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HomeMy WebLinkAboutBuilding Permit #316 - 183 GREENE STREET 10/19/2009 TOWN OF NORTH ANDOVER / APPLICATION FOR PLAN EXAMINATION Permit N0: 3G Date Received Date Issued: 'Q IMPORTANT: Applicant must complete all items on this page LOCATION -3 �rt ce/l 44�ou-ej / / n PROPERTY OWNER` Print MAP NO:_ t`i L-PARCEZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Buildingne family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, a lace Assessory Bldg Others: Demolition Other Septic Well floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: nk ou e- ow n vo- 9° nkf► l �0 K2 Identification Please Type or Print Clearly) OWNER: Name: B i 11 W©Rry)l'elr1 Phone:2 ?F )Ayd09 Address: CONTRACTOR Name: '► - CY\.s~" '17t1 c Phone: Address: O Lc- n C cc A+C Y'` Supervisor's Construction License: Exp. Date:_-/7 /?,0/ Home Improvement License: D Exp. Date: F 12-010 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. s Total Project Cost: $ �9a - FEE: $ ✓t 2 l d Check No.: I (K 4& Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature -of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A–F and G min.$100-$16-00 fine NOTES and DATA— (For department use ❑ Notified for pickup - Date ............................. ................................................................................... ....... ................................ Doc:.Building Permit Revised 2008 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 Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of BldgPermit t Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of BldgPermit t 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 An Hydraulic Calculations (If Applicable) d ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008 COMMENTS Location !O,9 Gry,,�.�n �c 1 No. _ DateUCI NORTq TOWN OF NORTH ANDOVER • O f js Certificate of Occupancy $ cMusBuilding/Frame/Frame Permit Fee $ s� t 9 Foundation Permit Fee $ AV- Other Permit Fee $ TOTAL $ Check # 2 25 r r" � L Building Inspector NORTH Town 0 t 19Andover No. .31)6 0 dover, Mass., 10 COCL A K 6 H1 I q. 0R4.r - C7 AT D BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THISCERTIFIES THAT...04(............. ....................................................................................... Foundation has permission to erect........................................ buildings on .1&5.4.�..'.wrt...CL-n........ gh ...s-J I P-0 I? t Chimney to be occupied as........... ...........j ...........0 �.Olal....... .................................................................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU! ST Rough ....... ... ........................... ....................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE _j Smoke Det. r 1 11JJ 11J �•Y J*N*R ,k� GUTTERS� INC. Hlc#108503 All Types of Home Improvement 38-40 Lancaster Street --� - Haverhill, MA 01830 Haverhill,MA: (978)372-4088 Boston,MA: (617)423-3559 Andover,MA: (978)475-3723 Nashua,NH: (603)595-2272 Woburn,MA: (781)937-4212 Portsmouth,NH: (603)433-1811 Natick,MA: (508)653-2200 Manchester,NH: (603)666-5502 www.jnrgutters.com Fax: (978)372-0360 Toll Free Nationwide: (800)966-9238 PROPOSAL SUBMITTED TO PHONE ATE Bill Wolfeden 978-258-00 6/8/200 # STREET - 183 Greene St JOB NAME Windows CITY,STATE and ZIP*�Mdover MA 01845 JOB LOCATION ARCHITECT JOB PHONE We JJxo13v51C hereby to furnish material and labor,,complete in accordance with specifications below, for th:$3,275,.5 of:Three Thousand Two Hundred Seventy Five Dollars;and 50/100 Payment to be made as follows dollars($ Il Authorized Note:this proposal may be � Signature withdrawn by us if not accepted within "�" = days. I We he y submit specifications and estimates for: � I J-n-R Gutters purpose is to install vinyl windows in the following manner: e a 1. Remove old windows and storms in a neat ond'professional manner. 2. Replace any rotted wood at additional cost. 3. Fill all window cavities with insulation fo*prevent any drafts and heat loss. 4. Prior to installing the new windows, J-n-R will seal edges around window casing. 5. Whenever removing the old wood around the window, we reinstall the wood unless it breaks, then we replace it with new wood at additional cost to the I customer. 6. When we remove the old wood the customer may have to touch up the wood with paint or stain. 7. Upon completion of installing new windows, J-n-R will then insulate any spaces prior to replacing trim around window. 8. Upon completion and payment in full, all workmanship is to be warranted for 1 year. 9. All jobs are to be done in a professional and courteous manner. NOTE: Price includes installing front door(to be supplied by customer). Price to repair siding & metal would be $195. ' .I I` t I Arr-eptanve of JJrolavoal - The prices,specifications and Do not sign this contract conditions listed above and on the back of this form are satisfactory and are if there are any blank sp ces: r hereby accepted. You are authorized to do the work as specified.Payment will be made as outlined above. Three day cancellation rights under section forty-eight of chapter ninety three,see- I' tion fourteen of chapter two hundred and fifty five,D or section ten of chapter one Signature hundred n forty D and as may be applicable. Y Y PP Date of Acceptance: r Signature 1.ACCEPTANCE.This agreement is expressly limited to and made conditional upon your acceptance of its terms and conditions.Any of your terms and conditions which are in addition to or different from those contained herein which are not separately agreed to in writing (except additional provisions specifying quantity,description of the products or work ordered and shipping instructions)are deemed material and are hereby objected to and rejected. You waive your objection to any terms and conditions contained herein if Contractor does not receive written notice of your objection within ten business days of the date of this agreement. You will in any event be deemed to have assented to all terms and conditions contained herein if any part of the products or work described herein are provided or performed. Please note particularly the Limited Warranty, Limitation of Remedies and Limitations on Actions and Liability provisions set forth below. You acknowledge that the prices stated are based on the enforceability of these terms and conditions, and on the limited Warranty,Limitation of Remedies and Limitation of Actions and Liability provisions below,that the price would be substantially higher if Contractor could not limit its liability as herein provided,and that you accept these provisions in exchange for such lower prices. 2. LIMITED WARRANTY.All work performed by Contractor is warranted to be free from defects in material and workmanship for one year from the date of completion of the installation subject to the terms below.Contractor makes no warranties regarding products sold but assigns to you any manufacturer warranties relating to the products.THIS EXPRESS WARRANTY IS IN LIEU OFAND EXCLUDES ALL OTHER WARRANTIES,WHETHER EXPRESSED, IMPLIED OR STATUTORY, INCLUDING IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE.This limited warranty does not cover damages relating to(a)accident,misuse,abuse,neglect,or,normal wear and tear;(b)failure to use or maintain the product in accordance with manufacturer's instructions;and(c)alteration,repair or attempted repair by anyone other than Contractor or its authorized representa- tive.You shall be solely responsible for the correctness of the plans and specifications and shall release and hold harmless Contractor from any damages resulting from improper,inadequate or vague information supplied by you.Contractor does not take on any obligation to inspect or evaluate the work of other parties in any manner or aspect.This warranty is not transferable. 3. INSURANCE. Contractor shall maintain workers'compensation (employer liability), as required by law,and$2,000,000 in general liability insurance while performing the work. Contractor reserves the right to be self insured to the extent allowed by applicable law. Contractor does not agree to name any other persons or entities as additional insureds. 4. LIMITATION OF REMEDIES.Your sole and exclusive remedy against Contractor for any and all claims for damages arising out of or alleged to have arisen out of the Work will be limited to the repair or replacement by Contractor,at Contractor's option,of any nonconforming work or to the issuance of a credit for such nonconforming work in accordance with these terms and conditions provided Contractor is given a reasonable opportunity to inspect the work and confirms such nonconformity.This exclusive remedy shall not be deemed to have failed its essential purpose so long as Contractor is will- ing and able to repair or replace the nonconforming work and, in any event,Contractor's maximum liability for any damages shall be limited to the total amount paid to Contractor for the Work under this agreement.This Limitation of Remedies clause shall apply to the parties to this agreement as well as to the current owner(s)of the project and its/their respective successors and assigns. If you receive a claim for damages by any owner arising out of or alleged to have arisen out of the Work,you agree to give written notice to Contractor of the claim and provide Contractor an opportunity to inspect the alleged damages within 30 days after Contractor receipt of the notice. If you fail to give the required notice and/or fail to pillow Contractor an opportunity to inspect the alleged damages within 30 days, you hereby waive any and all rights for damages and/or correction of work against Contractor. This Limitations of Remedies may be plead as a complete bar to any action in violation of this clause. 5. LIMITATIONS ON ACTIONS AND LIABILITY.All claims and/or lawsuits including but not limited to claims or lawsuits for indemnity and/or contribution against Contractor arising under this agreement must be made within 13 months from the date of completion of the installation. CONTRACTOR WILL NOT BE LIABLE FOR ANY LOSS, DAMAGE OR INJURY RESULTING FROM DELAY IN DELIVERY OF THE PRODUCTS OR FOR ANY FAILURE TO PERFORM THAT IS DUE TO CIRCUMSTANCES BEYOND ITS CONTROL.CONTRACTOR DISCLAIMS ALL LIABILITY FOR ANY AND ALL DAMAGE WHICH MIGHT BE SUSTAINED BY ANY PERSON WHO MAY BE ALLERGIC TO OR AFFECTED BY THE EMANATION OF PARTICLES FROM CERTAIN TYPES OF INSULATION.THE MAXIMUM LIABILITY,IF ANY,OF CONTRACTOR FOR ALL DAMAGES,INCLUDING WITHOUT LIMITATION CONTRACT DAMAGES AND DAMAGES FOR INJURIES TO PERSONS OR PROPERTY, WHETHER ARISING FROM CONTRACTOR'S BREACH OF THIS AGREEMENT, BREACH OF WARRANTY, NEGLIGENCE,STRICT LIABILITY OR OTHER TORT WITH RESPECT TO THE PRODUCTS,OR ANY SERVICES IN CONNECTION WITH THE PRODUCTS, IS LIMITED TO AN AMOUNT NOT TO EXCEED THE CONTRACT PRICE. IN NO EVENT SHALL CONTRACTOR BE LIABLE FOR ANY INCIDENTAL, CONSEQUENTIAL, LIQUIDATED, OR SPECIAL DAMAGES, INCLUDING WITHOUT LIMITATION, LOST REVENUES AND PROFITS,ATTORNEYS FEES AND/OR COSTS EVEN IF IT HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES.THE RIGHT TO RECOVER DAMAGES WITHIN THE LIMITATIONS SPECIFIED IS YOUR EXCLUSIVE REMEDY IN THE EVENT THAT ANY OTHER CONTRACTUAL REMEDY FAILS OF ITS ESSENTIAL PURPOSE. 6. PRICES,TERMS AND SHIPMENT.No cash discounts,back charges,set offs or counterclaims are allowed unless specified by Contractor. In addition to the prices specified,you agree to pay any federal,state or local excise, use,occupational,or similar tax now in force or to be enacted in the future, assessed against Contractor or you by reason of this transaction. No retention is permitted unless Contractor agrees otherwise in writing.Any past due payment will be,at Contractor's option, subject to interest at 1.5%per month (18%per annum)to the extent permitted by law.You agree to receive(or permit Contractor to receive)near the work site,any materials needed to complete the Work.You agree to protect such materials from damage or loss and provide Contractor, free of charge, with reasonable use of light, heat, water, power, storage space and use of available elevators and hoists as needed.Title to all materials under this agreement shall not transfer to you until Contractor receives payment in full. Contractor may charge you a fee and its actual expense if the job site is not ready for work on the date you specify. 7. FORCE MAJEURE.Contractor shall not be liable for any delay,failures,or default in performance of this agreement or otherwise,in whole or in part, caused by the occurrence of any contingency beyond the control either of Contractor or of suppliers to the Contractor.Such contingencies include but are not limited to failure or delay in transportation,acts of any government or any agency or subdivision thereof,judicial action,labor disputes,fire,accident, acts of nature,severe weather,product allocation or shortages, labor shortages,fuel shortages, raw material shortages, machinery or technical failure, or work that cannot be completed because of another contractor covering the pertinent portion of the building.If any contingency occurs,Contractor may allocate production,deliveries, and performance of work among its customers or substitute substantially similar materials, in its sole discretion,without liability for doing so. 8. CONFIDENTIALITY. If you visit Contractor's premises or you otherwise receive any proprietary or confidential information from Contractor,you shall retain such information as confidential and not use or disclose it to any third party without Contractor's written consent. 9. CREDIT APPROVAL. Shipment and delivery of goods and performance of work shall at all times be subject to the approval of Contractor's credit department and Contractor may at any time decline to make any shipment or delivery or perform any work except upon receipt of payment or upon terms and conditions or security satisfactory to Contractor. By signing this agreement,you authorize Contractor to check your credit and references. 10. CANCELLATION. This agreement, or any part of it, may only be cancelled with Contractor's written approval. In the event of cancellation of this agreement, any part hereof,you shall pay: (a)the contract price of all completed items; (b)that portion of the contract price that is equal to the degree of completion of products or work in process,effective on the date Contractor receives notice of cancellation;(c)the cost of any materials and supplies which Contractor shall have purchased to perform and which cannot be readily resold or used for other or similar purposes; (d) a restocking fee;and (e)any expenses incurred by Contractor(including legal fees and judgments)as a result of the cancellation of subcontracts or purchases related to this agreement. 11. DEFAULT.You may terminate this agreement for Contractor's default,wholly or in part,by giving Contractor written notice of termination as follows. You may give written notice of termination only if Contractor has received a written notice from you specifying such default, the default is not excus- able under any provision hereof, and the default has not been remedied within thirty(30)days(or such longer period as maybe reasonable tinder the circumstances)after Contractor's receipt of the notice of default. Delivery of nonconforming products or work by Contractor shall give you the rights set forth in paragraph 4 hereof but shall not be deemed a default for purposes of termination. In the event of termination for default,you shall be relieved of the obligation to pay for work not performed by Contractor prior to the effective date of such termination.A default on Contractor's part shall not sub- ject Contractor to liability,through payment by Contractor,set off or otherwise,for any other damages,whether direct,consequential or incidental, and whether sought under theories of contract or tort. If customer breaches this agreement the Contractor is entitled to reasonable attorneys'fees and litiga- tion expenses as determined by a"Court of Law." 12.ASSIGNMENT.You may not assign this agreement or any claim against Contractor relating to this agreement. 13.GOVERNING LAW.This agreement shall be construed,interpreted and the rights of the parties determined in accordance with the laws of the State of Contractor's address first listed on the front of this agreement. 14. DISPUTES AND MANDATORY MEDIATION. In the event that a dispute arises over the reasonableness of or entitlement to fees charged by Contractor,the prevailing party will be entitled to reasonable attorneys fees and costs. In all other disputes of any nature, each party shall pay its own fees and costs. Except as required to protect confidential information and to obtain preliminary injunctive relief to prevent irreparable harm,you and the Contractor agree that prior to the initiation of any legal action the parties will engage in facilitative mediation of any and all disputes in anyway related to this agreement. If the parties cannot agree upon a facilitative mediator within 30 days of when the dispute arose,one will be selected pursuant to the Commercial Mediation Rules of the American Arbitration Association. Each party will share equally the fees of the facilitative mediator and costs of the mediation. 15.Three day cancellation rights under section forty-eight of chapter ninety three,section fourteen of chapter two hundred and fifty five,D or section ten of chapter one hundred and forty D as may be applicable. 16.SEVERABILITY.If any provision on this agreement is not enforceable,that provision shall be effective only to the extent permitted by law and all other provisions of the agreement shall remain. 17. ENTIRE AGREEMENT.This instrument contains the entire agreement of the parties relating to the subject matter hereof and may only be waived, changed,modified,extended or discharged orally by a writing signed by the party against whom enforcement of any such waiver,change,mortification, extension or discharge is sought the terms and conditions of this agreement supersede any agreement to which it is attached. 18. INDEMNITY. Each of the parties to this agreement agrees to defend and indemnify one another from any and all claims, actions and/or lawsuits caused by the party's negligent acts or omissions.This indemnity clause and the obligations created herein shall control and take priority over any con- trary indemnity agreement entered into prior to this agreement. Furthermore,this indemnity clause and the obligations created herein shall control and take priority over any contrary indemnity agreement entered into subsequent to this agreement unless the subsequent agreement specifically refers to this indemnity clause and declares it null and void. X0/06/2009 12:15 FAX 9785322217 BKM, Inc 10002/003 DATE(MWDDIYYYY) Arco/ CERTIFICATE OF LIABILITY INSURANCE 10/6/2009 Pp (978)532-5 45 FAX: (978)532-2217 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE B.K. McCarthy Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 10 Centennial Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. West Entrance NAIC# Peabody MA 01960 INSURERS AFFORDING COVERAGE INSURERA:ProBuilders Specialty INSURED IN33618 JVIR Gutters, Inc. suRERB:Safety Indemnity INsuRER c:PMC Insurance Group 38-40 Lancaster Street INSURER D: Haverhi 1 MA 01830 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NMAY BE OTWITHSTAN DING ANY REQUIREMENT,TERM OR CONDITION OF MAY PERTAIN,THE INSURANCE AFFORDED BY TINE POOLICN IES DESCRIBED HEREIN S SUBJECT TO ALL THE RMS EXCLUS IONS CT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISFANDTCONDITIONS OFESUOCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFFECTIVE POLICY EXPIRATION LIMITS INSR DD'LF N POLICY NUMBER DATE MMIDD DATE M DD LTR N EACH OCCURRENCE S 1,0()0,000 GENERAL LIABILITY AMAGE 0T 50,0 0 0 PREMISES Ea occunence $ X COMMERCIAL GENERAL LIABILITY 5,0 0 0 A CLAIMS MADE �OCCUR 5022881 6/21/2009 6/21/2010 MED EXP(Any one person) $ PERSONAL&ADV INJURY S 11000,0001 GENERAL AGGREGATE $ 2,000,000_ PRODUCTS-COMP/OPAGG S 1,000■000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PEO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 11000,000 (Ea accident) ANY AUTO B ALL OWNED AUTOS 3945441 6/21/2009 6/21/2010 BODILY IN URY $ (Perperso X SCHEDULED AUTOS X HIRED AUTOS BODILY , RY S (Pet acad t) X NON-OWNED AUTOS PROPERTY DAMAGE S (Per accident) AUTO ONLY-EA ACCIDENT S GARAGELIABILITY EA ACC $ OTHER THAN ANY AUTO AUTO ONLY: AGG S EACH OCCURRENCE $ EXCESS/UMBRELLA LIABILITY AGGREGATE S OCCUR CLAIMS MADE S DEDUCTIBLE S RETENTION $ WC STATU• OTH- L, WORKERS COMPENSATION TORY I IM ITS AND EMPLOYERS LIABILITY YIN E.L.EACH ACCIDENT $ 500,000 ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICERIMEMBEREXCLUDED? Y 0009752701 9/20/2009 9/20/2010 EL.DISEASE-EAEMPLOYE $ 500,000 (Mandatary MEMBER EL.DISEASE-POLICY LIMIT S 500,000 If yes,describe under SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS Refer to policy for exclusionary endorsements and special provisions. CERTIFICATE HOLDER CANCELLATION POLICIES BE CANCELLED BEFORE TDA EXPIRATION SHOULD ANY OFTHE ABOVE DESCRIBED SAMPLE CERTIFICATE FOR DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN INSURANCE PURPOSES ONLY NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL SAMPLE COPY IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE John McCarthy/DC4 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009101) INS025(200901) The ACORD name and logo are registered marks of ACORD ?0/002009 12:15 FAX 9785322217 BKM,Inc 0003/003 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER. This Certificate of Insurance does not constitute a contract between the issuing insurer(s),authorized representative or producer, and the certificate holder,nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2009101) INS025(2ooe01) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street NE Boston, 111A-02111 www.massgov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 4 Address: Levi C City/State/Zip: JA&ue apt YYl )a 0 04one#: 7 7Y 3 �Z (16 Are you an employer? Check the appropriate box: Type of project(required): 1. II am a employer with -Z C� 4. ❑ I am a general contractor and I i ` employees full and/or part-time).* have hired the sub-contractors 6. E]New construction ( P ) 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. required.] officers have exercised their ❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.[] Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] k A..........f'.......♦ 1. X 1.... ,.y appscan that checks box;91 m=luau;illout the section below showing their workers'compflneeaation policy mfO mw; n. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating suck tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy infom►ation. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: C `� ----�T \OQ Policy#or Self-ins.Lic.#: �ii 0 0 Expiration Date: od 27<0y Job Site Address:- J City/State/Zip: • &N Attach Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration' date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the g DIA for insurance coverage verification. I do hereby certify under the pains andpe ' that the information provided above is true and correct Signature: Phone#: 7T 3 7,- D Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: > Massachusetts- Department of Public SafeIN Board of Building Regulations and Standards Construction Supervisor License License: CS 80515 Restricted to: 00 KEVIN M FRANCIS 35 WANNALANCET RD HAVE RHILL, MA 01830 JL Expiration: 7/21/2011 ('rnunissiunei Tr#: 18422 B°�� ��z� d°f Building Re - HOIV/E gulahO� Re is Cp�tTCD ards EXp�ratiQn y. 08503 R l 19/2010 KEV N FNRS SNC Type: SuPple►nent Card CISn , .. Haverhill,chill, MA 01830 ` - — a_ ninistra-tOr'`