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HomeMy WebLinkAboutBuilding Permit #432-2016 - 78 JEFFERSON STREET 10/6/2015 (NWIveD /91611-5' } .: NORTH BUILDING PERMIT `o�`t``� TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION - Permit NO: �2_ * " t�O Date Received '� °4 ;.....�, � rao Date Issued: 0 �> SScm IMPORTANT:Applicant must complete all items on this 2age LOCATION 780 Jefferson St r _ _ Print „ PROPERTY OWNER Judith Walker r _ Print MAP NO: .046-13-0 PARCEL-096 ZONING DISTRICT: Historic District yesno , ' Machine ShopVllag yes nd TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition M Two or more family ❑ Industrial IN Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Q Septic a Well I!Floodplain ❑Wetlands 0 Watershed District Water/Sewer Renovate bathroom , fie Identification Please Type or Print Clearly) OWNER: Name: Judith walker Phone: 978-6824328 l Address: 78D Jefferson St,N.Andover,MA 01845 CONTRACTOR Name: Phone: 603-434-1611 £rossroads Contracting Address. 15 Londonderry Rd,Unit#6, Londonderry,NH 0305 Supervisor's Construction License: Exp. Date: CS-090487 / 1iT7` Home Improvement License: Exp. Date: 160086 9/17/16 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: $ 22,230.00 FEE: $ 267.00 ` Check No.: AQ Receipt No.: Z-gLi'"l e NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund gnature ofAgent/Owner Signature of'eontractol - h Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ xTanning/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 ❑ ❑ COMENTS CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED 4 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 =i=1RE DEPARTMENT - Temp Dumpster on site yes no �� ocated"at 124 Main Street ire Department signature/date I COMMENTS Location No. 1 Date I . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ — Building/Frame Permit Fee $ 2:0 r ~l; Foundation Permit Fee $ �`R✓'i � Other Permit Fee $ 4.MD ate' TOTAL $ Check# t© rJ3 ' rz 294' fi wilding Inspector U • NORTFM BUILDING PERMIT oFstyeo TOWN OF NORTH ANDOVER p APPLICATION FOR PLAN EXAMINATION ;- y Date Received Permit No#: �SSgcFlUS Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ElAlteration No. of units: ❑ Commercial El Repair, replacement ❑Assess'ory Bldg ❑ Others: ❑ Demolition ❑ Other Septic [] Well `: ��FloodplainWetlands 0 "UVaters.hedllDistnct DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. � Total Project Cost: $ FEE: $ Check No.: Receipt No.: arae and not have access to the u ty f NOTE: Persons contracting with unregistered contractors do g aPn�., vyn� -� - :T., � � � natlll'o �f rnrfirart©� ���"��� r I SianaturP of Af% � IQ -- 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 4k Floor Plan Or Proposed Interior Work Q. Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses 4. 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) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. one copy and proof of recording must be submitted with the building application Doe:Building Permit Revised 2014 Plans Submitted Q Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Taming/MassageBody Art ❑ Swinu ing pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On Signature' COMMENTS i CONSERVATION Reviewed on Signature COMMENTS A WEALTH Reviewed on Signature s COMMENTS i Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments i Conservation Decision: Comments K Water& Sewer Connection/signature gate Driveway Permit T)T W'T'own Engineer: Signature: Located 384 Osgood Street F,FIRE DEPA1'MIEYVT' FTem3rrDtX „f �,... �, _ �, ti,, , ,;,. . .. »�� ti, � �L,;.� 12 umpster�on site d es . ..��...�.,r`Z: no,- F 4tLocated at 12.4 Main S '"" , . a � �F `" � # �4Fir eDepartmentsi na /ateq g,� to p y a h;, +r:a,w. } Z y,t �S t •Rft ` j;.l� , 1 +ti [� YfCS'�W "j °�'',�'tw,Y'is..,..• "i. •vim;meq ..s. I..l. ai�;+..Zap • r .:N.�_�. ;t �} " Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: (ELECTRICAL: Movement of Defer location, mast or service drop requires approval of Electrical Inspector yes No DANCER ZONE LITERATURE: yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA.— (For department use) LI Notified for pickup Call Email Date Time Contact Name Doc.Bnilding Pennit Revised 2014 i Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 221230.00 m $ - $ 266.76 Plumbing Fee $ 33.35 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 33.35 Total fees collected $ 433.45 78D Jefferson Street 432-2016 on 10/6/15 Renovate Bathroom and Repair water damage i tt0RT1i . Town of s E '. ndover O - H.. No. 44 * _ * i o�h ver, Mass, COCNIC Nl WKK y1' AERATE O S V BOARD OF HEALTH Food/Kitchen P E. RMIT T . LD Septic System vG ! BUILDING INSPECTOR � c=am- .__ THIS CERTIFIES THAT .............................................. .. ............. ......................................................... - �' - Foundation has permission to erect .......................... buildings on ..� ��...:. . ..........:� ................................ Rough t0 be occupied as ............... .�,.afe.4 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 INSPECTQR UNLESS CONSTRUCTION S 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. CROSSROADS CONTRACTING OF DERRY, LTD. 15 Londonderry Road, Londonderry, NH 03053 603-434-1611 FAX 603-434-9391 PROPOSAL:" SUBMITTED TO: Judy Walker Phone: 978-682-4328 WORK TO BE PERFORMED AT: 78 Jefferson St, North Andover, MA 01845 DATE: September 18, 2015 EMAIL: judyw976@gmail.com SI?ECIFICATIONS THANK YOU FOR ALLOWING CROSSROADS CONTRACTING TO SUBMIT THE FOLLOWING PROPOSAL. WE WILL SUPPLY THE MATERIAL, LABOR AND EQUIPMENT TO PERFORM THE FOLLOWING WORK: INTERIOR REMODELING LEAD SAFETY FOR RENOVATION, REPAIR, AND PAINTING 1. Determine if Lead-Based Paint is present using an EPA recognized test kit in all homes built before 1978: 2. If it is determined that Lead-Based Paint is present, all work will be performed according to EPA lead safe renovation guidelines. 3. Pricing to be determined and reported within 48 hours of test results. 4. Payment for lead testing to be made directly to the lead testing contractor per Massachusetts state law. PROJECT PREPARATION and DEMOLITION Customer to remove all items from walls.Customer to pack books,decorations,and lose items in boxes so that they can be moved around during construction without damage.Customer to move items in closet to allow access to the attic scuttle hole.Crossroads Contracting to move and cover furniture and packed boxes only.Crossroads Contracting cannot be held liable for damage to any belongings left in the work area: 1. Remove and dispose of all items in the Bathroom to the existing wall studs, ceiling joists, and floor sheathing. 2. Remove and dispose of the drywall and water damaged insulation from the entire Living Room exterior wall. ELECTRICAL Supply and install the following as per National Electrical Code 2011: This proposal assumes that the existing electrical panel will not need to be upgraded. BATHROOM 1. One (1)vanity light with switch. ($100 material allowance for light fixture) 2. One (1)fan/light with switch connected to the existing vent duct. Note: Property Management Company is responsible for supplying and installation of roof termination. 3. One (1) GFCI outlet. HALL 1. One(1)4" LED recessed light with switch. BASEMENT 1. Relocate the existing dryer outlet to the exterior basement wall. PLUMBING Supply and install the following: 1. One (1) 30"X 21" Foundation Malden Sarsaparilla vanity cabinet. 2. One(1) 31"X 22"White/White Cultured Marble vanity top with 4" backsplash and right side splash. 3. One (1) Kohler Devonshire (K-394-4-BN) Devonshire Widespread Brushed Nickel bathroom sink faucet. 4. One (1) Sterling Accord Smooth Series 60"x 30" Bath with Right-hand Drain (71240120-0). 5. One(1) Devonshire Valve Trim (K-T397-4-BN). 6. One(1) Kohler Rite Temp valve(K-304-K-NA). 7. One(1) Devonshire Bath Spout(K-389-BN). 8. One(1) Kohler Hydrorail Bath and Shower Column (K-45905-BN). 9. Install hot and cold.water shut offs from the main water lines into the house in the wall behind the shower)CAKA t Page 2 Judy Walker 78 Jefferson St. N.Andover, MA PLUMBING (Continued) 10. One(1) Kohler Flipside 2.5 gpm multifunction showerhead (K-15996-BN). 11. One (1) Kohler Flipside 2.5 gpm multifunction handshower(K-17493-BN). 12. One(1) Mastershower 60" metal hose(K-9514-BN). 13. One(1) Kohler Cimarron White Comfort Height two-piece round front toilet(K-3887-0)with trip lever(K-9466-L-BN), and Cachet seat(K-4639-0). Note:Crossroads to install Customer supplied towel racks,paper holder and mirror or medicine cabinet. INSULATION and DRYWALL 1. Fiberglass insulation to code where the water damaged insulation is removed. 2. %'drywall to the exterior wall where the drywall is removed. 3. '/2' moisture resistant drywall to the walls and ceilings of the Bathroom. 4. Patch and repair the water damaged drywall in the Bedroom. 5. Mud, tape, and sand to a paint ready condition. INTERIOR FINISH T-3 '/2' pre-primed colonial baseboard trim to the Bathroom and reworked exterior walls. 2. Remove and reinstall two (2)air conditioners, and install new pre-primeAim to finish. 3. Supply and install one (1)flysh woodgrain unfinished hardwood interio do lab in the Bathroom 4, i ttis t z�,�t N¢v, coo v .tY`tiv` OL4 /;ah-rezrw s"'C(e , TILE 1. Install cement backer board and 12x12 Ashland HL05 tile with Laticrete Dusty Grey P acolor grout on the Master Bathroom floor. It (✓�5 P (,i Ili q A I:-�1 ,s 6W INTERIOR PAINTING 1. One (1)coat of Killz primer to the water stained areas of ceiling drywall. 2. One (1)coat of primer to all new and reworked drywall. 3. Two (2)coats of finish paint to the Kitchen, Bathroom, and Bedroom ceilings.4, La vv�-5 20Vv'- 4. Two(2)coats of finish paint to all new trim to match the existing as close as possible. MISCELLANEOUS 1. Any changes needed due to building code issues that are not included in the scope of work outlined in this proposal, will be billed accordingly. 2. We will clean up and remove our construction debris, and leave the site vacuum clean. 3. Permits will be obtained by Crossroads Contracting and billed at face value to the customer. 4. $600 Partner Agreement retainer fee has been applied to the contract and is reflected in final price below. TWENTY TWO THOUSAND TWO HUNDRED AND THIRTY DOLLARS ($22,230.00) OPTION#1: INTERIOR PAINTING ADD $22060 0 INITIAL 1. Two(2)coats of finish paint to all drywall in the Bathroom, Living Room, Hall, an droom. OPTION#2: GRANITE COUNTERTOP ADD $1AZ0.00 INITIAL 1. Remove and dispose of the Kitchen countertop. Save sink and faucet for reuse. 2. Supply and install Rock-N-Roll Series Granite Countertops with 4" backsplash w ere the countertops are removed. 3. Install Customer supplied Kitchen sink and faucet. Page 3 Judy Walker 78 Jefferson St. N.Andover, MA This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A), but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of a"Massachusetts Consumer Guide to Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757. PERMIT NOTICE: 1. The following permits will be required to complete the agreed scope of work: a. Building Permit, Plumbing Permit, Electrical Permit 2. Permits will be obtained by Crossroads Contracting and the face value will be billed to the customer. 3. It is the obligation of the Contractor to obtain such permits as the Owner's Agent. 4. Owner's who secure their own construction-related permits or deal with unregistered Contractors shall be excluded from access to the Guarantee Fund provisions of MGL Chapter 142A. Total Contract Price and Payment Schedule: The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of: $22,230.00 Payments will be made according to the following schedule: $4,446.00 upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater) $4,446.00 upon Start of PROJECT $4,446.00 upon Start of DRYWALL $4,446.00 upon Start of TILE $4,446.00 upon SUBSTANTIAL COMPLETION (Law forbids demanding full payment until contract is completed to both party's satisfaction.) The following material/equipment must be special ordered before the contracted work begins in order to meet the completion schedule. Not applicable. (Law forbids demanding full payment until contract is completed to both party's satisfaction.) The following material/equipment must be special ordered before the contracted work begins in order to meet the completion schedule. Not applicable. I NOTE: Including i O cud g all finance charges law requires that any deposit or down payment required by the Contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Proposed Start and Completion Schedule: The following schedule will be adhered to unless circumstances beyond the contractor's control arise. Contractor will begin contracted work in: October, 2015 Contracted work will be substantially complete (At least 95%) in: November, 2015 EXPRESS WARRANTY—Is an express warranty being provided by the Contractor? Yes (all terms of the warranty must be attached to the contract.) Contractor warrants that Work will be of good quality, free from defects and in compliance with the requirements of the Contract Documents, as well as applicable local, state and federal laws, ordinances, rules and regulations. At the Owner's request Contractor shall promptly repair or replace defective work for a period of one year after the date of Work is substantially complete. All other statutory or common law warranties are specially disclaimed. Page 4 Judy Walker 78 Jefferson St. N.Andover, MA Subcontractors—The Contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement. Contract Acceptance—Upon signing, this document becomes a binding contract under law. Unless otherwise noted with this document, the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the Contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement Contractors and Subcontractors to be registered with the Director of Home e Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at One Ashburton Place, Room 1301, Boston, MA 02108 or by calling 617-727-3200 or 1-800-223-0933. • Does the Contractor have insurance? Check to see that your Contractor is properly insured. • Know your rights and responsibilities. Read the Important information that follows on this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the Contractor's normal place of business, provided you notify the Contractor in writing at his/her main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. (Two identical copies of the contract must be completed and signed. One copy should go to the homeowner. The other should be kept by the Contj4 ra or.) c ome//owner's Signature C tor's S na Date Date JB/HSUP89 Contractor Arbitration The Home Improvement Contractor Law provides Homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a Contractor. The same right is not automatically afforded to a contractor, however. The Contractor would have to resolve any dispute he/she has with a Homeowner in court unless both parties agree to the optional clause provided below. This clause would give the Contractor the same right to arbitration as is afforded to the Homeowner by the Home Improvement Contractor Law. The Contractor and the Homeowner hereby mutually agree in advance that in the event the Contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm which has bee .approved by the Secretary of the Executive Office of Consumer Affairs and Busines g tion and the consum all be required to submit to such arbitration ads provided in Massachusetts General L s, ch r 142A. 6meowner's Signature Contracto i Page 5 Judy Walker 78 Jefferson St. N.Andover, MA NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the Contractor. The Homeowner may initiate dispute resolution even where this section if not separately signed by the parties Homeowner's Rights A Homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A) and other consumer protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, Homeowners may be excluded from certain rights if the Contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The Contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the Contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the Contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the Homeowner and Contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a Homeowner's basic consumer rights. If you have questions about you consumer/Homeowner rights, contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be9 iven to the Owner and the other kept by the Contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day recision period has expired. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of"A Consumer Guide to the home Improvement Contractor Law" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170 Boston, MA 02116 (617) 973-8787 or 1-888-283-3757 If you want to verify the registration of a Contractor or if you have questions or need additional information specifically about the Contractor component Registration g p ent of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Bureau of Building Regulations and Standards One Ashburton Place, Room 1301 Boston, MA 02108 (617)-727-3200 or 1-800-223-0933 For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800 508-755-2548 413-734-3114 I I � J i : t . P l �L 1 : - --, "Alt, -1--� 13 DWI AJI -- I � I ' _ f j � rj ; I I I 1 I I. j I : Condo Property Record Card PARCEL_ID:210/046.0-0096-0051.G MAP:046.0 BLOCK:0096 LOT:0051.G PARCEL ADDRESS:78 JEFFERSON STREET FY:2015 _—_ - --sii __ PARCEL INFORMATION Use Code102 Sale Pace 47,500 :Book.` 04898_�RoadType: T �W Inspect Date: Owner. Tax Class: T Sale Date: 11/23/97—'Page:R�0299 Rd Condition: P �Meas Date:_' WALKER,JUDITH D Tot Fin Area 650Sale Type6 CerUDoc: �` Traffic:M Entrance: _ Address: lot Land Area: 0.00 Sale Valid: Y � Water � Collect Id - -. - 78D JEFFERSON STREET - Grantor: D—AV ID FROTH—IN GHAfJI Sewer: Inspect Reas— NORTH ANDOVER MA 01845 Exempt-13/1-0/6 / Resid-B/L%100/100 Comm-BM/ Indust-B/L% / Open Sp-B/L% / CONDO INFORMATION VALUATION INFORMATION Style: TH Tot Rooms: 3 Fn Liv Area: 650 Bsmt Area: 0 Current Total: 85,400 Bldg: 85,400 Land: 0 MktLnd: 0 Apt Unit#:--51--F611Bedc—�i �OnfCivArea: - FinBsmfSF: "' Prior Total: 81,300 Bldg: 81,300 Land: 0 MktLnd: 0 - -- -•---�-—---_. Unit Desc: Den/Part Bed: Load Dock SFc Fn Bsmt Grad: �_ o -g Res Unit Type: Full Baths 1 Bldg Escalfrs: Parking Class: C�_.. .__a C/1 Unt Type"Half Baths:1 _Bldg levaltrs: Parking Rstr:N Comp.Name: VICL/H8H1 QualitIF M No Ovrhd Dr. Paiking Open: GREEN 4.__..._ __ _—i _.__ Comp.Code: Kitchen'Type�O v Parking Covrd: 6 Comp.Class: Kitchen Qual: M Atypical: Parking Gar: Condor -_ ype: Bi Wall Heighf: Eff Yr Built: 1979 Pct Com.lnt:; Value Method:" - Flooiing: —Year Built: 1966 Pct lhtOWrld[ Base Flxio�. "-2 Ceillingsr 'Grade__._ A Int Adj Fctr: Num Floors. 1 _Fire Alarm: Condition: A Val Adj Pct: Pct Sprinkles: Pct Complete: Val'Adj Arntc --- ----- �.� HF -_—HW �� � ViewQuality: Heat Control: 1"` View Add: .- AC Control: ®``-"`— Unit Coc Adj Fireplaces:_-0'"-'- Market Adj: Stacks: 0_ Condo Val: i.-_— Hearths: Sougd Val-6-1 Misc Struc: SKETCH PHOTO No Skgetch ' No Picture AvY.&WIlable Ava"llamble Parcel ID:210/046.0-0096-0051.G as of 9/29/15 Page 1 of 1 The Commonwealth of Massachusetts Department of Industrial Accidents a 1 Congress Street,Suite 100 < Boston,MA 02114-2017 < www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicant Information Please Print Leeiblv Name(Business/Organization/individual): Crossroads Contracting of Derry,Ltd Address: 15 Londonderry Rd, Unit#6 City/State/Zip: Londonderry, NH 03053 Phone#: 603-434-1611 Are you an employer?Check the appropriate box:' Type of project(required): IQ I am a employerwith employees(full and/or part-time).* 7. ❑New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my properly. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5. xx I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.t p 6.Q We are a corporation and its officers have exercised their right of exemption per MGL C. 14,E]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners 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-contractors have employees,they must provide their workers'comp.policy number. I I am an employer that is providing ivorlcers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Netherlands i Policy#or Self-ins.Lic.#: WC8875773 Expiration Date: 11/01/15 Job Site Address: 78D Jefferson Rd City/State/Zip: K Andover,MA 01845 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). i Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of pe►juty that the information provided above is true and correct. Signature: Date: Phone#: 603-434-1611 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: CROSS-2 OP ID:SG ACORO" DATE(MWDD/YYM CERTIFICATE OF LIABILITY INSURANCE 11/18/2014 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(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER m CONTACT Jason M MIOCek Planright Insurance-Sale 224 Main Street Suite 3C Po Extl.*603-890-6439 FAX No):603-890-6521 Salem,NH 03079 ADDRESS:Jason M Mlocek DDDSS: ason santoinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Peerless Indemnity Ins Co 18333 INSURED Crossroads Contracting of INSURER 8:Excelsior 11045 Deny Ltd 15 Londonderry Road Unit 6 INSURER C:Netherlands 24171 Londonderry,NH 03053 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 INSURANCEADDLSUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD/YYYY MM/DD LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE E 1,000,00 0. CLAIMS-MADE M OCCUR BKS55672607 11/01/2014 11/01/2015 PREMISES Ea occurrence E 300,00 MED EXP(Any one person) E 15,00 PERSONAL BADV INJURY E 1,000,00 GEN'LAGGREGATELIMITAPPLIESPER: GENERAL AGGREGATE E 2,000,00 POLICY a JE T TM LOC PRODUCTS-COMP/OPAGG $ 2,000,00 OTHER: E AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident E 1,D00,00 B ANY AUTO BA8814314 11/01/2014 11/01/2015 BODILY INJURY(Per person) E ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIREDAUTOS X NON -OWNED PROPERTY DAMAGE E UTOS Per accident $ UMBRELLA B OCCUR EACH OCCURRENCE E EXCESS LlACLAIMS-MADE AGGREGATE $ DED RETENTION E E WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X I STATUTE I ERS C ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 08875773 11/01/2014 11/01/2015 E.L.EACH ACCIDENT E 500,00 OFFICER/MEMBEREXCLUDEDI NIA (Mandatory In NH) 3A: MA NH E.L DISEASE-EA EMPLOYE E 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POUCY LIMIT E 500,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) Jan Jacome as elected to be excluded from work comp coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For Information Only ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD rroads ACTING NN A Woman-Owned Business...Changing the Face of Remodeling. Subcontractor List Job Location: Judith Walker 78D Jefferson St N. Andover, MA 01845 JW Chick Electric 3563 Brown Ave Manchester, NH 03103 Shanley Plumbing & Heating, LLC 71 Pleasant St Danville, NH 03819 15 Londonderry Road Unit#6 Londonderry,NH 03053 Phone:603.434.1611 www.crossroadscontracting.com Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massac setts 02116 Home Improvement C for Registration Registration: 160986 Type: Private Corporation Z i Expiration: 9/17/2016 Tr# 256801 CROSSROADS CONTRACTING O JAN JACOME o - 15 LONDONDERRY RD. #6 LONDONDERRY, NH 03053 T 1b Update Address and return card.Mark reason for change. SCA 1 0 20M-05,11 � Address Renewal F� Employment F-1 Lost Card Vico tpa�rimo��usecc � as�2c�zcteeClJ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only TOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: ,,160,986 Type: Office of Consumer Affairs and Business Regulation Expiration--, G Private Corporation 10 Park Plaza-Suite 5170 ;� /� Boston,MA 02116 CROSSROAQS COt :_, - �ERRY LTD ,.i JAN JACOME 15 LONDONDERRY 1fb; 9N�ot0ali LONDONDERRY, NH 03. �3- Undersecretary without signature vhe�arn�nomu�eall�o��/�Gaauzc�cureC�s ice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVgpENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation eglstratiogf- 3 Type: 10 Park Plaza-Suite 5170 Expirali¢ - �G Supplement Card Boston,MA 02116 CROSSROADS CON-• qi - 'PERRY LTD JOHNNY HAWKES 15 LONDONDERRY R ;,;r;' LONDONDERRY,NH 03053 Undersecretary Noevalid out signature 1 Massachusetts -Department of Public Safety Board of Building Regulations and Standards ` Construction Supervmor _i License: CS-080487 f �`tig,T 1:ti OF JOHNNY P HAW1�S 37 T3NH 7�Il�ETO JW 11 Derry 03038 2 1 ���... M, Expiration Commissioner 01/21/2017 i