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HomeMy WebLinkAboutBuilding Permit #710-15 - 17 HALIFAX STREET 3/11/2015itt'i�� c L BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION. - Permit No#: �� °� I Date Received Date Issued: i, rte•• • n tt LED �! YMPORTANT: Applicant must complete all items on this page LOCATION /7 Hq 1 5.I Print PROPERTY OWNER l .' / .Ceti GN �' ✓_ '� Print 100 Year Structure yes no MAP UZ _ PARCEL611 ZONING DISTRICT: Historic District yes no Machine Shop Village yes no j TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial V'Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PE FORMED:' L c er� N e y if 40 K ct WL0 ✓2 fv V -es Q C e e ►i S' Gee l ri Idepti ication - Please Typ o rint Cl rly ,AJ t -�"t/e OWNER: Name: ().,v I be i/� .v-2 Phone: j 6I L9 Address: Q _ j �,) p Contractor Name: -t o"� V�d- Phone: 2 3 S / Address: 15 [it or a 6x. I,, C a Supervisor's Construction License: 0 Exp. Date: Home Improvement License:Ex / p.' Date:. O ,5�O Sld ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER •• $1000.00 OF THE TOTAL ESTIMATED COST BASEDO N$125.00 PER S_� Total Project Cost: $ F-- FEE: $ �j Check No.: Receipt No.: r>14S NOTE: Persons contracting with unregistered contractors do not have access to the guaranty -1c] -kind Signature of-Agent/Owner Signature of contr j C Plans Sub,nitted ❑ is "M Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYpF.D-F 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 PLANNING & DEVELOPMENT Reviewed On Signature COMMENTS CONSERVATION COMMENTS HEALTH ` COMMENTS Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes #Planning Board Decision: 'Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Dumpster on site yes Located at 124 Main. Street Fire Department signature/date _ COMMENTS Located 384 Usgood Street no 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 Emai Date Time Contact Name Doc.Building Permit 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 Li Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o 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 L3 Building Permit Application Li Certified Surveyed Plot Plan o Workers Comp Affidavit Li Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract Li Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application o 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 o Mass check Energy Compliance Report o 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 Doe: Building Permit Revised 2014 Location T�4ALL�c_'"" No. — Date Check # 14 J" TOWN OF NORTH ANDOVER Certificate of Occupancy $ FeBuilding/Frame Permit e ;q;& Foundation Permit Fee $ r Other Permit Fee $ _ TOTAL $ f, Building Inspector 0 ENO Q LL ° D Q m C cu L U Y -0 O LL E a� V N .Y Q V) Z Z m C 2 r 7 LLQ. L00 CC 61 E U _ LL 0 W Z Ve Z m C J d � 7 d' _ f6 I..L 0 a Z J u W W Lto � CCC U i V) 76 lL 0 WCL N Z Q L j 5 76 ll LU oC Q w W LL i 7 m z .1... 61 i N b ) O N o -�� � •N c C :Q o=� N W O O �C t O LU .E v Q o co °' >cc m O O � 0. 0 0 O W cn :a C7 0 . m v /1� zQ � 0 CL Z U cn LU 0 N . a' Z OX0 LU 0 c U U) W C W J CL Z 0 c 0 N N t O Z O a M J 0 CA L d 00 O Q Q C Q J � O O Z d N O i O �+ C O �a o N V L � '4n J�o I. dr. 0 V i �+ to V 3 N � �J � C � i C O O t/1 — 0 O � oz o -�� � •N c C :Q o=� N W O O �C t O LU .E v Q o co °' >cc m O O � 0. 0 0 O W cn :a C7 0 . m v /1� zQ � 0 CL Z U cn LU 0 N . a' Z OX0 LU 0 c U U) W C W J CL Z 0 c 0 N N t O Z O a M J 0 CA L d 00 O Q Q C Q J � O O Z d N Massachusetts Home Improvement Sample 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 legal advice if necessary. Any person planning home improvements should first obtain a copy of "A Massachusetts Consumer Guide to Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Name Company Name CLIFTON AND BEVERLY STONE WALSH GENERAL CONSTRUCTION Street Address (do not use a Post Office Box address) Contractor/ Salesperson/ Owner Name 17 HALIFAX ST. NORTH ANDOVER MA JAMES WALSH City/Town State Zip Code Business Address (must include a street address) 978-686-7618 15 MARLYN RD. BILLERICA MA 01821 Daytime Phone Evening Phone City/Town State Zip Code 978-361-5697 Mailing Address (It different from above) Business Phone Federal Employer ID or S.S. Number Home Impmvemmt Contactor Reg. Numhr Evuution date taa require'that ..athome :v:ua rtgi�atio oma 126909 08/05/2015 The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed, specifying the type, brand, and grade of materials to be used, use additional sheets if necessary J SUBMITTED ON ADDITIONAL SHEET Required Permits -The following building permits are required Proposed Start and Completion Schedule -The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of 03/16/2015 Date when contractor will begin contracted work. MGL chapter 142A.) 04/30/2015 Date when contracted work will be substantially completed. Total Uontract Price and Payment Schedule The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of $13,675 (*) Payments will be made according to the following schedule: $SUBMITTED upon signing contract (not to exceed 1/3 of the total contract price pr the cost of special order items, whichever is greater) $ ON by _/ / or upon completion of $ ADDITIONAL by / / or upon completion of $ SHEET upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be paid for NOTES: (a) Including all finance charges (* *) Law requires that any deposit or down -payment required by the contractor before work begins may not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty - Is an express warranty beine provided by the contractor? ❑ No ® Yes (all terms of the warranty must 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 labor under this aureement Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Imnrovement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to see a copy of a "proof of insurance" document. • Know 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 Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. OU INU I NIGIN I HIS UU1N'I'RAU'F 1N' THERE ARE ANY BLANK SPACES!!! Two identical copies of the contract must be compkted and sued. One copy should go to the The other copy should be kept by the contractor. Ho cowrie 's Si . to c Co actor's ignature Date Date Proposal 15 Marlyn rd WALSH Billerica 10" W-1 Tk Tw-v Im A 7r 10�v e% 'n Tnf F" -m PAGE I OF] LIC# 072199 '17-7 /1 "" 7r lL A T REG#126909 UrLIVERAL UU1V&311KUx,11U1V Jim Free Estimates RESIDENTIAL - COMMERCIAL 978-361-5697 PROPOSAL SUBMITTED TO rELEPHONE DATE STONE 03/0512015 978-686-7618 STREET JOB NAME 17 HALIFAX ST SAME CITY, STATE AND ZIP CODE JOB LOCATION NORTHAND0VER MA. SAME ARCHITECT DATE OF PLANS JOB TELEPHONE # We hereby submit specifications and estimates for KITCHENAND BATH REMODEL CONSISTING OF THE FOLLOWING 1. THEREMOVALOFALLEXISTINGCABINETSANDAPPLIANCES Z THE REMOVAL OF THE EXISTING HARDWOOD FLOOR. 3. THE REMOVAL AND REPLACEMENT OF ONE EXTERIOR DOOR(CUSTOMER TO CHOOSEAND PURCHASEDESIRED DOOR EXISTING STORM DOOR TO BE REUSED) 4. THE INSTALLATION OF NEWSUBFLOOR AND TILE TO THE ENTIRE KITCHENAAD HALL AREA(TILE TO BE AN ADDITIONAL COST) 5. THE INSTALLATION OFA NEWSTOVE EXHAUST (SUPPLIED BY CUSTOMER ADDITIONAL COST WHENINSTALLA TIONISDETERMIND) 6. THE INSTALLATION OFALL NEW CABINETS SUPPLIED BY CUSTOMER (ACCORDING TO NEW LAYOUT) Z THE INSTALLATION OFNEWDRYWALL TO WALL AREAS NECESSARY. (TAPE, COMPOUND, AND PRIME) 8. REMOVE THE EXISTING WALLPAPER (NOT TO INCLUDE REPAIR OF WALLS UNDER WALLPAPER IFNECESSARI) R PURCHASEAND INSTALL 3 SOLID MASOITE 6 PANEL INTERIOR DOORS 10. PAINT ENTIRE KITCHENAND FOYER AREA INCLUDING DOORS,CHAIRAIL AND MOLDINGS (KILOZPRIMER AND 2 COATS) 11. THE INSTALLATIONOFNEW TILE TOALL BACKSPLASHAREAS OFNEWKITCHEN(TILE 47LL BE ANADDITIONAL COST) 12. PLUMBINGAND ELECTRIC NECESSAR YSUBMITTED ON SEPARATE PROPOSALS 13. THE REMOVAL OF THEEXISTING FINISH FLOOR BASE MOLDINGS AND ONESUBFLOOR 14. FRAMER NEW CLOSETAREA WHERE THE TUB IS. TOACCOMMODATEA NEW WASHER DRYER AND SHELVING 15. THE INSTALLATION OFNEWBIFOLDDOORS TOTHENEWLAUNDRYAREA 16. THE INSTALLATION OFNEW318SSUBFLOOR AND TILE TO THE ENTIRE FLOOR AREA(TILE TO BEANADDITIONAL COST) 17. THE INSTALLATION OFNEWPRE-PRIMED BASE MOLDINGS 18. THE INSTALLATIONOF VANITY AND (CUSTOMER TO SUPPLY VANITY, TOILET, SINK TOP, FAUCETS) 19. THE INSTALLATION OFANY TOWEL BARS, MEDICINE CABINETS OR ACCESSORIES SUPPLIED BY CUSTOMER 20. FINISHANY WALL AREASALTERED 21. PAINT THE ENTIRE BATHINCLUDING KILZPRIMER AND 2 COATS ONALL EXISTING 6 PANEL PINEDOORS (BATHROOMSIDE) 22. OBTAIN PERMIT NECESSARY 23. CLEAN-UPAND DISPOSAL OFALL WORKRELATED DEBRIS 24. A FIVE YEAR PERSONAL GUARANTEE UPONALL WORK SPECIFIED 25. THIS PROPOSAL DOES NOT INCLUDEANYADDITIONAL DAMAGEDAREAS UNCOVERED,. 26 PROPOSED START DATE 0311612015 PROPOSED COMPLETIONDATE 0 510 112 0 1 5 WePwposehereby to furnish material and labor - complete in accordance with above specifications for the sum of: THIRTEEN THOUSAND SIX HUNDRED AND SEVENTY -FIVE dollars ($ 13,675 Payment to be made as follows: All or deviation from material is guaranteed to be as specified. All work to be Authorized completed in a workmanlike manner according to standard practices. Any alteration above specifications involving extra costs will be executed only upon Signature: written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our Note This proposal may be withdrawn by os if not accepted control. Owner to carry necessary insurance. Our workers are fully covered by Workman Compensation Insurance. ACCEPfANCEOPPROPOSAL-The above satisfactory and re hereby a cepte specified. Payment wan be adee Date of Acceptance: 6 specifications and conditions are are authorized to do the work as within days. DO NOT SPACES Proposal PAGE I OF I 15 Marlyn rd. WALSHLIC# 072199 Billerica a, �. T„-, , „ ,. „ w _ REG#126909 Ulf (VERA L Q,'UMi-1 K UQ. I UN -1 Jim Free Estimates RESIDENTIAL - COMMERCIAL 978-361-5697 PROPOSAL SUBMITTED TO rELEPHONE DATE STONE 03/0512015 978-686-7618 STREET JOB NAME 17 HALIFAX ST SAME CITY, STATE AND ZIP CODE JOB LOCATION NORTHANDOVER MA. SAME ARCHITECT DATE OF PLANS JOB TELEPHONE # We hereby submit specifications and estimates for KITCHENAND BATH REMODEL PAYMENT SCHEDULE CONSISTING OF THE FOLLOWING 1. THE INITIAL PAYMENT OF $2,000 UPON SIGNING THE PROPOSAL 2. THE SECOND PAYMENT OF $2,000 UPON THE START OF WORK 3. THE THIRD PAYMENT OF $2000 UPON THE COMPLETION OFALL OLD FIXTURE AND MATERIAL REMOVAL 4. THE FOURTH PAYMENT OF $2000 UPON THE INSTALLA TION OF CABINETR Y 5. THE FIFTH PAYMENT OF $2000 UPON THE COMPLETIONALL FLOOR INSTALLATION 6 THE FINAL PAYMENT OF $3,675 UPON THE COMPLETION OFALL WORK SPECIFIED WeProposehereby to furnish material and labor - complete in accordance with above specifications for the sum of: THIRTEEN THOUSAND SIXHUNDRED AND SEVENTY -FIVE 13,675 dollars($ Payment to be made as follows: All or deviation from material is guaranteed to be as specified. All work to be Authorized completed in a workmanlike manner according to standard practices. Any alteration above specifications involving extra costs will be executed only upon Signature: written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our Note: This proposal may be withdrawn by ns it not accepted control. Owner to carry fire, tornado and other necessary insurance. Our workers are fully covered by Workman Compensation Insurance. within days. ACCEPrANCF.OFPROPOSAL-The above prices, specifications and conditions are DO NOT satisfactory and re hereby accepted. You re authorized to do the work as specified. 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All dimensions size designations given are subject to verification on job site and adjustment to fit job conditions. III 90507fl b CW24 IN Lou W F5 This is an original design and must Designed: 9/6/2014 not be released or copied unless Printed: 9/6/2014 applicable fee has been paid or job order placed. All I Drawing #: 1 TNo Scale. 4 ----- --- - -- -- --- ---- ----126"- „ -- 30 24 T VSDB30R /-15" ------ --- g 7" - -- --- - _ � yu �' W3018 BUTT W1836Rj� W3036 BUTT CW2436L SR1K18 0.1 -.. B BWBT18-RANGE.GAS.3CB36 1TD 2FWT BUT BSSs; --------- iif i -A (n r V W Walsh Preliminary Kitchen 68-427892 978-361-5697 Cabinet Line: American Woodmark' Wood SpeciesMaple Door Style: Reading w Finish: Silk o Overlay: Full 'r cn Construction: All Plywood Construction i!'" "{ W I Top Molding: scm8 wd Bottom Molding:None�� Door Pulls: TBD Drawer Pulls: TBD N CA I Countertop Material: TBD Color: TBD o" Edge Detail: TBDw �I Backsplash: TBD 7 m _ Sink: TBD rl Faucet: TBD 0 NOTES: C X N -appliance specifications required prior to finalizing design , nI -Did not include any interior accessories C 0 � except trash cabinets cutlery divider �,' 4 -design has not been site verified or pier �I 7 00C Reviewed and is not ready for sale. X O I All dimensions .size designations given are subject to veri£cation on job site and adjustment to fit job conditions. I I 1-90507f1b krt Q� This is an original design and must Designed: 1/26/2015 not be released or copied unless Printed: 1/26/2015 applicable fee has been paid or job order placed. All Drawing #: 1 I No Scale. -- ------------------ 0) � N `J W p --- p N � ; N' � I I W W ' -- - W i This is an original design and must Designed: 1/26/2015 not be released or copied unless Printed: 1/26/2015 applicable fee has been paid or job order placed. All Drawing #: 1 I No Scale. LOr N ` - N ---- C' ..I CW2436L WW2 311 27" — 36" —/'-----304 of — W3015 BUTT L i� � 03618 X 24 DP BUT ' BUTT! _ . _.. W27 _. __ 36 BUTT ; -IN —,� W3012 BUTT LO— - -- -- _�__ V30 SH—� LOJ t0 M \� w - WTE �I; [TI 4 X 90R4ROT S-K.25-1TUB2 REF.2D.ICE.1DW36 9 NL LOCD r CO Iq BSS36L WD 315 4DVI SB30 BUTT DISH—IOWW \ \ B15R M - 1�I "- �� 36 -- 15 ----- "._ ...-----.- 11 30 / — 24 .../ IU 1� --- 34 -----36"- -��-----� /--15"-// 415 3" 3;6 -----4811-61' I All dimensions size designations given are subject to verification on job site and adjustment to fit job conditions. 90507fl b.kit This is an original design and must Designed: 1/26/2015 not be released or copied unless Printed: 1/26/2015 applicable fee has been paid or job order placed. El 2 Drawing #: 1 No Scale. •2 I M to 18.. 1511-11/l/ 2411 3011; - _ _ 3611 All dimensions -size designations given are subject to verification on job site and adjustment to fit job conditions. 90507f1 b.kit 871 015 not be released original design and orcopied nes Printed: 1Designed/26220/ 15 applicable fee has been paid or job order placed. El 1 Drawing #: 1 No Scale. (I -�A I J�q / �L� Existing layout VI "-�SI k/ S" New layout 3/16/15 16:17:06 ET T0:1970600954Z FROM: 9706714514 Merrimack Valley Ins 001 ,a►coRo�CERTIFICATE OF LIABILITY INSURANCE `r.../ CERTIFICATE IY DATE (MM/DD3/10/20155 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). PRODUCER Merrimack Valley Insurance Agency Inc 655 Boston Road, Suite lA Billerica MA 01821 Co NTCT Deborah Gilbert VEA FAX AONE N Ex : (978) 667-2541 AIC No: (978)671-4514 ADDRESS:DGilbert@mvins . com INSURER(S) AFFORDING COVERAGE NAIC it INSURERA.Main Street American Assurance 29939 INSURED WALSH GENERAL CONSTRUCTION 15 MARLYN RD - BILLERICA MA 01821-1901 INSURER B: INSURER C: INSURER D : INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER -2014 GL 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 LTR TYPE OF INSURANCE ADDL INER SUBR WVD POLICY NUMBER POLICY EFF MMIDDIYYYY11 POLICY EXP (MMIDDrAM LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR 4PT6295V /5/2014 /5/2015 EACH OCCURRENCE $ 1,000,000 DAMAGE O RENTED PREMISES 'Ea occurrence S 500,000 MED EXP (Any one person) $ 10,000 PERSONAL BADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO- LOC JECT PRODUCTS - COMPIOP AGG $ 2,000,000 $ - AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) S BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident) UMBRELLA LIAR EXCESS LIAB HOCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE S DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPMETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N 1 A WC STATU- OTH- E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) V GICt lfll..A 1 G nvt.ut=rc GANGtLLA I IUN 19786889542@sendfax.innopo Town of N Andover 1600 Osgood St Bldg 20 Ste 2035 N Andover, MA 01845 ACORD 25 25 (2010105) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOR12ED REPRESENTATIVE thony Lucacio/DEBG — © 1988-2010 ACORD CORPORATION- All riahts res.P_rverl_ 1NS025,9n1nns) ni Th. Arnon ".ma, ."A 11-(r am r.Aiefur.A m.rle. of A(tnpn RightFax`C3=1 3/11/2015 8:59:36 AM PAGE" 2/002 Fax Server P1=PT11=1rATF' CIP 11AR11 ITV INICI II2AKIPC DATE(MM/DD/YYYY) Tka4WIFICATE 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PHONE FAX MERRIMACK VALLEY INS 655 BOSTON RD. l A (A/C, No, Ext): (A/C, No): E-MAIL BILLERICA, MA 01821 ADDRESS: 73175K INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: AMERICAN ZURICH INSURANCE COMPANY WALSH, JAMES DBA WALSH GENERAL CONSTRUCTION INSURER B: INSURER C: INSURER D: 15 MARLYN ROAD INSURER E: BILLERICA, MA 01821 INSURER F: 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 ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MM\DD\YYYY) (MIADD\YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR. DAMAGE TO RENTED PREMISES (Ea occurrence) $ ED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERALAGGREGATE $ POLICY ID PROJECT [—] LOC PRODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) BODILY INJURY $ HIRED AUTOS NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DEDUCTIBLE $ $ RETENTION $ A WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY YM UB -2E643119-15 01/07/2015 01/07/2016 X i WC STATUTORY 'OTHER I LIMITS ANY PROPERITOR/R/EXECUTIVE OFFICER/MEMBER EXCLUDED? EXCLUDED? N/A E. L. EACH ACCIDENT $ 1,000,000 (Mandatory in NH) E.L. DISEASE- EA EMPLOYEE $ 1,000,000 If yes, describe under E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE WORKERS' COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR WALSH, JAMES. CERTIFICATE HOLDER CANCELLATION IUWN UN N ANDUVER 1600 OSGOOD ST, BLDG 20 SUITE 2035 N ANDOVER, MA 01845 ACORD 25 (2010/05) The ACORD name are registered marks 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 REPREAENTA'6LVE -------------- 0 ACORD CORPORATION., :All rights reserved. The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 yt www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNUTTING AUTHORITY. Name (Business/Organizationdndividual): Address: / W C( K' ( u dAJPV-GL ave City/State/Zip: %j . �� 1° C �( Phone Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/or part-time).* 1XII am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.# 6. ❑ We are a corporation and its officers have exercised their right of 'exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. ❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other *Any applicant that checks box #1 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 check 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 workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: 7— V Policy # or Self -ins. Lie. #: 60 Z_ 2- y rJ O G y 3 19 Expiration Date: S / S Job Site Address: �7( �d�k/ �S ,5,1zl jr.4 City/State/Zip: ?0� V i Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date) Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby c a y u der the pains and penalties of perjury that jke information provided above is true, and correct. 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 �I 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia assacnusetts - Dcpartrr. it of Puo c 51 >f, Board of Buil4ng Regulations and Stanazws (unoruction Supervisor License CS-072199 JAMES B WALSH= 15 MARLYN RD ; 13ILLFRICA MA7 01821 Ex r -+.e - ,)r•.,nissjcner 10122x2015 ��e `�ar�vr�2a�ttaecrlf� a�vl�Lcre�acfu�rl� _ _ _- - _ Office of Consumer Affairs & Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 126909 Type: Office of Consumer Affairs and Business Regulation Expiration: 81512-01-6 DBA 10 Park Plaza - Suite 5170 Boston, MA 02116 WALSH GENERAL CONST JAMES WALSH 15 MARLYN RD BILLERICA, MA 01821 WNot Undersecretary valid out sign r