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Building Permit #370 - 123 BONNY LANE 11/6/2006
TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIONof"°oT •+ti C A 1- A Permit NO: ate Received Date Issued: . r• ` SS�CMUSE IMPORTANT: Applicant` must complete all items on this page LOCATION A13 L, fVrint PROPERTY OWNER tyPtatV IJ4WSQI Print MAP NO.: �i PARCEL: ZONING DISTRICT: - -3'Y-PE-A-ND-USE OF-BUILDING HISTORIC-D.ISTRICT_YES-0 TYPE OF IMPROVEMENT PROPOSED USE - Residential Non- Residential ❑New Building One family ❑Addition ❑Two or more family ❑ Industrial k'Alteration No. of units: ❑ Repair, replacement ❑ Assessory Bldg ❑Commercial ❑ Demolition ❑ Moving(relocation) ❑Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED lacicf v ; d� 61IL- FIht'A r14 Oven G01bou 19dd t3,47h fx /Aec, /;/?c . Identification Please Type or Print Clearly) OWNER: Name: e,�yZ� 6-,y 1)f4C- S'on/ Phone ?fs- 6pS GC2 I Address: Z Y L,A/ CONTRACTOR Name:_e�wlis -� Phone �7?,F 5.26 S113 Address: 10 2 Entre s1 I- Supervisor's Construction License: 05-ff663 Exp. Date: 6 -< < - o Home Improvement License: l L1-206 Exp. Date: -.20o k ARCHITECT/ENGINEER DGEgN kasIcu b-koS Name: Phone: CI 96n RgII3 Address: ,'73 / 4,s o Uig (Zara-d Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL EST/MATED COST BASED ON$125.00 PER S.F. Total Project Cost :$ e ',3 g� S' FEE:$ % & 0 -7 Check No.:— M Receipt No.: Page 1 of 4 Location No. . V Date �ORTM TOWN OF NORTH ANDOVER 3? . OA y Certificate of Occupancy $ ` s•►c►,USE`�a Building/Frame Permit Fee $ Foundation Permit Fee $. Other Permit Fee TOTAL $ �s Check # 01� N 1 1-: 773 in 9 o Inspector 1 - TYPE OF SEWERAGE DISPOSAL Swimming Pools ❑ Tanning/Massage/Body Art ❑ Public Sewer ❑ Tobacco Sales ❑ Food Packaging/Sales El Well E1❑ Permanent Du pster on-Site � .,,. . Private(septic tank,etc. / Electric Meter location to project i NOTE: Persons contracting ith nre ster d contractors do e cess to the guara fund Signature of Agent/Owne Signature of contractor Plans Submitted ❑ P ns aived ❑ Certified Plot Plan ❑ Stamped Plans THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM i DATE-REJECT-ED-----DATE-APPROVED---------II PLANNING & DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DA f A ROVED HEALTH COMMENTS S FIRE DEPARTMENT - Temp Dumpster on site es i no Fire Department signature/date COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments i Water& Sewer Connection/Signature& Date Driveway Permit ;A ii Building Setback( Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area,based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA— For department use Page 3 of 4 i Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created IMC.Jan.2006 I 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 Addition Or Decks ❑ Building Permit Application ❑ 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) ❑ Mass check Energy Compliance Report (If Applicable) 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 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:OPFORM05 Page 4 of 4 NORTH own o Andover 0 No. .37o LA over, Mass., ��' G COCHICHEWICK Ij, ORATED BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT........ I .........P**4q$#.^............................... Foundation has permission to erect........................................ buildings on.14111 V......811114...A... . ..... .46w........... Rough f Chimney .Off" & # ......... 04)1.+ .......... . .. .. to be occupied as ............................... * ......... provided that the person accepting this permit shall 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, After nd C tr i 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 C et S UNLESS CONSTRU A Rough ,(....... Service .. .... .. . . ........... ...... BUILDING IN Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. PAW90N 17-d' 12'-4" 19'-7 iz-d' 17-8" 26 OCT.'06 V-2" 15 10 4•-0" 7-11%2" 13'-d' 2'-4" 4'-4" T-6" 4'-d' •-0" 2•-0 3'1131" 3-1134' EXISTING DECK 6'-d' 6'-O' 6'-6" 6 6° TO REMAIN EXTS REMAI NDOW C O EXISTING WINDOW EXISTING SLIDER EXI5TING DOW T REMAIN, TO REMAIN T 'REMAI J t Z< �� EXISrwG o Z Oz o w DOOR >� BATHROOM#2 31 NSC 2X8, 2 Zj n BATHROOM#1 17•_7' � U i N B �O O ! SHOWER_._ -)OU'VANITY SHOER �? x 2 cp N LIGHTED O O I I W/ - / —.O__. \_ _ U 2 / / - �i1CHH1� -2 X 6 - -- - —_ EGRE55 WI NDOWS— -OA If-- J OFFICE , + Irl i _. Q p (D Lu < N fl pEXISTIN G I � HIMNEY N 3'-0" u'' O Q W Cr -- --- �I 4'-4" 4'5" 4'4" 1 6, I N z wl (1) Q flL t Q � CLOSET I w Q w �= 6. 3.. 3' <� I tz iv BEDROOM#2 0 J 2- S<x fl Z U cli 2'-10j2 BEDROOM#3� o m Q = .6.. f 16"GLA55®TOP OF WALL w W_ 1 (0 1 U _ `xgz' I p I� � OL CJI la HALL b. 5'E511-PA 5'81=PAS Q N l 3 ISJING BI-mL XISTING BI-f CLOSET EX15TING CL05ET D W EXISTING CLOSET 1 ,- -J NOTE:BUILT-IN IRONING BOARD CABNEW ACCE55 PANELINET THIS AREA.FRA ACCORDINGME WALL OPENING 2 iv O LY. NOTE:IN5TALL SOUND DEADENING ---- A INSULATION IN ALL PARTITIONS. LLJ .2 4•_8.. 4._8.. O 4'-2" 9'4" 4'-2" U Z 1T-8" W p ZLu SECOND FLOOR PLAN � o �z o Q >- w 0 oz > EXISTING WALLS TO REMAIN F- Z Z O Q Q Q EXI5TING WALLS TO BE REMOVED g Q (J[ NEW WALL5 o d Lj (V � x 6'-7' 7 w ( r 7 FLOOR PLANS I J NOTE:ADD 3-2 X 10 BU LT UP BEAM ON � 3 Yi'LALLY COLS.ON 2 "X 24"X 12"CONIC.FTGS. g �� O WINDOW SCHEDULE :E 0 LOUIS G " CODE 5IZE&TYPE ROUGH OPENING REMARKS b o C J• rn v A CM35-3 ANDERSEN GA5EMENT 7-17/&"X 3'-5 3/8" W/5GREEN5 U RICHARD B 0145 ANDERSEN GA5EMENT 2'-0 5/&"X,4!-5 3/8" W/SCKEEN5 F N0. 11128 _ C � CN255 ANDERSEN CASEMENT 3'-51/4!'X 5'-5 3/8" W/SCREENS u� r D CW155-3 ANDEK5EN CASEMENT T-17/8"X 5'-5 3/8" W/5CREEN5 E C14 P= C14PICTJGASEM'T.COMBO 1d-07/8"XC-0 1/2- W/5CREEN5 3 O F CXWI5-3 ANDERSEN CASEMENT 9'-0 5/8"X 5'-0 3/8" W/5GREENS 0 EXISTING GARAGE FLOOR PLAN Al PAW5ON 26 OCT.'06 NOTE:REMOVE SMALL EXISTING"A"DORMER NEW SHED ROOF CONSTRUCTION: EXTEND GARAGE RAKE AND CONSTRUCT"SHED'DORMER. ° ASPHALT SHINGLES(MATCH EXISTING) OVERHANG ICE AND WATER SHIELD V COX PLYWOOD Ql) 12 2 X 8 RAFTERS®16"O.C. R- W/VAPOR BARRIER \\ 3•75 R-19 W/VAPOR BARRIER F– > PROPER VENT LL 2 X CLG.J5T5.0 1-6OL. NOTE:1'-0"OVERHANG W/VENTED SOFFIT. MATCH EXISTING FASCIA AND TRIM TYPE. 1.O METAL DRIP EDGE. CLG.LINE OFFICE b OFFICE \ NEW WALL CONSTRUCTION: ' Q d) EXTERIOR SIDING(MATCH EXISTING) \ I U TYVEK OR EQUAL BUILDING WRAP 12" COX PLYWOOD 2 X 4 STUDS®16"O.C. z R-13 INSULATION W/4 MIL.POLY VAPOR BARRIER p _ ° GYPSUM BOAKDAND SKIM COAT PLASTER -- —" --------------------- - FLR LINE - Cn = O d) J Lu EXISTING CONDITIONS FROf 05ED MODIFICATION FR0POSED REAR ELEVATION Q Z " @ OFFICE @ OFFICE @ OFFICE & GARAGE a LD C B B 2 .2 W U W NEW SHED ROOF CONSTRUCTION: Z W NOTE:REMOVE SMALL EXISTING R. DORMER ASPHALT SHINGLES Z Z AND CONSTRUCT"SHED'DORMER. (MATCH EXISTING) (n Q ICE AND WATER SHIELD W s/B' COX PLYWOOD 2 RIDGE VENT 2 X 8 RAFTERS®16"O.G. R-30 W/VAPOR BARRIER 12 375 () Q >- W \ \ PROPER EPNTR BARRIER MATCH EXISTING SHINGLES Z Z 2 X 8 CLG.JSTS.its 16 O.G. NOTE:1'-O"OVERHANG W/VENTED SOFFIT. —- TAL-DRIP-E9CE - — Z Z O MATCH EXISTING FASCIA AND TRIM TYPE. CLG.LINEZ METAL DRIP EDGE. > Q Q) Cl \ i VENTED SOFFIT O F Q F C� � b ��� NEW WALL CONSTRUCTION: � i � LL, � N BEDROOM#2 BEDROOM#2 ° EXTERIOR SIDING(MATCH EXISTING) LL Q Z TYVEK OR EQUAL BUILDING WRAP �0 )i' COX PLYWOOD L iv 2 X 4 STUDS®16"O.C. FLR LINE R-13 INSULATION W/4 MIL.POLY VAPOR BARRIER GYPSUM BOARD AND SKIM COAT PLASTER ---------------- --- v SECTION& MATCH EXISTING SIDING ELEVATIONS E - D �O •T y EXISTING CONDITIONS FROF05ED MODIFICATION FROF05ED REAR ELEVATION x �J is M @ BEDROOM #2 0 BEDROOM #2@ BEDROOM #2 Q RiCHARU v►I V J o p No.1112 Q A A CD !. 0 c 2 The Commonwealth of,tilassachuselts Department of Industrial:l ccidents Office of Investigations 600 Washington Street Boston, AM 02111 s 'M ww)v.mass.gov1dia t . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ll3usifie"S'Organiialionilniliviklual):Ckar� S 1'(4'Y �G �er> es �d S ! address: City'Statelip: LY- -GV Ct,1NE-, M4 Phone # ,Are you an employer?Check the appropriate box: Type of project(required): I.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.0,L,I am a sole proprietor or partner- listed on the attached sheet. ' Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp, insurance. y, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10,E] Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.[] 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 111 must also fill out the section below showing their workers'compensation policy information. y I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. Contractors that check this box must attached an additional sheet.showing the name of the sub-contractors and their workers'comp.policy information. I am tin employer that is providing workers'compensation insurance far my employees. Below is the policy and job site inf ormalion. Insurance Company Vame:_ _-- --------__--- --- -- Policy!t or Self-ins. Lic. !E: — Expiration Date:__ .lob Site address:. Cityistate/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%1GL c. 152 can lead to the imposition of criminal penalties of a Fine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a tine Of up to$250.00 a day against the violator. Be adv ised that a copy of this statement may be forwarded to the Office of Investigations of the DIAfor insurance coverage verification. 1 do here Ji under the s and penallies of perjury that the informflon provided above is true and correct. `i1; 4 FAY CONSTRUCTIONEstffilate 20 Beresford street 75 Lawrence, Ma 01843 - phone &fax 978-975-0242 = . - •-: - .r E-mail faycon1@comcast.net adrian 11/2/2006 1 • •BOCATIONI Adrian F Dawson Adrian F Dawson 123 Bonny lane 123 Bonny lane N Andover, MA 01845 N Andover, MA 01845 CONTACT. Adrian 978-689-0621 I • • b • Provide permit and inspection for the remodeling of discussed areas of 123 Bonny lane. Chuck Fay to work as construction super. I Sub contractors to be paid by Adrian Dawson[owner j Chuck Fay will receeive 10%of the subs labor.and$60.00 per hr.for meeting and inspections. 1.00 Estamated cost for project: Install dormers,windows,siding,roofing,install interior partition 1,119.00 $75.00 t$3,925.00 walls,for 1119 sq.ft of affected area.est.sq.ft.cost of construction and finish for these areas is $75.00 per sq.ft I • SUBTOTAL $83,925.00 TAX $0.00 TOTAL AMOUNT $83,925.00 "? ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID B DATE(MM/DD/YYYY) a FAYCO-1 11/03/06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Samuel J. Durso Insurance Agcy ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Charles S. Randone HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 198 Massachusetts Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Andover MA 01845 Phone: 978-682-5175 Fax:978-794-0313 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Travelers Insurance Company 19038 Fay Construction Co. INSURER B: National Grange Mutual 14788 Charles A. Fayy Jr. INSURER C: 20 Beresford Street INSURER D: Lawrence MA 01843 INSURER E: COVERAGES 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 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY DATE MM/DD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 UA AGE'UB COMMERCIAL GENERAL LIABILITY MPP48851 PREMISES(Eaoccurence) $ 500000 CLAIMS MADE [:] OCCUR MED EXP(Any one person) $ X Business Owners 06/07/06 06/07/07 PERSONAL&ADV INJURY $ 1000000 GENERAL AGGREGATE $2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2 000000 POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident). $ ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY . AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION ANDTATU- F-7 - EMPLOYERS'LIABILITY TORY LIMITS I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? If yes,describe under E.L.DISEASE-EA EMPLOYEE $ SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Carpentry Residential CERTIFICATE HOLDER CANCELLATION NORTHI3. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Town of North Andover NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 400 Osgood Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR North Andover MA 01845 REPRESENTATIVES. AORI REP SENTATIVE ACORD 25(2001/08) ©ACORD CORPORATION 1988 s mak; BOARD OF BUILDING REGULATIONS V License:CONSTRUCTION SUPERVISOR COMMONWEALTH OF MASSACHUSETTS Number:CS 058663 • • • •-• • Birthdate:05/11/1955OF JOURNEYMAN ELECTRICIAN ELECTRICIAN S AS A REG Expires:05/11/2006 !SSUEES THIS Li NSE-0 Tr.no: 25519 Restr CHARLES A FAY icted:00 CHARLES A FAYJR 20 BERESFORD ST LAWRENCE, s FAA 01843 Commissioner / 20 BERESFORD STREET LAWRENCE MA 01843-2431 29617 E 07131/07 074208 [�'alaii. • a MUM Fold,Then Detach Atong All Perforations TO WHOM IT MAY CONCERN, FAY CONSTRUCTION [CHUCK FAY] HOLDS THE FOLLOWING LISCENSES IN THE STATE OF MA. ANY QUESTIONS CALL OR E-MAIL ME AT, 978-975-0242 CELL 978-828-7835 E-MAIL fayconl@comcast.net i f Board of Building Regulations and Standard HOME'MPROVEAIENT CONTRACTOR Registration; 147062 �Ezpiration`=g/8/2007 1 -T 0 _individual CHARLES A FAY JR t 1,i CHARLES 20 BERESFORD LAWRENCE,MA 01843 Administrator I `2S DRAINAGE S 20° 25 14 E— -- . \ EASEMENT 369.09 GREEN AREA AND BUFFER EASEMENT 5 pF' LOT'8 / pp 2 V� P y ?y p Fp / LAN DSCAPE B MAINTENANCE EASEMENT N AREA=2 X0$0 Sf. a '-yO 5 y 402 65 0° S 2� SEE DETAIL OF AREA.- -N -9 q`30 R=60.00°ASO LANDSCAPE B2'BERS 7.— I+ EDGE OFBIT.CONC.DRIVE _9.28 O6 48 E� 1 HEREBY CERTIFY THAT PROPERTY LINER D / SHOWN ON THIS PLAN ARE THE LINER DIN DING 2L5fl ' 9�$�� -- £ EXISTING OWNERSHIPS.AND THE LINES OF THE �N 00°00 44"E 39, \ STREETS ANO WgYS SHOWN ARE THOSE OF L=22.00• '- 9 30° 232 5A1 Ir 1 ESTPUB48LISHEOOR pIAND THAT NO NEW WAYS ,NEB FOALREADY SIT. DRIVE 02 TOTAL LOT L___ -� ° DIVISION OF EXISTING OWNERSHIP OR FO R NEW WAYS A - RE SHOWN. L-27.40 '-,�'/- . N� R-30.00 6 02`08.30"E E%iSTING DWELLING N N 5. O 09 .1 EXISTING PROPERTY 1 2 m. - ° 1 LINE i ' �,,. I FURTHER CERTIFY THAT i HAVE'Do—FORMED APPRO%LOCATION OF'. TO THE RULES AND REGULATIONS OF THE `R w REGISTER OF DEEDS IN PREPARING THIS PLgN 16 cj S.B/da I EXISTING-LEACHING Oy3 1O fi O 26 FIELD. , T NAL LOT 9 \ OAVIO A.WEBS ER - ,�._ DATEe; 30`9A S B/Bn 0P le LOT 10 — DRIVEWAY LANDSCAPE fi MAINTENANCE EASEMENT os oO\3 IE AREA 5,07 AREA 62.77' ...5 20°06.48 E.... ...S 1 26.36• 39•E—'59.62 Oi .... .'. S S361 {P. S 36°03 39�E 173.02 `'N 19311 17 W DETAIL WT.S) ° PLAN OF �s NOTE PROPERTY LINER TAKEN FROM THE DEFINITIVE �r O LANDSCAPE AND MAINTENANCE CNANCE LASE11J'ENT SUBDIVISION FOR TAKEN COURT ESTATES RECORDED /�/ / w f.T PFf.STwY DF REEDS. / LOCATED IN - nota r�5r PJI 6a pew.as° � _ k1Ada 01 FROM THE OFFICE OF: Lillian Montalto Signature Properties,LLC 34 Park Street Unit 1 Andover,MA b1810 STANDARD FORM PURCHASE AND SALE AGREEMENT 1.PARTIES This Agreement prepared this 2nd day of October, 2006. Time is of the essence. Bryan W.Coles of 123 Bonny Lane,North Andover,Massachusetts hereinafter called the SELLER,agrees to SELL and Adrian Dawson of 7 Belle Isle Way,Andover Massachusetts hereinafter called the BUYER or PURCHASER, agrees to BUY,upon the terms hereinafter set Andover, the following described premises: A single family dwelling 2.DESCRIPTION consisting of seven (7) rooms which is situated on approximately 63,162 square feet and all land and buildings thereon known as 123 Bonny Lane North Andover,Massachusetts,and further described at the Essex North Registry of Deeds, Book 4309,Page 116. Included�in^the.sale as a art of said remises are the buildings, structures and improvements now thereon, and the 3.BUILDINGS, fixtures � � used in connection therewith including, if any, all venetian blinds, window STRUCTURES, shades;screens,screen doors,storm windows and doors,awnings,shutters,furnaces,heaters,heating equipment,stoves, IMPROVEMENTS, ranges oil and gas burners and fixtures appurtenant thereto,hot water heaters,plumbing and bathroom fixtures,electric FIXTURES and otter lighting fixtures, mantels, outside television antennas, fences, gates, trees, shrubs, plants, and dirt, air conditioning equipment, ventilators, garbage disposals, dishwashers, refrigerator, microwave, compactor, washer, dryer,drapes/window treatments,fireplace screen/equipment,central vacuum attachments. 4.TITLE DEED Said premises are to be conveyed by a good and sufficient quitclaim deed running to the BUYER or the nominee designated by the BUYER by written notice to the SELLER at least seven days before the deed is to be delivered as herein provided, and said deed shall convey a good and clear record and marketable or insurable title thereto, free from encumbrances,except a Provisions of existing building and zoning laws; b Existing rights and obligations in party walls which are not the subject of written agreement c Such taxes for the then current year as are not due and payable on the date of the delivery of such deed d Any liens for municipal betterments assessed after the date of this agreement e Subject to easements and restrictions of record which do not substantially affect the use of the property If said deed refers to a plan necessary to be recorded therewith the SELLER shall deliver such plan with the deed 5.PLANS in form adequate for recording or registration. 6.REGISTERED TITLE In addition to the foregoing, if the title to said premises is registered, said deed shall be in form sufficient to entitle the BUYER to a Certificate of Title of said premises, and the SELLER shall deliver with said deed all instruments,if any,necessary to enable the BUYER to obtain such Certificate of Title. 7.PURCHASE PRICE The agreed purchase price for said premises is ONE MILLION ONE HUNDRED THOUSAND DOLLARS $ 1,100,000.00 dollars,of which $ 1,000.00 paid on the 9T"day of September;:2006-j— $ 54,000.00 Have been 2006 and paid as a deposit this 2"d day of October, $ 1,045,000.00 Pbide of delivery of the deed in , bank check or Attorney $ 1,100,000.00 BUYERS INITIAL SELLERS INITIAL PERF RMAO NCE Such deed is to be delivered of 12:00 Noon on or before December 1,2006 at the Registry office of the Bank Attorn�ey provided said location is within ten miles of said Registry of Deeds. IT IS AGREED THAT TIME IS OF THE ESSENCE OF THIS AGREEMENT. of Deeds,or at i 9.POSSESSION AND Full Possession of said premises,FREE OF ALL TENANTS AND OCCUPANTS CONDITIO OF is to be delivered at the time of the delivery of the deed,said remises to PREMISES now are,reasonable use and wear thereof excepted,and(b)not in violation of sad b cept as her provided, p be then(a)in thegsame condition as th (c)•in compliance with the provisions of any instrument referred to in clause 4 hereof. The Bonin laws,ai entitled to an inspection of said premises prior to the delivery of the deed in order to determine whether 1 condition thereof complies with the terms of this clause.Interior of proper to be br U Maws, I to closing and free of all SELLER'S ersonal roe her tl SELLER property,rty,exterior of property to be fee of SELLER's debri to continue customary maintenance of property until closing. 10.FAILURE TO If the SELLER shall be unable to give title or to make conveyance;or to deliver possession of the re PERFEC— T E herein stipulated, or if at the time of the delivery of the deed the remises do not conform with the hereof, then premises,all provisior. Rill] I'll:! 1.11118 Iffif shall use reasonable efforts to remAiove any defects in title,or to deliver possession as provided herein,or to mak the said premises conform to th�e�provisions hereof, as the case may be, in which event the SELLER shall giv written notice thereof to the BUYER at or before the time for performance thereunder,and thereupon the time to performance hereof shall be extended for a period of thirty days. 11.BUYERS ELECTION The BUYER shall have the election, at either the original or any extended time for performance to a TO ACCEPT TITLE title as the SELLER can deliver to the said premises in their then condition and to pay therefor theaccept sucl without deduction. In case of damage to the premises by fire or other casualty and unless the property Previously have been restored to its former condition by the SELLER, the al E'ER may at hep tion,purchase phal cancel this agreement,and recover all sums paid hereunder or require as part of this agreement than he SELLER P ay over or assign on delivery of the deed, all sums recovered or recoverable on any and all insurance covering such damage. 12.ACCEPTANCE OF The accepptance and recording of a deed by the BUYER or his nominee as the case may be,shall be deemed DEED a full pertbrmance and discharge of every agreement and obligation herein contained or expressed,except such are,by the terms hereof,to be performed after the delivery of said deed. to be 13.USE OF PURCHASE To enable the SELLER to make conveyance as herein provided,the SELLER may, at the time of deliver has MONEY TO CLEAR deed? use the purchase move or an TITLE provided that all instruments so procured are recorded simultaneously ortion thereof to clear the twith theof yor delivery of sa d d ed interests days thereafter if additional time is needed to procure the instrument necessary to discharge the encumbrance. five 14.INSURANCE Until the delivery and recording of the deed,the SELLER shall maintain insurance on said premises as follo • As presently insured. 15.ADJUSTMENTS � , Water and sewer use charges, and taxes for the then current year, shall be apportioned and fuel value shall be adjusted,as of the day of performance of this agreement and the net amount thereof shall be added to or deducted from,as the case may be,the urchase rice payable by the BUYER at the time of delivery of the deed. amount of said taxes is not known at the time of the delivery of the deed,they shall be apportione on the basis of the taxes assessed for the preceding year with a reap ortionment as soon as the new tax rate and valuation can be ascertained,which latter provision shall survive the delivery oft Deed. 16.BROKER'S FEE A broker's fee for professional services of as per listing agree ent is due from the SELLER to Lillian Mont Signature Properties,LLC,if,as and when title passes an eed is recorded. Montalto IBroker f the SELLER pursuant to the terms of clause 19 hereof ret i s eposi s e hereunder by the BUYER,said amount qualbto entitled to broker's fee for ve professional serviices rdim the SELLER an ng to thisal o one ct fwh the whichever i so retained or an ver is the lesser. f BUYERS INITIAL SELLERS INITIAL 17'BROKER The Broker(s) named herein Lillian Montalto Signature Properties, LLC warrants that he/they are duly WARRANTY licensed as such by the Commonwealth of Massachusetts. BUYER(S) and SELLER(S) a owled e and understand Lillian Montalto Signature Properties, LLC R LISTING AGENCY is acting as Xg SELLER(S)AGENT in this transaction. 18.-DEPOSIT All deposits made hereunder shall be held in escrow by the Broker(s) Lillian Montalto Signature Properties, LLC in a non-interest bearing account,subject to the terms of this agreement and shall be duly accounted for at the time for performance of this agreement. In the event of a dispute relating to the de os h v t es �aggct,rRwn4LPhouvenrt'tins,paraga�n;�tne•eserow�agent'shall-havephe'right to gretain'•the�dep sit pe�ridirig the receipt of written instructions a�reed to and signed by SELLER and BUYER or of a court order directing the distribution of the deposit. BUYER and SELLER jointly and severally agree to indemnify and hold the escrow agent harmless from any and all costs and expenses, including reasonabl any such dispute. e attorney's fees, incurred in connection with 19.BUYER'S DEFAULT: If the BUYER shall fail to fulfill the BUYER's agreements herein, all depposits made hereunder by the BUYER DAMAGES shall be retained by the SELLER as liquidated damages.This shall be the SELLER's sole and exclusive remedy in law and equity. 20.BROKER AS PARTY The Broker named herein, agree in venting. joins in this agreement and becomes a party hereto, in so far as any provisions of this agreement expressly apply to him, and to any amendments or modifications of such provisions to which he may 21.WARRANTIES AND The BUYER acknowledges that the BUYER has not been influenced to enter into this transaction nor has he REPRESENTATIONS relied upon any warranties or representations not set forth or incorporated in this agreement or previously made in writing,except for the following additional warranties and representations,if any,made by either the SELLER or the Broker,if none,so state:None. 22.FINANCING Con mn __gfig&40R" in all A-FROUnt. the&Q -------------- 23.INSPECTION This Agreement is subject to the BUYER using reasonable and diligent effort to obtain, at the BUYER's option and expense, a complete home and real property inspection, including but not limited to termite/pest,lead paint, radon, septic system, well and water inspections, on or before September 22, 2006 from a person normally engaged in the business of conducting such inspections. If the property contains serious structural,mechanical or major other mor defects,then,at the option of the BUYER,with written notification this offer shall be null and void and all deposits returned to the BUYER. Should the BUYER fail to notify the§ELLER or his agent, in writing, on or before September 24,2006 then it shall be conclusively presumed that the BUYER is satisfied with the inspection and this contingency shall lapse and the BUYER shall be bound to perform his obligations under this Agreement. In the event the BUYER does not elect to have such inspection or to so terminate on or before September 22,2006 the SELLER and the Broker(s) are hereby released from liabilit relating to defects in the premises which the BUYER or BUYER's consultant(s) could reasonably discover. If applicable, the mandatory lead paint disclosure form is attached hereto. 24.LEAD PAINT The BUYER agrees that if any child 6 years of age or under resides in said premises after the time of the closing of the sale, that the BUYER will be responsible for compliance with any provisions of the State Statutes or Building Code relating to or regulating levels of lead paint in said premises. 25.SMOKE DETECTOR The SELLER shall supply a smoke detector and carbon monoxide certificate of compliance at the time of CARBON MONOXIDE performance of this agreement. 26.CONSTRUCTION This instrument,executed in four(4)parts,is to be construed under the laws of Massachusetts,is to take effect as OF AGREEMENT a sealed instrument,sets forth the entire contract between the pa ties, is binding upon and inures to the benefit of the parties hereto and their respective heirs,devisees,executor , d ' istrators,successors and assigns, and may be canceled, modified or amended only by a written ins n t exec u b the parties hereto or their legal representatives.If two or more persons are named herein as S L E or BU their obli ations hereunder shall be joint and several. BUYERS INITIAL SELLERS INITIAL P kS'Ert v—v. __. 1+. 27. ADDITIONAL 1. BUYER acknowledges that they have read,received and signed documents entitled: PROVISION a. Agency Disclosure b. Lead Paint Public Health Notification c. Seller's Description of Property,which is attached hereto and made a part of this Agreement. 2. In connection with the Purchase and Sale Agreement entered into by the undersigned and dated October 2,2006, BUYER acknowledges that they have been advised that they should consult an attorney of their choice for any legal advice that they desire concerning the purchase of the property located at 123 Bonny Lane,North Andover, Massachusetts. 3. Property is being sold in"As Is"condition. d ,� (� BUYER: drian Dawson DATE- —1 SEL ryan W.Coles DATE DATE: yV ( t/4 DATE Lillian Montalto Signature Properties LLC Lillian Montalto Signature Properties LLC SELLING OFFICE LISTING OFFICE ORIGINAL SIGNATURES AND DATES REQUIRED ON ALL COPIES Staple aidelS N A AcORTH BUILDING PERMIT o`J'f{.rD ,6g9tiO II _ �2 e�..'f 'N 6 TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION '' 70 Permit No#: t/" Date Receivedriw C �SSACHU5�4 Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION /r W Y Print PROPERTY OWNER Print 100 Year Structure yes � MAP =PARCEL: U ZONING DISTRICT: Historic.District ye � Machine Shop Village ye 4o 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 0 Septic > 01Nell . ' ❑ Flgodpla n 1Netlands- 0'. Wate_rShed�Distnct: ... r 0 Water/Sewer$ a x DESCRIPTION OF WORK TO BE PERFORMED: vntJ�l Identification- Pleas--e Tyke or Print Clearly OWNER: Name: �G��rr��Cf � lr//� f Phone: IAddress: a A/ 'l f 12-- Contractor Name: Phone: S (' Email: Address: �i . -c �` �°' y��v►« iiJb Supervisor's Construction License: 6V Exp. Date: Home Improvement License: 1 ` � l Exp. Date: C" 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: $ Ci FEE: $ Check No.: ( � Z Receipt No.: � � 1 NOTE: Persons contracting with unregistered contractors do not have access to th guaranty fund � M 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 o U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS i HEALTH Reviewed on Siqnature COMMENTS i Zoni,ng 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 DEPARTMENTTernpDumpjsteronsite,: yes�� } nog � `�•. L L19 �Jdj r24 Maim Street 4 , , u Firem u :rt moi•°i y ;�� Vit.+ y i� �w, ks F ti s as n a rtntsignatur4e/date , l ®M Mt�1,�m. ...` kr- t � '� - ! %� n f,.`� [. `? ". �. {'�.;< `�, �zt ✓ '`r`` i_ i�s,� ,ay"..5 x ti. 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) El Notified for pickup Call Email 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 Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses fi Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) f Engineering Affidavits for Engineered products a OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application F 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 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 In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals i 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 Location No. t i t-' Gut Date "t y • • TOWN OF NORTH ANDOVER � 1 p Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ , Other Permit Fee $ u' If. TOTAL Y, i Check# 0 29207 Building Inspector i NORTH Town of 2 E �. Andover 0 191, 241S� z "W19 A h , ver, Mass, A'�"j COC MIC Kl WICK V S U BOARD OF HEALTH Food/Kitchen PER'NL D Septic System THIS CERTIFIES THAT .................. . .,, . �� BUILDING INSPECTOR . .. Foundation has permission to erect . ..................... bui Ings on ..I.Q�i , ...... .�1 Ji,l:... �— _ ................................. Rough 1� V 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 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 MO THS ELECTRICAL INSPECTOR UNLESS CONSTRUCSS TSRough Service ..... ... ............................................. 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. MA Lic.#171618 PROPOSAL Tel:(978)758-7641 Lic.Builder CS#075904 EANT. COLLINS 75 Allen Road Billerica MA 01821 ROOFING & CONSTRUCTION Proposal submttted to Phone — +Dote - �. Adrian'Dawson s i 7/9/15 3 si Shy t�,e Ref.By 123.Bonny.Lane y Ctly State and Zip Code' Job fomtioo . North Andover, MA,:01845 - Architetl Date of Plans lob Phone Cover all walls and grounds with tarps.Strip the entire roof and remove all debris. —Remove gutters,apply coverage,and re-install gutters. Replace up to six sheets of plywood if needed,note:(20 ft of trim included),then check insulation. —Replace lead flashing at chimney,and then apply"GRACE"ice and water shield to bottom six feet of roof and entire rear shed dormer. —Rear shed dormer to recieve continuous vinyl intake venting.,apply synthetic underlayment to remaining areas,and then apply white 8"drip edge to perimeter. Apply lifetime shingles:color to match exisiting,and install ridge vent at peak. Re-flash all obstructions,use new pipe flanges,and magnetize ground for nails. —All work guaranteed ten years,insurance certificate and building permit included. Any materials purchased by homeowner will be deducted frrom total price below. Half labor cost due upon 50%completion. We propose hereby to furnish material&labor-complete in accordance with above specifications for the sum of: Fifteen Thousand, Four Hundred dollars do►lors($15,400 Payment to be made as follows: Terms to be discussed. NI work is guaranteed to he as specified.NI work to be completed in a workmanlike manner according to standard _ practices.Any alteration or deviation from above specifications involving extra costs will be executed only upon Authorized Signature _ written orders,and will become an extra charge over and above the estimate. Note:This proposal m withdraw Owner to carry fire,tomado insurance.Our workers are fully covered by insurance. by us if not accepted in Acceptance of proposal—The above prices,specifications and conditions are satisfactory and are . hereby accepted.You are authorized to do the work as specilied.Payment will be made as outline above. Signature Date of acceptance: Signature : The Commonwealth of Massa chusetts . Department oflndustrialAccidents 4 a. w tl 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia yV' Workers'Compensation Insuranice Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant information Please Print Legib Name(Business/Organizationadividual): -C / S Address. c L� � City/State/Zip: GIA /V/4 Phone#: � Gln Are you an employer?Checktiie appropriate box: Type of project(required): 1.❑lama employer with employees(full and/or part time).* 7. E]New construction 2.1�-�5_-sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition In I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10E]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 11. Electrical repairs or additions proprietors with no employees. 12..0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the atsheet. 13.Fof repairs These sub-contractors have employees and have workers'comp.insurance.# 6.Q 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 noemployees.[No workers'comp.insurance required.] 'Any applicant that checks box 41 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 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 fiave employees,they must provide their workeis'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: ��` � V City/State/Zip: '( ✓J� !� 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 hereby certify u der_the pains asnddpen_It es ofperjury that the information provided above is true and correct. Signature: rI �� Date: Phone#: r/ �" _ S — 7 4 ey Official 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other ! Contact Person: Phone#: I I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." ' An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another 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 has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority'." Applicants Please fill-out-the workers'compensation affidavit completely,by checking the-boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and-phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents fox confirmation of insurance coverage. Also be sure to sign and date the of iidavit. 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 Accidents. Should you have any questions regarding the law or if yoa.are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should'enter their - self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permitilicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to 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-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia A CERTIFICATE OF LIABILITY INSURANCEF7/22/ D IDD/YYYY) 2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions 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 CONTACT Scott Leavitt, CIC, LIA MTMBrainerd Inc PHONE (978)667-9031 FAX AIC No):(978)667-1018 lA Andover Road E-MAIL ADDRESS:scottl@brainerdinsure.com INSURERS AFFORDING COVERAGE NAIC# Billerica MA 01821 INSURERA:Safety Insurance Company 39454 INSURED INSURER B: Sean T Collins INSURER C: 75 Allen Road INSURER D: INSURER E Billerica MA 01821 INSURERF: COVERAGES CERTIFICATE N LIM BER:Nas ter GL 2015 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 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR - TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD/YYYY MM/DDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 A CLAIMS-MADE OCCUR MA0022049 5/14/2015 /14/2016 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ Include GENERAL AGGREGATE $ 2,000,000 GENI AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ Include X POLICY D PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F—] N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) This certificate of insurance represents coverage currently in effect and may or may not be in compliance with any written contract. CERTIFICATE HOLDER CANCELLATION mdeems@ townofnorthandover. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street Bldg 20 Suite 2035 AUTHORIZED REPRESENTATIVE North Andover, MA 01845 . I S Leavitt, CIC, LIA/S ------vg& � — ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 onlnn�l ni Tha Arr1R171 name and Innn arc ranictarnrt mnrtrc of Ar r)pn {Massachusetts -Department df Pabrc Secy f•: Board of Building Rggul-ations and Standards . Construction Supervisor } License.—CS-075904 ' Sean T Collin Q 75 Allen Road •Billerica MA 01811 V t . e Pirdtion j Commissioner 09/23/2015 `IT(C7 of Consumed ME IMPROVENIENT e6 e913tratoAn11618 " xy ,+ 14. -t_xpooation 4/2/2016=, r-� lviaual' ? # I'VEh"' R-- ^� *. , PCOLLINS �? ni� A FLLENRD i Lt?RICA MA'018ii, Uhdersecretn ., � a h