Loading...
HomeMy WebLinkAboutBuilding Permit #095-14 - 302 REA STREET 7/30/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION G/�� I Permit NO: D I"/ 114 Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION . / /I do Ve t, AM J t? A )L T -e f- Print to PROPERTY OWNER Print 100 Year Old Structure yes 0 MAP NO: PARCEL:©ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building bNolne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTIO1 OF WORK TO BE PERFORMED: Idepe�Cation lease or Print Clearly) n�� OWNER: Name: Phone: J Address: � 0 2 U14 St . *- AWJo�_e r Q � CONTRACTOR Name: bcyr Ca f ki n Phone: OAddress: r�D�x �.eR,p �'arc�,r ° bp( .lbr,° f Supervisor's Construction License: 3 Exp. Date: Home Improvement License: 'rip 3 Exp. Date: . )y ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. p� Total Project Cost: $ ?co 0 FEE: $ Check No.: Receipt No.: Z(,o& 7LI a. NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature,of contractor kW_ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ - - T J Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE-017 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW To`yo Engineer: Signature: gyp. FIRE DEPARTMVINIT Temp Dumpster on site yesLocated 384 Osgood Street_ Located at 124 Mainr Street no Fire Department signatureldate r 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 Ll Notified for pickup - Date ' EE I € Doe.Building Permit Revised 2010 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 o Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New ConstructionSin le and Two Family) ( g Y) ❑ 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) o 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 apw al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Bui!ding Permit Revised 2012 Location .3 c)tz, /fPa- 5�7 No. V J Date 73 i a • - TOWN OF NORTH ANDOVER Wr . Certificate of Occupancy $ Building/Frame Permit Fee $ �• Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check "Building Inspector NORTH own of EAndover 0 � ':.T. - No. 0% ,w Iq 0 rA. ver Mass O . 1 A-'P coctiicMewrcw 1. S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ��,I*e '# ...... BUILDING INSPECTOR .............................................�........................ ............. ......... ........... .. . ........ ..... has permission to erect ................ buildings on Z 416 � �e� Foundation .......... .............................................................................. Rough tobe occupied as ........ .. ...... ....... ...... �. �� ........:....................................... 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 UNLESS CONSTRUCTION STARTS Rough Service ................................................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT C Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 2 3 0 t > ��� �' ��� License Number Expiration Date Name of CSL-Hol r List CSL Type(see below) tRO(- a ( , dress U13 aye A0-`4P T Description U Unrestricted a to 35.{1(X)35.{1(X)Cu.FQ Restricted 1&2 Family Dwelling Si ature M Mason Oniy 7 7 8" e5)' 4�� RC Residential Rooting Covering Telephone WS Residential Window and Sidin SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition _ 5.2 Re 'stered Home Improvement Contractor(HIC) MIC Company Name or HIC R gistrant Narge Registratyon Number c. All6 Ad < aX f' 9 7 6 _ yg7 n1 Expiration bate S afar Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 1.52.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes'�(No 0 Current Certificate must be on file in office Yes SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, jkLAu �4 as Uvner of the subject property hereby authorizeto act on my behalf,in all matters relative to work authorized by}Itis building permit application. b.47 Signature of Owner Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION I, A t',A/`62,:�' C2,,tp14 � ,as Owner or Authorized Agent hereby declare that the stateme is and information on die foregoing application are true and accurate,to the best of my knowledge and behalf. Pnnt Name Sign iturc oC 9,er or Authorized Agent Date (Sigi ed under the ms and Wallies of lay 1 NOTES: 1. An Owner who obtains a building permit to do hisiber own work.or an owner who hires an unregistered contractor (not registered in the Horne Improvement Contractor(HIC)Program).will not have access to the arbitration i program or guaranty.fund under M.G.L.c. 142A.Other important information on the HiC Program and Constriction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I).R6 and 11).R5,respectivel}. 2. When substantial work is planned.provide the information below: Total floors area(Sq. Ft.) (including garage,finished basement/attics.decks or porch) Gross living area(Sq.Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of ltalf/baths Type of heating s stem _ Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" Proposal AB Carnes Inc. Page 1 of 1 30 Arrowhead farm Rd Boxford, Ma. 01921 978.887.1431 Mass, Builders License No.000230 Contractors Registration. No 100733 Proposal Submitted To: WALTER&ELIZABETH GILL Date July 25, 2013 302 REA ST Project Name SAME NORTH ANDOVER, MA 01845 Address 978-975-1622 We propose to furnish material and labor-in accordance with the specifications below: Sixty Four Hundred Dollars($6,400.00) Payment to be made as follows: $300,00 Deposit, Balance Upon Completion - - d Notice:All home improvement contractors and subcontractors engaged in home Authorized improvement contracting,unless specifically exempt from registration by provisions Signature a of Chapter 142A of the General Laws,must be registered with the Commonwealth Note:This`proposal may be withdrawn by us if not accepted within 30 of Massachusetts. Inquiries about registration and status should be made to the days. Mass.gov/licenses website. ROOF PROPOSAL ® STRIP ROOF OF ALL LAYERS OF ASPHALT SHINGLES.COVER ROOF DECK WITH TITANIUM RHINOROOF HIGH PERFORMANCE WATERPROOF UNDERLAYMENT MEMBRANE.COVER EXTERIOR WALLS AND FOLIAGE WITH TARPS TO HELP PREY AGE. ® INSTALL CARLISLE HIGH PERFORMANCE ICE&WATER BARRIER OVER ALL HEATED AREAlf SIX FEET IDE AT THE LEADING EDGE OF ROOF AND THREE FEET IN ALL VALLEYS&AROUND ALL ROOF PENETRATIONS. ; .. ® COVER ALL PERIMETERS WITH EIGHT INCH ALUMINUM DRIP EDGE. ❑ INSTALL RIDGE VENT AND/OR®AS NEEDED ROOF LOUVERS FOR ADDED ATTIC VENTILATION, ® COVER SOIL PIPES WITH NEW RUBBER FLASHING BOOTS. ❑ REPLACE WALL FLASHING(S)AS NEEDED WITH ALUMINUM OR LEAD AT THE ADDITIONAL COST OF PLFT.WE MAY NEED TO REMOVE THE SIDING TO PERFORM THIS WORK,YOU MAY NEED TO HAVE A CARPENTER REINSTALL THE REMOVED SIDING. ® CHIMNEY FLASHING;CUT ALL EXISTING TAR AND LEAD FROM TWO CHIMNEY(S).CUT NEW REGLET WITH CARBIDE SAW AND SECURE NEW LEAD FLASHING IN PLACE W/LEAD ANCHORS. PROPERLY SEAL REGLET JOINT. PLEASE ADD$500 IF NEEDED TO ABOVE PRICE. ❑ REBUILD CHIMNEY FROM ROOF DECK UP WITH NEW OR USED BRICK. ADD ==ABOVE PRICE. ® COVER ROOF SURFACE WITHCERTAINTEED LANDMARK ARCH ITECTURAL.LIFETIME.WARRANTY 240LB SHINGLES. ® REPLACE DEFECTIVE ROOF DECKING WITH CDX PLYWOOD AT AN ADDITIONAL COST OF$4.50PSQFT. ❑ COVER ROOF DECK WITH CDX PLYWOOD AS NEEDED TO REPLACE OR REPAIR DEFECTIVE DECKING,AT AN ADDITIONAL COST OF ® SHINGLES ARE TO BE STORM NAILED.ESSEX COUNTY BUILDING CODE REQUIRES SIX NAILS INSTEAD OF FOUR. ❑ REPLACE EXISTING SKYLIGHTS WITH NEW VELUX UNITS WITH FLASHING KITS,WE WILL PROVIDE THE SKYLIGHTS&FLASHING KITS AT OUR EXACT COST FROM OUR SUPPLIER.THERE WILL BE NO LABOR CHARGE IF THEY ARE THE SAME SIZE.INTERIOR WORK IS EXCLUDED. ❑ REMOVE EXISTING GUTTERS ❑INSTALL NEW SEAMLESS.032 ALUMINUM GUTTERS USING THE POSITIVE LOCKING BAR HANGER SYSTEM. ® REPLACE DEFECTIVE OR ROTTED TRIM BOARDS AS NEEDED WITH NO.2 PRIMED PINE,ADD$15.00 PER FOOT TO ABOVE PRICE. ❑ INSTALL NEW ALUMINUM DOWNSPOUTS. MECHANICALLY FASTEN ALL CONNECTIONS. CLEAN ALL PROJECT RELATED DEBRIS FROM OUTSIDE WORK AREA. THE PROPERTY OWNER AUTHORIZES AB CARNES,INC TO OBTAIN ALL PERMITS.WE CANNOT ACCEPT RESPONSIBILITY FOR DEBRIS FALLING INTO ATTIC�E'A —OHS%MMEI3ZH0ULD COVER VALUABLES GREAT CARE WILL BE USED TO PST CT THE STRUCTURE AND FOLIAGE.HOWEVER,SOME MARRING AND OR MINOR DAMAGE COULD 0D SPECIAL INSTRUCTIONS:. THE ABOVE PROPOSAL INCLUDES ALL ROOF SECTIONS WARRANTY UPGRADE:THE CERTAINTEED WIND WARRANTY WILL BE UPGRADED FROM 110, PHJO 130 MPH WITH AN UPGRADE TO THE HIGH PERFORMANCE HIP&RIDGE CAPS AND STARTER COURSE AT NO ADDITIONAL CHARGE.YES f EMAIL ADDRESS:4i L,� 4 Warranty:All work warranted against installation defects for 5 years;this warranty is limited to the installed item(s)and its repair only,Material is warranted by the manufacturer against defects for 50 years;please see the manufacturer's warranty for exact warranty performance. Cancellation:Customer has legal right under federal law to cancel this contract without penalty or obligation within four business days from the date of signing this agreement via Priority Mail Delivery Confirmation. Please see reverse side °F. Dispute Resolution under Massachusetts Home Improvement Law 142a:All pa i green advance that any and all disputes relating to this proposal shall be settled by binding arbitration.This forum is user friendly and does not require lawyers.Plea0e see reverse side,/ Iky Customer' �' Date Contract o f`F' Date s; Signing this Proposal means you have acoepted all the terms as stated on the front and back of t�iis agreement. Date of Acceptance Signature ! Slgnatu PLEASE SEE REVERSE SIDE i Massachusetts-Department of Public Safety Board of Building Regulations and Standards (on.trucuon supen 1sor License:CS-000230 I� BARRY S CARPIES 30 ARROWHEAD-FARM RD Boxford MA-o1921 = Expiration Commissioner 03/07/2014 Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Registration: 100733 Type: Private Corporation Expiration: 6/23/2014 Tr# 223142 A. B. CARNES, INC. Barry Carnes 30 Arrowhead Farm Rd. - ---"-� Boxford, MA 01921 Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card DPS-CAI 0 SOM-041040101216 " NORTH ANDOVER WASTE AFFIDAVIT As a result of the provisions of MGL Ch.40-s54, I acknowledge that as a condition of building permit# all debris resulting from the construction activity governed by this building permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL Ch.111-s150A. Waste Disposal or Solid Waste Facility: ALLIED WASTE Address: 300 FOREST ST Town/City, State, Zip: PEABODY, MA 01960 NAME OF HAULER: AB CARNES, INC. DUMP TRUCKS DATE: 7-29-13 SIGNATURE OF APPLICANT: i -� OP ID: SA ACORL7 CERTIFICATE OF LIABILITY INSURANCE DATE03/13DYYYV) �..�' 03/13113 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER 978-744-6715 NAME, AHMED Insurance Agency,Inc. 9787410127 PHONE --- —�- — FAX - - -- PO BOX 449 (A1C,No,Ext): (AIC,No): Salem,MA 01970 E-MAIL ADDRESS: Stephen G.AhmedPRODUCER ABCAR-1 f CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC p INSURED, A B Carnes Inc INSURER A:Essex Insurance Co 30 Arrowhead Farms Road INSURERB:Safety Insurance Company 33618 Boxford, MA 01921 INSURER C INSURER D: ` INSURER E: ' INSURER F; COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR TYPE OF INSURANCE ADDL 5UBR POLICY NUMBER MPOLICY EFF POLICY EXP LTR IDDlYYYY MMIDDlYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000,00 A X COMMERCIAL GENERAL LIABILITY 3DF9266 03/18113 03/18/14 DAMAGERENTED PREMISESS(Ea ococcurrence) S 60,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) S 1,00 PERSONAL&ADV INJURY S 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS COMP,OP AGG S 2,000,00 X POLICY PRO LOC PD Deduct - 50 AUTOMOBILE LIABILITY COMBINED LIMIT S 1,000,00 L ANY AUTO BOL?!LY INJURY,Per person $ ALL OWNED AUTOS BODILY INJURY(Pei acciden+.) a B X SCHEDULED AUTOS 6213192 05/02/12 05/02113 PROPERTY DAMAGE B X HIRED AUTOS 6213192 05/02/12 05/02/13 'Peracc,dent) Inc B X NON-OWNED AUTOS 6213192 05/02/12 051`02113 S S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE S DEDUCTIBLE S RETENTION $ S WORKERS COMPENSATION WC STATU- 0TH. AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE f—. E L EACH ACCIDENT $ OFFICE RIMEMBER EXCLUDED N f A (Mandatory In NH) `"— E L DISEASE-EA EMPLOYEE $ If yes aescnbe under DESCRIPTION OF OPERATIONS below El DISEASE•POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORO 101.Additional Remarks Schedule,If more,space is required) Roofing Contractor CERTIFICATE HOLDER CANCELLATION TOWNN04 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, 120 Main Street North Andover,MA 018 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD Berassachusetts ` �� Workers' Compensation Insurance Plan .acacia insurance Company NCUi �a,r-e' -'c ( [(\ dr,,ntstereC by Berrie, Assio,ec R s� Se,,. -}, O Boy '100 mirmeano— Mfnn,sSota `-r44. anone 60- b4;5­144 Fax 8,5�6 '8 'en F�ae K 4=_ smut 0eW,!vaSS,o-eCr,Sr cor, CERTIFICATE OF INSURANCE WCIP . ^ Jn'b! WC-20-20-004717-00 1 American Construction Inc ` r `a - Qti- iso 'Q4 242 Belmont Street Unit 2 Brockton. MA 02301 r/ 1 _� t'er`0" -' '' 412412013 412#12014 Nate^ lao-T: 5r312013 T"e Cerz.`icate s issued as a utter of wormation only anc confers ^o rionts .;-or, :rF �,ertty':3z" " s Certificate goes not amend extern or alter the, coverage afforceC c cv the 'oi , ls'el. oe �s to Certify trat the POIICV of Insurance described nere'n nos bee- 'SSued ,C '".c ^ "' a eo 3r0,'e t^' "')F a01icv period incitc3,ed Nott°."ihStancirg arty equirement tern' or :ondliio'' 0' a,,, 1oc, ment -;h recpaCt t0 wniG` 'nis Ce t fiCate (h''3V be SSUed Or nlaV pC'r 3 r 'Ile ins ranCe of{OrdCC Oy ;nc * ^ 1 V l@SCr 1F,C he'?'r S SLID�ect :o a',i `re tea's exclusiors anC conoitions of SUcr °otic, I TYPE OF INSURANCE i LIMITS OF LIABILITY , Part One �'-- :orcecs xmpensalior. Statutory. MA Fart Two 130011y InjU:v by Accideirt 51,000 900 each accice- Employers'uabihty Booily injury uy Disease S1.000 000 oohcy hrn;t 5ocnv nl�uv oy J Seale 5' i_'' ,, .yarn t-;• .e 5nouio am, of the ancve desc,�oed .oi)cies be Cancelled betore :he wxv•ration ;ate --)f ,ioiice v4'ii ne de!ive(cC n accordance wi," :he ovccJ provisions All Gbit tieslinsweds ;it:cate?-+oieer s 'gime arc! %.c1cress 1 American Construction Inc c�e-:,.Cr F. r , AB Carnes Inc ::3tec..ti Sri;:` '''-` _ 30 Arrowhead Farm Road officer Include Manuel J Tema Caquan, Boxford, MA 01921 5112013 Ace Insurance Services Inc 675 Warren. Ave Brockton, MA 02301 Signature r The Commonwealth of Massachusetts Department of Industria!Accidents �-- OffIce of investigations 600 Washington Street Boston, MA 02111 . ; • www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Businesslorgatvzatior/individual): Address: (��J�l f.��14(A r�A,/ v City/State/Zip: ,�C /��( Phone#: j90 1�01 Are you an employer?Check the appropriate b x: Type of project(required): 1.❑ 1 am a employer with I am a general contractor and I fi ®New construction employees(full and/or part-time),* have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling- 2. emodeling 2.[3 I am a sole proprietor or partner- ship and have no employees These sub-contractors have g. [�Demolition employees and have workers' working for me in any capacity. 9. ❑ Building addition [No workers'comp.insurance comp. insurance.+ required.] 5. We are a corporation and its 1 O.Q Electrical repairs or additions 3.❑ t am a homeowner doing all work officers have exercised their 11.[] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12Z Roof repairs insurance required.] c. 152,S 1(4),and we have no employees. [No workers' 13.0 Other _ comp. insurance required.] *Any applicant that checks box-"I must also fill not the section below showing their workers'compensation policy information. I Homeowncrs who submit this affidavitindicating they are doing all work and then hire outside contractors mustsubmit a new affidavit indicating such. tt'ontractors 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 jab site iq formation. Insurance Company Name: Policy#or Sclfins. Lic.#: Expiration.Date: — Job Site Address: City/State/Zip: 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 51,500.00 and/or one-year imprisonment,as wcli as civil penalties in the form of a STOP WORK ORDER and a.11 fie of tip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of I nvcstigai ions of the DIA for insurance coverage verification. I do herekt'ce under tlreysliins and penalties of perjury that the information provided above is true and correct. Si aturc: > f Date: .2 - Phone - Z Phone#: Official rise only. De not write in this arev,to be completed by city or town official. City or Town: PermitiL,icense# Issuing Authority(circle one): 1.Board of Health 2..Building Department 3.City/Town Cleric 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: FORM 153 The Commonwealth of Massachusetts DIA Use Only Department of Industrial Accidents r Office of Investigations-Dept. 153 1 Congress Street,Suite 100,Boston,Massachusetts 02114-2017 http://www.mass.gov/dia Invest./SWO ID#: AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPORATE OFFICERS OR DIRECTORS Chapter 169 of the Acts of 2002 amended M.G.L. c. 152, §1(4)by adding the following paragraph: "This chapter shall be elective for an officer or director of a corporation who owns at least 25 percent of the issued and outstanding stock of the corporation.Notwithstanding section 46,these provisions shall apply only if the corporate officer provides the commissioner of industrial accidents with a written waiver of his rights under this chapter.Said commissioner shall promulgate regulations to carry out the purpose of this paragraph.Violations of this paragraph shall subject the corporation to the penalties set forth in section 25C." Pursuant to M.G.L.c. 152,§1(4)as amended,I/We the undersigned officers of: AB Cames,Inc.30 Arrowhead Farm Rd Boxford,Ma 01921 (Name of Corporation and Address) each holding at least 25%of the issued and outstanding stock in said corporation,do hereby invoke the right to be exempt from the provisions of M.G.L.c. 152,§25A and therefore are not required to carry a workers' compensation policy covering the undersigned corporate officer(s)or director(s). IIWe the undersigned do also waive any and all rights to make claims for benefits as defined in M.G.L.c. 152 for any injuries that may be sustained while in the employ of the above-named corporation. Further,I/we the undersigned do understand that,should the above-named corporation hire or have in its employ any employee(s)in addition to the undersigned corporate officer(s)or director(s),said corporation is required to obtain workers"compensation coverage for the employee(s)as prescribed by M.G.L.c. 152,§25A. I/We the undersigned have read and understand the statements and obligations as delineated above and I/we have checked he appropriate box below my/our name(s)indicating my/our desire to be exempt or not o be 1pt Er the provisions of M.G.L.c. 152. ed under t pains and penalties of perjury: c� Barry Cames,President 04/3/2012 Si nature Print Name&Title Date(mm/dd/yyyy) wish to exercise my right of exemption or ❑ 1 wish NOT to exercise my right of exemption Anastasiya Cames,Director 04/03/2012 Signature Print Name&Title Date(mm/dd/vyyy) ❑✓ I wish to exercise my right of exemption or ❑ I wish NOT to exercise my right of exemption Signature Print Name&Title Date(mm/dd/yyyy) ❑ I wish to exercise my right of exemption or ❑ I wish NOT to exercise my right of exemption Signature Print Name&Title Date(mm/dd/vyyy) ❑ I wish to exercise my right of exemption or 111 wish NOT to exercise my right of exemption Note:ALL ELIGIBLE CORPORATE OFFICERS MUST SIGN.THERE CAN BE NO MORE THAN 4 SIGNATURES.Instructions on back. Form 153—7/2010 MA SOC Filing Number: 201287835330 Date: 5/30/20129:10:00 PM �-4 Cs- A The Commonwealth of Massachusetts No Fee 4William Francis Galvin _ Secretary of the Commonwealth,Corporations Division One Ashburton Place, 17th floor { Boston,MA 02108-1512 ►,i��, ►�'�` Telephone: (617)727-9640 mie MI&IT. . 1. Exact name of the corporation: A.B. CARNES,INC. 2. Current registered office address: Name: BARRY S. CARNES No. and Street: 30 ARROWHEAD FARM ROAD City or Town: BOXFORD State: MA Zip: 01921 Country: USA 3.The following supplemental information has changed: _Names and street addresses of the directors,president, treasurer, secretary Title Individual Name Address(no PO Box) First,Middle,Last,Suffix Address,City or Town,State,Zip Code PRESIDENT BARRY S.CARNES 30 ARROWHEAD FARM ROAD, BOXFORD,MA 01921 USA TREASURER BARRY S.CARNES 30 ARROWHEAD FARM ROAD, BOXFORD,MA 01921 USA SECRETARY BARRY S.CARNES 30 ARROWHEAD FARM ROAD, BOXFORD,MA 01921 USA DIRECTOR BARRY S.CARNES 30 ARROWHEAD FARM ROAD, BOXFORD,MA 01921 USA DIRECTOR ANASTASIYA CARNES 30 ARROWHEAD FARM ROAD, BOXFORD,MA 01921 USA X Fiscal year end: October X Type of business in which the corporation intends to engage: GENERAL CONTRACTING&MARKETING X Principal office address: No. and Street: 30 ARROWHEAD FARM ROAD City or Town: BOXFORD State: MA Zip: 01921 Country: USA X g. Street address where the records of the corporation required to be kept in the Commonwealth are located (post office boxes are not acceptable): No. and Street: 30 ARROWHEAD FARM ROAD City or Town: BOXFORD State:MA Zip: 01921 Country: USA which is X its principal office _ an office of its transfer agent an office of its secretary/assistant secretary _ its registered office Signed by BARRY S.CARNES, its PRESIDENT on this 30 Day of May,2012 ©2001 -2012 Commonwealth of Massachusetts All Rights Reserved MA SOC Filing Number: 201287835330 Date: 5/30/2012 9:10:00 PM THE COMMONWEALTH OF MASSACHUSETTS I hereby certify that, upon examination of this document, duly submitted to me, it appears that the provisions of the General Laws relative to corporations have been complied with, and I hereby approve said articles; and the filing fee having been paid, said articles are deemed to have been filed with me on: May 30, 2012 09:10 PM - t WILLIAM FRANCIS GALVIN Secretary of the Commonwealth