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HomeMy WebLinkAboutBuilding Permit #351-2017 - 184 CARLTON LANE 10/6/2016 / `\ BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION j A N0: Date Received d 40 Date Issued: 1b �9SSHUs IMPORTANT: Applicant must complete all items on this page LOCATION 181 Cay-U00 �.a t e Print PROPERTY OWNER Ken ind Ja.1I i NeUron Print MAP NO: PARCEL:A 193 ZONING DISTRICT: ;Historic District yes n Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building X One family ❑ Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer 1< Qew,,oye cav-Pe� ivi LR1D 21 t-ep lrce wl hGYcAwoad . 2. Kemove 1-c_otaT Ge w/ aor1L -Oyorly s- 3• Zeplatt "Ute& SI#71e-% : hULAA*r Valve, 4%J6 VCAlue n+n� Stiawer HI SS In y[j�siter('>~�-1, Keple-re 311dlizs dattr W Av7doW, Identification Please Type or Print Clearly) OWNER: Name: 54111 ge-gron Phone: SdB� 826 - 2.000 Address: Car46 n Lcv%e worik Ahclovet' M4 t !6E [Address: NTRACTOR Name: Phone: (g-21) 9$9-4YSf0 "C>WPl Cu S+ocn 13U idtn$ G roup 360 tAerrimack-5t Lawrence , mA OLA`l3 pervisor's Construction License:CExp. Date C15 -o�$a3� 001 64 Z) Home Improvement License: 1151 bb Exp. Dale: ' � ARCHITECT/ENGINEER �- Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 3% 13 3 FEE: $ Y Check No.: 3 2`7 `-1 L+ Receipt No.:_ 30T -- NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner Signature of contractor_U '��� ` � �(,,,i SCS of ND oT i BUILDING PERMIT 3� 6��<. *•'•"°� 0' TOWN OF NORTH ANDOVER o A - APPLICATION FOR PLAN EXAMINATION Permit NO:_3S l7 Date Received l 6 3-r3 Of b Date Issued: I VSs~cHus�� IMPORTANT: Applicant must complete all items on this page LOCATION 194 Ca r ) j on . ane Print PROPERTY OWNERken a�ncl ba �dCron Print MAP NO: to7A PARCEL: _ZONING DISTRICT: Historic District yes Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building X One family ❑ Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer 1. Qevnoye caypef Ih ts_olG�l orL - 00r(v S- 3• IzeRfe tt Sherr v4(ve _ 4yb vc4lue a 0z1 SHf)weY 5(4S5 In MaSife-r&A. iJ. Ke?lare 311dI ilS 414 r JAI AIJI \yzdow- Identification Please Type or Print Clearly). OWNER: Name: 5a) (Y 44 r0 h Phone: LE428) S26 - 2oy0 Address: I Pj.Car i'f 0 n Lcne AndovE M CONTRACTOR Name: Phone: {4-71) 9$1-4Yeto Powe! Cu S+am 5U Idsn$ Group. Address: 3>&o t-Aerrimack•5 Lawrenoe., 814 01843 Supervisor's Construction License:cs - Exp. Date: ��$a3� oaAyllg Home Improvement License: Exp. Date: !'151 b6 1 ARCHITECT/ENGINEER �— Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 31, 13 3 FEE: $ Check No.: `?a 2TILT Receipt No.: 3095 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Sid-nature of A ent/Owner ya _ g 2 ,/ Signature of contractor ��Y +. - _ . 17 _ _ .:...�. 'F ';. % .. .. - « ...•. ,.-. ...f f -. .::I ..'.a'. . . . . _.- b � Y - _ _ ti .. ,.. _ ,,. _ .�-. ..... �.-- —— -r s. .. _ y ... - .. _._: I .. .. ., .. �_ .. . I .. .' . . k _ _ .- `' Location /9 r A R-L -Yl1V '. . . C. . . . No. 1 -da 1-7 Date /b - 3- Of - . . -6 f' " - . • - TOWN OF NORTH AN - - - . • - Certificate of Occupancy $ Building/Frame Permit Fee $ "� . Foundation Permit Fee $ - % Other Permit Fee $ - '. . . .. 41 A 4 6 TOTAL $ , ` _ s Check# � J1 - A _ (I . - . n o f/�Building l spect r - , - I'll _ ..: .: . .. _. . „: . a. .... .. :::.. . . . ... _. .; . k . - . - - _ _ s) . _ . ,.. -r- .'X� :, _ ,,' .- . . . . I. Y i r.: .. :i'I .. r 1 V.vY 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS II HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Y Decision/receipt submitted es Planning Board Decision: Comments Y I Conservation Decision: Comments a Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: --� Located 384 Osgood Street i AFIRE ,... 77 PARTMENT Ternpf�Dumpsier onsite yes Located ate 1z24'xMain St eet ; Fire. Department signature/date _ eFCOMMENTS ` 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 Email Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The followingis 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 In Work + ❑ Engineering Affidavits for Engineered products De artment prior to issuance of Bldg Permit NOTE: All dumpster permits require sign off from p 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 Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan An ❑ Floor/ Hydraulic Calculations (If Applicable) Re)ort (If Applicable) ❑ Mass check Energy Compliancep ❑ Engineering Affidavits for Engineeer Fd a Department prior to issuance of Bldg Permit products NOTE: All dumpster permits require sign off fr 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 of Building flans (One To Be Returned) to Include Sprinkler Plan And ❑ Two Sets g Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ ed products Engineering Affidavits for EngineeF e Department prior to issuance of Bldg. Permit NOTE: All dumpster permits require sign off from ermit was required the Town clerks office must stamp the decision from the Board of Appeals In all cases if a variance or specialp f Deeds. One copy and roof of recording that the appeal period is over. The applicant must then get this recorded at the Registry o } must be submitted with the building application li Doc:Building Permit Revised 2014 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 39133.00 m $ - $ 469.60 Plumbing Fee $ 58.70 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 58.70 Total fees collected $ 687.00 184 Carlton Lane kitchen bath remodel 351-2017 on 10/6/2016 NORTIy '9 Town Of sAndover O `" 0 No. ( � t h soh ver, Mass, / 0 3 0/ 'QA COCMIC KtWKK S U BOARD OF HEALTH Food/Kitchen PERMITT.. LD Septic System THIS CERTIFIES THAT .. : ......Cus n h!I...... �,�I/��j!• ��� BUILDING INSPECTOR ................ .......... ...... . Foundation has permission to erect .......................... buildings on ......J.. .. ..... AOL +QN..... .. .. .......... to be occupied as ...ke..101ftf....W-11.r41 ......�!4!*040....#.R�i! .. ..�. .t Chimney Rough ' e provided that the person accepting this permit shall in every respect conform to the terms o the applica Ion Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT N SRough ............ Service -P.ta:= Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. CONSTRUCTION SERVICES AGREEMENT (short form) Where the basis of payment is a Stipulated Sum Contractor: IOwner: Date: Howell Custom Building Group, Inc. Phone: 973-939-9440 Ken&, Sall Heffron July 29, 2016 360.Merrimack St. Bldg 5 License: CSL 063332 134 Carlton Lane Project: Lawrence, NJA 013-13 License: HIC 175166 worth Andover;NIA 013-15 Renovations I. P.aRTIES & DATE OF AGREEMENT This contract(hereinafter referred to as"Agreement") is made and entered into on this 29`h day of July,2016 by and between Ken&Sally Heffron, (hereinafter referred to as"Owner"),and Howell Custom Building Group,Inc.,(hereinafter referred to as"Contractor"). II. SCOPE OF `FORK,CONTRACT Sni I& TIME A. SCOPE OF `YORK: In consideration of the mutual promises contained herein,Contractor agrees to perform the Work as described in the attached 4 page Scope of Work& Specifications dated July 29,2016. B. CONTR,kCT SUryM: Lump Sum for all Work described above:$39,133. C. TME: Commence work on or about September 12,2016 and achieve Substantial Completion of all work in this Agreement on or about October 7, 2016,not including,delays caused by: inclement weather,accidents,additional time required for performance of Chancre Order work(as specified in each Change Order),delays caused by Owner,and other delays beyond the control of the Contractor. III. GENERAL CONDITIONS FOR THE AGREEMENT ABOVE A. PAYMENTS: Invoices shall be prepared by Contractor and submitted to the Owner as the Work is completed and according to the Payment Schedule below. The Owner shall make payment within five(5)business days of the Invoice Date. Payment for each Change Order is due upon completion of the Change Order Work,and submittal of invoice by Contractor. Payments due and unpaid under the Contract Documents shall bear interest from the date )ayment is due at the rate of one and one half percent(l-1/2%)per month.The Owner shall be responsible for reasonable attorney's fees incurred by Contractor in collecting any sums due hereunder. I Initial Deposit due when Agreement is signed and returned to Contractor S6,000 2 Due upon completion of Cork Flooring $7,000 3 Due upon completion of Wood Flooring and Refinishing $7,000 4 Due upon completion of Bathroom Renovation $14,000 5 Balance of Contract Sum due upon Substantial Completion of all Work under Contract: S 5,133 Total of Payments CONTRACT SUVI) $39,133 3. EXCLUSIONS: Unless specifically included in the Scope of Work described above,this Agreement does not include labor or materials for the bllowing work: fees for design or engineering work;correction of concealed substandard framing;removal and replacement of existincr rot or insect nfestation; re-routing/removal of vents,pipes,ducts,wiring or structural members which may be discovered in the removal or cutting of openings in the ;risting structure; failure of surrounding part of existing structure,despite Contractor's good faith efforts to minimize damage;repair of damage to existing Iriveway that could occur when construction equipment and vehicles are being used in the normal course of construction;exact matching of existing inishes. :. CHANGE ORDERS: If conditions are encountered at the site which are(l)unforeseen,subsurface or otherwise concealed or(2)unknown onditions which differ from those ordinarily found to exist in construction activities of the character provided for in this Agreement,then the Contract Sum hall be equitably adjusted upon claim by Contractor. Any chancre from Work described in this Agreement involving extra costs of materials or labor will be erformed upon a written Change Order issued by Contractor and signed by Contractor and Owner prior to the commencement of Additional Work by 'ontractor. ). LLNIITED WARRANTY: Upon final payment by Owner of the entire Contract Sum including all change orders(if any)due to Contractor, 'ontractor warrants to Owner that the Work performed under the Agreement is free from defects,not inherent in the quality used,in materials,equipment nd workmanship for a period of two(2)years after the date of Substantial Completion. :. ENTIRE AGREEMENT: This Agreement represents the full and complete understanding of every kind or nature between the parties /ith respect to the services set forth in this Agreement,and all preliminary negotiations and prior representations,proposals and contracts,of ,rhatever kind or nature,are merged herein and superseded hereby. OWNER'S 3-DAY RIGHT OF RECISION: Owner may cancel this agreement with no further obligations by notifying Contractor in writing iat they wish to cancel the Agreement within 3 business days of the date they signed the Agreement. have read and understood,and I agree to,all the terms and conditions contained in the Agreement above. t2 0 7 Ify/ ��Cs�CwI,f' 6 late Step en D. Howell, President Date Owner Date Owner Howell Custom Building Group,Inc. Page: 1 of l Initials:0*/ '�lq/ SCOPE OF WORK DESCRIPTION & SPECIFICATIONS Contractor: Owner: Date: Howell Custom Building Grou ,Inc. Ken&Sally Heffron July 29, 2016 360 Merrimack St. Bldg 3 184 Carlton Lane Lawrence, NIA 01843 North Andover,MA 01845 Phone: 978-989-9440 Project: C.S.L. #068232 Renovations H.I.C. #175166 Project Overview • Cork flooring in Kitchen • Wood Flooring in Living Room and Dining Room • ivtaster Bath Renovation General Notes • All Work includes labor,materials and equipment unless otherwise noted. • Contractor shall have sole control over the means, methods, and sequence of construction. • Items marked Allotment Item have been included in the Contract Sum for the amounts listed below. Allotment Items are to be selected by Owner and supplied by Contractor. • Items marked Contract Option have not been included in the Contract Sum,but may be added for amount listed on List of Contract Options. See Separate List of Contract Options for amounts carried for each Contract Option. Owner Responsibilities • Owner to attend weekly project meetings on-site with Contractor. Meetings to be scheduled at a mutually agreed upon time on a weekday between the hours of 7:30am-4:00pm. • Owner to coordinate with Contractor on planning the detailed sequence of work. • Owner to provide information,selections and decisions to Contractor as requested by Contractor in a timely manner so as not to delay progress of the Work. • Owner to remove all personal items and furniture from the following Work areas: • Kitchen • Dining Room& Living Room • Master Bathroom Permits& Inspections • Contractor to prepare building permit application, file application,and post permit on-site. • Allotment Item: Town of North Andover Building Permit Fee-$450(M). • Plumbing Permit to be obtained and the fee paid, by Contractor's Plumbing Subcontractor. • Electrical Permit to be obtained,and the fee paid,by Contractor's Electrical Subcontractor. • Contractor to schedule and coordinate the various inspections required to complete the Work as described in this Scope of Work. Site Prep General Notes &Specifications: • Contractor to provide and maintain P. t on site during construction. • Contractor to seal off existing rooms adjacent to the areas affected by demolition and construction during the project with plastic sheeting and'or temporary wood-framed walls. • Contractor to protect existing finishes in affected areas, if those finishes are to remain. Existing Finishes to be protected with plastic sheeting,cardboard or other padding. Scope of Work: Page 1 of 4 Initials:*144N I-4j� Supp4-and Install Site Protection in the follotiving areas.- Kitchen reas:Kitchen • Dining Room& Living Room • ivtaster Bathroom Demolition General Motes& Specifications: • Owner shall notify Contractor and mark locations of all known underground water'sewer pipes, gas lines,electrical conduits/wires, irrigation pipes, dog fence wires, etc. that may be in the area of demolition or construction. • Contractor to disconnect electrical, cable,phone and plumbing as required in affected areas prior to demolition. • Where Contractor is removing and saving an item, he will use his best efforts to remove that item with minimal damage. Storing&protecting the saved items is the responsibility of Owner. Re- installation of the saved items is not included unless otherwise specified. • Where Contractor is removing existing tile,assume tile is laid on plywood or gypsum wall board. Removal of cement board underlayment or a mud base would be extra. • The abbreviations RS =remove&save, P,-DNS=remove and do not save. Scope of work: Contractor to perform demolition in the following,areas: Kitchen • R'S fiberglass insulation batts from kitchen floor and lower staple up radiant heat; save for reinstall. • R'S Refrigerator. • R'S Dishwasher. • R'S cabinet toekicks. • R,'DNS Interior Door Casing from Kitchen door to deck. • R DNS baseboard trim. • R'DNS Tile floor including plywood underlayment. Dining Room/Living Room • R'DNS Carpet,pad and taekstrip and underlayment. • R DNS triangle portion of wood flooring at peninsula. Master Bathroom • Cut(2)access holes to shower and tub. • R'DNS Glass Shower Door. • R'DNS stone cap on shower curb. • R,'DNS Vanity Top. • R'DNS vanity faucets, shower fixture and tub fixture. Floor Framing Kitchen • Repair uneven floor at addition. • Install 1/2" AC plywood cork flooring underlayment glued&nailed to subfloor. Plumbing • Allotment Item: Plumbing Fixtures to be selected by Owner and supplied by Plumbing Subcontractor. Master Bathroom • Disconnect and cap (2)sinks for Demo. • Finish plumbing for(2)vanity sinks and faucets. • Replace shower valve and finishes. • Replace tub valve and finishes. • Plumbing Fixture Allotments o (Vanity Sinks$400) ill Page 2 of 4 Initials:47)�/ r ' J anity Faucets x'800)Bbl D (Tub Fixture 5600)Bbl o (Shower FLYture S1,200) N1 Electrical Master Bathroom • Replace existing bathroom exhaust fan with a Panasonic L 10CFM Fan,'Li t. Connect to existing ductwork and wall vent. Insulation Kitchen • Reinstall staple up radiant tubing and fiberglass batt insulation. Plaster IVlaster Bathroom • Patch(2)access holes to shower and tub fixtures. Tide Supply and install Tile Work in the following areas: • ,Allotment Item: Stone Curb for Shower; match existing stone-$600 (NI&L). Interior Trim& ;Millwork Kitchen • Casing for Kitchen door to deck; match existing. • Install(2)piece baseboard moulding; match existing. • Reinstall cabinet toekick. Countertops General.Notes&Specifications: • Countertop Allotments include all materials and installation labor including materials and labor for templating. Scope of Work: Master Bathroom • Allotment Item: Vanity Countertop including side and backsplash-$2,150 (NUL). Appliances Kitchen • Reinstall, Dishwasher and Refrigerator. Specialties Master Bathroom • Allotment Item: Custom Glass Shower Enclosure including 112"glass,door, hardware and installation-$2,400 (NI&L). Page 3 of 4 Htials: Floor Coverings General Notes &Specifications: Hardwood Flooring: • 'i"x 2-1'4"Select Grade Red Oak. • Sanded and Finished onsite with(3) coats of oil-modified polyurethane. • Owner to select sheen(satin,semi-doss, high-doss). • Owner to select stain color, and the sheen of the polyurethane(satin or semi-gloss) . Scope of Work: Kitchen • Allotment Item: Supply and install cork flooring over underlayment including taping of seams in underlayment and glue down of cork floor—225SF r S12/SF=$2,700(Nl&L). Dining Room/Liviu Room • Supply, install sand, stain and finish approximately 493SF of oak flooring including triangular area at entry to kitchen. LA V 5s4; • Sand,stain& finish existing floor in Hallway, Front Entry,-Fre*-E Erb and Closet. Painting General Notes&Specifications: • Owner to select colors; Contractor to supply materials and labor. • All paints to be Benjamin Nloore, Latex unless otherwise specified below Scope of Work: Master Bath • Allotment Item:Paint Vanity cabinet,in place and existing bath trim; wallpaper to remain-$1,500 (Nl&L). ba�eboarc� r►-tw� ltd Ki�tl�erl 4 fovckv��S, S� t� Clean-up • Jobsite to be cleaned up daily. • All construction debris to be removed from site. • At completion of the Work, Contractor shall remove construction equipment,tools, machinery and surplus materials from site. • The house shall be left"broom clean"upon completion. • Contractor to provide on-site dumpsters during demolition and construction. Owner and Contractor to agree on exact location. Page 4 of 4 Initials:SDW/�/ AWSales: 800.448.3636 Phone: 804.271.2363 NEXT GENERATION Fax: 804.743.7779 LET'S GET IT DONE STORMWATER MANAGEMENT SOLUTIONS acfenvironmental.com Site Development and Retrofit • Low Impact Development • Green Infrastructure FOCALPOINT(high flow biofiltration) - R-TANK(modular subsurface storage) - PAVE DRAIN(paving,drainage,storage) - FABCO(decentralized treatment) -11 -�- -+ -�- - _ - -- - -- I - �--L -- — -- - - -t - ' The Commonwealth of Massachusetts Department of Industrial Accidents s 1 Congress Street, Suite 100 a Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): eusk B_Uil i0,c 6rou1> Address: _;to Aft rr I rN1aCk St• City/State/Zip: 4a&.jreV?ee , tYI# 6/843 Phone#: &79 989- 9YY0 Are you an employer?Check the appropriate box: Type of project(required): 1.[Ol am a employer with 12— employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 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 11.Q Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.n I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.= 6.n We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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. Iain an employer that is providing workers'compensation insurance for n:y employees. Below is the policy and job site information. _ Insurance Company Name.---A. 1. . M MUTUAL- 1"S u o'do t-e (26 Policy#or Self-ins.Lic.#: F_CG — Coo — `>t oria 681"a011v A Expiration Date: O&Is l2/7 Job Site Address:- /8y e a r-if0YI 4d,nq,1L City/State/Zip: Nur ► )JndfVfl- W14 OlStlS 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 DIA for insurance coverage verification. Ido hereby certify under thepains and penalties of peijuty that the informationprovided above is true and correct. Signature: Date: G7 0 Phone#: Cl (q78 484- 9Y5'0 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#: '1 HOWEL-1 OP ID: LL CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 06/27/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Lisa Lariviere Foster Sullivan Insurance NAME: 163 Main St. A N o Ext):978-686-2266 ac No:978-686-6410 North Andover,MA 01845 E-MAIL Foster Sullivan Insurance LLC ADDRESS:certificates@fostersullivangroup.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:union Insurance Company 25844 INSURED Howell Custom Building Group INSURER B:ACADIA INSURANCE 31325 Inc. 360 Merrimack St Bldg 5 Ste4N INSURER C:A-I-M MUTUAL INS CO 33758 Lawrence,MA 01843 INSURER D: INSURER E: 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 TYPE OF INSURANCE DDL B POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD (MM/DDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY CPA5250937 06/01/2016 06/01/2017 PREMISES Ea occur ence $ 250,00 CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY PRO LOC $ AUTOMOBILE LIABILITY EaCOMaBINEDcid SINGLE LIMIT $ 1,000,00 A ANY AUTO MAA5250938 06/01/2016 06/01/2017 BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED AUTOS X AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS PER ACCIDENT $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000 B EXCESS LIAB CLAIMS-MADE CUA5250939 06/01/2016 06101/2017 AGGREGATE $ 3,000,00 DED I X I RETENTION$ 10000 $ WORKERS COMPENSATION X TORY LAMITS JOTH R AND EMPLOYERS'LIABILITY C ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N ECC-600-4000681-2016A 06/01/2016 06/01/2017 E.L.EACH ACCIDENT $ 500,00 OFFICERIMEMBER EXCLUDED? ❑ N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ 500,00 1 L DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 175166 Type: Corporation Expiration: 4/29/2017 Trl1 263220 HOWELL CUSTOM BUILDING GROUP STEPHEN HOWELL - - 360 MERRIMACK ST - -- --- - -- LAWRENCE, MA 01843 — --- - - - Update Address and return card.Mark reason for change. SCA 1 t'/ 20M-05/11 C Address Df, Renewal ❑ Employment E] Lost Card l.%�C ((!t U!/J/c1l!lOPII���(��%(llJ3clCI!ll.iCllJ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only F10ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: registration: 175166 Type: Office of Consumer Affairs and Business Regulation xpiration: 4/29/2017 Corporation 10 Park Plaza-Suite 5170 k'—w / Boston,MA 02116 HOWELL CUSTOM BUILDING GROUP STEPHEN HOWELL 15 MT VERNON RD BOXFORD,MA 01921 Undersecretary of valid without signature Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-068232 Construction Supervisor rv,� STEPHEN D HOWELL 15 MT VERNON RD BOXFORD MA 01921 r--j"^:; `✓�--- Expiration: Commissioner 02/14/2018