HomeMy WebLinkAboutBuilding Permit #226-11 - 45 TURTLE LANE 9/6/2010 BUILDING PERMIT of NORTH
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION p
Permit NO:
Date Received 440
A �qS ACHU��
Date Issued:
IMPORTANT Applicant must complete all items on this page
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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 7 Other 1411
Pi`-T'
138•U�.�a�t,-. .rit��
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DESCRIPTION OF WORK TO BE PREFORMED:
dentification Please Type or Print Clearly)
OWNER: Name: 4 ,0 e
e: 77?
Address:
77
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.-BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ �
FEE: $__��
Check No.: �l`D
Receipt No.: t
NOTE: Persons contracting with unregistered contractors do not have ace s uaran fun
S gnature of Agent%Ouune`r g
S i riat�a re.0 coxa ra
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tann ing/MassageBody 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
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
r5
EIR DE1RTq111ET Tern `Du► pser on site yes yY ;no z - KF
``I vcated ofUlaira-'S#reet
E
Fere epar enit
niiture/date -
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.9
CO:IVI11",E`TS
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
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❑ Notified for pickup - Date
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Doe.Building Permit Revised 2010
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
❑ ,el Li led 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 a
Doc:Building Permit Revised 2008
Location �E
No. 47Date
3?0
o
NORT1y TOWN OF NORTH ANDOVER
O
Certificate of Occupancy $
CHUsE<� Building/Frame Permit Fee $ c3o
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # ' --?a /
234116
Building Inspector
ORT#q
Town of
No. (6LAK1-
,� oa dower, Mass.,
COCMICHEWICK
%d ADRATED
S BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
w3bL Catrdw BUILDING INSPECTOR
THISCERTIFIES THAT.......................................................................................................... ..... .............. ............................... Foundation
has permission to erect........ ........:...................... buildings on .....q�...... Vti..................... ��I`J`.......... Rough
tobe occupied as...........� . ...:......GV.1.. 0.A)..................................................................................................... Chimney
provided that the person accepting 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
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRU ST TS Rough
............................. ................................. IM 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.
CONTRACT#
�Iq
MASSACHUSETTS EXTERIOR SOLUTIONS INSTALLED SALES CONTRACT
INSTALLED SALES SPECIALIST NUMBER CUSTOMEJL—- 4
STORE NO. STREET A DRESS STAREEEET ADDRES
CITY STATE ZIP CITY STATE ZIP
,41 14/1 Ail
TELEPHON� � � TELEPH
ONE
/ / —
_GG(( CiC) r
w
DATE LOWE'S HOME CENTERS,INC.'s MA HIC NO.: 148688 CASH BANK F REG
FEIN:56-0748358 cARo CHARGE
This is only a quote for the merchandise and services printed below. This becomes an agreement upon payment. Upon payment,the entire agreement,including the specifically completed pages of this
document,the Terms and Conditions included with this document and any other addenda and attachments hereto,shall be referred to herein as this"Contract."
PLEASE READ ALL TERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS PAGE AND FOLLOWING PAGES BEFORE SIGNING.
INSTALLATION STREET ADDRESS CITY STATE ZIP
1 Go4 iA� S ' L / n eLJ L•v I It j I eA_
Contract Total
Are permits required for this installation?: A-f Yes [ ] No *applicable tax included
NOTICE TO CUSTOMER:Federal law requires Lowe's to provide you with the pamplet Renovate Right:Important Lead Hazard Information for Famil-
ies,Child Care Providers and Schools.By signing this Contract,Customer acknowledges having received a copy of this pamphlet before work began
informing Customer of the potential risk of the lead hazard exposure from renovation activity to be performed in Customer's dwelling unit.
Work is mence upon reasonable availability of Contractor and/or availability n/.y�spe ial order or custom made Goods which is anticipated
to be .) [fill in date]. Estimated completion date is t� [fill in date].
Said estimated substan al completion date is not oaf the essence. Contingencies that may materially change said estimated completion date follow:
(I??✓C1� r Royyy Ii If (If applicable,insert a statement of such contingencies).
IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full.
CCPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00:
Customer to Pay in Full; OR [ ]Customer to use the following payment schedule:
(1)'Deposit $ to be paid upon siging contract.Deposit should be 1/3 the total contract price;and
(2)Payment of$ to be paid anytime after this Contract is signed and before commencement of installation,I/We authorize Lowe's
to do one of the following(check appropriate box below):
[ ]Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed;
or
[ ]Deposit my/our check for the amount of the payment indicated above anytime after the date this Contract is signed;and
(3)Final payment of$100.00 to be paid upon completion of the installation and both parties'satisfaction.
NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED EY M.G.L.c.142A
LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT,THAT
LOWE'S MAY SUBMIT SUCH DISPUTE A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUT-
IVE OFFICE OF CONSUMER AFFAIR RtIND BUISNESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION
AS PR IDED IN M.G.L.c.142A7) g
By: . . Date:
Lowe" om n rs,Inc.
-By: � rDate:
Owner'SignatuO
THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED
BY LOWE'S PURSUANT TO M.G.L.c.142A.THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THE
SECTION ABOVE IS NOT SEPERATELY SIGNED BY THE PARTIES.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND
CONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT
BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDERSTAND AND AGREE TO THE
TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS
CONTRACT.YOU ARE ENTITLED TO A COPY OF THIS CONTRAC AT THE TIME OF SIGNATURE.
WITNESS OUR HAND(S)AND SEAL(S)BELOW THIS DAY OF7t1�d
Lowe's Home Centers, Inc'
Specialist or Above 1' Owner Spouse
Customer acknowledges receipt of a true copy of this contractrwhich wAs completely filled in prior to Customer's execution hereof.You,the buyer,may
------ nnfice of cancellation
TERMS AND CONDITIONS
1."LOWE'S"DEFINED.Within this Contract(as defined on the front page of this Contract),the term"Lowe's"shall refer to Lowe's Home Centers,Inc.,a
North Carolina corporation.
2.GENERAL DESCRIPTION.By this Contract,Customer and Lowe's agree that(1)Customer shall purchase and Lowe's shall sell the goods and/or
materials(the"Goods");and(2)Lowe's shall procure on Customer's behalf,and Customer shall pay for,the services to install the Goods(the"Installation
Services")in or on the premises identified on the face of this Contract(the"Premises")for the Contract Total stated on the face of this Contract(the
"Price")and according to the provisions of the Contract documents. The Contract documents shall consist of(1)the face of this Contract,(2)these Terms
and Conditions,and(3)any attached sketches,materials lists,floor plans,and/or specification sheets and other addenda or attachments hereto. The
Contract documents do not include any correspondence,advertisements,estimates or other documents that are not attached.
3.INSTALLATION SERVICES.Customer authorizes Lowe's on Customer's behalf to(a)arrange for the Installation Services to be performed by an
independent contractor(the"Installer")(licensed when legally required),(b)issue a work order to the Installer to perform the Installation Services,(c)have
the Installer's work inspected,should Lowe's in its discretion choose to do so(it being agreed that Lowe's has no obligation to do so),and(d)pay the
Installer after completion of the work and after receipt of a certificate,signed and dated by Customer,that the work has been satisfactorily completed(the
"Certificate of Completion").Customer understands that Lowe's will rely upon the Certificate of Completion in paying the Installer for the Installation
Services.CUSTOMER AGREES THAT THE INSTALLER WILL PERFORM THE INSTALLATION SERVICES ACTING AS AN INDEPENDENT
CONTRACTOR FOR CUSTOMER AND NOT UNDER THE SUPERVISION OR CONTROL OF LOWE'S.Customer agrees that the Installation Services
do not include architectural/engineering services or structural changes to the Premises or any other services beyond the ordinary and routine installation of
the Goods as specifically provided in the Contract.Customer is responsible,at Customer's cost,for providing any necessary architectural/engineering
services or structural changes to the Premises or any other services not specifically identified in this Contract.
4.GOODS.Lowe's will arrange for delivery of the Goods to the Premises.Any surplus materials upon completion of the Installation Services shall remain
the property of Lowe's and shall be returned to Lowe's by the Installer.
5.PRICE.The Price covers the Goods, Installation Services,and applicable taxes.The Price assumes sound existing substructures,superstructure and
points of attachments.The Price shall be increased by the cost and reasonable profit to Lowe's of having to provide additional Goods and/or Installation
Services as a result of defective substructures,superstructures,or points of attachments or the existence of any other Undisclosed Condition(as defined
in section 9 of these Terms and Conditions). In the event of an Undisclosed Condition or the foregoing,Customer will execute a change order or a new
replacement contract upon Lowe's request.
6.PAYMENT. If the Price is$1,000.00 or less,payment of the Price by Customer to Lowe's is due in full upon execution of this Contract.If the Price is
over$1,000.00,Customer may choose to pay in full upon execution of this Contract,but Lowe's may not require Customer to do so.If the Price is over
$1,000.00 and Customer does not pay in full at the time of sale,Customer agrees to pay Lowe's according to the payment schedule set forth in this
Contract.Customer agrees to pay a deposit upon execution of this Contract equal to one-third of the Price.Customer agrees to make a payment for the
balance of the Price less the final payment at least one day after the date this Contract is executed and prior to the commencement of the Installation
Services.Customer agrees to make the final payment upon completion of the Installation Services and Customer's satisfaction.Payment for a new
replacement contract is payable according to these Terms and Conditions.Payment for any change order is due at the time of that change order. Lowe's
will send to Customer by U.S.Mail a receipt evidencing Customer's purchase after Payment is processed.
7.LICENSES,PERMITS,SAFETY RULES,BUILDING CODES,ZONING ORDINANCES,AND OTHER LAWS.The Installer shall be solely responsible
to Customer for obtaining any and all licenses,registrations and certifications which are legally required to perform the Installation Services.The Installer
shall also be solely responsible to Customer for the Installation Services being performed in compliance with all applicable safety rules and all existing
building codes,zoning ordinances and other laws.Lowe's shall be responsible to Customer for obtaining building permits which are legally required to
perform the Installation Services where Lowe's is legally required to obtain such permits.Where Installer is required to obtain such permits then Installer
will be responsible to Customer for obtaining such permits.Customers who secure their own building permits will be precluded from claiming against
certain state guaranty funds relating to home improvements.Neither the Installer nor Lowe's shall be responsible for any pre-existing violations of safety
rules,building codes,zoning ordinances or other laws and shall not be required to address or correct same.If prior to the completion of work a change
occurs to any applicable safety rule,building code,zoning ordinance or other law which requires additional Goods and/or Installation Services to perform
this Contract,Customer agrees to pay Lowe's the cost and reasonable profit for such additional Goods and Installation Services and to execute a resulting
change order or new replacement contract as requested by Lowe's.No additional work will be performed under this Contract due to any change to any
applicable safety rule,building code,zoning ordinance or other law that occurs after the completion of work.
8.CUSTOMER'S WARRANTY AGAINST VIOLATIONS OF EASEMENTS,COVENANTS,AND THIRD PARTY RIGHTS.Customer warrants that
performance of Installation Services will not violate any existing real property easements,covenants,homeowner's association rules or rights of third
parties holding an interest in the real property being improved.
9.UNDISCLOSED CONDITIONS IN PREMISES.If Installer discovers any defect,weakness or dangerous condition including,but in no way limited to,
mold,mildew,rot,asbestos or infestation("Undisclosed Condition")in the Premises'structure,substructure,super-structure or points of attachment,
Customer must remedy the Undisclosed Condition at Customer's sole cost and expense and to Lowe's sole satisfaction.If Customer refuses to permit
inspection of the Premises as set forth below, Lowe's may terminate or rescind this Contract without remedy or recourse by,or further obligation to,
Customer,except as expressly provided below. If Customer and Lowe's disagree as to whether an Undisclosed Condition exists,Lowe's may in its sole
discretion obtain the services of an inspector to inspect the Premises at Lowe's sole cost and expense,and if Lowe's chooses to do so,such inspector's
report shall be final and conclusive as to whether an Undisclosed Condition exists. In the event of any Undisclosed Condition that Customer does not
remedy to Lowe's sole satisfaction,or any failure by Customer to perform any other obligation of Customer under this Contract,then at Lowe's option(1)
Lowe's may rescind this Contract and return the Price to Customer without further cost or obligation by either Customer or Lowe's if Lowe's notifies
Customer of its election to rescind this Contract prior to the earlier of delivery of the Goods and the Installer beginning performance of the Installation
Services,or(2)Lowe's may terminate this Contract without remedy or recourse by,or further obligation to Customer,except as expressly provided below if
Lowe's notifies Customer of its election to terminate this Contract after the earlier of delivery of the Goods and the installer beginning performance of the
Installation Services. In the event that Lowe's terminates the Contract as provided in this Section,then Customer may return the Goods(other than Goods
that have been"custom-made")in their original,unopened condition,to Lowe's for a refund or credit.Any such return must be made within 30 days after
Lowe's terminates this Contract.Customer will be charged a 15%restocking fee on any such returns.Goods not in their original,unopened condition,and
custom-made goods,may not be returned."Custom-made"goods include goods that have been uniquely altered,color-matched,shaped,sized,cut or
otherwise designed or fitted to accommodate the requirements of a particular space or environment.Examples of custom-made goods include,but are not
limited to,cabinets,countertops,floor and wall coverings,and window treatments.If Lowe's terminates this Contract as provided herein,Lowe's shall have
no obligation to refund any portion of the Price(except as expressly provided herein)and shall have no obligation to restore the Premises to their original
condition.
10.CUSTOMER'S RESPONSIBILITIES:Customer agrees to pay Lowe's according to these Terms and Conditions.Customer agrees to facilitate the
location of utility lines.Customer is responsible for identifying property lines.Customer agrees to ensure that work area is free of vermin and pre-existing
physical or environmental hazards,and building/zoning code violations.Customer agrees to provide the Installer with access to work areas during working
hours and to provide access to sanitary facilities or to pay the rental costs for such facilities.Customer agrees to ensure that any security system at the
Premises will not interfere with performance of the Installation Services.Customer agrees to provide power to,as applicable,climate control in,the work
areas.Customer agrees not to allow unattended minors at the Premises while the Installer is present.Customer agrees to control and keep pets away
from work areas.Customer agrees to keep posted permits on display at all times.Customer agrees that if Customer or anyone Customer controls
interferes with or delays performance of the Installation Services,Customer may be subject to transportation/storage charges or other resulting charges.
Customer agrees not to assign or transfer this Contract.Customer agrees that any claim against Lowe's or the Installer under this Contract should be
made to Lowe's within thirty(30)calendar days of the date Customer first becomes aware of a problem.(Lowe's will attempt resolution of any claim(s)
within sixty(60)calendar days of receiving Customer's notice.)CUSTOMER ASSUMES THE RISK AND THE FULL LIABILITY OF PHYSICALLY
ASSISTING WITH DELIVERY OF THE GOODS OR WITH PERFOMANCE OF THE INSTALLATION SERVICES.
11.MANUFACTURER WARRANTY FOR GOODS. Customer is entitled to any warranty provided by a manufacturer of the Goods sold under this
Contract.The Installer will provide Customer with any manufacturer consumer warranty information accompanying the Goods,and Customer may also
obtain such information by contacting Lowe's.Lowe's does not warrant the Goods AND EXPRESSLY DISCLAIMS ALL WARRANTIES,EXPRESS OR
IMPLIED TO THE FULLEST EXTENT PERMITTED BY LAW.
12. LOWE'S WARRANTY FOR INSTALLATION SERVICES/LIMITATIONS OF LIABILITY.
Lowe's does warrant that the Installation Services will be performed by the installer in a good and workmanlike manner.Lowe's warranty for Installation
services shall extend for a period of one year from the earlier of(1)the date the Certificate of Completion is signed by Customer or(2)the date that Lowe's
determines that the Installation Services have been completed,or for such greater period as may be required by applicable law governing consumer
warranties for workmanship(the"Warranty Period"). LOWE'S WARRANTY THAT THE INSTALLATION SERVICES WILL BE PERFORMED BY THE
INSTALLER IN A GOOD AND WORKMANLIKE MANNER DOES NOT COVER,AND LOWE'S WILL NOT BE RESPONSIBLE FOR,ANY DEFECT IN
SUCH INSTALLATION SERVICES DUE TO(1)ANY DEFECT,WEAKNESS OR DANGEROUS CONDITION,INCLUDING BUT NOT LIMITED TO,
MOLD, ROT,ASBESTOS OR INFESTATION IN THE PREMISES'STRUCTURE,SUBSTRUCTURE,SUPERSTRUCTURE OR POINTS OF
ATTACHMENT,OR OTHER PRE-EXISTING PHYSICAL OR ENVIRONMENTAL HAZARD,OR(2)ABUSE,MISUSE,NEGLECT,OR IMPROPER
CLEANING.LOWE'S WARRANTY FOR INSTALLATION SERVICES SHALL BE IN LIEU OF ANY OTHER WARRANTY EXPRESS OR IMPLIED TO
THE FULLEST EXTENT PERMITTED BY LAW. _
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Pella Corporation
20 Replacement
NFRC Double Hung
Annealed m �
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Natioriai Fwixtfation SunDefenseUM)Low—E
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ADDI i ZONAL PERFORMANCE RATINGS
Visible Transmittance
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anuhcmMr sopulates that these radngs conform to applicable NFRC procedures for detemlinin
hole product perlor'narics.NFRC ratings are determined for a fixed set of environmental condit! e
fill a specific product size. NFRC does not recommend any Droducts and does not warrant the
ItabI IV of Day prouuct for any specific use. For more Information,call(641)621-5114 or visit
Papa's web aIle at wdw. ella.com or visit NFPC's web site at www.nfro.o
V.ead load
Design Pressure � , , ,
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WD11A I iic, in. Pelle products labeled with the an VAndow i Door
eo livers�� Ion ( I 11111111111 CrrUllostion en tasted In eoomdaaoe weh
applicable WCIAA p..formence standards, which requires products be tested for air
infiltration. rater infiltration, and structural pertonner.cs. Peiormaoos of Pogo products
will ohenke over time depending upon the conditions of use. For details on Hallmark
16 Certification, go to www.wdme.com
2nlin vAM HUD 111(Gaapburg.PA)
Comp
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Florida Product Aporovd dem(FPAsi Number1l.111112
Glaring tips and lhickn=Anneded.2.9AMbcth prase.assigned per ASTM E1300
Window or Door Aatuil erre:311.25II'YNde br4eaaa"tell
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ConstructionSUDerviso: License
License: CS 42MS
Restricted to: OO
BRUCE J BAKER t
122 GORHAM ST
CHELMSFORD, MA 01824
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'"� Expiration: 316/2012
(..iaiui..i.,ner Ts=: 17748
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One Ashburton Place -Room 1301
' Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 112380
Type: Private Corporation
Expiration: 3111f2011 Tr# 281134
B B CARPENTRY SERVICE
BRUCE BAKER
122 GORHAM ST. -
CHELMSFORD, MA 01824
Update Address and return card.Mark reason for change.
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ERTIFICATE 18188UED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE
FICATE HOLDER.i He CERmFicATE Df�NOTAMEND.EXTEND OR ALTER THE COVERAIGE AFFORDED
E POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN
RUING IN$U AUTHORIZED REgR M04TAMVE OR PRODUC AND THE CERTIFICATE HOLDERTANT: If the CwWkMe holder is an ADDITIONAL INSURED.the poicT ms)moatbe endorsed. if 8UBROGATION
UED,subiedtothe terms wdcmdffamafthepercy,c�n.polannuvwandendomon md. AWMhm antcerfcate does not confer rdft b dte cerIM holder in leu of such endonlernent.
PRODUCER
D F M wphy in
201 NWh St
Groton.MIA 10
INSURED COMPANY A GAIMITE STATE INSURANCE COMPANY
Bb cerpt "Saevbm Inc
122 Gornm St
Chehettdbrd.MIi►OI 24-moo
THS Is TO CERnFYTHATTHE poUCW OF MMWE LMW tiE3 W MANE MW ISSEJ M TO THE Rbc Iiia ABOrE FOR
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OOCLUENT WITN WWW T TO WH CH TNS CERnRCATE MAYBE t8SM OR.MAS' tAK Tk+.E INBL CE AMr.WMTHIE
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CERTMATE HOWER CANCELLATM
LOV40 COMPANIES INC is IMWAIWCFTMEADMO ragsra,;ARCgst jWO M M
UT=9=7K5WW-K9=WU8E*KMRW RAC=RPAWZ
PO BOX 19 41 wtne t++ot.�cr s
NORTH WIUQMBORO.NC 2M6
AUTH RMWFIEBWATIWE .�
� .cl fr8 T Sb9t €3G6 T as n.ci aon,a�r e96 :80 OT 60 i nC
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ACC>cam® CERTIFICATE OF LIABILITY TTY INSURANCE Q�2��z0
PRODUIrER TSitS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION
Jay Colangelo Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
289 Chelmsford Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Chelmsford, MA 01824
—-...
INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA Arbella Protection Insurance
- i
BB Carpentry Service Inc INSURERS:
122 Gorham St INsuRERc
Chelmsford, MA 01824-3230 INSURER -
I _ INSURER E
COVERAGES -THE POLICIES OF LISTED BELOW HAVE BEEN ISSUED TOTHE INSU{ D NAMED
ABOVE S ECT TOWHIC!ILICY THIHIIS CERIOD TIFICATE CTA C.NOTWIT E NAY BE ISSUEEDIOR
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCuPJi1=N
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN is sua;ECT'rO ALL THETERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIDCIAIMS.
----
----- — .--- _ POLICY EFFECTIVE PO:lC'EXPIRATION
INSR AIX)'L POLICY NUMBED LIN9TS
GENERAL LIABILITY I EACH OCCURRENCE y$
r�'� DAMAGE TO RENTED
'�`'TI�COM1IPJIERCIAIGENEtRA�LL�WBILi-r P MISE OVUM
4 I
. .- .CLAIMS._MADE_ 1 f OCCUR,_ MED EXP(Arryorepason) — $ —.
- - — I PDtSON0.LS ADV INJURY 1 3
I � � GENERAL AGGREGATE IS
I
GEN'L AGGREGATE LIMIT APPLIES PER I PRODUCTS-CAM_------- I S
POLtGY
AUTOMOBILELIABILITY I E COMBINED SINGLE Lih9R
(Ea accidk r4) 5
A I X ANYAUTO 'CA-NB-13621. ^�?7f I.C1 1I27f11 I
i ALLOWNED AUTOS BODILY INJURY S 100,000
1' SCHEDULEDAUTOS (Perp son)
4 HIREDAUTOS BODILY INJURY 300,000
NON-OWNED AUTOS i (Peracddent) --
f PROPERTY DAMAGE ! $ 100,000
I I(Per accident)
_GARAGE LIABILITY I AUTO ONLY-EA ACCIDENT $
{ _ ANY AUTO I OTHER THAN EA ACC $
1 AUTO ONLY: AGG S
I
�.
EXCESS IUMBRELLALIABIUTY EACH OCCURRENCE $
OCCUR CLAIMS MADE I kc GATE $ _
S
�J DEDUCTIBLE I S
! I j RETENTION $ i
is _
WORKERS COMPENSATION t+Yc STATITS 1 40FR i AND EMPLOYERS'LIABILITY YIN
ANY PROPRIEI'ORIPARTNERIEXECUTIIIE i j E.L.EACH ACCIDENT
S
OFFICERAMIABER EXCLUDED?
(Mandatory in NH) E.L.DISEASE,EA EMPLOYEE1 $
Ifyes,describe under E.L.DISEASIF-POLICY LIMIT $
SPEGAL PROVIS IONS below
OTHER 1
DESCRIPTION OF OPERATIONS!LOCATIONS f VEHICLES I EXCLUSIONS ADDED BY E-14DORSEMENT I SPECIAL PROVISIONS
:Additional Insured: ]Lowes Companies Inc. and any and al]_ subsidiaries are named as
.additional insured as respects to Auto Liablity,
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OFTHEABOVE DESCRIBEDPOLJCIES BECANCELLED BEFORE THEEXPIRATK)N
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
Lowes Companies, Inc NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
i ATTN. IS INS IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
PO Box 1111 1 REPRESENTATIVES.
N Wilkesboro, NC 28659 AUTMDROMREPRESENTArnE
1Jaq Colangelo
ACORD 25(2009101) O 1:188 09 ORD CORPORATION. All rights reserved.
The ACORD name and loco ara reoistPredmarks of ACORD
9 'd f19 1 SbS17I3L6 i _Ia deg C eon-JR eGE =80 01 60 i nC
The Commonwealth of Massachusetts
,�� r Department oflndustrial Accidents
Office of Investigations
600 Washington Street
d e Boston,MA 02111
`"'�%;• P" www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please PrintLegibly
Name (Business/Organization/Individual): eCe�sy' � ill� c�YZ
Address: fa lye
City/State/Zip: d� 1.S��X z/ Phone#:
Are
ou an employer?Check the appropriate box: Type of project(required):
1 I am a employer with 4. ❑ I am a general contractor and I 6. E]New construction
(((((( employees(full and/or part-time).* have hired the sub-contractors
2.[:1I am a sole proprietor or partner- listed on the attached sheet. ❑ 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 10.❑ 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.E] Roof repairs
insurance required.]t employees. [No workers' 13 Other //�Q,� �t w 73
comp.insurance required.]
*Any gipplicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am 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.#: y� � � Expiration Date: �a
Job Site Address: Vt`f 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 the DIA for insurance coverage verification.
1
I do hereby certify under the pains and penalties ofpetjury that the information provided above i true and correct..
Si ature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house 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),addresses)and phone numbers)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 cavy 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 confinnation 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 sur&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 pennit/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 pen-nits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or pen-nit 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.govldia