Loading...
HomeMy WebLinkAboutBuilding Permit #186-2016 - 28 MORNINGSIDE LANE 8/11/2015 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION y� F 0• Permit No#: Date Received agAOR,TEo..Pa,�.�y Y< li 1` I�_ SSACHU$ Date Issued: � I IMPORTANT: Applicant must complete all items on this page LOCATION ©r Vn i✓7 � i�& r ,� Pr' t PROPERTY OWNER C,y1 ` Print c 100 Year Structure yesOno MAP Q PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building W,6ne family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial [.Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: ek Jt�zze &Z, 47� -r- C 2 C� Identific ion- Please Type or Print Clearly 44 OWNER: Name: Phone: 12/ Address: 670 n Contractor Name: - /byl Phone: 'rO 0,37./ Email: C r� Address: k n 2 S ✓J v l,• • ��� Supervisor's Construction License: V, 2- Exp. Date: Home Improvement License: Exp. Date: 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: $ CIO FEE: $ `' Check No.: 2— iO4 Receipt No.: ,4--� I l`t 3 NOTE: Persons contracting wi unregistered contractors do not have access to t e guara fund 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 ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS I CONSERVATION Reviewed on Signature j COMMENTS HEALTH Reviewed on _ Signature COMMENTS I I r Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes ! ` `J Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: -- Located _ Osgood Street FIREDEPAR�TMENT TAste empDum onsite r r., at 12�'49iMam,rStceet .. i Firej'iftj mend S-gnature/clate; _ i Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: r ELECTRICAL: Movement of Meter location, roast or service droprequires Electrical Inspector Yes q approval of No DANGER Z®NE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$1oo-$1000 fine I NOTES and DATA-- (For department use) t ❑ Notified for pickup Call Email Date A, `Time Contact Name Doc.Building Permit Revised 2014 F 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 ;r 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 OTE: 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 Plan Of Proposed Work With S �. Floor/Cross Section/Elevationrinkler Plan And p p 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 OTE: 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 No. Date • - TOWN OF NORTH ANDOVER Certificate 10ccupancy $ Building/Frame Permit Fee $Z� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# -216 Ll Buildi n4 inspector .. J NORTH own of E 1, ndover O - 0 No. 2-016 z h ver, Mass S� 1 o COCKICKl WICK V� RA'rEO PP��.(5 V BOARD OF HEALTH PERMIT T Food/Kitchen Septic System THIS CERTIFIES THAT .. . .. .. ... ...�.S.J.lY4+► BUILDING INSPECTOR .....D.....o.4. ...... ........ ......... s Foundation has permission to erect ...... buildings on aa.... ... �. .N! .. �Il. .... .......�...... p ......... . ...... I Rough to be occupied as ..........�.1.:�'../is A4R�IIce.....4V►.W\aNC... ..`............................................ Chimney provided that the person accepting 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 Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION SURT,59 Rough Service ......... .. ..:zy:............................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. Water/Ice Damage reconstruction project: Evangelista Family 28 Morning Side Ln. N.Andover MA Exterior • Roof ■ Remove and replace roof on main section of the home 26.1 square • Strip 2layers 2900.00 • Drip edge 250.00 • Ice and water 1000.00 • Roofing and roofing felt 5800.00 • Ridge vent 400.00 Total roofing 10,350.00 • Garage • R+R 16sf 5/8" blue board and plaster ■ Minimum charge 120.00 1n floor • Kitchen • Ceiling sf 302 • Walls sf 504 • Floor 269 • Perimeter 61 If perimeter Water damage due to ice damns leaked in through kitchen ceiling and light fixtures.Also there is a swollen seam in the back of the kitchen near the midline of the home. Ceiling • Minimum plaster repairs 120.00 • Replace 2 water damaged recessed lights 500.00 o Total Kitchen 620.00 • Dining room • Ceiling sf 147 • Walls sf 493 • Floor 147 • Perimeter 47.5 If perimeter �-7 • Water damage to the ceiling requires a 3'x3'section of ceiling to be Removed and Replace'.In order to get a seamless repair to the ceiling we would need to wet and scrape the textured ceiling down,skim coat and sand the entire surface,prime and apply a fresh coat of texture before painting.It is my opinion that going over the entire ceiling with a layer of 3/8"blue board and plaster would give the same desired effect with less labor(cost).Also 1 believe that wetting the ceiling to loosen the texture adds moisture to an already compromised ceiling. • Although the adjuster has put in for drywall repairs,I see no signs that it is drywall and not plaster.Due to the age and location of the home I suspect the walls to be a W blue board with 2 coats plaster. • Crown moldings detach and reset(all)541inear 160.00 • Ceiling • R+R 9 sf blue board and plaster(147 sf) 992.00 • Total dining room 1152.00 • Foyer Closet 1 • Ceiling sf 6.7 • Walls sf 77.99 • Floor 6.7 • Perimeter 10.52 ■ R+R%" blue board and plaster 84.69 sf 553.00 ■ R+R interior door casings 16 linear 256.00 ■ R+R insulation R-1518.54sf 21.00 ■ R+R baseboard moldings 32.00 ■ Seal/prime then paint twice(3 coats) 75.00 ■ Paint door casings and frame 2 coats 25.00 ■ Paint baseboard 2 coats 12.00 ■ R+R door 25.00 ■ R+R closet shelf and rod 62.00 Total foyerCloset2 1061.00 • Foyer Closet 2 • Ceiling sf 6.7 • Walls sf 77.99 • Floor 6.7 • Perimeter 10.52 • R+R%" blue board and plaster 84.69 sf 553.00 • R+R interior door casings 16 linear 256.00 • R+R insulation R-15 18.54sf 21.00 • R+R baseboard moldings 32.00 • Seal/prime then paint twice(3 coats) 75.00 • Paint door casings and frame 2 coats 25.00 • Paint baseboard 2 coats 12.00 • R+R door 25.00 • R+R closet shelf and rod 62.00 ■ Total foyer Closet2 1061.00 • 2"d floor • Master bedroom • Ceiling sf 254 sf • Walls sf 485 sf • Floor 254 sf • Perimeter 65 If perimeter • Water damage to exterior walls and ceiling,per adjusters recommendation we will be removing and wall board and insulation on the front facing exterior walls as well as a portion of the ceiling wall board and insulation.In order to get a seamless repair to the ceiling we would need to wet and scrape the textured ceiling down,skim coat and sand the entire surface,prime and apply a fresh coat of texture before painting. It is my opinion that removing entire ceiling and replacing with 1/2"blue board and plaster would be required).Also 1 believe that wetting the ceiling to loosen the texture adds moisture to an already compromised ceiling.Also the attic insulation is compromised due to exposure to water in multiple areas of the home. Removal and replacement can only be accomplished by removal of the ceiling due to no adequate attic access. • Although the adjuster has put in for drywall repairs,I see no signs that it is drywall and not plaster.Due to the age and location of the home I suspect the walls to be a%_" blue board with 2 coats plaster. • Due to the age of the home we must test for lead paint prior to any demolition. • Remove and replace 2 coats plaster over 1/2" blue board 125sf 810.00 • Remove and replace wall insulation R15 100.00 • Remove and replace all window casings and stops 42 linear 162.00 • Ceiling • Remove and replace 2 coats plaster over 12" blue board 254 sf 1700.00 • Remove and replace attic insulation R49 insulation 700.00 • Total Master bedroom 8229.00 • Master bathroom o R+R slab pine door ■ Door cost 125.00 ■ Labor 125.00 ■ Plaster minimum repair 120.00 ■ Seal/prime and paint ceiling twice(3 coats) 145 sf 165.00 • Total Master Bath 535.00 • Daughters bedroom • Ceiling sf 154.11 • Walls sf 402.5 • Floor 154.11 • Perimeter 53.67 If perimeter ■ Closet ceiling sf 9.27 ■ Closet walls sf 97.44 ■ Closet perimeter 12.99 • Water damage to exterior walls and ceiling,per adjusters recommendation we will be removing and wall board and insulation on the front facing exterior walls as well as a portion of the ceiling wall board and insulation.In order to get a seamless repair to the ceiling we would need to wet and scrape the textured ceiling down,skim coat and sand the entire surface,prime and apply a fresh coat of texture before painting. It is my opinion that removing entire ceiling and replacing with 1/2"blue board and plaster would be required).Also I believe that wetting the ceiling to loosen the texture adds moisture to an already compromised ceiling.Also the attic insulation is compromised due to exposure to water in multiple areas of the home. Removal and replacement can only be-accomplished by removal of the ceiling due to no adequate attic access. Due to the age of the home we must test for lead paint prior to any demolition. ■ Contents removed and reset 47.00 ■ Crown moldings detach and reset(all)541inear 160.00 ■ Remove and replace baseboard moldings(all 671inear) 205.00 ■ Baseboard heat detach and reset 101f 120.00 • walls ■ Remove and replace 2 coats plaster over 12" blue board 80sf 540.00 ■ Remove and replace wall insulation R15 80.00 ■ Remove and replace all window casings and stops 42 linear 162.00 ■ Ceiling ■ Remove and replace 2 coats plaster over 1/2" blue board 154sf 139.00 ■ Remove and replace attic insulation R49 insulation 200.00 Total daughter's bedroom 1606.00 • Office • Ceiling sf 124.63 • Walls sf 335 • Floor 124.63 • Perimeter 44.67 If • Closet ceiling sf 8.24 • Closet walls sf 90.11 • Closet perimeter 12.01 • Water damage to exterior walls and ceiling, per adjusters recommendation we will be removing and wall board and insulation on the front facing exterior walls as well as a portion of the ceiling wall board and insulation. In order to get a seamless repair to the ceiling we would need to wet and scrape the textured ceiling down,skim coat and sand the entire surface,prime and apply a fresh coat of texture before painting. It is my opinion that going over the entire ceiling with a layer of 3/8"blue board and plaster would give the same desired_ effect with less labor(cost).Also I believe that wetting the ceiling to loosen the texture adds moisture to an already compromised ceiling. • Although the adjuster has put in for drywall repairs, I see no signs that it is drywall and not plaster.Due to the age and location of the home I suspect the walls to be a%Z" blue board with 2 coats plaster. • Crown moldings detach and reset(all) 145.00 • Remove and replace baseboard moldings(all) 185.00 • Ceiling • Remove and replace 2 coats plaster over 12" blue board 254sf 1714.00 • Remove and replace attic insulation R49 insulation 200.00 • Total office $2244.00 • Bedroom#1 • Ceiling sf 127.71 • Walls sf 352.50 • Floor 127.71 • Perimeter 47.00 If perimeter • Closet ceiling sf 8.2 • Closet walls sf 90.44 • Closet perimeter 12.12 • Water damage to exterior walls and ceiling,per adjusters recommendation we will be removing and wall board and insulation on the front facing exterior walls as well as a portion of the ceiling wall board and insulation.In order to get a seamless repair to the ceiling we would need to wet and scrape the textured ceiling down,skim coat and sand the entire surface,prime and apply a fresh coat of texture before painting. It is my opinion that removing entire ceiling and replacing with 1/2"blue board and plaster would be required).Also I believe that wetting the ceiling to loosen the texture adds moisture to an already compromised ceiling.Also the attic insulation is compromised due to exposure to water in multiple areas of the home.Removal and replacement can only be accomplished by removal of the ceiling due to no adequate attic access. • Although the adjuster has put in for drywall repairs,I see no signs that it is drywall and not plaster.Due to the age and location of the home I suspect the walls to be a blue board with 2 coats plaster. • Crown moldings detach and reset(all)47 linear 145.00 • Remove and replace baseboard moldings(all 59.121inear) 205.00 • Remove and replace chair rail 11.58 linear 34.00 • Remove and replace 2 coats plaster over 12" blue board 80sf 540.00 • Remove and replace wall insulation R15 80.00 • Remove and replace all window casings and stops 15 linear 50.00 • Ceiling • Remove and replace 2 coats plaster over 12" blue board 127.71sf 865.00 • Remove and replace attic insulation R30 insulation 200.00 Total bedroom#1 2119.00 • Total cost 21926.00 The above estimate is an estimate only.The scope of the project will be determined by the final estimate drafted by the insurance company.The above list work, I the contractor believe necessary to bring the home at 28 Morning side Lane back to its pre-damage conditions.Any additional work required or requested during the reconstruction process will be billed separately to the homeowner or insurance company as a supplement to the claim. Estimate Provided by: Aaron M.Scarpello Home Improvements LLC. Salem NH,03079 603-858-0391 amshomeimp@)hotmaii.com / www.icanfixyourhouse.com i AMS Water/Ice Damage reconstruction project: Evangelista Family 28 Morningside Ln. N. Andover MA • The Evangelista family located at 28 Morningside Ln. North Andover MA, has chosen Aaron M. Scarpello Home Improvements LLC. (AMS)to perform the reconstruction of their home due to water and ice damage caused by the severe winter weather of 2015. • AMS will be responsible for preforming or subcontracting all phases of construction required to bring the home back to pre-damage conditions as determined by the insurance adjusters report/estimate. o Painting ■ Interior ■ Exterior o Carpentry ■ Framing ■ Trim and finish o Plaster and Drywall o Flooring ■ Hardwood ■ Carpeting ■ Laminate ■ Tile o Siding o Roofing o Electrical o Plumbing o HVAC ■ Note: All trades may not apply to your particular case. • If the homeowner wishes to make changes from the pre-damage conditions, while construction is underway, those conditions will be submitted to AMS in writing. Any price differences caused by a change of work order will either be credited back to the homeowner for use elsewhere in the project or, in the case of overages, be billed directly to the homeowner. • Special order materials 100%due at time of order(finished materials will be ordered and purchased at various times during the duration of the job) • Some finished materials may not be able to be returned or cancelled once the order is placed and some may be subject to a 20% restocking fee. These charges will be the responsibility of the homeowner if it is the homeowner requests the exchange or return. • This reconstruction is scheduled to begin June 2015. 1 • The Contractor agrees to provide and pay for all materials, tools and equipment required for the prosecution and timely completion of the work. Unless otherwise specified, all materials shall be new and of good quality. Contractor warrantee's materials and craftsmanship for one year, where manufacturer's warranty does not apply. • In the prosecution of the work, the Contractor shall employ a sufficient number of workers skilled in their trades to suitably perform the work. • All changes and deviations in the work ordered by the Owner should be presented to the Contractor, by the homeowner in writing, the contract sum being increased or decreased accordingly by the Contractor. • The Owner, Owner's representative and public authorities shall at all times have access to the work. • Contractor shall provide the Owner with a list of allowances for finish materials if applicable. The prices represent the Contractors estimate of average costs for such materials. These prices are subject to change based on actual price of item at the time of purchase and/or Owner's choice of material. • In the event the Contractor is delayed in the prosecution of the work by acts of God, fire, flood or any other unavoidable casualties; or by labor strikes, late delivery of materials; or by neglect of the Owner; the time for completion of the work shall be extended for the same period as the delay occasioned by any of the aforementioned causes. • The Contractor agrees to obtain insurance to protect himself, his workers and subcontractors against claims for property damage, bodily injury or death due to his performance of this agreement. • This agreement shall be interpreted under laws of the Massachusetts. • Attorney's fees and court costs shall be paid by the defendant in the event that judgment must be, and is, obtained to enforce this agreement or any breach thereof. Thank you for considering AMS Home Improvements: Aaron M. Scarpello Aaron M. Scarpello Home Improvements LLC. 603-858-0391 CSFA-096462 amshomeimp(o)hotmail.com www.icanfixyourhouse.com la As 2 RUG-10-2015(MON) 15: 11 (FRX)9785572130 P. 001/002 AARON-1 OP ID:JY DATCERTIFICATE OF LIABILITY INSURANCE 70811012015(MMIODNYY) 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 tho terms and conditions of the polity,certain policies may require an endorsement. A statement on this certificato doos not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: Mark S.Rowe,CIC _ Michaud,Rowe And Ruscak Ins. — P.O.Box 188 IAIC,PHON@ e,U!978 688 8829 j RUG-10-2015(MON) 15: 12 (FHX)9785572130 P. 002/002 7/7/201.5 8:20:05 AM PST (CMT-8) FROM: 100005-TO: 19705572130 Page: 2 of 2 AC4C>R& CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIOUNYYYI 7/7/2015 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 cartificale holder Is an ADDITIONAL INSURED,the POIICy(las)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions Df 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 endorsomen s, PRODUCER MICHAUD ROWE AND RUSCAK INSURANCE ASSO 43 PO HIGH S8T$SUITE 220 PHONE FAX NORTH ANDOVER, MA 01&15 Awl` INSURERS APFORDINO COVERAGE MAIC Pr INURED 4189 A: Liboffy Mutual Fire Insuranca 23035 AARON SCARPELLO HOME IMP LLC JMSURER t1. 2 MAGNOLIA AVENUE NSURERC: SALEM NH 03079 NSM&RD• Ntiu"R H! ' N80RERF- COVERAGES CERTIFICATE NUMBER: 25484817 REVISION NUMBER- TI-113 IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 9ELOW HAVE BEEN ISSUED TO THE INSURED NAMED A8OVE 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 DESCR19ED HEREIN 13 $1JUJECT TO ALL THE: TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIE$,LIMITS SHOWN MAY HAVE BEEN REDUCED DY PAID CLAIMS. I TSR TYPE OF NSUKANCEtF MM/D�EYP POUCYNUIreeq „LLDWITS COMMERCIAL O ENERAL LIABILITY EACH OCCURRENCE E CLAIMS-MAPF E OCCUR LSD PREMISES(Fn�,nmmml E KWO F-)V(Anyonepemon) $ rERsa AL&Anv INJURY Is 4 nEN iCREGATEI.IMrrAfTLIESIPEfi. i CENERALAGOMOATE 1C — F7 PRM PRODUC'-n-CCMrIOP AGG i 2 I M-IFR. i S AUTCOOMILE,uAsa"Y „„ Id s ANY AUTO BODILY INJUkY(FW psman) IS ALL OWNED RCNEDULED AUTos AUTCB BODILY INJURY(Parrdnani)I S HIRED AUTOS q� D RPE•del a s YMMKCLIA L1AeOCCUR r—OCCURRENCE S FYPF!!L�d HCLAIIAS-MADE AGGREGATE S DFA NT10N S A WORKERSCOMpI!r"TrON WC2-31S-380493-025 4/1912015 4/19/2015 l PFR N- ANO EIIPLOYERS'LIMnUTY Y I N OFFICERIMEMMSE��UDED9FCI.rTNt N!A E.L.EACH ACCIDENT $ 100000 (Mandalary in NN) IfYee deearba„m% 11.nIRFASE-EAEMPL.OHEE $ 100000 DF.3CRIPTInN OFOPERATIONA mhv F.L.C18EASE-POLICY LIMIT S 500000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACCRA 701,Addltlonal Rsmarka Schedule,may W 008chod lr,aore apses N?""red) Workers compensation Insurance coverage applies only to the workers compensation laws of the stats MA- This certificate cancels and Supersedes all previously Issued certiricates,only as they relate to workors'compensatlon coverage CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULb ANY OF7HEA13OVE DESCRIBED POLICIES BE CANCELLED BEFORE 384 OSGOOD STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUMORIUD WiPREEENTATNe n CLA-L�1 Uberty Mutual Fire Insurance V A ®1988 2014 ACORD CORPORATION, All rights reserved. ACORD 25(2014101) The ACORD name and logo are rag[stored marks of ACORD :548481.7 1-2eU493 19-16 WC yowah.p+LL1BLibertymutuaL-Cod 7/7/2oL3 8116!LS Ax (FDTI Pay.. L of f The Commonwealth ofMassiichusetts Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA. 02X14-2017 www mass go-v/dia Workers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE PILED WITH THE PERMITTING AUTHORITY. Applicant Information 'b ` /�// Please Print Le l Name (Bu /In siness/Organizationdividual): . „ f SL r-, /fie` ff� 2 i 7`// -- G Address: ' e., City/State/Zip: L�141 /U, �3UZ5 Phone#: o163 /-S-U 7�/ Are you an employer?Check the appropriate box: Type of project()required): 1.❑I am mployer with employees(full and/or part-time).* 7. E]New construction 2. am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3..Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 Building addition 4.❑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 11.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F1 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. Other ocy� irL� /' 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. fi Homeowners who submit Us affidavit indicating they are doing all work and then hire outside contractors must s4bmit 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.#: 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 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. I do hereby cern pal the pains andpenaldes ofperjury that the information provided above is true and correct. Sign e: Date: Z/—O/ /5 Phone#- Z0.3 .92 0354 Official use only. Do not write in this area,to be completed by city or town official.. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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 o 1i re, 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 cavy 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 foi•confirmation of insurance coverage. Also be sure to sign and date the ahiidavit. 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 yo'u'are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insur0d 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 till in the permit/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 permit 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-AIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Massachus "`` Boa efts-Department of P cons rd of Building Re public Safety uction Su 9ulations and Standards Lice Pe visor 1& I License: CSF 2 Family _ A-096862 A • i S`�L'MNS 030 a .. 11.�,��.Jj-jg la Commissioner Expiration _ -- 07/07/2016 Office o� �oorvi�ao� I mer Affairs$�� R661stiafipn MENr CONTRACTOR b'u►ation Expiration: 53859 x/18/2017 _NPe:`- AA ON M.SCARPDBA 1 pFELLO MOMS 1' AARON !- PROVEMENT S 2 MAGNOLIA AVE 'N SCgRPE4L0� C 1 + 4 !f SALEM IIAq 03070. .y�;� Undersecretary Massachusetts-Department of Public Safety ' Board of Building Regulations and Standards I Construction Supervisor 1 &2 Famih License: CSFA-096462 AARON M SCAR?kLLO '- 1 2 MAGNOLIA AVE ISALEM NH 030199 � .Y+ s. Expiration Commissioner 07/07/2016