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Building Permit #303-2016 - 45 SHANNON LANE 9/9/2015
seRw/-ep / OORTh q BUILDING PERMIT 3� ,6'�``D�`�°"�� TOWN OF NORTH ANDOVER ° " w APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: SS�cHuse IMPORTANT:Applicant must complete all items on this page =�2, ° u• '.`�3 ..wk pk, taps xa�t x ✓�,��,t r � '" a.�, 5 kH P. *,t war t,xa flCATI{)1 ;4.5 ahe►bn ane, 3�tiC�OVeI 'MA9 p .a+t ` :.. "r=",r, 'r .aS �+„'�w..: ”'° '` tris `• " z.:.m , , c x k k. g- QRflPITY{ 1NN�R °Richard StJsar}1;oWe 4 € dry a kk fi r � l ,. 6161, -x SSP a F4,I` ,�s-,� 1-rjr�t r�7wfi:' �':, .MAI? Nt7 ro7: 'ARGL§523 ZflNWG DISRIC '° Wstortc Distnc �� f }r�s tto `� .�¢ _ ;�aChltle SEI$ Vlllae �IdS �O � TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building n One family ❑ Addition ❑ Two or more family ❑ Industrial X Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Se tic ❑ ll We � loodpfa I Fm1 WetlandsS Watershed Dlstnct C.1.. ewer," Interior Interior renovations including replacing(2)windows, renovating(2)bathrooms. Plumbing&electrical permits needed. To be applied for by subcontractors. Identification Please Type or Print Clearly) OWNER: Name: Michael Flanagan C/O Richard Lowe Phone: 978-655-1794 Address: 45 Shannon Lane, N.Andover, MA GONTRACT7R Name,f �' '" „ pklane ;�6os416t�'� a. # Crotshp# sCbntracting D@rry to sg €ks + 15 Lcnde� Uhft' 6 Landonderryr NC � , m t "-John r., x•t 15 s � h1tfT r+ .byrq #jai a x gS094C7 a iti� HOme ImproU6lneritL(Cet1Se� � '°C'rossrbads Contracting of Derry Exp � x ` t = r ARCHI'1F-CT/ENGINEER Phone: Address:_ Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 81,670 FEE: $ 980.00 Check No.: ',Somi Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the gu ranty fund ignature owe t/n Ower Signature of contractor 09 17 BUILDING PERMIT ��NoEoT e�tio TOWN OF NORTH ANDOVER io- APPLICATION FOR PLAN EXAMINATION w . Permit No#: Date Received �'"�RArE, gSSA US�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: 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 ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: _ Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persor,.�,zontracting with unregistered contractors do not have access to the guaranty fund 5ia�nat�re of Ag n /Own -"`� r r � a 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS 7 Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes "Planning Board Decision: Comments 'Conservation Decision: Comments Wafter& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DERARaTMENT TemDumpster onAsite' ►yes. tion Lo_cated at d1 TAI lWdin#Str'eet Fi:re,Dsepartmeosignature/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 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) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks • Building Permit Application • Certified Surveyed Plot Plan • Workers Comp Affidavit • Photo Copy of H.I.C. And C.S.L. Licenses • Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) 4 Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products 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 Doc:Building Permit Revised 2014 Location No. 2-0 Date • - TOWN OF NORTH ANDOVER LED . ' Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ �,_ w b Other Permit Fee $ TOTAL $ Check# I Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 81 ,670.00 m $ - $ 980.04 Plumbing Fee $ 122.51 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 122.51 Total fees collected $ 1,325.05 45 Shannon Lane 303-2016 on 9/9/15 Renovate Two Bathrooms F tko Town of __ �_E �, . Andover p No. 0 3- Zd/,(w : - ,� oh ver, Mass 2.611T ;0COCH1[HEWIC�( �'�• x,95 RATED �'PP,`�(5 U BOARD OF HEALTH Food/Kitchen PER IT TSW. S44w LD Septic System THIS CERTIFIES THAT ........ 4. �we. .... BUILDING INSPECTOR ......... .....,.. has permission to erect .......................... buildings on .... ... .�. . .....SWA N� � � ...�� Foundation .... . .� .. . . ....MAP.n ..... Rough to be occupied as . ..... .� .... ..�..... .�.� 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 Ins ection, Altera ion and Construction of Buildings in the Town of North Andover. I�ew ��� PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR ko UNLESS CONSTRUCT ST S Rough Service ...... .... .................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. CROSSROADS CONTRACTING OF DERRY, LTD. 15 Londonderry Road, Londonderry, NH 03053 603-434-1611 FAX 603-434-9391 PROPOSAL SUBMITTED TO: Richard and Susan Lowe Phone: 978-655-1794 WORK TO BE PERFORMED AT: 45 Shannon Lane, North Andover, MA DATE: August 17, 2015 EMAIL: rslowe 1 00@g mail.corn SPCIFICATION' ' x THANK YOU FOR ALLOWING CROSSROADS CONTRACTING TO SUBMIT THE FOLLOWING PROPOSAL. WE WILL SUPPLY THE MATERIAL, LABOR AND EQUIPMENT TO PERFORM THE FOLLOWING WORK: INTERIOR REMODELING PROJECT PREPARATION and DEMOLITION Remove and dispose of the following: SECOND FLOOR MAIN BATHROOM 1. Vanity countertop and toilet. 2. Remove and retain two sinks and two lav faucets. MASTER BATHROOM 1. Vanity, countertop, sinks, lav faucets, and toilet. 2. Flooring and wall tile including underlayment. 3. Floor sheathing as needed to relocate plumbing lines. 4. Framing, drywall, doors and windows as needed to complete. MASTER BEDROOM/CLOSET 1. Wall components as needed to relocate the Closet wall, and install new window. 2. Carpet and pad from the Master Bedroom, Closet, and Hallway. WINDOWS Supply and install the following Harvey Building Products vinyl new construction windows, Energy Star rated with Low E Argon glass and full screens: 1. One(1) 35"x 65" double hung window. (Bedroom) 2. One(1)awning window. (Closet) FRAMING 1. Frame 2x4 interior walls as needed to create the new Master Bathroom and Closet layout. 2. Rework the exterior wall framing to accommodate the installation of new windows. 3. Install plywood sheathing where the existing sheathing is reworked as needed to complete. SIDING and EXTERIOR PAINT 1. Remove and reinstall pre primed siding and trim to match the existing House as needed where the new windows are installed. 2. Apply two coats of exterior finish paint to the new and reworked siding and trim. Page 2 Richard and Susan Lowe 45 Shannon Lane North Andover, MA PLUMBING Supply and install the following: SECOND FLOOR MAIN BATHROOM 1. Silicon Gold granite countertop with two(2) Kohler Caxton (K-2210)White undermount sinks. 2. Two(2) Kohler Forte(K-10272) Brushed Nickel lav faucets with sculpted handles. 3. One(1) Kohler Highline(K4199-0)White Comfort Height®two-piece toilet with Wellworth tank(K-4467), seat(K- 4636), and trip lever(K-9379). MASTER BATHROOM 1. One(1) 81"X 21" Kemper Whitman Maple vanity and medicine cabinets per East Coast Lumber Design 7/1/2015. (Allowance= $2,500) 2. Install Silicon Gold granite countertop with two(2) Kohler Caxton White undermount sinks. 3. Two (2) Kohler Forte(K-10272) Brushed Nickel lav faucets with sculpted handles. 4. One(1) Kohler Highline(K-4199-0)White Comfort Height®two-piece toilet with Wellworth tank(K-4467), seat (K- 4636), and trip lever(K-9379). SHOWER 1. Install plumbing drain connections for the new tiled shower. 2. One(1) High Flow Rite-Temp valve with stop(K-2971-KS-NA). 3. One(1) Forte Brushed Nickel shower trim (KT-10276-4-BN) 4. One(1) Mastershower Transfer Valve(K-728-K-NA) 5. One(1) Forte Transfer Valve Trim (KT-10290-4-BN) 6. Three(3) Kohler Watertile Round 27-nozzle Body sprays(K-8013-BN). 7. One(1) Forte Valve Trim (KT-10277-4-BN) 8. One(1) Kohler Rite Temp valve(K-304-K-NA) 9. One (1) Kohler Hydrorail-R Arch Shower Column (K-45211-BN). 10. One(1) Mastershower 60" metal hose(K-9514-BN). 11. One(1) Kohler Awaken G90 3 Function Handshower(K-72414-BN). 12. One(1) Kohler 8" Contemporary Round Showerhead (K-13688-BN). Note: Included in this proposal is a total allowance of$2,500 for the vanity and medicine cabinets. ELECTRICAL Supply and install the following as per National Electrical Code 2011: MASTER BATHROOM 1. Two(2) Customer supplied Vanity Lights. 2. Two(2)4" LED recessed lights. 3. Three(3) single pole switches. 4. One(1) Panasonic WhisperLite Exhaust Fan Light(Model#FV-O8VQL5)with two pole switch. Fan/light will be vented to the exterior. 5. Two (2) GFI receptacles. CLOSET 1. Four(4) 15A tamper-resistant duplex receptacles. 2. One(1) Customer supplied ceiling light with switch. 3. Six(6)4" LED recessed lights with two 3-way dimmer switches. Page 3 Richard and Susan Lowe 45 Shannon Lane North Andover,MA DRYWALL 1. '/z"drywall to the new walls. Moisture resistant drywall in the Bathroom. 2. Mud, tape and sand to paint ready condition. 3. Ceilings to have a smooth finish. 4. Patch and repair the reworked drywall on the walls and ceilings as needed to create a smooth finish, and sand to paint ready condition. INTERIOR TRIM and DOORS 1. 2 V pre-primed colonial casing to match the existing to the new window and doors. 2. 5 '/" pre-primed speed base to match the existing in the new and reworked areas. 3. Remove and save three (3) interior doors. (Master Bathroom Closet, Master Bathroom, and Master Bedroom Closet). 4. Reinstall the Master Bedroom Closet door in new Closet wall. 5. Supply and install one(1) interior pine door with frosted glass. (Master Bathroom) 6. Supply and install one(1) interior six panel pine pocket door. (Master Bathroom) TILE 1. Install cement backer board and Exquisite EQ11 Chantilly 12x12 tile on the Master Bathroom floor. 2. Install cement backer board and Exquisite EQ11 Chantilly 2x4 mosaic tile on the Master Bathroom shower floor. 3. Install cement backer and Marble Falls MA43 10x14 tile to the shower walls up to the ceiling including two recessed niches, and bench seat. 4. Install two(2)Tiger Eye TE22 Bali 1" random tile, vertical 12"wide accent strips. CARPET 1. Supply and install carpet and pad in the Masteredroom Closet. ($45 per sq. yd. labor and material allowance). C�O � $ f4A I INTERIOR PAINTING 1. One coat of primer to all new and reworked drywall. 2. Two coats of finish paint to all drywall in the Master Bedroom, Master Bathroom, Closet, and Hallway. 3. Two coats of finish paint to all new doors and trim in the Master Bedroom, Master Bathroom, Closet, and Hallway. MISCELLANEOUS 1. Any changes needed due to building code issues that are not included in the scope of work outlined in this proposal, will be billed accordingly. 2. We will clean up and remove our construction debris, and leave the site vacuum clean. 3. Permits will be obtained by Crossroads Contracting and billed at face value to the customer. 4. $500 Partner Agreement retainer fee has been applied to the contract and is reflected in final price below. EIGHTY ONE THOUSAND SIX HUNDRED AND SEVENTY DOLLARS ($81,670.00) This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A), but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of a"Massachusetts Consumer Guide to Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757. „ Page 4 Richard and Susan Lowe 45 Shannon Lane North Andover,MA PERMIT NOTICE: 1. The following permits will be required to complete the agreed scope of work: a. Building Permit, Plumbing Permit, Electrical Permit 2. Permits will be obtained by Crossroads Contracting and the face value will be billed to the customer. 3. It is the obligation of the Contractor to obtain such permits as the Owner's Agent. 4. Owner's who secure their own construction-related permits or deal with unregistered Contractors shall be excluded from access to the Guarantee Fund provisions of MGL Chapter 142A. Total Contract Price and Payment Schedule: The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of: $81,670.00 Payments will be made according to the following schedule: $8,167.00 upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $16,334.00 upon Start of PROJECT $16,334.00 upon Start of DRYWALL $16,334.00 upon Start of TILE $16,334.00 upon Start of PAINTING $8,167.00 upon SUBSTANTIAL COMPLETION (Law forbids demanding full payment until contract is completed to both party's satisfaction.) The following material/equipment must be special ordered before the contracted work begins in order to meet the completion schedule. Not applicable. (Law forbids demanding full payment until contract is completed to both party's satisfaction.) The following material/equipment must be special ordered before the contracted work begins in order to meet the completion schedule. Not applicable. NOTE: Including all finance charges law requires that any deposit or down-payment required by the Contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Proposed Start and Completion Schedule: The following schedule will be adhered to unless circumstances beyond the contractor's control arise. Contractor will begin contracted work in: October. 2015 Contracted work will be substantially complete(At least 95%) in: November. 2015 EXPRESS WARRANTY—Is an express warranty being provided by the Contractor? Yes(all terms of the warranty must be attached to the contract.) Contractor warrants that Work will be of good quality, free from defects and in compliance with the requirements of the Contract Documents, as well as applicable local, state and federal laws, ordinances, rules and regulations. At the Owner's request Contractor shall promptly repair or replace defective work for a period of one year after the date of Work is substantially complete. All other statutory or common law warranties are specially disclaimed. Subcontractors—The Contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement. Page 5 Richard and Susan Lowe 45 Shannon Lane North Andover, MA Contract Acceptance—Upon signing, this document becomes a binding contract under law. Unless otherwise noted with this document, the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the Contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement Contractors and Subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at One Ashburton Place, Room 1301, Boston, MA 02108 or by calling 617-727-3200 or 1-800-223-0933. • Does the Contractor have insurance? Check to see that your Contractor is properly insured. • Know your rights and responsibilities. Read the Important information that follows on this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the Contractor's normal place of business, provided you notify the Contractor in writing at his/her main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. (Two identical copies of the contract must be completed and signed. ne copy should go to the homeowner. The other should be kept by the Contractor.) Homeowner' S' ture Co actor's Si e ,0�i711,r- old Date Date JB/INT/P88 Contractor Arbitration 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 and the Homeowner 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 s, c pter 142A. Homeowner' ature Co ctor's ig NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the Contractor. The Homeowner may initiate dispute resolution even where this section if not separately signed by the parties Page 6 Richard and Susan Lowe 45 Shannon Lane North Andover,MA Homeowner's Rights A Homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A) and other consumer protection laws(i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, Homeowners may be excluded from certain rights if the Contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The Contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the Contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the Contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the Homeowner and Contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a Homeowner's basic consumer rights. If you have questions about you consumer/Homeowner rights, contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the Owner and the other kept by the Contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day recision period has expired. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of"A Consumer Guide to the home Improvement Contractor Law" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170 Boston, MA 02116 (617)973-8787 or 1-888-283-3757 If you want to verify the registration of a Contractor or if you have questions or need additional information specifically about the Contractor Registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Bureau of Building Regulations and Standards One Ashburton Place, Room 1301 Boston, MA 02108 (617)-727-3200 or 1-800-223-0933 For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-6524800 508-755-2548 413-734-3114 Subcontractor List Border Electric Contractor, LLC 91 Baboosic Lake Rd Merrimack, NH 03054 603-424-3959 Shanley Plumbing&Heating 71 Pleasant St Danville, NH 03819 603-548-7860 Seamless Drywall PO Box 7044 Nashua, NH 603-210-2451 R&S Carpet 325 Derry St Hudson, NH 03051 603-889-3867 European Quarry Imports 326 S. Broadway, Unit R Salem, NH 03079 603-894-6888 Well8' �. X, I I . ♦ r- e ' I PR t E k - _� { F JJJ « t � r , t w y i k 1 � � 1 , f I � q _ f I , y4 F„ ................... .......................... wwr.......... . . ............ ...... ............. .................... .............. ........... ..................................... ..................................... ................................... ...... ............ ........... ........... ........... . ...... ..... .... .......... .... .............. ............"- - ............. ........... ....... ..... .. ............ ....... .. . 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TO BE FILED WITH THE PERMITTING AUTHORITY. Ammlicant Information Please Print Leeibly Name(Business/Organization/Individual): Crossroads Contracting of Derry Address: 15 Lononderry Rd, Unit#6 City/State/Zip: Londonderry,NH 03053 Phone#: 603-434-1611 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 sole proprietor or partnership and have no employees working for me in 8. ®Remodeling any capacity.[No workers'comp.insurance required.] 3.F1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10❑Building addition 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 with no employees. 12.❑Plumbing repairs or additions 5.©I am a general contractor and 1 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.F1We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.F1 Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] i *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. i t Homeowners who submit 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,they must provide their workers'comp.policy number. I I am an employer tlrat is providing ivorkers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Peerless Indemnity Policy#or Self-ins.Lic.#: WC8875773 Expiration Date: 11/01/15 Job Site Address: 45 Shannon Lane City/State/Zip:N.Andover, MA 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. I I do hereby certify u er thep ins and penalties ofpe►jury that 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 b.Other Contact Person: Phone#: CROSS-2 OP ID:SG w CERTIFICATE OF LIABILITY INSURANCE DA11 18/2014 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 CONTACT Planright Insurance-Salem NAME: Jason M Mlocek 224 Main Street Suite 3C PHONE 603-890-6439 IIFM.No):603-890-6521 Salem,NH 03079 E-MAIL Jason M Mlocek ADDRESS:jason@,santoinsurance.com INSURER(S)AFFORDING COVERAGE I NAIC# INSURER A:Peerless Indemnity Ins Co 18333 INSURED Crossroads Contracting of INSURER a:Excelsior 11045 Derry Ltd INSURER C:Netherlands 24171 15 Londonderry Road Unit 6 Londonderry,NH 03053 INSURER D: 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. USR IL SR TYPE OF INSURANCE POLICY EFF POLICY NUMBER MMID MMID Y P LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,.000,00 CLAIMS-MADE 0 OCCUR BKS55672507 11/01/2014 11/01/2015 DAMAGE TO ENTEEF- PREMISES R occurrence $ 300,00 MED EXP one ) $ 15,00 PERSONAL BADV INJURY S 1,000,00 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,00 POLICY JET LOC PRODUCTS-COMPIOOPAGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY Ea aBINED SINGLE LIMIT S 1,000,00 B ANY AUTO BA8814314 11/01/2014 11/01/2015 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY t) AUTOS AUTOS (Per Bodden $ NON-OHIRED AUTOS X AUTOS (Per Per aa�d DAMAGE $ $ UMBRELLA UAB IOCCUR EACH OCCURRENCE $ EXCESS LIAR ICLAIMS-MADE AGGREGATE $ DED I I RETENTIONS $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY x I STATUTE I ERH C ANY PROPRIErOR/PARTNER/EXECUTIVE YIN C8875773 11/01/2014 11/01/2015 EL EACH ACCIDENT S 500,00 OFFICER/MEMBER EXCLUDED? N I A (Mandatory In NH) 3A: MA NH E.L.DISEASE-EA EMPLOYEE S 500,00 K yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS i LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached H more space Is required) Jan Jacome as elected to be excluded from work comp coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For Information Only ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs And Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvem.� tj`Gontractor Registration Registration: 160986 Type: Supplement Card CROSSROADS CONTRACTING O G . _. . - j Expiration: 9/17/2016 JOHNNY HAWKES _ 15 LONDONDERRY RD. #6 W v LONDONDERRY, NH 03053 , Update Address and return card.Mark reason for change. SCA 1 i? 20M-05/11 Address [:] Renewal [:] Employment Lost Card � �j /,� C C�OiJ3?//97.Or/2cvealCl ollb4GIY6jackaeM ce of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: <L '' Office of Consumer Affairs and Business Regulation egistratinn _ Type: 10 Park Plaza-Suite 5170 ' Expiratio - ` 6-± Supplement Card Boston,MA 02116 CROSSROADS CONTIU.Cdti�4O Or-`QERRY LTD JOHNNY HAWKESf_= 1 15 LONDONDERRY LONDONDERRY, NH 03053 Undersecretary of v wit t signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards. Construction Sunervisor License: CS-090487 I w F JOHNNY p HAWO$ 37 TSMNNETO]lb IMP f Derry NH 03038 r i z j i i �.•�.� "'A"a Expiration Commissioner 01121/2017