Loading...
HomeMy WebLinkAboutBuilding Permit #622 - 148 MAIN STREET 3/25/2013 i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: 3 -IMPORTANT: A licant must complete all items on this page LOCATION N2 Maw, vr n - ,wt _. PROPERTY OWNER4daiw � PIirlrll- Print 100 Year Old Structure yesno MAP NO: Q . PARCEL: ONING DISTRICT: Historic District yes no ( fj Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resi ntial Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial epair, replacement i✓tnd 5 ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer `I DESCRIPTI NOF WORK TO BE PERFORMED: ''�dentif ion Please Type or Print Clearly) OWNER: Name: LJ (M bLP fPhone:�Q17 (Q Address: d/� S�r Gl Gke-r Aa. G g7 L(5- CONTRACTOR Name: e I h Vi SiPhone: k3 Address: 21�22dWCZW1'1 Supervisor's,.Construction License:�S 03-7(a G3 Exp. Date: L411-7 `t Home Improvement License: 10 coz Vo Exp. Date: I ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 55�U FEE: $ (9� Check No.: t2 C2d Receipt No.: a(eaox NOTE: .Persons contracti with unregistered contractors do not have access to the guarantyfund ;Signature of°Agent/O_ erC Signature of contractor ' Plans Submitted ❑ lans Waived 11 Certified Plot Plan ❑ Stamped Plans Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools •C�, �,' Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ ' Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments I Conservation Decision: Comments 1 Water & Sewer Connection/Signature& Date Driveway Permit — • , DPW Too ]Engineer: Signatures ' Located 384 Osgood Street FIRE DEPARTMFhT - Terrip Drumpster on site yes no `*' Located at 124 MainStreet Fire Department-signature/date COMMENTS x 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 ® Notified for pickup - Date E £ i Doc.Building Permit Revised 2010 i Building Department The fohowing 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 a 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 o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit 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 app:al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm;tted with the building application Doc: Doc.Bui?ding permit Revised 2012 Location 1W tl/� No. ! Date • • TOWN OF NORTH ANDOVER Certificate of Occupancy $ � Building/Frame Permit Fee $ Foundation Permit Fee $ � Other Permit Fee $ TOTAL $ Check 46 26227 Building Inspector j1RT 0 #j Town of 2 E ,, 6 ndover ti No. � Z - ��f _ - Z y hver, Mass, COC NIC Kl WICK y1. ADRATED s L) BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT . ..�.h!�-... .. . ..�... Foundation hashas permission to erect .......................... buildings on .... . ......I'M! t........ .. ..............................• Rough to be occupied as ....lcY ........:. Y.. r. .. ........!.I.O.M.•.VWs,I. .............................................. 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO"T S Rough ` Service .. ............................ ....................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in •a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and_ Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE MaSSac]hULe_t s Rome Improvement Samtle Contract This foam satisfies all basic requirements ofthe skate's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek ofthe advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation`s Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information 'Contractor I Or>mmtiion Name r Company e Street dress o not sea Post Office Box address) Contractor/Salesperson/OwnerName City/Town State Zip Code 4BPsPssrAddre_ssX7stA�oludqree ddress) �cfs -Daytime Phone EveningPhone State Z ode AM A Mailing Address(It different from above) Business Phone Federal)Jrl,pIoyer ID or S.S.Number Lnw requires that most Itomc Home improvementcontmotorReg:Number Expiration date • improvement contractors have n vnlid registration number The Contractor agrees to do the following work for the Homeowner! (Describe in detail the workto completed,specifying the type,brand,and grade of materials to be used,use additional sheets ifnecessarv.) Reiluired Permits-The following building permitsare required Proposed Start and Completion,Schedule-'The following schedule will and will be secured by the contractor as-the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be ea eluded from the Guaranty Fund provisions of Date when contractor will begin contracted work MGC,chapter 142A.) Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform,the work,furnish the material and labor specified above for the total suns of- Payments will be made ac d' to the following schedule: $9 �� CUpon s g contract(not to exceed 1/3 of the total otal contract price or the cost of special order items,whichever is greater.) $ r~/ by or upon completion of -A� -/ $ by / / or upon completion of upon completion of the contract, (Law forbids demanding full payment until contract is completed to both party's satisfaction) . The following material/equipment must be special $ to beaid for ordered before the contracted work:begins in order p to meet the completion khedule.(**) $ to be paid for NOTES;(")Including all finance charges('i*)Law requires that any depositor down payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warr•tnty-Ts an express w tri arty benne provided by the contmetor ? ❑1Vo 11 Yes(111 terms of the warr•tnty must he 1ttiched to the coniractl Subcontractors The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third Party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for aterials and Labor under this a Bement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within,this document,the contract shall not implythat any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. o Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear.• o aloe sure the contractor has a valid Home 1m rovement Contractor Registration. The law requires most home improvement contractors and . subcontractors to be registered with the Director ofl3ome Improvement Contractor Registration. You may inquire about contractor • registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask:to see a copy of a"proof of insurance"document. o Know your nights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight ofthe third business day following the signing of this agreement See the attached notice of cancellation form,for an explanation of this right. ]DO NOT'SZGN TM[S CONJUR.ACT IF TDERE ARE ANY B LANj<SpACES+?! Two identical copies of the contract must be completed and signed One copy should go to the homeowner. The other copy shouldbe kept by the contractor, G er'sature Contractor's,Signature 'Date Date Confxaefor A rbitridi.on The Home Iiupiovement Contractor Law provides homeowners with the right to initiate an arbitration action(as an 'alternative to court action)if they have a dispute with a contractor. The same right is not automatically affordedto a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner'-in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby inutaally agree in advance that in the event the contractor has a dispute concerning this contract;the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to •such arbitration as-provided In Massachusetts General Laws, chapter 142A.. Homeowner's Signature Contractor's Signature NOTICE:The signatures of the parties above apply only-to the agreement of the patties to alternative dispute resolution initiated by the contractor: The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A) and other consumer protection laws (i.e.MGL chapter 93A)may not be waived in any way, even by agreement. However,homeowners may be excluded from certain rights if to contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaxanty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold-in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you.have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been Mod in or maxlced as void,deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the.original contract must be in writing and agreed to by`bofji parties- Contracted work=ay not begin,until both pa:Odes have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the.payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself- to im/herselfto be financially insecure,the contractor may require that the balance of fiends not yet due be placed in a j oint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said acco-ant would require the signatures of both parties. ;Additional Information If you have general questions or need additional it brmati.on about the Home Improvement Contractor Law or other consiuner rights, or if you wish to obtain.a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the OCABRwebsite at lam://wwtiv.mass.g�ov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration O•.Cfice of Consumer Affairs and-Business Regulation 10 ParkPlaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the IAC website at 112p://www.inass.goy/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: . hitl�://db.state.ma.usA iomeirnurovem ent/Iicenseelist.asp_ For assistance with informal mediation of disputes or to regisi;er formal complaints against a business,call: Consumer Complaint Section. Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4.800,508-755-2548 or 4.13-734-3114 Version 2.1-11/22/2010 Required Contract Terms Page 1 of 2 The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) Mass.Gov Consumer Affairs and Business Regulation Home>Consumer>Home Improvement Contracting> ..-................................ .......,..................._.......................................-..._._...-............_:..............................._.............................................................................. Required Contract Terms 4, Con-tracts-all'tontracts over$1,000(One Thousand Dollars)must be in writing. NEWS&UPDATES Th aw requires the following FOURTEEN items to be included in any contract between a homeowner and a OCA Survey Finds One in Five re istered home improvement contractor for home improvement work subject to MGL c.142A: Horne'Improvement Contractor w1he complete agreement between the contractor and the owner and a clear description of any other documents Advertisements Placed by ich are part of the agreement. Unregistered Entity The full names,federal I.D.number(if applicable),addresses(NOT P.O.Box numbers),of the parties,the More... contractors registration number,the name(s)of the salesperson(s)involved,if any and the date the contract was executed by the parties. Subscribe Lean more 3. The date on which the work is scheduled to begin and the date the work is scheduled to be substantially completed. RELATED LINKS ✓4. detailed description of the work to be done and the materials to be used. Yon Gid KonsomW d total amount agreed to be paid for the work to be performed under the contract. Massachusetts you Reparasyon ;,/A time schedule of payments to be made under the contract and the amount of each payment stated in dollars, nan Kay including any finance charges.Any deposit required to be paid in advance of the start of the work SHALL NOT D D D D O O D C D D D D D exceed one-third of the total contract price or the actual cost of any material or equipment of a special order or custom de made ature,which must be ordered in advance of the start of the work to assure that the project will proceed on Guia para Massachusetts Consumidor as sc dule. No final payment shall be demanded until the contract is completed to the satisfaction of all parties. Hooarpara Mejoras en a All parties must sign the contract. Gufa para el Consumidor de 8. A clear and conspicuous notice stating: I Massachusetts para Mejoras en el Hogar a.That all home improvement contractors and subcontractors shall be registered and that any inquiries about a contractor or subcontractor relating to a registration should be directed to: Office of Consumer Affairs and Business Regulation Ten Park Plaza,Suite 5170 Boston,MA 02116 Phone:(617)973-8700 b.The contractor's registration number must be on the first page of the contract. c.The homeowner's three day cancellation rights under MGL c 93 s 48; MGL c 140D s 10 or MGL c 255D s 14 as maybe applicable. d.All warranties on the owner's rights under the provisions of and MGL c.142A. e.In ten point bold type or larger,directly above the space provided for the signature,the following statement: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. f. Wheth9rany lien or security interest is on the residence as a consequence of the contract. fit...-fn enumeration of such other matters upon which the owner and contractor may lawfully agree. ,10. Any other provisions otherwise required by the applicable laws of the Commonwealth. 11. Permit Notice:Every contract shall contain a clause informing the owner of the following: a.any and all necessary construction-related permits; b.that it shall be the obligation of the contractor to obtain such permits. c.that owners who secure their own construction-related permits or deal with unregistered contractors shall be excluded from access jo the Guarantee Fund. Visit Our Showroom At: jcL. w%, Famous Brand Names 354 N. Broadway Certainteed VINYL ��®'1�♦+ Salem, NH 03079 9�4G Mastic Weds. - Fri. 12 -4 0 0 1 1 A Alcoa Sat. 9- 12 Inc, Andersen Tel. (603) 898-2259 Harvey Fax (603) 898 -2816 Proposal -Agreement Therma-Tru PROPOSAL SUBMITTED TO PHONE ��'7�� 2/ L/eP DATE 447 STREET JOB NAME CITY,STATE;7 CODE JOB LOCATION We hereby propose to furnish all materials and labor necessary for the completion of the following products in accordance with the specifications and drawings J� //�J /� LI 5 Til 1'Q �d�G�`c //►� 0+%M11 t` f dl�S ✓Vl �L� n S Aldo ee,', 1C Iv = 3S2>> vv V4" . P_eCe�g 4"s 074 IYda•do by c ,� 801 kbo 31 3113 �- 4A Total contract price is- ✓sln• �-e �}rrc;(� ,� =t�1e acv -� dollars ($ PAYMENTS TO BE MADE AS FOLLOWS: 1q04-6& -- 14m.- Cry ALL MATERIAL IS GUARANTEED TO BE AS SPECIFIED. ALL WORK TO BE COMPLETED IN A AUTHORIZED WORKMANLIKE MANNER ACCORDING TO SPECIFICATIONS PER STANDARD PRACTICES ANY ALTERATION OR DEVIATION FROM ABOVE SPECIFICATIONS INVOLVING EXTRA COST WILL SIGNATURE BE EXECUTED ONLY UPON WRITTEN ORDERS AND WILL BECOME AN EXTRA CHARGE OVER AND ABOVE THE ESTIMATE. ACCEPTANCE OF PROPOSAL. THEABOVEPRICES,SPECIFICATIONSANDCONDITIONS ARE SATISFACTORY AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK AS SPECIFIED, PAYMENTS WILL BE MADE AS OUTLINED ABOVE. CUSTOMER HAS THE RIGHT TO CANCEL THIS CONTRACT UP TO THREE(3) DAYS AFTER SIGNAT DATE OF ACCEPTANCE Qi N ^.. -r :-'- . �M n �` (/� � � �ne License or registration valid for individul use only ,� w #. Office�co 6Yff before the expiration date. If found return to: _�' HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation a _ Registration: .100286 Type' 10 Park Plaza-Suite 5170 mExpiration: `6/15/2014 Private Corporati n Boston,MA 02116 o IV- C: :,.,. � •� � M � �' �21N VINYL SIDING .. . , ix Cr4 v Kenneth Perigny �? �' ; 0 354 N. Broadway ��`�`"'�°'—�� Not valid without signature c �F ` 0 Salem, NH 03079 Undersecretary (U _ av� M ! tq 3 O E Co U 0 .0 O »J W IN - o � a m � I Require,Contract Terms Page 2 of 2 LIZAcceleration of payment: No contract shall contain an acceleration clause under which any part or all of the balance not yet due maybe declared due and payable because the holder deems himself to be insecure. However, where the contractor deems himself to be insecure he may require as a prerequisite to continuing said work that the balance of funds due under the contract,which are in possession of the owner,shall be placed in a joint escrow account requiring the signatures of the home improvement contractor and the owner for withdrawal. 13. No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract. 14. Arbitration: If the contractor determines that in the event of a-dispute,the contractor wishes the dispute to be settled by arbitration,this fact must be signified on the contract and both the contractor and owner shall sign this clause separately. The following format is acceptable(in 10 point type or larger); "The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this contract,the contractor may submit such dispute to a private arbitration service which has been approved by the Offrce of Consumer Affairs andBusiness Regulation andthe consumershall be required to submit to such arbitration as provided in MGL c I42A. Owner: Contractor: NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by the contractor. The owner may initiate alternative dispute resolution even where this section is not si ed separately by the i2arties." ©2011 Commonwealth of Massachusetts The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/Individual): (�r Address: 3514. 0 . road City/State/Zip: EO(eYr H�� Phone k (0UJ C�Q � 1 u ire yan employer?Check the appropriate box: Type of project(required): I am a employer with � 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors EJ I am a sole proprietor or partner- listed on the attached sheet. ? ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers'comp.insurance. Y p tY• 9. F1 Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions ❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees.[No workers' comp,insurance required.] 13.[1 Other iy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. omeowners Nvho submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,poli6y information. rn an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site brmation. _ urance Company Name: n(JLLc _ ,s (hs . . icy#or Self-ins.L/id.#: JO u 6 c,— b 9 to q o2 I Expiration Date: 61aq 2 A Site Address: L `t I a(h S- 3 G i City/State/Zip: L O V eY" O y 0 Sr :ach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 ip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of estigations of the DIA for insurance coverage verification. s 11ereby cert uncles•the pains and penalties of perjury that the information provided above is trite and correct. nature: Date: ,ne#: ?ffscial itse only. Do not write in this area,to be completed by city or town official. �ity or Town: Permit/License# ssuing Authority(circle one): .Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector �.Other '_nr�tar+_P_ar_enn• Ph nna 44. 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-contractor(s)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' 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 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 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. v 'he Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1.877-,MASSAFE q� CERTIFICATE OF LIABILITY INSURANCE 3/25,013 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 BtLOW. 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. N SUBROGATION IS WAIVED,subject to (he 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 endorsemengs). PRODUCERNA tfarneeArin ftthe rxAY/Crosa Ins-ManchesterE {603)669--3218' C Moc(603)e95-d]]1 1100 Elm street )DRESS-nbetkee cronsagencry,fu9m INS S AFFOA01NOCOVERAGE NAIG9 Manchester NH 03101 INSUR>:nAMerchant:s Mutual Ins Co 23329 INSURED INSURERS:Travelers Ins. Co. PELL$RIN VINYL SIDING t: INSURERC: REPLACEMENT WINDOWS INC INSURER D 954 N BROADWAY INSURCRE: SALEM NH 03079-2161 INSURER F: COVERAGES CERTIFICATE NUMBER:12-13 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 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iI TR TYPE OF INSURANCE AOvivo POIJCYNUMBER POU EFF PMWDDNYYYI OLICY LIMITS GENERAL LIABILITY • E,4G)1 OGCURiIENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY IBES EBOflbn : 500,000 A I CLAIMSMAOE NIOCCUR BOV1092643 0/28/2012 0/28/2013 MEODfP One aTon S 15,000 P ) PERSONAL a ADV IN.IURY i GENERALAGGREOATE i 2,000,000 OEN'LAOGREGATELIMIYAPPLIES PER PRODUCTS-COMP/OPAGO S 2,000,000 X POLICY Flrno, Loc S AUTOMOBILE LIABWTY M@INFO SIN ANYAUTO 60DILYINJURY(Pareer901I) S ALL OWqW AUT SS AUTOSUL� BODILY KMY(Pee auident) S N014-OVMED DAMAGE ; HIREDAUTOS AUTOS i VMQkLLA LL49OCCUR EACH OCCURRENCE T EXCESS LIAa HCLAIMU-MADE AGGREGATE S OED RETENTION$ S $ WORXERS COMPENSATION XOV88135195212 X WC STA OT)+ AND EMPLOYERS'LIABILITYL'MFR ANY PROPRIETORMARTNER/EXECUTIVE Y/N . (3a,) 1St E.L EACH ACCIOP14T S 5OO 000 OFFICE B(CLUDED7 a NIA (wwatorylnNtQ en >?erigny i Paul /z9I2012 /29/2019 ELOISFASE-EA EMPLOYE S 500;000 MAO=undar ollerin exaluded OESL`AIP ONOI'OPERATIONsedow ELOISEASE-POUCYLIMIT a 500 000 093CRIPTION OF OPERATIONS 1 LOCATIONS I VRHICLE5(ARAM ACORD 101,AddpbnW Romeft Sehedul9,II mora apace to re"Ybd) Issured ae evidence of Insurance for the Namad Insured 7ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCIELLED BEFORE THE EXPIRAYION DATE THEREOF, NOTICE WILL EIIE DELIVERED IN Town Of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main -Street North Andover, MA •01845 AUTH=Z9I)REPRESENTATIVE Arthur Molderez/191 Q NCORD 26(2010/06) ®19811-2010 ACORD CORPORATION. All rights reserved. • •�yr`� DATE(MM/ODIYYYY) CERTIFICATE OF LIABILITY INSURANCE 3/2 (MWOWy /2013 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 INSURERM), AUTHORIZED REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER. IMPORTANT: If the certiions of th holder la rt ADDITIONAL INSiJR6D,the Policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the ifirms and conditions of the policy,certain Pollcles may require an endorsement. A statement on this certificate does not confer rtghta to the certificate holder In Ilan of such endorsementle). PRODUCER GUNTACTlddPAABA!)n Betke FIAI/Crges Ina-ManchQgter ju PNDNFE. (603)669-3218 P M 1100 Mn Street. E- AIL Nn;(60])605-a331 .mbstkaecro$eAgenoy.com Manchester NH 03101 INSURE AFFOROM6 GE NAICI! INSURED INSURER A.Marchants Mutual Ina Cc 3329 PELLERIN VINYL SIDING b u+9oAERB:Travelcrs Ins. Co. _ REPLACEMENT WINDOWS INC INSURERC: 354 N BROADWAY INsuREao: SALEM INSURERE! NH 03079-2161 INsuaERF: COVERAGE$ CERTIFICATE NUMBER:12-13 REVISION NUMBER: SURED NAMED A THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INBOVH 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. LTR TYPEOPINSURANCE POLICYEFF MMI POUCYNUMBER EXP GENERAL LIAINLITY LIMITS Fi-CM OCCURRENCE fS M2,O0O..P00(n X COMMERCIAL GENERAL LIAeIUTV DAMAUE TO RE A CLAIMS-MADE Ei]occUrz oPz052f83 0128/2012 0/28/2013 PREMI MED EI(P one aeo„1PERSONAL&ADV INJURYWL AGGREGATE UMfY APPuEs PER: GENERPL AGGREC,ATE ?C POLICY "F% LOC PRODUCTS-COMP/opAGG $ 2,000,00 AUTOMOBILE UUIBILITY 8 C SINGLE LIMIT ANY AUrO sociden{ ALLO%NEO SCNEDULED e001LY(N.IURY(Perpermq) S ALIYOS BODILY INJURY(Per soGOenl) $ HIRED AUTOS AUTOS MVEO Pao R GE AUTOS Per ea dere S UMBRELLA LIAR OCCUR S EXCESS UAB EACH OCCUR;EMP;L CLAIMS-MADE AGGREGATE OED R�TENnONb B WORKERS COMPI:NsAms W88851969212 AND EMPLOYERS'LIABILITY X V1C STAANY PA0PMFTORIPARTNERIEXECUTIVE YIN (3A,) NH OFFICERNEMSER EXCLUD 07 NIA EL EAOHACG500 000(MandaorylnNo en Perigny i paul 5/29/2012 /29/Z013' � �L DISEASE. 500 000 oESC FOPERATIONS Deow ellerin excluded ELDI&EASE-POLICYL)MIT S 500 ,000 )E"P"TION OF OPERATIONS/LOCAMONS/VGMCLES(AnacD ACORD 101,A4dluonW Remwka Sche"w It more spasm Is mqulndj tssured as evidence of Insurance for tha Named Insured :ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCMeEo POLICIES Be CANCELLED BEFORE THE -EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Jim Hamblet ACCORDANCE WITH THE POLICY PROVISIONS, 148 Main Street, Bldg 0-301 North Andover, MA 01845 AUTHORIZED REPRESENTAIWE Arthus Moldere.%/NIDI Q.11th,Q. .ORO 25(2010106) ®1988-2010 ACORD CORPORATION. All tlghts reserved.