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HomeMy WebLinkAboutBuilding Permit #1156-2016 - 30 OAKES DRIVE 5/10/2016 f Uj�l� �� � 1.� BUILDING PERMIT o� NORTH b R6,6w- TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 7D I I — _ �D e" ». ~ 1\ Permit No#: Z�' Date Received ��pDR.17ED q�SACHUS�( Date Issued:4iqAVORTANT: Applicant must complete all items on this page LOCATION 30 DoJzes Wwad `� Print PROPERTY OWNER t-p Cwl tieAdrorrm xx Print 100 Year Structure yes no MAP PARCEL: UL ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial R-A eration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑..Septic- ❑swell` ❑ Floodpl,ain ❑Wetlands ❑ Watershed District Q:Wat�e/Sewe,r - - 4 a DESCRIPTION OF WORK TO BE PERFORMED:_ �k sob" .rear, d Identificatio Please Type or Print Clearly OWNER: Name: Pow1 H8d5 M Phone: Address: -�D keOriJe� Ac S"- Contractor Name: `So)•r, poram Phone: &Q3 3029 6o2-09 Email: /� // II Address: 21 kaer y-e- v% (:>,rL c- aei p [leo-A 1J F i Supervisor's Construction License: C S-pz-/ n 1S y Exp. Date: Home Improvement License: /01).07/ - Exp. Date: 613OZ Z6 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE;BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST EASED ON$125.00 PER S.F. Total Project Cost: $ /y 7S/, 0 j FEE: $ -* �-J -1 Check No.: D � I Receipt No.: 5-b -S NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund - _ — - - - r 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 ❑ 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 ori Signature COMMENTS e 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 FCREDEPi4RfTMEN�T-`TempDumpster;onsite iLo atetl[af i1�2:4�MainkSfreet• �'�." ' Y�� � t - ��..zti-:�!.�partmen#signature%date�� -f "•C O RVI IVI E NETS°; _ - 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.$10041000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits 4. 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 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 4 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 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 ik Photo of H.I.C. And C.S.L. Licenses i6 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 t or " '4 Location o No. �� � � 7G� Date a,- /1V A? . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee TOTAL $ 5 Check#—I i1 '� Building'Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 14,751 .00 m $ - $ 177.01 Plumbing Fee $ 22.13 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 22.13 Total fees collected $ 321.27 30 Oakes 1156-2016 on 5/10/2016 Bathroom remodel NORTH Town of �� : E : Andover `� may• 4`I 11 %_1_ 201 IL h ver, Mass, l o L^K. 1. CoCNIc"t—CK SRA TE D Pt f`; � S V BOARD OF HEALTH Food/Kitchen PERIT T LD Septic System THIS CERTIFIES THAT ....... ........ .I...... .... ....�... �..........�. ...... BUILDING INSPECTOR ... . . . . .. ............................................. has permission to erect .......................... buildings on .... ............... . 'ke's................................. Foundation Rough to be occupied as ............ ... ... . ....... ....r .................................................... 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 ARTSRough Service .................. . .. .sem .'`.............................. 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 Sample Contract basieregnitC_tractarIaw chapter This form satisfies ail rements o€ihe state's Home Improvemen (MCL imP language to protecthomeowners.Seek legal advice if necessary.Any pe's planninghome impmvements should fast obtain a copy of"A Massachusetts Consumer Guide to Home Improvement before agreeing to any work an your residence.YOU may obtain a five copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Ini nitation hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contmetor Information Nome Compaag Name �IID StreetpastOSceBmcaddress) CaaVadonf SalrpasenlQsvncNaare City/fawn Stam Tjptwe Rusin essAddress(muaiucludeastnxtaddress) (3/$ s ' _ — Cx state zip Code DaytimePbone liveningPhoae GtyRovm Mailing Addtes(ltdi$aartfromabove) Business Fh&e erlDorS.S.Namber rramebepo.eQmtaaeGma�sx� dam ran rrgohetmrmafttwme impmreamt mrtrarmas tare 6130116 The Contractor agrees to do the following work forthe Homeowner (Describe in detail thessmkmcompleted,specifyingdtetymbrand,and grade ofmaterials mbeused,um—ad aWdicesif ) 5 ee Cr-RakL (C` S J�EZ"f Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless ciratmstmoes beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of .� / Daze when connadorwiu begin contracted wtrrk MGL Chapter 142-9) Dau when connaded wm twill be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform thework,fwnisb the material and labor specified above for the total sum payments will be made according to thefnllowing srhednic order items,whichever is greater) S e•{�p G`�n s V ug contract(not to e>iceetl 113 ofthetotal contract price 2c the Dost ofspeaial )i / / or n completion t�+iv.NL �� t CC _N T }J�Qr-� I Y1 s Z Q Y upo comp ii / / or n completion of�� ►, 1 i►l 5>Lra f,f��(D,� /y e' !� �"�r`e?. F/Uor��i%� s C/t70 QrY__— ° $—�� ?S/.C(jnpon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) Thefollo Ging mwaiWequipmem must be special S_to be paid for ordered befarethecoanadedwarkbegmsmcider S mbepaidfor mMed thecompletionscbednl M) NOTES:(hIndudmgallfisanxthere+=(-')'A-nR"-thatanydnaordown-paymmtog itadbytee btOrcost beginsmay notexceedthegteateof(a)am3hirdaftbet0WcW adptiaear(b)theact<micostofauyspc+ale4utpmmtorn>smmmadematerial suhidr must bespecial ordered in advaneem mad thecoaapleion schedule wa is so emross warranty hem¢newided by the centraearm No©Yes tali terms of thewarraety mast be attached to the eontrael ble for completion of the work described regardless of the 8C(rens of any thud Subcontractors-The contractor egrets to be solely res to be solely ressponsatiMbl'all payme�to all subcontractors for patty/subcantradorutt7i2ed bytltecantracior Thecantr�cto[aetarfiathaagrees materialsand orunderthis ent contradmderlaw.Unless otherwise notedwithiaUrisdocument,the Contract Aeoepts°ce-Upon mB�ng,this document becomes a binding contract�`A&not imply that any lien or othersaaIIityinteresthasbeenplacedon.theresidence.Review the following cautions and notices �{pllyr before Signing this Contract. Don't be pressured unto signing the contract Tale time to read and folly rmderstand it.Ask questions if something is unclear. •R, tbeiuba�.arhasavalidHomeimmovementContractorRerristtation. The law requires most homeimpmvementcontractorsand • yy�nlradorstoitarepsbetedwith the Director ofliomaImprovement ComtadorRegistration You may inquire about contractor_ 87 or$99-283-3757- registration by writing to thernee?Director at 10 a Colulaaa,Room 5170,Bostnate n MAecopa y 116 information r 6yconing that you tan confirm coverage, askto . Does thecoutractothaveinsurance? Ask theContrarxorforhisinaaancecompany see a copy of a'proof of insnrana docrrmenL• aftbe ConsumernowyournghtsandresponaWmes Read the lmpmtantlnfrtmationOnthe reverse side ofthisfarm and gdawpy Guide to the HomelmprovemeatConw-torLaw. entifititasbxn agaodrtaplatx other thecontrador's normal pLrtx ofbnsiness,provided you notify the You may cancel this agrxm mast posted,by telcp_sent or by delivery;not later thou midnight of the contractor in writing at his/her main office"branch office by ordinary tbirdbnsinessdayfollowingthesigningoftbisaV=ment Seethe attached DO NOT SIGN THIS CONTRACT IF THERE AM ANY BLANK SPACESltt idafideofrbeamnanmmtbe�mpfetodsmds8 d°°mPY�00Bg°mtbeha®weic'hoateamPY�®idbelsQebYtbeeaoa+uoc contractor s signature Homcor+meds Sigoamre V Date 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 comract°r- The same right's not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner m court unless both pies agree to the optional clause provided below. This clause would give the contractor the same right 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 arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation 14and.the consumer shall be required jSub • o such _ on as providedInMassachusetts General Laws,ch�Cotot's Signature er's Signature t only to theagreement of the parties to alternative dispute NOTICE:The signatures of the parties above apply Y resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights GL chapter 142A)and other consumer A homeowner's rights under the Home Improvement Contractor L wa even by agreement. However,homeowners protection laws(Le.MGL chapter 93A)may not be waived in any Y: -bed by law. may be excluded from certain rights if the contractor they choose is not properly registered as pry ri Homeowners-,vho 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 f the described, escricontrato m a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights guarantees or provides an express warranty for workmanship or materials. vsddty to guarantees or warranties of merchantability and fitness for provided by the contractor,all goods sold in Massachusetts carhick animhe ho may be a particular pwpo�, An enumeration of other matters on which the homeowner and contractor lawfully agree restrict added to the terms of the contract as long as they do not t a homeowner's basic consumer rights- if You have mer/homeownernghts,contact the questions about your consuConsumer Information Hotline(listed below}. Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of ail exhibits and reference documents have been attached. Parties are also advised not to sign the documen ov� �sectionsh�ents n to filled in or marked as void,deleted,or not applicable One original signed copy writingal contract must be in be given to the owner and the other kept by the contractor.buntil . res have recto the eived a fully executed COPY of and agreed to by both parties.Contracted work egin the contract,and the three day rescission period has expired. Accelerated Payments ed on thepayment schedule in cases where the A contractor may not demand payments in advance c the dates specified insecure- However,in instance where a contractor deems him/herself homeowner deems him/herself to be financially to be financially insecure,the contractor may require that the balance of fiords not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work Withdrawal of fiords from said account would require the signatures of both parties. Additional Information ffyou have general questions or need additional information"A M�achusett CoImprovement uide to Home Improvement" consumer rights,or if you wish to obtain a free copy contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 ParkPlaza,Room 5170,Boston,MA 02116 617-973-87872 888-283-3757 or visit the OCABRwebsite at lion:` t>>>' t "•-t'�""'cabri ifyou want to verify the registrati on of a contractor or if you have questions or need additional information specifically component of the Home Improvement Contractor Law,contact: about the contractor registration comp Director of Home ImprovemenntContractor BusiRegulataoon Office of Consumer Affairs r 10 Park Plaza,Room 5170,Boston MA 02116 617-973-8782 888-283.3757 or visit the BIC website at liumi a\ Go online to view the status of a Home Improvement Contractor's Registration: lu�p ic!�»tate m 1-m1 onieimprol�ement iiczne,eiist.a;n formai complaints against a business,call: For assistance with informal mediation of disputes orto register Consumer Complaint Section Office of the Attorney General 617-727-9400 AND/OR Better Business Bureau 50"52-4800,508-755-2548 or 413-734-3114 vim;.2.1-i Inl-010 John Moran Construction, G.G.C. Bui(d ng and l*modd(ing 21 Evergreen Drive phone 603-329-6209 Hampstead,NH 03841 fax 603-329-6209 March 2,2016 Paul Hedstrom 30 Oakes drive. North Andover, Ma. 01845 Dear Mr Hedstrom: This is a proposal to remodel your bathroom as follows: 1. Remove tub, shower, cabinets and toilet. 2. Remove tile on the floor and walls. 3. Replace drywall that was removed with wall tile. 4. Frame area around tub to support tub deck. 5. Cover walls in tub area with poly and cement board. 6. Cover floor area with cement board. 7. Install cabinets and tub surround. 8. Install new baseboard to match existing as close as possible. 9. Install tile and grout on the walls around tub. Tile and grout not included. 10. Install tile and grout on the floor. Tile and grout not included. 11. This includes the plumbing work and the fixtures on the Peabody supply list. Toilet and under mount sink are not on the list. 12. Electrical work includes an exhaust fan and hook up for tub. 13. This estimate does not include the shower door, tub deck, countertop and installations. 14. Disposal of all debris included. 15. No painting included. 16. I will apply for permit. Cost: $14,751.00 Respectfully submitted, John Horan Page 1 State of Massachusetts Home Improvement Contractor License#102071 l��py State of Massachusetts Construction Supervisor License#47989 NAT-248331 10S., 71,,6" WOODMODE 84 FRAMELESS CABINETS T O EMBASSY RAISED PANEL DOOR STYLE M W FINISH: �_LBATHAILC.72-R _1j CEILING HT TO SOFFIT:90" i HANGING HT:87" MOLIDLINGS: MBB805 WITH MCR8218 ml� SHOW.D.OSHOW.D.OFRM.EXP :i� LO ml: T W .A A�W III M O, Fes-.� J TOI L. D 18872 '\ i BVB� 21 L N 00 µ W 33-1"_ 33" 18" 86" All dimensions_size designations LUCY ROSS This is an original design and must Designed: 10/31/2015 given are subject to verification on JACKSON not be released or copied unless Printed: 12/1/2015 job site and adjustment to fit job KITCHEN applicable fee has been paid or job conditions. DESIGNS order placed. HEDSTROM, BOBBY AND PAUL All Drawing#: 1 Scale : 0 9/16" = 1' The Commonwealth ofMassachusetts f Department of IndustrialAccidents X 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 PERMITTING AUTHORITY. , Applicant Information Please Print Legibly Name(Business/Organization/fndividual): or&A Cor dyycb'o1 LL C10 Address: err rQ�an 0 r"1✓e City/State/Zip: ei s eal O 3 Phone#: r D 3 3M 6a2 O Are you an employer?6e&&e appropriate box: Type of project()Vequired): 1.Rrfima employer with • .!/—,! employees(full and/or part-time).* 7. Q New construction 2.[J I am a sole proprietor,or partnership and have no employees working for me in 8. [�1£emodeling any capacity.[No workers'comp.insurance required.] 9. F!Demolition 3..❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 F1 Building addition .4.F]I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.ElElectricalrepairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions S. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ � � 13.[f Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.FJWe are a corporation and ifs,officers have exercised their right of exemption per MGL G. 14.❑Other 152,§1(4),and we have na employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also till out the section below showing their workers'compensation policy information. t homeowners who submif this affidavit indicating they are doing all work and then hire outside conhactors must submit a new affidavit indicating such. tContractors jhat check this box must-attach1.ed an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-coritractors fiave employees,they must provide their workers'comp.policy number.• .[am an employer that is pi ovidiiig works rs'compensation insurance for my employees.'Below is the policy and job site information. J Insurance Company Name: J ,� �hSU yYA^c g CA';'YY%!J e1,^y Policy#or Self-ins,Lie.#: , O%rC- 7D0�t 7 ' Expiration Date: Job Site Address: City/State/Zip: 114A AaAcvfr MQ,01$'lS 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 o. 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. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. signafore: Date: S .� Phone# X 03) `� "601 Oct 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.EIectrical 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 shire, 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." k- , 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,forany 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 ofpublic 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-contractors)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 foi 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 yo'u'are requiired to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should'enter-their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-NUSSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/clia Client#:490547 JOHNHORA ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 4106/2016 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 pollcy(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 CONTACTALori Hay Ext#12909 US!Insurance Services LLC PHONE (FA Ext):855 874-0123 A,e No):877-775-0110 3 Executive Park Drive,Suite 300 noRIESs: Loreen.Hay@usi.biz Bedford, NH 03110 INSURER(S)AFFORDING COVERAGE NAIC! 855 874-0123 INSURER A:Maine Mutual Group Insurance Co 15997 INSURED INSURER B:EastGuard Insurance Company 14702 John Horan Construction LLC INSURERC: 21 Evergreen Dr. INSURER D Hampstead,NH 03841 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 CONTRACTOR 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 UBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MA) MM/DDMIY A X COMMERCIAL GENERAL LIABILITY SC10955638 /01/2016 04/01/2017 ppEAAqC��HppOCCURRENCE $1,000,000 CLAIMS-MADE �OCCUR PREMIGBES ERarrDence s250,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 ❑ PRO- D LOG PRODUCTS-COMP/OPAGG 52,000000 POLICY JECT OTHER: $ A AUTOMOBILE LIABILITY KA10955638 01/2016 04/01/201 aBINeD SINGLE LIMIT S1,000}000 ANY AUTO BODILY INJURY(Per person) S ALL OWNEDIX SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS X HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ A V1 UMBRELLA UAB X OCCUR KU10955638 4/01/2016 04/01/201 EACH OCCURRENCE S1.000.000 EXCESS LIAR CLAIMS-MADE AGGREGATE S1,000,000 DED I RETENTIONS $ B WORKERS COMPENSATION JOWC700557 4/01/2016 04101/2017 X PER 0TH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVEa E.L.EACH ACCIDENT $5OO OOO OFFICERIMEMBEREXCLUDED? Y N/A (Mandatory in NH) E.L DISEASE-EA EMPLOYEE 5500 OOO It yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached III more space is required) This certificate covers all operations usual and customary to the insured's business. This Evidence of Insurance is issued as a matter of information only and confers no rights upon the holder and does not amend,extend or alter the coverage afforded by policies designated on the Evidence. CERTIFICATE HOLDER CANCELLATION John Horan Construction LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 21 Evergreen Drive ACCORDANCE WITH THE POLICY PROVISIONS. Hampstead,NH 03841 AUTHORIZED REPRESENTATIVE �J'L i- I ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD #S17622357/M17622353 LMHCX ��i (�rl��r.��rr��rttieril��a`�C��l.�ii,?rrcftrrJe�t1 . Office of Consumer Affairs&Business Regulation License or registration valid for individul use only �OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Riga, 102071 Type: Office of Consumer Affairs and Business Regulation Expiration:-_ 6[30/2016 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 JOHN V.HORAN CONSTRUCTION John Horan 21 EVERGREEN DRIVE_,.; ' HAMPSTEAD,NH 03841 Undersecretary Not valid without signature Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-047989 Construction Supervisor JOHN V HORAN " 21 EVERGREEN DR. HAMPSTEAD NH 03841 Expiration: Commissioner 03/02/2018 \ j