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HomeMy WebLinkAboutBuilding Permit #422-14 - 22 MARTIN AVENUE 11/12/2013 /TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: V Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION ,a MA RT i N A-V _N t,a xZ'T 1i AJ J G U,is9, lyl/i - Print. PROPERTY OWNER-GiA � % Print 100Year Old Structure yes MAP NO: ( PARCEL ZONING DISTRICT: Historic District yes Lfip- Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building V One family ❑Addition ❑Two or more family ❑ Industrial ❑ ration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ 0 Septic ❑Well El Floodplain ❑Wetlands ❑ Watershed District ®.Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: ;7/X' 71p i�Imo' /�, i�•�c�� l�i t Identification Please Type or Print Clearly) OWNER: Name:�C A 6,gj,5 . V, J r�i,C�` T�o Phone: 978'-6 Address: �1�- MARTiN AV ►=Nu5, No R-1-14 AND6VSk, N,A. CONTRACTOR Name:. �?� � ' ��. �_ Phoneme Address: c� / � t" l7ri�e. . Y �,.', . Supervisor's Construction License: ' 9yS" Date: v �'y�lo 'l��f Home Improvement- License; .__ ._. _. _ __ Exp. Date:... . ARCHITECT/ENGINEER /��/ Phone: Address: Reg. No. FEE SCHEDULE:BULDING PER $12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: FEE: $ Check No.: � Receipt No.:_-g 4. NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner o a pgature of contr acfo =/ � �'} tans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ ` Building Department `rhe fohswing 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 o Copy of Contract o Floor Plan Or Proposed Interior Work o 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 a Copy Of Contract o Floor/Crossection/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) a Building Permit Application o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: 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 apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must bP submAted with the building application Doc: Doc.Building permit Revised 2012 Plans Submitted ❑ Plans Waived C-ertified Plot Plan ❑ Stamped Plans ❑ T '-ORSEWERAGEDISP.OSAL Public Sewer Tanning/MassageBodyArt ❑ Swimming Pools. El. 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS .CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature b 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 DPW Tow; Engineer: Signature: Located 384 Osgood Street FIRE DEPART—ML - Temp Dumpster on site yes no Located'at 124 Main Street-- -Fire-Departme►�t signature/date_,z 4 COMMENTS Dimension Number of Stories: Totals square feet of floor or area, based on Exterior dimensions. .Total land area; sq. ft.: i ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL-Chapter-166 Section 21A-F and G min.$100-$1000 fine { NOTES and DATA— (For department use El Notified for pickup - Date i 7 - Doe.Building Permit Revised 2010 Locati n Mo" m• No. � ( Date V . • TOWN OF NORTH ANDOVER Certificate of Occupancy $ ' Building/Frame Permit Fee $��U Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 27094 Building Inspector 11/ 1G/ GV10 V.7.0L 1`L1A 1 010 U00 000V 111cL%_VV11cLiV OG fcL1161V11G VU1/VU-L OP ID:SHHE CERTIFICATE OF LIABILITY INSURANCE 711112113 YY) 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 TI4E COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorserrent(s). PRODUCERPhone:978-688-6921 NAME:CT Macdonald&Pangione Insurance PHONE PpX P.O.Box 428 Fax:978-688-5350 (AIC.No,ExU: 104 Main Street E-MAIL North Andover,MA 01845 ADDRESS: Michael Pan ione PRODUCER PangCUSTOMER ID q:ROBER17' INSURER(S)AFFORDING COVERAGE NAIC a INSURED Robert's Home Service&Repair INSURER A:Utica Mutual Insurance Co 6 Allenclair Drive INSURERB: Amesbury, MA 01913 INSURER C: INSURER D: INauncR e: INSURER F: COVERAGES CERTIFICATE NUMBER! REVISION NUMBER. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TI IC 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 JIM POLICY NUMBER MMIDD/YYYY MM/DCY/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE A X COMMERCIAL GENERAL LIABILITY 4473957 10/12/13 10/12/14 PREMISESEaEoNc urrence $ 50,000 CLAIMS-MADE F—IOCCUR MED EXP(Any one person) S 10,00 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP/OP ACO s 2,000,000 X1 POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 500,000 A ANYAUTO 4525648 04/30/13 04/301/14 (Ea accidant) BODILY INJURY(Per person) $ ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY(Per accident) $ PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ $ UMBRELLA LIAR HOCCUR I EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITYA ANY PROPRIETOR/PARTNERIEXECUTIVE YIN 4502768 02/26/13 02/26/14 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) Ir E.L.DISEASE-EA EMPLOYE $ 100,00 yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,It more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE: THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Brian Leathe 1600 Osgood Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 Michael Pangione ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Uf www.mass.gov/dia Workers'Compensation][assurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Na1ne(Business/Organization/Individual): ��o r�'S /�s�7� � 1' f , ' Zee. Address: Ale"G'lm'- City/State/Zip: tee,_Ek ,/ _ Phone#: ' ,-1;7 J- t<1.—s/J' Are ou an employer?Check the appropriate box: Type of project(required): 1. Are am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling / ship and'have no employees These sub-contractors have 8. F!Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1111 Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.E]Roofrepairs insurance required.]t employees.[No workers' 13.[i Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for fay employees Below is the policy and job site information. Insurance Company Name:. td 7/0e4 455 ,Yq ` �/I�f � �4 eve U1 rz' o Ute' Policy#or Self-ins.Lie. S Expiration Date: Job Site Address: Z- /a"o-¢r/I City/State/Zip: &_14 Aijaeesr 0t Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ' I do hereby cert under the pains and penalties ofperjury Mat the information provided above is true and correct. Signature: / Z 42,4 4 Date: ////Z(1 Phone#: _���� Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: NORTH Town of AndoveRo O �► No. o h , ver, Mass, COC L^K§ ICN y1. 0, 5 U BOARD OF HEALTH I Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT 6 .J.L .., ,t.,�;P¢,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, BUILDING INSPECTOR has permission to erect buildings on Foundation Rough tobe occupied as ................?�(......� ..... ........................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to1he provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR ' UNLESS CONSTRUCTION STARTS Rough Service ................................................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE From: Robert Almon <robertshsr@gmail.com> Date: November 11, 2013 7:37:07 AM EST , To: robertshsr@gmail.com ! D 1 Attachment, 645 KB W a ! JL AL •ti I Sent from my Phone Iq c a re sI Cie 3 ` From: Robert Almon <robertshsr@gmail.com> ,- Date: November 11, 2013 7:35:57 AM EST 1" To: robertshsr@gmail.com I> 1 Attachment, 750 KB snow p C k. fv _ a r Sent from my Phone ss�e� cc s Tre e Tmprovement Sal ' le Contract This age satisfies all basomen e ers.ment5 of the slate's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any andard Massachusetts Consumer Guide to Home Improvement"before agreeingto any woxlc own g homxesidence.You may obtain a free co a b p�of it �e Office of Consumer Affairs and Business R egulation's Consumer information Hotlik n 617-973-8787r residence. or 1u may 83-3757 re on copy by calling Homeowner nfolrl�a>Cn®n e. 'Contractor In f6rmition � Name &ACompany Nan , 13iCL V• , i'F�i i FPO D :� StreetAddress(do nctuse aPost Office Box address) _�e !�f x4 e Contractor/Salesperson/OwnerName a M A R N f v �vla 6' P� / City/Town State Zip Code /� �!! d� - BpsinessAddress(must include.a street address) NO RTH AN 'boirl:R, MA 6ifg5 AayumePhoneEveningPhone City(TownState Zip Code Mailing Address(It different from above) A/3 Business Phone FederalBmplayerID orS.S.Number EameImprovementcontmaorlteg:Number that mosthama xpirationdnte contrLnw requires improvreganraflannctors uinbe avn nvnhidra istratianmiinvcr The Contractor agrees to do the following work for the Homeowner: (Descn'bein detail theworlcto completed,specifying the type,brand,and grade of materials to be used,use additional sheets ifnecessa .) Required Permits-The following building permits ate required Proposed Start and Completion Schedule-The following schedule and will be secured by the contractor as-the homeowner's agent: be adhered to unless circumstances beyond the contractor' control arise 1 (Owners who secure their own,permits will,be excluded frons.the Guaranty Fund provisions of Z�lf �/� Date when contractor will begin contractedwo GJL chapter x�2A.) rlc. 1117Z Ld Date when contracted worlcwill be substantially completed. Total ContractPrice and PaMent Schedule The Contractor agrees to perform,the worlc,furnish the material and labor specified above for the total sum of 259ments will be made according to the following schedule: (�) upon signing contract(not to exceed 113 of he total contract price or the Dost Of special order items,whichever is greater) by or upon completion of -af by or upon completion of • upon completion Of the contract. (Law forbids demanding full payment until contract is completed to both The following material/equipment must bespecial P Y'ssausfaction) . ordered before the contracted work begins in order "— to be paid for to meetthe completion schedule.(.N) � tobepaidfor NOTES;(-'�Including all finance charges(°i*)Law requires that any deposit or down payment required by the contractor before worlcbegins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or costo which must be special ordered in advande to meet the completion m made material p on schedule. 1 x resswarran -Is an ex ress warrant bein rovidedb the Subcontractors-The contractor agrees to b.e solely responsible for contractor?completiNo es(all terms oithe marr on of the work described regardless ofthe t be attached to the contract Party/subcontractor utilized by the Contractor. The contractor futther agrees to be solei res onsible for all a actions o£anythird Materials and abornnderthis a Bement y p payments to all subcontractors for Contract Acceptance Upon signing,this doolmientbecomes abinding contractunaerlaw. Unless otherwise liotedwithin.this document,the ' contract shall not implythat any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. ° Don't be pressured into signing the contract,Take time to read and fully understand it. Ask ° questions if something is nuclear. ake sure the contractor has a valid Tome XmnrOyement Contractor Retristration. The law requites most home improvement contractors and subcontractors to be registered with the Detector o£Ho registration by writing to the Director me Improvement Contractor Registration. you may inquire about contractor at 10 parlcPlaza,Room.5170,Boston,MA..02116 or by caUhg.617--973 8787 or 888-283-3757. ° Does the contractor Rave insurance? Athe Contractor for his insurance company information so that you can confam coverage,or aslcto see a copy of a"proof of insurance"document. ° Iliac your rights and responsibilities. Read the Stnportaut Infox�xiation on the reverse side of this form and get a copy o£the Consumer Guide to the Home ruhprovement Contractor Law: E y cancel this agreement.if it has b Ben signed at aplaceother than the contractor's normal place of business,provided ou n 'or in writing at his/her main office or branch office by ordinary mail,posted,by telegram sent or by delivery,not lter than midnight of the siness day followin the si y othfy the g going oftbis agreement. See the attached notice of cancellation farm fox an explanation o£this right. DO NOT'SZC•�1'TRIS' C`®NTP CT J'TEMRE Two identical,copies ofthe contract must be completed and signed. One c. ARE�'�BL AMIIC Sg A C` S 4 copy should go to the homeowner. The otber copy shotddbe icept by tho contractor. Homeowner's Signature Contractor's Signature Date Coni racio:r.Arkiarition. The Hoare 7mpiovement Contractor Lawrovide ho 'alternative to Court actiop meownexs with the tight to initiate an arbitration action as an n)if they have a dispute with a coniTactor. The same right.is not automaticallafforded contractor,however, T 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 saxve right to arbitration as is afforded to the homeowner by the Home improvement Contractor Law. The contractor and the homeowner hereby' mutually agree' iaa. concerning Y � , advance that in the event the contractor has zxaaaa this c s a dispute g ontract•the rte 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 14.2A.• Homeowner's Signature NOTICE: g Contra Signatrre The si tes of arpatties above apply only-to the agreement of the patties to alternative dispute resolution initiated by the contractor: The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Elomeown.ear's Rights A homeowner's rights under the I-Iome Srnprovement Contractor L4.w(MGL chapter 1.42A.)and other consumer protection laws (i.e.MGL chapter 93A)may not be waived in any way, even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded'from all Guaranty Futid provisions of the Home Improvement Contractor-Law. The contractor isf responsible for completing the work as described,in a timely and worltmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty:for workmanship or materials. In addition to provided bythe contractor, all goods sold•in.Massachusetts carry an implied warranty ofin rchantala .or ty ani,warranties :for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may tae added to the terms of the contract as long as'they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline(listed below), Execution,of Contract The contract must be executed in du licate and should not be signed until a copy of all exhibits and referenced documents have been-attached. Parties axe.also advised not to sign,the document until all blank sections have been Cued in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given,to the owner and the other kept by the contractor. Any modification to the.original contract must be in writing and agreed to by both parties. Contracted work may not begin until both,parties have received a fully executed copy of the contract,and the these day rescission period has expired. .A.cceleratecl Paymn.•ts A contractor may not demand payments in advance of the dates specified on the•payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet:due be placed in a j oi-at escrow account as a prerequisite to continuing the contracted work. Withdrawal of fonds from said account would require the signatures of both parties. Additional Wormation 7f you have general questions or need additional information about the DoaneIarpxovement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consuuner Guide to Home Impiovement" contact: Consumer Information Hotline Oftiee of Consumer Affairs and Business Regulation 10 PaTlc Plaza,ROOM 5170,Boston, 02116 617-973-8787,'888-283-3757 or"visittthe OCABRwebs to MA � //wwcv.mass: ov/ocabr/ IfYou•want to very the registration of a contractor or if you have questions or need additional informatio about the contractor registration component of the Home Imlarovement Contractor Law, contact: n speciEcally Director of Hoare Improvement Contractor Registration Office of Consumer Affairs and-Business Regulation 617-973-8787, 888 283 3757 o a s t the I-UC website,Room 5170, NIA 02116 �.//ww�v mass gov/ocabr/ Go online to view the status o£a Home Improvement Contractor's Registration: , hii�a://db.state.ma.t2s/hoz moroveanent/]icenseetist.as Thr assistance with informal mediation,of disputes or to register formal complaints a against business,g siness, call: Consumer Complaint Section O:EE'ice of the Attorapy General 617-727-8400 Arm/OR Better Business Bureau 508-652-4.800,508-7755 2548 or 4.13-734-3114. UTICA NATIONAL INSURANCE GROUP Utica Mutual Insurance Company Producer Number: 70135 180 Genesee Street Producer: Macdonald &Pangione New Hartford, NY 13413 104 Main Street North Andover, MA 01845 POLICY NUMBER: 4473957 Renewal NAMED INSURED: ROBERTS HOME SERVICES REPAIR ADDRESS: 6 ALLENCLAIR DR AMESBURY, MA 01913 FORM OF BUSINESS: Corporation BUSINESS DESCRIPTION: Carpentry- Remodeling of Residential Property POLICY PERIOD: FROM 10-12-2013 TO 10-12-2014 At 12:01 A.M.*Standard Time at your address shown above. In consideration of the premium, insurance is,provided only for described premises scheduled below and those coverages or kind of property described or specified by a limit of insurance, subject to all the policy terms including forms and endorsements made a part hereof: *Exceptions: 12:00 noon in Maine, Michigan and North Carolina. CI1fl�lflC�+C� � BUSINESSOWNERS POLICY DECLARATIONS LIABILITY AND MEDICAL EXPENSES LIMIT-Per Occurrence $ 1,000,000 MEDICAL EXPENSES LIMIT-Per Person $ 10,000 Each paid claim for Liability and Medical Expenses reduces the amount of insurance we provide during the applicable annual period. Per Section II, Paragraph DA. of the Businessowners Coverage Form. DAMAGE TO PREMISES RENTED TO YOU LIMIT(Section II, Paragraph D.3.), unless higher limit shown $ 50,000 below. Deductible is $500 for Building and Business Personal Property coverages unless otherwise noted below. See below and coverage forms for deductible(s)applicable to other items. Optional Coverage/Glass Deductible is$500. LOC/ FORM LIMIT OF BLDG. NUMBER DESCRIBED PREMISES AND COVERAGES INSURANCE PREMIUM BP0003 Employee Dishonesty $10,000 Included BP0003 Forgery Or Alteration $10,000 Included BP0003 Money And Securities Inside The Premises $15,000 Included BP0003 Money And Securities Outside The Premises $5,000 Included BP0003 Outdoor Signs $10,000 Included s p Total Advance Premium $2,229.00 FORMS AND ENDORSEMENTS APPLYING TO THIS POLICY: See Form 8-S-1018 attached. MORTGAGE HOLDER: mpar-cy t=r 8-DU-BOP Ed.10-2007 Includes copyrighted material of Insurance Services Office,Inc. Unibill No . 100867124 07-29-2013 Your Bill Will Follow UTICA NATIONAL INSURANCE GROUP WC 000001A 180 Genesee Street New Hartford, NY 13413 Issuing Company: Utica National Assurance Company MEMBER OF UTICA NATIONAL INSURANCE GROUP WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Information Page Policy Number: 4502768 Renewal 1. The Insured and Mailing Address: Prior Policy Number: ROBERTS HOME SERVICES and REPAIR Inc 6 ALLENCLAIR DR Producer: Macdonald&Pangione 104 Main Street AMESBURY MA 01913 North Andover, MA 01845 Entity of Insured: Corporation Producer Number: 70135 Other workplaces not shown above: SIC#: 1521 Insured's I.D.Number: 450508567 NCCI Company Number: 36587 Risk I.D.Number: MA:000340737 2. The policy period is from 02/26/2013 to 02/26/2014 12:01 AM Standard Time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here:Massachusetts B. Employers Liability Insurance: Part Two of the policy applies to work In each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ $500,000 Each Accident Bodily Injury by Disease $ $500,000 Policy Limit Bodily Injury by Disease $ $500,000 Each Employee C. Other States Insurance: Part Three of the policy applies to the states,if any,listed here: All States except those listed in Item 3.A., ND,OH,WA,WY D. This policy includes these endorsements and schedules: 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans. All information required below is subject to verification and change by audit. ®See Extension of Information Page Code Premium Basis Rate Per$100Total est.Annual of Estimated Annual Classifications No. Remuneration Remuneration Premium e Minimum Premium: $ 500 MA Expense Constant $ Employer's Liab Minimum Premium: $ Total Estimated Annual Premium $ 3,193 If inc(icated below,interim adjustments of premium shall be made: Deposit Premium $ 3,193 100874555 Issuing Office: Date of Issue: Countersigned by (�f 8-D-WC Ed.08-2008 Copyright 1988 National Council of Compensation Insurance �. - •';%�c�r»ri»rvrracu�(� rrrsnr/rr� .. Ofiice of Oonsurrer Affairs w Bush-fess Reg ulation :1ME IMPROVEMENT CONTRACTOR ?� F�r�egistration: 143102 Type: >7 � ;Expiration: ._6/16/2014,. DBA ROBERT'S HOME IMPROVEMENT+'REPAIR INC �� _ROBERT ALMON 6"AL.LENCLAIR DR _ AMESEURY,MA 01913 Undersecretary U�=` 1 Massachusetts -Department of Public Safety Board of Building Regulations and Standards s C-Wrtirtim, Sufier-1 isnr '_icense: CS-090425 ROBERT W ALMON 6 ALLENCLAIR DRIVE j AMESBURY MA--01913 Expiration Commissioner 10/03/2014