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HomeMy WebLinkAboutBuilding Permit #108-16 - 1925 SALEM STREET 7/27/2015 O � X10 R TF/ BUILDING PERMIT 20�tt,Eo -6;�tio TOWN OF NORTH ANDOVER /6-��!f o APPLICATION FOR PLAN EXAMINATION ? Permit No#: ,�- Date Received �gssgcHua���5 Date Issued: 4?—/f s IMPORTANT: Applicant must,,complete all items on this page LOCATION 19625 czt Cw1 $4• ND(Ah&AoaGr ft. 0 (8 Y5 Print PROPERTY OWNER�)lDS\N -Pe �e_CS Print 100 Year Structure yes_n no MAP PARCELL D/3 ZONING DISTRICT: Historic District yes no Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer ESCRIPTIONPF ,JORK TO RE PE FORMED: x V% O L t sfqscs lb Ident kation- Please Type or Print Clearly OWNER: Name: � , � Phone: 97$-y9!95#7y Address: 9c2S o! Ari"ClAor . 01 a ZI S N 4,14014s "ss. Contractor Name: AVepA k ' r Phone: R 7 —90 S 9 Email Lt itrn ' . Address: t 16C.v+tc.rst r ye MA. 01J?g3 Supervisor's Construction License:—C 5 FA— /0139 Exp. Date: $ 277 O / Home Improvement License: g�S76 Exp. Date: :lk3 a0/ 7 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: $ /off. 9 77 FEE: $ Check No.: /'��l Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to th g a my and TOWN OF NORTH ANDOVER t30RT#1 APPLICATION FOR PLAN EXAMINATION V" l Permit NO: Date Received °RAT.° 4SS9CbN`'Et Date Issued: IMPORTANT:: Applicant must complete all items on this page LOCATION I �RC2 J `)cam le—et', 6f , �KA00e_r Print PROPERTY OWNER kers oq Print MAP NO.: ®• PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Resi ntial Non- Residential ❑New Building One family ❑Addition ❑Two or more family ❑Industrial ❑Alteration No. of units: ❑Repair,replacement ❑Assessory Bldg ❑Commercial ❑ Demolition ❑Moving relocation ❑Other ❑ Others: ❑Foundation only DESCRIPTION OF WORK TO BE PREFORMED 1 X ' DSA i t a�V1[� koo"�I^ 5. ) e.4 4kc fe �r�1MVN�l Identification lease Type or Print bear)Y) q OWNER: Name: 4mL r—_5, Phone. `�n 7��� Address: G `��G.G�l� S 0 kerA r' ,_t,,_n 01gq s- CONTRACTOR Name: S V Phone: qg Address: �i( �'`e_�S T� Lam. W?U 3 . Supervisor's Construction License: C O� — I� O Exp. Date: Home Improvement License, / go 370 Exp. Date: 7 ` ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.•$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost :$ /,91 S 9 7 x12.00=FEE:$ /S6 •ad Check No.: �� S Receipt No.: Page 1 of 4 f Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanaing/MassageBody Art ❑ Swimming Pools ❑ i well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANN & DEVELOPMENT Reviewed On Signature_ CO ENT i /CONSERVATION Reviewed on .S Signature 4116-4—'�� COMMENTS40 ki I A`—4,0 mi v _ jo�HEALTH Reviewed on Si nature hAdJua -&A— COMMENTS �( r Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments y Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIREDEPARdTMENT -Tenp _Dumpster,on►site; _inoa Located;at t124iMaiij:zSt�eef Fire De art` s .,_ t_ments_signafure/date CQMMENTS, s -- .• I Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: I ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANCER ZONE LITERATURE: lies No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email I Date Time Contact Name Doc.Building Pennit 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 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 ' 4 Workers Comp Affidavit 4 Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract rF 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 Doc:Building Permit Revised 2014 Location No.1&4e� Date . - TOWN OF NORTH ANDOVER LED j . Certificate of Occupancy $ e - Building/Frame Permit Fee $ ! Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ' Check# rs l �� / ,�, Building Inspector NORTH T ,own of E : I, ndover O No. p — zc) I * - Zy % h ver, Mass, COCHIC"RWICK y1' S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT o.iL.....P BUILDING INSPECTOR ............... . ........ ................... Lhas permission to erect .......................... buildings on ... Foundation ........ Rough to be occupied as ........�. ..1�.........Phai�tneery .. .......................................................... Chimney provided that the person accepting this permit respect conform to the terms of the application 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final fft:0PERMIT EXPIRES IN 6 ONTHS ELECTRICAL INSPECTQR UNLESS CONSTRUCT T Rough Service .......... ..... ..... .......... .............................. 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. Massachusetts Dome Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Name n Company Name f Street Address(do not use a Post Office Bo�ress) Contractor! alesp rson/Owner Name U5 _Sd [ S-� mn jo)yq5 Ci /Town State Zip Code Business Address(must include a street address) 7�- Yqb-gag . Daytime Phone Evening Phone City(rown State Zip Code '01s,13 Mailing Address(Il different from above) Business Phone I Federal Employer 11)or S.S.Number me.tmanvanen6n}�nor Reg Number Cap tion date Laweequin—z Chet mast home BSO {{yY77 imparo meat contractors have v lid re0slntim,vnmber - VA The Contractor agrees to do the following work for the Homeowner: 27 (Describe in detail the work to completed,specifying the type,brand,and a of materials to be used,use additional sheets if necessary.) C0VV%,?lekt0V% o Owe tOX Nk dtc:Vc . O'^e 5cr�t o� S o��• �gvt�tVtR• Zh5ka.1\t,,,C ?rbet,f 00FJ C Z ari R 0.�C4HCe�aa1j Required Permits-The following building permits are required Proposed Start and Com-plefi n Schedule-TfQ following schedule will and will be secured by the contractor It ft homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their o"FWmitsill be < excluded from the Guaranty Pund provtstons of I J Date when contractor will begin contracted work. MGL chapter 142A.) Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of. (*) Payments will be made according to the following3cl',edule: $1 5 ... upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ 005. by / ^/ or upon completion of d" �6n t%t� $ by_/ /�or upon completion of $ .9 7 7 upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ / to be paid for ordered before the contracted work begins in order / to meet the completion schedule.(**) $_ to be paid for NOTES:(*)Including all finance charges(**)taw requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule/ Express Warranty-Is an express warranty bein•Provided by the contractor' 9 No❑Yes fall terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. Seethe attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! —V Two id ea opie of the contract most be completed and signed.One copy should go to theil a other copy hould be kept by the contractor. Homeowner' Signature C tractor's Signature ex, 2,XIO T 2 D t oP r5 Jo:srt ' -� Ups 5av�v U �r��Phi s ,� ,e,. •� ;� _ f r J 5v �•'{s5 ' 1`. � ��� _ � 'i It' tF=,.;�S,. �. -r'Sr i i IXc J A. 47 , t �h�tAa��f s �y• —91 �-�� � 1��E. {flt � �r5 f�.,a:_ ...- je- t �.'� i g•y s,`... xy 'r it ee t - I ,y � $ ��.- 'N moi[ `fea � s £;• y ��� F .q N. a i i, Horizontal S f f�- � • _ f .. Datum NAD83, Meters Data legal Sources The data for this map was produced by Merrimack Valley Planning Commission(MVPC)using data provided by the Town of North Andover.Additional data provided by the Executive Office of nvironmental Affairs/MassGIS.The information depicted on this map is for planning purposes only.It may not be adequate for in definition or regulatory interpretation,THE TOWN OF - ANDOVER EXPRESSEDMAKES NO WARRANTIES, OR IMPLIED, THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY OF THESE D.TA.THE TOWN OF NORTH ANDOVERD North Andover MIMAP July 20, 2015 _._. ._.. _........ _.. _...... ... _ ._.. ........ _._. ._.. ......_. 106.6=01 , .::::::::"._..•:. 39•••= .,.•'•�:==.��=- . - :::::u) 1'0_:6:6-0'138.'... 106.6-012 ;G 106:6'=0063 _ -'flu i:r' "i °::::'wltc..•,i; .'106:6=0.15 7 115 OLYMPIC LN ....•:Valu.::=:••:.�=--:. 106:B-0064 *� _ _ 106.B-0136 .- .. u R1 y 127 OLYMPIC LN •`.'... lite.•.•`.-'••..��t _ - -- 106.B-0135 )u 9• t, -_ - _ _ = :. 1895 SALEM ST Sd/Q. i%`" i - .Vii- ' 139 OLYMPIC LN d �S -0134 106.6-0060 Quo ••:,. ••-�-• .. 1907 SALEM ST ... .......... / ._. y....:.:... . . 106_6-0071 /' I \ I, :10"6:6-01331;' 1 CAMPBELL RD / _.:`, •`.-.•_...;;..__�-•-._.aura •;-:,..... 106.B-0012 1925 SALEM ST - : 106.B-0013 j 1929 SALEM ST 106.6=0132',.:':" aUr Liu-- -' `_ j 106.B-0042 R2 106.6-01:45 299 WEBSTER'WOODS' !�• 1935 SALEM ST 106.B-0186 �106a-0168 106.6-0245 "v. 106.B-0015 265 WEBSTER WOODS •= .-_- 106.B-0181 �s ..:__. ._.. ... 106.B-0169 106.B-0016 295 WEBSTER WOODS 106.B-0183 — Rail Line Wetlands Zoning Interstates D Exempt Lands Busine s 1 District — tl Busine s 2 Dis(nct Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, —SR O Busine s 3 District Meters Data Sources:The data for this map was produced by Merrimack ■Busine s 4 District HORTol Valley Planning Commission(MVPC)using data provided by the Town of Roads ®Genera Business Distract Of t`1O r q� North Andover.Additional data provided by the Executive Office of r Easements O Planne I Commercial Dev 't •��OO Environmental Affairs/MassGIS.The information depicted on this map is MVPC Bounda Comido Development Dist 3 G for planning purposes only.It may not be adequate for legal boundary �' O Comido Development Dist O _— /in def nition or regulatory interpretation.THE TOWN OF NORTH ANDOVER 0 Municipal Boundary O Corrido Development Dist �' 9 MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING Indu,t6 I 1 District Zoning 0 ortay It t{ THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY C:Industri 12 Distract 0 Adult Entertainment • s * OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT 13 Industri 13 District Downtown Overlay District * o -• �� • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF ©Historic District O Industn 1 S District -- Reside ce i District 71,, °��r�°•�t.(g THIS INFORMATION 0 Water Protection Reside ce 2 District SSA�NUSE El Parcels O R—ide ce 3 District C:Hydrographic Features de ce4 District —streams 139 ft de ce 5 District !de ce 6 District ,a a a'dential District The Commonwealth of Massachusetts Department of IndustrialAccidents g d 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia ,�. Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ApOicant Information Please Print Le 'bl Name(Business/Organization/Individual): �2Q e�(itx.S f✓�-� O �/ Address: I� yk�es S� City/State/Zip: Lrid c,nl e PAA 01943 Phone#:_ Are yonAn employer?Check the appropriate box: Type/project(required): 1. �Iam a employer with employees(full and/or part-time).* 7. F4 New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling any capacity.[No workers'comp.insurance required.] 9. F1 Demolition 3..Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 0 Building addition 4.F1I 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.❑Electrical repairs or additions proprietors with no employees. 12.El Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.EJ Roof repair's These sub-contractors have employees and have workers'comp.insurance.# 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] IL *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 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,%ey must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.•Below is the policy and job site information. i Insurance Company Name: h Sy(-6,%A e Sn Glei -- Policy#or Self-ins.Lie.#: 1�1 1 >' [� d b C 7 J Expiration Date: l Job Site Address: i '1 J ,� k 41 S City/State/Zip: hw( 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. I do hereby certi z u d the pains and penalties ofperjury that the information provided ab ve is true and correct. Sign Date: _7420//5 Phone#• 7q, 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#: 7/15/2015 11:44:04 AM PST (GMT-8) FROM: 100005-TO: 19786815777 Page: 2 of 2 AC R® CERTIFICATE OF LIABILITY INSURANCE [--DATE(MmtDDMYYY) �....►� 7/15/2015 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: It the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. It SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require on endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemen a. PRODUCER MTM INSURANCE ASSOCIATES LLC AM".CT 1320 OSGOOD STREET PHONE V NORTH ANDOVER,MA 01845 " INSURERS AFFORDING COVERAGE NAIC INSu RA: LM Insurance Corporation 33600 INSURED NSURER B: STEP AHEAD CONSTRUCTION LLC 18 CUTLER STREET NSURERC: LAWRENCE MA 01843 NSURERD: INSURER E: INSURER F- COVERAGES CERTIFICATE NUMBER: 25593234 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. INSRTYPE OF INSURANCE ADO R P Y EFF POLICY EXP LTR POLICY NUMBER M LRIIITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEEMME S CLAUS-MADE f-1 OCCUR I ' 9 Me =Lulwcel S MED EXP(Any one person) $ PERSONAL d ACV INJURY f GENL AGGREGATE LMrr APPLIES PER GENERAL AGGREGATE f POLICY❑PR 0 LCC PRODUCTS-COMPIOPAGO S OTHER S AUTOMOBILE LIABILITY ' f Ee u' m ANY AUTO BODILY INJURY(Per person) S ALL OWNEC SCHEDULED BODILY INJURY Per eedtleM) $ AUTOS AUTOS 1 MIRED AUTOS NON-OWNED A S AUTOS f UMBRELLA UA13OCCUR EACH OCCURRENCE $ EXCESS LIAa HCLAIMSMADE AGGREGATE S DED RPTENTioN s 1 1 f A woRKERs COMPENSATION WC5-31$-008612-015 1/10/2015 1/10/2016n ort AND EMPLOYERS'LIABILITY YIN -' ANY PROPRETORAPARTNETLEXECVTNEEL EACH ACCIDENT $_ 100000 OFRCERIMEMBER EXCLUDED? a N/A (Mendemry M NH) El DISEASE•FA EMPLOYFF S ., 100000 d pes.descrbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY UM,T $ 500000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addlllonal Remarks Schedule,msy be■Ileched I(more space is rpuired) This certificate cancels and supersedes all previously Issued cm;llcates,only as they relate to workers compensation coverage. Workers compenseton insurance coverage applies only to the workers compensation laws of the state of MA. CERTIFICATE HOLDER CANCELLATION WN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OSGOOD STREET E EXPIRATION DATE THEREOF, NOTICE WALL BE DELIVERED IN 1600 NORTH ANDOVER MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE LM Insurance CO otat10n 81988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 25593274 1,-609612 15-16 K Lucy Garfield 7/15/2015 2:40:36 M (E1T,l Paye 1 of 1 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." ' An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill-out the workers'compensation affidavit completely,by checking-the-boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 - Boston,MA 02114-2017 Tel.# 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia DDNYYY CERTIFICATE OF LIABILITY INSURANCE7/14/2015 ) 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 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 London NAME: MTM Insurance Associates PAICHONE (978)681-5700 a/c No:(978)681-5777 1320 Osgood Street ADDRIESS:lisal@mtminsure.com INSURERS AFFORDING COVERAGE NAIC# North Andover MA 01845 INSURERANorthland Insurance Company INSURED INSURER B Step Ahead Construction LLC INSURER C: 18 Cutler St. INSURER D: INSURER E: Lawrence MA 01843 INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 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. F POLICY EXP "TR TYPE OF INSURANCE ADDL SUBDR POLICY NUMBER MM/DDnYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 100,000 A CLAIMS-MADE � OCCUR 5225440 1/9/2015 1/9/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Peraccdent $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION NC STATU- OTH- AND EMPLOYERS'LIABILITY Y/NLIMI ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/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. 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 St. AUTHORIZED REPRESENTATIVE N Andover, MA 01845 Mike Traverso/STEPH -- e Massachusetts -Department of.R blicSafety.afety. 8bard of$wilding Regulations and Standards. I- t Constructs,&n S"e'h sor 1 &2 Familv License: CSFA7106138 u NICHOLAS LUSSJkR 18 CUTLER STREET _ Lawrence MA 01B43 f Expiration commissioner 08/27/2018 on��mer A a�j e sOveggUWfi.> - � -_ - HOME IMPROVEMENT CONTRACTOR °^Registi=anon ��;180870r " TYPe Expiration 1IZ3/20"17 LLC f SQL AHE>AD C f�STR CTfOTL L"C. a `I c A, iNICHOLAS LUSS3E { � �z,1'BkCUTTER STEE RTTfI�.� �•- f / c rLAWRENCE MA;018 3 G U:ndersecr."M ty