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Building Permit #958-16 - 147 FRENCH FARM ROAD 3/9/2016
0ORTy AAY ��'/ BUILDING PERMIT o` tL�o �No TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION _ K 1. Permit No#: �[ Date Received �gSsacHus�`��y Date Issued: r IMPORTANT: Applicant must complete all items on this page LOCATION ! y� �'IZEn/Crl FA"2 r\l .b Print PROPERTY OWNER ��I(AJ "- t;/J V OM J713 _ Print 100 Year Structure yes Cno MAP` PARCEL: ZONING DISTRICT: Historic District yesMachine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition [I Two or more family 11 Industrial >Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition _❑ Other ® pti ®,Well - - ❑�Ilo plainsWetland _I Wat s dstictb ter/Sew,r DESCRIPTION OF WORK TO BE PERFORMED: �CI TClAEjJ -gjE;,-ti0yA:77 bJ Identification- Please Type or Print Clearly OWNER: Name: ;zy-bluj �)��tThi Phone: Address: /Ll7 FA TO Contractor Name: DA E1Wu R,47(--1 //u 6 Phone: "1 led Q O2 3360 Email: -DAZW,,�sMA-ZDtm (2� MC �c� NGT Address: iE'DD(fui 8%1C 11,1e7-Hue^' /lye. Supervisor's Construction License: —Exp. Date: Home Improvement License: 10,11f Exp. Date: 9 4-7—� ARCHITECT/ENGINEER Phone: Address: Reg. No. i FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. �} Total Project Cost: $ % �,�J� FEE: $ ft Check No.: 9 G ;1 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund _{. Location �4/ 7''r-�7i� f'�l n►'� ,� No. J 'l Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ d Check# �� 1 Building Inspector Flans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ FTYPEOFWERAGE DISPOSAL Tana ag/Massage/Body Art ❑ Swimming pools ❑❑ 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 r / COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/sictnature� mate Driveway Permit DPW Town Engineer: Signature: Loc 384 Osgood Street TIEDt EIaA ' ICIBS es { � RIIIIEN' �TemDumpster ontsit ,y Located at 12'4,,1Mam Street ' i ' ~'I`�` "" `� , '.Fi.r�DepamenfsRgnature/date . : s,� �' y A. fi z� li'yyC'�v�31 •`6d jf'�j1C f yy t ,{La 1: 1"rk'=)t ]) � "�j! y rr ��t� py,�t £ 7 GOMIVIEIVTS 4Abi 1µi axt 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) i U Notified for pickup Call Email Date Time Contact Name DocHailding Permit Revised 2014 I Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits .Ve, wilding Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses ,Copy of Contract � loor 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 Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products ISIOTE: 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 Doe:Building Permit Revised 2014 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 93,7 '550.00 m $ - $ 1,125.00 Plumbing Fee $ 140.63 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 140.63 Total fees collected $ 1,506.25 147 French Farm Road 958-2016 on 3/9/2016 Kitchen Renovation I { F NORT#i Town of No. 2% Cal Ito * zh A,, ver, Mass o k*L6*. COCNICMl WICII V BOARD OF HEALTH PERMIT T_ LD Food/Kitchen Septic System THIS CERTIFIES THAT ,,,,,,.... BUILDING INSPECTOR �irwV &— ......... h►w-........ .... .... ..,........�. ........................ has permission to erect .. g 1.404,,, �!i`� �' /Nti•............... Foundation ........................ buildin son .... ......... Rough to be occupied as ....K%. .....}.........Lfto ,// ....................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final I a PERMIT EXPIRES IN 6 M94THS ELECTRICAL INSPECTOR I UNLESS CONSTRUCTIO RRough 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. �� ► 0e tr Bn the;QUALM and�of "wery ' , ts ma 5nb tW TO John&Kart`$enventnto Construction Superw�c►irs Liccst 66341 147 Preget FarmRd. me In'` rovem Ho p ent l� traton t?A96! N-And MA We here y Purpose to furnish the matenals indicated and perfonn the labor necessary for the. comptetian of. Renovate kttichen and reloeate laundry room.(See,speeificatrats sheet) All..materal is nteed.'to be ass guard pecified,"and.the above w± rk to be performed An accord nce W' with the+drawings and-specificanas..submitted:;for above vuii rk and com -lehon in a;substantial workmam a manner in the sum of fifty mn b. dyed dou m _ Pnyuiertts to he made as fobs S 1,000.IX1 Upoir,ezecntion'ofcontras $15,000.40 men work bins. . Remaining poyments as work progeses. rtespectfully submitted Darren l�+rar#�no Any aleition or deviation from the above specificatiocons will be executed OM upon wntten.order,and will become-an extra.charge over and'above the estimate .All agraeme cod agent upowdccidents,or deiays beyond our eonfroi x Notg4bis MOP< may,. vv�thdrawn if-not accepted th3u iii days: 'Proposal pate 10107115 CCElyr, OF PROPOSAL; = The above paces;specificat oris,and conditions are satisfactory and acre hereby accepted Y" are suthorized',to do the work'as specified Payments will be aside as®utlined above. }- ovOx civ CT.9 MRE AIREAN YBLLA ivKcrA _ES -. .. :. .. . < '- Vr✓tel' :r . . - ,z I Z. I�. I-� I-I. I � i . .- . � I -�. i , t , � �`i: - I i, -, A. . �I I-1 11 , I . . :. ., P,, ,,, .., , - ,� I I -,1-1 I - v�,, . ,,.�,. .......... ,,,�,���,1,t?,�st',4�,,�"__� : - %� - -11 i_� -I �1,1.1�1 I�l 5.1 �I 11 ..,.. I � I 11 . . �i,�� f;. , .,;� I I , 11 . I . , __ ,,,,, I I � I ,R- -�T� ,"�—,_'l,�__-''.�',�;" -- ,, . . � 11,I � �, ,.�.;%.".���� .:,.,t� ,,.., - ,, I I I '�',CJ,"' SflGR ��, *t -�".-�, ,�'�',',�,,Y!:,_"".,,.,,ci",� I - - ,,� -.1 ., , . -�, � ,, ,�,',,,i.'. ii%,� - - ,-,,.-,--,",,� � � ��l� . , -�,,�,� , -, � �_-,��- - - � aP ooR arrrsran and renovattc�n" f ICrtrlien rrr l ting,'bit not IrmitedFto, new caljrnets,Jcowitet I t appliances, wrnlows, etc }Relocate=laundyrvom ta".upstuirs closer~;: , w, .. ,,�_ F P WAO PW 1VI Corrstructron will file+all nece., ,r paper ward tt obttrin the full y"itg pertnrts - bu ldm 7-i'_ -icat,pl imbirtg, atzd:debm remr�val. 7'he.cast a{ctll pe fts a»d fees riecessa rs IiI nvincludezl rntthrs estimate and w#ll be billed separately , sITEPREP In ane ort to trmit the dust enerated om theerwvatron 1. cress Doorw sand g `: ay apenings to other areas o tJte house wdl1..be sealed t ff red in reason with pinsttc or drop clr�thes 11 Carstruetvn1 .rs rPsponsbTe for rt1 delirrs gerrered �4 container will be placed yr site.to ensure a clean;work side The container is for,debrrs generated bf1l" i,y 1J1lCtrrstruction vrtty, i'l1. 5 _tis not I»tended or hvme1.oyvtier i�se ,_. .l ., , - . x 1. x. , ._ �. SEA ,(,, N F 1 rtc- demolition of es, cahmcts;`=drywall, Iran�es;rrrsulatrort; vor n etc: l?e 1. lar dy closet and take down:the wall Between the kitchen a _b+athr©om.< p'RfIfG 'sante a tiet�v,wall between the bathrzrom and the kitchen. Enlarge Ilse opening tv the drrcln racm. a the v g g petrarg ro the laving room: Framing as.necessary for re�octition of the texirtdi y ttito the upstairs hallway closet` To ensure proper fastening, solid'blocking wzll"be install bund alb cabinetryf. , ,. } " „- lJ 4 ' . 1�`rame rind install n1.e�v kitchen wm lows-.-Tire cast ull#are yvrndows, screens, ardor h are, , grills, etc rs covered Wider an-allowance.- f tae kitchPrz wrndaysvrll lie gamed to'°the cour�terto hei li#"arid bumped out P $ approrrriately 4 "to allow far the granite countertop ty form its sill=°The exter±vr wild be H w tJ.pvc term Boards and crown molding."A fYat le1.ad roof will be installed vn top of the wrtr1.dorti omi1.tsI 11 INKS T A. 010 r . . 77ze exteri©r krtclieri wall will receive grew.msulatron _ I i bR14-JL ,' L Inslriltatictn of 1.,,b�uebv-11 ar�l on all walls,,cerlin gs, yr other ar'"I.,here drywall. . , i been removed or_distitrliea� A skim coat of plt#ster wilt lie installed anally new blue$vara A11 p new ceilings will receive a�friirsh. r. . P Pv 871i1VIJ�D , TDF.10E + dl'Clt[C1ti ons Sheet FIMSWORK ltstallahon of neje term around the newitehcnwindow units Irtstatlation of new trim arorbrd the enlargers openritgs Install a stew paired goof unit for tie relocated laundry closet IntallAton of new baseboard as deemed necessary Mew window.trim and baseboard will match the existing corrdrtrd 17 AN S'TALt.ATlUN T A4 Confitrucaon is responsiblefar installation ofull°cabinetry*bnd"their rxssociated: maldrngs and Hardware Solid blacking,wrll,be`riistalled to assure.proper securing mall cabtne Iry: I'he:,c0 ''of the cabinets and t�ietr associated moldings:0 hitrdwar„e:rs covered ” under the Cabinetry All, ` recervi ng and fA*Wjig a frnrtl cabine#plan., l�►1tt Cor�sh tctlott > �titnate fs suh'ect to reserves the rl ht to g adjust the price of the conin�ct uprtrt finto:tece ►it of iris p n. �1PPL Al1T "STALLMON . : D 1 Construction will install the following appliances refrxgera#or, disytwasher, rrtnge; f exhaust fart microwa ,andgrttage disprisczl Tlie cost and delrverua the:cronlr'ances"is not ncladed in tuts contract dnd is the res, "'kit- tifthe homer wrier. `` Tf r eestti` to is subIjal to rereiviitg aril reviewing a,firurl appliance c iedule D1V1 t'o �truirort reserves the right to:adjust the price of the contract upon,final receipt of flus plain PAll1TG InteriorAll view plaster ceilings and walls will receive a firmer and two coats o f finish. Ail new trim will receive a primer.an,two coats of finish. error=Parixt two coats of finish on the newly install exteror window trim. Paint n ►s!. /jog", ecessary. : = - Relocate AC veins as rtecesso ry for the new kitchen layout Provide neeessa entin or the new ry gf dryer location: Proddephe necessary ventilation for the hood exhaust If the hoad selected requires make tg�air, this will incur extra cost. : IIA l� Q07) Zb0.1 PVG New har'div ood Installation of new red oak hcirdwood ftoorn "tlie i�itche g m n, new fl©dung will be sanded and receive three boats o l ane fPo.Y�eth' q lx�stmardwood g hSand and three coats;of pr?lyur ethane rn'the living rooms famrll' room dirxngr`botn, hallway, F EN 71 T[�1►tES'�DEIVU Snec�t C r ns eet' PL UhfiBVGIIf�CA77iVG be _Disco tnect Airdmpluming fattires and appliances rn the kitchen grid lrxundry room. • Irtchen-Provisions for and installation.of the following fraures: one mam sink one garbage disposal(on un arrswifch}, one drsliwasher; and a recessed box for the refrrgerato 'ice maker with a no burst hose. :.Pelvcrrte lomat lines as recess dd new baseboard or toekick er as,neCeS heat ' Laundry closet=Provide necessary water lines and drain lanes for relocated washing machtne rind electric dryer. The�vrm In .machirte.w ll be set rn a :Iristic ewer �, s dl ri ' ' g g.. ' P pd 77re spill part will dram dovri into.lhe base»tent:level All ttCuibY'nres ncludirrr, -sib fes' eta are cauefed u» 'er the Pluttrbt FuturesAliorvance: ' - EL ,ECyT`RICAL.. l3emolrtirsn Demo Jon qj _ wiring, receptacles, switches,and gyresnecessary ICemove, reroute, and:reYocate wiring as necessary Grali 't•ryvvrde standard white recept roles and GFCI receptticles as required by the t code.tn,all new'areas and all,areas to be.;renavatecl. �PPlrances Provisrfor the,following uppYiances: refrigerator,,dishwasher, *ge,7. exhaust an, microwave,, arba a zii oral, washn g g F g machine;and electric dryer. ill new appliances to be GFCr/�lFCI proe #erias reused kitchen 1'rvvrde GFQ r ce aeles on,the cvWerto s, q , l p and island as re aired w#tclitng for an}T recess lighting,pendant lighting, under counter"tighting tdca netlighting,' iundr closet Provisions for a was »tachine and electric dryer Installtition of a J luorescent Ir ht:` are: g Miscellaneous circuits will be tied into the existing paneY.. If the circuits required do dot fit In tYu extrtrng panel, a s i panel will be installed at a 1oeatiori tr�'be determ . This estimatedoes on fire protection(Strokes COQ etc) QTLY• The costo alirecess lititin t l titin vani Ir his under cabinet m'cabinet accent lights eeg fomes ,�t fang cvtch.lights etc is cauered under un aliowartce L � � ,, ,, �- . -,-,��,,,-��.,� I �:��-�,":'. . , . � .,,,,%, -�..", .,I . , �, , - �,��,��,,-�� -, -,. I ,�,�� -,�':......��,,.:�, , . ,�'�,�:,'T,,-, " , ,. ,- -, �, , ,- �, , , - , '�. . I I � -;:-. I : , � I'll 7 -�,:...... - � Z . ` . . W, ,,,,,�, �t--�,-�-z,-� "",,",'"Z�"!"�.",�z,"i'-_,;��. -�, ,",,��,, -,�... -1 .''-�,.., . , I .:, � , , . - , . At#��41VCES 1 f�tl#a tgir-1 I are I.1u�ed-in thr1.s a trrrrate:11 'he a##vwai►rce�c exist to r er tie . —I - - w , -�, .�. ,. , ,",., ., '. 1,, I . , I - I � - I -� -1 ��. 11 ' e of mrx# rI.rais nrrly,,un#esstherrse spec f ed l4zy rrnt spent.�n excess ofn al# tom v ll,ecur extra c©st:A y amour#less than tJ ailrnvar�ce vx# sr�arrartt d credit upon cdmpletron of the project dray extra costs cred#ts 1.wsll�#I he issuers11 :i �ABl�'M TNY $3#1,11 W6 I 7,-1.,al..;- , , cdvers the cost of all ca#inetry and herr assocrated mvlat ngs;"glass, slie#1. d. , rccesson""and hardware F -- _,: :� S TIO Y V�iI�VVV 119 ni#owance covers the cr i of a#f countertops atzr#therr`assoeiixtet#te#n�#ate d: rtrsta#lagan costs 4.,: : % z' " .. } PZUiI#ING � 'T"U1? S' 2,0(1fl br1: 'hrs a#lowance covers rhe cost-" a#I fC'#u�rrbtng "rture mcltng tut riot lmuted to sCr, Faucets, sbdp chspe»sers,itccessvrre11 Is,:etc.. , 1. I .1 , ;. . . ,- _ ., p-1�1his a'. o_ce covers the rrst rtfa#1 g tt tures T`hts alJvwance v rs the court of tabor att materia#s fi r recess lighf n , und1.er crit rnet, ightrng,ire-o:#net#Ightmr crud arty specially fractures, rirc#udrngI mess, litmners, etc. . E p#e�" �l)Itece light fair tight firm; white:ba ld and f bu#b$2UD, Cor p#etc �xa►iple �,,Recexs trghtw/air tight tri white ba; 'e, and Ha#ogeh#tutb :' 1G�;D(loirtthlete _, ti:_ . . . .: Z . r .. ...,j . r �. , 1. I.�1YITS $Z, 1tLa0° This cr##o►vance covers the cost rrt"a##<�vinc#inv units and Iherr assocrater#gr-t,, ha art, screens, ' 11 - 111 1 . -. - ,, a � � - - � ,: .� —: ' . 1--, 1 -- - l - , -11 , � ;� : . - � -7 .nd ei - - '-.-'-'-- . ,-.�xt .-I.-.. - - - - I - -. ' ', `--. - - I , - - err�rcri Jcimis --.- 1 .1-1- . . --., 1, ' 111 . 11- - -- : , - - - .-��2 .- - .- , I - ,-�, ,-,�.�,;,� .�, � " .",�' "' ,�,,� , '.- .. - -l. ;:.— - 1%� - : . � 1 . -- ! 1. � :, .; I - . t � - . - -..'-�'- I - '' . - - �. 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'.."- - .1- - .- - , CKWASWi.-S2.� - ' . . �', -I-1 - 11 . .� I - I - I � �I This al#v»we cavern thol- e cost v ati tyle, rnateriu#s, ani##abvr crssociatet Wirth total#rn g ©ztrng, dndedtrng rr,tile I#ikplh. ;. . - - ¢ .. .<. .,u .. .- .,- >, > — - .F - .-_.w. ..A- ,.. , ,< : .v d> ... a.a r. ..r,....- _ .._.",. v- - - B,GlT f G' E�l{lriJ�lii7,i..,Li l�Ll� 'his anntract Is subject to review upon:receipt of#he,fi�tat cal�tnetlatc arid,ffnal gPP#taCe cheultil�IyM construction reserves the rght to`=adjust tl�e price of t7ie conftct',dr reviewingtheses Cost could increase if anycha rges had an M*t ,act.r/n plumbing, veriring strue ral;work,Bhang of frami udditio : . �`P -More cabinetry, rrrti appYarrces, etG _ 1Vi►te.• I?ue to flue nature of`voted and the drastic terature artd itra ztag u ortr region,;You may notice the movement acrd shriitrking of the flooring a.. exterior and inte r trtn� fids ir.t,Ypuai of the i�gibn .pis not due to.defec�iue�rstallation : - Ch ragef rderswAny c ranges from the existing pla»s or tncreaserl'scape'o,f work im tviing extra costs will become an extra charge oyer arrat abovethe contractrc Change order ageentes mist begned beforteany walk commence T/u;following schedule wdI-re adhered to,inns circumstances beyond oar control arise: Bine fratefor'coritpetion demoh'tion bins to eortrpletion ►14 weeks 4 Subject to it beyond our control' u~delays associated x►ith delrve J'. lP o roducts,Gusto»�r c Tiia�sgeorders,eta) All worko be&ne Mnday Eo ruiriy between the hourso,f'7;;(1p am . 6.1111 ptra If deemed ne, sa 'tu worlfr ther tfte frO;eowrter <, �'�o. will be c onsulted firs MEMBER OFT"BETTER RtrISMES>VBrIREAU. HO 'ROVEAMNT CONT7tA�C7"OK 124961: C1111�5 COCT'1011�SUPERY1� W LACENSE4CSBb6�42 All hottte arnprovenrnt contractots and sabcontractors shall be regi. + ted Argy iufrrc : about a�eontraictor or.. ring to'rgistration',SItnll he d�to ce of CrtaAtr�ter r,�`aus and business Re, ulrin r Ten A k Pig ry Suite 5170 Bustin, IA. 2113 hone•(61 P x.973-8711© F 3 Client#:968806 DARREMAR2 ACORDTM CERTIFICATE OF LIABILITY INSURANCEDATE(MNIDD(YYYY) 2/22/2016 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(ies)must be endorsed.if SUBROGATION IS WANED,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 gA`mNTE�cr Terri Younes USI Insurance Services LLC-SCL PHONE8S5 874-0123 877-775-0110 103 Main Street A1C No Ftl: AC No ADDREss. terri.younes@usi.biz South Glens Falls,NY 12803 AFFORDING COVERAGE NAICs 855 874-0123 INSURERA:Nautilus Insurance Company 17370 INSURED INSURER 6: Darren Martino dba D M Construction INSURER C: 44 Adison Ave Ext INSURER D: Methuen,MA 01844 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 CONTRACTOR 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 LTR TYPE OF INSURANCE MSR Y 80 M14yl POLICY NUMBER POLICY/ 9 EFFMMI POLICY LIMITS A X COMMERCIAL GENERAL LIABILITY NN610631 D912112015 09/21/201 a EACH OCCURRENCE $1,000,000 CLAIMS-MADE Q OCCUR RUSIIVE a„. $100,000 X BIIPD Ded:500 MED EXP(Any one Person) $5,000 PERSONAL&ADV INJURY $1110001000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s2,000,000 PO POLICY E]JJECT _LOC PRODUCTS-COMPIOPAGG $2,000,000 HOTHER: $ AUTOMOBILE LABILITY COMBINED SINGLE LIMIT Ea sodden ANY AUTO BODILY INJURY(Per person) $ ALL AUTOS AUTOS BODILY BODILY INJURY(Per aocldenl) $ NON-OVITIED PROPERTY DAMAGE HIRED AUTOS ACOS Perecddent $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUT OFFICERIMEMBER EXCLUDED? �NE Y I N N I A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCIUFnON OF OPERATIONS 1 LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more;;ace k required) CERTIFICATE HOLDER CANCELLATION John Benvenuto SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED M 147 French Farm Rd ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE e ®1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) 1 of 1 The ACORD name and logo are registered marks of ACORD 9S17289892IM16306571 TXYCX 141 FWCA FARM TLD N . A 01xv JPX j M Ar 31.50" 129.50" pantry tuck dbl ovens into 49.75" broom Closet? feidge I I f knee wail SS.00" t 49.38" bev frg micro i 36" 85.00" cooktop 101.75` 36.00" bookcase or 27.00" d/w cabinet to sink counter? 78.00" 47.00"—- -- - — -- _ 175.00` _ The Commonwealth of Massachusetts ' ZA ccidents ust - . . �._ . ..._. : Department ofIndt"ta M 1 congress Street,Shite 100 Boston,MA.02114-2017 .. �t www mass.govtdia Workers'CompensationlnsuranceAffidavit:Builders/Contxactoxs/E,Xectricians/Plumbexs. TO BE FILED WITH THE PERAUTTING AUTHORITY• Please I'xiut Le�'bl A ' Name,(Businesslgrganization/Individual): Address: y �� ' n City/State/Zip:M U ' 0 f F L( Phone#: ? ' appropriatebox: Type of project(irecluvred); ` Axeyou an employer. Checkthe 101 am a employer with_ employees(fiill and/or part time).* 7. ❑NeV;r constrd6f1on 2Wam a sole proprietor or partnership and have no employees Working forme in $. 0 Demo litio g any capacity.[No workers'comp.insurance required.] 9, Demolition 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required]t 10E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical-repai�rs or additioxLs ensure that all coni rac. I either have workers'compensation insurance or are sole ' ��USI y 12.0'Plumbing repairs additions proprietors with noemployees. 5.❑I am a general contractor and I Have hired the sub-confractors listed on the attached sheet. 13 Roof repairs M..., These sub-confracprs have employees and have workers'comp.insurance 14. Other 6.Q We are a corporat— its,officers have exercised their right of exemption per MGL c. 152,§1(4),mgd'W6liav61ii6 employdes [No workers'comp.insurance required.] *Any applicant that checks bpx#1 must als6 till.out the section below showing their workers'compensation policy information' i Homeowners who submit,, }s aff!Ru. indicating they are doing all work andthen hire outside contractors must submit a new affidavit indicating such Confractors that check this box inusE attached an additional sheet showing the name of the sub-contractors and spate whether or not(hose entities have comp.policy number, employees. If the sub-contractors have employees,they must provide their workers' eloW is thepolicy and job site ees. .8 P ' n insz�xance m or y em to p Y kers con ensatto f lam an employer that is providingwor ,P information. Insurance Company Name: Expiration We, Policy##or Self-ins.Lic.#: City/State/Zip: Job Site Address: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). AttarFailure to secure coverage as recc ed under MGL c.152,§25A is a criminal violation punishable by a fine up to$1,500.00 as civil penalties in theform of a STOP and/or one-year imprisonment,as well ded to theffieoof fn ORDERORK 00 a tions of the DIA for i asuran a day against the violator.A copy of this statement may be foxes ar coverage verification. X do hereb certi under tliepains and penalties ofperjury that the information provided above is rue and correct: j Date: 3 Si ature: Phone Official rise 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.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their eanlilo-'e&' Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of lure, 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 ofthe foregoing engaged in a joint enferprise,and including the legal representatives of a deceased employer,or the receivef'0trusted 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 occnpa`iit 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 wh, hp not produced-acceptable evidence of compliance with the insurance coverage i quuiired:' Additionally,M%�gh?tpter 152,§25C(7)states"Neither the commonwealth nor any of its political subdi`isiom shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements ofthis chapter have been.presented to the contracting authority." - .Applicants Please fill out theWorkersl compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub, contractor(s)name(s),address(es)and phone number(s)along with their certificates)bf 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 orLLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The af5.davit should be returned to the city or town that the application for the permit or license is being requested,not the Deparknent of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a wgrkers' compensation policy,piease call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate ling. 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 permMicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT requited 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-AMSS.AFE Fax#617-727-7749 Revised 02-23-15 www-mass.gov/dia Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-066342 Construction Supervisor DARREN MARTINO 44 ADDISON AVE`ExV7---) y ,i- METHUEN MA 68"' Expiration: Commissioner 08/15/2017 �fe ira��zr�zanulealf�afC�/�2�a�:s�rclriself3 Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR egistration: .124961 Type: `Expiration:_- 9117!2017 Individual DARREN MARTINO, Darren MARTINO 44 ADDISON AVE.EXT. - METHUEN,MA 01844 Undersecretary