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Building Permit #1198-2016 - 59 BERRINGTON PLACE 5/16/2016
t10RT/t �-a BUILDING PERMIT TOWN OF NORTH ANDOVER " �j APPLICATION FOR PLAN EXAMINATION y t Permit NO: b Date Received Date Issued: �9SSgcHus���y IM ORTANT:Applicant must complete all items on this page LOCATION Be MlY 1"LACC . . . .. �.... :. . . Print PROPERTY OWNER CM016-- Print MAP NO: ZONING DISTRICT: Historic District yesJno o Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑ eration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: emolition ❑ Other D Septic ❑Well 0 Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer . . _ _ /2, 41 2sazz, a Identification Please Type or Print Clearly) ?",±g OWNER: Name: (JG�D/b' Phone:Address: ��934wo I"VtA CONTRACTOR Name: Phone: -q(7-9926 Address: 70 ©lfb7 Supervisor's Construction License:C,S-0 Exp. Date: /116 L40 X09 Home Improvement License......-_. .. .: Exp: Date: `O. ARCHITECT/ENGINEER TEYEW A A40 k Phone: 7JO/.- 35Y-5155 - y Address: 016n IUA0114i &P&7 Reg. No./OZ// FEE SCHEDULE.BULD/N PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. nn Total Project Cost: $ 7�,D©o FEE: $ I � `r--- J Check No.: 21`"I Receipt No.: 30-S-11 NOTE: Persons contractin with unre istered contractors do not have access to the guaran fund nature of contractor Signature of AgenUOwner _ ._ Sig�_ __ y . x BUILDING PERMIT a �TIORTFi O�R.a�.ED lg41, "6 TOWN OF NORTH ANDOVER CZ p 9 APPLICATION FOR PLAN EXAM INATI0 ` * _ M Permit No#: Date Received- SAC N11`�Q Date Issued: IMPORTANT:Applicant must complete all item—§odn tl s--page LOCATION Print PROPERTY OWNER Print 100 Year'Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shap Village 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 ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic 0 Well D Floodplain Wetlah--S ,1N'atershed'Disfnct, _ ; 01Nater/Sewer� _ _-_��. _ _._ _ .�_. __._ - . _�____ _ -A — - - DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp.. Date: Home Improvement License: Exp.;•Qat :::, ' ..' ARCHITECT/ENGINEER Phone: Address: Reg. No. ` FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED cosr,,RCsEwV 8.$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Recei t p - NOTE: Persons contracting with unregistered contractors do not have'access tothe guaranty fund .f r Location 51 Bee R I-Lq No. 2c'( Date tt� • -+ TOWN OF NORTH ANDOVER Certificate of Occupancy $ I Building/Frame Permit Fee $1�`l " Foundation Permit Fee $ Other Permit Fee $__ TOTAL $ Check# 1 % r J J 7 9 Building Inspector i Plans Submittbd ❑°`- Plans Waived ❑ Certified Plot Plan-Q -S{amped Plans ❑ TYPE OF SEWERAGE DISPOSAL -. Public Sewer ❑ Tanning/Massage/Body Art ❑ -rte MI g 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 Siqnature 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 ConneCfion/Siqnature&Date Driveway Permit DPW Town Engineer: Signature: F ,,�_� y � Located 384 Osgood Street FIRE DEP RTMENY Tem D t� t ,„urr�psteraontsiteYeS .a?►.__ ., .��. no' _ %ro"U-adt-e-d atg124 Main Street ire ©e i ment�i� �-�d E � p ' . gnatur�e/date t t�,iH"r'AP4 ?�°� N� R �... .Y�•""" __ - ..�...��.=.o-a�.....:�Rw'. go COMMENTS Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAI, Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools El 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ YA COMENTS .� -V1 -Dt-1 -k CW DA I E REJEU I ED A- 1 1:�A L1j111JVL c CONSERVATION ❑ 5 �C� �� Y" COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ 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 Drivewav Permit Located at 384 Osgood Street 3 FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signatu-reldate COMMENTS Dimension Number of Stories: Total square feet of floor area, baseit! °I terior dimensions. Total land area, sq. ft.: r ELECTRICAL Movement of Meter location, mast or service dr®p-riqwres approval of Electrical Inspector lies N® DANGER ZONE LITERATURE: Yes N® MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA—(For department rase) ❑ Notified for pickup Call Email Date Time Contact Name = Doc.Building Permit Revised 2014 Building Department The following is, 'st 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doe:Building Permit Revised 2014 i 384.88' - I REQUIRED ZONING SETBACK /NE D-53 I ' w I AREA = 114,385 SF N I / D-52 r I � D-51 \ EDGE OF I / WETLANDS h / 0 I PROPOSED LIMIT OF 100'PROPOSED f BUFFER ZONE �--- DECK SCREEN PORCH M 1 _ 52.00' EXISTING HOUSE \\\\ \\\ 44.4 \\\: 3 _ ZONING DISTRICT: R 1 MIN. LOT AREA = 87,120 S.F. MIN. LOT FRONTAGE - 175 FT. MIN. FRONT SETBACK = 30 FT. N MIN. SIDE SETBACK - 30 FT. MIN. REAR SETBACK = 30 FT. a\\ DO �y !.-r ! r/!yid r✓/ � �s - P 1 P IL ✓/iGir/ �!�!.O/ r j RIEN PROPOSED ADDITIONS FOR 64.,?o .c GISTEP SSS/OEN 59 BERRINGTON PLACE =� VAL IN NORTH ANDOVER, MASS. PREPARED FOR: BRYAN BENDIG CHRIS TIANSEN &SERGI PROLAND SURVEYORSEERS SCALE. 1" = 40' DATE. MAY 11, 2016 160 SUMMER ST. HAVERHILL, MA 01830 TEL. 978-373-0310 © 20168 Y CHRIST/ANSEN & SERGI, INC, s M. N0. 01.03900 384.88' I i AL REQUIRED ZONING SETBACK INE (TYP-.T — — D-53 I I / I I , I w D-52 AREA = 114,385 SF N I I 1, D-51 EDGE OF WETLANDS PROPOSED PROPOSED / '� LIMIT OF 100' DECK SCREEN PORCH f BUFFER ZONE 52.00 1 EXISTING HOUSE lyra;, 44.4 ' 1 ZONING DIS TRIC T. R 1 - • '�• MIN. LOT AREA 87,120 S.F. - MIN. LOT FRONTAGE - 175 FT. 1 MIN. FRONT SETBACK = 30 FT. MIN. SIDE SETBACK = 30 FT. --------------------- MIN. REAR SETBACK = 30 FT. /li�ir, 9� fir viii/�'�% Pi i IP Cy .Or' HRi EN j; if. i Il PROPOSED ADDI TIONS 'f'JF'''y ,i/;, i, �¢/ /�r 28895 87ri a FOR ?p " 9�i;'� .cis G/STEP 59 BERR/NGTON PLACE S'°"^`E IN NORTH ANDOVER, MASS. PREPARED FOR: BRYAN BENDIG CHRIS TIANSEN �,�SERGI rR°LAND1 DSURVEYORSEERs SCALE: 1" = 40' DATE: MAY 11, 2016 160 SUMMER Sr. HAVERHILL, MA 01830 I TEL. 978-373-0310 © 2016 8Y CHRISTIANSEN!& SERGI, INC. DWG. N0. 01.039007 Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 961000.00 m $ - $ 1,152.00 Plumbing Fee $ 144.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 144.00 Total fees collected $ 1,540.00 59 BERRINGTON PLACE 1198-2016 ON 5/16/2016 DECK AND PORCH AND VESTIBULE OORTH Town of* 3� ., ndover No. _ h ver, Mass, rA 21 16. T O LAME 1 A-'Q COC MIC Kl WICK y 7,�5 R,TEo ►'P�,��(5 U BOARD OF HEALTH Food/Kitchen PER -IT T D Septic System THIS CERTIFIES THAT z BUILDING INSPECTOR ....... !�.�. ...............�.... .....�.......... .......... ................ Foundation has permission to erect .......................... buildings onul...... . . Rough to be occupied as 11A..N.C.VJ....12..' ...I....x... 3�.,��.�:��... .. ..... .. ..t6.1.... Chimney provided that the person accepting this permit shall in every respect conform to the to sof 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. 5C(tP4W 7#0 1 PLUMBING INSPECTOR ' +e Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. VrS�, � ��• Final PERMIT EXPIRES IN 6 M0H ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service ...............:.... ........................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place onthePremises — Do Not Remove Final YY No Lathing or Dry all To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. 0 MICHAEL R. RRUSSARD BUILDER AND REMODELER A Proposal to Build a New Deck and Screen RoomNestibule at 59 Berrington Pl. in No. Andover, MA Presented to: Bryan & Michelle Bendig May 4, 2016 License #CS-060916 Mass. HIC # 164584 Bryan & Michelle Bendig Table of Contents INTRODUCTION.................................................................................................4 PERMITNOTICE...............................................................................................4 DEMOLITION.....................................................................................................4 EXCAVATION AND FOUNDATION WORK..........................................................4 REARDECK.....................................................................................................4 FRAMING..........................................................................................................5 ROOF...............................................................................................................5 EXTERIOR TRIM AND SIDING...........................................................................5 DOORPANELS.................................................................................................5 ELECTRICAL.....................................................................................................5 INTERIORTRIM.................................................................................................5 PAINTING..........................................................................................................5 GUTTERS.........................................................................................................6 UNDERSTANDINGS...........................................................................................6 FINANCIAL AGREEMENT..................................................................................6 STATEMENT OF RIGHTS UNDER THE HOME IMPROVEMENT CONTRACTORS ACT..................................................................................................................7 SIGNATUREPAGE............................................................................................8 2 Bryan& Michelle Bendig Introduction Michael R.Brussard,Inc. (MRB)is pleased to submit this proposal for building a new deck, screen room and vestibule at 59 Berrington Place in No. Andover,MA. Quote is based off of plans dated 04/10/16 by Steven Baczek. This proposal contains specifications,timing, and permits. Once this proposal is signed by MRB and Mr. and Mrs. Mc Bendig,this document shall become a legally-binding contract. Permit Notice It is the obligation of MRB to obtain all necessary construction related permits required for the completion of this project. Furthermore,any residential property owner who secures his/her own construction related permits, or who deals with unregistered contractors shall be excluded from access to the Guarantee Fund under the Home Improvement Contractor Act. Specifications Demolition • Removal of existing deck, stairs, footings and stair slab • Complete removal of all demolition and construction materials generated by MRB and their subcontractors • All materials will be disposed of at a legal offsite location Excavation and Foundation Work • Excavate for 13 "bigfoots",footings with building tubes on top of them as per plan • Fill all bigfoots with concrete • Install V stone under the perimeter of the deck, screen room and vestibule • No allowance for ledge, trucking to remove large rocks (3'x3'or larger) or unsuitable soil conditions—if encountered on the job, any such additional costs shall be payable by(honer and covered by a scope change Rear Deck • All framing will consist of Pressure Treated lumber as per plan • The decking installed under the screen porch and vestibule will be an IPE brand decking,this decking will be installed on an insect screen • This IPE decking will have groves on the sides to accept the installation hardware • The decking on the main"deck"area will be a Wolfe product,PVC decking, attached from the sides to the frame • The rails and balustrade will be composed of PVC material(white plastic) • All trim will be Versa-tec(also a white plastic) o This will consist of wrapping all posts as per plan 4 Bryan & Michelle Bendig o We will wrap the outside flame of the main box o The stair stringers and risers will also have the Versa-tec applied Framing • Framing of Screen room and Vestibule will be done as per plans Roof • Match the existing shingle color and style as close as possible Exterior Trim and Siding • Any siding and trim that is disturbed from the location of the old deck and the new deck will be replaced • All the trim around the screen porch and vestibule will be Versa-tec • All seams with the Versa-tec will be glued and nailed with stainless steel nails • Install CVG(clear vertical grain) '/z x 6"Primed Cedar clapboards on vestibule and screen room as per plan Door Panels • Install"Easy Change"Combination doors as per plans,clear view,no grille work • Install"Easy Change" combo door as per plan,again clear view Electrical • Allowance of 6 receptacles in the interior of Screen room/vestibule • Installation of 1 exterior GFI outlet by door to main deck • Installation of 1 client supplied fan in center of screen porch, switching to code • Installation of 1 client supplied surface mount fixture in vestibule • Install 4 5"Juno Recessed lights with white trim work and lamp • Installation of 1 client supplied exterior wall sconce,next to door, switch to code • Installation of 1 coax cable outlet, location per homeowner Interior Trim • Install 1 x 6 primed Tongue and grooved boards on walls and ceilings,this board has a 5"+exposure and has 2 sides,a bead board which is a small bead down the middle or a flat 5"+board with bevels on the ends. I can get you some pictures Painting • All new clapboards will receive 1 coat of oil based primer and 1 final coat of stain to match the house color • All new interior trim will receive 2 coats of paint,homeowner choice of color 5 Bryan & Michelle Bendig Gutters • Install white"K" style gutters (same as what you have now)on the vestibule and screen room,install downspouts off the back of the screen room Understandings • No allowances for anything not specified in this proposal. • Any change orders agreed upon will be documented and signed by a representative of each party Financial Agreement MRB is fully licensed and insured, and carries Workers Compensation. MRB warrants that the work performed by MRB under this project shall be fit for the purpose of a residential home improvement project in the Commonwealth of Massachusetts, in accordance with the State Building Code. Payment schedule to be broken down into four payments: i Payment 1-Deposit—Covers General Conditions,permit, demolition, dumpster costs...................................................... $24,000.00 Payment 2-Payment Due when the following is completed Main frame, bracing and decking is complete ........................... $24,000.00 Payment 3-Payment Due when the following is completed Vestibule, Screen Room are framed and roofed.......................... $24,000.00 Payment 4-Payment Due when the following is completed Stairs complete, railings finished, electrical complete, interior finish of rooms complete along with finish painting......... $24,000.00 Total cost of Construction: $96,000.00 Any change orders during job are due at next payment 6 i Bryan& Michelle Bendig Statement of Rights under the Home Improvement Contractors Act STATEMENT OF COMMENCEMENT OF WORK AND SUBSTANTIAL COMPLETION This project shall commence in or near the week of May 16, 2016 and this project shall be substantially complete by the end of the first week in June. Dates are subject to change due to weather conditions. Further, no work on this project shall begin prior to the signing of this document by MRB and Mr. & Mrs. Bendig,and transmittal to Mr. & Mrs. Bendig of a fully-signed copy of this document. STATEMENT OF REGISTRATION REQUIREMENT FOR HOME IMPROVEMENT CONTRACTORS AND SUBCONTRACTORS All home improvement contractors 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,Massachusetts 02116 (617)973-8700 STATEMENT OF THE ENTIRE AGREEMENT OF THE PARTIES This document, once signed by MRB and Mr. &Mrs.Bendig,shall constitute a binding contract and contain the entire agreement between MRB and Mr. &Mrs. Bendig. Furthermore,the agreement can only be modified by a written addendum signed by MRB and Mr. &Mrs. Bendig. The above prices, specifications,and conditions are satisfactory and are hereby accepted. MRB is authorized to perform the work as specified herein. Payment will be made by Mr.&Mrs. Bendig as outlined above. 7 Bryan & Michelle Bendig Signature Page DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES The respective parties hereby accept the terms of this proposal and understand that by signing below,they are entering into a legally-binding contract under the terms and conditions set forth above Michael R.Brussard,Inc. Authorized Name Michael R.Brussard,Inc. Authorized Signature Z Date �c (jl� Client Name: Bryan&Michelle Bendig Authorized Name Bryan.Bendig Authorized Signature Date 1 Authorized Name Michelle Bendig Authorized Signature to Date I The Commonwealth ofMassachusetts Department ofludustr"ialAceidents 1 Congress Street,Suite 100 Boston,MM 02114-2017 www mass.gov/dia . .'�•..:..sy:yt Workers,Compensation Insurance Affidavit:Builders/Contractors/1;;lectricians/Plumbers. TO BE MED WITH THE PERMITTING AUTHORITY. , Applicant Information Ple--a77s--��e Print Le 'bl Name(Business/OrgauizatioiAadividual): StY N� Address: 7d ✓ �� City/State/Zip: �S/Pholle#: rf'� 3a0.Z Are you an employer?Check the appropriate box: Type of project(required): 1.NJ1 am a employer with__employees(fall and/or part-time).* 7. 0 New construction 2.[]I am a sole proprietor or partnership and have no employees working for me in S. �Remodelirig any capacity.[No workers'comp.insurance required] Demolition 3.FJ I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. 4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t ' � 14.0 Other 6.Q 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.] *Any applicant that checks b6x4l must also fill out the section below showing their workers'compensation policy information. homeowners who subnzif this affidavit indicating they are doing all work and then hire outside contractors must s4bmit 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- actors have employees,&l nwst provide their workeis'comp.policy number. -fain an employer that is providiiig workerscompensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Q�✓ Policy#or Self-ins,Lie.#: �3�1 Expiration Date: �v 1h Job Site Address: NCity/State/Zip: Attach a copy of the workers'compensa n 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. X do hereby cert! nder ie pai andna11des of per' that the information provided above is true and correct. Signature: Date: Z� `� Phone#: Of 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 Instructs®ns 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 f 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 p erformance 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 atfidavit. The affidavit should be returned to the citypr 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 B oston,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 DATE(MMYY) �..+, CERTIFICATE OF LIABILITY INSURANCE 05/05/2011201 6 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 c NT TJa ueline Marie Montes MassPay Insurance Services,LLC NAME: 27 Garden Street,Unit 1 B AICNN Ext: (978)774-4338 x105 FAX,,,):(978)774-1318 Danvers,MA 01923 E-MAILADDRESS: jackie@philrichardinsurance.com hilrichardinsurance.com INSURERS AFFORDING COVERAGE NAIC# INSURERA: AmGUARD Insurance Company 42390 INSURED Michael R.Brussard,Inc. INSURERB: 70 Lawrence Road Reading,MA 01867 INSURERC: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR - POLICY EFF POLICY EXP LTR D POLICY NUMBER MWDD MMIDD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER- GENERAL AGGREGATE $ FPOLICY 1 Rd LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEC) I I RETENTION$ $ A WORKERS COMPENSATION MIWC696381 11/06/2015 11/06/2016STATUTE ORH AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? r 7N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 2 Client#:235841 MICHAELBR ACORD,. CERTIFICATE OF LIABILITY INSURANCE DADDIYYYY) 5!1 06120612016 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: HUB Int'I New England(WILSB) a8'"N 978 657-5100 FAX 299 Ballardvale St E-MAIL arc No: 978-988-0038 Wilmington,MA 01887 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Travelers Insurance Co INSURED INSURER B: Michael R Brussard Inc 70 Lawrence Road INSURER C: INSURER D: Reading,MA 01867 INSURERE: 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 CONTRACTOR 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 DDLSUB POLICY EFF - POLICY EXP LIMITS INSR WVD POLICY NUMBER MM/DD/YYYY MMlDD A GENERAL LIABILITY 6800502PO58 1010612015 1010612016.EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAME TO RENTED PREMI ES Ea occurrence $300000 CLAIMS-MADE F x1 OCCUR MED EXP(Any one person) s5,000 PERSONAL&ADV INJURY $1,000,000 _. GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO LOC $ JECT AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT �Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETORIPARTNER/EXECUTIVE E.L EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? F1 NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE 01988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S1605394/M1526223 DKO04 Massachusetts-Department of PublicrSafety Board of Building Regulations and Standards Construction Supervisor r License:CS-0609s ynCIEAEL R BRU�S`S 70 LAWRENCE READING MA086j Expiration 111OW2016 '� .. Conunissioner i �c rpomrmta�zu�etzlf�o�C�2'croau��uselld Office of Consumer Affairs&Business Regulation UPOME IMPROVEMENT CONTRACTOR IRegistration: 4164584 Type: xpiration 10/26120:17 Private Corporation } MICHAEL R.BRUSSARD INC f— u v+ MICHAEL BRUSSARD 70 LAWRENCE RD. READING,MA 01.867 4 Undersecretary