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Miscellaneous - 349 APPLETON STREET 4/30/2018
rN) i Location --} No. L Check 31617 Date ?--e l O t TOWN OF NORTH ANDOVER Certificate of Occupancy, $ Building/Frame Permit Fee $ Foundation Permit Fee, $ Other Permit Fee Afl e -r— $ - TOTALS $ Building Inspector Af�Location :M ,t7" —S�- f No. Check # � ` - 31617 Date 3 1 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Feet $151) TOTAL vS $ Building Inspector Town of North Andover BUILDING DEPARTMENT CONTRACTORS NAME: I- C CITY/ TOWN: r LJ� STATE: buir— ZIP: r 1 BTJS. PHONE: 6;'TP- 5�' 1 -7 / C,Ao CELL: MA. LIC #: MASTERS: j PERMIT # REQUESTED DATE: JOB LOCATION: OWNER: JOURNEYMANS: r N -GRID SR# G TIME: ", s� PHONE: WORKERS CELL: REASON FOR REQUESTED INSPECTION AND JOB DETAILS: r� CONTRACTOR SIGNATURE: NORTH A1VD®VER SUPERVLSOR SIGNATURE: e'd' I,,, -A se4-0 f 64-- 415—b 1 Contractors requesting INSPECTIONAL SERVICES due to weekend or after hour operations such as service related planned updates or special situations, will be required to provide a four hour minimum charge of $150.00 paid to the Town of North Andover at that time. Community Development Division, 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9545 Fax 978.688.9542 Web www.townofnorthandover.com I1 306 Date. q . � ... ...... TOWN OF NORTH ANDOVER ' PERMIT FOR MECHANICAL INSTALLATION A • This certifies that ..(�.� 1. ...c�. .... ...... has permission for mechanical installation .:> T ........... in the buildings of ................ at ..i�. (� .. ;���.... .r........ , North Andover, Mass. Fee ('f` Lic. No.... '1�:.. GAS _ j INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Commonwealth of Massachusetts Sheet Metal Permit Date: `,- I Z 2 1 (3 Estimated Job Cost: $ Z/ f 6 Plans Submitted: YES NO X Business License # 5-c t Permit # Permit Fee: $ Plans Reviewed: YES NO X Applicant License # y 6 ? Business Information: Property Owner / Job Location Information: Name: C'en-k'�1 Cool i nrn + �} 2(A�-�� ra, Tnc Name: � Street: q Nd r �vt aT_Se e,� Street: City/Town: W &urn, M)q QlS-Ul City/Town: �A`JIA �nc�a��ul� rMy4 Telephone: 2? f - q 3-3 — S r y Telephone: 7S1/ -R' S --F` 7a ? 5 E Photo I.D. required / Copy of Photo I.D. attached: YES NO Staff Wa8► 4-4-/ M-1 unrestricted license +4;M,2 -restricted to dwellings 3 -stories or less and commercial up to 10,000 sq. ft. / 2 -stories or less Residential: 1-2 family Multi -family Condo / Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. Number of Stories: L Sheet metal work to be completed: New Work: >C Renovation: HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney / Vents Air Balancing Provide detailed description of work to be done: !T111 ii -REF! � M.. iR_5 AS A BUSINESS DOUGLAS.A HAMILTON CENTRAL COOLING AND HEAT ING 9 N MAPLE ST WOBUR:N MA 0 18-0 1 — 0.0-0-0 52 08/30/14 X2299.9:: 12old, I hoji Uohdi Alowl COMMONWEALTH OF MASSACHUSETTS ASA MASTER -UNRESTRICTED.. ISSULS 1-1 ff'ABOVI': HCENSF 1'0: —DOUGLAS A HAMILTON 7 7 JCENTRAL COOLING & HEAT 9 NORTH MAPLE STREET W1.0 13,U R.N MA 01801=171 Xi ws 469 12/28/13 793i� nz Z' "LICENSE NO. EXPIRATION DATE SERI AL NO. ...... ....... f 4 N 'x /%MBER _�v 52954907 Z. Y; 5 4 '2014 12-16-1961 EST H T SEX 5-09 m -'HAM' I LTON DOUGLAS A: 70 LIBERTY ST N ANDOVER, MA 01845 -3357 . am - re 05-- m rv. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Map # Lot # IF 600 Washington Street Address' Boston, MA 02111 Permit # www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Informatioli Please Print Legibly Name(Business/ownizatiowbdividual): CenflZA eijd/%,,3 4-& ;„4 -Tnc— Address: % n/ar-ik . KAj21Q SfremE City/State/Zip:tA Are you an employer? the appropriate box: I am a employer with "7 O employees (full and/or part-time).* 2.0 I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] I D' I am a homeowner doing 411 work myself. [No workers' coo. insurance require&].t Phone #: 7 f t- 933 -Ta-8e', 4. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub-conuktors have employees and have workers' comp. insurance.# 5. We are a corporation and its officers have exercised their right.of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' Type of project (required): 6. 0 New construction 7. 0 Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 1 LO Plumbing repairs or additions 12.0 Roof repairs 13.E Other ,�/ - "Any applicant that checks box #1 must also 0 out the section below showing their workers' compensation policy information. t Homeownehs who aubmit this affidavit indicating they are doting all work and then hire outside, contractors mutest submit a new affidavit indicating such. tConbWtors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub -contractors have eniployees, they Yinist provide their workm' comp. policy number. X am an enpioyer that is provldiig workers' Compensation insurance for my employees•, Below Is the policy and; job site information. Insurance Company Name: ('s Lo b a 1 TrtsL rows P I&}-�.i_ a� Policy # or Self -ins. Lic. #: ?J3` d n n , 9 f- Expiration Date: /v _ -q 0 Job Site Address:_ S” ( Q , rz - City/Stawmp: N ` vv 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 Investisrations of the DIA for insurance covera¢e verification. Ido hereby under the pains and penalties of pedury that the information provided above is true and cow S' e:Date: 171211-113 _ use only. Do not write In this area, to be completed by c or town o, ffidaL City or Town: PermitUcense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. 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() 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 ai{hority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to .your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships, (LLP) with no employees other than the muembers 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 avurouriate fine. City or Town Offidals 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 him 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 nu nber. The Commonwealth of Masswhuseas Departnent of Industtie1-Acoidmts oti%e of hVesfiPloym wain! n�tot� S.� Boston, MA 02111 U. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 11-22-06 w�vw.mass.gavhlia PMIAOlrsmwmmm;e M0940 60) h :jagwnN 9sua31-1 sesueol-I jo aln;eu61S rl papu;sea-uosjadAawnor❑ uosaadAewnorE] p813u;saa-Ja;sBIN ❑ Ja;seW :esuaoi-1;o ads( i sIuauzuzoj Uol pacisiq I8ui3 sJuauzuzoD suogaa suI ssaa 01d IgnoaddV;luuad;o am;euBlg joloadsul al>;(I 31e(I ON S3A :uol;elle;suI uol;elnsul o4 jopd pa.11nbe l uopedsul Oona •smel 1eJau89 04; io tL L aa;deU pue apoO Bu!PllnB suasn40es2eW 044 10 uolslnoid;uoul}ied Ile 431m aouelldwoo ul aq Illm uoq"lldde s14; ao; ponssl;luued ay; Japun pauuojjed suol;elp1sul pug )Pom 1e40w48049112;e4; Pug aBPalmou)l Aw;o;saq ay; o; a;gjnaag pue enj; eje uol;eo11dde s14; Bu1P.JOBaJ (Papa;ue jo) pe;;Iwgns aAe4 I uol;euuo;ul pug s11e49P e4;;o pe;e4; A;gj90 AgaJa4 1'(]xoq sly; Bul3lae4a A8 ;ue6y s,.isumo jo jaumo;o ein;eu6ls ❑ ;u86V aaunn0 Aluo au0 310040 •;uawa.jinbei sly; sanlem uol;ealldde woad sly; uo ein4eu6ls Aw;e4; pue'sme-; lejeuea suesnyaessew ay;;o Zi l ja4de43 Aq pailnbaa 968JOA03 aaueJnsul ay; GAe4;ou saop 00sua311 04;1e4; aJeme we I :113AIVM 33Nvun9Nl 9,2I3NM0 El pu08 A41uwapul }o ads(; J8410 ® Ao!lod eoueansul A;lllgell V :molaq xoq apudoidde ay; Bunlaaya Ag 06ejanoa;o adA; 94; a;ealpul 'saA p9310040 ene4 noA;I [:]ON ®saA Zt6 '43 •1•J-W;o s;uawailnbej ay; s;aaw 4alym;uoleAlnbe s;l jo Aollod eoueinsu! !I! ll;uauna a ene4 I :3JVa3A00 30N"nSNl LOI3 Work Not Included: Any carpentry, painting, patching or sheet rocking Customer will supply subpanel from electrician that customer provides. We propose hereby to furnish material and labor - complete in accordance with the above specifications, for the sum $12,168.00 ( After Winter Work Rebates ). 1/3 deposit upon acceptance, progress bills to be submitted at the end of the month to be paid on the 10th of the following month, balance due to the service technician at the start up of the system. Past due balances will be charged 1 1/2% interest charged per month which is an annual percentage rate of 18% on past due amounts. Rebates and Tax Credit: Cool Smart Electric Company Rebate v The above system is eligible for a $500.00 rebate for NStar El ' or National Grid customers only (subject to available funding.) To claim eligible rebates the system must be purchased, installed and paid in full by 12/31/2013. Rebate applications must be received by the electric company before 1/31/2014. It is the customer's responsibility to pursue available rebates. After system is paid -in -full, Central Cooling & Heating will provide the customer with the appropriate invoice and rebate forms (please allow us 1-2 weeks from the date we start up the system to provide the invoice and rebate forms. System must be paid -in -full before we can provide the required invoice.) Central Cooling & Heating Instant Rebate for QIV Testing The above system is eligible for a $325 instant rebate. We are being reimbursed directly from the electric company for performing a QIV start up of the system including an air flow test. In order to get the rebate, the new system must be tested with the outside temperature above 60 degrees. The testing may be done at a later date, after we install your system, pending on the weather. This is an "instant rebate" that will be deducted from your balance due. Cool Smart Electric Company QIV Rebate The above system is eligible for a $150 rebate for NStar Electric or National Grid customers only. This is an additional and separate rebate from the electric company for performing a QIV start up of the system including an air flow test. In order to get the rebate, the new system must be tested with the outside temperature above 60 degrees. The testing may be done at a later date, after we install your system, pending on the weather. The electric company will mail you a separate check for this rebate, after the QIV test has been performed. Federal Tax Credit The above listed equipment is eligible for a $300.00- 2013 Federal Tax Credit (the maximum amount an eligible homeowner may receive in tax credits for "residential energy property" is $500.) The cap is on the total amount of credits a homeowner may claim for purchases between 2006 and 2013, not just for 2013. If a homeowner has already claimed credits of $500 or more through this allowance; they will be unable to claim new credits for improvements made during 2013. We recommend verifying with your tax adviser on how to best take advantage of this tax credit. Authorized Signature: Payment terms, warranty information and home owners responsibility are listed below Note: This proposal may be withdrawn by us if not accepted within 30 days. a.a —w wacacg ana nearing, inc. agrees io proviae a t wo (z) year warranty on parts and labor to repair or replace (at our option) any defective materials or equipment. Service agreements are available. Your Comfort is Our Priority... Since 1966 Serving The Boston Area (781) 932-9017 fax www.centralcooling.com Page 3 of 3 • This agreement does not include improvements to your present system except as specifically outlined in your contract. If it is not stated in writing in the contract, than it is not included! • Central Cooling and Heating, Inc. will endeavor to render prompt and efficient service, but it is expressly agreed that the company shall in no event be liable for damage or loss arising out of the performance of this agreement • It is mutually agreed that this agreement does not cover any work required because of negligence, misuse of equipment, or because of fire, flood, acts of God shortage of electrical or water supply, sabotage, or damage caused by freezing. • The company and the customer agree that any alteration or deviation from the specifications set forth in the contract agreement, including extra costs will be executed only upon written orders, and will become extra charge over and above the contract price. All agreements contingent upon strikes, accidents, or delays beyond our control. • All cooling and heating warranty service to be performed during normal business hours M -F 7.30AM-4:OOPM. Emergency heating warranty service will be provided only if heat is off completely • The homeowner agrees to have the work areas free and clear of personal belongings, construction materials etc, if this is not the case when our crew appears onsite, you will be billed the necessary time needed to safely move the articles to make the work area accessible. • Owner to carryfire, tornado and other insurance. Central Cooling and Heating, Inc. workers are fully covered by Workmen's Compensation Insurance • Central Cooling and Heating, Inc. adheres to sound environmental practices relating to the procedures governing n*IgeC re FYIrecycling, and reclaiming stated in the Federal Clean Air Act. Buyers Rights Option 1: Notice: Any holder of this consumer credit contract is subject to all claims and defenses which the debtor cou dirt against the seller of goods and services obtained pursuant hereto or with the proceeds hereof. Recovery hereunder by the debtor shall not exceed amounts paid by the debtor hereunder. Buyers right to cancel: You may cancel this agreement or purchase by mailing a written notice to the seller postmarked not later than midnight the third business day after the date this agreement was signed. You may use this page as that written notice by writing "I HEREBY CANCEL" at the bottom and adding your name and address. The notice must be mailed to 9 North Maple Street, Woburn, MA 01801. Option 2: Under the Mechanics lien law, any contractor, subcontractor, laborer, material man or other person who helps to improve your property and is not paid for his labor, service or materials, has a right to enforce his claim against your property. Under law you may protect yourself against such filings, before commencing such work of improvement, an original contract for the work of improvement thereof, in the office of the county recorder of the county where your property is situated and inquiring that a contractor's payment bond be recorded in such office. Said bond shall be an amount not less than fifty percent (50%) of the contract price and shall, in addition to any conditions for the perfdrmance of the contract, be conditioned in full of the claims of all persons furnishing labor, services, equipment or materials for the work described in said contract. To expedite installation, I hereby waive my right to the 3 -Day Recission Law. Payment Terms: Payment terms are agreed upon signing this contract to be 1/3 deposit upon acceptance, progress bills to be submitted at the end of the month to be paid on the le of the following month, balance due to the service technician at the start up of the system. Past due balances will be charged 1 1/2% interest charged per month which is an annual percentage rate of 18% on past due amounts. In instances of Punch list incidentals will only be done after payment is made in full. No service, warrantee or otherwise will be rendered if the customer has a past due balance. I acknowledge that this is a fair and reasonable charge for the above stated work. I undersigned understands the terms and conditions of payment, the Services to be performed as well as my responsibilities as far as having the work area ready and free and clear of personal property. The undersigned shall pay Central Cooling and Heating, Inc. one and one-half percent (1 1/:%) monthly rate of interest on any balances unpaid after 30 days after receipt of invoice plus any and all costs incurred in the collection of outstanding balances whether or not resulting in the initiation of litigation, including but not limited to reasonable attorney's fees. Customer signature Printed name as it appe,06 on your credit card Print Card Holders Address Credit Card Information: MasterCard_ Card Number Visa _ Expiration date Your Comfort is Our Priority.. Date 3 Vcode _ _ _ (last 3 digits on back of card) Since 1966 Serving The Boston Area (781) 932-9017 fax www.centralcooling.com Carrier Central Cool' 4 Heating Inc. August 19, 2013 Scott Bowman 349 Appleton Street North Andover, MA 01845 781-858-7279 blynike75@gmail.com Equipment: Page 1 of 3 ��.PEABODY AREA n (878) 531-4422 WOBURN AREA z: (781) 833-8288 NEWTON AREA (617) 828-3366 4` T r�Uil COb1XORl .. 00 V Ductwork and AC Installation Proposal : unaa tarns 1 Carrier FX4DNF037T00 High Efficiency, Fan Coil Unit 1 Carrier 24ACC630A003 2.5 Ton Performance Series Condenser 1 April Aire 2000 Series Air Filtration System Rating: AMU# 3657159; 16.0 SEER; 13.00 EER Work Included: • Installation of equipment listed above. All equipment locations will be coordinated with the homeowner. • Installation of new galvanized steel duct distribution system. The new ductwork will be installed per local building code to the proper insulation and sealing requirements. • Each supply branch will have a manual balancing damper. • Installation of returns to first floor and basement. Locations will be determined at site walk through with install foreman • Installation of new refrigeration lines and condensate drains. The lines and drains will be enclosed in slim duct on the outside of the house as needed. • Connect to existing thermostat on first floor • New poured concrete condenser pad. • Installation of power and control wiring to the existing sub panel installed by customers contractor • All permits and fees. Including town required building permit. • Start up, check system and explain operation. All material and labor is guaranteed for 2 complete years including maintenance after the 1' full year of operation. Carrier issues a 10 year warranty on all parts. Your Comfort is Our Priority... 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LOCATION ❑ 1NatersnedDistnct f . 0 WaterOSevver - – = PROPERTY OWNER Print - ,,.- IMAPNO:'PARCEL-€' P_rmt� w ZONING DISTRICT 106 ear Old'Structure _ ',Historic District ye's y' s no _. - - - Machine Shop Village - - y - - TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well . ❑ Floodplain E Wetlands: -, _ ❑ 1NatersnedDistnct f . 0 WaterOSevver . , DESCRIPTION OF WORK TO BE PERFORMED: o off N t v-, Identification Please Type or Print Clearly) OWNER: Name: 4;C_0ky Phone: q-)6 Z'T),aca 0 Address: `�,�-t`1 � C���e�-o ,r, Sk \gac>c�A g8gg c— MA- 01�s4 CONTRACTOR-",, = ___ - _ Rhone: g Address: __ . _ _ _- _ Y\ Supervisor's�Constru.ction `License `Exp 'Date Home lm`provement Licen a _-- _ ._ - - _ _ Exp _Date.;Aw 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: $ FEE: $ ILE Check No.: �� � Receipt No.: c>1 NOTE: Persons contracting wit unre i�totors do not have access to the guarantyfund i—.rwa.�.��..l+r Signature of`A ent/Owneri Si pature of contractors_ . = t Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Building Department The foE,3wing is a list of the required.forms to be filled out for the appropriate. permit to be obtained. Roofir-,g, Siding, Interior Rehabilitation Permits a Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work Li 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 L3 Certified Surveyed Plot Plan o Workers Comp Affidavit L3 Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract I - o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) E3 Mass check Energy' Compliance Report (If Applicable) E3 Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign, off from Fire Department prior to issuance of Bldg Permit I New Construction (Single and Two Family) o Building Permit Application F ❑ Certified Proposed Plot Plan L, Photo of H.I.C. And C.S.L. Licenses Li Workers Comp Affidavit Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) L3 Copy of Contract L, Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all casts if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apv_-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 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 Mr)Tl=-t,- nnr9 rIATA _ (Fnr r1PnarfmP-nf usel I/A I V)� Sr-� Doc.Building Permit Revised 2010 -c-, Ung } lA Notified for pickup - Date Doc.Building Permit Revised 2010 Plans Submitted ❑ Plans Waived ❑ C-ertified Plot Plan ❑ Stamped Plans ❑ "TYPE OF-.-.SEW-ERAGEDISP_OSAL - `• Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools t i ❑ y Well ❑ Tobacco Sales ❑ C i 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 COMMENTS HEALTH COMMENTS Reviewed on Signature Reviewed on Siqnature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comme Conservation Decision: Comments Water & Sewer Connectionisignature & Date Driveway Permit ]DPW Tovv;. Engineer: Signature: Located 6M usgooa street FIRE DEPARTMENT - Temp Dump'ster on site yes no Located at 124,Mair, Street E.^ - - Fire"Department signature/date C0M�M.EN' TS Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 149000.00 m $ - $ 168.00 Plumbing Fee $ 21.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 21.00 Total fees collected $ 310.00 349 Appleton Street 261-14 on 9/19/13 Finish Basement To" OF NORTJff ANDOVER OFFICE OF BUILDING DEPARTMENT :1.600 Osgood Street Building 20, -Suite 2-36 North Andover, Massachusetts 01845 Gerald A. Brown Telephone (978) 688-9545 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER -LICENSE EXENIpTION . DYTIDTNG PERNNIIT APPLICATION Please print S DATE: 1 JOB LOCATION:` n a j; �rn, Number Street"Address I MEOWNER PRESENT MAILING ADDRESS �r o\s e r r14 '1't,+Q+ata Zip Code ' The current exemption for "homeowners" was extended to include owner -occupied dwellings to Uvo units -or less and to allow such homeot,.mers to engage as idividual•for hire wh-license, o does not possess a provided that the owner acts as supervisor). State Building (Code Section I 0S.3.5.1) DEFINITION OF HOMEOWNER Person(s) who awns a parcel of land on which he/she resides or intends to considered a homeowner. reside, on which (here is, oris intended to be, a one or two family structures. A person who constructs more that _one home in a two-year period shall not e The undersigned "homeowner" as Applicable codes, sumes responsibility for compliances with the State BuildingCode and by-laws, rules andregulations, other The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department equ um rem inspection procedures and requirem is and tha he/she will com t3-with,said procedures and requirements, HOMEOWNERS SIGNATURE . Ma n • 1-7 Home Phone A /lA Work Phone APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption 130ARD OF APPEALS 688-9541COI�TSERVATION 686-9530 HEALTH 688-9540 PLANNING 688-9535 E CL thh r"\ �F y�d IDOCA14ispositions A J wo-ad I ARNL The Commonwealth ofMassachusetts - Department oflndustrialAcci6is Office of Investigations 600 Washington Street Boston, MA. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizationffndividual): Sc o� o c-,1 M C Address: City/State/Zip: N A v,) oJe-(— Aft Phone #: T) K Z -eaa (a 6-1 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ lam a soleproprietor or partner- ship and'have no employees working for me in any capacity. [No workers' comp. insurance \ required.] �. I am a homwner doing all work yself: [No weoorkers' comp. insurance required.] i have hired the sub -contractors listed on the attached sheet. I These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Typo of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. 0 Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other 'Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they 27re 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 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 thepolicy and job site information. Insurance Company Name:. Policy # or Self -ins. Lie. Job Site Address: Expiration Date: City/State/Zip; Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to .$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA. for insurance coverage verification. Xdo Iaereby cert der pWh ins an enalties ofperjury that the information provided above is true and correct. 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 - Pnnfn rf Pe:rcnn! Phone Information and Anstruction"s 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 ofhire,- 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 ofits 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 -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of ' insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LT C or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confnmation 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 (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 homeowner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Mass0,c-hV Ptts Departmeat offildustzxal Accidents Office ofIRycstigations 600 Washington Stroet Boston} MA 02111 Tool, # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Faze ## 617-727-7749 J0. W U. O m aV y -i \ O O LL E v T N U -Z Q a) N o d Z Vr Z m c O m "O c O O LL L to_ O O K (1 C E L U C LL y Z (7 Z m J d L O O w _CLO C LL wa NCA Z QZ U W J w L O K O U i a) N m O LL 0 U ui °• N C9 t O m C LL z Q W 0 °C LL 4J O m O z ++ t; N 4J aJ Y O E N O : f— a U) z 0 m //^^ v+ C/) F- O CL n W _ 0N _ x Z . 0 LU 0 cn W c WJ CL Z_ m O C O N d t O Z Q J O OF �V E O .a.+ V Z CL O N CM 01— A' c W Q N •4) W m W O �+ 0 0 O Q CDa O .'VSA/ O W U CL c 0 R p v O 'Q a 0. a� cc mQ w = o E Q, L y d �C y � L CD Cc : O L V v N Cc —1�J • > `c p O p H O O fA c — O 0 -0 o t U Q � d t t E O d OZ CL W cn p 0 H c �. 3 CM c c H :•�.1QQm L cr O w .N V i O p_ i cc 'a Q.4)Cc CO) LL .'s CL N _ `CL o _ W v L F• .0 w O. 0 U O : f— a U) z 0 m //^^ v+ C/) F- O CL n W _ 0N _ x Z . 0 LU 0 cn W c WJ CL Z_ m O C O N d t O Z Q J O OF �V E O .a.+ V Z CL O N CM 01— A' c W Q N •4) W m W O �+ 0 0 O Q CDa O .'VSA/ O W U CL c Building Department The following is a list of the required forms to be filled out for the aapropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application , Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products 3TE: 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/Cross Section/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 OTE: 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 2012 IECC Energy code Engineering Affidavits for Engineered products TOTE: 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 Doe: Building Permit Revised 2014 Location P P L F +7`o/J ST No. 5(+g - a-017 Date !f TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # ty cI r 612 A9 . I .Building Inspector x 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-$1000 fine NOTES and DATA — (For department ease) ® Notified for pickup Call Email Date Time Contact Name _ Doc.Bnilding Permit Revised 2014 Plans Submitted ❑ - Plans Waived ❑ Certified Plot Plan ❑ Starnped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Taming/Massage/Body Art ❑ Swuruniug Pools 11Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ permanent Dwnpster on Site ❑ THE FOLLOWING SECTIONSOOFFICE INTERDEPARTMENTAL • FORM PLANNIN -- PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH i s C)MMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Commen Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTIIIIEN �Ternp}D rnpster n sitgl%ee- Loeated at 11-1 fUlain Sfreet �` x x r Fire Dpartr�entsi,gnat x «${f+ �Mx� I V I E I V' I J.L,,..,,, d �• r ; '� { Y '� �,.�#!�� lr 4 � � A ,.'t 4 -}' � k� t a� �8 �a�� �? � �� s ` ';� r L J 2 LL o O 0 m C .0) Y O O LL E ate-. V) O_ N N O H z z z_ o m C .2 o 7 O LL O K v E L U @ LL Q H z _z m 2 d 7 O d' N O LL O Nu z Q u a (~J W W O d' d cu N t0 LL cr- ui tna z a .O d' c0 LL z ui o: W W LL i m O z it N Y a N Y O E N z z CO CL W W CL 141 w •,v W 0 o M 0- ' O . Nom 0 CD LI.-= W CD O cc O CL co Q O � i �CL. O U)z O U tU m **wwnl •a Vl o cc Cc 0 Q .r �o N V CL N <u W ti z z CO CL W W CL 141 w •,v W 0 o M 0- ' O . Nom 0 CD LI.-= W CD O cc O CL co Q O � i �CL. O U)z O U tU m J q 1Jjz ,{70� Podara1 t11 # 05-0405629RISE Engi ieexiitg RI Contractor Registration No 8186 MA Contractor Registration No 120979 , CT Contractor Registration NoG20120 RISE ap� El4G1iVEERi1JG" 60 Shawmut Road, Canton, iNA 02021 CONTRACT CONRA T 339-502-5335 1�AX339-502-6345 Page i PROGRAM {♦ TNIS CCNVtA=IS EKERED OnoR£THEEN HISS ('{MA-11JES E1401HURMDAM VIE CUSTM¢R FOR WORK AS DESCRIBED ovLow =MNER PHONE DA's ,�'jA ,. vim omm Robin Bowtmn (781}88 n79 10128120 =�;22 'L V SERVICE SIREET aal w STREET 349 Appleton Street 349 Appleton Street SERVICE CITY, SIAtE. IIP 831.£INe CIM, STATE. AP .., - ,,. ` , . North Andover, MA Of 945 North Andover. MA 01845 1i 1 JOB DESCRIPTION HAZARD BARRIER We have identified that there are recessed lights pre nt in your home. unless the recessed lights are certified as IC --rated (Insdat ion Contact Rated) ime xv£ll createa 3" clearance space around the fixtute by using fiberglass blanket insulation as a damming material, no insulation will he installed across the top and closed cavities which contain recessed lights will not be insulated, 50.ti0 AIR ALING: Provide labor and materials to seal areas of your home against Hastcful, excess air leakage. This work xxril be performed in concert with the use of special tools and diagnostic tests to assure that your home vi11 be lett xvith a healthful level of air ecchange and indoor air quality, Materials to be used to seal your home can include caulks, foams and other products. Primary areas for scaling include air leakage to allies, basements, attached gt nges and other unheated areas (windoxxs arc not generally addressed.) This will require (10) working hors A redo ction in cupric feet per minute (sfm) or air in) thration wi11 occur, bid the actual number of efm isnot p'tararitced. At the completion of the vxeatherization murk, and at no additional cost to the homeawner, a final bloxw:r door and/or combustion safety analysis still be conducted by the wb-contractor to ensure the sut'ety of the indoor air quality. $850.00 DAMMING: Provida labor and materials to install a 12" layer or R-38 unfaced fiberglass /mitts to (82) sI{cctre feet for damming purposes. $168.10 ATTIC FLAT: Provide tabor and materials to install a 6" lays- or R-22 Class i Cellulose added to (930) square feet of open attic space. $1,171.80 ATTIC ACCESS: Provide labor and materials to install (1) wsily moved, insulating cover for the attic access folding stair. A small fiat surface of plywood will be created around the opening within the attic. This will allow the Server's integral mcalher- stripping to restrict air leakage. NOTE: CUSTOMER WILL t7St: HDINl ERIOR W1 OLE HOUSE FAIN COVER. $237.65 VENTILATION: Provide labor and materials to install (.3 ) 8° diameter roof vLnt(s) to increase ventilation in attic areas. The vent can be supplied in (circle color) black, brown, gray or mill finish. 52561 50 VENTILATION: Provide labor and materials to install (2) insulated exhaust hose with roof mounted flapper vent to exhaust existingbathroom fan(s). 5237.50 VENTILATION: Provide labor and materials to install vent ilat ion chutes in (100) rafter bays to maintain air flow. $200.00 Federal tD 11106-0405629 RISE Engineering Rl contractor Registration No 9186 MAConiractorRegistration No 120979 CT Contractor Registration No820120 RISE 60 Sbawmut Road, Canton, .LA 02021 �y g1�ID CT B -2- ENGINEERING" i,,,� 339-502-5335 b`A.\ 339-502-6345 Page 2 PROGRAM t.'MA-tile ENCOMERINGGANDCCNMCTCS �RCi�U �WORKAES DESCRIBED DEUM CUSIONER PHONE DAIE Ctz-%T* WORK 0VMR Robin BowTmn (781)858-7279 l(Y2812016 442572 23902 SERVICE STREET BILLING $WET 349 Appleton Street 349Appleton Street SFMM 0W.3UtE.DP Guam COY, Mv, ZP North Andover MA 01845 North Andover, MA 01845 JOB i;?ESCRiMON VENTILATION: Provide labor and materials to install (1 1) 6" X 16" rectangular aluminum soffit vents to increase ventilation in attic areas. Specify color: White or Only. NOTE: VENTED DRIP LDGE EXXiwrs wwLVER 11' IS AI.L CRU911iD AND No CU`r 'm R( mi-i IN sf,(Yrs. $275.£30 RISE Engineering sill apply all applicable, eligible incentives to this contract. You will only be billed the Net amount. Currently, for eligible measures, %ou nbia fins offers 75% incentive. not to exceed $2,000 per calendar year, and an incentive of 100°!x, for the Air Sealing measures up to the first $690 and an additional $340 if saving are justified by the a4tor. Icor the safety and health of your home's indoor air quality, s%c will be conducting a blower door diagnostic of the available air flax in your home both before the work is bcgun, and after the wwtherization wort: is complete. We will also contest a full assessment orihe combustion safety of your heating system and utter healer. This has a value of $90 and is at no cosi to you. Total atlovmble weatherization incentive is.S3,110, The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting theirmunicipality at the completion or this sunk. $90.00 1; " 'total: $3,486.65 Program Incentive; $2,849.91 Customer Total: $636.64 W E AGREE HEREBY TO FURNl5H SERVICES. COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICAMMS. FOR THE SUM OP ***Six Hundred Thirty-Six 8L 641100 Dollars $636.64 UPON ANIAL INSPECUON AND APPROVAL BY RISE £RING. CU3�WN@R AGREES 30 REIATAMUNTDUE IN FULL MMREUTOF I% WILL DE CHARGED MON'INLY ON ANY URPAM BALANCE YS. SEE REVM tIA'+O1MNTtNrdRtMVON ON GUARJVM,M RMMOF RECISKRI. SCHROULING, AND CONMCA',VtaEtrk." RASrK i)o N07 SIGN THIS CONTRACT IF THERE ARE £CES r " A DSIeNAA}RE• ESE CIS lE1k ACCEPmNCE *=:'via CCW :4 as Y rMNDRAWN BY us I: NOTE7,ECUMD WMIN DA&OFACCEMNCE ACCFP'MNCE OF Ca.PdW=.131E ASME PRICES, SPEtWItAVONS AND CCADf I M ARE 30SAWACIORY 1DUS AND ARE HEREBY ACCEPIED, YOU ARE AtMORMM 10 00 M VMRK DAYII. AS SPECIRED. PAYN£NTNYRL BE K%M AS OMMED ABOVE The Commonwealth of Massachusetts Department of Industrial Accidents 1 office of Investigations -I Congress Street, Suite 100 H-7 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Lebl A licaett Information Builders Services Group d/b/a Quality Insulation Name (Business/Organization/Individual): Address: 110 Perimeter Rd City/State/ Nashua NH 03063 Phone #: 603-324-1974 — F_ Are you an employer? Cheek.the appropriate bi a a general contractor and 1 1- Q 1 am a employer with 100 D employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity - [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance 5.0 We are a corporation and, its . officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling g. ❑ Demolition 9. ❑ Building addition 10. [:1 Electrical repairs or additions 1 I.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.✓❑ Other Weatherization *Any applicant that checks box #1 must also fill out the section below showing their workers compensation policy information. and then outside contractors must submit a new T Homeowners who this boy must attachedavit ting they are number.additional sheet showioing all ng the name ofthe sub -cont ac ors and state whether or not dthose avit ,entit es have h 'Contactors that p,Policynumber. employees. If the sub -contactors have employees- they must provide their workerscoo I am an emplover that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ACE American Insurance Company Expiration Date: 6/30/201 I Policy 9 or Self -ins. Lic. #: WLRC 48151553 q �� City/State/Zip: Jro. Job Site Address: ( cy declaration page (showing the policy number and expiration date). Attach' copy of the workers' compensation poli Failure to secure coverage as required under Set onas5well as c vil2A of MGLc152 can e penalties inthe form of STOP WORK ORDER penaltiesd to the imposition of criminal f and, fine fine up to $1.500.00 and/or one-year imprisonment, 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. _'ins and penalties of perjury that the informati' n provided above is true and correct I do hereby certify under the p 603-324-1974 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 Phone #• Contact Person: fenof o�erairs (dVume's sl -e g 10 Park Plaza - Suite 5170 Foston, Massachusetts 02116 Home Improvem&contractor Registration BUILDER SERVICES GROUP, IN RICHARD SCHWARTZ 260 JIMMY ANN DRIVE DAYTONA BEACH, FL 32114 SCA ? co 20 8 5-0511 3 fJ/tf: L'C9)Li?L04tllfP�JG O�(%(ZQ.yq�!/bC�� of Consumer Affiirs & Business Regulation BUILDER RICHARD SCHWAF 110 PERIMETER RD NASHUA, NH 03963 CONTRACTOR Type: Supplement Card Underweretary Registration: 179141 Type: Supplement Card Expiration: 6125/2018 .te Address and return card. Mark reason for change. .',ddress ❑Renewal ❑Employment f Lost Card License or registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid without signature CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10,25/20,6 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 have ADDITIONAL INSURED provisions or 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 Aon Risk Services Central, Inc. Southfield MI Office CONTACT NAME: (AIC.NNo. Ext): (866) 283-7122 (ac. No.): (800) 363-0105 E-MAIL ADDRESS: 3000 Town Center Suite 3000 INSURER(S) AFFORDING COVERAGE NAIC ti Southfield Mi 48075 USA INSURED INSURER A: Old Republic Insurance Company 24147 TruTeam Builder Services Groun. Inc. INSURER B: ACE American Insurance Company 22667 d/b/a Quality Insulation A TopBuild Company INSURER C: INSURER D: 110 Perimeter Rd Nashua NH 03063 USA INSURER E: INSURER F: DAMAGE TO RENTED $2,000,000 PREMISES Ea occurrence COVERAGES CERTIFICATE NUMBER: 570064230317 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. Limits shown are as requested LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM DD MMIDD LIMITS A X COMMERCIAL GENERAL LIABILITY MWZY 106/3U/2017EACH OCCURRENCE $2,000,000 CLAIMS-MADE❑X OCCUR DAMAGE TO RENTED $2,000,000 PREMISES Ea occurrence MED EXP (Any one person) $25,000 PERSONAL& ADV INJURY $2,000,000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 X POLICY ❑ PRO ❑ LOC JECT PRODUCTS - COMP/OP AGG $4,000,000 OTHER: A AUTOMOBILE LIABILITY MWTB 307519 06/30/2016 06/30/2017 COMBINED SINGLE LIMIT $5,000,000 Ea accident BODILY INJURY ( Per person) ANY AUTO BODILY INJURY (Per accident) OWNED SCHEDULED AUTOS ONLY AUTOS JXX HIREDAUTOS X NON -OWNED ONLY AUTOS ONLY PROPERTY DAMAGE Per accident LIAB OCCUR EACH OCCURRENCE AGGREGATE JUMBRELLA EXCESS LIAB CLAIMS -MADE DED RETENTION B B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/ PARTNER /EXECUTIVE OFFICER/MEMBEREXCLUDED� (Mandatory in NH) NIA WLRC47860180 All other States SCFC47860209 WI Only 06/30/2016 06/30/2016 06/30/2017 06/30/2017 X SPER OTH- TATUTE IER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached 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 ACCORDANCE WITH THE POLICY PROVISIONS. Town Of North Andover AUTHORIZED REPRESENTATIVE Building Department Attn: Donald Belanger` 1600 Osgood Street, Suite 2035 Q North Andover MA 01845 USA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD r` w. Massachuseft Depattrne nt of Pu lc Safer y Board of Building Regulatims and Standards Lice"w. C SL-"Itf5M Construction Sogsarviscw Specialty �ps�.y �,�p� Bfw�.ItiJ �PJp irg�5a��i0�iCldii4Y�g9A1i+1M1Yy'ly.�yiL..? DAAY'TONA BEAT Coyhmisslotw 0=612018 Construclion Supervisor Specialty Restricted to, CSSL4C - InsWatim Contractor Fallum to mss s curtest edition of the Massachusetts State Buittfing Cade is cause for revocation of tht llcasse. [DPS Licensing infomation visit VWWaMASS;Gt'fb113P8