HomeMy WebLinkAboutBuilding Permit #921-15 - 23 APPLEDORE LANE 5/14/2015'L -F- BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION 2,3 Af
f
Print
PROPERTYOWNER4" 9MP�ogjtE Print 100 Year Structure
MAP PARCEL: ZONING DISTRICT: Historic District
Machine Shop Village
0
A-6!
yes no
yes no
yes no
TYPE OF IMPROVEMffN--T
PROPOSED USE
IAI f,)CI 51-
Residential
Non- Residential
El New Building
<One family
1�e) 1/ 11/ �Lo?
0 Addition
D Two or more family
0 Industrial
;K -Alteration
No. of units:
D Commercial
El Repair, replacement
D Assessory Bldg
El Others:
D Demolition
El Other
El'Septic pVVell
e
El wqwrsl�(.. strict
d
DESCRIPTION OF WORK TO BE PhKt-UKMtL):
- Please Type or Print Clearly
OWNER: Name:
Address: Z-3 19 C
Contractor Name: -75P "441'- . P
E m a i 1: -ted 4e llel.4- (�—p IVYX k- rL- ���e /1'
Address: 0/5� -s�,MA/ /60
Aolq ovf,-e—
8
e: q;�� 4 9-S- 1�%l Z -
Supervisor's Construction License: 6
/-0 _Exp. Date: 1!?,�Ohf
Home Improvement License: 16 rg&2 Exp. Date:
ARCHITECT/ENGI NEER Phone: "I
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: $ FEE: s
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered coptractors do not have access �Uhe guarantyfund
0 f
IAI f,)CI 51-
jC p;o-r 1045�1 rA
�1
Ae!�- 1�4, I?- I
A/C '1-"T A I 41�4 11
1�e) 1/ 11/ �Lo?
4
Q111,11- -�,PtIVR a
vepolv -�,l ir-
- Please Type or Print Clearly
OWNER: Name:
Address: Z-3 19 C
Contractor Name: -75P "441'- . P
E m a i 1: -ted 4e llel.4- (�—p IVYX k- rL- ���e /1'
Address: 0/5� -s�,MA/ /60
Aolq ovf,-e—
8
e: q;�� 4 9-S- 1�%l Z -
Supervisor's Construction License: 6
/-0 _Exp. Date: 1!?,�Ohf
Home Improvement License: 16 rg&2 Exp. Date:
ARCHITECT/ENGI NEER Phone: "I
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: $ FEE: s
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered coptractors do not have access �Uhe guarantyfund
Location
No. q 2 Date
Check# � 1K
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
Building Inspector
Plans Submitted [I Plans Waived 11 Certified Plot Plan 11 Stamped Plans F1
OF SEWERAGE DI§P-OSAL
[TYPE
Sew,
Public Sewer El
Tanning/Massage/Body Art F1
Swimming Pools El
well 11
Tobacco Sales El
Food Packaging/Sales El
Private (septic tank, etc. El
Permanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
Reviewed On Signature.
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes
Planning Board Decision: Comments
--�-,Conservation Decision: Comments
Water & Sewer Connection/ Permit
DPW Town Engineer: Signature:
IMP
sc
Located 384
Street
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use)
Q Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
Building Permit Application
Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
�k Building Permit Application
Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
4� Copy Of Contract
4. Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Mass check Energy Compliance Report (if Applicable)
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
Building Permit Application
Certified Proposed Plot Plan
Photo of H.I.C. And C.S.L. Licenses
Workers Comp Affidavit
Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (if Applicable)
Copy of Contract
2012 IECC Energy code
Engineering Affidavits for Engineered products
10TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doe: Building Permit Revised 2014
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
.209972.00
m
-$
$ -
$
251.66
Plumbing Fee
$
31.46
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
31.46
Total fees collected
$
414.58
23 Appledore
921-15 on 5/14/2015
Kitchen Remodel
pp -1:
le
4e
4m*
0
LLI
LL
0
oc
<
0
co
0
0
L�
E
0-
ai
V)
0
u
z
ID
z
a
1
co
0
L.L
U0
:3
0
=
E
=
U
0
.!=
L.L
ca
2
D
—i
bn
=$
0
cc
Lj-
0
u
11
z
-j
<
u
2
U
—i
LU
w
0
>
V)
m
Ll-
0
u
LLJ
0.
(A
z
W
o
z
ui
LLI
LLJ
5
L.L
Co
a)
V)
0
E
V)
<v
ji :: E
p 0 <L 0 75
No
Ca
0
42) >
-0 0
0-0
CD <
E -4- 0
0
CL CQ
r- 0
ca 0
> 0
0
CL a)
CL (1)
CL
(D
co
Ey o
uml I-- :E .2
LU E
0-0
cn CL 0
w .0 0
am cc o " a 0
Z moo
E
CL
(n
:2
0
U)
0
cc
tm
4)
w
tm
0
C"
0
0
:z
0
0
l—i--"
I M
0
LLI
CL
co
Z
CD
z
0
m
cc
9
Cl)
LLI
w
CL
x
LLI
LLI
a-
0
0
Cl)
U)
LLI
0
E
0
:z
0
E
a.
0
CL
U)
0
L)
CL
U)
r_
0
U
cc
'a
U)
7=17
L.:
0
CL
4) CF)
r_ a
0 1-
0 CL
CL
cn.<
S -0
-J -0
04)
CL
U)
c
TMK Remodeling 214 Sutton Hill Rd Contract
CSL 105086 North Andover MA 01845 Ensdorf-23—Appledore—Kitchen—R2
HIC 165887 978 852-4491
RRP LR000106 www.tmkremodeling.com
CONTRACTOR AGREEMENT
THIS AGREEMENT made this 20L_,5—by and between Theodore Kelley dba TMK
Remodeling, Construction Supervisor License # 105086, 214 Sutton Hill Rd, North Andover MA 01845
hereinafter called the Contractor, and Gail Ensdorf hereinafter called the Owner.
WITNESSETH, that the Contractor and the Owner for the consideration named herein agree as follows:
ARTICLE 1. SCOPE OF THE WORK
The Contractor shall perform all of the work described in the specifications entitled Exhibit A — Statement of
Work, as annexed hereto as it pertains to work to be performed on property located at 23 Appledore St North
Andover MA 01845.
ARTICLE 2. TIME OF COMPLETION
The work to be performed under this Contract shall be commenced on or before Ma
2015 and shall be
substantially completed on or before
,J2t1<, 20115
Jwt' i6l
ARTICLE 3. THE CONTRACT PRICE
The owner shall pay the Contractor for the labor and materials to be performed and supplied under the
Contract the estimated sum of Twenty Thousand Nine Hundred Seventy Two Dollars and No Cents
($20,972.00), subject to additions and deductions pursuant to authorized change orders. The contract price
includes two components;
Fixed cost of Thirteen Thousand Forty Two Dollars and No Cents ($13,042.00) for the building materials and
construction labor as specified in Exhibits A and B.
Variable cost of Seven Thousand Nine Hundred Thirty Dollars and No Cents ($ 7,930. 00) for the allowance
items listed in Exhibit B Allowances Schedule and will be 110% of the actual invoice price paid by the
Contractor to his suppliers. Exhibit B lists the allowance items and budget costs the Contractor will purchase
for the Owner Sales tax and freight are not in/cuded in allowance budget.
Contractor will furnish and install all building materials, fixtures and finish items unless noted otherwise.
Items supplied by Owners: seeessefies amd tFirms; CUU! RUI L
Ne
PL'OA�'C_;� . c4k. 124 C f 51ro-t7 mt af-ock4AV? I F�AW 1P 15 14 WAI tf'a—
ARTICLE 4. PROGRESS PAYMENTS
Payments of the Contract price shall be paid in the following manner from the Owner to the Contractor:
33% upon contract acceptance and signature; $6,990.67
33% upon rough building inspection;$6,990.67
33% upon final building inspection and owner sign -off; ($939.33) plus the actual contract price for allowance
items as defined in Article 3.
The contract cost for mutually agreed to change orders will be paid 50% at time of change order signature and
50% after completion and owner sign -off.
ARTICLE 5. GENERAL PROVISIONS
1. All work shall be completed in a workmanship like manner and in compliance with all building codes and
other applicable laws.
2. To the extent required by law all work shall be performed by individuals duly licensed and authorized by law
to perform said work.
3. Contractor may at its discretion engage subcontractors to perform work hereunder, provided Contractor
shall fully pay said subcontractor and in all instances remain responsible for the proper completion of this
Contract.
Initials Copyright TMK Remodeling 2014
All RIghts Reserved
)/V/4
Page 1
TMK Remodeling 214 Sutton Hill Rd Contract
CSIL 105086 North Andover MA 01845 Ensdorf-23—Appledore—Kitchen—R2
HIC 165887 978 852-4491
RRP LR000106 www.tmkremodeling.com
4. Contractor shall furnish Owner appropriate releases or waivers of lien for all work performed or materials
provided at the time the next periodic payment shall be due.
5. All change orders shall be in writing and signed by both Owner and Contractor. The cost for mutually
agreed to additional work, required due to unknown conditions or substantive change orders, will based on the
current bill rates for the actual time used. Additional materials will be billed at contractor cost. All change
orders subject to 10% markup for overhead.
6. Contractor warrants it is adequately insured for injury to its employees and others incurring loss or injury as
a result of the acts of Contractor or its employees and subcontractors.
7. Contractor shall at its own expense obtain all permits necessary for the work to be performed.
8. Contractor agrees to place all debris in an on-site trash receptacle (dumpster) and leave the premises in
broom clean condition.
9. In the event Owner shall fail to pay any periodic or installment payment due hereunder, Contractor may
cease work without breach pending payment or resolution of any dispute.
10. The Contractor and the Owner hereby mutually agree in advance that in the event that the Contractor and
Owner have a dispute concerning this contract, the Contractor may submit such dispute to a private arbitration
service which has been approved by the Office of Consumer Affairs and Business Regulation and the
Contractor and Owner s"ll be required to submit to such arbitration as provided in MGL c 142A.
ntractor
12. Contractor warrants all work for a period of 12 months following completion.
13. Contractor may post small signage (1 8x24") on property advertising services during the duration of the
project.
14. The Contractor and subcontractors shall be registered and any inquiries about a contractor or
subcontractor relating to a registration should be directed to:
Office of Consumer Affairs and Business Regulation
Ten Park Plaza, Suite 5170
Boston, MA 02116
Phone: (617) 973-8700
Copyright TMK Remodeling 2014
Initials AL� All Rights Reserved
Page 2
TMK Remodeling 214 Sutton Hill Rd Contract
CSL 105086 North Andover MA 01845 Ensdorf-23—Appledore—Kitchen—R2
HIC 165887 978 852-4491
RRP LR000106 www.tmkremodeling.com
15. The Contractor or Owner may terminate this contract at any time for any reason by giving 3 days notice in
writing to the other party. If the Owner terminates the contract as provided herein, the contractor will be paid a
fair payment for work (labor and materials) completed as of the date of termination plus any materials or
equipment that are backordered and not delivered. Fair payment is defined as actual job costs for the project
plus 10% overhead charge. The contractor will provide a written report detailing actual job costs plus overhead
for payment. If the Contractor terminates the contract as provided herein, then the Contractor will refund any
funds paid by the Owner that are a remaining balance for the labor and materials used as of the date of
termination plus any materials or equipment that are backordered and not delivered. The Contractor will make
arrangements for the backordered items to be delivered to the Owner.
ARTICLE 6. OTHER TERMS
ARTICLE 7. ACCEPTANCE
Signed this 3:!�!-day of '20
NOTICE: The signatures of the"parties above apply only to the agreement of the parties to alternate dispute
resolution initiated by the contractor. The owner may initiate alternative dispute resolution even where this
section is not signed separately by the parties.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Copyright TIVIK Remodeling 2014
Initials All RIghts Reserved Page 3
.119 C14
c
0
E Ro
a) .2
� CL
M CL
0
-a
LLI
E
;m o
0 0)
< ;; �i
0
0
E 0 > Lo E
0 co
(n oo
< r,
c)
z
CO
ID
'o
a) Zo V)
c
a) -J CL
0 U) Q�
iD L) w
0)
I M
O'laq
liki,
Q
0
E
.0
(D
C3)
.7
>,
CIL
0
- tnio 0 Lo u) to u3 o 0 Lo a Lo EO)
fA —MV wwo 0 �!F- v Olow
co 't ;z a W m m 0 0 0 0 W 0 a a Lo 0 0 M
vo wtw m v w m m r --r- N ww u) r- rll.- w
0 0 Cq CN V)� 613� W 'IT r-- GF� 0
0 4 fin, v)� z "J, ul, 6"
N V) W (& P, cv " N — — w 0 v m --tilm m —
69 u) 4a uy 6a Q', v� 60 'i qq� v) vi v). 6% 40
>
0
1
Aft
E
0
> (D
o
AD
E
(D
(D (D
sn
0)
0 �q C> w
IT co (00)
C,
0
LL
0
to (D to
69
Lo
—
(D 0
W
o V N
co Lo (D cq
LL
-loo Z�
IS: 0
Ln
0 o
co 3:
4
2o
4) a)
r c
LL I
U) C: 3f
w
bi
-E
u)
LL ol
v) co
>
Go). 61).
c
a) . 0
ZD 4)
(D co
c
CO CD
16
E
w x
c E
m Ir-
51
LL LL :3
w w
a
In cD a u� u� w) to 0 0 u) 0 u) 0
(ft co m m 0 0 La u) to c) c) (D Lo
0
co 'T co to v) 0) N r- u) 03, a) cm
o m N 60� 69 W Itt , 1- , 611 %D
0 co V w co m t- r- N w v) u) I-
m c4 to P. N N N - - w cD IT Go V
a
- 619� 613, ,z 6'3� 6o w, 6s Ce
c4
Vk 69- c4 to v) w, to)-,w� ; ca Go 69
m
40 v),
in 6a
a
c
9co c, Cl - - - 0
cm cm cq
co u) m m u) (D u� Lo
c)
w
C)
w CY
Ou 6
.2
76 16
c, (D
ca
E
>
w ca
u) -a
E
Z-
m, cL
I ca
0
w
I
a) ca
0
0)
L) M
CL ca
co o
o
o
u)
0
0
(D
>
o
E (u
t5
>
4) �;
W c
.2
2
ai
>
co w,
cL
a, T
.2
E
2
.'9
k: 0
8
co ca a)
>
a)
E 0
0 0
o
o u a) .2
li
0
0 -
12 �
-a
In I c 0 t:;
M 0—
.�2 0
.0 0
0
0
co Z -
E oi co 0 0)
0) (D
m 0
<
(D
-a
N
-o u
c E
cm
c ca co
cL Z; 2 E
c: cL
z
6
E .2 w 0 E
-, E c -
j_- co
cL
r c
8 m co
+ E Op
m
ca
o w
Z E o.8 m 0
m
0
u
2
4i co
Z5 ca A? Z
0
cL E 'r- C (D
"Z
M (D a) � Z w
! r- C
co ca L) Q o
42- c
-2
O'E
'T
E :2 rm: E
a) L)
a) a)
E
E m
0 o 'OL ca
B cL w E
LL . ca
cL
:E co ;5 .2 r
a) cL 0
x c -48 cm >,
0 4) c 0
cc
cL
c3 ca
E 4)
c 0 E:9
3
1)
S .2 8 0)
o
(D 0
(D 1 4) E
cL
0- -.
z,)
ci,
4) 'D
r- c
Lu + 4.)
2 6 E-
0
, d5 -a
4D a) U,� m
:a D
�� 8 �F- :2 -(rD- cu
cL
a — w
6 w t E
'66E 2 5
0 co +
cutn=u)�- 0 , 0 o
ca
1 2 v r- t5 D
r- cL 02 -j)
0-- = ca
o o 3: w wD- 8 mm
E 0 0 , �: �a , w 0) 0 t 0 -
-5-2
co
c.) m
0 a)
E -(D
D ul
ca 2,0
, -
co :3 3: 2
no wo 8 8 S'a 4) - (D o 0
cm
E
0
a)
0 o E 01
-a I>D -
-
E
a) C M m -2
-2 0
Q <
ca rn .x
o —
a) - C
0) w
ca -o 4L
CD cL cm �2 a,
E E E a) S
< 0 o
> V; 8
a cc
4R -or R 481 ca w
E (D 0
iz F
0 u
CL
-2 - -E r -a
Z5 cul o -a 0 o R
r c r
- r r
0) (L - -- -- . 3:
f f -o -a
>
o
Qi
w c cL.2 > q w
(L E
(D .2 E w
I w
-o
w -6
9
C, L
>
v
c
(L
'6 w 8
75 :3 -w
9 a c:
04 M co M cL
'E m :.22 cc
L:
4) w -D cL
0 m
Cl
co a) .0 m .- 'r- 0
(D 8
o 0 > T Mo Lo (D
8 8 0
,
< o
Z;
E- 65
I K t E
0 -9 o
E E X S W E E E
12 mn S2 a) o" w w w m . . . w
0
0 (D oa, cj Z w
il: o
:E
Z F- in W (L 0 3: i2
2 <
'n co 0 o'
s E Z - S: — LL LL LL
-ITF
-FT IT)
fff,,Tif- J*4
0)
I M
O'laq
liki,
Q
0
E
.0
(D
C3)
.7
>,
CIL
0
-�C 04
I-
3 0
0
E '00
0 T
� C,
Cc CL
W
E
0
0 CY)
<
0
C, 0
E 0 >
- Ln E
.0 CC) 0,
a co
c
< E
0
z
CID
C)
co co a
Lo OD C)
-J CL
L) Cn
'o
ID
4D
E
R
CIL
w w 0 0 a 0 C) 0 a wito ("m
vi 69
V7 k 0
6* 6% 40 69 V� 64 641� 613� 1 C%l
mo owwoao C>O
�2 0 0 W, 0 m ow) co C) Co
m m v IT OD W C-4 04
61) MA u). 6a u). .:- :.,i "i w� CIO
to], V% to 09.
04 V LO in 0 a to CD a
Cl) m Cl) C-1 m m in iw)
co (D Cl)
LL
LU
6-V
co co 0 C) 0 to W (D
Ln 0 Lr) 0004
;� Z� v 0 It m 0) m
Vv 61). cl� C6 61� .,.: -� �:;, C4
Vv 61�.;;
Cl)
<
C)
OL
OL
x
(D
M
aL
0
CA,
CL CL r-
0 =1
8
0
C'4 0
0 E w
c E ol
.0
U) 0
cis
M
(L -0 r- t�
CL.Q)
+ '0 co X
'Ru; >, Z' = -, . R LU
EC -L coo S U.) T CL,
CL M 0 Y CL
w 8 a
a) M M 41
M u) co 0 Gi
E U) zu Mil -
M > *E
0
M = R 0) 0 c 06 >
CL 0)
q) —
cL(O E < E a) Cl
a) C4 v C4 a) E >
o C4 co C4 c4 M (n F- o ;; 0.0
I'v. I Us I co co
'o
ID
4D
E
R
CIL
4) 04
0 -C
U) .2
(D V
0
c
M 0
3: -0
0
CL
0-
< I
cle)
04
o
x -0
LLI
LU
Fe -
0
CA
CL
0
0 <
C) C) 0 0
a
co 0 0 U-)
C')
CIJ 04 0 'IT
M
CD
U-
000
C14 C14
co
OC)O
C) LO
Lo
LO
E
C) I-
Ce)
IT
CW)
00
0
U)
C)
cm
< ;;
'IT
. s
-5
T
-0
0 ,T
1
0
E
C
E o c4
> Lo
0
E
0) 0 00
-0
U) c 00
CD
C14
Cl)
0
Q
<
w
[I-
<
M
0
z
Z5
x
a)
ca
a E
0 0
tf —
2
0 z
0
a) ca
E
E
0 0
LO
co
E CD
ca a)
rn
0
<
c
cn CO (D
0-
vi
CD
0
cu
E a)
't
—CL U)
co 'a
CO
00 00 C)
C)
CF) >
0 0 0
-0-0
CU
C, co 5
LO LO
U)
L: c o a <
0
m
6"2 0
0
V)
U) — (0
a) w -0 d- =
< tf
cn
2
0
E ii) -
c
Q
0 U) w
:D 0 i it
a) CW) 0
0 (D 0) C-4 Z
ca
0
0
o
W
a) a)
17- F- 0 CO
0
Fe -
0
CA
CL
0
0 <
The Commonwealth of Massachusetts
Department ofIndustrialAccidents
I Congress Street, Suite 100
Boston, MA 02114-2017
wwW-mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers-
Applicant Information To BE FILED WITH THE I,EFJ�HTTING AUTHORITY. Please Print Legib
Name (Business/Organization/Individual): 209 44���
Address: Zzl
C1;txi/qt5ttP./7in- ao!sr–
Phone #:— D e
Are you an employer? Check the appropriate box:
. p1 . I am a employer with e employees (full and/or part-time).*
rF-11 I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.FJ i am a homeowner doing A work myself [No workers' comp. insurance required.] t
4,F] 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.
5.F1 I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.t
6.F1 We are a corporation and its officers have exercised their right of 'exemption per MGL c.
152, § 1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7. E] New construction
8. A
_!Remodeling
9. El Demolition
10 n Building addition
ll.EJ Electrical repairs or additions
12. plumbing repairs or additions
13. Roof repairs
14. F1 Other_
I —
*Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
mployees, they must provide their workers' comp. policy number.
employees. If the sub -contractors have e m 6 1 jo ite
I am an employer that is providing workers' compensation insurancefor yemplyees. Beowisthepolicyand bs
information.
insurance Company Name:
5:320 ZZ- Expiration Date: A,
Policy # or Self -ins. Lic. #:
Job Site Address: . City/State/Zip: AM- oo?ff-
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the office of Investigations of the DIA for insurance
anverage verl ication.
do h �,,b erj h f
VZh e in ormation provided above is true and correct
.y,qi�ferth ainsandpenaltiesofp
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): i
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: — Phone
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
receiver or trustee of an 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 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 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 required."
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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an 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 pr town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have an y* questions regarding the law or if you 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 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 n ' umber 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 bum 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
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NlASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
-"M�
Atiir-:�MJ:X
THIS CERTIFICATE i,
CERTIFICATE DOEO
BELOW. THIS CE
REPRESENTATIVE C
IMPORTANT: If the
the terms and Condit
OP ID: J
CERTIFICATE OF LIABILITY INSURANCE (MWDDNVYY)
5114115
ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER- THIS
NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
IFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
� PRODUCER, AND THE CERTIFICATE HOLDER.
artIficate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUIRROGATION IS WAIVED, subject to
)ns of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the
,u of such endorsementis).
PRODUCER
Segrove & Hall lnsur.A�soc.lno
305 North Main St.
kndover, MA 01810
Lawrence J. Hall
978-976-1
TMKRE-11
'r4?JU.Kk:KJ5? "PURDINU QUVERAGE L- NAJC
INBURED TMK Reniodeling INSURER A: Arbella Protection Ins. Co. 41360
214 Sutto Hill Rd
An� iNsuRER u. AEIC 11104
North over, MA 01845
INSURIER C:
INSURER D:
I INSURER r;.
COVERAGES ('FPTI9If'ATF MI 11VICEP10-
'THIS IS TO CERTIFY T�AT THE POLICIES OF INSURANCE LISTED BELOW HAVJE BEEN ISSUED TO -THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHOTANDING ANY RF=QUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BEISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONPITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INUR TYFEOFIN4URAMCF- ADUL SUBR POLICY EFF PO —lw-
LTR mg -mn POLICY NUMBER_ _MWI[)DNYYYI (MM LIMITS
GENr;RAL LIA131UTY
EACH OCCURRENCE! $ 1,000,00
A x UU1WrAMKkAPJ. QtNERAL LIABILITY -I5A`MXG7TI7RE9TErF—
PREMISES (Es ocrunnnue) 100,00
CLAIMS-MADEIF—IOCCUR MED EXP (Any one perwn) $ 5,00
9520037133 03/08/15 D-3/08116 PERSONAL & ADV INJURY 3 1,000,00
GENERAL AGGREGATE $ 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000.00
7 POLICY F7 M F-� LOO $
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
(Ezacddent)
BODILY INJURY (Per person) S
—BODILY
ALLOWNEDALITOS
i
—INJURY (Per amident) $
SCHEDIJ�ED AUTO�
PROPERTY DAMAGE $
(Forecoldera)
HIRED AUTOS i
5
NON -OWNED AUTO$
S
UMBRELLA LIAB OCCUR
C
1100L
EACH OCCURRENCE
EXCESS UAG AIMS -MADE
AGGREGATE
DEDUCTIBLE
RETENTIQN S
13
WORKERS COFAPr=NSAT16N
AND EMPLOYERS' LIABILITY
YIN
ANY PK0PRIETCRIPARTN6R/RXrCUTIVE
OPFICERMEMBER E)(CLU =D?
(Mandatory In NK)
NO, de-wAbB ad 1
SreRIPTION &ER.AtIONS belo.
MIA
5005011872
04/01116
04101/16
1,TNCYSTATIJ
OR LIM T� " OTI1
I I ER
E. L. EAUH ACCIDEENT
E.L. DISEASE - F -A EMPLOYEE
E.L. DISEASE - POLICY LIMIT
u—nir i ivN ur Urrr.A 1 IUMN I LVLATIVN;� I VWIMLES JATUCH AWKID 101, AddItIanal Rarnarlft SCnGdUlb. if r1ftora spAcm Is requi red)
Town of Nbrth Andover
Building Inspector Bldg 20
1600 Oa= Suite 206
Norther r, MA 01845
SHOULD AMY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED RIEPRESENTATIVEE
@ 1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Super%-isor,
License: CS -105086
tEMK A(6,
THEODOT fLLEY
214 SUTTON
NORTH
VER MA 018
)rw Expiration
10/0812015
commiss.ioner
&21,
Mee of Consumer Affairs & Business Regulatio'n
ME IMPROVEMENT CONTRACTOR
i gistration: I - 65887 Type:
xpiration: �-4/5/2016
DBA
TMK REMODELING r:
THEODORE KELLEY
214 SUTTON HILL RD.
NORTHANDOVER, MA 01845 Undersecretary
I
License or registration valid for individul use only
before the expiration date. If found return to:
Office Of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, MA 02116
Not valid m1thout s-Ignature