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HomeMy WebLinkAboutBuilding Permit #752-13 - 107 LIBERTY STREET 5/13/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: _ Date Received Date Issued: PORTANT:Applicant must complete all items on this page LOCATION /() ) Ls b ex � `/ 5 f — Print PROPERTY OWNER L ttS C&T f a f l O Unit# Print MAP NO:CftPARCEL:MZONING DISTRICT: Historic District yenno Machine Shop Village yeit 100 year-old structure ye 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 ther ❑ Demolition ❑ Other t a� Oir r�Will #-Flo-virl'it t;i td 3n 1 1-1 - Ott: r:-1Wd District DESCRIPTION OF WORK TO BE PERFORMED: UuI� C e l�r., IUB 6t�--7r7 Ao to- 3 ir- (Identification Please Type or 1�int Clearly) OWNER: Name: L a i S Cc, "r, 11 (3 Phone: y7 S-- 5 2-1'4 7 y Address:l0 C to CONTRACTOR Name: Erk W.Palm Phone: 117 k )Y Y-kj yJ 3 HfftodSftd Address: Salem MA W70 Supervisor's Construction License: FS7 9 7 7 Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ;)406 . OD FEE: $ Check No.: fo I Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to-the guaranty fund Signature ofAgent/Ovvner` _' Sigriature of corit`ractor`. Building Department i 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 Per 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. G o�l( (7i/CiO (jCti0jl/LIeVa- ijojj '['°Tali C)f i''f't poSeCi VVuj,K vVl'(rj 4111-1lrI81- i-ian Ai a Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) a ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permii New Construction (Single and Two Family) i ❑ 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 .Perm'[ 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 Doe: Doc.Building Permit Revised 2008mi J j Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools ❑ We11 ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Peiinanent Durripster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED .PLANNING & DEVELOPMENT ❑ ❑ COMMENTS �'�����3$�r`.•' d f�s i`a i�G�i�`dY�:� .Jii vi%+ tcllGi�: COMMENTS i HEALTH Reviewed on Signature COMMENTS i ..3 h 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: FIRE DEPARTMENT - Temp Dumpster on site yes Locatedno384 Osgood Street 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.s1o0-$1000 fine i . i NOTES and DATA— For department use l El i i i Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi r s Location No. — 3 Date ' r a TOWN OF NORTH ANDOVER e Certificate of Occupancy $ s Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check it t- 26379 Building Inspector t%O R Tilt' Town o _ E �� ¢6 ndover No. �A... h ver, Mass, • 13 • t 3 A_ coc N lc MIWICK ^• 7.9 g04�rEo S U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT �..V.1. .........1� ,. ..C... . .L?............................................................. BUILDING INSPECTOR ........... ..... has permission to erect ...... buildings on J.Q ...... �':!` -. St' ., Foundation ..... ..... ........... ... ........ Rough to be occupied as ........A.. a..... rr1 -1!?. ...... ......... .:..J?.. ... -?�cir.. ....`.�...�h....R':'.. Chimney person accepting this permit shall i�feve respect conform to the terms of the application provided that the p p g p ry p pp 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final 3 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC N TARTS Rough Service _ ........ ..... ................. Final BUILDING INSPECTOR 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. SEE REVERSE SIDE Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements ofthe state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners!Seek legal advice if necessary.Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to'Iiome Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Bt siness Regulation's Consumer Information Hotline at 617-973-87 97 or 1-888-283-3757 or on our website.. Homeowner Information Contractor Information it Name L n r( (D Company Name t r Sheet Address(do not use a Post Office Box address). tlo Contractor/Salesperson/Owner Name - p c,6--A �- Crit_ tPt_1,7 . 61 R Jeffe►soa Avu-nue City1rown 4 State Zip Code Business Address(must include a street ad g e *,�A n y�q0 /U 4/1 c oto;; W �Yll' 019 Daytime Phone Evening Phone City/Town State Zip Code ? �,5-7 f(07"( Mailing Address(It different from above) -Business Phone Federal Employer IDor S.S.Number .. Home Improvement Contmelar nag Number Ezpita:ion date Lmv requlrn thnt mast homo Vmprovement eantmeton Imvc t n vnrd mgistrnticnnumhcr The Contractor agrees to do the following work for the Homeowner: ()escribe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if ne c ary) 0&(S Ir ceoj Required Permits-The followingibuilding permits are required Proposed Start and Completion Sched Ic-The following schedule will and will be secured by the contractor as the homeowner's ajent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be /; excluded from the Guaranty Fund provisions of G !/ Date when contractor will begin contracted work. MGL chapter 142A.) ' Date when contracted work will be substantially completed. Total Contract Price and Paymeit';Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of. Id OD (*) Payments will be made according to he following schedule: -��p. _�` S. upon signing con act nbt'toezcebli li3of tht:total oonlract price Qr foepost o�fspecial order item`s,"wiucfiederis greater)`—--— - $ by or upon completion of } $ J100 by_�! / fj or upon completion of TD $ YID`BJ upon completion 6f the contract, (Law forbids demanding full a � (L g payment un' contract is completed to both party's satisfaction) i The following material/equipm�rlt must be special $ to be paid for ordered before the contracted xlotk begins in order to meet the completion schedule�(**) $ to be paid for NOTES:(*)Tncluding all finance chaPges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of!(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Tc ane cess warrnitty beim z provided by th e contmetory ❑No❑Yes(a 11 terms of the witrranty must be attached to the contract) Subcontractors The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized is the Contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance Upon signing,this document becomes a binding contract under law.Unless otherwise noted with n th s document,the contract shall not imply that any lien for other security interest has been placed on the residence.Review the following cautions and notices carefully before signing this contract! I • Don't be pressured into signing the contract Take time to read and fully understand it.Ask questions if something is unclear. • Make sure the_contractor has a'valid orae Improvement Contractor Reeistration.The law requires most home improvement contractors and subcontractors to be registered'with the Director of Home Improvement Contractor Registration.You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurauce7 Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities.Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her maim cc or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. Seethe attached notice of cancellation form for an explanation of this right DO NOT SIG',N THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of the mntiact must be completed and signed.One copy should go to the homeowner.The other copy should be kept by the contractor. ��.. Homeowner's Signature Contractor's Signature Date` J� —7 Date l Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an#bitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a hIpI eowner in court.unless bdth parties agree to the optional clause provided below. This clause would give the contr�lctor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. ii The contractor and the homeowner hereby mutually agree in advance that in the event the Contractor has a dispute coneeming,this contract,'the coritractor'may submit the dispute to a private arbitration firma which has been appToved by the Searetary,of the Executive.Office of Consumer Affairs and Business Regulation and the consumer shall be required to su"ouiitto succi ntbitr"ation as provided In Massachusetts General Laws,chapter 142A. Homeowner's Signature Contractor's Signature NOTICE:The signatures of the parties above apply only to the agreement of the parties to;alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. c Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A).and other consumer protect,on laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the i4ork as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal nghts if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in MaAachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you liave questions about your consumer/homeowner rights,contact the Consumer Information Hotll t e(listed below). -Execution of Contract The caitract must be executed in duplicate and should not be signed until a copy of all e*bits and referenced -docWents have been attached. Parties are also advised not to sign the document until all�lank sections have been €1Iled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be%iven to the owner and the other kept by the contractor, Any modification to the origing contract mush be-.ht iYing --- -- - andagreed to by botl parties ionU-actea work may nol-begin unt—`li-bo1aities have receiu�ed a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a cpntractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet duejbe placed in a joint escrow aQoount as a prerequisite to continuing the contracted work Withdrawal of funds from said account would require the signatures of both parties. Additional Information If yen have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: i Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at htt-o://WWNv.mass.gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,comact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation ; 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at htto://www.ma'ss.zov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: httn://db.state.ma.us/homeimprovement/l.icenseeli st.asp For assistance with informal mediation of disputes or to register formal complaints against a business,call: I Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 Version 2.1-1122/2010 i DATE Ac CERTIFICATE OF LIABILITY INSURANCE 4/26/2013 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 terns 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 Construction NAME: Eastern Insurance Group LLC PHONE (SOH)651-7700 FAX c o: 233 West Central Street EApDA1L INSURERS AFFORDING COVERAGE NAIC# Natick MA 01760 INSURERAArbella Protection Ins. Co. 41360 INSURED INSURER B Arbella Indemnity Ins Co. 10017 Atlantic Weatherization INSURER C Nautilus Insurance Co 61 Rear Jefferson Avenue INSURER D: INSURER E: Salem MA 01970 1 INSURER F: COVERAGES CERTIFICATE NUMBERMASTER 2013 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 B POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD MM/DD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RE—N7E—D X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $ 50,000 A CLAIMS-MADE Ex_]OCCUR 8500042816 /20/2013 /20/2014 ,MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY X PRO LOC $ AUTOMOBILE LIABILITY 5E0, SINGLE LIMIT Eaaccid,nl 1,000,000 ANY AUTO BODILY INJURY(Per person) $ BIx ALL OWNED X SCHEDULED 020015871 /20/2013 /20/2014 BODILY INJURY(Per accident) $ AUTOS AUTOS NON OWNED PROPERTY DAMAGE HIRED AUTOS X AUTOS Per accident) $ PIP-Basic $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS UAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION$ 4600047820 /20/2013 /20/2014 $ WORKERS COMPENSATIONWC STATU- O7H- AND EMPLOYERS'LIABILITY Y/N �LIMITS I I FR- ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C POLLUTION LIABILITY PL2003786001 10/1/2012 0/1/2013 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE Rosemary Fulham/PMA ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 oninnm ni Tho Ar.npn nafna and innn aro roniatorod marlra of Arnpn Rightfax N2-1 3/11/2013 r-5-55 : 57 AM PAGE 2/002 Fax Server `} CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) T TIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to theterms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).. PRODUCER CONTACT NAME: EASTERN INS GROUP LLC PHONE FAX 233 WEST CENTRAL ST (A/c,No,EKt): (A/C,No): E-MAIL NATICK,MA 01760 ADDRESS: 221vILW INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: AMERICAN ZURICH INSURANCECOt/IPANY ATLANTIC WEATHERIZATION LLC INSURER B: INSURER C: INSURER D: 61 REAR JEFFERSON AVE INSURER E: SALEM,MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN SSU D TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMDDWYYY) (MM\DDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE =OCCUR. PREMISES(Ea occurrence) MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER; GENERAL AGGREGATE $ POLICY =PROJECT a LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'SCOMPENSATION AND X WCSTATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-58270121-13 03/2012013 03/20/201A LIMITS ANY PROPER IT OR/PARTNER/EXECUT IVEN/A E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRETA VE NORTH ANDOVER,MA 01845 w' � �~ "'' •' `r,�,,.. , ACO RD 25(2010/05) The ACORD name and logo are registered marks of ACO RD 1988-2010 ACORD CORPORATION. All rights reserved. I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Adantie Weatleri2afion,LLC 61,E Jefferson Avenue .Address: o„t,.�.,�,r,► n,cv�n Salem M i viii v City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with S 4. E] I am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner-. listed on the attached sheet. 7. ❑Remodeling ship.and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. ' employees and have workers' [No workers' comp.insurance comp.insurance.1 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees: [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. tHomeowners who submit this affidavit indicating they are.doing all work and then hire outside contractors must submit anew affidavit indicating such. 'tcontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation Insurance for my employees. Below is the policy and job site information. Insurance Company Name: ; LA4 C `L, Policy#or Self-ins.Lica#: .S a w f Expiration Date: � / Job Site Address: /0 7 �. h y City/State/Zip: /tel J Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under thepains and/penalties of perjury that the information provided above istrue and correct. Signature• /J/ // Date: J11 3 L/ f Phone#: 9?�_ 9 y y 1;�1 Y Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee 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,associaxiomorpther Ygal entity,employing employees. However the owner of a dwelling house having not more thanthree;apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do inaiiitenance,if, 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 or 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 not produced acceptable evidence of compliance with the insurance coverage required." 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 of this 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,supply sub-contractor(s)name(s),address(es)and phone number(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 number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. 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 Investigations 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 pennit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job 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 future permits or licenses. Anew affidavit must be filled out each year.Where 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 burn 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 us 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. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 . www.mass.govfdia, i Unrestricted-Buildings of any use group which Massachusetts usetts- a; ; contain less than 35,000 cubic feet(9914)of Board of l3u idtcg��sg�iatstns and-S,.� da 7v enclosed space. €,n:E� u it3r 3i'sC"5s_,;ir i_Fcense:CS-087977 ' ERIC WPALM,• 3 HILTON S11 t- SALIM MA 01970 - Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For ups uceminginformationvlsid:: www.MaSs-GGVIOPSExpiration Co; : issroi;ea 04/23/2094 L - i' License or registration valid for individul use only a before the expiration date. If found return to: Office o suer airs ins a` 1aII k' office of Consumer Affairs and Business Reguiation HOME fMP620VEMEt1rr CONTRACTOR c Plaza-Suite 5170 Reg'ististion• ...142089 Type: 10 Par1 Boston,KA 0211b Expiration: a 3!1?J2014 Ltd Liability Corpor A IC WEATHERI?XnQIV-t • � ERIC PAW! x i; 61 R JEFFERSON AV_E' Not valid without signs re i SALEM,MA 01970 Undersecretary _