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HomeMy WebLinkAboutMiscellaneous - 34 EAST WATER STREET 4/30/2018N rrAj 0 =i Ek 0) Lo rD zIVv n G v 0 A O o cap Q p D 4. D o I m O iy d O rb O (D 3 O (D �" 3 3 3 a' ] {p A A m O u i m r3r O s i r= 'a O N m O 'y1 v O n C N rrAj 0 =i Ek 0) Lo rD f rORT" A SS 0 .,1t�0 Ib Tr db'r ~ •a �` ��SSAI.P tty Fax 978-688-9542 Board of Appeals (978) 688-9541 Building Department (978) 688-9545 Conservation Department (978) 688-9530 Health Department (978) 688-9540 Public Health Nurse (978) 688-9543 Town Of North Andover Community Development & Services 27 Charles Street North Andover, Massachusetts 01845 LETTER OF COMPLIANCE DATE: October 10, 2000 TO OWNER OF RECORD To Owner of Record: Stalex Realty Trust, Richard Kates 358 Chestnut Hill Ave. Boston, MA 02135 William J. Scott Director (978) 688-9531 PROPERTY LOCATION Property Location: 34 East Water St. N. Andover, MA 01845 A Health Department ORDER LETTER dated, August 11, 2000 was issued to you as owner of record of the property listed above citing violations of the State Sanitary Code, 105 CMR 410.000, Minimum Standards of Fitness for Human Habitation. (Copies of this code can be obtained at the State House Bookstore in Boston). A re -inspection on September 13, 2000 and subsequent reports from the N. Andover Building Departments indicate that the correction of the violations listed have been completed. Planning A co of this letter is being sent to the person(s) who made the complaint. If the complainant Department copy g � () P p (978) 688-9535 has any questions or comments concerning this determination of compliance, the Board of Health must be contacted within ten (10) days of the receipt of this letter. Since ely, Susan Ford, R.S. Health Inspector Cc: Tenant, Hassem Sandra Starr, Health Director File Richard Kates 781-765-2322 Voice Mail/Beeper Attn: Susan Ford, Inspector Stalex Realty Trust C/o Data Management Corp 358 Chestnut Hill Avenue Boston, MA 02135 617-734-8955 Re: 34-44 East Water Street, N. Andover A six unit property. Dear Ms Ford; Firstly wc'd like to thank you and your supervisors and Board for staying calm in as torm By you and the building inspector allowing and expecting us to do the work we could do, and not concentrate on the work use couldn't gains access to, it allowed us to proceed on with the needed work. We hired a licensed contractor, as a general contractor. Then hired an electrician. We also Jtad the apartilrent # 34 inspected by a lead paint inspector. #34 has had a lot of work, replacement windows, interior doors, exterior doors, etc. Last week the lead paint inspector itrspected the unit. As soon rve receive the papers back, the lead paint contractor will proceed to obtain whatever approvals he needs, then he'll do the work. #40 this resident MOVED. We have the keys. The contractor wilt apply for a permit to take care of the issues in the Board of Health inspection. After doing some othw the apartment. er work, we'll notify you so you may inspect Exterior: A. Lights. Now the electrician can put in the outside rear light at 440. lie indicated that all the outer lighting has been taken care of. B. Rear Stairs are all in. I believe the contractor has asked, or will shortly ask the building inspector to inspect the work, General. We have tried over the years to be responsive to the residents. All the residents A (w"?, We also have tried to keep this housing affordable. Two of the residents pay about $550 per month My own son lives in Somerville, in a three fam#y home, and his rent just went up $250 a month to $1400 per month I can atocv sce that our rents, no matter what they are, low or somewhat higher, don't necessarily translate into a happy resident or an apartment that doesn't require work. We'll be more observant. But, we will always be rc nsive to your de artments. tier'r1u dA 14 nnce3, % w J 1 S lex Realty Trust Richard Kates, Tr I d Z'IIS9b9f Lig TIN 1` d EJSIHI-I'M 10d 11d fit Ind 00-9 N (C U in iL LU U Q LU a F O CL U) F H O W H� Z 9 M c 7 O T C Is your RETURN ADDRESS p completed on the reverse side? � °' "' 11� A G' ❑ ❑ ❑ ❑ ❑ CO n�, D o'�`zm xw voce m CD 'O_ CT� .0 a CCD „ f Q a g 0 N M c j w w i f lmT OD CD D Q j a] Q 3J j O 9 3 3 i Q 15 \/ CD ]7 9 m m m C c(D Z. (p 0 S app CD m z Q —D awo 3 m 2 as 3 a ro Z O co g n (D A o O nr3'J — < w m ' . L o(x1 m W I A SD N U CD 5 N p� W V kq ❑ 1:1'^ I� D D c�D W Oma" m X I o y cD W ECO 'O cn p II7 (n CD CD N J7 (n (D Am a, m (n Al \1 D y . N w Q Q Q (D �ur \! N � n 0 �CD o s Q (D CD 0 r ❑ ❑ c C7 C 7 y Q N (D C CD aru ID CD Q Q CD. Q I A SD N U CD 5 N p� ❑ ❑ O I� 31 DCD z I 0 Q CDvim, S �_ o a CD ° q� m \1 D y . CD. D m \! < Q m CD V 12 57 cD (D N CD O :D O -Z 370 627 487 US Postal Servift Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail (See rei Postage 1$ ' 3 _R I Certified Fee ui Special Delivery Fee Restricted Delivery Fee m LO rn Return Receipt Stowing to Whom & Date Delivered L Return Receipt Slxmirg to Wham, Q Date, & Addressee's Address 0 TOTAL Postage & Fees Postmark or DateLL V 1 ~! to d (aa)ke@dv`OE©gs �k k § ® \\ $ __ ) - k/ k 0E2 LL §#k f _ \ \\ \\ /\/ �)C _ k \a O �f co - . CL �\ k2ƒ &f E2 / ) mf $/0- 2 - ff7{J\ \ co \ § 22/k \} co OC )} 2» 2{f V 2]%/ k§ \- ;s -kfk-EE k®Aoa� : �k t§\ 5 #Q r, Lu ;\ � CL 0 ) 0 0� ��� �_ 0)\/\ \k \§ �§ k\,� rO § \ $f 2eKo. F� o- f) \ :E co ` a -cf £\k� $k E 2 0 k §DO »i ;Esq - G _f CL 0-le ��� /{ , z /{{§ ol ƒ / 2{ 27i wƒ w0&« �§ ama • 'a r K w6RTH h p �r y� $ssncwus�s Fax 978-688-9542 Board of Appeals (978) 688-9541 Building Department (978) 688-9545 Conservation Department (978) 688-9530 Town Of North Andover Community Development & Services 27 Charles Street North Andover, Massachusetts 0184 NORTH AND Issued under the provisions of the Statt Fitness for Human Habitation, 105 CN Date: August 11, 2000 To Owner of Record: Stalex Realty Trust, Richard Kates 358 Chestnut Hill Ave. Boston, MA 02135 cqo 765 William J. Scott Director (978) 688-9531 ,23 2 irds of Health North Andover Health Department personnel made an authorized inspection of your Department at the above address on u property bddAgust 11 2000. (978) 688-9540 This inspection revealed violations of certain regulations of the State Sanitary Code, Chapter H, as listed on the. attached Violation Form. You are hereby ORDERED to correct Public Health these violations within the time allotted on the enclosed form. Failure to comply within the Nurse allotted time period may result in a criminal complaint against you in the Lawrence District (978) 688-9543 Court and may result in an assessment of a fine. . You have the right. to request a hearing before the Board of Health if you feel this Planning order should be modified or withdrawn. A request for said hearing must be made in writing Department and received by the Health Department within seven (7) days from the receipt of this order. (978) 688-9535 At said hearing you will be given an opportunity to be heard and to present witness and documentary evidence as to why this order should be modified or withdrawn. All affected parties will be informed of the date, time and place of the hearing and of their right to inspect and copy all records concerning the matter to be heard. An attorney may represent you. You also have the right to inspect and obtain copies of all relevant records concerning the matter to be heard. S an Ford, R. S. Health Inspector �l l 2,2- 7 �1 Fax 978-688-9542 Town Of North Andover Community Development & Services William,/. Scott 27 Charles Street Director North Andover, Massachusetts 01845 (978) 688-9531 NORTH ANDOVER BOARD OF HEALTH ORDER Issued under the provisions of the State Sanitary Code, Chapter II, Minimum Standards of Board of Fitness for Human Habitation, 105 CMR 410.000. Department Appeals (978) 688-9540 This inspection revealed violations of certain regulations of the State Sanitary Code, (978) 688-9541 Date: August 11, 2000 Public Health Building To Owner of Record: Property Location: Department (978) 688-9545 Stalex Realty Trust, Richard Kates 34 East Water St. You have the right, to request a hearing before the Board of Health if you feel this 358 Chestnut Hill Ave. N. Andover, MA Department Boston, MA 02135 01845 Conservation documentary evidence as to why this order should be modified or withdrawn. All affected Department parties will be informed of the date, time and place of the hearing and of their right to inspect (978) 688-9530 also have the right to inspect and obtain copies of all relevant records concerning the matter to Health North Andover Health Department personnel made an authorized inspection of your Department at the above address on u property ddAgust 11 2000. (978) 688-9540 This inspection revealed violations of certain regulations of the State Sanitary Code, Chapter II, as listed on the. attached Violation Form. You are hereby ORDERED to correct Public Health these violations within the time allotted on the enclosed form. Failure to comply within the Nurse allotted time period may result in a criminal complaint against you in the Lawrence District (978) 688-9543 Court and may result in an assessment of a fine. . You have the right, to request a hearing before the Board of Health if you feel this Planning order should be modified or withdrawn. A request for said hearing must be made in writing Department and received by the Health Department within seven (7) days from the receipt of this order. (978) 688-9535 At said hearing you will be given an opportunity to be heard and to present witness and documentary evidence as to why this order should be modified or withdrawn. All affected parties will be informed of the date, time and place of the hearing and of their right to inspect and copy all records concerning the matter to be heard. An attorney may represent you. You also have the right to inspect and obtain copies of all relevant records concerning the matter to be heard. Swan Ford, R.S. Health Inspector . .r AN EFFORT TO REMEDIATETHE IMMEDIATE SAFETY HAZARDS MUST BE MADE WITHIN (24) TWENTY-FOUR HOURS AND VIOLATIONS TO BE CORRECTED NO LATER THAN (5) FIVE DAYS FROM RECEIPT OF THIS ORDER LETTER: -77 1) Rear exit door not functioning. Unable 410.500 /1 to open the door at all. and .501 - All doors must be in good working order Remove rear door immediately to eliminate safety hazard and then replace door. 5) No working fire detectors. 410.482 - The owner is required to equip dwellings with smoke detectors and maintain all such detectors Replace old detectors and install detectors as required by the state fire code. VIOLATIONS TO BE CORRECTED NO LATER THAN FOURTEEN (14) DAYS FROM RECEIPT OF THIS ORDER LETTER OR CONTRACT IN WRITING WITH A THIRD PARTY WITHIN FIVE (5) DAYS: VIOLATION REGULATION REINSPECTION 3) Windows in various rooms in disrepair. 410.501 Upstairs bathroom — can't close Upstairs front bedroom — front window won't stay open without being propped Living Room — Front side — Front storms not functioning Living Room — Side window - Won't stay open Kitchen — Won't stay open - All windows must be able to open and close easily And function as intended as not to cause a hazard Repair/Replace as necessary 4) No posting of landlord information 410.481 - An owner of a dwelling shall post and maintain near the mail boxes or elsewhere in the interior of a dwelling in a location l �� visible to the residents, a nonce constructed of durable material, not less that 20 square inches in size, bearing the name, address and telephone number of the managing trustee or partner. Post landlord information as required by code. .a 5) Exterior lighting 410.235(A) - The owner shall provide and so locate electric light switches and fixtures in good working order so that illumination may be provided for the safe and reasonable use of every porch, exterior stairway and passageways. Place working light fixtures as required by code. Pull all permits as may be required by the state building codes Cc: Sandra Starr, Health Director Renter, James and Joanne Hassam File NORTH ANDOVER HEALTH DEPARTMENT 120 Main Street • North Andover, MA 01845 Telephone (508) 682-6483, Ext. 32 Housing Inspection Report COMPLAINT # COMPLAINANT ADDRESS OF PREMISES S/ OCCUPANT OWNER /<« OWNER'S ADDRESS DATE OF INSPECTION 4 j 9:)'f-� HOUR l i In -Z) ROOMS/VIOLATION: n w �fl D, S � �s Tj fps Fes - Form MR -1 Action Press 885-7000 INSPECTOR Date/08/2000 Complaint Complaint# F 131 Complaintant James Hassam Addresss _ Phone# 34 E. Water Street 258-4080 Action Owner of Property Richard Gates Owner's Address Phone# Make sure apartment is deleaded & done the correct way with whatever is legally needed to do. OL Sent ❑ ��f p � .�-act.-�. �. o .— l` •-- � _ � ��/% f -tea " %/ = c� � �4 �"i SEP -09-2000 04:43 AM Faxto 1.918-688-9542 To: Board of Health, Town of N. Andover Attention: Susan Ford, Inspector From: Richard Kates, Tr. Stalex Realty Trust Today is September 8, 2000; It's 2:45 PM UPDATE: #34 East Water Street * The windows are replaced The door is new, front and rear The smoke detectors are installed Rear stairs have been corrected as requested by the The electrician will be installing a movement light, resident. This will be in addition to the private rear light controlled by the units own light switch. #40 East Water Street who we just spoke with, indicated *ata he is hoping for an Our attorney, agreement to be reached with the residents. As indicated prcvimove] or have noteritered the unit. When we can cntcr (yJ3U whe�ne Board of before, with an agreement, we'll not just fix the items Health list, but we'd like to replace the other windows in the apafinent, and more. General: Electrical Our electrician is Richard Cherkerziat►, of Richard's Electric. 617-926-1751. He was atthe property yesterday and indicated that he has introduced himself, and spoken with the electrical inspector. I'm assuming that be is ioekstep with the requirements, and we requested that he take out a permit and begin work as Soon as possible. As i understand it, he will be putting a rear light, of a proper type, switched on by each apartment's separate Light switch. He also knows of our interest in expanding the "movement lights" covering that rear section, and he'll do that as well. He entered #34, 38, 42 and 44 to look over conditions for his work. Stairs, rear. The contractor has replaced the stairs at 034. Yesterday, they were working on 036. They'll do all that require replacement or rebuilding. He has the go-ahead from us, and as I understand it, has a building permit. r Thank you for your understanding in this matter. Sincerely, TY Richar ates, P.01 kWjVWA. CrkMoe N"f W�M* Stalex Realty Trust C/o Data Real Estate Management Corp 3 S Chestnut Hill Avenue Boston, MA 02133 617-7344955 August 15, 200 Attention: Susan Ford, R.S. Health Inspector Thankyou for discussing the general overall issues at the property with me this morning. Please be asuned, we have every good intention of doing what's right at the property. Re, 40 East Water Street, N. Andover The tenant has indicated that they will be out on 10/1 /00. WE CANNOT ENTER Apartment at #40 without first obtaining percussion flfiom their lawyer. Though the lawyer's letter is long and involved, I enclose the relevant portion of their lawyer's letter. My attorney is in communication with theirs, Qbut this its a large impediment to doing the work on a timelle�jy TbassiIs..UHOOW -b deY EXPECT �j�t'atnel�E �1.a tANE c,�► �� 1�Nt�w. L 1�$ �th� Y ��h ua,'tawsrt #*& I have hired a lawyer, Richard JJ Manchester 1855 Beacon Street Suite I Srookllne� MA 02445. His telephone number is 617-730-3636, Fax is 617-730-3637. Our attorney is handling anything of a legal nature, but please if anything is not taking place in a timely manner, or the way you went, please speak with him as well as ane or Data Real Estate Management Corp's office. Frandsco Serett, the contractor indicated to me that the door is now working. Also, re the fire detectors, he told me that the husband took care of them. Since I'm not sure that they are all in, he will go them today to be sure. I asked him to speak with the building inspector, so we take caro of the other problems correctly. Thank you for your working with us, I want to do things the correct way. Sincerel�yq. j Richard Kates " Trustee Stalex Realty Trust Ps you requesed to see the two lead paint compliance letters. They aro enclosed I notice the inspector's name, address, etc. are on the letterhead. 0 Location C/ 7 F UA I e R S No. 1 Date NORT1y TOWN OF NORTH ANDOVER 3? I . OL • i ; : Certificate of Occupancy $ CNusE�Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ '3a' Check # ' Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVAT5 OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: / 17 -tv SIGNATURE: r—a-t� Building Commissioner for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: -3 9,4 Gua -,4e2 1.2 Assessors Map and Parcel Number: / Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) Public ❑ Private ❑ 1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of/�Reecord / y' n ST-AGk PE L/ Name (Print) C �` �s jy 9 y // �vsl 3`rC� cheIL r,, -f r oll tVOc3/v�( Address for Service: X NA6F(Z Signature 2.2 Owner of Recor : Name Print Telepho 97Y >S2q 07/8 Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: ��rYCt scrJ SEti`'IZ1 Lic�eatlsed Construction Supervisor: go I � I� 13e 1I o � F Address 1, l Sig 7r i �A 1 ! , 13 O� r0� W►� 97f, 3sa 8,b 1l�-civ Telephone Not Applicable ❑ C 06 License Number Expiration bate 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) 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 Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check A applicable) New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ Alterations(s) ❑ 1 Addition ❑ Accessory Bldg. ❑ I Demolition ❑ I Other ❑ Specify Brief Description of Proposed Work: Ya fiE Tlq 11e CJV 19VT7-1H6 lI a=1 :3 1Z GE Pg C.Y,I :MEigJLs ayid A l l4rlcY�p� � -rHF 60ublf- -rO bF 12/2,6ESSu/2E T E1qrE.4- I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Completed by permit applicant t;tMCIAI USE.O}.NLY 1. Building p� J(yoo, �� (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, l C k K} TF_ s l?U f eL,eTyPAA/y4 6F A2� as Owner/uthorized Agent subject property Hereby authorize /`(C !SCO E K I' t �% to act on My behalf, in all matt e tive to work authorized by this building permit application. CXR Signature of Owne Date SECTION 7b O R/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/Agent Date 91 111011210MON1111 111111 NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2 ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS 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 I (A Ce- & A, r -P(N t f:6rW& S+4(r'& wrtiD0W3- FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT!a* 7 PHONE ` ��73 j/- xa-45 ASSESSORS MAP NUMBED --k-7— LOT NUMBE `SIJBDWfSION----- c% / STREET �� STREET NUMBER 3 / y7 ........................................................................... OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS 0 0 � 8 a 21(:MANG Maine 7 5 9— DATE APPROVED CONSERVATION ADMINISTRATOR DATE REJECTED CAu1'1-+C,0�) DATE APPROVED TOWN PLANNER DATE REJECTED CONMIENTS DATE APPROVED FOOD INSPECTOR - HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR - HEALTH DATE REJECTED COMMENTS PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT CONflylENTS RECEIVED BY BUILDING INSPECTOR DATE C SAFETY ' DEPAR71ENT of Pi8,, Nut ber: cs Ur'll Restri'L,d To: PA,tTTSCl) SE9RET U2 W� SRORE 90 y< HOME IMPROVEMENT CONTRALIOR Registration 120711 Type - 084 Expiration 02125100 FRANK GENERAL CONTRACTOR FRANCISCO SERRET 7? &o� LAKE SHORE RD ADMUSTRATOR BOXFORD MA 01885 C SAFETY ' DEPAR71ENT of Pi8,, Nut ber: cs Ur'll Restri'L,d To: PA,tTTSCl) SE9RET U2 W� SRORE 90 46 Town of North Andover oti NORTH Al a'' O Building Department o 27 Charles Street North Andover Massachusetts 01845 978 688-9545 Fax 978 688-9542 c) c) ACHUS���y DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit 9 the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in /at: b pv S 0 c. cotes pp/Y y Facility location Signatur Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. rev CERTIFICATE OF LIABILITY INSURANCE DATE JUL 3100 PRODUJER DEGNAN INSURANCE AGENCY 237 ESSEX STREET LAWRENCE MA 01840 PHONE: 978-688-4474 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. POLICY NUMBER FAX: 978-687-7713 COMPANIES AFFORDING COVERAGE INSURED SERRET, FRANCISCO 180 LAKESHORE RD COMPANY A: UNITED NATIONAL COMPANY B: COMPANY C: W. BOXFORD MA 01885 NOV 20 00 COMPANY D: FIRE DAMAGE (Any One Fire) $ COMPANY E: 1^_nvFaer_Fc 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 INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE (MMMnfM LIMITS BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY GENERAL LIABILITYL7126390 COMMERCIAL GENERAL LIABILITY CLAIMS MADE ❑ OCCUR OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. NOV 20 99 NOV 20 00 EACH OCCURRENCE $ 500,000 FIRE DAMAGE (Any One Fire) $ MED. EXP (Any One Person) $ A PERSONAL & ADV INJURY. $ FGEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 500,000 PRODUCTS-COMP/OP AGG. $ 500,000POLICY PR4 LOC AUTOMOBILE LIABILITY ANY AUTO$ COMBINED SINGLE LIMIT (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS NON -OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY OCCUR CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ S DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY we srAru oTH E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ OTHER: DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS /�G�TICI�ATr IIAI www •r.w.�....•.. ...-..��� ... _..___ _-___ ----' v_lmV LA -MI IVIY HOME DEPOT ROUTE 28 BROADWAY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL SALEM, NH 03079 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Attention: wn�nn ne c •�Ins1 �� �� --� �• �• r cernticate # 599 uana M. Uegnan U V111 Cie The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print S 11 � EX PEA• C vsT Location: 3 11 ` LJ 1-1 LAST we 0TL- E sT City H . 1-0 O (/E 1L Phone aam a homeowner performing all work myself. 01 am a sole proprietor and have no one working in any capacity aI am an employer providing workers' compensation for my employees working on this job. Company names Address City Phone #: c% 86116 Insurance Co. Policy # Company name: Address City Phone #: Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of penury that the information provided above is true and correct. Signature Date Print name _ _ Phone # Official use only do not write in this area to be completed by city or town official ❑ Building Dept -JDCh¢ck if Jrqpoia4e response is requmt-d-- BMding Dept, ❑ Licensing Bo rd ❑ Selectman's d ffice Conthct person. Phone # ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION C/) Cf) 0 m CA 10 CD n Z CD CL r� o d CD o p CL c� %G C CCD O a: a) O � to CD CA 10 CD O Cos d d O c Cl c CO) CD O CD CSD y� CD CO2 O CD CD0 5 rn m ON z C ? IS, -0* d 2 O �• VN O CT N EL S CDV3 E, o 10 m � CD n C CO) C2 Gd p m z -CD _0 y CD ti •T1 CD =r0 = y CO —40 m CO) p N O m m = > > a o� a co % ZO Occ 10 n► o 11-21 m c =r' = . CL ~•may CD O N CD n� ' CL m� m CD O C4,: � N : O1 C42 d ca O': ba 5, CA � bm ? m H CD CD m.Ort N 3 M CD O c, �o CD CO) g a a om�• SDI f ofu R CL cp . Co.,CD� o CI c a ro Z . p'- o oGc O b w ,..o o�c Cil ,� w .0 ... GGOD m a'- n o�n o O.. SD C� r C �^ n o p x z O o x y 0 9 0 c