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HomeMy WebLinkAboutBuilding Permit #502-15 - 75 SUMMER STREET 11/25/2014BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: D� Date Received Date Issued: I IMPORTANT: Applicant must complete all items on this nage LOCATION PROPERTY Print 100 Year Structure MAP PARCEL: 303 _ ZONING DISTRICT 2 Historic District 'Machine Shop Village of _ 7`e^ 9 es yes' vess� TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential WNew Building One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other p Septic ❑,Well 0 Floodplain ❑ Wetlands El Watershed District ❑ Water/Sewer Address: rt5 ioneAContractor Name: t f f t6 Phone-­ Address: ddress:[Cf r7y-4vtct5,1'- �i� 12 c Supervisor's Construction :License GS _010 3 7 2 Exp. Date:... % Home Improvement License: .. Exp. Date:._- Lary a5AevA ARCHITECT/ENGINEER (;Z,)y ITN�� sf��! Phone: q 7 8 6&1 b(L i Address: N� R -e-4!4 M11- 01'n vt 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: $ 006 FEE: $ Check No.: V Receipt No.: �30 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent%Owner _ Signature of contractor_ I 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 Reviewed On Signature_ COMMENTS �10 �nl��c►S� �� Sd�- -i• 4%b Sv�A:Vis'*A bcst�n Ns CONSERVATION Reviewed on I U COMMENTS T'' :.0 z�t :E:c i -:0'a HEALTH HEALTH Reviewed on i tvl'- d' — c a7'- Sianature �x COMMENTS 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: uocatea su4s ooa Street FIRE DEPARTMENT - Temp Dumpster on site yes 0 o _ � Located at 124 Main Street Fine Department signature/date _ COMMENTS Dimension -3137 Number of Stories: Total square feet of floor area, based on Exterior dimensions. ` -- Total land area, sq. ft.: / 56 t 3 ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NU I t5 ana UA I A — (1 -or ae nt use ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 M 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 ❑ 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 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 Doe: Building Permit Revised 2014 Location ! Sym M164 S No. ,��j� Date '-. (� "( j . - TOWN OF NORTH ANDOVER -70 Certificate of Occupancy $ bC� &51-0 Foundation Building/Frame Permit Fee 5 Foundation Permit Fee $ Other Permit Fee �JEI TOTAL Check 4t 28303 Building Inspector QE MO °TN q 0 9 '117-O4rr. rrr�5�9 SS.S01 CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 502-15 on 11/25/2014 Date: November 18, 2015 THIS CERTIFIES THAT THE BUILDING LOCATED at 75 Summer Street MAY BE OCCUPIED AS a single family home IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Herrick Development LLC 19 Francis Street North Reading, MA 01864 Building Inspector Fee: PrePaid $100.00 Receipt: 28303 Check: 580 i t -QV— CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 502-15 on 11/25/2014 Date: November 18, 2015 'HIS CERTIFIES THAT THE BUILDING LOCATED at 75 Summer Street MAY BE OCCUPIED AS a single family home IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Herrick Development LLC 19 Francis Street North Reading, MA 01864 Building Inspector Fee: PrePaid $100.00 Receipt: 28303 Check: 580 %f -q—* O J r I 0 Hs LUPC C O N � O Q a) N v E Q, L N CD d • tm (� L r v 1: O 0 V N : O O � J N , o > c d y d o =a,o N '0 'a 0 CL c U Q N O O Z C b0 y O O o�L Q Q d O .0Cl) CD CL + .N Q L L CC F- 0 y t0,) m W O a �_ O O .y Q O N O LL V N 1— LLJ LLJ Lu LU Z cc o +s co LU Q W V `� 5 LL ai CL E cu N i FIY K V ��`\\\ ` OC I.l ii K LL m N to O J r I 0 Hs LUPC C O N � O Q a) N v E Q, L N CD d • tm (� L r v 1: O 0 V N : O O � J N , o > c d y d o =a,o N '0 'a 0 CL c U Q N O O Z C b0 y O O o�L Q Q d O .0Cl) CD CL + .N Q L L CC F- 0 y t0,) m W O a �_ O O .y Q O N O LL V N 1— .Lm c0i � 2 4 .__ 0 'O d O �> ;,= C N O t -W omOcm) O W CL V m '^ CO MC V/ 0 ~ cfl 0 Z V W 0- Z w0 CO ui a Z E O I ♦+ Z CL O N Q! 'c W Q •v�, W W O Gi CL O �+ V O O O Q CL CL c Q O A.) J �,VC O 4) C W v N CLC 0 I -t tee APPLICATION FOR CERTIFICATE OF OCCUPANCYANSPECTION eyy yes w^TE� �pa��y BUII_,DING PERMIT # SACHUS ADDRESS/LOCATION OF PROPERTY: 75 J Utrr of P r s:k Map_ (,P5 Parcel 303 Lot Number SUBDIVISION: DATE REQUESTED FILED/READY FOR INSPECTION: CLOSING DATE ON PROPERTY: FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20.00) WILL BE CHARGED IF THE -STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. „ /i A / Permit Issued to: Address APPLICANT SIGNATURE ROUTING TOWN ENGINEER, SITE PL4N — DRNE-WAY REVIEW"�( CONSERVATION � � � � (� 5 G PLANNING < < DPW -WATER METER SEWER CONNECTION DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCYANSPECTION REQUEST DPW SIGNATURE File: Application for OC form revised Jan 2007/2011 r U n •c E x v Ln co r O M L N IPI EE> rt '^ In n vI O V) z e a Ln LU Z 4,1 0 Z a o F- -Z 00 v OIO m4J N Q 2 00 > O .O 4o O co Z c O C �+ 0 u � O u W ae U- ae w NV v v 5 O qe 0 O rn Ln I21 p Ln u p 0 on 4J w ti w Ul a N ' Y a+ m Z r+ 0 3 c 0 r V on o Ol 41 ro O+ N O In O O O lh H W mCD N N I!'f O, O in C o bLr; T N O U o O Occ m 7p ++ N L ac C a L m li Q u M W = U- " C C N r IA oc y+ v, am+ N E A = u = o C v to N coMN y r N v o O w ' ,Lo, m on _� p er 3Y r _ 7 01 Ol a- IA O t v INA = � R d 0 N N M O 11'1 'O w i r •� C U c Eon o w cu DD Z L C i+ 47 Ln � c u w won O N c a o C Y W w y Q O V y on on 3 o u W ra 4) O 0 On- C� = u = z o_ Vf r U n •c E x v Ln co r O M L N IPI EE> rt '^ In n vI O V) z e a Ln LU Z 4,1 0 Z a o F- -Z 00 v OIO m4J N Q 2 00 > O .O 4o O co Z c O C �+ 0 u � O u N M Ln ,0, to Z 2 co c°�D w ° In Co Go Q` b CD O N N v o 'o u u C O t=n CSD u C r N CD on a0 -i M u L an C/ r S w o y 0 v CD 3 Q.' = m L ra 0 CL +o+ o N w F- v0 0 0 CL c `° x 3 v v o 0 M a N N w Z w w IL L, L w c � > Q E O p LA v 4J on C o m M o v 4' u on 4) u 4A 07 0 CD o O aO o U- -0 0) L C c c j� o _� aI con t Ii • J J d " T L L 011 a .0 O 4) a0+ i fm W C w ' Odl m 4 u u w t =► a ao 0 J 0 v 0 O u L .D 0 O m CF O Y L O •O a> o a v a T on aI = uA w L _ ` L pE avi o w u 0 on o > N m to ap N ra` E C � ®.00 N N c c •� `o C 0— Q N � O � O W u vUi iD on o v � a,vm 0 0 v J° � LTi V1 on 4r L c c on ix to C a+ W E O o= U N c ~ 0 O .D c O m E L 0 F- W U- w d Ln o 0 on w ti w Ul LU N ' Y m Z r+ 0 3 c 0 r V on o Ol 41 ro t � � V N N H W mCD v Z r a L m C o bLr; T N O U o O Occ m 7p ++ N L ac C a L m li Q u M W = U- " C C N oc y+ v, am+ N E A = u = o C v to v o H ,Lo, m on _� 3Y �� C j E E t � R d O o N M Ln ,0, to Z 2 co c°�D w ° In Co Go Q` b CD O N N v o 'o u u C O t=n CSD u C r N CD on a0 -i M u L an C/ r S w o y 0 v CD 3 Q.' = m L ra 0 CL +o+ o N w F- v0 0 0 CL c `° x 3 v v o 0 M a N N w Z w w IL L, L w c � > Q E O p LA v 4J on C o m M o v 4' u on 4) u 4A 07 0 CD o O aO o U- -0 0) L C c c j� o _� aI con t Ii • J J d " T L L 011 a .0 O 4) a0+ i fm W C w ' Odl m 4 u u w t =► a ao 0 J 0 v 0 O u L .D 0 O m CF O Y L O •O a> o a v a T on aI = uA w L _ ` L pE avi o w u 0 on o > N m to ap N ra` E C � ®.00 N N c c •� `o C 0— Q N � O � O W u vUi iD on o v � a,vm 0 0 v J° � LTi V1 on 4r L c c on ix to C a+ W E O o= U N c ~ 0 O .D c O m E L 0 F- OE NORTH �h H u T SSAC/IUSE CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 502-15 on 11/25/2014 Date: November 18, 2015 THIS CERTIFIES THAT THE BUILDING LOCATED at 75 Summer Street MAY BE OCCUPIED AS a single family home IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Herrick Development LLC 19 Francis Street North Reading, MA 01864 - Building Inspector Fee: PrePaid $100.00 Receipt: 28303 'Cheek: 580 LAWRENCE n. OGDEN, P.E. 198 EAST MAIN STREET GEORGETOWN, MA 01833 978-352-8318 fax 978 352-2858 March 16, 2015 cell: 978-542-5921. Mr. Chris Herrick. 19 Francis Street North Reading, Ma. 01.864 RE: 75 Sumner Street, North Andover Dear Mr.Herrick As you requested I conducted a site visit 3/16/15 to review the installation of the Engineered Materials consisting of LVLs,beams, Engineered joist and Steel beam utilized in the framing of the above project.. These are shown on plans prepared Guy Messier dated 8/20/14 with the framing plans sheet 9 and Detail Sheets D-1 to D-4 certified by me 8/20/14. At the time of this visit the house was framed, the roofing, siding, and garage door trim were in place. Based on the above site visit and based on what I could visibly see. I can certify that to the best of my knowledge the LVLs , Engineered joist and Steel Beam utilized in the framing as shown on the drawings are installed properly and meet the loading conditions of the 8th Edition of the Massachusetts State Building Code for 1 &2 Family Residences, provided the additional work as shown on SK -1 (attached ) dated 3/16/15 is performed. All other framing requirements of the drawings and code, including but not limited to materials, nailing schedules, blocking, connections, manufacturers installation requirements and other details are the responsibility of the licensed construction supervisor responsible for the project. Should you have any questions please do not hesitate to call. Yours truly, (/— W, Lawrence ,,-- Lawrence H. Ogden P.E. Structural 27765 March 16, 2015 Mr. Chris Herrick. 19 Francis Street North Reading, Ma. 01864 LAWRENCE H. OGDEN, P.E. 198 EAST MAIN STREET GEORGETOWN, MA 01833 978-352-8318 fax 978 352-2858 cell: 978-502-5921 RE: 75 Summer Streets North Andover Dear Mr.Herrick As you requested I conducted a site visit 3/16/15 to review the installation of the Engineered Materials consisting of LVLs,beams, Engineered joist and. Steel beam utilized in the framing of the above project.. These are shown on plans prepared Guy Messier dated 8/20/14 with the framing plans sheet 9 and Detail Sheets D -I to D-4 certified by me 8/20/14. At the time of this visit the house was framed, the roofing, siding, and garage door trim were in place. Based on the above site visit and based on what I could visibly see. I can certify that to the best of my knowledge the LVLs , Engineered joist and Steel Beam utilized in the framing as shown on the drawings are installed properly and meet the loading conditions of the 8th Edition of the Massachusetts State Building Code for 1 &2 Family Residences, provided the additional work as shown on SK -1 (attached) dated 3/16/15 is performed. All other framing requirements of the drawings and code, including but not limited to materials, nailing schedules, blocking, connections, manufacturers installation requirements and other details are the responsibility of the licensed construction supervisor responsible for the project. Should you have any questions please do not hesitate to call. Yours truly, Lawrence. H. Ogden P.E. Structural 27765 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 388,00.00 m $ - $ 4,656.00 Plumbing Fee $ 582.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 582.00 Total fees collected $ 5,920.00 75 Summer Street 502-15 on 11 /25/2014 Single Family Home n Qn 5� n r L = O cc _ � O V •� L cil J O N V O Q i 0 H O d Z u ui a V N O CD Q CccnJ W (� z ' > z N y � O = d C z 0 z O a O Z O as �._o N O O ,L _ w 3 o� CL •U, _, ___ O � cc � CL C7 Q 70-oo •�, Z C a W O LU 4J N CO O 'JJ d W � O LL a 7 :30 3 O it O V) LOL. K U LL W LL Ln IL W LL CO r L O � 4) NCL ( = O F- t w C. 00 co 2 z G co z COW w CLx LUW CL 0 N U E Q W O wW O —0 O 0 z O 0 I O . Q •CD m m ai 0 0 CL � O Q � Q O= i v J � �QO}: �z O C.) U) ca _ U) 2 = O cc _ � O V •� L cil d Q N V Q i H O d O O L (� V N CD Q CccnJ (� i m ' > = N y � O = d C C 0 d c�tUQ O O Z as �._o N O O ,L _ w 3 o� CL •U, _, ___ � cc � CL o 70-oo •�, °'MCA_ •C= C co 2 z G co z COW w CLx LUW CL 0 N U E Q W O wW O —0 O 0 z O 0 I O . Q •CD m m ai 0 0 CL � O Q � Q O= i v J � �QO}: �z O C.) U) ca _ U) 2 A� �® CERTIFICATE OF LIABILITY INSURANCE 1 11/4/2014 ) 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 CONTACT NAME: PHONE . (978) 664-0366 FAX (978)664-2209 AIC No A & K Fowler Insurance E-MAIL ADDRESS: 200 Park St INSURERS AFFORDING COVERAGE NAIC # INSURER AWestern World Insurance North Reading MA 01864 INSURED INSURER B INSURER C : Herrick Development, LLC INSURER D: 19 Francis St. INSURER E : 10/18/2015 INSURER F: North Reading MA 01864 COVERAGES CERTIFICATE NUMRFR-CL1411407448 RFVI.glnN NI IMRFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD�YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FOOCCUR PP1389031 0/18/2014 10/18/2015 DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ Per accident UMBRELLA LIABOCCUR HCLAIMS-MADE EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. OFFICER/MEMBER EXCLUDED? ❑ N / A CRY LIMITS I I FIR EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under I E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below I DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Insurance Verification CERTIFICATE HOLDER CANCFI_I ATION AGUKU Z5 (ZU9 U/Ub) INSn25 rgmnnst m ©1988-2010 ACORD CORPORATION. All rights reserved. Tho Ar C)Pr) name mnrl Innn aro ronic4ororl mmrlrc of Ar:r)Pn SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Herrick Development LLC ACCORDANCE WITH THE POLICY PROVISIONS. 19 Francis St. AUTHORIZED REPRESENTATIVE North Reading, MA 01864 �7 Nicole Orlanzo/NMO AGUKU Z5 (ZU9 U/Ub) INSn25 rgmnnst m ©1988-2010 ACORD CORPORATION. All rights reserved. Tho Ar C)Pr) name mnrl Innn aro ronic4ororl mmrlrc of Ar:r)Pn / ----- . . CO- I = \ O o. C; L' f .2 � § m0 \ 140 : § � 38 a � % m CO- I = \ O o. f to k \ / ( � § m0 \ 140 � ^ . ,AcoRv® CERTIFICATE OF LIABILITY INSURANCE `-►� 1/DD/YYYY) 111/4//4/ 2014 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 CONTACT NAME: A & K Fowler Insurance 200 Park St PHONE (978)664-0366 I 'FAX No:(978)664-2209 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # 0/18/2015 North Reading MA 01864 INSURER A Western World Insurance INSURED INSURER B INSURER C: Herrick Development, LLC 19 Francis St. INSURER D: INSURER E : North Reading MA 01864 INSURERF: COVERAGES CERTIFICATE NUMRFR-CL1411407448 RFVICIrNJ NII imRFR• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE DDL S BR POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MM/DDIYYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx_] OCCUR 21 Nicole Orlanzo/NMO I NPP1389031 I 0/18/2016 0/18/2015 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X1 POLICY 7 PRO-fEcT [7 LOC PRODUCTS - COMP/OP AGG $ 1,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ BODILY INJURY Per accident $ ( ) PROPERTY DAMAGE $ Per accident UMBRELLA LIABOCCUR EXCESS LIAB EDED CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F—]N (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below / A WC STATU- OTH- E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Insurance Verification CERTIFICATE HOLDER CANCELLATION AL:UKU LO (LUTU/UO) INS025 (201005).01 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Herrick Development LLC ACCORDANCE WITH THE POLICY PROVISIONS. 19 Francis St. AUTHORIZED REPRESENTATIVE North Reading, MA 01864 Nicole Orlanzo/NMO AL:UKU LO (LUTU/UO) INS025 (201005).01 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts , - - Department ojlndustriqlAcciknfs Office of Invesfigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): p� Address:16l _,F, �► 5 City/State/Zip: ►2-P w +nom-l�}- 6i f& H Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4• ❑ I am a general contractor and I �rnployees (full and/or part-time).* have, hired the, sub -contractors listed on the attached sheet. 2. I am a sole proprietor or partner ship and'have, no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its [No workers' comp. Insurance officers have exercised their required.] 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. ENo workers' comp. c. 152, §1(4), and we have no insurance required.] employees. Wo workers' comp. insurance required.] Type ofproject (required): 6. [New construction 7. [1 Remodeling S. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.[] plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other 'Any applicant that checks box41 mustalso fill outthe section below showingtheir workers' compensation policy information. 1-1-Tomeowners who submit this affidavit indicating they 2io doing all work and then hire outside contractors must submit anew affidavit indicating such. ?Contractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. X am an employer that is provicXing workers' compensation insurance for my employees: Below is the policy anci joh site information. Insurance Company Policy # or Self -ins. Lic. 9:. Expiration Date:, Job Site Address: 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 requiredunder 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 fne of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Xdo hereby eer urfr ertlie s clnapena tes olperjury tt2c�zr�ze inj-vrrraue,arc�..uY«=e== t=juY� to ==�� �•�« ��•_���• y 71 9 7Q i 7f, Z 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 Pers 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 moxe of the foregoing engaged iu 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, ox the occupant of the dweliing 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 b eon 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 -contractors) 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, apolicyis required. Be advised that this affidavit maybe submitted to the Department of Tndusirial 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 policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has b eon officially stamp ed 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. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license ox 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 shQ ald you have any questions, please do not hesitate to give us a call. 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