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Home My WebLink AboutBuilding Permit #792 - 870 GREAT POND ROAD 6/4/2007BUILDING PERMIT '1+0 TOWN OF NORTH ANDOVER i APPLICATION FOR PLAN EXAMINATION * , l/I coc. is NlwKw y Permit NO: Date Received �a> AZAD ARCHITECT/ENGINEER(-z-1',LQ 1aVS Phone: L.6201��p 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: $ 150-W, OVO FEE: $ Check No.: f 2 3 o Receipt No.: Zy3-:4`r,. NOTE: Persons contracting fyith unregistered contractors do not have access tp the guard Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL PLANNING & DEVELOPMENT COMMENTS (� C��S DATE REJECTED ❑ f,� ,, /r-4 chs"-, Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools i Well❑ Tobacco Sales "r Food P._ackagirig/Sales ; :N_ Private (septic tank, etc. ❑+❑ Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer, Connection/Signature & Date Driveway Permit Located at 384 Osgood Street PLANNING & DEVELOPMENT COMMENTS (� C��S DATE REJECTED ❑ f,� ,, /r-4 chs"-, DATE APPROVED [ GLA CONSERVATIO COMMENTS ATE REJECTED DATE APPROVED l (p HEALTH COMMENTS DATE REJECTED ❑ DATE APPROVED ❑ Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer, Connection/Signature & Date Driveway Permit Located at 384 Osgood Street Dimension 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.$100-$1000 fine NOTES and DATA — (For department use iV? ❑ 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 ❑ 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 Kermit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ 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 r i U f eer T 1,"W .� • ". No. -7 9a— Date TOWN OF NORTH -ANDOVER Certificate of Occupancy $ Building/Frame 9/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #1a� V 2U76 Building Inspector \I ENERGY CONSERVATION APPLICATION FORM F LOW-RISE RESIDENTIAL, NEW CONSTRUCTION and ADDITIONS 780 CMR Appendix J (effective 3/1/98) Applicant Name: Applicant Address:\� Site Address: rf� Cityri'own: 1*7 ti Use Group: Applicant Phone; 3 Date of Application: Applicant Signature: Compliance Path (check one): 0 Prescriptive Package (Limited to I- or 2 -family wood frame buildings heated with fossil fuels only) Package (A through KK from Table J5.2.1b Heating Degree Days (HDD cs) from Table J5 2 1 a: (For items d. through i., fill in all values that apply from Table J5.2.Ib:) a. Gross Wall Area sq.Ft f. Wall R -value R- b. Glazing Area' sq.ft. g. Floor R -value R - c. Glazing % (100 x b - a> % h. Basement wall R- d. Glazing U -value U- i. Slab Perimeter R_ e. Ceiling R -value R- j. Heating AFUE Component Performance: "Manual Trade -Off" (Limited to wood or metal framed buildings only) -limaie Zone (from Figure J6.2.2) �] Zone 12 El Zone 13 Zone 14 ar,zch Trade -Off Worksheet from Appendix J, [and HYXC Trade -Off Worksheet, if applicable) ] M.iScheck Software itizch Compliance Report and Inspection. Checklist printouts. ] Systems Analysis OR [j Renewable Energy Sources �ttzch Mass Registered Architect or Engineer Analysis A-LTERNATIVE FOR ADDITIONS.ONLY: .Gross Wall+Ceiling Arca%sq.ft. b, GlazingAreata�sq.ft. c-Glazing%(10oxb+a) 1G.I% 0 ADDITION with Glazing % (c.) up to 40% may use 780 CMR Table 71.1.2.11 below: MA.X1MUM U -value iviWIMUtri R-Valuu 1'Lngi7ailUn Ceiling Wall Floor Basement W!ME!T 039 R-37 R -l3 R-19 R-10 ] "SUNROOM" addition (greater than 40% glazing -to -wall and -ceiling gross area) ,:rzch "Consumer Information Form" from 780 CMR Appendix B. tnicial's Name: Official's Signature: .pplication Approved Denied Date of Approval/Denial: czson(s) for Denial: (provide additional details as needed on back side) 6 pE NOsor m'�R4 11th 1 ` p Town of North Andover t Office of the Planning Department 9qs Rgmp L'P " Is to certify that twenty i2017ftymmunity Development and Services Division ,MA 1 r; sq�K�s ve elapsed from date of decision, tiled 1600 Osgood Street without filing of an appeal pate �o0o North Andover, Massachusetts, 01845 Joyce A. ehaw ATTEST: Town Clerk NOTICE OF DECISION A True Copy n�Any appeal shall be filed within (20) days after the date of filing this notice in the office of the Town Clerks Petition of Ronald & Karen McCluskey 870 Great Pond Road North Andover, MA 01845 Town Clerk Date: May 2, 2007 Date of Hearing: April 17, 2007 Date of Decision: May 1, 2007 Doc s 94:258: 05=_30 20Q7-.: 2 C- w -t- Essex North.Land-Court R¢sistrs - Premises Affected: 870 Great Pond Road, North Andover, MA 01845, Map 103 — Parcel 112 Referring to the above petition for a Watershed Special Permit from the requirements of the North Andover Zoning Bylaw, Section 4.136. So as to allow to construct a proposed 458 s.f one-story, wood frame addition, with garage under, and patio and drainage infiastructure and associated minimal site grading within the Non -discharge zone of the Watershed Protection District within the R-1 zoning district Upon a motion made by Jennifer Kusek, 2`a by Alberto Angles to APPROVE a Watershed Special Permit as amended and based upon the following conditions. Voting members were: John Simons, Alberto Angles, Richard Rowen, Jennifer Kusek & Timothy Seibert. Vote was unanimous. 5-0. Richard Nardella abstained from voting, as he was not in attendance at the previous meeting. On behalf of& North An ver Planning Board John Simons, Vice Chairman Alberto Angles, acting Clerk Richard Rowen, regular member Jennifer Kusek, regular member Timothy Seibert, alternate member cc: Town Depar nients Essex ss. Land Courter; 3 �o_ Applicant �% a5 Engineer A true Copy of LandCourt Document Abutters 'i"( Page Certificate 3, Book tb $ Assessor 3 -- r Sad d al'_ .11L r l9 M Registere� _ Attest: Register of Deeds 870 Great Pond Road Map 103, Parcel 112 Watershed Special Permit The public hearing on the above referenced application was opened on April 17, 2007 and closed by the North Andover Planning Board on May 1, 2007, upon a motion made by Jennifer Kusek and seconded by Alberto Angles to GRANT a Watershed Special Permit as amended in order to construct a 458 s.f. one-story, wood frame proposed addition with garage under, and patio, and drainage structure within the R-1 zoning district within the Non -Discharge zone of the Watershed Protection District. The single-family residence is located at 870 Great Pond Road, North Andover, MA, Assessors Map 103, Parcel 112 and is located within the Non -Discharge Zones of the Watershed Protection District under the requirements of Section 4.136 & 10.3 of the North Andover Zoning Bylaw. This Special Permit was requested by Ronald & Karen McCluskey, 870 Great Pond Road, North Andover, MA The applicant submitted a complete application, which was noticed on March 27, 2007 and reviewed in accordance with Section 4.136 of the Town of North Andover Zoning Bylaw and MGL Chapter 40A, Section 9. The lot was created in 1970 and is subject to the Watershed Protection District provisions for lots created before October 24, 1994. The Planning Board voted on the motion in favor of the Watershed Special Permit. A special permit issued by the special permit granting authority requires a vote of at least four members of a five -member board. The applicant is hereby notified that should the applicant disagree with this decision, the applicant has the right, under MGL Chapter 40A, Section 17, to appeal to this decision within twenty days after the date this decision has been filed with the Town Clerk. In accordance with 4.136 the Planning Board makes the finding that the intent of the Bylaw, as well as its specific criteria, are met. This decision specifically stated by the Planning Board makes the following FINDINGS OF FACT: 1) That as a result of the proposed construction in conjunction with other uses nearby, there will not be any significant degradation of the quality or quantity of water in or entering Lake Cochichewick. The Planning Board bases this finding on the following facts: a) The topography of the site will not be altered substantially. The proposed addition was specially designed and located to minimize the amount of grading/topographical changes and take advantage of natural features of the property. Further, a proposed 500 gallon drywell was designed to collect all runoff associated with the roof areas of the proposed addition. The drainage infrastructure is designed to handle the 100 -year storm event and will serve to mitigate any potential storm water runoff problems from the proposed addition. b) The proposed extension of the bluestone patio will not alter present site grading. C) The limit of clearing and impact is restricted to the minimum necessary to construct the project. d) The proposed site work described will not have a negative impact to the surrounding watershed. There will not be any significant degradation of the quality or quantity of water in or entering Lake Cochichewick. The proposed drywell will serve to collect storm water runoff and provide a means 2 870 Great Pond Road Map 103, Parcel It 2 Watershed Special Permit of recharging the groundwater table. The drywell, in addition to the minimal site grading changes, will serve to promote mitigation measures to protect runoff from entering surrounding wetland areas, which ultimately discharge to the lake. e) The construction of the proposed addition and storm water management plan has been reviewed by the Town's Engineer and Town Planner and determined that there will be no degradation to the quality or quantity of water in or entering the isolated vegetated wetland or Lake Cochichewick. In accordance with Section 10.31 of the North Andover Zoning Bylaw, the Planning Board makes the following FINDINGS OF FACT: 1) The specific site is an appropriate location for the proposed use as all feasible storm water and erosion controls have been placed on the site; 2) The use will not adversely affect the neighborhood as the lot is located in a Residential 1 Zoning District; 3) There will be no nuisance or serious hazard to vehicles or pedestrians, 4) Adequate and appropriate facilities are provided for the proper operation of the proposed use; 5) The Planning Board also makes a specific finding that the use is in harmony with the general purpose and intent of the North Andover Zoning Bylaw; Upon reaching the above findings, the Planning Board approves this Special Permit based upon the following SPECIAL CONDITIONS: 1) Final approval of this Watershed Special Permit by the Planning Board is conditional upon a Notice of Intent to be issued by the Conservation Commission. 2) The Town Planner shall approve any changes made to these plans. Any changes deemed substantial by the Town Planner would require a public hearing and modification by the Planning Board. 3) Prior To Any Work On Site: a) A performance guarantee of two thousand dollars ($2,000) in the form of a check made out to the Town of North Andover must be posted to insure that construction will take place in accordance with the plans and the conditions of this decision and to ensure that the as -built plans will be submitted. b) The limit of work as shown on the plan by the erosion control line must be marked in the field and must be reviewed and approved by the Town Planner and Conservation Department. c) All erosion control measures as shown on the plan must be in place and reviewed by the Town Planner and Department. Deteriorated erosion control measures shall be replaced and maintained throughout the duration of the project. d) The site shall have received all necessary permits and approvals from the North Andover Conservation Commission, Board of Health, Zoning Board of Appeals and the Department of Public Works and be in compliance with the above permits and approvals. 4) Prior to issuance of a building permit: a) The Planning Board must endorse the final site plan mylars and three copies of the signed plans 870 Great Pond Road Map 103, Parcel 112 Watershed Special Permit must be delivered to the Planning Department. b) The decision must be filed with the North Essex Registry of Deeds. One certified copy of the recorded decision must be submitted to the Planning Department. c) No pesticides, fertilizers or chemicals shall be used in lawn care or maintenance within 325 feet of Lake Cochichewick or within 325 feet of wetland resource areas. The applicant shall incorporate this condition as a deed restriction, and a copy of the recorded deed shall be submitted to the Town Planner and included in the file. d) All erosion control measures as shown on the plan must be in place and reviewed by the Town Planner and Conservation Department. 5) Prior to release of the Performance Bond: a) The applicant shall submit an as -built plan stamped by a Registered Professional Engineer in Massachusetts that shows all construction, including storm water management services and other pertinent site features. This as -built plan shall be submitted to the Town Planner for approval. The applicant must submit a certification from the design engineer that the site was constructed as shown on the approved plan. b) The Planning Board must by a majority vote make a finding that the site is in conformance with the approved plan. 6) In no instance shall the construction of the project as proposed be allowed to further impact the site than as shown on the plan referenced in Condition # 11. 7) No open burning shall be done except as is permitted during burning season under the Fire Department regulations. 8) The Contractor shall contact Dig Safe at least 72 hours prior to commencing excavation. 9) The provisions of this conditional approval shall apply to and be binding upon the applicant, it's employees and all successors and assigns in interest or control. 10) This Watershed Special Permit was issued on May 1, 2007, however, this Special Permit shall be deemed to have lapsed after a two (2) year period on May 1, 2009 unless substantial use or construction has commenced. 11) This decision must be filed with the North Essex Registry of Deeds. The following information is included as part of this decision: Plan titled: 870 Great Pond Road Proposed Site Development Plan, located in North Andover, Massachusetts (Esser County) Prepared for: Ronald & Karen McCluskey 870 Great Pond Road North Andover, MA 01845 Prepared by: Sullivan Engineering Group, Inc. 22 Mount Vernon Road 0 -,— - - -- ------ CONSTRUCTION SERVICES AGREEMENT Contractor: Owner: Date: Howell Design & Build, Inc. Ronald and Karen McCluskey May 22, 2007 360 Merrimack St. Bldg 5 870 Great Pond Rd. Lawrence, MA 01843 North Andover, MA 01845 Phone: 978-989-9440 Project: C.S.L. #068232 Additions and Renovations H.I.C. #123237 I. PARTIES & DATE OF AGREEMENT This contract (hereinafter referred to as "Agreement") is made and entered into on this 22nd day of May, 2007, by and between Ronald and Karen McCluskey, (hereinafter referred to as "Owner"); and Howell Design & Build, Inc., (hereinafter referred to as "Contractor"). In consideration of the mutual promises contained herein, Contractor agrees to perform the following work: H. SCOPE OF WORK DESCRIPTION & CONTRACT SUM The Contractor shall perform the "Work" as described in this Agreement and the following Attachments, which are incorporated into this Agreement by reference below: A. ATT T TCHMENTS 1) 1s sheets of Plans titled "McCluskey Addition/Remodel" by Laine Jones Architects., all sheets dated April 20', 2007 2) 19 page Scope of Work Description & Specifications dated May 22"d, 2007 3) 3 page List of Contract Allotments dated May 22"d, 2007 4) 2 page Schedule of Values dated May 22"d, 2007 5) 1 page Substantial Completion Agreement dated May 22"d, 2007 6) 2 page Limited Warranty dated May 22"d, 2007 B. CONTRACT DOCUMENTS The "Contract Documents" consist of this Agreement, the Attachments listed above, and Modifications issued after execution of the Contract. There are three (3) types of modifications: 1) FCO "Field Change Order" is a written directive from the Owner for the Contractor to proceed with a change in the work prior to the final cost of the change being known, the exact amount of extra time required for performance of the change, and/or prior to a "Contract Change Order" being executed. 2) CCO "Contract Change Order" is a written agreement between the parties to change the Work including the cost, or estimated cost, of the change, and the change in days to the Date of Substantial Completion specified in this Agreement. The cost or estimated cost of the Change Order is then incorporated into the Schedule of Values and becomes payable according to the payment terms discussed below in the Agreement. 3) A written amendment to the Contract signed by both parties. C. CONFLICT OF DOCUMENTS If any conflict should arise between the Contract Documents, then the following order of precedence will be followed in determining the terms and conditions that shall be controlling and binding upon the parties to this Agreement: l) this Agreement Page: 1 of 8 Initials:* I 2) Substantial Completion Agreement 3) Limited Warranty 4) Schedule of Values 5) List of Contract Allotments 6) Scope of Work Description & Specifications 7) Plans D. CONTRACT SUM (price for all work described above): $ 508,000 E. TOTAL ALLOTMENTS included in Contract Sum): $ 91,781 (See attached "List of Contract Allotments") III. GENERAL CONDITIONS FOR THE AGREEMENT ABOVE A. DATE OF WORK COMMENCEMENT AND SUBSTANTIAL COMPLETION Commence work on or about May 290, 2007. Contractor to achieve substantial completion of all work in this Agreement on or about December 29'h, 2007 not including delays and adjustments for delays caused by: inclement weather, accidents, additional time required for performance of Change Order work (as specified in each Change Order), delays caused by Owner, and other delays unavoidable or beyond the control of the Contractor. B. EXCLUSIONS Unless specifically included in the Scope of Work described above, this Agreement does not include labor or materials for the following work: 1. Fees for design or engineering work including any additional D&E work required by building inspectors. All D&E work to be billed under separate Design Services Agreement. 2. Surveying that may be required to establish accurate property boundaries for setback purposes 3. Temporary sanitation, power, or fencing 4. Moving Owner's property around the site 5. Repair or replacement of Owner -supplied materials 6. Public or private utility connection fees 7. Repair of unforeseen and concealed conditions including, but not limited to, repair of concealed underground utilities not located on prints or physically staked out by Owner which are damaged during construction 8. Testing, removal and disposal of any materials containing asbestos (or any other hazardous material as defined by the EPA) 9. Removal of filled ground or rock or any other materials not removable by ordinary hand tools or other heavy equipment already on-site 10. Any digging or excavation below the grades shown on the plans in the event that soils unsuitable for supporting the specified footings are discovered 11. De -watering of excavations 12. Frost protection for open excavations 13. Cold weather additives to concrete or insulation of concrete forms if required due to cold weather conditions 14. Correction of existing out -of -plumb or out -of -level conditions in existing structure 15. Correction of concealed substandard framing. 16. Removal and replacement of existing rot or insect infestation 17. Re-routing/removal of vents, pipes, ducts, wiring, conduits, structural members, or steel mesh which Page: 2 of 8 Initials: W / /� IC ENTIRE AGREEMENT, SEVERABILITY, AND MODIFICATION This Agreement represents and contains the entire agreement between the parties. Prior discussions or verbal representations by the parties that are not contained in this Agreement are not a part of this Agreement. In the event that any provision of this Agreement is at any time held by a Court to be invalid or unenforceable, the parties agree that all other provisions of this Agreement will remain in full force and effect. Any future modification of this Agreement must be executed in writing in order to be valid and binding upon the parties. L. TRANSFERENCE This Agreement is between Owner and Contractor and is not transferable to other parties without the prior written consent of both Owner and Contractor which shall not be unreasonably delayed or withheld. M. EXPIRATION OF THIS AGREEMENT This Agreement will expire 30 days after the date at the top of page one of this Agreement if not accepted in writing by Owner and returned to Contractor within that time. N. OWNER'S 3 -DAY RIGHT OF RECISION The Owner may cancel this agreement with no further obligations by notifying the Contractor in writing that they wish to cancel the agreement within 3 business days of the date they signed the agreement. I have read and understood, and I agree to, all the terms and conditions contained in the Agreement above. Date Stephen D. Howell, President Howell Design & Build, Inc. i D e U er 5/-AVD7 Date Owner Page: 8 of 8 Initials: 6-91 11 / �A, 4 3 CL) Board of Building Regulaons and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 123237 Type: Public Corporation Expiration: 1/10/2009 Tr# 123442 HOWELL DESIGN & BUILD STEPHEN HOWELL 360 MERRIMACK ST. LAWRENCE, MA 01843 DPS -CAI 0 501,A-05/06-PC8490 ✓1ze -C�aininwnu�e� ��a�. Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR c- Registration: 123237 Expiration: 1/10/2009 Tr# 123442 Type: Public Corporation HOWELL DESIGN & BUILD STEPHEN HOWELL 360 MERRIMACK ST: . LAWRENCE, MA 01843 Administrator Update Address and return card. Mark reason for change. ❑ Address ❑ Renewal ❑ Employment ❑ Lost Card License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston, Ma. 02108 A7L Not valid without signatu .e .�{ _ ✓1� vromvnu�ruuea,�i o�,�/�ar%uael� . BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR . Number: CS . 068232 Birthdate: 02/14/1962 Expires: 02/14/2008 Tr. no: 16261 Restricted: 00 STEPHEN D HOWELL 15 MT VERNON RD BOXFORD, MA 01921 Commissioner Board of Buildin Re u(ations g One Ashburton P ace, Rm 1301 Boston, Ma 02108-1618 License: CONSTRUCTION SUPERVISOR LICENSE Birthdate: 02/14/1962 Number: CS 068232 Expires: 02/14/2008 Restricted To: 00 STEPHEN D HOWELL 15 MT VERNON RD BOXFORD, MA 01922 Tr. no: 16261 Keep top for receipt and change of address notification. 3-CA1 0 5OM-04105-PC8698 00 - 35,000 cf enclosed space (MGL C.112 S.60L) 1A - Masonry only 1 G -1 & 2 Family Homes Failure to possess a current edition of the Massachusetts Stale Building Code is cause for revocation of this license. II I Mr- cnrG rAI 1 rCAITCD• MOW 9.t� 7090 ACORD„ CERTIFICATE OF LIABILITY INSURANCE WOP EL J ROWEL -1 TE DA08/IDD/06 08/15/06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION LTR ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HUB International New England HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 299 Ballardvale Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Wilmington MA 01887 Phone:978-657-5100 Fax:978-988-0038 INS URERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Atlantic Charter INSURER B: Hartford Insurance 22357 Howell Design & Build, Inc 360 Merrimack Street, Bldg #5 Lawrence MA 01843 INSURER C: INSURER D: INSURER E: 06/01/06 COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NS TYPE OF INSURANCE POLICY NUMBER DATE (MMIDDIYI') DATE (MMIDD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 B X COMMERCIAL GENERAL LIABILITY CLAIMS MADE Fx-1 OCCUR 08SEAGH6835 06/01/06 06/01/07 PREMI8ES(Eaocc%nce) $ 300,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $1,000,000 X EPL -$5000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS- COMPIOP AGG $2,000,000 POLICY 7JET LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Es accident) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per person) $ HIRED AUTOS NON -OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per sccident) GARAGE LIABILITY ALTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ . ALTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR FICLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERLnv ANY PROPRIETOR/IETORI NCA00120704 0601PARTNER/EXECUTIVE / /06 06%01/07 TORY LIMITSIL� ER E.L. EACH ACCIDENT $ 100000 OFFICERRAEMBEREXCLUDED? If yes, describe under E.L. DISEASE - EA EMPLOYEE $ 100000 E.L. DISEASE -POLICY LIMIT $ 500000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS contactor GEK I IFICATE MOLDER CANCELLATION RIVERWI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Riverwalk Partners, LLC NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL 360 Merrimack Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Lawrence MA 01843 REPRESENTATIVES..)€�— AUTH��vATIVE �� ACORD 25 (2001108) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 IV- www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builde rs/Con tract o rs/El ectri cians/P lumbers Name (Business/Organization/Individual): Address: 2S� City/State/Zip: (awl- OCA M0 Phone #: IM � � - � q Ll V Areypu an employer? Check the appropriate bo I am a employer with 4. ['am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors ?. ❑ I am a sole proprietor or partner- listed on the attached sheet. + ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. dRemodelmg 8. [Demolition 9. & Building addition 10.E ctrical repairs or additions H. Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit 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 is providing workers' compensation insurance for my employees. Below is the policy and job site information. _ AAawV; c.. C"rk.�_ Insurance Company Name: d&rA Policy # or Self -ins. Lic. #: (A) C(Z o(� 1 a '� �-o l Expiration Date: (I1 l a Job Site Address: YaD C teak ?_SBA R City/State/Zip:�L 616N'e- A�T 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 celtify under the pairs pnd penglties of perjury that the information provided above is true and correct. 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 #: x w W y� a4 w Cf) U w2 x q U w �t= o x w � Z a w r w. x w w rr rA O cn y cn �1 O z J O J s a"I O Z � CL O y O c _ I C cm C ■A y p2 On s �E m m CL. 3� o ? 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