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HomeMy WebLinkAboutBuilding Permit #620 - 118 MEADOWVIEW ROAD 5/15/2009 BUILDING PERMIT o* OORTH q tttLlD 161 �O TOWN OF NORTH ANDOVER c2 - °�, APPLICATION FOR PLAN EXAMINATION '' Permit NO: Date Received AT D �SSACHUS�� Date Issued: IMPORTANT:Applicant must complete all items on this page 10CAT TIONtiW`tJic 2� PROPERTY OWNER ..� k n A n Print �_MAP NO: PARCEL: ZONING DISTRICT: - Historic District yes b-`no i Machine Shop Village,-,yes ,3 ono TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement ; Assessory Bldg Others: Demolition Other Septic 'Well Floodplain :Wetlands- Watershed`bistrict Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: T"ru\ f 11,oS Phone: ?&_ -zZ t12 Address: LO' 17,? e( �v' e L,,j k 1 CONTRACTOR 'Name:. _1%61;1ti`o 4-. 5e,� Phone: 7 -2712-6_?hF s Address: T__ t _ A DA 'ion T �nyys an 4.. - �1— e Super`visor's Construction L�icense: ,`$'�S 20D � � Exp. _Date: oD Home,arnprov ment License: - C Exp. -.Date: '`" /0 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: $_ Q �I�t Q FEE: $ Check No.:���� Receipt No.: oZd 7 C� NOTE: Persons contracting with unregistered contractors do not have access to the g ran ty and oignature of Agent/Owner r Signature of contract K I Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L' Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) 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 ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 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 Signature COMMENTS HEALTH Reviewed on Signature ('OMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE:DEPARTMENT Temp.Dumpster on site yes no Located-at 124 Main Street Fire Departmnt signature/date ffi COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use r ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 Location No. DateOf NORTH TOWN OF NORTH ANDOVER f 9 Certificate of Occupancy $ sACMUS t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Al 22L40 � Building Inspector V40RTly ovm Of tAndover 6 ?.d _ 1L. = A K E - dower, Mass., ' COC MIC KE WIEK �� �d ADRATED S BOARD OF HEALTH PERMIT T D . Food/Kitchen Septic System BUILDING INSPECTOR S THIS CERTIFIES THAT eS.. ....... • Foundation has permission to erect........................................ buildings on .Ale.......#7� .. .C.. ....,........... Rough to be occupied as.... ........ ....... Chimney provided that the person accepting tPispe:­7i:1:!:1a1ll1ii in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Ilk PERMIT EXPIRES -IN 6 MONTHS Final ELECTRICAL INSPECTOR. UNLESS CONS TR ST TS Rough . .. .............................................. ............................... Service BUIL G 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 Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. SEE REVERSE SIDE Smoke Det. 05-11-2009 11:22 FROM-HOMEDEPOT2685 +919789466421 T-100 P.002/006 F-428 Legend 1: BWBT15 2: SB36 3: WBEP r, 4: BLB39/42L {P} 5: D1318 4DWR 6: B12 2FWTR Ln 7: OVSF396 s" 8: B24 2FWT BUTT 1 24.DISHW 3 _ 9: WBEP — — - - 10: KDC24/21 11: DDR1224 12: UF3 13: UT3624 X 90 4ROT ice• 14: W2436 BUTT UJn N] 15: W3636 Z0) p 16: W3618 17: UF342 N a 18: B21 2FWTL gym) 19: WBEP 20: CAR36R WD 21: W2136L 22: W3018 N rn nod 23: W1236R `� 24: UF342 25: CWS2436R WD 26: CS12 - 27: CS12 28: CS12 36 EF-2D 10 8 13 7 L 15 16 14 All dimensions,size designations This is an original design and must Designed:4(30/2009 (iiVGrl=subject t0 vorifcation on nor.be reloascd or copied unless PYinzed!S/1112009 Job site and adjuSrrncnt to fit job applicable faa has been paid or.job conditions. order placed. 2010coA2.kit A.lj(no dims)I Drnwing''l:1 MAY-01-09 11:41 AM FROM- T-158 P.007/007 F-948 04/ZM/U11 1I :Jt rnla _T-- M LKIN & SONS STORE; METHUEN PLUMBING SCOPE OF WORK PO#: 85444909 PHONE 978-774-6380 JOB NAME: Spanos FAX 978-762-4581 DATE: 3/14/09 The following includes labor and pipe materials *Disconnect dishwasher, disposal, sink and faucet *Install new isolation valves for Kitchen sink and dishwasher *Install dishwasher ,disposal, sink and faucet *Remove 1Oft of baseboard *Insta.11 icemaker line with isolation valve *Leave with temp sink and faucet hookup until counters are installed *Customer to supply appliances and fixtures. Not responsible for previously slow drains and venting issues* Retail cost...$1440.00 To be entered as custom labor. 2 4 noel IAA- Page 7 of 9 No. 2685-161714 Home Improvement Agreement PLEASE READ THIS Important additional information regarding Customer's rights may be contained in an attached State Supplement. Scope: This "Agreement" consists of this page, the following General Terms and Conditions, the Invoice, the State Supplement if applicable, and any drawings or Change Orders expressly made a part of this Agreement. The Agreement is between the Customer identified on the Invoice and The Home Depot (including EXPO Design Center). Any installation services provided under this Agreement shall be performed by a licensed and insured third party Authorized Service Provider. The Home Depot does not perform architectural or engineering services, nor does it make structural changes to dwellings or other structures. The Home Depot and its Authorized Service Provider will perform installation services in accordance with applicable law. _ Payment Schedule: Payment is required as indicated belo,5� S Please initial here to opt to pay the total amount of the sale now;Customer has the option of paying less as further specified in the State Supplement. Payment: $ 16281 29 Due In full immediately. Sales Tax: $ 9-51 32 If applicable. Total Amount of Sale: $ 18512.81 Includes all applicable discounts,rebates,and taxes.Excludes finance charges' *Any interest payments or other finance charges will be determined by Customers separate cardholder or loan agreement,to which The Home Depot is NOT a party,and will be in addition to Customer's payment under this Agreement. Customer is subject to the terms and j conditions of the cardholder or loan agreement,as applicable. No funds should be made payable to Authorized Service Provider: however,Authorized Service Provider may collect Customer's payment(s)made payable to The Home Depot. Anticipated Delivery!Installation Schedule Delivery Date: TBD Start Date: 04/30/2009 Finish Date: 05/30/2009 Acceptance and Authorization: Customer authorizes The Home Depot to order and arrange for the delivery of all goods and services included on the Invoice. Customer further agrees and understands that this Agreement is the entire agreement between Customer and The Home Depot with regard to said goods and services and supersedes all prior discussions and agreements, either oral or written relating to said goods and services. This Agreement can not be assigned or amended except by a writing signed by Customer and The Home Depot. Customer acknowledges and agrees that Customer has read, understands,voluntarily accepts the terms of and is entitled to and has received a complete copy of this Agreement at the time Customer signs the Agreement. Do not sign if blank or incomplete. Electronic Signature: The parties to the Agreement agree that the digital signatures of the parties included in this Agreement are intended to authenticate this writing and to have the same force and effect as the use of manual signatures. Customer acknowledges that he or she is the person named on The Home Depot contract number identified on the point of sale device. CANCELLATION: CUSTOMER MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE 1S SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. Under such circumstances, Customers payment(s)will be returned within ten (10) business days after The Home Depot's receipt of Customer's notice. Accepted by: x 04/30/2009 Customer's Signature Date Authorized Service Provider's Full Businessfrrade Name,Address and X License No. or Now.,as applicable: Associate's/Authorized Service Provider's Full Signature Date Associate: Please print your salesperson's license number,if applicable. License No(s). Authorized Service Provider's Tel,No. Questions? If The Home Depot store and Authorized Service Provider are unable to answer Customer's questions, Customer may contact The Home Depot Customer Care Department at 1-800-553-3199 or use the address below. Home Depot U.S.A.Inc.,2455 Paces Ferry Road.N.W..Bldg 6.3.Atlanta.Georgia 30339 1112007 Pnnp 7 of q No. 2685-161714 Store Copy Zll-d 600/LOO d ££Z-1 410d 1Nd80:Z1 60-Z1-d VIN MAY-01-09 11:41AM FROM- T-158 P.006/007 F-948 04/29/09 17:34 rAA vro ru& Electrical .�..- Kitchen-Premium Type: Kitchen Level:First Level Note: Unit Qty Unit Description Notes 1 EA supply Electrical Permit as Specified 3 EA Supply&Install 20 Amp Duplex Receptacle For Desk/Hutch Area 7 EA Supply&I nstall.GFCI(2OAmp)Receptacle/For C Top Areas 1 EA Wire for New Feed For Relocated Switches From Pass Through 1 EA Wire For Toe Kick Htr 1 EA Supply&Install Single Poie Switch For Undercounter Lighting 1 EA Supply&Install 3-Way Switches for Relocated Lox 1 EA Relocate 2 gang switch currently in proposed Pass Through Area 1 EA Install(2)Puck Lights 3 EA Install Owners Pendant Light Fixture 1 EA Wire Stove or Cook Top(220)Change to 4 Wlre Due to Code 1 EA Relocate 3 Gang Switches currently in Pass through area 1 EA Wire Dishwasher 1 EA Wire Mcrowave 1 EA Wire Refrigerator 1 EA Wire Trash Compactor Subtotal: 2,278.27 Taxless: 0.00 Grand Total: $2,278.27 Client Signature 1 Date at Date client Signature 1 MAY-01-09 11:38AM FR0N— T-158 PU82/007 F-948 *8/00 17J 1`a& v'v ',^_°",^__-- KITCIJEN INSTALLATION S-nMATF-WORKSHEET 311412009 1"G.r 51 Will methumn S anus IV b. Remove ranita&solid, Remove ,6811 seffilli, 011 y;ltw Ll 0,8 Wall*action fgr pass thrU 12 "I SW a 51andes ex: r Inciall,nGW Wiltice mount light.ceiling tart,can fight to actisung servjqc;, \ ' � � °""..~~— gtf,ln,rbt$f,Eatq provided 15V installer pow!within T a c. Connatil tp underdi gr integral i3m%sink with faucet.oll | exiatMg 100ailcon-(installer prrWidea erawed ampply lines.shut off valves.piping and do X 16 0_17 ea X 41S jr,=N11 Bar r vOnitY sink with faq=within 3"of expiring wtali�� (Inerallerprovid95 X jr,=N11 Bar ,11 need ! *Pd°*wo _"=ngMarl—`-----' �� -- ~ MAY-01-09 11:39AM FROM— T-158 P-003/007 F-948 U4/40/vu I i ..,., >.>f> —.. - ,PolNr.3utr 77 M 5'_CA6lNINiPS: T1t]N•..:::';! 0 9. l/tiall Cabinet inst5lletl0n;ineluaes fillers.scribe handlesAarotr ea X 2.4 a qbl tin-sts{Iatlon:includes MGM scrim handlezlknona toe kirk b. Ba, „100 X 4 ° G. PenlnBulat�.lam"as inet instal anon:includes liars,scribe, antlle&kmags, kickobs toe kmk a, Pant RallcabinBllnstalWtion:lncludosfillere scribo. sndieWkn e. Singlaldaublo oven cabinet installation,InGuOezdlcrs,scrips,handlesFknobs,tat 0 o to support c�and micmwsves an X 4.5 kicK Includes all nscc8sary outaut..antl braving PP mdvdad f. Pillars and nVanB filar=each naaueB ° Manai9s or knobs an X 1 Mills Pude rabinele 8 RTA in atltlHlon -act an X 3 a h. AsseiaDla as I ° sans are e 0 A8011 in3le{led m the field not fndG IMstailed ea X 1.5 0 K. V2I2noes$shcl ;..,. BotflW. i. tn+atf.............. .,,_,•:.:...... :.::.�,:: JgQ:�ABINETRY.INORK'Jo6fShe quont x 1 ° a x ° SURTOTAL 5 i �I eoBars 6'CABINET:AL7EECATIOT{S' ':'':rr.' :'r co X 2.5 0 a. nrteramon:to cabinGtry lnolaB Gut In barx or bOIIOM at sink b5se for •a^are mer sn alteration ''n A't ICkha: , u to it • t i100r a1 (Up ° c v 1 ' BL[0 Oft ' u base Gab m X b. Budd P n9{911t,materials provided DY installer) 39Q�T+EIN �r��K�Eitil'fIONS:::fobslte•Cuah+.: X a d. SU9TOTALB �I ,Po 'SU PANEOr11ND 9ftlN 1 Ati±tigTl4rJ?St' ':'a=F'. - cs Q 0.75 0 a.3115"skins er decoradva ens nota p „a X 1.5 3 p,EIMESA--gamorwall end etolanctdeco Parte,trim him provided by CUSIatmCr X 3 0 ar G. AssrPlDte find install ll aPF�, as or ane ,. 9$Q PANEC ANO.SKIN INSTA11J1[11aN9 X 0 a X 0 e. Su L7 "S " 9aJ1HrS Br �r+ :' � TG7ri1'T.. 0 JVlC1LhaIfG INSTar TInDotwm ofIr1t . a, Molding for toP m of watt cabinets.Each I9yer priced X 0 Ced 19 .26 4 5 yo aratel t—Judas olockin at no Char e n 0.25 0 b,Basebbera Moldin Instellation For Panl6ul8 r Island wdt:a TOM kick wr J911 OL No INST{iLL'A710f7S' -Sift 00"::=.:";'! X a d. X 1 G SUIST07A18 I MAY-01-09 11:39AM FROM- T-158 P.004/007 F-948 04/Z9/UU 11 :00 rna GJv _ ____ r: I aQ�tlPr:5L'.5 9 APP' NGI=INSlA1.LA710N to 3.5 en X 4 0 a. Frim etsndm ter a InF1udL+s ran a card,installer rw/tles 4 0 b. COokta an X 5.5 0 r. Sin Iavrulloven d. Uepole wall even u, , aC Suppe rarl0u ter Ina Iter ea X 3 0 e. roD-I �I e•n rAna=,me u Ina � rrnid9S 3dalaon to 3f,if ea X 4.5 ° f M1cro hnoo sem o into EMU: ven6 into oedia+ted circuit(in re uirad as 3 0 Ran In hoed into i-tin vent G cirf, 0006 a roved 0rcuit x 1.2 0 n.Troch eom IiGrflr ea X 3 ° RBTGIOBTAtor "�X t D I. g 0 d for escn a.EI dance shut off k 1nstAll dishwashr-r wim tlttin s&ffir 9 fit 1, - feulaed b ir0vl(J d ,nslellen on X 2,3 ° I. Rr laee eldstin rdfritlerwar ice maxerwatcr line ImAtcrialyld dv�anstailer),i,rooli 0 m-Inhall nawrefrigerstor toe mskoirwster lint(rteterlals pro Y X D a roved Mittenat: n.Dewrldran unit of Ig ToSsipnol wmmerdal a tiences."Sub o" P4 site uotB a D o-"under the Counter"aPPllartra inSm"al10n X Jia'AP.Pr-�7CE'IfNSTALtl+tTl{rN��dIT— b•911s,ti X ° SUBTOTALS r.'r•'•::0 existing appliances may not be re.uasble after removal 1...._-...I.. ...:�,ba':. -..:1�;."=....:.::.:5:r.:;:.o-;.-7Nu PiIDml�{I:;i.:.:.:..-+:;;•::, .-• 9D':{LrOCf1fING:1NSTALI ATfGN::;e'> ala is/x3ao1 rdnelail a, Installation OP new ttooring,including but not limited to:full IV 7 spread,intrrtlax or inlaid shoot vinyl,sgW4re vinyl tilos,-famlc tile,nst vat stono,Blue-down hard1r. neu- down hardwood and noating Floor 9ystam.C.%tomer Supplies s11 Material 0 a e X 0.467 0 EL Installation of new nooring,including out not Gmltea lo:full Weao,intelfo tloryentald aneol vinyl.Square vinyl Ills*,caramictlle,natural stone,glucal Matarrdw down hardwood and floating flow system.su mmer SuDDlio;r D ZH it X 0,407 0 J$d'k.Wi041NSa Af I J1 SON'Job Ft' trots:'i' X 1 0 x 0 SUBTOTAL 10 C. PO t1 .PJt1 TING•' - a.Prmlin 24 '. X 1 24 b.one coat finish 0 x 't D c.Two coat finish D X 1 D d S said finish ?J8Q P711NT1NG;.J6b.51 Quo 4 X 1 Q p X 1 ° t Su8T0TAL 11 •575' I'-'�� i::���. } ..... .'Cl'aY UOf4 12{ARYiAIAGti1N01'tK .•:•:-..... p cr X 0.25 OD a. PaWt sntl ne air d all 0 X 0.1 b. Removed oil 0 of X 0.35 0 e. Remove and re lacy d all non-textured 0 of X 0.6 0 d. Remove and re 10006 11 textured ccilirt and aIt ss turn :.. u.„.; p.>•....:,.i[+`::<:°,: Rotch and re alr on yl$Q'dRYWIALL'W017K�.3ab�t�Bf]uo�-' 20 X 1 2B t SUBTOTAL 12 :�' r='=28 MAY-01-09 11:40AM FROM- T-158 P.005/007 F-948 �°::'.':. p ':i:': �:;QlY;�' UQIVC•:.::r. raet d�iJOTAf:?'': a3`Ct]N5i RUC.ON .1 x 0.9 0 :t6Q'CONSTRu�ONrL'ABDR'JO '31te'4tiolm''"• x 1 p c. X 0 ".::::elf:.::...._�....•....:;t->......h :......,>. � �•.�r'ii:':;:::::rbi!.. .•:....,; yq;:l1DRFTIONAL;CF1AttGEB if gcaul :.!:n° ne X 3 0 a Tfl rhisr a on X 5 0 D. Hi h Rise Cna a cu 3.5 0 ime cne o r-Travel Between 31-60 Mllee irOM dote-8 We one tx 7 0 d,Travel DOWW-n 51-100 M"es"M Store X 0 e-Travel over 100 miles trem Stora r JSOt j1001 f1CiNkl'CHAR6ES'10li+gife 0iotm';= X p X 0 fo'�;KitCNeii Jns ta4latiiii�rEstimBfi(i:: k --r 117.6 Stop 1 I lst total mints for Soctions 1-14 Here List$ 29-00 Swp 2 ill Pcr 5 3,40750 Ste 3 Multi I total girls X retail or pint $ 1,311.00 19 0 Ste 4 Kitchen PAfP0511109.00 Per BOX O S 950.00 $to 6 dP rmitCha s- fmm instahmr T � THE WNAMUST BE SIGNso sY BOTH F114AL KITCHEN INSTALLER ACOPYOFTHEfNAKfTCENESTIMAT€woRKSHF7lAUSTA650 MUST B MANUALLY FAXED Hi BE GVRN TO THF GU$TOMCR -JSQ-sob slla Quata CO all materials are at the job site job will be scheduled on Note The}SomO Depot does not Provide the following samlogS.(as part of kitchen installatlOn program)^ Rqrnova,alter or build load bearing Ovalle(other than atud SII framinfl) SIRlcta(al 6)teratimns or repalts Alterations to extgrice of namedards MCI Dorms and is Rgmgval of vinYI flmmring unloss in inmallem profesaianal�lpn)on that the lob Mae"indUetry star maltageablm untler Tho Hama DQPO%tlarardoue Matodals [ Date Cu9loMitT Signature: - Date G Aesmtiate Sl9natura: -- JOHN WALSH INSURANCE Fax:9787459557 May 1 2009 10:39 P. 02 Acov CERTIFICA7"E OF LIABILITY INSURANCE OPID ,7M DArE(NIMrODrYYYr) 93�iLI{OI 05/01/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS'UPON.THL Cr:kTIFjCATE', John JWalsh Ina.Agency, Inc .. HOLDER.'THIS duk'nFICATE DOES NOT AMEWb EXtEND bR F O Sox .44.07:: ALTER THE COVERAGE';AFFORDED BYTHE POLICIES BELOW. Salem MA 01970-5407 Phone: 978-745-3300 Fax:978-745-9557 INSURERS AFFORDING.'COVERAGE NA1C# INSURED ; INSURERA- Nautilus InsuranCE Go SSL �• � INSURER,B:• 1'raVel®r INSURER C:, _... 180....DAYTON,:::j. kiT.._.-_.. ..... : INSURER D:; ' INSURER E• . COVERAGES THE POLICIES OF INSURANCE LISTED BELOW RAVE BEEN ISSUED TO.THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PE;RTAIN,:XR£INSURANCE AEFORD7=D BY THE POLICI£S,'OESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS.AN0 CONDITIONS OF SUCH PGIJCIES.AGGREGATE LIMITS SHOWN NIAY HAVE BEEN REDUCED BY PAID'CLAIMS.' POLICY ti-FECTIVE: POLICY EXVIKATIUM LTR NSR TYPE OF INSURANCE POLICYNUMBER DATE MM/OD DATE(MIlli LIMITS ...,.......: .. ..e,l ..B ,. ..-1 :, �,..r.,. .. ,I. ,..7.':=.:��, - i�...Q� ;dh �:?��WS,•i, VWC! n " r� A X COMMERCUIL GENERAL LVABILI7Y, P.ftBNIS£$ E9•occufe»CB) ,,.$! IU- QO., r .I 7: d_• "Y „ , 10 03 08 10 "031 O 9 PERSONAL&Al INJURY $100000 J' r' , ,I.�gn,•1! 1, _ - .. T .0 S�E`R. �.. ^ :.'., : '<.,ri.' ;PRObt9 ,.IOMPid^•pt9ti:: '2',: k0 CY, I dOTOMABLLEIABIL'CbY ,,, 01: :i'. .i ... , , j.j I I Cbl1'IBl `�Ihl AU P. p yq f: C ;1: �eadtr-' CI 1 INJ II:> O.4W. OS• W H A „t. !ilN h k. �y f � J } �(: :I•. . . '�.,..e... . ...:.. ::... „ J } I ry ,..,..:, .:,.re,r.,,.r .. :a6.,..:,,;.:�;:::,.1,. ';ir riji' 8..: 'r:i•: ;�:J,,.; O��i^��A cc:w E: $� t.r , i -v 71 r Acro L y I. AqG . �7.. ... .-! r r.,. �d�. .. .._..._:� .. ..:- ;Ira:: ..:.: .. .. ,,, ,. J.I.; ,,. s h.> .,.<.A �..:.. ..;. ,1... •,i,..:.. . ......... „ OCCUR-- ..,.,.-.. 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I -I- DESCRIPTION OF Ol"V I ATIONS'I LOCATIONS I VEHICLES i P,XCLUSIONS ADDED BY ENDORSEMENT/.SPECIAL PROVISIONS CERTIFICATE MOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL FIJDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT•.BUT FA 11l TO DO SO SHALL STEPHEN SPANOS 118 MEADOWtTIft ROAD IMPOSE NO OIRLIGA17ON OR LIABILITY OF ANY KIND UPON THE INSURER,rTSAGENTS OR NORTH ANDOVER:MA 01845 REPRESENTATIVES. KOH INSURANCE AGENCY,INC:' AUTHORIZED REPRESENTATIVE John 'J. Walsh Ins. /1✓'� ACO RD 25(2001108) ®.ACORD wisiftMOON 1888 : i {= Board of Building Regulamons and tandar s One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration RegtStrat,or, 100654 TVDe (no)v,dual IRA G. MALKIN Exotration 6/22/2010 Tra 26787, Ira Malkin 180 Dayton St Danvers, MA 01923 Lpdate.Address and return card. dark reason for change. Address Rene-Aal Emplo%ment Lost Card .-.�"\ ��ie warn m•o-y�c��� a � Board of Building €i Reatlla ons and Standards One Ashburton Place - Room 1301 Boston. \lassachusetts 02108 Construction Supervisor License License CS 20014 Restrcuon 00 B r"cate 7. 955 Exarahon 7;2.!2GOS Trp !R;: G MALKIN 180 'DAYTON ST DANVERS, MA 01923 t pdate Address and return card.%lark;cason for change. Address Rene-al Lost Board of Building Regulations and Standards Construction Supervisor License License: CS 20014 Birthdate: 7131,/1955 Expiration: 7/31/2009 Tro .5631 «\g9 Restriction: 00 I IRA G MALKIN 180 DAYTON ST i DANVERS.MAOtgp3 Commissioner The Commonwealth oJ-Massachusetts Department of Industrial Accidents Office of Investigations . 600 Washington Street Boston, MA 02111 G�M SYe,, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Mk k(h JSONS _72?A AWLAN 0- M, Address: 180 D69 M 5T City/State/Zip: Phone #: I ?� — 7 7 q- 63" Q Are you an employer? Check the appropriate box: Type of project(required): 1.P'I am a employer © 4. Elam 6 I a general contractor and 1 with� E] New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 L Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp.insurance required.] `Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such (Contractors that check this box must attached an additional sheet showing the name of the sub-contracton and their workers'comp.policy infor rnation. I am an employer that is providing workers'compensation insurance for my employees. Below is the.policy and job site information. Insurance Company Name: Tk (/etef S Policy#or Self-ins. Lic. #: -7 {- JV6 - ao 1 X ! 6 S' "08Expiration Date: Job Site Address: /�8 rev U �`Z� 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/Mone-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. I do hereby ce,6 under l:ea' s and penalties of perjury that the information provided above is true and correct- Sip= orrect Si afar Date: / Phone#: ?7R- 77q- 6 3 M Oficial 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): I.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: