HomeMy WebLinkAboutBuilding Permit #134-2016 - 5-9 Alcott Way 7/31/2015 ����� �-� ;�. • l,r tiUILUINU F'tKMI I 3a bd . •e
TOWN OF NORTH ANDOVER . * ° : o
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
�sSg ►+ �
Date Issued: e171 custi9
IMPORTANT: Applicant must complete all items on this page
LOCATION `Alcott Way,North Andover «
Print
R j Alcott Village CondominiumT
ROPERTY OVVNE .
MAP NO: L PA1 E -,ZONING DISTRICT. (historic District yes no
—�-----�
Machine Shop .e
..
p 9 r yep; no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
171 Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑Septic" i Well
OF
loodplain i*fWetlands. 0WatersheetDistrct
a Water/SVuer � -
Roofing related trim and siding replacement.
Identification Please Type or Print Clearly)
OWNER: Name: AlcottVillage Condominium Trust/C/0 MSG Management Phone: 603-235-9188
Address: 231 Hampstead St. Methuen, Ma 01844
CONTRAGt(JRPhone:_ w X08-652 917ff
PrimetoUdh Services
Address K"
6 Nura3r #ick, MA 01767
Supervisor's:;Canstructiori License: Exp. Date: R
068912 9/03/2016
":Home Improvemerit Llcertse: }' Exp. Date: ,_
155685 - _ 5/1117
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: $ /aC, �l y` FEE: $
Check No.: f Receipt No.: 7-c111-z>7
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
signature of Agent/4�ur�e° Signature ofi contractor;:�--� ��G"��'�
� r.�J
I Z NORTH q
BUILDING PERMIT O
TOWN OF NORTH ANDOVER 0 �
APPLICATION FOR PLAN EXAMINATION
iT
Permit No#: Date Received '°°R,TE° "`cy
�is C USEt
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
0 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: Persons contracting with unregistered contractors do not have access.to the guaranty fund
.. r
Sionat ur of AaPnt/Owner Signature of oontrac or --T-�
i
Location
No. 7 `t ' Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ 2(j 7
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
V G
Check# �
-� . ; Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
i
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 ❑
1
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
Zoning Board of Appeals:Variance Petition etition No: Zoning Decision/receipt submitted yes
Manning Board Decision: Comments
Conservation Decision: Comments
Wafter& Sewer Connection/Signature&Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood god Street �
FIRETempDonsite
umpst
1;L�ocatecl�at51241MaintStreet� er - . _ ;yeS,�_-a � _�_ ��ino�� •_Vu���, �� _f ,
� ire; ®ep�artment=signature%date;
'F
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
DANCER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
-NOTES and DATA— (For department use)
I
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit 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
I 4 Building Permit Application
Workers Comp Affidavit
4� Photo Copy Of H.I.C. And/Or C.S.L. Licenses
� Copy of Contract
4 Floor Plan Or Proposed Interior Work
-t Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Building Permit Application
Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Mass check Energy Compliance Report (If Applicable)
Engineering Affidavits for Engineered products C
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
4; 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)
iL Copy of Contract
4 2012 IECC Energy code
4 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
f
o NORTH� ETown ndover
0 to
No. —
Z _ ti ;016
RA�h ver, Mass, 3
Cocett4fwlcK
S U
BOARD OF HEALTH
1 Food/Kitchen
i
_ Septic System
i
THIS CERTIFIES THAT .....PERMIT
I, , ,, C,,, or.. ....5�' BUILDING INSPECTOR
. ...... ... ....... ...........................
has permission to erect.. 1� Foundation
........ buildings �. ���....�!+....... .
......... ............. . .... ...
...................
•
Rough
to be occupied as ...........I.. ........�..�,. ...... ....�.�. Chimney
provided that the person accepting this permit shall every respect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHSELECTRICAL INSPECTOR
UNLESS CONSTRUCTION ST T Rough
Service
................................... ..................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Reguired 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.
TOWN OF NORTH ANDOVER
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142 A requires that the"reconstruction, alteration, renovation, repair, modernization,
conversion, improvement, removal, demolition, or construction of an addition to any pre-existing
owner occupied building containing at least one but not more than four dwelling units...or to
structures which are adjacent to such residence or building" be done by registered contractors,
with certain exception, along with other requirements.
Type of Work: Roofing related trim and siding Est. Cost `�)
Address of Work I Alcott Way, North Andover
Owner Name: Alcott Village Condominium Trust
Date of Permit Application: 7/31/15
1 hereby certify that:
Registration is not required for the following reason(s): For office Use Only
Work excluded by law Permit No.
Job under$1,000 Date
Building not owner-occupied
Owner pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS
FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FIND LINER MGL c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
7/31/15 Primetouch Services 155685
Date Contractor Name Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date Owner Name
i
i
Proposal for Pre and Post roof Carpentry Work of
Alcott Village Condominium Complex
North Andover,MA
Property Manager: Brian Oulette
MGS Management LLC
40 Alcott Way
North Andover,MA 01845
603-235-9188
MMGS.management46verizon.net
General Description of work to be performed:
Carpentry replacement to rakes and fascias prior o roofing and above roof corners and siding after roofing work to
exterior stained and painted surfaces of buildings A,B, C,D, E,F and G located at Alcott Village Condominiums,
Alcott Way,North Andover,MA.
Specific Description:
Areas Included:
Above roof clapboard siding,corner boards and rake boards,fascia boards.
Areas Excluded:
Window sash,inner window sills,door jambs,entry doors,decks,railings,
stairways,items listed under unit residentresponsibilities;any porch enclosures;any other area not specifically
included.
Unit Resident Responsibilities:
Removal and replacement of personal property from deck,parking cars well away from building during production,
unlocking windows, removal & replacement of storm windows, removal and replacement of window screens &
slider screens and providing timely access to entry doors.Non-cooperation will result in exclusion of these surfaces.
Prime Touch shall not be liable for any property that is not removed by the Unit Resident.
Production Process:
Timing:
The job will be completed in the 2015 painting season (April to October, 2015 weather permitting). The crew will
remain on the job site from start to finish of the project. Prime Touch will not leave the job site prior to completion.
Each building will be completed in a continuous fashion to minimize the disruption of the unit owners.
Communication:
Prime Touch will designate a Project Manager. The trustees are requested to designate one Property Manager and
one Board Member to be the project contacts for unit owners to communicate questions,issues and problems. Clear
controlled communication and swift remedy will provide all parties with a positive experience. Prime Touch will
utilize two way door hangers for the unit owners or tenants to communicate actions required to facilitate the painting
of their unit.
k
6 Huron Drive I
PRIMEtouch Natick,MA 01760
s E e V 1 c E s 800-767-8910
Alcott Village 2015 Exterior Carpentry Proposal 06/12/15
Page 1 of 6
Pre-Paint Carpentry Selection of Work Levels:
Demolition:
Inspect exterior siding and trim surfaces.
Remove deteriorated siding and trim boards
Remove deteriorated underlayment and flashings
Remove deteriorated sheathing, insulation and framing(billed @ time&materials)
Properly dispose of all debris
Rake and clean the jobsite daily
Carpentry Work:
Install new framing,insulation and sheathing(billed @ time&materials)
Install Ice&Water Shield where applicable at window&door openings,rooflines and decks
Install new underlayment and flashings
Install new siding&trim(billed per unit pricing table below)
Install aluminum flashing between all clapboard siding joints
Install new materials with stainless steel or galvanized fasteners
Prime all cut wood
Miter all joints to shed water
Caulk all new work with paintable caulk
Materials:
Framing Kiln Dried Spruce-Pine-Fur
Sheathing '/z"CDX Plywood
Underlayment Tyvek Home Wrap/15 lb.Felt Paper
Ice&Water Shield Grace Ice&Water Shield or Equal
Flashings Aluminum and lead flashing
Siding Pre-Primed Non Finger Jointed CVG Cedar Siding
Trim boards PVC Trim Boards
Interior Repairs:
Interior repairs(repairs inside the sheathing of the building)which may be needed caused by the Work which are
to be reasonably expected due to the nature of the Work, for example,interior wall cracks,nail pops,electrical,
plumbing,and hva.c lines hit by nails,etc,shall be addressed upon request of the Owner by Change Orders.
The determination of whether an interior repair was to be reasonably expected due to the nature of the work or as
a result of the negligence or other failure of the Contractor shall be decided by the designated Principles/Contacts
of the Owner and the Contractor.
6 Huron Drive
PRI MEtouch Natick,MA 01760
S E R V i f E S 800-767-8910
Alcott Village 2015 Exterior Carpentry Proposal 06/12/15
Page 2 of 6
PRIME TOUCH CARPENTRY PRICING: Price includes Labor,Materials,Equipment and Two-year Guarantee
The amounts listed as estimated work are based upon a ground level inspection of the property.Actual amounts of work will vary
from unit to unit. The billing for all work performed will be submitted to the Property Manager/Condominium Association
Representative for approval on a weekly basis.No additional work exceeding the cost of the Estimated Carpentry Work will be
performed without the written approval of the Property Manager/Condominium Association Representative.
I
All Dormer fascias will be removed prior to roofing as to install proper blocking and sheathing behind the soffit and
fascia,then covered in ice and water-shield and properly flashed by the roofer.
Ali front entrance lower roofs will have the siding and trim removed to be fully covered in Ice& water-shield by the
roofer.
All roof to wall transitions will have the siding and trim removed to be covered 18"up the side wall with ice and water-
shield by the roofer.
Pre roofing pricing is to replace ALL rakes and fascia.We will replace rakes and fascia,as needed using PVC trim invoiced at the
unit pricing below.The reason for the full replacement pricing is to give the option for total replacement.
Pre-Roofing Work Labor Cost Material Cost Total
A 1-4 $4,680 $2,340 S7,020
B 5-9 $5,850 $2,925 $8,775
C 10-15 $7,020 $3,5 tO $10,530
D 16-21 $7,020 $3,510 $10,530
E 22-29 $9,360 $4,680 $14,040
F 30-33 $4,680 $2,340 $7,020
G 34-39 $7,020 $3,510 $10,530
Total $45,630 $22,815 $68,445
Post roofing work includes all above roof corner boards and clapboard siding.Short chimneys will have corners and siding replaced in
full.Large rear chimneys removed by roofer.
Post-Roofing Work Labor Cost Material Cost Total
A 1.4 $6,098 $3,700 $91798
B 5-9 $7,623 $4,625 $12,248
C 10-15 $9147 $5,550 $14,697
D 16-21 $9,147 $5,550 $14,697
E 22-29 $12,196 $7,400 $19,596
F 30-33 $6,098 $3,700 $9,798
G 34-39 $9.147 $5550 $14697
Total $59,456 $36,077 $95,532
Painting includes one coat to pre-primed re laced areas of trim and siding
Painting Labor Cost Material Cost Total
A 1-4 $1,830 $450 $2280
B 5-9 $2,288 $563 $2,850
C 10-15 $2,745 $675 $3,420
D 16-21 $2,745 $675 $3,420
E 22-29 $3,660 $900 $4,560
F 30-33 $1,830 $450 $2,280
G 34-39 $2,745 $675 $3,420
Total $17,843 $4,388 $22,230
Optional work:
• Second coat of painting if chosen would be an additional$16,675
• Changing front small chimneys to vinyl siding instead of cedar clapboard -$225 per chimney
• At dormer fascia to roof transitions,removing sheathing to install blocking underneath$40/area
1, 6 Huron Drive
PR I M Etouch Natick,MA 01760
S E R V I C; E S 800-767-8910
Alcott Village 2015 Exterior Carpentry Proposal 06/12/15
Page 3 of 6
Additional Carpentry Work will be billed at the Unit Pricing listed below:
Item Unit Labor/Unit Material/Unit Cost/Unit
T 1-11 sq.ft $75.00 $150.00 $225.00
Clapboard Siding lin.ft $2.00 $1.75 $3.75
10 PVC lin.ft $4.50 $1.50 $6.00
Ix4 PVC lin.ft $4.50 $1.65 $6.15
1x5 PVC lin.ft $4.50 $1.85 $6.35
1x6 PVC lin,ft $4.50 $2.25 $6.75
Ix8 PVC lin.ft $4.50 $3.00 $7.50
1x10 PVC lin.ft $4.50 $3.75 $8.25
1x12 PVC lin.ft $4.50 $4.50 $9.00
5/4x4 PVC lin.ft $4.50 $2.50 $7.00
Garaize Door Stop lin.ft $4.50 $3.00 $7.50
PVC Sill Nosing lin.ft $4.50 $3.50 $8.00
908 Casing PVC lin.ft $4.50 $3.50 $8.00
Hourly Rate hour $48.00 $48.00
Material Mark U % $0.15 $0.15
*All repair work not included but not limited to sheathing,framing,window&door installation(including
measurement),interior window or door trim work,interior repairs due to sheathing or framing replacement,leak
investigation&repairs,deck/deck repairs and moving utilities will be billed at time&materials.
I'
I �
I
77 6 Huron Drive
PRIMEtOuch Natick,MA 01760
S E A V I t E 5 800-767-8910
Alcott Village 2015 Exterior Carpentry Proposal 06/12/15
Page 4 of 6
I
Prime Touch Guarantee: '
I
Prime Touch guarantees our workmanship and materials will not fail for two(2)years from the date your project is
completed as determined by the date that the specific building was accepted and invoiced. There are some
limitations to the Guarantee.Please see below.
Definition of Workmanship: The intent of this guarantee is to protect the customer from faulty
application by Prime Touch or faulty materials provided by Prime Touch. The intent of this
guarantee is not to transfer liability of existing deficiencies in building design, construction, or
previous workmanship and previous materials provided by other contractors, from the property
owner to Prime Touch. Areas where there has been a history of failure are not guaranteed unless h
corrective measures have been taken to eliminate the root cause of the historical failure.
Prime Touch guarantees to remedy failed areas, at no cost to the owner. Guarantee work shall be scheduled in the
production schedule after verification and completed in the order of the production schedule,weather permitting.
Definition of"remedy": Prime Touch will repair the failed area, and only the failed area. Due to fading,the
fresh coating applied to the failed area may not match exactly.All guarantee repair work will be performed
at the same level of preparation as performed in the original contract.
Service Limitations:
This guarantee does not cover any damage resulting from external cause such as, but not limited to, negligence,
misuse, abuse,unauthorized repair by others; defects in design,construction,or previous workmanship; fire, water,
windstorm,sand abrasion,hail or any other act of God. Work necessitated by any of the foregoing will be subject to
charge at our prevailing demand service rates. IN NO EVENT SHALL PRIME TOUCH BE LIABLE FOR
SPECIAL,INDIRECT,INCIDENTAL OR CONSEQUENTIAL DAMAGES.
Limitations to the Guarantee:
Guarantee applies to all areas except:
-Any area not specifically included in the contract
-Galvanized metal
-Varnished or transparent stained surfaces
-Walked-on surfaces,flat horizontal surfaces,windowsills
-Mildew or Algae
-Painted or stained roofs or gutters
-T- 111 siding,finger jointed trim and siding areas
-Sap stain bleeding,Knot staining
-Rotted or deteriorated substrates
-Coatings applied to factory finishes,plastic,vinyl or glass
-Any area or surface specifically excluded from guarantee in the above proposal
6 Huron Drive
PRI MMUCh Natick,MA 01760
S E A v .1 e E s 800-767-8910
Alcott Village 2015 Exterior Carpentry Proposal 06/12/15
Page 5 of 6
i
The Fine Print
Deposit:
A 10%deposit and the return of a signed proposal is required to secure a position in the
production schedule.20%payment is required upon start of the project.
Payment Schedule:
Prime Touch will submit invoices on a section-by-section basis.Invoices are due and payable seven (7)days from
date of submission. Prime Touch and the Property Manager/Condominium Association Representative will agree
upon the submission procedure prior to the start of the project. Past due amounts are subject to a service charge of
1.5%per month,which is an annual rate of 18%.
R
Utilities:
Pricing is based on the Condominium Association providing free and clear access on a unit-by-unit basis to water
and electricity required to perform the proposed service.
Unit Resident Responsibilities/Water Infiltration:
Removal and replacement of personal property from deck,parking cars well away from building during production,
unlocking windows, removal & replacement of storm windows, removal and replacement of window screens &
slider screens and providing timely access to entry doors.Non-cooperation will result in exclusion of these surfaces.
Prime Touch shall not be liable for any property that is not removed by the Unit Resident.Prime Touch shall not be
held responsible for water infiltrating any double pane window or door seal during power washing.
Sign Off Procedure:
Prime Touch requests and the Property Manager/Condominium Association Representative agree that each building
or section of a building will be signed off after an inspection by the Prime Touch Project Manager and either the
Property Manager/Condominium Association Representative. These inspections will be completed in a prompt
manner not exceeding forty-eight(48)hours from notification.
Proposal Validity:
This proposal expires thirty(30)days from the date found on Page 1. Due to ongoing requests for painting service,
acceptance of this proposal for production by Prime Touch is subject to the sole discretion of Prime Touch based on
available production capacity.Once accepted by Prime Touch,the project will be completed within the season.
Acceptance:
Alcott Village Condominium Association having met on �� agree to request that the above-
described work be accepted for completion for the above price.
Signed: r
my auth rized Representative of Alcott Village Condominium Association
Signed•
Property MAnager,Duly authorized Agent of Alcott Village Condominium Association.
6 Huron Drive
PRIMEtOuch Natick,MA 01760
S E R V EE E s 800-767-8910
Alcott Village 2015 Exterior Carpentry Proposal 06/12/15
Page 6 of 6
I
The Commonwealth of Massachusetts
Department oflndustr'ialAecidents
$ 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders!Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMCTTING AUTHORITY.
Applicant Information Please Print Legibiy
Name (Business/Organization/individual): Primetouch Services
Address: 6 Huron Dr.
City/State/Zip:Natick, MA 01767 Phone#:
Are you an employer?Check the appropriate box:
Type of project(required):
1.®I am a employer with 60 employees(full and/or part-time).* 7, F1 New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling
any capacity.[No workers'comp.insurance required.]
9. Demolition
3Q am a homeowner doing all work myself.[No workers'comp.insurance required.]t
❑
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 I have hired the sub-contractors listed on the attached sheet. 13,Q Roof repairs
These sub-contractors have employees and have workers'comp.insurance.$
6.0 We are a corporation and its officers have exercised their right of'exemption per MGL c.
14.®OtherTrim/Siding
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infonnation.
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 and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am mi employer that is providing workers'compensation irisurance for my employees. Below is the policy and job site
information.
Insurance Company Name:Star insurance Co.
Policy#or Self-ins.Lie.#:WC0452496 Expiration Date:4/1/2016
Job Site Address: Alcott Way, City/State/Zip:North 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 DTA for insurance
coverage verification.
I do hereby certify under the pains and penalties of per jury that the information provided above is true and correct.
i
Signature: ��y �` Date:7/31/15
Phone#: 508-652-9170
Official use only. Do not write in this area,to be completed by city or town official
I
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#:
PKIMt-7 UP ID:5UK
CERTIFICATE OF LIABILITY INSURANCE DATE 07/30/2015
07130!2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(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
FBinsure,LLC NAME: Loretta Brown
FA
DBA FBinsure (A/CONE,No Ell:508-824-8666 (,CC No); 508-880-0142
PO Box 509 E-MAIL
Taunton,MA 02780 SS:loretta@fbinsure.com
'
Tom Rogers,CIC,CRM,CWCA INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A:Selective Insurance Group 39926
INSURED Prime Touch Services Inc INSURER B:Star Insurance Company 18023
Attn: Mr. North
6 Huron Dr INSURER C:
Natick,MA 01760 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 ADD R POLICY EFF POLICY EXP
LTR POLICYNUMBER MMIDDfYYYY MM/DD/YYYY LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE X OCCUR S1916323 10/15/2014 10/15/2015 E N E
X Blkt Add'I Ina PREMISES jEa occurrence $ 500,000
MED EXP(Any one person) $ 10,000
X Blkt Waiver PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000
POLICY JECT LOC
PRODUCTS-COMP/OP AGG $ 3,000,000
OTHER: PD Ded $ 250
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Ea accident $ 1,000,000
A ANY AUTO A9092598 10/15/2014 10/15/2015 BODILY INJURY(Per person) $
ALLOWNED X SCHEDULED BODILY INJURY Per accident
AUTOS AUTOS ( ) $
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $
AUTOS Per accident
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 51000,000
A EXCESS LIAR CLAIMS-MADE 51916323 10/15/2014 10115/2015 AGGREGATE $ 5,000,000
DED X RETENTION$ $
WORKERS COMPENSATIONPER OTH-
AND EMPLOYERS'LIABILITY X STATUTE ER
B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN❑N N/A WC0452496 04101/2015 04/01/2016 E.L.EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000
A Equipment Floater S1916323 10/15/2014 10/15/2015 Lsd Equip 100,000
ACV/Special Form Ded 500
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Painting and Carpentry Contractor.
CERTIFICATE HOLDER CANCELLATION
ALCOTT1
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Alcott Village ACCORDANCE WITH THE POLICY PROVISIONS.
C/O MISS Management LLC
40 Alcott Way AUTHORIZED REPRESENTATIVE
Andover,MA 01845 Tom Rogers,CIC,CRM,CWCA
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supen isor
License: C"68912
MATTIRW T
13 Dana park. �y�'QH N f
Hopedale MA 01747 -
J.�.... ��l ►c.tt►4 V
EXpitatson
Commissioner 09/03/2016
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massm setts 02116
Home Improvement d otor Registration
Registration: 155685
Type: Private Corporation
Expiration: 511!2017 TO 285024
PRIME TOUCH SERVICES INC
WILLIAM NORTH
6 HURON DRIVE
NATICK, MA 01760 ---
Update Address and return card.Mark reason for change.
•
saAI o acM�osnt Address [] Renewal 0 Employment F] Lost Card
�'i s�oexo►w�ra.a•�d�o�o�ltaocaa4asah3 •
Office of Consumer Attain&Business Regulation License or registration valid for individul use only
OME IMPROVCMENT CONTRACTOR before the explration date. If found return to:
istratlon: 85 Type: Office of Consumer Affairs and Business Regulation
pinstfon Private Corporation 10 Park Plan-Suite 5170
Boston,MA 02116
PRIME TOUCH SE
WILLIAM NORTH Z''
B HURON DRIVE
NATICK,MA 01760k
Undersecretary Not valid without signature