HomeMy WebLinkAboutBuilding Permit #761-11 - 11 NORMAN ROAD 5/10/2011 NORTH
BUILDING PERMIT OFss�eo qti
TOWN OF NORTH ANDOVER -
APPLICATION FOR PLAN EXAMINATION -
Permit NO: kms/ Date Received "
Date Issued: gcHus���y s �� �`
MPORTANT: Applicant must complete all items on this page
J
LOCATION �� �tlQ.� C�✓? i� et
__Print
PROPERTY OWNER t
Print
MAP NQ: /PARCEL: i9 ZONING DISTRICT: .Historic District yes no
Machine Shop Village yes o
TYPE OF IMPROVEMENT PROPOSED USE
Reside tial Non- Residential
❑ New Building ne family
❑Addition ❑Two or more family ❑ Industrial
❑Mteration No. of units: ❑ Commercial
Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
optic 0 Well ❑ Floodplain ❑Wetlands ❑ Watershed�-District
Wbter/Sewer
DESCRIPTION OF WORK TO BE PREFOR ED:
11
Identification Please Type or Print Clearly)
OWNER: Name: ` cre,4 e 1AG �� Phone: o�
Address: �� �d/y?Gr,✓� /� �� ,/1�✓ot�G/` /�
CONTRACTOR Name: 7"oM ���' ' ���. Phone: �� S 7L%'�
Address: . . A4 o,4 _ � �y'>dd ✓` ���
Supervisor's Construction License: G� (pd - Exp: Date:
Home Improvement License: /3.�772 Exp. .Date:_ ., 2 ; /�`
ARCHITECT/ENGINEERS 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: $ owg�6 .,,::o FEE: $ loq�_
Check No.: `� �i`�� Receipt No.:
NOTE: Persons contracting with.unregistered contractors do not have access tot ,g ra fund
of contracto i
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 t' Si nature
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 384.0sgood,StrA6et
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located.at 124 MainStreet
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 re fres 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
o Building Permit Application
o Workers Com
III P Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
o Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
12///Building Permit Application
ertified Surveyed Plot Plan
a/ ' orkers Comp Affidavit
�uhoto Copy of H.I.C. And C.S.L. Licenses
opy Of Contract
OV Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
dJ Mass check Energy Compliance Report (If Applicable)
neering 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)
L3 Building Permit Application
L3 Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o 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
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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
i
Revised 2.2008 I
Location
No. Date
/v
,.oR*►, TOWN OF NORTH ANDOVER
• s
* ; , Certificate of Occupancy $
NUs<� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #✓ '�,64
2 + , 46
BAding Inspector
Date.). . .... ... ... . . ... ..
°F aNO°TM ,ti0
o� TOWN OF NORTH ANDOVER
' PERMIT FOR GAS INSTALLATION
° S
SSACHUSES h
This certifies that . .,f7 r:. . . . . . . <. .f. .{. . . . . . . . . . . . . . . . .
��_has permission for gas installation . . �. . . ... . . . . . . . . . . . . . . . .
G �
in the buildings of . . . ./. r:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
at . /Z. .//:,. �.��. .�'. . . . . .f�.�f . . . . .. North Andover, Mass.
Fee. .). . .: . . Lic. No.. . . . . :. . . . . . . . .:. . . . . . . : . :` -. . . . . .
GAS INSPECTOR
Check#
ZJ7 �
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO-DO GASFITTING
(Print or Type)
C NORTH ANDOVER Mass. '— Date Q
�uilding Location It, �orv�r��x.,n Permit 3j
R I Owners Name�.�(��; e- 14eo-^e—
• Y New Renovation II Replacement 12"" Plans Submitted D
9 FIXTUP=c
� W N
N o9 U a F- C
Ut O! O V
L
Cc us
Z m rA 1-' W w O O. 0 W t"
" to
Ncc ist Z V W .. trs W ,t Q a W
W W W a = ct Q W W
c� r z H z s•- W to a a ? t:_ r t
z a to a r` F' }- tat - o ul o i
ul , Q G d
t= O CZ n0.
W
G1
U. A O V ¢ y Q I- o
S11R-11S."AT. l
BASEMEXT
ISTFLOOR I
2ND FLOOR
J
3RD FLOOR
4TH FLOOR I
5TH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR -
(Print or Type) Check one: Certificate
Installing Company NameAndover P1 bg. & Htg. Co. , Inc. Q' Corp. 2122
Address 20 Aegean Dr. Unit-T0 Partner.
Metheun, MA 01844 Firm/Co.
Business Telephone: j_97R)
Name of Licensed Plumber or Gas Fitter Aa�rgp LaRnsp --
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy Ej�T Other type of indemnity D Bond
Insurance Waiver: I , the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner U Agent
I hereby certify that all of the details and information 1 have submitted (or entered)in above application are true and accurate to the best of my
knowledge and that a❑ plumbing work and Instailstions performed under'Permit izsLed for this application will-be in compliance with all pestirsent
provisions of tho hfatsachusetts State Cas Cade and Csapta 14:of tho General Laws. -
By YPE LICENSE:
Plumber
Title asfitter- Sign"a"ture of Licensed
City/Town: Master Plumber or Gasfitter
APPROVED (OFFICE USE ONLY) Journeyman License Number
ORTH
01" 0 6 Andover
"NN
No. 0 LAK
o dover, Mass., 6
�.
COC MIC KE WICK V
ADRATED
S V BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
THIS CERTIFIES THAT..............S.......
BUILDING INSPECTOR
... . a ...... ...G...............................................................................................
Foundation
has permission to erect.................:...................... buildings on ..//../Y ................. Rough
to be occupied as............... E ..S�i.L..l �'......................... .......
f.0-... .. .................. ............... Chimney
provided that the person accepting this permit shall in every respect conform to the arms 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
UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR
Rough
Service
LDING 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. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
d
Twomey & Legare Contracting, Inc.
Professional Building / Remodeling
P.O. Box 366
North Andover, Ma 01845
North Andover 978.685.7447
Haverhill 978.556.1547
CONTRACT
1. Date of Contract Signing:
2. List of documents part of this agreement:
A. Contract
B. Specifications
C. Drawing (see Exhibit C)
D. Payment Schedule (see Exhibit D)
E. Limited Warranty (see Exhibit E)
3. Parties to Contract:
A. Contractor: Twomey & Legare Contracting, Inc.
Shaun Twomey/Doug Legare
Federal ID# 20-3 43 6110
Address: PO Box 366 No. Andover Ma 01845
Contractor Registration No: 136779
B. Homeowner:
Nick & Stacy Lunger
11 Norman Road
North Andover Ma. 01845
774-644-9520
May 6, 2011
_ L
`. Description a-f woJk to dog:,and the materials to be used:
See Specrm-ations(see E�bitt B)
5_ i o`er amount am:eed to be paid iorwork to be pegeb=edunder corgi-ai,.:
5_ Time schedule of pa—mems to'oe made mde_!he Contac,fnance charges 1-or 1-ie jcees, :=
any-
Sea Payment Schedule isee Erin-b-D)
deposit rem to be paid in advance,el gF the VITO]k shad n€DI:exceed one-
bird oflhe toml canWaeAprime or ac`nal cst ofany mat;=. C-ore�pmeax o a sneoia,a-
custom made natu� 3F�—v h;must b3 order? in adivance o�F,)e m.--t of viork'Li assLZle eat
-the proa�ec_�wMI aroceed oat scheduler No Emil paymeHt shah be dem deCL
I U zi_•-Le
man aCL is completed:fit the she on of-91.1 pardes-
�- .i-Date—or-Ir is schedulad io begm. Se-- 14 -
. �:Y YY43F�iIS,SCL'CLSi���z�'43f:SLEJS'i�cs?:aity Cfl3pZLC: 1?
A- hflme Ipro Vement contractors and sabcontrac.,fl�rs shan be ragisfered and-�a<any
1cRlldesabouta onfta and subm SavQxl shabvxv �,.,_ au
ahoL�aCOF1�hC`af3�E?rall�}C�'3iTdCL3=_'I��a g if?cam. �rI�S�f31�€�'fiv d?.t�l'�;�d t`�2:
Director,Home knprovement Contractor Registration
One AshbLIrton-Place,Roam 1301
3oscon,3AssaChnse-,js Q2108
TelephoneNo-C617)727-83595
3-For cantractor's regiszedon ntt_rnber,see top of f=. pa_ae_
Homeovmers have a t�e-cay mncei a on riga � eer L c 3 n -T; n -
.8 _G f
Q10O1>IGLC255D 14 as may bea �, i_ ac,,.,-
D-
- o - -
tic! .
_cab v �, -
� �' Pp (see atrac_�elyo�ce o=C�?caiTaizoi),
1D.For avmees-F,,arrarty righis, see 780 CIS R6 and Mut;c
-hese
is no lienftr
or secud in�e_ t on the residence as a cns:. nenee or`mss coact.
G2emit Notice:
. snllo be retest cortneudone�a
fTot 3Ei3I3c Building-E` mCft�-pl-1113yi3in.
t Ze obI%ago-n of The Conf actor to obtain These pe3't3-tis �-Jse
7
3
C. Any owner hQ secures their ovrt constru uoz-_elated permits or deal v{i Q
unregiser ed con-Lactors shall be excluded Lom access to the Guarantee Fuiad.
i 7, Contactor reserves the right when he deems?iuusei i to be-?secure to regtire as a
rrarl tthat the F}a11ance:fl£=L c s due iinder re CO3zcCL
MUM-C-h are in:,ossessiou nfLe ovemer,sha'f be placed-In a Jhnt est Q-v acco
' ing the s�aattzEes of ii e�Gme i�'+2prove entcL'nmaCt-Qr and ite ovvmei for
12 Tie p�;TieS agree that no-orli sh^ + begin 7rlor to the signing ofthe con-tact
la smirtal to the ovine a copy of~he contract and he expi:adon of any appH cab-I v
resciss=on nell od.
13_fib=tragion C_rausa:The contractor ars _he horn_eownei•h-e;ebv,rUf
advCtr?Ce:hat in she event that the contractor has c d spateconcernir�o
this Contract,
:,%e cOj;2h-acfOr 72li V S?f_D-Mit such-dfspute to a pr-vate arbLa Sers�ICe�VI2ZC hos
beer 6proved by the OJ1 ce of COnsvrner,-jafrs and Busir-ess-Peg-a[atioE7s and the
consvmer shall be required to s7,bm-fi to such arbi%ration as Provided ,%0-C-L c i-42,-4.
Ia_ O;rerFrovisions:
_C oi'MnenceIIl nt Of WOIEWCOmpledon-Contrac or agrees to proceed diligent) ;
the agreed uponvias�c,cflr�eacmg Prompt-h;=foHowiL_c:
The comptedO'01-1--the Tiu1e V ins aLat on and cerdfcaaon of
coinpLance b the tov,Z�.
Issuance of a building pe--rmIi by the toyvn.
Estimated date ofcompieiio:
Conipledon date sb 11 be automi a:ucaLI
extended by the
u - _ -
s _ her Or�day s equal to aose On Which seller shall be
Prevented or%Indere I Sofa compTe- di?e co-ewe,
COndi-Lions, fldier acts Gf God,Iua Diliiy to obtain n tatercjs or
schedule due to delays caused by homeownef--s selection
process Or change of orders,and/or-fa thin.of�?omeovmers t0
in2ke' neb,rpajrra,ent'c as AyraeQ.
B. Final Payment shall be upon_the satisfac,LiOn 0f the i?OmeO;,ner. _he - i- c-
�7,,�= t - 1pa1 LGs ag e..
that a - s -
ttiv-issuance Qt a��.1 �aie fl1 o('{' agcy shat!Oe he obleciive sti ndard the,
the cont,act has been completed and the pages satisfied.-Any punch hist stall be
=eCl�zCei to vdrithl-g, idUh.a dale Ior COmj�!-eti0=2.the pa+yes armee Lnat no eSCrOv
-WL:;]-be held for punch list items.
a'
ID_ins -Contractor agrees"�-o Provide Et13ClELCE of__abEity,?oflce s com-Dena Stm.
and of e tsume-a Owmer a`- es To pruvi€e ropy o - ,-,;nsuranca as is re dire
sr contractor to cool Lia—M Qo_cdes_
Owner
Contractor_
N6& L jae_ k7r-eS O- P&IlcS aFOVIF--aruPl Ont v�W a9cee?e`uflhp£�D
a llZt=Maha di—sp ak resol m-Li n inia-d by me zontuar-tor +he ogr-n-.Eri : ve
J
i sz�v" s'3 '�73�_:fl n;:ieT i Er✓ S s e ialio --(}_si _ll^zaz .:: br - r aIties
DO NOT SIGN ` IHS C0-INTRA-CT lF TEM. 4E AR $LB�'1�S�9,CFS_
�l
0 Data `�flI L Date
Dare
A
Proposal
Twomey & Legare Contracting Inc.
Building & Remodeling
P.O. Box 366
North Andover Ma 01845
Phone 978-685-7447
Fax 978-685-7446
Fax 978-685-7446
To: Nick& Stacy Lunger May 6,2011
11 Norman Rd.
North Andover Ma. PH. 774-644-9520
Ref: New slider& 8x16 Deck
Thank you for the opportunity to quote the following project.
The TWOMEYAND LEGARE CONTRACTING price is based on our discussion.
On April 7, 2011
The following is a description of work as discussed.
0
Repair of exterior
1. New slider supplied by owner.
2. Remove double window unit.
3. Size opening for new slider, match interior trim and exterior trim as close
as possible. Repair siding.
4. Relocate baseboard heat.
5. Move any electrical that may be under window.
6. All disposal, permits and inspections as needed. By contractor
7. All painting-bf-ewe 1gv �°,c►����/�r Total $4,360.00
o New P.T. Deck with stairs
1. Deck size 8 x 16.
2. Dig footings 4 feet below grade
3. Frame deck, Decking and rails. New deck to be connected to existing
porch.
4. Stairs to grade.
5. Match existing as close as possible, no lattice work under deck.
6. Permits and inspections by contractor. Total $4,300.00
Job total & Payment schedule
Job Totals New Deck$4,300.00
New Slider$4,360.00
Job Total 58,660.00
Balance
'S`Payment on signing $2,000.00 $6,660.00
2nd Payment start of work $3,000.00
$3,660.00
3`d Completion of deck $2,000.00 $1,660.00
Frame.
Final-substantial completion
of project. $1,660.00
Thank you for considering Twomey& Legare Contracting Inc.for your
Project.Please feel free to call with any questions or concerns @ Office 978-685-7447
Cell 978-479-8174
Respectfully,
Shaun Twomey
Sig Date ° i !
_.. GGT-08-2010 FRI 12;44 PIS FAX N0. 9784750303 P. 05
a
Clients :13298 TWOMEY6
F �OR�=" CERTIFICATE QF LIABILITY INSURANCE DATE(MM/DDI77YYt
PROOUCER 10/07/10 I _
THIS CERTIFICATE:IS ISSUED AS A MATTER OF INFORMATION
I3vherty insurance Agency,Inc.; ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P.D.Box 1885 BOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
21 Elm Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Andover,MA 01810
INSURERS AFFORDING CO
INSURED VERAGE NAIC
Twomey Legare Contracting,Inc. INSURER A: Arbella Protection Ins Company
PO Box 366 INSURER 5:
North Andover,MA 41645 INSURER C:
NSURER D:
,vSukEk E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE:BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMCNT-TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPCCT 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
LTR NtiRTYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY CXPIRATtON
DA + + DAT Mv1D v LIMITS
A GENERAL LIA8ILRY - 8500043255 06/22/10 06/22/11 EACH OCCURRENCE S1 040 DDD
X COMMERCIAL G&NERAL LIABILITY DAMAGzTO RENTED S100000
CWIMS MADE FX OCCUR MED EXP(Any ono peron) $5,000
PE;:SONAL£ADV INJURY S1 000 000
GENERAL AGGREGATE 1 S2,000.000
GEN'L AGGREGATE LCWT APPLIES PER: PRODUCTS-COM?!OP AGG S2 000,000
x FOLICY PRC LOC
AUTOMOBILE LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT S
(ta BCUdent)
ALL OWNED AUTOS
BODILY INJURY S
SCHEDULED AUTOS (Per Peron)
HIRED AUTOS
BODILY INJURY 5
NON-OVaNED AUTOS (Per 6cr7dcrt)
—ROPERTYDAMAGE s
(F@(nCfitl>ni)
GARAGE LIABILITY
ANYAUTO
AUTO ONLY-EA ACCIDENT S
OTHER THAN EA ACC 5
AUTO ONLY: AGG 5
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE 5
OCCUR tI.AIMS MADE AGGREGATE £
DEDUCTIBLE S
RETENTION 5
WORKERS COMPENSATION AND WC STATU- OTH.
EMPLOYERS'LIABILRY
ANY?ROPkIETOWARTNERFXECUTIV£ E.L.'EACH ACCIDENT.
OFFICFAIMEMBER EXCLUDED?
R yBb,tlBEGiDe under E-L.DISEASE-SA FMFLOYEE S
hPECIAL PROVISIONS bolow
OTHER E.L.DISEASE-POLICY LI,j1Y 5
DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS
Covering operations usual to Twomey&Legare Contracting,Inc...
CERTIFICATE MOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE THE EXPIRATION
Town of Noah Andover DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WNITTEN
1600 Osgood Street i NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL
North Andover,MA 01.846 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORI R P ESENTA7IVE
ACORD 25(2801108)1 of 2 #526661/M26558 0 ACORD CORPORATION 1988
RJ-ghtFax N1-1 10/8/2010 8:54:54 ANI PAGE 2/002 Fax Server
ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) la,08,r2olo
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 pollcypes)must be endorsed. If SUBROGATION IS WAIVED,subject to the
terms 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:
DOHERTY WS AGFNCY INC PHONE FAX
(AIC,No,Ext): FAX
PO BOX 1985 EMAIL (AIC,No):
ADDRESS:
ANDOVER,MA 01810 PRODUCER
22YMX CUSTOMER ID#:
INSURED
INSURER(S)AFFORDING COVERAGE NAIC
INSURER A: TRAVELERS WDEMriTry COiViPANTY
TWOMEY&LEGARE CONTRACTING INC INSURER B:
INSURER C:
PO BOX 366 INSURER D:
NORTH ANDOVER,MA 01845 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.
HOTINR'F?STANTIING ANY REOUIREMFIJT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT Y11TH RESPECT TO.M TRI TMS CERTIFICATE MAY AT ISSUED
OR MAY PERTAIN.THE INSURANCE AFFORDED SV THE POLICIES DESCRIBED HEP,QT IS SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CERTIFICATE OF SUCH POLICIES.
LIMITS SHOV,'N MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDLSUBR
TYPE OF INSURANCE POLICY EFF DATE POLICY EXP DATE
LTRPOLICY NUMBER (MWDDIYYYY) (MMdDDIYYYY)
INSR LYVD LIMITS
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S
CLAIMS MADE OCCUR. DAMAGE TO RENTED $
PREMISES(Ea occurrence)
MED EXP(Any one psrson) S
GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL&&ADV INJURY S
POLICY PROJECT LOC GENERALAGGREGATE S
AUTOMOBILE LIABILITY PRODUCTS-COIAPIOP AGG S
ANYAUTO COMBINED SINGLE S
ALL OWNED AUTOS LIMiT(Ea accident)
SCHEDULE AUTOS BODILY INJURY S
HIRED AUTOS (Per'person)
BODILY INJURY S
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE S
(Per accident)
UMBRELLA LIAB OCCUR
EXCESS LIAB CLAIMS-MADE EACH OCCURRENCE S
DEDUCTIBLE AGGREGATE S
RETENTION $ $
$
WORKER'S COMPENSATION AND V1C STATUTORY LIMITS OTHER
EMPLOYER'S LIABILITY YiN U13-0290M994-10 09/18/2010 o I
ANY PROPERITORMARTNERIExECUTIJE Y 0..118.2077 E. EACH ACCIDENT $ 500,000
OFFICE.RIMEMBER EXCLUDED? E1-DISEASE-EA EMPLOYEE S 500,000
(Mandatory in NH)
It yes,describe under E.L-DISEASE-POLICY LIMIT $ 500,000
DESCRIP71ON OF OPERATIONS below
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES Attvy PRIOR CSZ71FICATE ISSUED TO THE CERTM'CATE HOLDER AFf.wriNG WORKIMS CO76f COVER (-
CERTIFICATE HOLDER CANCELLATION
TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
1600 OSGOOD STREET THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE
WITH THE POLICY PROVISIONS.
NORTH ANDOVER,MA 01845 AUTHORIZED REPRESENTATIVE
ACORD 25(2009109) Charles J Clark
1988-2009 ACORD CORPORATION. All rights reserved.
The'Commonwe¢lth of Massachusetts
Department o f£ndustrial Accidents
Office ofinvestigations
600 Washin,—Wn Street
Boston, J11Lq 02111
www.massgov/dia
Workers' Compensation Insurance Affida
Applicant nformation vit: Buiders/Contractors/Electricians/Plumber
s
Please Print'heaibly
Name(Business/Organization/Individual):
Address: d✓d Y' -
City/State/Zip:�i�� � t/..e./`' ,�. Ph -� -
one#:
you an employer?Check the appropriate box:
[I-AAre
•[31 am a employer with 4. ❑ I am a o Type of project(required):
general con �
tractor
employees(full and/or part-time).* have hire and I 6• New co
d the sub-contractors ,,❑��� �� ��ctron
2.❑ I am a sole proprietor or partner- listed on the attached sheet 1 ?• I[�Kemodehng
ship and have no employees These sub-contractors have
working for me in any capacity. workers,
rkers' comp,insurance. g' Demolition
[No workers'comp. insurance 5. [ e are a c 9. ❑Building addition
re orporation and its
] officers have exercised their 10-ElElectricalrepairs or additions
3.[:] q I am a homeowner doing all work right of exemption .1 LEI Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),•
❑
insurance required.] tand we have no 12• Roof r
employees. [No workers' ��
Pomp.insurance required.] 13 ❑ Other
`=n} a`opricaat that checks box.=l must also rite out the se^fion-barov,s' W.. _
Iiemeowners who submit this affidavit in they are doing aL'work and then'hire outride contra tors must.submit a new affidavit indicating such.
pchcy
.c meson
+Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp-policy info
information. on.
I am an employer that is providing workers'compensation irisrurance for my employees. Below is the policy and job site
Insurance Company Name: GtAe, ��� /
Policy#or Self-ins.Lic.#: ryd
-- � Expiration Date: �J
Job Site Address:�� /1��,� ,
City/State/Zip _/v .fid/`Ir
Attach a copy of the workers'compensation policy declaration pace(sho 0
Failure to secure coverage as required undQr Section 25A of MGL c. 152 can lead to ththe e impositionolicy number
bof criminal expiration date).
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties of a
of up to$250.00 a day against the violator. Be advised that a co Penalties m the form of a STOP WORK ORDER and a fine
Investigations of the DIA for insurance coverage verification. Py of this statement may be forwarded to the Office of
I do hereby certify u er the pains and penalties of perjury thw Me information
f rmation provided above is true and correct
Signature:
�i _ Date.:_ J lQ
Phone#- c7
[Er
only. Do not write in this area, to be completed by city or town ofciaL
n:
Permit/' cense#
thority(circle one):
Health 2.Building Department 3. Ci /Torun ptY Clerk 4.Electrical Ins ector 5.Piumbinb Inspector
son:
Phone#:
Information an- d 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 orother legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including tine legal representatives of a deceased employer, or the
receiver or t ustee of an individual,partnership,association og-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 whoemploys persons to do maintemauce,construction or repair work on such dwelling house
or on the grounds or building appurteaant thereto shall not because of suchemployment 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 it license or permit,to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of co=npliance 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 uncal 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-contractors)name(s),addresses)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'comp=sation 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 sire to sign and date the affidavit. The affidavit should
be r cturne to the city or town that the application for the p it or license is being requested,not the.D a* Pet 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 permit/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 permrits or licenses. A new 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 bum leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to than 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.-uumber....
The Commonwealth of Massachusetts
DcRartment of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,IIA 02111
Tel. # 617-72.7-4900 ext 40.6 or 1-977-MASSAFF
Revised 5-26-05
Fax# 617-727-7749
urvrm,mass-aov/dia
Office of eonsumer ffairs""t/i si A( egu 6100—
HOME IMPROVEMENT CONTRACTOR
t2iRegistration:. 136779 . Type:
j Expiration: .8/26/2012 Partnership
TV1(bMEY+LEGARE CONTRACTING INC_
SHAWN TWOMEY
87 BELMONT ST.
N.ANDOVER,MA 01845 Undersecretary
Massachusetts- Dcpa+tmcnt of Public Sufct"
9 Board of Building Regulations and Stitridards
Construction Supervisor License
License: CS 67560
Restricted to: 00
SHAUN M TWOMEY
61 PATROIT ST
N ANDOVER, MA 01845
Expiration: 10/25/2011
('ununi.�iuiicr Tr#: 4949
f �
N
s
Q
,� tl
I 1
7-7
911F.
NOTE: I HEREBY CERTIFY TO THE BEST OF MY KNOWLEDGE THAT THE NOTE: THIS ISA TAPE SURVEY NOT TO BE USED FOR ESTABLISHING
PREMISES SHOWN ON THIS PLAN ARE NOT LOCATED WITHIN THE PROPERTY LINES, HEDGES, OR ANY PURPOSE OTHER THAN ITS
FLOOD HAZARD ZONE A DELINEATED ON THE MAP OF COMMUNITY ORIGINAL INTENT. THIS PLAN WAS DRAWN FOR MORTGAGE PURPOSES
MASS. ONLY. NOT TO BE RECORDED.
EFFECTIVE BY THE DEPT.OF HOUSING
AND URBAN DEVELOPMENT FEDERAL INSURANCE ADMINISTRATION. THE LOCATION OF THE DWELLING AS SHOWN HEREON EITHER WAS IN
COMPLIANCE WITH THE LOCAL ZONING BYLAWS IN EFFECT WHEN
CONSTRUCTED (WITH RESPECT TO STRUCTURAL SETBACK
i CERTIFY THAT THE BUILDING SHOWN ON THIS PLAN IS ON THE REQUIREMENTS ONLY),OR IS EXEMPT FROM VIOLATION ENFORCEMENT
GROUND AS SHOWN. ACTION UNDER M.G.L.TITLE VII,CA0A,§7.
'icy MORTGAGE INSPECTION PLAN
o r'er L.G.BRACKETT COMPANY,INC.
,o TALMADGE WINCHESTER,MA
y}cNE£LPLAN OF PROPERTY IN SCALE: I"= .fJ
X22594 ye
'°f��t LnKa OWNED BY DATE: Q
COUNTY: ` X 1 CERTIFY THIS PLAN TO DATE OF PLAN:
PLAN: 8,6I 3A,�J U F .q r�f� %�%;t 7_�t`1 4f c9 .+7 PLAN
�a - 273
74,
zi Y-3
rS
107 71/