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HomeMy WebLinkAboutBuilding Permit #758-15 - 233 MAIN STREET 4/6/2015Vt RTfi w Of wt�ao 16 �N t [[ BUILDING PERMIT ` 44 AMA `6 Lt- TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATI N41 Permit NO: Date Received �} I Date Issued: ko,ss~cHus�t IMPORTANT: Applicant must complete all items on this paRe LOCATION c 3 J zm a I /U 5tz_eel_ Print PROPERTYOWNER/'aa A, /%vri,,cn % V-5fee 6f 2le- n")AYMC_y loa:ice7;Cc67- Print MAP NO: o�PARCEL��_ ZONING DISTRICT: Historic District yes <iD Machine Shop Village(—v—es-) no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ❑ One family ❑ Addition 0 Two or more family 0 Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement XAssessoryBldg 01Ze ❑ Others: ❑ Demolition ❑ Other ❑ Septic 0 Well ❑ Floodplain ❑ Wetlands ❑ Watershed District 0 Water/Sewer rA Identification Please Type or Print Clearly) OWNER: Name:/iana ,4. l<avImITA{ % s�C-e Qt1lC e�,Phone: 9ZL Address: 0 CONTRACTOR Name: 9 -7,q Phone: 7/9 611!W1 ,7"4Ce» 57'2 c-H&,o LZ C Address:13 01911 toyen Se - /P n-, /U 6,367y Supervisor's Construction License: Exp. Date: C�5 -� 106103 101103 Home Improvement License: / 7vl 062 y Exp. Date: S ``V/2 0 /4 00J_�'? ARCHITECT/ENGINEER 1.1,u;�2ence // 061 -den' PZ-� Phone: 9 X 57' 3S.z — 83/, Address: /9'5 ,Ca5T-0 &eoage76wa rnA O>VJ Reg. No. 27765 FEE SCHEDULE. BULDING PERMIT: $12A0 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 4 . 0, a 00 FEE: $ (D Ga •68 Check No.: k 21"")(10Receipt No.: abutiq NOTE: Persons contr ding with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature pf contractor )1 'q r 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 ❑ PLANNING & COMENTS THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED ❑ ❑ CONSERVATION ❑ ❑ itt t IS' >7111�5' " COMMENTS f\M > \ r,,,.cL , rl\k A c , It -A HEALTH COMMENTS ❑■ DATE REJECTED DATE APPROVED Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes a Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site Located at 124 Main Street Fire Department signature/date COMMENTS 1 4. e Dimension *. q Number of Stories: / Total square feet of floor area, based on Exterior dimensions.J�� 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) &,(,/ Cdw ❑ Notified for pickup - Date Doc.Building Permit Revised 2012 C 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products 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 ❑r 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: Building Permit Revised 2014 Location No.�� Check # t r 2Cv1�s Date �P TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee $ 1 TOTAL $ Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 50,200.00 m $ - $ 602.40 Plumbing Fee $ 75.30 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 75.30 Total fees collected $ 853.00 233 Main Street 758-15 on 4/6/2015 24x48 garage MAIN STREET NOTES 1. SEE TOWN OF NORTH ANDOVER ASSESSORS MAP o #31 LOT #3 AND DEED BOOK #2388 PAGE #150 o E.N.R.D. FOR SITE, U 00 0 cl U OF Atte. �r- u00� STErN StP*114 SCI ' 12/22/14 STEPHEN E;; STNPIKI, R.L.S. DATE PLAN OF LAND IN NORTH ANDOVER, MASSACHUSETTS DRAWN FOR KARA A. KAUFMAN, TRUSTEE OF THE MARKEY FAMILY TRUST OF SEPTEMBER 21, 2010 233 MAIN ST. NORTH ANDOVER, MA 01845 SCALE: 1"=30' DATE: DECEMBER 22, 2014 0 15 30 60 90 MERRIMACK ENGINEERING SER UCES 66 PARK STREET ANDOVER, MASSACHUSETTS 01810 sMo 04 0 ER * Z J i p 0Q m c u Y \ O LL E(31 h `n U fl_ (n p LU N Z Z m C O Y m 'O =5 LL _C D LL' ] v C V LL O uj CL Ln Z Z d -C D w @ LL 0 LU `^ Z U U W J W L V V1 m l- LL O W Z t j N LL' ca C LL Z LU w W W o m O Z - N N + N N O N 0 Jr ;, -1 v 1 1, 1 d u � Y= O <u W J< "o Q h 'NG0 ;o VS O m 0 •� L CL4) �a O Na r cn d r+ 0 c c ca glow:Cl)� c� L cn CD � > Cc CDCc L C N d O : )> t � c, 4a E o 0 m �CL Cn z c o y O O t •y = E. Coo L Q CL a) WL a+ � +� O cc r tm O O c CD CD N d V m c O O O N ++ cv> O N •� yam•,. .2 V E v � c 0i Q O 'a d cn m p c t $ CLoCU Y. O w CO Z Z 0 m V/ cfl Z V W x Z UJ v H C a w LLI —i CL Z w FO— -� .a m L- L - 0 o rmL C. CF) Q J � CL O � Z � VI a gs , 4 1 01 �, Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements ofthe state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of "A Massachusetts Consumer Guide to Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Name CompanyN e e �o� c a. Cr > rn ell vc�-i' o.J Street Address (do not use a Post Office Box address) Contractor/ Salesperson/ Owner Name Cityrrown State Zip Code Business Address (must inc lode a street address) 3 Daytime Phone Evening Phone Cityrrown State Zip Code 9V,,r 661 Mailing Address (It different from above) Business Phone I Federal Employer ID or S.S. Number Home Improvement ConhactorReg.Numher Eaphation date raw requires that most home Improvement mntr�ctors have .a na reghcrooan nnmhu �� 0,-2- The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed, specifying the type, brand, and grade of materials to be used, use additional sheets if necessary.) S,,�- 4-110 ck m e&)F� Required Permits -The following building permits are required Proposed Start and Completion Schedule -The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be r excluded from the Guaranty Fund provisions of t5 /y Date when contractor will begin contracted work. MGL chapter 142A.) D� Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule QD The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of J, Ot • C> o (*) Payments will be made according to the following schedule: $ /0 DD , upon signing contract (not to exceed 1/3 ofthe total contract price or the cost ofspecial order items, whichever riis greater) $ r C il,by / / or upon completion of ti�J a 1f lj/' N�!' P•2 y ) tQj $ by ___L_L_ or upon completion of $� upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to paid for NOTES: (*) Including all finance charges (**) Law requires that any deposit or down -payment required by the contractor before work begins may not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty -Is an express warranty being provided by the contractor? ❑ No Ekes fall terms of the warranty must be attached to the contract) Subcontractors -The contractor agrees to be solely responsible for completion ofthe work described regardless ofthe actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor tinder this agreement Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not haply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is tmclear. • Make stye the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to see a copy of a "proof of insurance" document. • Know your rights and responsibilities. Read the hnportant Information on the reverse side of this form and get a copy ofthe Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight ofthe third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. e DO NOT SIGN Two identical copies ofthe cont 'T IF THERE ARE ANY BLANK SPACESM One copy should go to the homemvner. The other copy should be kept by the contractor. i Contractor's SignatTr�r Date �?y JEFF PELLETIER CONSTRUCTION LLC 13 Clark Avenue Salem, New Hampshire 03079 Richard & Kara Kaufman 233 Main Street N. Andover, Massachusetts 01845 March 28, 2015 CONTRACT Garage construction at 233 Main Street, N. Andover, Massachusetts Jeff Pelletier Construction LLC will obtain a building permit (except electrical permit), and act as General Contractor for purposes of erecting a 24' X 48' garage at the property of 233 Main Street, N. Andover, Massachusetts. Duties include scheduling and supervising sub -contractors such as Excavation Company, concrete company, framing company, garage Door Company, and any other subcontractor needed to complete this project. Jeff Pelletier Construction LLC to provide materials to complete framing, roofing, and siding. Jeff Pelletier Construction LLC is to finish exterior of garage with roofing and vinyl siding to match existing house as best as possible. No interior finishes are included in this contract. Jeff Pelletier Construction LLC will provide a dumpster for construction debris and a portable toilet for use of construction personnel. Excavation Company, concrete company, and electrician to be paid directly by Richard Kaufman. ESTIMATED COSTS $50,200.00 Payment schedule for Jeff Pelletier Construction LLC $ 1,000.00 1s' Deposit for permits (PAID) $16,000.00 2nd Deposit due upon obtaining Building Permit $17,200.00 Due upon project completion/Final Inspection NOTES: 1. Jeff Pelletier Construction LLC will not be responsible for any extra costs involving site work or concrete work due to any unforeseen circumstances. 2. Jeff Pelletier Construction LLC will not be responsible for any damage to driveway, lawn or any other property by any construction vehicles including but not limited to excavation equipment, dump trucks, concrete trucks, cranes, lulls, or delivery trucks. 3. There shall be no guarantee in cracks in concrete. All measures of prevention will be taken such as good compaction, rebar, fiber mesh and control joints. 4. Garage doors will be metal clad R-11 insulated and have no glass. 2 doors will have openers with remote operation. One will be manual operation. Jeff Pelleti/ A/ — Richard Kaufman 33dT- Date ate April 4, 2015 WARRANTY, All materials and workmanship on the garage structure to be Built at 233 N. Main Street, N. Andover, Ma shall be warranted by Jeff Pelletier Construction LLC for a period of one year. Warranty starts on the date of the final inspection by the N. Andover Building Department. Damage resulting from storms, floods or any other act of nature is not covered. There is no warranty on cracks in concrete as mentioned in original contract. Jeff Pelleti r Date Jeff Pelletier Construction LLC Richard Kauf ' an- Owner The Commonwealth of Massachusetts Department of IndustrialAccidents b I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): N" Address: J CZd tz/g 4l/-6 City/State/Zip: SG l ej "1 Al vyPhone � / #: G 3 �/ S` ' 27 ��J Are you an employer? Check the appropriate box: 1.Q I am a employer with employees (full and/or part-time).* 2.0 II aim a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6. Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of roject (required): 7. O'f4ew construction 8. 0 Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.0 Electrical repairs or additions 12.0 Plumbing repairs or additions 13.0 Roof repairs 14.E] Other *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers" compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pain nd penalties ofpeijury that the information provided above is true and correct Signature- % -/'. __1 Date. /7//,% / /-5— Phone #: ("ice Cf-; _ y -.(- 9 S ' l c t 1 9 7 5F X) -5— 6" 6 V / Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): ; 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact 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 -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia NORTI/ 3? w 9 Town of North Andover WVIOXI• _ t '-s ' Machine Shop Village Neighborhood Conservation District Commission o:� �• 1600 Osgood Street North Andover, MA 01845 'rSAp1U5E� Certificate to Alter Date: /8 pe- I q Contact Name & Address: aic ha,rd r.aurm&A, Z33 Mato S -F NovFk 40ttovu- fK44 o(S-�t Project Address: .S 0-4**'� Project Description (attach additional pages, if needed): See Commission Vote: f ' Voted q too to grant /deny Certificate to Alter on Comments (attach additional pages, if needed): Signed 6�nwc "' no J Machine Shop tillage Neighborhood Conservation District Commission MSV NCDC Page 1 Scanned by CamScanner a i x nil 1 N �� �yyZ��C SpW<O yNW 4L LLy I nner va>wcn� w Mauwol vro A nw wmnam a1oraroay.iw ., f Ovmonats CWA)13ve ►+siwv aero aomois e a i x nil 1 N �� �yyZ��C SpW<O yNW 4L LLy I nner jd) )k I� §(k / (){ SOO ¢§k -0-M mm X, §)k Ac PE SO - \ 1 �- T 31 - 3K§ m§\ 2 2( k z®w - - _° `9 , 2;;� R3 /�k \� }/ �� j�V� �\ ;OMD ( ) ¢s « @ m ,Q Fw (Z § �! §2 C, j( A §� \ It - DOUBLE WIDE k \ - ) ( � `Q § ~ § - DOUBLE WIDE _» _IM m Euc2Es `Q ~ § �.PAI� --- - ------------- m! Ov �L^ W 4 ---------------- ARM m 1 vmm Mm faefsrae igZ 5 '-1fmlIIiY� p3c S 9 aamm® a$ o YIi.Mm<6 ?HIM 3; mT m M. m 1 m� oC 'sic '0 ru h y�pfnnip� I�j Z_ZNAA p0 O A� Zz ,ym =� pv0 C� m D� z m c K LiQ Os mm O mC1 gO�r � ma m m Dy. Dm • i z� o n m S z m igm z 11 po m! Ov �L^ W T 11 m m 1 vmm Mm Fo igZ AMISH BACKYARD STRUCTURES ���,+� p3c S m� �p a$ o YIi.Mm<6 ?HIM 3; mT m M. m 1 m� oC 'sic '0 ru h y�pfnnip� I�j Z_ZNAA p0 O A� Zz ,ym =� pv0 C� m D� z m c K mmom I.. Os mm O mC1 gO�r � ma m m Dy. Dm m� z� o n m S z m igm z m izi z I 0 8 0 0m M I m a aN o p CD �g 0 Z $Z s S au�e'OOum F WNE AMISH BACKYARD STRUCTURES S swumlAt YIi.Mm<6 s a ZURICH WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6ZZUB-4885P86-7-14) RENEWAL OF (6ZZUB-4885P86-7-13) INSURER: AFRICAN ZURICH INSURANCE COMPANY 1 NCCI CO CODE: 80012 INSURED: PRODUCER: JEFF PELLETIER CONSTRUCTION, DESANCTIS INSURANCE AGCY LLC 100 UNICORN PARK DRIVE 13 CLARK AVE WOBURN MA 01801 SALEM NH 03079 Insured is A LIMITED LIABILITY COMPANY Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 10-19-14 to 10-19-15 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: NH B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE EXCLUDED - REFER TO RESIDUAL MARKET LIMITED OTHER STATES INSURANCE ENDORSEMENT PIC 00 03 26 D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OFISSUE: 10-17-14 WC ST ASSIGN: NH OFFICE: ZURICH-ORLAN 809 PRODUCER: DESANCTIS INSURANCE AGCY 7853S Massachusetts -.Department of Public Safety Board of Building Regulations and Standards Construction Super%isoi License: CS -106103 *� %.-I FS JEFFREY P PEI'LETIER - r�r. 13 CLARK AVENUE Salem NH 03,079 =. r Expiration Commissioner 12/03/2015 �1ie �po�rwmo�ntueccltfi o�C> �ac�c�2eu�el�I Office of Consumer Affairs & Business Regulation I ME IMPROVEMENT CONTRACTOR o egistration: 172024 Type: xpiration: 5/1412016 Individual i JEFFREY P PELLETIER JEFFERY PELLETIER 13 CLARK AVENUE SALEM, NH 03079 Undersecretary i i 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 WNoIWOithout signature JEFF PELLETIER CONSTRUCTION LLC 13 Clark Avenue Salem, New Hampshire 03079 Richard & Kara Kaufman 233 Main Street N. Andover, Massachusetts 01845 March 28, 2015 CONTRACT Garage construction at 233 Main Street, N. Andover, Massachusetts Jeff Pelletier Construction LLC will obtain a building permit (except electrical permit), and act as General Contractor for purposes of erecting a 24' X 48' garage at the property of 233 Main Street, N. Andover, Massachusetts. Duties include scheduling and supervising sub -contractors such as Excavation Company, concrete company, framing company, garage Door Company, and any other subcontractor needed to complete this project. Jeff Pelletier Construction LLC to provide materials to complete framing, roofing, and siding. Jeff Pelletier Construction LLC is to finish exterior of garage with roofing and vinyl siding to match existing house as best as possible. No interior finishes are included in this contract. Jeff Pelletier Construction LLC will provide a dumpster for construction debris and a portable toilet for use of construction personnel. Excavation Company, concrete company, and electrician to be paid directly by Richard Kaufman. ESTIMATED COSTS $50,200.00 Payment schedule for Jeff Pelletier Construction LLC $ 11000.00 1t Deposit for permits (PAID) $16,000.00 2nd Deposit due upon obtaining Building Permit $17,200.00 Due upon project completion/Final Inspection NOTES: 1. Jeff Pelletier Construction LLC will not be responsible for any extra costs involving site work or concrete work due to any unforeseen circumstances. 2. Jeff Pelletier Construction LLC will not be responsible for any damage to driveway, lawn or any other property by any construction vehicles including but not limited to excavation equipment, dump trucks, concrete trucks, cranes, lulls, or delivery trucks. 3. There shall be no guarantee in cracks in concrete. All measures of prevention will be taken such as good compaction, rebar, fiber mesh and control joints. 4. Garage doors will be metal clad R-11 insulated and have no glass. 2 doors will have openers with remote operation. One will be manual operation. Jeff Peet' r Date Richard Kautman 45 ate rA a� J = p p O m t U Y O N Q LU Z Z Z 1 m O O F O T U O W Ln a0.LLI Z D d Z) 0 W Z j u U W W L U ? O: ,n Z Q � ra z W Q W W a: LJ. i z v a N 0 N 0 D Jr LTO LU am O CL N N .2 CD w CD m O C" C 0 N N _ O z O Q J O O W a U) z 0 in CO 0 to Z Cf) CO_ CO Q. 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