Loading...
HomeMy WebLinkAboutBuilding Permit #14-12 - 114 OLD VILLAGE LANE 7/7/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: /y_ Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION 114 d 1 aLane `p Print PROPERTY OWNER `t r FI 49U ry1 Unit# Print MAP NO: PARCEL:ZONING DISTRICT: Historic District yes no Machine ShopVillage es ho 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building )One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial KRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other eptic ❑ Well ❑Floodplain ❑ Wetlands ❑ Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: c ►:� �m s\^aQ.�o Ac-- -,-i cd,-ac, AO ClkOL�,e (Identificatio� , Please Type or Print Clearly) OWNER: Name: \JT CA"tog, 'F LG Almay Phone: 6 8F 3° $00 ,Address: 11 V- © Lb U �1-0-� 9 (kije- mok- 41 Ah yj CONTRACTOR Name: Phone: -79") 76(3 26.3 Address: o f 22-23 WdbCx'n MA of RFS- Supervisor's Construction License: 7391�1 Exp. Date: 41`7 12 Home Improvement License: 1 29 1-77 Exp. Date: ARCHITECT/ENGINEER ` A- Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 3 S WIS FEE: $ Check No.: Receipt No.: 41 NOTE: Persons contracting with linregistered contractors do not have access to the guaranty fund - _. _._ ___.�r �.�. — - _ K Signature of Agent/Owner Signature of contractor f M 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 J HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street m FIRE DEPARTMENT - Temp Du pster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. 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.$10041000 fine NOTES and DATA— For department use �I ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi Building Department l The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Skiing, 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 ❑ 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 o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 9 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 thea appeal period is over. The applicant mu PP P must then et this recorded at the R PP g Registry of Deeds. One co and roof of recording g Y PY P g � must be submitted with the building application Doc: Doc.Building Permit Revised 2008mi I . NORTH TO" of 2Andover .. dim aoiz _ _ _ o , �` dover, Mass., OC hI1C ME WICK y S � C - DRATED AP���� • BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..........U. C. �..w................ .........te..ut.y.- ...................................................................... Foundation has permission to erect......... ................. buildings on ...............................�.� .....ad. ... A3 ....... Rough to be occupied as.... irA. ........ .... ......... ..... .1/ .j...........�'..........�.t. ...... R .. Chimney C e provided that the person accepting this per shall in every respect conform to the terms of the application on file in Final. 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 MON S � ELECTRICAL INSPECTOR UNLESS CONSTRUC N T' Rough ................. .............................................................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. Page 1 of 7 1 29 "7-7 Nexus II Carpentry and Construction Design f" 1.5 �d1C�� •Lk P.O.Box 2823 11 ©C4 Woburn,MA 01888 781760 2031 Fax 978 9751263 M4 01,R4:5 n nexuscarpentryna,aol.com www.nexuscarl)entry.com Contract This is a contract between Victor Fleury of 114 Old Village Lane,North Andover MA 01845 (Hereafter referred to as the"owners" or"owner")and Nexus II Services (hereafter referred to as"Nexus")dated June 27'2011. GENERAL SCOPE OF WORK DESCRIPTION WE HEREBY SUBMIT SPECIFICATIONS AND CONTRACT FOR: work as stated below Scope of work: General details ♦ All work will be in accordance with local building code regulations and will be inspected by local officials prior to continuing with the next phase—Nexus will be responsible for arranging and being available for all inspections ♦ All work will be coordinated directly between"owners" and Nexus ♦ Nexus confirms that it is fully licensed, insured as required and ensures any sub- contractors utilized on this site will have the appropriate insurance coverage ♦ Nexus will be responsible for the safe storage of all its property and any materials to be used on the site ♦ Owner is responsible for removal and return of all items of the house in the areas that will be affected and their safe storage prior to our work commencing ♦ Owner will then be responsible for returning all items to these areas of the home after completion of the scope of work ♦ Nexus will be responsible to remove and trash into Nexus supplied dumpster all trash associated with this project SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT Page 2 of 7 General work Living room and dining room—electrical ♦ 7 recessed cans—balanced throughout room ♦ 1 eyeball/wall washer over fire place o ♦ 2 dimmer switches- supplied by Victor ♦ cable run-location to be determined ♦ CAT 5 run-location to be determined ♦ HDMI run- location to be determined ♦ 1 outlet- location to be determined ♦ remove existing speakers and wiring ♦ Proposed cost is $2, 920.00 First floor HVAC ♦ HVAC work allowance - $700.00 NOTE: specifically to the exposed vents in the 1St floor ceiling as discussed First floor ceiling prep ♦ Furnish and install strapping(to prepare for sheetrock installation),below the wiring that will be raised- $600.00 Dining room ♦ Furnish and install sheetrock and smooth plaster finish to walls and ceilings -$1, 500.00 ♦ Paint new sheetrock(no trim) - $400.00 ♦ Refinish existing floors - $800.00 3 cn tkr. Pio` ♦ Crown Molding-Furnish and install finger joint pine(paint grade) and to match existing design on 1St floor as closely as possible- $675.00 ♦ Chair rail -furnish and install (paint grade) - $470.00 ♦ Paint and caulk new crown molding including materials and labor- $450.00 Living room ♦ Furnish and install sheetrock and smooth Laster finish to walls and ceilings $2 p g , 000.00 ♦ Paint newhe s etrock no trim -$600.00 ♦ Refinish existing floors - $1, 300.00 3 Car 's A4 ♦ Crown Molding-Furnish and install finger joint pine (paint grade) and to match existing design on 1St floor as closely as possible- $860.00 ♦ Paint and caulk new crown molding including materials and labor- $500.00 Family room ♦ Sound proof pipes - $250.00 ♦ Electrics -2 outlets, 8 recessed lights on dimmer supplied by you and 2 wall sconces (supplied by you)on their own switch,HDMI/CAT 5/Cable - $2, 650.00 ---0' �b 4 ��-rS SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND pr PCS_ PROJECT MANAGEMENT �/r C00 . �"1�j Page 3 of 7 ♦ Furnish and install sheetrock and smooth plaster finish to 2 walls and ceilings -$1, 200.00 ♦ Paint new sheetrock(no trim) - $500.00 ��yy ♦ Refinish existing floors - $1, 200.00 9 C oa� a0ress Aca ir ♦ Crown Molding- Furnish and install finger joint pine (paint grade) - $800.00 ♦ Paint and caulk new crown molding including materials and labor- $500.00 Kitchen ♦ Demolish and trash the existing kitchen cabinets and counter tops NOTE:this work will be performed in strict coordination with the"owners" and the delivery of the cabinets ♦ Electrics -3 GFI outlets, 3 circuits,2 pendants over new counters and 1 ceiling fixture(supplied by you) on its own switch over sink and 5 recessed lights - $2, 300.00 ♦ Vent air duct- $300.00 ♦ Remove and trash existing hardwood floors,then furnish and install new hardwood floors - $1, 600.00 ♦ Install cabinets and trim supplied by you-$6, 000.00 ♦ Plumber for sink, faucet, dishwasher, refrigerator and new gas feed for stove top - $2, 500.00 ♦ Electrical work for additional circuits, electric double ovens - $1, 300.00 ♦ Furnish and install new trim to window then paint and caulk trim including materials and labor- $250.00 ♦ Paint new sheetrock walls where exposed including materials and labor- $350.00 Work not included in this contract Permit costs and unseen conditions Architect or engineering drawings Kitchen cabinets supply —Kitchen counters supply or installation Kitchen cabinet handles Insulation—Nexus will coordinate with your chosen company for correct dates of installation Structural beam work Painting or staining throughout other than stated in scope of work Electrical work beyond scope of work "Owner"supplied light fixtures as noted above Mechanical upgrades if required All items not specifically noted in scope of work above SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT Page 4 of 7 PERMITS "Nexus"has accepted the responsibility to obtain the necessary building permits. "Nexus"will act as a GC and work in accordance with fair and reasonable practices, and cooperate fully and under the guidance of the"Owners"and authorized parties. Standard Exclusions: Unless specifically included in the"General Scope of Work" section above,this agreement does not include labor or materials for the following work(any Exclusions in this paragraph which have been lined out and initialed by the parties do not apply to this Agreement): Removal and disposal of any materials containing asbestos or any other hazardous material as defined by the EPA. Custom milling of any wood for use in project. Moving"Owners"property around the site. Labor or materials required repairing or replacing any"Owners"- supplied materials. Repair of concealed underground utilities not located on prints or physically staked out by"Owners", which are damaged during construction. Surveying that may be required to establish accurate property boundaries for setback purposes (fences and old stakes may not be located on actual property lines). Final construction cleaning("Nexus"will leave site in"broom swept"condition). Landscaping and irrigation work of any kind. Temporary sanitation,power, or fencing. Removal of soils under house in order to obtain 18 inches(or code-required height) of clear space between bottom of joists and soil. Removal of filled ground or rock or any other materials not removable by ordinary hand tools (unless heavy equipment is specified in scope of work section above), correction of existing out-of-plumb or out-of- level conditions in existing structure. Correction of concealed substandard framing. Removal and replacement of existing rot or insect infestation. Construction of a continuously level foundation around structure (if lot is sloped more than 6 inches from front to back or side to side, "Nexus" step the foundation in accordance with the slope of the lot). Exact matching of existing finishes. Repair of damage to roadways, sidewalks, or driveways that could occur when construction equipment and vehicles are being used in the normal course of construction. The "Owner"is to enter into contracts for all of the above-mentioned services and provide direct payment to "Nexus"for all of the services we are to provide. "Nexus"will be responsible for removing all components and all construction materials relevant to the "scope of work" in this contract. Dumpsters,trailers and signs "Nexus"will provide as included in the cost of this project, a dumpster for the sole purpose of the removal of trash associated with this project. This dumpster should not be used by any persons for any other waste items or for any purpose outside of the specific use under the scope of work,unless authorization is received from"Nexus".Nexus may have on site for part, or the whole of the project,a trailer containing materials and tools belonging to "Nexus". This trailer will be parked in a position agreed to in coordination SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT Page 5 of 7 with the"Owners"and will be covered under the insurances of"Nexus"at all times. "Nexus"will have on site, a sign, with our contact details, in the event that anyone, including your neighbors,has a need to contact us directly. Photographs "Nexus"reserves the right to, from time to time,take photographs of the contracted work for use in its general marketing or for production on its web site. At no time will"Nexus" share any personal contact details of the"owner" for any photographs that it may use without seeking authorization from the "owner". Warranties All the components supplied by"Nexus"as part of the original order are covered under the warranty exercised by"Nexus"and supported by the vendors or sub-contractors. All labor and materials purchased from other suppliers to achieve completion of contract are warranted(1) one year from completion of the construction. Owner appointed sub contractors From time to time an"owner"may request that we incorporate a sub-contractor of the "owners" choosing on a project. "Nexus"will facilitate this request provided the assigned sub-contractor is connected directly with"Nexus"for all scheduling requirements and "nexus"will manage this sub-contractor in a fashion comparable with any other sub- contractor. All sub-contractors must be licensed and insured in accordance with State law. "Nexus"will meet with these sub-contractors and will ask them to submit a written proposal of all the work that will be included which"Nexus"will then confirm with the "owner". "Nexus"will oversee this scope of work and ensure that it is completed in a professional manner but the sub-contractor will be responsible for any future warranty issues directly with the "owners". All sub-contractors are responsible for the safe and clean upkeep of the working environment and will be responsible to remove their associated trash on a daily basis. Deliveries "Nexus"will be responsible for the safe arrival to site of all materials required for construction purposes for items contained within the scope of work. The "owners"shall be responsible for the safe arrival to site of other items outside of construction materials, however, should"owners"require"Nexus"to collect and bring to site, any of these items, "Nexus"will accommodate as able and add a minimal cost to cover time and fuel to a change order. Allowances with the contract cost Within the cost structure of this contract,certain cost allowances may have been given for the"owners"to purchase items chosen by them—these allowances will be noted above with the amount allowed clearly noted. If the"owners"do not spend the full allowance in an area,this amount will be credited back to the customer and not included in the fmal contracted amount. If the "owners" spend beyond the allowance noted,then the "owners" shall be responsible for this balance and a payment made to cover this amount either to the vendor,the sub-contractor or to "Nexus" SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT Page 6 of 7 Expiration of this Agreement: This Agreement will expire 30 days after the date at the top of page one of this agreement if not accepted in writing by"Owners"and returned to "Nexus"along with the necessary deposits within that time frame. People Authorized to Sign Chante Orders: The following people are authorized to sign Change Orders: "Ne Mark Gotobed "Owner/Owners": Victor Fleury Concealed Conditions: This Agreement is based solely on the observations"Nexus"was able to make with the area in its current condition at the time this Agreement was bid. If additional Concealed Conditions are discovered once work has commenced which were not visible at the time this proposal was bid, "Nexus"will stop work and point out these unforeseen Concealed Conditions to "Owners" so that"Owners"and"Nexus"can execute a Change Order for any Additional Work. Changes in the Work: During the course of the project, "Owners"may order changes in the work(both additions and deletions). "Nexus"will determine the cost of these changes and the cost of this additional work will be added to "Nexus"profit and overhead. Schedule of work It is agreed by both parties that this work will be coordinated with the"Owners"and "Nexus"to be undertaken in various stages to avoid complete disruption of the home environment. "Nexus"will give"Owners"no less than 2 days notice prior to arriving on site for commencement of any of the agreed stages of work to allow "Owners"to prepare. "Owners" commits to have sites identified for construction work available for start at the beginning of the scheduled day so as to avoid any unnecessary delays. SPECIALIZING IN QUALITY FINISH CARPENTRY, REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT Page 7 of 7 Contract Cost and Payment Schedule: Total cost of work description and materials included in the proposal(except materials/work stated) - $35, 475.00 (Thirty five thousand four hundred and seventy five dollars and zero cents) PAYMENT SCHEDULE C),)(- � 1st Payment due upon signing this contract 2� l� TOTA $11,825.00 2nd Payment due at end of 1St week TOTAL $5, 912.00 3rd Payment due at end of 2"week TOTAL$5, 912.00 4th Payment due at end of 3`d week TOTAL$4,000.00 5th Payment due at end of 4th week TOTAL $4,000.00 Final payment due upon completion of scope of work Pit CA Pm TOTAL$3, 826.00 Amount due upon signing this contract $11 825.00 b1291k ��� (J0.•n Mit s cor,\n'nc��1' o n s2�n0.b�e. F�('2SS, q.I have read and understand, and I agree to, all the terms and conditions contained in the proposal above. Date.6. 2'� . "Nexus"Authorization........................ ............. DaZj'�o 960.'1...0.L1... "Owner/Owners"Authorization........ ............................................ Date............................... "Owner/Owners"Authorization..................................................... SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT 2680 o MA VICTOR FLEURY OR 1gz-) i 1 53-13/182637 JACQUELINE FLEURYJAE LN [ Date -� 114 OLD VIL NORTH ANDOVVER MA 01845-4533 Pay to the Order of ���— Bank of America Advantage® Bankof America ACH R/T 011000138 ��� � � u■ 2 680 _ For rte/ �y1 A -- - L 38�• 0 0 0 0 1 4 6 •Y GUAR 011000 0 L 1000OlAN6 SAFETY BLUE ,w ,G— / - �= Massachusetts- Departnient trf pirhlic S;rfet,,- B/rMA of Building +� Re�trlaiiorts anti tandar(is I Construction Supervisor License License: CS 73991 Restricted to: 00 GERALD WHITE 23 GLENDALE DR DANVERS, MA 01923 c J _ :Zp Expiration: 4/7/2012 uniSllla�t++ltl`I' Tr=: 22470 GI Address Renewal E] Employment DPS-CAI 0 50M-0410L-G101216 ✓1re•C709 Pmonweall4o�✓llaarac;!uael�a License or registration valid for individui use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: ' HOME IMPROVEMENT CONTRACTOR •�; Office of Consumer Affairs and Business Regulation Registration:, 129177 10 Park Plaza-Suite 5170 Expiration: 7/19/2011 Ti# 287930 Boston,MA 02116 Type:-. Individual.,. Gerald White Gerald White 54 Emerald Drive Lynn,MA 01904 Undersecretary Not vali without signature RE: Windows Page 1 of 2 . From: whitey1611@aol.com<whitey1611@aol.com> To: Rhonda Rohtstein<rrohtstein@onbrand24.com>;Mark<nexuscarpentry@aol.com> Subject: RE:Windows Date: Fri, May 20,2011 1:25 pm Hi Rhonda Thanks for getting back to me. I will get you the fi res for the painting & bathroom over the weekend. Have a great weekend Regards Ged White Nexus Const r ction 781 760 203 --Sent fr my Palm Pre On Ma 20, 2011 11:10 AM, Rhonda Rohtstein <rrohtstein o rand24.com> wrote: Thank Ged, After some research and investigating I have decide to keep what I have! It was breaki my heart to dump all these windows in the trash and repla a them and I think I am just going to eep them. I didn't realize how good what I have is. I have local guy who is going to fix a couple o e ones in bad repair. I am still considerin he painting of the kitchen and refurbishing of do stairs bath if you have a ballpark idea of that co Thanks! Rhonda Rohtstein Vice President Business Develop nt OnBrand24 100 Cummings Center Suite 306L Beverly MA 01915 978 524 8777 ext 230 781 248 8265 cell rrohtstein(cbonbrand24.com www.onbrand24.com <http://www.onbr d24.com/>,- From: whitey1611(abaol.com [mailto:white 1611 aol.c ] Sent: Fri 5/20/2011 10:33 AM To: Rhonda Rohtstein; Mark Subject: Windows Hi Rhonda I hope all is well? I'm just checking in to see if you had chance to I ok over the quote I sent you for the windows replacement? Please let me know if you have any questions or concerns Regards Ged White http://mail.aol.com/33668-1 I 1/aol-1/en-us/mail/PrintMessage.aspx 5/21/2011 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 burn 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 PViassachusetts Department of Industrial Accidents Office of investigations 600 Washington Street Boston,MA 02111. Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia 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 Leg><bly Name(Business/Organization/Individual): Address:—? ,C), x X23 City/State/Zip:%4 o�D LA r(\, phone#: 181 160 ?,o 3 Are you an employer?Check the appropriate box: _ 1.❑ I am a employer with 4. Type of project(required): ❑ I am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet. # 7• ❑Remodeling hip and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. [No workers' comp.insurance 5. El We are a corporation and its 9 E]Building addition required.] .officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑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.] 13640ther *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 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 of up 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. I do hereby certify unde�M,�p , d penalties of perjurytltat the information provided abo a is tr a and correct. Si nature: Date: 6 3 0 1( Phone#: 70 X31 FFon only. Do not write in this area,to be completed by city or town official. n: Permit/License# hority(circle one)Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#: ACORD® C �.- ERTIFICAl"E OF LIABILITY E DATE(MMIOUVI'YYY) 3/9/2011 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(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 I10U of such endorsement(s). PRODUCER CONTA Lauren Goldman NAME: Cross Insurance-Peabody PHONE (978)532-5445_ .(?rc,.No, el: -�LNe);f97t1)433.aaa� 139 Lynnfield Street ab:lgoldmaaRcrossagency.com PRODUCER 000eo172 CUSTOMER ID N: Peabody MA 01960 INSURERIS)AFFORDING COVERAGE INSUREo _ _NAIC I 7NSURERA Western World ins. Co. INSURERB:Safe Tndemnity -- 3619 Nexus II Services LLC •• --• . ._ P.O. Sox 2823 INSURER c: •• - _ .._. INSURER D: Woburn MA 01888 INSURER E: -•• -- INSURER F: COVERAGES CERTIFICATE NUMBER:CL113943409 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI00 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 SUBJECTRES E ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES._LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR. . x=3RK - _.. _ LTR TYPE OF INSURANCEINSR WV POLICY NUMBER MM DO F M0Cr �P LIMITS - GENERAL UABIUTY EACH OCCURRENCE S 1,000,000 J COMMERCIAL GENERAL LIABILITY N E0' • PREMI Ee o%greme is A 1�CLAIMS-MADE OCCUR PP1286453 /12/2020 /12/2011 MEOEXP(Arty one vamon) s _ _ 5,000 PERSONAL QADV INJURY 3 11006,000 i - OENERALAGGREGATE _ S 2,000,000 `GLWLAGGRWAYELIMIT APPLIES PER -.COMP/OPAGG 5 1,000,000 —►Mx POL1cY' f- Loc - --- S AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT ANY AUTO actidem) B I ALL OWNED AUTOS 116632 BODILY INJURY(Pcrperw) S 1/10/2020 1/10/2011 250,000 R'SCHEDULED AUTOS BODILY INJURY(Per seddeel) $ 500,000 x HIRED AUTOS PROPERTY DAMAGE — , S (Peraz1ldent) 100,000 I X I NON-OWNEDAUTOS - - M edlrle p9ymenL• S 5 _ ,000 Waive Cdrtsipn Dedualote S I I UMBREL;7--H OCCUR EACH OCCURRENCE S i Excess CLAIMS-MADE - AGGREGATE S DEDUCTIBLE -- S RETENTION S WORKERS COMPENSATION S AND EMPLOYERS'UABILrrYY/N WCPROPRiGToRJPARSTATiImy 1 s I OTft OFFICERWEMBER EXCLUDEDUTwE F-1 NIA E.L.EACH ACCIDENT S it yer tory In NH)ad E.L.DISEASE-EA EMPLOYE S - 11 ,S6 deSTr0 a under OESCRIP710N OF OPERATIONS below I - ElDISEASE•POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEINCLES(Anach ACORD 101,Addlpomi Re=rks Schodule,M more epece to mquirodl Refer " 801icp for exclusionary ensvraemeats an0 special proviisions. CERTIFICATE HOLDER CANCELLATION (978)975-1263 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORED REPRESENTATIVE Timothy Tramonte/Ml - ACORD 25 20091 ( 09) ®1988-2009 INS02s ACORD aooeoe) The ACORD name and logo are registered marks of ACORD CORPORATION. All rights reserved. T00 O 33NMSNI SS0113 LTZZ ZCS BL6 %V3 BC:ST TT09/80/C0 Locationill Odd No. Date NORTH TOWN OF NORTH ANDOVER O��..•° ,•�y� � A + ; + Certificate of Occupancy $ % ��s• °'E<�' Building/Frame Permit Fee $ �cNus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2 4 J L,9 -�- ----- Building Inspector