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HomeMy WebLinkAboutBuilding Permit #80-13 - 25 CAMDEN STREET 7/31/2012TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building Une familo Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other 2, -�Wfe e0tic'-­" 11--;"-V 1Floodplain-, V, I et ands" W. at&rsh6d',Distri6t 'qv (/Sewer'-,�" DESCRIPTION OF WORK TO BE PREFORMED: #WNER: Name: J, i '� S Address: c2 �ala�,>1 'CONTRACTOR' upe7 ry )or --AC trudt s on ficense , is rv� Vv Horiei.m.prove f License: ARCHITECT/ENGINEER Type or Print Clearly) an Phone:_ Exp Phone: - 9W- �, "_ 1�0c;2_ ( Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: FEE: $ Check No.: al Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access t g ran fund Signature of Agp6VNvner , nature of contr c Location Q K No. - Date 1 Check # 1 -Z y J- 25562 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $� — Foundation Permit Fee $ Other Permit Fee $ TOTAL $_ I I � 1(1�= Building Inspector Plans Submitted ❑ } Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TypF OF SEWERAGE DISPOSAL Public Sewer ElTanning/Massage/Body Art ElSwimming 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 Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS { Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located Jd4 IRE'DEPART EM NT F= Temp umpsterronpsite t�yes ,: L)c ��cated►1.24Mairi`Strdeet: z i'eillp17. epartments grrature%elate s -_. Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions.. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 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 �v Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract - -- - ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 id 0 Q LL O Q O m Y O LL E N LnN u UJ {n 0 Z Z 0 C -o O LL s O W 47 c t U C LL p LLJ a Z Z m d t O= d' LL O a Z V F.. U W s O d' u O (n c LL OLLJ0 d Z Q C7 s O C LL W W OC cu 7 m Z ' N v Y {n **wwn p o C V v :: W 0 U O• rte-. Z � � L 'ry Z M O 1, rr 0 ai r S E :� Z O. r `` L w m 0 N G P 1NG0 Q. �. � i � •� m m O OCL M E — 4� v, W O � aN o� v0 O .a �Q c CL x Z 0 .�� O W 0 CL � C C p O O Mn _ W (acc ��.N3 c WJ a0 :5 aZ .QO :nQ-.°'NZ V 0_ CO d v 0 Q I V O C Q L L cuCL o H W 0.V m N W_ _ '0— O OLU .r - LL. N d N C O Q. L E .� = v ZO W L V d Q Q C) 0-0 aQ O N y �j N N .0p'� = 0 F-1 1— t Z Q. 0 C) > Ul U) W W 19 W Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the s'tate's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard language to protect homeowners. Seel: 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 1-888-283-3157 or on our website. -Er- _ ir._r_____ _ .a1u %,Urr11G1-LUAU I1 ULLU11 contractor formation iv Company Name 1l c' _ r t Address (do)1115e a Post O e Box address) Con tor/ Salesperson/ Owner Name " M I nd & 10 M City/Town State Zip Code BusinessAd4dreess ust include a street address) CIO Ov aytime Phone Evening Phone Ci /Town State Zip. Code "kk .0146 Mailing Address (It different from above) Business Phone Federal Employer ID or S.S. Number Law requires that most home Home Improvement Contractor Reg: Number Expiration date improvement contractors have a valid registration number line t;ontractor 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.) Zvi- Lg�p - 6 s90 Required Permits - The following building permits are required and will be secured by the contractor as -the homeowner's agent: (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of MGL chapter 142A.) m + 1 n Proposed Start and Completion Schedule - The following schedule will be adhered to unless circumstances beyond the contractor's control arise Date when contractor will begin contracted work. C' ` ate when contracted work will be substantially completed. -»• --�••.� uJaaan.aa� uwaw uu The Contractor agrees to perform the work, fiunish the material and labor specified above for the total sum of: (*) Payments will be made according to the following schedule: $"er_ upon signing contract (not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater) $ V by /t/-1,2 or upon completion of 71�e 2) by / / 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 be 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 ❑'Yes fall terms of the warranty must be attached io 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. o Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear, e 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 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757. o 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. o 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. T A ,J%-, IN %J 01% -TIN iota 4-V1.N 11CLAc 1 Iff tHEKN; ARE; ANY BLANK SPACES!!! Two identical copies of the contract must be completed and signed. One copy should go to the I eo ' Theo opy should be kept by the contractor. • r P -LAW A Ho�eowner's Signature ontractor's Signa e " Date Date 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 fiends from said account would require the signatures of both parties. Additional Information .If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at http://www.mass.gov/ocabr/ 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 Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at li=://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: 1=3: //db. state.ma.us/tioinei=rovem ent/l icenseelist.asp 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 or 413-734-3114 Version 2.1-11/22/2010 ICOR CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD,YYY1f) 11/16/2011 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO'RIGHTS<UPON THE CERTIFICATE HOLDER. THIS GERTIFICATE.DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW TH19 CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THI1 ISSUING:INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed.. If SUBROGATION IS WAIVED, subject to the terns and conditions of the policy, certain policies may require an endorsement_ A statement or+ ihls: certificate does not confer rights to the Certificate holder in lieu of such endorsement(s). iPCONTACT RODUCER _ NAME: _ _ Duffy :Insurance Agency, Inc. Pvc°NN ), 781.593.1200 I ac.No); 781.593.7260 317 Broadway E-MAIL SS: _ _ Wyoma Square - _ INSURER(S) AFFORDING COVERAGE _ NAIL #_ Lynn, MA 01904-2602 INSURERA: Seneca Specialty Insurance Co INSURED Ryan & Son Roofing, Inc, INSURER B: 93 New Salem Street INSURERc.:_ Wakefield, MA 01880 INSURER D INSURER AE: _ � — INSURER F— COVERAGES CERTIFICATE NUMBER: Biddinq Purposes 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. SPE OF INSURANCE v INSR WVD POLICY NUMBER (MM/DD/YYYY) MM7DD/YYYY) LIMITS _LTR GENERAL LIABILITY BAG100908811108/2011111/0812012 EACH OCCURRENCE $ 1,000y.000 X 1 COMMERCIAL GFNFRAL LIABILITY CLAIMS -MADE i x OCCUR I l PREMISES {E rrence} _ S — ioa'a 000 MED EXP (Any one person) 5 PERSONAL 8 ADV INJURY S 1, 000 o0o A I GENERAL AGGREGATE S 2, 000.;..00 PRODUCTS - COMP/OP AGG $ 1, 000.' O0 GEN'L AGGREGATE LIMIT APPLIES PER: P .f PRO- POLICY ECTRO LOC S AUTOMOBILE LIABILITY (Ea accident) S 1 ( ANY AUTO BODILY INJURY (Per person) $ ALL OWNED - SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ Per accident g �— _ I— HIRED AUTOS NON -OWNED AUTOS --I �S ^ j UMBRELLAUAB OCCUR I EACH OCCURRENCE S _ +{ EXCESS L1AB CLAIMS MADE I AGGREGATE S DED RETENTIONS + S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUT OF EXCLUDED? N7A A - H• TORY LIMITS ER E.L EACH ACCIDENT IS _ E.L. DISEASE - EA EMPLOYEE LS (Mandatory in NH) I If yes, describe Under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT — S f I DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remadrs Schedule, if more space is required) :ERTIFiCATE HOLDER For Biddina Puraoses Only +CORD 25 (2010105) CANCELLATION SHOULD ANY -OF THE ABOVE DESCRIBED POLICIES'BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCEWITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTA /J Marc ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD r. , up II.7: llM(: CERTIFICATE OF LUJ31LITY INSURANCE QAT04/09WYYYY) _ 04/09/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT! UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DUES NOT AFFiRMMATIVEL'Y OR NEGATIVELY AMEND, S=7CTEND OR ALTER THE COVERAGE AFFORDED BY THE POLiCiES I BELOW. THIS CERTIFICATE OF INSURMCE DOES NOT CONSTITIrrI5 A CONTRACT BETWEEI[ THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND 1'1- E CERTIFICATE HOLDER. _ IMPORTANT: If the certMeaM holder is a n ADDITIONAL INSURED, the poiicy(ies) must be endorser I. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, ce►tE in policies may require an mdorsemerrt» A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsem a a(s). PRODUCER ti S7"4.6S9ii DO ACr rMassiPsy Insurance Services,LLC _ --- 27 Garden Strut Unit 113 97$-998-6891 '"oNEAx _.l.t1L_.._....__._ __.— _----_.____ 1 ................... .__._ _....................... Beverly, MA 09915 Sharlene WullemanaaDAEsS.ROpUCE-- PRODUCER ......,.,.. .... RODUCER.la iiYANSON ........ ....._.__._.._..._.______......_,_,......._..M._._.._.,_............. ._..._........ _... __ ..._.......--�.------ ---INSURER{S1AHOR01Nt�COVERAGE NAIL# INSURED Ryan & Son Rooting, __ 93 New Salem St Wakefield, MA 01880 INSURER A : Are American Il'. strrance CO NSURER a : NSURER Q } _ t35URER E: ASURER F: COVERAGES CERTIFICATE NUMBER. REVISION NUMBER: ITHIS IS TO CERTIFY THAT TIME POLICIES OF WSURANCE LISTED BELOW RW-- BEEN ISSUED TO THE INSURED NAMED ABOVE F70R THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REOUIRI WENT, TERM OR CONDITIO14 OF ANY CONTRACTOR OTHER DOCUMENT WITH RESP5CT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERC/JN, THE INSURANCE AFFOR)EJ BY THE POLICIES DESCRIEED HEREIN I.S.. SUBJEcCr '10 ALL THE TERMS, i EXCLUSIONS AND CONDITIONS OF SUCH POL C ES_ LIMITS SHOWN MAY HAV -1 E EEN REDUCED BY PAID CLAIN IS. yyt5 s. TYPE, OF INSURANCE INS PMFO Exa r (MNUDQNI!Y M'}LIMIT'S„ GENERAL UABILrr'V ` EACH OGCURRENCL 15 . ..,,.. I L::�MMERCIi[t.. (�I:NERAI, LIABIk(eY EII DAMAyL'TO cNl�l �P7i I I """s CLAIMS -MAD OCCUR t i (;rN't. ACI. REOATE LUAtT APP! lF�r PER. � �.^S..t.E"zs�,-e eS.ui t ,��, ... ..,........... .._. .._µ... IaUkIL"Y r 1 PCT �— ..� t.O[' i I AUTOMOBILE UASILIYY — ' i ANY AU ICI I , ALL OWNEO AUTOS C.. L AGC3RE(aAIL PROnUCTS CCIMPJOP Afa( g $ LL 1 iI I $ SCHEOULE() AU1'05 HIRELD ADIOS NON•OWNED AUTOS 5 UMBRELLA t_IAB 1 OCCUR a i EXC£SSUAB l C.I.AiMS-MA[7F:. I iI UL()UCHULE PROPER IYDAMAGE RETENTION $ WORI(&RS rOMPEN:SAMON S ! ANO EMPLOYE.Ra LIABILITY Y/ N i A ANY PROF*RiET'OR(PARI'NER/EXECIJTIVfi OFCICERIMEMBER f=XCI.)0FrD7 F-1 N/ / I (Mandatory In NH) AAGGRFGAIE S rey[rc, desaibe Under JESGRIp1ION Or OPERATIONS below 3 i i 0�1t6/12 yyt5 s. LI POLICY NUMBER � POLICY F� tMMroIi�WYYY) PMFO Exa r (MNUDQNI!Y M'}LIMIT'S„ EACH OGCURRENCL 15 . ..,,.. DAMAyL'TO cNl�l �P7i �.^S..t.E"zs�,-e eS.ui t ,��, ... ..,........... .._. .._µ... %13 EXP to one pprsott} $ ( 1 {_ERy'ONAI &AQV INJURY C.. L AGC3RE(aAIL PROnUCTS CCIMPJOP Afa( g $ LL iI CONISINEO SCN(, I.F i IMIT $ ( B[IQiJ V tNJtJR'a (per {xr ort) 5 8001t,Y INJURY (Pr nocldnntl S PROPER IYDAMAGE I {Peracwdnnlj S t ` 1 EACH OCCURRLNC C 3 AAGGRFGAIE S 3 t 0�1t6/12 WC SST YI IM [7TH 4 S LOKIMUS,SES. 0311611 t ..D S .. ___.._.._ ._._... .. .. i,000,00COS62US-4571P66-9-1 i F 1, DISEASE • IIA EMPLOYFF $ 1,000,00C . ........_._.,...._. + ...... _.._..___.........__...... E ( t71SEASE - POLIGY LIMIT 1 9,000,00( I UESCITIPflON OIF gPERAnow / L.00A now / VEHICLES IN �t ACORD 101, Additional Rarrrari[. S heduie, It morn span Is nm?LdnxQ IEVidence of Insurance I . CERTIFICATE MOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE '('HEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE PO LICY PROVISIONS. AUT'HORUTO REPRESENTATFVE. C 1988-2001) AC, 3RD CORPORATION. All rights reserved. ACORD 25 {2009!09) 1'h? ACORD name and logo an- registered marks of AC011 Til 0r)P rrpaltati with ndfFactory tTISi iersion www.pdffactc)ry.com 93 New Salcill '-r,'Ircel, Wakefield KA () j Tel: 6 17-57 1. _9()% EM811: WWW.RVSnAndSonRoofing.com Construction Supervisor License: Nome., Improvement Contractor License Licensure. ........... fit Public .%a 0%, 8(w6d ul, 3uijdk;t- Ucen!;e: CS 104665 CLINTO GALVI 102, DELLA ONT AVE APT:2 LOWELL, MA 01852 Expiration: 7/11M14 P. Oil tilt i�!,if III(- Z. "'M P—Tex g/j, "woo, 0111c'!: Of COUSUMer Affairs, rz HOW IMPROVEMENT CON Den RegWalfioll Reqfiqration: 169538 TRACTOR Type: Expicition.- 71-1/2013 Private COrPoratiol A P AND SON ROOFING INC. CL. NTON GALVIN' 93 NEW SALEM 0JAKEFIF,:LD, MA 0188.0 411�-.7 Vndersecretary The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations 1 Congress Street Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers nnlicant Information Please Print Leffibly Name (Business/Organization/Individual): Address: /State/Zi Phone #: Are you an employer? Check the ` ropriate box: 1.X1 am a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.* required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] 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.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f 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. A I , Insurance Company Name; Policy # or Self -ins. Lie. ��� Expiration Date:-1� 42 Job Site Address::_2 _< C" i&A City/State/Zi p�dj l l�Q�i I��, 0.4 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DSA for insurance coverage verification. I do the information provided above is true and correct. 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 Person: Phone #: L Ups --Tba Proposal 93 New Salem Street, Wakefield MA 01880 Tel: 617-571-9056 small: RyanAudSonS(t�,Me,ccrn www.RvanAndSonRoofing.eom Submitted To: lob Location: Rita Cunningham 25 Camden Street 25 Camden Street North Andover, MA North Andover, MA Phone#: 978-682-8021 Email: Cunningham221@Verizon.net Proposal date: July 3, 2012 Revised: July 24, 2012 We are pleased to hereby submit this proposal to furnish materials and labor, completely in accordance with the below specifications: (Additional charges may apply for any change's not included below in proposal either by request of owner, or if Ryan and Son Roofing finds unforeseen circumstances that will affect the performance, quality or integrity of this job). In the event legal action is taken to enforce any provision of this agreement, the prevailing party shall be entitled to all its reasonable costs, including reasonable in-house or outside attorney's fees. Not responsible for debris in attic. THIS PROPOSAL IS TO: Strip M01 10 bare wood and re -shingle: Total $6,350.00 • Strip existing shingles down to bare wood • Check for rotted wood and replace as needed • Nail down any loose wood • Install ice & water shield to first 6 -feet, and in all valleys and around any protrusions • Install Palisades© premium synthetic underlayment (in place of standard 301b. felt paper) • Install all new 8" white drip edge on perimeter and step flashing, where needed • Install manufacturer suggested starter course of shingles • Install Lifetime/ architectural shingles in color of your choice • Core holes & install soffit vents where needed (FREE of charge;', • Install ridge vent • Cap ridge vent properly with manufacturers suggested cap (GAF Timbertex© or IKO Hip & Ridge 12) • Properly flash any protrusions and all new pipe flanges, if any on roof OPTION/chimnevwork: $350.00 • Re -lead chimney Remove satellite dish: FREE of charge Clean Up: will cover area with tarps to minimize debris and remove debris related to work • NOTE: Please cover any belongings in the attic, as they will get dusty, if applicable Payment TeMS Made GS QI<ttl : (This includes permit, labor, material & dump) Stripa shingle roof price: $6,350.00 OPTION/chimney work price: S 350.00 Remove satellite dish price: FREE of charge Total co changes] $6,760,0 I" payment due upon signing: $2,700.00 Balance due upon completion: $4000.00 Kindly remit payment to "PeterRyan" Thank you! Respectfully Submitted by: %/ ---- Accepted b • — All work is 100% guaranteed for ] 0- ear' n all crafism . All other warrantees are throu h the manuf cturer. All warrantees will b ull & void if g Y sW rf�� g job is not paid in full. Thank you for leaf' s serve you!!! Ryan And Son Roofing, Inc. is fully licensed (#169538) &insured. CC: Evan