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Home My WebLink AboutBuilding Permit #923-2016 - 219 FRENCH FARM ROAD 2/29/2016PermltNO: Date Issued: TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 'ANT: Applicant must complete all items on this LOcATioN 219 Z, H I I Print Print MAPNO:0��_PARCELP*� ZONINGDISTRICT: Historic District yes Machine Shop Village yes (0 100 year-old structure yes 49 a TYPE OF IMPROVEMENT 0 New Building 11 Addition 11 Alteration ,IR, -Repair, replacement 11 Demolition PROPOSED USE Residential El One family 0 Two or more family No. of units: D Assessory Bldg El Other Non- Residential 0 Industrial 0 Commercial 0 Others: 11 Cr C s c Lh0YPP.1AjD:'-,L9 - -It�` - DESCRIPTION OF WORK TO BE PERFORMED: S4M- — Ala It, C A-61AJ&7-1 _0AU,AJ-/Z= (Identiflcation Please Type or Print Clearly) OWNER: Name: -J-( JS1 /,AJ A VE f Address: 2J 9 F kY---1Vci+ GqR & go -41il9uu X CONTRACTOR Name: b A A� RE- M NA Mtsn& ---Phone: AIF- 9 62, 3? G) Address: qY Xb-bllokQ A ua /ra- a.4 t)&Ai Supervisor's Construction License: (0 el 3 Ll ---Yxp. Date: 9 -K-(7 Home Improvement License:. 9 (a Exp. Date: 9-/7-(7 ARCHITECT/ENG I NEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT. $1Z00 PER $l000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125-00 PER S.F. Total Project Cost: $ 56 2 6-J FEE: 095 Check No.: Receipt No.: _C?�,Cz NOTE: Persons contra'cting with unregistered contractors do not have access to the guarantyfund 2 �ri Location No. Co Date Check #q�-i 7 ') TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee TOTAL $ Building Inspector Plans Submitted 11 Plans Waived 11 Certified Plot Plan El Stamped Plans El TYPE OF SEWERAGE DISPOSAL Public Sewer El Tanning/Massage/Body Art E] Swimming Pools Well El Tobacco Sales El Food Packaging/Sales El Private (septic tank, etc. El Permanent Dumpster on Site F1 THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATEAPPROVED PLANNING & DEVELOPMENT El El COMMENTS CONSERVATION Reviewed on Si-qnature COMMENTS HEALTH Reviewed on Simature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit - DPW Town Engineer: Signa Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date 77� 02 oe -VOL COMMENTS 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.$10041000 fine NOTES and DATA — (For department use) Ll Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi 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 /Buil"ding Permit Application orkers 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 Li Workers Comp Affidavit • Photo Copy of H.I.C. And C.S.L. Licenses • Copy Of Contract Li Flo o, rlCrossectio n/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) Li 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 NOTE: All dumpster permits require sign o*ff 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 imust be submitted'with the building application Doe: Doc.Building Permit Revised 2009mi Enter construction cost for fee cal - North Andover Fee Cakuiation Construction Cost $ 56,250.00 rn $ - $ 675.00 Plumbing Fee $ 84.38 -Gas Fee 100 comm. $ 100.00 Electrical Fee $ 84.38 Total fees collected $ 943.75 219 French farm Road 923-2016 on 2/29/2016 Kitchen Remodel 0 z o CL SU = CL > cc 0 00 C < Q ID CL C7 CID 0 CD CL 0 S' = to CD CD 0 9-*, 0 n rU7 0 0 CD CD 3 (1) m 0 z 0 (D a 0 m 0 A L7 -- zs:*� a Z r, m m .cf) 0 .0 M z m Cl) 0— Z z .C.0 0 c): C/) -0: m 0 0 Cl) < 00-R a -q 0 0 rr U) Ma CD r -L co) o 2 ;mo z 0 0 CD 0 0 r.L 0 =r -h =R CD CD 2) CO) COD 0 CL 0) a > 0 Cl) --I cc CL to U) r -IL 0 0 S cQ) CD CD S. 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Andover, MA We hereby purpose to furnish the materials indicated and perform the labor necessary for the completion of Is' floor renovation (See specifications sheet) All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifications submitted for above work and comvletion in a substantial workmanlike manner in the sum of lusand two hundred fifty dollars -$56 Payments to be made as follows: S 1,000.00 Upon execution of contract. $10,000.00 When work begins. Remaining payments as work progresses. Respectfully submitted: Darien Martino-' Any alteration or deviation from the above specifications involving extra costs will be executed only upon written order, and will become an extra charge over and above the estimate. All agreements contingent upon accidents, or delays beyond our control. Note -This proposal may be withdrawn if not accepted within 10 days. Proposal Date 01/29/16 ACCEPTANCE OF PROPOSAL The above prices, specifications, and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Date: L ti- ik Signature:_ Date:- Signature: DO NOT SIGN THIS CONTRACT JIF THERE ARE ANY BLANK SPACES 12:217. 'C'"- DM Construction ha-racter of yesteryear. Building with the QUALITY and C 44 Addison Ave Ext. Methuen, MA 01844 (978) 685-3037 Estimate Submitted To: Justin & Jody Hayes Construction Supervisors License 66342 219 French Farm Rd. Home Improvement Registration 124961 N. Andover, MA We hereby purpose to furnish the materials indicated and perform the labor necessary for the completion of Is' floor renovation (See specifications sheet) All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifications submitted for above work and comvletion in a substantial workmanlike manner in the sum of lusand two hundred fifty dollars -$56 Payments to be made as follows: S 1,000.00 Upon execution of contract. $10,000.00 When work begins. Remaining payments as work progresses. Respectfully submitted: Darien Martino-' Any alteration or deviation from the above specifications involving extra costs will be executed only upon written order, and will become an extra charge over and above the estimate. All agreements contingent upon accidents, or delays beyond our control. Note -This proposal may be withdrawn if not accepted within 10 days. Proposal Date 01/29/16 ACCEPTANCE OF PROPOSAL The above prices, specifications, and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Date: L ti- ik Signature:_ Date:- Signature: DO NOT SIGN THIS CONTRACT JIF THERE ARE ANY BLANK SPACES 12:217. 'C'"- HA YES RESIDENCE Specirications Sheet GENERAL SCOPE OF WORK Renovation of Pfloor including: kitchen renovation, bathroom renovation, new doors, newflooring, etc. PERMITTING DM Construction willfile all necessarypaper work to obtain thefollowing permits: building, electrical, plumbing, gas, and debris removal. The cost ofall permits and fees necmar X is not included in this estimate and will be billed soaMLejl. SITE PREP In an effort to limit the dust jzeneratedjrom the renovation process. Doorways and openings to other areas ofthe house will be sealed offwithin reason with plastic or drop clothes. DEBRIS REMO VAL DM Construction is responsiblefor all debris generated. A container will be placed on site to ensure a clean work site. The container isfor debris generated by DM Construction only, it is not intendedfor homeowner use. DEMOLITION Kitchen — Remove existing appliances, countertops, plumbingfutures, and tile backsplash. Powder room — Demolition offixtures andflooring. General — Removeflooring in the kitchen, ftont hallway, and great room down to the original sub -floor. Remove all interior door units. Remove baseboard in the kitchen, ftont hallway, Y2 bath, and great room. Remove one side of cased openings to the living room(playroom) and dining room. FRAMING Enlarge pantry closet door openingfor larger door i(possible. DR YWALL All existing drywall will remain as is. This estimate does not include any drywall or plaster. FINISH WORK Installation offive (5) new interior door units on the Pfloor. All new door units to match the 2ndfloor existing door units. Installation ofnew baseboard in the kitchen, ftont hallway, Y2bath, and great room. Installation ofnew casings on one side ofcased openings into dining room and the living room(playroom). CABINETRYREPAIRSIUPGRADES Installation ofnew cabinet hardware (pulls & knobs only). The cost of the hardware is the responsibility ofthe homeowner. The existing hinges and drawer glides will remain as is. Installation of new toekick and baseboard around the cabinet bottoms as necessary. Modify cabinet to accommodate new refrigerator. Reinforce miscellaneous cabinetry as necessary. HA YES RESIDENCE Specifications Sheet APPLL4NCE INSTALLA TION DM Construction will install thefollowing appliances: reftigerator, dishwasher, range, microwave, andgarbage disposal. Ifthe microwave has a built in exhaust, it will only be vent to the exterior if it can connect to the existing duct work. The cost and deliverE oLthe appliances is not included in this contract and is the L,�s 2onsibili�y oLthe homeowner. PAINTING Kitchen —New trim will be primed and receive two coats offinish. Walls and ceiling will receive two coats offinish. Kitchen cabineLa —The existing kitchen cabinetry will be painted asfollows: alldoors and drawer heads will have their hardware removed, holesfilled & sanded, primed, and receive two coats offinish. All cabinetfaceftames will be sanded, primed, and receive two coats of finish. All the baseboard, fascia, and moldings will be sanded, primed, and receive two coats of finish. "Note: The interior of all cabinetry, including but not limited to the drawers, shelves, cabinet box sides & rear, etc will not be painted, they will remain as is. Bathroom —New trim will be primed and receive two coats offinish. Wallsandceiling will receive two coats offinish. Great room —New trim will be primed and receive two coats offinish. Wallsandceiling will receive two coats offinish. Front halllstairwelllu pstairs hallway - New trim will be primed and receive two coats of finish. Walls and ceiling will receive two coats offinish. All stairparts (risers, skirts, balusters, etc.) currently painted will bepainted two coats offinish. All stairparts (newelposts, handrails, etc.) currently stained will be lightly sanded and receive 3 coats ofpoly. Note. This estimate does not included any painting in the dining room, sunroom, or living room (playroom). HVAC Add register(s) as possible to cool sunroom. PLUMBINGMEATING Demolition — Disconnect and remove allplumbingfixtures and appliances in the kitchen andpowder room. Kitchen — Provisionsfor and installation of thefollowingfixtures: one main sink, one garbage disposal (on an air switch), one dishwasher, one dualfuel range, and a recessed boxfor the reftigerator ice maker with a no burst hose. Powder room — Installation ofa new toilet with a new shutoff. Installation ofnew sinklfaucet with new shutoffs. Installation ofnew baseboard heat covers. All Plumbine r"tures includine: sinks, faucets, etc. are covered under the Plumb Fixtures Allowance HA YES RESIDENCE Specirications Sheet ELECTRICAL Appliances-Provisionsfor thefollowing appliances: refrigerator, dishwasher, range, microwave, and garbage disposal, All new appliances to be GFUIAMprotectedas required. Powder room — Installation ofa new lightfixture. Installation ofnew GFI receptacle. Install of a receptacle in the closet. This estimate does not include at& recess 1 his, under cabinet I ht pedants, etc. !Ldesired & -ig_ these will incur extra cost. This estimate does not include aa work on fire protection (Smokies, CO2, etc) NOTE: The cost ofall recess 1�ghting, pendant lightigg vanq lights, under cabinet, in cabinet, accent lLyhts, ceiling fixtures, exhaust fans, coach lights, etc is covered under an allowance. TILE SETTING Powder room — Installation ofnew subfloor (hardibacker) on floor. Installation oftile on thefloor. The cost of the tile, grout, sealers, enhancers, etc. is covered under theflooring allowance. The costfor materials and labor ofthe backsplash is covered under the tile backsplash allowance. HA YES RESIDENCE ALLOWANCES Thefollowing allowances are included in this estimate. The allowances exist to cover the purchase of materials only, unless otherwise specified. Any amount spent in excess of an allowance will incur extra cost. Any amount less than the allowance will warrant a credit. Upon completion ofthe project any extra cost or credits will be issued COUNTER TOPS - $ 7,500. 00 This allowance covers the cost ofall countertops and their associated template and installation costs. PLUMBING FIXTURES - $4, 000. 00 This allowance covers the cost ofallplumbingfixtures including but not limited to: sinks, faucets, soap dispensers, toilet, accessories, etc. TILE BA CKSPLASH - $1, 500. 00 This allowance covers the cost ofall tile, materials, and labor associated with installing, grouting, and sealing a tile backsplash. FL WRING - $11, 000. 00 This allowance covers the cost ofall materials and labor associated withflooring. This allowance covers the cost all materials and labor associated with work on the main stair case including, treads, risers, handrail, balusters, newelposts, skirting, etc. HA YES RESIDENCE MISCELLANEOUS Note.- Due to the nature of wood and the drastic temperature and humidity changes in our region, you may notice the movement and shrinking of theflooring and caerior and interior trim This is typical of the region and is not due to defective installation. Change Orders -A ny changesfrom the evisting plans or increased scope of work involving Wra costs will become an ectra charge over and above the contract price Changeorder agreements must be signed before any work commences. Thefollowing schedule will be adhered to, unless circumstances beyond our control arise.- framefar com etion: U%en demolition kegLn� (o conip ti!�n 8-9 weeks* Rl� pL_ _ _ fe *Subject to delays beyond our controL (le. delays associated with delivety ofproducts, customer change orders, etc.) All work to be done Monday-Ftiday between the hours of 7. 00 am — 6. 00 pm. If deemed necessary to work any other times, the homeowner will be consultedfirst. MEMBER OF THE BETTER BUSINESS B UREA U HOME IMPROVEMENT CONTRACTOR: 124961 CONSTRUCTION SUPERVISOR LICENSE CS066342 All home inWrovement contractors and subcontractors shall be registered. Any inquiries about a contractor or subcontractor relating to registration shall be directed to: Office of Consumer Affairs and Business Regulation Ten Park Plaza, Suite 5170 Bostot4 MA 02113 Phone: (617) 973-8700 C ME � MCD r 2 -3) LR)U;?)L9)- I 44 Addison Ave Ext. Methuen, MA 01844 (978) 685-3037 DM Construction Building with the QUALITY and Charactef of yesteryeat CONTRACTOR ARBITRATAION AGREEMENT The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a contractor however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The Contractor (Darren Martino) and the Homeowners (Justin & Jody Hayes) hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws, chapter 142A. Homeow-ner's SWA'Ure __Son�, Sipa&r-e 1 11 W.W. W 'r'��4 �i" 0 =q:N' q :) E ? 7�. - -.- q DM Construction Building with the QUALITY and Charactef of yesteryeat 44 Addison Ave Ext. Methuen, MA 01844 (978) 685-3037 NOTICE OF CANCELLATION January 29, 2016 You may cancel this transaction, without any penafty or obligation, within three business days from the above date Ifyou cancel, any property traded in, any payments made by you under the agreement, and any negotiable instrument executed by you will be returned within ten business daysfollowing receipt by the seller ofyour cancellation notice� and any securUy interest arising out of the transaction will be cancelled. Ifyou cancel, you must make available to the seller atyour residence, in substantially as good condition as when received, any goods delivered toyou under this agreement, oryou may ifyou wish, comply with the instructions of the seller regarding the return shipment of the goods at the seller's expense and risk. Ifyou do make th e goods available to th e seller an d th e seller does n ot pick th em up with in twenty days of the date ofyour notice of cancellation, you may retain or dispose of the goods without anyfurther obligation. Ifyoufail to make the goods available to the seller, or ifyou agree to return the goods to the seller andfail to do so, then you remain liablefor performance of all obligations under the contract. To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written notice to: NAME OF SELLER: DARRENMARTINO ADDRESS. 44 ADDISON AVE EXT METHUEN, MA 01844 NOTLATERTHANMIDNIGHTOF. FebruarP2,201 I HEREBY CANCEL THIS TRA ASCA TION Date: Buyer's Signature.. I (we each) ackn ies of this formL Buyer. 7170 Buyer: 324" Do Co CO LL Lm Ul) cli C� cm C\l c r) LL U� x cm x x cgo mw cl a: co _j cc 00 ccqo � C'n to C\j cc 0 x 0 co m co C9 0 V 0 cq C') W XmLnoo cvoco��- LO Cf) LLLL 0 OHY- 0 C9 co C o o aj C, co co -i b cr co O)o (L CL 0 Cl) — —LL co 0) a (06 (n 3:�: mca 3:3: �L-u �L-Ucn 0 m LA 0 LU co 64 6 �6 0 0 0 4 di 6 NN N N N N uj cli 0 00 co 0 CC -i U) Cc, Z) LU c 0 00 z 0 Z ui CL LU t m 0 �o �o LU Z CDO zo- �b (15 0 LLI UA Ul z 0 co D 0— 00 LL C\j z W Lu cr W LU oz cc z cc < IF C) cc u z LU w 0.2 , x ;2 ej Z U) z7 j X CO)l > LL LU r (01 7D I OL > co ,C FT L IN —.Pr—. L g a The Cominonwealth ofMassachusetts Department of In dustrlqlAccldii�ts Office of Investigations 600 Washington Street Boston., MA 02111 qu vww.mass.gov1d1a Workers' Compensation Insurance Affidavit: Builders/Contractoris/Electricians/Flumbers AppReant Information Please Print Legib NaMa (BusinessfOrgai�zatiorAndividual):bAegw HA/zrjA Address: Yq ADD/Jo/i fit -L city/state/zip: AcylloeN (F Al O/J�� Phona#: Are you an employer? Check the appropriate b ox- Typq of project (required): 1. D I am a �mployer with 4. F1 I am a general contractor and 1 1� 6. . E] New oon,structioa pmployces (fall and/or part-time.).* have hired the sub -contractors 7 . 2kfl am a sole proprietor or partner- listed on the attached sheet. T ._,NrKemodo�ng ship and'have no employees These sub -contractors have 8. El Demolition working for me in any capacity. workers' comp. insurand . o. 9. E] Building addition [No workers' comp, insurance 5. We are a corporation and its 10.[] Electrical repairs or additions required.] officers have exercised their 3. 0 1 am a hom cowrior doing all work right of exemption per MGL 11. D Plumbing repairs or adations mys elf. [No workers' comp. c. 152, § 1(4), and we have no 12.E] Roofrepairs insurance required.] employees. [No workers' 13F] other comp. msurance requiredJ 'Any applicant that cheoks box #1 must also fill out the section bel6w showing their rke ' compensation policy information. T Homeowners who submit this affidavit indicating they aic doing all work and then hire outside contractors must submit anew affidavit indicating such. !Contractors that check this box must attached an additional sheet showing the naincofthosub-contractors and their workers' comp. policy'inforination. I am an employer that isproviding workers' com 'pe7isationinsuranceforr,iyein,vloyees. Below isthepolley andjob site information. Insurance Company Name-. Policy 4 or Self -ins. Lic. 9: ExpirationDate: lob Site Address: city/statelzip: Attach a. copy of the workers' compensation -policy ileclaration page (showing the policy number and expiration date). Failure to secure coverage as requixedunder Section 25A ofMGL o. 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 fine of up to $250.0 0 a day against the violator. Do advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do h ere by �ertto n n der M e p a in s an dp en affles ofp erju ry th at A e inform a tion pro vided ah o v e is fra e an d c orre c I -n!9- / Phone 9: Off7cial use only. Do not write in this area, to he completed by city or town official CityorTown: Pernift/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 9: Information %nd ffustructRon'-s Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their enaployees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract. ofhiro,- express or implied, oral or wxitten," An employer -is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the -receiver or trustee of anmidividual, partnership, association or other legal entity, employing employees. However the. owner of a dwalling 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 lie-ensingagency 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 requ.ired." Additionally, MGL chapter 15 2*, §25C(7) states "Neither the commonwealth nor any of its political subgAions shall enter into any contract for the performance ofpublic work imtil acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' com pensation affidavit completely, by checking the boxes that apply to your situation and, if necessary� supply sub-contractor(s) 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 auLT—C orLLP does have. employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirm�ation of -insurance coverage, Also be sure to sign and date the affldavit The affidavit should be returned to the city or town that thic application for the, permit or license is being requested, not,tho Department of fndustrialAccidants. Should you have any questions regarding the law or ifyou 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 Eno. City or Town Officials -P-JeRse, -be sure -that-the affidavit -is -complete -and-printedlegibly. -- ------ -- -- a space at t P bottom of the affidavit for you to a out in the, event the Office of investigations has to contact you regarding the applicant. Pleas ' a 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 (ifnecessary) 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 maybe provided to the applicant as proof that a valid affidavit ii on file for future permits or licenses. Anew affidavit must be filled out each year. Where a homeowner or citizen is obtaining a license oip-ermit not related to any business or commercial venture (i.e. a dog license or p* armit to bum leaves etc.) said person is NOT required to complete this affidavit. The, Office of hivestigations'would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fay, number: Tho CQMM011malth of W-ass.achwed-9 Departmeut of faduMal Accideal.- Office of ramtigatioli�- 6QG Washiugtou ft�t B. 0 ston, M.A 02111 TQL # 617-72-7,4900, oA406 or- 1-87WASSAFE Revised 5-26-05 FaK # 617-727-7749 Cliantg- 9&qRnfi nARRFMARI ACOR& CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 1 TYPE OF INSURANCE 2122/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CER71FICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTERTHE COVERAGE AFFORDED BYTHE 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 endoreement(s). PRODUCER NAGmN`Er�cT Terri Younes LISI Insurance Services LLC-SCL PHONE FAX - (AIC, N,, E101: 855 874-0123 (AC. NOY 877-775-0110 103 Main Street E -MAL ADDRESS. terri.younes@usi.biz South Glens Falls, NY 12803 MED EXP (Any one person) $5,000 855 874-0123 INSURER(S) AFFMING COVERAGE NAIC 0 RER A � Nautilus Insurance Company 17370 GENERAL AGGREGATE s2,000,000 INSURED Darren Martino dba INSURER 0: INSURER C: D M Construction 44 Adison Ave Ext INSURER D: Methuen, MA 018" INSURER E: =R BODILY INJURY (Per accident) $ F: GUVEKA0E-3 CERTIFICATE NUMBER: REVISION NI]MRFR- 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 CONTRACTOR 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 INSR SUER WVD POLICY NUMBER POLICY EFF (MM/DDIYYYY)` POLICY EXP (MMIDDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY — —1 CLfidMS-MADE nX OCCUR X .131/13D Ded:500 NN610631 (1912=0115 0912112016 EACH OCCURRENCE $11,000,000 RAM, MaD..) $100,000 MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GENt AGGREGATE LIMIT APPLIES PER: PRO- LOC POLICYE:1 JECT F POTHER-, GENERAL AGGREGATE s2,000,000 PRODUCTS - COMPIOP AGO s2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS S NON -OWNED HIREDAUTO AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per perwn) $ BODILY INJURY (Per accident) $ P -I;tD (PRMR AMAGE d $ MBRELLA uAE u EXCESS LIAB HCLAIMS- OCCUR E EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERSLIABLITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F] (Mandatory In NH) If r, descrft under 0 SCRIFPTION OF OPERATIONS below NIA PER = 7—TOTH- []A I I ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE1 $ E.L. DISEASE - POLICY LIMIT I S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached U more sWe Is required) Justin Hayes 219 French Farm Rd North Andover, MA 01845 ACORD 25 (2014101) 1 Of 1 #S17289893IM16306571 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE VWLL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE -dw-r <.aw 0 1938-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD TxYCx Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS -066342 Construction Supervisor DARREN MARTINO " ADDISON AVEEX T—o METHUEN MA Expiration: Commissioner 08/15/2017 &/—" W.11104WIffill1i I ' K1jj(rC1?"';e16 Office of Consumer Affairs & Bu.�'css "Regulation OME IMPROVEMENT CONTRACTOR egistration: '124961 Type: / - .. 017 Individual Expiration: 9 17/2 DARREN MARTINO Darren MARTINO 44 ADDISON AVE. EXT. METHUEN, MA 01844 Undersecretary