HomeMy WebLinkAboutBuilding Permit #139-2016 - 5-9 Alcott Way 7/31/2015 LIP
o tfUILUIN(i rtKMl l 40-
TOWN OF NORTH ANDOVER o
APPLICATION FOR PLAN EXAMINATION ; �*
Permit NO:
J n n
Date Received
Date Issued:
/ ACHUs�t�
IMPORTANT:Alicant must complete all items on this ae
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$LOCATIOf�I Alcott 1N ,forth Andousr,
Print
PROPERTY OWNER a i A1c6ttVIIlage Condominium l ust V F
-
VIAF? NO PARCEL Zt NJRr7 DISTRICT" Historic District yet o
0. k. Mchirte Shop Yifge yes a`
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
991 Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
i Septic. -7, bit U FioQdplain Wetlands ❑ Watershed District"."<
� lWater/Saver
Roofing related trim and siding replacement.
i
Identification Please Type or Print Clearly)
OWNER: Name: AlcottVillage Condominium Trust/C/O MSG Management Phone: 603-235-9188
Address: 231 Hampstead St. Methuen, Ma 01844
CONT4ACtCR Name - Phone 508-662-91 0
s
i?rinetouch Services
:'Adress. _
4Huron0r.-N6tick MA 01757
Supervisor's Coins#ri etidn License: Fxp. Bate:
r.
<s - 068912 . : 9/03/2046` �.
-borne Improvement License' Emp. Dke:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F-
Total Project Cost: $ /L, �/� FEE: $
Check No.: 1401 Receipt No.: 1`3g
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature.ofVAgt;ttt/{)Wri ,Signature of contractor
— - .. �
y pORTH
BUILDING PERMIT -[ .VD A6 6
TOWN OF NORTH ANDOVER 3 -
APPLICATION FOR PLAN EXAMINATION x .T ..
Permit No#: Date Received °DRA7ED
�SSACHUSfcC
I
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
EJ Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name: Phone:
Email:
Address:
I
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date.—
ARCH ITECT/ENGINEER
ate.ARCHITECT/ENGINEER Phone:
k
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
of Aqent/Q Signature of contractor
Location
�c w
No. ' ci-- 2 Date 3i 1 f
k
TOWN OF NORTH ANDOVER i
�, r
a
Certificate of Occupancy $
Building/Frame Permit Fee $ '7
Foundation Permit Fee $ f_
> i
Other Permit Fee $
° TOTAL $
Check#
Gi '� J Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ElSwimming Pools ❑
Tanning/Massage/Body Art ❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ `
THE FOLLOWING SECTIONS FOR.OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF e U FORM 4
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
' I
Conservation Decision: Comments
Water& Sewer Connection/Signature&Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
'FIRE�DEPA,�R�TMEN =Tempt®umpster,@onsite yes�—
F�ir¢e Depar,..t ignature/date, __ _
i
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)
i
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
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Building Department i
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
i6 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
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
IN OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
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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
NORT#1
Town of ? �: � _� ,, RAndover
O
No. r �,�_ ao T = - y wl 31 5
1 h ver, Mass,
coc.iiC" 1.c 1'
RATEO PIN?
`s U BOARD OF HEALTH
Food/Kitchen
Septic System
PE 1 �� BUILDING INSPECTOR
THIS CERTIFIES THATgT,
. . ..... .............. . ...... ........... .......
Foundation
buildings on . ..o.. .... .....
has permission to erec ....................... Rough
titw...
to be occupied as ..... „ Chimney
�..'!! t ... ' "' "
provided that the person accepting this permit sh n every spect 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 PLUMBING INSPECTOR
Construction of Buildings in the Town of North Andover.
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit. Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION STA4 Rough
Service
0000f
.................................. . ... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Final
Display in a Conspicuous Place on the Premises — Do Not Remove
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector.. Burner
Street No.
Smoke Det.
E
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 filet V/
Address of Work �6441cott Way, North Andover T
Owner Name: Alcott Village Condominium Trust
Date of Permit Application: 731/15
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
Ili
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.
i
OR: i
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date Owner Name
r
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
MGS.manageinent4,,a,verizon.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 resident responsibilities;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.
6 Huron Drive
PRIMEpouch Natick,MA 01760
S E R V t [ 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 '/2"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 hvac 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
PRIMENUCh Natick,MA 01760
S e a Vr s e s 800-767-8910
Alcott Village 2015 Exterior Carpentry Proposal 06/12/15
Page 2 of 6
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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.
AR 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.
All 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 $7,020
B 5-9 $5,850 $2,925 $8,775 `
C 10-15 $7,020 $3,510 $10,530 f
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 S69.44-
1;
Post roofing work includes all above roof comer 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 $9,798
B 5-9 $7,623 $4,625 $12,248
C 10-15 $9,147 $5,550 $14,697
D 16-21 $9.147 $5 550 $14.697
E 22-29 $12,196 $7400 S19,596
F 30-33 $6,098 $31,700 $9798
G 34-39 $9147 $5,550 $14697
Total $59,456 $36,077 $95,532
Painting includes one coat to re- rimed re laced areas of trim and siding
Painting Labor Cost Material Cost Total
A 1-4 $1830 $450 $2,280
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
6 Huron Drive
PRI MEMUch Natick,MA 01760
S E H v ; e_ E s 800-767-8910
Alcott Village 2015 Exterior Carpentry Proposal 06/12/15
Page 3 of 6
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Additional arpentry 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
Ix3 PVC lin.ft $4.50 $1.50 $6.00
1x4 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
1x8 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
..Garage Door Stop lin.ft $4.50 $3.00 $7.50
PVC Sill Nosing fin,ft $4.50 $3.50 $8.00
908 CasinR PVC lin.ft $4.50 $3.50 $8.00
Hourly Rate hour $48.00 $48.00
Material Mark UJ % I $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 t
ii,,, 6 Huron Drive
PP I M E touch Natick,MA 01760
S E A v r c E S 800-767-8910
Alcott Village 2015 Exterior Carpentry Proposal 06/12/15
Page 4 of 6
Prime Touch Guarantee:
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
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:
II I
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 MENU h Natick,MA 01760
S E A v i' C_ E s 800-767-8910
Alcott Village 2015 Exterior Carpentry Proposal 06/12/15
Page 5 of 6
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%.
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 "/z agree to request that the above-
described work be accepted for completion for the above price.
Signed:
my auth rized Representative of Alcott Village Condominium Association
Signed
Property MAnager,Duly authorized Agent of Alcott Village Condominium Association.
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i 6 Huron Drive
PRIMEtouch Natick,MA 01760
S E R V # C- E 5 800-767-8910
Alcott Village 2015 Exterior Carpentry Proposal 06/12/15
Page 6 of 6
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The Commonwealth of Massachusetts
Department of Industrial Accidents
I 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 PERMITTING AUTHORITY.
Annlicaut Information Please Print Legibly
Name(Business/OrganizatiorAndividual): 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. ❑New construction
2.E]I am a sole proprietor or partnership and have no employees working for me in S. E]Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.F-1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions
proprietors with no employees.
12.E)Plumbing repairs or additions
5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.EJ Roof repairs
These sub-contractors have employees and have workers'comp.insurance)
6.F-1We are a corporation and its officers have exercised their right of'exemption per MGL c.
14.®Other Trim/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 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.
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 am an employer that is providing workers'compensation insurance for my employees. Beloip 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(showingthe 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 do hereby cert fy under thepains and penalties ofperjuty that the information provided above is true and correct.
Signature: 0��� �� Date:7/31/15
Phone#: 508-652-9170
Official use only. Do not sprite in this area,to be completed by city or town offlcial.
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
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Contact Person: Phone#:
PKIMt-7 UP IU:5UK
D/YYYY)
E(MMID
._..r CERTIFICATE OF LIABILITY INSURANCE FoDATE
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
NAME: Loretta Brown
FBA FBi,LLC No,
o EPHONE
DBA FBi (A/C. 508-824-8666 ac No: 508-880-0142
nsurexc:
PO Box 509 EMAIL
Taunton, 9 02780 ADDREss:loretta fbinsure.com
Tom Rogers,CIC,CRM,CWCA INSURERS 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 ADDL BR POLICY EFF POLICY EXP
LTR POLICY NUMBER MM/DDNYYY MM/DD/YYYY LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE a OCCUR S1916323 10/1512014 10/15/2015 AMA E RE TED
X Blkt Add'I InsPREMISES Ea occurrence $ 500,000
MED EXP(Any one person) $ 10,000
X Blkt Waiver PERSONAL&ADV INJURY $ 1,000,000
GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000
POLICY[XI PEC F LOC PRODUCTS-COMP/OP AGG $ 3,000,000
OTHER 1PD Ded $ 250
AUTOMOBILE LIABILITY Ee acINED ddernSINGLE LIMIT $ 1,000,040
A ANY AUTO A9092598 10/15/2014 10/15/2015 BODILY INJURY(Per person) $
ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS PROPERTY DAMAGE
NON-OWNED $
X HIRED AUTOS X AUTOS Pareccitlent
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000
A EXCESS LIAR CLAIMS-MADE 51916323 10/15/2014 10/15/2015 AGGREGATE $ 5,000,000
DED I X I RETENTION$ 0 $
WORKERS COMPENSATIONPER OTH-
AND EMPLOYERS'LIABILITY STATUTE ER
B ANY PROPRIETOR/PARTNER/EXECUTIVE
YIN NIA X WC0452496 04/01/2015 04/01/2016 E.L.EACH ACCIDENT $ 1,000,000
D?
OFFICER/MEMBER EXCLUDE
(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.
!I i
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 MGS Management LLC AUTHORIZED REPRESENTATIVE
40 Alcott Way Tom Rogers,CIC,CRM,CWCA
Andover,MA 01845
C 1988-2014 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 Supcn icor
License: CS.060912
MATTMZW 1LVO
13 Dana park
Hopedale MA 01,1'47
Expiration
Commissioner 09/03/2016
Office of Consumer Affairs and Business Regulation
10 Park Plaza - "Suite 5170
Boston, Mass its 02116
Home Improvement qfor Registration
Registration: 155685
Type: Private Corporation
Expiration: 5/1/2017 Tr# 263024
PRIME TOUCH SERVICES INC
WILLIAM NORTH f
6 HURON DRIVE --- -�- M
NATICK, MA 01760 �� ----
Update Address and return card.Mark reason for change
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Ofte of Consumer Attain&Boa nese Regulation License or registration valid for individui use only j
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to; '
lstration: ! 65 Type: Office of Consumer Affairs and Business Regulation I
WO
iration Private Corporation 10 Park Plaza-Suite 5170
0
% r; Boston,MA 02116 ;
PRIME TOUCH SE
WILLIAM NORTH
6 HURON DRIVE
NATICK,INA 01760U
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"' ndersecretary Not valid without signature