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HomeMy WebLinkAboutBuilding Permit #712-2017 - 50 DEER MEADOW ROAD 1/12/2017A�q�ll A40 4 V Permit N Date LOCATION _ PROPERTY, ®WNER BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received ITORTANT: A] 0 )plicant must complete all items on this f Print �OR71y O �S`E D o - A . �R+ren re4' Ssacwus� MAP nnt s y _PT�DYearStructure PARCEL ZONINAG DISTRICTS :. H�stort ®istnct_ ny Machtne.ShopVillage�- Non- Residential ❑ New Building )eDne family rib _no - TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building )eDne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial --epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other - 080airy 1Nell Y 0- Fioo'dp(ain VVet(ands` ' ` .; Watershed Diist�icf D UUa r/ -S. _ - - - DESCRIPTION U1- WUKK 1 u bt t��t�r��iulCv: a, 6o -r Identification - Please Type or Print Clearly OWNER: Name: Phone: Address: Contactor Nae;: Nor T- Supervisor's Construction License _ _ _0_ t� Ex DateE P= Noma, Irririrniir�mi�nt t: iii ansP 12.. �P v .. - -. Ext: an: _ ARCHITECT/ENGINEER Phone: Address: Reg. No' FEE SCHEDULE: BULDING PERMIT; $12.00 PFR $100f.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. FEE: $ �-- _,'1"®ta�f Project Cost: $�_7�3 ' .. V Check No.: 77 'f Receipt No,, 72--)ILf NOTE: Persons contracting with unregistered contractors do not have: access to the ggadanty fund Location _,.,; 0 Ua2 vv 1*1 t A lJ 0 0% No. 7 0- —20 7 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ % :—O—#— Foundation Permit Fee $ Other Permit Fee $ TOTAL $ PC/OV Check�C�. , =� i // Building Inspector Plans Submitted ❑ Plans Waived El Certified Plot Plan ❑ Stamped Plans ❑ OF SEWERAGE DISPOSAL Sewer ❑ 7PubEc Tanning/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 PLANNING & DEVELOPMENT COMMENTS Reviewed On Signature CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT"- Temp Dumpster on site yes Located at 124 Main Street Fire Department signatureldate --n nn . -A I-- Located 384 Osgood Street no -imension 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 xequires approval of Electrical Inspector Yes No ®ANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine Doc.Building Permit Revised 2014 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 ci 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 VOTE: 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 act ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 10TE: 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 Doe: Building Permit Revised 2014 r, rA = J Q LL Q O m Y O LL >. 'n NO V) o H W O Z z m O m LL O d' v t U C LL o W CL Z Z J CL p d' LL o d Z J U J LY p C v h c LL oc W iA Z p CG c LL z W Q w W oc LL j m Z v In Y v O N z 2 CDz Cl) w CL w H W CL O W a Cl) CD0 Ca ti •,v U O U Cl) LLJJ E O z ^U) W i O O V a O V .U) O U m m r�1 L CL H � C O 00 L- CL CL ca S J O z CLN r_ ,4 / 9i9ndcr3/ries ,r..,y [ionic Improvement Contractor Law (MGL chapter 142A), but does not include standard person planning home improvements should first obtain a cobpy calling the This form satisfies all basic requirements of Al advice f necessary. Any pe any work on your residence. You may obtain a free copy - language to protect homeowners- Seek leg agreeing Massachusetts Consumer Guide to Home Improvement" before agr nformation M Regulation's Consumer Information Hotline at 617.973-87170 r I -888'283'3757 or on our website. office of Consumer Affairs and Business Reg Contractor Homeowner Information q°""John Toto Street Address (do not use a Post office Box address) 50 Deer Meadow Road City/rown state Zip CO( N Andover MA 01845 Evening Phone Daytime Phone 978-505-7043 .. .,,__ A AA- (It different from above) Coastal Industries, Inc. Contractor! Salesperson! Owner Name Jesse J Hileman Business Address (must include a street address) 77 Newark Street CityrTown State MA Business phone 918-373-1543 r eul Com:' +'o Home Improvement con Law -q,, wa1 most home HTC 182968 improvement contractors have CS -066103 a valid registntionnumber Zip Code 01832 ler ID or S.S. Number 04-251793 r Reg. Number E - 8/l0/2017 4/20/2017 brand and grade of materials to be used, use a_ d_ d_ i_onal sheets if necessary.) The Contractor agrees to do the following work far the Homeowner: (Describe in detail the work to completed, specifying the type, Remove & Replace 20 Double Hung Windows & 1 pictureWindow � Haverhill, MA Argon Windows to be manufactured by Coastal Industries, Inc 7 Series 3550 U value .27 Required Permits - The following building permits are required and will be secured by the contractor as the homeowner's agent: (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of MGL chapter 142A.) Proposed Start and Completion Schedule - The following schedule will be adhered to unless circumstances beyond the contractor's control arise 12/21/2016 Date when contractor will begin contracted work. 1/11/2017 Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of:,_ $9,773.94 O Payments will be made according to the following schedule: $ 4,500.00 Upon signing contract (not to exceed 113 of the total contract price or the cost of special order items, whichcver is greater) upon completion of upon completion of $ 5,473.94 upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be pard for NOTES: (•) including all finance charges (•') 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. Exnress warranty Is an express warranty being Provided by the contractors ❑ No X Yes tall terms of the warranty must be attached to the contract Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something isunclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to see a copy of a "proof of insurance" document • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement ContractorLaw. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THl I Two identical copies of the contract must be completed and signed. One copy should go 0-1 d---� Ho er's Signature Decent er 7, 2016 Date ARE A BLANK SPACESM aomeowner. other copy should be kept by the contractor. Contractor Arbitration The Horne Improvement Contractor Law provides homeowners with the .right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitrate firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required' to submit to such arbitration as provided In. Massachusetts General Laws, chapter 42A. Ho eo ner's Signature C ac or' .Signature NO E: The signatures of the parties above apply only to the agr me t of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumerlhomeowner rights, contact the Consumer Information Hotline (listed below) Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day rescission period has expired. Accelerated Payments 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. However, in instances where a contractor deems him/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 of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Ci ntractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide tq Home Improvement contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at http://www.inass,gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at http•//www.mass.gov/ocabrl Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/liomeimprovement/licenseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-6524800, 508-755-2548 or 41.3-734-3114 t NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR OBLIGATION, WITHIN THREE 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 BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU CANCELLATION NOTICE, AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED, ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION, YOU MAY RETAIN OR DESPOSE 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 SELLER 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 [Name of Seller], AT [Address of Seller's Place of Business] NOT LATER THAN MIDNIGHT OF (date). I HEREBY CANCEL THIS TRANSACTION. Date: Buyer's Signature: 1/12/2017 12:55 PM FROM: Journeay Insurance Journeay Insurance Agency TO: 1-978-688-9592 PAGE: 002 OF 002 ACOCERTIFICATE OF LIABILITY INSURANCE YYYY) DATE (2/2017 /1 Z/20RLY 0 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 Phone: 978-346-8761 Fax 978-346-9620 JOURNEAY INSURANCE AGENCY INC 8 WEST MAIN STREET MERRIMAC MA 01860 CONTACT Journeay Insurance Agency Inc PHONE 978-346-8761 F4 978-346-9620 PVC,No EM' AC No: E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC t INSURER : National Grange Mutual Insurance Co 14788 INSURED JESSE HILEMAN INSURERS DBA NEW ENGLAND BUILDING SOLUTIONS PO BOX 5344 INSURER X COMMERCIAL GENERAL LIABILITY HAVERHILL MA 01835 INSURER D: INSURER E INSURER F DAMAGE TO RENTED $ 500,000 PREMISES Ea occurence) COVERAGES CFRTIFICATF Nt1MFRFR• 1llR:'f RF\/ISI(1N AIIIMRFR• 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 ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADD'L INSR SUER WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY MPT8337L 11/01/16 11/01/17 EACH OCCURRENCE $ 300,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 500,000 PREMISES Ea occurence) CLAWS -MADE OCCUR MED. EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 300,000 GENERAL AGGREGATE $ 600,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 600,000 PER0.CT $ POLICY JLOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ ( ) AUTOS AUTOS HIRED AUTOS NON -OWNED PROPERTY DAMAGE $ AUTOS (per accident) UMBRELLA LIAS OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS -MADE AGGREGATE $ DED I RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH To LIMITS ER $ AND EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE Y, INS OFFICER/MEMBER EXCLUDED? ISI N/A E.L. DISEASE -EA EMPLOYEE $ (MandatorV in NH) IPTION under DESCIf yes,RIPTION DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) GtK I IhIGA I t KULUtK GANGtLLA FION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Hall THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover, Ma. ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Attention: fx:978-688-9542 Derek Journeay ACORD 25 (2010/051 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CnAQikln114 r+ATUVI CERTIFICATE OF LIABILITY INSURANCE DA TE (MM/DD/YYYI� 12!0812016 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 have ADDITIONAL INSURED provisions or 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 CON ACT Cathryn L. Liscombe NAM Charles F. Murphy Inc. 14 Storrs Ave Plc o, Et):n229 AX No 1 cathy@murphyinsgroup.com Braintree, MA 02184 INSURER(S) AFFORDING COVERAGE NAIC # 04130/2016 INSURER A:Arbella Protection Ins CO 41360 EACH OCCURRENCE $ 1,000,000 INSURED INSURER B:Arbella Indemnity Ins. Co. INSURERC: Coastal Industries, Inc INSURER D: 77 Newark Street Haverhill, MA 01832 PRODUCTS - COMP/OP AGG $ 2,000,000 $ INSURER E: INSURER F : LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY X AUTOS AUTOS ONLY X AUOTOIONLY COVERAGES CERTIFICATE NIIMRFR- RFVIAIr1N NI IIIIIPePR• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MMfD POLICY EXPLTR XL LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR 8500064020 04130/2016 04130/2017 EACH OCCURRENCE $ 1,000,000 DAMAGEPREMISE TOE RENTEDren 100,000 r $ MED EXP (Any oneperson) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 LA RE ATE LIMIT APPLIES PER: X POLICY ❑ j �T LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ B AUTOMOBILE X LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY X AUTOS AUTOS ONLY X AUOTOIONLY 1020018388 05/0512016 05/05/2017 EOMBIINdED ent,SINGLE LIMIT $ 1,000,000 BODILY INJURY Perperson) $ BODILYBOODILY INJURY Per accident $ PPeOr. den DAMAGE $ $ UMBRELLA LIABOCCUR EXCESS LIAR RCLAIMS-MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE FICER/MkMA EXCLUDED? FN andato in N1FF11 If yes, describe under DESCRIPTION OF OPERATIONS below N / A 22005453301 04/3012016 04/3012017 X PER OTH- STA TE ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Evidence of insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE C/w."-,, ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of .Massachusetts Department of lndusOal Acddents I coggress Sheet, Sate 100 Sosto.a' MA 02114-2017 www mass gov/dia Compensation bp c-��THEk ��Gon.A.TJTJB[Osi3I�X-�cza�as/Plmmbers. TOB-PTPaRe Print Namtl (BminesslOzg s?ion/Individu� — Address: e7 %- ) City/Statelzip: CC Are you an emploper? CJi eck the appzopxiate box: Phony #; 1.Q I am a employer with employees (fn and/or pact time)•' 2, amasolepropnotaorpaitamrl pandhavenoemployeesVaorlangfor mem ;ny capacity. jNovlorkers' comp. insurance required ] 3.am a homeowner doing all work myself [No workers' comp. insurance required 1 i 4.❑I am ahomeowner and wal be hizing coat cactazs to conduct all work onmy property. Imm ensurethat all cone eitherhave wozkers' compensation insurance or are sole proprietors withno oyees. 5.❑ I am a general contractor and I ees andhavee workers'tcr°mp msnr ached sheet These sub -contractors have employ 6,Q we are a corporation ands offledns have exercisedtheir rigbt of'exemptiou per MGL c. em loyees_ IN, vlorkers' comp. insurance required ] 5-S-4 3 Type of project (regi&etI); 7. ElN&Wdon8i4 tion 8. [] R..emode"MP; 9. ❑ D=OMI?n. 10 E] Building addition 11-E]Electrical repairs or additi9ns 12_U:plumb7ng repairs or additions 13•. [(Roof repairs 14. Other__ o lb G -W S T 152, §1(4), andwehaveno o- p — aPPlieamtha3cheaksbbic#lmastalsofllouithesectionbelowshowingtheirworkers' compensationpoficyinfozraatiozL allwozk andthenhire outside contractors muss sabmii anew affidavitindicaiing such. i Homeowners wha submit•thig affidavit indicating they are doing . �Coniraciorsthatchackth�sb°xm��hedaz''addrt�onalsheetshowingthenameofthes�-c°niractorsand.sEaieR'hetherornotthoseeniiiies ave �_,,�,a�. rf+1,Pc,�h-coniractorshaveemployees,theymustpzoaidetheixworkers'comp.poHcynumber. , d`' �r site X am azo employer{ tliatisprovidir2gwo�ers' co�rzpenscztiorz insurarzcefor my employees. Below zs t/iepolacy arz J -o information. Insurance CompanyName; ExpirationDate Policy # or Self ins. Li--- #:. �i� ..,�,►� lAf. P - City/State/zip: atLoU date). Job Site Address: Attach a copy of thevvorkers' compe»ationpoSicy declaration page (Showinga npo�h b by a ab up to $1.,500-00 Failure to secure coverage as required under M�T ' c x52, §25A is a cnmmal violation p and/or one-year imprisonment; as -well as civil penalties in the form of a STOP W ORK ORDER and a flue ofup to $25ano a day against the violator. A copy of this statement may �b e forwarded to the Office of Investigations of the DIA for Insurance , -,tTprn m. verification. - d d ai ove is fr ue a?d correct X do her°eliy under the penalties ofperjury tliat t7ie znfor7rcatton pfovz e pff�cial rise only. Do x�ot-Write in this cr area, to be corr�pleted by city or 10111z official. • Permitil -License # City or To-wn- lssuingAuthoxity (circle. one): ' ector S. PX h uglnspector 1. Board of I[ealth 2. Building ])epartment 3. CitylTo row Clerk 4. Elecirieal lnsp 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 employer is defined as "an individual, partnership, association, corporation or other legal entity, or anytwo ormore Of the foregoing engaged in a joint enferprise, and including the legal representatives of a deceased employer, or the receiver` •or f astde of an individual, partnership, association or other legal entity, employing emplbyees.. 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 dwellirig 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 applicazttwlid h'as not produced -acceptable evidence of compliance with the insurance coverage iequixed." Additionally, MGL chapter 152, §25CM 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 ofthi chapter have been presented to the contracting authority." Applicants Please fll out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply su°-b-contractors) name(s), address(es) and phone m nber(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees -other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of IndustrialAccidenis. Should you have any questions regarding the law or if you are required to obtain a w' orkers' compensatiori policy, Please call the Department at the number listed below. Seff-insinedcompanies shouldenter their self- insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office ofluvestigations has to contact you regarding the applicant. Please be sure to fill in the Permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple pemlit/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 b e provided to the applicant as proof that a valid affidavit is on file for futare permits or licenses. Anew affidavit must be fated 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 burg leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 021142017 Tel. # 617-727-4900 ext. 7406 or 1-877 MASSAFE Fax # 617-727--7749 Revised 02-23•-15 www.mass.govldia