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HomeMy WebLinkAboutBuilding Permit #092-2017 - 490 MAIN STREET 7/27/2016 DZIJ 490 Location l No. L✓�� --��b17 Date r • - TOWN OF NORTH ANDOVER „a.•.;;� � �v < spy.. � ,y Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ r Other Permit Fee $ TOTAL $ Check# r r `-Building Inspector �/ I \ f` !�^ BUILDING PERMIT a<<. • ' 0 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIO Permit NO: t - 11 Date Received 04 Ca;K:.�. • 1V 1i9s3 Oreo��,�� Date Issued: 21 I 1 ACHUS IMPORTANT: ApPlicant must com lete all items on this page ..-L( CATION Gly ST PROPERTY OWNER L' . . Print Sas `�i=cz� ii Print MAP NO: I PARCEL,. ZONING DISTRICT: Historic District yes nn Machine Shop Village yes ' TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: [commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other C Septic O Well ❑Floodplain b Wetlands ❑ Watershed District o Water/Sewer �r ��[� S1 tl�� F.c�—�(15� a a.� �LGi � V,t�,�JtU°v, in T afi(1 �kS �jeln� Identification Please Type or Print Clearly) OWNER: Name: —Sm ��,o�1 i Phone: q"?Ir- G Pt-?") 7'1 Address: ,3S A r r �c s,(- Zct r.c N�, G t:p q 3 ,. „ rte: . �; CONTRACTOR Name:" "��5 - Pho �- Address: n Supervisor's Construction License: .Exp. Date: p rat License Exp._ Date: Home Im roveme. l'77aoa �� 1y a � ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ )foaD•"'o FEE: $ kt Check No.: h Receipt No.: 2ja05 NOTE: Persons contracting with unre istered contractors do not have access to the guaranty fund Signature of Agent/Owner �` - _ e of contractor . fORT11 BUILDING PERI!�!T" OF NLED ,6'91• 9�+St -��= 16 TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION 4 Permit No#: Date Received gSSACHUS�� Date Issued: - IMPORTANT: Applicant must complete all items on this page i LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family [I Industrial ❑Addition ❑Two or more family ElAlteration No. of units: [i Commercial ❑ Repair, replacement-- ❑Assessory Bldg ❑ Others: ❑ Other [IDemolition Sep ,, f U oliFS dan ® e.�tla.«nds tc 0 ' hed a istrict DESCRIPTION OF WORK TO BE PERFORMED: I i Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: fl Home Improvement License: Exp. Date- ARCH ITECT/ENGINEER ate:ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: . - Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ...,s. ...mss_ 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 4 Building Permit Application 4� Workers Comp Affidavit 4, Photo Copy Of H.I.C. And/Or C.S.L. Licenses � Copy of Contract 46 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) j Building Permit Application 4, Certified Proposed Plot Plan 46 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 IECC 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 i Doc:Building Permit Revised 2014 i �1 Plans Submitted ❑ Plans Waived❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanni g/Massage/Sody Art ❑ Swiwming 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 LANNING & DEVELOPMENT Reviewed On /ZI�11 Signature_ MMENTS_ nJ!r&U;41 1 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on :(:k=Sinatur COMMENTS ejyjo(U_ Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes NPlanning Board Decision: Comments Conservation Decision: Comments Wafter& Sewer Connection/ Driveway Permit DPW Town Engineer: Signature: FIRE DEFA {, -_- Located 384 Osgood Street J � RfTMENT� Temp Dumpster onsite ,ayes '' " ` -�, t�Located at 1241VIain Street * t19 e partment si gnafutr�e/date .' tfi• It3Wk T-MV, 77 �r r COMMENTS. ... p s t�` '` i� t` ,' �`_� p � � _. . �.z f _ _ ..r• SiAi�TL[' �, - - L I Dimension I • 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) (?ItAnj. 40 6t- C6.;X�4 i ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 r 7/28/2016 KITCHEN REPAIRS-Laserfiche WebLink tLaserfiche" WebLink' Home - Browse - Search Town OfNorthAndover8>Properties>M>MAIN STREET>0490 MAIN STREET>Buildil Metadata I Thumbnails I Annotations Iu 18 GO ( PDF F #....... .. _.. _.X ti KITCHEN REPAIRS a Last Modified i 7/28/2016 12:52:45 PM { Creation Date ; 7/28/2016 10:22:10 AM 4 i i Fields Template: Property PPL Document Datet1l � NC 7/27/2016 �� , Street Name MAIN STREET T Street# _ Date issued. i 490 - ! Address ; FTT' i 490 MAIN STREET Parcel ; 071.0-0025-0000.0 ¢ -+ Owner—Name SAL LUPOLI z ; I Department II ` 9 Building RIP: NER R Document—Type Permitsg Department Subfolder 1 . F � 9 Building Permits r Business Name w - P SAUS PIZZA Public Yes k TYPE IMPROVEMENT PR( Rec. i D New Building I:1 _ Ei Addition Document management portal powered by Laserfiche , _....:. . .. WebLink 8.2.2©1998-2013 Laserfiche http://records.northandoverma.govMebLi nk8/DocV ew.aspx?id=107378&dbid=0 1/1 s� VvL;,fj PDQ= �t �,a�- NVA, "N"M A 0�3 1Ne�l-;JL A-I f NORT1y q BUILDING PERMIT 3 b'`.``�.�: °0 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIO Permit N0: 1 Date Received Zt nn � 1q COCMKMiw C V Date Issued: 2� l� kV �9SSgcNUs t� IMPORTANT: Applicant must complete all items on this page LOCATION__ N►G�� 5} Print _ PROPERTY OWNER �A L S P1 UA Print MAP NO: PARCEL. ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: &,6ommercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other r _ ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer p zRJy \ �� , a�y,�r Ca_c�t{� `nJ�,� t �I���,4�'. �►�-? Identification Please Type or Print Clearly) OWNER: Name: Phone: q`7 g= to Pt-?"7'7 Address: Ma 019,q3 CONTRACTOR Name: Phone: 7% Address: S ' k)k\, 0WAS,ea Is Supervisor's Construction License: Exp. Date: ct -as � c7 Horne Improvement License: 77 Exp. Date: l y 7 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.•$1200 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ I fC>ooFEE: $ kt Check No.: -2)sh�2 Receipt No.: 22holvi NOTE: Persons contracting with unre istered contractors do not have access to the guaranty fund Signature of Agent/Owner _ �% Rinm%fiira of contractor Plans Submitted ❑ Plans Waived❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE of SEWERAGE DISPOSAL t Public Sewer ❑ Tanning/Mas sageBody 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 FORINT LANNING & DEVELOPMENT Reviewed On Z1z,4I1 Signature_ �i'�r.•i MMENTS- /Aj?(-,-XjLjA-1 CONSERVATION Reviewed on Signature COMMENTS WEALTH Reviewed on Si natur COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decisionlreceipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Server Connection/signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street .FIR€ DEPS ` , t E T nes 4ye �. �.►�.., no ' : - � ART Tem Dempster o �f � at t 12, a <p e; 4Loc ed a St�re_et Fi ,re Department signature/date _ rF{+y �4 `��yf,•'3 NOPit Town of '2 . : � Andover h ver, Mass, 21. 74 Ito 190 COCNICl/l WICK 'll.9s RATED U BOARD OF HEALTH Food/Kitchen PERMIT Septic System ........SJ�s THIS CERTIFIES THAT .. Pat, BUILDING INSPECTOR ...... ..................... ...... .... .... ................... 0 Foundation has permission to pect .......................... buildings on ....... ... ........ .. !.... ....a . ................. Rough gee to be occupied asQ . . ... 1...... ...Qkqft +the . . .&............... Chimney provided that the person accepting this permit shall in every respect conw . form terries of the application Final on file in this office, and to the provisions of the Codes and By-Laws relatina to the Inspection, Alte ation and Construction of Buildings in the Town of North Andover. N! b W- k PLUMBING INSPECTOR 1 VIOLATION of the Zoning or Building Regulations Voids this Permit. pliok Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST - TIO Rough j Service .. ... .... ........... . .. .........:.......... Final IN INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. 1 1 t _ 41 411 I - _,veb,d : a W 'r-m JU�1V� * r , f , � t I I • i � E 1 1 � I 1 (�^,� � 1 ' � r _ r , E 4 1 1 E Z A 3L ........... -T-4 Cz OWN) oil Val -----------2 L. T-- __ _.�__ �._�.�_____...� ..�_..__��.�,. ...v ..�„ .,�,. p�,. � �.b � _ cif N `c. ��� �..1 �^�: t� ;L... W 17, T'I-) I�Z oil A lei IA .. ... . .... . Vo f A lei 'IfO IN . .......... AJ Vj A vq f-A A B C D E - 0 LiVIJ1 REF. 60 a"- NEW FULL HEIGHT VWLL to 1 ' 14'-0" ccMGN NEL GWNTIiIt r INFILLF JST.WNUl W:: I ' ' Itl'Mf)Vt.l'[WHIM.10 111 Ili \ NI.WI''nli'tIn1,IIF11111'IWAII. \ N/11.1.I'UIIVI,iUAl.lt](IItM'I'lll',Wnll — jig ut-- '111'+111fil' ' f �t - 1 111 �i in Ltl ren p�nri Ir Bull to ltul:�nitnl Ild,II fr'I' Correct Build & Installations 5 Shoreline Drive Hudson, NH 03051 (603) 886-1792 (603) 759-1909 TO: Sal's Pizza DATE: 07/05/2016 490 Main St. North Andover, MA 01845 REF: Renovations / Repairs to Kitchen area. ATT: Greg Ryan(603) 421-5578 gryan(a_sals-pizza.com / Phil (978) 852-1717 mccabe.phiI@comcast.net We hereby agree to furnish all labor as described below. Renovate/ repair existing kitchen area (phase 1) as per final walk through on 07/01/16 with Greg and Phil. MOP SINK AREA: Remove existing FRP, drywall and tile floor as needed. Remove mop sink and fixtures. Remove any damaged sub-floor in general area of mop sink, if applicable. Remove and stud framing if applicable. Remove vinyl cove base. Repair/ replace plumbing lines, etc. as needed. Repair/ replace stud framing as needed. Repair/ replace any sub-flooring a needed. Install new drywall. Install new FRP with applicable moldings. Install aluminum angle 4'0" tall on outside corners of walls. Install new quarry tile. Install new mop sink with fixtures. Install new vinyl cove base. WALK-IN COOLER: Install 1/8" aluminum diamond plate panels on the interior walls and door of cooler. The height of the panels will be 48" high and adhered using both glue and mechanical fasteners. The door will have an exposed perimeter of what is there now so when panel is added the door will close and seal properly. Fill in all other damaged areas with aluminum colored silicone. CORNER WALL NEAR WALK-IN COOLER: Remove existing FRP, drywall (if applicable), shelves and brackets. Remove vinyl cove base. Install new drywall (if applicable). Install new FRP with applicable moldings. Install aluminum angle 4'0" tall on outside corner of wall. Install new wire or solid shelving with brackets. Install new vinyl cove base. NEW INTERIOR DIVIDING WALL: Frame new interior wall app. 14'0" x 10'0" (extending existing wall). Install drywall on both sides of the new wall, tape and mud to receive stainless panels, by others. INTERIOR VESTIBULE: Remove existing glass panels (by others). Remove existing casings and trim as needed. Frame in openings. Install new drywall, tape, mud, sand and prime in-fills to be paint ready. REPAIR OF EXISTING DIVIDING WALL (Sagging): Remove quarry tile on both sides of existing wall. Temporarily support existing wall from basement. Make relief cuts on both sides of existing wall. Lift wall as best asp ossible. Install LVL beam under the existing wall in the basement to include lally columns to support the existing wall as best as possible from future sagging. Install new quarry tile as applicable. INCLUDES: Applying for Building and Plumbing Permits. Disconnecting, re-connecting of plumbing for mop sink and fixtures to include any insignificant repairs if applicable. Removal and disposal of all debris to customers dumpster. Cleaning of all products installed by Correct Build & Installations. EXCLUDES: Any Permits, Fees and inspections, if applicable. Any materials of any kind to include all job supplies etc. Any other additional work other than what is listed above. NOTES: *** All permits, fees and inspections by others, if applicable. *** All work is to be completed during off hours as best as possible. *** All work is to be completed on a time and material type basis. The hourly labor rate is $60.00 per man-hour. *** All materials to include any and all job supplies etc. are to be by Sal's Pizza. *** Any and all architectural, engineering, stamps etc. to include all applicable fees and or expenses affiliated with, will be the responsibly of Sal's Pizza. *** If any existing / additional damage becomes present during construction and or other items need to brought up to code the customer will be notified. These repairs will be completed on a time and material type basis if needed. Both parties will agree upon legal repairs, prior to completing the work. *** No warranty/ guarantee of any kind now or in the future against mold, mildew etc. due to existing conditions. This is the responsibility of the Building / Business owner/ Insurance carrier and should be confirmed that there are no current issues prior to completing the repairs / renovations. **** THIS PROPOSAL IS FOR BUDGETARY PURPOSES ONLY AND IN NO WAY CONSTITUTES THE EXACT AMOUNT OF MONEY TO BE PAID FOR THE SCOPE OF WORK LISTED ABOVE. THIS PROJECT IS TO BE COMPLETED ON A TIME AND MATERIAL TYPE BASIS AS STATED IN THE ABOVE PROPOSAL. THE AMOUNT i PROPOSED IS A BUDGETARY NUMBER AND MAY INCREASE OR DECREASE BASED ON THE MATERIALS USED AND THE TIME / MAN HOURS TO COMPLETE THE WORK STATED IN THIS PROPOSAL... TOTAL BUDGETARY PROPOSAL: $15,000.00 +/- PAYMENTS: 25 % Deposit prior to starting work. Weekly progress billing and payments based on work completed to date. Final payment to be paid within 21 days after completion of work (phase 1) is completed. ACCEPTED BY: CORRECT BUILD AND INSTALLATIONS: DATE: DATE: THANK YOU FOR THE OPPORTUNITY AND LOOK FORWARD TO WORKING WITH YOU! jau0!ss11-UU�00 ` ��,/ LiOZlgZlii e rymr�iarrrura//�r ava��rt/urel/i .U0,. dX3 Office of Consumer Affairs&Business Regulation r HOME IMPROVEMENT CONTRACTOR ' tlW Ot{WRlb3W Registration:(- 77202 Type: 098 o 3alSt4. Expiration: �i[fA2g17 LLC 1Nd,idO3S3-j-d04 CHARLES E.GALLAtG�NACING LLC. �' 30s►njadnS uo►;onygsuoD CHARLES GALL-AN t06d6�sO o p Geos Q� 30'1 EDGARWATER CAGE SUK,E �:;. �,. - suolleln6al �ujPlasn%A:) seW r ' ue�s p ed a VVA�CEFIELD;MA 01880 yep ue uawli a s�? Undersecretary q s�}a}eS ollgnd �o} i s Charles E Gallant General Contracting LLC. 285 Commandants Way Chelsea Ma,02150 1-781-248-6290 Ra Ilant.charles@yahoo.com July 18, 2016 Correct Build and Installations LLC 5 Shoreline Drive Hudson NH,03050 Job Location=490 Main St, North Andover(Sal's Pizza) Dear Ron: I propose to provide labor and materials as per scope of work listed below for the sums of; SCOPE OF WORK Include: Providing Labor for- Supervision General carpentry Metal work Tile work FRP Drywall and taping Protection and cleanup Excluded: Electrical and plumbing Supplying any Material Any Work not approved from owner Work is to be performed on a time and material cost. If any Material is purchased, Reimbursement is requested immediately. As noted at bottom of proposal 40.00 per Hr. Per man. Work is to be performed in a neat and clean manner Clean site daily. .r This proposal is valid for(30)days and furthermore subject to market conditions in regard to the building material cost inflation. If you should have any questions regarding this proposal or there are any changes, please call me at your earliest convenience. Any work performed under an agreement of time and material will consist of$40.00 per hour per man plus material cost. At any time,this project falls behind on payment work will seize and will affect schedule. Work will proceed when payments are current. If for any reason the scope of work grows and will not fit in time frame requested, new schedule will have to be rewritten. Professionally Yours, Charles E Gallant I agree as the agent or manager of Correct Build and Installations to have Charles E Gallant perform as contract states at time and material. Materials will be supplied by others and if any material is purchased by Charles E Gallant General Contracting they will be reimbursed as soon as receipt is summited. Authorized Agent or manager i I i I i I ASR ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 07/20/2016 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(les)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: Timothy LaRovere FRANCIS J. LAROVERE INSURANCE AGENCY INC. H N : (617)387-9700 (A/C,c No DDE-MARess: tlarovere@larovere.com 492 BROADWAY INSURERS AFFORDING COVERAGE NAIL# EVERETT MA 02149 INSURERA: ATLANTIC CHARTER INS CO 44326 INSURED INSURER B: CHARLES E GALLANT GENERAL CONTRACTING LLC INSURERC: INSURER D: 7 BURNSIDE LANE INSURER E: MERRIMAC MA 01860 INSURERF: COVERAGES CERTIFICATE NUMBER: 70402 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. ILiRR TYPE OF INSURANCE ADDL UBR POLICY NUMBER MM/DDY EFF MMIDD EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGES(RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PRO- [7JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINEDSINGLELIMIT $ Ea accident ANY AUTO h° BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY Per accident $ AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR i. CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X STATUTE ETH AND EMPLOYERS'LIABILITY Y/N -- ANYPROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUE NIA NIA NIA WCV01276600 12/09/2015 12/09/2016 — (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be 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 HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. TOWN HALL AUTHORIZED REPRESENTATIVE C NORTH ANDOVER MA 01845 Daniel M.Crey,CPCU,Vice President–Residual Market–WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I GALL-05 OP ID: MG AEP' CERTIFICATE OF LIABILITY INSURANCE DA071201201 I� 07/20/2016 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 F.J.LAROVERE INSURANCE AGENCY NAME: 492 BROADWAY PHONE FAX (A/C.No Ext): AIC No EVERETT,MA 02149-3617 MAIL DANIEL J.LA ROVERE,ESQ.,CPCU ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC d INSURER A:WESTERN WORLD INSURANCE INSURED CHARLES E.GALLANT INSURER B: GENERAL CONTRACTING,LLC 7 BURNSIDE LANE INSURERC: MERRIMAC,MA 01860 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE 1NSR WvD POLICY NUMBER MMIDD MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000100 A X COMMERCIAL GENERAL LIABILITY NPP8183921 09/09/2015 09/09/2016 PREMISES Ea occurrence $ 100,00 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'/AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 11000,00 POLICY jECT F]PRO- F] LOC $ AUTOMOBILE UABILITY Ea COMBIN SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS PER ACCIDENT UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY UMITS PER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTfON OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,K more space Is required) ADDITIONAL INSURED: TOWN OF NO. ANDOVER CERTIFICATE HOLDER CANCELLATION NOANDOV SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF NORTH ANDOVER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN HALL ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER,MA AUTHORIZED REPRESENTATIVE DANIEL J.LA ROVERE,ESQ.,CPCU ©1988-2010 ACORO CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD I The Commonwealth of Massachusetts Z Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Avylicant Information Please Print Legibly Name(Business/Organization/Individual): E rink 14 LJ Address: o2 gs CON\M kw r,,.d City/State/Zip: (� }e�Sr_l� Ca 1�,)a Phone#: 7111 q?~6 d 10 Are you an employer?Check the appropriate box: Type Of project(required): 1.[yl am a employer with__employees(full and/or part-time).* 7, ❑ any capacity.[No workers'comp.insurance required.] ew construction 2. am a sole proprietor or partnership and have no employees working for me in ❑I 8. Remodeling 3.[]]am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 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.❑ROOFrepalLS 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#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. +Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. r Insurance Company Name: LAVL'�I G 1 n gd , Policy#or Self-ins.Lic.#: W C V6 Q-X Ob Expiration Date: f p Job Site Address: 4 �[� ka�—/ City/State/Zip: MA U 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 and h pains a pe es of perjury that the information provided above is true and correct. Sign —1 � Date: _01 " Phone#: ` X C7���9a 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#: