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Building Permit #067-2017 - 69 PROSPECT STREET 7/22/2016
� NORrN q BUILDING PERMIT �ot��D °° o t TOWN OF NORTH ANDOVER ° ; o APPLICATION FOR PLAN EXAMINATION Permit NO: — (� Date Received 'l, `°, M1, M �/� SSACHU`�� Date Issued: IMP RTANT: Applicant must complete all items on this page OMP l=OTI0Y P 3 t {t- CAbON . 'a l 3+" € "8s•r a''3= "` ate' �3`:.- }-.fid 3 ils i m •gra v u »L ., A, y r3 .� PRPEF2 OWNER ,,, y Y a3 ;j °fl=P :,'a, Rou � # ilh Y 3 Y� '' ' oma 'aa... "'.a cn »{ n �( -{P '• v _a `,.r�' Sa � -a''aa` :aia p � , k.'d YrA'�3 ari� 33fl A3 3 3<f�} r,'a_, r33 3{ { xaxY#'- yr any�3 k9` w MAPNO� PARCELZONINGDISTRICTa Historic Distrtc3tU ayes nog 3 -9N•€�'R' l ' `4+.$un„.� �j! +rf' 6'T L (�'1�:; Y� 3v` R. K3�3+` 53 k K 3AagY�, '-4 ,j��a� 3Fs..y,`' a�, 1� e 'IG((ryry C✓ eU 3 nQ 'P,wflbn), } TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial ), (Alteration No. of units: i Commercial Repair, replacement G Assessory Bldg i Others: Demolition i Other ;sta .� d'"a'3 " 3 rz•43 3 rm'. roL'3 r x - - f �" i,; T'S"eptic Well s 3; Fl®®dplaih Wetlan s ,3 �Watemlgio h'ea bistro { �`^pµ} v } vxiy' Water/'���iwGl . �f3u3aY�i°t}T{ � 3 3� s, a,'' y r v 3 �'� ,„ ani, .:. ,n, . ;, Sir- Rash'� � '(� t V1C� e or) -hop! ov t/V l Cl 1 1/1 ho(As (2- ro x - 15 u a res Identification Please Type or Print Clearly) (rib OWNER: Name: Zo— spQv r o, P one: X86` 3SCZ Address'. PmspegGf St LAn 1 i*1_ r I 11r&ver-jMA 01?4G- CONTRACTORNarne � e � f , Ad��e.�� 3 as•, ��I'�.� '`i1 `� S 3 yrw� £4 � ? 3'"r., �'� Y���,�p �����a � � �w,��}gn`uul, �/h'u� ,a�� y�z�,> a'F � �da�'a33�3�I'n7 u 40 ' ' �',�., aj �,� Il`777 �$Yfitxa. ;' E Y 3R'*'I' Supervisors Cao str�uction-L�ceise a, Exp3 tee �,:. -��". 7tQ ;, �'. Y F,11 T �3� -aa ate P ; 5 , .... • kr Horne (mp'rovemer� L�cerse M nrExep Date �' � a }yk µ .a 3 ARCHITECT/ENGINEER fJA Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$cI 1T,�.00 PER S.F. Total Project Cost: $ �2. FEE: $ � Check No.: Receipt No.: �O d43 NOTE: Persons contracting with ur registered contractors do not have access t th guaranty fund Sgnature,ofx e{n vu ` x - r •51g�na#ur �ofcontract a-rS L a .. 0 NORTy q BUILDING PERMIT �TLEo TOWN OF NORTH ANDOVER o j APPLICATION FOR PLAN EXAMINATION q crcwrt. 1. Permit No#• Date Received SACHUS i Date Issued: a IMPORTANT:App this page Applicant must complete all items on p I LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE ill - Residential Non Residential ❑ New Building ❑ One family El Addition El Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement- [IAssesso ry Bldg El Others: ❑ Demolition ❑ Other '.t F P P r , , . .aF04! ® S-pti ®Y111e 1lootlp�ain # D W4,etlYY'c�'er/S-ek DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contraefing w1th unregistered contractors do not have access-.to, thewguaranty fund �S`Id a iiP o�Aa nt`/®vvner' --- �•—--�—�--Sia�t��r �of'contractor -- -'- - � --®- J _ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped flans ❑ TYPE OF SEWEIGE DISPOSAL Public Sewer ❑ Tanning/Mas sageB o dy Art ❑ Swimming pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ PermanentDmnpster on Site ❑ 1 THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING aA DEVELOPMENT Reviewed On Signature COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed ori Signature COMMENTS k Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/si nature Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street A.I. Fl•RE DEPART METMET NT m t�Lted at 12s Tep Dempster onjsiter�yes,, .� n0 � •k oea 4 Main Street Fire Departure tiggature/date .Q �A 'i-' ; • 'i'}�' ,: 8Y 1•, �>'1•i!T' `"T� gl'w- � il:' S }Sx •' , 'C4®MMENTS Dimension Number of Stories: Totals square feet t 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 i Date Time Contact Name Doc.Building Pennit Revised 2014 J Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. I 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 46 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 1 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 4- Engineering Affidavits for Engineered products OTE: 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 (191 � Y No.,Qy/*�' Z-01 Date 1 • - TOWN OF NORTH ANDOVER . Certificate of Occupancy $ Building/Frame Permit Fee $ ' z Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ' Check#Ml u 30643 Building Inspector NORTFI own Of 2 n over .Yr. �I No. - 2 � z O LAK• h ver, Mass, COON ICMl WICK V� R�1TE0 PPa��S U BOARD OF HEALTH L D Food/Kitchen PERMIT Septic System THIS CERTIFIES THAT r.. .. ........ ......, BUILDING INSPECTOR ...7:7W ......... Foundation has permission to erect . y�7 ...... ..... .... .. build' son .......... .. ......: .. .. .. . ........ ...... Rough to be occupied as .. .. .. .. ...... ... ................................................................... Chimney provided that the person accepting this ermlt shall in every spect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRI TIO Rough Service ... ..... .... ....... .. .......... Final BUILDING INS ECT GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Office Location: BOSTON Proposal Date 07/20/2016 Job Number 20712640 Sears Home Improvement Products,Inc. Customer Name JOSEPH VAVRA 59eairs P.O.Box 1024 Floridaida Central Parkway Customer's dome Phone Customer's Work Phone Longwood, FL 32750-7579 (978) 686-3502 Home Improvement Products Phone(800)469-4663 Street Address ESTIMATE AND PROPOSAL Contractor License/Registration Number 69 PROSPECT ST MA(148607) City State Zip Code Roofing All plumbing and electrical services performed by NORTH ANDOVER MA 01845 Is installation within city limits? licensed subcontractors Installation Address County ESSEX (Yes/No): YES FEIN 25-1698591 Billing Address(if different from above) City State Zip Code Project Consultant Name&License No.(if applicable) RALPH MUDARRI BOSTON Description-of the Project and Description of the Significant Materials to be Used'and iEquipment to be installed The work to be done under this contract includes the following(where checked): Specifications(Z=Included ❑=Not Included) Preparation 1. 0 Tear off existing roof shingles down to wood deck on entire house. 2. Z Inspect wood deck for rotten wood. 3. ® Replace any rotten wood found in the deck area at a rate of$ 3.20 per square foot. PLEASE NOTE:this amount is not included in the TOTAL PRICE shown below. Customer and Sears agree that the TOTAL PRICE will be amended via a Contract Change Authorization form to add the costs of replacing rotten wood in the deck area discovered after existing roofing materials are removed. Customer(s)initials Installation 4. 0 Furnish and install Exterior Shingle: TYPE: DURATION COLOR: SHASTA WHITE 5. 2 Furnish and install PROARMOR underlayment over roof decking. 6. ❑ Furnish and install ice&water eave&valley protector. 7. 0 Furnish and install starter shingle on all eaves. 8. Z Furnish and install/replace any deteriorated 1"flashing. 9. Z Furnish and install metal drip edge along rake edges and eaves. 10. ❑ Furnish and install skylight systems. ❑ Reuse existing 11. 0 Furnish and install new vent covers on all vent pipes. 12. 0 Furnish and install attic ventilation system(Check all applicable): ❑Turbines ❑ Power vents © Shingle-over ridge vents ❑Off-ridge vents ❑ Soffit vents 13. ❑ Furnish and install new flat roof Exterior Protection System: COLOR: Gutters 14. ❑ Furnish and install guttering: COLOR: 15. ❑ Dispose of old guttering. Clean-up 16. 0 Clean-up and removal of all job-related debris including excess materials. (Extra materials are shipped with each job to avoid delays).Manufacturer warranty will be sent upon completion of installation. Sears recommends that Customers have their chimney siding or mortar between brick, stone,or blocks inspected perio ically by a professional and tuck pointed and/or waterproofed as needed. Sears shall not be responsible for chimney integrity other than Customer(s)initials p� replacing the flashing in conjunction with the installation of the roofing materials described above. 0 Additional work to be done:R&D OF TWO ANTTENNAE Work NOT to be done: Repairs and replacement of any damaged existing structural members. Interior repair to walls or ceilings including sealing, painting, and/or drywall repair. Removal and/or re-installation of items that may otherwise impede Sears'ability to install a new roofing system prior to installation. Examples include, but are not limited to, satellite dishes,solar panels, pool heating panels, gutter protection systems,TV antennas,HVAC systems,and weather equipment. TWO FRONT LOWER ROOFS & LOWER REAR ROOFS SPECIAL INSTRUCTIONS:NEW ROOF ONLY ON TOP OF MAIN HOUSE All of the above check boxes, "Work NOT to be done," "Additional work to be done," and "Special Instructions"sections have been reviewed and explained to me. Customer(s)initials SRI-MA (Dig.) Rev 06/07/2016 Page 1 of 3 �I�I�III IIS�I� Job Number: 20712640 APPROXIMATE START DATE and APPROXIMATE COMPLETION DATE: The work will start approximately 2-3 WEEKS (Approximate Start Date) It will be substantially completed by approximately 1 DAY (Approximate Completion Date) These dates are subject to change at the time the contract is accepted by Sears Home Improvement Products, Inc. ("Sears")or at any other time by mutual written agreement.Customer understands that the Approximate Start Date is only an estimated date and the Customer will be contacted prior to this date to schedule the actual start date. ASBESTOS ABATEMENT: This Estimate and Proposal assumes that there are no asbestos containing materials ("ACMs") that would be disturbed in the performance of the installation work. If upon further inspection by the contractor or others it is learned that ACMs have to be disturbed to perform work,then Customer must arrange and pay for abatement of asbestos by a qualified person prior to the start or continuation of work. If Customer fails to arrange for necessary asbestos abatement within thirty(30) days, Sears may cancel this contract upon Customer(s)initials g� written notice to Customer. I IF The TOTAL PRICE including all labor,material,taxes and any applicable discount is$ 6,962-54 Contract Price $6,962.54 Initial Payment(not to exceed 30%of Total Price unless Special Order)$ 2,088.76 State Sales Tax( 0.00 %) $ 0.00 Final Payment(balance payable upon completion of job)$ 4,873.78 Local Sales Tax( 0.00 %) $0.00 The Initial Payment is due prior to Sears ordering products. I Total Amount Due $6,962.54 The form and method by which the Customer(s)will pay is described in a separate Cash/Credit Card Payment Addendum made a part of and incorporated into this contract by reference. Customer(s)initials o; NOTICE TO BUYER: YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY (FIFTH BUSINESS DAY IN ALASKA, FIFTEENTH BUSINESS DAY IN NORTH DAKOTA IF YOU ARE AGE 65 OR OLDER)AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. ADDITIONAL PROVISIONS Proposal and Approval.Sears offers to furnish the materials and arrange for their delivery and installation as specified on the first page and/or the attached sketches and specification sheets for the TOTAL PRICE shown.This offer must be approved by the Installation Department. If this is a credit sale or a payment on completion sale,it must be approved by the Credit Sales Department. If this proposal is not approved or the installation cannot be made in accordance with the law,this offer will be withdrawn and any payments you have made will be refunded to you.Any materials left over after the installation has been completed are Sears property and will be removed by Sears. Installation. I understand that Sears will not install the materials but will arrange for the installation. Sears is not responsible for materials or installation NOT furnished or arranged by Sears.Sears'installation contractor(s)will obtain all building permits required by local law. For homes located in historic or landmark zoning districts,Customer will be responsible for obtaining required approvals and related permits prior to the commencement of work on this contract. Authorization. I authorize Sears to: O arrange a for a contractor(licensed where required by law)to make the installation of materials; (2) issue a work order 9 for this installation to a contractor; (3)inspect the installation; and (4)pay the contractor when the installation is complete if I have signed a certificate that the installation has been completed to my satisfaction. Delays in Installation.I agree that Sears is not responsible for delays in delivery or installation due to weather,fire,strikes,war,government regulations or any causes beyond Sears'control. Oral Agreements and Changes in Contract.I understand that there are no oral agreements between Sears and me.Everything I expect Sears to do has been included in writing in this contract. Nothing can be changed in this contract unless it is in writing on a separate form accepted by me and Sears. Responsibility of Buyer. I agree that any information or measurements that I give to Sears are correct and complete. I am responsible for any special work described in this contract. Electrical& Plumbing Service. I will provide adequate electrical and/or plumbing service(s)to run any newly installed appliances or other furnishings. If the electrical and/or plumbing service(s)do not meet the standards of the utility company or electrical and/or plumbing codes,I will make the necessary changes at my expense unless Sears has agreed in this contract to make the changes. Payment.I will pay Sears the cash price that covers the price of material and installation as shown on the first page. Warranty Information.Appropriate product warranty documents will be given to me by Sears.Sears'Warranty on Installation is: SEARS'LIMITED WARRANTY ON INSTALLATION In addition to any manufacturer warranty extended to you on the product(s)used(which warranty becomes effective the date the merchandise is installed),if the workmanship(or application)of any Sears'arranged installation proves faulty within five years(Best),three years(Better),two years(Good)crone year(Limited) after products are installed,then upon notice from you Sears will cause such faults to be corrected by repair at no additional cost to you.If Sears determines that repair is not commercially practicable or cannot be timely made then,at Sears'sole discretion,Sears may elect to provide replacement or refund.Service under this Limited Warranty is available by calling Sears Home Improvement Products at 1-800-222-5030,Option 4.This warranty gives you specific legal rights, and you may also have other rights that vary from State to State. SRI-MA (Dig.) Rev 06/07/2016 Page 2 of 3 Job Number.• 20712640 NOTICE TO BUYER 1. DO NOT SIGN THEAGREEMENT IFANY OFTHE SPACES INTENDED FOR THEAGREED TERMS TO THE EXTENT OF THEAVAILABLE INFORMATION ARE LEFT BLANK. 2. YOU ARE ENTITLED TO A COPY OF THIS AGREEMENT AT THE TIME YOU SIGN IT.KEEP IT TO PROTECT YOUR LEGAL RIGHTS. 3. YOU MAY PAY OFF THE FULL UNPAID BALANCE DUE UNDER THE AGREEMENT AT ANY TIME,AND IN SO DOING YOU SHALL BE ENTITLED TO A FULL REBATE OF THE UNEARNED FINANCE AND INSURANCE CHARGES. 4. YOU MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY[FIFTH BUSINESS DAY IN ALASKA, FIFTEENTH BUSINESS DAY IN NORTH DAKOTA IF YOU ARE AGE 65 OR OLDER]AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. FAILURE TO EXERCISE THIS OPTION, HOWEVER, WILL NOT INTERFERE WITH ANY OTHER REMEDIES AGAINST THE RETAIL SELLER YOU MAY POSSESS. IF YOU WISH, YOU MAY USE THIS PAGE AS NOTIFICATION BY WRITING"I HEREBY RESCIND"AND ADDING YOUR NAME AND ADDRESS.A DUPLICATE OF THIS RECEIPT IS PROVIDED BY THE SELLER FOR YOUR RECORDS. 5. IT SHALL NOT BE LEGAL FOR THE SELLER TO ENTER YOUR PREMISES UNLAWFULLY OR COMMIT ANY BREACH OF THE PEACE TO REPOSSESS GOODS PURCHASED UNDER THIS AGREEMENT. NOTICE TO MASSACHUSETTS RESIDENTS ONLY In addition to the Notice to Buyer shown above, Massachusetts law requires that contracts for home improvement work state that all home improvement contractors and subcontractors shall be registered and that any inquiries about a contractor or subcontractor relating to a registration should be directed to: Office of Consumer Affairs and Business Regulation Ten Park Plaza,Suite 5170 Boston,MA. 02116 Telephone: (617)973-8700 Please note that owners who secure their own construction-related permits or deal with unregistered contractors shall be excluded from access to the Guarantee Fund. Notwithstanding any other language in the contract or associated documents, Sears will not remove, replace, or install any heating or air conditioning system, or any portion thereof, if asbestos or asbestos-containing material is known or likely to be present in that heating or air conditioning system,or any portion thereof. If it is determined or reasonably suspected that asbestos is present, either before commencement or during performance of the work, it shall be the customer's responsibility to select, retain and pay all costs of a Division of Occupational Safety ("DOS") licensed Asbestos Contractor to remove all asbestos or verify that none is present in the components involved in the job. If the determination or reasonable suspicion of the presence of asbestos arises after Sears has started the work, Sears will immediately cease performing the work until a DOS licensed Asbestos Contractor, hired by the customer, removes all asbestos from the components scheduled for repair or replacement in accordance with 310 C.M.R.7.00 and 453 C.M.R. 6.00 or verifies that none is present. By signing the contract the customer agrees that it understands the above. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES 0 Ux� 07/20/2016 07/20/2016 Customer's signature Date Customer's signature Date Accepted by Sears Home Improvement Products, Inc.("Sears")on 07/20/2016 by: Date Management Representative SR].-MA (Dig.) Rev 06/07/2016 Page 3 of 3 J The Commonwealth of Massachusetts W Department of Industrial Accidents a 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 Please Print Legibly Name (Business/Organization/lndividual):Sears Home Improvement Products Incorporated Address: 1024 Florida Central Parkway City/State/Zip: Longwood, FL 32750 Phone #: 860-753-0452 Are you an employer?Check the appropriate box: Type of project(required): 1.®I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.®1 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.]+ 4,[:]1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10E] Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.[,] Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.®1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.' 13.®Roof repairs 6.®✓ We are a corporation and its officers have exercised their right of exemption per MGL c. 14.M Other lRe 152,§1(4),and we have no employees.[No workers'comp.insurance required.] iv 1 *Any applicant that checks box 41 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. *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-contractors have employees,they 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: Ace American Insurance Company / Phone : 866-283-7122 Policy#or Self-ins.Lic.#: WLRC48589650 Expiration Diat 08/01/2016 qq Job Site Address: y� n. 1 C)IRA 1 1 w eL~., �t u t Cit /State/Zi —1 Y P Attach a copy of the workers' compe sation policy decla ion page(showing the policy number and ex iration 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. /do hereby cer er the pains d penalties of perjury that t!t informa ion prov'ded above is true and correct. Si Hato Date: - 53-0452 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 S. Plumbing Inspector 6.Other Contact Person: Phone#: RES'=T FORCUI AC 0® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 07/25/20,5 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 ''T certificate holder in lieu of such endorsement(s). PRODUCER CONTACT d7 NAME: D Aon Risk Services Central, Inc. PHONE (g66) 283-7122 FAX (800) 363-0105 d Chicago IL office (AIC.No.Ext): AIC.No.: .a 200 East Randolph E-MAIL a Chicago IL 60601 USA ADDRESS: T INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: ACE American Insurance Company 22667 Sears Holdinqs corporation INSURER B: ACE Fire Underwriters Insurance CO. 20702 dba Sears Home Improvement Products, Inc Attn: Risk Management E3-219A INSURER C: 3333 Beverly Road INSURER D: Hoffman Estates IL 60179 USA INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:570058793162 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. Limits shown are as requested SR ADD TYPE OF INSURANCE S UBRI POLICY NUMBER POLICY O C LIMITS LTR IN WVD MM/DD/YYYY MMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY HDOG2739 4 8 08/01/2015 08/01/2016 EACH OCCURRENCE $5,000,000 CLAIMS-MADE X❑OCCUR AG O S5,000,000 PREMISES Ea occurrence MED EXP(Any one person) EXCI uded PERSONAL B ADV INJURY $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $5,000, 000 rn X POLICY ❑PRO- ❑LOC JECT PRODUCTS-COMP/OP AGG $5,000,000 OTHER: o A AUTOMOBILE LIABILITY ISAH08859000 08/01/2015 08/01/2016 COMBINED SINGLE LIMIT r $5,000,000 � A ISAH08859012 08/01/2015 08/01/2016 Ea accident A ANY AUTO ISAH08859024 08/01/2015 08/01/2016 BODILY INJURY(Per person) O ALL OWNED SCHEDULEDZ X AUTOS AUTOS BODILY INJURY(Per accident) d X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE V AUTOS Per accident tL UMBRELLALIAB HOCCIR EACH OCCURRENCE U EXCESS LIAB CLAIMS-MADE AGGREGATE Dc-D RETENTION A WORKERS COMPENSATION AND wcuc48589662 08/01/2015 08/01/2016X PER OTH- EMPLOYERS'LIABILITY YIN OH, WA, WV STATUTE ER A ANY PROPRIETOR/PARTNER/EXECUTIE.L.EACH ACCIDENT VE $2,000,000 OFFICER/MEMBER EXCLUDED? N/A WLRc485896So 08/01/2015 08/01/2016 (Mandatory in NH) All Other States E.L.DISEASE-EA EMPLOYEE S2,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $2,000,000- DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE JG POLICY PROVISIONS. Sears Home Improvement Products, Inc. AUTHORIZED REPRESENTATIVE -� 1024 Florida Central Parkway Longwood FL 32750 USA eXYo�a ���sGQ.sms•�rrJ ��isye�tz�✓�za. � ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD i AGENCY CUSTOMER ID: 570000034159 LOC#: _ ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED Aon Risk Services Central, Inc. Sears Holdings corporation POLICY NUMBER see certificate Number: 570058793162 CARRIER NAIC CODE see certificate Number: 570058793162 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S)AFFORDING COVERAGE NAIC# INSURER INSURER INSURER INSURER ADDITIONAL POLICIES If a policy below does not include limit information,refer to the corresponding policy on the ACORD certificate form for policy limits. INSR ADDL SUBR POLICY POLICY TYPE OF INSURANCE POLICY NUMBER EFFECTIVE EXPIRATION LIMITS LTR INSD WVD DATE DATE MM/DD/YYYV MM/DD/YYYY WORKERS COMPENSATION B N/A SCFc48S89674 08/01/2015 08/01/2016 WI ACORD 101(2008/01) ©2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD r .......... _. ___ ........ . ......... .....__.. 1�1011'i'c ffZ/ r �W Office of Consumer Affairs nd Business Regulation MW 10 Park Plaza - Suite 51.70 Boston, !Massachusetts 021.16 Holnc I;n1P,t ovement Contractor Registration Registration: 148607 s 3A Type: Supplement Card .Expiration: 10/1.112017 SEARS HOME IMPROVEMENT PRUC}UGT° ..._... LUBOS SVEC 1024 FLORIDA CENTRAL PKWY _... . r LONGWOOD, FL 32750 _---...... .... ..................... _._.................... __. Update Address and return card.Mark reason for change. x Address x Renewal 1 Craployment [lost Card (mic."of Consumer Affairs R Business Reg aiionl icerise or registration valid for individual use only before the expiration dale. if found return to ,,A� kiOME IMPROVEMENT CONTRACTOR 1 Oftit:e of C'onsurner Aff;iirs anti Business Reoulation Registration—. Type:1�g607 10 Park Plaza-Suite 51710 Expiration 10/11 2 1;7 SupplernentCard Boston,MA 02116 SEARS HOME IMPROVE MEiNjT,,PRODUCTS INC. LUBOS SVEC 1024 FLORIDA CENTRAL PKWY LONGWOOD,FL 32750 _ Underseeretaryr Not valid without signature l x j E License: GS-097519 r LUBOS SVEC `" 4 827 THOMPSON 1110)� UO Thompson GT 0677 i f i 08/3112016 3 i £ i I R wJ -Commonwealth of MassachusettsFPernmit Official Use Only Department of Fire Services °.- BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice his or her intention to perform the electrical work described below. Location(Street&Number) 69 4 Owner or Tenant 3M gr I) Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service 10D Amps 20 /2Wo Volts Overhead © rd Und g ❑ No.of Meters New Service Amps / _Volts Overhead❑ rd Und g ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Com letion of the following tablemay be waived by the Inspector o Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above EJ o.o mergency tg mg rnd. rnd. ❑ Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners INo.of Detection and Initiatin Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers. Heat Pump Number...Tons KW No.of Self-Contained Totals: No.of Dishwashers Detection/Alertin Devices Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:X of.oN No.o f Water Devices or Equivalent vale nt �, No.of No.of Heate rs Signs Ballasts Data Wiring: No.of Devices or No.Hydromassage Bathtubs E uivalent No.of Motors ' Total HP Telecommunications Wiringg: OTHER: No.of Devices or E uivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) P fY:) I certify,under the pains and penalties of perjury,that the information on dais application is true and complete. FIRM NAME: 'I rt- Licensee: Cmc (,�11t klr LIC.NO.: X15 2g Signature LIC.NO.: (If applicable, enter " empt" . the license numb line.) Address: U, `j X dtk 2 Bus.Tel.No.:_ *Per M.G.L c. 147,s.57-61,security work req es Department of Public SaAlt Li fety"S"License: c.No'*-- OWNER'S INSURANCE WAIVER; I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the check one Owner/ A ent ) owner ❑ ❑owner's agent. Signature i Telephone N P o. PERMIT FE E. $ N • ELECTRICAL PERMIT N®. _ ELEC'IwcAL INSPECTOR-DOUG SMALL PORT: I.ROUGH INSPECTION: Passed—[ ] Failed—[ ] Re-inspection requiredT($50.00)-[ I Inspectors'comments: (Inspectors'Signature-no initials) s Date 2.'FINAL INSPECTION, Passed—[ I 'Failed—[ ,] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-no initials) . Date 3.UNDER..GROUND INSPECTION: Passed—[ ] Failed—[ ] Re-inspection required($50.00) [ ] Inspectors'comments: (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed—[ ] Failed—[ ] , Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-no initials) Date ------------- 5.INSPECTION-OTHER: Passed—[ ] Failed—[ ] Re-inspection required($50.00) Inspectors' comments: (Inspectors'Signature-.no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF T.OEA TO BE I INSPECTED IS NOT_ ACCESSIBLE AND A.RE-INSPECTION OF$50.00 IS TO BE CHARGED. The Commonwealth of Massachusetts Department of Industrial Accidents 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): Address: I-� (X 1, `( City/State/Zip: 6, Phone #: 4 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. El am a general contractor and I 6. E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached shget. 1 7• ❑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 required.] officers have exercised their 10.®Electrical repairs or additions 3.❑ I am a homeowner doing all work 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 required.]t employees. [No workers' 13.0 Other 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. $Contractors 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 the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: F,&y/y $`^ 2 Expiration Date: 61f, Job Site Address:— 6 c� City/State/Zip: "t (4V). / Attach a copy of the workers' compensation policy declaration page(showing the policy 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 forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date Phone#: Official use only. Do not write in this area,to be completed by city or town oftial 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 I ' Contact Person: Phone#: a 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." k Applicants r Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and 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 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 o 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 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia