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HomeMy WebLinkAboutBuilding Permit # 3/17/2015 BUILDING PERMIT t%ORT TOWN OF NORTH ANDOVER-­ 0 APPLICATION FOR PLAN EXAMINATION—— x Permit No#: Date,.R'eceived';;. ,t'll, TED Date Issued: 22� IMPORTANT:Applicant must,coMpf6fe alf�itemon tWS"page .......................... TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building 0 One family 11 Addition El Two or more family El Industrial El Alteration No. of units: Ig,Commercial epair, replacement E]Assessory Bldg El Others: El Demolition El Other ' ,W'S e X c e e g , �7 DESCRIPTION OF WORK TO BE OERFORMED:5?,. Identification- Please Type or Print Clearly' "I. I I I / OWNER: Name: NOdh wK �ogi�Jev Phone.] Address: 41 ..........__. ARCHITECT/ENGINEER Phone: Address: Rea-No,., FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: 'R51 -n FEE.-$_.._ Check No.: ReceilJt­No NOTE: Persons contracting with unregistered contractors,do not,have-;access t -the guaranty fund NORTH -Townof s E . I,­dOWWWWWAINndover AO � - �: I0% No. _4 � h ver, Mass, 2 A. o COCNICKl WICK y1. AORATEO � U BOARD OF HEALTH Food/Kitchen IT T LD Septic System �Ik I� .... BUILDING INSPECTOR THISCERTIFIES THAT ............. .......... 5'......�......... I.................................... ................... has permission to erect ..... buildings on ...AtJwo�. w.. a Foundation ..................... ..... .. .... . Rough rc� . ..r..�. . .-.. . .. �. . CJI. -F1j.�, to be occupied as . f ......... .. .. �.. t.�.� � `J•^••^•.11 Chimney provided that the person accepting this permit sh I in eve respect confor to the terms of the a1plication i Final on file in this office, and to the provisions of the-Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR - VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES 16 MONTHS ELECTRICAL INSPECTOR UNLESS_ CONSTRUCTION STARTS Rough Service ........... ..� �^................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Insurcomm Construction 3510 Lafayette Rd Portsmouth,NH 03801 603-430-7701 603-373-6214-Fax ici5@comcast.net Insured: Ethan Allen Property: 419 Andover St North Andover,MA 01845 Estimator: Neil Robbins Business: (603)430-7701 Business: 3510 Lafayette Rd Portsmouth, NH 03801 Contractor: Business: (603)430-7701 Company: Insurcomm Construction Inc. E-mail: ici4@comcast.net Business: 3510 Lafayette Rd Portsmouth,NH 03801 Claim Number: Policy Number: Type of Loss: Date of Loss: Date Received: Date Inspected: Date Entered: 3/16/2015 3:23 PM Price List: MAEM8X MAR15 Res toration/Service/Remodel Estimate: ETHANALLEN Insurcomm Construction 3510 Lafayette Rd Portsmouth,NH 03801 603-430-7701 603-373-6214-Fax ici5@comcast.net ETHANALLEN Display Room 1 LxWxH 22' 10" x 15' 3" x 8' DESCRIPTION QTY 1. 5/8" drywall-hung,taped, with smooth wall finish 332.00 SF 3. Drywall Installer/Finisher-per hour 10.00 HR Labor to feather and blend old drywall to new on walls and ceiling. 5 hours each surface 4. Batt insulation- 6" -R19-unfaced batt 184.00 SF 6. Polyethylene vapor barrier 184.00 SF 7. Detach &Reset Light fixture 9.00 EA 9. Remove Crown molding-2-piece-hardwood 57.13 LF Servpro removed 25% of the crown molding. The other 75%needs to be removed as the existing cannot be matched because of age and availability. 15. Crown molding-2-piece-hardwood 76.17 LF 11. Seal &paint crown molding, oversized- three coats 76.17 LF 16. Painter-per hour 2.00 HR Labor to paint sprinkler pipes 17. Seal the walls and ceiling w/latex based stain blocker- one coat 957.54 SF 18. Paint the walls and ceiling-two coats 957.54 SF 19. Casing-5" 40.00 LF 20. Seal&paint door/window trim&jamb-(per side) 5.00 EA 21. Remove Baseboard-3 1/4" 57.13 LF All walls were built after the carpet was installed so all baseboard sits on top of carpet. Base trim needs to be removed so remaining carpet can be removed 22. Baseboard-3 1/4" 76.17 LF 23. Seal &paint baseboard-three coats 76.17 LF 24. Floor prep-cutting carpet back to edge of wall after base trim removal 348.21 SF 26. Carpet pad 348.21 SF 27. Commercial carpet-heavy traffic 400.44 SF 52. Negative air fan/Air scrubber(24 hr period)-No monit. 6.00 DA Display 2 LxWxH 16' 9" x 15' 2" x 8' DESCRIPTION QTY 28. 5/8" drywall-hung,taped,with smooth wall finish 254.00 SF 29. Drywall Installer/Finisher-per hour 5.00 HR Labor to feather and blend old drywall to new on walls 30. Batt insulation -6" -R19-unfaced batt 134.00 SF 31. Polyethylene vapor barrier 134.00 SF 32. Detach&Reset Light fixture 11.00 EA 33, Remove Crown molding-5 3/8" to 6" 47.87 LF Servpro removed 25% of the crown molding. The other 75%needs to be removed as the existing cannot be matched because of age and availability. ETHANALLEN 3/17/2015 Page: 2 v Insurcomm Construction 3510 Lafayette Rd Portsmouth,NH 03801 603-430-7701 603-373-6214-Fax ici5@comcast.net CONTINUED-Display 2 DESCRIPTION QTY 34. Crown molding-5 3/8" to 6" 63.83 LF 35. Seal&paint crown molding,oversized- three coats 63.83 LF 36. Painter-per hour 3.00 HR Labor to paint sprinkler pipes 37. Seal the walls and ceiling w/latex based stain blocker- one coat 764.71 SF 38, Paint the walls and ceiling-two coats 764.71 SF 40. Seal&paint door/window trim &jamb-(per side) 2.00 EA 47. Trim board- 1" x 2" -installed(pine)-ceiling batten trim 64.00 LF 48. Seal&paint trim-two coats-ceiling batten trim 112.00 LF 41. Remove Baseboard-3 1/4" 47.87 LF All walls were built after the carpet was installed so all baseboard sits on top of carpet. Base trim needs to be removed so remaining carpet can be removed 42. Baseboard-3 1/4" 63.83 LF 43. Seal&paint baseboard-three coats 63.83 LF 44. Floor prep-cutting carpet back to edge of wall after base trim removal 254.04 SF 45. Carpet pad 254.04 SF 46. Commercial carpet-heavy traffic 292.15 SF 49. Remove Chair rail- oversized-5" 63.83 LF 50. Chair rail-oversized-5" 63.83 LF 51. Seal&paint chair rail-three coats 63.83 LF 53. Negative air fan/Air scrubber(24 hr period)-No monit. 3.00 DA Display 3 LxWxH 15' 3" x 11' 5" x 8' DESCRIPTION QTY 54. 5/8"drywall-hung, taped,with smooth wall finish 140.00 SF 55, Drywall Installer/Finisher-per hour 5.00 HR Labor to feather and blend old drywall to new on walls 56. Batt insulation -6" -R19-unfaced batt 92.00 SF 57. Polyethylene vapor barrier 92.00 SF 58. Detach&Reset Light fixture 8.00 EA 59. Remove Crown molding-5 3/8" to 6" 40.00 LF Servpro removed 25%of the crown molding. The other 75%needs to be removed as the existing cannot be matched because of age and availability. 60. Crown molding-5 3/8" to 6" 53.33 LF 61. Seal&paint crown molding, oversized-three coats 53.33 LF 62. Painter-per hour 3.00 HR Labor to paint sprinkler pipes 63. Seal the walls and ceiling w/latex based stain blocker-one coat 600.77 SF 64. Paint the walls and ceiling-two coats 600.77 SF ETHANALLEN 3/17/2015 Page: 3 Insurcomm Construction 3510 Lafayette Rd Portsmouth,NH 03801 603-430-7701 603-373-6214-Fax ici5@comcast.net CONTINUED-Display 3 DESCRIPTION QTY 65. Seal&paint door/window trim&jamb-(per side) 2.00 EA 66. Trim board - 1" x 2" -installed(pine)-ceiling batten trim 20.00 LF 67. Seal &paint trim-two coats-ceiling batten trim 66.00 LF 68. Remove Baseboard-3 1/4" 28.00 LF All walls were built after the carpet was installed so all baseboard sits on top of carpet. Base trim needs to be removed so remaining carpet can be removed 69. Baseboard-3 1/4" 53.33 LF 70. Seal &paint baseboard-three coats 53.33 LF 71. Floor prep-cutting carpet back to edge of wall after base trim removal 174.10 SF 72. Carpet pad 174.10 SF 73. Commercial carpet-heavy traffic 200.22 SF 76. Seal&paint chair rail-three coats 53.33 LF 77. Negative air fan/Air scrubber(24 hr period)-No monit. 3.00 DA Display 4 LxWxH 15' 3" x 12' 2" x 8' DESCRIPTION QTY 78. 5/8"drywall-hung, taped,with smooth wall finish 281.54 SF 79. Drywall Installer/Finisher-per hour 4.00 HR Labor to feather and blend old drywall to new on walls 80. Batt insulation-6"-R19-unfaced batt 96.00 SF 81. Polyethylene vapor barrier 96.00 SF 82. Detach&Reset Light fixture 7.00 EA 83. Remove Crown molding-5 3/8" to 6" 41.12 LF Servpro removed 25%of the crown molding. The other 75%needs to be removed as the existing cannot be matched because of age and availability. 84. Crown molding-5 3/8" to 6" 54.83 LF 85. Seal&paint crown molding,oversized-three coats 54.83 LF 86. Painter-per hour 3.00 HR Labor to paint sprinkler pipes 87. Seal the walls and ceiling w/latex based stain blocker-one coat 624.21 SF 88. Paint the walls and ceiling-two coats 624.21 SF 89. Seal&paint door/window trim&jamb-(per side) 3.00 EA 92. Remove Baseboard-3 1/4" 24.00 LF All walls were built after the carpet was installed so all baseboard sits on top of carpet. Base trim needs to be removed so remaining carpet can be removed 93. Baseboard-3 1/4" 54.83 LF 94. Seal&paint baseboard-three coats 54.83 LF 95. Floor prep-cutting carpet back to edge of wall after base trim removal 185.54 SF 96. Carpet pad 185.54 SF 97. Commercial carpet-heavy traffic 213.37 SF ETHANALLEN 3/17/2015 Page;4 Insurcomm Construction 3510 Lafayette Rd Portsmouth,NH 03801 603-430-7701 603-373-6214-Fax ici5@comcast.net CONTINUED-Display 4 DESCRIPTION QTY 98. Remove Chair rail-oversized-4" 54.83 LF Orig. Desc.-Chair rail-oversized-5" 99. Chair rail-oversized-4" 54.83 LF Orig. Desc.-Chair rail-oversized-5" 100. Seal &paint chair rail-three coats 54.83 LF 101. Negative air fan/Air scrubber(24 hr period) -No monit. 3.00 DA Display 5 LxWxH 24' 5" x 15' 4" x 8' DESCRIPTION QTY 102. 5/8" drywall-hung, taped, with smooth wall finish 288.00 SF 103. Drywall Installer/Finisher-per hour 4.00 HR Labor to feather and blend old drywall to new on walls 104. Batt insulation-6" -RI -unfaced batt 192.00 SF 105. Polyethylene vapor barrier 192.00 SF 106. Detach&Reset Light fixture 11.00 EA 107. Remove Crown molding-5 3/8" to 6" 59.63 LF Servpro removed 25%of the crown molding. The other 75%needs to be removed as the existing cannot be matched because of age and availability. 108. Crown molding-5 3/8" to 6" 79.50 LF 109. Seal &paint crown molding,oversized-three coats 79.50 LF 110. Painter-per hour 3.00 HR Labor to paint sprinkler pipes 11 1. Seal the walls and ceiling w/latex based stain blocker-one coat 1,010.39 SF 112. Paint the walls and ceiling-two coats 1,010.39 SF 113. Seal &paint door/window trim &jamb-(per side) 4.00 EA 114. Trim board- 1" x 2" -installed (pine)-ceiling batten trim 48.00 LF 115. Seal &paint trim-two coats-ceiling batten trim 156.00 LF Ceiling has beams running across,Crown molding is on the perimeter of the ceiling as well as both sides of each beam 126. Trim board- 1" x 4" -installed (pine) 40.00 LF 116. Remove Baseboard-3 1/4" 36.00 LF All walls were built after the carpet was installed so all baseboard sits on top of carpet. Base trim needs to be removed so remaining carpet can be removed 117. Baseboard -3 1/4" 79.50 LF 118. Seal&paint baseboard-three coats 79.50 LF 119. Floor prep-cutting carpet back to edge of wall after base trim removal 374.39 SF 120. Carpet pad 374.39 SF 121. Commercial carpet-heavy traffic 430.55 SF 125. Negative air fan/Air scrubber(24 hr period)-No monit. 4.00 DA ETHANALLEN 3/17/2015 Page: 5 Insurcomm Construction 3510 Lafayette Rd Portsmouth,NH 03801 603-430-7701 603-373-6214-Fax ici5@comcast.net Display 6 LxWxH 15'4"x 14' 10" x 8' DESCRIPTION QTY 127. 5/8" drywall-hung,taped, with smooth wall finish 181.33 SF 128. Drywall Installer/Finisher-per hour 4.00 HR Labor to feather and blend old drywall to new on walls 129. Batt insulation-6" -R19-unfaced batt 120.00 SF 130. Polyethylene vapor barrier 120.00 SF 131. Detach&Reset Light fixture 9.00 EA 132. Remove Crown molding-5 3/8" to 6" 45.25 LF Servpro removed 25%of the crown molding. The other 75% needs to be removed as the existing cannot be matched because of age and availability. 133. Crown molding-5 3/8" to 6" 60.33 LF 134. Seal &paint crown molding,oversized-three coats 60.33 LF 135. Painter-per hour 4.00 HR Labor to paint sprinkler pipes 136. Seal the walls and ceiling w/latex based stain blocker-one coat 710.11 SF 137. Paint the walls and ceiling-two coats 710.11 SF 138. Seal &paint door/window trim&jamb-(per side) 4.00 EA 139. Trim board- 1" x 2"-installed (pine)-ceiling batten trim 27.00 LF 140. Seal&paint trim-two coats-ceiling batten trim 81.00 LF Ceiling has beams running across, Crown molding is on the perimeter of the ceiling as well as both sides of each beam 141. Casing-4"-hardwood 20.00 LF 142. Remove Baseboard-3 1/4" 45.25 LF All walls were built after the carpet was installed so all baseboard sits on top of carpet, Base trim needs to be removed so remaining carpet can be removed 143. Baseboard-3 1/4" 60.33 LF 144. Seal &paint baseboard-three coats 60.33 LF 145. Floor prep-cutting carpet back to edge of wall after base trim removal 227.44 SF 152. Underlayment- 1/2"BC plywood 227.44 SF Plywood laid over tile so carpet and pad can be installed 146. Carpet pad 227.44 SF 147. Commercial carpet-heavy traffic 261.56 SF 151. Negative air fan/Air scrubber(24 hr period)-No monit. 4.00 DA Display 7 LxWxH 29' 9" x 15' 8" x 8' DESCRIPTION QTY 155. Remove Acoustic ceiling the 349.56 SF removal of existing as it cannot be matched due to age and new depth for installation 157. Acoustic ceiling tile 466.08 SF 158. 5/8" drywall- hung,taped,with smooth wall finish 135.00 SF 168. Drywall Installer/Finisher-per hour 5.00 HR Labor to feather and blend old drywall to new on walls 159. Batt insulation-6" -R19-unfaced batt 60.00 SF 160. Polyethylene vapor barrier 60.00 SF ETHANALLEN 3/17/2015 Page: 6 n r- Insurcomm Construction 3510 Lafayette Rd Portsmouth,NH 03801 603-430-7701 603-373-6214-Fax ici5@comcast.net CONTINUED-Display 7 DESCRIPTION QTY 161. Seal the walls and ceiling w/latex based stain blocker-one coat 1,192.75 SF 162. Paint the walls and ceiling-two coats 1,192.75 SF 163. Remove Crown molding-4 1/4" 189.75 LF 164. Crown molding-4 1/4" 198.83 LF The ceiling has beams running across it so the crown encased the perimeter of the ceiling as well as both sides of each beam 165. Seal &paint crown molding,oversized-three coats 198.83 LF 166. Detach& Reset Light fixture 23.00 EA 167. Detach&Reset Chandelier 1.00 EA 169. Casing-5" 68.00 LF 170. Seal &paint door/window trim &jamb-(per side) 7.00 EA 171. Remove Baseboard-3 1/4" 16.00 LF 173. Baseboard-3 1/4" 90.83 LF 172. Seal&paint baseboard-three coats 90.83 LF 174. Negative air fan/Air scrubber(24 hr period)-No monit. 4.00 DA 179. Floor protection-self-adhesive plastic film 466.08 SF Attic LxWxH 118' x 15' 5" x 4' DESCRIPTION QTY 180. Batt insulation- 8" -R25-unfaced batt 944.00 SF 181. Insulation Installer-per hour 6.00 HR Additional labor to work in crawlspace 182. Underlayment- 1/4"BC plywood 944.00 SF 184. Seal the ceiling w/latex based stain blocker-one coat 1,819.17 SF 185. Paint the ceiling-two coats 1,819.17 SF Exterior Formula Elevation 96'x 8' x 0" DESCRIPTION QTY Vinyl siding needs to be replaced due to damage from ice dam 186. Remove &Replace Siding-vinyl 768.00 SF 188. Two ladders with jacks and plank(per week) 4.00 WK 4 sets for 1 week 189. General Laborer-per hour 10.00 HR Labor to protect shrubs ETHANALLEN 3/17/2015 Page: 7 Insurcomm Construction 3510 Lafayette Rd Portsmouth,NH 03801 603-430-7701 603-373-6214-Fax ici5@comcast.net General conditions DESCRIPTION QTY 190. Dumpster load-Approx. 30 yards, 5-7 tons of debris 1.00 EA 191. Cleaning Technician-incl, cleaning agent-per hour 32.00 HR Labor for daily cleanup 193. Commercial Supervision/Project Management-per hour 40.00 HR 194. Electrician-per hour 8.00 HR Labor to re-fasten all floating outlets and switches and perform electrical check Grand Total 70,928.87 Neil Robbins Grand Total Areas: 5,666.00 SF Walls 3,848.98 SF Ceiling 9,514.98 SF Walls and Ceiling 3,848.98 SF Floor 427.66 SY Flooring 841.67 LF Floor Perimeter 2,356.67 SF Long Wall 1,628.33 SF Short Wall 841.67 LF Ceil.Perimeter 0.00 Floor Area 0.00 Total Area 0.00 Interior Wall Area 0.00 Exterior Wall Area 0.00 Exterior Perimeter of Walls 0.00 Surface Area 0.00 Number of Squares 0.00 Total Perimeter Length 0.00 Total Ridge Length 0.00 Total Hip Length ETHANALLEN 3/17/2015 Page: 8 - Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contrctor Registration Registration: 145192 i Type: Private Corporation Expiration: 1212212416 Tr# 260463 INSURCOMM CONSTRUCTION INC. _-- -___ --- NEIL- ROBBINS 3510 LAFAYETTE RD. SUITE 4 PORTSMOUTH, NH 03801 Update Address and return card.Mark reason for change. Address 1 Renewal Employment Lost Card -- 1 , :F,��drr�r,Ntr��r{f c ✓�rr xxclusecs License or registration valid for individul use only `� office of Cousumer Affairs&Business Regulation before the expiration date. If found return to- IMPROVEMENT o:I PROVEM1ENT CONTRACTOR Office of Consumer Affairs and Business Regulation -- egistration: 145192 Type: 10 Park Plaza-Suite 51.70 xpiratian; 1212212018 Private Corporation Boston,MA 02116 INSURCOMM CONSTRUCTION INC: r NEIL ROBBINS 3510 LAFAYETTE RD.SUITE 4 PORTSMOUTH,NH 03801 Undersecretary Not valid without signature Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS4KWDM S sv.T•I:ti q rll�u. ,-� 3510 LAFAY19 s PortssON&N Expiration Convnissioner 07/13/2015 cwwl Office of Consumer,Affairs and business Regulation 10 Park Plaza- ;quite 5170 Boston, Massac , etts 02116 Rome Improvement C!t for Registration .tion 1,w Registration: 145192 Type: Private Corporation Expiration: 12/22n..016 Tr# 26043 INSURCOMM CONSTRUCTION INC. ROBBINS 3510 ILAFAYETTE RD. SUITS 4 PORTSMOUTH, NH 03801 _.___... ..... ....... . Update Address and r rtaa ,...._on f p rn card,Mark reason Pur chane, U I_. Address Renewal ISrrrptoyrrrent " " t.astard License or registration valid for iudividul use only Office ofConsurner Affairs&fta NS$Re9011160n before the expiration date. If found return to: ME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation egtisfttton: 145192 Type. 10 Paris Plaza»Suite 5170 xpiration: 12t"16 Private Corporation Boston,ARA 02116 INSURCOMM CONSTRU&"CION INC, NEIL. ROBBINS 3r.10 LrAFAYETTE RE).sulTE 4 PORTSMOUTH,NH 038011 Undcnteretary Not valid without signature y ORM a; AUTHORIZATIONIV ImurcomM a _ ? . t0 AndO 8 . ,. yo requesis '11,00140 Oil .O: `: O fmirmwo, C44r$mny ojwl enowcomm iogroo on, � w ► fb, A o ; rNO tm*nfood that mm P" y reww"V6 for aniand l `v n ,. - The- ffab4ify of y, Willed to 0' s r g p' ,R de j it ot rox.4"l la t £ tfthr, ut4$ and ,n y R3 cust � s "li ' htghest raja, W by law- ust-1 f fee jf,,ezrj ^q {sg „y¢g( y ¢� T _ ff'' T t y Dar '.. -mom F �3 . k � � y The Commonwealth of Massachusetts Department of IndustrialAccidents 7 - - 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LelZibly Name (Business/Organization/Individual): jiJ�CI�(��G1( Address: 37(0 LA+"t-TTe R> �)':T6 4 City/State/Zip: Ytl i 5 tt t iT ,-� Phone#: (00 ' 4- 36 W 177a 1 Are you an employer?Check the appropriate box: Type of project(required): J 1. I am a employer with '0 employees(full and/or part-time).* 7. New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. F1 Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.[:]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.[]'Other W6f12�L c{uf - 152,§1(4),and we have no 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. tContractors 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 jab site information. Insurance Company Name: l 188 Ty vfiv�( Policy#or Self-ins.Lie.#: (� �r� Expiration Date: 1 t! 7LK Job Site AddressAl`1 AVl70f P, City/State/Zip: I`�f Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certQ under the pains andpenalties of perjury that the information provided above �i�true and correct. Signature: Date: Phone#: 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#: DATE.(MM/DD/YYYY) A�® CERTIFICATE OF LIABILITY INSURANCE 03/15/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT CHAD HANCOCK NAME: KANE INSURANCE PHON o Ext); 603-433-5600 �� No): 603-433-0007 242 STATE STREET E-MAIL CHAD KANEINS.COM ADDRESS: PORTSMOUTH,NH 03801 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: LIBERTY MUTUAL INSURED INSURER B: ROCK HILL INSURANCE CO INSURCOMM INC., FIRST RESPONSE CLEANING INSURERC: AND RESTORATION INSURER D: 3510 LAFAYETTE RD, STE 4 INSURER E: PORTSMOUTH, NH 03801 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Y EXP INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM/DD/YYYY MM/DLICY EFF DY LIMITS LTRME WVD A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 '.. X CLAIMS-MADE NJ OCCUR BKS56387675 11/7/2014 1/7/2015 DAMAGE TO RENTED 300000 PREMISES Ea occurrence $ s MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 '.. GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY 1 PRO F—] LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000000 Ea accidents ANY AUTO BA8999876 11/712014 111712015 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOSX AUTOS HIRED AUTOS Jt NON-OWNED PROPERTY DAMAGE S AUTOS Per accident $ A X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE US056387675 1117/2014 1/7/2015 AGGREGATE $ 1,000,000 '..... DED I X I RETENTIONS 10,000 $ A WORKERS COMPENSATION X ,... AND EMPLOYERS'LIABILITY STATUTE EERER H ANY PROPRIETOR/PARTNER/EXECUTIVE YIN NIA WC8999776 11/7/2014 1/7/2015 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 B POLLUTION POLICY RPL122014 12/20/201412/20/2015 PER OCCURRENCE:$1,000,000 AGGREGATE: $2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) '.. **ACTIVITIES USUAL AND CUSTOMARY TO BUILDING CONSTRUCTION,AND FIRE,WATER,AND MOLD REMEDIATION. **WORK TO BE PERFORMED AT ETHAN ALLEN,419 ANDOVER ST,N ANDOVER,MA 01845. CERTIFICATE HOLDER CANCELLATION CITY OF NORTH ANDOVER MA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 MAIN ST ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER,MA 01845 AUTHORIZED REPRESENTATIVE CHAD A HANCOCK r. ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD