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HomeMy WebLinkAboutBuilding Permit #719-16 - 200 OSGOOD STREET 11/12/2015Permit No# Date Issued: LOCATION BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION `'( Date Received — E ORTANT: Applicant must '00 ee-,J*41eo�-71 PROPERTY OWNER (7,7a r Tv, ,O' ,2�(-S PARCEL:_�-2,,- ZONI Print all items on this s / O� LED qt 1616 .l2 6 1 . �.+•, 0 � Z � Print 100 Year Structure yes no DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El New Building_ ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Com rcial ❑ Repair, replacement ❑ Assessory Bldg ers: ❑ Demolition ❑ Other Septic ❑ Well - R?ter/SeW0 ❑ Floodplain 11Wetlands ❑ Watershed District OW er , DESCRIPTION OF WORK TO BE PERFORMED: 1 entiiicat - Ylease 1 ype Yr nt (lead OWNER: Name: r i Phone: _� Address: // XGA Contractor Na Email: Address: Supervisor's Construction Licen&'+,j- Home Improvement License: ARCHITECT/ENGINEER ,/%j/��= Phon le Date/-b— Date: Address: Reg. N IV FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BAe-SEED ON $125.00 PER S.F. Total Project Cost: $ FEE: $ 'J Check No.: _I % Receipt No.:� NOTE: Persons contracting with unregistered contractors do not have access to uaran fund 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 ,l CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition Planning Board Decision: Conservation Decision: Comments Comments Zoning Decision/receipt submitted yes Water & Sewer Connection/semnature & Date Driveway Permit DPW Town Engineer: Signature: Located W4 usgooa 5ireei FL_REt.DEPA_RTMENT TempjDurnpster onisite ,yes_... ,ino - z_a Locatedl.at 124�MaincSt�eet� .� COMMENT 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 Ema 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 TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit 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/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 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 :at 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 TOTE: 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 0, n Check #r` Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ ' Other Permit Fee $ TOTAL $ 01, Building Inspector n Irl rA 5� x Q W LL O o Q O m VLn LL v to N p W d z z a m c O .2 LL d' ? cu E U C LL O W CL H z z m J a ,L d' LL O v W CL N z V J NJ -C00 O= d' O (n C LL Q ~ w z N .4 '>. d' C LL z CWC C w o LLI cc LL L i m 6 Z w N 4i N C N 7m 0.1 r V I- O coN = O .E Q. N cc c c O O v O n. m a, c o w, U E Q L N .c .F+ � AIM O O • cc O ci L �) U C J Lim CD c d Cc L CD O � O � CD t CD z N o 0 .r 3 H of O p •rn O = c L � CL cc •'� O . O m _ O O CLR y O O '!0 CDcn *, S •> %- r- 12 n: 0 0 E O CL MA m y U) tm c m L O c .O N d t w O Z O Q J O F. 2 z G z U) ui I.I W H W CL LS 2 E z 0 !!Ww Q _� v/ .E W W a~ 0 0OD0 �+ _0 0 a� Q OM c v J � .N 0 �z 0 ,A V t/1 c CLU Cl U cn j/O H V I- O coN = O .E Q. N cc c c O O v O n. m a, c o w, U E Q L N .c .F+ � AIM O O • cc O ci L �) U C J Lim CD c d Cc L CD O � O � CD t CD z N o 0 .r 3 H of O p •rn O = c L � CL cc •'� O . O m _ O O CLR y O O '!0 CDcn *, S •> %- r- 12 n: 0 0 E O CL MA m y U) tm c m L O c .O N d t w O Z O Q J O F. 2 z G z U) ui I.I W H W CL LS 2 E z 0 !!Ww Q _� v/ .E W W a~ 0 0OD0 �+ _0 0 a� Q OM c v J � .N 0 �z 0 ,A V t/1 c CLU Cl 0 t ft— r., � -.4 Cb AP. I— q�c� 4Z �— SLrt4 roposaa • e HIC # 174377 2010 � 201 DMhpousseve ��� _ ,fSut Roofing up 6 years running. A trusted name since 1938 Roofing • Siding • Windows 87 Belmont Street • North Andover, MA 01845 P: 978-683-4588 • F: 978-685-7446 NAME OF OWNER 5F ; ADRESS OF JOB TEL. 6 ?2 e:�>DATE: We will remove all roof shingles off total roof area, layer. Replace any boards or sheathing at additional cost. A new 8" white aluminum drip edge applied on all edges. Approx. 6ft of ice and water membrane applied on eaves, 3ft in valleys, strips around skylights, along chimney flashing and sidewall junctions. Existing step flashings to remain. A new base sheet applied. Architectural roof shingle installed with a limited lifetime warranty. Install new ventpipe boot flashings. Waterproof existing chimney flashing 'and remove debris. Shingle Color: Ridge Vent Upgrade Wood Sheathing Repair $3.50 per ft. We Propose herby to furnish material and labor - complete in accordance with above specifications, for the sum of: /� doll{$��)• Payment to be made as foll �� % © f V < /1i 1�� t• p Authorized Signature NOTE: This proposal may be witdrawn by us if not accep with in 714ys ACCeptmce of Proposes - The above prices, specifications and conditions are satisfactory and are herby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Signature i ,moi Date of Acceptance: �1"g lQ Signature Proposal - ( HIC # 174377 �o�o DDam housse Roofing LLP _ars A trusted name since 1938 yrunning, Roofing • Siding • Windows 87 Belmont Street • North Andover, MA 01845 P: 978�-683-4588 • F: 978-685-7446 NAME OF OWNERfit F� /-- ADRESS OF JOB TEL. vkf 0 DATE: We will remove all roof shingles off total roof area, Z� layer. Replace any boards or sheathing at additional cost. A new 8" white aluminum drip edge applied on all edges. Approx. 6ft of ice and water membrane applied on eaves, 3ft in valleys, strips around skylights, along chimney flashing and sidewall junctions. Existing step flashings to remain. A new base sheet applied. Architectural roof shingle installed with a limited lifetime warranty. Install new ventpipe boot flashings. Waterproof existing chimney flashing and remove debris. Shingle Color: Ridge Vent Upgrade Wood Sheathing Repair $3.50 per ft. xt" / 16 t/ ,rte A) /EP We Propose herby to furnish material and labor - complete in accordance with above specifications, for the sum of�:�, ` dollars Playme&lto be made as follows /tea es fit' Authorized Signature• NOTE: This proposal may b withdrawn by us if /acept edwith iv--4:�days Acceptance of Proposal- The above prices, specifications and conditions are satisfactory and are herby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Signature Date of Acceptance: Signature IM r rvNv�iaa o-vED 13v 1 HIC # 174377 Zo102015 Dam housse p. BestOfSurvey�. COM Roofing up 6 years running. -1 A trusted name since 1938 Roofing - Siding - Windows 87 Belmont Street - North Andover, MA 01845 P: 978-683-4588 - F: 978-685-7446 NAME OF OWNERe�/ � / T ADRESS OF JOB TEL.`C.�C.— DATE: We will remove all roof shingles off total roof area, layer. Replace any boards or sheathing at additional cost. A new 8" white aluminum drip edge applied on all edges. Approx. 6ft of ice and water membrane applied on eaves, 3ft in valleys, strips around skylights, along chimney flashing and sidewall junctions. Existing step flashings to remain. A new base sheet applied. Architectural roof shingle installed with a limited lifetime warranty. Install new ventpipe boot flashings. Waterproof existing chimney flashing and remove debris. Shingle Color: z Ridge Vent 1.10grade a Wood Sheathing Repair $3.50 per ft.,�- .r �Cs i We Propose herby to furnish material and labor - complete in accordance with above specifications, f the sum of: 1 dollars ($ ). Payment to be made as folio ' Authorized Signature Wit, NOTE: This proposal y be withdrawn by us i of accepted with n7' days Acceptance of f'oposai]l - The above prices, specifications and conditions are satisfactory and are herby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Signature Date of Acceptance: Signature HOME IMPROVEMENT CONTRACT TERMS AND CONDITIONS M.G.L.142A 1. WORK: Provided the Homeowner performs under this agreement, the Contractor shall perform the work on the Property as specified Proposal, attached incorporated herein. The work does not include extraordinary conditions of which the Contractor could not rcasonably be aware. If such conditions are encountered, this shall be an additional cost to the Homeowner. Materials selected by Homeowner may have to be ordered or custom made, which items are specified in the Proposal. The Contractor is not obligated to agree to any modifications, extras or change orders unless such items are agreed to in writing by the Contractor. All extras and changes shall be at an additional cost to the Homeowner. Contractor shall perform the work in a good and workmanlike manner using materials consistent with this contract. Lawn or Driveway may be damaged by dumpster or equipment. Due to material shortages Contractor may substitute materials of equivalent grade. 2. PERMITS: If a building permit is required for the work, the Contractor shall obtain same as Homeowner's agent. Contractor is not responsible for any other permits that may be required for the Work, and Homeowner is responsible to determine whether any zoning, planning or wetland related permits or approvals are necessary. Homeowners who secure their own permits or deal with unregistered contractors will not have access to the Guaranty Fund. 3. COMMENCEMENT AND COMPLETION: Homeowner acknowledges the commencement date of the work is fluid, and is subject to numerous factors such as scheduling other contractors, delivery of materials and weather. Contractor and Homeowner shall determine the commencement date of the Work when a more definite determination can be made and shall execute a written acknowledgment of same. The Work shall be substantially completed within 7 days of commencement, except for longer periods as may apply to particular projects as Contractor shall notify Homeowner in the Proposal, and subject to delays for circumstances beyond Contractor's control. Notwithstanding, the commencement date and substantial completion date may be extended, and the Contractor will not be liable for delays caused by, labor or material shortages, delays in delivery of items selected by the Homeowner, governmental action, and unforeseen events beyond the Contractor's control, including but not limited to weather, strikes, war, the acts of third persons or the acts of the Homeowner. The Homeowner recognizes that the commencement date may be delayed due to scheduling or the completion of Contractor's other jobs. 4. PAYMENTS: Contractor agrees to perform the Work and to furnish the materials and labor specified in the Proposal for the amount as stated in the Proposal. Thirty percent (30%) of the total is to be paid as a deposit with the signing of this contract. Upon cancellation prior to commencement of the Work, any remaining deposit will be returned less the costs for materials ordered for which Contractor was unable to cancel. Final payment shall be due upon completion of the Work and Homeowner agrees it may not hold any retainage. Late fees may be applied for late payments. Homeowner shall pay Contractor's reasonable costs of collection, including attorney's fees and costs. Time is of the essence hereof. 5. WARRANTY: For a period of 2 years after substantial completion of the Work the roof will be free of leaks caused by defects in workmanship, but not those caused by ice backing -up or extraordinary weather events, including blizzards, tornadoes, hurricanes or storms of greater than a twenty-five year duration or intensity. Contractor gives no warranties with reference to any materials or equipment installed in the Premises, passes any such warranties directly to Homeowner, and Homeowner agrees to look only to the manufacturer with reference thereto. This limited warranty extends to the Homeowner only and is not transferable to succeeding Homeowners. This Limited Warranty specifically excludes (i) all consequential and incidental damages; (ii) damage due to ordinary wear and tear, abusive use, misuse, or lack of proper maintenance; (iii) defects which are the result of characteristics common to materials used; (iv) defects in items installed or supplied by anyone other than Contractor; (v) work done by anyone other than by Contractor; and (vi) loss or injury due to the elements. There are no other expressed or implied warranties or representations made or given. 6. ENTIRE AGREEMENT: This contract and all documents referenced herein constitute the complete and final agreement between the parties. In the event that any of the provisions of this contract shall be held to be invalid, the remainder of the provisions of this contract shall remain in full force and effect. Two identical copies of this contract have been completed and signed. Homeowner acknowledges receipt of a completed contract signed by the Contractor. 7. HOME IMPROVEMENT REGISTRATION: In accordance with M.G.L.c. 142 A, § 9, Contractor is registered with the Bureau of Building Regulations and Standards Registration No: 174377. Homeowner may verify by contacting the Director at (617) 727-3200, ext. 25205. A Homeowner's rights under the Home Improvement Law (M.G.L.c. 142A) and other consumer protection laws may not be waived in any way. Homeowner acknowledges receipt of a copy of 780 CMR R6 and Massachusetts General Laws chapter 142A, and which are available online at www.mass.gov. Questions may be directed to the Consumer Information Hotline, (617)727-7780. 8. ARBITRATION: Contractor and the Homeowner hereby mutually agree in advance that in the event the Contractor has a dispute concerning this contract, the Contractor may submit such dispute to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulations and the consumer shall be required to submit to such arbitration as provided in M.G.L.c. 142A. No lien or security interest is imposed on the Property as a consequence of this contract, but Contractor has the right to record this contract or a notice of this contract, or seek a lien if the Homeowner breaches this Contract. 9. HOMEOWNER COVENANTS: The Homeowner agrees, represents and warrants that (a) the Homeowner grants permission to the Contractor to enter the Property to perform the work as covered by this contract; (b) the Homeowner has funds available to make full payment under this contract to the Contractor upon completion; (c) the Homeowner understands that construction as contemplated by this agreement creates a dangerous condition, and agrees not to enter portions of the Property under construction until the Contractor advises the Homeowner that the construction is completed; (d) Contractor may need use landscaped areas of the yard during the Work and Homeowner is responsible to provide protection for landscaping and (e) that code requirements may result in roofing nails penetrating through roof decking and will be visible on the underside of some surfaces. The Homeowner indemnifies, exonerates and holds harmless the Contractor from any loss, damage, claim, liability or expense (including reasonable attorney's fees, deposition costs and court costs) resulting from a breach of this provision. Contractor is not responsible for damage to landscaping that will grow back during the next growing season. 10. CANCELLATION: Homeowner may Cance is agreement provided Homeowner notifies the Contractor in writing at the address listed in the Proposal not later than midnight of the third b ss da Io ing the igning of this agreement. oe ROMEO DATE: Shingle: J�� / DEPOSIT: �� 4/17/2015 11:05:02 AM 8790 ® 02/02 F -10 �icor� CERTIFICATE OF LIABILITY INSURANCE DATE (MMfDDIYYYY) ., 04,17,2015 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(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 00474-001 0o 77 NAMEACT Doherty Insurance Agency Inc PO Box 1985 Andover, MA 01810 A2%.Ext): (978)475-0260 (Ikc. No.: /%Ess: INSURERS) AFFORDING COVERAGE NAIC I INSURERA : A.I.M. Mutual Insurance Company 33758 EACH OCCURRENCE $ INSURED Damphousse Roofing LLP INSURERS: PERSONAL & ADV INJURY $ INSURER C : 87 Belmont Street North Andover, MA 01845 INSURER D: /NSU ERE: NSU E 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. /LTR TYPE OF INSURANCE INSQR LU D POLICY NUMBER POLICY EFF PMIL,ICY I D/YYYY LIMITS GENERAL LIABILITY COtitMERCWL GENERAL LIABILITY CLAIMS -MADE ❑ OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED $ PREMISES Ea occurrence MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER* O- MOC OLICYI LE PRODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY ANY.AUTO ALL OVVNED SCHEDULED AUTOS AUTOS HIREDAUTOSH NON -OWNED AUTOS COMBINED SINGLE LIMB $ Ea acddon' t BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per acc(dent $ UMBRELLA LIAB EXCESS LIAR OCCUR CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A MM AND EMPLO�ERS LIIAABILIITY ANY pp��OPRIETOR/PARTN� Z&XECUTIVE YIN N OFFICERrTdEMBER EXCLUDED? (Mandatory In NH) DESsCRIlIM OF OPERATIONS below NIA AWC-400-7028774-2015A 4/17/2015 4/17/2016 /C g U X TORY LIMITS ER E.L. EACH ACCIDENT $ 500,000,00 E.L. DISEASE - EA EMPLOYEE $ 500,000.00 E.L. DISEASE -POLICY LIMIT $ SQQ 000,00 DESCRIPTION OF OPERATIONS f LOCATIONS f VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) No partners are covered by the workers compensation policy. 1IVN 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 �w s res ACORU Z5 (ZO1 U/US) The ACORD name and logo are registered marks of ACORD 6913 Client#: 14415 DAMPHOUSSE ACORO,r CERTIFICATE OF LIABILITY INSURANCE m MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH 04117/2015 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Doherty Insurance Agency, Inc. P.O. Box 1985 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 21 Elm Street POLICD[YYV __DATEY EXPIRATION IMMMOMI Andover, MA 01810 INSURERS AFFORDING COVERAGE MAIC # INSURED INSURER A: Western World Damphousse Roofing LLP 87 Belmont St North Andover, MA 01845 INSURER B' INSURER C: INSURER D: INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN5H LTR ADD' TYPE OF INSURANCE POLICY NUMBER 0 LICYME�CTIVE POLICD[YYV __DATEY EXPIRATION IMMMOMI LIMITS A GENERALLIABILITY NPP8202847 04112/15 04/12/16 EACHOCCURRENCE S1 000 OOO X COMMERCIAL GENERAL UABILITY DAMAGE TO RENTEDPREMISE S100,000 CLAIMS MADE FE OCCUR MED EXP (Any one person) S5000 PERSONAL 8 ADV INJURY $ 000 OGD GENERAL AGGREGATE s2.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP10P AGG $2,000,000 X POLICY JECTT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea aeeldenl) $ BODILY INJURY ALL OWNED AUTOS SCHEDULED AUTOS (Per pew) S BODILY INJURY HIRED AUTOS NON -OWNED AUTOS (Per accident) S PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC S ANY AUTO AUTO ONLY: AGO $ EXCESSJUMBRELLA LIABILITY EACH OCCURRENCE S AGGREGATE $ OCCUR CLAIMS MADE S $ DEDUCTIBLE S RETENTION $ WORKERS COMPENSATION AND WC $TATO- O R EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE E.L. EACH ACCIDENT S E.L. DISEASE - EA EMPLOYEE $ OFFICER.'MEMBER EXCLUDED? IIos, dawribe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT S OTHER DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Covering operations usual to Damphousse Roofing LLP... SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE SSUING INSURER WILL ENDEAVOR TO MAIL 19)_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR AUTHORQED ACORD 25 (2001108)1 of 2 #S31838/M31835 / / DML 0 I#WRD CORPORATION 1988 The Co»uttotnveattfi ofh7assachusetts Depattrrtent of Lzdttstt•tal Accideizfs Office of Lt vestigations 600 6Yashington Street Boston, A 02111 mmv.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Coutractors/)✓lectricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: / ' ✓�r�irs� �C/1114 City/State/Zi,046la✓` Phone #: Are y an employer? Clicck the' ppropriate box: 1.,K I am demployer.with -_ V_ 4. [:11 am a general contractor and I employees (full and/orpart-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- lisled on the attached sheet t ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised tbeir right of exemption per MGL C. 152, § 1(4), and we have no employees. [No workers' - comp. insurance required.] ' I *Any applicant that checks box Wl must also Gll 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 tContraclors that cheek this box must attached an additional sheet showing the name orthe sub -contractors and their workers' comp, policy information. I am an employer that is providing lvorkers' corrrperrsation insurance for lily employees. Below is the policy and job site information. w Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition I0.❑'Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. oofrepairs 13.❑ Other Insurance Company N J 45_� Policy # or Self -ins. Lic. #: /5/L�Z17J a Expiration Date:'�'����j Job Site Address: 'City/Stale/Z' Attach a copy of the workers' cont ensation 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 firm of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification - .1 do hereby certif urc rlJse pa rrd penalties ofperjuU that the infor-uratiorr P-rovided above is true and car•rect mature: 'Date: one #: s OJ,Tcial use only. Do not write in this area, to be cornpleted by cio) or town offciaL City or Town: PerrrdULicerise # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5..Plulttbing Inspector 6. -Other Contact Person: Pllone #: Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS -067560 Construction Supervisor SHAUN M TWOMEY 61 PATROIT ST NORTH ANDOVER MA 01846 -� '(--/Ili C t,- Expiration: Commissioner 10/26/2017 Office of on a 'air g*S/i� Reg�ti ' HOME IMPROVEMENT CONTRACTOR Registration: -_174377 Type: Expiration: X2%412017 LLP- -- TDHOUSSE ROO1=fNG SHAUN TWOMEY. 87 BELMONT ST } '� N. ANDOVER, MA s" Undersecretary