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HomeMy WebLinkAboutBuilding Permit #208-2016 - 530 FOSTER STREET 8/18/2015 AAW 1 BUILDING PERMIT r10RTli D�,t.En TOWN OF NORTH ANDOVER �� tip.., •6 APPLICATION FOR PLAN EXAMINATION 7° . 2 -2a� o ^ey Permit No#• Date Received a,4"�R,,,.Eo gSSACHU`'�C Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 3o /?S ? sT A---0 7V- Alt-9 V-v6Z A4 4-0 Print PROPERTY OWNER A?VZ>e-r.4J Print 100 Year Structure yes 2no�MAP PARCELZZZ ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building /One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic []Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: N' 1/ Identification- PleaseTie Ar Print Clearly OWNER: Name: =oPhone: Address: 5-3C 4" Contractor Name: Phone: f79 Em a L Z� & e-o 2-7 Address: A4 I Supervisor's Construction License: 10S--0,9 (,' Exp. Date: l-Oo / Home Improvement License: / 60 - vL�� Exp. Date: �f ii 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: $ 7 JO FEE: $ Zd?) Check No.: I Receipt No.: 2° 2-Z l NOTE: Persons contracting with unre istered contractors do not have access to th uaranty fund f LocationNo. 2-o I Date . - TOWN OF NORTH ANDOVER fob • . . Certificate of Occupancy $ Building/Frame Permit Fee $-2 Foundation Permit Fee $ Other Permit Fee $ TOTAL _ $��,� Check# r' r Building Inspector I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM ;PLANNIN DEVELOPMENT Reviewed On Signature_ MMENTS CONSERVATION Reviewed on l Signature COMMENTS HEALTH Reviewed on �J Si nature COMMENTS c� s � ".-Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/signature& Date Driveway Permit DPW Town Engineer: Signature: �� _. 8 FIREDEPARaTMENT temp ®umpster,on�sitej Located Osgood Street LEd-ated4at,�1, 41Mam1 Beet { F re Depar�tmentrs gnature/date COMMENTS, 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.$1oo-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit 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 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 ISIOTE: 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 I ECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 F NORTfi own of S E ndover No. jo �h Mass, � ti ver, o ,f- C0C"1CHewjcw 1' 7,9SoR�1Teo �`Pa`,��(y IJ BOARD OF HEALTH PE Food/Kitchen LD Septic System ammon— THIS CERTIFIES THAT d ,�„�, ,e ,,,,,,,,,,,,, BUILDING INSPECTOR .. . ....... ....... ... . .... .. ............. has permission to erect.......................... buildings on .... ... �............�� .... ...... .... Foundation. Rough to be occupied as ..... _ .. .. ....... :......... ..�,�.. .�.....1.� ..°.......... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT _-STAR Rough J � Service .......... ......... . '....... ... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. TMK Remodeling 214 Sutton Hill Rd Contract CSL 105086 North Andover MA 01845 Jeffrey_530—Foster Repairs_Shed HIC 165887 9788524491 RRP LR000106 www.tmkremodeling.com CONTRACTOR AGREEMENT THIS AGREEMENT made this LlS i l7 20Lry and between Theodore Kelley dba TMK Remodeling, Construction Supervisor License# 105086, 214 Sutton Hill Rd, North Andover MA 01845 hereinafter called the Contractor, and Andy& Dorothy Jeffrey hereinafter called the Homeowner. WITNESSETH, that the Contractor and the Homeowner for the consideration named herein agree as follows: ARTICLE 1.SCOPE OF THE WORK The Contractor shall perform all of the work described in the specifications entitled Exhibit A—Statement of Work, as annexed hereto as it pertains to work to be performed on property located at 530 Foster St North Andover MA. ARTICLE 2.TIME OF COMPLETION The work to be performed under this Contract shall be commenced on or before August 17, 2015 and shall be substantially completed on or before September 04, 2015 ARTICLE 3.THE CONTRACT PRICE The Homeowner shall pay the Contractor for the labor and materials to be performed and supplied under the Contract the estimated sum of Sixteen Thousand Seven Hundred Dollars and No Cents($16,700.00), subject to additions and deductions pursuant to authorized change orders. Contractor will furnish and install all building materials, fixtures and finish items unless noted otherwise. ARTICLE 4. PROGRESS PAYMENTS Payments of the Contract price shall be paid in the following manner from the Homeowner to the Contractor: 33% upon contract acceptance and signature; $5,566.67 33% upon rough building inspection;$5,566.67 33% upon final building inspection and 90%completion of finish; $5,566.67 The contract cost for mutually agreed to change orders will be paid 50%at time of change order signature and 50%after completion and Homeowner sign-off. ARTICLE 5.GENERAL PROVISIONS 1. All work shall be completed in a workmanship like manner and in compliance with all building codes and other applicable laws. 2. To the extent required by law all work shall be performed by individuals duly licensed and authorized by law to perform said work. 3. Contractor may at its discretion engage subcontractors to perform work hereunder, provided Contractor shall fully pay said subcontractor and in all instances remain responsible for the proper completion of this Contract. 4. Contractor shall furnish Homeowner appropriate releases or waivers of lien for all work performed or materials provided at the time the next periodic payment shall be due. 5. All change orders shall be in writing and signed by both Homeowner and Contractor. The cost for mutually agreed to additional work, required due to unknown conditions or substantive change orders, will based on the current bill rates for the actual time used.Additional materials will be billed at contractor cost.All change orders subject to 10% markup for overhead. Copyright TMK Remodeling 2014 Initials All Rights Reserved Page 1 TMK Remodeling 214 Sutton Hill Rd Contract CSL 105086 North Andover MA 01845 Jeffrey_530_Foster Repairs_Shed HIC 165887 978 852-4491 RRP LR000106 www.tmkremodeling.com 6. Contractor warrants it is adequately insured for injury to its employees and others incurring loss or injury as a result of the acts of Contractor or its employees and subcontractors. 7. Contractor shall at its own expense obtain all permits necessary for the work to be performed. 8. Contractor agrees to place all debris in an on-site trash receptacle(dumpster) and leave the premises in broom clean condition. 9. In the event Homeowner shall fail to pay any periodic or installment payment due hereunder, Contractor may cease work without breach pending payment or resolution of any dispute. 10. The Contractor and the Homeowner hereby mutually agree in advance that in the event that the Contractor has a dispute concerning this contract, the Contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and the Homeowner shall be required to submit tosuch rbitration as provided in MGL c 142A. Ho o er r Date: Co rad or Date: Notice: The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by the Contractor. The Homeowner may initiate alternative dispute resolution even where this section is not signed by the parties. 11. Contractor shall not be liable for any delay due to circumstances beyond its control including strikes, casualty or general unavailability of materials, or inclement weather. 12. Contractor warrants all work for a period of 12 months following completion. 13. Contractor may post small signage(18x24")on property advertising services during the duration of the project. 14. The Contractor and subcontractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Office of Consumer Affairs and Business Regulation Ten Park Plaza, Suite 5170 Boston, MA 02116 Phone: (617)973-8700 15. The Contractor or Homeowner may terminate this contract at any time for any reason by giving 3 days notice in writing to the other party. If either party terminates the contract as provided herein, then the contractor will be paid for work(labor and materials)completed as of the date of termination plus any materials or equipment that are backordered and not delivered. Payment is defined as actual job costs for the project plus 10%overhead charge. The contractor will provide a written report detailing actual job costs plus overhead for payment. The Contractor will refund any funds paid by the Homeowner that are a remaining balance for the labor and materials used as of the date of termination, plus any materials or equipment that are backordered and not delivered, plus 10% overhead charge. The Contractor will make arrangements for the backordered items to be delivered to the Homeowner. Copyright TMK Remodeling 2014 Initials All Rights Reserved Page 2 TMK Remodeling 214 Sutton Hill Rd Contract CSL 105086 North Andover MA 01845 Jeffrey_530_Foster Repairs_Shed HIC 165887 978 852-4491 RRP LR000106 www.tmkremodeling.com 16. The Homeowner is responsible for maintaining adequate access to the property including snow removal, personal property storage, and working doorways, stairways and walkways. In the event the contractor is required to provide access or repair to the doorways, stairways and walkways, then the Contractor will bill the Homeowner at the hourly bill rate for same. ARTICLE 6. OTHER TERMS i ARTICLE 7.ACCEPTANCE i Signed thisday of . 20 wner ontractor NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by the contractor. The Homeowner may initiate alternative dispute resolution even where this section is not signed separately by the parties. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Copyright TMK Remodeling 2014 Initials All Rights Reserved Page 3 Licenses: TMK Remodeling Exhibit A-Statement of Work CSL 105086 214 Sutton Hill Rd Jeffrey_530_Foster_Repairs_Shed HIC 165887 North Andover MA 01845 RRP LR000106 978 852-4491 www.tmkremodeling.com A B C D E F G I 1 Owner: 2 Andy&Dorothy Jeffrey Estimate: 2015-033 Estimate valid for 30 days 3 andy(a.mentalpilates.com Estimate Date: 08/17/15 Expiration Date: 09/16/15 4 530 Foster St 5 North Andover MA 6 508 284-2577 7 8 Scope of Work Repair exterior window case molding.Remove existing trim materials.Install PVC trim materials:case molding,sill nosing,aprons.Construct shed attached to garage approx 60x36"similar to existing.Relocate 9 electrical connection for generator.Remove hot tub.Construct 10x8'deck.Remove existing decking and hand rails.Install new PVC decking and composite hand rails. 10 Notes: 11 Pricing includes labor and materials to install finished item+allowances. EA=Each LF=Lineal Feet SF=Square Feet 12 EA LF SF Total Cost 13 Quantity Cost Quantity Cost Quantity Cost 14 1.0 Administration - W - 3 $2,837 $2,837 15 01 Plans and Permits:01.2 Building Permits 1 $200 $200 16 Building Permit 1 $200 $200 17 02 Site Work 1 $468 $468 18 15 Yd Dumpster 1 $468 $468 19 31 Overhead&Expenses 1 $2,169 $2,169 20 Overhead and project administration 1 $2,169 $2,169 21 Deck Expansion-80 SF4 $547 10 $679 160 $1,143 $2,369 22 03 Excavation 2 $247 $247 23 Excavation for 4'deep 12"wide footing 2 $247 $247 24 04 Concrete 2 $300 $300 25 Concrete 4000 PSI 2 $300 $300 26 10 Exterior Trim&Decks 10 $679 1.60, $1,143 $1,822 27 Install PT 2x10 joists,rim boards,fascia,beams,ground posts 80 $540 $540 28 Install TimberTech silver maple 1x5 finished decking materials 80 $603 $603 29 Install Radiance rails and balusters 10 $679 $679 30 Deck Improvements-180 SF 28 $1,900 360 $2,122 $4,023 31 02 Site WorkA2.10 Demo 1-80 $765 $765 32 Remove finished floor 180 $765 $765 33 10 Exterior Trim&Decks 28 $1,900 180 $1,357 $3,258 34 Install TimberTech silver maple 1x5 finished decking materials 180 $1,357 $1,357 35 Install Radiance rails and balusters 28 $1,900 $1,900 36 Exterior Repairs 13 $3,150 $3,150 37 -2'0-M-illwork&Trim 13 $3,150 $3,150 38 Remove and replace window case moldings and sill nosing approx 50x35"w/PVC materials. 2 $500 $500 39 Remove and replace window case moldings and sill nosing approx 54x46"w/PVC materials. 1 $250 $250 40 Remove and replace window case moldings and sill nosing approx 66x35"w/PVC_materials. 4 $900 $900 41 Remove and replace window case moldings,sill nosing and aprons approx 90x35"w!PVC materials 6 $1,500 $1,500 42 Shed 10 $1,394-- 15 $2,248 40 $680 $4,321 43 04 Concrete - - - - 8 $200 -+ $200 44 Concrete 4000 PSI 8 $200 $200 45 07 Wall Frame 15 $2,248 $2,248 46 Exterior 2x4 Wall Construction 8'high,paint,PVC trim,sheathing,siding,VB,R15 15 $2,248 $2,248 ©Copyright TMK Remodeling All Rights Reserved Page-4 Unlawful to distribute without permission 1711" - '�- Licenses: TMK Remodeling Exhibit A-Statement of Work CSL 105086 214 Sutton Hill Rd Jeffrey_530_Foster Repairs Shed HIC 165887 North Andover MA 01845 RRP LR000106 978 852-4491 www.tmkremodeling.com A B C D E F G I 47 08 Roof Frame 20 $440 $440 48 Frame roof 2x8 rafters,sheathing 20 $440 $440 49 09 Roof Finish 20 $240 $240 50 Roofing install:6'ice&water shield,architectural asphalt shingles 20 $240 $240 51 12 Doors&Trim 1 $814 $814 52 Furnish and install Pair 15/18/21_/24x78/80"interior doors,frame,trim,handset,painted 1 $814 $814 53 16 Electrical&Lighting 1 $380 $380 54 Relocate generator electrical box to new location _ _ _ _ ,V 1 $380 _$380 55 Grand Total 30 $7,928 _ W 53 $4,827 560 $3,945 $16,700 ©Copyright TMK Remodeling All Rights Reserved Page-5 Unlawful to distribute without permission `v i I OeX817 5+�,�s - ,«►� aNVH � j d3a►d � hio� X o� J °N .,8X,8 S1N3w3Sb7-� �` NQS2�,->S AY)CA ;tlX >}��Q o+ 1VO5 � 1 Wok NM�a }5 'm coo d�� w �"y""` S 850531102"E �y 7T°2a�4 209.47' 133 S 13°30'07"W 37.98' LOT 48B ? 47,268 S.F. s S°43'18sr ° .`0Co �b cr A. ,, House # 530 of N .13m `A!L#� ,AN SEPTIC CERTIFIED 827/98 ELEVATION TABLE m� ��► OUT OF HSE.=138.38 IN TANK= 13817 OUT TANK =13801 GO IN BOX =137.78 T I CERTIFY THAT THE OFFSETS SHOWN COMPLY OUT BOX =137.62#1 TRENCH =137.30 WITH THE ZONING BY-LAWS OF WHEN BUILT. 1 HEREBY CERTIFY THAT I HAVE INSPECTED THE #2 TRENCH =137.30 OFFSETS SHOWN ARE FOR THE USE OF THE BUILDING CONSTRUCTION OF THIS DISPOSAL SYSTEM AND INSPECTOR ONLY AND SUCH USE IS FOR THE DETERMINATION THAT THE CONSTRUCTION AND THE FINAL GRADING OF ZONING CONFORMITY OR NON-CONFORMITY WHEN CONSTRUCTED. HAS BEEN IN ACCORDANCE WITH THE DESIGNERS INTENT AND THAT THE MATERIALS USED CONFORM Assessors Map 1048 Parcel 222 _-- — — — TO THE PLAN SPECIFICATIONS AND 310 CMR 15.00. 6/24/98 ^----- - -• '-- • ------ - -- The Commonwealth of Massachusetts z . Department oflndustrialAccidents ^a. d X Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dna Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information / /` Please Print Le 'b l Name (Business/Organization/Ind:ividual): f? J( .Address: //Z City/State/Zip: /J_ AA-VOVtZ A14- Phone#: 97(f Are you an employer?Checkthe apliiopriate box: Type of project(required): I.ViI atn a employer with employees(full and/or part time). 7, []New construction 2.U I am'a sole proprietor or partnership and have no employees working for me in g. Remodelirig any capacity.[No workers'comp.insurance required.] 9. Demolition 3..Q I am a homeowner doing all work myself,[No workers'comp.insurance required.]t ❑ 10 [1 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my properly. I will ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 12..Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F1 ROOF repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c• 14KOther rL�- 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *.Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submif 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 pravide their workeis'comp.policy number. I am an employer that is pio'viding workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: 57y C-5-0 / 7 Z Expiration Date: t1l 1,6 Job Site Address: � � City/State/Zip: A'U/���?/L ' !J/j� ©1&'�1,� 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 o.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 DTA for insurance coverage verification. I do hereby certify u elerthepainsandpenattles o per- that the information provided above is true and correct. Sign e: Date: 8 Za Phone#: ? �//4'9 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 o li re, 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 bd 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-contractors)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 foi•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-fiisur6d 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 filll 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 OP ID:JG DATE(MMlDDIYYYY) Rte- CERTIFICATE OF LIABILITY INSURANCE 1/15 THIS CERTIFICATE IS ISSUF-D AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT 41FIRMATIVELY 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(iee) 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), CONTACT RO PDUCER 978-975-1300 NAME: Sagreve&Hall Insur.Assoc.lne 978-975-7596 PONE. Exl• FAx No 306 North Main St. E-MAIL Andover,MA 01810 Apo Ess' Lawrence J.HallDucER TMKRE-1 cusTO INSURERS AFFORDING COVERAGE NAIL# INSURED TMK Remodeling INSURERA:Arbella Protection Ins. Co. 41360 214 Sutton Hill Rd INBUReRe:AEIC 11104 North Andover,MA 01846 INSURER C: INSURER D: INSURER E: INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER-, THIS IS TO TT THE-P�ICIES OF NCE LISTED BELOW HAVE BEEN ISSUED O THE INSUR5-D NAMED ABOVE FOR THE POLICY INDICATED,CNOTTWITHSTANDING ANY REQUIREMENTT ,TERM OR CONDITION ON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH T HIS 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 PAI D LIMS, LIMITS r OF INSURANCE POLICY NUMBER IM MM/DD 1,000,001 RR6NCE $ TY 100,001 Ea Gaurrence $ L GENERAL LIABILITY 5,001 -MADE � OCCUR ny one person) $ 9520037133 03108115 &ADV INJURY 8 1,000,00 GENERAL AGGREGATE $ 2,000,00' PRODUCTS-COMP/OP AGG $ 2,000,00 TE LIMIT APPLIES PER:P O El LOC COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident $ ANY AUTO BODILY INJURY(Per person) S ALL OWNED AUTOS BODILY INJURY(Par acoldant) $ SCHEDULED AUTOS PROPERTY DAMAGR $ (Per seddent) HIRED AUTOS $ NON-OWNED AUTOS $:IZE RRENCE $UMBRELLA LIAB OCCUR SEXCESS LIAB CLAIMS-MADE SDEDUCTIBLESRETENTI N 't ATU- OTH- WORKERS COMPENSATION IMIAND EMPLOYERS'LIgBILnY Y/N CCIDENT $B qNY PROPRIETOR�PARTNER/EXECUTIVE N AOFFICERIMEMBER EXCLUDED7 5005011872 04101/15 04E-EA EMPLOYEE $(Mandatory in NH) 11 1 daec6be under E-POLICY LIMIT $ DESCRIPTION 0:0 F pPERAT10NS below DESCRIPTION OF OPERATrONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Ramarke Schedule,If more sp2ce Is require(l) CERTIFICATE HOLDER CANCEL ON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 6r-FORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St North Andover, MA 01845 AUTHOR)ZED REPRESENTATIVE ®1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2008109) The ACORD name and logo are registered marks of ACORD Massachusetts -Department of Public Safety Board of Building Regulations and Standards , Construction Supervisor � License: CS-105086 �. .. AL'Ab THEODORE M KELLEY---, 214 SUTTON HIIZ RD �i77 NORTH ANDOR MA 01845 f Expiration . 10/08/2015 Commissioner (glse wpow")?'aiacueal(�n�C��caaccc�uaelld ffice of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR gistration: 165887 Type: xpiration: 4/5/2016 DBA TMK REMODELING � I THEODORE KELLEY 214 SUTTON HILL RD. NORTHANDOVER, MA 01845 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 Not valid without signature