Loading...
HomeMy WebLinkAboutBuilding Permit #528-15 - 328 MAIN STREET 12/5/2014%40RT ted' `BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION (_ y ]r NO: Date Received T �09q <ucwuwlwK `VSO ��SSAC HUS���y Sued: IMPORTANT: ADDlicant must comulete all items on this nate LOCATION 328 Main St Print PROPERTY OWNER Eugene Beliveau & Maryann Beliveau Print MAP NO:MeS5 PARCEL:, ZONING DISTRICT: R4 Historic District yesno 3 3� Machine Shop Village ves no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ld One family ❑ Addition ❑ Two or more family ❑ Industrial 13 Alteration No. of units: ❑ Commercial ® Repair, replacement ❑ Assessory Bldg ❑ Others: l� Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer Repair structure from recent tree damage. Remove roof and wall down to sub -floor. Rebuild to existing footprint. Open wall to kitchen. Replace floor in kitchen. Identification Please Type or Print Clearly) OWNER: Name: Eugene & Maryann Beliveau Phone: 978-828-4393 Address: 328 Main St North Andover, Ma CONTRACTOR Name: Restoration Management, LLC Phone: 603-264-1127 Address: 100 Carl Dr, Unit 11 B Manchester, NH Supervisor's Construction License: cs-106038 Exp. Date: Home Improvement License: Exp. Date: /fid �O 9/26/2015 ARCHITECT/ENGINEER Team Engineering Phone: 603-497-3137 Address: 67B North Mast St, Goffstown, NH Reg. No.i FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 101,520.00 FEE: $ 1,218.24 47 Check No.: X251 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to th ua n fund Signature of Agent/Owner" ignature of contracto Permit No#: Date Issued: ;BOILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this page fi LOCATION. -_.Print PROPERTY OWNER. _ O�tt�.ED a64 NC of no Ono TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units.- ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑,Wel.l. ❑ Floodplain ❑ Wetlands` ElWatershed+District ` ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: AridrP�c Phone: Contractor'NAme: ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ EE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of�Agent/Owner Signature of contractor i Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPB OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed On Signature Reviewed on Signature Reviewed on Siqnature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Co Com Water & Sewer Connection/signature & Date Driveway Permit DPW Town Engineer: Signature: It Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o 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) o Building Permit Application Li Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o 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 Doc: Building Permit Revised 2014 Location M -A Ny,� Stz-e-4 No. L 't 5 Date 5 I t TOWN OF NORTH ANDOVER t Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Check # 07 28330 Buildin9 Inspector Plans Submitted R Ptbris Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer 0 Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMENTS DATE REJECTED DATE APPROVED ❑ - ❑ CONSERVATION ■ ■ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS - x Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes t Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site Located at 124 Main Street Fire Department signature/date / COMMENTS 0 Enter construction cost for fee cal - North Andover Fee Cakulation Construction Cost $ 1, 011520..0'0 m $ - $ 540.00 Plumbing Fee $ 152.28 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 152.28 Total fees collected $ 944.56 328 Main Street 528-15 on 12/5/2014 Repair from tree damage v C � � O N n v O CD CD 010 CL o CL D to U' O vCD CD C� Z3 cr CD CD. O CDCD a CL o v C• C � v O 10 Z 0 rt O CD O CD O e� 5 0 i 1.17 m z z Vrr=A+ 0 N N CD 'a > CD m O m n CL m Z5, = =-0 U) O N ar-OL — T rt O o .-• C m c W `D cn m "0N _ �. CD cCD o Q 0 rt O W r'► toM S C O O < .� to CD o � oo�a ?(� -� �Crt N CL co = 0 �. < Q. o o 0Q — Q y SD mCD CD W CL r a::Ec� . G :< O O :� CD :� CD CD N fir^ 'm P cD � n � y DM M -a MR: 0 � o CL . Ln 3 (D rD * N -moi (D - O Co O ' rD 70 v o m Tx O °—' O ago S G7 N H C) O T 7 °—' N O n O A O rm 3 r m n N m n O A T 3 °—' A O w 7' C W czi H m f'1 O T O' °' n S 3 7 O :O O 0 S T O 3 O.. OW *. O 7 C C z %i O Vf (D 0 < 3 T O a \ + z WO O m D r x O y 0 Fl.,l VRA REsq)e 7 - LN Par—a° - - —Z3 a r to _�i aj 4 + r ELP-vgPpry LlAa Q� Pot QL G icTVP- Es (4-7g &ELIU!ER\,) 9-9, 14,jp WFRE- 0+2 a Pr FA+� Rarer �, .Ei::,- i E� f 0l 5 J PC, FAtt a ccsn�rr c � AT VALLE t t t f> IWTP R 9C.. l 0- _f bti JPf. RAxt-Cr> -TF' . v.� rrt_ L insP. - C-) ,1Pei i1�'S�+�AC��4IxArT''a ;Roop oFF Fosr LwE A - p 00 1- JBUTS (D L )euE- 4q A7 Ltr4c - - - Lawrence H. Ogden P.E. Main 198 East M . - - n S _ t Georgetown, MA 01833 TOWN OF NORTH ANDOVER AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c. 142 A requires that the "reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units... or to structures which are adjacent to such residence or building" be done by registered contractors, with certain exception, along with other requirements. Type of Work: Demolition and repair of existing structure 0 Address of Work 328 Main St, North Andover Ma Owner Name: Eugene and Maryann•'Beliveau Date of Permit Application: 11/24/2014 1. hereby certify that: Copy of license attached. CS -106038 exp9/26/2015 Registration is not required for the following reason(s) Work excluded by law Job under $1,000 Building not owner -occupied Owner pulling own permit Other (specify) Notice is herebv given that: Est. Cost 101,000 For office Use Only Permit No. Date OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FIND LINER MGL c. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: 11/24/2014 Tom Kaloyanides, Restoration Management, LLC Date Contractor Name RegistrationNo. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: fa���apcA-",I J &&a4eev, Date Ownerr ame LAWRENCE H. OGDEN, PE. 198 EAST MAIN STREET GEORGETOWN, MA 01833 978-352-8318 cell 978-502-5921 lhogdenna,comcast.net September 12, 2014 Mrs. Mary Ann Beliveau 328 Main Street North Andover, Ma. 01845 RE: Beliveau Residence 328 Main Street, North Andover, Ma. Dear Mrs. Beliveau As you requested I visited your residence September 9, 2014 to inspect the damage to the Family Room at the rear portion of the structure. This area was struck by a falling tree during a storm which occurred on Saturday September 6, 2014. This event caused severe structural damage to the roof structure and supporting walls.The roof is constructed of beams, valleys and purlins supporting roof decking. There is approximately 4" of horizontal displacement of the roof, certain connections have failed and a portion of the roof decking has failed -The walls are constructed of studs with sheathing, the studs at the point of impact and the opposite end walls have failed. The end walls as well as the side wall are also displaced approximately 4" (see attached sketch and pictures). There are three structural issues that occurred as a result of this event. The first is the obvious damaged material that would have to be replaced. The second is the observed failure of some connections and latent damage to connections that can not be seen that occurred do the excessive 4" displacement of the roof. Connections of wood framing made with nails is not ductile, the nails slip and bend. This results in the connections not retaining there original strength or location when the loading is removed. I therefore believe that the nailing of the roof decking and wall sheathing was overstreesd and the capacity of these connections is inadequate. The third issue is that the existing roof and walls are under capacity to resist the snow and wind loading requiremnts of the current codes. A RESTORATION MANAGEMENT, LLC 100 Carl Dr, Unit 11B Manchester, NH 03103 OFFICE: 603413-5883 / 888-743-0245 FAX: 603-379-3323 Summary Line Item Total 82,799.61 Material Sales Tax @ 6.250% 1,800.32 Subtotal 84,599.93 Overhead @ 10.0% 8,460.16 Profit @ 10.0% 8,460.16 Replacement Cost Value $101,520.25 Net Claim $101,520.25 Tom .Kaloyanides 11/20/2014 We, the owners of said property and policy, herein -after referred to as OWNER, authorize Restoration Management, LLC, herein -after referred to as CONTRACTOR, to make repairs to our property located at: OWNER(s) Printed Name: MaryBeliveau Phone: (978) 828-4393 Loss Address: 328 Main St North Andover MA The date and approximate time of damage: OWNER agrees that the total scope and cost of remedy will be supported in accordance with the original and approved estimate. Any changes to the work as originally estimated and approved will require a supplemental estimate to be prepared by CONTRACTOR and approved by the adjuster of the insurance company. Any order that extends beyond the scope of remedy requires a change order estimate and must be approved by the OWNER and CONTRACTOR. This work authorization, along with the original and approved estimate, supplemental estimates and change order estimates as applicable, constitutes the contractual obligations of the OWNER and CONTRACTOR. OWNER understands and agrees with the following: CONTRACTOR has no connection with the insurance company or its adjuster. OWNER has the authority to authorize CONTRACTOR to make said repairs. Any deductibles owed are the responsibility of the OWNER. Any work not covered by the Insurance Company, including any change orders, must be paid by the OWNER. Terms and Conditions: 1. The repairs, replacement, or additions authorized herein relate to the specifications on the front page of this contract of those attached hereto and do not cover pre-existing deficiencies unless specifically stated. 2. All materials used will be standard stock materials, unless otherwise specified and will match existing materials within RM1007 BELIVEAU XO1 11/20/2014 Page: 10 RESTORATION MANAGEMENT, LLC 100 Carl Dr, unit 11B Manchester, NH 03103 OFFICE: 603-413-5883 / 888-743-0245 FAX: 603-379-3323 reasonable tolerance as to color, texture, design, etc. 3. All painting of existing surfaces is estimate to return existing paint surfaces to same color; any changes in color or type of material will be done at extra cost to owner. 4. The contract price is based on completion during normal working hours and owners agree to provide access to the job site as required for completion of the work. Owners electricity, water, and toilet are to be made available to the contractors personnel during the course of the work. S. Any work deleted from the work authorization must be agreed to by both the owner and contractor in writing, and the owner will be reimbursed for the work in an amount equal to the contractors projected cost on said work. 6. The Contractor will take reasonable steps to prevent the theft, disappearance of or damage to jewelry, art objects, silver, gold antiques or personal items in the OWNER's home by ensuring that all company personnel or sub -contractors have been thoroughly screened and the all personnel and sub -contractors only access areas within the OWNER's home, where work is being conducted. The OWNER will take reasonable steps to ensure that all valuables are stored in locked rooms, to which the CONTRACTOR's personnel have no access. 7. The contractor guarantees all workmanship covered by this authorization for a period of two years from date of use by owner. All materials used are covered by the normal guarantees, if any, provided by the manufacturers or suppliers. 8. The CONTRACTOR agrees to make all repairs in accordance with this written estimate for the total price of: $101,520.25. The OWNER is not responsible for any charges in excess of the agreed amount of the contract, unless both parties agree in writing to any modifications or changes. 9. ARBITRATION AND CHOICE OF LAW - All disputes, controversies, claims or differences, which arise between the parties out of or in connection to this agreement, including the scope and applicability of this arbitration clause, shall be finally settled under the rules of the American Arbitration Association by one arbitrator appointed in accordance with said rules. The place of the arbitration shall be Manchester, New Hampshire. The interpretation, construction and legal order: (i) the language of the Agreement; (ii) the intention of the parties to the Agreement; and (iii) by reference to the laws of the State of New Hampshire. The loosing party will be responsible for the total cost of arbitration as well as expenses associated with the dispute. All overdue and unpaid balances are subject to a 1.5% per month compound rate of interest. 10. Warranty work will not be paid for by CONTRACTOR when performed by others unless agreed to in advance. 11. Restoration Management, LLC may photograph and or record the repair process throughout its various stages. I understand that this material may be used in various publications, public affairs releases, or advertising related endeavors in print, on television and online. OWNER authorizes Mortgage Company to cooperate with CONTRACTOR in the handling of all matters associated with this insurance loss and grants approval fo7CON'RACTOR to discuss all such matters ith the mortgage servicer. Mortgage Company: , .�' Account#: Insurance Company: Home Owner Policy #: / OWNER authorizes the Insurance Company to make payment due to CONTRACTOR directly to CONTRACTOR. Where applicable, the owner further authorizes the Mortgage Company to make payments due to the CONTRACTOR directly to CONTRACTOR. If OWNER is named on the payment, OWNER agrees to promptly endorse said payment authorizing Mortgage Company to disburse payments to CONTRACTOR. If payment is made to the OWNER, OWNER will deposit payment into an escrow account in a bank acceptable to CONTRACTOR and disburse payment to CONTRACTOR as due. Disbursement of said funds will be according to the following milestones: 50% upon acceptance. 25% at 50% complete. RM1007_BELIVEAU XO1 11/20/2014 Page: 11 RESTORATION MANAGEMENT, LLC 100 Carl Dr, Unit 11 B Manchester, NH 03103 OFFICE: 603-413-5883 / 888-743-0245 FAX: 603-379-3323 Balance due at completion. The CONTRACTOR agrees to accept all payments as they are released by the Mortgage Company or the Insurance Company, including the Recoverable Depreciation without penalty to the OWNER if the CONTRACTOR is also named as a payee on the check. OWNER(s) Signature: /; Date: Statement of Satisfaction & Completion I have thoroughly reviewed all of the work performed and completed by Restoration Management, LLC.. I certify that all work performed and materials supplied by the contractor are in accordance with the work authorization and estimate. OWNER(s) Signature: Date: RM1007_BELIVEAU XOl 11/20/2014 Page: 12 12/11/2014 Office of Consumer Affairs & Business Regulation - Mass.Gov The Official Website of the Office of Consumer Affairs & Business Regulation (OCABR) 09ml, Consumer Affairs and Business Regulation Home Consumer Rights and Resources Home Improvement Contracting HIC Registration Complaints Registration 180580 Registrant Name THOMAS KALOYANIDES Address 100 CARL DR. UNIT 11B City, State MANCHESTER, NH 03103 Zip Expiration 12/04/2016 Date Complaints Details No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search © 2012 Commonwealth of Massachusetts. Mass.Gov® is a registered service mark of the Commonwealth of Massachusetts. http://services.oca.state.ma.us/hicAicdetai Is.aspx?txtSearchLN=82527 Home Improvement Contractor Registration Home Page Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supcn icor License; CS -106038 `� Vie:. � rS THOMAS S KA OYES-* 458 E HIGH STREET ¢ Manchester $R 03104 r IN Expiration Commissioner 09/26/2015 8 F, � W f4t �, 7 +Al • 1 i h' »ZAO v � )�� �✓,` �v� -pry}-' 3::r ��, tom-• y 4^ r�X} `.l 1 iC r" pz y4 95 r 1�1►+�t Ki y WY v 8 F, � W f4t �, 7 +Al • 1 i h' »ZAO v y pz Y -, tf- k 5�. a 1 r � i Y -, PG. 2 Beliveau residence September 12, 2014 In my opinion based on the above and the structural failures that occured this structure will requie reconstruction or the roof and exterior walls from the first floor up to the roof. This framing will have to be designed and constructed'to meet current code requirements. Should you have any questions please do not hesitate to call. Yours truly, Lawrence H. Ogden, P.E. 9112.! i4 27!65 QST Bit RESTO-1 OP ID: JT A "' CERTIFICATE OF LIABILITY, INSURANCE DATE(M 11/2441201/201 Y) 4 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Boyd & Boufford, LLC 8 Main Street Amherst, NH 03031 CONTACT NAME: ICCC. ONE Ext ; 603-673-7228 aC No): 603-673-7290 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Acadia Insurance 31325 CPA5081564-11 INSURED Restoration Management LLC dba Legacy Flooring 100 Carl Drive INSURER B: INSURER C : INSURER D; Manchester, NH 03103 INSURER E: INSURER F: GE N'L AGGREGATE LIMIT APPLIES PER: POLICY 1JECT F-1 PRO LOC UUVCKALsCJ CERTIFICATE NUMBER DPVIQlr%kl KIIIMRGD• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDIL SUBR POLICY NUMBER POLICY EFF MMIDD POLICY EXP MMIDD LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR CPA5081564-11 01/17/2014 01/17/2015 EACH OCCURRENCE $ 1,000,00 PREMISES Ea occurrence $ 250,0011 MED FRCP (Any one person) $ 5,00 PERSONAL & ADV INJURY $ 11000100 GENERAL AGGREGATE $ 2,000,00 GE N'L AGGREGATE LIMIT APPLIES PER: POLICY 1JECT F-1 PRO LOC PRODUCTS - COMP/OP AGG $ 2,000,00 $ X AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS CAA5135505-10 01/17/2014 01/17/2015 Ea ao tleD SINGLE LIMIT $ 1,000,00 BODILY INJURY (Per person) $ BODILY INJURY Per accident) $ PROPERTY DAMAGE PER ACCIDENT $ $ A X UMBRELLA LIAB EXCESS LIAB X IOCCUR CLAIMS -MADE CUA5081565-10 01/17/2014 01/17/2015 EACH OCCURRENCE $ 1,000,00 AGGREGATE $ 5,000,00 DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVEWCA5081566-10 OFFICER/MEMBER EXCLUDED? � (Mandatory In NH) If yes, desa be under DESCRIPTION OF OPERATIONS below N / A 01/17/2014 01/17/2015 WC STATU- OTH- TOY IMI S E E.L. EACH ACCIDENT $ 11000,00 E.L. DISEASE - EA EMPLOYEd $ 1,000,00 E.L. DISEASE - POLICY LIMIT I $ 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) L,CK I II-IL:A I C MULUCK 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 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations ' I Congress Street, Suite 100 ./ Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Restoration Management, LLC Address: 100 Carl Dr, Unit 11 B City/State/Zip: Manchester, NH Phone #: Are you an employer? Check the appropriate box: 1. ❑x I am a employer with 4. ❑x 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. employees and have workers' [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 3. ❑ 1 am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no 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. Rx Plumbing repairs or additions 12.E Roof repairs 13. Rx Other repair existing structure *Any applicant that checks box #1 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Acadia Insuran Policy # or Self -ins. Lic. #: WCA5081566-10 Expiration Date 1/1712015 Job Site Address: 328 Main St City/State/Zip: North Andover, Ma 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 certio undyr th9pains appenalties of perjury that the information provided above is true and correct. i//7I'L /Arf't- L//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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: _1 21'2" -A � m UO � n .�1 0 N 23'9" C 17 10" G12'10" 11,11° 11,11" 9.4' A b A� OQ t� o 18'8' -A J -A J 5 X O OD O N �. p p Q? N j Q p n N (mit p O �m w Q � �3�� �� _ �� so�oo'mm=.o�.aQQ m o R o rn ¢ � .6 m ° N (3) 13/;'X14" 2.0E Microllam LVL, Z _ 7 o Z �, o 0 o 3 O. p -• — 0. : — wra to match Df P Valle /Rafters Y a G1 d A V1 �°L 's°aQ=aQ�7� O �O p��'xao�Qm°Y.11ID H n m -r 60° a°op.6 7 0 0 -« O' O D,o y r ��N wQ�poo°0 3Q c0T� m0 OT vv, ZGl M O< . tpoX_ �j o cQ N6 4n �7> i ` S2'• 0a, °mn m3p D O ID D±!? 0 CD _ 00 ftq Ul O7ID o °c N f� 0 ^ O Q N S Q 7 0 U O Q N V' W _ a 0 6�a Q� 3. 3? Q mN mo C:Q D x ��no O x� w ? N� rn N� 0 N N ° (p fQ .1 r- ao ��.Q Z Q? N z"G1 >W.. X o ma n7 ciN omN`AOOv2.�NO_ToT 3�s - Sn ooO 00m 0. 0 < 0 o n A —Qo .0 y Z CDOOYpo7�°o o a am N D ? Q_ _O o (D QQ0oQ CL3 of— m <r- O m CD C. 3 �=sz5Z�ff,nn Q 7ON z n no' 0 . o:.J(o3n� O Z = — N X I DO N Z O ;� J " m T n mD Z p r T z N Z O /-v O D > m 4[;—> o 3 Z 6 x r. n ? O m _ 6 _ o O .0 Z � 3 D II c A Z 90 b O o 6 8 0 O I& " m X < N (D Z w W 0O N N N X v m P A N O7 O O _ w O f Z Q as 0 Q P O Q 0 r ro ' w 0 0 a to o o � so verify or install (2( 2"x10" garage door header a� Q A z N Lo m y _0 z 0 2X6 $ m 0 o 0 63 a (D m c m N Nm n m s o a M r m 3 z 0m 0 ry� O X N 0 O. � � a 0 v UrD y 0 0 0 z O z 0 C �P no zw» 0 o° = o `m y < ((D o oA9g ,� o X W O 0J A A N A Q. 3 CD a �o J-• A 30 N O O (D P 7 0 T T 0 so p � -n no h �oo03 oc N < _ .. Z fD O w°'m r n � O 0 N Z x 50 R m � cQ a IV 0 Qo rn o 0 0 0 70 r y m m o 3 c'0 OO D� N Q �� n m �� 6(. (p i+ Q N 3' a (Q O 4 D Q D Z o 0 Ste" D T A � a C (ND A = Q -� t7 n O ti Q � 3 T N y m N O 0 w p- 510- l t M f �f! 1 i' f 15 r 1 5 00 G m m m m o t — A� 'T r 10 �• O C� W 00 WIN E= JP., V 51 b CJ CD D R �A Ci A m to ara m 5 :4 m m m m c 0 E p� r ,r A� UQ A w r-� A W 5 C4 �A f\ u N O N O A L. co N O N O ra b W fJ CD D IW N O N O Oo R� J�- CDb CD V 3 00