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HomeMy WebLinkAboutBuilding Permit #143-2017 - 37 RIVERVIEW STREET 8/15/2016 1OF %4ORT1;1 q BUILDING PERMIT `= TOWN OF NORTH ANDOVER o . APPLICATION FOR PLAN EXAMINATION _ Permit No#• ' �� Date Received TED gSSRCHUSE� Date Issued: 1 ORTANT:Applicant must complete all items on this page LOCATION 37 r ca.) �J A0g Print PROPERTY OWNER AiA. Print 100 Year Structure yes no MAPPARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement- 0 Assessory Bldg ❑ Others: Demolition ❑ Other D Septic ❑1NeJII . - ❑y�Flpo�tlplain ❑'Wetlands 0 �Wate�81ed®istnct aim . -- �/ DESCRIPTION OF WORK TO BE PERFORMED: . ._. Q 1 i Z!�t'k� '1�'►'10 L;l/� ..�t/E �!Q 1-t�P� Identification- Please Type or Print Clearly OWNER: Name: 4491) `��Ca�aeGc'//nl�>��"�o��,P Phone: ��� ,�3�' S ail Address: Contractor Name: 7L"1QJILCA -s7� �U Phone ROD-338- 3l/ Email: Address �. JLR� 1 Sr` t/01I L 4 Supervisors Construction License: /66-_-4/09 Exp. Date. Home Improvement License: 1 7i Exp. Date: 3 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT-$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ 7'7i� los FEE: $ Act Check No.: I �CA « Receipt No.: 3D731 NOTE: Persons contractien,tlftn 'r ng with unregistered ontractors do not have access to the guava f nd - -_ --x -= reALAq - - - -- r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ti❑ . Starnped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanuing/MassageBody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed ori Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes V Planning Board Decision: Comments Conservation Decision: Comments Wi tter& Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRS DEPARTMENTemp�Dumpster on,sitex,yes . ,;< .. ,. : z �,'ino "j •" � Asa Lo-btecl�a 12_4 Ma ni*eet y' � ; "3 .', •, a. _ __ ,r s. tr_ - - ' s+ > °Fire De atmen sig � � � -p„ fi gnature/date�1•; `� _ '�—r ti' •< 1 ? . ... x,�, z: .. • i�i s '�:'t+.l- �$•-e .<:`—a.�.+�}«,--�,,,�;. .'N e rr i..k.,,'3`�`"`+R3 +Pt",�Y�,�'��� ,}��`y"�t�",}':,x<,. COMMENTS . ` : : t ; .�;•.%xs: ... . . . .. .• .. r ,. :3pa:� ==. �, . u U , ;t 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) r i ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pen-nit Revised 2014 7- -Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application �,4 Workers Comp Affidavit ,4 Photo Copy Of H.I.C. And/Or C.S.L. Licenses ,4 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) 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 Doe:Building Permit Revised 2014 I I f Location 3 tt 11 �wI1 C�.. 7 No. 1"t 2—C) Date t-�l • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ - Other Permit Fee $ k TOTAL h i -Check#_J3 7 JZ Building Inspector �/ �(� T Dermis Cushing ) ervice"ER Field Aanager ` Slto _-m Restoration Services ServiceMaster Elite Serving ME,Nli,MA,VT 58 Pulaski St Peabody,MA 01960 Toll Free:800-338-5311 Fax:800-443-1819 Cell:603-801-8813 Dennis@elitesvm.com 31 401-'V 'A e-.J www.elitesvm.com 24 Hour Emergency Services Catastrophe Response Dehumidification Project Management Water Damage Mitigation Fire&c Smoke Damage Mold Remediation Trauma Clean-up Packout/Content Cleaning Contents Restoration Trauma Clean-up Odor Removal Demolition Services NORTi, q Town of 1 sAndover ft ' h1. ver, Mass T O tw.af C OC NIC Nl W�CN S U BOARD OF HEALTH Food/Kitchen PERI T LD Septic System r THIS CERTIFIES THAT ....... d BUILDING INSPECTOR ...... .. �!!!�.............. I. ....................................................... has permission to erect .......................... buildings on . .. ....... ................................. Foundation Rough to be occupied as ..... ..... ......6..... ........................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS TION Rough Service .. ....... .... ..... ................ ....... Final BUILDING I . . P TO GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. ServiceAf sm ServiceMaster Elite Restore Massachusetts Divison 12 Continental Blvd Merrimack,NH 03054 Office: 800.338.5311 Fax: 800.443.1819 Tax ID#26-3242142 Insured: Ana Rojas Home: (978)242-2630 Property: 37 Riverview Street North Andover,MA 01845 Claim Rep.: Robert Swajian Business: (978)655-4994 Estimator: Dennis Cushing Business: (800)338-5311 Reference: Company: Mass Property Insurance Contractor: Company: ServiceMaster Elite Business: 58Rear Pulaski Street Unit L2 Peabody,MA 01960 Claim Number: 407956 Policy Number: Type of Loss: Fire Date Contacted: 7/24/2016 9:30 PM Date of Loss: 7/24/2016 Date Received: 7/24/2016 9:30 PM Date Inspected: 7/25/2016 4:00 PM Date Entered: 8/2/2016 2:20 PM Price List: MAEM8X JUL16 Restoration/Service/Remodel Estimate: ROJAS ANA Source:Fire Deductible Collected Y/N:N Amount: $ ITEL Sent Y/N: Date/time&Adj approval for extended dry time: CCAPS LLC, 12 Continental Blvd.Merrimack,NH 03054 TAX ID 26-3242142 ServicemsraR ServiceMaster Elite Restore Massachusetts Divison 12 Continental Blvd Merrimack,NH 03054 Office: 800.338.5311 Fax: 800.443.1819 Tax ID#26-3242142 ROJAS_ANA Main Level Main Level DESCRIPTION QTY REMOVE REPLACE TAX TOTAL 1. Dumpster load-Approx.30 yards,5- 1.00 EA 763.00 0.00 0.00 763.00 1 tons of debris 2. Haul debris-per pickup truck load- 1.00 EA 157.28 0.00 0.00 157.28 including dump fees Haul away refrigerator appliance due to freon-not able to be placed in dumpster 3. Add for personal protective 8.00 EA 0.00 17.50 8.75 148.75 equipment-Heavy duty 4. Respirator cartridge-HEPA only 2.00 EA 0.00 9.44 1.18 . 20.06 (per pair) 5. Respirator-Full face-multi- 2.00 DA 0.00 7.61 0.00 15.22 purpose resp.(per day) 6. Electrical(Bid Item) 1.00 EA 0.00 342.43 0.00 342.43 Electrician contractor called in to restore power and make safe Total: Main Level 9.93 1,446.74 Fmnt Porch 2'4-6- Kitchen/Dining Kitchen/Dining Room Height: 7' :droom2a o 393.42 SF Walls 232.50 SF Ceiling 't eltlDinin 625.92 SF Walls&Ceiling 232.50 SF Floor 25.83 SY Flooring 56.92 LF Floor Perimeter 1 ci a> r 71.92 LF Ceil.Perimeter r-s�-a, . 1 2'4" Door 2'6"X 6'8" Opens into BEDROOM1 Door 5'X 6'8" Opens into FAMILY-ROOM Door 2'6"X 6'8" Opens into HALLWAY Missing Wall 2' 11"X 7' Opens into STAIRS Window 2'6"X 4' Opens into Exterior Door 2'6"X 6' 8" Opens into FRONT-PORCH Door 2'6"X 6'8" Opens into BEDROOM2 DESCRIPTION QTY REMOVE REPLACE TAX TOTAL 9. Remove Paneling 393.42 SF 0.25 0.00 0.00 98.36 10. Remove 1/2"drywall-hung, 625.92 SF 0.35 0.00 0.00 219.07 taped,heavy texture,ready for paint ROJAS_ANA 8/10/2016 Page:2 Servicemsm ServiceMaster Elite Restm Massachusetts Divison 12 Continental Blvd Merrimack,NH 03054 Office: 800.338.5311 Fax: 800.443.1819 Tax ID#26-3242142 CONTINUED-Kitchen/Dining Room DESCRIPTION QTY REMOVE REPLACE TAX TOTAL 11. Remove Cabinetry-upper(wall) 10.00 LF 6.43 0.00 0.00 64.30 units 12. Remove Cabinetry-lower(base) 6.50 LF 6.43 0.00 0.00 41.80 units 13. Remove Countertop-Granite or 13.00 SF 4.62 0.00 0.00 60.06 Marble 14. Remove Granite or marble facade 17.00 SF 6.82 0.00 0.00 115.94 18" granite backsplash on wall 15. Sink-single-Detach&reset 0.50 EA 0.00 116.73 0.00 58.37 Detach only 16. Remove Range-freestanding- 1.00 EA 17.25 0.00 0.00 17.25 electric 17. Remove Refrigerator-side by side 1.00 EA 32.14 0.00 0.00 32.14 -22 to 25 cf 18. Remove Tile floor covering 232.50 SF 2.15 0.00 0.00 499.88 19. Remove 1/2"Cement board 232.50 SF 0.70 0.00 0.00 162.75 20. Remove Underlayment-1/2"BC 232.50 SF 1.38 0.00 0.00 320.85 plywood wood 21. Remove Underlayment- 1/4" 232.50 SF 1.38 0.00 0.00 320.85 lauan/mahogany plywood 22. Remove Underlayment-3/4"BC 465.00 SF 0.56 0.00 0.00 260.40 plywood 23. Remove Vinyl floor covering 465.00 SF 0.79 0.00 0.00 367.35 (sheet goods) 24. Remove Batt insulation-6"-R19- 119.00 SF 0.25 0.00 0.00 29.75 unfaced batt 25. Remove Baseboard-2 1/4" 28.00 LF 0.36 0.00 0.00 10.08 26. Tear out trim 102.00 LF 0.38 0.00 0.00 38.76 27. Remove Vapor barrier-visqueen- 100.00 SF 0.08 0.00 0.00 8.00 6mil 28. HEPA Vacuuming-Light-(PER 465.00 SF 0.00 0.51 0.00 237.15 SF) 29. Add for HEPA filter(for 1.00 EA 0.00 49.42 2.50 51.92 canister/backpack vacuums) 30. Contents-move out then reset 1.00 EA 0.00 52.51 0.00 52.51 Totals: Kitchen/Dining Room 2.50 3,067.54 ROJAS_ANA 8/10/2016 Page: 3 Service/trAsm ServiceMaster Elite Reston Massachusetts Divison 12 Continental Blvd Merrimack,NH 03054 Office: 800.338.5311 Fax: 800.443.1819 Tax ID#26-3242142 Hallway Height: 8' 9,H, 82.00 SF Walls 16.77 SF Ceiling 98.77 SF Walls&Ceiling 16.77 SF Floor 1 1.86 SY Flooring 9.42 LF Floor Perimeter 5" 14.42 LF Ceil.Perimeter Door 2'6"X 6'8" Opens into KITCHEN_DINI Missing Wall 2' 11"X 8' Opens into STAIRS Door 2'6"X 6'8" Opens into FAMILY-ROOM DESCRIPTION QTY REMOVE REPLACE TAX TOTAL 63. Remove Carpet 16.77 SF 0.23 0.00 0.00 3.86 65. Remove Carpet pad 16.77 SF 0.10 0.00 0.00 1.68 Totals: Hallway 0.00 5.54 t�ront Porch .z 8" 2'2"1 Bedroorn2 Height:7' 229.93 SF Walls 124.26 SF Ceiling throom "I iff" 354.18 SF Walls&Ceiling 124.26 SF Floor 113.81 SY Flooring 32.61 LF Floor Perimeter 37.61 LF Ceil.Perimeter Door 2'6"X 6'8" Opens into BATHROOM Door 2'6"X 6'8" Opens into KITCHEN_DINI Missing Wall 6'8 3/4"X 7' Opens into BAY DESCRIPTION QTY REMOVE REPLACE TAX TOTAL 66. Remove Carpet 124.26 SF 0.23 0.00 0.00 28.58 67. Remove Carpet pad 124.26 SF 0.10 0.00 0.00 12.43 Totals: Bedroom2 0.00 41.01 ROJAS_ANA 8/10/2016 Page:4 ServicewsrER ServiceMaster Elite Restore Massachusetts Divison 12 Continental Blvd Merrimack,NH 03054 Office: 800.338.5311 Fax: 800.443.1819 Tax ID#26-3242142 3'6" Bedrooml Height:7' III sw-s' t i d 289.81 SF Walls 176.44 SF Ceiling fV N N aearoo 1 466.25 SF Walls&Ceiling 176.44 SF Floor 1 Cl 19.60 SY Flooring 40.81 LF Floor Perimeter 53.31 LF Ceil.Perimeter 7'5" 3'4"+ ,lY Chase Door 2'6"X 6' 8" Opens into NURSERY Door 2'6"X 6'8" Opens into KITCHEN_DINI Door 2'6"X 6'8" Opens into BATHROOM >U z, , Subroom: Closet(1) Height:7' T i 112.50 SF Walls 15.17 SF Ceiling C t 127.67 SF Walls&Ceiling 15.17 SF Floor 1.69 SY Flooring 15.83 LF Floor Perimeter 20.83 LF Ceil.Perimeter Door 5'X 6'8" Opens into BEDROOMl DESCRIPTION QTY REMOVE REPLACE TAX TOTAL 68. Remove Carpet 191.61 SF 0.23 0.00 0.00 44.07 69. Remove Carpet pad 191.61 SF 0.10 0.00 0.00 19.16 Totals: Bedrooml 0.00 63.23 Front Porch Height:7' 6Y-6'6"r 428.96 SF Walls 123.21 SF Ceiling z's° ,F66 4rch 2'%-6' = 552.17 SF Walls&Ceiling 123.21 SF Floor 9' 13.69 SY Flooring 63.90 LF Floor Perimeter 68.90 LF Ceil.Perimeter Window 2'6" X 4' Opens into Exterior Window 2'6" X 4' Opens into BATHROOM Door 216f'X 6'8" Opens into KITCHEN_DINI Door 2'6"X 6'8" Opens into Exterior ROJAS_ANA 8/10/2016 Page: 5 ServiceafnsTER ServiceMaster Elite Restore Massachusetts Divison 12 Continental Blvd Merrimack,NH 03054 Office: 800.338.5311 Fax: 800.443.1819 Tax ID#26-3242142 CONTINUED-Front Porch DESCRIPTION QTY REMOVE REPLACE TAX TOTAL 58. Remove Suspended ceiling tile-2' 123.21 SF 0.19 0.00 0.00 23.41 x 4' 61. Remove Suspended ceiling grid- 123.21 SF 0.17 0.00 0.00 20.95 2'x 4' 62. Remove Batt insulation- 12"-R38 123.21 SF 0.34 0.00 0.00 41.89 -paper faced Totals: Front Porch 0.00 86.25 �2'11" Stairs Height: 17' ;Room 179.83 SF Walls 20.17 SF Ceiling Mrs 200.01 SF Walls&Ceiling 44.60 SF Floor 4.96 SY Flooring 19.97 LF Floor Perimeter 13.83 LF Ceil.Perimeter Missing Wall 2' 11" X 17' Opens into HALLWAY Missing Wall 2' 11" X 17' Opens into KITCHEN_DINI DESCRIPTION QTY REMOVE REPLACE TAX TOTAL 70. Remove Carpet 44.60 SF 0.23 0.00 0.00 10.26 71. Remove Carpet pad 44.60 SF 0.10 0.00 0.00 4.46 Totals: Stairs 0.00 14.72 X3'6" '9 Nursery Height:7' "� 280.55 SF Walls 115.09 SF Ceiling Chase `� o 1 0 `�'10 Nursery i F� 395.64 SF Walls&Ceiling 115.09 SF Floor ,eSC„ 12.79 SY Flooring 39.72 LF Floor Perimeter 47.22 LF Ceil.Perimeter Door 2'6"X 6'8" Opens into ROOMI Door 2'6"X 6' 8" Opens into FAMILY-ROOM Door 2'6"X 6' 8" Opens into BEDROOMI DESCRIPTION QTY REMOVE REPLACE TAX TOTAL ROJAS_ANA 8/10/2016 Page: 6 Servicemsm ServiceMaster Elite Restm Massachusetts Divison 12 Continental Blvd Merrimack,NH 03054 Office: 800.338.5311 Fax: 800.443.1819 Tax ID#26-3242142 CONTINUED-Nursery DESCRIPTION QTY REMOVE REPLACE TAX TOTAL 72. Remove Carpet 115.09 SF 0.23 0.00 0.00 26.47 73. Remove Carpet pad 115.09 SF 0.10 0.00 0.00 11.51 Totals: Nursery 0.00 37.98 E allwa 5, Family Room Height:7' �1'!-- X12'2' 5. 225.26 SF Walls 108.02 SF Ceiling ry i Family Room 0 333.28 SF Walls&Ceiling 108.02 SF Floor N 12.00 SY Flooring 31.70 LF Floor Perimeter 41.70 LF Ceil.Perimeter Door 21611 X 61811 Opens into NURSERY Door 2'6"X 6'8" Opens into HALLWAY Door 5'X 618#1 Opens into KITCHEN_DINI DESCRIPTION QTY REMOVE REPLACE TAX TOTAL 74. Remove Carpet 108.02 SF 0.23 0.00 0.00 24.84 75. Remove Carpet pad 108.02 SF 0.10 0.00 0.00 10.80 Totals: Family Room 0.00 35.64 Total:Main Level 12.43 4,798.65 Basement iBasement Height:6'6" IF� 652.13 SF Walls 564.23 SF Ceiling Basemen[ T"3 1 1,216.36 SF Walls&Ceiling 564.23 SF Floor N N 62.69 SY Flooring 100.33 LF Floor Perimeter - T 100.33 LF Ceil.Perimeter 26'11" 00 1 27'7"- Missing "-Missing Wall 2'7 15/16"X 6'6" Opens into STAIRS DESCRIPTION QTY REMOVE REPLACE TAX TOTAL ROJAS_ANA 8/10/2016 Page:7 Ser'viceMASTBR ServiceMaster Elite Restm Massachusetts Divison 12 Continental Blvd Merrimack,NH 03054 Office: 800.338.5311 Fax: 800.443.1819 Tax ID#26-3242142 CONTINUED-Basement DESCRIPTION QTY REMOVE REPLACE TAX TOTAL 33. HEPA Vacuuming-Light-(PER 282.11 SF 0.00 0.51 0.00 143.88 SF) Loose debris fell through floor planking 76. Equipment setup,take down,and 3.50 HR 0.00 45.91 0.00 160.69 monitoring(hourly charge) Setup equipment for drying on 07/28/16 and recover equipment on 08/02/16 77. Equipment setup,take down,and 3.00 HR 0.00 45.91 0.00 137.73 monitoring(hourly charge) Follow up on 07/29/16 and 08/01/16 49. Air mover(per 24 hour period)- 10.00 EA 0.00 24.95 0.00 249.50 No monitoring 50. Dehumidifier(per 24 hour period)- 5.00 EA 0.00 101.25 0.00 506.25 XLarge-No monitoring Totals: Basement 0.00 1,198.05 Total:Basement 0.00 1,198.05 Content DESCRIPTION QTY REMOVE REPLACE TAX TOTAL 55. Inventory,Packing,Boxing,and 14.50 HR 0.00 38.50 0.00 558.25 Moving charge-per hour 56. Contents Evaluation and/or 7.25 HR 0.00 48.20 0.00 349.45 Supervisor/Admin-per hour 57. Plastic bag-used for disposal of 81.00 EA 0.00 3.52 17.82 302.94 contaminated items Bags used to place content after inventory for disposal Totals: Content 17.82 1,210.64 Labor Minimums Applied DESCRIPTION QTY REMOVE REPLACE TAX TOTAL 60. Acoustic ceiling tile labor 1.00 EA 0.00 180.32 0.00 180.32 minimum 64. Carpet labor minimum 1.00 EA 0.00 21.89 0.00 21.89 Totals: Labor Minimums Applied 0.00 202.21 ROJAS_ANA 8/10/2016 Page: 8 ServiceMASTBR ServiceMaster Elite x Massachusetts Divison 12 Continental Blvd Merrimack,NH 03054 Office: 800.338.5311 Fax: 800.443.1819 Tax ID#26-3242142 Line Item Totals:ROJAS_ANA 30.25 7,409.55 Grand Total Areas: 5,465.75 SF Walls 2,385.65 SF Ceiling 7,851.40 SF Walls and Ceiling 2,432.36 SF Floor 270.26 SY Flooring 774.03 LF Floor Perimeter 0.00 SF Long Wall 0.00 SF Short Wall 857.49 LF Ceil.Perimeter 2,432.36 Floor Area 2,589.80 Total Area 5,014.56 Interior Wall Area 2,665.78 Exterior Wall Area 344.91 Exterior Perimeter of Walls 0.00 Surface Area 0.00 Number of Squares 0.00 Total Perimeter Length 0.00 Total Ridge Length 0.00 Total Hip Length Coverage Item Total % ACV Total % Dwelling 6,501.85 87.75% 6,501.85 87.75% Other Structures 0.00 0.00% 0.00 0.00% Contents 907.70 12.25% 907.70 12.25% Total 7,409.55 100.00% 7,409.55 100.00% ROJAS_ANA 8/10/2016 Page:9 ServiceMASTBR ServiceMaster Elite Restore Massachusetts Divison 12 Continental Blvd Merrimack,NH 03054 Office: 800.338.5311 Fax: 800.443.1819 Tax ID#26-3242142 Summary for Dwelling Line Item Total 6,471.60 Material Sales Tax 30.25 Replacement Cost Value $6,501.85 Net Claim $6,501.85 Denni Cushing ROJAS_ANA 8/10/2016 Page: 10 ServiceMasTBR ServiceMaster Elite Restore Massachusetts Divison 12 Continental Blvd Merrimack,NH 03054 Office: 800.338.5311 Fax: 800.443.1819 Tax ID#26-3242142 Summary for Contents Line Item Total 907.70 Replacement Cost Value $907.70 Net Claim $907.70 0-4'� Dennis Cushing ROJAS_ANA 8/10/2016 Page: 11 Servicewsm ServiceMaster Elite Restore Massachusetts Divison 12 Continental Blvd Merrimack,NH 03054 Office: 800.338.5311 Fax: 800.443.1819 Tax ID#26-3242142 Recap of Taxes Material Sales Tax(6.25%) Clothing Sales Tax(6.25%) Storage Tax(6.25%) Line Items 30.25 0.00 0.00 Total 30.25 0.00 0.00 ROJAS_ANA 8/10/2016 Page: 12 Servicemwu ServiceMaster Elite Restore Massachusetts Divison 12 Continental Blvd Merrimack,NH 03054 Office: 800.338.5311 Fax: 800.443.1819 Tax ID#26-3242142 Recap by Room Estimate:ROJAS_ANA Area:Main Level 1,436.81 19.47% Coverage:Dwelling 100.00% = 1,436.81 Kitchen/Dining Room 3,065.04 41.54% Coverage:Dwelling 100.00% = 3,065.04 Hallway 5.54 0.08% Coverage:Dwelling 100.00% = 5.54 Bedroom2 41.01 0.56% Coverage:Dwelling 100.00% = 41.01 Bedrooml 63.23 0.86% Coverage:Dwelling 100.00% = 63.23 Front Porch 86.25 1.17% Coverage:Dwelling 100.00% = 86.25 Stairs 14.72 0.20% Coverage:Dwelling 100.00% = 14.72 Nursery 37.98 0.51% Coverage:Dwelling 100.00% = 37.98 Family Room 35.64 0.48% Coverage:Dwelling 100.00% = 35.64 Area Subtotal: Main Level 4,786.22 64.86% Coverage:Dwelling 100.00% = 4,786.22 Area:Basement Basement 1,198.05 16.24% Coverage:Dwelling 100.00% = 1,198.05 Area Subtotal: Basement 1,198.05 16.24% Coverage:Dwelling 100.00% = 1,198.05 Content 1,192.82 16.16% Coverage:Dwelling 23.90% = 285.12 Coverage:Contents 76.10% = 907.70 Labor Minimums Applied 202.21 2.74% Coverage:Dwelling 100.00% = 202.21 Subtotal of Areas 7,379.30 100.00% Coverage:Dwelling 87.70% = 6,471.60 Coverage:Contents 12.30% = 907.70 ROJAS_ANA 8/10/2016 Page: 13 ServiceMASTBR ServiceMaster Elite Restore Massachusetts Divison 12 Continental Blvd Merrimack,NH 03054 Office: 800.338.5311 Fax: 800.443.1819 Tax ID#26-3242142 Total 7,379.30 100.00% ROJAS_ANA 8/10/2016 Page: 14 ServicemsTEe ServiceMaster Elite Restore Massachusetts Divison 12 Continental Blvd Merrimack,NH 03054 Office: 800.338.5311 Fax: 800.443.1819 Tax ID#26-3242142 Recap by Category Items Total % ACOUSTICAL TREATMENTS 180.32 2.43% Coverage:Dwelling @ 100.00% = 180.32 CONTENT MANIPULATION 52.51 0.71% Coverage:Dwelling @ 100.00% = 52.51 CONT:PACKING,HANDLNG,STORAGE 907.70 12.25% Coverage: Contents @ 100.00% = 907.70 GENERAL DEMOLITION 3,872.24 52.26% Coverage:Dwelling @ 100.00% = 3,872.24 ELECTRICAL 342.43 4.62% Coverage:Dwelling @ 100.00% = 342.43 FLOOR COVERING-CARPET 21.89 0.30% Coverage: Dwelling @ 100.00% = 21.89 HAZARDOUS MATERIAL REMEDIATION 840.25 11.34% Coverage:Dwelling @ 100.00% = 840.25 PLUMBING 58.37 0.79% Coverage:Dwelling @ 100.00% = 58.37 WATER EXTRACTION&REMEDIATION 1,103.59 14.89% Coverage:Dwelling @ 100.00% = 1,103.59 Subtotal 7,379.30 99.59% Material Sales Tax 30.25 0.41% Coverage:Dwelling @ 100.00% = 30.25 Total 7,409.55 100.00% ROJAS_ANA 8/10/2016 Page: 15 Basement 27' 7" 26' 11" 31- Basement NM-21 g N Stairs M Basement ROJAS_ANA 8/10/2016 Page: 16 Main Level 30'- 29'4" 0'29'4" Front Porch f-- 6'6"--i _6, 12' 11" 6'3 2'9 ---6 9"-- 2'2 10'7„ Bathroom Bedroom2 0 0 M N �2' 11" 14'S" f4'--4Kitchen/Dining Roo �n �n tair 1' M Bedrooml N Sem 60 allw 9'3"' 75" 10' 11'3" Chase 'v 3'S" 4'—+ Nursery Family Room M Closetl 1 14 Main Level ROJAS_ANA 8/10/2016 Page: 17 2nd Floor 30' 1 It6' S" 22A, — Closet (1) c� Master Bedroom Bathroom 0 U-k T -- 1811 N 2' 8 'way i8" ;�,I 3 31-t10' 11" LF11' 6" T N cn M loset (P) 3 1 I Chess rn �� f (V N 1 _ 1 Son's Bedroom NGuest Room Closett cove (•2) 2' 2141 1 - oset24 T 11' T N M i 269" LN 2nd Floor ROJAS_ANA 8/10/2016 Page: 18 The.Commonwealth of 1Mlass�chusetts Department of IndustrialAccidents 1 Congress Street Suite 100 ' Boston,MA 02114-2017 V;r www mass.gov/dia sV• Workers,Comp ensationInsurance Affidavit:Builders/Contractors/Electrzcians/Piumbers. TO Blit FILED WITH THE PERNNfIITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): cye✓l c r. ^45 L Address: /"� 00,4t—/1a to -1,l 1 City/State/Zip: m t44e,M / r1 0•0'I Phone#: SOD � .3 Areyou an employer?Checkt&apli`ropriate box: Type of project(required) L. q I am a employer-Mth employees(full and/or part-time).* 'J.• Q New conisttuction 2.p I am a sole proprietor or partnership and have no employees Working for me in 8. E]Remo delirig any capacity.[No workers'comp.insurance required.] 9, Demolition I❑I am a homeowner doing all work myself.[No workers'comp..fium once required.]t 10 n Building addiction 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. 12:0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. Roof repairs These sub-contractors have employees and have workers'comm.insurance ' 14.[]Other 6.Q we are a corporation and ifs officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no..employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also'fill out the section below showing their workers'compensation policy information. T Homeowners who subidit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must•attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,rliey must proyidetheir workers'comp.policy number. Iain an employer that is piovidfngworkers'compensation insurance for my employees'Below is the policy andjab site information. In Insurance Company Name:_ �L� lJGfJ+KA'1> � Policy#orSelf--ins.Lic.#: 1/Z C) ! / � � ExpirationDate: Job Site Address. 3`�W✓,?eV1 N AU) City/State/Zip: 4 dcle M O- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure 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. Ido hereby certify under thepains andpenaNes ofpeijury tlaat the information provided above is true and correct Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: CCAPLLC-02 AMORSE ACORO� CERTIFICATE OF LIABILITY INSURANCE DATE 1 8//20/220/2015 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 License#AGR8150 CONTACT NAME: Ann Morse Clark Insurance PHONE FAX 80 Canal St A/c No Ell:(603)622-2855 v( C,No:(603)622-2854 Manchester,NH 03101 E'MADDRESS:info@clarkinsurance.com INSURER(S)AFFORDING COVERAGE NAIC p INSURER A:Peerless Insurance 24198 INSURED INSURER B:Netherlands 24171 CCAPS,LLC dba Service Master Elite&MAJE,LLC dba Elite INSURER C:Nautilus Ins Co Construction 12 Continental Blvd INSURER D: Merrimack,NH 03054 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. ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MADDLSUBR MIDDY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED`__ CLAIMS-MADE P(I OCCUR CBP8869089 08/29/2015 08/29/2016 PREMISES Ea occurrenceL_ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY T ECT LOC 2,000,000 PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 B X ANY AUTO BA8867299 08/29/2015 08/29/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ XX NON-OWNED P Pc tlenIDAMAGE HIREDAUTOS $ AUTOS X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 A EXCESS LIAB CLAIMS-MADE CU8862891 08/29/2015 08/29/2016 AGGREGATE $ 10,000,000 DED I X I RETENTION$ 10,000 $ WORKERS COMPENSATION X PER I OTH- AND EMPLOYERS'LIABILITY STATUTE ER A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WC8994621 08/29/2015 08/29/2016 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? Y❑ N/A — (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 C ContractorsPollution CCP201258311 08/29/2015 08/29/2016 Each Occurrence 2,000,000 C Liability CCP201258311 08/29/2015 08/29/2016 Includes Mold DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Alan DeGeorge&Matt Troyer are excluded from Workers Compensation coverage. 3A States: NH/MA/MENT/NY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE C12 PS,LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ontinental Blvd ACCORDANCE WITH THE POLICY PROVISIONS. rimack,NH 03054 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD dT4 i,-ownlilo4weaAA Office of Consumer Affairs nd Business Regu atlon 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 165712 Type: Supplement Card Expiration: 3/22/2018 MADE LLC./dba Elite Construction ALAN DEGEORGE _ 12 CONTINENTAL BLVD MERRIMACK, NH 03054 _... ..., Update Address and return card.Mark reason for change. scat t, 20M-05/11C Address E] Renewal 7! Employment Lost Card t���('�f}l9t?/(G.ItCUC(7.1��0/}C'•/�Gi.if(CIIdLiC/fJ Mee of Consumer Affairs&Business Regulation License or registration valid for individual use only before the expiration date. If found return to: '�OME IMPROVEMENT CONTRACTOR 1 - / Office of Consumer Affairs and Business Regulation �• Registration:-=(165742.-, Type: 10 Park Plaza-Suite 5170 A Expiratl&h' 3%2212018=" Supplement Card Boston,MA 02116 MAJE LLC./dba Elitea;`on§trtaction ELITE CONSTRUCTION;°;`, ALAN DEGEORGE 12 CONTINENTAL BLVD";! MERRIMACK,NH 03054 Undersecretary Not valid without si ture I Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-106109 Construction Supervisor ALAN DEGEORGE ..� 12 CONTINENTAL BLVD MERRIMACK NH 03064 ZU7 CA,,,_ Expiration: 1 Commissioner 0311612018 Construction Supervisor Restricted to: Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. DPS Licensing information visit:WVVW.MASS.GOV/DPS I