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HomeMy WebLinkAboutBuilding Permit #508-13 - 27 WEYLAND CIRCLE 1/9/2013TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: ik5 b�- / � Date Received TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial 'Repair, replacement ❑ Assessory Bldg ❑ Others: Demolition ❑ Other �� Septic Well ®Floodp n Vetland�s' ®, aWaters-hed District OWNER: N Arirlrace DESCRIPTION OF WORK TO BE PERFORMED: L L f /'U7- S T r u C -t v ra L 6ea- y -- Re �i �e-C-1roc k Identification or Print Clearly) ARCHITECT/ENGINEER 1,tel+ W O `C �'� Phone: as 7 - 3 c7y Address: / S���1 sl/ 5Ia'OGJVI e�1a-moi l �tE Reg. No. FEE SCHEDULE: BULDING PERMIT: $112..00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 02 `7 Seo FEE: $ esbic� Check No.: 3a (-,7 Receipt No.: d NOTE: Persons contracting with unregistered contractors do not have access to the guaraj)� fund Plans Submitted ❑ Plans Waived 11 Certified Plot Plan ❑ Stamped Plans 11 4 1 gun'. Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public SewerSwimming Art ❑ Pools El 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 PLANNING & DEVELOPMENT ❑ DATE APPROVED 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 I Conservation Decision: Comments a.� Water & Sewer Con neCtion/Signature & Date Driveway Permit DPW Town Engineer: Signature: 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 DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$10041000 fine NOTES and DATA — (For department use ® Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The folowing 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 ❑ Workers Comp Affidavit ❑ 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 DOTE: 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 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application o Certified Proposed Plot Plan o 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) o Copy of Contract ❑ Mass check Energy Compliance Report o Engineering Affidavits for Engineered products 40TE: 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 subm;tted with the building application Doc: Doc.Building Permit Revised 2012 Location VuC/i G t 2— No. � -- k-' Date Checkzl 26081 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $30�;" Foundation Permit Fee $ �u Other Permit Fee $ TOTAL $ Ne�- Building Inspector 'di J Project: Joel Silverwatch Location: 27 Weyland Circle Window Header / tch Uniformly Loaded Floor Beam Si Mai Architects 2244 Mai [20 International Building Code(2005 NDS)] n Street Unit 3B (2) 1.75 IN x 11.875 IN x 11.0 FT _ - Salem, NH 03079 2.0E -2900F - APA EWS LVL Stress Classes Section Adequate By: 2.4% Controlling Factor. Moment CAUTIONS - Laminations are to be fully connected to provide uniform transfer of loads to all DEFLECTIONS Center Live Load 0.34 IN Li384 Dead Load 0.09 in Total Load 0.43 IN L/305 Live Load Deflection Criteria: L/360 Total Load Deflection Criteria: L/240 REACTIONS A 01 Live Load 5601 Ib 5601 Ib Dead Load 1469 Ib 1469 Ib Total Load 7070 Ib 7070 Ib Bearing Length 2.69 in 2.69 in BEAM DATAConte Span Length 11 ft Unbraced Length -Top 0 It Floor Duration Factor 1.00 Notch Depth 0.00 MATERIAL PROPERTIES 2.0E -2900F - APA EWS LVL Stress Classes Base Read Provided Bending Stress: Values Fb = 2900 psi Adjusted Fb' = 2904 psi 31.26 int Cd=1.00 CF=1.00 Moment of Inertia (deflection): 457.39 in4 Shear Stress: Fv = 285 psi FV = 285 psi Shear. Cd --1.60 .7897 Ib Design Live Load With Reduction: Modulus of Elasticity. E = 2000 ksi E'= 2000 ksi Comp. -I- to Grain: Fc -1= 750 psi Fc - -L = 750 psi Controlling Moment: 19443 ft -lb 5.5 ft from left support Created by combining all dead and live loads. Controlling Shear: 5939 Ib At a distance d from support. Created by combining all dead and live loads. Comparisons with required sections: Read Provided Section Modulus: 80.35 in3 82.26 in3 Area (Shear): 31.26 int 41.56 in2 Moment of Inertia (deflection): 457.39 in4 488.41 in4 Moment: 19443 ft -Ib. 19905 ft -lb Shear. 5939 ib .7897 Ib StruCak: Version 8.0.101.0 9/14/201010:53:54 AM � : o 9-7 m�f I� t1F N H. It FLOOR LOADING Side 1 Side 2 Floor Live Load FLL = 65 psf 0 psf Floor Dead Load FDL = 15 psf 0 psf Floor Tributary Width FTW = 16 ft 0 It Wall Load WALL = 15 pif Average Uniform Load: LL Ave = 65 psf Floor Loaded Area: FLA = 176 sf Reduction Based on Total Area: R1 = 0.02 Max Reduction Based On DULL Ratio: R2 = 0.28 Max Reduction Based On Total Area: R3 = 0.4 Controlling Reduction Factor. ' R = 0.02 Design Live Load With Reduction: LL = 63.6 pat BEAM LOADING Beam Total Live Load: wL = 1018 pff Beam Total Dead Load: wD = 255. plf Beam Self Weight: BSW = 12 pif Total Maximum Load: WT = 1285 plf NOTES prl "N�' 1.7 6 Iy �£ ►f9N_ { Project: Location: 27 Weyland Circle Window Header Uniformly Loaded Floor Beam [2009 International Building Code(2005 NDS)] ( 2 ) 1.75 INx11.875INx11.0FT 2.0E -2900F - APA EWS LVL Stress Classes Section Adequate By: 2.4% Controlling Factor: Moment Paste Joel wch / Silvervvatch atch Architects 224 Main Street Unit 313 Salem, NH 03079 StruCalc Version 8.0.101.0 9/14/2010 10:53:57 AM VMD DIAGRAM 6000 7070 lbs @ 0 ft 4000— bear (Ibs) 000bear(Ibs) a -8000 -7070 lbs @ 11 It 20000 19443 ftabs 6 ft 10000 M (ft4b) 0 -10000 -20000 -0.4 -0.2 on (in) 0 0.2 0.4 0.343 in@6.5it - - - lift aennsetas Home Improvement Sam -We Co This form satisfies all basic requirements of the state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard Ianguage to protect homeowners. Seek Iegal 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. RoMeowner Information Contractor Information Name Company Name 7eano,e_ cotack W a el-ely- EL Jai _5 Street Address do notu e aPost Office Box address) Contractor/ Salesperson/ Owner`Name ,�� ��Ce�� CI�CZ�ti,� /„gym wn State Zip Code aiooe Ai Q • 0 ;Phone Evening Phone Address (It different from Bpsiness Address (must include.a street address) /"S-/ a �n City/Town State Zip Code le ti g Business Phone Federal Employer ID or S.S. Number raw requires-tivat mostbomc Home ImprovementContmetorReg:Number Ex improvement contractors leave a valid registration number The Contractor agrees to do the following work for the Homeowner: (Describe in detail the worlcto completed, specifying the type, brand, and grade of materials to be used, use additional sheets ifnecessarv.) 'See PfUPoS-e Can- lctc-�- Dh W/rf� 70e-idr7 vF 1V.41vDouet-- 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.) Proposed Start and Completion Schedule -'The following schedule will 'be adhered to unless circumstances beyond the contractor's control arise y /3 Date when contractor will begin contracted work. 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: ti Payments will be made according to the following schedule: $ 500 • 00 upon signing contract (not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater) $ 5 ObU by / / or upon completion of ICrGZ .'H I $ �0� by 1 l or upon completion of boeZ Lt- $_� 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 $3000 to be paid for C " i /UCS l ordered before the contracted work begins in order to meetthe completion schedule.(**) $ to be paid for NOTES: Including all finance charges (21:41) 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 wars ante Nein provided by the contrlctor? 1 No ❑''Yes (111 terms of the warranty must be 1ttached io the contract) Subcontractors The contractor agrees to be solely responsible for completion of the work describedregatdless of the actions of any third pa materials a n ractorlLbor Under his the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and Labor under this a cement 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 fuliyunderstand it. Ask questions if something is unclear., o Make sure the contractor has a valid Home Improvement Contractor ReFdstration. The law requires most home improvement contractors and subcontractors to be registered with the Director ofHome Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 PafkPlaza, Room 5170, Boston; Na .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. 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. DO NOT' SIGN TMS CONTRACT IF TBERE ARE ANY E LAM < S]PAC]ES 1 r v, Two identical copies of the contract mast be completed and signed. One copy should go to the homeowner. The othe py should be ]cept by the contractor. owner's Signature Contractor's Sia fore 'Date Date Confraefor Arbitration The Home Impiovement 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 affordedto 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 frim 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 14 A.. Howner's Signature Contractor's SipLare I0T® ][CE: The signatures of the pasties above apply only -to the agreement of the parties to alte alive dispute resolution initiated by the contractor: The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the pasties. Elomeowner'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. Hyouu 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 bC gi Y.en to the owner a.'d 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 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 1=://ww,,v.rnass..gov/oc-,Lbr/ T-Fyouu 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 BIC website at bM://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: htt).-//db.state.m-a.us/- . eimprovement/licenseelist.am 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 508-652-4.800, 508-755-2548 or 413-734-3114• Version 2.1 - 11/22/20 10 WENTWO RT I PARTNERS &ASSOCIATES A Gold Standard Gompny WWMSM*" January 11, 2013 Mr. Mark Lacroix Phil Lacroix & Sons, Inc. 151 Shore Drive Salem, NH 03079 Re: Structural Certification New Kitchen Beam 27 Weyland Circle North Andover, MA 01845 WPA# 103-12 Dear Mark: 17 Malcolm Hoyt Drivc Suite 2 Newburyport, MA 01950 V. 978.462.5322 F. 978.462.5823 151 NIVater Strect PO Box 2285 Skowhegan, ME 04976 V 207.399.0900 r. 207.692.1020 Wentworth Partners & Associates (WPA) has reviewed the completed installation of the new kitchen beam. Refer to Photo Log attached for specific observations. The completed installation is acceptable and in conformance to WPA Sketch SK -1 dated 12/04/12 (see copy attached for reference). Very truly yours, WENTWORTH PARTNERS & ASSOCIATES Daniel W. Smith Principal — Project Engineer Attachments: Photo Log Sketch SK -1 Page 1 of 1 Ronald F. Bukoski, P.E. Principal —Chief Engineer �� i�%f 1 �[ �j� ^ 5 Y 1 `� r v i 1 17 Malcolm Hoyt Dram Suite 2 151 Water Street PO Box 2285 PARTNERS &ASSOCIATES Newburypan, MA 01950 Skowhegan, ME 04976 AColdStnnd"dCompwiy %'oi�ndrillA(M V. 978.4625822 T 978.462.5823 \r 207.399.0900 F. 207.692.1020 PHOTO LOG Completed Kitchen Beam Installation 27 Weyland Circle North Andover, MA 01845 Date: January 10, 2013 Picture No. 1— New kitchen beam bearing on new (2)-2x6 post Page 1 of 2 Picture No. 2 — New post cap connector a Picture No. 3 — Staggered fastener pattern Page 2 of 2 Enter construction cost for fee cal - North Andover Fee Cakulation Construction Cost $: 24,,360.00 m $ - $ 292.32 Plumbing Fee $ 36.54 Gas Fee 100 comm. $ 100,,00 Electrical Fee $ 36.54 Total fees collected $ 465.40 27 We land Circle 508-13 on 1/9/2013 Remove wall and put up Structural Beam Proposal Submitted to: Date: Street: City, State, Zip: Phil Lacroix & Sons, Inc. BUILDER / CONTRACTOR Since 1953 151 Shore Drive Salem, NH 03079 (603) 890-3998 Ms. Jeanne Colachico, Esq. 11127112 27 Weyland Circle North Andover, MA 01810 Following work: We will construct a 2x6 wall floor to ceiling in the garage. We will use 2 2x6 pt plates on the concrete and the remainder will be standard construction. We will run electric per code / also supply an outlet for the future ovens. We will insulate walls per code and use 5/8 fire code sheetrock on the garage side and '/ sheetrock on the inside wall and ceiling. All areas will be compound 3 coats and primed and painted. We will maybe have to build a suffix over new cabinets as per conversation but not sure of yet. Depends on the placement of the beam. We will set a micro lam beam in the existing wall to structurally hold up the floor above. This needs to be engineered and will be added in with this quote. We were hoping to make flush with ceiling joist that are in the ceiling now. If not there will be a reveal down from ceiling no more than 12" as per conversation. We will have to construct temporary TERMS AND CONDITIONS We propose hereby to furnish material and labor - complete in accordance with above specifications, for the sum of: $24,360.00 Note: Payment to be made as follows: $ 3000.00 for cabinets(paid) / 30 % at start of job / 25 % at rough electric / 25 % when cabinets are delivered / 10% at installation of cabinets / balance at completion 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 Workmen's Compensation Insurance. Mark Lacroix 12/12/12 Authorized Signature Date ACCEPTANCE OF Contract The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. ure Date Date walls on the garage side and kitchen side in order to perform work. We will remove cabinets on the desk wall and store in the garage until new cabinets come in. We will leave stove but will have to move temporarily to remove granite and make template for granite. We will also remove granite from desk area and reinstall after new cabinets are in. All granite will have to be modified a little to fit. We will install new cabinets for a double oven / 30" new drop in gas cook top / no micro cabinet instead we will install a 3 drawer cabinet with two large draws and top draw will be a false front non functional. We will put back desk cabinet / existing stand up cabinet / double oven cabinet / 2nd existing stand up cabinet. We will make all cabinets flush except for the cabinet over the desk that will be back like it is now. We will rework all crown molding / toe kick / end panels / to achieve the existing look. Note customer will supply all new appliances / and have old ones removed. I am not figuring to discard old appliances. This would be an extra cost to the owner. All granite will be put back and a new complimentary piece will be made to hold the new cook top as per our conversation. Bella surfaces will perform the fabricating of the granite. The the work will consist of patching in the floor using owners left over tile. If more is needed than we will try to find a close match but there will be some variation from new tile to the old. The back splash behind stove / not sure about this area yet to be determined ????? This would be an addenda but only for the price of the tile / labor figured in. We will hookup gas to new cook top and tie into existing vent for the owner supplied hood. We will install all appliances. Also we might have to move the sprinkler head in the garage out father than it is now. We will paint kitchen ceiling to blend in the new patch. We will areas and paint or touch up trim etc. NOTE: If major electrical movement is needed then will not know until we open up ceiling. Total for above work not including the permit nt walls in affected be an $ 24,375.00 cost. We Note: I have not price the cabinet area near dinin room not sure the be,,gf way to go. I think taking out what is there and replacing with n w cabinets is the y and color you want would be the best way to go. Then you will ac 'eve the best-bok for this area. We can use a cabico or Yorktown setup. Also with a comp i ary slab of granite. If you decide to paint the cabinets then what ever the price of paint and painter will be an extra. When Dave paints the areas we are doing then I can get a price to do this section??? H Z f'! 3�-m rq 3'-0" MAX. op II M ` o z I , I m a)„zz ,ZD10D� O z X r P I y vom�i” 00cn i Iz �+ z0m zDZccnn �=0� ;o� mr jm 00> �0� O Z�� D r I I� I I w :per c- 0 m D D O ,nom v zx �� �� Ccnrr- D oyo-1 -vm i iX Fro z 0 � z < >-a -n j i 01 w z 0 m 00 co >_ �mmz m> i� m0 m ��m (7� CD C2 I I Im I = n G�� X��0 �� iC Dm rcnr- -n (n -nDOcn O -1 cn C �= D X m0 j Icn I iW W(n m- cw--1-0 DODO �z �0 (nXco 7C n 0 r 0 I ID I I cp D �anoG�m D O x = OK>m TD I> -Ir D r KTm -n z cnmo� Fcci)�< Cr- I< �-n mpm m �rOT =O I Im Cm ; D00 O z C m� I I I I m r-c--r-i -4(n 0 m> 0 I I Z n= Ohm�- 2 I I I I 0 Z( O Dm .� O D D m I I W m Dox �z� fir- O I I I G m cn 0 O O ,ll -A - m0Z m O vn55 z mmD 30cl) coM K 0 \ O O D r z 0 p_ q� m 0 C y D m D C OO " "Z -OA rn r ArAa Z t� 5� _ Y W V V LNT V V �� J H 17 MALCOLM HOYT DRIVE NEWBURYPORT, MA 01950 SKETCH NUMBER PARTNERS &ASSOCIATES 978.462.5823 m SKl RAM-CnTrom6— www.wpa-design.com b W2009 PROJECT NAMED PROJECT ADDRESS, PROJECT NUMBERi DATE, KITCHEN 27 WEYLAND CIRCLE 103-12 12-04-12 RENOVATIONS N. ANDOVER, MA 11 C04 0 (J) 13 X 00 a , , u LJ c ; tz m 0 (1) , C: 0 E 1� r. , > = . to CL cn 0) C LCIO 0 co _0 u U. WU co tA 0 ca -e 0 % 11 0 LO ; tz 0 CL M UJI > 0 U LCIO Lu co L) < OL 0 % W z to .-2j W= 2w < (0 11 ti 0 E.9—* w = LL O o O co Nu) Y \ O O LL E N U a N N 0 a Z O Z :D m O m "OL O LL O cr N C E L U f6 C I.J., 0O a Z C7 Z J G. L O d' f° O LL 0O yV j 4A Z J Q u_ u J W L '� O Q' N _ U QJ N `0 C LL cc Q F- a {A Z N Q C7 L ' O d' `0 O L. W o~C Q a p LLI 5 LL N c 7 m Z +� ai a, I • N }; O Y E N C) LU U) Z m ■ Z Z A LLI IL Cl) X Z W OU H Cl) t/) Lu W J CL z v.� W ,O d L ,O Z CL O N O � A� tm 0 . - W Q .E •— L•/y3�• �S } 0 v D O 0 I � Q O v_ JCc 0 0-0 CD r Z O V � O The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 U www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: / i-% Sk) re b C. City/State/Zip: 030 7 Phone #: 03 3 - 89 0 Are you an employer? Check the appropriate box: ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. [`] We are a corporation and its required.] officers have exercised their ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. Remodeling 8. Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions I 11. F1 Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other j .ny applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. iomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating s ontractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy informati rm an employer that is providing workers' compensation insurance for my employees. formation. surance Company Name: e e rtes S -TrJS v ( c,,/,) c Below is the policy and job site dicy # or Self -ins. Lid. 7 f Expiration Date: �� 02 r / b Site Address: a2 1 1 L Gl !1 d c-,, f C Le City/State/Zip: . A 0 b()y r MCA - :tach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a te 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ✓estigations of the DIA for insurance coverage verification. !o hereby ceerty��under th ainss penalties ofperjury that the information provided above is true and correct. mature:—/ S i,57,Ai:C /�,/� Date: /� 3 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 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 pen-nit/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. # 617-727-4900 ext 406 or 1.877-MASSAFE Fax # 617-727-7749 From:Julie Dortona FaxID: Page 2 of 2 Date: 12/19/2012 08:55 AM Page:2 of 2 PHILL-1 OP ID: JD 14 "- CERTIFICATE OF LIABILITY INSURANCE TE 712J11M9'102012 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(les) 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 Ileu of such endorsement(s). PRODUCER Phone: 603-890-6439 CONTACT NAME: Planright Insurance -Salem Fax: 603-890-6521 224 Main Street Suite 3C Salem, NH 03079 Jason M Mlocek PHONE C No E A16Nol: E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE I NAIC 9 11/29/2012 11/29/2013 INSURER A: American Zurich Insurance INSURED Phil Lacroix & Sons Inc INSURER B: Peerless Indemnity Ins CO 18333 151 Shore Drive Salem, NH 03079 INSURER C: Peerless Insurance Company 24198 INSURER D : GEN'L AGGREGATE LIMIT APPLIES PER: POLICYX JECT PRO LOC INSURER E $ INSURER F AUTOMOBILE X COVERAGES CERTIFICATE NUMBER: 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 POLICY NUMBER POLICY EFF MMIDD POLICY EXP MMIDDIYYW) LIMITS B GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I—XI OCCUR CBP4586179 11/29/2012 11/29/2013 EACH OCCURRENCE $ 1,000,00 PREMIoccurrence) RENTED - SES $ 100,00 MED EXP (Any one person) $ 15,00 PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICYX JECT PRO LOC PRODUCTS- COMP/OP AGG $ 2,000,000 $ C AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS HIRED AUTOS X NON -OWNED AUTOS BA4586175 11/29/2012 11/29/2013 COMBINEDINGLE LIMIT 1 000 Ea accident $ 00 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIF�CUTIVE YIN OFFICERIMEMBER EXCLUDED? �N (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below I A 6ZZU80457M16012 3A NH 10/24/2012 10124/2013 X WC STATU- X OTH- Y IT E.L. EACH ACCIDENT $ 1,000,00 E.L. DISEASE- EA EMPLOYEE $ 1,000,00 E.L. DISEASE - POLICY LIMIT 1 $ 1,000,00 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Phil Lacroix Jr, Mark Lacroix and Philip Lacroix are excluded from workers compensation coverage. re: Colachico, 27 Weyland Circle No Andover MA TOWNNOA Town of North Andover Building Department 1600 Osgood Street No Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD