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Building Permit #138-15 - 15 WOODBERRY LANE 8/13/2013
TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION i Permit N0: � /s Date Received Date Issued:-z -/,0,3 IMPORTANT:Applicant must complete all items on this page LOCATION i' GOe bury -17 - - _ Print - PROPERTY OWNER 'Gt nfce c. �I`GJc`IeY Rrint 100 Year Old Structure yes MAP NQ::�>r PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial kl�epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ['Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TOBE PERFORMED: /V eW r .` G G iT/ Identification Please Type or Print Clearly) OWNER: Name: C G l<c 1 e>'I3�` ' Phone: C1 7$ /G/ Address: t d!x bU 0 CONTRACTOR Name:. 3clh Cct (/*61l/_ _ _ Phone:. 7V ' 9_ "94 3 o6I . Address: 3 7 HSC ;Hp? Supervisor's Construction License:—(. 5-, l:O665' ._ - _ Exp. Date:. d S!db/a6elb Home Improvement License: [ 3 6 7 Exp. Date:_ ari ARCHITECT/ENGINEER 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: $ FEE: $ Check No.: lReceipt No.: �� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Sof contractor A- ignature Plans Submitted ❑ Plans Waived ❑ 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 ❑ 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 Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW't ow;i Engineer: Signature: Located 384 Osgood Street FIRE-DEPARTI E'NT -Temp Dumpster on site yes no Located-at 124 Mair Street . Fire Departinerit signature/date" A 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 I i i U Notified for pickup - Date j i Doc.Building Permit Revised 2010 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract a Floor Plan Or Proposed Interior Work o 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 a Copy Of Contract ❑ Fioor/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 o 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 cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apo.-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Builjing Permit Revised 2012 Location t/ No. Date • • TOWN OF NORTH ANDOVER • o • rCertificate of Occupancy $ Building/Frame Permit Fee $% j Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 26723 Building Inspector NORTH Town of t EAndover O 3)Pv Co - h , ver, Mass, COC HICOEWK. �1' A0R�TED S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System • THIS CERTIFIES THAT ` _�.0%cu 0 ........�,.1..Rw. .. „••„••••••..•,,,,•, BUILDING INSPECTOR has permission to erect .......................... buildings on ....is..... .................... Foundation�Q��... . Rough to be occupied as ............. 5 .....�� .... ..........Q)..... L ....�1�1. ... ..�w. Chimney provided that the person accepting this erns s all in eve respect conform to the terms of thea lic ion p p p 9 p p pp 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 CONSTRU9=N ST S Rough Service ........ D............... .............................. BUI Final OR 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 ss�e�ni e s Ro a Improvement ' Ile (contract 'This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek Iegal advice if necessary. Atry person planning home tProvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeingto any work on your xesidence.You may obtain a free copy by calling the Office of Consum'rA•ffairs and Business Regulation's Consumer lnfolmationHotUne at 617-973-8787 or 1-888-283-3'157 or on our website. _Uomeowner J formagioln 'Contiractor]fr�iF®n�ni<nation Name _ �j) �a n/ Clyp Cv I �lr (@ Company Name StreetAddress(do notuse aPostOf&ceBoxaddress) V Contractor/Salesperso v ow.nnerName C� 15 r M C cc 1 �v f State Zip Code Bpsiness Address(must include.a street addre ) InC Pl 5q511 Daytime phone Evening Phone City/Town C� 7g— 3 /�/l �� / State Zip Code Mailing Address at differe l�4fcom above) e ""� "'�� O�Y �O Business Phone ral Elnpployer i or S.S.Number H�T! ent'ContmctorReg.NumberLawrcgnirrsthat mosthome F.xPhtion date improvemeniconfrttorsAave nvalid registration mimU ��The Contractor agrees to do the following work for the Homeowner: (Descn'be iii detail the workto completed,specifyingthe type,brand,and grade of materials to be used,_useadditional she ifnecessa .) r • Jltequirecl Permits-The followEg building permits are required Proposed Start and Completion Schedule-The following sc'rteduie and will be secured by the contractor as-the homeowner's agetrt; wn be ao�rexed to unless circumstances beyond the eontraons control arise (Gwlaers VJ10 secure their ownn permits will,be excluded from Vie Guaranty Fund provisions of 1S� -MGL chapter 142A.) p date when contractor wi.11 begin contracted work. o— °_L ate when contracted work Will be mbstaatially completed. TOW Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of. Payments will be made according to the following schedule: ( ) _ ��• upon signing contract(not to exceed 1/3 of the total,contract price ox the cost of special order items whichever is greater) -------by / / or upon completion of $— by / / or upon completion of 3 upon completion Of the contract, (Law forbids demanding full payment until eontractis completed both patty's satisfaction) . The followingmaierial/equipmentmustbespecial $ ordered before the contracted work begins in order to be paid for to meetthe completion schedule.(**) to be paid for NOTES;C*)Including all finance charges("1")Law requires that any deposit or down payment required by the contractor before workbeglns 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. x ress Warren -Is an egress M arnintybein rovided b the contractor? No ❑.y s a1I terms of the warren mnst be attached to the contract 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 materials and abornnderthis a Bement contrContract.Acceptance-Upon signing,this document becomes abinding contract under law. Unless otherwise noted withinthis document,the act shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices arefully before signing this contract. C Don't be pressured into signing the contract.Take time to read e Make sure the contractor has a valid Home�rorovemPnt r�„dr,�d firmly understand it. Ask questions if something is unclear, ires most home subcontractors to be registered with the Director ofl ome Improvement Contractor Registratioor R stration. The law n You may inquireabout contractorcontractors orctors and registration by writing to the.Directorat 10 ParlcPlaza,Room 5170,Boston,MA 02116 or by calling.617-973-8787 or 888-283-3757. a Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or aslc to see a copy of a"proof of insurance"document. o ICuO your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvemettt Contractor Law: You may cancel this agreemen�Iifit has been signed at a place other than the contractor's normal place of business, rovided you notify contractor es w ayfo at his/her office or broach office by ordinary mail posted,by telegram sent or by delivery,not J ate than znidnigbt o£th� third business day followinghning of this agreement. Seethe attached notice of cancellation farm for eel explanation o£tha right. ®NO'JC'SIGN 7TMS CONTRACT IF THERE ARE ANY]�1G.AI�I1I:SPA.C7ESr t I Two identical copies ofthe contractmust be completed and signed. 0110 copy should go to the homeowner. The oiber copy shotildbe Iceptbyflio contractor. H eowner's C t'ractor's Signature 'Dat }13 ��o' .nate C(Duiractor Arbitr� ion The Home Impiovement Contractor Law provides homeowners with the right to initiate an arbitration action.(as an 'alternative to couut action)if they have a dispute with a contractor. The same right.is not automatically affoxdedto a both part7es agree to the optionall clause prov contractor,however. The contractor would have to resolve any dispute he/she has with a hoxneowner.in court unless ave below. This clause would give the contractor the same right to arbitration as is worded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby imtaally agree in advance that in the event the contractor has a concerning this contract•the eontracto� dispute 1 may submit the dispute to a private arbitration ffim which has been approve b the Secretary of the Executive office of Consumer Affairs and Busines pp y to sun ' to such arbitration as. rovided Ta Massachusetts s Regulation and the consumer shall be required p husetts General Laws, chapter 14.2A.. • eowner Signa�,u e ' ontractor's S' 1�1'®7CJLCJE: gam, Signature The signatures of paries above apply only-to the agreement of the parties to alternative dispute resolution initiated by the contractor: The homeowner may initiate alterative dispute resolution even where this section is not separately signed by the patties. 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, evert by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded fom all Guuaranty Fund provisions of the Home Improvement Contractor Law. The-contractor iS responsible for completing"rhe 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 cany 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. Tf yo.LL have questions about your consumer/homeowner rights, contact the Consumer Information Ijotline(listed below). Execution.of Contract The contract must be executed in du licate and s �? hould not be signed gn d until a co of all exhibits an documents have copy d referenced ve been-attached. Parties-rtes are.also advised not to signthedocument um nt uultiz all blank sections have been .Cued in or marked 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. An modification to Any the.original contract must be in and agreed to by both parties. Contracted work may not begin until both parties 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.paymeat schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances whexe a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a j oint escrow account as a prerequisite to contizM ag the contracted work. Withdrawal of founds:from said-account would require the signattiures of both parties. Additional Information .If you have general,questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer GLiide to Home Improvement" contact: Consumer al-ormation Hotline Office of Consumer Affairs and Business Regulation 10 Palk 617-973-8787, 888-283-3757 omasitt&a OCABRwebs t:e at'11t�tp %VVW',V mass. ov/oc ' - Tf you want to verify the registration of a contractor or if you have questions or need additional information sped Ccally about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and-Business Regulation 10 Park Plaza,Room 5170,Boston,MA.02116 617-973-8787, 888-283-3757 or visit the 1-UC website at 11ttu://uwv.tnass gov/ocabi/ Go online to view the status of a Home Improvement Contractor's Registration: I1tt)://db.0tate.ma.t2s/ho7neimorovelnent/licettseelist as For assistance with informal mediation of disputes or to regisier:formal complaints again st a business,usmess, calx: Consumer Complaint Section Oface of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-6S2-4800,508-7755-2548 or 413-734-31.14 Version 2.1-11[9.2hm n B/14/2013 6:37:07 AM PST (GMT-8) FROM: 100005-TO: 19786889542 Page: 2 of 2 AC40RV CERTIFICATE OF LIABILITY INSURANCE1 8/14/2013 DATE(MMIDD/YYYY) 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 JOHN J LAMB INS AGENCY INC CONTACT NAME: 24 NORTH STREET, PHONE c No Ext), FAX A/C No): HINGHAM, MA 02043 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: INSURED INSURER B: JOHN H CARROLL DBA US HOME IMPROVEMENT INSURERC: 27 HAMILTON ROAD INSURERD: PEABODY MA 01960 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 17305828 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER MM/DD/YMMM/DD/YM LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES a occurrence $ CLAIMS-MADE M OCCUR MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY M PRO- LOC $ AUTOMOBILE LIABILITY COMBINED detS SINGLE LIMIT(Ea $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) AUTOS AUTOS $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WC2-31 S-379722-02210/7/2012 10/772013 WC sTAT1 CITH- AND EMPLOYERS'LIABILITY Y/N .� TORY LIMITSI ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100000 OFFICER/MEMBER EXCLUDED? Y NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100000 If yes,describe under4 -T DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR JOHN H CARROLL Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF NORTH ANDOVER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER MA 01845 AUTHORIZED REPRESENTATIVE Jeff Eldridge ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD C aT NO.: 17'0 628 Anne Cha ley 8/14/2013 6:34:04 Page 1 of 1 TPh _s cern icate canceY.S and supersedes LL previously issued certificates. 08/14/2013 10:04 7817498822 JOHN J. LAMB INS PAGE 01/02 ACORD CERTIFICATE OF LIABILITY INSURANCE D08113/2013 � C 08/1312013 PRODUCER 781_749.6960 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION—ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 11 Ellis Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Needham MA 02494 INSURERS AFFORDING COVERAGE' NAIL P INSURED INSURERA: Safety Insurance Company John H.Carroll dba US Home Improvement InURERB: 27 Hamilton Road NSURERC: Peabody MA 01969 NWAERD: IN8URER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR ADWL POUrYNUMBER POLICYOFFECTIVE POLICYE(PIRATION LIMRS 0- TYPE OF INSURANCE- DATE(1011111108M DATE(MMIDQ= UENERALLIAHILITY EACH OCCURRENCE $ 1,000,000 A Z COMMERCIAL GENERAL LIABILITY PRFMISES Irko uran o $ 100.000 CLAIMS MADE I 7 OCCUR MEDBXP Any onoporzon) $ 10,000 BP00005758 06/20/13 06/20/14 PERSONAL&ADV INJURY $ 1,000 000 GENE?RALAGGRI;OATE $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIESPER; PRODUCTS-COMIPIOPAGG $ 1,000,000 POLICY ECT PRO- D LOC AUTOMOBILE LIABILITY ANYAUTO COMBINEDSINGLE LIMIT $ EeacedeM AL1,OWNED AUTOS BODILYINJURY $ SCHEDULED AUTOS (Per P,eraon) HIRED AUTOS BbDILY 1 WURV NON-OWNEDAUTOS (Peraeoldeel) $ PROPERTYDAMAGE $ (PerecdAeM) OARAGELUIBILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHERTHAN EAACC E AUTO ONLY: ACG $ FXCESSIUMBRELLALIMILffV EACHOFCURRENCE $ OCCUR FICLAIMSMADE AGGREGATE $ $ DEDUCTIBLE . S R�fJTIVN $ $ WORKERS COMPENSATION AND WCSTATW - EMPLOYERB'LIABILITY ANY PROPRIETOR/PARTNr.R/EXECUTIVE E.L,EACH ACCIDENT S OFFICERIMEM BEREXCLUDED7 E.L,DISEASE-EA EMPLOYEE >a I SPECIAL solbq PROVnderISIONS H.L.DISFABE-POLICY LIMIT $ SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES l EXCLUSIONS ADDED BY ENDORSSMENTI SPECIAL PROV18IONS Window&Door Installations CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFOR2 THE EXPIRATION Town of North Andover. DATE THBREOP,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN 120 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUr FAILURE TO DO 80 SHALL North Andover MA 01845 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPgEBPMYATIVE S, gUTHORIZEDREPRESHNTATNE ACORD 25(20d1/08) OACORD CORPORATION 1988 08/14/2013 10:04 7817498822 JOHN J. LAMB INS PAGE 02/02 8/14/2013 6:38:08 PQM PST (GMT-8) FROM: 100005-TO: 17817498822 Page: 2 or 2 Aco� CERTIFICATE OF LIABILITY INSURANCE1 8114/217113 DATE(MMIDDAY" 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 ms the terand 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). PRODucw JOHN J LAMB INS AGENCY INC CONTACT NAME: 24 NORTH STREET HO E 1• AICN911 HINGHAM, MA 02043 EMAIL AD INSILIRER(Ali AFFORDING COVERAGE ►WCs INSURERA: INJVHN H CARROLL INSURERS: DBA US HOME IMPROVEMENT INBURERC: Z7 HAMILTON ROAD INSURER D; PEABODY MA 01960 INSURERE: INSURER F COVERAGES CERTIFICATE NUMBER: 17 828 REVISION NUMBER: THIS IS TO CERTIFY TWAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERMOR 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 13 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN9RCrIt TYPE OF MBURANLE AINSRAS POLICY NUMBS MMIDD POLICY DW DXP LAMIT9 GENVRALLMILrrY EACH OCCURRENCE $ OA COMMERCIAL GENEAA1,LIABILITY PRE a enITeurrance $ CLAMS•MADE 0 OCCUR MED EXP Wy ono parson) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE S GEN'LAGGRE(3ATSLIMITAPPLIESPER: PRODUCTS-COMPIOPAGO $ POLICY I PRO LCC $ AUTOMOBILE LJAJ3ILTTY a m $ ANY AUTO BODILY INJURY(Per Parton) ALLOWNEO SCHEDULED BODILY INJURY(Pefoaddam) AUTOS AUTOS OPERTY AMA HIRED AUTOS E AUTOS erecade,t $ S UMBRELLAUABOCCUR EACNOCCURRENCE $ D(CESS UAB HCLAIMS-MADE AGGREGATE $ OED Li RETENTIONS $ $ $ A WORKCRs COMPENSA71ON WC2-318-379722-022 10/7!2012 10/7/2013IAcsYI�T�- AND EMPLOYERS'LIABILITY YIN _ al ANY PROPRIEIO"ARTNERFXECUTIVEY E.L.EACNACCIDENT $ 100000 OFFICERJMEMKII EXCLUDED? ❑Y N/A (Mandatory In NN) E.L 1)18EA$E-EA EMPLOYEE $ 100000 II qq��,Ossa ba under 0E�CRIPTION OF OPERATIONS babw L.DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLUO(Attach ACORD 101,Additional Remarks Sahaaule,If more apace ie raqulredl THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR JOHN H CARROLL Workers coripenaation insurance coverage applies only to the workers compensation laws of the state of MA. CERTIFICATE LDER CANCEL SHOULD ANY of THE ABOVE DESCRIBPD POLICI£G BE CANCELLED BEFORE TOWN OF NORTH ANDOVER THE EXPIRATION DATE THEREOF, NOTICE VALL BE DELIVERED IN 120 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER MA 01845 AUTHORIZED RePlt WWATNE Jeff Eldridge ®1988-201 D ACORD CORPORATION. All rights reserved. ACORD 25(2010106) The ACORD name and logo are registered merles of ACORD 917 cared?fcata can cele and14supersedes 'fig" r'ev�ivusly issued certificates, I fie omvm�rxurea�t `rj' laaaczc�uiae� a�-a Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration:,(130768 Type' I DBA 4/18/2014 ! - a Expiration: '4'/18/2014 ; U.S. HOME IMPROVEMENT JOHN CARROLL' - t 1 -� 27 HAMILTON RD. PEABODY, MA 01960`'-.- _ Undersecretary f I Massachusetts - Department of Public Safety $oar_d cf Building Reguiattons and Standard:1 Construction Super-visor x, License: CS-106653 JOHN H CARROLL 27 HAMILTON ROADI --Peabody 1VIA 019760 # ` £f J � �i � , �,�\ xpirat�on A 05/06/2016 Commissioner 1 poalPage# of pages A&Vev PROPOSAL SUBMITTED TO: JOB NAME JOB# ADDRESS JOB LOCATION DATE DATE OP PLANS MINE# FAX# ARM IECT 78. 3 3 /V7 e hereby submit specifications and estimates for: r =� 414,5 aw ��1�� .rr?�1�j� _�fll �ti L� --�f—_a56_ a`fi� " ! a•�i�? �L � �_._ I cot8'i1 I e propose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of: i j $ Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra cost Respectfully will be executed only upon written order,and will become an extra charge submitted over and above the estimate. All agreements contingent upon strikes, j accidents,or delays beyond our control. Note—this proposal may be Withdrawn by us if not accepted within days. I - i j FFherebyaccepted. specifications and conditions are satisfactory and are j You are authorizedto do the work as specified. Signature Payments will be made as outlined above. I Date of Acceptance �Signature 1 I A-NC3819/T-e80 09-11 I Th e.Common wealth of Massachnseas Department of lndaastrial Accidents Office of Investigations 4 600 Washington Street �l Boston,M,4 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Blease Print Le�db Name(Business/Organization/Individual): 3-a h h �4/Y�/I f (�. kclme l� r'/�d✓��1+�/J�p��` Address: 7 -'`Cell o;�Co rc. City/S`bate/Zip: Petbay, /tf , y 1?6 d Phone#: 7fSt "8-57�F -6 3 Of Are you an employer?Check the appropriate box: Type of project(required): 1.M"I am a employer with R 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. 7. [remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for mein any capacity. employees anand have workers' 9. E]Building addition [No workers' comp.insurance comp.insurce.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. I 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 clieck this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workerts'compensation insurance for rosy employees. Below is the policy and job site haformadon. Insurance Company Name;_ 1.,-Pef1y My 1 Policy#or Self-ins.Lic.#: W -- 3 1 V` 37qa2 ?c? � Expiration Date: Cl? 67Cl3 Job Site Address:_ L5 Wlaab,,&I n City/State/Zip: 1V Gl,f'jkoc VI LM!;� 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 WORD 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 cercimuder the panus and penalties of perjury that the information provider(above is true and correct. �r _ .3 s; Si afore: /'' Date:,: . � �3 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#: