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HomeMy WebLinkAboutBuilding Permit #532-13 - 220 OSGOOD STREET 1/24/2013TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 6�7 _ 1'�) Date Received Z� Date Issued: IMPORTANT: Applicant must complete all items on this page Pnnt` 100Years01d1Structure� yes; no) ,.� s t f. .... - , w 5 of i MAF NO: �.PA RC.EL.=lJv1 ZONING.®,IStTRIC�T;: Hisfonc,D stnet yes; no) Machine;5hop}Village yesa riot TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building KOne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial )gRepair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other [];Septic Well ❑ Floodplain] O V1letlands;' Waterslied'Distriet? Water/Sewer DESCRIPTION OF WORK TO BEP RFORMED: nsra%W rPw C40 N\� �D eoc%swl \4 � c n �renMl vE 1,, \6 Ll v roo M -- IdentificaYo lease Type or Print Clearly) ��� OWNER: Name: ✓ Phone: - ddress: CONTRACT AOR'. Name: i'�'5 �C�ly BCGs Phone., I - 6o 'Add'ress, Qlale Z)6ye Supervisor s Constructi6n, License:; U73 / Expo, Date: __ I _ - -- _ aHome?Improvemenf,License:: i291`77 Exp D- �c %13 ARCHITECT/ENGINEER rJ (fit • Phone: Address: Reg. No FEE SCHEDULE. BOLDING PERMIT. $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED $125.00 PER S.F. 00 Total Project Cost: $ �- �`FEE: $ , Check No.: �Z�So 5240 Receipt No.: NOTE: Persons contracting i unregisteredcon actors'do,not have access to the guaranty fund JkY k ig:nature7ofAgent/Owner Signature of contractor + Plans Submitted Plan 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed on Signature Reviewed on Signature Zoning 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 DPW 'Tovavn Engineer: Signature: FIRE DEPARfmV _ 'f -,Temp Dumpster on si Located at124{Mair Strdet ` Fire Department signatureld "te . , COMMENTS Lo ted 3M Us ood Street %yes ; .. no 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 El Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application u Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses u Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks u Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o 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 VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Li Building Permit Application o Certified Proposed Plot Plan a Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report u Engineering Affidavits for Engineered products gOTE: 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 appal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Building Permit Revised 2012 Locatiop�20 '" S C) " No. Date l-3 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check 26114 Building Inspector L it Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 20,570.00 m $ - $ 246.84 Plumbing Fee $ 30.86 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 30.86 Total fees collected $ 408.55 220 Osgood Street 532-13 on 1/24/2013 Install new kitchen cabinets widen opening to living room CO) m m m X m CA F) v C � CD �a n 0 0 z U) CD 0-0 CL �N � `o 0 <vCD CQ 0 L cr _ CD CD o CD W W � CD CL(ID S• � v cn a CDz CD 0 O CD 0 CD O 0 O S7 z G) Z cn m <_ 0 g 2 _ CD CL 0 m 00 CL 3 m z c z 0' OO�Q• m -ti = c1) CDoo co N c N �• P CD CD o -% D O Q- O yCD c� c3 a N SD �p �� W rt CD C CD S. -1 o cc O `3 m O O ti CQ Z co CD C -% cr O CD Cn .L D �'Ll CL =oma co 2. < m o CL M (nC y �. • CD 00 r D r•r N rt O (MA Lo. W V1 p V1 M z O w C T c M K T 7 :0T O C N z N M 7 Gl V1 1 N (np .Z7 O C S T T r'i v r Z T 7 N ;o O C =r r C 3F z_ Z m n p -n C7 n 3 3 � Z1 O QCQ Q C N ~' O C z n tZil m 0 L 'O N N 3 O O (SD 3 W O v O T 2 m n _ U. i.6mao * 14 r1 - c 01 SID rA v , • c c� I Page 1 of 6 Nexus II Carpentry and Construction Design P.O. Box 2823 Woburn, MA 01888 781760 2031 Fax 978 9751263 nexusca rpentry(a�aol.com www.nexusearl!entry.com CS # - 073991 HIC # 129177 Contract This is a contract between Gerry and Meredith Varcarolis of 220 Osgood Street, North Andover, MA 01845 (Hereafter referred to as the "owners" or "owner") and Nexus II Services (hereafter referred to as "Nexus") dated January 19th 2013. GENERAL SCOPE OF WORK DESCRIPTION WE HEREBY SUBMIT SPECIFICATIONS AND CONTRACT FOR: work as stated below for installation of kitchen cabinets and other projects as listed 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 ♦ All work will be coordinated directly between "owners", architect if required and Nexus ♦ Nexus confirms that it is licensed, insured as required 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. Any items left on site will be covered under Nexus insurances ♦ Owner is responsible for removal and return where necessary of all items within the house and their safe storage prior to our work commencing SPECIALIZING IN QUALI7Y FINISH CARPENTRY, REMODELING, SPECIALIST ROOF SYSTEMS, SITE AND PROJECT MANAGEMENT Page 2 of 6 ♦ Owner will then be responsible for returning all items to the home after completion of the scope of work ♦ Nexus will remove all trash associated with this project into a Nexus supplied dumpster and arrange for safe disposal in to a registered site — if required ♦ Nexus will contact Dig Safe" and confirm all utilities location — if required Scope of work - Kitchen proiect; ♦ Remove and trash the existing tile back splash ♦ Install cabinets and trim supplied by you ♦ Install appliances supplied by you inclusive of refrigerator, microwave with built in fan, disposal, stove and relocating of dishwasher to new layout ♦ Furnish and install vent pipe to sink set up ♦ Furnish and install water feed to refrigerator ♦ Install under cabinet lights (fluorescent) supplied by you ♦ Coordinate counter top installation with your assigned company ♦ Furnish and install sheetrock patches with compound finishes to blend to existing plaster NOTE: Cover all holes in walls to prevent rodent entry, inclusive at floor level behind cabinets r l Mo ♦ Furnish and install ceiling fan &tpr-e supplied by you tACTi . XZgNV k AIc e T ♦ Proposed cost is $6, 000.00 20" aloor �cr�d►.�►� %,•$'• Rear entry hall; ♦ Remove and trash existing ceiling and fixture ♦ Furnish and install new sheetrock ceiling with plaster finish �, oo� ♦ Furnish and install new ceiling light fixture supplied by you -+ wSE' Z ♦ Proposed cost is $325.00 1. S Dining room; ♦ Remove and trash existing closet and shelf unit ♦ Remove and trash the upper shelf unit between the living room and the dining room ♦ Repair walls and apply a coat of skim coat where the closet and 2 shelf units are removed from ♦ Proposed cost is $580.00 General; ♦ Dumpster and permit fees allowance - $300.00 ♦ Electrician to remove cable and phone wires located on existing trim throughout home - $500.00 Living room; ♦ No work at this time SPECIALIZING IN QUALITY FINISH CARPENTRY, REMODELING, SPECIALIST ROOF SYSTEMS, SITE AND PROJECT MANAGEMENT S Page 3 of 6 Sunroom; ♦ Remove and trash 4 pieces of trim on house wall ♦ Remove and trash shelf unit in opening to living room and sun room-'--" o� r4euo one i ♦ Install ceiling fan supplied by you into existing opening in ceiling and utilizing the Sur existing light switch on wall believed to be for this location ♦ Remove existing casing around the opening and prepare for French door installation ♦ Install French door set supplied by you --0. ♦ Install trim detail around new doors ♦ Proposed cost is $1, 580.00 Create larger opening to living room from front entry; ♦ Increase size of existing opening to give a finished width of 36" after trim installation. This cost includes furnish and installation of a new header and jack studs in this area, sheetrock to walls, new trim (noting that any decorative trim will not be an exact match to existing trim ♦ Proposed cost is $1, 000.00 2"d floor bedroom closet • Open floor boards and investigate why the floor has some "give" to it. An easy fix is included in our overall contract cost. Anything beyond an easy fix will be advised. The above quotation does not include the cost of any of the following and in some cases where stated allowances have been given to assist you in selection. If requested, we would be happy to provide any costs on items listed below, if not here stated; Permit costs, unseen conditions, and architect or engineering costs Painting or staining or prep work Upgrades to existing utility conditions or structure Appliances or new interior doors Flooring work at all Cabinets, counters, special light fixtures and under cabinet light fixtures Building inspector upgrades if required upgrades to mechanicals and heating changes All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control owner to carry fire, tornado and other necessary insurance. Our workers are fully covered by Workman's Compensation Insurance. PERMITS "Nexus" has accepted the 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. SPECIALIZING IN QUALITY FINISH CARPENTRY, REMODELING, SPECIALIST ROOF SYSTEMS, SITE AND PROJECT MANAGEMENT Page 4 of 6 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. Dumpsters, trailers 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, including your neighbors, has a need to contact us directly. 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 or sub -contractors. All labor and materials purchased from other suppliers to achieve completion of contract are warranted (1) one year from completion of the construction. Owner appointed sub contractors From time to time an "owner" may request that we incorporate a sub -contractor of the "owners" choosing on a project. "Nexus" will facilitate this request provided the assigned sub -contractor is connected directly with "Nexus" for all scheduling requirements and "nexus" will manage this sub -contractor in a fashion comparable with any other sub -contractor. All sub -contractors must be licensed and insured in accordance with State law. "Nexus" will meet with these sub -contractors and will ask them to submit a written proposal of all the work that will be included which "Nexus" will then confirm with the "owner". "Nexus" will oversee this scope of work and ensure that it is completed in a professional manner but the sub- contractor will be responsible for any future warranty issues directly with the "owners". All sub -contractors SPECIALIZING IN QUALITY FINISH CARPENTRY, REMODELING, SPECIALIST ROOF SYSTEMS, SITE AND PROJECT MANAGEMENT Page 5 of 6 are responsible for the safe and clean upkeep of the working environment and will be responsible to remove their associated trash on a daily basis. Deliveries "Nexus" will be responsible for the safe arrival to site of all materials required for construction purposes for items contained within the scope of work. The "owners" shall be responsible for the safe arrival to site of other items outside of construction materials, however, should "owners" require "Nexus" to collect and bring to site, any of these items, "Nexus" will accommodate as able and add a minimal cost to cover time and fuel to a change order. Allowances with the contract cost Within the cost structure of this contract, certain cost allowances may have been given for the "owners" to purchase items chosen by them — these allowances will be noted above with the amount allowed clearly noted. If the "owners" do not spend the full allowance in an area, this amount will be credited back to the customer and not included in the final contracted amount. If the "owners" spend beyond the allowance noted, then the "owners" shall be responsible for this balance and a payment made to cover this amount either to the vendor, the sub -contractor or to "Nexus" 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. People Authorized to Sign Change Orders: The following people are authorized to sign Change Orders: 4�� ___ - "Nexus": Mark Gotobed or Ged White "O r/Owners". Gerry or Meredith Varcarolis 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. 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. SPECIALIZING IN QUALITY FINISH CARPENTRY, REMODELING, SPECIALIST ROOF SYSTEMS, SITE AND PROJECT MANAGEMENT Page 6 of 6 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. Contract Cost and Payment Schedule: Total cost of work description and materials included in the proposal (except materials/work stated) - $10, 285.00 (Ten thousand two hundred and eighty five dollars and zero cents) PAYMENT SCHEDULE 1st Payment due upon signing this contract AL $5,142.00 2nd Payment due upon cabinet installation TOTAL $3, 000.00 3rd Payment due upon completion of trim installation TOTAL $1,143.00 Final payment due upon completion of scope of work TOTAL $1, 000.00 I have read and understand, and I agree to, all the terms and conditions contained in the proposal above. Date.. �. ?. .. ............. "Nexus" Authorization ............. . Date..j./;-(/`,5 ........ "Owner/Owners" Authorization.... , AND/OR WVDate...l.. �..1.7�.......... "Owner/Owners" Authorization ............... ........... SPECIALIZING IN QUALITY FINISH CARPENTRY, REMODELING, SPECIALIST ROOF SYSTEMS, SITE AND PROJECT MANAGEMENT AD CERTIFICATE OF LIABILITY INSURANCE ltk�8/13/2012 DATE(MMIDDIYYYY) 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 Cross Insurance -Peabody 139 Lynnfield Street Peabody MA 01960 CNT NAMEACT Lauren Goldman PHONE (978)532-5445 FAX (978)532-2217 C No: noAgIELs.lgoldman@crossagency.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A Western World Ins. Co. INSURED Nexus II Services LLC P.O. Box 2823 Woburn MA 01888 INSURERB:Safety IndemnitY 33618 INSURER C National Grancie Ins Co INSURER D,. INSURER E : INSURERF: �wrn•n�cf`COTIrICATIP All IMRCRcL1281370619 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 INSURANCE AD L SUER NUMBER POLIPOLICY MMIDDYEFF IYYYY MWDDIYYYY EX LIMITS LTR TYPE OF GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE T RENTED PREMISES Ea occurrence $ COMMERCIAL GENERAL LIABILITY MED EXP (Any one person) $ 5,000 D NPP8113510 /12/2012 /12/2013 A CLAIMS -MADE OCCUR PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG S 1,000,000 $ LIMIT 7► _ UCY PRO- IFCTLOC AUTOMG ILE LIABILITY Ea (EaS BODILY INJURY (Per person) $ 250,000 \ AUTO BODILY INJURY (Par accident) $ 500 000 B ALL OWNED X71 SCHEDULED 116632 1/10/2011 1/10/2012 AUTOS AUTOS X X NON -OWNED PROPERTY DAMAGE Per accident)$ 100 000 HIRED AUTOS AUTOS Medical payments $ 5,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAS CLAIMS -MADE $ DED RETENTION $ WC STATU-OTH- WORKERS COMPENSATION EACH ACCIDENT $ AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE r--1E.L. E.L. DISEASE - EA EMPLOYE $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L. DISEASE - POLICY LIMIT 1 $ If yes, describe under DESCRIPTION OF OPERATIONS below CIM47109 /27/2012 /27/2013 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) Refer to policy for exclusionary endorsements and special provisions. For Insureds Purpose 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 Tramonte/NIDI .. •i+nen rnnnnow�rrnru wu a..ti�� .e�ar..a.i ACORD 25 (2010105) �... ---- • -_ __... _. _ INS025 oninnai m Tho Ar non nnma 2nr1 Inns era mnia+0M ( m7rlrc of Ar`npn The C®mmon nahth of Massachusetts Departmeh.t of Fire Services Office of the State Fire -Marshal P. 0. Box 102i State Road, Stow, MA 01775 PERMIT .r�lrwz Vriarse.; �''�6K � c� � o/ � North Andover I?erDaitNo Date: ( City of Town) (1f Applicable,) Dig Safe Number in accordance with the provisions of NLG.L.14 8 Chapter_] asprovidecl in secd0n S 7 7 ('MR 34 Start Dace 'Mas Permit is granted to: �� (J s' = r,-r`s-, Fu11 name of person, Firm or Corporation Permissionto locate dumpster for construction/renovation/demolition of building. 'a=erus: dumpster must be. 25' from structure if unable to place with required clearance dumpster must be covered with plywood or tarp end of 'work -day .t �s�-o O�'�oa✓ �S�it E T' . ( Give location by street and no., or descn�be in such manner as to provied adequate identification of location ) C. Paid 50.00 Fire Chief 'his Permit will expire J, - - /3 ( Signature of ofcal granting pernut) Offtcal granting permit ( Title) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Ut. 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name (Business/Organization/Individual): Address: `P 0. and _99_9 1k City/State/Zip: W p\btil' n M6 019W Phone #: —7? ( '760 -2031 j Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ElI am a general contractor and I employees (full and/or part-time).* X,1 have hired the sub -contractors 2. am a sole proprietor or partner- listed on the attached sheet. I 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.] 3. ❑ I am a homeowner doing all work officers have exercised their 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. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs ` 13.04 Other i n&j1 k� Q; 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. P Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site 'reformation. nsurance Company 'olicy # or Self -ins. Lic. #: Expiration Date: ob Site Address: City/State/Zip: lttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of svestigations of the DIA for insurance coverage verification. do hereby certify under the in dpenalties ofperjury that the information provided aboye is true and correct. ianature• Ic -A II;ZII13 Date hone #: % 91 0 ; p3' Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone #• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer" MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to 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, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 61.7-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia 'Aassachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS -073991 GERALD WHITES 23 GLENDALE DR = DANVERS MA 61923 Expiration Commissioner 04/07/2014 -CAT 0 50:1.01104•G101216 i l.01roftwea(�i F1ac(:4t a License or r tstraton valid ul use only ilid for individ Office of Consumer Affairs & 'Hess egtclatlon Y s • HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: � Registration: 129177 Type: Office of Consumer Affairs and Business Regulation ; f =' Ex iration: 7/19/2013 Individual IO Park Plaza -Suite 5170 �u Vic? p Boston, MA 02116 Ge lu While Gerald While / l 23 Glendale Or Danvers, MA 01923 Undersecretary t valid without signature li '21301OH 31V3Id11H30 3HI ONV '2130f10021d HO 3AIIV1N3S3Hd3H a3ZRIOHIt1V '(S)2i3mnSNI JNIIISSI 3HI N33M138 L0VNJLNO3 V 3I(1111SN00 ION S30O 3ONvunSNI d0 3IVOIJUM30 SIHI 'MO138 S310110d 3H1 A8 03U210cl v 3OV83AOO 3HI 21311V 2I0 ON31X3 '0N3WV Al3AIIVJ3N HO Al3AI1VWMIA:IV ION S300 31V31:11I 130 SIHI '21301OH 31VOIJUH30 3HI NOdn SIHDRI ON S213JN00 ONV A1NO NOIIVWMO:IN1 d0 2I31.LVW V SV 03f1SS1 SI 31V3Id1I2130 SIHI ,Akw atww£3iva8 33NvmnSNl All -118d11 -4O 31VOIJ 1133 ®o d R y -,j b d ^C rr 0 � =C .� -Z a ui0 c. � ari X„pQ� a� — � � CL r- CA 0o0 �mm r k -n OT ; w,�-1 �I� O N v W wo DI I w CA) w I: i a 3a O� _ ^C rr 0 � =C .� -Z %% ui0 c. � ari cWD 3c aD yV — � � CL r- CA 0o0 �mm r k -n OT ; w,�-1 �I� O yr 14 G) y aM C < CD M O = O N c4 3 Qo 0) (a rr 0 to m" V O f = = �I cu OD W co IOD to n � ai I � B21 L 1 W W co 00 a) � N 1� �I 'C co W w I 1 � co O m CO) ^C rr 0 � =C .� -Z %% ui0 �D c��n•I k0�=. �� aD yV — �p•o 0-0 I� CA t c� X M -n OT ; w,�-1 �I� ' yr 14 3 CD o cc I 1 � co O m CO) ^C rr 0 � =C CD W %% ui0 �D c��n•I k0�=. �� aD yV — �p•o 0-0 c r, o, 3 y o. t c� X M N Q(D = �. tQ yr 14 3 CD o cc aM C < CD M O = 00 rt c4 3 Qo 0) (a rr y—s to m" V 0. A)y tai O y O y M y S* y tD -w a'��-'� y r" 3 c'D d� a o 0 0 a cQ Q CL m 0 0 to a o �v . o y O y t tD Q. I 1 � co O m CO) ACOROrCERTIFICATE OF LIABILITY INSURANCE L..� D/23/ 201/DD/Y 1/23/3 3 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 Cross Insurance -Peabody 139 Lynnfield Street Peabody MA 01960 CONTACT Lauren Goldman NAME: PHONE (978)532-5445 FAX Noll: (978)532-2217 ApAg1Es:lgoldman@crossagency.com INSURERS AFFORDING COVERAGE NAIC # INSURER A:Western World Ins. Co. INSURED Nexus II Services LLC P.O. BOX 2823 Woburn MA 01888 INSURERB:Safety Indemnity 3618 INSURER C: INSURERD: INSURER E : INSURERF: COVERAGES CERTIFICATE NUMBERCL12112075339 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. ILTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MWDDY/YYYY MOMIIDD� LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A j[ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR NPP8113510 /12/2012 /12/2013 DAMAGE T RE TED PREMISES Ea occurrence $ MED EXP (Any one person) $ 51000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000 X POLICY I PRO LOC1 1 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea acc dent BODILY INJURY (Per person) $ 250,000 B ANY AUTO AALL UTOS X AUTOS 116632 1/10/2012 1/10/2013 BODILY INJURY (Per $ 500 000 500,000 X HIRED AUTOS X NON -OWNED Pe0PER' ntDAMAGE $ 100,000 Medical payments $ 5,000 UMBRELLA LIABOCCUR HCLAIMS-MADE EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB DED RETENTION$ $ WORKERS COMPENSATION WC STATU- I OTH- TORY LIMITS FIR AND EMPLOYERS' LIABILITY Y I N E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N / A E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Refer to policy for exclusionary endorsements and special provisions. t,tK 1 ItIk;A 1 r MULULK k;ANtrtLL.A I IUN (978)975-1263 Gerry Varcarolis 220 Osgood St North Andover, MA 01845 ACORD 25 (2010/05) INS025 r2mnnat m 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 REPRESENTATNE Tramonte/MD1 ©1988-2010 ACORD CORPORATION. All rights reserved. Tho Arrion nnma nnrl Inn^ nra ranictararl mnrka ^f Ar npn