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Building Permit #214-11 - 35 SAWYER ROAD 9/13/2010
BUILDING-PERMIT °F *iO pT�q TOWN OF NORTH ANDOVER �2 hist •'•..'6=6'�° APPLICATION FOR PLAN EXAMINATION Permit N0 Date Received Date Issued: - a�d ��SSgcHuSE��y IMPORTANT:Applicant must complete all items on this page s7 �'n•L'f:' c'''r L'--`y'r,�E3,S`:S•nk.l'w ::i�l:•fi.:.a•i 7•-,��i. -. - :�Y:I:' _ - "Y.�c,•- ,'-:',;I. i:n i._a_b•t t,`�'r'.z'c a.. �?:_?: s'N.' `•- '.'•s..'" ,81,1',• ..� :'LZ,- - -^d:,-,,,1. .;'e is::%',1^..Yiy:,a`:!.d`pfa.�4.,�,::>•:.cy.-- - E�, t gip_,. Y:1; °i •_ .=-F.-:_ ._ _ - `��. .-r..�LZ.,`nn...;n..,._uv v.;`. ==��' __ .•6 u'F,-r'.':�--rr=. r��., nM s:•f-. •[o-yr - - �..rfi_ ,r r 4.,,:.,=r:•...-r -.r.�,>._ __:._:xr.. `-wp•_.. •.s! - y �-tc.- __ rX_ �y4.a_. - •-ra�:•_rr_,.:t3s-•-_., _- :It,...�.n-, - Ti•-!.:+-,.:,-7'.- .a - ..1:J'T:v (-.r~' H.s.. :,:#•."f :_H--;r�.r-r .?-.j a3j:� y.-.`...J .5 {-.'(`;- .;�,f:=^:3`'+w::n2 G i ^ '•�i�-_:... - -.-•'1:L�.y:. 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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: DemolitionOther -a7�,�p"�I�ra`Fi-"'�,�.�.L� :-�"�:.r.`•_$•.`._''.:. r�' ;� kms- ( .-•ti,�%�i?�. ,s��'��,N.�"y- _-.:..%'aai. -� wu�:r�;r� .^u-, r.-��.�-�.:.r� ��.::.•w,s���.w a,;2'-ax:::«.�F'�,1+=ar':`"�'�Y''�ti`� .�-LF.,,e 7"-'S�L'����il}�ny'-ts-::�w�.`d��'elll�4�� .�x�t-x �.�-. �"'•,n. 5.- in, a- � ���;.;:, cam' ^�_ ��], •>_,r �, ,�`�-ry...- i�:x�=i;r",'.':J,�ty �:t�wa. :�,t-.-"•ice :+�•r'� •„f�7�.�..�• �a�?'.a �������r.:�$1�1;����/,r�'illll.����7�'�' � yi r��ca ;r�;rt�.�''�Ei}�k ��xs'�� M,:��� .•�z'a�%`n_�'=t F ;:t�' 3.- -Ti' .� k .�,.r,�'-. :�,;r�•N=-:,�:-n �:��r,>•' .-, .,':� ..r. ,y` �• ""�JIhSr '$;_ ,i - te7,",`�"s,`�..�•>�'� ,;.r�y r�^�-`„�'��`��, •r�".i-x,T ••`�'�:'T:' :-�•� �` tie :....__.:..._,.._.,.._.. .F_.,.:...._...rr_.. 3_,:�r-.. Je:S ._c:_nw. :�vi rfa.G.,�,S-r. •c:'+ I-r-µ�''�`.' .,`�4-�9".��•r'r�F>�;:��•r.�N`•S::F;=:-TaE•.�-.k_��.;�,�.?s,?NeJ 1'i_ro.a'.-.."[',--�z'� ......Y_._..,:rr''^�.,+.•f+l:.,r'�fu�'..".}n.,_.w�'Fj`_. .,,7'1.�;,, wa�:.�-ors. <'"rl�='_�',nr DESCRIPTION O WORK TO BE PREFORMED: es Identification PIease Type or Print Clearly) OWNER: Name:/.,, Pa, KlIe V Phone: 177 Address: 3� �` V .4<o/ '''rte.u'.: ol?"3k� %"h�: --�Fun •'.•gE;:'`"%+?v:,�s'i::::�.> .a,�;•�rar'r.:r-.-,t._ v '/ V/ �� �, m rvi?,� 'fr�FSfi;+.v:�.. 2r�. ,::w.i. •�'3.^:r.,- _r :. ;:•5 -- __ !R�.. y�...,,..T r.•' ..�+ -c�.�"?,'!�=k�'• `--::,sa:'rcF •gym>,-�-1 1 �, r.,rr'`Sir.T_`'a_..r'a�.r T"r'`:±5•i?•u :.��:. - -'NON v-•.:,-�;� z.t [Sy .Js-,65z'a.. -`z._:s•_* �J'.:' _.+y '".,h:�'-',Ly ,?,•r.-:-3 .�., r�-� 7: .�..� .1•ti';- $, ti`y •a='.i;','- .�'`rJ"r' -P .�SI%F�F,>:,.I.� s.•... ...ems. 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'�Sa.? •�.- .,.mo-'7 Vii'$:, s,=.�. :�r = ."4:!s.. _.•n.-f..,�r ��ya�.r�.:xa. ra:,,, - _ �� '� ..>_. rte t.•t:.. .,.,., ,. •li..r.'m'.".n .F r -•m., .%":r��:.^�7:•.ri..4r:.Yy:, z�• T.u�! .rt.r="'=`:,-?-Hur'�S�,�.•.;r- b•'=.+•-t �i.*d. _ �.-�a�'�. .a�,?;,f:r.� ...''`i}'-•.wr,a„r'�`w c ��'�-i��"yr..:� _.ti�n.5�s'- �:�:..�'.��•:�as-�ftr-- x-mn:e^=� ;C.•.�-1+hi'vi�^m' �•-a--4.T��,�,•�r"`_ •.moi.-��r ,�ir-`�-�,•.r=_7� .ar.. ,u rui�u-•r�.•'•k'_�;,�!.. >1,^e�� �__ - y�'-�='i"51'ra;.�.::5:` a�:�r}':,,�....u�.;:'i'4-•_-�fz r-.2.s•�� :t?._,..,•4. �. ��:slC'��•r�„�,;^y.s�.r'� J,*�:,�.�,....:aa'�. 7t".a_°-�d�''.''rV'�`M17_rf•_,.c':,4` .•g >:r=.: sirs: r=11.. '�i•_•`•;,x>t,-.=rho,- .-ri..: .=i"'1'� -';�z.'�5 r-�i'.•x.•; sv-l+.;t ,.--r:'.`-a,,��t., i s - i; I_3� �„$. - �F - >f'-I::_4drp "[�-k.=.. J'a •Mr Wiz,..:.=..r:��'+'Si^TTt f s, •;A,-..::a.:�� .,�. a-,rs-r..•..:x ���atr=stye �- �Fll�:�±i�s.,�.'�-.,ri.11:�-•:����-� ". -.�''y�#-'4,. -�_4;! _.�^y. '9^;. .��.a�_, �',F,.,rr' .�m '.�x.;•�-.y •'rl _ ..9!rvl 'a°�' ._ .�1�-��nr-.-.r=a:•��.�;5•;'s'J'r�'.�r��5`NL`i�t' �,y '} -�' I^ : , ,g�-:,.=''�]"v�.s,.i�.!T'`-��=• ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULD/NG PERMIT.,$12.00 PER$9000,00 OF THE TOTAL EST/MATED COST BAS ON$125.0 PER S.F. Total Project Cost: $ ��',��', �o� FEE: $ Check No.: d Receipt p No.. � Z- NOTE: Persons contracting with unregistered contractors do not have access t e c ua anty fund .-..��,�,ufu,�r:��.�: �.geril��aiur�•r'` - _ _ - - _ ��- � _ rSagnt�are�fcon�ra . `r �. Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tannin ansa eBod ArtTPackaging/Sales g Y I Well Tobacco Sales Private(septic tank c. P ,et . Permanent DumP ster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED- PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature • rel Il t•-'►.tT i C0IV MENV IS HEALTH Reviewed on Si nature COMMENTS Zoning Board of Appeals.'Variance, Petition No: Zoning Decision/receipt submitted yes Planning aoard Decision: Comments Conservation Decision: Comments Water & Sewer Connection/si4nature Date ' Driveway Permit _ DPW Town Engineer: Signature: Located 384 Os god Street - %}'X;:'•g •.-s �i�4� •r - _ BE <7, :';�'°�� r-_.'�:-�-•ys'=µ'Vi"•'�``° _ _ :t:..a>>:G4a�vrt:.:.t:, - __ _ _ _ ,-s_ •.. E,F" ':J_ 14,5.• ;�'t ..r..=_' w�1.. - ..S. 'l••-a rRE ^� [� , �=mow :�r:- - s.. ._,_-,._ .....,f,_:.•t-...:i'?3r.-e x.:.:. ,a-,7..f,.. ....,.�,. _.ice' - ;:7.; �� ..+c-=,:•.^:` --^5`.t„ ''tf"'-'=.:::=�:'..=r3.-- -,—t;...:,:y..,_,�v:;�;: 1, - .:1•'..'u'• - _.4't i - }}�� } I Dimension Number of Stories:________Total square feet of floor area b ased 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 Cbapter 166 section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup - Date 1 Doc.Building permit Revised 2010 Building Department The following is a fist of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or.-Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check.Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Ce►lifted Proposed Plot Pian. ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the-building application Doc:Buildine Permit Revised 2008 Location �' ./41' q- 3- iv No. �j �/ Date / 40RTH TOWN OF NORTH ANDOVER 3�0.,"..a o f w a Certificate of Occupancy $ cMuBuilding/Frame Permit Fee $ s� sE Foundation Permit Fee $ Other Permit Fee $ TOTAL $ F yJ� Check # - 234 `. �� ui ding Inspector CREATIVE DESIGNS In Kitchens and Baths 132 Great Road Stow, MA 01775 978-897-9920 Fax 978-897-9625 Home Improvement Registration# 127668 PROPOSAL DATE: July 26, 2010 PROPOSAL SUBMITTED TO: Patricia Riley ADDRESS: 36 Sawyer Road, North Andover, MA 01845 TELEPHONE: 978-686-1881 We propose to furnish materials and labor, complete in accordance with the attached, for the sum of$29,858.92. Payment to be made as follows: Deposit upon acceptance: $ 7,500.00 r� Payment due upon start of job $ 6,858.92 Payment due upon installation of blueboard & plaster $ 7,000.00 Payment due upon installation of cabinets & counters $ 3,000.00 Payment due when kitchen fully functioning $ 5,000.00 Payment due upon completion of any punch list items $ 500.00 All material is guaranteed to be as specified. All work is to be completed in a professional manner according to standard practices. Any alteration or deviation from the specifications involving extra costs, will become an extra charge. Additional costs of$1,000 or more will be in writing. Others may be agreed to verbally. All agreements contingent upon strikes, accidents or delays beyond our control. Materials and labor are guaranteed for one year. Manufacturers' warranties apply, if longer. All products are custom ordered and as such, cannot be returned or exchanged or credit given. Any changes to materials will be considered additions and require payment in full. Creative Designs reserves the right to assess interest charges @ 8% per annum for payments not made as scheduled. 70RIZED SIGNATURE FOR CREATIVE DESIGNS: Mae Zagapl, Owier ACCEPTANCE OF PROPOSAL -The above prices, specifications and conditions are satisfactory and are accepted. You are authorized to do the work as specified. 1 understand invoices will not be issued for payments specified above and I will make payments as they become due. Date: Signature: Creative Designs is authorized to place a jobsite sign on my tont lawn during the duration of the project Yes No Customer Initials July 26, 2010 Quotation for Patricia Riley Kitchen Remodeling-Option i (Island Plan) Cabinets: Adelphi, Ridgewood frameless series, Heritage doors, flat drawer fronts, White Birch, Autumn finish. All wood construction except, shelves are veneered particleboard. $11,026.09 Door&drawer pulls, SP-3-SS 0.00 Counters: Laminate,Wilsonart, Mesa Flint, beveled edge, 4"beveled edge backsplashes 2,019.06 Sink: Kohler Lakefield 1 1/2 bowl enameled cast iron, bisque, stainless bottom sink rack(for large! bowl)& 1 chrome sink strainer 667.45 Faucet: Danze,Antioch, single lever, separate spray&soap dispenser, polished chrome 0.00 Lighting: Volume International, 2 sconces, alabaster glass, brushed nickel trim on single bar 243.02 Door: Therma Tru, fiberglass, 1/2 raised panel, 1/2 glass, brushed nickel hinges, brushed nickel lockset&deadbolt(keyed alike) 950.27 Sub-total $14,905.89 Sales tax 931.62 Labor&Materials, including removal, disposal(except appliances) installation, carpentry, plastering, plumbing, electrical&lighting. Includes installation of plywood for vinyl floor. 15,512.00 Repeat Customer Discount- 10%off Materials ($1,490.59) Total $29,858.92 NOT INCLUDED: Disposal of appliances Painting, staining or wallpapering Installation of vinyl flooring I Po I, C a tea, %u /y ° lid. TB 7s T ! S 1,36 VEAI t t t . / OR X102 � g 0 R g` a� k ; { f 1?7 _ LLs I ; i 7r iii/C GF �t •' of.. F ZV Q L, 4(—,4 l3 iii'�i S 7gf - ---� - - Q 3 : � y • a ai I ij I ' * 67 r rs T - /c'CP.0/SCE 1 � !3 l _ J Z)/ – .. ._. j 1z1 — r — — p r f � � � F I F / ` c� i J - _ ._ - ti I I._. .. ._. _ �`" ��i'c✓ AA f ^ �; ��� � ,�J c� '.fie Q� ►t 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS A! ' r DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ 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 Drivewav Permit Located at 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on sit yes no Located at 124 Main Street Fire Department signature/date � z COMMENTS ` B o �uilaons an Nan �rs One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Registration: 127668 Type: Private Corporation Expiration: 12/7/2010 Tr# 277931 CREATIVE DESIGNS IN KITCHENS INC MAE ZAGAMI - 132 GREAT RD. STOW, MA 01775 Update Address and return card.Mark reason for change. Address E] Renewal [-] Employment Lost Card DPS-CA1 is 5OM•07/07-PC8490 BoWrTpofPfi� iCoiraan ars License or registration valid for individul use only _ HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 127668 Board of Building Regulations and Standards Expiration: Tr# 277931 One Ashburton Place Rm 1301 Type: Private Corporation Boston,Ma.02108 CREATIVE DESIGNS IN KITCHENS INC MAE ZAGAMI �. 132 GREAT RD. STOW,MA 01775 Administrator Not valid tho t signature Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construct►on Supervisor License License: CS 86163 Restricted to: 00 SCOTT T WARREN 200 WEST MAIN ST " NORTHBOROUGH,MA 01532 Expiration: 12!14/2010 Commixsioner TO: 11408 Resbicted to: 00 00- Unrestricted 1G-1 2 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Refer ta: WWW-Mass.Gov/DPS Aug 18 2818 11:18:36 Via Fax -> 9788979625 The Hartford Fax Page 803 0f 083 PNB CERTIFICATE OF LIABILITY INSURANCE R0 08_10-2010 THIS CERTIFICATEIS 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 ADDITIONALINSURED,the policy(ies) must be endorsed. If SUBROGATIONIS 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 AUTOMATIC DATA PROCESSING INS AGCY PHONE 250717 P: (877) 287-1316 F: (888) 443-6112 (ac No Ext): (877 287-1316 in c,Ne): (888)443-611 E-MAIL PO BOX 33015 ADDRESS: SAN ANTONIO TX 78265 MUUUUtK INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Hartford Ins Co of the Midwest CREATIVE DESIGNS IN KITCHENS INC INSURER 6: 132 GREAT RD. INSURER C STOW MA 01775 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. L ITR TYPE OF INSURANCE A POLICY NUMBER ffialh&N/DD/YYYY1 lMM/DD/YYVY1 LIMITS GENERAL LIABIL?Y EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY D ' PQ--Nihu PREMISES(Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY S GENERAL AGGREGATE $ G 'L AGGREA64 LIMIT AEE-UES PER: PRODUCTS-COMP/OP AGG S POLICY PRO-JFCT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO IEa accident) S ALL OWNED AUTOS BODILY INJURY(Per person) S SCHEDULED AUTOS BODILY INJURY(Per accident) 9 HIRED AUTOS PROPERTY DAMAGE S (Per accident) NON-OWNED AUTOS S 5 UMBRELLA UA8 OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE 5 DEDUCTIBLE S RETENTION S S WORKERS COMPENSATION AND EMPIO VERS'LIABIUTV X WC STATU- OTH- ANY pROPR1ETOR/PARTNERlEXECUTIVE V/N TORY UMITS ER A !OFFICER/MEBin Mandatory /INNEXCLUOED7 ❑ N/A E.L.EACH ACCIDENT 5 500, 000 76 WEG KP7002 08/17/2010 08/17/2011 E.L.DISEASE-EA EMPLOYEE S 500 000 If yes,describe under DESCRIPTION OF OPERATIONS bolow E.L.DISEASE-POLICY LIMIT S 5 0 O O O O DESCRIPTIONOF OPERATIONS1 LOCATIONS I VEHICLES(Attach ACORD 707,AddXional Remarks Schedule,if more space is m9ulmd, Those usual to the Insured' s Operations . CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE Town of North Andover DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD ST NORTH ANDOVER, MA 01845 AUTHORaW REPRESENTATIVES ®1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UT www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information _ Please Print Le 'bl Name(Business(Orpm ation/Individual): F J~ Address: City/StatelZi: - o� O1 Phone.#: 0 Are you an employer?Check the appropriate box: -Type of project(required):. 1)<I am a employer with 4. [] I am a general contractor and I employees(full and(or part-time).* ` Dave hired the sub contractors 6. ❑New construction 2.Q'I am a'sole proprietor or partner- listed onthe'attached sheet 7.�� temodeling ship and have no employees These sub-contractors have 8. []Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition (No workers'comp.insurance comp.insurance.$• 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 I LO Plumbing repairs or additions myself. (No workers'comp. right bf exemption per MGL j t c. 15212.E Roof repairs incrr*A�Ce required ,§1(4),and we have no employees.[No workers' 13.[]Other comp.insurance required.] *Any applicant that checks box#1 must also fin out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing a1work and thea 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. Uthe sub•canlrac*rs have employees,they must provide their workers'comp.policy number. I am an employer that Is providing workerscompensation Insurance for my employees. Below Is thepolicy and job ske information. /� Insurance Company Name: L.. Rte ) 1/t•`v • Policy#or Self-ins.Lic.M. P DOZ. Expiration Date: lob Site Address: 3(p sow C� �""' City/State/zip:/V0-4;7>a Attach it copy of the-workers'compensation policy declaration page'(showing the policy number and expiration date). Failme.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 instaance coverage verification. Ido hereby A 7rdfy under pains•and penalties of perjury that the information provided above is true and correct Sinature: Date: .3 .t7 © 9Z 0 — Phone#: ZZO fjtcial use only. Do not wrtte In.this area,to be completedby city or town ojflciaL 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 ContactPerson: Phone#: coRIO CERTIFICATE OF LIABILITY INSURANCE OP ID FL FDATE(MM/DDIYYYY) CREAT-2 07/27/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE H.H. Warren Insurance Agcy,Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P O Box 263 22 Gleasondale Rd ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Stow MA 01775 Phone: 978-897-7074 Fax:978-897-9320 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Safety Insurance Group 33618 INSURER B: Creative Designs in Kitchens Inc. INSURER C: 132 Great Road INSURER D: Stow MA 01775 INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER POLI Y EFFECTIVE POLICY EXPIRATION DATE MM/DDIYYYY DATE MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CP00000398 07/31/10 07/31/11 PREMISES(Ea occurence) $50,000 CLAIMS MADE X] OCCUR MED EXP(Any one person) s5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY PRO ECT LOC J AUTOMOBILE LIABILITY A ANY AUTO 2700739 04/23/10 04/23/11 COMBINED SINGLE LIMIT(Ea $1,000,000 (Ea accident) ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F1 CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATIONTAT - AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVF[::] OFFICER/MEMBER EXCLUDED? E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $0 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CREA002 DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 15 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Creative Designs in Kitchens IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Inc REPRESENTATIVES. 132 Great Road Stow MA 01775 AUTHORIZE 'REP E ATIVE ACORD 25(2009101) 1 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NORTH own of 6Andover .. (10 0 LAKE -0 dover, IVMass., • /3 • /y COCHICHEWICK �It, ORATED P'P�,�"`� BOARD OF HEALTH Food/Kitchen PER ITi T Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........... .... ................. 1.... ....... ...................................................................... Foundation Rough has permission to erect..............:. .Aug ildings on ..................... ..... �'!�.. ... .. g to be occupied as .+t!!!'`#AA,. Chimney . . . . . . . ......................................... provided that the person a cepting this permit shall in every respect conform to the terms of the application on ile in Final 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 j Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUO STARTS Rough .... .. ........................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det.