Loading...
HomeMy WebLinkAboutBuilding Permit # 5/4/2016 �1 r� y„qh 9b BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 5 � ..� a Date Received Permit NO: Date Issued: l;,n I1VIP®1IA1�1'[4 A licant must cam fete all items on this age LOCATIC?N; w rpt PROPERTY OWNER 1 Print MRP NfJ. PARCEL: 'ZONING`bI ST`RI°CT: Fl tcsric D�strit t yep" no 'Machine Shbp'Vill�age , ye no, TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential f_i New Building ❑ One family [� Addition wo or more family ❑ Industrial [,i Alteration No. of units: ❑ Commercial ,eAepair, replacement ❑ Assessory Bldg U Others: [1 Demolition o Other E1'8eptic :UI Well oFleodplain El Wetlands, 'Ji Watershed'District - i 1;Wa'tedSewer le VV i n& Cn an as 694d6d 5) 2"1406 fiiUL ��� mn:�� Identification Please Type or Print Clearly) OWNER: Name: l? SQ r 'C`YC- f °rr4 Phone ° I1I Address: CONTRACTOW,Name:: Address: Supervisor's Construction License: Exp, Date: Fpm l' Exp; `Nte; ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDIIUO PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: - Receipt No.: NOTE: Persons contracting with unregistered contractors da not have access to t aranPy.fund Signature of.Agent/Owner Signature of contractor NORTH - 0 A -mover tohwn ot Anct . 114 ' Pl� 41 C, h ver Mass, O LANE COC NIC Nl wICN � S U BOARD OF HEALTH Food/Kitchen ER ID Septic System THIS CERTIFIES THAT VBUILDING INSPECTOR Foundation has permission to erect.......................... buildings on .... .. ...... .... . .. f........ �. . ..�L.. .tr.\�.`. ....... .. ..� i Rough to be occupied as ... .. ......... ...... ...... .�.� ll!*r�. . .,. .............. Chimney provided that the person accepting this permit shall in every respect conform 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT I IN-6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS TIO *BUIL� Rough Service �. ...... .......... Final G INS CTOR 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 Approvedy the Building Inspector. Burner Street No. Smoke Det. Diamond Nill guilders, LLC• r a 98 Portsmouth Avenue, Stratham, NH 03885 (603) 580-53681 Fax(603) 580-5368 1 www.diarrioiicJfiillbiailclers.,coi> i.i e ® m Diamond Hill Builders offers complete building and remodeling services including new construction, renovations, home and business improvement needs for individuals and businesses throughout the Seacoast NH area. We are fully insured and offer the highest quality workmanship available. �t � In addition to new home construction and remodeling we specialize in home additions, garages, roofing, decks, windows, doors and siding. All of our work is guaranteed. Date: May 2, 2016 Job ID: Prescott Village: Repairs Customer Name: Great North Property Management / Debbie Peters Customer Address: Stacey Dr, North Andover NH Customer Phone: 978-530-5143 Customer E-mail: Debra.peters@greatnorth.net Repairs on Units 10, 11, 12, 13, 14, 15 and 18 • Remove and Replace the damaged trim from the bees. • Remove and replace the siding that is damaged and not properly overlapping. « Remove and replace the rotted windows casings. • Repair the Pent roof on unit 11 as needed. • Remove the replace the corner boards and rakes on the left gable end of unit 10 • Apply paint to the new trim and siding only on the gable end of unit 10. • Remove all job related trash from the property. • Repair the deck on unit 18. AAC • Unit 15 Replace rotted gable end lo' uvtel) Repairs to the fronts of unit 10-14 $ 49125.00 Deck Repair Unit 18 19440.00 Pent Roof Unit 11 39560.00 Gable end Louver Unit 15 0. 00 Tota 99325.00 Comments: Please note that this price is based on the work requested. Please note that any hidden damages are subject to a change order. Please note that this price includes labor, materials and dumpster. TERMS AND CONDITIONS 1. CHANGE ORDERS. Any additional work beyond the scope of the initial Job Specifications, including any work necessitated by any Hidden Conditions, as defined in Paragraph 8 below (the "Change Order") shall be discussed by Owner and Contractor to assess the feasibility of the requested changes in light of the scope and schedule for the Project. In the event that Owner informs Contractor that they would like to add a Change Order and Contractor is able to perform such additional work, Contractor will provide Owner with an estimate of the additional cost of the Change Order, including the expected terms of payment for the Change Order (the "Estimate") prior to the start of the specified work. The additional cost relative to such Change Order shall be added to the Agreement Price. Payment terms for any Change Order will vary depending on the work requested. If Owner requests a Change Order but does not proceed with the work in such Change Order, Owner will be billed for Contractor's administrative costs to develop the design, drawings and any other necessary collaterals and the cost estimate relative to the Change Order, at the rate of$65 per hour. Any Estimate must be signed by Owner and returned to Contractor within one (1) week of Contractor providing Owner with said Estimate. Contractor will not proceed with the additional work specified in any such Change Order until such receipt. If the Owner fails to return the signed Estimate to the Contractor within this one (1) week time period, said Estimate shall become null and void. Contractor shall use their best efforts to provide an Estimate for a Change Order. In the event that Contractor cannot give an Estimate due to uncertainties in the scope of the additional work requested, Contractor may, with Owner's written authorization, proceed with the Change Order and bill Owner for any and all costs of completion of such Change Order. 2. ALLOWANCES. As part of the Agreement Price, Contractor has budgeted specific amounts to cover the anticipated cost of certain selections to be made by Owner (i.e. fixtures, appliances, etc.) which were not yet selected at the time the Job Specifications were written. For allowance items that are exceeded, the difference will be applied to the final installment payment of the Agreement Price. (Allowances include material costs, tax and delivery to job site.) If Owner selects items for which the total cost is less than the allowance amounts budgeted by Contractor in the Agreement Price, Owner shall receive a credit for such difference, which credit shall be applied towards Owner's final installment payment of the Agreement Price. 3. OWNER'S COVENANT OF COOPERATION. Owner agrees that in order for Contractor to perform the work, Owner will be required to work with and cooperate with Contractor. Contractor shall not be responsible for any delays caused directly or indirectly by the Owner's failure to cooperate. Owner is expected to notify Contractor immediately of any conditions or issues of which Owner becomes aware or receives notice that may impair, delay or prevent Contractor from performing any portion or all of the work. Contractor shall not be responsible for any costs, damages or liabilities incurred by Owner as a result of such delays. 2 4. MATCHING EXISTING MATERIALS AND SUBSTITUTION OF MATERIALS. Contractor will use its best efforts to alert Owner to the limitations of matching all existing materials (i.e. plaster, wood trim, paint and stain, stucco, concrete, masonry and roofing materials), and while Contractor shall make every effort to match existing materials, textures, colors and planes, exact duplication is not promised or guaranteed. Contractor shall have the right to substitute materials of similar quality, pattern and design if unable to obtain the exact matching materials within Contractor's ordinary source of supply. 5. ELECTRICAL SERVICE. Unless specifically included in the Specifications, electrical work contemplates no change to the existing service panel other than the addition of circuit breakers or fuse blocks to distribute electric current to new outlets. Cost incurred in changing point of service, main switch, or meter that may be required by inspector or serving utility shall be paid to Contractor by Owner the same as any other Change Order. Changes to the existing wiring in areas not within the scope of or unaffected by the Project are not included. 6. SUB-SURFACE SOIL CONDITIONS. Contractor does not assume any risk as to sub-surface soil conditions of the property (i.e. muck, rock formations, ledges, buried trash or debris, etc.) and if any sub-surface soil conditions which affect the work to be performed are encountered they will be dealt with at Owner's sole expense and shall be considered and treated by Contractor as a Change Order. 7. PROPERTY LINES. Owner is solely responsible for the location of all lot lines and shall, if requested, identify all corner posts of his lot for Contractor. If any doubt exists as to the location of lot lines, Owner shall at his own expense, order and pay for a survey. If Owner wrongly identifies the location of the lot lines of the property, any resulting changes required by Contractor shall be at Owner's expense. This cost shall be paid by Owner to Contractor in full prior to the continuation or commencement, as the case may be, of work. 8. HIDDEN AND PRE-EXISTING CONDITIONS. Unless specifically indicated and set forth in the Specifications, the Agreement Price does not include "hidden conditions" or pre-existing conditions including, but not limited to, re-routing of vents, pipes, ducts or wiring conduits, correction of improper structural framing that may be discovered in removal of walls or cutting of openings in walls, insect or moisture damage and rot, sub-surface soil conditions as set forth in Paragraph 6 above, prior inferior workmanship or materials, pre-existing hazardous materials or toxic wastes or any kind, or other conditions which could not reasonably have been known to Contractor prior to the commencement of work (referred to as "Hidden Conditions"). Any work to be performed to correct such damage shall be subject to and covered by a Change Order in accordance with the terms of Paragraph 1 above. 9. ACCESS TO WORK. Owner shall grant unobstructed access to work areas for workers and vehicles and shall allow areas for storage of materials and rubbish. Owner shall also provide utility services required by Contractor at Owner's sole cost. Owner agrees to keep driveways clear and available for movement and parking of trucks during normal work hours. Contractors and artisans shall not be expected to keep gates closed for animals and children. Contractor shall protect adequately the property and adjacent property subject to this Agreement but shall not be held responsible for damage to driveways, walks, lawns, trees, and shrubs by movements of trucks unless due to Contractor's gross negligence. 10. REQUIREMENTS OF PUBLIC BODIES. Any changes, alterations, or extras from the drawing or Job Specifications that may be required by any public body, utility or inspector shall constitute and 3 be treated as a Change Order subject to additional cost to Owner in accordance with the terms and conditions of Paragraph 1 above. 11. MATERIALS REMOVED -- RUBBISH. All materials removed from the structure in the course of alterations shall be disposed of by Contractor except for Hazardous Materials as described in Paragraph 28 and those items designated by Owner prior to commencement or during construction. All construction rubbish shall be removed by Contractor at termination of work and the premises left in broom-clean condition. 12. INSURANCE. Contractor shall carry at its own expense general liability insurance of no less than One Million ($1,000,000) Dollars. 13. TOILET FACILITIES. Owner agrees to make toilet facilities available to all workers or reimburse Contractor for cost of rented units. 14.. PERMITS AND RESTRICTIONS. (Check the appropriate boxes.) ❑ Contractor Ell Homeowner shall be responsible for determining which permits are necessary and for obtaining the permits. ❑ Contractor ❑ Homeowner shall pay for all state and local permits necessary for performing the specific work unless otherwise specified. ❑ Contractor ❑ Homeowner shall be responsible for obtaining approval from the local homeowner's organization, society or association wherever such approval is required by covenant. Contractor shall comply with all requirements of such permits. Owner shall secure and pay for easements or other necessary property interests for permanent structures or permanent changes in existing facilities. Owner further covenants that there are no restrictions, easements of covenants restricting or requiring consent to the work to be performed. Contractor shall not be responsible for obtaining any variances should such variances be required to obtain a Building Permit. 15. CANCELLATION OF AGREEMENT. In the event of cancellation of this Agreement by Owner prior to commencement of construction, Owner will pay Contractor for all expenses incurred by L Contractor to such date. Contractor may cancel this Agreement because of material shortages or errors in computing the Agreement Price within ten (10) business days of acceptance of this Agreement by Owner, provided that (i) no work has commenced; and (ii) all amounts paid to Contractor are refunded to Owner. 16. UNDERGROUND PIPES. Contractor shall not be held responsible for damage to, or removing of pipes, sprinkler lines, water or sewage disposal systems or conduits in areas of excavating, grading, paving or construction. Any underground pipes which must be removed or re-routed or other unforeseen condition which must be addressed for the completion of the Project shall be a Hidden Condition, as set forth in Paragraph 8 above, and subject to a Change Order. 17. DAMAGE TO PROPERTY. Contractor shall not be held responsible for damage caused by Owner or Owner's agents and employees, Acts of God, soil slippage, earthquake, fire caused by reasons other than the Contractor's or a Contractor's agent's negligence, riot or civil commotion or acts of public enemy or terrorism. 18. EXTRA TIME AND UNFORESEEN CIRCUMSTANCES. Contractor agrees to diligently pursue work through to completion, but shall not be responsible for delays for any of the following 1.n i iJ f l--u__-___ 4 reasons: acts of neglect or omissions of Owner or Owner's employees or Owner's agents, Acts of God, stormy or inclement weather, strikes, lockouts, boycotts or other labor union activities, extra work ordered by Owner, acts of public enemy, terrorism, riots or civil commotion, inability to secure materials through regular recognized channels, imposition of government priority or allocation of materials, failure of Owner to make payments when due, or delays caused by inspections, or changes ordered by inspectors of concerned governmental bodies. Additionally, in the event the cost of construction, including, but not limited to, fuel, outside labor and materials, at the time of actual purchase by Contractor increases by ten (10%) percent or more of the cost at the time this Agreement is signed (although a modest price increase in materials cost may occur, large percentage increases of 10% or more are not reasonably foreseeable by Contractor as they are caused by extenuating circumstances causing an unexpected shift in supplies or demand for materials), Contractor shall notify Owner of such increased materials cost and reserves the right to adjust the Agreement Price by such increase. Owner agrees to pay such additional increase amount as part of the new Agreement Price. 19. LICENSING. Contractor shall comply with all state and local licensing and registration requirements for the type of work involved. 20. LIENS AND ASSESSMENTS. Unless specifically included in this Agreement, Contractor shall not be held responsible for any bonds, liens or assessments on existing real estate, nor sewer or utility assessments not yet a lien on said property. 21. PROTECTION OF OWNER'S PROPERTY. Owner agrees to remove or protect any personal property, inside and out, including shrubs and flowers that cannot be protected adequately by Contractor and Contractor shall not be held responsible for damage to or loss of said items. 22. WORK STOPPAGE. In the event that Owner fails to make any payment due under this Agreement, or in the event that Contractor deems itself to be insecure, Contractor may require as a prerequisite to continuing the work that the balance of funds due under this Agreement be placed in a joint escrow account requiring the signature of both Contractor and Owner for withdrawal. Nothing contained herein, however, shall abridge the rights of Contractor with respect to filing of Notices of Contract and Mechanic's Liens. 23. SIGNS AND PHOTOS. Unless restricted by local zoning bylaws or community covenants, Contractor is authorized to display signs advertising and promoting Contractor as performing work on the Property until completion of work. Owner also acknowledges and agrees to allow Contractor to take photographs of the Property before, during and following completion of the project. Owner consents to Contractor's publishing any such photographs in any medium for marketing and promotion purposes, including but not limited to, advertising, printed marketing materials, industry awards and editorial in suitable publications. Contractor agrees that in no event shall Owner's name, address or other private information be disclosed as part of any marketing process or in any publication of any kind without Owner's permission. 24. STANDARDS OF QUALITY. Work will be performed in a workmanlike manner and will be built to conform to all Town and State Building Codes. The builder further agrees that all materials and equipment used in performance of its obligation will be new unless otherwise specified, and that all work will be good quality and free from defects. 25, WORK BY OTHERS. Anything herein notwithstanding, Contractor shall not be responsible for work performed by contractors or individuals not contracted or employed by Contractor. This includes any work done that was not specified in the Job Specifications including, but not limited to, assisting 5 Owner to move furniture. Furthermore, Contractor shall not be liable for any damage to property or bodily injury caused by Owner, or caused by Owner's agents, employees or other trade contractors under direct contract to the Owner working on the site. Owner agrees to defend, indemnify and hold Contractor harmless from and against any and all claims, suits, losses or liabilities, including attorneys' fees and expenses, due to work performed by any individual or business other than Contractor (and subcontractors retained directly by Contractor) as part of the Project. This includes claims for any and all work which is contracted directly by the Owner. 26. DEFAULT. Owner agrees upon signing this Agreement, either before or after acceptance by Contractor, to be bound thereby and in the event of a breach of this Agreement by Owner, Contractor shall be entitled to full compensation for work performed, loss of profits, and in event of a legal dispute, all costs and reasonable attorney's fees. In the event Contractor fails to fully perform under the terms of this Agreement, Owner's sole and exclusive recovery shall be limited to their actual damages, but in no event shall any such recovery exceed the total of all payments actually received by Contractor under this Agreement, unless otherwise required by law. 27. LIMITATION OF LIABILITY. Contractor's total aggregate liability for any claims or damages arising out of or in connection with this Agreement will be limited to the lesser of (a) the amount in dispute, or (b) the amount of the last payment due on any applicable Schedule of Payments, except for Contractor's obligations as provided for in the Limited Warranty attached hereto. Contractor will not be liable to Owner for any indirect, special, consequential or punitive damages of any kind arising in any manner from this Agreement or the performance or nonperformance of any obligation under this Agreement. Contractor will not be liable to Owner for any claims or damages arising from any design work provided by an Independent Designer, not contracted or employed by Contractor. Owner must notify Contractor in writing within ten (10) business days of the completion of the project of any claim under this Agreement. 28. HAZARDOUS MATERIALS. Unless otherwise specifically provided for herein, Contractor shall not be responsible for removal and/or for disposal of any "Hazardous Materials" as defined by any federal, state or local law, regulation or ordinance, including without limitation, asbestos and asbestos containing material, lead paint and/or other lead-based substances, and if such "Hazardous Materials" are encountered in the course of Contractor's work, then Owner shall pay any and all additional costs to remove and / or dispose of such "Hazardous Materials" in accordance with such federal, state and local laws, regulation and ordinances. Owner shall indemnify and hold harmless Contractor from and against any and all claims, costs losses, damages and expenses, including, but not limited, to reasonable attorneys' fees, arising from or involving any such hazardous materials. If, in the course of construction, Contractor encounters materials reasonably believed to be hazardous or toxic which have not been rendered harmless, Contractor may suspend the performance of the work until a licensed EPA approved contractor abates or corrects said problem and renders the work area free of such hazard. In the event Owner elects not to proceed with the Project because of the discovery of the hazardous materials or any other environmental health hazard, Contractor shall be entitled to terminate this Agreement and shall be entitled to be paid, as liquidated damages and not as penalty, for all unpaid costs, fees and expenses, including the prorated cost of overhead expenses earned at the time of termination, as well as a prorated percentage of Contractor's total anticipated profits. 29. DESIGNATED CONTACT. To help streamline the process, the parties agree that Contractor may rely on the signature of either spouse or partner to bind Owner on any and all change order and selection forms and the verbal approval of either spouse or partner with respect to any other decisions to be made. NTY CONTRACTOR WARRANTS that all materials,facilities, work nanship, and equipment will be free of defects, and of specified quality; and will function properly for a period of i eaa,s).from the date first tivritten above. Contractor will assign and deliver to ovmer all guarantees, warranties,and operating instructions of any Subcontractors,Manufacturers.or Suppliers that are applicable to any portions of the work. Within ten (10) days of first knowledge of any defect, or failure to function properly, Contractor is to be notified, in writing; of same by owner or his/her agents. Contractor shall be given first opportunity to promptly repair,replace and/or correct any item found to be defective,or that fails to function properly,at no cost to owner,within, a reasonable period of time. This Warranty does not apply to any construction work that has been subject to accident,misuse and abuse, nor to any construction work that has been modified,altered, defaced and/or had repairs made or attempted by others.Under no circumstances shall Contractor be liable, by virtue of this Warranty or other-vvisc for damage to any person Ol-Property whatsoever. or consequential damages,of any nature, arisin out of tl e se Orinab li ,to usbecause of the construction or for any special, indirect, secondary defect. T HIS WARRANTY IS IN LIEU OF ALL OTHER WARRANTIESeEXPRESS OR IMPLIED. it; Cit-------- Diamond Hill Builders LLC ' ------------------ Great North Property management /Debbie pe#ers ��'1���'' � s-�------ Date-- Deposit $1,000.00 3r-c{ Due Progress Payment#1 At Si art $3,163.00 Due Date------------------ Progress Payment#2Ai JOGS' $3,162.00 Due Date--------------------- Final Paymen# $ 2,000.00 Due Date------ __------ We thank you for choosing us for your new project. We hope that we have been Knowledgeable and helpful to your design and pricing process. We look forward to doing business with you.. If you should have any questions please contact Chris at 603-235-9526 Diamond Hili Builders, LLC www.dial-nondhillbuilders.colli 7 The Commonwealth of Massachusetts Department of IndustHul Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 iviviv.nu Ss.govI(lia Workers'compensation insurance Affidavit:Builders/Conti•actors/Electi•icians/Plumbers. TO BE TILED WITH`i'HE PERMITTING ACITIiORITX. Applicant Information Please Print Le ibl le Name(Businessl0rgani7allon/individual): rl �_� � �--.1_b J Address: q far f�Vr�. ------------- City/State/zip: Q.�r l � N _O)885' Phone #: etre you an employer?Check file appropriate box: Type of protect(required): L am a employer with, employees(full and/or part-time). 7, ❑New construction 2.[]1 am a solo proprietor or partnership and have no employees working for me in R- n Remodeling any capacity.[No workers'carp.insurance required.] 9. [] Demolition 3.L]I all,it homeowner doing all work myself.[No workers'comp.insurance require,j t 10[]Building addition 4,1 Into it homcownrr and will be hiring contrctors to conduct all work on try propetty. 1 will ensure that all contractors eioter have workers'compensation insurance or are sole I LQ Fleetrieal repairs or additions proprietors with uo employees. 12,0 Plumbing repairs or additions 5.�I am a general contractor and I have hired the sub-contractors listed ora the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.F1Other-1-11 6,F]We are a corporation and its of3icen have exercised their right ofexemption per MGI,a 152,§1(4),and we have no employees.[No workers'comp.insurance required.) rAaay npplic�ant that cheeks box If I must also fill out file section below showing their workers'compensation policy information. t ttomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tGontractors 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'camp.policy number. I alit an enfployer that is providiffg)t)ort,els'c.ofnpensation insnralice for iffy employees. Below is the policy and job site inforfvation. �r Q Insurance Company Policy 11 or Self-ins.Lic,9 46 _87,43"2'01 d S Expiration Date: 001 1, Job Site Address:__ Y City/.State/Zip:Vtate/Zip. Atld6ver I cfA - — Attach a copy of the Workers'colliPensatiOn policy declaration page(showing the policy numbe>t and expiration elate). Failure to secure coverage as required underMGT.,a 152,§25A is n criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the forth 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(lo hereby certify uncle a gains affd pe pe►ju)y that the information provided above is true and correct Date121-2011 Signahtrc ._ _. __, _ Phone#' 5W- ,5_36 Official rose only. Do not write ill this area,to be completed by city at-town Official. City o►•Town:.-----,,---- Permit/License# Issuing Authority(circle one): 1. Board of health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector S.Plumbing Inspector (i.Other Contact Person: _ _--.-,_-- Phone li: ,.Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuint,to this statute,an einpl(�vee is defined as"...every person in the service of another under any contract ofIlirc, 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 tile foregoing engaged in it joint enterprise,and including the legal representatives of it deceased employer,or the receiver or trustee of in individual,partnership,association or other legal entity,employing ernployces. 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(to 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." MGI,chapter 159 &9.5Q61 also gnte-S 111"t"Cver Ys filte Or local licensing agency shall withhold tile issuance oil renewal of a license or permit to operate it 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,MGI,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 necessnry,supply sub-contractors)name(s),address(es)end phone number(s)along with their certificate(s)of insurance, Limited Liability Companies(LIX)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If all LLC or LLP does have employees, a policy is required, De advised that this affidavit may be submitted to the Department of Industrial Accidents foi-confirmation orinsurance 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 thatthe affidavit is complete and printed legibly. The Department has provided ispace I t the bottom of tile 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,all 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 RIOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, SUite 100 Boston, MA 02114-2017 Tel. // 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax It 617-727-7749 Revised 02-25-15 www.11lass.gov/(Iia ® DATE(MMIDDIYYYY) AC CERTIFICATE LIABILITY INSURANCE 4/28/2016 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 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). CN PRODUCER NAMEACT Jessica Hildret.h, ACSR CROSS INSURANCE - LACONIA (PAHONE (603)524-2425 F� (603 524-3666 1C o Ext 155 Court Street ADDRESS:jhildreth@crossagency.com INSURER S)AFFORDING COVERAGE NAIC# Laconia NH 03246 INSURERA.-Frankenmuth Mutual 13986 INSURED INSURERB:Continental Indemnity Com an DIAMOND HILL BUILDERS LLC INSURER C: 98 PORTSMOUTH AVE INSURERD: INSURER E: STRATHAM - STRATHAM NH 03885-2415 INSURERF: COVERAGES CERTIFICATE NUMBER-CL1592150689 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DD MMIDDIYYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED 300,000 A CLAIMS-MADE ❑X OCCUR PREMISES Ea occurrence $ BOP6165548 9/19/2015 9/19/2016 MED EXP(Any one person) S 5,000 PERSONAL BADV INJURY S 1,000,000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 JECT PRO- LOC PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY� � S OTHER: ''. AUTOMOBILE LIABILITY Ea aaccident)NED SINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) S A ALL OWNED SCHEDULED AUTOS Ix AUTOS BA 6165548 9/19/2015 9/19/2016 BODILY INJURY(Peraccident)AUTOS NON-OWNEDHIRED AUTOSpeOracEatlTY DAMAGE accident) $ Uninsured Motorist $ 1,000,000 $I UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 2,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000 DED RETENTIONS BOP6165548 9/19/2015 9/19/2016 $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETORlPARTNER/EXECUTIVE E.L.EACH ACCIDENT S 100,000 OFFICERIMEMBER EXCLUDED? NIA B (Mandatory in NH) 46-643442-01-05 9/19/2015 9/19/2016 EL_DISEASE-EA EMPLOYEE S 100,000 If yes,describe under '.. DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500 000 A EMPLOYMENT PRACTICES LIAB BOP6165548 9/19/2015 9/19/2016 EACH CLAIM $100,000 RETENTION: $5,000 AGGREGATE $100,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Christopher Howlett is excluded from Workers' Compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Great North Property Management THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Prescott Village, Ciation ACCORDANCE WITH THE POLICY PROVISIONS. 3 Holland W�yI- AUTHORIZED REPRESENTATIVE Exeter,,-Nf? 03833 G� J Hildreth, ACSR/JH5 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 roman ACCORE0 CERTIFICATE F LIABILITY 9 DATE(MNItDDIYYYY) 5/5/2016 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 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 NAMME: Jessa.ca Hildreth, ACSR CROSS INSURANCE - LACONIA PHONE (603)524.-2425 FAx ..(AIC—No. ------- -. NC Nod:C603),524-3666 155 Court Street aDQRE s:IL 7hildreth@crossagency.cam INSURER(S�AFFORDING COVERAGE NAIC# Laconia NH 03246 INSURERA:P'rankenmuth Mutual. 13986 INSURED INSURER B.Continental Indemnity Com an _......_ ...... DIAMOND HILL BUILDERS LLC INSURER C'_,. 98 PORTSMOUTH AVE INSURER D INSURER E: STRATHAM NH 03885-2415 INSUPER F: COVERAGES CERTIFICATE NUMBER:CL1592150689 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 A DLSU6R _.... �..._ LTR TYPE OF INSURANCE POLICY NUMBER l�004Amn EFF MPO DYNY P YI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S1,000,000 ---I A JCLAIMS-MADE C_�OCCUR DA A ETCSREPiTED~-- 300,000 _PREMISES IEa acrxxre—_ $ BOP6165548 9/19/2015 9/19/2016 MED EXP(Any ane person) S 5,000 _._..__ ........ __... PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 .�-POLICY E� f 1 LOC - PRODUCTS-COMPtOPAGG $ 2,000,000 OTHER: -----..., S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT BODILY INJURY(Per person) - - A ANY TO ( - (Ea accadent 1,000,000 ALL OWNED SCHEDULED _ AUTOS r AUTOS BA 6165546 9/19/2015 9/19/2016 BODILY INJURY(Perarc;dent) S • HIRED AUTOS -AUTOS PROPERTY OAMAGE NON-OWNED -- ._ }{ UMBRELLA uA6 Uninsured Maza ist S 1,000,000 OCCUR EACH OCCURRENCE S 2,000,0 00 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000 .__ .--- _ .....__ ._. DED RETENTIONS BOP6165548 9/19/2015 9/19/2016 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE_.... E_R __...,.... ANY PROMEMBER EXCLUDED?ECUTIVE r`-- E.L.EACH ACCIDENT $ 100,000 B If es,describe under _� N t A _ ._ _ ._. OFFICER/MEMBER EXCLUDED? ; Y (Mandato 46-643442-01-05 9/19/2015 9/19/2016 E.L.,DISEASE-EA EMPLOYE $ 100-Ir-90 0 D ns, OF OPERATIONS below ppp E.L.DISEASE-POLICY LIMIT $ 500,000 A EMPLOYMENT PRACTICES LIAR y d ROP6165548 9/19/2015 9/19/2016 EACH CLAIM $100,000 RETENTION: $5,000 4 tl AGGREGATE $100,000 I w DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space is required) Christopher Howlett is excluded from Workers' Compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE North Andover Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. Building 20, Suite 2035 North Andover, MA 01845 AUTHORIZED REPRESENTATIVE J Hildreth, ACSR/JH5 01988-2014 ACORD CORPORATION. A4 rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 i9ommi Massachusetts -Department of Public Safety Board of Building Regulations and Standards i✓orstruction Super"11sor License: CS-059504 PAULRABENIU3- 134 MILL RD N HAMPTON NIT 03$ Expiration Commissioner 09/19/2016