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Home My WebLink AboutBuilding Permit # 8/11/2015 0.1 NotaryBUILDING PERMIT TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received TED Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION -9 0 V) t PROPERTY OWNER V1 �27 C-1 10Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential [I New Building WZne family 11 Addition El Two or more family El Industrial El Alteration No. of units: El Commercial EZ,,W6pair, replacement El Assessory Bldg El Others: 11 Demolition El Other % DESCRIPTION OF WORK TO BE PERFORMED: 4-C) L Identirication: Please Type or Print Clearly 3.,V7 Phone: OWNER: Name . L Le Address:--12 Me, ,, -7 el J* Contractor Name: .. /t> C 46feA Phone: G, 3 5 9 0,1 Email: e L (7 Address: Supervisor's Construction License: -Exp. Date: Home Improvement License: Exp. Date: 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: Check No.: 2I Receipt No.:_ 2-,rl t ct,3 NOTE: Persons contracting wiz unregistered contractors do not have access to the guaral fund 1 7 S n1p hiractort-g IF M AM O TH 4"4over town of Anu - 0 16 3& -2-61 ver, > 0� c0cp1C I..C. �. A®`SRT E® 11 BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System • k�;:THIS CERTIFIES THAT ..... BUILDING INSPECTOR Foundation has permission to erect ................:..:...... buildings on .... ... �. ►�!.a�Slt. W -= Rough to be occupied as ........... �✓ .... ...... �. � ... ............................................ Chimney provided that the person accepting t/ispermit shall in every respect conm to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final EXPIRESPERMIT IN 6 MONTHSELECTRICAL INSPECTOR UNLESS CONSTRUCTIOAR Rough i Service ...........d..... ......... .. ..: ............................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Buildin Rough is lay in a Conspicuous Place on the Premises — Do Not Remove Final o Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector.- Burner Street No. Smoke Det. Water/Ice Damage reconstruction project: Evangelista Family 28 Morning Side Ln. N. Andover MA Exterior • Roof ® Remove and replace roof on main section of the home 26.1 square • Strip 2layers 2900.00 • Drip edge 250.00 • Ice and water 1000.00 • Roofing and roofing felt 5800.00 • Ridge vent 400.00 Total roofing 10,350.00 • Garage • R+R 16sf 5/8° blue board and plaster ■ Minimum charge 120.00 15t floor • Kitchen • Ceiling sf 302 • Walls sf 504 • Floor 269 • Perimeter 61 If perimeter Water damage due to ice damns leaked in through kitchen ceiling and light fixtures.Also there is a swollen seam in the back of the kitchen near the midline of the home. Ceiling • Minimum plaster repairs 120.00 • Replace 2 water damaged recessed lights 500.00 o Total Kitchen 620.00 • Dining room • Ceiling sf 147 • Walls sf 493 • Floor 147 • Perimeter 47.5 If perimeter l • Water damage to the ceiling requires a 3'x3'section of ceiling to be Removed and Replace'.In order to get a seamless repair to the ceiling we would need to wet and scrape the textured ceiling down,skim coat and sand the entire surface,prime and apply a fresh coat of texture before painting.It is my opinion that going over the entire ceiling with a layer of 3/8" blue board and plaster would give the same desired effect with less labor(cost).Also I believe that wetting the ceiling to loosen the texture adds moisture to an already compromised ceiling. • Although the adjuster has put in for drywall repairs,I see no signs that it is drywall and not plaster.Due to the age and location of the home I suspect the walls to be a%Z"blue board with 2 coats plaster. • Crown moldings detach and reset(all)541inear 160.00 • Ceiling • R+R 9 sf blue board and plaster(147 sf) 992.00 • Total dining room 1152.00 • Foyer Closet 1 • Ceiling sf 6.7 • Walls sf 77.99 • Floor 6.7 • Perimeter 10.52 ■ R+R'/z" blue board and plaster 84.69 sf 553.00 ■ R+R interior door casings 16 linear 256.00 ■ R+R insulation R-1518.54sf 21.00 ■ R+R baseboard moldings 32.00 • Seal/prime then paint twice (3 coats) 75.00 ■ Paint door casings and frame 2 coats 25.00 ® Paint baseboard 2 coats 12.00 ® R+R door 25.00 ® R+R closet shelf and rod 62.00 Total foyer Closet2 1061.00 • Foyer Closet 2 • Ceiling sf 6.7 • Walls sf 77.99 • Floor 6.7 • Perimeter 10.52 • R+R%i" blue board and plaster 84.69 sf 553.00 • R+R interior door casings 16 linear 256.00 • R+R insulation R-1518.54sf 21.00 • R+R baseboard moldings 32.00 • Seal/prime then paint twice(3 coats) 75.00 • Paint door casings and frame 2 coats 25.00 • Paint baseboard 2 coats 12.00 • R+R door 25.00 • R+R closet shelf and rod 62.00 ® Total foyer Closet2 1061.00 • 2"d floor • Master bedroom • Ceiling sf 254 sf • Walls sf 485 sf • Floor 254 sf • Perimeter 65 If perimeter • Water damage to exterior walls and ceiling,per adjusters recommendation we will be removing and wall board and insulation on the front facing exterior walls as well as a portion of the ceiling wall board and insulation. In order to get a seamless repair to the ceiling we would need to wet and scrape the textured ceiling down,skim coat and sand the entire surface,prime and apply a fresh coat of texture before painting. It is my opinion that removing entire ceiling and replacing with 1/2"blue board and plaster would be required).Also I believe that wetting the ceiling to loosen the texture adds moisture to an already compromised ceiling.Also the attic insulation is compromised due to exposure to water in multiple areas of the home.Removal and replacement can only be accomplished by removal of the ceiling due to no adequate attic access. • Although the adjuster has put in for drywall repairs,I see no signs that it is drywall and not plaster.Due to the age and location of the home I suspect the walls to be a%" blue board with 2 coats plaster. • Due to the age of the home we must test for lead paint prior to any demolition. • Remove and replace 2 coats plaster over 1/2" blue board 125sf 810.00 • Remove and replace wall insulation R15 100.00 • Remove and replace all window casings and stops 42 linear 162.00 • Ceiling • Remove and replace 2 coats plaster over 12" blue board 254 sf 1700.00 • Remove and replace attic insulation R49 insulation 700.00 • Total Master bedroom 8229.00 • Master bathroom o R+R slab pine door • Door cost 125.00 ■ Labor 125.00 • Plaster minimum repair 120.00 • Seal/prime and paint ceiling twice(3 coats) 145 sf 165.00 • Total Master Bath 535.00 _740 • Daughters bedroom • Ceiling sf 154.11 • Walls sf 402.5 • Floor 154.11 • Perimeter 53.67 If perimeter • Closet ceiling sf 9.27 • Closet walls sf 97.44 • Closet perimeter 12.99 • Water damage to exterior walls and ceiling,per adjusters recommendation we will be removing and wall board and insulation on the front facing exterior walls as well as a portion of the ceiling wall board and insulation.In order to get a seamless repair to the ceiling we would need to wet and scrape the textured ceiling down,skim coat and sand the entire surface,prime and apply a fresh coat of texture before painting. it is my opinion that removing entire ceiling and replacing with 1/2"blue board and plaster would be required).Also I believe that wetting the ceiling to loosen the texture adds moisture to an already compromised ceiling.Also the attic insulation is compromised due to exposure to water in multiple areas of the home. Removal and replacement can only be-accomplished by removal of the ceiling due to no adequate attic access. Due to the age of the home we must test for lead paint prior to any demolition. • Contents removed and reset 47.00 ■ Crown moldings detach and reset(all)541inear 160.00 • Remove and replace baseboard moldings(all 671inear) 205.00 ■ Baseboard heat detach and reset 101f 120.00 • walls • Remove and replace 2 coats plaster over 12" blue board 80sf 540.00 • Remove and replace wall insulation R15 80.00 • Remove and replace all window casings and stops 42 linear 162.00 ■ Ceiling • Remove and replace 2 coats plaster over 1/2" blue board 154sf 139.00 • Remove and replace attic insulation R49 insulation 200.00 Total daughter's bedroom 1606.00 • Office • Ceiling sf 124.63 • Walls sf 335 • Floor 124.63 • Perimeter 44.67 If • Closet ceiling sf 8.24 • Closet walls sf 90.11 • Closet perimeter 12.01 • Water damage to exterior walls and ceiling, per adjusters recommendation we will be removing and wall board and insulation on the front facing exterior walls as well as a portion of the ceiling wall board and insulation. In order to get a seamless repair to the ceiling we would need to wet and scrape the textured ceiling down,skim coat and sand the entire surface,prime and apply a fresh coat of texture before painting. It is my opinion that going over the entire ceiling with a layer of 3/8" blue board and plaster would give the same desired effect with less labor(cost).Also I believe that wetting the ceiling to loosen the texture adds moisture to an already compromised ceiling. • Although the adjuster has put in for drywall repairs, I see no signs that it is drywall and not plaster. Due to the age and location of the home I suspect the walls to be a%Z" blue board with 2 coats plaster. • Crown moldings detach and reset(all) 145.00 • Remove and replace baseboard moldings(all) 185.00 ■ Ceiling • Remove and replace 2 coats plaster over 12" blue board 254sf 1714.00 • Remove and replace attic insulation R49 insulation 200.00 • Total office $2244.00 '... • Bedroom#1 • Ceiling sf 127.71 • Walls sf 352.50 • Floor 127.71 • Perimeter 47.00 If perimeter • Closet ceiling sf 8.2 • Closet walls sf 90.44 • Closet perimeter 12.12 • Water damage to exterior walls and ceiling,per adjusters recommendation we will be removing and wall board and insulation on the front facing exterior walls as well as a portion of the ceiling wall board and insulation.In order to get a seamless repair to the ceiling we would need to wet and scrape the textured ceiling down,skim coat and sand the entire surface,prime and apply a fresh coat of texture before painting. It is my opinion that removing entire ceiling and replacing with 1/2" blue board and plaster would be required).Also 1 believe that wetting the ceiling to loosen the texture adds moisture to an already compromised ceiling.Also the attic insulation is compromised due to exposure to water in multiple areas of the home.Removal and replacement can only be accomplished by removal of the ceiling due to no adequate attic access. • Although the adjuster has put in for drywall repairs,I see no signs that it is drywall and not plaster. Due to the age and location of the home 1 suspect the walls to be a%" blue board with 2 coats plaster. • Crown moldings detach and reset(all)47 linear 145.00 • Remove and replace baseboard moldings(all 59.121inear) 205.00 • Remove and replace chair rail 11.58 linear 34.00 • Remove and replace 2 coats plaster over 12" blue board 80sf 540.00 • Remove and replace wall insulation R15 80.00 • Remove and replace all window casings and stops 15 linear 50.00 • Ceiling • Remove and replace 2 coats plaster over 12" blue board 127.71sf 865.00 • Remove and replace attic insulation R30 insulation 200.00 Total bedroom#1 2119.00 • Total cost 21926.00 The above estimate is an estimate only.The scope of the project will be determined by the final estimate drafted by the insurance company.The above list work, I the contractor believe necessary to bring the home at 28 Morning side Lane back to its pre-damage conditions.Any additional work required or requested during the reconstruction process will be billed separately to the homeowner or insurance company as a supplement to the claim. Estimate Provided by: Aaron M. Scarpello Home Improvements I.I.C. Salem NH,03079 603-858-0391 �-- arnshorneimhotmail.corn www.icanfix�ouse.co AM Ir Water/Ice Damage reconstruction project: Evangelista Family 28 Morningside Ln. N.Andover MA • The Evangelista family located at 28 Morningside Ln. North Andover MA, has chosen Aaron M. Scarpello Home Improvements LLC. (AMS) to perform the reconstruction of their home due to water and ice damage caused by the severe winter weather of 2015. • AMS will be responsible for preforming or subcontracting all phases of construction required to bring the home back to pre-damage conditions as determined by the insurance adjusters report/estimate. o Painting ■ Interior ■ Exterior o Carpentry ■ Framing ■ Trim and finish o Plaster and Drywall o Flooring ■ Hardwood ■ Carpeting ■ Laminate ■ Tile o Siding o Roofing o Electrical o Plumbing o HVAC ■ Note: All trades may not apply to your particular case. • If the homeowner wishes to make changes from the pre-damage conditions, while construction is underway, those conditions will be submitted to AMS in writing. Any price differences caused by a change of work order will either be credited back to the homeowner for use elsewhere in the project or, in the case of overages, be billed directly to the homeowner. • Special order materials 100%due at time of order(finished materials will be ordered and purchased at various times during the duration of the job) • Some finished materials may not be able to be returned or cancelled once the order is placed and some may be subject to a 20% restocking fee. These charges will be the responsibility of the homeowner if it is the homeowner requests the exchange or return. • This reconstruction is scheduled to begin June 2015. 1 • The Contractor agrees to provide and pay for all materials, tools and equipment required for the prosecution and timely completion of the work. Unless otherwise specified, all materials shall be new and of good quality. Contractor warrantee's materials and craftsmanship for one year, where manufacturer's warranty does not apply. • In the prosecution of the work, the Contractor shall employ a sufficient number of workers skilled in their trades to suitably perform the work. • All changes and deviations in the work ordered by the Owner should be presented to the Contractor, by the homeowner in writing, the contract sum being increased or decreased accordingly by the Contractor. • The Owner, Owner's representative and public authorities shall at all times have access to the work. • Contractor shall provide the Owner with a list of allowances for finish materials if applicable. The prices represent the Contractors estimate of average costs for such materials. These prices are subject to change based on actual price of item at the time of purchase and/or Owner's choice of material. • In the event the Contractor is delayed in the prosecution of the work by acts of God, fire, flood or any other unavoidable casualties; or by labor strikes, late delivery of materials; or by neglect of the Owner; the time for completion of the work shall be extended for the same period as the delay occasioned by any of the aforementioned causes. • The Contractor agrees to obtain insurance to protect himself, his workers and subcontractors against claims for property damage, bodily injury or death due to his performance of this agreement. • This agreement shall be interpreted under laws of the Massachusetts. • Attorney's fees and court costs shall be paid by the defendant in the event that judgment must be, and is, obtained to enforce this agreement or any breach thereof. Thank you for considering AMS Home Improvements: Aaron M. Scarpello Aaron M. Scarpello Home Improvements LLC. 603-858-0391 CSFA-096462 amshomeimpRhotmaii.com www.icanfixyourhouse.com 2 %EAUG-10-2015(MON) 15: 11 (FRX)9785572130 P. 0011002 it AARON-1 OP ID:JY �C4�4 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) ■ �.�- 08/1012015 ■ 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 be endorsed. If SUBROGATION IS WAIVED, subject to tho torms and conditions of the policy, Certain policies may require an endorsement. A statement on this certlflcato doos not confer rights to the certificate holder In llou of such endorsement(s)_ PRODUCER NAME: Mark&ROwo,CIC Michaud,Rowe And Ruscak Ins. PNONE 978 688 8829 ja, P.O.Box 188 Na): 978 557 2130 North Andover MA 01845 E-MAIL _80OREss;_—_-•—-- Mark S.Rowe,CIC _........._.._.--..—_. INSURERS AFFORDING COVERAGE NAIC P INSURER A:Harleysville Insuranco Company 26182 INSURED Aaron Scarpello Home Imp, LLC INSURER a:Liberty Mutual •,,_. .___, 2 Magnolia Ave. INSURER G Salem, NH 03079 — INSUaER D: INSURER E. INSURER P- 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. ILTR TYPE OF INSURANCE AWISODOLISUB POLICY NUMBER MMIDDlYYYY MMIDDr EXP LIMITS A I X I COMMERCIAL GENERAL LIABILITY EACId OCCURRENCE $ 500,000 . FV1FAMAGE CLAIMS-MADE OCCUR SPP39723L 11/28!2014 11/28/2015 PR M SE EXs LEa occurrnncn 100,000 MED P IAnv one person) S 5,000 I -P PERSONAL 5 ADV INJURY_ I s 500,000 GEN'L AGGREGATE LIMIT APPLIES PER GEN_E_RAL AGGREGATE it 1,000,00 POLICY j JCGT I Or PRODUCTG•COMPIOP AGG I t� 1,000,000 OTHER. I s AUTOMOBILE LIABILITY I l GMHINF,IJ SINCiIb LIMI I o � ( (Ea BCC(d6N1 ANY AUTO BODILY INJURY(Per peman) 1$ ; I � ._..._ '. ALL OWNED SCHEDULED I i BODILY INJURY(Pcro¢dcn1) $ AUTOSAUTOS —i NON-OWNED PROPERTY DAMAGE HIREDAUT05 i i AUTO..^, i i I,(Pnra�cidant) „I•y UMBRELLA UALI OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE S DFD ( 1 RF'fEN'r10N$ $ WORKERS COMPENSATIONPGR AND EMPLOYERS'LIABILITY YSTA'YU'I't.I._ ER 13 ANY PROPRIETORIPARTNER/EXECUTIVE ❑ NIA TO BE ISSUED DIRECTLY 13Y C.L.EACH ACCIDFNT 8 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) LIBERTY MUTUAL E.L.DISEASE-EA EMPLOYEE S If yyes,describe under f.4. , 10 OF OPFRATIONF twlnw E.L.D19EASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Addltlonai Remarks 80e01e,may be ariRched If more space la required) CERTIFICATE HOLDER CANCELLATION NORTHI3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS, Building Inspector 384 Osgood Street AUTHORIZED RkPRESENTATIVE North Andover, MA 01845 I ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD AUG-10-2015(MON) 15112 (FAX)9785572130 P. 002/002 7/7/201.5 8:20:05 AM PST (CMT-8) FROM: 100005-TO: 19705572130 Page: 2 of 2 ruumrr) CERTIFICATE OF LIABILITYY INSURANCE oaTe(M�nnlMIDUI /2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TIME CERTWICATE 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 certifiwle holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,Subject to the tmma 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 endoraemen s PRODUCER MICHAUD ROWE AND RUSCAK INSURANCE ASSOC 43 HIGH ST SUITE 220 PHONE FAX PO BOX 168 Mnl� NORTH ANDOVER, MA 01845 INSURER 9 AFFORDING COVERAOE /tAIG�r INSURER A: Libefly Mutual Fire Insuranca 23035 INSURED SURI`R N, AARON SCARPELLO HOME IMP LLC 2 MAGNOLIA AVENUE NSURERC, SALEM NH 03079 NSURtRD', MURM E! INSURER F COVERAGES CERTIFICATE NUMBER: 26484817 REVISION NUMBER: THIS IS TO CER-nF'Y THAT THE POLICIES OF INSURANCE LISTED 13ELOW 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 9Y THE POLICIES DESCRIU110 HEREIN IS $UI3JECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIE$,LIMITS SHOWN MAY HAVE BEEN REDUCE=D DY PAID CLAIMS. 1LTR TYPOOF NSUKANCe POLICYNUMSER M !! Mmmy I Umns COMMERCIAL O ENCRAL LIA1ULIrY EACH OCCURRENCE S CLAIAIS•MADF LIOCCUR TRE $ NFD P)T(MY one Demon) $ 1'ERS0NALdAnVIWURY Is I'`GEEN'LAGGR2GATELILIrTArrLIESPER. CENERALAGGREOATE` :r I H" POLrcv I I JECT 1. 4C PRODUCTR-CCMr`IOPAGG I S q OTHER. ' T AUTOMOWLE uAn-rrY r.001170rn S ANY ALrM BODILY INJURY(Pow peoehm) Is ALL OWNEDRCHEOULED aODILYINJURY(Pornedeanl)I S AUTom AUTU9 HIRED AUTOS AUr WINED Iperac R PERdemI s S UNROW11AUA00CCU11 rAr.H OCCURRENCE EXCESS Lt" CLAIMS•81ADE AGGREGATE S DFA NTION S A WORKERSCOMPtNSATION WC2-31S°3813493-025 4/19/2015 4/10/2016 AND 9MPLOYERS'LlAHILM AFFICL•R!A C tl"AKR MINEEOX EOtrTNIZ YO N/A E.L.EACH ACCIDENT S 100000 iMandabryinNH) FL.DISPME-EAEMPLOYEE $ 100000 J7owldarN OPERATIONR r. F.I..OIACASE-POLICY LIMIT S 500000 DtSCWI'ION OP OPERATIONS/LOCATIONS/VENICLYS (ACORp 101,Addldonnl Rema/ka 8enedule,my be at1wh6d Ir mwe space Ir"ulmd) Workers compensatlon Insurance coverage applies only to the workers compensatlon lati%%of the state MA. This certificate cancels and supersedes all previously Issued cdrtificates,only as they relate to workors'compensation Coverage CERTIFICATE HOLDER CANCELLATION WN OF NORTH ANDOVER SHOULD ANY OFTHEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN NOFOSGNO STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER MA 01845 accolzDANCEWITHTHEpoucYPROwsIONs. AMMORIMI)"FIR"ENTATNa Ubwiy Mutual Fire Insurance ®1988-2014 ACORD CORPORATION, All rights reserved. ACORD 25(2014101) The ACORD name and logo are registored marks of ACORD 5484817 1-5HU497 18-145 NC yoveah.p�EL18LibertymutuaL.Can 7/7/2013 8116:15 Ab (PDT) Paw 1 a8 1 Zhe Commonwealth of Massachusetcs Department oflndustrialAceidents P :d I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.go-P/dia 5y. Workers'Compensation lnsuran.ceAffidavit:Builders/Contractors/Electricians/Flumbers. TO BE FILED WITH TBE BERMITTING AUTHORITY- Applicant Information Please Print Le 'bl Name rtsnness/Or amzatton/Individual e � Address' r2J �, r`-1 c.,It, e, ., City/State/Zip: G1 0 7 Phone Z r- Are you an employer?Checktlieappropriate box: 'Type of project(required): 1.❑1 am A employerwith employees(full and/or part-time).* 7. New Construction 2. am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3..[]I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 F1 Building addition 4.❑lam 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.[]Electrical repairs or additions proprietors with no employees. 12.Q plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roofrepair:s These sub-contractors have employees and have workers'comp.insuuance.� 6.E]We are a corporation and its of�cers have exercised their right of exemption per MGL c. 14.[Other V1'4 W r 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 showingtheir workers'compensationpolicy 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. lfthe sub-conlraclors have employees,they must provide their workeis'comp.policy number. X am an employer that is providing workers'compensation insurance for my employees.'Beloiv is the policy aged job site information. Insurance Company Name: Policy#Z or Self-ins,Lic.#: ExpirationDate: Job Site Address: City/State/Zip: Attach a copy of the workers'eorapensatiou-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL o.152,§25A is a cximinal 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. ` X do hereby certi .hr...ep anis andPenaltzes•ofpejjuiy that the acorrect.ove is e and caec t. Date: //OZ Signature: ✓ 'I,,, Phone# 62 0 121 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#: f' Massachusetts _ Board of BuildingDepartment of Pub lic Construction super". gJsor i tions and Standards j License: CSFA_0964., Fani113- A-0g64B2 S MAGNOLIA L- 'r EMNH 0307q S. Commissioner EX pi ration 07/07/2016 /X, "— Office _ of Consumer HOME IMPROV Affairs&Bus❑ess� Reg�strafio EMENT CO RACTO gul4ion Ex n "153859�� R p ration 1/18%2017 -TYPe:~.. Aq ON M.SCARP ' DBA PI ELLO yO'M PE ROV 1M �. EMENT AARON SCARP EL� s t ! - �, 2 MAG { NOLIA AVE S 1�� , ' f�• SALEM MA 0307- ! _. Undersecretary X54,, Massachusetts -Department of Public Safety Qoard of Building Regulations and Standards Construction Supervisor 1 & 2 Family License: CSFA-096462 AARON M SCARPJELLO `= 2 MAGNOLIA AVE 0, SALEM NH 030 r Expiration Commissioner 07/07/2016