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HomeMy WebLinkAboutBuilding Permit #417-16 - 40 RIDGE WAY 10/2/2015 1�ws A.a t SCIVrV ea TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: Z. F7 V IWORTANT:Applicant must complete all items on this page LOCATION �6 X W E WAY Print PROPERTY OWNER Se Y(26- C 9-T COY tie7- Unit# �1 Print MAP NOP,r PARCEL:e'U ONING DISTRICT: Historic District yO Machine Shop Village y100 year-old structure y 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 ®f epti, ��c,. ff.�W�eff M Floocip_aai_m* M)Wefl�an__ds; , jaterlSe�wer�_ - - DESCRIPTION OF WORK TO BE PERFORMED: pl/Vj fNI;D '73NEMEA1 (Identification Please Type or Print Clearly) OWNER: Name: SLYCE CAUCoYmE Phone: 339-222 360, Address: L- y lzC1)(sC WAY AJ, AJ Du UGp , ly) 4 CONTRACTOR Name:A>zlL,6N MAX 1/til v Phone: 97 5- q6Z-33 Sv Address: Ll'( A )l Jct N Supervisor's Construction License: (06 :3 VL Exp. Date: Home Improvement License: l Z`1Exp. Date: 9-1'7-j7 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ /59.45-00 C@1`_ FEE: $ Check No.: U k Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund and y,�. i natu[e.,oftAgeritlO,wnerrX _F_ "_;_ <�t ' x< Si nature of�contracto A ="'. _{ I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped.Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS r Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes t Planning Board Decision: Comments Conservation Decision: Comments Water&Sewer Connection/Signature&Date Driveway Permit ,z- DPW Town Engineer: Signature: ' Located 384 Osgood Street FIRE DEPARTMENT Temp Durnp§4 Dumps: , on site yes no Located at 124,Main Street P Fire Department si afore/date COMMENTS ■ 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 servicedroprequires approval of Electrical Inspector Yes DANGER ZON --' LIT HRATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10041000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi 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 t I wilding Permit Application }a orkers Comp Affidavit iu/Photo Copy of H.I.C. And/Or C.S.L. Licenses dopy 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 o Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o FloorlCrossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o 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) ❑ Copy of Contract o 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 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: Doc.Building Permit Revised 2008mi i Location f ; �'/` f✓j`J"� X No. Date G l i • - TOWN OF NORTH ANDOVE1 Certificate of Occupancy ` $ Building/Frame Permit Fee $� t- Foundation Permit Fee $ Other Permit Fee $ TOTAL $ J� Check# V � � Building Inspector 2 462 Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 158,500.00 m $ - $ 1,902.00 Plumbing Fee $ 237.75 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 237.75 Total fees collected $ 2,477.50 40 Ridge Way 417-2016 on 10-2-15 Finish CA i NORTH own of EAndover O - .:�. No. All * � ero h v , Mass, COCNIG«eWKK y1. p04 4 TE D I'P�,`'�� S u BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System 1 THIS CERTIFIES THAT .......... .. r C. ,.1.! �?�.Ul. .................... BUILDING INSPECTOR has permission to erect g Foundation .......................... buildings ...�!Q.......Aape .....�.. ...............,. Rough to be occupied as ... . 1. - �..f .........�Gl . ..... .......... .r........ :.. U.... APPM 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI T !T Rough Service ...................... ...................................................... Final BUILDING INSPECTOR 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. DM Construction Building with the QUALITY and Character of yesteryear. 44 Addison Ave Ext. Methuen, MA M44 (978) 685-3037 Estimate Submitted To: Bryce& Lori Chicoyne Construction Supervisors License 66342 40 Ridge Way Home Improvement Registration 124961 N.Andover,MA We hereby purpose to furnish the materials indicated and perform the labor necessary for the completion of: FINISHED BASEMENT(See specifications sheet and drawings) All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifications submitted for above work and completion in a substantial workmanlike manner in the sum of One hundred fifty-eight thousand five hundred dollars- $158,500.00 Payments to be made as follows: $ 1,000.00 Upon execution of contract. $20,000.00 When work begins. Remaining payments as work progresses. Respectfully submitted: Darren Martino / Any alteration or deviation from the above specifications involving extra costs will be executed only upon written order, and will become an extra charge over and above the estimate. All agreements contingent upon accidents, or delays beyond our control. Note-This proposal may be withdrawn if not accepted within 10 days. Proposal Date 07/29/15 ACCEPTANCE OF PROPOSAL The above prices, specifications, and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will outlined above. Date: ,i- Signature: .A'4'/ Date: Signature: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES UILDING DEPT. COPY CHICOYNE RESIDENCE Specifications Sheet GENERAL SCOPE OF WORK Finishing of approximately 1400 square feet of the basement level. Including a bathroom,family room, exercise room, and play room. PERMITTING DM Construction will file all necessary paper work to obtain the following permits: building, electrical,plumbing, gas piping, HVAC, and debris removal. The cost of all permits and fees necessary is not included in this estimate and will be billed separated DESIGN/ENGINEERING This estimate is based on preliminary drawings provided by Salley Associates. Salley Associates has been hired directly by the homeowner. The cost of any additional drawings or engineering required by the building department is the responsibility of the homeowner. If the building department requires items that are not on the drawings, DM Construction reserves the rikht to review the final approved construction drawings and amend Pricing of this contract if necessary. DEBRIS REMOVAL DM Construction is responsible for all debris generated. A container will be placed on site to ensure a clean work site. The container is for debris generated by DM Construction only, it is not intended for homeowner use. DEMOLITION The existing concrete slab will be saw cut as necessary for the underground plumbing. All concrete will be removed from the site. The areas will be backfilled and cemented in upon completion of necessary inspections. FLOORING SYSTEM* The area designated to be finished will have the following flooring system installed. Installation of I"thick pressure treated sleepers 16"o.c. Sleepers will be secured to the slab with construction adhesive and concrete nails. 1"rigid insulation will be installed in between the sleepers. 3/4"t&gAdvantech will be secured to the sleepers with construction adhesive and ring nails. The flooring system is compatible with hardwood, tile, carpet, or engineered flooring. The floor system will not be installed in the mechanical room and storage area adjacent to the bathroom. *See optional pricing for simplified subfloor system. FRAMING Framing shall take place according to the submitted drawings. Beams,pipes, and duct work will be boxed in as deemed necessary. Any deviations from the submitted drawings could incur extra cost. DM Construction reserves the right to review the final construction drawings and adjust the pricing of this contract if necessary. This contract does not include cutting the beam and installation of a new concrete footing in the playroom. It also does not include removing the lally column near the bar area. CHICOYNE RESIDENCE Specirications Sheet WINDOWS&EXTERIOR DOOR UNITS Strip back siding as necessary,frame, install windows, reinstall siding for four(4) window units. One in the exercise room and three in the family room. Remove the existing egress door and install a new door unit. The cost of the door, windows, and all their associated hardware is covered under an allowance. INSULATION* Installation of R-13 batted insulation on all exterior walls. Installation of R-11 insulation around the mechanical room,for soundproofing purposes. *See optional upgrade to Blown in Blanket System (BIBS) DRYWALL Installation of%"blue board on all new walls, ceilings, and softs. All new blue board will receive a skim coat of plaster. All new ceilings will have a smooth finish. CABINET INSTALLATION DMConstruction is responsible for installation of the vanity and bar area cabinets*and their associated moldings and hardware. Solid blocking will be installed to assure proper securing of all cabinetry. The cost of the cabinets and their associated moldings and hardware is covered under an allowance. *This estimate is subject to receiving and reviewing a final cabinet plan. DM Construction reserves the right to adjust the price of the contract upon final receipt of this plan. PAINTING All new walls, ceilings, and trim will be primed and receive two coats of finish. The walls in the stairway to the main house will be painted. The new oak treads and handrail will be sanded and receive 3 coats of polyurethane. Paint colors to be determined. All paints will be Benjamin Moore, Sherwin Williams, or an equivalent. BAR AREA AND BATHROOM PREP Installation of%"durarock or ditra membrane on all floors receiving marble or tile. Installation of dense shield wall board in all shower areas receiving tile, marble, etc. Install blocking for all accessories. Install blocking for all bar area cabinets and bathroom vanities. ACCESSORIES* DM Construction will install all accessories including: towel bars, toilet paper holders, towel rings, robe hooks, medicine cabinets, etc. If locations are determined during framing, solid blocking will be installed for secure fastening of all accessories. The cost of the accessories is covered under the plumbing fixture allowance. *Mirrors-The purchase and installation of all custom mirrors is covered under the plumbing fixture allowance. CHICO INE RESIDENCE Syecitications Sheet FINISH WORK The basement level will have installation of new interior door units, door trim, and baseboard with the following specifications: Interior door units*: Solid jamb, solid core doors, smooth finish, 2 panel arched top door style. (To match existing conditions on the main level.) *Interior door units that lead to unconditioned space will have a threshold and be weather stripped. Specialty door: Installation of a set of pocket doors entering the playroom from the main area. Door hardware: To match existing conditions on the main level. Door trim: 3 %z"colonial casing. Window trim: 3 %2"colonial casing with a sill. Baseboard: S %4"speed base Wainscoting: Installation of wainscoting around the perimeter of the playroom walls. The wainscoting will be comprised of mdf beadboard approximately 36", torus backband as a cap, and matching baseboard at the bottom. Staircase: Remove existing framing, treads, risers, and skirt boards. Installation of new framing members as necessary and new oak treads,painted risers, oak Scotia, oak handrail, and painted skirt boards. The stringers will be insulated for soundproofing purposes. All treads will be glued and nailed Custom finish work& casework: Any built-in units, custom millwork, book cases, wainscoting, crown moldings, closet shelving, or storage units, other than those specifically mention above are covered under the custom millwork allowance. CHICOYNE RESIDENCE Specifications Sheet HEATING/AIR CONDITIONING/VENTILATION Scope of work on existing system: The existing system will continue to service the two main levels of the home. Removal of 15'of the existing return air duct and replace with a reduced size duct. Cut access holes in the bottom of the 24 x 8 return air duct to seal existing duct connections. Raise existing supply line running into the garage as deemed necessary. Relocate the existing humidifier. Scope of work for new unit servicing the basement level: Complete installation of one gas fired forced air heating and air conditioning system to serve the new finished areas of the basement. Equipment —Provide and install the following equipment: I -95%efficient Trane 40,000 BTU gas fired furnace. Furnace to be located adjacent to the existing furnace. I —Trane 1.5 ton, 13 s.e.e.r. condenser. The condenser will be located on the right side of the house and will be set on a condenser pad. I — Trane cased cooling coil. 1—Honeywell electronic programmable thermostat. Installation of new condensate lines to new condenser. Installation of one new flue system for the new furnace. Installation of one condensate pump. Installation of all supply and return duct work Installation of all diffusers and grills. Installation of all refrigerant and drain piping. Ventilation—Provide the necessary ventilation for the bathroom exhaust fan and new dryer. Fresh air kit—Installation of a fresh air kit that will be tied into the furnace. Fresh air will be conditioned before being introduced into the living area. CHICOYNE RESIDENCE Specifications Sheet ELECTRICAL General-Provide standard white receptacles and AFCI receptacles as required by the code in all new areas. All receptacles to be tamper resistant. Fire Protection-Installation of hard wired smoke detectors and CO2 detectors as required in the basement level. Mechanicals-Wiring as necessary for: one new furnace and one new condenser. Appliances-Provisions for the following appliances: beverage refrigerator, washer, and dryer. Bathroom—Provide and install one GFI receptacle. Switching for the following fixtures: exhaust fan, vanity light, one recess light in the shower, and one recess light over the toilet. Closets—Provide and install fluorescent light strips in all storage areas and mechanical room. Bar area—Provisions for GFI receptacles as required on the countertops and island. Provisions for one beverage refrigerator. Switching as necessary for pendant lights over the island. Family Room-Provisions for standard receptacles as required by code. Switching for recess lights (general lighting), one exterior flood light, and one exterior coach light. Provide one cable outlet and one phone jack. Plat/Room—Provisions for standard receptacles as required by code. Switching for recess lights (general lighting). Provide one cable outlet. Hallway and stairs—Provisions for 3-way switching as necessary for recess lighting. Exercise Area—Provisions for standard receptacles as required by code. Switching for recess lights (general lighting). Provide one cable outlet. Provide one receptacle for wall mounted TV. Provide 4—20 amp circuits for fitness equipment. NOTE: The cost of all recess lighting_pendant lighting vanityiQhts under cabinet in cabinet accent lights, ceiling fixtures, exhaust fans etc is covered under an allowance CHICOYNE RESIDENCE SpeciFcations Sheet PLUMBING/GAS PIPING Required System Ups—Relocate fire protection line into new storage area. Reinstall antieeze into the system, only if it is existing. Underground plumbing,—The slab will be cut as necessary for installation of gravity drain lines to be installed for the shower and toilet. The areas will be backfilled with sand and cemented after the necessary inspections. Gas Piping—Supply gas piping for the,following fixtures: one furnace. The gas line supplying the new furnace will be run new from the gas main. Provide make up air for the new furnace. All gas pipe and fittings will be black steel. Bathroom—Provision for and installation of the following fixtures: one toilet, one sinklfaucet, and one shower. All drains will be gravity. Bar Area—Provisions for and installation of the following fixtures: one main sink and one faucet. Drains to be gravity. Laundry Closet—Provision for and installation of the following fixtures in the closet next to the new bathroom: one washing machine and one gas or electric dryer. Provide necessary venting and makeup air for the new dryer. All drains will be gravity. Miscellaneous—All drains to be pvc and all water lines to be Type L copper pipe. Trenches will be saw-cut to allow for the placement of underground drains. All trenches will be backfilled with sand and new concrete will be poured and finished. Note: All gas piping for the generator will be covered under an allowance. Note: All gas piping for the new gas fireplace will be covered under an allowance. All lumbin fixtures including, to&M sinks aucets shower valves shower heads shower doors,shower enclosures, copper pans, tubs, etc. are covered under an allowance CHICOYNE RESIDENCE ALLOWANCES The following allowances are included in this estimate. The allowances exist to cover the purchase of materials only, unless otherwise specified Any amount spent in excess of an allowance will incur extra cost. Any amount less than the allowance will warrant a credit. Upon completion of the project any extra cost or credits will be issued. CABINETRY/COUNTERTOPS-$5,000.00 This allowance covers the cost of all bar area cabinetry, bathroom cabinetry, moldings, and hardware. This allowance covers the cost of all countertops and their associated template and installation costs. PLUMBING FIXTURES-$3,000.00 This allowance covers the cost of all plumbing fixtures including but not limited to: sinks, faucets, toilets, accessories, shower valves, shower heads, whirlpools, copper pans, shower units, shower doors, or shower enclosures, etc. LIGHT FIXTURES-$5,000.00 This allowance covers the cost of all light fixtures. This allowance covers the cost of labor and materials for recess lighting, under cabinet lighting, in-cabinet lighting, and any specialtyfixtures, including timers dimmers, etc. Example: 5"Recess light w/air tight trim, white baffle, and halogen bulb-$150.00 Complete FLOORING410,500.00 This allowance covers the cost of materials& installation of all flooring(hardwood, carpeting, engineered flooring, tile, rubber matting, etc.) WINDOWS/EXTERIOR DOOR UNITS-$4,500.00 This allowance covers the cost of all windows and exterior door units including but not limited to: screens, grills, extension jambs, hardware, etc. CUSTOM MILLWORK-$5,000.00 This allowance covers the cost ofmaterials and labor to build and finish custom millwork including but not limited to: built-ins, book cases, wainscoting, crown moldings, coffered ceilings, closet or storage room shelving, entertainment units, etc. SPRINKLER SYSTEM-$2,000.00 This allowance covers the cost of all materials and labor pertaining to the sprinkler system including but not limited to: relocating, adding, or modifying ofsprinkler heads and the testing and refilling of the system. BACK UP GENERATOR-$7,000.00 This allowance covers the cost of all materials and labor associated with the installation of a back-up generator including but not limited to: cost of the unit, transfer switch, breakers, electrical labor, gas piping, cement pad to support the unit, etc. GAS FIREPLACE-$6,000.00 This allowance covers the cost of all materials and labor associated with the installation of a gas fireplace including but not limited to: cost of the unit, glass enclosure, necessary electrical, gas piping, installation, venting, mantle, hearth, etc. CHICOYNE RESIDENCE MISCELLANEOUS This contract is subject to review upon receipt of the final construction drawings DM Construction reserves the right to adjust the price of the contract after reviewing these. Cost could increase if any changes had an impact on plumbing,gas,HVAC, or electrical, Cost could increase if the new plan required additional structural work or change of framing plans Cost could increase if the new plan added more cabinetry or additional appliances Note: Due to the nature of wood and the drastic temperature and humidity changes in our region,you may notice the movement and shrinking of the flooring and exterior and interior trim. This is typical of the region and is not due to defective installation. Change Orders Any changes from the existing plans or increased scope of work involving extra costs will become an extra charge over and above the contract price. Change order agreements must be signed before any work commences The following schedule will be adhered to, unless circumstances beyond our control arise: Time frame for completion: When work begins to completion: 14-16 weeks* *Time for completion is subject to arrival of special order items or other delays beyond our control. All work to be done Monday-Friday between the hours of 7:00 am—6:00 pm. If deemed necessary to work any other times, the homeowner will be consulted first. MEMBER OF THE BETTER BUSINESS BUREAU HOME IMPROVEMENT CONTRACTOR: 124961 CONSTRUCTION SUPERVISOR LICENSE: CS 066342 *All home improvement contractors and subcontractors shall be registered Any inquiries about a contractor or subcontractor relatingregistration to shall be directed to: Office of Consumer Affairs and Business Regulation Ten Park Plaza, Suite 5170 Boston,MA 02113 Phone: (617) 973-8700 w DM Construction Building with the QUALITY and Character of yesteryear. 44 Addison Ave Ext. Methuen, MA 01844 (978) 6853037 CONTRACTOR ARBITRATAION AGREEMENT The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a contractor however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The Contractor(Darren Martino)and the Homeowners(Bryce&Lori Chicoyne) hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws,chapter 142A. Ho wne s%nature Cont tors Signature Homeowner's Signature :ELDING DEF CO? rs � DM Construction � Building with the QUALITY and Character of yesteryear. 44 Addison Ave Em. Methuen, MA 01844 (978) 685-3037 NOTICE OF CANCELLATION July 29,2015 You may cancel this transaction, without any penalty or obligation, within three business days from the above dates If you cancel, any property traded in,any payments made by you under the agreement, and any negotiable instrument executed by you will be returned within ten business days following receipt by the seller of your cancellation notice, and any security interest arising out of the transaction will be cancelled If you cancel,you must make available to the seller at your residence, in substantially as good condition as when received, any goods delivered to you under this agreement;or you may if you wish, comply with the instructions of the seller regarding the return shipment of the goods at the seller's expense and risk. If you do make the goods available to the seller and the seller does not pick them up within twenty days of the date of your notice of cancellation,you may retain or dispose of the goods without any further obligation. If you fail to make the goods available to the seller, or if you agree to return the goods to the seller and fail to do so,then you remain liable for performance of all obligations under the contract To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written notice to: NAME OF SELLER: DARRENMARTINO ADDRESS: 44ADDISONAVE EXT METHUEN,MA 01844 NOT LATER THANMIDNIGHT OF.• July 31.2015 I HEREBY CANCEL THIS TRANSCA TION Date. Buyer's Signature: I(we each) acknowledge rece' two copies of this form. Buyer: Buyer: ` The Commonwealth of Massachatsetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 021.14-2017 UW www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Elechician&Tlumbers. TO BE FII ED WITH THE PERMITTING AUFRORTPY. AyAicant Information, A Please Print Letdbly Name(Business Organintion/Individual): l�/ t�WIV WLyzuk Address: ADD/,[ONLAm-- arr. City/State/Zip: .X 67 A0tia ,0A 6J y y Phone#: 63? Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part time* 7. ❑New construction 2.'I am a We proprietor or partnership and have no employees working for me in 8. n Remodeling any capacity.[No workers'comp.insurance required.] 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required]t 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. [will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole I LF Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.E]I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of'exemption per MOI.c. 14.�'Other /N/ f 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information tH i Homeowners who submit this affidavit indicating are doing all work end en hire id g they g then 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. If the sub-contractors have employees,they must provide their workers'comp.policy number. I I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site lnfor"holon. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/Statelzip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required underMGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the informradon provided above is true and correct Si atu Date' 1 S� Phon 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.Cityll'own Clerk Q.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C()states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees otherthaa the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retumed to the cityor town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if-you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 021142017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Client#:968806 DARREMAR2 DATE(MWDO/YYYY) ACORD. CERTIFICATE OF LIABILITY INSURANCE 1 9/29/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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: Terri Younes USI Insurance Services LLC-SCL PHONE Ez :855 874-0123 877-775-0110 A1C No AC No: 103 Main Street ADDRESS, terri.younes@usi.biz South Glens Falls, NY 12803 INSURER(S) ACING COVERAGE NAICs 855 874-0123 INSURERA:Nautilus Insurance Company 17370 INSURED INSURER 8: Darren Martino dba INSURER C D M Construction INSIktER D 44 Adison Ave Ext LN Methuen, MA 01844 INSUURRERE: SER 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 CONTRACTOR 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 TYPE OF INSURANCE ADD UB POLICY EFF POLICY EXP L1MfTS LTR INSR WVD POLICY NUMBER MWOD tiI1W0D A X COMMERCULLGENERALLIABILRY NN610631D912112015 09/21/201 e EACH OCCURRENCE $1,000,000 CLAIMS-MADE n OCCUR PREAlISES°a m,Em°snce $100,000 X BIIPD Ded:500 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1 000,000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s2,000,000 PRO- PRODUCTS-COMP/OP AGG $2,000,000 POLICY❑JECT LOC OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea atzid nt _ ANYAUTO BODILY INJURY(Par person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTYDAMAGE $ HIREDAUTOS AUTOS Per accident $ UMBRELLA LIAROCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORILERS COMPENSATION PER OTH- TATUTE Le-- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARINER/EXECUTNEYIN E.LEACHACCIDENT $ OFFICERIMEMBER EXCLUDED? F] N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ Ifyes describe under DESCRIPTION oi,OPERAITONS bb- E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached V more apace is required) CERTIFICATE HOLDER CANCELLATION Bryce Ch icoyne SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ry THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 40 Ridge Way ACCORDANCE WITH THE POLICY PROVISIONS. Andover,MA 01640 AUTHORIZED REPRESENTATIVE AW"a <UAW ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) 1 of 1 The ACORD name and logo are registered marks of ACORD #S163067041M16306571 TXYCX Massachusetts Department of Public Safety 1911 Board of Building Regulations and Standards License: CS-066342 Construction Supervisor I DARREN MARTINO %r 44 ADDISON AVE'EXT - F METHUEN MA 01844 " + �l S Expiration: Commissioner 08/16/2017 ��e�azzz-znnzzuterzlfl a�C�/l�cr�la�+�sef�t Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR egistration: 124961 Type: Expiration:. 9/17/2017 Individual DARREN MARTINO Darren MARTINO 44 ADDISON AVE.EXT. � - ��— METHUEN,MA 01844 Undersecretary