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HomeMy WebLinkAboutBuilding Permit #809 - 59 CRANBERRY LANE 6/7/2007BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION y Permit NO:_60� Date Received -2��� J Date Issued: IMPORTANT: Applic m s complete all items on this page LOCATION .5'r�b�.�C"` Lt��r L =gts` Pnnt z. ti { SPR PERTY OWNED w\ A 4 —tt t` Akt4" 2K 6N Pdnt MAF' NO:%, a,CEL: '_..ZONING DISTRICT.l HISTORIC DISTRIC y /NORTFI 6 FO A T � h \P O Al 74 AOAATEO 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 p Others: ❑ Demolition ❑ Other Sep tld-( UVe1I' D Floodprt o 1tVetlas i 'W atershed District I_wWater/ewer s DESCRIPTION OF WORK TO BE PREFORMED: CchJ�tQyc�c mw� a. \9�1t 3f3� IN ��yo�.�2 g Naa }fit CanfsTun�C�ro� 01, 7/'Z tvvi ARCHITECT/ENGINEER PAvi- A '?\ACLArJ x'12 Phone: 1$ob 'bctLGI-1 Address: %1+ 1'�ywzm_c.h aifLj4 Reg. No. jzs-38 FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ SL01 "P FEE: $ Check No.: %� �/�� Receipt No. 7 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner 'v P�e_e" Signature of contracto 4 Location Fri AlG cc No. 8d Date 44 TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ '� J^° • E<� Building/Frame Permit Fee $� AC Mus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # /,q g/ / 202%6 [u Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools Well ❑ Tobacco Sales F " Food Packaging/Sales ❑ Private (septic tank, etc. ❑ ,s Permanent Dumpster o4(t'; ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENTEl COMMENTS CONSERVATION n I_ COMMENTS DATE REJECTED DATE APPROVED El "'1-)7,,TE REJECTED DATE APPROVED 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 Driveway Permit Located at 384 Osgood Street FIRE bE 'ARTMENT ='Temp, Dumpster on site yes no Located a .24� Main Street., w Fire ©eparttnent signature/date k , P COM 09 a Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use P'J <;�) 1- "'� f(C1 el C�4kl Al 07 ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products 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/Crossection/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 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 �;'ma�^y� Fml rYy b °o w L v cn 9 .O co o w o aG U G x o G w O W o w cn G w o c�: c w' WOH ~ w cra O z cn cn O p U 0 z O U v / 0 v TIT P4 O O co L O CD CL. O y � C Ico cm � C O•— C* O y O O 'E CO m CL CD m O G O e_Qv o a ca C 00_•+ C Cc v EL O CD ca C CD O O. C..l a ` C Cc C b � cc COD �. W Y/ �W Uo W 19 LLIW U) c o � c � o � ,r c ` O y �3 06O la R m C �\. COM CD o. `0 Coz E .� m O G) $ : cm COL. c E • � L L go CA CD y mcc j C V1 W :Em ° m O a m y m _ = O Cm Cs oo m V y Z O �.: c L O CL C m y m c = m m�3CIO ti � �0+ y O ~ O W O �0+ �_ .. c .� O m •y O LL, m Ca m v Co OS c MO CIO Z a W m ' ` H s O a."m> O p U 0 z O U v / 0 v TIT P4 O O co L O CD CL. O y � C Ico cm � C O•— C* O y O O 'E CO m CL CD m O G O e_Qv o a ca C 00_•+ C Cc v EL O CD ca C CD O O. C..l a ` C Cc C b � cc COD �. W Y/ �W Uo W 19 LLIW U) I CERTIFY THAT THE OFFSETS SHOWN COMPLY WITH THE ZONING BYLAWS OF NORTH ANDOVER WHEN BUILT CERT/F/ED PLOT PLAN LOCATED IN NORTIJANDOVER, MASS. SCALE: 9 "= 40' DATE: 6/4/2007 Scott L. Giles R.P.L.S. Frank. S. Giles R.P.L.S. 50 Deer Meadow Road North Andover, Mass. OFFSETS SHOWN ARE FOR THE USE OF THE BUILDING INSPECTOR ONLY AND SUCH USE IS FOR THE DETERMINATION OF ZONING CONFORMITY OR NON -CONFORMITY WHEN CONSTRUCTED. CRANBERRY LANE �A�tN Of � 3 v, -13972 e s� 9FC/y'TERE� L LAND g (46. . An Aquatech Builder , NAME (Buyer)_ ENVIRONMENTAL POOLS, INC. 184R Riverneck Road • Chelmsford, MA 01824. << F978.256:0200 / 800.696:6976 / Fax 978.256.6620 E-mail: i'nfOC"environmentalpools Com 0 Website: WWw.Environmental poo ls.com Design Excellence: With A Personal Touch The General Terms, Representations; -and Conditions on reverse side are part of this Agreement. _J ` MAIL ADDRESS (n qN ' `i�R ass' . �V E CITY STATE M, ZIP o lal'. JOB ADDRESS ,.51 GAn11n ey-yw I-AWE.CITY :MO, Nt.IOm ect STATE'MA ZIP QVR JZ RESIDENCE PHONE. q'IS �$�-"74-q1'' . OFFICE PHONE MEMBER =® NATIONAL SPA & POOL ,INSTITUTE Environmental Pools, Inc. (hereinafter "E.P.I:') agrees with the buyer or buyers above (hereinafter the "Buyer") to construct a swimming pool and/or spa in a good and workmanlike manner in accordance with the following terms and specifications. DIMENSIONAL SPECIFICATIONS Width lot' ' Length 39 Shape CI&AAM Depth / to 1 GENERAL CONSTRUCTION SPECIFICATIONS 1. Structural engineeredplans........................................................................INCL. 2. Pool layout plans........................................................................................INCL.. 3. Layout pool for Buyer's approval................................................................INCL. 4.,:.Set pool elevation, for. Buyer's approval:....:................:.................................INCL. 5:; Perform normal .excavation,and remove soil on day of excavation only...... INCL. 6. Access wall or fence: .,removed by: „ replaced by: CO W ihlt 7. Trees in `access and working area to be cut-down so that the stumps do not exceed 2' in `height ........:.....: BUYER ................................................... UY 8. Remove from site NJA loads of: trees, shrubs, stumps, asphalt, " concrete and other`debris 9.' Hand form and"'s hape pool............:...........:........................:..:....................:INCL. 10. Removal or relocation of cesspool, septic tanks, leaching fields, sewers, pipes and utilities (overhead/underground) ................................BUYER 11. Steel, reinforci,ng,per engineered plans ........................................................INCL. 12. Engineered gunite structure to:meet,or exceed local or state codes..........INCL. 13.,, Watercure gunite shell,, twice dally for.seven days ........ ..:......BUYER 14..Install continuous bond beam, around skimmer ........INCL., 15. One set of shallow end steps with 4' bench..... INCL... 16. Swimout or loveseat 3 ►k - 17. Install 6" band of frostproof tile .................................................. ....:......INCL. 18i�-.Pavers,!Bullnose-Brick;, or, Bluestone .t 19 Cantilever form'for deck:;: 20-.-2 hrs,xbackfilling and grading -deck area only INCL. 21: Pool interior finish ..::.:...... INCL .... 22. 'Fllling'of pool promptly after interior finish .......... ...... BUYFR. s ` HYDRAULIC & FILTERING SPECIFICATIONS 23. Approved deidxe'filter' Type Size_' 'Z.5 25.,_ Pressure test for '''.T 24. -Pum aype''' SizeZ}�7 nd m, all pool piping .... T.::. INCL 26: Hook up:all waterlines from filter. to pool............:.... ................................ INCL. 27. Non -corrosive PVC plumbing throughout ....................................................INCL. 28. Hydrostatic valve.........................................................:............................:.INCL. 29. Provide return inlets for filtered water to pool ............................................INCL. suction line.with grate......................:.........................................INCL. 310Deluxei rSkimmain rr Including Weir. Gate and Large Basket............................INCL. 32. Vacuurh fittin outlet imskimmer...................... ........INCL. 33. Up to 30' of plumbing between filter and skimmer...................................:..INCL. 34. Pre -cast pad for pool equipment................................................................INCL. 35. Backwash line ................................ ....................................................INCL.. AUTOMATIC EQUIPMENT 36: Automatic pool cleaner`. Type VA C. 37. Stub plumbing for future pool cleaner INCL. 38. Floor recirculation system tree_.Qa&9 JAE -C *RLTuI iQ 39. Automatic chemical feeder...........................................................................INCL. 40. Automated Pool Controls �i A^. POOL HEATER.& UTILITIES 41.. Deluxe pool -Heater:.. Size ._ACO.606 Make UAU W' Atr Indoor utdool Nat/Pro Fuel connections, heater venting; fuel storage tanks, permit ..............BUYER 42. Install underwater light(s), each with 10' conduit ........................................INCL. 43. Electrical bonding of pool as required by city or town code 3A9t,tr 44: Electrical wiring and connection up to 75' from service panel �ti�cl Pool over 75' at $15.00 per foot. BUYER Heat Pump at $18:00 per foot BUYER. HYDROTHERAPY SPA 45. Attached Separate_ _ Raised P A4= Light• Y Blower' # Hydrotherapy jets Additional pees. ACCESSORIES 46. Deluxe cleaning tools (18" nylon brush, hand leaf skimmer, thermometer, pole, test kit, deluxe vacuum) ..........................................:...INCL. 47. Diving board: Size r4 )A Color 01A 48. 3-fread S.S. ladder/handrail til/A 49. Pool slide-.' Size 0A Color 0114 50. All jigs installed by decking contractor or buyer u/rN MISCELLANEOUS 51.. Raised Bond Beam: Tile Stone MI& 6" 12" 18" WJ4 52. Start-up chemicals: Initial start-up and follow-up instructions ...............::...INCL. 53. Water Condition _ $675.00 - 20 tons of 1.5" stone Additional.stone at $400.00 per load ..................................................BUYER 54. Clay soil - $450.00 ..... ........................... I ................................................. BUYER SALES TAX & INSURANCE 55.. Payment of all sales tax on pool components and accessories ..................INCL. 56. Motor vehicle insurance, workers' compensation insurance and general liability insurance....................................................................INCL. 57 ADDITIONAL SPECIFICATIONS 58. a,. 59 do 40�` k C�cf�'F'lI t' RA 1 + 61. ;. . 63. '^ 0tJSiR,-tQ%o S�b�r� G�`L C61/ Ail hr1 CCR(�',w�o 5 � c 65.Ii2i 04L *AliEL 0 a a f►. w 64 ej et{r ' POOL DECK PRICES SUB -BASE MAT RIAL IS, NOT.INCLUDE. D.., Deckingsquare foota e: T e 4 g /ZL)i yp 1(,;4 & �r r. lam£ Other: "e: LG C,., PAYMENT The. Buyer agrees to pay E.P.I. the following Contract Amount for. E.P.I's performance of its obligations under this Agreement. PAYMENT SCHEDULE / oU Contract Amount 910- 30% Day of Excavation $ t Z. Za Deposit $ 40% Day of Gunite $ - 6D BALANCE $ -`'%` `7'- 25% Day of Tile $6 5% Day of Interior Finish $ 3I.7 TOTAL $ TERMS AND CONDITIONS THE BUYER UNDERSTANDS THAT BY SIGNING THIS AGREEMENT, HE OR SHE ENTERS INTO A CONTRACT WITH E.P.I. AND THE BUYER CONCERNING E.P.I: S CONSTRUCTION OF A SWIMMING POOL, MEETING THE SPECIFICATIONS CONTAINED IN THIS AGREEMENT. ANY CHANGES IN ANY OFTHE TERMS OR SPECIFICATIONS OFTHE AGREEMENT MUST BE MADE IN WRITING SIGNED BY E.P.I. AND THE BUYER, AND NO VERBAL CHANGES IN THESE TERMS AND SPECIFICATIONS ARE PERMITTED. AS PART OF ITS OBLIGATIONS UNDER THIS AGREEMENT E.P.I. IS PROVIDING THE BUYER WRITTEN GUARANTEES REGARDING THE SWIMMING POOL WHICH IT WILL CONSTRUCT PUR- SUANTTOTHIS AGREEMENT.THESE GUARANTEES ARE CONTAINED IN A SEPARATE DOCUMENT WHICH IS PROVIDED TO THE BUYER., THE BUYER HAS THE RIGHT TO CANCEL THIS AGREEMENT AT ANYTIME BEFORE MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE ON WHICH EITHER THE BUYER OR E.P.I. HAS SIGNED THIS FORM BY GIVING WRITTEN NOTICE OF CANCELLATION TO E.P.I. THE BACK OFTHIS CONTRACT CONTAINS IMPORTANTTERMS AND CONDITIONS.THEY ARE PART OF THIS AGREEMENT. READ THEM. I ACKNOWLEDGE THAT THIS AGREEMENT IS A LEGALLY BINDING CONTRACT, SUBJECT ONLY TO THE ABOVE CANCELLATION PROVISIONS, AND I CERTIFY THAT 1 HAVE READ AND AGREE TO ALL TE AND CONDITIONS OF THIS AGREEMENT. ENVIRONMENTAL POOLS, INC. B RJ BY: , � -0<'1_ An�i B DATE -,)7 2cy 5Z DATE 15 Vo 1 T -- L A W V 5 0 Z� 1 Z �^ WQ� 0 Z 44 1 IA 44 tz (44 tq '44 �Q� ►.Q tae e� e N � �4 k 44 Lj TQO Ht'4 �c o �o� 2�• � >c44k;w voc h p v�+lW� ��lZiLt q t Q"T t rk �Z �►�. j �v,�Q vav� oh 4-4 Z> v4 0.ty r..,k ����v QV k� X14. DU F:Q � >Qa.cv It,: ow atV v,W �op�%Zz i;j�4p W hoa \o �q �� �v 4004, V �v��� lzt waa v zv v a� c o .? Q �a w 4 PG��S�rrs g< OMD M �N y � �JU Q ,s aNz C9 �3 tio�vwO0oj p� 1 O .j• ••.1� s• V v t Q z •• o �1 \L C�� a •' � V ��� V1• ' 1 e R P • .Q • a � a' Ve waa v zv v a� c o .? Q �a w 4 PG��S�rrs g< OMD M �N y � �JU Q ,s aNz C9 �3 tio�vwO0oj p� 1 O .j• ••.1� s• V z ",4 bb \L "m e0 V ��� V1• �V P • .Q crm a ACORD. CERTIFICATE OF LIABI PRODUCER (602) 635-4848 FAX: (866) 696-4918 AIMS Insurance Program Managers 15230 N. 75th Street, Ste 1002 Scottsdale AZ 85260 INSURED Environmental Pools, Inc. 184R Riverneck Road Chelmsford MA 01824 TY INSURANCE 5/16/2007 ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OF ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSUF2ERAArch Insurance. Company INSURER B: INSURER C: INSURER D: INSURER E: Ov OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING / N THE POLICIES WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERT .IN, ANY CONTRACT OR OTHER DOCUMENT REQUIREMENT, TERM OR CONDITION OF AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICI =S. THE INSURANCE R ATE LIMIT OW MAY HAVE BE REDUCED BY PAIDCLAIMS.POLICY EFFECTIVE POLICY EXPIRATION LIMITS ADD'L TYPE OF IN POLICY NUMBER DATE MMIDD/YY DATE MM/DD NSRnj EACHOCCURRENCE $ 1,000,C00 fA GENERAL LIABILITY DAMAGE TO RENTED 100 C 00 PREMISES Ea occurrence $ X COMMERCIAL GENERAL LIABILITY MED EXP (Any oneperson) $ 5,000 FxEOCCUR ZAGLE9044500 5/14/2007 5/14/2008 PERSONAL & ADV INJURY $ 1,000,C00 CLAIMS MADE GENERAL AGGREGATE $ 2, 000, C 00 PRODUCTS -COMP/OP AGG $ 2, 000, C OO GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY JR C LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ (Per accident) NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA A $ ANY AUTO - - .. AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY - EACH CC RR NC $ AGGREGATE $ OCCUR FICLAIMS MADE $ DEDUCTIBLE $ RETENTION A WORKERS COMPENSATION AND X TNR S IMIT OTR E.L. EACH ACCIDENT $ 1 , 000 , 1 ,00 EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ZAWCI9086000 5/14/2007 5/14/2008 E.L. DISEASE - EA EMPLOYE $ 1,000,1,00 E.L. DISEASE -POLICY LIMIT Is 1, 000 , 1100 If yes, describe under SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS *Except for ten (10) days cancellation notice applies for non payment of premium. CERTIFICATE HOLDER CANCtILL.AIIUN EVIDENCE OF INSURANCE ACORD 25 (2001108) I AICf17S in.nono_ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 'HE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO N 41L *30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, I UT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON 'HE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Peter Godfrey © ACORD CORPORATION 1988 Pe.. 1 of 7 �.-4k. 05'16/2007 WED 14:28 FAX 15158215 A 00 -RD. PRODL SER '.LALLSUI GFRTIF1CATF OF LIABILITY INSURANCEA0 A _ ON Y ANDCERT�CONFERS HO RIGHTS UPON THE CEnF RTIFICATE HOLDER- THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES gF10W- m Wdki,,A. DATE(mmmorrm t Tal)iot insurance Agency, Inc. 221. Chelmsford Street Che: msford MA 01$24 Pho les 978-256-3367 Fax=978-256-8315 I�suI:3 D ghvironnwmtal Poole, Inc - 1184R R.sverneck Rd Chei=ford NA 01.824 INSURERS AFFORDWO COVERAGE INSURERA: MerchantsInsurance Groff INSURER B- -- WSURER C: WSURER D: - 1NSURER E: COVI :RAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BM1 ISSUED TO THE INSURED NAMED ABOVE FT TO W1 POLICY PERIOD 4ICH THIS fCA7EWDCATED MAY BE ISSUED OR NOTWITHSTANDING ANY REQUIREMENT, TUM OR CONoMON OF ANY CONTRACT OR OYHE DOCU HEREIN &lE TO ALL THE TT�iNIS EXCLUSIONS AND C4 d N of SUCH MAN P9tTA1N, THE INSURANCE AFFORDED 8Y THE POLICIES 0=R — POL -IES. AGGRE-CATE LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. LIMITS -- PCIL1 �� LTR TYPE OF INSUtiAl1 .i`E POLICY NU11A6f31 DATE FACH OCCURRENCE S — Ev.denee of insurance. CEF TIRCATE HOLDER CANCELLATION _ 1111111 SHOULD ANY OF THE ABOVE DESCRJOED POLICIES BE CANCELLED 6E00RE THE EXP( ?a IDN DATE THEREOF, THE ISSUING INSURER WILL ENDPAVOR TO MAR. 10 DAYS WR m m NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEff, BUT FAILURE TO DO SO 16 LL gviden Ce of Tnsurazwe IIIIPOSE NO oWGATION OR LIABILITY OF ANY K= UPON THE INSURER ITS AGE►tt, OF iEPRR'.56f7ATIY6S. ... RD 25 {2001108) ® A ORD CORPORAT101; B$8 AGL GENERAL UABILRY - PREMISES Ea amu& -00 S COMMERCIAL LiENERAL LIABILITY CLAIMS MADE a OCCUR MED ESP (Any one Person) g _ $ PERSONAL & ADV INJURY g GENERAL AGGREGATE PR000CTS - COMPIOP AGG GEN -L AGGREGATE LIMIT APPLES PER POL.[CY LOC — - b 1, 000,00 } — - 7AN027-7014363 05/1+x/07H05/14/08 COMBINED SINGLE LIMIT F9 acdde"0 AUTOMOBILE LIABILITY ' ANY AUTO OWNED AUTOS BODILY INJURYALL (Per persaa) - X X SCHEOULFD AUTOS HIR::D AUTOS y -- BODILY Y (Per X NON-OWNEDAUTOS PROPERTY DAMAGE g 5 — S — S AUTO ONLY - EA ACGDENT GARAGE LIABILITY ANY AUTO EA ACC OTHER THAN AUTO ONLY. AGG S $ $ EACH OCCURRENCE ExcEswmsRELLA UABILITY CLAIMS MADE OCCUR 17 AGGREGATE DEDUCTIBLE RLiENTION S YVORK�S COMPEN3/i710N AND EMPLOYERS' I1ABILfTY - g _ $ — - � TDRY LIMITS ER i E -L EAMACCID NT ANY PARTNO�WE ROPM ETOWED?� oFr-C S y� dCx�� under SPECIAL PROVISIONS below OTHER EL DISEASE -EAEIIWLOYE EL DISEASE -POLICY LIMIT S — - 5 Ev.denee of insurance. CEF TIRCATE HOLDER CANCELLATION _ 1111111 SHOULD ANY OF THE ABOVE DESCRJOED POLICIES BE CANCELLED 6E00RE THE EXP( ?a IDN DATE THEREOF, THE ISSUING INSURER WILL ENDPAVOR TO MAR. 10 DAYS WR m m NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEff, BUT FAILURE TO DO SO 16 LL gviden Ce of Tnsurazwe IIIIPOSE NO oWGATION OR LIABILITY OF ANY K= UPON THE INSURER ITS AGE►tt, OF iEPRR'.56f7ATIY6S. ... RD 25 {2001108) ® A ORD CORPORAT101; B$8 AGL The Commonwealth of Massachusetts Department of Industrial Accidents UOffice of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ZwQ(Qoy..j mF_Y,.Ah(r RAS -:Wc Address: �b4 1 � City/State/Zip:C)Ne4uv�S�c�-d �1� ©\R zA _ Phone #: Chp- Zb o -LOO Are you an employer? Check the appropriate box: 1. I am a employer with 30 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box # l must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ,Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: &IM5 ah.&yJLPNCE i7et%c,.1M MAN4�ftS Policy # or Self -ins. Lic. #: ZA W L i `to& Expiration Date: Sfj j{ to —1-1 Job Site Address: SvI CJZr4 '0 L' V4 �ANG City/State/Zip:1Jo l-vAaUEt, �i} ®1&4E Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 the pains andpenalties ofperjury that the information provided above is true and correct. Phone #: q,1% •-zz(,� O -Loc Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # U 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 M ✓�,: {; ,:T�n,rr*=iru�aftr� :%`' r'lu;�;:rc;rr,w,u,; BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 093190 Birthdate: 06/28/1964 Expires: 06/28/2009 Tr. no: 93190 Restricted: 00 DAVID BRABANT ROAD WILMINGTON, MA Commissioner Board of Building Regulations and Standards License or registration valid for individul use only HOME IMRROVEMENT CONTRACTOR before the expiration date. if found return to: `a. Registiac%►; 07083 Board of Building Regulations and Standards c /2008 One Ashburton Place Rm 1301 Boston, Ma. 02108 -96 to Corpo;aiton ENIViRONMEid Andrew Everleigit R Riverneck Roan Cheirnsford, MA 01, 9epuy Administrator.Not valid without SI kure