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HomeMy WebLinkAboutBuilding Permit #596-2017 - 325 SUMMER STREET 12/2/2016 AW 4—d S NORTH BUILDING PERMIT TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION * z =h° Permit No#: '✓ ��"1 / Date'Received °"'ArED " c5 gSSAcHUs�c Date Issued: lti ` IlVIP RTANT: Applicant must complete all items on this page 1 L��►��-ice-d•1'. L®`C-AT101;�1� 3 -Sl., YYII ►�_S — pR®1?ERTYP OI/UNERt� Gll -A -- \Or�(� -. .�_. .cd1.1~ � : T^- Print `� ' `1fl©YearSfruct�ureT� noa V r Y, ( Historic D str�ct� y�� no MAPEL -Y! zZO:NING ®IS,TRlC`T _ Mac;me Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Residential ❑ New Building XOne family 0 Addition 0 Two or more family ❑ Industrial 0 Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition 'fel Other \ .I_jSepfc prWell; ,Floodplain Vl/etlandsD Watershed D�rtt_' �.D,�WaterlSewer DESCRIPTION OF WORK TO BE PERFORMED: C-e-1 x \ n 1 h Identification- Please Type or Print Clearly OWNER: Name: IPCI-W t) 1b O Phone:C112; - Sha -- 1141 Address: Sas SL- m er S� cu �.Contlactor'lyameM�r _ti'nc�C>` _� _hoo - - Ei�ail CS ��SSS .._ _� Ex Dafea,_?1L► l l.�1 _ - Superv`sor�s,C©nsfruction,License __ _ P Hornlm rouement License _ (�St� „P� .. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ Z ,4 'S FEE. $ Check No.: q�rl Receipt No.: 1 Z NOTE: Persons contracting with unregistered contractors do not Iiave access to the guaranty fund -- `- nature of c=ontractor ;Signature of AgentlOwner -- _----..__.._-- - h 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 I CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS °Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: .- Located 384 Osgood Street �FIRE3D R� IUIENT }, . �t F EPA TTempDumpster on-site es`AiL; �� . ' {no 112 t� ` Y�. ; �..�,.� t Lo ted 4;11%I�am Street 4_ eP.,A ntisignature%date i Dimension Number of Stories: Total square feet of floor area; based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine I 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 o Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses a Workers Comp Affidavit a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o Mass,.check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording , must be submitted with the building application Doc:Building Permit Revised 2014 l i Q pORT#1 BUILDING PERMIT ��°�t``!° °• "�� TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMINATION + - Permit NO: Date Received Date Issued: �9SSACHus���� IMPORTANT: Applicant must complete all items on this page LOCATION 325 Summer St North Andover, MA 01845 Print PROPERTY OWNER Paul Diorio Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building N One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer cellulose insulation in attic Identification Please Type or Print Clearly) Paul Diorio Phone: OWNER: Name: 978-886-1141 j Address: CONTRACTOR NameJoseph A Ryan, Merrimack Valley Insulation Phone: 978408-7832 i Address: j 23A Sullivan Rd Billerica, MA 01862 Supervisor's Construction License: Exp. Date: cs-075541 02/04/2017 Home Improvement License: Exp. Date: 180506 11/24/2016 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: $ 2,466.56 FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access th u ranty fund Signature of Agent/0wner see attached Signature of contractor T _ Location ✓ '` o ' No. LP Date`? i • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ �' Foundation Permit Fee Other Permit Fee $ - TOTAL $ i Check# / i- (wilding Inspector r '1 NORTH _ _ . w: .. . - ver. No. - C, h ver, Mass o� A_ coc«�c«ew�cw a. o S V BOARD OF HEALTH Food/Kitchen PE T LD Septic System 4 51111111100 THIS CERTIFIES THAT .... ... .......... T I. V... ....... Q....... .. ............ l .............. BUILDING INSPECTOR has permission to erect ......... buildings on �i. ...� ,Y �: Foundation .............. . ..... .... .......... Rough to be occupied as .............. ... .. . .. -CM........�►::!�. ..!!. ....... .................................................... 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 T Rough Service ............... . .. .... .. ......................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. RISE60 Shawmut Road,Unit 21 Canton,MA 02021I339-302-6335 ENGINEERING7 www.RISEengineering.com OWNER AUTHORIZATION FORM II (owner's Name) owner of the property located at. 3 , (Property Address) 0 C I 3 201 jVe[4� tq)Vbif� 14 4 L 0j' (Property Address) Merrimack Valley insulation 23A Sullivan Rd hereby authorize Billerica,MA 01862 } (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property'. This farm is only valid with a signed contract. Ther Permit will be secured by the insulation contractor,at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work, Ow 's Signature Date ' 62016 Federal ID 805A40Seca DISE En Oneering RlContractor ReglatratlonNo8186 %' I-- MA Contractor Registration No 120979 n( CT Contractor Raglstratlon No ■E1�1K\GIl1NEE1?i,�'G trOShatimutitoad.Canton.lf,1 CONTRACT(401):"8i-3700 FA.X(•101)'7&4-3710 Page 1 PROGRAM CMA-HES !'MM AW 7TK CU3TW�AFERFM IN NK As DESCRIM BELOW r'110nE 0117E - _•. cue"1 WORK OMER Pain Diorio (978086-1141 091261201 00 35003 scaevrce einEEr ,_. _ - - elua+o-sraEET 32.5 Stammer Street 325 Summer Street BIMICE CITY- r ,5 ATE,DP 8n1YN0 CITY.STATEYA . North Andover.MA 01 S45 North Andover.MA 01845 O C t — 3 2016 JOB DESCRIPTION AIR ShAUNCY.-Protide labor and materials 10 seal areas oftTrar home against%%=cful.excess air leakage. `Ibis wod;%%il performed in koncert with the use ot'special tools and diagrim'ic tests to assure that your home%till he lett with a healthful level of -,i%3atetials to he used to seal%our home can include caulks.foams and other products. Primary sic exchange and indoor air qualm areas for sealing include air leakage to attics,basements.attached garm-cs and other unheated areas tuindovts are not generally addressed) This mill require(10)working hours.A reduction in cubic fret per minute(cfm)of air infiltration will occur,but the actual number ofcfm is not ruarantced. At the completion ofthe tMtheriration mork.and at iso additionalLost to the honuomr.a.a final blower door andtor combustion safety analysis trill be conducted by the sub-contractor to ensure the safety of the indoor air quality. 5850.00 ATTIC FIAT:Provide;labor and materials to install an 8"'layer of R-28 Class I Cellulose added to(560)square feet ofopert attic space. 5767.20 F!X EXIST.NG INSUATION:Slash.the t•apor barrier,flip.or re-position(50)square fest of insutation in the attic area. S12.50 %%IHGU.'—HOUSE FAN Protide labor and materials to fabricate and install a rigid foam insulating coyer for the mhoilc house fan. $ 09.21 ATTIC ACCESS:Pro-tide labor and materials to insulate(1) back of the kncettall hatch with 2"rigid Thiara%board,and seal the edge of the batch%lith%%eatherstrippine. 560.00 ATTIC ACCT SS:Protide tabor,and materials to install 11 i easily moved,insulating cover for the attic access folding stair. A small fiat surface of plywood%sill be created around the openin»within the attic. This will allow the covtY%inte_rtnt aralher- stripping to restrict air l akagc. y S237.65 VENTILATION:Provide labor and matcriats to install ventilation chutes in(57)rafter bars to maintain air flow, S113.00 SASaIEN f CF.iU\G:Provide labor and materials to install 172)linear feet of R-19 unfoced fiberglass insulation to the perimeter of the basement ceilin--at the house sill. S126,00 RISE Engineering mill apply all applicable.eligible incentives to this contract. You will onh be billed the Net amount. Currenfiv for eligible measures.Columbia Gas oft-rs 754o incentive,not to exceed$2.000 per calendar year,and an incentive of 100°o for the Air Sealing measures up to the first 5680 and an additional 5340 ifsavings arejustified by the auditor. For the safety and health ofyour homes indoor air quality.%%-c,.,.ill be conducting a blo%%rr door diagnostic of the available air flow in your home both before the work is heeun,and:titer the wcatheriration work is complete.We%till also conduct a full assessment i RISE Engineering Federal ID A 05.=5629 RI ContracW Registration No SIBS tt INA Contractor'Registration'No 120979 RISE " z CT Contractor Registration No tNGIhfERIEVG 60 Shaw mut Road,Canton,AIA (401)7,44-3700 RAX(401)7Rs-3710 CONTRACT Page 2 PROGRAM AM FM CMA-11ES SAND Bio M 70 OR AS OESCRDIEDMOVI . WSTOMER Paul DioCiU WENT/ .WOOMORM (978)885-1'141 09P-612016 414900 35003 ;SERVICE STREET. oILUNG 3TR6ET 325 Summer Street 325 Summer Street SOME CITY.STATE,LP De1THO CITY.STATE.TIP North Andover,MA 01345 North Andover,MAO 1845 JOB DESCRIPTION or the Combustion safch or your heating system and nater bcatez.,This has a salue or$90 and is at no cost to.w. TmI 0WO'Anhic watherixation inccotim is$3,1 to.: S90.00 ILE C n OCT - 3 2016 Total: $2,466.56 Program Incentive: .$2,075.55 Customer Total: $391.01 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECMATIONS,FOR THE SUM OF "'Three Hundred Ninety-One&091100 Dollars $391.01 UPONF7!ULL.SPECTIDYAHDAPPROVALDY RISE EHGRNEMM.CUSTOMER ATR *TORENT AMOUNT DUE CJFULL C,TME-,YOF'N%TILLSECKARGEDiONMYON AM UNPAIO OALANCE AFTER 90 DAYS.SEE REVERSE FOR WPORTANT WORMAT%ON CH GUAP-KNnES,RIOHTS OF RECISION.SCIIEDULM.AND CONTRACTOR REWSTRAIM, 00 NOT SIGN THIS CONTRACT 1F THERE ARE ANY BLA K SPACES r AUiNtORQEOstatAnlRE.-RUEEn3Meerie, CUSTCAI.�. fPTAHCE N,O''E:TNt:3 CONTRACT MAYDEYATKDJUV,N BY US IF NOT EYE-CUM YOU" DATE OF ACCEPTANCE ACCEPTANCE CF CONTRACT--THE ABOVE PRKEE.aPECIFlCATIONS A"CONDITIONS ARE DAYS, SATISFACTORY TO US AND ARE HERESY:ACCEPTED.YOU ARE AUTHORIZED TO OO THE WORN AS SPWnED.PAYMENT WLL GEAADS AS-OU=NED'ADOYE y MERRVAL-03 WEJE DATE(lA?NDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 6l9312096 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 certifitxte holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION 1S WAIVED,subject to the:terms.and conditions of"thmay policy,certain:policies ay require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER. CONTACT NAME: Automatic Data Processing insurance Agency,Inc PHONEi FAX 1 ADP Boulevard AAIC.No Ext• Arc,No): Roseland,NJ 07068 ADDRESS : INSURER(S)AFFORDING COVERAGE NAIC R _ _. _. _ .__. .: .. . _.. .. .__ _... ._. INSURERA:5StarV3AA1C American Alternative insura–n INSURED Merrimack Valley Insulation Corp INSURERS: 23a Sullivan RdINSURERC: North B iilerica,MA 01862 —— -- – INSURER D: INSURERE- �--- -!- INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: r THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE-LISTED BELOW.HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. go-rwrrHSTANDING ANY REQUIREWIENT,.TERM OR.CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES_LingrrS SHOWN MAY HAVE BEEN REDUCED BY PAID_CLAIMS_ +INSR ADDL SUBR - _-'.POLICY EFF 7 Poi1dV MCP-1 LTR I TYPEOFINSURANCE POLICY NUMBER I M?AtDDIYYYY l Pr1F.91DD1YYYY I LIMITS 1 GENERAL LIABILITY I t EACH OCCURRENCE j 5 t ( I PARE1iAAGICOIAMERCIALGENERAL LIABILRY Ctt9AAEuOCCUPE at accurrnca It S MED EJ F(Any one person) PERSONAL&ADV INJURY_ S1 j —J GENERAL AGGREGATE _ a t GE N'LAGGREGATEUh11TAPPLIES PER: PRODUCTS-COTAPlOPAGG 5 -' I l !PRC- (� I ---- I POLICY t Ic 1 1 LOC i I S I AUTOL1OBILELIABILITY I i ( I COIdSINEDSINGLELIFA(r t ! Ea accident 5 A1,IYAUTO ! BODILY INJURY(Perperson) IS ALL OWNED SCHEDULED ! I BODILY INJURY Per accident)L S _ I AUTOS AUTOS i ( )I { NON-OWNED I I PROPERTY DAfAAGE HIRED AUTOS AUTOS ! i tj�Peraxiden:} - U11.18RELLALIAROCCUR ! EACH OCCURRENCE 5 EXCESS LIAS HCLAIMSA5ADEj i I AGGREGATE S FIC-ED I I RETENTIONS I � I I --` S — WORKERSCO&WENSATION 1 WCSTATU- OTH- .AND EfAPLOYERS'CtABIUTY YI'N � � TORY LIMITS ER A AI•IY PROPRIETORIPARTN=-MEXECi Mrcl ❑ V9WC749118 6(18(2016 6!1812017 E.L EACH ACCit7EClT 5^- -1,000,000 OFFICERN06 1BEP.EXCLUDED? �7 N 1 A ` — - j(MandatorVi,i NH) I` EL..DISEASE-EA EMPLOYE I S •hawl,flD if qqes,describe-under i OESCRIM ION OF OPERATIONS Mow E.1.DISEASE-POLtCY.UNIFT, 5 . 13000;00 t DESCRIPTION-OFOPERA*TbNSlLOCATIONSIVEHICLES(Atfach-ACORD101,Addiliona1RemarksSehedul%ifmorespaceisiequired) I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED.BEFORE THE EXPIRATION DATE' THEREOF, NOTICE WILL BE DELIVERED .IN Town of North Andover,Massachusetts ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andover,MA 01845 THORIZED REPRESENTATIVE 1 1988-201 0 ACORD CORPORATION. All rights reserved. ACORD.25(2010105) The ACORD name and logo are registered.marks of ACORD A DATE(MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 11/07/2016 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), AUTHORED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If'the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION 1S WANED,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,CONTACT Carolyn A Coughlin Charles J Coughlin Insurance 14 DinleyStreet PHONE _ (978)957-3588 AX No: P.O.Box 10 E,,DSS: carolyn@coughlinins.com Dracut,MA 01826 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Northland insurance Company 24015 INSURED Merrimack Valley Insulation Corporation Joseph A.Ryan,Jr. INSURER B: Safety Standard 39454 23A Sullivan Road INSURERC: Torus Specialty Insurance Company A0159 N. Billerica,MA 01862 INSURER D: 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDLSUBR PWDDYEFF POILICYEXP LIMITS LTR POLICY NUMBER A COMMERCIAL GENERAL LIABILITY WS274182 01/21/2016 01/21/2017EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE F2 OCCUR100,000 PREMISES Ea occurrence $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GE/NL AGGREGATE LIMIT APPLIES PERGENERAL AGGREGATE $ 2,DOO,000 POLICY F JE�CT Loc PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ B AUTOMOBILE LIABILITY 6205006 11/25/2015 11/25/2016 COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS ONLY I,/ AUTOS ( )HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLYAUPOS ONLY Per accident $ C J UMBRELLALIAB OCCUR 875931-161ALI 01/21/2016 01/21/2017 EACH OCCURRENCE $ 1,00,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I i RETENTION $0 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILI Y YIN STATUTE ER ANY PROPRIETORIPARTNERIEXECUTNE E.L.EACHACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS belay E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached ff more space is required) Insulation Installation CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover,M assachusetts ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street N orth Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improveme C-Nd tractor Registration Type: Corporation Merrimack Valle Insulation Corn '` Registration: 180506 Valley p;, Expiration: 11/23/2018. 23 A Sullivan Rd T ; a Billerica, MA 01862 h � W Update Address and return card. Mark reason for change. SCA 1 Q 2OM-05/11 AddrR*.�Q_gnns%1Pral r Fm�glnyment n 1 &XI w1W119)onaseas&11'a�C�/��ova�uaet� Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only — Type: Corporation before the expiration date. If found return to: registration Expiration Office of Consumer Affairs and Business Regulation A0506 11/23/2018 10 Park Plaza-Suite 5170 Boston,Boston,MA 02116 gI ;� l Merrimack Valley�li-"g'1atlo�orp ;Joseph Ryan ���P-0-7 ')23 A Sullivan RdiI ti Billerica,MA 01'6b2RF-F,j'' Undersecretary Not v id ithout signature �gassachuse`tts-Department cf Public Safety :card of a id'r :.iru'a icr s ^..S art arvs ., : s-;t,iitieutt.�tt taf9t s t : t cense.-GS-075541 JOSEPH A RYAIN 3 ynnfield WA 017940 y 4� FxpiraUon Co r tissioner 02)0412017 The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations Y; 600 Washington Street r4 Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aimlicant Information Please Print Legibly Name (Business/Organization/Individual): Merrimack Valley Insulation Corp. Address: 23 A Sullivan Rd. City/State/Zip: Billerica MA 01862 Phone#: 978-888-3495 Are you an employer?Check the appropriate box: Type of project(required): 1 1. X❑ I am a employer with 18 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors b. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. E]Demolition working for me in any capacity. employees and have workers' insurance.+ 9 E] Building addition comp.[No workers' comp. insurance P• required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other insulation comp. insurance required.] "Anv applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the 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. T nsurance Company Name: 5Star V3 AAIC American Alternative Insurance Policv#or Self-ins.Lic.#: V9WC749118 Expiration.Date: 6/18/2017 Job Site Address: 3a,S Summer t City/State/Zip:h.AndQVCr-41A 0►k4S Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 and penalties of perjury that the information provided above is true and correct. Si atDate: j� Phone#: 8-888-349 ` Official use only. Do not write in this area,to be completed by city or town official I 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#- The -assachusett of 1-a-ves-lasadons 600 W.-ishingtlif St B0St0a' =r `021 11 i'4 orke- s CompenSadou Thysnrmce Afifildavai: BUl; �sv?sl�.oTS�c o�5%',Ieeir=_ 'ckLsl Iu%?f3eiy ,A--.2p iiCBZon Info—tio' —Please]Ti*--.? j-�I v \ me CB-usiness 0rea-:�'-a-Z-.QLz?Lif?ItiTC!a�af�. �TiitBI ^fr.'.121%�il.a: ��1Ii=U �i�SCL C-7IJ1�� Czft=lS t�'Jaf.'�fd�� -ic- l Jia c Mhz- ones t�`��`� ��fg5 i ase you an emp?o er? Are oz?he honeo uer' aech he approp-ana_E I? er: 1. an an erral ver ivi.l'T F3Ti�.ticyaCs( u';.a1 c3" L z.?�e. i -- S. I aL•Z a Sole propree�3r ar parmeir hipQ iii i�no employeas roriidng zor mein any capaC2i}. `- . �. 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