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HomeMy WebLinkAboutBuilding Permit #463-2017 - 32 SAUNDERS STREET 11/2/20160ORT11 v ANO 4 BUILDING PERMIT TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION 0 Date Received Permit No#: act OA?ArED Date Issued: I I if ."�s o4ue E14PORTANT: Applicant nt must complete all items on this page t 4 LOCATION_ t PROPS_ RTY OWNER` P -A P 60re yes no MAP j� Jct Y fib, -0 PARCEL:, ZONING OISTRICT-- yqs no Waghft E No P Y(ha TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family D Ad tion El Two or more family 0 Industrial RIAlteration No. of units: El Commercial 0 Repair, replacement El Assessory Bldg 0 Others: R15'emolition D Other >jWellEl Floodplain Eii Wetlands El Waler$fie�d DistrictE:8epfic A-Wat&/Sewer DESCRIPTIUN Ut- VVUMM i u of rr-mrunivir-u- VIC— A A A fl 3 1, 0-4. 4�g Identific OWNER: Name: &et Address: SSU Please Type or Print Clearly W A C, 6 / one: Contractor'Name: .Phone: -92F 4-97- /2 Email- !A Address... Ae t /ZoW-7,PAV-7-, Supervisor's G-binst"futtio-n1icense'.1 Pl& DalLe: - , F E Hqm, Improvement License L "7 A' ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT., $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125,OOPER S.F. Total Project Cost: $ COCJ FEE: $ MEF 163 Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Owner Sianature of contractor 4 1 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swilling Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature, COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Planning Board Decision: Conservation Decision: Comments Comments Zoning Decisionfreceipt submitted yes Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT TempaQumpster.on site ,yes Located,af 124tMaintStreet Fire'Department sidnatUre/date _ COMMENTS. 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 MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 No 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 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, _S 4 y n No. 2 017 Date //�r}4,0/(0 Check # TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ (e Foundation Permit Fee $ Other Permit Fee $ TOTAL $ IV Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 133600.00 m $ - $ 163.20 Plumbing Fee $ 20.40 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 20.40 Total fees collected $ 304.00 32 Saunders Street 463-2017 on 11/2/2016 Kitchen remodel with 1/2 batj o - vO 0 2 'a O 0 '1 --CD n m ort = Q o cn Z C S S �' �_ O O cn „OyCD TI C E O, O o. 0. ill N S. mD '. CD 2 m D QQo to C7 _ O N• O N CD 0 z N � C �. CDD-0� � J CL r- Em ooh a H,' O Mcn 0 7 00 U3 Q VJ CL0 Z, Tom rt 7 < C Cj) CD p 03 y CD rtso •V CD 0 �• Q D TT� c -,`= ; n Z Q O .`� i 0 CD CD Va O W N z ° �, �D �p D CD iA C ZCD C/1 0 m O 34. vs p: o C*M)L r Ln 3 D (D rD Ln L N - Z O W j (MD S. 0 QUC S 5.(D 0) G rD rD T ; = S T Dl O ;a S 3 N n S 3 (D G A O �C S T O Q m K N (D 'a f1 N 1 T O a \ rr T v T y m z vi Z cn M n m m 0 y '— Z toN M m 0 V C w z G1 Z m O 0 Z C ° G _ Z m m 0 3 3 3 W O z v O T D r - E Q S4 J\ 4/ -.h March 22, 2016 To Whom It May Concern, Please be advised that I am working with 4 Construction Services, Inc. and Mr. Jose L. Vega, principal and owner. I will assist in the permitting process and job oversight at all the appropriate benchmarks and inspections. I will make myself available to discuss building codes or plan changes at any time the building official having local jurisdiction deems necessary. I have attached a copy of my Massachusetts Construction Supervisors License as well as my Lead Paint RRP and OSHA 10 certifications. Please do not hesitate to call me at 978 697-1317 if you have any questions or need to clarify my role in the permitting process. Thank you in advance for your anticipated coy Sincerely, r' Myles E. Burke CS -105552 t (978)726-1500/4sc.inc@gmaii.com This proposal will come into an agreement when both parties sign as a binding contract. This project is to commence on October 31, 2016. The time frame to complete thi's?project is ,four,.(41 weeks from the start date unless delays arise .due to inspections and%r inclement weather. Any additional upgrades will incur separate charges *Please note this total does not include: rountertop, cabinets, nor sliding door*. The total for thisproject in Labor and. Materials is $15;650:00. 1.) Bathroom: new bathroom with a toilet and sink; take down existing exterior door and close it up; .add new walls; new electrical; new door; and new plumbing. 2.) Kitchen: renovate kitchen - open the wall that divides the kitchen with the dining room to make an open console; close existing entrance to the living room; Add a LVL between kitchen and pantry; dining room will convert into the kitchen, existing kitchen will become open useable space with hard wood floors; add 5 new electrical :breakers with GFi for the *countertop/the new plumbing. 3.) Plumbing: plumbing charge of $3,500.00 includes gas4ine, dishwasher, kitchen sink, bathroom sink, and toilet. 4.) Window: remove existing kitchen window and replace with a *sliding door with a 6 x 10 deck pressure -treated; :install a .LVL over sliding door. Signature: rpt actor R Print Name Contractor Date Due Custorner Name: Telephone: Service tocation: c 0 $3,912.00 November 18, 2016 $3,912.00 November 25, 2016 Moe Machkour f9-78)376-4629 32 Saunders, Street,, N, Andover, -MA 018.4.5 E i Proposal Date: Contractor: Sub -Contractor. 10/28/2016 Myles E. Burke JL Vega/4Seasons Construction Services, Inc. This proposal will come into an agreement when both parties sign as a binding contract. This project is to commence on October 31, 2016. The time frame to complete thi's?project is ,four,.(41 weeks from the start date unless delays arise .due to inspections and%r inclement weather. Any additional upgrades will incur separate charges *Please note this total does not include: rountertop, cabinets, nor sliding door*. The total for thisproject in Labor and. Materials is $15;650:00. 1.) Bathroom: new bathroom with a toilet and sink; take down existing exterior door and close it up; .add new walls; new electrical; new door; and new plumbing. 2.) Kitchen: renovate kitchen - open the wall that divides the kitchen with the dining room to make an open console; close existing entrance to the living room; Add a LVL between kitchen and pantry; dining room will convert into the kitchen, existing kitchen will become open useable space with hard wood floors; add 5 new electrical :breakers with GFi for the *countertop/the new plumbing. 3.) Plumbing: plumbing charge of $3,500.00 includes gas4ine, dishwasher, kitchen sink, bathroom sink, and toilet. 4.) Window: remove existing kitchen window and replace with a *sliding door with a 6 x 10 deck pressure -treated; :install a .LVL over sliding door. Signature: rpt actor R Print Name Contractor Date Due Amount Due -November 4, 2016 $3,912.00 November 11, 2016 $3,912.00 November 18, 2016 $3,912.00 November 25, 2016 1 $3,914.00 Date, /a .1 1 '�/'_)& )�6 Signature '�Gi ' �--� Date f nt )Print)Name 190 Haverhill Street, #355, Methuen, MA 01844 Family Owned & Operated To,,� SINCE 1946 215 Market Street 10 Industrial Drive 67 Haverhill Rd Lawrence, MA 01843 Raymond, NH 03077 Amesbury, MA 01913 Phone: (978) 686-4141 Phone: (603) 895-5151 Phone: (978) 388-0366 Fax: (978) 687-5841 Fax: (603) 895-5152 Fax: (978) 388-9824 Bill To: CASH SALES (978)000-0000 000000000 Ship To: Material Receipt I Transaction # Date / Time 11/01/2016 8:27 am I Sales Representative Customer Copv LAWRENCE, MA 01843 Customer # Order # Order Date Oper Purchase Order Ship Via 1 421047 11/01/2016 200 CUST P/U LN# Item Number Ordered Shipped Description IUM Price/Unit Extension 1 LVL716 1 1 1 3/4 X 7 1/4 X 16' LVL EA Location: WH -D4L-001 51.35 51.35 SIGNATURE: ( ) Special order and manufactured merchandise is non -returnable Tendered Customer agrees that any amount not paid within 30 days of 60.00 invoice date will carry interest at the rate of 1.5% per Change month and further agrees to pay all costs incurred in 5.44 collection, including reasonable attorney's flees. Page 1 of 1 Amount: Tax: 3.21 Total: 54.5 Paid: 54.5 Due: 0.0 Cash 11/1/2016 Town of North Andover Mail - HIC License - 4Seasons Construction Services, Inc. NORTH ANDOVER Massachus�tfs `: OnoPaul Hutchins <phutchins@northandoverma.gov> HIC License - 4Seasons Construction Services, Inc. 1 message 4Seasons Construction Services, Inc. <4sc.inc@gmail.com> Mon, Oct 31, 2016 at 1:39 PM To: phutchins@northandoverma.gov Please see attached HIC License for Jose Luis Vega / 4Seasons Construction 2 attachments IMG_1984.JPG 146K IMG_1985.JPG 213K https://mai l.google.com/mai I/ca/uV0/?ui=2&i k=7d85827aOb&view=pt&search=i nbox&th=1581 bd38c7dcfe81 &situ 1=1581 bd38c7dcfe81 1/1 The Commonwealth of Massachusetts Department of IndfustrialAccidents 1 Congress Street, Sl Ite 100 Boston, AIA 02114-2017 www mass.gov/dia Compensation Insurance Affidavit: Builders/Contractors/Electricia:as/Plnmbers. TO BE FILED WITH THE PERMIT'I NG AUTICORI'T ' Name (Business/Organization/Individual).'. Address: / ► / City/State/Zip' whone #: Axe you an employer? Check the appropriate box: 1. Q I am a employer with employees (full and/or part-time).* 2.❑ I am a sole proprietor or partnership andhave no employees Workiug for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance requiredt 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 proprietors with no employees. 5.�7 am a general conizactor and l have hired the subcontractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insumnce.t 6. ❑We are a corporatioii and ifs, officers have exercised their right of exemption per MGL c. 152 employees. [No workers' comp. insurance required.] I (4) and we have no Type of project (required)_ 7. ❑ New'consiriiction g. pemodel.ig 9. ❑ Demolition 10 [] Building addition 11.❑ Electrical repairs or additions 12. [] glu—mbng repairs or additions 13•. 0 Ro6f repairs 14.0 Other a 'cant that checks box#1 must also fill out e section mbelaollwwoorrkwandthen hire eir outside cmpensation ntra ors molicy ust submit new affidavit indicating such PP Homeowners who submit•this affidavit mdida na Y g the name of the sub -contractors and state whether or trot (hose entities have tContractors that checkibis box must attached an additional sheet showing employees. If the sub -contractors have employees, they must provide their workers' comp. policy number- employees. Below is flue policy and)0h site jam an employer that is pr'oviding-workers, compensation insurancefor my emp information. Insurance Company Name: ExpirationDate_ " /% 7 Policy # or Self -ins. LIG. #: � u `, �_ City/State/Zip: O /`} Job Site Address: Attach a copy of the •workers' compensation policy declawing the policy number and expiration date)- punishable Failure to secure coverage as required under MGL c. 152, §he form criminal Snal W ORK ORDER•a-ad a fine of up to $250.00 a and/or one-year imprisonment, as well as civil Penalties statement may be forwarded to the Office of Investigations of the DIA for insurance day against the violator. A copy of this coverage verification. Xdo hereby certify u tliepains andpenalties ofperjury that flue information provided above is true and correct. .,V 12 �a 1lTf�a Official use only. Do notwrite in this area, to he completed by city or town official. Permit/License # City or Town - issuing Authority (circle one): ' 1. Board of Health 2. Building Department 3. City/Town Clerk 4, Electrical Inspector 5. Plumbing Inspector 6. Other Phone Contact Person: 1,5t7 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is d'efiued as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enferprho, and including the legal representatives of a deceased employer, or the receivet'or trastde 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 b6 deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or Iocal 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 xeq'w`red: ' 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 compliancewiththe 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 certificates) 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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial•Accidenis. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self insurance license number on the appropriate line. City 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 "fob 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 burr leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia The Commonwealth of Massachusetts F Department of IndustrialAceldents M v9 I Congress Sheet, Suite 100 Boston, KA. 02114-2017 �r . www mass.gov/dia • Yla�M SYy9 Work Compensation Affidavit* Builders/Contractors/Electricians/Pinlnbers. TO BE FILED WITH THE AU I gORIT'Y- uti , �01Pr;nk 1 A ldcanE.muur,�.a�l�u /[ r Name (Business/Oigan zation/Individual): i�t Address: City/State/Zip: - 1h a cno tare you an employer? Check the appropriate box: 1.Q I am a employer with employees (full and/or part time).'•` 2.©I dun a sole proprietor or partnership and have no employees Working for Mein any capacity. [Noworkers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself~ [No workers' comp. insurance required.] t 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 proprietors with no employees. 5. ❑I am a general contractor and I have hired the sub -contractors listed on the attached sheet These sub -contractors have employees and have workers' comp. insurance.t 6. Q We area corporation and its, officers have exercised their right of exemption per MGL c. 4 dwe have no employees. [No workers' compinsurance required.] o? 6- /So (-` Type of project (required); 7. ❑ Nd-W'd6nStr66ti0n g. 5 1jemodeag 9. ❑ Demolition 10 [] Building addition I1.❑ Electrical repairs or additions 12T�-Plumbing repairs or additions 13%0 Roof repairs 14.0 Other 152, §1( ), an _ *any applicant that checks box #1 srnrst also fill out the section below showing their workers' compensation policy information. t ow affidavit Homeowners who submit•this at*avrttt he � they are dnal oing showing the work and alldame o the sub -contractors en hire outside ands e wheth t ar or not thoseen ties have Contractors that checkthis BoXimrst .....,,i...— rftlin Rnb-contractors have employees, they must provide their workers' comp. policy nuunber. lam an employer tliat is providingworkers' compensation insurance for° my employees. Below is epolicy andyob site information. / •-- s� j, Insurance Company Name: 7� �'C rU „ n �� 63 � cez Expiration Date: 1 a—/-� Policy # or Self -ins. Lie. #: U y es City/State/Zipa Job Site Address:3a.San% Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration. date). e by a fbib up to $1,500-00 Failure to secure coverage as required under MGL en c.1 2i, §25A is form of criminal OPiWORK ORDERolation Iand a fine of up to $250.00 a and/or one-year imprisonment, as well as civil p may be forwarded to the Office of Investigations of the DIA. for insurance day against the violator. A copy of this statement coverage verification. :--7do hereby certify under thepains andpenalties ofperjury Mat the information provided above is true and correct. iso Official use only. Do not write in tliis area, to be completed by city or town official. permit/License # City or Town - issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector 6. Other Phone #:, ContactPerson Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver'or trustee ofan individual, partnership, association or other legal entity, employing employeeg..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 xequiired. " 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 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 for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of IndustrialAccident's. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self insurance license number on the appropriate line. City 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 pen it/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 fn.dustrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia A 4O �® �cJR CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 10/31/16 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 NAME: Eric Jansen Hasbany & Regan Insurance Agen a/C"N ExtI: 978-685-3188 FAX No): 978-685-9460 254 Pleasant Street Methuen, MA 01844 E-MAIL ADDRESS: aime@hasbany.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Utica First Insurance Company PREMISES DAMAGE 1 Ea occurrence $ 50,000 INSURED INSURER B: ACE -American Insurance Compa INSURER C: Safety Insurance 4 Seasons Construction Service C/O Jose Vega 190 Haverhill St INSURER D: $ Methuen, MA 01844 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 MAYBE 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. ILT R TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF MMIDDlY POLICY EXP MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR Y ART506388601 01/23/16 01/23/17 EACH OCCURRENCE $ 1,000,000 PREMISES DAMAGE 1 Ea occurrence $ 50,000 MED EXP (Any one person) $ 5,000 PERSONAL& ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: POLICY FIJ EST LOC �IOTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMPIOP AGG $ 2,000,000 $ C AUTOMOBILE LIABILITY ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS X HIRED AUTOS X NON -OWNED AUTOS 6233955 06/1211fi 06!12117 COEa aMccidentBINED SINGLE LIMIT $ BODILY INJURY (Per person) $ 100,000 BODILY INJURY (Per accident) $ 300,000 PROPERTYDAMAGE$ 100,000 UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I RETENTION $ $ B WORKERS COMPENSATIONIPER ND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YINE.L. OFFICER/MEMBEREXCLUDE1 ❑Y Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 6S62UB-2E69854-8-16 02/04/16 02/04/17 STATUTE ER H EACH ACCIDENT $ 1,000,000 E. L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Site Improvements, Inc. is included as additional insured on General Liabilty Policy owner (Jose Vega) has elected to exclude coverage for himself on his workers compensation CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. REPRESENTATIVE Aime Negron U 1856-2014 AGURD GURPURATIUN. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD CRIIe TG.411011rtle(Its, a`C�/l�Cl J(CC�I�JPC�1 Office of Consumer Affairs .& Business Regulation d_ .,—,',,--,HOME — IMPROVEMENT CONTRACTOR (Registration: 183820 Type: Expiration: 1111612017 Corporation j 4 SEASONS CONSTRUCTION SERVICES, INC. + i JOSE VEGA t 190 HAVERHILL ST #355 . Undersecretary METHUEN, MA 01844 i 6 MYLES E BURKE .6 ALTAMONT Si HAVERHILL, MA M832 Commonwealth of MA Div. of Pmfessioi A I-limisure "Q 57562 Licensed. Real Estate SaW-sperson ds.,��hux tt-+ Dqlat tencat "i Full6t: --Afut- Board- of Ouitdin,,� Rczuk!� ttion and Standall'.'s License. CS -105-5152 0 Lig erase: c;S 1US552 BURKF,--: X-5 ALTV40W STREET Hgvrrhiff MA OA32 MYLES BURKE 9,2, 28 WASHINGTON DRIV2 EH -tfj, �t,.A 02571 WAR.- A Massachusetts - Department Of Public Safety Board of Building Regulations and Standards License. CS -105-5152 BURKF,--: X-5 ALTV40W STREET Hgvrrhiff MA OA32 9,2, Expiration 0811 SIV2015 Expiratiwi: PRA51'20013 Tr--. IL35552 Massachusetts Department of Public Safety Board of Buiiding Regulations and Standards License: CS -105552 ConstrucUan Supervisor MYLES E BURKE 66 CRYSTAL COURT HAVERHILL MA 01832 Expiration: Com.missioner 0811612017 094 A * =&. i- �=- - ii -092M-1033 —1Wscard a-,�-.rmdedgss tbjFettbe C V P t rzj S y a r, d F a 1 h Ty -du g C ou r-.-. e Lr. COW Wles,Burke jean C.tA8Rj3,,, C,17 -269-7i 77 3115fa(M