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Home My WebLink AboutBuilding Permit #970-2016 - 119 AUTRAN AVENUE 3/15/2016 BUILDING PERMIT o*taORTFi t%OR TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 7D y C, O Permit No#: �O� Date Received '��ORATEO�TP��S VS US Date Issued: 1 ORTANT: Applicant must complete all items on this page LOCATION -t"r Ig a n " - Pr"int PROPERTY OWNERo Print 100 Year Structure yes no MAP f 1 PARCEL: ZONING DISTRICT:_ Historic District yes no Machine Shop Village yes _ _no _ _ _ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition E4-,Two or more family ❑ Industrial ❑Alteration No. of units: - ❑ Commercial P-Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District El Water/Sewer DESCRIPTION � WORK TO BE PERFORMED: /V-( iry i Y '� `� r >ti I�� t -e io f- I.�t/}f,r► rvc� /X/Pki b �► �-�-� w Cl l.0-i'd f�/moi° 1� )7-e 4,0,j Identification- Please Type or Print Clearly OWNER: Name: Phone: 979 3b0 q7),5 Address: Contractor Name: m i Phone: It -- Q Email: cr r. 1 . - Address: t J c Supervisor's Construction License: -AQ9£ Exp. Date:_/ �_ z G, -7 _ 7Home Improvement License: . ARCHITECT/ENGINEER Z- I10-c vt -ekq v-C r Phone: 9-7 & 1 'Zl - ( .2019 3 Address: 5- 'pir-A "s), -e- GA-P rA�„ , X14 g . Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. y y a a6 Total Project Cost: $ � r1CJ � ' _FEE: $ � w ` rr ,� �i� Check No.: ��Y�� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ignature of Agent/Owner __ Signature of contractor ` Location C' No. Date • - TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ / �- Check# 6-3 % BBu(ding Inspector _J I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL { Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools f] Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dw-npster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ I i COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes (Planning Board Decision: Comments p Conservation Decision: Comments ,g Water& Sewer Connection/Signature& Date Driveway Permit _ LDPW Town Engineer: Signature: FIRE DEPARTME, IrT Ternp Dump$'ter on�site� Located 384 Osgood Street yes _ iocatetldat�124 s-- = l70 + MainaStreet - �— Fire Department signature/,'ate i + CbMMENTS; r — L Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: i I ELECTRICAL: Movement of Meter location, mast or service droprequires Electrical Inspector Yes q approval of No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NO NOTES and DATA— (For department use) I I i e ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 ry 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 o 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ 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 Application Permit A lication ❑ 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 L3 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:Building Permit Revised 2014 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 48,;000.00 m $ - $ 576.00 Plumbing Fee $ 72.00 Gas Fee 100 comm. $ 110:0;.0,; Electrical Fee $ 72.00 Total fees collected $ 820.00 119 Autran Avenue 970-2016 on 3/15/2016 Kitchen and Bath Remodel � NORT1-� Town of ndover 16 ' r C h ver, Mass, 0A"_ 2AW IF T O IAK. COC NICK!WICK[ �d AERATED PP�`y�� BOARD OF HEALTH" Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT RC6.174.......Bw. �# MI ., BUILDING INSPECTOR .....' ... n ...... ......................... ..... ..... has permission to erect .......................... buildings on ..1.1.`x. ... .. l Foundation..... ..�r. !......, Rough tobe occupied as ................ ............. ....... .... .... V�.. ........................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO S ART Rough Service .............. .... ... . ....... . . ..:fes........................... 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. Lynch Construction Estimate 243 North Street Salem,MA 01970 Date Estimate# 3/10/2016 256 Name/Address Robert Burkinshaw 119 Autran Avenue North Andover,MA 01845 Project Description Qty Rate Total For the application to apply for a building permit for work described 500.00 500.00 in this estimate.We will apply all documents needed for a building permit,pay fee&pick up permit for work described below in this estimate. For the rental use of a 20 yard container,to be brought to site for 575.00 575.00 construction debris.All construction debris form job will brought to container&removed when full.Container has an overage weight of, 125.00 per ton over,weight will be billed in an invoice.Container has a 30 day limit,additional cost for rental could incur. For removing the ceiling on the first floor in the living room,& 1,425.00 1,425.00 dining room.We will remove all debris to the container.For removing the wall board from the wall,where the fireplace is located,in the first floor.We will remove any wall board,from area's on the second,in the hallway,kitchen where needed,&the room off the kitchen.For removing all wall board from bathroom on second floor,we will remove all debris to the container. For the installation of wall insulation&ceiling insulation on the 3,600.00 3,600.00 first floor,in the kitchen,in the room off the kitchen,in the bathroom,in the small hallway,&in the living room&dining room ceilings only will install R-19 in the walls,& R-30 in the ceilings. For installing any insulation in open walls,where needed on the second floor.All insulation,&labor is included. We thank you for letting us estimate your work. w� �• 3 (� � f � c� Tot � . � . / Page 1 Lynch Construction Estimate 243 North Street Salem, MA 01970 Date Estimate# 3/10/2016 256 Name/Address Robert Burkinshaw 119 Autran Avenue North Andover,MA 01845 Project Description Qty Rate Total For the installation of 5/8 gypsum board on the kitchen ceiling, 8,500.00 8,500.00 living room,ceiling,dining room ceiling,den ceiling,&bathroom ceiling,small closet ceiling,all on the first floor of house.For the installation of 5/8 gypsum wall board on the wall in the den,that abuts the garage.For installation of 1/2 gypsum wall board to the kitchen,den,small hall area,closet off hallway,&the fireplace wall in the living room.for installation of 1/2 green mold resistance board in the bathroom on the first floor.For instillation of green mold resistance board in the bathroom on the second floor.For applying tape on all seams&joints where needed.for applying a skim coat of plaster on all walls,&ceilings listed above.The application will be a smooth finish,on all walls,&ceilings listed above. For installing new wood trim where needed on the first floor on 4,200.00 4,200.00 home.We will install new colonial door frames,new colonial window frames,all new base boards to match existing rooms.We will install a new 6 panel pine door to the linen closet.For installing new wood trim where needed on the second floor of home.We will install new colonial door frames,new colonial window frames,all new base boards to match existing rooms.So basically we will install trim where required,&needed to get house back to original condition.All supplies&new trim,along with the labor is included in this topic. We thank you for letting us estimate your work. Tota Page 2 l Lynch Construction Estimate 243 North Street Salem,MA 01970 Date Estimate# 3/10/2016 256 Name/Address Robert Burkinshaw 119 Autran Avenue North Andover,MA 01845 Project Description Qty Rate Total For the painting of all walls,&ceilings,on the first floor in the 5,500.00 5,500.00 kitchen,den,living room,dining room,bathroom,small hallway,& linen closet.We will apply a primer to all new plastered area's& apply an additional(2)two coats of acrylic latex interior paint,to colors chosen by owner.We will stain any new trim that was installed,to match existing color.For the painting of walls,& ceilings on the second floor in the kitchen,den,bathroom,&small hallway.We will apply a primer coat to all new walls,&ceilings that were plastered,&apply an additional(2)two coats of acrylic latex interior paint,to colors chosen by owner.We will stain any new wood trim that was installed to match the existing color. For the installation of new red oak flooring.We will install new red 8,500.00 8,500.00 oak,in the kitchen,den,&small hallway,on the first floor of home. We will then sand all new flooring,to have ready for urethane.We will sand the living room,&dining room floors.We will apply(3) coats of urethane to all floors mentioned above,owner to pick finish of floors.We will install new red oak,in the kitchen,den,&small hallway,on the second floor of home. For the installation of hardie backer on the floor,in the first floor 1,700.00 1,700.00 bathroom.We will install new ceramic floor tiles,(to be chosen& purchased by owner)to complete floor in the first floor bathroom. We will grout complete floor once tiled,(color of grout to be chosen&purchased by owner.). We thank you for letting us estimate your work. Tot .is'/� Page 3 Lynch Construction Estimate 243 North Street Salem, MA 01970 Date Estimate# 3/10/2016 256 Name/Address Robert Burkinshaw 119 Autran Avenue North Andover,MA 01845 Project Description Qty Rate Total For the plumbing work to be done on the 1 st floor.We rough in 13,500.00 13,500.00 kitchen drain lines,vent lines,&water lines,for a kitchen sink, kitchen dishwasher,line for the refrigerator,gas oven in island.We will rough in bathroom drain line,vent line,&any water lines,for a lav,toilet,&corner shower.We will rough in drain lines,vent lines, &water lines for the 2nd floor kitchen sink,kitchen dishwasher, water line for refrigerator,we will rough in drain lines,vent lines,& water lines,for bathroom,toilet,bathroom vanities,&a bathroom shower enclosure.We will connect heat where as required&install under cabinet heaters,in both kitchens.Owner will supply or purchase all toilets,all vanities&sinks,all faucets,for kitchen& bathrooms,shower enclosures"s,&shower valves,.All other materials&labor are included. Payments to made as follows:5 equal payments of($9,600.00)Nine 0.00 0.00 Thousand Six Hundred Dollars.1 st payment of($9,600.00)Nine Thousand Six Hundred Dollars to start work.2nd payment of ($9,600.00)Nine Thousand Six Hundred Dollars,due after rough plumbing,&insulation has been inspected,&installed.3rd payment of($9,600.00)due after wall board has been hung&plastered& trim work has been installed,4th payment of($9,600.00)Nine Thousand Six Hundred Dollars,due after floors have been installed &coated.5th payment of($9,600.00)Nine Thousand Six Hundred Dollars,due when all work has been completed. We thank you for letting us estimate your work. Total $48,000.00 Page 4 I I A3 A-3 EXIST.12" CONCRETE MALL Q Q - III FAMILY ROOM I�REMOVE EXIST. S BASEMENT BEARIN6 WALL EXISTING 4" PROPOSED LVL U DIA.COLUMN 51ZE TO BE VERIFIED Q BY GC 0- EXIST.(4) III PPIOP05W 2X10 ABOVE A_2 III 4X4 POST ALIGN A-2 PROVIDE NEW WITH POSTS ABOVE 4"DIA COLUMN AND BELOW W/9'X3'F00rIN&, - 1'-0"DEEP ALIGN WITH P05T ABOVE FIREPLACE FIREPLACE T EXI5TIN6 P05T I TO REMAIN BASEMENT 1ST FLOOR SCALE:1/4"=F-0" SCALE:1/4"=Y-0" Zelloe+Weaver FLOOR PLANS ARCHITECTS,LLC JOB#: 16004 59 PARK ST. 119 ADTRAN AVE SCALE: 1/4"=F-0" BEVERLY,MA 01915 North Andover,MA 01845DATE: 02. 22.16A-1 978.921.6309 T 22.16 978.921.6316F DWNBY: MR CROSS REF. ATTIC EXIST.2X8 PROP05M FLUSH FRAMED LVL SIZE TO BE VERIFIED BY G0 I A-3 r FAMILY ROOM 2ND FL00 III EXIST.2X10 I PROPOSED FLUSH FRAMED LVL 51ZE TO BE VERIFIED BY GO REMOVE EXIST. r FAMILY ROOM III BEARING HALL T FAMILY ROOM I� 15T FLOOR PROPOSED LVL EXI5T.2X10 III 1ZE TO BE VERIFIED BY cle, III A_2 EXIST.(4)2X10 PROPOSED 4X4 P05T ALIGN `� BASEMENT WITH P05T BELOA r PROVIDE 36"X 36"X 12" CONCRETE FOOTING FIREPLACE B� EXIST.4"SLAB n2ND FLOOR n TRANSVERSE SECTION SCALE:1/4"=1'-0" 1 SCALE:1/4"=1'-0" Zelloe+Weaver SECTION ARCHITECTS,LLC 119 ADTRAN AVE JOB#: 16004 59 PARK ST. SCALE: 1/4"=1'-0" BEVERLY,MA 01915 North Andover,MA 01845 DATE: 02.22.16 A-2 978.921.6309 T 978.921.6316 F DWN BY: MR CROSS REF. ATTIC PROPOSED FLUSH FRAMED LVL PROPOSED 4"0 COLUMN FAMILY ROOM 2NDY_ PROP05ED FLUSH --•—.— FRAMED LVL PROPOSED 4"0 COLUMN FAMILY ROOM 15T F� EXIST.(4)2X10 BEAM TO REMAIN EXI5TIN6 COLUMN EXI5TIN6 COLUMN PROP05ED 4"0 COLUMN BASEMENT PROVIDE 36"X 56"X 12" g_p 5"_'w g_g CONCRETE FOOTING LONGITUDINAL SECTION SCALE:1/4"=I'-O" Zelloe+Weaver SECTION ARCHITECTS,LLC JOB#: 16004 59 PARK ST, 119 ADTRAN AVE SCALE: 1/4"=F-o" BEVERLY,MA 01915 North Andover,MAO 1845 A-3-Z 978.921.6309 T DATE: 02.22.16 V 978.921.6316 F DWN BY: MR CROSS REF. Residential Property Record Card Parcel ID: 210/045.D-0018-0000.0 MAP: 045.1) BLOCK: 0018 LOT: 0000.0 Parcel Address: 119 ADTRAN AVENUE FY: 2016 PARCEL INFORMATION Use-Code: 104 Sale Price: 135,000 Book: 06998 Road Type: T Inspect Date: 05/09/2015 Owner: Tax Class: T Sale Date: 08/09/2002 Page: 0189 Rd Condition: P Meas Date: 0 510 9/2 01 5 BURKINSHAW,ROBERT Tot Fin Area: 3088 Sale Type: P Cert/Doc: Traffic: M Entrance: X Address: Tot Land Area: 0.310 Sale Valid: A Water: Collect Id: RB 119 AUTRAN AVENUE Sewer: Grantor: BURKINSHAW,GEORGE Sewer: Inspect Reas: R NORTH ANDOVER MA 01845 Exempt-B/L% 0/0 Resid-B/L% 100/100 Comm-B/L% 0/0 Indust-B/L% 0/0 Open Sp-B/L% 0/0 RESIDENCE INFORMATION LAND INFORMATION Style: DX Tot Rooms: 9 Main Fn Area: 2024 Attic: NBHD CODE: 5 NBHD CLASS: 5 ZONE: R4 Story Height: 2.00 Bedrooms: 5 Up Fn Area: 1064 Bsmt Area: 2024 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class Roof: G Full Baths: 2 Add Fn Area: Fn Bsmt Area: 1 P 104 S 13500 0.310 N 177,720 Ext Wall: AV Half Baths: 1 Unfin Area: Bsmt Grade: DETACHED STRUCTURE INFORMATION Masonry Trim: Ext Bath Fix: Tot Fin Area: Foundation: CN Str Unit Mar-1 Msr-2 E-YR-BIt Grade Cond %Good PIF/E/R Cost Class Bath Qual: T RCNLD: 261402 Kitch Qua]: T Eff Yr Built: 1981 PG S 800 1988 A A /50//42 18,600 1 Mkt Adj: Heat Type: HW Ext Kitch: Year Built: 1973 VALUATION INFORMATION Sound Value: FuelType: G Grade: A Cost Bldg: 261,400 Current Total: 457,700 Bldg: 280,000 Land: 177,700 MktLnd: 177,700 Fireplace: 1 Bsmt Gar Cap: 3 Condition: AG Aft Str Val 1: Prior Tota]: 377,900 Bldg: 206,300 Land: 171,600 MktLnd: 171,600 Central AC: N Bsmt Gar SF: 960 Pct Complete: Aft Str Val2: Aft Gar SF: %Good P/F/E/R: /100//79 Porch Type Porch Area Porch Grade Factor P 40 T 100 W 100 Sketch Photo 10700 Sq 0 n 1�� 1 FMI B R) 9M S*k2M4 ��4 R 1064 4 k T 5 5 Ft 22T 10100 SriF10 119 AUTRAN AVENUE The Commonwealth of Massachusetts -.. .F Department of IndustrialAceldents _ 1 Congress Street,Suite 100 _ d02114 2017 Boston,MA. �r www mass.govldia o�M Sy.Vl y0pikexs'Compensation Insurance Affidavit:Builder/Contractors/Electricians/Plumbexs. TO BB FILED WITH THE PERMITT'NG AUTHORTTX. Please Paint Le 'bI' A licantlnformation P'' Name(Business1(3& ization/1'ndividual): / C.`'1 Address: / City/State/Zip: •S t�/-c [iv► Are you an employer?Check#Le appropriatebox: Type of project(7requixed); ern to ees frill and/or part-time). 7. ❑Nevi construction. 1.❑I am a employerwitb. '• P y ( 2.�azn a sole proprietor or partnership and have no employees working for me in 8. UIXemo deliAg any capacity.tNoworkers'comp.insurance required.] 9. ❑Demolition 3.E]1 am a homeowner doing all work myself[No workers'comp.insurance required]' 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 11.[]Electrigal'repairs or additions ensure that all contractors either have workers'compensation insurance or are sole '_ �:.�. � , 12.��'pj n.Mg repairs'or additions proprietors withno,eanpldyees. 5.❑I am a general contraetor and I have hired the sub-contractors listed onthe,attached sheet. 110 Roof repairs These sub-contractors have employees and have workers'comp.insuzancet 14 Other 6•❑We are a corporation and its,officers have exercised their right of exemption per MGL c. have 152,§1(4),and y�e �iib employees:[No workers'comp.insurance required.] *Any applicant that chdcks box#li must also fill out the section below showing their workers'compensation policy information: i Homeowners who submit,this affidavit indicating they are doing all work andthen hire outside contractors must submit a new affidavit indicating such. Contractors that checkthis*box must attached'an additional sheet showing the name of the sub-contractors and state whether or not(hose entitigs have employees. Ifthe 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. j Insurance Company Name: I Policy#or Self-ins.Lie.#: !c`o 6 a 2-J `'t 5 Z Expiration Date: y �a n t llCity/State/Zip: A), A✓lCJS u-C-e ,-4 l� Oi Vt L(� Job Site Address: ;Tv-r rrv� G_�v�in`�� Attach a copy of the v' rkers'compensation policy declaration page(showing the policy number and expiratitoxr date). ed under MGL e.152, Failure to secure coverage as requirthe f m of aaSSTOP WORK ORDER and a fine of up to $2500.00 0-00 a and/or one-yeax imprisonment,as well as civil penalties m be forwarded to the Office of Iuvestigations of the DIA for insurance day against the violator.A copy of this statement may coverage verification. I do hereby certify under thepains and penalties of perjury tliat the information provided above is true and correct: p(' Date:_-3/& 6' Phone#: Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): Lrl.Bo�ardoflfealth 2.Building Departmtent 3.City/Town Clerk 4.ElectricalInspector 5.Plumbing Inspector on• Phone#• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their enlpfoy es. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of ft express or implied,oral or written." An employer is d'eflned as"an individual;partnership,association,corporation or other legal entity,or any two or more ofthe foregoing d in a joint ente rise and including g g en a eg g J rp the legal representatives of a deceased employer,or the receivet'dttrustee of an individual,partnership,association or other legal entity,employing emplbyees..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 who employs persons to do maintenance,construction 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�Lias not produced-acceptable evidence of compliance with the insurance coverage ieequked." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter intp any contact for the performance of public work until acceptable evidence of compliance with the insurance r 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),address(es)and phone numbers)along with their certificates)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 anLLC 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 Accidenis. Should you have any questions regarding the law or if you are required to obtain a workers' compensatiori.'policy,please call the Department at the number listed below. S elf-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(ifnecessary)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 proofthat a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license orpermit 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MA.SSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia CERTIFICATE OF LIABILITY INSURANCE °A�2ffi""°°'""" 103/10/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF WFORNWTION 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), AUTHOR® REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. 1 ANT: If the certificate holder is an ADDITIONAL INSURED, the ) must be endorsed. If SURROGATION 19 WAIVED, subject to the terms and cond-rtions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s� PRODUCER NAME Rchard P Bertolino Jr Insurance Agency PHONE (978) 423 - 8995 �k(976) 531 - 0718 MMr 1200 Salem St Unit 121 154MIL Lynnfield, Ma 01940 NSUREt(S)AFFORDNGCOVERAGE NAICS NSTIMA:Western World INSURED eauitwe:AIM Mutual � Lynch Construction Nsuu3tc: Attn Bill Lynch NSURERD: { 243 North St NsuaelE: i Salem Mass 01970 978-808-6045 NSRERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS i 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. LTR TYPE OF INSURANCE RM WVD POLICY NId+BER (MD MDWYYY) (MMfODM M LVAITS A G NERALuwU Y TBA 01/18/201 01/18/2017 EACH OCCURRENCE $ 1,000,000 UPJAAUh $ 100,000 rGERL MEtCVit GENERAL LIABILITY PREMISES(Ea ooarrenx)CLAIMSAMDE ®OCCUR MEDE(P(Nryonepersm) $ 5,000 PERSONAL B.ADV INJURY $ 1,000,000 G'ENERALAGIGREGATE $ 2,000,000 GREGATELIMITAPPLIESPER: PRODUCTS-COMPIOPAGG $ 1,000,000ICYT LOC $ AUTONIOBILE LIABILITY (Ea accident) $ ANYAUTO BODILYINJURY(Perpersm) $ I ALL OWNED SCHEDULED BODILY INJURY(PN accident) $ AUTOS AUTOS NON-OWNED PROPERTYDAMAGE $ HIREDAUTOS P AUTOS (PeracdClert) UMIBRBIALWB OCCUR EACH OCCURRENCE $ EX LUIS BADE AGGREGATE $ DED RETENTION $ $ B WORKE325 CTR- WNPHNSATION vwc 100 6021452 2016 a 02/29/201602 9 TORYUMRS ER ANDBAPLOYERsuABun YIN ANY PROPRIETORIPARRNERIEMCtRNEElNIA EL EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? (rye ayint" E.LDISEASE-EAEMPLOYEE $ 100,000 ff yes'describe under EL DISEASE-POLICY UIMrr Is 500,000 DESCRIPTION OF OPERATIONS bdm DESCR[PnONOFOPERAIIMILOCATIONSIVEHK3ES(AttachACORDIDLAdMonalRemaksSdwdd%ffmorespace isregrired) Seperate, cert has been ordered for holder from Mass Workers Comp Taiting Bureau 119 Autran Ave North Andover CERTIFICATE HOLDER CANCELLATION Toen Of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN I North Andover Mass ACCORDANCE WITH THE POLICY PROVISIONS. AVniONOM REP7� Q198"2 I O ACORD CORPORATION. All rights reserved. ACORD 26(2010!05) The ACORD name and Ingo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Q Boston, Massachusetts 02116 Home Improvement Con r ctor Registration Registration: 127853 �1 Type: Individual Expiration: 1/18/2017 Tr# 263169 WILLIAM E. LYNCH WILLIAM LYNCH 243 NORTH STREET w SALEM, MA 01970 r j Update Address and return card.Mark reason for change. k a� ❑ Address [-] Renewal Employment ❑ Lost Card SCA 1 0 20M-05/11 / �p /�� — JJ / & (DdYhmont!/Pall,o�V!/LtcQ�CLCI7iLIQe�,b Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Uqgistration: :Ti7853 Type: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 piration:->1_%1820;17 Individual Boston,.MA 02116 WILLIAM E.LYNCH`, 'Y= WILLIAM LYNCH 243 NORTH STREET. SALEM, MA 01970 Undersecretary Not valid without gnature Ai Massachusetts -Department of Public Safety Board of Building Regulations and Standards 1.C1�.1LI jll L1111 .`iuj ti"E iiOi .�. f License: CS-098454 SL:r PR WILLIAM E LYNN 243 NORTH STRVET% ° SALEM MA 019'0 z 0 01, Expiration Expiration Commissioner 04/23/2017