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HomeMy WebLinkAboutBuilding Permit #320-13 - 31 FOXHILL ROAD 10/17/2012 i i TOWN OF NORTH ANDOVER i APPLICATION FOR PLAN EXAMINATION Permit NO: I Date Received Date Issued 0/ IMPORTANT: Applicant must complete all items on this page 77- 77 Print PR®PERTY OWNER %_ / P crit nt 100 Year,.01 ,Structure�n yes: no MAP=NO ; ARCEL. ZONING�DISTTRIC,ti� HistoncDistnct yes _ Machine', ho0Nillage yes3 w n 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 ❑,Sgptic - ❑Well+ T " -4Eloodplain � ` -If 1NetIands, "❑a 1Nat �diDist.rict# ershe ❑NV ter/S:ewer�: y .- . i DESCRIPTION OF WORK TO BE PERFORMED: LC r--7- �4 I I Identification Please Type or Print Clearly)YP OWNER: Name: Phone: Address: . `CONa,RACTOR' Name ryAmv one.: _ ` ter I . ��7_ 1 Supervisor=s Construction LicenseS � s� Exp, ®.ate — - a - _ l,Home�� mprovemenf License: O Exp Date. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. I Total Project Coat: $ ��_ 705s FEE: $ I Check No.: / 2 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature ofAent%Owner; ,.. �. - Si naftareof contracto Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ . Sta ped Plans ❑ Location No20 Date% 2 — • TOWN OF NORTH ANDOVER AA Certificate of Occupancy $ , Building/Frame Permit Fee $ x. Foundation Permit Fee $ � Other Permit Fee v $ TOTAL $ Check#�� 25847y' Building Inspector .; to I 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 ❑ � 1 1 I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ I COMMENTS 1 I CONSERVATION Reviewed on Siqnature I COMMENTS 'I I I HEALTH Reviewed on Siqnature COMM�NTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes i1 Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Siqnature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT = Temp Dumpster on.siteyes no Located at 124,Main'Street= . _ ._ ...m .. Fire Deparfinent signatureldafe ra COMMENTS I I Dimension i Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: I, ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No I' DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use I I B Notified for pickup - Date Doc.Building Permit Revised 2010 III . Building Department The foliowing is a list of the required forms to be filled out for the appropriate permit to be obtained. ! � I Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit Li Photo Copy Of H.I.C. And/Or C.S.L. Licenses I o Copy of Contract Li Floor Plan Or Proposed Interior Work Li Engineering Affidavits for Engineered products (VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o 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 Construction (Single and Two Family) L3 Building Permit Application o Certified Proposed Plot Plan L3 Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract Li Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits p p s 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: Doc.Building Permit Revised 2012 i I ` L ve No. 43;oaw _ ver, Mass • Y O 13LATh ^. > > 0 Ab COC.IICNl—CK V `� CRATED I'Pp��S S u BOARD OF HEALTH PERMIT D Food/Kitchen Septic System THIS CERTIFIES THAT ................ . ,. .. ...... ....... .... ► �!°.. .............................................. BUILDING INSPECTOR has permission to erect ...... buildings on ....a(...... • , Foundation Rough Sto be occupied as ........... ......... ...................... .®. .._.................. ...... Chimney provided that the person accepting this permit shall in every respect confo 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO A 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 Fina' No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by.fhe Building Inspector. Burner { Street No. Smoke Det. SEE REVERSE SIDE From:6177422832 10/23/2012 14:35 #115 P.001 /001 Righ N2-1 10/19/2012 6: 08 : 18 AM PAGE 2/002 Fax Server Ir ' ' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) T . IFICATE 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 and endorsement. A statement on this certificate does not confer rights to he certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: KNAPP SCHENCK&COMPANY PHONE FAX 137 LEWIS WHARF (A/C,No,Ext): (A/C,No): EMAIL BOSTON,MA 02110 ADDRESS: 265KW INSURER(S)AFFORDING COVERAGE NAIC 0 INSURED INSURER A: ACE AMERICAN INSURANCE COMPANY INLAND QUALITY BUILDERS LLC INSURER B: INSURER C: 28 MEADOW LANE INSURER D: INSURER E: WESTFORD,MA 01886 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: HIS IS TO CERTIFY THAT THE POLICIES OF INSURANICELISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HER13N IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_ INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MKDD1YYYY) (MMDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE g COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE C]OCCUR. REMISES(Ea occurrence) ED EXP(Any one person) $ ERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY [:]PROJECT Q LOC RODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY OMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS ODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS ODILY INJURY $ NON-OWNED AUTOS (Per accident) ROPERTY DAMAGE $ Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X WC STATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-4701PB98-12 06/15/2012 06/15/2013 LIMITS ANY PROPERITOR/PARTNER/EXECUTNE a N/A E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTR(CTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER BUILDING DEPARTMENT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL B DELIV IN ACCORDANCE WITH THE POLICY Pl! VMl AUTHORIZED REPRESENTATIVE NORTH ANDOVER,MA O 1845 .1. - Z!2-- ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CC A I ghts reserved. From:6177422832 10/17/2012 09:42 #079 P.002/002 CERTIFICATE OF LIABILITY INSURANCE DATE(MM oD/YYYY) T64ZER7IFICATE IS ISSUED ASA 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: KN.AP P SCHENCK&CO.MPANY PHONE T(A 137 LEWIS VVI!412 ' (A/C,No,Ext): Na}: BOSTON,MA 02110 EMAIL ADDRESS: 265KW INSURERIS)AFFORDING COVERAGE NAIC 11 INSURED INSURER A: ACE A2MERICAN WSURa�:CE CGI.TF-Ni INLA JDD QL'ALIT:'BC}I.DERS LLC INSURER B: INSURER C: } INSURER D: 28 1vrEADOW LAlv'F. INSURER E LLrESTFORD,MA Cl 886 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER HIS is T CERTIFY AT TH POWCIES F INSURANCE LI5T D B W HAVE BEEN ISSUED TO TkE INSURED NAMLIJ ABOVE FOR THEPOUCY 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 NSURANCEAFFORDED 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, ;SR ADD SUR POLICY EFF DATE POLICY EXP DATE LTR TYPEOFINSURANCE L R POLICYNUMBER (MROMYYYY) (MMJ]DIYYYY) LIMITS GENERAL LIABILITY ACH OCCURRENCE rGFI1r'L MMERC!AL GENERAL.LIABILI rY $ CLAIMS MADE O OCCUR. DAMAGE TO RENTED 1$ REMISES(Ea occurrence) rr.ED EXP(Any one person) $ GREGATE L!!�1tT APPLIES PER. ERSONAL&ADV:NJURY ($ .ICY [--I PROJF..0 T IOC ENERAL Zr,GRE,3A"-E I'S RODUCTS-COMP/OP AGG 5 � AUTOMOBILE LIABILITY � ANY AUTO OIYBINED SINGLE I$ IMIT(Ea accident) ALL OWNED AUTOS ODILYNJURY $ SCHEDULE AUTOS Per person) HIRED AUTOS ODILY NJURY $ NON-OWNED AUTOS Per accident) PROPER'"Y DAMAGE i$ (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE_ ':,$ EXCESS LAB CLAMS-MADE IkGGREGATE Ig DEDUCTIBLE I$ RETENTION s A WORK ER'S COMPENSATION AND =L0 TORY OTHER EMPLOYER'S LIABILITY Y/N UB-4701P493-12 08/15/2012 08/'5/2013 y ANY PROPER!TOR:PARTNER/EXECUTIVE N/A 1 OFFICERNIEUGER EXCLUCED4 E L.EACH ACCIDEI.IT' ;s 100.000 yioryin NH) Tes.ues�;ne�rarE.L.E. DISEASE-EA EMPLOYEE $ 100,000 lyes. OFSCR!PTCJN OF OPERATIONS bs*'ow E.L.DiSEASE-POLICY LIV.;fT i$ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS 71113 REPLACES ANY PRIOR CERITF'ICATE ISSUED TO THE CERTIFICATE HOLDER AFcEC,1W. G WopXERS COMP COVERASE CERTIFICATE HOLDER rAUTHORIZED THE ABOVE DESCRIBED POLICIES BE CANCELLED PIRATION DATE THEREOFNOTICE WILL 8 DELIV D WITHTHEPOLIGYPROV l OF ACORD 25(2010!05) The ACORD name and logo are registered marksof ACORD 1988-2010 ACORD CORPO A I ' ngh s eserved. From:6177422832 10/17/2012 09:19 #077 P.002/002 INLAQUA-01 SWHITEHURST CERTIFICATE OF LIABILITY INSURANCE i - DATE(MMIDD/YYYY) -' 10/17/2012 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 J j 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). - (PRODUCER CONTACT NAME__ Kri pp,Schenck&Company Insurance Agency,Inc. PHONE -- - - FAX 1137 Lewis Wharf -LAic.No.Ext)_(617)742-3366 ac Ne 617 742-2832_ :Boston,MA 02110 EMAIL ( ) ADDRESS: INSURERS)AFFORDING COVERAGE NAIC q �— -- INSURERA:Endurance American Specialty Ins Co i INSUREDINSURER 8: Inland Quality Builders,LCC INSURERC: --- - 28 Meadow Lane INSURER D: Westford,MA 01886 --- ---.___-------- --•---.._..._-..-- i ' I INSURER E: _____._.___._.__ INSURER F: --- '- --- - ---- j 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 If 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, i EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRR I TYPE OF INSURANCE Ai51)LISUB ---_r POLICY EFF POLICY EXP -- -� -•- _._..__._.—__ --..-.---- A. �WVD I _POLICY NUMBER MM/DLIMITS GENERAL LIABILITY X fEACH OCCUR FENCE 1,000,000 A COMMERCIAL ' GENERAL LIABILITY j iCBC10001218100 9/1/2012 1 9/1/2013 bAMAGS Rt=FTEb------''--- i "PREMISES(Ea occurrence) _ $-- 100,000! CLAIMS-MADE OCCUR X� ! r� I Li I j MED EXP_(Any one person) _1-$ _- 5,0001 IPERSONAL&ADV INJURY j$ 1,000,0001 —J__................ _. f _GENERAL AGGREGATE $ _2,000,0001 GEN'L AGGREGATE LIMIT APPLIES PER: }PRODUCT—S-COMP/OPAGG '$----- 1,000,00 POLICY DEO- CL_1-L011I j AUTOMOBILE LIABILITY i — t i i COMBINED SINGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED I �- -- -� I I� Per accident ---„ AUTOS AUTOS II ( ) $' NON-OWNED BODILY INJURY I I P! ROPERTY DAMAGE HIREDAUTOS AUTOS '1PERACCIDEN7) ' r$ — L h -' — - --- - --- I I$ 'UMBRELLA LIAR -- I !OCCUR I - !EACH OCCURRENCE $ I EXCESS LIAR CLAIMS-MADE iAGGREGATE !$ DEO? RETENTION$ WORKERS COMPENSATION —� i WC STATU- 0TH- $ AND EMPLOYERS'LIABILITY YIN N TORY LIMITS,1 ANY PROPRIETOR/PARTNER/EXECUTIVE - E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? N/A — (Mandatory in NH) I E.L.DISEASE-EA EMPLOYEF41 $ If yes,describe under I - _ E'1I'�� DESCRIPTION OF OPERATIONS below _ j I E.L.DISEASE-POLICY LIMIT!$ (DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Workers Compensation coverage is active and in good standing.A Certificate of Insurance will come directly from the carrier. - i ii ! 1 I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE-, Town of North Andover,Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN i 11600 Osgood Street j ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 iI AUTHORIZED REPRESENTATIVE -- ---� i ©1988-2010 ACORD CORPORATION, All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD htlaiid Quality Builders Date Estimate# 28 meadow Lu Westford, A 01886 INLAND M 9/13/2012 311. QUALITY BUILDERS I.LG Phone# 617-839-2659 GENERAL CONTRACTOR Dmi@lrdajidQualityBtiAders.com NEW CONSTRUCTION/REMODELING �' 1l-Nlnv.liil:u]dQualityBuilders.com Proposal For: Name/Address Steve&Denise Frick 31 Fox Hill Rd North Andover,MA 01845 Project Roof Description Total IQB proposes the following scope of work listed below: Main House/Sunroom Addition/Great Room 10,700.00 -Remove two layers of roofing down to wood deck on main roof.Also remove one layer of roof on sunroom and great room.IQB will tarp of house and bushes when stripping the roof.IQB will dispose of all debris into dumpster,that will be located on site. -IQB will Install G of Grace Ice&water shield underlayment on roof eaves and valleys,around chimney and all roof penetrations. -Install synthetic roofmg paper over exposed roof boards. -Install 8".025 gauge heavy duty aluminum drip edge on all roof perimeters. -Install Certainteed/GAF 30 yr architectural shingles on roof. -Install new flashing on plumbing pipe. -Install Cobra vent ridgevent on entire ridge. -Re-lead chimney. TOTAL PRICE FOR MAINE HOUSE:$10,700.00 Note: -IQB will remove all debris from property on a daily basis. -All permits will be provided. -Five year warranty on workmanship. -$50.00 dollars per sheet to replace any damaged plywood on roof if needed. -$2.50 per lineal foot to replace any damaged roof boards if needed Thank you for giving IQB the opportunity to provide this quote for you! Total $10,700.00 I This proposal expires one month from the date written All work is warranted for materials and labor for a minimum of one year.This proposal is valid for one month from the date above.The total listed above is the total cost of your project as outlined above.Change Orders will be written for all changes in the scope of the work.Each change order must be approved by you before work begins.Payment for all change orders is expected at the time they are signed.If this proposal is accepted please sign one copy and return it to Inland Quality Builders.We also understand that Inland Quality Builders reserves the right to delay completion of the work for nonpayment of any invoices.Signature below acknowledges receipt of two Rights of Rescission forms included Signature ate �O/ -7 /2012 Customer Signature4 , ate IC)/ f 7 /2012 hila„d Quality Builders Represeuitive i �G�z o�v`/�dacYi.U/r — — �cec y"� rzcuur ularion Office of Consumer Affairs&Busi CT R r OME IMPROVEMENT CONTRA Type. egistration, 167038 DBA xpiration QUALITY BUILD RS4 1=+` IN QUA Y`. 1 y DANIEL MCGONIGLEfi t 69 ARNOLD AVE. Undersecretary LOWELL,MA 01852 •. vlussachusetts- Depaa-tm.ent of Public Safet" and Board of Builth -Supervisor� andards License Construction License: CS 94579 DANIEL J MCGONIGLE 28 MEADOW LANE WESTFORD, MA 01886 li Expiration: 10/23/2013 i Tr#: 6831 i - The Commonwealth of Massachusetts Department of Industrial 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 Legibly Name (Business/Organization/Individual): /XV AA1n? (Itlam//% `� I,/L �-e��--- Address: City/State/Zip:_tL/,4— S r Phone#: 17 Are ou an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. $ 7. [Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working forme in any capacity. workers' comp.insurance. 9. E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.El'*Roof repairs insurance required.]i employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.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$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 Flo hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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." p p 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-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-7274900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 avised 5-26-05 ,