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HomeMy WebLinkAboutBuilding Permit #632-14 - 361 MARBLERIDGE ROAD 3/17/2014TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: V --1 Date Received , I Date Issued: IMPORTANT: Applicant must complete all items on this page _ LOCATION _-_ -2 Print m 1PROPENER ,_ _ -- — -_ Pririf ,� 1'OO�Year�Old �tructure� yes: n)- "Rw"O-w MAPNO: �y�PARCEL ZONIsNGs DISTRICT JHstonc Distract yes TYPE OF IMPROVEMENT PROPOSED USE sidential Non- Residential ❑ New Building Aone family ❑ Addition ❑ o or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ ySeptic . ❑Well" Floodplam:Y. ❑ V1letlands F TT❑ at ®istrict k r ❑;UVater/SewerT_ DESCRIPTION OF WOKK I U tit rtru-uruvitu: Identification Please Type or Print Clearly) OWNER: Name: Phone: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING 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 acce o the guaranty nd natu e ofA ent/Owner_ 5� �ature�of .contractor, Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Lampe lans ❑ Building Department -The fol; -)wing it, -a- list of the required.forms to be filled out for: the appropriate. permit to .be obtained. Roofing, Siding, Interior Rehabilitation Permits Ll' ' Building Permit Application o Workers Comp Affidavit u Photo Copy Of H.I.C. And%Or C:S.L. Licenses o Copy of Contract o 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 Li Building Permit Application u Certified Surveyed Plot Plan Li Workers Comp Affidavit u Photo Copy of H.I.C. And C.S.L. Licenses u Copy Of Contract a Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) E3 Building Permit Application o Certified Proposed Plot Plan o 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) a Copy of Contract a Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all casts if a variance or special permit was required the Town Clerks office must stamp tlie decision from the Board of Appeals that the apn,?al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Bui?ding Permit Revised 2012 e . . A Plans Submitted ❑ Plans Waived ❑- .:,.Certified POf Plan ❑ Stamped Plans ❑ TI'PE OUEWERAGEDiSPDEAL" ' Public Sewer ❑ Tam,ing/Massage/BodyArt ❑ .. _Swimming Pools ❑ Well ❑ -Tobacco-Sales E1 _ Food Packaging/Sales ❑ Private (septic tank, etc._ ❑ =Permanent Dwupster on -Site ❑ THE_ FOLLOWING SECTIONS FOR OFFICE USE ONLY _ INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED ... PLANNING & DEVELOPMENT` ❑'. COMMENTS ,CONSERVATION COMMENTS HEALTH COMMENTS DATE. APPROVED Reviewed on Signature Reviewed on Siqnature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Commen Conservation Decision: Comments Nater & Sewer Connection/Signature Date Driveway Permit DPW Towx! Engineer: Signature: Located 384 Osgood Street FIRE DEPARTpht RIT:-.Tem_ p Dumpsteron site -.yes no Located at:,124xMa r Street �` FireD ai rg epartine �tsi natureldate COMMENTS :.: I - im-ensicyn Number of Stories: Total square feet of floor area, based on Exterior dimensions. --Total land area; sq. ft.: -ELECTRICAL: Movement of. Meter,locatron, mast or service drop requires approval of Electrical Inspector Yes No DANGER Z®NE LITERATURE: Yes No MGL.Chapter166.Section 21A —,F and G min.$100-$1000.fine and DATA — (For department use ® Notified for pickup - Date Doc.Building Permit Revised 2010 r— Location No.—W-A Date Check #,�-Ioo I 27350 TOWN OF NORTH ANDOVER Certificate of Occupancy $- Building/Frame Permit Fee $ 18 Foundation Permit Fee Other Permit Fee TOTAL $ 66ilding Inspector J uj LL Q - m L Y O O LL a0+ N v O_ Q) V) U LLI Z _ m .. O +� "O-. O. O- LL -C .� O K Q) v C- .E L_ U tp -C LL O w Z (7 m J L- h00 O -� - - C: C LL O a Z Q W uj -O1 .. t to O CC, u i N .. N C LL CC O uwa Z H Q �. L CA Cr c6 C LL Z w a a tIJ LL v i CO Op Z a N VV)) �+ N Y O V) 3 0 H O F. v v O O U3 z z b� I ti cn N cn H O cn v �z O O w Z Cl) .z Z uj,w a+ w W J v CL Z v v O Proposal Submitted To: MURTHY & DIANE AYYAGARI 361 MARBLERIDGE RD NORTH ANDOVER, MA 01845 978-689-0578 Proposal AB Carnes Roofing, Inc. 30 Arrowhead farm Rd Boxford, Ma. 01921 978.887.1431 MA. CS -000230 and HIC Reg. 176928 Date March 11, 2014 Project Name SAME Address We propose to furnish material and labor- in accordance with the specifications below: Eighty Six Hundred Dollars ($8,600.00) Payment to be made as follows: $300.00 Deposit, Balance Upon Completion Page 1 of 1 Notice: All home improvement contractors and subcontractors engaged in home improvement contracting, unless specifically exempt from registration by provisions of Chapter 142A of the General Laws, must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Mass.gov/licenses website. ROOF PROPOSAL ® STRIP ROOF OF ALL LAYERS OF ASPHALT SHINGLES. COVER ROOF DECK WITH THE UPGRADED RHiNOROOF HIGH PERFORMANCE WATERPROOF UNDERLAYMENT MEMBRANE. COVER EXTERIOR WALLS AND FOLIAGE WITH TARPS TO HELP PREVENT DAMAGE. ® ICE DAM PROTECTION: INSTALL CARLISLE HIGH PERFORMANCE ICE & WATER BARRIER OVER ALL HEATED AREAS SIX FEET WIDE AT THE LEADING EDGE OF ROOF AND THREE FEET IN ALL VALLEYS. WRAP THE CHIMNEY(S) AND SKYLIGHT CURBS UNDER THE FLASHINGS WITH SAME. ® COVER ALL PERIMETERS WITH EIGHT INCH PREFORMED ALUMINUM DRIP EDGE. ® INSTALL GAF COBRA RIDGE VENT AND/OR ❑ ROOF LOUVERS FOR ADDED ATTIC VENTILATION. ® COVER SOIL PIPES WITH NEW RUBBER FLASHING BOOTS AND FLANGE. ❑ REPLACE WALL FLASHING (S) AS NEEDED WITH ALUMINUM OR LEAD AT THE ADDITIONAL COST OF PLFT. WE MAY NEED TO REMOVE THE SIDING TO PERFORM THIS WORK AND YOU MAY NEED TO HAVE A CARPENTER REINSTALL OR REPLACE THE SIDING THAT WAS REMOVED. ® CHIMNEY FLASHING: CUT ALL EXISTING TAR AND LEAD FROM TWO CHIMNEYS .CUT NEW REGLET WITH CARBIDE SAW AND SECURE NEW LEAD FLASHING IN PLACE WITH METAL ANCHORS. PROPERLY SEAL REGLE . P ADD $350.00 EACH TO ABOVE PRICE. ® COVER ROOF SURFACE WITHCERTAINTEED LANDMARK ARCHITECTU . L LIFETIM - RRANTY 240LB SHINGLES. ® REPLACE DEFECTIVE ROOF DECK AS NEEDED WITH CDX PLYWOOD AT A DITIONAL COST OF$4.00PSQFT. ❑ COVER ROOF DECK WITH CDX PLYWOOD AS NEEDED TO REPLACE OR REPAIR DEFECTIVE DECKING, AT AN ADDITIONAL COST OF ® STORM NAILING: (HURRICANE NAILING) SECURE SHINGLES WITH SIX NAILS AS THIS IS CODE IN ESSEX COUNTY. ❑ SKYLIGHTS: REPLACE EXISTING SKYLIGHTS WITH NEW VELUX UNITS. WE WILL PROVIDE THE SKYLIGHTS & FLASHING KITS AT OUR EXACT COST FROM OUR SUPPLIER. THERE IS NO LABOR CHARGE IF THEY ARE THE SAME SIZE. INTERIOR WORK IS EXCLUDED. ❑ REMOVE EXISTING GUTTERS ❑ INSTALL NEW SEAMLESS .032 ALUMINUM GUTTERS USING THE HIDDEN ZIP SCREW HANGER SYSTEM. ® REPLACE ANY ROTTED TRIM BOARDS AS NEEDED WITH 30 YEAR PRIMED PINE, ADD $15.00 PER FOOT TO ABOVE PRICE. ❑ INSTALL NEW ALUMINUM DOWNSPOUTS AND MECHANICALLY FASTEN ALL CONNECTIONS. CLEAN ALL PROJECT RELATED DEBRIS FROM OUTSIDE WORK AREA. THE PROPERTY OWNER AUTHORIZES AB CARNES ROOFING TO OBTAIN ALL PERMITS. WE CANNOT ACCEPT RESPONSIBILITY FOR DEBRIS FALLING INTO ATTIC AREAS. CUSTOMER SHOULD COVER VALUABLES. GREAT CARE WILL BE USED TO PROTECT THE STRUCTURE AND FOLIAGE, HOWEVER, SOME MARRING AND OR MINOR DAMAGE COULD OCCUR SPECIAL INSTRUCTIONS: THE ABOVE PROPOSAL INCLUDES ALL ROOF SECTIONS OF THE HOUSE. CHIMNEY FLASHING: THIS SHOULD BE DONE AS PROPOSED ABOVE OR LEAKS MAY OCCUR WARRANTY UPGRADE: THE CERTAINTEED WIND WARRANTY WILL BE UPGRADED FROM 110 MPH TO 130 MPH WITH AN UPGRADE TO THE CERTAINTEED HIGH ERFORMANCE HIP & RIDGE CAPS AND STARTER COURSE AT NO ADDITIONAL CHARGE. YEV EMAIL ADDRESS, S [10 IDP° vt QtJ cavvnaan d Cory) Warranty: All work warranted against installation defects for 5 years; this warranty is limited to the installed item (s) and its repair only. Material is warranted by the manufacturer against defects for 50 years; see the manufacturer's warranty for exact warranty performance. Cancellation: Customer has legal right under federal law to cancei this contract without penalty or obligation within three business days from the date of signing this agreement via Priority Mail Delivery Confirmation. Please see reverse side. Dispute Resolution under Massachusetts Home Improvement Law 142a: All parties agree that any and all disputes relating to this proposal shall be settled by arbitration. This forum is user friendly and does not require lawyers. Please see reverse side. Signing this Proposal means, you have accepted all the terms as stated on the front and back of this agreement. Please see reverse side. *Date of Acceptance ©� Signatur � /.� — ---- *Signature ' Signatu e �.0 PLEASE SEE REVERSE SIDE 4/ The Commonwealth of Massachusetts Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish a One- o:• Tiro -Fancily Dwelling '= f Revised Hauch 2011 This Section For Official Ude Only Building Permit Number: Date Applied: Building Official (Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.l a Is this an accepted street? yes no 1.2 Assessors Map &Parcel Numbers Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area (sq 11) Frontage (11) 1.5 Building Setbacks (ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c. 40. §54) Public ❑ Private ❑ 1.7 Flood Zone information: Zone:_ Outside Flood Zone? Check ifves❑ 1.8 Sewage Disposal System: Municipal ❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner' of Record: Name"(Print) C1tr:.State. ZIP U✓-1.%��C�� /'^✓ ,� �G��� J �(1 Ko. and Street �— Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2 (check all that apply) New Construction O Existing Buildina Owner -Occupied. I Repairs(sK I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work`: SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only 1. Building S 1. Building Permit Fee: S Indicate how fee is determined: ❑ Standard City/Town Application Fee ❑ Total Project Cost' (Item 6) x multiplier x 2. Other Fees: S List: '. Electrical ` S 3. Plumbing S 4. Mechanical (HVAC) S 5. Mechanical (Fire Suppression) S Total All Fees: S Check No. Check Amount: _ _Cash Amount: 0 Paid in Full 0 Outstanding Balance Due: 6. Total Project Cost: S `� f�laf.�' SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor Licensee (CSL) , License Number Expiration Date Name o('CSL }-} der List CSL hype {see below) v � Type Description No. and Street A?�� �T— / �'! Unrestricted (Buildings tip to 35.000 cu. ft.) R Restricted 1&2 1�amily Dwelling +f"n � ity/Town. State, ZIP M Masonn RC Roofin_ Covering WS Window and Sidine SF Solid Fuel Burning Appliances I insulation D Demolition Telephone Email address 5.2 Registered Home Improvement Contractor (HIC) 9 A13 burs � �=��' �.•,.� � on N r—,A/-Igrl R� 'HIC Registration Number Expiration Date HiC Company Namc or HIC Registrant Name and Street �, f ���,� Or" p i . Email address ,z City/Town. State. ZiP Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G..L. c. 152, § 25C(6)) Workers Compensation insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached? Yes .......... No ........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1. as Owner of the subject property., hereby. authorize to act on my behalf. in all matters relative to work authorized by this building permit application. Print Owners M ie (Electro tcgnature) Date SECTION 7b: OWNER` OR AUTHORIZED AGENT DECLARATION ) B ente ' Y name be w, J hereby attest under the pains and penalties of perjury that all of the information on ined in this ap 'cation is true and accurate to the best of my knowledge and understanding. nfiTnt OwneCs or Authorized Agent's Name (E ectronic Signature) Date ( NOTES: 1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (not registered in the Home improvement Contractor (HiC) Program). will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A..Other important information on the HIC Program can be found at www.ntass.gov/oca Infonnation on the Construction Supervisor License can be found at www.ntass.Vov,dps 2. When substantial work is planned, provide the information below: Total floor area (sq. ft.) (including garage, finished basement/attics, decks or porch) Gross living area (sq. ft.) Habitable room count _ Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/ porches Type of cooling system Enclosed Open _ 3. "Total Project Square Footage" may be substituted for "Total Project Cost' 41 Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS -0002X BARRY S CARNES` r 30 ARROWHEADS FARM Boxford MA 01911 s ✓�.., ,11�6G. " "` Expiration Commissioner 03/07/2016 [✓ fl��1��%/f�%�i7�1�iQ��/f'�i ���!���LiT�/��(�/i./�,f�/�T/%. Office of Consumer Affairs and Business Regulation 10Park Plaza - , Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor. Registration ` Registration: 176928 74 Type: Corporation Expiration: 10/10/2015 Tr# 245633 AB CARNES ROOFING, INC. BARRY CARNES 30 ARROWHEAD FARM RD--- �� ��- BOXFORD, MA 01921 Update Address and return card. Mark reason for change. n Address Renewal _, Emplovment I Lost Card SCA 1 •a 20M-05/11 ACORU® CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDD/YYYY) `.� 11/4/2013 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 CONTACT Commercial Lines NAME: Harris -Murtagh Insurance Agency, Inc. 30 Central Street PHONE . (978) 532-2844 Fvc No: E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # 0/11/2014 Peabody MA 01960 INSURER AWestern World Insurance Co INSURED INSURER B AB Carnes Roofing, Inc INSURERC: 30 Arrowhead Farm Rd INSURER D INSURER E: INSURER F: Boxford MA 01921 COVERAGES CERTIFICATE NUMBER:CL1311417584 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. ILTR TYPE OF INSURANCE AODLSUBR POLICY NUMBER MM/LD@Y E EXP MMIDD LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F_x] OCCUR er, MA 01845 NPP137217 0/11/2013 0/11/2014 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTEIT PREMISES Ea occurrence $ 50,000 MED EXP (Any one person) $ 5,000 PERSONAL& ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JFCT PRO LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / NTORY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WC STATU- OTH- LIMITS E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION ACORD 25 (2010/05) INS025 nntnnsi m ©1988-2010 ACORD CORPORATION. All rights reserved. Tho Anopr1 n2mc nnrl Innn era ronicfcrorl mnrke of or`npn SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. th Andover EOsgoodStreet QNorth AUTHORIZED REPRESENTATIVE er, MA 01845 J S Scholnick/PJR ACORD 25 (2010/05) INS025 nntnnsi m ©1988-2010 ACORD CORPORATION. All rights reserved. Tho Anopr1 n2mc nnrl Innn era ronicfcrorl mnrke of or`npn NORTH ANDOVER WASTE AFFIDAVIT As a result of the provisions of MGL Ch.40454, I acknowledge that as a condition of building permit # all debris resulting from the construction activity governed by this building permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL Ch.111-s150A. Waste Disposal or Solid Waste Facility: ALLIED WASTE Address: 300 FOREST ST Town/City, State, Zip: PEABODY, MA 01960 NAME OF HAULER: AB CARNES ROOFING, INC. DUMP TRUCKS DATE: 3-16-2014 SIGNATURE OF APPLICANT: The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations � _4 1 Congress Street, Suite 100 Boston, MA 02114-2017 ww►v mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): AB CARNES ROOFING, INC. Address:30 ARROWHEAD FARM RD City/State/Zip:BOXFORD, MA 01921 Are you an employer? Check the appr ❑ i am a employer with. employees (full and/or part-time).* . ❑ I am a sole proprietor or partner- ship and have no employees working forme in any capacity. [No workers' comp. insurance required.] ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] ' Phone 4:978-887-1431 44. Ml a a general contractor and i ave hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' omp. insurance.* ✓❑ e are a corporation and its officers have exercised their right of exemption per MGL e. 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. E] Plumbing repairs or additions 12.❑✓ Roof repairs 13.❑ Other "Any applicant that checks box f l must also fill out the section below shoving their workers compensation policy information. 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. I f the sub -contractors have employees. they must provide their workers' comp. policy number, l am an employer that is providing workers' compensation insurance for my employees. Below is lite policv and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: .lob Site Address: City/State/Zip: 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 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 t v under the airs nd enalties o er'u , that lite information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or towit 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 #: FORM 153 The Commonwealth of Massachusetts DiA Use Only - �;� Department of Industrial Accidents Office of Investigations -Dept. 1.53 "� - , Y✓ 1 Congress Street, Suite 100, Boston. Massachusetts 02114-2017 http://www.mass.gov/dia Invest./SWO ID #: r AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPORATE OFFICERS OR .DIRECTORS Chapter 16.9 of the Acts o1*2002 amended -1 G.L. c. 152, §1(4) by adding the•follotit.,irng pai-agt-aph: "This chapter shall be elective for an officer or director of a corporation who owns at least 25 percent of the issued and outstanding stock of the corporation. Notwithstanding section 4E.. these provisions shall apply only if the corporate officer provides the commissioner of industrial accidents with a written waiver of his rights under this chapter. Said commissioner shall promulgate regulations to carry out. the purpose of this paragraph. Violations of this paragraph shall subject the corporation to the penalties set forth in section 25C." Pursuant to M.G.L. c. 152, §1(4) as amended. ]/We the undersigned officers of: AB CARNES ROOFING, INC. (Name of Corporation and Address) each holding at least 25% of the issued and outstanding stock in said corporation.. do hereby invoke the right to be exempt from the provisions of M.G.L. c. 152, §25A and therefore are not required to carry a workers' compensation policy covering the undersigned corporate officer(s) or director(s). I/We the undersigned do also waive any and all .rights to make claims for benefits as defined in M.G.L. c. 152 for any injuries that may be sustained while in the employ of the above-named corporation. Further, I/we the undersigned do understand that. should the above-named corporation hire or have in its employ any employee(s) in addition to the undersigned corporate officer(s) or director(s).. said corporation is required to obtain workers' compensation coverage for the employee(s) as prescribed by M.G.L. c. 152, §25A. 1/We the undersigned have read and understand the statements and obligations as delineated above and I/we have checked the appropriate box below my/our name(s) indicating my/our desire to be exempt or not to be exempt f ojn the provisions of M.G.L. c. 152. ed under the/(iains and penalties of perjury: BARRY CARNES, PRESIDENT 09/24/2013 S' ur Print Name & Title ✓❑ 1 wish to exercise m) right of exemption or ❑ I wish NOT to exercise nry right of exemption rbo ANASTASIYA CARNES, DIRECTOR Signature Print Name & `Title ❑✓ i wish to exercise my right of exemption or ❑ 1 wish NOT to exercise my right of exemption Signature Print Name & "title ❑ I wish to exercise my right of exemption or ❑ I wish NOT to exercise my richt of exemption Signature Print Name & Title ❑ I wish to exercise my right of exemption or ❑ I wish NOT to exercise my right of exemption Date (mm/dd/yyvv) 09/24/2013 Date (mm/dd/v),}y)t\ Date (mmidd/yyvN1 Date (mmldd/yy�,y1 Note: ALL ELIGIBLE' CORPORATE OFFICERS MUST SIGN. THERE CAN BE NO INIORE THAN 4 SIGNATURES. Instructions on hack. form I-.7/20I(t MA SOC Filing Number: 201340178570 Date: 6/26/2013 6:21:00 PM The Commonwealth of Massachusetts D'linimum Fee: $250.110 William Francis Galvin Secretary of the Commonwealth, Corporations Division One Ashburton Place. 17th floor Boston, ;MA 02108-1512 Special r;ilina Instructions • .r Telephone: (617) 727-9640 Federal Employer Identification Number: 001116484 (must be 9 digits) ARTICLE I The exact name of the corporation is: AB CARNES ROOFING, INC. ARTICLE II Unless the articles of organization otherwise provide, all corporations formed pursuant to G.L. C156D have the purpose of engaging. in any lawful business. Please: specify if you want a more limited purpose: COMMERCIAL & RESIDENTIAL ROOFING AND ROOFING RELATED WORK. THIS SHALL INCLUDE ALL TYPES EXTERIOR & INTE:RIOR REMODELING ARTICLE III State the total number of shares andpar value, if any, of each class of stock that the corporation is authorized to issue. All corporations must authorize stock. If only one class or series is authorized, it is not necessary to specify any particular designation. Par Value Per Share Total Authorized by Articles Total Issued Class of Stock Enter 0 if no Par of Organization or Amendments and Outstanding Vzan of Shares Total Par Value Num 0/Shares CNP $0.00000 1,000 S0.00 I Mo G.L. C156D eliminates the concept of par value, however a corporation may specify par value in Article III. See G.L. C156D Section 6.21 and the comments thereto. ARTICLE IV If more than one class of stock is authorized, state a distinguishing designation for each class. Prior to the issuance of any shares of a class, if shares of another class are outstanding, the Business Entity must provide a description of the preferences, voting powers, qualifications, and special or relative rights or privileges of that class and of each other class of which shares are outstanding and of each series then established within any class. ARTICLE V The restrictions, if any, imposed by the Articles of Organization upon the transfer of shares of stock of any class are: ARTICLE VI Other lawful provisions, and if there are no provisions, this article may be left blank. Note: The preceding six (6) articles are considered to be permanent and may be changed only by filing appropriate articles of amendment. ARTICLE VII The effective date of organization and time the articles were received for filing if the articles are not rejected within the time prescribed by law. If a later effective date is desired, specify such date, which may not be later than the 90th day after the articles are received for filing. Later Effective Date: Time: ARTICLE VIII The information contained in Article VIII is not a permanent part of the Articles of Organization. a,b. The street address of the initial registered office of the corporation in the commonwealth and the name of the initial registered agent at the. registered offiice: Name: BARRY CARNES No. and Street: 30 ARROWHEAD FARM .RD City or Town: BOXFORD State: MA Zip: 01921 Country: USA c. The names and street addresses of the individuals who will serve as the initial directors, president, treasurer and secretary of the corporation (an address need not be specified if the business address of the officer or director is the same as the principal office location): Title Individual Name Address (no PO Box) First. Middle, Last. Suffix Address. City or Town. State. Zip Code PRESIDENT BARRY S CARNES 30 ARROWHEAD FARM RD BOXFORD, MA 01921 USA TREASURER BARRY S CARNES 30 ARROWHEAD FARM RD BOXFORD, MA 01921 USA SECRETARY ANASTASIYA V CARNES 30 ARROWHEAD FARM RD BOXFORD. MA 01921 USA DIRECTOR .BARRY S CARNES 30 ARROWHEAD FARM RD BOXFORD, MA 01921 USA DIRECTOR ANASTASIYA V CARNES 30 ARROWHEAD FARM RD BOXFORD, MA 01921 USA d. The fiscal year end (i.e., tax year) of the corporation: October e. A brief description of the type of business in which the corporation intends to engage: COMMERCIAL & RESIDENTIAL ROOFING f. The street address (post office boxes are not acceptable) of the principal office of the corporation: No. and Street: 30 ARROWHEAD FARM RD City or Town: BOXFORD State: MA Zip: 01921 Country: USA 41 g. Street address where the records of the corporation required to be kept in the Commonwealth are located (post office boxes are not acceptable): No. and Street: 30 ARROWHEAD. FARM RD City or Town: BOXFORD State: MA Zip: 01921 Country: USA which is X its principal office an office of its transfer agent an office of its secretary/assistant secretary _ its registered office Signed this 26 Day. of .lune, 2013 at 6:23:02 PM by the incorporator(s). (If an cristing corporation is acting as incorporator, type i)r the exact name of the businnecs entity, the state on• other jrrriscliction rvherc: it tiros incorporated the name of the persona signing on behalf afsaid business entiti. and the title heAhe holds or other authorinv big >~-hich such action is taken.) BARRY S CARNES i 2001 - 2013 Commonwealth of Massachusetts All Rights Reserved MA SOC Filing Number: 201340178570 Date: 6/26/2013 6:21:00 PM THE -COMMONWEALTH OF MASSACHUSETTS I hereby certify that, upon examination of this document. duly submitted to me, it appears thaCthe provisions of the General Laws relative to corporations have been complied with, and I hereby approve said articles; and the filing fee having been paid, said articles are 1 ` deemed to have been filed with me on: June 26, 2013 06:21 PM WILLIAM FRANCIS GALVIN Secretai-i" of the Convnomi-eallh CERTIFICATE OF LIABILITY INSURANCE DATE(MN,(DDNYYY) �._ 11/8/2013 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 CONTACT _ NAME Berkle Assigned Risk Services Ace Insurance Services Inc PHONE FAX (A.C. ND. Ex ; 800 634-4589 Art No.) (866) 215-8118 675 Warren Ave EMAIL ADDRESS: PolicyServlces@berklevrisk.Com INSURER B: 1 American Construction Inc - — --- -- - - - - - - - INSURER C: 242 Belmont Street Unit 2 INSURER D: Brockton, MA 02301 INSURER e: INSURER F' `GpVERAGES CERTIFICATE NUMBER: REVISION NUMBER: )HIS-t6-ldU.(_tRT IFY JJI A.T T.HE-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 ADDL _LTR TYPE OF INSURANCEINSR _ SUBR NMo POLICY NUMBER POLICY EFF POLICY EXP (MMIDD;YYY� (MMD,'W I�YY} LIMITS G ENERAL LIABILITY _ AUTOMOBILE LIABILITY i I $ WORKERS COMPENSATION j WC ST AT U- DTH. AND EMPLOYERS' LIABILITY Y;N I 70R1' LIMITS_ ER ANY PROP RIETOR/PAP.TNERIEXE CUTIV EQ i A OFFICEIMEMBER EXCLUDED? .I NIA . WC -20-20-0047117-00 04/24/2013 04/24/2014 E.L EACH ACCIDENT S 1,000,000 E.L DISEASE -EA EMPLOYEE 1.000,000 (Mandatory in NH) ! If ves, de Scribe under I E.L. DISEASE -POLI CI'L IMlT IS 1•00o'000 DESCRIPTION OF OPERATIONSbelow DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (.Attach. ACORD 101, Additional Remarks Schedule, it more space is requned) Coverage Election Category Elect. Status Name State(s) i All Entities/Locations Officer Include Manuel 3 Lema Caguana MA 1 American Construction Inc 242 Belmont Street Unit 2 Brockton, MA 02301 CkR-IFIGATE HOLDER rWAara=imw-%rr lA ' AB Carnes Roofing Inc SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 30 Arrowhead Farm Road Boxford, MA 01921 Signature: ,' ���>,-�'�_�•�- .f �-"- - _.� ACORD 25 (2010/05) BRAC 3139 MA SOC Filing Number: 201316881130 Date: 4/23/2013 10:36:00 AM The Commonwealth of Massachusetts Minimum Fee: $250.00 7'"i William Francis Galvin Secretary of the Commonwealth. Corporations Division lel One Ashburton Place, 17th floor Special Filing Instructions Boston, MA 02108-1512 Telephone: (617) 727-9640 Federal Employer Identification -Number: 001098338 (must be 9 digits) ARTICLE I The exact name of the corporation is: 1 AMERICAN CONSTRUCTION INC ARTICLE II Unless the articles of organization otherwise provide, all corporations formed pursuant to G.L. C156D have the purpose of engaging in any lawful business. Please specify if you want a more limited purpose: ARTICLE III State the total number of shares and par value. if any, of each class of stock that the corporation is authorized to issue. All corporations must authorize stock. If only one class or series is authorized, it is not necessary to specify any particular designation. Par Value Per Share Total Authorized by Articles Total Issued Class of Stock Enter 0 if no Par of Organization or Amendments and Outstanding Num ofshares Total Par Value Vann ol'Shares CNP $0.00000 20,000 50.00 20.000 G.L. C156D eliminates the concept of par value, however a corporation may specify par value in Article III. See G.L. C156D Section 6.21 and the comments thereto. ARTICLE IV If more than one class of stock is authorized, state a distinguishing designation for each class. Prior to the issuance of any shares of a class, if shares of another class are outstanding, the Business Entity must provide a description of the preferences, voting powers, qualifications, and special or relative rights or privileges of that class and of each other class of which shares are outstanding and of each series then established within any class. ARTICLE V The restrictions, if any, imposed by the Articles of Organization upon the transfer of shares of stock of any class are: ARTICLE VI Other lawful provisions, and if there are no provisions, this article maybe left blank. Note: The preceding six (6) articles are considered to be permanent and may be changed only by filing appropriate articles of amendment. ARTICLE VII The effective date of organization and time the articles were received for filing if the articles are not rejected within the time prescribed by law. If a later effective date is desired, specify such date, which may not be later than the 90th day after the articles are received for filing. Later Effective Date: Time: ARTICLE VIII The information contained.in Article Villus not a permanent part of the Articles of Organization. a,b. The street address of the initial registered office of the corporation in the commonwealth and the name of the initial registered agent at the registered office: Name: MANUEL LEMA-CAGUANA No. and Street: 12 WALL STREET City or Town: BROCKTON State: MA Zip: 02301 Countrv: USA c. The names and street addresses of :the individuals who will serve as the initial directors, president, treasurer and secretary of the corporation (an address need not be specified if the business address of the officer or director is the same as the principal office location): Title Individual Name Address Ino PO Box) First. Middle. Last. Suffix Address. City or Town, State, Zip Code PRESIDENT MANUEL LEMA-CAGUANA 12 WALL STREET BROCKTON. MA 02301 USA TREASURER MANUEL LEMA-CAGUANA 12 WALL STREET BROCKTON, MA 02301 USA SECRETARY MANUEL LEMA-CAGUANA 12 WALL STREET BROCKTON. MA 02301 USA DIRECTOR MANUEL LEMA-CAGUANA 12 WALL STREET BROCKTON. MA 02301 USA d. The fiscal year end (i.e., tax year) of the corporation: December e. A brief description of the type of business in which the corporation intends to engage: GENERAL CONSTRUCTION f. The street address (post office boxes are not acceptable) of the principal office of the corporation: No. and Street: 12 WALL STREET City or Town: BROCKTON State: MA Zip: 02301 Countrv: USA g. Street address where the records of the corporation required to be kept in the Commonwealth are located (post office boxes are not acceptable): No. and Street: 12 WALL STREET City or Town: BROCKTON State: MA Zip: 02301 Country: USA which is X its principal office _ an office of its transfer agent an office of its secretary/assistant secretary _ its registered office Signed this 23 Day of April, 2013 at 10:37:21 AM by the incorporator(s). (If an existing C-017)01-,16017is acting as incorporator. tvpe in the exact name of the business entity, the state or other jurisdiction >,alrere it was incorporated, the name of the person signing on behalf of said business entih- and the title he%she holds or other ar.rthorih, by which such action is taken.) MANUEL LEMA CAGUANA rJ 2001 - 2013 Commonwealth of Massachusetts All Rights Reserved i 3 MA SOC Filing Number: 201316881130 Date: 4/23/2013 10:36:00 AM THE COMMONWEALTH OF MASSACHUSETTS I hereby certify that, upon examination of this document. duly submitted to me. it appears i that the provisions of the General Laws relative to corporations have been complied with, and I hereby approve said articles, and the filing fee having been paid, said articles are deemed to have been filed with me on: April 23, 2013 10:36 AM WILLIAM FRANCIS GALV�IN Secr•etciqof the Co1rn77orn�1ealth