Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Building Permit #299-2017 - 37 RIVERVIEW STREET 9/20/2016
r , BUILDING PERMIT of N0RT1 q Ia TOWN OF NORTH ANDOVER o .. - APPLICATION FOR PLAN EXAMINATION � 2 n Permit No#: i Date Received y A°R17ED 4=140-3RTANT: CHUSDate Issued: Applicant must complete all items on this page LOCATION Arr A=VF-R-1XF-% -ST Print PROPERTY OWNER AT44 'ioSAS /�] Print 100 Year Structure yes Eno MAPv 'Z- PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building W-One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial 9 Repair, replacement - ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ®1NeJl © Floodplain, ®Wetlands 1Natershed'District 1Nater/Sewer - DESCRIPTION OF WORK TO BE PERFORMED: �EcoNS-rQ �X-r-r-,,,�( D u�� ��-Q� �A n�PrG-r✓ ,. SX�z.FTcia►-�.a� R G i�a'�iZ W o�1L- 6 a._._ �SmF'-c—L-c_ EP tLS -�o �ZES of *-kOwxc as C -0 ro,04-0 Identification- Pse Type or Print Clearly OWNER: Name: ArtAA z-11 S Phone: $-� �- o Address: ( c Contractor Name: Phone: Email r OL^ C e...1:-gas-4&1 . C oty) Address" L;X Supervisor's Construction License: LS- 0553` 8' Exp. Date: Home Improvement License: 16571 a. Exp. Date: 31�z�aQ ►� 4 ARCHITECT/ENGINEER_!�(I 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. Total Project Cost: $ ( . 000 FEE: $ 4�2, Check No.: l 6 1 Receipt No.: �6111 NOTE: Persons contracting with unregistered ontr FS do noljwxe access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 'OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Mas sageBody Art ❑ Swimming pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING a DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature 'rOMMENTS HEALTH Reviewed ori Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Wafer& Sewer Connection/signature Date Driveway Permit DPW Town Engineer: Signature: 1 ocated 384 Osgood Street �F1RErDEPAR�TMEIV,Tf ,Temp Dumpsfier on;site.: oyes. �r nog .p _ ` �_ Located at'-124:Main Street +� k TM P",Departinenf signature/dated COMMENTS '^ v Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of:the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits 4 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 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 _ 4, 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 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 Doc:Building Permit Revised 2014 r -- Locationt3 Z-yk C--} lkaufT No. t w �" Date T • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# V d f v Building Inspector .. Ur pORTy Of,�i�:c y p Town of North Andover D.B.A. —Zoning Compliance Form Tap 978-688-9545 4SSACHU`��� This form must be reviewed with the Inspector of Buildings. Office Hours are Monday-Friday 8-10 am,and 1-2 pm Monday-Thursday. Applicant L c)f CD Name of Business: �Olc�t � Cbl Address of Business: 31 Pliyeld(6W Zoning District : '1 Map Lot Phone: 0-4,1 Email Q()QfQ 3P-0 c©yy) Nature of Business: �_n540O n Do you own this property?Yes No X, If no, written permission is required from your landlord. Will you have clients coming to this property? Yes No Will you have any employees? Yes No X Will you have any major deliveries? Yes No— Description o—Description of Business Activity(Must be Completed) Inst'a SIL �i o() Signature of Applicant 'Fa6 on Lco 6 Cn O For Signage Refer to North Andover Zoning Bylaw Section 6 The proposed uN is an alloyed use in this zoning district. Issued By Date 6 ��f Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 415000.00 m $ - $ 492.00 Plumbing Fee $ 61.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 61.50 Total fees collected $ 715.00 37 Riverview Street 299-2017 on 9/20/2016 reconstruction due to fire, repair to kitchen and dining room I NORT1y Town of Andover LAKG 'Ch ver, Mass, 62aA I�IQ coc"Ic"a K. 1- PPa`61 y S U BOARD OF HEALTH Food/Kitchen ���AA.. � LD Septic System THIS CERTIFIES THAT ..PERN ! T %^ BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on .... ............. • .. ........ Rough rem.. . . . . .. .. :. 10. . .. . .to be occupied as ... .... ...... ......... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the a lication Final on file in this office, and to the provisions of the Codes and By-Law elating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. �� w�`I. • PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS TION Rough Service .. . ..... . ...... ... ""' ""' Final BUILDIN SPEC OR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/BodyAxt ❑ Swiumingpools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic Tank, etc. ❑ Pernnanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING DEVELOPMENT Reviewed On Signature COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed ori Si nature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments '!dater& Sewer Connection/signature�nate . Driveway Permit DPW Town Engineer: Signature: h FIRE DEPAR,TMEfVT located 384 Osgood Street , - „ :u N I Temp0um ster on,,site., es_�. . 'Located at 12�.47.MainStreet p y �FirelDepart t ignature/date •:� COM11/IENTS Main Level 30'- 29'4" 0'29'4" Front Porch 'v 9'6" 6'9„ 13'3" 6'3" 2'S"a 9 1 Bathroom Bedroom2 o M 214'5" 4'-----4Kitchen/Dining Roo M M 1..' tair 1' cn BedroomlI I LU I sem allw 9'3" 7'S" 10' 11'3" Chase `O 3'5" Nursery Family Room M losetl (1) �I 14' ...LLL Main Level ROJAS_ANA 8/4/2016 Page: 132 2nd Floor 30' 1" 6' S" 22' Closet (1) Fn �o `y Master Bedroom N Bathroom 0 T 5' 8" 2 8Ha1lway 3 ih N T � 11' 6" - N M M Closet T 1 Chan N 1 Alcove 2 Son's Bedroom Guest Room ClosetT" 21 11 C11 2'4' I 1 oset24 T 31111-1 111711 N M rn N Uti7 1 26' 9" �j 2nd Floor ROJAS_ANA 8/4/2016 Page: 133 Basement 27' 7" 26' 11" Basement ~3' N 2� 8n N Stairs UV Basement ROJAS_ANA 8/4/2016 Page: 131 tI :93Ed 91OZ/t, vmv svfou `soi w �— �I ,b ws.£ Iuioog�ijnz�Eg 1 faos.inN -- � 1 p aSE a s All s y ern 1^ndwo7 cL � w TulooiPag Swtlov z3a Lr%-o 1 Va-LISfd4}. O IIIIQ/U IQ id w a3 fw�vovdwv� N�i e�-E+ scr`.'^s 7 oo.l a Z� P S � uioonqlEg �1"z b c►o-i� . .6.LSJZ_ d luo,j �si3wSo� .6 �woo� �an�S Nozibro���1 �]"zdatsrv�-5 aQc� - SkkM N h'].i271� �c3Hvub4 `a rilt N Q-j�n rgxL%rll%- 3 �p [aA9'1 UIPW `2nd Floor 30' 1" 22'. --- - ' Clo"set M -N Master Bedroom r, Bathroom o r r allway M Closet fP) �o T 1 1--3' Ill hs-6 Son's Bedroom N Guest Room Close [Alcove (2) n2� T M 3' 1"--+ 11' 7" N 26' 9" 2nd Floor ROJAS_ANA 8/4/2016 Page: 15 i Basement 2717" 26' 11" oN C3¢.u?xTS 'Fy�.,NG woQjc-�.� CN Basement ~31 N N N f Stairs _ L1V Basement ROJAS_ANA 8/4/2016 Page: 13 Kitchen Design & Specifications Project ID:Rojas,Ana 96;" 37 Riverview St.N.Andover,MA ! Cabinet Specifications: ' 49-1 24 234,E Manufacture:Waif Cabinets F330 _ i Line:Wolf Classic . Style:Saginaw W2130L W1 530R Material:Maple Color:TBD-customer to select d B09L d B15R Features: ----- . __ >Made in America M .-..F330--,.-SQ30 N >Maple door with a raised veneer center panel >Solid maple slab drawer heads O O C >Full A"plywood sides,backs,tops and bottoms ao i >%"solid wood corner blocks N IO Q M ! >'/"bullnosed adjustable plywood shelves M >Dovetail drawer construction with sidemount.glides >Hidden plywood hanging rails top and bottom _.. ... ._............ ...... . J By signing below,l agree to the cabinet design and M specifications being presented.I further understand that I will not be held liable for any measurement errors this to be the responsibility of the ! contractor. Customer Signature REF_21D_ICE36 W3612 Date 1 A m o Please sign and date Page 1 of 4 Digital Representationof your kitchen e ��� � I � tihA� a•� "�', i�, Page 2 of 4 ;t ..i..yrs •4'�,�,.u�� n 11 I ; .�1 r�;��ifr Digital Representation of Your Kitchen (Optional Upgrade) *Full height pantry,fridge panels, and deep above fridge cabinet not included. Additional cost for labor and material please add$943.80 77 , N ` 1t dd } 'i a.; `arc«. ' �G•y Page 3 of 4 i I Cabinet Information -- . - --- - ........ . --- ------ ......----- ... _. SAGI NAW .. _ -- __ ........ --____... -._. Classic styling,with a nod to what's new The raised panel cabinets say"traditional'but with a slightly bolder, cleaner line,which makes wolfs Saginaw cabinets ideal for a wide range of kitchen designs. Choose from four rich finishes:crimson,chestnut,honey or dark sable. Whatever you decide,you'll enjoy genuine American craftsmanship, including the solid American maple cabinet doors and drawer fronts that are standard in all wolf cabinets. Available Colors Crimson Chestnut Honey Dark Sable 4 SaginawDark Sable s http://www.wolfhomeproducts.com/classic-cabinets/#saginaw Sample Kitchen (shown in honey) Page 4 of 4 ELITE CONSTRUCTION I Massachusetts A DIVISION OF SERVICEMASTER ELITE This Agreement is made between MAJE Inc. d/b/a Elite Construction, herein called "Contractor" and Boias. Ana herein called "Customer". This Agreement incorporates by reference any"Agreement for Services" previously executed by the parties. In the event of an express conflict between a term in the prior agreement and this agreement,the terms of this agreement shall control. Customer(s): Contractor: Rojas,Ana Elite Construction Fed.Employer ID: 271456522 37 Riverview 12 Continental Blvd Street Merrimack,NH 03054 North Andover,MA 01845 (603)888-4100 Mass.Reg.#: 165712 Customer Phone Numbers:Cell:(978)242-2630:ANA'S# Cell:(978)884-0064:BROTHERS# Contractor and Customer,for the considerations named,agree as follows: Article 1. Scope of Work The Contractor shall furnish the materials and perform the work as described in the attached Scope of Work(a.k.a. Estimate)on property at:37 Riverview Street North Andover.MA 01845(the"Property"). If Customer is dissatisfied with any aspect of the materials provided or work performed, Customer must notify Contractor, in writing, within 10 days of the date the particular work/service at issue was performed, or within 10 days that the particular issue was discovered or could have been discovered by Customer upon a reasonable inspection: otherwise Customer is presumed to be full satisfied with the materials provided and the work performed. Permits: The following building permits are required and will be secured by the Contractor as Customer's agent unless otherwise agreed: (Customers who secure their own permits will be excluded from the Guaranty Fund provisions of MGL ch. 142A.) Article 2: Time of Completion Subject to payment of th de osit, the work described in the Scope of Work shall be commenced within 15 da of r ceiving signed contract or before I I -9 and shall be substantially completed within 60 days of job startor before o I.�O For purposes of this Agreeme t, s bstantial completion is defined as at least 95%of the work complete as per the Scop of W rk. Any changes to the Scope of Work, additional work required, delays due to non-payment, or unforeseen circumstances may change the substantial completion date. Article 3: The Contract Price Customer shall pay the Contractor for materials and labor to be performed under this contract the sum of forty thousand six hundred sixty six & 76/100 Dollars ($40.666.76). Contractor reserves the right to collect any supplemental funds from Customer and/or the insurance company for scope oversights or understatements, including mechanical or electrical expenses, roof repair expenses, or other unforeseen issues. In the event the insurance company pays out additional funds for work Contractor performs above and beyond the agreed Contract Price and/or original Scope of Work, the notification and approval requirements in Article 5 shall not apply and Customer shall immediately pay said funds, in full, to Contractor. Contractor will deduct amounts for any work not performed under the Scope of Work. Article 4: Payments The Contract Price shall be paid in the following manner: A deposit of $TBD on bank or$15,000.00 is due at the time of signing. Second payment of$TBD on bank$15,000.00 is due upon completion of 50%of entire project. Third payment of$0.00 is due upon substantial completion of entire project. Balance of$TBD on bank or$10,666.76 is due at the completion of the job. If payment is not made when due, Contractor may suspend work on the job until all payments have been made. A failure to make payment for a period in excess of 7 days from the due date of the payment shall be deemed a material breach of this contract. Article 5: Chanqes to Scope of Work The Scope of Work will be used by Contractor to determine the work to be performed; however, due to the nature of such work and the inability to predict what is present, or absent, behind walls, the Scope of Work may not be followed exactly and changes may be made in the field at the discretion of Contractor. Customer will be notified of such changes only when the change: results in an increase to the total cost of the Contract Price; involves a structural or mechanical element; involves installation of an item of inferior quality than what was set forth in the Scope of Work; or, involves a significant visual/aesthetic change. In the case of such changes, Customer may object to the change, in writing, after which Contractor and Customer shall work together with any adjuster,to resolve the issue. If there is any additional charge for any change, the additional charge will be due upon completion of the alteration or deviation work. If any work is required in order to meet state or federal building code requirements, or to obtain a certificate of occupancy, Customer hereby agrees, without further notice or permission required, that Contractor may complete that work and that Contractor shall be paid by Customer for that work in the event the insurance company does not cover it. Article 6: Limitation on Damages/Waiver of Jury Trial The parties hereby waive the right to seek or collect indirect, consequential, punitive, exemplary or special damages in any action arising out of or relating to this Agreement. Contractor's maximum liability arising for any claim arising out of or related to this Agreement shall be the amount paid to Contractor by Customer under this Agreement. The parties also irrevocably waive trial by jury in any action arising out of or relating to this Agreement. If Customer is in default of its payment obligations under this Agreement and Contractor commences a court proceeding to collect amounts due hereunder, Customer shall be liable for Contractor's reasonable attorney's fees incurred in such collection action. Customer consents to the jurisdiction of the Massachusetts Essex County Superior Page 1 of 2 Court-Lawrence with respect to any action or proceeding arising under or relating to this Agreement. Such jurisdiction is non-exclusive and suit may be brought in a different court having jurisdiction over the parties.This Agreement shall be interpreted in accordance with Massachusetts law,exclusive of Massachusetts choice of law provisions. NOTICES Massachusetts law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757. YOU MAY CANCEL THIS AGREEMENT IF IT HAS BEEN SIGNED AT A PLACE OTHER THAN THE CONTRACTOR'S NORMAL PLACE OF BUSINESS, PROVIDED YOU NOTIFY THE CONTRACTOR IN WRITING AT 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. IF YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT, AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE CONTRACTOR OF YOUR CANCELLATION NOTICE, AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. YOU WILL, HOWEVER, BE RESPONSIBLE FOR PAYMENT OF,AND CONTRACTOR MAY RETAIN ANY PAYMENT RECEIVED FOR,WORK ALREADY PERFORMED AT THE TIME THE CANCELLATION WAS RECEIVED. IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE CONTRACTOR AT YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED,ANY MATERIALS DELIVERED TO YOUR PROPERTY UNDER THIS CONTRACT; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE CONTRACTOR REGARDING THE RETURN SHIPMENT OF THE MATERIALS AT THE CONTRACTOR'S EXPENSE AND RISK. IF YOU DO MAKE THE MATERIALS AVAILABLE TO THE CONTRACTOR AND THE CONTRACTOR DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION, YOU MAY RETAIN OR DESPOSE OF THE MATERIALS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE MATERIALS AVAILABLE TO THE CONTRACTOR, OR IF YOU AGREE TO RETURN THE MATERIALS TO THE CONTRACTOR AND FAIL TO DO SO, THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE TO Elite Construction, 12 Continental Blvd, Merrimack, NH 03054, TO BE RECEIVED NO LATER THAN MIDNIGHT OF (3 days from date signed below). I HEREBY CANCEL THIS TRANSACTION. Date: Customer's Signature: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Two identical copies of the contract must be completed and signed. One copy to the Customer.The other copy to be kept by the Contractor. If there is more than one owner of the Property, all owners should sign below. Notwithstanding the signature of any one owner binds all other owners. Dated: � t &a ustomer! ner Dated: A (� Customer/Owner Dated: t t X= Co ctor, E, Inc.,d/ a Elite Construction G :PA, ` Name of Elite Salesperson,,A' different 12 CONTINENTAL BLVD • MERRIMACK NH • 03054 PHONE: 603/888-4100 SERVING NEW HAMPSHIRE, VERMONT, MAINE AND MASSACHUSETTS Page 2 of 2 The Commonwealth ofMass�chusetts Depaptinent of Industrial Accident, 1 Congress Street,Suite 100 ' Boston,MA.02114-2017 www mass.govtdia y�. Workers,Compensation Insurance Affidavit:Builders/Contractors/Elecixicians/Plumbers. TO BE JE'ILED WITH THE PERMITTING AUTHO12rTY. A_ licant Information • Please Print Legibly Name(Business/Organization/Individual): mpiz-E 1.,L-G CLl a.L rz Ccs�S �cQ'moo .Address: I a C,o --•-•v e. °r-�-_ ��.Y City/State/Zip: iwlteA-z•+r,a-c,� I WR o30s Phone#: Le Q1,- 2$'8-_ �,F� o o Cb Are you an employer?Checkt&appropriate box: Type of project(required): 1.k i am a employer Wth_1P!! employees(full and/or part-time).* 7.. El New colistruction 2. I am a sole proprietor or partnership and have no employees working forme in 8. Remo deag any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3 Q I am a homeowner doing all work myself[No workers'comp..insurance required]t 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 1Electrical repairs or.additions proprietors withno employees. 12,[]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. I .-n Roof repairs These sub-contractors bade employees and have workers'comp.insurance.; • 14.El Other 6.Q vde area corporation and its officers have exercised their right of'exemption per MGL c. 15%§I(4),and we have 4oJemployees.[No workers'comp.insmancerequirAl *Any applicant that checks box41 must also fill.out the section below showing their workers'compensation policy information. i Homeowners who sdlimif tlmis affidavit indicating they are doing all work and then hire outside contractors must submit anew 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-con actors have employees,they must provide their workers'comp.policy number. Iain an employer that is piovidiingworkers9 compensation insurance for my employees'Below is thepolicy andjob site information. _ Insurance Company Name: �EE��� T"`3 S Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip:t' -4N MM M4 l of$N5 Attach a copy of the workers' compensation policy declaration page(showing the policy number and e4irati no date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. Ido hereby certify under the ains and penalties ofpetjury that the information provided above is rue and correct Si afar Date: Phone#: la 3`TVfttlao Offacial 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): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: CCAPLLC-02 AMORSE ACORO� CERTIFICATE OF LIABILITY INSURANCE DATE 1 `•—�� 9//12/212/2016 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). CONTACT PRODUCER License#AGR8150 NAME: Ann Morse,CIC Clark Insurance PHONE 603 716-2367 FAX, (603)622-2854 One Sundial Ave Suite 302N Alc No Ext:( ) A/cNo Manchester,NH 03102 noDREss:amorse@clarkinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Peerless Insurance 24198 INSURED INSURER 8:Netherlands 24171 CCAPS,LLC dba ServiceMaster Elite INSURER C:Crum&Forster Specialty Insurance Co 44520 MAJE,LLC dba Elite Construction 12 Continental Blvd INSURER D Merrimack,NH 03054 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR IND WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE III OCCUR CBP8869089 0812912016 08/29/2017 PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY 1 JECT F—] LOC PRODUCTS-COM P/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY CEa OMccidBINEDentSINGLE LIMIT $ 1,000,000 a B X ANY AUTO BA8867299 08129/2016 08/29/2017 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIREDAUTOS X AUTOS Peraccdent $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 A EXCESS LIAB CLAIMS-MADE CU8862891 08/2912016 08129/2017 AGGREGATE $ 10,000,000 DED I X I RETENTION$ 10,000 $ WORKERS COMPENSATIONOT - AND EMPLOYERS'LIABILITY X STATUTE I EERH A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 08994621 08/29/2016 08/29/2017 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? Y❑ N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If as,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 C Contractor Pollution PKC104371 08/29/2016 08/2912017 Each Occurrence 2,000,000 C Liability PKC104371 08/29/2016 0812912017 Includes Mold DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Alan DeGeorge&Matt Troyer are excluded from Workers Compensation coverage. Workers Compensation States covered in 3A: NH/MA/MENT/NY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover MA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 of North ood A Suite MA ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD == Office of Consumer Affairs nd Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement.Contractor Registration Registration: 165712 Type: Supplement Card Expiration: 3/22/2018 MAJE LLC./dba Elite Construction JAMESRYAN ------ -----------------------_---- ---_-__ -- 12 CONTINENTAL BLVD -- - --- MERRIMACK, NH 03054 Update Address and return card. Mark reason for change. `1 Address i_j Renewal [] Employment 7i Lost Card SCA 1 0 20M-05/11 ca r=%�c �n�rrrrrcurrvr'n�/�r�('flrr.lsrrclrc:r>/1� free of Consumer Affairs&Business Regulation License or registration valid for individual use only before the expiration date. If found return to: OME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation ' 7 Registration: . 65712 Type: 10 Park Plaza-Suite 5170 3 r ` /t Expiration; 3/22/2018 Supplement Card Boston,MA 02116 MAJE LLC./dba Elite Construction ELITE CONSTRUCTION JAMES RYAN v 12 CONTINENTAL BLVD •..--_-.-._ MERRIMACK,NH 03054 Undersecretary valid without signature I + � Massachusetts Depar6nenf of Public Safety ry Board of Building. Regulations and Standards License: CS-055348 Construction Supervisor., F.. . K J TAMBONE, JR-- . t ; Expicationr ; roger as�2retzo�8�