HomeMy WebLinkAboutBuilding Permit #813-2016 - 148 MAIN STREET 1/19/2016 `° _ BUILDING PERMIT S o� NORr y q�
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TOWN OF NORTH ANDOVER o �� :..• , p
APPLICATION FOR PLAN EXAMINATION
Permit No#: Z-0 Date Received �4 o a
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Date Issued: l
ORTANT:Applicant must complete all items on this page
LOCATION !�I
Print
PROPERTY OWNER W\,Q tV-- V ty ca-tA�
,t� Print 100 Year Structure yes no
V
MAP 0 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
)Wepair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
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DESCRIPTION OF WOR TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: Phone: 9}R-L9-2.-Vto3
Address: Lac, A
Contractor Name: 6so (.tPhone: QH -33�.•-Igo
Email:
Address: in
Supervisor's Construction License: C S-L�re3 9 0 Exp. Date:
Home Improvement License: ( laO213`-i; Exp. Date: k O yj-i 1 b
a
ARCH ITECTIENGINEER Phone: b
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Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S F +
Total Project Cost: $ _ L1-4 , 3 FEE: $ 1qq , Oo
Check No.: _ 1112— Receipt No.:
NOTE: Persons contractin with registered contractors do not have access to the guar fund
BUILDING PERMIT o`"�D b�tio
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
(b.
Permit No#: Date Received A
7 Q�H.IrED
�SSACHuS
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER
Print 100 Year Structure yes no
MAP 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
lSeptic 0 Well: U Floodplain []fNetlantls 0 Watershed Districts
Ci Vlfaterl,Sewer � ___ _
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone: t
� 4
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
SI anatrP of AgAlriOwrrer ^� i Sianatare of cnnfrartcr z -
_._ _ -
Plans Submitted D 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. ❑ Pennanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF m U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
P
Conservation Decision: Comments
r '.
b
Water& Sewer Connection/Signature Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
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Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL; Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$10041000 fine
NOTES and DATA-- (For department use)
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Q Notified for pickup Call Email
Date Time Contact Name
Doc.Suildinab Permit Revised 2014 N�—
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
a. Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Building Permit Application
Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract
Floor/Cross Section/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
OTE: 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
.4. 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)
4 Copy of Contract
2012 IECC Energy code
Engineering Affidavits for Engineered products
OTE: 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
I
Doc:Building Permit Revised 2014
Location ty HAD
Nob �-O'� Date (c1 1
. - TOWN OF NORTH ANDOVER
ED I .
Certificate of Occupancy $
v � J
` Building/Frame Permit Fee $
Foundation Permit Fee. $
Other Permit Fee $ .
TOTAL $
Check# W-
y 2 2 Building Inspector
NORT1y
own of ? �. : ndover
No. I —
h ver, Mass,
CO[NICHIWICK
�i9sDR'�reD
V BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
THIS CERTIFIES THAT
BUILDING INSPECTOR
has permission to erect .......................... buildings on'.gff..rAaA
.� ... ......
..... .... a... A%VA Foundation
Rough
to be occupied as ........ .. ir.►.. ....... .......;rgo .. .............................................. Chimney
provided that the person accepting this permit shall in every respect con 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
�son PERMIT EXPIRES IN 6 NTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCT R 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.
Hub City Builders, LLC
10 Lacy Street
North Andover,MA 01845
WILLIAM POGOR as GENERAL CONTRACTOR
Representing Hub City Builders, LLC
MA CSI.
License No.083917
MA HIC
License No.180234
Inquiries may be made to:
Contractor Registration
One Ashburton Place
Boston,MA 02108
(617)727-8598
CONTRACT
Customer: Mark Vincent
4 Lacy St
North Andover,Ma 01845
Project Location:
148 Main St,
Stevens 429
N Andover,MA 01845
Nature of Work:
❑ Design/Layout/Concept Bid Services,Permit Acquisitions
X General Contracting Services
This Contract relates to the above checked services that William Pogor as General
Contractor through Hub City Builders, LLC shall provide to Customer. The services
being provided are spelled out in the next section The Customer's Payment Schedule is
provided for in the section following that. This is a written binding contract. Do not sign
if there are any sections or spaces remaining blank. If the contract is not understood,
please have it reviewed by an attorney of your own choice.
Customer Initials Con ctor Initials
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Hub City Builders, LLC
10 Lacy Street
North Andover,MA 01845
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Services to be performed:
I. General Description of Work
1. PERMIT ACQUISITIONS
1.1. Building Permit.
1.2. Waste Removal Permit. (If required).
1.3. Forms and Filings necessary.
1.4. Meetings On/Off-site as required. (Owners agent)
1.5. Pertaining to permits,any extra permits beyond the scope of this contract,if
required,the financial burden shall be subsequent to this contract and shall be
billed on a time and materials basis and stated in the change of work order.
Note:Design Professionals or other professionals engaged for consultation,
(energy envelope, Structural engineer,ect)if required,the financial burden shall
be subsequent to this contract and shall be billed on a time and materials basis
and stated in the change of work order.
*NOTE: If applicable all working drawings were prepared as an instrument of
services for the two fold purposes of making these designs available scrutiny (client
services, design professionals and contractors) for the securing of construction
material and trade bid costs for the project secured herein. Although they have
fulfilled their purpose when such is accomplished, they are complete set of
documents from which the project may be constructed provided they conform to all
local and state building requirements. Since these drawings are artistic and conceptual
in nature ALL DIMENSIONS SHOULD BE FIELD VERIFIED. At no time should
these drawings be considered or mistaken as Architectural or Structurally Verified
drawings unless the corresponding seals have been placed appropriately upon these
documents by registered licensed professionals.
1. Remove Furniture and all Impediments from Kitchen including Dishes, Silverware,
Cooking utensils to the guest room.
2. Remove all items in the Entry,Hallway,Guest Bath,Living room to the guest room.
Note* Limited liability to use a"best care scenario'is expressed,and is not a
replacement liability when moving Personal Affects or furniture. All personal
affects of any value(jewelry,paintings,sculptures,ect.).No liability is expressed
or implied. It is obligation of the owner to inform the tenant.
3. Demolition
3.1. Remove engineered flooring,Kitchen,entrance hall,Hallway,Bath.
3.2: Remove the Carpet&pad from the living room.
3.3. All Debri is to be removed off site daily.
3.4. Remove and secure bathroom and kitchen plumbing fixtures.
W
Customer Initials *Concto—rin—itials
2
1
Hub City Builders, LLC
10 Lacy Street
North Andover,MA 01845
3.5. Kitchen cabinets, sink, faucet,dishwasher,stove,microwave and disposal
removed, shall be delivered to 4 lacy st,01845 and placed under the exterior
deck,tarped on a temporary basis at the customer's request.
3.6. Bathroom Vanity,sink, and faucet, shall be delivered to 4 lacy st, 01845 and
placed under the exterior deck,tarped on a temporary basis at the customer's
request.
4. Tile&Kitchen Cabinets
4.1. Acquire Tile from Lumber Liquidators and Kitchen cabinets from Cabinets to Go
of 1207 Hanover St Manchester,New Hampshire for the client,prepaid by the
client.This line item is to be billed according to time and materials as stated
herein for acquisition and transportation.
4.2. Acquire appropriate amount of"Versa bond Thinset'mortar SKU: YFY1077 or
comparable. This line item is to be billed according to time and materials as
stated herein for materials.
4.3. Prepare and place tile with 1/8 "grout lines in the bath, entry,hall,kitchen and
living room. Orientation to be marked on the attached diagrams and initialed by
client.
4.4. Seal the with satin sealer before grouting.
4.5. Grout tile with client's choice,(ref 4.3).
4.6. Kitchen Cabinets to be assembled and installed. As indicated on the attached
drawings.This line item is to be billed according to time and materials as stated
herein.
4.7. Install temporary counter tops(waterproof plywood contractors choice). Two
counters,stove side and sink side.
5. Plumbing Rough
5.1. Guest Bathroom
5.1.1. Re-plumb to accommodate new Vanity sink.
5.1.2. Install new toilet, Accommodations for one two piece toilet(guest bath
only).
5.2. Kitchen
5.2.1. Install Dishwasher provided by client.
5.2.2. Install Refrigerator provided by client.
5.2.3. Install Microwave provided by client.
5.2.4. Install Stove provided by client.
5.2.5. Install Disposal provided by client.
6. Finish Plumbing
6.1. Finish Trims-Install all finish surface trims guest bathroom and kitchen.
7. Electrical-'Note-Code upgrade requirements- AFCI Receptacles the National
Electrical Code has been updated for 2414 and it addresses the use of Outlet Branch
Circuit(OBC)Arc Fault Circuit Interrupter(AFCI)Receptacles as an alternative to
Cysto er Initials
lContor Initials
3
Hub City Builders, LLC
10 Lacy street
North Andover,MA 01845
breakers when used for modifications/extensions, as replacement receptacles or in
new construction. AFCI Receptacles work to address the dangers associated with
potentially hazardous arcing conditions(parallel arcs and series arcs)by interrupting
power to help prevent dangerous arc-faults that may lead to an electrical fire.AFCI
protection is mandated by the 2014 Code in residential family rooms, dining rooms,
living rooms,kitchens,parlors,libraries,dens,bedrooms,laundry rooms,sunrooms,
recreation rooms,closets,hallways or similar rooms.AFCI receptacles look similar to
GFCI receptacles in that they have a TEST and RESET button on the face of the
device for localized testing.Any upgrade deemed necessary to accommodate building
code,energy envelope requirements,building plans,and as deemed necessary by the
general contractor, structural engineer and or as required by local,state or federal
authorities.If these upgrades are required,the financial burden shall be subsequent to
this contract and shall be billed on a time and materials basis and stated in the change
of work order.
7.1. Accommodations For-
7.1.1. Frigerator
7.1.2. Stove
7.1.3. Microwave
7.1.4. Garbage Disposal
7.1.5. Counter Outlets
II
Note* (7.1.1:7.1.5)If these electrical upgrades are required,the financial burden shall
be subsequent to this contract and shall be billed on a time and materials basis and
stated in the change of work order.
8. Communications-None
9. Insulation-None
10. Sheetrock-Minor repairs included.
11.Kitchen Counter Tops
11.1. Granite will be acquired,paid for and coordinated by the client separately from
this contract.
11.2.Faucet will be acquired,paid for and coordinated by the client separately from
this contract.
11.3. Sink will be acquired,paid for and coordinated by the client separately from this
contract.
12. Carpentry
12.1. Install single bowl Vanity guest bath.
12.2. Install Kitchen cabinets following attached elevation diagrams.
12.3. Install Kitchen kick plate finish as provided.
12.4. Install 3/4", r/4 round all areas as needed,provided by contractor(PVC type
material).
Customer Initials 4Contomr Initials
4
Hub City Builders, LLC
10 Lacy Street
North Andover,MA 01845
13. Paint
13.1.No Paint
13.2.No fill or Putty all holes.
14. Substantial Completion-as notified by contractor as defined here in.
15. Clean up-Construction clean,all surfaced wiped clean and vacuumed if required.
16. Return all items moved in Item#1,#2 in a"best case scenario"to the same locations
as pictorially documented.
11. Dates of Performance:
Commencement Date: As Soon as Deposit for services is received and within two
weeks after the rescission date as stated herein.
Substantial Completion Date: A.S.A.P—target date,as indicated herein. (60 Days)
Note: Definitions
1. As defined herein the phrase"owners agent"refers to the ability of William Pogor
through Hub City Builders Owner's or Representative designation as used in the
construction industry to describe an individual tasked with controlling the design and
development and process while protecting the best interests of the owner,in the
contracting individuals,local, State and Federal authorities. This Authority is limited
to the project scope contained herein.
2. As defined herein the phrase"substantial completion"refers to 95%point where
work on a specific requirement is complete,as defined by contract herein,and or a
point designated by the contractor.
3. As defined herein the phrase"Preparedness only"refers the state where the next
action can be taken by the owner or a separateldifferent contractor. But a previous
action/paper work will be filled out and completed.
4. As defined herein the phrase"ongoing designs"refers the state where daily as build's
drawings are required by either the building dept,design professionals,or building
contractors as the General Contractor(Hub City Builder's or their designated agents)
determines necessary to proceed expediously to a specific tasks conclusion.
5. As defined herein the phrase"max fixture allowance"refers the state where a
allowance for a single fixture,materials or services is specified on a line item
contained herein. Example,"max fixture allowance($40.00)". This means in the
context of this contract that you can spend up to$40.00 per fixture type indicated by
the line item where the amount is listed. If allowance in question does not reach the
example amount,there is no credit implied or realized. If the amount exceeds the per
fixture allowance a change of work order would be required,signed by all parties and
the allowance amounts will be predetermined.
Customer Initials IlaT
r Initials
5
Hub City Builders LLC
10 Lacy Street
North Andover,MA 01845
6. As defined herein the phrase"best case scenarid'refers to the state where workers
are doing the best they can overall to perform the task assigned. Through no fault or
malicious behavior a fault occurs, (breakage,scratch,dent,misplacement,ect.)of
objects furniture,appliances, artwork,jewelry,dishes,rugs, walls,doors, rails, floors,
granite, sinks, ect.)
Other Particularly Ar—reed Dates
1. Target Date 1/25/2016 Commencement,As soon as permitted by the North Andover
Building Department.,
1.1. Item#1 Agreed te: 1/25/2016 Commencement
Contractor Int: Date: 1 ib - 1k
Owner Int: t Date:
III-Dates of Performance:
Commencement Date: As Soon as Deposit for services is received and within two
weeks after the rescission date as stated herein building permit application is applied for.
Substantial Conwkdon Date: A.S.A.P—target date,as indicated herein.
Other Particularly Agreed Dates
2. Target Date
2.1. Item#1 Agreed Date: 1/31/2016
Contractor Int: 6L� Date: C '
Owner Int: /AdDate:
3. No-work on weekends, (unless constrained by completion date), no work
Thanksgiving and Christmas and recognized holidays.
Customer Initials n for Initials
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Hub City Builders, LLC
10 Lacy Street
North Andover,MA 01845
IV. Work Changes
Any changes to this contract must be mutually agreeable and put in writing under a
Change Order Form. A blank Change Order Form is attached after the signature lines
below and shall be the form used for any changes to this contract. It shall be the
obligation of both parties to adhere to this provision.
Contractor's Conditions of Performance
All dates of performance are subject to reasonable extension(s), at the Contractor's
request, if request is made due to inclement weather, labor disputes, issues involving
acquisition of materials or permits from appropriate authorities, mutual dissolution of
contract by the parties, stop work order(s) by state or local municipalities, or act(s) of
God. Approval of such request(s) shall not be unreasonably withheld. No acceptance of
liability is expressed, assumed or implied due to any of these circumstances. Work may
be stopped, interrupted or ceased at the sole discretion of Contractor if payment(s) under
the terms of this contract, or any written amendment thereto, is not made by Customer as
agreed herein Work shall be performed in an ordinary standard. It is understood that
certain portions of Contractor's consulting and drafting work is deemed artistic and/or
subjective in nature, and therefore, disputes related to subjective portions of Contractor's
work shall never be grounds for non-payment by the Customer.
Permits for Work
The types) of permits that will be required for the Contractor's work herein shall
include:
1. North Andover Building Permit.
2. North Andover Electrical Permit if required.
3. North Andover Rubbish Removal(Dumpster Permit)as Needed.
Customer Initials or Initials
7
Hub City Builders, LLC
10 Lacy Street
North Andover,MA 01845
Owners Agent
Customer
Unless otherwise requested by the Customer, the Contractor shall act as the owNERs
AGENT with regard to Andover Building Department for the sole purpose of obtaining all
necessary permits required to undertake and complete the project. If the Customer
undertakes to obtain their own permit(s)the Customer will be excluded from the guaranty
fund provisions of M.G.L. c. 142A.
Special Conditions of Services:
(If this section is intended to be left blank,state"none"):
1. None
Customer Payment Schedule:
This Contract is:
0 Agreed Fee
11 Time and Materials Invoiced
X Combination Agreed Fee and Time and Materials Invoiced
Agreed Fee(If applicable):
Contract Base Price Total $14,559.00
Remainder due: *Time and Materials on weekly basis(see below)
1"PaymenVDeposit $4,853.00
2nd Payment on completion of item#3.4 as referred to herein $4,853.00
3'd Payment upon substantial completion as defined herein and
notified. $4853.00
Final Payment,due upon submission as invoiced.
Customer Initials tractor Initials
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Hub City Builders, LLC
10 Lacy Street
North Andover,MA 01845
*Time and Materials/Labor Invoiced as needed(If Applicable):
Contractor shall be paid at a rate of$60.00/per man hour for (Design Bidding services
only). Building contract requires $120.00/per two men per hour. Both rates are subject to
the addition of all materials and out of pocket expenses, including, but not limited to
invoiced subcontractors, consultants and materials suppliers. Contractor shall provide an
itemized entry of his time billed as part of his invoice together with incurred expense
invoices. Invoices shall be issued weekly. Payments due under invoice shall be made
withinn
seve ('n days of receipt of invoice. Receipt shall be upon delivery to Customer's
address, email or in person. Contractor may suspend or cease work under this contract if
payment is more than seven(7)days overdue.
Special materials,or materials of a special order or
custom made nature,shall be separately invoiced and
require advance payment by Customer prior to order.
Description of Combination Agreed Fee and Time and Materials:
I. As specified by any extra work orders
Payment terms may not be altered
Unless expressly agreed by the parties in writing.
Deposit Terms
If there is an initial deposit, it shall be refundable only after a full accounting of incurred
cost by the contractor. Incurred costs shall be considered non-refundable inclusive of the
Contractors time. The Customer acknowledges and agrees that the Contractor shall
commence work in good faith upon receipt of said deposit, utilize his time and that of
contractors and/or consultants he may work with, and that the Contractor shall be fairly
compensated for such commencement of work and dedication of time to this Customer
that might otherwise be devoted to other projects. The parties agree there is valid
consideration for the non-refundable deposit.
Customer Initials
*tor-InW' als
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Hub City Builders, LLC
10 Lacy Street
North Andover,MA 01845
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DEFAULT OF CUSTOMER
If the Customer defaults for any reason, the Contractor shall be entitled to immediate
payment of all monies owed as of the date the Contractor notifies the Customer in writing
that he deems the Customer to be in default. The Contractor's Notification shall state all
sums deemed to be owed and due from the Customer. Said sums shall be due and
payable within seven(7) days of delivery of said notice. Any sums due after such notice
of default shall be assessed an interest charge of 1 '/z%per month, or 18%per year until
all sums are paid in full. If the Customer defaults, and does not tender payment of all
sums due within said seven (7) days, the Contractor may record this contract in the
registry of deeds and seek a lien on the property for the enforcement of payment. The
Customer shall be responsible and owe the Contractor all costs and expenses incurred in
the collection of monies owed under this contract,including,but not limited to reasonable
attorney fees.
ALTERNATIVE DISPUTE RESOLUTION
The Customer and the Contractor mutually agree that in the event the Contractor has a
dispute with the Customer, the Contractor may submit such dispute to a private
arbitration service, of the Contractor's sole choosing; provided however, such private
arbitration service shall have been approved by the Secretary of the Executive Office of
Consumer Affairs and Business Regulations and which shall have been in business for
more than five (5) years, and shall be staffed with at least one retired justice of the
Massachusetts Court System. This provision is an election at the sole discretion of the
Contractor. This provision is in addition to any rights afforded the Customer under
M.G.L. c. 142A. The arbitration, if elected by the Contractor, shall follow the rules and
regulations of the American Arbitration Association. Nothing in this provision shall
Prohibit the Contractor from initiating a civil action for any such defaults. The
Contractor may have the right to institute a civil action to obtain and enforce any
statutory liens rights the Contractor may have, while contemporaneously seeking
arbitration of the underlying disputed claims, which determination shall be conclusive as
to the amount,if any the Contractor may enforce through such civil action lien.
Customer Initials *or Initials
10
Hub City Builders, LLC
10 Lacy Street
North Andover,MA 01845
This Contract shall be construed in accordance with the laws of Massachusetts.
This Contract may be executed in duplicate. Customer acknowledges receipt of copy by
signing below.
THIS IS A BINDING LEGAL DOCUMENT.CLIME DO NOT SIGN THIS CONTRACT
IF THERE ARE ANY BLANK SPACES OR YOU DO NOT UNDERSTAND ANY
TERMS HEREIN.
Customer Date Email
Customer Date Em
X— 4 1,164 billawilliampo or.com
Date Email
Hub City Build L
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4Customer Initials or Initials
11
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Hub City Builders, LLC
10 Lacy Street
North Andover,MA 01845
WORK CHANGE ORDER FORM
Owner
Mark Vincent
4 Lacy St
North Andover,Massachusetts
Project Location
148 Main St,
Stevens 429
North Andover,MA 01845
Original Contract Date:
Time and Materials Billing:
Description of Change(s):
This Work Change Order changes only those items specifically addressed herein.
Nothing in this Change Order shall be construed to change any other term or condition of
the Original Contract.
Customer Initials C n or Initials
12
I
The Commonwealth ofMassgehusetts
u
Department o.f'Industryal.Alceldents
M Street,Suite.100
1 Congress Str ,
Boston,MA.02114-2017 ,
www.mass.gov/dia
s�.
Workers,Compensation Insurance Affidavit:]Builders/Contractors/Electrieians/Plumbers.
TO BE FILED WITH THE I'ERNI[TTING AUTHORITY.
Applicant Information /,, Please Print Leaibly
Name(sttsin12
ess/Organization&dividual): ff! 6�
.Address:
City/State/Zip: Phone##: qiS 3-7 6 Ig '7 S
Areyou an employer?Checktlie appropriate box: Type of project(Tgquired):
1.m 1 am a employer with employees(full and/or part-time).' 7. Q New construction
2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remo delitig
any capacity.[No workers'comp.insurance required.] 9, ❑Demolition
3..❑1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 FJ Buj(yng addition
4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will
0
ensure that all contractors either have workers'compensation insurance or are sole 11.. Electrical repairs or additions
•
— "_propridors-With noemployees.-- Q•T.'lumbingrepairs,oradditions_.,.
5.F1 1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs
These srtb-contractors bade employees and have workers'comp.insurancet
• � 14.)QOthex
6.Q We are a corporation and its offigers have exercised their right of exemption per MGL c.
152,§1(4),and we have nq emplo -I:-
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy informatio
i Homeowners who sulimit this affidavit indicating they are doing all work andthen 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 state whether or not those entities have .
employees. If the sub-con�racfozs fiave employees,ttiey must provide their workers'comp.policy number.
1 am an ethployer that is piadvi029 workers'compensation insurance for my employees' Below is the policy and jo�i site
information.
Insurance Company Name: Am ","d _TI45�e ra Mfg- �� f
Policy#or Self-ins,Lic.#: lie -3 Expiration Date:
rob Site Address:IV91M m4in�% 5�ey�2'fu� ������ City/State/Zip:111oE'>�9
Attach a copy of the workers' compensation policy ddttlaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL o.1.52,§25A is a cximinal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance
coverage verification.
IT do Hereby cer fy under r ains and penalties of peifury tliat the information provided above
is true and correct.
Si attire:
Date: i / 1�
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 bf 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 anotherwho 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-'contractox(s)name(s),address(es)and-phone number(s)along with their certificate(s)of
Insurance.—Limited-Viability-C-ompanies-(L-LC)-or Limited- iahiiity-Partierslups(LLP)—with-mo employees o er aha
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 o£insurance coverage. Also be sure to sign and date the affidavit. The'affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law oz•if you'are required to obtain a workers'
compensation policy,please call the Department,at the number listed below. Self iii'sured companies should'enter-their-
self insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(ifnecessary)and under"fob Site Address"the applicant should write"all locations in (city ox
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
(Lo.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 021.14-201.7
Tel.#617•-727-4900 ext.7406 or 1-877-AMSSAFE
Fax#617-•727-7749
Revised 02-23-15 www.mass.gov/dia
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