Loading...
HomeMy WebLinkAboutBuilding Permit #719-15 - 419 ANDOVER STREET 3/17/2015Permit No#: Date Issued: -i-t Li BUILDING PERMIT`., TOWN OF NORTH ANDOVER`.'.- APPLICATION FOR PLAN,EXAMINATION''", 19 — TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑. Industrial ❑ Alteration No. of units: 9'Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ,,❑ S`e"pt�cWell �IFloodplain 1Netlavnds YgWates�,ecf€®istrct 1}5 xWate`r;L%e&we- -- �; DESCRIPTION OF WORK TO BE PERFORMED:°" OWNER: Name:CST{ Address: 414 4-mq O;oni tract®ra NN°amen=-� Address 50 Supenri�,,®r&s "C®nst�u - Please Type or Print.. Clearly. ti ®n License, -� " IExp` fat ne 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: $ Check No.:1 �© Receipt::No �® NOTE: Persons contracting with unregistered contractors: do, riot.have ecess tq the guaranty fund Location 4A 1 44we.,s No. 1tG1 I—t5 Date 3 1 TOWN OF NORTH ANDOVER Certificate of Occupancy $-- Building/Frame .Building/Frame Permit Fee $��'-' Foundation Permit Fee $ j" Other Permit Fee $ TOTAL $ , Check # l l o { C) 2 fBuilding Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ .TYPF*"F 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 CONSERVATION COMMENTS HEALTH COMMENTS Signature_ Reviewed on Signature Reviewed on Siqnature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: t Comm d Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: .sterron situf�yesya� � Located 3no�T�sg^oWo� Street FREDERMETTen®uAtT�mp iLocated4at 124IMa �FrelDepar��`menu€signatur�eldafe;._._ �_____ _ 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 i; f 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 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 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 70,929.00 m $ - $ 851.15 Plumbing Fee $ 106.39 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 106.39 Total fees collected $ 1,163.94 419 Andover Street - Ethan Allen 719-15 on 3/17/15 Water Damage Repair E ''wwn Vl I 'a O �C WV o i•r 4 ice o 4 p. fr N V CL c y w .2+p+ y � CIO) • ly O : *# "' 3 cc �J L T O � U) L O C d > $ O CD O { D Q: Eo a� O z lax. O- c .0 p O 3 � o� L cc •� C � ` v O = �_ N O b1 Q CCD m W_ C -01- O O lL Q ;� (n LU O � � LU .pE0 CD.E aoi�°'N ti = cc= O Z O- 0 V O a H J W !i 0Q O m O L Y Y a'�U-, O O LL U n In fl_ N N 0 LLI d Z Z D m C O y m C 7 O LL W O O d' °1 O t U O LL p W a of Z z J a tw : O d' O LL O W d H Z Uco u W W GA O O C v U O1 N C LL O U LLI CL Z a C7 bm O 0.' C LL Z W Q W 0 LLI 25 U. i 7 CO O N a+ N }' OJ v Y O E N ''wwn Vl I 'a O �C WV o i•r 4 ice o 4 p. fr N V CL c y w .2+p+ y � CIO) • ly O : *# "' 3 cc �J L T O � U) L O C d > $ O CD O { D Q: Eo a� O z lax. O- c .0 p O 3 � o� L cc •� C � ` v O = �_ N O b1 Q CCD m W_ C -01- O O lL Q ;� (n LU O � � LU .pE0 CD.E aoi�°'N ti = cc= O Z O- 0 V N O a �z z m O Cl) O Cfl Z V W CL Z O LL, U H U c JCL W z N Insurcomm Construction 3510 Lafayette Rd Portsmouth, NH 03801 603-430-7701 603 -373 -6214 -Fax ici5@comcast.net Insured: Ethan Allen Property: 419 Andover St North Andover, MA 01845 Estimator: Neil Robbins Business: 3510 Lafayette Rd Portsmouth, NH 03801 Contractor: Company: Business: Claim Number: Date of Loss: Date Inspected: Insurcomm Construction Inc. 3510 Lafayette Rd Portsmouth, NH 03801 Policy Number: Price List: MAEM8X MAR15 Restoration/Service/Remodel Estimate: ETHANALLEN Business: (603) 430-7701 Business: (603) 430-7701 E-mail: ici4@comcast.net Type of Loss: Date Received: Date Entered: 3/16/2015 3:23 PM Insurcomm Construction 3510 Lafayette Rd Portsmouth, NH 03801 603-430-7701 603 -373 -6214 -Fax ici5@comcast.net ETHANALLEN Display Room 1 DESCRIPTION LxWxH 22' 10" x 15' 3" x 8' QTY 1. 5/8" drywall - hung, taped, with smooth wall finish 332.00 SF 3. Drywall Installer / Finisher - per hour 10.00 HR Labor to feather and blend old drywall to new on walls and ceiling. 5 hours each surface 4. Batt insulation - 6" - R19 - unfaced batt 184.00 SF 6. Polyethylene vapor barrier 184.00 SF 7. Detach & Reset Light fixture 9.00 EA 9. Remove Crown molding - 2 -piece - hardwood 57.13 LF Servpro removed 25% of the crown molding. The other 75% needs to be removed as the existing cannot be matched because of age and availability. 15. Crown molding - 2 -piece - hardwood 76.17 LF 11. Seal & paint crown molding, oversized - three coats 76.17 LF 16. Painter - per hour 2.00 HR Labor to paint sprinkler pipes 17. Seal the walls and ceiling w/latex based stain blocker - one coat 957.54 SF 18. Paint the walls and ceiling - two coats 957.54 SF 19. Casing - 5" 40.00 LF 20. Seal & paint door/window trim & jamb - (per side) 5.00 EA 21. Remove Baseboard - 3 1/4" 57.13 LF All walls were built after the carpet was installed so all baseboard sits on top of carpet. Base trim needs to be removed so remaining carpet can be removed 22. Baseboard - 3 1/4" 76.17 LF 23. Seal & paint baseboard - three coats 76.17 LF 24. Floor prep- cutting carpet back to edge of wall after base trim removal 348.21 SF 26. Carpet pad 348.21 SF 27. Commercial carpet - heavy traffic 400.44 SF 52. Negative air fan/Air scrubber (24 hr period) - No monit. 6.00 DA Display 2 LxWxH 16'9" x 15'2" x 8' DESCRIPTION QTY 28. 5/8" drywall - hung, taped, with smooth wall finish 29. Drywall Installer / Finisher - per hour Labor to feather and blend old drywall to new on walls 254.00 SF 5.00 HR 30. Batt insulation - 6" - R19 - unfaced batt 134.00 SF 31. Polyethylene vapor barrier 134.00 SF 32. Detach & Reset Light fixture 11.00 EA 33. Remove Crown molding - 5 3/8" to 6" 47.87 LF Servpro removed 25% of the crown molding. The other 75% needs to be removed as the existing cannot be matched because of age and availability. ETHANALLEN 3/17/2015 Page:2 Insurcomm Construction 3510 Lafayette Rd Portsmouth, NH 03801 603-430-7701 603-373-6214- Fax ici5@comeast.net CONTINUED - Display 2 DESCRIPTION QTY 34. Crown molding - 5 3/8" to 6" 63.83 LF 35. Seal & paint crown molding, oversized - three coats 63.83 LF 36. Painter - per hour 3.00 HR Labor to paint sprinkler pipes 37. Seal the walls and ceiling w/latex based stain blocker - one coat 764.71 SF 38. Paint the walls and ceiling - two coats 764.71 SF 40. Seal & paint door/window trim & jamb - (per side) 2.00 EA 47. Trim board - 1" x 2" - installed (pine)- ceiling batten trim 64.00 LF 48. Seal & paint trim - two coats- ceiling batten trim 112.00 LF 41. Remove Baseboard - 3 1/4" 47.87 LF All walls were built after the carpet was installed so all baseboard sits on top of carpet. Base trim needs to be removed so remaining carpet can be removed 53.33 LF 42. Baseboard - 3 1/4" 63.83 LF 43. Seal & paint baseboard - three coats 63.83 LF 44. Floor prep- cutting carpet back to edge of wall after base trim removal 254.04 SF 45. Carpet pad 254.04 SF 46. Commercial carpet - heavy traffic 292.15 SF 49. Remove Chair rail - oversized - 5" 63.83 LF 50. Chair rail - oversized - 5" 63.83 LF 51. Seal & paint chair rail - three coats 63.83 LF 53. Negative air fan/Air scrubber (24 hr period) - No monit. 3.00 DA Display 3 DESCRIPTION LxWxH 15'3" x 11'5" x 8' QTY 54. 5/8" drywall - hung, taped, with smooth wall finish 140.00 SF 55. Drywall Installer / Finisher - per hour 5.00 HR Labor to feather and blend old drywall to new on walls 56. Batt insulation - 6" - R19 - unfaced batt 92.00 SF 57. Polyethylene vapor barrier 92.00 SF 58. Detach & Reset Light fixture 8.00 EA 59. Remove Crown molding - 5 3/8" to 6" 40.00 LF Servpro removed 25% of the crown molding. The other 75% needs to be removed as the existing cannot be matched because of age and availability. 60. Crown molding - 5 3/8" to 6" 53.33 LF 61. Seal & paint crown molding, oversized - three coats 53.33 LF 62. Painter -per hour 3.00 HR Labor to paint sprinkler pipes 63. Seal the walls and ceiling w/latex based stain blocker - one coat 600.77 SF 64. Paint the walls and ceiling - two coats 600.77 SF ETHANALLEN 3/17/2015 Page:3 Insurcomm Construction 3510 Lafayette Rd Portsmouth, NH 03801 603-430-7701 603 -373 -6214 -Fax ici5@comcast.net CONTINUED - Display 3 DESCRIPTION QTY 65. Seal & paint door/window trim & jamb - (per side) 2.00 EA 66. Trim board - 1" x 2" - installed (pine)- ceiling batten trim 20.00 LF 67. Sea] & paint trim - two coats- ceiling batten trim 66.00 LF 68. Remove Baseboard - 3 1/4" 28.00 LF All walls were built after the carpet was installed so all baseboard sits on top of carpet. Base trim needs to be removed so remaining carpet can be removed 82. Detach & Reset Light fixture 69. Baseboard - 3 1/4" 53.33 LF 70. Seal & paint baseboard - three coats 53.33 LF 71. Floor prep- cutting carpet back to edge of wall after base trim removal 174.10 SF 72. Carpet pad 174.10 SF 73. Commercial carpet - heavy traffic 200.22 SF 76. Seal & paint chair rail - three coats 53.33 LF 77. Negative air fan/Air scrubber (24 hr period) - No monit. 3.00 DA Display 4 LxWxH 15'3" x 12'2" x 8' DESCRIPTION QTY 78. 5/8" drywall - hung, taped, with smooth wall finish 281.54 SF 79. Drywall Installer / Finisher - per hour 4.00 HR Labor to feather and blend old drywall to new on walls 80. Batt insulation - 6" - R19 - unfaced batt 96.00 SF 81. Polyethylene vapor barrier 96.00 SF 82. Detach & Reset Light fixture 7.00 EA 83. Remove Crown molding - 5 3/8" to 6" 41.12 LF Servpro removed 25% of the crown molding. The other 75% needs to be removed as the existing cannot be matched because of age and availability. 84. Crown molding - 5 3/8" to 6" 54.83 LF 85. Seal & paint crown molding, oversized - three coats 54.83 LF 86. Painter -per hour 3.00 HR Labor to paint sprinkler pipes 87. Seal the walls and ceiling w/latex based stain blocker - one coat 624.21 SF 88. Paint the walls and ceiling - two coats 624.21 SF 89. Seal & paint door/window trim & jamb - (per side) 3.00 EA 92. Remove Baseboard - 3 1/4" 24.00 LF All walls were built after the carpet was installed so all baseboard sits on top of carpet. Base trim needs to be removed so remaining carpet can be removed 93. Baseboard - 3 1/4" 54.83 LF 94. Seal & paint baseboard - three coats 54.83 LF 95. Floor prep- cutting carpet back to edge of wall after base trim removal 185.54 SF 96. Carpet pad 185.54 SF 97. Commercial carpet - heavy traffic 213.37 SF ETHANALLEN 3/17/2015 Page:4 Insurcomm Construction 3510 Lafayette Rd Portsmouth, NH 03801 603-430-7701 603-373-6214- Fax ici5@comcast.net CONTINUED - Display 4 DESCRIPTION QTY 98. Remove Chair rail - oversized - 4" 54.83 LF Orig. Desc. - Chair rail - oversized - 5" 99. Chair rail - oversized - 4" 54.83 LF Orig. Desc. - Chair rail - oversized - 5" 100. Seal & paint chair rail - three coats 54.83 LF 101. Negative air fan/Air scrubber (24 hr period) - No monit. 3.00 DA Display 5 LxWxH 24'5" x 15'4" x 8' DESCRIPTION QTY 102. 5/8" drywall - hung, taped, with smooth wall finish 288.00 SF 103. Drywall Installer / Finisher - per hour 4.00 HR Labor to feather and blend old drywall to new on walls 104. Batt insulation - 6" - R19 - unfaced batt 192.00 SF 105. Polyethylene vapor barrier 192.00 SF 106. Detach & Reset Light fixture 11.00 EA 107. Remove Crown molding - 5 3/8" to 6" 59.63 LF Servpro removed 25% of the crown molding. The other 75% needs to be removed as the existing cannot be matched because of age and availability. 108. Crown molding - 5 3/8" to 6" 79.50 LF 109. Seal & paint crown molding, oversized - three coats 79.50 LF 110. Painter -per hour 3.00 HR Labor to paint sprinkler pipes 111. Seal the walls and ceiling w/latex based stain blocker - one coat 1,010.39 SF 112. Paint the walls and ceiling - two coats 1,010.39 SF 113. Seal & paint door/window trim & jamb - (per side) 4.00 EA 114. Trim board - 1" x 2" - installed (pine)- ceiling batten trim 48.00 LF 115. Seal & paint trim - two coats- ceiling batten trim 156.00 LF Ceiling has beams running across, Crown molding is on the perimeter of the ceiling as well as both sides of each beam 126. Trim board - 1 " x 4" - installed (pine) 40.00 LF 116. Remove Baseboard - 3 1/4" 36.00 LF All walls were built after the carpet was installed so all baseboard sits on top of carpet. Base trim needs to be removed so remaining carpet can be removed 117. Baseboard - 3 1/4" 79.50 LF 118. Seal & paint baseboard - three coats 79.50 LF 119. Floor prep- cutting carpet back to edge of wall after base trim removal 374.39 SF 120. Carpet pad 374.39 SF 121. Commercial carpet - heavy traffic 430.55 SF 125. Negative air fan/Air scrubber (24 hr period) - No monit. 4.00 DA ETHANALLEN 3/17/2015 Page:5 Insurcomm Construction 3510 Lafayette Rd Portsmouth, NH 03801 603-430-7701 603-373-6214- Fax ici5 @comcast.net Display 6 LxWxH 15'4" x 14'10" x 8' DESCRIPTION QTY 127. 5/8" drywall - hung, taped, with smooth wall finish 181.33 SF 128. Drywall Installer / Finisher - per hour 4.00 HR Labor to feather and blend old drywall to new on walls 349.56 SF 129. Batt insulation - 6" - R19 - unfaced batt 120.00 SF 130. Polyethylene vapor barrier 120.00 SF 131. Detach & Reset Light fixture 9.00 EA 132. Remove Crown molding - 5 3/8" to 6" 45.25 LF Servpro removed 25% of the crown molding. The other 75% needs to be removed as the existing cannot be matched because of age and availability. 60.00 SF 133. Crown molding - 5 3/8" to 6" 60.33 LF 134. Seal & paint crown molding, oversized - three coats 60.33 LF 135. Painter - per hour 4.00 HR Labor to paint sprinkler pipes 136. Seal the walls and ceiling w/latex based stain blocker - one coat 710.11 SF 137. Paint the walls and ceiling - two coats 710.11 SF 138. Seal & paint door/window trim & jamb - (per side) 4.00 EA 139. Trim board - 1" x 2" - installed (pine)- ceiling batten trim 27.00 LF 140. Seal & paint trim - two coats- ceiling batten trim 81.00 LF Ceiling has beams running across, Crown molding is on the perimeter of the ceiling as well as both sides of each beam 141. Casing - 4" -hardwood 20.00 LF 142. Remove Baseboard - 3 1/4" 45.25 LF All walls were built after the carpet was installed so all baseboard sits on top of carpet. Base trim needs to be removed so remaining carpet can be removed 143. Baseboard - 3 1/4" 60.33 LF 144. Seal & paint baseboard - three coats 60.33 LF 145. Floor prep- cutting carpet back to edge of wall after base trim removal 227.44 SF 152. Underlayment - 1/2" BC plywood 227.44 SF Plywood laid over tile so carpet and pad can be installed 146. Carpet pad 227.44 SF 147. Commercial carpet - heavy traffic 261.56 SF 151. Negative air fan/Air scrubber (24 hr period) - No monit. 4.00 DA Display 7 LxWxH 29'9" x 15'8" x 8' DESCRIPTION QTY 155. Remove Acoustic ceiling tile 349.56 SF removal of existing as it cannot be matched due to age and new depth for installation 157. Acoustic ceiling tile 466.08 SF 158. 5/8" drywall - hung, taped, with smooth wall finish 135.00 SF 168. Drywall Installer / Finisher - per hour 5.00 HR Labor to feather and blend old drywall to new on walls 159. Batt insulation - 6" - R19 - unfaced batt 60.00 SF 160. Polyethylene vapor barrier 60.00 SF ETHANALLEN 3/17/2015 Page:6 Insurcomm Construction 3510 Lafayette Rd Portsmouth, NH 03801 603-430-7701 603-373-6214- Fax ici5@comcast.net CONTINUED - Display 7 DESCRIPTION QTY 161. Seal the walls and ceiling w/latex based stain blocker - one coat 1,192.75 SF 162. Paint the walls and ceiling - two coats 1,192.75 SF 163. Remove Crown molding - 4 1/4" 189.75 LF 164. Crown molding - 4 1/4" 198.83 LF The ceiling has beams running across it so the crown encased the perimeter of the ceiling as well as both sides of each beam 165. Seal & paint crown molding, oversized - three coats 198.83 LF 166. Detach & Reset Light fixture 23.00 EA 167. Detach & Reset Chandelier 1.00 EA 169. Casing - 5" 68.00 LF 170. Seal & paint door/window trim & jamb - (per side) 7.00 EA 171. Remove Baseboard - 3 1/4" 16.00 LF 173. Baseboard - 3 1/4" 90.83 LF 172. Seal & paint baseboard - three coats 90.83 LF 174. Negative air fan/Air scrubber (24 hr period) - No monit. 4.00 DA 179. Floor protection - self-adhesive plastic film 466.08 SF Attic DESCRIPTION LxWxH118'x15'S"x4' QTY 180. Batt insulation - 8" - R25 - unfaced batt 944.00 SF 181. Insulation Installer - per hour 6.00 HR Additional labor to work in crawlspace 182. Underlayment - 1/4" BC plywood 944.00 SF 184. Seal the ceiling w/latex based stain blocker - one coat 1,819.17 SF 185. Paint the ceiling - two coats 1,819.17 SF Exterior Formula Elevation 96' x 8' x 0" DESCRIPTION QTY Vinyl siding needs to be replaced due to damage from ice dam 186. Remove & Replace Siding - vinyl 768.00 SF 188. Two ladders with jacks and plank (per week) 4.00 WK 4 sets for 1 week 189. General Laborer - per hour 10.00 HR Labor to protect shrubs ETHANALLEN 3/17/2015 Page:7 Insurcomm Construction 3510 Lafayette Rd Portsmouth, NH 03801 603-430-7701 603 -373 -6214 -Fax ici5@comcast.net General conditions DESCRIPTION QTY 190. Dumpster load - Approx. 30 yards, 5-7 tons of debris 1.00 EA 191. Cleaning Technician - incl. cleaning agent - per hour 32.00 HR Labor for daily cleanup 193. Commercial Supervision / Project Management - per hour 40.00 HR 194. Electrician - per hour 8.00 HR Labor to re -fasten all floating outlets and switches and perform electrical check Grand Total Grand Total Areas: 5,666.00 SF Walls 3,848.98 SF Floor 2,356.67 SF Long Wall 0.00 Floor Area 0.00 Exterior Wall Area 0.00 Surface Area 0.00 Total Ridge Length Neil Robbins 3,848.98 SF Ceiling 427.66 SY Flooring 1,628.33 SF Short Wall 0.00 Total Area 0.00 Exterior Perimeter of Walls 0.00 Number of Squares 0.00 Total Hip Length 70,928.87 9,514.98 SF Walls and Ceiling 841.67 LF Floor Perimeter 841.67 LF Ceil. Perimeter 0.00 Interior Wall Area 0.00 Total Perimeter Length ETHANALLEN 3/17/2015 Page:8 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5 170 Boston, Massachusetts 02116 Home Improvement C. * '-.,tor Registration SCA 1 0 20M-OSM I Ofriet of Consumer Affairs & BusinesS Regulation ME IMPROVEMENT CONTRACTOR istration: 145192 Type. xpiration- 12122f2016 Private Corporation INSURCOMM CONSTRUCTION 44C; NEIL ROBBINS 3510 LAFAYETTE RD, SUI I i=-4 PORTSMOUTH, NH 03801 Understcretary License or registration valid for individul use only before the expiration date. If found return to: office of Consumer Affairs and Business Regulation 10 Park Plan - Suite 5170 Boston, IMA 02116 riot valid without signature Massachusetts - Deparbysent of Public Safety Board of Building Reguiations and Standards Construction Supervisor License: N®RIELL S RONSM 3510 ILIAAFAYR pbrumma m Expiration Convnisskww MUMS t 6�?e Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 B stop Massaclx setts 02116 0 .s Home Improvement Co�ctor Registration Registration: 145192 : Type: private Corporation Expiration: 122212016 Tr# 260463 INSURCOMM CONSTRUCTION INC — NEIL ROBBINS----- 3510 LAFAYETTE RD. SUITE 4 PORTSMOUTH, NH 03801 Update Address and return card. dark reason for change. C] Address E] Renews Employment; Lost Card SCA1 0 20M -W11 �/e� `�t'asw+nenu+euz/lei o�ia.�tre+4us�s Office of Cossaxaer Affairs & Basiaess Regaiation ME IMPROVEMENT CONTRACTOR h&Sdon: 145192 Type: piration: 127231016 Private Corporation INSURCOMM CONSTRUCTION ice• NEIL ROBBINS 3sto LAFAYEiTE RD. SUrM 4 PORTSMOUTH, NH 03601 Uaderseereary License or registration valid for individut use only before the expiration date. if found return to: office of Consumer Affairs and Business Regulation 10 Park Plaza . Suite 5170 Boston, MA 02116 �7 Not valid without signature ,a The Commonwealth of Massachusetts Department of IndustrialAccidents - I Congress Street, Suite 100 t Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 10S(JIi'(pl04 A 00116 EtLTI!/✓L l�►`l C Address: ZiM _R-�) �,)rr6 4 City/State/Zip: k(*( (0 4 0 � a�i s Phone #: (003-4- 30- 17170 Are you an employer? Check the appropriate box: 1.�am a employer with 410.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. 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. E] Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. ❑ Electrical repairs or additions 12.0 Plumbing repairs or additions 13.0 Roof repairs 14. a0ther UJKMIz ,tw ,E - .lirzyw�t cc�ER) *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 Policy # or Self -ins. Lic. #:�( q Qq� / 7 & Expiration Date: l 1171 t e— Job Site Address: 1LUi S`[-• City/State/Zip:_ i�f /lx4<C(2.t' 64 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. Ido hereby cert' under the ains andpenalties ofpeijury that the information provided a`ybove,i true and correct. ��� 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 #• ACORO® CERTIFICATE /OF LIABILITY INSURANCE DATE(MM/DD/YYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 03/15/2015 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 CHAD HANCOCK NAME: PHCN o EM. 603-433-5600 FAX No 603-433-0007 KANE INSURANCE 242 STATE STREET E-MAIL ADDRESS: CHAD//��@KANEINS.COM INSURERS AFFORDING COVERAGE NAIC # PORTSMOUTH, NH 03801 INSURER A: LIBERTY MUTUAL EACH OCCURRENCE $ 1,000,000 INSURED INSURER B: ROCK HILL INSURANCE CO INSURER C: INSURCOMM INC., FIRST RESPONSE CLEANING INSURER D: AND RESTORATION INSURER E: 3510 LAFAYETTE RD, STE 4 INSURER F: PORTSMOUTH, NH 03801 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY) POLICY EXP (MMIDDIYYYYI LIMITS A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X1 CLAIMS -MADE ®OCCUR BKS56387675 11/7/2014 111712015 _ DAMAGETOEaRENTED 300000 PREMISES occurrence $ s MED EXP (Any one person) $ 15,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ® JECT El LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: A AUTOMOBILE LIABILITY ._ 'CEOMaBINEDSINGLELIMIT $ 1,000,000 BODILY INJURY (Per person) $ ANY AUTO BA8999876 11/7/2014 11/712015 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident X HIRED AUTOS, NON -OWNED AUTOS A X UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 EXCESS LIAB US056387675 11/7/2014 111712015 DED I x I RETENTION $ 10,000 $ A WORKERS COMPENSATIONPER AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N OFFICER/MEMBER EXCLUDED? ® (Mandatory in NH) N / A WC8999776 11/7/2014 111712015 OTH- STATUTE I ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYE $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 B POLLUTION POLICY RPL122014 121201201412/2012015 PER OCCURRENCE: $1,000,000 AGGREGATE: $2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) ** ACTIVITIES USUAL AND CUSTOMARY TO BUILDING CONSTRUCTION, AND FIRE, WATER, AND MOLD REMEDIATION. **WORK TO BE PERFORMED AT ETHAN ALLEN, 419 ANDOVER ST, N ANDOVER, MA 01845. CERTIFICATE HOLDER CANCELLATION CITY OF NORTH ANDOVER MA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 MAIN ST ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE CHAD A HANCOCK u ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01), . The ACORD name and logo are registered marks of ACORD