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Building Permit #802-15 - 196 CARLTON LANE 4/14/2015
BUILDING PERMIT ; TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Z' r _ Date Received Date Issued: LOCATI O IMPORTANT: Applicant must complete all items on this p, (JL./ I rvk tk�w_ , �c 44 4v-Ja v Print PROPERTY OWNER IZ" Y 90kv' - -1 ISSi —I Print MAP NO: PARCELM�ZONING DISTRICT: Historic District ye no Machine Shop Village v i no TYPE OF IMPROVEMENT PROPOSED USE - Residential Non- Residential ❑ New Building 'One family ❑ Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial A Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District El Water/Sewer "� �(�� pw � �GG ✓ �'t'� {l�L� N,4.WI� � (�) cJ Cli �c.t.y 1 OWNER: Name: Address: Identification Please Type or Print Clearly) I— Qe,wL-t 2u 55, ?7U'�yv-63 3 CONTRACTOR Name:cc f Phone: s'" G J�t V, `��WGi f _ Address: Supervisor's Construction License: 7 Exp. Date: 6 S -OGd z 3� 7 fi I Home Improvement License: / Exp. Date: r/ 1 r ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ �vGG FEE: $ Check No.: 1-2— i Receipt No.: ' NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature: of Agent/Owner ature of contractor C 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 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 x Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street - „"77777 " FI E D_EPAR�TMENTdTemp ®u Aster on sit dyes n®� - � Fire De �rtrnerit ri n ture/date`#� T P � f j €? s Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. 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 Call Email Date Time Doc.Building Pennit Revised 2014 Contact Name 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 BldgPermit mlt 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 ❑ 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 )TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit .n all cases if a variance or special permit was required the Town clerks office must stamp the decision from the Board of Appeals hat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording nust be submitted with the building application Doc: Building Permit Revised 2014 uo doomG C*4 S9 * IN rA A'n W 0 c _ O O - R c Ci O d Q � VJ V • Q. L � 4A.W. • o +r c R • v ' vN d Lcc J N C to c N N y ' O c O O CD O c �'cCI VQ U) .QE o as 0 z CL 0 •«. — oo .� N c •.. . = o0 a CL 0 4 •� _ cc ..: • c M 07 O c .c = N Q 4 i- U) O V m W_ O LL -� u N c H • I�LO E .2 v .d 0-0CL L t cc 4. 0. o toy U) N N d L 0. 0 V CL .CL V m 5=7 00 0 �a t � cv M J d z v CL n W U- W LU9L CL N 4 t, QVV� Q� x = LL N ^ „ N (~j Lu O :_ z CL Q W o oc z m actu i N c O o m = y � 1 m i J m LU W LL C > LA t O O ` z o O u a t c 3 7 '� m t j C t u 7 s 3 C v E v Y O LL to LLL t C. u d' LL Cc %j lL d' LL CO l j (A 0 c _ O O - R c Ci O d Q � VJ V • Q. L � 4A.W. • o +r c R • v ' vN d Lcc J N C to c N N y ' O c O O CD O c �'cCI VQ U) .QE o as 0 z CL 0 •«. — oo .� N c •.. . = o0 a CL 0 4 •� _ cc ..: • c M 07 O c .c = N Q 4 i- U) O V m W_ O LL -� u N c H • I�LO E .2 v .d 0-0CL L t cc 4. 0. o toy U) N N d L 0. 0 V CL .CL V m 5=7 00 0 �a t � cv M J d z v CL T W 7� O O O O V a m ca • a� a N V Q i N .4+ O :Of O a) t O i O � O d v i V N cn .. m L,_ U) L Z o Z a, o •: c = o v _ o _ � �"a T Md � � `~ o �Z y�c._.0 � 0 3 o� Q CL a) w +� c c CD o c a Q12 ca = as CL CD N cc s � m W = -a— O O LULL N O N r -O-t O N = — � *3 W. E _ 0 V O 'a 0Q N o C Hcc CLoU o W CL U) Z 0 - J m U) t7 .ti i w O O z . W U LLI d 0 W LL pWCL z z Z oc a Q Z zz V LLI Q J m Q LLI u 5 m C m J J LL O C d LLI u Y T N co41 Ocu Z \ 'a u y, o -C Op C t bD t u C h0 s to — cu , C Q� v Y O CL 7 7 C 7 C O m 7 �. it O LL N LL = U LL cr LL K N LL ti' LL CO {% N 7� O O O O V a m ca • a� a N V Q i N .4+ O :Of O a) t O i O � O d v i V N cn .. m L,_ U) L Z o Z a, o •: c = o v _ o _ � �"a T Md � � `~ o �Z y�c._.0 � 0 3 o� Q CL a) w +� c c CD o c a Q12 ca = as CL CD N cc s � m W = -a— O O LULL N O N r -O-t O N = — � *3 W. E _ 0 V O 'a 0Q N o C Hcc CLoU o W CL U) Z 0 - J m U) t7 .ti i w CONSTRUCTION SERVICES AGREEMENT (medium form) Whcre the basis of payment is a Stipulated Sum Contractor: Owner: Date: I Jowell Custom Building Group. Inc. Rov and Donna Rossi January 21. 2015 360 Men•imack St. 196 Carlton Lane Lawrence, MA 01843 North Andover, VIA 01845 Project Address: Phone: 978-989-9440 (same) _ C.S.L. t#068132 Project: H.I.C. 4175166 Sun Room Renovations I. PARTIES & DATE OF AGREEMENT This contract (hereinafter referred to as "Agreement") is made and entered into on this 21st day of January, 2015, by and between Roy and Donna Rossi, (hereinafter referred to as "Owner"), and Howell Custom Building Group, Inc., (hereinafter referred to as "Contractor"). I1. SCOPE OF WORK CONTRACT SUM & TINME in consideration of the mutual promises contained herein, Contractor sliall perform the "Work" on the structures and grounds at the Project Address as described in this Agreement, the following Scope of Work and any Attachments which are incorporated into this Agreement by reference below: A. ATTACHMENTS 1. No Attaclunents B. SCOPE OF WORK & SPECIFICATIONS: Project Overview • Sunroom: • Replace (5) existing sliding glass doors with (10) iviauvin Integrity Double hung windows. • Replace (1) existing sliding glass door with (1) Marvin Integrity Sliding Door. • New exterior siding and trim • Insulate floor, walls and roof • Install Mitsubishi mini split Heat,/AC system • New plaster, interior trim, carpet • Interior & Exterior Painting • Breakfast Room: • Replace (1) existing, sliding glass door with (1) Marvin Integrity Sliding Door. General Notes • All Work includes labor, materials and equipment unless otherwise noted. • Contractor shall have sole control over the means, methods, and sequence of construction. Owner Responsibilities • Owner to attend weekly project meetings on-site with Contractor. Meetings to be scheduled at a mutually agreed upon time on a weekday between the hours of 7:30am-4:00pm. • Owner to coordinate with Contractor on planning the detailed sequence of' work. • Owner to provide information, selections and decisions to Contractor as requested by Contractor in a timely manner so as not to delay progress of the Work. • Owner to remove all personal items and furniture from the following Work areas: • Exterior areas around Sunroom to allow staging to be built as needed. Page I of 13 Initials:9AX9,_ F— P • Interior of Sun room includinu window treatments and blinds NrI11its & Inspections • Contractor to prepare building pennit application, file application, and post permit on-site. • Allotment Item (S600): Town ot'North Andover Building Permit Fee. • Electrical Pcnnit to be obtained. and the fee paid. by Contractor's Electrical Subcontractor. • HVAC Permit to be obtained. and the fee paid. by Contractor's HVAC Subcontractor. • Contractor to schedule and coordinate the various inspections required to complete (lie Work as described in this Scope of Work. Site Prep General Notes & Specifications: • Contractor to provide and maintain a Portajolm on site during construction. • Contractor to seal off existing rooms adjacent to the areas affected by demolition and construction during the project with plastic sheeting and/or temporary wood -framed walls. • Contractor to protect existing finishes in affected areas. if those finishes are to remain. Existing finishes to be protected with plastic sheeting. cardboard or other padding. Scope of Work: Sttpply and Install Site Protection in the following arcus: • Protect deck access to Suru-oom and Breakfast areas • Secure Family Room doors during construction • Protect breakfast area floor Demolition General Notes & Specifications: • Contractor to discomiect electrical as required in affected areas prior to demolition. • Where Contractor is removing and saving an item, Ile will use his best efforts to remove that item Nvith minimal damage. Scope of Work: Contractor to peilbrin demolition in the 6llowing areas: • Remove and save the following: • (l) Existing ceiling fan to be rc-installed • Remove and do not save the followiam: • (6) Slider doors in Sunroom V • (1) Slider at Breakfast area. • Exterior Trim & Siding up to top of existing doors • Carpet & Pad • Ceiling/Wall Plaster • Under floor cardboard • NuTone electric wall heater Excavation/Sitework • none: Concrete • none l�tasonry • none Floor Framing Scone of Work: Page 2 of 13 Initials: `A peg Rri-ov P Sul)irlr trnd install Floor Fronting in the 1611mvirrg areas: • 'r." Pressure Treated Ply,xeood on underside of floor fianie after insulation is installed. Wall Framing General Notes & Specifications: • Framing lumber to be kiln -dried i-42 SPF unless otherwise noted. • Match existing wall framing (3x4 studs with IT' exterior plywood) • Existin- headers to remain Scope of Work: Suj)p4v and install If all 1 --raining, in the follo,ving areas: • Frame (5) new double window openings inside of (5) existing door openings in Sunroorn • Pad/adjust (2) openings for new sliders as needed in Sunroom and Breakfast Room Roof Framing norrc Roofing & Flashing • none Gutters & Downspouts • none Exterior Trim General Notes & Specifications: • All exterior trim to be PVC installed with stainless steel fasteners. • Window casinszs: 514x4 • Windowsills: V1 -3t4" x 1-7 8" • Door Casings: 5«3x4 • Door Kick board: 1x6 • Eaves, Rakes & Corner Boards: existing to remain Scope of Work: Stgyply card install Crterior Trim in the following areas: • (5) New window casings & sills around double windows • (2) New Door casings & kicks around sliders Siding General Notes & Specifications: • Tyvek Housewrap, taped seams • Western Red Cedar, lit" x b" Clapboards: VG FJ, primed, hand -nailed w' stainless steel nails (smooth texture, match existing) • Prime all end cuts in the field during installation. Scope of Work: Serpph° and install Siding ill the frlbnring areas: • New sidin- on 3 exterior walls of Sunroom around new windows and sliders (existing siding above the new windows & doors to remain) • Patch new siding into existing at gable end of Sunroom. Exterior Doors & Windows General Notes & SDeCifica6011S: • Manufacturer: %Marvin • Series: Integrity • Exterior: Ultrex. Stone White Page 3 of 13 Initials:6DA'PER -PPR • Interior finish.: Bare Pine • Window Grills: Simulated Divided Lights, with insulated spacer bars. Wood interior ;,rill fixed to ;lass: Ultrex exterior grill fixed to glass. I? over I lights in windows (Upper sash to be 3 lights high by 4 lights wide. lower .ash to have I light, i.e. no grills in lower .ash) • Glazing: insulated -lass, low E with argon • Exterior Casing: None (applied in field) • .Iambs: 4 9 16„ • Window Screens: lull height. Stone white exterior. charcoal fiberglass mesh • Window Hardware: Almond Frost Sash Locks • Door Hardware: Cambridge Collection, Almond Frost interior Handle Set and White exterior Handle Set • Door Grills: Simulated Divided Lights, with insulated spacer bars. Wood interior grill fixed to glass; Ultrex exterior -rill fixed to -lass. 3 Transom lights in Doors • Door Sill: Ultrex • Door Screens: Stone white exterior, charcoal fiberglass mesh Scope of Work: ~ Supply and install Exterior Doory & If'induii:s in the J61/uu•in." m -e as: • (10) Double Hung Windows, 3' wide and 5' high (Note: window next to door to be tempered glass) • (1) Sliding French Door 6' wide x 6'-8"hi-h in Sunroom • (1) Sliding French Door 6' wide x 6'-S" high in Breakfast Area Porch & Deck Finishes • Hone Plumbing none IIVAC Scope of Work: .S'applr (Itd install HVAC IPnrk as folloivc: • Mitsubishi Ductless Split Heating & Cooling Unit: o Model tf N-IF7_-KA09, I I I SNA o 21,000 BTUrhr cooling, 27,600 BTUihr heating. IS SEER o Outdoor Unit located under Sunroom o In -door Unit - located in -floor Electrical Scope of Work: Stq)ply and insttdl Electrical 16•or•k in the lollowing areas: • Run electrical service to new mini -split • New TV outlet in wall • Re -install Ceiling- Fan • Disconnect and cap existing, feed to Nutone Wall heater • Note: (4) existing duplex receptacles in walls to remain • Add (I ) additional duplex receptacle Insulation General Notes & Specifications: • Floors: 9-1 '4" Kraft -faced fiberglass batts.. R-30 Walls: 3-1/2" Closed Cell Foam. R24 • Roof: 7" Closed Cell Foam. R49 • Dralt stop caulking in framing as required by code Page 4 of 13 lnitials:wD . - b, -g QP Scope of Work: Supply and install htsa&aivn FFnrk in the Julknring areas: • insulate Sunroom floor from below • Insulate Sunroom (3) exterior walls and roof • Insulate around new windows and doors with foam Plaster General Notes & Specifications: • Walls: ;'z" ,vpsum blueboard screwed to studs; smooth skint -coat plaster finish. • Ceilings: '%" gypsum biueboard screwed to strapping; Textured (match family room) • Scope of Work: Supphv and install Plaster if ark in rhe Jollotring areas: • (3) exterior walls and ceiling of Sun Room • Patch plaster in Sunroom where electric heater was removed Tile • none Interior Doors • none Interior Trim & Millwork General Notes & Specifications: • Window Trim: mitered casing with stool & apron, stain -grade clear pine (match existing) • Door Trim: mitered casing•. stain -grade clear pine (match existing) • Baseboard: 2 -pc, stain -grade clear pine (match existing) Scope of Work: Supply and install Plaster ff'ork in the follotring areas: • New window and door trim in Sun room • New Baseboards around entire Sunroont • Patch -in baseboards at new Breakfast area doors Cabinets None Floor Coverings • Allotment hent (S1250): New carpet and pad for Sun Room Painting General Notes & Specifications: • Owner to select colors; Contractor to supply materials and labor. • All paints to be Benjamin Moore. Latex unless otherwise specified below • Ceilittns: flat, white: other colors or sheens would be extra. • Walls: flat or eggshell (1) color per room. dark colors may require additional coats to cover, which would be extra • Interior Trim, Doors & Windows: (1) coat stain plus (2) coats satin polyurethane • Exterior PVC Trint: prep plus (2) coats paint • Exterior Siding: prep plus (2) coats paint Sapplr and install Painting in the fbIlonvr>vt; areas: Scope of Work: • Sun Room: Interior: (f) walls and ceiling. new pine windows & doors and trim. Page 5 of 13 htiiials:4D1\ We RK> 3 Exterior: new siding & trim including the existing siding on gable end of Sun room. Exterior: existing PVC skirt around Sunroom (2 sides not including skirtaround deck) Breakfast Area: o Interior: new Aider doors and trim (note: protect wall paper which is to remain) c Exterior: new trim around slider Clean-up • lobsite to be cleaned up daily. • All constriction debris to be removed from site. • At completion of the Work. Contractor shall remove construction equipment.. tools, machinery and surplus materials from site. • Contractor to provide on-site dunrpsters during demolition and construction. Owner and Contractor to agree on exact location. • The house shall be left "broom clean" upon completion. C. CONTRACT DOCUMENTS The "Contract Documents" consist of this Agreement. [lie Attachments listed above (if any), and iModifications issued and signed by the parties after execution of the Contract. There are three (3) types of modifications: Field Chanee Order. Contract Change Order, and a written amendment to the Contract signed by both parties. D. <ornitted> E. CONTRACT SUM (lump sum for all Work described above): $ 49,800 F. TOTAL ALLOTIMENTS (included in Contract Sum): $ 1,850 Listcd above in Scope of Work Description above and summarized as follows: Building Permit Fec S 600 Floor Coverings S 1,250 G. <ornitted> H. CONTRACT TDIE Contractor to Commence Work on or about May 26, 2015. Contractor to achieve Substantial Completion of all Work in this Agreement in approximately 6 weeks from date of Work Commencement not including delays and adjustments for delays caused by: additional time required for performance of Change Order Work (as specified in each Change Order), delays caused by failure of Owner to perform their responsibilities under this Agreement. inclement weather, accidents. and other delays unavoidable or beyond the control of Contractor. M. GENERAL CONDITIONS FOR `rHE AGREENIENT ABOVE A. CONTRACTOR'S DUTIES Contractor asrees to: 1. Obtain the necessary permits and approvals pertaining to the construction of the Work. 2. Perform the Work in a timely and workmanlike manner in accordance with the Contract Documents and applicable state, federal and local laws.. and building and safety codes. 3. burnish competent construction management and to adequately supervise the Work in progress. 4. Keep the Project site free from accumulation of waste material or debris arising out of the Work of Contractor. and remove all debris caused by its Work. S. Keep hill and detailed accounts and exercise such controls as may be necessary for detailed and responsible Page 6 of 13 Initials: 40 'PC,,� PPR financial m;.nnagcmcnt of all aspects of this Agreement. All such bill and detailed accounts shaft be open to inspection, il'requested, by Owner or Owner's representable it reasonable times and upon reasonable advance notice, and shall be maintained by Contractor for not less than thirty-six months from the date of Final Completion. B. OWNER'S RESPONSIBILITIES Owner agrees to: 1. Promptly furnish to Contractor all details and decisions about unspecified construction finishes so as not to delay the progress of the Work, 2. Promptly consent to or deny Changes in Work that may arise so as not to delay the progress of the Work. 3. Furnish Contractor with continual unobstructed access to the job site. d. Furnish site surveys and a legal description of the site. 5. Except for permits and fees which are the responsibility of Contractor under the Contract Document;, Owner shall secure and pay for necessary approvals, easement's, assessments and charges required for the construction. use or occupancy of permanent structures or permanent changes in existing facilities. 6. Provide and pay for utility connection and/or usage fees, including but not limited to water, electricity. gas, heat, to the sitc during construction.. 7. Purchase and maintain insurances as required by the Contract Documents C. EXCLUSIONS: Unless specifically included in the Scope of Work described above, this Agreement does not include labor or materials for the following Work: 1. Fees for Design and Engineering ("ME") Work including any additional ME Work required by building inspectors, 3. Surveying that may be required to establish accurate property boundaries for setback purposes 3. Temporary sanitation. water, power. or utility usage fees of any kind 4. Temporary fencing 5. Moving Owner's property around the site 6. Repair or replacement of Owner -supplied materials 7. Public or private utility connection fees 3. Repair of unforeseen and concealed conditions including. but not limited to, repair of concealed underground utilities not located on prints or physically staked out by Owner which are damaged during construction 9. Testing, removal and disposal of any materials containing asbestos (or any other hazardous material as defined by the EPA) 10. Removal of tilled ground or rock or any other materials not removable by ordinary hand tools or other heavy equipment already on-site 1 l . Any digging or excavation below the grades sholvn on the plans in the event that soils unsuitable for supporting the specified footings are discovered 4 12. De -watering of excavations 13. Winter Conditions of any kind, including but not limited to: frost protection for open excavations: cold xveather additives for concrete and masonry: insulation or protection of concrete placements: temporary heat: snow and ice removal; including shoveling. snow blowing, sanding, salting or plowing 14. Correction of existing out -of -plumb or out -of -level conditions in existing structure 15. Correction of concealed substandard framing 16. Removal and replacement of existin�� rot or insect infestation 17. Re-routing/removal of vents. pipes, ducts. wiring. conduits.. structural members, or steel mesh which may be discovered in the removal or cutting of openings in the existing structure 18. Failure of surrounding part of existing structure. despite Contractor's good faith efforts to nlniiiilnize daillage such as piaster or drywall cracking and popped trails in adjacent rooms- 19. ooms19. Repair of damage to existing roadways, driveways. sidewalks. or grass areas that could occur when construction equipment and vehicles are being used in the normal course of construction 20. Exact matching of existing finishes. \Vllere Contractor's Work involves the "matching of existing finishes or Page 7 of 13 initials: j materials." Contractor will use his best efforts to match existim, finishes and materials. However. an exact match is not guaranteed due to such factors as discoloration due to the aging process, difference in dye lots. and difficulty of exactly matching certain finishes, colors, and planes. 3 I. Final construction cleaning (Contractor will leave site in "broom swept" condition) 22. Landscaping and irrigation Work of any kind. 23. Erosion and sediment control, and wetlands protection, maintenance or replacement ofany kind '4. Any item on the Plans marked "Not in the Contract" or "NIC". D. CONTRACT SUiT The Contract Sum is stated in the Agreement and. including adjustments authorized through Change Orders, or amendments to this Agreement, is the total amount payable by Ounner to Contractor for performance of tine Work under the Contract Documents. E. PROGRESS PAYi\IENTS AND COMPLETION 1. APPLICATIONS FOR PAY.MEN'C: Based upon Applications for Payment (invoices) submitted to Owner by Contractor. Owner shall make progress payments on account of the Contract Sum to Contractor as provided in the Contract Documents. Applications for Payment (invoices) shall be prepared by Contractor approximately every two (2) weeks and submitted to Owner. Payment is due within five (5) business days after receipt of the Application for Payment by Owner. 2. CALCULATION OF PAYMENT ANIOUNT: Applications for Payment (Invoices) shall itemize the amounts due thtu the Invoice Date for completion or partial completion of the Work and. -or project milestones as shown on the Schedule of Values below and any Change Order Work added to the Schedule of Values. The Schedule of Values, which allocates the Contract Sum to the various portions of the Work and project milestones, shall be used as a basis for Contractor's Applications for Payment, belt shall not he used as a iasis fir the value of Fork added to or deleted from the Agreement. SCHEDULE OF VALUES: 1 I Initial Deposit due when Agreennent is signed and returned to Contractor S 2,500 2 Upon ordering of Marvin Windows & Doors S 10.000 3 Demolition & Framing S 4.000 4 Installation of Marvin Windows & Doors S 4,000 5 Siding & Exterior Trim S 4,000 6 Rough Electrical & HVAC S 4.000 7 Finish Electrical & IIVAC S 2.000 8 Insulation S 5.000 9 Plaster S 2,000 10 Interior Trim S 2,000 11 Carpet S 1.500 1 ? Painting S 2.000 13 Final Payment S 3.800 TOTAL CONTRACT SUi\t: $ 49,800 3. FAILURE OF PAYMENT: if Owner does not pay Contractor within the time indicated above.. then Contractor may stop the Work until payment of the amount owing has been received. The Contract Tune shall be extended appropriately and the Contract Sum shall be increased by the amount of Contractor's reasonable costs of shutdown, delay and start-up, plus interest as provided for in the Contract Documents. 4. INTEREST ON OVERDUE PAYMENTS AND AT'TORNEY'S FEES: Payments due and unpaid under (lie Contract Documents shall bear interest from the date payment is due at the rate of one and one half percent (I- 1 2%) per month. Owner shall be responsible for reasonable attorney's fees incurred by Contractor in collecting any sums clue Increundcr. Page 8 of 13 Initials:Oj A,59 R �?� F. <omitted> G. <otnitted> 11. <omitted> I. <omitted> J. OXVNER'S SEP.,kPuTE SUBCONTRACTORS Owner shall not hire separate Subcontractors to work on the site at same time as Contractor without prior written consent from Contractor. Contractor reserves the right to not allow uninsured, unlicensed or unquali ied subcontractors to work on the site at the same time as Contractor. Owner may hire separate Subcontractors to work on the site either before Contractor's date of Work Cortunencement or after final completion of the Work. K. CHANGE ORDERS 1. FIELD CHANGE ORDER (hereinafter referred to as "FCO") is a written or verbal directive from Owner for Contractor to proceed with a change in the Work prior to the final cost of the change being known, the exact amount of extra time required for performance of the change. and prior to a "Contract Change Order" being executed. Owner may issue a verbal FCO to Contractor for a change in the Work, and may direct Contractor to coninience with the change prior to signing a written FCO or CCO. In this case. Contractor shall commence with the change in the Work and Owner shall be obligated to pay for additional costs incurred as a result of the change in the Work. Contractor shall follow-up with a written FCO or CCO to be signed by Contractor and Owner, as soon as is reasonably possible. 2. CONTILUCT CHANGE ORDER (hereinafter referred to as "CCO") is a written signed agreement between the parties to change the Work including the cost of the change, and the change to the Date of Substantial Completion specified in this Agreement. The cost of the Change Order is then incorporated into the Schedule of Values and becomes payable according to the payment terms of this Agreement. 3. CONCEALED CONDITIONS: If conditions arc encountered at the site which are (1) unforeseen. subsurface or otherwise concealed , and which differ from those indicated in the Contract Documents or (2) unknown conditions which differ from those ordinarily found to exist and generally recognized as inherent in construction activities of the character provided for in the Contract Documents. then a CCO shall be written to equitably adjust the Contract Sum and Date of Substantial Completion due to the Change in the Work as determined by Contractor. 4. CHANGES IN THE WORK: Any change from the Scope of Work referred to in the Contract Documents involvinsi extra costs of materials or labor will be performed upon a written or verbal FCO or a written CCO issued by Contractor and signed by Contractor and Owner prior to the commencement of Additional Work by Contractor. Contractor's profit and overhead, and any supervisory labor will not be credited back to Owner with any deductive Change Orders (Work deleted from Agreement by Owner). 5. <omitted> G. <emitted> L. PAYINNIENTS AND COMPLETION 1. <omitted> 2. DEFINITION OF SUBSTANTIAL COMPLETION: Substantial Completion is the sta4ge in the progress of the Work when the Buildin-York or Improvement or designated portion thereof is sufficiently complete in accordance with the Contract Documents so that Owner can occupy or utilize the Building,Work of Improvement for its intended use. 3. PUNCH LIST WALK-THRU. When Contractor considers the Work, or portion thereof, which Owner agrees to accept separately. is substantially complete, Contractor and Owner shall perfor i the Punch List Walk-thru and agree on the list of Work remaining for Contractor to achieve "Final Completion" of the Work. This list of Work shall be referred to as "The Final Punch List". Contractor and Owner will then place a fair and reasonable value on each iter( on the Final Punch List. d. suBs`CAN'I'lAl. CO1-iP1.ET'ION AGREE.\IENT: Contractor shall prepare and submit to Owner the Substantial Completion Agreement. The Substantial Completion Agreement shall contain the Final Punch List Page 9 of 13 Initials: NXg p�% along with the value of each putsch list item. By signing and dating Part i of the Substantial Completion Agreement, Contractor and ONtiier agree that. a. the Work is Substantially Complete on the date noted on the agreement, b. Warranties required by the Contract Documents shall commence on the date of Substantial Completion. c. Contractor is entitled to the Final Payment as shown on the Schedule of Values. less the Holdback for Punch List \fork as described in Subparagraph 5. 5, FINAL PAYMENT AND HOLDBACK FOR PUNCH LiST WORK: The Final contract payment is due and payable upon Substantial Completion ([lot Final Completion) of the Work under contract. At the time of making the final contract payment. Owner may hold back the value of the Punch List Work times two. or SI000, whichever is greater. This hold back for Punch List Work assures Owner that Contractor will complete all Punch List Work in a timely manner. G. Fi\AL CONIPLETiO\ AND PAYMENT OF IiOLDBACK: Upon completion of the Punch List Work, Owner shall pay the hold back amount and any other amounts due and payable to Contractor under the Contract Documents. 7. <emitted> 8. PAYiNIEITS/CREDITS FOR ALLOTMENT OVERAGES/UNDEItAGES: 'Che cost of items designated in the Agreement as Allotments have been initially factored into the Contract Sum and Schedule of Values. If the actual cost of an item exceeds the Allotment amount. the difference between the actual cost including taxes and delivery charges and the Allotment amount will be added to the Contract Sum via Change Order. Contractor overhead and profit will not be added to material only Allotment overages as long as the scope of work to receive, handy, install, and warrant such materials has not increased. For Allotment items that include materials and installation labor, overhead and profit will be added to the labor portion of an Allotment overage. If the actual cost of an item is less than the Allotment amount, a credit will be issued to O\vner after all billings related to this particular Allotment have been received by Contractor. This credit will be issued via Change Order prior to calculating the final payment owing under the Agreement. The amount of the credit will be the difference between the Allotment and the actual cost of the item including taxes and delivery charges. Contractor overhead and profit will not be credited back to Owner on Allotment undcrages. 9. <omitted> NI. INSURANCES 1. CONTRACTOR'S INSURANCE: Contractor shall carry the insurances listed below throughout the course of the project, and file certificates of such insurance with Owner prior to commencement of Work: a. General Liabilitv Insurance b. ivlassachusetts Worker's Compensation Insurance for its employees 2. OWNER'S INSURANCE: Owner shall purchase and maintain replacement cost property insurance on all property existing at the Project Address throughout the course of the project. and file a certificate of such insurance with Contractor prior to the Date of Work Commencement as follows: a. Owner's Insurance shall be written on an, "All Risk" or "Special" covera`e basis including earthquake and flood. b. Owner's Insurance shall include replacement cost coverage of all completed Work of this project to the hull insurable value thereof. and remain in effect whether or not Owner occupies the premises during construction. c. Owner shall supply Contractor an insurance binder reflecting Owner's insurance carrier is aware of project by listing project in remarks section of binder. d. Owner's Insurance shall contain a provision that the policy will not be canceled or allowed to expire until at least 30 days' written notice has been given to Contractor. e. Owner shall name Contractor as a Loss Payee on Owner's Insurance until all sums due tinder this Agreement have been paid by Owner to Contractor. L Owner asrees, to the extent permitted by law. to bold harmless, indemnify and defend Contractor from tory and all loss arising out of this project not wholly caused by the negligent acts or omissions of Contractor or its subcontractors. Any liability of the Contractor under this contract is limited to its available insurance. Paas 10 of 13 initials:W1 pC(< `. WARRANTY 1. Upon final payment by Owner of the entire contract sum including all chang=e orders and allotment overanes (if any) due to Contractor, Contractor warrants to Owner that the Work performed under the Agreement is free from defects. not inherent in the quality used, in materials, equipment and workmanship for a period of ovo (2) ,years after the date of substantial completion as described in the Agreement. 2. THIS LIMITED WARRANTY CONTAINS ALL EXPRESS WARRAN'T'IES OF CONTRACTOR, ALL OTHER WARRANTIES EXPRESS OR Iit'IPLIED ARE EXCLUDED AND HEREBY DISCLAI VIED, INCLUDING WITHOUT LIMITATION, ALL WARRANTIES OF MERCHANTABILITY, HABITABILITY AND FITNESS FOR A PARTICULAR PURPOSE. Except for any warranties implied bylaw and not subject to exclusion, there are no warranties that extend beyond the express warranties set forth herein. The tenor of any warranties implied by lav and not subject to exclusion shall end upon the termination of this Limited Warranty. In the event of breach by Contractor, Owner's recovery shall be limited to the actual cost to repair any defect or deficiency covered by this Limited Warranty. Owner waives any and all claims for incidental, consequential. special and consumer protection damages. The parties agree that Nlassachusetts law shall control this Limited Warranty and jurisdiction is proper in the iNdassachusetts Superior Court. 3. Owner shall notify Contractor in writing, within thirty (30) days after the discovery of any failure, defect or damage: otherwise the claim shall be deemed waived. In the event of an emergency failure (i.e. roof or plumbing leak), Owner should contact Contractor immediately by telephone at the number listed above. If Owner gives Contractor proper notification and if the condition is covered by this Limited Warranty, Contractor or subcontractors chosen by Contractor will replace or repair the defect (the decision to repair or replace is Contractor's sole decision) at no charge or cost to Owner within a reasonable time, not to exceed sixty (60) days, unless weather conditions, labor problems or shortages causes delays. Any steps taken by Contractor to correct defects under this Limited Warranty shall not extend the time of this Limited Warranty. d. Owner acknowledges that the following, as applicable.. are EXCLUDED from this Limited Warranty: a. Defects which are the result of characteristics common to materials used, such as. but not limited to, warping or deflection of wood, fadin-, chalking andfor checking of paint due to sunlight, cracks in concrete, plaster, brick, masonry, erouts and caulking due to drying and/or curing. b. Hairline cracks and seams in plaster and drywall other than those caused by structural defects, provided that joints are properly located to minimize cracking. Any repair of plaster or wallboard, caused by structural defects, may not completely blend with surrounding materials. c. Shrinkage, swelling, or leakage of doors and windows attributable to weather conditions. d. Occasional dents of interior woodwork and twisting, and hairline checking of wood framing, plywood, exterior siding and wood trim. ~ e. Shrinkage or separation of hardwood flooring. f. Damage to roofs caused by snow or ice backing up under shingles or damage, if any, caused by windblown rain or snow through roof, gable or soffit vents, or louvers into attic space, unless caused by negligent workmanship or defective material. It is Owner's obligation to insure free passage in gutters and downspouts at all times. g. Fading or darkening of paints. stains and other finishes exposed to sunlight. h. Defects in items supplied or installed by Owner, or anyone other than Contractor or its subcontractors acting at Contractor's order. i. Defects in materials or equipment that are covered by manufacturer's warranties including labor to repair same, even if such labor cost is not wan -anted by manufacturer. Contractor, at Owner's written request and at no expense to Owner, shall act as Owner's agent in pursuing the manufacturer for any defects in materials supplied and installed by Contractor. j. Damage due to abuse, improper or insufficient maintenance. improper operation. alteration. modification or normal wear and tear under normal usage. k. Contractor assumes no liability for damages to personal property of Owner. I. Loss or damage which Owner has not taken timely action to mmnumrze. in. The presence or development of radon and mold are products of environmental conditions that are beyond Pace 1 l of 13 initials:51DA_. 2 the control of Contractor. therefore Contractor docs not warrant and expressly disclaims any responsibility for the presence or development of radon or mold. O. WORD: STOPPAGE, TERMINATION Or CONTRACT BY CONTRACTOR 1. Contractor sliall have the right to stop all Work on the project and keep the job idle if: a. payments are not made to Contractor in accordance with the Payment Terms in this Agreement,. or if b. Owner repeatedly fails or refuses to furnish Contractor with access to the job site and /or product selections or information necessary for the advancement of Contractor's Work. 2. Simultaneous with stopping Work on the project.. Contractor must give Owner written notice of the nature of Owner's default and must also wive Owner a fourteen (14) day period in which to cure this default. 3. if Work is stopped due to any of the above reasons (or for any other material breach of contract by Owner) for a period of fourteen (14) days, and Omer has failed to take significant steps to cure his default. then Contractor may, without prejudicing any other remedies Contractor may have. wive written notice of termination of the Agreement to Owner and demand payment for all completed Work and materials ordered through the date of Work Stoppage, and any other loss sustained by Contractor, including Contractor's overhead and profit at the rate of twenty percent (20%) on the balance of the incomplete Work under the Agreement. 4. Payment for this final invoice is due within seven (7) days of submittal of invoice by Contractor. Thereafter, Contractor is relieved from all other contractual duties, including all Punch List and warranty work. S. If the contract is terminated and Owner pays all outstanding balances owed to Contractor, then materials ordered through the date of Work Stoppage become the property of Owner. P. TERMINATION OF CONTRACT BY OWNER 1. Owner shall have the right to initiate tennination this Agreement if: a. Project remains idle for longer than fourteen (14) consecutive days after the Work has been started without reasonable written notification of the cause of the Work Stoppage by Contractor to Owner, or if b. Contractor repeatedly fails to perform the Work according to the Contract Documents. 2. Owner must give Contractor written notice of the nature of Contractor's default and must also give Contractor a fourteen (14) day period in which to cure this default. 3. If Contractor fails to take significant steps to cure his default within the fourteen (14) day period. Owner may give written notice to Contractor of Owner's desire to terminate this Agreement. 4. Upon receipt of Owner's written notice of desire to terminate this Agreement. Contractor has fourteen (14) days to respond with an invoice for payment for all Work completed and materials ordered through the date of Work Stoppage. Payment for this final invoice is due within 7 days of submittal of invoice by Contractor. 5. Atter payment of final invoice Owner may terminate this Agreement and Contractor is relieved fi-ont all other contractual duties, including all Punch List and Warranty Work. 6. If the contract is terminated and Owner pays all outstanding balances owed to Contractor, then materials ordered through the date of Work Stoppage become the property of Owner. 7. Contractor shall not be responsible for any incidental or consequential damages incurred by Owner as a result of such termination. y Q. DISPUTE RESOLUTION 1. The parties agree that Massachusetts law shall control this Agreement and jurisdiction is proper in the Massachusetts Superior Court. 2. Any controversy or claim arising out of or related to this Agreement involving an amount of less than the maximum limit of the small claims court must be heard in the Small Claims Division of the district where Contractor's office is located. 3. Any controversy or claim arising out of or related to this Agreement which is over the dollar limit of the Small Claims Court shall be settled by bindin« arbitration administered by JAMS in Boston, MA in accordance with the Construction Industry Arbitration Rules. 4. The patties agree that mediation administered by JAiviS in Boston.. in accordance with the Construction Industry Arbitration Rules shall be a condition precedent to arbitration.. 5. Judgment upon the award may be entered in any Court having jurisdiction thereof. Page 12 of 13 Initials: s _i] Dwel-fJ2111 � Pl� R. ENTIRE AGREEMENT, SENTILWILITY, AND MODIFICATION This Agreement represents (lie full and complete understanding of every kind or nature between the parties with respect to the sera ices set forth in this Agreement. and all preliminary negotiations and prior representations. proposals and contracts. of whatever kind or nature. are merged herein and superseded hereby. No verbal agreement or implied covenant shall be held to vary the provisions of this Agreement. Any modification of this Agreement will be effective only upon written execution signed by both Owner and Contractor. In the event that any provision of this Agreement is at anv time held by a Court to be invalid or unenforceable, the parties agree that all other pro%isions of this Agreement will remain in full force and effect. S. <omitted> T. <omitted> U. OWNER'S 3 -DAY RIGHT OF RECISION Owner may cancel this Agreement with no further obligations by notifying Contractor in writing that they wish to cancel the Agreement within three (3) business days of the date they signed this Agreement. I have read and understood. and I asrce to. all the terns and conditions contained in the Agreement above. d4, WM//, Ro rt -5 to e, M Dat Stephen D. I Iow•ell, President Howell Custom Building Group. Inc. Date Owner P. L, Date Owner Page 13 of 13 Initials:Wn T2 Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supcnisor License: CS -068232 t 11♦ STEPHEN D HOWELL:-' 15 MT VERNONRD BOXFORD MA 01921,`,` %f Commissioner LIN-\ GI/,&/(I jJCtexI(ie LCA QJ>2 �7Z.�C�-'72lClr?�l'�. Z C� Office of Consumer Affairs and Business Regulation 10 Park Plaza -Suite 5170 vwo Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 175166 Type: Corporation Expiration: 4/29/2017 Tr# 263220 HOWELL CUSTOM BUILDING GROUP STEPHEN HOWELL 360 MERRIMACK ST LAWRENCE, MA 01843 SCA 1 0 zona -0511I Update Address and return card. Mark reason for change. Address f Renewal F] Employment C Lost Card /rs �`e�lir��fair��«��/// r Business Regulations//, License or registration valid for individul use only Office of Consumer Affairs &Business Regulation g Y MOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: . egistration: 175166 Type: Office of Consumer Affairs and Business Regulation A'xpiration: 4/29/2017 Corporation 10 Park Plaza - Suite 5170 Boston, MA 02116 HOWELL CUSTOM BUILDING GROUP STEPHEN HOWELL 15 MT VERNON RD BOXFORD, MA 01921 Undersecretar 1 Not valid without signature HOWEL-1 OP ID: JD2 A�C.O�RD" CERTIFICATE OF LIABILITY INSURANCE DA06/09/2014Y) 06/09/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 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(ies) 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 endorsement(s). PRODUCER North Andover Insurance Agency M.J. Foster Insurance Services 163 Main St. Andover, MA 01845 CONTACT John Dussault PHONE FAX A/C No Ell:978-686-2266 A/C No): 978-686-6410 n DRE SS: Jdussault@fostersullivangroup.com North INSURER(S) AFFORDING COVERAGE NAIC # Michael J. Foster INSURER A: HARLEYSVILLE INSURANCE GROUP 23582 EACH OCCURRENCE $ 1,000,00 INSURED Howell Custom Building Group, Inc INSURER B:ACE AMERICAN INSURANCE COMPANY 22667 PERSONAL & ADV INJURY $ 1,000,00 360 Merrimack St Bldg 5 Ste4N INSURER C : INSURER D: Lawrence, MA 01843 INSURER E: A INSURER F: LIABILITY ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS HIRED AUTOS X NON -OWNED AUTOS COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE DL U POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FK OCCUR SPP44402T 0610112014 0610112015 EACH OCCURRENCE $ 1,000,00 DAMAGE TO RENTEU- PREMISES Ea occurrence $ 500,00 MED EXP (Any one person) $ 15,00 PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X PRO LOC PRODUCTS - COMP/OP AGG $ 2,000,00 $ A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS HIRED AUTOS X NON -OWNED AUTOS BA44403T 0610112014 06/0112015 COMBINED SINGLE LIMIT 1,000,000 Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ PER ACCIDENT A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CMB44404T 06/0112014 06/01/2015 EACH OCCURRENCE $ 3,000,00 AGGREGATE $ 3,000,00 DED I X I RETENTION$ 10,000 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED' ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A MA WCAR CERT ISSUED BY CARRIER 06/01/2014 06101/2015 WC STATU- OTH- T RY LIMIT ER E.L. EACH ACCIDENT $ 500,00 E.L. DISEASE - EA EMPLOYEE $ 500,00 E.L. DISEASE - POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER, MA 01845 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts ? r,� Department of Industrial Accidents =-» , Office of Investigations 600 Washington Street F Boston, MA 02111 `'- www.mass.gov/dia Workers' Compensation Insurance Affidavit: BuilderslContractors/Electricians/Plumbers Applicant Information Please Print Leaibly Name (Business/Organization/Individual): Address: Ci Phone #: Are you an employer? Check the appropriate boa: 1. ❑ 1 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ II a sole proprietor or partner- listed on the attached sheet. ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 5 3. ❑ I am a homeowner doing all work myself. [No workers' camp. insurance required.] t These sub -contractors have employees and have workers' comp. insurance.* ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 15 2, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *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 a new affidavit indicating such. *Contractors 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 -contractors have employees; they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance far my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #:. Expiration Date: Job Site Address: City/State/Zip: 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 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Sianature: Date: Phone #: Official ase 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 #: J I!IIIIl� a rR rs_.� 11 HAMA I�I l� 11 1 0 Illl