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Home My WebLink AboutBuilding Permit #536-11 - 34 COLUMBIA ROAD 1/10/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued:- ORTANT: Applicant must completeall items onthis LOCATION u/ L 61)vl /3 / R C Print PROPERTY OWNER K61Y .Si leo de -1 - Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes o Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ Addition ❑ Alteration ❑ One family ErTw- o or more family No. of units: ❑ Industrial ❑ Commercial ❑ Repair, replacement ❑ Demolition - 0 Assessory Bldg ❑Other ands ,k Fypn 0TetF _ TT/1T11 .fTT. ❑ Others: OWa sehdlDtc �tirc �{ s ` �.'�.1..��.-'. DES (;RIP 11UN Ur w UxuL 1 U Jnr, rXtu vtuvm1J; Ce Lz T&N, SG J`' r lT64Ne-1-S , G Identification Please Type or Print Clearly) OWNER: Name: hie N ST e) d e c.. Phone: Address: 241004- '/1 R/P CONTRACTOR Name: �.lr, GU/� Sv�S Phone: Address: \S' &%--'d o3Hr Supervisor's Construction License: 02 -?6,)-0 Exp. Date: Home Improvement License:11,3��,3 Exp. Date: 61-1117 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. QD Total Project Cost: $ 3 FEE: $ Check No.: 5�k) Receipt No.: C9 -3 3 NOTE: Persons contracting with unregistered contractors do not have access tithe guaranty fund Location `s Cir✓�"'+ �� A/ No.Date NORTry TOWN OF NORTH ANDOVER 3?O�`t`•O I•,hO O F w A � y Certificate of Occupancy $ �' b''••°''<�' Building/Frame /Frame Permit Fee $ cHusa 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 23853 Building Inspector Plans Submitted ❑ - Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ElTanning/Massage/Body Art ElSwimming 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 COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED ❑ ❑ Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Commen Conservation Decision: Comments Water & Sewer Connection/Sianature &Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date CONROENTS 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 - Date Doc:.Building Permit Revised 2008 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 ❑ 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 ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o 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 o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o 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 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit n all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals hat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording lust be submitted with the building application Doc: Doc.Building Permit Revised 2008mi m m m m N m v m W , F C � CO) Cl) CD a Z y CD 06 r O CL —' y n� 70-4 o v CD CDCL o Q� CD CSD O CSD C CD y� EL- v y to CD I a v y O Z O CD O CCD I C C ? p d = O �• VJ O cr h n p O y . EARS O o0an � m 0 ^� o yo' Zo asm m m- �OCA cop � O r► � ' O :E ? O pZyC) ,m C � CO2 O CL to 0 VJ = O m H Cm 1C/)co c» c o n� c0c* CL =r cn a 0 c' cny � � nm 01M. fmA c1V. (A� CD • ?V � •�+ CCC ,;� �o m o 0 cn -� m C cn cn W C2, oCD: 0 m m � •O C7 n o - �C. c o: 0 SCD: 5 o rD 0 0 w G O �' �� r �' w G x w o 5 r b � ; O x O y 7d 2) W O C CS # 022680 H I C# 103358 Propool = A. J. Walsh & Sons 55 Pleasant Street .North Andover, MA 01845 # of 978-688-6737 or 1-866-AJWALSH Proposal Submitt� To: Job Name Job # /ILA-1�C. Address .' Job Locattiio�n Date / Fat�O' Plans Phone # 7e _ 6 k6 ,� j Fax # Architect Wehereby submit specifications and estimates for:......._._ .......................... ..... ._.-.-.......... -_.... -_._........ ........... .... _.-- ..........- ...-:_...._.....—__.-... _................. ._---_................ _._.__..... _......... __..--.:-.._..........._.... C/1G% We propose hereby to furnish material and labor — complete in (accordance with the above specifications for the sum of: $ ;� �%Yt�Li f�Zil�/! Lt'��.%t ( �1..� ��, Dollars with paymeri s to be made as follows: Any alterexecuted only up eviction from above specifications involving extra o will be Respectfully executed onl upon written order, and will become an extra charge over and submitted J above the estimate. All agreements contingent upon strikes, accidents, or delays r beyond our control. Note — this proposal may be withdrawn by us if not accepted within days. acceptance of j)eoPogai The above prices, specifications and conditions are satisfactory and are e, Signature hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Date of Acceptance / / y - // Signature Q. CS # 022680 HIC#103358 q Propool = A. J. Walsh & Sons 55 Pleasant Street .North Andover, MA 01845 # of 978-688-6737 or 1-866-AJWALSH Proposal Submitted To: Job Name Job # P.r �, i�. c er r 1 - f ...r jr. r ,•tt r � . [r ..../' Address I / Job Location Date / Date of Plans Phone # Fax # ' ' Architect We hereby submit specifications and estimates for: ...... ........ . ... .... . .................. . .. . ..... ... .... . ...... . . ........... . . ............... — - - --------- -- ------......._... _.._.-.---.-___.___._.-----._.._..........._.__.—._......___..._._._.—_.._......__.__._.___._............... _...... -_._._................ ........... .... _._.._.__..____..__....... - ..... _._.__._.......__.____-. J � °./�i it t.� :/ f _ � `, ' �! • fl /� We propose hereby toJ furnish material and labor — complete in accordance with the above specifications for the sum of: with payments to be made' as follows: Dollars Any alteration or deviation from above specifications involving extra costs will be Respectfully executed only upon written order, and will become an extra charge over and submitted above the estimate. All agreements contingent upon strikes, accidents, or delays beyond our control. Note — this proposal may be withdrawn by us if not accepted within days. acceptance of Propogar The above prices, specifications and conditions are satisfactory and are _ f - Signature `I hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. t✓ Date of Acceptance Signature _/ t�' "tr'4.•?t_iitriiltr;t:ll�f� r:!:, i/tfii�';-ii:.:J� _ Office of Consumer Affairs & 11u� ness Regulation .HOME IMPROVEMENT CONTRACTOR Registration: 103358 Type: Expiration: 7/7/2012 Private Corporatior A. J. WALSH & SONS,INC. Arthur Walsh,Jr 55 Pleasant Sty'` N Andover, MA 01845 tindersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation i 10 Park Plaza - Suite 5170 Boston, NIA 02116 `i Not validwithout sign ture :�` 11a��,rrhu.rtt. - !)ciru•tmrnt �+t i'uhlir '�;ifet� linar'd fit' 13uiIII in,; RL,:ulilt inn. ;Md >CANdu II'd� License: CS 22680 ARTHUR J WALSH JR 159A WAVERLY RD N ANDOVER, MA 01845 Expiration: 6/9/2012 1-r::; 29327 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYY) 12/21/2010 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 CONTACT Durso & Jankowski Insurance TAME` PHONE FAX Agency Inc (A/C. No. Ext): (A/C. No): E-MAIL 198 Mass Ave Suite 10113 ADDRESS' PRODUCER Y,,aI� p North Andover, MA 01845 CUSTOMER IDt. INSUREDS) AFFORDING COVERAGE NAIC r PERSONAL L ADV INJURY $ INSURED INSURER A: A.I.M. Mutual Insurance CO Arthur Walsh dba A J Walsh & Sons INSURER B: INSURER C: INSURER D: 55 Pleasant Street INSURER E: North Andover, MA 01845 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. Iner Lt, TYPE OF INSURANCE POLICY NUMBER POLICY EFF IxB/DD/YYYY) POLICY EXP ,wI/DD/YYYv) LIMITS GENERAL LIABILITY EACH OCCURANCE $ ❑C.MMERCIAL GENERAL LIABILITY 1:1❑CLAIMS MADE OCCUR DAMAGE TO RENTED $ PREMISES (Ea. occurrence) NED EXP (Any one person) $ PERSONAL L ADV INJURY $ ❑ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES ER: PRODUCTS - COMP/OP AGG $ ❑POLICY ❑PROJECT ❑ LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S (ea accident) ❑ANY AUTO BODILY INJURY (per person) $ FALL ..NE. AUTOS BODILY INJURY(per accident) S ❑ SCHEDULED AUTOS HIRED AUTOS PROPERTY DAMAGE er Paccident) $ (P_ ❑NON -OWNED AUTOS 9 F $ ❑UM,BRELLA LIAB ❑ OCCUR EACH OCCURRENCE $ [:]EXCESS LIAB ❑ CLAIMS MADE AGGREGATE $ ❑ DEDUCTIBLE $ ❑ RETENTION $ $ WORKERS COMPENSATION xc araru- oxx- AND EMPLOYEES LIABILITY roxx ttxtra Fn ® E.L. EACH ACCIDENT $ 100,000 THE PROPRIETOR/PARTNERS/ A EXECUTIVE OFr'ICERS ARE ❑E.L. incl ® excl 7014648012010 11/14/2010 11/14/2011 DISEASE -POLICY LIMIT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 COMMENTS / DESCRIPTION OF OPERATIONS OR LOCATIONS: ARTHUR WALSH IS NOT COVERED BY THE WORKERS'COMPENSATION POLICY. 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 1600 OSGOOD STREET POLICY PROVISIONS. NORTH ANDOVER, MA 01845 AUTHORIZED AEPAESENTATIVE MASSACHUSETTS HOME IMPROVEMENT CONTRACT This form. satisfies`all basic pquitements of the state's Home Improvement Contractor Law (MGI: chapter 142A) but does not include standard language to protect homeowners. Seek legal advice If necessary: Any person planning home vnProvemints should .firs( obfain a copy of"a Massachumma consumer guide to home•improvement" before agreeing to any work on yourresidence; You may obtain a 5tie copy by'calling the Office of Consumer Affairs and Business Regulation'is Consumer Information Hotline at617-973'8787 or 1+88842834717. Homeowner Information Contractor Information sine o cityfrown State Zip Code D 66" A'+ Daytime Phone Evemag one - Mailing address (It different from above)' The Contractor agrees to do the following work for the H (� w Divi AU�CS. Co vek Tit it I�YXutr� Pa c, Kers wn/OwntrName rye ut include a BMW addresy) . gate Lip tone XWO edmal-Employer ID or S.S. Number o• Acme Cmmtlm Rea N®6e 8xpi. dta �/f✓�DD� � lfi'�l rs..Gil . Required'• Permits The -following building permits are required Proposed Start and Completion Schedule - The fdllowiiig schedule will and will besecured:by the contractor as the'homeowners agent; be adhered to unless circumstances beyond -the connaetoftcontrol arise (Owners who secure their own Permits will be // excloded .from the;:Gtaaranty Fnnd`provisions of �t'Date when contractor will begin Contacted work, MGL chapter 142A.) d II&W when contracted .work will be substamially completed. Total Contract Price and Payment Sebedule , .,.o a Unwtv' Wr. agmcs m penorm ire wonr, mmtsh the material and labor specified above for the total sum of: .. - (•) Payments will be made according to the&Uowing schedule: $ .upon.signing contract (not to exceed 1/3 of the total.contract price. yr the cost:of special order items.whicbever is greeter) $ --by_! / or upon completion of $ ,/may—� by / / or upon completion of aqw coupon completion of the connect (law forbids demanding full payment until .contract is completed to both party's. satisfaction) The following mneriayNaipment must be special S be paid for ordered before the'contraeted work begins in order $ to be paid for to meet the completion schedule(**) NOTE $: (h locittding all finance charges (••) Law requires that any deposit or down -payment required by the contractor before work begins may not mceed the greater of (a) one-third of the total contract price or (b) the actual cost of any special.equipmeat or custom made material which must be special ordered in advance to meet the completion schedule. Express Wsrranri - Is as express warranty being, nodded by the contractor^ No Yes tad terms of «. t..,, c cuarracrr Subcontractors The contractor agrees to be solely responsible for Completion of the work described regardless of the actions of any thud . Party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors foi materials and labor under this aerecment Contract Acceptance - Upon signing this document becomes a binding contract under:law, Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract • Don't besured into signing -'? r, "='i Pres ghing lite contract Take time to read asci fully understand it Ask'questious if something is unclear. • Make sure the contractor has a valid Home Imrnovement Contractor Registration The ltiiv requires most home improvement contractors and . subcontractors to be registered with the Director ofHome Improvement Contrzaar Registration. You may inquire about contractor registration by writing to the Director itt>ne Ashburton Place, Room 13Q1, Boston, MA 02108 orby. calling 617-727-3200.or 1-800-223-0933. • Does the contractor have insurance? Check to see that your contractor is properly insured. • Knowourri rights Y g responsibilities. Road the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law: You may cancel this agreement if it has been signed at a place other. than the cofactor's normal place of business, provided you notify the contractor in writing ai his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement . See theausched.notice of cancellation form for an explanation of.this right DO NOT SIGN THIS CONTRACT IF THFRR ARF Alco Rr.A wrr CD AlnTaorrt Two ide"tini CMO ottheoonnaetnag bekmd�ads' -- �"'• �a�vaAa.uU::i �p tsoad one oepyshaWd ao to the Tho other sham be kept by the contractor. GLS Ho�wner's Signature Con 's Signature /Date nate t, i Contractor Arbitrslion The Home linvement'Contractor Law provides; homeowners withthe nghi to -initiate an arbitration action (as an altemative tocourtaction) if they; have a.dispute with a contractor. The same.rightis not automatically afforded to "'a contractor, however., owever. the contractor -would havetp resolve any.dispute he/she.has.with a homeowner in court unless ' both parties agree to the optionalclause 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 and -the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws, 142A. . H6meowner's Sign&m ntractor's Signature OT10E:1he signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor., The homeowner may initiate alternative: dispute resolution even where this section,is not Homeowner's Rights A homeowner's rights under'the Hpme'hnprovement Contractor Law (MGL chapter 142A) and other consumer protection laws (Le. MGL chapter -93A) may not be waived in any way, even by agreement: However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeownerp who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and -:workmanlike manner. Homeowners may be entitled to .other specific legal.rights: if the contractor guarantees or provides .an.express warranty for workmanship of materials. In addition to.guarantees orwarranties provided by the contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness-for particular purpose. An enumeration of other matter, on which the homeowner and contractor lawfully agree.may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights, ,contact the Consumer Information Hotline (listed below). Execution of Contract The contract must be executed in du Lica a and should not be signed until a copy of all'exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by. the contractor. Any modification to the Tiginal contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day recission period has expired. Accelerated Payments A contractor mpy not demand payments inadvance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However, in instances where -a. contractor deems him/herself to be financially insecure, the contractor may require thatthe.balance of funds not yet due be placed in 'a joint escrow .. account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or.need additional information about the Home Improvement Contractor Law or other consumer rights, .or if you wish to;obtain a fir ee:copy of "A Consumer Guide to the Home.Improvement Contractor Law,". contact Cgnsumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 (617) 973-8787 or 1-(888) 2833757 If you want to verify the registration of a contractor or if you have questions or need, additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Bureau of Building Regulations and Standards One Ashburton Place, Room 1301, Boston, MA 02108 T (617)727-3200or1-800-223-0933 For assistance with informal mediation of disputes or formal to register complaints against a isus ess, call:': Const er'Complaint Section Office of the Attorney General (6.17)727-8400 AND/OR Better Business Bureau y (508)652-4800 (508) 755-2548 (413)734-3114 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYY) 12/21/2010 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 CONTACT Durso & Jankowski Insurance t PHHONON E FAX Agency Inc (A/CNo.Ext): (A/C. No): LNo. 198 Mass Ave Suite 101B PPROUCE: ODUCER North Andover, MA 01845 CUSTOMER IDi. INSUREDS) AFFORDING COVERAGE HAIC R INSURED INSURER A: A.I.M. Mutual Insurance CO Arthur Walsh INSURER B: dba A J Walsh & Sons INSURER C: INSURER D: 55 Pleasant Street INSURER E: North Andover, MA 01845 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 RAVE BEEN REDUCED BY PAID CLAIMS. xnar Loa TYPE OF INSURANCE POLICY NUMBER POLICY EFF ,w2/DD/YYYn POLICY ZXP (m IDD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURANCE $ ❑COMM.ERCIAL GENERAL LIABILITY ❑ ❑CLAIMS MADE OCCUR DAMAGE TO RENTED $ PREMISES (Ea. occurrence) MED EXP (Any one person) 9 ❑ PERSONAL i ADV INJURY $ ❑ GENERAL AGGREGATE $ GEW L AGGREGATE LIMIT APPLIES ER: PRODUCTS - COMP/OP AGO $ ❑ POLICY ❑PROJECT ❑LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (aa accident) $ F11111 AUTO £ODILY INJURY (per person) $ ❑ALL OWIJED AUTOS BODILY INJURY(per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ (per anniaann ❑HIRED AUTOS ❑NON -OWNED AUTOS g ❑ $ ❑UMBRELLA LIAB ❑ OCCUR EACH OCCURRENCE $ [:]EXCESS LIAB ❑ CLAIM,S MADE AGGREGATE $ ❑ DEDUCTIBLE $ ❑RETENTION $ $ WORKERS COMPENSATION - ® Rc srwYv- OTx- AND EMPLOYEES LIABILITY rOAY LSNSr9 ER E.L. EACH ACCIDENT g 100,000 THE PROPRIETOR/PARTNERS/ A EXECUTIVE OFFICERS ARE [3 incl ® excl 7014648012010 11/14/2010 11/14/2011 E.L. DISEASE -POLICY LIMIT g 500,000 E.L. DISEASE - EA EMPLOYE£ g 100,000 COMMENTS / DESCRIPTION OF OPERATIONS OR LOCATIONS: ARTHUR WALSH IS NOT COVERED BY THE WORKERS'COMPENSATION POLICY. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES HE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE 1600 OSGOOD STREET POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE NORTH ANDOVER, MA 01845 dN The Commonwealth of Massachusetts I Department of Industrial Accidents 1. r' Office of Investigations listed on the attached sheet. 600 Washington Street >.,14 Boston, MA 02111 ' wwrv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): %�°"�% !N/Ty��Y �D!✓� Address: cam?LCC-TS'�11J` City/State/Zip: ,4 ^oo6?�x /" 7&— Phone #: 9�f--Cs' -(g737 Are you employer? Check the appropriate box: l.. I am a employer with % 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] f employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New. construction 7. emodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. E] Roof repairs 13.❑ Other `Any applicant that checks box # I 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 their workers' comp. policy information. 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. !l Expiration Date: A, Job Site Address: t)`1 C �J6VMA mz - City/State/Zip: /14Yd%C11r1t /Vl-- 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 c. 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 ceWy under the pains and penalties of peijmy that the information provided above is true and correct. 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 #: