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HomeMy WebLinkAboutBuilding Permit #036-14 - 607 TURNPIKE STREET 7/10/2013 r TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: o(, -4 Date Received Date Issued: - 3 IMPORTANT:Applicant must complete all items on this page LOCATIONS rO®7-z T�i�N9j/C , / B l'l7 i�J.AoYz-:iQo PR PgRT,Y°01NNER PwT-7 / bzUgkog=-1 Pflnt100 Year,Old�Structuryes', MAi PaNO PARCEL ZONIC, yes, _ no., Machine.Sho.pkVillage ' yes not. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family Addition ❑Two or more family ❑ Industrial ®.Alteration No. of units: D(Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: Demolition ❑ Other q Septic;, ��Wellt. ElFlood.plain? ❑1Netlands D Watershed�Distrlct: <} I w❑Water/Sewed - DESCRIPTION OF WORK TO BE PERFORMED: e� vle 5' �i' cJ`r` 6�2pG/G,2ise/�4 nr'//®rle��ec�sf�c sire q!Atl 46.,XA5GJ4y�K,e,e,0C1-,o5x-d Qh e-,X% O `�ieG' ,tLcara-� gev�i' �.Q vi c� /4�5 �i�t� � + E ; • — Iden •fication PleaQ Type o Print Clearly) OWNER: Name: c�udc/ Phone: �� fP�g- 7�"c� Address: t ,1 GO �V Phone: CONTRACTOR .Name1�(z. a 1Z. RSl04� + v :Address µ/1,41�-' MOO: Dt-l�� i Su enrlsor"'s Construction License 7 i8 P, kD.ate /O p ..� Home{In'ip�ovement License' $ ARCHITECT/ENGINEER�0ni-4 �� �R >9°�'�•P one: (87407 -,;z 4Z4,66 Address:16g / � 1�G��/��2�li/� •. 0Aef34 Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. a Total Project Cost: $ 19,6- 0 FEE: $ �7 Check No.: � Receipt No.: -�� NOTE: Persons contracti •h unr i tered contractors do not have access to the gun 'an ♦ � b Signature of Agent/Ovvne_ - Sictnatu e of-contractor Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plan- Plans Submitted Plans Waived ❑ 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 ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS ' HEALTHs Reviewed on Signature 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 DPW Tow ! Engineer: Signature: Locat 384 Osgood Street FIRE-DEPARTMENT - Temp Du m 'sten offs yes no Located at'124 Mair,, Street Fire Depa�kiner'it signature/date E. COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Dieter location, mast or service drop requires approval oif 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 - Date Doc.Building Permit Revised 2010 Building Department The fol;?wing 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 o 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 apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Bufiding Permit Revised 2012 Location [;;��-,57-�� 4� ! No. a�l� //7/ Date I • - TOWN OF NORTH ANDOVER o _ Certificate of Occupancy $ Building/Frame Permit Feel _ Foundation Permit Fee i $ a`fr Other Permit Fee $ <C # a f s� TOTAL s $ a Check rda;: 26606 Building Inspe b�"' a Coniracior Axbifr�Ltion The Home Impiovement Contractor Law provides homeowners with the right to initiate an arbitration action (as an 'alternative to coturt action)if they have a dispute with a contractor. The same light is not con g automatic tractor. howe --. all afforded ver. The c Y duo a ontractor would have to resolve any dispute he/she has with a both parties agree to the optional clat � �� ,; homeowner.in.court unless P clause.0 d�elO . arbitration as is afforded to the homeowner by the Home 7mprovemen Contractor Law.the contractor the same xlght to The contractor and the homeowner hereby mutually agree in advance that in the event the contract ` concerning•flus contract;the contractor may submit the dispute to a private arbitration:he which or has spate by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as Provided In Massachusetts General.Laws, chapter 142A.• Homeowner's Signature Contracto s Si a 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 flus section is not separately signed by the parties. Romeown.e:r's Rights A homeowmr's rights under the Home Improvement Contractor Law(MGL chapter 14.2A)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 Flmd provisions of the Home r.,,.,provement Contractor Law. The contractor is responsible for completing the e work as described,in a timely and worlananlil<e manner. Homeowners may be en:iided to Other specific legal rights iftl- contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or walra;nties provided by the contractor,all goods sold-in Massachusetts tarty 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. 7f you.have questions about your eonsumer/b.omeowner 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 eybibits and referenced documents have been attached. Parties axe.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 attacher:elits is to be gi`v en to the owner an l the other kept by the contractor. Any Mo difi•cation 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 s ecified on the SP .p a yment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him&erself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a j oint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said acco2utit would require the signatures of both paries. Additional bdofrm.ation 7f you have general questions or need ad6-;ion 1 ::iionu aCdon about the Home?improvement Contractor Law or other cconslimer ngbts, or"You wisiu to obtain.a free copy of "A Massachusetts Const=er Guide to Dome Improvement" —contact: Consumer Information.Hotlim Office of Consumer Affairs and Business Regulation 10 Park Plaza,Roam 5170,$aston,MA 02116 617-973-8787,'888-283-3757 or vlsitthe OCABRwebsite ath2p://ww`vmass gov/ocaUr/ If you want to verify the registration of a contractor or if your have questions or need additional inform.a�dor - ' about the contractor registration component of the Home Improvement Contractor Law, contact: "speu�caily Director of Home improvement Contractor Registration Office of Consumer Affairs and-Business Regulation 1b ParkPlaza, 5170,Bostonoom 617-973-8787, 888-283-3757 or viissit the WC website, bsite'at�02�1www.rna tr ss.eov/oca�br/ Go online to view the status of a Home Improvement Contractor's Registration: , hi:t7�://dU.state.•ma us/ho7•neimnrovement/licettseelist as • For assistance with informal mediation of disputes or to register formal complaints against a business,usiness, call: Consumer Complaint Section Office of- Attorney General 617-727-8400 AND/OR Better Business Bureau. 508-6S2-4.800,508,75:5-2548 or 413-734-3114 Version 2.1-ivg-,i-mi n Rome ®lm act This age satisfies t basic requirements le the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language se 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 B egulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Juforma ion 7� C,QvdC/erj I�z _Contractor nf6rmat.pn Com ny Name Street ddress(do nota a � aPoOox address) Contractor/Salesp / erson/Owno ,e _ erNamhem G c� — City/Town State Zip Code Bwsmess Address(must include.a street address) ytime Phone --� EvenmgPhone . City/Tawn State Zip Code Mailing Address 33 ss �`� ������3 Business Plione ]ederal>;mpIoyer ID or S.S.Number Homelmpmvementcontmcro�ieg:Number Expiration ate im • � Lnwrem�iresthatmosthome �{8 provement contractors have a valid registration n"inbcr The Contractor agrees to do the following work for the Homeowner: (Descnbe in detail the workto completed,specifying the type,brand,and grade of materials to be used,use additional sheets ifnecessa ) eibl7 F5 cl / i.J ^ ��7�5'nt/7 00-1 � � ," c,l C� �CG/7S• ti Required Permits-The following building permits required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as-the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their owe,pernlits will,be excluded frons.the Guaranty rued provisions - •�•rvx. ons offDate when contractor will begin contracted work. -vim cly�.pter I.�•�.A..) L9®`0 Date when contracted worlcwill be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,:furnish the material and labor spec idied above for the total sum o£ �S a� dQ, :payments will be made according to the following schedule: _v upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever iseater or.Zenon.corniget:on c.r. &Px� �.7� 1"s �? �Jf ) 9 � s �_ $ � byjf ( /f or upon completion of $ upon completion ofthe contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction . The following material/equipment must bespecial $ ) ordered before the contracted work begins in order to be paid for to meet the completion schedule.(**,) to be paid for NOTES:(1)Including all finance charges C"'I")Law requires that any deposit or down payment required by the contractor before worIcbegins may not exceed the greater of(a)One-third of the total contract price or(b)the actual cost of any which must be special ordered in advande to meet the completion schedule. special equipment or custom made material ICUre85 vfn'-'^...s.i•,-Tr..n nlmrres Wart•IntY bein provided by the contractor No Ywarrantymust attaof ntract-) Subcontractors-The contractor agrees to be solelyxees ball terms ofthe be ched to the co sponsiblelox comg�.tion nftLLa vrcrlc escr; .Pa rAaardless ofthe actions anythird party/subcontractor utilized by the contractor. The contractor flu Cher agrees to be solely responsible for all a materials and aborunderthisa Bement payments 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. Aslc questions iC something is unclear.. ° Yajcesurcjbecontractor has a valid Home Ten rovement Contractor Re istration. The law requires most home improvement contractors and subcontractors to be registered viarect the 10 Parr laza, e Improvement Contractor Registration. You may in about contractor registration by writing to the Director at 10 PaxlcPlaza,Room 5170,Boston,MA.02116 or by calling.617-973-8787 or 888-283-3757. ° Does the contractor have insurance? AsIc the Contractor for Itis insurance company information so that you can confii7si coverage,or asIc to sce a copy of a"proof ofinsuranca"document. ° Know your rights and responsibilities. Read the Important Information on the reverse side cf is yam d a copy of Guide to the Home Improvement Contractor Law: d p the Consumer 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 o third business clay following the signing ofthis agreement. See the attached notice of cancellation form for an explanation f the o£this right D®N®'JC'SIGN TMIS 'CONTRACT]T'TB ERE Two identical copies ofthe contractmust be completed and signed. One c ARE ANY��r�� PACES! T 1 opy should go to the homeowner. The ower copy shoiddUe IcepEbytho contractor. Homeowner's Signature Contractor's Signature 'Date Date ATTY: Sj.,Ls q 2-` i coz- i C) 4 I CERTIFY THAT THIS LOT IS NOT IN THE F.I.A. FLOOD ZONE. CERTIFIED PLOT PLAN THIS CERTIFICATION IS BASED ON THE SURVEY MARKERS OF OF LAND AT OTHERS AND IS NOT A PROPERTY SURVEY, FOR MORTGAGE PURPOSES ONLY. _ 1,c)7 42J _ Sf I CERTIFY THAT THE BUILDINGS ARE LOCATED AS SHOWN AND, c THAT THEY CONFORMED TO THE ZONING BY—LAWS OF THE CITY/TOWN OF 'NCi'EVK 12�'vWHEN CONSTRUCTED. SCALE: 1" _ fpr AS DRAWN FOR: DEED BOOK PAGE Z 7 7 s q,FF� AREA HOBEnT PLANALRN L L' ENDfUTASYS m ., ASSESSOR MAP L ca °�No 29�7�1 ,� ? L BLOCK Z5 �� R.A.M. ENGINEERING {�� 16® Ma3a Strowt LOT p '' J Haved 1,Masowhusetb 02$30 TE.:(978)377-0449 FAX: (978)372.7183 ,42//m Location 7,j/ No. ���!/�/ Date 1f w / 0 . TOWN OF NORTH ANDOVER ��� b 76y6 i . Certificate of Occupancy $ Building/Frame Permit Fee $ - Foundation Permit Fee $ Other Permit Fee $ TOTAL 1� �iG f�S'� $ Check# 3 G /" Building Inspector TOWN OF NORTH ANDOVER 0. OFFICE OF - p BUILDING DEPARTMENT �e 1600 Osgood Street �qs Zr.. ��y Building 20 Suite-2-36 14 North Andover,Massachusetts 01845 Telephone(978)688-9545 Gerald A.Brown Fax (978)688-9542 Inspector of Buildings AFFIDAVIT FOR FINAL COST OF CONSTRUCTION In accordance with the provisions o the Massachusetts State Building Code, Article 1, Section 110.4 and � 114.2, the total estim ted cost Of thecpnstru�ction jnc din al related construction costs* of the buildin located.at Qo� ���11 � amounts to I f f1 f�tG�it Ak being the person referred to as the owner identified below, do solemnly swear that the statements made herein are strictly true and correct and made in good faith. *Related construction costs included all work done with or concurrently with the work contemplated by the Building Permit including demolition, plumbing, heating, electrical, air conditioning, painting, carpentry, landscaping, site improvement, etc. Furnishings and portable equipment are not part of the total construction.costs. l Signature of Owner COMMONWEALTH OF MASSACHUSETTS r ss�x s.s._ r�ly 2� 20 03 Then personally appeared the able named Made an oath that the above statement is true. i I Before, Me, S Notary Public OFFICIAL USE: Final Cost: Original Estimate cost of general work: Cost Difference: Additional Fee Required: - oe �.-. TO AMEND FEE UNDER PERMIT NO.: Inspectional services Department 2005 1 F:Uinalcostaffidavitfonn Strict code enforcement makes the town safer Before buying, renting,leasing check zoning BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 68$0535 Loca1tion22 tt Fid t `T t No. ">�o -~1 Date t _r ' o - TOWN OF NORTH ANDOVER DI a. Certificate of Occupancy Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 268,67 Building Inspector ONOi oT�1ro • O CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 036-14 on 7/10/2013 Date: September 18, 2013 THIS CERTIFIES THAT THE BUILDING LOCATED ON 607 Turnpike.Street MAY BE OCCUPIED AS _a_dog grooming business — "Bark of The Town" IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Patty McCrudden 607 Turnpike Street North Andover, MA 01845 , Building Inspector Fee: $100.00 Receipt: 26867 Check : 1574 own ofndover z : , ?. to No. � LAKI ver, Mass, �� • [OC NIc"twic 11,9 A�R^rEo S U ��✓✓ BOARD OF HE PERMIT LD ood Ki he ' Septic System ` �2 THIS CERTIFIES THAT71 BUILDING INSPECTOR .......... ....JQ... ....... ........ ..... .. . . ` , .. ............................... Fburiclatior ,i has permission to erect.......................... buildings on .... . .00 .... ojo. ...1�.... ugh to be occupied as ..A-rofF{.S.�1A 0- . ........�4_ #%..?....... 111� .■. .... Aney provided that the person accepting this permit hall in every respect conform to the terms of the application inai) ZY on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and " ` � Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. ere* q Fi a d ' PERMIT EXPIRES IN 6 MATHSELECTRICAL INSPECTOR UNLESS CONSTRUCTIOP JKART Rough Service .................. .... .............. ............. ........................ Fine BUILDING INSPECTOR - GAS INSPECTOR Occupancy Permit Requiredto Occupy Building Rough lop Display in a Conspicuous Place on the Premises — Do Not Remove Final i� No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass govIdia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly Name(Business/Organization/Individual): �Z //J �/per Address:_ ? fc!E: s'(5X1:549e,QC19eq_, 1,572K. , 0/('SLI City/StatelZip: ,ZacoRe1)ce,1?W, olfel Phone#: 6�1F) —1333 Are you an employer?Check the appropriate box: Type of project(required): 1.[g I am a employer with 4. ❑ I am a general contractor and I ` } 6. ❑New construction { employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. Remodeling ship and'have no employees These sub-contractors have 8. (Demolition working for me in any capacity. workers'comp.insurance. 9. [�Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]r employees.[No workers' comp.insurance required.] 13.❑Otheru� cess�;��/ y a�n�fl *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they aie 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:. :4,E,1 C 4nd,,�24114J 10aOT'2C/7-0n Zj _g, CO , Policy#or Self-ins.Lic.#: t!J c c s©/O m/2 ®/Z 8 Q'l xpiira iioon Date: Job Site Address:_40OO City/State/Zip: /V,�nd©Ve Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requireclunder 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 maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certio under the pains and penalties of perjury that the information provided above is true anti correct. Signature: Date: Phone#: 3 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other - - - Contact Person: Phone#: i i Information and ffastructions 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 ofhire,• 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 j oint 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 riot 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 performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants x 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 certificates)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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or 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-coin-complete and Tinted legibly.- The De artmeriflias--rovided a s-ace at the bottom p pp p- p--- 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: t The Cmm. onmalthofJ\4_assarhvsPtts Department off dustnial Accidents Office oflntvestigations 604 Washington.Street Boston,MA.02111 Tel,#617-727-4900 oxt 406 or 1-877:,MASSAFB Revised 5-26-05 Fax 0 617-727-7749 _ OP ID:WC ACO DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 06104113 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 978-975-1300 NAME:CONTACT Segreve&Hall Insur.Assoc.lnc 978-975-7596 PHONE `aC No 305 North Main St. E-MAIL Ext ML Andover, MA 01810 ADDRESS: Edward Ramirez PRODUCER LOPEZ-1 CUSTOMER ID#: INSURERS AFFORDING COVERAGE NAIC# INSURED Lopez Interior Exterior INSURER A:Arbella Protection Ins.Co. 41360 Painting LLC INSURER 8:AEIC 11104 968 Essex Street INSURER C: Lawrence Mass.01841 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. 14TR POLICY NUMB DDL UB POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE ER MM/DD/YYYY MM/DD/YYYY GENERAL LIABILITY i I EACH OCCURRENCE I$ 1,000,000 04/24/13 04/24/14 DA AG TO T REND 100 000 A X COMMERCIAL GENERAL LIABILITY I 8500055177 PREMISES Ea occurrence $ ' CLAIMS-MADE OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ — 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000'000 X POLICY PRO JECT LOC I $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO I BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ (Per accident) HIRED AUTOS $ NON-OWNED AUTOS UMBRELLA LIAB OCCUR I EACH OCCURRENCE ( $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ i DEDUCTIBLE $ RETENTION $ WC STATUS OTH- WORKERS COMPENSATION I X TORY LIMITS ER AND EMPLOYERS'LIABILITY 04124!13 04/24/14 E.L.EACH ACCIDENT $ 100,00, B ANY OFFICERIMEM ER/EXCLUDED?ECUTIVE Y� NIA WCC 5010937012012 E.L.DISEASE-EA EMPLOYEE $ 1 OO,OO (Mandatory in NH) 500,00, If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BLANK ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD *s liassachilvett+- Depatinteral (if Public: Safel. Board of Builtl.in-a- Regulations and Stanthi rtls Construction Supervisor License License: CS 47056 " LW-- Expiration: MARCOS A DEVERS 16 WOODLAND ST LAWRENCE, MA 01849 10/25/2013 E c+nett+istrter' Tr--- 5685 r-ix Y�'eoir lfrr>ir��:r����/1+; �' tsr irrrYtr�.;i•I'.: Oftice of Cossomer Affairs&Bnsifess Reguladoo E IMPROVEMENT CONTRACTOR gbf uon: laws Type: A 7/24=14 Private Co"ralk MDJ INC. Marcos Devers 61 WOOD LAND STREET LAWRENCE,MA 01841 Undersecretary COMMONWEALTH OF MASSACHUSETT n ENGINEERING REGlPROF CIVIL ENGINEER ; ISSUES THE ABOVE LICENSE TO° MARCOS A DEVERS ,a 16 WOODLAND ST n LAWRENCE MA 01541-2315 33848 06/30/14 183409 E� E ucSD-roa122s International Safety Education Institute USED W o-UC San Diego i Extension Am�a erica n� U) z ""ER"A110TVIDUCAMN l"SI72i1TE dSt71 Safe i W ""W( Q . MARCOS DEVERSQ CO *} +. - 1+5di".,gentfynµfa<+Ih.nafti ':A�elM*..- - +*"•'; VJ 304-tow OSHA Hazard Recognition Training for the C*nst.uctw Indus'ty Cou" on BI M12 " LL .., l;rma ri.Ua-v._•.arvrlC-A•v,•ma`:a zl'rin an:rr,msa+ro:`afi•"YCLcd: Mferti se+ I. U O +14 LJJ —� W CL 1;t a rs.. R •n '..ihllh la'fI StMlAti[IIM(«,-.«-_. � 1s ,� NORTH Town of tndover 0 No. 01w"4110- SAME h ," ver, Mass, �a cocNicNew.cw �1. A004.rED ' S U BOARD OF HEALTH Food/Kitchen PERMIT L D I Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ........�IQ. . ..... ...... ................cfw-A ........................... has permission to erect.......................... buildings on ....6.Q.! ....Tu%.Mo. ..� S .�.. Foundation . . �.. ugh to be occupied as .,A!* .(�►.�.,,. :....... ,�!!!,.. ......."�•...... JV1� ti!! .... .... r>Tney provided that the person accepting this permit hall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 M THS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO ART Rough Service .................. .... .............. ........................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE