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HomeMy WebLinkAboutBuilding Permit #812-14 - 148 MAIN STREET 5/11/2014 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: ,2 'l / Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION ,°1 n hneA T LG AtQ&ye , lit 1� L�lg nnt. ---- PROPERTY OWNER _ »dalm;Yx A)4s C r Print 100 Year Old Structure yes no 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 Ifwo or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ['Others: , ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District o Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) ��d),4 Aellwv�Z PUrhIo � ��r� OWNER: Name: Phone: Address: CONTRACTOR Name: . ' A11'L j uX (phone: c � Address: 98�2 L-lVth)GMw b-( G> 'U MA- - 0�d��, Supervisor's Construction License: S—C>'I4TOCt Exp. Date: Oq I Zq) -ac>1 . Home Improvement License: Exp. Date: f, c ) ARCHITECT/ENGINEER /�� Phone:_ /i4. - Address: Reg. No._ i FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ � �� FEE: Check No.: �7.6 __Receipt No.: -�2 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent%Owner Y Signature of contractor _ + Plans Submitted E Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ " Plans Submitted: Plans.Waived ❑ ...Certified Plot Plan ❑ Stamped Plans ❑ :TWE OE_SEWERAGEDISPQSAL" Public Sewer ❑ Tanning/Massage/Body Art ❑. . ._Swimming Pools ❑ Well ❑ Tobacco.Sales ToodPackaging/Sales ❑ Private'septic tank, etc._ - . Permanent.Dumpster on Site ❑ THE-FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN.OFF - U FORM DATE.REJECTED DATE:APPR-OVED PLANNING & DEVELOPMENT' ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature . COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . tPlanning Board Decision: Comments v _ Conservation Decision: :Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Tow;! Engineer: Signature: Located 384 Osgood Street FI=RE DEPARTMeNt Temp Dumpster on siteyes no Located-at 124 Mair, Street Fire Departine►it signature/date"- COMMENTS . Dim-ension-- 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-.Chapter166.Section.21A=F and G min.$100-$1000:fine NOTES and DATA — (For department use ® Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department ,---The fol'-)wing is"a list of the requirred.forms to be-filled out for:the.appropriate.permit to.be obtained. Roofh,g, Siding, Interior Rehabilitation Permits LjBailding Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/ rAC.S.L Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dum ster. ermits require sign offrom 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 ❑ 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 cas<s if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apu•?al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application I i Doc: Doc.Building Permit Revised 2012 Location /I Ila No. ' �C/ Date . - TOWN OF NORTH ANDOVER . Certificate of Occupancy $ • Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ - TOTAL $ Check# 3 r Building Inspector F NORTH Town of 2 S EAndover AIL h ver, Mass, �'" �•/ coc Nlc Nl WICK 1' S fJ BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT ......... 4. c:: .. A,; .f.�= �oy ?;•;;�; ;,r,, �'�,� `.. .,., BUILDING INSPECTOR has permission to erect .......................... buildings on .���ai%�.���;:?�..5.��........:................................... Foundation .��.." � Rough to be occupied as ...... !�. ................................................................................ :................ Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough ............................. Service ........... ....... . .. . Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. .0 .ee0We Wo vjix & Weat6teepwojim# 9mc. 830 LIVINGSTON ST.#13 TEWKSBURY,AAA 01876 (978)851-8304 FAX(978)851-9884 - t T�Nt3NWrAL M--OE[% A-T9ACFiUSE IT5 1 massachusens - -Department of Pubt:c Safety 3aard of 3widing P,eg=atat;ons and S.anda-cts SHEET METAL WORKERS ( ,n%tructinn Sill en i,or AS A MASTER-UNRESTRICTED ISSUES-H=HSOVE UCENSETO: -:cense- CS-079509 STEPHEN P LECLAIR STEPHEN P LE C L A I R 38 BRETT CIR - _ PELHAM PIH 43076 38 B R E TT CIRCLE PELHAM NH 03076-2865 4omm;ss�one 09/27/2014 • 11427 09/28/14 244603 re «,..un=,.«f<a 0A lrnl;nc/r%el! License or registration valid for individul use only Office of Consumer Affairs&Bosifiess Regulation OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: = egistration' 121050 Type: Office of Consumer Affairs and Business Regulation `Expiration: : 4/1/2016- Private Corporation 10 Park Plaza-Suite 5170 . Boston,MA 02116 LECLAIR ROOFING t£WEATHERPR INC STEVE LECLAIR 830 LIVINGSTON ST a TEWKSBURY,MA 01876 Undersecretary Not valid without signature OORIc-FIVAL PROFESSIONAL SERVICE .LeClair Roofing ro E0 FERVID & Weatherproofing Inc. 830 Livingston Street#13 Tewksbury MA,01876 (978)851-8304 FAX(978)951-9884 APR 18 2011 April 10,2014 Sutton Pond Condominiums Trust Phone:978-2784000 148 Main Street Fax:978-2784068 North Andover,Ma 01845 Re:Sutton Pond Condo's (6)Low Rubber Ro0014'at cements=I*mgs Builth Roo HVAC Roo ` _and Crafts Builth toof'- ridge Roo oof ' o exceed 12,842 square feet an AttachmentA"Edge Roof D�g Dated 4-7the Abbott and Osg - North Andover,Ma Base Bid LeClair Roofing&Weatherproofing,Inc.("Seller")proposes the following to Sutton Pond Condominiums Trust("Buyer'). 1. Roofing work not to exceed 12,842 square feet.This proposal includes(6)Low roofs at Abbott and Osgood only per site visit on April 4,2014. 2. Leave the existing Fully Adhered rubber membrane at all Low Roof Areas and cut the existing membrane in 10'x10'grids required by Firestone prior to the new roof installation. 3. Re-roof over the existing insulation. 4. Supply and install the following a. (1)Layer of new U2"Firestone ISOGARD HD cover board insulation LTTR=2.5 mechanically attached directly over the existing insulation&101x101grid cut membrane.Note:To be fastened to meet 72 MPH wind gust guideline per Firestone Technical at a rate of(12) in field and(16)-for the first 410"of the perimeter edges and(16)in all 41x4'inside and outside corners with as approved Firestone fasteners per 41x8'board. b: A Firestone.060 Reinforced Fully Adhered Gray TPO roofing system as per manufacturer's specifications. c. Flashings included for all existing roof penetrations. d. Flashing for all existing roof drains and any broken or clogged drains will be charged as an extra. e. All perimeter edge metal to be shop fabricated.050 aluminum standard kynar fascia with continuous hook cleat at all perimeter.edges to match the existing profiles. S. Supply'Manufacturer's twenty(20)year material and labor warranty and 12 mph wind gust warranty included. Special Note:(All Architect/Engineer Fees to Verify the Existing Structure will meet Local Code Minimum Weight Requirements to issue the required Re-Roofing Permit if required is not included.) Pagel of 3 Exclusions: Bond, Permits,conduit/lighting fixtures beneath roof deck,winter conditions,snow shoveling,weather delays, rotten/damaged decking,asbestos,lead paint,ponding water,police details,parking permitstices,cleaning of existing roof drains,replacement of wet existing roofing insulation(see alternate#1 and#2 below),replacement of any damaged or not running properly existing condenser roof units prior to the lifting slightly of the existing condenser units(Note:First Realty Property Management to have the existing condo owners to verify the unit condition prior to roofing replacement and Will not warranty any owner's equipment beyond our scope of work.disconnecting and re- connecting the connections of the existing condenser units so that the existing roofing system can be replaced,All existing pitch pockets to remain and any and all up grading of the existing condenser unit low voltage lines is not included,Community Building PVC White Railing must be removed by others prior to the new roofing system installation,All Electrical Disconnect and Re-Connect as need prior to the new roofing installation by others and HVAC Roof Condensers may need to be Disconnected and Moved to install the New Roofing System by others(see Attachment"S"Field Photo dated 4/4/2014.Note:Pricing of the HVAC Roofing Area may have to be adjusted if condensers unit cannot be Disconnected and Moved by others. Seller proposes.hereby to famish material_and labor—complete in accordance with the above specifications,for the sum of NINETY THOUSAND DOLLA $_90,000.00 (Subject to manufacturer's price.increases as they occur) �-- Notes: Additional work beyond the above scope will be done at a rate of$75.00/inan/hour for roofing and$80:00/man/hour for sheet metal(rates subject to change)portal to portal,plus materials and a$.58 per utile travel expense and any per diem charges. The above price.is contingent upon roof deck meeting manufacturer's fastener pull requirements to issue warranty and access next to building for trucks,dumpsters,and crane. We may withdraw this proposal if not accepted within(30)days. Payment: 1/3 will be billed upon delivery of materials and the balance will be billed Net 30 Days as work is complete,a 1.5% Per month finance charge will be added to all invoices on the 311,day.All legal and/or collection fees will be paid by Buyer. r Alternate#1: Supply and , ewTapered Polyiso insulation at The Community Building Roof Area only to match the Existing being removed and properly dispose of Legally to include Dumpsters and Crane not to exceed 2,710 square feet. Total Add$14$ 00.00 Alternate#2:Supply and install new 01 Flat Polyiso insulation at the Arts and Crafts Building Roof only to match the Existing being removed and properly dispose of legally to include Dumpsters and Crane not to exceed 1,598 Square feet. Total Add$7,900.00 Alternate#3:To Execute and provide a written Annual Spring Roofing Survey identifying all noted issues due to winter Snow and ice damage if any to the New Firestone Gray TPO Roofing System at the Abbott and Osgood High Roofs and(6)Low Roof Areas and LeClair Roofing and Weatherproofing,Inc.to erate a repair Proposals for each individual Building as needed. r7 Total Add$1,150.00 VJ Page 2 of 3. f Alternate#4:Supply labor to get and provide the required Town of North Andover Re-Roofing Permits not carried in The above Base Bid Price. To i Add$2,175.00 Date:Apri110,2014 La ei'tR Then-644U SPft0r, Robert R Therrien,Senior Estimator LeClair Roofing&Weatherproofing,Inc.. Note:We may withdraw this proposal if not accepted within(30)days. Acceptance:The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the work as specified.Payments.will be made as outlined above. Date:' < < Print and sign n 61uAtitlVx Page 3 of 3. f a iPROMPT PROFESSIONAL SERVICE LeClair Roofing 11licil 1W & Weatherproofing Inc 830 Livingston Street#13 Tewksbury MA,01,876 O (978)851-8304 FAX(978)851-9884 all February 27,2014 Sutton Pond Condominiums Trust API one. 278-4000 148 MainStreet Fax:978-2784008 North Andover,Ma 01845 Re:Su and Condo's bottand Osgood High Main Roof Replacement North Andover,Ma Base Bid LeClair Roofing&Weatherproofing,Inc.("Seller")proposes the following to Sutton Pond Condominiums Trust eBuyer"). 1. Roofing work not to exceed 21,835 square feet.This proposal includes the.main roofs on Abbott and Osgood,with three higher penthouse and small inside Slate Tower membrane roof area at Osgood only per site visit on February 7,201 3 —'Ntste"Sia rrepizemautrr arcs on a owerooharnot, uae in e e o`w Base rIT19cing. 2. Vacuum all loose gravel off the Abbott Building only and dump on site to include the 2'x21x2"concrete pavers with the. Location by owner. 3. Remove and properly dispose.of all existing loose laid:mbber roofing membrane at the Abbott Building only. 4. Leave the existing Fully Adhered rubber membrane at the Osgood BuildingTenthouses and cut the existing membrane in 10'x10'grids required by Firestone prior to the new roof installation. 5. Re-roof over the existing 2.5"insulation at Abbott and 2.5"and tubber membrane adhered to be cut per Firestone specifications. 6. Supply and install the following: a. (1)Layer of new 1R"Firestone ISOGARD HD cover board insulation LTTR-2.5 mechanically attached directly over the existing 2.5"insulation and 2.5"-&101x101grid cut membrane.Note:To be fastened to meet 72 MPH wind gust guideline per Firestone Technical at u rate of(12) in field and(16) for the first 810"of the perimeter edges and(16)in all 81x8'inside and outside corners with an approved Firestone fasteners per 41x8'board. b. A Firestone.060 reinforced fully adhered Gray TPO roofing system as per manufacturees.specifications. c. 4.0".Firestone polyiso insulation at the inside of the large parapet walls to eliminate the jog in the 29"high parapet so that the new.060 Gray TPO membrane will be a straight and flat inside parapet wall with less possible leak issues in the future. d. Flashings included for all existing roof penetrations. e. Flashing for all existing roof drains and any broken or clogged drains will be charged as an extra. f. All perimeter edge metal to be shop fabricated.050 aluminum standard kynar fascia with continuous hook cleat at all perimeter edges to match the existing profiles. g. (50)Lineal feet of Firestone(1)30"wide rolls of TPO walkway'included at new roof access hatch, doors and ladders included only. 6 Supply Manufacturer's twenty(20)year material and labor warranty and 72 mph wind gust warranty included. Page 1 of 3 t � i 7 (54)Existing Condensers to be lifted only and the existing pressure treated wood sleepers to be reused and lowered on'a loose laid TPO membrane slip sheet and the two condensers wood sleeper to be joined together(2) pressure treated 2x4 included. Note:All Condenser Unit to remain connected and only lifted an 1"or less to allow the new%11 ISOGARD and TPO membrane to be installed below' Special Note:(All Arcbitect/Engineer Fees to Verify the Existing Structure will meet Local Code Minimum Weight Requirements to issue the required Re-Roofing Permit if required is not included.) Exclusions: Bond,Permits conduit/lighting fixtures beneath roof deck,winter conditions,snow shoveling,weather delays, rotten/damaged decking,asbestos,lead paint,ponding water,police details,parking permits/fees,cleaning of existing roof drains,replacement of wet of wet 2.5"existing roofing insulation(see alternate#2 below),replacement of any damaged or not running properly existing condenser roof units prior to the lifting slightly of the existing condenser units(Note: First Realty Management to have the existing condo owners to verify the condenser unit condition prior to roofing. replacement and will not warranty anyowner's equipment beyond our scope of work,disconnecting and re-connecting the connections of the existing(54)condenser units so that the existing roofing system can be replaced..Ail existing pitch pockets to remain and any and all up grading of the existing condenser unit.low voltage lines is not included.Slate Tower Slate Roof Replacement,New Gutter and Downspouts at the Osgood Building over the front entrance,Masonry wall repairs and new wall fabric flashing and weep holes at the old storage elevator(Note:Waiting for his pricing quote for this,added work I will send an Alternate Add upon receiving his pricing quote. Special Note: A 50'Scissor Lift has been added to.the below Base Bid Price for(2)Months to access the existing roof in Lieu of using the building elevator and,stairs. Seller proposes hereby to furnish material and labor—complete in accordance with the above specifications,for the sum of. --� UV VrONE HUNDRED FIFTY NINE T8OUSAND-DOLL $159,004.Q0 (Subject to manufacturer's price increases as they occur) Notes: Additional work.beyond the above scope will be:done ata rate of$75.00/man/hour for roofing and$80.00/man/hour for sheet metal(rates subject to change)portal to portal,plus materials and it$.58 per mile travel expense and any per diem charges. The above price is contingent upon roof deck meeting manufacturer's fastener pull requirements to issue warranty and access next to building for trucks,dumpsters,and crane. We may withdraw this proposal if not accepted within(30)days. Payment: 1/3 will be billed upon delivery of materials and the balance will be billed Net 30 Days as work is complete,a-1.5% Per month finance charge will be added to all invoices on the 31st day.All legal and/or collection fees will be paid by Buyer. Alternate#1: Supply and install new 2.5"polyiso insulation to replace any wet or badly damaged existing 2.5"insulation to Include dumpster,prior to the installation of the new roofing system at the Abbott Building only where the Existing Firestone membrane is being removed exposing the Ioose laid 2.5"existing insulation as directed by Great North Property Management prior to any existing 2.5"insulation replacement. Unit Cost Add of$2.25/SF Alternate#2:1.Supply labor and materials to cut out the brickwork and prepare for installation of metal thru wall Flashing on(4)sides at the Abbott Building Old Storage Elevator Penthouse brick walls. 2.Supply and install brickwhere brick were removed matching building as best as possible,with weep Holesevery24"to replace the existing wall weep holes below the roof membrane flashings. Total Add$7,700.00 t v Q Page 2 of 3 e Alternate#3:To add 10%(6)Condenser Unit Allowances for Damages due to lifting only in place the,exiting(54) Condenser unit without disconnecting the condensers. tal Add$6,000.00 Alternate 94:Supply and install(300)additional 30"wide TPO Walkway so as to replace the existing 2'x2'x2"Pavers And Rubber 30'x30"walkway existing which will be disposed of legally. T tat Add$4.606k-4 1 Akernate#5:Supply labor to get and provide the required Town of North Andover Re-Roofing Permits not carried in The above Base Bid Price. Total A 53,400.0 Alternate#6:Supply a 50'Scissor Lift for(2)months to the access the High Main Roof Areas in lien of using the Stairs and existing elevators during the roof replacement. To Add$4,100.00 -) Date: February 27.2014 gobe>rtR nm�E—M S"gor. 1=i�wvta r Robert R.Therrien,Senior Estimator LeClair Roofing&Weatherproofing,Inc. Acceptance:The above prices,specifications and conditions are satisfactory and are hereby accepted.You are'authorized to do the work as specified.Payments will be made as outlined above. Date: ��I .✓� -;- /'j %i-Y/ //�✓'J Printffi4-9ijidnam and.title s' i Page 3 of 3 AIL The Commonwealth of Massachusetts . Department of Industritrl Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workexs' Compensation Insurance Affidavit:Buifclers/Cont°actors/Elecfricians/Plumbers Applicant Information Please PrintLe0bXy Name(BusinessVOrganization/Individual):k L=A 12ee `f,( � � T f�4. G. Address: � 6 pi City/StateMp. �— A Pone#: �J�'g�; •-��{' Are�u an employer?Clieck the appropriate box: Type of project(required): 1.[KI am a employer with_2�O 4• ❑ 1 am a general contractor and 1 6. F]New construction f 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• ❑Remodeling ship and'liaveno.employees These sub-contractors have 8. []Demolition working forme in any capacity. workers'comp.insurance. 9. F1 Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions X equired.] officers have exercised.their 3.0 1 am.a homeowner doing all work right of exemption per MGL 11.❑1';umbing repairs or additions myself [No workers'comp. c.152,§1(4),anal we have no 12.[4 Roofxepairs insurancerequired.]; employees.[No workers' 13.[]Other comp.insurance required.] !Any applicentthat checks box0f must also fill cutthe section below showingtheir workers'compensationpolicy information. 7 Homeowners who submit this affidavit indicatingthey t�e doing allwont and then hire outside contractors must submit a new 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 and joh site information. Insurance Company Name; �� J.1J�1E� l �/�yYl� M Policy##or Selfins.Lic.ff: Expiration Date: b lob Site Address,, g ¢}) 5b:—q, ' Cityistate/Zip: � A Attach,a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as regp redunder Section 25A ofMGL 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 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 cert under tli . c� nalties a � _t}Zu1e irifriativn provided above is true and correct. - si atare• Date: M Phone#: 918_ 8S") — 91� X3)q Offrelal use oily. Do not write in this area,to be completed by city or town official. City or Town: Permit/License 0 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other ContactPerson: Phone 4: 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 orimplied,oral orwritten." An employes 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 dwolliag 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 employes." 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 ofpublic work until acceptable evidence of compliance with theinsurance requirements of this chapter have beenpresented 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),addresses)and phone numbers)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,aro notrequired to carry workers'compensation insurance. If an LLC or LLP does have employees,apollcyisrequired. Baadvised that this affidavit maybe.submitted tothe Department of Industrial Accidents fox confirmation of insurance coverage. Also be sure to sign and date the affidavit. 'he affidavit should be retumed to the city or town that the application for thepeimit 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,Incense number on the appropriate line. City or Town Officials Please be sure thatthe affidavit is complete andprinted 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-suxe 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 PORGY information(ifnecessary)and under"fob 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-ii on file for future permits or licenses. Anew 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 orpermit 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: Tho CQ=_ouwrcalth of Mfos�achwotts Doparbeut ofkdmWal.A,ccidents Ofl e o:C1iRVestzgajion, 600 W48WWon Sbxeet Boston,MA 02111 :Revised 5-26-05 Fax#617-727-7749 vvznass„g�vfcla A R" CERTIFICATE OF LIABILITY INSURAN OP ID:ML DATE iMM/DD/YYYY) C C THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND511 CONFERS N0. RIGHTS UPON THE CERTIFICATE HOLDETHIS 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. I IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the Policy(les) must be endorsed. If S the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certifiOGATION IS WAIVED,subject to cate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER Phone:781-935-8480 CONTACT . DeSanctis Insurance Agcy,Inc. NAME: 100 Unicorn Parts Drive Fax:781-933-5645 PHONE FAX o, xt Woburn,MA 01801 EMAIL A� -_— ADDRESS: CUSTOMER ID p:LECLA-1 INSURED LeClair Roofing _ INSURERS)AFFORDING COVERAGE �— INSURER A:Acadia Insurance Company —- NAIc a Weatherproofing,Inc, --- -�- P_.-�Yi3.__ 31325 830 Livingston Street INSURER B:Star insurance_Company X012245 Tewksbury,MA 01876 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 PAIAIMS. 'NSR D CL _ LTR i TYPE OF INSURANCE B�POUCY NUMBER Iq pY M/ D VEXP w GENERAL LIABILITY LIMITS { ' EACH OCCURRENCE A X I COMMERCIAL GENERAL LIABILITY !CPA5077662 01/01/14 01/01/15 '000'00 - PREMISES Me occurrence) $ 250,00 I j CLAIMS-MADE ILX I OCCUR j X"Blkt Contractual MED EXP(Any one Person) ;$ 5,00 PERSONAL&ADV INJURY !$ 1 000 00 X j XCU Hazards i l , GENERAL AGGREGATE , GEN'L AGGREGATE LIMIT APPLIES PER: I �_s2 000 00 F I PRODUCTS-COMP/OP AGG i s 2,000,00 POLICY X PRO- �;LOC I$ L AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT ! ANY AUTO f (Ea accident) $ 1,000,00 r ALL OWNED AUTOS I i BODILY INJURY(Per person) �s ! i i BODILY INJURY A ! X I SCHEDULED AUTOS !CAA5077664 I 01/01/14 01/01/15 _ (Per $ 1 X i PROPERTY DAMAGE _.......— i X HIRED AUTOS ( tperaeGdent) 1$ i X NON-OWNED AUTOS ' i _.. $ X i UMBRELLA UAB OCCUR EACH OCCURRENCE (� ExcEss LIAB CLAIMS-MADE I F ---_�-.--- 5,000,00 A f j — CUA5077665 01/01/14 01/01/15 ,l AGGREGATE ;$ 5,000,00 DEDUCTIBLE I --- i --- X 'RETENTION s NONE i ! ---- --- — WORKERS COMPENSATION j WC STATU- OTH-i s AND EMPLOYERS'LIABILITY X1 L(M B ANY PROPRIETORIPARTNER/EXECUTIVE Y/N j + __, TORY 1 ; ERI WC0707947 01/01/14 I 01/01/15 OFFIC£RIMEMBER EXCLUDED? i N I A, I I i I E.L.EACH ACCIDENT g 1,000,00 (MantlatorylnNH) !MA,NH — ---_ If yes,describe under I E.L.DISEASE-EA EMPLOYEE;$ _1,000,00 DESCRIPTION OF OPERATIONS below 1 I r- ----- _�.__. I E.L.DISEASE-POLICY LIMIT $ 1,000,00 A 'Installation Float i �CPA5077662 01/01/14 01/01/15 Limit 100,00 ;Stored Materials ( Deduct DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) 50 "ADDITIONAL INSURED LIMITS ARE NO GREATER THAN THOSE REQUIRED BY WRITTEN CONTRACT." Project: 214-008 and I14-009. First Realty Management Corp., all it's owned and managed properties, entities, and subsidiaries are included as additional insured for ongoing and completed operations with Respects to the GL, Auto 6 Excess (Umbrella) Policies. SEE ATTACHED CERTIFICATE HOLDER CANCELLATION FIRST26 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE First Realty Management THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN C/O Compliance Depot ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 115006 AUTHORIZE EPRESENTATn/E Carrollton,TX 75011 / f ©1988-2009 COR CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD 1 COMMERCIAL GENERAL LIABILITY CL CG zo sa o312 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS: AUTOMATIC STATUS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. SECTION 11-WHO iS AN INSURED is amended E. With respect to coverage to include as an additional insured any person or 9 provided under this organization for whom you have agreed to add as endorsement, the Exclusions of of exclusion added I to an additional insured on your policy in a written contract or agreement, but only.with respect to PROPERTY DAMAGE ABILITY: INJURY AND liability for "bodily injury" or "property damage" caused, in whole or, in part, by "your work" This insurance does not apply to"bodil injury"or performed for that additional insured and "property damage"arising out of the rendering of, included in the "products-completed operations or the failure to render,any profesprofessionalhazard", architectural,engineering or surveying services, B. The coverage provided to the additional insured including: by this endorsement does not apply to "bodily (1) The preparing, approving, or failing to prepare injury"or"property damage"beyond: or approve, maps, shop drawings, opinions, a. the reports, surveys, field orders, change orders or period of time required by the written contract or agreement governing drawings and specifications; and g g'your woric", or 10 years from the date of the completion of (2) Supervisory, inspection, architectural. or "your work" described above, whichever is engineering activities. less;or F. With respect to the coverage provided under this b. two years from the date of the completion of endorsement, the following replaces paragraphs "Your work" described above, if the written 2.a. and 2.b. of SECTION IV - COMMERCIAL contract or agreement does not specify the GENERAL LIABILITY CONDITIONS: period of time. a. You and any additional insured must see to it C. With respect to coverage provided under this that we are notified as soon as practicable of endorsement,the following is added to the end of an'Occurrence"or an offense which may result SECTION III-LIMITS OF INSURANCE: in a claim. To the extent possible, notice The limits of insurance for any additional Insured should include: are the limits in this coverage form or the limits (1) How, when and where the "occurrence" or You agreed to in the written contract or offense took place; agreement governing "your work", whichever is (2) The names and addresses of any injured less. These limits of insurance are inclusive of and are not in addition to the Limits of Insurance persons and witnesses;and shown in the Declarations. (3) The nature and location of any injury or D. With respect to covers a damage arising out of the "occurrence" or endorsement, the faigwi Provided under this offense. V is added to Paragraph 4,a. of SECTION I -COMMERCIALIf a claim is made or GENERAL LIABILITY CONDITIONS: b• any insured, the insured must: brought against The insurance provided to the additional insured (1) Immediately record the specifics of the is primary to,and will not seek contribution from, claim or"suit"and the date received; and the additional insured's own insurance when required by written contract or agreement. (2) Notify us as soon as practicable. CL CG 20 60 0312 Includes copyrighted material of insurance Services Office with its permission Page 1 of 2 the insured must see to it that we receive written notice of the claim or"suit"as soon as Practicable. This Insurance does not apply unless the written contract or agreement has been executed prior to the "bodily injury"or"property damage Page 2 of 2 Includes copyrighted material of Insurance Services Office with its permission CL CG 20 60 0312