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HomeMy WebLinkAboutBuilding Permit #091-15 - 14 HIGHLAND TERRACE 5/1/2018 NORT11 BUILDING PERMIT TOWN OF NORTH ANDOVER io22ry ''- APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received �,4AorEv Py;y* �SSAC HUS�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition - El Other El Septic ❑Well 0 Floodplain ❑Wetlands El Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Address: Supervisor's Construction License: Exp. Date: 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: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/OwnerSignature of contractor V J - Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swiimning Pools El 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 On Signature_ COMMENTS j I CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes i 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 l 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 DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit 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 o Building Permit Application Li Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract Li Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster p permits require sign off from Fire Department prior to Issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan o 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) 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) ❑ Building Permit Application ❑ Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic y raulic Calculationslicable If Applicable) Pp ) o Copy of Contract ❑ 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 Doc:Building Permit Revised 2014 Location N T } (�No.-CA Date r7l� . - TOWN OF NORTH ANDOVER . Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 1 �� Building Inspector � c1pRT1� Town o � _ ndover 0 0 1 No. ,� oh ver, Mass, 2 COC NIC N(WICK y�. PER S U BOARD OF HEALTH j Food/Kitchen IT L Septic System • THIS CERTIFIES THAT BUILDING INSPECTOR ...... .....a:.c -�:,.1�.......... ..�. ........ ............................................. has permission to erect .......... g 4 „ ,,,,,4, ,1�1�y „1,!/lJ1r�...................... Foundation ................ buildings .. ... ...... ..... Rough tobe occupied as ........... .....:. ......rt:... 1�..................................................................... Chimney provided that the person accepting the permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR {: • UNLESS CONSTRUCTION T TS Rough { 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. Massachusetts Home Improvement Sample Contract c; This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard i language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy a "A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Name y Name Uva wed Street Address(do not use a Post Office Box address) Contra /Salesperson/Owner Name Arnim AA OVIVIS UY6L1 City(Town State Zip Code Business A nest include a street address) Daytime Phone Everting Phone City/fown State Zip Cade 3�6� N'1 0 Mailing Address(It different from above) Business Phone effederal Employer ID or S.S.Number Home Impmee -CummamReg.Number Hxpirdtim dale i law.90—ib.moll home im.Hd a gi t eoatmcl.b have I -�3 3 j v*nad reghslralioa•oroD¢r /'tel The Contractor agrees to do the following work for the Homeowner: V (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if nems!n.) Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of � p�1]d Date when contracwr wt egin contracted work MGL chapter 142A.) n r'�Q_I�e w1�n contract— ed work will be substatally )gleet. Total Contract Price and Payment Schedule 1 1 The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: (•) Payments will be made according to the following schedule: $��i upon signing contract(not to exceed 1/3 of the total contract price gz the cost of special order items,whichever is greater) $ by ( / or upon completion of $ f by / I_or upon completion of $� J upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.('*) $ to be paid for p� NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the owttractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of ally special equipment or custom nhade material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty being Provided by the contractor? ❑No Yes(all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for Materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract trader law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires 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 Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get 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 contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. Seethe attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM Two identical co ies of the contract mus[be completed and signed.One copy should go to the homeowner.The other copy should be kept by the contmetor. Ho eowne lure �,Ig—_nature r 1,911'( %_7 L7 Date Date Contractor Arbitration ,L 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 not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she 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 Home 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 firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitrptkon as provided In Massachusetts General; ,�char 142A. Ho own is a ontractots Signature NOTI .The signatures of the parties above apply only to the agreement of the parties 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 homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL 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 are automatically excluded from all Guaranty Fund provisions of the 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 other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner 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 exhibits 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 agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy 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 him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the 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 Home 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 Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at http://www.mass.gov/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 http://www.mass.Rov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: b!W://db.state.ma.us/homeimp—rovement/licenseelist.asl2 For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 Version 2.1-11/22/2010 NOTICE OF CANCELLATION YOU MAY CAN THIS TRANSACTION, WITHOUT PENALTY OR OBLIGATION,WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU CANCELLATION NOTICE,AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL,YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE,IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED,ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY,IF YOU WISH,COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION,YOU MAY RETAIN OR DESPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER,OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO,THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION,MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO [Name of Seller],AT [Address of Seller's Place of Business]NOT LATER THAN MIDNIGHT OF (date). I HEREBY CANCEL THIS TRANSACTION. Date: Buyer's Signature: Page No. of Pages x �xXJ� Builders License # 58443 Home Construction Reg. # 167338 (V Tel 8A& )T(D U,V,10 (781)944-1994 (978)664-2557 READING NORTH READING P.O. Box 637, North Reading, MA 01864 Please visit us at www.duvalroofing.com PROPOSAL SUBMITTED TO DATE `ulhrl / L/ STREET/ ptC CITY,STATE AND ZIP CODE / / 1 �CrFa ( ' t/e r We hereby submit specifications and estimates for: k Rip& Remove all existing roof related debris from roof as well as job site with our own disposal truck. NO DRIVEWAY DUMPSTERS ❑ 1 layer of existing roof shingles Z2 layers of existing roof shingles ❑3 layers or more of existing roof shingles 0 Replace any damaged roof decking; not to exceed 32sq.ft. (additional at$1.70 per sq.ft.) 0 Install 8"Aluminum Drip-edge/Rake-edge along entire perimeter(Choicehite, Brown or Mill) stall ICE&WATER UNDERLAYMENT on all horizontal eaves, sidewalls, skylights,chimney flashing and valley areas Ef Install a premium base sheet underlayment(felt)that is in compliance with the asphalt shingle manufacturer chosen by the homeowner Install The Homeowner's Choice of the selected Tamko/IKO or GAF Limited Lifetime Architectural Roof Shingles ",See individual manufacturer's warranty for specific�details or please call us with any questions 21 eplace all existing bathroom louver and/or Oxha su t pipes)with new aluminum flanges Chimney(s)-counter-flash and re-step existir flashing f ❑Cut& Install new lead flashing ' ❑ Install a continuous low profile Ridge-Vent on all ridge lines LJ Soff it-Vents 8( Roof Louver-Vents ❑Seamless Aluminum Gutters-Custom fabricated on site with our own gutter machine ❑ Downspouts at additional ❑Leaf Guards Ef Other l ,1.1it 4n, P��r ;:"I,i Cr ijej ttd 'It V, u /l// ~ �aJhld l it t� rrc; tf��i 7:�t i,t t+l r' !� r�e'n �Pt f rc, I t pig ❑ Roof Insulation- Increase existing R.value to R.value lf r/1 f D (t^^b VP j t`t r sr ?ic n % We JJrapuse hereby to furnish material and labor-complete in accordance with above specifications,for the sum of: Total price not including options. dollars($ ' 7 q6 ). Payment to be made as follows: 30%deposit required before ordering materials.Balance due in full upon day of completion. Please make all payments out to Kenneth Duval, mailed to: P.O. Box 637, No. Reading, MA 01864 Final Payment is due upon day of completion and is subject to the Authorized C_ J 'j- supplemented Terms&Condition sheet when scheduling. Signature THIS PROPOSAL IS VALID FOR y DAYS DUE TO FLUCTUATIONS IN MATERIAL&DISPOSAL PRICES. NOTICE N NOTICE TO 0a TO EMPLOYEES EMPLOYEES 0,1M Svc The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law,Chapter 152, Sections 21,22&30, this will give you notice that I(we) have provided for payment to our inured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P .O. BOX 1450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY (7PJUB-023ON91 -9-14) 03-11-14 TO 03-11 -15 POLICY NUMBER EFFECTIVE DATES r- GILBERT INS AGCY 137 MAIN ST Ln— READING MA 01867 M NAME OF INSURANCE AGENT ADDRESS PHONE# o� DUVAL ROOFING LLC 184 PARK STREET o'.= o- NORTH READING _ MA 01864 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services °'— provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably '— connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 004315 W20P1G02 TO BE POSTED BY EMPLOYER A�© CERTIFICATE OF LIABILITY INSURANCE 6/18/2014 °/18/2 D14YYj 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 pollcy(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 NAMNTACT Barbara McDonough Gilbert Insurance Agency, Inc. PHONE (781)942-2225 FAX .(781)942-2226 137 Main Street EMAILADDRFSS.bmcdonough@gilbertinsurance.com INSURERS AFFORDING COVERAGE NAIC# Reading MA 01867-3922 INSURER A:HARLEYSVILLE/WORCESTER INS CO. 6182 INSURED INSURERB:Travelers Ins. Co. 0031 Duval Roofing, LLC. INSURER C: P.O. BOX 637 INSURER 0: INSURER E: North Reading MA 01864 INSURER F: COVERAGES CERTIFICATE NUMBER CL1331300142 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. ILTR NSR TYPE OF INSURANCEADDL UM POLICY EFF POLICY EXP POLICY NUMBER LIMITS GENERAL LIABILITY EACH OCCURRENCE $ _ 1,000,000 X COMMERCIAL GENERAL UABILITY DAMAGE TO PREMISES Ea NTE15n $ 100,000 A CLAIMS-MADE OCCUR L6415BG 10/23/201310/23/2014 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 PRO- X POLICY LOC AUTOMOBILE LIABILITY COME INED SINGLE LIMIT a accident 500,000 A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BA64456G 10/23/2013 10/23/2014 AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ Uninsured motorist BI split limit $ 100,000 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ B WORKERS COMPENSATION ro be provided directlyWC STATU- 101 M_EMPLOYERS'LIABILITYI FR ANY PROPRIETOR/PARTNERIEXECUTIVE Y/N is Travelers Insurance $ 100 000 OFFICEPJMEMBEREXCLUDED? ❑ E.L.EACH ACCIDENT N/A (Mandatory In NH) /11/2014 /11/2015 E.L.DISEASE-EA EMPLOYEd$ 100,000 If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Evidence of Coverage CERTIFICATE HOLDER CANCELLATION 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. North Andover, MA AUTHORIZED REPRESENTATIVE Gilbert, CIC/BARBAR ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. Alt ' rI ht g s reserved. INCn95l9MM.Nn1 Tho arnon noma ane!Irma ere raniotoroA mor6e of arnan a Vie f COUSUmer Affairs ONfpAGSOR .Type. Office IMPROVE 633 G 0.04 Re a stra'on; 012Ot4 ExPiratio° 91t - y. - 'y 0 G L OF N 1 g: R K�NNESN 0\3\4 NIL �ndersecre�ry NO,R Massachusetts -Department of Public Safety Regulations and Standards Board of Building Re 9ular , cr iso 'on Sup . C'Licen a -058443 License: CS i KENNETH P DUYAL " PO BOX I" 72 NORTH ST 1564` N READING MAR Expiration 1211012015 Commissioner 77ae Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Duval Rooifng, LLC Address: P.O. Box 637 City/State/Zip: North Reading, MA 01864 Phone#:978-664-2557 Are you an employer? Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 8 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' comp. insurance.$ 9. ❑Building addition [No workers' comp. insurance P• required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.M Roof repairs insurance required.] # c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp, insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their worker'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. Travelers p y Policy#or Self-ins. Lic.#:7PJub-0230N91-14 Expiration Date:3/11/15 Job Site Address: " City/State/Zip: A) Attach a copy of the workers' co m nsation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cefti er t pains and penalties of perjury that the information provided above is true and correct D S i atur Date: Phone#: 978-664-255 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#: