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HomeMy WebLinkAboutBuilding Permit #816-13 - 67 PROSPECT STREET 5/1/2018 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATI73h' Permit NO: Date Receivedl3 Date Issued: IMPORTANT:Applicant must complete all items on this page PROPERTtYOWNI , P nt X100 Year®Itl Structure ;MAN® PAARCE � ZONING DITrRIC * 'Histone®istrict y �r TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑ New Building One family El Addition El Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ,Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ®iSeptic ❑Well< a Floodplain jOlWetlan � �; NWaarshetl ©is rt;ictI ®�1Nater/Sewer fJil "' DESCRIPTION OF WORK TO BE PERFORMED: t r• Identification Please Te or Print Clearly) OWNER: Name: ��U� C�/Cly, �- Phone: Address: k C®NTRACT®R �Name: �.l � ,, 77t- 4j n �6 tv Address _ r�, d -� r!L __... �: V. 49 /D , .._ � !� 'Exp aate, , SuprvisorConsauct on License ,� _ .� � p Home Improvement License __ ___. x- Exp Dat Z ARCHITECT/ENGINEER Phone: x Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. 'Total Project Cost: $ FEE: Check No.: Z � Receipt No.: NOTE: Persons contracting with unregistered contractors do not have aco the guaran fund Signature of Agent/Ovvner ._.,.,.•: .{_ _ Si Mature of 7tamp Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ ed Plans ❑ i 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 ❑ R THE FOLLOWING SECTIONS FOR OFFICE USE.ONLY 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 l Conservation Decision: Comments Water & Sewer Connection/s_ignafure� Date Driveway Permit DPW Tow;! Engineer: Signature: Located 384 Osgood Street FIRE DE ARTMENT = Temp Dumpster on site yes no Located at,124 Main Street Fire De -r metit-sigiiature/date COMMENTS `„ Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ Total land area, sq. ft.: ELECTRICAL: Movement of Dieter location, mast or service drop q pp 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 13 Notified for pickup - Date i� Doc.Building Permit Revised 2010 Building Department The fol owing is a list of the required forms to be filled out for the appropriate.permit to be obtained. Roofirig, Siding, Interior Rehabilitation Permits i ❑ Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L: Licenses o Copy of Contract Li Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) !' o Copy of Contract ❑ Mass check Energy Compliance Report a Engineering Affidavits for Engineered products DOTE: 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 apm al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording roust be submitted with the building application Doc: Doc.Bui!ding permit Revised 2012 pco Location 50 C�7q1117) No. Date . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ z Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 1`' 26450 Building Inspector NORTH own o 6Andover o0%- J.- h ver, Mass, G 29, 20 cocN�c„ew�cu �1. �i1 A�R'�TED rPa�.(5 _ S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ..........5+.t\1e . . IC .1 .... ........... BUILDING INSPECTOR ..... ............................................ Foundation has permission to erect ...... buildings on Rough to be occupied as ...........Jt... ....... .......4...mroo f................................................................ 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 STARTS 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 Proposal AB Carnes Inc. 30 Arrowhead farm Rd Page 1 of 1 Boxford, Ma. 01921 978-887.1431 Mass, Builders License No.000230 Contractors Registration.No 100733 Proposal Submitted To: STEVEN &MICHELLE COHEN Date May 19, 2013 67 PROSPECT ST Project Name SAME NORTH ANDOVER,MA 01845-1718 Address 978-686-7768 OR 978-284-9048 We propose to furnish material and labor-in accordance with the specifications below: Fifty Eight Hundred Dollars($5,800.00) Payment to be made as follows: $300.00 Deposit, Balance Upon Completion Notice:All home improvement contractors and subcontractors engaged in home Authorized J improvement contracting,unless specifically exempt from registration by provisions Signature of Chapter 142A of the General Laws,must be registered with the Commonwealth Note:This pr osal may°lie withdrawn by us if not accepted within 30 of Massachusetts. Inquiries about registration and status should be made to the days. Mass.gov/licenses website. i ROOF PROPOSAL ® STRIP ROOF OF ALL�AYERS OF ASPHALT SHINGLES.COVER ROOF DECK WITH 15LB ASPHALT COATED UNDERLAYMENT PAPER.COVER EXTERIOR WALLS AND FOLIAGE WITH TARPS TO HELP PREVENT DAMAGE. ® INSTALL CARLISLE HIGH PERFORMANCE ICE&WATER BARRIER OVER ALL HEATED AREAS IX FEET W 0E AT THE LEADING EDGE OF ROOF AND THREEFEET IN'ALL VALLEYS&AROUND ALL ROOF PENETRATIONS. ® COVER ALL PERIMETERS WITH EIGHT INCH ALUMINUM DRIP EDGE. ® INSTALL RIDGE VENT AND/OR®AS NEEDED ROOF LOUVERS FOR ADDED ATTIC VENTILATION. ® COVER SOIL PIPES WITH NEW RUBBER FLASHING BOOTS. h ® REPLACE WALL FLASHING(S)AS NEEDED WITH ALUMINUM OR LEAD AT THE ADDITIONAL COST OF$25.00PLFT.WE MAY NEED TO REMOVE THE SIDING TO PERFORM THIS WORK.YOU MAY NEED TO HAVE A CARPENTER REINSTALL THE REMOVED SIDING. ❑ CHIMNEY FLASHING;CUT ALL EXISTING TAR AND LEAD FROM CHIMNEY(S).CUT NEW REGLET WITH CARBIDE SAW AND SECURE NEW LEAD FLASHING IN PLACE`JV/LEAD ANCHORS. PROPERLY SEAL REGLET JOINT. PLEASE ADD TO ABOVE PRICE. ❑ REBUILD CHIMNEY FROM ROOF DECK UP WITH NEW OR USED BRICK. ArLIFE7TIM�EOFRRANTY OVE PRICE. ® COVER ROOF SURFACE WITHCERTAINTEED LANDMARK ARCHITECTU 240LB SHINGLES. ® REPLACE DEFECTIVE ROOF DECKING WITH 1X8 SPRUCE BOARDS AT AN ADD1TI NAL COST OF$4.50PLFT. ❑ COVER ROOF DECK W°TH CDX PLYWOOD AS NEEDED TO REPLACE OR REPAIR DEFECTIVE DECKING,AT AN ADDITIONAL COST OF �® SHINGLES ARE TO BE STORM NAILED.ESSEX COUNTY BUILDING CODE REQUIRES SIX NAILS INSTEAD OF FOUR. ® REPLACE EXISTING SKYLIGHTS WITH NEW VELUX UNITS WITH FLASHING KITS.WE WILL PROVIDE THE SKYLIGHTS&FLASHING KITS AT OUR EXACT COST FROM OUR SUPPLIER.THERE WILL BE NO LABOR CHARGE IF THEY ARE THE SAME SIZE.INTERIOR WORK IS EXCLUDED. N REMOVE EXISTING GUTTERS ❑INSTALL NEW SEAMLESS.032 ALUMINUM GUTTERS USING THE POSITIVE LOCKING BAR HANGER SYSTEM, ❑ REPLACE DEFECTIVE OR'ROTTED TRIM BOARDS AS NEEDED WITH NO.2 PRIMED PINE,ADD PER FOOT TO ABOVE PRICE. ❑ INSTALL NEW ALUMINUM DOWNSPOUTS. MECHANICALLY FASTEN ALL CONNECTIONS. CLEAN ALL PROJECT RELATED DEBRIS FROM OUTSIDE WORK ARE THE PROPERTY OWNER AUTHORIZES AB CARNES,INC TO OBTAIN ALL PERMITSE CANNOT ACCEPT RESPONSIBILITY FOR DEBRIS FALLING INTO ATTIC A TOMER SHO >D.V.E-I�.�h9Lt1f�6�_�S�GRE E U 0 PROTECT j THE STRUCTURE AND FOLIAGE.HOWEVER,SOME MARRING AND OR MINOR DAMAG COULD OCCUR. SPECIAL INSTRUCTIONS: THE ABOVE PROPOSAL INCLUDES ALL ROOF SECTIONS. 1.REAR LOW PITCHED ROOF SECTION"F"ON PAGE FOUR OF THE EAGLEVIEW REPORT WILL BE COVERED WITH A CERTAINTEED FLINTLASTIC TWO PLY ROOF SYSTEM. 2.SKYLIGHTS:THESE SHOULD BE REPLACED WITH THE NEW ROOF INSTALLATION. YES ( ) 3.GUTTERS:THE EXISTING GUTTERS ARE SECURED BY ROOF HANGERS.THE GUTTERS IL BE REMOVED AND REINSTALLED FOR A PROPOER ROOF INSTALLATION. WARRANTY UPGRADE:THE CERTAINTEED WIND WARRANTY WILL BE UPGRADED FROM 1 130 MPH WITH AN UPGRADE TO THE HIGH PERFORMANCE HIP&RIDGE CAPS AND STARTER COURSE AT NO ADDITIONAL CHARGE.YE I EMAIL ADDRES fC Warranty:All work warranted against installation defects for 5 years;this warranty is limited to the installed item(s)and its repair only.Material is warranted by the manufacturer against defects for 50 years;please see the manufacturer's warranty for exact warranty performance. Cancellation:Customer has legal right under federal law to cancel this contract without penalty or obligation within four business days from the date of signing this agreement via Priority Mail Delivery Confirmation. Please see reverse side Dispute Resolution under Massachusetts Home Improvement Law 142a:All Tandof that any and all'disputes relating to this proposal shall be settled by bindigg#itration.This forum is user friendly and does not require Ierse side ;�i Customer °a ` I Dat / --� Dated=/ 7 Signing this Proposal means you have accepted all the terms as stated on the froement. Date of Acceptance 4t j Signature `vi < - Signatures PLEASE SEE REVERSE SIDE Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supers icor AWNk License: CS-000230 s BARRY S CABLES 30 ARROWHEAD 1+ARM RD Boxford MA01921; f - Expiration Commissioner 03/07/2014 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 ' Boston, Massachusetts 0211.6 Home Improvement C:ontTactor Registration Registration: 100733 Type: Private Corporation Expiration: 6/23/2014 Tr# 223142 A. B. CARNES, INC. "" Barry Carnes x 30 Arrowhead Farm Rd. Boxford, MA 01921Zr -- =- Update Address and return card.Mark reason for change. Lost Card )PS•CA1 0 50M-04/04-G101216 J Address ❑ Renewal F, Employment � NORTH ANDOVER WASTE AFFIDAVIT As a result of the provisions of MGL Ch.40-s54, I acknowledge that as a condition of building permit# all debris resulting from the construction activity governed by this.building permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL Ch.111-s150A. Waste Disposal or Solid Waste Facility: ALLIED WASTE Address: 300 FOREST ST Town/City,State, Zip: PEABODY, MA 01960 I NAME OF HAULER: AB CARNES, INC. DUMP TRUCKS DATE: 5-28-2013 SIGNATURE OF APPLICANT: i•"1 OP ID: SA AIIC"R" CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDDIYYYY) 03/13/13 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 978-744-6715 NAME: AHMED Insurance Agency,Inc. 978-741-0127 PHONE,Ext); (afc PO BOX449 ,No): Salem,MA 01970 E-MAIL Stephen G.Ahmed PRODUCER CUSTOMER ID#:ABCAR'1 INSURER(S)AFFORDING COVERAGE NAIC N INSURED(BoOxx B Carnes Inc INSURERA:ESsex Insurance Co 0 Arrowhead Farms Road INSURERB:Safety Insurance Company 33618 ford, MA 01921 ` INSURER C: INSURER D; INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER: POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDDIYYYY MMIDDIYYYY GENERAL LIABILITY EACH OCCURRENCE S 1,000,00 A X COMMERCIAL GENERAL LIABILITY 3DF9266 03/18/13 03/18/14 DAMAGES(RENTED $ 50,00 . PREMISES Ea occurrence_) CLAIMS-MADE X OCCUR MED EXP(Any one person; S 1,00 PERSONAL&AOV INJURY S 1,000,00 GENERAL AGGREGATE S 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG $ - 2,000,00 X . POLICY PRO- LOC PD Deduct - 500 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT' s 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS B X SCHEDULED AUTOS 6213192 05/02/12 05/02!13 BODILY INJURY(Per accident) S PROPERTY DAMAGE 5 in B X HIRED AUTOS 6213192 05/02/12 05/02/13 (Per acadent) B X NON-OWNED AUTOS 6213192 05/02/12 05/02/13 S .S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE - AGGREGATE _S DEDUCTIBLE S I RETENTION S $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN T CRY LIMITS ER ,. ANY PROPRIETORIPARTNERIEXECUTIVE —} NIA E L EACH ACCIDENT 5 OFFICER/MEMBER EXCLUDED'r �f (Mandatory in NH) E L DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101.Additional Remarks Schedule.If more space is required) Roofing Contractor CERTIFIC T OLDER CANCELLATION TOWNN04 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE I ©1988-2009 ACORD CORPORATION, All rights reserved. ACORD 25(2009/0The ACORD name and logo are registered marks of ACORD Massachusetts Workers' Compensation Insurance Plan B_&kley Acadia Insurance Company NCCI Carrier Code 33391 Administered by Berkley Assigned Risk Services S$GN [ji�� `M°vit7 P.O.Box 1100, Minneapolis, Minnesota 55440-1100 Phone(605)945-2144 Fax(866)215-8118 Toll Free(800)634-4589 www.berkleyassignedrisk.com CERTIFICATE OF INSURANCE 1. The Insured: WCIP Policy Number: WC-20-20-004717-00 CBrockton, ruction Inc Tax ID#: F 46-1868194 et Unit 2 01 Policy Period: From: 4/24/2013 To: 4/24/2014 Date of Mailing: 5/3/2013 The Certificate is issued as a matter of information only and confers no rights upon the Certificate Holder. This Certificate does not amend, extend or alter the coverage afforded by the Policy listed below. This is to certify that the Policy of Insurance described herein has 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 Policy described herein is subject to all the terms, exclusions and conditions of such Policy. TYPE,OF INSURANCE. LIMITS OF LIABILITY Coverage Part One State(s) Workers'Compensation Statutory MA Part Two Bodily Injury by Accident $1,000,000 each accident. Employers' Liability Bodily Injury by Disease $1,000,000 policy limit. -Bodily Injury by_Disease $1;0001000 each employee Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. All Entities/Insureds: Certificateer's8 Name and Address: 1 American Construction Inc Election Election AB Carnes Inc Category Status Name 30 Arrowhead Farm Road Officer Include Manuel 3 Lema Caguaw Boxford, MA 01921 .t• Date Issued: 5/3/2013 Ace Insurance Services Inc 675 Warren Ave Brockton, MA 02301 Signature_ — r� Tile Commonwealth of Massachusetts Department ofindustrial Accidents ' Off ice of Investigations 600 Washington Street t �--~ -> Boston, NIA 02.1 Ar. ,t; >ft;'►v►v rrtass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anpllcant Information Please Print_Ue i l`r I Name(T3usiness/Organizationandi,,Iduat): A Address: 42JLU w/d/-`A +11�- City/State/Zip: fOA1 Phone#: _92--) la _ Are you an employer?'Check the appropriate ox: Type of project(required): with 4. I am a general contractor and I 1.[] I am a employer rt 6. New construction employees(full and/or part-time).* have hired the.sub-contractors 2.[-1 I am a sole proprietor or partner- listed on the attached sheet. 7. ( Remodeling ship and have no employees These sub-contractors have 9. 0 Demolition working for me in any capacity. employees and have workers' 9. ( Building addition [No workers' comp. insurance comp.insurance.t required.] 5. We are a corporation.and its I0.0 Electrical repairs or additions 3.Q I am a homeowner doing all work officers have exercised their 11..[)Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12:56Itoof repairs insurance re uired. c. 152,§1(4),and we have no q ] ` employees. [No workers' 13.n Other comp.insurance required.] :Any applicant that checks box 4!1 roust also fill out the section below showing their workers'compensation policy information, Flomcownetc 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 roust provide their workers'comp.policy number. I ant an employer that is providing workers'compensation insurance for my employe-c. Below is Me policy=and job site information Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration.Date: ,lob Site Address: City/Statc/Zip: _ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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 tip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce under the irts and penalties of perjury that.the information provided above is true and correct Sitnature: J Date: f Phone#: Q fflcial rise only. Do not write in this area,to be completed by city,or town official City or Town: Permit/lAicense# Issuing Authority(drtele one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: FORM 153 The Commonwealth of Massachusetts DIA Use Only Department of Industrial Accidents Office of Investigations-Dept. 153 1 Congress Street,Suite 100,Boston,Massachusetts 02114-2017 http://www.mass.gov/dis InvestAWO ID#• AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPORATE OFFICERS OR DIRECTORS Chapter 169 of the Acts of 2002 amended M.G.L. c. 152, §1(4) by adding the following paragraph: "This chapter shall be elective for an officer or director of a corporation who owns at least 25 percent of the Issued and outstanding stock of the corporation. Notwithstanding section 46, these provisions shall apply only if the corporate officer provides the commissioner of industrial accidents with a written waiver of his rights under this chapter. Said commissioner shall promulgate regulations to carry out the purpose of this paragraph. Violations of this paragraph shall subiect the corporation to the penalties set forth in section 25C." Pursuant to M.G.L. c. 152, §1(4) as amended, I/We the undersigned officers of: AB Carnes, Inc. 30 Arrowhead Farm Rd Boxford, Ma 01921 (Name of Corporation and Address) 5 each holding at least 25%of the issued and outstanding stock in said corporation, do hereby invoke the right to be exempt from the provisions of M.G.L. c. 152, §25A and therefore are not required to carry a workers' compensation policy covering the undersigned corporate officer(s) or director(s). I/We the undersigned do also waive any and all rights to make claims for benefits as defined in M.G.L. c. 152 for any injuries that may be sustained while in the employ of the above-named corporation. Further, Uwe the undersigned do understand that, should the above-named corporation hire or have in its employ any employee(s) in addition to the undersigned corporate officer(s) or director(s), said corporation is required to obtain workers' compensation coverage for the employee(s) asrescribed by M.G.L. c. .152 25A. P I/We the undersigned have read and understand the statements and obligations as delineated above and I/we have checke_ he appropriate box below my/our name(s) indicating my/our desire to be exempt or not tojunder pt fir the provisions of M.G.L. c. 152. et pains and penalties of perjury: Barry Carries, President 04/3/2012 ❑Si nature Print Name&Title Date(mm/dd/yyyy) ✓ wish to exercise my right of exemption or I wish NOT to exercise my right of exemption Anastasiya Carries, Director 04/03/2012 ❑Signature Print Name&Title Date(mm/dd/yyyy) ✓ I wish to exercise my right of exemption or [:11 wish NOT to exercise my right of exemption Signature Print Name&Title Date(mm/dd/yyyy) I wish to exercise my right of exemption or ❑ I wish NOT to exercise my right of exemption Signature Print Name&Title Date(mm/dd/yyyy) ❑ I wish to exercise my right of exemption or I wish NOT to exerci ❑ se my right of exemption Note:ALL ELIGIBLE CORPORATE OFFICERS MUST SIGN. THERE CAN BE NO MORE THAN 4 SIGNATURES. Instructions on back. Form 153-712010 MA SOC Filing Number: 201287835330 Date: 5/30/2012 9:10:00 PM The Commonwealth of Massachusetts No Fee William Francis Galvin All Secretary of the Commonwealth, Corporations Division �i One Ashburton Place 17th floor Boston, MA 02108-1512 Telephone: (617) 727-9640 I. � •D : � �d�3 � Di : � � �W7W uuC6� 1. Exact name of the corporation: A. B. CARNES, INC. 2. Current registered office address: Name: BARRY S. CARNES j No. and Street. 30 ARROWHEAD FARM ROAD City or Town: BOXFORD State: MA Zip: 01921 Country: USA 3. The following supplemental information has changed: _Names and street addresses of the directors, president, treasurer, secretary Title Individual Name Address (no PO Box) First, Middle, Last, Suffix Address,City or Town,State,Zip Code PRESIDENT BARRY S.CARNES 30 ARROWHEAD FARM ROAD, BOXFORD, MA 01921 USA TREASURER BARRY S.CARNES 30 ARROWHEAD FARM ROAD, BOXFORD, MA 01921 USA SECRETARY BARRY S.CARNES 30 ARROWHEAD FARM ROAD, BOXFORD, MA 01921 USA DIRECTOR BARRY S.CARNES 30 ARROWHEAD FARM ROAD, BOXFORD, MA 01921 USA DIRECTOR ANASTASIYA CARNES 30 ARROWHEAD FARM ROAD, BOXFORD, MA 01921 USA X Fiscal year end: October X Type of business in which the corporation intends to engage: I GENERAL CONTRACTING & MARKETING X Principal office address: No. and Street: 30 ARROWHEAD FARM ROAD City or Town: BOXFORD State: MA Zip: 01921 Country: USA X its principal office _ an office of its transfer agent an office of its secretary/assistant secretary _ its registered office Signed by BARRY S. CARNES , its PRESIDENT on this 30 Day of May, 2012 i ©2001 -2012 Commonwealth of Massachusetts All Rights Reserved i i I i I I i MA SOC Filing Number: 201287835330 Date: 5/30/2012 9:10:00 PM THEM CO MONWEALTH OF MASSACHUSETTS I hereby certify that, upon examination of this document, duly submitted to me, it appears that the provisions of the General Laws relative to corporations have been complied with, and I hereby approve said articles; and the filing fee having been paid, said articles are deemed to have been filed with me on: May 30, 2012 09:10 PM WILLIAM FRANCIS GALVIN Secretary of the Commonwealth The Commonwealth of Massachusetts Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR Building Permit Application To Construct, Repair,Renovate Or Demolish a t « Revised One-or Two-Family Dwelling March 2011 This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Ad. ess: 1.2 Assessors Map&Parcel Numbers l.la Is this an accepted s eet?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record:Recor tlze NME(Print) - � City,State,ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction❑ Existing Building Owner-Occupied Repairs(s).Nl� I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': P P SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2.Electrical $ Project CostItem 6 ❑Total Pro a J ( )x multiplier x 3.Plumbing $ 2. Other Fees: 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Su ression Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ !l ���i 11 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) /A � License Number Expiration Date Name of CSL-rHoI� , R List CSL Type(see below) L�( dress /�oyep®�` T Description. U Unrestricted(u to:35;1)()0 Cu.Ft.) Restricted 1&2 Family Dwelling Si ature M Masonry Only RC Residential Roofmg Covering Telephone WS Residential Window and Side SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) /0 0211 I�IC Company Nam orHIVRegistr Namef17 OX Reg onhstra Number 9 7A &9!2 y�1 Expiration Date fSatu5r !�� Telephone r � SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes-�(No ❑ Current Certificate must be on file in office Yes SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT U, �,�`�W as Owner of the subject property hereby j authorise zn to act on my behalf..in all matters relative t wo authorized by this building permit application. tature orvwner Date SECTION 7b.OWNER'OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare that the stateme is and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. Prm Name �' 2��Js Sign tore er or Authorized Agent Date Si under the pains and penalties of NOTES: I. An Owner who obtains a building permit to do his/her own work or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.86 and 110.115,respectively. 2. When substantial work is planned,provide the information below: Total floors area.(Sq. Ft.) (including garage,finished basement/attics,decks or porch) Gross living area(Sq.Ft.) Habitable room count I Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system. Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost"