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HomeMy WebLinkAboutBuilding Permit #974-2016 - 9 MORTON STREET 3/16/2016V7 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Issued: IWORTANT: Applicant must LOCATION. 11 Date Received all items on this PROPERTYOWNER- Print 100 Year St-ructur( ,MAP A FrZ C -7E ZONING" DISTRICT: Historic (District Machine Shop yes no yes, no. TYPE OF IMPROVEMENT PROPOSED USE Resi.Oential Non- Re'sidential New Building (VOne family 0 Addition El Two or more family El Industrial El Alteration No. of units: El Commercial A [VRepair, replacement D Assessory Bldg 0 Others: El Demolition El Other 0 Septic QWeIV Ei Floodplain'. 0 Wettands 0 Watershed: District, ewer AWO DESCRIPTION OF WORK TO BE PERFORMED: .fi . Ide t !gation- lease Type or Print Clearly OWNER: Name: Phone:�&-ff 7-A33 Address: Ac)-, Rife C'ontr?tctor N'8me: SupeOvisor"s Construotio License: Exp. Date:A�76-17 n� te Exp. ba ,Hbm,,e Imo-r"veme 0 . -htLicense: ARCH ITECT/ENGI NEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: 5bA?:Ae I NOTE: Persons contracting with un tered contractors do not have access to the guar, tv fund J41N r7Li.S-" A N /"% ��'l fi %, Plans Submitted 11 Plans Waived [I Certified Plot Plan 11 Stamped Plans P TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/1\4assage/Body Art Swimming Pools 11 well Tobacco Sales Food Packaging/Sales Private (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On — Signature. COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes � Planning Board Decision: Cpnservation Decision: Comments Comme Water & Sewer Connection/signature & Date Driveway Permit 6 DPW Town Engineer: Signature: Located 384 Osgood Street _qp yu ' -.r MCR, y --9 g i �uem,)iLm tg ronct$ 'PA g(It gk't�:, A-01 -0 s :!�gh 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 MGL Chapter 166 Section 21A —F and G min.sloo-sl000 fine NU I t5 and UA I A — (For department use Ll Notified for pickup Call Emai Date Doe.Building Pennit Revised 2014 Time Contact Name No 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 ci Building Permit Application L3 Workers Comp Affidavit (i Photo Copy Of H. 1. 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) u Building Permit Application Li Certified Proposed Plot Plan • Photo of H.I.C. And C.S.L. Licenses • Workers Comp Affidavit • Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (if Applicable) • Copy of Contract • Mass check Energy Compliance Report • Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit in all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 C, 1 0 , - I Location 1 6 " tj -5)t I M� No. Date C h e c k 4t��( A, —X-) 30126 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $-I Other Permit Fee $ TOTAL $ "Building Inspector i — CD 0 z f-01 CD 0-0 CL =r 0 U) > to 0 0 CD < 0 D 0 - Cr CD 0 CD CD 0 U) CL CD 0 S' = CO CD 0 z CD 0 0 r -41L 0 CD a 0 CD < 00-0- Z5 0 = -1 0 —h 0 o- W = S CD CD > CD CL 0 (D 0 CD 0 M 0 CL 0 z 0 -0 = 0 0 0 0 CL MR Cf) CD ID 0 (D '0 CD CD 0 -1 -% CD to CL 0 m 0 < Co. to 0 U) Cl) CD 0 = cc h U)'O cn a z CD IV 0 t7 0 1-40, ;L C. 0 M 0-' = — X > CD (1) z U) = 0=' CL 0 to cn Cl) 2. O< CcDL 0 CL m 0 Z 7 M< m (n C/) 0 cn CML Go - mo ;two 0 5.0 Cl) 0 — . 0 . =r Z Ci) CD CD u) CD . ay -0 Z a (D F= 0 0 Z =r > (D Z CD CO) m 0 0 0 0 CL Ln 3 0 X- rD Ln (D m 03 z m m V > M, z -n �u 0 m =r CA) > m r) 0 U) M (D �O 0 c aq =r m r, m m 0 -n w C) c GQ =r r, z G) z (A V m 0 X M =3 w n =r �* m ;a 0 c m - 0 c 0 :3 P C) m C) 0 (.n rD -a Ul) (D 3 -n 0 0 CL T5 (D 0 > 0 m > moo 0 0 )Val 0 0 W", Iq 0 41� CD 01 Massachusetts Home ImDrovement Sample Contract This form satisfies all basic requirements ofthe state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of "A Massachusetts Consumer Guide to Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the Office ofConsumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. laomeowner information Contractor Information Name Com�pp��me 66 ar-1,jeft - , /2 1 Z 0 jrC1;L_ a . "I - rl " 'A 0 Z Street Addregs (do not use a Post Office Boi'addressT CQWL IG Cityllown State Zip Code M)JAaa A4. Business Address (must include a street address) M494110- !S*Y Daytime Phone " EviningPhone .0. 'r e --% 77P's'-:5-7 '5633 City/Town Code 44W 91011 Mailing Address (It different from above) Business Phone Federal Employer D or S.S. Number "I "It I'll finprove—t M. a valid mhuration number Home mp—lContactorReg.Number t d% ^ 07 > Expiration date 111d W 0 The Contractor agrees to do the following work for the Homeowner: O)escribe in detail the work to completed, specifying the type, brand, and grade of materials to be used, use additional sheets ifnecessary.) %r_ t P (P erlc�6 Required Permits - The following building permits are required Proposed Start and Completion Schedule - The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be —Y I excluded from the Guaranty Fund provisions of 3—Alk—Date when contractor will begin contracted work. MGL chapter 142A.) when contracted work will be substantially completed. Total Contract Price and Payment Schedule �# .. :5; Ile Contractor agrees to perform the work, flimish the material and labor specified above for the total sum o Payments will be made according to the following schedule: $ a upon signing contract (not to exceed 1/3 ofthe total contract price or the cost of special order items, whichever is greater) $ 0 by . . . or upon completion of $ 6 by or upon completion of A__)50upon completion ofthe contract. (Law forbids demanding full payment unfil contract is completed to both party's satisfaction) ne following material1equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(") s 0 to be paid for NOTES: (*) including all finance charges (**) Law requires that any deposit or doom -payment required by the contractor before work begins may not exceed the greater of (a) one-third ofthe total contract price or (b) the actual cost ofany special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty - Is an express warranty being Provided by the contractor? El No Yes (all terms ofthe warranty must be attached to the coni[ISII Subcontractors - The contractor agrees to be solely responsible for completion ofthe work described regardless ofthe actions ofany third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions ifsomething is unclear. • Make sure the contractor has a valid Home lmorovement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director ofHome Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to see a copy ofa "proof of insurance" document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement ifit has been signed at a place other than the contractoes normal place ofbusiness, provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight ofthe third business day following the signing ofthis agreement. See the attached notice ofcancellation form for an explanation ofthis right. DU NUFSH;NTHIS CUNTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of the contract must be completed and signed. One copy should go to the homeowner. The other cold c kept by the contractor. Homeowner's Signature ignature —) 3. — / -S Date Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the 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 Regulationk and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Law9shapter 142A. HomeownJi's Signature C tractor's Signature NOTICE: The signatures of the parties above apply only to the agreeme t of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even Aere this section is not separately signed by the parties. Homeowner's Righis A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer protection laws (i.e. 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. 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. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, 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 questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). Execution of Contract I The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections. have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day rescission period has expired. Accelerated Payments A 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. However, in instances where a contractor deems him/her ' self to be financially insecure, the contractor may require that 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. % Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at http://www.mass.jzov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at http://www.mass.p_ov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeimprovement/licenseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 1 508-652-4800, 508-755-2548 or 413-734-3114 Version 2.1 - 11/22/2010 Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the 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 Regulatid �nd'ihe consurner shall be required to submit to such arbitrat , ion.as provided In Massachusetts General Laws_fhapter 142A. Homeowner's Signature C jPractor's Signature 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. I - Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, homeowners may be excluded from certain rights if the contractor/ihey choose is not properly registered as prescribed by law. 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. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, 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 questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). Execution of Contract .,-j % \�- The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents hav`e-1Te-6h gttach�d. Parties are also advised not to sign the document until all blank sections. have been filled in or ma�red'as voidGeleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the thre6 day rescission period has 'expired. Accelerated Payments A 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. However, in instances where a contractor deems him/herself to be financi�lly- insecure, the contractor may require that the balance of funds not yet due be placed in ajoint escrow account as aprerequisite to continuing the contracted work. With&wal of funds. from said account would require the signatures of both parties. Q) Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at http://www.mass.gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at htip://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeimprovement/Iir,enseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Off,66 of the Attorney General A 60-727-8400 AND/OR Better Business Bureau . \1 k 508-652-4800, 508-755-2548 or 413-734-3114 Vemion 2. 1 - 11/22/2010 actorsJFleqdciaUs1P1Wbers- Worj�e3(sl, Compensation bsuraned Affidavit: Builders/Contr TO BE FILED WITH THE FFIRMTTNo AuTilomy- Name (Bnsffi6gsidr'goizationftdivi4,ial)'- Address: 4� I ��Jjo City/State/Zip: �i 64 te uk-the appropr'R box: -Are you art emp!oye 01 phone:ff: 11KI am a employer Vith__�_�'Uloyees (fL'U andlor part-time).' 2.E] I an a sole proprietor or partnership and have no employees vvorking for mein any capacity. [Ko workers, comp. insurance required.] 3.E] I am a homeowner doing all work myselt (No workers' romp. insurance required] 4.Fj I am a homeowper and vAU be hiring contractors to conduct all work on My Property' 1 will ensure I workere compensation insurance Or axe sole that all contractifs either have , "W H F- 63�61 - proprietors wj� jjo eW6�ees�. e the attached sheet. s.E1 I am a general con�ctor'and I �ave hired the sub-cOntractols list don . - .­�, 4'�� e., - i ' have workers' comp. insurancO These sub-con"qt�64� eTP oyces and 6. Q We are 1517 91 *Any app1lic t i Romeawners tContractors that emnlovees. If tflhe _con#act9rs hav Type aprojea oequn:i 0 7. El N6V !6Rstrddfi011 8. E] P6modelffig 9. C1 Demolition 10 E] Building addition Elec�ri4a`1'fep*s or additiggs, 12. JM.,P��ing repairs'6r dadiiiOlis 13& g�eoff repairs 14.n Other I -,:-- �1, ;�f�,Mqfinlx - compens F id, ting I , contractors must submit a new affidavit indica suc -contractors and statq whqther or pot thosp jentig�� have Pmnlovees. thev must provide their workers' comp. policy number. I- am an employer th at is providing WOrkers' information. A- __rk compensation insuranccfOr MY employees. h . elow is thepolky and)ob slt� fnsurance Company Name: Policy 9 or Self -ins. Lie. It: )1AX-4co -76, 23 � -A . Expiration Date.�_� . tyoq�- City/state/Zip: wow H# Job Site Address: !ration dat q_�p e ' mpelisation policy declaration page (showing the policy number and exp, -e) Attach a copy of th WQTkers' co . a criminal violation punishable by a RAO up to $1,500.00 Failure to Secure coveragG as required under MGL o. 152, §25A is of pto$250.00a and/or one-year imprisomnent, as well as civil penalties in the form of a STOP WORK ORDER and a fine IT day against the violator. A copy of this statement may be forwarded to the Office of fnvestigdtions of the DIA for basurance coverage verification 1 do hereby Wtify under pen alties ofperjury th at th e information Proviaea aV0Ve Is Ir" 0 "Ir4v� one –Tc 7 ,4 : -1 (j2 � :zV - Official use only. Do not -Write in this area, to he completed by city or to-wn officiaL City or Tovu: permit/License Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. CityiTown Clerk 4. Fjectrical inspector 5. plumbing Inspector 6. Other Contact Person: — Phone Commonwealth ofHassachusefis .The Department of IndustrialAccidents Q- I Congress Street, S�!M 100 Boston, MA 02114-2017 w.mass.gov1dia actorsJFleqdciaUs1P1Wbers- Worj�e3(sl, Compensation bsuraned Affidavit: Builders/Contr TO BE FILED WITH THE FFIRMTTNo AuTilomy- Name (Bnsffi6gsidr'goizationftdivi4,ial)'- Address: 4� I ��Jjo City/State/Zip: �i 64 te uk-the appropr'R box: -Are you art emp!oye 01 phone:ff: 11KI am a employer Vith__�_�'Uloyees (fL'U andlor part-time).' 2.E] I an a sole proprietor or partnership and have no employees vvorking for mein any capacity. [Ko workers, comp. insurance required.] 3.E] I am a homeowner doing all work myselt (No workers' romp. insurance required] 4.Fj I am a homeowper and vAU be hiring contractors to conduct all work on My Property' 1 will ensure I workere compensation insurance Or axe sole that all contractifs either have , "W H F- 63�61 - proprietors wj� jjo eW6�ees�. e the attached sheet. s.E1 I am a general con�ctor'and I �ave hired the sub-cOntractols list don . - .­�, 4'�� e., - i ' have workers' comp. insurancO These sub-con"qt�64� eTP oyces and 6. Q We are 1517 91 *Any app1lic t i Romeawners tContractors that emnlovees. If tflhe _con#act9rs hav Type aprojea oequn:i 0 7. El N6V !6Rstrddfi011 8. E] P6modelffig 9. C1 Demolition 10 E] Building addition Elec�ri4a`1'fep*s or additiggs, 12. JM.,P��ing repairs'6r dadiiiOlis 13& g�eoff repairs 14.n Other I -,:-- �1, ;�f�,Mqfinlx - compens F id, ting I , contractors must submit a new affidavit indica suc -contractors and statq whqther or pot thosp jentig�� have Pmnlovees. thev must provide their workers' comp. policy number. I- am an employer th at is providing WOrkers' information. A- __rk compensation insuranccfOr MY employees. h . elow is thepolky and)ob slt� fnsurance Company Name: Policy 9 or Self -ins. Lie. It: )1AX-4co -76, 23 � -A . Expiration Date.�_� . tyoq�- City/state/Zip: wow H# Job Site Address: !ration dat q_�p e ' mpelisation policy declaration page (showing the policy number and exp, -e) Attach a copy of th WQTkers' co . a criminal violation punishable by a RAO up to $1,500.00 Failure to Secure coveragG as required under MGL o. 152, §25A is of pto$250.00a and/or one-year imprisomnent, as well as civil penalties in the form of a STOP WORK ORDER and a fine IT day against the violator. A copy of this statement may be forwarded to the Office of fnvestigdtions of the DIA for basurance coverage verification 1 do hereby Wtify under pen alties ofperjury th at th e information Proviaea aV0Ve Is Ir" 0 "Ir4v� one –Tc 7 ,4 : -1 (j2 � :zV - Official use only. Do not -Write in this area, to he completed by city or to-wn officiaL City or Tovu: permit/License Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. CityiTown Clerk 4. Fjectrical inspector 5. plumbing Inspector 6. Other Contact Person: — Phone Information and Instructions Massachusetts General Laws chapter 152 require� �11 emplbyqs to provide workers' compensation for their �mp*fqy��qs. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of express or impH4 oral or written." An employer ig deffi6d as "an individual, partnership, association, corporation or other legal entity, or agy two or more Ofthe foregoing engaged in ajoint enf6rpriso, and including the legal representatives of a deceased employer, or the receiver I ohtr4stoodanindividu partnership, association or other legal on*, employing empl6ypp§., Ho 0 . . al, . I wove ' r the owner of a dwelling house having not more than three apartments and who resides therein, or the occi'p;'5�i df �h6 dwelling house of another who employs persons to do maintenance, construction or repair work on such dwe4�ng 4ouse or on the grounds or building appurtenant thereto shall not because of such employment h6 deemed to be an employer." MGL C i hapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to opdrate a business or to construct buildings in the commonwealth for any applicant whdt has produced -acceptable evidence of compliance with the insurance coveragd � ' ed." reqiiir Additionally, �14 qh4pipr 1,52, §25C(l) states "Neither the commonwealth nor any ofits political subdivisio'ns shall enter into any contract for the performance ofpublic; work until acceptable evidence of compliance with the insurance requirements of thi I s chapter have beenpresented to the contracting authority." Applicants Pleasb fill out the�vorkers' compensation affidavit completely, by checking the boxes that apply to your situation and, if nec6sary, supply sub4contractor(s) name(s), address(es) and phone number(s) along with their certificateb) of insurance. Limited -Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employe s oilier than the members or partners, are not required to carry workers' compensation insurance. If anLLC orLLP do'e's have employees, a policy is required. 'Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidAvit should be returned to the city or town that the application for the permit or license is being requ�steq, not the Department of IndustrialAccidenis. �hould you have an y* questions regarding the law or if you are req*ed to obtain a W�`9'rftrs' compensat&ipolicy, please call the Department at the number listed below. Self-insured companies sl�oiiid enter their self-insurahoic license number on the appropriate lind. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the, bottom ofthe affidavit for you. to fill out -in the event the Office ofInvestigations 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 hpplicant thai 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 been officially stamped or marked by the city or town may be �rovided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A now 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 bum leaves etc) said person is NOT required to complete this affidavit. The Department's address, telephone and fkx number: The Commonwoalth of Massachusetts Department of Industrial Accidents I 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 ACCORDF CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDNYYY) 03/15/2016 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 TH E 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorseiment. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: Carla M Degnan DEGNAN INSURANCE AGENCY, INC. PHONE I FAX UVC, No. Ext), (978) 6 84474 AIC, Nol: E-MAIL ADDRESS. cdegnan@degnaninsurance.com INSURER(S) AFFORDING COVERAGE NAIC 0 85 SALEM ST. INSURERA: AIM MUTUAL INS CO 33758 LAWRENCE MA 01843 INSURED INSURER B: INSURERC: JAMES DEBRECINI FAMILY ROOFING & PAINTING INSURER D: INSURERE: 12 TANAGER WAY INSURER F: ,,LONDONDERRY NH 03053 COVERAGES CERTIFICATE NUMBER: 37186 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 19SUED 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 ADDLSUBR J= ima POUCYNUMBER POLICY EFF fMM/DDIYYYY) POLICY EXP 1MMIDDfYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ --I DAMAGE TO RENTED CLAIMS MADEE OCCUR PREMISES (Ea occu�.nce) $ MED EXP (Any one person) $ ±ERSONAL & ADV INJURY $ N/A GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY [�] PRO- JECT F—] LOC PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE UA91UTY MBINED SINGLE LIMIT (CEO, accident) $ BODILY INJURY (Per person) $ ANY AUTO ALL C Uj00SWNED S HEDULED A AUTOS N/A BODILY INJURY (Per accident) $ NON -OWNED HIREDAUTOS AUTOS PROPER DAMAGE (Par cddZ I) $ UMBRELLALIAB IOCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB I CLAIMS -MADE N/A i-1 DED I I RETENTION$ $ A wbRKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? FN 17A (Mandatory In NH) NIA NIA AWC40070259002015A 05/11/2015 05111/2016 ER OTH- PSTATUTE ER E.L. E CH ACCIDENT s 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 If gs, describe under .D SCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If mom space Is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date ofthis certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at Www.mass.gov/lwd/workers-compensationAnvestigabons/. Sole proprietor has not elected coverage. 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. 1600 Osgood Street Bldg 20 Suite 2035 AUTHORIZED REPRESENTATIVE North Andover MA 01845 I Daniel M. C r��Y, CPCU, Vice President — Residual Market — WCRIBMA %) 1983-2014 ACORD CORPORATION. All rights reserved, ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD VMassachusetts Department of Public Safety j Board of Building Regulations and Standards IRV License: CSSL-099685 Construction Supervisor Specialty JAMES J DEBRECENI 2 TANAGER WAY LONDONDERRY NH r'-jZCK- C"A'— 6piration: . Commissioner 12/06/2017 a (92. �L\. Office of Consumer Affairs & Busin� lation ME IMPROVEMENT CONTRACTOR Type: egistration: 122385 x x o 4, pirati n:-8/wawa�� DBA J-& D WEATHERSEAL AMES DEBREC 'ME 2 TANAGER WAY. LONDONDERRY, N.H 0308�'--'­ Undersecretary vidul use only License or registration valid for indi before the expiration date. If found return to: ell A ff-irs and Business Regulation. Office o 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid4aWithout signature.