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Home My WebLink AboutBuilding Permit #27 - 437 SUMMER STREET 7/13/2007 BUILDING PERMIT ott►O oT b�ti TOWN OF NORTH ANDOVER �+t' ''' o A APPLICATION FOR PLAN EXAMINATION h Permit NO: Date Received ( SSACH�ISE Date Issued: ' /3 6 IMPORTANT: Applicant must complete all items on this page LOCATION s en _ PROPERTY OWNER Print MAP NO:1QPARCC: ZONING DISTRICT: Historic District yes �j6e ": ate:. Machine Shop Village yes 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 PREFORMED: -�— o n + 1 ►��U-hs -S' Ident' icatio lease Type or Print Clearly) OWNER: Name: 0; 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:MOO $1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ --6�i ro 01 FEE: $ i Check No.: ( (�— Receipt No.: 0 NOTE: Persons contracting with unregistered contractors do not have acces the guar my nd �ignature;of Agent/Owner ^` Signature of con#ract 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED . DATE APPROVED HEALTH COMMENTS I Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Si nature& Date Driv av Permit Located at 384 Osgood Street FIRE`DEPARTMENT `Temp°Dum ster on site yes ffi no Located at 124 Main Street Fire Department signatureldate 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 f I r i i i I ❑ Notified for pickup - Date i i Doc.Building Permit Revised 2007 i 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/Crossection/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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location No. i Date ? -0 �-- a NORTH TOWN OF NORTH HANDOVER W74 Mr � m _ Certificate of Occupancy $ CHusEt� Building/Frame Permit Fee $ — Foundation Permit Fee $ Other Permit Fee $ c TOTAL $ �� Check # Building Inspector NORTH Town of No. � d dower, Mass., b Q Z_ LAKE COCHICHEWICK V 7�A0ATED P'? R '9S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......... .. .....` ...... doy+-4 .a............................................................................. Foundation has permission to erect........................................ buildings on ...... .3.7.......Sam-nM.�Gn.....eo....i.'-.............. Rough to be occupied as........Slin.4(...t..... -f�-4?.� ...................�9...L w�. .o.w s...... ....,.................................... Chimney provided that the person accepfing this permit shall in every respect conform to the terms of the application on file in Final 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 ' S 3 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR. UNLESS CONSTRUC N S TS Rough ................... ... ............................................................I ................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. .77 , ."}-`�--.G— -� "cx,�l,� a�✓��a�vac�,rcaeCta .,,`1 Board of Building Regulations and Standards 4 HOME IMPROVEMENT CONTRACTOR •<, Registration: 108424 Expiration: 8/18/2007 Type: DBA ; ` ,"• ARCO ROOFING&,CONSTRUCTION „ Joseph Gys - a 10 MEGHANN LANE LOWM, MA 01852 Administ"ator �'�� , .4.-. ffte y�JdI97R120'�7•t!/2lGI[.f1 ef��ftiz;dex�'�€r[defi':�l _ BOARD OF BUILDING REGULATIONS I 9 Lieensey CONSTRUCTION SUPERVISOR y Number: CS 092469 Birthdate: 09/27.11954 '*...,. Expires:09/27/2009 Tr.no:` 92469 Restricted: 00 • ., JOSEPH J GYS s $ 10 MEGHANN LANE L`OVIIFLL, MA:01.852. A * Commissioner. 860-277-0111 5/4/2007 11 :28:52 AM PAGE 003/003 Fax Server ACORD. CERTIFICATE OF INSURANCE DATE(MM0DWY) 05-04-07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE TRANSIT INS AGCY INC HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 217 ALBANY ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE BOSTON,MA 02118 COMPANY 28NWT A TRAVELERS DIRECT ASSIGNMENT INSURED COMPANY B CARTER CORPORATION THE COMPANY 840 SUMMER STREET C SOUTH BOSTON,MA 02127 COMPANY D COVERAGE 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,TERMOR CONDITION OF ANY CONTRACTOR 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. CO POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDIYY) DATE(MMIDDIYY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMPIOP AGG. $ CLAIMS MADE OCCUR. PERSONAL&&ADV.INJURY $ OWNER'S&&CONTRACTOR'S EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ MED.EXPENSE(Anyone $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS BODILY INJURY(Per Person) $ SCHEDULE AUTOS BODILY 114JU RY(Per Accident) $ HIRED AUTOS PROPERTY DAMAGE $ NON-OWNED AUTOS GARAGE LIABILITY ANY AUTOS AUTO ONLY-EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGREGATE $ EXCESS LIABILITY UMBRELLA FORM EACH OCCURRENCE $ OTHER THAN UMBRELLA FORM AGGREGATE $ WORKER'S COMPENSATION AND A EMPOLYER'S LIABILITY UB-5444C981-06 08-09-06 oi-06-07 STATUTORYLIMITS X THE PROPRIETOR/ EACH ACCIDENT $ 100,000 PARTNERSIEXECUTIVE X INCL DISEASE-POLICY LIMIT $ 500,000 OFFICERS ARE: EXCL DISEASE-EACH EMPLOYEE $ 100,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLESIRESTRICTIONSISPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EY,PIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO ~` = MAIL SUCH NOTICE SHALL IMPOSE NO O.'&fGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Charles J Clark ACORD 25-5(3193) 13:21 MAY 04, 2087 ID: FRED C. CHURCH TEL N0: 976-454-1865 #232257 PAGE: 112 DA ACCRCra CERTIFICATE OF LIABILITYINSURANCE05i0Ii7 0 04.26YY' PRODUCER (R0Oi325-IROS ! THIS CERTIFICATE IS ISSUED AS A:-MATTER OF INFORMATION Fred C.Church 11 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 41 Wellman Street ( HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Lowelt.MA 01 RSl ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 800_35_1865 INSURERS AFFORDING COVERAGE A NAIC# INSURED IINSURERA: PeedesslnsnMrIeeCompany Jowpb Gys dba Abco Cbimruclion 10 Meghann Lane It SUR£R3 Lowell,MA 01853 I INSURER C: j INSURER 0: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO 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 AL THE T=RMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD` POLICY NUMBER POLICY EFFECTIVE I POUCY EXPIRATWN I LTR !NSR P PLI OF INSURANCE I DATE(MAVDD/YYI ! DATE MRV1R)A UMRS GENERAL UABnITY I i EACH OCCURRENCE 1$500. 000 D N IS X COMtr1ERCIAI GENERAL LIABILITY ! j j. PREMISES_(Ea ocmmn-e 50-oo j CLAIMS MADEOCCUR I I MED EXP(Any one parsm:) $5.000 /{ CCPR3?1803 /?n;'_i�D- j =."?!)tli)1j I PERSONALBADVINJURY 5500.000 i GENERAL AGGREGATE S 1.000;000 1 I GENt AGGREGATE LIMIT APPi.IES PER:! }PR ODU�CTS.COMPJOP A GG 1-000.000 FR.^^•- j POLICY £CT i LO I j I AUTORIOBILELIABILITY j 1 I -0 BINED SINGLE LIMIT ANY AUTO - !.Ea ac:Jde raj i S i ALL OWNED AUTOS' i I��H""HHH' BODY INJURY 1S-^REDUCED AUTOS ! (Ferpersonj I S 11 LHIRED A UTOS + ; I ROD'LY INJURY � NON-0,.^VNED AUTOS (Per acddera) f 5 � i1 t PROPERTY DAMAGE 1(Per=r:kenl) GARAGE UABILIfY AUTO ONLY•EA ACCIDENT 15 I ANY AUTO II ! EA ACC 5 I( rOT ) i AUTO ONLY: AGG IS I � I I -- I---]OCCUR MBRELLA UA80. EACH OCCURRENCE S fTY i OCCUR CLAIMS MADE ( :AGGREGATE IS I i 1 :::i• i$ r(- DEDUCTIBLE 5 RETENTION 5 I$ WORKERS COMPENSATION AND + ThC STi'TU- 'OTH- f EMPLOYERS'UABILRY ANY PROPRIETOFUPARTNER/EXECUTNE- j. E.L EACH ACCIDENT 5 OFFICEWMEMBEREXCLUDED7 I If yes.describe antler E.L.DISEASE-£A EMPLOY _ 5 i SPECIAL PROVISIONS below I I E.L.DISEASE-POLICY LIMIT S OTHER 1 I I I i I DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS VA'O1lcers'Compensation Ceriificite.will be ismed by Liberry\-Tuinal Tnsuranee Company-. CERTIFICATE HOLDER CANCELLATION - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 1 I DATE THEREOF,THE ISSUING INSURER MLL ENDEAVOR TO MAIL 10 DAYS WRITTEN KCTICE TO TPE CERTEIC4TE HOLDER NAMED TO THE LEFT;BUT FAILURE TO DO SO SHALL IMPOSE NO ORUG:.TION OR LIABILITY 6F ANY KIND UPON THE INSURER.ITS AGEkTS OR I 1 . REPRESEYiA71l.S. � . I I ALRHORIZEO REPR=_EENT.TIVE ACORD 25(2001!^; Clicw, 4"E 11 6 Cc,ACORT CORPOKATION 1988 } pis,; 13.21 MAY 04, 2087 ID: FRED C. CHURCH TEL NO: 976-454-1865 #232257 PAGE: 1/2 ACOR� CERTIFICATE CE LIABILITYINSURANCE DATE 01/200 09:2YYY1 �+ OSi01/2007 04:26 PRODUCER _ (800)225-1865 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Fred C.Church ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 41 Wellman Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Lowell,MA 01851 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 800-225-1865 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: Peerless Insurance Company - Joseph Gys dba Abco Construction 10 Meghann Lane INSURER B: Lowell,MA 01852 INSURER C: INSURER D: INSURER E: , COVERAGES 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 THETERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICY NUMDER POLICY EFFECTNE I POLICY EXPIRATION LTR SR P OF INSU A C DATE MIDDlYY DATE MM/DDIYY I LIMITS GENERAL LIABILITY I EACH OCCURRENCE $500.000 X COMMERCIAL GENERAL LIABILITY. I PREMISES(Ea occurence) S 50.000 CLAIMS MADE OCCUR .. E MED EXP(Any one Parson) $5,000 A CCP825180_ 41' 6/1j)()7 4..'26,2008 PERSONAL&ADV INJURY $500,000 IIII GENERAL AGGREGATE S 1,000,000 GENL AGGREGATE LIMIT APPLIES PER. I I PRODUCTS-COMP/OP AGG S 1.000.000 F—PRC- ! - POLICY JECT I i LOC I AUTOMOBILE LIABILITY, i I I COMBINED SINGLE LIMIT S ANY AUTO ! I (Ea accident) - ALL OWNED AUTOS BODILY INJURY ! s 1 SCHEDULED AUTOS I (fPsr person) . I I I HIRED AUTOS I I Not-4-OWNED AUTOS I(Per INJURY BODILYcrad-nt) I S PROPERTY DAMAGE (Per acadenti IGARAGE LIABILITY - I AUTO ONLY-EA ACC IDE NIT S ANY AUTO ! OTHER THAN EA ACC S - ! - AUTO ONLY. - AGG I S ' EXCESS/UMBRELLA LIABILITY I EACH OCCURRENCE I$ OCCUR CLAIMS MADE AGGREGATE $ Is DEDUCTIBLE $ RETENTION S Is WORKERS COMPENSATION AND I VYC STATU• 107H- EMPLOYERS'LIABILITY - I TORY IMtT 1 ANY PROPRIETOR/PARTNER/ECECUT'VE' E.L.EACH ACCIDENT $ OFFICERIMEMSEREXCLUDED? - E.L.DISEASE-EAEMPLOYEE S If yes,dsscdbe under SPECIAL PROVISIONS below E.LDISEASE-POLICYLIMIT S OTHER ! I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS - hzb Wooers C Ginpensarmn Ceriificare wit be issued by Liberty Mutual Insurance Company. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE.ISSUING INSURER MLL ENDEAVOR TO MAIL 10 DAYS WRITTEN - 13 NCTICE TO'IHE CERTI ICATE HOLDER NAMED TO THE LEFT,BLIT FAILURE IO DO SO SHALT ± IILiPOSE NO OBLIGATION OR LIAMUTY OF ANY KIND UPON THE INSURER,,ITS AGENTS OR II REPRESENT nTIVES. AUTHORIZED REPRESENTF:TIVE r ACORL,25(2005/0.8,) �.(ielltr =116: 1v.cst C-h ACORD CORPORATION 1989 860-277-0111 5/4/2007 11 :28:52 AM PAGE 003/003 Fax Server ACORD. CERTIFICATE OF INSURANCE DATE(MMLDOWY) 05-04-07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE TRANSIT INS AGCY INC HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 217 ALBANY ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, COMPANIES AFFORDING COVERAGE BOSTON,MA 02115 COMPANY 28NWT A TRAVELERS DIRECT ASSIGNMENT INSURED COMPANY B CARTER CORPORATION THE COMPANY 840 SUMMER STREET C SOUTH BOSTON,MA 02127 COMPANY D COVERAGE 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 REOUIREMENT,TERMOR CONDITION OF ANY CONTRACTOR 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. CO POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER DATE(MMLDDLYY) DATE(MMIDDLYY) LIMITS GENERAL UABILITY GENERAL AGGREGATE S COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ CLAIMS MADE OCCUR. PERSONAL&&ADV.INJURY S OWNER'S&&CONTRACTOR'S EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ MED.EXPENSE(Anyone S AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS BODILY INJURY(Per Person) $ SCHEDULE AUTOS BODILY INJURY(PerAccident) $ HIRED AUTOS PROPERTY DAMAGE $ NON-OWNED AUTOS GARAGE LIABILITY ANY AUTOS AUTO ONLY-EA ACCIDENT S OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGREGATE S EXCESS LIABILITY UMBRELLA FORM EACH OCCURRENCE S OTHER THAN UMBRELLA FORM AGGREGATE S WORKER'S COMPENSATION AND A EMPOLYER'S LIABILITY UB-54440981-06 08-09-06 ,_ 08=09-07 STATUTORYLIMITS X THE PROPRIETOR/ EACHACCIDENT S 100,000 PARTNERS/EXECUTIVE X INCL DISEASE-POLICY LIMIT S 500,000 OFFICERS ARE: EXCL DISEASE-EACH EMPLOYEE $ 100,000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSA/EHICLESIRES TRICTIONSRSPECIAL IT , EMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION SHOOLD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE • ePIRARON DATE I ERi EOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRIT-=N NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO -' MAIL SUCH NOTICE SHALL IMPOSE NO 03LIGATION OR LIABILITY OF ANY KIND UPON THE CC*APANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIzED REPRESENTATIVE Charles J Clark ACORD 255(3193) APN The Commonwealth of Massachusetts Department of Industrial Accidents I� Office of Investigations 600 Washington Street Boston, MA 02111 "~ www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address:- City/State/Zip- /k Phone #: 9 Are X -an employer?Checkh appropriate box: Type of project(required): 1. ` I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their I0.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks boz#I 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance form employees. Belo s the policy and job site information. Insurance Company Name: t Policy#or Self-ins. Lic.#: 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of t DIA for insurance coverage verification. I do here(cerdf!y�undealties of perjury that the information provided above}' true and correct Signature: Date: Phone#: Officia se 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 of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not 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 Investigations has to contact you regarding the applicant. Please be sure to fill in the pen-nit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia II + Page No. of Pages' ABCO ROOFING &' CONSTRUCTION CO. CONTRACT LOWELL, MA 01852 x HIC# 108424 a Super Contractor License#092469 978-937-5840 or 978-475-7544 PROPOSAL.SUBMITTED:TO PHON , DATE - a7 STREET 7 JOB NAME / CITY, STATE AND.ZW CODE JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for. �- / _ r r r OVI .�/L6L�✓�-f jr� W",V _rte-,, � �-�;r-�� ... AF G?1` �'`� pCLti e4 k,4A We Propose hereby to furnish material and-labor complete in accordance. with.above specifications, for the sum of: dollars ($ �� ). Payment�Wbe made as�l ows: C x,/ 11. JJallfo-7 . All.moterial is guaranteed to be as"specified. All work to be completed in a workman- .like manner according to standard practices. Any alteration or deviation from above Authorized specifications involving extra costs will be.executed only. upon written orders, and Signahrre _ —Awo will become an extra.charge over and above the estimate: All agreements contingent � (f j upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado Noffe his proposal may be Landc6nditions d theecessary insurance. Our workers are fully covered by Workmen's Com- withdrawn by us if not accepted within--- days. urance.. / nce of Proposal -The above prices, specifications are satisfactory and are=hereby accepted.:You are authorizedork.as specified. Payment will be made as outlined above. Signatureceptance: t Signature '�� S' ....lam ... _ _ ..., ... .... Page No. of Pages' .ABCO ROOFING & CONSTRUCTION CO. CONTRACT LOWELL, MA 01852 HIC# 108424 a Super Contractor License#092469 978-937-5840 or 978-475-7544 PROPOSAL.SUBMITTEQ.�n�• ( � J� � �t�` PHONE DATE STREET' G/ f t�U � —.jp� JOB .NAME - ell CITY, STATE AND ZIfD, +CODE r JOB LOCATION ARCHITECT _ DATE OF PLANS JOB PHONE We hereb submit specifications and estimates for:, . 21) W17 va& CIA" r� 0 ! 1 � We Propose hereby to furnish^mater'al and (ibor comp to in accordance with above specifications, four the sum of: � / Zz dollars fS -6 Payment 'to be made as.follbws: (/ L -# / s �✓i"t�'""°` All moieriol is guaranteed to..be as specified. All work to be completed in a lworkm:an- f / like manner according: to. standard.practices. Any alteration or deviation frbm above AuThort ed specifications involving extra costs will be executed only. upon.written'orders, and Signature' will become . extra .charge over and above the estimate. All.agreements contingent upon strikes, accidents .or deloys beyond our, control. Owner to carry fire, tornado Note Thi proposal may be and other necessary insurance. Our workers are fully covered by Workmen's Com• withdrawn by us if/not.accepted within days. rDate nsation Insurance.. r. cceptance of Proposal p specifications -The above races, --f' \ nd conditions are satisfactory and are hereby_accepted .You are authorized Signatur/e ' do the work.as specified. Rayment,will be made as outlined above. J of Acceptance. Signature.= ---- � i