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Building Permit #608-13 - 22 LINDEN AVENUE 3/20/2012
TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 60?'/3 Date Received Date Issued: ✓//' " IMPORTANT: Applicant must complete all items on this page - , , 2 z L1 /4t�� LOCATION PRORERTYtOWNER, JASd Print, 10;0 Yearr0ld�Structure� ye r MA 0: _ PARCELS: --ON .1, _-Histonc0stnct, ye nog Machihe;Sho '),q'ageo gess no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ A eration No. of units: ❑ Commercial R'Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other M S_.eptic ❑ Well 0 Fl oodp0 lain Wetlands. ❑ Watershed D istrictf . �. ❑WaterL.Sewelt DESCRIPTION OF WORK TO BE PERFO /P Z x0 D'crP6v1UA-e I. - WISH HT G � ,�v�� %y 6s Use r s I entification Please Type or Print Clearly) OWNER: Name: �1 3y,J Phone: .•moi `J Address:--lNI7r ✓�!/t CONTRA- 0'. Name:/ (fSc` _ T__ .. 4_ �.r F^hone: 7`17 S' Address: Su:pervisorC_onstruction License: �? _ Exp, Date:C�-"- _ Home;Improverrnent LicenseExp. Date:, ARCHITECT/ENGINEER Phone: Address: Reg. No. - FEE SCHEDULE: BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 27 /z FEE: Check No.: 731(o Receipt No.: l� NOTE: Persons contractin%ithnregistered contractors do not have acces toytheAr,aand Signature.ofe wne_= Si nature of'contract . 9 _ uejD 9 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED 0 DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Com -.41. Water & Sewer Connection/Signature & Date Driveway Permit ]LPW Town, Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT =,Temp Dumpster on site yes no Located at;1244Mairl Street ,, r F,; :, Fire t � Departmensignature/date h COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use Ll Notified for pickup - Date S Doc.Building Permit Revised 2010 Building Department The folpwing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg 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 app; 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'Ated with the building application Doc: Doc.Building Permit Revised 2012 No.— 6 0 'fv Check # 2.1?1-6 26211 Date TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Z Building Inspector Enter construction cost for fee cal - North Andover Fee Calculatioh Construction Cost $ 27,129.00 m $ - $ 325.55 Plumbing Fee $ 40.69 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 40.69 Total fees collected $ 506.94 22 Linden Avenue 608-13 on 3/19/2013 Finish Basement J. LLI 2 LL o�C 0 m v U Y O LL W A^ O 3 W vZ U LL o CL H Z Z J d d' LL L-7 � Q) M J. LLI 2 LL o�C 0 m v U Y O LL E v O0 a). V) N Z Z n co� ON ty0 LL 3 W vZ U LL o CL H Z Z J d d' LL O CL H Z u W J W 7 d' Q) M C LL Q V OW. Ln t w LL W a W 0 0 5 LL m a+ v y cu O In In J V; Q 2 F- N LL W fn c C 0 O O 0 v �, V' Q. Q o U) V cL L y w C d d w+ �: 0 � w E cmO Jo�+ _ 0 ci °03 J ' O C : L m N o U) •: � as > %c— o-0 > Nva U) \t.0 E o .2 �cZ �,00 ©�a>o c o V n0 CL0 .y v 0 'C C cmCD = L L m .0 O (D N o '2 O ., o y = Q' y O j C M 0 J 0 �CLo0 > 0 W CLZ Z m Cl) r Q Z O U) G O Z Cl) .. Lu am xO �v Cl) am Z -: d 7/ Office o Consumer A airs Busine�egulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvem� s ontractor Registration Registration: 137943 Type: Supplement Card • i t(;: Expiration: 1/29/2015 OWENS CORNING BASEMENT DANIEL WALSH 60 SHAWMUT RD CANTON, MA 02021 SCA 1 Co 20M-05/11 C�lie �po�r��w�euea/�i o�C> �czcLtec6el� of Consumer Affairs & Business Regulation IMPROVEMENT CONTRACTOR '4--�SW Expin OWENS CORNIN DANIEL WALSH 60 SHAWMUT RD CANTON, MA 02021 J Type: Supplement :,ard SHING SYS Undersecretary late Address and return card. Mark reason for change. LJ Address � Renewal ❑Employment � Lost Card License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid without signature Mas<<tc"husetts - Department i f Public Sacet� Boat d of Building Regulations xnc1, Standiir{i5,' Con'struetion Supervisor License ,License: Cs '79893 17 DANIEL E WALSH.. 488 KENDALLRD TEWKSBURY MA`0,1;876: J Expiration: 10/5/2013 t'omnutitiiorier ' r Tr#: 6504 4 ACORDF CERTIFICATE OF LIABILITY INSURANCEDATE(MMMONYYY) F9/13/2012 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 terns 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 Andrew G. Gordon, Inc. 680 Main Street P. 0. Box 299 CONTACT NAME: PHONE RIC,X c No Ext: No):781-659-472-9 E-MAIL ADDRESS: info@a ordon.com Norwell MA 02061 PRODUCER CUSTOMER D : 4440 INSURERS AFFORDING COVERAGE NAIC 0 LIMITS INSURED Bay State Basement Systems, LLC 60 Shawmut Road INSURER A: Peerless Insurance 24198 INSURERS: Pilgrim Insurance Company 21750 INSURERC:Star Insurance Company 18023 Canton MA 02021 INSURER D: 9/5/2013 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1448763903 RFVISIAN NIIURPR- 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 I TYPE OF INSURANCE ADDLSUBR WVD POLICY NUMBER POLICY EFF MM/DD POLICY EXP MM/DD LIMITS A GENERAL LIABILITY CBP8512851 9/5/2012 9/5/2013 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $50,000 CLAIMS -MADE 7 OCCUR MED EXP (Any one person) $10,000 PERSONAL BADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 POLICY PRO LOC X7JECT L1$ B AUTOMOBILE LIABILITY N N PGC10007161409 1/17/2012 1/17/2013 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON -OWNED AUTOS $ $ A X UMBRELLA LIAR OCCUR CUS511953 9/5/2012 9/5/2013 EACH OCCURRENCE $1000000 EXCESS UAB ___ CLAIMS -MADE AGGREGATE $1000000 DEDUCTIBLE $ X RETENTION $10000 $ C WORKERS COMPENSATK)N AND EMPLOYERS' LIABILITY WC0428715 5/24/2012 5/24/2013 X WC LtMW 0TH - ER Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYE $1,000,000 NH) (Mandatory in and H yes, describe under E.L. DISEASE - POLICY LIMIT $1, 000, 000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more apace Is required) Sales and installation of Owens Corning finished basement systems f�G�T�CIf�•TC �lA� �e�e� Vim\ 1 IV I� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED Bay State Basement Systems IN ACCORDANCE WITH THE POLICY PROVISIONS. dba Owens Corning 60 Shawmut Road AUTHORIZED REPRESENTATIVE Canton MA 02021 W I VOO-cuua ACUKU CUKPUKATION. All rights reserved. ACORD 26 (2009/09) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ,Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): U461�5 Address: 60 City/State/Zip: a> lyt A #: rT7;?1 Fz< 600 kre yo n employer? Check the appropriate box: YI am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors ❑ I am a sole proprietor or partner- listed on the attached sheet. t 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 ❑ 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. URemodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other ty applicant that checks box # 1 must also fil l out the section below showing their workers' compensation policy information. omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. Fn an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site brmation. urance Company Name: icy # or Self -ins. Lid. #: W T 7S 7-1 Expiration Date: Z Site Address:2 Z 1�j�1��`J City/State/Zip: 10. :ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 tp to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of estigations of the DIA_fb&_surance coverage verification. hereby certify i der the p ' d penalties of perjury that the information provided above its true and correct. nature: �i// Date: 3 ?fficial use only. Do not write in this area, to be completed by city or town official. :7ity or Town: Permit/License ssuing Authority (circle one): . Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector �. Other 'nx�}art Pnr_enn• PhnnA fb 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 permithicense 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 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. 'he Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. 0 617-727-4900 ext 406 or 1-877-MASSAFE 7-717-77AQ CONTRACT TO INSTALL OWENS CORNING BASEMENT WALL FINISHING SYSTEM Owens Corning Basement Finishing Division (the contractor) hereby submits this proposal to sell and install the Owens Corning Basement Wall Finishing System and related items as described herein at the residential premises set forth below. This proposal shall not become a binding commitment unless and until it has been signed by the Contractor and the Customer. Contractor: Owens Corning Basement Finishing Systems a division of LUX Renovations, LLC. 60 Shawmut Road, Canton, MA 02021 Telephone # (781) 821-0060 Facsimile # (781) 821-8552 Federal Tax ID # 14-1855297 Mass. Home Improvement Contractor Reg. # 137943 Date Customer: Customer Name A'Soro $bN i 1*�oaq e, l r Street Address CS �..-�ryi e(V N1lr. City, State, Telephone This is a contract between the Contractor and the above named Customer to sell and install the Owens Corning Basement Wall Finishing System and related items specified herein at the Customer's residential premises identified below: Installation Premises: Street Address City, State, Zip—:�CV..n.e.. Scope of Work: Are Sketches and/or specification sheets attached? WYes* ❑ No *All attachments are incorporated into and become a part of this contract ` - Description of dna. ""Ulri w�.1_ N'06A>rr tA?f &01 tict,r Work Schedule": r Approximate Commencement Date: A 15 j3 Approximate Completion Date: u1 W1 13 **The proposed work schedule is approximate and subject to change Contract Price: Total Contract Price: $ 1 , ' ;C( Deposit with order: $ a��C Ct ❑ Cash Balance Due: $ Terms: ❑ Cash C1YFinance (Cash terms are 10% deposit, 50% on commencement, 40% on completion) Due on Commencement I 1 �a, Due on Completion rCheck # 13S %c» x DO NOT SIGN THIS CONTRACT UNTIL ALL APPLICABLE BLANKS ARE COMPLETELY FILLED IN AND UNTIL YOU FIRST READ AND UNDERSTAND THE ENTIRE CONTRACT, INCLUDING ANY ADDENDUM ATTACHED HERETO, AS WELL AS ANY ATTACHED SKETCHES, MATERIAL LISTS OR THE LIKE, AND THE TERMS AND CONDITIONS ON THE BACK OF THIS CONTRACT DOCUMENT. YOU ARE ENTITLED TO A COMPLETE, FULLY EXECUTED COPY OF THIS CONTRACT AT THE TIME OF EXECUTION. Witness our han ,(,$) an se below on this �00 day of T;� `0 LUX Rego,, ti uthorized Representative: Sig Print Name DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES M CustoI6r Signature 7—(�� lV �f Print Name 0 Customer Signature v Print Name Contractor may have certain lien rights in the premises until the price is paid in full. You have the right to cancel this contract, without any penalty or obligation, at any time prior to midnight of the third business day after the date you signed this contract. See the notice of cancellation below for an explanation of this right. ***Customer acknowledges receipt of a true copy of this contract which was completely filled in prior to customer's execution hereof. NOTICE OF CANCELLATION Date You may cancel this transaction, without any penalty or obligation, within three (3) business days from the above date. If you cancel, you will not be liable for any finance or other charges, and any security interest given by you, including any such interest arising by operation of law, becomes void upon such cancellation. In addition, any property traded in, any payments made by you under the contract of sale, and any negotiable instrument executed by you will be returned within twenty (20) business days following receipt by the Contractor of your cancellation notice. If you cancel, you must make available to the Contractor at your residence, in substantially as good condition as when you received, any goods delivered to you under this contract or sale or you may, if you wish, comply with the instructions of the Contractor regarding the return shipment of the goods at the Contractor's expense and risk. If you do make the goods available to the Contractor and the Contractor does not pick them up within twenty (20) days of the date of your notice of cancellation, you may retain or dispose of the goods without any further obligation. To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written notice to: Owens Corning Basement Finishing Division 60 Shawmut Road, Canton, MA 02021 Phone: 781-821-0060 Fax: 781-821-8552 I hereby cancel this transaction. Date Customer's Signature I hereby acknowledge receipt of two copies of this Notice of Cancellation advising me of my right to cancel. j Date Custom r s Signature Date Co -Customer's Signature iK TERMS and CONDITIONS GENERAL DESCRIPTION: By this contract, Customer agrees to purchase and Contractor agrees to sell and install the Owens Corning Base- ment Wall Finishing System and related items identified on the first page of this contract in the above identified premises, for the stated total contract price and according to the specifications and other provisions of the contract documents including (a) this contract form, (b) the Addendum, if and to the extent applicable, (c) any attached sketches, materials lists, floor plans, and/or specifications sheets. SCOPE OF WORK. Contractor shall be responsible to Customer to supply the Basement Wall Finishing System and related products and for the performance of the installation services, as required by the contract. All drywall, wood or other paintable surfaces shall be primed and ready for final touch up and paint. Painting, staining or decorating are not a part of this contract. PRICE. The Price owed by Customer is a lump -sum, turn key price, covering the Basement System and the labor necessary to install it. The Price assumes sound existing substructures, superstructures and points of attachments. The Price shall not include the cost and reasonable profit, as determined by contractor, of having to provide (i) additional products or installation services as a result of defective substructures, superstructures, or points of attachments, and (ii) any additional goods or installation services beyond those originally specified in the contract which are requested or approved by the Customer and reflected in a change order signed by the customer and the contractor. PAYMENT. Payment of the price by Customer is due in full upon the terms set forth in this contract, but in no event later than completion of the work. In the event that the Contractor declares the project completed but the customer still has some reasonable "punch -list" items, it is agreed that the Customer may be entitled to withhold 5% of the total contract price until such items are completed. ENTIRE AGREEMENT/CHANGES. This contract accurately states the entire agreement between Customer and Contractor concerning the Basement System and the work and replaces and supersedes all prior agreements and understandings relating thereto, both oral and written. Any additions or changes to this contract must be in writing signed by the Customer and the Contractor. WARRANTY. Customer is entitled to the product warranty provided by Owens Corning for the Basement Wall Finishing System as well as any other product warranty provided by a manufacturer of other goods or products comprising part of the Basement System installed under this contract. Contractor will provide Customer with any such manufacturer consumer warranty information. Contractor warrants that the work will be performed by Contractor in a good and workmanlike manner. Contractor's warranty for the work shall extend for a period of two (2) years from the date the work is completed or for such greater period as may be required by applicable law governing consumer warranties for workmanship. Customer must give Contractor written notice within the warranty period of any warranty claim relating to the work. Customer agrees that its sole and exclusive remedy against Contractor for a warranty claim is reinstallation in a good and workmanlike manner, including the repair or replacement of any goods or product if and to the extent reasonably necessary to correct the defective work. Customer shall have no other remedy against Contractor for a Warranty claim, including without limitation remedy for loss or damage caused by normal wear and tear, loss or damage which has not been reasonably mitigated, loss or damage caused by intentional or negligent acts, loss or damage caused by acts of God, incidental or consequential damages for lost profits, sales, injuries to persons or property, or any other incidental or consequential damages. CONTRACTOR'S WARRANTY FOR THE WORK SHALL BE IN LIEU OF ANY OTHER WARRANTY EXPRESSED OR IMPLIED, INCLUDING WITHOUT LIMITATION ANY IMPLIED WARRANTY OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. IN CON- NECTION WITH ANY WARRANTY CLAIM, CUSTOMER AGREES, AT NO COST TO THE CONTRACTOR, TO PREPARE THE PREMISES, INCLUDING THE REMOVAL AND REPLACEMENT OF FIXTURES INCIDENT TO THE REPAIR AREA, SO THAT CONTRACTOR CAN CORRECT THE DEFECTIVE WORK WITHOUT UNDUE DELAY. LICENSES, PERMITS, SAFETY RULES, BUILDING CODES, ZONING ORDINANCES, AND OTHER LAWS. Contractor shall be responsible to Customer for assuring that any and all licenses and/or building permits are obtained. If Customer obtains permits on his own, Customer will be precluded from claiming against certain state guaranty funds relating to home improvements. Contractor shall also be responsible to Customer that the contract shall be performed in compliance with all applicable safety rules and all existing building codes, zoning ordinances and other laws. If a change occurs to any applicable safety rule, building code, zoning ordinance or other law which required additional goods, products or installation services to perform the contract, Customer agrees to pay the cost and reasonable profit for such additional items and to execute a resulting change order or new replacement Contract as requested by Contractor. CUSTOMER'S WARRANTY AGAINST VIOLATION OF EASEMENTS, COVENANTS, AND THIRD PARTY RIGHTS. Customer warrants that performance of this contract by Contractor will not violate any existing real property easements, covenants, or rights of third parties holding an interest in the real property being improved. UNDISCLOSED CONDITIONS IN PREMISES: Customer represents and warrants that any defect or weakness in the Premises' structure, substructure, superstructure or points of attachment that might affect performance by Contractor has been specifically and fully disclosed and described in this contract. If any undisclosed defect or weakness is later discovered after performance of this contract has commenced and such defect or weakness makes additional goods, products, or installation services necessary, Customer agrees to pay the cost and reasonable profit for such additional items and to execute a resulting change order or new replacement contract as requested by Contractor. ARBITRATION. If Customer has any questions or complaints regarding the contract, Customer may contact the Contractor whose name and telephone number appear at the top to this contract. All disputes and claims between Customer and Contractor concerning this contract which any party believes cannot be resolved informally, including without limitation any warranty claims, shall be resolved by binding arbitration conducted by a single arbitrator under the auspices, rules and procedures of the American Arbitration Association and in accordance with applicable federal and state arbitration statutes. The arbitration shall be held in the city or county where the premises are located or in such other location as the parties may mutually agree. No discovery shall be allowed except as may be agreed to in writing by the parties. Either party may demand arbitration, and the arbitrators final award shall be issued within ninety (90) days after the service of the arbitration demand on the other party. It is agreed that all arbitration costs shall be borne by the party that does not prevail. REMEDY FOR BREACH. If Customer breaches this contract, Contractor shall be entitled to recover the greater of liquidated damages in the amount of 20% of the total contract price or such actual damages as the contractor may prove. Also, if Customer fails to pay the Price in accordance with this contract, Contractor shall be entitled to recover its legal costs, including reasonable attorney's fees, in connection with arbitrating, obtaining judgment on an arbitration award, or otherwise pursuing Customer for collection. In the event that the Contractor cancels this contract, a written notice will be sent within 30 days of contract date and all deposits or monies on account will be promptly refunded to the Customer. UNAVOIDABLE DELAY OR FAILURE IN PERFORMANCE EXCUSED. Any delay or failure by Contractor in performing this contract because of strike, fire, floods, acts of God, inability to obtain goods, or any other causes beyond the reasonable control of the Contractor shall be excused and shall not be breaches of this contract. MISCELLANEOUS. The contract shall be interpreted under and governed by the law of the state where the premises are located, without reference to its choice of law provisions. If any provision of this contract is contrary to any law to which it is subject, such lawful provision shall be ineffective without invalidating the other provisions which shall remain in full force and effect. All home improvement contractors shall be registered, and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director, Home Improvement Contractor Registration One Ashburton Place, Room 1301 Boston, MA 02108 Tel. (617) 727-8598 MOLD RESISTANCE. Customer acknowledges that although the Owens Corning Basement Finishing Components are designed to resist the development of mold, they are not capable of preventing mold if the conditions for mold growth otherwise exist in the basement. Customer further understands that virtually all basements require dehumidification in order to maintain an appropriate humidity level, and that a failure to dehumidify could result in mold or mildew development in the completed area and upon the contents. By initialing here customer acknowledges that they have reviewed and understand the terms and conditions of this contract: Customer Customer a YToCwon? su�Aas Business egulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Im rovenf t'`. ontractor Registration OWENS CORNING BASEMENT F DANIEL WALSH 60 SHAWMUT RD CANTON, MA 02021 SCA 1 is 20M-05/11 of Consumer Affairs & Business Regulation IMPROVEMENT CONTRACTOR Expiratii OWENS CORNING1;I i" l DANIEL WALSH 60 SHAWMUT RD CANTON, MA 02021 Type: Supplement ':ard ISHING SYS Undersecretary Registration: 137943 Type: Supplement Card Expiration: 1/29/2015 late Address and return card. Mark reason for change. U Address � Renewal ❑Employment � Lost Card License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid without signature 1Vlassatrhusetts - Dc Department if Peiblic S-�� ttctw� Bc).artl of, Build inl; Regulations atoll. Stxndiu Qr;, Construction Supervisor License -License: cS '79893 DANIEL F WALSH: a` fin, ;488 KE'NDALL `RD TEWKSBUJRY 'NIA 01;876..,..lj ` Conunissioiier' Expiration; tp/5/2013 Tr#: 6504r<'" AC01R o'er CERTIFICATE OF LIABILITY INSURANCE F9/13/2012 DDNYYY) 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 Andrew G. Gordon, Inc. 680 Main Street P. 0. Box 299 NAME: NAME: FAX c No Ext: 7 81 - 6 S 9 - A/C No: - - ADDRESS: info@aqordon.com Norwell MA 02061 PRODER CT MUCER Dn: 4440 INSURER(S) AFFORDING COVERAGE NAIC p 9/5/2012 INSURED Bay State Basement Systems, LLC 60 Shawmut Road IN SURERA:Peerless Insurance 24198 INSURER B:Pilgrim Insurance Company 21750 INSURERC:Star Insurance Company 18023 Canton MA 02021 INSURER D: INSURER E: INSURER F: MED EXP (Any one person) $10,000 COVERAGES CERTIFICATE NUMBER: 1448763903 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 POLICY NUMBER POLICY EFF MM/DD POLICY EXP MM1DD LIMITS A GENERAL LIABILITY CBP8512851 9/5/2012 9/5/2013 EACH OCCURRENCE $1,000,000 MERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR 4-101 DAMAGE TO RENTED PREMISES Ea occurrence) $50,000 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/OPAGG $2,000,000 PRO LOC X POLICY JECT $ B AUTOMOBILE LIABILITY ANY AUTO N N PGC10007161409 1/17/2012 1/17/2013 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ I—XX SCHEDULED AUTOS PROPERTY DAMAGE (Per accident) $ HIRED AUTOS X NON -OWNED AUTOS $ A X UMBRELLA LIAB OCCURCU8511953 9/5/2012 9/5/2013 EACH OCCURRENCE $1000000 EXCESS UAB CLAIMS- MADE AGGREGATE $1000000 DEDUCTIBLE $ $ X RETENTION $10000 C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N / A WC0428715 5/24/2012 5/24/2013 X STATU- DTH - E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYE $1,000,000 (Mandatory In NH) ff yes, describe under E.L. DISEASE. POLICY LIMIT $1,000, 000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Sales and installation of Owens Corning finished basement systems %,ER I iFiCA I t HOLDER CANCELLATION Bay State Basement Systems dba Owens Corning 60 Shawmut Road Canton MA 0202.1 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 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD - —t 1 - -- r - - - - L F 1c y_ akoP{ P-40-01- - L - - - Sill ,II -- k --4 - Fo goo TO 511 ea BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: v e/ Date Received O/\pORTH O�St�eo �6r TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other. DESCRIPTION OF WORK TO BE PREFORMED: Please Type or Print Clearly) OWNER: Name: Address: 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: $ �S � � `' FEE: $ Check No.: A4 Receipt No.: NOTE: Persons contr tin with unregistered contractors do not have acces tothe uar fund n' I Signature of Agent/Owne Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ YPE OF SEWERAGE DISPOSAL ublic 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 ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS ■ ■ DATE REJECTED DATE APPROVED ❑■ DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED u Zonin6 Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — For department use ❑ Notified for pickup - Date ........................................................................................................................................................................................................................................................................................................................................................................................................................................ . ......................... Doc.Building Permit Revised 2007 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 /I Location ;� r) Cio aem No. 60�1 Date -0 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ s CHUst Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # j-0 2 0 E;��uilding I�nspector E 5L E c�j 0 MA2 E Cc o C3 Z Con *A CD Ef > ca 0 'o cc CL 00 Lo E 0 T " a LO Cj 3r cn (D T 0, 0 LO C'! T CO 0 co I 0 0 .6 00 r— M o6 m 76 r- C, = m w = = C, IE 2 m 0 2 9 '3= E t2 m 13- L,_ C uj 0 MA2 E Cc o C3 Z Con *A Carbonless ;; NC 3818-50 3 PART PROPOSAL �+^ ` ,? c PROPOSAL SUBMITTED TO: NAME ADDRES s c� L_ t n C Le r-1 f 1 V. e— t•J PHONE NO. WORK TO BE PERFORMED AT: ADDRESS DATE OF PLANS e ARCHITECT DATE J_ �j —6. / J I W propose to furnish the materials -and peVorm h .labor necessary f r the cprnpletion of Mereby MZe /c j� •� (J C/ }/r /� 1Y_4% 46G A4, A f1 fes- } All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifi- •ons cp submitted for a ove work and completed in.a substantial workmanlike manner for the sum of J ollars ($ ) wit payments to be made as follows. Respectfully submitted Any alteration or deviation from above specifications involving extra costs will be executed only upon written order, and will become an extra charge Per over and above the estimate. All agreements contingent upon strikes, ac- cidents, or delays beyond our control. Note—This proposal may be withdrawn by us if not accepted within days. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Date At# 1 0 1 Lk )1 Signature _ r Signature / O,&ORTH 1 4t`eO 'e ti0 a , O — 9 TOWN OF NORTH ANDOVER �9"°•., °'`� BUILDING DEPARTMENT SSqHst 1600 OSGOOD ST BUILDING 20 SUITE 2-36 NORTH ANDOVER MA 01845 978-688-9545 978-688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print DATE / U� JOB LOCATION '2-2- N u lt,% Av,,_�Xo o -sr' . Nt A O � (y S Number Street Address Map/Lot HOMEOWNER JtV ✓\tkA-L_ 0 -IV . w�3 A3 3 1, Name Home Phone Work Phone PRESENT MAILING ADDRESS ZZ It N. Ay,,6 UIjkr City/Town 0 MA 01�&q1�, State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1.) DEFINITION OF HOMEOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is or is intended to be, one or two family dwelling, attached or detached structures attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection pro' edures and requirements and that he/she will comply with said procedures and requirements. , /-\ . n HOMEWOWNER'S SIGNATURE APROVAL OF BUILDING OFFICIAL ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID C DATE(MM/DD/YYYY) T&DVI-1 04/04/07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Michaud, Rowe And Ruscak Ins. 198 Massachusetts Ave ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Andover MA 01845 POLICY EXPIRATION DATE MM/DD/YY Phone: 978 688 8829 Fax: 978 557 2130 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA: Preferred Mutual Insurance Co. 15024 INSURER B: T & D Vinyl Siding INSURER C: Anthony DeBartolo DBA 25 Buco Avenue Methuen MA .01844 INSURER D: INSURER E: COMMERCIAL GENERAL LIABILITY COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, LTR_INSR1 TYPE OF INSURANCE POLICY NUMBER POLI Y FFECTIVE DATE MM/DDIYY POLICY EXPIRATION DATE MM/DD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 100000 COMMERCIAL GENERAL LIABILITY CPP0100528701 PREMISES (Eaoccurence) $ 50000 CLAIMS MADE OCCUR MED EXP (Any one person) $ A X Business Owners 06/21/06 06/21/07 PERSONAL& ADV INJURY $ 100000 GENERAL AGGREGATE $ 200000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OPAGG $200000 POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND- EMPLOYERS' LIABILITY TORY LIMITS ER E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMIT $ SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Siding Installation CERTIFICATE HOLD ER rAMf`FI I ATIMI SAMPLEI I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRA DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Sample for bidding purposes. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. ACORD 25 (2nnl/nR% (DACURD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers nniie2n* Tnfnrm-&*1nv. Name (Business/Organization/Individual): Address: uC0 City/State/Z* A: !J k24t) �14 l�le'W Phone. #: Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other Homeowners who submit this affidavit indicating they aro doing all work and then hire outside contractors nuon must submiojicy information. new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether w not those entities have employees. If the sub -contractors have employees, they must Provide their workers ' comp. Policy number, l win an employer that Is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_,G`�(U� Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: L iw 6'.- /4(/� , ty/State/Zi p� Ci 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 [nvestieations of the DIA for insurance coverage verifirot4— I do hereby use only. Do not write in this area, to that the information provided above is true and correct or town of, jlcla[ IZ���J City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plrrmht.... 6. Other Contact Person: Phone #: Are ou 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 2. ❑ 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. employees and have workers' [No workers' comp, insurance comp. insurance.) required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers, comp, right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp, insurance required] :Any aPPlicant that checks box #1 nasi also fill out the section below showing their workers+ Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other Homeowners who submit this affidavit indicating they aro doing all work and then hire outside contractors nuon must submiojicy information. new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether w not those entities have employees. If the sub -contractors have employees, they must Provide their workers ' comp. Policy number, l win an employer that Is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_,G`�(U� Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: L iw 6'.- /4(/� , ty/State/Zi p� Ci 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 [nvestieations of the DIA for insurance coverage verifirot4— I do hereby use only. Do not write in this area, to that the information provided above is true and correct or town of, jlcla[ IZ���J City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plrrmht.... 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employdrss nompt�e service of another under any contractorkers' compensation for their �of lures Pursuant to this statute, an employee is defined as ...every per 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 partnership, association or other legal entity, employing employees. However the receiver or trustee of an individual, p P+ owner of a dwelling house having not more t than to do maintenance, construction oepair work on such dwelling house apawho resides rtments dwelling house of another who employs persons or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." nc .MGL chapter 152, §25C(6) also states that "every state or local licensing ng agency steal othhod the issua h for anyr renewal of a license or permit to operate a business or to constructbuildings applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for. the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), addresses) 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 permittlicense 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 applicanshould write t 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext.406 or 1-877-MASSAFE liar # 617=727-7749-- ._ Revised 11-22-06 www.mass.gov/dia FNr- {� I 2 • y CA o _o o c O N O 0 V V CL A O. C W O 000-0 sID �v o CD 3 W 0 e Q� W qICDL ' f' ! Q0 �{ m N � w O,l "f'f a E N 3 = O CO I �• :.Cm 0 dot ce W c O aw C7303 r � awm�: m w o cm Go c► o Q � O I c �O x40 m cavo W '3 Z o o .�.cp a m `mc e = m :mCOD 3 N ~ w dim z umiW Cc +� •N dt '!.s Z W E �0 w,o, o C ti aC.2 0 m= o1 z =Go z So.�m 0 w a O O Ca O Ea E O. O C O CD v 1.4 L O is co CLCIO C 0� CM C CD O C CIO m 3� O O L d O O. C Q O 'O O Z s IDCLy C Lij LLI U) ce W 19 W U) C4 a a C�j v 8 cn U r w° a� v G U w W a W U w o z y CA o _o o c O N O 0 V V CL A O. C W O 000-0 sID �v o CD 3 W 0 e Q� W qICDL ' f' ! Q0 �{ m N � w O,l "f'f a E N 3 = O CO I �• :.Cm 0 dot ce W c O aw C7303 r � awm�: m w o cm Go c► o Q � O I c �O x40 m cavo W '3 Z o o .�.cp a m `mc e = m :mCOD 3 N ~ w dim z umiW Cc +� •N dt '!.s Z W E �0 w,o, o C ti aC.2 0 m= o1 z =Go z So.�m 0 w a O O Ca O Ea E O. O C O CD v 1.4 L O is co CLCIO C 0� CM C CD O C CIO m 3� O O L d O O. C Q O 'O O Z s IDCLy C Lij LLI U) ce W 19 W U) ULATIONS . ate: 09/0611955 BirthO RestiicW4 0%_ ANTIWO 25 BUCO AVE,` - METHUEN, MACommissioner`..I' .. " c__--- ' b r