HomeMy WebLinkAboutBuilding Permit #731-15 - 41 VILLAGE GREEN DRIVE 3/24/2015BUILDING PERMIT
TOWN OF NORTH ANDOVER
,-""APPLICATION FOR PLAN EXAMINATION
Permit NO. Date Received
Date Issued: <3 1 7WI
I ORTANT: Applicant must complete all items on this pane
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LOCATION M('%/,(/+�Cye�7',Q /Y/�% D/�3'%
—� Print -IV
PROPERTY OWNER
Print
MAP NO: PARCE& ZONING DISTRICT: Historic District yerno
Machine Shop Village ye
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ Addition
❑ One family
gTwo or more family
❑ Industrial
❑ Alteration
No. of units: dl L,
❑ Commercial
Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
•4•
0
Identification Please Type or Print Clearly)
OWNER: Name: ye411� 1k1v9a X6&14-, Phone: 9-i8`- 9/g, YID
Address:
CONTRACTOR Name: Phone: /?1
Address:
I.D?
Supervisor's Construction I ense: � / Exp.ate:
Home Improvement License: z�D `�� Exp. Date: 9
ARCHITECT/ENGINEER WZ4 Phone:
,h
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: $ I �PFEE: $ R I (o
Check No.: 1046et-l. Receipt No.:
NOTE: Persons co tracting-with unregistered contractors do not have access to g ty fund,
Signature of Aaent/Owner nR .t l i,, b . ignature of contract _ % ..
BUILDING PERMIT*
TOWN OF NORTH ANDOVER:...,`
APPLICATION FOR PLAN EXAM I NATION77" :Y'
Permit No#: Date,Receivjed.-tr,;,.
nntp
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
0 One family
El Addition
El Two or more family
0 Industrial
El Alteration
No. of units:
El Commercial
0 Repair, replacement
El Assessory Bldg
El Others:
El Demolition
0 Other
0 P,
e
kt A
..........
DESCRIPTION OF WORK TO BE PERFORMED:
Identification - Please Type or Print Clearly'
OWNER: Name: Phone:
Addrt=q_q-
ARCHITECT/ENGI NEER —.Phone,:.
Address: Regi No
FEE SCHEDULE: B ULDING PERMIT. $12.00 PER $1000.00 OF THE TO TA LES TIMATED COST BASED ON $125.00 PER S. F.
Total Project Cost: $
Check No.: Rec.ei0lN.62t,`:'.:
NOTE: Persons contracting with unregistered contractors:do-*iiot,.'have:access to the guaranty fund
N., V n --
en
Plans Submitted ❑
Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPF'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
COMMENTS
Signature_
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
0
Reviewed on
Sianature
s Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Locatea M4 usgooa Street
IFI,RE IDEPARITMENO— -Temp'®umpster on site: ,yes
__..-
Locatedat �124�Main Street
r SFres�,Department4signatur4e/date 4
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
a 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
o Engineering Affidavits for Engineered products
VOTE: 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
Location
H4 NJ.
Na —1 �A— � X5 Date -3 Z
Check 40014
2 iJ V S3
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ ^'
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
Building Technologies, Inc
Design & Construction
Building Code and Airport Consultant
Complete Engineered Building Systems
Charles I Martin P.E.
Office: 800-433-4410
400 West Cummings Park
Office: 781-245-6615
Suite 1725 -121
Cell: 617-620-0205
Woburn, MA 01801
Fax: 781-246-3040 or 781-623-0553
Web: www.BldgTech.com
Email: CMartin@BldgTech.com
"INTEGRITY is NON-NEGOTIABLE,
and RESPECT for ALL."
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$) 1128 ;GGIO)AG
m
$ -
$
216.00
Plumbing Fee
$
27.00
Gas Fee 100 comm.
$�
1!00.001
Electrical Fee
$
27.00
Total fees collected
$
370.00
44 Village Green Drive
731-15 on 3/24/15
Repairs due to water damage
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New England Design and Building Technologies Inc.
FIXED CONTRACT AMOUNT
THIS AGREEMENT, Made as of (March 9), In the Year of (2015),
Between the Owner: Robert and Shannon MacInnis
44 Village Green North Andover Mass.
978-918-4607
And the Contractor: New England Design and Building Technologies
400 W. Cummings Park Woburn Massachusetts
800-433-4410
For the Project: 44 Village Green
North Andover, MA 01845
ARTICLE 1. CONTRACT DOCUMENTS
1.1 The contract documents consist of this agreement, general conditions, construction documents,
specifications, allowances, finish schedules, construction draw schedule, all addenda issued prior to
execution of this agreement and all change orders or modifications issued and agreed to by both parties.
All documents noted herein shall be provided to the Contractor by the Owner. These contract documents
represent the entire agreement of both parties and supersede any prior oral or written agreement.
ARTICLE 2. SCOPE OF WORK
2.1 The Owner agrees to purchase and the Contractor agrees to construct the above mentioned
structure and fixtures attached thereto in (North Andover, Essex County Massachusetts) according to
the construction documents, allowances, finish schedules, all addenda, change orders, modifications and
specifications set forth in the specification booklet.
Repair existing condo due to flood damage, replay sheet rock, flooring, finish trim, and cabinets.
ARTICLE 3. TIME OF COMPLETION
3.1 The projected completion date shall be approximately (90) days from the first day of
construction, however any change orders and/or unusual weather might delay or otherwise effect the
completion date. Barring inclement weather or owner related delays, the Contractor shall pay liquidated
damages of ($50 per day if the project is not completed within (three) months.
ARTICLE 4. THE CONTRACT PRICE
4.1 The purchase price of the project shall be set at the sum of (eighteen thousand) Dollars,
($18,000.00), subject to additions and deductions pursuant to authorized change orders and allowances.
Closing costs shall be paid by the Owner.
4.2 The Owner and the Contractor acknowledge that the Owner will pay a sum of (three thousand)
Dollars, ($3,000.00), upon signing of this contract and before construction begins as a deposit and part of
the purchase price of the project.
Initialed by: Owner Contractor
MacInnis
North Andover Mass.
Page 2 of 4
ARTICLE 5. PROGRESS PAYMENTS
5.1 The Owner will make payments to the contractor pursuant to the attached construction draw
schedule as work required by said schedule is satisfactorily completed. Owner shall make draw
payments to contractor within (seven) days after request by contractor. Should the owner fail to make
payment, contractor may charge a penalty of (12%) annually upon the unpaid amount until paid.
5.2 If payment is not received by the Contractor within (30) days after delivery of payment demand
for work satisfactorily completed, contractor shall have the right to stop work or terminate the contract at
his option. Termination by Contractor under the provisions of this paragraph shall not relieve the Owner
of the obligations of payments to Contractor for that part of the work performed prior to such
termination. Termination by Owner under the provisions of this paragraph shall not relieve the Owner of
the obligations of payments to Contractor for that part of the work performed prior to such termination.
ARTICLE 6. DUTIES OF THE CONTRACTOR
6.1 All work shall be in accordance to the provisions of the plans and specifications. All systems
shall be in good working order.
6.2 All work shall be completed in a workman like manner, and shall comply with all applicable
national, state and local building codes and laws.
6.3 All work shall be performed by licensed individuals to perform their said work, as outlined by
law.
6.4 Contractor shall obtain all permits necessary for the work to be completed.
6.5 Contractor shall remove all construction debris and leave the project in a broom clean condition.
6.6 Contractor shall furnish lien waivers or release forms for all work performed and materials
purchased.
ARTICLE 7. OWNER
7.1 The Owner shall communicate with subcontractors only through the Contractor.
7.2 The Owner will not assume any liability or responsibility, nor has control over or charge of
construction means, methods, techniques, sequences, procedures, or for safety precautions and programs
in connection with the project, since these are solely the Contractor's responsibility.
ARTICLE 8. CHANGE ORDERS AND FINISH SCHEDULES
8.1 A Change Order is any change to the original plans and/or specifications. All change orders
need to be agreed upon in writing, including cost, additional time considerations and signed by both
parties. 50% of the cost of each change order will be paid prior to the change, with the final 50% paid
Initialed by: Owner Contractor
Maclnnis
North Andover Mass.
Page 3 of 4
upon completion of the change order. A 12% fee shall be added to all change orders and overages in
excess of initial allowances. Additional time needed to complete change orders shall be taken into
consideration in the project completion date.
8.2 Completed Finish Selection Schedules shall be submitted to the Contractor as follows:
8.2.1 Schedule #1 within four weeks after site clearing begins.
8.2.2 Schedule #2 within eight weeks after site clearing begins.
8.3 Any delays or changes in finish selection schedules will delay the projected completion date.
ARTICLE 9. INSURANCE
9.1 The Owner will keep in force a Builder's Risk Insurance Policy on the said property to protect
both owner's and contractor's interest until construction is completed.
9.2 The Owner will purchase and maintain property insurance to the full and insurable value of the
project, in case of a fire, vandalism, malicious mischief or other instances that may occur.
9.3 The Contractor shall purchase and maintain needed Workman's Compensation and Liability
insurance coverage as required by law and deemed necessary for his own protection.
ARTICLE 10. GENERAL PROVISIONS
10.1 If conditions are encountered at the construction site which are subsurface or otherwise
concealed physical conditions or unknown physical conditions of an unusual nature, which differ
naturally from those ordinarily found to exist and generally recognized as inherent in construction
activities, the Owner will promptly investigate such conditions and, if they differ materially and cause an
increase or decrease in the Contractor's cost of, and/or time required for, performance of any part of the
work, will negotiate with the Contractor an equitable adjustment in the contract sum, contract time or
both.
ARTICLE 11. ARBITRATION
11.1 Any dispute that arises which cannot be settled otherwise between the parties will be resolved
with binding arbitration. Notice shall be served in writing to the other party stating the grievance and
naming a person to act as an arbitrator. The other party shall then name an arbitrator, and these two
arbitrators shall select a third. The decisions of any two of said arbitrators shall be binding and
conclusive to all parties.
ARTICLE 12. WARRANTY
12.1 At the completion of this project, Contractor shall execute an instrument to Owner warranting the
project for (one years) against defects in workmanship or materials utilized. The manufacturer's
warranty will prevail.
Initialed by: Owner Contracto
Maclmus
North Andover Mass.
Page 4 of 4
ARTICLE 13. TERMINATION OF THE CONTRACT
13.1 Should the Owner or Contractor fail to carry out this contract, with all of its provisions, the
following options and stipulations shall apply:
13.1.1 If the Owner or the Contractor shall default on the contract, the non -defaulting party may
declare the contract is in default and proceed against the defaulting party for the recovery of all
damages incurred as a result of said breach of contract, including a reasonable attorney's fee. In
the case of a defaulting Owner, the Earnest money herein mentioned shall be applied to the
legally ascertained damages.
13.1.2 In the event of a default by the Owner or Contractor, the non -defaulting party may state
his intention to comply with the contract and proceed for specific performance.
13.1.3 In the case of a defaulting Owner, the Contractor may accept, at his option the earnest
money as shown herein as liquidated damages, should earnest money not cover the expenses to
date, the Contractor may make claim to the Owner for all work executed and for proven loss with
respect to equipment, materials, tools, construction equipment and machinery, including
reasonable overhead, profit and damages applicable to the property less the earnest money.
ARTICLE 14. ACCEPTANCE AND OCCUPANCY
14.1 Upon completion, the project shall be inspected by the Owner and the Contractor, and any
repairs necessary to comply with the contract documents shall be made by the Contractor.
14.2 The Owner shall not occupy the property until final payment has been received by the Contractor
and a Certificate of Occupancy has been obtained.
14.3 Occupancy of the project by the Owner in violation of Article 14.2 shall constitute unconditional
acceptance of the project and a waiver of any defects or uncompleted work.
WITNESS our hand and seal on this 10th._ day of March, 2015.
Signed in the presence of:
Initialed by: Owner Contracto
4 -
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street, Suite 100
< Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Business/Organization/Individual):
Address: /D Lf%i.Vs���7G2
P�
City/State/Zip: L a,4 e jJI Phone #: 8OO '/33 y /p
Are you an employer? Check the appropriate box:
1.01 am a employer with _employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.t
6. Q We are a corporation and its officers have exercised their right of exemption per MGL c.
152,,§1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7. ❑ New construction
8. Remodeling
9. ❑ Demolition
10 0 Building addition
11.❑ Electrical repairs or additions
12.0 Plumbing repairs or additions
13. [] Roof repairs
14. Fj;;KOther �iif2)1r,4 / P;1 /PgA
*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.
#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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: _/&& e��R ! NS' .
Policy # or Self -ins. Lie. #: G' h y rJ � �/V ��"' �"' �.3 Expiration Date: 3 — 2,7-�'C
Job Site Address: h�/y /j//,ao� Reel✓ /Y - �/�CrO' ✓dam City/State/Zip: o
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 certify r to pa' s and penalties of perjufy that the information provided above is tru and correct.
Si nature• Date:
Phone #: ke e) 3 IV 4/D A1JJ_ 10 7 /e a d' 'ea4
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 #:
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 of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint 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' ofanother 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 produced acceptable 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 of public 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-contractor(s) 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 may be 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 Inv8tigatioiis 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 yeax, 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. A new 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 Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
MAR -17-2015 TUE 10;10 AM TSB INSURANCE SERVICES I FAX N0, 7812243938 P. 01
AC 0'OP ID: C
CERTIFICATE OF LIABILITY INSURANCE t]AT:(MMIDDIYYYY,
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. It SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies: may require an endorsement. A statement an this certificate does not confer rights to the
certificate holder In lieu of such endomemen s .
PltOaucERcoNT
CHARLES MARTIN
Insurance Services, Inc NAREfT
161 Main StreetArc L781-240-3040
IVakefieid, MA 01880 11.
SSB Insurance Service Inc 83:
PPDDUCK
CUBTA"r!,o „. NEWEN-1
INs LIMO New England Design & Building INSURERA.Travelers Ins.
10 Winship Drive INSURER s:
Wakefield, MA 01880
INSURER C :
INSURER D:
INSURER E
INIUMm
COVERAGES CERTIFICATF NI IURFR, s1=1Ln0,^u u„llnr-n_
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 MOUIREMENT, 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,
SR
TYPE OF INSURANCE
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
TOWN OF NORTH ANDOVER
PODGY
NORTH ANDOVER, MA
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VWGKMPA COMPENSATION
AND EMPLOYERS' LIABILITYYIN
ANY PROPRIETOEXCLUDED? NEER/EECUTIVE ❑
(Mandatary In NH)
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DESCRIPTIO OF O S below
N / A
6 -KUB -0227N8"-19
03/28/2015
03/28/2018
x WC STATU- OTW-
D
EL, EACH ACCIDENT S 100,00
E.L Dt8EASE - EA EMPLOYEE 111 500,00
E.L. DI$EA8E - POLICY LIMIT & 100,00
DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Addlllonal RwnsrM SahWul% M RISTs $114" is,squired)
CFDTICICATF 41f%l 111:12 I%AUJ%I=l 1 AVIAa1
TOWNOFN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
TOWN OF NORTH ANDOVER
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORPANCE WITH THE POLICY PROVISIONS.
NORTH ANDOVER, MA
AU 0MM REf"NENTATIVII
-TS 6 Ic
c-"88-2008 ACORUCORPORATION. All rights reserved.
ACORD 25 (2008109) The ACORD name and logo are registered marks of ACORD
03/17/2015 TUE 10:15 [TX/RX NO 53381
Massachusetts - Department of Public Safety
Board of Building Regulations and'Standards
Construction Supervisor
License: CS -003501
-CHARUS J MARLIN
10 WINS1W DR
Wakefield MA 01990
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Expiration
Commissioner 04/12/2016
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9Office of Consumer Affairs & Business Regul4on
ME IMPROVEMENT CONTRACTOR
'egistration:�`0a16 Type:
iration c HW016_; Individual
CHARLES J. MARTIN''PE F ,
bHARLES MARTIN fix{ y
xnY
p0 WINSHIP DR.
WAKEFIELD, MA 01880 U d
License or registration valid for individul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulatiow,
10 Park Plaza - Suite 5170
Boston, MA 02116
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n ersecretary of va ' th signature
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