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HomeMy WebLinkAboutBuilding Permit #390-15 - 40 BRENTWOOD CIRCLE 10/24/2014 BUILDING PERMIT of"°DT"qti TOWN OF NORTH ANDOVER 0� APPLICATION FOR PLAN EXAMINATION Permit No#: -390-- /� Date Received SSACHUS�� Date Issued: 9 I RTANT:Applicant must complete all items on this page ,� �=� .•5 €- ti -, 3 -" _ � ... tLO C,CA�TOIV n-7�® -�'r2n .5.00 2 4:.Ei7ff in : � o - k IP 1 t �R— :i G .ma x M", Structure yes nod syr MAP tl � PAFtC;EL Z®NING�D�IST ��Historic®i lflr eyes {no __ t _ MachineRSh p.u�,l age}`eyes: lnoy i TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑64eration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 17 yr '" '2 _� "' ❑- pt O1Well �V ©sFloodplam� OfWetlantls � p <❑ Vllatershed Distria" `. Water/Sewer. 11 DESCRIPTION OF WORK rTO BE PERFORMED: J �T1-t S tkc�� I af�lo� w'f C�'l AAC n o T cu A Sr't La C k 60:f! o 4 rC rL.,-p rl7 Tee -�Qi�A or kow-, Identification- Please Type or Print Clearly OWNER: Name: Tljon10-S M ur,QhV Phone: 97Y-lot-56,0.1 � Address: L/O &Y,Pvi"�woocQ C,'r, Al, 4nctovu- mA 016(isrl yl 4 �na �ji x v a 1 Co:ntraName k n Wr�o,h-f-� Phaone g)� 6���da�7 � ��� a 'A` 3 _:,E,-Ti��att V __x,,,,. > k •M..�s�'�,`r`��$�"'h rs .: � y-.� a� , � vr,yr '`��" �, Addre33p Supery sorr o struct� ionLiceIll ser ARCHITECT/ENGINEER Phone: A .� r /A///L/ Address: Reg. No. r FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASED ON$125.00 PER S.F. Total Project Cost: $ $L/D0,00 FEE: Check No.: Z- C Z Receipt No.: —1 Y NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Si'g�_nature�ofAgentl0wne �k� '`��,_ ���:Sig ature of.�contractor-`" - }�-�' �'-" /fir ' -� Location V P..� G�v D No. �— Date v ` (i • ' TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ ---"' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# Z 1 �` , 2817 Building Inspector 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision:on: Comments , Conservation Decision: Comments r Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street zRFIRE DE�PARTMENTT, emp-�x umpsten�s e s no � - L�o ateci ata124;MainStreet. �� � 11,113 It asaoF-ag`.- c � 0' "'. a.�j E �'t 1^ er � F.�r�etD,�epartirmentsigna�ture/dates R.,� .�� T -��� f..a� "�•£ e��-- 4 -..�- "�ii3 a t t- 3+ .r '"" 3�'' -- a�'� �y,tv �� a�� '� •-� +-.. - � „ .x 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.$1oo-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 W. 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 /Building pp Permit Application a/Workers Comp Affidavit w/ Photo Copy Of H.I.C. And/Or C.S.L. Licenses m/ 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/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 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 1 ❑ 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 dumpsterermits require sign off from Fire p q g 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 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor License: CS-102663 - "J"SCOTT W W RIGk T ,. 350 BERRY ST ° ANDOVER MA NORTH iQ1845 L w Expiration Commissioner 08/12/2015 �fe�omr�nanaueul�o� ,aaoaclaQeld"d . Office of Consumer Affairs&Busibbess Regulation ME IMPROVEMENT CONTRACTOR legistrationt -:138569 MType: - _. xpiration: 4/1412015 DBA WRIGHT GUTTERS ; - SCOTT WRIGHT 350 BERRY ST. �, NO.ANDOVER,MA 01845 " Undersecretary i %AORT#i Town Of tAndover No. h ver, Mass, Coc"t, N�WtCK �It ��S RATED 1.4P��5 V BOARD OF HEALTH Food/Kitchen PERMIT . T LD Septic System i THIS CERTIFIES THAT ..............(.. . AVAQ.&....... BUILDING INSPECTOR Foundation has-permission to erect .......................... buildings on .......... ...... 61110111111111l �..... .......��� -- Rough mw to be occupied as ............... ..... ..... ........... 0. ........ ............................ Chimney provided that the person accepting this permit shall in every respect c orm 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 d •• PERMIT EXPIRES IN 6 MO HS ELECTRICAL INSPECTOR UNLESS CONSTRUCT RTS Rough Service ............. .. .... ... �....................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building (tough 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. Ma.ssac1.1.2efts Home Lnprovement *—Contract IM nag satisfies'all basic requirements of the slate's 1:Tome Improvement Contractor Z•aw(MGL chapter 142A),but does not include standard Massachusetts Consumer Guide Iar E``ache to protect homeowners. Seek legaladvice if necessary. Any person planning home improvements should first obtain a copy of"A to Home Improvement"before agreeingto any woxlc on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Re halation's ConsumerlufbmationHotline at 617-973-8787 or 1-888-283-3757 or on our website. �olneowner fori�tatA®� 'Contractor Innformition None � � CompanyName / 01— !F f1W 5-1 �lt GLA tJ1 iLrS StreetAddre (do notuse aPost Office Box ad ress) Contractor/Salesp son/OwnerName -e.h. WOcia Cid CAi/ty_/Town State Zip Code S' C a Wr� � B smessAddress(mn st Iude.a street address) 3 5_06- _ 1,ayttmePh.onP gv 2x4(- S+ qen ng Phone City%iown State ---- 74–?0/–5-683 Zip Code S Rm� r,�o l�prveN. IM/4 0 GBvs- Mailing Address(It different from above) Business Phone?78-68 - 7 Federal Employer ID or S.S.Number �on5{rUc'��vh S�p�rvt°Sor 52�CeImprovement Home Contmctorite:Number X,awrcrpi;restbatmastliomn � Expimtiondate C° S JOa improvement contractors linve 663 Exp. 9//d_/;Z10/5_ nv"lid registration number / 38 569 y//y/aO/.- The Contractor agrees to do the following work for the Homeowner: Sfrr' sin e c�¢ar sti /f&A o,, (Desengaein detailthe worlcto completed,specify�}'nngthetype,brand,and grade of materials to we us d,rise additional sheets icessa deck,' USe of Q(1 QGvdS, USe iCeft.ca er sk,¢IoC ',h atl valle,�z, up wallaa.•&arok.,& RH¢ivti, 'on )rceFwa rShWd On plr,'pe mahik on alf kGveS rakes, CfS2 GRF P l fLSe 3olb 1.00 Ver vavoor toav-eAkr• C�arcoa( 80 �ea,•r-ar,cLu'�tt - 1l0eve h w,hd trxfed vta�is { `s1„r .�u�ps r -� CaSkss2 CAn*.,n&-ort ' of Havzy-A,'J n14 fo fake -F� destc afo �c hcQ`� 11, V pa��c ori Noo`� wo,,k c " Reirulred Permits-The following building permits are required Proposed Start and Completion[Schedule-The following schedule will and will be secured by the contractor as-the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owuers Who secure their own Permits�Wiu be excluded from.the Guaranty Fund provisions of0 MGL chapter 1.42A.) a / Date when contractor will begin contracted wozlc. Date when contracted work will be substantially completed. Total Contract Price and Pa •ent Schede � le The Contractor agrees to perform,the work,:furnish the material and labox specified above for the total sunt of: 00 Payments will bemade according to the following schedule: g� 0©.0 0 upon signing contract(not to exceed 1/3 of the total con tract price or the cost of special order items,ms,whichever is greater) $ 1"y _� or upon completion of /� $ by —::: or upon completion of N • � 0�.00 upon completion of the cant ac i" (Law forbids demanding fan payment until contract is completed to both party's satisfaction) . The following material/equipment must bespecial ordered before the contracted work begins in order $—e4D--to be paid for // /I to meettlie completion,ichedule.(**-) $ /� to be paid for_ i(/1 NOTES;('t')Including ail finance charges(*"')Law requires that any deposit or down payment required by the contractor before workbegins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material Which must be special ordered in advance to meet the completion schedule. x ress Warran , -Xs an ex ress warranty being provided b the contractor? No s(all term Subcontractors-The contractor agrees to be solelyresponsiblefnr completion o£ work described regardlessLo—ine warran must be attached to the contract party/subcontractor utilized by the contractor. The contractox,fmther agrees to be solei res onsible for of the actions of any third aterials and labor under this a Bement y p payments to all subcontractors for Contract Acceptance-Upon signing,this document becomes ab. contract shall not thany Tien or other security nding contract under law. Unless otherwise noted within this document,the caxefiilly before signringing this contract.i interest has been placed on the residence. Review the following cautions and notices s • Don'tbepressured into si the gnmg contract.Take time to read and fully understand it. Ask questions if something is unclear, Make sure the contractor has a valid Home 7m rovement Contractor Re 'stration. The law requires most home improvement contractors and subcontractors to be registered with the Director ofHome Improvement Contractor Registration. You may inquire about contractor • registration by writing to theDirectcr at 10 ParlcPlaza,Room 5170,Boston,MA.02116 or by calling 617-973-8787 or 888-283-3757. Does the contractor have insurance? AsIc the Contractor for his insurance company information so that ybu can confuxn coverage,or aslc to see a copy of a"proof of insurance,document. o I�u ow your rights and responsibilities. Read the Important Information on the reverse side of this fora and get a copy of the Consumer C7uide to the Home Improvement Contractor Law: You may cancel this agreement if it has been signed at a place other than the contractor's normal Lace contractor in writing at his/her main office or branch office b other p of business,provided you notify the third business day following the signing of this agreement. See the attached notice f cancellation•foront m for delivery, n explanation o£this right of the DO NOYSIGN TMS L;()NTRACT IF Two identical n�::�1,e co must be ompleted and signed. One copy should go to flu;homeowner. The otber copy sliol. vibe]sept by the contractor. Nome e s ignatuxe ontra or's ignatare 'Date . 6 / Date Contractor Arbitration The Home Impiovement Contractor Law provides homeowners with the right to initiate an arbitration action(as an 'alternative to court action)if they have a dispute with a contractor. The same right isgot automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner.ia court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract;the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Can Affairs and Business Regulation and the consumer shall be required to s"xbmit o ' arbitra.' n as.pr 'ded InMassachnsetts General Laws, chapt'ex 142A. 1J1A Ho owner's Si tti e j 0ontractor's Signattitr NOTICE:The signatures of Zparties above apply only-to the agreement of the parties to alternative dispute resolution initiated by the contractor: The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 14.2A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way, even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Ftiund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and worltmanlike mawier..Homeowners maybe entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold•in Massachusetts cant'an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which tlfe homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. Hyou have questions about your consumer/homeownerrights,contact the Consumer Information Hotline,(listed below). ]Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced docunents have been attached. Parties are also advised not to sign the document-until all blank sections have been filled in or marked as void,deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the.original contract must be in writing and agreed to by both parties. Contracted work may not begin-until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the,payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a j oint escrow accozw.t as a prerequisite to continuing the contracted work. Withdrawal of fiends from said account would require the signatures of both parties. A.dditiowd Information If you have general questions or need additional ir6orltination about the Hoene Improvement Contractor Law or other constumr rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Baston,MA 02116 617-973-8787, 888-283-3757 or visit the OCABRwebsite at 1=://ww,,v.mass.gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and-Business Regulation 10 ParkPlaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visitthe IRC website atbM://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: . ht11�://db.state.ma.us/11o1n.eimt�rovement/licenseelist.asp - ' For assistance with informal mediation of disputes or to register formal complaints against a business, calx: Consumer Complaint Section Office of the Attorney General 617-727-84QO AND/OR Better Business Bureau 508-652-4-800,5 08-755 2548 or 413-734-3114 VIII , Version 2.1-11/22/2010 A6 0 CERTIFICATE OF LIABILITY INSURANCE DA ! ID iy ' 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 T A SULLIVAN INSURANCE AGENCY INC NCCT AME: 135 MERRIMACK ST PHONEFAX D No: METHUEN, MA 01844 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: LM Insurance Cor oration 33600 INSURED INSURER B: SCOTT WRIGHT DBA WRIGHT GUTTERS INSURER C: 350 BERRY STREET INSURER D: NORTH ANDOVER MA 01845 INSURER E: i INSURER F' COVERAGES CERTIFICATE NUMBER: 21153469 REVISION_ NUMBER: E 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. ILTR TYPE OF INSURANCE AODL SWVD UER POLICY NUMBER MMIDDIYEYYI MM/DDmYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S DAMAGE TO RENTED i CLAIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) S PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ i POLICY PRO- ❑ JECT LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY (CEO,MeccBINED ident SINGLE LIMIT S ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS Per accident I $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE S DED I I RETENTION$ $ A WORKERS COMPENSATION IWC5-31S-387187-013 9/30/2013. 9/30/2014 �/ STATUTE ORH AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 100000 OFFICER/MEMBER EXCLUDED? ❑Y N i A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 100000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 � I I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR SCOTT WRIGHT. This certificate cancels and supersedes all previously issued certificates,6nly as they relate to workers compensation coverage. Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TO 1 INSPECTOR THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD ST BLD 20 STE 2035 NORTH ANDOVER MA 01845 AUTHORIZED REPRESENTATIVE _'� M �LM Insurance Corporation W C(Y( ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 'ERT NO.: 21153469 CLIENT CODE: 1623570 Didi Dangas 8/7/2014 7:31:21 PM (EDT) Page 1 Of 1 10/16/2014 09:09 9787948570 TA SULLIVAN PAGE 01/01 WRIGSC2 OP ID:AC CERTIFICATE 4F LIABILITY INSURANCE DATE IT 1 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 endorsemen s. PRODUCER CONTACT T.A.Sullivan Agency,Inc. PHONE P 13S Merrimack St UVG.NP,e*j;978.-683-4700 AIC Ne Methuen,MA 0164401843 E-MAIL ADDRESS. INSURERS AFFORDING COVERAGF NAIL p INSURERA:Agenoy Intermediaries INSURED Scott Wright INSURERS: Wright Gutters and Home INSUAERC: Improvement 350 Berry St INSURER D: N.Andover,MA 01845 INSURERE: 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 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REOUCEO BY PAID CLAIMS. _LTR TYPE OF INSURANCE POLICY NUMBER M D prYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR L117001598 12/0112013 12/0112014 DA_PREMl Mt;NI oe $ 300,00 MED EXP(Any one arson 4 50,00 PERSONAL a ADV INJURY a 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER! GENERAL AGGREGATE $ 2,000,000 POLICY E PRO- IJ JECT '_I LOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LI I ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED AUT08 AUTOS BODILY INJURY(Per accident) S PROPERTYDMAGE HIRED AUTOS NON-OWNED AUTOS $ ant S UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAQ HCLAIMS-MADE AGGREGATE $ DED RET NT ON$ g WORKERS COMPENSATION IPER OT AND EMPLOYERS LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUMVE OFFlCER/MEMBER F,XCI,UDEN/A E.L.EACH ACCIDENT $ D7 (Mandatory In NN) E,L,DISEASE-EA EMPLOYEE $ If os dmscl{hp unC?r DE RI TI NOF OPERATIONS below E,L,DISEASE-POLICY LIMIT A Commercial AppliCa L117001598 12/01/2013 12101/2014 A DESCRIPTION OF OPPRATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Ramarke Schedule,may be attached It more space Is roqulrad) Installation of gutters siding and some roofing CERTIFICATE HOLDER CANCELLATION TOWNOFN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF NORTH ANDOVER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCO CE WITH THE POLICY PROVISIONS-. Brian Leatche 1600 Osgood St Bldg 20 Ste 2-3 UT RIZ R ESEN ATIVE North Andover, MA 01645 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD M The Commonwealth of Massachusetts - Department of Industrigl Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UV www.massgov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/OrganizatiorAndividud): W d'i'q U` tA,s Address: 35-D City/State/Zip: /V. A dIUe-ir,/1?jq 0/3 yS Phone#: 9?�- 6 -�d /7 Are ygu an employer?Check the appropriate box: Type of project(required): 1.RI am a employer with 4. ❑ T am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. �• ❑Remodeling ship and'have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. g E]Building addition [No workers' comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ frepai//rs insurance required.]i employees.[No workers' 13Other sTr' r V0 . comp.insurance required.] — 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t-Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name:. Ll b er j PlU f U O C Policy#or Self-ins.Lie.#: W C S-3 S 3 87187"0 Expiration Date: 913 0//-J' Job Site Address: 1{0 43ren`ti e oo d( Or. Pity/State/Zip:_ /V An GQOVR I' Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido Izereby cert u er the paamss and penalties ofperjury that the information provided above is true and correct. - Si ature: Date: Phone#: 9 7f-0 7- did V 7 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical 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 ofhire,- express or implied,oral or written." An employeiis defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a j oint 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. However 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 producedacceptable 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 ofpublic 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance 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 listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town 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 a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone anal fax number: The Commonwalt1l of Massa.,chusetts Department off dustrial Accidents Office of Iavestigations 600 Wasbingtoa Sffeet Boston}MA;02111 Tel,#617-727-4900 ext 406 or 1-877-MASS.AFE Revised 5-26-05 Fax#617-727-7749 749 wwWMEtS,%goVaa