Loading...
HomeMy WebLinkAboutBuilding Permit #146-2017 - 73 HOLLY RIDGE ROAD 8/16/2016 L / �j + 4NORTy♦ YBUILDING PERMIT w-O TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION J( �l® pq Permit No#: " Date Received (� �C �,� �R,TEo,P��cS yy .SSACHUSE Date Issued: t -PORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year structure yes (jno MAP PARCEL: CRL3 /_7 ZONING DISTRICT: Historic District yes Machine Shop Village yes 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 3tSepti: vWl = , - ic�t Flootlplain— Wetla�„n� ®'s.W� atershe�Distr � , DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name:K:)C�,�ooa t cxc,� 5G\-__1 Ik Phone-c`7a FoF _�c_ i Address: Contractor Name:WCX Vt--e<-- Phone: 9J FL ISS) 5r; 1 Email: IN^ Address: c) Supervisor's Construction License: Exp. Date: Home Improvement License: z✓K---, 1 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.�ypEP-S,F. XTotal Project Cost: $`�.�I , Iu � FEE: $ Check No.: f � / Receipt No.: NOTE: Per ns contrin with unregistered ontract do=not gess to the guaranty fund t . -- :,fi i I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL t Public Sewer ❑ Tanning/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 m U FORM I PLANNING a DEVELOPMENT Reviewed On Signature_ COMMENTS I I CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed ori Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decisionfreceipt submitted yes �701anning Board Decision: Comments Conservation Decision: Comments Water & Sewer ConnectioniSignature & Date Driveway Permit DPW Towyn En r:..Signature: Located 384 Osgood Street ,. .Y ,I.R azrn� s yea AFIRE DEPARSTMENT Tem Dumpss eron site Lro ated at 124 Main Street" ' a: 73'11, .3-� ."sats t.Y is• `ue,e 0 nx."v F .r. i4 ''..t i#�.. Fire MEN Lillentsignature/dat'e K i='4°i�`i �'g} -`V..,,{Y.. �. '�J: t.•-.t' li`'> fiK.r '' *}'°�, J-3 ..t t, �:.. tlCtYt 4A * ;'' Y"4 1' ^� s�'r .'r,`• *C®MMEfVTS + ' �6 � I`_ ... �;F.7Cz.7a..,:YrMca.:+�_ _..Y'3 f"t,a, i�L x ,'': 4 k,C 'a.^srlc*?� S.�i•,.,;t'1�,�t'tl:::J:..t.g334aAt ,y.+. t-tiy ®imension 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 lies No DANCER ZONE LITERATURE- Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ti ® Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 i s I Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit { Photo Copy Of H.I.C. And/Or C.S.L. Licenses 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 f Addition Or Decks i 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) a. Building Permit Application 46 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 No: L�`t Iy� Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ • Building/Frame Permit Fee $ 1 " Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# j r7 Building I spector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 49,951 .00 m $ - $ 599.41 Plumbing Fee $ 74.93 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 74.93 Total fees collected $ 849.27 73 Holly Ridge Road 146-2017 on 8/16/2016 kitchen remodel Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 49,950.59 m $ - $ 599.41 Plumbing Fee $ 74.93 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 74.93 Total fees collected $ 849.26 73 Holly Ridge Road 146-2017 on 8/16/16 Kitchen Remodel F NORTH Tow.n ofndover _ s O "`�.�- 0 No. 21 h ver, Mass, 'Q COC NIC Nl WKK ��� �•9 A�R�reo +1Pa,`�(5 S U BOARD OF HEALTH Food/Kitchen PER ITi T /LD Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ...... 1...0.+.!x. . ....... ...M�, art �. .`�..�'r.. . ............... ...... . . . ... .... ..... .... � �.. ... . .,. Foundation has permission to erect ....... ................. buildings on .... ...... .... . 1.. � - �L Rough to be occupied as ................ . .74 J_...... ..... . .. .. . ... .. �i .. .lj.. ... . .. Chimney provided that the person accepting this permit shall in every respe conform`to the terms 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 CONST CTION T Rough Service .. .. ... ..... 41iNiP� ... Final BUIR 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. ;-- F.A 0 1 F� e �I I W 1v j �l#4� F .A 34 (le) Pf it, iv ' .t 1 2q 934 w It 3/4 3DB 30 vat � 2L X . qj 7rri tt . Ni AP 'ROVED LAYOUT Cit �, jqJ/j g _ _ ,. l10 - " 96 s" � � � t'.~, _T - _� �/p�'p4 rG '! y��. j�� (,. ��, Divi i�_ss, �i•� � j utlp 'cn ORA ; � t'ja�c4a o v a e of- YP 1111- - �f --=- ivtf way ShGl3� 4' ,z 0 cr m 3 `t PA/ > z Toy to/ x3 gh .56 5q IA v) o L7 � 'f�. - - vc 3 3 33 u� 3*3 c WO /� � - ..,.,__...,...........�..._•.....,�..., ..r_...__�.. -•oma-.�..�_..-.,t.,-..�---.-- r NORTH HILL DEVELOPMENT INC. 8 WINDING WAY, WESTFORD MA. 01886 NORTHHILL@COMCA.ST.NET General Renovation - Fixed Contract Amount This Agreement, Made as of June 16, In the Year of 2016, Between the Owner: Donna and Michael Schiff 73 Holly Road North Andover, Massachusetts 01845 Contact Primary Telephone And the Contractor: North Hill Development Inc. 8 Winding Way Westford, Massachusetts 01886 United States 067067 978-551-5519 For the Project: Donna Michael Schiff Kitchen Remodel 73 Holly Road North Andover, Massachusetts 01.845 Construction Lender: Project Lender Full Address Article 1. CONTRACT DOCUMENTS Article 1.1. The contract documents consist of this agreement, general conditions, construction documents, specifications, allowances, finish schedules, construction draw schedule, information disclosure statement, all addenda issued prior to execution of this agreement and all change orders or modifications issued and agreed to by both parties. All documents noted herein shall be provided to the Contractor by the Owner. These contract documents represent the entire agreement of both parties and supersede any prior oral or written agreement. Article 2. SCOPE OF WORK: Remodel kitchen area including new windows, lighting plan, exterior doors and general upgrades throughout main floor of residence. Initialed by: Owner Contractor(j� Donna Michael Schiff Kitchen Remodel Thursday, June 16, 2016 Page 2 of 8 SPECIAL CONDITIONS: Cabinetry, plumbing fixtures, under counter lighting and counter tops supplied by Dream Kitchens. TOTAL BASE PRICE: $49,950.59 Project Totals: ►Name_ = Qesc�iption Total Cost `; Plarining Permits Building Permit $2,588.24 Permits Subtotal: $2,588.24 i Planning Subtotal; $2 588 24 Demollt#on - - Demolition Labor Cabinetry,countertops and appliances Removal $1,035.29 S Kitchen Window Removal $517.65 Sliding Door removal and new $517.65 wall opening Living Room Window Removal $517.65 Demolition Labor Subtotal: $2,588.24 Demolition Removal Covers removal of all debris to be Dumpster Removal removed from sight throughout $1,047.06 remodeling project Demolition Removal Subtotal: $1,047.06 Demnlrt�or Sub3ota! $3 638 30 Initialed by: Owner S Contractor Donna Michael Schiff Kitchen Remodel Thursday, June 16, 2016 Page 3of8 Framtng Framing Labor Sliding Door Frame new opening for new sliding glass $1,035.29 door Kitchen Window Opening Expand opening and rework exterior $517.65 base. Framing Labor Subtotal: $1,552.94 Materials Framing Materials Rough Framing materials $529.41 Window and Door Materials Trim and siding materials $588.24 Materials Subtotal: $1,117.65 Framing SubtotaF $2 S�0 59 '` Ext WI!�cf�ws.& ©Dors - Windows Kitchen Window 61"by 48"casement or awning window $1,294.12 single mulled. 97"by 55"double Mulled window with Living Room Window fixed cater window with casement or $2,216.47 awning windows on ends Windows Subtotal. $3,510.59 c Exterior Doors 3-0"Front side Entry Fiber glass half-light insulated door $817.65 6-0"Sliding Glass Anderson French Wood with screen panel $2,529.41 Exterior Doors Subtotal: $3,347.06 Windows&Exterior Doors Labor Window Doors installation Including installation and exterior trim and $2,070.59 siding installation/rework Windows&Exterior Doors $2,070.59 Labor Subtotal: Ext Wandows&Doors Subtotal $8,82824 Electrical Systems _ ; Electrical Labor ,_------ .._........._ ... . ... a...__. Initialed by: Owner 0, Contractor� - Donna Michael Schiff Kitchen Remodel Thursday, June 16, 2016 Page 4 of 8 Lighting per proposed lighting plan.4" Kitchen Lighting Recessed 13 QT.2"Recessed 11 QT. $3,857.65 Pendants(Supplied by Homeowner)3 QT. Install/rework electrical layout to conform General Kitchen to new design and current Electrical $2,117.65 codes to include under cabinet lighting and power strips Living Room Lighting Install 4"recessed lights 6 QT in living $1,294.12 room slanted ceiling. Electrical Labor Subtotal: $7,269.42 :l Electrrcai Systems Subto#ai $7 269 42 Plutnbmg Systems _ - Plumbing Labor Disconnect existing sink and appliances, Plumbing Labor Costs install new shutoffs and drains and $2,470.59 reconnect new appliances. s Plumbing Labor Subtotal: $2,470.59 Plumbing Systems Subtotal _ $2 47Q 59 fireplaces &Trtm Masonry Fireplace Labor Masonry Cleaning Clean brick fireplace walls and granite $1,764.71 t hearth using acid based cleaning. Masonry Fireplace Labor $1,764.71 f Subtotal: F�replaces8Trrm:Subtotal- $1764 71 Insulation 8 Drywall_' Drywall Labor Repair ceiling and walls throughout Kitchen area kitchen area after new lighting and $1,294.12 window and doors are installed. Livingroom Plaster smooth entire angled ceiling area. I $2,117.65 r Drywall Labor Subtotal: $3,411.77 Irlsulatiorr'�Drywll Subtotal $3 411 77 initialed by: Owner ContractorlJJL--- Donna Michael Schiff Kitchen Remodel Thursday, June 16, 2016 Page 5 of 8 Interior Trtm &Stairs - Interior Trim Labor Installation Labor Install new trim to areas reworked during $517.65 renovation including baseboard. Interior Trim Labor Subtotal: $517.65 Interior Trim Materials II Base Molding Molding required for rework. $376.47 Interior Trim Materials Subtotal $376.47 Interror Term 8�Stairs Subtotal _ $894 12 Faooroovermg - Hardwood Flooring Labor Sand bear and install two coats of I polyurethane to dining/kitchen area (Repair any missing flooring under cabinet Refinishing Labor layout, Livingroom area,office,hallway, $3,717.65 back steps and 7 back steps and front 14 steps with second floor landing. Approximately 1320 SQFT and 21 steps. Hardwood Flooring Labor ? Subtotal: $3,717.65 Floorcovermg Subtotal _ - - - - _ - =' $3 71;7 65, lntertor=Flnlshes - _ __ . . _. . Paint Labor Exterior Paint Labor Paint new window trim and replaced $658.82 siding. Paint kitchen,dining room and living room including painting all existing stained trim Interior Paint Labor to white trim.Walls and ceilings will $3,211.76 receive two coats using Ben Moore products. Paint Labor Subtotal: t $3,870.58 lttenor finishes Subtotah $3 87D 58 Construetlon Clean"UP - - Clean Up-Final Initialed by: Owner 5, Contractor Donna Michael Schiff Kitchen Remodel Thursday, June 16, 2016 Page 6 of 8 Clean Up-Final Costs Clean main floor of house including $823.53 cleaning interior windows Clean Up-Final Subtotal: $823.53 Construction Clean Up Subtotal: $823.53 supervision Supervision Jobsite Supervision $7,905.88 Supervision Subtotal: $7,905.88 Supervision Subtotal: $7,905.88 Grand Total $49,950.59 Article 3. Article 3.1. The Contractor agrees to renovate the above mentioned project in (North Andover MA. 01845) according to the plans, drawings, addenda, modifications and specifications set forth in the specification booklet. Article 4. TIME OF COMPLETION Article 4.1. The approximate commencement date of the project shall be (August 10 2016). The approximate completion date of the project shall be (September 30 2016), however any change orders and/or unusual weather might delay or otherwise affect the completion date. Barring inclement weather or owner or vendor related delays, the Contractor shall pay liquidated damages of($100.00) per day if the project is not completed within (2.5) months. The contract execution date shall be (August 10 2016). Article 5. THE CONTRACT PRICE Initialed by: Owner Contracto�� Donna Michael Schiff Kitchen Remodel Thursday, June 16, 2016 Page 7 of 8 Article 5.1. The cost for renovating the project as specified in the construction documents shall be set at the sum of(Forty Nine Thousand and Ninety Five Dollars and Fifty Cents) Dollars, ($49,950,50), subject to additions and deductions pursuant to authorized change orders and allowances. Article 5.2. The Owner and the Contractor acknowledge that the Owner will pay a sum of (Twelve Thousands Dollars) Dollars, ($12,000.00), upon signing of this contract and before renovation begins as a deposit and part of the purchase price of the project. Article 6. PROGRESS PAYMENTS Article 6.1. The Owner will make payments to the contractor pursuant to the attached construction draw schedule as work required by said schedule is satisfactorily completed. Owner shall make draw payments to contractor within (5) days after request by contractor. Should the owner fail to make payment, contractor may charge a penalty of(2.5%) annually upon the unpaid amount until paid. Article 6.2. If payment is not received by the Contractor within (10) days after delivery of payment demand for work satisfactorily completed, contractor shall have the right to stop work or terminate the contract at his option. Termination by Contractor under the provisions of this paragraph shall not relieve the Owner of the obligations of payments to Contractor for that part of the work performed prior to such termination. Termination by Owner under the provisions of this paragraph shall not relieve the Owner of the obligations of payments to Contractor for that part of the work performed prior to such termination. Article 7. DUTIES OF THE CONTRACTOR Article 7.1. All work shall be in accordance to the provisions of the plans and specifications. All systems shall be in good working order. Article 7.2. All work shall be completed in a workman like manner, and shall comply with all applicable national, state and local building codes and laws. Article 7.3. All work shall be performed by licensed individuals to perform their said work, as outlined by law. Initialed by: Owner 0.�- Contractor (—' Donna Michael Schiff Kitchen Remodel Thursday, June 16, 2016 Page 8 of 8 Article 7.4. Contractor shall obtain all permits necessary for the work to be completed. Article 7.5. Contractor shall remove all construction debris and leave the project in a broom clean condition. Article 7.6. Upon satisfactory payment being made for any portion of the work performed, Contractor shall furnish a full and unconditional release from any claim or mechanics' lien for that portion of the work for which payment has been made. Article 8. OWNER Article 8.1. The Owner shall communicate with subcontractors only through the Contractor. Article 8.2. The Owner will not assume any liability or responsibility, nor have control over or charge of construction means, methods, techniques, sequences, procedures, or for safety precautions and programs in connection with the project, since these are solely the Contractor's responsibility. Article 9. CHANGE ORDERS AND FINISH SCHEDULES Article 9.1. A Change Order is any change to the original plans and/or specifications. All change orders need to be agreed upon in writing, including cost, additional time considerations, approximate dates when the work will begin and be completed, a legal description of the location where the work will be done and signed by both parties. 10% of the cost of each change order up to a maximum of$1000.00 will be paid prior to the change, with the remaining amount paid upon completion of the change order. A 15%fee shall be added to all change orders and overages in excess of initial allowances. Additional time needed to complete change orders shall be taken into consideration in the project completion date. Article 9.2. Completed Finish Selection Schedules shall be submitted to the Contractor as follows: Article 9.3. Any delays or changes in finish selection schedules will delay the projected completion date. Initialed by: Owner Contractor lJ®'�- Donna Michael Schiff Kitchen Remodel Thursday, June 16, 2016 Page 9 of 8 Article 10. INSURANCE Article 10.1. The Owner will keep in force a Builder's Risk Insurance Policy on the said property to protect both owner's and contractor's interests until construction is completed. Article 10.2. The Owner will purchase and maintain property insurance to the full and insurable value of the project, in case of a fire, vandalism, malicious mischief or other instances that may occur. Article 10.3. The Contractor shall purchase and maintain needed Workman's Compensation and Liability insurance coverage as required by law and deemed necessary for his own protection. Article 11. UNKNOWN CONDITIONS Article 11.1. If conditions are encountered at the site which are: (1) Subsurface or otherwise concealed physical conditions which differ materially from those indicated in the Contract Documents (2) Unknown physical conditions of an unusual or unacceptable nature, which differ materially from those ordinarily found to exist and generally recognized as inherent in construction activities of the character provided for in the construction documents Then notice by the observing party shall be given to the other party promptly before conditions are disturbed and in no event later than 21 days after the first observance of the conditions. The Owner will promptly investigate such conditions and will negotiate with the Contractor an equitable adjustment in the contract sum, contract time or both. Article 11.2. If the Contractor wishes to make claim for an increase in the contract sum, written notice as provided herein shall be given to the Owner before proceeding to execute the work. Prior notice is not required for claims relating to an emergency endangering life or property. Article 11.3. If the Contractor wishes to make claim for an increase in the contract time, written notice as provided herein shall be given. The Contractor's claims shall include an estimate of cost and of probable effect of delay on progress of the work. In the case of a continuing delay, only one claim is necessary. Initialed by: Owner(). Contractor Donna Michael Schiff Kitchen Remodel Thursday, June 16, 2016 Page 10 of 8 Article 11.4. If adverse weather conditions are the basis for a claim for additional time, such claim shall be documented by data substantiating that weather conditions were abnormal for the period of time and could not have been reasonably anticipated, and that weather conditions has an adverse effect on the scheduled construction. Article 12. HAZARDOUS MATERIALS, WASTE AND ASBESTOS Article 12.1. Both parties agree that dealing with hazardous materials, waste or asbestos requires specialized training, processes, precautions and licenses. Therefore, unless the scope of this agreement includes the specific handling, disturbance, removal or transportation of hazardous materials, waste or asbestos, upon discovery of such hazardous materials the Contractor shall notify the Owner immediately and allow the Owner/Contractor to contract with a properly licensed and qualified hazardous material contractor. Any such work shall be treated as a Change Order resulting in additional costs and time considerations. Article 13. ARBITRATION OF DISPUTES Article 13.1. Any controversy or claim arising out of or relating to this contract, or the breach thereof, shall be settled by arbitration administered by the American Arbitration Association under its Construction Industry Arbitration Rules, and judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. Article 14. WARRANTY Article 14.1. At the completion of this project, Contractor shall execute an instrument to Owner warranting the project for(2 years) against defects in workmanship or materials utilized. The manufacturer's warranty will prevail. No legal action of any kind relating to the project, project performance or this contract shall be initiated by either party against the other party after(1 years) beyond the completion of the project or cessation of work. Article 15. TERMINATION OF THE CONTRACT Initialed by: Owner 04, Contractor Donna Michael Schiff Kitchen Remodel Thursday, June 16, 2016 Page 11 of 8 Article 15.1. Should the Owner or Contractor fail to carry out this contract, with all of its provisions, the following options and stipulations shall apply: Article 15.1.1. If the Owner or the Contractor shall default on the contract, the non-defaulting party may declare the contract is in default and proceed against the defaulting party for the recovery of all damages incurred as a result of said breach of contract, including a reasonable attorney's fee. In the case of a defaulting Owner, the Earnest money herein mentioned shall be applied to the legally ascertained damages. a es. 9 Article 15.1.2. In the event of a default by the Owner or Contractor, the non-defaulting party may state his intention to comply with the contract and proceed for specific performance. Article 15.1.3. In the case of a defaulting Owner, the Contractor may accept, at his option the earnest money as shown herein as liquidated damages, should earnest money not cover the expenses to date, the Contractor may make claim to the Owner for all work executed and for proven loss with respect to equipment, materials, tools, construction equipment and machinery, including reasonable overhead, profit and damages applicable to the property less the earnest money. Article 16. ATTORNEY FEES Article 16.1. In the event of any arbitration or litigation relating to the project, project performance or this contract, the prevailing party shall be entitled to reasonable attorney fees, costs and expenses. Article 17. ACCEPTANCE AND OCCUPANCY Article 17.1. Upon completion, the project shall be inspected by the Owner and the Contractor, and any repairs necessary to comply with the contract documents shall be made by the Contractor. Article 17.2. Initialed by: Owner).Contractor A� Donna Michael Schiff Kitchen Remodel Thursday, June 16, 2016 Page 12 of 8 Article 17.3. Occupancy of the project by the Owner in violation of Article 16.2, shall constitute unconditional acceptance of the project and a waiver of any defects or uncompleted work. Witness our hand and seal on this day of 120 Signed in the presence of: Witness Witness Contra "tor SignatuOwner Signature Initialed by: Owner Contractor The Commonwealth ofHassgchusetts z . Department oflndustrialAccidents 1 Congress Street,Suite 100 - _ Boston,MA 02114-2017 www mass:gov/iia s,• Workers,Compensation Insurance Affidavit:Builders/Contractors/EleetricianslPlumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A_pplicant Information j� Please Print Legibly Name(stisiness/Organization/Individual): V o r Address: LJ�.�e t/� d hone#: City/State/Zip: c`T"' � � C 1 Are you an employer?Check&e appropriate box: Type of project(required)- -LF]I am a employerwitb. employees(full and/or part-time).* 7.- []New construction 2.Q I am a sole proprietor or partnership and have no employees working for mein 8.�Remodeling any capacity.[No workers'comp.insurance required.] 9, El Demolition 3-Q I am a homeowner doing all workmyself(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 r' proprietors with no employees. 12:Q Plumbing repairs or additions 5Q 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet ' 13.'[J Roof repairs These sub-contractors have employees and have workers comp.insurance. 14. Other 6.Q We are a corporation-pd#q RfCcers have exercised their right of exemption per MGL c. [] 152,§1(4),and wg havp 11Q mployeas.iNo workers'comp.insurance required.] '`Any applicant that checks box#1 must also fill out the section below showing theirworkers'compensation policy infonnation. I Homeowners who mliniit Ibis afAdavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must-attached an additional sheet showing the name o£the sub-contractors and state whether or not those entities have employees. lfthe sub-conlraclors fiave employees,they must provide their workers'comp.policy number. I am an employer tT,at is pi'ovidingworkers'compensation insurancefor my employees.'Beloit/is thepolicy aridjob site information. f n ' ,,\ Insurance Company Name.V "L�� -1-i'" c I:," w ` Policy#or S elf-ins.Lic.#: Expiration Date: n Job Site Address-:7Ztc4c, City/State/Zip:V_-)o �►�r+1!rai��P �1 Attach a copy of the workers' cbrarkisatibn po cy declaration page(showing the policy number and expiration date). Failure to s-ecure 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 cer, under theai and penalties ofperjury tlaat the information provided above is&ue and correct p.signafore: Date: Phone# Official use only. Do not write in this area,to be completed by city or town offacial. City or Town: Permit/License# Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other Contact Person: Phone#: NORTH-1 OP ID:TH ACORO" DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 08/16/2016 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 policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Eric Semple Westford Insurance Agency IncP HONE 978-692-3073 aICC No: 9T8-692-0429 PO Box 308 AIC No Ext Westford,MA 01886 nooRLEss: Eric@Westfordlnsurance.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Preferred Mutual 15024 INSURED North Hill Development Inc. INSURER B:Associated Employers Insurance Walter Lorette 8 Winding Way INSURER C: Westford, MA 01886 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 SUBR POLICY EFF POLICY EXP LIMITS LTR D POLICY NUMBER MM/DD/YYYY MMIDD/YYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR BOP0100717368 05/02/2016 05/02/2017 DAMAGES( RENTED PREMISES Ea occurrence) $ 50,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY 1 PRO JECT F—] LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTNE YIN WCC-500-5013347-2015A 05/14/2016 05/14/2017 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re:73 Holly Ridge Rd North Andover Ma CERTIFICATE HOLDER CANCELLATION NORTHAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 384 Osgood St North Andover, MA 01845 AUTHORIZED REPRESENTATIVE �W a c y AW c.y ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I �e�ndnz�zaaeusecz�C�a���cuaac�ic��e/,�Ji 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: •,:139935 Type: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Expiration;=_ 9k3%2017 DBA I Boston,MA 02116 NORTH HILL CONSTRUCTION LORETTE WALTER c 8 WINDING WAY WESTFORD, MA 01886 Undersecretary of valid with signature Massachusetts Department of Public Safety 1-191 Board of Building Regulations and Standards License: CS-067067 Construction Supervisor WALTER H LORETTE,JX;.. r, 8 WINDING WAY- x,0 WESTFORD MA 01886 Expiration: Commissioner 09/06/2017