HomeMy WebLinkAboutBuilding Permit #1049-2016 - 59 KARA DRIVE 4/6/2016 y
Il� TOWN OF NORTH ANDOVER
OE tta�'h 7
l APPLICATION FOR PLAN EXAMINATION •_��� 6
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Permit NO: Date Received
CNUS tag
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION 59 Kara Drive,North Andover,MA
Print
PROPERTY OWNER Partip&Swati Mukhergee
Print
MAP NO.:00098 PARCEL:A0088 ZONING DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT PROPOSED USE
Resid 'al Non-Residential
New Building kTOne family
Addition ❑Two or more family ❑Industrial
❑Alteration No. of units:
Repair,replacement ❑Assessory Bldg ❑Commercial
❑Demolition
-ElMovin relocation ❑Other ❑ Others:
Foundation only ,
DESCRIPTION OF WORK TO BE PREFORMED �s
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Identification Please Type or Print Clearly) 10 14`(60 HnR1 ,
OWNER: Name: Partip&Swati Mukhergee Phone: 978-689-0483
Address: 59 Kara Drive,N Andover,MA
CONTRACTOR Name: Boston Board Up Services,i-i_C Phone: 781-983-0522
Address: 1268C Broadway,Unit#221,Saugus,MA 01906
Supervisor's Construction License: CS-058505 Exp. Date: 04/11/2018
Home Improvement License: 184766 Exp. Date: 03/09/2018
ARCHITECT/ENGINEER Name: Phone: `
Address: Reg.No.
FEE SCHEDULE.BULDING PERMIT. $12.00 PER$1000.00 OF TME TOTAL ESTIMATED COST A$ED ON$125.00 PER S.F.
Total Project Cost :$78,500.00 x12.00=FEE:$ qoa—
Check No.: ` 0 Z Receipt No.: ��2-�Z
Page i of 4
e t �
TYPE OF SEWERAGE DISPOSAL Swimming Pools ❑
Tanning/Massage/Body ody Art ❑ �
Public Sewer
❑ Tobacco Sales ❑ Food Packaging/Sales 11l
Well ❑
Permanent.Dempster on Site
Private(septic tank,etc. ❑ Electric Meter location to
project
NOTE: Persons contracting with unregis ► d c tors do not have access to the guaran
Signature of Agent/0 e of contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF-U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
❑Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION ❑ ❑
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
Nater&Sewer connection/Signature&Date Driveway Permit
Temp Dumpster on site yes—no— Fire Department signature/date
i
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanniag/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 m U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENT'S
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed ori 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:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dempster onsite yes no
Located at 1.24 Main Street
Fire Departmen signature/date
�oC��MMEN�TS
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 LIf ERATUREo Yes N®
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
I
NOTES and DATA— (For department use)
�I
LJ
Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
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
NOTES and DATA-- (For department use)
® Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
Plans Submitted ❑� Plan Wa""iveedd ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑
I
THE. FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_ 4
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
U i Water& Sewer Connection/Signature& Date Driveway Permit
]DPW Town FuOueer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dempster on sit yes no
Located at 1►24 Main Street
Fire Departmen signature/,date
COMMENTTS
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
Building Permit Application
Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Building Permit Application
Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
4. Mass check Energy Compliance Report (If Applicable)
;i; 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
Doc:Building Permit Revised 2014
Location bt �L:Are y ��''`J c—
No.
(A()— 2 G 1Date �i �.o ��7
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• - TOWN OF NORTH ANDOVER
«M
3` Certificate of Occupancy $
Building/Frame Permit Fee $014 a'-
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#A
! � f
Building Inspector
Enter construction cost for fee cal - North Andover Fee Cakulation
Construction Cost
$ 78,500.00 m
$ - $ 942.00
Plumbing Fee $ 117.75
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 117.75
Total fees collected $ 1,277.50
59 Kara Drive
1049-2016 on 4/6/16
Kitchen Remodel
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Town of ndover
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x.95 RATED
V BOARD OF HEALTH
Food/Kitchen
PER T D Septic System
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THIS CERTIFIES THAT �C BUILDING INSPECTOR
............ ....... .. ............ ... .... ......... ...��. ..................................
P
Foundation
has permission to erect ..... .................... buildings on�1..... .. . .�.. .. .. . . . ..........................
Rough
to be occupied as .............. .. �.. .... ... .. Chimney
provided that the person accepting this permit shall in every respect conform to. he terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the InsDection, 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 CONSTRUCTION STARTS Rough
Q� ......... Service
................... .... .���iZ�:r��;.�(. �rr_...�............. Final
I BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildinz 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.
Contract for Construction
This Construction Contract is made as of , 2016, (The Effective Date)
by and between Partip & Swati Mukhergee, 59 Kara Road, North Andover, MA
01845 (hereinafter referred to as the "Owner') and Boston Board Up Services, LLC,
1268C Broadway #221, Saugus, MA 01906, (hereinafter referred to as the
"Contractor"). The Contractor and Owner for the consideration named as follows agree
to enter into the following construction contract concerning the Owner's property located
at 59 Kara Road, North Andover, MA 01845.
This offer is good for 15 days from receipt. If the Owner signs and returns this
offer, it becomes a binding contract.
THEREFORE, in consideration of the mutual promises set forth below, the parties agree as
follows:
Description of Services:
Beginning on or about 2016 (within 30 days of signing of contract),
Boston Board Up Services, LLC will provide to the owner the following services outlined
in the scope of services listed below:
Scope of Work:
Provide the following services as itemized below due to water damage:
Foyer:
1. Supply and install blue-board where missing.
2. Apply skim coat plaster to new blue-board.
3. Install ceramic floor tile, material allowance $1.19 per/sf.
4. Supply and install new baseboard trim.
5. Paint affected walls and trim.
Second Floor Master Bathroom:
1. Re-install previously removed wall tile adjacent to lavatory.
Dining Room:
1. Supply and install missing wall insulation.
2. Supply and install blue-board where missing.
3. Apply skim coat plaster to new blue-board.
4. Supply and install new hardwood flooring, white oak#2, sand and finish.
5. Supply and install door casing where previously removed.
6. Supply and install new baseboard trim.
7. Supply and install chair rail.
8. Supply and install trim for a raised panel effect.
9. Paint affected walls and trim.
Boston Board Up Services,LLC, 1268C Broadvvmy#221,Saugus,MA 01906 Page 2 of 8
Living Room:
1. Supply and install missing wall insulation.
2. Supply and install blue-board where missing.
3. Apply skim coat plaster to new blue-board.
4. Supply and install new hardwood flooring, white oak#2, sand and finish.
5. Supply and install door casing where previously removed.
6. Supply and install new baseboard trim.
7. Paint affected walls and trim.
Kitchen:
1. Remove existing, upper and lower cabinets.
2. Remove and reinstall existing granite counter tops. NOTE: there is no
guarantee that the counter top can be removed without damage or that it will
fit properly to the new cabinets. New countertops can be supplied at the
owner's request, for an additional cost.
3. Supply and install new white cabinets. Price to supply cabinets, included in
contract, not to exceed $ 6,500.00.
4. Remove and re-set existing kitchen sink.
5. Remove and re-install dishwasher.
6. Install new water line to refrigerator.
7. Supply and install missing wall insulation.
8. Supply and install blue-board in missing areas, (walls and ceiling).
9. Apply skim coat plaster to new blue-board, ceiling shall be sand finish.
10. Install tile backsplash at counters, $3.00 perlsf material allowance
11. Supply and install new hardwood flooring, white oak #2, sand and finish.
12. Supply and install door casing where previously removed.
13. Supply and install new baseboard trim.
14. Paint affected walls and trim.
Hallway:
1. Supply and install blue-board where missing.
2. Apply skim coat plaster to new blue-board.
3. Supply and install new hardwood flooring, white oak#2, sand and finish.
4. Supply and install new baseboard trim.
5. Paint affected walls and trim.
Boston Board Up Services,LLC, 12680 Broadway#221,Saugus,MA 01906 Page 3 of 8
Laundry Room:
1. Supply and install blue-board where missing.
2. Apply skim coat plaster to new blue-board.
3. Supply and install new hardwood flooring, white oak#2, sand and finish.
4. Supply and install new baseboard trim.
5. Paint affected walls and trim.
First Floor Half Bathroom:
1. Remove and re-set existing vanity.
2. Remove and re-set existing sink.
3. Remove and re-set existing toilet.
4. Supply and install blue-board where missing.
5. Apply skim coat plaster to new blue-board.
6. Supply and install new hardwood flooring, white oak#2, sand and finish.
7. Supply and install new baseboard trim.
8. Paint affected walls and trim.
Garage:
1. Supply and install missing wall insulation.
2. Supply and install missing blue-board walls and ceiling.
3. Apply light stucco finish to new blue-board.
4. Remove two existing garage doors.
5. Supply and install two new garage doors (allowance not to exceed $2,400.00)
Entry Adjacent to Garage:
1. Install Solid Vinyl Tile, (SVT) floor, material allowance not to exceed
$1.00 per/sf.
2. Install carpeting on stairs from Garage to First Floor.
Utility Room:
1. Patch missing blue-board and apply skim coat plaster with light texture finish.
2. Paint affected areas.
Contract Price DOES NOT include:
1. Any and all code upgrades as/ if required
2. Testing of any type.
3. Engineering analysis, design, and drawings of any type.
4. Engineering inspections or approvals.
Boston Board Up Services,LLC, 1268C Broadway#221,Saugus,MA 01906 Page 4 of 8
5. Abatement of hazards
6. Mold remediation
7. Work to non-affected areas.
8. Anything other than what is described in the "To include"section of this contract.
Time of Completion:
Performance of Contractor's Work shall commence upon signing of the contract and
receipt of contract deposit and shall be substantially completed no later than 180 days
(180) after commencement, (hereinafter the "Completion Date"). If Contractor is delayed
in completing Contractor's Work by reason of strikes, work stoppages, inability to
procure materials, restrictive governmental acts or regulations, riots, war, flood, rain or
any other reasons beyond Contractor 's reasonable control, Contractor may extend the
Completion Date for such time as is reasonably required to enable Contractor to
complete Contractor's Work.
Contract Price:
Owner shall pay Contractor for the performance of Contractor's Work subject to
additions and deductions hereinafter provided, or subsequently agreed to in writing, the
following price:
Seventy-Eight Thousand Five-Hundred Dollars and 00/100 ****$78,500.00****
Payment Schedule
The payment schedule for the contract price shall be as follows:
1St Payment, Due at Signing: $25,000.00
2nd Payment, Upon Completion of Installation of Insulation: $25,000.00
3`d Payment, Upon Completion of Removal of Existing Kitchen Cabinets: $ 5,000.00
4th Payment, Upon Installation of Kitchen Cabinets: $ 5,000.00
5th Payment, Upon Installation of Flooring: $ 15,000.00
6th Payment, Final Payment Upon Completion and Final Walk-through $ 3,500.00
Finance Charges: A 1.5% per month carrying charge shall be applied to outstanding
balances over 30 days.
Default and Remedies:
Contractor's Default: Should Contractor abandon Contractor's Work for more than
fourteen consecutive days (other than by reason of a dispute or for reasons beyond
Contractor's control), or should Contractor become insolvent, make an assignment for
the benefit of creditors or the like, or should Contractor file a voluntary petition in
bankruptcy, or should an involuntary petition in bankruptcy be filed against Contractor,
or should a receiver be appointed for Contractor by any court of competent jurisdiction,
then Contractor shall be deemed in default hereunder. In the event of such a default,
Owner may replace Contractor at the Owner's discretion in order to mitigate damages
Boston Board Up Services,LLC, 1268C Broadway#221,Saugus,MA 01906 Page 5 of 8
Owner's Default: Should Owner, insurance company or bank fail to make any payment
as outlined in this Contract or should Owner attempt to terminate this Contract without
good cause, then Contractor shall have the following remedies, in addition to any
remedies available at law or in equity:
1. Contractor may proceed to enforce this Construction Contract or seek damages
for its breach in a court of competent jurisdiction.
2. Owner expressly agrees to pay Contractor, in addition to any moneys due for
delivered goods and completed services, a sum equal to 50% of the remaining
balance of the Construction Contract.
3. Contractor may also cease work if any payment is not paid when due as per
schedule of payments.
4. Seek any court actions, including any liens or attachments.
5. The unpaid balance of delivered goods and completed services shall accrue
interest at the rate of 1.5% per month from the date of Owner's breach of this
Construction Contract.
Collection of Outstanding Balances:
In the event that Contractor has to undertake collection of any outstanding balance, or
take legal action to enforce any of rights due Contractor under this Agreement, Owner
shall pay, in addition to any outstanding obligation, reasonable costs and attorney's fees
incurred by Contractor resulting from the necessity of having to take such action.
Captions:
Captions of paragraphs and sub-paragraphs are for convenience only and should not
be relied upon.
Merger:
All prior negotiations, statements, representations, warranties, and agreements, if any,
pertaining to any or all of the details of this transaction are superseded by and merged
into this Construction Contract, which contract constitutes the entire agreement of
parties.
Change Orders:
Any changes or modifications to the agreed upon scope of work during the term of this
contract shall be made in written "Change Order" which is signed and dated by both
parties. Such change order shall become part of the written contract and the customer
agrees to pay any increase in the cost of at the signing of the change order. In the
event the cost of a Change Order is not known at the time a Change Order is executed,
Boston Board Up Services, LLC shall estimate the cost and therefore and the owner
shall pay the actual cost.
Boston Board Up Services,LLC, 1268C Broadway#221,Saugus,MA 01906 Page 6 of 8
Owners Cancelation Clause:
Owner has the right to cancel this contract with no penalty within 3 days of signing this
contract provided you notify the Contractor in writing, by ordinary mail, not later than
midnight of the third business day following the signing of this contract in accordance
with the Notice of Cancellation located in Attachment A of this document.
Owner acknowledges receipt of 3 day right to cancel Initial: 01
SIGNATURES:
0/Dfa
ate Date 4�r
Boston Board Up Services, LLC Representative
Lwt S ?ALO Date 3 1
Name of Owner or Owner Representative (printed)
Date AA�
Authorized Signature of Owner or Owner Representative:
' WK Date ' !
Name of Co-Owner or Co-Owner Representative (printed)
Date
Authorized Signature of Co-Owner or Co-Owner Representative
Boston Board Up Services,LLC, 1268C Broadway#221,Saugus,MAO]906 Page 7 of 8
ATTACHMENT A
NOTICE OF CANCELLATION
Boston Board Up Services,LLC, 1268C Broadway#221,Saugus,MA 01906 Page 8 of 8
NOTICE OF CANCELLATION
YOU MAY CANCEL T[IIS 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 CANCELLED.
IF YOU CANCEL,YOU MUST MADE AVAILABLE TO TEE SELLER AT
YOUR RESIDENCE;IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN
RECEIVED,.ANY GOODS DELIVERED TO YOU UNDER TRIS CONTRACT OR
SALE;OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF
THE SELLER REGARDING THE RETURN SHTMENI'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 DESPOSE OF THE GOODS WI`T'HOUT
ANY FURTHER OBLIGATION. IF YOU FAIL TO MADE THE GOODS AVAILABLE
TO THE SELLER,OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER
AND FAIT,TO DO SO,THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL
OBLIGATIONS UNDER THE CONTRACT.
TO CANCEL TMS 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 (date).
I HEREBY CANCEL THIS TRANSACTION.
Date: Buyer's Signature:
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Department of Indust Id Accidents
Office of l"es igadous
-1 Congress Shed,suite 100
Bacton,MA 02114-2017
www.NMLgov/dra
Workers'Compensation Insurance Affidavit:Builders/ContradorslElectrich ns/ph mbers
Applicant Information Please Print Legibly
Name(Burin ionandividual): _'��/� � ,0 af S ('f�� f
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City/State0p: ' Ci b b Phone
Are an employer?Check the appropriate box:
1. am t3 employer with 4. Q I am a getleral contratxor and I Type of project( ' :
employees(M andfor part-time).* have hires die 6. 0
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nstruction2.QI am a sole proprietor orpartner- listed on the attached sheet. 7. elutg
ship and have no empk"es These sub-contractors have
working for me in any capacity. employees and have workers' S. Q Demolition
[No workers'comp.insurance comp.insuranc e t 9. Q Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.Q Plumbing tis or additions
myself[No workers'comp. right of exemption per MGL urnce 12.0 Roof
insarequired.)t c. 152,§1(4N and we have no
employees,.[No workers' 13.Q Other
comp.insurance required.)
•Any applicant that chats box f 1 mug also fig out the acctioa bc1aw showing ftwworker=pgnMm pollci'mfotm t OL
t Harnenwrras who sabmtt this affidavit indicating they are doing all work and thea hie outside conductors mast submit a new aft indicating so&
tCOnductors that check this box must amicbed an oddWoml stmt showing the wme of ifie subsonftams and state whether or not d ww entities have
employers. Ifthe subvoubactors bm employees,they most provide their workers'comp.policy number
I am an employer that Rs pmaft workers'conpensadotr msr wreefor my mployam Below h Ihepo&y and job ske
Inform 01L
Insurance Company Name:
Policy#or Self-ins.Lic.pp#,,: �v"��}-}�� R FR \F� Expiration Date:
Job site Address: 5 1 mat t-r �C , N•t t►�ll( 1="i,y� ckyls ;
Attach a copy of the workers'compensationpolicy declaration page] (showing the poll y number and expiration date).
Failure to segue coverage as required tinder Seton 25A of MGL c. 152 can lead to the imposition of criminal pernahies ofa
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 S250.00 a clay 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 cegFy trader the o that the W rn a ion psovlded
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City or Town: Permit/License#
Luning Authority(circle one)
I.Board of Health 2.Building Department 3.City/To"Clerk 4.Electrical Inspector S.Plumbing Inspector
6-Other
Contact Person- Phone d:
AC4RD�, CERTIFICATE OF LIABILITY INSURANCE °"03!3-0/2013
PRODUCER ';�2� �� THIS CERTIFICATE IS NSSUED AS A MATTER OF INFORMATION
�'}f`iL�GiS:`-.S=C i 'S ��.it4CcGLi�'C`•: ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THS CERTMATE DOES NOT AMNDID, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE BELOW.
INSURERS AFFORDING COVERAGE NAIC#
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THE POLICIES OF INSURANCE UST®BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATID_NOTWITHSTANDING
ANY REQUKMAENT,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-AGGREGATE L TTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLANS.
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DATE THEREOF,TILE ONSIG HOUREcR WILL 91DEhVOR TO NAB. ''= DAYS VRITTEN
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ACORD 25(2001108) 'ACORD CORPORATION 1988
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41 Ambrae Street
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OME IMPROVEMENT CONTRACTOR
Registration: 184766
Type:
Expiration;-.-3/912018, Supplement Card
ON BOARD UP SERVICES LLC
FAL.ZARANO
BROADWAY#221,
US, MA 01906 Undersecretary