HomeMy WebLinkAboutBuilding Permit #629-16 - 679 SOUTH BRADFORD STREET 11/19/2015J;!17A,V4'-0 11-25--16-
Permit
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Permit NO: �2--
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Date Issued: 1111411
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
TANT: Applicant must complete all items on this
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PROPERTY OWNER�C
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MAP NO:1oyJD PARCEL: CASO ZONING DISTRICT: Historic District yes (-nz
Machine Shop Villaoe ves \no
TYPE OF IMPROVEMENT
PROPOSED USE
Re 'dential
Non- Residential
❑ New Building
One family
❑ Addition
❑ Two or more family
0 Industrial
❑ Alteration
No. of units:
❑ Commercial
Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
Identification Please Type or Print Clearly)
OWNER: Name: Thomas Browne A -�—<Dl. GrLV1 Phone: 978-609-1416 `
Address: 679 South Bradford Street, North Andover, MA 01845 —R
CONTRACTOR Name: Jaime Morin Phone: 508-351-2200
Address: 86 Gardiner Street, Lynn, MA 01905
Supervisor's Construction License: CS -090125
Home Improvement License: 170810
Exp. Date: 10/6/2016
Exp. Date: 12/23/2015
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: 4913.00
Check No.:
NOTE: Persons contracting wit
FEE: $ 60.00
Receipt No.:
contractors do not have access to the guaranty fund
Signature of contractor __��
w
Plans Submitted ❑ Plans Waived.❑ Certified Plotlkan rl Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimnning Pools ❑
Well F1
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Pennanent Dumpster on Site ❑
THE -FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
Signature
CONSERVATION Reviewed on Siqnature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
IS
Ycated a Q-4,1 injSlff et'
C D p rte ment�sig atureldat6, _
Located 384 Osgood Street
eyes �` a T.,.�.�.�._.
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 Penroit 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
10TE: 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)
I ❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
IOTE: 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
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Renewal
byAndersenta-
iw
Renewal by Andersen Corporation License 0170810 (Expires 12123/2015)
Federal Tax in 041-iQ1Rd1a
30 Forbes Rd. Northborough, MA 01532
(509) 351-2200 Fax (508)-986-7072
CUSTOMER WINDOt!1r AND DOOR REMODELING AGREEMENT
Buyer(s) Name Date:
THOMAS BROWNE - JOY BROWNE
NOVEMBER 4., 2015
Buyer(s) Street Address city State Zip Code
679 S BRADFORD ST
NORTH ANDOVER
MA
I 01845 `
Entail Address Home Telephone Number Work/Cell Telephone Number �
JOYWALKERBQG MAI L.COM
978-609-1416
978-688-3800
(Buyer(s) hereby jointly and severally agrees to purchase the goods andlor services of Renewal by Andersen Corporation ("Contractor"), in accordance with
the terms and conditions descried on the front and the reverse of this agreement and on the attached specification sheet(s) (collectively, this "Agreement").
Buyer(s) hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement.
Total .sob Amount $ 4,913
cum Fitranoed $ _ 0
EstEst. Start
Method of Payment
Check/Gash
Deposit Received (33%) S 1,637.67
Deposit at $ 0.00
f0 -t2 weeks
Balance Slav of Job (33%) S 1,637.67
Check B
Balance on Substantial
Completion of Job (33%) $ 1,637.67
At SuDNarfwi
Completion $ 0.00
Est. Install Time
Credit Card
NDfined sheat be CemarMed umiaN are ee>�9ed
_
I -2 days
It credit card is selected, please
see Credit Card Payment form
Buyer(s) agrees and understands that this Agreement constitutes the entire understanding between the parties, and that there aro no verbal understandings
changing or modifying any of the terms of this Agreement. No alteration to or deviation from this Agreement will be valid without the signed, written consent
of both Buyer(s) and Contractor. Buyer(s) hereby acknowledges that Buyar(s) t) has read this Agreement, understands the terns of this Agreement, and has
received a completed, signed and dated copy of this Agreement, Including the two attached Notices of Cancellation, on the date first written above and 2) was
orally informed of Buyer's right to cancel this Agreement. 00 NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Renewal by Andersen Corporation Buyers) Buyer(s)
By: %I%j2lir AP-dlrz, 01 11 k. "*,—
Signature of Consultant Si ure Signature
X MARC FESTA THOMAS BROWNE JOY BROWNE
Printed Name of Consultant Printed Name Pnre d Name
YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.
SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT.
-
----------- - - - - - - - - - - - - - --------------- - - _. _
NOTICE OF CANCIUlATIOICa
NOTICE OF CANCELLATION a
Date. ofTraasaetion 11/4/15 . Ymonayeaneeithis 1 Date of Transaction ill4/15 . Ym may cancel this
transaction, withoutany penalty or obligation, within three business days from the transaction, withoutany penalty or obligation, within time business days from the
above date. if you cancel, any property traded in, any payments made by you under a above date. If you cancel, any property traded In, any payments made by you under
the Contract of Sale, and any negotiable instrument;wonted by you will he t die Contract of Sale, and any negotiable fnstrumem eaeeated by you wail he
returned within 10 days following receipt by the Contractor ("Seller") of ,your t returned within 10 days foltowing receipt by the Contractor ("Seller") of your
cancellation notice, and any security interest arising out of the tsunsactionwill he. t cancellation notice, and any security Interest arising out of the transaction will be
. canceled. If you cancel, you must make available to the Seller at your residence, in t canceled. If you cancel, you must mat, available to the Seller at your residence, In
substantintly as good condition ca when received, any goods delivered to yon under i substantially as good condition m whm received, any goods deUvered to you under
,this Contract or Sale; or you may, it you wish, comply, with the fastrncdons of the t this Contract or Sale; or you may, if you wish, tromply,with the instructions of the
Seller regarding the return shipment of the goods at the Sellers expense and risk. I Seller regarding the return shipment of the goods at the Seller's expense and risk.
tf you do make the goods available to the Seiler and the Seller does not pick them up t If you do make the goods available to the Seller and the Seller does not pick them up
within 20 days of the date of your'Notice of Cancellation, -you may retain or dispose within 20 days of the date of your Notice of Cancellation, you may retainor dispose
of the goods without any further obligation. If you fill to make dee goods available � of the goods withom any further obligation. If you fill tomake the goods available
to the Seller, or if you agree to return the goods to the idler and fall to do so, then to the Seiler, or if you agree to return the goods to the Seller and fait to do so, then
remain liable for, ortnance of all obligations under the Contract. To cancel a
you remaina you remain Uabtefor performance of all obligations under the Contract. 7b cancel
this transaction, man, or deliver a signed and dated copy of this cancellation notice t this transaction, mail or defiver a signed and dated coM of this cancellation notice
or any other written aatice, or send a telegram to ContractortRenewal by Andersen, I or any other written notice, or send a telegram to Contractor. Renewal by Andersen,
30 Forbes Rd. Northborough MA 01532 t 30 Forbes Rd. Northborough, MA 01532.
1 HEREBY CANCEL 7WS TRANSACTION. t HEREBY CANCEL THIS TRANSACTION.
I
I
Y airyaY 6�purre -- Pri`t N— one i soft s4;` a P61 Names Lac
I t
Re■ 4ewal Renewal by Andersen Corporation MA Home Improvement Contractor
byAndersen. 30 Forbes rd Northborough, MA 01532 License #170810 (Expires 12123/2015)
WrrLOew ACPLACEMENt (508) 351-2200 Fax; (508)-986.7072 Federal ID #41-1918413
Window Specification Sheet
]:-iU)'C r�$} Name Window
Of ApCCnit:nt
THOMAS BROWNE
JOY BROWNE
WED, Nov 4. 2015
The buyers) listed above hereby jointly and sewe,nily agree to purchase the goods and/or services listed below, in accordance ]vith the prices and terms described
on the Specification Sheet and the front and the reverse of the accompawing CUSTOM MTiVi 101V AND DOOR REMODELING AGREENIEN7T. of which
Ilse Specification Sheet is part.
WINDOW & DOOR DETAILS
Room # App. App. Appx Exterior/Interlor Color Hardvmre Hardware L,owEa / Grtio Game Glas^,
wtdm w. Wirtdow/Uoor Style Detail Cast Ext-int C�OIGr style Screens Smartsun Gdlltts Sash ted Sash 2 lifts options
Total 1 BAY BOW & BUILD OUT DETAILS
Approx
Stylaf)etal! width/ Approx. Number Framo Window End Cantor LOWEI Roof/ Hardware
Room ...Count S Flankers _ nos le Liter interior IAM Color Grilles sashas sashes Screons Smartcun Soffit Color
SPECIALTY WINDOW DETAILS
Fun/ Approx. Lov,Er Specialty BAY/BOW ADDITIONAL WORK NOTES
Room Count St Insert U.I. smartsun GAlbs Grille Style ExMre Color
_
Hall 201 S rin line Full 1 159 ISmartSun irnw I Colonial WHIOV
ADDLTIONAL WORK DETAILS: Home oumew are p!#ttiak4T home back on the market on anuar 6th. The would like the unit iostaftedbl, that time.
I No Contractor will wrap exterior casings with coil stock color of
2treatments/hardware
✓
Owner is aware that Contractor does not do any painting/staining or removal installation of alarm system or window treatments/hardware. it is the responsibility of
the homeowner to have the alarm system and window treatmentslhaniware removed prior to installation. We make no guarantee as to whether alarms or window
will fit after replacement. Customer is also aware in some cases there will be glass loss. If theca is, the amount will be dependent on the type
of existing windows, type of installation and window style. We make no guarantee as to the amount of glass loss. Customer Is aware and understands any and all
unseen rot is not included in this contract Should any rot be found there will be an additional charge for time and materials unless so stated in this contract.
.t Yec Contractor will insulate, caulk and seal windows with 3-point system to prevent water and air infiltration. Removal and disposal of all job related debris,
windows, doors, storm windows and vacuum rightly included. Upon completion of the job and payment in full, a limited warranty shaft be issued.
! Yes Building Permit--Contractor will secure any and all necessary permits. The fee for the permit(s) Is included in the total contract price.
r, Yes All discounts have been applied to this agreement.
G Yf"S No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment /finance form(s).
It is agmvd and understood by and 1WIN .l•en the pmtie� Ont. this Filveifir.rtion Shfet, illong with the CI.;STOM 1yfN1)OW XND DOOR RrATODrLTNG ACREFI' 'IFN7r emwituten lite entitr
undemanding lwtwcett the parties and there are tut �rrbal understandings rhanging or modiMng any of the. terms. This Six-cirwation Sherr may not be. changrd or its terra modified or snded in
any Hny unless surh elands •dm in writing and signed by both the lhryeres) and Contractor. Buverls) hereby acknowledge that &nler(s) has mad this Spftiftcmion Sheet..
Renewal by Andersen Corporation 13uyr�s; !;oyer{s} ,p
e, 1141/G Afy'!L
Signature of Consultant s4nature gignature
MARC FESTA THOMAS BROWNE JOY BROWNE
Print Name of Consultant Print Name Print Name
WIN 0o WS•0 a 0115
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Andersen' NFRC Certified Total Unit Performance (con0auad)
Andegsorr Product Gi-ss Type U•Factm' SHGCv Vit
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lip Law E4 Sm elsua w/Gr91es 0.28 0.21 0.49 `�+
lipid-E4y_ _ 02_8033 0.58
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... ---._...__-_..-___.._._.-.-_..._-..---..0.0.00.-...__....
033
0-16
0.23
_.-
Fymroh Door
1[P Law -E4 San with Grilles
035
0.14
0.20
-
_-_--0..000._.._._.
Ira 1.911,154 Smmmun
0.32
-Cl-r
0.17
6.37
-.
..
lip Low -E4 SmEaSon w/GdUez.
.......... .-0..000_._.....-___
0-34
0.15
032
--
lip Low -114
_
038_.._.
_
...- ...
RP law -E4 V !
_--__9il
_0.33
- 033 ^
_D2_7_
- 021
1034
Flood French Door • -
-
---._ HP Ine E4 Sun
033
0.14
0.21
-
SfdaHgln
N_P_law-E•4Sam with _Gdlles
_ 0.34
0.13
0.919•----
- __._ HPLarE45mad5un
D.32
0.15
0.34
-
HP Lor -E4 SmarlSunw/Grilles
0.33
014
030
-
IW Law -E4
0.32
925
OA 1
-
IfLON-Mwith GdOes
033
O.D.
6,37
Fixed Trmrsom
-_-.
I11' Low -FA Sun
0.32.
0.15
013
-
French Door
lip Luff -E4 Sun with Grilles
0.33
0.14_
0.20
-
-
HP Law•EI SrrarlSun
_-
032
016
0.31
-
UP Luv E4 SmarlSuf w/Gillies
032
OAG
�
.---
lip Low -E4
020
00..93
0.4_4_ --•--
-
-
_
--_ -'If Lula-E4 with Wes-
_0.35
0.35
0.23 _-
038
----
_
0.24
Folding Door
- _----.HPlaa•T51Sun---0.35
_-0.16
HP Lax -E4 Sure withW.s
0.36
0.14
0.21
-
00.00_
....._- UPImhElSnicnSun
.... -._-._
634
017
0.39
-
- _ T
---._-...... _.._.....-......_..
lip Lou -E4 Smagun w/rAlles
-
__..-_.
_ 0.36
-----__._._._
OAS
- 0.34___
-.......
� -
• Fm NMC cenfried total unit parfirmance on units with capillary broathertabes for high eitituth-, pl3ase visit and rsanwindaus.cam.
•-high-Parfamlarrce'tow•F4" (IIP Lnwf.4),'HiFh-Perfmraamce'I aw FQ'SmartSun'(HPlow-T-4SmartSim)and 'iilgh-Parfarmance Inor -E4' Sun' (lip Low-E4Sun) amAnder^nlrademorlrs fnr'Law-Fplass.
' U-Factordefnealhoamaantoffic3t tnssthrough the mtel unit in BTU/hrs0.10F.The [Oyler the value, the loss heatis luslthrough the andre product while. valuestepresent nun trmpmed gicc3. Uceaftempered glasscan
tner5no U-Factar radnps. See ender..nwindmvs.com far spoeffic performance values. Door values represent tempered glass.
' Saler Heat Gain CocMchmi (SIIGC) defines Ore fraction of solar radialfon admitted through the gl::ss boN directly hensmltlad and absdihed and subseq3ently released inward. The lower the valla, the lees heat is transntdted
through the product.
' VIsIbleTransmiltmme (VI) measures haw much fight comes [hough a product ()ass and frame). The higto; Ute value, from 0 to 1, the more dcylEght the product Ir.La in aver the pladucCs lata) Unit area. VL -i Uta Iransmfliance
is measured over the 390 to 760 nanomefr.r panian of dm sntaf speclmm.
• NFIIC 1811n8s are based an modelingby a third as validated by an independent test fab in compliance whir NFRC propnm and procedural Terplfrements.
•ihizdata fsaecurteasofDocendip.0f10.[)notuangoingleraduclchanges, updated trstresultsarnewindushysiandardsorrepuimmenls,thisdatamaychangeavrrthn RnDnpsamrnrsfusspeaftedbyNnICfar
testing and certification. Rnungs may vary depending an mi of tempered glass, different grille opUmlr, plass for Pit�h,Mltudes, etc.
• PasslveSun" plass values are available nt16ne ai ande.r.,enwlndu'as. corn
277
PRODUCT PERFORMANCE
Anuuersen' il'r" , C Cartilled Total Unit Perfermance (CdOmira)
kwomen, pmdw
GIM3 Type
11RLcmrt
sv.ecf
VP
200 Swim
ae,fWdpaw-
0.45
0.50
0.63
Ck_T Duel pale wlih GdK:
OAS
0.!d
ass
_
a wh h
law-:
a30
032
095
_
Doubleiiang Wiadtwr
Iaw{wp CAF,
030
0.V
OA3
HP taw -E4 SMWISm
030
am
0.4^
HP 6;i4 Sms S. We lks
0.31
0.19
0-43
.:
_ G',1rDMPcn
0.45
0.6.1
0.64
-
OWWRioe'
Ckar_Ou:I Pmre vM fides
01�
0.54
0.57_
--
w
OaeNe-Nunslltndm
lm"
0.90
O a2
658
LatfE am tidies
021
0-:9
O.M
- -
CI rDuidP3tm
0.44
0.63
also
-
pawa�p'
(h Ar DuW P -m -b 6x1165
DA4
057
0.69
Transom Window
LO*E
0.27
O,S4
0.58
_:-•�
-.-_-
l wEWID6410
0.27
031
0.52
`"
s
Ck3rDulPam
0.45
OM
033
-
CW. -r WJFJ pn-I fft edlkm
0.45
a=ll
058
109.6
am
am
D55
;7
tlidiag Wfndew
lan•E ugh Ulm
L30
OZq
0.49
��
J
lbw-ES®i Sw
030
021
x49
3
lax-E9u=tSLmw* 0m
031
x19
a49
..'.�°
L7rirMWPete
0.43
ab1
a.0
Cle-r coral Pena wOh 136: �;
(L,!3
_
QM
05,
hmd, Treason,
_ L*4
0.26
03z
am
Chde Top"' VWadhw
_
Ln E tdlh Gdlse
0.1-9
a30
a-%
_y
1
Lw -C- SmartSen
01Y
Dm
asi
'
1
Lew `9mnt5m a8h colts
0.77
0.40
aA5
Cks•Dwei Pem
0.44
0.61
0.84
Cker00:4P9eeaft fallee
0.45
0.53
0.56
-
iaw
056
Natmiine'
LavE tft GsR',i
0.90
am
0.40
841dleg Patio Daars
LawE 9Cn
am
0.20
0.31
• Ln ESmwilLGalks
031
0.18
02P
Lea•ESm Fen
038
alt
0.30
Leet E 9mad5m wdh 6d1's
0.30
119
am
�
1
Qwnhw Pere
0.43
0.81
GL54
-
_ CImr Dual Pero veA Gtlir-
0.44
x54
0.66
-
LMIE
0.28
032
OM
Pa_na•Shtdd'
Imr•i ttdh GdD,:5
030
029
0.48
Clldm,; Paan Dome
LmwESm
0.29
0.19
0.30
LM -E AM am 6Ales
0.40
0.17
0.27,
lasrESmavSm
027
022
050
Lmw♦: SnsrSeo uft Qm-
D29
019
0.44
CW -r am Pane
M43
91:5
0.47
C1'^r0help&WVMGAk:
0.43
039
1140
_
Lbw{
0.3'?
0.24
DA1
Hingri inawittg
1nw-E wM 6d63
093
021
0.-3
-
ma Dmn.
UN -E San
D32
415
O ZI
A
IN
LnwfSudad0l9i
034
0.13
IL19
Loa ESmmt&n
032
au
r
�_
law -E 9ocrSm MDL dam
0.33
_0.16
0.14
031
-
The Comnwuwealth of trIassachinees
— - .Depmomit of Xndustrkd accidents
Cyrice of1'nvestit<atiow
600 Flaskington Street
Boston,117iA 02111
A
wwwmmgov/diia
Workers' CAmpensation Insunace Afiituavii: Builders/Contractors/ElectriciansM lumbers
Applicant_ If mr-don fleas,& w'rintpi-My
Name(Busine-.s/0rganirationilndividual): RENEWAL. BY ANDERSEN _
Address: 30 FORBES ROAD
City/State/Zip: NORTHBORO,MA 01532 Phone. 4: 508_3512200
Are you an employer? Check the appropriate box:
1.' 1 4. [� 1 am a �onowor and I
Type of project (required).
am a anployer with30 `
employees (frill and/or part-titnej.*
general
have hired the sub -contractors
b, ❑ New wnstructi�on.
7.Remodeling
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. t
ship and have no employees
These sub-contraLicrs have
S. ❑ Demolition
working for me in any capacity.
insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
9. ❑ Hailding addition
[Ilio workers' comp.
required.]
officers gave exercised their
l0.0 Flectri"-a1 repairs or additions
3. ❑ 1 am a homeowner doing all work
right of w-emption per .MOL
I I .[] Plumbing repairs or additions
myself [No workers' comp.
c. 15`, 61(4), and we have no
110 Roof mmirs
insurance required.] t
emplovees. [No workers'
1311 Cither
comp. insurance required.]
—
* nny appttc ant UM cMCKS nor rt 1 must a,sr till OUT tM section Maw snow their workers' compensation policy information.
t Homeowners who submit this affidavit indicaking dreg are doing all work and lien hire outside cwnlivAors must sWki it a hm affiidavit'n ti,;ating such
+Contractors that cnecic this box must -Za hed an additional meet showing the name of the sub oontraaors and thm workers' comp, policy inf;imation.
lam an employer that is providPng workers' compensation insarance for mV employees. Below is Mepolley andjob sire
information.
Insurance Company Name: OLD REPUBLIC INS, CO. -_
Policy # or Self ins. Lic. #: M C 305437,QQ____ _
Job Site Address: 679 South Bradford Street
lxpiration Date: _1001-16
-C'ity/State,"Zip:NQdb,Andoyer. MA 01845
Attach a copy of the workers' compensation policy declaration page (showing the pol'cy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be :orwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do here y jrto u or the pains and penalties of perjury that the Wormarion provided above is true and correct
Phone 508-351-2200
Official use only. Do not write in this area, to be convfered by c4 or town offleiat
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector 5. plumbing Inspector
6. Other
Contact Person: Phone M
s
ANDECOR-01 YADAVYO
A'14- "/j1KL1W CEff IMA i E OF LIABUTi Y IMSURANCE
DATE(MMIDDIYYYY)
111!112015
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(les) 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
Willis of Minnesota, Inc.
C/o 26 Century Blvd
P.O. Box 305191
Nashville, TN 37230-6191
ONTANAME: CT Willis Certificate Center
PHONE
AIC No.
o E.6: (877) 945-7378 FAX No)*. (888) 467-2378
p pR ; Cerdf`rca willis.com
INSURERS) AFFORDING COVERAGE NAIC k
LIMITS
INSURER A:Old Republic Insurance Company 24147
INSURED
INSURER B
INSURERC;
Renewal by Andersen LLC
30 Forbes Road
Northborough, MA 01532
INSURER D:
INSURER E:
INSURER F:
MED EXP (Any one person) $ 10,00
. rwnwr=n.
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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSR
LTR
TYPE OF INSURANCE
ADDL
INSD
SUOR
WVD
POLICY NUMBER
POLICY EFF
MMIDD
POUCY EXP
MMIDDIYYYY
LIMITS
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS40ME � OCCUR
c,AWZY 305440
10101/2015
10/01/2016
EACH OCCURRENCE $ 1,000,0001
PREMISES K oocurrencel $ 500,000
MED EXP (Any one person) $ 10,00
PERSONAL & ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
X POLICY r ECT LOC
GENERAL AGGREGATE $ 4,000,0()
PRODUCTS - COMPlOP AGG S 4,000,00
OTHER:
$
OWI aEeD SIN KE LIMIT nt)g 5,000,000
A
AUTOMOBILE
X
LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS NON -OWNED
AUTOS
MWTB 305438
10/01/2015
10/01/2016
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
D
Per ecra lent $
$
UMBRELLALIAR
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
A
DED RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNERIEXECUTIVE Y�IN�
OFFICERIMEMBEREXCLUDED? L==J
(Mandatory NH)
nder
DESb CRIPTON OF OPERATIONS below
NIA
MWC30543700
10/01/2015
1010112016
$
X STATUTE ER
E. L. EACH ACCIDENT $ 1,DOO,000
E.L. DISEASE - EA EMPLOYE $ 1,000,000
EL. DISEASE -POLICY LIMIT $ 1,000,00
DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarim Schedule, maybe attached if more apace is required)
TE HOLDER
of
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
CW �- b !
C 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
it
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor ;), r
License: CS090125 f '
JADM L MORIN = �',,. :,
86 GARDIRM ST
LYNN MA 01905
Expiration
Commissioner 10/06/2016
C�l�e �o�reontusa�b� n�C-acs�ua�Lt �,
Me of L"oaasmer Afhirs & Business tlesufa6on
tint=
lwqwvmmwt c01Im<'YOR
!3 SupplemioKtr
RENEWAL BY ANORR9WOOAjbOMTjON
104 Ons STGtEEt
WRTH90ROUCH, MA 01532 iladernecr try [[�i
' u}
Location
No.6;2�7,0* Date /5--
Check'#9
2�9707
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $�2�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $--,
Building Inspector