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HomeMy WebLinkAboutBuilding Permit #361-2017 - 26 WOODBRIDGE ROAD 10/5/2016 NORTM 9 BUILDING PERMIT S TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received /U -S' U� °q <a�,<•.. . • `°R,T.o Date Issued: 1 0 t� �ssgcHus�� IMPORTANT: Applicant must complete all items on this page LOCATION Print 1 ,� PROPERTY OWNER �r UVLA ZO)kJ Print MAP NO:-tL —?PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic []Well, Rei Floodpiain 0 Wetlands Q Watershed District ❑Water/Sewer rR,„a `QH S. \cr.� ,r� ° a �X��r.�f �o�� S ` Identifi'ca_tiion Please Type or Print Clearly) OWNER: Name: PhonA: S W6 I�W Address: CONTRACTOR Name Phone: , Address: Y) Supervisor's Constructi n License Exp. Date:, r=w � Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: AddressN�jn STAyc\Y1 <V, �_ nw" A01SP,3 Reg. No. \.A\N3 FEE SCHEDULE:BULDINQ PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: FEE: $ �f Check No.: 5-1 Receipt No.: 3 0 NOTE: Persons contracting with unre istered contractors do not have access to the gua mty fund _e ctognatureofAgent/Ow Signature,of contraSr i _ J Plans Submitted ❑ Plans Waived ❑ Certified,Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ l� 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 I CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Si nature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments I Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: -- _ Located 384 Osgood Street FIREs•DEPAIk aMENT Temp-Dumpster onJsite Located at 12:4(Main;Street YeS -- no+ _ Fire Department signature/date COMMENTS t 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 a ro Electrical Inspector Yes pp val of No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A–F and G min.$1o0-$1000 fine No NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time __._�.._.._------------ Contact Name Doc.Building Permit Revised 2014 — r 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 I ❑ 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 o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o 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) o Mass check Energy Compliance Report (If Applicable) a 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 Li Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit E3 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 o 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 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 Location C9 jo No. l L ti Date • - TOWN OF NORTH ANDOVER ° Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# - 0 6 Building Inspector J ;, " NORT01 '9 Town of ?_ .a n over 0 �+ ,� oh ver, Mass, / 0 0 S 79 pDRATED pPP��S S U BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT , ,,,, ,,,, ,,,, ,,,,tI BUILDING INSPECTOR .....Y�.^�.......�. !N..rc.... ................. has permission to erect .... buildings on .......s..& 'b �6 p Foundation .................'�.................... Rough to be occupied as Ric eKu*/l......W.�Y.Of k I Ocl���V........,�Qv/e�'. ��'!�it . ... himney 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 CONSTRUCTION TS 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. MASSACHUSETTS HOME IMPROVEMENT CONTRACT Homeowner Information Dean and Laura Bates 26 Woodbridge Rd. N. Andover,MA 01845 978-988-9261 Contractor Information Turner Carpentry CSL# 108738 EXP 10/17/2018 Ryan Turner H1C# 178626 EXP 5/5/2018 17 Baypoint Ln. Tax lD 46-4976419 Haverhill, MA 01835 978-478-7756 WORK TO BE PERFORMED AND MATERIALS TO BE USED Work to be done by contractor: Remove and replace 2 exterior door. Install 2 double hung windows. Frame all walls to spec for windows and doors being installed. Open wall to kitchen and install Beam per engineers specs being provided by homeowner. Insulate walls and ceilings as necessary. Hang drywall only.No taping or finishing. Materials to be used by contractor. All materials to be supplied by homeowner. Work Scheduled To Begin 10/20/2016 on or around Expected Date of Completion: 11/20/2016 on or around TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE The Contractor agrees to provide the work, furnish the material and labor specified above for the sum of$3,379.83 Payments will be made according to the following SCHEDULE: 1 $1,115.34 Deposit before work is started. $1,149.14 Due after framing and windows are complete Balance of$1,115.34 due upon completion of the contract. In order to meet the completion schedule, the following material/equipment must be special ordered before the contracted work begins: _Doors,windows,beam DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Dean Bates{Sep 2 96 Customer's Signature Contractor's Signature Dean Bates Ryan Turner Sep 20,'2046 9i2012016 Date Date You may cancel this agreement if it has been signed by a party thereto at a place other than at the address of the seller,which may be his main office or branch thereof,provided you notify the seller 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 the agreement. See attached notice of cancellation for an explanation of this right. REQUIRED PERMITS The following building permits are required: Town of North Andover,MA Building permit. It is the obligation of the contractor to secure such permits as the homeowner's agent and any costs which contractor will incur in doing so are included in the price for this job as set forth above. Please note that homeowners who secure their own permits or deal with unregistered contractors are excluded from the Guaranty Fund provisions of MGL C. 142A. Is an EXPRESS WARRANTY being provided by the contractor? No Yes X The following warranty will be provided by the contractor under this contract: 1 Year Workmanship and material warranty any materials under warranty will be through manufacturer of such materials. 2 Please note that all home improvement contractors and subcontractor shall be registered and any inquiries about a contractor or subcontractor relating to registration should be directed to: Director, Home Improvement Contractor Registration, One Ashburton Place, Room 1310, Boston, MA 02108, 617-727-8598. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A) 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 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 and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be 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 duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled 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 three day rescission period has expired. ARBITRATION 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 such dispute to a private arbitration service 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 for in MGL C. 142A. Contracto Homeownerbean Batas(Sep 2 , ffl— Date: 9/20/2016 Date: Sen 20, 2016 NOTICE: the signatures of the parties above apply only to the agreement of the parties to alternative dispute settlement initiated by the contractor. The owner may initiate alternative dispute resolution even where this section is not separately signed by the parties. 3 . i i ACCELERATION OF PAYMENT Homeowner's Financial Insecurity. 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. Contractor's Financial Insecurity. 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 joint escrow account as a prerequisite to continuing the contracted work. Withdrawal from said account would require the signatures of both parties. Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at http://www.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 and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283- 3757 or visit the HIC website at http://www.mass.gov/ocabr/Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeimprovement/licenseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 OTHER CONTRACTUAL DOCUMENTS This contract includes as contract documents the following additional enumerated documents: 4 NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR OBLIGATION,WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOUR CANCELLATION NOTICE,AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE,IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED, ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY,IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION,YOU MAY RETAIN OR DISPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO, THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION,MAIL OR DELIVER A SIGNED A DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO(Name of Seller),AT(Address of Seller's Place of Business)NOT LATER THAN MIDNIGHT OF (date). I HEREBY CANCEL THIS TRANSACTION. Date: Buyer's Signature: 5 KITCHEN c� z o DOOR DOOR GARAGE EXISTING WALL TO BE REMOVED AND REPLACED WITH NEW LVL BEAM S BREEZEWAY ST I WAY o x W DRYWALL TO BE INSTALLED ON THIS EXISTING DOOR TO SIDE OF WALL BE REPLACED WITH FIRE RATED DOOR EXIST. WINDOW EXIST. DOOR EXIST. WIiIDOW EXISTING WINDOWS AND DOORS TO BE REMOVED AND REPLACED WITHIN NEW STUD WALL 2x6 0 16" 0/C PARTIAL FIRST FLOOR PLAN SCALE: Y4" = l'-0" BREEZEWAY FLOOR PLAN PREPARED FOR A LAURA AND DEAN BATES BATES RESIDENCE 26 WOODBRIDGE ROAD 26 WOODBR4DGE ROAD 10/03/16 NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 12 8 EXISTING RAFTERS TO REMAIN EXISTING CEILING JOISTS TO REMAIN EXISTING WOOD PLANK CEILING TO REMAIN I ' PROPOSED Y" DRYWALL NEW WINDOW — a DOOR BEYOND NOT SHOWN FOR CLARITY EXISTING CONCRETE SLAB EXISTING HARDWOOD �. ON GRADE TO FLOORS REMAIN EXISTING SUBFLOOR NEW 2x6 STUD WALL EXIST.FLOOR a JOIST TO REMAIN s a � os a EXISTING CONCRETE EXISTING CONCRETE FOUNDATION TO FOUNDATION TO REMAIN REMAIN BREEZEWAY SECTION SCALE: %$" = 1'-0" BREEZEWAY SECTION PREPARED FOR A- 2 LAURA AND DEAN BATES BATES RESIDENCE � 26 WOODBRIDGE ROAD 26 WOODBRIDGE ROAD 10/03/16 NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 GENERAL NOTES AND MATERIAL SPECIFICATIONS ALL WORK SHALL CONFORM TO THE 8th EDITION OF THE COMMONWEALTH OF MASSACHUSETTS STATE BUILDING CODE. ARCHITECTURAL ITEMS (WALL FINISHES, WINDOWS, EXTERIOR FINISHES, INSULATION) BY OTHERS. THE CONTRACTOR SHALL VERIFY ALL CONDITIONS AND DIMENSIONS IN THE FIELD & WITH THE ARCHITECTURAL DRAWINGS AND SHALL NOTIFY THE OWNER/ENGINEER OF ANY DISCREPANCY BEFORE PROCEEDING WITH THE WORK_ EXISTING CONDITIONS SHOWN ARE NOT GUARANTEED. THE CONTRACTOR SHALL PROVIDE ALL NECESSARY BRACING & SHORING UNTIL ALL STRUCTURAL WORK IS COMPLETE. LOADING — RESIDENTIAL CONSTRUCTION PER 780 CMR 53.00: LIVING AREA — 40psf LIVE LOAD & 12psf DEAD LOAD SLEEPING ROOMS 30psf LIVE LOAD & 12psf DEAD LOAD ATTIC AREA — 20psf LIVE LOAD & 12psf DEAD LOAD IF >42" HEIGHT, 10psf LIVE LOAD IF <42" HEIGHT ROOF — DEAD LOAD = 15psf GROUND SNOW LOAD = 50psf WIND SPEED = 100mph ALL CARPENTRY WORK SHALL CONFORM TO THE LATEST NLMA STANDARDS USING: SPRUCE PINE FIR #2 KD, Fb = 870 psi (202) & E = 1.4 x 10^6 psi FOR DIMENSION LUMBER Fb = 2,600 psi (12" deep beams) & E = 1.9 x 10"6 psi for .LVLs NAILING PER TABLE 5602.3(1) OF THE MA STATE BUILDING CODE. ALL POSTS SHALL BE CONTINUOUS THROUGH FLOOR FRAMING AND BEAR DIRECTLY ON THE 2-2X6 SILL OR SUPPORTING BEAMS. PROVIDE JOIST HANGERS AT ALL FLUSH FRAMING NTH FULL LENGTH NAILS. ALL METAL CONNECTORS/HANGERS SHALL BE AS INDICATEDAS MANUFACTURED BY SIMPSON STRONG—TIE OR APPROVED EQUAL. LEGEND ABBREVIATIONS V.W.O. = VERIFY WITH OWNER VIF = VERIFY IN FIELD UNO = UNLESS NOTED OTHERWISE �� 0 SIM. = SIMILAR GALV. = GALVANIZED , HAS EXIST. = EXISTING 6TBUC URAL Cn t * N.T.S. NOT TO SCALE. 10.411 cy � " vT 4 . M Brae - LLC BREEZEWAY WALL REMOVAL PREPARED FOR GENERAL NOTES LAURA AND DEAN BATES Structural Design&Sales BATES RESIDENCE 26 WOODBRIDGE ROAD SK - 1 160 SYLVAN STREET TEL 978-646-0097 26 WOODBRIDGE ROAD NORTH ANDOVER, MA 01845 09/22/16 WIM€S,WA QMz' FAX VPM'N.1d B%FCrx KITCHEN r 3T �- E 75TJs TS REMA N GARAGE 4-1%"x7%" LVL I DOOR HA WALLI DROPPED BEAM TAIR V kY RE ZE AY EXIST JOTS TO R MAIN I i zxs 3-28 3-2K8 NDOW' D R iANDOW 1-JACK SND AND 1-KING STUD EACH SIDE OF HEADER PARTIAL SECOND FLOOR FRAMING PLAN SCALE: y4„ tp TR 'OT!lAE q N1514111 43 .. F StONAL V- _ M BrleLLC BREEZEWAY WALL REMOVAL PREPARED FOR PARTIAL SECOND FLOOR FRAMING LAURA AND DEAN BATES SK - 2 Structural Design&Sales BATES RESIDENCE 26 WOODBRIDGE ROAD 160 SYLVAN STREET TEL. 978-646-0097 26 WOODBRIDGE ROAD NORTH ANDOVER, MA 01845 09/22/16 DANVERSO MA 01923 FAX 997718-646-coi NORTH ANDOVER, MA 01845 I 2" TYR I TWO ROWS OF DOUBLE SIMPSON SDS225x6* SCREWS O 24'0/C STAGGERED (127 2-12 -NET SPACING) TYP' NEW.BEAM MEMBER-TYPICAL FOUR MEMBER DROP BEAMS TYPICAL NAILING DETAILS FOR BUILT UP BEAMS SCALE: NOT TO SCALE 3— 200 NTH 2— 200 WITH TWO LAYERS OF ONE LAYER OF 1/2-PLYWOOD 1/2"PLYWOOD SPACER SPACER ALL 26 EXTERIOR do LOAD ALL 2x4 EXTERIOR'&LOAD BEARING WALL HEADER BEARING WALL HEADER ABOVE DETAILS ARE TYPICAL AT ALL OPENINGS`UNLESS OTHERWISE NOTED ON FRAMING PLANS PROVIDE DOUBLE JACK STUDS FOR SUPPORT OF BEARING WALL HEADERS UNLESS OTHERVASE NOTED ON FRAMING-PLANS STANDARD EXTERIOR & LOAD BEARING WALL HEADERS SCALE: NOT TO SCALE HEADER POSTS FROM ABOVE POST UP O LVL HEADER (WHERE APPLICABLE) PER FRAMING PLAN LOCATION OF LVL HEADERS INDICATED ON FRAMING PIANS DOUBLE 70P PLATE (NAIL TO TOP PLATE) _ CRIPPLE STUDS AT 16" O/C DOUBLE JACK STUDS UNDERAl STANDARD HEADER(SEE ARCH. LVL HEADERS U.N.O. DWGS FOR ELEVATION —IYP,) 2—JACK STUDS(LOAD BRG. WALLS FOR 2 FULL HEIGHT STUDROUGH OPENINGS 3B"&GREATER AND S (LOAD BRG @ EXTERIORLVL HEADERS U.N 0). WALLS) i-.TACK STUD(NDN-LOAD BRG WALLS& BRG WALL w/GPENINGS LESS.THAN 3B') 1 FULL.HEIGHT STUD T umt SILL (NON-LOAD BRG. WALLS) CRIPPLE STUDS AT Ir 0/C FLOOR JOISTS WWALL.BOTTOM PLATE z r SEE PLAN POSTS O HIE CONTINU�w—TBE TE(WHERE BELOW UBLE TOP APPLICABLE E A a wALL PLATEs—EYP. ) TP#C7At WALL/DOOR OPENING CONSTRUCTION SIMILAR No.4114 SEE PLAN FOR JACK STUD QUANTITY FOR LARGE OPENINGS CIfi 'TS T eti ELEVA11ON — TYPICAL WINDOW FRAMING NOT TO SCALE McB' le LLC BREEZEWAY WALL REMOVAL PREPARED FOR DETAILS LAURA AND DEAN BATES SK - 5 Structural Design&Sales " BATES RESIDENCE 26 WOODBRIDGE ROAD 160 SYLVAN STREET TEL. 978-646-0097 26 WOODBRIDGE ROAD NORTH ANDOVER, MA 01845 09/22/1 6 2nd ANVERS.MA 01923 FAX DWWW.MCBRIE COM NORTH ANDOVER, MA 01845 The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERWrTING AUTHORITY. Applicant Information Please Print Le ibl Name(Business/Organization/Individual): y = Y-i/X-1Lk ur Address. City/State/Zip: v ) ,n(-\ M0.3 5 Phone#: 1,e) Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(fiill and/or part-time).* 7. New construction I am a sole proprietor or partnership and have no employees working for me in g. Remodeling any capacity.[No workers'comp.insurance required.] ❑ 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition 4.❑I 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 I I.[]Electrical repairs or additions proprietors with no employees. 12.n Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors 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 subcontractors have employees,they must provide their workers'comp.policy number. f am an employer that 1sproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. Ido hereby certify under epains andpenalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 18 'A I JE�l 7 S Official use only. Do not write in this area,to be completed by city or tmvn official City or Town: Permit/License# Issuing Authority(circle one): ; 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other I Contact Person: Phone#: DATE(MM/DD/YYYY) AC(:>R O CERTIFICATE OF LIABILITY INSURANCE 7/11/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Kimberly Savage Sullivan Insurance & Financial, Inc. (978)372-2790 ac o•(978)373-2281 IA&No 487 Groveland Street Ap E .ksavage@sullivanIF.com INSURER($)AFFORDING COVERAGE NAIC# Haverhill MA 01830 INSURER A:Harle sville Worcester 26182 INSURED INSURER B: Ryan Turner, DBA: Turner Carpentry INSURERC: 17 Baypoint Lane INSURER D: INSURER E: Haverhill MA 01835 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1671102904 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 SUER POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MMIDDIYYYY MM/DDIYYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE I X(OCCUR DAMAGE TO RENTED $ _ 300,000 SPP00000027152Y 7/1/2016 7/1/2017 MED EXP(Any oneperson) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE.,.. $ 2,000,000 POLICY u PRO- "I LOC PRODUCTS-COMP/OP AGG I$ 2,000,000 JECT OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ Al ITOS At ITOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOSAPer,=dentl $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION PER I 1. OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER _ ANY PROPRIETOR/PARTNERIEXECUTIVE a NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If ves.describe under DE CRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Construction Operations CERTIFICATE HOLDER CANCELLATION North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St. ACCORDANCE WITH THE POLICY PROVISIONS. suite 2035 N. Andover, MA AUTHORIZED REPRESENTATIVE 01845 �< / � Kayt Holland/KSAV V_ ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD Massachusetts -Department of Public Safety Board of Building Regulations and Standards Cunctrucfiun Surcn icor License: CS-108738 h c RYAN TURNER = 17 BAY POINT LANE Haverhill MA 01935 Expiration Commissioner 10/17/2018 ,e� ��e zpavzmzn-�reueall�of'C3/l�iiuuc�u�el,�i Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration: . 17.8626 Type: Expiration:.--'6ikdm DBA TURNER CARPENTRY - �: , RYAN TURNER 17 BAY POINT LN HAVERHILL,MA 01835 Undersecretary