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HomeMy WebLinkAboutBuilding Permit #236-2017 - 105 AUTRAN AVENUE 9/6/2016 NORTI-� BUILDING PERMIT TOWN OF NORTH ANDOVER 02 APPLICATION FOR PLAN EXAMINATION h Permit No#: �� Date Received °RwreD�Paq9 gSSACHV`'�� Date Issued: if I PORTANT: Applicant must complete all items on this page LOCATION _ /t�7 (l% ,�► . ,.� 1t Imo _ _._ Print 00 PROPERTY OWNER !? -r, Print _ 1'00 Year Sttucture yes no MAP - PARCEL:ZONING DISTRICT:.Historic District ye no Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Ix6ne family ❑A ition ❑ Two or more family ❑ Industrial ❑fiteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain 0 Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please � dle r„ rintarly 1 � hone:OWNER: Name: p /g 417 � -�,/ Address: Contractor Name: ,,A & d,,L2tok- -0hone: Email: Address . , . , . J.✓�z Supervisor's Construction License: 'Z".�i � _ Exp. Date: :2 • 7•% Home Improvement License: ? 4 _` _ Exp. Date: G? +? ”' 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: $ 7 4 FEE: $ 9�, 0,q Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acce aran fund Signature of Agent/Owner _ Signature of contracto ��� Location As J No. o� 3[f� " �'l 7 Date �!o • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ; ,! Check#t'"i 1t�I"1 -, Building llispector r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ 4 h Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dwnpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM t PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature 1 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: _ _ r _ FERE DEPARrcT ___ . _ MENT = Ternp'Dump-tenon,site yes._ _ oca e 84 Osgood Street n:o Iodated at 1244 Main.Street _ -- - Fire Department signature/date r.0 Ii I Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: I i 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 i NOTES and DATA— (For department use) i I ❑ Notified foricku Call p p Email Date Time Contact Name --- Doc.Building Permit Revised 2014 1 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 o Building Permit Application o Workers Comp Affidavit a Photo Copy Of H.I.C. And/Or C.S.L. Licenses a Copy of Contract o Floor Plan Or Proposed Interior Work L3 Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks a Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o 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 o 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 o Mass check Energy Compliance Report o 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 NORTI-f Town of ,, s ndover 11- I No. 0150—0101 +1 �v I AML twv i h K* h ver, Mass, kk,Vv% [OCKICKlwKK V^' S I1 BOARD OF HEALTH Food/Kitchen PER T D Septic System 1 BUILDING INSPECTOR THIS CERTIFIES THAT ...... ..... ........ ............. ... ........ ......... ...... ...... ........ ....... .. ....... ............. Foundation has permission to erect ...... ................... buildings on ...] .... .............. ... ... �!�. �.... • Rough tobe occupied as ........ . ....... .. � ..................................................................... Chimney provided that the person acceptin 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 CONST CTION S Rough Service .. ... . . .. ..... ...... ........ ...... ..... Fina BUILDING 1 PECTOR GAS INSPECTOR Occupancy Permit Reguired toOccupy 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. Proposal AB Carnes Roofing,Inc. Page 1 of 1 30 Arrowhead farm Rd Boxford,Ma.01921 978-887-1431 MA.CS-000230 and HIC(76 Proposal Submitted To: MOHAMMADALI KHORRAMI Dt 25,2016460 RIVER RD.,APT 323 PUTRANANDOVER,MA01810 i ANDOVER,MA 01845 781437-1750 7 `�r 4,lv f YAO We propose to furnish material and labor-in accordance with the specifications below: Sixty Four Hundred Dollars($6,400.00) Payment to be made as follows:$300.00 Deposit,Balance Upon Completion} Notx;a:All home improvement contractors and subcontractors engaged in home improvement contracting,unless specifically exempt from registration by provisions of Chapter 142A of the General Laws,must be registered with the Commonwealth of Massachusetts.Inquiries about registration and status should be made to the Mass.govllicenses website. ROOF PROPOSAL ® STRIP ROOF OF UP TO TWO LAYERS OF ASPHALT SHINGLES.COVER ROOF DECK WITH THE UPGRADED RHINOROOF TITANIUM U20 HIGH PERFORMANCE SYNTHETIC UNDERLAYMENT MEMBRANE.COVER EXTERIOR WALLS AND FOLIAGE WITH TARPS TO HELP PREVENT DAMAGE. ® fCE D_Alt PROTECTION"INSTALL CARLISLE HIGH PERFORMANCE ICE&WATER BARRIER OVER ALL HEATED AREAS SIX FEES WIDE AT THE LEADING EDGE OF ROOF AND THREE FEET IN ALL VALLEYS.WRAP THE CHIMNEY(S)AND SKYLIGHT CURBS WITH ICE AND WATER BARRIER. 0 COVER ALL PERIMETERS WITH EIGHT INCH PREFORMED ALUMINUM DRIP EDGE. ® INSTALL GAF COBRA MIDGE VENT AND/OR❑ ROOF LOUVERS FOR ADDED ATTIC VENTILATION. ® COVER SOIL PIPES WITH NEW RUBBER FLASHING BOOTS AND FLANGE. ® REPLACE WALL FLASHING(S)AS NEEDED WITH ALUMINUM OR LEAD AT THE ADDITIONAL COST OF$25.0oPLFT.WE MAY NEED TO REMOVE THE SIDING TO PERFORM THIS WORK AND YOU MAY NEED TO HAVE A CARPENTER REINSTALL OR REPLACE THE SIDING THAT WAS REMOVED. I@ jCHIMNEY FLASHING:REMOVE EXISTING FLASHING FROM IF ANY CHIMNEY(S).CUT NEW REGLET INTO THE BRICK AND SECURE THE NEW '0A LEAD WITH METAL ANCHORS AND SEAL. PLEASE ADD TO A BLACK TAR USED BY OTHERS IS NOT FLASHING) ® COVER ROOF SURFACE WITHCERTAINTEED LANDMARK 235E IFETIME WARRANTY DESIGNER SHINGLES. ® REPLACE DEFECTIVE ROOF DECK AS NEEDED WITH SIMIAR ATNAL COST OF$4.o0PSQFTIPLFT. ❑ COVER ROOF DECK WITH COX PLYWOOD AS NEEDED TO REPLACE OR REPAIR DEFECTIVE DECKING,AT AN ADDITIONAL COST OF ID NAILING,SECURE SHINGLES WITH EIGHT IN TOTAL COATED ROOFING NAILS AS PER CERTAINTEED SPECIFICATIONS. ❑ SKYLIGHTS;REPLACE EXISTING SKYLIGHTS WITH NEW VELUX OR WASCO UNITS.WE WILL PROVIDE THE SKYLIGHTS&FLASHING KITS AT OUR EXACT COST FROM OUR SUPPLIER.OUR LABOR CHARGE IS$90.00 EACH IF THEY ARE THE SAME SIZE.INTERIOR WORK IS EXCLUDED. ❑ REPLACE DEFECTIVE TRIM BOARDS WITH CUSTOMERS APPROVAL USING NO.2 PRIMED PINE,ADD$15.00PLFT TO THE ABOVE PROPOSAL. CLEAN ALL PROJECT RELATED DEBRIS FROM OUTSIDE WORK AREA.THE PROPERTY OWNER AUTHORIZES AB CARNES TO OBTAIN THE ROOFING PERMIT.WE CANNOT ACCEPT RESPONSIBILITY FOR DEBRIS FALLING INTO ATTIC AREAS. CUSTOMER SHOULD COVER VALUABLES. GREAT CARE WILL BE USED TO PROTECT THE STRUCTURE AND FOLIAGE.HOWEVER,SOME MARRING AND OR MINOR DAMAGE COULD OCCUR. IN ADDITION,WE CANNOT BE RESPONSIBLE FOR ITEMS FALLING FROM WALLS,SHELVES OR CEILINGS DURING THE ROOFING PROCESS. SPECIAL INSTRUCTIONS: THE ABOVE PROPOSAL INCLUDES ALL SHINGLED ROOF SECTIONS OF THE HOUSE UPGRADE SHINGLES TO THE LANDMARK 300LB HIGH DEF PREMIUMS,ADD$935.00 TO THE ABOVE PRICE.YES( )THIS IS OUR EXACT COST WARRANTY UPGRADEJHE CERTAINTEED WIND WARRANTY WILL BE UPGRADED FROM 110 MPH TO 130 MPH WITH UPGRADE TO THE CERTAINTEED HIGH PE FORMANCE HIP&RIDGE CAPS AND STARTER COURSE AT NO ADDITIONAL CHARGE.YES k140DEMAIL ADDRESS: V L Warranty:All work warranted against installation defects for 5 years;this warranty is limited to the installed item(s)and its repair only.Material is warranted by the manufacturer against defects for 50 years;see the manufacturer's warranty for exact warranty performance. Cancellation:Customer has legal right under federal law to cancel this contract without penalty or obligation within three business days from the date of signing this agreement via Priority Mail Delivery Confirmation. Please see reverse side. Dispute Resolution:All parties agree that any and all disputes relating to this proposal shall be settled by arbitration as provided by the AAA.This forum is user friendly and does not regal lawyers.Please see reverse side. Signing this Proposal means you have accepted all the terms as stated on the front and back of this agreement. Please see reverse side. *Date of Acceptance © Signature Signature �'`�� Signature weer,Barry Carnes PLEASE SEE REVERSE SIDE i I TOWN OF NORTH ANDOVER WASTE AFFIDAVIT i As a result of the provisions of MGL Ch.40-s54, I acknowledge that as a condition of building permit# all debris resulting from the construction activity governed by this building permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL Ch.111-s150A. Waste Disposal or Solid Waste Facility: ALLIED WASTE Address: 300 FOREST ST Town/City, State, Zip: PEABODY, MA 01960 NAME OF HAULER: AB CARNES ROOFING, INC. DUMP TRUCKS DATE: 9-06-2016 SIGNATURE OF APPLICANT: The Commonwealth of'Massachusetts x w Department of'Industrial Accidents 1 Congress Street,Suite 100 Y Boston,MA 02114-2017 www massgov/dia Wurkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/individual):AB CARNES ROOFING INC Address:30 ARROWHEAD FARM RD City/State/Zip:BOXFORD, MA 01921 Phone#:978-887-1431 Are you an employer?Check the appropriate box: Type of project(required): I.Q 1 am a employer with Some employees(full and/or purt-tune).* 7. E]New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in $, Remodeling any cupacity.[No workers'comp.insurance required.] 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. 0 Demolition 4.0 l am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'cornpensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees, 12.❑Plumbing repairs or additions 5.0 I am a general contractor and l have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurances 13.R Roof repairs 6.0 We are a corporation and its officers have exercised their tight of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp,insurance required.] *Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. t Homeowner who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tCoutactors that check[Itis box must attached an additional sheet showing the name of the sub-contractors and stale whether or not those entities have employees. If the sub-contactors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:TRAVELERS INDEMNITY CO OF AMERICA Folic k or Sell'-it s.Lic.#:6H OG36156-6-15 t 10/15/2016 ~ Policy p Lxpirakion Date: Job Site Address:_ ___ City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§§'25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un /rep7lins and pen ties of peryury that the information provided above is true andcorrect. Si nature: / � �J A. t"- _ Date:-- Phone-ft:978-887-1 31 official use only. Do not write in this area,to he completed by city or town official. City 01•'1'own: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plutubing inspector 6.Other Contact Person: Phone It: ® DATE(Mtd/DDIriYY) ACORO `f CERTIFICATE OF.LIABILITY INSURANCE s/os/2ois 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 cerdficate.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). PRODUCER NAME: BRIAN L. PRESCOTT&SONS INS PHONE FAX 963 EASTERN AVE E-MAILE-faAR .,xtl:(281)�2�-2350 A(CLNo.L•.._,,,,,,.------------- MALDEN,MA 02145 INSURER(S)AFFORDING COVERAGE NAIL p .. _......_.—_....__...._.._..._..... INSURER A: INSURED AB.CARNES ROOFING INC INSURER B.; Travelers Indemnity Company of America •-- I--••------------------- 30 ARROWHEAD FARM RD INSURERC BOXFORD,MA 01921 INSURER D; . INSURER E .. 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 Y PAID CLAIMS. INSR TYPE OF INSURANCE -- - POLICY F POLICY EXP _ . LTR :. POLICY NUMBER M LIMITS .. GENERAL LIABILITY EACH OCCURRENCE _ $ COMMERCIAL GENERAL LIABILITY ,Si PREMISES E�occurcence $ ,,., _,_„__,•, CLAIMS-MAGE {L!OCCUR ... I one person) -------- � MED EXP An PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPlOP AGG $ ........ -------- POUCY .. PRO-JECT. F-71 LOC .. $ .. AUTOMOBILE LIABILITY M N D IN LE LIMIT FI FF Ea acddent) $ANY AUTO i I I BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOSBODILY INJURY(Per accident) $ I_--_— AUTOS 1 NON-OWNED I PROPERTY DAMAGE HIREDAUTOSI_ AUTOS I I S $ UMBRELLA LIAR OCCUR 1 ._ EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGG�—. --- I REGATE_._._............_....__ $ DEC) RETENTION$ - WORKERS COMPENSATION WC STAT OTH- AND EMPLOYERS*LIABILITY Y/N I x TORY-LIMLL� ER ---- B ANY PROPRIETORlPARTNER/EXECUTIVE (''� I E.L.EACH ACCIDENT $ 100,000 OFFICE/MEMBER EXCLUDED? N❑ N/A 1 6HUB-OG36156-6-15 - 10/15/2015 110/15/2016 E.L. (Mandatory In NH) I E.L.DISEASE-EA EMPLOYEE $ 100,OOQ_.,___--- tt yes,descAbe under ERATIONS be) ' ... E.L.DISEASE-POLICY LIMIT ..$500,000 I DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Aftach ACORD 101,Additional Remarks Schedule,if more space Is required) _ ROOFING CONTRACTOR CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 OSGOOD ST ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER MA 01845 AUTHORIZED REPRESENTATIVE Brian.N..Leary,PRESCOTT&SONS INS. ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD L00/L00'd O£0# LZT0:90 9 LOZ/90/60 Zb969999L6 V0i:(/VO»' ALCOR® CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) 9/06/2016 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(les)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). PRODUCER CONTACT NAME: BRIAN L. PRESCOTT&SONS INS PHONE FAX E A/C No): 963 EASTERN AVE E-MAIL ADDRESS: MALDEN,MA OZ1 - INSURERS AFFORDING COVERAGE NAIC# - p INSURER A: INSURED AB CARNES ROOFING INC INSURER B: Travelers Indemnity Company of America 30 ARROWHEAD FARM RD INSURER C BOXFORD,MA 01921 INSURER D INSURER E: _ 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE NTED COMMERCIAL GENERAL LIABILITY � PREMISES Ea $ CLAIMS-MADE OCCUR �' occurrence)MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC $JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ r $ UMBRELLA LIAB OCCUR I "�� EACH OCCURRENCE $ EXCESS LIABHCLAIMS-MADE AGGREGATE $ DED FTRETENTION$ $ WORKERS COMPENSATIONX[PDC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N t CRY LIMIT ER B ANY PROPRIETOR/PARTNER/EXECUTIE.L. CH ACCIDENT $ OFFICE/MEMBER EXCLUDED? N/A� 6HUB-OG36156-6-15 10/15/2015 10/15/2016 100,000 (Mandatory in NH) E.L.DISEASE.EA EMPLOYE $ 100,000 If yes,describe under ..aa : DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) ROOFING CONTRACTOR CERTIFICATE HOLDER------ CANCELLATION CNOANDIOVER,MA01845 MADALI KHORRAMI' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Brian N.Leary,PRESCOTT&SONS INS ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD NOTICE ZW NOTICE TO > > a TO EMPLOYEES f �_ EMPLOYEES y0W 9H S-8 The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114 — 2017 617-727-4900 — http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21,22&30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO MA 02344-1450 C(GHUB-OG36156-6-15) —" ADDRESS OF INSURANCE COMPANY 10-15-15 NUMBER EFFECTIVE DATES PRESCOTT & SON INS 963 EASTERN AVE m= "— MALDEN MA 02148 CAEB E-OF"'I ',RANGE AGENT ADDRESS PHONE# o— o= RNES ROOFING INC 30 ARROWHEAD FARM RD BOXFORD MA 01921 LOYE^'R / ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 000849 W20P1G15 TO BE POSTED BY EMPLOYER Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-000230 Construction Supervisor BARRY S CARNES 30 ARROWHEAD FARM RD BOXFORD MA 01921 �-j^^'7 b'— Expiration: Commissioner 03/07/2018 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 176928 Type: Corporation Expiration: 10/10/2017 Trak 269957 AB CARNES ROOFING, INC. BARRY CARNES 30 ARROWHEAD FARM RD --- -- - -- BOXFORD, MA 01921 Update Address and return card.Mark reason for change. SCA 1 ii 20M-05/17 Address Renewal Employment Lost Card ,