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HomeMy WebLinkAboutBuilding Permit # 11/16/2015 BUILDING PERMIT OoRgH TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION : ¢ Date Received ° ��A°agTEO PZR��t5 Permit N® �SSAC}iL15�� Date Issued: IMPORTANT: Applicant must complete all items on this page ...,,.. .,::rrr, ,r rr ,,. ri.. ,✓, „.::r: D. r ,,: ..✓a /. J,.. e..,, ,r r / ,,:r J .� r r ✓ a i / r rrr r,, r//. ,r � ,,, r` f ��// r /r r�!/ �f%����rOr/���/�i✓,r/,,, �ii r ,��//�/i/�/ / ,,. r / r l / r. ✓ r//r r r /// / /i r / // r, rrr „�;,,�� ( / r ;,, r ���/�%✓r/,I�ir�%i//��r�.i/��/������/%�r���//i // ,, / /,, ,,,,,, rrr r. r r � e re, �r /. ,� r r r,/.✓�/�/ / t/. J,/ // r. r. �a� /i�/J,rr„.... r��, � ,r�G�/ ��/�///r / r �/ ./i/�o �///� r, //, ✓a /i/c ,, ,.0 .,�1,� / ��ri��/ice � �r l// i.,, ., /I� ,. //, CT ,r✓oor„r,ril H est rt ra��,�, // res ./n , yr TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 00ne family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg _ ❑ Others: ❑ Demolition ❑ Other rr r r r, ” � ' '” ''' !Wetlands „❑ Watershed Distract /, e tic.;%� a :Well, rr , ❑ Flood{'')Iam ❑ ,/ r� DESCRIPTION OF'WORK TO EE PERFORMS®: Identification- Please Type or Print Clearly OWNER: Name: CJ /Al e Phone: Address: 177 ._ 1116h" , ` e- Contractor Name .Phone ,c, r/// /, %///�/ r /�/ii� r/j% ✓�/rr,: i,�p,/,�' r //, �i,r rrd �/ / ///�, 1% r / �����/� �i%J //�%r r Email / r ,rorr r r r r r r r r / r// ,/.,, r r// / ///.../ / / „r�..,/ r „/�. ./ rrr //. �. „✓a, ,,,.. ✓ / rrr a // r / / ,. / // �// / a/ //i / /� ,r, �, /r,ri ria ,ari,,, i i .�, ,✓ ,rr, ,.. ,, i.. :r.,<. / //r/ l � ,/i ,�r /1/I/ r /n„ /,,, r e� isor/s,Constructian Licens �,,�i, � , r r , / / ,,/ „or, r r ,..,., rr ,.:: .// ori, ri ✓, /// r„ r ,.//.„ !✓ ,. ,/,.,, , r r r, ./ //,/ / r .,/ / „i/. / ✓ ..i, o/l r✓ /rr //:///�,1,,,,. ��/./r �/�% „eoirvrliaavi✓ar,iii ,.,P�r//oa/ .ri.�r r/,1,/d,it„✓ -.,,/, ,.,,,/ /lI' / /i/irrriii � ,/lim,,,e ARCHITECT/ENGINEER °° Phone: Address: Reg. No. FEE SCHEDULE:BULDING PE MIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. i Total Project Cost: $ FEE: $ q (P — Check No.: 1, 1 Se Receipt No.: Q100ft NOTE: .Persons contrachkg7wi& unregistered c ntractors do not have access to the guaranty fund Signature of Agent/Owner ignatur1.e of_contractor .... Plans Submitted ❑ Plans Waived.[] Certified Plot Flan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools ❑ 7] Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF ® U FOR PLANNING & DEVELOPMENT Reviewed On 11- 16 -(07 Signature_ , COMMENTS I �Ii11 Y1 Gia r Al crC� aC� a C T� CONSERVATION Reviewed on Si nature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE®EPART g t I�IENT Temp Dum Located at 124 Main Street s er on site yes no Fire®epartmen sig gat are/dale r„ t COMMENTS y y %AORT¢ It own of . ......... ..... 0 20P IL Z h `' ver, Mass, �9� COCMICMIwrCK � BOARD OF HEALTH Food/Kitchen Septic System TIFFS THAT ......... .. � ........ . .. . ...... ... BUILDING INSPECTOR JT T LD Iit�sl0n to erect buildings on Foundation ........... ............. ... .... .......... .. ...... . ......................... Rough dcupledas ... .... .o. .. ............................................................ Chimney ded That the person accep mg this permit shall in every respect conform to the terms of the application Final dei 6'this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and eii6ctlon of Buildings in the Town of North Andover. PLUMBING INSPECTOR 43� � LATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MON T S ELECTRICAL INSPECTOR UNLESS CONSTRUCT S RTS Rough Service .. .... ....... ....................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Ruildinor 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. Hank Tucker Hank.Tucker Carpentry, Inc. 38 Newell Street Lowell, MA 01851 Email: a I2 1( rricast.net Res.: 978-453-5196 Cell: 978-815-8186 Fax: 978-455-7614 License#050463 -Reg. #179255 www.hanktucke e It -CM-11 ........... 10/25/15 Robin Morgasen 147 High Street North Andover, MA 01845 978-828-2892 ri rnomasen(ebaniail.coin *Work Telephone: *Emergency phone numbers: Dig safe# p Is- '13,6 ffi Dig safe start date: ji. 10 - 7-6 19- ?VTA'" Schedule for Completion of Work:__. Approximate start date: 11/23/15(weather dependent) Approximate completion date: 11/28/15(weather dependent) All prices are good for 30 days. Description of work: Contractor will furnish all materials and perform all labor in a good, workmanlike and substantial manner for the following described project upon the following described property. All subcontractors will demonstrate valid licenses and or certificates of insurance in compliance with Mass. State Regulations. 1 911 Permit Notice: The Contractor shall be obliged to obtain any construction related permits as the owner's agent. The owner's who secure their own construction-related permits or deal with unregistered contractors shall be excluded from access to the Guarantee Fund. (MGL 142A) Special orders are absolutely non- returnable.Any returnable item has a 25% restock fee from supplier as well as an hourly rate of$75.00/hr. for return labor. X Payment Schedule: Owner will pay the Contractor the sum of$7,974.63 installments as follows: Date Amount of Work/Services to be Performed Amount of Payment 11/12/15 Unit,rentals,permit, supplies,concrete $6,174.63 11/28/15 sign off of permit $1,800.00 All payments are to be from a local bank. If not possible the check will be due 7 days ahead of payment schedule to allow for processing time. If check is returned, home owner is responsible for all bank check fees-$25.00. Checks to be made out to Hank Tucker Carpentry Inc. Signature and date: Required by City and Town Halls: All municipal fees,taxes, liens,etc. must be up to date before a permit will be given. Contractor will not be responsible for payment and will not proceed on permit until written conformation is received. Damage found from previous Contractors: If during the project,when opening walls,flooring, ceilings, excavations, etc, damage or unsafe conditions are observed that can be attributed to previous work, the Contractor will notify and show said damage to homeowner. If homeowner refuses to acknowledge or repair damage,the Contractor will bring in the appropriate inspectors to verify that said damage was not the cause of the current Contractor and will not be held responsible legally or fmancially if homeowner refuses to repair this work. Home owner will not be allowed to be "General Contractor" Under the authority of the "Toxic Substances Control Act"section 402 c (3) of TSCA, any home built prior to 1978 is subject to testi"Lor Lead and Lead Safe practices must be followed. �imture and date: 2 Description of Work: COPY Bulkhead estimate: To excavate down below footing Cut through concrete foundation Install precast basement stair unit with Gordon doors on top 1 door at base of staircase that vents Seal to foundations a �„d.y � 6r rpt. Backfill with /a„stone U e,CC 01,1 e- Pour Pour concrete apron around unit c: -1-2- �.N V Remove all excess from site —"f) Permit will be pulled, Dig Safe will be notified Cost: Unit"C", cutting through foundation,removal of excess fill, concrete and supplies,tax: $5,196.47 20%overhead: $978.16 Labor: $1,800.00 Total cost: $7,974.63 Signature and date: 3 COPY Terms and Condition: A. Guideline: This project will be constructed in strict conformance to the plans and specifications which have been examined and approved by the Owner. All workmanship is guaranteed for 2 years from the sign off of permit. B. Compliance: The project will be completed in strict compliance with all laws, ordinances,rules and regulations of the applicable government authorities. C. Control: The agreement,plans and specification are intended to supplement each other. In case of conflict,the plans will control the specifications and the agreement provisions will control both. D. Change orders: As directed by the Owner, construction lender,public body or inspector, any alteration or deviation from the specification that involves extra costs (subcontract,labor, and materials) will be executed only upon the parties entering into a written change order. Expense incurred because of unusual or unanticipated conditions will be paid for Owner. Labor and Materials: Contractor will provide and pay for all the materials necessary to complete project. Contractor is released from the obligation for expenses incurred when the Owner is in arrears in making progress payments. If Owner purchases stock or material, or is given at contractor's cost, Owner is responsible for all warranties on products and materials. If product is in need of repair or replacement, an hourly charge plus cost of$75.00 per hour replacement product and 20 % over head with Contractor assuming responsibility for product. Special orders are absolutely non-returnable.Any returnable item has a 25% restock fee from supplier as well as an hourly rate for return labor. X E. Permits: Contractor will obtain and pay for all required building permits. F. Taxes, Assessments and Charges: Taxes, special assessments of all descriptions, and charges required by public bodies and utilities will be paid for by the Owner. G. Bankruptcy: If either party became bankrupt,the other part has the right to cancel this agreement. H. Cancellation: Owner and Contractor have an unconditional right to cancel the Agreement,without penalty or obligation,until midnight of the third business day after the Agreement was signed. Cancellation must be done in writing. Upon cancellation,any property traded in,any payments made under this Agreement,and any negotiable instrument executed will be returned within 10 business days following receipt by the contractor of cancellation notice. Property Lines: Owner shall locate and point out property lines to the Contractor. Contractor may, at his option,require the Owner to provide a licensed land surveyor's map of the property. Liens: Failure to pay persons supplying materials or services according the terms of the Agreement may result in the filing of mechanic's liens on the affected property. Signature and date: 4 I COPY Insurance: Owner will maintain property damage insurance at least equal to the Agreement price. Damage to Project: Contractor will not be responsible for any damage caused by the Owner, or other causes beyond the control of the Contractor. Owner will pay for any restoration work. Contractors Rights and Responsibilities: a. Delay: Contractor will be excused for any delay beyond his reasonable control. These delays may include but are not limited to,Acts of God, labor disputed, inclement weather, acts of public authority, acts of the Owner, or other unforeseen contingencies (ground water,underground objects, soil conditions, anything not visible). Under such conditions,there will an extra charge for stock plus 20%overhead and labor rate of$65.00 per hr. Contractor will be excused of delays incurred by suppliers shipping time frames or special orders/custom orders. (If stock is held up, Owner has the right to hold up cost of item, it not paid for and a reasonable hourly rate $65.00 per hr. to install product only). b. Right to Stop Work: If any payment under this Agreement is not made when due,the Contractor may suspend work on the job until such time as all payments due have been made. Any failure to make payment is subject to claim enforced against property in accordance with applicable lien laws. If Owners sub-contractors do not comply with Agreement, contractor has the right to stop work and bring in building commissioner to settle matter. c. Substitution of Materials: Contractor may substitute materials without notice to the Owner in order to allow work to proceed,provided that the substituted materials are of no lesser quality than those listed in the specifications. d. Salvage: All salvage resulting from work under this Agreement is to be retained by the Contractor unless other agreements are contained in the written specifications. e. Insurance: Contractor will maintain comprehensive public liability insurance policies. f. Sub contractors: Should Owner hire their own Sub contractors, a copy of their license, workman's compensation,and liability insurance certificate is due before they can begin work at site. If not licensed and insured they will not be allowed on job site. Owner is responsible to maintaining Sub contractors j schedule and to monitor clean up after Sub contractors each day, and to insure Sub contractors maintain a safe and professional work site. Any damage by Sub contractor on project site or damage to stock on project site will be the Owners responsibility. Contractor has right to terminate any sub contractor that homeowner hires if job is not being completed according to code and 'obspecifics and unreasonable delgy in completion. Signature and date: 5 Completion of Project: a. Notice- Owner agrees to sign a Notice of Completion within 5 days after completion of the project. It the project passes final inspection and Owner does not sign the Notice,the Contractor may act as the Owner's agent and sign the notice. b. Cleanup: Contractor is responsible for removing debris and surplus material from the property, and leaving the property in a neat and orderly condition. pyfflpster: Dumpster on job site is for construction trash only. Any other trash will be removed from the unit and Owner will be responsible. An exception to this is if Contractor agrees to Owners trash and it meets container company's trash requirements. Sign off with Contractor is required. Conflict Provisions: a. Arbitration: Any controversy or claim arising out of this Agreement that cannot be resolved is subject to arbitration,with an arbitrator of mutual agreement, and all parties (including Owner, Contractor,Architect and Sub- contractors) are bound to this arbitration. If any party does not appear at arbitration proceedings,the arbitrator is empowered to decide the controversy in accordance with whatever evidence is presented by the party (ies)that do participate. b. Attorney Fees: If either party becomes involved in litigation arising out of this Agreement,the court shall award costs/expenses including attorney fees to the justly entitled to them. c. Limitations: No action related to this Project may be made by either party against the other more than I year after the completion of work. General Provisions: a. Notice: Any notice required or permitted under the Agreement may be given by certified or registered mail at the addresses contained in the Agreement. b. Prohibition of Assignment: Neither party may assign the Agreement or payment due under this Agreement without the written consent of the other party. Agreement must be signed by both property Owners in attendance of each other. c. Qualification: This document constitutes the entire agreement of the parties. No other agreements exist. This Agreement can be modified only by written agreement signed by both parties. d. Space: Contractor may require yard space for following when needed durapster, storage box for tools and equipment, off street parking for construction trucks and stock. e. Worldng conditions: Construction/work hours will be 8:00a.m. Through 4:30p.m. Monday through Friday. Occasional weekend work will be may be required and advance notice will be given to Owner. A.ccence of Agreement: Homeowner has read and understandoerms. ✓ Authorized 81—gnature Date OwnerSj6ature Date Lic. 050463-Reg. 179255 16. 74-U Contractor License Number Date Signature 6 COPY Project site Questionnaire Yes Into 1. Will workers be allowed to use bathroom? If no, a Porta-Potty will be used at a nominal charge to homeowner. 2. Will access to all electrical services,be allowed? i.e. basement,utility room, etc. If no access and fuse is blown,homeowner will pay contractor for day as he will have to leave site. 3. Will there be access to external water Silcocks? 4. Are there any external electrical plugs? 5. Are there any pets to work around or to put away from workers? 6. Are there any special plants,trees, bushes that Contractor needs to be aware of? 7. Are there any underground services I should know about such as: Electrical/water or drainage pipes/sewer lines/septic line, box or leaching field/ dog fence/security systems. Circle or Add ! 'q- 8. If yes on lawn sprinkler,what is time of use 9. Any house or yard services? Days: Times: 10. Do you have a house alarm and is it connected to Police/Fire/Other I will need alarm code/key and phone number to company if possible. , , Depending on job,Hank will need a key to house. If home owner is not at home full time or if homeowner has to leave,Hank will not leave home unlocked at any time or for any one. 11. I will not let any unauthorized person/people on to the property unless otherwise informed. 12. Do work hours need to be changed from standard work hours, due to family work schedule, 8:OOa.m-4:30 p.m.,Monday through Friday. 13. Children will not be left on job site without proper supervision. I am not a baby sitter. 14. All Homeowners vehicles should be removed from work area while work is going on. 15. Is smoking permitted on property? 16. I will not answer the phogg,,or accept deliveries. Signature and date: 7 (001PY CHANGE ORDER PROVISIONS CHANGE ORDERS: As directed by the Owner, construction leader,public body or inspector, any alteration or deviation from the specifications that involves extra costs (subcontract, labor, and materials)will be executed only-upon the parties entering into a written change order. A deposit on stock will be required up front, and upon completion of changes, payment in full for that part of the Agreement. Expense incurred because of unusual or unanticipated conditions will be paid for by Owner. Acceptance of Change Order: Authorized Signature Date Owner-Si afore Date Lic. 050463 Reg. 179255 Contractor License Number Signature Date 0,4D 9� r1cf—I a4lt' 5*c"A'D 3,ec,� 7–a M� 4r Y,066 7v Kw 8 North Andover MIMAP November 16, 2015 and »» J , '0 rr,✓ .Furber A�e�ue s 0 I r✓ i O MVPC Be Interstates Horizontal Datum:MA Slateplane Coordinate System,Datum NAD83, '... Meters Data Sources:The data for this map was produced by Merrimack —SR %40RTN Valley Planning Commission(MVPC)using data provided by the Town of Roads Of 4aC r q� North Andover.Additional data provided by the Executive Office of 4W¢Easements ,1u. 4aK+ 4*s 00 Environmental AffalrslMassGIS.The information depicted on this map Is '..,. Parcels3' L for planning purposes only.It may not be adequate for legal boundary 4 ti- to definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING y * THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY } f ^ k OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF „•b'ppg THIS INFORMATION �`rSACHUs�i V=41 ft 3-E r North Andover MIMAP November 16,2015 53.0-0017 ct� ..067.0-0036 Op 067.0-0029 067.0-0037 157 HIGH 5T 067.0-0030. 10 BRIGHTWC ODAVE 053.0-0018 067.0-0038 153 HIGH T �I 067.0-0031 067.0-0032 R4 067.0-0039 146 N 147 HIGH ST 10 FURBER AVE i 053.0-0016 9 C1" 0 Furber,pvenue r 137 HIGH ST" 138 MGH 5T 067.0-0063 053.0-0020' 067.0-0071 MVPC Be =z Wetlands Zoning ric stt [ Municipal Boundary Exempt LBusine s 1 Di ands Ps- Busine s 2 District Horizontal Datum:MA Slateplane Coordinate System,Datum NA063, Rail Line M Mine's 3 District Meters Data Sources:The data for this map was produced by Merrimack 6t Busine s 4 District ORTH Valley Planning Commission(MVPC)using data provided by the Town of Interstates N _I 0 GeneraBusiness District Of r 'q�. North Andover.Additional data provided by the Executive Office of —SR Id Planne Commercial Dev y tt 6 r°00 Environmental ABalrslMessGl3.The information depicted on this map is Corrido Development Dist b �, for planning purposes only.it may not be adequate for legal boundary Roads )N Corrido Development Dist O fh definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER 4�p Easements IN Corrido Development Dlst �" MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING ❑Parcels IndusUi I 1 District - w THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY Industn l 2 Disldct OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT Zoning Overlay f.'z Industn 13 District * �p+A " ,�<4t ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF ®Adult Entedainment M Industn I S District °t"""`" THIS INFORMATION 13 Downtown Overlay District Reside ce 1 District �l,' °h�1.o (3 Historic District Reside ce 2 District SgCHUS'� 0 Water Protection it cidece 3 District I Hydrographic Features d de ce 4 District Streams I"=41 ft de ce 5 District «d y.de ce 6 District `'-,age esidamaI District ■ ■ From:M&M Assurance/Mason&Mason Ins 603 356 9290 11 /16/2015 11 ;09 #519 P.001/001 HANKTUC-01 TRAMIREZ IW'1A"DD!YYYYI CERTIFICATE OF LIABILITY INSURANCE 11/16/2015 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. j IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(IGS)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 NAME: _ _ Mason&Mason Insurance Agency,Inc, n!occ�xtt:(781}447-'i531FAX jAtc,No,:(781)447-7230 ;458 South Ave. E Rnall _ �.�_. Whitman,MA 02382 ADDRess:Info masonandmasoninsurance.com _ INSURER(S)AFFORDING COVERAGE _ _NAIC ft '... _ INSURER A:Travelers Casualty Ins, Co.of America 19046 ItISURED-._._.- _ -"--'--"- -- INSURER B: --- -- --_ .__...- Hank Tucker Carpentry Inc INSURER C: _ — — 38 Nowell Street INSURER D; Lowell,MA 01851 (INSURER E: 1N5URERF. '... COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED N.ALIED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUPI-NTV!ITH RESPECTTO VVHICH THIS f CERTIFICATE MAY BE ISSUED OR I'VI.AY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERms' EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOVV4 MAY HAVE BEEN REDUCED BY PAID CLAIMS. TNSR-- -- _ A�tl ! -------- - POLICY EFF 'POLICY EXP ------ -�-- ��� LTR TYPE OF INSURANCE IVSD iµND POLICY NUMBER WfJDD Mf&DD LIMITS j A i x COh1MERCIAL GENERAL LIABILITY I EACH OCCURRENCE E 1,000.0001 ..I c al rs r�Ae- OCCUR ; !I680SA4550261542 09/27/2015 0912712016 RIA ETO Er�reb � 300,000?RER1VE5 E.00LLTfet MED EXP(Any.r.e person) S 5,0001 �- -__ -- I PERSONAL&ADVI^IJURY 1; 1,000,000] L AGGREGATE LIMIT APPLIES PER: ! GEN=RAL AGGREGATE $ 2,000:0001 PRO- 2,00 0 � POLICY JECT __I LOC PRODUCTS-COi l OTHER: 1 AUTOMOBILE LIABILITY i •COMBiNEDSih3'LE LIM[-, S '...... 115a accident, _ A ANY AUTO qx 6806A4550251542 09/271201 ti 09/2712016 BODILY INJURY(?erperson',ALL OY-NED SCHEDULEDPODILY INJURY aeraxlde r1, SALTOS AUTCS t ); 9;000,00NON-O'NNECPROPERTYDAESAGEHIREDAUTOSAUTOS 1 (Per�xidentl UMBRELLALIAB -i OCCUR ! EACHOCCJRRENCE S EXCESS LIAH I cLa.MS-:1a.D= I ;GGREGATE S - DED ! RETENT OV$ t S '... WORKERS COMPENSATIONi L SER 1 OTH- AND EMPLOYERS'LIABILITY 'SiWTU_E I I ER aNY?ROPRIETORrPARTNER'EKECUTI'JE a Y/N NTA L.EACHACCIDE\"T S 1 OFFICERWEMBER EXCLUDED? � --- —••- -- (Rlandatory In NH) E.L.DISEAS EA.EMPLOYEES If yes,dmcrk:a under ID=SCRIPTION OF OPERAT11OKS oaloei ! =.L.DISEASE-POKY UFAFT $ I e I DESCRIPTION OF OPERATIONS;LOCATIONS!VEHICLES (ACORD 107,Additional Remarks Schedule,maybe attached If more space is required) I t j i I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, Building Department 1600 Osgood Street Building 20,Suite 2035 AUTHORIZED REPRESENTATIVE North Andover,MA 01845 ©1988-2014 ACORD CORPORATION. All rights reserved, ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts .Department of IndustrialAccidents 1 Congress Street,,suite 100 Boston,MA 02114-2017 •°` www.mass.gov/dia yy♦y Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE FILED WITH THE PERARTMiG AUTHORITY. _Applicant Information Please Print Legit Name (Business/Organization/Individual): ' Address: City/State/Zip: '' GG f 5. ) Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑lama employer with employees(full and/or part-time).* 7. []New construction 2.F]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. El Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 E]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.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.F]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs Theso sub-contractors have employees and have workers'comp.insurance.t 14.P!�th&6. 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.] *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 mustattached 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,1hey must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy acrd job site information. Insurance Company Name: Policy#or Self-ins.Lia M Expiration Date: Job Site Address: 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 required under MGL a 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 WORD ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certify under the pains anenol 'es o e ury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official.. City or Town: Permit/License# Issuing Authority(circle one): LLth Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#: vp wA ,I%%� � rr `6 Ofrr /. M Vw -Department 01Pw �'tl 71, ti . 1111,11, 1 ni fJffice of Consumer Affairs&Business Regulation �i Vp ME IMPROVEMENT CCINTRACTOR rassli RUl � aflrar St �a3 Type: Corporation egistration: 179255 xpiration 7/10/2016 L"ucn ; CS-050463 HANK TUCKER CARPENTRY INC JUNRY A TUCICE$t 38 NEWELL ST LOWELL NIA 0851`rt °�,a HANK`TUCKER i % 8 NEW,'TELL ST LOWELL,MA 01851 Undersecretary Exparabon e 1111612016r G Comnjassao er VJAYYf�'�9°�3�9ir5' 7Cd;P^'",,, r