HomeMy WebLinkAboutBuilding Permit #656 - 17 HALIFAX STREET 3/16/2012TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION 17
Print
PROPERTY OWNER C I . f S oyq Unit #
` Print
MAP NO: � PARCEL: I ZONING DISTRICT: Historic District yes no
Machine Shop Village ye no
100 year-old structure yes no
TYPE OF IMPROVEMENT'
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ Ad)ition
teration
❑ One family
❑ Two or more family
No. of units:
❑ Industrial
❑ Commercial
❑ Repair, replacement
❑ Demolition
❑ Assessory Bldg
❑ Other
❑ Others:
°M Sep c '❑a.�f
'
Water/ti,Sew�r,;��tg
ry�,; .�
❑9.0041, VJ�tlan'ds
r`
Wa e shed ►1s 'ct`
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tWIN kill wki1uL 1V tsl:�rrxrVKNIbl):
- ,41s,44 IFxc.*I, b 0 & " -- . 3o
(Identification Please Type or Print Clearly)
OWNER: Name: C rl� i,c;:1 Sf -o cy,
Address: 14 k, ��y
1,
q'�g (1?� 71olff,
CONTRACTOR Name: Lj o r -e- yn , Phone: 603 �z6 D &1p
Address: _ �d � P� /o( MY 6 �)
Supervisor's Construction License: /10 d Vi & Exp. Date:
Home Improvement License: _ 14IJ-6 3 y Exp. Date: /2— Z -i2.
ARCHITECT/ENGINEER Phone:
Address: Reg. No
FEE SCHEDULE: BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ � O 1 ' _"FEE: $ 69'?,
Check No.:
a Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
_
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Art ❑
Swimming pools ElTanning/MassageBody
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
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE APPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comm
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
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
Doc:.Building Permit Revised 2011 June/mi
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
o Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition or Decks
❑ Building Permit Application
❑ Certified Surveyed ,Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit
In all cases if a variance or special permit was required the Town clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
Location 11:2�14 )I, xz=
v
No. Date(
,.� , %, - / 2 -
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $—I��
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check # 5340 Q�3
25101 N Building Inspector
•
Contracting, LLC.
J06 �
/ ..% Date
Name !/
Address 7
Phone (H) ✓ i�✓' (A)
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Thank you for taking the time to meet with me and discuss windows for your home. I would briefly
Ike to tell you about My Home Contracting, and why you should choose us foryour remodeling
Project.
My Home Contracting Protects your Property by coveringyou with $2,000,000.00 of liability
insurance. Workmen's Compensation Insurance covers all of our employees so you are not exposed
to any liability.
We are proud members of the Better Business Bureau (BBB). We maintain this affiliation to
provide you with the highest level of confidence and customer service. All of our employees attend
pre -approved on-going training to keep them up to date on the latest technological advances in
replacement windows.
Should you elect to make your home improvement investment with My Home, we shall strive for
1009o' customer satisfaction.
V truly yours,
l
Donald 1=. Lucciano
Owner
MY HOME CONTRACTING, LLC
Registered In Massachusetts & New Hampshire
P.O. Box 989 Methuen, W 01844 * Tel. (978) 682-9052
P.O. Box 144 " Deerfield. NH 03037 Tel. (603) 463-8898
Toll Free Telephone: (800) 92I-9052 Fax (603) 463-8911
XvNvW.illV11017necontracting. c0111
job #
This project has been sl,)ecified in accordance with local building codes, industry standards and
manufacturers'specification requirements. All work will be installed by certified craftsman to assure
qualifications for the long-term window warranty.
GENERAL SCOPE OF WORK
➢ Remove existing storm windows.
➢ Remove interior stops from the sides and top of windows. (Care is taken to cut the paint line to minimize
chipping of the interior finish.)
➢ Expect paint to chip at joints. Touch up paint of the interior trim is not included.
> Remove the existing sashes.
➢ Remove the parting bead if existing at the sides and top.
➢ Remove the existing balance systems and fill with fiberglass insulation as required
➢ Apply caulk sealant to the interior of the exterior stops.
➢ Install the new.double hung replacement windows plumb and square.
➢ Screw the new window to the original wood frame.
➢ Adjust the expander on both sides to remove any bow in the master frame.
➢ Caulk both sides of the new windows. This will prevent air movement at the perimeter of the windows
and reduce any drafts.
INTERIOR FINISH Are we installing new interior trim?
( r'\
Caulk the perimeter of the interior with paintable caulk sealant.
➢ Clean all windows upon completion and vacuum work area when done.
➢ Canvases are used during installation when needed.
Any painting or staining is not included in this proposal.
EXTERIOR TRIM DETAILS ( Are we wrapping window casings?
➢ Fabricate PVC coated aluminum triA
tock to cover the window casings, joining the corners with 45 -
degree angles. Color tl� Qty
➢ Use #900 SOLAR SEAL for caulk around all window trim. This advanced caulking is based on terpolymer
technology, which offers an alternative to silicone and urethane sealants. Its high performance terpolymers
impart exceptional weather -resistance, adhesion, elongation and color fade resistance. Color to be
matched to exterior trim color.
4 MY HOME CONTRACTING, LLC
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B33B Registered In Massachusetts & New Hampshire
P.O. Box 989 Methuen. MA 01844 " Tel. (978) 682-9052
MEMBER P.O. Box 144 Deerfield, NH 03037 Tel. (603) 463-8898
Toll Free (800) 921-9052 Fax (603) 463-8911
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GENERAL DETAILS
➢ Drop cloths will be used for areas of installation.
➢ Dispose of all debris and scrap materials.
➢ Work area shall be kept neat and clean on a daily basis and returned to normal upon completion of the
project.
➢ A written materials warranty shall be provided upon receipt of final payment.
➢ We maintain a current General Liability and Workmen's' Compensation Insurance Policy. A copy is
available upon request to verify coverage.
➢ Also followed are special considerations set forth by the manufacturer for the application of the specific
product line.
Local and National Affiliations
— Massachusetts Better Business Bureau (BBB)
— Energy Star Retail Partner
Certifications
— Authorized Alside Window Dealer
—Authorized Thermal Industries Dealer
—Advanced Alside Installation Certification
Your investment with My Home Contracting includes the following –
➢ Estimate includes all permits, fees and applicable taxes
➢ Double strength glass is standard on all windows
➢ Limited Lifetime Warranty on windows
➢ All windows priced with double low -E glass and argon gas with warm edge spacer unless
otherwise noted
➢ Glass Breakage Warranty on qualifying windows
_. SG H U,a,
.,�, ' MY HOME CONTRACTING, LLC
7 BBB s. Registered .In Massachusetts & New Hampshire.
P.O. Box 989 Methuen, NIA ' 01844 Tel. (978) 682-052
MEMBER P.O. Box 144 Deerfield, NH 03037 . Tel. (603) 463-5898
Toll Free (800) 921-9052 Fax (603) 463-891 1
wzvw.myhomecontracting.com
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Job #
INVESTMENT TOTAL FOR SPECIFIED PROJECT
WE HEREBY PROPOSE TO FURNISH ALL LABOR AND MATERIALS IN
ACCORDANCE WITH THE ABOVE SPECIFICATIONS
FOR THE SUM OF n
Deposit
Deposit Due on Re -measure
$ Cash
$ At. #
Deposit Payment Options
Visa MasterCard
Balance Due On Completion $
Indicate payment method for Name as it appears on card:
Balance Due On Completion
Check
S geature of My HC
/1� thorized Signature:
thorized Signature:
BBB
MEMBER
Credit Card
Rep
Finance
Exp. Date
'By my/our signature below, I/We agree to allow My Home Contracting, LLC to
charge the above referenced credit card for the amount indicated above.
Cardholder's Signature Date
�tive: r'
/ice D y. Date: — ( —��—
MY HOME CONTRACTING, LLC
Date:
Registered In Massachusetts & New Hampshire
P.O. Box 989 Methuen, MA ' 01844 Tel. (978) 682-9052
P.O. Box 144 Deerfield, NH 03037 Tel. (603) 463-8898
Toll Free (800) 921-9052 Fax (603) 463-891 1
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Terms & Conditions
1. Parties: "You" refers to the buyer or buyers. "We" or "Us" refer to the seller, My Home Contracting, LLC.
2. Cancellation: Should you attempt to cancel or refuse to perform under the terms of this contract, there shall be agreed upon damages. The base amount of
agreed damages shall be 25% of the contract price. If any part of the work has been done, the agreed damages are the proportionate price of the work done plus
25% of the balance of the contract price. In addition to the base amount of damages, you shall pay necessary attorney's fees, court costs and interest. Interest
rate shall be 18% of the unpaid balance or the highest permissible rate by law. You will pay interest from the date of breach of contract. You will pay it at the
highest legal rate.
3. Insurance: We agree to carry Workmen's Compensation and Public Liability Insurance. They cover the work to be done under this contract.
4. Debris: We will remove all construction debris from the job unless specified otherwise. It is agreed that we shall not be liable or responsible for any damage
that may occur as a result of the use, delivery or removal of dumpster receptacles or any facsimile there of, i.e., driveway, lawn damage, sidewalks, etc.
5. Interference with Performance: We are not responsible for any interference with the performance for reasons beyond our reasonable control. This includes
strikes, fire, weather, inability to obtain material, extra work requested by you, failure to pay for extra work you authorize us to perform, acts of God, or
withholding by you of any or all progress payments due us_ Should work be stopped by more than three (3) days by any or all of the conditions set forth in this
paragraph, we may terminate this contract and collect for all work performed plus the agreed upon damages for breach of contract.
6. Warranties: The following refers to warranties:
a. We warranty all workmanship for a period of ten (10) years from the date of substantial completion on all work performed by us.
b. Our warranty does not cover damages or deterioration from causes beyond our control. Examples are: Collisions with foreign objects, acts of God,
misuse or failure to follow maintenance instructions.
c. We will provide warranty service and warranty remedies only where there has been no breach of obligation to make payments under the contract.
d. If a replacement product is unavailable we will provide a substantial product of equal grade at our option as determined by us.
e. For warranty service, write us at P.O. Box 989, Methuen, MA 01844. In the event of an emergency, call our local office.
f_ You may not withhold any portion of any payment of the contract as a holdback for guaranteed performance by us under this warranty.
g_ All material warranties are provided by the manufacturer.
7. Limitation of Liability: These limits apply to our liability:
a. We have no liability for incidental on consequential damages.
b. We have no liability over the amount of the contract price_
c. We have no liability for any interior damages to the building or contents if normal application procedures are followed. .
d. The limits apply to all claims whether for breach of express or implied warranty, negligence, or any other reason.
8. Entire Agreement: This contract is the entire agreement, and it is agreed by the parties that entire understanding is contained in this written contract between
you and us. It is further agreed that any subsequent changes to this agreement must be in writing and signed by the parties. No oral agreements or
understandings not specifically stated in this written agreement will have any force of effect.
9. Compliance with Law: This document is intended to comply with all applicable laws and rules. This includes, federal, state, and local laws, rules and
regulations of every kind. If any provisions or part does not meet any such requirement, that part may be considered ineffective, nevertheless, such portion shall
not affect the validity of the remaining portions of this contract.
10. Verifications: Our construction specialists check the measurements and calculations made by the sales representative in determining the work involved. If there
was a significant mistake or special construction problems are involved, we reserve the right to cancel the contract without liability. Any down payment shall be
refunded if the contract is cancelled under this provision.
11. Alterations: You agree to pay us our normal selling price for all additions, alterations or deviations from the agreed upon specifications. No additional work
shall be done without prior written authorization by you. Any such authorizations shall be on a Change order form approved by both parties, which shall
become a part of this contract. Where such additional work is added to this contract. It is agreed that all terms and conditions of this contract shall apply equally
to such additional work. Any changes in specifications or construction necessary to conform to existing or future building codes, zoning laws apply equally to
such additional work. Any changes in specifications or construction necessary to conform to existing or future building codes, zoning laws or regulations or
inspecting Public Authorities, shall be considered additional work to be paid by you.
12. Payment schedule: Payments shall be made by you, as per the attached or separate payment schedule. Acceptance of the Public Authority shall be conclusive
evidence that the work has been complete. Such completion entitles us to the complete progress payments according to the schedule set forth. We have the
right to stop work and keep the job idle if payments are not made to us when due. If any payments are not made to us when due, you shall pay us an additional
charge of 10 percent of the amount of such payment.
13. Survey: You are solely responsible for the location of all lot lines and shall, if requested, identify all corner posts of your lot. If any doubt exists as to the
location of lot lines, you shall provide, at your own cost, a survey. If you wrongly identify the location of the lot lines of property, any changes required by us
shall be at your expense. This cost shall be paid to us prior to continuation of work.
14_ Subcontracting: We have the right to subcontract any percentage of work agreed to be performed.
15. Landscaping: We shall not be held liable or responsible for damage to landscaping or grounds, trees, shrubs and /or vegetation arising out of the use of any
vehicles or heavy equipment or related equipment that is used to perform its obligation and duties under the terms and conditions of this and/or all agreements
between the parties. We shall be responsible to provide a rough grade finish only, which does not include loam, seed, or sod, unless otherwise specified in the
contract.
16. Payment of Invoice: We shall pay all valid bills and charges for materials and labor authorized by us arising out of the construction of the structure and will
hold the owner of the property free and harmless against any liens of labor and materials filed against the property.
17. Legal Costs: Should it be necessary for us to bring suit to enforce provisions of this Agreement or to recover damages or judgments, it is agreed that you will pay
reasonable fees and court costs to us.
18. Job Signs: You grant us the right to display a job sign and advertise at the job site during the construction process and 30 days after completion. The sign will
remain our property.
19. Workmanship: We agree to complete the work in a substantial and workmanlike manner, but are not responsible for failures or defects that result from work
do e by oth rs prior, at the time of subsequent to work done under this agreement.
20. Da\C4
a shall not be responsible for damage to existing walks, curbs, driveways, cesspoo , septic tanks, sewer lines, water or gas lines, arches, shrubs,
latvt esl telephone and electric lines, etc. by us or any of our subcontractors or Supp i Fs incurred in the performance of work or in the delivery of
mnaf b
Prope v�0 ner Property Owner
MY HOME CONTRACTING; LLC
6 BBQ Registered In Massachusetts & New Hampshire
P.O. Box 939 * Methuen; MA 01844 1: (978) 652-9052
MEMBER P.O. Box 144 ' Deerfield, NH ' 030'7 Tel. (603) 463-8898
Toll Free (800) 921-9052 , Fax (603) 463-8911
www.myhomecontracting.corn
Job #
IN HOME SALE OR SERVICE NOTICE OF CANCELLATION
YOU MAY CANCEL THIS TRANSACTION, WITHOUT ANY PENALTY OR OBLIGATION, WITHIN THREE BUSINESS DAYS OF THE
DATE OF THE CONTRACT. IF YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENTS MADE BY YOU UNDER THE
CONTRACT, AND ANY NEGOTIABLE INSTRUMENT EXECUTED BY YOU WILL BE RETURNED WITHIN 10 BUSINESS DAYS
FOLLOWING RECEIPT BY SELLER OF YOUR CANCELLATION NOTICE, AND ANY SECURITY INTEREST ARISING OUT OF THE
TRANSACTION WILL BE CANCELED. THERE WILL BE A SERVICE CHARGE EQUAL TO TWENTY-FIVE PERCENT (25%) OF THE
CONTRACT AMOUNT IF YOU CANCEL THIS TRANSACTION AFTER THE THIRD BUSINESS DAY FOLLOWING THE DATE OF
THE SALE.
IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD
CONDITION AS WHEN RECEIVED, ANY GOODS DELIVERED TO YOU UNDER THE CONTRACT, OR YOU MAY COMPLY WITH
THE INSTRUCTIONS OF SELLER REGARDING THE RETURN OF THE GOODS AT SELLER'S EXPENSE AND RISK.
IF YOU MAKE THE GOODS AVAILABLE TO THE SELLER BUT THE SELLER DOES NOT PICK THEM UP WITHIN 20 DAYS OF
THE DATE OF YOUR NOTICE OF CANCELLATION, YOU MAY RETAIN THE RIGHT OR DISPOSE OF THE GOODS WITHOUT
ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO
RETURN OF THE GOODS TO SELLER AND FAIL TO DO SO, YOU WILL REMAIN LIABLE FOR PERFORMANCE OF ALL
OBLIGATIONS UNDER THE CONTRACT.
TO CANCEL THIS TRANSACTION, MAIL A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE TO MY HOME
CONTRACTING, LLC AT P.O. BOX 989, METHUEN, MA 01844, NO LATER THAN MIDNIGHT OF
Ll —/
Acknowledgement of Receipt of Notice of Cancellation
IIWe hereby acknowledge receipt of Notice of Cancellation set forth above and that Seller has orally informed melus of our
/_/ )— Date
Date
Customer's Signature
Customer's Signature
I HEREBY CANCEL THIS TRANSACTION Date Signature
I HEREBY CANCEL THIS TRANSACTION Date Signature
MY HOME CONTRACTING, LLC .
BBQ .c Recistered In Massachusetts & New Hampshire
._ P.O. Box 989 Methuen, MA 01844 -k Tel. (978) 682-9052
MEMBER P.O. Box 144 Deerfield, NH T 03037 Tel. (603) 463-8898
Toll Free (800) 921-9052 Fax (603) 463-8911
Ni-NN,,,,.myhomecontractiila.com
job #
WINDOW sr--PCI>Fl A`f10NS
Total Windows
Purchased
�'
Qty
Qty
Double Hung
Bow Window
4 Lite / 5 Lite
Picture Window
Garden Window
2 Lite Slider
Patio Door
5 ft. / 6 ft. / 8 ft. / 9 ft. / 12 ft.
3 Lite Slider
Traditional / Equal
Entry Door
Single Casement
Storm Door
2 Lite Casement
Window Capping��-
3 Lite Casement
Mullion Removal
Awning
Screens �.
Half Full
Basement Hopper
Colonial Grids
Wood Steel
/
Bay Window
30 -Degree / 45 -Degree
Metal Window Conversion
ADDITIONAL NOTES
I
A 2
Homeowners' Initials My Home Representative's Initials
MY HOME CONTRACTING, LLC A—) ;� sRe(yistered In Massachusetts & Ne« Hampshire ; TP.O.Box989 *Methuen, MA 01844 Tel ((978) 682-9062
MEMBER P.O. Boa 144 Deerfield, NH * 03037 Tel. (603) 463-8898
Toll Free (800) 921-9062 Fax (603) 463-8911
N-Nr;�,A,N-.mylhomecontractin a.com
job #
My Home's Guarantee
(Installed Products Only)
I. TEN YEAR WORKMANSHIP WARRANTY
All workmanship is guaranteed for ten 0 0) full years from the date of the
installation of windows. There will be no charge labor or materials due to
faulty workmanship in that 10 -year period. i
2. THREE YEAR INSPECTION WARRANTY
My Home also guarantees thaffor a period of three years, My Home will
make an annual inspection of the products they have installed to ensure
you, the customer, the product is in proper working order. Customer's
obligation is to call My Home to set the inspection appointment, and My
Home will make the inspection within fifteen 0 5) working days.
3. MANUFACTURER'S WARRANTY
My Home also guarantees that it will provide upon receipt of final
payment, all manufacturer's warranties for the type of product purchased
from My Home Contracting, LLC and also guarantees that each type of
product purchased will carry a manufacturer's warranty.
4. GLASS BREAKAGE WARRANTY (ON QUALIFYING WINDOWS)
All windows include a Limited Lifetime Warranty for cover ge on
accidental glass breakage.
GLASS BREAKAGE WARRANTY INCLUDED
YES NO
t
My Home Authorized Signature
Approximate Installation Date
MY HOME CONTRACTING, LLC
BBB
Re-istered In Massachusetts & New Hampshire
_ P.O. Box 989 =1= Methuen, AIA 01844 ` Tel. (978) 682-9052
MEMBER P.O. Box 144 Deerfield, N.H 03037 ' Tel. (603.)463-8898
Toll Free(800)921-9052 Fax(603)463-8911
xvww.myhomecontracting.colil
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And The,
o m e
CONTRACTING
WINDOWS &VINYL SIDING
ZZ�R?0' (:��] M wo, �:
I, the undersigned, the owner of the property located at
hereby verify that I have authorized myHom
ne Contracting, LLC to apply to the Building Department in the
city/towof IJ > �I;Pek�All, to act as m agent in obtaininc, a building d r
JY b b b permit an /•
zoning requriemenets to obtain permits.
igna ure Propertycaner Date
my HOME CONTRACTING, LLC
Registered In Massachusetts & New Hampshire
P.O. Box 989 �° Methuen, MA 01844 Tel. (978) 682-9052 u�
P.O. Box 144 Deerfield, NH 03037 Tel. (603) 463-8898MEMBER
Toll Free (800) 921-9052 Fax (603) 463-8911
www.myIlomecontracti ng.coul
The Commonwealth of Massachusetts
Department of Industrigl Accidents
'OUT I -v Office of Investigations
600 Washington Street
Boston, MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lezibly
Name (Business/Organization/Individual): M}thy �U v►-*- Lt 1 J oc—. ft ! i
Address: P Bovc
City/State/Zip: Pzze.14,ld /ym X67 Phone #: 603 YG 3 9 g?1,F
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2a I am a sole proprietor or partner-
listed on the attached sheet. #
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. E] Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11. F1 Plumbing repairs or additions
12. ❑ Roof repairs
IIF Other W ► K a vyS
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:. 1A. '401D Ifin -M XV0Al ��G0,
Policy # or Self -ins. Lic. #: T V P7 70 Expiration Date:
Job Site Address: % %1A% 26.-:w S , City/State/Zip: / l/, AyaGrpeee— _
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certtfy under the pains and penalties of perjury that the information provided above is true and correct.
Signature:l.-a�i_ Date:
Phone #: 6160--3 h 7 Y 3-7f2
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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The CommnwealthofMassaehusPtts
Department of Industrial .Accidents
Office ofInvestigations
600 Washington Street
Boston., MA 02111
Tel, # 617-727-4900 ort 406 or 1-877.7MA.SS.AFB
Revised 5-26-05 Fax # 617-727-7749
v `VitW-Mass.goV/dia
A� V CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DO/YYYY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERI•IFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(es) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsements).
PRODUCER
CONTACT
NAME: Eric Jansen
Hasbany Insurance Agency
PHONE 978 685-3188 FAX N : (978) 685-9460
236 Pleasant Street
ADDRESS: eric@hasbany.com
Methuen, MA 01844
1/1/13
EACH OCCURRENCE $ 1,000,000
INSURER(S) AFFORDING COVERAGE NAIC #
INSURERA:Western World
INSURED
INSURERS: Travelers
MY HOME CONTRACTING, LLC
C/O Don Lucciano
INSURERC:
PERSONAL&ADVINJURY $ 11000,000
14 Coffeetown Road
INSURER D:
Deerfield, NH 03037
INSURER E:
INSURER F:
V.UVtKAlat3 CERTIFICATENUMRFR* 17FVICInkl killutir-0.
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 PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
ADD
N
SUBR
POLICY NUMBER
POLICY EFF
M/DD/Y
POLICY EXP
MMIDDVYYYY
UMTS
A
GENERALLIABILITY
NPP1080275
1/1/12
1/1/13
EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE Fil
DAMAGE TO RENTEDP E I occu $ 100,000
MED EXP (Arty one person) $ 5,000
PERSONAL&ADVINJURY $ 11000,000
GENERAL AGGREGATE $ 2,0 0 000
GEN'LAGGREGATELIMITAPPUESPER
PRODUCTS -00MP/OP AGG $ 2,000,000
X1 POLICY PRO LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
accident $
..,d.')
BODILY INJURY (Per person) $
ANY AUTO
ALLOWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY Per accident $
( )
NON -OWNED
HIREDAUTOS _ AUTOS
PROPERTY DAMAGE
Per accident) $
UMBRELLA LIAR
OCCUR
EACH OCCURRENCE $
EXCESS LIAB
CLAIMS -MADE
AGGREGATE $
DED RETENTION $
$
B
WORKERS COMPENSATION
AND EMPLOYERS LIABILITY Y / N
ANY PROPRIETOR/PARTNERIEXECUTIVE
OFFICERIMEMBER EXCLUDED?
NIA
4904P770
1/1/12
1/1/13
X WCSTATU- O7H-
E.L. EACH ACO DEW $ 100,000
E.L. DISEASE -EA EMPLOYEE $ 100,000
(Mandatory in and
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE -POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Addtdonal Remarks Schedule, tf more space Is required)
Windows and Siding Installation
ACORD 25 (2010/05)
Phone:
Toss ZULU ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Fax: E -Mail:
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Eric Jansen
ACORD 25 (2010/05)
Phone:
Toss ZULU ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Fax: E -Mail:
EPA RRP Certified Renovator
n Haberstroh .
North Rd.
Meld, NH 03037
sires: 2/10/2015
18692-10-00101
Lead-Edu ° 23 Nute Rd ° Madbury,NH 03823 0 (603)749-5775
Office ok,fa'Zrra.rs i d"s.nA ,;u aon
HOME IMPROVEMENT CONTRACTOR i
- Registration: 145039 Type:
ti Expiration: „ 12/2/2012 Individual
`y_HABERSTROHO
JASON HABERSTROH,
200 NORTH RDS`
i DEERFIELD, NH 03037_ Undersecretary
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction SuperNisorSpecialty
License: CSSL-100416
1vsc is 's
JASON R HARE'RSTROH
225 RAYM6N'LOAD
DEERFIELD i- ,0303{7, h
\� I i y
7
I �
Commissioner Expiration
02/13/2014