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HomeMy WebLinkAboutBuilding Permit #276-2017 - 149 MIDDLESEX STREET 9/14/2016 nri5 ee-P rv►j&D BUILDING PERMIT o� NORTy MO UP ��t�eo 6� �•O TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION // -- � o Bey Permit No#: 1p -261 Date ReceivedAr 9 �Ssgc Hus���y Date Issued: � IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER T'1AID`/ , Am HOT, b{ Print 100 Year Structure yes no MAP ?-49 PARCEL: O,� ZONING DISTRICT: P14 Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: I�roN b F 0)(C-az iry if 6 K -TU)E W a Nr-w LAulvDicy I b S 't ��D iii 3-I�bfllM f in/eo� � o LA 1S-T i N G JAA A1ZOOVA Identti ication- Please Type or Print Clearly OWNER: NameA N Dy AN Homf Phone: Address: 4 T Contractor Name: C) $� N Phone: 9 1 Email: AbPOAB3R %WGA C-40PAkL.rin,nn Address:u f-1 W4Nue--ri-15�e Jtt N fwbaeE � iNE a�8u S Supervisor's Construction License: CS \OLI�-12 Exp. Date: zj_�� 2.()1$ Home Improvement License: Exp. Date: At ► 2 o))!:z ARCHITECT/ENGINEER n tCy , As6yc_ Phone: I V LI-75 5203 WA HURL-C^55 o C ®G M 06i Lc v w� Address: ANt>QVCTc —Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: I)n FEE: $ t0 Check No.: 91 Receipt No.: NOTE: Persons contracting with unregiste d contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ 'Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Permanent Dwupster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS )l CONSERVATION Reviewed on Signature i i COMMENTS I HEALTH Reviewed on Signature COMMENTS i i Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature& Date Driveway Permit i DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPAR=TMENT --Ternp)Dumpster on-site .yes no; "LL L,ocated±at:1241MaimStreet - Fire,Department signature/date COMMENTS f 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) ❑ Notified for pickup Call Email 3 Date Time Contact Name Doc.Building Pennit Revised 2014 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 z 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application ;r< 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 I ECC Energy code Engineering Affidavits for Engineered products OTE: 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 Location No. .a t �, " � Gi� Date �y �� • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee - Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# ;7 l' Building Inspector f � NORTI� q Town of Andover O216 .0Pz6 rl lA i Z a � ' th ver Mass 'Q COCNIC"1WICK V �a "0 D PPa,�'�5 S U BOARD OF HEALTH Food/Kitchen PER T LD Septic System � BUILDING INSPECTOR THIS CERTIFIES THAT .....ML.. ...................................�......... .......................................... ..t ....�.�d.Ij�Dy� ... Foundation has permission to erect .......................... buildings on .. .. .. ... ...... . ` Rough to be occupied as Tfoln ..................... Chimney provided that the person accepting this permit shall in every respect to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to th Inspection, Alteration and Construction of Buildings in the Town of North Andover. �� A PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST TIO Rough rr.�_ rMA.0 Service .. -... .. ... M . . . ... ........... Final BUILD.. . .. 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. Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ F OF SEWERAGE DISPOSAL c Sewer ❑ 'Tanning/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 e U FORM PLANNING & DEVELOPMENT Reviewed On I Mb Signature_ (�4 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 Conservation Decision: ' Comments Water & Sewer Connection/S�nature& Date Driveway Permit DPW Town Engineer: Signature: F.. Located 384 Osgood Street FIRE,DEPARTMENT TernpfDumpsteron site :yes_ ,nog_ _ Located at 1124 Man:St�eet ' -� � FirejDepartmentit ignature/date='_ t nr.-Nnnnni-nITn { . Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, trust 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-$1000 fine NOTES and DATA— (For department use) e ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 The Commonwealth of Massachusetts Department of Fire Services a office of the State Fire Marshal P.0.Box 1025 State Road,Stow,MA 01775 Permit No PERMIT Date: City of Town) If Applicable Dig Safe Number In accordance with the provisions of MG.L. Chapter 10 as provided in section 5 2 7 CMR 34 This Permit is granted to: Start Date Full name of person,Firm or Corporation Permission to locate dumpster for construction/renovation/demolition of structure Comments: dumpster be 25 ' from structure or covered with tarp or plywood Restrictions: at end of workday at (ave location by street and no.,or describe in such manper as to rovied adequ identification of location) Fee Paid$ This Perna will expire (Signature of offioal granting permit) -0 al granting permit A(Title) �' TWI_C PIMMIT MI LCT'FRF r_nKIsPIr_I Ir91 ICI V Pf)1tiTpn l lPnPJ THF PPPUI-qt=s A ' The Commonwealth of Mass, Department of Fire Services a Office of the State Fire Marsh; P.O.Bos 1025 State Road,Stow,MA 01775 PERMIT Permit No (city of Town) (If Applicable) In accordance with the provisions of MG.L. Chapter 1 Oas provided in section 5 2 7 CMR This Permit is granted to: Full name of person,Firm or Corporation Permission to locate dumpster for construction/renovatic Comments: dumpster be 25 ' from structure or covered wi Restrictions: a t end of workday at (Give location by street and no.,or describe in such ma er as to rovied adequ Fee Paid� This Perms will expire (Signature of offical grantingpermit) fJ al grantu �� TWIA PPRMIT MI 1-QT AP CnNC0IC_1 IC'1 I_CI V Pn-QT1=11 11F r t�� 9L 3z b ?A •O Itz( Wells Fargo Acme Mortgage, Inc. Amb ITS,mE e1wmm MORTGAGE INSPECTION PLAN t CERTA'T INAT 7FE 8LIDDOICQ�IOYR4 DO( 1D SETBACK RD BA TTS U)C IM IN ►�(fRDFiT.BIDE.1 REAR SE1dAtat 0 9vo)DI Norto n mer N 0 R T H ANDOVER wmi cnasmimi�OR ART:V WAn AM VRILAT M 1 ffOW M ACTION UNM MARS HU$ETTS ru vD ==MOOR gEomm y onlgLMSE N4Rn 1 NIRIFIER CERTIFY TiAY lids PIlOPFATY notX LOGIFA"'m Emw3nm nm IIAjARO AREA.Oom;:u TY 250098 00030 DAM 6-2-9.3 °°� 15850 TRS COMPANY M NOT RENUISSL9 FM ANY 8811)mm MAGE Vjn=W TO W IM=M80018 OAIE OF IRE LATor DEED OF RECORD. PACE_��' I*MrIER BUA.0MM ARE SHM LEM MM CK FOOT FROM 1NE PROPERTY UNE R M AVVMM IMT A MORE PRWX SURW BE MAGE Ib VERIFY&M MEASUIBI PEAT Nm �INiCJtl10N m BASM dN Ym LOCAlm OP stntWy MaT RMI M PACE A PROPERTY iSOp1�l:VER>FMIPW OF SIRVEY 2��7r� MA l8HE�ApTC�j�; ,NFa ONLY 8Y AN A=MAIK.INSTIL ANN Ys IEp PLAN f -DAM 1=�^ ota THIS &71nGA11ON M BE LIM FOR larch 26, 2003 FWTS AS SHOWN E NOT USM FOR nff ESSTABL ENT OF "' . BRADFORD. r NGINEERING CO. • �^ �"""" ° P.O.8W,244 Uum W. Imumulus e e MAVt t Mti To TOTAL P.02 r ' k 3Z boo �J000 t eA 007 --._.��.ham DL..�•��X .. . . __.��-� TO TME We-Us Fargo Home Mortgage, Inc. AM M MORTGAGE INSPECTION PLAN ctanRFY T 1 Rte RDICDMOS l+IRDiN Do( t�u� �, WCA1m N Lt:(Fi�RRT S7JE!R6AR SEaRA6Tt ONL1n D/ North AitfiOve� NORTH ANDOVER RE vn00 n +o y fle°u viou�w ui rAs rte. Ni4 USETTS 1 PURTHEx CTo"o 1HA7 7MS onnot e �lEb N Im ESrAmm ea nam DEED HAZARD Af►g�OOMtiaAnTY Paan. Na: 250098 00030 DATE 6-2-93 7M CM*Wff M HOT REWaGML9 Fat ANY RMOMM MAW SMMM TO THE FgaM BOOL OAIE OF THE LAMf3Y DEED OF RF7COR'r PAGE , 7Mmw-lm BULMM ARE 9tOfit!LESS 1"m OHE FOOT mom THE PROPERTY RUE R m AOVMD l"T A MORE M=X VJRM BE MACE 70 MWY MW iiJl&D!E}Q! CST:fa eRiDTl-al M BASED ON Ym LCCATIRR or affnt y MAAI RROf PLAN BK PA A PROPERTY d>AW.VFRo~mlm OF guw=MARI MA E$ oN' ApCtOMN.UMM ONLY BY AN ACCMIk INSIRLUMT AY6 X TED mm i Z27_4-DAM /=� tS WiMQGAMON TO BE USED FOR MOR March 26, 2003 FSrM AS WN ARE NOT USED FORM MASWUMSC MENT t3P IUKA4f BRADFORD , f NGINEERING CO. SAMM W. MUGMUKAs RJ-3. 4 VIM wt Ins TOTRL P.02 * Co. Building&Remodeling Adam Brien CSL 104428 417 Waverly Rd. HIC 168512 North Andover, MA 01845 LLC 978-479-1526 8/22/16 adambrico@gmail CONSTRUCTION CONTRACT This Construction contract dated as of 8/22/2016 By and between Andy Van Horn of 149 Middlesex st North Andover MA, and BriCo Building and Remodeling Owner and contractor in consideration of the mutual covenants hereinafter set forth, agree as follows Article 1 Contractor shall construct the items in Exhibit A in accordance with contract documents, as identified in this contract on property which is located at 66 Cedar Lane. Article 2 Contract Price The Owner agrees to pay BriCo Building and Remodeling $57,900.00, for doing the work outlined above. The following payments will be paid to the contractor in the following manner: • First Payment is of$10,000.00 is due once contract is signed. Secure permit fees, dumpster, window order and product organization with extensive lee times.(3 weeks prior to the beginning of construction) • Second Payment of 15,000.00 is due once construction has begun, lumber and materials on site. • Third Payment $15,000.00 Once structure is weather tight this will also coincide with allowance orders • Fourth payment of$10,000.00 is due at completion of Sheetrock and plaster. • Fifth payment of$6000.00 is due at completion of flooring finishes. • Final payment at completion of project. Allowance totals to be calculated and credit or extra cost will be presented. Article 4 Change Orders Both parties shall agree any unforeseen work or changes requested during this project to be granted with written approval. Any extra work resulting from unforeseen problems will be priced accordingly on site and be done with written approval Article 5: Contractor's Representation Contactor has familiarized itself with the nature and extent of the contract documents, work site, and all local conditions and regulations that in any manner affect cost, progress and performance of the work. Contractor is duly licensed to perform the work as required by laws and regulations. Article 6: Contractors Responsibilities The contractor agrees to perform this work in a competent and skillful manner according to standard industry practices, and all work performed shall be subject to final approval by Owner. All work to be done incompliance with Massachusetts building code. All materials and equipment shall be of good quality and new. All materials and equipment shall be installed in accordance with manufactured specs. Contractor shall be fully responsible to owner for all acts and omissions of its subcontractors, suppliers and other persons performing or furnishing any work under contract with contractor. Contractor shall be responsible for initiating maintaining and supervising all safety precautions in connections with work. Contractor shall comply with all applicable laws and regulations relating to the safety of persons on the property Contractor shall repair or replace at Contractors sole expense every portion of the work that is damaged or destroyed before final completion. Contractor warrants and guarantees to Owner that all work will be in accordance with the contract documents and will not be defective. If within one year after the date of the final completion or such longer periods of time as may be described by laws or regulations or by the terms of any specific provisions or applicable special guarantee in the contract documents and work is found to be defective. Contractor shall promptly without cost to owner and in accordance with written approval correct such defective work. Article 7., Insurance Contractor shall maintain general liability and work-mans comp insurance for the work being performed at66 Cedar Lane North Andover MA. Contractor shall deliver to Owner certificates of proof. Owner shall be responsible for purchasing and maintaining Owners Liability insurance and or other reasonably appropriate insurance. Article 8 Termination Termination by Owner. If Contractor breaches any obligations under this agreement then owner may give Contractor written notification identifying such breach. If Owner has not cured such breach within 7 days from written receipt or if breach cannot be cured or Contractor does not begin to cure or fails to diligently prosecuted cure to completion Owner may terminate contract and take possession of work. Termination by Contractor. If Owner breaches any obligations under this agreement then Contractor may give the Owner written notification identifying such breach. If breach is not cured in 7 days or Owner has not agreed to resolve such breach then contract may be terminated. Exhibit 9 Owner and Contractor each bind itself, its partners, successors, assigns legal representatives, to the party hereto, its partners successors, assigns and legal representatives in respect to all covenants, agreements and obligations contained in the Contract Documents. This contract and all issues disputes and matters arising out of it shall be governed by and construed in accordance with the laws of the state in which the Property is located, exclusive of the body of the law governing conflicts of laws. IN WITNESS WHERE OF, Owner and Contractor have signed this Contract This Contact will be effective on August 22, 2016 Owner: Address of os:�aPr erty:_1 9 Middlesex st N. Andover MA Contractor:-Ada-m Brien BriCO Building and-Remodeing Address:417 Waverley Rd North Andover MA 01845 Title: Owner Operator riCo. Building&Remodeling g Adam Brien CSL 104428 417 Waverly Rd. HIC 168512 North Andover, MA 01845 LLC 978-479-1526 8/16/16 adambrico@gmail CONTRACT Andy Van Horn 149 Middlesex st North Andover MA EXHIBIT A Job Description: Addition over existing Kitchen, with bathroom remodel. • All construction built to plans provided. • Demolition of existing roof over kitchen. Demolition in existing bathroom to plan. Permitted Dumpster will be placed on site for debris. Temporary protection and dust control installed during construction. • All framing constructed to plan. Exterior plywood to be "Zip System" All partition movement and structural elements built to plan. All structural beams and columns to be approved by engineer. • Roof of new addition to receive architectural shingles, color and brand to be matched. Shingle to be blended into existing. Due to age and dye lot, shingle may not match 100% • New addition to receive cedar shake siding primed. All exterior trim to PVC and pine material • New Harvey windows installed where dictated on plan, glass to meet energy rating and style to match existing windows. (If existing windows can be re-used credit will granted) • All exterior walls, ceilings and floors to be insulated to meet energy code. • All new walls and ceilings and patching to receive blue board and plaster with smooth finish • Flooring o Master Bedroom floor, to be sanded and refinished, master closet to receive flooring that matches the bedroom. i I o 2 Bathroom floors and Laundry room floor to receive Hardi-backer underlayment prepped for tile installation. An allowance of $900.00 is included for the purchase of tile and grout. • Master Bathroom o Shower walls to receive cement board underlayment prepped for the installation. Custom shower pan supplied and installed. A $600.00 allowance is included for the purchasing of tile and grout. Wall niche and seat incorporated into design. (Tile pattern and design may reflect a price increase in labor.) An allowance of $200.00 is included for shower head and trim kit. An Allowance of $600.00 is included for vanity, top, sink and faucet A An allowance of$300.00 allowance is included for the purchasing of toilet and seat. Toiletries and mirrors not included but BriCO will install at no expense. Glass shower enclosure not included(NIC estimate$800.00) • Remodeled Bathroom. o Tub and toilet location to remain. Tub walls to receive cement board underlayment prepped for tile installation. A $300.00 allowance is included for the purchasing of tile and grout. Wall niche incorporated into design. (Tile pattern and design may reflect a price increase in labor.) An allowance of$200.00 is included for shower head and trim kit. An Allowance of$800.00 is included for vanity, top, sinks and faucets. An allowance of$300.00 allowance is included for the purchasing of toilet and seat. Toiletries and mirrors not included but BriCO will install at no expense. Glass shower enclosure not included(NIC estimate $ 800.00) • Laundry Room o Washer dryer hookups built in wall. Dryer vent hard piped outside for venting o Cabinet and counter top installed an allowance of$1000.00 is included for products (extensive design may result in price increase) • Electrical scope to consist of the following. Plugged and switched to code. o Master Bedroom, to remain the same electric layout o Master closet to receive surface mount fixture, plugged to code. o Master Bathroom to be wired to code, exhaust fan light combo vented to outside, recessed light over shower, vanity lights fixture o Remodeled bathroom to receive exhaust fan light combo vented to outside. Surface mount light (fixture supplied by owner), vanity light (fixture supplied by owner) • All new doors to be primed solid core Masonite, all trim work installed to reflect the style of the remaining house finishes (old doors attempted to be installed frames to be provided, price adjustment TBD) • Master closet to receive no shelving Bathroom closet to receive 3 shelves • Permit fee included Not Included • Interior and exterior Painting • Washer Machine and Dryer • Light Fixtures • Desk Area Design? Total Allowance figure $5,400.00 Grand Total $57,900.00 The Owner agrees to pay BriCo Building and Remodeling $57,900.00, for doing the work outlined above. The following payments will be paid to the contractor in the following manner: • First Payment is of$10,000.00 is due once contract is signed. Secure permit fees, dumpster, window order and product organization with extensive lee times.(3 weeks prior to the beginning of construction) • Second Payment of 15,000.00 is due once construction has begun, lumber and materials on site. • Third Payment $15,000.00 Once structure is weather tight this will also coincide with allowance orders • Fourth payment of$10,000.00 is due at completion of Sheetrock and plaster. • Fifth payment of$6000.00 is due at completion of flooring finishes. • Final payment at completion of project. Allowance totals to be calculated and credit or extra cost will be presented. All subcontractors that are hired by BriCo or the homeowner must carry the appropriate license and insurance to perform work in the state of Massachusetts. The contractor agrees to perform this work in a competent and skillful manner according to standard industry practices, and all work performed shall The contractor agrees to perform this work in a competent and skillful manner according to standard industry practices, and all work performed shall be subject to final approval by Owner. All work to be done incompliance with Massachusetts building code. BriCo takes on full responsibility of all necessary inspections. All craftsmanship is warrantied for one full year from completion of construction. Warranty is voided if repairs are necessary due to a natural disaster. All glass installed meets state energy code for performance and efficiency. Each glass unit will contain its own energy certificate. Any unforeseen work or necessary repairs found during this project to be brought to the owners attention as soon as possible. Any extra work resulting from unforeseen problems will be priced accordingly on site and be done with written approval. BriCo is not responsible for anything that occurs on site that is not directly involved with the construction of this project. BriCo Building and Remodeling is a fully licensed and insured LLC company. License numbers are provided in the header above and current insurance documentation upon request. BriCo is a full service general contracting company. We take pride in our work look forward to the opportunity to work with you. X ,S,<z6) .) XIcy The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Y www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):ZrZ( Zl t 1 ( D 1N C- Address: � City/State/Zip,%g7),a AN S M'A Phone#: -7 Are you an employer?Check the appropriate box: Type of project(required): 1.KI am a employer with 1 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7• Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers' comp.insurance. 9. B3 Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 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.]f employees. [No workers' comp.insurance required.] 13.[:]Other *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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. _.�-�--� Insurance Company Name:- AVUCAK Policy#or Self-ins.Lic.#: \)S L\A l V F Son 1 6 Expiration Date: `1 17 )20 1�-j Job Site Address:1 M 1 bD(_ `,E x 5� City/State/Zip_N,P1N t>t) 'C; MA O iV44S Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct o Signature: Phone#: 9 Lf-79 1 2 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#: ,eco CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 07/11/2016 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 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: Trudy Lawler MICHAUD INSURANCE AGENCY aCCO (978)685-2549 FAX AJC No): E-MAIL trudylawler@michaudinsurance.com 105 HAVERHILL ST. INSURER S)AFFORDING COVERAGE NAIC# METHUEN MA 01844 INSURERA: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B BRICO BUILDING&REMODELING LLC INSURER C: INSURER D: 417 WAVERLEY RD INSURER E: NANDOVER MA 01845 INSURER F: COVERAGES CERTIFICATE NUMBER: 67853 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPEOF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDD/YYY MMlDD/Y LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE FIOCCUR DA MAG ETORENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑P, F LOC PRODUCTS-COMP/OP AGG S OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNEDPROPERTY DAMAGE HIREDAUTOS AUTOS er accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION V PER OTH- AND EMPLOYERS'LIABILITY YIN /� STATUTE ER ANYPROPRIErOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBER EXCLUDED? N!A NIA NIA 7PJUB4618P50716 04/19/2016 04/19/2017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 N/A E 7 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensationAnvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St AUTHORIZED REPRESENTATIVE North Andover MA 01845 Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD AC40 o® CERTIFICATE OF LIABILITY INSURANCEDATE(MM1,DD,""Y) 7/11/16 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: N the certificate holder is an ADDITIONAL INSURED,the pollcy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemen s. PRODUCER CONTACT NAME Armand P. Michaud Insurance Ag PHONE Tricia Sabulis FAX (978 685-2549 NI: (978) 794-0822 105 Haverhill Street ADDRESS: triciasabulis@michaudinsurance.com Methuen, MA 01844 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Green Mountain Insurance Co. INSURED INSURER B:Norfolk & Dedham MA BRICO Building & Remodeling LL INSURER C: Adam J Brien INSURER D 417 Waverley Rd INSURER E, N Andover, MA 01845 INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR POLICY EFF POLICY EXP LTR TYPEOFINSURANCE imPOLICY NUMBER M/DD/Y MMIDD/YYYY LIMITS A GENERAL LIABILITY 20009201 4/13/16 4/13/17 EACH OCCURRENCE $ 1 000 000 XCOMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS-MADE ®OCCUR MED EXP(Anyone person) $ 5,000 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 21000,000 GENTAGGREGATELIMITAPPLIESPERPRODUCTS-COMP/OPAGG $ 2.000,000 PRO- POLICY LOC $ B AUTOMOBILE LWBIUTY 91561617A 6/18/16 6/18/17 COMBINEDideniSINGLE LIMIT $ ANYAUTO BODILY INJURY(Per person) $ 100,000 ALLOWAUTOS X AUTOS BODILY BODILYINJURY(Peraccident) $ 300,000 NON-OWNED PROPERTY DAMAGE HIRED AUTOS _AUTOS eraccident $ 100,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION WORKERS COMPENSATION WC STATU- I 10TH AND EMPLOYERS'LIABILITY Y/N ER ANY PROPRIETOR/PARTNEWEXECUTNE OFFICERIMEM13EREXCLLDED? NIA E.L.EACHACCIDENT $ (Mandalory in NH) E.L.DISEASE-EA EMPLOYEE Ifyes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMB DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is requ red) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Tricia Sabulis ©1988,2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The AC ORD name and logo are registered marks of ACORD Phone: (978) 685-2549 Fax: (978) 794-0822 E-Mail: triciasabulis@michaudinsurance.com Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-104428 Construction Supervisor ADAM J BRIEN _ f 417 WAVERLY ROAD + NORTH ANDOVER MA 01845. 'L, I " I Expiration: Commissioner 05/12/2018 h` �. � Vsze�o�nvnwauun�o��.a�cr�uael�s I _-Office of Consumer Affairs&Business Regulation, 11 OME IMPROVEMENT CONTRACTOR egistration: '168512 Type: 1 Expiration `311/2017 LLG 1 BRICO BUILDING AND REMODELING LLC t ADAM BRIEN ` 417 WAVERLY RD s -- NORTH ANDOVER;MA,01845 Undersecretary