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Home My WebLink AboutBuilding Permit #387 - 2125 TURNPIKE STREET 11/13/2006 TOWN OF NORTH ANDOVER T►� APPLICATION FOR PLAN EXAMINATION of r10RiOR t Permit NO: 3Date Received C"`�: , Date Issued: �f/ ��SS�cHuSE�� IMPORTANT: Applicant must complete all items on this page LOCATION 2— � Print PROPERTY OWNER 2P Print// W / G�— MAP NO.: PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building t2,0ne family edition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: C Repair, replacement p � p ❑ Assessory Bldg ❑Commercial Demolition Moving(relocation) ❑ Other ❑ Others: Foundation only DESCRIPTION OF WORK TQ BE PREFORMED Identification Please Type or Print Clearly) OWNER: Name: ��1� ,��1c1 J U(/� � Phone: 11V7 7k Z 7026 Address: CONTRACTOR Name: Phone: ?� f1ZF�� Address. Supervisor's Construction License: Exr. Date: ?Z� 24_ Home Improvement License: 106?(�p-7 Exp. Date: -212-7 WO?-- ARCHITECT/ENGINEE IlWhb Name: Phone: Address: Reg. No. FEE SCHEDULE.BULDING PFR. IT.•512 00 PER 8'1000.00 OF THE TOTAL ESTIMATED COST BASED ON 5125.00 PER S.F. Total Project Cost :$_TJ,-4--f�� FEE:$__ Check No.: i ��'� ��' P Recei t No.: Page I U4 TYPE OF SEWERAGE DISPOSAL Swimming Pools E,_I Tanning/Massage/Body Art El Public Sewer Tobacco Sales ❑ Food Packaging/Sales Well Permanent Dumpster on Site Private(septic tank, etc. Electric Meter locatio to project NOTE: Persons contracting with unregistered contractors do not have access to lif*ef,,nf fund Signature of Agent/Owner Signature of contract Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ ns ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS T REJECTED DATE APPROVED CONSERVATION COMMENTS No fill DATE REJECTED DAT PPROV HEALTH ❑ ❑ q) 1 COMMENTS y v a ra w 4�' FIRE DEPARTMENT - Temp Dumpster on sit ryes n no Fire Department signature/date COMMENTS Zoning Board of Appeals: Variance, Petition No: "Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer connection/Signature& Date Driveway Permit I Building Setback ( Front Yard Side Yard Rear Yard Required Provided Re uired Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA— For department use Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created AT Jan-2006 I Building Department artment 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 Addition Or Decks ❑ Building Permit Application ❑ Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) 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 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:INSPECTIONAL.SERVICES DEPAUNIEN'r:BPPORN105 Page 4 of 4 Location /C)S 7"J��,oj t p No. 33f Date NORTH TOWN OF NORTH ANDOVER F P t Certificate of Occupancy $ + s a <�' Building/Frame(Frame Permit Fee $ ss+cwuse 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 01 19791 Building Inspector t AORTH own of No. 3 9 07 b O 0; C% over, A COC HICHEW/Io I's RATED PPS` Co BOARD OF HEALTH Food/Kitchen DSeptic System PERMIT Wok 'k.3 BUILDING INSPECTOR THISCERTIFIES THAT.......... ............h........................................5.................................................................................... Foundation has permission to erect........................................ buildings on .lar.....TV ................. Rough to be occupied as........ ..%a . M1/�...... ......�ir.0.,Q�a/►... .� � �r�/ .��..�i/.�.. Chimney provided that the pers pting this arm d shall in every respect conform to the terms of the application on-Mein Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRU TS Rough ........ .. .................. . Service .. ..... ...... ....... BUILDING INSPECTOR Final Occupancy Permit Required to Owipy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. W7 A DESIGN & CONSTRUCTION, Inc. 309 Pearl Street 781-944-0202 Reading,MA 01867-1352 douglassdesign@comcast.net October 31, 2006 Mr. John and Mrs. Heidi Watters 2125 Turnpike Street North Andover, MA 01845 978 258-7072 watterlu _comcast.net jwaters _GPlnet.com Re: Specifications for Remodeling Project at 2125 Turnpike St. N. Andover. Douglass Design and Construction Inc. submit for our consideration the following proposal 9 9 Y 9p p for the construction services you requested. The details of the proposal are given in the specifications below in conjunction with the drawings by Twomey Design 10/23/2006 sheets 1_—9 and structural sheet S1 of 1 by Daniel Webb P.E. Thank you for your consideration of Douglass Design and Construction, Inc. We look forward to working with you on your remodeling project. Please feel free to call with any questions regarding this proposal. Project Specifications General 1. .Owner will remove and,relocate all personal items that are to be maintained. DDC will assist.in moving large items. 2. Owner realizes that a project of this magnitude will disrupt living arrangements. DDC, Inc. will make reasonable attempts to mitigate such disturbances and holds no liability withstanding. 3. Due to the nature of remodeling and issues at the interfaces between the new and old structures, unforeseen or concealed items may cause additional design and construction costs to be incurred. These items will be discussed with the owner as soon as possible and the owner should maintain a reasonable contingency for such items. 4. DDC will make provisions for maintaining a clean work site and confine material to the affected work area. Dust and dirt will migrate to all corners of the existing house. MA LIC #CS031962 MA HIC #106767 4 . � ® � Or'DESIGN & CONSTRUCTION, Inc. 309 Pearl Street 781-944-0202 Reading,MA 01867-1352. douglassdesign@comcast.net Final dusting and clean up of the house including the addition will be the responsibility of the owner. DDC, Inca will remove all construction debris and leave the job site broom clean upon completion. 5. Owner realizes that the coordination of this project is critical and will make all reasonable attempts to provide requested decisions and information as,soon as possible to the contractor. . 6. Access to the site will be over the front lawn. The front lawn will be damaged during the project due to the impact of heavy.trucking. Reconstruction of the lawn is the owner's responsibility and.is not included in this contract. 7. Access to the construction site will be via the owner's driveway. All necessary construction equipment and delivery equipment will access the site in this manner. The driveway may incur damage, the repair of which is wholly the owner's responsibility. There are no provisions or allowances in this contract for repair of any damage. Plans and Permits 1. DDC will compile owner provided plans and file permit. 2. Owner to provide check for permit fee. The fee is payable via a check to "The Town of North Andover". This permit fee is not included in the contract price. 3. Owner to provide plot plan. Site Work 1. Layout site for excavation. 2. Excavate and remove unnecessary fill materials to provide for the construction of foundation as per the plan. 3. Backfill foundation with materials reserved on site for such and rough grade around the foundation area. 4. Final grading and landscaping is not included in this contract. Page 2 of 5 MA LIC #CS031962 MA HIC #106767 DESIGN & CONSTRUCTION, Inc:- >a 309 Pearl Street 781-944-0202 Reading,MA 01867-1352 douglassdesign@comcast.net Foundation 1. Provide new concrete foundation per plan for addition at left side of the existing house. 2. Cut access door through existing house foundation into new addition at workshop. 3. Foundation to be poured with 10."x 20"concrete footing, 10" concrete walls. All concrete to be 3000-psi minimum. 4. Waterproof exterior of foundation from footing to grade. 5. Install$/4" stone to top of footings in basement area and compact under slabs. 6. Pour 4" concrete floors in basement area to be smooth trowel finish. 7. Slabs to have#10 6x6 wire mesh reinforcing over poly vapor barrier. Frame and Exterior 1. Provide and install all framing elements as detailed on plans-to.construct addition and interior frame elements. 2. Provide and install exterior trim to match existing house, i.e. rakes, fascias, soffits, mudsills, and corner boards. 3. Provide and install Anderson Tiltwash Series (vinyl and break metal as required) windows according to the plans. Windows to have fine line between the glass grills, screens, and white hardware. All windows to be ordered pre-finished white interior and exterior as available from Anderson. Other window options or grill configurations are available at owners' request and will be at additional cost. 4. Provide and install new roofingon addition to match existing, including flashing, ice 9 9 9 and water shield, etc. Strip and re-roof entire house using new architectural style shingle. 5. Frame interior elements of family-room access opening per plans. 6. Provide and install new"4" Clapboard Style" vinyl siding on addition and existing house. 7. Provide and install new Aluminum gutters and downspouts on addition with underground leader tubes for drainage. 8. No exterior painting is included in this contract. Interior General 1. Frame interior elements per plan 2. Demolish and remove existing interior elements as required for construction. Page 3 of 5 MA LIC #CS031962 MA HIC #106767 DESIGN & CONSTRUCTION, Inc. 309.Pearl Street 781-944-0202 Reading, MA 01867-1352 douglassdesign@comcast.net. 3. Provide temporary dust barriers, keep site broom clean, remove all trash to barrels or on site dumpster. As stated in General conditions, DDC, Inc. is responsible for removal of all construction debris from the site. 4. All area indicated for painting will be; walls to be primed and painted two coats, ceilings to be two coats, woodwork primed and painted two coats. Interior Details Basement Below Family Room [Workshop] 1. Provide concrete floor with smooth trowel finish. 2. Provide and install double steel door to exterior area under the deck. 3. Provide and.install four(4) keyless lamps and four (4) outlets. 4. Provide cut-through access to existing basement with new door. 5. No trim, plaster, heat, etc are provided in this area. Family Room 1. Provide an enlarged opening_ into the dining area with opening maximized, half wall, and columns. 2. Ceiling to have recess lights and ceiling fan. Ceiling fan provided by the owner. 3. Provide and install insulation for the walls — R-19, and floor and ceiling R-30. 4. Provide and install all wiring for outlets, switches, cable TV, CAT 5, and speakers. 5. Plaster walls and ceiling smooth. 6. Provide and install paint grade trim for windows and doors to match existing 2 Y2" Colonial casing. 7. Rework the heating loop on the existing zone to extend into the new room. 8. Finish flooring.is not provided in this contract. (Owner plans to carpet room on completion on contract work.) Exterior Details Rear Deck 1. Provide concrete footings on "Big Foots" 2. Construct frame with pressure treated lumber elements. 3. Provide and install decking—composite plastic"Fiberon" or equivalent. " 4. Provide railing - composite "Premier Rail" 5. Construct one set of wooden steps with composite treads to"grade. 6. No lattice under deck. Page 4 of 5 MA LIC #CS031962 MA HIC #106767 DESIGN & CONSTRUCTION, Ing. Pearl Street _ _ 309 781 944 0202 Reading, MA 01867-1352 douglassdesign@comcast.net Utilities 1. All electrical circuits are to be provided from existing electrical service. If an additional sub-panel or service upgrade is required or requested, additional costs will apply. 2. All heating will be provided off of existing heating systems. DDC, Inc. will provide required plumbing and ductwork for renovated area as required. Total cost of products and services per drawings and as listed in the specifications given above. $ 94,741.00 Payment terms are on the attached "Payment Schedule". Thank you for your conside.ration of this proposal. Respec Ily, uglass E. Webb,President Douglass Design and Construction, Inc. Owners Accept noe: Date: 37 Q John W tt s r . Heidi Watters Page 5 of 5 MA LIC #CS031962 MA HIC #106767 it PLAN OF LAND IN NORTH ANDOVER, MASS. OWNED BY JOHN AND HEIDI WATTERS Scott L. Giles R.P.L.S. Frank. S. Giles R.P.L.S. SCALE: I"=40' DATE:10/10/2006 50 Deer Meadow Road 1023/2006 North Andover, Mass. TURNPIKE STREET 150.00' THE ZONING DIST. IS R2. 150'FRONTAGE 43,560 S.F.AREA 30'SETBACKS ALL AROUND. tw Oi �o � y 72 It uao la v��b 53' #2125 Exisr. O 47' HSE. PROP. FND. FAM/LY N 51' ROOM N PROP. DECK N 16, M cfl M LOT 5 LOT 4 LOT 3 PLAN 41607A LANDCOURT CONFIRMATION N �t I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE THE OFFSETS OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE WITH THE ZONING DETERMINATION OF ZONING BYLAWS OF CONFORMITY OR NON-CONFORMITY WHEN CONSTRUCTED. WHEN BUILT Permit Number REScheck Compliance Certificate Checked By/Date Massachusetts Energy Code REScheck Software Version 3.6.Release 1 Data filename: Watters.rck PROJECT TITLE: WATTERS RESIDENCE CITY:North Andover STATE: Massachusetts HDD: 6322 CONSTRUCTION TYPE: 1 or 2 Family, Detached HEATING SYSTEM TYPE: Other(Non-Electric Resistance) WINDOW/WALL RATIO: 0.22 DATE OF PLANS: 10.23.06 PROJECT DESCRIPTION: 2125 Turnpike Street North Andover, MA DESIGNER/CONTRACTOR: �FgEo A Nancy J. Twomey � =CY J. ` Twomey �Desi Associates 23 California Road c Reading, MA 01867 EADiNG A �COMPLIANCE: Passes ,��Of Maximum UA= 88 Your Home UA= 85 3.4%Better Than Code(UA) Gross Glazing Area or Cavity Cont. or Door Perimeter R-Value R-Value U-Factor UA Ceiling 1: Cathedral Ceiling(no attic) 352 30.0 0.0 12 Wall l: Wood Frame, 16" o.c. 513 19.0 0.0 24 Window 1: Wood Frame:Double Pane with Low-E 51 0.330 17 Door 1: Glass 62 0.330 20 Floor 1: All-Wood Joist/Truss:Over Unconditioned Space 352 30.0 0.0 12 COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the Massachusetts Energy Code requirements in REScheck Version 3.6 Release 1 (formerly MECcheck) and to comply with the mandatory requirements listed in the RES check Inspection Checklist. The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125%of the design load as specified in S 'ons 780CMR 1310 and J4.4. Builder/Designer ` Date J � din Re gulat'onsan tan ar�YYoBui g One Ashburton Place - Room 1301 a Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 106767 Type: Private Corporation Expiration: 7/27/2008 DOUGLASS DESIGN & CONSTRUCTION, I ---_. Douglass Webb ----------- 309 Pearl Street Reading, MA 01867 Update Address and return card.Mark reason for change. Address 'E] Renewal Employment Lost Card DPS-CAI ai 5OM-04/05-PC8698 Board of Building Regulations One Ashburton Place, m 1301 Boston, Ma 02108-1618 License: CONSTRUCTION SUPERVISOR LICENSE Birthdate: 10/23/1963 Number: CS 031962 Expires: 10/23/2007 Restricted To: 00 DOUGLASS E WEBB 309 PEARL STREET READING, MA 01867 Tr. no: 5409.0 Keep top for receipt and change of address notification. DPS-CAI 0 50M-04/05-PC8698 v TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION yORTI� Cftt��o '6�4'O i � A 9 Permit NO: Date Received ,SS�cNus�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION- 212-5 (u KN PIKG ST N , )fN-WN eyz, P nt /� PROPERTY OWNER �O fR= TT-z�2 Print MAP NO.: PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building N16ne 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 A-MmA t %tm a Identification Please Type or Print CI arly) T IfMT- 7a2o OWNER: Name: J MAa _�5 Phone: q�g ��J Address: //1 tis- �� wpi r,� Aw)weg., /r tA-::: CONTRACTOR Name: Po� e: Address: 30 Supervisor's Construction License: 0 Exp. Date: 0 Home Improvement License: to � 6 Exp. Date: ? 17,117,008 ARCHITECUENGINEERTWOMEN I-D,WmName: Phone:i�ri q 4D 475�_ �sL 'ZZ —1 33� Address: �t eg. No. 1/'V FEE SCHED ULE:B ULDING PERMIT-$1200 PER$1800.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost :$ 7�7. 06 x 12.00=FEE:$ Check No.: Receipt No.: Page lof 4 TYPE OF SEWERAGE DISPOSAL Swimming Pools ❑ F1 Tobacco Art E]Public Sewer Tobacco Sales ❑ Food Packaging/Sales ❑ Well ❑ ElPermanent Dumpster on Site Private(septic tank,etc. Electric Meter loc n to proj ect _ r� NOTE: Persons contracting with unreris!ereY contractors do not have access to the ra ty fund Signature of Agent/Own Signature of contrac Plans Submitted ed PI ns Waived ❑ Certified Plot Plan Stped Plans / Ad' THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM DATE REJECTED DATE APPROVED PLANNING& DEVELOPMENT ❑ ❑ ❑Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning p Board of Appeals: Variance,Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water&Sewer connection/Signature&Date Driveway Permit Temp Dumpster on site yes—no— Fire Department signature/date ACtxRD CERTIFICATE OF LIABILITY INSURANCE OP ID JDDATE(MkVDDh'YYY) DOUGLAS � 08/22/06 PRorJucER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE Waverley Insurance Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 493 Trapelo Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Belmont MA 02478- Phone: 60-484-5216 2478-Phone: 60-484-5216 Fax:617-489-4626 INSURERS AI'FORDINGCOVERAGE !NAIC# INSURED -------'---- _ IN,3UREF:A }f;in0'VGr Insurance Co an 2292 -- IN61JP.EF'B Arbella Protection Snsuxmce -- — Dougids Design & Construction INSUkthC Merican rnternational Cs Pmy 309 Pearl Street NgUREF.D L Reading MA 01667 ----.------ —_..---- —_-- _--- If4StIRER E COVERAGES 7H�ICIFS OF INSIIRAN(;F I ISTFR RIF1,0'JI HAVF RFFI`ISnIIFO TO THF NS!IRF I)NAMFO AR(TJF FOR THF POI iCY FFRIOTI INrI!CATFD NOTWITHS1AND IN6 I NVY Ht;JUIRLMEN I ILRM CH CONUI IION OF ANY CCMr'IHAC I OH O Hti:UUGUI+aNI\AII I H HES'tC I IU WH!CH IHIb GER IIFICAIL MAY HE bSUEU CMS KAY PERTAIN -HE IV3URANCE AFFORDED BY THE P0_ICI ES DESCRIBEC HEREIN IS SUBJEC-TO ALL THE TERMS EXCLUS ON5 AND CONDI-IONS�i-SUCH POLICIES AGGREGATE LIMITS GI IOWN NtPN IIAVC DCCN F:CDUCID DY PAID•C1tiIV3 POCILY EFFECTIVE CLICYEY,FM1M --- ---- LTR NSR _ TYFE OF INSURANCE POLICY NUMBER DATE(MMIDDIYY) DATE IMrNX!YY)� LIMITS GENERAL LIABILITY �— EACH OCCUMENCE 1,000,000 � 13 X CDtOMERCIALGENERALUASILIT� 85500028155 Of/O6/06I OEf06/07 FFEh�S'�i,,"�E',g=0n,'�ce) X50,000 E — --- - CL''.IPS MADE X ')CC.UR ' IJED EXP(Ant+gnu-o s n 5 i _ 1 �' � r_'��) 5,000 PL-RSONAL L ADV INJURY S 1,000,000 -- ; i �JE!VEP.AI-AGGREGATE ti 2,000,000 i GENT AGGREGATE LIMIT APPLIES PER PP.UDLI,To COMP I O -- ------- I I ;OP?.GG � 1,000,000 POLICY , ' i PRO- -- JECT LOC i AUTOMOBILE LIABILITY I i AFN840619 j GUMbINEU SIrJG.t,;Mli s A I ANYA(I-° 2 08 '11 06 OS 11 07 (Ea,3061-0t1 N.ALL OW`dE-D AUTOS 1 SOCJLY INJURE 250,000 i X I SCHEDULED AUTOS l'erp2rsJn) X HIREDA.UTOS IEGCILY INJURY' }{ NON-OWNECkUT04 I I(Pm'acr.ideng >500,000 PROPERTYDAMAGE (�araccicel ) 100,000 GARAGELIABILITY ----- r—' I I AUT'J CNLY-En ACC'DEtJ? !5 i I .ANY AU-0 CA T- 1 01HER THAN AUT'DONLYA I I EXCESS/UttIBRELLALJiBILI?Y i I EACHOCCUNRENCE I I I I i JC:C:UR U CU,Ih'.Sr+Pllt A(:CHEGA;It I S IL is DEDUCTIBLE I RE-ENT ON $ WORKERS CONWENSATiONAND TOR;1IIJi75 II j EMPLOYERS'LIABILITY C I ANY+'RUPRItIMF'P.RINtR/tXtCUllht WC8938125 02/27,/06 02/27/07 F I FACHAt:CiDFnT _ S 100000__ i OFFICERIMEIABER EXCLUDED? I CISEAS_F.EA Eh;r-L�J"rLJ, 100000 If yes,deser'heunder I SFECIAL PROVISIONS blim �E L,DISEASE;POLICY UbPT]Z500000 --JOINER I DESCRIPTION OF OPERATIONS]LOCATIONS IV I LES!EXCLUSIONS ADDED BY ENDORSENIENTJ SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BC CANCELLED BEFORE THE EKPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL iJohn Watters IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 2125 Turnpike Street REPRESENTATIVES. North Andover MA 01845 AUTHORIZEDRFPRESFNTATIVE Haril, n ImRoc:ca _ ACORD 25(2001108) C ACORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Please Print Name: Location: City Phone 0 am a homeowner performing all work myself. 01 am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. rr Company name: Address City: A KA- Phone#: Insurance Co. Polic # WC 8 ,� Company name: Address City: Phone#: Insurance Co. Policy# Failure to secure cover a as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'im iso ment as well as civil penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. I understand that a o y o this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do herby cert' u d the pains aEke ninformation provided above is true and correct. Signature Date LO 17,4/7-40 Print nameRI? Phone#�a Y4-616 - Official use only do not write in this area to be completed by city or town official' ❑ Building Dept ❑Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone#: ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION