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HomeMy WebLinkAboutBuilding Permit # 10/7/2016 UILDI G PE IT ��� �+�,,, "°16 TOWN OF NORTH ANDOVER ° 16 APPLICATION FOR PLAN EXAMINATIN Permit NO: � ' date Received � Date Issued: SACHU�� T P'ORTANTo Applicant must com fete all items on this page LOCATION I t? PROPERTY OWNER 1 Pr% ., Print MSP NO; / PARCEL: 1;?UZON`ING DISTRICT: Historic District yes no Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential [] New Building 4 One family ❑Addition C] Two or more family ❑ Industrial IJ Alteration No. of units: ci Commercial --...........-.. C epair, replacement CI Assessory Bldg [-.I Others: El Demolition i;� Jther "" cx-Je.. CCI Septic [.':I Well 0 Floodplain 0 Wetlands C1 Watershed District 0 Water/Sewer . 1 I .� .. �:, �)t . "�.�. Identification Please'T'ype or Print Clearly) - � .OWNER: Name: : 2— Address: C CONTRACTOR Name r ' M1µ Phone.- (AlI Address: .M .o. g � Supervisor's Construction License Exp. Date; n LLL Hone Improvement License; Exp. Date: ZiOC'7 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PLR$1004.00 OF THE TOTAL ESTIMATED COST BASED ON$125.04 PER S.F. Total Project CoIX t: $ °" r'f FEE: $ w ;: Check No. ie . - -- �� Receipt No.. NOTE: Persons contracting with unregistered access to h�*�aranty fund . � � u d ccrutractars ors rr�t have 9 Signature of contr w. . Signature of A ent/Owner r Plans Submitted ❑ Pians Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISP A Public Sewer Tanr�ing/MassageBody Art ]EE11 Swimming Pools ❑Well ❑ Tobacco Sales Food Packaging/Sales ❑ .Private(septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On 1p ' Signature'—"O COMMENTS L� -- � CONSERVATION Reviewed on J Si gnature , COMMENTS 00" HEALTH Reviewed on Signature COMMq'i � Zoning Board of Appeals.Variance, Petition No: Zoning Decision/receipt submitted yes Manning Board Decision: Comments Conservation Decision: Comments Wafter & Sewer Connection/Signature& Date Driveway Permit DPW Town Lngineer: Signature: FIRE Located 384 Os ood Street DEPARTIVIENT ` Temp D Yr�p r an s to yam. +.''� 1;1 a .7t Located� F kf fh ? at124 Main�'Street r Frre-Depldate f RIZ :COMMENTS ^� �� " Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: 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 rin.$9p0-$1000 fine NOTES and DATA -- (For department use) cx CA-04a�❑ Notified for pickup Call Email Date Time Contact Name Doc-Building Permit Revised 2014 OORT� s Town of _ Andover ver, Mass, a wrc« 4R' 11 S U BOARD OF HEALTH Food/Kitchen PERIT T LD Septic System THIS CERTIFIES THAT .....9N� d r� ,.... BUILDING INSPECTOR ....... ............. ...... .......... ....... has permission to erect.......................... buildings on .10.,.1...Br,.�+.`.!!.�!!!�o4...�t��......,., Foundation ... Rough to be occupied as .... .. .. ..... ... .,.... Chimney provided that the person a cepting 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 th pection, 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 EXPIRES 16 MONTH ELECTRICAL INSPECTOR UNLESS CONSTRUC N ST TS Rough Service .......... ....... ......... ............................. Final BUILDING INSPECTOR GASINSPECTOR ......-Ey .,Bu Rough Rough �cct� arc Permite ���ed to ®ccs � Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. _ r nnis 109 BrentwoodCircle North Andover MA 10-1-16 13"6" ' i House 2` 1 I � E j 7" 10 JO iiis CM 'IVO.CL 1 E 'm r - °'Ledqert Lok Bots 2 per bay i staggarea I Ilk7' 2x! m I - � ivsieps duly(Please n is is w 26- bove ill E �[ l I'-EZ Tube with "Base Foot x35 13"6" `i - 13'6" I: f 7' I 3" 5'3" 51311 I [ 4 I 3 i , z 7' Af 1 L i 3 =--- 13'6" =i i� i g1 !i414j*'os!wnhAzeK Sleeves fthrough boned-nto rim jois,and blockinc il Ji PIMf 541WILM111fill III PVC Vinvi Rad System 'AZEK) Iwi UJI �lltqj§11-119 i - S14xO-Composite Deeck Roor furooved ridden tastener) 2 " illi I till 11" EZ-TUBE wilt;22"Base 48 !A Section'xS-- ' I! EZwwTmUmBE m, OF BASE SECTION YOUR SIMPLE, IMMED ATEI ' LOW COST, SOLUTION - _ I `~ -- Se c{ i-of e„g.. Ste.. S }s� top, 4seiling bag A Bases--�atior easiiy - .Y l--w ate` .yr ops _fir' j1 !e fly t h nn-chow is Insert c, P E--P S fEC 3 � \, 'he UNH strenoth, 1355-000, 5 a 05-X, jl -System can 0e i Seal -vvtM or Vvitnoul ;-i r ect r eaw V� ink - t ac'. r teo 'V - ct. ,, S-DE VIEVY E£F 'SASE SEGTgL3ht 3. Slice Uipone- Over a7, hdesii s " 3 in no, Add oL -^ �# nut BUILD! 'Further eng neerma informat on ay. ';able upon request, v ~� L BASS ��� 5 � SZmTUBEGET MORE INFORMATION MMMAM BOUT Z—TUSK QUALITY FOOTINE-35 EZwwT*U'B'= kow Receive all the Letaiis on, iow E-Z Tube - Your Question, ;'Is LI ere a better, av ,: I s foot lr s Can benefit your buiiding prosect . been answered Els Tube is here! Call your tG al distr: utor for more seta€sed rlf rrl ?c1 and full specifications. i:o,r dealers free ;: valluabie ccm ere space by keepi n EZZ-I Ube out in Ln � weathe . Pius sell the tube= plastic case, arc ho a and' concrete ail in one. �dl Customers check out,the once ^\ comparison below to see hov 7-Tube matches up ac a f 1st other methods for building foot n s. t Pour in Place lune, concrete. relr, anchor bolt, o. cement m er.. mixer rental, Plast-c, � ~ base forma \ \ Approx. $106 Ihr .abor and cure bri e a Whole precast pier+ large I equipment rental. Approx. $295-410 ud d. Z Tube 4U!Dr,er Sections —aseSect or } x� _fin&or DI STRI E3 UTO R: HUTo-TIG Copyright 2012 E-Z Creie LLC. All rgnis reserved, a w S vs, Proposal four Services FS ProJect.. 109 Brentwood Circle 1.09 Brentwood Circle North Andover, MA 01845 Prepared For: Denis Dragonas 109 Brentwood Circle North.Andover,MA 01845 Pre ai-epi 13y: Chuck Huntley Schernecker Property Services,Inc. 283 Second Ave,Waltham,MA 02451 (781) 487-2516 chuck.huntley@spsinconline.com www.spsinconline.com ,SPS HIC #: 123615 Expiration Date: November 5, 2015 r Date Submitted: August 27, 2015 Proposal #: 5440987 109 Brentwood Circle 109 Brentwood Circle I Proposal#:5440987 Scope at' Work General Description: SPS,Inc.will provide the necessary supervision,labor,and materials to perform the work specified in this PFS in a good and workmanlike manner and in compliance with applicable laws and codes.The pricing provided in this PFS encompasses,in general,the following: Misc.Repairs at 109 Brentwood Circle in North Andover,MA. Included Areas: • Pressure wash with bleach/water to remove mildew,surface dirt,and dust to provide a clean surface for paint adhesion. • Furnish and Install (19) Harvey Building Products "Majesty" Double Hung Vinyl Replacement windows with Clear Pine Wood Interior/White Clad Exterior,LowE/Argon,Simulated Divided Lites and Half Screens. • Exterior Staining-Power wash to remove dirt,debris and mildew.Scrape to remove loose and peeling stain and spot prime bare wood with an alkyd Stain.Apply (2)Full finish coats of 100% Semi Transparent Alkyd Stain by Cabot to the exterior of the Home.Prep and Paint all Exterior Doors with 100%Acrylic Latex Paint by Cabot.This includes staining mailbox and Stand. • Spot Carpentry Replacement-Replace rotted Clapboards,Corner Boards,Storm Door Gasket at Breezeway,Front Door Trim Moldings,Lattice Repairs,Broken Deck Boards,Rear Garage Door Gasket,Any Gutter Damage,Replacement of Woodpecker damagedT&G Siding and necessary repairs to Cupola. • Re-Flash Rear Study at 2nd floor to Main House. • Clean all Roof Shingles Clean All Gutters and Downspouts,Replace cracked and broken downspouts,Tar inside Gutters and fix gutter supports where necessary. • Seat Chimney and Fix Rot at HouseTransition • Install Gutter screens oil all gutters. • Furnish and Install new Shutters on (4)Front windows of main house only. 0 Strip Breezeway roof,Install full Ice and Water coverage and flash roof to house transition properly and install new roof shingles.(6 feet up and 20 feet long -Total area= 1.2 squares) • Repair Rear Spigot Leak Remove and Replace(2)Garage Doors with "Thermacore" Sectional Doors as manufactured by the Overhead Door Corporation (Doors only,existing motors will stay). Remove Weathervane from Garage Cupola,Transport to Don's Brass and Copper Polishing,Have it re-finished,Transport back to 109 Brentwood Circle and Re-Install (Allownace only until Don can see the weathervane). 0 Stain(19)Interior Windows to match existing Interior Decor. Excluded Areas: All other requests Total Price for work as specified in the Scope of Work: $33,000.00 z S 109 Brentwood Circle 109 Brentwood Circle I Proposalft:5440957 Pricing provided on Page 5 is for specific items not included in the contracted Scope of Work.Please note that these items are additional to the"Total Price". Schedule of Work (determined at proposal signing)The work heretofore described is scheduled to commence on with an expected duration of approximately days.Substantial completion is expected by Acceptance of Proposal The undersigned,as authorized representative(s)of the property listed,have read the terms stated herein and accept the terms as written. JIK�Ao� 08/27/15 SIGNATURE DATE SIGNATURE DATE Chuck HuntlV Vice President Denis Dragonas NAME TITLE NAME TITLE u 3i I 109 Brentwood Circle 109 Brentwood Circle I Proposal#:5440987 Tot,al 11"Irice, fi,,)r work4as sp(: dfied in (he, Scope of Work Type of Price/Type Item Description Quantity Quantity of Quantity Extended Price 1. Furnish and Install (19)Harvey Building Products 1.00 Entire House $16,205.00 $16,205.00 "Majesty" Double Hung Vinyl Replacement windows with Clear Pine Wood Interior/White Clad Exterior, LowE/Argon,Simulated Divided Lites and Half Screens. 2. Exterior Staining-Power wash to remove dirt,debris 1.00 Entire House $5,900.00 $5,900.00 and mildew.Scrape to remove loose and peeling stain and spot prime bare wood with an alkyd Stain,Apply (2)Full finish coats of 100%Semi Transparent Alkyd Stain by Cabot to the exterior of the Home.Prep and Paint all Exterior Doors with 100%Acrylic Latex Paint by Cabot.This includes staining mailbox and Stand. 3, Spot Carpentry Replacement-Replace rotted 1.00 Entire House $3,500.00 $3,500.00 Clapboards,Corner Boards,Storm Door Gasket at Breezeway,Front Door"Trim Moldings,Lattice Repairs,Broken Deck Boards,Rear Garage Door Gasket,Any Gutter Damage,Replacement of Woodpecker damaged T&G Siding and necessary repairs to Cupola. 4. Re-Hash Rear Study at 2nd floor to Main House. 1.000ne Location $750.00 $750.00 5. Clean all Roof Shingles 1.00 Entire House $300-00 $300.00 6. Clean All Gutters and Downspouts,Replace cracked 1.00 Entire House $500.00 $500.00 and broken downspouts,Tar inside Gutters and fix gutter supports where necessary. 7. Seal Chimney and Fix Rot at House Transition 1.00 Chimney $425.00 $425.00 8. Install Gutter screens on all gutters. 1.00 Gutters $375.00 $375.00 9. Furnish and Install new Shutters on(4) Front 1.00 Shutters $600.00 $600.00 windows of main house only. . __ — � I--- &I one 109 Brentwood Circle 109 Brentwood Circle I Proposal#:5440987 and install new roof shingles.(6 feet up and 20 feet long-Total area= 1.2 squares) 11. Repair Rear Spigot Leak 1.00 Spigot Leak $50.00 $50.00 12. Remove and Replace(2)Garage Doors with 1.00 Garage $2,385.00 $2,385.00 "Thermacore" Sectional Doors as manufactured by Doors the Overhead Door Corporation (Doors only,existing motors will stay). 13. Remove Weathervane from Garage Cupola,Transport 1.00 Refinish $250.00 $250.00 to Don's Brass and Copper Polishing,Have it re- finished,Transport back to 109 Brentwood Circle and Re-Install (Allownace only until Don can see the weathervane). 14. Stain (19)Interior Windows to match existing Interior 1.00 Stain $1,045.00 $1,045.00 Decor. 15. REPEAT/LOYAL CUSTOMER DISCOUNT 1.00 DISCOUNT ($610.00) ($610.00) Total: $339000.0 Additional Items, Alternate Iterns C,Ind thlit Prices Type of Price/Type Item Description Quantity Quantity of Quantity Extended Price There are no additional or alternate items to note. 109 Brentwood Circle 109 Brentwood Circle I Proposal!/:5440987 Prol,-,)ertly Notes & .I)Tesent Job C"'onditions The following conditions were identified during the visual analysis of the property.These notes are not meant to be, nor to replace,an engineering report.Additional historical information and/or an invasive analysis would be likely to provide further information. Pricing Notes EPA RRP / Lead paint The pricing provided assumes that the property was built after 1978 or that the work being performed will not require SlIS,Inc.to follow the EPA guidelines for renovation,repair and painting(EPA RRP rule).If the work is subject to the guidelines of the EPA RRP rule or any DEP or local rule regarding lead paint,then the pricing will be re-evaluated and will likely increase. Permit SPS,Inc.acting as the Owner's agent,will apply for and obtain any necessary construction-related permits. The cost of any such permits will be paid by SPS,Inc.and shall be included in the pricing provided,unless specifically excluded.The Owner or its agent shall assist SPS,Inc.,with any required signatures,documents,or other cooperation necessary to obtain such permits.Construction control by a licensed engineer or architect,if required by the permitting authority or if elected by Owner,is not included in the pricing provided and is to be contracted directly by the Owner. Unforeseen Conditions/Change Orders Renovation work involves removal of existing materials to expose hidden surfaces.By its nature,renovation work is likely to result in uncovering conditions that were not foreseen.It is likely that unforeseen conditions will be uncovered when existing materials are removed. Unforeseen conditions usually necessitate changes in the scope of work and an increase in the total price of services.Changes to the scope of work as a result of unforeseen conditions will be presented to the Owner or managing agent in the form of a written Change Order.All Change Orders,regardless of the reason for the Change Order,must be documented and approved in writing by SPS,Inc. and Owner or Owner's agent.Change Orders may be approved by email. Additional Pricing Notes 109 Brentwood Circle 109 Brentivood Circle I Proposal/f:5W987 Proposal Tenn's Proposal:This proposal is valid until November 5,2015. If this proposal has not been accepted by said date,then this proposal is deemed withdrawn by SPS. Acceptance of Proposal: The signature of the Owner or Owner's authorized agent shall constitute Owner's agreement to the terms and conditions contain herein. Owner's Managing Agent: If Owner has engaged the services of a property management company("managing agent")to act OD its behalf with regard to the subject matter of this agreement,the managing agent and its representatives shall be considered authorized agents of the Owner.With regard to the subject matter of this agreement,Owner shall be bound by and SPS,Inc.shall be entitled to rely upon statements and actions of the managing agent. Entire Agreement:This proposal and any documents specifically listed under Conti-act Documents or incorporated by reference constitute the entire agreement between SPS,Inc.and Owner,Both parties warrant that there have been no promises,obligations or undertakings,oral or written,other than those herein set forth.No material modification of the terms of this Agreement shall be effective unless approved in writing by SPS,Inc.and Owner or Owner's agent.Modifications may be approved by email. Work Progression:Start dates,amount of time needed to complete the work,and completion dates will be estimated a I t the time of signing of the PFS,prior to the commencement of the work.The schedule may be modified by mutual agreement for any reason.Changes in the Scope of Work are likely to impact the schedule.Inclement weather and other circumstances beyond SPS,Inc.'s control are also likely to cause changes in the work progression.Delays caused by Owner,its managing agent or their representatives,may result in additional charges. Representations:SPS,Inc.is in the business of providing maintenance and capital improvement services to real property.The PFS contained herein has been prepared on the basis of a visual inspection of the property.SPS makes no warranties or representations about the physical condition of the property at the time of this proposal. Materials Storage and Inspection:SPS,Inc,requires that it be allowed to store the materials and equipment necessary for the performance of the specified work on the property in a mutually agreeable location.Such materials and equipment shall be subject to inspection and approval by the property agent. Protection of Work Areas:The work areas are to be secured and protected during the performance of the work.Unless otherwise noted,SPS Inc.will be responsible for damages to the Owner's property caused SPS Inc.during the performance of the work. Rubbish Clean Up and Removal:SPS,Inc.will dispose of rubbish,trash and debris resulting from the performance of the work in a mariner approved by the Owner or authorized agent.Such disposal will be in compliance with applicable laws and regulations.SPS,Inc.shall maintain the job site in reasonably neat and clean condition during the performance of the work. Completion and Acceptance:The work will be deemed to be complete when the conditions as described in the PFS have been performed by SPS,Inc.Upon completion,SPS,Inc.will provide notice to the Owner that the entire work or an agreed portion thereof is complete.Upon such notification,the Owner or Owner's agent will promptly inspect the work and will notify SPS,Inc.of any incomplete or defective work.SPS, Inc.shall take such measures as are reasonably necessary to complete such work or remedy such deficiencies. Insurance:SPS,Inc.maintains Worker's Compensation Insurance,General Liability Insurance and Automobile Insurance.Upon request,SPS, Inc.will facilitate the delivery of a Certificate of Insurance from its insurance agent naming the property Owner as an"Additional Insured." Warranty:Unless otherwise noted,SPS,Inc.warrants the work performed under this PFS against defective workmanship for a period of two (2)years from the date of completion and acceptance.This warranty is expressly conditioned upon the Owner's full performance of its payment obligations hereunder.Any holdback or nonpayment by Owner will invalidate this warranty. Owner shall also have the right to terminate the agreement for convenience.Owner shall give SPS,Inc.ten(10)days advance written notice. Owner shall be responsible for paying SPS for all work performed to the date of termination plus SPS reasonable costs of demobilizing plus twenty percent(20%)of the value of the work remaining to be performed under the agreement. Nominal versus actual dimensions:The actual dimension of a 2x4 is approximately 1.5"x 3.5"."2x4"is the nominal dimension.The actual dimensions of many materials differ from their advertised nominal dimensions.Nominal dimensions are used in proposals and specifications. 109 Brentwood Circle 109 Brentwood Circle t Proposal#:5440987 damages,loss or expense was due to gross negligence,willful misconduct or material breach by SPS,Inc.Owner shall indemnify SPS,Inc., for any and all damages,losses,and expenses arising therefrom including but not limited to attorney's fees and expenses. Termination:SPS,Inc.'s termination for cause.Should(1)the work be stopped by any public authority for a period of thirty(30)days or more, through no fault of SPS,Inc.;(2)the Owner fail to make any payment properly due hereunder in a timely manner;(3)the Owner cause or fail to prevent a condition that results in an unreasonable delay in SPS,Inc.'s ability to perform hereunder;or(4)the Owner fail to comply with other material terms of this agreement,then SPS,Inc.,shall give written notice by certified mail or by hand to Owner or Owner's authorized agent specifying the grounds for termination.Owner shall have seven(7)days to correct the condition giving rise to the notice.If the Owner fails to cure within seven(7)days after receipt of the notice,then SPS,Inc.may stop work or terminate the Contract.SPS,Inc.shall be entitled to recover from Owner payment for all work executed plus twenty percent(20%)of the value of the work remaining to be performed under the agreement. Owner's termination for cause.Should SPS,Inc.(1)abandon the work;(2)fail to diligently prosecute its obligations under this agreement;(3) or blatantly disregard applicable laws and codes;then the Owner shall give written notice by certified mail or by hand to SPS,Inc.,specifying the grounds for termination.SPS,Inc.,shall have seven(7)days to correct the condition giving rise to the notice.If SPS,Inc.,fails to cure within seven(7)days after receipt of the notice,then the Owner may terminate the Contract.SPS,Inc.shall be entitled to recover from Owner payment for all work performed to the date of termination. Safety: SPS,Inc.will maintain a safe work zone.Anyone entering the work zone should wear appropriate Personal Protective Equipment (PPE).At a minimum this includes hard hat and safety glasses.Other PPE may be required depending on the work being performed.Once inside the work zone,any outside party including inspectors shall comply with SPS,Inc.and OSTIA safety guidelines.Inspectors and/or outside parties should be escorted by an SPS,Inc.employee inside the work zone. Governing LawNenuelllispute Resolution:This agreement is governed by and subject to the law of the Commonwealth of Massachusetts.In the event of a breach of this agreement,the non-breaching party shall be entitled to recover its reasonable attorney's fees and expenses.Any issue, claim,or dispute related to this agreement,its performance or a breach thereof shall be shall be decided by an independent single arbitrator in or within 25 miles of the city of Boston using American Arbitration Association,JAMS,or another similar mutually acceptable arbitration service. The arbitration shall be conducted in accordance with the Construction Industry Arbitration Rules of the American Arbitration Association currently in effect.The award rendered by the arbitrator or arbitrators shall be final,and judgment may be entered upon it in accordance with applicable law in any court having jurisdiction thereof.The finding shall be binding with no other recourse.The parties shall share equally the cost of arbitration and arbitrator's fees.The prevailing party shall be entitled to recover its attorney's fees and expenses including its share of the cost of arbitration and arbitrator's fee. No Consequential or Delay Damages: SPS,Inc.and Owner waive claims against each other for consequential damages arising out of this agreement.This mutual waiver includes damages incurred by Owner for delay,rental expenses,loss of use,income,profit,and the like.This mutual waiver includes damages incurred by SPS,Inc.for office expenses,office personnel,business and reputation,and for loss of profit except anticipated profit arising directly from the work,as specifically provided for herein. No Third Party Beneficiaries: This Agreement will not confer any rights or remedies upon any person other than SPS,Inc.and Owner. Specifically, this is not an agreement with any individual unit owner of a condominium association when the Owner is a condominium association.No unit owner has the right to expect or demand any work or performance by SPS,Inc. Hidden building components:Fasteners are required to penetrate the sheathing in order to achieve the material manufacturer's installation guidelines.Any mechanical lines,electrical lines,pipes,ducts,other means of conveyance,or equipment located directly behind 1 beneath the sheathing may be subject to harm.SPS is not liable for any damage to items in this zone. lee Dam Warranty Exclusion:Water backup behind an ice dam results in building components being submersed in water.Building envelope systems are not designed to prevent water intrusion when the building components are submersed in water.Leaks are likely to occur in these situations.Unless specifically noted otherwise,the work is not warranteed against leaking caused by water backup from ice dams or similar conditions. The Commonwealth of Afassachusetts Departr'nent of fndustrialAccidents 1 G:`ongjess Sheet, ,5`r,c 100 Boston,MA 02.7142017 �. ' wt www.mass.gov!dia a� y� ers' Compen�oon LrSX ra ed Affidavit TIJ [[rNG A C3S Ort X lricians/)?lumbexs. Please 'rint L' Tel A ' licant lnformation . . .dual " �• "" .�� �( _ �____, 1T3 (I3ussnesslOrgabivati.ozxllndlvz )•_ Address: e, - Cxt /State/.Lxp:,_.- � � __._._____-=�--�- ____-- —. - Y Type of4project{7c ciuired); Ar you au employer? _CC the appropriate box: I.- Tin a employer with `employees(RM and/or part-time), 7. �( cansfriictioxt ?..E]i am a sole proprietor or partnership and Inave no employees working Forme irx �. ��errzodeliii any capacity.[Noworkers'comp,insurance required.] 9, L Dernolitiau 3.L]l am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 E]Building addition Y P p y 4.EjJam a lxorneowner and will ba hiring contractors to carxduct all work on m ro Prt . Iwill1],L]Elcu�ica,l xppaixs or?dditions ensure that all contractors either have workers'compensation insurance or are sole 12 4 ,p ing repair, or additions IlInDproprietors with no empliryees. ISI .E]Roof reliairs 5.❑l am a general carxtractoac and l have hiredthe sub-coxnfractors listed onthc attached sheet. 13' These sub-contractors have errrployees aad havo workers'comp.insurance,$6.0 We We aro a corporatin3a and its.officers have exercised their right of'exemption per MCxI c. 152,§l(�I),and we liavi no employees.[llo workers'comp.insurance required.] policy Any applicant that checks laixxiil affidavit indicating they are doinglow showing their all work and thou outside compensation retractors must slrtrsnft information affidavit indicating such T Jim who Sul atfx _v tCantractors that check ibis tiox must attached ha additional sheet showing the name of tile sub contractors and stag whether ar not thane entities ave employees, if the sub-c6i&a�tors have employees,they must provide their workers'comp.policy number. — - -= `�-- X am anernplayer t/zat is pNovidiragrvar*/(er°s'carni)ensatiorz insuranceft"my ern�ployees. elaw is the porky arzilfoTr szte information. ., —~ . . cw 7nsuranco CoarilranyName:.' .ry� D ExpiratxonD�ite: �� t Policy/f or Self-ins.Lie. f✓' � .��"""e ,City/State/��'•. �numex 6►n.d.expiration� � ^. . date . fob Site A.etdress: �- �"--------------� Attach a copy offhewo?.'bets' compextsationpolicy declaration page(sixow ogthepolieby a fineupto$1,5©0.00) li allure to secure coverage as requit ed under MOT,c.152,§25A is a criminal v punishableTI and/or one-year imprisonment,as yell as civilPc ma�z be forty 1cled to the OfCts the co oin form of a STOP fuVes�tionsrof the DIA far ils iron e a day against the violator. ol�"of 's state m n y coverage verification. __ —-- deer{the and i naltaes of�erjzzry tTzat the znfar�raaatiora provided above is true and correct X do her° �,c °tz.�J"11 Il°µ..,w•.°., D zezexl zzse only. leo rent wr ite in this are,,,to he completed Try city or town offzriar .ff City'or .'own'_ — — --- -- _ Permit/License# -- – — Issuing Authority(circle one:): Glens d.Electrieal ' 1.13oard of Health 2.Bu!ildi'ngpepartment 3.City/l."o`cvrz xnspector 5.:1'lumbinglsaslxecfox 6.Other Phone Contact _ _ ._ DATE(MMIDONYYY) A�I CERTIFICATE OF LIABILITY INSURANCE 12/24/2015 THIS CERTIFICATE lS 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 CONT A T Claire Boutilier NAME: Cleary Insurance Inc PHONEFAX (617)723-0700 (AM No,(617)723-7275 226 Causeway street anaeless:cboutilier@clearyinsurance.aom INSURERS AFFORDING COVERAGE NAIC P Boston MA 02114-2155 INSURIE"RA:Continental Western Insurance 10604 INSURED INSURERB:Acadia insurance Company 31325 SChernecker Property Services, Inc. INSURER C: 283 Second Avenue INSURER D: INSURER E Waltham MA 02451 INSURER F: COVERAGES CERTIFICATE NUMBER.2015-16 Liability 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. MSR ADDLISUORLTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 15AN96E RENTED A CLAIMS-MADE � OCCUR PRE IS S Ea occurrence $ 300,000 CPA 0183614-19 12/31/2015 12/3.1/2016 MED EXP jAny one person $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JEC ❑ LOC PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER; 05 $ AUTOMOBILE LIABILITY accident INGLL IT $ 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED IM 0183615-19 12/31/2015 12/31/2016 BODILY INJURY(Per accident)AUTOS S NON-OWNED ROPER YIOAMAGE $ X )TIRED AUTOS X AUTOS $ X Uk1eRELi11 LIAR X OCCUR EACH OCCURRENCE $ 5,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I I RETENTION CVA 0183616-18 12/31/2015 12/31/2016 WORKERS COMPENSATION X STATUTE ER H AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y!N N/A E,L.EACH ACCIDENT $ 1,000,000 OFFICEB (Mandet MEMBER EXCLUDED? WCA 5074780-13 12/31/2015 12/31/2016 E.L.DISEASE-EA EMPLOYE $ 1,000,000 (Mandatory In lYH} If yes,ESCdescribe under DRITION OF OPERATIONS below Excludes MA E.L.DISEASE-POLICY LIMIT 11000,000 P DESCRIPTION OF OPERATIONS 1 LOCATIONS!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 Scherneckar Property Services, Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 283 Second Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Waltham, MA 02451 A1JTHORI7.90 REPRESENTATIVE John Sernardin/JCB - C ©1088-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD I NS025(201401) Client#: 1025557 SCHERPRO DATE(MMIDDIYYYY) ACORD.. CERTIFICATE OF LIABILITY INSURANCE 1 12/15/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. 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 NAME: Kathy Wagner USI Insurance Solutions, LLC . (A/C INE,EXt:A13 750 4222 FArc,Np; 610 537 9481 123 Interstate Drive E-MAIL ADDRESS: Kathy.Wagner@usi.biz West Springfield, MA 01089-3600 855 874-0123INSURER(S)AFFORDING COVERAGE NAICR INSURER A:ABC Mass Workers Camp Self-Insu 99999 INSURED INSURER B Schernecker Property Services, 283 Second Avenue INSURER C: Waltham, MA 02451 INSURER 0: INSURER E 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 CONTRACTOR 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DDNYY MM/DD/YYY COMMERCIAL.GENERAL.LIABILITY EACH OCCURRENCE $ CLAIMS-MADE � OCCUR PREMISES0 a o cur ence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO PRODUCTS-COMPfOPAGG $ POLICY JECT LOC OTHER: MBINED SINGLE LIMIT AUTOMOBILE LIABILITY CEa Oaccident ANY AUTO BODILY€NJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accidenf $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LtAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION ASCMA12000116 1/01/2016 01/01/201 PER E AND EMPLOYERS'LIABILrrY T B Y/N ANY PROPRIETORIPARTNEAIEXECUTtVE E.L.EACH ACCIDENT $1,000,000 OFFICERlMEMBER EXCLUDED? NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 It yes,describe under I L 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) Proof of Massachusetts Workers Compensation Coverage Proof of Massachusetts Workers Compensation Coverage CERTIFICATE HOLDER CANCELLATION ELLED For Insurance Purposes only THE u LD XPIRA IONANY OFH DATE VTHER OF DESCRIBED NOTICEI ES WILL BE CBE CDE IVERED0RE IN QO ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) 1 of 1 The ACORD name and logo are registered marks of ACORD #S16841233/M16801281 BVSZP e ut,C:pnsumer, t't'eirs&Business'Rogalatiun wi�"rl E IMNROVEMENT CONTRACTOR )ME 123815 Type: ° Expiration: 3/14/2017 SupplementCer Schernecker Property Services, Inc. KURT SLIMAK 283 Second Avenue .__..-- Waltham„MA 02451 Undersecretary Massachusetts C)epar'trrrenl r'af Pub6c; Safety Board of Buil mg Regul atrcrrs and Standards License CS-083665 Constrti,uctuOn Supervisor KURT M SLIMAK s 42 SEARLE STREET GEORGETOWN MA 01633 03/0712018