HomeMy WebLinkAboutBuilding Permit #631-14 - 371 MARBLERIDGE ROAD 3/17/2014Permit NO:
Date Issued:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
II ' Date Received ??I,,
4�7 11-7 11 j -
IMPORTANT:
must complete all items on this
u 100;YearO0 Stcu
ICT ]H..istoric sDistrict
YAAnf- 'ina Zhnei
yes:no'
yes,
es :na
TYPE OF IMPROVEMENT.
PROPOSED USE'
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
Septic ❑Well " - -
z �YFloodplatn, ❑Wetlands
F' ❑Watersheds®istricf
❑ Water/Sewer a -
OWNER: Name:
Ar9rlracc•
DESCRIPTION OF WORK TO BE PERFORMED:
/ .
CONTRACTOR Name -/V/ AA—ZAP--f7- Phone
Address; . -
Superviso_s Construetion,License _ 0 r Exp: 1Qate;
Home Improvement -License. -_ Exp Date: 4
��-9� -
ARCHITECT/ENGINEE
Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT.
$12.00 PER $101 p
00.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
y
Total Project Cost: $ 7 & • FEE: $ I LP • 1-13 --
Check No.: 1 (,-0 Receipt No..-
NOTE:
o.:NOTE: Persons contracting with unregistered contractors do not have est' to the guaran fund
Sig ature of Agent/Owner�- `, r , ;. 4_ __ 5q ature of contracto
Plans Submitted 1.i Plans Waived ❑ Certified Plot Plan EV Stamped Plans ❑
Building Department
-The foE',owing is`a=list of:the requited.forms to befilled out for:the.appropriate. permit to be obtained.
Roofiii-ig, Siding, Interior Rehabilitation Permits
Li ' Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: 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/Crossection/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
NOTE: 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
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cas<s .if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the aprr,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submJted with the building application
Doc: Doc.Building permit Revised 2012
J0
Plans Submitted ❑ .'Plans Waived ❑
.Certified Plot Plan ❑
Stamped Plans ❑
,TYPE OF:;SEWEIZAGEDiSP.OSAL-
Public Sewer ❑
Tanning/Massage/Body Art ❑ ..
_Swimming Pools ❑
Well ❑
Tobacco.Sales El
•FoodPackaging/Sales ❑
Private (septic tank, etc._
permanent Dpster on -Site El
THE_ FOLLOWING SECTIONS FOR OFFICE USE ONLY
_ INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED:
PLANNING & DEVELOPMENT ❑
DATE. APPROVED
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No:
Planning Board Decision:
Conservation Decision:
Comme
Comments
ing Decision/receipt submitted yes
Water & Sewer Connection/Signature � Date Driveway Permit
DPW Towiz Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTN'�_NT. -:•Temp Dumpster on site .yes no
Located at:lk Mair Street
Fire Depart&6r,it ignature/date .tit -. { x f ;, ,r:,;;z ��� s a �i�r`, _ :�• . , :
COMMENTS
.-Dimension-
Number of Stories: Total square feet of floor area, based on Exterior dimensions.^
.Total- land -area; sq. ft.:
:ELECTRICAL: Movement of. Meter. locatl6 , M'ast or service drop requires approval of
Electrical Inspector Yes No
DANGERZONE LITERATURE: Yes No
MGL -.Chapter 166. Section 21A -F and G min.$100=$1000-.fine
and DATA — (dor department use
El Notified for pickup - Date
Doc.Building Permit Revised 2010
Location We -vi
No. Date
Check #
27349
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
— .4
Buildin.dInspector
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, The Commonwealth of Massachusetts
Board of Building Regulations and Standards;
\�ryi Massachusetts State Building Code, 780 CMR
Building Permit Application To Construct., Repair, Renovate Or Demolish a
Iteried
s ed
One- orTivo-Fancily Divellin�'
Marchvi
2011
This Section For Official Use Only
Building Permit Number:
Date Applied:
Building Official (Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 )Property Address: *1 i
1.2 Assessors Map & Parcel Numbers
1.l a Is this an accepted street? yes no'
N4ap Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area (sq ft) Frontage (tl)
1.5 Building Setbacks (ft)
Front Yard
Side Yards
Rear Yard
Required
Provided
Required
Provided
Required
Provided
1.6 Water Supply: (M.C.I. c. 40. §54)
1.7 Flood Zone Information:
1.8 Sewage Disposal System:
Public ❑ Private ❑
Zone: _ Outside Flood Zone?
Check if ves❑
Municipal ❑ On site disposal system ❑
SECTION
2: PROPERTY OWNERSHIP'
2.1 Owner' of Record:
��'��..-.� � r''®1�� � e��•�/� ��� ��s� /x,04
Name (Print) —� City. State. ZIP
No. and Street Telephone L'mail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑
Existing, Building'�@K
Omer -Occupied
Repairs(s)
4lteration(s) ❑
Addition ❑
Demolition ❑
Accessory Bldg. ❑
Number of Units Other ❑ Specifj:
Brief Description of Proposed Work`. r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:
Official Use Only
(Labor and Materials)
1. Building
S
1. Building Permit Fee: S Indicate how fee is determined:
❑ Standard City/Town Application Fee
?. Electrical
$
❑ Total Project Cost' (item 6) x multiplier x
3. Plumbing
S
2. Other Fees: S
List:
4. Mechanical (HVAC)
S
5. Mechanical (Fire
S
Suppression)
Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost:
S
&,
_
0Paid in Full ❑Outstanding Balance Due:
PM
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
6%y f✓�f
Z
License Number Expiration Date
LCSI-Type List CSype (see below)
Name ol'CSL i1 der
f
,/}
r�� Ab A4 Pv,
T
Type Description
No. and Street
nU
�S � �'�
Unrestricted (Buildings u to 35.000 cu. ft.
R Restricted 1&2 1 an-ii1v Dwelling
City/Town. State. ZIP
M llasonry
RC Roofing Covering
WS Window and Sidine
SP Solid Fuel Burning Appliances
L
i Insulation
Telephone Email address
1) Demolition
5.2 Registered Home improvement Contractor (HIC)
f4 i3 /� t^✓cI fyrz �.-=r.
-%
HIC Registration Number Expiration Date
Email address
HiC Compan Name or Ill Registrant Name,
A -AA -P^. nap
and Street y h �1, .v� J� ya /
City/Town. State. ZIP f v 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 AU ORIZATION 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.
GAb, L
Print Owner's Name (F..lecty nic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
t
fay ente ' y name be w,,I'hereby attest under the pains and penalties of perjury that all of the information
on fined i>this apkation is true and accurate to the best of rn} knowledge and understanding.
int Owner's or Authorized Agent's Name (E ectronic Signature) Date
NOTES:
I . 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.mass.�-owoca Information on the Construction Supervisor License can be found at W%%7w.1118ss.3oV1dps
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'
011
Proposal Submitted To:
WILLIAM & GLORIA FOLEY
371 MARBLERIDGE RD
NORTH ANDOVER, MA 01845
978-204-0780
®p®sal
AB Carnes Roofing, Inc.
30 Arrowhead farm Rd
Boxford, Ma. 01921
978.887.1431
MA. CS -000230 and HIC Reg. 176928
Date February 17, 2014
Project Name SAME
Address
We propose to furnish material and labor- in accordance with the specifications below:
Seventy Five Hundred Dollars ($7,500.00)
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 ZAS NEEDED 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 ONE CHIMNEYS . CUT NEW REGLET WITH CARBIDE SAW AND SECURE NEW
LEAD FLASHING IN PLACE WITH METAL ANCHORS, PROPERLY SEAL REGLE NT.. E ADD $500.00 IF NEEDED TC ABOVE PRICE.
® COVER ROOF SURFACE WITHCERTAINTEED LANDMARK ARCHITECTU L LIFETIME RRANTY 240LB SHINGLES.
® REPLACE DEFECTIVE ROOF DECK AS NEEDED WITH CDX PLYWOOD AT AL 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 ONLY THE UPPER MAIN HOUSE. THE REAR LOWER ROOF SECTION IS NOT INCLUDED BECAUSE IT IS MUCH
NEWER.
WARRANTY UPGRADE: THE CERTAINTEED WIND WARRANTY WILL BE UPGRADED FROM 110 MPH TO 130 MPH WIT PGRADE TO THE
CERTAINTEED HIGH PERFORMANCE HIP & RIDGE CAPS AND STARTER COURSE AT NO ADDITIONAL CHARGE. Y 6),
EMAIL ADDRESS
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 cancel 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, y ,u have accepted all the terms as stated on the front and back of this agreement.
*Date of Acceptance
i
*Signal —
Please see reverse side.
PLEASE SEE REVERSE SIDE
,4� o® CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDNYYY)
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
Harris -Murtagh Insurance Agency,Inc.
30 Central Street
Peabody MA 01960
CONTACT Commercial Lines
NAME:
PHONE (978)532-2844 FAX No:
E-MAIL
ADDRESS:
INSURERS AFFORDING COVERAGE NAIC q
INSURER A.Western World Insurance Co
INSURED
AB Carnes Roofing, Inc
30 Arrowhead Farm Rd
Boxford MA 01921
INSURER 8:
INSURERC:
INSURER D:
INSURER E:
INSURER F:
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 VVITH 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
LTR
TYPE OF INSURANCEIm
ADDLSUBR
POLICY NUMBER
MM/DDY/YYYY IEFF
LICY EXP
MM DD/YYYY
LIMITS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE Fx_] OCCUR
J S Scholnick/PJR L'1_�
RPP137217
0/11/2013
0/11/2014
EACH OCCURRENCE $ 1,000,000
_
DAMAGE TO RENTEU
PREMISES Ea occurrence $ 50,000
MED EXP (Any one person) $ 5,000
PERSONAL 8 ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY 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 LIABOCCUR
EXCESS LIAB
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
DED RETENTION $
$
COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVEF—]
OFFICERIMEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N / A
WC STATU- O R
Y LIMITSWORKERS
E.L. EACH ACCIDENT
_$
E.L. DISEASE - EA EMPLOYE $
E.L. DISEASE - POLICY LIMIT I $
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
rcoTtcirATc unl nco CANCELLATION
ACORD 25 (2010/05)
INS025 on+nns ni
U 198S-2U1U AGUKU GUKPUKA I IUN. All rignts reserved.
Tho ArnR11 n2mo 2nri Innn 2ro roniclororl m2rlrc of A( 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.
own Of North Andover
600 Osgood Street
(NorthAndover, MA 01845
AUTHORIZED REPRESENTATIVE
J S Scholnick/PJR L'1_�
ACORD 25 (2010/05)
INS025 on+nns ni
U 198S-2U1U AGUKU GUKPUKA I IUN. All rignts reserved.
Tho ArnR11 n2mo 2nri Innn 2ro roniclororl m2rlrc of A( npn
1 Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS -000230
BARRY S CARNES
30 ARROWHEAIYFARIVI;RD
Boxford MA 01911
°J12-... ma c. Expiration
Commissioner 03/07/2016
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 51.70
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 176928
Type: Corporation
_ - Expiration: 1 011 0/201 5 Tr# 245633
AB CARNES ROOFING, INC. f
BARRY CARNES
30 ARROWHEAD FARM RD
BOXFORD, MA 01921 — -- -- --
Update Address and return card. Mark reason for change.
i Address - Renewal Employment '` Lost Card
SCA 1 0 20M-05111
NORTH ANDOVER
WASTE AFFIDAVIT
As a result of the provisions of MGL Ch.40-s54, 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 APPLICAN
The Commonwealth of Massachusetts Print Form
t-- - - — Department of Industrial Accidents
+Y Office of Investigations
1 Congress Street, Suite 100
Boston MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/individual); AB CARNES ROOFING, INC
Address:30 ARROWHEAD FARM RD
itv/State/Zin:BOXFORD, MA 01921
Are you an employer? Check the appr
1.0 I am a employer with
employees (full and/or part-time).*
2.0 1 am a sole :proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
req u fired. ]
3.0 I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
Phone #:978-887-1431
✓� I aA a general contractor and I
ave!hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
mployees and have workers:
F c mp.. insurance.*
e are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152. C ](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
10.0 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.0✓ Roof repairs
13.0 Other
`Any applicant that checks box 91 must also fill out the section below showing their workers' compensation policy inibrmation.
t HomeoWnerS who suhmit 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 most attached an additional sheet showing the namc of the sub -contractors and state whether or not those entities have
employees. If file suh-contractors have employees. they must provide their workers' comp. policy number,
I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
iti formation.
insurance Company Name:
Policy 4 or Self -ins. Lic. #:
.lob Site
Expiration Date:
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 a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DiA for insurance coverage verification.
/ do hereby t y under the pains Ondpenalties n er'u a that tthe iu oormation. provided above is true and correct. correct.
}
ej e-7
Official use onh% 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 #:
FORM 1.53 The Commonwealth of Massachusetts DIA use Only
Department of Industrial Accidents
Office of Investigations - Dept. 153
Congress Street. Suite 100, Boston. Massachusetts 02114-21117
;r= —7 7
'._=j„. httpJhvww.mass.gov/dia lmest./SWOiD#:
'.
..r : AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPORATE
OFFICERS OR DIRECTORS
Chapter 169 of'the Acts of )002 amended ill.G.L. c. 152, `{1(4) by adding the folloiving paragraph:
"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 46. 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. 1.52. § 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 employees) as prescribed by
M.G.L. c. 152, §25A.
I/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 frofn the provisions of M.G.L. c. 152.
under thehains and penalties of perjury:
BARRY CARNES, PRESIDENT 09/24/2013
S' urx i'rint Name &.Title
❑✓ I wish to exercise my right of exemption. or ❑ I wish NOT to exercise my right of exemption
r� — ANASTASIYA CARNES, DIRECTOR
Signature Print Name & Title
❑✓ I wish to exercise nth right of exemption or ❑ i wish NOT to exercise nly right of exemption
Signature Print Name & Title
❑ I wish to exercise m} right of exemption or ❑ 1 wish NOT to exercise my right of exemption
Signature Print Name & Title
❑ 1 wish to exercise my right of exemption or 1-11 wish. NOT to exercise my right of exemption
Date (rnm/dd/vyyy)
09/24/2013 CIO
Date (mm/dd/yy, v)t )
Cn
Date (mm/dd/vy\C
Date (mnvdd/y y yy )
Note: ALL ELIGIBLI: CORPORATE OFFICERS MUST SiGN. TIIERF.. CAN BE NO MORE TITAN 4 SiGNATURES. htstruetionc
mi hack. Form 1;3 - 7/2010
MA SOC Filing Number: 201340178570 Date: 6/26/2013 6:21:00 PM
The Commonwealth of Massachusetts Nlinimuwn Fee: $250.00
William Francis Galvin
Secretary of the Commonwealth, Corporations Division
One Ashburton Place, 17th floor
Boston, MA 02108-1512 Succial Filing Instructions
Telephone: (617) 727-9640
Federal Employer Identification Number: 00.1110484 (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 & INTERIOR REMODELING
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 ol'Shures Toia Par Vuhte Num of Shares
CNP 50.00000 1.000 $0.00 1.000
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 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 office:
Name: BARRY CARNES
No. and Street: 30 ARROWHEAD FARM RD
City or Town: BOXFORD State: MA Zip: 01921 Countty: 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
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: 0 192 1 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). (II'cnr c.t-istin,�' corporation is
acting as incorporator-, type in the exact name (?f the business entity, the state or other• jur•is&cion v here
it ivas incoapor•ated. the name of*the person sigitingon hehalfQfsaid business entity and the title he%she
bolds or other- authority by tyhich such action is taken.)
BARRY S CARNES
^c� 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
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:
June 26, 2013 06:21 PM
WILLIAM FRANCIS GALVIN'
Secretai-Y of the Coininonivealth
Ar- ?R b- CERTIFICATE OF LIABILITY INSURANCE D.ATE(MMiDDAYYY)
_j-- ' 11/8/2013
THIS;:ERTIFICATE 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 _ NCONT
AM -ACT BerkleyAssigned Risk Services
Ace Insurance Services Inc PHONE =AX
AC. No. E1d1: 800 634-4589 1 (A/C. No.) (866)215-8118
675 Warren Ave AcoREss: PolicySerAces@berkleyrisk.com
Rrnrkt�rs.,.M^fl fY93A'f �""�
1 American Construction Inc INSURER B: - - --- -- — - -
242 Belmont Street Unit 2 INSURER C.
INSURER O
Brockton, MA 02301 INSURER E
INSURER F'
COVERAGES , -CERTIFICATE NUMBER: REVISION NUMBER:
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.
WSR
LTR
TYPE OF INSURANCE ADDL
.INSR
GENERAL LIABILITY I
SUBR
NND
POLICYNUMBER
POLI
MM'DD%Y. YY Y EFF PO Dc" ICY )XP t
LIMITS
'
--
AUTOMOBILE LIABILITY
WORKERS COMPENSATION
Y;
MA SOC Filing Number: 201316881130 Date: 4/23/2013 10:36:00 AM
-�- The Commonwealth of Massachusetts Minimum Fee: 52511.00
.`� William Francis Galvin.
-'� Secretary of the Commonwealth. Corporations Division
One Ashburton Place, 17th floor
Boston, MA 02104-1512 Special Filin,, Instructions
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 11
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
Nunn gf"Shrrre s Total Pw 1%alit, Vim nfShares
CNP $0.00000 20,000 S0.00 20.000
G.L. C156D eliminates the concept of par value, however a corporation may specify par value in Article 111. 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
re:ARTICLE V1
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 office:
Name: MANUEL LEMA-CAGUANA
No. and Street: 12 WALL STREET
City or Town: BROCKTON State: MA Zip: 02301 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 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 Country: 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: 0230.1 Country: USA
which is
X its principal office _ an office of its transfer agent
an office of its secretarylassistant secretary _ its registered office
Signed this 23 Day of April, 2013.at 10:37:21 AM by the incorporator(s). (11'an existing cm poration is
acting as incorporator. type in the exact name of the business entity. the state or other urisdiction tvhere
it was incorporated, the name of the person signing on behalf of said business entity and the title heXszhe
holds or other authorith b}v it?hich such action is taken.)
MANUEL LEMA C.AGUANA
O 2001 - 2013 Commonwealth of Massachusetts
All Rights Reserved
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
that the provisions of the General. Laws relative to corporations have been complied with,
and I hereby approve said articles, and the film,, fee having been paid, said articles are
deemed to have been filed with me on:
April 23, 2013 10:36 AM
WILLIAM FRANCIS GALVIN
Secretary ofthe Connnonivealth