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HomeMy WebLinkAboutBuilding Permit #736-2017 - 573 JOHNSON STREET 1/25/2017BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: % 3(P ' �L0 f 7 Date Received t Date Issued: LVIPORTANT: App hcant must complete all items on ibis page .PRO MAP rn o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building KOne family 0 Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial 0 Repair, replacement ❑ Assessory Bldg 0 Others: ❑ Demolition ❑ Other 0 Septic Vilell 4 - 0 Floodplain Wetlands ' ' 0 Watershed Distract ❑ Water/Sewer.; M _- -- DESCRIPTION OF wURK I U kir rtKrUKIVICv: �Z�.r�^ O � �'L K� � G1� �✓� i'� Q�.0 �.Ct (� i r.te.�3' CUu ,•.►�-�� o n, � � t � �-� �„J tL 'Seg --k -ts, (z, c e C' ever- }14TH-t®•�, Identification - PIease Type or Print Clearly OWNER: Name: Sc(4.Jc30"JPhone: '7SI. 7'1ck 6a3 Address: -7 Q Contractor Name:... _ ._. Phone;, Address:_..- Supervisor's Construction) L46 Sp:; c -S _ __ Exp 'Date o �J '� i Hca°I ome�lmprovement icense .. �o�-g =xp: �I -tai 1 HL „.� _ .._... _ E bate � ARCHITECT/ENGINEER Phone: ' '9:i % — Address: 1,eck e- I�A Wew 8Jr`71 Reg, No.. 3 ia'S � FEE SCHEDULE; BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. f Total Project Cost: $ S 000 FEE: $ O Check No.: SS a -q Receipt No.: 91-;!{7 ' NOTE: Persons contracting with unregistered contr tors do not have. access to the guaranty fund Signature of_Agent/ig Owner nature of contractor'' Plans Submitted ❑ Plans Waived Ell Certified Plot Plan ❑ Stamped Plans. El -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 ❑ 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 t. Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes ra c 1 ,Planning Board Decision: Comments 1. 4" Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT -.Temp Dumpster on site yes Located at 124 Main Street Fire Department signature/date COMMENTS Locatea do4 usgooa street no 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 lies No ®ANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine No 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. r , Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ 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 ❑ 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 40TE: 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 Location 5 7 3 Jo h -by S o /y No. 73 (p - 01pt 7 Date I - -AS- • ,;Lo / 7 TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Check # t1 Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 85,000.00 m $ - $ 1,020.00 Plumbing Fee $ 127.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 127.50 Total fees collected $ 1,375.00 573 Johnson Street 736-2017 on 1/25/2017 Kitchen Remodel 0z r-10CD o Cr a) CL to O 0 p CD C C Cr CD 0 WCDo Q 0 c0 CD y CDD 0 71 Ow. U) 10 0 V CD CD CD U) v Z CD 0 O �q r v N o c T o < x r- N 0 c CD, D' Z� m w o 0 Q' rn O T m Nn 0 O y O Cl) - c� oor•a s m W CD mO to N N CD CD CD N x S O M cc cU) CLO rb O�, n . Z W Err r � cn y CD-a-0 NC Z cu• o3e' ;o C 'm �• O = N -h 0n Z MU3 CD o 0 a� O Z NDc° c� a:� cnz :N 0 C 0 CL '� c CL m cn N CD _r fi cn ui Z:.* CD t -0 � C v rtrt OO c 5 � .-e Z __ CD CD � V) � m m 0 0, O rt y CD O �q r v N o T o < x r- N 0 c CD, D' m w o 0 Q' rn O T Nn 0 O y O O. (C =r-' oor•a s m W CD mO to N N CD CD CD N x S n cc cU) CLO O O�, n . W Err r � y CD-a-0 NC CL cu• o3e' N C CDD O = N -h �A MU3 CD zr NDc° c� a:� �m :N 0 C 0 CL '� c CL m cn N CD _r CD 0 cn CD t -0 C rtrt OO 5 � .-e __ CD CD � � m 0 0, O rt y CD M r 0 . a) fl1 0 0 Q O �q r v N T .o T N ao T w n w T Nn T (C N S O O m NO C C NC N C O �A zr 0 �m 2 O O rt r 3 m r- w m T m C C 3 =3 pp N g o W n z M N o D z m z vZi = -� m m m m D zO 0 0 2 0 6 1 �� IA 0 c TESTA Building and Remodeling 5 APPLETON STREET NORTH ANDOVER, MA 01845 (978) 682 2023 Proposal Submitted To: Paul and Cheryl Sciaudone 573 Johnson Street North Andover, MA 01845 Job: Remodel kitchen Start date Jan 30 2017 Finish date April 10 2017 HIC Lic. 120296 Expires 11/19/17 CSL Lic. CS 54718 Expires 6/8/18 Proposal January 21, 2017, Phone: (781) 799-6231 Obtain building permit Complete removal of all demolition and construction materials Generated by Testa Building and Remodeling and its subcontractors. DEMOLITION: Remove all cabinets, counter tops, appliances, tile floor and underlayment, walls, ceiling And remove all insulation. CONSTRUCTION: Remove the existing window and frame a larger opening to receive a new Anderson 400 series double hung triple window. Patch the siding and trim on the back of the house. Remove the center wall that divides the kitchen from the living room and the wall that divides the living room from the foyer. Install an LUL that was designed by the structural engineer. Add a Lally column in the basement under the new point load. PLUMBING: Kitchen sinks to stay in same general location. Hook up the rest of the kitchen plumbing fixtures. Vent the hood over the cook top vent to be in the back yard. Install new toilet and vanity in half bathroom. Note: There is no allowances for plumbing fixtures ELECTRICAL: Add new circuits in the kitchen area where needed. Rewire kitchen to code. Supply and install 14 recessed lights. Wire all new appliances. Wire and supply one angle plug strip under the window. Run two new circuits for the electrical floor heat. Note: There is no allowances for light fixture other than the Recessed. INSULATION Insulate the walls and the ceiling to code. PLASTER: Hang 1/2 blue board and plaster all walls and ceiling. Hang Cement board behind the stove as fire proofing. CARPENTRY: Install all the kitchen cabinets and molding as per the designers drawings. Install new trim in the kitchen around the windows and doors to match the existing trim in the house. Installation of all kitchen appliances and wood fronts. Note: There is no allowance for cabinets and or countertops. FLOOR: Prep the floor for tile. Install Ditra Heat underlayment throughout the kitchen area, living room , foyer and half bathroom. Install large format tile allowing grout lines as expansion joints. TILE: Install tile along the back splash. Labor and adhesive supplied by contractor. Note: There is no allowance for tile or grout. PAINTING: Prime and paint the ceiling, walls, and new trim in the kitchen, living room and in foyer. A finance charge of 1!/2% per month (18% per year) will apply to all accounts over 30 days past due. In the event collection activity is required the customer shall be responsible for all costs associated with collection, including reasonable attorney's fees. I propose hereby to furnish material and labor complete in accordance with above specifications, for the sum of: $ 36,790 Thirty six Thousand Seven Hundred Ninety Dollars One- third to start, one-third after rough inspection, one- third upon completion. Authorized signature I reserve the right to cancel this contract if not accepted in_30_ days Signature.r Signature DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES This form satisfies all basic requirements of the state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of "A Massachusetts Consumer Guide to Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work. MGL chapter 142A.) Express Warranty - Is an express warranty being provided by the contractor? 5 No El Yes (all terms of the warranty must be attached to the contract) Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement. Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to see a copy of a "proof of insurance" document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. DO 1N THIS CONTRACT IF THERE ARE ANY BLANK SPACESM Two id ical c� es f the c9i Tact must be completed and signed. One copy should go to the homeowner. The other copy should be kept by the contractor Homeo er's S� ature Contractor's Signature 91 f. Date Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the cons s require o submit to such arbitration as provided In Massachusetts General Laws, chapter 142Y-� Homeowner's Signature Contractor's Signature NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself to be financially insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at http://www.mass.gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the RIC website at http://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeimprovement/licenseelist.as For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800, 508-755-2548 or 413-734-3114 Version 2.1 —11/22/201 NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR OBLIGATION, WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE, AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU CANCELLATION NOTICE, AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELED. IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED, ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION, YOU MAY RETAIN OR DESPISE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO, THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO [Name of Seller], AT [Address of Seller's Place of Business] NOT LATER THAN MIDNIGHT OF t (date). I HEREBY CANCEL THIS TRANSACTION. Date: Buyer's Signature: .. FIX ENGINEERING 2 Silver Ledge Road SHEET NO. ' of Z Newbury, MA 41951 CALCULATED DATE 111f 119 978-462-4331 Email: ifix@comcast.net CHECKED SY DATE _Arlat S: FIX ENGINEERING 2 Silver Ledge Road Newbury, MA 01951 978-462-4331 Email: jfix@comcast.net JOB_ --73 SMMTNOLr� ole CALV"TW eY 00 f HATE ff /� CHECKED BY. DATE m rn T ago icn Z T �r w i+ o r- CQ m r � O n z 8 v >c� mz rn z r� c w T O 0 w N 73 T the Commonwealth of Massachusetts DepartmeKt ofIndustrialAccidefats I Cowers Street, Suite 100 Boston, MA. 02114-2017 www mays gov/dia e�M Citi Wavkers' CompensaiionTnsance Affidavit. BuilderslCoUtr AUIOscians/lum ars. T0BRMEDWrM U7o�eaPrinf 7 Na1Tle (Business/Orga=,iion/Individuat):� 2 j L -Q. Address: cx5du �g a- ave 3 City/Stat 11 - �%r�-o.� tl ►�"� Phone #: 4�� 'Type of project (recluir8d) Axe you an employer? Cieckthe appxopriata box: } IFI I am a employer with employees (full and/or part time). 7. El Nem consfru'oiion g. �emodelvig 2. J/ Lam a s ole proprietor Or Partnership and have no employees Wor &.g for me 3n 9 � D e7T o i - any oapacty. [Noworkers' comp. insurance required.] On 3.Q Tam a homeowner doing all work myself~ [No workers' comp. insurance required ] ' 10 ❑ Building addition 4.F]I am ahomeowmr aadwill be hiring co tactors to conduct all work onmy property- Iwill 11.❑ Electrical repairs or additions ensurethat all contractors eitberhave workers' compensation insurance or are sole M Plum-biug repairs or a-dditionS proprietors with no employees. 5-❑I am a general contractoz and Thave hiredthe sub -contractors listed on the attached sheet 13.[]Roofrepairs These sub -contractors have employees and have workers' comp. insurance � 14. n Other 6. QWe ane a corporation and tis, officers have exereisedtheir rigbt of'•exemption per MGI c. 152, §1(¢), aad We have no employees. [No worker' comp. insurance required ] �nyapp]i°a thatcheclosbox#Imusitalsofilloutjhesectionbelowshowingiherrworkers'comperactonpolicyin332ita ion` _ Homeowners who submii•tivs affidavit indicating they are doing all workthe name -tl o scuba coma°tom ana fiatewhether or not fttosementii?esnh Ya ecb tCoutractors that checkthis Box must attached an additional sheetshowing employees. If the sub -contractors have employees, they most pro vide thein workers' comp- policy number. loyees. Below is t/iepolicy arzd job X am an employer that is providingworkexs' compensation insurance for° my empsite information. jusurance Company Policy # or Self -ins. Lic. ExTirationDate_- City/State/Zip: Job Site Address: Attach a copy' of the workers' compensafion Policy declaration page (showing the policy number and expiration. date). a ab to 500.00 Failure to secure coverage as re ed undeM MGLo. xnthe m criminal� -violation OR1� a fine ofuli to $250.00 a and/or one-yeaT imprisonment, as well as P day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby cern under tliepains andp—enall iess ofperjury that tiie information provided above is true and correct ( / Date' �a� �461`1 Phone #: Official use only. Do not-rvrite in tills area, to be coripleted by city or town offaclai Permit/License # City or T'ovn' IssuingA-athoritY(circle one): actor .Plumbing inspector 1. Board of E(ealth 2. Building Department 3. CitylT'own Clerk 4. Electricalinsp 6. other Phone #:. Contact Information and Instructions Massachusetts General Laws chapter 152 requires alt 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 ernployer is defined as "an individual; partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enferprha, and including the legal representatives of a deceased employer, or the receiver'or trustee ofan 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 ofthe 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 b6 deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant WIA has not produced -acceptable evidence of compliance with the insurance coverage requix•ed." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic 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 cartificate(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 confnmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retained 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- ,Yorkers' compansatioii policy, please call the Department at the number listed below. Self-insuredcarripanias should enter their self-insurance license number on the appropriate find. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space atthe 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 thai 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 applicaut should vaite •"all locations in (city or town.)." A copy of the affidavit that has b aan officially stamp ed or marked by the city or town may b e provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew 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, Susie 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.Daass.gov/dia ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE (MN/DDIYYYY) 1/25/17 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 ofthe 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 R.W. Testa Insurance Agency, IPHONE 855 Turnpike Street North Andover, MA 01845 NONTACT AME: Rich Testa FAx 978) 681-9002 (978) 685-1150 A/ N(1: E-MAIL rich@testainsurance.com INSURER(S) AFFORDING COVERAGE NAIC# INSURERA:COMMERCE INS CO INSURED B Testa Building And Remodeling -INSURER INSURER C: 5 Appleton Street North 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 LTR TYPEOFINSURANCE ADOL SUBR WVD POLICY NUMBER POLICY EFF M/DDIY POLICY EXP MVIIDDIYYYY LIMITS A GENERAL LIABILITY S16388 6/1/16 6/1/17 EACH OCCURRENCE $ 1,000,000 X COMMERCIALGENERAL LIABILITY DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 CLAIMS-MADE Fx—] OCCUR MED EXP (Anyone person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATELIMI TAPPLIE SPER PRODUCTS - COMP/OPAGG $ 2,000,000 POLICY 7 PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT a accident $ BODILY INJURY (Per person) $ ANY AUTO ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ par.(: dent NON -OWNED HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION WC STATU- I OTH- ICIRY I IM ITS FR AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTNE OFFICERIMEMBER EXCLUDED? N I A E.L. EACH ACO DENT $ E.L. DISEASE -EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is regli red) 573 JOHNSON ST, NORTH ANDOVER, MA 01845 \TCR 11r 1%1MI C IIVLUCR I, AVL rLLAI IUM TOWN OF NORTH ANDOVER 120 MAIN ST NORTH ANDOVER, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE RICHARD W TESTA JR © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: 8 Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-054718 Construction Supervisor JAMES M TESTA 5 APPLETON ST >' N ANDOVER MA 01845 r" jZZK CA— Expi ration: Commissioner 06/08/2018 I!'��c �torttrttnrtrucrrl(� r f r•j�ces3crc�r%te(I' �._ Office of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR t Registration: 120296 Type: yv, Expiration: 11/19/2017 DBA TESTA BUILDING & REMODELING JAMES TESTA 5 APPLETON STREET KANDOVER, MA 01845 Undersecretary