HomeMy WebLinkAboutBuilding Permit #358-13 - 50 ROYAL CREST DRIVE 11/1/2012 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: 7i
IMPORTANT:Applicant must complete all items on this page
LOCATION Royal Crest BUILDING_# 41 LIr
Print
PROPERTY OWNER AIMCO, Royal Crest Estates LLC UNIT#
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes o X
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: Z ❑ Commercial
'Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
r .9a:
.is i -e 1 0 00 ain a Ian s a e'rshed 1 istri
Sewer
DESCRIPTION OF W RK O BE PERFORMED:
2s xR - els
(Identification Please Type or Print Clearly)
OWNER: Name: 94i! C 4 el-r 195 A-41Ft 5 Lz-L Phone: Q'7�"6 8/ - /,V2 Z
Address: �b �� C�1.2sT d fut,A.
CONTRACTOR Name: Thomas H. Kinnal Phone: 978-360-0051
Address: 286 Broadway, Haverhill MA 01832
Supervisor's Construction License: CS 82747 Exp. Date: 6/20/201'
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ 3, 3 q d FEE: $
Check No.: Receipt No.: C3,S a `�—
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty, and
,�Signature �Agwner Signature ofntr or \ � �
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
i
'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 ❑
i
i
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY I
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
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
Conservation Decision: Comments
Wa',gr & Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA
— For department use
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2008mi
i
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
❑ Co of Contract
ct
❑ 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
❑ 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/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
❑ 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
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit
Fn all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
:hat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
nust be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
Location 6I2esr
No. Date.ff—
1
• - TOWN OF NORTH ANDOVER
Certificate of Occupancy $ y
Building/Frame Permit Fee $ �
C Foundation Permit Fee $
Other Permit Fee $
TEDa $
TOTAL
Check#
25897 Building Inspector +-
NORT"
Town of y . s E �, ndover
0
No. low 0.
-
h ver, Mass,
�J COC NAKS
ICNlWICI( y�
J9 QOJArEv 01f C7
S V
BOARD OF HEALTH
Food/Kitchen
PER IT T Septic System
THIS CERTIFIES THAT �ii�... �ir...... k.. .......................................................... BUILDING INSPECTOR
has permission to erect . buildings n ..�!'C. ....! � WAFoundation
g
Rou h
'4111 ,
....... AoA0 ..... lnl......... _ .... Chimney
to be occupied as ......... .. .... .�.l�:tr ................. ... ............ y
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
b, PERMIT EXPIRES IN 6 MON HS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTI TS Rough
Service
............... ....................................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and-Approved by the Building Inspector. Burner
Street No.
Smoke Det.
SEE REVERSE SIDE
NORTH
own of E ndover
No. -
h over, Mass,
coc Nlc MlwicK ��•
�.9 A0RATEO I.P���S
S u
BOARD OF HEALTH
Food/Kitchen
PER ITT D Septic System
i
THIS CERTIFIES THAT ............. ....... .. ...... ...... ........... ..........................................................
BUILDING INSPECTOR
has permission to erect . buildings n Foundation
Rough
.. •
to be occupied as ......... !1':i�r........ ..............�� ......
...............hl. .......................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
• Final
PERMIT EXPIRES IN 6 MON HS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTI TS Rough
Service
............... ....................................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and- Approved by the Building Inspector. Burner
Street No.
Smoke Det.
SEE REVERSE SIDE
ZJ1=1'(V1GLS AGREEMENT
This SERVICES AGREEMENT (this "Agreement") entered into by and3'7
between the Property Ottner (as identified on Exhibit A attached hereto " 1a)•ntentfor.Sen•ices
("I'ropetty Owner")and fast Coast General Contracfin tkn Thomas It
Kinnel (legal name)("Provider ) with its principal place of business at 236 Unless otherwise egret by filo Parties, Property Owner shall remit payment
Broadway, Haverhill. MA 01332. Together, Property Otcn r and Provider to Provider as specified in the Addendum; provided, however, Property
are referred to herein individually as a "Party" and, collectively, ;is Ile Owner shall not be obligated to pay ;any portion of an Invoicewhich it
"Patties." disputes in good faith and Futinuils to arbitration pursuant to Section 3.13 of
this Services:'Agreement. AIMCO(or an affiliate thereof)shall have the right,
but not the obligation, to make a payment owed 6 the Pro
Property Owner mhereunder provided
manages certain property located at the Property identified on here petty Owner
however, nothing contained'hereshall result in any
Exhibit .t attached hereto ("Property").t Property Owner desires to engage liability of AI\ICO or its affiliates, and no such payment shall create or
Provider to provide certain services to Property Owner, and Provider is constitute a course ofdealing or course ofconduct b AIMCO or its affiliates,
willing to furnish the same oft the tcrnts and conditions vel forth herein and Provider hereby waives any such claim. In the event that AJMCO has
notified Provider of its infention to make a payment due hereunder and such
fit consideration of the mutual promises of the Parties contained herein and payment is not made, Property Owner shall remain fully liable for such
other good and valuable consideration, the receipt and sufficiency of which Pa}'ments. Property Owner may take a 2%discount from the invoice price for
are hereby acknowledged, the Parties, intending to be legally boundhereby payment made within 20 days of receipt of invoice;otherwise,nei
t ptcnt s
agree as follows- to be tendered
within 30 days. a}'n
I SERVICES 3.3 Taves
^
Subject to the terns and conditions of this Aprecment. Provider will provide Provider shall be solely responsible for all taxes with respect to any
to Property Owner the services (tile "Services" as more fully described in compensation due hereunder or under the Addendum for any Services
Section 2.4 below)that are ordered by Property Owner in a jointly-agreed provided hereunder.
work order (the "Addendunl"). Property Otvncr agrees that Provider is
responsible for performing only the tasks that are specifically set forth in a IV TEWAI AND'fETWINATION
jointly-agreed Addendum.
4.1 Tererr
It DEFINITIONS'
11iis Agreement shall commence on lie Effective Date:and shall continue in
2.l "Confidential fl fortnatialt" effect until April 311, 2011 unless this Agreement is earlier terminated (the
"Terni'). Property Owner may terminate this Agreement at any time by
ntca»s any information of;lily kind, nature, or description concerning any Providing Provider with thirty(30)calendar days' written notice. in the event
matters affecting or relating to Provider's services for Property Owner, filee that Property Owner terminates this Agreement prior to Provider's completion
Of the Services under a Addendum,and Property Owner or Al MCO has paid
6uuinosu or oporalions of Property Owner and ilc a(Iilialoa, information
ror uuch Sorvices in full,Provider Oulu pay to Property Owoor or;1lkwo,as
concerning any of the tenants, residents or invitees of Property Owner, the case may be,any Fees th;t do not represent actual vt•ork perfonued and/or
employees of Property Owner or its alliliates,and/or the products,drawings, actual costs incurred, as described in Article Ill
plans,processes,or other daft of I'rpcty Owner or its aftiliatcsof this Agreement. Upon, termination,the sole liability and obligation of Properly Owner is for Property
Otvrter to pay for such Services provided by Provider prior to the elfectite
2.2 "F_fJ`ective Date" date of termination: provided, however, Property Owner may offset any
damages incurred by it against such amounts owed to Provider and Provider
shall mean the date that the Addend')",has specified as lite Effective Date. shall remain liable to Property Owner for any[homages caused by Provider's
default.
2.3 "lees"
4.2 Ter+nuratiorr for/french
shall mean all of the fees, taxes, expenses, charges, incidental expenses
described in and payable under the Addendum,collectively Fees Ill Fpayable Either Party shall have the right to tenninale this Agreement,as the case stay
hereunder ae payable solely in United Stales dollars. be,if the other Party fails to cure any material breach of the Addendum or this
Agreement within ten(10)calendar days of receiving written notice of such
2.4 "Services" breach(such time period is referred to herein as file"Cure Period").Consent
to extend the Cure Period shall not be unreasonably withheld,so long as the
shall mean work performed by Provider for Property Owner pursuant to the bind pursues cureaching Pyof the breach e n goodd thetre fatitlt the breach during the Cue Period
e
Addendum or under this Agreement. The schedule for the Service,¢shall be
agreed upon by the Parties. This Services Agreement is not an exclusive
dealings contract; Property Owner may purchase services similar or identical Provider wnershall and agrees that its sole recourse of any breach by
to the Services being provided hereunder from other service providers. Property Ovr shall he Ute assets of Property Owner, provided, however,
that nothing contained herein grants Provider any lien or similar rights with
III INVOICING.PAl \fENT AND TAXES respect to the applicable pro a Yor other assets of Property Owner.
3.1 Invoicing 4.3 Effect of Ternrinatiots
The Fees for the Services shall be set forth in the applicable Addendum. UpnPropertyOwner to
sole liability and obligation of Property Owner is for
Unless otherwise agreed by the Parties,Provider agrees to invoice("Invoice' et tivz date of tetntina[onG pcDvuch Sded ciowzes e provided Prperty Otaner ter proy offset
Property Owner for the Services,and provide a copy of all Invoices to such any damages incurred by it against such amounts owed to Provider and
address or addresses as Apartment Investment and hfanagement Company Provider shall remain liable to Property Owner for any damages caused by
("AIhICO")or Property Owner may provide in the Addendum(which may be Provider's defaulL
changed by AIMCO at lily time) or otherwise, within thirty (30) calendar
days after the provision thereof
The provisions of this Agreement tvhich, by their reasonable terms, are
intended to survive termination of this Agreement shall survive (including
indemnification and confidentiality provisions).
Page 1 of 10
Master Service Agreement over$10k version 2.0
March 2009
SERVICES AGREEMENT
� Y
V C'OV'ENANTS At\D\VARRANTIES
b) neither Provider nor its employees, agents or
S.1 Ca,•eamue contractors shall cause or permit to be caused env hazardous Substances
(defined below) to he located for whatever reason on the Propertv.
"llazardous Substances" means (a) any chemicals materials or substances
Provider covenants and warrants to Property Ottner that: defined as or included in the detinition of"hazardous sunstances,"`'hazardous
oyster," `'h:¢:trdous materials," "extrentel}' hazardous wastes," "restricted
(a) the Senices shall he performed consistent ttith hazardous tvasl .
nnienjal
generally accepted induxtry srrndards by adequately trained and competent �,."toxic suhslances,"'toxre pollulutLs,"^contunirtanfs" or
personnel, in a professional manner, utilizing rosined and suitable pollututls,"or wends of similar import, under any
[.atr,and(U)any other chemical,material or substance, exposure e,to%shish is
equipment, with quality supplies, materials, in a manner so as to minimize Prohibited, limited or reg
annoyance, interference or disruption to tenants, occupants or invitees ofttc Mated by any governntent¢tl authority,
Environmental tutu" means any tcJeral, slaty or local statute,
Property,and in accordance will,the terms and conditions of this A reen Regulation,ordiuutce,code,polis or rola late, role,
and the Addendum: g tcrtt Y of common late now
effector he '•
mid in each case as amended, and any judicial or adnti listrative
interpretation thereof including any judicial or administrative order. consent
decree(b) if the Services include the provision of products, such Substances,toinctlud ng�without limilatlating to the tion the`Cotnprcbensive Env�onntefnttts
producca ts shall to free of defects, tit for their intended use, conform to the Response,Compensation and Liability \ct of 1950,as:upended,42 U.S.C. §
Addal
endum,
s, terms and conditions set forth in this Agreement and the 9001, cl se the ILtztrdau kfaterials "fransportalias act, as amended, t9
f\dduuhunh free oGuty liens:rad conveyed with good Litle;
q-;
U.S.C.app- § 1501,et seq.;the Resource Conservation and Rccovcry Act,as
amended,42 U.S-C.§6901,et seq.;the Federal 1V;rtcr Pollution Control Act,
(9) Provider shall comply with all applicable federal, state amended,33 U.S-C.§ 1251,et se the Toxic Substances Control Act, l5
and local laws, ordinances, regulations :uhd orders (collectively, q''
well as with all rales and regulations pronuilgated by Property Owner with U.S.C.§2608,`'a((t`�the�'tcan Air Act,42 U.S.C. § 7401, et seq.; and llw
respect to entry onto the Property,and shall promptly notify Property OWner Safe Drinking\ I U.S.C. §300f,ct sc
ofany violation orpotenlial viola(ion ofthe I.atvs; q
(k) in the event that Provider tiles for bankruptcy or
(cl) Provider shall, prior to aaumcueing
;Illy
work receivership frderal shall d vfmissrsuch actirnt tvi•lthiofedagaiGstita similar
hereunder or under the Addenduul, oblain and maintain throughout the'fern rucecdinn
all approvals, licenses and/or permits required by any Law or governmenLrl filing, Y ( ) }s attar
agency,hoard or olherjurisdiel ion;
(f) neither Provider nor its empee
loys, agents or
(�) cunlractors s
Properly Owner's reqhall use lead-based paint (or any constituent qr product that
u st"Poar store the Property to its Original condition,l(ii)
contains Iced-based paint)un the Property;and
leave the Properly clean and free oF;tll tools,equipment,waste materials and
donna;and(iii)he liable for the cost ofany utilities leis on by Providcr or its pro;?ucl risk of!ass for le root?nets stall ret :r• '•• r n
(rah) if the provision of Services includes the provision of
contractors,subcontractors or agents ager completing ore Services and for;try Products shall be delivered and accepted by Properly Owner. all dolivcry
cost associafcd with Provider's n0ncontpliance with this subsection(c); r t t •Owner,
.cr until s r
shipment, freight and other similar charges shall be the Sole responsibility of
Provider. Provider shall ship all or in Intl,except whore Property Owner
(n Provider shall O responsible for damage to or theft of has given its prior approval to receive partial orders. Provider may »col
caul ed personal properly to Property r cr or tenants located al the Property Substitute products wi(hout the prior tvrilten approval of Properly owner, in
caused by Provider's employee.,,,contractors or agents;
Property Owners'sole discretion-Time Shall he of the essence with respect to
this Agreement and the addendum. If Provider foils to deliver on time,
(g) where requested by Property Owner, Provider shall Propc:rtY Owner may purchase replacements from a third ,:u-t
provide reports to Property Owner regarding the provision of Services; Shall be liable for life actual and reasonable costs and dantagestin caProvider
rred by
Property Owner.
(h) Provider shall not infringe on any trademark,copyright,
Patent or outer intellectual property right utilized in providing the Services;
5.2 1l irrraiures
(r) Provider shall maintain insurance that is customarily (a) Provider has not and will not disclaim any implied or
maintained by others in the industry, but in no event shall Provider have
primary insurance in an amount less than the Collotvin.- express vv hrranlies.
customary activities the following requirements apply. For ltsual and
the following requirements c10 nbt apply include higher risk services. Some t PP y of the Ser-vices or products; the failure of Properly Pp y- ctivities for which (b) Property Owner shall not be required to inspect
vner to
examples of higher risk services include asbestos abatement, h rove anP" or
environmental testin phase II discover defects or deficiencies therein shall not constitute an a cep n ace of
g moving and storage, and professional senices any defective or deficient Service or product,and shall not relieve Provider of
performed by architects engineers, or accountants. \lr
insurance as required b D1l efS COrnPensalion its responsibilities pursuant to this Agreement.ff any products supplied do not
q Y law, commercial general liability, including conform to those warranted Provider shall timely substitute conforming
contractual liability,insurance on an occurrence naris in an amount of not less
products; provided, that, if Provider is required to produce and supply
an$1,000,000.00, automobile liability insurance on an occurrencx basis in b products as a result of breach of'this`:arrant Properly
an amount of not less than Y ( conforming r
$I,s than .UO, and excess liabilit umbrella shall not be responsible for any costs or fees associated therewith.P Y Otaner
coverage)in an amount of not less than$1,000,000.00 on an occurrence basis
and an amount of not less than S1,00000.00 in the aggregate. Upon
commencement of this Agreement, Prouder shall cause the insurer issuing OWNERSHIP OF MATERIALS
such policies to issue a certificate to AI,\1CO confirming that such policies
have been issued and are uh frill force and effect and give 30 days PrvperlY Owner shall have all right,title and interest in and to all information
written notice to AI2t4C0 of cancellation or non-renewal In addition, and\vat{ product,including but not limited to all inventions, original works
Provider shall provide Ai1v1C0 with written notice as soon as it becomes of authorship, Bevelopments concepts, know-how, discoveries,
Y policy. AINWO,and AIMCO's subsidiaries unprovemrnts, trade secrets, secret processes, patents, 'patent applications,
and affiliates that may directly or indirectly 0,n•n or manage an properly or
service marks, trademarks, trademark applications, copyright and cop}'right
Properties at or for which Prov7der performs an work, Y P P' y registrations,
additional insured on the general liability and automobile liability coverage ed as rat ns uhe[her or not Patentable or registerable under co
trademark or other similar latus, aade or
c ohne cop)-fight,
conceived by provider,in whole or in part,alonellorrwith others,asa tresuIt of
providing Services hereunder(tire"Works-). The Works shall be deemed t
be "works made for hire" under United States cop}right law (17 U.S.C.o
Page 2 of 10
Master Service Agreement over$10k version 2.0
March 2009
SERVICES AGREEMENT
t y
Section 101 ct seq.)and inada in the course of this Agreement- To the extent Provider acknowledges that its breach of this Section SA may cause
such Works ilia), not, by operation of law, vest in Property Owwner or such irreparable injury to Property Owner for\which monetary damages may not be
works may not be considered to be works made for hire, all right, title and ,ui adequate remedy. Accordingly,Provider shall be entitled to seek injunctive E
interest therein are hereby irrevocably assigned to Property Owvner. Provider or other equitable reliefin the event ofsuch a breach.
understands that Property Ovvner may register the cop)vighi,trademark,patent
and other rights in rho Works in Property Owner's nnnia. Provider ngrres not
3.2 Relationship l3crree+r the,Parties
to use the Works for the benefit of anyone other than Property Owner,wcithout
Property Owner's prior written pernlission.
The relationship between the Parties shall at all times be that of independent
contractors.Nothing contained in this \greement shall be construed to create
II I2E\[L'DIES,DAMAGES AND INDEMNIFICATIONcontractors.
partnership, joint venture, agency or other firm of joint enterprise
relationship between the Parties. Eich Party shall be solely responsible for
7.1 Ciunrrlative Remedies payment of all compensation owed to its employees, as well as eniployntent
related taxes. Neither Party shall have authority to contract for or bind the
Property Owner's tights and remedies herein shall be cumulative .and in other Party in any manner whatsoever.This Agreement confers no rights upon
addition to any other or fitrther rights and remedies available at law or equity, either Party except those expressly granted heroin.
7.3 Dnrrrn-es 8.3 Governin;f.mvand.hirisdiction
Except with respect to indemnification provided in Section 7.3 below, each This Agreement,and all matters arising out of or relating to this Agreement,
Party waives the right to special, indirect, consequential and punitive shall be governed by and construed in accordance with ilia laws of the Slate of
damages, including lost profits. Notwithstanding anything to the contrary, in Colorado and shall be deemed to be executed in Denver,Colorado. Any legal
no event shall Property Owner be liable for damages or losses in excess of the action or proceeding relating to this :Agreement shall he adjudicated in the
actual amount payable by Property O%Nncr to Provider for the supply of a District Court of the County of Dcnvcr,Slate of Colorado or the United States
particular Service actually provided li seunder. District Court for the State of Colorado. The ['allies agree to subunit to the
exclusive jurisdiction of, and agree that venue is proper in, the aforesaid
7.3 indemniftcntion
courts in any such legal action or proceeding.
Provider shall indemnify,hold htinnlcss and,if requested by Property Owner 8.4 Notices
in its sole and absolute discretion,defend(with counsel approved by Property
Owner) Property Owner, its employees, agents, principals and stocuoiders All notions,inchiding notnga of adtlroHa uhungo,rJdtllNd to bo PJill hJroundJr
(the"Indemnified Parties")and hold them harmless against any loss, liability, shall be in writing to the address listed in (lie applicable Addendum, with a
deficicucy, damage, expense or cost (including reasonable legal expenses), Copy to:
actually incurred or paid (collectively, "Losses'"), which the indemnified
Panics may suffer, sustain -or become subject to, as a result of(i) any Legal Department
misrepresentation in any of(lie representations and warranties of Provider AIMCO
contained herein or in the Addendum; (ii) my breach of, or failure to 4582 South UlslerStreet Parkway,Suite 1100
perform, any agreement or covenant of Provider contained herein or in the Denver,CO 80237
Addendum; (iii) Provider's negligence or misconduct; or (iv) Provider's
violation of,or noncompliance with any Law. Notices shall be delivered and shall be deemed received:(a)by hand delivery,
upon receipt thereof; (b)by mail, seven(7)clays after deposit in the United
7.4 Wah'er States mails, postage prepaid, sent via first-class mail; (c) by facsimile
transmission, upon electronic confirmation thereof,(d)by next clay delivery
Provider hereby waives any and all chtims against the Indemnified Parties for service,upon such delivery;or(e)by e-mail.
any Losses incurred by reason of or arising out ofany injury to or death of any
person(s), damage to property, loss of use of any property,violation of Law, 8.5 Severability
or otherwise in connection with the condition of the Property or any facilities
therein, any event or occurrence on or about the Property or the acts or In the event that any provision of this Agreement is held to he illegal, invalid
omission of any person,except with respect to the gross negligence or willfitl or uneriforecable, such provision sluill he elimitutcd or eliminated to the
misconduct of an Indemnified Party. minimum extent necessary so that the remaining provisions of this Agreement
witl remain in full force and effect and be enforceable.
V111 GENERAL
8.6 {I Inver
8.1 Nondisclostire
The waiver by either Party of any default or breach of this Agreement,or the
Property Owner may disclose to Provider Confidential Information;however, failure by a Party to exercise any rights hereunder, shall not operate or be
Provider agrees that it will not use the Confidential Information for purposes deemed a waiver of any other or subsequent default or breach or of such
other than those necessary to directly fitrther the purposes of this Agreement_ Party's rights or any other rights in the future. Except for actions for
Except as otherwise expressly permitted in this Agreement,Provider will not nonpayment or breach of either Party's intellectual property rights,no action,
disclose to third parties the Confidential htformatioa without the prior written regardless of form,arising out of this Agreement may be brought by eithor
consent of Property Owner. Provider shall protect the Confidential Party more than one(1)year after such cause of action has occurred.
Information from unauthorized disclosure or use with the same degree of care
that Provider uses to protect its own like information.Provider shall notify its g,7 F,rrtire:lgreemetu
receiving employees, agents and contractors of their confidentiality
obligations with respect to the Confidential Information of Property Owner
and shall require its employees,agents and contractors to comply with these This •4greenient, together with any associated Addendum that specifically
obligations. Other than as to infomtation related to Fees due under this references this Agreement, constitutes the complete agreement between ilia
Agreement, which shall tenninate tvo (2) years after the termination or Parties and supersedes all previous and contemporaneous agreements,
expiration of this Agreement,the confidentiality obligations of Provider and Proposals or representations,written or oral,concerning the subject matter of
its employees, agents and contractors shall survive indefinitely after the this Agreement-
termination
greementtermination or expiration of this Agreement.
Page 3 of 10
Master Service Agreement over$10k version 2.0
March 2009
I
SERVICES AGREEMENT
y
8.8 1»rendiueut 8.14 Gifts
\wither this Agrecnment nor an Addendum may be modified or amended Provider is prohibited from providing gills or other things of value worth
except in writing signed by a duly authorized representative of each Party.No more than S25 cunudative during the Tenn of the Agreement to Property
other act,document,usage or custom shall be deemed to amend or modify this Owner or its affiliates,employees agents or contractors.
Agreement. or an Addendum. ft is expressly agreed that any teens and
conditions of Property Owner's purchase order,terns sheet,agreement or other 8.15 Third Pare,ffencfciariev
negotiations with Provider shall be superseded by the teens and conditions of
this Agreement and the applicable Addendum_
This Agreement is for the sole benefit of the Parties,except that r\[CICO and
its affiliates are intended to be third patty beneficiaries of this:Agreement with
8.9 Farce alnjrrrre respect to Sections 3.2,5.15,6.17 and the Indemnified Parties with respect to
Provider's indemnification.
tach Party shall be excused for failure to perform:umy part of this Agreement
due to events beyond its control,including but not limited to fire,stonn,Hood, 8.16 No Uve of Aame
earthquake, explosion, accident, riots and other civil disturbances, sabotage,
strikes or other labor disturbances, injunctions, transportation embargoes,
computer vintses,acts of teiTorisnt or delays, failure of performance of third Provider shalt not publicize, publish or other y advertising,
use the pante of Property
parties necessary for the Parties' performance under this Agreenmen� or the Owner, documeAIMCOnt,
or any th their a(fisclostes in way a contractual
r customer list or
laves or regulations of the federal, state or local government or branch or sumhilar document, or otherwise disclose the contractual relaliouship vwilh
agencyereofthereof, provided, however, no force tuajeure event shall excuse the Property Owner,AINICO,or their affiliates,without the prior written approval
obligation of the i'arty claiming the benefit of it force majcatre event from of:\I\[CO,which may he given or withhold in:1IMC0's sole discretion.
paying the applicable Pees for any Services provided; and, furter provided,
that the party whose performance is being interrupted shall provide inunediate 8.17 Ao 1lecordatiorr
notice to the otter Party.if(tic force nhajeure event continues for len(10)or
more days, then such nun-performing Patty may terminate this agreement, Provider shall not record this:\greenest,the Addcndunh or it memorandum of
Property Owner may procure services from all alternative service provider either.
during anti alter a period of force nmajeure.
8.18 Electronic 3l:vtem frrtegraliou
8.10 A.vsigrrahilitl; Yuc•cavvors•crndAssigns
Provider agrees to provide all reasonable cooperation requested by Property
Neither Party hereto shall assign this Agrecmaat in whole or in part without Owner as Property decors necessary in order to allow Property Ovvner to
the prior written consent or the other Party hereto,which consent shall not be implement and integrate an electronic method of purchase order submission;
unreasonably withheld or delayed, provided, however that MMCO or an electronic meted of procurement and payanenl; and an c-commerce
Property Owner shall have the right to assign this Agreement without program system. Upon implementation of such electronic systems, Provider
Providor's consent.11riM Agreement shall inure to the bcrwfit of and 76..11 bo shall accept and record purclhaso orders and paymonta from Propotiy Owner
binding upon the suceassor and permitted assigns of the Parties hereto. through such electronic systems.
8.11 Construclion 8.19 frrtellectual Property
13cscriptive headings to Sections are for convenience only and Miall not a. In ilio event that the Services involve the provision of
control or affect the meaning or construction of any provisions in this :any sollw:re, material, information or products that involve Intellectual
Agreement. Property, Provider represents that it has agreements in place with its
employees and independent contractors sufficient to convey all ownership in
8.12 Counterparts such work product to Property Owner,and that Provider will,during the temm
of this Agreement,including any renewal term,enter into agreenhents with its
employees and independent contractors,sufficient to convey all ownership in
'flmis Agreement ilia),be executed in one or more counterparts,each of which such work product to Property Owner.
shall be deemed an original instrument,but all of which counterparts together
shall constitute one and the same instrument.Transmission by facsimile of an
executed counterpart signature page hereof by a Party hereto shall constitute b• If Provider refuses or Properly Owner is unable for any
due execution and delivery ofthis Agreement by such Party, reason to secure Provider's signature to execute any assignment or to apply for
or to pursue any application of any United Slates or foreign patents,
trademarks or copyright applications or registrations covering the Intellectual
8.13 Arbitration Property, then Provider hereby irrevocably designates and appoints Property
Owner and its duly authorized managers,members,representatives and agents
In the event a dispute shall arise between the parties to this Agreement or the as the Providers agent and attorney in fact, to act for and in the Provider's
Addendum, it is hereby agreed that the dispute shall be administered in behalf and stead to execute and file any such applications and to do all other
accordance with the then current Commercial Arbitration Rules of the lawfully.pennitted acts to further the protection and issuance of letters patent,
American Arbitration Association ("AAA-)_ Any matter to be settled by or copyright registrations thereon with the same legal force and effect as if
arbitration shall be submitted to the AAA in Denver, Colorado. The Parties executed by Provider. Provider further agrees that Provider's obligation to
shall attempt to designate one arbitrator from the AAA. If they are unable to execute or cause to be executed,when it is in Provider's power to do so,any
do so within 30 days after written demand therefore, then the AAA shall such instrument or papers shall continue after the termination of this
designate an arbitrator. The arbitration shall be final and bindin- and agreement until the expiration of the last such intellectual property right to
enforceable in any court of competent jurisdiction_The arbitrator shall award expire in any country in the world-
attomeys' fees (including those of in-house counsel) and costs to the
substantially prevailing party and charge the cost of arbitration to the Party 8.20 IirebsiteAcc•ers
which is not the substantially prevailing Party. Notwithstanding anything
herein to the contrary,this Section 8.13 shall not prevent either Pauly from
seeking and obtaining equitable relief on a temporary or permanent basis from Property Owner or AINICO may permit,in their sole discretion, Provider to
a court of competent jurisdiction located in Denver, Colorado. The court's access certain websites which contain information about AINICO, its
Jurisdiction over an such equitable maser, however, shall he expressly affiliates, andror their properties or business. If Property Owner or.AIhfCO
Jurisdiction
} q V P } permits such access, Provider will be given a user name and password.
limited only to the temporary, preliminary or permanent equitable relief
sought Property Owner or AINICO may change the user name or password at any
time or deny access to the website(s)at any time. Property Owner or AIMCO
Page 4of10
Master Service Agreement over$10k version 2.0
March 2009
r
SERVICES AGREEMENT
rt
also may change the inforntation on tho websites) at any time. The
information contained on the website(s) is confidential and Subjact to the
confidentiality provisions of this Agreement. None of aU ICO, Property
Owner or their alliliates make any representations or warranties regarding the
information contained on the website(s)and Provider uses such information at
its own risk: Provider may use the inforntation on the website(s) only for
Purposes of liuthering its activities tinder this Agreement.
3.21 Books mul Records
Provider shall maintain books and records with respect to the Services to be
provided and the Compensation to be paid hereunder. Property Owner shall,
for a period of three years afler the expiration or termination of this
Agreement, have the right to review and audit the books and records of
Provider with respect to such Services. fm the event such audit determines that
Property Owner has overpaid Provider, Provider shall immediately pay the
aniount of overpayment plus interest at 12%per annum from the date when
such Compensation originally was paid.
5.22 Signvfnre l uthority and Mandity
Any trunnnolion ovor$10,000.00 in ounudativ.valuo over tho Turns of thin
Agreement,or binding more than one(1)Property Owner,shall be valid only
if signed by a vice president or higher ranked individual within Properly
Owner.
[the remainder of this page intentionally lc jt bleinki
Page 5 of 10
Master Service Agreement over$1 Ok version 2.0
March 2009
'jLRVlLL,S AGREEMENT
i
ADDENDUM TO SERVICES AGREEMENT—EXIIIBIT A
-
1. 1\rame of Property Omier: AIMCO NORTH ANDOVER, L.L.C.
2. COIII 111urlily Name(if applicable):Roayl Crest Estates
3. Apartment Property Address(include street address,city, slate and zip code):.
-S0 Royal Crest Drive,North Andover, 11tA,01845
-t. Apartment Property Telephone Number&Facsimile Number(include area code):
Phone: (978)681-1822
Fax: (973)682-9064
5. Address for Im oices: AINICO, PO Box 981725, El Paso TX 79998-1725(w/duplicates to property)
6. Full Lc8al Name of Provider: East Coast Cener:ll Contr: sting alta Thomas 11. Kinnel
7. Provider's Address(include street address, city, state and zip code):
286 Broadway,E1a1•crhill MA 01832
8. Provider's Teleptlone Number& Facsimile Number(include arca code):
Phone: 978-360-0051
Fax: 978-372-4215
East Coast General
BUILDING RESTORATION PROFESSIONALS
286 Broadway Haverhill, Ma. 01832
Phone 1-978-360-0051 Fax 1-978-372-4215
10/30/12
North Andover 48-04 Drywall Repairs
Provide and apply Drylock foundation coating to interior of exposed foundation.
Provide and install baits insulation as necessary.
Provide and install 6 mil poly vapor barrier over installed insulation.
Provide and apply compound,sand smooth,prime and paint bath ceilings to match existing.
Provide and install 640 Sq/Ft of M.R.sheetrock on all areas removed by others.
Provide and apply compound to all new sheetrock.
Sand smooth,prime and paint all new sheetrock surfaces two coats.
Provide and install 60 L/Ft.of 3 'A inch wooden baseboard.
Paint baseboard to match existing.
Provide plastic floor and wall protection through out the project.
Clean up and removal of all job related debris.
Household cleaning of affected areas.
Sheetrock to be removed by others.
For the sum of,Three Thousand Three Hundred and Forty Dollars. $3,340.00
co East coas eneral ntra
DATE MMIDONYYY)
A912712012
�d CERTIFICATE OF LIABILITY INSURANCE `
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 FRED C CHURCH INC CONTACT NAME
CONNECTOR PARK 41 WELLMAN ST PHONE(AIQ No.E,0- 78 8-1865 FAX INC.No): (9781454-1865
LOWELL, MA 01851
E-MAIL AIXx+Ess:
INSURER AFFORDING COVERAGE NAICS
INSURER A: Ube&j Mutual Insurance
INSURED INSURER 13:
THOMAS H KINNAL
DBA EAST COAST GENERAL CONTRACTING INSURER C:
286 BROADWAY INSURER D.
HAVERHILL MA 01832 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 1423 61 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 I SUIBR TYPE OF INSURANCE POLICY NUMBER POLICY
u�EFFPOLICYYY
EXP
LTR LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
COMMEROAL GENERAL LIABILITY PRE141SES(Ea occurrence) $
CLAIMS44ADE D OCCUR MED EXP(Arty one person) $
PERSONAL&ADV INJURY $
GENERAL AGGREGATE $
GEN1.AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPiOP AGG $
POLICY PRO ECT LOC IMIT $
AUTOMOBILE LIABILITY Ea aaident I $
ANY AUTO BODILY INJURY(Per person) $
AALUT�ED 8 AUTOS LED BODILY INJURY(Per acdderR) $--
HIR®AUTOS AllrOS P�tOPreDAMAGE $
er
$
$
UMBRELLA UAB OCCUR EACH OCCURRENCE $
EXCESS UAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
$
$
A WORKERS COMPENSATION WCS-31S-353816-M 2/23/2012 2/23/2013 T'0%UMIUTS
AND EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE Y111 EL EACH ACCIDENT $ 500000
OFFlCER/MEMBEREXCLUDEO'T Q N/A
(Mandatory In NH) EL DISEASE-EA EMPLOYE $ 500000
If yes,=under
DESCRIPTION OF OPERATIONS bebw EL DISEASE-POLICY LIMIT $ 500000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,0 more space Is required)
Workers compensation insurance coverage applies only to the workers compensation laws of the state MA.
CER71FICATE HOLDERCANCELLAM N
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
AIMCO NORTH ANDOVER LL.C. THE EXPRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
50 ROYAL CREST DRIVE ACCORDANCE WITH THE POLICY PROVISIONS.
NORTH ANDOVER MA 01845
AUTHORIZED REPRESENTATIVE
M�L UaAA
Jeff Eldridge
m 1988-2010 ACORQ CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
CWP NO.: 14235761 Katherine Nicholos 9/2712012 2te2:1. PN Page i of 1
This certificate cancel.and supersedes ALL previously issued certificates.
i
f 1 ® DATE(MMIDONYYY)
AC
��REP CERTIFICATE OF LIABILITY INSURANCE 091V12012
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).
CONTACT PRODUCER NAME: AMreaGaOagher
Fred C.Church,Ina PHONE 97832Z7172 FAX 978 4541865
41 Wellman Street - AIC N Ext): AI No.
Lowell,MA 01851E-MAIL agalloghe +urchmm
(80(11)225.1885 ADDRESS:
INSU AFFORDING COVERAGE MAIC#
INSURER A• Peerless Insurance Company 24198
INSURED
Thomas H Kmnm DBA East eral Contrxting INSURER B
Co"ast
INSURER C:
285 Broadway
Haverhill.MA 01832-2908 INSURER 0:
INSURER E:
INSURER F:
COVERAGES
-
COVERAGES CERTIFICATE NUMBER 21121 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.
�� TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1.000,000
DA ACE TO KEM M
X COMMERCIAL GENERAL LIABILITY PREMISES Ea oceurrence $ 100,000
CLAWSMADE M OCCUR MED EXP Arty one person) $ SAW
A CSPS384091 2115=12 7!152013 PERSONAL&ADV INJURY $ 1'000'000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,00000
POLICY PRO- LOC $
AUTOMOBILE LIABILITYO wart)BIINED SINGLE LIMIT $ 1,000,000
(EaANYAUTO BODILY INJURY(Per Person) $
A AAL ED X SCHED LED BAS382891 2/132012 2!132013 BODILY INJURY(Per accidea) $
OS X HIRED AUTOS X
AUTOS (Par,PROW DAMAGE $
er accmerd
$
UMBRELLA UABHCLA,MS-MADE
OCCUR EACH OCCURRENCE $
EXCESS UAB AGGREGATE $
DEC) I I RETENTION S $
WORKERS COMPENSATION WC STATII OTH-
AND EMPLOYERS'LIABILITY Y I N EfL
ANY PROPRIETORIPARTNERIEXECIITIVEa MIA EL EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED)
(Mandatory in NH) E.L.DISEASE-EAEMPLOYEE $
=:
scribe under
PTION OF OPERATIONS bebw EL DISEASE-POLICY LIMtT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Sdadule,I more space is required)
Property Name:Royal Crest Estates(North Andover)
COr1baG No:14MM-404879-CP-00002
Coverage includes owner as Additional Insured
CERTIFICATE HOLDER CANCELLATION
AI MCO NORTH ANDOVER LLC
50 Royal Crest Drive SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
North Andover,MA 01845 THE EXPIRATION DATE THEREOF, NOTICE WILL. SE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
_
CraMa Met# Z1 125 CertHOlder# ®1888-2010 ACORD CORPORATION. All rights reserved.
ACORD 26(2010/03) The ACORD nine and logo Bre registered marks of ACORD
The Comwnweatth ofHassachusetls
fn Am Department oflndustrial Accidents
Off"ice of.nvadgations
600 Washington Street
Bosfon,M4 02111
,�. www.massgovldia
Workers, Compensation Jmsuranre Affidavit:Bonders/Coxxt racEors/FIectdciaw)Plu tubers
Applicant Information `� Please Brant LesaiblY
NaNam(ausftm40rgsaizeiionRadivlduaD: 4A-6T COO-r 6 g/�i4 l 60 417Fer` -ff'u 4-
Address• 2-9'6 6 V4 nw4i
City/State/Zip: /4A;v-tl'l A M/g- D t 9Y Z_ Phone#: 9 7S' 3:;�6
Are you an employer?Check the appropriate box: Type ofproject(required):
1.�I am a employerwith 4. Q I am,a general contractor andI 6. ❑New constnm&.n
employees(fall-andlorpart tame).* have biredthe sub-contractors
2.0 I am a sole proprietor orpartrrer- listed on the attadlxed sheet t 4. ❑Remodeling .
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me im any capacity; workers'comp.insurance. 9. Building addition
(No workers'comp.insurance 5. Q We are a corporation and its 10.❑Electrical xepairs or additions
xeguized.) officers hava exercised their
3.Q 1 am a homeowm doing all work right of exemption per MOL. 11.E]Pk mbing repairs or additions
myself [No workers'comp. c.152,§1(4),and wehave no 12TIRoofrepairs
em 1 ees. o workers'
insurancexegnired.]fi p o3' � 1313 off=
comp,asarancereT*e ]
?Any applicantthatchedrsbocilnniddtofliIoutthoswff=betowshowIngth*worIM&compeusaKonpolieyfi onnWan.
THomeaiamm who submitt5is dMr&kdkztingthey am doing ail work and$hen hue outside codmotw must sobmR a na affidavit indicating snoh.
ToDnhactorsthat check fiilsboxmnstaNarhedanadditionalshod mhowingfhenam ofihesub-contracft and thekwoXIM'comp.policy i CRUM dIon.
I am aPt employerfltat isprovidingMarkers'eomper�.satian insuraxceformy errgfloyeea: Betow is thepoTicy and'job srte
informat/rin, ��� / [
/
Iusmance CoMpanyName: It l �
Policy#or self-ins.Lie.# WC 5 3 r. 3 53'_3 a DwitaflonDate; Z Z 3. /✓2
]'ob Site Address- -5-0 4t C-fts7" tele � Ci[ylState/Lip: �•/{WB64, A(,+�
Attach a copy of fixe workers'compensation pollcy declaration page(showing the policy nmxrber and eapiraflon date).
Faa7ura to secure coverage as required wader Section 25A of MGL c 152 can leadto tine imposition of criminal penalties of a -
fine up to$1.,500.00 and/or one-year imprisammmt:as well as ek&penalties iatlw farm of a STOP WORK OEDBR and a fm
ofup to$250.00 a day agahwtiho violator. Be advised that a copy oftixis statementmaybe forwarded to the Office of
Investigations oftheDIAfor imsmance coverageveaftcation.
Ido Trereby eert'ify under Mepaft penalties ofperjury mat the fnflormadonprovidedab veIs true iMdcorrec4
g.
Date:
Phone A: 360 —60-5' 1
OfjZdar use ordy. Do not wrI&in this aretg to be completed by c8fy or fnWn official
City or Town: Permff/Mcense#
Issuing Auftiorw(cirdle one):
1.Board ofHealth Z.ButidiagDepartment 3.City/Town Clerk 4.Electrical hTeetor IFImmbingInspector
6 Other
ContactPerson: . phone N.-
Massachusetts -Department or" Pubilc Safety
Board of Swiding Regulations and Standards
Construction Supcnisor :H
License: CS-082747
THOMAS H IQNNCI. ..,
286 BROADWAY.
HAVERHILL MA 01832 ,L
Grxrr�xs,ioner 06/20/2014
n
5
4
' � I