HomeMy WebLinkAboutBuilding Permit #963-16 - 35 SANDRA LANE 3/10/2016LP BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No# -9 �3,- (V Date Received
Date Issued: /(0 1/07
'IMPORTANT: A-DDlicant must complete all items on this page
LOCATION -3�5 SCXCOQX LCT)e—
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PROPERTY WNER Vnb De(-N(NeL-?
Print
MAP PARCEL: 4-'Z ZONING DISTRICT
0
*0 Year Structure yes C no
Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
El One family
El Addition
El Two or more family
0 Industrial
0 Alteration
No. of units:
El Commercial
p4lRepair, replacement
0 Assessory Bldg
0 Others:
[I Demolition
D Other
TEN Fe—bd * W,,,:e I
=,7, MT,
gf, QC, 7
DESCRIPTION OF WORK TO BE PERFORMED"
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Identification - Please Type or Print Clearly
4t OWNER:. Name: Phone:
Contractor Name: News 'JE - 5;�\/ k CP -3 Phone: -AN -760 203(
Email: #Y-\cL(,k 0� com
Address: P0. Z" 2—R2—S IAO')o�r,�f M8 0 \?S?
Supervisor's Construction License: C5 P' -)3q91 Exp. Date:
Home Improvement License: 12 9 i-7�7 Exp. Date: �7
ARCH ITECT/ENGI NEER K \ �.A Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. MOO PER $1000.00 OF THE TOTAL ESTIMATED COSTBASQ—,Q& $125.00 PER S.F.
Total Project Cost: $ ;-16. cx +L4�. FEE: $ !;�& 57(e,—
r,' 6 /Zil 000' 1 -r
Check No.: WK� 701 --,\ Receipt No.:
NOTE: Persons contracting wit4 i(nregiste�edcptquctors do not have � lo' rheguarantyfund
At
L�
Plans Submitted [I Plans Waived [I Certified Plot Plan [I Stamped Plans 11
TYPE OF SEWERAGE DISPOSAL
Public Sewer El
Tanning/MassagelBody Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales 11
Private (septic tank, etc.
Permanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE, ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Siqnature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoninb Decision/recelpt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer ConnectionlSignature & Date DrivewaV Permit
DPW Town Engineer: Signature:
'Located 384 Osgood Street
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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
MGL Chapter 166 Section 21A —F and G min.$10041 000 fine
NOTES and DATA — (For department use
11i'm
I LJ Notified for pickup Call I Email I
Date Time Contact Name
Doc.Building Pemit 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
4� Building Permit Application
4� Workers Comp Affidavit
4. 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
Copy Of Contract
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
4� 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
IOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the, Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doe: Building Permit Revised 2014
Location
No. 1?61 � —)roe D ate �, "S 1/0/� �/j
JI - t p (-
Check # ��!5 .0
30112
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $__w
TOTAL $
Building Inspector
Enter construction cost for fee cal -
North Andover Fee Cakulation
Construction Cost
$ 43�000.00
m
$ -
$
516.00
Plumbing Fee
$
64.50
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
64.50
Total fees collected
$
745.00
35 Sandra Lane
963-2016 on 3/10/2016
Remodel Kitchen
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Nexus 11 Carpentry and
Construction Design
P.O. Box 2823
Wobum, MA 01888
7817602031
Fax 978 975 1263
nexuscaryentry(&aoI.com
C61itiract4r- t
Page 1 of 4
A
This is a contract between Robert and Kimberly Denney of35 Sandra Lane, North
Andover MA 01845 (Hereafter referred to as the "owners") and Nexus 11 Services
(hereafter referred to as "Nexus") dated February 8112016.
GENERAL SCOPE OF WORK DESCRIPTION
WE HEREBY SUBMIT SPECIFICATIONS AND CONTRACT FOR: work as stated to
repair water damages as below
Scope of work:
General details
Meet with local building official and apply for permits
All work will be in accordance with local building code regulations and will be
inspected by local officials prior to continuing with the next phase — Nexus will be
responsible for arranging and being available for all inspections
Nexus will contact "Dig Safe" prior to commencing any excavation work for their
clearance
All work will be coordinated directly between "owners" and Nexus
* Nexus confirms that it is fully licensed, insured and ensures any sub -contractors
utilized on this site will have the appropriate insurance coverage
# Nexus will be responsible for the safe storage of all its property and any materials to
be used on the site
* Owner is responsible for removal and return of all items of the house in the areas that
will be affected and their safe storage prior to our work commencing
* Owner will then be responsible for returning all items to these areas of the home after
completion of the scope of work
SPECIALIZING IN QUALITY FINISH CARPENTRY, REMODELING, SPECIALIST ROOF SYSTEMS, SITE AND
PROJECT MANAGEMENT
AV
-A .
Page 2 of 4
Remove and trash into Nexus supplied dumpster all trash associated with this project
NOTE: appliances are not allowed to be put in durapsters without additional costs
4�owners" are responsible for removal from site
Scope of Work
Kitchen water damage repairs;
* Provide dumpster to remove debris associated with this scope of work
+ Furnish and install plastic protection to provide dust control
* Remove and trash existing "discovered" hardwood flooring
* Remove and trash existing wall cabinets
* Detach existing refrigerator and stove
* Furnish and install updated plumbing lines for sink.. faucet, dishwasher and water feed
to refrigerator
* Furnish and install updated electrical connections
* Furnish and install insulation to exposed exterior wall and to ceiling of basement
laundry room
* Furnish and install patched sheetrock with smooth plaster finish to walls only -
* Install kitchen base and wall cabinets, construct island and associated trim details
(supplied by owners and not included in this cost proposal)
* Furriish and install hardwood flooring to patch to remaining hardwood flooring
* Sand existing hardwood flooring existing and new hardwood flooring in kitchen and
eat in area only
+ Furnish and install 3 coats of polyurethane to existing and new hardwood flooring in
kitchen and eat in area only
4 Furnish and install paint grade baseboard trim
* Install sink and faucet (supplied by owner and not included in this proposal)
* Furnish and paint the 4 walls of the kitchen and eat in area
+ Furnish and paint the ceiling of the kitchen and eat in area
* NOTE: no trim painting included
* Furnish and install new suspended ceiling tile in laundry room
* Install appliances and fixtures supplied by owners
* Proposed cost including materials and labor as noted above is
- Work not included in this contract
— Building department fees
— Engineering or architect costs
— Permit costs
— Unseen conditions
— Cabinets or counters
— Painting or staining work not specifically noted in the above scope of work
— Appliances, sinks, faucets or fixtures
— Servpro, asbestos or any demolition costs previously invoiced
— Utility upgrades, changes to existing layouts, lighting changes
— Any other work not specifically noted above
SPECIALIZING IN QUALITY FINISH CARPENTRY, REMODELING, SPECIALIST ROOF SYSTEMS, SITE AND
PROJECT MANAGEMENT
Page 3 of 4
PERMITS
"Nexus" will accept responsibility to obtain the necessary building permits. "Nexus7 will act as a GC and work in
accordance with fair and reasonable practices, and cooperate fully and under the guidance of the "Owners" and
authorized parties. Nexus will pass the cost of the permit directly on to the"Owners" once advised by the Building
department.
Standard Exclusions:
Unless specifically included in the "General Scope of Work7 section above, this agreement does not include labor or
materials for the following work (any Exclusions in this paragraph which have been lined out and initialed by the
parties do not apply to this Agreement): Removal and disposal of any materials containing asbestos or any other
hazardous material as defined by the EPA. Custom milling of any wood for use in project. Moving "Owners�" property
around the site. Labor or materials required repairing or replacing any "Owners" - supplied materials. Repair of
concealed underground utilities not located on prints or physically staked out by "Owners", which are damaged during
construction. Surveying that may be required to establish accurate property boundaries for setback purposes (fences
and old stakes may not be located on actual property lines). Final construction cleaning ("Nex&' will leave site in
"broornswept"condition). Landscaping and irrigation work of any kind. Temporary sanitation, power, or fencing.
Removal of soils under house in order to obtain 18 inches (or code -required height) of clear space between bottom of
joists and soil. Removal of filled ground or rock or any other materials not removable by ordinary hand tools (unless
heavy equipment is specified in scope of work section above), correction of existing out -of -plumb or out -of -level
conditions in existing structure. Correction of concealed substandard framing. Removal and replacement of existing rot
or insect infestation. Construction of a continuously level foundation around structure (if lot is sloped more than 6
inches from front to back or side to side, "Nexus" step the foundation in accordance with the slope of the lot). Exact
matching of existing finishes. Repair of damage to roadways, sidewalks, or driveways that could occur when
construction equipment and vehicles are being used in the normal course of construction.
The 'OwneC' is to enter into contracts for all of the above-mentioned services and provide direct payment to "Nexus7'
for all of the services we are to provide. "Nexus7' will be responsible for removing all components and all construction
materials relevant to the "scope of work" in this contract. The "Owners" have received a copy of the lead hazard
information pamphlet informing them of the potential risk of the lead hazard exposure from renovation activity to be
performed in the dwelling unit. This was received before the work began and the "owners" are responsible for
informing their tenants of all potential hazards.
Dumpsters, trailers and signs
"Nexus" will provide as included in the cost of this project a dumpster for the sole purpose of the removal of trash
associated with this project. This dumpster should not be used by any persons for any other waste items or for any
purpose outside of the specific use under the scope of work, unless authorization is received from "Nexus"_ Nexus may
have on site for part, or the whole of the project, a trailer containing materials and tools belonging to "Nexus". This
trailer will be parked in a position agreed to in coordination with the "Owners" and will be covered under the
insurances of "Nex&' at all times. "Nexus" will have on site, a sign, with our contact details, in the event that anyone
has a need to contact us directly.
Photogr phs
"Nexus" reserves the right to, from time to time, take photographs of the contracted work for use in its general
marketing or for production on its web site. At no time will "Nexus" share any personal contact details of the "owner"
for any photographs that it may use without seeking authorization from the "ownee'.
Warranties
All the components supplied by "Nexus" as part of the original order are covered under the warranty exercised by
"Nexus" and supported by the vendors. All labor and materials purchased from other suppliers to achieve completion of
contract are warranted (1) one year from completion of the construction.
Expiration of this Agreement:
This Agreement will expire 30 days after the date at the top of page one of this agreement if not accepted in writing by
;'Owners�' and returned to "Nexus" along with the necessary deposits within that time frame.
Changes in the Work:
During the course of the project, "Owners" may order changes in the work (both additions and deletions). "Nexus"
will determine the cost of these changes and the cost of this additional work will be added to "Nexus" profit and
overhead.
SPECIALIZING IN QUALITY FINISH CARPENTRY, REMODELING, SPECIALIST ROOF SYSTEMS, SITE AND
PROJECT MANAGEMENT
People Authorized to Sign Change Orders:
The following peoVjq are authorized to sign Change Orders:
White
Kimbierley
Page 4 of 4
Concealed Conditions:
This Agreement is based solely on the observations "Nexus" was able to make with the area in its current condition at
the time this Agreement was bid. If additional Concealed Conditions are discovered once work has commenced which
were not visible at the time this proposal was bid, "Nexus" will stop work and point out these unforeseen Concealed
Conditions to "Owners" so that "Owners" and "'Nexus" can execute a Change Order for any Additional Work.
Schedule of work
it is agreed by both parties that this work will be coordinated with the"Owners" and "Nexus" to be undertaken
in various stages to avoid complete disruption of the home environment. "Nexus" will give "Owners" no less than
2 days notice prior to arriving on site for commencement of any of the agreed stages of work to allow "Owners"
to prepare. "Owners" commits to have sites identified for construction work available for start at the beginning
of the scheduled day so as to avoid any unnecessary delays.
Contract Cost and Payment Schedule:
Total cost of work description and materials included in the proposal (except
materials/work stated) - S 11, 454.16 (Eleven thousand four hundred and fifty four dollars
and sixteen cents)
PAYMENT SCHEDULE
1st Payment due upon signing this contract TOTAL $3, 820.16
2nd Payment due upon Installation of kitchen cabinets TOTAL $3, 820.00
Final payment due upon completion of scope of work TOTAL $3, 814.00
Amount due upon signing this contract - $3, 820.1
I have read and understand, and I agree to, all the terms and conditions contained in the-
proposalabove.
Date .... ..... . "Nexus"
Date .... 3-,- �- -(V ..... .. Client"
Date ............................... . Client" Authorization ......................................................
SPECIALIZING IN QUALITY FINISH CARPENTRY, REMODELING, SPECIALIST ROOF SYSTEMS, SITE AND
PROJECT MANAGEMENT
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Page I of 4
I I t
Nexus 11 Carpentry and
Construction Design
P.O. Box 2823
Woburn, MA 0 1888
7817602031
Fax 978 975 1263 C>r
neXUSCarpentr,V(d,)ao1.com
Cbntf 112"
This is a contract between Robert and Kimberly Denney of 35 Sandra Lane, North
Andover MA 01845 (Hereafter referred to as the "owners") and Nexus H Services
(hereafter referred to as "Nexus") dated March 8" 2016.
GENERAL SCOPE OF WORK DESCRIPTION
HEREBY SUBMIT SPECIFICATIONS AND CONTRACT FOR: work as stated for
6-
* Meet with local building official and apply for permits
* All work will be in accordance with local building code regulations and will be inspected by
local officials prior to continuing with the next phase — Nexus will be responsible for
arranging and being available for all inspections
* Nexus will contact "Dig Safe" prior to commencing any excavation work for their clearance
* All work will be coordinated directly between "owners" and Nexus
* Nexus confirms that it is fully licensed, insured and ensures any sub -contractors utilized on
this site will have the appropriate 'insurance coverage
* Nexus will be responsible for the safe storage of all its property and any materials to be used
on the site
* Owner is responsible for removal and return of all items of the house in the areas that will be
affected and their safe storage prior to our work commencing
* Owner will then be responsible for returning all items to these areas of the home after
completion of the scope of work
* Remove and trash into Nexus supplied dumpster all trash associated with this project NOTE:
appliances are not allowed to be put in dumpsters without additional costs "owners" are
responsible for removal from site
SPECIALIZING IN QUALITY FINISH CARPENTRY, REMODELING, SPECIALIST ROOF
SYSTEMS, SITE AND PROJECT MANAGEMENT
'S
Page 2 of 4
of
* Provide duinpster to remove debris associated with this scope of work
* Remove and SAVE existing rear entry door NOTE: door to be given to Ray
# Frame this opening in preparation for new sheetrock and siding
4 Remove and trash the existing rear facing window
+ Remove and re -work existing baseboard heat pipes to allow for installation of a 6' 0"
Andersen 200 Permashleld sliding patio door
* Remove and trash framing in this area to create rough opening dimension for the new 60" x
6' 8" Andersen 200 Permashield sliding patio door
* Furnish and install new 60" x 68" Andersen 200 Permashield sliding patio door -
prefmished white on the interior and exterior and with "satin nickel" hardware.
* Furnish and install insulation into this rear wall
* Remove and trasb existing kitchen ceiling and the ceiling of the "eat -in" area
* Remove and trash existing hardwood flooring in the kitchen area only - NOTE: Leave
flooring in "eat in" area C�
* Furnish and install electrics to code inclusive of island outlets, 2 - pendants (supplied by
owne ' r) over new island, I ceiling fixture over potential table by bay window. up to 6 recessed
cans in the kitchen area and I exterior wall sconce outside new sliding patio 'door
4 Furnish and install 2 kick space heaters fed from the existing floor zone (NOTE: I heater
under kitchen sink -and I under new window seat area)
* Furnish and install sheetrock with smooth plaster finish to exposed framing of walls and
ceiling
* Install additional cabinets to kitchen layout NOTE: cabinets provided by "owners"
* Install "Bay window" cabinetry and window seat provided by "oxvners" (NOTE: all materials
are expected to arrive pre -finished and ready to be installed)
* Furnish and install new hardwood flooring to blend into existing flooring
* Sand entire hardwood flooring in kitchen and "eat in" area
+ Furnish and install 3 coats of polyurethane to this floor only (NOTE: no other floor areas to
be included at this time)
# Fu i mish and install paint grade trim to new door, window and baseboard and to match to the
existing style in the home, as closely as possible
o Painting as includedin contract #1- walls, ceiling and trim in kitchen/eat in area
— Work not included in this contract
— Building department fees
— Engineering or architect costs
— Permit costs
— Unseen conditions
— Kitchen window change nor its installation ($920.00 previously quoted being materials cost +
$200.00 labor cost)
— Cabinets or counters
— Painting or staining work not specifically noted in the above scope of work
— Appliances, sinks, faucets or fixtures
— Utility upgrades, changes to existing layouts, lighting changes
— Any other work not specifically noted above
SPECIALIZING IN QUALITY FINISH CARPENTRY, REMODELING, SPECIALIST ROOF
SYSTEMS, SITE AND PROJECT MANAGEMENT
Page 3 of 4
PERMITS
"Nexus" will accept responsibility to obtain the necessary building permits. "Nexus" will act as a GC and work in
accordance with fair and reasonable practices, and cooperate fully and under the guidance of the "Owners" and
authorized parties. Nexus will pass the cost of the permit directly on to the "Owners" once advised by the Building
department.
Standard Exclusions:
Unless specifically included in the "General Scope of Work" section above, this agreement does not include labor or
materials for the following work (any Exclusions in this paragraph which have been lined out and initialed by the
parties do not apply to this Agreement): Removal and disposal of any materials containing asbestos or any other
hazardous material as defined by the EPA. Custom milling of any wood for use in project. Moving "Owners" property
around the site. Labor or materials required repairing or replacing any "Owners" - supplied materials. Repair of
concealed underground utilities not located on prints or physically staked out by "Owners", which are damaged during
construction. Surveying that may be required to establish accurate property boundaries for setback purposes (fences
and old stakes may not be located on actual property lines). Final construction cleaning ("Nexus" will leave site in
"broom swept" condition). Landscaping and irrigation work of any kind. Temporary sanitation, power, or fencing.
Removal of soils under house in order to obtain 18 inches (or code -required height) of clear space between bottom of
joists and soil. Removal of filled ground or rock or any other materials not removable by ordinary hand tools (unless
heavy equipment is specified in scope of work section above), correction of existing out -of -plumb or out -of -level
conditions in existing structure. Correction of concealed substandard framing. Removal and replacement of existing rot
or insect infestation. Construction of a continuously level foundation around structure (if lot is sloped more than 6
inches from front to back or side to side, "Nexus" step the foundation in accordance with the slope of the lot). Exact
matching of existing finishes. Repair of damage to roadways, sidewalks, or driveways that could occur when
construction equipment and vehicles are being used in the normal course of construction.
The "Owner" is to enter into contracts for all of the above-mentioned services and provide direct payment to "Nexus"
for all of the services we are to provide. "Nexus" will be responsible for removing all components and all construction
materials relevant to the "scope of work" in this contract. The "Owners" have received a copy of the lead hazard
information pamphlet informing them of the potential risk of the lead hazard exposure from renovation activity to be
performed in the dwelling unit. This was received before the work began and the "owners" are responsible for
informing their tenants of all potential hazards.
Dumpsters, trailers and signs
"Nexus" will provide as included in the cost of this project, a dumpster for the sole purpose of the removal of trash
associated with this project. This dumpster should not be used by any persons for any other waste items or for any
purpose outside of the specific use under the scope of work, unless authorization is received from "Nexus". Nexus may
have on site for part, or the whole of the project, a trailer containing materials and tools belonging to "Nexus". This
trailer will be parked in a position agreed to in coordination with the "Owners" and will be covered under the
insurances of "Nexus" at all times. "Nexus" will have on site, a sign, with our contact details, in the event that anyone
has a need to contact us directly.
Photographs
"Nexus" reserves the right to, from time to time, take photographs of the contracted work for use in its general
marketing or for production on its web site. At no time will "Nexus" share any personal contact details of the "owner"
for any photographs that it may use without seeking authorization from the "owner".
Warranties
All the components supplied by "Nexus" as part of the original order are covered under the warranty exercised by
"Nexus" and supported by the vendors. All labor and materials purchased from other suppliers to achieve completion of
contract are warranted (1) one year from completion of the construction.
Expiration of this Agreement:
This Agreement will expire 30 days after the date at the top of page one of this agreement if not accepted in writing by
"Owners" and returned to "Nexus" along with the necessary deposits within that time frame.
Changes in the Work:
During the course of the project, "Owners" may order changes in the work (both additions and deletions). "Nexus"
will determine the cost of these changes and the cost of this additional work will be added to "Nexus" profit and
overhead.
SPECIALIZING IN QUALITY FINISH CARPENTRY, REMODELING, SPECIALIST ROOF
SYSTEMS, SITE AND PROJECT MANAGEMENT
A
Page 4 of 4
People Authorized to Sign Change Orders:
The following people are authorized to sign Change Orders:
"Nexus": Mark Gotobed or Ged White
-eli�nt,': Robert 6
,�Krnbcrley Denney
Concealed Conditions:
This Agreement is based solely on the observations "Nexus" was able to make with the area in its current condition at
the time this Agreement was bid. If additional Concealed Conditions are discovered once work has conunenced which
were not visible at the time this proposal was bid, "Nexus" will stop work and point out these unforeseen Concealed
Conditions to "Owners" so that "Owners" and "Nexus" can execute a Change Order for any Additional Work.
Schedule of work
It is agreed by both parties that this work will be coordinated with the "Owners" and "Nexus" to be undertaken
in various stages to avoid complete disruption of the home environment. "Nexus" will give "Owners" no less than
2 days notice prior to arriving on site for commencement of any of the agreed stages of work to allow "Owners"
to prepare. "Owners" commits to have sites identified for construction work available for start at the beginning
of the scheduled day so as to avoid any unnecessary delays.
Contract Cost and Payment Schedule:
Total cost of work description and materials included in the proposal (except
materials/work stated) - $14, 575.00 (Fourteen thousand flve hundred and seventy five
dollars and zero cents)
PAYMENT SCHEDULE
1st Payment due upon receipt of permit
2nd Payment due ul)on Installation of sheetrock TOTAL $4,859.00
Final payment due upon completion of scope of work TOTAL $4,858.00
TOTAL $4, 858.00
Amount due upon signing this contract -
.$ — contract #1 deposit covers this reques
I have read and understand, and I agree to, all the terms and conditions contained in the
propos
Date .... ........... "Nexus" Authorization ......
..........................
Date ...... .......... .. Client" Authorization.PT,,.�<-�... .. K/
Date ........ 3. ........ .. Client" Authorizatic
SPECIALIZING IN QUALITY FINISH CAF
SYSTEMS, SITE AND
, REMODELING, SPECIALIST ROOF
T MANAGEMENT
The Commonwealth ofMassa.�husefis
Department of IndustrialAccidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass-gov1d1a
Wetkers, compensation Insurance Affidavit: Bailders/ContractorsXWetri
TO BE, FMBID VITH TBE PF-PMTT)NC'c AUTRO"JTY' Please Print Leg!�l
A
�ppllcantynforMafiffll
Name, (B-,isiucss/organization/Individual):
Address: P 0 &27N gi��
City/State/Zip:
Areyou an employer? 6e�kt& app"riopriate box:
-7r
Phoile#:7?1 '� 00 U06)
I.F1 I am * a employerwith --L--��Ioyoos (flu and/or part-time).* for me in
I am a sole proprietor or partnership and have no eMPloyecs'WoTk'rfg
any capacity. (No workers, comp. insurance required.]
I am a homeowner doing all work myself, [No workers, comp. insurance required.] t
4.[] lam a homeowner and will be hiring contractors to conduct all work on my proPertY. lVVill
ensure that all contractors either have workers' compensation insurance or are sole
5. R1 i am a general contractor and I have hired the sub-cofitractois listed on the attached sheet.
---Thes . o sub-contractors`�aV'e ei�ploye�s and have w�rkers' coi�p- insurancG.� M (2ke--
6.FJ We are a corporation and i ts offiqqrs have exercised their right of 'exemption p or MGL c.
152, § 1 (4), M4 v�a hav ��S. [No workers, comp. insurance required.]
Type of project (TqqUired):
1. New construction
8. kllRemodelfrig
9. Demolition
10 FJ Building addition
11. F1 Electrical repairs or additions
13. 0 Rooft ' epairs
14.E] Othbr
I n policy infbrm�fi—
*Any applicant that checks must s4binit a now afff davit indicating such.
f Homeowners who sfib and state -whether or not those entities have
TContactors that check thi
employees. If the sub -c6'.
I am an employff th ees.' Below is thepollcy andjOb Site
information.
Insurance Company
Policy 9 or Self -ills, Lio-
Expiration Date;
fob Site Address: City/State/Zip:
Attach, a copy of the Workers, compelisation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required -under MGL o. 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 STO-P 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 Investigati6lis of the DIA for insurance
coverage verification.
�dohe�reh fpejjvry that the informationprovided above L'q true and correct.
y cer�fify unde he ains andpenaltles o
Phone
offleial use only. Do not -write in this area, to he completed by city or town Official
City or Town:
Permit/License
issuing Authority (circle One): i
1.13oardoff(ealth 2. )Building Department 3. CitylTown Clerk 4. Electrical inspector 5. Plumbing Ynspector
6. Other
Fhone#:
Contact Person'
Massachusetts General Laws chapter 152 requires aA employers toprovide workers' compensation for their employees.
in e sery e
Pursuant to this statute, an employee is defined as "...every person th ic of another under any contract 6f Aire,
express or implied, oral or written."
All employer is defined as "an ind&iduo, partnersWp, associati�n, carpoTation or other legal entity, or'any two or more
of the foregoing engaged in ajoint 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 ofthe
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 b6 deemed to be an employer."
MOL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the ls�suance or
renewal of a license or permit to operate a businesg or to construct buildings in the.commonwea" 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 !h6boxes that apply to your situation and, if
necessary, supply sub'contractoi(s) naine(s), address(es) and -phone number(s) along with their cartificate(s) of
—insurance�L-imite&Liabilit3r-C-ompan-ics-(�-C-)-or-Limited-L-iab-ility?utnffrshiVs(E;LPY-w-itlrn—o-bem--p-iro-yeeso er anth
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP do . es have
employees, a policy is required. Be advised that this affidavit may,be submitted to the Depaitment of ffidustrial
Accidents fb� confirmationofinsurance, coverage. Also be sure to sign and date the a.Mdavit. The laffidavit'should
be returned to the city or town that the application for the permit or license is being requested, noi the Department of
Industrial Acciden�s. �hould you have any questions regarding the law o*r if yoa'are r�qt �*Iredfto obtain aworkers'
compensatioti �olic�, please call the Department. at the number listed below. Self-fiisur6d companies should'enter-their -
self-insuranZe 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 Investig4tions 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 pertnit/license, applications in any giv* on year, need only submit one affidavit indicating current
poli' information (if necessary) and under "Job Site Address" the applicant shouldwrite "all locations in (city or
cy
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. 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 burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachuset ts
Department of IudustrialAccidents
I Congress Street, Suite 100
Boston.7 MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAPE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
1 0
ACCOR" CERTIFICATE OF LIABILITY INSURANCE
k.�
DATE (MM/DDAI`YYY)
1 3/8/2016
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 THEASSUING 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, certiln policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(Is).
PRODUCER
Cross Insurance -Peabody
139 Lynnfield Street
Peabody MA 01960
CONTACT Lauren Goldman
NAME:
(978)532-5445 (FAX
I A/C. No): (978)532-2217
E-MAIL
ADDRESS: Igoldman@cros IS agency. com
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A.Western World Ins. Co.
INSURED
Nexus II Services LLC
P.O. Box 2821
.Woburn MA 01888
INSURER B:Saf ety Indemnity 33618
INSURER C:
INSURER D:
INSURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER-.CL15102253381 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
LTR
TYPEOFINSURANCE
ADDLSUBR
INSD
WVD
POLICY NUMBER
POLICY EFF
(MWDDNYYY)
POLICY EXP
(MWDDNYYY)
LIMITS
A
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE F1 OCCUR
NPP8290737
8/12/2015
8/12/2016
EACH OCCURRENCE $ 1,000,000
DA AGE To RENTED
PREM MISES (E. occurrence) $
MED EXP (Any one person) $ 5,000
PERSONAL & ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER
PRO- LOC
POLICY 7 JECT F
OTHER,
GENERAL AGGRE ATE $ 2,000,000
PRODUCTS - COMP/OP AGG $ 1,000,000
Damage to Rented $ 50,000
B
AUTOMOBILE
X
LIABILITY
ANY AUTO
ALL OWNED X SCHEDULED
AUTOS AUTOS
HIRED AUTOS X NON -OWNED
AUTOS
3116632
11/10/2015
11/10/2016
COMBINED SINGLE LIMIT $
(Ea accident)
BODILY INJURY (Per person) $ 500,000
BODILY INJURY (Per accident) $ 500,000
PR ER DAMAGE
(P Op . Z I $ 100,000
era d
Medical payments $ 5,000
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
DED I I RETENTION$
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y/N
ANY PROPRlETOR/PARTNER/EXECUTIVE
OFFICERIMEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
NIA
PERT
ST JOTH
A UTE ER
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEd $
E.L. DISEASE - POLICY LIMIT I S
DESCRIPTION OF OPERATIONS / LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be aftached if more space is required)
Kim and Rob Denney
35 Sandra Lane
North Andover, MA 01845
ACORD 25 (2014/01)
IN%n2s (2niAnii
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
Goldman/MD1 AM24 6-
@ 1988-2014 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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