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HomeMy WebLinkAboutBuilding Permit #439-2017 - 731 JOHNSON STREET 11/2/2016 OORTFf --, BUILDING PERMIT 32�et�,�a.. TOWN OF NORTH ANDOVER ; APPLICATION FOR PLAN EXAMINATION e * Permit NO: 14 Date Received 0 p �'�, : f • q�RArgo Date Issued: L 9SSACHus�t IMPORTANT:Applicant must complete all items on this page if x� �LO�ATIC?Ng'73l f'��o !tsu S''� N 7s� ,r-. .��✓a � y F ":k s Pnnt 17 ROI�ERTY;OWNEI Su��- Print WARO`1\Ip RARCEL - ZONINGISTRICT g Historic District :n yh Machine ShapVallage ;yes no TYPE OF IMPROVEMENT PROPOSED USE Resid ntial Non- Residential ❑ New Building H6ne family ❑Addition ❑Two or more family ❑ Industrial U,'91teration No. of units: ❑ Commercial repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic L1,':tVellp 'Floodplain Wetlands xa © 11Vatershed District ❑Water/Sewer r A�J 1j 6-�'�ru J w� 11 L Li.Ad'1�J S'c wt,eJ /- Identification Please Type or Print Clearly) OWNER: Name: �'Je y' ✓` Phone: J j X- YZ 3- 1 F31 C Address: w✓�- CONTRACTOR Name F'hbne: 4 Address A = F, A Supervisor's Construction License �• Expp Date" " t A j Wome improvement License f� '' " exp ' k y Date ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST.BASED ON$125.00 PER S.F. Total Project Cost: $ y(o (�� • S� FEE: $ ` Check No.: 31 ,-- Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to theuaran d g ry ignature of.Agent/Owner.. Signature of'contractor r j BUILDING PERMIT -ORTH 0 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received SSAC Date Issued: IMPORTANT: Applicant must complete all items on this page [7 77 hOCATTION-i 4 PRO f i5 r RT Y, 0'W N E"R w .— 7 i -"k ar Structure Ms., 1 nP @ Y MAP PAA L ZONIN .. Print Hst dj§tn. yes: no Maehme Shop Village TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building D One family 0 Addition 11 Two or more family 0 Industrial 11 Alteration No. of units: 11 Commercial El Repair, replacement 0 Assessory Bldg El Others: D Demolition ❑0 Other tidA El W-011- Wbt hJkd11 Di' t I Wet! _S r.c.,4, 101W 6tV(/,S.'6W JL. DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: - C -tracto on r 4aftil Email: Add-re-s- 4 151-"U e- itLicense: Exp: ®ate. 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: $ FEE: Che6k No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ignature.,ofOWN(�L- f contractor L lz�� '7— Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/IVlassage/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 Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS f HEALTH Reviewed on Siqnature COMMENTS J Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit i DPW Town Engineer: Signature: Located 384 Osgood Street YFIRE PERARTMEN `Te%F p Dump ter on sityes e ep o, • ;s Y Ntl tiLocated at124xMainfitr etF n ^' b g r . a FreDepartIF W MR mentsc�`iature/date n ,m t _ 4 G Building Department i 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 I ❑ 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 i ❑ 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 I NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the 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 Y Location 6 14,v S 47 No. 41.3C/_ do�� s Date la' ?S'- go/6 • ' TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ H:- Other Permit Fee $ I' TOTAL $ E. r. Check# r� , � Building Inspector 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMENTS CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED • HEALTH � II ❑ ❑ IC COMMENTS SAY,(1 ' S 5 6 I VLanCcm(-�C- r'n 0, bf n- A Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature&Date Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT fEmp Dumpster�n slte `yes `z Ana .Located at 1241Main-Sfreet . s . Fire Department signature/date / . COIVIMEIVTS . T 21. L A4- rs Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 453567.00 m $ - $ 546.80 Plumbing Fee $ 68.35 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 68.35 Total fees collected $ 783.51 731 Johnson Street 439-2017 on 11/2/2016 Kitchen and bath remodel .. ��� � �� � � w � � �,� �- _. d .o• n . '� -'i ' ! � � � � , ,r �� • ) r i ,. � � ` - r r � �� � � y : ,. � � �. � . , �_ _ . � _ � _ � � . � � �i � F� �; x. `� � � t i �' �. �, � � . �. ��.: l� o � � I li � 1� � � �; �r � ..A. _ t � - ,,� \ f°,; e ,.. ._� �.' � _;; '� r,� c10RTF� Town of, O 16 No. it /volio Y h T LAN, h ver, Mass, COC NIC NlWKK y1• I.9 A�RArED S U BOARD OF HEALTH R-M IT D Food/Kitchen P E T Septic System THIS CERTIFIES THAT �11�...P.C-0. .R9..M.a.���!./.!1... .......��.� .................... BUILDING INSPECTOR has permission to erect buildings on ...... ............... Foundation Rough to be occupied as . !!v...... .!�* ...... E/!�� 4.�..`....0�1 IM4. .'............ Chimney provided that the person accepting this permit shall in every respect 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 CONSTRUCT.Tioy START Rough Service ........ ... ....,... .......,.:... .,. Final BUILDING INSPECTOR 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. Darren JSturtevant Home Improvements Description of work to be performed: I Kitchen Gut Kitchen 1200.0 Remove interior wall(s)and install LVL 1500.00 Frame in existing door/window and insulate 75.00 Install subfloor 550.00 Install%" Hardiebacker to floor 460.00 Tile floor(tile not included) 1296.00 Install kitchen cabinets 1300.00 Install backsplash (tile not included) 475.00 Bathroom(main floor) � I Gut bathroom 250.00 Install Hardibacker to shower surround 275.00 Install Hardiebacker to floor 250.00 Install shower tile(labor only) 500.00 Install floor tile (labor only) 450.00 Dining room Frame opening and install French door (includes door, knobs,trim) 920.00 Basement Gut basement 420.00 Strap as needed to receive new plaster 645.00 Frame walls for laundry/utility and new bathroom 1000.00 Install 3 pre-hung door (labor only) 300.00 Sunroom Remove and replace existing roof rafters 2775.55 Replace rolled roofing 450.00 Insulate-walls and ceiling 600.00 Frame and install 30"door(includes door, hardware) 440.00 Wrap exterior trim and sills with coil stock. 600.00 Install laminate flooring(labor only) 1836.00 Dumpster 1200.00 Permit 300.00 Plaster 4100.00 Finish trim work(Fireplace Mantles) 2400.00 ALL MATERIALS TO BE PROVIDED BY HOMEOWNER 22000.00(estimated value) Contractor to supply insurance binder, copy of licenses and building permit. Terms: 1/2 down and final payment upon completion. Total: 46,567.55 f Sue Gavin Darren Sturtevant i 239 " 8 1464" 72" 21 8" j W3036B W3036B 1AV�V�W N F396-3/4 7'_ LU 0 24(3) _ B3 B P2490 IDWR IfM S3309R �L+ m m O O O O 0 M> N ' -� M N ml SB30B M DWR33412 REP2496-3/4" CO B18-L DISH-IQ1 CO CIJ EPB24D R PB- DL EP62CO P624D R M C 00ON LL LL DWR33412 m DWR33412 WF3-3/4 794 REP2496-3/4" All dimensions_size designations This is an original design and must Designed: 9/26/201.6 given are subject to verification on not be released or copied unless Printed: 10/3/2016 job site and adjustment to fit job 2020 applicable fee has been paid or job conditions. order placed. Design B JAII Drawing#: 1 Scale : 0 3/8" = 1' f I t i s v► �J iC, Z ►dfr 4 �,P� 1 nth Vo j4A ! , , _ 1 ' N _ ! i i _. � _ ;__- fir.. .___.- -- - - — ,- -.. _ ✓. I ; • 1 , , f Is } , .II11 , i Ask ©06 3µ" INS n rains 511 a11 0l; �2e wtoVA��C 33" Suva! '�1oav-., Sc.ceie�. I.Z I ! oa+r Ia --sari. .. . . . -. ._. _. - _.. _.... .. .. j 6 1. , 1� _-------.-, I �1 ol re e- i (_. : i _ 4 , , , : bW : e � I I ri I I ! I , 31vcK -_ f i • , : i I I - _ 1 : 1 1 : , -..__...... -_. -.. ,. ...._ i I I i I I �'y I I I ' I q 1. r`e`f 1 .o : _ _ .. ... LwL, w Sa\ IJi77I : - 1 olopwM o �� f ✓ p` lance j ti�vyr! No +n �l�l al s _ % _.,_._ _ • i I _ i ' �I`lynor"'?.� :b u�r�n,5 �3�►aeiv��M pfi� I � ..: : I { i 111 I CTK R!�{ ��a_►►T_gy2{"r�_aliI LAO •_ .3- ydy Lvec ' h 4oCL. 41k,44, F A Gt _ __. r _ 'If x =v. � r t : I i , r ; I i : i Client: Doyle Lumber Date: 9/20/2016 Project: Designer: isDesignT Address: 371 Johnson Street Job Name: Barter North Andover,MA Project#: FB01 2AE PWLVL 1.750" X 18.000" 2-Ply - PASSED Level:Level 1 i .xi. ryk �u,Fey�, � -W+ar�yy +�"- •Y�.•'fikpgy..yrx+ o S, _ Jz H �' - �.�'....-?;?..,e�M*_s�'Irn `;'"". Nr,•-...fir o,,.' �s�" �P'""�# `rG'tk�.,t3'ar°' �:: ,u ._�-:.s^^S!!: 1 SPF -� 2 SPF 20' ' 31/2" 20' Member Information Reactions Type: Girder Application: Floor Brg Live Dead Snow Wind Const Plies: 2 Design Method: ASD 1 4800 1761 0 0 0 Moisture Condition: Dry Building Code: IBCIIRC 2009 2 4800 1761 0 0 0 Deflection LL: 360 Load Sharing: No Deflection TL: 240 Deck: Not Checked Importance:- Normal Vibration: Not Checked Temperature: Temp<=100°F Bearings Bearing Input In Cap. React D/L Total Ld.Case Ld.Comb. Length Analysis Ib 1-SPF 4.5W, 4.500" 98% 1761/4800 6561 L D+L Analysis Results 2.SPF 4.500" 4.500" 98% 1761/4800 6561 L D+L Analysis Actual Location Allowed Capacity Comb. Case Moment 31599 ft4b 10' 45022 ft4b 0.702(70%)D+L L Unbraced 31599 ft-Ib 10' 31641 ft-Ib 0.999 D+L L (100%) Shear 5456 Ib 1'8 1/4" 119701b, 0.456(46%)D+L L LL Defl inch 0.471(U500) 10'1/16' 0.654(U360) 0.720(72%)L L TL Defl inch 0.644(v366) 10'1/16' 0.981(U240) 0.660(66%)D+L L Design Notes 1 Girders are designed to be supported on the bottom edge only. 2 Multiple plies must be fastened together as per manufacturers details. 3 Top loads must be supported equally by all plies. 4 Compression edge bracing required at 3'10"o.c.or less. 5 Lateral slenderness ratio based on single ply width. ID Load Type Location Trib Width Side Dead 0.9 Live 1 Snow 1.15 Wind 1.6 Const 1.25 Comments 1 Uniform 16.0-0 Top 10 PSF 30 PSF 0 PSF 0 PSF 0 PSF Self Weight 16 PLF 23-2016 STRUCI U Notes chemicals 6.For flat roofs ovine Manufacturer Info i pr proper drainage to Prevent Calwetea st acwred Dasg re is reaponc ne D ay or the Handling&Installation po 6rg Pacific Wgodtech Corp [ t`af S � etnxNrel edaquaq tri tltia aomponem based do fie t.LVL beams must not be cut or drilled 1850 Park Lane �.} design crity of ami tont r a for It is me 2 Refer to manufacturers product information Burlington,WA 98233 NAL resporrsidlty of the customer and/or fire wrbacton to regarding instellabon requirements, ensure the component suitability of the intended ming details,tem strength values,and code 888 707-2285 aPPlicber antl to verify the dimansioris and bade, approvals Damaged wwwpacificwoodtech.com Lumber 3.Damaged Beamstop edge is l teed APA:PR-L233,ICC-ES:ESR-2909 1.Dry service conditions,unless noted othenMse I Deeign assumes top edge is laterally restrained 2 LVL not to be treated with fire retardant or corrosive 5.Provide lateral support at bearing points to avoid lalarel displacement and rotation Beta Citrix Version 16A.041 Powered by iStruct- �„ i e VDAC V y ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (GZZUB-7H70737-7-16) NEW-1 6 INSURER: AMERICAN ZURICH INSURANCE COMPANY 1 NCCI CO CODE: 17965 INSURED: PRODUCER: STURTEVANT, DARREN J MONICA INSURANCE AGENCY 25 ADAMS TERRACE 19 MILL ST LOWELL MA 01852 LOWELL MA 01852 Insured is AN INDIVIDUAL Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 10-04-16 to 10-04-17 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One.of the policy applies to the Workers Compensation Law of the state(s) listed here: MA 0 B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in o_ item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 1000000 Each Accident Bodily Injury by Disease: $ 1000000 Policy Limit Bodily Injury by Disease: $ 1000000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any,listed here: m m COVERAGE REPLACED BY ENDORSEMENT WC 20 03 0GB n m 0 W_. D. This policy includes these endorsements and schedules: r SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE o� .4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 10-07-16 RT ST ASSIGN: MA OFFICE: ZURICH-ORLAN 809 PRODUCER: MONICA INSURANCE AGENCY 78D4C 010650 VDAC ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6ZZUB-7H70737-7-16) CLASSIFICATION SCHEDULE: PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATIONS CODE NO REMUNERATION REMUNERATION PREMIUM SEE EXTENSION OF INFORMATION PAGE SCHEDULE(S) SIC-CODE: 1751 NAICS : 238350 ------------------------------------------------------------------------------------ STANDARD TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 737 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 250 TERRORISM 3 TOTAL ESTIMATED PREMIUM 990 TAXES AND SURCHARGES 37 DEPOSIT AMOUNT DUE 1027MP A/R WCIP Minimum Premium: $ 500 EMPLOYERS LIABILITY MINIMUM: $ 75 ST ASSIGN: MA DATE OF ISSUE: 10-07-16 RT OFFICE: ZURICH-ORLAN 809 PRODUCER: MONICA INSURANCE AGENCY 78D4C m e ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE-SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (GZZUB-7H70737-7-1 6) INSURER: AMERICAN ZURICH INSURANCE COMPANY INSURED'S NAME : STURTEVANT, DARREN J 17965-MA RATE BUREAU ID: 001071877 PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM LOCATION 001 01 FEIN 012608294 ENTITY CD 001 STURTEVANT, DARREN J 25 ADAMS TERRACE LOWELL, MA 01852 SIC CODE : 1751 NAICS: 238350 MASONRY NOC 5022 IF ANY 9.70 STONE , MOSAIC, TERRAZZO OR TILE WORK - INSIDE 5348 5000 5.12 256 CARPENTRY NOC 5403 IF ANY 11 .00 CARPENTRY - DETACHED ONE OR o'er TWO FAMILY DWELLINGS 5645 5000 8.11 406 i oma. o� ' m m- n O� U Y� DATE OF ISSUE: 10-07-16 RT ST ASSIGN: MA SCHEDULE NO: 1 OF MORE 010651 ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE-SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (6ZZUB-7H70737-7-16) PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM LOCATION 001 01 (CONT'D) CARPENTRY - DWELLINGS - THREE STORIES OR LESS 5651 IF ANY 8.11 ------------------------------------------------------------------------------------ 2 .00% EMPL . LIAB. INCREASED LIMITS(9812) $ 13 ADD FOR INCREASED LIMITS MINIMUM (9848) 62 MERIT RATING/EXPERIENCE MOD: NONE MODIFIED PREMIUM NONE TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 737 EXPENSE CONSTANT(0900) 250 0.0300 TERRORISM (9740) 3 5.60% MA WC SPECIAL FUND AND TRUST FUND 37 TOTAL ESTIMATED PREMIUM 1027 DEPOSIT AMOUNT DUE 1027 I DATE OF ISSUE: 10-07-16 RT ST ASSIGN: MA SCHEDULE NO: 2 OF LAST ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 00 00 01 (A ) POLICY NUMBER: (GZZUB-7H70737-7-16) LISTING OF ENDORSEMENTS EXTENSION OF INFO PAGE We agree that the following listed endorsements form a part of this policy on its effective date. WC 00 00 01 A - 001 INFORMATION PAGE WC 00 00 01 A - 001 INFORMATION PAGE 2 WC 00 00 01 A - 001 EXTENSION OF INFORMATION PAGE - SCHEDULE WC 00 00 01 A - 001 ENDORSEMENT LISTING WC 00 04 14 00 - 001 NOTIFICATION OF CHANGE IN OWNERSHIP ENDT WC 00 04 22 B - 001 TERRORISM RISK INS PROG REAUTH ACT ENDT WC 20 03 01 00 - 001 MA LIMITS OF LIABILITY ENDORSEMENT WC 20 03 02 A - 001 MASSACHUSETTS - ASSESMENT CHARGE WC 20 03 03 D - 001 MA NOTICE TO POLICYHOLDER ENDORSEMENT WC 20 03 06 B - 001 MA LIMITED OTHER STATES BENEFIT ENDT WC 20 03 ,07 00 - 001 MA ASSIGNED RISK POOL ELIGIBILITY WC 20 04 03 00 - 001 MA. CONST. CLASS PREM. ADJ. PROGRAM WC 20 04 05 00 - 001 MASSACHUSETTS PREMIUM DUE DATE ENDT WC 20 06 01 A - 001 MA CANCELLATION ENDORSEMENT WC 20 06 04 00 - 001 MA POLICY DEFINITION ENDT �r— oma. o'er o = of m o� o. o = DATE OF ISSUE: 10-07-16 ST ASSIGN: MA Page 1 of LAST 010652 I The Commonwealth of Massachusetts Department oflndustrialAccidents I 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. Aynlicant Information Please Print Legibly Name(Business/Organization/Individual): bAcra,— 65TJrf-_-U Address: < ADAvA City/State/Zip: L-eu-e-C l VVIA QVyQ Phone Are you an employer?Check the appropriate box: Type of project(required): I.Eg*fam a employer with ( employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $, emodeling any capacity.[No workers'comp.insurance required] 3.❑I am a homeowner doing all work myself[Ido workers'comp.insurance required.]t 9. ❑Demolition { 10❑Building addition 4. 1 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.E]Roof repairs Those sub-contractors have employees and have workers'comp,insurance.: i 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 no 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. 1 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,they must provide their workers'comp.policy number. I am rat employer iliat is providing ivorlters'con:pensatlon insurance for itiy employees. Below is the policy and job site iitf0rination. Insurance Company Name: ev r r 4 %C5 Ife- � Policy#or Self-ins.Lie.#: V G ` Expiration Date: S G�G.tS Job Site Address: � City/State/Zip; /J a—�u 4-4 0Jy�f A44- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). r Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 E 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 I do hereby cern y rinde the pains and penalties ofpetjury that the information provided above is true and correct. Signature: Date: C, Phone#: Official use only. Do not sprite 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 M A�® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/ AE(MM/ 01D 6m THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THE 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), AUTHORIZE11 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 t4 I the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to th certificate holder in lieu of such endorsement(s). PRODUCER A.I.I.Insurance Brokerage of Mass.,Inc. NAME: CONTACT 183 Davis Street PHONE FA/c No)* P.O.Box 1139 ADDRIESS: Douglas MA 01516 PRODUCER INSURERS AFFORDING COVERAGE NAIC& INSURED INSURER A: Darren Sturtevant 25 Adams Terrace INSURER 13: Lowell MA 01852 INSURER C: INSURER D: -INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY 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. ILSR ADDL TYPE OF INSURANCE B POLICY NUMBER PM/DICY EFF POLICY YM EXP LIMITS GENERAL LIABILITY APP61414103 09/28/2016 09/28/2017 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 CLAIMS-MADE �OCCUR MED EXP(Any one person) $ 5,000 PERSONALS ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,000 X I POLICY PROj F LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ I UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION — WC STATU- OTH- AND EMPLOYERS'LIABILITYFR ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Remodeling Contractor CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 384 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD r �. �.a S°'. �.:^A '7�'`t" ', - � -_ a.`Y',�. a,a-._�i '" �- +4�•,.ra u� '�,:'�"'3i x.r'-.,'�^ ,�'� °�' ��`'a. "�:. .w':... .�r...� �xr e;';� ��;�-�. s.t:,fir-' :::i�•-� �,fi- x .,, `��:: �.. .�tii7P '. _.i .. ,:-. �. __., ...R.:`� .,r s. dry.: ,,� m..,� a!"' '��.'"+�, ,.-."�R�.a.� �`t�`<._ ... ,y was ,y s..s� •.-��"'t s��. y-. ��'N`Rbt� -"is.�. .?,i4. y CS-099244 N, ' r s WAINOR DECARVALHO 5 s � 124 WESTFORD ST LOWELL MA 01861 toov 0,ft 1 0"" s .>. x r vu 6 "M 17"I f } : I _ t I , L,q,,►uDAe� lc It�;k , , _ 1 l�J G 3 4�... l�rt'L�T t : : Z4 20 to I : . , t f + W ue 1ke 1°Q M T bCYr`_ : { trCS�h 1 dock; + I _ t ( i , • j • f kl f + S , , 34'" I�t/�Ktob1,� 5�Wa11 0�3 fLe'wioVab�. bo,-,or . 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'-1Q'a/a��- - --- — '- M � i T ,ala i , - i , I _ r Jijj k � 1 e t Darren J Sturtevant Home Improvements Description of work to be performed: Kitchen Gut Kitchen 1200.0 Remove interior wall(s) and install LVL 1500.00 Frame in existing door/window and insulate 75.00 Install subfloor 550.00 Install%" Hardiebacker to floor 460.00 Tile floor(tile not included) 1296.00 Install kitchen cabinets 1300.00 Install backsplash (tile not included) 475.00 Bathroom(main floor) Gut bathroom 250.00 Install Hardibacker to shower surround 275.00 Install Hardiebacker to floor 250.00 Install shower tile (labor only) 500.00 Install floor the(labor only) 450.00 Dining room Frame opening and install French door (includes door, knobs,trim) 920.00 i I