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HomeMy WebLinkAboutBuilding Permit #466 - 75 HAY MEADOW ROAD 1/23/2008Permit NO: 'L' BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 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 Sepia>r it rr �JD�Ja� ,� �+eas , �. tersEc stnci�7� ,y �..�,.,.f� g-"F,.k� Rta�sr.,iix...��!t s.Cr ts- �'ri}` a? ?� fir♦ ir'�'r•.�� t' IX iL�y�_ .% ..5 t DESCRIPTION OF WORK TO BE PREFORMED: 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: $712 _'] 'FEE: $. 3 Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have fund 0\ e 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes _ Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street 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 MUTES and DATA - (For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report Of Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location-?�— A4.1-1 �%?eAd�� No. Date r NpR'" TOWN OF NORTH ANDOVER O�tJo ,,h.O F? • • 0 Certificate of Occupancy $ �•�s''^"�t�' Building/Frame /Frame Permit Fee $ J3� JwCHust 9 Foundation Permit Fee $ Other Permit Fee $ _ TOTAL $ Check # 20907 _ Building Inspector o as u Q U A o c w° qj cn U w 0 V a d w oa F W a W a C2 � cn co w Q a C2w E+ W w G o cn D J f 2 a r .T 2 O O O G3 O V Z m CL O y � C di Om IpCA 'OO c LA E m m =CD O � a� co L O O d E: rm CA 0.O O V FL Co ca ts r.. co O d V cc cc CO2 0 c c CO c c o ` c H O G O CJ V CLG A R m G 2 Cc O IA Co. Oct o c fE V r �m O. y :O= C.3 O .r CD c_ :g E CL Cos L L ao. y vs o 3 = +• . � m �p y C O •. C m � Z C y 0 ca cm y O m t = O 92 Of :moa C=O, 7: acO O 4- V y O L CL F• y O C •C _ CD ��: m =.r p A CO) N ep .. c � •tii � °C o.r c •y •E C-2 -0 wU 2 o CD COD FE O• m� O� ���� s I � a CL4-F. f 2 a r .T 2 O O O G3 O V Z m CL O y � C di Om IpCA 'OO c LA E m m =CD O � a� co L O O d E: rm CA 0.O O V FL Co ca ts r.. co O d V cc cc CO2 0 M Member: National Kitchen & Bath Association National Association of Home Builders Merrimack Valley Chamber of Commerce Massachusetts Home Improvement Contract Registration # 119849 Massachusetts Construction Supervisor License #113726 Insurance Coverage: Harleysville We are proud to provide you with the following services: Custom Remodeling & Additions Custom Finish Work Architectural Design Structural Engineering Interior Design Lighting Design Landscape Design AGREEMENT Mr. & Mrs. Adam Lawrence Date: January 15, 2008 643 East Broadway Phone: W (617)335-7609 H (978)689-2366 Haverhill, MA 01830 Email: cc924@comcast.net MASTER BATH & CLOSET RENOVATION FEATURES AND SPECIFICATIONS 1. PERMITS: • Obtain building permit • Obtain plumbing permit • Obtain electrical permit 2. PROJECT SET UP: • Architectural and Interior design plans of Master Bathroom Suite • Install dust barriers and floor protection covering 3. FLOOR AREA: • Bathroom Floor: Remove existing tile floor and underlayment • Bathroom Floor: Install new concrete board underlayment • Bathroom Floor: Install new electrical radiant heating under file approximately 16sq' coverage with programmable thermostat. • Bathroom Floor: Install new tile floor in bath allowance $4.00sq' • Bathroom Floor: Install new marble threshold between bedroom and bath space. • Closet Floor: Reinstall existing carpet into existing closet space. 4. WALL & CEILING AREA: • Remove existing wall partitions per plans • Remove existing plaster walls and ceiling to framing • Install new concrete board on walls and ceiling of shower • install new plaster on walls and ceiling of bathroom and closet, note walls and ceiling to have smooth finish. Christian Builders, Inc. www.christianbuildersinc.com PO Box 652, Reading, Massachusetts 01867 Tel: 781 944-6124 Fax: 781 942-9327 m j 5. WINDOW UNIT: • Bathroom: remove existing casement window unit • Bathroom: Install new Pella Casement Size 4' V x 3' 4 %' white clad, wood grilles and screens • Bedroom Windows: Second Floor (3) units @ 4' V x 4' 8 V white clad, wood grilles and screens • Install new 2 %" casing around interior of window unit and 908 casing exterior Azek 6. ELECTRICAL: • Bathroom: Install (2) wall mounted lights with an allowance of $100.00 each. • Bathroom: Install (1) exhaust fan unit and install (1) new exhaust fan with light in same location. Note: New exhaust fan unit to have a reduced noise level and higher level of exhaust. • Closet: Install (5) recessed lights with door jamb switch 7. HEATING: • Reuse existing heating and cooling supply for renovated bathroom • Radiant floor heat see floor area. 8. PLUMBING: • Remove existing water closet and install new Kohler Memoirs water closet allowance $350.00, color white. • Remove existing shower unit and install new custom tiled shower with clear glass door, clear glass side wall , brushed nickel hardware. Symmons shower valve, hand held sprayer and granite shower seat. Note: wall, ceiling and floor file allowance custom shower @ $4.00sq' q\Aixk ee • Remove existing vanity, countertop, and faucets, install new custom c r vanity with two b sinks, makeup area, (2) faucets, granite countertop and (1) custom framed mirror Note vanity suite Kraft Maid Chermy per plans. 9. INTERIOR DOORS: 01-1- V\ • Bathroom: Install (1) new six panel pine door unit • Closet: Install (1) new six panel pine door unit 10. CLOSET ORGANIZER: • Closet Organizer System: Allowance $2,300.00 Contractor Initial Homeowner Initials _L4e— Page 2 of 8 Contractor Initi 11. PAINTING: • Woodwork to oiled based primed and finished with acrylic latex • Walls and ceiling to be.acrylic latex primed and finished with acrylic latex • Note: We use Benjamin Moore high quality paint finishes PROJECT COST BATHROOM AND CLOSET $39,108.00 PELLA WINDOW UNITS (3) @ $1,873.20 5,619.60 TOTAL PROJECT COST $44,727.60 This space was left blank intentionally Homeowner Initials -41 Page 3 of 8 PAYMENT SCHEDULE The Owners shall pay to the Contractor in respect of said work and materials, the sum of Forty Four Thousand Seven Hundred and Twenty Seven Dollars and sixty cents subject to additions and deductions as herein provided, to be paid as follows: Payments due upon the following events: Amount Signing of Proposal, Deposit $11,181.90 Corpletion of rough plumbing and electrical $11,181.90 Completion of tiling floor $11,181.90 Completionofproject $11,181.90 Total of all paynerts: $44,727.60 These prices reflect material costs as of January 2008. Due to the pending nature of the work involved, material costs may cause changes to payment structure above and total payment amount. PROJECT SCHEDULE 113 - 1 ZZ Construction Of Project January X, 2007 — February 18, 2008 Approximately (20 -22 ) days, not including delays and adjustments for delays caused by additional time required for Change Order work, and other delays, unavoidable or beyond the control of the Contractor. The work to be performed under this contract shall be commenced upon the acceptance and signing of the contract and after receiving a building permit. Contractor Initi Homeowner Initials Page 4of8 T., AGREEMENT TERMS A. EXPIRATION OF THIS AGREEMENT This Agreement will expire 30 days after the date at the top of page one of this Agreement if not first accepted in writing by Owner. B. CONTRACT AGREEMENT This agreement represents and contains the entire agreement between the parties hereto and there are no verbal agreements. This contract may be modified or amended by written order only, signed by both parties. VERBAL AGREEMENT NOTE: Due to the wide range of conversations that are typical in the development of any project, only those specifications outlined in the final written contract can be considered binding. Any perceived or recalled verbal agreement will not be considered binding. C. CHANGE ORDERS 1. CONCEALED CONDITIONS - This agreement is based solely on the observations contractor was able to make with the structure in its current condition at the time this agreement was bid. If additional concealed conditions are discovered once work has commenced which were not visible at the time this proposal was bid, contractor will stop work and point out these unforeseen concealed conditions to owner; so that the owner and contractor can execute a Change Order for any additional work. Concealed condition Change Orders are not assessed an administrative charge. 2. DEVIATION FROM SCOPE OF WORK - Any alteration or deviation from the scope of work referred to in this agreement involving extra costs of materials or labor will be executed upon a written Change Order issued by contractor and should be signed by contractor and owner prior to the commencement of additional work by contractor. Five Change Orders will be allowed without an administrative fee; thereafter, a $50.00 administrative fee will be assessed to each Change Order. Due to scheduling there is the possibility that Change Orders will cause delays in project D. DISPUTE RESOLUTION Any controversy or claim arising out of or related to this Agreement involving an amount of $2000.00 or less must be heard in the Small Claims Division of the Municipal Court in Woburn, Massachusetts. Any controversy or claim arising out of or related to this Agreement which is over the dollar limit of the Small Claims Court must be settled by binding arbitration administered by the American Arbitration Association in accordance with the Construction Industry Arbitration Rules. Judgment upon the award maybe entered in any Court having jurisdiction thereof. The prevailing party in any legal proceeding related to this Agreement shall be entitled to payment of reasonable attorney's fees, costs and expenses. Contractor Initial'i. Homeowner Initials I'- Page 5 of 8 A ti E. STATUTORY DISCLOSURES 1. Contractor certifies that he is registered with the Commonwealth of Massachusetts as a Home Improvement Contractor, MC #1 19849, and as.a Construction Supervisor, CSL #069118. 2. Acceleration of contract: No contract shall contain an acceleration clause under which any part or all of the balance not yet due may be declared due and payable because the holder deems himself to be insecure. However, where the contractor deems himself to be insecure, he may require as a prerequisite to continue said work, that the balance of funds due under the contract, which are in the possession of the owner, shall be placed in a joint escrow account requiring the signatures of the home improvement contractor and owner for withdrawal. F. RIGHT OF CANCELLATION The homeowners may cancel this transaction at any time prior to midnight of the third business date after the date of this transaction. MGL c.93, s. 48; MGL c. 140D, s.10; MGL c.255, s.14; as maybe applicable. G. INSURANCE ENDORSEMENT Homeowner is responsible for any and all physical loss or destruction of materials once installed to your home. CBI strongly recommends that you purchase an Insurance Endorsement on your Homeowner's Insurance from your insurance agent. If your agent will not issue one, our office has names of agents who will. H. WARRANTY Christian Builders, Inc. will warranty labor and materials for one years. While under construction CBI warrantees the house against damage caused by CBI or its agents. I. EXCLUSION TO WARRANTY Repair of the following items is specifically excluded from Christian Builders, Inc. warranty. Damages resulting from lack of Owners following maintenance instructions; damage resulting from Owner neglect or ordinary wear and tear; deviations that arise such as the minor cracking of concrete, minor stress fractures in plaster board due to the curing of lumber; minor warping and deflection of wood; minor shrinking/cracking of grout; minor shrinking and gapping of hardwood flooring; minor shrinking and gapping of interior trim boards; and fading of paint and finish exposed to sunlight. Cracking in walls ceilings and foundation are considered minor if they are ''/<" or less. Shrinking in wood trim, hardwood flooring, and grout in tile are considered minor if they are 1/8" or less. Warping or deflection of wood is considered minor if it is '/" or less. J. PAYMENT TERMS Payment of Contract Payment for contract is DUE WITHIN 48 HOURS OF NOTICE FROM CBI THAT THE PHASE IS COMPLETE AND SATISFACTORY INSPECTION BY HOMEOWNER Payment of Change Orders Payment for each Change Order is DUE UPON APPROVAL OF CHANGE ORDER by Homeowner. Payment of Special Order Items J Payment for special order items are PAYABLE IN FULL UPON ORDER OF EACH ITEM. Contractor Initial Homeowner Initials Page 6 of 8 C77— i 1 V& a K. CLEAN UP Christian Builders, Inc., shall be responsible for all debris to be removed from the site and disposal shall comply with all state and local ordinances. At the end of each day, the job shall be broom cleaned. NOTE: All hazardous materials that are encountered while in construction process, will be removed by homeowner's agent. L. PROJECT PREPARATION Christian Builders to: • Provide building inspector necessary plans to obtain building permit..In doing this Christian Builders, Inc. acts as the owner's agent. Owners' who secure their own construction related permits or deal with unregistered contractors will be excluded from access to the guaranty fund • Install dust control barriers and floor protection covers • Setup materials and equipment at job site • Organize materials on job site at the end of each day NOTE: Homeowner is responsible for the removal of household items, furniture, and window treatments from construction area. * ALLOWANCES Allowances are indicated for items that will be selected at the homeowner's discretion. If the cost of the actual selection for an individual item exceeds the allowance, an invoice for the excess amount will be presented to the homeowner and will be payable on receipt. If the cost of the actual selection for an individual item is lower that the allowance, a credit will be applied to the homeowner's account and the credit amount will be deducted from the next payable invoice presented to the homeowner (see payment schedule below). Items purchased through Christian Builders, Inc. against an allowance will be subject to a fee to cover warranty labor and administrative fees. Items purchased by the client with a vendor directly are not covered by 1 -year warranty, must be inspected by the customer to ensure that the product is free of defects, and must be delivered on time in order to meet the schedule of the builder. Items purchased by the client may cause unforeseen delaysAth"onstruct�q�hedule, which the client may be responsible for. Homeowner Signature Contractor Homeowner Initials a ,b/ -,Y - Date Date N Page 7 of 9 / ubmitted to Homeo er by: 4) John MATT ow skiDate President Christian Builders, Inc. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES No work shall begin prior to the signing of this contract. All parties are to be in receipt of signed copy of contract. I have read and understood, and I agree to, all the terms and conditions contained in the Agreement above. _ „ /l Homeowner signature VA All home improvement contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director, Home Improvement Contractor Registration _ One Ashburnton Place Room 1031 Boston, NIA 02108 Tel. (617) 727-8598 Contractor Initial/ 4& Homeowner Initials —(Q' LT— (_� Page 8 of 8 Graham Waste Services is actively involved in waste industry issues at the local and national levels as a member of the National Solid Waste Management Association ("NSWMA"). We are committed to environmentally sound waste disposal practices, and are committed to recycling and other green initiatives. We are also involved in regional business issues as a member of the South Shore Chamber of Commerce. Waste Material Customer represents and warrants that the materials placed in the equipment shall be "waste material' as defined herein and shall contain no other substances. The term "waste material' as used in these Terms & Conditions shall mean solid waste generated by Customer excluding radioactive, volatile, highly flammable, explosive, biomedical, infectious, toxic or hazardous material. The term "hazardous material' shall include, but not be limited to, any amount of waste listed or characterized as hazardous by the United States Environmental Protection Agency or any state agency pursuant to the Resource Conservation and Recovery Act of 1976, as amended or applicable by law. Title to and liability for any waste excluded above shall remain with Customer and Customer expressly agrees to defend, indemnify and hold harmless Graham from and against any and all damages, penalties, fines and liabilities resulting from or arising out of such waste excluded above. Other prohibited items include, and are not limited to, medical waste, biohazards, paint, paint thinner and other solvents, equipment containing gas or oil, chemicals and items with asbestos content. Restrictions and fees may apply to other items including, but not limited to, appliances, propane tanks, refrigerators, freezers, box springs, mattresses, air conditioners, tires, televisions, monitors and computers. Please contact us if you have any questions regarding certain materials. 215 Chief Justice Cushing Highway • Cohasset, MA 02025 Toll -Free: 888-480-4600 / Phone: 781-383-3383 / Fax: 781-383-9669 ISSUE DATE (MM/DD/YY) zF 'N°SVRN CR`I'I�'ICAT�JOI�._ - P4YODUC.ER Minuteman I1)Isurauce Agency 'PHIS 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 POLICIES BELOW. COMPANIES AFFORDING COVERAGE 76 Blanchard Road Burlington, MA 01803 INSURED !COMPANY Genesis Consolidated Services Inc 76 Blanchard Road LETTER A A.1.M. Mutual Insurance Co Burlington, MA 01.803 i COVERAGES THIS IS TO CERTIFY THAT TIE 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 RESPECTTO WHICH THIS .CERTIFICATE MAY BE ISSUED-OR MAY. PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS- SUBTEL T TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY J.-DAVE BEEN REDUCED BY PAID CLAIMS. — - CO LTR TYPE Or INSt)RANCE - -- POLICY NUMBRR I POLICY f;m- X-TIVIi�POISf'Y DATE(MM/DD/YY) ICXPIRAT[O DATE(MM/DDlYY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ .LAIMS MADEEDICCUR PERSONAL & ADV. INJURY $ EACH OCCURRENCE $ OWNER'S R CONTRACTOR'S PROT. FIRE DAMAGE (Any one fire) $ Y _ MED. EXPENSE (Any one person) $ AUTOMOBILE LIABILITY ANY AUTO - 1 COMBINED SINGLE LIMIT ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per person) $ --__- ` 141RU AUTOS NON-OWNED .AUTOS BODILY iNI11RV (Per nceirreut) - $ GARAGU.. LIABILITY i PROPERTY DAMAGE $ EXCESS LIABILITY I EACH OCCURRENCEF-: $ MBRELLA FORM 1THER AGGREGATE $ T14AN LIMBRELLA FORM 'Ar. ORKER'S COMPENSATION AND EMPLOYERS' LIABILITY WC STATU- TORY LIMITS F.l EnLH�Q( AUNT _ EL DISEASE--POLICY r.,IMIT $ uu A THE PROPRIETOR/X PARTNERS/EXECUTIVE rNc:l: 7020582012007 02/12/2007 02/12/2006 __ $ 1,000,000 FI_ DISEASE-EA. EMPLOYEE $ 1000 000 OFFICERS ARE,: E\CI- OTHER i I DESCRIPTION OF OPERATIONS/I.00ATIONS/VEMCLES/SPECIAL ITEMS COVERAGE IS RESTRICTED TO EMPLOYEES LEASED TO: CHRISTIAN BUILDERS, INC. CERTIFICATE HOUDER CANCEL LATjk)ty CHIRISTIA.N BUILDERS, INC. 30 AZALEA CIRCLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLrD BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL. 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO MAIL SUCH NOTICE SITALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY FIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. READING, MA 01867AlYMORIZED RrPRESENTATIVE ACORD CERTIFICATE OF LIABILITY INSURANCE:::I: EATE,(,mjm:,/D:2DN,,:(yy:7y) PRODUjER (781)942-2225 FAX (781)942-2226 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Gilbert Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 137 Main Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Reading, MA 01867-3922 INSURED 104 TREMONT ST PEABODY, MA 01960 rr)11PRAn=Q INSURERS AFFORDING COVERAGE I NAIC # INSURERA: WESTERN WORLD INSURANCE COMPANY INSURER B: INSURER C: INSURER D: INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDIN 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILT R INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE JUMIDDLYYI POLICY EXPIRATIODATE DAN LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR TBD 01/31/2007 01/31/2008 EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED$ 50,000 MED EXP (Any one person) S 2, 500! PERSONAL & ADV INJURY $ 1, 000, 000! GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC PRODUCTS - COMP/OP AGG $ 2,000,000 AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) S ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT S OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY OCCUR F CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ $ f — DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY 11STATU- OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. EACH ACCIDENT $ _ E.L. DISEASE - EA EMPLOYE S J If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT S OTHER DESCRIPTION OF OPERATIONS! LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS ORKERS COMPENSATION HAS BEEN APPLIED FOR WITH THE MASSACHUSETTS ASSIGN RISK POOL NCE ASSIGNED WE CAN REQUEST CERTIFICATE FOR WORKERS COMP. CHRISTIAN BUILDERS CARLOS P 0 BOX 652 READING, MA 01867 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE uUKEEN M DONOHUE ACORD 25 (2001/08) ©ACORD CORPORATION 198P y, d r i Workers' Compensation Applicant Information Name Business/Oreanization/Individ Address: . The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, RSA 02111 www.mass.gov/dia ' isuragce Affidavit: Builders/Contractors/Electricians/Plumbers City/State/Zip: Are,you an employer? Check the ppn 1. ❑ I am a employer with employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp, insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 6AY.., Phone.#: ��' J �'�'�—' 1,12A 4. [ I 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.* 5. ❑ We are a corporation and its officers have exercised their . right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required):., 6. ❑ New construction 7. Q Rernodeling 8. ❑ Demolition 9. ❑ Building.addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other "Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeo masers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors 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-contractorshave employees, they must provide their workers' comp. policy number. I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site information. i .4-'> „ , j I „ I , Insurance Company Name: /-, -1,-1"1 UV � U� {k 1 �}� ( I a Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: 6. Attach a copy of the workersauired ompensation policy declaration page (showing the policy number and expiration date). Failure. to secure coverage as r 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of I do hereby penalties of provided above is true and correct Ujj1c1u.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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employ6rs to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including I the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the .occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "everstate or local Iicensing agency shall withhold the issuance or renewal of a license or permit to,bpers tee business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "'Neither the commonwealth nor any of its political subdivisions shall enter into any contract for. the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the laworif youare required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town .Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Cormnonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street. Boston, MA 02111 Tel. # 617-727-4900 ext.4M or 1-877-MASSAFE ` Fax # 617-727-7749 Revised 11-.22-06 www.mass.govldia J&'1unurvi,msuxrazu , pNWvY<.r_.. 7+r �'� r'II n U' iTV �f✓4. , ASSMHOLOVER. T ALTER THE CI�3Vl� ax:� AFFdt�l3fEC1 BY 7FiJ� pig �� g1Low, �, MA Qom . C fllMEANIES &�F�FrJi R� � - OOMPANY COMPANY INBUgED //Y/\ I �r `I'�}•'' � ,ter... . ti•�' C. R�j'�/C.�G Y p COMPANY _. •• S7— OOMPANY f v'r U_ do- e>. .NSU T411S IS DCNi51WiTM5HAT THE TAht� NGOANIYIREQUIREMENT,TERM 17R�C CONDITION 4ES 0 INF8ANY CONTRACT OR OTHEF! oOCUMENT vdlt R� MA THE T THIS INDICA I.SaUpD IND(G Fi D, MAY BE TANDIN OR MAY RTHE ERM O N0 A ITIONi F by TYita Pr:SLIC163 OSSCAISED HEREIN IS SUI§JHCT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POW01$S, LIMITS SHOWN MAY HAVE BEEN REDUCEb E•Y PAID CLAiM_S. I POLICY EFFECTIVE Ptyl P:Y twIPATION � WMrrS POLICY NUMBER CO ` TYPE QP INSURANCE DATE (MMIDDIVY) DATE (MUMMY) I LTR GENERAL AGG1150ATE S 1 OETIERAL LIABILfTY ataaouBTS • COMPRIP A4r1 $ __ t+L7MMrnu,n� "..•.�. •♦ , FIR NAIjS RY"'u"r7'S PROT �RDAN'd4tae tAny_�+� I AvromoB11.E LIA8ILITY i COA7SINED $iNgLE ""'T S ANY AUTO I ! S it-yrII 4 I ALL OWNED AUTOS { I leer person) (Per SCHEDULED AUTOS 1 MIRED AUTOS I j SONNY INJuRv S I j (Per oaddone, NON-OWNG-0 AUTOS II�-- . I I PROPERTY DAMALIIc � . AUTO 6NLY • EA A=ID6fJT & GARAGE LIARR" OTHER THAN0 LY: 2 ANY AUTO t_AONpG��.IDG�M' $ ffff j EAGt11�dCtJRR6NGE L1A11J UMSREL�A FORM I AGGREGATE f6 OTHER THAN UMSRELLA FORM ! WE RTU- �5��1 OB�Q. GH r. COMPENSATION AND _1-7 . FWORKek$ EMp1,4Yi LfA81Ll'K I ELERCF!AGCIDEN"r S �.. THE PROPRIETOR! INCL i t EL OI$EA^u>; - POLICY LVMtF I PARTNERSIEXECUTIVE OFFICERS ARE EXCL @L ❑ISEASE- EA EMPLGIYEE OTHER I DESCRIPTION OF OPERATIONS&OCATIONSMEHICLESISPh_"CIAI,1TEb1S ♦ sY. .. .<. L r\....J vn 5'?nii5� ..< r .r�.i .�<'.:h ��Mr IrIM 1<i:t�?m.4[45?n w. n ♦ .. .� '1 IN .l MWER Is, . j£J /�6}/,�%�/� iCJ / /� ''`�^•-�" � •^^"'�" SHOULD ANY OF THE AROVE DESCRISED 00.101M m6 CANCELLED Be MAE THr; EKPIRATION LATE THEREOF, THE ISAUING COMPANY iMLM AKEICAVQp TO MAIL DAYS WAITTEN NOTICE TO THE PrAliftICATB MOLOER NAMEta YCI •I•HR LEFT, ALIT FAILURE TO SUON NOTICE SH IMPOSS NO ro1NI. L WT OBLIGATION OR LIASIY OF DINE P N TME COMPA ITS AULPN;p OA , REMMSENTAWYM V,.►�,,1� +'moi f i" AUTH H ATIVE ! "G°s3•". ,I'W53�"<i"(;ri{�"' ..`�='^'>'' s"r .'`3f�` < `[: "�:" ra:ny<e.ery,... ,.� ✓tae tpomnranuie�l o��/`ac%uae6 3oard of Building Regulations and Standards Construction Supervisor License License: CS 69118 Birthdate: 1/18/1955 sem' Expiration: 1/18/2009 Tr# 8543 ` Restriction: 00 JOHN M JANOWSKI �> PO BOX 652 READING, MA 01867 Commissioner ,sem ✓iae �oo9rrmeoar�ued� ��4� \ Board of Building Regulations and Standards G }TOME IMPROVEMENT CONTRACTOR Registration: 119849 Expiration: 9/7/2009 Tr# 260015 Type.. Private Corporation CHRISTIAN BUILDERS, INC JOHN JANOWSKI 30 AZALEA CIR READING, MA 01887 Administrator 00 - 35,000 cf enclosed.space IA - Masonry only 1G - 1 2 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. License or registration valid for individul use only before the expiration date. if found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston, Ma. 02108 Not val' without signature