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HomeMy WebLinkAboutMiscellaneous - 32 CHURCH STREET 4/30/2018 (2) C 32 CHURCH STREET 210/042.0-0004-0000.0 401' TRAVELERS J� The Standard Fire Insurance Company P.O. Box 1450 Middleboro, MA 02344-1450 04/27/2015 Town of North Andover Building Department 1600 Osgood Street Building 20 Suite 2038 North Andover MA 01845 Insured: Maureen Hanawalt Claim Number: HVX7921 Policy Number: OHF434-992086694-636 -1 Date of Loss: 04/22/2015 Loss Location: 32A Church St North Andover MA To: Board of Selectmen Building Commissioner Inspector of Buildings Board of Health A claim has been made involving loss, damage or destruction of the above captioned property which may either exceed $1,000 or cause Massachusetts General Laws Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws Chapter 139, Section 313 is appropriate, please direct it to my attention and include a reference to our insured, the policy number, the claim/file number, the date of loss, and the location. If you have any questions, please feel free to contact me at (508)946-6556 or email me at KWILL119@travelers.com. Sincerely, Keisha Williams Claim Professional (508)946-6556 Ext. 9466556 Fax: (877)786-5584 Email: KWILLI19@travelers.com On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Signature Date P0062 F3162C1515118004011 00001 N Cunningham Lindsey U.S.,Inc. eA P.O.Box 703689 Cunnin �1a !/ m � Dallas,TX 75370-3689 Lindsey Telephone(888)738-8714 Facsimile(214)488-6766 CLCAT@CL-NA.COM ***********************AUTO**3-DIGIT 018 765 T3 P1 95000058955 Building Commissioner or Inspector of Buildings 120 MAIN STREET N ANDOVER,MA 01845 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 3B Claim Number: 2578420 Policy Number: 2578420 03 Company Name: MERRIMACK MUTUAL FIRE INS Ln 0) Cause of Loss: ICE DAM U) Date of Loss: 3/3/2015 0 Insured: C/O LAUREN ROBERTS 32-34 CHURCH ST CONDO ASSOC Property Location: 32A CHURCH ST Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section 3B. No insurer shall pay any claims (1) covering the loss, damage, or destructions to,a building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code,to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however,that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885 Ot Mo.TN . O CIWSt CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 784 6/23/05 Date: June 26, 2006 THIS CERTIFIES THAT THE BUILDING LOCATED ON 32 A Church St MAY BE OCCUPIED AS Apartment Renovation IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Christopher York 32A Church Street No i Andover MaD01845 Building Inspector Town o .ort over No. t f North Andover, Mass., ,a Arar W BOARD OF HEALTH Food/Kitchen PERMIT TO BUILD Septic System THIS CERTIFIES THAT........AA44PAWA- BUILDING INSPECTOR .................. .............................................W............... Foundation 4 .......... has permission to erect...04-OVO4.1..... buildings on .... . .... ............. Rough to be occupied as......... .......��QO..r.......Ix.... .......Ar T*..... C * ne r provided that the person accepting this permit shall in every respect conform to the terms of the application on file in anal this office, and to the provisions of the Codes and By-Laws relatin to the Inspection, Alteration and Construction of - �/�� Buildings in the Town of North Andover. q a. / 7 1 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this P& Final ,r ELECTRICAL INSPECTOR Rough ........ .. .....e..c.......... :; .0.*6� iService. .. .. i6iiK& k GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done ) FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Location "� � CAL-, * No. Y Date - NORTH TOWN OF NORTH ANDOVER � A Certificate of Occupancy $ �7s'••° '��' 9 CMU Building/Frame/Frame Permit Fee $ s� sr. Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # ' Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING 3 � ic for Official Use Onl x'."� �{�.�.:� "^% ::-.�, �� ,e,„.�. zv _�,,.,��- BUILDING PERMIT NUMBER: p-� DATE ISSUED: O M1 (� Z SIGNATURE: 0 Buddin Commissioner/Inspector of Buildings Date 1.1 Property Address. 1.2 Assessors Map and Parcel Number: 2 A Czar o'/-I- ,4) Z,/"3 Ap yz- q /6 e 7Y /��v6�� — Map Number Parcel Num fier 1.3 Zoning Information: 1.4 Property Dimensions: / v 1,6113(o Zonin District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS(ft) m Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided ti 1.7 Water S ly M.G1..C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public Private ❑ Zone Outside Flood Zone Municipal On Site Disposal System ❑ _. y r 2.1 Owner of Record Name(Print) Address for Service: �, ���� j'7 S'• 3 G o • %L ��' m ignature Telephone 2.2 Authorized Agent D Name Print Address for Service: Z 0 Signature Telephone m e90 3.1 Licensed Construction Supervisor Not Applicable ❑ Address License Number 0 M Licensed Construction Supervisor: Expiration Date r Signature Telephone .� 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name Registration Number M r Address r Expiration Date Z Signature Telephone Y J fi SECTION a-wORx xS c l sa clirr + . c 25 Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yea.......El No.......❑ SECTION S-PROFESSIONAI,DISIGNAND C VNSTRUCTIONSERVICES MR BVff,,MG-S AND STRUCKS SEl$ACT TO CONS Ri1CT1ON CONTROL PU1 CI I T TO 780 CMR 116 I AINIlSIG1V1 MOVE THAND 3",009 GF,OI+`F.�TCLOSTcTT1'sI'ACE) 5.1 Registered Architect: Name: Address Signature Telephone 5:z Register+ed Prniessiu>�1 rtuu�:: Area of Responsibility i Name: Registration Number Address: Expiration Date Signature Total Not applicable ❑ Name: Registration Number Address Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature y Telephone Expiration Date Not Applicable ❑ Company Name: Responsible in Charge of Construction :t$C`il'I !Le.S 'it 'Tt©lV'., F PYIaPOD10 $)K (cheek all applicable), New Construction ❑ Existing Building Repair(s) Alterations(s) ❑ I Addition F Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: (�Py1-7 rte' tJ n e 77 s //cam✓ fl T,'//L-7✓ le-2�J v l ay F cia� t USE GROUP Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ IA ❑ A4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ C Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ IInstitutional ❑ I-1 ❑ I-2 ❑ I-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R residential ❑ R-I ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: BUILDING AREA EXISTING if applicable) PROPOSED Number of Floors or Stories Include Basement levels Floor Area per Floor s 'r Total Area s Total Height ft .0 IMOMM Independent Structural Engineering Structural Peer Review Required Yes ❑ No ❑ SECTION 10a Owner Authorization- TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property Hereby authorize to act on My behalf,in all matters relative two work authorized by this building permit application Signature of Owner Date Al as Owner/Authorized Agent Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury 6-1 Print Name Signature of Owner/Agent Date Item Estimated Cost(Dollars)to be ( ) t)Al£Y ew Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical _ (b) Estimated Total Cost of Scx%1,2/ Construction from(6) 3 Plumbing Building Permit fee (b) 4 Mechanical(HVAC) 5 Fire Protection 6 Total (1+2+3+4+5) jz .6 o d Check Number r ltrr ev f � n r• t lt, iN�tdf� � * 14k� L ! 6ly,.t,r � i � � r tf.: fi. d! { } NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 ND 3 RD SPAN r DEMENSIONS OF SILLS DEMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE • r .a t the Commonwealth of Massachusetts Department of-Industrial Accidents Office,of Investigations > 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �Me 51jP YW_ Address: Z04 Cl-tI62c lv City/State/Zip:,J(,Q2 -I/AIA0oa/4/ Phone#: 7 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 employee's(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7. N 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 3. Iequired.] officers have exercised their 10.ED Electrical repairs or additions am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. C. 152,§1(4),and we have no 12.�Roof repairs insurance required.] t employees. [No workers' • comp. insurance required.] 13.E3 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 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: 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. I do hereby certify under the ain van enal ie f perjury that the information provided above is rue an correct 19444re: Date: 2 3 65, Phone#: 7� �� C-) 9 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): L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• pORTH r i � TOWN OF NORTH ANDOVER BUILDING DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER MA 01845 978-688-9545 978-688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print DATE Zz-- 3 6 5— JOB LOCATION -5 Z 4 Zl�i eGA e- 57;° Number / Street Address Map/Lot HOMEOWNER 4r//i? i5Tri � Ydl1/C �7�•_?5&• $SAO 97FS Ao-�`"Zg Name HomePhoneWork Phone PRESENT MAILING ADDRESS eXI AW&5,3u g V ill o 4/3 City/Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1.) DEFINITION OF HOMEOWNER: Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is or is intended to be,one or two family dwelling,attached or detached structures attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEWOWNER'S SIGNATURE APROVAL OF BUILDING OFFICIAL FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT ()$r(0 %fk PHONE I T"3U A��1r,�,� bL LOCATION: Assessor's Map Number �/ f PARCELu- Ib 16q), —d��- u SUBDIVISION LOT (S) STREET C1��r�� U� ST. NUMBER OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS -SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT � � .�� ��F DUMPSTER PERMIT RECEIVED BY BUILDING INSPECTOR DATET FORM U-Revised 6.03 JMC NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at:52-v3 ' 5%Rer-71S that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will-be disposed of in: (Location of Facility) Signa e o Permit Applicant Fire Department Si off '`" "~ P � Dumpster Permit G-d- Date NORTIy Town of No. dower, Mass. .0 D rop COCMICHEWICK ' ' ��S RATED .PPa��� BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.........`��.* .!4........P...... ,*ft........... . ......................................... ................ Foundation has permission to erect...04-N1..... buildings on .� . .....k!eec, .. ! Rough .. .. to be occupied as......... .....5 .......d�'l ..r.......,.3��...16.0)�I......./A � A* Chimney • . ................. provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Lawry reiatin to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. q Z / PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTSELECTRICAL INSPECTOR Rough ...... ........................................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Date....................p... 4 NORTH TOWN OF NORTH ANDOVER ° . p PERMIT FOR WIRING ,SSACHUSE� This certifies that ........:....0..-e... .......LA/1.4....J!U. .. . .. . ..... ......... ........................................ has permission to perform .......t:S�`...!?..°.a.....�a ... .......................................... wiring in the building of................. . .........�� .................................................... at....Z�. . r...�3 u ...... ¢...........................North dover,Mass. ................. 'F'ee....4rP....... Lic.No.-r�3o... ..........�.....r ��:. ... .:............... ...... -- ELECTRICAL IN ECTOR .Check # DFAiIW1i ENTOFPUB[1C30M Permit No. �© u BOARDOFFMPREVFIVMNRDGULAT M527aMIZiO9 Occupancy h Fees Checked 1 ' APPUCATION FOR PERIVIlT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 ,A (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat ,0" Town of North Andover Tothe Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street 8t V Number)n1� Owner or Tenant `' a 1 Owner's Address is this permit in conjunction with a building permit: Yes® No (Check Appropriate Box) Purpose of Building T���"" Utility Authorization No. Existing Service AmpsVolts Overhead a Underground [M No.of Meters New Service AmpVolts Overhead Underground EM No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming PoolAbove Below Generators KVA ground yound No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Tota FIRE ALARMS No.of zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained DetectiodSourding Devices No.of Dryers Heating Devices KWLacal Municipal Other -� aConnections a No.of Water Heaters KW No.of No.of signs Bailasis No.Hydro Massage Tubs No.of Motors Tota HP OTHER• b h"=C aW AletavDdletaFwTnftcf&bndiwftGmnWLawa Ih=aaaMLietAylrnt 0=FbicyirJudr>g(bn#le aribat9N egivAa YES 0 NO Q IhmewWiWdvaidpKdofsffw1D t OfikZ YES ffywhaedaJWYMpi=irtd ',dretypecf=wFby INSLRAN E BM M O nim 1:3 re** E+rpi�donDele EftetedVakr dE1w ical Wbdc S WorkbSmrt IrWeMmDaleite4rekd Rath Find Mir RRMNAME 4.ljjc aueNoL 550 kz��� IlorraeNo Bt�,t�Td 3 u Add=-44 M AtTdNa 7 .3 OWNFst'S WANFR;Iarnawaiedletdlelioense�lrl�dleirauarixeo�ea�alsai�rrialerlliivalentagr�}>[odbyNle�ecfiselesGerleralLatWa �ddlatmysig�leenerndispean[appicabortwaivesdisn:gi>wn (Please check one) Owner Agent _ Telephone No. PERMIT FEB S aignallift 01 UWnCr Of Agent DEPAW sF1Vl'OFPIIB[xS MY Permit No. 0 BQARDOFF=P�RFX�i1lA W 527(Z&t av9 a, Occupancy at Fees Checked A.PPUCATIONFOR PERMITTO PERFORMELECTRICAL WORK AIL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 7—// ;PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. ` / Location(Street&Number) U I lFr1 Owner or Tenant 01 Owner's Address Is this permit in conjunction with a building permit: Yes® No (Check Appropriate Box) Purpose of Building T� Utility Authorization No. Existing Service Ampa�L.V olts Overhead [:] Underground No.of Meters New Service Ampex Volts Overhead [M Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No.of LighdaB Outlets No.of Hot Tubi No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Opreratara KVA Uound 1:3 and No.of Receptacle Outlets No.of OU Burner No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Oce Bumps No.of Ranges No.of Air Cond. Tota FIRE ALARMS No.of Zones Toro No.of Disposals No.of Heat Total Total No.of Detection and Pumps Toro KW initiating Devices No.of Dishwasher Space Ara Heating KW No.of Sounding Devices No.of Self Contained Detectior4owding Devices No.of Dryer Heating Device KW local Municipal Other Connections No.of water Heaters KW No.Of No.of Siam Bailask No.Hydro Message Tubs No.of Motors Total HP knee 1'�nctoalerac}i><sra�ata�da>trGalemllawa aaamtI�e6rTtylrta�loeR�iCyirl�rdrBC�rr arkt rialec}tivalmt YM ED NO atrnibdvaidPVd0fsmlolhe0f1r-Y$4ET E3 Ifyouha�edededYBS,pi=irdc�ettztMrcfa vwVby RANIE ®t=ft 9 Im r � BWD OIfiFR Q'fea� 110ilinrtD* Edn*dVatleefEkc"Wok S IOSW Ra* lint NAME �1 1 r LraQleeNa % I3amteNo "�2�- &jd=Tdrl 3 �' u s 24 AlTdNa c 3 l �. !1VYIVCIC's WA1VDt;Iamawarethe dzLi=wdd=mtdziz==wKr*Qilsa>bsttialtx}iva nffizg*adl kmchlqdbrl�rleralLawa ` �,hetmyrnuispeQr,tappir�iwwai�tietac}iar,�t lease check one) Owner In Agent _J, Telephone No. PgWT FEE tgnalure of Owner OF Ageng I Date. . . . r TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING ,SSACHUS� I This certifies that . .tA "'°7 . . . . . . . '': . . F�-.r . �. . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . at . . . . . ... . . . . .. North Andover, Mass. Fee~-��. . Lic. Na:.' . .!.r . j 1:. '. �. . . . . PLUM ASPECTOR Check ��/ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS n�C�r Date Building Location `,Z �t�tic�LC� Owners NamC+-18=) / Permit# Amount Type of Occupancy A C1 pFryt -S �,t� tr°► New Renovation I y1 Replacement Plans Submitted YesNo `f FIILTURES R4SM r M FIDCR 3v2 KDM �t FIDCit 4MROM 5MFIOCR 6M FL" 7IH FLOCK SIH HDCR (Print or type) rr Check one: Certificate G Installing Company Name�PLY"1� f�f�Tiit-� El Corp. Address P . 13ay >0 7� Partner. Business Telephone © Firm/Co. Name of Licensed Plumber. Insurance Coverage: Indicate the type insurance coverage by dhecking the appropriate box: Liability insurance policy r ] Other type of indemnity D Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner 0 Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mass etts State Plur7.ngde and C te�14=f the General Laws. By: tgna c ns Type of Plumbing License Title /g City/Town License n mU'er Master D Journeyman ? APPROVED(oma USE ONLY �G� " Date. . .. .r./. . 0' No°T 41 TOWN OF NORTH ANDOVER �j 0- PERMIT FOR PLUMBING SSAUS� This certifies that . . r �. !.�. . . . !-!:t. .. ; has permission to perform . . . . . . . . . . . . . . . . . . . . plumbing in the,buildints of . . . . . . . . . . . . . . . . . at U 174_ti:�_r . �-�-' �;, . .�' . . . . . . . North Andover, Mass. . .. .. . . . . . . . . . . PLUMBWG ji4SPECTOR 4 Check ,H 7l MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS r,, L Date �""�"�- Building Location b�--r— + L -I Owners Name e' i,-L) Permit# z.6–,p 7 // Amount ,`.;p_ C71" Type of Occupancy( New Renovation Replacement Plans Submitted Yes No FIIKTURES Cr HAg1VIIV1' 1SIC FIDQt 3�D ROQi -ID Fl" 4M R" MEL" 6M FL" 7M Fl" gm Hfm ti (Print orype) Check on Certificate Installin�Comp y Name � �tCorp. Address 1,;6k- C?L95N /91t i- e / 0 Partner. usiness Telephone Ct r El Frm/Co. Name of Licensed Plumber: Roove ' aW L4 Insurance Coverage: Indic to the type insurance coverage by Checking the appropriate box: Liability insurance policy Other type of indemnity Bond Insurance Waiver: I,the un ersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the a best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the ss chusettsS e Pl b' g C d Chapter 142 of the General Laws. By: Sign–amm-oT DEMME T ype of Plum_bing License Title City/Town r-icense NumoerMaster Journeyman APPROVED(OFFICE USE ONLY Location r���t%'�.-�X No. Date pORTq TOWN OF NORTH ANDOVER O?O•,•`•D I•,�Os A Certificate of Occupancy $ wwww L Building/Frame Permit Fee $ Foundation Permit Fee $ s�cHusE Other Permit Fee $ Sewer Connection Fee $ ' Water Connection Fee $ TOTAL $ Building Inspector Div. Public Works Location - No. Date -� HORTM TOWN OF NORTH ANDOVER �?O•,f``D I.1�OR op Certificate of Occupancy $ Building/Frame Permit Fee $ cNusE`� Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector Div. Public Works 'ERlItT No. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE I MAP KJO. "tL7;�_ I LOT NO. 1 O 2 RECORD OF OWNERSHIP (DATE BOOK :PAGE ZONE SUB DIV. LOT N . 'l LOCATION v2r PURPOSE OF BUILDING OWNER'S NAME 7r0l 1) e-+J, NO. OF STORIES SIZE OWNER'S ADDRESS �(� /� ky� C"� j BASEMENT OR SLAB 61 s-- �-.L ///ARCHITECT'S NAME. l_ J SIZE OF FLOOR TIMBERS 1/1ST l 2ND 3RD _ / BUILDER'S NAME arjjQGpAN V DISTANCE TO NEAREST BUILDING J J DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES-SIDES REAR GIRDERS AREA OF LOT ,O \S�J S� FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW ji C) SIZE OF FOOTING - x IS BUILDING ADDITION ND MATERIAL OF CHIMNEY IS BUILDING ALTERATION yec' I .la_ I� r e IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO//''REQUIR MENTS OF CODE yes IS BUILDING CONNECTED TO TOWN WATER Yes' BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER YeS IS BUILDING CONNECTED TO NATURAL GAS LINE �S / INSTRUCTIONS 3 PROPERTY INFORMATION 12G/vl0 /P SEE BOTH SIDES LAND COST /� UrQ/(,✓dr� EST. BLDG. COST 3b(')b �,`C/C� (, PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. !�/ PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. --- ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS T 'r, PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR �MyQ '/DATE FILED ED /ff�� 1�(�D 2 a '9 8 dlnae /��1? ' BUILDING INSP[CTOR SIGNATURE OF OWt4LW OR AUTHORIZED AGENT FEE '`� OWNER TEL.If PERMIT GRANTED 77 TEL# WF)04e? • 17 1B ---- CONTR.LIC.# Yt. v gr H.I.C.rT 1< 9 x DEPARTMENT OF PUBLIC SAFETY y License: CONSTRUCTION SUPERVISOR Number Expires Birthdate CS 862941 06/06/1998 06/0611968 ` JOHN J TORNAME 82 LINDEN AVE coissIor,eR N ANDOVER, NA 81845 [ HOME IMPROVEMENT CONTRACTOR 'RegistrAtion, 118789 C '. Typo - DBA 1 R EYpiratioa 04/20/99 I { 1 i TORNAME BUILDERS I ; JOHN J. TORNANF f y�cl�•r.o f!gi LIBERTY ST it AP*`STFAiOR MIODLETON MA 01949 Town of North Andover �oRTM OFFICE OF c?oma •,�o COMMUNITY DEVELOPMENT AND SERVICES ►- p x •• 146 Main Street North Andover,Massachusetts 01845 �+,'•�`:,;,;.. .y a WMIAM J.SCOTT SACMust� Director In accordance with the provisions of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by iviGL c I 11, S 150A. The debris will be disposed of in: a✓�PsS� (Ptl A4 1)S-,(- � � C o�� l�1as f� I)S aSal (03)'773—/ F$Go (Location o Facility) l Orh ek ni e- !� S nature of Permit App 'eant ZV — r7 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 OR T/y jTown of f = over No. AT4 * sdover, Mass., 2-7 19 ° LAKE '9 COC NICNEMICK`1Y 1• BOAAD'OF HEALTH Food/Kitchen PER. MIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT . 1�....................:..C.... .. .......................................................... Foundation P. C u �c_. . .............5 P�....... has permission to ewsf--..........��:��.... buildings on ......�_.��.�..................�........ .. �T" _ ......... Rough to tie occupied as.... .... . ........'n...this....(Jtfp 4 o.� .....reS.. -.e.tei�`''...0 ................................. Chimney provided that the person accepting p every p 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 in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMU EXPIRES IN 6 MONTHS UNLESS CONSTRUCTI ON ST T ELECTRICAL INSPECTOR Rough .. .. ............................... .. .... ...... Service .... ..... . ........ ......... ........ B DING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Re Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. TOWN OF NORTH ANDOVER (� + APPLICATION FOR PLAN EXAMINATION Permit NO: l�— Date Received Date Issued: PORTANT:Applicant must complete all items on this page LOCATION �S y'l Vl 1• Nb, IcOUC; 4 ! 1 Q ✓� / Print PROPERTY OWNER EKE''& Print 100 Year Old Structure yes MAP NO: �' PARCELM no ZONING DISTRICT: Historic District s 'o Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial 4stAlteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: U/ W Identification Please Type or Print Clearly) OWNER: Name: MAL)9�7v A+4 J*WstG Phone: 578 37S-cISls" Address: , v S . k Gey L yS CONTRACTOR Name:��/A,CE�v� Lir l_�L.4 uc Phone: 928 qOL AP31 Address: �,Y f�,(" �IZ. Supervisor's Construction License: �05 �t�t?� Exp. Date: Home Improvement License: 0-� 7.,74 Exp. Date: 71571/6 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: $ y FEE: $ �361_' Check No.: � Receipt No.: a rl 1 0 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/C QSignature of contractor _ Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ - Plans Submitted ❑ Plans Waived ❑_ ..Certified Plot Plan ❑ Stamped Plans ❑ ;TI'PE0E-:-SIJ TRAGEDtSPOSAL Public Sewer ❑ Tanning/Massage/BodyArt ❑ Swimming Pools ❑ Well ❑ Tobacco.Sales ToodPackaging/Sales ❑ .. ❑ Private{septic tank, etc._ El =permanent Diunpster on-Site - THE.FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE.APPR-OVED PLANNING & DEVELOPMENT` ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: :Comments :r Water & Sewer Connection/Signature& Date Driveway Permit DPW Tow;: Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMe_NT =Temp Dumpster on site yes no Located at 124 Mair Street -Fire Departme►1t signator"e/date` COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ _Total land area; sq. ft.: -ELECTRICAL: Movement of.Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL-.Chapter 166.Section 21A-F and G min.$100-$1000 fine NOTRS and DATA— (For department use ® Notified for pickup - Date t Doc.Building Permit Revised 2010 Building Department The following W'a-list of<the required-forms to be filled out for the appropriatepermit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o' Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases.if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apn;,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Building Permit Revised 2012 Location �2 A � ,-, f" " No. M11-- �� Date TOWN OF NORTH ANDOVER a Certificate of Occupancy $ Building/Frame Permit Fee $ -3U Foundation Permit Fee $ Other Permit Fee $ 1 TOTAL $ Check#-74q ` Building Inspector pORTII Town of 2 1Andover O - 0 -1� No. Ct& 19 * .Y o h ver, Mass Z 2bt4011, LAKR COCNICNl WICK ��• ��S RATED pPP�,�Gj U BOARD OF HEALTH Food/Kitchen Septic System 1c, . .....,,. .. BUILDING INSPECTOR THIS CERTIFIES THAT ....PERMIT 5.. ............ 1 �1�........................... has permission to erect ....... g �� Foundation ... ............... buildings Bab......... .... . , Rough tobe occupied as ... '. ......� ............................................... ............... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN MONTHS ELECTRICAL INSPECTOR • UNLESS CONSTRU 5'10N TARTS Rough Service .......... ......... ... ............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildin,:? 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. OP ID:S! CERTIFICATE OF LIABILITY INSURANCE DATE(M1120 4 03/21/2014 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 CONTACT NAME: Durso&Jankowski Ins Agcy LLC PHONE FAX 198 Massachusetts Avenue A/c No Ext): A/c No): North Andover,MA 01845 E-MAIL Durso&Jankowski Ins.Agcy. ADDRESS: PRODUCER POLAR-1 CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED Polar Bear Insulation Co.Inc. INSURER A:Penn America 32859 P 0 Box 958 INSURER B:Safety Insurance Co. 33618 Andover,MA 01810 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDD MMIDD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY PAC7022861 03/24/2014 03/24/2015PREMISES Ea occurrence) $ 50,00 CLAIMS-MADE F OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 1,000,00 POLICY F PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT B ANY AUTO 2100926 01/04/2014 01/04/2015 (Ea accident) $ 1,000,00 BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (PER ACCIDENT) X NON-OWNED AUTOS $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,00 EXCESS LIAB CLAIMS-MADE AGGREGATE $ A PAC6906385 03/24/2014 03/24/2015 - DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATIONSTATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORWC Y LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEd$ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) G.L.C.A.C. , National Grid Corporate Services LLC DBA National Grid, Action Inc, Boston Gas Company, Colonial Gas Companpr Essex Gas Company & Columbia Gas Co.; are additional insured for general liability with respects to work performed on their behalf by the above. CERTIFICATE HOLDER CANCELLATION GLCAC11 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE G.L.C.A.C. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN &Columbia Gas Co. ACCORDANCE WITH THE POLICY PROVISIONS. 350 Essex Street AUTHORIZED REPRESENTATIVE Lawrence,MA 01840 4641L ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents r Office of Investigations . 1 a 600 Washington Street Boston,MA 021.11 www.mass•gov/dia - Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information . Please Print Legiblv Name (Business/Organization/lndividual): ?tJUlz &Alz tN S U L&A4 �O• h1C. Address: 1P• O• 4f� W 1S$ City/State/Zip: OL 910 Phone #: 1 S (o-g�^51 9.S Are you an employer? Check the-appropriate box: Type of project(required): 1. I am a employer with t]' 4. ❑ 1 am a general contractor and I 6. [:] New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet $ ❑ 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 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12:❑ Roof repairs insurance required.] t employees. [No workers' l3.[,�A 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 are doing all work and then hire outside contractors must submit a new affidavit indicating such (Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workersl compensation:insurance for my employees. Below is the-policy and•job site information. Insurance Company Name: D SZ A U AtLA Policy#or Self-ins.Lic. #: P O w C S 5 pO 65 Expiration Date: / J/J/S Job Site Address: 3o)- (,I'(�4 City/State/Zip: a, kC*,-*4 � 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 coveragq.verification. Ido hereby entify under the pains andpenalties ofperjury that the information provided above is true and correct sijznature: Date: 7�7 Phone#- 179 Oficial 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#: � CERTIFICATE OF LIABILITY INSURANCE DA0,"4' ACORU® 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 CONTACT NAME: PHONEAX Automatic Data Processing Insurance Agency,Inc. E-MAIL Eat: AIC No: 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE MAIC 0 INSURER A: NorGUARD Insurance Company 31470 INSURED INSURER B POLAR BEAR INSULATION CO INC INSURER C: Po Box 958 Andover,MA 01810 INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 231099 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. LTR TYPE OF INSURANCE POLICY NUMBER MIDD POLICY ID LIMITS GENERAL LIABILITY EACH OCCURRENCE _ COMMERCIAL GENERAL LIABILITY PREMISES ocarrence $ CLAIMS-MADE D OCCUR MED EXP(Any one Person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG i POLICY PRO-F—] T LOC $ AUTOMOBILE LIABILITY $ a ac6dent ANY AUTO BODILY INJURY(Per person) $ ALL LED AUTOS AUTOSSCHEDU- BODILY INJURY(Per accident) $ NON-OYIMED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peraccident i UMBRELLA LIAROCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ = WORKERS COMPENSATIONWC STATU OTH- AND EMPLOYERS'LIABILITY Yl N X TRY MIT ANY PROPRIETORIPARTNER/EXECUTNE E.L.E. EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED7 �Y NIA N POWC550065 01/01@014 01/01/2015 (Mandatory In NH) E.L DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT E 1,000,000 i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H mora space is required) MASSAVIVRISE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Columbia Gas of Massachusetts ACCORDANCE WITH THE POLICY PROVISIONS. 4 Technology Drive,Suite 250 Westborough,MA 01581 AUTHORIZED REPRESENTATIVE k- O 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Xe Office of Consumer Affairs&Business Regulation License or registration valid for individul use only = T -4reNOME IMPROVEMENT CONTRACTOR c Registration: 102726 before the expiration date. If found return to: ,'� ' 016 Expiration: 7/2/2 Type: Office of Consumer Affairs and Business - DBA 10 Park Plaza- Regulation POLAR 8EAR INSULATION C0Boston, Suite 5170 ,MA 02116 Vincent LeBlanc 51 SO.CANAL ST.#5A LAWRENCE,MA 01841 Undersecretary -------__�_____ - Not valid without signature t Massachusetts -Department of Pubiic Safety Board of Building Re ufoiions and g atardai,.,,dz , Construction Super is,,r Specialty ;cense: CSSL-105924 VINCENT E LEBLANC 24 LANDING DW , METHUEN MA 01844 :�JA Six—--" r- ;xpiration, Commissioner 01/30/2016 DR LIIVER`g CENSE {•, - 9a310 Iss QNUBER . ..o .2n•2o13 NONE 509063933 -1b C i;11a?D�S N�,E 15 41'id wr 6,09 30194'( . g _ AIN 2 VINCENT E a 24 LANDING DR atiaoaea� METHUEN,MA 01844.5029 5 00l3•21-20U Revj?.j&2000