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HomeMy WebLinkAboutBuilding Permit # 9/30/2016 %AORTJI —BUILDING PERMIT ". 1 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 9' Date Rec Permit No#: eived C HU5 o2e .z, s Date Issued: IM-PORTANT: ApRlicantj,�-iust eori�p_ _ jete-all items oil this Page LOCATION, e- Laoe Print PROPERTY OWNER 1a4'%A Prin't"" 100 Year Structure yesno MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes Lno TYPEOF IMPROVEMENT PROPOSED USE Residential Non- Residential Li New Building ❑ One family [I Addition 0 Two or more family F1 Industrial #<Alteration No. of units: —----- El Commercial-_--- p<Repair, replacement - ❑Assessory Bldg [_-] Others: L] Demolition 0 Other F1 Septic 11 Well 0 Floodplain 0 Wetlands [I Watershed District E Water/Sewer .6,44�WCRIPTION OF WORK TO BE PERFORMED: r- ce- Identification- PI se Type or Print Clearly OWNER.- Name: Phone: 978' 360 4L4 %J I Address: 8cl 01�, \1'\\OC4e % - e. t�o(+k �taAo er N\h 0 184-S .__......m_...._..._. -------- mm-- Contractor Name: Kexus &er,%Ac_es Phone: _T?l -760 2CG0 Email: aeckL-5) cAp-gusc-arp - Com Address,-:1_0,2_&x�� ,\4 Supervisor's Construction License: CS- 0-73qgj___Exp. Date: -71;Z0 18'_ Home Improvement License: 129 1-77 Exp. Date: -7 1201-7 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEESCHEDULE.BULDING PERMIT.'$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. 00 Total Project Cost- $ 4q. 36, FEE: Check No.: 7 01 Receipt No.: NOTE4 : Persons con i;;" tla uni,egisrred contractors elo not have access to thhegualrant fu,,n,,d -------------- Ag!_ &6�ner Plans Submitted ❑ Pians Waive, Aft is ❑ TYPE OF SEWERAGE DISPOSAL, i Mark Gotobed Tanbrn /M al Manager well ❑ Tobaccgo S,' Nexus li Carpentry Gener P.O.Box 2823,Woburn,MAO 1888 1'rzvate(septic tank, etc_ ❑ Ponuanent T 781.760.2031 F.978.975.1263 r>lark@nexuscarpentry,com www.Ne .c -----_-_._ xuscar entr Y i THE FOLLOWING SE_CTIoNs F'OR OFFICE USE ONLY INTERDEPARTMENTAL, SIGN OFF a U FORM /PLANNING & DEVELOPMENT Reviewed On Signatsre��. COMMENTS CONSERVATION Reviewed on Si nature l 41-�l COMMENTS �1 (� HEALTH Reviewed on Signature COMMENTS rte' Zoning Board of Appeals:Variance, Petition No: Zoning Decisionfreceipt submitted yes. Planning Board Decision; Comments Conservation Decision: Comments Water & Sewer Connection/S� nat�ro&Date ©riuswa Permit ]DPW Town Engineer: Signature: Located 384 Osgood Street FIREI DLPARTMERNT - Temp Dumpster gn.site yes no. Located at 1N Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. fl.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE° Yes NO MGL.Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES And DATA-- {dor department "se e I AN 3 I i 3 3 9 3 u 0 Notified for pickup Calf Email Date Time Contact Name Doc.Buildin;Permit Revised 2014 11V&®RTq Town of 4 b over C,, h� ver, Mass, �x� 70 'QA coc Mic Ka wacR`41' F.Q 0.?ArED p,VA�.�S S BOARD OF HEALTH Food/Kitchen PERMIT LD Septic System THIS CERTIFIES THAT ......A.0 .......... .. ,� BUILDING INSPECTOR ........................... ..._. Foundation has permission to erect ..................... uildings on .. .. ...�1! ,.. �....� ... ., . Rough to be occupied as , ... .... .:. ... ,. ... Chimney provided that the person accepting this per shall in ery respect conform the terms of the app ' Final on fife 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 T ELECTRICAL INSPECTOR LESS CONST N S Rough Service ., .... . ..... ... Final BUILDING INSPE OR GAS INSPECTOR ecy2ancy Permit Required t® Occupy BuildrnRough 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 wilding Inspector. Burner Street No. Smoke Det. t AC 'cit�ase cJ� rOL ; Ice,e, � ���� s`� � ed e- RAS JJ AWG' 4-4,em'. H rf, i Tc),, Akj(-OjAy',JG 1N or a r tl t fir ' ` 3 t. ` = `. R 1} � V ny t ` } `' Page 1 of 6 Nexus II Carpentry and Construction Design P.O.Box 2823 Woburn,MA 01888 781 760 2031 Fax 978 975 1263 nexuscar entr aol.com Contract This is a contract between Nancy and David Phillips of 89 Old Village Lane, North Andover MA 01.845 (Hereafter referred to as the "owners") and Nexus 11 Services (hereafter referred to as "Nexus") dated September 12th 2016. GENERAL SCOPE OF WORK DESCRIPTION WE HEREBY SUBMIT SPECIFICATIONS .AND CONTRACT FOR: work as stated below to repair/replace existing deck, install a screen room and turn mud room into an enclosed breezeway Scone of work: u. General details ♦ Meet with local building official and apply for permits ♦ All work will be in accordance with local building code regulations and will be inspected by local officials prior to continuing with the next phase----Nexus will be responsible for arranging and being available for all inspections ♦ Nexus will contact "Dig Safe"prior to commencing any excavation work for their clearance ♦ All work will be coordinated directly between"owners" and Nexus ♦ Nexus confirms that it is fully licensed, insured and ensures any sub-contractors utilized on this site will have the appropriate insurance coverage ♦ Nexus will be responsible for the safe storage of all its property and any materials to be used on the site ♦ Owner is responsible for removal and return of all items of the house in the areas that will be affected and their safe storage prior to our work commencing SPECIALIZING IN QUALITY FINISH CARPENTRY, REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT Page 2 of 6 ♦ Owner will then be responsible for returning all items to these areas of the home after completion of the scope of work ♦ Remove and trash into Nexus supplied dumpster all trash associated with this project NOTE: appliances are not allowed to be put in dumpsters without additional costs "owners" are responsible for removal from site Scope of Work—Deck, screen room and breezew ♦ Provide an onsite dumpster for the duration of the project Deck ♦ Remove and trash existing deck structure ♦ Furnish and install sonatube foundations to code o Furnish and install framing to code and to existing layout ♦ Furnish and install an insect screen on top of all the floor joists across the new deck ♦ Furnish and install all flashing details and structural connections ♦ Furnish and install "Azek Slate Gray" deckingu��� ♦ NOTE: Azek Slate grey is a nice looking/color/board at an affordable price -there are many other colors to choose from(some cheaper/some more expensive) - if you have a different color you want me to get a price for-just let me know!! ♦ Furnish and install White composite risers to new stairs e Furnish and install white vinyl posts, handrails and ballesters - Intek brand(photo attached) ♦ Add white skirt boards and trim to perimeter and side of new stairs ♦ Proposed cost including materials and labor is $23,500.00 Screen room -Basic "rustic look" o Remove and trash existing shingles from 2 existing house walls ♦ Furnish and install 6" x 6" posts to create a screen room approximately 16' x 12' ♦ Furnish and install ceiling joists onto structural headers to form a'lean to" roof NOTE: Ceiling joists will be exposed ♦ Furnish and install exterior grade plywood to top of ceiling joists ♦ Furnish and install roof shingles (to match to existing shingles on home as closely as possible) ♦ Furnish and install a screen door to entry room ♦ Add a ceiling fan with switch and light(fixture supplied by you) o Furnish and install an exterior grade white vinyl bead board to the 2 walls (currently I� where your siding is!!) Proposed cost including materials and labor is $11 275.00 additional SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT i 3: Page 3 of 6 Breezeway/mud room o NOTE: existing ceiling to remain "as is" but be painted ♦ Furnish and install framing with planned opening to the front and rear of the existing breezeway NOTE: front wall to have a 36" entry door and 1 window- rear wall to have 1 slider ♦ Furnish and install 1 window to front wall and to match to windows in home Furnish and install 1 - 9 lite fiberglass entry door to front wall o Furnish and install 1 - 6' slider to rear entry wall (no grills) o Remove siding from the 2 long walls and install sheetrock with a smooth plaster finish, add baseboard trim,then paint- $1, 750.00 allowance as per previous email ♦ Furnish and install insulation to front and rear wall AND garage wall and breezeway ceiling- $600.00 allowance as per previous email o Furnish and install a wall mounted electric heater on its own thermostat($930.00 allowance based on cubic area required) -Nancy and I discussed having this separate to the existing heating so it can be controlled individually!! Furnish and install 4 - 6" recessed ceiling cans 1 Furnish and install 2 wall sconces (supplied by owner) on 2 separate switches (1 to front and 1 to rear entry) Furnish and install sheetrock with smooth plaster finish to new framing only o Furnish and install interior trim to new doors, window and baseboard only o Furnish and paint the walls, ceiling and trim ♦ Make minor repairs to the existing concrete floor using an epoxy($430.00) ♦ Furnish and paint the concrete floor($380.00) o Proposed cost including materials and labor is$12 590.00 additional Work not included in this contract Building department fees Engineering or architect costs Permit costs Unseen conditions Window changes Customer supplied electrical fixtures - fan x 1 + exterior lights x 2 to front and rear of new breezeway Tile, grout, sealant for grout or Threshold as noted Customer supplied items as noted above g —Nor any other items not specifically included in the scope of work above. Optional extra#1; Screen room - Ceiling option_Add an exterior vinyl white bead board ceiling in sheet form- adds $2 300.00...........OR...........an exterior grade tongued and grooved board to ceiling- adds $21900.00 _Optional extra#2; Optional extra 41; Breezeway- install tile, grout and sealant supplied by you to floor of breezeway (including floor leveler) - adds $2, 500.00 Optional extra#3; Breezeway- Remove sheetrock from the ceiling and install sheetrock with a smooth plaster finish,then paint - adds $1,200.00 SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT t Page 4 of 6 PERMITS "Nexus"has accepted the responsibility to obtain the necessary building permits."Nexus"will act as a GC and work in accordance with fair and reasonable practices,and cooperate fully and under the guidance of the"Owners"and authorized parties. Standard Exclusions: Unless specifically included in the"General Scope of Work''section above,this agreement does not include labor or materials for the following work(any Exclusions in this paragraph which have been lined out and initialed by the parties do not apply to this Agreement): Removal and disposal of any materials containing asbestos or any other hazardous material as defined by the EPA. Custom milling of any wood for use in project. Moving"Owners"property around the site. Labor or materials required repairing or replacing any"Owners"-supplied materials. Repair of concealed underground utilities not located on prints or physically staked out by"Owners",which are damaged during construction. Surveying that may be required to establish accurate property boundaries for setback purposes(fences and old stakes may not be located on actual property lines). Final construction cleaning("Nexus"will leave site in "broom swept"condition). Landscaping and irrigation work of any kind. Temporary sanitation,power,or fencing. Removal of soils under house in order to obtain 18 inches(or code-required height)of clear space between bottom of joists and soil. Removal of filled ground or rock or any other materials not removable by ordinary hand tools(unless heavy equipment is specified in scope of work section above),correction of existing out-of-plumb or out-of-level conditions in existing structure. Correction of concealed substandard framing. Removal and replacement of existing rot or insect infestation. Construction of a continuously level foundation around structure(if lot is sloped more than 6 inches from fi•ont to back or side to side,"Nexus"step the foundation in accordance with the slope of the lot). Exact matching of existing finishes. Repair of damage to roadways,sidewalks,or driveways that could occur when construction equipment and vehicles are being used in the normal course of construction.The"Owner"is to enter into contracts for all of the above-mentioned services and provide direct payment to"Nexus"for all of the services we are to provide."Nexus'will be responsible for removing all components and all construction materials relevant to the "scope of work"in this contract. Dum stern trailers and sip-as "Nexus"will provide as included in the cost of this project,a dumpster for the sole purpose of the removal of trash associated with this project.This dumpster should not be used by any persons for any other waste items or for any purpose outside of the specific use under the scope of work,unless authorization is received from"Nexus".Nexus may have on site for part,or the whole of the project,a trailer containing materials and tools belonging to"Nexus".This trailer will be parked in a position agreed to in coordination with the"Owners"and will be covered under the insurances of"Nexus"at all times."Nexus"will have on site,a sign,with our contact details,in the event that anyone, including your neighbors,has a need to contact us directly. Photoeraphs "Nexus"reserves the right to,from time to time,take photographs of the contracted work for use in its general marketing or for production on its web site.At no time will"Nexus"share any personal contact details of the"owner" for any photographs that it may use without seeking authorization from the"owner". Warranties All the components supplied by"Nexus"as part of the original order are covered under the warranty exercised by "Nexus"and supported by the vendors or sub-contractors.All labor and materials purchased from other suppliers to achieve completion of contract are warranted(1)one year from completion of the construction. Owner appointed sub contractors From time to time an"owner"may request that we incorporate a sub-contractor of the"owners"choosing on a project. "Nexus"will facilitate this request provided the assigned sub-contractor is connected directly with `Nexus"for all scheduling requirements and"nexus"will manage this sub-contractor in a fashion comparable with any other sub- contractor.All sub-contractors must be licensed and insured in accordance with State law."Nexus"will meet with these sub-contractors and will ask them to submit a written proposal of all the work that will be included which "Nexus"will then confirm with the"owner"."Nexus"will oversee this scope of work and ensure that it is completed in a professional manner but the sub-contractor will be responsible for any future warranty issues directly with the owners".All sub-contractors are responsible for the safe and clean upkeep of the working environment and will be responsible to remove their associated trash on a daily basis. Deliveries "Nexus"will be responsible for the safe arrival to site of all materials required for construction purposes for items contained within the scope of work.The"owners"shall be responsible for the safe arrival to site of other items outside of construction materials,however,should"owners"require"Nexus"to collect and bring to site,any of these items, "Nexus"will accommodate as able and add a minimal cost to cover time and fuel to a change order. SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT i I Page 5 of 6 Weather Delays Nexus has made provision to attend the site throughout the project,and as weather allows—any changes to this schedule will be advised to the client as appropriate.Inclement weather, inclusive of hurricanes, tornado's,snow storms and other events,will affect the ability of Nexus to attend the site, and will therefore affect the ability of Nexus to perform those tasks assigned within this contract. In the event of an unplanned weather event, it is the responsibility of the`owner"to ensure that access to the site is maintained,so as to allow for work to recommence as soon as possible. Personal Property,Pets and Children "Nexus"will be respectful at all times, of the personal property of the"owners"but does ask that all personal items be removed by the"owners prior to commencement of the scope of work,and not returned to the area until the scope of work is complete.It is the responsibility of the"owners"to make alternative arrangetnents for the safety of any pets that dwell in the residence or facility,and"Nexus"will not be responsible for the care of these pets,or other live animals,during the duration of the scope of work. Children living in the residence or facility,should be advised by the"owners"of the dangers connected with construction projects and the need to stay clear of the areas being worked upon,as well as away from any tools that will be on site. Allowances with the contract cost Within the cost structure of this contract,certain cost allowances may have been given for the"owners"to purchase items chosen by them--these allowances will be noted above with the amount allowed clearly noted. If the"owners"do not spend the full allowance in an area,this amount will be credited back to the customer and not included in the final contracted amount. If the"owners"spend beyond the allowance noted,then the"owners"shall be responsible for this balance and a payment made to cover this amount either to the vendor,the sub-contractor or to"Nexus" Expiration of this Agreement: This Agreement will expire 30 days after the date at the top of page one of this agreement if not accepted in writing by"Owners"and returned to"Nexus"along with the necessary deposits within that time frame. People Authorized to Sign Change Orders: The following ogle are authorized to sign Change Orders: "Ne s": Mark Gotobed or Ged White l r "Cli t' ancy or Dav' hill' s1 Concealed Conditions: This Agreement is based solely on the observations"Nexus"was able to make with the area in its current condition at the time this Agreement was bid. If additional Concealed Conditions are discovered once work has commenced which were not visible at the time this proposal was bid, "Nexus"will stop work and point out these unforeseen Concealed Conditions to"Owners"so that "Owners";and"Nexus"can execute a Change Order for any Additional Work. SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT Page 6of6 Schedule of work It is agreed by both parties that this work will be coordinated with the"Owners" and "Nexus" to be undertaken in various stages to avoid complete disruption of the home environment."Nexus"will give"Owners"no less than 2 days notice prior to arriving on site for commencement of any of the agreed stages of work to allow"Owners"to prepare. "Owners"commits to have sites identified for construction work available for start at the beginning of the scheduled day so as to avoid any unnecessary delays. Contract Cost and Payment Schedule: Total cost of work description and materials included in the proposal (except materials/work stated - $47, 365.00 (Forty seven thousand three hundred and sixty five dollars and zero cents) PAYMENT SCHEDULE Ist Payment due upon signing this contract TOTAL $15, 788.00 2nd Payment due upon completion of deck TOTAL $20,000.00 3rd Payment due upon completion of screen room TOTAL $10,000.00 Final payment due upon completion of scope of work TOTAL $1, 577.00 Amount due upon signing this contract-_$152.788.00 1 have read and understand, and 1 agree to, all the terms and conditions contained in the proposal above. Date....l .� m............ "Nexus" Authorization..................... ........... Date...� .�. .. �....... Client" Authorization.......... . .. ....... Date............................... "Client"Authorization...................................................... SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT i i I ra i f Q rw r I ri/rr P r /ii ii rii r / / rrlr r�JI� F � Yi a r , r uw rr� � Y �r ql r'i (• �p�j' r l^�"}r" r/r, r� w r �✓r���1� ll r iv/ r� 'ti Irl 1 1 V i 1, r J �il r' I I "gym �trig / d 41 r ar 4 Nil YAW i 7 ill I ,,J G/ / —JIM r/trI 'IVII' lrM r 1 7NEW�\ti £� — °sj" North Andover MIMAP September 13, 2016 6*7 CF��1�90��2FtY�LPd���!u � y 7 058:0-f1d6d a 446.0-pa9O� , � l 103 qLd 1eGILLAG;E LYY ���/gyp,\�%`i%�'!� I r �1i1 iV 446.0-Oa88 ��„� 058.0-006w % r r d5s.a-dd6�1 a46.a-dag� a46.a-da85 �4 CxC D WILLAG Lhd 046.0-aa84 /,, 0 MVPC Be Interstates Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, I Motors Data Sources:The data for Ihis map was produced by Merrimack —SR 14bWTN Valley Planning Commission(MVPC)using data provided by the Town of Roads 0* 4+� r "� North Andover.Additional data provided by the Executive Office of 4"u Easements ,�.. �ea"e'dp Enviromcentai Afralm/MassGIS.The informalaon depicted on this map is 4 Pascals L for planning purposes only.It may not be adequate for legal boundary— "" 0 ...mdelloillon or regulatory Interpretation.THE TOWN OF NORTH ANDOVER + MAKES NO WARRANTIES.EXPRESSED OR IMPLIED,CONCERNING Y f} ♦"”'"""'., THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION 'MAC Wt is 1"=67 ft }-' North Andover MIMAP September 16, 2016 046:0-a101 28 COPLEY CTR 046.0-0103 859.0-pp92 059.0-oa70 '35 046.0 0p9y J,' RAY LPd ,r 4.7 GRAt�9a�R ,;... + 1 4 � "' +�,rlrA➢kzr[tir &:ml". ��T'�ia�' k �J// h 59 Cf�hi'�8B6RFiY Llw# � � I u I II�IV� �irylxmlir��r , C'J� �, oJh�a, 2x23 CMIICKBR"IN4 RD 38 CC1F�f EY GIR Agit e'r r� ��ti� �rrrt�� My C�oQ��� p4M6 0 0100 Cr C''flu�l l 05�9�0- 3 6�7 CF���'NBERRYLfMV . 1 45 COFy'LEY CIR46 COPL�Y GTR ! „N o46.o-ao99 r 209 CMAC-K�RI•iVG RD ,�" a� �� 046.0-p005 � 69 OLD VILLACaE LI�J I 059.0-0060 " �UrT9�1L.p UILL.AG6 LN 125 OLD VILLIRG� Lhl 046.0-0090 e 046.p-0088 89.�(7LD UxLL�aCe : LAA ,I' p59.0-0063 I 103 OLD YLLLAGB LI'�%�, ��"' lNl� r 76 OLD bTLLAGE Lh➢ 124 OLD UILL�#G LIQ � ( �aC` 05'9.17-4706.2 � 86 OLD VILLAGE LN r`. 114 OLD UILLAIGE LN 059.0-OO,6�],;��` 96 OLD ULLLAGE LfV 046.0-0093 100 OLD WILLAfiE LN 046.a-Op95 p46.0-0094 046.0-0008 059.0-0017 (3 MVPC Be Interstates Horizontal Datum:MA Slateplane,Coordinate System,Datum NAD83, --I Meters Data Sources:The data for Ibis reap was produced by Merrimack —SR NORT►y Valley Planning Commission(MVPC)using data provided by the Town of Reads O� �a r A,V North Andover.Additional data provided by the Executive Officer of < e• O Envkonmemet AffairsfMassGIS.7"he information depicted on this map Is tr Easements "�` b� 4 for'planning purposes only.It.me not be adequate for legal boundary { i 4r rep. e Y a9 g Y Parcels Q .-. � definition or regulatory interpretaliarr.THE TOWN OF NORTH ANDOVER F- 'xi MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY *rf. OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT rl• e`a5�* ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE Or 4w<as.• wa M,., THIS INFORMATION �1s^s'AC HUS�Se(°' 1"=114ft y AC R" CERTIFICATE OF LIABILITY INSURANCE DATE x/14/201616 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 CONTACTLauren Goldman NAME: ._..._,_., Cross Insurance-Peabod PHONE (978)532-5445 FAX (978)532-2217 y ,Na,Ext): .....,. _._ AIC No: 139 Lynnfield Street ADDRESS,lgoldman@crossagency.com INSURERS)AFFORDING COVERAGE NAIC# Peabody NIP, 01960 INSURER A:Western World Ins. Co. INSURED INSURERB:Sa£ety, Indemnity _ 33618 Nexus II Services LLC INSURER C: ...... P.O. Box 2823 INSURER D INSURER E Woburn NIA 01$$$ �INSURERF: COVERAGES CERTIFICATE NUMBER:CL1683184059 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. .W.-.._ADDL SUHR �_....� POLICY EFF POLICY EXP .. IN TYPE OF INSURANCE LIMITS LTR NSD D POLICY NUMBER MMIDDIYYYY MMIDDIYYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A CLAIMS-MADE FIOCCUR PREMISES Ea occurrence},_, $ NPP8382051 8/12/2016 8/12/2017 MED EXP(Any one person) $ 51000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO 1 LOC PRODUCTS-COMPIOP AGG $ 1,000,000 JECT __ OTHER: Damage to Rented $ 50,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ 500,000 ALL OWNED SCHEDULED 3116632 11/10/2015 11/10/2016 BODILY INJURY(Per accident) $ 500,000 AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ 100,000 X HIRED AUTOS X AUTOS Per accident Medical payments $ 5,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE % DED RETENTION$ �.._... $ WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY YIN STATUTE], ER ANY PROPRTETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT _ ,$ OFFICER/MEMBER EXCLUDED? NIA — -"_"--" (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E,L,DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE David and Nancy Phillips THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 89 01d Village Lane ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE V I Lauren Goldman/MD1 f 6. ,✓ddfd&wA_, ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 1NS0250m4n1t �.. _._. The CatttneaulveaCth of Massachusetts Department a,f ndustrialAccidents w � I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Conti-actors/Electricians/Plumbers. TO BE TILED waif TETT;PERMITTING AUTHORITY. Alatrlicant Information Please Print Legibly Name (Business/Organization/Individual):_ r� _j9 J�1 C Address: . 0 • t�,C+�JC ��� --------- City/State/Zip: WOS�taft� 01 Phone M t -766 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with___„_.-.-_._-._ employees(frill and/or part-time).* 7. E]New construction 2.M I am a sole proprietor or partnership and have no employees working for me in S, E]Remodeling any capacity.[No workers'comp,insurance required.] 9. ❑Demolition 1,[—] am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.Fj I aan 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 I I.❑Electrical repairs or additions proprietors with no employees. 12,E]Plumbing repairs or additions 5, 1.ama general contractor and I have hired the sub-contractors listed on the attached sheets 13 Roof repairs 'hese sub-contractors have employees and have workers'comp.insurance.' 01\ , \p- , G.F�We are a corporation and its officers have exercised their right of exemption per MGI,c. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. f Ilomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional shect showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they trust provide their workers'comp.policy number. lain tin en:player tliat is providing workers'co»tpensation itisurarece for my enrl)loyees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lie.#: _...__ __- .. _ Expiration Date: Job Site Address: (,'ity/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,c. 1.52,§25A is a criminal violation punishable by a fine tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORI{ORDER and a fine of tip to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c tify ut l Z�� alties of pet jury that the information provided above iq triite and correctSi nature: Date: 1 Phone#: � ).-..,_..r O 1 Ofjicial use only. Ido not write in this area,to be conyVeted 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#: ., r/ r / / ,.o... r ,.�„ is ,... ,. ✓�../ .r...� /rr /� �/.. r ,,,,.... .., „ ,,,/.... r„ :,.: r/ _.///,,, it „/�/,. 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