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HomeMy WebLinkAboutBuilding Permit #392-13 - 101 CROSSBOW LANE 11/9/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: a Date Received Date Issued: IMPO ANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Old Structure yes MAP NO: PARCEL4 ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 6One family ❑Addition ❑Two or more family ❑ Industrial P Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District El Water/Sewer DESCRIPTION OF WORK TO BE PERFORM D: Identification Please Type or Print Clearly) OWNER: Name: Tr r► Dal 1611 Phone: Address: /01 "c-bp&,L J.A4NP— A-S-C, CONTRACTOR Name: . �Y\ �Orrt^ Phone: 603 3d,9- 6205 Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: 30 70/ ARCHITECT/ENGINEER Phone: Address: Reg. No. .� FEE SCHEDULE.BULDING PERMIITT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 0 a-� ,O© FEE: $ 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 l Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Sfamped Plans ❑ Location /o/ clocr&,) I'law No. -' Date ! '1- • TOWN OF NORTH ANDOVER e . y Certificate of Occupancy $ Building/Frame Permit Fee � . ' Foundation Permit Fee $ z Other Permit Fee $ TOTAL $ Check# A�p C/ ✓' 25937 Building fnspector I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS f f Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes ' l Planning Board Decision: Comments P Conservation Decision: Comments Water & Sex4er Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT = Temp Dumpster on site yes no Located at 124 Main Street.. Fire Department signature/date COMMENTS I Dimension Number of Stories: Totals square feet of floor area based o q n 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 min.$100-$1000 fine NOTES and DATA— For department use i I i I ® Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application ❑ Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses Li Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application I Doc: Doc.Building Permit Revised 2012 i Enter construction cost for fee cal- North Andover Fee Calcination Construction Cost $ 58,214.00 m $ - $ 698.57 Plumbing Fee $ 87.32 Gas Fee 100'comm. $ 100.00 Electrical Fee $ 87.32 Total fees collected $ 973.21 101 Crossbow Road 392-13 on 111/9/2012 Remodel Kitchen I - � NORTIy TOwn of = ndover No. b C+ 0 h ver, Mass, x2 4A COCNI C,NWIC,`y1 S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System ll J� NJ / �C f�(Q BUILDING INSPECTOR THIS CERTIFIES THAT ....... .. ..../ ... ........ .. .. ....... ...................................................z.............. has permission to erect i �� �l��S�a �('.Vf Foundation p ....... .............. ... buildings on ....... ..................................................................... Rough to be occupied as ''o ,� y �� ........ �..�.V.. . .�j.4�.'..;?:............................................................ Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STAVS Rough Service ...................... .... ..... . . . .�`.�...................... Final UILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. _Massachusetts Home Improvement Sample Contract This form satisfies all basic regniroments of the scare's Home Improvement Contractor Law(MGD-chapter 142A�but does not include standard huago ge to proted homeowners. Suck legal advice if necessary.Any p—plaoniOS ham improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement before agteeang to any work on yonr residence.You may obtain a free copy by calling the ollice of Consumer Affairs and Business Regulations Consumer lnformation Hodine at 617-973-8787 or 14888-283-3757 or on our website. Homeowner information Contractor Information Name Company Name C Street Address(do not use a YOM Office Box address) Conuactod Salesperson/Owner Name )6-k Gr P&S ,Z,� 1CLn4- Zya�lr--4 o(,rxr--, Citylrown State zip Code Business Address(must include a street address) 0, q, R ,&Jes MA 0 1 S D� £.r cee_r-) Gk ' Daytime Phone Everingnone City/fovm State Tape f-1 M rte, s1W_d.c1 �Q}'1 D 3 9 Mailing Address(it differed from above) liusiihrs Phone O (u Employer ID or S.S.Number trornb*e,i=tnCaa..eoraraN nb. kzpubradde am MW> It Contractor agrees to do the following workfor'the Homeowner. (Desiaibe in detail the work to completed,sparafyingthe type,b=4 and grade of materials to be used,use additional Meets if ne2MEMv.) it Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homemmees agent: be adhered to unless circumstances beyond the conhadoes control atise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of Date when contractor will begin contracted w°rk MGL chapter 142A.) Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum o£ �a1�t�.t�© (`) Payments will be made according to the following schedule: $ ,7000 upon signing contract(not to exceed 1/3 of the total centrad price gC the cost of special order items, /Iw>,idrever is greater) S Q OD _by / !or upon completion of 170 4 tk i r i n( o 1n»,b b n a-(31 tku-,t i 1.+S lt. $_%000 by / / or upon completion of Utrb i n e l 1 n S 14+160N — S upon completion of the contrail. (Law forbids demanding fall payment until contract is completed to both party's satisfaction) Thefollowmg matensilaquipment must be special S to be paid for ordered before the contracted work begins m order to meet the conviction sdmhdc.('* S to be paid for Nt7t ES:(•)Indnding a0 fi_chaps(")Lawmqui-that any deposit or down-payman required by the contractor befat work begins may not exceed the greater of(a)one-third ofthetotal contrail pnoe or(b)the actual cost ofany special equipment or custom made material which must be special ordered in advance to meet the completion schedule n - an lWarrarstv e eon ,+r ❑Yes sill oft a ora n a ci, m e contra t ess of the actions of third Sbbcontractors-The contractor agrees to be solely responsible for completion of the work described regardless any party/subcontractor utilized by the conbat;tor.The contractor further agrees to be solely responsible for all payments to all subwnhaciors for "ala and 1 der th' ® i Contract Acceptance-Upon signing,this document becomes a binding contract under law.Unless otherwise noted within this document,the contract shall not=Ply that any lien or other security interest has been placed on the residence.Review the following cautious and notices carefully before signing tbis contract. . Don't be prate into signing the contras.Take time to read and fully understand it Ask questions if something is unclear. . )_uluke sure the wTir;ctor has_.aria Home Worovement(`nntractor Reeislra. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. . Does the contractor have insurance?Ask the Contractor for his instance company information so that you can confirm coverage,or ask to see a copy ofs,"proof of insurance"document . Know you rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy ofthe Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at aplaee other then the contractor's normal place ofbusmess,provided you notify the contractor in writing at his/her main office or brach office by ordinary mail posted,by telegram sent orby delivery,not later than midnight of the third business day following the signing ofthis agreement See the attached notice of cancellation form for an explanation of this right DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM iwoidmdcuwpiesorde,- i ctmust.becompndodmdsigmdOsoopyshoddgorodcbrazowoc The copy Aodabekept byme cautractur. xomeowuee's Signna� J Contras s signature ��j3r�ia 1�13J11Z. I Date »ate � i Contractor Arbitration The Home Improvement Contractor Law provides homeowners withthe right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute helshe has with a homeowner in court unless both parties agree p se to the optional clause provided below. This claim would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the'Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws,c 142 1 � 1 1 Homeowner's Signa / Con tot's Signature NOTICE:The signatures of the Parti ove apply only to the agreement f the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's nights A homeowners rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection}aws(i e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights iFthe contractor they choose is not properly registered as prescribed by law. homeowners who secure their own building permits ar a automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner• Homeowners may be entified to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition ot merchantabilityw�loess for ies r all goods sold in Massachusetts carry an imp warranty provided by the contractor, a particular propose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be ' 'added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in dWlicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been d ract with attachments is to i ed filled in or marked as void,deleted,or not applicable. One original signed gn copy of the cont be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract and the three day rescission period has expired. Accelerates Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/hemelf to be financially insecure,the contractor may require that the balance of fiords not yet due be placed in a joint escrow account as apre'eqursr rte to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of"A Massachusetts Consumer Guide to Home Improvement" contact Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 park plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at /ocabri If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at cabr/ Go online to view the status of a Home Improvement Contractors Registration_ lata'//db state inn us/homeimArov-nient/licenseelistasn For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-6524800,508-755-2548 or 413-734-3114 vasio"2.1-11l22/2010 I John Yforan Construction, L.L.C. Bui(ding andRemodeCng 21 Evergreen Drive phone 603-329-6209 Hampstead,NH 03841 fax 603-329-6209 October 4,2012 Tim& Sue Mellody 101 Crossbow Lane No. Andover, MA 01845 Dear Tim& Sue: This is an estimate to remodel your kitchen as follows: 1. Tear out existing cabinets,countertops,drywall, ceiling and flooring in kitchen and front hallway. 2. Tum French doors around. 3. Cut opening into hallway closet. 4. Frame walls in closet area and in dining room opening and end wall of kitchen. 5. Install a new Harvey DH Classis window over sink. 6. Drywall ceiling and new wall fill-ins. Taped and sanded finish. 7. Install cabinets in kitchen and dining room per plan. 8. Install new trim on kitchen window and reuse casing on dining room opening. .9. Electrical work: a. Outlet for microwave and island outlet. b. Wiring for appliances and disposal outlet. c. Progress LED lighting under cabinets on sink wall. d. Eight recessed lights and three pendant light connections. Pendant light fixtures not included. e. Wiring for toe space heaters. 10. Plumbing: a. Dishwasher and sink connections. b. Three toe space heaters. c. Refrigerator water connection. d. Disposal connection. Disposal not included. 11. Tile backsplash. Tile and grout not included. 12. Install appliances. 13. Painting: a. Prime and finish new ceiling. b. Paint trim in kitchen area. c. Kitchen walls. d. Dining room affected walls and trim only. Page 1 ' State of Massachusetts Home Improvement Contractor License#102071 State of Massachusetts Construction Supervisor License#47989 NA7.24839-i John Moran Construction, G.G.C. BuiOing and Wsmodefing 21 Evergreen Drive phone 603-329-6209 Hampstead,NH 03841 fax 603-329-6209 14.' Dumpster for debris included. 15:I will apply for permit. Cost: $22,972.00 Flooring options: Tile and cement board subfloor: 1. Tile installation and grout. 2. Tile and grout not included. Additional cost: $3,356.00 Hardwood floor: 1. Installation of a prefinished hardwood floor. 2. Rosen paper and flooring staples included. 3. No flooring included. Additional cost: $1,360.00 Respectfully submitted, John Horan I Page 2 State of Massachusetts Home Improvement Contractor License#102071 State of Massachusetts Construction Supervisor License#47989 NAT-24639-1 John Yforan Construction, L.G.C. BuiUzng and r§modding 21 Evergreen Drive phone 603-329-6209 Hampstead,NH 03841 fax 603-329-6209 October 27,2012 Tim& Sue Mellody 101 Crossbow Lane No. Andover,MA 01845 Dear Tim and Sue: These are the costs for the deductions that you were asking for. Deduction for the front hall flooring: $864.00 Deduction for under cabinet lighting in the buffet: $450.00 These are the costs for all the changes that will be applied to the contract: Cost for the kitchen work based on the original estimate: $22,972.00 Tile option for kitchen and front foyer: New cost. 2,492.00 Additional cost for bathroom flooring and plumber 1,400.00 Pot filler in kitchen 300.00 LED lighting in upper cabinet of buffet,two refrigerator outlets in buffet and outlets in corner cabinet in kitchen(new cost) 1,050.00 Total cost after adjustments: $28,214.00 If these costs are acceptable,please send a return email and I will create a contract based on these numbers. Respectfully submitted, John Horan I Page 1 State of Massachusetts Home Improvement Contractor License#102071 ,o tq State of Massachusetts Construction Supervisor License#47989 �..L� NAT-24639-1 idavls �.,•• ur"�f ,.CeCt .. CAI CS-047989 i f JOHN V HOR41`T 21 EVERGRM DR - _ Hampstead NH 03841' Ge Frr;sstp 03/02/2014 n/E: �a;rrc�u;cl1' License or registration valid for individul use only e, Office of Consumer Affairs&Bns�dess Regulation before the expiration date. If found return to: ME IMPROVEMENT CONTRACTOR office of Consumer Affairs and Business Regulation Tom. "registration: 102071 10 Park Plaza-Suite 5170 �> DBA Boston,MA 02116 �1xpiration 6/30/2014 JOHN V.HORAN CONS71ZUC7lQN.= John Horan 21 EVERGREEN DRIVE Not valid without signature HAMPSTEAD,NH 03841' [Inderseeretary 4/ Client#:490547 JOHNHORA ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDnYYY) 4/24/2012 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:Ifthe certificate:holder Is an ADDITIONAL INSURED,the pollcy(ies)must be endorsed.If SUBROGATION:IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). ACT PRODUCER CNS USI Insurance Svcs of NE,Inc. >aoNE 603 625-1100 .No PO Box 6360 E M1UL ADDRESS: Manchester,NH 03108-6360 INSURER(B)AFFORDING COVERAGE Nac II 603 6254100 INSURER A:Maine Mutual Group Insurance Co 15997 INSURED INSURER B.]EastGuard Insurance Company 147102 John Horan Construction LLC INSURERC: 21 Evergreen Dr. INSURER D Hampstead,NH 03841 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. L .; TYPE OF INSURANCE yyyp POLICY NUMBER PO Y EFF SLID EXP LIMITS A GENERAL LIABILITY SC10955638 0410112012 041011201 EAAqCC�H��OOCCUR��R�� S'IENCE 000 000 x COMMERCIAL'GENERAL LIABILITY PRENtISES Ea oa�vr�rence s250,000 CWMS-MADE F XI OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1A00.000 GENERAL AGGREGATE s2,000,000. GEWL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG $2,000,000 POLICY ' EIS LOC $ • AUTOMOBILE LIABILITY KA10955638 0112012 04/011201 E, B. SINGLE.LIMIT 1,00000 X ANY AUTO BODILY INJURY(Per person) $ V ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS x NON-OWNED PROPERTYDAMAGE $ AUTOS eracciderd $ A X UMBRELLALIABOCCUR KU10955638 0410112012 040112013 EACHOCCURRENCE $1000000 EXCESS LIAR HCLAIMS-MADE AGGREGATE $1 00O'000 DED RETENTIONS $ WCSB WORKERS COMPENSATION JOWC225195 0112012 04/01/201 X TORY LI IT OTI1- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNEROMCUTIVE YIN N E.L.EACH ACCIDENT S50000 OFFICERIMEMBER EXCLUDED? � N I A (Mandatory in NH) El..DISEASE-'EAEMPLOYEE$500000 Myes,describeunderEL DISEASE-POLICY LIMB $500,000 DESCRIPTION OF OPERATIONS below i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,IF more space is required) This Certificate covers all operations usual and customary to the insured's business. i CERTIFICATE(HOLDER CANCELLATION For Information Purposes Only SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE rP y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD.25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S7173249IM7173245 LCACA 82" - - - - - - - - - - - 116;5•- - - - - - .—�12""�--36"--'y�24�---48" �--15"-�--29" 1 1}"� 701 794" 284^ 87n' 12" 6" 12" 18" 6" 24 26 901 BROOKHAVEN 1 FRAMLESS CABINETRY - - - - -- i� � — ' '� — �� �'p�' DOOR STYLE:EDGEMONT FULL OVERLAY SQUARE RAISED PANEL ------ --. MAIN CABINETS:MAPLE WITH VINTAGE BLACK WITH BROWN UNDER, HY, y� GE LACE FINISH _. .. ....__._ ._.___. -< ISLAND AND BUFFET — HOOD 2 THROUGH ONLY iE DISTRESSING.RUB THROUGH ONLY 1 '-r CEILING HT:90 7/8+/- \ I O O W2430 , i 1530 W293013 ro 4; HANGING HT:84" PWS098401L _ _ I - L T M N 1 '0 - _— as�y�g 24.DISWW -- G; CROWN MOLDING:MTTB805 WITH MCR8338 WITH 3/4"ROPE MRPS34 DD -�. TOE KICK MOLDING.MSU805 _DECVALANCE Z .�""" _ --- - _ _ _ _-'"` - TOE BOARD MOLDING:MBB805 AROUND ISLAND BACK AND SIDES - - -In" 83D3634 � 840263424 rl LIGHT RAIL MOLDING:BLV6 PWS098401L ®eJ �L'md O O m DECORATIVE PANELS ON ALL EXPOSED ENDS 1-SPICE PULL OUT �10 2-DOUBLE PULL OUT TRASH m i 3-TWO TRAY PARTITIONS -r_ B303634 BMW83034 B1834 a ": "4-TWO ROLL OUT TRAYS m p �401! © a—i Y 5-DOUBLE OVEN LOCATION - --- --`- ---_. TCBF34 M L�o �I P 973407{{A 9� Q 7-PULL CABINET TO DEPTH OF PANEL REFRIGERATOR HAS ARCH TOP j' 8-MICROWAVE CROWAVE LOCATION W361224 9-FLUTED POSTS SPLIT IN HALF LENGTH WISE f i / 10-FIVE ROLL OUT TRAYS r.. TIC308424 - \.....I �. ._...... .. •1 - 42}" ".�� �. '._ _ _ (f 11-CLEAR GLASS WITH TRADITIONAL MULLIONS J ® 8315" 33"— -36" � 12-DECORATIVE VALANCE STYLE H ATTACHED OST148 TO TOP,DOORS TO REMAIN ON BOTTOM WFRB034813 T 85 " TOP OF DRAWER TO ALIGN AT KITCHEN HEIGHT 34 112" � 1 9 B153418R 13-SPLIT DRAWER HEAD ON TOP 3 1 BAE033424R ANGLED FILLERS WITH FLUTING I OST134 l o DOORWAY MADE SMALLER TO ACCOMODATE 14-ANGLED WALL FILLERS WITH FLUTING CLOSET TO BE ALTERED TO I �I I REFIGERATOR AND DOUBLE OVEN ACCOMAOATE PANTRY AND ILJ1 OST134WET BAP AREA I i AE033424L ! �8153418� ll dimension, .JdesifsTlaeons LUCY ROSS This is an original design and must Designed: 8/23/2012 given are subjecN&WHIR icn JACKSON not be released or copied unless Printed: 9/24/2012 Job site and adjustment to fit job KITCHEN applicable fee has been paid or job conditions. DESIGNS order placed. MELLODY, TIM AND SUE#3 IAII I Drawing#: 1 Scale : 0 3/8" = 1' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): "MOhr\ 1�j A^ 664S4irGf/On W- Address: ` City/State/Zip: 3?q/ Phone#: 603 Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with./ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. I [7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner,doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required:]t employees. [No workers' comp.insurance required.] 13.❑Other 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 anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. t am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: a I�6 y ,1 C Co ?olicy#or Self-ins.Lic.#: Expiration Date: f Loo 3 lob Site Address:_ 1 d t i Gr056boyv City/State/Zip: _A1.6rk �p 611F11r kttach a copy of the workers' compensation policy,declaration page(showing the policy number and expiration date). ,ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 if up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certi under hepains andpenalties ofperjury that the information provided above is true and correct. i nature: Date: !7 `� za hone#: 603r� 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#: i Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. !Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple-permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as,proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 www.mass.gov/dia