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HomeMy WebLinkAboutBuilding Permit #645-13 - 71 WAVERLY ROAD 4/4/2013Permit N0: ZJ Date Issued: Ll L4 i LOCATION PROPERT` TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received I (IMPORTANT: Applicant must complete all items on this page MAP NO: PARCEL_: Q. Z_ONING'DISTRICT: Historic=District; Machine Shop V.il yes no yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septic We11: 3 ❑ Floodplain ❑ Vlletlands: ❑ WatershedlDistrict) 0 Water/Sower . DESCRIPTION OF WORK TO BE PERFORMED: .._-.Identification Please OWNER: Name: VG4J�eh.. Address: -7/ �Ja J," s> M1, '�T or Print Clearly) Phone: %'Zha 73 966-6 CONTRACTOR Name: A-) -Phone: , CQ �i2i Address: 30 ((11 Supervisor's Construction License: l.�I 040 �-� Exp: Date: 1- Home Improvement. License,- �j Exp. Date: - Zs I _ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ Z6252FEE: $ Check No.: Receipt No.:�0 NOTE: Persons contracting with unregistered contractors do not have access to -e- 'gu ranty fund 'Signatureµof AgenUOwnerSignature of contract7. o- ` Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan 0 S mped Plans ❑ Building Department The foliowing 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 o 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;tted with the building application Doc: Doc.Bui?ding Permit Revised 2012 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL , Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED El DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision:____ Comm Water & Sewer ConneC$ion/Signature & Date Driveway Permit � f DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMF-'N f - Temp Dumpster on site yes no Located at*124.Main`Street Fire Departinert.signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Dieter 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 El Notified for pickup - Date I Doc.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 o 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) o 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 appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm;tted with the building application Doc: Doc.Bui?ding Permit Revised 2012 Permit N0: (IV �[ e I Date Issued: 14 - W 1 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 1 IMPORTANT: Applicant must complete all items on this page tit PROPERTY01NNER Print; 100!Year Old structure.yes MAPtNO: PARCEL: o. ZONING DISTRICT: Wistonc Distnct� 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 ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic .[] Weq ❑ Floodplain ❑ Wetlandsr 0 WatershedtDisthct= , D Water%Sewer . DESCRIPTION OF WORK TO BE PERFORMED: Identification Please OWNER: Name: V 6kJ'b,, J �`—�' • or Print Clearly) W31 17,a 73 go 6-6 Address: CONTRACTOR Name: Address: � ^-VJVL4 `-41M. ? ._ Supervisor's Construction License.b. 00 - *� Exp: Date: -7I Home lmprovemenf, License �1� Exp: Dater Z ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ �' o FEE: $ Check No.: Receipt No.: �O0% 5,3 NOTE: Persons contracting with unregistered contractors do not have access t e gu ranty fund SI nature'of A ent/Owner 7 of con racfo Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ S mped Plans ❑ Location �21 " I z -_-1,41o7 N —3 o. Date Check # 1� � �� 26253 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL 'gu—flding Inspector Proposal AB Carnes Inc. 30 Arrowhead farm Rd Boxford, Ma. 01921 978.887.1431 Mass, Builders License No.000230 Contractors Registration. No 100733 Proposal Submitted To: VICTORIA & JASON FANTASIA 71 WAVERLY RD Date April 2, 2013 Project Name SAME NORTH ANDOVER, MA 01845 Address 978-273-9058 OR 617-429-0627 We propose to furnish material and labor- in accordance with the specifications below: Ninety Six Hundred Dollars ($9,600.00) Payment to be made as follows: $300.00 Deposit, Balance Upon Completion 6` Notice: All home improvement contractors and subcontractors engaged in home improvement contracting, unless specifically exempt from registration by provisions of Chapter 142A of the General Laws, must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Mass.govllicenses website. Page 1 of 1 ,$ ,/`` Authorized Signature �- Note: This prpo may ithdrawn by us if not accepted within 30 days. / . ROOF PROPOSAL ® STRIP ROOF OF UP TO TWO LAYERS OF ASPHALT SHINGLES, COVER ROOF DECK WITH 15LB ASPHALT COATED UNDERLAYMENT PAPER, COVER EXTERIOR WALLS AND FOLIAGE WITH TARPS TO HELP PREVENT DAMAGE. ® INSTALL CARLISLE HIGH PERFORMANCE ICE & WATER BARRIER OVER ALL HEATED AREA; SIX FEET�DE AT THE LEADING EDGE OF ROOF AND THREE FEET IN ALL VALLEYS & AROUND ALL ROOF PENETRATIONS. ® COVERALL PERIMETERS WITH EIGHT INCH ALUMINUM DRIP EDGE. ® INSTALL RIDGE VENT AND/OR ®AS NEEDED ROOF LOUVERS FOR ADDED ATTIC VENTILATION. ® COVER SOIL PIPES WITH NEW RUBBER FLASHING BOOTS. ® REPLACE WALL FLASHING (S) AS NEEDED WITH ALUMINUM OR LEAD AT THE ADDITIONAL COST OF $25.00PLFT. WE MAY NEED TO REMOVE THE SIDING TO PERFORM THIS WORK, YOU MAY NEED TO HAVE A CARPENTER REINSTALL THE REMOVED SIDING. ® CHIMNEY FLASHING; CUT ALL EXISTING TAR AND LEAD FROM ONE CHIMNEY(S). CUT NEW REGLET WITH CARBIDE SAW AND SECURE NEW LEAD FLASHING IN PLACE W/LEAD ANCHORS. PROPERLY SEAL REGLET JOINT. PLEASE ADD $500.00 TO ABOVE PRICE. ❑ REBUILD CHIMNEY FROM ROOF DECK UP WITH NEW OR USED BRICK. ADD OABOVE PRICE. ® COVER ROOF SURFACE WITHCERTAINTEED LANDMARK ARCHITECTU LIFETIME RRANTY 240LB SHINGLES. ® REPLACE DEFECTIVE ROOF DECKING WITH 1X8 SPRUCE BOARDS AT A AL COST OF$4.50plft. ® COVER ROOF DECK WITH CDX PLYWOOD AS NEEDED TO REPLACE OR REPAIR DEFECTIVE DECKING, AT AN ADDITIONAL COST OF$4.00psgft. SHINGLES ARE TO BE STORM NAILED. ESSEX COUNTY BUILDING CODE REQUIRESp NAILS INSTEAD OF FOUR. ❑ REPLACE EXISTING SKYLIGHTS WITH NEW VELUX UNITS WITH FLASHING KI [S. WE WILL PROVIDE THE SKYLIGHTS & FLASHING KITS AT OUR EXACT COST FROM OUR SUPPLIER. THERE WILL BE NO LABOR CHARGE IF THEY ARE THE SAME SIZE. INTERIOR WORK IS EXCLUDED. ® REMOVE EXISTING GUTTERS ® INSTALL NEW SEAMLESS .032 ALUMINUM GUTTERS USING THE POSITIVE LOCKING BAR HANGER SYSTEM. ® REPLACE DEFECTIVE OR ROTTED TRIM BOARDS AS NEEDED WITH NO.2 P11IMED PINE, ADD $15,00 PER FOOT TO ABOVE PRICE. ® INSTALL NEW ALUMINUM DOWNSPOUTS. MECHANICALLY FASTEN ALL CONNECTIONS. CLEAN ALL PROJECT RELATED DEBRIS FROM OUTSIDE WORK AREA. THE PROPERTY OWNER AUTHORIZES AB CARNES, INC TO OBTAIN ALL CANNOT ACCEPT RESPONSIBILITY FOR DEBRIS FALLING INTO ATTIC A • ST-QUE—R.SIJOL DLVEER VALU. BLES GREAT CARE WILL BE I THE STRUCTURE AND FOLIAGE. HOWEVER, SOME MARRING AND OR MINOR DAMAGE COULD OCCUR. ` SPECIAL INSTRUCTIONS: THE ABOVE PROPOSAL INCLUDES ALL ROOF SECTIONS ON PAGE FIVE OF THE EAGLEVIEW REPORT. 1. ANY LOW SLOPED ROOF SECTIONS WILL BE COVERED WITH A CARLISLE RUBBER ROOF SYSTEM. 2. WE CAN REPLACE ANY DEFECTIVE GUTTERS FOR YOU AS PROPOSED ABOVE OR AS INSTRUCTED BY YOU. PLEASE ADD $15.00 PLFT YES ( ) NO 04 3. AS PER OUR DISCUSSION WE WILL REPLACE THE TRIM BOARDS ON THE FACE AND SIDE OF. THE "A" WINDOW DORMERS UNDER TRIM WORK. 4. UPGRADE TO THE CARRIAGE HOUSE SCALLOPED SHINGLES FOR ALL SHINGLED ROOFS PLEASE ADD $3200.00 TO THE ABOVE PROPOSAL. YES 04 NO ( ) WARRANTY UPGRADE: THE CERTAINTEED WIND WARRANTY WILL BE UPGRADED FROM 110XP TO 130 MPH WITH AN UPGRADE TO THE HIGH PERFORMANCE HIP & RIDGE CAPS AND STARTER COURSE AT NO ADDITIONAL CHARGE. YES EMAIL ADDRESS;/ 'c-4 My 'C.- V1,1 Warranty: All work warranted against installation defects for 5 years; this warranty is limited to the installed item (s) and its repair only. Material is warranted by the manufacturer against defects for 50 years; please see the manufacturer's warranty for exact warranty performance. Cancellation: Customer has legal right under federal law to cancel this contract without penalty or obligation within four business days from the date of signing this agreement via Priority Mail Delivery Confirmation. Please see reverse side Dispute Resolution under Massachusetts Home Improvement Law 142a: All parties agree in ad.vance b.,i y and4j disputes relating to this proposal shall be settled by binding arbitration. This forum is user friendly and does not require lawyers. PI a reverse side Customer Date i3 Contractors , If c� Signing this Proposal means you have accepted all the terms as stated on the front and back If this agreement. Date of Acceptance 1 j Signatur ipk_ Signature f PLEASE SEE REVERSE SIDE Date The Commonwealth of MassachuseUs Department of industrial Ateiden's _ — O&C of invesdgations _ ra 600 Washington Street Boston, MA 42111 www.if)'mas,&g'ov%slim Workm, compemt ion Insurance Affidavit: Buiidet siCoactorslElmtricianslPlumbers A>alli nt Information Please Print L l N111]G(BusinaslOrganizatiotillndividual Address: D /�(�.0 f.Jf1t">Al� ✓� Ai Are you an employer? Chcck the apps 1. [] I am a employer with employees (full and/or part-time).* 2. [1 I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t Phone #: riate ox: 4. I am a general contractor and I Ntlave hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. msurance.t 5.XWe arc a corporation and its officers have exercised their right of exemption per MGL c. 152, y 1(4), and we have no employees. (No workers' comm. insurance required.l 0 Type of project (required): 6. ❑ New construction 7. Q Remodeling 8. Q Demolition 9. F1 Building addition 10.0 Electrical repairs or additions 11.[] Plumbing repairs or additions 12Roof repairs 13.[:] Other, *Any applicant: that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit Otis affidavit indicating they are doing all worts and then hire outside contractors must submit a new affidavit indicating such. tr-onttactors that check this box mustattached an additional sheet showing the nxme of the sub -contractors and state whether or not those entities have employes. if the sub -contractors have employees. they must provide their workers' comp, policy number. 1 atm an employer that is providing workers' compensation insurance for my employem Below is the porcy anti jo site informadom Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/Statc/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under 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 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 ander the ins artd penalties of perjury that the hi ormadon provided above is true and correct: 7 �---�. ----) /--",, .n / rintP- t1. Ql - l � Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitfLlcense # 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 #: FORM 153 The Commonwealth of Massachusetts DIA Use Only Department of Industrial Accidents Office of Investigations - Dept.153 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 http://www.mass.gov/dis InvestJSWO ID #• AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPORATE OFFICERS OR DIRECTORS Chapter 169 of the Acts of 2002 amended M G.L. c. 152, §1(4) by adding the following paragraph: "This chapter shall be elective for an officer or director of a corporation who owns at least 25 percent of the issued and outstanding stock of the corporation. Notwithstanding section 46, these provisions shall apply only if the corporate officer provides the commissioner of industrial accidents with a written waiver of his rights under this chapter. Said commissioner shall promulgate regulations to carry out the purpose of this paragraph. Violations of this paragraph shall subject the corporation to the penalties set forth in section 25C." Pursuant to M.G.L. c. 152, § 1(4) as amended, I/We the undersigned officers of: AB Carries, Inc. 30 Arrowhead Farm Rd Boxford, Ma 01921 (Name of Corporation and Address) each holding at least 25% of the issued and outstanding stock in said corporation, do hereby invoke the right to be exempt from the provisions of M.G.L. c. 152, §25A and therefore are not required to carry a workers' compensation policy covering the undersigned corporate officer(s) or director(s). I/We the undersigned do also waive any and all rights to make claims for benefits as defined in M.G.L. c. 152 for any injuries that may be sustained while in the employ of the above-named corporation. Further, I/we the undersigned do understand that, should the above-named corporation hire or have in its employ any employee(s) in addition to the undersigned corporate officer(s) or director(s), said corporation is required to obtain workers' compensation coverage for the employee(s) as prescribed by M.G.L. c. 152, §25A. I/We the undersigned have read and understand the statements and obligations as delineated above and I/we have checke he appropriate box below my/our name(s) indicating my/our desire to be exempt or not o be pt ir the provisions of M.G.L. c. 152. ed under t pains and penalties of perjury: Barry Cames, President 04/3/2012 Si ature Print Name & Title Date (mm/dd/yyyy) wish to exercise my right of exemption or [] I wish NOT to exercise my right of exemption Anastasiya Carries, Director Signature Print Name & Title I wish to exercise my right of exemption or ❑ I wish NOT to exercise my right of exemption 04103/2012 Date (mm/dd/yyyy) Signature Print Name & Title Date (mm/dd/yyyy) F1 I wish to exercise my right of exemption or F� I wish NOT to exercise my right of exemption Signature Print Name & Title Date (mm/dd/yyyy) El I wish to exercise my right of exemption or ❑ I wish NOT to exercise my right of exemption Note: ALL ELIGIBLE CORPORATE OFFICERS MUST SIGN. THERE CAN BE NO MORE THAN 4 SIGNATURES. 1nS&1tC i0ns on back. Form 153 — 7/2010 MA SOC Filing Number: 201287835330 Date: 5/30/2012 9:10:00 PM The Commonwealth of Massachusetts No Fee William Francis Galvin i Secretary of the Commonwealth, Corporations Division One Ashburton Place, 17th floor Boston, MA 02108-1512 Telephone: (617) 727-9640 1. Exact name of the corporation: A. B. CARNES, INC. 2. Current registered office address: Name: BARRY S. CARNES No. and Street: 30 ARROWHEAD FARM ROAD City or Town: BOXFORD State: MA Zip: 01921 Country: USA I 3. The following supplemental information has changed: a i _ Names and street addresses of the directors, president, treasurer, secretary Title Individual Name Address (no Po Box) First, Middle, Last, Suffix Address, City or Town, State, Zip Code PRESIDENT BARRY S. CARNES 30 ARROWHEAD FARM ROAD, BOXFORD, MA 01921 USA TREASURER BARRY S. CARNES 30 ARROWHEAD FARM ROAD, BOXFORD, MA 01921 USA SECRETARY BARRY S. CARNES 30 ARROWHEAD FARM ROAD, BOXFORD, MA 01921 USA DIRECTOR BARRY S. CARNES 30 ARROWHEAD FARM ROAD, BOXFORD, MA 01921 USA DIRECTOR ANASTASIYA CARNES 30 ARROWHEAD FARM ROAD, BOXFORD, MA 01921 USA X Fiscal year end: October i X Type of business in which the corporation intends to engage: { j GENERAL CONTRACTING & MARKETING X Principal office address: t No. and Street: 30 ARROWHEAD FARM ROAD City or Town: BOXFORD State: MA Zip: 01921 Country: USA X its principal office _ an office of its transfer agent an office of its secretary/assistant secretary _ its registered office Signed by BARRY S. CARNES, its PRESIDENT on this 30 Day of May, 2012 j i © 2001 - 2012 Commonwealth of Massachusetts { All Rights Reserved i MA SOC Filing Number: 201287835330 Date: 5/30/2012 9:10:00 PM THE COMMONWEALTH OF MASSACHUSETTS I hereby certify that, upon examination of this document, duly submitted to me, it appears that the provisions of the General Laws relative to corporations have been complied with, and I hereby approve said articles; and the filing fee having been paid, said articles are deemed to have been filed with me on: May 30, 2012 09:10 PM WILLIAM FRANCIS GALVIN Secretary of the Commonwealth 4f Massachusetts - Department of Public Safety - Board of Building Regulations and Standards Construction Super%kor License: CS-000230 _ i. BARRY S CARNES 30 ARROWHEAD FARM RD Boxford MA:01921 IsA Expiration Commissioner 03/07/2014 c Office of Consumer Affairs and Business Regulation ;- 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 100733 Type: Private Corporation Expiration: 6/23/2014 Tr# 223142 A. B. CARNES, INC. Barry Carnes 30 Arrowhead Farm Rd. Boxford, MA 01921 Update Address and return card. Mark reason for change. F'Address 7.. Renewal Employment 7� Lost Card )PS -CAI 0 50M•04/04 -G101216 NORTH ANDOVER WASTE AFFIDAVIT As a result of the provisions of MGL Ch.40-s54, I acknowledge that as a condition of building permit # all debris resulting from the construction activity governed by this building permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL Ch.111-s150A. Waste Disposal or Solid Waste Facility: ALLIED WASTE Address: 300 FOREST ST Town/City, State, Zip: PEABODY, MA 01960 NAME OF HAULER: AB CARNES, INC. DUMP TRUCKS DATE: 4-4-13 SIGNATURE OF APPLICAN' From Rapo Jepsen Insurance 1.5U8.8/5.5885 Fri uct 5 U1:315:71 zu1L m3I rdye i vI c ACOR-DCERT'IFICAT'E OF LIABILITY INSURANCEDATE(MMIDDIYYYY) 10/Os/2012 THIS CERTIFICATE -IS ISSUED AS A MATTER OF iNFORMAT.ON ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and Conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemerd(s). PRODUCER Rapo & ]epsen Financial and Insurance Services 1103 Commonweal th Ave Boston; MA O221S Boston NAME: a"c"x;617.783.1160 AIC Ne: 617. 793. 2062 ADDRESS: WSURER(S)AFFORDING COVERAGE NAICY INSURERA: Nautilus InsurancEe Company INSURED Manue Jacinto Lema 12 Wall St Apt 1 Brockton, MA 02301 INSURERS: Liberty Mutual Insurance CO. pNSURERC: INSURER D: INSURER E: INSURER F : rnv�oanGR CERTIFICATE NUMBER: A.B. CARNES INC REVISION NUMBER: THIS IS TO CERM THAT THE POLICIES OF INSURANCE LISTED BELOW RAVE BEEN IMUED 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 SHOV N MAY HAVE BEEN REDUCED BY PAID CLAIMS. . LTR TYPE OF INSURANCE R WVD POLICY NUMBER MM/D LIMITS A GENERAL LIABILm COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F—I OCCUR I NN229621 04IM2012 04126/2013 EACH OCCURRENCE S 1,000,000 PREMISES Ea o=mw=l $ SO,O MED EXP (Any one person) S 5,000 000 - PERSONAL&ADV INJURY S 1.000.-0." GENERAL AGGREGATE 5 2 , 000 GENERAL GENL AGGREGATE LIMIT APPLIES PER, POLICY L7 JEC ! LOC PRODUCTS -COMPIOPAGG S 2,000,0 1 AUTOMOBILE LIABILITY ANY AUTO ALL OWNEDSCHEDULED O NON-OWNED HIREDAUTOS AUTOS ( CQMtMNktD`bS Ea accident $ BODILY INJURY (Per person) S BODILY INJURY (Per accideN) S Per aoadent S S UMBRELLA UAB EXCESS UAB OCCUR CLAIMS MADE EACH OCCURRENCE S AGGREGATE 5 a DEC) RETENTION S B WORMRSCOMPENSATION AND EMPLOYERS' LIABILITY YIN OFFICERIMEMBERREXC UD ?D PROPRIETORIPARTNERJEXECUTIV ANY EM (Mends" M NH) descrbeunder irDESRIPTION OF OPERATIONS below NIA 4 WC2-;:1S-381563-02 0611Z/2012�0811212013 I TORYLIb11TS ER.. _-- -._.----- E.L. EACH ACCIDENT S 1,000,000 E.L. DISEASE • EA EMPLOYE S 1,000,000 E.L. DISEASE-POLICYLiM1T $1 000 0 I 1 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, AddlUonal Remarks Schedule, N more space Is n -UM) afAt, i iTOAle CERTIFICATE HVL.DEft - - FAX: 978.8$7.1432 SHOULD ANY OF TME ABOVE D C POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THERE F. E WILL BE DELIVERED IN ACCORDANCE W17H THE POLE f NS w AUTHORIZED REPREUF:N I'Tp / A.B. CARNES INC �� 30 ARROWHEAD FARM RD 80 FORD r MA 01921 © logo- O AC ORPORATION. All ACORO-25 (2010105) The ACORD name and .ogo are regia mark of ACORD OP ID: SA CERTIFICATE OF LIABILITY INSURANCE DAT F INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER 03113D/YYYY) 03113!13 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 978-744-6715 NAME: CONTACT AHMED Insurance Agency, Inc. 978-741-0127 PO BOX 449 PHONE FAX AIC No Ext;- Salem, MA 01970 _ (A/C NoZ: EMAIL - - Stephen G. Ahmed ADDRESS:PRODUCER - - — 50,00 ABCAR-1 CUSTOMER ID #_ ---INSURERS AFFORDING COVERAGE NAIC # INSURED A B Carnes Inc INSURER A: Essex Insurance Co 30 Arrowhead Farms Road INSURER B:Safety Insurance Compal 33618 Boxford, MA 01921 - --- INSURER- 2,000,00 INSURER D PRODUCTS - COMP/OP AGG $ INSURER E: X i POLICY I PRO I Loc INSURER F: ------- ----------------- r\cvW V1\IYVnflor- C: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO PERIOD WHICH CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THIS THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUB POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY -- -- , LIMITS - GENERAL LIABILITY I EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY 3DF9266 03/18/13 03/18/14 r ! _--' ;_6AMAGE TORENTED PREMISES Ea occurrence $ - - — 50,00 CLAIMS -MADE L X� OCCUR j--��-- -- -- - ! MED EXP (Any one person) -i $ —1,00 PERSONAL 8 ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 jGENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,00 X i POLICY I PRO I Loc PD Deduct $ 500 AUTOMOBILE I' LIABILITY COMBINED SINGLE LIMIT r (Ea accident) $ 1 000 00 , ANY AUTO ALL OWNED AUTOS i BODILY INJURY (Per person) r $ B X I SCHEDULED AUTOS , 6213192 05/02112 I 05/02/13 BODILY INJURY (Per accident) i $ -- — -- B X I HIRED AUTOS 6213192 05/02112 05/02/13 ; PROPERTY DAMAGE (Per accident) $ In B I X NON -OWNED AUTOS 6213192 05/02/12 05/02/13 $ ! UMBRELLA LIAB L� !OCCUR j EXCESS LIAB I CLAIMS -MADE ! EACH OCCURRENCE $ -- - - — i ----- ----- --- L J-------- � AGGREGATE_ _ _ _ !$ (� DEDUCTIBLE ! RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N WC STATU- 0TH - __T LI ISS __ER.� ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A ( E.L. EACH ACCIDENT $ - - (Mandatory in NH) If yes, describe under E.L. DISEASE - EA EMPL$ EE -- - -- --- —_ _ DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ I I I i i I � DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Roofing Contractor TOWNN04 Town of North Andover 120 Main Street North Andover, MA 01845 iMu 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 W I"0-ZUU11 Ak UKU L;LJKPURATION. All rights reserved. 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