Loading...
HomeMy WebLinkAboutBuilding Permit #1072-15 - 60 RALEIGH TAVERN LANE 5/1/2018 } f `tORTh q P4W +0L�F BUILDING PERMIT TOWN OF NORTH ANDOVER ° 1- APPLICATION FOR PLAN EXAMINATION - Permit NO: V � '� �/� Date Received * 0 40 Date Issued: 9SSacNus�t IMPORTANT: Applicant must complete all items on this page LOCATION (00 �'"' ai� Tauex �&3r�kAAANu - 1 Print ` PROPERTY OWNER Urger f v � d S Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Buildingne family ❑Addition ❑Two or more family ❑ Industrial .,+I'Ateration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ri Septic ❑Well C, Floodplain F Wetlands [] Watershed District ❑Water/Sewer Identification Please a or Print Clearly) OWNER: Name: �10'�Y' Phone: 3^ Address: Ct ✓ CONTRACTOR Nam6: Phone: l�'4�L L-2 Address: 96` � P//] A1,2ZI 4A?�� Supervisor's Construction License:CExp. Date: S���� �Z Home Improvement License: l � ) Exp. Date: �, 20�Z � x e ARCHITECT/ENGINEER Phone: Address: Reg. No. c Y FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Proj4ct Cost: $ ���o�� FEE: $ 7 � Check No.: 2�z Ll(a s- Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to a guarantyfun Signature of Agent/Owner Signature of contract _ BUILDING PERMIT o* NORTFr q 4t'OER X 6 7 tiO TOWN OF NORTH ANDOVER �2 tib''`- __ '•; APPLICATION FOR PLAN EXAMINATION A� R 1• Permit No#: Date Received 74°�RA IE 4y �SSACHus�� 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 0 Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: + ARCHITECT/ENGINEER Phone: Address: Reg. No. ' FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tar ing/MassageBody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS i CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoe ing Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: . Located 384 Osgood Street ._FIRE',DEPART.MENT -.Tempy,Durnpster onk�site ,yes _ LL ono__ Locatedat 124Mam�S.feet� ...A. Fre�Departmenta�ignature/d'a"te _._ COMMENTS -- Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Suilding Pennit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract aFloor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) 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) ik Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses �. Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location r No. / 7 ^ Date . - TOWN OF NORTH ANDOVER e. Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ • TOTAL $ 41, Check# & Buiiding Inspector t Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 391820.00 m $ - $ 477.84 Plumbing Fee $ 59.73 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 59.73 Total fees collected $ 697.30 60 Raleigh Tavern Road 1072-15 on 6/23/2015 Remodel 3 bathrooms Location 60 6 No. ` Date 121- 27- TOWN 2TOWN OF NORTH ANDOVER . Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee -- $ t;�b TOTAL V Q � �' $ Check {1 of / i7 u 1 Building Inspector NORT1y Town Of _ Andover No. b 2— * _T... * h - ver Mass 26145 o LAKs 1. e Coc"ICKl. V �.qs a�reo U BOARD OF HEALTH Food/Kitchen PE' R Septic System THIS CERTIFIES THAT „ . ........�......,i',,,.,� ......... , ................ BUILDING INSPECTOR Foundation has permission to erect .. ................. .... buildings on .. ... .......... Rough to be occupied as ....... r ........ ....... .� .............................. Chimney . 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC I _N STA TS Rough Service i 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. t%ORTH own of s 711, Andover 0 1'In No. h ver, Mass, cOCHIC" WIC.' 1_ �•9 A°R'4rIE S U BOARD OF HEALTH Food/Kitchen PERIT T LD Septic System THIS CERTIFIES THAT ........ �U—� :.. . .....e?.. �:: ............ BUILDING INSPECTOR Foundation has permission to erect ......... ................ buildings on . ../. .. ?.J. l../r�.�......l. .l�.�:��Y... G � / ...... Rough to be occupied as .......... .....1� .Gc�� ...... .y. ✓-,r,1;4�7.n' ................................... 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST RTS 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. 10 Briclwnts Mill Road Hampstead,NH 03341 phone:!603,1 329.507 i Fast:(603)3'_'4.:0'_'6 ACCEPTANCE/PROPOSAL LETTER Revision#2 Date: May 14,2015 Client Name: Rob & Susan Rogers Job Location: 60 Reliegh Tavern Lane, North Andover, MA Telephone Number: 617-943-2176 Job Description: Bathrooms Remodel & Interior Millwork Dear Mr. & Mrs. Rogers; We propose hereby to furnish labor and materials in accordance with the customer provided specifications (as discussed), for the scope of work as follows: Powder Room Remodel Tear Out 1. Remove and dispose of existing toilet. 2. Remove and dispose of existing baseboard molding, and door casing. 3. Remove and dispose of existing the flooring and underlayment 4. Remove and dispose of existing pedestal sink and faucet. 5. Remove and dispose of existing mirror. 6. Remove and dispose of existing wall sconces. 7. Strip and remove existing wallpaper. 8. Remove and dispose of existing FHW baseboard heat trim, and end caps. Install Bathroom- 1. Supply materials for and patch drywall as necessary due to wire relocation, tape and sand. 2. Skim walls as required to prep for new wallpaper installation. 3. Supply materials for and skim coat remaining wall areas. 4. Supply and install new underlayment and tile flooring. (Allowance included for tile, is $120.00) Customer Initials: 5. Install customer supplied mirror, above pedestal sink. 6. Supply and install new primed colonial baseboard trim. 7. Supply and install new primed 2 '/z" colonial door trim. 8. Prepare walls and install new client provided wallpaper. 9. Install new towel bar, toilet paper holder. (Allowance included for accessories is $65.00). 10.No priming, painting or staining, has been included in this estimate. Plums 1. Install new toilet, same location. (Allowance included for Kohler toilet is $342.70) 2. Provide materials for, install and new "White Gerber" pedestal sink, and "Danze" brushed nichol faucet and make final connections to same. (Allowance included for new pedestal sink is $254.00 and new faucet is $227.23). 3. Supply materials for and replace FHW baseboard heat trim and end caps. Electrical- 1. lectrical-1. Relocate wiring and install new single light bar above new mirror. Light bar to be provided by client. 2. Update outlet to GFI, as per code. 3. Provide wiring for and install new fan/light unit. (Allowance for fan/light unit included is $251.77). 4. Provide materials for and vent new fan unit to exterior. Debris Removal- 1. Remove and dispose of all construction debris from site. 2. Apply for building permit, call for inspections as required. Building permit fee to be billed at face value, cost of permit has not been included in this estimate. Powder Room Remodel Total $6,185.00 2nd Floor Bathroom Remodel Tear Out 1. Remove and dispose of existing toilet 2. Remove and dispose of existing vanity, vanity top, sink, and faucet 3. Remove and dispose of existing light bar. 4. Remove and dispose of existing medicine cabinet, and light bar 5. Remove and dispose of room center light fixture. Customer Initials: SE 6. Remove and dispose of existing drywall on all walls, and ceiling. 7. Remove and dispose of existing exterior wall insulation. 8. Remove and dispose of existing cast iron tub unit 9. Remove and dispose of existing the on half walls, and the on shower walls, and shower ceiling. 10.Remove and dispose of existing shower head, valve, trim, tub spout, and drain assembly. 11.Remove and dispose of tub/shower header. 12.Remove and dispose of existing FHW baseboard heat trim cover and end caps 13.Remove and dispose of existing baseboard, door and window trim. 14.Remove and dispose of existing the flooring, and underlayment. Install 2nd Floor Bathroom 1. Aid plumber with installation of new 60" X 32"tub unit with the flange. 2. Provide and install new exterior wall insulation. 3. Provide and install new tile substrate at shower area, tape and waterproof. 4. Provide and install (1) recessed shower niche at shower area. 5. Provide and install drywall on all walls. 6. Provide and install drywall on ceiling, tape and sand. New ceiling to have smooth textured finish. Drywall on ceiling is to be applied to existing strapping; no leveling of ceiling has been included in this estimate. 7. Provide and install new tile flooring, including underlayment. (Tile allowance included in this estimate is $275.00) 8. Install new Woodpro Ashford Maple vanity base cabinet, including toe kick molding and hardware. (Vanity and hardware allowance included in this estimate is $893.00). Shim cabinetry as necessary due to tile floor installation. 9. install new Palette granite vanity top, with bowl, with left side splash. (Vanity top allowance included in this estimate is $245.00). 10.lnstall new client provided mirror above new vanity bowl. 11.Provide blocking for curtain rod, and install client provided rod. 12.lnstall new towel bar, toilet paper holder. (Allowance included for accessories is $65.00). 13.Supply and install clear pine colonial baseboard molding 14.Provide and install new primed colonial 2 '/2n door and window molding. 15.No priming/painting or staining has been included in this estimate. Plumbing/Heating 1. Install new toilet, (12" rough), at existing location. (Toilet allowance included is $438.00). 2. Rework existing plumbing as required, and make final connections to new vanity bowl and "Danzen Fairmont faucet. (Faucet allowance included is $257.59). Customer Initials: SQ 3. Provide materials for and rework tub drain as required. 4. Provide materials for and install new 60 X 32" 3 piece tub and wall unit. (Tub allowance included in this estimate is $1,306.00). 5. Provide materials for and rework and install new"Danze"Fairmont showerhead, valve, trim kit, tub spout, and drain assembly. (Showerhead and valve allowance included in this estimate is $233.00). 6. Provide materials for and install new FHW baseboard trim and end caps. Electrical- 1. Install new client provided light bar above new medicine cabinet, rework line as required. Wire to existing switch. Light to be raised higher than existing. . 2. Provide materials for and install new GFCI outlet, at existing standard outlet location, as per code. 3. Provide wiring for and install new fanllight unit. (Allowance for fan/light unit included is$251.77). 4. Provide materials for and vent new fan unit to exterior. 5. Provide and install new sealed recessed light in shower area, wire to appropriate switching. Debris Removal- 1. Remove and dispose of all construction debris from site. 2. Apply for building permit, call for inspections as required. Building permit fee to be billed at face value, cost of permit has not been included in this estimate. 2"d Floor Bathroom Installation Total $13,935.00 2"d Floor Master Bathroom Remodel Tear Ou 1. Remove and dispose of existing toilet 2. Remove and dispose of existing vanity, vanity top, sink, and faucet 3. Remove and dispose of existing mirror, and light bar 4. Remove and dispose of shower light fixture. 5. Remove and dispose of existing drywall on all walls, and ceiling. 6. Remove and dispose of existing exterior wall insulation. 7. Remove and save for reinstallation existing fan/light unit. 8. Remove and dispose of existing heat lamp, wiring and switch.. 9. Remove and dispose of existing tile on walls, and tile on shower walls. 10.Remove and dispose of existing showerhead,valve,trim,and drain Customer Initials: SSC Z assembly. 11.Remove and dispose of shower header and wall framing. 12.Remove and dispose of existing FHW baseboard heat trim cover and end caps 13.Remove and dispose of existing baseboard, door and window trim. 14.Remove and dispose of existing tile flooring, and underlayment. 15.Remove existing closet framing, door and shelving. 16.No rot or mold repairs have been included in this estimate. Install 2nd Floor Master Bathroom 1. Provide materials for and frame half wall at shower area, approximately 34" length, 42" in height. 2. Aid plumber with installation of new 64"X 34" shower pan, center drain. 3. Provide and install new exterior wall insulation. 4. Provide and install new tile substrate at shower area, tape and waterproof. 5. Provide and install (1) recessed shower niche at shower area. 6. Provide and install drywall on all walls. 7. Provide and install drywall on ceiling, tape and sand. New ceiling to have smooth textured finish. Drywall on ceiling is to be applied to existing strapping; no leveling of ceiling has been included in this estimate. 8. Provide and install new the flooring, including underlayment. (Tile allowance included in this estimate is $365.00) 9. Provide and install new shower wall the and floor tile (tile to ceiling). Wall tile pattern installation included (Wall the allowance included in this estimate is $800.00) 10.Install new Woodpro Ashford maple double bowl vanity base cabinet, including toe kick molding and hardware. (Vanity and hardware allowance included in this estimate is$1,545.00 ). Shim cabinetry as necessary due to tile floor installation. 11.Install new Palette granite vanity top, with (2) bowl, with left side splash. (Vanity top allowance included in this estimate is $498.00 ). 12.lnstall (2) new client provided mirrors above new vanity bowls. 13.Template for and Install new frameless shower door. (Shower door allowance included is $1,600.00) 14.lnstall new towel bar, toilet paper holder. (Allowance included for accessories is $65.00). 15.Supply and install clear pine colonial baseboard molding 16.Provide and install new primed colonial 2 Y2" door and window molding. 17.No priming/painting or staining has been included in this estimate. Plumbing4Heating 1. Install new toilet, (12" rough), at existing location. (Toilet allowance included is $438.00 ). 2. Rework existing plumbing as required for new double bowl, and make final Customer Initials: 5 Z.l connections to new vanity bowls and "Danze" Fairmont faucets. (Faucet allowance included is $515.18). 3. Provide materials for and shower drain as required. 4. Provide materials for and install new 64 X 34" shower pan unit. 5. Provide materials for and rework and install new"Danze" Fairmont showerhead, valve, trim kit, and drain assembly. Shower control valve to be installed at half wall location. (Showerhead and valve allowance included in this estimate is $273.00). 6. Provide materials for and install new FHW baseboard trim and end caps. Electrical- 1. lectrical-1. Wire for and install new client provided light bars above new medicine cabinets, wire to appropriate switch 2. Provide materials for and install (1) new GFCI outlet, as per code. 3. Provide materials for and relocate existing outlet and switch as per new layout. 4. Re-install existing fan//light unit, connect to existing exterior duct work. 5. Provide and install new sealed recessed light in shower area, wire to appropriate switching. Debris Removal- 1. Remove and dispose of all construction debris from site. 2. Apply for building permit, call for inspections as required. Building permit fee to be billed at face value, cost of permit has not been included in this estimate. 2nd Floor Master Bathroom Installation Total $19.700.00 Grand Total $ 39.820.00 TERMS OF PAYMENT $ 4,000.00 To be paid at signing of this contract. $ 3,000.00 To be paid upon start of project S 5,000.00 To be paid at delivery of product $ 5,000.00 To be paid at the start of demo of master bathroom $ 5,000.00 To be paid at the start of installation of drywall main bathroom. $ 4,000.00 To be paid upon start of tile work in main bathroom. Customer Initials: -SCR- S 5,000.00 To be paid upon installation of finish trim and product installation of main bathroom and powder room. $ 5,000.00 To be paid upon start of the work in master bathroom $ 2,000.00 To be paid upon template of master shower door. $ 1,000.00 To be paid upon substantial completion. $ 820.00 To be paid upon completion of job. Substantial completion-Area in which work has been performed is functional,or occupancy can occur,and only punch list items remain to be addressed. Completion-When job has been completed as described in scope of work. Warran - (3)year warranty begins upon completion of contracted work. Warranty covers: - Defective workmanship,performed by Dube-Plus Construction. - All products are covered under manufacturer's warranties. - Items purchased by the client for install are not covered by the Dube-Plus warranty. Proposal price is valid for 30 days from receipt of contract. No rot repair has been included in this estimate,unless otherwise noted above. If rot is discovered, additional repair cost will be discussed with the client at time of discovery. initial Unless otherwise noted above all construction debris is to be disposed of in a dumpster that is to be located in a mutually acceptable location on the client's property. It is common for a dumpster and/or the truck servicing the dumpster,to leave marks and /or damage the lawn and/or driveway. Repairing the lawn and/ or the driveway is not included in this agreement; it is the total responsibility of the HOMEOWNER.The dumpster company is not to be held responsible:this is a standard term of their agreement and policy. initial Any unforeseen problems uncovered at the time of excavation such as underground electrical, ledge,etc. may result in additional charges AND if the existing material is not suitable for the backfill of the new foundation or slab, additional charges may be incurred. ,2 initial The homeowner is responsible to remove any and all furniture,pictures and fixtures in or around the work area prior to the installation process.All cabinetry must be emptied and appliances removed from the countertops.All pictures and valuable items should be removed from the vicinity of the work area as the installation Customer Initials: s� process often creates small vibrations that may cause these items to fall from the walls or shelves.While our workers take the utmost care to prevent incidental damage,we cannot be held responsible for damage to items that the homeowner neglected to remove.�VQ initial Out of Network Materials or Sub Contractors—Although not preferred,Dube will allow the use of materials from an approved out of network supplier or use of approved subcontractors that are not Dube Subcontractors; However,Dube can not guarantee the quality of the materials / installation or prevent delays that may occur. Dube reserves the right to apply additional charges in the form of a"change order" if costs are incurred to Dube while using"out of network" materials or subcontractors. S£ initial SERVICE CHARGE: A service charge on past due accounts will be computed at "Periodic Rate"of 2% per month,which is an"Annual Percentage Rate" of 24%. Customers shall be and are responsible for all costs of collection,including reasonable attorney's fees,arising from any breech of this agreement or failure to pay any amount due and owing Changes to the above specifications will be accepted only if a written request is made. We will then complete a"Change Order" to supply you with the additional charges or credits. No work can be changed, altered, or cancelled without an authorized"Change Order". Payment of "Change Order" is as follows: Full Payment will be due Upon Signature of Change Order. ACCEPTANCE: the price(s), specifications and conditions above are satisfactory and are hereby accepted. You are hereby authorized to proceed with the work as specified. I/We agree to make payment as detailed above. My/our (the customer's signature below constitutes full agreement. Wood Related Products- Wood is a product of nature and includes a variety of species with various densities,colors and grain patterns. Through this natural process,graining differences,mineral streaks and color variations should be expected. Color variation within a wood species is influenced by a number of factors such as moisture and mineral content of the soil,exposure to sunlight and genetic makeup. All of these variations combine to produce unique characteristics that provide the beauty and essence of natural wood. All woods change color over time,and no two pieces are exactly the same. The amount of change varies depending on the wood species,type of cut,and amount and color of stain pigment used. Customer Initials: Sic r While color samples give a general idea of the appearance of specific stain color and wood species combination,it is impossible to represent all of the grain patterns,wood and stain colors,and natural variations that will occur. I have tread and fully sussder:r nd the above described information 1 , Clients 3'ignature Date t-Rob rs Date UV ogers Date z i rianga�Ztruction, Date Dube-Plus It, . PLEASE INITIAL THE BOTTOM OF EACH PAGE BEFORE SIGNING Customer Initials: !?-' , tt r I i - — _:t:<�_ �, ��t.�.s'�'i its^�' � N` ._( � r_ �-• � _ I _ i . f I I _ 1 r • yi IcID j 01 Lo IleM _ , r IT I r , I � — � .. � _ .. .:.���Y � �„•.`IIS 1 , - – ,i 6 , iib m�{� ✓� y I �- � �—„ x P' t 1 _ ' ate+ i v.e✓ •. – ----_� - I r i a� NIP ��i � 1 f. . i . I i I F :, Department of IndustrialAccidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):Tk Address:10 ZLk, V .) City/State/Zip: 6 I Phone M 66 P92�-7 —gcn7 Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6.V[]NlNemoconstruction I am a sole proprietor or partner- listed on the attached sheet. 7. deling ship and have no employees These sub-contractors have g• ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance. 9 E] Building addition required.] 5. E] We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. o workers' right of exemption per MGL y � comp. 12.F] Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other. Comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such, :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have nployees. If the sub-contractors have employees,they must provide their workers'comp.policy number. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site iformation. isurance Company Name: IA- clicy#or Self-ins. Lie.MWCASO d Expiration Date: G )b Site Address: / City/State/Zip: ttach a copy of the workers' comp nation policy declaration page(showing the policy number and expiration date), iilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the•imposition of criminal penalties of a ae 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 'up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of .vestigations of the D for insurance coverage verification. 16 hereby certify un er the pai s nd penalti fperjacry that the information provided above is true and correct. natur : -_._.. .. . _._._. - _....... __. �._...... _..... - - -- ..-......- Dater.. lone#: — Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: A�® CERTIFICATE OF LIABILITY INSURANCE DATE{A1l,VDDJYYYY) F4/24/2015 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 pollcy(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 NAME: Judith George CIC,CPIA,CPIW FIAI/Cross Insurance PHONE (603)659-3218 FAX ,(603)645-4331 1100 Elm Street ADDRESs:7george@crossagency.com INSURER(S)AFFORDING COVERAGE NAIC 9 Manchester NH 03101 INSURERA.Union Insurance Company 25844 INSURED INSURERB:RCadia Ins CO, THOMAS A. DUBE CONSTRUCTION-PLUS INC. DBA INSURERC: Dube Plus & Dirt Pro; Watertown Village, LLC INSURERD- 10 BRICKETTS MILL ROAD SUITE C INSURERE• HAMPSTEAD NH 03841 INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 All 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 TYPEOFINSURANCE ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR POLICYNUMBER IMMIDDIYYYYI 1MM1DDNYYY) X COMMERCIAL GENERALLUI6ILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE OCCUR MAP RENTED $ 250,000 X No GL Deductible X CPA5028190-13 4/25/2015 4/26/2016 MED EXP(Any one person) $ 5,000 PERSONAL&.ADV INJURY $ 1,000,000 GENLAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 PRO- POLICY JECT LOC PRODUCTS-COMPIOPAGG S 2,000,000 OTHER: AI-OmwILessea1Contmdor-A S AUTOMOBILELIABILITY CLIN 1tSINGLELIMIT S 1,000,OOO B X ANYAUTO BODILY INJURY(Perperson) $ ALL OWNED SCHEDULED AUTOS CAA5028191-13 4/26/2015 4/26/2016 130DILY INJURY(Perao ident) $ X PROPERTY DAMAGE N yAV4NED $ HIREOAUTOS AUTOS Peratzrdml UnnstrodmWatpromft $ 25,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS UAB CLAIMSALOkDE AGGREGATE $ 1,000,000 DEO I I RETENTIONS CUA5028192-13 4/26/2015 14/26/2016 $ %YORKEROTH- S COMPENSATION WPA5028193-13 X AND EMPLOYERS`LIABILITY STA UTE ER ANY PROPMETORIPARTNERIFJCECtmVE YfN NIA (3a.) 1:4A &NS E.LEACHACCIDENT S 500,000 B (Mandatory IntNy EXCLUDED? Thomas Dube. excluded 4/26/2015 4/26/2016 EL.DISEASE-EA EMPLOYEI $ 500,000 NYes.desrnbs under DESCR1P110NOFOPERATIONS Wow E.L.DISEASE-POLICYUMIT S 500,000 DESCRIPTION OF OPERATIONS l LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule may be attached If more space Is required) Covering work performed by the Named Insured during the policy period. Lowe's Companies, Inc. and any and all subsidiaries are Additional Insured under General Liability and Auto Liability policies as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Lowe's Companies, Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Installed Sales Insurance ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 111 N. Wilkesboro, NC 28556 AUTHORIZED REPRESENTATIVE ,n J George CTC,CPIA,CPI `C1r ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 1NS0251�n1401t Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor �» License: CS-094372 LORIANN J LAN(,iAN 7 CREST ROAD KINGSTON NH 03848 � r Expiration Commissioner 07/31/2015 . r7f. //C l(71+)YR•///OJt[[/C11��� Mee of Consumer Affairs&Business Regulation s ME IMPROVEMENT CONTRACTOR fs; egistration: 119623 Type: Expiration: 8/6/2015 Supplement Dube Construction-Plus,-Inc: LORIANN LANGAN 10 Bricketts Mill Road,Suite"C" 2�+.� _ Hampstead,NH 03841 Undersecretary