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HomeMy WebLinkAboutBuilding Permit #453 - 444 SALEM STREET 12/5/2011 TOWN OF NORTH ANDOVER j APPLICATION FOR PLAN EXAMINATION Permit NO: ► Date Received / 7� Date Issued: IMPORTANT:Applicant must co-m Tete all items on this page LOCATION Print PROPERTY OWNER S 1`C Unit# riot MAP NOAPARCEL: ZONING DISTRICT: Historic District yes n Machine Shop Village yes o j100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition l Two or more family El Industrial ❑Alteration No. o � f units. ❑Commercial ❑Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic"" ®Well ' ' D►Flood lain - � ' ti� P ❑Wetl s WSter/S e—w-e 4 5 '"}4�w"i x A f r. a ?' ® Wat he DiB ct DESCRIPTION OF WORK TO BE PERFORMED: �. z#, y S S (Identification Please Type or Print Clearly) ° OWNER: Name: r- u t 2 - 2 Phone �� Z to s g� Address: S • Y7 CONTRACTOR Name: 1v Phone: . Address: Supervisor's Construction License: Exp. Date: Home Improvement License: i 03 Exp. Date: 5 S' y Z ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER f _ R S.F. � Total Project Cost: $_ _ 7 S FEE: $_ I Check No.: r - i Receipt No.: � NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fiend nature_:of�Agent/Owner � ` 4Si natu e -W`- t t 4 �g . of�contracfor_ Zia- - =a I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Swimming Pools Public Sewer ❑ Tanning/Massage/Body Art El ❑ 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 ❑ ❑ i t COMMENTS CONSERVATION Reviewed on Si nature { COMMENTS HEALTH Reviewed on Si nature COMMENTS ' Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water&Sewer Connection/Sicinature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date I COMMENTS - Dimension Number of Stories: _Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement service drop requires approval of t of Meter location, mast oYes No Electrical Inspector DANGER ZO N ELITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine �i NOTES and DATA— For department use I 4 'I t �I Il ❑ Notified for pickup - Date I Doc:.Building Permit Revised 2011 June/mi I� Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. I 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 1I ❑ 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 I Hydraulic Calculations (If Applicable) ❑ Copy of Contract 4 ❑ 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: Doc.Building Permit Revised 2008mi I Location No. Date / NORTH TOWN OF NORTH ANDOVER •. O Certificate of Occupancy $ s;CNUs Building/Frame Permit Fee $ Q Foundation Permit Fee $ r Other Permit Fee $ TOTAL $ Check #/ �/ 24857 Building Inspector J*N*R amm ioxo Hlc#108503. All Types of Home Improvement www.jnrgutters.com 38-40 Lancaster Street•Haverhill,MA 01830 n-•� Haverhill,MA: (978)372-4088 Nashua,NH: (603)595-2272 ` Andover,MA: (978)475-3723 Portsmouth,NH: (603)433-1811 Woburn,MA: (781)937-4212 Manchester,NH: (603)666-5502 i, .Natick,MA: (508)653-2200 Dover,NH: (603)740-3099 '/+ Boston,MA: (617)423-3559 Rochester,NH Lakes Region: (603)335-0068 Toll Free Nationwide:(800)966-9238 Fax: j' — (978)372-0360 PROPOSAL SUBMITTED TO PHONE DATE / .l? x /L. 64 S'h'Q (cap, 2 STREET JOB NAME CITY, TATE and ZIP CODE JOB LOCATION P PrI1110Sr hereby to furnish at4ial and labor-complete in accordance v itli spe,ifications below, for the sum of: I dollars($ Payment to a made as follow 4 AutCor>� Note:this proposal may be �,^ Signature' withdrawn by us if not accepted wi itfl n days. eby submit specifications and estimates for: Scope of wo e her Tarp and cover all areas at worm area to help protect against damages caused by striping. Remove existing roofing system down to roof deck and dispose of in a legal fashion. • Check existing sheathing and replace and renail as'necessary. Install 2 sows of Ice and Water Shield along bottom, 3'along rakes, 3' in valleys and a minimum of 12" up all adjoining walls. " e install new step flashing at all roof transitions. e install 8"white aluminum drip edge to all exterior edges,then apply 6" strip of Ice anJ water shield over exposed etre of drip edge. Install 3` ice and water shield around all existing roof penetrations.. Install new pipe flanges around all existing soil pipes. Install 15#felt paper to remaining roof surface. Install new Certainteed 30 year architectural shingles to roof surface nailing in a hurricane nailing pattern. • Check ridge vent for proper ventilation and cut as necessary,&inst;all a new shingle ridge vent, Clean job site on a daily basis and run magnet around entire house to minimize nails left behind from roof removal. ""ADDITIONAL CHARGE TO REPLACE ANY ROTTED SHEATHING WOULD BE AT _ A COST OF$4.00 PER 'SQ FT AND ROTTED FRAMING MEMBERS WOULD BE$12.: ,PER BOARD FOOT. AND LABOR RATE FOR MISCELANEOUS REPAIRS WOULD BE$68,50 PER MAN HOUR PLUS MATERIALS, --ADDITIONAL COST TO INSTALL 3 ROWS OF ICE AND WATER SHIELD WOULD * `"ADDITIONAL.COSTJO INSTALL ICE AND WATER SHIELD OVER ENTIRE ROOF SURFACE WOULD BE ,/5th ' ""ADDITIONAL COST FOR CERT"AINTEED 5-SURESTART PLUS COVERAGE WOULD BE . ',�izC�t HdCH INCLUDES: 100% COVERAGE FOR 25 YEARS ON DURATION, MATERIALS &LABOR,TEAR-OFF, DISPOSAL AND WORKMANSHIP. J-N-R GUTTERS CAN'T D FE LD RESPC NCABLF FOR DEBRIS AND OR D1�ST IN YOUR ATT1G. Ag RECOMMEND L?N REMOVAL AND OR COV IN ANY VAUBL S 4krciept rtre of 13rap[Tsal - The prices,specifications and Do not sign this contract conditions listed above and on the back of this form are satisfactory and are if there are any blank spaces: hereby accepted. You are authorized to do the work as specified.Payment will be made as outlined above. Three day cancellation rights under section forty-eight of chapter ninety three,sec- tion fourteen of chapter two hundred and fifty five,D or section ten of chapter one Signature hundred and forty D as may be applicable. Date of Acceptance: l "� SJ s /% Signature 1.ACCEPTANCE.This agreement is expressly limited to and made conditional upon your acceptance of its terms and conditions.Any of your terms and conditions which are in addition to or different from those contained herein which are not separately agreed to in writing (except additional provisions specifying quantity,description of the products or work ordered and shipping instructions)are deemed material and are hereby objected to and rejected. You waive your objection to any terms and conditions contained herein if Contractor does not receive written notice of your objection within ten business days of the date of this agreement. You will in any event be deemed to have assented to all terms and conditions contained herein if any part of the products or work described herein are provided or performed. Please note particularly the Limited Warranty, Limitation of Remedies and Limitations on Actions and Liability provisions set forth below. You acknowledge that the prices stated are based on the enforceability of these terms and conditions, and on the limited Warranty, Limitation of Remedies and Limitation of Actions and Liability provisions below,that the price would be substantially higher if Contractor could not limit its liability as herein provided,and that you accept these provisions in exchange for such lower prices. 2. LIMITED WARRANTY.All work performed by Contractor is warranted to be free from defects in material and workmanship for one year from the date of completion of the installation subject to the terms below.Contractor makes no warranties regarding products sold but assigns to you any manufacturer warranties relating to the products.THIS EXPRESS WARRANTY IS IN LIEU OFAND EXCLUDES ALL OTHER WARRANTIES,WHETHER E')CPRESSED, IMPLIED OR STATUTORY, INCLUDING IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE.This limited warranty does not cover damages relating to(a)accident,misuse,abuse,neglect,or,normal wear and tear;(b)failure to use or maintain the product in accordance with manufacturer's instructions;and(c)alteration, repair or attempted repair by anyone other than Contractor or its authorized representa- tive.You shall be solely responsible for the correctness of the plans and specifications and shall release and hold harmless Contractor from any damages resulting from improper, inadequate or vague information supplied by you. Contractor does not take on any obligation to inspect or evaluate the work of other parties in any manner or aspect.This warranty is not transferable. 3. INSURANCE. Contractor shall maintain workers'compensation (employer liability), as required by law, and$2,000,000 in general liability insurance while performing the work. Contractor reserves the right to be self insured to the extent allowed by applicable law. Contractor does not agree to name any other persons or entities as additional insureds. 4. LIMITATION OF REMEDIES.Your sole and exclusive remedy against Contractor for any and all claims for damages arising out of or alleged to have arisen out of the Work will be limited to the repair or replacement by Contractor,at Contractor's option,of any nonconforming work or to the issuance of a credit for such nonconforming work in accordance with these terms and conditions provided Contractor is given a reasonable opportunity to inspect the work and confirms such nonconformity.This exclusive remedy shall not be deemed to have failed its essential purpose so long as Contractor is will- ing and able to repair or replace the nonconforming work and, in any event, Contractor's maximum liability for any damages shall be limited to the total amount paid to Contractor for the Work under this agreement.This Limitation of Remedies clause shall apply to the parties to this agreement as well as to the current owner(s)of the project and its/their respective successors and assigns. If you receive a claim for damages by any owner arising out of or alleged to have arisen out of the Work, you agree to give written notice to Contractor of the claim and provide Contractor an opportunity to inspect the alleged damages within 30 days after Contractor receipt of the notice. If you fail to give the required notice and/or fail to pillow Contractor an opportunity to inspect the alleged damages within 30 days, you hereby waive any and all rights for damages and/or correction of work against Contractor. This Limitations of Remedies may be plead as a complete bar to any action in violation of this clause. 5. LIMITATIONS ON ACTIONS AND LIABILITY.All claims and/or lawsuits including but not limited to claims or lawsuits for indemnity and/or contribution against Contractor arising under this agreement must be made within 13 months from the date of completion of the installation. CONTRACTOR WILL NOT BE LIABLE FOR ANY LOSS, DAMAGE OR INJURY RESULTING FROM DELAY IN DELIVERY OF THE PRODUCTS OR FOR ANY FAILURE TO PERFORM THAT IS DUE TO CIRCUMSTANCES BEYOND ITS CONTROL.CONTRACTOR DISCLAIMS ALL LIABILITY FOR ANY AND ALL DAMAGE WHICH MIGHT BE SUSTAINED BY ANY PERSON WHO MAY BE ALLERGIC TO OR AFFECTED BY THE EMANATION OF PARTICLES FROM CERTAIN TYPES OF INSULATION.THE MAXIMUM LIABILITY, IF ANY,OF CONTRACTOR FOR ALL DAMAGES, INCLUDING WITHOUT LIMITATION CONTRACT DAMAGES AND DAMAGES FOR INJURIES TO PERSONS OR PROPERTY, WHETHER ARISING FROM CONTRACTOR'S BREACH OF THIS AGREEMENT, BREACH OF WARRANTY, NEGLIGENCE, STRICT LIABILITY OR OTHER TORT WITH RESPECT TO THE PRODUCTS, OR ANY SERVICES IN CONNECTION WITH THE PRODUCTS, IS LIMITED TO AN AMOUNT NOT TO EXCEED THE CONTRACT PRICE. IN NO EVENT SHALL CONTRACTOR BE LIABLE FOR ANY INCIDENTAL, CONSEQUENTIAL, LIQUIDATED, OR SPECIAL DAMAGES, INCLUDING WITHOUT LIMITATION;LOST REVENUES AND PROFITS,ATTORNEYS FEES AND/OR COSTS EVEN IF IT HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. THE RIGHT TO RECOVER DAMAGES WITHIN THE LIMITATIONS SPECIFIED IS YOUR EXCLUSIVE REMEDY IN THE EVENT THAT ANY OTHER CONTRACTUAL REMEDY FAILS OF ITS ESSENTIAL PURPOSE. 6.PRICES,TERMS AND SHIPMENT.No cash discounts,back charges,set offs or counterclaims are allowed unless specified by Contractor. In addition to the prices specified, you agree to pay any federal, state or local excise, use,occupational, or similar tax now in force or to be enacted in the future, assessed against Contractor or you by reason of this transaction. No retention is permitted unless Contractor agrees otherwise in writing.Any past due payment will be, at Contractor's option, subject to interest at 1.5%per month (18%per annum)to the extent permitted by law.You agree to receive(or permit Contractor to receive) near the work site,any materials needed to complete the Work.You agree to protect such materials from damage or loss and provide Contractor, free of charge, with reasonable use of light, heat, water, power, storage space and use of available elevators and hoists as needed.Title to all materials under this agreement shall not transfer to you until Contractor receives payment in full. Contractor may charge you a fee and its actual expense if the job site is not ready for work on the date you specify. 7. FORCE MAJEURE.Contractor shall not be liable for any delay,failures,or default in performance of this agreement or otherwise, in whole or in part, caused by the occurrence of any contingency beyond the control either of Contractor or of suppliers to the Contractor.Such contingencies include but are not limited to failure or delay in transportation,acts of any government or any agency or subdivision thereof,judicial action,labor disputes,fire,accident, acts of nature,severe weather, product allocation or shortages, labor shortages,fuel shortages, raw material shortages, machinery or technical failure, or work that cannot be completed because of another contractor covering the pertinent portion of the building. If any contingency occurs,Contractor may allocate production,deliveries, and performance of work among its customers or substitute substantially similar materials, in its sole discretion,without liability for doing so. 8. CONFIDENTIALITY. If you visit Contractor's premises or you otherwise receive any proprietary or confidential information from Contractor,you shall retain such information as confidential and not use or disclose it to any third parry without Contractor's written consent. 9. CREDIT APPROVAL. Shipment and delivery of goods and performance of work shall at all times be subject to the approval of Contractor's credit department and Contractor may at any time decline to make any shipment or delivery or perform any work except upon receipt of payment or upon terms and conditions or security satisfactory to Contractor. By signing this agreement,you authorize Contractor to check your credit and references. 10. CANCELLATION. This agreement, or any part of it, may only be cancelled with Contractor's written approval. In the event of cancellation of this agreement,any part hereof,you shall pay: (a)the contract price of all completed items; (b)that portion of the contract price that is equal to the degree of completion of products or work in process, effective on the date Contractor receives notice of cancellation; (c)the cost of any materials and supplies which Contractor shall have purchased to perform and which cannot be readily resold or used for other or similar purposes; (d) a restocking fee; and (e)any expenses incurred by Contractor(including legal fees and judgments)as a result of the cancellation of subcontracts or purchases related to this agreement. 11. DEFAULT.You may terminate this agreement for Contractor's default,wholly or in part, by giving Contractor written notice of termination as follows. You may give written notice of termination only if Contractor has received a written notice from you specifying such default, the default is not excus- able under any provision hereof, and the default has not been remedied within thirty(30)days (or such longer period as maybe reasonable under the circumstances)after Contractor's receipt of the notice of default. Delivery of nonconforming products or work by Contractor shall give you the rights set forth in paragraph 4 hereof but shall not be deemed a default for purposes of termination. In the event of termination for default, you shall be relieved of the obligation to pay for work not performed by Contractor prior to the effective date of such termination.A default on Contractor's part shall not sub- ject Contractor to liability,through payment by Contractor, set off or otherwise,for any other damages, whether direct, consequential or incidental, and whether sought under theories of contract or tort. If customer breaches this agreement the Contractor is entitled to reasonable attorneys'fees and litiga- tion expenses as determined by a"Court of Law." 12.ASSIGNMENT.You may not assign this agreement or any claim against Contractor relating to this agreement. 13.GOVERNING LAW.This agreement shall be construed, interpreted and the rights of the parties determined in accordance with the laws of the State of Contractor's address first listed on the front of this agreement. 14. DISPUTES AND MANDATORY MEDIATION. In the event that a dispute arises over the reasonableness of or entitlement to fees charged by Contractor,the prevailing parry will be entitled to reasonable attorneys fees and costs. In all other disputes of any nature, each party shall pay its own fees and costs. Except as required to protect confidential information and to obtain preliminary injunctive relief to prevent irreparable harm,you and the Contractor agree that prior to the initiation of any legal action the parties will engage in facilitative mediation of any and all disputes in anyway related to this agreement. If the parties cannot agree upon a facilitative mediator within 30 days of when the dispute arose,one will be selected pursuant to the Commercial Mediation Rules of the American Arbitration Association. Each party will share equally the fees of the facilitative mediator and costs of the mediation. 15.Three day cancellation rights under section forty-eight of chapter ninety three,section fourteen of chapter two hundred and fifty five, D or section ten of chapter one hundred and forty D as may be applicable. 16.SEVERABILITY. If any provision on this agreement is not enforceable,that provision shall be effective only to the extent permitted by law and all other provisions of the agreement shall remain. 17. ENTIRE AGREEMENT.This instrument contains the entire agreement of the parties relating to the subject matter hereof and may only be waived, changed, modified,extended or discharged orally by a writing signed by the party against whom enforcement of any such waiver,change, mortification, extension or discharge is sought the terms and conditions of this agreement supersede any agreement to which it is attached. 18. INDEMNITY. Each of the parties to this agreement agrees to defend and indemnify one another from any and all claims, actions and/or lawsuits caused by the party's negligent acts or omissions.This indemnity clause and the obligations created herein shall control and take priority over any con- trary indemnity agreement entered into prior to this agreement. Furthermore,this indemnity clause and the obligations created herein shall control and take priority over any contrary indemnity agreement entered into subsequent to this agreement unless the subsequent agreement specifically refers to this indemnity clause and declares it null and void. The Commonwealth ofMassachusetts Department of lndustrial Accidents Office of Investigations 600 Washington Street 5� Boston,MA 02111 www-Marss gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Alpylicant Information Tease Print Le ibl Name(Business/organization/Individual): Address: 3 ® City/State/Zip: © l d Phone#: 7'� 2-Vo Are you an employer?Check the appropriate box: 1. I am a employer with Z 0 4. Type of project(required); ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheget.1 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp,insurance. [No workers'comp,insurance 5. ❑ We are a corporation and its 9• ❑Building addition required.] officers have exercised their 10.El EIectrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.(]Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no insurance ]redemployees.[No workers re ui . 12.❑Roof repairs q coinpinsurance re qufir ed.] 13.( Other -------- !Ary applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: �. Policy#or Self-ins.Lic.#: LSC d p cj Gt Expiration Date: Job Site Address:__�q � S C1 Y,n c & , City/State/Zip- y Lt- Attach acopy of the workers'compensation policy declaration page(showing the policy number and expiration ate). 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 o Of up to$250.00 a day against the violator. Be advised that a copy of this statement f a STOP WORK ORDER and a fine Investigations of the DIA,for insurance coverage verification. may be forwarded to the Office of fP J r1' ` I do Izereby certify under the pains and penalties o er'u tliat the information provided above is true and correct. Signature: 1 c � Date: ?ho ne#: 1 � 7 bd Z official use only. Do not write an this area,to be completed by city or town official. City or Town: Permit/License# Issuing use (circle one): I.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 ry per m as ...eve son 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 apartinents 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 ofpublic 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-contractors)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 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(ifnecessary)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 NOTrequired 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: Tue�`O�'nr�OA�tWeal'iii Off.�c�.$Sa.Gr�l?SetCS Department Of Industrial Accidents Office of Investigation$ _ 600 Washington Street Boston;M-A,42111 Tel.#617-727-4900 ext 406 or 1-877-1ASS.FE Revised 5-26-'05 Fay,#61.7-727-7749 W w.mass.jZ-ov/dia 11/22/2011 09:43 FAX 978 532 2217 CROSS INSURANCE U002/003 A CERTIFICATE OF LIABILITY INSURANCE I °ATE`'""I'°°"'M �,•� 11/22/2011 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.poiicy,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 Donis® CimBtti Cross Insurance-Peabody PHONE (976)532-5445 FA"I&C Not.(978)532-2217 139 Lvnnfield Streit EMAIL -dcimetti@crossagency.com INSURERS AFFORDING COVERAGE MAIC 0 Peabody MA 01960 INSURER A kierchants Ins Group INSURED INSURERS:COmmerCe TndustME Ins Co JNR Gutters, Inc. INSURER C: 38-40 Lancaster Street INSURER D: INSURER E: Haverh-ill - Haverhill MA 01830 INSURER F: COVERAGES CERTIFICATE NUMBER:CT-1192053826 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 TERM$, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUDR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSRPOLICY NUMBER LIMITS GENERAL LIA51UTY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMA ET RENTED REML=a $ CLAIMS-MADE D OCCUR MED EXP(Any one,person) S PERSONAL&ADV INJURY $ GENERAL AGGREGATE 5 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 17 POLICY PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 11000,000 A ANY AUTO BODILY INJURY(Par porton) 5 ALL OWNED X SCHEDULED CA7015134 6/21/2011 6/21/2012 BODILY INJURY(For L AUTOS AUTOS ( ) HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident PIP-9asic 5 UMBRELLA LIA9 OCCUR EACH OCCURRENCE 5 EXCESS UAB CLAIMS-MADE AGGREGATE S DEC, I I RETENTION 5 1 $ $ WORKERS COMPENSATIONX WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN T ANY PROPRIETORIPARTNERIEXECUTIVEEL S 500 EACH ACCIDENT QQO OFRCERIMEMBER EXCLUDED Q (Mandatory in NH) NIA CO09774192 /20/2011 /20/2012 E.LDISEASE.EAEMPLOYE S 500,000 Iryee,desaribe under DESCRIPTION OF OPERATIONS 6alow E.L.DISEASE-POLICY LIMIT I S 500 000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,AQdlUonal RamaiMs Schaduln,If more space Is required) R0£er to policy £or exclusionary andorsement5 and special provisiona_ CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SAMPLE CERTIFICATE FOR ACCORDANCE WITH THE POLICY PROVISIONS. INSURANCE PURPOSES ONLY SAMPLE COPY AUTHORIZED REPRESENTATIVE Timothy Tramonta/DC4 Y& i e ACORD 25(2010105) ®1986-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD Np q TL,� , ® oAndover , , No. s17 o , dover, Mass., T O LAKE Ifs COCMICMEWICK V �RATE D ��� 7 u BOARD OF HEALTH Food/Kitchen Septic System rER I T D 11 1 BUILDING INSPECTOR THIS CERTIFIES THAT...........eje.111101.111410101 ..... .............. ....�.1�.................................................................................. Foundation has permission to erect......... .... buildings on .....1 ........ ............... .....I.................... Rough tobe occupied as........g.. ..... " '............. ............�.�..... ...................................................................... chimney provided that the person accepti this permit shall in every respect coRheiinspection, m to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to 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 N S ELECTRICAL INSPECTOR UNLESS CONSTRU S Rough ...................................... .......... Service BUILDING INSPECTO... R 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. ACS CERTIFICATE CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �-� 09/20/2011 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). CONTACT PRODUCER 978-374-2500 866-494-4513 NAME: Daniel J. Seaman Daniel J. Seaman a/c°No Ext:978-374-2500 FAX No:866-494-4513 229 Primrose Street E-MAIL SS:dan@seamaninsurance.com PRODUCER CUSTOMER ID#: Haverhill MA 01830 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A:Atlantic Casualty JNR Gutters Inc INSURER B:The Hartford 38-40 Lancaster Street INSURER C: Haverhill, MA 01830 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY A EACH OCCURRENCE $1000000 COMMERCIAL GENERAL LIABILITY DAMAGERENTED PREM MISS (Ea occurrence) $5 OOO CLAIMS-MADE F-1 OCCUR MED EXP(Any one person) $5000 L18507 07/20/2011 07/20/2012 PERSONAL&ADV INJURY $1000000 GENERAL AGGREGATE $2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2000000 POLICY PRO- El LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ $ UMBRELLA LIA11 HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TQRY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Business Property Equiptment Leased or Rented from Others 08MS HE3720 7/2012011,07/20/2012, Limit$275,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Siding, Gutters, Roofing, Windows and General Repair CERTIFICATE HOLDER and Additional Insured CANCELLATION Barer SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE a ©1988-2009 ACORD CORPORATION. All rights reserved. Massachusetts-.Bepartmient of Public Safety x `r Board of Buiitlin�,Regulations and Standards ., Construction Supervisor License License: CS 80515` I KEVIN M FRANCIS' 35 WANNALANCET RD HAVERHILL, MA 01830 Expiration: 7/21/2013 <'uuunissiunrr Tr#: 16840 i =.5•, ,� �fte TD iorrUnto�2taei24ll o� aclr,�Gvl�. OfficmsnssRuli e n e; xOME IMPROVEMENT-CONTRACTOR' , Registration:- -08503 TYP ;i Expiration g/__Tg)2012� Supplement C 1s J N R GUTTERSIdNC � 8 jEa KEVIN FRANCIS; , 38-40 LANCASTER ST Haverhill, MA 01830 Ade secreta y a i n i