILITY MA
EPROPRIEroRJ ELEACHACCIDENT S 100,000
A ARNERSIE4ECUTfvE
FTiCIEEIS ARE- 7W9464012009 11/09/2009 11/09/2010 ELDISEASE-POLICYLIM T 500,000
INCL ®ERCL
EL DISEASE--EACH 100,000
EMPLOYEE
COMMENTS!DESCRIPTION OF OPERATIONS OR LOCATIONS:
LL UNDER ONE ROOF IS NOT COVERED BY THE WORKEWCOMPENSATION POLICY.
WOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE
rflEREOF,THE ISWWO COMPANY WELL ENDEAVOR TO MAIL ILWRMYN NOTICE TOTHE CERTIFICATE
OLDER NAMED TO THE LEFT,BUT FAIIAM TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION
R LIABILITY OF ANY EM UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES,
OWN OF ANDOVER C�
6 BARTLET STei�)Vtl
ANDOVER,MA 01810 UTHORIZEDREPRESENTATIVE
Massachusetts- Department of Public Satet".
Board of Building-Regulations and Standards
�f Construction.Supervisor License
License: CS 69120
Restricted to: 00
JOHN
W LANZAFAME
30 TEMPLE DR
METHUEN, MA 01844
Expiration: 4/3/2011
('unnnissiuner Trl#: 13449
u
t
I
ala ons and tan s
Board of BwldIng Reg
One Ashburton Place - Room 1301
Boston. Mass4chusetts 02108
Home Improvement'Coontraetor Registration
- R0910 IOn: 137057
Typo: DBA
e „ lrxplratlon: 10!2/2010 Tr# 275510
ALL UNDER ONE ROOF `" ► _
JOHN LANZAFAME
166 A MERRIMACK ST. 4 t
METHEUN, MA 01844
Update Addreas and return card.Mark reason for change.
_ -' Address Renewal f Employment Lost Card
-CAI Q 50M 05105 P CO490
Boord of Buildiao RCralatlo o and I.tandorda License or registration valid for individul use only
4HOME 111�PROVCMCFIT GIzi�TfiAf;Td11 Wore the expiration date. It found return to:
Board of Buildlnji ltf uhllono and Standards
Roglatrallon: 137057 One Ashburton W(D iiw`) 1,101
IE�xplra*= 19/212010 Y'(�? �'i``illi 0o ton.Na.0710
• Too.- 02A
ALL UNDER ONE ROOF
JOHN LANZAFAME
168 A MERRIMAW—)T.
fait+t a•i•,9.:i 1:_ Eis j'_. Wtfre
L 27TMI:UN,PAA o1VIA
Chirnne'ys Residential & Commercial Roofing All Types Of
Siding CHIMNEYS POINTED-REBUILT-CAPPED Expert Masonry Work
Mass Toll Free C'r�c�f`Geulr_,
[ _ .-_ Licensed & Insured
Laca!/y Owned& Operated Since J 976 !'"
1-800-WAIT-4-US ® _ ` License#034200
(924-848T) IKO G'aee wozm Oz qvh" We Work year Hound
1� :ai!i•" 1 � �%� ~i'�' . • f �� ����'.,t'�z��e fC� ��t��?;�r,('lit�J :�?lt'.r•:.-• ,�t. �_lll�!���: t�.'.. ;���]1-��Cala; .i�i�. 4�:�=5:�'s
Proposal To: Lynn Crosby Date 2/12/10
Street: 104 French Farm Rd. 978-794-4985
N. Andover, MA 508-265-9566
Roof proposal
L Strip all shingles from entire main roof and rear
addition. Total cost: $ t�v�
2. Inspect and re—nail any loose or lifted plywood. 1S !��6_ I
3. Any compromised plywood will be replaced at an
17
additional cost of$50.00 per sheet of 1/2" cdx fir.
4. Install heavy gauge 8" aluminum white drip edge Balance due upon completion
to all eaves and rakes.
5. Install 6' of IKO Armourguard ice and water Referrals available upon request
shield along all eaves. 6' MA state code.
6. Install all new pipe boots. Highly rated member of the BBB
7. Above the ice and water, install heavy 301b felt
base sheet.
8. Install IKO Cambridge AR- 30year architectural Thank you!
shingles to entire roof.
9. Install new GAF Cobra ridge vents. Remove ex- In— House Crew, NO Sub Contractors!
isting static vents.
10. Counter-flash chimney with ice and water
shield.and seal lead with clear sealant.
11. Building permit included.
12. Removal of all work related debris.
13. Shingles are covered by the manufacturer up to
30yrs.(Pro-rated after 5 years.)
14. Contractor workmanship warranty=10 years un-
der normal wind and rain conditions. X
ceeptance of Proposal—The above prices, specifications and conditions are satisfactory and a herby ac-
epted. You are authorized to do the work as specified. I layment will be made as outlined above.
ate of Acceptance: Signature: