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HomeMy WebLinkAboutBuilding Permit #851-2016 - 34 UNITY AVENUE 2/3/2016a�1�4 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 14 -One family ❑ Addition ❑ Two or more family ❑ Industrial ❑aeration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic 0 Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer ,1, q-115 Identification Please Type or Print Clearly) OWNER: Name: . I )a\,) ,\_G (_\ U \ Phone Address: CONTRACTOR Name: Phone: 92EY76 -yu Address: Supervisor's Construction License: C Exp. Date:. .Home Improvement License: Exp. Date: --� �-I I ��0 ARCHITECT/ENGINEER Phone: Address: Reg. l0. FEE SCHEDULE: BULDING PERMIT: $12.00 PER$\\1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ '�� ��� FEE: $ Check No.: �)1eu Receipt No.:.74PI%—:2 � NOTE: Persons contracting�vith unregistfred contractors do not have access to the guarantyfund nature I- r, ? Permit No#: BUILDING PERMIT ' TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNE � NORTy� 0 CTf1.EG 7�16�C Print 100 Year Structure yes no MAP PARCEL: 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 ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑�eptic ❑ 1Nell)❑Flo plains fWetl'ands ❑�IN+ater�sh d ®st�i`ct Wa r DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Email: Address: Supervisor's Construction License: Home Improvement License: ARCHITECT/ENGINES Phone: Exp. Date: Date: Phone: Address: Reg. No FEE SCHEDULE. BULDING PERMIT. $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty.,f and Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Taming/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 m i;9 FORM PLANNING & DEVELOPMENT Reviewed On Signature COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH _ Reviewed on Siqnature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments x Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FDEP�4 E .�t� R IViEN.T Temp Dumpsterpongsite Rm—i,yes i no f� Located at 1»2jj�4 Main Street;' eY �-y� ` ' Fire Dekamentsignature/date`��� g` . � �(� .j. Cyt .+r4 � "4,: =`-lh CO75}!.� A-• F iisrvs-� s o f 1 t\ i � r q�S i t .t � � }� k t MMENT°S ���'���� _�.��.�.�, t�. tz� • �_ :���,, ,» > �3 �;t� E� ���3,�* ,��y DAmensi®n 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 Emai Date Time Contact Name Doc.Building Peruvit 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 4; Copy of Contract 46 Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit . . Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract 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 Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 Location No. 2c)t? Date TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee .4 Other Permit Fee TOTAL Check # 29982 Building Inspector J 2 LL D Q O m C t u \0 O LL E °+' > 'yu-i 0_ (n tail z Z 0 J > m C ° .2 C 7 LOL to � d' E U f6 L.L O LU Z Z m > J a LOO of N LE 0 LLI Z U u W J W �hA d' U Lo — c6 L1 oC OU a Z a U LCO .7 oc @ LL Z LLI a W W E5 LL i m Z N 4J {% Q Y O (n a C O� v •Q C �a +� c - o E CL 0 ;CIO Ln C .r c E� O= �0 0 04tol V N O - N� >2.Cc ® .__> � _, •mo= U Q � d t t '= E O O N Z C o ®*'W: H O tm o0 CD ccn Occ F- C,3 d V m co W C •a O O uj LL •� N Cc H C •� O WL- :.� 0 O i Q O� Oma, Cl)' N •> — N CO) .Q O "' _ F— t 0 45 O. O V J oc Z L cc z w w xui. G W 0- J E O O V O tA Z CL ":� O U)o� O CL ':2 o L Q N a � CL Q C .v j -0 Z 94 Q = O Z O 94 Z2 v O V U) O ca U) 0 , February 2, 2016 Solar Endeavors, LLC 216 Lafayette Road Rye, NH 03870 RE: The Livingston Residence Dear Aaron, I visited the Livingston residence to review the roof structure. I have included my field report. In summary, the roof rafters should be reinforced with additional collar ties. Please let me know if there is any additional :information you need. Sincerely. A� Dave Gleason Architects P.O. Box 596 Stratham, New Hampshire 03885 603 772-7370 gleasonarcihitects@gniail.coni Field Report — February 1, 2016 The Livingston Residence 34 Unity Avenue North Andover, MA The roof is a hip structure with 2 x 6 rafters at 16" on center. There are 1 x 6 collar ties at every third rafter. Although the roof is stable and does not appear to have any damage or deformation, the rafter need to be reinforced with 2 x 6 collar ties at each member. The collar tie should be installed at 113 the distance of the rafter near the ridge. There appears to be no other concerns. Pictures: 9a Gleason Gleason Architects ��oP�� E. P.O. Box 596 Stratham. New Hampshire 443My / 603 772-7370�q,> gleasonarchitects@gmail.com K & C Contracting, Inc. "A Full Service Remodeling Company" CUSTOMER INFORMATION David Livingston 34 Unity Ave North Andover Ma 01845 CONTRACTOR INFORMATION K&C Contracting, Inc Kevin Kondrat 7 Marvin St Methuen Ma 01844 978-476-4450 FID# 261729246 CS# 99457 WORK TO BE PERFORMED Contractor Agrees To Do The Following Work For Homeowner: Install solar panels January 13, 2016 The following schedule will be adhered to unless circumstances beyond the contractor's control arise.- TOTAL rise: TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE The contractor agrees to perform work, furnish materials and labor specified for the SUM OF: $$33,915.00 PAYMENTS will be made according the following SCHEDULE; $11,305.00 Deposit $11,305.00 Half complete $11,305.00 Upon completion 6 Client's Signature Date �tl Contractor's Signature 1 c Date 1,42— NOTE: All home improvement contractors and subcontractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration shall be directed to: Director, Home Improvement Contractor Registration One Ashburton Place, Room 1301 Boston Ma 02108 617-727-8598 Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on this residence. ARBITRATION The contractor and homeowner hereby mutually agree in advance that in an event the contractor has a dispute concerning this contract, the contractor may submit such dispute to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulations and the consumer shall be required to submit such arbitrationasprovided M.G.L c. 142A. _ ll l Date 1 k Client Signature r. Contractor's Signature �� /cCeru� Date NOTICE: THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NO SEPARATELY SIGNED BY THE PARTIES. ACCELERATION OF PAYMENT Homeowner's Financial Insecurity: A Contactor may not demand payment in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. Contractor's Financial Insecurity: In instances where a Contractor deems his him/herself to be financially insecure, the Contractor may require that the balance to funds not yet due be placed in a joint escrow account as a prerequisite to continuing contracted work. Withdrawal from said account would require the signature of both parties. 1 P TUV Power controlled: aj Lowest measuring tolerance in industry l] Every component is tested to meet 3 times IEC requirements J Designed to withstand heavy accumulations of snow and ice J Sunmodule Plus: Positive performance tolerance J 65 25 -year linear performance warranty and 10 -year product warranty J t, Glass with anti -reflective coating �J World-dasSualit °Xaa ee.l6c6ms 9 Y • Safety fated, IEC SMO Q Fully-automated production lines and seamless monitoring of the process and mate oe 81°"'ne"na""'"".IEC6°°68'.68 • Ammonia feslstanceIEC 6xn6 rial ensure the qualitythat the company sets as its benchmark for its sites worldwide. :ftawki.1p1 <;o.''E""°' us '..c<XomanFP<al°n UL 1703 SolarWorldPlus•Sorting a� °°"«tontid1ad Plus -Sorting guarantees highest system efficiency. SolarWorld only delivers modules / • ' F t • 11 that have greater than or equal to the nameplate rated power. C ` Homelnnotfalion XGEt GEEEX FE<nfIFX. 25 -year linear performance guarantee and extension of product warranty to 10 years SolarWorld guarantees a maximum performance digression of 0.7% p.a. in the course DUE of 25 years, a significant added value compared to the two-phase warranties com- mon in the industry, along with our industry -first 10 -year product warranty.' U 'in accordance with the applicable SolarWorld Limited Warranty at purchase. www.solarworld.com/warranty solarworld.com MADE IN USA OF US AND IMPORTED PARTS I Sunmodulp%Plus SW 285 MONO (33mm frame) PERFORMANCE UNDER STANDARD TEST CONDITIONS (STC)` Maximum power Pm„ 285 Wp Open circuit voltage Voc 397V Maximum power point voltage Vmpp 31.3 V Short circuit current Isr 9.84 A Maximum power point current I -P 9.20 A Module efficiency nm 17.0% 'STC: 1000 W/m°, 25'C, AM 1.5 1) Measuring tolerance (P ) traceable to TUV Rheinland: THERMAL CHARACTERISTICS +/- 2% (TUV Power Controlled). NOCT weight 46 "C TCI, 0.04 %/"C TC— Maximum reverse current -0.30 %/'C TC P -PP 3 -0.41 %/"C Operating temperature Design Loads' -40"C to 85°C 4.20 (106.65) 712 (180.85) 0 0 a V., Module voltage (V) U (28750)t ri—Li—Lijil 1 �-- I 39.4 (1001) 1.30 (33) I I All units provided are imperial. SI units provided in parentheses. Solar World AG reserves the right to make specification changes without notice. PERFORMANCE AT 800 W/m2, NOCT, AM 1.5 Maximum power P,,,,, 213.1 Wp Open circuit voltage Vx 36.4 V Maximum power point voltage V,,,Pp 28.7 V Short circuit current Iu 7.96-A Maximum power point current IPP 7.43 A Minor reduction in efficiency under partial load conditions at 25'C: at 200 W/m�. 100% (+/-2%) ofthe STC efficiency (1000 W/m2) is achieved. COMPONENT MATERIALS Cells per module 60 Cell type Mono crystalline Cell dimensions 6.17 in x 6.17 in (156.75 x 156.75 mm) Font Tempered glass (EN 12150) Frame Clear anodized aluminum weight 39.7 lbs (18.0 kg) SYSTEM INTEGRATION PARAMETERS Maximum system voltage SC 11 /NEC 1000 V Maximum reverse current 25A Number of bypass diodes 3 Design Loads' Two rail system 113 psf downward 64 psf upward Design Loads' Three rail system 178 psf downward 64 psf upward Design Loads` Edge mounting 178psfdownward 41 psf u pwa rd `Please refer to the Sunmodule installation instructions these load cases. ADDITIONAL DATA for the details associated with Powersorting' -0 Wp /+5 Wp I -Box IP65 Module leads PV wire per UL4703 with H4 connectors Module type (UL 1703) 1 Glass Low iron tempered with ARC Compatible with both "Top -Down" and "Bottom" mounting methods 1 Grounding Locations: —4 locations alongthe length ofthe module in the extended flange. SW -01-7102U512-2014 J SolarEdge Single Phase Inverters For North America SE3000A-US / SE380OA-US / SE5000A-US / SE6000A-US / SE760OA-US / SE10000A-US / SE1140OA-US y`� WaRantiY �,; 4 The best choice for SolarEdge enabled systems Integrated arc fault protection (Type 1) for NEC 2011 690.11 compliance Superior efficiency (98%) Small, lightweight and easy to install on provided bracket Built-in module -level monitoring Internet connection through Ethernet or Wireless Outdoor and indoor installation Fixed voltage inverter, DC/AC conversion only Pre -assembled Safety Switch for faster installation Optional — revenue grade data, ANSI C12.1 USA - GERMANY - ITALY - FRANCE - JAPAN - CHINA - AUSTRALIA - THE NETHERLANDS - ISRAEL Ii www.solaredge.us S%jKWO Single Phase Inverters for North America SE3000A US/SE3&OOA US/SE5000A US/SE6000A-US/ 183 - 208 - 229 Vac AC Output Voltage Min: Nom: Max.rtl 211- 240 - 264 Vac AC Frequency Min: Nom: Max.ltl Max. Continuous Output Current GFDI 12.5 1' 1 11 1' 1' 1 59.3 - 60 - 60.5 (with HI country setting 57 - 60 - 60.5) 24 @ 208V 48 @ 208V 16 21 @ 240V 25 ( 32 I 42 @ 240V 1 e Thresholds Yes 47.5 Hz A A Yes INPUT Supported Communication Interfaces SE760OA-US / SE1000OA-US / SE1140OA-US RS485, RS232, Ethernet, ZigBee (optional) 3/4" minimum / 16-6 AWG SE3000A-US SE380OA-US SESOOOA-US SE6000A-US SE760OA-US SE1000OA-US SE1140OA-US OUTPUT 3/4" minimum / 1-2 strings / 16-6 AWG Rapid Shutdown - NEC 2014 690.12 (STC) 3750 4750 6250 7500 9500 12400 14250 W Transformer -less, Ungrounded Grid Connection Standards Yes Emissions 9980 @ 268V Max. Input Voltage . (HxWxD) Nominal AC Power Output 3000 3800 5000 6000 7600 325 11400 VA Vdc Max. Input Currentlal 9.5 13 16.5 @ 208V 18 23 I ( I 33 @ 208V 34.5 10000 @240V dBA Min. -Max. Operating Temperature 15.5 @ 240V version available(61) ` 30.5 @ 240V 5400 @ 208V Max. Input Short Circuit Current 10800 @ 208V 45 NEMA 3R Max. AC Power Output 3300 4150 6000 8350 77'F/25'C. 12000 VA do oversizine euide.Ddf 600kn Sensitivity 5450 @240V Maximum Inverter Efficiency 97.7 98.2 10950 @240V 98.3 98 98 98 AC Output Voltage Min: Nom: Max.ltl CEC Weighted Efficiency 97.5 98 97.5 @ 208V 97.5 97.5 ( 97 @ 208V 97.5 161-40 version P/N: SExxxxA-USOOONNU4 98 @ 240V 97.5 @ 240V ✓ Nighttime Power Consumption < 2.5 < 4 183 - 208 - 229 Vac AC Output Voltage Min: Nom: Max.rtl 211- 240 - 264 Vac AC Frequency Min: Nom: Max.ltl Max. Continuous Output Current GFDI 12.5 1' 1 11 1' 1' 1 59.3 - 60 - 60.5 (with HI country setting 57 - 60 - 60.5) 24 @ 208V 48 @ 208V 16 21 @ 240V 25 ( 32 I 42 @ 240V 1 e Thresholds Yes 47.5 Hz A A Yes INPUT Supported Communication Interfaces RS485, RS232, Ethernet, ZigBee (optional) 3/4" minimum / 16-6 AWG Recommended Max. DC Powerl2t Optionall" 3/4" minimum / 1-2 strings / 16-6 AWG Rapid Shutdown - NEC 2014 690.12 (STC) 3750 4750 6250 7500 9500 12400 14250 W Transformer -less, Ungrounded Grid Connection Standards Yes Emissions 30.Sx12.5x10.5/775x315x260 Max. Input Voltage . (HxWxD) 775 x 315 x 172 500 Vdc Nom. DC Input Voltage 51.2 /'23.2 325 @ 208V / 350 @ 240V Ib / kg Vdc Max. Input Currentlal 9.5 13 16.5 @ 208V 18 23 I ( I 33 @ 208V 34.5 Adc dBA Min. -Max. Operating Temperature 15.5 @ 240V version available(61) ` 30.5 @ 240V Range Max. Input Short Circuit Current 45 NEMA 3R Adc Reverse -Polarity Protection For other regional settings please contact SolarEdge support. Yes Izi Limited to 125% for locations where the yearly average high temperature is above 77'F/25'C and to 135% for locations where it is below 77'F/25'C. Ground -Fault Isolation Detection For detailed information, refer to http://www.wiamdee.us/files/Ddfs/inverter do oversizine euide.Ddf 600kn Sensitivity 1T A higher current source may be used; the inverter will Maximum Inverter Efficiency 97.7 98.2 98.3 98.3 98 98 98 % CEC Weighted Efficiency 97.5 98 97.5 @ 208V 97.5 97.5 ( 97 @ 208V 97.5 161-40 version P/N: SExxxxA-USOOONNU4 98 @ 240V 97.5 @ 240V Nighttime Power Consumption < 2.5 < 4 W ADDITIONAL FEATURES Supported Communication Interfaces RS485, RS232, Ethernet, ZigBee (optional) 3/4" minimum / 16-6 AWG Revenue Grade Data, ANSI C12.1 Optionall" 3/4" minimum / 1-2 strings / 16-6 AWG Rapid Shutdown - NEC 2014 690.12 Functionality enabled when SolarEdge rapid shutdown kit is installed 151 STANDARD COMPLIANCE Safety 30.5 x 12.5 x 7 / 30.5 x 12.5 x 7.5 / UL1741, UL1699B, UL1998 , CSA 22.2 Grid Connection Standards IEEE1547 Emissions 30.Sx12.5x10.5/775x315x260 FCC DartlS class B INSTALLATION SPECIFICATIONS AC output conduit size / AWG range 3/4" minimum / 16-6 AWG 3/4" minimum / 8-3 AWG DC input conduit size / q of strings / 3/4" minimum / 1-2 strings / 16-6 AWG 3/4" minimum / 1-2 strings / 14-6 AWG AWG range Dimensions with Safety Switch 30.5 x 12.5 x 7 / 30.5 x 12.5 x 7.5 / in / 30.Sx12.5x10.5/775x315x260 . (HxWxD) 775 x 315 x 172 775 x 315 x 191 mm . Weight with Safety Switch 51.2 /'23.2 54.7/24.7 88.4/40.1 Ib / kg Cooling Natural Convection Fans (user replaceable) Noise < 25 < 50 dBA Min. -Max. Operating Temperature 13 to +140 / -25 to +60 (40 to +60 version available(61) F VC Range Protection Rating NEMA 3R For other regional settings please contact SolarEdge support. Izi Limited to 125% for locations where the yearly average high temperature is above 77'F/25'C and to 135% for locations where it is below 77'F/25'C. For detailed information, refer to http://www.wiamdee.us/files/Ddfs/inverter do oversizine euide.Ddf 1T A higher current source may be used; the inverter will limit its input current to the values stated. 141 Revenue grade inverter P/N: SExxxxA-U5000NNR2 pi Rapid shutdown kit P/N: 5E1000 -RSD -51 161-40 version P/N: SExxxxA-USOOONNU4 gx df: a sr .trnvlt6r �, ufui � 7 ! s . I •Q&r, •f cy%Tw�t --i♦b r • ► . cY��I�t6rrrirNi �aII-.ficmmlidanm - 'ta,9lt�flT,'� @Il. ��d0:na1K�,t3FaQitnf�li�� air�'Sritla�m�•�d6raia�•wPi�l F � � tSl�. �7.iE)�Cd1 Ra Hi41z�ty�µ� � kf CU 2 -LO / � ~\ § �@ Q § u \ :3 a Fr--- / ■ \ Q ; \ // �k=kms 2 2 \\ %/ f q .� /jf \< . \/\$ k ) / cl) � � « z ®�� g] (k to OD g �q )\° 3y( \ � i£ LU \{ƒ Mill Mill 0 ) MEN \ / k§ \ , � �\ � LU 2 ■{ \ §' Q »� §} ® } �\ § @ §§ca /. m � ( Q � � ME � 4-J :5 Mill O |�§$ 222; FO . \ V w a� � m 0 L 00 rn N O'% II Cn 40+ -0 t1. i- '' 0 ° O U cz O (n N In O M k- d >, 0 Q O a �NaC 3 ° 'n CU ko o �z A y CN C Cl) > d o O a � v a ,D vi o 0 c _ 2, 0 cz aI` (L) r ui R y o cz c W O o V w a� � m 0 L 00 rn N O'% II Cn 40+ -0 t1. i- '' 0 ° O U cz O (n N In O M k- The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations - m d 1 Congress Street, Suite 100 .�` Boston, MA 02114-2017 swww mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: V `� (---, Q: City/State/Zip: ChiL� Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ®1 am a general contractor and I 6. New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g. Demolition working for me in any capacity. employees and have workers' 9. E] Building addition [No workers' comp. insurancecomp. required.] insurance.$ 5. are a corporation and its I0.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ 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 13.❑ Other employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 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. Insurance Company Name: lort el MU Policy # or Self -ins. Lic. #: J60 10 1616) 7 D � Expiration Date: Job Site Address: �� P/m. 41 City/State/Zip: /V�'i- �,g(z�, 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 c ify under t1 pains and penalties of perjury that the information provided abovel its true and correct~ Sianature: 1 Date: 11, Phone #: C�-7� 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): ].Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: K&CCO-1 OP ID: SR CERTIFICATE OF LIABILITY INSURANCE FDATE (MM/DD/YYYY) 01/14/2016 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 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 Michaud, Rowe And Ruscak Ins.PHONE P.O. Box 188 North Andover, MA 01845 Michaud, Rowe & Ruscak CONTACT NAME: Michaud, Rowe & Ruscak 978 688 8829 AX No):978 557 2130 AIC No Ell: A E-MAIL ADDRESS: BOP0100721827 12/19/2015 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Preferred Mutual Insurance Co. 15024 DAMAGE TORE TED PREMISES Ea occurrence $ INSURED K & C Contracting Inc. Kevin Kondrat 7 Marvin St INSURER B: INSURERC: GENT AGGREGATE LIMIT APPLIES PER: POLICY 1 PRO - 1 ❑ LOC OTHER: Methuen, MA 01844 INSURER 0: 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. 1NSR ' LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMI DPOLICY EFF /YYYY POLICY EXP MM/DDIYYYY LIMITS A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE E OCCUR X Business Owners BOP0100721827 12/19/2015 12/19/2016 EACH OCCURRENCE $ 1,000,000 DAMAGE TORE TED PREMISES Ea occurrence $ MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: POLICY 1 PRO - 1 ❑ LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS AUTOS L COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Peraccident $ A X UMBRELLA LIAB EXCESS UAB HCLAIMS-MADE OCCUR UC0100608971 12119/2015 12119/2016 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 DED I X I RETENTION $ 10000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N I A PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ PROPERTY 2,500 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Carpentry NORTH13 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St Bldg 20 Suite 2035 AUTHORIZED REPRESENTATIVE North Andover, MA 01845 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD le 15""In-MMY RMUIStie! irs & BasineSs Off,ct of ffaCOW IMPROIJEMENT type, 'gist'ation: 160272 private U COTPC 7171201 P! ration, K6ndfit St Undersccrct'"' moihuen, Mp, 01844 Massachusetts - Department of Public Salf�'v Board of Building Regulations and §t4,ndardZ Construction SUPCII tfrt' License: CS -0997 Kevt, 4 Kondrat 7 Mjjrvjm[ Street e;: -- MA 019-44 Expiration commissioner 0412712016