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HomeMy WebLinkAboutBuilding Permit #637-12 - 140 COLONIAL AVENUE 3/6/2012 i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: r �/ IMPORTANT:Applicant must complete all items on this page I LOCATION fyC) Ccs>ontC5,� I IqU< Print PROPERTY OWNER n , /2 Unit# Print MAP NO �P.ARCEL:�ZONING DISTRICT: Historic District ye n Machine Shop Village y s no 100 year-old structure ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building &6ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition t ❑Other ®RSe i3 ,®We �, , '. ® oodplE ®Wetlands -f ® Wa�rshedD"stnct t � O1tUJter �wer � DESCRIPTION OF WORK TO BE PERFORMED: (�emod e it n o 0 165AI-61160WS (Identification Please Type o Print Clearly) OWNER: Name: MYZ e, i ri CA Phone: 777 Address: 1 q® lon 1 ct ND AkL tj&)>UeX- AMSS CONTRACTOR Name: ,10 5e p�'� 12(J�I6r� (St? Phone: ��f�' 3'9�/S'��/' 2�`1" \ 3"72 Address: 0� < pig} yLk Re H4 0Z-1 S/ t Supervisor's Construction License: )3xp. Date: 7 /lb /Z01 - Home Improvement License: 15-7 zi3d Exp. Date: It ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.•$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ oD FEE: $ 31 `f1- Check No.: Receipt No.: , wi NOT Persons contracting with unregistered contract ------ -- -- _ -- --- -;�-- ----- ------------ con-t-r-ac-t -_ ---- to the guarantyf nl - -- - -- -----------ems`" ;signature of°A`genti.Qwner: , atureofkcontracforf ri:._},;:=::1 Location_ No. L Date ,i. - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fees Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# �4/0 a 25071 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Swimming Pools ❑ Tanning/Massage/Body Art ❑ 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS '?oning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS I 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 — d G min. MGL Chapter 166 Section 21A Fan 100-$1000 fine$ NOTES and DATA— For department use ® Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi. Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition or Decks ❑ 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/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (if Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building 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 ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit An all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals khat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording roust be submitted with the building application Doc: Doc.Building Permit Revised 2008mi rtmc $t• ntnndtundurd, M ►ssachuct (iin„ Refulutio � goa►Cof nsttrruction Supervisor License License: CS 58791 JOSEPH FRUCIANO JR 211 PARK AVE i REVERE, MA 02151 Expiration' 711012012 Tr#: 29709 ('ummisiuncr gYfe �c�%li °�'� License or registration valid for individul use only ( - HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:,137430 Type: Office of Consumer.Affairs and Business Regulation + Expiration: -1:1112/2012 Private Corporation 10 Park Plaza-Suite 5170 I 'Boston,MA 02116 III ij NORTH SHORE DESIGN IN JOSEPH FRUCIf�NO=��t -= 211 PARKAVE. --tea NORTH SHORE Design e,�&modefing, Inc. Thone/fax 781.284.3 729 northshoredesigninc@comcast.net February 21,2012 Pg. 1 Mr. and Mrs. Mike Fanning 140 Colonial Ave. North Andover, Mass Bathroom remodeling(children and Master Bathroom) Scope of services rendered are as follows ➢ To prep and to add floor coverings and protect steps and railings with bubble wrap and plastic as needed. ➢ To provide small dumpster on site for debris removal. ➢ We will demo children's bath tub and walls around tub only. ➢ We will re-work closet next to tub as per design. ➢ We will demo master bathroom complete down to framing of walls. Except the exterior wall of bathroom. ➢ All fixtures in master bath will be removed. ➢ Ounce wall board has been removed we will make sure insulation is up to today's energy stretch codes,If this needs to be updated will not know until all board has been taken off. ➢ We will reframe bathroom as needed to accept new shower and tub. ➢ We will provide electrician to install a Panasonic quite fan in children's bathroom. ➢ Electrician will install a fan in master bathroom also along with new lighting as needed per design. ➢ All electrical in master bath will be brought up to code as needed. ➢ We will provide plumber to install valve and tub in children's bathroom also to repair toilet internal parts in this bathroom. ➢ We will provide plumbers to install new tub with whirl pool jets,new toilet not being moved, and new shower valve with shower pan made of rubber. Also install double sinks in vanity that will be installed by N.S.D. Plumbing at sink area will not be moved if so plumbing price will need to be adjusted. ➢ We will apply all cement board around tub and shower area in children's bathroom. This is preparation for tile contractor,tile to be installed by others. ➢ We will also apply cement wallboard around shower area and tub area in master bathroom. We will also prep floor as needed for tile contractor,tile to be done by others. ➢ The rest of the master bathroom will get %2 inch wallboard and skim coat of plaster as needed. North Shore Design Inc. 211 Park Avenue Revere Mass 02151 NORTH SHORE Design e�*modeling, Inc. Phone/fwc 781.284.3 729 northshoredesigninc@comcast.net February 21, 2012 Pg. 2 Mr. and Mrs. Mike Fanning 140 Colonial Ave. North Andover, Mass Bathroom remodeling(children and Master Bathroom) Scope of services rendered are as follows ➢ All finish moldings in master bathroom will be reinstalled and match existing best as possible. ➢ We will purchase and install finish trim around mirror in children's bathroom and apply some base molding if needed. ➢ We will add open shelving in re-worked closet above bottom door in children's bathroom. ➢ We will remove all floor coverings and railing protector when job is completed. The cost breakdown of bathrooms will be as follows Plumbing cost for bathrooms= $5,700.00 Electrical cost for bathrooms= $2.700.00 All other demolition costs as well as carpentry and moldings Plastering and finish carpentry needed to complete project Labor and materials are included= $17,800.00 Total cost to N.S.D. not including option shower door= $26,200.00 Please note not included in our price are: Fixtures plumbing or electrical (except Fans and recess lighting) Cost of permit application and if any additional documents needed to get permit. No tile or tile labor(except all preparation for tiling) No cabinet vanities or tops (except cabinet install) No towel bars,toilet paper holders Etc. (except to install standard fixtures) No painting or painting preparation Please see separate page for options for project Thank you for this opportunity to bid on your home remodeling Project. If this estimate is accepted we will provide a payment Schedule as well as a detailed time frame of work being performed With dates and we will keep to this time schedule best as possible. Please direct all questions to Joe Fruciano @ 617.593.9215 North Shore Design Inc. 211 Park Avenue Revere Mass 02151 NORTH TO" 0Andover, 0 o , d.over, MassLAKE ., I� COCKICKEWICK 0"QATED 7�7 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........................ Y!!11�►vw^....................................................ft............................................ •••• Foundation has permission to erect........................................ buildings on ....146........ ....... Rough t0 b8 eCCUpled as.... .0��......... .�4. . i�l.�......... ....... .r.. Emoo.... Chimney C e provided that the per, accepting his 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, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR, VIOLATIONof the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR. UNLESS CONSTRU O TARTS Rough ..... ...... ................................................... Service BUILDING INSPECTOR 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. NORTH SHORE !Design c�@§modeling, Inc. (Phone/fa.-(781.284.3 729 northshoredesiyninc@comcast.net February 21, 2012 pg. 3 Mr. and Mrs. Mike Fanning 140 Colonial Ave. North Andover,Mass Bathroom remodeling(children and Master Bathroom) The payment schedule will be as followed 1St payment due when contract has been signed 10%of contract price= $ 2,620.00 2nd payment due when project has been started 40%of contract price= $10,480.00 3rd payment due when master bathroom has been gutted as needed 40%of contract price will be needed= $10,480.00 Final 10%will be at the end when all is complete and customer is Satisfied and all inspections have passed 15%of contract price= $ 2,620.00 Total paid under contract price= $26,200.00 Work schedule will be as follows A work schedule cannot be given until a start date has been established. Ounce permit application has been submitted and given back from building department a work schedule with dates can be presented. Contractor �� Homeowner t���� <J � 0 Joseph Fruciano Mr. and Mrs. Mike Fanning North Shore Design Inc. 211 Park Avenue Revere Mass 02151 Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Name Company Name Street Address(do not use a Post Office Box address) Q Contractor/Salesperson/Owner Name City/Town State Zip Code Business Address(must include a street address) N044 4A)Q0Vr221 �`15Sd, I I N►2 19ve 13�9s�r►�� 1 Daytime Phone Evening Phone City/Town State Zip Code �/?- 70797$- -16 I2euen HP D Z 1 S I Mailing Address(It different from above) Business Phone 6 1?- Federal Employer ID or S.S.Number d1� -Gy�J7 Home Improvement Contractor Reg.Number Expiration date Law requires that most home S_7 14 3© improvement contractors have a valid registration number / L The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) �lease See Alpckie 6ar+TX)gC_T Slgp�c� . 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 ,6OLZ-Date when contractor will begin contracted work. MGL chapter 142A.) f 31 I�G/ZDate when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: �rOy 26r-) Payments will be made according to the following schedule: P1[.4 eze Sem 100C4ed S(g�_)&_ $ upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ by / / or upon completion of $ by / / or upon completion of $ 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 NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of (a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty beine provided by the contractor? ❑No R Yes fall 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 res,Ponsible for all payments to all subcontractors for materials and labor under this agreement 1I 11 P-19 d2't S G 14tQ pro p Q,14 &,/ Contract Acceptance-Upon signing,this document becomes a binding contract under 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. See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of the contract must be completed and signed. One copy should go to the homeowner. The other co y should be kept by the contractor. Homeowner's Signature s %ontract 's Signature {Date___ _ 'Date_ 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 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 arbitration as provided In Massachusetts General Laws, apter 142A. Homeowner's-SignaWre-:> ontractor's Signature NOTICE: The signatures of the parties above apply only to theaeement 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 Y pY p pY 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.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeiml2rovement/licenseelist.asp 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 t The Commonwealth o,f'Massachusetts Department of-IndustrialAccidents Office oflnvestigationg 600 Washington Sheet s� Boston,MA 0.211.1 www,massagQv/�'ia - Workers' Compensation JCnsur4nceAffidavit:Builders/Contractors/L+lectricians/.Plumbers A. Iicant Xufoxmation I.'lease Print Le 'bl Name(Business/Organization/individual): p S6 Address: �� y City/State/Zip: v end Phone !�7-t9 pis Are you an employer?Check the appropriate box: 1.111 am a employer with 4. ❑,I am a general contractor and Z Type ofprojeet(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2111 am a sole proprietor or partner listed on the attached sheget.x 7• remodeling ship and have no employees These sub-contractors hove working for me in any capacity. workers'comp,insurance. 8. Womblition [No workers'comp,insurance 5. ❑ We axe a corporation and its 9. El Building addition required,] officershaveexercisedtheir 10•❑Electrical repairs or additions 3. I am a homeowner doing all work right of exemption per IVIGL 11.❑Plumbing repairs or additions myself;[No workers'comp, c.152,§1(4),and we have no insurancerequired j i em to employees. 12•[]Roofrepairs p Y [No workers' comp,ins mancerequired.] 13•j]Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. i Homeowners who check thitthis s box must indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. � tContracfors that check this boxmust attached an additional sheet showing the name of the sub-contractors and their comp,policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: Pb-fe_IeSS dl i4fl Policy#or Self-ins.Lic.#: / y4' ' i�c /B� / 1 Expiration Date: ?l i�j l ZO[Z, lob Site Address:_I q0 60 b5Alc � AVC City/State/Zip:_ /(,rjit�A I�nrxrv�yt �(�SS . 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 ofMGL c.152 can lead to the imposition of criminalpenaliies of a sue 11P to$1,500.00 and/or one-year imprisonment ►f up to$250 ,as well as civil penalties in the form of a STOP WORK ORDER and a flue t .00 a day against the violator. Be,advised that a copy ofthis statement may be forwarded to the Office of nvestigations of'the.D9 for insurance coverage verification. do liereb cer fp � ry ,Y y under the pains an o er'u that the information providers above is frue and correct. afore: Date: Z AD/ Lone A �l 2 Official use only. -1)o not Write an this area,to be completed by city or town official City or Town: Permit/License# fssuingAuthority(circle one): I.Hoard of Health 2.Building Department 3.City/Towzr CIerk 4.Electrical Inspector 5.Plumbing Inspector �.Other Information and histructions 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 thereiii,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"everystate 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 ofpublic 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),addresses)andphone 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 maybe submitted to the Department of Industrial Accidents for confirmation-of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of T 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-insured companies should enter their ,self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit iscomplete and printed legibly. The Department has providedaspace atthe,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/Iicense number which Will be used as a referencd.number. in addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current Policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy ofthe 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 notrelated to any business or commercial venture (i.e.a dog license or permit to burn leaves etc)said person is NOTrequired to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: e C01-11I oa-wea f'f,Of Ma:ssadawetts Depaftent Of Tadustfial.Accidents ®ice of Inve'stig_aROIRS 600 Washington Street Bostm M- 0 11 X TeI.#617•-727-4.900 ext 406 or.1-$77-MA.SS.AFE ACORU DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 03/02/2012 PRODUCER Phone: (617)846-0731 Fax: (617)846-0732 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HARDY OFFICE/WELSH&PARKER INSURANCE AGENCY,INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 57 PUTNAM STREET HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR WINTHROP MA 02152 ALTER THE COVERAGE AFFORn INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: PEERLESS INS CO 24198 NORTH SHORE DESIGN,INC. INSURER B: Atlantic Charter 211 PARK AVENUE INSURER C: REVERE MA 02151 INSURER D: 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. LTR INSREI TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMA DATE DATE NWWDD GENERAL LIABILITY CBP 7368406 09/17/11 09/17/12 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurence $ 300,000 CLAIMS MADEQ OCCUR MED.EXP(Any one person) $ 5.000 A 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- POLICYnjw" LOC AUTOMOBILE LIABILITY BA7368401 09/17/11 09/17/12 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ A X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN FAACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR a CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION$ WC STA WORKERS COMPENSATION AND WC100103800 09/19/11 09/19/12 TORY LIMMiTS OTHER EMPLOYERS'UABILITY YIN E.L.EACH ACCIDENT $ 500,000 B ANY PROPRIETORIPARTNER/EXECUTWE a (Mandatory (M nddatoryinxNHRER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,desaibe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION Mr.and Mrs.Mike Fanning SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 140 Colonial Avenue EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO North Andover MA 01810 DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Attention: Mildred C9. IV�-C •li.�/ ACORD 25(2009/01) Certificate# 47576 ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD N 1 c /G I i j CoJoh(C."-1 I I 0% '-�qm(f, �Ocjq);or� i r-OATon tUe� ` `j II�,�►c° +- ���ec'�rt;c✓� 1 I , I � ' 1 LD i ! � ' M ' ! ' Ct I + ! 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