HomeMy WebLinkAboutBuilding Permit #673-15 - 53 BRIDGES LANE 2/26/2015If
Permit NO: lfC
Date Issued:
LOCATION_
PROPERTY
%O'
MAP NO: /
Vn
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINAT O �)
Date Received
RTANT: Applicant must complete all items on this
Pard
ARCEL: 6?_W ZONING DISTRICT: Historic District yes no
Machine Shop Village ves ( no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
Kone family
❑ Addition
❑ Two or more family
❑ Industrial
Alteration
No. of units:
❑ Commercial
)(Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
o bgAfo
vrls —
Identification Please Type or Print Clearly)
OWNER: Name:
Address:
CONTRACTOR Name:
ie:
0 -034-061
Address: l '
Supervisor's Construction License: Exp. Date:
CS 12$l�,SYo
Home Improvement License: /8o (f8.,3 Exp. Date:
ARCHITECT/ENGINEER h J, MOCCiq Phone: r -a*
Address: Reg. No. :13a e 7
FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ �'�s� �- FEE: $ 6, a �
Check No.: 4;�l.I— Receipt No.:
NOTE: Persons contracting with a is red contractors do not have access a ua antyfund
Signature of Agent/Owner Signature of contractor
Permit No#:
Date Issued:
BUILDING PERMIT 42',%Ir
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAM INATION.4�'
Date Received.:
IMPORTANT: Applicant must complete all items°on.tli-is page
-7P
= 6Nnnt
IM -
WO
- ZONING E®ISTRIC
es no
,yes no:
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Others:
❑ Repair, replacement
❑ Assessory Bldg
❑ Demolition
❑ Other
_
';❑SepticWell
ti❑Floodplain0;1Netlands
:p �Wate,rshedDlstnct t
:❑ 4Wate�/Sewers h
-
_
utbUKIV i 1UN ul- WORK TO BE PERFORMED:
Identification - Please Type or Print Clearly
OWNER: Name: Phone:
ArIrlrPcc
�Gontractor,INarne
n
Address
_.
Supervisor's'Consst'ructionLicen� e _ _�� �_ _ IExp-
lH:ome,llrnnrovemen`tll ICPn�e_ torr'_ tnatna -
ARCHITECT/ENGINEER
Phone -
Address: Reg..: No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE:; $
Check No.: Receipt No.-"'-`:....
NOTE: Persons contracting with unregistered contractors do not,hai ve. access to the guaranty fund
` ignatur`e of Agent/Ovvn2 _ Signature of corgi ctora
��.,n�.�.s_,«.=..:...ma�wtc-,�,.-+ �a-...n,��+�c;--°--_,: r..":-'-+�-�CF.;tir v�':�i-.;x.�e�:: •_;-�:-..�-.'S�.?R a-r..a.
i
Location
No.
Date
Check # C
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ �-
Building/Frame Permit Fee $
Foundation Permit Fee $_
Other Permit Fee $
TOTAL $
Building Inspector
./
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑
., t
Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools _ ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. X
Permanent Dumpster on site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT ❑
COMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
•
0
DATE REJECTED
DATE APPROVED
11
DATE REJECTED DATE APPROVED
❑ ❑
Zoning Board of Appeals: Variance, Petition No: Zoning Decisiontreceipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
Located at 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes (---- no
Located at 124 Main Street
Fire Department signatureldate— .S11-4
COMMENTS
Plans Subs-nitted ❑
Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TW -06 SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Permanent Du npster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date _ Drivewav Permit
DPW Town Engineer: Signature:
_ Located 384 Osgood Street
FhRE iDEPA`R ENT Temp®u�mpsterron �sitees - ry
Lo7-5 at 11241--ain Sfr�eeY:
t ono
�FireDeparfinentsgnat'area _
r
/dates
-
COYMIUIEN3T�
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA — (For department use
❑ Notified for pickup Call Email
Date Time Contact Name
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
o Building Permit Application
❑ Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
❑ Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/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
Li 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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Building Permit Revised 2014
r;
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Enter construction cost for fee cal -
North Andover Fee Cakulation
Construction Cost
$ 76,775.00
m
$ -
$
921.30
Plumbing Fee
$
115.16
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
115.16
Total fees collected
$
1,251.63
53 Bridges Lane
673-15 on 2/26/2015
Kitchen and Bath Renovation
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3 Patriots Lane
Nottingham, NH 03290
Phone / Fax: (603) 734-2464
symmetryconstruction.com
Contacts: John & Bill Cantwell
CUSTOMER I
Patrick & Sari Walsh
53 Bridges Lane
North Andover, MA 01845
(781) 929-3878 mobile
S
�1V1 M E;rR
TOTAL
Y
CONSTRUCTION
Lane North Andover, MA. Symmetry Construction to supply materials and labor to perform work
as outlined below.
Scope of Work
Modifications of existing dwelling as per conceptual design discussed with homeowner.
603-734-2464
Contractor agrees to perform in a good and workmanlike manner all work detailed below. Such
Estimate
DATE ESTIMATE#
2/25/2015 1354c
ITEM
DESCRIPTION
TOTAL
Description
Provide construction services for customer owned single family dwelling located at 53 Bridges
Lane North Andover, MA. Symmetry Construction to supply materials and labor to perform work
as outlined below.
Scope of Work
Modifications of existing dwelling as per conceptual design discussed with homeowner.
Contractor agrees to perform in a good and workmanlike manner all work detailed below. Such
work consists of the following:
General Requirements
Building Permits
All applicable building, demolition and tradesman permits to be obtained by contractor and
issued by the town of North Andover, MA.
($850.00 allowance)
Dumpster
Waste debris container to be on job site during construction.
Bathroom
1st Floor Bathroom
14,652.00
Remove all existing cabinets, bathroom fixtures, plumbing fixtures and electrical fixtures.
Remove all existing tile and flooring.
Remove all existing wallboard from walls and ceiling.
Complete bathroom demolition back to wall studs and subfloor.
Insulation to be installed as required for exterior wall.
1/2" concrete board to be installed on subfloor.
1/2" blueboard installed on walls and ceiling and plaster skimcoat to be applied.
New tile and grout installed for floor.
Install new cabinets, bathroom fixtures, plumbing fixtures and electrical fixtures.
All electrical and plumbing to be installed as per code.
Existing washing machine/dryer to be stacked. Customer to supply hardware.
Thank you for the opportunity to submit this estimate.
Tota!
Page 1
3 Patriots Lane
Nottingham, NH 03290 •
Phone / Fax: (603) 734-2464
symmetryconstruction. com
Contacts: John & Bill Cantwell
CUSTOMER
Patrick & Sari Walsh
LIC
53 Bridges Lane
North Andover, MA 01845 • •
(781) 929-3878 mobile
Estimate
DATE ESTIMATE#
2/25/2015 1354c
ITEM
DESCRIPTION
TOTAL
Kitchen
Kitchen Renovation
21,852.00
Removal of all existing cabinets and countertops.
Removal of wallboard to studs for walls and ceiling.
Removal of existing flooring to subfloor.
Complete removal of all demolition and construction materials.
Installation of new framing required for new window sizing/kitchen design.
Re -work existing wiring as required and removal of existing unusable wiring.
Install all required electrical as per code.
Installation of recessed ceiling mount cans (6), pendant light at sink & general room lighting.
Install all required switches and GFCI outlets.
Dedicated wiring for new appliances.
Customer to choose lighting fixtures.
Install all required plumbing as per code.
Rework existing sink water feeds and drains.
Install water feed and drain for new dishwasher.
Install water feed for new refrigerator.
Installation of all fixtures.
Installation of new exhaust for cooktop.
Customer to choose plumbing fixtures.
Replace insulation for exterior walls as required by code.
Installation of firestop for all floor penetrations.
Walls and ceiling to have 1/2 inch blueboard installed with a smooth plaster skimcoat applied.
New customer provided kitchen cabinets and trims to be installed as per design provided to
Symmetry Construction.
New baseboard to be installed.
New window casings to be installed.
Installation of tile and grout for back splash area.
Appliances provided by customer.
Interior Rework
Dining/Kitchen Wall
5,966.00
Removal of dividing wall for kitchen/dining room.
Installation of an approximate 12ft LVL header beam to accommodate weight load for upper
floor.
Rework existing electrical wiring.
Rework existing plumbing for heat.
Patch wallboard for ceiling and walls and wallboard exposed beam.
Thank you for the opportunity to submit this estimate.
Total
Page 2
3 Patriots Lane
Nottingham, NH 03290
Phone / Fax: (603) 734-2464
symmetryconstruction.com
Contacts: John & Bill Cantwell
�iM'MEfrR
iii 7�7 J7_�
Estimate
CUSTOMER
Patrick & Sari Walsh
u.c
53 Bridges Lane
North Andover, MA 01845
DATE ESTIMATE#
(781) 929-3878 mobile
2/25/2015 1354c
j ITEM
DESCRIPTION
TOTAL
Floor Coverings
Hardwood Flooring
14,305.00
1st Floor (Great Room)
Removal of existing carpeting and installation of 495 square ft. of prefinished hardwood flooring.
1st Floor (Dining, Front Entry, Hallway, Porch)
Removal of existing flooring and installation of 430 square ft. of prefinished hardwood flooring.
1 st Floor Kitchen
Installation of 175 square ft. of prefinished hardwood flooring.
Allowances
$4,950.00 1,100 square ft. Hardwood flooring
$490.50 109 square ft. Tile & Grout- Bathroom Flooring / kitchen backsplash
$550.00 Plumbing Fixtures
$250.00 Electrical Fixtures/Lighting
$450.00 Window (Kitchen)
$1,500.00 Exterior Door
$8,190.50 Total Allowances
Customer to provide kitchen / bathroom cabinetry and countertops.
Painting not included as part of this estimate.
Thank you for the opportunity to submit this estimate.
Total
Page 3
3 Patriots Lane
Nottingham, NH 03290
Phone / Fax: (603) 734-2464
symmetryconstruction.com
Contacts: John & Bill Cantwell
fAIME11YrR
Estimate
CUSTOMER
s
Lff-
Patrick & Sari Walsh
53 Bridges Lane
North Andover, MA 01845
• • '
DATE ESTIMATE#
(781) 929-3878 mobile
2/25/2015 1354c
ITEM
DESCRIPTION
TOTAL
Warranties
The Contractor warrants that work furnished hereunder shall be free from defects in materials and
workmanship for a period of one year following completion and shall comply with requirements
of this Agreement. In the event any defect in workmanship or materials, or damage caused by the
Contractor, his subcontractors, employees or agents, is discovered within one year after
completion of any job, including cleanup, the Contractor shall, at his own expense, forthwith
remedy , repair, correct, replace, or cause to be remedied, repaired or replaced, such damage
defect in materials or workmanship. The foregoing warranties shall survive any inspection
performed in connection with the agreed upon work.
All warranties for equipment supplied by the Contractor under this Agreement shall be those
given by the manufacturers of such equipment, which shall be and are hereby passed through
directly to the Owner. Under such manufacturers' warranties, the Owner may be required to
register or mail in warranty card or other evidence of ownership and use of such equipment in
order to activate such warranties. The Owner's failure to mail in or register such documentation,
which failure voids manufacturer's warranty, shall not create any responsibility to the Contractor
to warranty such equipment.
The Warranty gives the Owner specific legal rights, and Owner may also have other rights which
vary from state to state.
Terms and Conditions
Payment terms to be 25% initial first payment and remaining amount progress payments to be
paid on approximate 2 week intervals as per invoice detail worksheet as percentage of work
complete. Change orders to be written as separate estimates with payment terms to be 25% initial
first payment and remaining amount progress payments to be paid on approximate 2 week
intervals as per change order invoice detail worksheet as percentage of work complete.
All material is guaranteed to be as set forth. All work to be completed in a workmanlike manner
according to standard practices. Any changes to above specifications involving additional costs,
will be made only by request in writing, and will be an additional charge. All agreements
contingent upon strikes, accidents or Acts of God. Owner to carry fire and other necessary
insurance. Our workers are fully co e ed by Workmen's Compensation and Liability Insurance.
This proposal may be withdrawn r bjec c ccepted within 30 days.
Authorized Signature
Acceptance of Proposal
The above prices, specifications and conditions are satisfactory and are hereby accepted. You are
hereby authorized to d e work specified. a nt will be ad outlined above.
Acceptance Signature
Thank you for the opportunity to submit this estimate.
Total $56,775.00
Page 4
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1-26-15
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CS Beam4.605
ItinBeatnPirgire 4.6.1.0
MaterfalsDela6aso 1476
Member Data
Description: Member Type: Beam
Application: Floor
Top Lateral Bracing: Continuous
Bottom Lateral Bracing: Continuous
Standard Load: Moisture Condition: Dry
Building Code: IBURC
Live Load: 40 PLF Deflection Criteria: U360 live, L240 total
Dead Load: 10 PLF Deck Connection: Nailed
Member Weight 10.4 PLF
Filename: Beam1
Other Loads
Type Trib. Other
(Description) side Begin End Width start
Dead
End start End
Category
Replacement Uniform (PSF) Top 0' 0.00" 12' 6.00" 13' 6.00" 30
10
Live
Additional Unffoml S Top 0' 0.00" 12' 6.00" 13' 6.00" 20
10
Live
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12 6 0
12 6 0
Bearings and Reactions
Input Min
Location 'type Material Length Required
Gravity Gravity
Reaction uplift
1 0' 0.000" Wan SPF Plate (425psi) 5.500" 3.767"
5603# —
2 12' 6.000" Wan SPF Plate 425 sl 5.500" 3.767"
5603#
Maximum Load Case Reactions
thud lar applying point loads or fins loads) to mWO9 memo=
Live Dead
1 3WN 1844#
2 3959# 1844#
Design spans
11' 8.750
Product 2.0 RigidLam LVL 1-3/4 x 11-7/8 2 ply
PASSES DESIGN CHECKS
Connect members with 2 rows oiled common nails at 12.0" oc
Design assumes continuous lateral bracing along the top chord
Design assumes continuous lateral bracing along the bottom chord
Allowable Stress Design
Actual Afioirable Capacity Location Loading
Positive Moment 16430.* 199054 82%
6.25' Total Load D+L
Shear 4658.# 7897.# 58%
Max. Reaction 5603.# 8181.# 68%
0.4' Total Load D+L
a Total Load D+L
TL Deflection 0.41.65" 0.5865" L/337
6.25' Total Load D+L
LL Deflection 0.2943" 0.3910" L/478
6.25' Total Load L
Conn d: Positive Moment
DOLE: Live=100% Snow=1150% Root=125% Wtr d=lWo
OF
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Cop*M (C) 2019 by Simpson Slrong•1le Company for. ALL RK HM RESERVED.
e
"passing Is defined as when One member;.e0or)ouL beam mge6 shown on thla dmahp meets appiirable design ror
olteds Loads, Loading Conditions, and Sponslisled on this street.
The desgn mus be reviewed fir a qualllied deYgnerordesfgn professierral as repaired for approval: Thta design assumes pmdud instaOatlon a=nnng to the manuradurers
eanona
P.O. Box m
E. KAMPSTEAD, MH 03026
"M =9450
FAX (MM 32944
TITLE
SUBJECT
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OESIGN SERVICES
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Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supen isor
License: CS -081956
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JOHN D CANTWgLL
3 PATRIOTS LN
NOTTINGHAM SH, 8 .
Expiration
Commissioner 08/05/2015
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la —' Registration: .:180883
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Expiration 112312017 LLC
`i ETRY CONSTftIJCT,ION LM
JOHN CANTWELL
Type:
3 PATRIOTS LANE-�
NOTTINGHAM, NH 03290:."'..: - Undersecretary
02/26/2015 10:27_ _6034329822 BENWAY JOHNSTON INS PAGE 01/01
OP ID: PC
DATE_ (MMIODIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 02/2)x/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY �XTEND OR ALTER TRIGHTS
HE COVERAGE AFFORDEDUPONTHE ABY THE POLICTE HOLDER, NES
IS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,
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 e pollcy(ies) must be endorsed. s SUBROGATION IS WAIVED, subject to
an ADDITIONAL INSURED, thment on this
the terms and conditions of the policy, certain policies may require an endorsement. A statecertificate does not confer rights to the
certificate holder In lieu of such endorsements . coNTacr
PRODUCER NAME:
Benway-Johnston Insurance Inc. PNONC FAX
PO Box 750, 36 Crystal Ave C -MAIL
Derry, NH 03038 ADDRESS-
Benway-Johnston Ins., Inc. "6Ro�� srg.1
INSURED Symmetry Construction LLC tNSURERA:Merchant9 Mutual Ins. o. _
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John Cantwell INsuRER B : Riv®rpoint Insurance Co.
3 Patriots Lane INSURER 0:
Nottingham, NW 03290 INSURER D 7
INSURER P: _
OVERAGES CERTII-It;A I r- IVUWI0r- c:
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 HF_REIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAY 9:PID CLAIMS.
rvsR TYPE OF INSURANCE rw,�., i...,,i,.,.,. •------ - - -
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GENERAL. LIABILITY
BOP1045129 0111212015 01/12I2016
A X COMMERCIAL GENERAL LIABILITY
CLAMS -MADE � OCCUR
LIMIT APPLIES PER:
AUTOMOBILE L1A91LITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
UMBRELLA LIAR OCCUR
EXCESS LIAR CLAIMS -MADE
DEDUCTIOLE
,
R NTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN WC -28-83-002887-05 01/1912015 011191201(
B ANY PROPRIFTOR/PARTNER/EXECUTIVE N / A
OEFIC."MEMBER EXCLUDED9
(Mandatory In NN)
If ves, defieride under _
I LOCATIONS I VEHICLES (Ahneh ACORD 101, Addltlonei Remarlro Schndule• Ir Moro spaeo la rrlgoLroE)
ENTRY
Town of No Andover
1600 Osgood St.
Bldg. 20 Suite 2035
No Andover, MA 01845
LIMITS
EACHOCCURRENCE
UA
PREMI ES S (Ee occurrence),
MED CXP Any ono person) _
PERSONAL & ADV INJURY
$ 1,000,00(
R 600,001
S 6,001
a 1,000,001
GENERAL AGGREGATE
a 2,000,001
PRODUCTS - COMPIOP AGO
$ 2,000'001
COMBINED SINGLE LIMB
(Ea accident)
S
_
BODILY INJURY (Per pnrnon)
BODILY INJURY (Per aocldenl)
S
PROPERTY DAMAGE
(PER ACCIDENT)
$
EACH OCCURRENCE
S
S ,
AGGREGATE
a
$
WC STATU- OTH-
TABY� IN1LI EP_ E.L. EACH ACCIDENT
a
$ 100,0(
E.L. DISEASE - EA EMPLOYF-F
$ 100,0(
E.L. DISEASE- POLICY LIMIT $ 500'0(
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
Benway-Johnston Ins., Inc.
®1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD I
CNN
The Commonwealth of Massachusetts
Department of Industrial Accidents
ti d 1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Business/Organization/Individual):
Address:
City/State/Zip:
45
Phone #: (03 '---Z ,3 y^ 0 �p
Are you an employer? Check the appropriate box:
1.xI am a employer with _employees (full and/or part-time).*
2..❑"' I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4. ❑ 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
proprietors with no employees.
5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.I
6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7. ❑ New construction
8. ❑ Remodeling
9. ❑ Demolition
10 ❑ Building addition
11. F] Electrical repairs or additions
12. ❑ Plumbing repairs or additions
13. ❑ Roof repairs
14. ❑ Other
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. r
Insurance Company Name: A ' NCiV0117 4 47/7,5(!d'Q61 e (j r
Policy # or Self -ins. Lic. #: to ( —p;i67—F3 —009097 O� Expiration Date:
Job Site Address: ,0)6hiCity/State/Zip: GCv U . Oe
Attach a copy of the workers' c4 policy declaration page (showing the policy number and expiration ate).
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 certifyy5*r the ai and penalties of perjury that the information provided above is true and correct.
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), 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 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
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be 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 of Investigations 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 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, telephone 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-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia