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HomeMy WebLinkAboutBuilding Permit #468-15 - 240 MARBLERIDGE ROAD 11/13/2014Permit No#: 4 `r v ( J Date Issued: 1 LOCATION BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received RTANT: Applicant must complete all items on this 00 T \ 0 _ F o1 H T `� ��A. cocwicwewrtw , 10 *I PROPERTY OWNER NOGG _ ] /� Print 100 Year Structure yesrnoMAP tPARCEL:,V� I� ZONING DISTRICT. Historic District yesMachine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building IW6e family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial P-ifepair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic El Well ❑ Floodplain ❑ Wetlands E Watershed District Water/Sewer _ DESCRIPTION OF WORK TO BE PERFORMED: SNS�L N�.J t^i3t�e✓�7:� ���Nfr Identification - Please Type or Print Clearly OWNER: Name: jc kTt Phone: 6uS 16 31C3 Sw Address: Z-"0 Contractor Name:. -"Phone: _ by -__5'i 2-11-7 Address: i'ZZ!:, Arr-t Supervisor's Construction License G'-'�_. - 09 7.6- xp. Date: 'Z 11— Home- — o- Home Improvement License: x._'78 -Exp. Date:-J1Au ARCHITECT/ENGINEE Phone: Address: — Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST B SFD ON $125.00 PER S.F. Total Project Cost: $ 36� 1 FEE: $ l/,1�/ Z Check No.: Receipt No.: Zz V; NOTE: Persons contracting kith unregistered contractors do not have access to the guaranty fund nature of Aaent/Uwnerl A/Y-.. *tri A•T- _ A15ianatUre 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 o Workers Comp Affidavit Li Photo Copy Of H.I.C. And/Or C.S.L. Licenses o 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 u Workers Comp Affidavit u Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) u 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) u Building Permit Application u Certified Proposed Plot Plan o 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 a Mass check Energy Compliance Report o 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 4 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swumning 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 Reviewed On Signature, Reviewed on Signature Reviewed on Siqnature Zoning Board of Appeals: Variance, Petition N Planning Board Decision: Conservation Decision: Comm Comments Zoning Decision/receipt submitted yes Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street -- FIRE DEPARTMENT - Temp Dumpster on site Yes--, _ Locate&at 124 Main Street - - - Fire'Department signature/date 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 NU i is ana UA I A — (For department use ❑ Notified for pickup Call Emai Date Time Contact Name i..._._....... _—_ Doc.Building Permit Revised 2014 Location 2�0No. A�P� Date o - TOWN OF NORTH ANDOVER o Certificate of Occupancy $ Building/Frame Permit Fee $ "' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 8265 Building Inspector 'eq * - C � O V }, •� L Q iQ �+ s a o • E C. O d • 0 E O7 O C z u J O O oc z U W O W OW. � 2 tail tail of Z U LL Z z d Q O z W o z U Z ~LU 0 o m J W LL N � C fl J W +U T + T O N v z Y o d j! j E m D m _ i m _ j m N O cu 0c c c c LL In LL LL LL K N LL [Y LL m N N - C � O V }, •� L Q iQ �+ s a o • E C. O d • 0 E O7 O C z u Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws, chapter 142A. Homeowner's Signature Contractor's Signature NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself to be financially insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional infonnation about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Consumer Guide to the Home Improvement Contractor Law," contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 (617) 973-8787 or 1-(888) 2833757 If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Bureau of Building Regulations and Standards One Ashburton Place, Room 1301, Boston, MA 02108 (617)727-3200 ort -800-223-0933 For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)734-3114 Massachusetts Home Improvement Contract This form satisfies all basic requirements of the 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. Homeowner Information Contractor Information Name Kate Morgan I Company Name _ PROFESSIONAL BUILDING SERVICES /PETER CIARALDI Street Address (do not use a Post Office Box address)Contractor/ Salesperson/ Owner Name 240 Marbleridge Rd. 9 OLDE WOODE RD City/Town State Zip Code North Andover, MA 01845 Daytime Phone Evening Phone 978-758-6181 Address (must include a street address) SALEM NH 03079 State Zip Code Mailing Address (It different from above) Business Phone Federal Employer ID. or S.S. Number 603-898-2977 45-3129617 Law requires that most ]ionic Home Improvement Contractor Expiration Date Improvement contractors have a valid reg. number Registration number CS97650 7/15 The Contractor agrees to do the followi g work for the Homeown r: (Describe in detail the work to completed, specifying the type, brand, and grads of materials to be used, usl additional sheets if necessary.) Reference Professional Building Services Estimate #2172 & #2175 Required Permits - The following building permits are required Proposed Start and Completion Schedule - The following and will be secured by the contractor as the homeowner's agent, schedule will be adhered to unless circumstances beyond Owners who secure their own permits will be the contractors control arise excluded from the Guaranty Fund provisions of Week of 10/20/14—Date when contractor will begin contracted work. MGL chapter 142A.) 11/12/14 Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of. _$36,869.50 (*) Payments will be made according to the following schedule: $_ 12,289.00 upon signing contract (not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater) $ 6,146.00 upon James Hardie stock delivered $ 6,146.00 upon house stripped, wrapped and deck demo -ed $_ 6,146.00 upon trim finished $ remainder 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 $_N/A to be paid for N/A ordered before the contracted work begins in order $N/A to be paid for N/A to meet the completion schedule.(**) 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 Yes (all terms of the warrantv must be attached to the contract) Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless of the 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 under this agreement. Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply 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 unclear. Make sure 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 One Ashburton Place, Room 1301, Boston, MA 02108 or by calling 617-727-3200 or 1-800-223-0933. • Does the contractor have insurance? Check to sec that your contractor is properly insured. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the 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 of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of the contract must be completed and signed. One copy should go to the homeowner. The other copy should be kept by the contractor. R7111�1 Homeowner's Signature Contractor's Signature 11/13/14 09/17/2014 Date Date � � « ,.» t72 � � « � t72 ii c z Ci CL W :0 pro O < CL 5 �2 to rn a LU IM -j 0 CL UJ Z 0 -XII-M-El"Au < o Ail ou)) l 'til 11, w G7 O LU UJ U- LU UJ 000 0 < 0- CL in m 0 CL 0 cr c z Ci CL W :0 pro O < CL 5 �2 to rn a LU IM -j 0 CL UJ Z 0 -XII-M-El"Au < o Ail ou)) l 'til 11, w A uj LU UJ tt� Z0. W :0 pro Z 0 CL 5 �2 to rn a LU IM -j 0 CL UJ Z 0 -XII-M-El"Au < o Ail ou)) l 'til 11, z A uj LU UJ U- LU UJ 0 < 0- CL in m Professional Building Services by PMC, LLC Kate Morgan 240 Marbleridge Rd North Andover, MA 01845 Professional Building Services by PMC, LLC 9 Olde Woode Road Salem, NH 03079-1863 (603)898-2977 info@professionalbuildingservices.com www.professionalbuildingservices.com Estimate Date Estimate No. 08/02/2014 2172 Exp. Date 08/16/2014 Sales Rep MB Activity Quantity Rate Amount • Building Pen -nit - Administration Fee 0 375.00 0.00 Home owner can pull building permit themselves. If customer wishes Professional Building Services to pull permit, please add $375. **Fee is for the initial process of obtaining building permit with the building inspector s office and retrieval of that approved permit so project can begin. Any additional requirements mandated by the municipality such as conservation committee onsite visits or board meetings, will be an additional fee. ** Customer to reimburse Professional Building Services cost of permit fee paid to Town/City. ** • Building Permit Fee paid to Town/City - TBD 0 0.00 0.00 This fee to be reimbursed to Professional Building Services or customer can pay directly to municipality Continue to the next page Page 2 of 2 Activity Quantity Rate Amount • Remove and dispose of existing decking and railing and dispose 164 35.00 5,740.00 Replace with Trex Transcend flat post caps, skirts and 4x4 posts. Trex Transcend decking- grooved. Not picture framed. No fascia and stair risers to be wrapped with PVC. Will use hidden fastener system and color matching screws where necessary. Replace existing foot print with decking. Frame to remain in place. Deck color - TBD. Non- Tropical Colors • 20 yard dumpster with 3 tons. If additional dumpster needed, customer agrees to 1 550.00 550.00 pay for additional dumpster or dumping fee. • Stairs: 4 260.00 1,040.00 Stair tread stringers to be installed 12" o.c. with Trex Transcend matching decking and PVC on risers. Price per tread $260 • Lattice: 0 250.00 0.00 Will install privacy lattice around bottom of deck as an upcharge if requested. Will frame with pressure treated wood Will use PVC to trim out Price per section • Trex lighting pricing: 0 0.00 0.00 Post cap $75/light Riser light $24/light Recessed deck lights $24/light Side post light - $50/light Labor to install - $30/light Transformer with timer switch - $259 • Transcend decking and porch planks installed by TrexPro Platinum's in 2012 (and beyond) will receive a free 2 year labor warranty from Trex upon project registration. When installed over Trex Elevations Steel Deck Framing, this coverage will be extended to 5 years. • CONCEALED CONDITIONS: This Agreement is based solely on the observations 1 0.00 0.00 Contractor was able to make with the structure 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 the proposal was bid, Contractor will stop work and point out these unforeseen concealed conditions to Owner so that Owner and Contractor can execute a Change Order for any Additional Work. • ROT REPAIR - remove, dispose, purchase and install 4x8 plywood - $100/sheet 1 0.00 0.00 Structure/frame repair - $65/hr for Master Carpenter $30/hr for laborer Materials receipt to be provided plus 15% for administration fee i THANK YOU ! We appreciate the opportunity and look forward to working Total $7,330.00 with vnn nn ,n— n —;— —;—t Accepted By Accepted Date Professional Building Services by PMC, LLC ress Kate Morgan 240 Marbleridge Rd North Andover, MA 01845 Professional Building Services by PMC, LLC 9 Olde Woode Road Salem, NH 03079-1863 (603)898-2977 info@professionalbuildingservices.com www.professionalbuildingservices.com Estimate Date Estimate No. 08/02/2014 2175 375.00 Exp. Date 08/16/2014 Sales Rep MB Activity Quantity Rate Amount • Building Permit - Administration Fee 0 375.00 0.00 Home owner can pull building permit themselves. If customer wishes Professional Building Services to pull permit, please add $375. **Fee is for the initial process of obtaining building permit with the building inspector s office and retrieval of that approved permit so project can begin. Any additional requirements mandated by the municipality such as conservation committee onsite visits or board meetings, will be an additional fee. ** Customer to reimburse Professional Building Services cost of permit fee paid to Town/City. ** • Building Permit Fee paid to Town/City - TBD 0 0.00 0.00 This fee to be reimbursed to Professional Building Services or customer can pay directly to municipality • 30 yard dumpster with 4 tons. If additional dumpster needed, customer agrees to l 675.00 675.00 pay for additional dumpster or dumping fee. I I Continue to the next page i ! i i I Page 2 of 2 Activity Quantity Rate Amount • Total Coverage: 29 1,050.00 30,450.00 Strip all siding down to exterior sheathing and dispose Strip all window and door trim and dispose Strip all fascia and soffit and dispose Install Vycor (or equiv) wrap around all wndows and doors. Install James Hardie House Wrap around entire dwelling and tape all seams Install James Hardie Hardieplank Cedarmill painted fibercement siding to manufacturers specifications. Standard paint color - James Hardie Color of Choice Trim color - Arctic white Reveal = 5" Corner boards - 4" fibercement boards Hardie fascia & soffit replacement included Window trim -4" fibercement boards on top and sides. Window sill to be standard PVC sill • ELECTRIC: 1 300.00 300.00 Electrician to remove and reconenct electrical panel to code. Siding will be installed behind panel. Estimate does not provide for any alterations to or upgrades of the electrical systems or wiring found to be defective, deficient or illegal at the time such discrepancies may be discovered during the course of the project • Gutters & downspouts Price per L.F. 0 12.25 0.00 • R&R Vinyl Shutters per pair 0 75.00 0.00 • CONCEALED CONDITIONS: This Agreement is based solely on the observations 1 0.00 0.00 Contractor was able to make with the structure 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 the proposal was bid, Contractor will stop work and point out these unforeseen concealed conditions to Owner so that Owner and Contractor can execute a Change Order for any Additional Work. • ROT REPAIR - remove, dispose, purchase and install 4x8 plywood - $100/sheet 1 0.00 0.00 Structure/frame repair - $65/hr for Master Carpenter I $30/hr for laborer Materials receipt to be provided plus 150/. for administration fee _ $31,425.00 THANK YOU ! We appreciate the opportunity and look forward to working SubTotal with you on your upcoming project. --- Discount (6%) $ -1,885.50 Total: $29,539.50 Accepted By Accepted Date The Commonwealth of Massachusetts - Department of Industrlgl Accidents Office of Investigations 600 Washington. Street Boston, MA. 02111 www mass gov/dia Workers' Compensation Insurance .Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): �ll r7 3,c��/� t�"L. 51A U71 AJ7, SLS rpt C 1✓ 5 Address: '0-:;a RcZ�c Ny-t�t City/State/Zip: Dy—a g_ q AM- Phone #: 6D; S--1 S 2-9 -7 -7 Are you,,an employer? Check the appropriate box: Type of project (required): 1. , am a employer with 4. ElI am a general contractor and 1 6. E]New construction F employees (full and/or part-time).* have Hired the sub -contractors r 7 'modeling 2. El am a sole proprietor or partner- listed on the attached sheet. t ship and'have no employees These sub -contractors have 8. ❑ Demolition working forme in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5. El We are a corporation and its 10. ❑ Electrical repairs or additions required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] i employees. [No workers' 13.❑ Other comp. insurance required.] 'Any applicant that checks box #1 must also fill outthe section below showing their workers' compensation policy information. i -Homeowners who submit this affidavit indicatingthey ate doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and joh site information. Insurance Company Name:. 11 il.i^AYZ i c -L— I ,/ii5. -5M2- - fir\,_ C__ Policy # or Self -ins. Lic. #: U W %Z- 4.l? f !j�O !I Expiration Date: g Job Site Address: ifyLa C € 4i� City/State/Zip: lJ iM A C_:l g'-( Attach a copy of the workers' compensation -p olicy 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 maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby cergfy under the pains andpenalties ofperjury that the information provided above is true and correct. U 113.)1 Phone #: 60�5 S- q S 7-9 "7 1 v Official use only. Do not write in this area, to he 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 j oint 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 employes." 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 ofpublic 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 maybe 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 anal fax number: Tho Commonwealth ofMam..,d- usetts Department of Musfiarial. Accidents Office ofIa--vestigat�ion,% 6,00 washiugtoa Street Boston, MA 02111 ` QL 4 617-727-4900 at 406 oz 1-577-MASSAFB Revised 5-26-05 Fax 4 617-727-7749 www.=ss,gc VMa.. ,4� �� CERTIFICATE OF LIABILITY INSURANCE 9;18;2 D14YY) 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 Financial Insurance Services Inc PO Box 950 Derry NH 03038 CONTACT Patricia Blais NAME: PHONE (603)432-6414 FAX No): (603)432-3852 AEbmpAg'LESS:pblais@fisins.com INSURERS AFFORDING COVERAGE NAIC ;t INSURERA:National Grange Insurance Co INSURED Professional Building Services, LLC 9 Olde Woode Road Salem NH 03079 INSURER B:Hartford Insurance Company INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:14-15 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 ADDL SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FE OCCUR Sam Fragala/PAT 14PT1630H /5/2014 /5/2015 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 500,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS BIT1630H /5/2014 /5/2015 (CEO accideDISINGLE LIMIT 1,000,000 000000 BODILY INJURY (Per person) $ BODILY INJURY (Per acddent) $ PROPERTY DAMAGE $ Per accident Medical payments $ 5,000 UMBRELLA LIAROCCUR EXCESS LIAB HCLAIMS-MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A I 04WECLB1809 I /5/2014 /5/2015 WC STATU- I OTH- TORY I IMITS EEL E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - FA EMPLOYE $ 100,000 E.L. DISEASE - POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION ACORD 25 (2010/05) INS095 rgmnnsi m ©1988-2010 ACORD CORPORATION. All rights reserved. Tho annon namo anrt Innn tiro ronlotororil maria of annon SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Kate Morgan ACCORDANCE WITH THE POLICY PROVISIONS. 240 Marbleridge Rd AUTHORIZED REPRESENTATIVE North Andover, MA 01845 Sam Fragala/PAT ACORD 25 (2010/05) INS095 rgmnnsi m ©1988-2010 ACORD CORPORATION. All rights reserved. Tho annon namo anrt Innn tiro ronlotororil maria of annon