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Building Permit #340-2016 - 64 MAY STREET 9/16/2015
%40RTH BUILDING PERMIT oFst,ED ,6gti TOWN OF NORTH ANDOVER �� '`- t° �0 o L .,� " APPLICATION FOR PLAN EXAMINATION h T Permit No#: - -[�� Date Received QDR^TED rP�`�y igSSACHUS Date Issued: ! I IMPORTANT: Applicant must complete all items on this page LOCATION (o4 - ( (D 0. Y S-f re-el Print PROPERTY OWNER ci _ 4d' Print 100 Year Structure yes no MAP © � PARCEL: D ZONING DISTRICT: Historic District ye no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition 5�Two or more family ❑ Industrial @Alteration No. of units: ❑ Commercial &Kepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: �..l�.�11 (off add 3a�fi�ic9e?�_�.�-, I �'(�c�- C�ic,�ti� �- �/ � �/��•� ���ti �`u ��� (�o�l� �' �( U-AD n a i^km' - Re thou 2 -I add ; CJo � r efr V r�j heJ® �y I 'P, n,, r( A �" 91ov` Qodt�ncnt�' , Fehlao -'I^o J-( Po e-A r�c�l� O( GQ pc Kt oy iQeyt l oxb, Identification- Please Type or Print Clearly OWNER: Name: BrCA=4 4. 9oa e-s 60 uC i,h T vLC_ Phone' foS..,r—Waj Address: P -U GoK -7 Lawrence- N 0 0 L9 4- 2, �2 v LS Cv rvt n a h t e S T PIC Contractor Name: (16 e Lev1.S_ Phone: 9] X -(off 7 -7 Z Y,, Address: i b Piea.saK �Sfreef Po rk f- h � hdv ve r Kfr Supervisor's Construction License: CS-0 36 l Exp. Date: l ' -7 - 1 b �I Home Improvement License: ( G 3-77 Exp. Date: Z of ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST iBASED ON$125.00 PER S.F. Total Project Cost: $ CJ U FEE: I 0 Check No.: ` Z Receipt No.: 117q NOTE: Persons contracting with unregistered co actors do not have access to the guaranty fund Signature ofAgent/Owne Signature of contractor J i 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS { Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes f ,Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: j Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes t/ no Located at 124 Main Street Fire Department signature/date COMMENTS I 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 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 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 Doe:Building Permit Revised 2014 Location �� lr? /' HX-'1 No. 'i 11— ��t Date 212 t, • - TOWN OF NORTH ANDOVER • Certificate of Occupancy $2"""' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 1 Z Building Inspector Location No. 3L�b ""2b,SO Date 91k,16 • - TOWN OF NORTH ANDOVER ' Certificate of Occupancy $ • ` � :� s' aka . wR w Building/Frame Permit Fee $ TIP Foundation Permit Fee $ * Other Permit Fee $ TOTAL $ _ Check# C Building Inspector � Otar. r*"19 00 'SSACf1U5E4 CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 340-2016 on 9/16/2015 Date: February 26, 2016 THIS CERTIFIES THAT s THE BUILDING LOCATED at 64 May Street MAY BE OCCUPIED AS a single family home IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Bread & Roses Housing Inc. P.O. Box 7 Lawrence, MA 01842 Bu' fling Inspector Fee: $100.00 Receipt: 30049 Check : 12622 own �► �- . E ndover No. OPP soh ver, Mass, IL �A COC'CNl WICK`y1 �.4 �RwrEo ►.P�`�.(5 S U BOARD OF HEALTH I Food/Kitchen i Septic Sys emPERMIT T LD MNIr /THIS CERTIFIES THAT ...... .... ...... ... ,,, ,,.. ,�,. So.r.. ... LDING S T R .... ..... has permission to erec .......... ............ buildings on .4i' ".. ... ��I....... ........ Foundation • ough to be occupied as ...: ... . /.J................... ..... ............... ..............AS_. ..... ... ..p �� "eney provided that the person accepting this permit shall in every respect conform to the terms of the appllcatio `F" al 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. �j�� LUMBING INE.CTOR Rough s "l VIOLATION of the Zoning or Building Regulations Voids this Permit. --i-46 4� - Final P� PERMIT EXPIRES IN 6 MONTH ELECTRICAL INSPECTOR Q V UNLESS. CONSTRUC 'i T Service ////��'�,� .........l�.... .:.. ................................................... Fina �`y Z � BUILDING INSPECTOR GAS IN PECT R Occupancy Permit Required to Occupy Building Rough z 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. �f mo e JL���, / ' OS NORTH{1ti N {{^I b olu CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 340-2016 on 9/16/2015 Date: February 26, 2016 THIS CERTIFIES THAT THE BUILDING LOCATED at 66 May Street MAY BE OCCUPIED AS a single family home IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Bread & Roses Housing Inc. P.O. Box 7 Lawrence, MA 01842 Bui ding Ins ector Fee: $100.00 Receipt: 30049 Check : 12622 V. Town n over to h ver, Mass, ��W 614 11 coc"ic„ewccw 1' •Q.o `� 0R�►TEo S U BOARD OF HEALTH Food/Kitchen PERMIT T LD'4% Septic Sys em THIS CERTIFIES THAT ...... .... ...... ...��....�.��.%..� ss P! e'.! ,,,.,,,............ it ILDING S T R J f( has permission to erec ......... ............ buildings on .4� `...40 Ile,... � :�... ........ Foundation ' ♦ �� ough to be occupied as /J dam ..... .... !.� ............. .. ..... ... ,� L... ..� ney provided that the person accepting this permit shall in every respect conform to the terms of the applicatio `F' ai 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. �s )* �� LLIMBING INY.E T R Rough S �� l VIOLATION of the Zoningor Building Regulations Voids this Permit. g g Final 4 12 PERMIT EXPIRES IN 6 MONTH _a ELECTRICAL INSPECTOR 0 UNLESS CONSTRUCTIT RFU n Z-- --� Service .........1'a.... .... ..:........................................:........ BUILDING INSPECTOR Fina ® jl, � GAS IN PECT R Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final 5: Ap No .Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building_ Inspector. Burner Street No. . � mo e C. NORTH I own of �. ? E 1, ndover :, - to NO. zT _ , h , ver, Mass, 6pA v COCKICNl WICK �' S r# U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THATs�H�, ...... .... ... 0059.%... .....'................ BUILDING INSPECTOR ���. ... .. ... Foundation has permission to erec ........................ buildings on .. '� .�L .................... Sough to be occupied as .... .. .l�r!.��. ..... ...............'!.� ....... .. ..... ... �...` ...� /�mney h provided t at the person accepting this permit shall In every respect conform to the terms of the applicatio 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. ` Yk &A mooPLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTH ELECTRICAL INSPECTOR �ooUNLESS CONSTRUCTe T 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. I. Project Description A. For a price identified below, Contractor agrees to complete home improvements (identified as the Project in this agreement) for Owner. II. Contract Price A. In addition to any other charges specified in this agreement, Owner agrees to pay Contractor $ 150,000 for completing the Work described as the Project. III. Scheduled Start of Construction A. Work under this agreement will begin within 10 Calendar Days after the following contingencies have been met. 1. All appropriate building permits have been issued. IV. Scheduled Completion of Construction A. Work under this agreement will be Substantially Complete within 65 Calendar Days after the date construction begins. V. Documents Incorporated A. This agreement incorporates by reference certain disclosures and notices required by federal and state law. B. This agreement incorporates by reference certain documents which define and describe the Work to be done. The following documents are incorporated as though included in full as art of this rP g p agreement. Specifications Specifications dated Consisting of sheet(s) Prepared by Last changed on_/_/ And further identified as 1. Proposal (Estimate or Bid) Proposal (Estimate or Bid) dated Consisting of_sheet(s) For the amount of$ Entitled And further identified as Reference to Contractor's proposal dated is is for convenience only. Other Contract Documents identify the Work to be completed under this agreement. VI. Ownership of Plans A. Plans, Drawings, Specifications and copies prepared for use in construction under this agreement are the property of Contractor. Contractor retains all common Law and statutory rights to these Plans, Drawings and Specifications. Owner agrees that these documents will not be used on any other project and, with the exception of one record set to be retained by Owner, will be returned to Contractor on request. Page 2 VII. Scope of Work A. Contractor shall supervise and direct the Work and accepts responsibility for construction means, methods,techniques, sequences and procedures required to complete the Project in compliance with the Contract Documents. VIII. Cutting and Patching A. The color, texture and planes between existing and new materials might not match exactly. Contractor will use due diligence to create the best match possible. Owner acknowledges that patched surfaces may be detectable when construction is complete. IX. Compliance with Law A. Contractor and Owner mutually commit to use reasonable care to meet the Requirements of state, federal and local Law when discharging their responsibilities under this agreement. B. If Law enacted after the Contract Date changes the Scope of Work under this agreement, Contractor and Owner will execute a Change Order adjusting the Contract Price and Contract Time to accommodate the change in the Scope of Work. X. Permits and Fees A. In compliance with Massachusetts General Laws 142A, Section 2(a)(10), Contractor has: (1) Provided Owner with a list of building permits required to complete this Work, (2)Advised Owner that it's normally the obligation of a Contractor or Subcontractor to obtain the required permits for their Work, and(3)Advised Owner that homeowners who secure permits for Work on their own homes are excluded from the guaranty fund provisions which appear in Massachusetts General Laws 142A, Section 5. Contractor accepts responsibility for securing building permits for the Project. Description of the permit: Unit 64 add a bathroom 2nd floor, convert 0 floor bath to '/z bath with laundry, remove (2) interior walls add (3) closets refinish 2nd and 3rd floor bedrooms (2)new heating systems. Pour concrete slab unit 64. Replace front porch railings and steps and decking in rear_ orches. Replace existing cabinets with new cabinets on unit 66. Replace (5)vinyl windows replace roofing shingles. Name of the permit issuing authority: Town of North Andover A. Contractor will pay the building permit fee, Plan check fee, business license fees for Contractor and Subcontractors, and charges levied by government for testing, Inspection and Re-Inspection of the Project. XI. Payment Plan A. Owner will pay to Contractor the Contract Price in installments consisting of an initial payment, progress payments, and a final payment on completion of the Work. XII. Initial Payment A. On initial delivery of materials to the Job Site, Owner shall pay to Contractor$ 0 B. The initial payment is refundable to Owner, less actual cost to Contractor, if Owner is not able to obtain a commitment for construction financing in an amount adequate to complete the Work. XIII. Progress Payments A. Schedule of Progress Payments Page 3 1. Progress payments are due as each phase of the Work is completed. a) Amount due when Job is complete: $ b) Amount due when Job Phase 2 is complete: $ Job Phase 2 is complete when c) Amount due when Job Phase 3 is complete: $ Job Phase 3 is complete when d) Amount due when Job Phase 4 is complete: $ Job Phase 4 is complete when B. Processing of Progress Payments 1. No less than 2 Calendar Days before each progress payment is due under the terms of this contract, Contractor shall provide Owner with an application for payment(invoice)in a form which complies with generally accepted trade practice. 2. Except as provided otherwise in this agreement, Owner shall pay the amount due within 2 Calendar Days after approval of any application for initial,progress or final payment. XIV. Interest A. Payments due and not paid under the Contract Documents shall bear interest from the date payment is due at an monthly rate of 1 '/2 percent. B. When payment is withheld pending settlement of a bona fide dispute on the quantity, quality, or timeliness of the Work, interest shall accrue only on the amount ultimately paid. C. Payment of interest does not abrogate or replace any other rights Contractor may have under this agreement. D. Any interest which remains unpaid at the end of any 30-Calendar Day period shall be added to the principal amount due and thereafter shall accrue interest at the same rate as the principal. XV. Final Payment A. Contractor will submit an application for final payment to Owner when the Work has been completed in compliance with the Contract Documents. If Owner agrees that Work has been completed, payment is due Contractor for the entire unpaid balance of the contract amount(including any Retainage). B. Making of final payment constitutes waiver of all Claims by Owner against Contractor except those Claims previously made in writing and delivered to Contractor and those obligations otherwise provided by this agreement or by operation of Law. C. If completion of the Work is delayed unreasonably at no fault of Contractor, Contractor shall be entitled to final payment for all Work completed(including Retainage)without prejudice to the right of Contractor to complete the Project at a later date and without prejudice to the right of Owner to make Claims against Contractor for Defects in Work completed. Page 4 Massachusetts Home Improvement Disclosures Massachusetts General Laws 142A, Section 2(a)(8)requires that home improvement contractors and subcontractors register with the Director of Home Improvement g p ment Contractor Registration. You may inquire about contractor registration by writing to the Director at One ,Ashburton Place, Room 1301, Boston, MA 02108 or by calling 617-727-3200 or 1-800-223-0933. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. See the attached Federal Right of Rescission form for an explanation of this right. Massachusetts law grants lien rights to builders. Any construction contractor, subcontractor,tradesman or material supplier who is not paid can record a lien on the property being improved. If not discharged by payment,this mechanics'lien will become a security like a mortgage on the property. Massachusetts General Laws 142A, Section 2(a)(8)provides that, "No contract shall contain an acceleration clause under which any part or all of the balance not yet due may be declared due and payable because the holder deems himself to be insecure. However, where the contractor deems himself to be insecure he may require as a prerequisite to continuing said work.that the balance of funds due under the contract, which are in the possession of the owner, shall be placed in a joint escrow account requiring the signature of the contractor and owner for withdrawal." Massachusetts General Laws 142A, Section 2(a)(8)requires that the property owner receive, at the time of signing, a copy of the contract signed by both the contractor and the owner.No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract. Massachusetts General Laws 142A, Section 2(a)(8)requires that this contract include a notice disclosing all warranties and the rights of Owner under this agreement. Except as provided elsewhere in this agreement, Contractor makes no express warranty. Owner waives, renounces and disclaims all implied warranties of fitness for purpose,merchantability,habitability and good construction. Page 5 Signatures This contract is for immediate acceptance. Any delay in acceptance beyond 16 /_Z��will require renegotiation of the terms of this agreement. DO.NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES'.'.: This agreement is entered into as of the date«xitten below. Oti is N' s: Ox ner 1 gnature i (Date) \ Bread and Roses lIousina ' (Primed Larne) Contractor Name: J �e h . Contractor ( c ature) (Date) 1G (PrAe�Name and Title) Page 6 The Commonwealth of Massachusetts J. Department of IndusiWalAccidents M e �:�. �•_:��:.d X Congress Street,Suite 100 =^`F .Boston,MA 02114-2017 www mass gov/dia Sy. Workers'Compensation lnsuran.ceAffidavit:Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH TEE PERARTTING AUTHORITY. AplolzcantInformation Please Print Legibly Name(Business/Organization&dividual): t✓' v 14 ca--9e)a gd p C In C Address: City/State/Zip: pi Ua J 1Jriu.2 Phone 7 Areyou an employer?Cheekthe appropriate box: Type of project(xequired): 1.LTJTam a employer with employees(full and/or part-time).* 7. ❑N construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 4<emodeliAg any capacity.[No workers'comp.insurance required.] 9. El Demolition 3..❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 [f Building addition 4.❑lam a homeowner and will be hiring contractors to conduct all work on my property. l will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors withno employees. 12..Q plumbing repairs or additions 5.❑I am a general contractor and I have hued the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.C1 Other 152,§1(4),and we have no employees.[No workers'comp,insurance required.] *Any applicant that checks box 41 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 andthen hire outside contractors must submit anew affidavit indicating such. ?Contractors 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-conlractors fiave employees,they must provide their workers'comp.policy number. I can employer that is pi oviding workers9 compensation insurance for my emplayees.'Below is the policy and job site information. Insurance Company Name: (.l-Gl V — Policy#or Self-ins,Lie.#: IP l t.J r C24' G G Expiration Date: Job Site.Address. Ui 41_GG� � •�� City/State/Zip: &- 'dol u^ a 7 Attach a copy of the workers'compepsation•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 DTA.for insurance coverage verification. X do hereby certify under the pains andpenatties ofperjury that the information provided above is true and/correct. sign 0: Date: Phone#• I l� (g��' 7 ir 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.Plumbing Inspector 6.Other Contact Person: Phone#: i Information and Instructions ' 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 of hire, express or implied,oral or written." Art employer is defined as"an individual,partnership,association,corporation or other legal entity,of 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 trustda 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 licensMg 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 Please fill-out-the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractor(s)name(s),address(es)and-phonenumber(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 De ariment of Industrial Y P Accidents fox 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 gou'are required to obtain a workers' compensatiori 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 permi'i 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 Boston MA 02114-2017 Tel.#617-•727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia -'rte LEVIS-1 OP ID: KM ATE CERTIFICATE OF LIABILITY INSURANCE D05!11111101Y2015 055 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 pollcy(les)must be endorsed, if SUBROGATION 1S 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 NAME: Lawrence R.Michaud,CIC Michaud,Rowe And Ruseak Ins. Iuc Nol:978 557 2130 P.O.Box 188 PHONE :AX Ezt:978 688 8829 North Andover,MA 01845 EMAIL lmichaud@mrrinsurance.com Lawrence R.Michaud,CIC ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A;Preferred Mutual Insurance Co. 15024 INSURED'----L2V15 COM BnIeS Jnc.. - ----- --- p - ----...............-iNsu1eR s:Safe .......Insurance Joseph Levis INSURER C:NorGuard 154 Pleasant Street North Andover,MA 01845 INSURER D.- INSURER :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. INSRTYPE OF INSURANCE Al3bT SEIPOLICY EFF POLICY EXP LTR INSO D POLICY NUMBER MMIDCDYN YY MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000 FP_CLAIMS-MADE OCCUR CPP0180589059 10!26!2014 1012612015 PREMISES Ea AGETURIM-fErrence) 5 100,000 4 MED EXP(Any one person) S Excluded { 1 PERSONAL&ADV INJURY S 11000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I I GENERAL AGGREGATE 15 2,000,000 —7 POLICY�JECTPRO- u LOC PRODUCTS-COMPIOP AGG I S 1,000,000 HOTHFR: Is AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accidents S 1,000,000 B ANY AUTO 821254 01/01/2015 0110112016 BODILY INJURY(Per person) 15 ALL OWNED Ix SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident)I S Y. NON-OWNED PROPERTY DAMAGE I HIRED AUTOSAUTOS rP_raccidenll �S UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I I RETENTIONS S WORKERS COMPENSATION _ AND EMPLOYERS'LIABILITY YIN STATUTE ER H C ANY PROPRIETORIPARTNER/EXECUTIVELEWC647061 02/27/2015 02127/2016 EL.EACH ACCIDENT 5 100 OFFICER/MEMBER EXCLUDED? � NIA rOO (Mandatory In NH) E.L. MPLOYEES DISEASE•EA E 100 OO If yes clears under r DESCRIPTION OF OPERATIONS below EL nISEASE-POLICY LIMIT I S 600,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space Is roqulradj CERTIFICATE HOLDER CANCELLATION NORTHI3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 384 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE /f ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Massachusetts -Department of Public Safety Board of Building Regulations g and Standards Construction Supenisor License: CS-030651 JOSEPH GIEVIS:` 154 Plemant St. North Andover WA 0 Expiration Commissioner 01/0712016 Office of Consumer Affairs&Business Regulation OME iMPROV6NiENT CONTRACTOR egistration: 772 Type: Expiration==y = s� individual JOSEPHG.LEVIS r_ .3 JOSEPH LEMS r*j 154 PLEASANT STR =' NORTH ANDOVER,MA Undersecretary