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Building Permit #338-13 - 95 CANDLESTICK ROAD 10/24/2012
s r� TOWN OF NORTH AW-DOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: v. IMPORTANT:A � lie�ant must omplete all itemson this age h ""ATI©N aw�i +5 r s« . _� c + r*�✓ 2 s YB as iu$ z�a . � ad v� t r�r -fav' ��' gPflnt °r 4 k,�':. .�, �.s., i {. a• x { r: ' �'ti 'APROPERTY OWNER s ash». j, sa -4ywrf uit t trUCtUfe 2S tf10 xMAPNOi. �.tARCELZUf NINGDISTRICT �%=€ Hist%cDity tno �`L,.�:ri.-.;.,�°�.ETe- + k.:.�e_�-a-�id� r�;ice ,� ��4.x�•'R3.3_.ti-,�r,.��w'� .�- -� -rt v(�a t-- . .. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family 11 Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ Floodlain r O1U1/etlandsr ; is ® Septic ®tWell p ... ���Watershedtnct `'❑41Nater/Sewer ��`,. � fl �' '° �'�� .< f DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address `'? ya..r .s tfc,'T' ,#''�"" `a4+� a 1' x. y� .# .r.xKt•^. ri .tsw ,r -,try''"'l�i-�` •. fi +p�, "f '"'�€..aq. t„ -La� e..°� n ." ,`.t' 5"'_ i 4 'J3Kl �`�: �'$ Y "' z o."+'K`. ��� C® TSRACT®R Name : . ,� Phone its � 1 .a A.N '�`"�''• «�'v� a'r'-5't .• ;ra �, s *:*• `g ' Su ervisoris GonstructionjLen�se :s�rExp� D'ate r` i�W ', -4 s & '�a..sat'°>��� �;i9c•'�, �'rr:rs��`z-� � �� � � �.yis� ��s,��#�� HomeImprovementLacense � �.a ,. � z ,ExpDate 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: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Age.nt/Owner :x ,- . :_.. . Signature of contractor Dinne Ct thrni++crl I—I Plnnc Waived I I Certified "Plot Plan ❑ Stamped Plans ❑ %%ORTit BUILDING PliRMIT 3�os•. oma TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATI N Permit NO: 3� ` Date Received �Atoo q Q Date IssueV _ /y 9SS�CHU`��� Issued IMPORTANT: Applicant must complete all items on this page LOCATION . 41, x PROPERTY OWNER Ptmtk , MAP NO: 1( , . PARCEL:Dlc ti ZONING D1ST 'id 1 .. �xFHstoric Duct des no `tVlachlne Sh6 Voltage .eyes { o TYPE OF IMPROVEMENT PROPOSED USE Reside ial Non- Residential ❑ New Building ne family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑Septic ❑Well ❑Floodplain .0 Wetlands n Watershed District o Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: d i1 GIS, e_ n Identification Please Type or Print Clearly) i OWNER: Name:_ I✓��v`��, s` ✓r,n 1%4c-Ca o ii Phone:—+? Address: COTO C R Name; ` ., r h no: NTRA y - .1. Address: ' 11r Su 's t' S - 1 rVl S COn i o sttucti r�,License: n 4 "t , Home Improvement Licenser 1 U Exp. Date: 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: $ yo o DO -C-10 FEE: $ Q Check No.: ��n Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ignature o€Agentt�er S na' re of contractor s Location � G --- /_/ TOWN OF NORTH ANDOVER -,7.1 . �L• v "i • _ Certificate of Occupancy $ Building/Frame Permit Fee $ = � - Foundation Permit Fee $ Other Permit Fee i � $ a TOTAL $ Check*D S v 25872 wilding Inspector 4; 4 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools ❑ Well ❑ ' Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS i F 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 DPW Town Engineer: Signature: FIRE DEPARTMENT = Temp Dumpster on site yes Located 3n00s Osgood street Located at'124 MainStreet ` Fire Department signature/date f I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ C(MMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes i, Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature&Date Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT Temp.Dempster on site yes . no k Located at:924`Main Street Fire Department signa#ure/date KK' l COMMENTS * 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 i I I ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008 I Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ 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: Doc.Building Permit Revised 2008 �%ORTH Town of _E ._ .,,, Andover O Y No. 1 i h o : LAME h ver, Mass, 00 «MAC»11w,c« �'►• �•9 A044Teo okP���S S U BOARD OF HEALTH Food/Kitchen PE . IT Septic System T LD THIS CERTIFIES THAT .. .MkW. Meo... .�r��!1.......... . ................................. BUILDING INSPECTOR... has permission to erect ..........................13uildings on ......q'T.....Caro Foundation - --` Rough to be occupied as ........ ............ ..... ��.....WI.Irb 0 40A...................................... Chimney provided that the person ccepting this permit hall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of.North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR rpw UNLESS CONSTRUCTI S TS Rough Service ... .. 4e........................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or 'Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE NORTH own of 2 s E ndover O _ y � 117 h vera� Mass � o LAN• ver, Mass, 1O COC NI CNl WIC. �d pC)RgTEV S U , BOARD OF HEALTH IT LD Food/Kitchen PE . Septic System THIS CERTIFIES THAT _* ... ,,, „C,�IA/,�........ BUILDING INSPECTOR has permission to erect ........ ..........13uildings on . ca, Foundation _ Rough to be occupied as ........ ............ ..... T..... �.I�!1► ...................................... Chimney % provided that the person �ccepting this permit hall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIVSTAFTS Rough Service ... .. ........ ....................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE RenewalMA Home Improvement Contractor b ,��� License#170810(Expires 12/23/2013) yAndersen. WINDOW REPLACEMENT an Andersen Company Renewal by Andersen Corporation Federal Tax ID#4I-1918413 104 Otis St.,Northborough,MA 01532 (508)351-2200•Fax:(651)351-4810 CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer(s)Name Date of Agreement Buyer(s)Street Address,City,State,and Zip Code E-Mail Address Home Telephone Number - Work Telephone Number -79/- 9576- 39`t-5 Buyer(s).hereby jointly and severally agrees to purchase the products and/or services of Renewal by Andersen Corporation ("Contractor'%in accordance with the terms and conditions described on the front and the reverse of this agreement and on the attached specification sheet(s) (collectively,this"Agreement").Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Estimated Starting ate: Method of Payment: Total Job Amount:� Amount Financed /'_�{� 5 i Check ❑Cash Deposit Received(33%): 1 SQ6 l0 6 E]Visa/MC ❑Discover Balance at Start of Job(33%): 0 WFInanced ❑AMEX Estimated Completion Date: If credit card is selected,please Balance on Substantial ) [ ©Qo r/l a�{ ?>-4 O( see Credit Card Payment Form. Completion of Job(33%):/ /� Jn /�1 Sy " Buyer(s)agrees and understands that this Agreement constitutes the entire understanding between the parties,and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alteration to or deviation from this Agreement will be valid without the signed,written consent of both Buyer(s) and Contractor. Buyer(s) hereby acknowledges that Buyer(s) 1) has read this Agreement, understands the terms of this Agreement, and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Renewal by Andern orporation u e (s) uyer(s) By: Sigtreof yye�t anager Signature /� _ACSignature/fit 5 a r D+,/ C "'Ni✓ i,Gh� �C(C N/6. Print Name of Product Manager Print Name Print Name YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. — — — — — — — — — — — - —�c - - - — — - - - — — — — — -�-c- - - - — - - — - - - - - - -� NIOTICF,OF CANCELLATION X NOTICE OF CANCELLATION Date of Transaction -2,7--- -A! . You may cancel Date of Transaction 2— . You may cancel this transaction,without any penalty or obligation,within this transaction,without any pena or obligation,within three business days from the above ate.If you cancel,any I three business days from the above ate.If you cancel,any property traded in,any payments made by you under the I property traded in,any payments made by you under the Contract of Sale,and any negotiable instrument executed I Contract of Sale,and any negotiable instrument executed by you will be returned within 10 days following receipt I by you will be resumed within 10 days following receipt by the Contractor ("Seller") of your cancellation notice, I by.the Contractor ("Seller'l of your cancellation notice, and any security interest arising out of the transaction will I and any security interest arising out of the transaction will be canceled.If you cancel,you must make available to theI be canceled.If you cancel,you must make available to the Seller at your residence,in substantially as good condition Seller at your residence,in substantially as good condition as when received, any goods delivered to you under as when received,any goods delivered to you under this this Contract or Sale; or you may, if you wish, comply Contract or Sale;or you may,if You wish,compl�r with the with the instructions of the Seller regarding the return instructions of the Seller regarding the return shipment of shipment of the goods at the Seller's expense and risk. I the goods at the Seller's expense and risk.If you do make If you do make the goods available to the Seller and the I the goods available to the Seller and the Seller does not Seller does not pick them up within 20 days of the date I pick them ujp within 20 days of the date of your Notice of your Notice of Cancellation,you may retain or dispose I of Cancellation,you may retain or dispose of the goods of the goods without any further obligation.If you fail to without any further obligation. If you fail to make the make.the oods available to the Seller, or if ou agree I Fr ds available to the Seller,or if you agree to return the to return the goods to the Seller and fail to do so,then I ds to the Seller and fail to do so,then you remain liable you remain liable for performance of all obligations under I performance of all obligations under the Contract. the Contract.To cancel this transaction,mail or deliver a To cancel this transaction, mail or deliver a signed and signed and dated copy of this cancellation notice or any I dated copy of this cancellation notice or any other written other written notice,or send a telegram to Contractor. I notice,or send a telegram to Contractor. Renewal by Andersen Corporation, 104 Otis Renewal by Andersen Corporation, 104 Otis Street, Street, Northbo�qugh, MA 01532, BY NOT LATER THAN Northb rou h,MA 01532,BY NOT LATER THAN MIDNIGHT MIDNIGHT OF 'x-2(0 L .(Date) OF - -/ .(Date) I HEREBY CANCEL THIS TRANSACTION. i 1 HEREBY CANCEL THIS TRANSACTION. Buyer's Signature Print Name Dale Buyer's Signature Print Name Data RbA Copy- White Buyer Copy-Yellow Buyer Copy-Pink QBLLP2009.RBAFh.MANH Renewal .. anewal by Andersen Corporatit MA Home Improvement Contractor bYAnderSen. •, 104 Otis St.,Northborough,MA 01532 License#170810(Expires 12/23/2013) WINDOW REPLACEMENT an Andersen Company (508)351-2200•Fax:(651)351-4810 Federal Tax ID#41-1918413 WINDOW SPECIFICATION SHEET Buyer(s)Nam Date of Agreement The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices and terms described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMENT, of which this Specification Sheet is a part. WINDOW DEfAHS 1. Contractor will Install a total windows in Owner's home,using the following individual quantifies: 3 Double Hung(DB) Equa sash—Cottage sash(1/3 top,2/3 bottom)—Oriel sash(2/3 top.1/3 bottom)_Flat sill aware of cuss of 1-Casement(CS)_Hinge right_Hinge left(as viewed from exterior) Double Casement(CD) 2 Lite Gliding Window(GW) � Casement/Picture/Casement(CT) / 1:1:1 or_1:2:1 Glider/Picture/Glider(GPW)_1:1:1 or_1:2:1 Picture Window Bay or Bow Awning Window _#Lights Soffit/Roof Shingle/Copper Specialty Window Patio Doors(see separate door spec sheet) Seat to be Primed/Oak/Pine 2. Qty of Windows to be Custom Fit Replacement: -_/// 3. o Qty of Windows to be Custom Fit FuI[frame(INCLUDES INTERIOR&EXTERIOR CASINGS) Exterior sings:_Pine_Maintenance-free material Factory applied 908 Fibrex brickmold 4.Glazing I be: i/HP Low-F,-4 TM —Tempered —Other Ifof r,please specify: 5.Exterior color to be: White_Sand Canvas. Terratone C — ocoa Bean_Dark Bronze Forest Green_Black 6.Interior color to be:V White_Sand_Canvas_Pine_Maple_Oak_Same as Exterior Note:Wood interiors need to finished by Owner. 7.Hardware:A�White_Stone_Canvas_Estate Hardware: Style: 8. '—" Install Lifts with Double Hung WindoWN t�a rC.Meo r S 9. Screens:windows to have: V Half or-,/Full screens Screens to be:_FiberglassAluminum_TruScene GRIME DETAILS 10 indows have grilles:_Grille Between Glass(GBG)_Removable Interior Wood(INTW)_Full Divided Light(FDL) Owner approved(initials) Draw grille patterns below `Use additional sheet if needed Qty: Qty: Qty: Qty QCT. Qty: E:1 ADDITIONAL WORK DETAILS 11. Qty of_Sills_Sill noses to be replaced by Contractor 12. Contractor will remove metal frames of windows. 13. Contractor will install new_paint-ready or_stain-ready_Interior_Exterior casings in_Pine_Maintenance-free material 14.` _�CO ctor will install new_paint-ready or stain-ready_Interior_Exterior stops in_P ne_Maintenance-free material 15. Mills Owner is aware that Contractor does not do any painting. 16. ntractor will wrap exterior casings with coil stock of color. Note:Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in casing. 17. Contractor will insulate,caulk and seal windows with 3-Paint system to prevent water and air infiltration. Removal and disposal of all job related debris,windows,storm windows and vacuum nightly included. Upon completion of the job and payment in full,a limited warranty shall be issued. 18. Yes❑No Building Permit--Contractor will secure any and all necessary permits.The fee for the permit(s)is not included in the Contract Price and a separate check is required t the time of sale this fee. Ck# $�9- —� ) dew 19.LEJ Yes El No All discounts have been applied to this agreement price. yQ / fr G2 L v�, /G¢�vrwy(n/a�1dewS 20.Additional job details: lT � � dh_ •t �t 21.❑Yes❑No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment/finance form(s). It is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,constitutes the entire understanding between the parties,and there are no verbal understandings changing or modifying any of the terms.This Specification Sheet may not be changed or its terms modified or varied in any way unless such changes are in writing and signed by both the Buyer(s)and Contractor.Buyer(s)hereby acknowledge that yer(s)has read this Specification Sheet. Renewal rse rp ration Buyer ) Buyer(s) t By: Signa e,A/of P d ct.Manager Signature ignature Print Name of Product Manager Print Name Print Name The Cm.,owzweakh of Ilam acltuseft Depar inee.of InAr tial Accidetrls Office of Dives�igat�itins ; 6#0 Wash*gton,Street ' 'Boston;h�4 QZ�iI1 . - r.ma=M,,1dia Workers •Compensation Insnrince Affidxvit $mlders/Contrs.cbars/Flectricisns/Pb mbers A�giicatnt Infar�na4ian bly Please Pri t Led Nmnt(jfi�R/ : tZ'e A P U o.� V)u Addrese: b L{ City/Stet./ : iJr�,�- -��, o, 'PNIs I S 3 Phase 1;S 1-�a�C;) U Are yon sn empioytxl Check the apprcpaatr'bam Type of project(required); 1 I am a employes wi& T 4. ElI tam a general coahactnr and I '6. ❑New camstructioa employ= (fan and/orpa=t-fine):° have hind tic sub-cont<actnm 7 2.❑ I am e Role proprietor or part=- listed on the attached sheet t ship and have no employees lbese sob-camdrecto�h$ve 8. E]DcmolitiAan woc ing for me in any capacity, wart=' end'insu , 9. []Bal ins addition .' [No wmi=r' comp.iaeroe S. ❑ We are a etapamfion and it 10.❑Meakir4d repairs or additions rzguind] officen;hwe=m tsised ticir . 3. I am a homeowner doing eIl warJc right of esearption Per MGL 11.[]Phr�iag rapeas or additions c. 152, j 1(4),and we}live no 12.[3 Roof repairs �ysel£ [No warkrast-comp. '� � � . insurance roquiiad-] to o work=' 13.[]Ofhex Comp,ins�itrgaired:] °AM eppfiaoet thea ahecZz box 91 meat 990 fill cot for amtiM below shost�ag their e'adtea•'roo>pmsatiam PDbq man. t Homeowaea who aohmtt this x fidavk indi-6nB they sae doiag ell wort:ead 1hm hue ao�de aoaha =X1 m*=k s sew affidavit Mcli a ft aoeh ICCMftRntnts-fat rhmox r this bmoat47-1 U ed3itiaael doxt showing the==ofthe' ®d their wodm'comp.pokey t an raw an mWIvpex fiw is provi6w wort ,eoaiparaion area irmwe for my eixplayeaa• Below is the par—and job s Insarmace buy Nom'_ �- .W t � �'� Fxpirsfioa l?afa, 1 © - '1 - 1 Policy�or self-ins,L'in,#n, f + - • . Job Rite Adih:=: l i �� a '> c;tC Aflarb a copy of the vmrkera't:mmpensat3on policy dedarsSna gage(showhq the poIiq number and expiration dt`t$). Faiknre,to pecure coverage as requimd mfldar Section 25A ofMCL c. 152-can lead to the imposifiom of-i-inO penalties of e fine-up to S 1,500.00 and/or one-pear mcgm as well as civil penalties in the fo m of a SMP WORK ORDER and a fine of up in 5250.00 a day-against tie violator. Be advised-that a copy oif'tbis st etamee may-be fnrwarded.ta the Ofee of I,-V=ft4fft'OM of the DIA far mmrzj c coverage w ficeban. n .I do Aa rby.cMIV j� r/ :tireDUE POWIfiff of wd u y that type igfarmatihn provided above is true=d correct Phone# O, curl usa wgi% Do not writ>Zr twAw;fo-be compktA d by city or tvwn•o idd . C21 ar Tow • ���g A�ot3tt-+p-(d�rcie.onej:• - . I. Bear-&of Heap 2•iW[Dgar6wxt .3. CSty/Taorn aiarrk 4;Eiectri b spe w 3.P'hmMag h wpecmr 6.•other. - .. ' -CanhLhL t•ra=- I'htme cc'Ri� CERTIFICATE OF LIABILITY INSURANCE a9 5/20°'2""' 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(les)must be endorsed. N 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 1-612-333-3323 CONTACT NAME: Jonelle Hargrove or Eric Johnson Hays Cmpanies PHONE . 612-333-3323 FAx 612-373-7270 AIC No 80 South 8th Street E'wuL ADDRESS: Suite 700 PRODUCER Minneapolis, MN 55402 CUSTOMER ID 8: INSURER(S) AFFORDING COVERAGE NAIL i INSURED RI Renewal 8y Andersen Corporation INSURER A: OLD REPUBLIC INS CO 24147 INSURER B: NATIONAL UNION FIRE INS CO OF PITTS 19445 104 Otis Street INSURER C: Northborough, MA 01532 INSURER 0: INSURER E: IN8URER F: ' COVERAGES CERTIFICATE NUMBER: 29229436 REVISION NUMBER: 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 ADDLSUBR LTR TYPE OF INSURANCE WVOPOLICY NUMBER PMIDQ EFF MIDD EXP UMITS A GENERAL LIABILITY MIrZY 59828 10/01/1 10/01/13 EACH OCCURRENCE s 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO R NTED 500,000 PREMISES Ee occurrence E CLAIMS-MADE FiIOCCUR MED EXP(Any one person)* $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 4,000,000 GEN L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 3,000,000 X POLICY PRO- LOC $ A AUTOMOBILE LIABILITY MNTB 21700 10/01/la 10/01/13 COMBINED SINGLE LIMIT X ANY AUTO (Eaaoddent) s 3,000,000 ALL OWNED AUTOS BODILY INJURY(Per person) $ SCHEDULED BODILY INJURY(Per aoddent) $ HIRED AUTOS AUTOS PROPERTY DAMAGE X (Peraoddent) $ XSNON-OWNED AUTO $ s B X UMBRELLA UAB X OCCUR 13273355 10/01/1 10/01/13 EACH OCCURRENCE $ 25,000,000 rEXCESS LIAR CLAIMS-MADE AGGREGATE $ 25,000,000 DEDUCTIBLE x RETENTION $ 25,000 $ A WORKERS COMPENSATION MNC 117946 00 WCSTATU OTH $ AND EMPLOYERS'LIABILITY YIN 10/Ol/1 10/01/13 X � ML ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDEDI NN.. NIA E.L.EACH ACCIDENT $ 1,000,000 (Mandatory M NH) M s,describe under E.L.DISEASE-EA EMPLOYE j 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach AGO RD 101,Additional Remarks Schedule,K more space is requ" Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION Evidence of insurance 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 ariei ' r1•AAO AAAA lwwww wwwwww.ww.. ......_... Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor I License: CS-095707 1 BRIAN D DENNISON �J 7 LAMBS POND CIRC Charlton MA 01507 Expiration Commissioner 09/08/2014 ✓lze Pam�eo,�uea�/z °� a�ivaelld Office of Consumer Affairs&B sines Regulation I HOME IMPROVEMENT CONTRACTOR Registration: .,; 70810 Type: . Expiration 12/2-2/2013 Corporation 1 R WAL BY ANpI£t?SENCp}�p.OR,gTION I BRIAN DE NNIS01i 104 OTIS ST. rat 4t �� i NORTHBOROUGH,MA;03532-; "'-' Undersecretary r i r 7 "Du not remove un flab node inspeakrL Save 1681 forwwrE rge m,=- cn � k' m � v- u E Lri m m �M+1811 s4s�DoY p ® 0tterdtddl4dmLts�la enewal FEF.^ et: V'myU�Naad CampositE NialErleJ �} rAon 'Low�4 SmattuRtD• Dual PrDduct Type: Ficture. ERE iGi POFDRh"cE RA.TIN�S L-Faatar • Salar flaat Gala Caemcleilt o � 2 7 " (uv-p') p' N�e6iclSl' 4DDr c*kL PERFORMANCE RATINGS Vlsibla Transmifianae 0.-. 5 1 ' . . ... . . , . prnewmtdnv Wnm�pt��• Menut.=Mt'4puutrstn¢m�•n t�nPt rarh m m spp0eioln Rf =u On==0I:g2mt ettunnsroa i1FR�rtilnanue stualminsslars roan seat tai an�1 ryeFina Em°u¢Iwsro 4Y rs "Iff nt ape encs n¢retmnmerm m P1e°uwp D n . - Lensr¢mmuFuwml= tu�tmtvptcou¢peRutmmixlnfumrsllun,• . . .. wavrtthralp ersen Co erabarC RbA MAA Window uuyq senna • . (2afing y �pZ,rmm rtmMMcsl.rnusA.44 ;. 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DUW Arygn l mv-E4 F tP ducf'TYPE cassmerl SiERG1' PET r RVMaE Rai Iles tJ acEor Solar H,ed Gain Cmafitr,ieRt _ 09,29 X955 0 , 2-8 ADC) C]bb L ''PSVDFA hMCE •RkT'W135 ' � Ylstble Trarlsm[ffanae . • A1�ur�c�pWa�°r.'""'""ra511�•mNarm.m ap}ilL�11�1F�p�iurt3•mret�endhlmRidmlcprudw ' ^^^^^^a•— TU'�r�n�i¢drhallMaimt re=d erte,`euvllvlm+erCflvm�m md��r1��'�.1,. . /a-l�dnrimtiexi®darpplrmuG>ald dc.�trtEwmxtla=�l7¢�tl�It�A'�ri"�'�rrmccm . -Rn:dn�ha-a61e�m�m�lnlonlo5m' ' ' w�tCMc.atP er-an Cwpwdc3rr Rb1 ca_-1U oty' , SCpW eGp[m7GeQ7m 1 nW1llq Ivat�u21�4awv�aa� tau��rna®es pp pse IDP'M. 4 r m>�aa�a�sn i e al e G � . decserL WINDOW REPLACEMENT �aMdeaptCe Rom WoodM*Composite IF Duel DmMeArgon Low E4 9mertsun ung 100-00478611")o ENERGIE PERFORRMCE RATINGS U-Factor•(U.S)A-P Solar Heat Gain Coefficient 0 '0111L 9 ou " a 11 Z w I ' * 9", —ADDITIONAL PERFORIi MCE RATINGS - Visible Transmit%gce 4 1 2"' to r o.het.w•.Ib.1.1rtrtter.NOW I'w100"eabbtIFACpwftd.wewenuw➢,MywUeM,pwdeot p.dennr...IIf110 retin0eaw d.MrwN.d lerase.d nt dawiwdw.NSIagWY MdaepoK¢pwddet aha. NfTIC dar ar wea.m.W a.y Ppd.eftad deft ar caudat tee.eawty elawypwddu feraq.p..We w. ammo mndmmw%v*mum b etw pradm Petlsrr"Aae ltttmaeBA. . WWWAItU M �. a1�EtNOK'Ma.yt.ry waar�N t �i-.•.�..�. "iP •a0A eaw.*ad are l�.wredt PSD.ad tNNNdw./ed.pijpAai • ri wwdelt 52.1 .. DESIGN PRESSURE(PSF) LIN[�'12d'-. RbA DB Sloped Sill DH IN. TrYC1o11AFi92d'MMM9�AM�A1CN5fMNE IWtAaerW tph Naerabfp.erM.E.C.CEC.ttEC.C.Air eNlllatkN wa.eemnNerYOMAI"am 04dy.at anamm t TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: t IMPORTANT: Applicant must complete all items on this page LbCATI.ON i' c'' 'i�c r PROPERTY OWNER7. r�' ,/ P r ! Pant MAP,NO:J PARCELAjr ZONING,DISTRICt�Htstoric=District Yes -- s . Machine SI1op Vigage . yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial eration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic 'well', Floodplain Wetlanus 1Natersl3ed District ' W ter/Sewer _ DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: �� � rJ� Phone: Address: fS g::21y06s'57-1e_e l4tv ,CONTRACTOR Name: / L Phone: �. �_,l_ Address:- ff. Supervisor'sConstruction:License: Exp. Date: �c Home Jmprovement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ l � `� 4 FEE: $ '-1 Check No.: � Receipt No.: Z� 2 7 Z NOTE: Persons contracting with unregistered contractors do not have access to the guaran f d ig; ire of Agent/Owrer.a' ri :7 - Signa#ure ofcontractor.. h Location S No. "� "' Date . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ r Building/Frame Permit Fee $L1'-`" � Foundation Permit Fee $ � . Other Permit Fee $ '.a TOTAL $ Ili ',3 Check# _ . L82`2 Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature Q COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE.DEPARTMENT Temp IJumpster on site`s Vires' J no ` 9 � � i:.ocated at 9 24;Main Street fire Department signature/elate, COMMENTS - . Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 142500.00 m $ - $ 174.00 Plumbing Fee $ 21.75 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 21.75 Total fees collected $ 317.50 Fouhdation 100 95 Candlestick Road 474-15 on 11/17/2014 Bath Remodel NORTH Town ofAndover _ .. O `l. .. 'Y to No. - h ver Mass ' 2b Iq , COCHICH&WICK RATED S U BOARD OF HEALTH Food/Kitchen T LD Septic System THIS CERTIFIES THAT j .�!!�I................... C& ......, BUILDING INSPECTOR .... ..�. ��� L ' Foundation has permission to erect ......................... buildings on .... .. Rough tobe occupied as ......... .. .. ........�"41.6's'.............................:.............................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN OMONT S ELECTRICAL INSPECTOR UNLESS CONSTRUCTITA Rough Service ................................................:. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Fina' No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. 1, Y � Sharon&Andy McCann 95 Candlestick Road North Andover, MA 01845 (H) 978-687-8922 (C) 781-956-3945 andrewsharongverizon.net November 16, 2014 Master Bathroom Remodel Revised Work to be included includes: • Acquire Building Permit • Demo of existing tub, vanity and floor. • Removal of wall at end of vanity. • Complete all required plumbing. • Complete all electrical. • Install vanity and Shower Base • Install vanity/makeup desk. • Open up doorway to closet area. • Install new blueboard and plaster where needed. • Install DenseShield Tile board on shower walls. • Install tile on shower walls. • Install DenseShield tile board on floor. • Install new tile floor. • Install new baseboard heat cover and baseboard. • Install new toilet paper holder,towel bars. • Removal of all debris. TOTAL LABOR AND MATERIAL $ 14,500.00 Note: This quote does not include any plumbing fixtures,vanity,tiles, grout,granite, or paint. A custom 3/8 glass shower enclosure would be$ 1,875.00 additional. Terms: $4,800.00 upon signing of contract(not to exceed 1/3 of contract price) $4,800.00 after plaster complete $4,900.00 when job complete Submitted By: Chris Rivet MA Lic#CS072173 HIC#139962 207 Winter Street (C)508-265-3115 (H)978-794-1165 North Andover,MA 01845 All Home Improvement Contractors shall be registered.Inquiries about a contractor relating to a registration should be directed to; Registration Division,Program Coordinator One Ashburton Place Room 1301 Boston, MA 02108 Tel:617-727-3200 ext.25239 All building permits required will be the obtained by the contractor.Homeowners who obtain their own permits are excluded from access to the Guarantee Fund. ACCEPTANCE OF PROPOSAL The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified.Payments will be ade as outlined above. Date Homeowner Signature Date ///e /C Contractor Signature /� 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 s been approved by the Secretary of the Executive Office of Consumer Affairs and Busine Regulation a the consumer shall be equired to submit to such arbitration as provided In Massachu s eneral s pter 142A. ��Z, Homeowner's Signature Contractor'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. 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 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 riot 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 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/herself 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 Consumer Guide to the Home Improvement Contractor Law", contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 (617)973-8787 or(888)283-3757 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor i License: CS-072173 - 4 v CHRISTOPHER F-RIVET ` 207 WINTER ST { , N ANDOVER MR 01845.E fi Expiration Commissioner 06/02/2016 � Office of.Cons6ner Mrs&Business Rebulatton «SOME IMPROVEMENT CONTRACTOR { 3,egistration: 139962 Type: .expiration: ,9/8/2015 Individual n CHRISTOPHER F.RIVET CHRISTOPHER RIVET 207 WINTER ST. ItI.ANDOVER,MA 01845 Undersecretat OP ID:SHHE ,A " CERTIFICATE OF LIABILITY INSURANCE 7TE091301(MM/DDIYYYY) 13 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 Phone:978-688-6921 CONTACT Macdonald&Pangione Insurance NAME' P.O.Box 428 Fax:978-688-5350 (A//C ,N Ext): ' FAX No: 104 Main Street E-MAIL North Andover, MA 01845 ADDRESS: PRODUCER Michael Pangione CUSTOMERID#:CHRIS-5 INSURERS AFFORDING COVERAGE NAIC# INSURED Christopher Rivet INSURER A:Preferred Mutual Ins Co 15024 207 Winter St. INSURER B: North Andover, MA 01845 - INSURER C INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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.)) lLTR NSR I TYPE OF INSURANCE INSR WVD I POLICY NUMBER I MML DYfYYYY I MM/DD/YOLICY YYY I I LIMITS GENERAL LIABILITY � I I , EACH OCCURRENCE s 1,000,000 A X j COMMERCIAL GENERAL LIABILITY , CPP 0180 57 0105 09/26/13 09/26/ DAMAGETO RENTED I PREMISESoccurrence Ea S 100,000 ( 1 CLAIMS-MADE OCCUR MED EXP(Any one person) S 5,000 --;— PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 1 PRODUCTS-COMP/OP AGG s 2,000,00 i PRO- POLICY LOC I i s AUTOMOBILE LIABILITY j i ( COMBINED SINGLE LIMIT (Ea accident) S ANY AUTO i I BODILY I ALL OWNED AUTOS � j � NJURY(Per person) i $ l ' I BODILY INJURYaccide t Per I SCHEDULED AUTOS ( i ( accident) $ PROPERTY DAMAGE HIRED AUTOS t (Per accident) S NON-OWNEDAUTOS S I , g UMBRELLA LIAB I_ I OCCUR j EACH OCCURRENCE I S EXCESS LIAB I CLAIMS-MADE 1 AGGREGATE S DEDUCTIBLE 1 ` RETENTION S 1 f Es WORKERS COMPENSATION i AND EMPLOYERS'LIABILITY Y/N 1 i I j j �_ I TNRYTA IT 1 �OER ANY PROPRIETOR/PARTNER/EXECUTIVE i OFFICERIMEMIBER EXCLUDED? �!N/A I I E.L.EACH ACCIDENT is (Mandatory in under III E.L.DISEASE-EA EMPLOYEE S If DESCRIPTION dscribe aund3 � OF OPERATIONS below I f E.L.DISEASE-POLICY LIMIT S i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES E CLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) _ CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St ACCORDANCE WITH THE POLICY PROVISIONS. No Andover, MA 01845 AUTHORIZED REPRESENTA IV Michael Pangio ox/ I ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,AM 0211.1 UV fvww.mass.gov/dia Workers' Compensation)Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print lLeeibly /f` r Name (Business/Organization/Individual): Address: c.X 0 City/State/Zip:A---LI, A/y C 57,Y< Phone Are,you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.[31",am a sole proprietor or partner- listed on the attached sheet.t ? [-remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working-for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5• ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees. [No workers' 13.❑Other comp.insurance required.] Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all ivork and then hire outside contractor 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 worker'comp.policy information. ant an employer that is providing workers'compensation insurance for my employees. Belolp is the policy and job site ftformation. nsurance Company Name: ,f .�li�cf'/,z2 (_ f/z.�;. 'olicy#or Self-ins.Lic.#: f�„ r / ; G " "%< %e�! Expiration Date: ob Site Address: City/State/Zip: kttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). 'ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of avestigations of the DIA for insurance coverage verification. do hereby cert?f}'11 der to pains and p alties of perjury that the information provided above is true and correct. ienature: /� -�'�/, � Date: hone#: 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 it: