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HomeMy WebLinkAboutBuilding Permit #540 - 84 MOODY STREET 2/8/2007Permit NO: b Date Issued: TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received. ,�, �-, U IMPORTANT: Applicant must complete all items on this page I LOCATION 91� 'VN0064 5x ree+ j Print PROPERTY OWNER Jy\ ` e /� i1 OV -0 — h �� Print MAP NO.� 00 j' U PARCEL: Uc,P ZONING DISTRICT: .w . frim rrot+ AT. OTTTT lr%Md'S MgT091C niCTR1rT YES ❑ i-TrE Aril USE yr nvalw"u.v TYPE OF IMPROVEMENT - —-------- PROPOSED USE --- Residential Non- Residential ❑ New Building .& One family ❑ Addition ❑ Two or mom family ❑ Industrial l Alteration No. of units: ❑ Repair, replacement ❑ Assessory Bldg ❑ Commercial ❑ Demolition ❑ Moving relocation 0 Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED Identification Please Type or Print Clearly) ii r �UYC , cid �-,(QFr1al43$ OWNER: Name: J u i � e Phone: O©c_ ,v e-� 6,4h , /I r.(l w CONTRACTOR Name: P,,& A-210) Q e h6UCA,C r c Phone: "-I t , 40S D-3 Address: L a 5� i >1� h ��4 Xhc� cs�e r PI 1� a �� Supervisor's Construction License: 3 Exp. Date: 1 U Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE. BOLDING PERMIT. $12.00 PER 51000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S F. Total Project Cost :$ Q) -7,0S --G FEE:$ Check No.: �-O Receipt No.: Page 1 of 4 TYPE OF SEWERAGE DISPOSAL Public Sewer Well ❑ Private (septic tank, etc. ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Permanent Dumpster on Site ❑ Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner c Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 HEALTH COMMENTS DATE REJECTED DATE APPROVED ❑ I ❑ x i FIR--74, DEPARTMENT - Temp Dumpster on site Fire Department signature/date,D COMMENTS •••••s Wi nNFUa13: variance, f e[inon rvo: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Sianature R Date Driveway Permit Building Setback ft. Front Yard Side Yard Rear Yard ed Provided R uired Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: 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 Addition Or Decks ❑ Building Permit Application ❑ 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 (If Applicable) 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 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 DEPARTMENTMFORM09 Page 4 of 4 Location 4 • No. Date- �oRTM TOWN OF NORTH ANDOVER s Certificate of Occupancy $ •,SSACMUS Building/Frame Permit Fee $ 's Foundation Permit Fee $ 3 Other Permit Fee $ a TOTAL $ Check # 2 2 (a 19979 CD � Building Inspector r.� s. LU zCL ci o ` O y C O Q CJ MC O LO L m = o� r0: 0 c cn Qoc 4 .,EE O 4- • �: c� Ss c Em _+ y s C �: y cmy zoo y W O L', m o cm y J j4czo o► : C Z m F� m o� r;vo"z o co� CL c ~ 0 v; CL m z c •- vyi az "5 Z ui w 90 cm h a m4 O� J a m zoo M 0 7 O U s O z C. O ca � c _ 0� pm I O� D as._ h O O m CO CL. dome 3� O � � L cc O d ora S Co c ev CL. C3 O ca c z a) �..� CLy O c C � c O CA) is LLI 0 LLI Y/ W W V9 W [a h o v w a ww2' `� � x � u. r.Q US LU zCL ci o ` O y C O Q CJ MC O LO L m = o� r0: 0 c cn Qoc 4 .,EE O 4- • �: c� Ss c Em _+ y s C �: y cmy zoo y W O L', m o cm y J j4czo o► : C Z m F� m o� r;vo"z o co� CL c ~ 0 v; CL m z c •- vyi az "5 Z ui w 90 cm h a m4 O� J a m zoo M 0 7 O U s O z C. O ca � c _ 0� pm I O� D as._ h O O m CO CL. dome 3� O � � L cc O d ora S Co c ev CL. C3 O ca c z a) �..� CLy O c C � c O CA) is LLI 0 LLI Y/ W W V9 W [a h BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number:CS_ 083511 Birthdate 1U/28/1�966 Expires �10Y28/2QQ8 Tr: no: 3634.0 Restricted 00 ; CHRISTOPHER J MATEY 32 WASHINGTON AVE.4 ANDOVER, MA 01810 t` - G` Commissibrier HOWE INSURANCE Fax:9784752171 Nov 7 2006 1327 P.01 THE POUCIES OF INSURANCE USITOBELOW HAVE BEEN IGW6U IU I146 INSUNkU NAMED ABOVE FOR THE POUCYP[IUOD INDICATED, NMMYM3TANDINO ANY ReQUIREMFKT. T MM OR CONDITION OF ANY OONTRAOT OR Cyn I t DOCUMENT WAM MT RMT TO WHICH THIS CERTIFI4ATE MAY BE 16'SI.IEO 4R MAY PERTAIN, THE INSURANOE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AU.THE TERMS, OCCLUSIONS AND CONDITIONS OF SUCH POIICi£6 AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED By PAID CLAIMS mm TYPE or INSURANL% POLICY NUMBO! °ry l^r P � T^� BATF, Oft 0eV FWMAMN LATE LIMITS GENERAL LIABILITY X COMMERCLALOENERALI,IARnm txAIMS MAUI � OC.C.UR MPS76266 03125f06 03125407 EACN OOOURRENCE $ 1100.00 PI IeQyamme16p. f $00,000 u" F� (o.- � M^I^^) i 101000 A PERSONAL 3 ADV INJURY 5 1,000,000 GENEPALAGGRRGATE $ 200,000 G&ML AGOREOATE UIM }APPLICO Mt POUbY JECT 7LO0 PftQmw=-*QMPIOP ACG. T 219901000 ANTOM09"A LIABILITY ANY AU I U MMNHH734 90/13448 1011 00MOW P CINGL2 LIMIT (EL owdent) $ ALL OWNED AUTOS HOUILY INJUIIY B X fC;WQOLILmAU'M9 X HIREDAVIUS NON.OWN X ®AUTOS (Perperaw) 6 250,000 80dLY INJURY (Pei ACUtlent) t 600,000 DAMAO� I 100.000 "PACE LIABIUN ANY ALM AUTOOKX_EAACCIDENT 5 4TuCRTww CA nee f AUTOONLY. AC4 f EXCESS/ UMBRELLA LIABILITY c7 --NA U CLAIMS MADE EACH OCCURRENCE > AGGREGATE S s a DEDue;r16LE RETENTICIN S S WCRKGiG OOMI'MCATION AND Pw*L.CYF*9LIABILITY w�7,�� � 0BI"07 we srATli oTL+Er: TDrtrtnera ML. tAt TI AL MULIN4 m LOO C AER'17EEiFAIEAMER EXIBSIa dlTIVE E.L. DI: FAW.—EA EMPLOYEE 1 14,044 F I IroecARPP Pra Ir•V I IMIT s r,00,A00 areauma"mmarMr. OTHEIR DESCRUMON OF OPERATIONSILOCATlON51VENIClESIEXCLUSION5 AUUED BY ENDORKXF!NT4 SPEpAL PROVISIONS ONT1FIckme HBLDER RFA APPLE RENOVATIONS INC 32 WASNIHMN AVENUE AIMEW IWR YA 01810 Atmntian-. 878.915-2418 ACORD 25 (20011W) Q t"kate # 2475 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVORTO ML 16 OAYB IWRMINNIOTICE To THE CWnRCATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO Ad >0 80 MABRL IMPOSE,NO 8NES TIOU OR LIABIUTV OC ANV KIND UPON THC INSVRCR Ire Q►ACORD CORPORATION 1968 holit/' tv111od1'1/ttg 1)re)11'.%Nlo ttt%5 Construction Contract This construction contract (the "Contract"), dated October 13, 2006 is by and between the following homeowner(s) and contractor: Homeowner(s): Property address City, State, Zip Contractor: Representative: Street Telephone Federal Identification Number: Massachusetts License Numbers: Construction Supervisor Home Improvement Julie Mehta 84 Moody Street North Andover, MA 01845 Red Apple Renovations, Inc. Chris Matey, President 9 Bartlet Street, #332 Andover, MA 01810 978.409.1293 56-2309042 CS 083511 138132 1. GENERAL In consideration of the mutual promises contained herein, Contractor agrees to perform the following work: furnish all labor, materials, tools, equipment, and supervision to construct or renovate the Homeowner's residence according to this Contract and the following documents (collectively with this Contract, the "Contract Documents"). The project is generally described as remodel the second floor bathroom (the "Project"). The Contract consists of this document, Exhibit I - General Conditions, and Exhibit II - t ie Project. Change orders and modifications shall be in writing and shall become part of this Contract 2. PRICE The total projected price for the work agreed upon is $27,050. Payment terms are set out below in Paragraph 6. 3. STARTING AND SUBSTANTIAL COMPLETION PROVISIONS The work will begin on or about The work will be substantially completed on or about 1. 4. SPECIFIC REQUIREMENTS FOR MATERIALS AND WORKMANSHIP a. This Contract will be completed by the Contractor in a good and workmanlike manner, using good quality materials. b. If applicable, the Contract price includes the allowances listed in the Contract Details Section, S. EXPIRATION OF THIS CONTRACT This Contract will expire thirty (30) days after the date first written above if not accepted in writing by Homeowner and returned to Contractor within that time. 6. PAYMENT a. Timely payment by the Homeowner of all sums due under this Contract is of the essence to this Contract. The parties agree to the following schedule of payments: 1. Initial payment: 8,000 (due at time of Contract signing). 2. Progress payments: The Homeowner will be billed weekly for the work completed through the end of that week. The deposit paid by the Homeowner will be applied to the final invoice. Demolition Complete 3,600 Rough Plumbing Completed 4,200 Finish Plumbing completed 2,000 Floor Tile Completed 2,000 Shower the Completed 2,000 Wallboard taped and hung 2,000 Painting Complete 2,000 3. Final payment: $1,250 Due at the completion of the project. The Contractor shall provide the Homeowner with his own waiver or cumulative subcontractors' waivers equal to the amount paid for any progress payment. b. The Contractor may cease operations if the Homeowner as required herein does not make any progress payment, and proceed to collect any balance due with any legal remedy. Alternatively, the Contractor may continue operations, as set forth in the attached. 7. SIGNATURE Attached hereto as EXHIBIT I are General Conditions governing the rights and obligations of the parties to this Contract. The parties are further subject to the laws of Massachusetts governing contracts and mechanics' liens, and acknowledge the right of the Contractor to place a lien or security interest on the property of the Homeowner. IN WITNESS WHEREOF, we have hereunto set our hands and seals this day of tiro,te.mye w-., 200(x, DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Homeowner(s)v.ki G-�i tS;y�-��ij� ContractorC�, Homeowner(s) c f OL The Homeowner may cancel this Contract if it has been signed by the Homeowner at a place other than the office of the Contractor, provided that the Homeowner notifies the Contractor in writing at the Contractor's office by ordinary mail, telegram or personal delivery, not later than the midnight of the third business day following the signing of the Contract. See attached Notice of Cancellation for further explanation of this right. It - EXHIBIT I GENERAL CONDITIONS These General Conditions are part of the Contract between Julie Mehta ("Homeowner") and Red Apple Renovations, Inc. ("Contractor") for work at 84 Moody Street, North Andover, MA 01845, dated October 13, 2006. 1. CONTRACTOR'S DUTIES — GENERAL a. To direct and control the work contracted for in accordance with the terms of this Contract and all applicable codes, laws, and regulations, and as the building permits, if any, issued for this project require. b. To inspect the site, examine the plans and specifications, if any, and supervise all of Contractor's employees, and to direct the work of all subcontractors selected by Contractor. c. To maintain the work site in a safe and clean condition, to the extent consistent with the Contract. The worksite will be left in a "broom clean" condition. d. To advise the Homeowner promptly if concealed conditions are ascertained which require additional or different work, and to proceed in such event in accordance with this agreement. 2. HOMEOWNER'S DUTIES — GENERAL a. To provide adequate utilities for the work agreed upon. b. To advise the Contractor of any condition of the property which affects Contractor's ability to perform. c. To provide secure storage areas for materials delivered to the work site. d. To execute in a timely manner all permit applications and other documents necessary for the work to proceed. e. To perform no work on the project without a written agreement with the Contractor. f. To avoid interfering with workers. g. To make no agreements with any tradesperson, subcontractor, or Contractor's employee outside the scope of this Contract without the written consent of the Contractor. h. Homeowner shall notify his insurance agent of the execution of this Contract and obtain any necessary Riders to his current coverage or any locally customary forms of coverage, such as Builder's Risk, to cover Homeowner's interests and liabilities during the construction process. 3. DELAY Contractor shall not be responsible for delays caused by events beyond the control of the Contractor, including but not limited to: strikes, war, acts of God, riots, governmental regulations and restrictions. Delays caused by Homeowner's failure to make allowance materials' selections or caused by the performance by Contractor of additional or necessary work shall likewise be excusable delays. 4. PERMITS The contract will obtain the following permits: Town of North Andover Building Permit It is the obligation of the Contractor to secure such permits as the Homeowner's agent. Note: if the Homeowner secures its own permits or deals with unregistered contractors, the Homeowner is excluded from the Guaranty Fund provisions of MGL c. 142A. S. INSURANCE Contractor agrees to maintain all necessary forms of insurance to protect the Homeowner from liability for any occurrence arising from the performance of this Contract. Contractor agrees that he shall cover his own employees for worker's compensation and carry general liability, and that all forms of insurance carried hereunder shall be with reputable companies licensed to do business in this state. Homeowner agrees to carry full coverage on the subject property covering Homeowner's risk of loss during the construction period, together with all special forms required by reason of the performance of this Contract. Specifically, Homeowner shall contact Homeowner's insurance agent and secure any necessary Builder's risk coverage prior to the commencement ofthe work. 6. HIDDEN, CONCEALED and UNFORESEEABLE CONDITIONS The parties agree that in the event Contractor discovers a condition requiring an extra cost that they shall proceed as follows: The Contractor shall notify the Homeowner verbally at once to expedite agreement as to the charge to correct or cure such condition, and provide a written estimate as soon as practicable. The parties must agree to such extra charges, or agree to a resolution method, or this Contract may be canceled by either of them. For purposes of this section, a "hidden, concealed and unforeseeable condition" shall mean a condition not readily observable to a prudent contractor inspecting the subject property for the purpose of performing this Contract. 7. ADDITIONAL WORK Any additional work or materials desired by the Homeowner shall be agreed upon in writing and such extras shall become a part of this Contract. Unless otherwise agreed, any additional work shall be paid for as performed. Failure of the Homeowner to sign a change order shall not preclude recovery for same by Contractor, and acceptance of said additional work or materials shall be presumed, unless there is written notice to the contrary. Contractor shall advise Homeowner at the time of agreement on any additional work as to any additional time required to perform this Contract. 8. TERMINATION and CANCELLATION Contractor shall have the right to stop all work on the project and keep the job idle if payments are not made to Contractor in accordance with the payment schedule set forth above, or if Homeowner repeatedly fails or refuses to furnish Contractor with access to the job site or product selections or information necessary for the advancement of the work. Simultaneous with stopping work on the project, Contractor shall give Homeowner written notice of the nature of Homeowner's default. If work is stopped due to any of the above reasons (or for any other material breach of Contract by Homeowner) for a period of seven (7) days after notice, and the Homeowner has failed to cure the default, then Contractor may, without prejudicing any other remedies Contractor may have, give written notice of termination of the Contract to Homeowner and demand payment for all completed work and materials ordered through the date of work stoppage, and any other loss sustained by Contractor, including the balance of the Contract. Thereafter, Contractor is relieved from all other contractual duties. Upon such termination, the Contractor shall have all remedies provided by law, including such lien rights as then apply. The Homeowner may terminate this Contract upon the following conditions: a. Any other failure to perform this Contract required by the terms of this Contract. c. No termination shall be effective unless 10 days notice of Homeowner's intent are given as provided below, during which time the default may be cured by the Contractor. 9. DISPUTE RESOLUTION AND ATTORNEYS' FEES a. Dispute Resolution. The Contractor and the Homeowner hereby mutually agree in advance that in the event that the Contractor has a dispute concerning this contract, the Contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided in M.G.L. c. 142A. Contractor: Homeowner: G- K - Homeowner: tf -- NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by the Contractor. The Homeowner may initiate alternative dispute resolution even where this section is not signed separately by the parties. b. Small Claims Court. Any controversy or claim arising out of or related to this Contract involving an amount of less than $2,500.00 (or the maximum limit of the court) must be heard in the Small Claims Division of the District Court in Essex County. c. Attorneys' Fees. In the event of any litigation between the parties relating to this Contract, the party against whom any adverse final judgment is entered (as specifically determined by the Court), following the expiration or exhaustion of all appeals, shall reimburse the other party for such party's costs and expenses (including, without limitation, all reasonable attorneys' fees, expenses and disbursements) of such litigation. d. Inquiries Regarding Contractor. All home improvement contractors and subcontractors shall be registered and that any inquiries regarding a contractor or subcontractor relating to a registration should be directed to: Registration Division, Program Coordinator One Ashburton Place, Room 1301 Boston, MA 02108 Tel: (617) 727-3000 ext. 25239 10. WARRANTIES a. The work of the Contractor, including materials and labor, shall be guaranteed for a period of two (2) years during which period Contractor shall at its own expense correct any defect arising from its work unless Paragraph 7 of these General Conditions applies. This provision is in lieu of all other warranties, express or implied, and Homeowner has no action at law or in equity against the Homeowner after said date. b. Any and all warranties for appliances or mechanical systems shall be delivered to Homeowner when Contractor's final payment is received. c. Notwithstanding any manufacturer's warranty of any component, appliance, or system, no action may be brought against the Contractor on this contract, for the performance of this work, except as provided above. 11. NOTICES Notices may be sent to either party at the addresses shown above, or mailed by certified or registered mail. Any mailed notice shall be deemed given as of the date of mailing. 12. SEVERABILITY If any portion of this agreement is found invalid or unenforceable by any court, the remaining provisions shall remain in force between the parties. 13. ENTIRE AGREEMENT This Contract consists of the documents defined above, and constitutes the entire agreement of the parties. It can be modified only by a written document. UA I RENOVATIONS lrr,rtrr� r-r�runrlr�lirr,�; �,r-r,�i�.wtinrtrrll Exhibit II Second Floor Bathroom Remodel Second Floor Bathroom This project involves remodeling the second floor bathroom within the existing footprint. The renovation of the second floor bathroom would include the following: The existing fixtures and floor in the second floor bathroom will be removed. The walls and ceiling will be removed back to the framing. Water and waste lines would be roughed in for a new tub and shower. The plumbing includes the installation of a shower valve with a single shower head. Any other shower features such as body sprays or hand showers will incur additional plumbing and installation costs. The plumbing for the tub includes replacing all the drain piping under the floor from the tub to the main plumbing stack. The plumbing work will also include connecting the existing waste lines in the bathroom to new PVC vent pipes. These vent pipes are required by code and help the waste lines function more safely and efficiently. The main water line from the service entering the house will be upgraded to a one inch line. This is required by the plumbing code to ensure that the new bathroom has sufficient water pressure. New electrical wires will be roughed in to support new outlets, lighting and switches as required. The vanity light fixture to be installed is VS6704 PW (25' x 8' x 8"). All wails, except where otherwise noted, will be covered with one-half inch sheetrock, taped and finished with three layers of joint compound. The floor will be finished with ceramic tile installed over one-quarter inch cement board. All installed the will be grouted and the grout will be sealed. 9 Bartlet Street X1332 Andover, MA 01810 tel: 978.409.1293 fax: 978.945.2446 The floor will be tiled with Vil 8 x 8 floor tiles. The tiles will be grouted in a color chosen by the homeowner. The walls of the tub replaced with Swanstone Artie Granite shower walls with integral trim (SSIT603AG). The following fixtures will be installed: Item Model Number Quantity AB&A Trip Lever Kit 61871 1 Grohepressure-balance valve 352553000 1 Grohe Valve Trim 19708AV 1 Grohe 5 port diverter 78323 1 Grohe Seabury diverter trim 92433 1 Grohe Shower Arm 59425 1 Grohe Shower Head 59424 1 Grohe Tub Spout 92341 1 Grohe Wall Union 59293 1 Grohe External Vac Braker 133124 1 Grohe Bar satin nickel 59322 1 Strasser vanity Base 120117 1 Sanstone Vanity Top 22917 1 Jaco Faucet 853948144 1 Panasonic fan 1 Gineger double towel bar 112224SN 2 Ginger Towel Ring 1105SN 1 Ginger Open Toilet Paper Holder G110915 1 Totl Ultramsx ADA height toilet MS854114SL 1 Jalco Toilet Tank Lever 904SN 1 A new tub will also be installed, this proposal contains and allowance of $675 for a new tub. The tub to be installed will be selected by the homeowner. This contract does not include any shipping or handling fees charged by any vendors. These will be added to the cost of the project when the costs are incurred. If the fixtures are not purchased from a Red Apple Renovations, Inc. preferred vendor a handling fee may apply. A new exhaust fan/light will be installed and attached to a switch near the door. The fan will be vented to the outside. Finish electrical work will be done to install new lighting switches and outlets. Finish plumbing will be done to install the toilet, sink and shower valve, shower trim, tub faucet and shower head. New paint grade baseboard, window and door trim will be installed in a pattern to match the existing trim in the house. The walls and ceiling will be painted with one coat of drywall primer and two finish coats of paint in colors to be chosen by the homeowner. 9 8artlet Street #332 Andover, MA 01810 tel: 978.409.1293 fax: 978.945.2446 The trim will be painted with one coat of primer and two finish coats in a color to be chosen by the homeowner. All debris will be removed by the contractor. The job site will be broom clean at the end of each day. Permits and inspections will be managed by the contractor. Notes: 1) An allowance is an amount set aside in the contract for a specific item. The final cost will be determined by the fixtures determined by the homeowner. 2) Paint grade means a material intended to be painted rather than stained. Homeowner(s) (a,& -k. Ct. %, LrM fNJ\jC - Homeowner(s) Date i 1 -7 to tc Date it 1'I O 9 Bartlet Street #332 Andover, MA 01810 tel: 978.409.1293 fax: 978.945.2446 The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/E lectricians/Plumbers _Applicant Information Please Print Legibly Name (Business/Organizationflndividual): Address: LUO, AIM,�c: City/State/Zip: %� ��� u1 ey V - 01 V k6 - Phone #:_ �' 1 Are you an employer? Check the appropriate box: . 0 I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).--,- 2.1-1 art-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 have hired the sub -contractors listed on the attached sheet $ These sub -contractors 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. Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also 61l 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. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I ani an employer that is providing workers' compensation insurance for n:y employees. Below is the.polhy and job site information. Insutrance Company Name: Policy # or Self -ins. Lic. if: C Q -7 q d � �- �- Expiration Date: G I F16 -7 Job Site Address: Sloe PA- City/State/Zip: �o h h�cva ✓ I G IF L Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator..- Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA -for insuzance cover�tg verification. I do hereby c,,7-tify under tWa td pertal.i etjuwltat the information provided above is true and correct. Phone #: C�1 �-, 4oo,� 1a' 13 Oficial 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 #: Informati®n and Instructions Massachusetts General Laws chapter 1.52 requires all employers 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 unplied, 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 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 "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a 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-contractor(s) name(s), addresses) and phone number(s) along with their certificates) 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 may be 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 law or if you are 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 permit/license number which will be used as a reference number_ In addition, an applicant that must subnut multiple permiJliceise applications -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 pennits 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 burn leaves etc.) said person is NOT required to complete this affidavit- The ffidavit 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-N4ASSAFE Fax # 617-727-7749 revised 5-26-05 www.mass.gov/dia