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HomeMy WebLinkAboutBuilding Permit #47 - 15 WILEY COURT 7/19/2007 BUILDING PERMIT cf OOaRoTFI TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION p Permit NO: Date Received Date Issued: - G � cHus IMPORTANT:Applicant must complete all items on this page Print PROPERTY O1NNER # CA4- --Print MAP NO 1'ARCE�L: -0 , Z KING DISTRICT. . = Histor`ic District es no 31 tUlac ine'Shop Va13age fires, 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 epllcell Floodplain, Wetlands later-sel Distnc#. Wa#ecJSewer DESCRIPTION OF WORK TO BE PREFORMED: � o p m m r orae 6,1- 2 0� A5;2 e D k>,r C,-,' X'h 57-4 &L n e� /?.CIO t'- -'k9 A7 f /E'S� ChoI�S •`h9S� �' (T� ✓es'L�,_r�9 Identification Please Type or Print Clearly) OWNER: Name: Rif C ` N�v e5Phone: Address: / Y✓i e ©�2�1 ®�2-i / -�/!�e VGA ILIA- CONTRACTOR Name '77 "=Phone: 17 2 5 -Address X7,,44 AlVW ,. , Supervisor's.Constrtactio.n .#cense- C Exp. Da#e: j Horne'Iffl'p(bylern,ent Ucense: � �= Exp. Da#e: ARCHITECT/ENGINEER A/C /' Phone: Address: 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: $__ , d o FEE: $ 0 Z Check No.: a Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund mat a„µof Aer�t%Owner _ S°igneture of'cotiti acto%_ ?3 -J� 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 Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH COMMENTS C A Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Y Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit Located at 384 Osgood Street �J� i2 o'�EJ Cts J i4c �� F RE OEPARTMENT� -.Temp Dumps r ori e ye .. no Located at,92 main Street Fire ep rtmentsfgnature%date COMMENTS .:., 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 - Date Doc.Building Permit Revised 2007 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 7U--ICYUIIUIIIY Application Workers CompAfttVt ❑ Photo Copy H.I.C. nd/Or C.S.L. Licenses ❑ Copy of Contract ❑ F an Or Proposed Interior Work ❑ E- xjk g or ngln Tered pro ducts NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/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 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location �" �� l ( G~► No. Date r NaRTN TOWN OF NORTH ANDOVER 3? � • SOL 9 Certificate of Occupancy $ Building/Frame Permit Fee $ —10i-4 - Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2041 _ Building Inspector NORTH Town of No. 0 �. dowerfMaAJ14o ss.f o • D COCMICMEWICK 7,ps RATED l BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT / !!� .............PA.. ...... ... ...�.. .. ................ ........�............................................ Foundation has permission to erect........................................ kq411.ngs on . .. ...........�RI�............. Rough .... ....... to be occupied as Si t .���.. Chimney ....... .... ... . .. . ......... provided that the person accepti this permit shall in every re ct conform to the terms of the application on file in Final 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 d y .. PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUST TS Rough ................... Service BUILDING INSPECTOR TWO Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. NORTH Town of 'AVT O N-.�r,N•.4� 'ti 1'�A, f)`'Y14'.:.R,., i ,o• Y7 y C% o . dover, Mass., r I 1 . O T O '- LAKE I� COCHICH:.C:K V oRATED PP��"`� �7 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT / �!!!� .............PA..ok.r. ..... . .. ....................... """'.""""""' Foundation has permission to erect........................................ bu"dings on./S..!7.`/­`7) Rough ........ to be occupied as.......5� ...........* .. ........................ Chimney ......... ...................................................... provided that the person accepti this permit shall in every re ct conform to the terms of the application on file in Final 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 d PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR. UNLESS CONSTRU ST TS Rough ....................................... ... Service .. .. .......... ...... .. 100 BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. �6oa�d oaf D�I ,n'g�cgu ano�i n and It.. ars License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registration:.108740 One Ashburton Place Rut 1301 Expiration: 8/24/2008 Boston,Ma.02108 F i-TYpa:. DBA'4 ALLEN CONSTRUCTION CO d, ROBERT ALLEN °""" 86 ANDOVER ST K '^�'`.'' Not valid without sign__ature N ANDOVER,MA 018Deputy Administrator PROPOSAL AVen c C a t . u c _. . Cc . Construction t' P ., i -_ PROPOSAL NO 86 a North r ,.-:0 S . a .0' ;';l:- r+� � iZ F, z= ;t 5"7 i5 t] SHEET NO. 1 978-37"-6919 CeT i:4 DATE Sun€ta.Y, Ju'5n�^�:e 5' `�it 1�d PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT: NAME ADDRESS 15-17' WTei' Court t`,ial"th hndo x r Mia ADDRESS .15 WV:MY Court; Joh Descaiption nst a f.innew roof mate is is an 17 Wiley court DATE OF PLANS North Andover,Ma.01945 PHONE N0. 078-687,4963, rtGrvss# ARCHITECT 975-?65-7791 Cell# We hereby propose to furnish the materials and perform the labor necessary for the completion.of Installation of nrT Roof;ns mcac`erlals.dont;ra `f or wilfobta?n the building pez; y tr.CT;lnt~Y actor will. supply umpvter.Re ove all' existing roofing materials off entire a ea(one 2aye 7f sh117gles s r dge ventidg,any metal drip edg _3a) tG underlayment exists hsr?Krn_otly.a 1, :ps': Il'61u81 grade aluminum(white)along all perimeter er eta y es. Insta 51a G,k`"ice ice/V:ater sf"il.r?ld along a!! ?<'rave?:s starting at er,:ge "a4`id heading t rat kFards ' tNe r (J'e tnStrartwJ !Vy'trip prior to installing drip eamce" along eaves.1pply Gra a, ju :U, 101113d s 1"etrtaillIng rout area M9 Tul-toEX ol,t L:C,weerT FysLL?ek^t. sa ..,bx..a.:k.-4 ....i u..,,s,_ v.,w x.g "tsncc7: ro"" +and..-1 ±016 J_."...J 1..._A.� . ..1.d�.'^.S.+ii ;L, new boat -i..L0841111 0 t i Q s n o t -r,i pg 4; rq j9Q 2 0? r,r n r' r, /` -'1-.,... mottle o f sting! 3a�n 'y � 7"",Y:,a Y' �;�'t tY T Cs:�-_�t-1:i� ''1:r i art rJ F_a Y' C�"' �n :"M �rz � 5 •. � .^n.:-5� 4_-� :`t^:C t�-s 't 1 €" "$ rn a F--sr'r_i 3.. shLT't'ale by r stvle Mae yontinnQltotal Fl. .nr x r _ aTS JS cars --4 h._...nir _ t ail 'length are Vs: for field shingles and Zr for capsS l raY."t4-,'c.?nd lead flashing and vent pipes via'xt"h clear Gepeel `„ry tulymer sealant-Clean up and p:t,ace- all u6cf2 s into T ne UQ MPsFL�Ingle _0ioT is :iiiaj t,laC.t mT � warranty z t e.C� 2 5 y r s Labt.'lt Warranty: roof :;i;tad.an''.eed againstI ea%s for 5yrs fr.:m Completion dat e due to Paul y installation. material W;.'rrani;y4shi.ngles : firsts 5y s 100%C'GiPr:'.rc3.ge on unateria! and labor 00 - install new shingles.l,abor to remove ;aF'i'racti'fI'e , as.l'1gl s is not; €.overed. After Orse Own >f IitC�.tes moera d and laborr n-I PnCI bed All material Is guaranteed t -be-as`speclfled, and t above work to be performed In accordance with the drawings and specifi cations submitted for above work and completed in a substantial workmanlike manner for the sum of i!+bt i hous;?i1d four hundred s3 =I e 1'3' t _ Dollars ($ 8468 ,Q Cs ) with payments to be made as follows. Y*f d ow n $0.8 2 2. .0 0.B a 1 a n qe at c 0”" p l y t i o $5616 '00, Respectfully submitted Any alteration or deviation from above specifications involving extra costs will be executed only upon written order, and will become an extra charge Per over and above the estimate. All agreements contingent upon strikes, ac- cidents,or delays beyond our control. Note—This proposal may be withdrawn by us if not accepted within days. ACCEPTANCE'OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted"r,You, are authorized to do the work as specified. Payments will be made as outlined above Proposal'sal lYi'€ .:it: t? ,:EgT'L•'"d by both part',ies € � �a �L� asp• E>✓.:�- "fit building obtain permitSignature cvyv..ro6 r i t Date , ? _. _f Signature y.. _-. .,r : a NC 301800 PROPOSAL The Commonwealth of Massachusetts Department of Industrial Accidents V11Office of Investigations ,a u ' 600 Washington Street nuu i Boston, MA 02111 r - www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): W t (' 2 n t Address: (© Ari City/State/Zip: N V - Phone#: 97 Ir CP S --;' Y 516 i?--- Are you an employer?Check the appropria!gAox: Type of project(required): L❑ I am a employer with 41d V' 1 am a general contractor and I 6. E]New construction employees(full and/or part-time).* ff��have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.F-1 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions myself [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks boz#I 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: Policy#or Self-ins. Lie.#: Expiration Date: / 5- ). Vh i 1A C o Job Site Address: N L2 Z:1:4L ,466 V P_fZ ✓�'t � 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 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 certif under the pains and penalties of pe&ry that a information provided above is true and correct.Si ed Signature: '' Date: VOL- 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-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. The 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. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7743 www.mass.gov/dia The Commonwealth of Massachusetts c Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 a'mss' www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): LA=A Regd\4 _=mc , Address: , roctc�(-O! 1A City/State/Zip: LSA�(o'a M-A C49LI I Phone #: `l Is` g ^ gc> °J Are you an employer?Check the appropriate box: Type of project(required): 1.®'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 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. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑ Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL 1 1.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks boz#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: T !j� r cy—r- ,� 1-es — Policy#or Self-ins. Lic.#: S-J $ Expiration Date: l Job Site Address: City/State/Zip: �_SwrPw .Mfl Attach a copy of the workers' compensation p licy 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 p alties of perjury that the information provided above is true and correct. Si nature: Date: '-I — 19 " Phone#: (q d 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' 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. The 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 Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia ACORD TM CERTIFICATE OF LIABILITY INSURANCE D 07i9D07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Lockton Companies,Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 8110 East Union Avenue,Suite 700 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Denver,CO 80237 COMPANIES AFFORDING COVERAGE COMPANY A National Union Fire Ins.Co. INSURED COMPANY Insurance Co. State of Penn B LABOR READY NORTHEAST,INC. POBox 2910 COMPANY Tacoma,WA 98401 COMPANY D COVERAGES 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 POLOCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LT DATE (MM/DD/YY) DATE (MM/DD/YY) GENERAL LIABILITY 159536$ 07/01/2007 07/01/2008 !GENERAL AGGREGATE 5000000.00 ---------------- A } COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG i 1000000.00 CLAIMS MADE XOCCUR PERSONAL&ADV INJURY 1000000.00 OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE 1500000.00 FIRE DAMAGE(Any one fire) 1000000.00 MED EXP(Any one person) 0.00 AUTOMOBILE LIABILITY ANY AUTO [COMBINED SINGLE LIMIT ALL OWNED AUTOS BODILY INDURY SCHEDULED AUTOS (Per Person) HIRED AUTOS BODILY INDURY NON-OWNED AUTOS (Per Accident) (PROPERTY DAMAGE i GARAGE LIABILITY ;AUTO ONLY-EA ACCIDENT ANY AUTO OTHER THAN AUTO ONLY: I EACH ACCIDENT AGGREGATE 2'EXCESS LIABILITY E TEACH OCCURRENCE 3 UMBRELLA FORM ? GA GREGATE OTHER THAN UMBRELLA FORM WORKER'S COMPENSATION AND 1616298 07/01/2007 07/01/2008 X WC STATUTORY'OTHER B EMPLOYER'S LIABILITY LIMITS THE PROPRIETOR/ (EL EACH ACCIDENT INCL 1000000,00 PARTNERS/EXECUTIVE EL DISEASE-POLICY LIMITT 1000000.00 EXCL .... H ._._.. ......... EL DISEASE-EA EMPLOYEE 1000000.00 f OTHER NOT APPLICABLE [[[E E DESCRIPTION OF OPERATIONS/LOCATIONS/ VEHICLES/SPECIAL ITEMS: THE ABOVE COVERAGES APPLY TO LABOR READY TEMPORARY EMPLOYEES DISPATCHED TO WORK ON BEHALF OF THE CERTIFICATE HOLDER CERTIFICATE HOLDER CANCELLATION ALLEN CONSTRUCTION CO. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 8G ANDOVER ST. EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, N.ANDOVER MA 01845- BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OF LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZEDP ATIV ACORD 25-S(1/95) @ ACORD CORPORATION 1988