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HomeMy WebLinkAboutBuilding Permit #282-16 - 41 BRUIN HILL ROAD 9/3/2015 L �Cl4svw�"D D+✓ � �/ l5'' NORTh BUILDING PERMIT °F�tLEo 'gq't'o TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION - p Permit No#:A / T Date Received ' ��Ssgcwus�`�y Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION "7 �O - T/� ( Print ` PROPERTY OWNER Print 00 Year Structure yes Mq�PARCEL:_ ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resid tial Non- Residential ❑ New Building k0ne family El Addition El Two or more family 11 Industrial El Alteration No. of units: El Commercial El Repair, replacement ElAssessory Bldg El Others: ❑ Demolition ❑ Other - 0 Septic v p WellQ Floodplain, ❑Wetlands ❑ Watershed ®istfict u,Wate#Sewer'_ DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name:fiv),dL �- ��1� sr�u Phone: !! Address: ?' �'�°�'� /r/'`/ /ego Contractor Na e, '� Phone- 0 hone- — Email: 1 Addres' '�S /J r>1 �°► '� c� Supervisor's Construction License: 0&S C) l cl Exp. Date: Home Improvement License: k77 3�7 Exp. Date: ., ARCHITECT/ENGINEER /tr� Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED WS BA�ON$125.00 PER S.F. Total Project Cost: $_4 G/ �> FEE: $ Check No.: Receipt No.: of NOTE: Persons contracting wt h unregistered contractors do not have access o the guaranty fund Location / 16)1,n /! No. Date . - TOWN OF NORTH ANDOVER d Certificate of Occupancy $ Building/Frame Permit Fee $we 1,J Foundation Permit Fee $ Other Permit Fee $ 4TED TOTAL $ Check#.�� �/ Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private se tic tank eta P Permanent Dp um ster on Site El THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM i PLANNING & DEVELO T Reviewed On Signature_ COM TS 7 N Reviewed on-.0 Signature / CU MMENTS is N v� `` Reviewed on - Signature 7�d COMMENT A L , uU an— a - Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/si nature&®ate Driveway Permit � y DPW Town Engineer: Signature: Located FIRE DEPA TMEIVT �`' t d 384 Osgood Street , , • l R T,�emptDumpsteraon�site; -,yes�.s �� et Y }i tip ,� �_ �, . ` no1_��_•. i,LLoc"atedaf�124IVIancStr eta °FiretDepartrnent sgnafurye/elate, COMMENTS: Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Dieter location, mast or service drop requires approval of Electrical Inspector Yes No DANCER ZONE LITERATURE: Yesi N® MGL Chapter 166 Section 21A—F and G min.$1oo-$1000 fine NOTES and DATA— (For department rase:) ® Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit 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 4. Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses j Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department pt�r to is uance 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) dill!" Engineering Affidavits for Engineered products X11* 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 Certified Proposed Plot Plan 4, Photo of H.I.C. And C.S.L. Licenses 4; Workers Comp Affidavit 46 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 i Doc:Building Permit Revised 2014 1 ,y NORTH Town of t E 1, Andover No. - *� �otlf-v' h , ver, Mass, COCNICHI WICK V TED pDR� PPa\ �y ,9S, BOARD OF HEALTH' Food/Kitchen PER IT T LD Septic System THIS CERTIFIES THAT ........... G. a �` BUILDING INSPECTOR . .. .. .. .... .......... . Foundation has permission to erect .......................... buildings on ....... .�....... .1..�.11.!�...... .. /.........!��i r..!'! Rough g tobe occupied as Jak.. .........�• �............................................................................. Chimney provided that the person accepting this ermit 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 ELECTRICAL INSPECTOR SQ=r- UNLESS CONSTRUC Rough Service ............ .... .................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises' - Do Not Remove Final T No Lathing or Dry Wall 1 o Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. NORTH own of E ndover 0 No. C Rk. ver' 'Mass O LKE COC MICKEWICK 9p°amore o �`Pa` •(y BOARD OF HEALTH' Food/Kitchen PER.. IT T LD Septic System THIS CERTIFIES THAT ........... G. , BUILDING INSPECTOR ........... ...x..1....1 ................. .... .... .... Arm . .. .. .... ........... Foundation has permission to erect .......................... buildings on ....... . ...... .�n...... .. h...... Rough g to be occupied as .104*A.It........ .�............................................ ................................. Chimney provided that the person accepting this ermit 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 ELECTRICAL INSPECTOR S UNLESS CONSTRUC Rough Service ............ ..... .................................................... Final 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. Davie's Home Improvements. 617-968-6595 Construction Supervisors License 085049 Home Improvement Registration 138307 www.davie's-home-improvements.com Proposal prepared for: Bonnie and Lee Wilkinson Project address: 41 Bruin Hill Rd. North Andover Ma. New deck Description of work to be completed: Footings: Dia and pour new concrete footings as required 12" diameter 48" deep Dig and pour concrete landing pad for stairs Framing: All new pressure treated joists,posts, and stair stringers 6"x6" support posts 4"x4" railing posts bolted to framing Ledger board lagged to house All fasteners to be corrosion resistant Decking: Install customer supplied decking Railings: Install customer supplied rail system Lattice/Trim:. Install white pvc lattice to close in underside of deck on side facing street Provide"end install white pvc skirt and trim boards I� Pricing includes labor only Client to supply all materials All workmanship to comply with Ma. state building code, and guaranteed for a period of 1 year, starting at completion date Cost: $9,000 Terms: $2,250 at start: $2,250 after completion of framing $2,250 after installation of decking $2,250 after installation of railing Proposed start date: 9/14/15 Estimated completion date: 9/25/15 Homeowners signature: �� Date: 8 30 /1 Contractors signature: � �. ��-, �. Date: sy'� North Andover MIMAP 41 Bruin Hill August 24, 2015 A •, etc . 77 i 5 a � c r ..r { p a , l y j , �S ` �a a r. ' "y •-: .3 - ' =�.104:A-0032'�'• �� - � `�' I, HILL 71 .' .ar a �� gra 02 �,= 104.A-0076; Y „_ W, X49 BRUIN HILL RU 901WINTER ST x _ k «` � ,.� � ':� ,ice'� � - ��� +•' �,� � C ww 't- MVPC Bo Interstates —I Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, —SR Meters Data Sources:The data for this map was produced by Merrimack --Roads Cf NOR71y q Valley Planning Commission(MVPC)using data provided by the Town of it�ao ,6 ti North Andover.Additional data provided by the Executive Office of ,Easements .6 OQ Environmental Affairs/MassGIS.The information depicted on this map is ]Parcels F _ 9 for planning purposes only.It may not be adequate for legal boundary to definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING Y • THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY It = ^ ; OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION 1SSACHUSet V 50 ft ��° _. �NMV soon soon= xlww� IN= mmmu= sm m WASHOW I ISI tl soon= M� mm�mw &SUMMOMMMI p ISI MEMI mmommi NINE== loomml mmumommomm mmml�� ONE= am MENUMM -am= t t as R COWSTPG'C'710/V � s 7z'3 ' op, 1 6 69. . S 7238'30" TOTAL FRD/VT�{GE 5I9. 78' s� 5�7 ' E 133.3$' TO T4 / RO/V TA GF `- 6A j SFS { � = g3, 704 �.1 p Sr TO AREPLANpS— 65, OUS coNTIo y 9ER7 i 5 s EXIS77NG FOUNDA 7AON 1 . '. O CP. a 0 oz moo � Aw g 10 SF 6 M. TQTAt ARUpLANOS= ' � ;N1 7 � N 2 } �9'n.LoNPS l ' 00 o� ,,gi 17 4all '\ The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 r wwmmass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print L ibl Name(Business/Organization/Individual): g�M „s Address: C..4 , RfvtrtL4 14ut_,. City/State/Zip: HrA,+►` se, 1/`-_A 07-17k Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).; 7. 21�slew construction 2.0 I am a solo proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.)t 9. 0 Demolition 10E]Building addition 4.0 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 11.0 Electrical repairs or additions proprietors with no employees. 12.EJ Plumbing repairs or additions 5.,I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.= 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§I(4),and we have no employees.[No workers'comp.insurance required.) *Any applicant that checks box 11 l 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. $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-contractors have employees,they must provide their workers'comp.policy number. I ani au employer that is providing ivorkers'contpensatiott insurance for my employees. Below is fire policy and job site Information. Insurance Company Name: Policy#or Self-ins.Lic.M Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration 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. I do hereby cerlir 1 nd pet ies of peiluty that lite information provided above is true and correct Si nature pal Date: —Z n Phone#• ' 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.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone M ASCIGI1 OP ID: BD DATE(MM/DDNYYY) CERTIFICATE OF LIABILITY INSURANCE 09/24/2014 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(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 CONTACT Supino Insurance-Malden NAME: Supino Insurance Agency, Inc. 1012 Eastern Ave/Rt 60 PAHic°No Ext):781-322-2800 A/Ic No): 781-321-2414 Malden,MA 02148 EMAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Utica First 15326 INSURED Giuliano Asci INSURER B: 3 Lorenzo Rd Lawrence, MA 01843 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 I ADDL SUBR LTR TYPE OF INSURANCEPOLICY NUMBER POLICY EFF POI-111 Y EXP —YYYY MM DD/YYYY LIMITS A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 500,000 CLAIMS-MADE 1-1OCCUR ART501984503 10/04/2014 10/04/2015 DAMAGE T RENTED X Business Owners PREMISES Ea occurrence $ 50,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 500,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OPAGG $ 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDRETENTION$ $ WORKERS COMPENSATION PER 0TH- AND EMPLOYERS'LIABILITY Y/N STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN GIUIlanO ASCI ACCORDANCE WITH THE POLICY PROVISIONS. 3 Lorenzo Rd Lawrence, MA 01843 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD i ASCIGI1 PAGE 2 NOTEPAD INSURED'S NAME Giuliano Asci OP ID: BD Date 09/2412014 BOP Policy Received: 10/31/11 Form #: XSP1 Form Name: EXCL-COMMERCIAL SPRAY PAINTING Form Ed Dt: 12/01/96 Form #: AP-100 Form Name: CONTRACTORS SPECIAL POLICY Form #: AP 0432 Form Name: Amendatory Endorsement - MA Form Ed Dt: 12/01/03 Form #: UFR-1 Form Name: ROOFING EXCLUSION Form Ed Dt: 07/01/11 Form #: AP 0233 Form Name: EXCLUSION-WAR & MILITIARY ACT Form Ed Dt: 01/01/08 Form #: AP 0235 Form Name: Can-Spam Exclusion Form Ed Dt: 02/01/08 Form #: AP-0225 Form Name: Asbestos Exclusion Form Ed Dt: 10/01/05 Form #: AP"0643 Form Name: ART MANDATORY FORM Form Ed Dt: 12/01/99 Form #: AP 0689 Form Name: Mold Exclusion Form Ed Dt: 06/01/02 Form #: GL-212 Form Name: EXCLUSION - EXPLOSION, COLLAPSE, UNDERGROUND PROPE Form #: GL-895 Form Name: EMPLOYEE REDEFINED Form #: GL-890 Form Name: LEAD LIABILITY EXCLUSION Form #: AP 0365 Form Name: Virus Or Bacteria Exclusion Form Ed Dt: 10/01/06 I BOP Policy Received: 10/31/11 06/01/02 Form #: AP-0611 Form Name: LOSS OF INCOME COV 72 HR WAIT Form Ed Dt: 01/01/99 Form #: XCNTROS Form Name: Excl of Injury to Empl,Contract Form #: GL-894 Form Name: PUNITIVE DAMAGE EXCLUSION Form #: AP 0692 Form Name: Construction Defects Exclusion Form Ed Dt: 06/01/02 Form #: AP 0851 Form Name: Other Insurance Amendment Form Ed Dt: 09/01/09 Form #: AP 0852 Form Name: Information Distribution and Form Ed Dt: 09/01/09 Form #: AP 0853 Form Name: Exclusion-Communicable Disease Form Ed Dt: 09/01/09 Form #: AP 0690 Form Name: EIFS Exclusion Form Ed Dt: 06/01/02 Form #: AP 0230 Form Name: Silica Exclusion Form Ed Dt: 10/01/05 Form #: AP 0700 Form Name: Certified Terrorism Loss Form Ed Dt: 01/01/08 Form #: CL 1045 Form Name: Notice of Terrorism Coverage Form Ed Dt: 01/01/08 Form #: CL 0605 Form Name: Certified Terrorism Loss Form Form Ed Dt: BOP Policy Received: 10/31/11 Form #: PRIV0401 Form Name: PRIVACY STATEMENT Form Ed Dt: 04/01/01 Form #: AP-0661 Form Name: Contractors Tools Form Ed Dt: 04/01/00 Location #1 Prem Info - Cov Cd: EAOCC Curr Term Amt: 705.00 Building #1 Subj of Ins: TOOLS Cause of Loss: BASIC - Basic) - Prem: $150.00 Subj of Ins: TERRO Cause of Loss: BASIC - Basic) - Prem: $19.00 Package Policy Received: 10/31/11 Canc Info - Req: Company Reason Cd: Underwriting Reasons Method Cd: Flat WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 26158 POLICY NO. AWC_400-7024258-2014A PRIOR NO. AWC-400-7024258-2013A' ITEM 1. The Insured: Giuliano Asci DBA: Mailing address: 3 Lorenzo Road FEIN:"-"'9748 Lawrence,MA 01843 Legal Entity Type: Sole Proprietor Other workplaces not shown above: See Location 2. The policy period is from 05/29/2014 to 05/29/_2015_ 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers'Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of j Annual Remuneration Remuneration Premium INTRA 316704 INTER SEE CLASS CODE SCHEDU E Minimum Premium $500 Total Estimated Annual Premium $500 GOV ; GOV Deposit Premium $500 STATE;CLASS MA ! 5403 MA Assessment Chg. S..00�x 3.40/00% n $ This policy,including all endorsements,is hereby countersigned by 04/11/2014 Authorized Signature Date Service Office: Supino Insurance Agency Inc B Third Avenue Burlington MA 01803 1012 Eastern Avenue Malden,MA 02148 WC 00 00 01 A(7-1f) Includes copyrighted material of the National Council on Compensation Insurance, used with Its permission. l A.I.M. Mutual Insurance Company Insured: 7024258 Producer: 03125-001-001 Giuliano Asci Supino Insurance Agency Inc 3 Lorenzo Road 1012 Eastern Avenue Lawrence, MA 01843 Malden, MA 02148 Insured FEIN: "-"'"9748 Issue Date: 04/11/2014 Policy Number: AWC-400-7024258-2014A Endorsement Effective Date: 05/29/2014 Policy Period: 05/29/2014-05/29/2015 Endorsement Number: ENDORSEMENT SCHEDULE The forms listed below are included in this policy: Form No. Form Description Applicable States Policy Effective Date PRIVACY Privacy Notice 05/29/2014 AIMIMPT AIM - Important Policyholder Notices 05/29/2014 AIM-61 AIM -Servicing Carrier 05/29/2014 AIM-3 AIM Waiver of Subrogation Notice 05/29/2014 AIM-4 MA Benefits Claim and Aggregate Deductible Program 05/29/2014 AIM-5 AIM Commitment of Service 05/29/2014 AIMCI AIM -Cl Phone Numbers 05/29/2014 Servonl Services Online Instructions 05/29/2014 WCRIB WCRIB Circular Letters Notice MA 05/29/2014 Location Location Schedule 05/29/2014 Class Code Classification Code Schedule 05/29/2014 Installment Installment Schedule 05/29/2014 Rating Summary Rating Summary by State 05/29/2014 AIM-1A Dividend Classification Endorsement 05/29/2014 AIM-2 MA Workers Compensation Assigned Risk Pool 05/29/2014 WC 00 00 00 B Policy Conditions 05/29/2014 WC 00 04 04 Pending Rate Change End. MA 05/29/2014 WC 00 04 14 Notification of Change in Ownership 05/29/2014 WC 20 01 01 MA Terrorism Endorsement MA 05/29/2014 WC 20 03 01 MA Limits of Liability Endorsement MA 05/29/2014 WC 20 03 02 A MA Assessment Charge MA 05/29/2014 WC 20 03 03 D MA Notice to Policy Holder Endorsement MA 05/29/2014 WC 20 03 06 8 MA Limited Other States Insurance Endorsement MA 05/29/2014 WC 20 03 07 MA Assigned Risk Pool Eligibility Endorsement MA 05/29/2014 WC 20 04 05 MA Premium Due Date Endorsement MA 05/29/2014 WC 20 04 01 MA Pending Premium Change Endorsement MA 05/29/2014 WC 20 06 01 A MA Cancellation Endorsement MA 05/29/2014 WC 20 06 04 MA Policy Definition Endorsement MA 05/29/2014 EMPNOTICE MA Notice to Employees MA 05/29/2014 Insured EndorsementSch(04111) A.I.M. Mutual Insurance Company Insured: 7024258 Producer: 03125-001-001 Giuliano Asci Supino Insurance Agency Inc 3 Lorenzo Road 1012 Eastern Avenue Lawrence, MA 01843 Malden, MA 02148 Insured FEIN: -"'9748 Issue Date: 04/11/2014 Policy Number: AWC-400-7024258-2014A Endorsement Effective Date: 05/29/2014 Policy Period: 05/29/2014-05/29/2015 Endorsement Number: LOCATION SCHEDULE Insured Unit:001 Workplace:001 Business Type:Sole Proprietor Business Type: Giuliano Asci 3 Lorenzo Rd Lawrence,MA 01843 TAX ID:012549748 Business Type: Business Type: Business Type: Business Type: Business Type: Business Type: Business Type: Business Type: Business Type: Business Type: Insured (11/11)LocationSch A.I.M. Mutual Insurance Company Insured: 7024258 Producer: 03125-001-001 Giuliano Asci Supino Insurance Agency Inc 3 Lorenzo Road 1012 Eastern Avenue Lawrence, MA 01843 Malden, MA 02148 Insured FEIN: "-*'*9748 Issue Date: 04/11/2014 Policy Number: AWC-400-7024258-2014A Endorsement Effective Date: 05/29/2014 Policy Period: 05/29/2014-05/29/2015 Endorsement Number: CLASSIFICATION CODE SCHEDULE Policy Unit: 001 Unit State Code: MA Policy Unit Name: Giuliano Asci Billing Plan:Annual Classification Class Payroll Rate Estimated Description Code No. Amount Per$100 Premium CARPENTRY NOC 5403 If any 9.86 0 CARPENTRY - DETACHED ONE OR 5645 If any 8.06 0 CARPENTRY - DWELLINGS-THREE 5651 If any 8.06 0 Manual Premium 0 Standard Premium 0 Loss Constant 50 Expense Constant 159 Minimum Premium Adjustment 291 Estimated Premium (Minimum Premium) 500 DIA ASSESSMENT 3.40% 0 Total Estimated Premium&Surcharge(s) 500 Insured ClassCodeSch(04/11) i A.I.M. Mutual Insurance Company Insured: 7024258 Producer: 03125-001-001 Giuliano Asci Supino Insurance Agency Inc 3 Lorenzo Road 1012 Eastern Avenue Lawrence, MA 01843 Malden, MA 02148 Insured FEIN: 012549748 Issue Date: 04/11/2014 Policy Number: AWC-400-7024258-2014A Endorsement Effective Date: 05/29/2014 Policy Period: 05/29/2014-05/29/2015 Endorsement Number: INSTALLMENT SCHEDULE Policy Unit No: 001 Units Billed to this Unit:1 Policy Unit Name: Giuliano Asci Billing Plan: Annual Installment/ DIA Total Amount Due Date Billed Endorsement No. Assessment Annual Payment $0 $500 05/29/2014 Insured InstaltmentSch(04/11) A.I.M. Mutual Insurance Company Insured: 7024258 Producer: 03125-001-001 Giuliano Asci Supino Insurance Agency Inc 3 Lorenzo Road 1012 Eastern Avenue Lawrence, MA 01843 Malden, MA 02148 Insured FEIN: " *9748 Issue Date: 04/11/2014 Policy Number: AWC-400-7024258-2014A Endorsement Effective Date: 05/29/2014 Policy Period: 05/29/2014-05/29/2015 Endorsement Number: POLICY RATING SUMMARY BY STATE Massachusetts Manual Premium 0 Standard Premium 0 Loss Constant 50 Expense Constant 159 Minimum Premium Adjustment 291 Estimated Premium (Minimum Premium) 500 DIA ASSESSMENT 3.40% 0 Total Estimated Premium&Surcharge(s) 500 Total Estimated Premium &Surcharge(s) $500 Insured RatingSum(01/12) _ A.I.M. Mutual Insurance Company Insured: 7024258 Producer: 03125-001-001 Giuliano Asci Supino Insurance Agency Inc 3 Lorenzo Road 1012 Eastern Avenue Lawrence, MA 01843 Malden, MA 02148 Insured FEIN: "-'"'9748 Issue Date: 04/11/2014 Policy Number: AWC-400-7024258-2014A Endorsement Effective Date: 05/29/2014 Policy Period: 05/29/2014 -05/29/2015 Endorsement Number: DIVIDEND CLASSIFICATION ENDORSEMENT As required by Section 80 of Chapter 175 of the General Laws of Massachusetts, notice is hereby given that the risk insured by this policy is classified for the purpose of fixing and determining the percentage of dividend or expiration return of premium to be paid on expiring or cancelled pollcies in the classification(s) hereafter designated by an "X" below: Workers Compensation except such policies subject to the Company's Retrospective Rating Plans, Loss Ratio, Safety Group, Retention, Large Risk Deductible, or those policies assigned by The Massachusetts Workers Compensation Assigned Risk Pool or those policies placed by brokers within the scope of the Company's Brokerage Agreement. _ 2. Workers Compensation Policies subject to Retrospective Rating Plans. J 3. Workers Compensation Policies subject to Loss Ratio Plans. 1 4. Workers Compensation Policies subject to Safety Group Plans. _I 5. Workers Compensation Policies subject to Retention Plans. I_ 6. Workers Compensation Policies subject to Large Risk Deductible Plans. I` 7. Workers Compensation Policies subject to (1) above placed by brokers within the scope of the Company's Brokerage Agreement. F 8. Workers Compensation Policies subject to Hospitality Loss Ratio Plan. 9. (Reserved for Future Use) 10. (Reserved for Future Use) Nothing herein contained shall waive,alter,or extend any condition or provision of the policy other than as above stated. Countersigned by Insured AIM-1A(07/11) i Massachusetts -Department of Public Safety Board of Building Reg ulaticns and Standards Construction SuperNisor License: CS-085049 JAMES G DAVIE,#R 25 CHWMAN AVE Melrose MA 021'T6 Y Expiration commissioner 09/12/2016 4, A4 Office of Consumer Affairs&Business Regulation 5,WROME IMPROVEMENT CONTRACTOR Type. ti _... — $1egistration: 138307 Expiration: 3/19/2017 DBA DAVIE'S HOME IMPROVEMENTS i JAMES DAVIE 25 CHIPMAN AVE. -- --- MELROSE,MA 02176 Undersecretary