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HomeMy WebLinkAboutBuilding Permit #171-2017 - 523 OSGOOD STREET 8/18/2016-- j 11, I ao T'� Int' BUILDING PERMIT of NOR.ry q ` TOWN OF NORTH ANDOVER C PPL CATION FOR PLAN EXAMINATION Permit No#: I� I l�"� Date Received SSACFiU`-+� Date Issued: �� IMPORTANT: Applicant must complete all items on this page LOCATION 4'03 Oo too� S/ E Pr t ] � PROPERTY OWNER %'� A) 7 Print 100 Year Structure yes no MAP_1J� ----PARCEL:ZONING DISTRICT: Historic District yes no �/ Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building VOne family i/Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑Well ❑ Floodplain 0 Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly ' OWNER: Name: S:22yef- D Phone: 7 N 83_5"636 I Address: I Z OS .e;Jg Fa a lz S" Contractor Name: at, ��%i�� Phone: D2-G476-0 Aga Email: 5,( j�iocl/@ ,�;��c51 /✓�T Address: /02 �,V-o Supervisor's Construction License: 4'S QS'���// Exp. Date: Home Improvement License: 1,!;0'3 8/% Exp. Date: 5 ARCHITECT/ENGINEER DEQ Phone: Y ' Address: oW olk17�� �c,�jie Z'? Reg. No. 77G z I FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ �)qq .Ub c' I Check No.: �-J 0 X Receipt No.: 30650 NOTE: Persons contracting with unregister contractors do not have access tot e guara ty fund I J Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ f TYPE OF SEWERAGE DISPOSAL ,t Public Sewer Tanning/Massage/Body Art ❑ Swialming Pools ❑ Well Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Pennanent Dumpster on Site ❑ n� THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM 1 PLANNING & DEVELOPMENT Reviewed On qjflZL& Signature_ ! i� COMMENTS__ CONSERVATION Reviewed on rr � to Si nature j 4 f COMMENTS EALTH Reviewed on Signature COMMENTS ►" �► I I Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes I Planning Board Decision: Comments Conservation Decision: Comments I E � i - ' 'Water& Sewer Connection/Signature& Date Driveway Permit � DPW Town Engineer: Signature: OsgoodLocated 384 FIRE4DEPARTMENT -, _ , X TempxDumpster-ion+s oa __ _ _ - ite yes Located_ at`'>1241 aintStreet ,. -�..c „ '. `- `_ ,. -•. -------�--- -..- = i Street .T Fi"re�Department signature/date - r R COMMENTS. . . � • t � ,r - .. . _F µ- _ - __�. � i Dimension Number of Stories:_Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) r ❑ Notified for pickup Call Email Date _ Time Contact Name Doc.Building Permit Revised 2014 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 C 4 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 I 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) 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 2012 IECC Energy code 4. 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 Doe:Building Permit Revised 2014 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 749900.00 m $ - $ 898.80 Plumbing Fee $ 112.35 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 112.35 Total fees collected $ 1,223.50 523 Osgood Street 171-2017 on 8/18/2016 Build new 2 car garage and add 6'to kitchen Plans Submitted ❑ Plans Waived ❑ P Certified Plot Plan ❑ Stamped Sta TYPE OF SEWERAGE DISPOSAL p lens ❑ Public Sewer Well Tanuing/Massage/Body Art ❑ S w1nming Pools ❑ Private(septic tank, etc• Tobacco Sales 11❑ Food Packaging/Sales ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR ®FF(CE 11SE ®NLI� IIdTEP®EPART(�IENT'�4L SIGN OFF m 11 F®RM PLANNING Reviewed ' ewed On Cd il� Sire COMMENTS CONSERVATION Reviewed on ! � � b Signature . ca` COMMENTS .Q Cab EALTH Reviewed on Si nature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Si nature& pate Town E DPWTownDrivewa Permit gineer: Signature: FIREDEpgRTMENT a {T` ' Located 384 Osgood Sfireefi Locat of 12 = " t J,*-,pFDumpster on J-,4,Main,Street _. .- �r ,safe YeS:��_ . Fire.Dei k„rit � ,�,�, a� z� .rno �.. �. gnaturp/date�._�� ,CtL..7 w-.%e GT„i kt� '-f�,4•s r. -i � y�. ;y' r :. r, A '+ ;+ '-I- COMM . t; - ,►.-, * t EN-1`S '� � J tw•qty C tY {. :ts,^e+pFv E„F�= .� ,.� 'r'--.—� SI NORTH q Town of t ., s ndover p No. � t oh ver, Mass, 1k+ t IcUkv A_ AAW c0cmic"IWscw y7' 7d p�R�TEO Hrgk t 5 S U BOARD OF HEALTH Food/Kitchen PER T LD Septic System THIS CERTIFIES THAT ....... .. �.... � SIJ ` BUILDING INSPECTOR ....... ....................................................... ........................... "on 5a0.... .. �...ggke'. Foundation has permission to erect .......................... buildi . ... ...............� �� Rough be occupied as .ri. lRAIN. �R�I. ......... .. .. . .....�.�. .�t............... Chimney provided that the person accepting this permit shall in eve respect conform to the terms of thea lication every p pp Final on file in this office, and to the provisions of the Codes and By-Law relati ' the 'nspe tion Alteration and Construction of Buildings,in the Town of North Andover. li TT PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST TIO Rough 2 Service .. ... .......... Final BUILD' INS ECTOR 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. North Andover MIMAP August 18, 2016 77. MO j rs r X •3 xm ^ 4 i w $ ,��, �L tdy • w � 550 USGOOD r' 4-1 `.036.0-0005 ..101.0-0012 � • - •- 538 0360-0006 ' l � un :gyp" � Y ) � 523 OSGOO<j ST= - �"• � ,036.0-0015 yt t J H r � . r . 5, u I �Y ti�� ,� 510 USGOOD ST �. . •,, � � .-:� � �� .. t�tiq � 18 STEYENS ST '� 498 O`S,CaOD T�Y� 18 STE�/E ST 102.0-0002 `�� t 036 0-0010 1 2?0-0001 al. 1 03 6.0-000r7 ❑MVPC Bo Interstates Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, —I Meters Data Sources:The data for this map was produced by Merrimack —SR NORTN Valley Planning Commission(MVPC)using data provided by the Town of Roads pt a qNorth Andover.Additional data provided by the Executive Office of i t Easements ? ± •e �O Environmental Aftairs/MassGIS.The information depicted on this map is ❑ParcelsG 3• for planning purposes only.It may not be adequate for legal boundary O definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING It * THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY ♦L OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT ✓F o' .,.. •� ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF ,o THIS INFORMATION �SSAcNus�t 1"=135 ft ^�• North Andover MIMAP August 18, 2016 00 101.0-0010 J* 101.0-0009 0361.0=0003: J# 101;0-0008 7 7: -:7:a& .. ...... .... 550 iOSPQQD�$,T- 036;0-0005 R-2 538-OSG -00,St 0 09� 101 M"0012 -!0006 6�10 5,23,69bobb sT, Y 7vlrr 102.0-0005 52 ,10IS6,0T 0D Si§,,TEVENS ST ... ..... 6 .*46i.:0-00 r. .J& btu `ul A, 036.0-0010" 102;0-0004 in SMO 181$T EV E N Si ST ST- 4-90,0;�PPOD-ST -4 1�$TTVPR�f�T-1 102;0-0002 03 0, '6- zooto � 102;0-0001 salfr : 03 6.:'d-,-:i5'0'0 7-i*'- Ave, MVPC Bo Zoning Overlay Zoning [3 Municipal Boundary [3 Ad.ft Entertainment Distric Busine i s 1 District EI Machine Shop Village Ove 13 Busine s 2 District Horizontal Datum:MA Statelplane Coordinate System,Datum NAD83, — Rail Line 2 Watershed Protection Dist 13 Busine a 3 District Meters Data Sources:The data for this map was produced by Merrimack Interstates El Historic Mill Area D Busine!s 4 District pORTii Valley Planning Commission(MVPC)using data provided by the Town of 0 Medical Marijuana 0 Genera Business District North Andover.Additional data provided by the Executive Office of (3 Downtown Overlay 1, SII District Plann&I Commercial DevEnvironmental AffiairstMassGIS.The information depicted on this map is Historic District Z*Corrido Development Dist for planning purposes only.It may not be adequate for legal boundary Roads U Osgood Smart Growth(40 13 Corrido Development Dist definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER 6 Easements Hydrographic Features 13 Corrido Development Dist MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING ❑ C} ZZI:I District THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY Parcels Streams ndu in 2 District I., OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT 13 Industri�l 3 District Wetlands ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF 13 Indu tri IS District THIS INFORMATION I Exempt Lands Reside ce I District so — aside,ce 2 District 3 .. R SS USe C Reside ce 3 District C" 4�dd.ce 4 District V=135 ft dece 5 District a :a 8 District ential District PLOT PLAN 401 SOUTH BROADWAY LAWRENCE, 1ASSOCIATES$ INC. ( ) 837-3335 FAX:(978) 837-3336 MORTCAGOR: STEPHEN DUFRESNE DEED REF. 1968/159 LOCATION. 523 OSGOOD ST/AKA 0 STEVENS ST PLAN REF. #5958 CITY,STATE.- NORTH ANDOVER, MA DATE.- 8/15/16 SCALE: >"-60' JOB #: �s c H � a� �HFD Q / � / / PROPOSED 1 STY ADDITION # 523 DK 1.5f ACRES cr ,. off+ EXISTING �SCRN DWELLING PORCH O 00 vA �'�• S u �.. 67 S PLOT PLAN NORTHERN 01843-3522 ASSOCIATES, INC.SOUTH BROADWAY LAWRENCE, MA ( s) 837-3335 FAX:(978) 837-3336 MORTGAGOR. STEPHEN DUFRESNE DEED REF. 1968 LOCATION.- 523 OSGOOD ST/AKA 0 STEVENS ST PLAN REF. #59581151 CITY,STATE.- NORTH ANDOVER, MA DATE. 8/15/16 SCALE: >".60' JOB #: "d C SHED C�� i i i PROPOSED 1 STY ADDITION # 523 DK 1.5t ACRES �O EXISTING SCRN � DWELLING PORCH O 'd DO 'C-a �� s R.S. HEBERT Construction & Remodeling Inc. 102 Adams Ave. No. Andover Mass. 01845 (978) 686-0786 Phone / Fax Lic. #:058241 Reg. #:153811 DATE: 8/15/16 OWNER'S NAME: Steve Dufresne 523 Osgood ST. North Andover MA. 01845 Tel.# 978-833-9036 JOB. Two stall garage I. PARTIES This contract (hereinafter referred to as "Agreement") is made and entered into on this 15th day of August 2016 by and between Steve Dufresne (hereinafter referred to as "Owner"); and R.S.Hebert Construction & Remodeling Inc., (hereinafter referred to as "Contractor"). In consideration of the mutual promises contained herein, Contractor agrees to perform the following work, subject to the terms and conditions below: II. GENERAL SCOPE OF WORK DESCRIPTION Supply and install all material and labor required to complete The following work. 1. Supply building permit. 2. Demo existing one stall garage. 3. Excavate for footings and foundation per plan. 4. Form and pour concrete foundation. 5. Pour 4" concrete garage floor. 6. Frame and make weather tight two stall garage and kitchen addition per plan. 1411 Contractor Owner Owner A. LUMP SUM PRICE FOR ALL WORK ABOVE* $ 74,900.00 III. GENERAL CONDITIONS FOR THE AGREEMENT ABOVE 1.STANDARD EXCLUSIONS: Unless specifically included in the "General Scope of Work" section above, this Agreement does not include labor or materials for the following work: Plans, engineering fees, Testing, removal and disposal of any materials containing asbestos (or any other hazardous material as defined by the EPA). Labor or materials required to repair or replace any Owner-supplied materials. Repair of concealed underground utilities not located on prints or physically staked out by Owner which are damaged during construction. Surveying that may be required to establish accurate property boundaries for setback purposes (fences and old stakes may not be located on actual property lines). Final construction cleaning (Contractor will leave site in broom swept" condition). Landscaping and irrigation work of any kind ,correction of existing out-of-plumb or out-of-level conditions in existing structure. Correction of concealed substandard framing. which may be discovered in the removal of walls or the cutting of openings in walls. Removal and replacement of existing rot or insect infestation. Failure of surrounding part of existing structure, despite Contractor's good faith efforts to minimize damage, such as plaster or drywall cracking and popped nails in adjacent rooms or blockage of pipes or plumbing fixtures caused by loosened rust within pipes. Exact matching of existing finishes. Public or private utility connection fees. Repair of damage to roadways, driveways, or sidewalks that could occur when construction equipment and vehicles are being used in the normal course of construction. Cost of /testing/remediating mold/fungus/mildew and organic pathogens unless caused by the sole and active negligence of Contractor as a direct result of a construction defect that caused sudden and significant water infiltration into a part of the structure. Cost of removing ponding ground water or other unusual concealed site conditions during excavation B. DATE OF WORK COMMENCEMENT AND SUBSTANTIAL COMPLETION Commence work: when permit is granted. Construction time PC Contractor Owner Owner through substantial completion: Approximate 8 weeks, not including delays and adjustments for delays caused by: holidays; inclement weather; accidents; shortage of labor or materials; additional time required for Change Order and additional work; delays caused by Owner, Owner's design professionals, agents, and separate contractors; and other delays unavoidable or beyond the control of the Contractor. C. CHARGES FOR ADDITIONAL WORK: CONCEALED CONDITIONS, DEVIATION FROM SCOPE OF WORK, AND CHANGES IN THE WORK 1. CONCEALED CONDITIONS: This Agreement is based solely on the observations Contractor was able to make with the project in its condition at the time the work of this Agreement was bid. If additional concealed conditions are discovered once work has commenced or after this Agreement is executed which were not visible at the time this Agreement was bid, Contractor will point out these concealed conditions to Owner, and these concealed conditions will be treated as Additional Work under this Agreement. Contractor and Owner may execute a Change Order for this Additional Work. Contractor is released, held harmless, and indemnified by Owner from all pre-existing mold, fungus, mildew, and organic pathogen problems and is not responsible for costs or damages associated with correcting, containing, testing, or remediating the same. . DEVIATION FROM SCOPE OF WORK: Any alteration or deviation from the Scope of Work referred to in this Agreement involving extra costs of materials or labor (including any overage on ALLOWANCE work and any changes in the Scope of Work required by Owner, Owner's design professional, Owner's agent, or building inspectors) will be treated as Additional Work under this Agreement resulting in an additional charge to Owner. Contractor and Owner may execute a Change Order for this Additional Work. Contractor Owner Owner D. PAYMENT SCHEDULE AND PAYMENT TERMS 1. PAYMENT SCHEDULE: * First Payment: $ 5000.00 Due when Agreement is signed and returned to Contractor. 2nd payment: Due when work starts. $25,000.00 3rd payment: $25,000.00 Due when foundation is complete. 4t" payment: $10,000.00 Due when frame is complete. * Final Payment: $ 9,900.00 Balance of contract amount when work is complete. 2. PAYMENT OF CHANGE ORDERS/ADDITIONAL WORK: Payment for Additional Work is due upon completion of either all or part of the Additional Work and submittal of invoice by Contractor. E. WARRANTY Thank you for choosing our company to perform this work for you. Your satisfaction with our work is a high priority for us, however, not all possible complaints are covered by our warranty. Contractor does provides a limited warranty against material defects on all Contractor- and subcontractor-supplied labor and materials used in this project for a period of one year following substantial completion of all work. This warranty covers normal usage only. You must contact the Contractor upon discovering an item in need of warranty service. Additionally, Owner's hiring of others or direct actions by Owner or Owner's separate contractors to repair a warranty item are not covered by this warranty and will not be reimbursed by Contractor. No warranty is provided by Contractor on any materials furnished by the Owner for installation. No warranty is provided on any existing materials that are moved and/or reinstalled by the Contractor within the dwelling or the property (including any warranty that existing/used materials will not be damaged during the removal and reinstallation process). One year after substantial completion of the project, the Owner's sole remedy Contractor Owner Owner (for materials and labor) on all materials that are covered by a manufacturer's warranty is strictly with the manufacturer, not with the Contractor. Repair of the following items and related damages of every kind are specifically excluded from Contractor's warranty: problems caused by lack of Owner maintenance; problems caused by Owner abuse, Owner misuse, vandalism, Owner modification, or alteration; and ordinary wear and tear. Damages resulting from mold, fungus, and other organic pathogens are excluded from this warranty unless caused by the sole and active negligence of contractor as a direct result of a construction defect which caused sudden and significant amounts of water infiltration into a part of the structure. Deviations that arise such as the minor cracking of concrete, stucco, and plaster; minor stress fractures in drywall due to the curing of lumber; warping and deflection of wood; shrinking/cracking of grouts and caulking; fading of paints and finishes exposed to sunlight are all typical (not material) defects in construction, and are strictly excluded from Contractor's warranty. F. WORK STOPPAGE AND TERMINATION OF CONTRACT FOR DEFAULT Contractor shall have the right to stop all work on the project and keep the job idle if payments are not made to Contractor strictly in accordance with the Payment Schedule in this Agreement, G. DISPUTE RESOLUTION AND ATTORNEY'S FEES Any controversy or claim arising out of or related to this Agreement involving an amount less than $5,000 (or the maximum limit of the Small Claims court) must be heard in the Small Claims Division of the Municipal Court in the county where the Contractor's office is located. Any dispute over the dollar limit of the Small Claims Court arising out of this Agreement shall be submitted to an experienced private construction arbitrator that shall be mutually selected by the parties to conduct a binding arbitration in accordance with the arbitration laws of the state where the project is located. The arbitrator shall be either a licensed attorney or retired judge who is familiar with construction law. If the parties can not mutually agree on an arbitrator within 30 days of written demand for arbitration, then either of the parties shall submit the dispute to binding arbitration before the American Arbitration Association in accordance with the Construction Industry Rules of the American Arbitration Association then in effect. Judgment upon the award may be entered in any Court having jurisdiction thereof. Contractor Owner Owner H. ENTIRE AGREEMENT, SEVERABILITY, AND MODIFICATION This Agreement represents and contains the entire agreement and understanding between the parties. Prior discussions or verbal representations by Contractor or Owner that are not contained in this Agreement are not a part of this Agreement. In the.event that any provision of this Agreement is at any time held by a Court to be invalid or unenforceable, the parties agree that all other provisions of this Agreement will remain in full force and effect. Any future modification of this Agreement should be made in writing and executed by Owner and Contractor. I have read and understood, and I agree to, all the terms and conditions contained in the Agreement above. 9 � DATE CONT OR'S SIGNATURE DATE OW A R'S SI C,NATURE DATE OWNER'S SIGNATURE OWNER HAS THE RIGHT TO CANCEL THIS CONTRACT WITH IN THREE DAYS OF SIGNING THIS CONTRACT Contractor Owner Owner The Commonwealth ofMass�chusetts F Department oflndustrial Accidents d 1 Congress street,Suite.100 N. Boston,MA 02114-20.17 www mass.goy/dia Workers'Compensatio-a fmmrance Affadavit:Builders/Contractors/EIectricians/Pinmbers. TO BB FILED WITH THE RERMITTING AUTHORITY. Please Print Legibly Alicaut hformation Name(Business/Organization/lndividual): Address: /00- ,,Gr'•�r�tsc1G= City/State/Zip,A �tl c. 104. 01Y f IS` Phone Areyou an employer?checktlie appropriate box: 'hype of project(required): 1.❑l am a employerwith 9 i employees(full and/or part-time).* 'J.• Now colistraction 2.EJ I am a sole proprietor or partnership and have no employees Working forme in 8. 0 Remodeling any capacity.[No workers'comp.insurance required] 9, ❑Demolition I Q I am a homeowner doing all work myself[No workers'comp.-insurance required.]t 10 [Building addition 4.F1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or.additions proprietors withno employees. 12,0 Plumbing repairs or additions 5.❑I aul a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance � 14.0 Other 6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no.e ployees.Vp workers'comp.insurance required.] *Any applicantthat checksbox#1 must also'fin outthe section below showingtheirworkers'compensationpolicy infomiaiion i Homeowners who stb it t�hr affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such �Coniractors that check this box must•attaghed an additional sheet showing the name of the sub-contractors and state whether or not those entities have s. employees. Ifthe sub-con{ractors have emplsyees,they must provide their workeis'comp.policy number. Iain an employer tri at is pr'ovzdiizgworkers'compensation insurance for my employee,-'BeZoiv is the policy acidjob site information. f" Insurance Company Name: r7�G'� Policy#or Self-ins.Lic.#: ExpirationDate:/ Job Site Address: S70 OS PO i S1 City/State/Zip:%Yc+ 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 cerci der the ns andpenaldes ofperjury tlaatthe information provided gbove is Prue and correct Si ature. C Phone#: / , Official use only. Do not write in this area,to be completed by city or town official City or Town: PermWLicense# Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/'T'own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions ' Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enferprise,and including the legal representatives of a deceased employer,or the receiver-or trustee of-an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or to cal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the common7alth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements ofthis chapter have been presented to the contracting authority." Applicants Please fill-out-the workers'compensation affidavit completely,by cheoldng the boxes that apply to your situation and,if necessary,supply sub=contractoi(s)name(s),address(es)and-phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees'other than the members or p artners,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-flidustrial Accidents for-confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be,returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidenis. Should you have any questions regarding the law or if you.'are required to obtain a workers' compensation policy,please call the Department•at the number listed below. Self-in'sur6d companies should'enter their self-insurance license number on the appropriate line. -' City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has-provided a space at the bottom of the affidavit for you to fillout in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as areference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephona and fax number: The Commonwealth of Massachusetts Department'of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-AIASSAFE Fax##617•-727-7749 Revised 02-23-15 www.mass.gov/dia RSHEB-1 OP ID:KM gCp/e p^ DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 08/17/2016 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 Michaud,Rowe And Ruscak Ins. NAME: Lawrence R.Michaud,CIC P.O.Box 188 acc°NN E,d:978 688 8829 Fvc No):978 557 2130 North Andover,MA 01845 E-MAIL Lawrence R.Michaud,CIC ADDRESS:lmichaud@mrrinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Commerce Insurance Company 34754 INSURED R S Hebert Const&Remod,Inc. INSURER 13:NorGuard 102 Adams Avenue INSURER C:AmGuard N Andover, MA 01845 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL UB POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DDIYYYY MM/DD/YYYY C COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE 0 OCCUR RSBP611273 05/11/2016 05/11/2017 DAMAGE TO RENTED SO,OO PREMISES Ea occurrence $ X Business Owners MED ERCP(Any one person) $ PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY 1 PRO JECT F—]LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 Ea accident A ANY AUTO BBCM08 12/19/2015 12/19/2016 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LS IABILITY TATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN RSWC759421 01/01/2016 01/01/2017 E.L.EACH ACCIDENT $ 100,00 OFFICERIMEMBER EXCLUDED? F—] N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,0() PROPERTY 5,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Steve Dufresne THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 523 Osgood Street North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD y Massachisr tis Department cf Public Safety 4J Board of Building Regulations and Standards License: CS-058241 Construction Supervisor RONALD S HEBERT 102 ADAMS AVE N ANDOVER MA 01845 1^ Exp;ration: Commissioner 01/08/2018 ✓fie�arr�rzoaaule�o�✓�aaaar�'ivael#b_� Office ac Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration:,-P153811 Type: Expiration:_ =119/-2017 Private Corporatin R .HEBERT CO:& - " LIN .REMODEG-INC. E FI N RONALD HEBERT. 102 ADAMS AVE. 4 " NO ANDOVER,MA 01845 h Undersecretary Location`' No. ��+— 2 tJ��1 Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ y Foundation Permit Fee $ Other Permit Fee $ , TOTAL Check# uildinnspectorBg