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HomeMy WebLinkAboutBuilding Permit #598-15 - 210 FARNUM STREET 1/12/2015 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NOo® Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION � Gl{—t1 ti� R Print PROPERTY OWNER I-liZ-� � ' ' .e l -i\ �,. . Print 100 Year Old Structure yes x. . .. __ MAP NO-/ , r. ARCED ZONING DISTRICT Historic District yes n 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 ❑ Septic ❑Welly ❑ Floodplain 0 Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: �yu cl� a (AO(Y\ ;l\ vvle_ \60semet _ 13 t x 16 Identification Please Type or Print Clearly) OWNER: Name: TZ&'% e ��� ��n'r�e� 3Kone3JJ �c�0 —aa-3 v Address: d am CONTRACTOR Names Phone: 7760 2.03_l Address '&x . d C1 AAA 0_te Supervisor's Construction License:Gs_ r Exp. Date: �- Home Improvement License: 2 - Exp. Date:_ ) 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: $ 20 �^ FEE: $ Check No.: f �� Receipt No.: � ( NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Own- , Signature of contractor Plans Submitted FE Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Location &10 Wt �+ No. �i � Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy *$ Building/Frame Permit Fee ' Foundation Permit Fee Other Permit Fee $ TOTAL $ Check# Building Inspector - Plans Submitted ,❑ Plans Waived ❑ ...Certified Plot Plan ❑ Stamped Plans ❑ :TYPE_OF`-.SEW-.ME ... - Public Sewer ❑ Tanning/Massage/Body Art ❑... 5wimmmg Pools ❑ Well ❑ Tobacco Sales ❑ -Food Packaging/Sales ❑ Private{septic tank,etc._ Permanent IDampster on Site THE-.FOLLOWING SECTIONS FOR'OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM _ DATE REJECTED .-- _. DATE:APPROVED 'PLANNING &.DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS r Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: :Comments Water & Sewer Connection/Signature Date Driveway Permit DPW T ovv;: Fnglneer: Signature: Located 384 Osgood Street FIRE DEPARTtl ENT :=:Tern.p Durhpster on site . yes . . : no Lbcated-bt;124.Mairi Street ,1 -Fire Departiiie►it signatiareldate `, " � .. ;• COMMENTS r . i r 1 i --Dimension- Number DimensionNumber of Stories: Total square feet of floor area, based on Exterior dimensions. i =Total land-area;sq. ft.; ELECTRICAL: -Movement of.Meter locatfbn,`mas$-or service drop requires approval of Electrical lnspector Yes No DANGER.Z®NE LITERATURE: . =Yes No MGL.Chapter166.Section 21A.-F and G min.$100-$1000.fine NOTES and DATA— (For department tent us e ® Notified for pickup - Date I f€ E Doc.Building Permit Revised 2010 Building Department b -The folilowing is a list of-the required.forms to be filled out-for.:the appropriate permit to be obtained. Roofir°ag, Siding, Interior Rehabilitation.Perm its u Building Permit Application u Workers Comp Affidavit o Photo Copy Of H.I.C. And/0'r G.S:-L Licenses a Copy of Contract o Floor Plan Or Proposed Interior Work u Engineering Affidavits for Engineered products NOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks a Building Permit Application u Certified Surveyed Plot Plan Li Workers Comp Affidavit u Photo Copy of H.I.C. And C.S.L. Licenses u Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses Li Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Copy of Contract L3 Mass check Energy Compliance Report a 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 apn,?al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Building Permit Revised 2012 � NORTIy own of y. : _ : ., +6Andover C, - ;h ver, Mass o� � > > CONIC Nl "C �1. �f.9s R�reo �PP��S U BOARD OF HEALTH Food/Kitchen PERMI LD Septic System THIS CERTIFIES THAT ( 6411BUILDING INSPECTOR has permission to erect .......................... buildings on ... i ........�,ek.f v.O.V4......cro......... Foundation 0 Rough to be occupied as J.1k.x.14. � 9� ..v.�" �"� .......... ................ ....... ............................................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final _ PERMIT EXPIRES IN 6014TH,. ELECTRICAL INSPECTOR UNLESS CONSTRUC S S 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 Lath1ng or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. IVMassachusetts-Department of Public Safety Board of Building Regulations and Standards . Construction Supero icor - License: CS-073991 = - GERALDWEM-` 23 GLENDALE Did DANVERS MA (F1923T Expiration 04/07/2016 commissioner rl/r rr?v,iri rvrnrrrrnn i Trr-M., •':tJirce ol. onsgiWATi'ift- Ation F;). _—gfOME IMPROVt(VIENTCONTi2AtTOR`'` -6--- registration: 129177' •" --. type: ' �y,Expiration: 7/19/2015 • Individual Gerald White Gerald White 23 Glendale Dr Danvers,MA 01923 Undersecretary or:reg►Stratinn valid4orindividid use.-o01y,-. betorg#ite•expiratjgn date.rIf ounrd_relnrn to:. Office of Consumer Affair's and Business Regulathon' ,>1.0 Park Plaza-Suite 5170 Boston,MA 02116 Not valid without signature A PRODUCER CONTACT NAME: PAYCHEX INSURANCE AGENCY INC PHONE FAX AIC,No,Ext: 8 362.6785 A/C,No): 877 677-0447 150 SAWGRASS DR E-MAIL ROCHESTER,NY 14620 ADDRESS:paychex@iravelers.com (877)362-6785 PRODUCER CUSTOMERIDM 675BP1151 SV996 70A INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER&THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT WOODRIDGE CONTRACTING LLC INSURER B: 35 MAIN ST INSURER C: GLOUCESTER,MA 01930 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE-NUMBER: 738766046151780 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. NSR ADDL SUBRPOLICY EFF POLICY EXP TR TYPE OF INSURANCE INSR POLICYNUMBER MMIDD MMIDD LIMITS GENERAL LIABIRY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO-RE-NT-EU PREMISES Ea occurrences $ CLAIMS-MADE �OCCUR MED EXP(Any oneperson) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ PRO- POLICY 7 JECT LOC $ AUTOMOBILE LIABILfrY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO - BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS HIRED AUTOS (Perr eccidenDAMAGE $ NON-OWNED AUTOS $ $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION NIA UB-3938X716-14 01/24/2014 01/24/2015 X WCSTATD- 01T R4 AND EMPLOYERS'UABIUTY YIN TORY LIMITS ER "NY FROPRIeiGrtirAR iTJER/EXECUTtiE❑ - E.L.EACH ACCIDENT $100;000 ER/MEMBER EXCLUDED? OFFIC (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under SPECIAL PROVISIONS belmv E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) CERTIFICATE HOLDER CANCELLATION NEXUS II SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE PO BOX 2823 EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WOBURN,MA 01888 WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �I/ � • ��", ©1988-2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD A�`(� ® DATE(MM/DD/YYYY) 16..—•rrrr����� CERTIFICATE OF LIABILITY INSURANCE 09/29/2014 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 CONTACT Mary B Rawson CISR Phil Richard Insurance,Inc. PHONE (978)774-4338 x115 FAX (978)774-1318 27 Garden Street (AIC,No Ext: aC No Unit 1B E-MAIL ma hilrichardinsurance.com Danvers,MA 01923 ADDRESS: ry@P , INSURERS AFFORDING COVERAGE NAIC# INSURERA: Main St Amer Assur Co 29939 INSURED Vita Limoli DBA Vetro Plastering INSURER B: ACE American Insurance Company 22667 Carmelo Limoli 8 Roosevelt Ave INSURER C: Peabody,MA 01960 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE WVDPOLICY NUMBER MM/DDIYY MM/DDlYYYY LIMITS A GENERAL LIABILITY MPT2466E 04/10/2014 04/10/2015 EACH OCCURRENCE $ 1,000.000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 500,000 CLAIMS-MADE ®OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO-JECTLOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ - ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE HIREDAUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ B WORKERS COMPENSATION 6S62UB-5B65973-8-13 10/18/2013 10/18/2014 we srATU- I OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMSER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) r4 Q� 1.� CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Nexus II Services THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P.0.BOX 2823 ACCORDANCE WITH THE POLICY PROVISIONS. Woburn,MA 01888 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD I MONIZ-1 OP ID:NC ACOREIrDATE(MM wYYYY) CERTIFICATE-OF LIABILITY INSURANCE F1210212014 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(les)must be endorsed. If SUBROGATION IS WANED,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 NOMECT Joseph Moniz KW insunince(Cambridge) PHONE FAX 1361 Cambridge Street N .617-492-4150 No:617-492-0139 Cambridge,MA 02139 EADD�RESS- 1AS AFFORDING COVERAGE NAIL# INSURERA:Arbella Protection Insurance 41360 INSURED Moniz Electric Inc. INsuRERsArbella Protection Insurance 41360 33 Franklin St INsURERc;Arbella Protection Insurance 41360 Somerville,MA 02145 INSURER D INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN-IS SUBJECT TO ALL THE TERMS, OCCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. !LTR TYPE OF INSURANCE AD B POLICY NUMBER MM1D POLICY EFF UCY EXP N UMITS A X comma cLAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 1PNIAGE TO CLAINS.MADE ❑X OCCUR 038506 1111MO14 11118/2015 PREMISES Ea °occurrence S 100,00 MED EXP(Arty one person) $ 5,00 PERSONAL&ADVIJURY $ 1100010 GERL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,00 X POLICY JIE T �LUC PRODUCTS-COMPIOPAGG $ 2,000,00 OTHER Is AUTOMOBILE LIABILITY EOMs(NNW SINGLE LIMIT $ at AANY AUTO 1020029408 05/07/2014 05/07/2016 BODILY INJURY(Per person) $ 250,00 ALLOMED X SCHEDULED BODILY INJURY(Per accident) $ 500,00 AUTOS AUTOS PROPERTYDAMAGE X HIREDAUTOS X AUTOS V�� Peracidara IS 250,00 UMBRELLA LULB OCCUR EACH OCCURRENCE $ EXCESS LIAS CtAIM3-0fJV)E AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STAME ERTM _ AND EMPLOYERS'LIABILITY YIN A ANY PRoPmEToFuPARTNERv(EcunvE 106291113 11722/2014 11/2212015 EL EACH ACCIDENT $ 100,000 OFFICERMEMBEREXCLUDED? FN N/a 900,00 (Mandatory in NH) E.L.DISEASE-EAEMPLD $ 1Iyes,desm'6eunder 500,00 DESCRIPTION OF OPERATIONSbeivn EL DISEASE-POLICY UNIT $ DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached U more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE VMM THE POLICY PROVISIONS. Nexus 11 Carpentry 8: Construction Design EPRESEWATME PO Box 2823 Woburn,MA 01888 O 1988-2014 ACOAD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are reg tered marks of ACORD DATE AC40RVCERTIFICATE OF LIABILITY INSURANCE 1/12M2015YY) 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 ACT NAME: Lauren Goldman Cross Insurance-Peabody PHONEIN . (978)532-5445 ac No:(978)532-2217 139 Lynnfield Street E-MAIL 1 oldman@crossa enc com ADDRESS: g g y INSURERS AFFORDING COVERAGE NAIC# Peabody MA 01960 INSURER A:Western World Ins. Co. INSURED INSURER B:Safety Indemnity 33618 Nexus II Services LLC INSURERC: P.O. Box 2823 INSURER D: INSURER E: Woburn MA 01888 INSURER F: COVERAGES CERTIFICATE NUMBERCL14121825721 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 ADDL S BR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDD MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE 111 ENTED PREMISES Ea occurrence $ A CLAIMS-MADE Fx_1 OCCUR NPPS236669 /12/2014 8/12/2015 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 X1 POLICY JECTPRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident B ANY AUTO BODILY INJURY(Per person) $ 500,000 ALL OS X SCHEDULED 116632 1/10/2014 1/10/2015 BODILY INJURY Per accident) $ 5500 000 AUTOS AUTOS ( X HIRED AUTOS X NAUTOSON-OWNED PerOa ER cidentDAMAGE $ 100,000 Medical Payments $ 5,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATIONWC STATU- 9TH EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASEEMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E .DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Refer to policy for exclusionary endorsements and special provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Elizabeth Thurber ACCORDANCE WITH THE POLICY PROVISIONS. 210 Farnum Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE yy Timothy Tramonte/NIDI oG. ACORD 25(2010/051 ©1988-2010 ACORD CORPORATION. All rights reserved. The Commonwealth of lVfassachusetts - - Department of IndusfrlglAccidents Office of Investigations 600 Washington.,street Boston,MA 02111 -www mash govldia Workers' Compensation bsurance Affidavit:Builders/Cont°actors/Electricians]Plumbers Applicant Informatiion Please Print Leibly Name(Business/organizationllndividual): ► v e4ks Address: City/State/Zip: d��n _O I Phone#' 0 1 60 2�3 Are you an employer?Check the appropriate box: Type of project(required): 4. �I am a general contractor and I 6. New construction 1.❑ I am a employer with ___ ❑ employees(full and/or part time}•* have hired the sub-contractors 2.El am a sola proprietor or partner- listed on the attached sheet.T' 7• Remodeling ship and'have no employees These sub-contractors have S. ❑Demolition working forme in any capacity. workers'comp.insurance, g• F]Building addition [No workers' comp.insurance 5. ❑We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their ht o£exem tion per MGL 11.❑Plum-bingxepairs or additions 3.ElriI am a homeowner doing all work g 52 myself.[No workers c comp. ,§1(4),and we have no 12.❑Roofrepairs insurance required.]i employees.[No workers' 1311 Other comp.insurance required.] *Any applicant that:checks box#1 must also fill out the section below showing their workers'compensation policy information. -Homeowners who submit this affidavit indicating they si'e doing all work and then hire outside contractors must submit anew affidavit indicating such. tcontractors that cheekthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,pollcy information. X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. insurance Company Name:. Policy 0 or Self-ins.Lic.#: Expiration Date: Job Site Address: CitylState/Zip: Attach a copy of the workers'compensation-Polley declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredundex 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 WORD 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. !SSi:ature.eby cert u pa• nd penalties ofperjury t72at the information pYovidecl above i true and correct. - Date: Z 5 �7 Phone 0 Official use only. Do not write in this area,to be completer)by city or town off tial 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#: L 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 ofhire,- express or implied,oral or written." An employer is deigned 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 t to 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 t6`do maintenance,ponstraetion dr repair work on such dwelling house or on the grounds or building appurtenant thereto shallnot because of such employment be deemed to bean employer." MGL chapter 152,�25C(6)also states that`:every state or lobal 11unsiing agency shall withhold the issuance or renewal of a license or permit to olierate a business or to construct Buildings in the cowl' Qnwealth dor arty. applicant who has not produced.acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have beenpresentedto the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If au LL C or LLP does have employees,a policy is required. Be,advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. 'rhe 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 Departmenthas provided a space at the bottom of the affidavit fox 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"Job Site Address"the applicant shouldwrite"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 fature permits or licenses. A new affidavit must be lxlled out each year.Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,teleplfon e and fax number: `i;`he Commonwal&ofMassachymfts Depar(meAt o_ff dusidal Aocxdonts Offloe ofImstigatiom 6.00Waftgt a Sb=t Boston MA 02111 TOL#61.7-22,7n4900 at 406 Qx x-877-MASSA F, Revised 5-26-05 Fax#617-727-7749 WWw.MaagavIdia Page 1 of 5 Nexus II Carpentry and Construction Design P.O.Box 2823 Woburn,MA 01888 781 760 2031 Fax 978 975 1263 nexu sca rpentryna,aol.com Contract This is a contract between Elizabeth Thurber of 210 Farnum Street,North Andover MA 01845 (Hereafter referred to as the"owners") and Nexus II Services (hereafter referred to as"Nexus") dated January 8th 2015. GENERAL SCOPE OF WORK DESCRIPTION WE HEREBY SUBMIT SPECIFICATIONS AND CONTRACT FOR: work as stated below to your basement Scope of work: General details ♦ Meet with local building official and apply for permits ♦ All work will be in accordance with local building code regulations and will be inspected by local officials prior to continuing with the next phase—Nexus will be responsible for arranging and being available for all inspections ♦ Nexus will contact"Dig Safe"prior to commencing any excavation work for their clearance ♦ All work will be coordinated directly between"owners" and Nexus ♦ Nexus confirms that it is fully licensed, insured and ensures any sub-contractors utilized on this site will have the appropriate insurance coverage ♦ Nexus will be responsible for the safe storage of all its property and any materials to be used on the site ♦ Owner is responsible for removal and return of all items of the house in the areas that will be affected and their safe storage prior to our work commencing SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT Page 2 of 5 ♦ Owner will then be responsible for returning all items to these areas of the home after completion of the scope of work ♦ Remove and trash into Nexus supplied dumpster all trash associated with this project NOTE: appliances are not allowed to be put in dumpsters without additional costs "owners" are responsible for removal from site Scope of Work ♦ Make application to the Building department for building permit only ♦ Provide a layout drawing of proposed space ♦ Provide an on-site dumpster for the duration of the project ♦ Furnish and install 2" x 4" wood framing to create a perimeter wall with 2 entry door openings ♦ Furnish and install 2" x 4" wood framing to "box in" around the electrical panel and water meter ♦ Furnish and install electrics to code inclusive of outlets, 4 recessed ceiling cans, a cable jack and a duplex outlet where the TV will be mounted(TV by "others") ♦ Furnish and install insulation to all 4 walls ♦ Furnish and install sheetrock with smooth plaster finish to walls only ♦ Furnish and install sheetrock to ceiling with smooth plaster finish ♦ Furnish and install "access panels"to the ceiling to allow easy access to any"shut- off'valves ♦ Furnish and install 2 x hollow core, 6 panel colonial style,paint grade, doors in frames ♦ Furnish and install paint grade trim (2 %" colonial)to 2 door set ups (NOTE: no baseboard trim is included as no floor is being installed) I Work not included in this contract Building department fees —Engineering or architect costs Permit costs Unseen conditions —Painting or staining work Customer supplied electrical fixtures Utility upgrades if required Flooring —Heating or cooling Any other work not specifically noted above SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT Page 3 of 5 PERMITS "Nexus"will accept responsibility to obtain the necessary building permits. "Nexus"will act as a GC and work in accordance with fair and reasonable practices,and cooperate fully and under the guidance of the"Owners"and authorized parties.Nexus will pass the cost of the permit directly on to the"Owners"once advised by the Building department. Standard Exclusions: Unless specifically included in the"General Scope of Work"section above,this agreement does not include labor or materials for the following work(any Exclusions in this paragraph which have been lined out and initialed by the parties do not apply to this Agreement): Removal and disposal of any materials containing asbestos or any other hazardous material as defined by the EPA. Custom milling of any wood for use in project. Moving"Owners"property around the site. Labor or materials required repairing or replacing any"Owners"- supplied materials. Repair of concealed underground utilities not located on prints or physically staked out by "Owners",which are damaged during construction. Surveying that may be required to establish accurate property boundaries for setback purposes(fences and old stakes may not be located on actual property lines). Final construction cleaning("Nexus"will leave site in"broom swept" condition). Landscaping and irrigation work of any kind. Temporary sanitation,power, or fencing. Removal of soils under house in order to obtain 18 inches(or code-required height)of clear space between bottom of joists and soil. Removal of filled ground or rock or any other materials not removable by ordinary hand tools(unless heavy equipment is specified in scope of work section above),correction of existing out-of-plumb or out-of-level conditions in existing structure. Correction of concealed substandard framing.Removal and replacement of existing rot or insect infestation. Construction of a continuously level foundation around structure(if lot is sloped more than 6 inches from front to back or side to side,"Nexus"step the foundation in accordance with the slope of the lot). Exact matching of existing finishes. Repair of damage to roadways, sidewalks, or driveways that could occur when construction equipment and vehicles are being used in the normal course of construction. The"Owner"is to enter into contracts for all of the above-mentioned services and provide direct payment to"Nexus"for all of the services we are to provide. "Nexus"will be responsible for removing all components and all construction materials relevant to the "scope of work" in this contract. The"Owners"have received a copy of the lead hazard information pamphlet informing them of the potential risk of the lead hazard exposure from renovation activity to be performed in the dwelling unit. This was received before the work began and the"owners"are responsible for informing their tenants of all potential hazards. Dum sters trailer n s and signs "Nexus"will provide as included in the cost of this project,a dumpster for the sole purpose of the removal of trash associated with this project. This dumpster should not be used by any persons for any other waste items or for any purpose outside of the specific use under the scope of work, unless authorization is received from"Nexus".Nexus may have on site for part,or the whole of the project,a trailer containing materials and tools belonging to"Nexus". This trailer will be parked in a position agreed to in coordination with the"Owners"and will be covered under the insurances of"Nexus"at all times. "Nexus"will have on site,a sign,with our contact details, in the event that anyone has a need to contact us directly. SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT Page 4 of 5 Photographs "Nexus"reserves the right to,from time to time,take photographs of the contracted work for use in its general marketing or for production on its web site.At no time will"Nexus"share any personal contact details of the"owner"for any photographs that it may use without seeking authorization from the"owner". Warranties All the components supplied by"Nexus"as part of the original order are covered under the warranty exercised by"Nexus"and supported by the vendors.All labor and materials purchased from other suppliers to achieve completion of contract are warranted(1)one year from completion of the construction. Expiration of this Agreement: This Agreement will expire 30 days after the date at the top of page one of this agreement if not accepted in writing by"Owners"and returned to"Nexus"along with the necessary deposits within that time frame. Changes in the Work: During the course of the project, "Owners"may order changes in the work(both additions and deletions). "Nexus"will determine the cost of these changes and the cost of this additional work will be added to"Nexus"profit and overhead. PeovletAuAnrized to Sign Chan a Orders: The1 n people are authorized to sign Change Orders: "Nex ark Gotobed or Ged White "Client": zabeth Thurber Concealed Conditions: This Agreement is based solely on the observations"Nexus"was able to make with the area in its current condition at the time this Agreement was bid. If additional Concealed Conditions are discovered once work has commenced which were not visible at the time this proposal was bid, "Nexus"will stop work and point out these unforeseen Concealed Conditions to"Owners"so that "Owners"and"Nexus"can execute a Change Order for any Additional Work. Schedule of work It is agreed by both parties that this work will be coordinated with the"Owners"and "Nexus"to be undertaken in various stages to avoid complete disruption of the home environment."Nexus"will give"Owners"no less than 2 days notice prior to arriving on site for commencement of any of the agreed stages of work to allow"Owners"to prepare. "Owners"commits to have sites identified for construction work available for start at the beginning of the scheduled day so as to avoid any unnecessary delays. SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT Page 5 of 5 Contract Cost and Payment Schedule: Total cost of work description and materials included in the proposal(except materials/work stated)-$11,420.00(Eleven thousand four hundred and twenty dollars and zero cents) PAYMENT SCHEDULE 1st Payment due upon signing this contract TOTAL$4,000.00 2nd Payment due upon completion of rough framing inspection TOTAL$4,000.00 3rd Payment due upon completion electrical installation TOTAL$2,000.00 Final payment due upon completion of scope of work TOTAL$1,420.00 Amount due upon signing this contract-$4,000.00 I have read and understand,and I agree to,all the terms an c nditions contained in the proposal above. Date...l�J�-,.1� ............."Nexus"Authorization ...... .. ........................................... Date.. .(--/(.Y............."Client"Authorization......... .... ..................................... Date..............................."Client"Authorization...................................................... SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND PROJECT MANAGEMENT a 0000 e u,1 QOJ _ , "Y'4 p 1 1 0 1