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Building Permit #526-2011 - 481 REA STREET 1/5/2011
BUILDING -PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:_ J��—,2(f // Date Receivers IL lM V��tyCD �6T MO Identification ntification PIease Type or Print Clearly) OWNER: Name:_ /,'cf . ,'- , / , � /'� �/� Phone: ARCHITECT/ENGINEER Phone: r 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 Cosi: FEE: $— Check No.: Receipt No.:-3Jq/ NOTE: Persons contracting with unr�egister�ed contractors do not have access to e ?unraaftfv A -4r f� Plans Submitted Pians Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/MassageBodyArt Swimming Pools Well ' �— Tobacco Sales Food Packaging/Sales P�ivate (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING &: DEVELOPMENT COMMENTS CONSERVATION Reviewed 1� (Do r\l IR ENT i S kHEALTH COMMENTS DATE REJECTED DATE APPROVED - Reviewed on dv Zoning Board of Appeals. Variance, Petition No: Zoning Decisionheceipt submitted yes Plannirir,. award Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature sate • Driveway Permit DPW Town Engineer: Signature:_ 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 Doc -Building Permit Revised 2010 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or. -Decks a"" Building Permit Application r3' Certified Surveyed Plot Plan d Workers Comp Affidavit d Photo Copy of H.I.C. And C.S.L. Licenses a' 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 ❑ Ceiiified 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 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 2008 Location I-Ifl 4 ` e--4 '57r No. JW — 2p// Check # /d2 � 23841 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ �3 Foundation Permit Fee $ Other Permit Fee $ TOTAL Buildi ?1spector ri W RS � w w o o w° N j�a .a J) 0 w a ai or. r. CD '� 0 w �'' �o a4 w 0 H a w '.a W °C a: u Cl) w" o C7 'Cno rz w" w w w ° Z co Q cn ui am CD 0 E O O O v Z co O y CD CM 0 C I C C O— y Q O ' m m O O O CL_~ y=... Z O� �3 CD C O CD L CD CL C Cl c Cc ev tZ O? COD Z G3 V y cccc L: � C CO2 0 c� 0 CD 0 0 c O N O C3 c.3 CL c ev cc d c := o � o m EQ Jv m CF N u cm �i N W m C'. m 0 a. O N H N CD � t c�mq o N C Uo cc ` E (04 v `o 0 CL3 m (� & cm CN O O m O .�. cm C_ CD -3o N N •O"N a4 �--� m m COD !m O .2 �_ �N A A C O W E cS = w .N V a 0�:� C y O 4D 210 32 = W.5 F— .0 `O O CL r=.. Co O CD 0 E O O O v Z co O y CD CM 0 C I C C O— y Q O ' m m O O O CL_~ y=... Z O� �3 CD C O CD L CD CL C Cl c Cc ev tZ O? COD Z G3 V y cccc L: � C CO2 0 CERTIFIED PLOT PLAN Scott L. Giles R.P.L.S. LOCATED /N Frank. S. Giles R.P.L.S. NORTH ANDOVER, MASS. 50 Deer Meadow Road SCALE: ? "-40' DATE: 12/13/40 North Andover, Mass. REA I CERTIFY THAT THE OFFSETS SHOWN COMPLY WITH THE ZONING BYLAWS OF NORTH ANDOVER WHEN BUILT STREET OFFSETS SHOWN ARE FOR THE USE , OF THE BUILDING INSPECTOR ONLY r �t AND SUCH USE IS FOR THE = DETERMINATION OF ZONING CONFORMITY OR NON -CONFORMITY - w WHEN CONSTRUCTED. I Z LLZS-E684 09) Olizo V5 4 'uOI90G oloz Z1 'C)SCI Siva HNLu'euPuirn HI?S# MON Pipul 19PE Cg .1 = �,'t7/1 ],VDS •PX U0ISarn f ajOo ;usLudOjaAa(n 1191 PGN :03SIA3�J EIDIAXHS NIIJV'IQ AVAk0lI I-jo,} umPJd IIauU00 iPiGH G�1l4ONIMVK LLZS-£684£09) HILI WugPuiAk 'P -d uolsaA� t HDIXEIS NI.LJV'dQ AVMO'IZAI olizo vw 'UOI OG H JS# mOZ�4 PIpuI }99E] G9 djoo Juawdojanacj I9l paN -JO} umeaa "ZI •09Q 31da ii 31V OS :a3SIA32J 0 7177 J 4 LLZS-£68-(£09) O11M l`w 'uplcjoG �Oa 31VG HILI uz'UuPuirn HIJS# mo i P l pu l 19PEl G9 i = 0711 3�v os 'PX uoIsaAkt •djoo JuaLudola/\a(n 1191. paw :43sIA3�l HDWIRS DNIIJV-"dQ AVAkOlIHN :JOJ unread 9NIMVdO 0 0 N OL ♦' o O S-,� x LLZ9-�684 09) 011ZO 'S7`14 'UO}SOG HN uz'Cupuim HO)S# MON P i pub 159EI Cq p� uo�sarn •d�o� �uau�dol a�a� l ! �1 PSN HDIAUHs DNIIL4V da AVAW11ax :aoj umejQ 3 u Np 13 0 u 00 0 N Q Qzw LL w a aOQLL U QO�Q F - Z w w Il �i Q 0 pC w X U, u Z op 6 i �j Q = W Z QoWQQ ON'cQ - � N x e + � OIOZ'Zi 'CIaCIVK I - u :G IISH V S a I I m� w i 9 N 'n I i Q a 0 0 s .n _ N LL N u QX) -� n� til Q L O N N .O 7 O � o � � 0 U 0 ° oo LL C: � U x tJ X d) c Q c0 @ x N [Q n U Srl � c� - N I I �— X ago _ 4e pa 4 •0op a4 d N �n y O O Ulw X x n n N a C LL e + � OIOZ'Zi 'CIaCIVK I - u :G IISH V S RED TAIL DEVELOPMENT CORP. BUILDING AND REMODELING 65 E. INDIA ROW, #36H BOSTON, MA 02110 978-265-7641 CONTRACT Massachusetts Registration # 167450 Massachusetts Construction Supervisors # CS 5693 Federal ID # 000838586 Contractor's Name: David A. Kindred Date: 12/10/10 Notice: All home improvement contractors and subcontractors must be registered with the Commonwealth of Massachusetts. Inquiries regarding registration status should be made to the Office of Consumer Affairs and Business Regulation, Ten Park Plaza, Suite 5170, Boston, MA 02116. Phone: (617) 973-8700 Read this agreement and make sure you understand it before signing it. This agreement has legal force and effect and binds those who sign it. This Agreement is made on the day of between Red Tail Development Corp hereinafter called "Contractor" and Mike and Heidi Connelly, 481 Rea St. No. Andover, MA 01845, hereinafter called "Owner". Work to be Performed The Contractor agrees to perform, in a good and workmanlike manner, all work detailed in the Specifications and plans attached hereto, including all materials and labor unless otherwise stated. Any changes from Specifications or plans must be in writing. Page 1 of 5 Materials to be Used The materials to be used are described in the Specification sheet attached hereto as Addendum A. Contractor agrees to do all work described for the total price of $35,,500 (thirty-five thousand dollars) Payment Payment will be made as follows: $11,500 prior to start of construction $11,500 when roof shingles are installed $12,500 upon completion to the satisfaction of the Owner Commencement and Completion of Work Contractor will not begin work or order materials before the third day following the signing of this Agreement unless specified in writing. Contractor will begin work on or about January 15, 2011 Barring delay caused by circumstances beyond the Contractor's control, the work will be completed by March 31, 2011 The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that delays attributable to the presence of hidden conditions or requiring additional work discovered during the course of construction, or delays arising out of the receipt of equipment and/or materials, that are not avoidable by the contractor, shall not be considered violations of this Agreement. k Any materials to be supplied by the Owner shall be delivered to the jobsite not less than forty-eight (48) hours before the date upon which they will be required by the Contractor in order to continue the work described. Failure of the Owner to supply such materials in a timely manner shall not be considered the responsibility of the Contractor. Page 2 of 5 No Acceleration of Payments but Escrowing Allowed No contract shall contain an acceleration clause under which any part or all of the balance not yet due may be declared due and payable because the Contractor deems himself to be insecure. However, where the Contractor deems himself to be insecure he may require, as a prerequisite to continuing said work, that the balance of funds due under the contract, which are in possession of the Owner, shall be placed in a joint escrow account requiring the signatures of the Contractor and the Owner for withdrawal. Insurance Contractor will be responsible to the Owner for any third party or property damage or bodily injury caused by himself, his employees, or his subcontractors in the performance of, or as a result of, the work under this Agreement. Contractor agrees to carry insurance to cover such damage or injury. Subcontracting Contractor agrees that, notwithstanding any agreement for materials and/or labor between the Contractor and a third party, Contractor is responsible to the Owner for completion of all work in a timely and workmanlike manner. Construction -Related Permits The following construction -related permits will be necessary in order to complete the work included in this Agreement: Dumpster, Building, Electrical, Plumbing and Gas. The Contractor, under the provisions of CH 142A of the general laws, is required to apply for and obtain all construction -related permits. The Contractor shall not be deemed responsible for delays in the work described in this Agreement caused by regulatory, permit -granting or inspection agencies, authorities or individuals. NOTICE: If the Owner obtains his own construction -related permits for the work described under this Agreement, the Owner is hereby advised that in the event of a dispute, judgement, or nonpayment of the Contractor, the Owner will not be Page 3 of 5 entitled to make a claim to or collect from the guaranty fund established by CH 142A of the general laws of Massachusetts. Modification This Agreement cannot be changed except by a written statement signed by both Contractor and Owner. However, Cancellation by the Owner is allowed in accordance with the Notice of Cancellation outlined under Rights to Cancellation below. Warranties The Contractor warrants against structural, electrical, plumbing and gas related defects for one year from completion. Other minor and cosmetic defects are warranteed for 60 days. Contractor agrees to correct any defects promptly. The Owner agrees to notify the Contractor of a defect as soon as the defect is discovered. All notices of defect shall be in writing and shall state with specificity the defect discovered. Contractor agrees to provide Owners with all manufacturers' warranties, guarantees, instructional booklets and other informative literature of the products and materials used in the home. No employee, agent or subcontractor is authorized to make any representation or warranty on behalf of the Contractor other than those contained in this Agreement. This warranty is nontransferable. Completeness of Agreement for Execution The Owner should not sign this Agreement unless and until all blank sections have been filled in or marked as void, delete or as not applicable, and until all addenda and related or referenced documents that are incorporated herein are attached hereto. Copy of Agreement to be Given to Owner This Agreement is governed by the Laws of Massachusetts. It must be executed in duplicate, and an original signed copy given to the Owner at the time Page 4 of 5 of execution. No work under this Agreement shall begin prior to the signing of this Agreement and transmittal to the owner of copy thereof. Addenda Addendum A: Specifications RIGHTS TO CANCELLATION The Owner may cancel this Agreement provided the Owner notifies the Contractor in writing not later than midnight of the third business day after the signing of this Agreement. NOTICE TO HOMEOWNER DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. THIS CONTRACT IS TO EXECUTED IN DUPLICATE WITH ONE COPY RETAINED BY OWNER AND ONE COPY RETAINED BY CONTRACTOR. ontractor AAI-AX� k4�1 Owner Owner Page 5 of 5 Date Date /a--44910-6/6 Date RED TAIL DEVELOPMENT CORP. BUILDING AND REMODELING 65 E. INDIA ROW, #36H BOSTON, MA 02110 978-265-7641 October 2, 2010 To: Mike and Heidi Connolly 481 Rea Street North Andover, MA 01845 SPECIFICATIONS For: Addition - construction of a new 10'-6" X 13' room as described below, and as per attached plans. This proposal includes all materials and labor unless noted otherwise. Plans: Architectural drawings for permitting and construction will be attached to contract. Footings: Concrete 2'X 2' base footings and 12" sonotubes Frame: 6" X 6" support posts per plans 2" X 8" floor joists 3/4" Advantec subflooring 2" X 6" exterior walls 2" X 8" ceiling joists 2" X 8" rafters 1/2" CDX plywood wall and roof sheathing Roof: IKO shingles to match existing house as closely as possible Ice and water shield at drip edge Page 1 of 3 Siding: Pre -primed finger -jointed cedar clapboards Tyvek house wrap or equivalent Windows: 4 Silverline vinyl double hung windows ($2000 total allowance) Vicor Bituthane sealant around all windows Electrical: 7 outlets 4 recessed lights 2 cable outlets Heat: Forced hot water heat on separate zone Insulation: Floor - fiberglass batts R-30 Walls - fiberglass batts R-19 Ceiling - fiberglass batts R-30 Poly moisture barrier Fireplace: Heatilator Novus NDV 36301 gas fireplace with 8" tile surround with $8/square foot the allowance Walls and Ceilings: Smooth drywall walls and ceilings Interior Trim: To match windows and door trim in existing adjacent room Paint: Exterior: Siding and trim to match existing house as closely as possible, primer plus 2 coats paint (Sherwin Williams) Interior: Trim: to match existing house as closely as possible, primer plus 2 coats paint (Benjamin Moore) Walls: 2 coats flat wall paint (Benjamin Moore) Flooring: Pre -finished hardwood - $5.00/ square foot materials allowance or Tile - $8.00/square foot materials and labor allowance Page 2 of 3 INCLUDES: Removal of all construction debris EXCLUDES: Certified plot plan Permit costs Ledge or other unknown obstruction Page 3 of 3 RED TAIL DEVELOPMENT CORP. BUILDING AND REMODELING 65 E. INDIA ROW, #36H BOSTON, MA 02110 978-265-7641 CONTRACT Massachusetts Registration # 167450 Massachusetts Construction Supervisors # CS 5693 Federal ID # 000838586 Contractor's Name: David A. Kindred Date: 11 /05/10 Notice: All home improvement contractors and subcontractors must be registered with the Commonwealth of Massachusetts. Inquiries regarding registration status should be made to the Office of Consumer Affairs and Business Regulation, Ten Park Plaza, Suite 5170, Boston, MA 02116. Phone: (617) 973-8700 Read this agreement and make sure you understand it before signing it. This agreement has legal force and effect and binds those who sign it. This Agreement is made on the day of between Red Tail Development Corp., hereinafter called "Contractor" and Mike and Heidi Connelly, 481 Rea St. No. Andover, MA 01845, hereinafter called "Owner". Work to be Performed The Contractor agrees to perform, in a good and workmanlike manner, all work detailed in the Specifications and plans attached hereto, including all materials and labor unless otherwise stated. Any changes from Specifications or plans must be in writing. Page 1 of 5 Materials to be Used The materials to be used are described in the Specification sheet attached hereto as Addendum A. Price Contractor agrees to do all work described for the total price of $42,000 (Forty-two thousand dollars) Payment Payment will be made as follows: $14,000 prior to start of construction $14,000 when roof shingles are installed $14,000 upon completion to the satisfaction of the Owner Commencement and Completion of Work Contractor will not begin work or order materials before the third day following the signing of this Agreement unless specified in writing. Contractor will begin work on or about January 15, 2011. Barring delay caused by circumstances beyond the Contractor's control, the work will be completed by February 15, 2011. The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that delays attributable to the presence of hidden conditions or requiring additional work discovered during the course of construction, or delays arising out of the receipt of equipment and/or materials, that are not avoidable by the contractor, shall not be considered violations of this Agreement. Any materials to be supplied by the Owner shall be delivered to the jobsite not less than forty-eight (48) hours before the date upon which they will be required by the Contractor in order to continue the work described. Failure of the Owner to supply such materials in a timely manner shall not be considered the responsibility of the Contractor. Page 2of5 No Acceleration of Payments but Escrowing Allowed No contract shall contain an acceleration clause under which any part or all of the balance not yet due may be declared due and payable because the Contractor deems himself to be insecure. However, where the Contractor deems himself to be insecure he may require, as a prerequisite to continuing said work, that the balance of funds due under the contract, which are in possession of the Owner, shall be placed in a joint escrow account requiring the signatures of the Contractor and the Owner for withdrawal. Insurance Contractor will be responsible to the Owner for any third party or property damage or bodily injury caused by himself, his employees, or his subcontractors in the performance of, or as a result of, the work under this Agreement. Contractor agrees to carry insurance to cover such damage or injury. Subcontracting Contractor agrees that, notwithstanding any agreement for materials and/or labor between the Contractor and a third party, Contractor is responsible to the Owner for completion of all work in a timely and workmanlike manner. Construction -Related Permits The following construction -related permits will be necessary in order to complete the work included in this Agreement: Building, Electrical, Plumbing and Gas. The Contractor, under the provisions of CH 142A of the general laws, is required to apply for and obtain all construction -related permits. The Contractor shall not be deemed responsible for delays in the work described in this Agreement caused by regulatory, permit -granting or inspection agencies, authorities or individuals. NOTICE: If the Owner obtains his own construction -related permits for the work described under this Agreement, the Owner is hereby advised that in the event of a dispute, judgement, or nonpayment of the Contractor, the Owner will not be Page 3of5 entitled to make a claim to or collect from the guaranty fund established by CH 142A of the general laws of Massachusetts. Modification This Agreement cannot be changed except by a written statement signed by both Contractor and Owner. However, Cancellation by the Owner is allowed in accordance with the Notice of Cancellation outlined under Rights to Cancellation below. Warranties The Contractor warrants against structural, electrical, plumbing and gas related defects for one year from completion. Other minor and cosmetic defects are warranteed for 60 days. Contractor agrees to correct any defects promptly. The Owner agrees to notify the Contractor of a defect as soon as the defect is discovered. All notices of defect shall be in writing' and shall state with specificity the defect discovered. Contractor agrees to provide Owners with all manufacturers' warranties, guarantees, instructional booklets and other informative literature of the products and materials used in the home. No employee, agent or subcontractor is authorized to make any representation or warranty on behalf of the Contractor other than those contained in this Agreement. This warranty is nontransferable. Completeness of Agreement for Execution The Owner should not sign this Agreement unless and until all blank sections have been filled in or marked as void, delete or as not applicable, and until all addenda and related or referenced documents that are incorporated herein are attached hereto. Copy of Agreement to be Given to Owner This Agreement is governed by the Laws of Massachusetts. It must be executed in duplicate, and an original signed copy given to the Owner at the time Page 4 of 5 of execution. No work under this Agreement shall begin prior to the signing of this Agreement and transmittal to the owner of copy thereof. Addenda Addendum A: Specifications RIGHTS TO CANCELLATION The Owner may cancel this Agreement provided the Owner notifies the Contractor in writing not later than midnight of the third business day after the signing of this Agreement. NOTICE TO HOMEOWNER DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. THIS CONTRACT IS TO EXECUTED IN DUPLICATE WITH ONE COPY RETAINED BY OWNER AND ONE COPY RETAINED BY CONTRACTOR. tractor n Owner Owner Page 5 of 5 I D to Date /,;"A, 4 0 Date RED TAIL DEVELOPMENT CORP. BUILDING AND REMODELING 65 E. INDIA ROW, #36H BOSTON, MA 02110 978-265-7641 November 6, 2011 To: Mike and Heidi Connolly 481 Rea Street North Andover, MA 01845 SPECIFICATIONS For: Kitchen and Tile as per attached contract Cabinets: Disconnect and remove sink and appliances Remove existing cabinets Install new Cabico Espresso cabinets ($13,000.00 allowance) Allowance will duplicate existing layout in raised panel cherry or other style and color - see Cathy Stathopoulis at B&G Cabinets by appointment. (978-465-6455 Ext. 227) Countertops: Granite countertops installed ($60.00/square foot allowance) Tile backsplash installed ($8.00/square foot allowance) Tile floor: Remove tile and prep floor Install new the floor in kitchen and adjacent areas @ $8.00/square foot allowance Plumbing: Install ice maker hook-up to new refrigerator Install new sink ($300 allowance) and faucet ($200 allowance) Electrical: Connect new dishwasher, cooktop and ovens to existing wiring. Cost of upgraded wiring required for new appliances, if any, to be determined. Page 1 of 2 Appliances: Install new dishwasher, cooktop and ovens. Venting of appliances is not included. (no allowance for appliances is included) Paint: Paint walls in areas that are tiled, 2 coats flat wall paint (Benjamin Moore) INCLUDES: Removal of all construction debris EXCLUDES: Permit costs Smooth ceiling plaster and paint (to be done for contractor's cost of time and materials) Page 2 of 2 j)cpsjj--tmvnt of Public ItBoard of Btlildin' Re! -'l "i" WSupervisor License v- Constructio License: CS 5693 Restricted to: 00 41 DAVID A KINDRED 660 WASHINGTON ST #25B e-"4'0,4 BOSTON, MA 02111 Expiration: 1!13/2012 Trt: 14627 9�Tlw eowwwwt4eald Office of Consumer Affairs andVUSness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 167450 Type: Corporation Y Expiration: 9/23/2012 Tr# 203692 RED TAIL DEVELOPMENT CORP DAVID KINDRED 65 EAST INDIA ROW # 36H BOSTON, MA 02110 Update Address and return card. Mark reason for change. 1— Address F] Renewal Fj Employment 1 Lost Card DPS-CA1 0 50M-04iO4-(3101216 Office tfP&ifi1fffftWk,36 hAlkWf O —' HOME IMPROVEMENT CONTRACTOR =- Registration: 167450 Type: Expiration:9123/2012 Corporation F= r� IL DEVELORMENT:C,ORP :. DAVID KINDRED : F 65 EAST INDIA ROW # 36H . BOSTON, MA 02110' Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid withou 1gnatur_ _ ''40RLr i--� CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYM 12/21/2010 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 Astatement on this certificate does not confer rights to the certificate holder in lieu of such endomemengs). PRODUCER M P ROBERTS INS AGCY INC 1060 Osgood Street North Andover, MA 01845 CONTACT NAME: A/C No, ,EA: 978 683-8073 (AIC No):(978)683-3147 ADDRESS:sandi@mprobertsinsurance.com INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: ESSEX INSURANCE CO INSURED POWDERHILL DEVELOPMENT CORP A/0 RED TAIL DEVELOPMENT A/0 GARY KELLOWAY P.O. BOX 131 BOXFORD , MA 01921 INSURER B: ASSOCIATED EMPLOYERS INS CO INSURER C: 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. INSR TYPE OF INSURANCE AFULIUY INS POLICY NUMBER (MM/DD� LAP (MMIDD/YYY1) LIMITS GENERAL LIABILITY EACHOCCURRENCE $$110001000 PREMISES (Ea occurrence) $ $50,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE r x r OCCUR MED EXP (Anyone person) 0 A PERSONAL &ADV INJURY $ L0001000 Q00 3DD9840 07/22/10 07/22/11 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 0 POLICY PRC LOC $ AUTOMOBILE LIABILITY Ea accident $ BODILY INJURY (Per person) $ ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ F[ EXCESS UAB CLAIMS MADE AGGREGATE $ DED I RETENTION $ $ B WORKERS COMPENSATIONWC AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVEWCC5008521012010 OFFICER/MEMBER EXCLUDED? ❑ (Mandatory In NH) If yes, describe under N/A $/01/10 0$/01/11 STATU- OTH TORY LIMITS ER E.L. EACH ACCIDENT $ $500,000 E.L. DISEASE - EA EMPLOYEE $ $500,000 E.L. DISEASE- POLICY LIMIT $ $500,000 DESCRIPTION OF OPERATIONS below ON OF OPERATIONS /LOCATIONS /VEHICLES (AttachACORD 101, Additional Remarks Schedule, if more space is required) CATE HOLDER TOWN OF ANDOVER BARTLET STREET ANDOVER, MA 01810 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD25 (2010/05) The ACORD name and logo are registered marks of ACORD www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please PrinfLeizibly Name (Business/Organization/Individual): Address: City/State/Zip: ti, /J//Q Phone #: Are you an employer? Check the appropriate box: The Commonwealth of Massachusetts c w Department of Industrial Accidents 1 Office of Investigations i iri{�'e• i °1 !u l it llll 2 600 Washington Street ti Iq Boston. MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please PrinfLeizibly Name (Business/Organization/Individual): Address: City/State/Zip: ti, /J//Q Phone #: Are you an employer? Check the appropriate box: 1. L'� 1 am a employer with Q 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12. EJ Roof repairs 13.❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors a»d their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. #:. Expiration Date: Job Site Address: Yfl /ef4f S 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 fonn 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. I do hereby certify under the pains andpenalties of pefjury that the information provided above is true and correct.' Sifznature: Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 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(7) 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-contractor(s) name(s), address(es) and phone nurnber(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to cant' 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 confinnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pen -nit 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 pennit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license 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 pen -nits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pen -nit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFB Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/di-a ENERGY CONSERVATION APPLICATION FORM FOR LOW-RISE RESIDENTIAL NEW CONSTRUCTION and ADDITIONS 780 CMR Appendix J Applicant Name:�o � / ��� 411 Site Address: Applicant Address: , City/Town:�„f��� Applicant Phone: Use Group: _ Date of Application: Applicant Signature: Compliance Path (check one): ❑ Prescriptive Package (Limited to 1- or 2 -family wood frame buildings heated with fossil fuels only) Package (A through KK from Table J5.2,1b): Heating Degree Days (HDD65) from Table J5.2.1a: _ (For items d. through i., fill in all values that apply from Table J5.2.1b:) a. Gross Wall Area sq.ft f. Wall R -value R- b. Glazing Area' sq.ft. g. Floor R -value R - c. Glazing % (100 x b _ a) % h. Basement wall R- d. Glazing U -value U- i. Slab Perimeter R- e. Ceiling R -value R- j. Heating AFUE ❑ Component Performance: "Manual Trade -Off" (Limited to wood or metal framed buildings only) Climate Zone (from Figure J6.2.2) ❑ Zone 12 ❑ Zone 13 ❑ Zone 14 Attach Trade -Off Worksheet from Appendix J, [and HVAC Trade -Off Worksheet, if applicable] ❑ MAScheck Software Attach Compliance Report and Inspection Checklist printouts ❑ Home Energy Rating System Evaluation Attach Home Energy Rating Certificate (HERS rating score must be 83 or higher) ❑ Systems Analysis OR ❑ Renewable Energy Sources Attach Mass Registered Architect or Engineer Analysis ALTERNATIVE FOR ADDITIONS ONLY: a. Gross Wall + Ceiling Area �sq.ft. b. Glazing Area` S , s 9 sq.ft. c. Glazing % (100 x b = a) J3>L% Q'ADDITION with Glazing % (c.) up to 40% may use 780 CMR Table J1.1.2.3.1 below: 1 2 3 MAXIMUM U -value NQNIMUM R -Values Fenestration' Ceilin Wall Floor I Basement Wall T slab Perimtter, De th 0.392 R-3 R-13 It 0 1 R-10 It Glazing Area may be either Rough Opening or Unit di ensions. Based on NFRC listing. Applies either to every unit, or to area -weighted average of all units. R-30 ceiling insulation may be used in place of R-37 if the insulation achieves the full R -value over the entire ceiling area (i.e: not compressed over exterior walls, and including any access openings.) ❑ "SUNROOM" addition (greater than 40% glazing -to -wall and ceiling gross area) Attach "Consumer Information Form" from 780 CMR Appendix B. Official's Name: Official's Signature: Application Approved ❑ Denied ❑ Date of Approval/Denial: Reason(s) for Denial: (provide additional details as needed on back side)