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Home My WebLink AboutBuilding Permit #358 - 129 MAIN STREET 10/25/2008 BUILDING PERMIT o` r10RTH TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION * yy* h T Permit NO: J Date Received JD qs Arita,�C SACHUS� Date Issued:-Lo— IMPORTANT: Applicant must complete all items on this page LOCATION 13z_ (Y\4�l� s 1 v t e i //0A ANJ VVuA (WA 0 t 94 s"" c } Print PROPERTY OWNER F \C`n,g ircl rp-t.4 At,I,,� Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village 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 Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer �\ \ %7 DESCRIPTION OF WORK TO BE PREFORMED: Ft'VY y o A L. - fJf'A'.' Vk A ark 0 A 6j�41:r Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: Dr /i k, g>_� Phone: Address: 193 o r�to �/ , �t. ,ya 1/ et ;- 1&:I. _ Supervisor's Construction License: G7 40A Exp. Date: Home Improvement License:. 7 Q + Exp. Date: '7 ,V 0/0 ARCHITECT/ENGINEER 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: $ FEE: $ �Z► Check No.: Receipt No.: 0?/ Z' NOTE: Persons cont acting with u egistered contractors do not have access to the guaranty fund Oignature of Agent/Owner Signature of contractor 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 x .V 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 FIRE DEPARTMENT Temp Dumpster 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.$100-$1000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 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 ❑ Building Permit Application ❑ Workers Comp Affidavit moo_ Photo Copy Of H.I.C. And/Or C.S.L. Licenses �py 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 o 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) ❑ 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 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 Doc:Building Permit Application Revised 2.2008 Location 3 Z-- VYU t A � No. �5� Date I -ak NORTIy TOWN OF NORTH ANDOVER Fj• •• O� + Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # ' r 2 1 7 2 vv Building Inspector X10RTH 0VM 0ndover , 0 10 o dower, Mass. / ? r 0 - LAKE ' ' COCMICMEWI': 0/?ATED O'Pa,`�5 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System • • BUILDING INSPECTOR THIS CERTIFIES THAT........ . ....�r .......L�IM.. ...t!! .4.................................................. ................ .......................... Foundation has permission to erect........................................ buildings on ...�01 L........... I.h,........... Ali.................. Rough to be occupied as........... . Chimney provided that the pers accepting this permit shall in M.- tct 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 PERT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR. UNLESS CONSTR ST TS 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. Catenory Summary Mitigation Restoration Replacement O and P Non Taxable Taxable Total Antique Shop $4,737.27 $926.47 $120.00 $0.00 $5,783.74 $0.00 $5,783.74 Basement $134.95 $239.63 $0.00 $0.00 $374.58 $0.00 $374.58 Bathroom $0.00 $193.23 $0.00 $0.00 $193.23 $0.00 $193.23 Bathroom $108.98 $146.80 $0.00 $0.00 $255.78 $0.00 $255.78 Bedroom $0.00 $223.05 $0.00 $0.00 $223.05 $0.00 $223.05 Front T.V.Room $0.00 $217.80 $0.00 $0.00 $217.80 $0.00 $217.80 Job $1,205.00 $0.00 $0.00 $0.00 $1,205.00 $0.00 $1,205.00 Kids Bedroom $0.00 $204.55 $0.00 $0.00 $204.55 $0.00 $204.55 Kitchen $0.00 $356.61 $0.00 $0.00 $356.61 $0.00 $356.61 Office $497.88 $332.83 $0.00 $0.00 $830.71 $0.00 $830.71 Sitting Room $27.50 $224.76 $0.00 $0.00 $252.26 $0.00 $252.26 Storage $0.00 $209.34 $0.00 $0.00 $209.34 $0.00 $209.34 $6,711.58 $3,275.07 $120.00 $0.00 $10,106.65 $0.00 $10,106.65 Structure and Contents Summary Structure Contents O and P Non Taxable Taxable Total Antique Shop $5,468.74 $315.00 $0.00 $5,783.74 $0.00 $5,783.74 Basement $374.58 $0.00 $0.00 $374.58 $0.00 $374.58 Bathroom $183.23 $10.00 $0.00 $193.23 $0.00 $193.23 Bathroom $245.78 $10.00 $0.00 $255.78 $0.00 $255.78 Bedroom $223.05 $0.00 $0.00 $223.05 $0.00 $223.05 Front T.V.Room $217.80 $0.00 $0.00 $217.80 $0.00 $217.80 Job $1,085.00 $120.00 $0.00 $1,205.00 $0.00 $1,205.00 Kids Bedroom $204.55 $0.00 $0.00 $204.55 $0.00 $204.55 Kitchen $341.61 $15.00 $0.00 $356.61 $0.00 $356.61 Office $813.21 $17.50 $0.00 $830.71 $0.00 $830.71 Sitting Room $216.96 $35.30 $0.00 $252.26 $0.00 $252.26 Storage $209.34 $0.00 $0.00 $209.34 $0.00 $209.34 $9,583.85 $522.80 $0.00 $10,106.65 $0.00 $10,106.65 Trade Summary Amount O and P Non Taxable Taxable Total Carpet Cleaning/Restoration $117.64 $0.00 $117.64 $0.00 $117.64 Content Moving/Manipulation $27.50 $0.00 $27.50 $0.00 $27.50 Contents Cleaning $480.30 $0.00 $480.30 $0.00 $480.30 Demolition/Tear-out $4,717.24 $0.00 $4,717.24 $0.00 $4,717.24 Emergency Services $706.84 $0.00 $706.84 $0.00 $706.84 Equipment Rental $975.00 $0.00 $975.00 $0.00 $975.00 Mold Mitigation $1,138.96 $0.00 $1,138.96 $0.00 $1,138.96 Structural Cleaning-Interior $1,675.17 $0.00 $1,675.17 $0.00 $1,675.17 Water Damage Restoration $50.00 $0.00 $50.00 $0.00 $50.00 Window/Door Restoration $218.00 $0.00 $218.00 $0.00 $218.00 $10,106.65 $0.00 $10,106.65 $0.00 $10,106.65 In Progress Richard Lentini Tuesday,November 25,2008 Page 8 of 9 (c)SERVPRO® Intellectual Property, Inc. 8:26 AM Massachusetts- Department of Public Safet'N Board of Buildin<- Rei-ulations and Standard Construction Supervisor License License: CS 67602 Restricted to: 00 DAVID R HART 230 ESSEX ST/PO BOX 1723 HAVERHILL, MA 01831 Expiration: 5/23/2010 ('innmissioller Tr#: 26944 Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 143708 Ecplratran -7721/2010 Tr# 27183: Type. DBA SERVPRO OF HAVERHILL•: DAVID HART 230 ESSEX STREET HAVERHILL, MA 01830 " Administrator The Commonwealth of Massachusetts Department of Industrial Accidents Office Of Investigations ' 600 Washing ashinQton Street Boston , MA O2II1 i `- '- www-mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers ApPlicant Information Please Print LeaibIv bn')P t v`Fp �Cb, P 5 S 1la` SL S ear-,-j+�S �1 e Name (Business/Organization/Individual): �/� �p� SerJDrO O Address: ZSC-) SSQIL Sfi city/state/zip:_ I�av�rh`I , �l.t US39L Phone#: Are you an employer?Check the appropriate box: l.❑ I an. a employer with 4. ❑ 1 am a aeneral contractor and I F7. ype of project(required): employees(full and/or part-time).* have hired the sub-contractors ❑ New construction 2.El am a sole proprietor or partner- listed on the attached sheet I ❑ Remodeling ship and have no employees These sub-contractors have 8. [ emoiition working for me in any capacity. — Viers' comp. insurance. [No workers' comp. insurance 5. We are a corporation and its 9' ❑ Building addition required.] officers have exercised.their 10:❑Electrical repairs or additions 3.❑ I an a homeowner doing all work right of exemption per MGL 11.7 Plumbing repairs.or additions myself. [No.workers' comp. c. 152, §1(4),and we have no insurance required.] t employees. [No workers' 12.[] Roof repairs comp. insurance required.) 1.3.❑ Other *Any applicant that checks box#1.must also fill out the section below showing their workers'compensation policy information. +Homeowners who submii.this afiidevit indicating they art Lain,En ivoa."at-, !her,hi outside contractors muni submit a new amriavit indicting suet. tContractors that check this box must attached an additional sheet showing the name of the sub- ontractots and their workers'comp,policy information. I am an employer that is providing workers'compensation insurance or employees. Below is the policy andjob site information fP cY J Insurance Company Name: �l 1 Policy#or Self-.ins. Lic.#: ��(�,� - S - 62S C2 _ g Expiration Date: D Job Site Address:_ tj, p: �0�-�.•� ,q.t,.� y�Y Ci /State/Zi � q p b Attach a copy of the workers' compensation policy declaration age showing kW-t ( e the policy number and expiration date).O�y5 .Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the im fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form position of criminal penalties of a of a STOP W of up to$250.00 a day against the violator. Be advised that a co Wo ORDER and a fine Investigations o . copy of this statement may be forwarded to the f the DIA for insurance Office of Investigations e coverage verification. I do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct S i mature: [� Date• � Phone#: 37 7 �. 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# 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 o r 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&f 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 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 reg-rdirg the law or if you are required to obtain a workers' compensation policy,please call the Department at the nuanber,listed below. Self-ins•�rr•ed companies should enter their self-insurance license number on the appropriate line. City or Town Officiais 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 pennit/license number which will be used as a reference number. in addition,an applicant that must submit multiple permit/hcense 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 fixture 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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 4.06 or 1-977-MASSAFE Revised 5-26=05 Fax#617-727-7749 wu-w-mass.gov/dia i r Client#: 1007912 02SPHOMEAUT ` ACORDTM CERTIFICATE OF LIABILITY INSURANCE702/ DA DD/YYYY) 211/22v2oos PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION BUT Insurance Services,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 3605 Glenwood Ave HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Raleigh,NC 27612 919 716-9777 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Restoration Risk Retention Group,In RRG Home&Auto Professional Services, Inc. INSURER B: P.O. Box 1723 INSURER C: Haverhill,MA 01831 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 0613131 TYPE OF INSURANCE POLICY NUMBER POLICY EFFECVE POLICY EXPIRATION LIMITS NSR DATE MM D DTE MM D A X GENERAL LIABILITY RGLO50012 03/01/08 03/01/09 EACH OCCURRENCE $1.000.000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RSES IF,ENTED $100,000 PREMCLAIMS MADE FE OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE s2.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY J RCOT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR FICLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU- OTH EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If es,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ A OTHER Pollution RPU050015 03/01/08 03/01/09 $1,000,000/$2,000,000 A Ltd Service RLS050261 01/01/08 01/01/09 $250,000/$250,000 jI DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS **Supplemental Name** Home&Auto Professional Services,Inc.DBA Servpro of Danvers-Ipswich; DBA Servpro of Haverhill/Newburyport (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION ServPro Ind.lnc DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL In DAYS WRITTEN ServPro Hold.CO.Inc; Ernet Prop.Resour.GrpLLC NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL P O Box 1978 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Gallatin,TN 37066 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE &j" 4e. .vYA ACORD 25(2001/08)1 of 3 #S2379973/M2379968 IDS 0 ACORD CORPORATION 1988 rV,_MG 8/20/2008 8: 19 PAGE 002/002 LMG s ` Certificate of tnsue»n THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON YOU THE CERTIFICATE HOLDER. THIS CERTIFICATE IS NOT AN INSURANCE POLICYAND DOES NOTAMEND,EXTEND,OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES LISTED BELOW. This is to Certify that. PRODUCER Or RECORD: HOME&AUTO PROFESSIONAL SERVICES RISK STRATEGIES CON PANY 230 ESSEX STREET 100 NORTH INLUN STREET HAVERHILL,MA 01830 RANDOI.PH-,3VIA 02368 At the issue date of this certificate,the insured named above has been issued a policy(es}by the Company udder the policy(es)listed below. The insurance afforded by the listed policy(ies)is subject to all their terms,exclusions and conditions and is not altered by any requirement,term or condition ofany contract or other document with respect to which this cer'ti6cate may be issued. TYPE OF POLICY POLICY DATE POLICY NUMBER LIMITS OF LIABILITY Coverage Afforded UnderWC COV.B Law of the Following States 08/19/2008 WC2-31 S-368163- MA Bodily Injury By Ea WORKERS 0811912009 018 Accident A cidn $500,000 t COMPENSATION Bodilylnjury By Disease Each $500,000 Person $500,000 Policy Limit GENERAL General Aggregate-Other than Prod/Completed Ops LIABILITY $ Products/Completed Operations Aggregate N/A N/A Bodily Injury and Property Damage Llatallity Per Pe rson/ Organization OCCURRENCE AUTOMOBILE Each Accident-Single Limit- LIABILITY B.I.And P. D.Combined OWNED Each Person El NON-OWNED NIA N/A Each Accident or Occurrence HIRED Each Acd dent or Occurrence OTHER LOCATION(S)OF OPERATIONS&JOB#(IF APPLICABLE) NOTICE OF CANCELLATION: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAIv1ED BELOW,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILIT! 1 OF AMY KIND UPON THE CCOFANY,IT'SAGENTSOF,REF R ESENTAT IVES. LIBERTY MUrUAL INSURANCE GROUP SER.VPRO INDUSTRIES INC CERTIMATE SERNTRO HOLDING CO INC HOLDER AUTHORIZED REPRESENTATIVE ERNET PROPERTY RESOURCE GROUP LLC Dover NH Office 016C PO BOY 1978 DATE ISSUED GALLATIN,TN 37066 d812012008 This certificate is executed by LIBERTY MUTUAL INSURANCE GROUP as respects such insurance as is afforded by Those Companies 135 772RE Summary Totals Structure: $9,583.85 Contents: $522.80 S/C Total: $10,106.65 Overhead: $0.00 Profit: $0.00 O/P Total: $0.00 Non Taxable: $10,106.65 Taxable: $0.00 Sub Total: $10,106.65 0.00%Sales Tax: $0.00 Total: $10,106.65 Deductible NOT COLLECTED: In Progress Richard Lentini Tuesday,November 25,2008 Page 9 of 9 (c)SERVPRO® Intellectual Property, Inc. 8:26 AM Servpro of Haverhill 230 Essex St r a e Q PO Box 1723 p SAI �^+ 4 p Haverhill,MA 01832 & Fire Water - Cleanup & Restoration' Phone 978 374 8555 Fax servprohaverhill@aol.com Tax ID 042887465 Loss Information Loss Statistics FNOL Date: 10/22/2008 Richard Lentini Loss Date: 10/22/2008 138 Main Street Unit 3 North Andover„MA 01845 Company: Arbella Insurance Home: (978)758-1102 Work: Agent: Costello,Bill Type: Smoke Cause: Other Adjustor: Hagopian,Greg Claim#: Estimator: Kevin Eddy Policy#: 7500015016 .lob Calculations Room Offset Missing Totals IfFloorPerimeter 546.93 20.57 0.00 567.50 sfCeiling 1,748.42 24.37 0.00 1,772.79 sfFloor 1,748.42 24.37 0.00 1,772.79 sfWalls 4,577.88 195.46 0.00 4,773.34 Description Quantity UOM Unit Price Total Tax O/P 1 Indoor Air Quality Air Scrubbers,<750 cfm 3.00 DAY $95.00 $285.00 2 Temp.Power Generator 5.00 DAY $125.00 $625.00 3 On Site Supervision Labor 2.00 HR $60.00 $120.00 (Note:4 Trips To Job Site-Charging For Only 2) 4 Rental Equipment 1.00 EA $175.00 $175.00 (Note:VAPOR BLITZ II STEAM CLEANER USED ON SHOP CEILING- ENTIRE BACK OFFICE-BATHROOM (2 DAYS)) Mitigation: $1,205.00 Structure: $1,085.00 Restoration: $0.00 Contents: $120.00 Replacement: $0.00 Total: $1,205.00 Kitchen Calculations Room Offset Missing Totals Box sfCeiling 215.73 0.00 0.00 215.73 Length: 16 ft 11 in sfFloor 215.73 0.00 0.00 215.73 Width: 12 ft 9 in sfWalls 474.72 0.00 0.00 474.72 Height: 8 ft 0 in Description Quantity UOM Unit Price Total Tax O/P 5 Clean Ceiling 215.73 SF $0.12 $25.89 8 Clean Light,Fixture,LG 1.00 EA $8.00 $8.00 7 Clean Wall 237.36 SF $0.18 $42.72 (Note:This is Painted) 8 Clean Wall 237.36 SF $0.18 $42.72 (Note:This is wood) 9 Clean Window Unit,(per side)21 -40 sf 2.00 EA $15.00 $30.00 In Progress Richard Lentini Tuesday,November 25,200887 _ Page 1 of 9 (c)SERVPRO® Intellectual Property, Inc. 8:26 AM 10 Clean Cabinet,Wall,Exterior 10.00 LF $4.63 $46.30 11 Clean Cabinet,Base, Exterior 14.00 LF $4.63 $64.82 12 Clean Counter Top 12.00 LF $0.92 $11.04 13 Clean Microwave,Built-In 1.00 EA $8.00 $8.00 14 Clean Sink 1.00 EA $5.00 $5.00 15 Clean Floor 215.73 SF $0.23 $49.62 16 Clean Radiator 1.00 EA $7.50 $7.50 17 Clean Stove/Oven 1.00 EA $15.00 $15.00 Mitigation: $0.00 Structure: $341.61 Restoration: $356.61 Contents: $15.00 Replacement: $0.00 Total: $356.61 Kids Bedroom Calculations Room Offset Missing Totals Box sfCeiling 132.95 0.00 0.00 132.95 Length: 9 ft 4 in sfFloor 132.95 0.00 0.00 132.95 Width: 14 ft 3 in sfWalls 377.28 0.00 0.00 377.28 Height: 8 ft 0 in Description Quantity UOM Unit Price Total Tax O/P 18 Clean Ceiling 132.95 SF $0.12 $15.95 19 Clean Light,Fixture,MD 1.00 EA $6.00 $6.00 20 Clean Wall 377.28 SF $0.18 $67.91 21 Clean Door,Per Side 2.00 EA $4.00 $8.00 22 Clean Window Unit,(per side)21 -40 sf 2.00 EA $15.00 $30.00 23 Clean Floor,Hardwood 132.95 SF $0.37 $49.19 24 Clean Radiator 1.00 EA $7.50 $7.50 25 Remove,Clean, Replace Closet,Storage 1.00 EA $20.00 $20.00 Mitigation: $0.00 Structure: $204.55 Restoration: $204.55 Contents: $0.00 Replacement: $0.00 Total: $204.55 Bathroom Calculations Room Offset Missing Totals Box sfCeiling 50.41 0.00 0.00 50.41 Length: 9 ft gin sfFloor 50.41 0.00 0.00 50.41 Width: 5 ft 2 in sfWalls 238.72 0.00 0.00 238.72 Height: 8 ft 0 in Description Quantity UOM Unit Price Total Tax O/P 26 Clean Ceiling 50.41 SF $0.12 $6.05 27 Clean Light,Fixture,SM 1.00 EA $4.00 $4.00 28 Clean Light,Swag 1.00 EA $20.00 $20.00 29 Clean Wall 119.36 SF $0.18 $21.48 30 Clean Wall,Tile 119.36 SF $0.32 $38.20 31 Clean Door,Per Side 2.00 EA $4.00 $8.00 32 Clean Window Unit,(per side)21 -40 sf 1.00 EA $15.00 $15.00 33 Clean Cabinet,Medicine, In and Out 1.00 EA $10.50 $10.50 34 Clean Sink 1.00 EA $5.00 $5.00 35 Clean Floor 50.41 SF $0.23 $11.59 36 Clean Toilet 1.00 EA $12.00 $12.00 In Progress -}° RichardLentini - -.- - _�. -� s.. =_ _ _Y _._ _ ��_ __._-_-.._ _ r TuesdayiAovember25;2008-"7�__ Page 2 of 9 (c)SERVPRO® Intellectual Property, Inc. 8:26 AM 37 Clean Tub/Shower 1.00 EA $23.91 $23.91 38 Clean Radiator 1.00 EA $7.50 $7.50 39 Clean Mirror 1.00 EA $10.00 $10.00 Mitigation: $0.00 Structure: $183.23 Restoration: $193.23 Contents: $10.00- Replacement: $0.00 Total: $193.23 Storane Calculations Room Offset Missing Totals Box sfCeiling 78.43 0.00 0.00 78.43 Length: 15 ft 2 in sfWalls 325.44 0.00 0.00 325.44 Width: 5 ft 2 in Height: 8 ft 0 in Description Quantity UOM Unit Price Total Tax O/P 40 Clean Ceiling 78.43 SF $0.12 $9.41 41 Clean Wall 162.72 SF $0.18 $29.29 (Note:This is Painted) 42 Clean Wall 162.72 SF $0.18 $29.29 (Note:This is Wood) 43 Clean Window Unit,(per side)21 -40 sf 1.00 EA $15.00 $15.00 44 Clean Cabinet,Wall,Exterior 15.00 LF $4.63 $69.45 45 Clean Cabinet,Base,Exterior 8.00 LF $4.63 $37.04 46 Clean Counter Top 8.00 LF $0.92 $7.36 47 Clean Sink 1.00 EA $5.00 $5.00 48 Clean Radiator 1.00 EA $7.50 $7.50 Mitigation: $0.00 Structure: $209.34 Restoration: $209.34 Contents: $0.00 Replacement: $0.00 Total: $209.34 Bedroom Calculations Room Offset Missing Totals Box sfCeiling 148.03 0.00 0.00 148.03 Length: 14 ft 4 in sfFloor 148.03 0.00 0.00 148.03 Width: 10 ft 4 in sfWalls 394.56 0.00 0.00 394.56 Height: 8 ft 0 in Description Quantity UOM Unit Price Total Tax O/P 49 Clean Ceiling 148.03 SF $0.12 $17.76 50 Clean Light, Fixture,MD 1.00 EA $6.00 $6.00 51 Clean Wall 394.56 SF $0.18 $71.02 52 Clean Door, Per Side 4.00 EA $4.00 $16.00 53 Clean Window Unit,(per side)21 -40 sf 2.00 EA $15.00 $30.00 54 Clean Floor,Hardwood 148.03 SF $0.37 $54.77 55 Clean Radiator 1.00 EA $7.50 $7.50 56 Remove,Clean,Replace Closet,Storage 1.00 EA $20.00 $20.00 In Progress Richard Lenffni - _- _ _-. __ _. Tuesday,November 25,2008 Page 3 of 9 (c)SERVPROO Intellectual Property, Inc. 8:26 AM Mitigation: $0.00 Structure: $223.05 Restoration: $223.05 Contents: $0.00 Replacement: $0.00 Total: $223.05 Minn Room Calculations Room Offset Missing Totals Box sfCeiling 200.36 0.00 0.00 200.36 Length: 16 ft 3 in sfFloor 200.36 0.00 0.00 200.36 Width: 12 ft 4 in sfWalls 457.28 0.00 0.00 457.28 Height: 8 ft 0 in Description Quantity UOM Unit Price Total Tax O/P 57 Clean Ceiling 200.36 SF $0.12 $24.04 58 Clean Light,Fixture,MD 1.00 EA $6.00 $6.00 59 Clean Wall 457.28 SF $0.18 $82.31 60 Clean Window Unit,(per side)3-9 sf 2.00 EA $10.00 $20.00 61 Clean Window Unit,(per side)21 -40 sf 1.00 EA $15.00 $15.00 62 Clean Carpet 200.36 SF $0.31 $62.11 63 Clean Radiator 1.00 EA $7.50 $7.50 64 Clean Book Case 12.00 SF $0.65 $7.80 65 Manipulation Furniture/Contents 1.00 EA $27.50 $27.50 Mitigation: $27.50 Structure: $216.96 Restoration: $224.76 Contents: $35.30 Replacement: $0.00 Total: $252.26 Front T.V. Room Calculations Room Offset Missing Totals Box sfCeiling 179.13 0.00 0.00 179.13 Length: 12 ft 6 in sfFloor 179.13 0.00 0.00 179.13 Width: 14 ft 4 in sfWalls 429.28 0.00 0.00 429.28 Height: 8 ft 0 in Description Quantity UOM Unit Price Total Tax O/P 66 Clean Ceiling 179.13 SF $0.12 $21.50 67 Clean Light, Fixture,MD 1.00 EA $6.00 $6.00 68 Clean Wall, Paper 429.28 SF $0.18 $77.27 69 Clean Window Unit,(per side)3-9 sf 2.00 EA $10.00 $20.00 70 Clean Window Unit,(per side)21 -40 sf 2.00 EA $15.00 $30.00 71 Clean Carpet 179.13 SF $0.31 $55.53 72 Clean Radiator 1.00 EA $7.50 $7.50 Mitigation: $0.00 Structure: $217.80 Restoration: $217.80 Contents: $0.00 Replacement: $0.00 Total: $217.80 In Progress Richard Lentini Tuesday,November 25,2008 Page 4 of 9 (c)SERVPROV Intellectual Property, Inc. 8:26 AM Antique Shop Calculations Room Offset Missing Totals Box IfFloorPerimeter 84.84 0.00 0.00 84.84 Length: 27 ft 11 in sfCeiling 404.84 0.00 0.00 404.84 Width: 14 ft 6 in sfFloor 404.84 0.00 0.00 404.84 Height: 10 ft 0 in sfWalls 848.40 0.00 0.00 848.40 Description Quantity UOM Unit Price Total Tax O/P 73 Health&Safety Personal Protective Equip. 2.00 SET $25.00 $50.00 74 Remove Ceiling,Acoustical Tile 404.84 SF $0.25 $101.21 75 Remove Ceiling,Acoustical Tile Grid 404.84 SF $0.17 $68.82 76 Removed Broken flouresent lights 4.50 HR $35.00 $157.50 77 Remove Wall 848.40 SF $0.55 $466.62 (Note:Plaster/Wooden Stapping) 78 Remove Wall 848.40 SF $0.55 $466.62 (Note:First Layer Paneling-2nd Layer Sheet rock) 79 Remove Insulation,Wall 636.30 SF $0.42 $267.25 (Note:Blown In Insulation) 80 Remove Nails/Screws,Wall 254.52 SF $0.35 $89.08 *Remove 81 Remove Floor 303.63 SF $0.35 $106.27 (Note:2 TILE SECTIONS) 82 Remove Floor 404.84 SF $0.35 $141.69 (Note:SECOND LAYER WOOD PRESS BOARD) 83 Remove Floor 404.84 SF $0.35 $141.69 (Note:FIRST LAYER OF PLYWOOD) 84 Remove Floor 404.84 SF $0.35 $141.69 (Note: THIRD LAYER OF BEIGE 12"X12"FLOOR TILE) 85 Remove Floor 404.84 SF $0.35 $141.69 (Note:FOURTH LAYER 2"WOOD FLOORING) 86 Remove Floor 404.84 SF $0.35 $141.69 (Note:FIFTH LAYER VYNAL FLOORING) 87 Remove Floor 404.84 SF $0.35 $141.69 (Note:SIXTH LAYER OLD PLYWOOD GLUED DOWN) 88 Remove Floor 404.84 SF $0.35 $141.69 (Note:SEVENTH LAYER PAPER PRESS BOARD GLUED DOWN-BROKE APART IN VERY SMALL SECTIONS-HAD TO BE SCRAPED OFF) 89 Removed From Multiple Layers Floor Staples 2.50 HR $35.00 $87.50 90 Hepa Vacuum Ceiling 404.84 SF $0.25 $101.21 91 Hepa Vacuum Wall 848.40 SF $0.25 $212.10 92 Hepa Vacuum Floor 404.84 SF $0.25 $101.21 93 Antimicrobial Ceiling-Heavy smoke Double Pass 404.84 SF $0.38 $153.84 94 Antimicrobial Wall 848.40 SF $0.20 $169.68 95 Clean Floor,Subfloor 404.84 SF $0.30 $121.45 96 Clean Equipment 1.00 EA $25.50 $25.50 97 Disposal Debris 50.00 HR $35.00 $1,750.00 (Note:Bag-Haul-Pack Onsite Dumpster With Debri) 98 Removed/Wall Boarded Up Ac Unit 1.00 HR $35.00 $35.00 99 Cleaned Primed with white Primer For looks Out Side Doorway 1.00 HR $35.00 $35.00 (Note:Price Includes Primer) 100 Dispose Insulation 10.00 BAG $12.00 $120.00 101 Remove Trim 84.84 LF $1.25 $106.05 In Progress Richard Lentini Tuesday,November 25,2008 Page 5 of 9 (c)SERVPRO® Intellectual Property, Inc. 8:26 AM Mitigation: $4,737.27 Structure: $5,468.74 Restoration: $926.47 Contents: $315.00 Replacement: $120.00 Total: $5,783.74 Office Calculations Room Offset Missing Totals Box Offset Furnance 1 3 ft 3 in X 3 ft 10 in X 10 ft 0 in sfCeiling 112.00 24.37 0.00 136.37 Length: 8 ft 0 in Offset Hall 1 3 ft 4 in X 3 ft 7 in X 9 ft 0 in sfFloor 112.00 24.37 0.00 136.37 Width: 14 ft 0 in sfWalls 325.48 195.46 0.00 520.94 Height: 9 ft 0 in Description Quantity UOM Unit Price Total Tax 0/P 102 Rental Equipment 1.00 EA $175.00 $175.00 (Note:Vapor Blitz II Steam Cleaner To Remove Acid and Soot From Left By The Fire This Line Item Includes Use Of Vapor Blitz In Bathroom) 103 Remove Ceiling,Acoustical Tile 136.37 SF $0.25 $34.09 104 Remove Ceiling,Acoustical Tile Grid 136.37 LF $0.18 $24.55 105 Remove Carpet 68.18 SF $0.26 $17.73 106 Remove Floor-Double Pass 34.09 SF $0.70 $23.86 (Note:Vynal Flooring in Hallway and Plywood Subfloor) 107 Hepa Vacuum Ceiling 136.37 SF $0.25 $34.09 108 Hepa Vacuum Wall 520.94 SF $0.25 $130.24 109 Hepa Vacuum Floor 136.37 SF $0.25 $34.09 110 Antimicrobial Ceiling-Heavy smoke 136.37 SF $0.23 $31.37 111 Antimicrobial Wall-Heavy smoke 520.94 SF $0.30 $156.28 112 Clean Light,4 Tube Florescent 2.00 LF $14.00 $28.00 113 Clean Floor,Vinyl-Heavy smoke 34.09 SF $0.51 $17.39 (Note:Front of Bathroom) 114 Clean Floor,Subfloor-Heavy smoke 102.28 SF $0.45 $46.02 115 Clean Equipment 1.00 EA $25.50 $25.50 (Note:Office And Bathroom Cleaning) 116 Remove Floor Staples 0.50 HR $35.00 $17.50 117 Disposal Debris 1.00 HR $35.00 $35.00 (Note:HAUL DEBRIS TO DUMPSTER) Mitigation: $497.88 Structure: $813.21 Restoration: $332.83 Contents: $17.50 Replacement: $0.00 Total: $830.71 Basement Calculations Room Offset Missing Totals Box sfCeiling 195.69 0.00 0.00 195.69 Length: 25 ft 3 in sfFloor 195.69 0.00 0.00 195.69 Width: 7 ft gin sfWalls 528.00 0.00 0.00 528.00 Height: 8 ft 0 in Description Quantity UOM Unit Price Total Tax 0/P 118 Hepa Vacuum Ceiling 195.69 SF $0.25 $48.92 119 Hepa Vacuum Wall 528.00 SF $0.25 $132.00 120 Antimicrobial Ceiling 195.69 SF $0.15 $29.35 121 Antimicrobial Wall 528.00 SF $0.20 $105.60 122 Clean Floor,Subfloor 195.69 SF $0.30 $58.71 In Progress Richard Lentini Tuesday,November 25,2008 Page 6 of 9 (c)SERVPRO® Intellectual Property, Inc. 8:26 AM Mitigation: $134.95 Structure: $374.58 Restoration: $239.63 Contents: $0.00 Replacement: $0.00 Total: $374.58 Bathroom Calculations Room Offset Missing Totals Box sfCeiling 30.85 0.00 0.00 30.85 Length: 6 ft 2 in sfFloor 30.85 0.00 0.00 30.85 Width: 5 ft 0 in sfWalls 178.72 0.00 0.00 178.72 Height: 8 ft 0 in Description Quantity UOM Unit Price Total Tax O/P 123 Hepa Vacuum Ceiling 30.85 SF $0.25 $7.71 124 Hepa Vacuum Wall 178.72 SF $0.25 $44.68 125 Hepa Vacuum Floor 30.85 SF $0.25 $7.71 126 Antimicrobial Wall-Heavy smoke 178.72 SF $0.30 $53.62 127 Antimicrobial Ceiling-Heavy smoke 30.85 SF $0.23 $7.10 128 Clean Light, Fixture,SM 1.00 EA $4.00 $4.00 129 Clean Mirror 1.00 EA $10.00 $10.00 130 Clean Sink 1.00 EA $5.00 $5.00 131 Clean Faucets 1.00 EA $7.50 $7.50 132 Clean Vanity 2.00 LF $5.88 $11.76 133 Clean Door,Jamb Opng.,Per Side 2.00 EA $3.98 $7.96 134 Clean Door,Per Side 2.00 EA $4.00 $8.00 135 Clean Door,Hardware 1.00 SET $3.75 $3.75 136 Clean Floor,Vinyl-Heavy smoke 30.85 SF $0.51 $15.73 137 Remove Ceiling,Acoustical Tile 30.85 SF $0.25 $7.71 138 Remove Ceiling,Acoustical Tile Grid 30.85 LF $0.18 $5.55 139 Clean Window Unit,(per side)10-20 sf 1.00 EA $13.00 $13.00 140 Disposal Debris 1.00 HR $35.00 $35.00 (Note:HAUL DEBRIS TO DUMPSTER) Mitigation: $108.98 Structure: $245.78 Restoration: $146.80 Contents: $10.00 Replacement: $0.00 Total: $255.78 In Progress Richard Lentini Tuesday,November 25,2008 Page 7 of 9 (c)SERVPRO® Intellectual Property, Inc. 8:26 AM