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HomeMy WebLinkAboutBuilding Permit #123-15 - 400 BEAR HILL ROAD 8/4/2014 � ltORTlf� BUILDING PERMIT 3i:� ``� •e°o ^ TOWN! OF NORTH ANDOVER ��{(/ APPLICATION FOR PLAN EXAMINATION Permit NO: Date R a _ eceived Date Issued: �9 SgcHus�� iRTANT: Applicant must complete all items on this" LflcATIONAh iloer- JOL PROPEM OWNEf MAP NO; PARCEL ,ZONING DISTRICT_� � Hidorie Dish t yesfn* ay Machir�eShop Village- :yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑ New Building- 00ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑Demolition ❑Other Cl Septic ❑UVeti Flaodolaia,`; II 111letlands _ t3 Watershed ltric Identification Please Type or Print Clearly) r OWNER: Name:' C-' Phone: (?-7 qv . 'irk Address. k 1 -0' 7 CO'ITRACTORs Name �. � Phone .. �. t Address- Ar-1 ddress ..., Supervisor's.Cos�struon:Eicense .Date Hw IrrlpM' vernent Licerm per, • : I s ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PEIKIM$12.00 PER$1000 00 OF THE TOTAL ESMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE; $ � ' {r : `t Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to t1 uaranty Pund Si nature,of -ent/Owner.R _ _ _ _..� 9 9 fir.; Signature of contractor BUILDING PERMIT °F"°oT j TOWN OF NORTH ANDOVER F APPLICATION FOR PLAN EXAMINATION 00 * ery Permit No#: Date Received 0ED R4 �gSSACHU`����� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Print - - PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 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: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Ager t/Owner l Signature of contractor Location No. ^ Dat � 1 o" TOWN OF NORTH ANDOVER 0 o Certificate of Occupancy $ } Building/Frame Permit Fee $ Foundation Permit Fee $ " Other Permit Fee $ TOTAL $ Check 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: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street 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 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 ❑ 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/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 ❑ 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 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 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 70,223.00 m $ - $ 842.68 Plumbing Fee $ 105.33 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 105.33 Total fees collected $ 1,153.35 400 Bear Hill Road 123-15 on 8/5/2014 Remodel 3 Bathrooms Rug 04 2014 11 : 07nm Boston Kitchen 978-657-0670 p. 2 Bion itahe,n FaIDesigm,Inc 215 South Main St 56 Brook Rd 179 Summer St#6 Middleton, MA 01949 Needham,MA 02494 Kingston, MA 02364 978-750-1403 781-444-4711 781-585-0919 Conditions of Sale 1. Upon approval of this contract all Orders/Deposits are non-refundable and non-cancelable. Customer agrees to promptly pay the balance of the contract price. 2. All balances become fully due and payable once the cabinets ship from the manufacturer. This includes payment for the complete order, including products such as countertops,even if they are to be delivered at a later date. 3. Payments with in-state personal checks must be received by Boston Kitchen Design, Inc.two banking days prior to scheduling a delivery date,out of state checks will need five banking days to process,before a delivery date can be scheduled. Master and Visa charge cards must be presented by credit card holder at any of our showrooms, in order to be swiped through the credit card machine. We do not accept credit card payment by any other means such as phone or faxing. 4. All designer fees and retainers are non-refundable. 5. Installation is not included unless specified on the Invoice. 6. Cabinets and countertops will be delivered to the end of the truck. Customer is responsible for unloading all goods. 7. If an arranged delivery cannot be made for any reason where the customer is at fault,the customer will incur a second delivery charge when re-shipped. These reasons may include inability to pay the balance, inaccessibility to the job site, or no one available to accept the delivery. 8. Access way to the room or other place of delivery must be clear-no deliveries will be made through windows,up ramp-ways or boards,via hoist or by any other unsuitable method or dangerous means. 9. All orders must be picked up or delivered within five (5)days after the receipt of goods by Boston Kitchen Design,Inc. If delivery is delayed by the customer for more than five (5)days after the items arrive at the warehouse,the customer agrees to pay a storage fee of$100.00 per month. 10. Customer is required to inspect all goods within forty eight (48)hours of delivery or pickup prior to installation.If any damage is found, goods must be returned free from screw holes in its original carton with all packing materials. 11. Boston kitchen Design, Inc reserves the right to repair damaged goods. 12. It is the responsibility of the client to adjust all hinges, drawers, doors etc. 13. It is the responsibility of the client to furnish all glass as required. 14. All cherry cabinets and white frames will darken with age and/or show slight frame joint lines. Customer expressly acknowledges that wood products have slight color variations,knots and other slight imperfections, which are naturally occurring conditions beyond the control of Boston Kitchen design, Inc. 15. Customer acknowledges receipt of Manufacture's cabinet specification sheet and a layout. Aug 04 2014 11 : 08AM Boston Kitchen 978-657-0670 p. 3 Collection Interest at Eighteen percent(18%)per annum shall accrue on all invoices/orders outstanding in excess of thirty (30)days from the date of delivery to Boston kitchen Design, Inc.'s warehouse. In the event the customer defaults on payment terms hereunder described customer expressly agrees to pay Boston Kitchen design,Inc.all costs of collection, including, without limitation, attorney fees and costs incurred to collect the outstanding debt. Warranty Limitations and Exclusions Customers accepts the terms and conditions of the Manufacturer Warranty. Manufacturer will not have any further warranty obligation under this agreement if the material is subject to abuse,misuse, negligence or accident, or if the customer fails to perform any of the duties set forth herein, Boston Kitchen Design, Inc. and its employees are not licensed general contractors and therefore not liable for any structural,electrical, plumbing, HVAC and/or cosmetic work required for the completion of your project. Boston Kitchen Design, Inc. recommends that you review all of your kitchen plans with appropriate trades people to ensure no issues prior to installation. Please feel free to direct any kitchen design relaxed question to your Boston Kitchen Design,Inc sales representative. Boston Kitchen Design, Inc. is not responsible for any labor which is associated with products purchased and/or replaced. Customer Signature, C7-~��-� Date; Print Name: Aug 04 2014 11 : 07RM Boston Kitchen 978-657-0670 p. i Boston � Ift � , - Designs oales Onaker 215 South Main Street Sales Order 0 5532 Middleton, MA 01949, Job/Tag# STONE DOTTM BATHS-GM-5500 1(Phone 978-750-1403 Date 6/27/2014 Fax 978-642-9595 Bill To Ship To DOTTIE STONE DOTTIE STONE 400 BEAR HILL ROAD 400 BEAR HILL ROAD NORTH READING NORTH READING 978.794.9271 978.794.9271 978.407.8639 978.407.8639 Designer GM-0 Store Loc Terms Ln.# Qty. Item Mfr. Model&Description Rate Amount Cabinet MATERIAL FOR 3 BATHROOMS 38,323.00 38,323.00T Installation INSTALLATION FOR 3 BATHROOMS TO 30,950.00 30,950.01 INCLUDE DEMO,REBUILD .CABINETS COUNTERTOPS;TILE,ELECTRIC, PLUMBING,PAINTING Delivery DELIVERY OF MATERIAL 950.00 950.01 CUSTOMER WILL PAY FOR PERMIT FEES AND DUMPTSTER ON SITE RETAINER$3,000 PAYMENT 13EFORE ORDER THE MATERIAL S 15,000 , PAYMENT JULY 21$15,000 START DAY AUGUST 5TH TUESDAY, PAYMENT AUGUST 7TH FRIDAY $20,000 PAYMENT AUGUST 25TH MONDAY $12,000, PAYMENT AUGUST 29TH FRIDAY $5,000 FINAL BALANCE OF THIS AGREEMENT ON COMPLETION OUT OF THE 3 BATHROOMS THE MASTER BATHROOM Wn.L HAVE HEATED FLOOR We Appreciate Your Business! Subtotal $70,223.0 Sales Tax(6.25... $2,395.1 www,bostonkitchen.com Total $72,618.1 NORT1i Town ®f .71 ..•.1,., Andover .yam. No. Ikeb . hh ver, Mass, A- COC KICKl WICK 7d A�R�tTED �'Pa,`'�5 S U BOARD OF HEALTH Food/Kitchen PER L D Septic System THIS CERTIFIES THAT ............... ... .. . . ........�.. .. ��.. ...... ........... ..... . ............ BUILDING INSPECTOR '.. ..�......... Foundation has permission to erec ........................ buildings on ... . ....... ... !".'.... .1. ......... Rough to be occupied as .... . ... ........ ....... ............................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final q PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI ST TS Rough Service ................ ..... ... ... ... ......................... Fina BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. —� Boston Ilgc'lnam Sal es Order Designs 215 South Main Street Sales Order# 5532 Middleton, MA 01949 Job/Tag# STONE DOTTIE BATHS-GM-5500 Phone 978-750-1403 Date 6/27/2014 Fax 978-642-9595 Bill To Ship To DOTTIE STONE DOTTIE STONE 400 BEAR HILL ROAD 400 BEAR HILL ROAD NORTH READING NORTH READING 978.794.9271 978.794.9271 978.407.8639 978.407.8639 Designer GM-0 Store Loc Terms Ln.# Qty. Item Mfr. Model&Description Rate Amount Cabinet MATERIAL FOR 3 BATHROOMS 38,323.00 38,323.00T Installation INSTALLATION FOR 3 BATHROOMS TO 30,950.00 30,950.00 INCLUDE DEMO,REBUILD.CABINETS COUNTERTOPS,TILE,ELECTRIC, PLUMBING,PAINTING Delivery DELIVERY OF MATERIAL 950.00 950.00 CUSTOMER WILL PAY FOR PERMIT FEES AND DUMPTSTER ON SITE RETAINER$3,000 PAYMENT BEFORE ORDER THE MATERIAL$15,000, PAYMENT JULY 21$15,000 START DAY AUGUST 5TH TUESDAY,PAYMENT AUGUST 7TH FRIDAY $20,000 PAYMENT AUGUST 25TH MONDAY $12,000, PAYMENT AUGUST 29TH FRIDAY $5,000 FINAL BALANCE OF THIS AGREEMENT ON COMPLETION OUT OF THE 3 BATHROOMS THE MASTER BATHROOM WILL HAVE HEATED FLOOR We Appreciate Your Business! Subtotal $70,223.00 Sales Tax(6.25... $2,395.19 www.bostonkitchen.com Total $72,618.19 0 d 0D Note: This drawing is an artistic 20 2061r), Designed: 6/24/2014 interpretation of the general T E C H N O t O G 1 E 5 f' Printed: 7/31/2014 appearance of the design. It is not meant to be an exact rendition. Stone Master Bath george All Drawing#: 1 KX O 0 Note:This drawing is an artistic20 2Op`� Designed: 6/24/2014 interpretation of the general TECHNOLOGIES €/ Printed: 7/31/2014 appearance of the design. It is not meant to be an exact rendition. Stone Master Bath george All Drawing#: 1 752, 36"� L �--(`- W1242 Af2CHVAL60 12-4 J2 -1 q )BT21_ �BT21 -330 I � H U TILE.FLO.T.DIA.BORI f U) � . W O U 1 J� 0- 1411'14" 00 M I `�-- X 4 6 v i 38"-/ All dimensions_size designations �p� `� This is an original design and must Designed: 6/24/2014 given are subject to verification on TECHNOLOGIES Gf! not be released or copied unless Printed: 7/31/2014 job site and adjustment to fit job applicable fee has been paid or job conditions. order placed. Stone Master Bath george All Drawing#: 1 No Scale. I Note: This drawing is an artistic 2020617 Designed: 6/6/2014 interpretation of the general TECHNOLOGIES Printed: 7/31/2014 appearance of the design. It is not meant to be an exact rendition. Stone Main Bath All Drawing#: 1 154" �45" 334" 1152" — i NJ 04 L.-L- 0.JJ, (DaT-1-81 C. 33Q ...--- -- ----_- ---- � TOIL.CLASSIC VSBT2718 VSBT2718 ii0 W =O ! 00 pip 00 i LL Z — r BATH CIL:LC.60;RM—R w �a M 4�28 BC241284 BC24 � >--� X I I� N a ; /1152"' 66" All dimensions-size designations ��,�� This is an original design and must Designed: 6/6/2014 given are subject to verification on TECHNOLOGIES not be released or copied unless Printed: 7/31/2014 job site and adjustment to fit job applicable fee has been paid or job conditions. order placed. Stone Main Bath All Drawing#: 1 No Scale. Note: This drawing is an artistic20 MO�] Designed: 6/6/2014 interpretation of the general TECHNOLOGIES Printed: 7/31/2014 appearance of the design. It is not meant to be an exact rendition. Stone Downstairs Bath All Drawing#: 1 382' 35 " (V V 18 - I I - -- FL3L MIS i U N� CY) W I , I� 731211 All dimensions-size designations '�(""�� /����] This is an original design and must Designed: 6/6/2014 given are subject to verification on rECHtt0LOGIEs Y1LJ not be released or copied unless Printed: 7/31/2014 job site and adjustment to fit job applicable fee has been paid or job conditions. order placed. Stone Downstairs Bath All Drawing#: 1 I No Scale. - o"a"N SCOTT-1 OP ID:JD /$16� CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDDIYYYIf) 08/01/2014 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 Wilmington Insurance Agency NAONE Wilmington Insurance Agency F PH Five Middlesex Avenue Unit 14 yvc,No Ext:978-658 805 a No):978457-5724 P.0.Box 1010 E-MAIL Wilmington,MA 01887-0580 ADDRESS` John F.Doherty INSURER(S)AFFORDING COVERAGE NAIC k INSURER A:Hartford Insurance Company INSURED Scott Robichaud INSURER S:Cornerstone 21 Draper Avenue Wilmington,MA 01887 INSURER C: 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. INSR DIL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MMI M LIMITS B X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE a OCCUR OS103374 0412212014 04122/2015 DAMAGE TO RENTED_ PREMISES Ea occurrence $ 10,00 MED EXP(Any one person) $ 1,00 PERSONAL&ADV INJURY $ 11000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,00 X POLICY1-1 ECa JT LOC PRODUCTS-COMP/OPAGG $ 1,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OS SCHEDULED BODILY INJURY Per accident) $ AUTOS AUTOS ( NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peracadent UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATIONPER OTH- AND EMPLOYERS Y 1 N LIABILITY X STATUTE I ER A ANY PROPRIETOR/PARTNER/EXECUTIVE 8880UB-0380N77412 02/22/2014 02/22/2015 E.L.EACH ACCIDENT $ 100,00 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,00 If Yes,tlescribe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached B more space Is required) CERTIFICATE HOLDER CANCELLATION NORTHAN 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. 1600 Osgood Street AUTHORIZED REPRESENTATIVE 84 North Andover,MA 015 v. 0 44%p� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD SCOTT-1 OP ID:JD _ ATE IMM .ACOR®� CERTIFICATE OF LIABILITY INSURANCE FD 0810 I°°"'""' 08/01/2014 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). PRODUCERME: Wilmington Insurance Agency Wilmington Insurance Agency PHONEFAX Five Middlesex Avenue Unit 14 a No •978-658.3805 AIC No):978-657-5724 P.O.Box 1010 F-MAILF_ss: Wilmington,MA 01887-0580 John F.Doherty INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Hartford Insurance Company INSURED Scott Robichaud INSURER a:Cornerstone 21 Draper Avenue Wilmington,MA 01887 INSURER C: INSURER 0: 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. IL7RR ADDILSUSR POLICY TYPE OF INSURANCE D. POLICY NUMBER MWDDI EFF MWPOLICY EXP LIMITS B X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS MADE OCCUR OS103374 04/2212014 04/2212015 DAMAGE TO RENTEU__PREMISES Ea occurrence $ 10,00 MED EXP(Any one person) $ 1,00 PERSONAL&ADV INJURY $ 1,000,0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 XPOLICY❑PRCT O ❑LOC PRODUCTS-COMP/OP AGG $ 1,000,00 JE OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED P OPE EccidenDAMAGE $ HIRED AUTOS AUTOS UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STAT YIN UTE ER A ANY PROPRIETOR/PARTNER/EXECUTIVE 8S80UB-0380N77412 02122/2014 02/22/2015 E.L.EACH ACCIDENT $ 100,00 OFFICER/MEMBER EXCLUDED? Y❑ N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEd$ 100,00 IP es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached ff more space Is required) CERTIFICATE HOLDER CANCELLATION STONDOT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Dottie Stone ACCORDANCE WITH THE POLICY PROVISIONS. 400 Bear Hill Road AUTHORIZED REPRESENTATIVE North Andover,MA 01845 � t� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Massachusetts -Department of Public Safety �}*Board of Building Regulations and Standards Construction Supen-isor License: CS-MM9 SCOTT J ROBIC#AUD -- 17 DRAPER DR WILMINGTON 14YA 01887 r I� Expiration: Commissioner 10/28/2016; �e�onr.��ronr�)e�r�N o�'C�/lE�fiu�c�rue/r'. Office of Consumer Affairs&Business Regulation ' _ - ME IMPROVEMENT CONTRACTOR gistration: 108458 Type: - xpiration: .8!18/2016 Individual SCOTT J.ROBICHAUD Scott Robichaud 17 DRAPER DR WILMINGTON,MA 01887 Undersecretary 08/02114 8:25 AM Page 1 The Commonwealth of Massachusetts Department of Industrial Accidents s Ofike of Investigations a 1 Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders!Conttractors/N,'Iectricians/Plumbers Applicant Information Plea N t 1, ihl Name (Resines;/O)rRattiuttiotdlntiividual): Uo. (Nob, U Address: ? e Y. City/State/Zip: c �l r�n �a. �� Phone : Arc ou an employer?Cheek the appropriate box: Type of project(required): I. l am a employer with 4. ❑ t am a general con"ctor and I t,mpluye:es(full and/or part-time).*s have hired the sub-contractors b [J New consttvction 2.❑ I am a sole proprietor or partner- I isted on the attached shat- 7. FVRemodeling ship wid have no employees 'these sub-contractors have R- ❑ Demolition workingli,r me in an c employees and have workers' Y itY• i y. [:]Betiding addition LNo workers' comp,insurance comp.insurance. reyuirud i i, ❑ We are a corporation and its 10.❑ Electrical repair~or additions 3.❑ l am a homeowner doing all work ollicers have exercised their 11.❑Plumbing repairs or additions myself. 1No workers' comp. right of exemption per MGI. 12.❑ Roof repairs insurance required.] t c. 152,§1(4),and we have no employees, [No workers' 13,[]Other comp, insurance required.! *Any applicant that checks box#i mud also Lillout the section below showing their workers'cxmnpensation policy information. t Homeowners who submit this off idavit indicating they am citing all work and then hire outside contractors must submit anew affidavit indicating such. tCunlna:tors that check this box must attached an additiunal shed.showing the name of the sub-Lvntractors and state whnthei or not those cooties have employees. Ir the soh-contractors have employees,they must provitlo dwir wtxkers'comp.policy numhec. I am an employer that&providing workers'compensation in.varonce for my employees Below is the policy and job site Information. - lnsutaneo Company Name: 1 JQ1J�Jk 101SUftAilce co, — Policy f#or Self-ins. Lic. It: 6,�f60Gt(j -03 e `�" -7-7y 1 � Expiration nate_ at a" F Joh site Address: /-/.aL-Ik/ I d li& - . City/State/Zip: /)ljndov2.r U�Yq5 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverugu as required under Section 25A of MGI,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 corm of a STOP WORK 01U)ER and a fine of up to$250.00 a clay against the violator. Bc advised that a copy of this statemcnt,may he farwardcd to the Office of Investigations orthe DIA for insurance coverage verificatitm. I oto hereby certify and the pa;V penalties of perjury that the in,far►nution provided above Is true and correct Signature: 6, _ Dutz: f- 2,�l.�— -- Phone#: Of, e al use only. Do not write in this Area,to be completed by city or town official. City or Town: _ Permit/License 0 _ issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector b.Other (contact Person: Phone#: