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Miscellaneous - 140 APPLETON STREET 4/30/2018 (2)
140 APPLETON STREET 21D/037.&002&0000.0 140 APPLETON STREET 210/037.6-0028-0000.0 6/23/16 To, Department of Inspectional Services North Andover Please be aware that I have termated Anderson Electric and have hired Joe's Electric for work being at 140 Appleton street. please reffer to permet number 650-14 Electrical rough inspected on 3/25/14 Philip Brown 1 Date ............ .................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING Bs+cHU This certifies that ....JA,04—) A1C&X1v................ . .............................................I....... ........................................... ::has permission to perform . ................................................................................... ... .wiring inAthe buildingof.................. .............. , ........ . at. .. .... . . North AndoverMass. ... ........ .................. North Fee:9...................Lie. ..... .......................................................... ELECTRICAL INSPECTOR Check# � Commonwealth of Massachusetts Official Use Only HER Department of Fire Services Permit No. �- Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 eaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION Date: S—01.v'-/c/ City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) I V Owner or Tenant A, Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes [�f No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: A)e0 Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires 3 No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Battery Units �--- No.of Receptacle Outlets 3 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Num_ber Ton_s KW No.of Self-Contained Totals: .... ................ Detection/AlertinL,Devices No.of Dishwashers Space/Area Heating KW Local❑ Munici al [I Other Connection No.of Dryers Heating Appliances r Security Systems:* J No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No,of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as regidred by the Inspector of Wires. Estimated Value of Electrical Work: /,po c3 (When required by municipal policy.) Work to Start:3-�S�"�V Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) C I certify,ander the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: . clefs 0 I LIC.NO.: 36 Y� SSS Licensee: V o.04,le AYWI.w./ Signature LTC.NO.: � (If applicable,enter"exe t',in the license number line.) Bus.Tel.No.• 7$�'7�d ��6� J 1 Address: a 12I A0 A S.9cA Ji /176 0/506 Alt.Tel.No.: � *Per M.G.L c. 147,s.57-61,security work requ' es Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent ,�- Signature Telephone No. PERMIT FEE.$ ', ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed , on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-temr economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass I Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass EN Failed❑' Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrim2C.COm The Commonwealth of Massachusetts Department of Industrial 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 Lezibly Name(Business/Organization/Individual): Address: 01 we City/State/Zip: S ja�u S g2d � Phone#: ?71-760 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.,4 lam a sole proprietor or partner- listed on the attached sheet. F1 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.❑ 1 am a homeowner doing all work right of exemption per MGL 11.E]Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 131i Other !Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they are 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 Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: � %l�,e(L/ u City/State/Zip: /Vp,A Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Hereby Mder thins and penalties ofperjury that the information provided above is true and correct. Signature: Date: Phone#• 2y/'760 -Ja?(-,) 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#: 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-contractor(s)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 cluestions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The CQMMonwealth of Massachusetts Department of lndustriai Accidents Office of Investigations 600 Washington Stxeot Boston,MA,02111 Tel,#617-727-4900 ext 406 or 1-877_MASSAFE Revised 5-26-05 Fax 4 617-727-7749 www.mass,govfdia s t�3-COMMONWE4f OF MAS5I�CHUSETTS • • • • - • • BOARD OF I �ECTRICIANS ISSUES THE FOLLOWING LICENSE:.::: AS A RSG ;JOURNEYMAN >ELECTRI-CIANa` STEPHEN K ANDER,.S(�N 2 M I LAN Ix V < J SA.1G(1S MA..o1906-3086 38.364: 07/3 /16 19 301 Location 1Wvn5"+ No. — ,� Date `2 • TOWN OF NORTH ANDOVER • �, Certificate of Occupancy $ :N Building/Frame Permit Fee $ 12-0 tfJ �; Foundation Permit Fee $ Other Permit Fee $ 3�s.rTEI)N:v . TOTAL $ Q{� Check 27370 Building Inspector _ TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION . Permit NO: —0 Date Received Date Issued: q/, � IMPORTANT:Applicant must complete all items on this page 11 LOCATION _- Print_ PROPERTY OWNER I L o wq �- Print 100 Year Old S;ucture yes no MAP NO �PARCEL��? ZONING DISTRICT Historic District yes no Machine Sliop Village yes, no TYPE OF IMPROVEMENT PROPOSED USE ' Resid tial Non- Residential ❑ New Building ne family ❑Addition ❑Two or more family ❑ Industrial ❑AI ation No. of units: ❑Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic < ❑Well ❑ Floodplain ❑Wetlands D Watershed District" ❑Water/Sewer _ - --- nn DESCRIPTION OF W K TO BE PERFORMED: N�.� z 942:2:4 n I entificatio ` Please Type d Print Clearly) OWNER: Name: l'hit. Q cz,csww Phone: Address: CONTRACTOR Name: T4-C- �.cy�i;irM�-'.ts , ...__Phone: 0 s���i - 3s' ° T �Ury Address: i^g-j;�t, e 2 0 A 0)5 Supervisor's Construction License-.--Q-5 G�f Zq -:Exp. Date:-,-'�.- -3 ^A ome Im rovement License: = Z1 �_: Exp. Date: H p - - s ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDI G PERMIT.$12. ER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ Z l> FEE: $ Check No.: 2-2 457 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to th ranty fund r- ------*-- _:g .- .. /IrSi nature of ent/Owli C- _ _ ccont _=ure of Aractor Plans Submitted L.- Plans Waived � Certified Plot Plan ❑ Stamped Plans ❑ Building Department The fol owing is'a list of the required.forms to be filled out for:the appropriate.permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o B,ailding 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 o 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 o 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 u Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o 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 be submAted with the building application Doc: Doc.Bui!ding Permit Revised 2012 Plans Submitted ❑ Plans Waived ❑- ."Certified Plot Plan ❑ Stamped Plans r] TYPE OF-.SEW_ ERAGE-DISP-GSA Public Sewer Tanning/Massa eBod Art ❑. . Swimming Pools Elg Y Well Tobacco.Sales 0 •Food Packaging/Sales ❑ ,.. ❑ Private{septic tank,etc._ Perinarierlt Dempster on-Sit e 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 Decisionfreceipt submitted yes Planning Board Decision: Comments 'P Conservation Decision: Comments Water& Sewer Connection%Signature&Date Driveway Permit DPW Toyv Engineer: Signature: Located 384 Os ood Street FIRE DEPARTMV-N ;Temp Dumpster on site yes no Located at:124,Mair.,Street:- Fire Departure►if signature/hate 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,rriast or service drop requires approval of Electrical Inspector Yes No DANGERZ®NE LITERATURE: Yes No MGL-Chapter 166.Section 21A-F and G min.$100-$1000 fine NOTand DATA— (For department use E) Notified for pickup - Date Doc.Building Permit Revised 2010 i PREFERRED MUTUAL INSURANCE COMPANY COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS DIRECT BILL RENEWAL BUSINESS Policy Number: CPP 0120 60 35 84 Named Insured: J & C CONTRACTORS INC Address: 85 RIVEREDGE ROAD NORTH BILLERICA MA 01862 Replacement or Renewal Number of CPP 0110603584 Agent: MTM/BRAINERD INC 20 35600 Address: BILLERICA MA 01821 Policy Period: From 05/15/13 to 05/15/14 12:01 A.M. standard time at the mailing address of the named insured as stated herein. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. LIMITS OF INSURANCE GENERAL AGGREGATE LIMIT(Other than Products-Completed Operations) $ 2,U00,000 PRODUCTS-COMPLETED OPERATIONS AGGREGATE LIMIT $ 2,000,000 PERSONAL AND ADVERTISING INJURY LIMIT $ 11000,000 EACH OCCURRENCE LIMIT $ 11000,000 DAMAGE TO PREMISES RENTED TO YOU LIMIT(Any One Premises) $ 500V000 MEDICAL EXPENSE LIMIT(Any One Person) $ 10,000 The Named Insured is: CORPORATION Business of the Named Insured is: CARPENTER Audit Period: ANNUAL FORMS & ENDORSEMENTS ATTACHED TO THIS POLICY CG2 0509)) CG2503(0509j CG9501(0101 CG9502(0101 CG2033(0704) CG2151(0989) CG21471207) CG9506 0709} CG0068(0509� CG2132(0509) IL0003(0908) IL0021(0908) CG2171 0608)) CGO203 0308) CG2187(0107) CG2167 1204 CG2186(1204) CG2426(0704) CG9505(0104) CG2160 0998) CG2161(0498) CGOD01(1207) TOTAL ADVANCE PREMIUM $ 11829.00 THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD. PMD1 (06-10) Includes copyrighted material of Insurance Services Office,Inc.,with permission.Copyright, Insurance Services Office, Inc., 1993, 1994. 04/01/13 TMB GS INSURED COPY CPP GLO 0120603584 958827142 00085 License or registration valid for�itdividul use only }I before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 Is sassachus-at �r*ra r+t f?tv�i Sae y +. Not valid without signatur t : -.oar of Buitding Reg 3i tuns and '.as"�`��` ' i Con,truction:Stjpercisol' 1 �icansei: C5-072§29 ROBERT G INGS-- 85 RIVERED(GE RD N BILLERICA NfA 01862 com.,rnissione'r 05/03/2014 Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991m)Of enclosed space. r.. title j 1/0'11l-jerrfu�e//t'Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR Failure to possess a current edition of the Massachusetts '`.,egistration: 12756.1Type: State Building Code is cause for revocation of this license. I xpiration: 11/16/2014 Private Corporatio For DPS licensing information visit: www.Mass.Gov/DPS &C CONTRACTORS INC ROBERT INGS 85 RIVEREDGE RD �' -- a BILLERICA,MA 01862 Undersecretary i AccmiiCERTIFICATE OF LIABILITY INSURANCE a, �;niAl��^{r,;;__ THIS CERTIFICATE IS ISSUED AS A MATTER OF IK-FOR?V,'�eT!CN ONLY AND CONFERS NO Rjr5 T5 UPON THE CERTorA,-, HOLDER. ';'r-is j CEFTWICATE DOES NOT AFfeWMATIVELY CTR NEGATIdE:.Y At lyD, EXTEND pR AtTFR THe WVIEPAGE PWO DED By THE POI�CiEd ! GER.: ; THIS �CERTIFICATI: OF INSURANCE DOES N0T C0K3TITJTE A C04TRACT RE'MER! THE ISSU;PJti, IP�SLii2ER$.- 1.1 THIS?I7C0 RERF'ESENTATi4E OR PRODUCER,ANO THE CERT I'I+„'ArtE HOLVER. IMPORTANT: If the aerGgCate holder Is eR AD6JTIONA:.INSURED,Or pasiity(irsl must be endCfgAd. If SURROGAriON IS WAIVEa,!'tjcst;.e the ferMS 81td conditiors of tNr<oo!lcy,earlain Pa1IC-10 t may requIre an endorsenterd. A stpterfent on Ols rerrifio to,foes not ceder r�gtlfa to tsa ; `G�r4i,ic4e holder in h6u of such endarcamont s, � ;�A4 Sect T V:Ltt, :ZC, LIP, -- °",tT:�:Prain�ra ;.n.. j'H7He t9'8?667--9C33 �_TFrx c '' _ iiAtC.;JnV.1578J�c7-;,ig_: j 1A Aandovgr SP.O$,j. LITS Ord U y't r lj_ t7 C ".or..t:ra2to�a Inc. - -- �- 65 Riveredg'e Itaa.:3 _l }�S (� HCl 1 VlCt � 11 -- — -- ;_North bil'erie.� w,p, 01E62 -� _---F--COVERAGES CkRTIFICATE i l O -- 7 _ (� / ;!OKI NUMBER: HIS t5 TO CERTIFY THt,T TIyE aC+C10Ifn5�^F itv9GRA IEC n6GVE FCR'h1 PfiL::- INDICATED NC,TV1JTHSTANDfNG ANY RECUIREMSN'I IENT WITH RESP=CT T VINIC.-1 7•>',, CERTIFICATE MAY PC 15SLAD OR MAY PEttTkik TF c'N IS SU$JEC'TC/•LL THE 71;R.11* EXCLUSION'S AND CC•WN Now nr sucit FUIJCIES.LI .!. �__ +.TOr IPMRANCEAA11h:iT3 i O 'V`� �CZySd r.Yf I CCJ2 'mr : I .1 A i J CLAPJ1�KK4 Lleet R I , k 1 �v , X 181ar ke t Add+ I g�� �?fart snc�c.�. ,g x,�u,ed IN.�I�, i iA.a,::C-Ff_c_c-A 3 ,33 0. :_G t . `hl'�!i66R€C4Tl ,VT NPPLIE9 PGR I I L --- —� i LTs_ .off h�J?nC ti :iC;, 1 'X I POLICY i7 OUT-M401MLE LIASUrY 1�A.APr.AUTC I i FrCI�riN1LRYl�• a i--- -m.--- -_ _ ALL OWN RD — i 171.nUTpF "LTO NON CV;^tFI i 'rtlFEw AUTOS j �e I I IIS I ----�---------° acouk j E7[ ESS LIAR �._J i fArNW.'UPRENCE � �......-. ._._ i ..�„�„_—' ClAlitlS•ttAgE� I ; � I .�GC'�i3ATt_.�_•._�p a» _.. AND 9!MF'.0Yi3F8''.IAi1UTY � i r VC CTAT _j ..1-• � •fitly pRApRIETC �gFf'cRreXEQ4 'VE OPF�.�.=w`i=_lases E?cG_��FC% � v a.� I ! _,hGH r✓'GIUEr;; g I{RI®ndmry:n riHi It toc.dQK01W L.&' j IeCiBEr•Sa.[�Eh rl-,vL,;`z ❑_oCR+P"ON CF I�CkATIDNS Wo. i I I .��..._- 1 i---�•�-- —�----._ ! �L Ji'x�-.A.SS•F�'(Iry.�74Ii I F i CGSCRIrTi a ON OF OP@RA7dON3/I.OGATI0Ia8/VElil(:L_F IAtFaeh 4CCR0,8't,A!iet!t{.:.,,,i�swnevrs Gah�dxfe,d morn I R mgtiirctli i CE:R;€FICAT'E HOLDr=R CANCELLATIOP! SHOLILC ANY OF IHE.AEDVE DRSCRIPEn PoLtClrS SR ChNCULED�+[-::h♦n "HE EXPIRATION DATE THEREOF, NOTtr.E Vdr1 SE DSLI4`ERC'. IN . heabaut Hill Rc_-:a1ty/T9tC,LLC 4CCOPOANCEWITH T';EP0UCy'FRDV;S)ONS. 3.G0 Independer.La lnr C:g8atrnt-kt_l, Ik 02447 FVTHLt.MDF.'1TPTSrNTAn'-Z S J.9a9Yltt. CIC, =A S AORD+261$3$•201C ACORI]GORPORA110k All Fightg rc�seaUFd� The ACORD name and 1090 are reg1s09Md marks of ACORD The Commonwealth of Massachusetts Department of IndustrialAccidihis 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): C C01\.4 1,iLn C l6 J\,S 1 C. Address: g ►U2,tl.kl CIA-e l< City/State/Zip: I .MCCS VY�A &A 2Phone 8 S - q S'(d ct 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.El am a sole proprietor or partner- listed on the attached sheet. �• F1 Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑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 1L Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *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 aire 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 Name: i 1 11?► ( C 6 M '�' �(31'�-S WtJ Policy#or Self-ins.Lic.#: 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 required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certIV uncle-a and penaltie ofperjury that the information provided above is true and correct. Date: / `/ Phone#: illi'`' 5--7q " 3 C S t 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#: 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-contractor(s)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 cavy workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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 Coaximojawealth of Massachusetts Department of Industrial,Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel,it 617-727-4900 ext 406 or 1-877-MASSAFB Revised 5-26-05 Fax#617-727-7749 www.mass,gov/dia J& C Contractors,Inc. 85 Riveredge Rd. . t Billerica,MA 01862 Offee/Fax-(978)667-8014 Cell Phone-(508)574-3588 Email-jccontractorsinc@gmail.com PROPOSAL March 16,2014 ATTN: Phil Brown 140 Appleton St. North Andover,MA 01845 RE: Master Bath Remodel Permitting 1. Obtain building permit. 2. Frame bathroom as needed for closet, shower wet wall and water closet knee wall, window frame and in shower seat area.Also shower door frame threshold/water barrier. 3. Insulate complete room as needed with fiberglass and foam. 4.Install vent to soffett venting of heat light/fan combo purchased and installed by others. 5. Board and plaster all walls,ceiling and shower area as needed. 6. Tile floor per specs complete with any trim chosen and supplied by customer. 7. Tile shower floor per specs complete with any trim chosen and supplied by customer. 8. Grout and seal newly installed tiles per specs. Grout and sealer to be supplied by customer. 9. Tile walls per specs complete with any trim chosen and supplied by customer. I O.Tile shower walls per specs complete with any trim chosen and supplied by customer. I I.Grout and seal newly installed tiles per specs. Grout and sealer to be supplied by customer. 12.Customer to paint at this time. 13.Install all finish trim and window trim as needed. 14.Reasonable job site clean up related to this project. r J& C Contractors,Inc. 85 Riveredge Rd. Billerica,MA 01862 Office/Fax-(978)667-8014 Cell Phone-(508)574-3588 Email-jccontractorsinc@gmail.com PROPOSAL March 16,2014 ATTN: Phil Brown 140 Appleton St. North Andover,MA 01845 RE: Master Bath Remodel Permitting 1. Obtain building permit. 2. Frame bathroom as needed for closet, shower wet wall and water closet knee wall, window frame and in shower seat area.Also shower door frame threshold/water barrier. 3. Insulate complete room as needed with fiberglass and foam. 4. Install vent to soffett venting of heat light/fan combo purchased and installed by others. 5.Board and plaster all walls,ceiling and shower area as needed. 6. Tile floor per specs complete with any trim chosen and supplied by customer. 7. Tile shower floor per specs complete with any trim chosen and supplied by customer. 8. Grout and seal newly installed tiles per specs. Grout and scaler to be supplied by customer. 9. Tile walls per specs complete with any trim chosen and supplied by customer. I O.Tile shower walls per specs complete with any trim chosen and supplied by customer. 11.Grout and seal newly installed tiles per specs. Grout and sealer to be supplied by customer. 12.Customer to paint at this time. 13.Install all finish trim and window trim as needed. 14.Reasonable job site clean up related to this project. MC Contractors.Inc.Labor Costs as follows: Framing $1400.00 Tiling $1500.00(?) Finish Trim $750.00 ------------ -------------- Total Labor Cost $3600.00 Plastering Stock and Labor +$1050.00 Total Cost of above=$4700.00 All misc. Stock required to complete bathroom project will be billed separately per our discussion ** There will be an additional charge added for any changes or additions to this proposal* Respectfully Submitted, Kathy Ings/President J&C Contractors,Inc. carries workman's compensation and full liability insurance.All work performed will be done to your satisfaction and in a workmanlike manner. All work areas will be left in a clean manner throughout projects.This proposal may be withdrawn by us if not accepted within 30 days. Acceptance of Proposal-The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorizedto o the work as specified. Date �///�/' Zgnature 0 I MC Contractors,Inc.Labor Costs as follows: Framing $1400.00 Tiling $1500.00(?) Finish Trim $750.00 --------------------------- Total Labor Cost $3600.00 Plastering Stock and Labor +$1050.00 Total Cost of above=$4700.00 All misc. Stock required to complete bathroom project will be billed separately per our discussion ** There will be an additional charge added for any changes or additions to this proposal** Respectfully Submitted, Kathy Ings/President J&C Contractors, Inc. carries workman's compensation and full liability insurance.All work performed will be done to your satisfaction and in a workmanlike manner. All work areas will be left in a clean manner throughout projects.This proposal may be withdrawn by us if not accepted within 30 days. Acceptance of Proposal-The above prices, specifications and conditions are satisfactory and are hereby accepted.You are authorized to o the work as specified. Date J //'/Ntgnature a NORTHTownofAndover O l No. W;�7 ' ih ver, Mass, OCA16k o .., . a_ SQA COC K KICKI WICK`y 71,95°R�reo rPP��S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT . V..! ...... .................................. BUILDING INSPECTOR . .. ..... .... has permission to erect .......... buildings on ... C4r. ..... .. .. lake, Foundation ................ 1 .... .y.`....t..... . ... p ..... � f.......bckeft. ^... ... !!! !.... . ... Roughyt0 be OCCU ied asChimney provided that the person accepting this permit shall in every respect confor to the terms of the applicati Final on file in this office, and to the provisions of the Codes and By-Laws relating to 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 UNLESS CONSTRUC1r111nN ST RT Rough Service .......... .... ...... ... ... ..................................... Final BUILDING INSPECTOR GASINSPECTOR 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. Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 10,000.00 m $ - $ 120.00 Plumbing Fee $ 15.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 15.00 Total fees collected $ 250.00 140 Appleton Street 650-14 on 3/21/2014 Master Bath Remodel Location No. Date L NORTH TOWN OF NORTH ANDOVER � • O F � 9 s , • i ; , Certificate of Occupancy $ HuS Building/Frame Permit Fee $ �o Foundation Permit Fee $ Other Permit Fee $ / & TOTAL $ Check # / Building Inspector TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION ed Print PROPERTY OWNER ro`o n Unit# Print MAP N0:��PARCEL:J2-OZONING DISTRICT: Historic District yes no, Machine Shop Village yes no` 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Resi ntial Non- Residential ❑New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑fiteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑Other ❑ SeptF �© ®Flo{odplamk ®�UWetlands) ® aWatershed Dstnctl t �• • DESCRIPTION OF WORK TO BE PERFORMED: . vl e� J i -A T e— fr✓ �� 3TC � 51 Gr r�Fr f2_e_�o (Identification Please Type or Print Clearly) OWNER: Name: J v n�.R�dw h Phone: Address: 140 APPJ•_'�dr► lip CONTRACTOR Name: Z fu6/ s �A z //� t� Phone: 77f-7S- Address: ��I�z����9 Q7 ,1?i )/ Supervisor's Construction License: (P 7 fc Exp. Date: Home Improvement License: �I'>- 3 Exp. Date: / Z, ARCHITECT/ENGINEER d7 byI -_� Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000,00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $�f( T�, FEE: $ f cfd2, 4`T1 Check No.: L ;7 Y(;:f Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund I : F �' m:9 _ - iSignature;ofcortracto�F ,S-�7ci nature,of�Agent/Owner�`-.,....�. 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 a 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 o Building Permit Application ❑ Certified Surveyed.Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract u 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) o 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 2008mi 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 COMMENTS HEALTH Reviewed on Signature COMMENTS e Zoning Board of Appeals:Variance, Petition No: Zoning Decisionfreceipt 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 Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS I I 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-$1000 fine NOTES and DATA— For department use r ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi . r The Commonwealth ofMassachusetts .Department oflndustriafAccidents Office of-Investigations 600 Washington Street Boston,MA 02111 ovldia WorkersCompensation Insurance Affidavit:$uiders/Contractors/Electricians/Plum A licant Information bers . Please Print Le 'bl Name(Business/Organization/Individual):- % / 6L-�J ------------ Address: -City/State/Zip: p Phone Are you an employer?Check the appropriate box: 1.ElI am a employer with 4• Type of project(required): ❑1 am a general contractor and I 2•❑ employees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction 1 am a sole proprietor or partner- listed on the attached shget.t 7. ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers'comp,insurance. 8' 0 ,emolition [No workers'comp.insurance 5. ❑ We ate a corporation and its 9. E1Building addition required.] .officers have exercised their 10•❑Electrical repairs or additions 3. 1 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 insurance required.]t employees.[No workers' 12.0 Roofrepairs camD,insurancerequired.] I3.LJ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Y Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and their workers'comp.policy information. Iain an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self ins.Lie.#:_ 7 Expiration Date:_ GJ—o� v2 O J , Job Site Address: A City/State/Zip:��r , �MAttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date)'v Failure to secure coverage as required under Section 25A of MGL C.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Do' dvised that a copy of this statement may be forwarded to the Office of Investigations ofthe DIA,forins ante coverage verification. I'do hereby certify under painsa enalties ofperjury that the information provided above is true and correct. , 3i nature: Date: —Z© 'hone#: Official use only. Do not Write in this area,to be completed by city or town offlelal. City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/TownClerk 4.Electrical Inspector 5.Plumbing g Insector p Contact Person: Phone#: Informatio • Information and Instructions Massachusetts General Laws chapter 1;52 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 ofpublic 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-contractor(s)name(s),address(es)andphonenumber(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. B e advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation ofinsurance 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. Plede 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(ifnecessary)and under"Job Site Address"the applicant should write"all locations in • (city or town)."A copy of the affidavit that has been'officially stamped or marked by the city or town may be 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 NOTrequired 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: ------------------------------ COMMOrmealtL,o.i t IMaclaasetts Department of Jadusttial Accidents Office of JTnVestigatxQ.US 600 Washington Sheet Boston MA- 02111 Tel.6 617727-,4900 ext 406 ox 1.-877-MASSAFE Revised 5-26-05 Fax 9 617"727779.9 wwwaljass,govf d_ia A00RO® CERTIFICATE OF LIABILITY INSURANCE ii�iiaol�) 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 CONTACT Gail Conlin NAME: Nicholas A. Consoles Insurance Agency, Inc. PHONE (978 223-4037 FIAIC.N (978)223-9038 153 Andover Street EMAIL .gail@consolesinsurance.com Unit 208 INSURERS AFFORDING COVERAGE NAIC p Danvers MA 01923 INSURER A:Northl and Insurance Company INSURED INSURERB:Safety Insurance Company 39454 HGM Industries, Inc. INSURERC:Star Insurance Company P O BOX 54 INSURER D: INSURER E Georgetown MA 01833 INSURERF: COVERAGES CERTIFICATE NUMBER:Master Cert 2011 to 2012 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICYNUMBER MM/DDIYYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 A CLAIMS-MADE OCCUR NS112733 9/13/2011 9/13/2012 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- JECT RO LOC 1 1 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident B ANY AUTO BODILY INJURY(Per person) $ 250,000 ALL OWNED X SCHEDULED 6204154 11/1/2011 11/1/2012 BODILY INJURY(Peraccident) $ AUTOS AUTOS 500,000 X HIRED AUTOS X AUUTOSWNED Parr.cdentDAMAGE $ 250,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y I N ANY PROP RIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) C0678752 9/22/2011 9/22/2012 E.L.DISEASE-EA EMPLOYE $ 50-0 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Building Inspector Town Hall AUTHORIZED REPRESENTATIVE North Andover, MA 01845 N Consoles/GAIL ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD ✓fie �U01:pvmo,ztueiE a� 'Office of Consumer Affairs&Edsiness$egulation HOME IMPROVEMENT Registration •,123289 ` TYPe. } Expiration x/22/2013 Individual. S VAZQUEZfY jX "# LOUIS VAZQUEZ�y r ) t r ; 2 STRAWBERRY LPNET ,'i .BRADFORD,MA 01835r Undersecretary 1 -♦ _ _ fi,: MassaC IusCi �- DCi)1ltlifCa)t of PlibfiL S.YE', r.,� -, Board q#'961dim RC;41;teurrti all c9 St hitt►ni#" ;,Construction Supervisor.License,,_ License: CS 67992r Restricted to: 00 LOUIS L VAZQUEZ PO-BOX 54 GEORGETOWN,.MA 01833 I expiration: 5/24/2012 it (:'unmissiw�yr Tr#: 27408 , int � „ a H.G.M. INDUSTRIES INCORPORATED Commercial-Residential Roofing P.O.Box#54 Georgetown,MA 01833 TELEPHONE(781)771-7859 OFFICE(781)592-5846 FAX(978)914-6712 ........:...................... ..................................�. ............................�..f,`.� • June Brown November 21,2011 d • 140 Appleton Road �.�/� � (. • North Andover, MA (781 )581 -3685(617)959-1919 • ITEM:Roofing and Flashing • PROJECT:Front,Left and Right side Roof areas(Rear newer side not included) • Scope of work includes; • .Strip off and remove all existing asphalt roofing shingles and dispose of properly and legally. • • Inspect all existing roof deck boards for rotted,missing and damage, replace as required(Limited to 50 sq.ft.of roof deck board replacement(non structural),additional boarding will be an extra cost rate of$5.00 per sq.ft. ) . . • Install new Ice and water sheild to all Eves(Bottom edges) and in all valley areas. • • Install new asphalt roofing felt paper to all remaining balance of roof deck boards. . . Install new(white)(8") aluminum Drip-edge to all Rake and eve edges of roof areas. • • Install new Aluminum flashing flanges to all pipes located on proposed roof areas. • • Install new Lead Flashing to existing Brick chimney and incorporate into new roofing system. • . Install new 30 year Architectural roofing shingles (GAF Timberline series)(Color:Charcoal). • .Install new Timbertex Hip and Ridge coping caps to all Proposed hip and ridge areas. . • Install(4)new Roof louvres(vents approx.8"x 12") to existing vent openings located on proposed roof areas (New holes will be cut if required). • •Clean and remove from property all Debris pertaining to roofing work on a Daily basis. • •A Ten year guarantee on all workamnship by HGM Industries Incorporated. Total Cost for above scope:$8,000.00 Subrhitte8 b , Aeptance by, ` Date - ( 20� � Louis L. qUeZM4 Jun Brown • Roofing Contractor r6perty Owner • MA.HIC Lic#123289 • MA C S Lic#67992 NORTH L � Town of over 0 �W. r No. 50 3 X. o , '� dover, Mass., i • 1 I - 12-- COC MIC ME w ICK It. ADRATED P?���� S U BOARD OF HEALTH PER _M� IT T D Food/Kitchen Septic System QQ BUILDING INSPECTOR THIS CERTIFIES THAT......�...!!ti'L !. ..�Ow .......... Foundation has permission to erect........................................ buildings on Rough _ �.r�..........fpp.. c. .... to be occupied as.................... "� Chimney . . . . . . . . . . . . . . . ........ . .. . . ..................................... provided that the person acceptin thi rmit shall in every respect confor to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings tri 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 UNLESS CONSTRUC S TS Rough ....... ................. ............................................ ..... Service BUILDING INSPECTOR Fina] Occupancy Permit Required to Ocotpy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To BeDone FIRE-DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE]] Smoke Det.