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HomeMy WebLinkAboutBuilding Permit # 6/28/2016 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: / Date Received °R�re° ---Lil � SAC HUS�� Date Issued: IMPORTANT: Applicant must complete all items on this page CATION"""""'q rint PROPERTY 01NNER ,> P point,; , PaRCEL ZONINpISTRICT: Historic 't- no, , r chineSliopVillage yes- no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other d'81 Septic ❑�UVe{I ❑Floodplain ❑Wetlands ❑ Watershed'District ❑'Water/Sewer S n X22 Identification Please Type or Print Clearly) OWNER: Name: Phone: '1 - ® 3 qO Address: AclI„ EJ r v�AJ CONTRACTOR':Name: Can hone: $ (g ' a Nq 3 a Or(.P � n 4: Mid X01 lq ,Address: , Super'V sor's Constrtactton License: Exp. Dafe: Horne CrrYra�remerif LEcer�se ; ,, Ex Date: (� p �ojn 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: $ 90,ooQ FEE: $_ W Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of'contractor , --- —3 t%O R TH Town of W Andover � - Lp ® AIL , �nKa ver, a.ss coc"ic„lW.CX U BOARD OF HEALTH Emma Food/Kitchen P El AL Septic System 6 64 THIS CERTIFIES THAT .............. ..................................3 T LD ... ...................... .................. ........ . .. ...,... BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on ...... :...........�. Jusef..... ........o.............. ... ............. Rough tobe occupied as .............. ......... ... .. .. F......:............................................. 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST I Rough Service . ....... ... .... ..... Final (2B . . G I. C OR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing r Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. DIAMOND CONSTRUCTION, C® 1 Worcester St.,Suite 10 Grafton,MA 01519 xefil diamondconstructionma@gmail.com 1 /7 HIC License# 176910 DIAMOND CS Lic.080830 CONSTRUCTION INC. CONSTR[7CTION AGREEMENT THIS AGREEMENT is made at On this day of I q of 2016,_by and between DIAMOND CONSTRUCTION, INC. (hereinafter the "Contractor") and f��� oc7}°fes (hereinafter the "Owner")located at es ���t DESCRIPTION OF SERVICES Diamond Construction,Inc.agrees to provide labor,materials,equipment and other facilities required to complete the following work: Scope of work at the property located at which owner warrants that it is the owner with full authority to enter intoAhis agreement. Diamond Construction, Inc. agrees to start this project on l h5' and shall complete the work on 13 le' , .If the project passes filial inspection and Owner refuses to sign Notice of Completion,then Contractor may sign this Notice of Completion on behalf of Owner as it will be assumed that he is satisfied with the work. PAYMENT i C/2015-This document is binding and has serious legal consequences.Feel free to consult with a qualified attorney prior to signing. SCOPE OF WORK ImMIMI '�B ®• a e 1) There will be a Project Manager inspecting the project � 100% 1 1 i i 2) Install Safety equipment before starting working l j j 100% ✓ ! 1 { 3) Cover house&shrubs with tarpaulins for the protection { i 100% ✓ 4) Strip 2 layers roof shingle all the way strait to the wood 1 100% 5) (Each additional layer plus$30.00 per Iayer/per SQ) f � ? " ? i (If cedar$50/per SQ)(If Slate$90/SCS) ( 6) Re-nail all loose roof boards I 100% ✓ t I _ ' 7) If wood is needed,the extra charge is'54-7,00 per Y? 3 � [ ? ; ? Cf.-)X plywood or$ -.00 linear foot of legend Hoards 8) Install Leak Barrier/Ice and Water Shield: 100% ✓ GAF Storm Guard 0 Weather Watch 0 OR CertainTeed Winter Guard(D: Sand I. Granular❑ High Tack/1-ffgh Temperature(1711n1)0 on 6 feet on the eaves,6 feet on the valley,3 feet on rakes and 2/a"Overhang to the fascia j 1 9) Install Synthetic Underlayment: ! 100% ✓ GAF Tiger Paw TM 0 Deck-Armor 0 OR ( ! l I R i CertainTeed Diamond Deck( 911, f1 10) Install Drip Edge: 100% ✓ ! 8"to the roof deck in 1"Overhang to the fascia aluminum to all i edges. Color Choice: White E Silver 1]Brown 0 11) Install Attic Exhaust Ventilation: ' 11 100% ✓ 1 #� GAF Cobra® Rigid Vent'11 Cobra@) Snow Country'"0 or f CertainTeed Ridge Vent C " ji O 12) Install Ridge Cap Shingle: 1000/( _ ✓ t i GAF Timber Tex@)❑ Seal-A-Ridge®❑ or � f j CertainTeed Ridge&Hip Cap L/ 13)Apply Starter Strip Shingles to be aligned next to one 3 ? 100% ✓ another with sealant toward the eave. f 14) California Cut(If any) j 10 % ✓ I 15) Install New Vent Pipes (If any) CJV DIAMOND CONSTRUCTION,INC. 1 WORCESTER ST,Suite 10,GRAFTON,MA 01519 -'.-E-MAIL:diamondconstructionma@gmaiLcom Phone:(508)365-7300-(508)688-4493 H 716)Install Metal Flashing at every dormers and`Nall Areas 100% � 17)Install New Aluminum Step Flashing to the Chimney 100% 18) (Lead Flashing Chimney at fair-market price:a ? ? 19) Mote.If the siding removal is needed,extra cost may apply for ? ? labor and material. 20) Install New Architect Roof Shingle: sq.Ft $ GAF Timberline❑ Certai anrxia ®kms Color Choice: 1a 21) Clean all the Gutters on the New Roof 100% V 22) Use 3ft magnet to remove all the nails from around the house 100% 23) includes M Hurricane Nailing©Permits MDumpster 100% 24) Material is supplied by Diamond Construction INC. 100% 25) S1q Light 26) Cutters ? 27) Garage 28) Fascia -h' 29) Shed House , 30) Soffat Y ? 31) RED I4r'ICANS: THAT IS NOT INCLUDED IN THE PRICE ESTIMATE OR CONTRACT-ADDITIONAL CHARGE WILL APPLY FOR LABOR AND MATER"IAL. 32) This Symbol V means that is included on the estimate or contract price. GRANT TOTAL $ DIAMOND CONSTRUCTION,INC. 1 WORCESTER ST,Suite 10,GRAFTON,MA 01519 vo®E-MAIL:diamondconstructionma@gmail.com Phone:(508)36S-7300-(508)688-4493 DIAMOND CONSTRUCTIOr, INC. Owner agrees to pay Contractor the amount of$ (subject to adjustments such as additions and deductions pursuant to authorized change orders).Owner shall pay for all permits,licenses and easements for permanent structures or permanent changes in existing facilities.In the event Owner obtains their own permits,Owners shall be excluded from Residential Contractor's Guaranty Fund pursuant to Mass.General Laws Chapter 142A.City permits and licenses to complete the work shall be paid by Diamond Construction.All payments are due and payable upon receipt. Payments will be made according to the following schedule: C .00 Upon the execution of this agreement.Includes material costs,permit costs, Aster fee; $ .00(whichever is greater)of the contract sum upon commencement of the work; $.� 00 (whichever is greater)of the contract sum upon completion of the work. If material/equipment required were special ordered there will be no exchanges, refunds,credits,or returns. Payments shall be made in available U.S.funds and payable to"Diamond Construction,Inc."Payments made will be non-refundable once Contractor starts to perform, starts to demobilize in any way,engaged subcontractors,or has ordered materials.All payments will also be subject to deduction for administrative expenses.Owner agrees to pay $50.00 for each and any non-sufficient fund checks.If an invoice is not paid when due, interest will be added to and payable on all overdue amounts at 6% per year.Owner shall pay all costs of collection,including without limitation,court costs and reasonable attorney fees. PLANS/SPECIFICATIONS Prior to the start of the work,Owner shall provide to the Contractor all plans, surveys, specifications, drawings, blueprints, and reports describing the physical characteristics, soil, geological and subsurface conditions,utility locations, and similar documents that may assist Diamond Construction,Inc.in properly evaluating the extent and character of the work at the estimate stage. If any drawing, blueprint,floor plan, or specification violates or is in conflict with local law or/and ordinance, and where any such situation results in any necessary changes in the work, then Diamond Construction, Inc. shall be entitled to a reasonable adjustment to the Contract price and time to correct it. 2 C/2015-This document is binding and has serious legal consequences.Feel free to consult with a qualified attorney prior to signing. DIAMOND CONSTRUCTION, C® CHANGE ORDERS All change orders shall become part of this contract and incorporated by reference. The Owner shall notify Contractor of any changes in construction or plan and shall provide revised drawings,plans,or specifications followed by a change order. If the changes in the change order pertain to differing site conditions,errors in the plans and specifications, or other circumstances beyond the control of the Contractor (including acts by the government,fire,flood, unusual delay in transportation, abnormal weather conditions, labor disputes, strikes, war, lack of worksite access, acts of God, natural disasters, or acts of third-parties), then Contractor shall submit to the Owner an estimate and proper adjustments to the contract price and time.If pricing is inapplicable, cost of the change or the amount of the adjustment shall be determined based on the cost to -Diamond Construction plus reasonable amounts for overhead and profit. Contractor shall not be obligated to perform changes in the work or additional work until the Owner has approved,in writing,the changes to the contract price and time. SITE CONDITIONS Owner acknowledges the -duty to disclose any and all pertinent and known hazardous condition information to Contractor and subcontractors and may not mislead or conceal any material or property facts such as how many layers of roof or type of roof was originally installed. Where a site owner does not disclose facts that subsequently cause delay or need further cost,then the Contractor will then be entitled to recover damages and a change order shall be allowed fox additional costs. After consultation and agreement with the Contractor, Owner must immediately make an adjustment in the contract time and payment by issuing a change order if Contractor discovers and notifies owner of any of the following: (1)11azardous Materials deemed by any federal, state or local governmental authority to pose a present or potential hazard to health,safety,or the environment; (2)Any Subsurface, visible, nonvisible, or latent physical conditions that are found unexpected or that seem different from the work agreed upon; (3) Unknown physical or other conditions that seem strange or materially different frpzn those encountered by Contractor's during and based on his construction experience. 3 C/2015-This document is binding and has serious legal consequences_Feel free to consult with a qualified attorney prior to signing. DIAMOND CONSTRUCTION, C® Upon discovery of any of the above, Contractor shall immediately stop work at that particular site. Contractor shall have no obligation to perform any corrective or remedial work. TERMINATION Owner is required to first provide a 5 day advance notification of any alleged breach and allow Contractor 10 days to cure such alleged breach. Owner may terminate the Contract if the Contractor knowingly disregards applicable laws, statutes, ordinances, or local codes,has committed a material breach,if contractor made an assignment for a creditor,or becomes insolvent. Diamond Construction, Inc. may terminate this Contract if. Owner becomes insolvent, will not allow access to the site, Owner commits a material breach or fails to pay an invoice on time;work is suspended for 10 consecutive days through no act or fault of the Contractor or a Subcontractor, Sub-subcontractor or their agents or employees; or there is a stop work order by any court,or any stop work order issued by any town or authority. If any of the above occurs,then Diamond Construction shall send a written termination notice to the Owner and recover from the Owner payment for work performed,including reasonable overhead and profit,costs incurred by reason of such termination, and damages. If the Owner terminates the contract on convenience, he shall communicate of this intention writing to Contractor as soon as possible. Then, on or before the termination date, Contractor shall be paid its actual costs for that portion of the work performed to the date of termination and for all costs of termination, including demobilization and any termination payments already made to vendors and subcontractors, plus 20 percent of all such costs for overhead and lost profit. INSURANCE The Diamond Construction, Inc. shall carry and maintain throughout the project period valid Workers' Compensation and General Liability insurance. Certificates of insurance can be provided to Owner upon request prior to commencement of the work. Contractor ensure that the general liability coverage to includes the Owner as additional insureds for claims caused in whole or in part by the Contractor's negligent acts or omissions during the Contractor's work. 4 C/2015-This document is bindigg and has serious legal consequences.Feel free to consult with a qualified attorney prior to signing. DIAMOND CONSTRUCTION9 INC. The Owner must have and maintain throughout the project and until completion property insurance coverage (Builders Risk Insurance or other suitable cover) at minimum the amount of the contract price. Property insurance including loss or damage shall cover the Owner, Diamond Construction, Inc., Subcontractors and Sub-subcontractors for their interest in the Work and shall insure against the perils of fire with extended coverage and physical loss or damage including coverage for theft, vandalism, malicious mischief, collapse, debris removal. Owner waives all rights of recovery against the Diamond Construction, Inc. for loss of use of the Owner's property,including consequential losses due to fire or other hazards,however caused . If the Owner does not have and will not obtain property insurance,the Owner shall inform Contractor in writing prior to start of the work.If the Diamond Construction,Inc. is damaged by Owner's failure to have or maintain insurance as described above, without notifying the Contractor, then Owner will be responsible for all costs associated to such damage. Owner and Diamond Construction, Inc. waive all rights against each other and. against all other Subcontractors and Owner for loss or damage to the extent reimbursed by any property or equipment insurance applicable to the work,except such rights as they may have to the proceeds of such insurance. If any applicable policies of insurance require an endorsement or consent of the insurance company to provide for continued coverage where there is a waiver of subrogation, the owners of such policies will cause them to be so endorsed or obtain such consent.Owner must not use or borrow any tools or ladders owned by Contractor. If Owner, without consent, uses Contractor's tools or ladder, then he shall hold Contractor harmless of any liability whatsoever and will not place any claim on Contractor's insurance. DELAY Diamond Construction,Inc. shall provide to the Owner notice of any delay in work. for changes necessary due to work schedule, suspension of work or any other unforeseen cause beyond Diamond Construction's control and/or where there is no fault by the Contractor, its Subcontractors or supp4ers. The contract time shall then be extended as necessary to accommodate delays via change order. SUSPENSION OF WORD 5 C/2015-This document is binding and has serious legal consequences.Feel free to consult with a qualified attorney prior to signing. DIAMOND CONSTRUCTION9I Cm Diamond Construction,Inc.,may suspend work for Owner's failure to pay invoice on time, due to differing site conditions, or for changes requested by Owner where Contractor deems it may suffer financial hardship.If work is stopped for a period of 10 consecutive days due to no act or fault of the Contractor or a Subcontractor or their agents or employees; or if because the Owner has repeatedly failed to fulfill the Owner's obligations under the contract then Contractor, at his discretion, may immediately suspend work, terminate the Contract, and recover from the Owner. illevwner racy suspend work vY�ith advance notice to the Contractor. The written_ notice shall specify the date and the estimated duration of the suspension. Any Owner suspension shall not exceed 24 hours. Once the suspension is removed,the Contractor shall resume performance of the Work as soon as it is possible. Owner will be liable then for all and any damages for suspension of work which may include costs of demobilization, extended overhead costs,jobsite costs,etc. Any suspension of work under this Contract will also suspend the progress and completion dates. FORCE MA.JEURE if performance of this agreement or any obligation herein is prevented, restricted, interfered by reason of act of God, fire, flood, or other natural disaster, malicious injury, strikes, lock-outs, or other labor troubles, riots, insurrection, war or other reason of like nature beyond either party's reasonable control then performance of such act or obligation shall be excused for the period of the delay.If any delay under these circumstances exceeds 5 days,then either party shall have the option to terminate this Agreement. INDEMNIRCATION Diamond Construction, Inc. shall indemnify and hold Owner,its employees, officers, directors, and affiliates harmless from any loss, cost, expense, or damage claimed by third parties for property damage and/or bodily injury,including death,to the proportionate extent such loss, cost, expense, or damage arises from the negligence or willful misconduct of Diamond Construction,Inc.,its employees,officers,or directors in connection with the Contract or project.Owner shall indemnify,defend,and hold Diamond Construction,Inc.,its Subcontractors, employees, officers, directors, and affiliates harmless from and against any and all claims, demands,causes of action,liabilities, loss,cost, expense,or damage claimed by third parties for property damage and/or bodily injury, including death, to the proportionate extent such loss, cost,expense,or damage arises from the negligence,fault, or 6 C/2015- This document is binding and has serious legal consequences_Feel free to consult with a qualified attorney prior to signing_ DIAMOND CONSTRUCTION, C® willful misconduct of Owner, architects, designers, its employees, officers, or directors in connection with the Contract or project. WARRANTY Diamond Construction, Inc. warrants that the work will be conducted in good professional workmanlike manner, and warrants that materials furnished will be of good quality and new. If within two years after the date of completion any of the work, it is found not to be in accordance with good craftsmanship, the Contractor shall correct it promptly after receipt of written notice from the Owner. The Owner shall give such notice promptly after discovery of the condition. During the two-year period for correction of Work, if the Owner fails to notify the Contractor then Owner waives the rights to require correction by the Contractor and to make a claim for breach of warranty.In the event that any of the provisions of the warranty shall be held invalid, the remainder of the provisions of the warranty shall remain in full force and effect. Where Contractor's repair warranty work involves the matching of existing finishes or materials,he will use his best efforts to match existing finishes and materials.However, Contractor does not guarantee an exact match due to such factors as discoloration due to the aging process,difference in dye lots, and difficulty of exactly matching certain finishes, colors,and planes.This warranty specifically excludes consequential damages and the following: 1.Damage on shingles due to ordinary wear and tear,abusive use,normal wear and tear, . improper use,misuse, or lack of proper maintenance of the home or its component parts or systems. 2.Defects,or loss or injury not caused by the negligence of Diamond Construction,Inc. or its subcontractors. 3.Defects in items installed by the Owner or anyone other than Diamond Construction,Inc. or its Subcontractors or defects in items supplied by the Owner. 4. Conditions not caused by Diamond Construction,Inc. and or it's Subcontractors resulting from condensation,or contraction of materials. ACCESS The Owner shall provide ample access to the site to Diamond Construction, Inc. throughout the project. Any delay or blocking of access by Owner will entitle Diamond Construction,Inc.to a reasonable adjustment in the contract price and time. 7 C/2015-This document is binding and has serious legal consequences.Feel free to consult with a qualified attorney prior to signing. DIAMOND CONSTRUCTION,INC. INDEPENDENT CONTRACTOR STATUS The parties agree that the contractual relationship between Contractor and Owner is of an independent contractor.No documents signed create a partnership,join venture or any other relationship between the parties. ADDITIONAL CLAUSES. ® Diamond Construction,Inc.'s suggestions are not a substitute for professional engineering, architectural, or design services,and are not to be relied on as such by Owner. ® This agreement represents the entire agreement between the parties regarding the work described above and supersedes any prior written or any oral agreements or communications. This agreement may only be modified or terminated in writing. ® No breach of any agreement,warranty or representation shall be deemed waived unless expressly waived in writing by the party who might assert such breach. ® If any clause of this Contract is determined to be illegal or unenforceable for any reason,it shall be severed from the Contract and the rest of the Contract shall be given full force and effect.The terms,covenants and conditions of this Contract shall be binding upon and shall inure to the benefit of the successors and permitted assigns of the respective parties to this Contract. ® The agreement shall be governed by the laws of the Commonwealth of Massachusetts.The parties hereby agree to submit to the jurisdiction of the courts located within this Commonwealth for any controversies arising out of this agreement. ® Owner hereby acknowledges he/she has had ample opportunity to consult with independent legal counsel,has read it,understands it,and is signing it freely and voluntarily. ® If Owner is signing this agreement at his home,or at a place other than at the contractor's office or business,then there is a 3-day cancellation right. I as-a-Owner.of the subject property,hereby authorized DIAMOND CONSTRUCTION INC to-act on my behalf,in wall matters relative to work authorized by any building permit applications. �. �v�l Diamond Construction,Inc. Owner's Name: Contractor �o�t?ct Manager Owner's Signature: ` Phon � Phone: : 508( )365-7300 ` ( , Office:(508)688-4483 Email: � -/� diarnondconstructionmaCD gmail.com 8 C/2015-This document is binding and has serious legal consequences_Feel free to consult with a qualified allomey prior to signing. DIAMOND CONSTRUCTION, INC. INDEPENDENT CONTRACTOR STATUS The parties agree that the contractual relationship between Contractor and Owner is of an independent contractor.No documents signed create a partnership,join venture or any other relationship between the parties. ADDITIONAL CLAUSES. • Diamond Construction,Inc.'s suggestions are not a substitute for professional engineering, architectural,or design services,and are not to be relied on as such by Owner. • This agreement represents the entire agreement between the parties regarding the work described above and supersedes any prior written or any oral agreements or communications. This agreement may only be modified or terminated in writing. • No breach of any agreement,warranty or representation shall be deemed waived unless expressly waived in writing by the party who might assert such breach. • If any clause of this Contract is determined to be illegal or unenforceable for any reason,it shall be severed from the Contract and the rest of the Contract shall be given full force and effect. The terms,covenants and conditions of this Contract shall be binding upon and shall inure to the benefit of the successors and permitted assigns of the respective parties to this Contract. • The agreement shall be governed by the laws of the Commonwealth of Massachusetts.The parties hereby agree to submit to the jurisdiction of the courts located within this Commonwealth for any controversies arising out of this agreement. • Owner hereby acknowledges he/she has had ample opportunity to consult with independent legal counsel,has read it,understands it,and is signing it freely and voluntarily. • If Owner is signing this agreement at his home,or at a place other than at the contractor's office or business,then there is a 3-day cancellation right. I as-a Owner of the subject property,hereby authorized DIAMOND CONSTRUCTION INC to-act on my behalf,in wall matters relative to work authorized by any building permit applications. Owner's Name: UQ' _ Diamond Construction,Inc. Owner's Signature: r Contractor ' tManager Phone: ��� Phos :'f 508)365-7300 Email: f CZ tw G a Office:(508)688-4493 diamondconstructionma@ gmail.com 8 C/2015-This document is binding and has serious legal consequences.Feel free to consult with a qualified attorney prior to signing. The Commonwealth of Massachusetts Department of IndustrialAccidents t i I Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information PI ase Print Legibly Name(Business/Organization/Individ al): i � �� Address: VU �J �e- . State/Zip: iState/Zip: a7 7 CMMA 01 5AOi Phone#: 5 0 Are you an employer?Check the appropriate box: Type of project(required): 1.52'am a employer with _employees(full and/or part-time).* 7. ❑New construction 2.❑1 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 In I am a homeowner doing all work myself.[No workers'comp.insurance required]t 10 Q 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.Q Plumbing repairs or additions 5_❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp_insurance$ 14.F30&her e 6.[3We 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 must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information.Insurance Company Name:�2;4w O —1 U Q -- Policy#or Self-ins.Lic.#: �C—L00 6 Q I t tALq Expiration Date: 0.O�� Job Site Address: hLI'VSek 5� City/State/Zip: [ CEJ\)Q�� �A�- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify der the pa' ndpenalties ofperjury that the information provided above is true and correct: Si afore• l Date: Phone#: $ J 3 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#• - — - -- — - -- - - - - - - — uz/zV1zu1b THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Jana Grady NEIGHBORHOOD INSURANCE LLC. /PHONE E 508-476-5535 a No 9 MAIN ST AIL ADDRESS: jgrady@neighborhoodinsuranceagency.com SUITE 3A1 INSURER(S)AFFORDING COVERAGE NAIC# SUTTON,MA.01590 INSURER A: CATLIN SPECILATY INSURANCE INSURED INSURER B: Mapfre/COMMERCE INSURANCE DIAMOND CONSTRUCTION INC. INSURER C: A.I.M.MUTUAL 1 WORCESTER ST INSURER D: INSURER E Grafton,MA01519 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE AND WVDR POLICY NUMBER MM/DD /YYYY MM /DD EXP LTR LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE ®OCCUR 20020028 4/06/2016 4/06/2017 PREM SES(Ea occurAMAGE TO rence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL BADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 F] POLICY❑PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY Ea BINEDtSINGLE LIMIT $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED D32577 3/01/2016 3/01/2017 BODILY INJURY Per accident) $ AUTOS AUTOS ( ' HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per.accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETORMARTNER/EXECUTIVE Y/N WWC 100 6017419 4/23/2016 4/23/2017 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ® N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION TWIT of North Andover Building Dept SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St, BLD 20,Suite 2035 ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE Jana Grady Ccl iQRR_9nia arms rnAPAROTWIN All rinhtc racarvad Construction Supervisor Restricted to: Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a currentedition of the Massachusetts State Building Code is cause for revocation of this license. ®FSS Licensing information visit: .MAIsafiAV 81,0Z/601" aauolsSIUMOO :uol}ealdxg ZLEO X0'8'4'd VNNVM){N IAH ac�sl�.�srlt�� uc�l��rou�isub� OCRO 0" :esua0l-1 spiepuejS pue suolielnCaS 5ulpilne fc paeog x,nwo nnan.i so ivaw:pedaa s4asn4oesseW - - _ Office of Co � nsumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement-Contractor Registration Registration: 176910 DIAMOND CONSTRUCTION INC. Type: supplement Card Expiration: 10/10/2017 RYAN HANNA - 1 WORCESTER ST SUITE 10 WORCESTER, MA 01604 SCA 1 Co 20M-WlI Update Address and return card.Mark reason for change. -- ❑ Address ❑ Renewal _--— ❑ Employment E] Lost Card 93earta�na�trae2ll� ice of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date . If found return to Registration 176970- Office of Consumer Affairs and Business Regulation Type. 10 Park Plaza-Suite 5170 Expiration: 1D%10/2097 DIAMOND CONSTRUCTSupplement Card Boston,MA 02116 ION INC. RYAN HANNA } 1 WORCESTER ST SUITE 10' WORCESTER,MA 01604 y Undersecretary N"' without signature