HomeMy WebLinkAboutBuilding Permit #604-16 - 147 HIGH STREET 11/16/2015 BUILDING pa PERMIT �ORTy BO�1 -7 #6 TOWN OF NORTH■ ANDOVER ER �� h&, O APPLICATION FOR PLAN EXAMINATION * ,� � 'nom �� � '✓ a Permit No#•. � Date Received U t � RA7eD PP R5 Date Issued: IMPORTANT: Applicant must complete all items on this page tL®GAON MTIf �� - — s-- Pr .tM tPR®F'ERTYV1/NER��_�. /y _ Rnnta 100 Year Struc �e yes tno, �IM'AFP 110 �PA`RCy v Z®NINE,jD.ISTRICT _,�Histonci®istrrct� yes "n© _. iMachirie Shopi es�:� tno Il:Agey , TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building $'One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: 0 Commercial 0 Repair, replacement ❑Assessory Bldg ❑ Others: 0 Demolition ❑ Other F �— - � — �-.-�-_,x ,..t� � .� ••_ .�,-�.- - _ __. � ms=s�,... ,.>� Septic ❑�1Nel r 3� Floodplai`nk ❑Wetlands _ 401 rshed ®strict`== I - 91LA few DESCRIPTION OF WORK TO BE PERFORMED: �� ��s r�aG �2� Ghs� �GLfi���� i/�>T. �>7� G�� �tJ� �in��• ZIA,J TT �l L t-lit rc Y6 SIPS Identification- Please Type or Print Clearly OWNER: Name: J?6�3/h/ MOf 6416"' Phone: Address: 711/6� } I� Su G z f6 sU 6.3 _.lExp� iDate pervtsor"s Construction License S � a .� Expo I®ate:zy- �l �Homerlmpr©�ementLicense /_ z � 7- - � _ _ s ARCH ITECT/ENGINEERA )14 _ Phone: Address: Reg. No. FEE SCHEDULE:BULDING PE MIT.•$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST 13A`SE-D ON$125.00 PER S.F. Total Project Cost: $ � 6 3 FEE: $ q l0 Check No.: lei Receipt No.: —Q�(a NOTE: Persons contrac g wA unregistered c ntractors do not have access to the guaranty fund 77- ignaturefofcontractor. _ t , 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 ❑ 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 40TE: 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 o 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 VOTE: 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 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Plans Submitted ❑ Plans Waived.❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swmunmg Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM /PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS ejo uf0SG icti-a,. CONSERVATION Reviewed on 6 Si nature r b COMMENTS HEALTH Reviewed on Siqnature COMMENTS �� II 6 Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes M Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPART NT i � � -p- 4 Located 38 Osgood Street Q �I t Trnp Dum�ster�ron�site yes lno� got, Writ, - F re�DeWrit, ents gnature/date _ a 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 MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine I NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doe.Building Pemit Revised 2014 f Location ! No. Date l 1 . = TOWN OF NORTH ANDOVER ` q Certificate of Occupancy $ Building/Frame Permit Fee $J Foundation Permit Fee � . ' Other Permit Fee $ TOTAL $ Check#29680 Building Inspector NORTH Town o EAndover _ o 0 =� � .- 20P f Zh ver Mass o L^ > > coc"ICHew.c.c 1. gOR�1TE0 S 11 x BOARD OF HEALTH W� ~" Food/Kitchen P �ER TF Septic System 01 ' i I CERTIFIES THAT ......... .. ►........ Q. .. . �. �rt. .. .. .......................... BUILDING INSPECTOR h4c0on"118$lon to erect .......... buildings on Foundation Rough A befoccupled as ...v.01. . �.� ...... Chimney ....................................................... P*Ided that the person acce Ing this permit shall in every respect conform to the terms of the application Final ' ori file In this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MIDS ELECTRICAL INSPECTOR UNLESS CONSTRUCT S RTS Rough Service ................................ .......... .... Final i BUILDING INSPECTOR 1 GAS INSPECTOR Occupancy Permit required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. COPY Hank Tucker Hank Tucker Carpentry, Inc. 38 Newell Street Lowell, MA 01851 Email: al22683geomcast.net Res.: 978-453-5196 Cell: 978-815-8186 Fax: 978-455-7614 License#050463 -Reg. #179255 www.hanktuckercMentry.com 10/25/15 Robin Morgasen 147 High Street North Andover,MA 01845 978-828-2892 PUmor asen@gmail.com Work Tele hone: *Emergency phone numbers: -- big _safe#: g O J$'• y,�0 - �2 Dig safe start date �J� ,0 1-6 1 Schedule for Completion of Work: Approximate start date: 11/23/15t dependent) Approximate completion date: 11/28/15(weather dependent) All prices are good for 30 days. . Description of work: Contractor will furnish all materials and perform all labor in a good, workmanlike and substantial manner for the following described project upon the following described property. All subcontractors will demonstrate valid licenses and or certificates of insurance in compliance with Mass. State Regulations. Permit Notice: The Contractor shall be obliged to obtain any construction related permits as the owner's agent. The owner's who secure their own construction-relatedP ermits or deal with unregistered contractors shall be excluded from om access to the Guarantee e Fund. MGL 142A Special orders are absolutely non-returnable.Any returnable item has a 25/ restock fee from supplier as well as an hourly rate of$75 00/hr for return labor Payment Schedule: Owner will pay the Contractor the sum of$7,974.63 installments as follows: Date Amount of Work/Services to be Performed Amount of Payment 11/12/15 Unit,rentals,permit, supplies,concrete $6,174.63 11/28/15 sign off of permit $1,800.00 All payments are to be from a local bank. If not possible the ch _ _ p check will be due 7 days ahead of payment schedule to allow for processing time. If check is returned, home owner is responsible for all bank check fees-$25.00. hecks to be made out to Hank Tucker Carpentry Inc ignature and date: �0 __ 1 COPY Required by City and Town Halls: All municipal fees,taxes,liens,etc. must be up to date before a permit will be given. Contractor will not be responsible for payment and will not proceed on permit until written conformation is received. Damage found from previous Contractors: If during the project,when opening walls,flooring,ceilings,excavations,etc, damage or unsafe conditions are observed that can be attributed to previous work, the Contractor will notify and show said damage to homeowner.If homeowner refuses to acknowledge or repair damage,the Contractor will bring in the appropriate inspectors to verify that said damage was not the cause of the current Contractor and will not be held responsible legally or financially if homeowner refuses to repair this work. Home owner will not be allowed to be"General Contractor" Under the authority of the "Toxic Substances Control Act"section 402(c) (3) of TSCA, any home built prior to 1978 is subject to testing for Lead and Lead Safe practices must be followed. mature and date: 2 Description of Work: COPY Bulkhead estimate: To excavate down below footing Cut through concrete foundation Install precast basement stair unit with Gordon doors on top I door at base of staircase that vents Seal to foundation , Backfill with V stone J2e''" Pour concrete apron around unit ,C e. C, Remove all excess from site ,,j Permit will be pulled, Dig Safe will be notified *-r Cost: Unit"C", cutting through foundation,removal of excess fill, concrete and supplies,tax: $5,196.47 20 %overhead: $978.16 Labor: $1,800.00 Total cost: $7,974.63 fi g attire and date: 3 COPY Terms and Condition: A. Guideline: This project will be constructed in strict conformance to the plans and specifications which have been examined and approved by the Owner. All workmanship is guaranteed for 2 years from the sign off of permit. B. Compliance: The project will be completed in strict compliance with all laws, ordinances,rules and regulations of the applicable government authorities. C. Control: The agreement,plans and specification are intended to supplement each other. In case of conflict,the plans will control the specifications and the agreement provisions will control both. D. Chane orders: As directed by the Owner, construction lender,public body or inspector,any alteration or deviation from the specification that involves extra costs(subcontract, labor, and materials)will be executed only upon the parties entering into a written change order. Expense incurred because of unusual or unanticipated conditions will be paid for Owner. Labor and Materials: Contractor will provide and pay for all the materials necessary to complete project. Contractor is released from the obligation for expenses incurred when the Owner is in arrears in making progress payments. If Owner purchases stock or material,or is given at contractor's cost,Owner is responsible for all warranties on products and materials. If product is in need of repair or replacement, an hourly charge plus cost of$75.00 per hour replacement product and 20 % over head with Contractor assuming responsibility for product. SU cial orders are absolutely non-returnable.Any returnable item has a 250 o restock fee from supplier as well as an hourly rate for return labori E. Permits: Contractor will obtain and pay for all required building permits. F. Taxes Assessments and Charges Taxes, special assessments of all descriptions, and charges required by public bodies and utilities will be paid for by the Owner. G. Bankruptcy If either party became bankrupt,the other part has the right to cancel this agreement. H. Cancellation: Owner and Contractor have an unconditional right to cancel the Agreement,without penalty or obligation,until midnight of the third business day after the Agreement was signed. Cancellation must be done in writing. Upon cancellation,any property traded in,any payments made under this Agreement,and any negotiable instrument executed will be returned within 10 business days following receipt by the contractor of cancellation notice. Property Lines: Owner shall locate and point out property lines to the Contractor. Contractor may, at his option,require the Owner to provide a licensed land surveyor's map of the property. Liens: Failure to pay persons supplying materials or services according the terms of the Agreement may,resul in the filing of mechanic's liens on the affected property. Signature and date: 4 COPY Insurance: Owner will maintain property damage insurance at least equal to the Agreement price. Damage to Project: Contractor will not be responsible for any damage caused by the Owner,or other causes beyond the control of the Contractor. Owner will pay for any restoration work. Contractors Rights and Responsibilities: a. Delay: Contractor will be excused for any delay beyond his reasonable control. These delays may include but are not limited to,Acts of God, labor disputed,inclement weather,acts of public authority,acts of the Owner, or other unforeseen contingencies (ground water,underground objects,soil conditions, anything not visible).Under such conditions,there will an extra charge for stock plus 20%overhead and labor rate of$65.00 per hr. Contractor will be excused of delays incurred by suppliers shipping time frames or special orders/custom orders. (If stock is held up,Owner has the right to hold up cost of item,it not paid for and a reasonable hourly rate 65.00 per hr. to install product only). $ Y) P P b. Right to Stop Work: If any payment under this Agreement is not made when due,the Contractor may suspend work on the job until such time as all payments due have been made. Any failure to make payment is subject to claim enforced against property in accordance with applicable lien laws. If Owners sub-contractors do not comply with Agreement,contractor has the right to stop work and bring in building commissioner to settle matter. c. Substitution of Materials: Contractor may substitute materials without notice to the Owner in order to allow work to proceed,provided that the substituted materials are of no lesser quality than those listed in the specifications. d. Salvage: All salvage resulting from work under this Agreement is to be retained by the Contractor unless other agreements are contained in the written specifications. e. Insurance: Contractor will maintain comprehensive public liability insurance policies. f. Sub contractors: Should Owner hire their own Sub contractors,a copy of their license, workman's compensation,and liability insurance certificate is due before they can begin work at site. If not licensed and insured they will not be allowed on job site. Owner is responsible to maintaining Sub contractors schedule and to monitor clean up after Sub contractors each day, and to insure Sub contractors maintain a safe and professional work site. Any damage by Sub contractor on project site or damage to stock on project site will be the Owners responsibility. Contractor has right to terminate any sub contractor that homeowner hires if iob is not being completed according to code and 'obspecifics and unreasonable delay in completion. Signature and date: I 5 COPY Completion of Project: a. Notice: Owner agrees to sign a Notice of Completion within 5 days after completion of the project. It the project passes final inspection and Owner does not sign the Notice,the Contractor may act as the Owner's agent and sign the notice. b. Cleanup: Contractor is responsible for removing debris and surplus material from the property, and leaving the property in a neat and orderly condition. Dumpster: Dumpster on job site is for construction trash only. Any other trash will be removed from the unit and Owner will be responsible. An exception to this is if Contractor agrees to Owners trash and it meets container company's trash requirements. Sign off with Contractor is required. Conflict Provisions: a. Arbitration: Any controversy or claim arising out of this Agreement that cannot be resolved is subject to arbitration,with an arbitrator of mutual agreement,and all parties(including Owner, Contractor,Architect and Sub- contractors)are bound to this arbitration. If any party does not appear at arbitration proceedings,the arbitrator is empowered to decide the controversy in accordance with whatever evidence is presented by the party(ies)that do participate. b. Attorney Fees: If either party becomes involved in litigation arising out of this Agreement,the court shall award costs/expenses including attorney fees to the justly entitled to them. c. Limitations: No action related to this Project may be made by either party against the other more than 1 year after the completion of work. General Provisions: a. Notice: Any notice required or permitted under the Agreement may be given by certified or registered mail at the addresses contained in the Agreement. b. Prohibition of Assignment: Neither party may assign the Agreement or payment due under this Agreement without the written consent of the other party. Agreement must be signed by both property Owners in attendance of each other. c. Qualification: This document constitutes the entire agreement of the parties. No other agreements exist. This Agreement can be modified only b written agreement signed by both parties. d. Space: Contractor may require yard space for following when needed Y dumpster, storage box for tools and equipment,off street parking for construction trucks and stock. e. Working conditions: Construction/work hours will be 8:00a.m. Through 4:30p.m. Monday through Friday. Occasional weekend work will be may be required and advance notice will be given to Owner. AccepUnce of Agreement: Homeowner has read and understands erms. !Authorized signature Date _ _OwnerS6ature _ Date Lic. 050463-Reg. 179255 10. Contractor License Number Date Signature 6 i r Project site Questionnaire COPY � 1. Will workers be allowed to use bathroom? Yes No If no, a Porta-Potty will be used at a nominal charge to homeowner. 2. Will access to all electrical services be allowed? i.e. basement,utility room, etc. If no access and fuse is blown,homeowner)will pay contractor for day as he will have to leave site. 3. Will there be access to external water Silcocks? 4. Are there any external electrical plugs? 5. Are there any pets to work around or to put away from workers? 6. Are there any special plants,trees,bushes that Contractor needs to be aware of? 7. Are there any underground services I should know about such as: Electrical/water or drainage pipes/sewer lines/septic line, box or leaching field/ e , � °''' dog fence/security systems. Circle or Add /t 0' 8. If yes on lawn sprinkler,what is time of use 9. Any house or yard services? Da s: Y Times: 10. Do you have a house alarm and is it connected to Police/Fire/Other I will need alarm code/key and phone number to company if possible. , Depending on job,Hank will need a key to house. If home owner is not at home w� full time or if homeowner has to leave,Hank will not leave home unlocked at any LA time or for any one. 11. I will not let any unauthorized person/people on to the property unless otherwise informed. 12. Do work hours need to be changed from standard work hours, due to family work schedule, 8:OOa.m-4:30 p.m.,Monday through Friday. 13. Children will not be left on job site without proper supervision. I am not a baby sitter. 14. All Homeowners vehicles should be removed from work area while work is going on. 15. Is smoking permitted on property? 16. I will not answer the phon or accept deliveries. ignature and date: 7 COPY CHANGE ORDER PROVISIONS CHANGE ORDERS: As directed by the Owner, construction leader,public body or inspector, any alteration or deviation from the specifications that involves extra costs (subcontract, labor,and materials)will be executed only upon the parties entering into a written change order. A deposit on stock will be required up front, and upon completion of changes, payment in full for that part of the Agreement. Expense incurred because of unusual or unanticipated conditions will be paid for by Owner. Acceptance of Change Order: Authorized Signature Date Ownn" afore Date Lie. 050463 Reg. 179255 Contractor License Number Signature Date 7-a M9 a 6r yd et- 7a � t i I 4 � 8 I North Andover MIMAP November 16, 2015 s q Q r A .. a UU 'y .�, l fur bei e C MVPC Bo Interstates Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, —_I Meters Data Sources:The data for this map was produced by Merrimack Roads t gORTM 4 Valley Planning Commission(MVPC)using data provided by the Town of p .NQ North Andover.Additional data provided by the Executive Office of l r Easements ? 6� ° 0 Environmental AffairslMassGIS.The information depicted on this map is []Parcels 3 L for planning purposes only.It may not be adequate for legal boundary F A definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSEDOR IMPLIED,CONCERNING # ry THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY # "s ^# OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT - �ooq .a # ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION S4 CHIM 1"=41ft ^�' North Andover MIMAP November 16, 2015 53ti10 00�1�7 06ti70?003 N 067.0=0 +067. 003„7 15P7.HIGDH )T w 05��3'F0�;007 10 BRIGH1TTWIT11 1/E c153 H71 G:HST) A �;U6T�:Om0031� (6--C7!�-0032. JR4 � )06710-0039y �. f0 FURBER AVE nQoX147 HIGHT N &5_3�0 O039J 90 t 100 fry----_ venue Surber A 129 Vi_a �1�37 HIGH�S�vT .. ;1�381�HIGH S�Tf 067:0,0063' �;053!0`N-0020 1U6*7.0;:007, 0 0 0 MVPC Be -:Wetlands Zoning C Busine s 1 District [1 Municipal Boundary p Exempt Lands p Busine s 2 District - - Honzonlal Datum:MA Stateplane Coordinate System,Datum NAD83, — Rail Line 0 Busine s 3 Dislricl Meters Data Sources:The data for this map was produced by Merrimack d Busine s 4 District ORT Valle Planning Commission MVPC using data provided b the Town of Interstates N M Y 9 ( ) 9 P Y —I G Genere Business District Of Sao 9 North Andover.Additional data provided by the Executive Office of —SR A Plannei I Commercial Dev a<< r�r 6O Environmental Affairs/MassGIS.The information depicted on this map is d Corrido Development Dist 3= �' OL for planning purposes only.It may not be adequate for legal boundary Roads O Cornice Development Disl O A definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER 1 Easements O Cornice Development Dist MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING ❑Parcels Indusln 1 Dislricl 4 - THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY i7 Industn 12 Dislricl ♦ t ; OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT Zoning Overlay 13 Industri 13 District o ��� 41 ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF 0 Adult Entertainment O Indusln I S District •c°`"""' THIS INFORMATION Downtown Overlay District Reside ce i District ©Historic District C:Residei ce 2 District SSACHUS@ 0 Water Protection a P—idei ce 3 District O Hydrographic Features de ce4 DisMct - 1"=41 ft " oda ce SO DisMct —Streams de ce6 District - ,a a esidential District From:M&M Assurance/Mason&Mason Ins 603 356 9290 11/16/2015 11 :09 #519 P.001/001 HANKTUC-01 TRAMiREZ '400.1YYYYJ � ®� CERTIFICATE OF LIABILITY INSURANCE DATEIfJf 11/1fi/20152015 F 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 NAME: Mason&Mason Insurance Agency,Inc. PHONE -- "- - FAX - - ,458 South Ave. ALC,No. xt:(i 781)447-0531 __ NoI_(781)447-7230 E-MAIL _.._.__.. Whitman,NIA 02382 AODREss:info�masonandmasoninsurance.com — -INSURER(S)AFFORDING COVERAGE NAIC IF INSURER A;Travelers Casualty Ins, Co.of America 19046 INSURED INSURER B: Hank Tucker Carpentry Inc INSURER c_ 38 Newell Street INSURER D; Lowell,MA 01851 INSURER E: ` � I ENSURER F• --- --- --_-. -- I COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TD THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERR1 OR CONDITION OF ANY COWRACT OR OTHER DOCUrJ_NT V-ATH 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 KAY HAVE BEEN REDUCED BY PAID CLAIMS. .'NSR -- ---- — A� LTR TYPE OF INSURANCE POLICY EFF POLICY E%P --- NSA'"JV POLICY NUMBER M?rJDD PA[r.:DD LIMITS A X COMMERCIAL GENERAL LIABILITY I EACH OCCURR=VC= $ 1,000;0001 CLAIMS-MADE I -- I OCCUR I 6806A4550251542 0912712015 09/27/2016RE REMISES occurrence' s __ 30 1000 i,rED EXF(Any we person' $ 5,000( P_RSONALE,ADVINJURY $ - 1,000,0001 IGENPLAGGREGATE LIMIT APPLIES PER: I GEN=RRL AGGREGATE $ 2,O00,oO0I C PR r I-� I T _ _ POLICY JECT LOC ?RODL�;T'S-CO'dF.+OFAG3 .5 2,000,0001 OTHER: I S AUTOMOBILE LIABILITY I COMBINED S'K31_E LIMIT I1E2accoant, _ A ANY AUTO _ ,6806A4550251542 09/27/2015 09/2712016 BODILY INJURY(Per person; ALLOVNED SCHEDULED ! �----- ---.£ ALTCS Al,`TCS ( BODILY INJURY(Per accident)I S 1,000,00 KX NON-OVfJEC j ERT DAP.��G�— H;REDAUTOS I AUTOS fPeracdUentl _ 1 I ( I _.Ls - UMBRELLALIAe -I OCCUR EA. HOCCJRRENCE —I S - i EXCESS UAB CLA!P.1S-h1A.DE ! AGGR GATE I$ I DEO i RETENTION S g VVORKERS COMPENSATIOL PER I I OTH- AND EMPLOYERS'LIABILITY Y f N 'STk'U=E I I ER ANY PROPRIETOR/PARTNER.'EXECUTIIIE E L.EACH ACCID=NT $ OFFICER!IZEMBER EXCLUDED? i N!A - --.-_. _ _......-. (Mandatory In NH) .L.DISEASE-EE.EMFLOYEE ; If xeS,describe under _- .DESCRIPTION OF OPERL.TJONS oalwi I E.L.DISEP.SE-F'OUCY Ub1T $ 1 I I DESCRIPTION OF OPERATIONS:LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) I I CERTIFICATE HOLDER CANCELLATION I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I Town of North Andover I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Building Department 1600 Osgood Street Building 20,SURD 2035 AUTHORIZED REPRESENTATIVE North Andover,MA D1845 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 . �°t www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lezibly Name(Business/Organization/Individual): e� F /1/, Address: J D Id IF ll' City/State/Zip: G 0W 1�t L ' jS Phone#: �� J `� gza Are you an employer?Check the appropriate box: Type of project(required): 1.Q I am a employer with employees(full and/orpart-time).* 7. 0 New construction 2.F]I am a sole proprietor or partnership and have no employees Working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. F1 Demolition 10 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. " 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors bade employees and have workers'comp.insurance.$ 6.[M We are a corporation and its officers have exercised their right of exemption per MGL c. 14.P40ther 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit'this affidavit indicating they are doing all work.and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number." I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under thepains au enol 'es o e ury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract 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 licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub'contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. 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 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' compensationpolicy,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 file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia ._.m' t' (17779774Nt11CC,�.f 4 /G11'dSC,C�L,d1/16 # Massachusetts-Department of.Public Safety, Office of Consumer Atfairs&Business Regulation Board of Building Regulations and Standard's-.. 917 ME IMPROVEMENT CONTRACTOR = i gistration: 179255 Type' Construction Supers icor , 'Corporation 1 License: CS-050463 piMUon 76 4 IANK TUCKER CARpENTRY�INC , f ENRY A TUCKk JR r 38 NEWELL ST LOWELLMA 0m, • HANK'`TUCKER z s ' { i 38 NEV�AVELL ST LONIELL,MA0.1851 Undersecretary Expiration, 11/1612016' Commissioner N M w v ti