HomeMy WebLinkAboutBuilding Permit #686-2017 - 495 Forest Street 1/3/20171111 hAN 4 V,
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: 6y - Date Received /* .
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
)4 One family
R t:
0 Addition
El Two or more family
0 Industrial
)�Alteration
No. of units:
0 Commercial
0 Repair, replacement
El Assessory Bldg
0 Others:
0 Demolition
0 Other
1�Septc,Well
FloO'pa7 in" Wetlands
Watershed
EL7.
E)ESGKIF I IL)Nrt- VVUKtX I Li or rr-mrunivir-Li.
SL �
OWNER: Name:
Address: q95 �e,
- Rlease Type or Print Clearly
Phone;
Phone:
ARCHITECT/ENGINEER Phone:
Reg. No.
Address:
FEE SCHEDULE. BULDING PERMIT: $12,00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
'._,rotal Project Cost: $ 0C)o FEE: $ 37
Check No.: Receipt No,: 13139
NOTE: Persons contracting with unregistered contrac ors do not pave: accfo ta-the g ntyfund
'Acontractor
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Sup -s tfu
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ARCHITECT/ENGINEER Phone:
Reg. No.
Address:
FEE SCHEDULE. BULDING PERMIT: $12,00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
'._,rotal Project Cost: $ 0C)o FEE: $ 37
Check No.: Receipt No,: 13139
NOTE: Persons contracting with unregistered contrac ors do not pave: accfo ta-the g ntyfund
'Acontractor
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Plans Submitted
Plans Waived Certified Plot Plan ❑ Stamped Plans ❑
TypE'OF SEWERAGE DISPOSAL
Public Sewer ❑
Tauning/MassageBody Art ❑
Swimming Pools
well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
permanent Dempster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
CONSERVATION
COMMENTS VLO
Reviewed on
Signature
HEALTH Reviewed on -11-72-,00 IV - SianatureA "Vt"T
\Q
COMMENTS � ------- --- -7 -.1 OP�
mooning Board of Appeals: Variance, Petition No:
A
Planning Board Decision: Comments
6
ing Decision/receipt submitted yes
Conservation Decision: Comments
Water & Sewer Connection/SLgnaiure Date Driveway Permit
DPW Tomo. Engineer: Signature:
Located 384 Osannd Street
rime ur-r-Ate i MLN I I emp Dumpster on site yes no v
Located at 124 Main Street
Fire Department signatureldate
COMMENTS
iimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, roast or service drop requires approve! of
Electrical Inspector Yes No
DANCER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
Doc.Building Permit Revised 2014
r
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
r
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.1. C. And C. S. L. Licenses
❑ Copy Of Contract
o 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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
• Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Building Permit Revised 2014
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 319000.00
m
$ -
$
372.00
Plumbing Fee
$
46.50
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
46.50
Total fees collected
$
565.00
495 Forest Street
686-2017 on 1/3/2017
basement remodel
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AGREEMENT FOR SERVICES
This CONTRACT satisfies all basic requirements of the State's Home Improvement Contractor
Law (M.G.L.c. 142A), but does not preclude parties from adding language to protect their specific interests.
Seek legal advice if necessary. Before agreeing to any home improvement work on your residence you
should obtain a free copy of "Consumer Guide to Home Improvement Contractor Law" by calling the
Office of Consumer Affairs and Business Regulation's Information Hotline at 617-973-8787.
You may cancel this Agreement if is has been signed by a party thereto at a place other than an
address of K & R Contractors, Inc., which may be its main office or branch thereof, provided you notify K
& R Contractors, Inc., in writing at its main office or branch by ordinary mail posted, by Telegram sent or
by delivery, not later than midnight of the third business day following the signing of the Agreement.
See Attached Notice Of Cancellation For An Explanation Of This Right.
Homeowner Information
Josh Haley
495 Forest St
North Andover, MA
Kenneth Roy, President
Business Street Address
K & R Contractors, Inc.
I Campbell Road
North Andover, MA 01845
Business Phone: 978. 726.5062
Federal Employer ID: 000961723
Salesperson(s): Kenneth Roy, President
Contractor Registration: 80721 Exp. Date: 4/29/17
Contractor/Owner Name: MA Sup. License: 137557
WORK TO BE PERFORMED AND MATERIALS TO BE USED
Contractor Agrees To Do The Following Work For Homeowner: Fully gut existing finish basement and
rebuild to same layout except kitchenette will be removed and space added to bathroom for laundry
Work description: Finish basement
Includes permit, framing 2x4 walls, moving water heater, electrical (consisting of 16 recessed light, outlets,
cable drop and switches), insulate walls to r-13, plastered walls, paint and painting, trim (around windows,
doors and baseboard), move central vac unit, tile entry (allowance of $3/SF for tile purchase), carpet
remainder of finished area with mid grade carpet, and suspended ceiling with Sahara the
The following schedule will be adhered to unless circumstances beyond the contractor's control arise*
Work Scheduled To Begin: 1/2/17
Expected Date Of Completion : 3/1/17
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
The Contractor agrees to perform the work, furnish the material and labor specified above for the
SUM OF $31000
Payments will be made to the following SCHEDULE:
$10000 due upon signing this contract
$14000 due upon completion of rough plumbing and electrical
$7000 due upon completion of this project
Law requires that any deposit or down payment required by the contractor before work begins may not
exceed the greater of:
(a) one-third of the total contract price or
(b.) the actual cost of any special equipment or custom made material which must be special ordered in
advance to meet the completion schedule* ) No final payment shall be demanded until the contract is
completed to the satisfaction of the parties thereto.
OTHER IMPORTANT PROVISIONS
You are dealing with a Registered Home Improvement Contractor and are entitled to certain rights under
the provisions of 780 CMR R6 and M.G.L.c.
142A.
Payments: If payment is not received as per the Contract, then the Owner shall be responsible for all
attorneys' fees, court costs, and other costs incurred by the Contractor and enforcing Contractor's rights
hereunder.
Pets: Homeowner agrees to keep all pets out of the work area and take whatever steps are necessary to
safeguard them from any harm that may come to them as a result of the work being performed under this
Contract, including but not limited to injury on or outside the Premises or ingestion or inhalation of, or
contact with, hazardous substances. Company assumes no responsibility for any harm to the pets as a result
of the work performed under this Contract. Further, Homeowner shall take all steps necessary to protect
Contractor, its agents, servants, contractors and employees, from any harm as a result of contact with said
pets.
Characteristics of wood: Wood is a hygroscopic material. Wood swells and/or shrinks in relation to the
humidity, temperature and environmental conditions of its surrounding. Generally, wood flooring is
expected to shrink in any conditions and expand when exposed to moist conditions.
Natural wood also contains variations of graining, texture, hardness and/or knots, depending on the wood
chosen. Contractor cannot be responsible for the natural features of the wood chosen. Contractor is not
responsible for shrinkage, checking, swelling, or other conditions which are the normal condition of wood
or the result of household or environmental humidity, heat, cold, or other conditions.
Colors: You may choose colors and finishes for the parts being used in
your remodeling project. It is important to remember that a color or finish you see at the store or in a
showroom may not look the same in your home, especially after all of the different colors and finishes are
brought together upon the completion of a project. In addition, one manufacturer's named color is not the
same as another manufacturer's named color. The Contractor cannot be responsible for the appearance or
lack of coverage from Homeowner/chosen paints and/or stains and finishes.
Building.Officials: Any additional costs incurred by Contractor as a result of decisions made by Building
Officials will be the responsibility of the Homeowner. The costs of additional work will be calculated as
follows: cost of materials plus an hourly rate of $45 per man hour.
Liens: In the event of non justifiable non-payment, Homeowner's residence or property may be subject to
a Mechanic's Lien as a consequence of signing this Contract.
Utilities: The Contractor will use reasonable efforts to notify the Homeowner in advance of any
interruption of utility services. However, there may be instances where the Contractor must shut down
these services without advanced notice. Homeowner must arrange for emergency backup service for any
utility critical equipment such as medical devices and computers. The Homeowner must also,notify the
Contractor at the start of the work day if you will be engaged in any utility critical activities in that the
Contractor makes a notification in writing in the daily log book or otherwise.
Additional work: Any additional work requested by the Homeowner which is beyond the scope of the
work to be performed as set forth in this Agreement, shall be the subject of a separate agreement, and/or if
not, subject to the same terms and conditions as set forth in this Agreement and billed on a time plus cost of
materials basis at Contractor's normal hourly rate.
Contractor's normal hourly rate per man hour is $45.
In the event that additional work is to be performed on an hourly plus cost of materials basis, the
Homeowner shall be required to execute a Change Order which shall include Contractor's best estimate as
to the time required, together with the cost of labor as well as the type and cost of materials necessary.
Delays: Contractor is not responsible for delays attributable to
Homeowner initiated modifications or additions, or for delays incurred due to the actions or inactions of
city/town officials, strikes, acts of God, unfulfilled customer obligations, vendor delays, interference by
other tradespersons, customer supplied items or other delays beyond Contractor's reasonable control.
Contractor will use reasonable efforts to stay on each job until substantial completion by allotting specific
time periods to each Homeowner to complete each job in as timely a manner as possible. In the event that
Homeowner does not allow Contractor and/or his employees or sub -contractors access to the residence or
property so as to allow Contractor to perform his obligations and/or to complete the scope of work in as
timely a manner as possible, other than for reasons of safety or other reasons mutually agreed to between
Homeowner and Contractor, then the Homeowner shall be responsible to pay Contractor the sum of
$500.00 per day, on a pro rata basis, to cover the costs of delay. Contractor reserves the right to suspend
work and/or delivery of materials in the event of unjustified non-payment. In such event, the Contractor
shall have no liability to the Homeowner for alleged delays or damages due to said suspension.
Punch -list Items: The Homeowner agrees that routine "punch -list" or repair items after substantial
completion are outside the agreed scope of services, and covered by Contractor's warranty obligation and
will be completed as soon as practicable and according to Contractor's and Homeowner's mutual
availability. Homeowner agrees that it shall use his/her best efforts to make himself/herself available to
observe and/or sign off on the completion of any such punch -list Items, and that the approval of one
Homeowner regarding the completion of any such punch -list items, as well as change orders shall be
binding upon all Homeowners.
Unforeseen Conditions/Circumstances: Contractor shall not be responsible for any changes at the request
of the Building Inspector. Contractor shall also not be responsible for any unforeseen bedrock/ledge or
latent defects such as structural and/or dry rot or insect damage to the existing structure, or for preexisting
faulty or inadequate wiring or plumbing.
Contractor shall also not be responsible for any pre-existing code violations or responsible for correcting
contiguous work completed by others not under the Contractor's authority.
Insurance: Homeowner agrees to carry fire, theft, vandalism, liability and all other necessary insurances to
protect their personal property while construction is in progress. Contractor will carry all required and
necessary insurances including worker's compensation insurance. Contractor will ensure that all personnel
including sub -contractors will be covered by all required and necessary insurance including worker's
compensation insurance.
Homeowner's Cancellation Rights: In addition to the rights the Homeowner has, as set forth in the
attached Notice of Cancellation, the Homeowner may have rights under other Massachusetts Statutes,
including M.G.L. c. 93 § 48, M.G.L. c. 140D, § 10 and M.G.L. c. 255D § 14.
EFA
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Identical copies of the
contract should go to the homeowner and the contra, or.
Homeowner's Signature:" �'' Date: %Z-
Contract 's Signature K & ontractors, Inc.:
Date:
By: Kenneth Ro
Its: President
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of
the seller, which may be his main office or branch thereof, provided you notify the seller in writing at his
main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of
the third business day following the signing of the agreement.
See attached notice of cancellation for an explanation of this right.
NO WORK WILL BEGIN UNTIL BOTH PARTIES SIGN THE CONTRACT AND THE OWNER
RECEIVES A COPY .
REQUIRED PERMITS
The following building permits are required. It is the obligation of the contractor to secure such as the
homeowners agent:
Electrical rough and finish
Plumbing rough and finish
Insulation
Framing insp.
Finish and occupancy
NOTE: Owners who secure their own permits or deal with unregistered contractors are excluded from the
Guaranty Fund provisions of MGL c. 142A.
EXPRESS WARRANTY
All workmanship and materials to be free of material defect for a period of one (1) year. During the
Warranty period, the Company may, at its option, either repair or replace products or workmanship. which
prove to be defective. This Warranty shall not apply to defects or damage arising from improper or
inadequate maintenance by the customer, customer's applied products, unauthorized modification or
misuse, damage incurred as a result of acts of God or civil strife, or normal characteristics of the materials
such as wood shrinking, expanding and otherwise reacting to moisture or environmental conditions. The
Company's liability is limited to the repair or replacement, at its option, set forth herein and Company shall
not be liable for any consequential, sequential, incidental or other damages not set forth herein. The
Warranty set forth herein is exclusive, and no other Warranty, whether written or oral, is expressed or
implied. Company specifically disclaims the implied Warranties of Merchantability and Fitness for a
Particular Purpose.
NOTE: All home improvement contractors and subcontractors shall be registered and any inquires about a
contractor subcontractor relating to a registration should he directed to:
Director, Home Improvement Contractor Registration One Ashburton Place, Room 1301 Boston, MA
02108
617-727-8598
Unless otherwise noted within this document, the contract shall not imply that any lien or other security
interest has been placed on the residence,
,/
ARBITRATION
The contractor and the homeowner hereby mutually agree in advance that in the even the contractor has a
dispute concerning this contract, the contractor may submit such dispute to a private arbitration service
which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business
Regulations and the c nsumer shall he required to submit to such arbitration as provided in M,G,L. c. 142A.
Contractor:411-Axik-,
i
Date: t' Z- t 7
Homeowner: Date: ' Z `l - L`
NOTICE: THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF
THE PARTIES TO ALTERNATIVE DISPUTE SETFLEMENT INITIATED BY THE CONTRACTOR.
THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS
SECTION IS NOTSEPARATELY SIGNED BY THE PARTIES.
ACCELERATION OF PAYMENT
Homeowner's Financial Insecurity -A Contractor may not demand payments in advance of the dates
specified on the payment schedule in cases where the homeowner deems him/herself to be financially
insecure.
Contractor's Financial Insecurity- In instances where a contractor deems himself/herself to be financially
insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work. Withdrawal from said account would require
the signatures of both parties.
Homeowner agrees to allow reasonable access to allow Contractor to reasonably attempt to remedy any
outstanding uncompleted, disputed or non -satisfactory item.
If you have general questions or need additional information about The Home Improvement Contractor
Law, contact:
Consumer Information Hotline
Commonwealth of Massachusetts
Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170 Boston, MA 02116
617-973-8787
If you have questions about Contractor Registration, contact:
Director of Home Improvement Contractor Registration Board of Building Regulations and Standards One
Ashburton Place, Room 1301 Boston, MA 02108 617-727-3700, x25205
NOTICE OF CANCELLATION
YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR OBLIGATION, WITHIN
THREE
(3) BUSINESS DAYS FROM THE ABOVE DATE.
IF YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENTS MADE BY YOU UNDER THE
CONTRACT OR SALE, AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE
RETURNED WITHIN TEN (10) BUSINESS DAYS FOLLOWING RECEIPT BY THE CONTRACTOR
OF YOUR CANCELLATION NOTICE, AND ANY SECURITY INTEREST ARISING OUT OF THE
TRANSACTION WILL BE CANCELLED.
IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE CONTRACTOR AT YOUR
RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED, ANY GOODS
DELIVERED TO YOU UNDER THIS CONTRACT; OR YOU MAY, IF YOU WISH, COMPLY WITH
THE INSTRUCTIONS OF THE CONTRACTOR REGARDING THE RETURN SHIPMENT OF THE
GOODS AT THE SELLER'S EXPENSE AND RISK.
IF YOU DO MAKE THE GOODS AVAILABLE TO THE CONTRACTOR AND THE CONTRACTOR
DOES NOT PICK THEM UP WITHIN TWENTY (20) DAYS OF THE DATE OF CANCELLATION,
YOU MAY RETAIN OR DISPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF
YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO
RETURN THE GOODS TO THE CONTRACTOR AND FAIL TO DO SO, THEN YOU REMAIN
LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT,
TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS
CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO
K & R Contractors, Inc.
I Campbell Road, North Andover, MA Ol 845
NOT LATER THAN MIDNIGHT OF TBD.
I HEREBY CANCEL THIS TRANSACTION.
Date:
Buyer's Signature:
Received:
The Commonwealth of Massachuvetts
... Department of Indus -41 lAccidents
T_ r i congress Street, ,Sithe 100
Boston,.VA
02114-2017
www mass.gov/dza
•a'ra�M ��v
WgVkers' Compensation Xusuraned Affidavit- Bu=ilders/CO tr
A'UI kt0 sItTJC �cians/�lmnbers.
TO BE FILED WUH� P RIVS I IN �, r �o p, ;,,+ I
Name(Businessloiganize:ion&dividual)
Addxess: 1 C
City/State)'ip: /v �-tf
Are you an employer? CAecktIie approprlatebox:
A Ak (1-110ne #:
1.❑ I am a employer with
employees (full andlor part time).*
2);A
I am a sole proprietor or partnership andhave no employees working forma in
any capacity. INoworkers' comp. insurance required.]
3.E] I am ahomeowner doing aU-work myself [Noworkers' comp. msurancerequired] s
Jam a homeowner audvM be hiring coafractors to conduct all work onmy property. I will
ensure fliat all cotols either have workers' compensation insurance or are sole
r.
proprietors withno b, as.
5.❑ I am a general co�ractor and Ihave biredthesub-contractors listed onihe attached sheet;
W6 . to ees and have workers' comp. insurance.?
These sub -contractors have emp Y
6. ❑vie are a corporation. and its. of(ic6rs have exercised their right of'exemptim per MGL c.
152 1(4) and zwe havz no empldyees. [No workers' comp. insurance required.]
9�1�. 7Z(" S;_oG2
Type of project ()vequixerl);
7. ❑ N6 construction
8. O Remodeag
9. ❑ Demolition
10 [] Building additifln.
11.0 Electrical repaixs or additions
12T[] Plumbg repairs or additions
13'. [] Roof repairs
14.M Other
*Anyapphcantthat chem box#1 must also fill ouithe sectionbelow showingtheirworkers' compen"fl"'LpoTcy information
T Homeowners who submit thig o f davit indi6atingi hey are doing all work andthea hire outside contractors must submit a new affidavit indicating such
tContractorsthatcheckthisliokuuustattachedanadditionalsheetshovingthenameofthesub-contractorsandstatewhetherornotthose,en 0shave
comp.
P y
employees. If the sub -contractors have employees, they must provide their workers' co olic number.
f am an employer tlicat isprovidingworkers' compensation Msrarancefor° my employees Below is tFiepo7icy andj oh site
information. _
Insurance Company
policy # or Self -ins. Li'c. #:
ExpirationDatw
City/State/Zip:
Job Site Address:
compensation p olzcy declaration page (showing the policy number and expiration dale).
Attach a copy of the woxkers' to
Failure to secure coverage as required under MOL
2xn§fie form o5A is a f a STOP WORK ORDER Iand a fine oifup to $250.00 a
and/or one-yeax imprisonment; as well a penalties
day against the violator. A copy of this statement may be forwarded to the Offrca of Jnvestigdiions of the DIA. for insurance
rovemaeverification. d correct
Xclo Iiereliy certify under• mpains and
t%aai the infor7na_tzon provzded wave � it'r�e ar? .
Oficial rse only. Do not -write in this area, to he con2pleted by city or tovn official.
City or Town:
PerndflLicense #
fssuiugAuthoriiy (circle one):
3. Ciiyllown Clerk 4, ElectricalXnspector 5. PZnmbinglnspectox
1. Board ofp[eal-th 7, Building Department
6. Other
Phone #:
Contact person•
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
ritten-
An employer is defiu6d as "an individual; partnership, association, corporation or other legal entity, or any two or more
Of the foregoing engaged in a joint enferprise, and including the legal representatives of a deceased employer, or the
receiver'or trustde 6f an individual, partnership, association or other legal entity, employing employees. , However the
ovmer 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 dwelllaig house
or on the grounds or building appurtenant thereto shall not because of such employment b6 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
applicantwh6 has not produced -acceptable evidence of compliance with the insurance coverage xequ ited."
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=conlractor(s) name(s), address(es) and phone numbers) along with their certifcate(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 L LC ox LLP d6es have
employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmation of fi Wince 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
IndustrialAccidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensatioA 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 thatthe affidavit is complete and printed legibly. The Department has provided a space atthe bottom
of the affidavit for you to fill out in the event the OMtce of Investigations has to contact you regarding the applicant.
Please be sure to Min the permit/license number which will be used as a refexence number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one afi7davit 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 pennifis or licenses. Anew 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 bum leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, Na 02114-2017
Tel. # 617-727-4900 ext. 7406 ox 1-877 MA.SSAFE
Fax # 617-727-7749
Revised 02-23-15 www.naass.gov/dia
OP ID: PS
'a4C4C>RoP CERTIFICATE OF LIABILITY INSURANCE
DATE 017
01 /03/2017
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
Foster Sullivan Insurance
163 Main St.
CONTACT Pete Sullivan
NAME:
AIC. o Ext : 978-686-2266 --TF—AX,/No): 978-686-6410
North Andover, MA 01845
Stephen Sullivan
SS: psullivan@fostersullivangroup.com
ADDRESS:
PRODUCER K&RCO-1
CUSTOMER ID #:
INSURER(S) AFFORDING COVERAGE NAIC #
INSURED K $ R Contractors, Inc.
Ken Roy
1 Campbell Road
INSURER A: MERCHANTS INSURANCE GROUP 12775
INSURERS:
A
North Andover, MA 01845
INSURER C:
INSURER D:
BOP1062559
INSURER E:
12/09/2017
INSURER F:
MED EXP (Any one person) $ 15,000
GUVERAGE5 CERTIFICATE NUMBER: RFVISIAN NLIMRFR-
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.
ILTR
TYPE OF INSURANCE
L
SUBIR
POLICY NUMBER
MM/DDY EFF
MM DDY EXP
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE � OCCUR
BOP1062559
12/09/2016
12/09/2017
PREMISES Ea occurrence $ 500+000
MED EXP (Any one person) $ 15,000
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 2,000,000
PR0 LOC
X POLICY JFCj F]
$
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
(Ea accident) $
BODILY INJURY (Per person) $
ALL OWNED AUTOS
—
BODILY INJURY (Per accident) $
SCHEDULED AUTOS
PROPERTY DAMAGE
(PER ACCIDENT) $
HIRED AUTOS
$
NON -OWNED AUTOS
$
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
EXCESSI
CLAIMS -MADE
AGGREGATE $
DEDUCTIBLE
$
$
RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
N / A
WC STATU- OTH-
ITQRY LIMITS ER
E.L. EACH ACCIDENT $
E.L. DISEASE - FJA EMPLOYE $
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
I
E.L. DISEASE - POLICY LIMIT i $
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
mdeems@northandoverma.gov
** INSURANCE EVIDENCE **
L.ERTi Fi :AI I- MULLIL.K 11AAI/IEI I ATIf1u -
v 1938-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
TOWN OF NORTH ANDOVER
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
fax # 978-688-9542
AUTHORIZED REPRESENTATIVE
MAURA DEEMS
120 MAIN STREET
NORTH ANDOVER, MA 01845
v 1938-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
A
✓ 1GG v/ L�Y'2�7207t1!/P.CLLGfL a�✓l�GaddCLCILUQP,�" " i
Office of Consumer Affairs
& Bdsiness Regulation
HOME IMPROVEMENT CONTRACTOR
Registration; ,y.162123
Type:
Expiration:. .1.120!_2017
Private Corporatio
K & CONTRACTORSN=tC,:-:._
KENNETH ROY 'i
1 CAMPBELL RD.
N. ANDOVER, MA 01'8:45==
Undersecretary
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
P C"
Constructionoulc'iviSOr
License: CS -080721
cF:
KENNETH R ROS`
1 CAMPBELL RIf JE,'lf
North Andover NfA 0�;�
r
!Z2 A'j41'` Expiration
Commissioner 04/29/2017