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HomeMy WebLinkAboutBuilding Permit #664 - 39 WEYLAND CIRCLE 4/1/2013Permit NO: Date TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: ADDllcant must comblete all items on this Daae LOCATION3fl9-u (-A V4" G 1 RC -US - Print PROPERTY OWNER -TAlym .S 6T. Se�d k (EDEN Print 100 Year Old Structure yes no MAP IVO: GG PARCEL: 23 ZONING DISTRICT: Historic District yes no Machine Shop Village ves no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family 5(Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: SA4"AES G• W K kr-E" Phone: Address: C `L -c- J CONTRACTOR Name: I Lv Sv«xjeizs or- Fhone: Address: 2Tar - : ��C�-tr '4z-t� t�E-cj 4b Supervisor's Construction License: gg"3 y Exp. Date: Home Improvement License: I t GG $ Exp. Date: -7 12-4 ( Zz 1 N ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 10 k- FEE: $ 1 --ko Check No.: Receipt No.: C9 -&J---4 NOTE: PersonAcointracting with unregistered contractors do not have access to the guarantyfund Signature rof Agent/Owner Signature of confra/cto�,° Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑Swimming Art ❑ Pools El Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS I L11 " CONSERVATION Reviewed COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED ❑ Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit r DPW Tower (Engineer: Signature: t_ocatea Jb4 US9000 atreet FIRE DEPARTMENT - Temp Dumpster on site yes no Located at'124 MainStreet Fire Department signature/date COMMENTS 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 - Date Doc.Building Permit Revised 2010 Building Department The fohowing is a list 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 o 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 ❑ 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 ❑ 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 app: al 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: Doc.Building Permit Revised 2012 -3? / Location No. 7 Date Checkv99T- 26275 TOWN OF NORTH ANDOVER Certificate of Occupancy $- Building/Frame Permit Fee $ 1A 0 Foundation Permit Fee Other Permit Fee $- TOTAL $ Building Inspector x J LU LL Q D m u \ o o LL dcu 'A N U a ai N 0 rj z Z m c O a+ 'p Z) o LL L � o w a C r U LL 0 U L Z z m J a L � o CC F c LL 0 W Z J u J W L °° a d' U v N c LL ,., W Lry z L to o w c LL z LL Q w G LLJ Y. CU = : m O Z v v N a Y o C/I ;koj ,~`Odo "PO. ** C 3 O 1 N J � 4so N .0 0 0 �: ^• N N Q C �: JJJ ••. vim -O C _ o t p_ N ztm N c as o � � 0) > 0 c oCL H =a �. co CL .. O p •N O Q i L � � •Q N N 2 m d: W _ -0:5 O O LLJ I--- A 0. Z .2 z LL .N L N C O w — V a+ V O W i 0 m .- O U Q. 0-0 m Q ti N O _ �_ N � H t � 0.00 > Z O U) J w 0 V W CL U) z CD z 0 J N ZI cj ,4 �,l N 0 W W X W n 5� Q � o 2 •Q. L A ,^ W � •• c Y E C. L N <v W p i ai f u Q — ILq ;koj ,~`Odo "PO. ** C 3 O 1 N J � 4so N .0 0 0 �: ^• N N Q C �: JJJ ••. vim -O C _ o t p_ N ztm N c as o � � 0) > 0 c oCL H =a �. co CL .. O p •N O Q i L � � •Q N N 2 m d: W _ -0:5 O O LLJ I--- A 0. Z .2 z LL .N L N C O w — V a+ V O W i 0 m .- O U Q. 0-0 m Q ti N O _ �_ N � H t � 0.00 > Z O U) J w 0 V W CL U) z CD z 0 J N ZI cj ,4 �,l N 0 W W X W The Commonwealth of Massachusetts De, artment of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ,www.mass.gov/Zia Workers' CompensationInsurance davit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Naffie (Business/Organization/Individual): l��l�iC�. �v� �'�c2S b'� g'beo2— , LQf— -ity/State/Zip: �7V�.. (Lp ryb Phone #: ? $ 2 ? S — S 0 0 2 ,re you an employer? Check the appropriate box: I am a employer with 2.. 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. [] Demolition 9. ❑ Building addition 10. F1 Electrical repairs or additions 11. F1 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other y applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. ,meowners Nvho submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. itractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. n izn employer that is providing workers' compensation insurance for my employees. Below is the policy and job site Irmation. xrance Company Name: icy # or Self -ins. Lid. #: U ?>' 41 69-P 4'975 Expiration Date: Site Address: 39 City/State/Zip: N • PVN_0CzvE'2 z Mv`%- ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 p to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of ;stigations of the DIA for insurance coverage verification. hereby certify under thepains andpenaldies ofperjury that the information provided above is true and correct. tature ! Y 9 fa., Q Date: 4 1 SII 13 ►ffzcial use only. Do not write in this area, to be completed by city or town official. :ity or Town: Permit/License # ;suing Authority (circle one): Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Other nnfnrf PPrenn• Phnna #! 1 ® A� 0 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) TYPE OF INSURANCE 3/6/13 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 Twinbrook Insurance Brokerage 400A Franklin Street Braintree, MA 02184 ACT NAME: Maureen Curran PHONEIAIC._N Edi, 781 817-6814 FAX No; (781) 898-6100 E-MAIL ADDRESS: mcurran@twinlbrook.com INSURE S AFFORDING COVERAGE NAIC # INSURERA : Acadia Insurance RENTE DAMAGETOE.occu a co $ 250,000 INSURED INSURER B : INSURERC: Deluca Builders of Bedford LLC INSURERD: 2 Battle Flagg Road INSURERE: Bedford, MA 01730-0307 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 CONTRACTOR 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POUCYNUMBER POLICY EFF M/DDIY POLICY EXP MMIDD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR Joseph Rizzo / do CPA 0196926-16 1/1/13 1/1/14 EACH OCCURRENCE $ 1,000,000 RENTE DAMAGETOE.occu a co $ 250,000 MED EXP (Any one person) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER POLICY F PRO LOC JECT PRODUCTS-OOMP/OPAGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANYAUTO ALLOWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS _ AUTOS COMBINED SINGLE LIMIT a accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROaP�ltl(Y DAMAGE $ e UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNERIEXECUTIVE = OFFICEPJMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA WC 'RYSTAI.TU- OTH- IR E.L. EACH ACO DEM $ E.L. DISEASE -EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Rena rks Schedule, if more space is requred) Workers Compensaton requested from carrier !`CDTICI(_eTG NAI 11952 r:ANCFI 1 ATION © 1988 2010 AGUKU GUKPUKA I IUN. Ali rignts reserveu. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: (978) 688-9542 E -Mail: SHOULDANY 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 Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 Joseph Rizzo / do © 1988 2010 AGUKU GUKPUKA I IUN. Ali rignts reserveu. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: (978) 688-9542 E -Mail: CERTIFICATE OF LIABILITY INSURANCE03/07/2013 DATE (MMIDDIYYYY) TIFICATE 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PHONE FAX TWINBROOK INS 400A FRANKLIN STREET (AIC, No, Ext): (AIC, No): E-MAIL BRAINTREE, MA 02184 ADDRESS: 22LDG INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: AMERICAN ZURICH INSURANCE COMPANY INSURER B: DELUCA BUILDERS OF BEDFORD LLC INSURER C: INSURER D: 2 BATTLE FLAGG RD INSURER E: BEDFORD, MA 01730 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 ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE [_] OCCUR. DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY [:] PROJECT [—] LOC DRODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT (Ea accident) BODILY INJURY $ ALL OWNED AUTOS SCHEDULE AUTOS (Per person) BODILY INJURY (Per accident) $ HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS-MADE DEDUCTIBLE $ RETENTION $ A WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY YIN UB-4109P485-13 01/01/2013 01/01/2014 XWC STATUTORY LIMITS OTHER E. L. EACH ACCIDENT $ 500,000 ANY PROPERITOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) N/A E.L. DISEASE - EA EMPLOYEE $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONSISPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 120 MAIN STREET IN ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER, MA 01845 AUTHORIZED REPR TAyjVE } AGORD 25 (2070105) The AGOKD name ana logo are registered mar Ks oT m umu iyaa-cv�u r��.vrcv a.vnrvrv, i wn. nu �ynw �cac� vcu. j CEJ/ze Va��rir�ta�rcuealf� a�C��allcrcicdiel� ` �• Office of Consumer Affairs & Busihess Regulation VME IMPROVEMENT CONTRACTORistration: .106558 Type:iration: 7/24/2014 Private Corporatioia. BEDFORD BUILDERS, INC. F ; I NICHOLAS DELUCA 2 BATTLE FLAGG RD BEDFORD, MA 01730 Undersecretary I. qolassachusctts - ucrtr•trncnt of PuhliCSafctE Board of Building Regulations an' -d:' :. Construction Supervisor License License:. CS 88348 NICHOLAS Q DELUCA 2 BATTLEFLAGG RD ^r_ BEDFORD, MA 01730 Expiration: 8/9/2013 ('oannissinacr Tr#: 20126 BEDFORD BUI P.O. soki, BED RD, MA j0] 0FFiGE (781)12 FAX j (781) 27� JOBA-l' $ Wipbows INC. )307 SHEET N OF --- �M-A )02 CALCULAb A, I OCApaw 013 6 I 71-f PAIT tZ Al V(A) Lill I De - re -pill 7. •S!(5 A-. -01H, col Iry ilxa q 6 Lc re 4e ..... ... .. ----- 4 ----- Yp V Ail . . . . . . . . . . . . . . -- -- ------ VP ------- ----- It -j C) QA ..... ....... 6l . . ......... -------- — - -------------- ----------- -- 112 bilb" �_�G�t{t- • I A I . tv Use- --- ---- 4-f >. ---- --- - ------- .. ......... - -- ----- l HJ 641k) -ed" z IS .............. 46a-sil : al u I'll z F Cie. aTfqs ol ION-.AINO 4-4 ---------- 4r Olt LA 46a-sil : al u I'll z F Cie. ---------- i To: James G. Whiff -en 127 Cambridge St. Burlington, MA 01803 From: DeLuca Builders of Bedford LLC Place of work: 39 Weyland Circle North Andover, MA Contract Please refer to attached, "Whiffen Residence Plans' pages I of 6 and 6 of 6, for details on work specifications. ALLOWANCES 1. Deck material to be GAF pve decking, fiam,e is p.t wood, cedar rails, no steps off deck. 2. Deck labor allowance is 5k, materials allowance is 5k. Page 2 Terms: Deposit upon signing of contract $5,000.00 Final payment upon contract items substantially complete: $5,000.00 Note: Any unfinished items can be incorporated into a punch list with values attached to each item and any additional labor or materials not in contract can be added thru D.B. LLC change orders Total Due: $10,000 i 39 Weyl ftcle�o ndover, Ma Owner: 127 Cambridge St Burlington, MA 01803 Contr o r(�(,p,4�►dJ_ DeLuca Builders of Bedford, LLC t.1at f 13 2 Battle Flagg Rd Bedford, ma 01730 (781)771-5785 `Iass,acbusctts - Depaa-tinrnt of Public Safct, Boar(I of Building Rcwl;ations and SlAndal-6 { C®nstruction SupervisorLicense License:. CS 88348 NICHOLAS Q DELUCA 2 BATTLEFLAGG RD BEDFORD, MA 01730 Expiration: 8/9/2013 ('unmiissiurcr Tr'tr.: 20126 aa)uveCclf� a�. lflJ9C[C�u elt j Office of Consumer Affairs & Business Regulation 1�OffiffivOME IMPROVEMENT CONTRACTOR k egistration: 106558 Type: I, Expiration: 7/24/20.14 Private Corporation. BEDFORD BUILDER5,.INC: i NICHOLAS DELUCA 2 BATTLE FLAGG RD BEDFORD, MA 01730 Undersecretary I ' CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 03107/2013 TIFICATE 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: TWINBROOK INS 400A FRANKLIN STREET PHONE (A/C, No, Ext): PAX (A/C, No): BRAINTREE, MA 02184 E-MAIL ADDRESS: 22LDG INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: AMERICAN ZURICH INSURANCE COMPANY DELUCA BUILDERS OF BEDFORD LLC INSURER B: INSURER C: 2 BATTLE FLAGG RD INSURER D: BEDFORD, MA 01730 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 LTR TYPE OF INSURANCE ADD L SUB R POLICY NUMBER POLICY EFF DATE (MMIDDIYYYY) POLICY EXP DATE (MMIDDIYYYY) LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea occurrence) $ CLAIMS MADE � OCCUR. ED EXP (Any one person) $ GEN'L AGGREGATE LIMIT APPLIES PER: ERSONAL & ADV INJURY $ ENERAL AGGREGATE $ 5POLICY PROJECT ❑LOG RODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULE AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE Is EXCESS LIAB CLAIMS-MADE AGGREGATE Is DEDUCTIBLE Is RETENTION $ Is A WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY YIN ANY PROPECERIME BER EXCLUDED? CUTIVE OFFICER/MEMBER EXCLUDED? N/A UB-4109P485-13 01/01/2013 01/01/2014 X WC STATUTORY LIMITS OTHER E. L. EACH ACCIDENT $ 500,000 (Mandatory in NH) If yes, describe under E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 120 MAIN STREET BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVEF, MA 01845 AUTHORIZED REPR TA VE nrnRn 91z ron4nrnei Tu AFFER ---- --� --- --- --- - . ----- --- - - -- ••"•••" "••" "'uw a'w lwu� ic g11a1R.�, U1 ra.vrcU -iyaa-AU-iU A%,UKU L;UKrUKAIIUN. All rights reserved. 0 A� o CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 3/6/13 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(les) 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 Twinbrook Insurance Brokerage 400A Franklin Street Braintree, MA 02184 ACT NAME: Maureen Curran PHONE 781 817-6814 FAX No: (781) 848-6100 ADDRESS: mcurran@twinbrook.com INSURER(S) AFFORDING COVERAGE NAIC# INSURERA:Acadia Insurance INSURED Deluca Builders of Bedford LLC 2 Battle Flagg Road Bedford, MA 01730-0307 INSURER B : INSURERC: INSURER D : INSURER E: INSURER F: rnVFRACFS 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 LTR TYPE OF INSURANCE AML INSR SUBR WVD POLICY NUMBER POUCY EFF MIDDIY POUCY IXP MMIDDVYYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F OOCUR Joseph Rizzo / do CPA 0196926-16 1/1/13 1/1/14 EACH OCCURRENCE $ 1,000,000 PRE SE IE.occTED urrence) $ 250,000 MED EXP (Any one person) $ 5,000 PERSONAL&ADVINJURY $ 1,0 0 000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER POLICY PRO JECTLOC PRODUCTS -COMPIOPAGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANYAUTO ALLOWNED SCHEDULED AUTOS AUTOS NON-OWNED HIREDAUTOS _ TOS COafaBcd rtSINGLELIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ ccident (Peraccident) UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE 7 OFFICEPJMEM13ER EXCLLDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA OTH- WC STATU-T. DRYAND E.L. EACH ACO DEM $ E.L. DISEASE -EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101, Additional Remarks Schedule, ff more space is requi red) Workers Compensaton requested from carrier eCRTICtCATI= unt 11C0 CANCFI I.ATION V IWW-=ZUTU AUUKU 6UKYUKA 1 1U All r1911l5 ICSCr va'U. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: (978) 688-9542 E -Mail: 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 Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 Joseph Rizzo / do V IWW-=ZUTU AUUKU 6UKYUKA 1 1U All r1911l5 ICSCr va'U. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: (978) 688-9542 E -Mail: The Commonwealth of Massachusetts fn Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 www.mass.gov/Zia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Uplicant Information Please Print Leizibly value (Business/Organization/Individual): pz,�Ju ' dd :�ity/State/Zip: (2D INY� 1"�3� Phone #: ! & - .re you an employer? Check the appropriate box: I am a employer with 2. 4• ❑ I am a general contractor and I employees (full and/or part-time).* ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. # ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. . [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. E] Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other y applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. )meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. atractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. n iin employer that is providing workers' compensation insurance for my employees. Below is the policy and job site mmation. .trance Company Name: eyR—rrI lei n6! 1 W�- icy # or Self -ins. Lid. #: U $— 41 69 P 4 9-5 ` 1 2' Expiration Date: Site Address: 39 Ml6�,, �-AISA�%> C -112C1 City/State/Zip: 1\i• ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 ip to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of ,stigations of the DIA for insurance coverage verification. hereby certify under thepains andpenalties ofperjury that the information provided above is trite and correct. iatwe �Y I � Date ne#• �?$1--111-S78-5' )fflcial use only. Do not write in this area, to be completed by city or town official. :ity or Town: Permit/License # ssuing Authority (circle one): . Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Other 30 SS's ��' c �-• . 221 oo s, F, ��• 1 No "p moa R'� a of . y 8- . QOM \ 1 �•c�vrE,>-ry L/.vES Gviy/,/ �' •p,,,, eNs/v�vs ��� N6meV cewrwe 7b rye rire-,r ivreebr",a 727 XVW AW.-Vor TX4r rove- sowwezAw rr [ac.+rWp oov rlEcorgs jwktwvgovo nwrrrvacs ccw,-zww )rlrll rNE' r -l- OAr Z.Cwl vd eird"AMW—V ' r. vcx A&A07:Cttrl we 7W -4,r CWlr"14W rt ,vor -nurr-o i,✓ rve• fEAer.� ,�zaea .sr�zito ,relc.�. SHd�vN ON i!'MA COMMt/N/ry P.INCL '� ..u.. �.SOO� OCb7C �� .' 6/z/5 Z 3 I RG O T e4l-7'4 AN /N • �C�D . /9�-IOD�� A.S.; . O.�r�I�✓it/ 'F4.P .�� Z .�,vvo�E,c� ,N,�s.�ccvvs��rs � olein ■ .