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HomeMy WebLinkAboutMiscellaneous - 907 DALE STREET 4/30/2018 (2)Location s-� ��`� z— No.Date ` 6 N°"T" TOWN OF NORTH ANDOVER a Certificate of Occupancy $ 41 r Building/Frame Permit Fee $ cMusE� Foundation Permit Fee $ r�� a 0 s/7o sr�� �O U 0,t) /" Perm! Fee $ . f Sewer Connection Fee $ �� �� �NlafflOb�"he�flin Fee $ TOTAL C7� $ 1991 �-- Building Inspector Div. Public Works La W N W Z i o a 0 N z a � N W LC W F a z x J U � a m �L r- 0 J LL O W a 4 r u Z a a u 0 00 m ui WW u z a� N0 _a �I Z�z 0 IL J 0 f- LLZO Ooa N—N Z Omu NWQ w 0 ..a. 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N0111 -1 ANDOVEIt 0 •;,Ss4 HU9E44 UI\'ItiION OF PLANNING & COMMUNITY DEVELOPMENT KAREN I I.P. NI -A -SO N, I)IIZI:(:"1 OIZ 12O M;lilI slif.(•t N0,1II I AI If )vrI, alt Ltiti711'I 11 IF1'I Iti O I ii•t 1111 7) (its i 4777, In accordance with the provisions of MGL c 40, S 54, a condition of Building I'crnrit Number is that the debris resulting fro►rt this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S 150A. The debris will be disposed of in: ignature ul 1'crntit Applirrnt Da to - NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Location 9,C �? ✓_�� L I,�- - ),—t No. �"`' �/ t" Date i N°R'" TOWN OF NORTH ANDOVER O ,� p Certificate of Occupancy $ Building/Frame Permit Fee $ 'ss�cM�sE`� Foundation Permit Fee $ �t/zGot= ✓� Other Permit Fee $ 2 G Sewer Connection Fee $ Water Connection Fee $ TOTAL $ c Building Inspector Div. 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COMMONWEALTH OF BOSTON, so MASS. 02215 MASSACHUSETTS NSE LICE CONSTR . SUPERVISOR EXPIRATION DATE LIC NO. 6 EFFECTIVE DATE 01!31/1993053171 RESTRICTIONS 02101 199t) %oWE SPOLAK STEPHEN M BRADFORD 51 SOUT" 3, E VA C1845 NO A Y R HDO SS 015-50-7765 FEE: PHOTO (BLASTING opR ONLY) �E�o 13Y LICENSEE AND OFFICIALLY .0. 00 NOT VALID UNTIL SIGN LIFE Of E COMMISSIONER SIGN STAMPED HEIGHT� DOBI OF LICENSEE 211'511958 SIGNATURE THIS DOCUMENT MUST BoEF CAFtRIED ON THE PERSlo.G - !��MMISSIONEFI THE MOLDER WHEN OCCUPATION IN THIS OCCU E OTHERS RIGHT THUMB PRINT 200M.2-8781429 t )7 1wo `ii U_ BUILDING PERMIT TOWN OF NORTH ANDOVER / APPLICATION FOR PLAN EXAMINATION Permit No#: -7 016 Date Issued Date Received ANT: Applicant must complete all items on this /0��,�LED ,f / 6 � 4 PROPOSED USE y�i/i. Residential LOCATION cft7rl _bo�je_ � � �� 4q&vQ,r MA ©t?YS Print PROPERTY OWNER �BttYlCas�rc��t Print 100 Year Structure yes Ono MAP `��G PARCEL: / �� ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Buildingne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ A eration No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg_ ❑ Others: ❑ Demolition ❑ Other w s g - ©`Septic 1Nell _ Flootlpl`aira Wetlands nj 1Natershed�'®istnct; _,,ptv DESCRIPTION OF WORK TO BE PERFURIIIItu: � Sf�'l`� s.e- a�Jej Identification - Please Type or Print Clearly OWNER: Name: • Phone: 9 7$-G??-aX inn �.. C f]c �vr�C►n Address: e7 J7 _ A 4 0 19 Y, - Contractor Name: EC6- f- wr- �, �� Phone: `r7 Email 4 - Address: 308 zra, Supervisor's Construction License: C-3- Exp. Date: 1 a �_o >s' Home Improvement License: / 38569 Exp. Date: V/5(40/7 ARCH ITECT/ENGINEE { Address: Phone:, 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: $ /S yS©. 0()J FEE: $ / y�r_ Check No.: �_Receipt No.:%3 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty f and Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimaning Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed On Signature. Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments COnnservation Decision: Comments Whter & Sewer Connection/Signature & Date Driveway Permit ]DPW Town Engineer: Signature: Located 384 Osgood Street \ F,IREDEPArR�TMERIT�` « ' v ' „ - - , - ��:� a ,� �, ,T:emptD.urnpster�4onisiteryes, :..ono r:� r.i t Lr&7E�ed aty1124 MainESt%eet " n i.,.fa r `� ,• t` y { eDeparc rtmenasignature/date Jr`se �" r w .�` Tp_c"'`•`'-"`' ^`i COMMENTS t Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL; Movement of Rueter 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.$1o0-$1000 fine Doc.Bnildin,; Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits OTE: Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract 45 Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products 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) 4, 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 Doc: Building Permit Revised 2014 Location No. If 7/ %6 Date Check # f �/ TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $���' Foundation Permit Fee $ Other Permit Fee $_ . TOTAL $ Building Inspector < C m - C --I-h < CD y -� CD0-0 •CD n • 5 = CD , . Cl) CD � N p ' cp CD 2 �• C CL m a D O�• C ' N C.) y o rt CD W �' mCD 0 ny C =_. C D 0� ;zZ'� � oo �,�� - �;.� CL o �ic to� � o0U, o Ill c � � rt 'a 'O Q v, Q- 0 O p n c 0 0� .a N. < CD t0 � o T ~ N _ Q NZ cr 2)Z Up CD CD CD O O ZCD rt co 4 CD —S CL v SCA• y 3 .� = N —I 0 O AJCCD CD n N CDry .••� z O CDC C zi ° "D u 01 O =rt 4 cv. I� ow 0 c fD 0s W T ;u T N ;q T �o T (7 .Z7 m In T UV1 p pr o m 1 m - z O c (D p N O C 3 d O c 5.0 N c j N :3 O c S O c Q �. O m "o n O O M •n m D 3A{m zO D m m m Q A Z m z C Z C Z m m S m 3 W O 0 m D = cv. I� ow 0 c fD 0s FREE ESTIMATES PROPOSAL Construction Supervisor Lic. # CS102663 FULLY INSURED H.I.C. Reg, # 138569 WMGHT RooFINo-GUTTERS AND HOME u"ROVEMENT All Types of Roofimg 81: Gutters 350 BERRY STREET o NORTH ANDOVER, MA 01845 TELEPHONE: 978-687-2247 PROPOSALSUBMITTEDTo J�ca knav PHONE DME `- ° 683 35"1 18/0/5- STREET `i0'7 bcdc 1-3f, JOB NAME l LOCATION S 4M � CITY, STATE ANDaP CODE ppm ,{� i 1`� D a �vw ,m 1d6gJ JOBSTART OATEE V Roof�t r /� C j i_ is f -C IQ - "o� 0-) � ���r 3 C y � 000 c.s e Jfrip ' t 'U)1 � w� e f de c . U.S 6 © � to f c)d� ak .e# eo a t I eave-s� Ct t n. 1,f ,a.ltev e c v-0 it k dLr ice► y� Iu s u Ply r yet /AQ'y' (Z46,. c�j M,� v Y-o`tom t�,3 43"p 4'oG� u 4- s1��-r o `T` �p �:� Wood. Re-- )moi C�i'iw /may jtl `t- k L+s+ P --W tai cep a {.'ver,+.�b� oo-�.s v i^ pt� e -d s OL � � A� k� �Lv'V'^LAY vW (J I h i L✓i �,ix 4uie (�j J OK i�ljl ifh t �. i is it V b qtr r -"l L Yt lYl YY Z p S► vt v�s�,� 4 l t `511 e�4 n Cj Ci;U. '-p I d uV'j L. �� Q �•� �v- �- a ` , �"�' cue-sc 1QAa 3(v sp C�) XV00 cc I 110�14/ 1/0 01 010 re -lead &ire, We PropOSC hereby to furnish material and labor - complete in accordance With above specifications, for the sum of: $ 5-0.0 0 Payment to be made as follows: -i -- A f b�to, kice ©nGQ- C®,�,�, (eaeLl'r�Sff'c{J. 00 �# S10- 141 Ali material is guaranteed to be as speci ' ork to be completed in a substantial workmanlike r s submitted, per standard practices. Any alteration or deviation from Authorized _ above specifications involving extra costs will be executed only upon written orders, and will become an Signature extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our workers are fully proposal maybe This r p covered by Workmen's Compensation Insurance. Non payment by agreed party may result In litigation NOTE: TE: withdrawn is r if not accepted within with penalties including court cost and compensation both real and punitive. edays. Acceptance of Proposal - The above prices, specifications and conditions are satisfactory and are hereby accepted, making this a valid contract. You are authorized to do the work as specified. Payment will be made as outlined. • - - • ' .%Si1l7/li i Signature Signature (92, — W r L o,�,+ G- ��e_r-s - — a This form satisfies all basic requirements of the state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of "A Massachusetts Consumer Guide to Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information contractor iniormatton Name (1 � ,, ( �Q 0.h Cyt.J �Wl�.h Company Name` (+ ��► N.� J StreetdresoPost Office ConVactor/ lesperson/Own�� eon���os*� - SG 1j rte Cityfrown State Zip Code N, 411&Ov'a4-- (AA- 0105- Business Address (mus nclude a street address) N. 4iA L/m Vtti & 6) ! 8 LI- D ytimePboae Evening Phone �� 683-9351 City/Town State Zip Code /VVer At A ®t SYS - M filing Address (It different from above) Business Phone9 ederal Employer ID or S.S. Number Q/ Lan tequirn that most home }IDmeCoatraao,Reg.Nnmber B/Uon data tmpr d rglstt fl.. mb have a valid ssytstmtfon Dumber n The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed, specifying the type, rand, and grade of materials to be use use additional sheets if necessary.) Required Permits - Tbefollowing but7dingpetmits are required Proposed Start and Completion Schedule -The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work- MGL orkMGL chapter 142k) g/3� /, // J Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule % Sys®. i3� The Contractor agrees to perform the work fiunfsh the material and labor specified above for the total sum o y J. Payments will be made according to the following schedule: $ 515-0. 00 upon signing contract (not to exceed 1/3 ofthe total contract price g the cost of special order items, whichever is greater) or upon $ by—_. / / or upon $/ (%0 b 0 upon completion ofthe contract. (Law forbids d ing full payment until contract is completed to both party's satisfaction) The following material/equipment must be special 5 to be paid for �- ordered before the contracted work begins in order to meet the completion schedule.('") S o be paid for NOTES: (*) Tncluding all finance charges (**) Law requires that any deposit or down -payment required by the contractor before work begins may not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty -Ts an express warranty being provided by the contractor? No ❑ Yes (all terms of the warranty must be attached to the contract) Subcontractors - The contractor agrees to be solely responsible for completion ofthe work described regardless ofthe actions of any third party/subcontractor utilized by the contractor. The contractor fiuthrer agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear. • Make cure the contractor has a valid Home hnorovement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm: coverage, or ask to see a copy of a "proof of insurance" document. • Know your rights and responsibilities. Read the Important information on the reverse side ofthis form and get a copy oftlre Consumer Guide to the Home Improvement Contractor Lwo. You may cancel this agreement if it has been signed at a place other than the contractor's nomad place of business, provided you notify the contractor in writing at Ids/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight ofthe third business day following the signing ofthis agreement Seethe attached notice of cancellation form for an explanation ofthis right. DO NOT SIGN THIS CUiVT ACT Ik"I'. ERE; AXE AN x t3LANK S AC LNH I Two identical copies of du contract mustbe completed and signed. Ona copy should go to due homeosm to ower a py should : ept by the connector. teowner' Signature —contractor's Signature 76 Date Date f` The Commonwealth of Massachusetts _.P....ririt Form_ .-- --- Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 �} Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le6bly Name (Business/Organization/Individual): Address: 3 5 0 B City/State/Zip: v4LMA ©$ Phone #: q V - 07 -d -)_V 9 AVu an employer? Check the appropriate box: 4. I am a contractor and I Type of project (required): 1.am a employer with general g 6. ❑ New construction employee nd/or part-time).* (fulI have hired the sub -contractors 2. ❑ am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g, ❑ Demolition workingfor me in an capacity. y P n'• employees and have workers' 9. ❑Building addition [No workers' comp. insurance required.] comp. insurance.t 5. ❑ We are a corporation and its 10. El Electrical repairs or additions K ❑ I am a homeowner doing all work officers have exercised their 11. E]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ f repairs insurance required.] t c. 152, § 1(4), and we have no 13. Other S'4c'r� IV, O r employees. [No workers' 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. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: L /l D,t/' rn rt _ Policy # or Self -ins. Lic. #: %�J C � ,31$ 387 ( Expiration Date: 9 30o2n I S Job Site Address: ?01 "bode -3-41 City/State/Zip:-Al.&c- mpf Q (g yg- 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 erification I do hereby certi ggder the 4ains and enalti erjury that the information provided above is true and correct. - g Q ._ - _ ianafirre• ' IA LOP]d hs Phone #: q7/P- 6 S? -OUY7 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an ••••••••^ • 1 7-,M -=A A (11MITA WIT A PrInirAntnr I IIP. QATTIP. rtOht 1Q not mitmmnfirn IItr AifnrriPri to A ContracioI, noweveI. ine contractor would nave to resolve any dispute ne)SCe has with both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. I The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be reouired 1`^ --',. °;++.-• --,.,h orA;t at;^ „rn..M-1 r Massachusetts General Laws: chanter 2A. NOTTf F' ThP .QiunafirPQ nfthP nsrtias AhnvP nnnly only to tnP narPPmPnt nft11P nart;PQ to altPrnat;— rl;on,itP resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. lunmoc�,raria p;n1,tQ A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by lav,-. o OMCOV,13 S -"-G SMUG uiCir Owu building perinitS are automatically ext-Auded fCom all Guaranty Fundprovisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as thev do not restrict a homeowner's basic consumer rights. I£vou have questions about Your consumer/homeowner rights. contact the Consumer Information. Hotline (Ii0ed helnur) Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been d;llPA in nr mar_YP i aQ vni t APiPtP l nr not Annlinal+lP ()r P oris . of o; P i ...> V A'.n f r...:�t et.,..t . ens -'sraur be given to the owner and the other kept by the contractor. Any modification to the or;mnai c^atr2ct mu.- be ...J i< and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, andthe three day rescission period has expired. Ace eierated rayments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself c _ J.; ranci2,,1v +msecure. the contractor may require that the balance of funds not vet due he placed in a ioint escrow account as a prerequisite to continuing the contracted work Withdrawal of funds from said account would reo_uire the signatures of both parties. Additional 1.nformatiou if you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer iniormarion riotime Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at hgap /rvww.mass.gov/ocabr/ If'you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at http://www.mass.eov/ocabr/ Go online to view the status of a dome Improvement Contractor's Registration: http•//db state m&us/homeiLnprovement/licenseelist asR For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General 617-727-8400 Better Business Bureau 508-652-4800, 508-755-2548 or 413-734-3114 Version 2.1 -11/22/2010 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage: Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to 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 Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 7-2010 www.mass.gov/dia ACORV CERTIFICATE OF LIABILITY INSURANCE QWM DAg z1� ) 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 T A SULLIVAN INSURANCE AGENCY INC 135 MERRIMACK ST METHUEN, MA 01844 CONTACT NAME: PHONE FAX Ext A/C No E-MAILo ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: LM Insurance Corporation 33600 INSURED SCOTT WRIGHT DBA WRIGHT GUTTERS INSURER B: INSURERC: INSURER D: 350 BERRY STREET INSURER E: NORTH ANDOVER MA 01845 INSURER F: Cr)VFRAt;FS CERTIFICATE NUMBER: 9.r,RA97.F9 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DDIYYYY MM/DD/YYYY LICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE F-1OCCUR DAMAGE TO RENTE (Ea occur ence) $ -PREMISES MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRODUCTS-COMP/OPAGG $ POLICY1:1 PRO ❑ LOC JECT OTHER: A AUTOMOBILE LIABILITYaccident) COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) S ANY AUTO BODILY INJURY (Per accident) S ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION$ $ A WORKERS COMPENSATION WC5-31S-387187-014 9/30/2014 9/30/2015 I PER 0 �/ STATUTE ER AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE❑Y OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N / A E.L. EACH ACCIDENT $ 100000 E.L. DISEASE - EA EMPLOYEE $ 100000 E.L. DISEASE - POLICY LIMIT $ 500000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) THE WORKERS' COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR SCOTT WRIGHT. This certificate cancels and supersedes all previously issued certificates, only as they relate to workers' compensation coverage. WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. GERTIFIGAI E MULUEK %1A114%1CLLM i 1%J" -- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF NORTH ANDOVER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATTN: LOCAL BUILDINC INSPECTOR BRIAN LEAF ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET, BLDG 20, SMITE 2035 NORTH ANDOVER MA 01845 AUTHORIZED REPRESENTATIVE ✓� ^ � g � ��G/�� LM Insurance Corporation V 99513-LU14 AUUKU L UKF'UKA I IUN. Ali rlgnLs reserveO. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 25682752 1 1-387187 1 14-15 WC I shankar.gadale®libertymutual.com 1 7/22/2015 11:28:27 AM (PDT) I Page i of 1 soard al, 31A; iA­ ­,S 371d Slal­;ards L e se M102M SOMWWRMHT 350 BERRY ST O8H2aOiS office of Cmwmtr AM&$ Ife Dusben RVA%dm iAE HURDVEMWCOUTRACTOR Avalstra"m 138M Type: 4114017 OaA VAWGWGUT TERS WA)TT WRIW 350 WARY ST. s. NO. MDOVEFL MA 01845