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HomeMy WebLinkAboutBuilding Permit #304-15 - 259 OSGOOD STREET 9/25/2014 BUILDING PERMIT of"°oT"�tio TOWN OF NORTH ANDOVER �� y ~'- -} '` ° APPLICATION FOR PLAN EXAMINATION 2 h T Permit No#: Date Received w� re D � �gSSACH►15���� Date Issued: IMP RTANT: Applicant must complete all items on this page LOCATION a5 05CVOJ Al 11 I.AV,rTr - A/q 0 (e�lSi Print �- PROPERTY OWNER_ _�YL�r �Y�S�1 rt Print 100 Year Structure yes MAP PARCEL: _ZONING DISTRICT:.Historic District yes . Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Resi ential Non- Residential ❑ New Building VOne family ❑Addition ❑Two or more family ❑ Industrial ❑ teration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: &J�c r CwUw2 : a yPAAJ(-k sk I Lg iroo Cl vL J r'Ro Lp-,L w i Q y-C L,194 S kti,�1 - u Identification- Please Type or Print Clearly OWNER: Name: Phone: Address:- Contractor'Name: ddress:Contractor'Name: SCo# 1,A)n (Phone: Address: 3S4 d3c�c-r- nrJCo✓�r� /It Supervisor's Construction License:0,5-/od KK 2 Exp. Date: O$ /a do/s- Home Improvement License: S6 Exp. Date: y �r ARCHITECT/ENGINEER Phone: 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: $ '1oW0.00 FEE: $ Check No..- d� Receipt No.: OL NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor 1 Plans Submitted ❑ Plans Waived ❑. Certified Plot Plan ❑ Stamped Plans ❑ TYPE'OF SEWERAGE DISPOSAL i Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ 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 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 I Conservation Decision: Comments f Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street � FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street - Fire Department signature/date COMMENTS i 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 ❑ Notified for pickup Call Email Date Time Contact Name t Doc.Building Permit Revised 2014 I 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 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 ❑ Copy Of Contract ❑ 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 ❑ 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 off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance orspecial permit was required the Town Clerks office must Stam the decision from the Board f p o Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 1 Location r No. — Date .l . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $A-I -- Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 2 T Q `' J V "i Building Inspector � � » wR1 NT 5� r,�/ Rf• WAMR-Mvement Samble Q®-*-rp r-- IfRn fOlmRge satisfies all basic requirements Of the state's Home Improvement Contr'ctor Law(MGL chapter 142A),but does not include standard Ia ass ah se protect homeowners. 101neSeelc legal advice if necessary. Any pers 'planning home improvements should first obtain a copy o£"A Massachusetts Consumer Guide to Home Improvement"before agreeing a y work on Oyour residence.YOa free copy U ffice o£ConsumexAffaixs and Business 1�egulation's GbnsumerinformationHotline at 617-973-8787 or x 88 2 3.3757 or on our bv ebs g e Homeowner Wa r'iml a ie>m 'Contractor JCnf®rma.tion Name 50.. cM 0 r� Company Name Street Address(do not use aPost Oflice Box address) aSG O$ Contractor/Salesperson/ wnerName o�� S�. SCOW- Wrr' ti+ City/Town State Zip Code Business Address(must include.f street address) , nC1jVzeV- ,+7R Dl�'y5 3So ` Daytime Phone Evening Phone 8 a r r City/Town State Zip Code 683-5-do l S�m� • Mailing Address(It different from above) �lF Ah�ove,,- /h 4 OJ 8 y5_ Business Phone rye•j,ggs � Federal Employer ID or S.S.Number gfS Homermprovement contrectorltog Number �V�6 XnwrcgnirestlmtmastJtmne Expiratiandate Improvementatlannurob r I -6 n vniid regstrntien nnmver The Contractor agrees to do the foIIowing work for the Homeowner: S�r,,p Q.t�'s4;,,5L a /y 15- On S (Describe in detail the worlcto completed,specifying the type,brand,and grade of materials to be used,use additional sheets ifnecessas ctnd i�0.FeN-sh+els{ on gill eccveS, uSe 3olb fel�P��er v��pov-parr i'�r-o�,res.,at�inc ! )deck++t�,use 6 o7cice 01dve.S Grw�irp�i eS Pufd©wen G,4FT1wi5erl;hQ ��f, slt,, L1 desk_US¢ V11CH altAM, da-lpe� yKe./a onctlf �e?o_k wi� C�b�av� �vt�,�sn<�r prod, r� �s.L',"A //O+mph &";Idvct���� l,lSe r1Qw >ap� U2nT bae•�S.Ve:.{ Let Qrs� rC'e%YtA vr�Q .+v 'pe ke d e,6 n r 4o Gies j' np'I'eel N nd 474 /c�S and will b Permits-the Following building permits are required Proposed Start and Completioix Schedule-'The following schedule ' and w>v be secured by the contractor as-the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise 1 (Owners who seenre their own pernaifs:WM be excluded from the Guaranty Fund provisions of MGL chapter 142.A,.) Date when contractor wilt begin contracted work. �© /y Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specs-ed above for the total sun-,of. Payments will bemade accoxdingto the following schedule: ( ) a 00. upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) by / orupon completion of $� by / or upon completion of � gdd.00 upon completion ofthe contr :::���� act, (Lawforbids demanding fall payment Until contract is Completed to both The following material/equipment must be special g paxty'ssatisfaction) . ordered before the contracted work begins in order to be paid for to meet the completion khedule.(**) to be paid for Law requires that any deposit or down payment required by the contractor before workbegins may NOTE' ('i')Including all finance charges not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet tite completion schedule. x ressWarranty-7e an -press tntvbeina , rroytded by the contrac�or: No [] Yes aU1 .erms of the warran mast be attached io the contract Subeontxactors-The contractor agrees to or. Tel cc onsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all a materials and Labor under this alzreement p yments to all subcontractors for Contract Acceptance-Upon not i signing,this document becomes abin contract shall ding contract under law. Unless otherwise noted within this document,the carefully before signingingth thiss contract.any lien or other security in has been placed on the residence. Review the following cautions and notices O Don't be pressured into signing the contract.Take time to read and fuliy understand it. Aslc questions if stion. omething is unclear.• aloe sure the contractor has a valid Home 7m rovement Contractor Keri str,, subcontractors to be registered with,the Director ofI3ome Improvement Contractor Re The law ri quires may inquiremost home r aboutcotcontractor contractors and registration by writing to the Director at 10 ParlcPlaza,Room 5170,Boston,IVIA-02116 or by calling 617-973-8787 or 888-283-3757. Does the contractor have insurance? of Ask the Contractor for his insurance company information so that you can con coverage,ox isle to see a copy of a"pooh£veinsuxance"document. o I<u ow your rights and responsibilities. Read the Contractor Law:Important Infoxxnation on the reverse side of this fo Guide to the Home Improvementi�n and get a copy of the Consumer You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you no' e contractor in writing at his/her main office or branch office 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. Seethe attached notice of cancellation Form For an explanation of this right, �®IoTpies of Gl�17C 7[S C;ONTRACT IF TDERE ARF A1VY]�1GAl�TJ[�SJPAC�S!!! Two identical copies of contractmust be completed and signed. One copy should go to the homeowner. The other eopy'sltouldbe lceptbgtl,e contractor, "j Rome, is ignatare Contractor's Signature v /C_ • 'Date ( /�S//C/ Date Contractor Arbitration 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 Tight is not automatically affordedto 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 light to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner 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 axbitrationftm which has been approved by thtSe tary of the Executive Office of Consumer Affairs andBusiness Regulation and the consumer shallbe required tt to 'such orb' tion as.provided 7n Massachusetts General Laws,chap er 142A.. Ho e caner s s' titre Contractor`s Signat NO ][C]E:The signatures of the parties above apply only-to the agreement of the patties to alternative dispute res tion initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this sec n is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor L4.w'(MGL chapter 14.2A) 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 to contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded:from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike 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 guarantees or warranties provided by the contractor,all goods sold.in Massachusetts carry an implied warranty of merchantability anal:6.tness for a particular purpose. An enumeration of other matters on which tffe homeowner and contractor laud ally agree maybe 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 InformationHoilino(listed below). Execution of Contract; The contract must be executed in duplicate and should not be signed until a copy of all exhibits and Teferenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been :filled in or maxlted as void,deleted, or not applicable. One original.signed copy of the contract with attachments i.s to be given to the owner and the other kept by the contractor. Any modification to the.original contract=ust be in writing and agreed to by both parties. Contracted work may not begin-until both parties have received a fb y executed copy of the contract,and the three day rescission period has expired. Accelerated payments A contractor may not demand payments in advance of the dates specified on the,paytuent 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 requite that the balance of funds not yet due be placed in a j oint escrow accour t as a prerequisite to continuing the contracted work. Withdrawal of funds:from said-account would require the si&mttitxes of both parties. Additional formation If you have general questions or need additional in-ormation about the Home Improvement Contractor Law or other consuxv er rights,or if you wish to obtain:a free copy of "A Massachusetts Cons-Loner Guide to Home Impiovemene contact: Consumer:information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 orvisitthe OCABRwebsite atI=://wwrv.mass.gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional,information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs an.d•Business Regulation 16 PaxkPlaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visitthe I-RC website atb :/p /7m,�v.tnass.gov/oeabr/ Go online to view the status of a Home Improvement Contractor's Registration: , httt�://db.state.ma.tis/hoyneimprovein ent/licenseeTist.asb For assistance with informal mediation of disputes or to regisf er formal complaints against a business, call: Consumer Complaint section Off Lep of the Attorney General 617-727-8400 .AND/OR Bever Business Bureau 508-652-4-800.,508-755-2548 or 413-734-3114• Version 2.1-11/22/2010 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS402663 SCOTT W WRIGIJA 350 BERRY ST NORTH ANDOVER MA 01845 Expiration Commissioner 08/12/2015 Cheam�nt2nraerrll>lz a�C iG(rzJJac�u3E(tS Office of Consumer Affairs&Busibess Regulation UTxMIrE IMPROVEMENT CONTRACTORgistration: 138569 Type:pation: 4/14/2015 DBA WRIGHT GUTTERS SCOTT WRIGHT i 350 BERRY ST. NO.ANDOVER,MA 01845 �— Undersecretary i� - NORTII n Of n over Tow _ .Yr. No. 6 tiz� lC0C"1C"1W1C% *_� h ver, Mass, a5.. �d A04 ATED 0'4 %,`,�5 S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System 0 • BUILDING INSPECTOR....................... THIS CERTIFIES THAT .... .. .. ........ .............. ............�... ..�.�l�.��...... ®�• •�ad. � Foundation . has permission to erect .......................... buildings on .. .....•••• •••••• Rough to be occupied as ......... + N� ..'.'I...... ....................... ............. .................................... Chimney provided that the person accepting this permit shall in every respect con m 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 PLUMBING INSPECTOR Construction of Buildings in the Town of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT S S Rough Service ............ .... ........................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Final Display in a Conspicuous Place on the Premises - Do Not Remove No Lathing.or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. ne Commonvealth offfassa Auseft . , O•f ee o•fbMsfigWORS 00 Washkeow Mweet Rostov,MA 02111 wow.masygovIdIa wakey$l ComRemationbwance Affidavit:J��c�erc���o��eac�ox�I�tcc���c�a�sl�'�u��iUP 'Name(Btnsin.ess/drganiaatioxftdtvidiial):17 Cady/ �a��I. ` : g. . � �yg ; 61A 019VS Phane� 9'78 -687- �ay7 Are,pxxan eMPXope0 Che&tiio appropxiato'hom. Typo ofPxoject(ream,red): I Pfl am a employer Y.th 3 4, U I ata.a genard confractox andl 6, New cansft-ac lo-. employess(x5zlland(oxpax�t7me)T ha-veBftodtheMb-cantea0toxB 2.Q I am a sale Pxopxietor or partn.ex~ listed on.the atiached sheet°� 'T• �Rema�deling ship ax�d'havena.employees These sulr-contxactoxshavo S. [{Demolition working £oxine in as capacity. woxl�exs'comp.insurance. g. Building addition worRas'comm.insurance 5, �( l e are a coxpoxatzoxt and its [No off(c have exexcised.theix •10•0 Electxicalxepais or acTditians recftrired.] 3.Cl z am a homeowner doing all work right of exemption p or MOL Il=0 PIMbingxepairs or additions myseL (owgrkers'comp. o.1.52,§1(4),andwehawxo 1-2.[1R fxelrais r insuxaxzc�xe�.ixed.�� employees.[No workers' 13. flthex ��SP F R�=Roof comp.lumanceregfted.I ��•applicantihaicf�eeksbo�#�Zmustalso�Tlouithese�tioazbelbwshawingtheirwbrkers'compensation.policpinfozmation. '� 1 omeoVvners who snbm-MhkaWdavitindicatingiliekkedgingaaworkandthenhireoutsideconizactorsmustisubmitanewaffidavit hdicatingfth. TGontractomMe,P'TICAVM. box ustaifached�!additionalsheetshovringthenameofthesubcoUiracforsandtheitworkereCOMP.poiicyIfnnatzon. I arm an employer tridbVrovMV9 wffhfs comVewadan znsuraneo formy ewfoyeest 13eToWhe'vo.11ey oviijob SIM.- i�,fo�.ma�zox�. ,�y� /� L`tsnxartce Compaxly Tame;. L! bz �� I J A IS011'IJP Pi TnS, / �hC. Rolicy orel ins.Vic.#: W C S- 2► S -38 7 X87 —0 13 ExpiratzonDate: `�130111-1. rob Bite-A.ddxess; aS-9 �S �d Y- Pityisfatelzip: Andagc, Mil 0/8YS fachacopyoxthewinkera,compensation-Polleyileclaxatzon.page(showiug�tltepoucyxtmnlaexantie pitatloadate. Yailma to secure covexage as xeciu%xeduuder SectionZA.ofWff,c.152 can leadto the imposition of of a Ae up to$1,500,00 an.dlor Otte-year h aptisoment,.as well.as cipilpenaltzes hZ the fox.!of STOP WORT.ORDER and a.f a o£uMa io$250A U a.day against tf o M- 0Zatox: Be advised that a copy oftha stateMen-tmaybe foxwax'dedto VIG Of irlo Uf• Znvestigatioxzs of the DU for insurance coverage veriffcation. :aine yce zfyei4fornatiox� mvicTecTa ove is zee anrTcorr�ei° Date: �lione#: fl cic�Z�c se a� Ty. /Io rza wxife in trim a ett,z`c�die cox TetetT by cies o Lawn 0ff af City or Town.: BexxClxt/Eicextse# fSsuing.t -affiarity(circle tixte): Z.$aaxd ofUealth 9 uRdingDepaxtmeet 3.Q€ JTowa Clerk �.�lectxzeal lrnspee�ox �.�lnna�irtg�izspecto� f:Other - - - Information and Instructions . Massachasefis General Laws chapter 152 requires an employers to providewoxlzexs'compensation fox them employees Parsuaxittogig statute,anevri3Orayeeisdefntedas11—evexy'pexsonhi.-Ehesexviceof motherMderany co. fractofAbite; express ox•implied,oral ox Wxitfen:' II Alt 1gyer7 defined as"an ztsdzvidnal,paxiaexsSizP,assoofafion,cor_poxalt ort OZ of Lerlogal entity,ox ap-yfWa ox anoxe oftheforegoingengagedivajointenterpxisa,and kof-adingli a legalxepxesentativesofa•deceasedPPINI a,.oxtTie receiver or- sfee a anindividual,paxtetexship,association ox ofhexlegal entity,emplaying employees, 1Sowevexthe oWazex oia dweliingzxousehavingnatmoxe-tha�x�xee apattmenfs and Wzto xeszdes l�hexein,ox the occupazzf o�'�ie dWellingll-ause Of another Who employs,persons to do maintenance,coxistr�zctzon oxxevaix woxzz on such dwellxugzZouse or onfhegxounds oxbuilding appuzienanttherefo shalfnot because ofsuch,employxnentbe deemedtabe an.employe:" MGIC chapter 152,§25C(6)also states fhat"every state or local licensing agency shall withhold the Issuance or renewal of a Ifeeme ox pexMit to operate a business or to construet buildings:k the commonwealth for arty applicant who has nOt praduced•acceptable evidence of coz-01fance witzt the insurance coverage required;' Additionally,MGL chaiex 152,§25C(7)stafes`Weithex the commonwealth nor any of its political sab divisions shalt enter into any contractfor the p erfoM2MGe of public work until accepfable evidence of compliance with the inswance xecluirements oftbis chapiexhavebeenpresentedtaiil�.ecopiract�gauthoxity," .c�pp.ucanrs P1eas�X11 out the Workers'compensalZon afdavif completely,by checking Elie boxes tbat apply to your sztuaon and;ii iiecessaxp,supply sub-contracfax(s)name(s),addxess(es)and�honenumbr,*)along WM their carMcate(s)of insbxauce. LimitedUabiliVeompanies(LLC)or mztedLiabihtyPaxtnexships(M)Withno einplayees othexthintlze members oxpartners,axenotxecluixeczta caxtyWoxl ers'compematio.ufimmnce. 1fanT I C oxLLP do e, employees,a policyisxeq*ed. Be advised afdavitmaybe,submitfedtotheDepaxtmentof Tudustrial Accidmt�for confirmation ofiasuxance coverage. .Also be sue to 31P and date the affidavit' 'the afiYdavit shoufd bexefumedto the city or toWo that applicatzonfoxtfieperout oxliceuse is beingxegaested,not theDe�artment of kdusErialAccidenfs. Shouldyouhave,any cluestionsxegaxdingthe law orzfyouare xeclazxedtoobfaiva�orl�exs' compensationpolicy,please call thaDepartmentattltemzmberlistedbelow. Self-jr rxedeompaniessbouldenferfheix sell insurance license numb ex on the appropriate line. City or Town 0Mcia is PZeasebesuxetltattlieazrzdavitiscompleieandpxintedlegibly. T.heDepaxtmenthasProvided aspaceattha�eLom oftho aMlavitfoxyoutofill outiathe eventthe Office of1•nve3tigafkashasto contactyouxegardingthe apjlicant Pleasebe-suxetaz"tlfixttbepermxt/ficensenumbexq� cbvriljboused asareiexOnce numbex, fitaddition,anappltcarti fhat�nttstsubmii7nufiiplepezntif/ ce eappltoa onsitzanygivenyeax,needonfysubmifone,aj2davatiudicatingcutxent p olicy information(h�'necessaxy)and under"1'ofa,Site Address"the applicant should Write to "afllocatlo�s in .(city or Wft)"A copy of the aiddavi4 thathas be' ofRciallY.S ainp0d orm.arkedbyle city or towxtmaybepxovtded to tl�e appzzcant as pxbof'that avalid affl&Vit is 6n ftfe�or'5xtvxepermifs oxlicenses. Ajaew azftdavit:nustbe filled out each year.Whexaab,omeOmeroroitizzenisobfai ingalicenseoxpermit,notxelatedtoany'busi-oessaxaomrneeLd67entaGA doglieense oxliermitto bWM leaves eta)said person is NOTmquixedtoComplexe this afAdavz The office of Investigations wWd life to that you in advance fox your cooperation and should you have any gtzesf'tons, please do xto f-hesitate to give us a call. The Depaxtm,ent's address,felepl�.one aizd faxnumber: . Qr 3��pax�xtext�a�.�x�du�rz�.�acc�t�e�.t� Revised 5 2605 � � ATE Mks�y ' Aco CERTIFICATE OF LIABILITY INSURANCE ° 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($), 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 endorsement(s). PRODUCER T A SULLIVAN INSURANCE AGENCY INC NAME:CONTACT_ 135 MERRIMACK ST ATONE FAX No: METHUEN, MA 01844 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC p INSURERA: LM Insurance Corporation 33600 INSURED INSURER 8: SCOTT WRIGHT DBA WRIGHT GUTTERS INSURER C: 350 BERRY STREET INSURER D: NORTH ANDOVER MA 01845 INSURER E: INSURER F' COVERAGES CERTIFICATE NUMBER: 21153469 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MMIDDIYYYY j COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE �OCCUR DA AGE 0 REN E PREMISES Ea occurrence) $ MED EXP(Any one person) S PERSONAL 8 ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY PROJECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident �S ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED i $BODILY INJURY Per accident)AUTOS AUTOS ( _ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS I AUTOS Per accident $ UM13RELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE j AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION WC5-31 S-387187-013 9/30/2013. 9(30/2014 AND EMPLOYERS'LIABILITY Y/N I ✓ STATUTE OERH ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S 100000 OFFICER/MEMBER EXCLUDED? N/A ❑Y j (Mandatory In NH)es,describe under I( E.L.DISEASE-EA EMPLOYEE S 100000 y DESCRIPTION OF OPERATIONS below I I E.L.DISEASE-POLICY LIMIT $ 500000 i I i t DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR SCOTT WRIGHT. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BLD INSPECTOR THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 OSGOOD ST BLD 20 STE 2035 ACCORDANCE WITH THE POLICY PROVISIONS, NORTH ANDOVER MA 01845 AUTHORIZED REPRESENTATIVE _ LM Insurance Corporation ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 'ERT NO.: 21153469 CLIENT CODE: 1623570 Didi Dangas 8/7/2014 7:31:21 PM (EDT) Page 1 of 1