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HomeMy WebLinkAboutBuilding Permit #129-2017 - 112 STONECLEAVE ROAD 8/10/2016 WO, NORTH 9 BUILDING PERMIT ttL�� b ti TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION Permit No#: 7 Date Received �ssgcHus���5 Date Issued: IMPORTANT:Applicant must complete all items on this page LO *CATION <<2 ;5v .c C�ee�y-e_ -�SZei t►c�l 1 r r � { i~•- i i-i' . .� 7. 't.•n rY.,,♦ePrint" PROPERTXOWN ER^'_ t l J tr ae f StfuCtUf@ n MAP , PARCEL `: :,`ZONING E)ISTRICT Historic District �£t yes°` S f 3F f1 1 ' t Machine Shop�/illage yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family Addition ❑Two or more family D Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑. ep d Well: i Q>'Floorlp�airr Wetlantls, ❑ 1NatershetlD,stFt ❑``1"lU a -wo b DESCRIPTION OF W RK TO BE PERFORMED: A Identification- Please Type or Print Clearly OWNER: Name: ( Ir�r-�s L�'.s�-e.� Phone: Address: r'Contractor Name' n Y Phone: -53�J, ~' ` ' y ,:,.. w-r.7 - .J �`,i - r ?Y-, _ jT- •ice ka ..�a :. -mall r` _ tgi. _ .mac n tib zo- Super'visor's;ConstructionLicense `~���!S�U ��iK 'Exp�Date � 6';�Z� >*x t1 J r '.. t .. ..�„ ., _ 'v. lift f �»�•�4Y ';,.,. . ,Home Improvement License: ARCHITECT/ENGINEER S i-y hcJfit,­. 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: $ }yIf u FEE: $ �3 3 'Z— Check No.: 3�� Receipt No.: NOTE: Persons contract' ith unregistered contractors do not have access to the guaranty fund a f 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 4 Building Permit Application 4. Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract 45 Floor Plan Or Proposed Interior Work 4 Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 1 Building Permit Application ' I Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract i Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) 4. Mass check Energy Compliance Report (if Applicable) 4. Engineering Affidavits for Engineered products + OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit f New Construction (Single and Two Family) Building Permit Application 4 Certified Proposed Plot Plan 4. Photo of H.I.C. And C.S.L. Licenses 4; Workers Comp Affidavit 4 Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 4. 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit i 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 f I Doc:Building Permit Revised 2014 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 m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals M� Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Drivewav Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT ,Temp ®wrnpster on sit- yes `' no Located at 1x24 Main Streets = Fire Department sign tu71 reMd` to , , . COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Dieter 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) M ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pemait Revised 2014 Plans SubmitteT5 Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tauning/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 m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature t COMMENTS HEALTH Reviewed on Signature i _ I COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments -Conservation Decision: Comments Water& Sewer Connectioi7lSignature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE 151 VIM Durnpster on sit- yes^` `• no i ' '' y . Located at 124 Main Street _ �• - Fire Department sign ture C 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 Call Email Date Time Contact Name Doc.Building Permit Revised 2014 i I Location No. Io` j' G/7 Date 4' l a/' l r � • • TOWN OF NORTH ANDOVER k; Certificate of Occupancy $ Building/Frame Permit Fee $�3=Z- Foundation Permit Fee $ Other Permit Fee $ ._ TOTAL $ 4 _ iry Check#13`/9/ (;? 570716 Bu I'ding Inspector j� i Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 111 ,000.00 m $ - $ 1,332.00 Plumbing Fee $ 166.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 166.50 Total fees collected $ 1,765.00 I 112 Stonedeave Road 129-2017 on 8/10/2016 add master bedroom and renovate existing bathrooms i i NORTH Town of 2 aAndover O - 0 No. 74 11 6 ver, Mass, �Jd A�R'�TED PP�`t� BOARD OF HEALTH Food/Kitchen PER IT L D Septic System �In M ' +S'wkTHIS CERTIFIES THAT G •„........�..... , BUILDING INSPECTOR 0� ... ••• � ��+t Foundation has permission to erect .......................... buildings on .:. . .............. ......,. .. . Rough to be occupied as . .. 4.. ..@ I.r . •••• •• ••�• ..R•..... Chimney provided that the person accepting th s permit shall in every respect nform to he terms f t e ppl ation 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 N Rough Service .. . .. ... ....... ..... ............ Final BUILDI INS ECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. Plans Subrnittei Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans - P F PE OF SEWERAGE DISPOSALlic Sewer ❑ Tanning/MassageBodyArt ❑TFood gPools ❑ well ❑ Tobacco Sales ❑ kaging/Sales D Private(septic tank,etc. Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - .0 FORM PLANNING DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS WEALTH Reviewed on Signature COMMENTS I h Zoning Board of Appeals Zoning Decision/receipt submitted yes ..Planning Board Decision: Comments -Conservation Decision: Comments Water& Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: � —, ed od Street FIRE DEPAFITN1ENl' Tern Dorn a p ,psfier on sit- yes Located 8 sgo * • no 's Fire De - artment si, , p gn ture/date ,a Str et Kevin. M rp y 98 North An over, • North Andover,MA 01845 • PH:978-688-5335 Building Contractor FAX:978-688-7207 Proposal To: Chris&Mary Litster 112 Stonecleave Road All Home improvement Contractors and Subcontractors engaged in home improvement contracting,unless North Andover, Ma. 01845 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 Director,Home Improvement Contract Registration,One Ashburton Place, From: Kevin Murphy Room 1301,Boston,MA 02108.(617)-727 8598 CC: Date: 8/10/2016 Job: Renovate second floor Date of plans: 8/16 AnChitect: Steve Foster Location: Same Section 1-Work Schedule Contractor will begin the work or order the materials before the third day following the signing of this agreement, unless specified here in writing contractor will begin work on or about 8/22/16. Barring Delay caused by circumstances beyond Contactors control,the work will be completed by 11/15/16.The owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall no be considered as violations of this agreement. Section 11-Warranty The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of 1 year following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contractor, his subcontractors, employees or agents, is discovered within one year after completion of any job, including cleanup,the Contractor shall,at his own expense,forthwith remedy,repair correct,replace,or cause to be remedied,repaired,or replaced, such damage or such defect in materials or workmanship. The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. Section 111-Scope of Work Page 1 of 4 Kevin Murphy Page 2 of 4 Building Contractor 98 Forest Street North Andover,MA 01845 PH:97888&5335 FAX 97&688-7207 General Proposal is to renovate/reconfigure existing second floor, and add master bedroom over existing kitchen area. Permit will be obtained by contractor. Plans to be provide by owner. Demolition Existing second floor area will be gutted as required. Building All frame, roof, and siding materials will be supplied and installed to match existing/as shown on plan, to meet code. Harvey windows will be supplied and installed as shown on plans. New interior petitions will be built as shown on plans. Plumbing Plumbing required to renovate/expand two existing baths as shown on plan,will be provided. Plumbing fixtures to be supplied by owner, installed by contractor. Electrical Electrical work required to wire second floor to code will be provided. General layout to be approved by owner, prior to rough. Any surface mounted fixtures to be supplied by owner, installed by contractor. No allowance has been made for any high def TV wiring/installation. Heating/Air Conditioning Forced hot water heating will be added in new master bedroom area. Heat in existing second floor will be replaced/relocated as required. Air conditioning will be provided in new master area, relocated in other areas as required. Insulation Added/renovated areas will be have fiberglass insulation installed to code. Plaster All added/renovated areas will be blueboarded and skimcoat plastered. Interior Trim/Doors Pre-primed interior trim and doors will be supplied / installed to match existing. Bathroom cabinets will be supplied by owner, installed by contractor. Counters to be provided by others. Painting All interior, and any minor exterior painting, will be provided. One coat of primer, and two coats of finish will be applied. Kevin Murphy Page 3 of 4 Building contractor 98 Forest Street North Andover,MA 01845 PH:978Z8BS335 FAX 978688-7207 Flooring Hardwood floors will be supplied / installed and finished with three coats of oil based urethane in all added / renovated areas. Existing floors to be refinished where possible. Tile floors and shower/tub walls will be supplied/installed in both bathrooms. An allowance of$7 per square foot has been inluded for tile materials. Waste Removal All demolition/construction debris will be disposed of by contractor. Other Allowances An allowance of$2000 has been included to supply and install glass shower door in master bathroom. a y �y Kevin Murphy Page 4 of 4 Building Contractor 98 Forest Street North Andover,MA 01845 PH:97t}68853 i5 FAX 9788W7207 Section N-Price Schedule We hereby propose to furnish material and labor—complete in Accordance with above specifications for the sum of... ... ... ... ... ... ... ...... ... ... ....$ 111,000 Payment to be made as follows: Percentage/Item Description Amount 1 Permit obtained / deposit $3000 2 Roof framing complete $25,000 3 Siding /windows installed $15,000 4 Rough plumbing /electric complete $20,000 5 Plastering complete $10,000 6 Interior trim installed $8000 7 Flooring /the complete $20,000 8 Job 100% complete $10,000 -Tot-l 8 $111,000.00 —Notice:No agreement for Horne improvement contracting work shall require a drnm payment(advance deposit)of more that one-third of the total contract prioe of the total amount of all deposits or payments which the contractor must make,in advance,to order andlor otherwise obtain delivery of speoal order materials and equ pmeM whichever is greater Contractor: Kevin Murphy 98 Forest Street No.Andover, MA 01845 Registration No: 101874 Section V-Acceptance Acceptance of Proposal—I have read this document and accept the prices,specifications,and conditions stated. I understand that upon signing,this proposal becomes a binding contract.You are authorized to do the work as specified. Payment will be made as outlined above. You the buyer may cancel this transaction at any time prior to midnight on the third business day after the date of this transaction cancellation must be done in writing DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Signature Date ?/(i0 l Signature Date a �OD►NS ����5 9� Zj a OUT_ LINE OFJ r I /I �RUBELOW /—ROOF � f � � � \-5 i rj kL 5 BAT BATH O g m minx m3 O C� BEDROOM CCL. CL. CLMASTER . BEDROOM uF BEDROOM BEDROOM Tia Tra �y�. SECOND FLOOR PLAN (FAUMa) LITSTER RESIDENCE 112 STONECLEAVE ROAD NORTH ANDOVER, MA �ww.r.s oioewrn� 4 PROPOSED 4WD R.ADDITION NEW D.H.WINDOW. .. .. _ .:._.. MATCH EXISTING. ... _. . .. . _ RFLOCATEWNEW WINDOW UNUNITS FINISH 2ND FLOO FINISH IST FLOOR -- - - - .. MODIFY E708TIN0 SCREENED .. 1114 OPENING(S) UIRED ('trrNo(b)Ae REO FINISH BASEMENT FLOOR — � NEW SCREENED PORCH DOOR REAR ELEVATION LITSTER RESIDENCE 772 STONECLEAVE ROAD NORTH ANDOVER. MA �ewaw�r-r oaew�n� PROPOSED 2ND R.ADDITION ASPHALT SHINGLES NEW D.H.WINDOW. MATCH EXISTING - -' -- .\ - - - NEW AWNING WINDOWS SIDING TO MATCH EXISTING FINISH 2ND FLOOR _ .. EXITING WINDOWS TO REMAIN _----UNLESS NOTED OTHERWISE. -- FINISH IST FLOOR . _ .. .. PROVIDE TREATED WOOD STAIRS AND RAILING SYSTEM. FINISH BASEMENT FLOOR MISTING POURED CONCRETE FOUNDATION — �N'-,:EXISTING GARAGE RIGHT ELEVATION LITSTER RESIDENCE 112 STONECLEAVE ROAD NORTH ANDOVER, MA �owew-r-s uaeemr PROPOSED PND FL.ADDITION ASPHALT SHINGLES SIDING 8 TRIM TO MATCH 90STING - .. FLASH EXISTING = DWELLING FINISH 2ND FLOOR EXISTING PORCH ROOF TO REMAIN. G EXISTING RAILING PORCH PORCH OPENING OPENING FINISH IST FLOOR --- `44114-4-141-444444- i 1 If MODIFY EXISTING STAIRS ——— U-F AS REOUIRED ——— il,l.j # :;'� '� I.I FINISH BASEMENT FLOOR LEFT ELEVATION LITSTER RESIDENCE 112 STONECXEAVE ROAD NORTH ANDOVER, AAA �owew.r-a o�+ee�aR NEW D.H.WINDOW. MATCH EXISTING D.H.WINDOW SME MIN.SIZE PER EGRESS REOUREMENTS PROPOSED 2ND FL.ADDITION EXISTING PORCH .. .. 4'-T ROOF TO REMAIN - - _ � SECTION B-B WALK4N CLOSET N EXHAUSTFAN a _-. .'- - MASTER HARD DUCTED TO EKTERIOR _I_ - -- BEDROOM NEW AWNING WINDOWS(8) 7-fr C.O. 4r WC BATH O , �. `�L BEDROOM EXISTING WINDOW TO REMAIN. 81NKa8SINKS& VANITY CL. O � VANRY NEW D.H.WINDOW. V.I.F.HALLWAY WIDTH. MATCH EXISTING 4 EXISTING STAIRS TO REMAIN RAILING ;G Q EMC . HALL EXISTING WINDOW 0) TO DOWN TO 18T TO REMAIN 7d NEW WALLS SHOWN SHADED EXISTING WINDOW TO REMAIN. SYN g BEDROOM BEDROOM EXISTING UNSHADED ATTIC 7-0" WILLLIS TO ROAM EXISTING(8)WINDOWS T FRONT WALLTO REMAIN SECOND FLOOR PLAN (PROPOSED) nasion LITSTER RESIDENCE 112 STONECLEAVE ROAD NORTH ANDOVER, MA �osew.e.s sosrnr NOTE: REFERENCE DRAWINGS SK-1,SK-2 8 SK-3 DATED 721LIS FOR ALL STRUCTURAL COMPONENTS OF THIS RENOVATION. RIDGE VENT AS REQUIRED 2X10AT1S'O.G 'ZIP SYSTEM'ROOF SHEATHING R-49INSULATION. ASPHALT SHINGLES(MATCH EXISTING) TYIPCAL ALL CEIIJNGS 2X8 AT 18.O.C. TYPICAL EAVES DETAIL: FASCIA&SOFFIT TO MATCH EXISTING 2 X E AT 1E'O.C. PROVIDE SOFFIT VENTING AS REQUIRED DOUBLE TOP PLATE -r TYPICAL INTERIOR WALL: METAL DRIP EDGE 2 X 4 AT 1S'O.C. ICFJWATER SHIELD C GWB EACH FACE .t TYPICAL EXTERIOR WALL' FLASH SIDING TO MATCH EXIST! { BUILDING WRAP 3 EXISTING PORCH ROOF STRUCTURE MP SYSTEM'SHEATHING 2 X$AT 1B'O.C.LATION MASTER p VAPOR BARRIER BEDROOM CL. LL GM (NEW) (NEL) NEW BEAM FINISH 2ND FLOOR ? EXI NO BEAM z STING KITCHEN WALLS-\ I JOIST HANGERS 2X10®18' V2'EXT.PLYWOOD O.G I KITCHEN flLL JTY FULL PORCH STING DEPTH Wlti+INSULATION (EXISTING) I FINISH'IST FLOOR EXISTING KITCHEN FLOOR PROVIDE SUPPORT POSTS TO EXISTING FOUNDATION. TYPICAL EACH END OF BEAM. 4'111'(V.I.F.:%r GARAGE (E(ISTING) E)QSTTNG GARAGE IF NIGH BASEMENT FLOOR FOUNDATION WALL ,w. SECTION B-B LITSTER RESIDENCE 112 STONECLEAVE ROAD NORTH ANDOVER, MA fi I - 1 r .. _ , . .I - , i r i' �� ..._S W«�i•.r '.j` � I � -- • + � ri ,o n. --- i .� ENI ERGY CONSER v ATION APPLICATION FORM' FOR L0_VV-RISE RESIDENTIAL NEW CONSTRUCTIONN l and ADDITIONS S 780 CMR Appendix J Applicant Name: Ve-11 1 Ke Site Address: l�-� S�,w� C�.•v� Il ►.�,r�t RT I own: �/� brf.• -., �• Use Group: _ Date of Application: f" o � Applicant Phone: 4,-\t. �,y 3 3 Applicant Signature: Compliance Path(check_ one): ❑ Prescriptive Package(Limited to 1-or 2-family wood frame buildings heated with fossil fuels only) Package(A through FLK from Table J5.2.1 b): Heating Degree Days (HDD65) from Table J5.2.1 a: (For items d.through i., fill in all values that apply from Table J5.2.1 b:) a. Gross Wall Area sq.ft f. Wall R-value R- b. Glazing Areal sq.ft. g. Floor R-value R- c. Glazing%(100 x b_a) % h. Basement wall R- d. Glazing U-value U- i. Slab Perimeter R- e. Ceiling R-value R= j. Heating AFUE ❑ Component Performance: "Manual Trade-Off'(Limited to wood or metal framed buildings only) Climate Zone(from Figure J6.2.2) ❑ Zone 12 ❑ Zone 13 ❑ Zone 14 Attach Trade-Off Worksheet from Appendix J, [and HVAC Trade-Off Worksheet, if applicable] ❑ K4&heck Software Attach Compliance Report and Inspection Checklist printouts ❑ Home Energy Rating System Evaluation Attach Home Energy Rating Certificate(HERS rating score must be 83 or higher) ❑ Systems Analysis OR ❑ Renewable Energy Sources Attach Mass Registered.,`.rchitect or EnL-incer Analysis A-TEM NATWVE FOR LDDTTIONS ONLY: a. Gross Wall T C ciiiii j.i ea (,6ki sq.ft. b. Glazing Areal 3 sq.ft. c. Glazing% (100 x b=a) ,k.—1 % ❑ .A-DDMOIV with GIazing % (c.) up to 40% may use 780 CMR Table J1.1.2.3.1 below: M.:,1I\FtINTii-vnlue I Prfl�Th1TiW1 R-\%aluec 1Venestratior.- C61iny3 1 \A:all I door Basement Wall ' slab Perimeter I>e in 0.39— R-37 . -13 R-19 R-10 R-i0.4 ft 1 Glazing Area may be either Rough Openin o:Unit dimensions. 2 Based on NFRC Iisting. t1pplies either to every unit,or to area-weighted average of all units. F_30 ceiling inmlation :ay be used in place of R-37 if the insulation achieves the full R-:clue over the entire ceiiirr a:ea licit coni-Pressed c ver e::ter:or%.'alis,- d incl d- 2nV access c ening-) ❑ acC4_c:l=d tJ t�T' rtdditif)n (greater f-han 40% b1a:ing-to-wall and ceiling gra::s area) .t,-LaCh `Cons urn er 11-110,l.,i;�tion :„rm''Prem /080 C1,ice' .'_ppendi B i:� V. -oo-�.wnx�armrr 1'�' lie' C31TiciRl'S �i�TlatIIre: The Commonwealth of Massachusetts Department of Industrial Accidents t I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Alorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED M`ITH THE PERMiTI'ING AUTHORM. Applicant Information Please Print Legibly Name(Businessforganization&dividual): Address: - City/State/Zip: too , iz� N%, , t?: �s< Phone#: I\t 5- Are Are you an employer?Check the appropriate box: ` Type of project(required): 1.0 1 am a employer with employees(full and/or part-time)' 7. ®New construction 21:]I am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required] 301 am a homeowner doing all work myself[No workers'comp.insurance required.]t 9- Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on10®Building addition ensure that all contractors either have workers'cvm mY Property_ I will pensatton insurance or are sok 11.0 Electrical repairs or additions proprietors with no empbyees_ 1.2.E]Plumbing repairs or additions 5�I am a general contractor and I have hired the subtantractors listed on the attached sbca. "these sub-contraaors have employers and have workers'comp.ias=ncr 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14-[]Other 152,§1(4)�and we have no employees.(No workers'comp,inRuancercquired.] ;Any applicant that checks box N must also fill out the section below showing their workers'compensation policy inn formatioHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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 subcontractors 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 sue information. Insurance Company Name: G"'A Policy#or Self-ins.Lic.0: c 1;;k.�, —l2�, SD Expiration Date: _,t i Job-Site Address: k 12 . r t.7+,-4 c,l e,m `R'''"-01- City/State(Zip: Ni. 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 51,500.00 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.A copy of this statement may be forwarded to the Office of Investigations ofthe DIA for insurance coverage verification_ I do hereby certify rttxder the painsfJa`nd penalties of perjury that the information provided above is true and correct Signature Date Phone 9- ez ti _1z_- -S '<I%_N/ OVAcial use only. Do not write in this area,to be completed by city or town odwiaL City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: DATE(A4AODNYYY) jovb�R CERTIFICATE OF LIABILITY INSURANCE 7/11/2016 THIS CERTIFICATEIS ISSUED ASA MATTER OF INFORMATIONONLY 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 REPRESENTATN®R PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:H the certificateholder is an ADDITIONAUNSURED,the policy(es}nust have ADDITIONAUNSURED provisionsor be endorsed. N SUBROGATIONS WAIVED,subjectio the termsand conditionsof the policy,certain policiesmayrequirean endorsement A statemerdon this certificatedoesnot confer rights to the certificateholder in lieu of such endorsement(s). PRODUCER CONTACT NAME Sandi Munroe M P ROBERTS INS AGCY INC PHONE FAX -3147 ASC,No,Ext- (978)683-8073 7Ne: (978)683 1060 Osgood Street DDRESS: sandi@mprobertsinsurance.com DDR A North Andover, MA 01845 INSURER(S)AFFORDING COVERAGE NAICO wsURERA: MERCHANTS INSURANCE INSURED KEVIN MURPHY BUILDING & REMODELING INSURERB: GUARD INSURANCE 98 FOREST STREET INSURERC: NORTH ANDOVER, MA 01845 INSURERD: INSURER E INSURERF: :OVERAGES 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, D(CLUSIONSANDCONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVEBEEN REDUCED BY PAID CLAIMS. POLICY EFF POLICY EXP TYPE OF INSURANCE POLICY NUMBER LIMITS X COMMERCULLGENERAL LIABILITY EAC I OCCURRENCE $ 1 000,000 IJAMAUE 10 HEN I EU CLAM— OCCUR PREMISES a--cc) $ 500,000 MED EXP("one pcn—) $ 15,000 BOPI068945 1/22/15 1/22/16 A PERSONAL&ADV INJURY $ INCLUDED GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY O JJEECCT D LOC PRODUCTS-COMPAPAGG s 2,000,000 OTHER $ AUTOMOBILE LIABILfiI' COMBINED SINGLE LIMIT $ 1,000,000 ANYAUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED MCA7013608 1/23/16 1/23/17 BODILY INJURY(Peraccident) $ A AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Peracddent UMBRELLA UAB OCCUR EACH OCCURRENCE $ 1,000,000 A X EXCESS UAB HCLAIfMSAa4ADE AGGREGATE $ 1,000,000 RETENTION $ 100 CUP9145304 1/22/15 1/22/16 $ WORKERS COMPENSATION X PER OTE+ D EMPLOYERS'LIABILITY STATUTE ER YIN °"—T—" '•`n^'r - E.L.EACH ACCIDENT $ 500,000 B :-- m sxcwosm N NIA (MandatwIin NN) KEWC726509 7/01/16 7/01/17 E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,desalbe under DESCRIPTION OFOPERATIONS belay E.L.DISEASE-POUCY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 107,AddMo al Remads Sdadde,may be attached If spare is required) CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER 1600 OSGOOD STREET SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE 94 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD25(2016/03) The ACORD name and logo are registered marks of ACORD Ar Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-053099 . Construction Supervisor KEVIN W MURPHY- 98 URPHh98 FOREST ST NORTH ANDOVER M Ill 0(',g{,� r i ��li )1"1411\ Expiration: Commissioner 06/29/2017 ��e (Oanvnzarzcuea��C�/r'aa�ac�,ctself 4Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration: Re , 1� 9 101874 Type: Expirations. =6%29%20;18 Individual KEVI MURPHY si== Kevin Murphy 98 FOREST ST. N.ANDOVER, MA 01845 ' Undersecretary