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HomeMy WebLinkAboutBuilding Permit #486-2017 - 201 RALEIGH TAVERN LANE 11/8/2016-T)1J4'J'SCiz1)JN& I-) BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 7,617 Date Received- /3 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building /One family 0 Addition 11 Two or more family D Industrial 0 eration No. of units: [I Commercial placement 0 Assessory Bldg-_ 11 Others: D Demolition D Other n NZA 14�' e P M, W e I I ON . N W --4-M -#I'. r" r� A -, F 10 o d p 18 1 U M- n _; .. 4, Wi::�Fl N p Wors e. , C ­t '0 UTA fiat 2, ate Mv, nr-Qr'P1PT1nK1 OF WORK TO RE PERFORMED: R�lo b6l :K Ali -R I �U.6//VeD ARCHITECT/ENGINEER Phone: Address: Reg. No.. FEE SCHEDULE. BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. ----,,,Total Project Cost:$ ��10(0'00 FEE: $ `7 Check No.: I ba>01 Receipt No.: 13 it S-� NOTE: Persons contracting with unregistered contractors do not have: access to the g ara14, nd Signature--- - Signature of contractor -bf-Agent/0e v Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYI'F- F SEWERAGE DISPOSAL j Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. R( permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature CONSERVATION Reviewed on Signature , COMMENTS HEALTH COMMENTS Reviewed on I k'--1 ' Zoning Board of Appeals: Variance, Petition No: it Planning Board Decision: Comments Conservation Decision: Comments Zoning Decision/receipt submitted yes Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located Jd4 Usgood Street FIREDEPARTMENT =.Temp Dumpster on site yes no �. Loccatedkat 124Main. Street Fire;Department'signature/date: r f S�µe � i �" s � S w .. a" - *� i t. V 5 �;" 1 Y �•. �r � ! k h=am v Y�u '; Y �' � � '�!''€ .? 'i_,, ,� ' t ✓ � S � t 4 �,4 r 4 ?� j .^^��,,,,fix., i, COMMENTS ti. y � ' I L. { 4 a limension Number of Stories: Z— Total square feet of floor area, based on Exterior climensions.Zj 00 Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector lies No ®ANGER ZONE LITERATURE: lies MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use) No 1/7Ll c>Z ❑ Notified for pickup Call Email ate 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. r Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application o 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 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 o 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 NOTE: 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 ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products VOTE: 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 Locationt^✓e +e r3 G No. _ �� Date Check # l u �I TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $���" Foundation Permit Fee $ Other Permit Fee $ TOTAL $ CD � Z CD O Cr as a;, Q �. > to O 00 C CD O Q O tO CD civ C7 O n' O r_ E 0 cD CD a CO. CD iv O O CD O CD 0 o 0 - 0 x y �' < CD _0 FMU n — CCD o -Os n z o =r -a O vi C• h o. �7 O 0 . + O_ STI CD N W CD mO toy CD <D = 0 Q fy O CL O O .� O .-r CO's .-r = �D O C CD O. 0 C o < CQ �rt .2: CD 0 Z D co cn 00 a -" 3 CDC 0 � PM- < 0_o� 0 IS en 0CD O N su CD CAI.CD L: . volm su �- ICD) . 0 O O �r. N CD 'o' �, = D� AL w = o su o � � 0 ANOW a e O O fD m O rD N - z � - z O 'QQ 7' < � 7.7 O MI S rnm T j 41 70 O Q=G S .c ic (") S j• (D ,C 7,7 O m S T O 7 0- O1 0 (n (D � n Ln ,< < H T O o - \ 7C c0m T v zX 0 C ILA 0 4 55 ;orn 3 S 3 0- O DCIO A 00 c v �i M: o 0 - 0 x y �' < CD _0 FMU n — CCD o -Os n z o =r -a O vi C• h o. �7 O 0 . + O_ STI CD N W CD mO toy CD <D = 0 Q fy O CL O O .� O .-r CO's .-r = �D O C CD O. 0 C o < CQ �rt .2: CD 0 Z D co cn 00 a -" 3 CDC 0 � PM- < 0_o� 0 IS en 0CD O N su CD CAI.CD L: . volm su �- ICD) . 0 O O �r. N CD 'o' �, = D� AL w = o su o � � 0 ANOW a e O O fD m O rD N - z � - O 'QQ 7' < � 7.7 O MI S T j 41 70 O Q=G S T j N (") S j• (D ,C 7,7 O m S T O 7 0- O1 0 (n (D � n Ln ,< < H T O o - \ 7C Y T v 0 70 r m n m 0 M C ILA 0 W C 0 Z m 0 3 S 3 W 0 D Dm 41L 0-1 2;0� DocuSign Envelope ID: 657983ED-FF3F-4422-B9E5-40456ECDCCBF Home Improvement Agreement E&C Contracting LLC 14 McGrath Hwy Somerville, MA 02145 781-526-7501 E&C Contracting LLC of 14 McGrath Hwy, Somerville, Massachusetts 02145 ("Contractor") and Karen O'Donohue of 6 Queen Street, Newburyport, Massachusetts 01950 ("Owner") enter into this agreement effective on October 1. 2016, providing for certain renovations and improvements to Owner's property located at 201 Raleigh Tavern, North Andover, MA 01845 (the "House"). The parties agree as follows: 1. Contractor Information. Contractor, a Massachusetts Limited Liability Company, is licensed as a home improvement contractor by the Commonwealth of Massachusetts, Office of Consumer Affairs and Business Regulation. Contractor's Home Improvement Registration Number is 183579. Contractor's license will expire on October 26, 2017. Notice: All contractors and subcontractors must be registered by the Director of Consumer Affairs and Business Regulation. Any inquiries about a contractor or subcontractor relating to a registration should be directed to the Director. Home improvement contractors are regulated under Chapter 142A of the Massachusetts General Laws, which chapter provides certain warranties and non-waivable rights to homeowners including access to arbitration services and, where qualifying, to payments from a Guaranty Fund established to compensate owners for certain uncollectable, actual losses. 2. Ownership and Condition of the House. Owner is the owner of the House. Kitchen, bathroom, hallways, paint and flooring throughout are dated and in need of repair/replacement. 3. Start Date and Completion Schedule. Unless circumstances beyond Contractor's control arise, Contractor will begin the contracted for work on or before October 10, 2016 (the "Scheduled Start Date") and will have substantially completed the work before November 30, 2016. 4. Description of Work. i. Interior Painting: Contractor shall paint the interior of the entire house, walls and trim work as per prior conversation; smooth all the ceilings through the house; applying the finish coats of Benjamin Moore interior paint, in colors selected by Owner, to all interior wall and ceiling surfaces of the House; [$15,800.00]; ii. Flooring Replacement in kitchen and front entrance hallway: Contractor shall (i) remove the existing floor in the kitchen and entrance hallway area, prepare subfloors for installing new hardwood floors, and (ii) purchase flooring and Install new hardwood floor (matching the living and dining room), sand and apply three coats of polyurethane; [$5,700.00]; iii. Refinishing Flooring: Contractor shall refinish the floors in the office, dining and living rooms; sanding and applying three coats of polyurethane; [$1,550.00] Page 1 of 5 DocuSign Envelope ID: 657983ED-FF3F-4422-B9E5-40456ECDCCBF iv. Repair deck and porch floor: Contractor shall replace rotten boards on the porch and deck; remove all the deck boards in the area that is sinking, fix the frame (straighten it) install boards back. Paint/Stain the entire deck and porch floor; [$1,100.00]; V. Kitchen Remodel: Contractor shall (i) provide all rough material, (ii) remove all existing cabinets, counter tops and appliances, (iii) dispose of all debris, (iv) update electrical and plumbing, and (v) install new cabinets, counter tops and appliances; [$15,000.00]; vi. Upstairs Master Bathroom Remodel: Contractor shall provide all rough materials and shall (i) demolish the existing bathroom, (ii) update plumbing, (iii) update electrical, (iv) prep subfloors, and walls, (v) install cement boards on floors and walls, (vi) install stand up shower, vanity, medicine cabinet, toilet, tile, and (vii) paint; [$16,000.00]; vii. Upstairs Hallway Bathroom: Contractor shall provide all rough materials and shall remove and replace double sink vanity and counter top; Replace the faucets, and plumbing fittings. Remove and replace medicine cabinet. Remove and replace toilet. Remove and replace radiator; [$2,800.00]; viii. Downstairs Half Bath: Contractor shall provide all rough materials and shall remove and replace full width vanity and counter top; replace the faucets, and plumbing fittings, remove and replace toilet; remove and replace radiator; [2,000.00]; ix. Furnace / Hot Water: Contractor shall provide all of the materials, equipment, plumbing and electrical work and shall install a new furnace with an on demand tankless hot water system; [$6,400.00]; X. Incidentals: Contractor shall perform such incidental home improvement services as may be necessary in Contractor's sole determination and such as may be informally requested by Owner, but shall not perform any such incidental services beyond those the total cost of which would exceed $2,000.00 except in accordance with the herein "Changes" provisions. xi. Completion of Contractor's work: Upon completion, Contractor shall clean up the work site removing any debris, equipment, tools, supplies, and materials. Contractor shall perform all work in a good and workman -like manner. Other than as specified herein, Contractor is not required to perform any repairs or correct any structural defects, and Contractor is not required to perform work on any other structures, including without limitation, sheds, garages, or fences. 5. Total Contract Price and Payment Schedule. Contractor shall furnish all tools, supplies, equipment, material (including without limitation, rough materials, primer and paint), labor and supervision, and shall perform the work described above for the total price of $[66,350.00] (the "Total Contract Price"). Owner shall make payments, by check or cash, to Contractor according to the following schedule: a deposit of $20,000.00 prior to the start of Contractor's services, a progress payment of $25,000.00 by the later of the fourteenth day following the Scheduled Start Date or the day following completion of interior painting, iii. a final payment of the balance then owing on the Total Contract Price upon completion of the work. Page 2 of 5 DocuSign Envelope ID: 657983ED-FF3F-4422-B9E5-40456ECDCCBF Contractor's obligations to begin and to continue any work are conditional upon receipt of the deposit and progress payments outlined above and upon Owner's performance of his or her obligations and responsibilities detailed below. Contractor understands the pricing agreed to herein is an essential term of this agreement and that Owner would not have entered into this agreement but for such pricing terms. In the event that cost overruns acceptable to Owner occur, and such cost overruns result in a final price exceeding the herein agreed upon Total Contract Price, Contractor agrees to receive the excess overrun amount from Owner upon Owner's sale of the House, and Owner agrees that Contractor may place a lien for such amount on the House. 6. Owner's Obligation and Responsibilities. 6.1 Color Notification. No later than scheduled start date, Owner shall notify Contractor of the product number, color name, and color number of each finish paint color and the surface areas to which each specified color will be applied. 6.2 Appliances, Cabinets, Countertops. Owner shall purchase and have delivered all replacement kitchen appliances [stove, microwave, refrigerator], cabinets, and countertops. 6.3 Bathrooms. Owner shall purchase and have delivered all finishes including fixtures, vanities, toilets, tubs, medicine cabinets, and tile. {Contractor's estimates: expect to spend on finishes between $800 to $1,000 for a half bath, $1,200 to $1,700 for full bath and $2,000 to $3,000 for master bath.} 6.4 Utility Services. Owner shall provide all necessary water and electrical power to the work site while the work is on-going. 6.5 Access to Work Site. Owner shall provide 24-hour everyday access to the work site while the work is on-going. 6.6 Clear Work Area. Owner shall relocate and protect all items, including but not limited to, plants, automobiles and fixtures, that would inhibit Contractor's free access to the work area. If Owner fails to remove any items that impede the work or that may be damaged in the normal course of performance of the work, Contractor may relocate those items, without liability for damage to the items while relocating them or in the course of performance of the work. 7. Changes. If Contractor determines that the occurrence of unforeseeable circumstances, other than increases in the cost of hourly labor, or that changes requested by Owner, will require that Contractor incur greater than reasonably anticipated costs, the parties shall negotiate and enter into a written, equitable, price modification which will be incorporated into this Agreement. 8. Miscellaneous. 8.1. Access to Interior of House and Facilities. Contractor shall have access to the interior of the House including bathrooms. 8.2 Permits. Contractor shall obtain all permits required for this work and for all agreed upon change orders. Where permits are required, owners who secure their own permits will be excluded from the Guaranty Fund provisions of MGL chapter 142A. Page 3 of 5 DocuSign Envelope ID: 657983ED-FF3F-4422-B9E5-40456ECDCCBF 8.3 Subcontracting and Delegation. Contractor may subcontract or delegate the performance of any work contemplated by this Agreement. Contractor shall at all times be responsible for the activities and the work subcontracted or delegated. 8.4 Advertising. Contractor is entitled to display an advertising sign at the work site beginning on the date that work starts and continuing uninterrupted until the latest of the seventh day after work is completed or the day final payment on the Total Contract Price has been received. 9. Mechanics Lien. Under the Massachusetts Mechanics Lien Statute, MGL Chapter 254, any person performing home improvement work on Owner's House, including Contractor, has the right to place a lien on the House if that person is not paid for work or for materials. 10. Duplicate Execution. The parties may execute this agreement electronically. If executed in hard copy, two identical copies, one to the Owner and one to the Contractor, must be completed and signed. Notice: Under Chapter 93, Section 48, of Massachusetts General Laws, 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. See the attached notice of cancellation form for an explanation of this right. Do not sign this contract if there are any blank or incomplete spaces. E&C Contracting LLC Docusigned by: By'VeTB'a&(va, Manager November 2, 2016 1 16:45 EDT Karen O'Donohue y�� T.,V7 o 37C17BCEsoAr,416... November 2, 2016 1 15:56 EDT Page 4 of 5 P fl III a CT https:Hmail.google.com/mail/ca/u/O/#inbox/l582b259584c551 a?projector=1 1/1 11/3/2016 FullSizeRender.jpg https://mail.google.com/mail/Ca/u/0/4Anbox/l582b292bd47e6eb?projector=1 1/1 ACOR 1 0 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 10/11/2016 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 Claudia Victoria AL PONTE INSURANCE AGENCY INC p/oN o Ext): (617) 492-7600 NC No: no DRESS: claudia.victoria@thepontegroup.com INSURERS AFFORDING COVERAGE NAIC# 819 CAMBRIDGE ST. INSURERA: ATLANTIC CHARTER INS CO 44326 SAUGUST MA 02141 INSURED INSURER B: INSURER C: E&C CONTRACTING LLC INSURER D: INSURER E: 24 KINGSTON STREET INSURER F: NORTH ANDOVER MA 01845 COVERAGES CERTIFICATE NUMBER: 92278 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 LTR TYPE OF INSURANCE ADDL SUBR POLICYNUMBER POLICY EFF MMIDD POLICY EXP MM/DD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE 1-1OCCURA ACBE RENTED PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ N/A GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ RPOLICY F1 PRO JECT 7 LOC PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNEDSCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per accident) $ NON -OWNED HIREDAUTOS AUTOS PROPER DAMAGE $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE N/A DED RETENTION $ $ A WORKERS COMPENSATIONX EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? I NIAJ N/A N/A WCV01260000 10/29/2015 10/29/2016 AND STATUTE ETH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. M-4 g11.1 P7L11111i NORTH ANDOVER 1600 OSGOOD STREET NORTH ANDOVER 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 L MA 01845 Daniel M. Cr a v, y, CPCU, Vice President —Residual Market — WCRIBMA @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD ACORV CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYYj 9/22/16 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 Al Ponte Insurance Agency 819 Cambridge St g Y Cambridge, MA 02141 CONTACT NAME: PHONE FAX 617 492-7600 A/ No, (617) 354-0401 E-MAIL ADDRESS: CLAUDIA. VICTORIA@ THEPONTEGROUP. COM NPP1427032 10/28/15 INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: WESTERN WORLD DAMAGE TO RENTED PREMISES (Ea occurrence)_ $ 100,000 INSURED INSURER B : E &C CONTRACTING LLC 24 KINGSTON STREET NORTH ANDOVER, MA 01845 INSURER C : INSURERD: 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. ILTR TYPE OF INSURANCE INSR AML WVDSUBR POUCY NUMBER PMIUODY/Y% CY MNILIDD/YYYYYY LIMITS A GENERAL LIABILITY DCOMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR NPP1427032 10/28/15 10/28/16 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence)_ $ 100,000 MED EXP (Anyone person) $ 5,000 PERSONAL &ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 200,000 GEN'L AGGREGATE LIMITAPPLIES PER }( POLICY PRO- LOC PRODUCTS - COMP/OPAGG $ 2,000,000 AUTOMOBILE LIABILITY ANYAUTO ALLOWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS EO a6 W�cciEDtSINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ P eOr aCc�d Y DAMAGE $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PROPRIETOR/PARTNER/EXECUTIVE OFFICE RIMEMBER EXCLUDED? (Mandatory in NH) Ifyes, desalbe under DESCRIPTION OF OPERATIONS below N / A WC STATU- OTH- TORYANY E.L. EACH ACCT DENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) NORTH ANDOVER 1600 OSGOOD STREET NORTH ANDOVER, MA 01845 ACORD 25 (2010/05) Phone: 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 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Fax: E -Mail: Workers, Compensation Insurance Affidavit: Builders/C�n UTHO 5��. tricians/Pl>zmbers. TO BE FILED WITH THE PERMPI TAV Name (Business/(5igavization/Individual): Address: Z 45 r City/State/Zip: Axe yon an employer? Check the appropriate box: 1. lam a employer with employees (full and/or part time).* 2.0 I am a sole proprietor or partnership andhave no employees VVorkiag forme in any capacity. [No Workers ' comp. insurance required.] 3. ❑ lam a homeowner doing all work myself. [No workers' comp* insurance required.] t 4.I]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 proprietors with no employees. s. ❑I am a general contractor and I have hired the sub -contractor listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurauce.t 6. F] We are a corporation and its, officers have exercised their right of exemption Per MGL c. 152 ees. [No workers' comp. insurance req § 1(4) and ive have no employuired.] v /4 Type of project (required); 7. 0 Nd-W'd6nstr6ction g, �emodeliiig . 9. [l Demolition 10 0 Building addition 11.0 Electrical repairs or additions 12T[ Plumbing repairs or additions 13•. [] Ro6f repairs 14.0 Other icy *Any applicaut that checks bbat#1 must also till out the are doing all work andthen hire outside w showing their workers' aontracto�s must submit new affidavit indicating such. I Romeo wners who submit•tbis affidavit indicating they tCmtractors that check this fiox must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. compensation insurancefor my employees..Below is the policy and job site X am an employes flint is ps oviding workers' information. ` C/ Q Insurance Company Name: v • -- � O — :?— I — / 7 ExpirationDate_ Policy # or Self -ins. Lic. t��7 /] / Cl(N ! V L N City/State/Zip: lob Site Address: li �' Attach a copy of the workers' policy declaration page (showing the policy number an expiration date). e by a ae up to 0.00 Failure to secure coverage as required and MGL c. form ofis a STOP WORK ORDERal violation Iand tine f up to $200.00 a and/or one-year imprisonment, as P day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverate verification. X do hereby certr the that the information provided aoove as arae arem, Gul 1 : _ „�+_- I/ -0,3-/(o official use only. Do notwrite in t1lis area, to be completed by city or town official. Permit/License # City orTown' Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Tuspector 6. Other Phone #- Contact Person: °The Commonwealth of Massaehusetts _ Department of IndustrialAceldefats F X Congress, Street, S-iite 100 Boston, NIA 02114-2017 wV w mass.gov/dia Workers, Compensation Insurance Affidavit: Builders/C�n UTHO 5��. tricians/Pl>zmbers. TO BE FILED WITH THE PERMPI TAV Name (Business/(5igavization/Individual): Address: Z 45 r City/State/Zip: Axe yon an employer? Check the appropriate box: 1. lam a employer with employees (full and/or part time).* 2.0 I am a sole proprietor or partnership andhave no employees VVorkiag forme in any capacity. [No Workers ' comp. insurance required.] 3. ❑ lam a homeowner doing all work myself. [No workers' comp* insurance required.] t 4.I]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 proprietors with no employees. s. ❑I am a general contractor and I have hired the sub -contractor listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurauce.t 6. F] We are a corporation and its, officers have exercised their right of exemption Per MGL c. 152 ees. [No workers' comp. insurance req § 1(4) and ive have no employuired.] v /4 Type of project (required); 7. 0 Nd-W'd6nstr6ction g, �emodeliiig . 9. [l Demolition 10 0 Building addition 11.0 Electrical repairs or additions 12T[ Plumbing repairs or additions 13•. [] Ro6f repairs 14.0 Other icy *Any applicaut that checks bbat#1 must also till out the are doing all work andthen hire outside w showing their workers' aontracto�s must submit new affidavit indicating such. I Romeo wners who submit•tbis affidavit indicating they tCmtractors that check this fiox must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. compensation insurancefor my employees..Below is the policy and job site X am an employes flint is ps oviding workers' information. ` C/ Q Insurance Company Name: v • -- � O — :?— I — / 7 ExpirationDate_ Policy # or Self -ins. Lic. t��7 /] / Cl(N ! V L N City/State/Zip: lob Site Address: li �' Attach a copy of the workers' policy declaration page (showing the policy number an expiration date). e by a ae up to 0.00 Failure to secure coverage as required and MGL c. form ofis a STOP WORK ORDERal violation Iand tine f up to $200.00 a and/or one-year imprisonment, as P day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverate verification. X do hereby certr the that the information provided aoove as arae arem, Gul 1 : _ „�+_- I/ -0,3-/(o official use only. Do notwrite in t1lis area, to be completed by city or town official. Permit/License # City orTown' Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Tuspector 6. Other Phone #- Contact Person: 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 receivet'or• trustee Qfan 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 ofthe' 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 xequired" 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 certificates) 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 au 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 Iudustrial-Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please ca11 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 burn 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 wwwmass.gov/dia � 1 ass=.husetts _ Department of Public Safety `s Board of Building Regulations and ;Standards i l#1i li t1� LIi/1! .31s V I License: SCS -0862 ELIEL A DASILVj 11 EARL" AVE MEDFORD MA 159 dS XA t, IAN EX pi ration Ccfrunissioner 1'3QI2.016 1 s}4. A: F ��� ZJ�?,.G�YlfiG'-G'�L��• f.1' ����f�:�:1CtC�2{t.��,�- *: . "Office of Consumer Affairs & Business Regulation dOME IMPROVEMENT CONTRACTOR `. egistration: 183570 Type: xpiration: ".'10126/2017 Corporation E & C CONTRACTING LLC.,:+ " ji ELI'EL DASILVA - 24 KINGSTON NORTH ANDOVER, MA 01845 Undersecretary Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ I -[- OF SEWERAGE DISPOSAL 77YPE Public Sewer ❑ Tanning/MassageBody Art F]Swi,rming pools El Well ❑ d Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGNOFF- U FORM PLANNING & DEVELOPMENT Reviewed On Signature. COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on I1'I ' [W S COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments 41 Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 364 Usgooa Street FIRE DEPARTMENT' : Temp Dumpster on site yes no Located.at 124; Main Street Fire Departinentsignature/date< _ .. + �` r =` COMMENT limension Number of Stories: Z— Total square feet of floor area, based on Exterior dimensions.2,n� o� Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service droprequires approval of Electrical Inspector Yes No DANC=ER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use) W. l/ 7 1 oZ. Vj ❑ Notified for pickup Call Email ate Time Contact Name Doc.Building Permit Revised 2014