HomeMy WebLinkAboutBuilding Permit #621-2016 - 650 FOREST STREET 11/19/2015BUILDING PERMIT TOWN OF NORTH ANDOVER i APPLICATION FOR PLAN EXAMINATION Permit No#: I' Date Received Date Issued: IMPORTANT: Applicant must complete all items on this ECRATI®:N V �4SLa'n n�?c�a TYPE OF IMPROVEMENT PROPOSED USE 4 . Residential Non- Residential ❑ New Building %One family ❑ Addition ❑ Two or more family ❑ Industrial .Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other [® Septib . l% Well`® FIS oodplan ` UUends'° ®ilNatersf ed ®` str'c�t� D Watery.4/Sewer - ' DESCRIPTION OF WORK TO BE PERFORMED: 0 t *3 C-- -- Identification - Please Type or Print Clearly OWNER: Name:' Phone: AfifiYPCC' C©nt�racr,Name:`s�._�`'`aa�S�s, Phoney 1?�r���-._-�, �° I Email ' 4 . Supi W sori ttCons�tr�cti©_n f teens F d' Y k �-.� nowaw 9�1ri '••� ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT. • $12.00 PER $1000.00 OF THE TOTAL ESTIMATED OST BASED ON $125.00 PER S.F. U� Total Project Cost: $�, FEE: $ Check No.: -3 Receipt No.: NOTE: Persons contracting with unregistered contractors do 1�gesis�o theghuaranty fund ,,Ignatl a H Locatior(ib( I — (0 No. Chelc� # 29.698 (�Lo t-ZwLA!t&7- sor� Date TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee sLj n Foundation Permit Fee Other Permit Fee TOTAL $ 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 ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORM PLANNING & DEVELOPMENT Reviewed On Signature. COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature r COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decisionfreceipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: t_ocatea Jd4 usgooa Street �Kt Ut1='ARTME-N�.Tf�p ®umpste aonste; Leoaetdat1024M11_ r'et �....�.,.�.�,._,� �,-...ter Fire Department signature/date, C®MM NTS P9, MB ice+ 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 DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.$10o-$1000 fine NOTES and DATA -- (For department use) ® Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 No oL 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 d®TE: 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 TOTE: 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) o Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products ®TE: 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 C O CD CD 0-0 C F• �- O CL to N 0 o vCD CD 0Q cr (D CD O W W u CD i CD CLO N S• = CO CD � v Z CD 0 � O CD O CD =- O ® a) x < CD N N r � _> O• N O CD n 0 .A•r .•r = C'1 � � Z 0'_S�$ N• -I N O O N r -OL CD rt O� O 3 CL X71 N � CD CD CDcDCD 2 0 m �. n �' Q rt N O W CD CD (D 'a CL —i c • 0 CO � N e -t ;CD O �• N to Co Z CD 0, a' .=r : O D M N Q N O 0 s 0' O N _• N N CD O fl1 Q. cnC CD r as :f fc.)N O p- 41** 1 J (n 0 C T :u T VI � Z T A T (� X T M N T cn 1— 0 7 O O O O j O O' S Om O (D O O N z 0 cu Cl) �• CC �. Q O 000 W O UO0 UCO Cl) Z rD � rC-- w Ln Z Z rr (D n O O =- O ® a) x < CD N N r � _> O• N O CD n 0 .A•r .•r = C'1 � � Z 0'_S�$ N• -I N O O N r -OL CD rt O� O 3 CL X71 N � CD CD CDcDCD 2 0 m �. n �' Q rt N O W CD CD (D 'a CL —i c • 0 CO � N e -t ;CD O �• N to Co Z CD 0, a' .=r : O D M N Q N O 0 s 0' O N _• N N CD O fl1 Q. cnC CD r as :f fc.)N O p- 41** 1 J (n 0 00 T :u T VI � T A T (� X T N T 3 1— 0 7 O O O O j O O' S O O (D O O N cu �. Q O 000 W UO0 UCO Z rD (D w Ln rr (D O n r 3 S T m C WN 3 (D, O C W 0 Q H W M A Z M y GZ) cl O T7 •v 3 m 0 m y Z'i O 2 0 0 c f rOi`auL; �5 SIDING CONTRACT COASTAL eu i. , G 'ALis arl�l�cen',^;17d7?`• WINDOWS tW Gunmrrin, gs• Ce'm" e&r,SuYe 235-H •iSeverlKE'IAo1975 �.��'�C.n�1•/`-•sem\•) SOURMCEN._L� ERORS, INC.s`�r 'iEXQ-) + C yLe,�) [e8a7&3fY-09n5 Q12-2783 • Fax:97e-3O•t928 � vnvsv.mycoastalsvindovn.cvm ���w ,s \J L P Name: C 4 r 1 i 1. t ) "L t Phone: Res: Bus: (Residential) Home Address: 6al-6-4 5t City: i Zip: INVe. the owners of the premises described below, hereinafter referred to as "Purchaser" offer to contract with Coast Windows & Exteriors herein eferred to as "Contractor', to furnish. deliver and arrange for installation of all materials necessary to improve the physicial premises located at: Check (if addresses are the sante) (Street) (City) (State) (Zip) Accc rdblto the following specifications -This agreement is subject to financing which you must secure within thirty (30) daysafte, the date of this Agreement. If financing acceplaitfe to Coastal Windows & Exteriors is not obiainM within 30 days, This Agrrrmem ratty be canceflcd by eilber parry. All home improvrmtent contractors and subcontractors must be registered by the Chief Adminkirator of the Massachuseus Board of Building Regulations and Stondards. Any inquiries about acontrac[or or sulcomranor elating Boatel)_isiration shadd bedizened to Director of Home improvementContractorRegistration, One Ashbunon place, Room 1301. Roston, MA 02180.(6171727.8598. TIn Contractor shall obtain and pay for the building permit and other permits and governmental fees. licenses andinspections necessary for proper execution and completion of the Work. 11 the Ov ner elects to nbtain the foregoing permim m to deal with unregistered contactors. the (hvncr will be excluded from the guaranty provisionsof M.G.Lc:. 142A. The Ova- shall obtain and pav for all other necessary approval,, easemems, assessments and charges. TficContrarorand the hatteosvnerltereby muwaly agree inadvance that in nterrenrtheConnaaat ,a sput.concer in, as attract.[lie Contractor maysubmiuhesucharbBmtim as nmvidrd in Mass rhu�cns General 4jwSj`haptcr 142A. ur��rern ni�� ecu aur ma rarssKua"'- NOTIt:E:TheS.g atmr, orthe ptair, aboveap y only to the Contract of the. paniestoahernative dispute resolution initial ehomenvmer mryiniiiati ahenraGve fispute resolirtion even where this secfian is not. separatetysigned try the parties. NosvorkshaO ltngin priortothesigningnithis Canract andtransmittaltothe[haterofacopyofthis Contract.Th- contract consbartes the p. ies' total agreement. This contract may be amended or supplemented only by a wtilten change order signed by owneraud commctor. All surphn material' ropertyof COASTAL WS& EXTERIORS. You agree to be bound by the general conditions of the r verse side. The anter has seen "sample`wananties that willlie pmvkferi by COASTAL WINDOWS& EXTERIORS upon installation jly5arnple wammues pmJded to Owner. NO ORAL AGREEMENTS ARE ACCEPTED DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Youfor the buyer, may cancel this transaction at anytime prior to midnight of the third3business day gfter the date of this fransactian. Seethe NoH<eofCancellationformprovided to you herewith fon explanation of this right.IN WI(NESS WHEREOF. IIhe parties have hereunto signed their names this _ (lay of -�4T� =� 26xS./�_ %rIFR MAKE ALL C CKS PAY/ABLE TO COASTAL WINDOWS & EXTERIORS .Mt Kt11LD ratcav (CV519-im PRICE S I pC NOT S �t INCLUDED INCLUDED J �� 1. fl Existin sides inn Type: (.C/ �i� # of sq. Ft.; " r✓ SIDING: 2. -- Remove _ t } ❑ idin Type:J Style: ( J Ship lap) L t`(7,T_ ADDMONAt DEPOSIT DUE UPON DELIVERY Payment Method _ ,... FinanCPd By �.,� Color: I 1 i iY # of Sq. FL:.- TOTAL DUE 3. U .. mit areas of me with Vinyle Soffit System: fl of Sq. FL. Color: Pattern: Except those areas noted: <. fl Fascia areas Cust rayl-CladgCtumium: # of Sq. Ln: Color. Except those areas note fl 5. U Home Owner Obtains ALL necessary permits and insurances. PREPARATION:: 6. -_kJ_ U inspect surfaces work area. renail loose wood, replace rotten surface wood (as necessary) in work area (mha harge.) 7. j6- Fir out walls (Brick. Block or Stucco) Siding Areas: Location: 8, ,U,7 yy._ Q Caulk and seal around all sidings & doors in work area (as recommended by manufacturer). CUSTOM TRIM: g, 4d- Install inulation on flatwail areas to be sided with '318"insulation (fan -told) Preservation only. 10. nxCI c[3^ ❑ ❑ Remove — or — CJ Remove and reattach of existing gutters. fl Remove — or — W -Remove and reattach of existing downspouts. J 7 r)% � (J� 11. 12. '..- 11� Pat- U Custom %- ap-(SiIIs1MuIWHeaders) with luminum: Color V f---• c`�--Y `•"�= U Remove and eNR Faff (existing) Shutters 13.'' U Customvrrsp door facings rrika.alt+rpimm. Location:A"itr'%- Color (%%.t 'r 14. Custotn•en garage door single/double with Virt�PAd tttC. Color. (f, ilii 15. f..) 1U,r - Standard Vinvi (J -Channel) Type: 1 1/2` Face (Integra Only) Color: 16. fl t14J�tt /S Standard. Vinyl (J -Channel) Type 1" Face (Preservation Only) Color: 17. i] Af- Deluxe Vinyl (J -Channel) Type 2 12` (Preservation Only) Color. (white only) 18. ❑ (� j8- Deluxe Vinyl (Window- Trim Channel) Type 31/2" (Integra or Preservation) Co�lglc i,(white only)ez 19.- Standard comer-Posts(4:�w/ttttegra-9'�wtRreseuratfoN (3olo1 ix t '-' 7_'-1 c2-'YN>� •P3>)1Z1fS7 20. El/La' ¢p❑,��}} Deluxe 3 -Piece Corner System: 2 pc. 3 12-11 pc. Bull -nose (into a Only) Calor: (white only) CLEAN UP:. 21. � ❑ Clean up and removal of all job related debris: 22. l� U Each job is aver- shipped to avoid delays. Remove excess materials and re -stock. WARRANTIES: 23. cc1- crAnr nA7>:• '�! �. U Mail customer warranty after satisfactory completion. pp/ :1 r Xl 1'�) f FCT (na4p DATE. 0.n, t 1114, �f'� � � SECURITY INTEREST: YES (.] NO FJ -This agreement is subject to financing which you must secure within thirty (30) daysafte, the date of this Agreement. If financing acceplaitfe to Coastal Windows & Exteriors is not obiainM within 30 days, This Agrrrmem ratty be canceflcd by eilber parry. All home improvrmtent contractors and subcontractors must be registered by the Chief Adminkirator of the Massachuseus Board of Building Regulations and Stondards. Any inquiries about acontrac[or or sulcomranor elating Boatel)_isiration shadd bedizened to Director of Home improvementContractorRegistration, One Ashbunon place, Room 1301. Roston, MA 02180.(6171727.8598. TIn Contractor shall obtain and pay for the building permit and other permits and governmental fees. licenses andinspections necessary for proper execution and completion of the Work. 11 the Ov ner elects to nbtain the foregoing permim m to deal with unregistered contactors. the (hvncr will be excluded from the guaranty provisionsof M.G.Lc:. 142A. The Ova- shall obtain and pav for all other necessary approval,, easemems, assessments and charges. TficContrarorand the hatteosvnerltereby muwaly agree inadvance that in nterrenrtheConnaaat ,a sput.concer in, as attract.[lie Contractor maysubmiuhesucharbBmtim as nmvidrd in Mass rhu�cns General 4jwSj`haptcr 142A. ur��rern ni�� ecu aur ma rarssKua"'- NOTIt:E:TheS.g atmr, orthe ptair, aboveap y only to the Contract of the. paniestoahernative dispute resolution initial ehomenvmer mryiniiiati ahenraGve fispute resolirtion even where this secfian is not. separatetysigned try the parties. NosvorkshaO ltngin priortothesigningnithis Canract andtransmittaltothe[haterofacopyofthis Contract.Th- contract consbartes the p. ies' total agreement. This contract may be amended or supplemented only by a wtilten change order signed by owneraud commctor. All surphn material' ropertyof COASTAL WS& EXTERIORS. You agree to be bound by the general conditions of the r verse side. The anter has seen "sample`wananties that willlie pmvkferi by COASTAL WINDOWS& EXTERIORS upon installation jly5arnple wammues pmJded to Owner. NO ORAL AGREEMENTS ARE ACCEPTED DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Youfor the buyer, may cancel this transaction at anytime prior to midnight of the third3business day gfter the date of this fransactian. Seethe NoH<eofCancellationformprovided to you herewith fon explanation of this right.IN WI(NESS WHEREOF. IIhe parties have hereunto signed their names this _ (lay of -�4T� =� 26xS./�_ %rIFR MAKE ALL C CKS PAY/ABLE TO COASTAL WINDOWS & EXTERIORS .Mt Kt11LD ratcav (CV519-im PRICE S I pC D POStrwil'H ORDER S �t BALANCE TO BE FINANCED' SALESTAX ! S �^ ADDMONAt DEPOSIT DUE UPON DELIVERY Payment Method _ ,... FinanCPd By TOTAL DUE i s7,% (�r BALANCE TO BE, PAIDS CASH ON COMPLETION rt t vel. -This agreement is subject to financing which you must secure within thirty (30) daysafte, the date of this Agreement. If financing acceplaitfe to Coastal Windows & Exteriors is not obiainM within 30 days, This Agrrrmem ratty be canceflcd by eilber parry. All home improvrmtent contractors and subcontractors must be registered by the Chief Adminkirator of the Massachuseus Board of Building Regulations and Stondards. Any inquiries about acontrac[or or sulcomranor elating Boatel)_isiration shadd bedizened to Director of Home improvementContractorRegistration, One Ashbunon place, Room 1301. Roston, MA 02180.(6171727.8598. TIn Contractor shall obtain and pay for the building permit and other permits and governmental fees. licenses andinspections necessary for proper execution and completion of the Work. 11 the Ov ner elects to nbtain the foregoing permim m to deal with unregistered contactors. the (hvncr will be excluded from the guaranty provisionsof M.G.Lc:. 142A. The Ova- shall obtain and pav for all other necessary approval,, easemems, assessments and charges. TficContrarorand the hatteosvnerltereby muwaly agree inadvance that in nterrenrtheConnaaat ,a sput.concer in, as attract.[lie Contractor maysubmiuhesucharbBmtim as nmvidrd in Mass rhu�cns General 4jwSj`haptcr 142A. ur��rern ni�� ecu aur ma rarssKua"'- NOTIt:E:TheS.g atmr, orthe ptair, aboveap y only to the Contract of the. paniestoahernative dispute resolution initial ehomenvmer mryiniiiati ahenraGve fispute resolirtion even where this secfian is not. separatetysigned try the parties. NosvorkshaO ltngin priortothesigningnithis Canract andtransmittaltothe[haterofacopyofthis Contract.Th- contract consbartes the p. ies' total agreement. This contract may be amended or supplemented only by a wtilten change order signed by owneraud commctor. All surphn material' ropertyof COASTAL WS& EXTERIORS. You agree to be bound by the general conditions of the r verse side. The anter has seen "sample`wananties that willlie pmvkferi by COASTAL WINDOWS& EXTERIORS upon installation jly5arnple wammues pmJded to Owner. NO ORAL AGREEMENTS ARE ACCEPTED DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Youfor the buyer, may cancel this transaction at anytime prior to midnight of the third3business day gfter the date of this fransactian. Seethe NoH<eofCancellationformprovided to you herewith fon explanation of this right.IN WI(NESS WHEREOF. IIhe parties have hereunto signed their names this _ (lay of -�4T� =� 26xS./�_ %rIFR MAKE ALL C CKS PAY/ABLE TO COASTAL WINDOWS & EXTERIORS .Mt Kt11LD ratcav (CV519-im The Commonwealth of Massachusetts : F Department of IndustrialAceldents F 1 Congress Street, Suite 100 ==' Boston, MA 02114-2017 www mass.gov/dia sV• Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TEE PEPJVRTTING AUTHORITY. Name (Business/Organization/fudividual): Address: I n b lNl M I (I LS LTR- -5�- ab -a City/State/Zip: 4 . Of � 15- Phone #: Are you an employer? Check the appropriate box. 1. I am a employer with_o� : employees (full and/or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.FJ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.F] I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. n lam a general contractor and I have hired the sub-coiitractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.# 6. Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no. employees. [No workers' comp. insurance required.] - I n) g Ig P q93 Type of project (required): 7. [] New construction 8. ERemodeling 9. ❑ Demolition 10 ❑ Building addition 11. ❑ Electrical repairs or additions 12. [] Plumbing repairs or additions 13.0 Roof repairs 14. ❑ Other *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 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 state whether or not those entities have employees. If the sub-coriiractors have employees, ley must provide their workers' comp. policy number. lam an employer that is providing workerscompensation insurance for my employees.' below is the policy and job site information. Insurance Company Name: t— Policy # or Self -ins, Lic. #: S b Qy � 1 Y j��� L 15 "✓,:..�q Expiration Date: Job Site Address:S t City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificatioii .Id do hereby ce under z ai wand pen s of per jug +� tliat the infoYmation provided abl ve i� true and correct. Official use only. Do not write in this area, to he completed by city or town official. . City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and 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." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the 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 -contractors) name(s), address(es) and -phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of kdustrial Accidents fok 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 complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia AIC"R�® `r./ CERTIFICATE OF LIABILITY INSURANCE DATE (MM/Y) 11/19/20152015 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 MassPay Insurance Services, LLC 27 Garden Street, Unit 1 B Danvers, MA 01923 CONTACTJoyce M Keller PHONE FAX AIC o Ext : (978) 774 4338 x115 arc Na : (978) 774-1318 E-MAIL ADDRESS: Ioyce philrichardinsurance.com INSURERS AFFORDING COVERAGE NAIC # INSURER A: The Hartford A/R HAR EACH OCCURRENCE $ INSURED Coastal Windows & Exteriors Inc INSURER B: INSURERC: 100 Cummings Center Ste 236H GEN'L AGGREGATE LIMIT APPLIES PER: JECT POLICY ❑ PRO LOC OTHER: Beverly, MA 01915 INSURER D: INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TR OF INSURANCE ADDLTYPE IVSD SUER POLICY NUMBER EFF MM/DD/YYYY MLICY LEXP /YYYY MI DY LIMITS North Andover, MA 01845 COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1 OCCUR EACH OCCURRENCE $ PREMISES (Ea occu DAMAGE TO ence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: JECT POLICY ❑ PRO LOC OTHER: GENERAL AGGREGATE $ PRODUCTS -COMP/OPAGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED ED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident UMBRELLA LIAB EXCESS LIAR HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUI— YIN OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 6S60UB-99951-15-5-15 11/14/2015 11/14/2016 STATUTE OERH E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Proof of Workers Compensation Insurance r`1=DTICIr`ATF IJnl nGD CONCFI I ATI()N ©1988-2014 ACORD CORPORATION. All rignts reservea. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St Bldg 30 ACCORDANCE WITH THE POLICY PROVISIONS. Suite 2035 AUTHORIZED REPRESENTATIVE North Andover, MA 01845 ©1988-2014 ACORD CORPORATION. All rignts reservea. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 11A NdLUI 11111C 1 I1 11.114LV 18 I.7.V 1 .7/OJd 1 a 14L 11/10/2015 15:58 9785315142 r .vv I PAGE 01/05 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MUfDOlY1M� 1Z/10/2015 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 certlflea% holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsod. N SUBROGATION IS WANED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statemont on this certificate does not confer rights to the certificate holdor In Ilan of such endorsamentla). PRODUCER John V. Zannino Insurance AgencyPHONS,g78-531-5?57 16 Poster Street Peabody, MA, 01960 NAME FAX nJCNo):978-531-5142 ADDRESS: INauRER(aJ AFFOAnINo GOYERAOE Naca 11/14/15 INSURER A : MA,?FRE COMh7ERCE INSURANCE COMPANY INSURED COASTAL WINDOWS & EXTERIORS, INC. INSURER B ; INSURER C: 100 COMINGS CENTER STE#236R INSURQR D BEVERLY, MA 01915 INSURER E: PRODUCTS - COMPlOP AGG S EXCLUDED 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 DR 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. IIL1TA TYPE OF INSURANCE INao WVO POLICY NUMBER M MM1D0lYYYY LIMIT'S A X COMNSWAL GENERAL UUA�AMUTY CLAIMS-MADEIRK OCCUR Y BGLHM 11/14/15 1/14116 EACH OCCURRENCE S 21000,000 PREMISES Ea accurronrc b 300,000 tJ'"(Any dnaponw) $ 5,000 PERSONAL& AOV INJURY s 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY El JJEEC 17 LOC OTHER: GENERAL AGGREGATE S 4,000,000 PRODUCTS - COMPlOP AGG S EXCLUDED S AUTOMOBILE LIABILrrY ANYALITO ALLOWNED SCHEDULED AUTOS AUTDS HIRED AUTOS AAUDTOSWNCD I B BCCdeM S BODILY INJURY (Per Donlon) S BODILY INJURY t PM stCNontJ S -DAMOF. PRO Per actid�I 3 S UMBRELLA LIAR EXCESS LL48 OCCUR CLAIMSJJADE EACH OCCURRENCE S AGGREGATE $ ow I RETENTION 5 $ WORKERS COMPENSATION AND EMPLOYERS LMILITY ® YIN (� PROPRRTORPARTNERfEW.CUMr, OFFICeWUSMaER EXMUa7 Q IMS ddmy In" If ee, deWbe undo' DESCRIPTION OF OPERATIONS below MIA STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE . EA EMPLO - S EJ_ DISEASE -POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS / VE141CLF,S (ACORD 101, Addruone, Remarks Smedule, may be attained a more spece is required) CUMMINGS PROPERTIES LLC AND BUILDING OWNER(S) ARE INCLUDED AND LISTED AS AN ADDITIONAL INSURED AS REQUIRED BY LEASE OR MUTTEN CONTRACT. LEASED PREMISES: 100 CUMMMGS CENTER, SUITE 2368, BEVERLY, MA 01915. CERTIFICATE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERF-0 1N 1600 Osgood St Bldg 30 ACCORDANCE WITH THE POLICY PROVISIONS. Suite 2035 North Andover, MA 01845 AU" RESEATATIVE ACORD CORPORATION. All rights ACORD25(2014/01) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation -- 10 Park Plaza -Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 174725 Type: Private Corporation Expiration: 3/14/2017 Trlt 263330 COASTAL WINDOWS & EXTERIORS, CNC. STEPHANIE VANDERBILT 100 CUMMINGS CENTER, STE 236H BEVERLY, MA 01915 SCA 1 0 20M-05111 �+, -��11G 11�P7770124%LCOP.CL(Clf, o���l�GlY.11ClCl/CG1Cl��i -� Office of Consumer Affairs & Business Regulation ffiffio�lj_OME IMPROVEMENT CONTRACTOR r egistration: 174725 Type: \expiration 3/14/2017 Private Corporation COASTAL WINDOWS &EXTERIORS; INC. STEPHANIE VANDERBILT, ; 100 CUMMINGS CENTER, STE 23 gtVERLY, MA 01915 Undersecretary Update Address and return card. Mark reason for change. Address E] Renewal [:] Employment 0 Lost Card License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid without signature 4 �- / _ X20 2 � E ( 2 t' f j\ G ) to }A \