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HomeMy WebLinkAboutBuilding Permit #130-14 - 113 CHESTNUT STREET 8/9/2013 TOWN OF NORTH ANDOVER ClAPPLICATION FOR PLAN EXAMINATION Permit NO: 13 (� ` t —1 Date Received a ✓ Date Issued: - MPORTANT: Applicant must complete all items on this page LOCATION I C.�f-s r V,U _ _r PROPERTY OWNER ���'�� g - 100 Year Old Structure :yes noPrintMAP NO: 11 � PARCELZ ZONING DISTRICT: Historic District noMachine Shop Village no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family 11 Addition ❑Two or more family El Industrial R1 Alteration No. of units: El Commercial '&Repair, replacement ElAssessory Bldg El Others: ❑ Demolition 0 Other ❑ Septic ❑Well ❑ Floodplain 0 Wetlands ❑ Watershed District 0 Water/Sewer - - DESCRIPTION OF WORK TO BE PERFORMED: l w New 'o A,5� p � OD !2 / le '-tt�.,� ah (( Ie I.`�5 �` �f41 Lill IIAE5 eP0 Nkt ` QQ CsJiCj�G�u�� /aoES Loodscf 9� .e2 Con �eµwJ`: ,v5l�ali �v`I- c�ot� �'2 T1��u�` W S ✓� 1Si AW14 E, AW4 �L vk Flag ! Erl�att J:Ntej61 Rep Joa bu e%�a�t �J 97�rr�r�ru�5 S elees �n �aseen Identification Please Type or Print Clearly) e� SUZ OWNER: Name: �e��OR- f' lie �eW� CCj w AVS Phone:1-]0 Address: 113 C�-e'5I AU 5 , rEHome CTOR Name: ��OOACO LL(-- MV, �`flPhone: j r A � ,C) , � r's Construction License: USS 1 Exp. Date:. � tZoI2®1 I rovement License: -x62-7Exp. Date: fJ00 I ARCHITECT/ENGINEER Phone: Reg. No. Address: A FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$12.00 PER S.F. Total Project Cost: $ I�2pk �� - � FEE: $ �qq b Recei t No.: Check No.: p NOTE: Person c n acting with unregistered contractors do not have access to the guaranty fund Signature of Agent/OwnerSigafure of contractor Plans Submitted ❑ Plans aived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Location t `t C f S T" No. (� - `'� Date o - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ � Foundation Permit Fee Other Permit Fee $ r'.., TOTAL ' $ Check# ' 2v7 1 Building Inspector J Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE-:0F `:SEWERAGE D1SP.OSAL Public Sewer ❑ Tanning/Massage/BodyArt ❑ .. Swimming Pools ❑ Well ETobacco.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 r C COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planningf Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/si nature& Date Driveway Permit DPW To`v;. Engineer: Signature: Located 384 Osgood Street FIRE DEPARTIVI�_NT -Terho Dumpster on si DL _ no Located at 124 Mair, Street Fire Depditimer t-sigrnature/date r- 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 min.$100-$1000 fine NOTES and DATA— For department use I i 0 Notified for pickup - Date I Doc.Building Permit Revised 2010 I I � Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofirg, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ 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) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) 1 ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ 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 apo,-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Building Permit Revised 2012 Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 120,000.00 m $ - $ 1,440.00 Plumbing Fee $ 180.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 180.00 Total fees collected $ 1,900.00 113 Chestnut Street 130-14 on 8/9/2013 New Roof, New Siding, Master Bath Remodel, New Deck I NORTH own of O - 0 No. SANE h ,"' ver, Mass, q t 3 �� coc«�«ewrc.c �1' p°R�TEO ►'P���S s U BOARD OF HEALTH Food/Kitchen PERMIT T , LD Septic System fill 11 THIS CERTIFIES THAT g 11111111111W . ...........C.0_110.114.111llsBUILDING INSPECTOR has permission to erect .......................... buildings on ....��.. ..... T .......Aw...0......... Foundation � Rough to be occupied as ........ � . . ..r..:.... 1.. .r....uA%dow%..4...... .. ...&AL%, Chimney provided that the person acc ting 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 yea PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTJOt t6TATS Rough Service ............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz Rough Display in a Conspicuous Place on the Premises — Do Not Remove Fina' No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE A fl GJenco, LLC P.O. Box 145 N. Chelmsford, M4 01863 Contra August 1, 2013 Customer Name: Mr.&Mrs.Robert Cowan Subject Property: 113 Chestnut St, N.Andover, MA Scope of work; To construct from a specifications below Permit-Town of North Andover Building Permit Estimate-2,500.00 Contents- Use necessary precautions to protect personal property during construction. Dust protection-Dust/Floor protection as necessary-500.00 Dumpster- A dumpster shall be used on site. Jobsite is to be kept clean and safe during construction-3,000.00 Driveway- Call dig safe,excavate out all existing,hot top and remove from property,excavate material beneath drivewaydown 8"and remove from property,furnish and install 6"of Y/."crushedbank run gravel and 2"recycled asphaltbase,grade and compact base to correctelevation with a 5 ton or greatervibratory roller,install a 2"asphaltbinder course and 1.5"asphalt top coat,provide an emulsion tock to bind thenew asphalt to roadway (base and asphalt thicknesses are after compaction)-7,500.00 Walks&Steps- Shrub Removal,Remove and dispose of the existing shrubsadjacent to the house along the front,left sideand the rear.Apply a minimum of 4"of loamto areas to prepare for new plantings. Ensurethat water drains away from house. Remove the one small wild apple tree on theright rear corner of the house that overhan sthe walkway.All stumps removed anddisposed of.Upon completion apply aminimum of 4"of loam and hydro seed asnecessary to repair the disturbed lawn areas-5,100.00 Granite Steps- Remove and properly dispose of theexist' recast concrete steps at thefront door and the side entrance.Supply ins new grey granitesteps th t will be the same size as thepresent steps.The steps will beinstalled on the existing concretefooting.Install a Grace 36"Vycor V4OSelf-Adhered Flashing behind stairsand up 3 feet above the top landing ofthe granite stairs Slight modificationsto the footing,may be required.Provide Rod Iron handrails installedper local code,style of railings to bedetermined by customer from Contractor samples-5,800.00 a /d sfePJ � o7L , L Front Walk- Remove and dispose of the existing bricks.Excavate and install a base for the walk toconsist of 10"of processed gravel compactedin place.A 2"layer of stone dust will then beaded which will be a setting bed for the brick. Supply and install new quality waterstruck paving bricks such as those by Cambridge Pavers.The outside border of the walkway will have a soldier course of pavers.tnstall plastic edging to hold pavers in placealong with a Polymer based grouting sand.The dimensions of the new walk are 4'6"wide and approx. 50'long to the front doorand 4"6"wide x 9'long to the side entrance.The exact layout for the walk the paver's styleand color will be determined prior to the start of construction-5,400.00 Side Walkway- Remove and dispose of the brickwalkway leading to the pool area.Remove and dispose of the groundcover.Supply and install 18-20bluestone squares 2'x 2'as steppingstones for the new walkway.Installstone dust as necessary to adjust gradeunder bluestone.Loam will be addedas necessary so that the soil level isflush with the stones.Uponcompletion the lawn area will beseeded.TBD-pave stonevs.blue stone-2,400.00 Landscape- Landscaping/plantings-4,250.00 Pavers around bulkhead-1,500.00 Roofing- Main House,Family room and GarageSET UP TARPS TO PROTECTSIDING AND ROUNDS,Removeand provide new gutters with covers tobe reinstalled after trim and roofing isreplaced.Remove roofmg down to theroof boards.Inspect the roof boardsand replace any unsuitable deckingboard,re-nail roof decking as necessaryto eliminate any loose decking and toensure that the decking is nailed tomeet local building code.Install Azek trim to all fascia and rake boards. Apply 6'of GAF Storm Guard leak barrier alongthe lower edges of the roof,aroundchimneys,and all penetrations as well as inall valleys and at all sidewalls.ApplyGAF Deck Armor to the remainder ofthe roof area, Install 8"(.024")aluminum drip edge to all perimeteredges of roof in white finish. Replaceall pipe flanges and vent caps,replaceall lead flashing around chimney.Apply GAF lifetime warrantyTimberline Architectural shingles withGAF Golden Pledge warranty to entireroof along with corresponding starterstrip and cap(COLOR-To Be Determined by homeowner),Install- 11,250.00 Rear 3 Season Porch Roof INSTALL WEATHERBOND FULLYADHERED.060 RUBBER ROOFING SYSTEM OVER 1/2"ISOINSULATION BOARD.Strip and remove old roofing material.Replace any rotten wood and securedecking material prior to installing newroof materials.Follow allmanufacturers'instructions and Effortsshould be made to install fasteners forlSO insulation into framing to reduceinjury hazards as the underside of theroof is exposed.Install white aluminumedge trim to the entire low angle roof perimeter.Extend rubber roofinembrane up the family room roof a minimum of 1 foot before starting GAFshingles. Storm guard roof barrier willbegin at the intersection of the two roofsystems.Seal the rubber roof to theStorm guard barrier to prevent waterfrom backing up between the membranes.—3,100.00 Upgrade blown out rakes with roof/soffit/trim.—2,500.00 AZEC Fascia and rake boards-2,750.00 s X135 Windows- Harvey window icon classic.Double hung,low e,argon glass,gridin glassful screen with � 0� Built in 3.5inch exterior casing with stool cap.Ensure thatall Azek trimboards AV L/ areinstalledaccording tolnterior pre made 1 piece casing and stool cap.Paint&Wall touch up.>Manufacturer recommendations.All double hung windows will havegrids between the glass,Low E withargon panes,white PVC exterior trimand factory jamb extensions. h� ci r J Y Size the replacement windows to maximize theexisting openings from stock sizes. 0 t� Maintain consistent dimensions for window applications(IE.Bedrooms,living room, bathroom,Etc.). Sprayfoam pockets,remove shutters.Insidetrim will be installed with J w new and is tobe determined by customer fromContractor samples.(May need onemore C7 for garage?)all trim fasteners should be stainless steel-15,850.00 Siding- Remove all old siding and dispose of properly.Repair any damaged or rottenplywood. Remove and close in with framingand plywood all gable vents.Check and installas necessary soffit venting for attic ventilationwith proper venting to allow air flow fromsoffits to ridge.Install Tyvek house wraptaping all seams and openings to homeexterior prior to installing new siding.Properly flash all windows and doors. Alsowrap window and door openings with Grace6"Vycor V40 plus Self-Adhesive Flashingover aluminum flashing.Install 38 square Vinyl siding andsoffit,withl/2".Foam board insulation on sheathing,front facing Parts of home to have D7cedar im all other areas tohave monogram clapboard style siding with breadboard Soffi metal facias d rake boards Install smooth 6 inch Vinyl comers.Remove allexisting siding an prep wa tion.Price includes installingnew aluminum gutters and Downspouts,with top gutter guard to preventdebris.Install water board along front of house only with Azek.(like Graniteville Rd,Westford).All trim is to be installed to manufacturer's specifications for this region with stainlessteel fastenersSpecial note will be paid to ensure properinstallation according to man acturers'specifications for spacing and caulking among other things-34,800.00 Sib,,, Cr A J , Decks- Decks Azek vinyl deck and Azek premier rail system,includes all materials And labor to remove existing decks,rails,3 season porch Rails,decks,steps and rails.The system is a screwed,thenblind plug to match decking.Each railsystem has posts,bottomRing and cap.Also,shim any dips etc in decking frame installed per manufacturer's approved 5 (A � method. Contractor to install a screw and plug method for install deck. New screen ( (0) room doors,replace screens when done-31,700.00 fib' •�'J L Install 1 x 12"Azek trim on exteriorof deck frame.Repair White vinyllattice along bottom of deck Install Azek risers to both sets of stairs-2,400.00 Living room AC-Install rigid metal duct work from attic trunk through master bedroom closet toprovide supply air to living room.Enclose duct using plywood panelingwith gypsum wallboard J applied overt nish and paint to match wall fmish incorporating any baseboard and ceiling �V4-N trim to match existing.Installmetal diffuser box in living room ceiling with white Q louvered corner grill to distribute conditioned air-1,700.00 r J ��f Family room- 2,000 AJ_&a T 2,-- Ar- 'r, ° r C!r E v; PPS; 7-a P,_- , r-c r4 c•%-/ 4 K r-r c N F 72� + Electrical- Trouble shoot electrical on deck,hardwire outside lights,other electrical as discussed- 0t9`4_ A S 1,250.00 A,/,q r`l*6 Tree Removal/Stump grindingTree Removal/Stump grinding-5,500.00 � �7 `�Lr 7 ✓ Remove designated trees in rear/side of property not covered in landscaping quote.Loam i"✓G seed,labor-2,500.00 S -}r G t J - 1 3 S „F s p s,,1 G Hardwood floors-Upstairs-2,600.00 � v K (rc 44./ /+-1 OL-(3,—L- — D. 5 r 170V_L� Downstairs bathroom- N/C -� Bathrooms- N/C Upstairs bath-(entire ceiling painted)- N/C t k G J c.✓ c �'�1 ,.t,J o r k,r y t �.i -�, C �• p��� Painting-(included in windows etc,family N/C unless identified) Laundry room-2,200.00 Basement/kitchen ceilings- N/C Basement/new workout room/storage room- New framed wall to completion with paint,trim,electrical,etc.Paint walls,suspended ceiling,and new rubber. Workout flooring in front area,carpenter vinyl in rear room. Paint existing bead board,install carpet on stairs.Create Wood shelving in front storage room,repair leaks,and remove all existing materials 6,500.00 Master bedroom(excludes hardwood floors)-1,200.00 Master bath/shower/tile removed,prepped install New tile shower,fixtures in shower, tile walls,floors. Install doors,new trim,outside of bath,closet area tiled,frameless shower door,the works-6,800.00 Upstairs Bedroom.Hardwood floors included)-1,900.00 New bulkhead cover(can't get in backyard for complete)-1,200.00 Bulkhead Faucets-500.00 Painting/wall paper/All Painting-16,700.00 whit ro oEI3 qll Garage doors and openers-(as discussed-Like Graniteville)-2,800.00 Gas connection for new stove/oven and installation-top gas,oven electric(owner to buy stove/oven)- TBD Granite light posts-(replace existing by walkway and end of Driveway)-TBD Jack McHugh will do ALL interior trim work Total - including permits 197,650.00 Contractor will secure at owner's expense all Town of N.Andover,MA applicable building/ construction permits.Estimated at$2,500.00.The owner will be responsible for permit expenses over this amount The contractor herewith submit proposal for materials and labor to be supplied at the sole request of Mr.&Mrs.Robert Cowen herein revered to as the"owner"for the work performed at 113 Chestnut St,N.Andover,MA. Both parties agree to the plans and specifications attached,all materials are guaranteed to be as specified and to carry each items manufacturer'swarranty.All work will be completed in a neat and workmanlike manner,(conforming to and remedied as per the NAHB"Quality Standards for Professional Remodeling Industry"manual")in the event a dispute arises regarding satisfaction of �� JJ 0[� workmanship,materials and/or other both parties agree to bind themselves to arbitration by a qualified arbitrator chosen by the Better Business Bureau and abide by the findings and restrictions. Any alterations or deviations from specifications and plans involving extra labor and/or material costs will become an extra charge over the below agreed amount.Owner will supply contractor in writing(email is agreed and accepted)with any upgrades with the appropriate agreed value or "extra"charge.No statement,arrangement or understanding,expressed or implied not contained Herein will be recognized.Gjenco LLC is not responsible for delays due to back ordered materials or circumstances beyond its control.The Contractor therefore agrees the cost of materials,labor and contracting for attached plans and specifications are$197,650(One hundred and ninety seven thousand one hundred fifty dollars and 00/100 cents). The Contractor will request an initial downpayment of$25,000.00 at the signing of the contract on order to purchase special materials which are custom made for this construction and to bind agreement. The contractor will request the following payments for work performed and materials ordered as follows.Heretofore,known as progress payments. 1.After all trees and shrubs have been removed from property around home and property perimeter take$3,000 from walks and steps budget and and$4,500 from Perimeter tree removal Budget. Total payment due $7,500. 2.After the entire roof is installed and all excess roofing materials have been removed from premises and the windows have been ordered.After the blown out rakes and trims have been installed.After all of the current siding has been removed And all debris has been removed from property. Total payment due $20,000. 3.After 1/2 of the siding has been installed to include 1/2 gutters and downspouts and 1/2 the new windows installed. Total payment due $14,900. 4.After siding has been installed and completed to include the installation of remaining gutter and windows.After the garage doors have been installed. Total payment due $14,900. S.After the existing decking has been removed and all decking debris is removed from property and all Azek trim&decking material and Azek railings material is at property ready for installation. Total payment due $15,000. 6.After the entire trim decking and railings have been installed to include all stairs and risers.and 3 season porch ceiling and posts have been painted and the electrician has repaired or installed per spec sheet at 3 season porch and allAzek skirts around outside of deck have been installed. Total payment due $20,000. 7.After all the concrete steps have been removed and replaced with granite steps and wrought iron rails.After all the brick walkways have been removed and replaced with pavers per specsalong the front side and rear patio.After all the new plantings have been installed and the new loam and seed have been installed and a 18inch stone border in designated areas along the back and mulch with buried fabric along the front has been installed. Total payment due $20,000. 8.After all window trim has been installed and all the required demo and prep of the basement,Laundry room,front basement room,master bath shower and existing tile and carpet has been removed and living room duct work has been installed to include closet framing,after family room tile floor has been removed and all interior f,�� debris is gone.After upstairs rear bedroom has had carpet removed and debris removed. Total payment due $7,500. 9.After master bedroom bath has had tile installed and bathroom is complete and all other plumbing work is complete to include exterior faucets.After basement laundry room floor and basement room walls have been framed and suspended ¢ ceiling in basement room and wall board in laundry room have been installed and 0 d prepped for paint. Total payment due S1/000- 10 00. 10.After all remaining interior items are completed which are contained in this scope of the work herein,and the owner has created a punch list for all remaining exterior items and that punch list has been completed by contractor toowner's satisfaction. t Total payment du 11.After the driveway has been installed and the owner has created a punch list Q �� for all remaining interior items and the contractor has completed those items to owner's satisfaction. Total payment due $20,000. The final payment which constitutes the remaining balance will be paid 14 days from the owners written acknowledgement(email will be an accepted form of Acknowledgement)after the completion of payment 10.The contractor will supply Owner with all manuals,manufacturers'warranties and rebates from materials. Final payment due $5,350. The contractor will request payments on the Tuesday of every week for completed work.The owner agrees to pay the contractor directly as requested for completed work.If owner fails to pay for completed work by 7 days of its request,then contractorcan stop the job until said payments have been made to all outstanding progress payments.The contractor agrees to bi-weekly meetings with owner to select materials,review completed work,plan upcoming work and any general questions or concerns it may have.It is further agreed that the owner will begin his material selections in a timely manner to move project forward. The owner has final say on all material selections and decisions so long as these decisions do not affect the contractors'ability to obtain a completion certificate or final as built plan which will be approved bt the Town of N.Andover,MA. The contractor agrees to keep job area clean and free from hazardous situations.Contractor has a Massachusetts comprehensive insurance certificate on file with the Town of N.Andover,MA and a $1,000,000.00 liability policy in effect for the duration of the contract.Contractor will issue an additionally insured certificate to both the owner and Gjenco,LLC.The contractor agrees to,that the owner may wish to perform some aspects of the work to reduce some costs of the project or hire Laborers for the same,however,the contractor must agree to the credits for work or materials prior to performance to cost and content. T tal Cost $197,650.00 /3 �3 3- 203 Glenco, L Date �Mrs. ert Cowan Date Dean le ns d " The- P.o.mmonweafth of Massachusetts Departmeh.t of Fire Services Office of the State Fire Marshal P.0.Sox 1027j Statc Road,Stow,NL4 01775 PERMIT. Date: North Andover �'ermRNO (Citl of Date: ,Dig Safe Number . In accordancb with the provisions of vL G.L_.l 4 8 Ghap.ter_j_G_as provided in section—i22—f= 3 4 � �q /J .This Permit is granted to: Scut Date Full name ofperson,Firm*or Corporation Permissionto locate dumpster - for construction/renovation/demolition of building. RcsLrictictions Convon dumpster must be . 25 ' from structure if unable to lace with reauired :clearance d um ster P must be covered with 1 wood or tarp end of work -day (Give location by street and no.,or desc c to such manner as to provied adequate identification of location) r=PaidS 50 .00 expire his Permit~rill OC. g Fire Chief 1 _ ?. 3 (S io afore of offical, anting permit) Ofncai wanting permit (Tide) The Commonwealth of lilassachusetts - Department ofIndustrialAccidents Office of Investigations 600 (Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizationgndividual): Address: V Uln') S 7- city/state/Zip: 0 o P`j l ���t C c.,, , AA �k Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. KI I am a general contractor and I 6. E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.? 7• L 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.[Noworkers.' comp. c.152,§1(4),and we have no 12.0Roofrepairs 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 ai e 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy awl job site information. Insurance Company Name:. �A)S CLQ Policy#or Self-ins.Lic.#: Expiration Date: rob Site Address:_ -j C VIAS 14 V% ,5%, V. &dOagz City/State/Zip: Al, Attach a.copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requirodunder Section 25A of MGL o.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine ofup $ p to ,250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert unde heins a enatties o er'u that the information provided above is true and correct. - fP 1 � f signature:10" Date: 13 Phone 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.EIectrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: 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.wxitten." An employeY is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a j oint 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 producedacceptable 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 ofpublic 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-contractors)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 notrequired to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. B e advised that this affidavit maybe submitted to the Department of Industrial Accidents fox confirmation of insurance coverage. AIso 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-andprintedlegibly: Th6-DepEff i biit fias pfovided 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 additiona, n applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current Policy information(ifnecessary)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. Anew affidavit must be filled out each year.Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license orpermitto 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: Tho CQM�T QRW.Dat6f assa.,rhv.:setts Dep.axtmezat offadustda .1 Accidents Office of luvestigatio.m.. 600 Washiugtou Street Boston?M.A 02111 `A,#61.7-727-4900 0A 406 ox z-$77-WS FF, Revised 5-26-05 Fay#617"727=7749 Office of Consumer Affairs and Bu iness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contfactor Registration Registration: 145027 Type: Private Corporation err a .-4/u ll, Expiration: 12/14/2014 Tr# 234887 GENETTI'S GENERAL CONT, INC. MICHAEL GENETTI r� - WW1 55 HIGH ST UNIT #2 N. BILLERICA, MA 01862 _~= i pdate Address and return card.Mark reason for change. Address Renewal Employment Fj Lost Card SCA 1 G 20M-05111 Massachusetts -Department of Public Safety Board of Building Regulations a' s 9, and Standards Conm,lictiun SulxVni.�iit License: CS-081368 ' MICHAEL GEI!] TTI `' 227 POND S NO BI' LLEIqCA NO CoExpiration mmissioner 04/20/2014 OP ID: TD CERTIFICATE OF LIABILITY INSURANCE DATE08/06D/YYYY) 08106113 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 j 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 Phone:781-935-8480 NAME:CONTACT DeSanctis Insurance Agcy,Inc. PHONE Fax: 781-933-5645 FAX 100 Unicorn Park Drive _1At9,A%,9Ath-m_,___________ —__�ivc NoZ__—_—____-___.-_ Woburn, MA 01801 E-MAIL - ADDRESS: PRODUCER JAGCO-1 INSURER(S)_AFFORDING COVERAGE NAIC p _ INSURED Jagco, LLC. INSURER A:Nautilus Insurance Company 227 Pond Street — ------- ----f—'--- INSURER B:Zurich Insurance Group l-) Billerica, MA 01821 -- -- --- — ------ INSURER C: � INSURER D 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR i - IADDL'Sl�ek' P- -C�-17 E-FF 1 POLICY EXP LTR TYPE OF INSURANCE I i POLICY NUMBER I MM -/Y YY M/ D/YYYY — LIMITS — GENERAL LIABILITY I — EACH OCCURRENCE $ 1,000,00 A I X COMMERCIAL GENERAL LIABILITY NN301868 02/01/13 02!01/14 Eb —� I PREMIDAMA SES Ea occurrence E 100,00 CLAIMS-MADE u OCCURI I i t MED EXP Any one person) $ _-_-5,00 PERSONAL&ADV INJURY $ _ 1,000,00 GENERAL_AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG I $ — 2,000,00 I POLICY ir- PRO- r--I LOC � I - ! ;_..- -------------I-$-....----------- - AUTOMOBILE LIABILITY I I COMBINED SINGLE LIMIT I $ (Ea accident) I ANY AUTO I-------- --------....------ BODILY INJURY(Per person) I $ ALL OWNED AUTOS BODILY INJURY(Per accident)I $ SCHEDULED AUTOS i--- t— -- - -- PROPERTY DAMAGE I HIRED AUTOS I i j (Per accident) $ NON-OWNED AUTOS I $ Is j UMBRELLA LIAR i I I OCCUR I ( � I I ; EACH OCCURRENCE 1 $_- EXCESS UAB CLAIMS-MADE i I ! I i AGGREGATE I $ DEDUCTIBLE i ! i i.-._.___..--.-----------`$ -I RETENTION $ I I ---- --------I$------ --- WORKERS COMPENSATION I i X_� WC STATU- OTH- AND EMPLOYERS'LIABILITY IQAYlIIdIT.S. —. B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN I IMA-CERTIFICATE TO BE SENT j 03/19/13 03/19/14 1 ----$ ----__..,.-i OFFICER/MEMBER EXCLUDED? �Y i N/A I I I I -E.L.EACH ACCIDENT 100,00 (Mandatory in NH) DIRECTLY FROM CARRIERj I— I I i E.L.DISEASE-EA EMPLOYEE] $- 100,00 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ 5500,00 r I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) "The Workers Compensation policy. does not. provide._coveragge for_Michael Genetti." Evidence of Coverage..Gjenco LLC is listed-as Additional_Insured. CERTIFICATE HOLDER CANCELLATION ANDOV15 SHOULD ANY OF THE ABOVE DESC IBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREO , NOTICE WILL BE DELIVERED IN 120 Main St n of N.Andover ACCORDANCE WITH TH POLICY PR 1SIONS. 120 N.Andover, MA 01845 AurHA IZED REPRESENTAT E 0 988.2009 ACORD.C,QRR?Q TION. All rights reserved.