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HomeMy WebLinkAboutBuilding Permit #523 - 274 MIDDLESEX STREET 1/29/2007Permit NO: *�–g 3 Date Issued: To TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received L O N �^ � T 1 T IMPORTANT: Applicant must complete all items on this -page I LOCATION Print PROPERTY OWNEi—C-145-LL t: ct L4 - Print MAP NO PARCEL: T AT T)TTTT Y%TXJf/ ZONING DISTRICT: MC.TnRIC DlgTRICT YES ❑ 1 Yrr Aril uaE yr nuiLLil.v - - ---- TYPE OF IMPROVEMENT PROPOSED USE Zo D % Residential Non- Residential ❑ New Building 4bne family ❑ Addition ❑ Two or more family ❑Industrial ❑ Alteration No. of units: epair, replacement ❑ Assessory Bldg ❑ Commercial ❑ Demolition ❑ Moving (relocation) ❑ Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORME"DJ Ld / Q Identification Please Type or Print Clearly) OWNER: Name: Q\\,�vu a C� oc� 1rG Lt -P Phone: �1 9�� 06 q 2- Address: Address: z ? 1/11 d dl�S •e xG�--�-� 1 CONTRACTOR Name: S z1�U-t°e QUA�� s Phonm, 08- Address: ( 0 / 7,5 Supervisor's Construction License: Exp. Date: 7, Zo D % Home Improvement License. Exp. Date: '7 • ARCHITECT/ENGINEER h► Name: Phone: 1A(S Address: ti ( c, Reg. No. W A FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1!100.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost :$Zo,J1sr: �' FEE:$ -zgJYssg o)yS— Check No.: S Receipt No.: Page 1 of 4 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� uilding Permit Application p orkers Com Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract r1Floor Plan Or Proposed Interior Work Addition Or Decks ° k • R ❑ Buildih&Vermi tvplii4i© ; ❑,Surveyed Plot Plan �- ❑ or drs tom filo t ❑ Photo Copy of H.I.C. And C.S.L. Licenses °� eco tFa` t ? # � �� ,� L.�.3 " G 6 o ..e��pl�Y, Of� ��; ��. ❑ Floor/Crbsse�tio'tY/Elevation Plan Of ProposedWork With Sprinkler Plan And `Flydt414 jc,,l Nc*ations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) 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 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:BPFORM05 Page 4 of 4 TYPE OF SEWERAGE DISPOSAL r / Tanning/Massage/Body Art ❑ Swimming Pools ❑ Public Sewer Lv Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ (septic tank, etc. ❑ Permanent Dumpster on Site L1Private Electric Meter location to ATATT _ project _ ju• re.wm vun�rag1 wl yrn unrerea contr tors do not have access to the guaranty fund �- Signature of Agent/Owner 7 Signature of contractor t Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE REJECTED 11 0 DATE REJECTED I LE DATE APPROVED DATE APPROVED DATE APPROVED FIRE DEPARTMENT - Temp Dumpster on site yes ✓ no Fire Department signature/date ` 170-17 ,� lW �„ 1, „a COMMENTS Zoning Board of Appeals: Variance, Petition No: Planning Board Decision: Conservation Decision: Comments Comments Zoning Decision/receipt submitted yes Water & Sewer Connection/Signature & Date Driveway Permit Building Setback (ft.) Front Yard Side Yard Rear Yard Re wired Provided Required Provides Required Provided Page 3 of 4 Doc: INSPECTIONAL SERVICES DEPARTMENT:BPPORM05 Created 1MC. Jan2006 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA — (For denartment noel Ame a-&& o - 4wL oAc., Uv Al O O*j (,4 �► �2 S .� w T f ah f L; Page 3 of 4 Doc: INSPECTIONAL SERVICES DEPARTMENT:BPPORM05 Created 1MC. Jan2006 �ORTN TOWN OF NORTH ANDOVER' • OL A Certificate of Occupancy $ Building/Frame /Frame Permit Fee $ q S7 s�cwust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 1(, 19956 Building Inspector EADUESEL •=... aiM, - .B U I L B E R S Designers & Builders of Quality Remodeling Projects EARL DUESEL 104 Edinboro street, Marlboro, MA 01752 508 481.3184 z o �:co O N `n ; c, w j CL d c O A kO C O 'r� 0 C: E a CZCn _o o a y 0 CD 0 0 f moo, CD c V 0 =G* y C/)y �; cm m y v 'O Cgo 0 �' O ru cm O 0 0 cmc .� o cm ,0 � c 4��a � W q: TL mom C:, cm c Ny c C = m m z W CO c +� F.. y at O C Z W E " cm O V • mats d H y a1 y1 O z . CLS S OI 0 �� E O Z D H CD E O CD v h O CL y C V R C d CA 0 W 0 W N ce x Q ,•may cii a A w° a U w w � a G i�. U w o� w � XO � w u. w ��r ro O U) E cn o �:co O N `n ; c, w j CL d c O A kO C O 'r� 0 C: E a CZCn _o o a y 0 CD 0 0 f moo, CD c V 0 =G* y C/)y �; cm m y v 'O Cgo 0 �' O ru cm O 0 0 cmc .� o cm ,0 � c 4��a � W q: TL mom C:, cm c Ny c C = m m z W CO c +� F.. y at O C Z W E " cm O V • mats d H y a1 y1 O z . CLS S OI 0 �� E O Z D H CD E O CD v h O CL y C V R C d CA 0 W 0 W N ce RIGHTS TO CANCEL The Owner may cancel this agreement if it has been signed by the Owner at a place other than an address of the Contractor which may be his main office, or branch office thereof, provided that the Owner notifies the Contractor in writing at his 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 attached Notice of Cancellation. HOMEOWNER: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. ri k, �,- Owner's Signature Owner's Signature I/23/0�- Date signed Date signed Contractor's Signature Date signed 06/99 Page 10 of 1S XIV. ARBITRATION OF DISPUTES Contractor and Owner hereby mutually agree in advance that in the event of a dispute concerning this contract or the labor, materials, and equipment supplied or to be supplied hereunder, the Parties shall submit such dispute to a private arbitration service that has been approved by the Secretary of the Executive Office of Consumer Affairs, as provided in Chapter 142A of the General Laws, prior to either party proceeding to legal action in the Courts. Contractor '17,'? 0 7 - Date signed /,z-3'02 Date signed Notice: The signature of the parties under Section XIV (Arbitration of Disputes) apply only to the agreement of the parties to alternative dispute settlement as may be required by the Contractor. The Homeowner, under provisions of said Chapter 142A, may initiate alternative dispute settlement even where that section is not separately signed by the parties. XV. FORM INTENDED TO COMPLY WITH LAW The Contractor and Owner acknowledge that the form, substance, content, and notices contained in this Agreement are intended to comply with the applicable portions of Massachusetts General Laws, Chapter 142A, and regulations promulgated thereunder. In the event of any instance of non-compliance, only such portion shall be invalid and the remainder of this Agreement shall be in full force and effect. In addition, any such portion not in compliance shall be read and interpreted so as to have its intended meaning to the maximum extent allowed under such law and applicable regulations. 06/99 Page 9 of /S'- During the stated warranty period the Contractor shall be responsible for service for repair or adjustment BUT the Contractor shall NOT be responsible for normal maintenance, repair due to abuse or misuse, and normal wear and tear, which shall be the responsibility of the Owner. In the case of service by the Contractor under the warranty provision, the choice of repair or replacement shall be at the discretion of the Contractor. All claims for adjustments, repair or replacement, shall be made by the Owner, in writing, and mailed by postage prepaid first class mail to the Contractor at the Contractor's address as given at the beginning of this Agreement. XII. COMPLETENESS OF AGREEMENT FOR EXECUTION The Owner is hereby advised that he should not sign this Agreement unless and until all blank sections have been filled in or marked as void, deleted, or not applicable, and until all exhibits and related or referenced documents that are incorporated herein are attached hereto. The Contractor and Owner agree that the following additional documents, plans, specifications, and change orders are attached hereto and incorporated by reference into this Agreement: Contract Completion Slip Page 11 Work Change Order Page 12 Notices of Cancellation Pages 13 & 14 S-IPAL er, 04� 'ou �?� it- XIII. COPY OF AGREEMENT TO BE GIVEN TO OWNER This Agreement is governed by the Laws of Massachusetts. It must be executed in duplicate, and an original signed copy hereof given to the Owner at the time of execution. No work under the Agreement shall begin prior to the signing of the Agreement and transmittal to the Owner of a copy thereof. The Owners acknowledge receipt of a true copy of this contract, acknowledge that they have read and understand the contents thereof, and agree that there are no other agreements, understandings, representations, warranties, or guaranties, oral or written, expressed or implied, which are not specifically incorporated herein, and no understandings, representations, warranties, or -guaranties, -collateral --or otherwise-,-shalYnow or hereafter be binding unless made in writing and signed by the parties. 06/99 Page 8 of 4 Unless specifically stated, no excess fill will be removed from site, and all grading will be rough. It is assumed that all existing ground material which will support typical footings, piers, or foundations, is of such strength as to give proper support. All footing and/or pier placement assumes normal digging with hand tools, with no large stones, ledge, etc. All foundation placement assumes normal digging with typical mechanical equipment, with no large stones, ledge, tree trunks, roots, etc. The Contractor is to be permitted to proceed with the work without interruption, and is hereby authorized to do such work on the building or buildings on said premises, as in his opinion, is necessary to complete. the work in good and workmanlike manner. The Owners agree to obtain all necessary permissions from adjoining property owners. XI. WARRANTIES The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship fora period of one year following completion, and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contractor, his subcontractors, employees or agents, is discovered within one year after completion of any job, including clean-up, the Contractor shall, at his own expense, forthwith remedy, repair, correct, replace, or cause to be remedied, repaired, or replaced, such damage or such defect in materials or workmanship. The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. All warranties for equipment and materials, including cabinets and vanities supplied by the Contractor under this Agreement, shall be those given by the manufacturers of such equipment, which shall be and are hereby passed through directly to the Owner. Under such manufacturers' warranties, the Owner may be required to register or mail in a warranty card or other evidence of ownership and use of such equipment in order to activate such warranties. The Owner's failure to mail in or register such documentation, which failure voids the manufacturer's warranty, shall not create any responsibility for the Contractor to warranty such equipment. This warranty gives the Owner specific legal rights, and Owner may also have other rights which vary from State to State. Under Massachusetts law, sales of goods carry an implied warranty of merchantability and fitness for a particular purpose. It is agreed by the parties hereto that if any of the contract work after its completion is found to be improper or defective, that the Owners will notify the Contractor thereof and give the Contractor a reasonable time thereafter to remedy such improper or defective work before employing anyone else to do so, and it is further agreed that if the Owners do not so notify the Contractor and do not so give the Contractor a reasonable time thereafter in which to remedy such improper or defective work, that the Contractor shall not be liable to the Owners for any moneys expended by the Owners for the doing of said work. 06/99 Page 7 of IS- VII. INSURANCE Contractor will be responsible to Owner or any third party for any property damage or bodily injury caused by himself, his employees, or his subcontractors, in the performance of or as a result of the work under this Agreement. Contractor agrees to carry insurance to cover such damage or injury. The Contractor shall participate in any fire loss recovery by insurance during the period of this contract. VIII. SUBCONTRACTING Contractor agrees that, notwithstanding any agreement for materials and/or labor between Contractor and a third party, Contractor is responsible to Owner for completion of all work described in a timely and workmanlike manner. IX. CONSTRUCTION -RELATED PERMITS The following construction -related permits will be necessary in order to complete the scope of work included in this Agreement: The Contractor, under provisions of Chapter 142A of the General Laws, is required to apply for and obtain all construction -related permits. The Contractor shall not be deemed responsible for delays in the work described in this Agreement caused by regulator, permit granting, or inspectional agencies, authorities, or individuals. Notice: If the Homeowner obtains his own construction -related permits for the work described under this agreement, the Homeowner is hereby advised that in the event of a dispute, judgment and non-payment of the Contractor, the Homeowner will not be entitled to make a claim to or collect from the guaranty fund established by Chapter 142A, M.G.L. X. MODIFICATION This agreement, including the provisions relating to price (Section II) and payment schedule (Section III) cannot be changed except by written statement signed by both Contractor and Owner. However, cancellation by Owner is allowed in accordance with the Notice of Cancellation (annexed). All additional work and/or materials requested by the Owner must be authorized in writing, in the form of a Work Change Order, and signed by the parties prior to commencement of said work. Only one signature from each respective party shall be necessary to execute the Work Change Order. All Work Change Orders will be subject to Contractor's usual mark-up. HIDDEN CONDITIONS AND NECESSARY ADDITIONAL WORK All hidden, concealed, or unforeseeable conditions, including code violations, may require adjustment in the overall price of the necessary work related to this Agreement. In such case the Contractor shall inform the Owner of such conditions forthwith, and where necessary a written amendment -of this -Agreement -will -be -negotiated -arid executed -by the -Contractor and Owner. 06/99 Page 6 of k.';- The S DELAYS IN COMPLETION DUE TO HIDDEN CONDITIONS The Owner hereby acknowledges and agrees that in certain remodeling work, the demolition of portions of the pre-existing structure may reveal additional defects, conditions or the need for additional work, which must be repaired, altered or carried out in order to commence or to 10 complete the work described under this Contract. In such case(s) the Homeowner agrees that the duration of the work and the scheduled date of completion may differ from the date contained at the beginning of this Section IV, and that such variation which is not avoidable by the Contractor shall not be considered to be a violation of this Contract. If performance by the Contractor of the Contract work or any part thereof is prevented, postponed, or delayed by reason of any request, act, or acts of the Owners, then in that event, the Owners agree to pay the Contractor, in addition to the price set forth in the Contract, such additional amount as will reasonably compensate the Contractor for all losses and additional expenses caused to the Contractor by such prevention, postponement, or delay. If the Owners do not permit the Contractor to complete the work provided for herein, the parties agree that the measure of damages to be recovered in any legal proceeding brought by the Contractor to recover therefore shall be the difference between the Contract price and the total of what would have been the cost to the Contractor for the necessary labor, and the necessary materials which would have had to be used by the Contractor in completing the work. V. MISCELLANEOUS Landscaping: Contractor shall have no liability for damage to landscaping as a result of gaining and maintaining access to the job site. Unless specifically stated, all lawn and/or landscape reconstruction is by others. Plumbing and Wiring: The parties acknowledge that any electrical or wiring changes and/or plumbing changes to existing wiring/plumbing, that by regulation and/or inspectors direction must be upgraded in accordance with the existing code, are not included in the contract sum, and will be charged by work change order. Utilities: All utilities are to be paid by the owner during the construction period. Signage: Owner agrees to allow Contractor to display job site sign while project is ongoing to act as advertisement of Contractor. Tool trailer: Owner agrees to allow Contractor to park tool trailer on site while project is ongoing, and to take reasonable care in its' protection. Excess Materials: All excess construction materials remain the property of the Contractor. Trash Container: On site trash container for Contractor use only. VI. NO ACCELERATION OF PAYMENTS BUT EXCROWING ALLOWED The Contractor may not require payments to be made in advance of the times specified in Section III (Payment) above for the reason that he deems himself or the payments to be insecure. If, however, he deems himself to be insecure, he may require as a prerequisite to continuing the work described herein, that the balance of the payments under this contract that are in the control of the Owner, shall be placed in a joint escrow account that requires the signature of both the Contractor and the Owner for withdrawal. 06/99 Page 5 of IS- If the owner fails to issue a payment within ten days after payment is due, the contractor may, upon seven days written notice to the owner, terminate the contract and recover from the owner payment for all work executed, and for proven loss sustained upon any materials and equipment, including reasonable profit and damages. In case this contract is not paid for in full when it shall become due, the undersigned Owners agrees to pay all costs and expenses of collection, including attorney's fees, plus interest at 20 percent on the unpaid balance. The Owners agree to sign a completion slip upon the Contractor's usual form, immediately upon completion of the work provided for herein. Upon the signing by the Owners of said completion slip, or upon the negotiation of said note or notes by the Contractor in compliance with the terms of this contract, thereafter the Owners shall be estopped to deny the proper and complete performance of this contract against the subsequent holder or holders of said note or notes. The Owners hereby certify that they are the only owners of record of said premises, and agree that the equity in said real estate shall be and remain as security for the payment by the Owners of the contract price herein. Notice: Notice of this agreement is being filed with the Registry of Deeds of County, in order to create a mechanic's lien on the owner's property to secure the payment of amounts due under this Agreement. Failure to make the agreed upon payments could result in the loss of your home. IV. COMMENCEMENT AND COMPLETION OF WORK Contractor will not begin the work or order the materials before the third day following the signing of this Agreement, unless specified here in writing. Contractor will begin work on or about ]a. 7S 2z'o 7 . Barring delay caused by circumstances beyond Contractor's con 1, the work will be completed by Feld Lu G,,, ti %G, 2oz- 7 . The Owners hereby acknowledge and agree that the scheduling dates are approximate and that delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement. VARIATIONS IN SCHEDULED START AND COMPLETION OF WORK The actual dates that construction will commence and be completed may vary due, but not limited to: the time required to apply for and obtain necessary permits; delays caused due to necessary inspections; delays in the scheduling of work crew(s); the presence of hidden conditions or necessary additional work discovered during construction; or delays in the receipt of equipment and/or materials which must be ordered and/or delivered to the site. NOTICE OF SCHEDULE CHANGES The Contractor agrees that when any such delays become known to the Contractor, the Contractor will advise the Owner as soon as is reasonable. 06/99 Page 4 of IS Any materials to be supplied by Owner shall be delivered to the job site not less than 48 hours before the date on which they will be required by the Contractor, in order to continue the work described in Section I above. Notice: Failure by the homeowner to supply such materials in a timely manner may delay the completion date of the work under this agreement, which delay shall not be considered the responsibility of the contractor, and may add additional expenses which are the responsibility of the homeowner. The discovery and/or removal or testing of any hazardous materials as defined by the Environmental Protection Agency (EPA) is excluded from the scope of work. The contractor reserves the right to stop work until such materials are removed. II. PRICE o0 Contractor agrees to do all work described in Section I for the total price of $ -Z a, 3 i� Z , — 1�'-e c T ltio u �4 u , 1�e�� � ,� 'e q j `t- „ v 0& / Dollars. 33y7 �23 • III. PAYMENT Payment will be made as follows: $337 $ 33 9 7 upon signing Contract; upon start of project; upon commencement of � i 1,A.4,Z1C, .1 i US I,)))i'.�; upon commencement of LN est 'h" ".40J)"k.t/ ; and the remaining ($ 33 9 ) upon verification of the work by Owner and Contractor as having been substantially completed, which verification shall take place promptly after substantial completion. Dollar amount to be held back for Punch List items not completed at the time of substantial completion payment will be negotiated between the parties, to cover the cost of each Punch List item. The total amount will be deducted from the substantial completion payment, and will be released to contractor in increments as the Punch List items are completed. Notice: No agreement for home improvement contracting work shall require a down payment (advance deposit) of more than one-third of the total contract price or the total amount of all deposits or payments which the contractor must make, in - - - - - - - advance-,- to- order and/or otherwise- obtain- delivery- of special_ order__ materials_ and equipment, whichever amount is greater. 06/99 Page 3 of PT I. DETAILED DESCRIPTION OF WORK TO BE PERFORMED Contractor agrees to perform all work deta' ed below. Such work consists of the following: 'emsi5+�1 4 t ocs �otNt 40 4U06('oVI^ Gu. V, 4V LI -s d %A a �S aA41S,o• 01.1 •� 1 04 I 1 V 1G ao ` O "'014 cd J DETAILED DESCRIPTION OF MATERIALS TO BE USED Materials to be used in performing the above described work consist of the following: MATERIALS AND/OR EQUIPMENT TO BE SUPLIED BY CONTRACTOR: o ; —J If L e:V.3s I'(1 -SA 1 a940. S I 7G1.�e W 6-,:" c,1' ce-r At. ei,,104ed1 o bL Lo1214w,o 41vLu'6 cA -fl; s s ��n a Le -'LA -4.91 vu ♦ mol . TO BE SUP PL D BY OWNER: 06/99 Page 2 of / 49 UMBEL 10q F- 446040 3-: Construction Supervisor's License No. 008258 Marlboro, MA 01752 Home Improvement Contractor I L it E 1 1 Phone/Fax: 508-481-3184 Registration No. 104362 0 $0804 8 I• 3 A • • RESIDENTIAL CONTRACTING AGREEMENT Read this agreement and make sure you understand it before signing. This agreement has legal force and effect, and binds those who sign it. 000000000000 Notice: All^ home improvement contractors and subcontractors engaged in home improvement contracting, unless specifically exempt from registration by > '\ provisions of Chapter 142a of the general laws, must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director, Home Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, MA 02108. Designated Registrant's Name: Earl R. Duesel Registration Number: 104362 Salesperson's Name: , l 0wese ) Contract Number: 7c>3 r" This agreement is made on \ tA L Z 3 Z-vo2 between E. R. Duesel Builders of 218 West Date) Main Street, Marlboro, MA 01752, telephone: 508-481-3184, hereinafter called "Contractor" and ��_ -, � � 4 S C . vC 1�c� U. �. c3, u� C�► t�; .s� � � r. � C�v�-�,1� �; � (Owner) of ?, 7 (Phone Number) hereinafter called "Owner". 06/99 Page 1 of !-r3- Construction Supervisor's License No. 008258 Home Improvement Contractor Registration No. 104362 CONTRACT COMPLETION SLIP 1c,-4 F-Jct46o6o S -- Marlboro, MA 01752 Phone/Fax: 508-481-3184 Work performed for: Name: U t o v�-? Q 5 Street: 2 71/ VM, d1jegty, City/State: U In , ���ou -P-A - 1i1/I c c5i �� Contract Number: tj 2CL3 Dated: uu 73 2� Work Change Order(s) No: Dated: Number of Pages: / Total Contract Price: $ ZU/ 3?Z CERTIFICATION OF COMPLETION OF CONTRACT The undersigned certifies that to the best of their knowledge, belief, and information, the work covered by the above referenced contract has been completed in accordance with the Contract documents, and that the final payment is now due. Owner's Signature Contractor's Signature 06/99 Page 11 of IS— Date signed Date signed Construction Supervisor's License No. 008258 Home Improvement Contractor Registration No. 104362 WORK CHANGE ORDER Owner's Name: Contract Number: Change Order No.: 104 Fd1'k13P41 S+. 218 Wesi Main Street Marlboro, MA 01752 Phone/Fax: 508481-3184 This Work Change Order is an addendum to the original contract. The payment schedule on the original contract is unaffected by this additional work, and this Work Change Order has its' own payment terms and schedule. E. R. Duesel Builders is hereby authorized to supply the following materials and/or perform the following additional work not covered by the original contract: Price: The total price for the above materials and/or additional work is $ Payment: Payment will be made as follows: Owner's Signature Owner's Signature Contractor's Signature 06/99 Page 12 of t-9- Date signed Date signed Date signed Dollars. �Cc u 23 Zn;) 07 (E ER DATE OF TRANS CTION) NOTICE OF CANCELLATION You may cancel this transaction, without any penalty or obligation, within three business days from the above date. If you cancel, any property traded in, any payments made by you under the agreement, and any negotiable instrument executed by you will be returned within ten business days following receipt by the Contractor of your cancellation notice. Any security interest arising out of the transaction will be canceled. If you cancel, you must make available to the Contractor at your residence, in substantially as good condition as when received, any goods delivered to you under this Agreement; or you may, if you wish, comply with the instructions of the Contractor regarding the return shipment of the goods at the Contractor's expense and risk. If you do make the goods available to the Contractor and the Contractor does not pick them up within twenty days of the date, of your Notice of Cancellation, you may retain or dispose of the goods without.any further obligation. If you fail to make goods available to the Contractor, or if you agree to return the goods to the Contractor and fail to do so, then you remain liable for performance of all obligations under the Agreement. To cancel this transaction, mail or deliver a signed and dated copy of this Notice of Cancellation, or any other written notice, or send a telegram to: E. R. Duesel Builders 218 West Main Street. Marlboro, MA 01752 iM4 -2jl"b4o 9+. NOT LATER THAN MIDNIGHT OF 9—C, . -Z e, , 2r�� (date) I HERE BY CANCEL THIS TRANSACTION. (date) (Owner's signature) (Owner's address) (Two copies of this form to be attached to the Residential Contracting Agreement.) 06/99 Page 13 of /Y— Q , . - - 23 200 (EN ER DATE OF TRANSACTION) NOTICE OF CANCELLATION You may cancel this transaction, without any penalty or obligation, within three business days from the above date. If you cancel, any property traded in, any payments made by you under the agreement, and any negotiable instrument executed by you will be returned within ten business days following receipt by the Contractor of your cancellation notice. Any security interest arising out of the transaction will be canceled. If you cancel, you must make available to the Contractor at your residence, in substantially as good condition as when received, any goods delivered to you under this Agreement; or you may, if you wish, comply with the instructions of the Contractor regarding the return shipment of the goods at the Contractor's expense and risk. If you do make the goods available to the Contractor and the Contractor does not pick them up within twenty days of the date of your Notice of Cancellation, you may retain or dispose of the goods without any further obligation. If you fail to make goods available to the Contractor, or if you agree to return the goods to ,the Contractor and fail to do so, then you remain liable for performance of all obligations under the Agreement. To cancel this transaction, mail or deliver a signed and dated copy of this Notice of Cancellation, or any other written notice, or send a telegram to: E. R. Duesel Builders I_ 248 West Maio Street lot Marlboro, MA 01752 NOT LATER THAN MIDNIGHT OF -Z Zyo 2 (date) I HERE BY CANCEL THIS TRANSACTION. (date) (Owner's signature) (Owner's address) (Two copies of this form to be attached to the Residential Contracting Agreement.) j 06/99 Page 14 of /-S,- C EiRsOUESEL Construction Supervisor's License No. 008258 B U I L D E R S Designers & Builders of Quality Remodeling Projects Home Improvement Contractor Registration No. 104362 In accordance with the Environmental Protection Agency Pre -Renovation Lead Information Rule (PLIR), also known as Section 406(b) of the Toxic Substance Control Act, I hereby acknowledge receipt of the EPA pamphlet entitled "Protect Your Family From Lead in Your Home ". s Signature Contractor's Signature Page t-5— of /S Date signed I -.3/0 �, Date signed 3718 Wes$ treel, Marlboro, MA 01752 PhonelFax: 508-481-3184 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wMawww.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): 9— Address: L4 to oar -o City/State/Zip: "lI V (G 1,1 )a�) b -o VVo, O l 792 Phone #: S_,50 /. 3l S'LL AFI an employer? Check the appropriate box: 1.m a employer with / 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of 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. t 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 n, Insurance Company Name: Policy # or Self -ins. Lic. #:_ VW C_ (=,.C)O 9 % 2Dp 1 Z oc)(o Expiration Date: % . zo Job Site Address: 774 c 12 3'P�L � City/State/Zip: U/. , U� U. _t _ VVt Q t-Ya,5 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 DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. use only. Do not write in this area, to City or Town: or town official. Permit/License # Z? Zeo% 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 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 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 bum 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 Mee of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext.406 or 1-877-MASSAFE Revised 11-22-06 Fax # 617-727-7749 www.mass.gov/dia J HN-de-&M'f 1d:, 5 Lersn Isar i norougn SIO ylD L7J17 r. vilf ris AC if, CERTIFICATE OF LIABILITY INSURANCE IGR TYPE QP IN$Uktm o1/22/2007I FROwjcFR (508) 465-1526 3TEPHSN W. OEM 7148. AGCY . ) MONUHMT AVS. THIS CERTIFICATE IS ISSUED AS A -' INFORMATION ONLY AND CONFERS NO RIGM UPON THE CERTIFICATE tIOLDER. THIS CERTIFICATE DOES NOT AUQENO E7CTEMQ OR ALTER THE COVERAGE AFFORDED THE POLICI W. LIINTS V J4SOTRO, M. 01752 - INSURERS AFIFORDMIG COVERAGE NAIL 0 vsuREb INFJRER LMffllAL C;A$LxAm Co. INSURER IPA L T . M . I'i TUATo INS. CO. :R DUESEL EMLDERS Immc, L04 EDINBORO STREET IRWRORD: QRUMM, NA. 01752 MURER E: — `h►tLDAGCG TI(E POLICIES OF INSURANCE LLWW BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TME POLRGY PERIOD rMICATED. NOTWITHSTANDING ANY RECIUiREh1ENT. TFPM OR CONOR ON OF ANY CONfIMC7 O%t OTHFA OOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 8E ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND GONDIIIONS OF SUCH POLICIES. AEGATE LIMITS $"OWN MAY HAVE BEEN REDUCED KYPAIP CLAMS, IGR TYPE QP IN$Uktm POLICY NIi71dPR POLIDATE 90#v&m OUCT 'LSD LIINTS A 0@RQ4ALwow" CCX 0296062 04/10/2006 04/10/1007 ucHp R E I 1,000,000 P-11 atoom- 100,000 x RCIALE ,000 WD ooa AA am n 4 51000 rAAWS MA45G / / / / „ 4 1,000,000 fg=l& I ACV WMAY GMERAL AGGREGATE t 2,000,000 d$NLA60RECiAMUWTAPPLgSMR' oa _ p 42,000,000 ri mm pm M AVYWONA LN BILIN COMBINED W4L9 LIST (Ee euatlent} 4 ANY AUTO BODILT INJURY ALL ONAYED ALrr03 I / / ! SCHEDMI) ALTT03 ALID9.Y INJURY 4 SPe►np MMED AUTOS NQ0b01flbtER AUTOS % / / % PROP07YOAILIAGE (pw a=wvno H / / I GARAGE LIANUM No ONLY . EA ACCIDENT4 OTHER TRW EA ACC 4 AUTO ONLY- MPG 4 ANY AUM / / / I 6ILCESSWIPWA .LAL.IAZLIV / / / ! EACH OCCLRRENCE 10 A OCCUR rI CLAMS MAM s DEDUCT�Lc J ! I / ANY PROPAI€f4N1R�VE oFFICEwr,�laF�toICLUI}Eps 6009720012006 07/2012006 / / 07/20/2007 / / OFR E 1. EACH ACCIDENT 100,000 F -L DIS -� 4 5 40 000 e.4oFS crL�rT a 500,000 Nyee.aeeonleLrr7er ffto%q bmim & H� jr5MPTION OF 3iwwawvucwow anwn�c+�cw..�-c....�...�..�...... DR. TSOMS GOC$A= 214 MIDDLESEX STREET SOUTH ANDOVER, Nk. 01899 - INS025 (mom -os SNDULo AMY OF TNL AWVE 8=wap POLICIES W CAMPAUAD BEFORE THE EXPIRATION DATE TN6010FL TNF =MG MURER 9066 040EAVOR TO WIL 10 DAY3 SRIPRTER NOTl66 ro TNP L3 RTIP40ATE LLOL.DEN awgo T4 rAm LEFT, BIR FAILURE TO 970 50 311AL.S UNME 00 08UGATM OR LIABILrre OF AMY Wo L7POM We 0907NOMO LAM FOWSaPION - ¢JOp V -W5 a PW 1 ail Tr ni 12 rat n 7 1 �� z c �� N 6 S go L7 t a�p54�� 015364270 WN DATE OF BIRTH CUSS REST 07-14-1946 DM EXPIRES 07-14-2009 DUESEL EARL R 104 EDINBORO ST MARLBOROUGH,MA 01752-3318 MIm Is W j ucariza Board of Building -,]K 01iti us-abdStatida E.R. DUESEL Earl Duesel 104 EDINBOR, Marlboro, MA 01752 Ale O/L BOARPQ:BUILDING REGULATION' ..F 9U cense; CONSTRUCTION - SUPERVISOR Number m 008258 Tr. no: 1-5312 fit j,� ,, ,�M{-�,.+E!"•en"�'�"�"1 f J � e � t a♦ M P M In 27�t V41 ,,��e�e� S- :./ Etta, Ki1 ll a yam. ,$j 2,?q VA -\I Oil ii a 2,?q VA -\I m . A I rev 777