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HomeMy WebLinkAboutBuilding Permit #841-14 - 97 LOST POND LANE 5/20/2014TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Received Date Issued: 2� u, I PORTANT: Applicant must complete all items on this page LOCATION -,_L Print PROPERTY 01NNER �.� Print 1.00 Year Old Stru MAP NO; PARCEL_ ZONING:DISTRI;CT Historic District Mach=ine Shop yes -no- Yesno e veS Silo. q TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition 0 Two or more family ❑ Industrial &&&aeration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Se fic [],Well ❑Flood lain Wetland's ❑ Watershed District'' ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: e9p, ,.( U Identification Please ype or Print Clearly) OWNER: Name: Phone: Address: ,R et.. _ _ 61(CONTRACTOR CONTRACTOR Name _ e Address: Gf✓,� ( /���� ._ . Supervisor s Constructl,on'License _ G f%y6 �. Exp. 'Date. /a� %�.y _ - - - Homeq Improvementlicense: Exp Date:._ f 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: $ 9 FEE: $ Check No.: �a �� Receipt No.:6�' NOTE: Persons contracting with unregistered contractors do not have access tote gugranty_ fund Signature=ot Agent/Uvvner T. .- )q�ghatureio Vcontractor __ ° ;� ILa � J Plans Submitted LJ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans Building Department '`rhe fol?owing 9 ffstof the'required:forms to be filled out-for:the appropriate. permit tube obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application ❑ Workers Comp Affidavit LiPhoto 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 o 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 cas, s 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 be submAted with the building application Doe: Doc.Building permit Revised 2012 -__.'Plans Submitted ❑ Plans Waived,❑.. Certified Plot Plan ❑ Stamped Plans F1 YPEJ OP:SEWERAGEDISPOSAL Public Sewer ❑ Tanning/MassageBodyArt ❑ Swimming Pools ❑ Well ❑ Tobacco Sales .: Food Packaging/Sales ❑ Private:{septic tank, etc- . - .-.. _. -permanent pt inpster on -Site ❑ THE -..FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN _OFF - U FORM DATE REJECTED PLANNING &. DEVELOPMENT ❑ COMMENTS DATE 'APPROVED -CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS M Zoning Board of Appeals: Variance, Petition N b Planning Board Decision: Comments Conservation Decision: :Com Zoning Decision/receipt submitted yes Water & Seger ConnectionDriveway Permit DPW To -vv 2 Engineer: Signature: Located 384 Osgood Street FIRE DEPART Mf_� iM. .',:Te.p Dumps,ter on site yes no Located -at :124 Mair, Street _ COMMENTS .t: _ Number of Stories: Total square feet of floor area, based on Exterior dimensions. .Total land -area, sq. ft.: ELECTRICAL.: -movement of. Meter.Idcatlon-, Mast -or service drop requires approval of i Electrical Inspector Yes No DANGER ZONE LITERATURE:. Yes No MGL -.Chapter. 166. Section 21A: -F and G min.$100=$1000.fine Doc.Building Permit Revised 2010 Location No. S611-14 Check i 27595 Date _71 le '� / /' 7�5ZZ -/ TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee. Foundation Permit Fee $ Other Permit Fee $ TOTAL Building Inspector Enter construction cost for fee cal - North Andover Fee Cakulaflon Construction Cost IL A,000.00 m $ - $ 420.00 Plumbing Fee $ 52.50 Gas Fee 100 comm. $; 110:0.0,01 Electrical Fee $ 52.50 Total fees collected $ 625.00 97 Lost Pond Road 841-14 on 5/20/2014 Finish Basement with Bathroom v cn 1• C � iw N n 'a O CD CD CL �o a cO N �o�, 0`3vm o CL cr CD M o CD v C• 5.0 U) cQ CD 5 v cn o 0 o O m a CD n F 0 O O CD N O CQ O S.W CL CD 0 CA 0 N CA CD o=�° Ln WO Z -0 cn T c CD, CD 2i 5 - c� T 0 N. n cn- o T V7 T 0 0 .� CL nrn m c 7 r OX c�mM ° G1 N M O j . cP O O� z = 5. 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(� N rNr O 3 O n. \ S N O z 0 -n x x AcooRbr CERTIFICATE OF LIABILITY INSURANCE DATE 2/4/2014) 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. 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 EA Stevens Company, Inc. 389 Main St. P. 0. BOX 188 Malden MA 02148 CONTACT Linda Gallant NAME: PHONE (781) 322-2324 F o: (781)397-7672 _01C No E-MAIL g ADDRESS: linda @eastevensins.com INSURERS AFFORDING COVERAGE NAIC # INSURERA:Nautilus Insurance INSURED Brian Nolan, DBA: Omni Construction Corp 8 Pyburn Road L nnfield MA 01940 INSURERB:Safety Indemnity Company 33618 INSURER C: INSURER D : INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2013-2014 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx ] OCCUR NN397287 0/2/2013 10/2/2014 EACH OCCURRENCE $ 1,000,000 DAM PREMI O ELATE ISES Ea occurrence $ 50,000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ B AUTOMOBILE X LIABILITY ANY AUTO ALL OWNEDSCHEDULED AUTOS X AUTOS HIRED AUTOS X NON -OWNED AUTOS 5054060 10/28/2013 0/28/2014 OMBIIINEDtSINGLELIMIT 1,000,000 (Ea de accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident Waive Collision Deductible $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATIONWorker's EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE Y/N OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N I A CompensationWCSTATU- certificate to be issued irectly by insurance ompany. OTH- LIMI FR E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Job location: 97 Lost Pond Lane, North Andover, MA Gary & Louse Daubresse 97 Lost Pond Lane North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Thomas Cares, Jr/WV....��"'"�'":% M%,%Jrcv 1;3 kcu f u/uo) U 1988-2010 ACORD CORPORATION. All rights reserved. INS025 rgmnrim m Tl.o AnnPi1 name nnrl Innn mro ronieforarl marke of Armon The Commonwealth of Massachusetts Department oflndifstrigl Accidie is Office of Investigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workeis' Compensation Insurance Affidavit: Bunders/Contractors/Electricians/Pliimbers Applieant -Mormation Please Print Legibly Name (Business/0rganizaiionlindividual): i� �``��Y 6n�� Address: �?- City/State/Zip:�� �i`i �l/ Phone #: 7,�'/- -70-(a `/1/&Y Are you an employer? Check the appropriate box: Type of project (required): 1. [ ]. am. a exnployex with � 4• ❑ X am a general contractor and I 6. ❑ New ebnsizuciion employees (full. and/or part-time).* 2. El am a sole proprietor or partner- have ]fired the sub -contractors listed on the attached sheet. 7• ❑Remodeling ship and`have no.employees working forme in any capacity. These sub -contractors have workers' comp. insurance. 8. [I Demolition y. El Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] 3.E1 Z am a homeowner doing all work officers have exercised.their right of exemption per MGL 11. [] Plumbing repairs or additions myself. [No workers' comp. c.152, §1(4), and we have no 12.[]Roofrepairs insuraacere ed. i a employees. [No workers' 13.❑ other comp. insurance required.] xAny applicaatthat checks box#I must also fill out the section below showingtheir workers' compensationpolicy information. ('Homeowners who submit this affidavit indicatingthey are doing allwork and then hire outside contractors must submit anew affidavit indicating such. tContractors that checkthis box must attached as additional sheet showing the name ofthe sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation-poRcy declaration page (showing the policy number and expiration date). Failure to secure covexage,as req * dunder Section 25A of MGL o.152 can, lead to the imposition of criminal penalties of a flue 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 tine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the ATA. for insurance coverage verification. I do Hereby cert& un the pat Pena of perjury that the information provided alcove % f tr an' ire and -T- 12'a Phone#: ' official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitlLicense # issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an errtployee is defined as "...every person tri. the service of another under any contract ofhim,• express or implied, oral or written." An employer is defined as "an. individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a•deceased employex, or the redeiver or trustee ofan individual, partnership, association. or other legal entity, employing employees. However the owner of a dwelling house having not more Than three apartments and who resides therein,, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced.acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the, performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapterhave beenpresented to the contracting authority." Applicants Please i7ll. out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certi£icate(s) of Insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than, the members or partners, are not required to carry workers' compensation insurance. If an LL C or LLP does have employees, a policy is required. Be advised Matthis affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. he affidavit should be retained to the city or town that the applicatim for thepemlit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure thatthe affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be -sure to Min the pemvt/11cense number which will be used as a reference number. in addition, an applicant thatmust submitmultiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." .A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavitis on file .for future permits or licenses. A new affidavit must be filled out each year. 'Where a home owner or citizen is obtaining a license oz permit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves etc) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have anyquestions, please do not hesitate to give us a call. The Department's address, telephone aiid fax number: ThoCQMMQIIweajtbLOfWassa.,c�hvsPtia - DepattmeRt of fadmixial .Accidents Office QUIRVestipaoi 60 washivc . 8txeet Boston, , 021 It `fie . # 617-7.27-4.9QQ ext4Q6 Qx x -8,7 -7 -MS .AFF Revised 5-26-05 Fay, # 617-727-7749 www—mu,s,govldia AM111111 Massachusetts - Department of Public Safety Board of Building Requiations and Standards Construction Supen-isor ' & 2 Farnih License: CSFA-074364 RICHARD C DICKS 6 DALE STREET2 WEST PEABODY MA 0 Expiration Commissioner 10/20129114 1 Office of Consumer Affairs& Business Regulation OME IMPROVEMENT CONTRACTOR egistration: 163299 Type: F individual Expiration: 61112015 RICHARD DICKS RICHARD DICKS 6 DALE ST PEABOSY, MA 01960 UnderserretarY OMNI CONSTRUCTION CORP 8 Pybum RD, LYNNFIELD, MA 01940 Name / Address Gary & Louise Daubrese 97 Lost Pond Lane North Andover, ma Contract/invoice Date Estimate # 4/23/2014 73 Signature 111/ Phone # 781-726-1464 Terms Project Description Qty Cost Total frame, wire, plumbing for bathroom in celler and possable future 35,000.00 35,000.00 sink at bar area, insulate, blueboard and plaster, paint, trim with same trim as upstairs install engineered floor on basement floor and stairs and railings for stairwell going up will be discused 35,000 to 42,000 hvac is still getting prices and possible better way to do it 0.00 0.00 Total $35,000.00 Signature 111/ Phone # 781-726-1464 9 J - Date.....,.-;bf /z3K . .................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that.... has permission for as installation 9 in the buildings of.. ......... 1.� .... ..... ..... ................................................. at........................ .......................................................................... , No�t�, Andover, Mass. Fee..,6.19 ........... Lic. No/ . ........ �.. .. /� .. .. ........................... S(IN'SPECT& Check # UL, 10393 Date n;�� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... I ��- e� ... �Zrr .................................... . ..................... ................ has permission to pe rfonn ...... .......... plumbing in the buildings offfl&�� 40 ................. at.................................................... .................. fee&'.'�'�qAic. No/ Chec" ........................... , o , Andover, Mass. ..... ........... .......................................... c ... �UIVIBING INSPECTOR INTERCEPTOR (INTE KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING _ OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES - 10 D L IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY QC BOND M OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [I AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tru and ccurate to the best of my know] and that all plumbing work and installations performed under the permit issued for this application will be in anc with all Pertinent provision of the IMassachusetts State Plumbing Code and Ch ter 142 of the General Laws. PLUMBER'S NAME LICENSE # SIGNATURE mp [D/ JP EI CORPORATION DJ #PARTNERSHIP ®# _ LLC . COMPANY NAME l �t�-%� ADDRESS CITYdy& IISTATE ZIP ,� TEL FAX CELL I �J EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY VMA DATE _PERMIT# JOBSITE ADDRESS ��/��� OWNER'S NAME—� POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMM CIAL ® EDUCATIONAL ® RESIDENTIAL A PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO© FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM 1IL DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN (..-__-_-( _.-_- FOOD DISPOSER i _. -_._..1 I.._._�4 ._._� I ._ _.._I ! l (J f _ ._ _ f _ ( I (f ..._---. ........__. I �� P 1 I [ I III I FLOOR/AREA DRAIN e_1 � --_- INTERCEPTOR (INTE KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING _ OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES - 10 D L IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY QC BOND M OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [I AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tru and ccurate to the best of my know] and that all plumbing work and installations performed under the permit issued for this application will be in anc with all Pertinent provision of the IMassachusetts State Plumbing Code and Ch ter 142 of the General Laws. PLUMBER'S NAME LICENSE # SIGNATURE mp [D/ JP EI CORPORATION DJ #PARTNERSHIP ®# _ LLC . COMPANY NAME l �t�-%� ADDRESS CITYdy& IISTATE ZIP ,� TEL FAX CELL I �J EMAIL H z z O H U W a In w o z O � W W � w O W a 4t Z LUQ w O a W LU w LU p z a W �-- J a IL 0) w z w 1- LL H O Z z FST , v H U P-1 tz 4 �7 a a f � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Uf www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers, Address: City/State/Zip:-I&LCdL( Phone Are you a mployer? Check the appropriate box: 1. a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its [No workers' comp. insurance required.] officers have exercised their 3.01 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an'additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees: Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lie. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of ke D1A for insurance coverage verification. I do hereby 4ertify_bnder the pains aW penalties ofperjury that the information provided above is true and correct. Phone M 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 #: Q, Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, ;express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who.has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate he. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations 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 applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Gor .onmalthofMassachusetts Department of Industdal .Accidents Office of lavestigatious 600 Washington Strout Boston} MA, 02111 Tel # 617-727,4900 at 406 or 1-877,7MASSAFB Revised 5-26-05 Fax # 617-727-7749 wwwamass,gov/dia FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER =— ROOM / SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER _ f UNVENTED ROOM HEATER I WATER HEATERI OTHER F INSURANCE COVERAGE I have a current liability nsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES A NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY F-31 OTHER TYPE INDEMNITY E] BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT]I SIGNATURE OF OWNER OR AGENT 1 he eby certify that all of the details and information I have submitted or entered regarding this application are tru greculate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp an witWall Pertinent provision of the Massachusetts State Plumbing Coded Chapter 142 of the General Laws. PLUMBER- ASFITTER NAM LICENSE # IGNATURE ---,._ MP MGFI JP JGFR J LPGI CORPORATION D# PARTNERSHIP 0#= LLC D# COMPANY NAME: ^_.__ ADDRESS J CITY i STATE/ZIP TEL FAX CELL—s EMAIL =I - — MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 9, CITY �' MA DATE �- — # qltc>6� JOBSI ADDRESS •---P—ER—MIT OWNER'S NAME 4� GOWNER ADDRESS TEFAX TYPE OR PRINT OCCUPANCY TYPE COMCIAL EJ] EDUCATIONAL RESIDENTIAL CLEARLY NEW: [Q RENOVATION:13 PLANS SUBMITTED: YESF- N0FJI APPLIANCES Z FLOORS—► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE 1 -- -- ..-�— _ _—_J Z _ .__ _I FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER =— ROOM / SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER _ f UNVENTED ROOM HEATER I WATER HEATERI OTHER F INSURANCE COVERAGE I have a current liability nsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES A NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY F-31 OTHER TYPE INDEMNITY E] BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT]I SIGNATURE OF OWNER OR AGENT 1 he eby certify that all of the details and information I have submitted or entered regarding this application are tru greculate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp an witWall Pertinent provision of the Massachusetts State Plumbing Coded Chapter 142 of the General Laws. PLUMBER- ASFITTER NAM LICENSE # IGNATURE ---,._ MP MGFI JP JGFR J LPGI CORPORATION D# PARTNERSHIP 0#= LLC D# COMPANY NAME: ^_.__ ADDRESS J CITY i STATE/ZIP TEL FAX CELL—s EMAIL =I - — H 0 z 0 U W A W � o a z C)u) El W > F— W o °z a U w �* W rA CO w WW �+ w a gLn a a �( J a Q � w x w F- LL rA N 0 z 0 H U W a C�7 a The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3111 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. E] Remodeling 8. ❑ Demolition 'I 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roofrepairs 13. ❑ Other 'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. t -Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certo under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: • t Informati®n and Instructi®ns Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, • express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who,has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations 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 applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call: The Department's address, telephone and fax number: The Commonwealth ofMossarhwetts Department of Industrial. ,Accidents Office ofhavestigatlou 600 Washington Stroet Boston, MA 02111 TeX, # 617-7274900 at 406 or 1-8777MASSAFB Revised 5-26-05 Fay, # 617"727-7749 wwwarnass,goV/c a co o® CERTIFICATE OF LIABILITY INSURANCE10i 16 2013) i 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 policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Robert Marino NAME: R & R Insurance PHONE Ext: (781)289-3627 AIFAXC No: (781)289-4147 406 Revere Beach Parkway E-MAIL Anna,. Bmarino@rrinsurance.net INSURER(S)AFFORDING COVERAGE Revere MA 02151 INSURERA:Scottsdale Insurance C INSURED INSURERB : t S even Ferro, DBA. Ferro Plumbing & Heating INSURER C: 2 Cherry St INSURERD: INSURER E : Danvers MA 01923 1 INSURER F: COVERAGES CERTIFICATE NUMBER:CL13101601752 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. INSIR LTR rypE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MM/DDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrDence $ 50,000 A CLAIMS -MADE I X1 OCCUR CPS1822742 /13/2013 /13/2014 M ED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000 X POLICY PJECTRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ ` HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY y / N TORY LIMITS ER E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ NIA E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below I I E.L. DISEASE- POLICY LIMIT $ DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) 9786809542 Town Of North Andover 1600 Osgood Road Suite 2035 North Andover, MA 01845 CANCELLATION 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 Marino/BOBM ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 (201005).01 The ACORD name and logo are registered marks of ACORD