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HomeMy WebLinkAboutBuilding Permit #1089-16 - 345 RALEIGH TAVERN LANE 5/1/2018 BUILDING PERMIT OF N_oT 6�tio I PVS► N4 AivN'e4 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION T Z b T Permit No#: �� Date Received 4q `y �RATEO PPP .�5 �gSSACHUS�� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION 3y���/GN (ft1>>EQ.c� ,�i� A'� Do✓f.2 �y,a /Print PROPERTY OWNER &ort' Print 100 Year Structure yes 69) MAP J(0_7,APARCEL:6 ZONING DISTRICT: Historic District yes Co Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑Addition ❑Two or more family ❑ Industrial "Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: Rl�emolition ❑ Other �rSeptic ❑WeIIsY A -2 � Flo©dplain 6Wetl Md-ii�_ ©a UVatershed Dstrict ` a DESCRIPTION OF WORK TO BE PERFORMED: LSD df_Z�sZnzG ,resAieAl Ad:r,,,Ei PASS 7—a1,fut 7.o' .;;-y 1;.,ek.4 t �C'k14.Uc. g2 Identification- Please Type or Print Clearly OWNER: Name: tLl�gCiASc.L,-7-,r- .c��_ Phone:/- 97,x'- .,0- 1,13 ' Address: 3 y_�- Plu z i c a 7 J6zV ZAJaQ7-14 vA2 Contractor Name: Phone: Email: � ,uC�u�,�tUGr'f��J Address: t-11wLf_T7- s-r- Shaaas Supervisor's Construction License: CS 67, 94 Exp. Date:O-F-dG-.2D7 Home Improvement License: 192 G yZ Exp. Date:6 7--/3 -20/ 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: ' FEE: $ Sa 3 . a Check No.: �l 3 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to guaranty fund F << µ I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL f 1 Public Sewer ❑ Tanning/Massage/Body Art ❑ SwiiMi g 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 HiALTH Reviewed on Signature 3 COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes e Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature & Date Driveway Permit ]DPW Town Engineer: Signature: Located 384 Osgood Street f•w.. ,� _ +...rr�� r FIRE DEPA�RrTMEN VT;e mi bumpster onosite^�K,ymgS,,i i�w,�,c4�,; . no "1#11 �" 1 '�+C Y9.. a a} .,F..'.'/ &1r. i y r a�;.,..,...+,.a.w.w—,T...•.°.."�..�,...�..,.� r ;Locatedi t 124iMain treet '� r e tE �, f =7:r ,1'kltrc fi�v, iF yl�i �'�'93;d ��i e��*w �itT i'w r .. .L _i►, s❑ IFir�e pepartmentsignature/date x n, -► a •xv5°Y y� 'iF'�?s �s�f � t }�ti. `r �'J r M r�'� ,Yi#Y'e`+ �te'V.+•:-- i..�.6a...�..�r...,.. 'G^£:z1 t -r v.$ J,-r.a }a '' s.. s� .a . J •. i i 3 Y �f of�. s!M "fi �` r5•i"'� }R { f 1 f .a t dr "tY y,yf".: ti y # 4' ;`.ti• i. tY k„1 . 'l"'..I . COMMENTS ." r lrY� l �k* �t 4.`p r s' f.. t ►�l] t °4. 4r "S� �t •sa. r.. ..._ .d .�,..�...eC..L..rr'.,`rpt,.t.+.::...,o...:�..?..3"tr:.�i.........,+.3�-�;,d 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: Fes No 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 i 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 4. Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract a 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 f 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 4� Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application i Doc:Building Permit Revised 2014 I Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 4302,O)L 1©) m $ - $ 522.24 Plumbing Fee $ 65.28 Gas Fee 100 comm. I$a 111020:0) Electrical Fee $ 65.28 Total fees collected $ 752.80 345 Raleigh Tavern Lane 1084-2016 on 4/29/2016 Kitchen Remodel c1ORT11 Town of p 0 h ver, Mass oLAKI > > cot HL.c«twit« �as RATED ?P,`�5 U BOARD OF HEALTH Food/Kitchen PERMIT T . LD Septic System J "' " F THIS CERTIFIES THAT �...! BUILDING INSPECTOR ........ .. ..................................................... ..................................................... 4."/..................................Gr�� Foundation has permission to erect .......................... buildings on ..................... ..... Rough to be occupied as ......... � ................................................................ • 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 STARTS Rough ........... .. ............................... Service r_14�vl BUILDING INSPECTOR Final GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Fina' No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. ' r} fY Eastern Construction +� PO Box 1266 Saugus,MA 01906 US Invoice trNN (781)233-5333 �.ea tern n � � .� �� ,�� ��� RI\_ J1 s co struction@comcast.net easternconstruction.net (, (a N S T R LL 1' I 0 BILL TO ,. Marcia and Scott Lane �364'Paleigh Tavern Lane 3 North Andover,MA Marcia:978-609-4345 Scott:978-578-5329 INVOICE# DATE TQ'fAL DUE • ENGLQSEp __... 1589 12/17/2015 $32,170.00 -w I II ft r DESCI�1PT1ON OF tAIORK ., _ .�. I AMOUNT ii -__..,-....-_ .__ .._..��..._. _,.��� �..�waw ,..,.,-a;.,�.�.,...�,�,.� -._ •. ..�___.. .. _,. :. ._ .... _. : 1---Remove existing kitchen appliances,cabinets,sink,flooring,and door leading to rear screened in porch area . .,......... 2---Remove existing wall coverings down to wall studs 3---Remove existing insulation 4---Install new framing as needed to make opening where sliding door was removed smaller to accommodate a new door. exact size to be determined 5---Install new door in new framing 6---Seal new door as needed using Geocel Tripolymer Sealant 7--Install temporary supports as needed to support house where wall is to be removed between kitchen and dining room and opening is to be made wider between kitchen and hallway 8---Remove existing wall separating kitchen and dining room and wall separating kitchen and hallway 9---Install new LVL beams or equivalent as needed to support house where wall in kitchen was removed separating kitchen and dining room 10--Install new LVL beams or equivalent as needed to support house where opening between kitchen and hallway was made wider 11--Install new wiring as needed for appliances and 7 recessed lights in new kitchen 12--Install new plumbing as needed for a new sink and garbage disposal 'new sink is to be located in peninsula between kitchen and dining room 13--Install new plumbing as needed for a new water line for refrigerator y 14--Install new insulation between exposed wall studs to code 15--Install new blueboard over all walls and ceilings in kitchen area and in porch area where door was changed 16--Apply a new skim coat of smooth plaster over new blueboard 17--Install new 7 recessed lights in kitchen ceiling 18--Install new electric outlets in kitchen area to code s 19--Install new light switches 20--Install new homeowner supplied kitchen cabinets and crown moldings includes drawer pulls,cabinet knobs,etc... 21--Install new Durock Wonder Board on floor and on back splash of wall behind stove 22--Install new homeowner supplied ceramic or porcelain tiles on kitchen floor and back splash of wall behind stove 'additional charges may apply if tiles are not ceramic or porcelain or if accent pieces are to be installed with tiles 23-:Apply new homeowner supplied grout to new tiles 24--Install new electric toe kick heat 24--Remove excess grout 25--Install homeowner supplied appliances 26--Install new mist trim in new kitchen as needed baseboards,door casings,etc... 27--Prime and paint new walls,ceilings,and trim 28--Remove all job related debris F� ....... DESCRIPTION OF WORK AMOUNT <. —This estimate has an allowance of$600.00 to purchase a new door —This estimate has an allowance of$2,800.00 for pluming,not including fixtures which the homeowner is to supply —This estimate has an allowance of$4,650.00 for electrical; including 7 recessed light fixtures,switches,outlets,plates,and electric toe kick heat —This estimate does not include repairs if necessary to the dining room ceiling. "'Additional charges may apply if repairs are necessary to the dining room ceiling —Add$230.00 to this estimate for each LED under counter lights "'Add$2,400.00 to this estimate for electric radiant heat,a thermostat,wiring,and installation 33,170.00 All materials are guaranteed by the manufacturer. All work is to be completed in a professional manner according to standard practices. Any hidden conditions:alterations,or deviations from above specifications involving extra costs will be executed upon written orders,and will become an extra charge over and above the original contracted price. All agreements are contingent upon weather and/or delays beyond the control of Eastern Construction. Ar,initial depoeit is to be paid upon proposal acceptance. 'Add 3%for Mastercard,Visa,and American Express transactions TOTAL 33,170.00 'All estimates are based on current product pricing and are subject to DEPOSIT change without notice 1.000.00 'Any changes,variations.or alterations to this estimate will result in BALANCE DUE ��^' �O.oO additional charges i DESCRIPTION OF WORK AMOUNT' ""This estimate has an allowance of$600.00 to purchase a new door —This estimate has an allowance of$2,800.00 for pluming,not including fixtures which the homeowner is to supply —This estimate has an allowance of$4,650.00 for electrical; including 7 recessed light fixtures,switches,outlets,plates,and electric toe kick heat —This estimate does not include repairs if necessary to the dining room ceiling. `"'Additional charges may apply if repairs are necessary to the dining room ceiling '"'Add$230.00 to this estimate for each LED under counter lights —Add$2,400.00 to this estimate for electric radiant heat,a thermostat,wiring,and installation 33,170.00 All materials are guaranteed by the manufacturer. All work is to be completed in a professional manner according to standard practices. Any hidden conditions,alterations,or deviations from above specifications involving extra costs will be executed upon written orders,and will become an extra charge over and above the original contracted price. All agreements are contingent upon weather and/or delays beyond the control of Eastern Construction. An initial deposit is to"e paid upon propcsa!acceptance. ...... ......... ........... 'Add 3%for Mastercard.Visa,and American Express transactions TOTAL 33,170.00 'All estimates are based on current product pricing and are subject to DEPOSIT 1,000.00 change without notice `Any changes,variations,or alterations to this estimate will result in BALANCE DUE additional chargesr ' JJ I �y bal �d4 i i u � i - I C C7 v� HLm- CC->ktT Ae.&C- Note: This drawing is an artistic NORTHEAST KITCHENS Designed: 12/3/2015 interpretation of the general 206 SOUTH MAIN Printed: 1/22/2016 appearance of the design. It is MIDDLETON, MA 01949 not meant to be an exact rendition. 978-774-8001 SUSAN SHALKOSKI, C.K.D 7 6 w Tiur � I o ! f Note: This.drawing is an artistic NORTHEAST KITCHENS Designed: 12/3/2015 interpretation of the general 206 SOUTH MAIN Printed: 1/22/2016 appearance of the design.It is MIDDLETON, MA 01949 not meant to be ari exact rendition. 978-774-8001 S rL - SUSAN SHA -KOSKI, C.K.D _a�- Northeast Lane=Kalman :, All Drawing 9: 1 1494" T_390 — f— F336_.1 ILW3036 W3015 _ W3036 � N W361824 a0D 6F 2DB24 PB920TPWW 3DB30 f I ' - U 189024 330 6-`._.. TEP2490WD I f ««««««wwwwww«w«www««««««wwwwwww«wwwww««ww««ww N CABINETRY: SCHROCK APC `DOOR STYLE: PARKER -� :WOOD SPECIES: CHERRY I ,FINISH: ClnlnlAMON 'DRAWER: MATCHING 5PC ,wwwwww«wwwwwww«w«*wwwwwww«w«www«www««««««wwerw -_._1, -- _SB27 -._'._ . 4DB1 1 N i I BWB18 ! i'DWT500RWW X a l 0 9 I— 'NEW I =io FLOORING I!—! SBSi i r— I 40-1/2" HIGH WALL BUILT Y CONTRACTOR 90AII I I dimensions -size designation'; NORTHEAST KITCI-FENS This is an original design and must Designed: 12/3/2615 :n are subject to verification on 206 SOUTH MAIN not be released or copied unless '; Printed: 1/22/201 site and adjustment to fit job MIDDLETON, MA 01949 applicable fee has been paid or job i 9itions. 978-774-8001 order placed. 5 PL SUSAN SHALKOSKI, C.K.D .heast-Lane-Kalman All Drawing : 1 ,.;.�-4 ". '�e"`^'":.t.,_..... _�^.' .... ,,•soR,.:;+�«n-.,--..t.�*.�.,.=w'�,.r s..a•_ ._�..- •_....•-w.•..w-....�,.+«.•v ..�.,.....-.. ..-.,....,...--�..,....-.�.._...w.. _ - - - M� D� G AS Pte= ' - Evs r o i , F I i IRC s Note: This drawing is an artistic NORTHEAST KITCHENS Designed: 12/3/2015 interpretation of:the general 206 SOUTH MAIN. Printed: 1/22/2016 appearance of the design. It is MIDDLETON,MA 01949 {. not meant.to be an exact rendition. 978-774-8001 SUSAN SHALKOSKI, C,.K.D '< �a-02016 Northeast-Lane-Kalman All Drawing } $ ''�� �, r r BOMBARDIER l" , STRUCTURAL ENGINEERING n -_ Bombardier Structural Engineering e` �N 131 Lincoln Street,Abington,MA 02351 _J Tel:508-631-3332 Z` I� .. - w w w.K W H d e s I g n.nel �. ►- ro i5 �, f April 12,2016 ` KWH design.Inc Kekh5LEED AP BD*C X 164 Keith Hinzman,LEED AP BD+C BOSTON.MA 07205 �� st KW H Design,Inc. keii 913-4714 n t PO BOX 51644 —KMd..fp ner 4�' f Boston,MA 02205 BOMBARDIER Re: Structural Review _"-. �' •~ � 345 Raleigh Tavern Road,North Andover,MA. STRUCTURAL ENGINEERING (508 1)671.2062 FAX 631-3332 VOICE 345 RALEIGH TAVERN LANE • Dear Mr.Hinman: (76 Per your request,I have reviewed your drawings for 345 Raleigh Tavern Road, North Andover,MA. dated April 10,2016. The new-door header for the opening to the kitchen is correctly sized.One section of the main beam, four 2x10's,supporting the first floor is sistered with an additional 2x10.This is an acceptable solution to increase load capacity where the existing header post and the two new posts at the doorway header load the beam. —� It is important that all posts are blocked solid to the beam with like sized material.The new 2x10 should be fastened to the adjacent member with 2 rows at 6 inches on center of a/a"diameter by 3 Y2"long SDS screws. In my opinion,the drawings are structurally adequate. Sincerely, OF Matic or LEON yea F A. BOMBARDIER 9 No.27616 p¢ 345 RALEIGH Leon A.Bombardier,PE TAVERN ROAD Structural Engineer COVERSHEET vn}n m,me., PmJed Number 2018-0412 AuOmr reeve Checker _CS- i i ww W.KWHde e I Bn.net KWH ftWgn,Inc. KeBh Hinman,LEED AP BD+C PO BOX 51644 BOSTON,MA 02205 (617)8134714 1W.W.KNMdIntpnet i BOMBMOIM STRUCTURAL ENGINEERING (508)631-3332 VOICE (781)871.2062 FAX i I EXISTING(4)2(10 CARRYING BEAM ABOVE V �2a10 SISBOVE I 11lTT`/-"/\ill SISTERED BEAM NOTE: ALL POSTS TO BE BLOCKED SOLID TO THE BEAM WITH LIKE SIZED MATERIAL,THE NEW 2X10 SHOULD BE FASTENED TO THE ADJACENT MEMBER WITH 2 ROWS ATB INCHES ON CENTER OF 1/4 INCH DIAMETER BY 312 INCH LONG SDS SCREWS. I FRONT STEPS 345 RALEIGH TAVERN ROAD BASEMENT FLOOR P.,.—, P.I dNumber N. 20160412 n M Author wW Checker BASEMENT A1.01 a 1/4'-1'-0' TRUE HALFS¢E SET 61.. � h0651GN www.KWHde sign.net K1NH d"dol Inc. KeOh Hin—,LEED AP SO-C PO BOX 516" BOSTON,MA 0.6 (617)913-0714 t �— _ keith KWH deslgn.re-- -------------- E ww«.Kweaee/gn.ner - - BMBAIUaM EXISTING THREE STRUCTURAL ENGINEERING SEASONPORCH _ EXIBTN _ (508)6313332 VOICE _DECK 0 (787)871-2082 FAX NO HEADER—IU--REMOVE m REQUIRED i i EXISTING NON-BEARING 11 WALL _ __S 10'd"SPAN RENOVATED._— "'—EXISTING-�_— .`_________ -___-__— �1 1 IqTCHEN BEDROOPANM )q T I 4 O g LL (E TING) �.�I S'NEEM mac ^ NEW NEW NEW m EXISTING POST, POST, POST, POST. P21 P22 P23 P25 - ---__..-----__—_ -- --____--__-_-___ — _ EXISTING STAIR NOT SHOWN h G�jb 345 RALEIGH TAVERN ROAD 8 1ST FLOOR vA}no.� ProhR Number 2016-0412 w q Author Checker 1 7STFLOOR A1.02 ' 1/4-=1'-0' TRUE HALFSIZE SET Cp �D ——— — ————— ———————————————————————_F IC ww w.KWKtleetgn.nal KWh deNpn,Inc. Kakh X5164,LEED AP BD-C PO BOX,MA 44 BOSTON,MA @308 (817) k1 hd.4 kalih®WMdvsl n.net 1ST FLOOR w.rw.KWNdealpn.nef I L- --- --- BOMBARDIER SPLIT STRUCTURAL ENOINEERM (508)631.3 VOICE (781)871.2082 FAX South TRUE HALFSIZE BET QE QD CQ QB A f I I I ————— TA'MC V R F M-1 I SPLIT —— ——————Y—————— ————— 4 345 RALEIGH TAVERN ROAD BASEMEN V EXTERIOR ELEVATIONS -'a wmeai Pmjact Number 2018-04-12 w a Author baq Checker x 4 Waal A201 7t4'=1' TRUEMLFSIZESET 1/4"-1'4Y e _____-__ -_-rte �D www.KW Xaeelgn.net KWX ft.1p,Inc. KeBb Himman,LEED AP BD+C PO BOX 51844 BOSTON.MA 022D5 (6/7)813-4714 I ST FLO Ik.lth@kwhdeDIgnKKw Mayan—t "V v SPLIT OMBAMER STRUCTURAL ENGINEERING (508)631-3333 VOICE _ BASEMENT (781)871.2082 FAX 2 �� J 1/4".1'!P TRUE HALFSIZE SET I II 1 l ----- - ------ A,C V � I i I 1ST FL00__R_n _-—__oil ___—_— ____—_ _—_—__--- 4-6 6"Q/— QF 345 RALEIGH 9TAVERN ROAD BASEMENTS EXTERIOR ELEVATIONS noFttn+�^�^ Pmled Number 201804.12Dm nw q Aur wer Checker A202 1 Ea1/4"r =1'd TRUE H4LFSQE SET 7/4"=1'd" I � I www.NO Kwllaeelpn.nel ATTID r NO HEADER REQUIRED—+` KWH aeelpn,Inc. Keith HI—n,LEED AP BD+C PO BOX 51644 BOSTON,MA C2205 (617)813-4714 keith@kwhaeeipn.net I vmw.KW11Ms1pn.nef 7ST FL00—R_n oM MRDIM STRUCTURAL ENGINEERING SPLIT (508)6 -033 312 VOICE (781)877-2082 FAX I ' BASEMENT 2 SHORT SECTION i/4"=1'-0"TRUE HAlF51ZE SET TRUE HALFSIZE SET SISTERED BEAM NOTE: ALLPOS TO BE BLOCKED SOLID TO THE BEAM WITH LIKE SIZED MATERIAL.THE NEW 7X10 SHOULD BE FASTENED TO THE ADJACENT MEMBER WITH 2 ROWS ATS INCHES ON CENTER OF 114 INCH DIAMETER BY 3-112 INCH LONG SDS SCREWS. ATTIC , .......EHeADER HDO3 F HD01 DBL 8.25'LVIs ABOVE INEI(ITC HEN OPENING5 P21r 4b" A�� i'd•I- 1STFLOOR (5)b103I EXISTING(4)b10e DROP-FRAMED BEAM __ _ --I.________- -- PL7 P2 P3 P4 1e--PS SPLIT ——————— — —— EwxX76sISTEReD — — ————— ——— ————4'-8 & ? 345 RALEIGH IST GC.IP TO EXISTING BEAM I TAVERN ROAD CO WALLS EXISTING LALLV COLUMNS BASEMENT SECTIONS 10V" 9'.10• P.Pn—.r Project N—th, S'•10• 7--s- T-0" 10'-T^ 10'3^ 2016-0412 nwnw Author 0801 0807 D803 44•d^ D804 0800 ww Checker A301 1 LONG SECTION WMA 1'47'TRUE HALFSIZE SET - PR-05-2016 TUE 05: 10 PM P. 001 CERTIFICATE OF LIABILITY INSURANCE �TE(MMID4LYYYYY)16 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMA71VELY 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@), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights tD the certificate holder In Ileu of such endorsement(9). PRODUCER CONTACT NAME: Joan Spears Joseph O Danca Jr Ina Agcy Inc PHONE Ddi, (791 322-1322 A N (761) 322-9778 182A Highland Avenue dto ADDRESS: joan@dancainsurance.com Malden, MA 02148 INSURENS)AFFORDING COVERAGE NAIC# INSURER A:Northland Ins INSURED INSURER B; AA 6 K Construction Inc INSURERC: C/O Steven Kalman INSU D, P.O. HOx 1266 INSURER E: Saugus, MA 01906 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'PERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. L R TYPE OFINSURANCE AWL 9UBR POLICY NUMBER PM/ODnEYYP! MM/DD LIMITS A OENERAL LIABILITY N N WS253980 6/2/15 6/2/16 EACHOCCURRENCE S 1.000,000 COMMERCIAL GENERAL LIAB ILITY DAMAGE TORENTED $ 50,000 X CLAIMSMADE D OCCUR MED EXP(Any mne person) $ EXCLUDED PERSONALS ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APP LIES PER PRODUCTS-COMP/OPAGG $ INCLUDED POLICY PRO- LOC $ AUTOMOBILE LIABIUTY OMBeNEeDDSINGLE LIMIT (Ea a $ ANY AUTO BODILY INJURY(Per person) S ALLOWNED SCHEDULED BODILY INJURY(Pereccldenl) S AUTOS AUTOS Ip AMAGE $ HIRED AUTOS _AUTOS Peraccl e4 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCES6LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION WC STATU- 0TH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNERIEXECUTIVE ] N/A E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) EL,DIS jaE-EA EMPLOYEE Ifee describe under DS4rRIPTION OF OPERATIONS below F,L.DISEASE•POLICY LIMB S DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Addldonal Rorrorks Schedule,if more space is required) CONTRACTOR : JOB LOCATION 345 RALEIGH TAVERN LANE, NO ANDOVER MA 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 ACCORDANCE WITH THE POLICY PROVISIONS. 120 MAIN ST NO ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE Joan S ears ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: (978) 688-9542 E-Mail: PR-05-2016 TUE 01 : 19 PM P, 001- ® ,a►�oRo CERTIFICATE OF LIABILITY INSURANCE DATQ(MM/DOrrYYV) 04/05/2016 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 to an ADDITIONAL INSURED,the pollcy(lee)muet 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 rightB to the certificate holder In lieu of ouch andomement s. PRODUCER NAME? oMEACT ,Joan spears IAK JOSEPH O. DANCA, JR. INSURANCE AGENCY INC. PMCNE 781)322-1322 .0. C No: MAIL joandtdanceineuronca.com ADDR2SS: 182A HIGHLAND AVENUE, IN611Re11S AFFORDINOCOVER--- NAIC6 MALDEN MA 02140 INSURER A; TRAVELERS PROPERTY CAS CO OF AM 25874 INtURPD INSURER B: A A$K CONSTRUCTION INC DBA EASTERN CONSTRUCTION CO INSURERC; INSURER D: PO BOX 1288 INSURER E; SAUGUS MA 01908 INBII ERF COVERAGES CERTIFICATE NUMBER. 4218B REVISION NUMBER: THIS15 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. SUER INSR TYPE OF INSURANCE POLICYNUMBER MMIDICDYPMID LIMITS L COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE $ IV CLAIMS-MADE E]OCCUR Ea amurre $ MED EXP(Airy oqe eraon S N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S PRODUCTS-COMPIOP AGG $ POLICY JET LOC S OTHER: I I ' AUTOMOBILE LIABILITY COMBINEDBIN $ ANY AUTO BODILY INJLIRY(Per person) S AUTOWNFO AUMOSULEO NIA BODILY INJURY(Per aorJdent) S NON-OWNED PROPERTY DAMA $ HIR90ALITOS AUTOS Perec E UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCegeL1AB CLAIMS-MADE N/A AOOREpATE $ 0FORETENTION tb $ YATUTE WORKERS COMPENSATION X OTH- ER AND EMPLOYERS'LIABILITY Y/N E.L EACH ACCIDENT E11000,000 ANYICERIM MB R,a XC UDEEXECUTIVE A (Mandatory In NIA NIA NIA 7PJUB2E27247015 05/22/2015 05/22/2018 E.L.DISEASE-EAEMPLOYEE $ 1,000,000 (Mendetory In NH) If yes,descrMa under E.L DISEASE-POLICY LIMIT $ 1.000,000 DE50RIPTION OF OPERATIONS Delow NIA DESCRIPTION OF OPERATIONS(LOCATIONS f VEHICLES(ACORD 101,Additional Remarks Schedule,may ba anaahad If more epsee is requlrad) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 08 9,no authorization is given to pay claims for benefits to employees in states other than Massachusetts If the Insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy In force on the dale that this certificate was issued(unless the expiration date on the above policy precedes the Issue date of this certlficate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensatlon/Investigations/, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of No Andover ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Sl AUTHORIZEDREPRPSENTATIVE No Andover MA 01845 Dan lei M.Crqey,CPCU,Vice President—Residual Market—WCRIBMA ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD The Commonwealth gfAIMQachasetts ` De artment of XndustrlalMceldents P 1 Congress Street,Svelte 100 Boston,MM 02114-2017 www.mass.gov1d1a yV'orizexs'Compensation �OB7G�'II.ED'�THT�fE�ERM[TrTJN�.A.xTJTJEI:ORITY.trczcians/Plumbexs. A licantt Information Please Print Legib Name(BusinessioxganizaationLtudividual): 6 vfi P� .A.d&ess: I I-/Lour S' T Ciiy/State/Zip: hi^�c r`2A- ©14�� Phone Areyou ant employer?Check the appropriate box: Type of project(reCluired)' 1. am a employer with _employees(full.andlor part tlme).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for mein 8. Q Remodelilig any capacity.[No workers'comp.insurance required.] 9. JODemolition 3,❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 F1 Building addition 4.E]I am a homeowner and will be hiring contractors to conduct all work on my property. "Will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions ' —- 1.2.[�l�lumbxng-repairs-or-adchttons—– 5.0 I am a general contractor and I haye hired the sub-contractors listed on the attached sheet. 13•❑Roof repairs These snb-contractor'sliade employees and have workers'comy.insurances 14. Other 6.Q We area corporaion and its offteers have exercised their right of exemption per MGL c. 152,§i(4),andwe have ng etrrlployees.[No workers'comp.insurance required.] *Any applicant that checks box41 must also fill out the section below showing their workers'compensation policy information. i Homeowners who subniit11 is affidavit indicating they are doing all work andthea hire outside contractors must submit anew affidavit indicating such. tContractors that check this box musk-attached an additional sheet showing the name of the sub-contractors and state whether or not th_ose entities have . employees. if the sub-conlraclors Have employees,lliey must provide their workers'comp.policy number. lam an employer that is piovidlhg workers'compensation insurance for my employees'Below is the policy and joie site information. Insurance Company Name: /7i4V «S l.c�syi2 �� Policy#or Self-ins,Lic.#: Expiration Date: S Z Z'� 7 job Site Address: �i ys �rt��{ Ae) City/State/Zip:�i�¢rH Jr�yr/i�Z /�/0 dIB'h�� Attach a copy of the Workers'comapepsation policy declaration.page(showing the policy number and expiration date). Failure.to secure coverage as required under MGL e. 152,§25A is a criminal violation punishable by a fma up to$1,500.00 P 0a a of to 250.0 ' the forms of a STOP WORK ORDER and a fin. p $ e as civil penalties rn • ens as well . and/or one-year imprisonment, p day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. it do hereby certify or the pa' and penalties ofpelytiry tlzat the information provided above is true and correct. Si ature Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official.. City or Town: Peimit/License# Issuing Authority(circle one): 1.Board of Ifealth 2.Building Department 3.City/Town Clerk 4.]Electrical Inspector 5.Plumbing Inspector 6,Other Contact Person: Phone#; Information and. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation,for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract 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 of an individual,partnership,association or other legal entity,employing employees. Ilovv ever 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 required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance 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=contractoz(s)name(s),address(es)and-phone number(s)along with their certificate(s)of imsur.,mse.--Lirnited-Lxab lity-eompanies-(LL--C)-or-Liirdted-LiabilYty l'at is (TlLF)wifih no emp oyees o er an a members or partners,are not required to tarty 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 foir confirmation ofinsurance coverage. Also be sure to sign and date the affidavit. The affidavit'should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you'are required to obtain a workers' compensation.policy,please call the Department at the number Iisted below. Self fiisur6d companies should'entertheir self insuratice license number on the appropriate line. City or Tonna.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 areference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current pollcy information(ifnecessary)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. Anew 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 ludustrialAccidents 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 �Y y' j�yYy� r t 1 Sz S t ............._............... .-..._......... Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Super1•isor License: CS-075948 STEVEN R KAL11JAN PO BOX 1266 WIN i SAUGUS MA 0106' . r ✓l. � '�� �'t Expiration Commissioner 03/06/2017 i C77 j . 3 / • Office of Consumer Affairs and Buslness Regulation li 10 Park Plaza - Suite 5170 i Boston, Massael setts 02116 Home Improvement C µr for Registration Registration: 182642 Type: Corporation Z J Expiration: '7/13/2017 Tr# 268344 AA & K CONSTRUCTION CO, INC. y T Y i STEVEN KALMAN n _ P.O. BOX 1266 = SAUGUS, MA 01906 i ti ,6 Update Address and return card.Mark reason for change. SCA 1 e, 20M-05i11 l'- Address Renewal Employment ❑ Lost Card 3 qJ l2gl-E IG M TA✓tg r1 /7a &P-TH ANDaIJUZ /`l i I i � i � I + t � I f rr'" Nth A!L tG . 7,4" t 41 I � ltL�►bLL � , r Or�urrtb I-U----' -- - Location f No. "' ` — �l. Date r . - TOWN OF NORTH ANDOVER 7 . "_. • W Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# '�` J n 0 Building Inspector