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HomeMy WebLinkAboutBuilding Permit #091-2017 - 135 BEAR HILL ROAD 7/27/2016 t%ORTlI. BUILDING PERMIT I 0, g4LED TOWN OF NORTH ANDOVER t6 o APPLICATION FOR PLAN EXAMINATION ~ Permit No#: l�` �ul� Date ReceivedArgo ��SSgCHUs���y Date Issued: v EVIPORTANT: Applicant must complete-all items on this page LOCATION. 1"3 L9)eQC RI-1 I . Prin PROPERTY OWNER Pri 100 Year Structure yesOnoMAP PARCEL: ZONING DISTRICT: Historic District yeMachine Shop Village ye TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building '94ne family ❑Addition ❑Two or more family ❑ Industrial 9-'Alteration No. of units: ❑ Commercial epair, replacement-- ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 'Septic ❑':Well'. D Floodplain ' ❑UVetlan,s 'D .Watershed:_®istnet 0 Water/Sew_er r r t ' c- DESCRIPTION OF WORK TO BE PERFORMED: ax ,NNe at)c( nP- ()icace_ and dmr o ro en Identification- Please Type or Print Clearly YP OWNER: Name: V t 10 Ce nl �—�P.) f 1T �i C_b . Phone: C)1 g' (n�5� �c�l�} Address: 135 P,5eo - HI* ) ) Rd Contractor Name: C 11LPhone: �J Email u M e-, Address: !� CD Supervisor's Construction License: f—'�,—naq ?3 0"31 Exp. Dater a/ L ) _ Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �{ , C US ' S-7 FEE: $ Check No.: Receipt No.: ���'� NOTE: Persons contracting with unregistered contr o s do n ha access to the guaranty fund ----- -__...--------- ----...--- ---- -- --------.. ----- - .. Location No. {.^/L1 l �G t ' Date • - TOWN OF NORTH ANDOVER 3 x6 Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ " TOTAL $ Check# 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. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING DEVELOPMENT Reviewed On Signature' A COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed ori 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 DrivewaV Permit DPW Town]Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster onsite yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department ease) i i ® Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 1 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 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) Engineering Affidavits for Engineered products 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 4 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 4- 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit 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 %ee/BUILDING PERMIT ., o*T�oT 6�.1; TOWN OF NORTH ANDOVER 32 g '`- �- APPLICATION FOR PLAN EXAMINATION Permit No#: �� " Date Received gSSACHU! Date Issued: 1 ORTANT: Applicant must com lete all items on this page LOCATION. I ��� R Prin PROPERTY OWNER r Prirft 100 Year Structure yesno MAP z PARCEL: ZONING DISTRICT: Historic District ye no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building S14ne family ❑Addition ❑Two or more family ❑ Industrial B,Alteration No. of units: ❑ Commercial epair, replacement - ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well 0 Floodplain ❑Wetlands ❑ Watershed District_ .0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly nl f—� I b- ID Phone: CJ-]x' (a` OWNER: Name: V 1 n ce Address: iJ)COf- H1 I I R Contractor Name: V� McKch I C TYLOM Phone: C) IR R91 Email: ti C- Address: v Supervisor's Construction License: Exp. Date: ate, Home Improvement License: Exp. Date: 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: $ Ll Hol C co S ' FEE: $ `` �ln Check No.: 1 "1 �,� Receipt No.: NOTE: Persons contracting with unregistered contY 0 s don ha access to the guaranty fund � NRTf-� Town of ? _On over O R► "1 I h ver, Mass, Mt4 CONIC Nl WICK �ov x.95 RArED J"V U BOARD OF HEALTH Food/Kitchen Septic System ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, BUILDING INSPECTOR • THIS CERTIFIES THAT .....PERMIT .�.�1.�. . ...............e................................ has permission to erect .......................... buildings on ...ff.'s... ....&k&.%.44.A.... .-............ Foundation Rough to be occupied as ...I.o�t.... .. ....A^v.%.4..�N!��5....... ..... 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 rel ' g to the Inspetion,Alteration and Construction of Buildings in the Town of North Andover. 4 _ PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST ION Rough Service . . ..... .. ... . . .... .... ......... ....... Fina BUILDIN INSPE TOR 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. W MCKAY CONSMiTC1 ON LLC L)d aS ACADEMY A`TEAT M AL AF I HA'EHHL,MA oa835 wrw° ° ckayconstreaedon.com PHONE# 978-891-2303 PROPOSAL 4/26/16 Project name: Vincent Helfrich Bear Hill Rd. North Andover,MA 01845 SCOPE:CHANGE OF ENTRY WALL WINDOWS&FINISH • Provide portable toilet per client request. • Provide permits for all work in scope below. • install plastic wall in the foyer to protect the other areas of the home from dust,debris and contamination from construction. • Remove sheetrock on entire front wall. • Remove windows and doors from entire front wall. • Remove all trim and siding on front entry only. • Reframe entry to accommodate new window and door layout agreed upon with the homeowner. • Window removal and replacement in the front of the existing house. • Design new exterior and interior finish details for new window layout in the foyer. • Insulate all exposed foyer walls per code. • Install%"blue board and plaster to all affected areas of remodel of front foyer wall. • Install interior and exterior trim details of foyer as per design accepted by homeowner. • All materials excluding door and windows will be purchased on HB Jackson account. PELLA WINDOWS&DOOR:$12,161.00 GRAND TOTAL:$40,068.37 A 50%deposit of$20,000 is due to be put on the schedule and to purchase windows and door which both have lead times. **This price includes the Pella door option as agreed.There is no electrical or paint included in this Proposal.Disposal will be done daily to a dumpster provided by the WMC.WMC work will be completed in a imely nd clean manner and in observance of OSHA regulations. ** C M ay Construction LLC Vincent Helfrich i I I� I Massachusetts Home Improvement Sample Contract This form satisfies all basic tcquitancms of the states Home improvement Cantractor Law(MGL chapter 142A),but docs not Include standard language to protect homeowners.Seek legal advice If necessary.Any person planning tome imptovemtaits should first obtain a copy of"A Masan usetts Consumer Guide to Home Improvement"before agreeing to any work on your residinm You tray obtain a free copy by calling the Me ofConsumcr Affairs and Business Regulation's Consumer Infatuation IloUiac at 617.973-8787 or 1-888-281-3757 or on our website. HaVtn=merwn r Int atioonna G o tractor It pr a Name CoinparcyName �--- �-- J E Street Address(do not use a Post Office Ras addness) Cossmictod Salespasurd Owner Name S Y Gawp Slate Tap Code Btuietgs fddecss(mutt iaek k a ) Daytime Phone EveniagPhone city/coram talc Zip coa d 1!2 Malliag Address(h diffaaot from above) Ruane s;Phone Fakrol Errlayer In err S.S.Number le�,rr.gwven•w tb.Prete.aq tr.sar F.srais.w Iw•.paha tact cow e••e t.....e..n...u..r.r►.r. /7-7,J&!5 7 I o l a sap rrcmrtttaa sa�aa The Contractor agues to do the following work for the Homeowner. (Dacril c in dnaail the avtk to coaepirial sp cifying the type,brand,and grade of materials to be sisal,else Mtat gourd ham"If ftscom.) Required Permits•The following building permits ate required Proposed Start and Completion Schedule-The following schedule will and will be seelnod by the contractor as the haincownces agent: be adhered to unless circumstances beyond the coutsactut's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of e�Date when contractor will begin contracted work, MGL chapter 142A.) rd 14Dato whoxh contracted work will be suhstantially compicted. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,fumish the material and labor specified above for the total sum or. Payments will be made according to the fallowing schedule; e LLw upon signing conryatt(not to exaxd 1/3 of the total contract price yi the cost of sype^cial Older items,whicbbeveris greater) Sl C�by / t or upon completion of J r I '���J '/\P, __,CW _ "Why / / or upon completion of S upon completion of the cotitract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) 'Mc following material/equipment meat be special s to be paid for arderd Won:the cantracted work begins in order to mea the ermplaimt sehaluk.(••) S to be paid for NOTES,(')lacludiog att fl wrece closes(")taw requires that any deposit of down•payment soyuirrd by doe aretractar before wruk beers may not execal the smsct of(a)one-third ordic total contract price nr(b)the actual con of any special equipnett or custom made material which must be special exdeai in advance to mccl the cumplalms schodule by Subcontractors-The contractor agrees to be solely mgonsiblc for complexion of tete work described tegardIcza of the actions or any third party/subcontractor utilized by the contractor.The contractor further agrees to be solely rtspomible for all payments to all subcontractors fur materials t)ud latior u der.this aercemcni Contract Acceptance-Upon signinr,this doctumil becomes a binding contract under law.Unless otherwise noted within this document,the contras shall not imply that any lira or other security interest has betas placed on the fesidemea.Review the following cautions and notices carefully before signing this contract. • DOM be pressured Into signing the contract.Take time to read and fully understand it. Ask questions if sonvilsing is unclear. Mike site tits contra of hall a valid I tom£IStpmvemcot Contractor Reeiseration.Tlic law rec(uires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plarn,Room 5170.Boston,MA 02116 or by callmg 617.973.9787 or 8211-2.83-3757, • Discs the contractor have Insurance?Ask the Contractor for his insurance company information so that you can confirm coverage,or risk to ser a copy of n"proof ar insurance'document • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and gra a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the cuntractoes normal place of business,provided you nasi ly the contractor in writing at his/her main ofl'icc or branch office by ordinary otul posted,by telegram sent or by delivery,not later thast ttaadnight of the third business day following the signing of this agreement. Set the ottachnl notice of cancellation form for an explanation of this ri t. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESIit ret,.ides• eupiea of etfaasr aw be cagrkftd sal sips,&o:re ceps shwu @t m am treaow •ota:rapy as apt by me wdwnar. liomeo er'ssignature Contrarignatu "771Z) 2 ZQ(en Dau Dust Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is mgt automatically afforded to a contractor,however. The contractor would have to resolve any dispute Wilic has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Hone Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration farm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and th consumer shall be required to submit to such itratio�jls provided In Massachusetts General Laws,chap,r 142A. Hom a's Signature Con o:'s S' NOTICE:The signatures of the parries above apply only to the agreemen of the pailies to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeawner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGI-chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits arc automatically excluded from all Guaranty Fund provisions of die Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of tither matters on which the homeowner and contractor lawfully agree may be added to the terms of the contact as long its they do not restrict a homeowner's basic consumer rights. If you have questions about your consumcriluomcowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibitti and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and nVecd to by both parties.Contracted work may not begin until both parties have received a fully executed(ropy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems hirn/iterself to be financially insecure. However,in instances where a contractor deems himthcrself to be financially insecure,the contractor may require that lite balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Ilornc Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Infomwtion Hotline Office of Consumer Affair.:and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8797,88&283-3757 or visit the OCABR website at hJiwwww.massrov-ocabr! If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at hmp.4www.rrixca.covloc hr' Go online to view the status of a Home Improvement Contractor's Registration: lisp:/!lb.at:ta4.qip.usgiomcimrrovcinentlliecnseeItst.asp For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attumev General 617-727-8400 ANDIOR Rater Business Bureau 50&652-0800,508-755-2548 or 413-734-3114 Venkm2.1-11/22MI0 The Commonwealth of Massachusetts 2. Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA.02114-2017 www mass.gov/dia SV• Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information r,/� Please Print Leaibly Name(Business/Organization/Individual): W INACK a L 1 Cts I 1 )M C-11 OIC U -C ' Address: - AVE City/State/Zip: /-/ e- ) VAo iMhol1e Are you an employer?Checic&ee appropriate box: .'Type of project(xequired) 1.r4I am a employer with !: employees(full and/or part-time).* 7. oxwcolistruction 2.0 I am a sole proprietor,or partnership and have no employees working for me in 8. gRemodelffig any capacity.[No workers'comp.insurance required.] 3_Q I am a homeowner doing all work myself[No workers'comp..nisurance required.]t 9. L1 Demolition 10 ❑Building addition 4.F]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.Q Electrical repairs or additions proprietors withno 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.F]Roof repairs These sub-contractors haveemployees and have workers'comp.insurance. 6.Q we area corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 52 1 4 and we have no em to ees.�o workers'comp.insurance required.] 1 Y P *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,&y must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees.'Below is the poliey acid job site information. Insurance Company Name:— ( J acd 'I n5umnce- 16-l5Umnce- 69�2- Policy#or Self-ins.Lic.#: M�� l.V�'�_ Expiration Date: Job Site Address: 1 55 5 '� City/State/Zip: I . And ov MA O)�4 Attach a copy of the woykers' 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. I do hereby certify and zepa' s an enalties ofperjury that the informationprovided above is true and correct. Signature: Date: f Phone#: 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 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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 ofhire, 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. B e advised that this affidavit may be submitted to the Department of-Industrial Accidents foi-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 you'are required to obtain a workers' compensation.policy,please call the Department at the number listed below. Self-insure_d 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(if necessary)and under"fob 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 bum 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-NIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia ® 77�7 MIDD/YYYY)�'�© CERTIFICATE OF LIABILITY INSURANCE7/26/16 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 NAME: sandl Munroe M.P. Roberts Insurance Agency PtioNE- FAx 978) 683-3147 1060 Osgood Street EMAIL (978) 683-8073 A/ No: l North Andover, MA 01845 ADDRESS: sandi@mprobertsinsurance.com INSURE S AFFORDING COVERAGE NAIC# INSURER A:Merchants Mutual Insurance Co _ INSURED INSURER B: W MCKAY CONSTRUCTION LLC INSURER c: --L ATTN: BILL MCKAY INSURER D: _ 18 ACADEMY AVENUE INSURER E is HAVERHILL, MA 01835 INSURER F: ^T� 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 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANDCONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AODL SUBR POUCY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER M/DD/YYYY MM/DD/YYYY LIMITS A GENERAL LIABILITY BOP9097489 8/14/16 8/14/17 EACH OCCURRENCE $ 1.000,000 DAMAGE TO RENTED 5OO 000 X COMMERCIAL GENERAL LIABILITY PREMISE.S_(Ea_oocurreoce)_,_. CLAIMS-MADE Fx1OOCUR MED EXP(Anyone person) $ 15,000 PER SONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATELIMITAPPLIESPER PRODUCTS-COMPIOPAGG s 2 000,0 00 X POLICY PRO-JECTLOC AUTOMOBILE � SINGLELIMA !MCAI002126 Tidnl $ 1,000,000 ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED AUTOS X AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE FX HIRED AUTOS X AUTOS Per accident $ A X UMBRELLA LIAB X OCCUR CUP9147266 8/14/16 8/14/17 EACH OCCURRENCE $ 1.'0001000 EXCESS LIAB CLAIMS-MADE AGGREGATE S 1,000,000 DED X RETENTION$ 10,000 Is WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ( TORY-LIMITS R i�i ANY PROPRIETOR/PARTNER/EXECUE.L.EACH ACCIDENT 1$ OFFICE RIME MBER EXCLUDED? J N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ Uesdescribe under RIPTIO N OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I S DESCRIPTION OFOPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space isreguired) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN VINCENT HELFRICH ACCORDANCE WITH THE POLICY PROVISIONS. 135 BEAR HILL ROAD NORTH ANDOVER, MA 01845 AUTHORIZED RE EN TIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: WILLI-6 OP ID: LANK g i ACORO DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 07/26/2016 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(les)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 Phone:978-688-6921 CNAO ATE cT Kim Landry Macdonald$Pangione Insurance PHONE FAX 104 Main Street Fax:978-688-5350 ,� No Ext):978-688-6921 A/c No):978-688-5350 North Andover,MA 01845 E-MAIL Lisa Ross ADDRESS:kim@mpins.net INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Guard Insurance Group INSURED W Mckay Construction,LLC INSURER B: Billy 18 Academy Avenue INSURER C: Haverhill, MA 01832 INSURER D: INSURER E: INSURER F: 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 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 POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD MM/DD/YMLIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE ToRENTEU-- COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE 1-1OCCURMED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY JECT PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per $ AUTOS AUTOS ( accident) HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per.ccident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N X TORY LIMITS E A ANY PROPRIETOR/PARTNER/EXECUTIVEWMWC700002 03/29/2016 03/29/2017 E.L.EACH ACCIDENT $ 500,00 OFFICER/MEMBER EXCLUDED? r N/A (Mandatory In NH) E.L.DISEASE-Fly EMPLOYEE $ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town OF North ANdover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St Norht Andover,MA 01845 AUTHORIZED REPRESENTATIVE 4–� 9�� ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD I � ,q r.�/r P, (!!'/JL///C/!//'[fllC�C/C�(f(CGiJC{CfLLI.iCtC.3 •_...............�<+..................r._.._4-.......�.`_....�._._.. _._.__ Office of Consumer Affairs&Business Regulation License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 179265 Type: Office of Consumer Affairs and Business Regulation Expiration:.. 7/10/2018 LLC 10 Park Plaza-Suite 5170 W.MCKAY CONSTRUCTION LLC. Boston,NIA 02116 WILLIAM MCKAY 18 ACADEMY AVE. HAVERHILL,MA 01835 Undersecretary Not v lid ut signature 81.OZ/80/£0 jauoissiww03 ,uouejadx_ —YD S£8L0 VW I'1IH213AVH 3nN3AV AW3GV3V 81• AVNOW WVI-IIIM aosiAladnS uoilonjlsuo0 Z££680-SO :as u aoi-1 spaepueiS pue suoi}eln6a6 6uiplin8 to pleo8 AjajeS oilgnd jo ivawliedao sjasnyoesseNi '� I