HomeMy WebLinkAboutBuilding Permit #762-2016 - 120 OSGOOD STREET 12/20/2015 PH 6 N,,,J 1.Lr NORTH BUILDING PERMIT of ED 'q tt e do P1A'J 6CAr Je4 TOWN OF NORTH ANDOVER ''- O APPLICATION FOR PLAN EXAMINATION ' IL Permit No#: l�Z 7Z Date Received �S " ���� SgACHllSfc Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Print _ PROPERTY OWNER ,C', S"r-f.a�D n Print 100 Year Structure yes MAP PARCEL: ZONING DISTRICT: Historic District Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building F�One family ij>Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District %Water/Sewer DESCRIPTION OF WORK TO tE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: �-z- Phone: -.,C VO?, -311-3 Address: u�b 0.3a "Ot- 5v J-�-_#_fi Contractor Name:` 1—,ntn Phone: Address: . t r-- s�t�►.- -r Supervisor's Construction License: 0 T1 t Exp. Date: L "_.en Home Improvement License: Lib t"�,l Exp. Date: ARCHITECT/ENGINEER �-4� Phone: Address: LC% 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: $ t-3 , glJ J FEE: $ 5-9-�* - J D Check No.: Z6 Receipt No.: � 0` 0 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor 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 PLANNING & DEVELOPMENT Reviewed On2�— Signature_ OMMENTS ! u P(WAhIJ6 - 6� CONSERVATION Reviewed on )1-5 Si nature1-4 VU COMMENTS (OO ` 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 Osgood_ Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS u Dimension I 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.$10041000 fine NOTES and DATA— (For department use) 1,bll 5- \3 ❑ Notified for pickup Call Email 3 Date Time Contact Name Doc.Building Permit Revised 2014 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 o Workers Comp Affidavit ❑ 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 Li Building Permit Application o Certified Surveyed Plot Plan Li Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application ❑ Certified Proposed Plot Plan ❑ 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 Doe:Building Permit Revised 2014 Location No. --? lc 2 Date . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ "- Foundation Permit Fee $ Other Permit Fee $ i TOTAL $ Check# ' f`` L ,; 4) Building Inspector LAWRENCE H.OGDEN,P.E. I"EAST NUIN STREET GEORGETOWN, MA 01833 978-352-8318 fax 978 352-2858 cell: 978-502-5921 March 5, 2016 Mr. Kevin Murphy 169 Boxford Street North Andover, Ma. 01.845 RE: Fredo Residence 120 Osgood St.North Andover Dear Mr. Murphy As you requested I conducted a site visit 3/3/16 to review the installation of the Engineered Materials consisting of LVI.s, beams utilized in the framing of the above project. The I,vls are shown on plans prepared Mr. Stephen Foster dated 12/3/15 with the framing plans sheets certified by me 2/12/16. 1 can certiA,that to the best of my knowledge the LVLs members and associated details utilized in the framing as shown on the drawings are installed properly and meet the loading conditions of the 8th Edition of the Massachusetts State Building Code for 1&2 Family Residences. This certification is based on what I could visibly see at the time of this visit when the framing was complete. The purpose of this site visit was to form an opinion and comfort level that the construction appears to be constructed in compliance with the drawings. This certification should not be construed as a thorough detailed inspection of the construction and framing. Nothing in this certification relieves the Licensed Construction Supervisor and or the permit holder of the responsibility for construction of this project per Section l 10.R5.2, and sub section I IO.R5.2.15 or of the Massachusetts Residential Code 780 CMR 51, or the proper execution of the details and framing requirements of the drawings, including but not limited to materials,blocking,manufacturers installation requirements and nailing schedules or other requirements of the code. Should you have any questions please do not hesitate to call. Yours truly, I V of 4j,La ence H. Ogden P.E. Structural 27765 'oma Lu,R84a HAROLD OGDHN {� Lao *$Coco QT H 3` 27765 Q LAWRENCE H. OGDEN,P.E. 198 EAST MAIN STREET GEORGETOWN,MA 01833 978-352-8318 fax 978—352-2858 cell:978-502-5921 March 5, 2016 Mr. Kevin Murphy rp y 169 Boxford Street North Andover,Ma. 01845 RE: Fredo Residence 120 Osgood St.North Andover Dear Mr. Murphy As you requested I conducted a site visit 3/3/16 to review the installation of the Engineered Materials consisting of LVLs, beams utilized in the framing of the above project. The Lvls are shown on plans prepared Mr. Stephen Foster dated 12/3/15 with the framing plans sheets certified by me 2/12/16. I i can certify rt fy that to the best of my knowledge the LVLs members and associated details utilized in the framing as shown on the drawings are installed properly and meet the loading conditions of the 8th Edition of the Massachusetts State Building Code for 1&2 Family Residences. This certification is based on what I could visiblythe time see at me of this visit when the framing was complete. The purpose of this site visit was to form an opinion and comfort level that the construction appears to be constructed in compliance with the drawings. This certification should not be construed as a thorough detailed inspection of the construction and framing. Nothing in this certification relieves the Licensed Construction Supervisor and or the permit holder of the responsibility for construction of this project per Section l l O.R5.2, and sub section 11.O.R5.2.1.5 or of the Massachusetts Residential Code 780 CMR 51, or the proper execution of the details and framing requirements of the drawings, including but not limited to materials,blocking,manufacturers installation requirements and nailing schedules or other requirements of the code. Should you have any questions please do not hesitate to call. Yours truly, VI OF La enc e H. Ogden P.E. Structural 27765 //'�� IA MNcZ��yG I NANOID OGDEN P l lio esce� �f A � 27765 0 LAWRENCE H.OGDEN,P.E. 198 EAST MAIN STREET GEORGETOWN,MA 01833 978-352-8318 fax 978,-352-2858 cell:978-502-5921 March 5,2416 Mr. Kevin Murphy 169 Boxford Street North Andover,Ma. 01845 RE: Fredo Residence 120 Osgood St.North Andover Dear Mr. Murphy As you requested I conducted a site visit 3/3/16 to review the installation of the Engineered Materials consisting of LVLs, beams utilized in the framing of the above project. The Lvls are shown on plans prepared Mr. Stephen Foster dated 12/3/15 with the framing plans sheets certified by me 2/12/16. I can certify that to the best of my knowledge the LVLs members and associated details utilized in the framing as shown on the drawings are installed properly and meet the loading conditions of the 8th Edition of the Massachusetts State Building Code for 1&2 Family Residences. This certification is based on what I could visibly see at the time of this visit when the framing was complete. The purpose of this site visit was to form an opinion and comfort level that the construction appears to be constructed in compliance with the drawings. This certification should not be construed as a thorough detailed inspection of the construction and framing. Nothing in this certification relieves the Licensed Construction Supervisor and or the permit holder of the responsibility for construction of this project per Section 110.R5.2,and sub section 110.R5.2.15 or of the Massachusetts Residential Code 780 CMR 51,or the proper execution of the details and framing requirements of the drawings,including but not limited to materials, blocking,manufacturers installation requirements and nailing schedules or other requirements of the code. Should you have any questions please do not hesitate to call. Yours truly, 'A OF La ence H. Ogden P.E. Structural 27765 0� u CE��yG w�xOLD N OGDM FO U j20 *S6690 b ST H `A 2M5 V NORTH wn �. . . ver o No. - a � h ver, Mass, O� O LAKE 1 COCNtC//l WIC11 �as RArEO rPp��S U BOARD OF HEALTH Food/Kitchen PERMIT D Septic System THIS CERTIFIES THAT ..........� ..�'s........... .... .. .... BUILDING INSPECTOR ..... .. N1,14 ALI Foundation has permission to erect . .. .................. buildings on ... �I ...... ... . ...... .... ....... Rough to be occupied as .. .. .. '[. ,`.. ... . ............. .. .. .......�. .....�.... 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 Inspecti , Alte ation 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 CONSTRUCTION STARTS Rough .................... Service ..................... .....� Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildin-e 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. • 98 Forest Street Revzon Mumphy • North Andover,MA 01845 PH:978-M-5335 Building Contractor FAX:978.6887207 Proposal To: Scot&Kristen Fredo 120 Osgood Street All Hare 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,MA021o6.(617}7271598 CC: Date: 12/19/2015 Job: Master bedroom addition/bath remodels Date of planes 12/15 Architect: Steve Foster Location: Same Section I-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 1/15/16. Barring Delay caused by circumstances beyond Contactors control,the work will be completed by 6/29/16.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 II—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. Page 1 of 5 Kevin Murphy Page 2 of 5 Building Contractor 98 Forest street North Mdover,MA 01845 PH:978.68853 FAX 978£68.7207 Section 111-Scope of Work General Proposal is to add 24'x24 master bedroom/bath,and renovate two existing bathrooms. Building plans,structural engineering,and plot plan to be provided by owner. Building permit will be obtained by contractor. No allowances have been made to obtain any variances, conservation,or historical society approvals Excavating Excavation required to install full basement area will be provided. Any additional fill will be removed from site. Backfilling and rough grading will be provided. No allowance has been made for removal of ledge, relocation of underground utilities, lawn sprinklers, landscaping,or lawn repairs. Foundation Poured concrete foundation,for full basement area,will be provided as shown on plans. Footings will be 10x20", walls will be 10"thick, grade to match existing. Four inch thick concrete floor will be poured over crushed stone base. Interior perimeter drain will be installed under floor. Concrete cutting will be performed to gain access to new basement area. Opening will be approximately 42"wide. Building All frame, roof, and siding materials will be provided to match existing/meet code/as shown on plans. Floor joists will be 2x10, exterior walls will be 2x6, roof rafters will be 2x10. All floor, wall, and roof sheathing will be fir plywood(3/4 on floor, 1/2 on walls, 5/8 on roof) . Roof shingles to match existing. Ice and water sheild will be installed at all roof edges and valleys. Exterior walls will be wrapped with Tyvek or equivalent. Cedar siding to match existing. Comer boards and window trim will be Azek. Harvey windows will be supplied and installed as shown on plans/to match existing. Interior petitions will be 2x4. Plumbing Plumbing required to add four fixture master bath,and renovate two existing baths will be provided.A second sink will be added in existing main bathroom. Electrical Electrical work required to wire addition and bathrooms to code will be provided. Panasonic fan/lights will be supplied and installed in each bathroom. Ten recessed lights have been included. Surface mounted fixtures( wall sconces, ceiling fans) to be supplied by owner/installed by contractor. General layout to be approved by owner prior to rough. No allowance has been made to upgrade existing electrical service. Phone / cable / computer lines to be roughed in by electrician,to be connected by service provider,at owner's expense. Any high def TV wiring,or surround sound to be done by others. Electrical line to pool will be relocated as required. Heating/Air Conditioning A separate zone of forced hot water heating will be added in new master bedroom/bath area. Heat in existing baths to remain. New heat enclosures will be supplied and installed in bathrooms. Condensor for central air will be relocated. Central air conditioning will be provided in new master bedroom. Insulation Kevan Murphy Page 3 of 5 Sundin J Contr=ftw 98 Forest SbW N0M Andover.MA 01845 PH:9788885M FAX 978588.7207 Addition and bathrooms will have fiberglass insulation installed to code. Plaster Addition and bathrooms will be blueboarded and skim coat plastered. Walls will be smooth, ceilings to match existing. Interior Trim/Doors Pre-primed interior trim and doors will be supplied and installed to match existing. Painting All interior and exterior painting will be provided. One coat of primer, and two coats of finish will be applied to all painted surfaces. Flooring Hardwood floors will be supplied, installed, and finished in master bedroom. Three coats of oil based urethane will be applied. Tile floors will be provided in all three bathrooms. Walls around tub in main bath, and entire shower in master bath,will be tiled.An allowance of$6 per square foot has been included for tile materials. Waste Removal All demolition/construction debris will be disposed of by contractor. Demolition Two existing bathrooms will be completely gutted. Other Allowances An allowance of$1500 has been included to supply and install shower door in master bath. No allowance has been made for glass tub enclosure in main bath. An allowance of$1500 has been included to supply vanity/counter in master bath.Vanities/counters for existing baths,to be provided by owner. An allowance of$2000 has been included for plumbing fixtures in master bath. Plumbing fixtures in existing baths to be provided by owner. Items Not Included There have been no allowances made for any built in units/custom cabinetry. i . . 14 Erevan Murplzy Page 5 of 5 Building Coubuctoar 98 Forest Street North Andover,MA 01845 PH:9785685335 FAX:978,6W7407 Section IV-Price Schedule We hereby propose to fumish material and labor—complete in Accordance with above specifications for the sum of ............... ......................$ 133,000 Payment to be made as follows: Percents e/ltem Description Amount 1 Permit obtained / Deposit $3000 2 Foundation poured $15,000 3 Roof frame complete $20,000 4 Siding /windows installed $15,000 5 Rough plumbing /electric complete $15,000 6 Plaster in addition complete $10,000 7 Trim /the in addition complete $15,000 8 Addition complete $10,000 9 Tile complete in two existing baths $18,000 10 1 Job 100% complete 1 $12,000.00 Total 10 $133,000.00 '*Notice:No agreement for Home improvement conbaclirg work shall require a down payment(advance deposit)of more that oneahird ofthe total contract price of the total amount of all deposits or payments which the contractor must make,in advance,to order andlor dAxn-ise obtain delivery of special order materials and equipment,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 Signature �'U Date i -__-_ _- -------------------------- ----- FREDO RESIDENCE I I - - - - ► - - - -1 1111 720 080000 STREET 7 III NORTH ANDOVER, MA I I .117 I I POUNED CONCRETE TE IOOTNO 111 i 11 FILLED BDTAEECLMMU M I I I II P61SlR6tRXOMTiON01MN ( L.1 J • I i MMM4aTt�oc w 11 -!I I 4X4iVMWM1 111 I WJPPM Pam 1 1 r 11 1 Isaaaaaa� aaaaaa� Iii FOUNDATION PLAN L J If i IPWWJOO AMM �� RWVOEIeWSAeealr A0�OP611is. W.P.LOM M oanuo To RM MK wATrssRooPo+asPxArrr ATMOSTOIMMPOU DM IM ornorn E TO 16T RAO 1 �I/I.IOI FREDO RESIDENCE 120 OSGOW B REEr NORTH ANDOVER, MA cusm i1 ASTER DROOM QNwwr uvp=m4 II oast vvvcm '""'Z .wn.... OMT Lmopcom I I I x w� ANffY sci+ m OSH<ADTRMKI I EXHAUlYr FIRST FLOOR PLAN �,,,�T� I �v �IIfN DOOR• I o"°'�Rwiorw I aI I wFWDUCTED TOEXTER R A'" 3� id W4 awe s OWNt WOMOOLMI BA rH 9 CUEfOM7�Ed1lE wATMOM seeR 10MV. s1mm Ct.. r V eLDo DR gataw am BATH KITCHEN BEDROOM ® eEDRooM c� HALL ®� a. t GARAGE eEDRooM LMNO ROOM DINING ROOM RasevENr :p ersler RDOPaHEATINo MATCH EWFM ROOF PITCH 2 XSAT 1a'O.O. ASPHALTS ROMMI. MATCH OOaTNO RAPTERTOTOPPLATE FRAMM)OONa3CIOR 2XMT1s'O.R COIANIIONSDOL LETOPPLATE TYPICAL EAVES DETAIL:lam'( HEADER2-2X10TYPOAL PAWK11,SCFFUTOMATCH E70SISp ppp�� \ RAS NMaAT10N rSONSW-1 Tm O mm DSQIND OAMdi aM'TiOPLYWOOD. IXSSTRAPPM K#L&GMTO MALOWWRAP 21P SHEIOFIq SYSINI PERMETER IIEWOH.OISP 20 SlILATION 2NO FO RGLAS SEUATON AT VAPORSMRaBI In"!!! 16T FLOOR O9AERSPAtl am + EV TVPMLMLUUAL• (MATCH EXISTING ELEVATO ANUNMBMIVAU= r— MLampowliaLmm / 2XSATWOA S-2x10 oa�asx�Tw LL t! it aaanNl011sAasOMAM surmcONCRE7Emm e 2aeRraAR FNEHORADE. i nEELPIPE OMA1N d' lWasm. atAPE TO ortASL r CONCRE76 YYA7�00/SlD6Ys1EY THOKim OONCRETBa" pM0{ 1O=ONOREM i FOOTNSi FCLfOIOXN FINISH EASEMENT FLOOR `4 + (MATCH EXISTING ELEVATION) t PERSIIER POISOATON MV&t ———— S,CRiblM STOW 'C OUL PCMORATIIII)PYO PIPE SWORJM®STORK FLTERPAEVAPOR BARRIERaO'INtN► DECIWLOE TOAPPROY®1AW POND r sow PMC ausm A7904 V".ADEOIIATE soL sEARNo ONMOIN TYPICAL CROSS SECTION A-A FREDO RESIDENCE 120 OSGOOD STREET NORTH ANDOVER, MA 8GLLE1M-1'P MlE 1]M6 RooEVENT zParaleA Noor OHEM44 lam RsAY MATCHE)O MBOOPPI CH 2XSATla'QC. 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MLOMTOORAK .i t WATEWROOPNOEYUM t wsmxirm*L i CONCReIe rTNXaccnNlslaTEaw PounmooNcaere Poo7ayaa POUDATIaN FINISH GA6EMENT FLOOR FLOOR + (MATCH EXISTING ELEVATION) N'l PCiaEIlRPOUOATIONCRAE! — — —— awCRUMMOa7C! — — —— s`oY►PEIVOM7W PMC PPE CAP CRUaIr®aRxas VAPOR EAINNIN FILTER PASM'IYRAP• DUMIAINETOAPPROWW WW POM• aoID PMC aU!IMII ATS O.Q V".ADEQUA E sOL MNu/0 CAPACITY TYPICAL CROSS SECTION B-B FREDO RESIDENCE 120 OSGOOD STREET NORTH ANDOVER, MA r.v1M•1'V MlE 1LY16 E108TIN0 JPIROPOSM � WloOWli(� W X l r SHOWK TO MA EXWM i� MKftT8HWMW.M WTgI E98IN0 ♦ ♦ Tqf E>O�IpD wase mm FINISH IST FLOOR Liu— M10NBAl9BRlIISFI YMTH MRDOW AYWB FINISH OASEMEN'T FLOOR — + RIGHT ELEVATION FREDO RESIDENCE 120 OSGOOD STREET NORTH ANDOVER. MA OuenNo J PRo�o nooevert I DA WIDOWS(4) mw►TCHoanra riN�eM ger r�ooR M"SPANAW MIN WM WNOOW HOVE TINT! SA86MEtE FLOOR I - - - - - - - - - - - - - LEFT ELEVATION FREDO RESIDENCE 120 OSGOOD STREET NORTH ANDOVER, MW TERM AT VAU.ETO(1YPr-W RbOE dfJIM 3-2X4PONHEADSt 1/ FEM IELUI 11 � i� 11 1 1 �� II II 11 1 11 II EX161N0 BATT 2-4X4P06T0 I I II A WAKWEMBIM 4 + I FLIM OWMENT FLOOR _ _- L - J Peuc>tetort�w REAR ELEVATION FREDO RESIDENCE 120 OSGOOD STREET momm ANDOVER, MA The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 kvwww.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Elects icians/Plumbers. TO BE FILED WITH THE PERNT UTTING AUTHORITY. Annlicant Information Please Print Legibly Nate(Business/Organization/Individual): �`. Address: �� ry�,,-, S�.�,,,►. City/State/Zip: wt. ylraLm Phone#: b p�-S-7 35 Are you an employer?Cheelt the appropriate box: Type of project(required): l.[b am a employer with�_employces(full and/or part time).k 7. E]New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required]t 10'4 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 1 LE]Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. Roof repairs These sub-contractors have employees and have workers'comp.insumnce.i 6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.lNo workers'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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employe:•t/rat is providing ipor/vers'compensation insurance for rrzy employees. Below is the policy and job site information. /� Insurance Company Name: 1,���. .A r C, Policy#or Self-ins.Lic. 63 3 Expiration Date: kA3,o / Job Site Address: �.`a.-J C/1�=,v 1't�..�..:�1 City/State/Zip: �./� �.J-.r._. f,,�,� G i 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido he y certify under the pains and penalties of perjury that the information provided above is trite and corract. Sisnatur • Date: Phone#: L - 7 Official use only. Do not sprite in t ' ea,to be completed by city or tory:official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector• 6.Other Contact Person: Phone#: IDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE Fi;71';112015 THIS CERTIFICATEIS ISSUED ASA MATTER OF INFORMATIONONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATEHOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELYAMEND, 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 REPRESENTATWWR PRODUCER,AND THE CERTIFICATEHOLDER. IMPORTANT:N the cerdficateholder is an ADDITIONALINSURED,the policy(ies)must be endorsed.N SUBROGATIOMS WAIVED,subject to the terms andcondiNonsofthe poliryyrfain policleenayrequlreenendorsement A staterntntan this certificatedoesnot conferrights to the certificatsholder in lieu of such endamement(s). PRODUCER CONETACT Sandi Munroe NAM M P ROBERTS INS AGCY INC PHONE FAX AIC,Ne,Ert: (978)683-8073 , N� , (978)683-3147 1060 Osgood Street SIL ADDRESS: sandi@mprobertsinsurance.com North Andover, MA 01845 INSURER(S)AFFORDING COVERAGE NAIL# INSURERA: MERCHANTS INSURANCE INSURED KEVIN MURPHY BUILDING & REMODELING INSURER B: GUARD INSURANCE 98 FOREST STREET INSURERC: NORTH ANDOVER, MA 01845 INSURERD: INSURER E INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, D(CLUSIONSANDCONDITTONS OF SUCH POLICIES LIMITS SHOWN MAY HAVEBEEN REDUCED BYPAID CLAIMS. a wa POLICY EFF POLICY EXP TYPE OFINSURANCE POLICY NUMBER LIMITS X COMMERCUILGENERAL LIABILITY EACH OCCURRENCE $ 1 000,000 DAMAGE TO RENTED CWMSMADE M OCCUR PREMISES Ea oamnence $ 500,000 MEDEXP(Anyonepa� ) $ 15,000 A BOP1068945 1/22/15 1/22/16 PERSONALE ADV INJURY $ INCLUDED GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JEcr Loc PRODUCTS-COMPMPAGG S 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1000,000 E.eWdent / ANYAUTO BODILYINJURY(Perpers ) $ ALL OWNED SCHEDULED MCA7013608 1/23/15 1/23/16 BODILY INJURY(Per acddeM) $ A Auros X AUTOS NONOWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS er acdderd E UMBRELLA LIAR occl>R EACH OCCURRENCE $ 1,000,000 A EXCESS UAB CLAIMSMADE AGGREGATE $ 1,000,000 CUP9145304 1/22/15 1/22/16 DED I I RETENTION $ $ ORKERS COMPENSATION X I PERT DTH• STALITE ER AND EMPLOYERS'LIABILfry � YIN 500 000 �OP1U�O��r'"r�w'r'r �NIA E.L EACH ACCIDENT $ / B °`w�"„� �,�aaa°' N KEWC633734 7/01/15 7/01/16 (Mandatoryn NN) L.E. EMPLOYEE $ 500,000 If �•d�"nd� 500 000 DESCRIPTION OFOPERATIONS bet= EJ-DISEASE-POUCY LIMIT $ / DESCRIPTION OFOPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additlmal Remaft SdvdUe,may beanatlmd H mue space is repimed) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF NORTH ANDOVER THE EXPIRATION DATE THEREOF, NOME WLL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER MA 01845 AUD40RiZED REPRESENTA VE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD25(2014/01) The ACORD name and logo are registered marks of ACORD ! I Pomcff r----_ - - --_ - - - - - - �,I FREDO RESIDENCE F— — — — — I I — — — —1 I I In COMM STREET 7 i i i I law i" 11 I I 30'X30•X 12. 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