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HomeMy WebLinkAboutBuilding Permit #363-2013 - 531 FOREST STREET 10/5/2016 1 F le NORTH BUILDING PERMIT �� �tLE° '6gtio TOWN OF NORTH ANDOVER F= tb op APPLICATION FOR PLAN EXAMINATION * ,� Permit No#: Date Received � ArED W qss Date Issued: IMPORTANT: Applicant must complete all items on this page Lb,CATI:ON1i ,m a PROPERIN,OWNER Pant =10 a nog MAP _ �= PSARCEL. :: _� ZCl'NING`DISTR'I {T__ Histonc,DiStnct yds, no y t. _ -� - h Sf�op —-- og�- �V _ ��� lage � yes: n I TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition El Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ 0 Septic ❑UVelli ❑ Floodplain; ❑Weflands - _WatershediD�stnef Wates/Sewer DESCRIPTION OF WORK TO BE PERFORMED: A Identification- Please Type or Print Clearly OWNER: Name: Phone: I Address Gontra:ctor�N,ame- u = Ph©N Email Address Supervsorls Constrwction L^icense s _- �_ Expo x n . ~ - Ext Date{ � Hornpr©vementwLicense 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.: i Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund i nature of A ent/65---r ___ _ -- Signature of contractoro 9 g Location -53/ fae e s No. Date • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ C Foundation Permit Fee $ f. Other Permit Fee $ TOTAL $ M Check# . oY - Building Inspector. , � Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ 'Tanning/MassageBody Art ❑ S�'ming 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 Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS 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: FIREDgF�TMENT y Located 384 Osgood Street ak� = Temp ®§umpster �siteY eyes } F no Lacatedt 124MainStreetF 71 - FrreDepart►neritsi ,' gnatureldate � w AMM ENTiS T�. 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 I NOTES and DATA— (For department use) d I i I t I ❑ Notified for pickup Call Email Date Time Contact Name Doe.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 ❑ 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 ❑ 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) 1 ❑ Building Permit Application ❑ Certified Proposed Plot Plan I ❑ 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 j ❑ 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 DpjL) SCa,vNeD - , C The Commonwealth of Massachusetts �a•:g !.� FOR 1 Board of Building Regulations and Standards MUNICIPALITY Massachusetts State Building Code, 780 CMR,7h edition USE Building Permit Application Revised August, 2012 This Section For Official Use Only Building Permit Number: Date Applied: Signature: Building Inspector Date SECTION 1:SITE INFORMATION Residential ❑ Commercial ❑ Other Description: 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 531 Q9,. 1.1 a Is this an accepted street? yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: pp y: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ ? Municipal❑ On site disposal system ❑ Zone: Outside Flood Zone. , Commercial- Service Size Check if yes[] SECTION:2: PROPERTY OWNERSHIP` 2.1 Owner'of R` d: asoN ,4_,,j S3t ;E� S a a"A*J & QI�kS Name(Print) Address for Service: S2.t_ AAG Signature Telephone E-Mail Address SECTION, :DESCRIPTION OF.PROPOSED WORK Z:(check:all Ghat apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition Accessory Bldg.❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work- IaoVkt 0t WAte jT*fxJ %.lM.2&A�S {„ k/hPN L.—CAb 2t,N;�..41 / k.,�krfit, 16 FS C "tAA � _�,$Pr�A�rE l_PAI,N�10 C � T��.�Fb`ph1►!/� SECTION 4:ESTIMATED CONSTRUCTION'COSTS Item Estimated Costs: (Labor and Materials) Official,Use Only; 1.Building $ 1.` 'Building'Permit Fee:$ IV 2.Electrical $ 2• Indicate how fee is determined: ❑Standard City/Town Application Fee 3.Plumbing $ ❑TotalProject:Cose(Item 6)x multiplier x . 4.Mechanical (HVAC) $ 3 :Other Fees: $ 5.Mechanical List: (Fire Suppression) $ Total All Fees:$ 6.'Total Project Cost: $ /Os�j_?,.5- Check No.'s 0 Check Amount: _Cash Amount: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) C 661 dab Z)Zo��►3 License Number Expiration Date Name of C90Holder Lk C � d1L.1 RD. \A)% A�,7 M�k D,AI List CSL Type(see below) Address Type Descci fiori K U Unrestricted(up to 35,000 Cu.Ft.) Signature R Restricted 1&2 Family Dwelling 6w)(.%. Z'L(,i2 M Masonry Only RC Residential RoofingCovering Tele hone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation E-mail Address D Residential Demolition 5.2 Re Wed Home Im rovement Contractor(HIC) - (o Coibo a 11S%2--1( HIC Co e or C Registrant Name Registration Number am Address., III 3q u c i QC1Gt �Q��(���•2,ZL{Z Expiration Date Signature Telephone S23-A.•ti;kcsz. C'lAa►•�,ct x E-mail Address SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT.M G.L.<c.452.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached? Yes .......... 0 No...........0 SECTION 7a:.OWNERAUTHORIZATION.TO BE COMPLETED WHEN . OWNER'S AGENT OR,CONTRACTOR APPLIES FOR BUILDING PERMIT 1, , as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b:..OWNER'OR AUTHORIZED.;AGENT DECLARATION as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. Signature of Owner or Authorized Agent Date (Signed under the pains and penalties of perjury) NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CNIR Regulations 110.R6 and 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basement/attics,decks or porch) Gross living area(Sq.Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open r i r , NORTF{ 0 ve- ,eA. .. -d O No. oh ver, Mass, / Q • n O/� _ CaCNIC NIwKM y1. �i9 A�R'�TEO ►`P�,`'�5 S u BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .... ..£ .�:....Pr'S� BUILDING INSPECTOR . . . . . . . . ... ............................. has permission to erect .......................... buildings on .....531 ro R eps r Foundation ..................... .......................... ............... Rough to be occupied as .............SC It Vie..........W.!444......P09 w1 r!a ................................. 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 CONSTRUC ON ST3-tB�UILDING Rough Service ..... .......................... Final 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. SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) _tea R�11 �•(. k*n,-� (LS—NO Name of C -Holder License Number Expiration Date c"huts RD t•l1 Aµ, �t�o, � List CSL Type(see below) Address x T e Descn* tion Signature U Unrestricted(u to 35,000 Cu.Ft.) R Restricted 1&2 Family Dwellin M) (.qq Z.Z. Z. M Maso On] Tele hone RC Residential Roofinja covering tq WS Residential Window and Siding E-mail Address SF Residential Solid Fking A2pliance Installation 5.2 Re 'stered Home Improvement Contractor(HIC) D Residential Demolition ��o HItv �S TZ,l C CorgplTri targe o 11 Registrant am llj YwII L �A Registration Number Addres ��� Signature Expirdtion Date tTelephone E-mail Address SECTION b.WORKERS':COMpENSATION INSURANCE AFFIDAVIT(1►IG.L,c.152:§:25C Workers Compensation Insurance affidavit (�) must be com 1 eted and this affidavit will result in the denial of the issuance of the buildingsubmitted with this application. Failure to provide permit. Signed Affidavit Attached? Yes .......... p No.. ,p SECTION 7a:.OWNER AUTHORIZATION TO>BE CAlI II'LEif :WHEN OWNER'S AGENTORlCONTRACTOR AppLIES:FOR BUII:DING RERNiIT I, authorize as Owner of the subject property hereby relative to work authorized by this building permit application. to act on my behalf,in all matters Si nature of Owner Date SECTION 7b•:OWNERi ORAUTHORIZED AGENT DECLARATIOpJ I, as Owner or orized Agent hereby declare that the statements and information on the foregoing application are true and accurate,t the best of my knowledge and behalf. Signature of Owner or Authorized Agent (Signed under the pains and penalties of perjury) Date NOTES: FAnOwni,!:11­01yhs/herown workoranowner who hires an unre istered in the Home Improvement Contractor HIC Proave g ty fund under M.G.L.c. 142A.Other important info o)on he HIC Pogram andaccess to tConstructihe onprogram r Licensing(CSL)can be found in 780 CMR Regulations I I0.R6 and 110.R5,respectively. 2• When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) Gross living area(Sq.Ft.) (including garage,finished basement/attics,decks or porch) Number of freplaces Habitable room count Number of bathrooms Number of bedrooms Type of heating system Number of half/baths Type of cooling system Number of decks/porches Enclosed Open Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence,MA 01842 Tax ID#02-0353691 Client: Johnson,Ben Home: (978)314-7857 Property: 531 Forest St. Nortth Andover,MA 01845 Operator: STEVEN Estimator: Steven Fumero Business: (978)688-2242 Company: SERVPRO Of Lawrence-SERVPRO Of The E-mail: steven@servprooflawrence. Andovers- SERVPRO Of Salem/Plaistow com Business: 8 Blakelin St. Lawrence,MA 01840 Type of Estimate: Water Damage Date Entered: 9/27/2016 Date Assigned: i Price List: MAEM8X_SEP16 . Labor Efficiency: Restoration/Service/Remodel Estimate: 2016-09-27-1136-1 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence,MA 01842 Tax ID#02-0353691 2016-09-27-1136-1 Main Level ,r�2A --9,s..-� Kitchen Height: 8' T y.ab T �. nwetcabinc"( I 340.22 SF Walls 137.00 SF Ceiling ii N Kitchen N 477.22 SF Walls&Ceiling 137.00 SF Floor T 7 -er a^ �(B2 15.22 SY Flooring 41.67 LF Floor Perimeter Bland(B3 46.83 LF Ceil.Perimeter -9'_ 2'1 Missing Wall-Goes to Floor 2'7"X 6' 8" Opens into Exterior Missing Wall-Goes to Floor 2'7"X 61811 Opens into Exterior DESCRIPTION QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 1. Tear out non-salvageable tile floor&bag for disposal 137.00 SF 2.88 2.06 396.62 (0.00) 396.62 2. Tear out non-salt'underlayment&bag for disposal 137.00 SF 1.24 0.77 170.65 (0.00) 170.65 3. Countertop-flat laid plastic laminate-Detach 12.00 LF 4.89 0.00 58.68 (0.00) 58.68 4. Cabinet-lower(base)unit-Detach 12.00 LF 15.12 0.00 181.44 (0.00) 181.44 5. Sink-single bowl-Detach 1.00 EA 22.56 0.00 22.56 (0.00) 22.56 6. Tear out wet drywall,cleanup,bag for disposal 16.00 SF 0.81 0.19 13.15 (0.00) 13.15 7. Tear out and bag wet insulation 16.00 SF 0.64 0.07 10.31 (0.00) 10.31 Totals: Kitchen 3.09 853.41 0.00 853.41 Total: Main Level 3.09 853.41 0.00 853.41 Basement 1 10-7 1 Basement Height: 8' 342.67 SF Walls 1.14.17 SF Ceiling Basement = 456.83 SF Walls&Ceiling 114.17 SF Floor ^ 12.69 SY Flooring 42.83 LF Floor Perimeter 42.83 LF Ceil.Perimeter 1 DESCRIPTION QUANTITY UNIT PRICE TAX RCV DEPREC. ACV 8. Tear out and bag wet insulation 114.17 SF 0.64 0.50 73.57 (0.00) 73.57 9. Clean floor or roof joist system 114.17 SF 0.75 0.14 85.77 (0.00) 85.77 10. Remove wet suspended ceiling tile and bag for 114.17 SF 0.36 0.50 41.60 (0.00) 41.60 disposal 2016-09-27-1136-1 9/28/2016 Page: 2 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence,MA 01842 Tax ID#02-0353691 CONTINUED-Basement DESCRIPTION QUANTITY UNIT PRICE TAX RCV DEPREC. ACV Totals: Basement 1.14 200.94 0.00 200.94 Total: Basement 1.14 200.94 0.00 200.94 Line Item Totals: 2016-09-27-1136-1 4.23 1,054.35 0.00 1,054.35 Grand Total Areas: 682.89 SF Walls 251.17 SF Ceiling 934.06 SF Walls and Ceiling 251.17 SF Floor 27.91 SY Flooring 84.50 LF Floor Perimeter 0.00 SF Long Wall 0.00 SF Short Wall 89.67 LF Ceil.Perimeter 251.17 Floor Area 281.94 Total Area 682.89 Interior Wall Area 820.56 Exterior Wall Area 95.00 Exterior Perimeter of Walls 0.00 Surface Area 0.00 Number of Squares 0.00 Total Perimeter Length 0.00 Total Ridge Length 0.00 Total Hip Length I I 2016-09-27-1136-1 9/28/2016 Page: 3 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence,MA 01842 Tax ID#02-0353691 Summary for Dwelling Line Item Total 1,050.12 Material Sales Tax 4.23 Replacement Cost Value $1,054.35 Net Claim $1,054.35 Steven Fumero 2016-09-27-1136-1 9/28/2016 Page:4 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence,MA 01842 Tax ID#02-0353691 Recap of Taxes Material Sales Tax(6.25%) Clothing Sales Tax(6.25%) Storage Tax(6.25%) Line Items 4.23 0.00 0.00 Total 4.23 0.00 0.00 2016-09-27-1136-1 9/28/2016 Page: 5 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence,MA 01842 Tax ID#02-0353691 Recap by Room Estimate:2016-09-27-1136-1 Area: Main Level Kitchen 850.32 80.97% Area Subtotal: Main Level 850.32 80.97% Area: Basement Basement 199.80 19.03% Area Subtotal: Basement 199.80 19.03% Subtotal of Areas 1,050.12 100.00% Total 1,050.12 100.00% 2016-09-27-1136-1 9/28/2016 Page: 6 Servpro SERVPRO of Lawrence 2064 SERVPRO of Salem/Plaistow 5389 SERVPRO of The Andovers 5390 978.688.2242 office@servprooflawrence.com PO Box 328 Lawrence,MA 01842 Tax ID#02-0353691 Recap by Category Items Total % CLEANING 85.63 8.12% GENERAL DEMOLITION 701.81 66.56% WATER EXTRACTION&REMEDIATION 262.68 24.91% Subtotal 1,050.12 99.60% Material Sales Tax 4.23 0.40% Total 1,054.35 100.00% 2016-09-27-1136-1 9/28/2016 Page: 7 NOTEPADWHITKE1 PAGE 2 INSURED'S NAME KeJo Corporation OP ID: PI Date 09/28/2016 Named Insured: Kejo Corporation dba Servpro of Lawrence dba Servpro of Lawrence-Three dba Servpro of Lawrence-Two dba Servpro of Salem/Plaistow dba Servpro of The Andovers NA-ain Level 12' 8" 8' 12' —Iovoew Cabinets (B 1) M 6' 2' Kitchen —+ N L we Cabinet (132) N 4' 9" Island(133) �o M LKJ Main Level 2016-09-27-1136-1 9/28/2016 Page: 8 Basement 10. 8" 10' Basement Basement 2016-09-27-1136-1. 9/28/2016 Page: 9 Authorization to Perform Services and Direction of Payment Ben Johnson 09/19/2016 Customer Name: Date of Loss: Loss Address: 531 Forest St City: NORTH ANDOVER State: MA Zip: 01845 Insurance Company: SAFETY Insurance Claim Number(if available): Bos71783 The undersigned Customer, being the building owner, owner's representative, or resident, authorizes the Provider identified below to perform any and all necessary cleaning and/or restoration services on Customer's property located at the property address above, and with respect to items that need to be cleaned at a remote location to remove and clean such items as necessary. Customer authorizes SAFETY Insurance Insurance Company, herein referred to as"Insurance Company,"to pay Provider solely and directly for that portion of the work covered by Customer's insurance policy. If, for any reason, Customer receives a check from Insurance Company made payable to Customer, Customer agrees to pay Provider immediately upon receipt of the check. In order to expedite payment to Provider, Customer hereby appoints Provider as attorney-in-fact, authorizing Provider to endorse Customer's name on Insurance Company checks or drafts, and to deposit Insurance Company checks or drafts for Provider services. 00 Customer agrees to pay Customer's deductible in the amount of$ $0. that applies to this claim. If any amounts owing to Provider for Provider services are not covered by insurance, Customer agrees to pay those amounts to Provider within fifteen (15) days of Customer's receipt of invoice. It is fully understood that Customer and its agents, successors, assigns, and heirs are personally responsible for any and all deductibles and any costs not covered by insurance. Interest and finance charges will be charged at the maximum allowable by law, or at 1.5% per month, whichever is less, on accounts over thirty(30)days past due. Time is of the essence. Customer agrees that Provider is working for the Customer and not Customer's insurance company or any agent/adjuster. Property Owned By Ben Johnson - Remarks: I HAVE READ THIS AUTHORIZATION TO PERFORM SERVICES AND DIRECTION OF PAYMENT, INCLUDING THE TERMS AND CONDITIONS OF SERVICE ON THE NEXT PAGE HEREOF, AND AGREE TO SAME. Customer Reviewed Customer Information Form: O Y ON Provider's Signature: Customer's Signature: Franchise Legal Name: KEJO CORP Printed Name: Ben Johnson ® The Andovers d/b/a SERVPRO of: Date: 09/29/2016 09/29/2016 Date: E-mail Address: bjohnson131 @yahoo.com Contractor License#: ©SERVPRO®INTELLECTUAL PROPERTY,Inc. ALL RIGHTS RESERVED FE-051707 1.0 28000 05/16 Each SERVPRO®Franchise is Independently Owned and Operated. The Commonwealth of Massachusetts a Department of Industrial Accidents 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. Applicant Information Please Print Legibly Name (Business/Organization/Individual): %eayPRd Address: 'i 'RA Qu"rA '• City/State/Zip: L,a %OOL-lc Phone Are yo n employer?Check the appropriate box: Type of project(required): 1. I am a employer with (P employees(full and/or part-time).* 7. n New construction 2.M I am a sole proprietor or partnership and have no employees working for me in 8. any capacity.[No workers'comp.insurance required.] 9. remodeling 3.M I am a homeowner doingall work myself t 1 LLLIIII Demolition y [No workers'comp.insurance required.] 10E]Building addition 4.n I am a homeowner and will be hiring contractors to conduct al!work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I Ln Electrical repairs or additions proprietors with no employees. 12.[:]Plumbing repairs or additions S.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑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. 14.[:]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I 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. tContractors 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. Insurance Company Name: t, CoQ,�b�:�LoA Policy#or Self-ins.Lic.#: C Expiration Date: 2J:;)o tot Job Site Address:�'�l � c5k City/State/Zip-�-�p�BQ,PA 0Lt% .;- 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 certify under thepains andpen lues ofperjury that the information provided above is true and correct. Si nature: Date: Phone#: 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 I Contact Person: Phone#• AC CERTIFICATE OF LIABILITY INSURANCE r DATE(MM/DD/YYYY) 09/28/2016 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 NAME: Dabney Collier PHONED 901 529-2900 FAA/C No: 901 529-2916 c/o Collier Insurance E-MAIL 606 S.Mendenhall;Suite 200 ADDRESS: Memphis,TN 38117 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: American Zurich Insurance Company 40142 Adams Keegan,Inc. INSURER B: 6750 Poplar Ave Ste 400 INSURER C: Memphis,TN 38138 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:15TNO09858085 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 ADDL SUER LTR TYPE OF INSURANCE POLICY NUMBER MMIDDfYYYY MM/LDDY� LIMITS COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO-P POLICY❑ ❑ PRO- LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SIN LE LIMIT $ Ea accident _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED - AUTOS AUTOS BODILY INJURY(Per accident) $ HIREDAUTOS AUTOS ED PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN X STATUTE I i ER A ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? NIA WC 56-11-865-02 12/01/2015 12/01/2016 (Mandatory In If yes,describe under E.L.DISEASE-EA EMPLOYEO$ 1,000,000 DESCRIPTION OF OPERATIONS belo I E.L.DISEASE-POLICY LIMIT 1$ 1,000,000 Location Coverage Period: 12/01/2015 12/01!2016 Client# 2410-MA DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Coverage is provided for KEJO Corporation dba:SERVPRO of Lawrence Bi only those co-employees Weekly of,but not subcontractors 8 BLAKELIN ST to: Lawrence,MA 01842 CERTIFICATE HOLDER CANCELLATION Ben Johnson SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 531 Forest St. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE .._....._........... ........._..._.............. ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD WHTKE1 OP ID: PI CERTIFICATE OF LIABILITY INSURANCE DATE 09/28/2016 Y) 09/28/2016 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 James R.Mc Donald Stanley McDonald Agency PHONE FAX 1101 Main StreetA/C No.E •608-788-6160 (A/C. A/c No):608-788-7012 Onalaska,WI 54660 E-MAIL James R.Mc Donald ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURERA:Rockhill Insurance Company 28053 INSURED KeJo Corporation INSURER B:The Federal Insurance Co. 20281 dba Servpro of Lawrence INSURERC:ACE Property&Casualty 20699 See Note For Named Insured PO BOX 328 INSURER D: Lawrence,MA 01842 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. /LTR TYPE OF.INSURANCE D LSUBR D POLICY NUMBER MM/DDS POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 IV CLAIMS-MADE a OCCUR ENVP016006-00 03/01/2016 03/01/2017 PREA Ut SES Ea ccurrence $ 50,000 MED EXP(Any one person). $ 51000 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY❑PRO JECT ❑LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURYPer accident $ AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED P OPER Y DAMAGE $ AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1;000,000 C EXCESS LIAB CLAIMS-MADE M00798617 01/14/2016 01/14/2017 -AGGREGATE $ 1,000,000 DED I X I RETENTION$ 10000 $ WORKERS COMPENSATION PER' 0TH- AND EMPLOYERS'LIABILITY y/N T TUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Pollution Liab ENVP016004-00 03/01/2016 03/01/2017 Pollution $2mil/$3mil B EmployeeDishonesty 670-66-47 03/01/2016 03/01/2017 Crime 25,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION JOHNBE1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL. BE DELIVERED IN Ben Johnson ACCORDANCE WITH THE POLICY PROVISIONS, 531 Forest Street North Andover,MA 01845 AUTHORIZED REPRESENTATIVE C 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD fil/Y 10 1!1001111? Office of Consumer Affairs&Business Regulation License or registration valid for individul use only IMPROVEMENT CONTRACTOR before the expiration date. If found return to: jf 1 ' '` ',Registration: 158271 Type: Office of Consumer Affairs and Business Regulation � Expiration: 12/31/2017 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 KEJO CORPORATION SERVPRO OF LAWRENCE, ET ALS. GREGG WHITE 8 BLAKELIN STREET LAWRENCE, MA 01841 Undersecretary '" of valid without signage Nlassachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-067690 GREGG M WHITE 4 CHATBURN RD i WINDHAM NH 03087 `xplratlon. CommisS over 02/20i2018 I