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HomeMy WebLinkAboutBuilding Permit #488-16 - 684 MASSACHUSETTS AVENUE 10/16/2015BUILDING PERMIT TOWN OF NORTH ANDOVER r APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received Date lssuedJ*V4-r IMPORTANT: Applicant must complete all items on this page LOCATION cv�5 H M Ci t A-ge— • Norin Ando,,gC Y Print PROPERTY OWNER N i c�t� arNO Mcg Pin Print 100 Year Structure yes MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition ❑ Two or more family ❑ Industrial )lAlteration No. of units: ❑ Commercial 111 Repair, replacement 0 Assessory Bldg ❑ Others: ❑ Demolition ❑ Other �: Septic 0 Well i ��Flo°otlplain`Wet1`and5 ❑ Watershed'District j r . 6 ❑."\Nater/S`ewe� � - _ _ - _ -- DESCRIPTION OF WORK T BE PFKI-UKM U: NO a Identification - OWNER: Name: Address: (025``1 lvlo: -,� MEQ Contractor Name: Email: W M < Address: I (�5 Supervisor's Construction License: Home Improvement License: -7 q a La ARCHITECT/ENGINEE or Print Clearly L.Q_ )Phor 1 Exp. Date: / 7->�/ 1 L.0 . Date: %/) D Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $c� J , 0 9 q ' 00 FEE: $i Check No.: - Receipt No.: r d not have access to h ran and NOTE: Persons contracting with unregistered contractors o �gu�i ty f • • P Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL DPW Town Engineer: -Signature: Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales . ❑ Private (septic tank, etc. ❑ Permanent Dempster on Site ❑ , THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m 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 Planning Board Decision: Comments Conservation Decision: Comm Water & Sewer Connection/Signature Date Driveway Permit DPW Town Engineer: -Signature: Located 384 Osgood Street p�,� IVIEN� ^7 a5 v3'. 'z r 4d "4 �; _,. ,• .a. i1REDEPAR� i rTenp�s®umpster�on�site yes�.�o `'.�'�...;v;* Lo acedpbjat124Mam SfreeerFll ireDa m nt sign u ra.. r •f=] .#a.��+ ' a ' Fr Y � � Y [ r COMMENThS#_ •. r .saa_s _ ... K'' i 4%.r's �.'~� ,_,u� .al. _� Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. fl.:, ELECTRICAL: Movement of Meter location, avast or service drop requires approval of Electrical Inspector Yes No DANGER•ZONE LITERATURE: Yes MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department ease) I ® Notified for pickup Call Email Date Time Contact Name Doc.Bnilding Pennit Revised 2014 ZIM 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 OTE: 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 OTE: 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 2012 IECC Energy code Engineering Affidavits for Engineered products TOTE: 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 Location No. Date f _ Ae'CERTIFICATE OF LIABILITY INSURANCE DATE (MMIoom-y ) 01/11/2012 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 - 1-612-333-3323 Hays Companies CONTACT Joaelle Hargrove or Katie Psimos NAME: PHONEo Ez 612-333-3323 AX;No;612-373-7270 AI N E-MAIL ADDRESS: BD South Bth Street PRODUCER CUSTOMERI D Suite .700 Minneapolis, MN 55402 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA: OLD REPiIBLIC� INS CO 24147 INSURER B; NATIONAL UNION FIRE INS CO OR PITTS 19445 Renewal By Andersen Corporation INSURER C: 1D4 Otis Street INSURER D Northborough., MA 01532 INS URER E -INSURER F, rrr•vcoAr-cc r•CDTICl/"A.TC AIIINMRGIi• 25114167 KrVIS1UN NUNIrSCK: 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 LTR. TYPE OF INSURANCE ADDLSUBR - POLICY.EFF POLICY EXP 5 POLICY NUMBER MM/Do MMIDD LIMBS A GENERAL LIABILITY M%ZY 59313 1.0/01/1 10/01/12 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED Ea occurrence $ 500,000 -PREMISES MED EXP (Anyone person) $ 10, 000 CLAIMS -MADE a OCCUR PERSONAL &ADV INJURY. $ 1,000,000 GENERAL AGGREGATE S 4,000,0DO GEN'LAGGREGATE LIMIT.APPUESPER. - COMP/OP AGG S 3,000,000 -PRODUCTS S ' 'X POLICY PRO- JECT F7'LOC A AUTOM091LE LIABILITY . MA'TB 21377 10/01/1 10/01/12 COMBINED SINGLE LIMIT S 3,000,000 (Ea accident) X ANY AUTO BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ ALL OWNED AUTOS PROPERTY DAMAGE (Per accident) S - X SCHEDULED AUTOS HIRED AUTOS _ S X NON-OWNED'AUTOS $ B X. UMBRELLA.LIAB X OCCUR 25030519 10 .EACH OCCURRENCE $ 25,000,000 AGGREGATE S 25, D00, 00D EXCESS LtAB CLAIMS -MADE DEDUCTIBLE S $ X RETENTION $ 25,000 - A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNERIEXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? N (Mandatory in NH) N / A MFTC 117140 00 .10/01/1 10/01/12 X WCSTATII OTH E -L EACH ACCIDENT $ 1, 000, DOD E.LDISEASE- EAEMPLO $ 1., DDD, DOD E.L. DISEASE - POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 1 Di, Additional Remarks Schedule, if more space is required) Evidence of Insurance. GtK I IFiGA I t HLJLL1tK .KlV4CLL �I rVl\ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE .EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE t kDrimos © 1988-2D09 ACORD CORPORATION. All rights reserved. ACORD 25,(2009/09) The ACORD name and Logo are registerea marcs DT .A�,LJ cu. 25114267 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 3509.00 m $ - $ 421.19 Plumbing Fee $ 52.65 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 52.65 Total fees collected $ 626.49 684 Mass Avenue 488-2016 on 10/16/2015 Redo Roof n I W �•� WVA E � o z O C o C W Q N •E CD V � L o CL a. C- c Q O = � •a .Q O F; C Z V 0 CLN •C �F+ C U) 0 0 H O z oc J V LV W Q W CWC d H N U G Z Z LLI LL Z D. Z a D_Z Z U W m _ 0 C Q W J I - m J LL C E J v N m C d W a 6v j[ V7 (6 4J v i Z C N O Q :3 :3 C :3 C :3 C :3 C L (n LL d' U LL Of LL D' Ln LL CC LL m {% (n E � o z O C o C W Q N •E CD V � L o CL a. C- c Q O = � •a .Q O F; C Z V 0 CLN •C �F+ C U) 0 William McKay Construction 18 Academy Avenue Bradford, MA 01835 Phone: (978) 361-6402 Email: wmc3cons@msn.com Find us on Facebook! PROPOSAL 8/18/15 Project name: Nicole Peterson 684 Mass Ave. North Andover, MA 01845 _Scope of Work: • Provide plans for the building department. • Demolition of existing roof. • Extend existing dorma at both sides of house leaving 18" cheek of roof to the new sidewalls. • Fully extend Jorma one bedroom side only. • Separate existing baby's room to create two bedrooms. • Add all electrical outlets to meet code. o Install four new windows. • Supply and Install electrical per code. • Supply and Install insulation per code. • install new roofing on shed dorma only as well as flashings. • Supply and Install new siding and trim on entire second floor. *Note this may not match existing ,if so this may be an extra cost.* • Apply 1/2" sheetrock and mud and tape on all interior changes. • Install all standing and running trim. • Patch in hardwood floor in expanded areas. *Rooms will have to be sanded and refinished in entirety in order to match existing.* • All work will be in a clean and timely manner. • All debris will be disposed of in daily in a dumpster supplied by W McKay Construction LLC. Total Price of above Scope of Work: $35,099.00 Please note that adding an extra bedroom may require updating existing smoke detectors that need to be hardwired by the NAFD. if this occurs it will result in an extra cost. All materials, labor, plans, and permit fees are included in this quote except for Paint which will be handled by the Clients. All aspects of this Proiect including Subcontractors materials and otherwise will be supplied and handled by W WILLIAM MCKAY CONSTRUCTION LLC. 18 Academy Ave Haverhill, MA 01835 # 978-361-6402 CONSTRUCTION CONTRACT This Construction Contract (hereinafter the "Contract") is hereby made on 8/18115 by and between Nicole Peterson (hereinafter "Client) and W McKay Construction LLC of 18 Academy Avenue, Haverhill, MA 01835 (hereinafter "Contractor") collectively referred to herein as the "Parties". ARTICLE 1 A. Contractor shall provide the following Construction Services (the "Project'), as agreed to in a signed Proposal related to said scope. B. Client engages Contractor and Contractor agrees to provide to Client all necessary service , materials, and labor necessary for the completion of the Project including, but not limited to, all building and construction materials outlined in the signed scope. Material estimate and all necessary tools and machinery needed for Project completion. All construction materials should be new and of the highest quality, unless previously specified by the Client. C. Contractor shall provide the construction services for the Project at the property located at 684 Mass Ave. , North Andover, MA 01845. D. The Contract shall be comprised of the following: this Construction Contract, Plans, Specifications, Addenda, Drawings, Photos, Proposal, materials estimate if applicable all signed and witnessed, all of which are attached hereto and are a part of this Contract as exhibits. ARTICLE it A. Contractor will be scheduled once deposit is received. B. In the event that Client and Contractor agree on changes to the Project after this Contract is executed, the Parties will agree to new time deadlines that are reasonable in light of the modifications and that schedule change will be signed and witnessed and become a part of this Contract. rtA ARTICLE ill A. In consideration of the performance of this Contract, Client agrees to pay Contractor the sum of $35,099.00 (the "Contract Price") on the following payment schedule for the services. Contractor shall receive a 50% deposit of $ 17,549-50 before the start of the Project to be used for initial material purchases, etc.. Thereafter, Progress payments shall be made as reflected progression of the Contractor's services continue through to the completion. B. After receiving notification by Contractor of each stage of completion, Client or its designee will inspect and approve the work or request any necessary adjustments to same. Client agrees to make payments to Contractor after approving work. Payment shall only be adjusted upon the mutual consent of both Parties if due to unseen events or the parameters of the work are expended materially beyond the terms of the Contract. This Contract and associated fees will be modified accordingly in the form of Extra Work Orders which once signed and witnessed to shall become a part of this Contract. ARTICLE IV A. All changes or modifications to the work ordered by Client must be made in writing, with appropriate adjustments made to total payment and payment schedule. The approval of both Parties shall be required in the form of an Extra Work Order for substantial Project changes as these changes will effect date of completion, Project price, and notifications of these changes must be made in a timely manner. B. If these changes should require additional expense to Contractor, Contractor must make a claim for increase in payment, in writing to Client in a timely manner. Client must approve this claim for increase in writing prior to any changes to the work, Project or schedule. All such documents relating to changes to this Project must be signed and witnessed to and will become a part of this Contract. ARTICLE V A. If Contractor is delayed from completing required work due too unavoidable casualties, Client shall grant Contractor an extension for the completion of work equal to the delay. Unavoidable casualties include, but are not limited to, fire, flood or natural disasters, delayed acquisition of materials or material delivery, and negligence or non- payment on the part of the Client. 10 same against any and all claims, losses, liabilities, damages, and expenses, including legal fees, fines, judgments, settlement amounts all made in connection with , or arising from errors in any representation or warranty made by Contractor under this Contract, any breach of the Contract by Contractor, or any omission or negligent act or error by Contractor in connection with this Contract, provided by such negligent act, omission, or error was not done at the direction of Client. ARTICLE X A. Contractor is responsible for insurance to protect against any property damage, bodily injury, death, or other claims for damages that may result from the commission of the work, including general liability insurance and workers compensation insurance for its employees and/or subcontractors. Contactor will supply Client with said Certificates of Insurance before the Project begins. B. COVERAGES: (Apply only to actual work performed as set forth in contract) 1. Structure: For a period of one year after the date of completion, the floors, ceilings, walls and other internal structural components of the dwelling, which are not covered by other parts of this Limited Warranty, will be free of substantial defects in materials or workmanship. 2. Systems: For a period of one year after the date of possession, the plumbing, heating and electric wiring systems will be free of substantial defects in materials or workmanship. 3. Roof: For a period of one (1) year after the date of roof installation, the roof will be free of leaks caused by defects in materials or workmanship, but not those caused by ice back-up. C. EXCLUSIONS FROM COVERAGE: We specifically do not assume responsibility for any of the following items, each of which is specifically excluded from this Limited Warranty: 1. Defects in appliances or pieces of equipment which are covered by manufacturer's warranties including furnace and hot water tank. 2. Damage due to ordinary wear and tear, abusive use, misuse or lack of property maintenance of the dwelling or its component parts or systems. 3. Defects which are the result of characteristics common to materials used. 4. Defects in items installed, supplied or work done by you or anyone other than by us or our subcontractors at our order. ry� B. in the event of unavoidable casualties, Contractor shall properly document both the event and the impact of the event on Project completion. Documentation shall be presented to Client in a timely manner. ARTICLE V1 A. If Contractor fails to correct defective work or persistently fails to supply materials or equipment in accordance with the Contract documents, Client may order Contractor to stop the work or any portion thereof, until the cause for such order has been eliminated. ARTICLE VII A. Free access to the work and the Project site shall be granted by Contractor to Client, the designated agents of the Client, and all necessary public authorities. B. Contractor agrees to keep the premises clean and orderly. Contractor shall remove all debris as needed during the hours of work in order to maintain work conditions free of health or safety hazards. ARTICLE VII A. Contractor shall conduct its activities in a professional manner and adhere to reasonable wishes of Client in relation to its working schedule. Additionally, Contractor's work shall adhere to and be in compliance with both the Standard Practices of the Trades and any relevant Manufacturers Specifications. B. Contractor shall protect all work adjacent to the Project site from any damage resulting from the work of Contractor and shall repair or replace any damaged work at its own expenses. Contractor shall take all precautions to protect persons from injury and unnecessary interference or inconvenience. ARTICLE IX A. Client agrees to hold harmless, indemnify and defend Contractor and each individual or entity that is an agent, affiliate, partner, officer, or stockholder of same against any and all claims, losses, liabilities, damages, and expenses, including legal fees, fines, judgments, settlement amounts all made in connection with , or arising from errors in any representation or warranty made by Client under this Contract, any breach of the Contract by Client, or any omission or negligent act or error by Client in connection with this Contract, provided by such negligent act, omission, or error was not done at the direction of Contractor. B. Contractor agrees to hold harmless, indemnify and defend Client and each individual or entity that is an agent, affiliate, partner, officer, or stockholder of VA 5. Any loss or injury due to ground water. 6. Loss or injury due to elements, including, but not limited to weather and other acts of God. 7. Conditions resulting from condensation on, or expansion/contraction of materials. 8. Your failure to properly care for lawns. 9. Consequential or incidental damages. 10. Due to large trucks, equipment, dumpsters, etc., driveway may crack, create divots etc. Also during construction, lawn may be damaged. Contractor is not responsible for the same. ARTICLE XI A. Contractor wi11 be responsible for obtaining all the necessary permits and licenses to fulfill the services specified in this Contract. ARTICLE XII A. Contractor is responsible for maintaining proper work, safety and environmental protection standards. Contractor agrees to hold Client harmless for all fines from federal, state or local agencies and regulators. Contractor will work in compliance with all standards required by EPA, OSHA and other applicable federal agencies. Contractor will be responsible for paying all fines and judgments levied by these agencies resultant from the performance of this Contract. ARTICLE X111 A. The relationship created between the Parties shall be limited to that of independent contractors. Neither party shall undertake any actions that would imply or seek to establish, any partnership, ownership, employment, joint venture, or trust relationship between the Parties, except by amendment to this Contract. ARTICLE XIV A. Any dispute or claim related to or arising from this Contract, its performance, breach, interpretation, validity, or enforceability, shall be exclusively(except as provided below) resolved by final binding arbitration before AAA American Arbitration Association utilizing AAA Commercial Arbitration Rules. B. The arbitrator shall be selected using AAA procedures. The arbitrator shall render a written decision within thirty calendar days of the hearing. The arbitrator may award attorneys' fees or punitive, incidental, consequential, treble, or other multiple or exemplary damages. C. Awards shall be final, binding, and non -appealable, with the exception of the grounds for appeal guaranteed by the Federal Arbitration Act and applicable laws. All awards may be filed with one or more courts, state, federal or foreign having jurisdiction over the party against whom such award is rendered or its property, as a basis of judgment and the issuance of execution of its collection. ARTICLE XV A. Both Parties are expressly prohibited from assigning this Contract or any rights or interest flowing therefrom. Assignment will only occur with the express written consent of both Parties. B. This Contract contains the entire agreement and understanding between the Parties and supersedes any prior or contemporaneous written or oral Contracts, representations, and warranties between them respecting the subject matter of this Contract. C. This Contract will be interpreted and enforced under the laws of the State of MA, without regard to conflict of laws. IN WITNESS WHEREOF, the Parties hereto execute this Contract: CLIENT nl catt ?-eiceror) , Name and Title (L I LLlA M C. Name and Title OWN License # 179265 The Commonwealth of Massachusetts M Department of IndustrialAccidents 1 Congress Street, Suite 100 ' Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. _Applicant Information v ^ 1C1' 1 ,� Please Print' Legib V\V I 1 ly Name (Business/Organization/Individual): D U COEnt—{U �ILG O 1l. Address: City/State/Zip: a O'SPhone #: q -IS _-�(p 1(D 4 0 a Etre yo an employer? Check the appropriate box: Type of project (required): 1.maemployer with �employees(full and/or part-time).* %. QNew construction 2. ❑ I am a sole proprietor or partnership and have no employees working for me in 8. remodeling 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 F1 Building addition 4. ❑ 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 11. ❑ Electrical repairs or additions proprietors with no employees. 12. ❑ Plumbing repairs or additions 5. I am a general contractor and I have hired 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. Other 152, §1(4), and we have na. employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 -contractors have employees, &y' must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. _ Insurance Company Name: N © r C u air 01 �? <, co Policy # or Self -ins. Lie. #: M INC (o3L,5 5 / Expiration Date: 3IfZ Ci `I 11G9 Job Site Address:—Cpa�I M aS Ave • City/State/Zip: o ye. lel MA (o 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 verification. I do hereby certify,#19fthe of perjury that the information provided above is true and correct. 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 A00RU CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DDNYYY) 8/24/2015 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 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 Risk Strategies Company 15 Pacella Park Drive Suite 240 Randolph MA 02368 CONTACT Ly PHONE(781)986-4400 FA)(AIC( 0.(781)963-4420 E-MAILADDRESS.kly@risk-strategies.com INSURERS AFFORDING COVERAGE NAIC # INSURER A NorGuard Insurance Co 31470 INSURED W McKay Construction LLC 18 Academy Avenue Bradford MA 01835 INSURER B: INSURER C: INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE Nt1MBERCL154892045 DGvlslnlu rulllumcc. 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 LTR OF INSURANCE ADDL UBR POLICY NUMBER POLICY EFF M D/YY POLICY EXP MID LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1-1OCCURMED DAMAGE O ENTED PREMISES Ea occurrence) $ EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accident ( ) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per a.Ont) cident $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE. AGGREGATE $ DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I NLIM ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under N / A C634557 /29/2015 /29/2016 X I WC STATU- OTH- ER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYE $ 100,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Evidence of insurance only. CERTIFICATE HOLDER rANrFI I ATInN AGOKD 25 (2010/05) INS025 (201005).01 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORb SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Nicole Peterson ACCORDANCE WITH THE POLICY PROVISIONS. 684 Mass Ave. AUTHORIZED REPRESENTATIVE North Andover, MA 01845 Michael Christian/KIL AGOKD 25 (2010/05) INS025 (201005).01 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORb CERTIFICATE OF LIABILITY INSURANCE 7—DATE(MMOFNYYW) a12s12015 THIS CERTIFICATEIS ISSUED AS A MATTER OF INFORMATIONONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATEHOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELYOR 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 REPRESENTATIVEDR PRODUCER, AND THE CERTIFICATEHOLDER. IMPORTANT: If the certlilcateholder is an ADDITIONALINSURED,the policy(iss)must be endorsed. H SUBROGATIONIS WAIVED, subject to the terms and conditions of the poficyicertain poficiesnayrequirean endorsement A statementon thiscertificatedoes not coMerrights to the certiFcateholder in lieu of such endorsement(s). PRODUCER CONTACT NAME Sandi Munroe M P ROBERTS INS AGCY INC 1060 Osgood Street North Andover, MA 01845 PHONE -8073 FA Na: (978) 683-3147�..EA: (978)683 E-MAIL ADDRESS: sandi@mprobertsinsurance.com INSURER(S) AFFORDING COVERAGE NAICe INSURERA: MERCHANTS INSURANCE INSURED W MCKAY CONSTRUCTION LLC INSURER 8: 18 ACADEMY AVENUE INSURERC: INSURERD: BRADFORD, MA 01835 INSURER E INSURERF: COVERAGES CERTIFICATE NUMBER: RFVIRInN NIIMRFR: 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, DCCLUSIONSANDCONDITIONS OF SUCHPOLJCIES. LIMITS SHOWN MAY HAVEBEEN REDUCED BYPAID CLAIMS. maw TYPEOFINSURANCE area POLICY NUMBER POLICY EFF POUCYEXP UMITS X COMMERCIALGENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 PREMISES a occunenoe $ 100,000 CLAIMSAIADE El OCCUR MEDEXP(Anyoneperaon) $ 15,000 PERSONAL BADV INJURY $ INCLUDED A BOP9097489 8/14/15 08/14/16 GEN'L AGGREGATE OMIT APPLIES PFR: X POLICY JEECCT LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLEUMrT Ee acciderd $ BODILY INJURY (Per person) $ ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HOLED AUTOS AUTOS PROPERTY DAMAGE Per.. $ $ X UMBRELLA L1ABX OCCUR EACH OCCURRENCE S 1,000,000 A EXCESS UAB CLAIMSMADE CUP9097489 8/14/15 8/14/16 AGGREGATE $ 1,000,000 OED I X I RETENTION $10,000 $ WORMERS COMPENSATION PER DTH• BILITY D EMPLOYERS'LIAYIN STATUTE ER PA0A0Ef4�^nTXe' u'^'� ceuaeaaae exc�uceor � N/A EL EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYEE $ (Nwndetoryn NH) If yes, dmoibe under E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OFOPERATIONS below DESCRIPTION OFOPERARONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remadm Schedule, may beattachad O mae space is reWh" NICOLE PETERSON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 684 MASS AVE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER MA 01845 AUTHORIZED REPRESENTATIVE ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD25(2014/01) The ACORD name and logo are registered marks of ACORD z�` j ƒ ■$■ �!� -�■ I42 22 � 2 . ]� >)/§ �2 \}� \22§�� \ . N 0 0 � � � `` z - � /® o * zB01 \/2\ &k �(3)C-4 . ■1--»23 �§\-�do?y\� \ i / § \ /« » ] - 2 = \ » a G / k k § ) ` c ' k § J / } § ) < (K < > _\ z�` W. MCKAY CONSTRUCTION LLC. WILLIAM MCKAY 18 ACADEMY AVE. �.- HAVERHILL, MA 01835 Undersecretary Not valid �Without signature 7 f Massachusetts - Department of Public Salet`.! Construction super1j"n License: CS -089332 -� WILLIAM MCKA_V 18 Academy Avenue Haverhill MA 01835 Commissioner 03/08/2016