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HomeMy WebLinkAboutBuilding Permit #418-14 - 96 FARNUM STREET 11/7/2013 TOWN OF NORTH ANDOVER i (,APPLICATION FOR PLAN EXAMINATION Permit NO: f I Date Received Date Issued: �f I ORTANT:Applicant must complete all items on this page / k) G .. LOCATION.. .. in � _ _ __ ' Print. ,.,. PROPERTY OWNERP 910 Na w#-0 107 A` d Print 100 Year Old Structure yes no MAP NO- PARCEL:ZONING DISTRICT: Historic District yes no Machine Shop Village yes no r TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building j-.�ne family ❑Addition ❑Two or more family ❑ Industrial ,0-0eration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District El Water/Sewer DESCRIPTION OF ORK TO BE ERFORMED: 60t� "444hko" ate* Identification PIType or Aint Clearly) OWNER: Name Gr i` �r-e�- v`rr � iooi� Phone: Address: X79- CONTRACTOR Name:-126tVO4 2� Phone: Address: Supervisor's Construction License:,51YAI-3Exp. Date- rd f_ LHomp Improvement License: Exp. Date: 5110I 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: $T '--- FEE: $ Check No.: Receipt No.: l NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent%Own�. gpature of con El- tractor Plans Submitted —flans aived ❑ Certified Plot Plan ❑ Stamped Plans ❑ LocationlA No. Date . - TOWN OF NORTH ANDOVER 6 . . Certificate of Occupancy $ Building/Frame Permit Fee $ s � Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#0 4 l U tJ �: Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE:OF,:SEWERAGE MSPOSAL 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 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 To`v 2 Engineer: Signature: FIRE DEPARTMENT - Temp Dumpster on site yes Located 384 Osgood Street no Located-at 124 Mair, Street Fire Department-signature/date t 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 DANDER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A-F and G min.$100-$1000 fine NOTES and DATA — For department use El Notified for pickup - Date F Doe.Building Permit Revised 2010 Building Department The fol.swing is-a-list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/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 apw al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must bo subm.tted with the building application Doc: Doc.Bui?ding Permit Revised 2012 r -, NORTfy A. , o No. — I - �oh , ver, Mass, 3 COCHIC IW.C. y1. �d A01fA rE S U BOARD OF HEALTH Food/Kitchen PER T T LD Septic System BUILDING INSPECTOR THIS CERTIFIES THAT .�.�A.dew ... Foundation has permission to erect .......................... buildings on ..........J(...... .�,Mr�. ...........hV. Rough to be occupied as ... .. Oepting ...... .. ... . . M!�T.... .' �. ... Chimney provided that the person ac this permit shall in every spect 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 MO S ELECTRICAL INSPECTOR UNLESS CONSTRUCTION SUR Rough Service ......................... ........ ..... .................... Final B DING 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 Page No. of Pages r' Builders License # 58443 Home Construction Reg. # 167338 DuvaIAL Ap RvofingII , LLC (781)944-1994 (978)664-2557 READING NORTH READING P.O. Box 637, North Reading, MA 01864 " t Please visit us at www.duvalroofing.com DATE � PROPOS SUBMI ED TO PHONE'AN Ionx/ b� aU •,�OS STREET QY,STATE AND ZF CODE We hereby submit specifications and estimates for: I f Rip& Remove all existing roof related debris from'oof as well as job site with our own disposal truck. NO DRIVEWAY DUMPSTERS ❑ 1 I; of 3xisting roof shingles, © layers of existing roof shingles ❑3 layers or more of existing roof shingles W'Replace any damaged roof decking; not to exceed 32sq.ft. (additional at$1.70 per sq.ft.) 1 ❑"install 8"Aluminum Drip-edge/Rake edge along entire perimeter(Choice o Whi )Brown or Mill) I Q Install ICE&WATER UNDERLAYMENT on all horizontal eaves, sidewalls, skylights and chimney flashing 0 Install a premium base sheet underlayment(felt)that is in compliance with the asphalt shingle manufacturer chosen by the homeowner I Install The Homeowner's Choice of the selected Tamko/IKO or GAF Limited Lifetime Architectural Roof Shingles See individual manufacturer's warranty for specific details Replace all existing bathroom louver and/or exhaust pipe(s)with new aluminum flanges { ®Chimney(s)-counter-flash and re-step existing flashing li ❑Cut&-Install new lead flashing ! 0-Install a continuous low profile Ridge-Vent on all ridge lines ❑Soffit-Vents ZRoof Louver-Vents ❑Seamless Aluminum Gutters-Custom fabricated on site with our own gutter machine ❑Downspouts at additional ❑Leaf Guards ❑Other I 11 f c lC+ ( t! 1 r<; t 'a ri //, i ✓ t �G7 /. �. r I I ( I 1 I I i i *Please Note:All items in roof attic should be removed or covered due to falling roof particles, at time of roof tear-off i Price includes all items above that are checked only/others may be priced separately upon request. i We JJropose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of: ",Total price not including options. dollars($ , rl./ ). Payment to be made as follows: 30%deposit required before ordering materials.Balance due in full upon day of completion. Please make all payments out to Kenneth Duval, mailed to: P.O. Box 637, No. Reading, MA 01864 Final Payment is due upon day of completion and is subject to the Authorized supplemented Terms&Condition sheet when scheduling. Signature ! _�/ THIS PROPOSAL IS VALID FOR DAYS DUE TO i FLUCTUATIONS IN MATERIAL&DISPOSAL PRICES. I I 11/07/2013 14:23 FAX 781 942 2226 GILBERT 17J001 WRDPCERTIFICATE OF LIABILITY INSURANCE D/10/JDDIY 9/10/2013 3 HIS 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 polley(les)must he 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 Ileu of such endorsement(s). PRODUCER " A Barbara McDonough Gilbert Insurance Agency, Inc. PHONE Elt (7g1)942-2225 s Ax I.(701)942-2226 IftJ137 Main Street E.MAIL bmcdonough@gilbertinsurance.coml INSURER AFFORDING COVERAGE NAICB Reading THA 01867-3922 INSURERA:HARLEYSVILLE/WORCESTER INS CO. 26182 INSURED INSURER B;Travelers Ins. Cc. 0031 Duval Roofing, LLC. INSURER C: P.O. BOX 637 INSURER O: INSURER E: I North ReadingMA 01964 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1331300142 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. IN5R ADDL SUOR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea a MZ7 S 100,000 A CLAIMS-MADS 7 OCCUR ZL641580 10/23/2013 0/23/2014 MED EXP(Anyone arson) I S 5,000 PERSONAL a ADV INJURY s 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 1 5 21000,000 X POLICY PRO- LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I 500,000 A ANY AUTO BODILY INJURY(Per person►1 5 ALL OWNED X SCHEDULED 644560 0/29/201310/23/2014 BODILY INJURY(Per $ AUTOS AUTOS (P 1 X HIRED AUTOS X NON.ONNED PROPERTY DAMAGE ; $ AUTOS Par kicaldonli Uninsured molonar BI s it limit $ 100,000 UMBRELLA LIAR OCCUR EACH OCCURRENCE s EXCESS LIAM CLAIMS-MADE AGGREGATE 3 DED RETENTIONS g B WORKERS COMPENSATION T9 be prvvidod directly WCSTATU• OTHi AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN is Travelers InsurancO OFRCERIMEBER EXCLUDED? N/A ENT E.L EACH TORYLIMIT S 100,000 ❑ (Mandatory IM NN) /11/2013 /11/2014 E.L DISEASE-EA EMPLOYE) S 100,000 If yes describe under DES8RIPT1ON OF OPERATIONS below E,L DISEASE.POLICY LIMIT S 500 000 DESCRIPTION OP OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more apace Is required) Evidence of Coverage CERTIFICATE HOLDER CANCELLATION (978)685-9542 SHOULD ANY OF THE A9OVE 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 North Andover, MA AUTHORIZED REPREBENTATIVC M Gilbert, CIC/BARBAR ACORD 25(2010105) ®1988-2010 ACORD CORPORATION.;All rights reserved. INS026 aotom.oi The ACORD name and logo are registered marks of ACORD Massachusetts Home Improvement Sample Contract • This form satisfies all basic requirements of the 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 of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Name Company Name �LnCja1),e S /Address( not use a P t ffice Box address) Con tor/Salesperson/Owner Name City/Town Sta Zip Code Business Address mus[fnc lude a street address) Daytime Phone Evening Phone Cityfr State Zip Code o MA C)l6`- Mailing Address(It different from above) Business Phline A I Federal Employer ID or S.S.Number as hnpmvem®t Comrade,Reg.Number Expbation date Law rteoirea that mnai home imp o.meat eoatredn r hoe / G 7 3 3!J •vaad regirtranoo number The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the e,brand,and grade of materials to be used,use additional 4W e .) 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 homeownet's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be v 2 excluded from the Guaranty Fund provisions of 044"bate when contractor will begin contracted work. MGL chapter 142A.) atm e when contracted wo will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: M Payments will be made according to the following schedule: upon signing contract(not to exceed 1/3 of the total contract price pr the cost of special order items,whichever is greater) $ by / /_or upon completion of $ by_/_/_or upon completion of $ 41 upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction)—r a The following material/equipment must be special $ to be paid for 1 ordered before the contracted work begins in order to meet the completion schedule.(*") $ to be paid for ^R NOTES:(")Including all finance charges(••)law requires that any deposit or down-payment required by the contractor before work begins may V not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty bein¢provided by the contractor? ❑No OYes tall terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any 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 agmrmmt 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 if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home 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 of a"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 if it has been signed at a place other than the contractor's normal place of business,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 of the third business day following the signing of this agreement. Seethe attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies a contract turret be completed and signe<L.One copy should go tOhm ./The other cop�shoWd ptby the conlydetor. I .... Hom wne s Si a Signature Date Date ++r 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 Se retary of the Executi of Consumer Affairs and Business Regulation and the consumer shall be required to s t to su r a6ri?prov' edIn Massachusetts General Laws pter 142A. Horn Signature Contractor's Signature ICE: a signatures ofo a artles 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 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 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 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.izov/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.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: hLV://db.state.ma.us/homei=rovement/licenseelist.g§R 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 508-652-4800,508-755-2548 or 413-734-3114 Version 2.1-11/22/2010 ✓ elation ---- J�e Pnoorrm�ae� siness Reg Office of Consumer Atf Tr CONTRACTOR HOME IMPROVEMEN Type: _ ; Registration: 167338 LLC Expiration: 9/1012014 AL ROOFING.LLC. F KENNETH DUVAL NORTH ST � '-'�— 72 NOR Undersecretary NO.READING,MA 01864 1Ixs5.zchuutt�-t3clru-tment Of Puitlic Safety Beard of Building Regulations anti StandM IAS Construction Supervisor License License: CS 58443 , KENNETH P DUVAL " PO BOX 190172 NORTH ST N READING, MA 01864 -e` Expiration: 12/10/2013 t urumi<v3,>ner Tr#: 6884 i The Commonwealth ofMassachusetts -Department oflndustria[Acculents Office oflnvestigations 600 Washington Street Boston,MA 0211.1 pY ` Www-Mrss Workers' Compensation Insurance Affidavit:Builders/C A hcant Information ontractors/Electricians/Plumbers 'lease Print Legibly Name (Business/Or an' g izafton/Individual): D�V3i Roofing, LSC . Address: Reading, MA 01664 .City/State/Zip- E. Phone#:____�-��� A,�r-e yon employer?Check the appropriate box: t� 1 am a employer with �i 4. Type of project(required): employees(full and/or part-time).* ❑have hired the sub contrra to scontractor and S 2.❑ I am a sole proprietor or partner listed on the attached sh et.1 ti l New construction ship and have no employees These sub-contractors have El Remodeling working for me in any capacity, workers'comp.,insurance. 8. 0 Demolition [No workers'comp,insurance 5. ❑ We are a corporation and its 9' El Building addition required.] .officers have exercised their 10.El EIectrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Pl bing repairs or additions Myself [No workers' comp, c.152, §1(4),and we have no insurance required]7 em to ees. 12• oofrepairs p Y [No workers' comp,in suranceregaired.] 13.[]Other Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy info= ation• I Homeowners who check this thibo affidavit indicating they are doing all work and then hire outside contractors must submit a do affdavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.poli information ram an employes tlzntisproviding tvor'kers'compensation insuranceformy ernptoyees Below zs thepolicy and'ob site . information, � Insurance Company Name: � Policy#or Self-ins,Lie.#: Expiration Date: Job Site Address:•�� �� ,�„ , ,�� �— Attach acopy of the workers'compensation policy declaration page(showin 1 the Failure to secure coverage as required under Section 25A g policy number and expiration date), fine up to$1,500.00 and/or one-year imprisonment,as well as�civil penalties inethe f ad to t impositionhe a STOP'WORK ORDS aloes of a 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 d a fine Investigations of the DIA for insurance coverage verification. t do hereby certif r tl a pains and enalties o p ffperjury that the information provided above is true and correct. c= >i nater 'hone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Issuing Authority(circle one): Permit(License# X.Board of Health 2.Building Department 3.City/To�vn Clerk 4.Electrical Inspector 5.pIumbin 6 Other g Inspector Contact Person: Phone#: V-*MIS /2013 09:19 FAX 781 942 2226 GILBERT 10001 RO CERTIFICATE OF LIABILITY INSURANCE ; 9�i/2013�RTIFICATE 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 endor9ement. A statement on this certificate does not confer rights to the eettifl°ate holderinlieu of such endorsement(s). PRODUCER COME CT Barbara McDonough Gilbert Insurance Agasiey, Inc. PNONa . (761)942-2225 Fa� Na L(�e1i 9az-zzze 137 Main Street EMAIL ,bmadonough@gilbertinsurance.com INSURER(SI AFFORDING COVERAGE I NAIC A Reading t-a 01867-3922 INSURERA;HARLEYSVIZ1M ORCESTER INS CO. 26182 INSURED INSURER6;Travelers Ins. Co. 0031 i Duval Roofing, LLC. INSURERC; P.O. Box 637 INSURER D INSURER E I North ReadingMA 01864 INSURER F t COVERAGES CERTIFICATE NUMBER:CL1331300142 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. IR POLICY EFF POLICY EXP UMIiTS LTR TYPE OF INSURANCE POLICY NUMBER MMrOD GENERALLIAHILITY EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY PRMI HS TED ES 100,000 A CLAIMS-MADE FX OCCUR L64158G 10/23/203.2 0/23/2013 MED EXP(An ons Orson S 51000 PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE $ 2,000,000 OENIL AGGREGATE LIMITAPPL0 PER: PRODUCTS-COMPIOP AGG S 2,000,000 X POLICY PRO LOC 3 AUTOMOBILEUABIUTY O 91NED SINGLE LIMIT 500,000 ' r ANY AUTO BODILY INJURY(Per person) $ A ALL MEo X SCHEDULED cci 64459G 10/23/2012 10/23/2013 BODILY INJURY(Per eaenq $ OSD NON-OWNED PROPERTY DAMAGE 5 X HIRED AUTOS X AUTOS d°nt Uninsured motorist ai s tit limit S 10-01000 UMBRPLLA UA6 OCCUR EACH OCCURRENCE 3 EXCESS LIAR CLAIMS•MA13E AGGREGATE S DED I I RETENTIONS I $ $ WORKPRS COMPENSATION To be provided directly WC STATU- I0TH- AND EMPLOYERS LIMIUTY YIN ___JJDzXLwI:TAL ANY PROPRIETORIPARTNERIEXfiCUTN f A IVE is Travelers insurance E.L.EACH ACCIDENT S 100,000 OFFICERIMEMBER EXCLUDED? /11/2013 /11/2014 (Mandatory In NH) E.L.DISEASE.EA EMPLOYE S 100,000 If yyeS desclbe under S6 DtbEASE-POLICY LIMIT S 500 000 DESCRIPTION OF OPERATIONS bQlow DESCRIPTION OF OPGRA71°NS I LOCATIONS I VEHICLES (Attach ACORD 101,Addlllonal Ramarks Schedule,If moee space is roqulrud) Evidence of Coverage CERTIFICATE HOLDER CANCELLATION (978) 686-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL i BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Oagood Street North Andover, MAL REPRESENTATNE M Gilbert, CIC/B?JU AR ACORD 25(2010/05) m 1988.2010 ACORD CORPORATION.; All rights reserved. • ���� ----• -• Tun ar_nun nommis And Innn ara renistered marks of ACORD NOTICE Z NOTICE TO a TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152,Sections 21,22&30,this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P .O. BOX 1450 MIDDLEBORO MA 02344-1450 ADDRESS OF INSURANCE COMPANY (7PJUB-023ON91 -9-13) 03-11 -13 TO 03-11 -14 POLICY NUMBER EFFECTIVE DATES GILBERT INS AGCY 137 MAIN ST READING MA 01 867 NAME OF INSURANCE AGENT ADDRESS PHONE# DUVAL ROOFING LLC 184 PARK STREET 0 NORTH READING MA 01864 EMPLOYER ADDRESS u,— EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE ^ MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services Q provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 001907 WZOP,Goz TO BE POSTED BY EMPLOYER