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HomeMy WebLinkAboutBuilding Permit #480-2017 - 84 FOXHILL ROAD 11/7/20166 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building Uo@15e- family 0 Addition 0 Two or more family [I Industrial 0 Alteration No. of units: 0 Commercial 4-,lTe'pair, replacement 0 Assessory Bldg 0 Others: [I Demolition 0 Other Septic EMIT LFloo,b ain b WetlaNds' -*Va" t&sh6-.,istHG, All DESCRIPTION OF WORK TO BE PERFORMED' 4J Va V 1- 1 -es . .5 i,. 4 -5, , r--cx U C�� moi) - - -S / ,,&, Ide tifi tion Please Type or Print Clearly iA OWNER: Name: Dn zM"aVT Phone:&O 30' Address: Fox W1 I � Mof � X4cvee— at ro- I.— Contractor N Ph,bne;, ame., 'ddr'es- A� AN , LIZ --7p-77 M FT -51 -ig -JL -i� U nI: /.:vY m EAj D 81 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: $j 0 FEE: $ Check No.: Receipt No.: - - " Aar, NOTE: Persons contracting with unregistered contractors do not have. access t th'e, guar my fun lgjlp,tqre of con' Acien U re: of wh Location No. ,qo%f'" Check # 31143 Date Q! TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $1"" t Foundation Permit Fee $ Other Permit Fee $ TOTAL $ .t li Building Inspector4,. Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ TYPE bF 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 e U FORM PLANNING & DEVELOPMENT Reviewed On Signature, COMMENTS CONSERVATION Reviewed on Signature COMMENTS r t A HEALTH; E {; Reviewed on Signature COMMENTS ,Zoning Board of Appeals: Variance, Petition No: 's {' `. Zoning Decision/receipt submitted yes Planning Board Decision: Comments ,j, Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT' - Temp Dumpster on site yes Located at 124. Main Street Fire Department signature/date 1 , -COMMENTS k Lucateu jo4 usgooa Street no -Nmension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop.,requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter; 166 Section 21A —F and G min.$10041000 fine Doc.Building Permit Revised 2014 Building Department The following is a list of the required'forms to be filled out for the appropriate permit to be obtained. r 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 40TE: 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 C - slapowai woojgje8 960Z/L/I6 uo L60Z-08-V Pe02l IM X0 J t78 9 VLOE $ pajoalloo seal le}ol ZL*OZ $ aad leoploa13 00006 $ -wwoo 006 aad see ZL'OZ $ aad bulgwnld ZL 99 6 $ - $ w 00"0 WE Isoo uollonilsuoo uopelnoleo aamf aanopu y 4PoN - leo aa} aol Isoo uoilonilsuoo ja}u3 v N C � n p CD �. CD o CL r- o o CLa D cc. � O � 0 CD CD CL r.r Sv � CD CD O ca CD �CD CLoCD C' � v CDO Z CD 0 �®•1' 0 CD a C CD A Z V rn rn Cl) 0 rn Z X U) 0 • -j Z 0��0 2) __ <,caD y N C �, C 0 CD 0 Cl) Q' n � yr fl;, �• � O O .y O_ o.O R1 W0� y cn 0 CD 2 C Q O '+ N O O rt n •" C' O CD S CD 'a O� O < CQ LA: -0•w O y D `D � a. �. Q 0 cc oL CD < N o O O CL ' O FL N �D N o CD o O �CD CD �D C'1 CD (un) � rt D CD CD _m tv O O � y O p ((D Z O W m 0 c S T v L G n m .17 C T nOi .o C oo T °—' (7 _S 3 m C .Z7 O oma =r T O � CL ' O Ln fD a f*)� In T O a T m mm D m Z -i N tZi+ mZ A O m r- m N m A � C W Z G7 Z N m A 0 C C Z O Z N m 0 rt m 3 S M W > 00 T = m r _ Ord a 1 J c Peluso 325 Main Street North Reading, MA 01864 PAINTING & RESTORATION (978) 664-4300 derek@pelusoservices.com ADDRESS David Laubner 84 Fox Hill Road North Andover, MA f PROPOSAL # i DATE I 1289 _ 09/29/2016 Proposal DESCRIPTION �" --' -� AMOUNT Carpentry Remodef Main Bath, Master Bath and 1/2 Bath. Main bath Demo floor, vanity, counter, sinks and toilet. Install new the floo vanity, counter sinks and toilet. Install new bathroom fan light combo and vent out of house. Master bath Demo floor, shower surround, vanity, counter, sink and toilet. Install new tile floor, shower surround, vanity, counter sink and toilet. Install- new bathroom fan light combo and vent out of house. 1/2 bath Demo floor, vanity, counter, sink and toilet. Install new tile floor, vanity, counter sink and toilet. All permitting and trash removal paid for by contractor. Electrical budget of $1500 included is price. Plumbing budget of $2500 included in price. Customer responsible for tile, plumbing and electrical fixture costs including vanity and counter tops. Plumbing and electrical issues unforeseen in the walls would result in an extra. ! All extra work will be discussed financially be for work is started. We propose to furnish labor and materials in complete accordance with the above specifications. Accepted By TOTAL Accepted Date -Nu V 2 1 `�--� 1 � 13,810.00 $13,81 ULU J Pew 325 Main St. North Reading, MA PAINTING £t RESTORATION 01864 RESIDENTIAL CONTRACTING AGREEMENT Read this agreement and make sure you understand it before signing it. This agreement has legal force and effect and binds those who sign it. 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 of Massachusetts, must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director, Home Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, MA 02108. OWNER (HEREINAFTER "HOMEOWNER") INFORMATION No: Name: David Laubner Street Address: 84 Fox Hill Road City/Town: North Andover, MA Date: 11/2/16 Telephone: 617-308-0724 Peluso Painting & Restoration agrees to do the following work for the HOMEOWNER at (Detailed specifications are provided in the proposal dated September 19th, 2016, which is attached hereto and incorporated herein by reference). TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE In consideration of the labor, materials and work performance specified above by the Contractor; the Homeowner (s) agree (s) to pay Contractor the total sum of $13,810 Payments will be made according to the following schedule: $ 1300.00 Non-refundable deposit upon signing. $ 5000.00 Start of the: demo $ 4000.00 Start of the: tile. $ 3510.00 Completion of: vanity install All payments to be made the days of invoicing. If payments are not made within fifteen days of the invoice date, a late charge in the amount of 1.6% of said payment shall be assessed for every (30) day period that said payment(s) remain outstanding. If other contractors are employed by the Homeowner, payments to Contractor cannot be delayed due to incomplete or insufficient work of other contractors. If non payment becomes a legal matter, Homeowner will be responsible for all legal fees incurred by both parties. NOTES: (*) including all finance charges. (**) Law requires that any deposit or down -payment required by the contractor before work begins may not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of any special equipment or custom-made material which must be special ordered in advance to meet the completion schedule. PROPOSED START AND COMPLETION SCHEDULE Contractor will not begin work or order the materials before the third day following the signing of this contract unless specified herein in writing. The following schedule will be adhered to unless circumstances beyond the contractor's control arise: Date when Contractor will begin contracted work: within (10) business days of permit approval. Date when contracted work will be substantially completed: within (60) business days of start date above. NOTWITHSTANDING ACCEPTANCE OF THIS CONTRACT BY CONTRACTOR, THIS CONTRACT SHALL BE CANCELABLE BY THE CONTRACTOR IF HOMEOWNER IS UNABLE TO FINANCE THE PAYMENT OF THIS WORK THROUGH AN ESTABLISHED BANK OR OTHER FINANCIAL INSTITUTION, WHEN REQUIRED BY THE CONTRACTOR OR WITHIN FIFTEEN (15) DAYS. LIEN OR SECURITY INTEREST Unless otherwise noted, the contract shall not imply that any lien or other security interest has been placed on the property: SECURITY INTEREST YES NO ACCELERATED PAYMENTS Contractor may not demand payments in advance of the dates specified on the payment schedule. In cases where the Homeowner deems him/herself to be financially insecure, the Contractor may require the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. REQUIRED PERMITS - The following permits are required and will be secured by the Contractor as the homeowner's agent:(Building) Notice: Homeowners who secure their own permits will be excluded from the Guaranty Fund provisions of MGL Chapter 142A. The contractor shall not be deemed responsible for delays in the work described in this agreement caused by regulatory, permit granting or inspectional agencies, authorities or individuals. WARRANTIES Contractor guarantees its labor, materials and workmanship for one(1) year from date of completion. Contractor will replace defective labor, workmanship and material within the period of guarantee free of charge. All requests must be in writing. All warranties for equipment supplied by the Contractor under this Agreement shall be those given by the manufacturers of such equipment, which shall be and are hereby transferred through directly to the homeowner. Under such manufacturer's warranties, the Homeowner may be required to register or mail in a warranty card or other evidence of ownership and use of such equipment in order to activate such warranties. The Homeowner's failure to mail in or register such documentation, which failure voids the manufacturers warranty, shall not create any responsibility for the contractor to warranty such equipment. INSURANCE Contractor shall indemnify and hold Homeowner harmless for any third party damage or bodily injury caused by Contractor, its employees or subcontractors in the performance of or as a result of the work under this Agreement. Contractor agrees to carry workers compensation and liability insurance of no less than $1 million person $2 million accident to cover such damage or injury. Prior to the start of work Contractor shall provide Homeowner with an insurance binder naming Homeowner as an additional insured. 2 j i SUBCONTRACTING Contractor agrees that notwithstanding any agreement for materials and/or labor Contractor and a third parry, Contractor is responsible to Homeowner for completion of all work described in timely and workman like manner. Contractor shall indemnify and hold Homeowner harmless for any mechanics liens or other liens filled by any subcontractor on the project, including all legal fees and costs incurred in resolving any lien issue. Homeowner's initials Contractorskfiitials CONTRACTOR ARBITRATION The Home Improvement Contractor Law provides Homeowner with the right to initiate an arbitration action (as an alternative to court action) if s/he has a dispute with Contractor. The same right is not automatically afforded Contractor. The Contractor would have to resolve any dispute it has with a Homeowner in court unless Contractor and Homeowner agree to the optional clause provided below. The clause would give the contractor the same right to arbitration as is afforded to the Homeowner by the Home Improvement Contractor Law. Contractor and Homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the Contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation. Such arbitration is not mandatory and binding. Homeowner retains the right to resolve any dispute through the courts. Homeowner NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the Contractor. The Homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. MODIFICATION This contract, including the provisions relating to price and payment schedule, constitutes the entire agreement of the parties and no other agreements, representations and/or warranties, expressed or implied, shall be binding on either party hereto and cannot be changed except by a written statement signed by both contractor and Homeowner -Any alteration or deviation on the specifications listed above involving extra costs of materials or labor will be furnished and performed only upon written change order dated and signed by both parties and will be in addition to the cost price of the contract. CONFLICT OF TERMS AND CONDITIONS If any provisions of this contract are in conflict with any statute, regulation, ordinance or rule of law, such provisions shall be deemed null and void to the extent that they may conflict therewith, but without invalidating the remaining provisions hereof. 3 HOMEOWNER'S RIGHTS A homeowner's rights under the Home Improvement Contractor Law (MGL Chapter 142A) and other consumer protection laws (EE: MGL Chapter 93A) may not be waived in any way, even by agreement. However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Contractor represents and warrants that it is duly licensed by the Commonwealth of Massachusetts # 75630 to perform the work provided for this Contract. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. All goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have any questions about your consumer/homeowner rights, contact the Consumer Information Hotline: Executive Office of Consumer Affairs and Business Regulation One Ashburton Place, Room 1411 Boston, MA 02108 (617) 727-7780 HOMEOWNER'S RIGHT TO CANCEL Subject to the provisions stated below (Contractor's Right to Cure), the Homeowner may cancel this contract if it has been signed by the Homeowner at a place other than an address of the Contractor which may be his main office or branch thereof provided that the Homeowner notifies the Contractor in writing at his main office or branch by ordinary mail, posted by telegram, sent or by delivery, not later than midnight of the third business day following the signing of the contract. CONTRACTOR'S RIGHT TO CURE Should the Homeowner deem work completed by the Contractor unsatisfactory, the Homeowner must notify the Contractor in writing by first class mail and allow the Contractor 10 business days from receipt of the Homeowner's written notice in which to cure said work indicated in the written request to the Contractor. Homeowner shall not terminate any agreements with the Contractor, unless Contractor has been afforded its right to cure after Homeowner's written request as required by this clause. NOTICE OF CANCELLATION You may cancel this transaction, without any penalty or obligation, within three (3) business days from the date of execution of this transaction. If you cancel, any property traded in, any payments made by you under the agreement, and any negotiable instrument executed by you will be returned within ten (10) business days following receipt by the Contractor of you cancellation notice, and any security interest arising out of the transaction will be cancelled. If you cancel, you must make available to the contractor at your residence, in substantially as good condition as when received, any goods delivered to you under this agreement, or you may if you wish, comply with the instructions of the Contractor regarding the return shipment of the goods at the Contractor's expense and risk. If you do make the goods available to the Contractor and the Contractor does not pick the goods up within twenty (20) days of the date of your notice of cancellation, you may retain or dispose of the goods without any further obligation. If you, fail to make the goods available to the Contractor, or if you agree to return the goods to the Contractor and fail to do so, then you remain liable for performance of all obligations under the contract. This transaction can be cancelled by mailing or delivering a signed and dated written notice identifying Homeowner's name, address, contract number, and stating "I wish to cancel" or any other written notice, or sending a telegram to: Not later than midnight of November 6, 2016 (Date of third day after transaction date). El CONTRACTOR'S RIGHT TO CANCEL This Contract may be cancelled by an officer of the Contractor, but only within three (3) business days from the date of execution and in a similar manner of the Homeowner(`s) right of cancellation. EXECUTION OF CONTRACT This Contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents that are incorporated herein are attached hereto. Homeowner is further advised not to sign this Contract unless and until all blank sections have been filled in or marked as void, deleted or not applicable. Homeowner(s) hereby certify(s) that s/he has (they have) read this Contract, that the terms and conditions and the meaning thereof have been explained to her/him (them) and s/he (they) fully understand said terms and conditions. HOMEOWNER: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. TWO IDENTICAL COPIES OF THE CONTRACT MUST BE COMPLETED AND SIGNED. ONE COPY GOES TO THE HOMEOWNER, THE OTHER COPY TO BE KEPT BY THE CONTRACTOR. and seals this day of Representative Accepted By: 1" " q 2016. Homeowner 5 ADDITIONAL PROVISIONS 2. Contractor responsible for items that are listed in proposal documents provided by the contractor and accepted by the homeowner. 2. Contractor responsible for any accepted proposals (signed and dated by homeowner and contractor) accompanying this contract. 3. Change orders will be paid in full at time of signing and before work on the change order begins. 4. Homeowner is responsible to clear area for construction. Homeowner: The Commonwealth of Massachusetts _ ..{ Department of IndustrialAccidents M _ r 1 Congress Sheet, Suite 100 ' ` d Boston, lYl.1� ��A 021'14201 7 _ F ... ^ .. �r www ma,ss.gov/dia a'iM SJ'yo Worlrere Compensation InsuranceAffidavit, Builders/Contractors/1♦leciricians/Plnmbers. TO BE FILED WITH THE PERMITTING AUTifORITY. Name (Business/(jrgariizationllndividuat): Ire t vs., bac , Address: 31 s Al d Phone: City/State/Zip: or Areyou an ployer? Cheelcthe approprlatebOx. Type of project (required): 'P Yem to ees full and/or part-time)."' 7. ❑ Ne ""construction 1, � am a em to er with P Y ( 2.❑1 am a sole proprietor or partnership and have no employees Working for me m $, emo deluig any capacity. [No workers' comp. insurance required.] 9. ❑ Demolition 3.EJ 1 am a homeowner doing all work myself [No workers' comp. insurance required.] 10 ❑ Building addition <11 am a homeowner and willbe biring contractors to conduct all work on my property. twill 11.❑Electrical repor additions ensure that all contractors either have workers' compensation insurance or are sole airs <� :. 12TQ Plumbing repairs or additions proprietors with no employees. 5. 1 am a general contractor and 1 have hired the sub -contractors listed on the attached sheet. 13•, Rbof rep airs These sub -contractors have employees and have workerscomp. insurance.t 14.[] Other 6. Q We are a corporation and its, officers have exercised their right of exemption per MGL G. 152, §1(4), and We have no empldydes. [No workers' comp. insurance required.] compensalicy their workers' Any applicant that check's box 41 must also fill out the section belo�lw rokwamngdthen hire outside ccontractors moust submit a new affidavit indicating such I Homeowners who submit -this affidavit indicating they doing }Contractors that check this Box must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number- employees. am an employer that is providingworkers' compensation insurance for my employees. Below is the policy and job site information. k \ Insurance CompanyName: r, N ""`-' - - P �e � c � 3 Expiration Date_ � /iq Policy # or Self -ins. Lie. #:. mtYS City/State/Zip: / V , Job Site Address: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration d to Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $I,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER. and a flue 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 do hereb under pains andpenalties ofperjury that the information provide hove isitrr�e�araJ c�orr�e'jct. bate: /VoV ! �' 6 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 d'ef 6d as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enferprise, and including the legal representatives of a deceased employer, or the receiver'or trustee of an individual, partnership, association or other legal entity, employing employees. , However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." �n 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 M" the commonwealth foie any applicairtwh6 has not produced -acceptable evidence of compliance with the insurance covet'age xequiired." Additionally, MGL chapter 152, §25C(l) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for.the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Pleasb 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 certificates) 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 retained to the city or town that the application for the permit or license is being requested, not the Department of Ind-astrialAccidents. 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 Iuvestigations 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 dddition, an applicant that must submit multiple pennit/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 tovrn may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts r Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia A�4OgCERTIFICATE OF LIABILITY INSURANCE DATE 2016 D/16 10/31/D0 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: Automatic Data Processing Insurance Agency, Inc. 1 Adp Boulevard Roseland, NJ 07068 PHONE o Ext): AIC No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIL # INSURER A: AmGUARD Insurance Company 42390 INSURED PELUSO PAINTING AND RESTORATION LLC INSURER B: INSURER C: 325 Main Street Suite 301 North Reading, MA 01864 INSURER D: INSURER E: INSURER F l.vvCR/iuCJ GtK111­IGAlt NUMbtR: 5172fU7 RFVIRIAN NIIMRFR- 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 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 ADUL INSD SUSK WVD POLICY NUMBER POLICY EFF MM/DD POLICY EXP MWW LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ PREMISES Ea occurrence $ MED EXP (Any one person) $ _ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO- JECT F—] LOC GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL AUTOS OWNED AUTOESULED BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOSAUTOS PROPERTY DAMAGE Per accident $ UMBRELLA LIABOCCUR HCLAIMS-MADE EACH OCCURRENCE $ EXCESS LIAB AGGREGATE $ DED I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE— OFFICER/MEMBER EXCLUDED? N / A N PEWC734158 07/09/2016 07/09/2017 PER _ X STATUTE ERH _ EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) a+�R r rrwf%I C r7V1_UCR CANCFI 1 ATlnkl Town of North Andover Attn: David Laubner 84 Fox Hill Road North Andover, MA 01845 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 4 ACORD CORPORATION. All riahts racarvarf AGURD 25 (2014/01) The ACORD name and logo are registered marks of ACORD ACC>R D CERTIFICATE OF LIABILITY INSURANCE DIDD/YYYY) 2//3/23/2016 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 terns 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 Li.nnane Insurance Agency Inc. 280 Main St. #101 CONTACT - AME: PHONE(9 JBL 664-2000IAIC. No FA 664-200A C. (976)66a-0180 E-MAIL N. Reading MA 01864 INSURERS AFFORDING COVERAGE NAIC p INSURERAMain St. America INSURED .Peluso Painting & Restoration LLC INSURER 8, INSURER C INSURER D: 325 Main St .Suite 301 North Reading MA 0.864 INSURER E: INSURER F: wnrua.r�. 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 AODL SUER POLICY NUMBER POLICY EFF MM D POLICY EXP M D LIMITS A GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurren e $ 500,000 CLAIMS -MADE FOOCCUR T0501H /28/2016 /28/2017 MED EXP (Any one person) $ 10,000 PERSONAL& ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY PRO- -IFCTLOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT - Ea acciden ANY AUTO _ BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident)$ $ UAB OCCUR EACH OCCURRENCE $ 4UMBRELLA EXCESS UAB CLAIMS -MADE AGGREGATE DED RETENTION $ WORKERS COMPENSATION $ WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) •? If yes, describe under E.L. DISEASE - EA EMPLOYE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CFRTIPICATF• LJnr-- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. David Laubner 84 Fox Hill Road AUTHORIEDREPRESENTATIVE North Andover, MA 01845 11 M Linnane/LINKLI ACORD 25 (2010105) ©1988-2010 ACORD CORPORATION. All rights reserver INS025 (2o1om).o1 The ACORD name and logo are registered marks of ACORD �c C(nozzarra•>rtucrzlt� off.'G?���1crc�rrlc Office of Consumer Affairs & Busibess Regulation OME IMPROVEMENT CONTRACTOR egistration: 169554 Type: xpiration: , -7/5/2017. Individual THOMAS PELUSO :. , ` THOMAS PELUSO 200 CHANDLER ROAD.,";-: . ANDOVER, MA 01810 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid without sign e Massachusetts - din Department of Public S Board of Burlafety Re Mations and Standards Constructir,n Sunea i is»r License: CS -1025M � �•• '` THOMASM PEL�Sp_ �' 200 Chandler Road Andover IIIA 0180 r v rt 1�„„ �f't41 �• "CoM missioner Expiration XW2017