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Home My WebLink AboutBuilding Permit #419 - 32 DEER MEADOW ROAD 11/21/2006 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION o V.�T 616 Permit NO: Date Received Date Issued.e, a RSSACHU5�� IMPORTANT: Applicant must complete all items on this page :DE LOCATION ��,//�f Pr' PROPERTY OWNER /�'`Ci?� 464 Print MAP NO.: 20 /4 PARCE • d ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑New Building ne family ❑ Addition ❑ Two or more family ❑ Industrial Iteration No. of units: epair, replacement ❑Assessory Bldg ❑ Commercial ❑ Demolition ❑ Moving(relocation) ❑ Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED Identi kation Please Type or Print Clearly) OWNER: Name: &ana 41" Phone: Address: CONTRACTOR Name: f�l/�J ��'d6 ce s Phone: Address: 101� �lil Supervisor's Construction License: (s'/ ��d Exp. Date: 3� Home Improvement License: /0& q30 Exp. Date: -2 ARCHITECT/ENGINEER CC40LLC Name: Phone: �� 6�� Q Address: Reg. No. FEE SCHEDULE.BULDING PE M/T:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost :$ r 7.15, /87 FEE:$,9nL-1 r- C--%) . Check No.: Receipt No.: 1'oZ Page I of 4 Location `� -f' r r.-\ yJ —11A No. 917 5 Date NpRTp TOWN OF NORTH ANDOVER ` Certificate of Occupancy $ Building/Frame Permit Fee $ JACMUS r Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 19824. Building Inspector TYPE OF SEWERAGE DISPOSAL Swimming Pools ❑ ❑ Tanning/Massage/Body Art ❑ Public Sewer Tobacco Sales ❑ Food Packaging/Sales ❑ Well 11Permanent Dumpster on Site Private(septic tank,etc. Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fun Signature of Agent/Owner Signature of contracto Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Sta ped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS FIRE DEPARTMENT -Tem Dum ster on sit es no P P Y Fire Department signature/date �,L� l //.V►0 Lw� COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit Building Setback(ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA— For department use Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created IMC.1an2006 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 Addition Or Decks ❑ Building Permit Application ❑ Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) 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 In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORMOS Page 4 of 4 NORTH Town of over No. 41/ C% A over, Mass., 0 L COCHICHEW#CK 7�S OA-rEf) BOARD OF HEALTH Food/Kitchen PERMIT T Septic System BUILDING INSPECTOR THISCERTIFIES THAT......A.W, .............................................................................................................. Foundation has permission to or ct.............. buildings on ..Z. ......�kf-C_FM- 4". #WJ.....................# Rough -ac .... Chimney to be occupied as ..... . .....ft. ...... .... provided that the perso accepting this permit shall in every resp ication on lie in Final "respect orm to the torli-rowft!hwe thea rpl�i&- this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough 3Z0 q1W PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRU S S Rough TS 1&40M T ....... . .... ...................................... Service ING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Bumer Street No. SEE REVERSE SIDE Smoke Det. =rom:Georgia Raneri At: LJM Insurance Agency FaxID: To:Julie Date: 11/14/2006 02:13 PM Page:2 of 2 OP ID G DATE(MM/DD/YYYY) ACORD CERTIFICATE OF LIABILITY INSURANCL- ARSSE_1 11/14/06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE LJM Insurance Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 327 Union Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Framingham MA 01702 Phone: 508-872-0662 Fax:508-879-5299 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Steadfast Insurance Company INSURER B: StPaul Travelers Insurance 40282 A.R.S. Services Inc. INSURER C: Guard Insurance Group 612R Washington Street INSURER D: Fireman's Fund Newton MA 02158 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 3,000,000 A X COlvMERCIALGENERAL LIABILITY GPL 5860576 02 09/24/06 09/24/07 PRE,41SES(Eaoccurence) $ 100,000 CLAIMS MADE n OCCUR NIED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 3,000,000 X Pollution & Profe GENERAL AGGREGATE s4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000 POLICY jE'� LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 B ANY AUTO BA 7428C571 09/24/06 09/24/07 (Ea accident) ALL OWNED AUTOS BODILY INJURY $ I IX SCHEDULED AUTOS (Per person) I i HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ $5,000,000. D X OCCUR ❑ CLAIMS MADE XAE 98570591 09/24/06 09/24/07 AGGREGATE $ $5,000,000. DEDUCTIBLE $ X RETENTION $ $ WCSAWORKERS COMPENSATION AND X TORY LI[A TS ER C EMPLOYERS'LIABILITY ARWC704758 10/15/06 10/15/07 E.L.EACH ACCIDENT $ 1000000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 1000000 If yes;describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1000000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS *30 Days GL & UMB/20 Days AUTO/10 Days WC CERTIFICATE HOLDER CANCELLATION REIMANN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL * DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Manny Rel IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 32 Deer Meadow Road North Andover MA 01845 REPRESENTATIVES. AUTHORIZ�DITE SE ACORD 25(2001108) o ACORD CORPORATION 1988 Received Time Nov- 14. 2: 13PM I A.R.S. Services, Inc. 612 R Washington Street Newton,MA 02458-1449 (617)969-1119 RESIDENTIAL CONTRACTING AGREEMENT Read this agreement and make sure you understand it before signing it. This agreement has legal force and effect and binds those who sign it. A.R.S. Services, Inc. Notice: All home improvement contractors and subcontractors engaged in home improvement contracting, unless specifically exempt from registration by provisions of Chapter 142A of the general laws,must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director, Home Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, MA 02108. All construction techniques, methods and standards of quality to be within allowable tolerances as noted in the National Association of Home Builders, Residential Construction Performance Guidelines for Professional Builders and Remodelers. Designated Registrant's Name: David Baker Registration Number: 091586 Salesperson's Name: Richard Piltch This agreement is made on /X4 between David Baker (D#qE) (CONTRACTOR) of A.R.S. Services,Inc.,612 R Washington Street,Newton,MA 02458 (617)969-1119 (ADDRESS) (PHONE NUMBER) hereinafter called"Contractor"and Manny and Jennifer Rei _ y �p of 32 Deer Meadow Road,North Andover,MA 01845 (OWNER) (?7f) 7 (ADDRESS) (PHONE NUMBER) hereinafter called"Owner". I. DETAILED DESCRIPTION OF WORK TO BE PERFORMED Contractor agrees to perform in a good and workmanlike manner all work detailed below. Such work consists of the following: See Exhibits 1 & IA DETAILED DESCRIPTION OF MATERIALS TO BE USED Materials to be used in performing the above-described work consist of the following: See Exhibits 1 & IA Receptionist\C\MS Office\Winword\Forms\ResidentalContractAgreement.doe ' \Y II. PRICE Contractor agrees to do all work described in Section I for the total price of $275,185.00 . III. PAYMENT Payment will be made as follows: Payment#1 20 % ($55,037.00)upon acceptance; Payment#2 20 % ($55,037.00)upon garage framing; Payment#3 20 % ($55,037.00)upon rough inspection.; Payment#4 15 % ($41,278.00)upon completion of plastering; Payment#5 15 % ($41,278.00)upon completion of painting and the remaining 10 %($27,518.00)upon verification of the completion of Punch List work by Owner and Contractor. Verification shall take place promptly after completion. Notice: No agreement for home improvement contracting work shall require a down payment (advance deposit) of more than one- third of the total contract price or the total amount of all deposits or payments which the contractor must make, in advance, to order and/or otherwise obtain delivery of special order materials and equipment,whichever amount is greater. Contractor reserves the right to bill each line item in the contract that has a price associated with it independently from all other line items. Payment for each line item, which has been satisfactorily completed, is due upon receipt of invoice from Contractor. More specifically, the customer agrees to not withhold payment on any item, which has been satisfactorily completed due to his/her complaint(s)with any other item(s). Upon completion of the painting and receipt of payment# 5 the owner and contractor shall assess the completed work and establish a"Punch List" of remaining outstanding items. These items shall be recorded on the enclosed form(see Exhibit I) and shall be signed by both parties. Upon completion of those items, the final payment shall be due. Any other item that subsequently comes to the attention of the homeowner or contractor shall be considered a warranty item and shall not be grounds for withholding of final payment. Any punch list item(s), which, cannot be, completed whether due to dissatisfaction, lack of available materials or seasonal delays shall have "fair market value" assessed and shall be from the contract. Final payment shall not be withheld for such items. IV. COMMENCEMENT AND COMPLETION OF WORK Contractor will not begin the work or order the materials before the third day following the signing of this Agreement,unless specified here in writing. Contractor will begin the work on or about November 27,2006 barring delay caused by circumstances beyond Contractor's control,the work will be completed by March 16,2007 .The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement. V. NO ACCELERATION OF PAYMENTS BUT ESCROWING ALLOWED Receptionist\C\MS OfficeMnword\Forms\ResidentalContractAgreement.doe The Contractor may not require payments o be made in advance of the times specified in Section III (Payment) above for the reason that he deems himself or the payments to be insecure. If,however,he deems himself to be insecure,he may require, as a prerequisite to continuing the work described herein,that the balance of the payments under this contract that are in the control of the Owner, shall be placed in a joint escrow account that requires the signature of both the Contractor and the Owner for withdrawal. VI. INSURANCE Contractor will be responsible to Owner or any third party for any property damage or bodily injury caused by himself,his employees or his subcontractors in the performance of, or as a result of, the work under this Agreement. Contractor agrees to carry insurance to cover such damage or injury. VII. SUBCONTRACTING Contractor agrees that, notwithstanding any agreement for materials and/or labor between Contractor and a third party, Contractor is responsible to Owner for completion of all work described in a timely and workmanlike manner. VIII. CONSTRUCTION-RELATED PERMITS The following construction-related permits will be necessary in order to complete the scope of work included in the Agreement: Plumb*m Electrical Building The Contractor under provisions of Chapter 142A of the General Laws is required to apply for and obtain all construction-related permits. The Contractor shall not be deemed responsible for delays in the work described in this Agreement caused by regulatory, permit granting or inspectional agencies,authorities or individuals. Notice: If the homeowner obtains he own construction-related permits for the work described under this agreement,the homeowner is hereby advised that in the event of a dispute,judgment and nonpayment of the contractor,the homeowner will not be entitled to make a claim to or collect from the guaranty fund established by Chapter 142A,M.G.L. IX. MODIFICATION This Agreement,including the provisions relating to price(Section lI)and payment schedule(Section 111)cannot be changed except by a written statement signed by both Contractor and Owner. However, cancellation by Owner is allowed in accordance with the Notice of Cancellation(annexed). X. CHANGE ORDER Change orders are additional items contracted subsequent to the signing of this agreement,and the sum of which is not included in the original design and specifications stated on the original scope of work. Upon agreement of a change in scope to the original contract,a Change Order form(see Exhibit I11) shall be signed by both parties. Any additional charge established by the change order, shall be due upon signing of the change order form. The change order shall be treated as a separate contract and completion of those items specified in said change order shall not be grounds for withholding any payments specified in the original residential contracting agreement. All change orders are subject to an administrative fee of$75.00 per change order. XI. COLLECTION FEES Receptionist\C\MS Office\Winword\Forms\Resi dentalContractAgreement.doe 1.5% interest per month will be charged o..past due accounts over 30 days. Should collection proceedings be instituted for payment, customer agrees to pay reasonable attorney's fees,court costs,and other costs incurred. There will be a$25.00 charge for any returned checks. XII. SETTLEMENT OF DISPUTES Any controversy or claim arising out of or relating to this contract, or the breach thereof, shall be settled by arbitration before one arbitrator administered by the American Arbitration Association (AAA) under its Construction Industry Arbitration Rules and judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. In all other cases,the fees will be split evenly by both parties. As an alternative to arbitration,both parties may voluntarily agree to have the matter settled in the appropriate Small Claims Session of the Trial Court of Massachusetts. Such an agreement must be put in writing and signed by both parties. If either party does not agree to submit the action to Small Claims,the arbitration clause contained herein shall be in full force and effect. XIII. WARRANTIES The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of one year following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials,or damage caused by the Contractor,his subcontractors,employees or agents, is discovered within one year after completion of any job, including cleanup, the Contractor shall, at his own expense, forthwith remedy, repair, correct, replace, or cause to be remedied, repaired, or replaced, such damage or such defect in materials or workmanship will be performed based on Residential Construction Performance Guidelines for Professional Builders and Remodelers. The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. All Warranties for equipment supplied by the Contractor under this Agreement shall be those given by the manufacturers of such equipment, which shall be and are hereby passed through directly to the Owner. Under such manufacturers' warranties, the Owner may be required to register or mail in a warranty card or other evidence of ownership and use of such equipment in order to activate such warranties. The Owner's failure to mail in or register such documentation,which failure voids the manufacturer's warranty, shall not create any responsibility for the Contractor to warranty such equipment. This warranty gives the owner specific legal rights, and owner may also have other rights, which vary from state to state. Under Massachusetts's law,sales of goods carry an implied warranty of merchantability and fitness for a particular purpose. XIV. COMPLETENESS OF AGREEMENT FOR EXECUTION The Owner is hereby advised that he should not sign this Agreement unless and until all blank sections have been filled in or marked as void, deleted or not applicable, and until all exhibits and related or referenced documents that are incorporated herein are attached hereto. XV. COPY OF AGREEMENT TO BE GIVEN TO OWNER This Agreement is governed by the Laws of Massachusetts. It must be executed in duplicate,and an original signed copy hereof given to the Owner at the time of execution. No work under the Agreement shall begin prior to the signing of the Agreement and transmittal to the owner of a copy thereof. Receptionist\C\MS Office\Winword\Forms\ResidentalContractAgreement.doc RIGHTS TO CANCEL The owner may cancel this agreement if it has been signed by the owner at a place other than an address of the contractor which may be his main office or a branch thereof, provided that the owner notifies the contractor in writing at his main office or branch by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. See attached Notice of Cancellation. HOMEOWNER: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Owner' ignature to Signed Contractor's Signature !Date Signed Receptionist\C\MS Office\winword\Forms\ResidentalContractAgreement.doc ENTER DATE OF TRANSACTION NOTICE OF CANCELLATION You may cancel this transaction,without any penalty or obligation,within three business days from the above date. If you cancel,any property traded in,any payments made by you under the agreement,and the Contractor of your cancellation notice will return with any negotiable instrument executed by you,in ten business days following receipt,and any security interest arising out of the transaction will be canceled. If you cancel,you must make available to the Contractor at your residence,in substantially as good condition as when received,any goods delivered to you under this agreement;or you may,if you wish,comply with the instructions of the Contractor,regarding the return shipment of the goods at the Contractor's expense and risk. If you do make the goods available to the Contractor and the Contractor does not pick them up within twenty days of the date of your notice of cancellation,you may retain or dispose of the goods without any further obligation. If you fail to make goods available to the contractor,or if you agree to return the goods to the Contractor and fail to do so,then you remain liable for performance of all obligations under the agreement. To cancel this transaction,mail or deliver a signed and dated copy of this Notice of Cancellation or any other written notice,or send a telegram to David Baker (NAME OF CONTRACTOR) at 612 R Washineton Street,Newton,MA 02458 (ADDRESS OF CONTRACTOR'S PLACE OF BUSINESS) NO LATER THAN MIDNIGHT OF I HEREBY CANCEL THIS TRANSACTION. (DATE) (OWNER'S SIGNATURE) (OWNER'S ADDRESS) (Two copies of this form to be attached to the Residential Contracting Agreement) Receptionist\C\MS Office\Winword\Forms\ResidentalContractAgreement.doe ENTER DATE OF TRANSACTION NOTICE OF CANCELLATION You may cancel this transaction,without any penalty or obligation,within three business days from the above date. If you cancel,any property traded in,any payments made by you under the agreement,and the Contractor of your cancellation notice will return any negotiable instrument executed by you with ten business days following receipt,and any security interest arising out of the transaction will be canceled. If you cancel,you must make available to the Contractor at your residence,in substantially as good condition as when received,any goods delivered to you under this agreement;or you may,if you wish,comply with the instructions of the Contractor,regarding the return shipment of the goods at the Contractor's expense and risk. If you do make the goods available to the Contractor and the Contractor does not pick them up within twenty days of the date of your notice of cancellation,you may retain or dispose of the goods without any further obligation. If you fail to make goods available to the contractor,or if you agree to return the goods to the Contractor and fail to do so,then you remain liable for performance of all obligations under the agreement. To cancel this transaction,mail or deliver a signed and dated copy of this Notice of Cancellation or any other written notice,or send a telegram to David Baker (NAME OF CONTRACTOR) at 612 R Washington Street Newton MA 02458 (ADDRESS OF CONTRACTOR'S PLACE OF BUSINESS) NO LATER THAN MIDNIGHT OF I HEREBY CANCEL THIS TRANSACTION. (DATE) (OWNER'S SIGNATURE) (OWNER'S ADDRESS) (Two copies of this form to be attached to the Residential Contracting Agreement) Receptionist\C\MS Office\Winword\Forms\ResidentalContractAgreement.doc A.R.S. SERVICES, INC. Restoration &Renovation 612R Washington Street Newton, MA 02458 Phone: (617) 969-1119 FAX: (617) 244-1115 Exhibit 1 See attached Scope of work v Receptionist\C\MS Office\Winword\Forms\ResidentalContractAgreement.doc A.R.S. SERVICES, INC. Restoration &Renovation 612R Washington Street Newton,MA 02458 Phone: (617)969-1119 FAX: (617)244-1115 EXHIBIT IA Date: EXHIBIT IA Upon completion of the following punch list items listed, See Code Upgrade Scope of work (the Job) will be considered complete and the final payment due in full. Balance due upon completion: $ Agreement to completion list Date: (client's signature) Agreement to completion list Date: (A.R.S.'s signature) Punch list items completed in full Date: (client's signature) Receptionist\C\MS Office\Winword\Forms\ResidentalContractAgreement.doc A.R.S. SERVICES, INC. Restoration &Renovation 612R Washington Street Newton,MA 02458 Phone: (617)969-1119 FAX: (617)244-1115 EXHIBIT III Date: Project#: Change Order# Contractor is directed to increase the scope of the work to include: Total: $ In acceptance of this Change Order, , , shall pay A.R.S. Services, Inc. the sum of$ for the additional items not included in the plans and specifications. Payment shall be due and payable upon the signing of this change order. If the foregoing correctly sets forth our understanding and agreement,please sign where indicated. Accepted and Agreed To: Buyer: By: Signature Signature Receptionist\C\MS Office\Winword\Forms\ResidentalContractAgreement.doc C The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,MA 02111 Y � www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): t� �/j/j[e— Address: , C City/State/Zip: ;2 Phone#: Ar4eou an employer?Check the appropriate box: Type of project(required): lam a employer with 70 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 Remodeling , ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp.insurance 5. [1 We are a corporation and its officers have exercised their 10.[:] Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13.❑ Other *Any applicant that checks box#l must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. +Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: e &=a Policy#or Self-ins.Lic.#: ,� 9q Z'S$cl� Expiration Date: A9/45/z 5 Job Site Address: S2 &&eJo City/State/Zip: �. A',ale I/Ax 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 and hep ' nd penalties of perjury that the information provided above is true and correct. Si nature: Date: -2 Phone#: r Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, or express implied,oral or written." p p An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, lease do not hesitate to give us a call. p The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia