Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Building Permit #415-15 - 1451 GREAT POND ROAD 10/30/2014
Of NORTH A BUILDING PERMIT TOWN OF NORTH ANDOVER ti 0 APPLICATION FOR PLAN EXAMINATIO 4` - Permit NO: Date ReceivedArgo 1J 1 + Date Issued: �4SsAcNUS TMP RTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER L A.A40 /-1 ty t✓l.E– �`e�`�`t /10 Print MAP NO: R PARCEL: 0" ZONING DISTRICT: Historic District yesno Machine Shop Village yes I no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building R'Dne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial lei-Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer / v Identification Please Type or Print Clearly) OWNER: Name: L, W&S Phone: Address: CONTRACTOR Name: . 4 L Phone: 9 87-s'S-8Y' Address: , ,Qs`Peocevl .s1, /t), ta. Supervisor's Construction License: Exp. Date: CS - c�3 7/20 5'`7�a vi c Home Improvement License: /00 ,269 o0 ,269 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. r FEE SCHEDULE:BOLDING PERMIT:$1200 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. �— � Total Project Cost: $„ 9'p 70-96 FEE: $ / i Check No.: el� Receipt No.: Z13203 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor / 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/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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New ConstructionSin le and Two Family) � 9 Y) ❑ 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 In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals haat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording nm ust be submitted with the building application Doc:Building Permit Revised 2014 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) ' t t ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pen-nit Revised 2014 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swirnming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS I Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit I 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 / Location No. .4 Date . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $15S Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# U Building Ope Page 1 of 1 2014-10-31 12:10:28 EDT 17815856260 From: A. James Lynch, Inc_ iDATE u CETIFF LIABILITY INSURANCE ! 10-31.2014 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 CONI"ACT NAME: A JAMES LYNCH INS AGCY PHONE FA 297 BROADWAY AEC.No.Ext): X Arc NU: LYNN,MA 01904 E MAIL INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:AMERICAN ZURICH INSURANCE COMPANY INSURED INSURER e: JARZYNKA WILLIAM DBA BILL JARZYNKA CARPENTRY NSl1RFR C: 25 PEQUOT ST INSURER D: BILLERICA,MA 01821 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. "TR IDDL SUB POLICY EFF POLICY EXP NSR TYPEOFINSURANCE INSR WVD POLICYNUMBER (MI DIYYW) (MM/DDIYYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGETO RENTED $ '- PREMISES(Ea occurrence CLAIMS-MADE OCCUR MED EXP(Any.one.person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ — _..__ —.__............ POLICY1-1 j�� .... LOC $ ' i AUTOMOBILE LIABILITY OMBINED SINGLE LIMIT $ i a aardent ANY AUTO BODILY INJURY(Per person) $ t ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Pe!aocidont) $ HIREDAUTOS NON-OWNED AUTOS Per I�OPERI-Y dent AMAGE $ _ c I $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ I EXCESS LIAR CLAIMS-MADE AGGREGATE $ 77 DED I j RETENTION$ $ 1 WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N X TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVF NIA A E.L.EACH ACCIDENT $100,000 OFFICERlMEMBER EXCLUDED? ❑Y 67-ZUB 10-23-2014 10-23-2015 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under 999OM47A DESCRIPTION OF OPERATIONS below E.L.DISEASE.POLICY LIMIT $500,000 I f DESCRIPTION OF OPERATIONS f LOCATIONS 1 VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) i THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR JARZYNKA,WILLIAM. __..._.._...........--——— -- -CERTIFICATE HOLDER TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE 1600 OSGOOD ST,BLDG 20 STE 2035 CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NORTH ANDOVER,MA 01845 NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE i. I JOHN J.LUPICA,President ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD r Page 1 of 1 2014-10-30 10:19:08 EDT 17815856260 From: A. James Lynch, Inc_ „B.ILLJ-1 OP Q:LS DATE(MMtDD/YYYY) CERTIFICATE. F LIABILITY INSURANCE 110/30i2014 :THIS.CERTIFICATE'IS ISSUED..AS,A MATTER OF INFORMATION ONLY AND CONFERS NO:RIGHTS: U,PON'THE:CERTIFI.CATE HOLDER..THIS. CERTIFICATE DOES NOT AFFIRMATIVELY;OR NEGATIVELY AMEND, EXTEND :OR ALTER THE COVERAGE AFFORDED, BY TtiE POLICIES BELOW, THIS CERTIFICATE.OF INSURANCE DOES N.O,T CQNSTITUTE.A CONTRACT BETWEEN THEJSSUING_ 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 tq thp.terms and..conditions.of the policy,certain.policies may require,a.n endorsement. A statement on this certificate does not confer rights to..the: certificate holder in lieu of such endorsement(s). PRODUCER. .. CONTACT Th A James Lynch Insurance Agency PHONE Thomas'R Ross - F�-__ _.._................... 297 Broadway_ ��O E ext;781-598-4700A/C No): 761-59...... Lynn,.MA 01904 E-MAILs: T Thomas R Ross —_ ` _____INSURER IS)AFFORDING COVERAGE _ NAIC.N. INSURER A:Safety Insurance - 39454 -IN SUR—F ... Bill..Jarzynka Carpentry INSURER B: - - -- 25 Pequot Street .. .. ..... . .. Billerica,.MA 01821 INSURER C: _.— . ....,..... _..... .., INSURER D.: INSURER E: INSURER F: - -- _----_- COVERAGES. CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES'OF INSURANCE USTED.BELOW HAVE'1 EEN ISSUED TD.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 HEREIWIS.SUBJECT TO ALL TPIE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.:LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- -- - INSR -""'—" DOLtU LTR TYPE OF INSURANCE POLICY EFF POLICY INSRPOLICY NUMBER MM/DDVYYYY MM/DD/YYYY LIMITS ... .. GENERAL LIA6ISITY - EACH I , OCCURRENu1,000,00 A X CONMERCIAI,GENERAL LIABILITY 05/04/2014 05pE EIG-Te . RISgS(Ea ocwrrence) . 5 1.00,00 CLAIMS-MADE. U.00CUR ` - MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 _.—.. GENERA LAGGRFGATF S - 1,000,00C. CEN'LAGGREGATE:LIMITAPPLIES PER: � .. " � �� . ��- � PRODUCTS-COMPlORAGG $ 1;000,00 POLICY PRO- n LOC I$ AUTOMOBILE.LIABiLILY. - COMBINED SINGLE LIMIT .. .,. -- fEa accident` � .ANY'AUTO ... BODILY INJURY(Per person) S ALL OWNED SCHEDULED. -- - AUTOS AUTOS BODILY INJURY(Per,eccldenl) S HIRED.AUTOS NON-OWNEDAUTOS PROPERII _PER ACCIDENT UMBRELLA LIAB. OCCUR EACH OCCURRENCE 5 EXCESS LIAB. CLAIMS-MADE .. - AGGREGATE DED RETENTION$ $ WORKERS COMPENSATION "' WC STATU- 0TH- AND EMPLOYERS'LIABILITY YIN ..IAR�_MITS R_--- ANY PROPRIETOR/PARTPoERIFXECUTIVE OFFICER/MEMBER EXCLUDED?��..,., .❑ .N lA E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under ---------- _ DESCRIPTION OF OPERATIONS below E.L-DISEASE-POLICY LIMIT $r DESCRIPTION OF OPERATIONS)'LOCATIONS/:VEHICLES-(Attach AC.pRD'let,Additional Remgrks Schedule,if mono space.is[equlrod) ca.rpen.try , CERTIFICATE HOLDER CANCELLATION ,. SHO .ULD ANY OF THE ABOVE.DESCRIBED POLICIES BE:CANCELLED BEFORE THE. EXPIRATION DATE THEREOF, NOTICE WILL. .BE ;DELIVERED IN Town.of.North Andover '. ACCORDANCE WITH THE POLICY PROVISIONS.. , 1600..Osgood Street Bldg 20.Suite 2035 AUTHORIZED REPRESENTATIVE. North Andover,MA 01845 oc� ©.1988-2010.ACORD..CORPORATION...All rights reserved.. ACOR0:25.(20.11,0i.05) . . ._..............:The..ACORD.name..and..lago.arer.egistered.marks.of.AC.O..RD ..... ..................... l NORT1-!' own of tAndover 0 . - ..�. No. I - 0 4 AIL I ver, Mass, lip COCNIC»l WICK 1 S V BOARD OF HEALTH Food/Kitchen PE Septic System THIS CERTIFIES THATMT 4m;C61� Zee BUILDING INSPECTOR ........... ............................... air, ........oq.rj ,,., q . ....� ... Foundation has.permission to erect .......................... buildings on SS .... Rough p� � .. �.... 1�.. ....5.0 5 1... ..... Chimney to be occupied as . .. ..... .... y provided that the person ccepting 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 B - aws relating o the Ins tion, erati n an Construction of Buildings in the Town of North Andover. �G 4� ��� ,� PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. !3 Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI TA 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 T No Lathing or Dry Wall o Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Bill JaWnka Carpentry 25 Pequot Street North Billerica, MA 01862 978-987-5584 Licensed and Insured f1/ HOMEOWNER INFORMATION Name 4r lLo, -1 r/27 e�/N Zerb ey Daytime Phone j 78— coo StreetAddress(NotP.0 Box) Evening Phone City/Town/\), /9•.4ovA State KY\4• ZipCodeQ(f/SldlailingAdd ress(if different from Street Address) WORK TO BE PERFORMED AND MATERIALS TO BE USED Bill Jarzynka Carpentry agrees to perform the work set forth in Exhibit for Homeowner and to use such materials inconnection therewith as set forth also in Exhibit A,attached hereto and made a part hereof. The following schedule shall be adhered to unless circumstances arise beyond Bill Jarzynka Carpentry's control: Work scheduled to begin:/o /3�Y/Y Expected date of completion:/2/,/if May be based upon arrival of special order material TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE Bill Jarzynka Carpentry agrees to perform the work,and furnish the material and labor set forth in Exhibit A for the Total Contract Price of:$ (which amount includes all finance charges). Payments shall be made by Homeowner according to the following payment schedule: $ Initial deposit upon signing this Contract (the initial deposit shall not exceed the greater of one-third(1/3)of the Total Contract Price as set forth above; OR the Total Cost of Special/Custom Orders as set forth below). $ '�;c)00, c7 Is $ �, ooJ Q.2 --- II ele%v.,.y off' Mallwu $ f o,;;c°upon completion of the Contract In order to meet the completion schedule set forth above, the following materials/equipment must be special ordered before the Contract work begins, for a Total Cost of Special/Custom Orders of $ $ to be paid for building perms $ �j to be paid for $ to be paid for DO NOT SIGN THIS CONTRACT IFTHEREARE BLA7SPACES. HbKeownersSignature Date Contractor ign re Date �v 2 2,C—C-5 Q;1/ Jl d rz-Y h )� Homeowner's Name(Printed) t Contractor's Name(Printed) You may cancel this Contractf it has been signed by a party thereto at a Ihce other than an address of Contractor,wlixh may be its main office or branch thereof, provided you notify Contractor in writing at is main office or branch by ordinary mail posted, by t6gram sent or by delivery, no later than midnight of the third business day following the signing of this Contract. See attached notice of cancellation for an explanation of this right. See reverse side for additional Homeowner Terms and Conditions The Commonwealth of Massachusetts - Department oflndustrinlAccidents Office of Investigations to 600 Washington Street Boston,MA.02111 www.mass gov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Orgmization/In.dividual): ��f �2i,-z��y� �S2 Address: City/State/Zip: �9 Q~l��r��z >"1 a- Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.B1 am a with employer0 4. ❑ I am a general contractor and I . 6. E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• Plemodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. El IIuilding addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.F1 Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.[JRoof repairs insurance required.]i employees.[No workers' 13.❑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 ftie 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 their workers'comp.policy information. lam an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name:, Policy#or S elf-ins.Lie.#: nn Expiration Date: Job Site Address: /y�� �r e z� y'w c� -Pity/State/Zip:_ Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 certto under the p nd penal's of perjury that the information providedaboveis true and correct. Simafore: Date: U 3C) 2 1)7 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.PIumbing 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 of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a-deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local li"nsing 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 producedacceptable 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. Do advised that this affidavit maybe submitted to the Department of Industrial Accidents for coufnmation 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 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-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on filo for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The 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: Tho GoauAonwoalth of Massavhusetts Department of Industdal Accxdeats Wce of Investigations 6.00 Washington.Street Boston,MA 021.1.1 TQL#61.7-727-4900 ext 406 ox 1-577-.MASSAFE Revised 5-26-05 Fax#61.7-727~7749 www-mass ovfC 1a• Office of Consumer Affairs&Business Regulation License or registration valid for individul use only IMPROVEMENTCONTRACTOR before the expiration date. If found return to: gistration: 108288Type: Office of Consumer Affairs and Business Regulation VIVE iratton 8/14/2016;. Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 WILLIAM C.JARZYNKk . William Jarzynka _ 25 PEQUOT ST. " N. IL B LERI CA MA 01862 862 Undersecretary Not valid out s ature Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor , License: CS-037120 :. i WHIIAM C JAR2:YNKA 25 PEQUOT ST N BUTARICA MA 01,862 >1,15L, Expiration 04/1712016 Commissioner i I -� BILLJ4 OP ID:LS ACORO" DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 08/13/2014 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 CONTACT Thomas R Ross A James Lynch Insurance AgencyPONE FAX 297 Broadway A E,d:781-5984700 AJC'No):781-099-0580 Lynn,MA 01904 EMAIL Thomas R Ross ADDS: INSURERS AFFORDING COVERAGE NAIC A INSURERA:Safety Insurance 39454 INSURED Bill Jarzynka Carpentry INSURER B:Safety Indemnity 33618 25 Pequot Street Billerica,MA 01821 INSURER c INSURER D: INSURERE: 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. ILTR TYPE OF INSURANCE ADDL U POLICY EFF POLICY EXP LIMITSPOLICY NUMBER M/DD MMIDD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY BMA0000478 05/04/2014 05/0412015 PREMISES accr rrence $ 100,00 CLAIMSMADE a OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000+00 GENERAL AGGREGATE $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,00 POLICYPRO- LOC $ AUTOMOBILE LIABILITY Fa COMBINED SINGLE LIMIT $ 1,000,00 B ANY AUTO 1703290 08/07/2014 08/07/2015 BODILY INJURY(Per person) $ ALL OWNED XSCHEDULED BODILY INJURY(Per accident) $ 1, 000,00 AUTOS AUTOS X HIRED AUTOS X NON-0WNED PROPERTY DAMAGE $ 1 OOO OO AUTOS ACCIDE + + $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ S WORKERS COMPENSATIONWC STATU- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETORIPARTNERIEXECUTIVEE.L.EACH ACCIDENT S OFFICEWMEMBER EXCLUDED? F-1 N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space is required) carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Moynihan Lumber ACCORDANCE WITH THE POLICY PROVISIONS. 164 Chestnut Street North Reading,MA 01864 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD - I . RightFax 173-1 8/15/2014 8:09:01 AM PAGE 2/002 Fax Server DATE(MNWD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 1n 14 TMISwCaTtIFICATE 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. D 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 and endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: A JAMES LYNCH INS AGCY PHONE FAX 297 BROADWAY (A/C,No,Ext): (A/C,No): E-MAIL LYNN.MA 01904 ADDRESS: 29SYJ INSURER(S)AFFORDING COVERAGE NAIC tt INSURED INSURER A: AM:TRICANZURICHINSURANCECOMPANY JARZYNKA,WILLIAM DBA BILL JARZYNKA CARPENTRY INSURER B: INSURER C: INSURER D: 25 PEQUOT ST INSURER E: BILLERICA,MA 01821 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 CEIITFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN B SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICYEFFDATE POLtCYEXPDATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMI MYYYY) (MMDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY AMAGETORENTED S CLAIMS MADE F-1 OCCUR. REMISES(Ea occurrence) H� — ED EXP(Any one person) $ ERSONAL A ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE S POLICY a PROJECT LOC RODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per Peen) HIRED AUTOS BODILY INJURY S NON OWNED AUTOS (Per accident)PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAR []OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ S A WORKER'S COMPENSATION AND X WC STATUTORY OTHER EMPLOYER'S LIABILITY YM UB-9990M47A-13 1012312013 10/23/2014 LIMITS ANY PROPERITORIPARTNERIEXECUTIVE NIA E.L.EACHACCIDENT $ 100 000 OFRCER1MEMEIER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE I S 100,000 Dunder E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION X) OF OPERATNSbelow DESCRIPTION OF OPERA-nONS1LOCA'nONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THRS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR JARZYNKA.WILLIAM. CERTIFICATE HOLDER CANCELLATION MOYNIHAN LUMBER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 164 CHESTNUT ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPR A E N.READING,MA 01864 = ">" ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1989-2010 ACORD CORPORATION. All rights reserved.