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HomeMy WebLinkAboutBuilding Permit #732-13 - 68 INNIS STREET 5/6/2013TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION . Permit NO: �' Date Received Date Issued: Yi IMPORTANT: Applicant must complete all items on this page LOCATION fY Print PROPERT T ER „j ok , Tt io Print 100 Year Old Structure yes no MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes. no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial VRepair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: ICt m6ofl `�1G1S �r�¢ fG.r�nn Ghn.l /�G�s%�,: L✓r�� itJG�l, %���� Sia��ri G'� Identification Please Type or Print Clearly) OWNER: Name: 5�4., I �o-c> ib Phone: '4t E`/" " 11-3 I Address: �,€ r;,, ,,! � 55 f V CONTRACTOR Name: �t� �... pn, r t, Phone: -79/ Address: /'5 Rt/ .c&- k..,-, i, -*+e 0/3' &V Supervisor's Construction License: G FOcp-- Exp. Date: 114, 3 1, Home Improvement License: Date: /0 A,7 / 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: $ YIc,0 FEE: $ Check No.: Receipt No.:`1 NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner der ` Signature of.contractor Plans Submitted ❑ Plans Waived 11 Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ . _ Swimming Pools 0 - Well ❑ 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 COMMENTS HEALTH e COMMENTS Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition N Planning Board Decision: Conservation Decision: Comments ning Decision/receipt submitted yes Water & Sewer Connection/Signature & Date Driveway Permit DPW Tow, ]Engineer: Signature: FIRE DEPARTMENt Temp Dumpster on site yes Located at 124 Mair Street Fire Department signatureldate COMMENTS Located 384 Osgood Street no 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 ti0n&' DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A -F and G min.$10041000 fine NOTES and DATA — (For department use ® Notified for pickup - Date F E s Doe.Building Permit Revised 2010 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/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 app:.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:rted with the building application Doc: Doc.Bui?ding Permit Revised 2012 Location No./. 2 - /.j Check #_ / P 26354 Date TOWN OF NORTH ANDOVER 1 Certificate of Occupancy $ Building/Frame Permit Fee $.�� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector J z Oz C \ O 0 LL d Ln U O_ Q)LL N w O G ZLL z m 'ZS 3 i 7 K 0 ) C U LL o W z = d t 7 d' <O LL 0 u z Q u J LL! ,C j d' U N N �p - ii O a z t O d' C U- z LU 0. LU LU d' LL C m O z N N N O 0 cn LU z 2 Z cfl Z W w X LLIH W CL 2 E 0 0 Z N Q AI, 01- E .- W Q •E W W CL 0 �+ 0 cao CL a CL co 0 V J 0 .a .0'0 CDU) Z � C-) cU cc i C C O p + r- 0 •� i a+ cc � Q O, "NN U) cD C L Q' MW 7• 0 E cm NLp• � - Cc o (� L " 3 �Lm %1 a N mc C d N N O 'a > -U 4 a N CO) t t E o O o CL ..s N p o C �cm LL N3 c c � H 'a Qpm c 0 .y oL 1— _ O E p cm = .O Q L L iC -0 _ F- O Q as '5 to 2 CO N N W IL p 'a +�+ O O O ' N C O N 'E p .Q O w W L r- Q 0 d O fn CL O >;�, C J N = o 0 2 Z cfl Z W w X LLIH W CL 2 E 0 0 Z N Q AI, 01- E .- W Q •E W W CL 0 �+ 0 cao CL a CL co 0 V J 0 .a .0'0 CDU) Z � C-) cU cc i en.t This form satisfies all basic requirements of theslate's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard Ianguage to protect homeowners. Seck Iegal advice if necessary. Any person, planning home improvements should first obtain a copy of "A Massachusetts Consumer Guide to Home Improvemem" befoie agreeingto any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer information Hotline at 617-973-8787 or 1-888-283-3157 or on our website. ®ID.00R'ne1' ®TCffiauon Street Address (do not use aPost Office ;Box /address) City/Town State Zip Code Daytime Phone Evening Phone Address .Conixactor Z tt-n c.._ 1-onuaccor/ salesperson/ OwnerName Bpsiness Address (must include.a street address) Clty/Town State Zip Code Business Phone I ederal Employer ID or S.S. law retpuires that most7iomo _ r " "" `­""""` %us. "'umoer . improvement confractors Iuavc a Valid ragistratian number The Contractor agrees to do the following worIc for the Homeowner: (Describe in detail the worlcto completed, specifying the type, brand, and grade of materials to be used, use additional she ifnecessarv) Required Permits - The follgwing building permits are required and will be secured by the .contractor as•the homeowner's agent: (Owners who secure their Own peranlits:wM be excluded from the Guaranty Fund provisions of MGL chapter 142A.) date Proposed Start and Completion schedule - The following schedule will be adhered to unless circumstances beyond the contractor's control arise _ &/ 3 Date when contractor will begin contracted work. &1/_/L/1 _SDate when contracted work will be substantially completed. Total Contract Price and Payment Schedule f� The Contractor agrees to perform the work, :Cornish the material and labor specified above for the total sum of. T e) Payments will be made according to the following schedule: $_ZLE cy upon signing contract (not to exceed 1/3 ofthe total contract price or the cost of special order items, whichever is greater) $ Z dG. byG l_�I _ or upon completion of rh�/ w �°'S. k----. by / / or upon completion of upon completion ofthe contract. (Law forbids demanding full payment until. contract is comps ted to both party's satisfaction) . The following material/equipment must be special $L_ to be paid for ordered before the contractedworlc begins in order J� to meet the completion schedule.(.ra°) $ to be paid for INT07TS: M) including all mance charges ; i..i.) Lair requires that any deposit or down payment required by the contractor before work begins may not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. subcontractors -The contractor agrees to be solely responsible forcompletion of the work described regardless of the actions ofeanythirdontraet Party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for aterials and laborunder this a Bement Contract Acceptance - Upon signing, this document becomes abinding contract under law. Unless otherwise noted within this docume4 contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautiothe ns and notices carefully before signing this contract. • • Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear., aloe sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered withDirector the -10 P rlc olmome Improvement Contractor Registration. You may inquire about contractor registration by waiting to the Director at 10 ParlcPlaza, Room 5170, 13oston, MA .02116 or by calling 617-973-8787 or 888-283-3757. Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can. confnm coverage, or aslc to see a copy of a "proof of insurance' document. o ISnow your rights and responsibilities. Read the Important Information on the reverse side of ibis form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor contractor's normalplace of business, provided you notify thethird business s day following he sigwriting at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the tning of this agreement. Seethe attached notice of cancellation form for an explanation of this right. DO NOT'SIGN TMS CONTRACT IT TBERE .ARE ANy ISLAMC SPACES!!! Two identical copies of the contract must be completed and signed. One copy should go to the homeovmer. The other copy shotddbe Icept by the contractor. Romeo 's Signature 'Date Contr or's Signature G. Date Contractor .Arbitrit ion The Home Impiovement Contractor Law provides homeowners with the right to initiate an arbitration action. (as an 'alternative to court action) if they have a dispute with a contractor. The same right is not automatically aifordedto a contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner.in court unless both parties agree to the optional clause provided below. This clause would give the contractor the in right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract; the contractor may submit the dispute to a private arbitration firm which has been approved 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 7n Massachusetts General Laws, chapter 142A.. Homeowner's Signature Contractor's Signature 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 alterative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner'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 exchtded :from alt Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner.. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold -in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree maybe added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If You have questions about your consumer/homeowner 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 exhibits and referenced documents have been attached. Parties are 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 contract with attachments is to be given to the owner and the other kept by the contractor. Any modification 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 specified on the.payment schedule in cases where the homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself to be financially insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted worts. Withdrawal of fiends from said -account would require the signatures of both parties. Additional Information. .If you. have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the 0CABRwebsite at 1�://wwrv.rrlass ,gov/ocabr/ if you want to very the registration of a contractor or if you have questions or nbed additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and -Business Regulation 10 ParkPlaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the HCC website at bM://wvAv.inass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: . htft3 /db. state.ma.usAaoin! rovei-nent/IicemeeIigLg For assistance with informal mediation of disputes or to regisi er formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General 617-727-8400 .AND/OR Better Business Bureau 508-652-4.800, 508-755-2548 or 413-734-3114• Version 2.1-11/22/2010 The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print ]Legibly Name (Business/Organization/Individual): ?,TL L t`, t Address: J� �a Ye,,d RvC City/State/Zip: Gtg Phone Are you an employer? Check the appropriate box: Typo of project (required): 1. lel I am a employer with ! 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. El am a sole proprietor or partner- have hired the sub -contractors 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 10.0 Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their 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 ] ired. re q u employees. [No workers' 13. Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors 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 thepolicy and job site information. Insurance Company Name: L r 3 Lys; ley4* I Policy # or Self -ins. Lic. #: Expiration Date: 3�3� Job Site Address: & 8' ,,, 7 t V X' 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 requiredunder 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 forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Simature• G�'��'"�Date: 5��3 Phone #: 7k7-- yaII 6,01 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): I. 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 ofpublic 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 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 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 bum 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: The Conumamalth ofMassachuspits Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel, # 617-72.7"4900 ext 406 or 1-877 MASS.A.k'B Revised 5-26-05 Fax # 617-727-7749 wWwanass,govfdza PJZINCO-03 BSULLIVAN '4� R�. CERTIFICATE OF LIABILITY INSURANCE DAT3/612 D/YYYY) L 3/6/2013 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 endorsemengs). PRODUCER Salem Five Insurance Services, LLC 445 Main Street Woburn, MA 01801 CONTACT NAME: PHONE X AIC No FAExt : (781) 933-3100 AIC, No): (781) 933-9048 ADDRILESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Liberty Mutual Insurance 0023 EACH OCCURRENCE $ INSURED INSURER B: INSURER C: PJZ Inc INSURER D: PO Box 1167 Lynnfield, MA 01940 INSURER E: INSURER F: AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON-OWNEDPROPERTY HIRED AUTOS AUTOS 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 CONTRACTOR 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 LTR TYPE OF INSURANCEADDLSUBR INSR WVD POLICY NUMBER POLICY EFF MM/DD POLICY EXP MWD LIMITS GENERAL LIABILITY MERCIAL GENERAL LIABILITY CLAIMS -MADE D OCCUR it EACH OCCURRENCE $ AMA E PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC JECT PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON-OWNEDPROPERTY HIRED AUTOS AUTOS COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ DAMAGE CCIDENT $ PER ACCIDENT) UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATIONX AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICERIMEMBER EXCLUDED? F7 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WC231S339159022 3/3/2013 3/3/2014 WC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT I $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required) NS3Ci1112Ley 1\13iLei 1110IR V Fl6t X4995 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 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 11M Massachusetts - Department of Public Safety V-1 Board of Building Regulations and Standards Construction Supenisor License: CS -0.08002 PETER J ZAiv)`1� ter. P.O. BOX 116' Lynnfield M� •01940 Expiration Commissioner 11/03/2013 A Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration -- - Registration: 132021 Type: Private Corporation Expiration: 10/27/2014 Tr# 232917 P J ZINC. PETER ZANNI 25 PILLINGS POND RD . - LYNNFIELD, MA 01940 `Update Address and return card. Mark reason for change. Address 0 Renewal [] Employment Lost Card DPS -CAI is 50M -04/04-G101216 2. p� ` fC r Affairs o�✓js Regulation License or registration valid for individul use only �\ Office of Consumer Affairs & Bu'smess Regulation g Y VFJ'l HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 432021Type: Office of Consumer Affairs and Business Regulation Expiration: 10/27/2014 Private Corporation10 Park Plaza -Suite 5170 Boston, MA 02116 PETER ZANNI 25 PILLINGS POND RD LYNNFIELD MA 01940•7"= - _- Undersecretary nt valid withrort cianatnrP