HomeMy WebLinkAboutBuilding Permit #369-2016 - 243 GREAT POND ROAD 9/22/2015 C ivn.FO �1291/6-
BUILDING PERMIT '.: of N°C
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TOWN OF NORTH ANDOVER...; o - w
APPLICATION FOR PLAN EXAMINATION::-7.7"."'1
Permit No#:
I gSSACHUs�t�.
Date Issued: I /
IMPORTANT:Applicant must complefe°all items on this:` age
L
PROPERTY OWNER
Y >' Print 100r1'ear,S#ru�tuse - yes - no
PARCEL._ ZONING DISTRICT. Historic ®istrict yes, no
Machine Shop Village yes. no'
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building L�-O_he family
❑Addition ❑Two or more family ❑ Industrial
U-91-teration No. of units: 0 Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition -0-Other
❑ Septic ❑.Wel I; El Floodplain ❑Wetlands ❑ Watershed :District
Q Wpter/Sewer_
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: _ �Te l/G eOy/y'® Phone: 9'/ ��6' l`Y6 3
Address: o?'Y3 6 A2erfj 12/y00,11e&
Contractor Name-R!,/Z_-I- - Phone:-
Q
Address:- j7Q / �/�'l1./?/Orr/ -5 j 4� ��
Supervisor's Construction Lieense: f C»D Exp. .Date.:-` a, � 7
Home Improv- ment License:
ARCHITECT/ENGINEER Phone:
Address:
Reg** No,
FEE SCHEDULE.,BULDING PERMIT:$92.00 PER$1000.00 OF THE TOT AL ESTI MATED•COSTBASED ON$925.00 PER S.F.
Total Project Cost: $ ��Q FEE::
Check No.:
NOTE: Persons contracting with unregistered contractors do::yiot:have.access to the g ran nd
�Sgnature of Agent/Owner - �gnture,ofcontracto�
- - --- - -_--- - -- _ r
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
r
Roofing, Siding, Interior Rehabilitation Permits
o Building Permit Application
❑ Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
o 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
o Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
a Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
o 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)
o Copy of Contract
o Mass check Energy Compliance Report
o Engineering Affidavits for Engineered products
VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doe:Building Permit Revised 2014
_ l
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)
i
I -
l
j
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
F
SEWERAGE DISPOSAL
ewer Tanning/MassageBody Art ❑ SwimmingPools❑ Tobacco Sales ❑ Food Packaging/Salesseptic tank,etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
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 Town Engineer: Signature:
Located 384 Osgood Street
FIFZE DEPARTMENT - Te p ®umpster on site yes no
Lo-a ed a24 Main Street
Fire Department sig a u.re/date
� C®MMENTS
Location C
No. 3�`1 - l ° Date 2Z 1 I:;-
1
. - TOWN OF NORTH ANDOVER
. Certificate of Occupancy $
Building/Frame Permit Fee
i
Foundation Permit Fee $
Other Permit fee $
TOTAL $
Check# r
i
29395
9395 Building Inspector
Enter construction cost for fee cal- North Andover Fee Calculation
Construction Cost
$ 259000.00 m
$ - $ 300.00
Plumbing Fee $ 37.50
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 37.50
Total fees collected $ 475.00
243 Great Pond Road
369-2016 on 9/22/2015
Bedroom and Bath In Basement
r1 NORT1i
- _ .
Wn o . 1 _ �� . Andover
0 -
7s�
.. - h
2415
o h ver, Mass,
4
C OC LIC HlWKL 1
A°RA re o
_ S U
BOARD OF HEALTH
Food/Kitchen
MIT,,, Septic System
PER T LD
so %THIS CERTIFIES THAT ........ BUILDING INSPECTOR
%& .. .�. ................. . ........to..A....... .... .....
... .... ...... .... .........
has permission to erect .......................... buildings on . .. ...P".. .. , ,
Foundation
� Rough
to be occupied as ....agArw .... ....� ....�.^.... . !!1.l�. '................ 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 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
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
• UNLESS CONSTRUCTI T 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.
IW-6"
o = Steve Boyco
4 n
" c 243 Great Pond Road
CD 00
North Andover MA 01845
s
\ k
FD N -
LExisting Basement
Bedroom 4'-7"00
;
N
Z-3" 6'-0"
°D ----------
M-01, 2-4"x F 2'-4"x 8'-8"
4
Box in column
Y �4 M
ry�
W
Cn 1611 -
Egress ' _o
windowr�
� 4'-1 /;" ice— - 15'4 1/2"
N �
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4'-0"
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Selecting the Proper Size ScapeWEL° Egress Window Well
STEP 1:
Measure and calculate dimension A as Building
shown in the detail on the right based Line window well side panels must
on the site's grade conditions and extend 4 inches above grade level.
Grade must be sloped away from
foundation height. well.Downspouts must also be
directed away from the well.
STEP 2:
Determine the required window well Window-0.
side panel height by performing this Egress
simple calculation: Dimension Q
Measure from Window
top of window sill
Required Side Panel Height= to grade level Wel
Dimension A+7-112" System
Use 3/4"clean
*3-1/2" free-draining
From the first column in the table rock or A6 stone
below,select the closest side panel 44•'Maximum 's' at least 12"in
height that will meet the site conditions. from floor to window width around all
sill to meet egress ' sides of the well,
code requirements ,-r; Fill to depth of
STEP 3: foundation
footing.
"' '�''' *Wells can be installed lower
Once the side panel height has been , ;'= than the recommended 3-1/2"
„�� � .r �
determined read across and select '". `='�:*• {
'. to help meet grade conditions
desired window width.With the window '
size selected, read across to select the i Tie et fill into
� perimeter drain if available
proper window well and cover. v
ScapeWEL® STANDARD SIZES AND MODEL NUMBERS
Side Panel Height Maximum Window
Well Model Inside
Number of Projection Optional
Tiers from
With Extension* Width
Number Width Dome
(steps) Foundation Standard Model Wall Buck Cover
Height Number Mount Mount
4048-42 2 42" 41" 48" X X 42" 38" 4042C
4048-54 2 54" 41" 48" X X 54" 50" 4054C
4048-66 2 66" 41" 48" X X 66" 62" 4066C
4862-42 3 42" 49" 62" 81" 3019-42 42" 38" 4842C
4862-54 3 54" 49" 62" 81" 3019-54 54" 50" 4854C
4862-66 3 66" 49" 1 62" 81" 3019-66 66" 62" 4866C
*Extensions are only available for 3-tier window well models
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Andersen.
Andersen Windows -Abbreviated Quote Report Andersen
Project Name: ratte
Quote#: 2319 Print Date: 08/27/2015 Quote Date: 08/26/2015
iQ Version: 15.1
customer:
Dealer: Billing
Address:
Phone: Fax:
Sales Rep: Administrator Contact:
Trade ID: Promotion Code:
MY
By: Location Unit Price Ext.Price
Item y Item Size(Operation)
$ 366.10 $ 366.10
-�=- 0002 1 CW14(L)
RO Size=2'4 7/8"W x 4'0 1/2"H Unit Size=2'4 3/8"W x 4'0"H
Unit,Sandtone/White-Factory Painted,L Handing,Straight Arm Hardware,High Performance Low-E4 Glass
Insect Screen,White
�. Hardware Pack, PSC,Traditional Folding-White
U-Factor:0.29, SHGC:0.31
Subtotal 366.10
Total Load Factor Tax(0-000%) ($ — 0.00
0.152 Grand Total �-366.10
Customer Signature
Dealer Signature
**All graphics viewed from the exterior
** llow for use of building wraps or flashings or sill panning or brackets or fasteners or
Rough opening dimensions are minimums and may need to be increased to a
other items.
Quote#: 2319 Print Date: 08/27/2015
Page 1 Of 2 iQ Version: 15.1
a
I
R. Joseph Ratte, Inc.
General Building Contractor
ee&&a&zg otwA Gv yeano 4 nexaice
&&tMoked 9954
i•
t RESIDENTIAL CONTRACTING AGREEMENT
Read this agreement and make sure you understand it before signing it.This Agreement has legal
force and effect binds those who sign it.
Notice:
All home improvement/general contractors and subcontractors engaged in home improvement
contracting,unless specifically exempt from registration by provisions of Chapter 142a of the
general laws,must be registered with the Commonwealth of Massachusetts.Inquiries about
registration and status should be made to the Director,Home Improvement Contract Registration,
One Ashburton,Place,Room 1301,Boston,MA 02108.
Designated Registrant's Name:Roger J.Ratte',Inc. DBA R.Joseph Rand,Inc.
Salesperson's Name:Joseph R.Ratte'
Registration Number: 100294
License Number:015004
This agreement is made on September 1,2015,between Roger.J.Ratte',Inc.
DBA R.Joseph Ratte',Inc.of 340 Mt.Vernon Street Lawrence,MA 01843 Ph.(978)-688-8839
hereinafter called"Contractor"and Steve Boyko of 243 Great Pond Road N.Andover,MA 01845
Ph.(978)-886-4863 hereinafter called"Owner".
I. DETAILED DESCRIPTION OF WORK TO BE PERFORMED
Contractor agrees to perform in a good and workmanlike manner all work detailed below.
Such work consists of the following:
Construct new bathroom and bedroom in basement as directed by owner.
Add egress window.
DETAILED DESCRIPTION OF MATERIALS TO BE USED
Materials to be used in performing the above described work consist of the following:
As directed by owner.
II. PRICE
Contractor agrees to do all work described in Section I for the estimated cost of$25,000.00
Work shall be done on a"Cost Plus"basis.
Billing shall be from direct material and subcontractor invoices.
All permits,fees,material,and subcontract work shall be subject to a 20%overhead charge.
All direct labor provided by Contractor including meetings and supervisory time will be billed at
an hourly rate of$60.00.Plumbing labor at an hourly rate of$85.00
(978)423-6154 340 Mt.Vernon Street Lawrence,MA 01843 Fax(978)688-7476
R. Joseph Ratte, Inc.
General Building Contractor
eeQeBxa&t#otwm 60 yeaue of aeuwice
EoW&fted 1954
HIDDEN CONDITIONS AND NECESSARY ADDITIONAL WORK:
Hidden conditions or additional work may require adjustment in the overall estimated price for the
necessary work related to this contract. In such case the Contractor shall inform the Homeowner
of such conditions forthwith and where necessary a written amendment of this Contract will be
negotiated and executed by the Parties.
III. PAYMENT
Payments will be made as follows:
$1,000.00 deposit with signed contract.
Future billing will be upon receipt of invoices.
$1,000.00 deposit will be credited prior to development of final punch list.
Payments as provided above shall be postmarked within 7 days of invoice date.
Notice: No agreement for home improvement contracting work shall require a down payment
(advance deposit)of more than one-third of the total contract price or the total amount of all
deposits or payments which the contractor must make,in advance,to order and/or otherwise obtain
delivery of special order materials and equipment,whichever amount is greater.
IV. COMMENCEMENT AND COMPLETION OF WORK
Contractor will not begin the work or order the materials before the third day following the signing
of this Agreement,unless specified here in writing. Contractor will begin the work on or
about September 30,2015. Barring delay caused by circumstances beyond Contractor's control,
the work will be completed on or about October 31,2015.The Owner hereby acknowledges and
agrees that the scheduling dates are approximate and that such delays that are not avoidable by the
Contractor shall not be considered as violations of this Agreement.
V. NO ACCELERATION OF PAYMENTS BUT ESCROWING ALLOWED
The Contractor may not require payments to be made in advance of the time specified in Section
III(Payment)above for the reason that he deems himself or the payments to be insecure.
If,however,he deems himself to be insecure,he may require, as a prerequisite to continuing the
work described herein,that the balance of the payments under this contract that are in the control
of the Owner,shall be placed in a joint escrow account that requires the signature of both the
Contractor and the Owner for withdrawal.
VI. INSURANCE
Contractor will be responsible to Owner or any third party for any property damage or bodily
injury caused by himself,his employees or his subcontractors in the performance of,or as a
result of,the work under this Agreement. Contractor agrees to carry insurance to cover such
damage or injury.
(978)423-6154 340 Mt.Vernon Street Lawrence,MA 01843 Fax(978)688-7476
R. Joseph Ratte, Inc.
General Building Contractor
ee&&cati q twat 60 yeana of aeutice
bE d&ficed 1954
VII SUBCONTRACTING
Contractor agrees that,notwithstanding any agreement for materials and/or labor between
Contractor and a third party,Contractor is responsible to Owner for completion of all work
described in a timely and workmanlike manner.
VIII CONSTRUCTION-RELATED PERMITS
The following construction related permits will be necessary in order to complete the scope of
work included in this contract and are the responsibility of the Contractor:
(mark X where applicable)
Building X Demolition
Plumbing Electrical X
The Contractor under provisions of Chapter 142A of the General Laws is required to apply for and
obtain all construction related permits.Home improvement work(i.e..additions,garages,porches,
etc.)may require other permits including but not limited to Variances and Special Permits under
Zoning by-laws through the Board of Appeals,Board of Health Permits for expansion of sewage
disposal systems,Conservation Commission for an Order of Conditions,etc. Such permits which
may require non-construction related,engineering,technical or legal representation of the
Homeowner,shall be the responsibility of the Homeowner.
Notice:
If the homeowner obtains his own construction-related permits for the work described under this
agreement,the homeowner is hereby advised that in the event of a dispute,judgment and
nonpayment of the Contractor,the homeowner will not be entitled to make a claim to or
collect from the guarantee fund established by Chapter 142A,M.G.L.
IX. MODIFICATION
This Agreement,including the provisions relating to price and payment schedule cannot be
changed except by a written statement signed by both Contractor and Owner. However,
cancellation by Owner is allowed in accordance with the Notice of Cancellation(annexed).
X. WARRANTIES
The Contractor warrants that the work furnished hereunder shall be free from defects in materials
and workmanship for a period of 1 year following completion and shall comply with the
requirements of this Agreement. In the event any defect in workmanship or materials,or damage
caused by Contractor,his subcontractors,employees or agents,is discovered within one year after
completion of any job,including cleanup,the Contractor shall,at his own expense,forthwith
remedy,repair,correct,replace,or cause to be remedied,repaired,or replaced,such damage or
such defect in materials or workmanship. The foregoing warranties shall survive any inspection
performed in connection with the agreed-upon work.
(978)423-6154 340 Mt.Vernon Street Lawrence,MA 01843 Fax(978)688-7476
R. Joseph Ratte Inc.
General Building Contractor
ee&&xcWng.mw%60 cyewo of 6ewice
btaBl?iaW 1954
All warranties for equipment supplied by the Contractor under this Agreement shall be those
given by the manufacturers of such equipment,which shall be and are hereby passed through
directly to the Owner. Under such manufacturers'warranties, the Owner may be required to
register or mail in a warranty card or other evidence of ownership and use of such equipment in
order to activate such warranties. The Owner's failure to mail in or register such documentation,
which failure voids the manufacturer's warranty,shall not create any responsibility for the
Contractor to warranty such equipment.
XI. COMPLETENESS OF AGREEMENT FOR EXECUTION
The Owner is hereby advised that he should not sign this Agreement unless and until all blank
sections have been filled in or marked as void,deleted or not applicable,and until all exhibits and
related or referenced documents that are incorporated herein are attached hereto.
XII. COPY OF AGREEMENT TO BE GIVEN TO OWNER
This Agreement is governed by the Laws of Massachusetts. It must be executed in duplicate,and
an original signed copy hereof given to the Owner at the time of execution. No work
under the Agreement shall begin prior to the signing of the Agreement and transmittal to the owner
of a copy thereof.
RIGHTS TO CANCEL
The owner may cancel this agreement if it has been signed by the owner at a place other than
an address of the contractor which may be his main office or branch thereof,provided that
the owner notifies the contractor in writing at his main office or branch by ordinary mail posted
by telegram sent or by delivery,not later than midnight of the third business day following the
signing of this agreement. See attached Notice of Cancellation.
HOMEOWNER DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Owner's Si Date Signed Contractor's Signature ate Signed
(978)423-6154 340 Mt.Vernon Street Lawrence,MA 01843 Fax(978)688-7476
The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
;� www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERIVIITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
i
Address:
City/State/Zip:G J/L/ m{f Phone#: 9 2 45
Are you an employer?Check the appropriate box:
Type of project(required):
1.01 am.a.employer with 0. : employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t
�
4.F1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
❑ 13.0 Roof repairs
• These sub-contractors have employees and have workers'comp.insurance.#
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no.employees.[No workers'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 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
employees. If the sub-contractors have employees,They must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. 7 c Expiration Date:
Job Site Address: �y3 Gf�eIfr0,1`ayt/b RD City/State/Zip: /V/
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
coverage verification.
Y do hereby certi -under tIz pains enalti of erjury that the information provided ab ve is true and correct.
Sinature: Date:
Phone#•
Official use only. Do not write in this area,to be completed by city oi-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#:
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(LLC)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 or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any 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
ppropriateline.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 pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or pennit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext.7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
RATTE-1 OP ID:KM
CERTIFICATE OF LIABILITY INSURANCE DATE(MNWD/YYYY)05/05/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE. POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endomeme s.
PRODUCER NMIEcT Lawrence R.Michaud,CIC
Michaud,Rowe And Ruscak Ins. PHONE 978 688 8829
P.O.Box 188 A/c N E (arc.Not:978 557 2130
North Andover,MA 01845 ADDRESS:lmichaud@rnrrinsumnce.com
Lawrence R.Michaud,CIC
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A:Preferred Mutual Insurance Co. 15024
INSURED Roger J.Ratte,Inc. INSURER 13:Saf Insurance CompaMf 12808
Attn.:Joe INSURER c:Guard Insurance Group
340 Mt.Vernon Street
Lawrence,MA 01843 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH'RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR TYPE OF INSURANCE L SUER POLICY NUMBER POLNMMNYYYI ICY PO P LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 500,000
DAMAGE TO RENTED
CLAIMS-MADE FKOCCUR CPP0170594188 03/28/201:5 03/28/2016 PREMISES Ea occurrence $ 100,000
MED EXP(Any one Person) $ 50,000
PERSONAL&ADV INJURY $ 500,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000
POLICY❑PRO:
JECI ❑LOC PRODUCTS-COMP/OP AGG S 1,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
B ANY AUTO 1500030 01/16/2015 01/16/2016 BODILY INJURY(Per person) $ 250,000
ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ 500,000
Autos Autos $ 100,000
NON OWNED PROPERTY DAMAGE
X HIRED AUTOS 'K AUTOS Par accident
S
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $ _
WORKERS COMPENSAnIN
OTH-
AND EMPLOYERS'LIABILnY ST TLITE ER
C ANY PROPRIETORIPARTN=RIEXECUTIVE YIN
ROWC633972 04/231201:5 04/23/2016 E.L.EACH ACCIDENT S 100,000
OFFICER/MEMBER EXCLUDED? El N I A
(Mandatory In NH) , E.L.DISEASE-EA WPLOYEE $ 100,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Sehedula,may be attached H mora space Is required)
CERTIFICATE HOLDER CANCELLATION
NORTH13
SHOULD ANY OI:THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of North Andover ACCORDANCE VWTH THE POLICY PROVISIONS.
120 Main Street
North Andover,MA 01845 AUTHORIZED REPRE:LENTATIVE
C 19E;8-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
i
Office.of Consumer Affairs&Business Regulation `
ME IMPROVEMENT CONTRACTOR:
- egistration: j60294 Type:
xpiration: :;_::6I--- b1.6. Private Corporatic.z
ROGER J. RATTE, INC
Joseph Ratte - -
340 Mt.Vernon St
Lawrence, MA 01843 Undersecretary
Massachusetts Department of Public Safety
Board of Building Regulations and Stanplards
License: d"15004
Construction Supervisor
JOSEPH R RATTE:
340 MT VERNON--ST
LAWRENCE MA x:018
^^� Expiration:
Commissioner
08/2712017