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HomeMy WebLinkAboutBuilding Permit #027-2017 - 44 SAUNDERS STREET 7/7/2016 A1ly � TOWN OF NORTH ANDOVER NORTh APPLICATION FOR PLAN EXAMINATION °a<•�°°;•'"o ° 4 9 .Itll o9q Permit NO: Date Received • '� ��SSICNUS t Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION 99 - 4 6 :_ x Print PROPERTY OWNER '•T-EVr- Ntir Na' q nt MAP NO.: / PARCEL: ZONING DISTRICT: �aU ✓, TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building ❑One family ❑Addition ATwo or more family ❑Industrial Alteration No.of units: ❑Repair,replacement ❑Assessory Bldg ❑Commercial ❑Demolition ❑Moving relocation ❑Other ❑ Others: ❑Foundation only DESCRIPTION OF WORK TO BE PREFORMED IrP1AC. cxS- , ]�) r- tCine Plot L PranMON I)At L boolS MISC.. .�AITFJ� )OZ '"ri�INO I?-p1A CE 1 Vv)Nb0 VV Identification Please Type or Print Clearly) OWNER: Name: ST'gy j=NJuG.F-rvT Phone:q7$ 34t SIS S Address: 14Dl10W 7-fff-< / Aw IJor-111 8 td DOVE R CONTRACTOR Name: 01 R r1Ehl &ZI�4) &11 Phone: 9 73 tA-75 - IS2 6 Address:q a msyem- y th Nom N kwve g MA 6%%4& Supervisor's Construction LicenseCS1 b`-11-12'9' Exp. Date: 5112 11? Home Improvement License: l 6$ S 2 Exp. Date: 1 �� ARCHITECT/ENGINEER N1'f, Name: Phone: Address: Reg.No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST Bj D ON$125.00 PER S.F. Total Project Cost :$ �`pQ . Ulf x12.00=FEE:$ — Check No.: C�� Receipt No.: 61y Page tof4 Plans Submitted ❑ Plans Waived ❑ Certified Plot ala, J Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments ` Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE .DEPARTMENT - Te mpi©umpster on.site ,yes nog Located;af.1243MainrStmet ------ Fire Fire•Department signature/date z COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. I 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.$10041000 fine NOTES and DATA— (For department use) I ❑ Notified for pickup Call Email Date Time Contact Name = )oc.Zuild'inb�Permit Revised 2014 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 ,r< 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 OTE: 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 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 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 2012 I ECC 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 Doc:Building Permit Revised 2014 Location Date . - TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee $ E ✓ Foundation Permit Fee $ ; Other Permit Fee $ TOTAL $ Check# / 1 f s/ Building Inspector �� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION C� NU 1 `s,,�e.'e 't'O Permit NO: Date Received '� . •>' �9SS' Date Issued: �CHUS IMPORTANT:Applicant must complete all items on this p4ge LOCATION LI LI 4J�:5 Fnnt PROPERTY OWNER Pnnt MAP NO.: PARCEL: �~ ZONING DISTRICT: /�� < '_ TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building ❑One family ❑Addition ATwo or more family ❑Industrial Alteration No.of units: ❑Repair,replacement ❑Assessory Bldg ❑Commercial ❑Demolition ❑Moving relocation ❑Other ❑ Others: ❑Foundation only DESCRIPTION OF WORK TO BE PREFORMED �-Pi�.C ,,rr:S — . —]�) r- -AW 1-b — W`b envr mo -�)A i 1 D r,s7 � -4- ._M i" Slat E fo )0 17 —TI M €PIA Cx Nb()VV Identification Please Type or Print Clearly) OWNER: Name: "STr yj5 NIV(,F,rvT Phone:17$ Address: ';�>S AQ110 l �'t�c-r- LAPjV--� CONTRACTOR Name:NA int ►���� I &ZQY) gull b)N r. Phone: 97R to 7] f lj2 6 Address:�i7 6LNyE-1C1-x Y br NO El R A wNovC R MIA Supervisor's Construction Licensed b t-1 -12 R Exp. Date: 5 !h2 ` 1 Home Improvement License: 10 5 1 Exp. Date: I N ARCHITECT/ENGINEER M i4N Name: Phone: Address: Reg. No. FEE SCHEDULE.-B ULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$725.00 PER S.F. Total Project Cost:$_ S�ey) , t,t) x12.00=FEE:$ — Check No.: Receipt No.: c` Page tof4 Y,A-7- - r 7 NORTH . •4. ve 0 22617 � z % h , ver, MasQq Coc"Ic"a M/KM U BOARD OF HEALTH Food/Kitchen PERM L D Septic System THIS CERTIFIES THAT ........ ... BUILDING INSPECTOR4 .... . ................. Foundation has permission to erect ..................... buildings on ftj * . Rough to be occupied as .. .... ... ..... !� .1. ,� �.. aw. 0 Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST T N Rough Service . . ...... .. ...... ........ Final BUILDIN PECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. Ah a 1 * Co. Building&Remodeling Adam Brien CSL 104428 417 Waverly Rd. HIC 168512 North Andover, MA 01845 LLC 978-479-1526 6/20/16 adambrico@gmail CONTRACT Steve Nugent 46 Saunders St North Andover MA 01845 Job Description 1: Installation of 5 exterior doors and replacement of 1 window • Supply and install 2 Therma Tru, exterior doors at main entrance, style selected by owner. • One exterior door supplied and installed for second floor unit exit onto deck and exiting unit on second floor. • One exterior door supplied and installed in common hallway for unit 2. • Window in back common hallway replaced with new unit. • Miscellaneous, trim work performed in common hallways including balusters after new carpet is installed by other. • All debris disposed of off site • Painting not included • Permit fees included Total contracted amount $5900.00 Payment of$5000.00 received 7/6/16 Any unforeseen work or necessary repairs found during this project to be brought to the owners attention as soon as possible. Any extra work resulting from unforeseen problems will be priced accordingly on site and be done with written approval. BriCo is not responsible for anything that occurs on site that is not directly involved with the construction of this project. BriCo Building and Remodeling is a fully licensed and insured LLC company. License numbers are provided in the header above and current insurance documentation upon request. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): At/w -St_,l 1_N 1 N Address: 1- )'j V A ISE(t if y 1-b City/State/Zip:Nair-t14 AgbQY¢Q Mao1 �p Phone#: i 7$ 9 )� Are you an employer?Check the appropriate box: Type of project(required): 21 I am a employer with z. employees(full and/or part-time).* 7. [l New construction I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.FJI am a homeowner doing all work myself[No workers'comp.-insurance required.]t 9. F1 DemoIition 4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. • 12:FJ Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.ORoofrepairs These sub-contractors have employees and have workers'comp.insurance.# 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. i Homeowners who siubnuf 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,' Iain an employer that is providing workers'compensation insurance fog'my employees.'Below is the policy acid job site information. Insurance Company Name: �,P Ve LfFq S Policy#or Self-ins.Lie.#: 7 P J'V 1'3 L 1 b]a p g p`i 16 Expiration Date: `1 Job Site Address: 9 --57-A V N D e e S !\-r City/State/Zip:.10 dl MA o%V-1 S 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains aann�d penalties ofpetjury that the information provided above is true and correct. Signature: Date: "7 17 I 16 Phone#• 9 7$ L-T1I �5t;: 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.PIumbing 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 or fore , 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-contractox(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£oi 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 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 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 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 ACOR ® RATE(MM/DO/YYYY) CERTIFICATE OF LIABILITY INSURANCE 6/23/16 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(!es)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 endorsements). PRODUCER CONTACT NAME: Trud Lawler Armand P. Michaud Insurance Ag PHONE Fax 978 794-0822 105 Haverhill Street E-MAIL (978) 685-2549 N Methuen, MA 01844 ADDRESS: INSURE S AFFORDING COVERAGE NAIC# INSURERA:Green Mountain Insurance Co. INSURE) INSURER B:Norfolk & Dedham MA BRICO Building & Remodeling LL INSURERC: Adam J Brien INSURERD: 417 Waverley Rd INSURER E: N Andover, MA 01845 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 AWL SUBR POLICY EFF POLICY DIP LTR TYPEOFINSURANCE POLICY NUMBERMIDDIY MMIDWYYYY LIMITS A GENERAL LIABILITY 20009201 4/13/16 4/13/17 EACH OCCURRENCE $ 1,000,000 }( COMMERCIALGENERAL LIABILITY DAMAGE TO RENTED PREMISES(Ea occuffenc-4 $ CLAIMSWADE ®OCCUR MED EXP(Ary one person) $ 5 000 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER PRODUCTS-00MP/OPAGG $ 2,000,000 POLICY PRO LOC $ B AUTOMOBILE LIABILITY 91561617A 6/18/16 6/18/17 CO3=,cEDSINGLELIMfT $ ANYAUTO BODILY INJURY(Per person) $ 100.000 ALLOWAUTOS�D SCHEDX AUTOS 300,000 BODILY INJURY(Per accident) $ 30O 000 PROPEYAMAGE HIREDAUTOS _AUTOSWNED ( erra.dn° $ 100,000 $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION WORKERS COMPENSATION WC STATU- I OTH- AND EMPLOYERS'LIABILITY Y 114 ANY PROPRIETOR/PARTNER/EXECUTIVE E. ACHACCIDENT $ OFFICERMIEMBER EXCLUDED? /A (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 (Attach ACORD 101,Additional Renarks Schedule,'rfmorespece isrequired) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Steve Nugent ACCORDANCE WITH THE POLICY PROVISIONS. 44 Saunders St. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Trudy Lawler ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The AC ORD name and logo are registered marks of ACORD Phone: (978) 685-2549 Fax: (978) 794-0822 E-Mail: trudvlawler@michaudinsurance.com ,Aco O® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 06/23/2016 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 NAME: Trudy Lawler MICHAUD INSURANCE AGENCY PAIC,HONNo.E t: (978)685-2549 ac No: ADDRESS: trudylawler@michaudinsurance.com 105 HAVERHILL ST. INSURERS AFFORDING COVERAGE NAIC# METHUEN MA 01844 INSURERA: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B BRICO BUILDING& REMODELING LLC INSURER C: INSURER D: 417 WAVERLEY RD INSURER E: NANDOVER MA 01845 INSURER F: COVERAGES CERTIFICATE NUMBER: 63876 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMBS LTR POLICY NUMBER MMIDD MM/DD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE r_1 OCCUR DAMAGE TO RENTED PREMISES Eaoaurtenca $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PRO ❑LOC JECT PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ �/ $ WORKERS COMPENSATION X STATUTE ETH AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNER/FXECUTIVE -- E.L.EACH ACCIDENT $ 100,000 A OFFICERIMEMBEREXCLUDED? I NIAI NIA N/A 7PJUB4618P50716 04/19/2016 04/19/2017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDE CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Steve Nugent ACCORDANCE WITH THE POLICY PROVISIONS. 44 Saunders St AUTHORIZED REPRESENTATIVE rth Andover MA 01845 —) �r L Daniel M.Cro�v�y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(201 The ACORD name and logo are registered marks of ACORD I 6�E;a►aas�apnn 5 860 yW`2GAO4NV H12/ON a-1`lb3AVM L07 x : N3189WVGV oil 0, QOIN aNd ONimin8 OORlB Oil �LLOZIf7£ :uol;endx3 :adlll 26589 :uol;ej;si6a 21O10`dii 1N O01N 3 W3 AO2!d W 1.3 W 0 aolielnMd ssaalsng sne V�awnsaoO 3o aaylp. �t favrnn �a a--ffrtcUa a� Massachusetts Depa ment of Public Safety ulations and Standards Board of Building Reg License: CS-j044 2isor Construction Super ADAM J BRIEN W WAVERLY ROAD ' V NORTH ANDOVER MA 01845f Expiration: 05/12/2018 Commissioner ..................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION HU This certifies that . .............. ..................................... .................................... on has permission for gas installati ......................................... • V inthe buildings of.................................................................................................................... I at ................ Nofth Andover, Mass. Fee .... Lic. No. GASINSPECTOR Check# L�/, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY [,d,/ 22 f�j f�p�l _• MA DATE PERMIT# JOBSITE ADDRESS / OWNER'S NAME .5' oGtiUT OWNER ADDRESS ib✓ntA fY '72L-,J� FAXE::�.... TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL RESIDENTIAL PRINT �,/ CLEARLY NEW:0 RENOVATION:[] REPLACEMENT:[I -r6sT'0 PLANS SUBMITTED: YES[I NO[-1 APPLIANCES Z FLOORS-; BSM i 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER µ COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER _ ROOM f SPACE HEATER ROOF TOP UNIT l TEST ' UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability nsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES F1 No 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY M OTHER TYPE INDEMNITY Q BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General taws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: 0 ER [:] AGENTE] SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and to o the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance . at ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I Steven Carr LICENSE# 15366 SIGNATURE MP EI MGF[„1 JP[] JGF r—j LPGI[D CORPORATION[-j# PARTNERSHIP El# LLC 0# 27150996 COMPANY NAME:j SPC Plumbing&Heating ADDRESS 12 Concord SL CITY Methuen STATE[MA ZIP 01844 ITEL[L78-815-3936 FAX978 208-1081 CELL 978.815-3936 JEMAIL spcph@veriwn.net The Commonwealth of Massachusetts Department of Industrial Accidents > I Congress Street,Suite 100 Boston,MA 02114.2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE RILED NVITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leyibiv Name (Business/Organization/Individual): J 1 C. 1 U C-1 7j t r.J nT 1 t"3 Address: 12- Co c,-s (_c,1?fl 'S City/State/Zip:jlt UL 1,3 M { `� y Phone#: '� Are you an employer'C teck the appropriate boa: Type of project(required): I, I am a employer with _9z--employees(full and/or part-time). 7. New construction 2.❑I am a sole proprietor or partnership and have no employees working for tare in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 I airs a homeowner doing all work myself[No workers'comp.insurance required.] 10[]Building addition 4.O I am a homeowner and will be hiring contractors to conduct all work on my property. T will ensure that all contractors either have workers'compensation insurance or are sole I t.❑Electrical repairs or additions proprietors with no employees. 12.(.Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurencet 6.❑We are a corporation and its officers have exercised theirright t of exemption 14.❑Other tpa gh p per MGL C. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section belovv showing their warkers'compensation policy information. 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 empioyem If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing Hwrkers'compensation insurance for m1'employees Below is the policy and jab site Information. Insurance Company Name: StV904 Fo i /Z eE p4A f-1 Policy 9 or Self-ins.Lia#: b'y �} �� 9 4 a Expiration Date: Job Site Address: 7'� JPN�4s f7 City/State/Zip: 1J AN40v�_�j�q —, 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,fi25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment, 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 ca his statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify�under gins and penalties of perjury that the information provi7771 ' true and correct. Signature: Date: �r Phone n: 217/f- / S% ,/" 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5,Plumbing Inspector 6.Other ContaetPerson: Phone#: