HomeMy WebLinkAboutBuilding Permit #959-15 - 172-174 WATER STREET 5/22/2015Permit NO:
Date Issuedt;
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicant must complete all items on this
LOCATION
Print
PROPERTY OWNER V041V YdA�W 2MAhk
(,-V - 7 —'— '
.,,/ Print
MAP NOJ If f9 PARCEL ZONING DISTRICT:
TYPE AND USE OF BUILDING
HISTORIC DISTRICT YES F1
el�n��vot
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
?(Addition
El Alteration
[] Ppe family
V'wo or more family
No. of units: z
11 Industrial
E Repair, replacement
0 Demolition
11 Assessory Bldg
0 Commercial
D Moving (relocation)
11 Other
11 Others:
I] Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
ZI D/ D / A) -a C- ZA CX 6F ��ZA) Llzhu�-
AMDC 3
Identification Please Type or Print Clearly)
OVVNER: Name: Ya /L) VoAle Z#/ -m J Phone:—�N/ - L2
Address: 1:�2
CONTRACTOR Name: IINVACDW Phone: Jqf -W3/k
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE: BULDINGI)ERMIT.- $IZOOPER S1000.00 OF THE TOTAL ESTIMATED COSTBASED ONS125.00PER S.F.
Total Project Cost xl2.00=FEE:$
Check No.: /()/S-- Receipt No.: C96S I
Page W4
IN- %AORTH
1
BUILDING PERMIT 0 F. D
TOWN OF NORTH ANDOVER C
0
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER
Print 100 Year structure yes no
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes. no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
El New Building
[] One family
El Addition
0 Two or more family
El Industrial
El Alteration
No. of units:
El Commercial
0 Repair, replacement
El Assessory Bldg
El Others:
El Demolition
El Other
4,076ik
Z�� lz=k4 N
@'g inq P 71,gftffs
DESCRIPTION OF WORK TO BE PERFORMED:
Identification - Please Type or Print Clearly
OWNER: Name:
Address:
Contractor Name: Phone:
Emait
Address:
Supervisor's Construction License:
Home Improvement License:
ARCH ITECT/ENGI NEER
Phone:
Exp. Date:
Date:
Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT., $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F.
Total Project Cost: $
FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
jl�'-
Plans Submitted Plans Waived Certified Plot Plan Sta'M'Ped Plans F1
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools 0
well
Tobacco Sales
Food Packaging/Sales D
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 Reviewed on Signature
COMMB-�TS
HEALTH
COMMENTS.
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes
Pfanning Board Decision: Comments
-�onservation Decision: Com
Water & Sewer Connection/signature & Date Driveway Permit
]DPW Town Engineer: Signature:
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.$100-$l 000 fine
NOTES and DATA — (For department use
LJ Notified for pickup Call Ema
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
Building Permit Application
Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
4� Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit'(
Addition Or Decks
4-- Building Permit Application
4� Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
Mass check Energy Compliance Report (if Applicable)
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
Building Permit Application
Certified Proposed Plot Plan
Photo of H.I.C. And C.S.L. Licenses
Workers Comp Affidavit
Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Copy of Contract
2012 IECC 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
Doe: Building Permit Revised 2014
.1
Location
Date
Check # LDLUS�-
28816
TOWN OF NORTH ANDOVER
Certificate of Occupancy $-
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee $
TOTAL . $
Building Inspector
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Solar W?chnotogles
I I I v a g 1 mawell) ON I
This TURNKEY CONTRACT is made this 14" day of May, 2015 (the "EFFECTIVE DATE")
by and between:
"ITC'9
Invaleon Technologies Corporation
ATTN: Tom Wu
451 Andover Street Suite 330
North Andover, MA 01845
P: (978)-794-1724
F.1,101
"CLIENT"
(Name) YuanYong Zhang
(Address) 172/174 Water Street
North Andover, MA 0 1845
(Phone) 781-324-8883
ITC desires to provide Solar Installation services to the CLIENT and the CLIENT desires to
obtain such services from the ITC.
THEREFORE, in consideration of the mutual promises set forth below, the parties agree as
follows:
1. PROJECT MANAGER. Tom Wu is an employee of Invaleon Technologies Corporation,
and will act as the PROJECT MANAGER and representative for ITC.
2. PROJECT LOCATION: 172/174 Water St, North Andover, MA 01845
3. CONTRACT PRICE: $6,000.00
4. SOLAR SYSTEM SPECIFICATIONS. ITC will install one layer of Owens Coming Hallow
Fox Grey Architectural Shingles on the roof of the Project Location.
The installation of the "ENTIRE SYSTEM" shall hereinafter be referred to as the "WORK".
5. INSTALLER WARRANTY. The ENTIRE SYSTEM will have a minimum 5 year labor
warranty provided by the ITC to protect the CLIENT against defective workmanship. The
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Solar TL-chnologles
warranty will cover the ENTIRE PROJECT, including shingles, and provide for no -cost repair or
replacement of the PV project or system components, including any associated labor during the
warranty period.
SECTION 6. (Omitted)
7. PLANS, SPECIFICATIONS AND CONSTRUCTION DOCUMENTS. The CLIENT will
make available to ITC all plans, specifications, drawings, blueprints, and similar construction
documents necessary for ITC to provide the Services described herein. Any such materials shall
remain the property of the CLIENT. ITC will promptly return all such materials to the CLIENT
upon completion of the WORK.
8. REQUIRED PERMITS. The following building permits are required and will be secured by
ITC as the CLIENT's agent:
9 Building Permit from the Town of North Andover
9. PAYMENT SCHEDULE. The following schedule will be adhered to unless circumstances
beyond ITC's control arise
Payments will be made according to the following schedule:
$2,000 for material procurement. (* *)
$2,000.00 upon commencement of construction.
$2,000.00 upon completion of this contract
NOTES: (**) Law requires that any deposit or down -payment required by the Primary
Installer/Integrator 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.
10. SUBCONTRACTORS. ITC shall have the right, at its sole discretion, to perform all or any
part of the work through subcontractors and sub -subcontractors. ITC shall be responsible for any
work performed by subcontractors and sub -subcontractors as if it has performed such work
through its own forces. ITC shall not be obligated to obtain the CLIENT 's prior consent to the
use of any subcontractor(s) or sub-subcontractor(s). The CLIENT shall not communicate
directly with any subcontractor(s) or sub-subcontractor(s), all communications, changes,
instructions, or orders regarding the WORK shall be communicated directly to ITC by the
CLIENT. The CLIENT recognizes that unauthorized communications with ITC's
subcontractors may result in changes to the WORK, for which the CLIENT shall compensate
ITC in accordance with the provisions of Section 9 above.
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11. CHANGE ORDER. The CLIENT may make changes to the scope of the work from time to
time during the term of this TURNKEY CONTRACT. However, any such change or
modification shall only be made in a written "CHANGE ORDER" which is signed and dated by
both parties. Such CHANGE ORDER's shall become part of this TURNKEY CONTRACT. The
CLIENT agrees to pay any increase in the cost of the WORK as a result of any written, dated
and signed CHANGE ORDER. In the event the cost of a CHANGE ORDER is not known at the
time a CHANGE ORDER is executed, ITC shall estimate the cost thereof and the CLIENT shall
pay the actual cost whether or not this cost is in excess of the estimated cost.
12. CONFIDENTIALITY. ITC and its employees, agents, or representatives will not at any
time or in any manner, either directly or indirectly, use for the personal benefit of ITC, or
divulge, disclose, or communicate in any manner, any infon-nation that is proprietary to the
CLIENT. ITC and its employees, agents, and representatives will protect such information and
treat it as strictly confidential. This provision will continue to be effective after the termination of
this TURNKEY CONTRACT.
Upon termination of this TURNKEY CONTRACT, ITC will return to the CLIENT all records,
notes, documentation and other items that were used, created, or controlled by ITC during the
term of this TURNKEY CONTRACT.
13. INSTALLATION WARRANTY. ITC shall provide its services and meet its obligations
under this TURNKEY CONTRACT in a timely and workmanlike manner, using knowledge and
recommendations for performing the services which meet generally acceptable standards in
ITC's community and region, and will provide a standard of care equal to, or superior to, care
used by service providers similar to ITC on similar projects. ITC shall perform the WORK in
conformance with the plans, and specifications signed by ITC and the CLIENT.
In addition to any additional warranties agreed to by the parties, the ITC warrants that the work
will be free from faulty materials; constructed according to the standards of the building code
applicable for this location; constructed in a skillftil manner and fit for habitation or appropriate
use. The warranty rights and remedies set forth in the Massachusetts Uniform Commercial Code
apply to this contract.
14. FREE ACCESS TO WORKSITE. The CLIENT will allow free access to work areas for
workers and vehicles and will allow areas for the storage of materials and debris. Driveways will
be kept clear for the movement of vehicles during work hours. ITC will make reasonable efforts
to protect driveways, lawns, shrubs, and other vegetation. ITC also agrees to keep the SITE
clean and orderly and to remove all debris as needed during the hours of work in order to
maintain work conditions which do not cause health or safety hazards.
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Solar R!cAnologles
15. UTILITIES. The CLIENT shall provide and maintain water and electrical service, connect
permanent electrical service, gas service or oil service, whichever is applicable, and tanks and
lines to the building constructed under this TURNKEY CONTRACT after an acceptable cover
inspection has been completed, and prior to the installation of any inside wall cover. The
CLIENT shall permit ITC to use, at no cost, any electrical power and water use necessary to
carry out and complete the work.
16. INSPECTION. The CLIENT shall have the right to inspect all work performed under this
TURNKEY CONTRACT. All work that needs to be inspected or tested and certified by an
engineer as a condition of any government departments or other state agency, or inspected and
certified by the local health officer, shall be done at each necessary stage of construction and
before further construction can continue. All inspection and certification will be done at the
CLIENT's expense.
17. DEFAULT. The occurrence of any of the following shall constitute a material default under
this TURNKEY CONTRACT:
a.The failure of the CLIENT to make a required payment when due.
b.The insolvency of either party or if either party shall, either voluntarily or involuntarily,
become a debtor of or seek protection under Title I I of the United States Bankruptcy Code,
c.A lawsuit is brought on any claim, seizure, lien or levy for labor performed or materials used
on or ftimished to the project by either party, or there is a general assignment for the benefit of
creditors, application or sale for or by any creditor or government agency brought against either
party.
d.The failure of the CLIENT to make the building site available or the failure of ITC to deliver
the Services in the time and manner provided for in this Contract.
18. REMEDIES. In addition to any and all other rights a party may have available according to
law of the State of Massachusetts, if a party defaults by failing to substantially perform any
provision, term or condition of this TURNKEY CONTRACT (including without limitation the
failure to make a monetary payment when due), the other party may terminate the TURNKEY
CONTRACT by providing written notice to the defaulting party. This notice shall describe with
sufficient detail the nature of the default. The party receiving said notice shall have 90 days from
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Solar X-chnologles
the effective dateof said notice to cure the default(s). Unless waived by a party providing notice,
the failure to cure the default(s) within such time period shall result in the automatic termination
of this TURNKEY CONTRACT.
19. FORCE MAJEURE. If performance of this TURNKEY CONTRACT or any obligation
under this TURNKEY CONTRACT is prevented, restricted, or interfered with by causes beyond
either party's reasonable control ("FORCE MAJEURE"), and if the party unable to carry out its
obligations gives the other party prompt written notice of such event, then the obligations of the
party invoking this provision shall be suspended to the extent necessary by such event. The term
FORCE MAJEURE shall include, without limitation, acts of God, fire, explosion, vandalism,
storm, casualty, illness, injury, general unavailability of materials or other similar occurrence,
orders or acts of military or civil authority, or by national emergencies, insurrections, riots, or
wars, or strikes, lock -outs, work stoppages, or other labor disputes, or supplier failures. The
excused party shall use reasonable efforts under the circumstances to avoid or remove such
causes of non-performance and shall proceed to perform with reasonable dispatch whenever such
causes are removed or ceased. An act or omission shall be deemed within the reasonable control
of a party if committed, omitted, or caused by such party, or its employees, officers, agents, or
affiliates.
20. CONTRACT ARBITRATION. ITC and the CLIENT hereby mutually agree in advance
that in the event the ITC has a dispute concerning this contract, ITC may submit the dispute to a
private arbitration firm which has been approved by the Secretary of the Executive Office of
Consumer Affairs and Business Regulations and the CLIENT shall be required to submit to such
arbitration as provided in Massachusetts General Laws.
CLIENT Signature:
ITC's PROJECT MANAGER's Signature:
NOTICE: The signatures of the parties above apply only to the agreement of the parties to
alternative dispute resolution initiated by ITC. The CLIENT may initiate alternative dispute
resolution even where this section is no separately signed by the parties.
21. Indemnification and Limitation of Liability
To the fullest extent permitted by law ITC will indemnify and hold harmless the CLIENT and
its employees from and against claims, damages, losses and expenses, including but not limited
to reasonable attorneys' fees arising out of or resulting from performance of the WORK,
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Solar Ted7nologles
provided that such claim, damage, loss or expense is attributable to bodily injury, sickness,
disease or death, or to injury to or destruction of tangible property, but only to the extent caused
by the negligent acts of omissions of ITC or its subcontractor or anyone directly or indirectly
employed by them. Nothing contained in this TURNKEY CONTRACT shall be construed as
creating any personal liability on the part of any officer, director, owner, employee, manager,
member or agent of ITC. Notwithstanding any other provision to the contrary in this TURNKEY
CONTRACT, and to the fullest extent permitted by law, ITC's liability under this TURNKEY
CONTRACT, shall be limited to the sums recovered by ITC under insurance policies taken out
by ITC or ITC's subcontractors in respect to the WORK.
ITC shall not be liable to the CLIENT for damages incurred by the CLIENT as a result of a
failure to obtain Utility Interconnect approval.
Notwithstanding any other provision in this Agreement, under no circumstances shall ITC be
responsible for or be under an obligation to compensate the CLIENT for lost energy sales,
regardless of the reasons for such lost sales.
22. Taxes
The CONTRACT PRICE includes all sales, consumer, use, and other similar taxes on materials
provided by ITC, which are legally enacted by the governing authority in the area where the
installation is located.
23. Miscellaneous
This TURNKEY CONTRACT represents the entire and integrated agreement between the
CLIENT and ITC with respect to the WORK and supersedes all prior negotiations,
representations or agreements, either written or oral. This TURNKEY CONTRACT may be
amended only by written instruments signed by both the CLIENT and ITC. Any oral
representation of modification concerning this TURNKEY CONTRACT shall be of no force or
effect.
This TURNKEY CONTRACT shall be executed in two counterparts, both of which taken
together shall constitute one and the same instrument. The undersigned individual(s) represent
that they are fully authorized to bind their respective entities.
The CLIENT acknowledges that it has carefully read this TURNKEY CONTRACT and
understands the contents thereof, that it has had the opportunity to consult with its own
attorney(s) in respect to the terms and conditions set out herein and it has agreed to the
provisions hereof without reliance on any representation or promise by ITC or anyone acting on
behalf of ITC.
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Solar Technologles
The invalidity or unenforceability of any particular provision of this TURNKEY CONTRACT
shall not affect the other provisions, and this TURNKEY CONTRACT shall be construed in all
respects as if any invalid or unenforceable provision were omitted.
Nothing in this TURNKEY CONTRACT shall be construed or deemed to create a contractual
relationship between ITC and any third party; a cause of action in favor of a third party against
ITC; or create any third party beneficiary rights of any kind.
ITC and the CLIENT waive all claims against each other for consequential damages arising out
of or relating to this TURNKEY CONTRACT. This mutual waiver applies, without limitation to
all consequential damages which arise as a result of either party's termination of this TURNKEY
CONTRACT.
24. GOVERNING LAW. This TURNKEY CONTRACT shall be construed in accordance with,
and governed by the laws of the State of Massachusetts, regardless of the choice of law
provisions of Massachusetts or any other jurisdiction.
25. ASSIGNMENT. Neither party may assign or transfer this TURKNEY CONTRACT without
the prior written consent of the non -assigning party, which approval shall not be unreasonably
withheld.
26. 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 property. Review the following cautions and
notices carefully before signing this contract.
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IN WITNESS WHEREOF, the undersigned have duly executed and delivered this TURNKEY
CONTRACT as of the day and year first above written.
DO NOT SIGN THIS TURNKEY CONTRACT IF THERE ARE ANY BLANK SPACES.
No work shall begin prior to the signing of the TURNKEY CONTRACT and transmittal to
the CLIENT of a copy of such contract.
ITC
Name:
Title:
Signat
Date:
CLIENT
Name
Signature:
Date:
-1--4--15
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NOTICE OF CANCELLATION
YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR
OBLIGATION, WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE.
IF YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENTS MADE BY
YOU UNDER THE CONTRACT OR SALE, AND ANY NEGOTIABLE INSTRUMENTS
EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS
FOLLOWING RECEIPT BY THE SELLER OF YOU CANCELLATION NOTICE, AND ANY
SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED
IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR
RESIDENCE, THE SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED,
ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU
MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER
REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE
AND RISK.
IF YOU MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER
DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF
CANCELLATION, YOU MAY RETAIN OR DESPOSE OF THE GOODS WITHOUT ANY
FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE
SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO
DO SO, THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS
UNDER THE CONTRACT.
TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED
COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR
SEND A TELEGRAM TO INVALEON TECHNOLOGIES CORPORATION, AT 451
ANDOVER STREET SUITE 3 3 0, NORTH ANDOVER, MAS SACHUSETTS, 0 1845 NOT
LATER THAN MIDNIGHT OF
DATE:
I HEREBY CANCEL THIS TRANSACTION.
BUYER'S SIGNATURE:
Page 9 of 9
The Conzinonwealth of Massachitsetts
DePartftlellt OfIndimtrial A ech-lewtv
(Y'rice of A Vestigations
600 Washington Street
Boston, MA 02111
WIVIV. MaSs-govIdia
Workers' Compensation Instirance Affidavit: Buiiders/Conti-actors/Electricians/Plumbers
Name (B usi nessiftani zati on/l nd i vi dual):
Address:_4t5 J ST
_ 612,
OCWT Phone #:
_r ---------- ===== — __-
Are you an employer? Check the. appropriate box:
21 am a employer with __3
4. 1 am a general contractor and I
employees (full and/or parl-time).*
2. ED I
have hired tile sub -contractors
listed
am a sole proprietor or parvier-
on the attached shect.
ship and have no employees
Thew. sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' conip. insurance
comp, insurance.,.
required.)
5. We are a corporation and its
3. ED I am a homeowner doing all work
officers have exercised their
myself [Nio workers' comp.
right of exemption per MGL
insurance required] t
C. I i2, § 1 (4), and we have no
employees. [No workers'
comp. insurance reauired. I
2
M
Ty e f roject (required):
P
6. R.Iepw' construction
7i Remodeling
8. Demolition
9. F-1 Building addition
10. El Electrical repairs or additions
11.0 I'lumbingrepairs or additions
12.0 -Roof repairs
13TI Other
"Any AI)Plicarit that checks liox #1 Inust also i'll' out thc see - tion W, Ow ShOwil1r, their w0fkeTs' conipmaj ion'Pol icy information.
110111cowncts, who gubmit thi% affidavit i"dicating they are doing all work And their hire
otifiside. conUtctorS Must sub"llit a IICW affidavil indicafirm such,
*Corltractors that check this box inust attached an addiliollal sliceishowing the n3nic of1he sub-coniractors and state whether or notthoseentili $ I-
Cillilloyem ifthe Sub -contractors have eniployecS, tile), Intist provide their worke.rsl conip. polioynumber. e lave
an) dip eniployer that is providing workers' Compensation hisurancefor tqy Mplq�,ees. Below 1V the P011C)l andjOb Site
information.
Insurance Company Name:
Policy 4 or Self -ins. Lic. #: LA
Expiration Date:
Job Site Address:
M4- LolkW'_
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date),
Failure to secure, cove -rage as required underSection 25A of MOL 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 f0rin of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be for%varded to the Office of
Inves6gations of die DIA for insurance coverage verification.
Idaherellycer YU11 , thep is 7adpenalties OfPOdUrV that The inlorination provided,�bove is true and correct.
1i "!,'�'!!w -.Cn
/S-
OffiCifil Use only. Do nof write in 111is area, to be completed ki cio) or town official,
City or Town: Permit/laicense #
Issuing Authority (circle one):
I - Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone M
ACORD CERTIFICATE OF LIABILITY INSURANCE
DATE (MWDDNM)
1 3/10/2015
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 SUIBROGATION 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
MTM Insurance Associates
1320 Osgood Street
North Andover MA 01845
NT
CN 10 MIE�CT Lisa London
PHONE F,I. (978) 681-5700 1 FAX.
(A/C No A,. Nal: (978) 681-5777
F'MAIL
ADDRESS. lisal@mtminsure. com
INSURER(S) AFFORDING COVERAGE NAIC N
INSURERA-Atain Specialty Ins Cc
INSURED
Invaleon Technologies, Corp.
451 Andover Street
Suite 330
North Andover MA 01845
INSURER B -National Union Fire Ins Cc of
INSURER C:Travelers Insurance Group
INSURER D:
INSURERE;
INSURER F:
COVERAGES CERTIFICATFNLIMRFR-15-16 MaSter List RFVI.RInN N1 IMRFR-
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED B5LOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NDT\AnTHSTAN DING 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
ADDLSUBRI
POLICY NUMBER—
POLICY EFF
I MIDDIYYY'Yi
POLICY EXP
(MM/DD[YYYY1
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
A
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE Ex_1OCCUR
CIP229969
2/2/2015
2/2/2016
DAMAGE TO RENTED
PREMISES (Ea occurrence) $ 100,000
MED EXP (Any one person) $ 5,000
PERSONAL& ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GENT AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMPIOP AGG $ 2,000,000
7X POLICYF� J`rR,0i F7 Loc
$
AUTOMOBILE
LIABILITY
COMBINED SINGLE r1M_1T
(Ea accident)
BODILY INJURY (Per person) $
ANY AUTO
1
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
BODILY INJURY (Per accident) $
P
(PROP.ERTY DAMAGE
r. dntl $
$
X
UMBRELLA LIAB
HCLAIMS-MADE
OCCUR
EACH OCCURRENCE $ 1,000,000
AGGREGATE $ 1,000,000
B
EXCESS LIAB .
DED I X I RETENTION$ C
�BD UMB
3/12/2015
3/12/2016
WORKERS COMPENSATION
TNC STATIU- OTH-
I FER
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR/PARTNER]EXECUTIVE
OFFICER/MEMBER EXCLUDED?
NIA
CRY LIM TS
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
(Mandatory In NH)
It yes, describe under
DESCRIPTION OF OPERATIONS bel
I E.L. DISEASE - POLICY LIMIT 1 $
C
Crime Coverage
i1:6,
106254087
2/27/2015
2/27/2016
Limit $100,000
Deductible $5,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
This certificate of Insurance represents coverage currently in effect and may or may not be in compliance
with any written contract.
Next Step Living
21 Dry Dock Ave
2nd Floor
Boston, MA 02210
A%,%JKLJ X0 tAul WUD)
INS025 (qninnsi ril
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
Laorenza/STEPH 1_0
@ 1988-2010 ACORD CORPORATION. All rights reserved.
Tho arnRn nnirina nnell Infin 2ra ramictaraff markc f%fvng2n
Rightfax N2-1 3/13/2015 12:39:57 PM PAGE 3/004 Fax Server
F-
C;EMIS
ACa If CERTIFICATE OF LIABILITY INSURANCE
E�q -
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 POLKNES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN
THE ISSUING INSURER(% AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
WPORTANT: It the Cwdftsts holder Is an ADDITIONAL INSURE% ine poliCyplij) MUSt bg endOMM. ff SUBROGATION 19 WAIVED,
subject to the terms and conditions of the policy, certain POIIcIeG fnBY Fequire an endorsmerit. A 111111811wt an this cwtifiesta do"
-- - -- — the certificate holder In HOU of such endorsernent(s).
PRODUCER C
MTM INS ASSOCIATES LLC N F;
1320 OSGOOD ST ��ONE I FAX
N ANDOVER, MA 01835 I.;=4—
INSURE R(S) AFFORDINO COVERAGI; NAIC
INSURER A: TRAMERS PROPERTYCASCOOFAM
INSURED
INVALEON TECHNOLOGIES CORP INSURER 8:
451 ANDOVER ST STE 330 INSURER C -
NO ANDOVER, MA 01845 INSURER 0:
INSURER E
COVERAGES BER� INSURER F;
THIS IS To, CERTI Fy UMBER�
ABOVE FOR THE P THAT TH POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED
OLICY 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.
MR
TYPE OF INS wi-50 I Wei
URUCE — MR WV _tLX Y �MMEF�l POLICY EFF PiU— �Ww
RAL LIABPJN ARRM-1-121 mgwym LIMITS
COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE $
MS -MADE OCCUR ME
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PERSONAL&AOVINJURY If
ERL AGGREGATE LIMIT APPLIES PER; GENERAL AGGREGATE
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UTOS
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UMBRELLA LLAB OCCUR
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ANY PFIOPRIETOA/PAFITNEFVEXECLrrivi�4 _T�TOFli�E.
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wanammy n NH) Tus 03-06-2015 03-06-2018 G.L. EACH A=10ENT TI -00=0
If Vas. de= ur4or 2E768008 E.L. DISEASE - EA EMPLOYEE $100.000
OESCR IPTION OF OPERATIONS balo, . . ........ ........ 1. L —ois EASE - PoL icy L �m- —IT jg-00
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NEXT STEP LIVING, INC.
21 DRYDOCK AVE, 2ND FLOOR
BOSTON,MA 02210
ACORD 25 (2010/03) The ACORD name and bgo am
ANY OF THE ABOVE DESCRIBED POLICIES
.ED BEFORE THE EXPIRATION DATE THERI
WILL BE DELIVERED IN ACCORDANCE WITH
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