Loading...
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 u IVA OF 44. o CRAIG m VANCURA NO. 36127 0"'0 L) L/�RV E� N /F CHARING CROSS CORPORATION 6 )3, LOT Al P� oo�Qv oo AREA=27,757±S.F. Ate. �P 2 4' CHAIN LINK FENCE o�F�' ° o Q �h' 7 I WOOD STEPS IRON PIPE S8 ° FOUND � o 1 /o DECK aA PROPOSED COVERED LANDING 21.6 -�7/ PROPOSED o SPLIT-LEVEL EVEL GARAGE 00 2 FT. OVERHANG 22.0 :22.0 2 BRICK ::::0:1.5' 88 ALK 22.0 Y PHILIP & NANCY )�7/ lQGERACI(/ �� / h N /F 'z- THE GARDNER FAMILY \� REVOCABLE TRUST If 5 -L. 132.00 I 0 l0 1 � I � 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 0 15 30 60 120 1-4-12 1 " = 30 FT. 2011047 O F=4 w w x o c c w a c • a�CD w a c "�a W 9) o � O H a w C o w° co a cn ocd w° u U w a n°' w U a W 0 w o x o 94 G w w a w v m o z cn v v o cn L- 7 W z �— co 0 E CD 0 o v Z CD 0 y 0 C ica co O � G '9 m m i O CD (D 0.a o w 0 0 c_0v o Q co C o *" c acc CO Q CL V y cc C C C c 0 ui U) LLI U) W W W to c c c • a�CD c "�a o � c h O C V V `= o m E¢ c 'Z �► VJ EE i 0 = o$ � : :C VCME me I=.— L � mm �: cm O y _m ev • -p c y C=,3 O .a E D CL m H m WPM s o cm" vs c y. O q m c> > Z o . ev.o� co c o � c m C ,p = m "Or Q= p mom~ N ND _W �w�t W N E: dt vw '.O v .y Z O V m a b�� C O COcm Go z=5 . o 0aZm- �— co 0 E CD 0 o v Z CD 0 y 0 C ica co O � G '9 m m i O CD (D 0.a o w 0 0 c_0v o Q co C o *" c acc CO Q CL V y cc C C C c 0 ui U) LLI U) W W W to J LJLJ z u o LE y ) J) w A o w° a°' U w w a°' c 'E o � p a: w w w x w� cn v o C/) n LJLJ z ll in i ICO Com_ � p 'O COD O O .- m m CL ~ CD �' � Ca Q CD c_v o a CL cmQ C O C �� - 1 .CLCO2 O � C ts V CO) c C C C c LLI y LLI Y/ W W 19 W C4 c c • Mm c 'E o � O y O vV C. RCc m C h � s o CD CD E a w C;CL CA O= w$ tel► : � m c � y A •L C2 C* CD 3 m s m a V1 C C � O _m CO'O .": y A O 'Em v aCCD m CA m cm t c oa d C Z m C � m m Z O C C O C Q � y -m c •p 1=— 4D O ID N GO _U y CL Z y no eeo Ft 'E R. o V��a:4a-m� E ll in i ICO Com_ � p 'O COD O O .- m m CL ~ CD �' � Ca Q CD c_v o a CL cmQ C O C �� - 1 .CLCO2 O � C ts V CO) c C C C c LLI y LLI Y/ W W 19 W C4 Qv � Z O� Q7 N /F PHILIP & NANCY �z° GERACI 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. ('��mmi..iuncr