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HomeMy WebLinkAboutBuilding Permit #174-2017 - 64 WHITE BIRCH LANE 8/19/2016 BUILDING PERMIT of 6 T ,�t�.eo ,°• �O TOWN OF NORTH ANDOVER o� 11 APPLICATION ' ' APPLICATION FOR PLAN EXAMINATION 'y' Permit No#: �� Date Received OR^TEO IPa .�5 '9SSq C HUS�� Date Issued: �- IM O1RTANT::,AAppli cant must complete all items on this page LOCATION1�C. `f'l�Ytr &Lver �,a Print PROPERTY OWNER A'C' r �,` 4 t 100 Year Structure yes (no MAP ( PARCEL: bq� ZONING DISTRICT:_ Historic District yeso Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building VOne 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 D Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 1' 1 z- I N 1 � Id ntificn- Ple se Type or Print Clearly OWNER: Name: ' Phone: l -5q_o 6 5 j Address: Wh' 'r k YLQ, �oclkfndo" Igio Contractor Name- Phone: y- 6m 93 Email: A , Address: k4 p h Supervisor's Construction License: -Exp. Date: 04Oq I fg Home Improvement License: 6q Exp. Date: w Ito I In 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: $ IWO FEE: $ r` Z� �J �1 Check No.: //b �I Receipt No.: NOTE: Persons contracting wi nregist red contractors do not have access to the uaranty fund $;Ignajyr� ignature of contractor r --~ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM , PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature. COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes V , Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FLRE,DEPARTMENT - TempsDumpster onsite Nyes lno,___.___ LocajN,af 1241Main 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) I Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits 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 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) 4, Building Permit Application 4 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 Permit Doc:Building Per t Rev►sed 2014 �nLocation � � 61;1C, k Lr, ` "' � � � �` No. [ -7G� Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $�? Foundation Permit Fee $ Other Permit Fee $ TOTAL Check _ n Building Inspector ,� i NORTH - Town of I,. 6Andover p - y` 0 No. I - o h ver, Mass, st 11 -wy COCNICNl WICK y�. I,p D04- E D S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ........ C6BUILDING INSPECTOR �e � L��............. Foundation has permission to erect .......................... buildings on M............ ........ .... ...... 6 . �� � Rough tobe occupied as ............. ....'......... .......... ................................................................................. chimney provided that the person accepting th s 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 CONS CTIO Rough IL Service . .... ..... =NS�i .. ...... Final BUI OR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. DIAMOND CONSTRUCTION, INC. I Worcester St,Suite 10 Grafton,MA 01519 ` HIC License:#176910 CSL License: #080830 D IAM O N D info@diamondconstructionma.com CONSTRUCTION INC. CONSTRUCTION AGREEMENT HIS AGREEMENT is made at On this day_R of I of 2016, by and between DIAMOND CONSTRUCTION, INC. (hereinafter the "Contractor") ands-le-s 0JcmA 5 V (hereinafter the "Owner")located at d q U,11 ,YP K:P,4 Lo ufg k-!+ , qAAae d_ u" DESCRIPTION OF SERVICES Diamond Construction,Inc.agrees to provide labor,materials,equipment and other facilities required to complete the following work: Scope of work 5-Ar P 12 r-2-tn=j 0 at the 1 iroperty located at Which owner warrants that it is the owner with full authority to enter into this agreement. Diamond Construction, Inc. agrees to start this project on RDI-& and shall complete the work on ..(Y/,�*U/`&. If the project passes final inspection and Owner refuses to sign Notice of Completion, then Contractor may sign this Notice of Completion on behalf of Owner as it will be assumed that he is satisfied with the work. 1 C/201 This document is binding and has serous legal consequences.Feel free to consult with a qualified attorney prior to signing. DIAMOND CONSTRUCTION,INC. SCOPE OF WO PRODUCT LIST/Description CERTAINTEED z 1) There will be a Project Manager inspecting the project 100% 2) Install Safety equipment before starting working o j ✓ 100/o 3) Cover hou3e&shrubs with tarpaulins for the protection r i 100% 4 Strip 2 lay rs roof shingle all the way straight to the wood 100% ('W V _ 5) (Each additional layer plus$30.00 per layer/per SQ) ? ? (If cedar I 50/per SQ)(If Slate$90/SQ) i 6) Re-nail all loose roof boards i100% 7) If wood is aeeded,the extra charge is$47.00 per 1/2" CDX plym ood or$4.00 linear foot of legend Boards i 8) Install Le k Barrier/Ice and Water Shield: 100% ✓ GAF uard❑Weather Watch 10 OR <:EertainTe ed WiZerG�uardO- S�and)*,,,,IGranularD Hig ack Hign 6 feet on the eaves,6 f feet on the valley,3 feet on rakes and Y2"Overhang to the fascia 9) Install S thetic Underlayment i 4 100% ✓ GAF Tiger Paw'❑ Deck-Armor'" R f ' ,---UertainTe ed Diamond DeckO 10} ;stall Dr p Edge: J� 100% ✓ 8"to the r of deck in 1"Overha to the fascia aluminum to all edges..Col r Choice: White Silver❑Brown n 11) Install A c Exhaust Ventilation: �— 100% ✓ GAF Cobr O Rigid Vent'O Cobra®Snow Country TM❑ or ertainT dRidge ent 12) Install Rk ge Cap Shingle: i _ 100% (� ✓ i GAF Timber Tex@❑ Seal-A-Ridge@❑ o r i ertainTed Ridge�Ca 1. 13)Apply Stai ter Strip Shingles to be aligned next to one another u 100% ✓� t with sealint toward the eave. 14) CaliforniaCut(1f any) 100% _ ✓ 15) 1pstall New Vent Pipes (If any) 100% ✓ 2 C/201 This document is binding and has serious legal consequences.Feel free to consult with a qualified attorney prior to signing. DIAMOND CONSTRUCTION,INC. PRODUCT ► ► QUANTY PRICE 16)Install M tal Flashing at every dormers and Wall Areas 100% 17)Install New Aluminum Step Flashing to the Chimney 100% 18) (U-ad Flashing Chimney at fair-market price$ ? 19)Note:If tlie siding removal is needed,extra cost may apply for ? labor and matei ial. 20) Install Ne w Architect Roof Shingle: GAF Timb rline❑ or CertainTeed Landmark O er" Sq.Ft $ Color Choice: ?irD Ye/to art? V cam►.c b _ q(3 21)Clean all me Gutters on the New Roof 100% ✓ 22) Use 3ft m gnet to remove all the nails from around the house 100% ✓ 23) Includes 21 Hurricane Nailing QPermits QDumpster 100% ✓ 24) Material is supplied by Diamond Construction INC. 100% ✓ 25) Sky Light 26) Gutters 27) Garage 28) Fascia 29) Shed Hou;e 30) Soffit 31) RED MEA S: THAT IS NOT INCLUDED IN THE PRICE ESTIMATE OR CONTY ACT.ADDITIONAL CHARGE WILL APPLY FOR LABOR AND MATERIAL. 32) This Symbol✓means that is included on the estimate or contract price. GRANT TOT $ 3 C/2015 This document is binding and has serious legal consequences.Feel free to consult with a qualified attorney prior to signing. DIAMOND CONSTRUCTION, INC. PAYMENT Owner agrees to pay Contractor the amount of $iD D (subject to adjustments such as _ additions and deductions pursuant to authorized change orders).Owner shall pay for all rmits _ licensf s and easements for permanent structures or permanent changes in existing facilities. In the a ent Owner obtains their own permits, Owners shall be excluded from Residential Contractor's Guaranty Fund pursuant to Mass. General Laws Chapter 142A. City permits and licenses to complete the work shall be paid by Diamond Construction. All payments are due and payable upon receipt. Payments will be made according to the following schedule: $ .00 Upon the execution of this agreement. Includes material costs,permit costs,and dumps er fee; 0 .00(whichever is greater)of the contract sum upon commencement of the work; $ �O .00(whichever is greater)of the contract sum upon completion of the work. If mate 'al/equipment required were special ordered there will be no exchanges, refunds, credits, or retw is. Payments shall be made in available U.S. funds and payable to "Diamond Construction, Inc." ayments made will be non-refundable once Contractor starts to perform, starts to demob lize in any way,engaged subcontractors,or has ordered materials.All payments will also be sub ect to deduction for administrative expenses. Owner agrees to pay $50.00 for each and any no -sufficient fund checks. If an invoice is not paid when due,interest will be added to and payablr on all overdue amounts at 6% per year.Owner shall pay all costs of collection,including without limitation,court costs and reasonable attorney fees. PLANS/SPECIFICATIONS 1VO f_Lec.C/eS b_Ov Prior to the start of the work, Owner shall provide to the Contractor all plans, surveys, specifications, drawings, blueprints, and reports describing the physical characteristics, soil, geolo cal and subsurface conditions, utility locations, and similar documents that may assist Diamo id Construction, Inc. in properly evaluating the extent and character of the work at the estima e stage.If any drawing,blueprint,floor plan,or specification violates or is in conflict with local li w or/and ordinance,and where any such situation results in any necessary changes in the work,1 hen Diamond Construction,Inc.shall be entitled to a reasonable adjustment to the Contract price a id time to correct it. 4 C/2015-This document is binding and has serious legal consequences.Feet free to consult with a qualified attorney prior to signing. DIAMOND CONSTRUCTION, INC. CHANGE ORDERS All change orders shall become part of this contract and incorporated by reference.The Ownei shall notify Contractor of any changes in construction or plan and shall provide revised drawiE gs, plans, or specifications followed by a change order. If the changes in the change order ertain to differing site conditions, errors in the plans and specifications, or other circurr stances beyond the control of the Contractor (including acts by the government, fire, flood, unusual delay in transportation, abnormal weather conditions, labor disputes, strikes, war, lack of worksite access, acts of God, natural disasters, or acts of third parties), then Contra-,tor shall submit to the Owner an estimate and proper adjustments to the contract price a id time.If pricing is inapplicable,cost of the change or the amount of the adjustment shall b determined based on the cost to Diamond Construction plus reasonable amounts for overlie d and profit. Contractor shall not be obligated to perform changes in the work or additional work until the Owner has approved,in writing,the changes to the contract price and time. SITE CONDITIONS Owner acknowledges the duty to disclose any and all pertinent and known hazardous condition information to Contractor and subcontractors and may not mislead or conceal any material or property facts such as how many layers of roof or type of roof was originally installel. Where a site owner does not disclose facts that subsequently cause delay or need further cost, then the Contractor will then be entitled to recover damages and a change order shall b allowed for additional costs. After consultation and agreement with the Contractor, Owner must immediately make an adjustment in the contract time and payment by issuing a change order if Contractor discovers and notifies owner of any of the following: (1)Hazardous Materials deemed by any federal, state or local governmental authority to pose a presei it or potential hazard to health,safety,or the environment; (2)Any Subsurface,visible,nonvisible,or latent physical conditions that are found unexpected or that eem different from the work agreed upon; (3) U own physical or other conditions that seem strange or materially different from those encounlered by Contractor's during and based on his construction experience. 5 C/2015- his document is binding and has serious legal consequences.Feel free to consult with a qualified attorney prior to signing. DIAMOND CONSTRUCTION, INC. Upon discovery of any of the above, Contractor shall immediately stop work at that particular site. Contractor shall have no obligation to perform any corrective or remedial work. TERMINATION Owner is required to first provide a 5 days advance notification of any alleged breach and allow C ontractor 10 days to cure such alleged breach. Owner may terminate the Contract if the Contractor knowingly disregards applicable laws, statutes, ordinances, or local codes, has committed a material breach,if contractor made an assigm rient for a creditor,or becomes insolvent. Diamond Construction, Inc. may terminate this Contract if Owner becomes insolvent, will not allow access to the site, Owner commits a material breach or fails to pay an invoice on time; work is suspended for 10 consecutive days through no act or fault of the Contractor or a Subcontractor, Sub-subcontractor or their agents or employees; or there is a stop work order by any co or any stop work order issued by any town or authority. If any of the above occurs, then D amond Construction shall send a written termination notice to the Owner and recover from d a Owner payment for work performed, including reasonable overhead and profit, costs incurre I by reason of such termination,and damages. If the Owner terminates the contract on convenience, he shall communicate of this intentic n writing to Contractor as soon as possible. Then, on or before the termination date, Con for shall be paid its actual costs for that portion of the work performed to the date of termine tion and for all costs of termination, including demobilization and any termination paymei its already made to vendors and subcontractors, plus 20 percent of all such costs for overhe and lost profit. INSURANCE he Diamond Construction, Inc. shall carry and maintain throughout the project period validWorkers' Compensation and General Liability insurance. Certificates of insurance can be provided to Owner upon request prior to commencement of the work. Contractor ensure that the general liability coverage to includes the Owner as additional insureds for claims caused in whole or in part by the Contractor's negligent acts or omissions during the Contractor's work. The Owner must have and maintain throughout the project and until completion property insurance coverage (Builders Risk Insurance or other suitable cover) at minimum the amount of the con met price. Property insurance including loss or damage shall cover the Owner, Diamond Construction,Inc., Subcontractors and Sub-subcontractors for their interest in the Work and shall 6 C/2015- rhis document is binding and has serious legal consequences.Feel free to consult with a qualified attorney prior to signing. DIAMOND CONSTRUCTION, INC. insure against the perils of fire with extended coverage and physical loss or damage including coverage for theft, vandalism, malicious mischief, collapse, debris removal. Owner waives all rights of recovery against the Diamond Construction, Inc. for loss of use of the Owner's propery, including consequential losses due to fire or other hazards, however caused, If the Owner does not have and will not obtain property insurance, the Owner shall inform Contractor in writ g prior to start of the work. If the Diamond Construction, Inc. is damaged by Owner's failure to have or maintain insurance as described above, without notifying the Contractor, then Owner will be responsible for all costs associated to such damage. Owner and Diamond Cons"ction, Inc. waive all rights against each other and against all other Subcontractors and Owner for loss or damage to the extent reimbursed by any property or equipment insurance applici ble to the work,except such rights as they may have to the proceeds of such insurance. If any ap licable policies of insurance require an endorsement or consent of the insurance company to pro 'de for continued coverage where there is a waiver of subrogation, the owners of such policies will cause them to be so endorsed or obtain such consent. Owner must not use or borrow any tolls or ladders owned by Contractor. If Owner,without consent, uses Contractor's tools or ladder,then he shall hold Contractor harmless of any liability whatsoever and will not place any claim Contractor's insurance. DELAY Diamond Construction,Inc. shall provide to the Owner notice of any delay in work. for chariges necessary due to work schedule, suspension of work or any other unforeseen cause beyond Diamond Construction's control and/or where there is no fault by the Contractor, its Subcoactors or suppliers. The contract time shall then be extended as necessaryt o accommodate delays via change order. SUSPENSION OF WORK DiamoAd Construction,Inc.,may suspend work for Owner's failure to pay invoice on time, due to differing site conditions, or for changes requested by Owner where Contractor deems it may suffer f nancial hardship. If work is stopped for a period of 10 consecutive days due to no act or fault of the Contractor or a Subcontractor or their agents or employees; or if because the Owner has repeatedly failed to fulfill the Owner's obligations under the contract then Contractor, at his discretion,may immediately suspend work,terminate the Contract,and recover from the Owner. The Owner may suspend work with advance notice to the Contractor.The written notice shall specify the date and the estimated duration of the suspension.Any Owner suspension shall not exceed 24 hours. Once the suspension is removed,the Contractor shall resume performance of 7 C/2015-i his document is binding and has serious legal consequences.Feel free to consult with a qualified attorney prior to signing. DIAMOND CONSTRUCTION, INC. tMt.,Wdrk as soon as it is possible. Owner will be liable then for all and any damages for suspension of work which may include costs of demobilization, extended overhead costs, jobsite�costs,etc.Any suspension of work under this Contract will also suspend the progress and compl i ion dates. FORCE MAJEURE If performance of this agreement or any obligation herein is prevented, restricted, interfered by reason of act of God, fire, flood, or other natural disaster, malicious in' strikes, > lock-outs, or other labor troubles, riots, insurrection, war or other reason of like nature beyond either party's reasonable control then performance of such act or obligation shall be excused for the period of the delay. If any delay under these circumstances exceeds 5 days, then either party shall have the option to terminate this Agreement. INDEMNIFICATION Diamond Construction, Inc. shall indemnify and hold Owner, its employees, officers, directors,and affiliates harmless from any loss,cost,expense,or damage claimed by third parties for property damage and/or bodily injury,including death,to the proportionate extent such loss, cost, ecpense, or damage arises from the negligence or willful misconduct of Diamond Construll coon, Inc., its employees, officers, or directors in connection with the Contract or project. Owner shall indemnify, defend, and hold Diamond Construction, Inc., its Subcontractors, employees, officers, directors, and affiliates harmless from and against any and all clai I s,demands,causes of action,liabilities,loss,cost,expense,or damage claimed by third parties or property damage and/or bodily injury, including death, to the proportionate extent such to s, cost, expense, or damage arises from the negligence, fault, or willful misconduct of Owners architects,designers,its employees,officers,or directors in connection with the Contract or proj ct. WARRANTY Diamond Construction,Inc. warrants that the work will be conducted in good professional workmanlike manner,and warrants that materials furnished will be of good quality and new. If within two years after the date of completion any of the work, it is found not to be in accordance with good craftsmanship, the Contractor shall correct it promptly after receipt of written(notice from the Owner. The Owner shall give such notice promptly after discovery of the condition. During the two-year period for correction of Work, if the Owner fails to notify the Coritractoren Owner er waives the rights to require correction by the Contractor and to make 8 402015-This document is binding and has serious legal consequences.Feel free to consult with a qualified attorney prior to signing. 1 DIAMOND CONSTRUCTION, INC. a claim for breach of warranty. In the event that any of the provisions of the warranty shall be held i I�valid,the remainder of the provisions of the warranty shall remain in full force and effect. Where)Contractor's repair warranty work involves the matching of existing finishes or materials, he will use his best efforts to match existing finishes and materials. However, Contractor does not gue an exact match due to such factors as discoloration due to the aging process, difference in dye lots, and difficulty of exactly matching certain finishes, colors,and planes. This warranty specifically excludes consequential damages and the following: 1. Damage on shingles due to ordinary wear and tear, abusive use, normal wear and tear, improper use, misuse, or lack of proper maintenance of the home or its component parts or systems. 2. Defe�,cts, or loss or injury not caused by the negligence of Diamond Construction, Inc. or its subcontractors. 3. Defects in items installed by the Owner or anyone other than Diamond Construction, Inc. or its Subcontractors or defects in items supplied by the Owner. 4. Conditions not caused by Diamond Construction, Inc. and or it's Subcontractors resulting from cdndensation,or contraction of materials. ACCESS The Owner shall provide ample access to the site to Diamond Construction,Inc.throughout the project Any delay or blocking of access by Owner will entitle Diamond Construction,Inc. to a reasonable adjustment in the contract price and time. INDEPENDENT CONTRACTOR STATUS The partes agree that the contractual relationship between Contractor and Owner is of an independent contractor. No documents signed create a partnership, join venture or any other relationship between the parties. 9 C/2015-This document is binding and has serious legal consequences.Feel free to consult with a qualified attorney prior to signing. DIAMOND CONSTRUCTION,INC. ADDITIONAL CLAUSES • Diamond Construction, Inc.'s suggestions are not a substitute for professional engineering, architectural,or design services, and are not to be relied on as such by Owner. • This agreement represents the entire agreement between the parties regarding the work described above and supersedes any prior written or any oral agreements or communications. This agreement may only be modified or terminated in writing. • No breach of any agreement, warranty or representation shall be deemed waived unless expressly waived in writing by the party who might assert such breach. • If any clause of this Contract is determined to be illegal or unenforceable for any reason, it shall be severed from the Contract and the rest of the Contract shall be given full force and effect. The terms, covenants and conditions of this Contract shall be binding upon and shall inure to the benefit of the successors and permitted assigns of the respective parties to this Contract. • The agreement shall be governed by the laws of the Commonwealth of Massachusetts. The parties hereby agree to submit to the jurisdiction of the courts located within this Commonwealth for any controversies arising out of this agreement. • Owner hereby acknowledges he/she has had ample opportunity to consult with independent legal counsel,has read it,understands it,and is signing it freely and voluntarily. • If Owner is signing this agreement at his home,or at a place other than at the contractor's office or business,then there is a 3-day cancellation right. • I as a Owner of the subject property,hereby authorized DIAMOND CONSTRUCTION INC to act on my behalf,in wall matters relative to work authorized by any building permit applications. Owner's Information(All sections required-PLEASE print clearly.) Owner's Name: Chcv)�Ir C, 0 srcmr 4 y Diamond Construction,Inc. Contra t r/P ject Manager Owner's Signature:-a-,(�C Phone: q l y- SFU ��s Ph#e:e: (508)365-7300 Email: CC O i-✓yl s t k 0 Vel Office:(508)688-4493 info@diamondconstructiomna.com 10 C/2015-This document is binding and has serious legal consequences.Feel free to consult with a qualified attorney prior to signing. The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www massgov1dia A'orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Avylicant Information Please Print Le ibl Name (Business/Organization/Individual)' 0 -�C N Address: I�G Qr)(-.� i0(1Q, Rd So 1 t 9, a R City/State/Zip:FROnii01101 Phone#: 50S- 69t � y g 3 Are you an employer?Check the appropriate box: Type of project(required): 1.26 am a employer with _employees(full and/or part-time)' 7. ❑New construction 2.[]l am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.F11 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions with no employees. proprietors 12.❑ g reP Plumbing airs or additions 5 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance+ 13.[—]Roof*reaino O 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. he cma 152,§1(4),and we have no employees.[No workers'comp.insurance required.] fle_ C 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. r 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. Below is the policy and job site information. nn ? Insurance Company Name: Policy#or Self-ins.Lic.#: C 1 WA Expiration Date: —O q/0 9 Job Site Address: 4 City/StateJZip: ` A,�opec" Attach a copy of the workers'compensation policy declaration page(showing the policy number,and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerci nder thepains and penalties ofperjury that the information provided above is true and correct. Signature: ate: 06• Phone#: U 508— 'A4393 S—r(300 Dflicial 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#: DATE(MWDD/YYYY) A�O CERTIFICATE OF LIABILITY INSURANCE 02/29/2016 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(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 ACT NAME: Jana Grady NEIGHBORHOOD INSURANCE LLC. PHONE . 508-476-5535 No: 9 MAIN ST ADDRl�: jgrady@neighborhoodinsuranceagency.com SUITE 3A1 INSURERS AFFORDING COVERAGE NAIC t SUTTON,MA.01590 INSURER A: CATLIN SPECILATY INSURANCE INSURED INSURER 13: Mapfre/COMMERCE INSURANCE DIAMOND CONSTRUCTION INC. INSURERC: A.I.M.MUTUAL 1 WORCESTER ST INSURER 0: INSURER E: Grafton, MA01619 I 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. ILTR TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LIMITS POLICY NUMBER MMID MMID X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE ® OCCUR 20020028 410612016 4/06/2017 PREMDAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ ALL OSCHEDULED AUTOSS AUTOS D32677 3/01/2016 03/0112017 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAS CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N ERWWC 100 6017419 4/23/2016 2312017 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEq$ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below L L E.L.DISEASE-POLICY LIMIT 1$ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Twn of North Andover Building Dept SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St,BLD 20,Suite 2035 ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE Jana Grady ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD - d Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 176910 Type: Corporation Expiration: 10/10/2017 Tr# 270501 DIAMOND CONSTRUCTION INC. JOHN MALO 1 WORCESTER ST SUITE 10 WORCESTER, MA 01604 Update Address and return card.Mark reason for change. SCA 1 w 20M-05/11 E] Address D Renewal F-� Employment Lost Card �c cfsar�aiiea�rttueul��-n/'C�/ll�r�anc�uJclls -_ -Office of Consumer Affairs&Business Regulation License or registration valid for individul use only == HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:. 176910 Type: Office of Consumer Affairs and Business Regulation Expiration: 10/10/2017 Corporation 10 Park Plaza-Suite 5170 " Boston,MA 02116 DIAMOND CONSTRUCTION INC: JOHN MALO 1 WORCESTER ST SUITE.10 WORCESTER, MA 01604 Undersecretary Not valid signature / Massachusetts Department or rumic-ka—y Board of Building Regulations and Standards License:MA0830 construction Supervisor RYAN K HANNAOk P.O.BOX#5372 'FAYVft.LE NSA 09745 - 4 p,.--' ..U\ CA,_— Expiration: Commissioner 04/0912098 'as"o o t lU!Bunumn Sd4 n4aesseW aytio uoA Pi8S o�a�nQej 10(slaw 01100 1,66)Pei oino e0eds pmloue WWoa Wmm dnw6 asn cue sBu 000 S8 UV4 ssal �° mina-Pamiswun 'oswadn S uo � q3n4suco