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Building Permit #320-2017 - 35 MERRIMACK STREET 9/26/2016
�Ir�NS Nd T �C/I V)V A p10RTM BUILDING PERMIT "Jr° TOWN OF NORTH ANDOVER / APPLICATION FOR PLAN EXAMINATION s Permit NO: �Uvi Date ReceivedATED ; Date Issued: C �9SSACHus IMP RTANT:Applicant must complete all items on this page " LOCATION- 35' s/ PROPERTY OWNER l3W.F,C N Print Print MAP NO:W,0 P EL: ZONING DISTRICT: l3 Historic District es no Machine Shop Village s ' no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family y,Addition El Two or more family El Industrial ❑Alteration No. of units: ICommercial ❑ Repair, replacement ❑Assessory Bldg ❑ thers: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer Identification Please Type or Print Clearly) OWNER: Name: 4'sq '23V?'r-r Phone: Address: CONTRACTOR Name: Phone: 971?- 9gr'/p�� Address: Supervisor's Construction License: C�y Exp. Date: a8 Home Improvement License: Exp. Date: ARCH ITECT/ENGINEER_ Jo( S;l�R k..Q�v� Phone: Address: �5� � a ti,tee rt, 1.9 ^'►�'1 ti, S`'ef 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: $ /?J� FEE: $_ 7t' Check No.: lr Receipt NoNOTE: Persons contracting with unregistered contractors do not haveo the rantyfunSignature of Agent/Owner Signature of contra L d� NORTH BUILDING PERMIT 6 r y� :e TOWN OF NORTH ANDOVER 3 - APPLICATION FOR PLAN EXAMINATION , Permit No#: Date Received ATED gSSAC HUS�t Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT:_Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family 11 Addition El Two or more family El Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement [IAssessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic El Well ❑ Floodplain El Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: i Address: FContractor Name: Phone: Email: Address: LHevimprovement risor's Construction License: Exp. Date: j License: Exp. Date: I ARCHITECT/ENGINEER Phone: j 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: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund of rnntrartnr__.� _ Sia�na�r of AaPn /OwnF-r x Signat y^ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑• Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On q126�l 6 Signature_ -/4� COMMENTS_ -4, zoo SC r-r �'�;��,,,, �►a � I-(S� CONSERVATION Reviewed on ern Si nature COMMENTS ATH Reviewed on `oSinature COMMENTS z _ Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submittedY es Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature& Date Driveway Permit DPW Town Engineer: Signature: " FIREDEPAR+TMENT'-= Ternp)Dumpster on site ,yes: - - - Located 384 Osgood Street nQq Located{at !-u Main,Sftet Firebeparment signature/date _ COMMENT- t` s 7— f - 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) I ❑ Notified for pickup Call Email i Date Time Contact Name Doc.Building Pennit Revised 2014 J. 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 ;rt 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses 4. Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ;rt Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: 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 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 ly1 ' No. 'S CJ—�G17 Date 2 (PI —T • - TOWN OF NORTH ANDOVER Certificate of Occupancy $. Building/Frame Permit Fee $ '�' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#,q0 Building Inspector/, ~ r r J I pORT#1 '9 Town of s aAndover O .�... �+ No. ,Z6- 1 - �o h ver, Mass, jo coCAIC"A.". X1,9 ogAreo S U BOARD OF HEALTH Food/Kitchen PERMIT -T LD Septic System THIS CERTIFIES THAT ....... BUILDING INSPECTOR Foundation .... has permission to erect .......................... buildings on .. ... ... ....... ..It.......... . .. .. .. ... . • Rough to be occupied as ... ..ve."..... .�. .... Chimney provided that the person accepting this permit shall in every respect conform to the ter f the applicatlo# Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONTI Rough Service ......WON .... ....... Final BUILDING IN19PECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Burner Street No. Smoke Det. Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL; Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On 426/16 Signature_ COMMENTS -� ZOO 5 , � f � A�'r o� vizi �'" MSv CONSERVATION Reviewed on ` Signature COMMENTS , �4EALTH Reviewed ori °07 (4Q �Siqnature COMMENTS toning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/si nature& Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPAR�TIUIENT' Located 384 Osgood Street !, j � TgTernpDumpster ori site es - S�Y�'_ F � _. c, t ;y tint_1� I,,i. �`sa h inOi fi. Locetetl atr;124JWfitstreet F ri eDeparien�t4srgnature/elate ' COMMENTS, i NOflT1 OOf... e •1tic 3?' Town of North Andover -- A Machine Shop Village Neighborhood Conservation District Commission ;;ro.:�o•%'tt�• 1600 Osgood Sircct North Andovcr.MA 01815 � SSwcMus° Certificate to Alter Date: Contact Name& ddress: Project.Address: �3 5 y t r-r� �u Project Description(attach additional pages,if needed): lit u' Y) agfI CCP fio I')e.�-C11 �- I 0 'D Commission Vote: Voted__a to 0 to grant l deny= Certificate. to Alter on Comments (attach additional pages,if needed): Ile Machine Shop Village Neighborhood Conservation District Conanission MSV NCDC Page 1 Scanned by CamScanner NORTH q 01i"Eo ,aF tiQ Town of North Andover Machine Shop Village Neighborhood Conservation District Commission 1600 Osgood Street North Andover, MA 01845 SACHUS Application For EXCLUSION From Certificate to Alter Certain alterations are excluded from review by the Machine Shop Village Neighborhood Conservation District Commission in accordance with the Bylaw. Applicants for exempt projects must fill out the form below and submit to the Commission Chairperson(contact info below). Date: �Izk Contact Name&Address: o or,? y Project Address: Project Description(attach additional//pages,/if needed): ,�qop /� /yaw /400iT.g. �a�/yC dIG /�/lEir. fyJwGlt,IFG �} Nd�o1�. 1 3/`' X ��/ �v .4r.��r.ec•4i C ��w.53a/ps:�y�A,/� 7L ts'M��,y 4J s1r�'�e tSl�1N'R1S Exclusion From Review Requested For: ❑ 1.Interior Alterations existing conditions including materials, design and dimensions. ❑ 2.Storm windows and doors, screen windows and doors. ❑ 9.Replacement of existing substitute doors,substitute siding or substitute ❑ 3.Removal,replacement or installation of windows with new materials that are gutters and downspouts. substantially similar to the existing condition. ❑ 4.Removal,replacement or installation of window and door shutters. ❑ 10.Replacement of original fabric windows or doors with substitute ❑ 5.Accessory buildings of less than 100 windows or doors that maintain the square feet of floor area. architectural integrity with respect to form,fit and function of the original ❑ 6.Removal of substitute siding, windows or doors. ❑ 7.Alterations not visible from a public ❑ 11.Reconstruction,substantially similar in way. exterior design,of a building,damaged or destroyed by fire,storm or other disaster, ❑ 8. Ordinary maintenance and repair of provided such reconstruction is begun architectural features that match the within one year thereafter. MSV NCDC Pagel Current Chair:Liz Fennessy,77 Elm Street,lizettafennessy@vahoo.com,978-688-2915 SILVERWATCH ARCHITECTS, LLC Architecture Engineering Land Planning Design Friday, September 23, 2016 Inspector Donald Belanger Town of-North Andover, Massachusetts Building Department 1600 Osgood Street North Andover, Massachusetts 01845 RE: John Breen Memorial Funeral Home Addition Code Review Inspector Belanger, Folowing is our code review for a minor addition to the existing John Breen Memorial Funeral Home located at 35 Merrimack Street. Project o�ect Narrative: The project consists of a 180 SF addition to the rear of an existing funeral home facility. The addition will be used as a workroom for the preparation and embalming of human remains. The existing, preparation room that is currently located in the basement of this ancient building does not meet the current standards set by the Commonwealth of Massachusetts nor does it:provide for easy access for transport and handling of remains. The State of Massachusetts has ordered the facility to upgrade the current conditions to meet current standards required for licensing by the Commonwealth. There are no modifications made to this existing building's construction type, occupancy type, occupant load calculations or affecting any required egress routes. Space is simply being relocated from the basement to the main level. The existing facility would fall under an A-3 Funeral Parlor Occupancy Type. The construction type will be continued as Type 5B Combustible—Unprotected. Allowable area, story and heights for this occupant and construction type is as follows: 40 Feet High, One story and 6000 SF per floor. The .proposed addition adds 180 SF to an existing 2100 SF facility. 2280 SF is well below the allowable 6000 SF allowed per code. The addition is on the same single level and is 8 feet high at the wall plate and well below the the existing building,height. This concludes our review. �,,etRED A/?C SILVF cerely, Qr �P o No.9671 s � WINDHAM, v, gJoelvid k'verwatch, Architect AIA ;o NH a�Jy Tk OF MP 155 Londonderry Road Windham,New Hampshire 03079 603.894.4450 Licensed: New Hampshire, Maine,Massachusetts Associate Member: Massachusetts Building Commissioners and Inspectors Association,Inc. #1391 HAMMERTIME CONSTRUCTION HOME IMPROVEMENT CONTRACT HOMEOWNER INFORMATION CONTRACTOR INFORMATION NAME: COMPANY NAME: Lisa Breen, Breen funeral Home HAMMERTIME CONSTRUCTION STREET ADDRESS: OWNER NAME: 35 Merrimack St. JAMES GODFROY CITYlTOWN: STATE ZIP BUISINESS ADDRESS: N.Andover Ma 1845 382 PRIMROSE HILL RD DAYTIME PHONE: CITY/TOWN: STATE ZIP DRACUT MA 01826 EVENING PHONE: EMAIL: PHONE #: VICSDAD COMCAST.NET 978-995-1898 MAILING ADDRESS IF DIFFERENT): CONTRACTOR H.I.C. REG. # (EXPIRATION): 139503 (7/21/2017) EMAIL: CONST. SUPERVISOR LIC. # (EXPIRATION): CS92065 3/28/2017 HAMMERTIME CONSTRUCTION AGREES TO DO THE FOLLOWING WORK FOR THE HOMEOWNER: The following work to be completed at the above address. Build custom addition to the existing building per plans prepared by Silverwatch Architects to include Dig foundation hole to provide for concrete foundation Supply labor and materials for poured concrete footing and walls to grade. Backfill exterior of foundation to grade and patch pavement as necessary and loam and seed. Frame walls and roof per plans including tie into existing roof. Install vapor barrier and vinyl siding to match existing structure. Install shingles to match as close as possible. Supply and install all plumbing supply and drain lines. Supply and install new electrical circuits including outlets,switches and lights Supply and install insulation to code. Supply and install concrete slab floor with provisions for floor drain Supply and install ductless mini split and ERV system per drawings. Supply and install drywall with plaster and finish to smooth texture Supply and install FRP around entire new room four feet up wall. Paint walls and ceiling color of choice. Provide all necessary permits and inspections. Dispose of all demo debris and trash daily off site.. REQUIRED PERMITS (REQUIRED AND PROPOSED START AND COMPLETION SCHEDULE SECURED BY HAMMERTIME CONSTRUCTION (THE FOLLOWING SCHEDULE WILL BE ADHERED TO ACTING AS THE PROPERTYAGENT): UNLESS CIRCUMSTANCES BEYOND THE CONTRACTORS CONTROL ARISE): DATE WHEN CONTRACTED WORK WILL BEGIN: 8/22/2016 DATE WHEN CONTRACTED WORK WILL BE SUBSTANTIALLY COMPLETED: HAMMERTIME CONSTRUCTION HOME IMPROVEMENT CONTRACT 9/30/2016 TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE: HAMMERTIME CONSTRUCTION AGREES TO PERFORM THE WORK, FURNISH ALL MATERIALS AND LABOR SPECIFIED ABOVE FOR THE SUM OF: $ (*) $54,475.00 PAYMENTS WILL BE MADE ACCORDING TO THE FOLLOWING SCHEDULE: $ 15,000.00 upon signing contract(not exceeding 1/3 of the total price OR the cost of special order items, whichever is greater) $ 15,000.00 by / / or upon completion of Complete dry in and rough sign ofi $ 15,000.00 by /_/ or upon completion of Electrical, Plumbing and HVAC Finish sign off $ 9,475.00 upon completion of the contract. The following material/equipment $ to be paid for must be special ordered before the contracted work begins in order $ to be paid for to meet the completion schedule(**) NOTES: (*) Including all finance charges (**) Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. EXPRESS WARRANTY- YES NO (All warranty terms will be attached if needed) SUBCONTRACTORS-HAMMERTIME CONSTRUCTION agrees to be solely responsible for the completion of the work described regardless of the actions of any third party/subcontractor utilized by HAMMERTIME CONSTRUCTION. HAMMERTIME CONSTRUCTION further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement. CONTRACT ACCEPTANCE-Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. 1. Don't be pressured into signing the contract. Take time to read and fully understand it. 2. Make sure the contractor has a valid Home Contractor Registration. 3. Ask the contractor for insurance information so you can confirm coverage. 4. Know your rights and responsibilities. Get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram HAMMERTIME CONSTRUCTION HOME IMPROVEMENT CONTRACT sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM! I HOMEOWNERS SIGNATURE: CONT RS SIG URE: DATE: DAT 8/ 1/2016 CONTRACTOR ARBITRATION -The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is NOT automatically afforded to a contractor, however.The contractor would have to resolve any disputes he/she has with a homeowner in court unless both parties agree to the OPTIONAL clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided in Massachusetts General Laws, chapter 142A. HOMEOWNERS SIGNATURE: CONT. TO NATURE: HOMEOWNER'S RIGHTS-A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A) and other consumer protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the workas described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provide by the contractor, all goods sold in Massachusetts carried an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). EXECUTION OF CONTRACT-The contract must be executed in DUPLICATE and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as voided, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and HAMMERTIME CONSTRUCTION HOME IMPROVEMENT CONTRACT the three day rescission period has expired. ACCELERATED PAYMENTS-A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself to be financially insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. ADDITIONAL INFORMATION - If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you with to obtain a free copy of"A Massachusetts Consumer Guide to Home Improvement'contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at: hftp://www.mass.gov/ocab If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at: http://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeimprovement/licenseelist.as[) For assistance with informal mediation of disputes or to register formal complaints against a business call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800, 508-755-2548 or 413-734-3114 1 HAMMERTIME CONSTRUCTION HOME IMPROVEMENT CONTRACT NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION, WITHOUT 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 CONTRACT OR SALE, AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOUR CANCELLATION NOTICE, AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED, ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLERS EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION, YOU MAY RETAIN OR DISPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO, THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO JAMES GODFROY (HAMMERTIME CONSTRUCTION), AT 382 PRIMROSE HILL RD, DRACUT, MA 01826, NOT LATER THAN MIDNIGHT OF (DATE). I HEREBY CANCEL THIS TRANSACTION. DATE: BUYER'S SIGNATURE: i The Commonwealth of Massachusetts Department of Xndustrical Accidents 1 Congress street,Suite 100 Boston,MA 02114-2017 www.rnass gov1dia SY. Workers'Compensation Insurance,Affidavit:Builders/ContractorslElectTicians/Plumibers. TO BE MED WITH TBE PERMITTING AUTHORITY. A licant Information • Please Print Legibly Ile- Name, Name(Business/Organization/Individual): 0621�S Address:_ City/State/Zip: ��ac of Phone 0: �27 Are you an employer?Checkt&apl rl opriate box: 'Type of project(Tgquired): 2�I am a employer mitt_.0, employees(fullandlor part time).* 7.• New constriction I am a sole proprietor or partnership and have no employees Working forme in 8. Remo delitlg any capacity.No workers'comp.insurance required-] 9 ❑Demolition. I Q I am a homeowner doing all work myself»[No workers'comp.-insurance required.]f 10 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.[!Electrical repairs or.additions proprietors withno employees. 12 n Plumbing repairs or additions S.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.'[(Roof rep airs These sub-contractors have employees andhave workers'comp.insu ance.1 ' ' 14.0 Other 6.0 We are a corporation pad ifs officers have exercised their right of exemption per MGL c. 152,§1(4),andwehave no..e nployees.[Noworkers'comp.insmancerequired.] `Any applica atthat checksb6x#1 must also fdl out the section below showingtheirworkers'compensationpolicy information. T Homeowners who sa6 ittivs affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such (Contractors that check this box must-attached an additional sheet showing the name of the sub-contractors and state whether or notthose entities have employees. If the sub-coniracfrirs have empl6yees,Iey must provide then workers'comp.policy number. _ I ain an employer that is pfovzdiizg7vorkersI compensation insurance for my employees'Below is thepolicy acid job site information. Insurance Company Name: n(> /� — Policy#or Self-ins.Lic.#: !o S b V o S� �a 4 Expiration Date: Job Site Address: 'P.�l/1-i City/State/Zip: � v✓<� oteyr Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to s-ecure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A,copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do h:ereby—c�eeorfi2ffyun the pains and enalties ofperjury that the informationprovided alcove is true andcosi ect. Si afDate: Phone# Official use only. Do not-write in this area,to he completed by city or town officiaL. City or Town: Perznit/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#: i I AC40® DATE 1.� CERTIFICATE OF LIABILITY INSURANCE 08-01-2016 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 j not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: FRANCIS E PROVENCHER INS PHONE FAX 530 ROGERS ST A/c No Ext): A/C No): LOWELL,MA 01852 E-MAIL INSURERS)AFFORDING COVERAGE NAIC# INSURER A:HARTFORD UNDERWRITERS INSURANCE COMPAN INSURED INSURER B: GODFROY JAMES DBA INSURER C HAMMERTIME CONSTRUCTION 382 PRIMROSE HILL ROAD INSURER D: DRACUT,MA 01826 INSURER E: 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 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 ADDLTYPE OF INSURANCE INSR SUB POLICY POLICY NUMBER MM/DD EFF POLICY EXP LIMITS LTR INSR WVD ( /YYYY) MM/DDlYYYY GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES Ea occurrence CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- JECT LOC $ AUTOMOBILE LIABILITY C (Ea OMBINED accidentI SINGLE LIMIT $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per person) $AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED AUTOSeraOPERTntY AMAGE $ cade I $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ --FD XCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATIONX WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIMB R/PXCLUDE/EXECUTIV N/A E.L.EACH ACCIDENT $100,000 ((Mandatory in NH)R EXCLUDED? Y 6S60UB 07-22-2016 07-22-2017 (Mandatory in un 4305P306 E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space is required) THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR GODFROY JAMES CER1481DOE HOLDER CANCELLATION LISA BREEN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE 35 MERRIMACK ST. CANCELLED BEFORE THE EXPIRATION DATE THEREOF, N ANDOVER,MA 01845 NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 6L� ACORD 25 2010105 ©1988-2010 ACORD CORPORATION.All rights reserved. ( ) The ACORD name and logo are registered marks of ACORD G0DFJA1 OP ID: BW CERTIFICATE OF LIABILITY INSURANCE DATE o7n29/i2016`n o1s 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(les) 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 CONTACT Francis Provencher Insurance NAME: Agency, Inc. PHO Ext: FAX No: 530 Rogers Street E-MAiL Lowell,MA 01852 ADDRESS: Mike Provencher INSURERS AFFORDING COVERAGE NAIC S INSURER A:Preferred Mutual Insurance Co. 15024 INSURED James Godfroy dba INSURER B: Hammertime Construction INSURER C 382 Primrose Hill Road Dracut,MA 01826 INSURER D: INSURER E: 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 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. 1NSR TR TYPE OF INSURANCE JM&WVD SUB POLICY NUMBER PM/DD/EFF MMSPOLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 500,00 A X COMMERCIAL GENERAL LIABILITY BOP0100719540 09/13/2015 09/13/2016 D MAGE ( RENTE PREMISESS Ea occurrence) $ 50,00 CLAIMS-MADE [XI OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 500,00 GENERAL AGGREGATE $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,00 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per $ AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS PER ACCIDENT UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N RY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) **CERTIFICATE FOR WORKERS' COMP COVERAGE WILL BE ISSUED DIRECTLY FROM THE COMPANY WITHIN 2 BUSINESS DAYS** CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ` THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN isa Breen ACCORDANCE WITH THE POLICY PROVISIONS. 5 Merrimack St. N.Andover, MA 01845 AUTHORIZED REPRESENTATIVE 3E ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 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 @re, 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 enferprise,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 lias not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states`2leither 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-contractors)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 maybe submitted to the Department of•7Adustrial Accidents for confL m.ation ofinsurance coverage. Also be sure to sign and date the a-fifidavit. 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-insure_d companies should'euter 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 hag provided a space at the bottom of the of adavit 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 areference 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 maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA.02114-2017 Tel. # 617•-727-4900 ext. 7406 or 1-877-MAS SAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia OSHA I U.S,Department of Labor Ooarpatiarral safety SW Health Adwrtwatron James Godfroy has successfully conT.Wed a toduax Occupational Safety and HN" Training Course in C tstrttcfiottSafety&Heatth Te-ter e Doo/.7 771312009 i �JG� C�i:nr��ro�rioca�/�nfCf�crsnclr�.te/%' Office ofConsumer Affairs&Business Regulation License or registration valid for individul use only �0ME IMPROVEMENT CVNTRACTOR. before the expiration date. Hfound return to: e9tstrati6n: 139503 Type: Office of Consumer Affairs and Business Regulation yE;Expirat=on: -7121120'17 DBA 10 Park Plaza-Suite 5170 HAMMERTIME CONSTRUCTION&REMODELING Boston,MA 02116 JAMES GODFROY 382 PRIMROSE HILL RD DRACUT,MA 01826 Undersecretary Not valid without signature Massachusetts-Department of Public Safety Board of Building Regulations and Standards Unrestricted-Buildings of any use group which Construction Supervisor contain less than 35,000 cubic flet(991M )of License: CS-092065 enclosed space. -JAMES H GODFRbY T- 3921PRIMROSE HILL ¢ r+ Dracut MA 01821 f Failure to possess a current edition of the Massachusetts S..G.•. .� •'" Expiration State Building Code is cause for revocation of this license. Commissioner 030=17 For DPS Licensing information visit: www.Mass.6ov/DPS HAMMERTIME CONSTRUCTION MA HIC#139503 &MA CSL#92065 HAMMERTIME CONSTRUCTION x Licensed and Insured General Contracting,-Rim odeling J1 M,sournf)Y - Vinyl Siding,Windows & x General Contractor New Construchan '- ,. f i • }��n" f i VICSDAD@COMCAST.NET 382 Primrose Hill Rd Dracut,MA 01826 (978)995-1898