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HomeMy WebLinkAboutBuilding Permit #636-2017 - 1675 GREAT POND ROAD 12/13/20164 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: �-o t I Date Issued: —.010 l� IMPORTANT: Anuli LOCATION PROPERTY OWNER_ MAP PARCEL u��� j'C_(L must cc 16-1 'rint 4el?, Date Received N— 15 - �- fete all items on this Print 100 Year Structure yes no ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE - Exp. Date: LJ An 12,4 Residential Non- Residential 0 New Building ne family Exp. ❑ Addition 0 Two or more family ❑ Industrial 0 Alteration No. of units: ❑ Commercial 0 Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other D Seip i�„ ®iUUe 1 » Flootl lain ®1Netlands}- p 171N,�ate �eI� OWNER: Name UtbUKIF I JUN OF WORK TO BE PERFORMED: Identification - Please OC(C 6d 14C - or Print Clearly Address: 16 '-) 5 (x/12 /�� IL Contractor Name: 7DSA �,PAZA/ L�- Phone Email: -TRay CQ a Address: ne: 91,?-91)--1Ij-�l S a Supervisor's Construction License: (Z - Exp. Date: LJ An 12,4 Home Improvement License: Exp. Date: 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.: V(3-7 Receipt No.: 3t3 NOTE: Persons contracting with unffgistered contractors do not have access to tke guaranty fund A n Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanuing/MassageBody Art ❑ ST, bmn'ng 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 e U FORM PLANNING & DEVELOPMENT Reviewed On Signature. COMMENTS CONSERVATION Reviewed on Signature COMMENTS " HEALTH Reviewed on Siqnature COMMENTS P Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Wafter & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 364 Osgood Street FIREjD77 EPAkfMENT.'-Temp.Dumpsteron.site ;yes= Located at 124 Macri Street . �` °,r s � x s Fire�Departrnent signature{date ,r .rt. ,� }; �'�.3°.� 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: lies MGL Chapter 166 Section 21A—F and G min.$10041000 fine NOTES and DA I A — (For department use ® Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 IAC Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Pian Or Proposed Interior Work Engineering Affidavits for Engineered products TOTE: 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/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 4 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 U—Z -I No.�o Date Ch eck #G4:�7 313 2 8 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL $ Building Inspector = 2 LL. O O Q O m u +_ \ O O LL N U CL ai N p H V N Z O Z ca I C: O m "O 7 O LL L 7 O d' ? ai C E L U 6 c LL O ~ N Z Z m J d .� m p C — ro c LL o: O N Z J u J W L p K U O N f6 c LL cc O W Vf Z LM Q C7 I L OA .O p w — f6 c LL z W D: Q W W C LL i p CO O Z N v N ++ N Y N Q LU U) Z 0 m zQ o F� W XUJ O CO W J a. z w v O E z 0 a� .E CL s O V Cl - 0 O V _cc CL cn lw L: a CD a, = c o� m m 00 O CL of Q s � Cc J � O CD z CD CL r_ z E O Q. t U) C O 0) a) �a m L O C O N O t 0 z 0 Q J 0 i C-. V O O O F=- U U oC Z J w& a a F - of U Z Z Z LL CL a a g u z W Z ? cuj o ° c� m J W LL E Lm cuJ c d W ? 2 O aj N T Z O C _cu _ _ _ Y O Q = G ro ro ? �III �u�I I IIIIIVI � 1F i I, III V V IIV'I_ 1 ` Commercial Roofing - n �a 8� ode t Chimneys Res 9 All Types Of Siding CHIMNEYS POINTED -REBUILT -CAPPED Expert Mas my Work Mass Toll Free Roof Leaks Experts * Licensed & Insured Locally Owned & Operated Since J976 """ 1-800-WAIT-4-uS ® License #034200 (924-848T) IKO G'aee ?Zv¢rX cz ,�Vhn UaJ We Work Year Round Proposal To: Nick Daher Date 11/16/2016 I Street: 1675 Great Pond Rd.I 978-423-7782 I Methuen, MA IRoof proposalI nicholasdaher@dahercompanies.com I IKO Cambridge/Certainteed Landmark 1. Extra caution will be taken to protect house and landscaping as best as possible. (tarps etc.) Magnets run at final clean up. 2. Remove all shingles from entire house. 3. Inspect and re -nail any loose or lifted plywood. Any compromised plywood will be replaced at an additional cost of $60.00 per sheet of 1/2" CDX. 4. Install heavy gauge 8" white aluminum drip edge to all eaves and rakes. 5. Install 6' of Certainteed winter guard or IKO Armourguard ice and water shield to all eaves and top to bottom in all valleys. 6. Install IKO Cool Grey or Certainteed Diamond Deck synthetic underlayment to remaining sheathing up to ridge. 7. Install all new pipe boots. 8. Install IKO Leading edge or Certainteed Swift Start starter shingles to all eaves. 9. Install IKO Cambridge AR or Certainteed Landmark Limited Lifetime architectural shingles to entire house. IKO 15 year and Certainteed 10 year material MFG. warranty. (See extended warranty) All shingles will be installed and fastened according to mfg. specs. All valleys woven. 10. Cut and install new GAF Cobra ridge vent and cap with color matched Certainteed Shadow hip and ridge shingles. (MA code) 11. Counter flash existing chimney lead, wall connections and all roof protrusions with ice and water shield, tie into new shingles and seal with clear Geo -Cel sealant. 12. Removal of all work related debris. Planks will be placed under dumpster to prevent any damage to driveway. 13. Building permit included. 14.Contractor workmanship warranty: 10 years under normal wind and rain conditions. Total IKO cost: $159600.00 IKO Shield Pro Plus or Certainteed 3Star extended MFG warranty: A fully transferable 100% coverage against material defects for a fully non pro rated period of 20 years. Please refer to pamphlet left in estimate folder. Offered to our existing customer referrals and included in this proposal at no additional cost. Balance due upon completion. no deposit reauired! References available upon request Hizhly rated member of the accredited BBB and Anizie's List Thank you! 1 TMe Common -wealth of Massa huseits z... .7 -Tartment oflndusWalAccidents I Congress Steeet, Suite 100 -- -Roston, MA. 0.2114-:2017 yV4kexs' CoxnpeaizonlnsrxrauceAdavzi: Baiiders/ConixactorslElectriciazis/Plmnbers. TO BE,FffXD WffR � TERAffrDNGAUTICORITSZ. A licant.7nformation • Please Print iftdbly Name (Business/C rganizaiion/Tndivzdnal): 11 L L 11 n 1�9- -e%( Address: A r.+Fg1,4�'i-ai'e!%iYl: fA.1)-,-� ✓m.1141 Areyou au employer? Gbecktlio 4�opxiaiebox; -'hone #: l.n I am a employer—, i • semployees (fiill andlorpart-time).;' 2.0 I am a sole pmpi-ab:= ar1)ari amhip and have no employees vr0rkk9 forme iu any capacity. [No workers' comp. insurance required_I 10 1 am a homemnerdoing all workmyself. INo workers' comp. ;,,sorauce raqukGd.] 1 4.[] I am a h0meowneran6vM behiring contractorsto conduct all work onmyproperty. Iwh% ensure that all comtacmrs either have woikas7 compensation iucurAnee or are sole prof iietors Taffiao Dnployees. 5_ am a general 0omto- or znd Ibavehired the sub contractors lis d on the attached sheet thesesnb-ooutractor- ha employees andhaveworkms' comp_ insurance1 6.[l We areacorporatimpedals o cershave exereisedtheii Wight of egempiionPerM TC2c• 152, §1(4), andwehaveno.,e uployees. rNoworkers' comp. ksmanceregrLed.] 917Y, /"'73 ! Type of project (TegEdIxed): 7.- [] Now corisixvctton 8. [] Remodeling 9. ❑ Demolition 10 F] $uilding addition 11. [] Electrical repairs or.additions 12: [ Plumbing rep airs or additions 13.[[Roafrepairs ,/ 14.210thex -:Anyapplicaotthabcheclrsbdx*l must alsolriloutthesecuoncyinionnatiou 'iSomeownemwhosidimifibisa[;fldavftMchc4h gtheyaredoingalllvorkandtheahireoutsidecorkaciorsmusisizbm?ianewaiiidaviiirtdicatingruch Coi&actorsthatcheckt7 sb�mns�a`tachedanadditionalsheetslmwingth.rnameofthe sub-tort¢actomandsatewhetherunoirlioseeniitieshave p axe erriproyer 6 at aspYo�idir�g�vorkers' compewation hmurancefor rrg er7zprayee�s.' J3ero�u is theporicy grid job site infor7nador2. Insurance Company 14ma; Policy# or Self -ins. Zit. #: Expiration-Da#e: ! ATA lob Site Address: .Attach a _copy of theyForkers' co:npewation policy declaration page (showing the policynumber and expirati= date). Failure to secure coverage as requiredunderMGL c. 152, §25A is a criminal violationpunishable by a fine up to $1,500.00 and/or one -Year lmprlsonment; as wel( as civil. penalties inthe for. of a STOP WORK ORDER and a Eno of up to $250.00 a day against the violator_ A, copy of this statement may be forwarded to 11e Offtce of Investigations of the DIA for insurance coverage verificatiorf . I do hereriy certify r deer t Ief- azmvs arad_ penalties ofpeijZry tlaat the Zuformation provided above�s%arae iv-,.deon rect. ti.,� Date: /2.�/Z(_zal/ Phone i# 0 q offidaz - onry. -Do not -write zn this area, to be corrapreted by city or toYvn officiar City Or Towax: • • PermitlLicense k iss-langAuaority (eixcle on i 1. Board of $eaM 2. BuffdingDeparianent 3. Cityl'P'own Clerk 4. Electrical Inspector 5. RI-ambinglnspector 6.Other Contact Person: Phone Information and Instructions Massachusetts General Laws chapter X52 requires all employers to provide workers' compensation fortheir employees. Pursuant to this statute, an empZoyee is defined as "...every person m the service of another under any contract bf brie, express or implied, oral or written." Au, 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 enferprise, and including the legal representatives of a deceased employer, or the receiver -or trustee cf-a u 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 dwalling house of anotherwho 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 b6 deemed to bean employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shah withhold the issuance or renewal, of a license or permit to operate a business or to cons -ft act buildings in the commonwealbl fox• any applicantwho Jtias nat produced acceptable evidence of compliance vvitdr the iusurance coverage requared." Additionally, MGL chapter 152, §25C(7) states `Neither the commonwealth nor any ofits 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 wormers' compensation affidavit completely, by checkingihe boxes that apply to your situation and, if necessary, supply sub-'contactor(s) name(s), addresses) and-phonenumber(s) along with theirceztificate(s) of insurance. Limited Liability Companies (LLC) or Limited LiabfftyPartnerships (LLP)with-noemployees'other than the members or p artners, are not required to carry workers' comp ensation insurance. If an LLC or LLP do es have employees, apolicyisrequired. Be advised that this affidavit maybe submitted to the Department of-In-dustrial Accidents foi confttmation of: nu=ance 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 regardingthe law ox if you'are required to obtain a workers' compensation policy, please call the Department. at the number listed below. Self-insured compni aes 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 aff davit for you to fill out in the event the Office of -Ivestigations has to contact you regarding the applicant. Please be sure to fill in the permit/license, number which will be used as areference 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 `Tob 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 maybe 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 notrelated to any business or commercial venture (i.e. a dog license or pem t to bum leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number_ The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617.727-4900 ext. 7406 or 1-877-MASSAFE Fax # 6177277749 Revised 02-23-15 wwwmass.gov/dia F rom An i ve rsa l Insurance To:19789750461 06/14/2016 13:15 #533 P.002/002 CORD CERTIFICATE OF LIABILITY INSURANCE DA06/14/20 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 6 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCERBenhaline Universal Insurance Agency, Inc. 374 Belmont Street Worcester. MA 01604E Puccio PHON! FAX N.1i (508) 752-9303 -MAIL , BPUCCIOCUNIVERSALINSAGENCY.COM INSURER(SJ AFFORDING COVERAGE MAIC N v A)Wt0 INSURER A: ESSEX INSURANCE CO 39020 INSURED MGG CONSTRUCTION INC 12 WATER STREET #1 INSURERS: INSURER C : Milford, MA 01757 INSURER D: GENERAL AGGREGATE $ 2,000.000 INSURER E t PRODUCTS •COMP/OPAGG = 1,000,000 INSURER F: f KGVIOrVn FILA 1DCK: 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. 30 TEMPLE STREET NSR TYPE OF INSURANCE S R PO IC FF POLICY EXP POLICY HU-MRER M Y MM LIMITS A COMMERCIAL OENER& UABIUTY 3EA6951 05/20/2016 5/20/2017 EACH OCCURRENCE S 1,000,000 CLAIMS -MADE 12 OCCUR DAMAGET51kEM15 v A)Wt0 FREMISES IEe oc r S 50.000 MED EXP(Any.one eraon S 5,000 PERSONAL 3 ADV INJURY $ 1,000,000 GEMLAGGREGATE LIMRAPPLIES PER: PRO' El GENERAL AGGREGATE $ 2,000.000 POLICY JEGT LOC PRODUCTS •COMP/OPAGG = 1,000,000 OTHER. f AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT E $ ANYAUTO BODILY INJURY (Pe(Person) S ALL OWNED SCHEDULED BODILY INJURY (Per accident) 5 AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS PROPEa TY DAMAGE S , 4 UMBRELLA LUB OCCl1R EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ OF[) I RETENTION S $ WORKERS COMPENSATION ORS AND EMPLOYERS' LIABILITY Y I N TAT ANY PROPRIETORrPARTNERIEXECUTIVE =E.L. OFFICERIMEMSER EXCLUDED? N I A EACH ACCIDENT $ (Mandatory 1n N) _ tl yyes tlesodbe IxMer DES( RIPTION OF OPERATIONS below E,E.L.DISEASE - EA EMPLOYEE S E.L. DISEASE - POLICY UMI S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, may be mashed If mwe space Is required) CERTIFICATE un1 nrn Fax 0: (978) 975.0461 �.aent,CLL.FA I wn ALL UNDER ONE ROOFING SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 30 TEMPLE STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Methuen, MA 01844 AUTHORIZED REPRESENTATIVE v A)Wt0 ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD ACC►R& CERTIFICATE OF LIABILITY INSURANCE ill—� DATE(MMIDDr") 1110812016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terns 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 02051-001 RRUPCT Branch 2051-1 Pe Insurance Agency LLC NorthAndover,And ver, MA 01846 kM8p.1ILd. Ext: (978) 665-7690 Ne: (976) 687-0149 ADDRESS: EACH OCCURRENCE $ INSURED All Under One ROOF INSURER(S) AFFORDING COVERAGE INSURER A@ A.I.M. Mutual Insurance Company INSURER B: C/O John Lanza£ame INSURER 0, 30 Temple Drive I E Methuen, MA 01844-0000 INSURER F,_ COVERAGES renTrer^A - -- r%crwrVrs nvmcr-K; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD CERTIFIICCATENMAYABESISSUEID OR MAYNY EPERTA N. THE INSURANCE AFFORDED BY THE POL CIEOR S DESCRIIBEE HEREIN DOCUMENT5 SUBJECTPTO A L WHICH TRMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN L TYPE OF INSURANCE �$W POLICYNUMBER ANSM MIS. LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 0 OCCUR EACH OCCURRENCE $ A E TOPRrMISES(ERENTED $ MED EXP (Any one person) $ — PERSONAL 6 ADV INJURY S GENERAL AGGREGATE S EN'L AGGREGATE LIMIT APPLIES PER: UCY of OC PRODUCTS- COMPIOP AGG S AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOSAUTOg HIRED AUTOS VNED AUTOS AUTOS CO D SING IT S accidentlALL BODILY INJURY (Per person) S _ BODILY INJURY (Per accident) S PROPERTYDAMAG (Par accident) $ - UMBRELLA UAB EXCESS LIAR OCCUR CLAIMS MADE ---- ---_.___� EACH OCCURRENCE S __�_` ------- __-__.DED DED RETENTION S S /� yyoRKEpgC��p gpTt N pANNyDE�M�PpLpO�Y�7ERpSR�/CpIgAS�ILQETgY/ YI AKICFJi/MEMBER EXCLUDEDp ECUTIVE (Mandatory In NH) Y IItt es dd �py �d D SCRI '�r0� �F OPERATIONS below NIA AWC-400-7009464-2016A 111912016 11/912017 gTq��J TH. X TsKluk OER _ E.L. EACH ACCIDENT S --- E.L. DISEASE . EA EMPLOYEE S F -L DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required) PROOF OF COVERAGE The workers compensation policy does not provide coverage for John Lanzafame CERTIFICATE HOLDER CANCELLATION All Under One Roof 30 Temple Methuen, MA A 01844 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2010106) The ACORD name and logo are registered mar0198 ks of ACORDACORD CORPORATION. All rights reserved. Wssaahusetts • Department of pU4,10 Sirr, Board of Dulldin Ro gtfi4tlonJ 41%41.a S. tra ar t`un<tru0 ctiun Suprrrhur 1.taaltsa: C9469120 ► % 330'nMBDR � t. . MST=NMA 81off 111110 �dmfntsaloe,a� 04r03&17 11 vV VVVi/r/!q �moi/ �/ _—..._ _ -•�wJssw Office of Consumer Affairs and Business Regulation 10 Park Plaza, - Suite S 170 Boston, Massachusetts 02116 Home Improvement C©tractor Registration Registration: 137057 ALL UNDER '• ' -. TYPO: DBA ONE ROOF t "' �` •, :. Expiration: lormo18 •► JOHN NZAFAME~_ -� - 291333 166 A MERRIMACK ST METHEUN, MA 01844=' :� ..', `•� SCA 1 4 20M W11 • , Update Address and return card. Mark reason for change. ' C3 Address 0 Renewal ❑ gmPI o�ept ❑Lost Card t Office orcons nN�nrrrl�/. o/r+ jlaunc/iiJcYYl nsamerAtrairs& $usibessRegulation HOME IMPROV!MENT CONTRACTOR R Re date. If glstvalid o n rete ni use only before the Reglstratloq: 137057 tton Expiration: IOM2018 fie' CBA Office of Consumer Affairs andBusinew �• 10 Park Plaza . Suite 5170 Regulation ALL UNDER ONE ROOF Boston, MA 02116 JOHN LANIAFAME 166 A MERRIMACK S7 METHEUN, MA 01844 dersecretary Not valld without sIgaata? i t� t vV VVVi/r/!q �moi/ �/ _—..._ _ -•�wJssw Office of Consumer Affairs and Business Regulation 10 Park Plaza, - Suite S 170 Boston, Massachusetts 02116 Home Improvement C©tractor Registration Registration: 137057 ALL UNDER '• ' -. TYPO: DBA ONE ROOF t "' �` •, :. Expiration: lormo18 •► JOHN NZAFAME~_ -� - 291333 166 A MERRIMACK ST METHEUN, MA 01844=' :� ..', `•� SCA 1 4 20M W11 • , Update Address and return card. Mark reason for change. ' C3 Address 0 Renewal ❑ gmPI o�ept ❑Lost Card t Office orcons nN�nrrrl�/. o/r+ jlaunc/iiJcYYl nsamerAtrairs& $usibessRegulation HOME IMPROV!MENT CONTRACTOR R Re date. If glstvalid o n rete ni use only before the Reglstratloq: 137057 tton Expiration: IOM2018 fie' CBA Office of Consumer Affairs andBusinew �• 10 Park Plaza . Suite 5170 Regulation ALL UNDER ONE ROOF Boston, MA 02116 JOHN LANIAFAME 166 A MERRIMACK S7 METHEUN, MA 01844 dersecretary Not valld without sIgaata? co LO 0) co Lo 0 0 0 0 Cunningham Lindsey U.S., Inc. P.O. Box 703689 Dallas, TX 75370-3689 Telephone (888) 738-8714 Facsimile (214) 488-6766 CLCAT@CL-NA.COM ***********************AUTO**3-DIGIT 018 766 T3 P1 95000058956 Building Commissioner or Inspector of Buildings 120 MAIN STREET N ANDOVER, MA 01845 Claim Number: Policy Number: Company Name: Cause of Loss: Date of Loss: Insured: Property Location: Cunning= C�Lindsey _ Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 3B 1113820 1113820 26 MERRIMACK MUTUAL FIRE INS ICE DAM 3/2/2015 MAUREEN DAHER 1675 GREAT POND RD Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 313 is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section 3K No insurer shall pay any claims (1) covering the loss, damage, or destructions to;afi building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss,'damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the'said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed.to a city or town under the provisions of this section. On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885