Loading...
HomeMy WebLinkAboutBuilding Permit #344 - 74 STONECLEAVE ROAD 11/28/2009 O�NLu b,gti0� BUILDING PERMIT TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION y� Date Received RATED 0,` C3Permit N0: 9SSACHV`��� Date Issued: ll leLof —IMPORTANT Applicant must complete all items on this page .. cz:.. ern, Q *yea. £ ce< Y•rx a .y�,i '- . � -iq i •Fad LOCITIC+N, 3 , E s "pROPER TQ�©WNER J � fIt � t x44 i'dki I T1� � stot Des tct s b !{AI' O Ills TYPE OF IMPROVEMENT PROPOSED USE Resitial Non- Residential ❑ New Building One family Addition ❑ Two or more family ❑ Industrial [I Alteration No. of units: 0 Commercial [I Repair, replacement ElAssessory Bldg nOthers: [I Demolition [I Other Faodla�n Cetlands N4�latshec strt> e ttC ell k k ` Waer�r]t Sewer�,.� �..;,,u. . �c;i��F°.•.', ` - ��' PREFORMED: RK TO BE WO DESCRIPTION O D• 4 I /7[ jP identification Please Type or Print Clearly) OWNER: Name: Phone: , Address: r roveti CO{ TRACTR eim t �# i Address x ' x �t Superv1s 'sCons#rctaoi rceaase 5 , t Xp Dai r �=ia..ate. �Ho�e l�rn§pt-��reme�t License ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$1/2.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 6,5`17 �/ 6 � — FEE: $ Check No.: o y Receipt No.: 2 NOTE: Persons contracting wit11 unregistered contractors do not have access to the guaranty fund A .~ 77 Signature of contactor Signature of p;gent/Owner M . �_ _, k- 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 F1 DATE COMMENTS DATE REJECTED DATE PR ED CONSERVATION ❑L . 7 0 COMMENTS hmh DATE REJECTED DAT PROVED HEALTH El ❑ c> a9 COMMENTS �-��-,..� T u l.-U ✓'GN* '��d pr L dh ! ✓�7b jr.�s G Zoning Board of Appeals: Variance Petition No: Zoning Decision/receipt submitted -yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/sic nature A r)ate Located at 384 Osgood Street Drivewav Permit FIRE DEPARTt171ENT Tsmp to Du it ., raps r on s Located at�24�/la�r St�ee#�' Ftre Department s�gna, Idate _w+''r �... . COENTS h roK X fra-t ( VC `M,.dc G', t Z •sp b ^R Dimension Number of Stories:_ Total square feet of floor area, based on Exterior dim ensionsQ�;�'G� Total land area, sq. ft.: �� 576 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) F7_ L::: l Notified for pickup - Date Doc.Building Permit Revised 2007 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 o 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 o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster, permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location 7 47n No. 3 V9 Date NOR,h TOWN OF NORTH ANDOVER D ` Certificate of Occupancy $ -TS Mus9 '� Buildin /Frame Permit Fee $ �cE Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 7-fl r Check # Q T 2252 Building Inspector Daniel J.Parker,A.I.A. A R C H I T E C T 158 Gale Avenue Bradford,MA 01835 Architecture ♦ Planning ♦ Project Development Voice/Fax:978-373-2446 January 8, 2010 Doug Legare TWOMEY & LEGARE CONTRACTING P. O. Box 366 North Andover, MA 01845 R�zs �ddit i onecleave Road l�Andover A Framing Inspection Dear Doug, Per your request, I visited the Project on Friday, 01/08/2010 to review the framing of the addition for the Project noted above. During the visit I reviewed all framing members including the LVL's, beams, rafters and joists and observed that the materials and connections installed to be consistent with the Project specifications and the installation to be in compliance with the details shown on the construction drawings that were submitted for the building permit. It is my professional opinion that the framing appears complete per the construction drawings. If you should have any questions, please feel free to give me a call and I'll be glad to discuss them with you. ours truly, `S,��RED AP CyiTF s CO A.LA, H"ERHILL, 4, Daniel J. Pa � MASS, Architect NORTH Tovm OfAndover . .4 _ No. TO 34V - p w �'� 2.1 o ' dover, Mass., I� COCHICHEWICK AORATED `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT / ... (�...... / "`. .. Foundation y . ........ buildings on ...... ... .. has permission to erect...........................:... g ,71..............4. '.0/.. �✓ .c...�'�.�....................... Rough <B-�� / to be occupied as.................. y. .... ... ......... .......:......... .......� ...� D c?. ................................ Chimney . . . . . . .. . .. provided that the person accepting this permit shall in every respict conform to the terms of the application on file in Final 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 PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS Rough ... ..... .e...%Vrc ,..... ............................ Service UILDING INSPECTOR Final Occupancy' Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To BeDone FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. rr®J ect Total October 22,2009 And payment schedule Job total $651,650.00 1s` Payment on signing. $10,000.00 $55,650.00 2nd Day construction starts. $12,650.00 $43,000.00 3'd Completion of framing& roofing. $15,00000 $28,000.00 4'* Completion of all rough inspections. $10,000.00 $18,000.00 5t" Completion of blue board plaster. $8,000.00 $10,000.00 6'* Completion of Interior trim and tile. $7,000.00 $3000.00 Final Payment $3,000.00 Completion of painting and final inspection. r ;gnDate C o Proposal Twomey & Legare Contracting Inc. Building&Remodeling Office 978-685-7447 P.O.Box 366 Fax 978-685-7446 978-556-1547 No.Andover Ma. 01845 October 21,2009 To: Clyde &Joan Hall 74 Stone Cleave Road. No. Andover Ma. 01845 Ref: Addition/Family Room Thank you for the opportunity to quote the following project. The TWOMEYAND LEGARE CONTRACTING price is based on our discussion on August 17,2009 concerning your project at the above address. The following is a description of work as discussed. • 14 x 22 Addition to Include porch with steps to grade 1. Contractor to contact Massachusetts Dig Safe prior to excavating 2. Excavate as required for footings 3. Frame height to be determined on site 4. Demo to include removal of siding at addition location,removal of window and existing deck. 5. Addition to have a clipped ceiling to plan. 6. Structures to be built according to plan provided by owner in accordance with these specs. 7. Floors to be 2 x 12 joists. 8. Floor sheathing to be 3/4""Advantec plywood. 9. Walls to be 2x6 construction. 10. Wall sheathing to be '/2"OSB plywood. 11. Ceiling joist to plan. 12. Roof rafters to plan. 13. Roof sheathing to be 5/8"CDX plywood. 14. Install ice and water shield 3 ft up from eves and in valleys. 15. Roof addition with 25 years shingle match as close as possible to existing. 16. Wrap exterior walls with Tyvek house wrap. 17. Siding to be cedar clapboard 4"exposure. (match as close as possible) 18. Tran on addition to be primed pine trim. 19. Insulate addition to code. t a y J, 1 ' 20.Drywall in addition to be V27'blueboard w/uncal plaster, smooth walls and sand swirl ceilings or light skip trowel. 21. Interior trim to match as close as possible. 22. Interior painting by contractor in new room and bath room. 23. All new door knobs to be schlage. 24. Disposal of debris by contractor. 25. Stamped construction drawings by owner.And permits by contractor. 26. Contractor to grade area with existing material. Lawn will be disturbed by general foot traffic. 27. Deck to have Timber tec decking and rails. Choice of 3 stock colors. Cedar/redwood and gray. Rail option white. 28. Any additional landscaping by owner. 29. If ledge is encountered,removal cost is not included and damage of underground unmarked utilities not included. 30. Plot Plan by owner. • Plumbing 1. Baseboard heat to continue of existing boiler on it's own zone. • Electrical 1. 1-Center light/fan combo-fixture by owner. 2. Interior outlets to code. 3. 1- Porch light location-fixture by owner. 4. Switch locations as needed. 5. 1-flood light- fixture by owner 6. 1- Smoke/Carbon sensor combo detector to code. (Main house not in cost of project) 7. 1-cable 1-phone • Window specs 1. All Anderson windows to plan. • Exterior Door Specs. 1. Anderson to plan. 1 ,f • Interior Door Specs. ,r 1. Double active French door unit. 2. Door for laundry not in cost of job. Owner to decide after frame is complete. • Flooring Tile to match kitchen. • Allowances 1. Tile-$1,500.00 2. Heat- $2,000.00 Based on old system. **Any additional items not listed above are not included in total cost.** Thank you for considering TWOMEYAND LEGARE CONTRACTING for your project. Please feel free to call with any questions or concerns at 978-685-7447. Respectfully, Shaun Twomey 1 ign Date t .i Twomey & Legare Contracting, Inc. Professional Building / Remodeling P.O. Box 366 North Andover, Ma 01845 North Andover 978.685.7447 Haverhill 978.556.1547 CONTRACT 1. Date of Contract Signing: ATIY6141( 2. List of documents part of this agreement: A. Contract B. Proposal/ Specifications C. Drawing(see Exhibit C) D. Payment Schedule (see Exhibit D) E. Limited Warranty (see Exhibit E) 3. Parties to Contract: A. Contractor: Twomey&Legare Contracting, Inc. Shaun Twomey/Doug Legare Federal ID# 20-3436110 Address: PO Box 366 No. Andover Ma 01845 Contractor Registration No: 136779 B. Homeowner: Clyde&Joan Halll 74 Stone Cleave Road North Andover Ma, 01845 Ph. 978-686-2348 October 21, 2009 4. Description of work to done and the materials to be used: See Specifications(see Exhibit B) 5. Total amount agreed to be paid for work to be performed under the contract: 6. Time schedule of payments to be made under the contract,finance charges for late fees, if any. See Payment Schedule(see Exhibit D) *Any deposit required to be paid in advance of the sit o€the work shall not exceed one- third of the total contact price or actual cost of any mattaial Of eq*mOt of a special or custom made nature,which must be ordered in advance of the start of work to assure that the project will proceed on schedule.No final paynumt shall be demanded until the contract is completed to ft salon of all parties. 7. A.Date work is scheduled to begin: See No. 14 - B. Date work is scheduled to be substantially completed: See No. 14 8. Notice: A_All home improvement contractors and subcontractors shall be registered and that any inquiries about a contractor and subcontractors shall be iregistavd and that any inquires about acontractor or subcontractor relating to a regishatiion should be dhWrd to: Director,Home Improvement Contractor Registration One Ashburton Place,Room 1301 Boston,Massachusetts 02108 Telephone No.(617)727-8598 B.For contractor's registration number,see top of first page. C.Homeowners have a three-day cancellation rights under MGL c 93 §48;MGL c 140D § 10 orMGL C 255D§ 14 as may be applicable(see attached Notice of Cancellation). D.For owner's warranty rights, see 780 CMR R6 and MGL c 142A. 9. There is no lien or security interest on the residence as a consequence of this contract. 1 O.Permit Notice: A.The following permits will be required in connection with the work to be performed on your property: Building-Electrical-Plumbing . B. It is the obligation of the contractor to obtain these permits as the owner's agent. 2 C.Any owner who secures their own construction-related permits or deal with unregistered contractors shall be excluded from access to the Guarantee Fund. 11. Contractor reserves the right when he deems himself to be insecure to require as a prerequisite to continuing work that the balance of funds due under the contract, which are in possession of the owner,shall be placed in a joint escrow account requiring the signatures of the home improvement contractor and the owner for withdrawal. 12. The parties agree that no work shall begin prior to the signing of the contract, transmittal to the owner a copy of the contract and the expiration of any applicable rescission period. 13.Arbitration Clause: The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this contract, the contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulations and the consumer shall be required to submit to such arbitration as provided in MGL c 142A. 14. Other Provisions: A. Commencement of Work/Completion-Contractor agrees to proceed diligently with the agreed upon work,commencing promptly following: • The completion of the Title V installation and certification of compliance by the town. • Issuance of a building permit by the town. • Estimated date of completion: • Completion date shall be automatically extended by the number of days equal to those on which seller shall be prevented or hindered from completion due to weather conditions, other acts of God,inability to obtain materials or schedule due to delays caused by homeowner's selection process or change of orders, and/or failure of homeowners to make timely payments as agreed. B. Final payment shall be upon the satisfaction of the homeowner. The parties agree that the issuance of a certificate of occupancy shall be the objective standard that the contract has been completed and the parties satisfied. Any punch list shall be reduced to writing,with a date for completion. The parties agree that no escrow will be held for punch list items. 3 �1 to rovide evidence of liability,worker's compensation J D.Insurance-Contractor agrees p and other risk insurance.Owner agrees to provide copy of hazard insurance as is required by contractor to coordinate policies- Owner. Con or. Notice:The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by the contractor.The owner may initiate alternative dispute resolution even where this section is not signed separately by the parties. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Owner Date ontractor D to Ado.. O e D Contractor Date 4 TI ol rN- '"t d Stan of Building ' i Board sor,jcense Construction Super j use; CS 67560 1 1 ' Birthdate 1012511966 Tr# 6403 E16ot a512009 - F{�sstrictiop 00 , S"''U N M T1IVOMEY ��-_ 61 PAYOR ST Coruml peer N ANDOVER,MA 01845 y - ✓tae�arrz+�u»�c 't!!� ✓jlacaa�u,�e� Board of RmMing Reg6tati n.,and Stznuards HOME IMFROVEMENT CONTRACIG'JR Rer-bation: 136779 Expiration: 8,/26/2010 Tri- 272934 TWOMEY+LEGARE CON-TWIC PING INC. SNAm wvoO iY 61 MAW ST.' N.A.WOOVER,MA 01 is%ia i: Ada'iagtMer - Massachusetts- Department of Pulzlic SafetN Board of Buildtin<-Regulations and Standards Construction Supervisor License License: CS 55108 Restricted to: OQ DOUGLAS J LEGARE 79 GARY AVE HAVERHILL, MA 01830 Expiration: 9/2/2010 ('nnmissiuud'r Tr#: 3242 ClfenW.13MO TWOMEY6 ACORD- CERTIFICATE OF LIABILITY INSURANCE p ip9m MUM= THIS CEffnFICATE IS ISSUED AS A MATTER OF INFORMATION Doherty insurance Agency.Inc. ONLY AND CONFERS NO RIMITS UPON THE CERTIFICATE P.O.Box 1985 ALTER THIS CERTIFICATE DOES NOT AMEND.EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 21 Ehn Street Andover,MA 01610 INSURERS AFFORDING COVERAGE MAIC 6 o BSURERA. ArbeOa Protection his Company Twomey 8 Legere Contracting,Inc. INSURER& PO Box 366 n4SRIRER c North Andover,MA 01845 Il91l1RER o: RARER E COVERAGES THE POUCIES OF IISURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURE)NAMED ABOVE FOR THE POLICY MOM INDICATED NOTWITHSTANDING ANY REOIUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER OOCUMf U WITH RESPECT TO WHICH THIS CERTIRCATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN G SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POWES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MOM LNsm TYPE OF 11M)PANCE POLICY NUiNIEtLmlTB A GENERALUAINIM BS0004325S 06mm 06=0 EACH OCCURRENCE SI.M.000 X COMMERCIAL GENERAL LIA112M DAMAGE TO RENTED 5100 CLAIMS MAOE a OCXIR FED EXP(Anj a w partoa) S5AW PERSONAL 6 ADV INJURY SIM,000 GENERAL AGGREGATE S 000 GENL AGGREGATE LIMIT APPLIES PER: PROO{ICTS-COUPIOP AM $Z008,000 X POLICY PR4 LOC AUTOMOBILE LIA911 Y COMBINED SINGLE LWT ANV AUTO maS ALL OWNED AUTOS SCHE018ED AUTOS (PWP-) 5 HIRED AUTOS 8OD0.YBWURY $ �NOINOWNEDAUTOS LeerPROPERaeoasra) Np_acaft"lTY 1DAIRAGE S GARAGE LIABILITY AUTO ONLY-EAACCIDENT S ANYAUTO OTHERTNAN EAACC S AUTOONLY: AGG S MO<CE3SAIMBREI.I I"I m YTY EACH OCC URItE N E S OCCUR CLANS MADE AGGREGATE S S DEDUCTIBLE S RETENTION $ PR S TPmllletSCATWIAFD tVCSTATU TH 6NPLOYERS'UABLL1rY E.L.EACH ACCIDENT $ ANY OFFICERIMEMBEREXCLUDE07 ELDISEASE-EAEMPLOYEE S STes.I ander SPECIAL pRDIASHON5paHar: E.L.OSEASE-POLICY UMIT S OTHER DESCRIPTION OF OPERATNNIS I LOCATIONS I VE10CLESIEXCUISDNS ADDED BYENDORSBUNT I SPECIAL PROVISKM Covering operations Malum to the insured... CERTIFICATE HOLDEk CANCELLATION ANY OF THE AYE POMCESBE BEFTb1E THIE EI�BTATIOM Town of North Andover TETf1EREOF.THEISSUOIGNStltNTLLENOEAYOIRTOMAiL �0_ oAYSWRrtTEx 1600 Osgood Street NOT=TO TIE CERTIFICATE NOUNR RAISED TO THE LEFT.eUT FALURE 10 00 80 SHALL North Andover,NIA 01845 OHOMKOGRUGAIMORUABIMOFMYMCUPWIMOMWMLIMAGEMSOR ATIVES ACORD 25(260 IMI of 2 #325239MMS234 L 0 ACORD CORPORATION 1986 141fjllvl un ani v -Lc / iVr &.VVU U.VO.OV MLV YHUF.., of VVJ F&A 001 YOL ACORD. CERTIFICATE OF INSURANCE DATE(MWDMYY) 12-16-08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE DOHERTY INS AGENCY HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 21 ELM STREET' ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO BOX 1985 COMPANIES AFFORDING COVERAGE ANDOVER,VIA 01810 COMPANY 22YV11 A TRAVELERS INDEMNITY COMPANY INSURED COMPANY B TWOMEY&.1,EGARE.CONTRACTING 1NC COMPANY PO BOX 360 C NORTH.ANDOVER.MA 01845 COMPANY D COVERAGE 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. CO POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM0DiYY) DATE LIMITS GENERAL UABLITY GENERAL AGGREGATE $ COMMERCIAL GENERAL PRODUCTS-COMP/OPAGG. $ CLAIMS MADE OCCUR- PERSONAL&&ADV.INJURY $ OWNER'S&&CONTRACTOR'S PROT. EACH OCCURRENCE FIRE DAMAGE(Any one fire% $ MED.EXPENSE;Any one perm) AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL CANNED AUTOS BODILY INJURY(Per Person) SCHEDULE AUTOS BODILY INJURY(Per Accident) $ HIRED AUTOS PROPERTY DAMAGE $ NON-OWNED AUTOS GARAGE LIABILITY ANY AUTOS AUTO ONLY-EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGREGATE $ EXCESS LIABILITY UMBRELLA FORM EACH OCCURRENCE $ OTHER THAN UMBRELLA FORM AGGREGATE $ WORKER'S COMPENSATION AND A EMPOLYER'S LIABILITY UB-0290M994-08 09-18-08 09-18-D9 STATUTORY LIMITS x THE PROPRIETOR' EACH ACCIDENT $ 500.000 PARTNER&EXECLITIVE INCL DISEASE-POLICY LIMIT $ 500,000 OFFICERS ARE: X EXCL DISEASE-EACH EMPLOYEE $ 500,000 OTHER DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLESlRESTRICTIONSiSPECIAL ITEMS THIS REPLACES ANY PRIOR CERIIPICATE ISSUED TO T HE CERTIFICATE HOLDER AE'FP.CRNO WORKERS CO.MY COVERAGE. CERTIFICATE HOLDER CANCELLATION SHOULD ANI'OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TO WN OF NORTH ANDOVER EXPIRATION DATE THEREOF,THE ISSUING COMPANYYYILL ENDEAVOR TO MAIL 10 DAYSWRITTEN NOTICE TOTHE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT 1000 OSGOOD STREET FAILURE TO\bkIL SUCH NOTICE SHALL IMPOSE NO OELIG.ATION OR LIABILITY OF ANY HIND UPON THE COMPANY.IT$AGENTS OR REPRESENTATIVES. NORTH ANDOVER,MA 0184 AUTHORIZED REPRESENTATIVE ACORD 25.5(3193) Charles 1 Clark The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street_ Boston, 1WA-02111 www.mass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Legibly Name(Business/Organization/Individual): A--,/6 t( , „C, 1!!�It L i Address: J� / 1 City/State/Zip: Phone#: � AByl ou an employer? Check the appropriate box: Type of project(required): 1. am a employer with�_ 4. ❑ I am a general contractor and I 6. ❑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 sheet.1 7• ❑ Rem deling ship and have no employees These sub-contractors have 8. ❑ olition working for me in any capacity. kers' comp. insurance. 9. Building_addition [No workers' comp. insurance 5.0 We are a corporation and its required.] officers have exercised their 10.[:1 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.❑ Other comp. insurance required.] A.... I' that ect... ..�1 ... --'So C. .� - r.a-applicant th the m-bon 11 m-= 0 out the section below showing their worlrPrg'on-mnencation phi mL-rmation. 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: p Policy#or Self-ins. Lic.#: �`l �f� �/��I��CF�� Expiration Date: _ lzll�l-,125i Job Site Address: '��� f ,�'��,i„c ;� City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as 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 th pains d penalties of perjury that the information provided above is ue correct: Si ature: Date: `r Phone#: � Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit(License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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 apartrnents 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." Applicants 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 permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog Iicense or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would Iike 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 Invesfigations 600 Washington.Street Boston MA 021.11. Tel. 4 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-72.7-7749 NAr"rw.mass.govfdia N/F NEW ENGLAND POWER CO. 107.67 -•� _ moi, r ,2156 RECORD OWNERS: $• CLYDE M. & JOAN F. HALL 74 STONECLEAVE ROAD N/F NORTH ANDOVER, MA JEFFREY A. REFERENCES DEED BOOK 1350, PAGE 6 01 & SANDRA MERIDIAN� BAS PLAN 7906 ED ON PC MUSE AN 7906 j' J t cp 0 f PROPOSED NOTES: 1 STORY 1 ) THIS PLAN WAS PREPARED TO SHOW A PROPOSED ADDITION RELATIVE ADDITION TO PROPERTY LINES AND ACCOMPANY A BUILDING PERMIT APPLICATION.� � 2.) THE PLAN WAS PREPARED BY PERFORMING AN INSTRUMENT SURVEY IN AUGUST OF 2009. r I I-'pl> 'fel 3.) NO UTILITY LOCATION, RESEARCH OR PLOTTING PERFORMED. 51t�:F'> 'fel 4.) NO TITLE EXAMINATION PROVIDED, THEREFORE OTHER 22 30.2 EASEMENTS NOT SHOWN HEREON COULD EXIST. 1 ��14 �� � 3o MW JO 0 FT ) A 2.0 G TO THE NEW ADDITION AT THE RIGHT REAR CORNER OF THE 3&9 EXISTING DWELLING WOULD ALLOW FOR THE CLOSEST CORNER OF THE N/F F--W59.5' PROPOSED ADDITION TO BE 30.5 FT. FROM THE NORTHERLY PROPERTY LINE. DOUGLAS ;, 4. 2. AS 1lVI } : [) W,[)WELLING PATRICIAN .___��:. `�. �•������x�`�`' �:� =�;M A. BR # , c BARRY I // IN c � €� N/F f f�` 8 JJ//�� dpi % r VAHID & SIMININ PROPOSED 4 N MIRSAIIDI PLOT PLAN 1 OF LAND IN N � � NORTH 0 o 0 ANDOVER, MASSACHUSETTS AT 74 STONECLEAVE ROAD O t CA eJ ` 00 PREPARED FOR �= OF MAS TWOMEY LEGARE CONTRACTING, INC. i LOT 2 8AA _� BY AREA=499688±S.F. IG VANCURA N VANCURA & BRENNAN 0 127 9#36 P 1 JACKSON STREET, NEWBURYPORT, MA 01970 �FESS\Z� TEL. 978-395-1689 FAX 978-463-7947 lq/v) �. INFO &VANCURABRENNAN.COM } 31 /JvcA� 0 20 40 80 160 150.00' ' STONECLEAVE ROAD 8-13-09 1" = 40 FT. 2009036