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Home My WebLink AboutBuilding Permit #515 - 148 MAIN STREET 2/16/2010 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: LDate Received Date Issued: — o�" d IMPORTANT: Applicant must complete all items on this-page LOCATION f f � not PROPERTY OWNER Print MAP NO: P CEL:4.ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building Onef, Addition or more family Industrial AI - No. of units: Commercial Repair, replacement Assessory Bldg Others: olition Other Septic a Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERF RMED: t 41 jy- fit rtZl `tet Identification Please Type or Print Clearly) OWNER: Name: `�� ,, 1 j /' Phone: Address: CONTRACTOR Name: iW1 , Phone: 1;�-e K Address: Supervisor's Construction License:_ Z�Exp. Date: Home Improvement License: A Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDIN ERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COy-BASED ON$125.00 PER S.F. Total Project Cost:" �� , � FEE: $ l Check No.: O0iJ Receipt No.: d NOTE: Persons contracting with unregistered contractors do not have access t th uaranty f n Signature of Agent/Owner Signature of contract0 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 " I CONSERVATION Reviewed on Signature a � _ COMMENTS HEALTH Reviewed on R 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 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 ❑ 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 Per 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 r_ 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: Doc.Building Permit Revised 2008 00- Location/ldf1�/? S/ !K?No. 4�75— Date 69l� �oRTh TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # nM•�/ M 22Lu4 Building Inspector 01/21/2010 11:31:1 YAA DUs aao ocov ,... .�.....• .. -- DATE(MMIDDIYYYY) �e CERTIFICATE OF LIABILITY INSURANCE 01/21/2010 39 60; PRODUCER , 8.6320 FAX 603.898.8269 THIS CERTIFICATE 18*SUED AS A MATTER OF INFORMATION Foy ER 601.39urance Group - Salem ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THS CERTIFICATE DOES NOT AMEND,EXTEND OR 130 Main St - Suite 103 ALTER THE COVERAGE AFFORDED BY THE POLIO LOW. Salem, NN 03079INSURERS AFFORDING COVERAGE MAIC III Terri Truhn INEURERA: American Safety Indemnity Co 2 ,433 INSURED Carignan 41119at on ServTces, LLC DBA: PuroClean Disaster Recovery Services INSURER B; 32 Kristin Drive INSURER C: Derry, NH 03038 INSURER O: 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 CE CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR POLICIES.AGGREGATE MAY N.THE INSURANCE URALIMITS SHOWN ED BY THE BEEN RIEDUCED REED HEREIN I SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH INSR DD POLICY NUMBER P6=Y EFFE V LICY IRATION LIMITS TYPE OF INSURANCE EACH OCCURRENCE 9 ] 000.00 GENERAL LIABILITY ENV017457-03-03 1p/1S/2009 10/15/2010 DAMAOt TO RENTED s S0,00 ( X COMMEACIALGENERAL LIABILITY NIED EXP(Any one WOOM) t S10001 j X CLAIMS MADED OCCUR A X Professional PERSONAL AADV INJURY s 1,000 00 GENERAL AGGREGATE S 2.000,00 I � PRODUCTS•coMProP AGG s 2,000 00 GEN L AGGREGATE LIMIT APPLIES PER; POLICY jeO.T LOC AVTOMOBLE LIABILITY ENV017457-08-03 10/22/2009 10/15/2010 COMBINED SINGLE LIMIT 6 (Ex ocakw%) 11000.0 00 j ANY AUTO ALL OWNED AUTOS BODILY INJURY S � (Pet peroOA) SCHEDULED AUTON A X HIRED AUTOS BODILY INJURY S (Pereecaem) X NON-OWNEO AUTOS j PROPEATY DAMAGE S (Por eeellem) AUTO ONLY•EA ACCIDENT S GARAGE LIABILITY ANY AUYO OTHE KHAN FAACS A20 5 EXCEfSNMBRELLALIABILMY EACHOCCURRENCE E OCCUR CLAM MADE AGGREGATE a DEDUCTIBLE _ RETENTION f WC STATU 0TH• $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY E.L.EACH ACCIDENT S ANY PROPRIETORIPARTNEWEXECUTNE OFFICERIMEMBER EXCLUDED? E.L.DISEASE•EA EMPLOYEE S 9 ya,dowbe ceder E.L.DISEASE-POLICY LIMIT s SPECIAL PROVISIONS below OTHER I DE6CRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS dditional Insured: Mary O'Donnell ERTIFICATE HOLDER CANCE SHOULD ANY OF YHE ABOVE DESCRIBED POLICIES BQ CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO TNF CERTIFICATE HOLDER NAMED TO THE LEFT, 148 Main Street tL+� BUT FAILURE TO MAIL SUCH NOTCE$HALL IMPOSE NO OBLIGATION OR LIABILITY Unit C43% OF ANY KIND UP014 THE INSU R.RS OR REPRESENTATIVES. North Andover. MA 01845 AUTHORIZED aeP NT TI Terri Tru ACORD 26(2001/08) FAX: 978.688.9S42 ®/1CORD CORPORATION 1988 � NORTI-� Tovm o 4Andover . O M, ,•4: No.ks�SO 0 0 y _ L A E dover, Mass.,A* • �� COCMICMEWICK 7d ADRATED GPS` �C� `S BOARD OF HEALTH Food/Kitchen PER T Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......... ... .�w� ....... ..... �5e*;Aft. .w...... .......................... .............. Foundation has permission to erect... ................................... bukin on ..1...J�...�a,�*...af0...............�r... fff.f_ Rough to be occu led as.. . . �........... . .... p Chimney provided that the erson ace tin this permit shall in eve res ect co ab . $ p p p g p ry n 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 EXPIVINONTHS ELECTRICAL INSPECTOR UNLESS CONSSTARTS 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 T No Lathing or D■ ) Wall 1 o Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration: 157719 10 Park Plaza-Suite 5170 4. Expiration: 10/31/2011 Tr# 289895 Type: DBA Boston,MA 02116 PUROCLEAN DISASTER RECOVERY SERVICES c' RICHARD CARIGNAN 232 N. BROADWAY SALEM, NH 03079 Undersecretary Not valid Without signature OR EmLEAF Environmental Contracting Service Authorization Customer: Jeanne McCusker Address: 148 Main Street,North Andover,MA 01845 Insurance Company: CAU/Peerless Claim Number: Adjuster: Joan Otto/David Vincent Deductible: Type of Emergency/Service: Water mitigation and repair I(we)hereby authorize the locally owned GreenLeaf business(GreenLeaf)to perform the above referenced contracting service at my(our)property at the above address and with respect the items that need to be restored at a remote location,to remove and store such items. If applicable, I(we)authorize and direct the insurance company listed above to pay GreenLeaf directly for the work covered by insurance. If for any reason the payment should come to me(us), I(we)hereby agree to pay GreenLeaf immediately upon receipt of the payment from the insurance company. If the payment comes to GreenLeaf and includes my name as a payee,GreenLeaf has the authority to deposit that payment without my endorsement if they are unable to reach me. I(we)understand that GreenLeaf is working for me(us)and not the insurance company, adjuster, contractor, and/or agent. It is fully understood that I(we)am/are personally responsible for any and all payments for services, deductibles, depreciation or any other charges or costs not covered by your insurance that is beyond the deductible on your policy. Furthermore, I herby grant the insurance company permission to release any and all information to GreenLeaf regarding their contracting and/or repair work including but not limited to any payments made on the claim identified above until the claim is closed and all outstanding proceeds have been paid to the contractor. The liability of GreenLeaf is expressly limited to the total amount of the services authorized herein and in no event shall GreenLeaf, its agents or assigns,be liable for consequential damages of any kind. GreenLeaf is responsible for only the personal property listed on the inventory signed by me(us)and by a GreenLeaf representative. In the event that legal proceedings must be instituted to recover any amounts due, GreenLeaf shall be entitled to recover the cost of collection including reasonable attorney's fees. I(we)understand that I(we)have the right to cancel a home construction contract within three days of signing this form or prior to the commencement of the repair services being provided. Amounts paid: Date Received: Signature: E Date: D (Insured/owner) Signature: Date: (Insured/owner) Greenleaf Environmental 4 Raymond Ave Salem, NH. 03079 (603)-890-8911 This agreement for professional services is entered into on this 10 day of February , 2010 , by and between GreenLeaf Environmental Contracting (MA Lic #: hereinafter called "GLE" or "Contractor," and the party(s) signing below, hereinafter called "Owner," governing work to be performed on the property and building located at: Jeanne McCusker (Address of building to be built or remodeled) for: 148 Main Street, Unit C438, North Andover MA 01845 (Name(s) of all legal owners of the building) Phone: 978-688-6117 (All phone numbers of legal owners, home and business) GLE shall furnish all labor to perform the work described in the following specifications and incorporated by reference as part of this Contract and any addendum attached hereto. ' t Conditions of This Contract I. Owner understands and agrees that all communications concerning the job status, job changes, pricing, or any other job issues outlined in this contract, will only be between the owner and Green Leaf Environmental., GLE will not be held liable for any discussions or agreements made between Owner and any other parties including GLE employees, GLE hired sub-contractors, or suppliers. II. GLE will not be responsible for any bills, charges, debts, invoices, or other encumbrances incurred in, on, or for this job by anyone other than GLE or its immediate authorized employees. III. Without invalidating this agreement, Owner may order extra work or change the existing contract by the use of a change or additional work order. A change may consist or additions, deletions, or modifications to the original contract work (the contract sum and time being adjusted accordingly), providing the document is mutually agreed to and signed by both the Owner and GLE. Such modifications to the original contract, or subsequent contracts or change work orders, may only occur with a signed change work order. This change of work order may change the job completion date. a. Any additional sum shall be paid in full (100%), at the next progress payment due or the final payment due, whichever may come first. b. Owner understands that a design/estimating and coordination fee of$100 per hour will be incurred on the design, drafting, and pricing of the change or additional work, whether the change is elected or not by the Owner. c. GLE will not be liable for any changes made without a completed and signed change work order. GLE will not be liable for any agreements made between Owner and any party(s) other than Green Leaf Environmental. IV. Owner understands and agrees that any and all animals that may inflict injury on GLE staff or GLE sub-contractors will be kept out of all work areas and all storage areas for the duration of this job. Owner will provide access to all work and storage areas from 7:00 am to 6:00 pm, Monday through Saturday, for the duration of this job. If at any time access to the work or storage areas is not available to GLE crews or sub-contractors due to the presence of and potential harm from the Owner's pet(s), Owner agrees to reimburse GLE or GLE sub-contractors for expenses incurred for travel and lost time at the rate of$35 per man hour lost, and $.50 per mile per vehicle. a. Owner understands and agrees that GLE personnel and GLE sub- contractors will not attempt to enter any work or storage area if Owner's animals have open access to that area. b. Owner also understands and agrees that GLE employees and GLE sub- contractors will not be responsible for any pet(s) leaving the home due to doors, windows, gates, or other openings in the home being left open due to work in progress. V. GLE is solely responsible for securing all labor, materials, sub-contractor work and other related items included in this contract, and for scheduling, construction techniques, and procedures, and the coordination of all trades and sequences hereunder. VI. Owner, Owner's agents, or any other parties, are prohibited from directing, or attempting to direct in any way, the progress of the work. Any questions, problems, or requests for changes of work will be solely directed to the James Souther . (Project Manager) VII. Owner shall be solely responsible to pay any and all sub-contractors for work performed at Owner's direction without written authority of GLE, and Owner shall indemnify, defend, and hold GLE harmless from loss or liability which results from claims of any sub-contractors or others arising from the performance of such work. a. In addition, Owner will be solely responsible for all costs resulting from delays or interference on the part of the Owner, Owner's agents, or Owner-solicited sub-contractors working on this job. All resulting corrective work, including labor, materials, subcontract or any other costs and construction liens resulting from that work will be the sole responsibility of the Owner at the rate of cost plus 40 percent. VIII. Owner has read, understands, and agrees with the total payment schedule as shown in this agreement. Owner will pay GLE the initial investment, progress payments, and the final payment, as per agreement and without retention. Final payment of the entire contract price is due on the day of SUBSTANTIAL COMPLETION of the work and by use of the Owner. a. If net amount due on progress payment is not paid by the Monday of the week following the due date, GLE reserves the right to stop work until the progress payment has been made, increased by a rate of 1% for each day payment is overdue, costs of shutdown, delays incurred, and startup. b. GLE reserves the right to terminate this agreement altogether if work is stopped for ten (10) continuous calendar days due to failure of the Owner to make prompt progress payments. GLE further reserves the right to recover payment for all work executed and losses from delays or stoppage of the work, including reasonable overhead, profit, and damages. In no case will GLE be entitled to less than their total expenses plus an additional sum of 40 percent of the total expenses incurred. GLE is excluded from all special, indirect, or consequential damages resulting from work shutdown or termination of this agreement. c. Payments not made by the due date are delinquent and shall bear interest at the rate of one percent per day, or the maximum allowed by law, whichever is more, until paid. d. Owner shall pay reasonable costs incurred by GLE in the collection of any delinquent amounts, includingattorney fees and costs of preparing and Y p p 9 filing liens, regardless of whether suit or action is instituted. IX. Owner understands and agrees that any checks or other medium of payment presented to GLE by the Owner, or Owner's agent, that is returned to GLE for insufficient funds, or any other reason that delays the deposit by GLE of monies due as outlined below in the payment schedule for this job in this contract document, will incur an additional charge of $50, plus any and all fees assessed by the bank or other institution handling these monies, and any and all other resultant charges, fees, or late fees, regardless of the reason or the extent of those charges or fees. X. Owner understands and agrees that all and any unsupervised children must be kept out of all work and storage areas between the hours of 7:00 am and 6:00 pm Monday through Saturday. a. GLE employees and sub-contractors will not perform work on the Owner's premises in the presence of unsupervised children in work and storage areas. The Owner agrees that a delay of work caused by the presence of unsupervised children in work and storage areas will result in a charge of $35 per man hour lost for each hour that work is delayed. XI. Owner understands and agrees that GLE will charge $35 per man hour lost and $.50 per mile per vehicle for the inability of GLE to access any work and storage areas during the hours of 7 am to 6 pm Monday through Saturday. XII. GLE will not move furniture or personal items, unless otherwise stated in this contract. If GLE is unable to perform the work in this contract without moving furniture or personal items, GLE will move the items at the rate of $100 per hour. XIII. Unless otherwise stated in this contract, GLE not be responsible for trash removal. If trash is to be removed and it is not otherwise stated in this contract, Owner shall be responsible for the cost of trash removal, including GLE's employee's time at $35 per man hour, dumpster rental, dump fee, and any other associated costs not listed here. XIV. Owner will be responsible for the cost of any and all permits and associated fees, unless otherwise stated in this contract, including $100 per hour for GLE to secure and maintain permits. XV. Owner understands and agrees to reimburse GLE for all materials and stock used for the work stated in this contract. a. Materials and stock invoices will be presented to Owner on a regular basis, with the agreement that the total due for materials and stock be paid in full on the due date. b. Any overdue material and stock payments will be subjected to the terms and conditions listed above for labor payments. This construction contract is entered into on the 10 day of February , 2010 , by Green Leaf Environmental Contracting (MA Lic#: S `I/ Nereinafter called Contractor or GLE, and the party(s) signing below, hereinafter called Owner. The above specifications and conditions are satisfactory and are hereby accepted. GLE shall furnish all labor to do the work described in the above specifications and Owner agrees to pay GLE as follows: TOTAL CONTRACT PRICE $ 10,680.00 DOWN PAYMENT $ INITIAL PAYMENT AT START OF WORK $ FINAL PAYMENT AT COMPLETION OF WORK $ MATERIAL AND STOCK PAYMENT To be paid by owner as job progresses ATTENTION: HHI will do only that work which is written in the above specifications for the above agreed upon amount. The terms and conditions stated are part of this contract. This contract is subject to GLE's office approval. You, the buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. See the attached notice of cancellation form for an explanation of this right. M • • (Owner's signature) (Date) (Owner's signature) (Date) Owner acknowledges receipt of a copy of this contract, and that they have read, understood, and agre1withe rms of this contract and the payment schedule for this ob. C2 � //0 (G a LeafE - o ent I Contracting) (_Date The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA-02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): Address: City/State/Zip: , ,� �- /� _ Phone#: Are you an employer? Check the appropriate boa: Type of project(require 1.MI am a employerd): with 4. ❑ I am a general contractor and I 6. E] New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.$ ;8. emodeling ship and have no employees These sub-contractors have Demolition working for in any capacity. workers' comp. insurance. Building addition [No workers' comp. insurance 5• ❑ We are a corporation and its 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' 13.[:] Other comp. insurance required.] ay^yileant:hat checks box# inu�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. ZContractors 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 thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: _ �3 City/State/Zip: Ae_9k 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 GL 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 certi nder the pains and pen 'sof provided jury that the in f p ded above is true and correct Sianafore _- Date: Phone Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4. 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 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-contractors)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability.Partnerships(LLP)with no employees other than the members or partners, are 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 anddate 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 Deparhnent 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 theermit/license number which will 1 be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would Iike 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 6100 Washington Street Boston,MA 0.2111 Tel. # 617-7274900 ext 4406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 ",w-mass.gov/ciia ✓fze ZoamrrcaruuP,a,��z o�'✓�faaaculuoella Board of Building Regulations and Standards Construction Supervisor License License: CS 96473 Birthdate: 9/29/1976 Expiration: 9/29/2010 Tr# 96473 Restriction: 00 JAMES SOUTHER 8 JENKINS DRIVE BILLERICA,MA 01862 Commissioner 1 Client: McCusker,Jeanne Home: (978)688-6117 Property:Y� 148 Main Street,Unit C438 N.Andover,MA 01845 Operator Info: Operator: RCARIGNA Type of Estimate: Water Damage Date Entered: 12/25/2009 Date Assigned: Price List: MAEM5B JAN10 Restoration/Service/Remodel Estimate: 091224 MCCUSKER REP2 Repair Bill for McCusker: Includes repairs to ceiling and painting walls in the hallway only(assuming we are able to match paint)and painting the ceiling in the hall and living room. Note: Ceiling in hall and living room is contiguous. This project is expected to be covered by insurance. It is possible the insurance carrier may change the scope of the project. Excludes: -Carpet and pad replacement -Electrician charge to attach recess lights in hall 1 f 091224 MCCUSKER REP2 Main Level Main Level DESCRIPTION QNTY 20. Haul debris-per pickup truck load- 1 load 1.00 EA 23. Supervisory/Administrative-per hour 2.00 HR Supervisory fee-scope project and discussions with home owners,adjusters,property manager and insurance company. 70. Taxes,insurance,permits&fees(Bid item) 1.00 EA Halll Ceiling Height: 8' DESCRIPTION QNTY 25. Containment Barrier to contain dust during ceiling removal in hall 120.00 SF 27. R&R Batt insulation- 10" -R30 80.00 SF 24. Containment Barrier-tension post-per day 16.00 DA Tension posts used for containment for hanging of drywall,mudding,taping and sanding. 26. Drywall repair on ceiling and adjoining walls in hallway. 1.00 EA Inclides materials,haning drywall on ceiling, corner tape,mud and tape, sanding and ready for painting. 42. R&R Recessed light fixture- Standard grade 2.00 EA Replace 2 recess light fixtures damaged by water damage. Hall2 Ceiling Height: 8' DESCRIPTION QNTY 65. Tear out wet drywall,cleanup,bag for disposal 17.22 SF 64. R&R 1/2"drywall-hung,taped,texture,ready for paint 17.22 SF 34. Paint acoustic ceiling texture 17.22 SF 44. R&R Carpet pad 17.22 SF 56. Remove Carpet-wool-looped 17.22 SF 51. Carpet-wool-looped 19.81 SF 15 %waste added for Carpet-wool -looped. Grand Total 2,890.59 091224_MCCUSKER_REP2 1/27/2010 Page: 2 1 � Grand Total Areas: 1,811.89 SF Walls 395.07 SF Ceiling 2,206.96 SF Walls and Ceiling 395.07 SF Floor 43.90 SY Flooring 225.33 LF Floor Perimeter 0.00 SF Long Wall 0.00 SF Short Wall 232.25 LF Ceil.Perimeter 395.07 Floor Area 447.46 Total Area 1,811.89 Interior Wall Area 623.33 Exterior Wall Area 86.67 Exterior Perimeter of Walls 0.00 Surface Area 0.00 Number of Squares 0.00 Total Perimeter Length 0.00 Total Ridge Length 0.00 Total Hip Length 091224_MCCUSKER_REP2 1/27/2010 Page: 3 Main Level I I ' 4 lflllll 9'6' ! 8'10' T 3 � f Ksch— I � i i i m toll m 3' 3'6' S 4' 2'B' !AB m _ m Hr�[Met m S 2' 4dR,,I 4'10' 1� m i Bathf. f 24'T 4 Main Level 091224_MCCUSKER_REP2 1/27/2010 Page: 4