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Home My WebLink AboutBuilding Permit #287-14 - 279 WINTER STREET 9/22/2014 pORTIH BUILDING PERMIT Eo TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION y h Permit No#: Date Received * � H �.9 q�R17eo SSACHUS� Date Issued: zi ORTANT: Applicant must complete all items on this page LOCATION .t --57"" Ag 6, 441 Ac,L1, Cf. r Print PROPERTY OWNER �_4 Cil Print 100 Year Structure - yes no MAP j�97 C PARCELj�� ZONING DISTRICT:`Historic District yes no Machine Shop Village yes no 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 ❑ Floodplain ❑Wetlands 0 Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: /,e/r2�9 lee 7-*aA, 1� _ nth l✓r� � ��! �t �-eh/� iY19�C.� Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: 2 �� w��T �� •�i��c�/ 2 1✓ O��yS Contractor Name: ff,„,/5Phone: 7✓'� ' 7 L7 Z 7f' ' r .�=��4� Address: Supervisor's Construction License: Exp. Date: Home Improvement License: �. r JC": Exp. Date: /��lf� 2G/ -� ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST ZBASE D ON$125.00 PER S.F.CPy Total Project Cost: $ � (P FEE: $ 2S Check No.: Receipt No.: �� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor ' ..— Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE'OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dumpster on Site ❑ 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 r' Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine 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 ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location No. ' I Dat ZZ t � . • TOWN OF NORTH ANDOVER Certificate of Occupancy $ J v Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �►- Check# ,5 Building Inspector Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 23608.00 m $ - $ 2,840.02 Plumbing Fee $ 355.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 355.00 Total fees collected $ 3,650.02 279 Winter Street 287-14 on 9/22/2014 Interior Demo Remodel Great Room, Kitchen and 2nd Floor Bathroom New Electrical Service and Wiring Add Propane Tank and gas fireplace New Plumbing and Stack I S10 R Tly Town of t E : �� Andover O - h 0% ver, Mass, coc"I "IWIcw 1' �•9 A�R'�TED P-'?90 �(5 S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System G �• THIS CERTIFIES THAT BUILDING INSPECTOR has permission to erect buildings on ... W.� '�+ 5�, .�, Foundation 40 Rough OW &4 A to be occupied as ......... . ..�w...... ..... .............. ...... !................................. chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR a �� • UNLESS CONSTRUCT N TS Rough Service ............. ....... I.................................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. 8 Cedar Road Lasting 14 Licensed &Insured Andover, MA 01810 f CSL # 89930 Tel 978 470-0492 IMPiressions HIC #137381 Fax 978 623-0932 tustam D*sign and build, Inc. Lead# LR000135 Attachment A: Project Scope Specification for Remodeling at the home of Diane Huster 279 Winter Street North Andover, MA Rev 4.0 September 21, 2014 (Please See Rev 4.0 Drawings) I. Infrastructure Propane for new fireplace Locate tank on left side of garage: prepare site and trench for gas line to left rear family room (approx.25 L Ft) • No need to add electrical to trench for future use • Heidi from NA Conservation says no wetlands, so no problem with propane tank placement or trench or deck or patio plans Remove/replace oil tank per Haffner quote of 4/2/2014; to be billed at actual cost Upgrade electrical panel to 200 amp Add insulation (fiberglass batts and/or cellulose) To attic space from garage To attic on second floor To all opened walls Vermiculite insulation removal: to be billed at cost +15% New lockset in Bronze for existing Andersen door Replace approx 85' square area of existing exterior front pavers with new brick-like ones and stone step. $1500 material allowance. t Huster Rev 4.0, 9-21-2014 Page 2 of 10 II. Scope of Work: Great Room Scope (includes Entry, Dining and Family Room): Demo Disconnect electrical/provide temp power and internet/TV connection SAVE ALL LIGHT FIXTURES Disconnect FHW baseboards. Demo and dispose: interior walls, rear glass doors (NOT front glass doors), side doors, garage entry door, all windows. Ceilings to remain. Demo steps in garage Demo AND SAVE FOR PICK UP wood stove and exhaust, Demo brick wall behind wood stove and brick platform DO NOT DEMO exterior deck Open old bulkhead for access to basement. Dispose of old freezer in basement Rough Frame partition walls, fireplace feature, windows (1 set double panel with transom, 2 sets of sliding doors with transoms, 1 double casement window). Windows and exterior door shall be Andersen brand, paintable inside, white vinyl outside with screens. If upon demolition it is found that unplanned structural work is needed for implementation of the fenestration plan, then a Change Order shall be executed before proceeding. Reframe bulkhead area and gable end as needed Install windows and exterior doors/locksets (including replacement lockset for existing Andersen door). Patch/repair wall areas from previous doors and windows as needed; blend exterior finishes (incl paint) with existing as much as possible. Patch/repair roof and ceiling from removal of old wood stove pipe. New interior walls shall be blueboard/plaster. Paint per Homeowner color selections. Build new stairs from Entry to garage in new location per plan. Supply/install panel access panel to enclose existing attic opening in garage LASTING IMPRESSIONS CUSTOM DESIGN AND BUILD, INC. Huster Rev 4.0, 9-21-2014 Page 3 of 10 Great Room Scope, cont, Rough electrical: Install outlets, light boxes, electrical connections, switches per plan and/or code. Gas fpl wiring. Thermostat. Doorbell. Internet/TV • No outlets in floor Provide connection for new propane line at rear/left family room: NOTE that additional charges may be charged if propane line from left/rear location requires additional materials or labor from initial plan at rear/center gable wall. Provide propane gas connection for fireplace. Replace family room/dining/entry FHW baseboards with new FHW baseboards Insulation to code: fiberglass batts and cellulose as applicable Finish Install fireplace unit (fireplace company to complete), electrical finishes and fixtures. Blend subfloor over bulkhead with existing in preparation for carpet (assume that existing subfloor will be sufficient for carpet in Dining and Family Rm areas). Install suitable subfloor for Entry tile. Install 6-panel closet door, 6-panle fire door to garage. Install standard Colonial casings, 3" crown/cove and speed-base baseboard. Trim ceiling edge between dining area and cathedral ceiling such that dining area can be wrapped with crown. Install single rod and shelf unit in closet. Install standards, brackets and shelving for 2, approx.30" wide x 16" deep shelves on left closet wall Install pre-fabricated mantel Frame area in front of FPL for recessed the installation, install suitable subfloor for tile. Cap 2 small half-height walls in entry with painted pine. Tile surround to fireplace and recessed hearth (18x18 granite tiles) Prep and paint walls, ceiling and trims including planked ceiling per Homeowner color selections LASTING IMPRESSIONS CUSTOM DESIGN AND BUILD, INC. Huster Rev 4.0, 9-21-2014 Page 4 of 10 Kitchen Scope Demo Disconnect electrical/provide temp power. SAVE ALL LIGHT FIXTURES Disconnect sink, refrigerator ice-maker, DW, FHW radiator. Protect doorways, floors from dust migration/traffic. Demo and dispose: cabinets, counters (SAVE COUNTER BESIDE RANGE), fixtures, appliances, window, wallboard, ceiling, flooring. Take respirator precautions for possible asbestos dust in ceiling and walls - breach ceilings and walls to determine if vermiculite is present. If so, stop work until remediation. Rough Frame raised floor extension for eat-at counter into dining area, Frame half-height wall for eat-at counter. Frame partition walls and new window(s) per kitchen layout. Install supplied kitchen window. (Andersen double casement, paintable inside, white vinyl outside Supply/install exhaust venting for range hood Patch/repair interior/exterior wall areas as needed; blend exterior finishes (incl paint) with existing as much as possible. Interior walls and ceilings to be blueboard/plaster. Paint per Homeowner color selections. Rough electrical: Install outlets, light boxes, electrical connections, switches per plan and/or code. Appliance connections will include electric range, microwave oven on shelf, garbage disposal, refrigerator, vent hood. Install rough plumbing FHW panel on open wall, DW, refrigerator ice-maker, single undermount sink with garbage disposal, single-hole faucet Insulation: Fiberglass batts and cellulose to code for opened walls and ceiling (along with Family Room) Finish Install supplied cabinets, 2 spice pull-outs and one trash pull out. Install supplied backsplash tile to 3 walls (window-wall, range and right of range up to height of wall cab and vent hood) Install granite counters LASTING IMPRESSIONS CUSTOM DESIGN AND BUILD, INC. Huster Rev 4.0, 9-21-2014 Page 5 of 10 Kitchen Scope, cont. Install electrical finishes and fixtures Install decorative light fixtures Install plumbing fixtures Install appliances Instal subflooring Install supplied T&G hardwood floor Supply/install trims (casings, crown, baseboard same as Great Room) Prep and paint walls, ceiling and trims per Homeowner color selections. LASTING IMPRESSIONS CUSTOM DESIGN AND BUILD, INC. Huster Rev 4.0, 9-21-2014 Page 6 of 10 Bathroom (Floor 2) Scope Demo Protect doorways, floors from dust migration/traffic. Disconnect electrical/provide temp power. Disconnect water. Disconnect FHW baseboard Demo and dispose: cabinets, counter, toilet, sink, cast iron bathtub. Existing door and window to remain. Take respirator precautions for possible asbestos dust in ceiling and walls - breach ceilings and walls to determine if vermiculite is present. If so, stop work until remediation. Then continue demo and disposal of walls, ceilings and floor. Rough Frame attic access hole with panel in hallway outside of bathroom Frame shower walls and toilet closet wall (pocket door). Frame linen closet in hallway. Add blocking for towel bar under window and to the left of vanity, as well as for tissue holder. Patch/repair interior/exterior wall areas as needed. Opened walls and ceiling to receive blueboard/plaster (except shower shall receive materials suitable for tile). Beadboard wainscoting to be installed to 48" height. Install new roof on shed dormer: Strip existing roof to sheathing, install Ice-and- Water-Shield on etire surface, drip edge and 30-yr shingles similar to rest of house. Rough electrical: Install outlets, light boxes, electrical connections, switches per plan and/or code. Install circuit and connection for heated floors Rough Plumbing: Install rough plumbing for 2 undermount sinks, two, 8" spread faucets and for thermostatic valve with 1 diverter to hand sprayer on a stick, shower drain; one toilet. Install acrylic shower pan and drain. Center valve and shower stick horizontally on wall. Insulation: Fiberglass batts and cellulose insulation to code for open walls and ceiling (along with Great Room) Finish Install cabinets LASTING IMPRESSIONS CUSTOM DESIGN AND BUILD, INC. Huster Rev 4.0, 9-21-2014 Page 7 of 10 Bathroom Scope, cont. Install counters Install tile for shower walls (NO recessed niche)- subway the on walls Install electrical finishes and fixtures, including 1 Panansonic WhisperWarm unit outside shower, 1 fan/light in WC room (light and fan separately switchable) supplied thermostat for heated floor, 2 decorative wall sconces, 1 wet area recessed lights in shower. Also, swap-out hallway ceiling fixture (disconnect from stairwell circuit) for recessed light on its own switch. Install plumbing fixtures: thermostatic valve with 1 volume controls, 1 hand spray, shower drain, 2 sinks, two 8" spread faucets, 1 toilet. Install subflooring for electric mat and the floor Install supplied electric mat and porcelain flooring (18 x 18) as specified Install supplied WC 6-panel pocket door, 18" wide linen closet door. Install casings, crown, baseboard same as Great Room, and 4' high paintable beadboard wainscot, topped with chair-rail Hang Homeowner-supplied tissue holder, 2 towel bars and robe hook Prep and paint walls, ceiling and trims per Homeowner color selections LASTING IMPRESSIONS CUSTOM DESIGN AND BUILD, INC. F77Huster Rev 4.0, 9-21-2014 Page 8 of 10 III. Material Selections Great Room Selections Exterior Doors and windows: Andersen paintable inside/vinyl white outside. Hardware-bronze o Replace existing Andersen door hardware to match Interior doors: 6-panel paintable pine closet door; 6-panel paintable mdf composite fire door. Schlage lever/lockset in bronze Flooring for entry and family room o Entry Porcelain tile: VESTA - 6.5 X 6.5 (SF) and VESTA -13 X 13 (SF) in Hopscotch pattern o Family room carpet and pad over existing subfloor: $37/yd allowance Lighting: One fan/light, one chandelier, one entry light, one closet light Allowance $1500 Fireplace unit - propane: Mendota Gas fpl DXV-35 DT3 with Wellington surround Mantel - "Classique" painted to trim color. 18" x 18" granite tile to surround, plus recessed stone hearth: approx. 20 sq ft. $100 material allowance. Painted Trims (3" crown, speedbase baseboard, Colonial casings, beams) Benjamin Moore paint colors TBD Kitchen Selections Window - double casement, Andersen, paintable inside, vinyl white outside Lighting: 4 pendants; $1036 allowance Cabinets (Bali, Latte on maple, frameless; press board boxes, soft-close, front flush open toe kick on sink cabinet only; sink cabinet and spice inserts extend out from window wall. Cabinet hardware (interior features, pulls, knobs) - oil rubbed bronze, to be selected, $6 per piece allowance Counter material - Viscount White granite or equivalent Backsplash - Seafoam green glass tile, 3" x 6" in brick pattern LASTING IMPRESSIONS CUSTOM DESIGN AND BUILD, INC. Huster Rev 4.0, 9-21-2014 Page 9 of 10 Kitchen Selections, cont. Sink - single, undermount ELUH211510 Faucet - single hole, pull out spray, Moen 7285SRS Garbage Disposer -- cont feed PR0750 Refrigerator - French, standard depth, SS with icemaker -Kitchenaid KBFS25ECMS Range - all electric, double oven, slide-in, front controls - GE CS980STSS Microwave oven under counter—GE JES11425PSS Dishwasher-Bosch SHP53TL5UC, Stainless Steel Exhaust Hood-Zephyr 30", in stainless steel with light Flooring - T&G red oak. Similar to existing Painted Trims (3" crown, speedbase baseboard, Colonial casings, beams) Benjamin Moore paint colors TBD Bathroom Selections Lined door hardware - Schlage "Plymouth" polished brass knob; chrome pocket door hardware Lighting: Panansonic WhisperWarm unit outside shower, 1 fan/light in WC room (light and fan separately switchable); one wet-area shower light; 2 decorative sconces (sconce allowance $400) Cabinets (Monaco, Latte on maple, press-board boxes, frameless, soft close, standard toe) 2 sink bases 21 deep flanking 4-drawer cabinet 24" deep Cabinet hardware (interior features, pulls, knobs) - chrome, $6 each allowance Counter material - stone remnant, $1000 allowance Backspiash - same as countertop Sink - 2 rectangle undermount, "Muse" Sink fixtures -- Bancroft 8" centers, chrome; Shower pan and drain—Archer 42045 in white LASTING IMPRESSIONS CUSTOM DESIGN AND BUILD, INC. Huster Rev 4.0, 9-21-2014 Page 10 of 10 Bathroom Selections, cont. Toilet: Kohler"Kathryn" in white Tile (shower floor, wall, trim pieces) PORTFOLIO 3 X 6 AW (SF), white subway tile with bevel in brick pattern with matching pencil edge pieces Thermostatic valve and volume control combined - Kohler with Bancroft trims, chrome Handspray on adjustable rod - chrome, Riobel 4-jet #747 Frameless shower surround, French door, clear glass/chrome: Maax 136452-900 Grab bars: 18" Kohler"Purist" in chrome Shower double corner basket - Riobel 260 in chrome No towel bars/rings, TP holder, hooks - labor to install 4 items is included Flooring-porcelain: 18" x 18" Carrara MEDCARRBRUSHFFI8, no pattern or diagonal Painted Trims (3" crown, speedbase baseboard, Colonial casings, 48" high beadboard wainscot with char rail) Benjamin Moore paint colors TBD LASTING IMPRESSIONS CUSTOM DESIGN AND BUILD, INC. Huster Remodeling Contract Rev 4.0 Page 1 of 12 Construction Contract This agreement is made this 21st day of September, 2014 between Diane Huster of 279 Winter St. No. Andover, MA and Lasting Impressions Custom Design and Build, Inc., with principal place of business at 8 Cedar Road, Andover, MA (hereinafter referred to as "Lasting Impressions"), with Federal Identification No. 37-1445324 Home Improvement Contractor Registration No. 137381 Construction Supervisor's License No. 89930 Lead-Safe Renovation Contractor License No. LR000135 Whereas Diane Huster (hereinafter referred to as "Owner") represent that she is the owner of the property located at 279 Winter St. No. Andover, MA (hereinafter referred to as "the Property"). Whereas Owner is desirous of hiring Lasting Impressions as a general contractor for the renovation of a house located on the Property. Now, therefore, in consideration of the mutual covenants and considerations hereinafter set forth, the parties hereto agree as follows: I. Agreement Documents and Scope of Work This Agreement consists of this, the Construction Contract, and by reference, the provisions contained in the documents listed herein. Except for written modifications signed by both of the Parties, subsequent to the execution of this Agreement, the terms of this Agreement are limited to the provisions contained in this Construction Contract, and the following documents, which shall be attached hereto and made a part of this Agreement: Attachment A: Project Scope Attachment B: Limited Warranty Attachment C: Notice of Cancellation II. Work to be Performed Lasting Impressions shall in good, faithful and workmanlike manner, and in compliance with the Massachusetts State Building Code 780 CMR and the EPA Renovation, Repair and Maintenance Program (40 CFR Part 745), provide labor and materials for the work specified in the Attachment A. Lasting Impressions shall keep the site broom clean and in compliance with the Lead-Safe Renovation Contractor requirements, but is not otherwise responsible for cleaning. Except as noted, no repairs or corrections to the preexisting structure, utilities or grounds are included in this Agreement, i.e., the existing structure, utilities and grounds are assumed sound, in conformance with building code and local ordinances and functional for the intended use of the area(s) of the Property impacted by this Agreement. Unless otherwise stated, capacities of existing electrical, plumbing, gas, heat, air conditioning and � t Huster Remodeling Contract Rev 4.0 Page 2 of 12 sewer/septic systems are assumed sufficient to support the implementation of the Approved Design and can be easily accessed without structural modification. In projects requiring excavation, the area to be excavated is assumed free of ledge, water, boulders, underground utilities or other impediments to ordinary excavation methods. Should Lasting Impressions uncover site conditions requiring correction, it shall notify the Owner of the condition and the parties shall execute a Change Order (as described in Section VII to follow) to correct the condition. Except as noted, Owner is responsible to secure and pay for any easements, variances, zone changes, assessments, engineering or connection fees required by government agencies or utilities. Unless ess s ecified As Built Site Plan Certified Plot Plan Structural Engineering, Civil P � Engineering, Construction Documents or other Professional or Consultant fees if applicable) 9 9. ( PP ) are not part of this Agreement. Permit fees shall be billed at cost, unless specifically noted as included in price. Except as noted, Owner agrees to provide electricity, drinking water, electricity and bathroom facilities for employees and subcontractors of Lasting Impressions and to grant them free access to the work area and a parking area. Owner shall also allow areas for storage of materials, equipment and debris. Should a dumpster be required, Owner agrees to make space available to it, and shall refrain from using the dumpster for any purpose other than construction debris removal, unless otherwise agreed to by Lasting Impressions. GC shall supply a "Porta-Potty" for the first 5 months of demolition and construction activity. Owner agrees to allow its suitable placement on the Property. Owner is responsible for any additional disposal fees for debris which cannot be disposed of in a conventional dumpster (e.g., asbestos). Owner agrees not to hire additional tradesmen or contractors to work on the Property while this contract is active. In the event of an accumulation of snow or ice it is Owner's responsibility to clear their driveways and walks. Lasting Impressions will not work if there are unsafe snow conditions. Lasting Impressions shall make a reasonable effort to protect driveways, lawns and landscaping, but it is not responsible for damage to these items unless the damage results from its gross negligence. Renovation work involving framing or wall openings to adjacent rooms or to the exterior may cause cosmetic damage to neighboring walls, ceilings and/or floors. Furthermore, demolition or construction activities may cause cracks or movement in the structure outside of the renovation area. Lasting Impressions shall make a reasonable effort to minimize such damage, but unless noted will not attempt repair. If cosmetic repair is part of the Specification in the Approved Design, then Lasting Impressions will attempt to blend its work with existing materials, textures and colors, but exact duplication is not guaranteed. Lasting Impressions will make reasonable efforts to make renovated areas similar to existing areas. However, Owner understands and agrees that older homes and existing construction have sometimes been constructed in a manner which does not fully comport 5 ' Huster Remodeling Contract Rev 4.0 Page 3 of 12 with existing construction standards and building code provisions. Accordingly, it is not always possible to make the renovated areas fully match existing areas. III. Price to be Paid The price for Lasting Impressions' work pursuant to the terms of this Agreement shall be $236,668. This amount includes rebate of down payment of $2000 made on 2/24/2014 and waiver of additional $2000 due per 2/24/2014 contract as condition of acceptance of this Construction Contract and compliance with all payment provisions outlined in the following. Lasting Impressions shall receive at this signing of this agreement the sum of $60,000 IV. Payment Schedule Lasting Impressions shall submit invoices for additional payments as follows 1. A payment of $10,000 upon start of demolition work 2. A payment of $10,000 upon start of vermiculite remediation 3. A payment of $10,000 upon start of framing 4. A payment of $10,000 upon placement of window order 5. A payment of $10,000 upon rough plumbing inspection 6. A payment of $10,000 upon rough electrical inspection 7. A payment of $10,000 upon rough framing inspection 8. A payment of $10,000 upon insulation inspection 9. A payment of $10,000 upon start of wallboard installation 10.A payment of $10,000 upon cabinet order placement 11.A payment of $10,000 upon flooring order placement 12.A payment of $10,000 upon cabinet delivery 13.A payment of $10,000 upon countertop order placement 14.A payment of $10,000 upon start of interior painting 15.A payment of $10,000 upon final plumbing inspection 16.A payment of $10,000 upon final electrical inspection Huster Remodeling Contract Rev 4.0 Page 4 of 12 17.A payment of $10,000 upon final inspection 18.A payment of the balance as final payment at the time of substantial completion of all work included in this Contract to the satisfaction of both parties. . The time of substantial completion is the date when construction is sufficiently complete for the renovated area to be used as intended and will be conclusive and binding on all parties in establishing that Lasting Impressions will be entitled to receive the full contract price. This Date shall establish the "Effective Date" of the Limited Warranty outlined in Attachment B. Notwithstanding the foregoing, Lasting Impressions will not be entitled to final payment until the work has been completed to the satisfaction of the Owner, pursuant to Chapter 142A and 780 CMR R6. V. Terms and Finance Charges Unless otherwise specified, Owner agrees to pay invoices upon receipt. Lasting Impressions may assess, and Owner agrees to pay, finance charges of 2% per month on any balance outstanding 10 days from invoice date. In addition to the foregoing, in the event Lasting Impressions deems itself to be insecure Lasting Impressions may, pursuant to 780 CMR R6 and as a prerequisite to continuing work pursuant to this Agreement, demand that Owner place the balance of the funds due under this Agreement in a joint escrow account which requires the signatures of both parties for the withdrawal of said funds. Lasting Impressions further reserves the right to obtain security for performance of obligations under this Agreement by placing a lien on Owner's Premises pursuant to MGL ch.254 and any other applicable laws associated therewith. VI. Time of Completion Lasting Impressions will begin its work under this Contract on or about October 1, 2014, 2014 Substantial completion of this project shall be on or about February 1, 2015. Normal working hours shall be 7 am to 3 pm, Monday through Friday. Lasting Impressions agrees to start and diligently pursue the work through completion. However, the completion date may be extended due to delays beyond the control of Lasting Impressions, including but not limited to: delays in the issuance of necessary building permits or zoning variances, funding of loans, disbursement of funds, adverse weather conditions, unavailability of materials or labor, illness, unavoidable casualties, an act or neglect of Owner, additional work changes requested by Owner, failure of Owner to make payments when due, delays occasioned by acts of God, strike, changes in governmental regulations, acts of governmental agencies or their employees, catastrophes, wars, riots, and all similar occurrences beyond Lasting Impressions', its subcontractors' or suppliers' control. Owner agrees that the date of completion may be extended for a reasonable period of time without incurring damages or penalty for such delay or stoppages. Huster Remodeling Contract Rev 4.0 Page 5 of 12 If Lasting Impressions' work is delayed without the fault or responsibility of Lasting Impressions, then the time for Lasting Impressions work pursuant to this Agreement shall be extended to account for such delay and until such time as Lasting Impressions can complete such work. VII. Changes to Work Lasting Impressions' price for its work pursuant to the terms of this Agreement is based upon Attachment A. Owner may from time to time without invalidating this Agreement order such extras, additions, alterations or other modifications of Lasting Impressions' work under this Agreement as it may deem necessary. Changes shall be documented and agreed to b 9 Y Y 9 9 Y Owner and Stephanie Moore of Lasting Impressions. Such change order(s) shall set forth the scope of the additional work to be performed by Lasting Impressions and the price to be paid. Unless otherwise specified, change orders are payable in advance. If the contract price and specifications include allowances, then deviations from the specification shall be handled through the change order process. If the customer exceeds or under-spends the allowance, but without affecting other installation costs, then the change order shall reflect the change of the net price (including any tax, handling or delivery fees). Changes to allowances which also necessitate a change in other materials and methods will be handled on a case-by-case basis. Notwithstanding the foregoing, in the event Lasting Impressions is required to perform additional work in the absence of a written change order in order to comply with the State Building Code and the instructions of state and/or local officials, Owner agrees to pay for said additional work upon receipt of Lasting Impressions invoice for same. VIII. Subcontractors A subcontractor, for the purpose of this contract will be a person or entity with whom Lasting Impressions has a direct contract to perform a portion of the work described herein. Lasting Impressions has the right to subcontract any part or all of the work herein agreed to be performed. All subcontractors will be duly registered as required by the laws of the State of MA. Lasting Impressions agrees to bind every subcontractor by the applicable terms of the contract documents. The contract documents will not be construed as creating any contractual relationship between a subcontractor and Owner. Owner will have no authority to negotiate with Lasting Impressions' subcontractors or to directly subcontract any of the work described herein or to have any subcontractor work at the site under the terms of the contract without the written approval of Lasting Impressions. Huster Remodeling Contract Rev 4.0 Page 6 of 12 Lasting Impressions will have sole control of the construction personnel, including subcontractors. Owner will not issue any instructions or otherwise interfere with construction personnel, including subcontractors. IX. Insurance Lasting Impressions agrees to maintain liability insurance coverage to at least $1,000,000. Workers Compensation Insurance will cover all on-site employees and subcontractors. X. Owner-Supplied Materials Lasting Impressions shall have the right to reject any owner-supplied materials that are defective or require correction. Lasting Impressions will not be required to perform any work until such time as Owner provides Lasting Impressions with proper materials to perform its work pursuant to the terms of this Agreement. Lasting Impressions bears no responsibility for the scheduling, delivery, unpacking, associated debris disposal or transport of customer-supplied materials to the point of installation. XI. Signage In conformance with local signage codes Lasting Impressions is authorized to place signs for advertisement and to identify the site for material deliveries. Lasting Impressions is authorized to take photos for future use in portfolios and advertising provided that it does not provide specific information about the Owner or the Property address without the Owner's prior permission. XII. Warranty/Final Payment Release Upon Lasting Impressions' receipt of all payments due to it the under this Agreement, including payments for Change Orders, the Owner shall receive the limited warranty set forth in Attachment B, Limited Warranty. Lasting Impressions does not warranty any materials, fixtures or appliances that it does not supply and install. Lasting Impressions does not warranty leaks or other defects in piping due to freeze up situations, power failures or any other uncontrollable circumstances. XIII. Law and Effect The Laws of the Commonwealth of Massachusetts shall govern this Agreement. Huster Remodeling Contract Rev 4.0 Page 7 of 12 XIV. Severability and Waiver The partial or complete invalidity of any one or more provisions shall not affect the validity or continuing force and effect of any other provision. The failure of either party hereto to insist, in any one or more instances, upon the performance of any of the terms, covenants or conditions of this Agreement, or to exercise any right herein, shall not be construed as a waiver or relinquishment of such term, covenants, condition or right as respect to further performance. XV. Breach of Agreement/ Arbitration/Attorney Fees Controversies or claims arising out of or relating to any provision of this Agreement, or any breach or alleged breach of the Agreement, shall be settled by binding arbitration, subject to the requirements of Chapter 142A, or by litigation filed in the appropriate District or Superior Court of the Commonwealth of Massachusetts. The laws of the Commonwealth of Massachusetts shall apply to any and all such disputes. In the event Lasting Impressions prevails it shall be entitled to any reasonable attorney's fees, court costs, filing fees, court costs, or other legal or expert fees incurred to bring about such arbitration or litigation, in addition to any other recovery obtained in any litigation, arbitration or other legal action. OWNER'S CONSENT TO ARBITRATION BY THE REQUEST OF LASTING IMPRESSIONS Lasting Impressions and the Owner hereby mutually agree in advance that in the event Lasting Impressions has a dispute concerning this contract, Lasting Impressions may submit such dispute to a private arbitration service which has been approved by the Secretary of State of the Executive Office of Consumer Affairs and Business Regulations and the consumer shall be required to submit to such arbitration as provided in M.G.L. c. 142A. 1A Lasting Impressions: f Owner: NOTICE: THE SIGNATURES OF THE PARTIES ABOVE APPLYT NLY 0 O THEA AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE SETTLEMENT INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES XVI. Entire Agreement This Agreement is solely for the benefit of the signatories hereto and represents the entire and integrated agreements between the parties hereto and supercedes all prior negotiations, representations or agreements, either written or oral. XVII. Representation Owner represents that at the time of executing this Agreement that all parties who have performed work or supplied materials at the property have been paid in full. Huster Remodeling Contract Rev 4.0 Page 8 of 12 XVIII. Permit Notice As the Owner's agent, it is the responsibility of Lasting Impressions, directly or through its licensed subcontractors, to obtain any and all construction-related permits. The work as specified shall require the following permits: Building, Electrical and Gas Fitting, Plumbing and Mechanical. Should additional permits be required, Lasting Impressions shall obtain them directly or indirectly through its licensed subcontractors. Owners who secure their own construction-related permits or deal with unregistered contractors shall be excluded from the Guarantee Fund, pursuant to the provisions of MGL ch.142A. XIX. Miscellaneous Provisions Owner acknowledges receipt with this Agreement of the pamphlet entitled Renovate Right, informing Owner of the potential risk of lead hazard exposure from renovation activity to be performed on the Property. All Home Improvement Contractors and Subcontractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to Director, Home Improvement Contractor Registration One Ashburton Place Room 1301 Boston, MA 02108 Tel. (617) 727-8598 Owner has a 3-day cancellation right pursuant to MGL c.93 s 48, MGLc 140Ds 10 or MGL c 255D s 14 as may be applicable. A copy of said Notice of Cancellation form is provided herewith for use by the Owner. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES We, the undersigned, have read, understand and agree to each of the provisions of this Agreement and hereby acknowledge receipt of a copy of this Agreement. LASTING IMPRESSIONS OWNER CUSTOM DESIGN AND BUILD, INC. Wb Diane Huster Date eph nie L. Moore, president bate Huster Remodeling Contract Rev 4.0 Page 9 of 12 Attachment B: Limited Warranty Project Name: Owner(s): Effective Date of Warranty: For good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the undersigned warrantor (also referred to as "Contractor") hereby warrants to Owner, their heirs, successors and assigns, as follows: The Contractor warrants that the renovation and all accessories thereto were designed and constructed in accordance with the specifications set forth in Attachment A to this Contract, and the documents referenced therein, and generally accepted standards for a quality remodeled space; Contractor further warrants that there are no structural non-conformities or material defects in the remodeled area or accessories. This warranty shall not apply to defects or damages which are the result of normal contraction or expansion or the result of other normal or ordinary characteristics of building materials. This warranty shall not apply to defects or damage resulting from or to the extent aggravated by any neglect or failure on the part of the Owners to properly maintain such property in such manner as a reasonable prudent person would do. This warranty shall apply only to the area(s) that the Contractor remodeled under this Contract and does not apply to any materials, work, fixtures, appliances or systems that were not supplied by the Contractor. As applicable to the referenced project, the warranty shall include, but not be limited to, the items more specifically described below, with the exclusions as specified: 1. Plumbing and Sewer Disposal Systems. The operation of plumbing and sewage disposal systems is guaranteed for a period of one year, under normal usage. Dripping faucets or loose fixtures occurring within 120 days will be repaired by the Contractor. Frozen faucets are not covered in this warranty. 2. Mechanical Equipment and Appliances are covered by manufacturer's warranties and the Contractor hereby passes these through and assigns these directly to the Owners which Owners agree to look to in the event of a defect. However, this warranty covers the installation of mechanical equipment and appliances for a one-year period. In some cases, parts are covered and labor is not. Be sure to check each individual manufacturer's warranty. All kitchen and bathroom equipment P ui ment and countertops are assured to be accepted by the Owner unless the Contractor is notified of any defects in writing at the pre-settlement walk-through. All equipment must by maintained by the Owner according to the manufacturer's instruction. 3. Electrical Adjustments will be made by the Contractor, if required, for a period of ninety (90) days. Electrical appliances that cause a circuit breaker to cut out must be unplugged before resetting the circuit breaker. The electrical system, excluding light bulbs, is warranted against defects in materials and workmanship for a period of one year. Electrical appliances that cause a circuit breaker to cut out must be unplugged before resetting the circuit breaker. Huster Remodeling Contract Rev 4.0 Page 10 of 12 4. Glass or Screen Breakage is not covered by this warranty unless the Contractor is notified in writing at the pre-settlement walk-through or the glass or screen breakage is a result of improper installation. 5. Lawn. The responsibility for germination of seed and successful growth of grass remains with the Owner. Lawns must be watered carefully to receive the equivalent of 1" rainfall per week. Occasionally rocks will appear after a rain, or in the spring. These should be removed by the Owner. Washouts and ruts are normal and must be repaired and reseeded by Owner. 6. Exterior Doors are warranted for a period of one year against warping over 3/8". 7. Trenches for water, sewer and utilities are warranted against cave-in for one (1) year. 8. Ceramic and Resilient Tiles occasionally contain imperfections which do not require service. The occurrence of scratches, cracked tile, or missing or cracked grout is not covered by this warranty unless the Contractor is notified in writing at the pre- settlement walk-through. Loose tiles and flat-stones are covered by this warranty for ninety (90) days. Seams in plywood underlayment and protruding nails are covered for ninety (90) days. 9. Counter Tops Laminated counter tops are covered for ninety (90) days against delamination. Bubbling or scorching caused by hot objects is not covered. Granite and soapstone counter tops are covered for 1 year against cracking or seam separation. Stains or chips after installation are not covered. 10. Exterior and Interior Paint is covered for one (1) year against blistering and peeling. Normal fading of paint is not covered. Paint or stain on clapboards is warranted for a period of one (1) year. No interior nicks, dents, scratches or other imperfections in the paint are covered unless the Contractor is notified of such defects in writing at the pre- settlement walk-through. 11.Clapboards and Shingles are covered against splitting for one (1) year; however, it is not always possible to match paint, and any variance on color subsequently applied is unavoidable. As this splitting condition is not evidence of structural failure, replacement is not always advised. 12. Protruding Drywall and Plaster nails or seams are covered for ninety (90) days. Hairline cracks and seams are not covered by this warranty as they do not represent structural failure. However, any cracks in drywall or plaster caused by structural failure are covered for one (1) year. Repairs of plaster or gypsum wallboard may not completely blend with surrounding materials as it is almost impossible to match exactly the color and texture of the original surface. Repairs without charge will be limited to the problem area. 13. Repair of Hardwood Flooring which swells or buckles is covered for one (1) year. Minor shrinkage and separation of floor boards is normal and is not covered. Minor shrinkage and separation of floor boards can be retarded by raising the relative humidity in the dwelling. 14. Doors, Drawers, Windows, Cabinets and Interior Finish are covered by this warranty for warping, sticking or looseness for a one (1) year period. These items have a tendency to swell and shrink at different times of the year. Some may warp in winter and straighten in summer. Within one (1) year, items that cannot be made to operate will be exchanged. Windows are not 100% leak proof, and cold air outside can set up moving air inside. If this is the case, storm windows are recommended. Shrinkage of doors inside the jamb is normal, and if doors can be made to operate within industry standards they will not be replaced. Normal shrinkage and joint opening of door and window and baseboard casings is not covered by this policy. During the summer months the space between doors and jambs and sills is approximately 1/8" to 1/4". During the winter this increases f approximately 1/4" to 3/8". 15.A Tight Roof, including but not limited to those areas around the chimney and under the shingles, is warranted for one (1) year. Damage, if any, caused by snow or ice backing up under shingles, is excepted from the provisions of this warranty. It is the responsibility of the Owner to insure free passage in gutters and downspouts at all times. Gutters and downspouts, when installed, are warranted for one (1) year against Huster Remodeling Contract Rev 4.0 Page 11 of 12 leaks and looseness. Damage, if any, caused by windblown rain or snow through the roof, gable or soffit vents of louvers into attic space is excepted from the provisions of this warranty. 16.Concrete Foundation and Floor is warranted as being structurally sound. It is not possible to prevent concrete from cracking because of the nature of the material. Cracking, pitting, and flaking occur and are not covered, except for those foundation cracks greater than 1/4" in width or vertical displacement, or those that emit water, which are covered for one (1) year. Also covered for one (1) year are depressions exceeding 1/4" in 32" length and uneven floor area where crown exceeds 1/4" in 32" length. Cracks do not impair the structural strength of the dwelling. 17. Masonry Brick is warranted for a period of thirty (30) days, except with respect to issues related to installation and workmanship, which are warranted for one (1) year. To guarantee proper drafting, all masonry should be used in a reasonable manner. Unlike wood-burning stoves, fireplaces should not be subjected to the hottest fires. 18.Some Other Items of Construction not requiring service and not covered by this warranty: • Checks and twisting of studs, joists, and beams. ■ Crazing (hairline checking) in interior exposed beams and exterior plywood. ■ Minor shrinkage of wood materials. • Normal occasional dents associated with installation of woodwork. Claims Procedure. If a defect should appear which Owners think is covered by this warranty, Owners must notify Contractor promptly and within the applicable warranty period in writing. Describe the defect briefly and tell Contractor when Owners will be at home so that Contractor can schedule service calls appropriately. If delay will cause additional damage (i.e., if a pipe burst), telephone Contractor. Repairs. Upon receipt of Owners' written report of a defect, if the defectiye items are covered by this warranty, Contractor will repair or replace them at no charge to Owners as quickly as reasonably possible, but in no event later than within sixty (60) days unless due to weather conditions, labor problems or materials shortages beyond Contractor's control. The work will be done by Contractor, or subcontractors chosen by us. The choice between repair or replacement is ours. SEVERABILITY In the event that any of the provisions of this warranty shall be held to be invalid, the remainder of the provisions of this warranty shall remain in full force and effect. CONSTRUCTION OF WARRANTY This warranty shall be construed in accordance with Massachusetts law. LASTING IMPRESSIONS CUSTOM DESIGN AND BUILD, INC. Stephanie L. Moore, President Attachment C: Notice of Cancellation YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR OBLIGATION, WITHIN THREE BUSINESS DAYS FROM THE CONTRACT ACCEPTANCE DATE. IF YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE CONTRACTOR OF YOUR CANCELLATION NOTICE, AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. 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 CONTRACT OR SALE; 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 CANCELLATION, YOU MAY RETAIN OR DISPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE 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 CONTRACT. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO CONTRACTOR'S PLACE OF BUSINESS AS LISTED HEREIN, NOT LATER THAN MIDNIGHT OF ,20 I HEREBY CANCEL THIS TRANSACTION Date: Homeowner's Signature: .r Gas FPL FPL Switch DO NOT DEMO EXTERIOR LIGHTS salvage lights,wiring Outlet cut into mantel top or on wall just above and switches if possible One new ext outlet on deck-no other ext snv wriing FAMILY (Cathedral Ceiling) Tel jack-Comcast \ 258 sq ft phone line on left wall \ of Family Room,near Dining area \ Outlets to code and/or \ where indicated v ° DINING 190 sq It \\ New framed half-walls v D v v ° undercounter \eM� New framed walls Mwave Cubby outlet ° v \ D II IGHT) D L7 3E: \ \ I �ft v ec4em and RoutHtng Thermostat ["/-�_ �--- -- �� \ CLOT D D to sq It aoM QOM p '� KITCHEN ?`ti TV jack midway 0. ———— —— I counter,above 4' 150 sq ft i7 p v D I [7 Eacksplash v 10 sq ft \ \\ dan yebally D `_ I I_— `HW Panel _ FHW el vDp —--- -- ---- -—--- ar— — v � D $ D � ° I Huster Rev 120" 4.0 SCALE Outlet in left wall toward rear 1 , 7 ® SunTouch heating mat to be installed under porcelain the floor. t / Beadboard GFC wainscotting to be T installed up to 48" — height. a DM Install switches/ thermostat above wainscot. One outlet beside entrance door ganged with Disconnect existing switches Huster hallway light from top Rev 4.0of stairs circuit. Install new recessed ry!! light on dimmer switch. 120" SCALE 960WWO Jauolsslwwoo uol4eJldx3 --ow-e- 91919 -ow- -IB19 VW HZAOQMd QAC xvuza s BI11 MdRIS ' p£6ggti-SO :asuaol� losl.uadnS uo4:)n i;suoa spJe1pue1S pue suol;elnBaH Butpling;o pJeog AlaleS oygnd lo;uampedafl- s4asnyoesseW � dTrurrci�recaerrl/a�C�/��a�acccEure License or registration for individul i Office of Consumer Affairs&Business Regulation on valid use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: r Wxegistration: �g73gZ Type: Office of Consumer Affairs and Business Regulation piration:_(/.51.20:14 Private Corporatic'• 10 Park Plaza-Suite 5170 Boston,MA 02116, Lasting Impressions CW6rh Design&"Buil Stephanie Moore 8 Cedar rd. Andover,MA 01810 Undersecretary of valid wit out sig ature � 'he Commonveakk ofHassad.aseft } - �►e�aptmeatof.��tcl�st.�t��'.Acczc�e�ts • . Q.flee o, luvesfigafeons . 6#0 Wasfiington Street Poston,MA 02111 VwW.,rilassgovIdliz 't o)rke)col C-iO)UP owatiffla bsuranceAfidadt: 6TO Applwan Orcma zOz� PX ase ' xn Le bX 'Name,(Busies.ass/0zganizationlXndWdM): 1146;7146-7 1.xI/O/-($S l CRL5 ��-�. Z,41G Ad&ess• Cl I�tatel� : /-��i'�l�_NJ�' �"/8 /Clphoue�:, �'�� ®� �� • , . Ax•e yovt an employer?cheek mo appropxzate To Type of project(required): 41 am a general contractor and f 1.Q �am a employer with�_.. 6. ❑dew constx�tctzon. em to ees fqilland(ox Mt-fte).T havebiredtbesu�b-contractors - p y ( � � 7. .emadeling 2.[] I am a sole proprietor or partner . listed on the attached sheaf SMP and`liaverza•employees These sub-contractowhave 8. Demolition working forme in any capacity. workers'comp,insurance, g, ❑Buffding addition o workers'cam pUsurance 5. ❑�l e are a corporation and its 10. Bleetricalxe atrs ox additions required.] p• officers have exerelsed.tlieir p 3.[� X azn a b o�neownex doing allwork right of exemption pexlr/zG11 l'lumbingxepairs or additions Mysels.[go WAO&comp. c.152,§1(4),andwehaven.o -12.p RiQDfXqPaLrs insurancere ed. employees.[No workers' 13.E]Other comp.insurance required.] 'a kShDX#ZPIcniilaiobecmvsialso lionitheseetiozzbelov�showingtheirwbzkers'compensat[onpolicyinfozmation dthenhize ouiside conizacfors mvsL sv7zmai a nem aff+Zdayii indicaitng size&. i�ozneovrners v,�ho subzniithis af�daviiindicating�iey pi's doing alltvorlc an xCoslxacfors�J>ai aheckthis bo�mnsiattaehed an.additional sheeisho�vingthename ottiZe sub-eoniraefors andthei�vrorkers'eom�.�olicyinformaiion. _'arm,w employe,.tkat is providing Wogejs,eornpe�asatlon insr�rartee fov��y ernproyees. Burow is tkq liey amcijob site ira,fQtatior2. • Lnsurance CompmyName:. .Policy#or Bel ins.ic.#: ExpiratzouDate: • City/State/Zip: rob Site A.ddxes�: r . A•Bch,acopy oft�ewoxke&compensation-policy declaration page(show.ing-thepolicylimber and exl ravoucrate). Nailrtre to secure covexage as xegr dredunder,S`ection.2J''.A.ofMOL o.152 can lead to the imposition of eziminalpenalties of Sze up to$1,500.00ancTlor one�yeaximpxison�nertt,aswellaschRpenaldminthefoxrxofaSTOPWORISORDSanda ne ofup to$250.00 a.day against the wojator. Be advised that a copy ofthis siatamentmay be foxwardedto•the MOD of• Investigations ofthe DIA.for insurance coverage'4erifICation. ado Zzereby certify n�ic� the Tains c cipenarti o per,j uy Mat Ate infor�rta�`ion,provid'ed above is ftae and Bora ed, C � Data. 244° �. atizre• 'hone 4. offaeial'usa o,vly. Do notwiiie in this area,to be comprefeciby city ora tout 0 Wifff City or Town: Bermit/�icense# Sssuing A.nthoxity(circle ones: 1.Board of�ealth 2.Buildingl�e�artmextt �.City1'�owb.Clerl� �.ElectxzcaYxnspeetor �.>'IturabinglGzspector• f.Other information and Instructionsr Massachusetts General Laws chapter 152 requires all employers to providewoxkexs'compensation fortbei employees. Pursuantto thisstatute,an e�r�pToyeeis deT7ned as"...evexyperson:Kfhb service ofmother under any contract of hire; • express oximplied,oral oxwxitten." .Art e Tlaye�is deffned as"an.Individual,partnership,association,coxpoxation.ox other legal entity,or anytio ox�oxe' Of the foregoing engaged in ajoint enterprise,and includingtha TegaTxepxesentatives ofa'deceased empTQyex,.or the receiver o trustee off;an individual,pa�exsli%p,ashoiatiou ox other legal entity,employing employees. fflowevextha owner of a dwelling househavhgnotmoxe thaathxee apartments and who resldes'iherein,or the occupant oftA0 dwelling house of another who employs,persons to do maintenance,constmetion orxepair wort on such dwelling house ox onthe grounds or building appurtenant thereto shallnot because of such employment be deemed to be an.employer;" MGL chapter 152,§25C(6)also states that"every state or l0Cal lic-ensiug agency shall withhold the issuance or .renewal of a license or permit to operate a business or to construct brffldings in the commonwealth for•any appllmt who has not produced-acceptable,evidence of compliance with the insurance coverage required" .Additionally;MGL chapter 152,§25C(7)stafes `Neitherthe commonwealth nor any of its political subdivisions shall enter into any contract for the p exfonnmee of public woxT until a ccepfable evidence of cornpJiance wztlz tlxe ins�xan:ce regaixemenfs of this chaptexhave beenpxesentedta the contracting authority." Applicants Please iYtl out the woxSrexs'coinpensaiZon afOdavt completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractox(s)name(s),addxess(es)and honenumbex(s)along with their eertMeate(s)of insurance. LimitedUabifftyCompanies(LLC)orUmNdLkbilityPartnexships(f M)withno employees ofhertbmthe members oxpartners,arenotrequiradto carryworlters'compensation.insurance. Tian LLC orLLP doeshave employees,apolicy is xequhad. Do advised that"affidavitmay be submitted to the Department of Industrial Accidents for confirmation of Insurance covexage. Also be sure to sign,and date the affidavit. !te atzrdavit should be,xeturnedto the city or town that the application fox thepexmit or license is being requested,zrot Me De�axtment of In dustrial Accident. Shouldyou have any questions regarding the law or if you are xequired to obtak a*oxltexs' CQmV emationpolicy,please call the Department at ftmunber listed below. Self-:insuxedcoxnpaniesshouXdentextheir • self insurance license number on the appxopxiate Ike. City or Town OMcials Pleasebesuxethattlrea�izdavitiscompleteandpxintedlegibly: TlieDeparEmmenthaspxovidedaspaceatthehottom ox the aiNavit fox you too out k the avant the.Office of hVestigations has to contact youxegarding the applicant Please be-sure to zdl into pannit/license number w1doh-Will be used as a xefexence number, I addition,an applicant thatmust submitmultiple permit/license applications is any givenyear,need only submit one affidavit indicating current policy infomration(Ifnecessary)and under"hb Site Address"the applicant shouldwxite"all Tocatiens in (city or towzt)"A copyo thea idavitthathasbeenofWallystainpedoxmarkedby-thecityoxtownmaybeprovidedtothe applzcantaspzoofthatavalidaft'davitisonfzleoxi�turepexmzfsorlicenses, Anew aifxdaviErnustbelledouteacTZ year Whexeahomeowmerorcitizen,isobtainingaTicenseox,penniEnotrelatedtoanybusinessorcommercialventuxe (i.e.a clog license orjexmitto bum leaves eta)said person is NOT xequiredto complete this affidavit. The Office of lnvesfigaffons would lika,to Ifi nk you in advance for youx coop exation and should you have any cpesfxons, please do not hesitate to give us a call. The Department's address,telephone and fay numbex: TNI Go ozaN-GaM ofMUSO'c"imottI I)cTaTIMODt QVIICT l tai GCS(8X1t Moe offmAkA 6QQas�3l�g� a Qdon,M. 02111 Revised 5 2605