HomeMy WebLinkAboutBuilding Permit #676 - 317 HILLSIDE ROAD 3/26/2012NORTH
BUILDING PERMIT o�,t,.�o
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received ' Z- 3 Vo 4r.to, cy
�SSACH1`+��
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION —:?17 L.
Print
PROPERTY OWNERG>G
Print
MAP 210 �% � PARCEL: 260 ZONING DISTRICT,C,�2.Historic District yes r�r''
Machine Shon Villaae ves
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New—Building uilding
One famil
dditi
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
ater/Sew
DESCRIPTION OF WORK TO BE PREFORMED:
R
Identi iS tion Please Type or Print Clearly)/
OWNER: Name��iJ��� ��i� Phone:
Address: /� /'t/��� � !� �c �-o-- 5
CONTRACTOR Name-;&��'Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License:
Exp. Date: ./.3
ARCHITECT/ENGINEERPhone:,R,� T7Z d/�
Address: �J� e��141-0 /46/z- �/�✓��Reg. No.
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $ q (Ilk
Check No.: (4(4 L -�" Receipt No.: %- I al -
NOTE:
Persons contracting with unregistered contractors do not have access to the uaranty.fund
Signature of Agent/Owner Signature of contractor
F
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
,A61uilding Permit Application
ertified Surveyed Plot Plan
3horkers Comp Affidavit
oto Copy of H.I.C. And C.S.L. Licenses
o y Of Contract
oor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations- (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
Engineering Affidavits for Engineered products
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
Doe: Building Permit Revised 2008
Dimension
Number of Stories: 7' Total square feet of floor area, based on Exterior dimensions. `V6
01
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop r ares 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 - Date
........................................... _.... _...--........ _....... _.._................................................................................ _........ —------- ---..........._....................................................._._.__._..........._........................._._._...................._........................................................._................_._......................................
Doc.Building Permit Revised 2010
^�-- �G.COrlt1
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF S ERAGE DISPOSAL
Public er
Tanning/Massage/Body Art
Swimming Pools r
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
COMMENTS AJOC tC
HEALTH
COMMENTS
Reviewed on ( 1 L1I la
Ck PasS , y : 6d 6o -\-
Reviewed on Signature
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 Town Engineer: Signature:
t_ocatea 664 usgooa street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Locations 7� /!O`er 7 X,0-4
No._ 6
Check # (0/0 2 -L-
25127
Date��
YT—
TOWN OF NORTH ANDOVER
I
Certificate of Occupancy $
Building/Frame Permit Fee ` $C
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
Proposal
Twomey & Legare Contracting Inc.
Building & Remodeling
87 Belmont Street
North Andover Ma. 01845
Office 978-685-7447
Fax 978-685-7446
To: Chris & Suzan Nobile
317 Hillside Road
North Andover Ma. 01845 phone 978-686-8814
Ref: 22x20 garage with two bedrooms above with sitting area.
November 19, 2011
Thank you for the opportunity to quote the following project. The price is based on our discussion
on September 28, 2011 concerning your project at the above address.
The following is a description of work as discussed.
• Garage Addition.
Contractor to contact Massachusetts Dig Safe prior to excavating.
1. Excavate for foundation, for garage with 2"d story above.
2. Height to be determined on site.
3. Install one 6' foot trench drain in front of each garage door. Add pipe to sump pump to be
added in new garage.
4. Cut grade of driveway to new garage and widen driveway. Designed by a landscape designer
provided by owner. New area to be paved 18x70, side of garage on right side to be graded
close to level for some type of paver. Supplied and installed by owner.
5. Rebuilding of retaining, New landing with walkway and steps, by owner.
6. Demo to include removal of some siding on the garage and roof and removal of interior
partition. To plan
7. Structures to be built according to plan provided by contractor in accordance with these
specs.
8. Floor joist to be I joist size to be determined.
9. Floor sheathing to be 3/4" advantec plywood 50 year warranty.
10. Walls to be 2x6 construction.
11. Wall sheathing to be 1/2" OSB plywood. '/z inch wall sheathing is standard.
12. Roof rafters to be 2x12.
13. Roof sheathing to be 5/8" CDX plywood
14. Install ice and water shield 3 ft up from eves.
15. Roof addition with shingle to match existing as close as possible.
16. Customer may want to consider, re -roofing entire front side of home. Additional cost to be
priced on site.
17. Siding to be masonite siding and wrap exterior walls with Tyvek house wrap.
18. Eaves and rakes on addition to be primed #2 pine trim boards.
19. Insulate addition to code.
20. Drywall in addition to be '/2" blue board w/ unical plaster, smooth walls and textured ceilings.
21. Walls and ceilings in new sitting area to be patched and repaired.
22. Interior trim to be match existing house as close as possible.
23. Interior and exterior painting by contractor
24. Contractor to reuse existing garage doors.
25. Disposal of debris by contractor
26. Stamped construction drawings by contractor
27. Additional specs. On completion of construction plans if needed
28. Any additional landscaping by owner. Contractor to spread and grade existing loam: Owner
responsible for seeding and shrubs. *
29. All permits and inspections by contractor.
30. If ledge is encountered removal cost is not included or damage to underground utilities.
• Plumbing & Heating
Extend existing heat into new rooms off existing zone.
Add one exterior faucet.
• Electrical
1. Wiring of new addition to code.
2. Lighting layout to be completed with final construction design.
3. Interior outlets, GFCI or AFCI were required by code
4. Switch locations to plan. To be completed on final plan.
5. Smoke/Carbon detectors to code in addition. No additional smokes in main house.
6. Closet lights by contractor, all other light fixtures by owner. Interior and exterior.
7. 3- cable 2- phone
8. Exterior lights -1- flood, 2- porch lights and l - garage light and 2 - exterior plugs.
• Window specs
1. New construction Harvey units. With Low E and Argon, grills and 'h screen.
2. 5 - double hung units.
3. 2 - double mulled unit with half round above.
4. 1 - Fixed panel velux sky light.
J��
• Exterior Door Specs.
• 1- 6 panel steel insulated fire door to laundry room.
• Interior Door Specs.
4- 6 panel hollow core masonite doors for bed rooms.
2- Double door units for closets.
I - Cased opening to sitting area.
Flooring
1. Flooring in new bedrooms to be oak hardwood flooring match existing as close as
possible.
2. Includes replacing flooring in new sitting area. Flooring in new master closet to remain.
3. Refinish living room, family room, dining room, kitchen and hall.
4. Hall to stop at new master bedroom doorway.
5. Finish stairs also.
6. Change risers on upper stairs to poly finished wood risers.
Basement,
1. Expand laundry room into old garage to be a mudroom.
2. Size to be around 10x10
3. 1- fire door.
4. l - light with switch.
5. Plugs to code
6. Blue board and plaster
7. No flooring
,A I�'J
Initis � .�'V Date
Job total & Payment schedule
IS` payment On signing of contract
2lid payment The day work starts
3rd payment completion of foundation
4'h payment completion of weather tight shell
Roofing, Windows and Tyvek
5t" payment completion of Electrical and
Plumbing roughs also insulation
6'h payment completion of Dry wall plaster
;"h payment completion of interior trim &
Interior painting
e final payment completion of project
With final inspection.
Job Total
" $7,000.00
76,600.00
$15,000.00
$10,000.00
$10,000.00
$15,000.00
$10,000.00
$6,000.00
$3,600.00
Balance
$69,600.00
$54,600.00
$44,600.00
$34,600.00
$19,600.00
$9,600.00
$3,600.00
[ Customer Date 3
Date
Contractor
Sign
Allowancepage
1. Gutters---- - --$450.00
Z. Trench Drains and pump system --$1,900. 00
3. Driveway --$3,400.00
4. Painting -------- $4,000.00
Date iz12-311
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AL4-02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): /(,Z4,�i
,
Address:
City/State/Zips- Phone #:
Are you am employer? Check the appropriate bog:
1. U! am a employer with !
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet
ship and have no employees
These sub -contractors have
working for me in any capacity.
v onters' comp. insurance.
[No workers' comp. insurance
5• We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
1213 Roof repairs
13.❑ Other
rtify uypcuc:aUL u:a[ G6GGi:5 6Gx +rf '.iii uwv .r rl out me SeCt16n below St16[Ying theLr wortiPrc' rnmpgn�atinn po i in- rmat'ion.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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: %/` �L'_ /�i� S _72W i
Policy # or Self -ins. Lic. #:r��-'�Q Expiration Date: % /--
Job Site Address:_ Z eZILi 4 ,� / City/State/Zip:,,�0zaU%2/.t
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above 4 true and correct
r �
Y�__
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):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-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 permittlicense 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, NIA 0.21.11
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-72.7-7749
�.mas.s.gov/dia
Board of Buildin�a Re{aulations and Standards
Construction Supervisor License
License: CS 67560
SHAUN M TWOMEY'
61 PATROIT ST
N ANDOVER, MA 01845
Expiration: 10/25/2013
t'unlniissiuncr Tr#: 4913
�= �lassachusctt, -
Dep.11-1tile,,t ri{ I't4I?I1C latci�
Board of Building, Rei_yulatioi)s and Standards
License: CS 55108
DOUGLAS J LEGARE
79 GARY AVE
HAVERHILL, MA 01830
r
Expiration: 9/2/2012
i °f f lTll)l f �41f f 71 i'i' Tr--: 2766
I.�?Olil/l7LfrYyll.CCLQ`. fStt � <� ,���/"fe-' e4
Office o�I Consumer airs siness Aegulalion
HOME IMPROVEMENT CONTRACTOR
j� Registration:. 136779. Type:
I�`'
Expiration: .8/26/2012 Partnership
TAMEY LEGARE.CONTRACTING INC.
SHAWN TWOMEY
87 BELMONT ST.
N. ANDOVER, MA 01845 Undersecretary
�7
I
24-2011 WED 04:09 PM
A �4RD1M•.... . . �LY6
CERTIFICATE OF LIABI
ODUCER
9herty insurance Agency, Inc.
0. Box 1985
Elm Street
Idover, MA 01810
URtO
Twomey & Legare Contracting, Inc_
PO Box 366
North Andover, MA 01845
FAX N0, 9784750303
P. 05
IT INvu�08/24111
�C� DA7E(MM/DD/y"
THIS CERTIFICATE IS ISSUED AS A MATTER OF INF RMATION
ONL AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOL ER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR
ALTI R THE COVERAGE AFFORDED BY THE POLICIES BELOW,
SUR RS AFFORDING COVERAGE
URER : Art1811a protection Ins Comnanv MAIC #
E POLICIES OF INSURANCE tISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ROVE FOR THE POLICY pERtOD INDICATED, NOTWITHSTA
LI REQUIREMENT.'
INSURANCE SHOWAFFON
ED BY � POLICIES DESCRIBED HEREINCONTRACT R THE -RD CU ES S BIr ITTHI E T S ALL THE TER
LILIES. AGGREGATE OMITS SHOWN MAY PAVE BEEN REDUCED BY PAID CLAIMS. SPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR DING
LT Na MS, EXCLUSIONS AND CONDITIONS OF SUCH
TYPE OF INSURANCE
POLICY NUMBER O YC EP EC VE POLI
A GENERAL LIABILITY
8500043255 A EXPIRAMN
it COMMERCIAL GENGRAL LIABILITY 06122/11 LIMITS
06/22!12 EACH OCCURRENCE s1 OOO OOO
CLAIMS MADE X OCCUR
DAMAGE TO RENTED
$100000
MED EXP /Any Ono parson) $5000
GE
PERSONAL & ADV IN,IUAY S1 000 000
MLAGGREDATEUMITAPPLIES PER:
UM09ILE LIAOILITY
ANY AUTO
ALL OWNED AUTOS
SCHEOVLCDAUTO$
HIRED AUTOS
NON•OWNEO AUTO$
09 LIABILITY
ANY AUTO
EXCESS/UMBRELLA LIABILITY
OCCUR CLAIMS MADE
DEDUCTIBLE'
RETENTION S
ERS COMPENSATION AND
OF OPERATIONS /LOCATIONS! VEHICL-------------
ES / EXCLUSIONS ADDED BY ENDDRgEMENT/SPECIAL
operations usual to Twomey & Legare Contracting, Inc...
Town of North Andover
1600 OSgood Street
North Andover, MA 01845
ACORD 21'2001108) 1 of 2
#S27512/M27509
- COMP/OP AGG
COMBINED SINGLE LIMIT
IEe accident)
BODILY IN.IURY
(Per person)
BODILY INJURY
(Per accidont)
PROPERTY OAMACE
(Per aCCidono
AUTO ONLY - EA ACCIDENT
OTHER THAN EA
AUTO ONLY! _
vcr`►.N71 III .
LD ANY OF 7 E ABOVEOESCgIBE0 POLIES BE CANCEL
THEREOF, LED BEFORE THE EXPIRATION
ISSUING.MIBURER WILL ENpEAVORTO MAIL
E TO THE �0_ DAYS WRITTEN
CERTIFICATE TIFH:gTE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO S
ENO OBHOADON OR LIABILRY HALL
OF ANY KIND UPON THE INSURER, ITS AGENTS OR
ISENTATIVES
DML 0 ACO CORPORATION 1988
ghtFax Ni -1 10/8/2010 8:54:54 AM PAGE 2/002 Fax Server
ACORD. CERTIFICATE OF LIABILITY 114SURANCE DATE(MM/DD/YYYY) lof0812010
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 tNOT 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, thepolTCAISS) must be endorsed. if SUBROGATION IS WAIVED, subject to the
terms and conditions of the policy certain Policies may: equine and endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endarsemeht(s).
PRODUCER
DOHERTY INS AGENCY LqC
PO BOX IM
ANDOVr" R, ?14A 0I810
22
INSURED
TWOMEY & LEGARE CONTRACTING\TC
CONTACT
NAME:
PHONE FAX
(AIC, No, Ext): FAX
E-MAIL (A/C, No):
ADDRESS:
PRODUCER
CUSTOMER 10 >:
INSURER(S) AFFORDING COVERAGE
INSURER A: TRAY-ELERS INDEMNTFV CQMgAI*1•
INSURER B:
INSURER C:
PO BOX 366 INSURE?. D:
NORTH ANDOVER, VIA 01845 INSURER E:
COVERAGES CERTIFICATE NUMBER: INSURER F.
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOtJ HAVE BEEN ISSUED TOTHE 6dSURED NAMED ABOL'E FOR THE POLICYPERIODINDICATED.
OR MAY PERTAIN.
ANY REOUIREINSURANCE
AFT, TERM Oy THE PO ONES ANY CONTRACTOR OTHER DOCUMENT L'A'TH RESPECT 70 L'SHICH THIS CERTIFICATE MAY REISSUED
OR ITS PERTAIN. THE E BEEN
RE AFFORDEDAI THE POUQES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
LRdRS SHOWNMAY HAVE BEEtN REDUCED BY PAID CLAIMS.
INSP.
TYPE OF INSURANCE ADDLSUBR POLICY EFF DATE POLICY EXP DATE
LTR POUCYHUMEIER (AR4JTD1YYYY) (RWDMYYYY)
GENERAL L NSR 1YVD LIMITS
(ABILITY
COMMERCIAL GENERAL LIABILITY
EACHOCCURRENCE S
CLAIMS MADE OCCUR.
DAMAGE TO RENTED S
PREMISES (Ea occurrence)
MED EXP (Any one person) S
GEN'L AGGREGATE Ufi,TTAPPLIES PER:
PERSONAL 3R ADV INJURY S
POLICY PROTECT IAC
GENERAL AGGREGATE, c
AUTOMOBILE LtA81L17Y
PRODUCTS - COMPIOP AGG S
ANY AUTO
COMBINED SINGLE c
ALL OWNED AUTOS
LIMIT (Ea accident)
SCHEDULEAUTOS
BODILYINJURY $
HIRED AUTOS
(Per person)
BODILY INJURY $
NON -OWNED AUTOS
(PST accident)
PROPERTY DAMAGE S
(Per accident)
UMBRELLA LIAR OCCUR
EXCESS LIAS CLAIMS—MApE
EACH OCCURRENCE S
DEDUCTIBLE
AGGREGATE S
REIENTtON $
$
r
WORKER'S COMPENSATION AND Vic STATUTORY UMITS OTHER
EMPLOYER'S LIABILITY YIN US-029CM994-10 09/18/2010
ANY PROPERITCRiP ARTNER+EXECUTIVE Y 09118?2011 E. L EACH ACCIDENT $
OFFICE.. .?EMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE S
(mandatory in Nit) '
11 Ya,, describe end-, E.L DISEASE - POLICY LIMIT S
DESCP.IPTION OF OPERATIONS tzar
DESCRIPTION OF OPERATtOtNS/LOCATIONSIVEHICLMRESTRICTIONS/SPECIAL ITEMS
A
T�iS REPLACES
ANY PRIOR C iiFICATV ISSULT3 TO T'M CERT-MCATE
HOLDER A ECTti\TG 1VORIiT RS CONe COV-171AGE
CERTIFICATE HOLDER
TOWN OF NORTH ANDOVER
1600 OSGOOD STREET
NORTH ANDOVER, MA 01845
ACORD 25 (2009/09)
MAIC
500,000
500,000
500,000
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE
WITH THE POLICY PROVISIONS_
AUTHORIZED REPRESENTATIVE
Charles J Clark
1988-2009 ACORD CORPORATION- All rights reserved.
A'Al 111/114//
Twomey & Legare Contracting, Inc.
Professional Building / Remodeling
87 Belmont Street
North Andover, MA 01845
HIC #136779
North Andover - 987.685.7447 Haverhill - 978.556.1547
CONTRACT
1. Date of Contract Signing:
2. List of Documents/Counterparts of this agreement:
A. Contract
B. Specifications/Proposal (See Exhibit B attached)
C. DrawingTlan (see Exhibit C attached)
D. Payment Schedule (see Exhibit D attached)
E. Limited Warranty (see Exhibit E attached)
F. General Notes (See Exhibit F attached)
3. Parties to Contract:
A. Contractor: Twomey & Legare Contracting, Inc.
Shaun Twomey/Doug Legare
Federal ID# 20-3436110
Address: 87 Belmont Street, No. Andover, Ma 01845
Contractor Registration No.: 136779
B. Homeowner: Chris & Suzan Nobile
317 Hillside Road,
North Andover, Ma. 01845
978-686-8814
4. Description of work to be done and the materials to be used: See Specifications
(Exhibit B)
5. Total amount agreed to be paid for work to be performed under the contract:
6. Time schedule of payment to be made under the contract, finance charges for late
fees (if any)*: See Payment Schedule (Exhibit D)
11(01wner Initials: Contract
Contractor Initials: ,
Page 1 of 4
*Any deposit required to be paid in advance of the start of the work shall not
exceed one third of the total contract price or actual cost of any material or
equipment of a specific pr custom made nature, which must be ordered in advance
of the start of the work to assure that the project will proceed on schedule. No
final payment shall be demanded until the contract is completed to the satisfaction
of all parties.
7. A. Date work is scheduled to begin: (see No. 14 below)
B. Date work is scheduled to be substantially completed: Lsee No. 14 below)
8. Notice:
A. All home improvement contractors and subcontractors shall be registered
and any inquiries about a contractor and/or subcontractor relating to a
registration should be directed to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza, Suite 5170
Boston, MA 02116
(617) 973-8700
B. For contractor's registration number, see first page.
C. Homeowners have a three (3) day cancellation right under MGL Ch. 93 §
48; MGL Ch. 140D § 10; or MGL Ch. 255D § 14 as may be applicable.
See attached Notice of Cancellation.
D. For homeowner's warranty rights, see 780 CMR R6 and MGL Ch. 142A.
9. There is no lien or security interest on the residence as a consequence of this
contract.
10. Permit Notice:
A. The following permits will be required in connection with the work to be
performed on your property: Building — Electrical — Plumbing
B. It is the obligation of the contractor to obtain these permits as the
Homeowner's agent.
C. Any homeowner who secures their own construction -related permits or
deals with unregistered contractors shall be excluded from access to the
guarantee fund.
/11IV'S AJ -,-�
'� '
Owner Initials: Contract Contractor Initials: _
Page 2 of 4
11. Contractor reserves the right, if he deems himself to be insecure, to require, as a
prerequisite to continue work, that the balance of funds due under the terms of the
contract, which are in possession of the owner, be placed in a joint escrow
account requiring the signatures of the contractor and the homeowner, for
withdrawal.
12. The parties agree that no work shall begin prior to the signing of the contract,
transmittal to the owner a copy of the contract and the expiration of any
applicable rescission period.
13. Arbitration Clause: The contractor and the homeowner hereby mutually agree in
advance that in the event that the contractor has a dispute concerning this contract.
the contractor may submit such dispute to a private arbitration service which has
been approved by the Office of Consumer Affairs and Business Regulations and
the consumer shall be required to submit to such arbitration as provided in MGL
Ch. 142A.
14. Other Provisions:
A. Commencement and Completion of Work - Contractor agrees to proceed
diligently with the agreed upon work, commencing promptly, following:
• The completion of the Title V installation and certification of
compliance by the town.
• Issuance of a building permit by the town.
B. Final payment shall be upon the satisfaction of the homeowner. The
parties agree that the issuance of a certificate of occupancy and/or final
inspection shall be the objective standard that the contract has been
complete and the parties satisfied. Any final punch list items shall be
reduced to writing, with an estimated date for completion. The parties
agree that no escrow will be held for punch list items.
C. Insurance — Contractor agrees to provide evidence of liability, workers
compensation and other risk insurance. Owner agrees to provide copy of
hazard insurance as is required by contractor to coordinate policies.
Owner Signature:
Date:
Owner Sig'riature: i Date:
Owner Initials: Contract Contractor Initials:
Page 3 of 4
A - . a
Contractor Signature;` =' Date:
Contractor Signature:
Date:
Notice: The signatures of the parties above apply only to the agreement of the parties to
alternate dispute resolution initiated by the contractor. The owner may initiate alternative
dispute resolution even where this section is not signed separately by the parties.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Owner
Date
f✓�
!r'`� c'✓' � /trjR� ! /�
Contra ctorr
ate
Owner tials:
Owner /
Date
Contractor
Date
Contract���
Contractor Initials:
Page 4 of 4
Office o onsumer",XrTfi
HOME IMPROVEMENT CONTRACTOR Type:
Registration:- 136779
Partnership
Expiration: ..8126!2012
+ l EGARE CONTRPCT.ING INC.
TWOMEY
ONT ST.
VER, MA OiW Undersecretary
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RECORD OWNER:
SUZANNE L. NOBILE
317 HILLSIDE RD., NORTH ANDOVER, MA
REFERENCES:
DEED BOOK 7665, PAGE 211
PLAN NO. 8118
HILLSIDE ROAD
1.) THIS PLAN WAS PREPARED TO SHOW BUILDING RELATIVE
TO PROPERTY LINES AND PROPOSED GARAGE AND ENTRANCE WAY.
2.) THE PLAN WAS PREPARED BY PERFORMING AN INSTRUMENT
SURVEY IN NOVEMBER OF 2011.
3.) NO UTILITY LOCATION, RESEARCH OR PLOTTING PERFORMED.
4.) NO TITLE EXAMINATION PROVIDED, THEREFORE OTHER
EASEMENTS NOT SHOWN HEREON COULD EXIST.
OBTAINING A TITLE EXAMINATION PRIOR TO CONSTRUCTION IS
RECOMMENDED.
5.) OVERHEAD WIRES NOT SHOWN HEREON.
6.) WETLAND DELINEATION WAS NOT PART OF SCOPE OF WORK.
7.) FLOOD PLAIN WAS NOT RESEARCHED
8.) ZONING AND OTHER APPLICABLE OVERLAY DISTRICTS WERE
NOT RESEARCHED OR PLOTTED.
PROPOSED
PLOT PLAN
OF LAND IN
NORTH ANDOVER, MASSACHUSETTS
AT 317 HILLSIDE ROAD
PREPARED FOR
TWOMEY AND LEGARE CONTRACTING, INC
BY
VANCURA & BRENNAN
1 JACKSON STREET, NEWBURYPORT, MA 01970
TEL. 978-395-1689 FAX 978-463-7947
INFO &VANCURABRENNAN.COM
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wlz
RECORD OWNER:
SUZANNE L. NOBILE
317 HILLSIDE RD., NORTH ANDOVER, MA
REFERENCES:
DEED BOOK 7665, PAGE 211
PLAN NO. 8118
NOTES:
N /F
CHARING CROSS
CORPORATION
N/F
THE GARDNER FAMILY
REVOCABLE TRUST
HILLSIDE ROAD
1.) THIS PLAN WAS PREPARED TO SHOW BUILDING RELATIVE
TO PROPERTY LINES AND PROPOSED GARAGE.
2.) THE PLAN WAS PREPARED BY PERFORMING AN INSTRUMENT
SURVEY IN NOVEMBER OF 2011.
3.) NO UTILITY LOCATION, RESEARCH OR PLOTTING PERFORMED.
4.) NO TITLE EXAMINATION PROVIDED, THEREFORE OTHER
EASEMENTS NOT SHOWN HEREON COULD EXIST.
OBTAINING A TITLE EXAMINATION PRIOR TO CONSTRUCTION IS
RECOMMENDED.
5.) OVERHEAD WIRES NOT SHOWN HEREON.
6.) WETLAND DELINEATION WAS NOT PART OF SCOPE OF WORK.
7.) FLOOD PLAIN WAS NOT RESEARCHED
8.) ZONING AND OTHER APPLICABLE OVERLAY DISTRICTS WERE
NOT RESEARCHED OR PLOTTED.
PROPOSED
PLOT PLAN
OF LAND IN
NORTH ANDOVER, MASSACHUSETTS
AT 317 HILLSIDE ROAD
PREPARED FOR
TWOMEY AND LEGARE CONTRACTING, INC.1
BY
VANCURA & BRENNAN
1 JACKSON STREET, NEWBURYPORT, MA 01970
TEL. 978-395-1689 FAX 978-463-7947
INFO &VANCURABRENNAN.COM
0 15 30 60 120
12-2-11 1 " = 30 FT. 2011047
Twomey & Legare Contracting, Inc. /W
Professional Building / Remodeling U
87 Belmont Street
North Andover, MA 01845
HIC # 136779
North Andover - 987.685.7447 Haverhill - 978.556.1547
EXHIBIT F
General Notes
Unforeseen Changes & Extras
1. Existing, unforeseen code violations are not included in this contract and will be priced at
time and material.
2. Any unforeseen frame or sheathing rot is not included in this price.
3. All subcontractors are in contract with Twomey & Legare Contracting, Inc. and are not
available for direct hire by homeowner for a time of six (6) months after completion of
project.
4. Contractor will keep home and site as neat as possible. At end of job, the homeowner is
responsible for final cleaning and window washing.
5. Any plumbing, electrical or miscellaneous material purchased by homeowner is
homeowner's responsibility to get product to site in a reasonable time for installation.
Contractor does not hold warranty on these items.
6. If contractor is needed to pick up project, homeowner will incur a trip charge of $50.00
per hour, with one hour minimum.
7. Any additional work beyond contract will only be done with a signed and agreed to price
change order sheet. Said payment is due in full on next progress payment.
8. Please review all items on Specification pages. Verbal additions and wants, if not in
writing, are not included in the project.
9. Due to large trucks, equipment, dumpsters, etc, driveway may crack, create divots, etc.
Also during construction, lawn may be damaged. Contractor is not responsible for same.
10. During excavation, any ledge or boulders over 20 inches will be an extra priced on site.
10. Please review plans when received to ensure design is correct.
11. Any changes made when customer is with architect will not be included if not on original
Specification pages. It will only be included if a change order sheet is created and
executed.
f.
contractor Siai`�re
� Date Homeowner signature ate
COwner Initials: General Notes Contractor Initials:G'
Page 1 of 1
a Q
*Any deposit required to be paid in advance of the start of the work shall not
exceed one third of the total contract price or actual cost of any material or
equipment of a specific pr custom made nature, which must be ordered in advance
of the start of the work to assure that the project will proceed on schedule. No
final payment shall be demanded until the contract is completed to the satisfaction
of all parties.
7. A. Date work is scheduled to begin: (see No. 14 below)
B. Date work is scheduled to be substantially completed: (see No. 14 below)
8. Notice:
A. All home improvement contractors and subcontractors shall be registered
and any inquiries about a contractor and/or subcontractor relating to a
registration should be directed to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza, Suite 5170
Boston, MA 02116
(617) 973-8700
B. For contractor's registration number, see first page.
C. Homeowners have a three (3) day cancellation right under MGL Ch. 93 §
48; MGL Ch. 140D § 10; or MGL Ch. 255D § 14 as may be applicable.
See attached Notice of Cancellation.
D. For homeowner's warranty rights, see 780 CMR R6 and MGL Ch. 142A.
9. There is no lien or security interest on the residence as a consequence of this
contract.
10. Permit Notice:
A. The following permits will be required in connection with the work to be
performed on your property: Building — Electrical — Plumbing
B. It is the obligation of the contractor to obtain these permits as the
Homeowner's agent.
C- Any homeowner who secures their own construction -related permits or
deals with unregistered contractors shall be excluded from access to the
guarantee fund.
/A
Owner Initials:
Contract Contractor Initials:
Page 2 of 4
11. Contractor reserves the right, if he deems himself to be insecure, to require, as a
prerequisite to continue work, that the balance of funds due under the terms of the
contract, which are in possession of the owner, be placed in a joint escrow
account requiring the signatures of the contractor and the homeowner, for
withdrawal.
12. The parties agree that no work shall begin prior to the signing of the contract,
transmittal to the owner a copy of the contract and the expiration of any
applicable rescission period.
13. Arbitration Clause: The contractor and the homeowner hereby mutually agree in
advance that in the event that the contractor has a dispute concerning this contract,
the contractor may submit such dispute to a private arbitration service which has
been approved by the Office of Consumer Affairs and Business Regulations and
the consumer shall be required to submit to such arbitration as provided in MGL
Ch. 142A.
14. Other Provisions:
A. Commencement and Completion of Work - Contractor agrees to proceed
diligently with the agreed upon work, commencing promptly, following:
The completion of the Title V installation and certification of
compliance by the town.
• Issuance of a building permit by the town.
B. Final payment shall be upon the satisfaction of the homeowner. The
parties agree that the issuance of a certificate of occupancy and/or final
inspection shall be the objective standard that the contract has been
complete and the parties satisfied. Any final punch list items shall be
reduced to writing, with an estimated date for completion. The parties
agree that no escrow will be held for punch list items.
C. Insurance — Contractor agrees to provide evidence of liability, workers
compensation and other risk insurance. Owner agrees to provide copy of. hazard insurance as is required by contractor to coordinate policies.
t a
Owner Signature: Date: Z Z�
��Owner Sigature: Date: 0�'
Owntr
Contract Contractor Initials:���_
Page 3 of 4
Contractor Signature:/'`Date: i44�—
/
Contractor Signature:
Date:
Notice: The signatures of the parties above apply only to the agreement of the parties to
alternate dispute resolution initiated by the contractor. The owner may initiate alternative
dispute resolution even where this section is not signed separately by the parties.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
6wner il Date
�z i
Contractor i% ate
Owner I�itials: A
Owner
Date
Contractor
Date
Contract Contractor Initials: --
Page 4 of 4
t
Twomey & Legaie Contracting, Inc.
Professional Building / Remodeling
87 Belmont Street
North Andover, MA 01845
HIC #136779
North Andover - 987.685.7447
CONTRACT
1. Date of Contract Si
2. List of Documents/Counterparts of this agreement:
Haverhill - 978.556.1547
A. Contract
B. Specifications/Proposal (See Exhibit B attached)
C. Drawing/Plan (see Exhibit C attached)
D. Payment Schedule (see Exhibit D attached)
E. Limited Warranty (see Exhibit E attached)
F. General Notes (See Exhibit F; attached)
3. Parties to Contract:
A. Contractor: Twomey & Legare Contracting, Inc.
Shaun Twomey/Doug Legare
Federal ID# 20-3436110
Address: 87 Belmont Street, No. Andover, Ma 01845
Contractor Registration No.: 136779
i
i
B. Homeowner: Chris & Suzan Nobile
317 Hillside Road,
North Andover, Ma. 01845
978-686-8814
4. Description of work to be done and the materials to be used: See Specifications
(Exhibit B)
5. Total amount agreed to be paid for work to be performed under the contract:
6. Time schedule of payment to be made under the contract, finance charges for late
fees (if any)*: See Payment Schedul� (Exhibit D)
Owner Initials: Contrast Contractor Initials..
r
Page 1 sof 4
Proposal
Twomey & Legare Contracting Inc.
Building & Remodeling
87 Belmont Street
North Andover Ma. 01845
Office 978-685-7447
Fax 978-685-7446
To: Chris & Suzan Nobile November 19, 2011
317 Hillside Road
North Andover Ma. 01845 phone 978-686-8814
Ref: 22x20 garage with two bedrooms above with sitting area.
Thank you for the opportunity to quote the following project. The price is based on our discussion
on September 28, 2011 concerning your project at the above address.
The following is a description of work as discussed.
• Garage Addition.
Contractor to contact Massachusetts Dig Safe prior to excavating .
1. Excavate for foundation, for garage with 2nd story above.
2. Height to be determined on site.
3. Install one 6' foot trench drain in front of each garage door. Add pipe to sump pump to be
added in new garage.
4. Cut grade of driveway to new garage and widen driveway. Designed by a landscape designer
provided by owner. New area to be paved 18x70, side of garage on right side to be graded
close to level for some type of paver. Supplied and installed by owner.
5. Rebuilding of retaining, New landing with walkway and steps, by owner.
6. Demo to include removal of some siding on the garage and roof and removal of interior
partition. To plan
7. Structures to be built according to plan provided by contractor in accordance with these
specs.
8. Floor joist to be I joist size to be determined.
9. Floor sheathing to be 3/4" advantec plywood 50 year warranty.
10. Walls to be 2x6 construction.
11. Wall sheathing to be %s' OSB plywood. %2 inch wall sheathing is standard.
. f�
12. Roof rafters to be 2x12.
13. Roof sheathing to be 5/8" CDX plywood
14. Install ice and water shield 3 ft up from eves.
15. Roof addition with shingle to match existing as close as possible.
16. Customer may want to consider, re -roofing entire front side of home. Additional cost to be
priced on site.
17. Siding to be masonite siding and wrap exterior walls with Tyvek house wrap.
18. Eaves and rakes on addition to be primed #2 pine trim boards.
19. Insulate addition to code.
20. Drywall in addition to be '/2" blue board w/ unical plaster, smooth walls and textured ceilings.
21. Walls and ceilings in new sitting area to be patched and repaired.
22. Interior trim to be match existing house as close as possible.
23. Interior and exterior painting by contractor
24. Contractor to reuse existing garage doors.
25. Disposal of debris by contractor
26. Stamped construction drawings by contractor
27. Additional specs. On completion of construction plans if needed
28. Any additional landscaping by owner. Contractor to spread and grade existing loam[: Owner
responsible for seeding and shrubs. *
29. All permits and inspections by contractor.
30. If ledge is encountered removal cost is not included or damage to underground utilities.
• Plumbing & Heating
Extend existing heat into new rooms off existing zone.
Add one exterior faucet.
• Electrical
1. Wiring of new addition to code.
2. Lighting layout to be completed with final construction design.
3. Interior outlets, GFCI or AFCI were required by code
4. Switch locations to plan. To be completed on final plan.
5. Smoke/Carbon detectors to code in addition. No additional smokes in main house.
6. Closet lights by contractor, all other light fixtures by owner. Interior and exterior.
7. 3- cable 2- phone
8. Exterior lights -1- flood, 2- porch lights and 1- garage light and 2 - exterior plugs.
• Window specs
1. New construction Harvey units. With Low E and Argon, grills and 1/2 screen.
2. 5 - double hung units.
3. 2 - double mulled unit with half round above.
4. 1- Fixed panel velux sky light.
• Exterior Door Specs.
• 1- 6 panel steel insulated fire door to laundry room.
Interior Door Specs.
4- 6 panel hollow core masonite doors for bed rooms.
2- Double door units for closets.
1- Cased opening to sitting area.
Flooring
1. Flooring in new bedrooms to be oak hardwood flooring match existing as close as
possible.
2. Includes replacing flooring in new sitting area. Flooring in new master closet to remain.
3. Refmish living room, family room, dining room, kitchen and hall.
4. Hall to stop at new master bedroom doorway.
5. Finish stairs also.
6. Change risers on upper stairs to poly finished wood risers.
Basement,
1. Expand laundry room into old garage to be a mudroom.
2. Size to be around ] 0x10
3. 1- fire door.
4. 1- light with switch.
5. Plugs to code
6. Blue board and plaster
7. No flooring
%[ lnitia � Date 1 _('
, /' 1 %fir' l/
Payment
Job
r d
ule
1Jo��otal 76,600.00
1,
Balance
IS' payment On signing of contract $7,000.00 $69,600.00
2nd payment The day work starts
3rd payment completion offoundation
4'h payment completion of weather tight shell
Roofing, Windows and Tyvek
payment completion of Electrical and
Plumbing roughs also insulation
6'h payment completion ofDry wall plaster
?'fi payment completion of interior trim &
Interior painting
8''` final payment completion of project
With final inspection.
$15,000.00 $54,600.00
$10,000.00 $44,600.00
$10,000.00
$15,000.00
$10,000.00
$6,000.00
$3,600.00
$34,600.00
$19,600.00
$9,600.00
$3,600.00
Customer Date l Z - Z3 11
Contractor j4�. Date �/
The -commonwealth of Massachusetts
Department of Industrial _9ccidents
Office of rnvestlgations .
600 Wash ine ton Street
Boston, MA 02111
www massgov/din
Workers' Compensation insurance Affidavit. Builders/Contractors/Electricians/Plumbers;,
Applicant Information Please PrintleiiiSly '.
Name(B,isu,ess(Orgznization/lndividtial): M�L/✓i%
Address:: V,/'D� . LY/
City/State%Zip:%U- e17 dLV4, -' Phone #:
Are y an employer? Check the appropriate box:
1. I am a employer with �_
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contactors.
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet t
ship and have no employees
These subcontractors have
working for me in any capacity.
workers' comp. insurance,
EWe
[No workers' comp. insurance
5. are a corporation and its
required.]
officers have exercised their
3. ❑ 1 am a homeowner doing all work
right of exemption..per MGL
myself [No workers' comp.
C. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
POMP. insurance required.]
Type of project (required): .
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ding addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
-UY a9auca1111 ma: Cn— M. F: mus! atso iYt cet tht: s xo= erne, -0--9,E-Cir ,E -Cir worms' comr„�;_�^ee Y jig; �.o msiiaa
Iiomeowuers who submit this affidavit indicating they are doing al,' work and then'hire outside eonuactnrs 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 nu,employees. Belowis the policy and job site
information. -
Insurance Company Name: G!
Policy # or Self -ins. Lie. #aq-�76/�% 7 g jExpiration Date:,e �/�
Sob Site Address: ] City/State/Zip ��,4614 w, G
Attach a copy of the workers' compensation policy declar.ation .Page (showing the policy number and expiration on date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify the paia penalties of perjury that the information provided above is true and correct
/ Y
Phone 4: � Z�i-4 Pc S %Vy7
Z__�
Official use only. Do not write in this arca, to be completed by cite or town official,
City or Town:
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3
6. Other
Contact Person:
PermitUcense #
City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector
Phone #:
1
htFax C1-1 3/7/2012 5:04:29 AM PAGE 2/002 Fax Server
ACORD. CERTIFICATE OF LIABILITY INSURANCE 03/07/2012
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: H the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. H 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
DOHERTY INS AGENCY INC
PO BOX 1985
ANDOVER, MA 01810
22YMX
INSURED
TW OMEY & LEGARE CONTRACTING INC
CONTACT
NAME:
PHONE
FAX
(A/C, No, Ext):
FAX
(AIC, No):
E-MAIL
ADDRESS:
PRODUCER
CUSTOMER ID #-
INSURERS) AFFORDING COVERAGE'
INSURER A: TRAVELERS INDEMNrrY COMPANY
INSURER B:
INSURER C:
INSURER D:
PO BOX 366 INSURER E:
NORTH ANDOVER, MA 01845 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 FORTHE 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 SUBJECTTO ALLTHETERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
TYPE OF INSURANCE
LTR
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE OCCUR.
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PROJECT LOC
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULEAUTOS
HIRED AUTOS
NON -OWNED AUTOS
UMBRELLA LIAB OCCUR
EXCESS LIAB CLAIMS -MADE
DEDUCTIBLE
RETENTION $
ADDLSUBR POLICY EFF DATE POLICY EXP DATE
POLICY NUMBER (MNRDDIYYYY) (MM,DDIYYYY)
INSR VNO
LIMITS
EACH OCCURRENCE $
DAMAGE TO RENTED $
PREMISES (Ea occurrence)
MED EXP (Any one person) $
PERSONAL && ADV INJURY $
GENERAL AGGREGATE $
PRODUCTS - COMPIOP AGG $
COMBINED SINGLE $
LIMIT (Ea accident)
BODILY INJURY $
(Per person)
BODILY INJURY $
(Per accident)
PROPERTY DAMAGE $
(Per accident)
EACH OCCURRENCE $
AGGREGATE $
WC STATUrORY LIMITS OTHER
WORKER'S COMPENSATION AND
EMPLOYER'S LIABIUTY WN UB -0290M994-11 09/18/2011 09/18/2012 E. L. EACH ACCIDENT $
ANY PROPERITOR/PARTNERfFXECUIIVE Y E.L. DISEASE - EA EMPLOYEE $
OFFICER/M EMBER EX CLUDED?
(Mandatory In NH) E.L. DISEASE - POLICY LIMIT $
It yes, describe under
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPIACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE-
CL
OVERAGE
CL
NAIC #
500,000
500,000
500,000
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Charles J Clark
1988-2009 ACORD CORPORATION. All rights reserved.
CERTIf/CA E
Uo erty Insurance Agency, Inc.
P. Box 1885
211 1m Street
Anc over, MA 01810
INSU Ep
Twomey & Legare Contracting, Inc.
PO Box 366
FAX N0, 9784750303
P. 02
INSURANCE
DATE (MMiDD/n Yy)
03106112
tTIM(C' 11 IS 133UEp AS A MATTER OF INFORMATION
ID CONFERS NO RIGHTS UPON THE CERTIFICATE
. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
HE COVERAGE AFFORDED BY THE POLICIES RFI nw
INSURE AFFORDING COVERAGE NAIC #
INSURERA Arbella Protection Wins
North Andover, MA 01845 IN6URER C:
INSURER 0:
CINSURER E:
O RAGES
THE POLICIES OF INSURANCE LISTED BELOW HAvE PEEN ISSUED TO THE INSURED NAMED AlOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
AN REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH R
(CIES. AGGREGATE SPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MA PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HER IS SUBJEC TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH
PO LIMITS SHOWN MAY HAVE BEEN REDUCED DY PAID CLAIMS.
RIK am
_TR TYPE OF INSURANCE POLICY NUMBER POL E C POLICY EXP IRA ION
1 —2= iMMIDPIVI
A GENERAL LIABILITY 8500043255 LIMITS
X COMMERCIAL
06/22111 06122112 EACH OCCURRENCE $1.000,000
GENER�AL LIABrLITr DAMAGE TO RENTED
CLAIMS MADE 1��.1 OCCUR - s10O 000
MED EXP (Any one e6raon) S5 000
PERSONAL & ADV INJURY x1 AAA nnn
GEN*. AGGREGATE LIMIT APPLIES PER;
X I POLICY M PRO_
JECT � LOC
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
GARAGE LIABILITY
ANY AUTO
EXCI=531UMBRELLA (,!ABILITY
OCCUR CLAIMS MADE
DEDUCTIBLE
RETENTION S
ERS COMPENSATION AND
IYERS' LIABILITY
iOPRIVOR/PARTNER/EXECUTIYE
:R/MEMBER EXCLUDED-)
Ieacribn Under
OF OPERATIONS) LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL
operations usual to Twomey & Legare Contracting, Inc...
COMBINED SINGLE LIMIT S
(Ea accident)
a001LYINJURY
(Pb, Person) 1i
aODILY INJURY
(Pdraocidenl) 5
PROPERTYDAMAGE
(Per accident) S
AUTO ONLY. EA ACCIDENT $
OTHER TKAN EA ACC S
AUTOONLY: _
AGGRCGATE S
S
S
S
WC STATU- DTH.
E.L. EACH ACCIDENT S
E.L. DISEASE • EA EMPLOYEE S
E.L. DISEASE - POLICY LIMIT S
SHOULD ANY 01 THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THERPOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL _110 DAYS WRITTEN
NOTICE TO THE ERTIFICATE HOLDER NAMED TO THE LEFT, OUT FAILURE TO DO 90 SMALL
IMPOSE NO SBL CATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
25 (2001108)1 o12 #S28050IM27509—.e�z,aT.TE
DML o 0 CORPORATION 1908
hiic Safet>
Dci,at�tncnt of Pu rids
,_.-\Iassachusttts - Rc�^ulations xnd Stand:
4 Board of Btiiidinli � ervisor License
'p Construction SuP
License: CS 67560
SHAUN M
TW OMEY
1 PATROIT ST
6 MA 01845 �
N ANDOVER,
Expiration'. 1012512013
rr#. 4913.
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