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HomeMy WebLinkAboutBuilding Permit #202-13 - 87 WOODCREST DRIVE 9/13/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: Z_ IMPORTANT:Applicant must complete all items on this page LOGATIOO N mtt PROPERTi*'Q__ VNER t � % 1� ✓ P te_ _ --_ Printf s 100)Yea)QJd3Structurno MAP1N0' w �. :PARC;EL ZONING�DISTRICT 'HistoncrD�stnct+. est nog rw. r -` - I e� mexShop;Vil age) esi no— ­ Mach ; TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ElAddition ❑Two or more family 11 Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ _ - - su ❑'Septic ❑,Weill � Floodplaml [J:V1Cetlandsa WatershedDistnct DESCRIPTION OF WORK TO BE PERFORMED: I Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: I' CONTIRACT®.R �.. _— - _ -- = - � Phone -9146 A/3 Y . - i SuperVisor,'sConstrucfon Licenser . C�IpC7 _ Expo, Date _031 � �. -- j Horne;lm rovemeLicense= p nt; ARCH Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST 8 SED ON$125.00 PER S.F. FEE:Total Project Cyst: $ U,in � t7 Check No.: �?i�® Receipt No.: IS NOTE: Persons contracting with unregistered contractors do no`t/Jhhave access to toe guaranty f`� y �� '5-z � �� 4 a.i j Si natureofA ent/Ownerx w Signatureofcontractor �.:st ... Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools 0 Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ I COMMENTS CONSERVATION Reviewed on Si qnature IIS COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments 11 Water & Sewer Connection/Signature& Date Driveway Permit +I DPW.z n Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT = Temp Dumpster on site yes no Located at:124.Mam Street: Fire Department signatureldate ` °� s ° z. COMMENTS i I Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, roast 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 NOTES and DATA— For department use I i ® Notified for pickup - Date Doc.Building Permit Revised 2010 II 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 a Building Permit Application j u Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract u Floor Plan Or Proposed Interior Work 4 u Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit I Addition Or Decks u Building Permit Application u Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) u Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit a New Construction (Single and Two Family) jj u Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract u Mass check Energy Compliance Report u 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: Doc.Building Permit Revised 2012 Location No. 2bZ aj Date (Zi IZ - TOWN OF NORTH ANDOVER • c,�f•T.l I FD 1�'y�;' �. Certificate of Occupancy $ ' ' Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#2210 % F 25'702 Building Inspector o .a P0,C4 6� The Commonwealth of Massachusetts Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised One-or Two-Family Dwelling March 2011 This Section For Official Use Only Building Permit Number: Date Applied: : . Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers l.l a Is this an accepted street?yes L" no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Public❑ Private❑ — Check if yes❑ Municipal ❑ On site disposal system 13 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 01,001� VA ALL. Nam (Print) City,State,ZIP No.and Street . Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work : . SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Labor and Materials) Official Use Only 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost (Item 6)x.multiplier x 3.Plumbing. $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ -Suppression) Total All Fees: $ +a0 Check No.2PIO Check Amount: Cash Amount: 6. Total Project Cost: $� V! Paid in Full 0 Outstanding Balance Due: i SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) �—Z A A.AV li Licens Number Expiration Date Name of CSL-Ho1� List CSL Type(see below) LC- �`t7G�9 R S T Description dress j�j o�c/o.-� U Unrestricted to 35 000 Cu Ft Restricted 1&2Family Dwelling Sinature M MasonryOnly 1&p. en /f/ � RC Residential Roofing Covering... Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.MeiJstered Home Improvement Contractor(HIC). � , /A-�,L r'Registration Number HIC Company Name or HIC R gistrant NSIC Z. /,4/A (51®x T 9 �A . &Szyk7l Expiration Date .. S` tur, Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152..§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application Failure to provide this affidavit will result in the denial of the Issuannce of the building permit. Signed Affidavit Attached? .Yes No 13 Current Certificate must be on file in office Yes SECTION:7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorizcr�'/! ��� to act on my behalf in all matters —e c relative to work.auth 'zed by this building permit application. "13-127 Si ye Dai CTION.7b:OWNER'OR AUTHORIZED AGENT DECLARATION IA It Aie CAA62,eLf as owner:or Authorized Agent hereby declare. that the stateinedis and information he foregoing application are true and accurate,to the best of my:knowledge and behalf. Pnn ame Si tore er or Authorized Agent Date Si under the pams and penalties of NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations l 1.0.86 and I IO.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basement/attics,decks or porch) Gross living area(Sq.Ft) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system. Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" NORTH Town. Of _ 6Andover ON No. - "a;tol o 4F,6)22o1Z h ver, Mass COCNICKaWICK V !'P��,�y S u BOARD OF HEALTH Food/Kitchen Septic System PERMITTHIS CERTIFIES THAT LD 1 . BUILDING INSPECTOR ..... :v�. .... .. ....... . ... ................... ........................................ has permission to erect ...........;ui.1.1in son ...04��r% Foundation .......... ... ....... ... ........... ..................... Rough tobe occupied as ................ ji►.. ..... .. ..................................................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO TARTS Rough Service ................. .�...... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE Proposal AB CARNES, INC. 30 Arrowhead farm Rd Page 1 of 1 Boxford, Ma. 01921 978-887-1431 or 781-599-9197 Mass,Builders License No.000230 Contractors Registration. No 100733 Proposal Submitted To: ALVIN&MAUREEN YADGOOD Date September 8, 2012 87 WOODCREST RD Project Name SAME NORTH ANDOVER, MA 01845-1335 Address 978-314-0330 _ We propose to furnish material and labor-in accordance with the specifications below: Sixteen Thousand Seven Hundred Dollars($16,700.00) Payment to be made as follows: $300.00 Deposit.50%Upon Half Completion.,balance Up CoTp _ Notice:All home improvement contractors and subcontractors engaged in home Authorized;' improvement contracting,unless specifically exempt from registration by provisions Signature ' of Chapter 142A of the General Laws,must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Note:This proposal may be withdrawn by us if not accepted within 30 Mass.govllicenses website. days. ROOF PROPOSAL ® STRIP ROOF OF ALL LAYERS OF ASPHALT SHINGLES,COVER ROOF DECK WITH 15 POUND FELT PAPER. COVER EXTERIOR WALLS AND FOLIAGE WITH TARPS TO HELP PREVENT DAMAGE. ® INSTALL ICE&WATER SHIELD SIX FEET WIDE AT LEADING EDGE ONLY, AND THREE FEET IN ALL VALLEYS AND ALL ROOF PENETRATIONS.UNHEATED AREAS EXCLUDED. ® COVER ALL PERIMETERS WITH EIGHT INCH ALUMINUM DRIP EDGE. ® INSTALL RIDGE VENT AND/OR®AS NEEDED ROOF LOUVERS FOR ADDED ATTIC VENTILATION. ® COVER SOIL PIPES WITH NEW RUBBER FLASHING BOOTS. ® REPLACE WALL FLASHING(S)AS NEEDED WITH ALUMINUM OR LEAD AT THE ADDITIONAL COST OF$25.00PLFT.WE MAY NEED TO REMOVE THE SIDING TO PERFORM THIS WORK.YOU MAY NEED TO HAVE A CARPENTER REINSTALL THE REMOVED SIDING. ® CHIMNEY FLASHING; CUT ALL EXISTING TAR AND LEAD FROM TWO CHIMNEY(S).CUT NEW REGLET WITH CARBIDE SAW AND SECURE NEW LEAD FLASHING IN PLACE W/LEAD ANCHORS. PROPERLY SEAL REGLET JOINT. PLEASE ADD$450.00 EA IF NEEDED TO ABOVE PRICE. ❑ REBUILD CHIMNEY FROM ROOF DECK UP WITH NEW OR USED BRICK. ADD TO ABOVE PRICE. ® COVER ROOF SURFACE WITH CERTAINTEED LANDMARK ARCHITECTURAL LIFETIME WARRANTY SHINGLES. ® REPLACE DEFECTIVE ROOF DECKING WITH CDX PLYWOOD AT AN ADDITIONAL COST OF$4.50 PSQFT. ❑ COVER ROOF DECK WITH CDX PLYWOOD AS NEEDED TO REPLACE OR REPAIR DEFECTIVE DECKING,AT AN ADDITIONAL COST OF ® SHINGLES ARE TO BE STORM NAILED.(USE SIX NAILS PER SHINGLE) ❑ INSTALL SKYLIGHTS PROVIDED BY CUSTOMER,FRAME ROOF DECK AS NEEDED,PROPERLY FLASH UNITS WITH FLASHING KIT(S)PROVIDED, CUSTOMER TO PERFORM ALL INTERIOR WORK. ADD TO ABOVE PRICE. ❑ REMOVE EXISTING GUTTERS ❑INSTALL NEW SEAMLESS.032 ALUMINUM GUTTERS USING THE POSITIVE LOCKING BAR HANGER SYSTEM. ® REPLACE DEFECTIVE OR ROTTED TRIM BOARDS AS NEEDED WITH#2 PINE PRIMED,ADD$15.00 PER FOOT TO ABOVE PRICE. ❑ INSTALL NEW ALUMINUM DOWNSPOUTS. MECHANICALLY FASTEN ALL CONNECTIONS. CLEAN ALL PROJECT RELATED DEBRIS FROM OUTSIDE WORK AREA. OBTAIN ALL PERMITS AND CARRY ALL NECESSARY INSURANCE AS REQUIRED BY LAW. WE CANNOT ACCEPT RESPONSIBILITY FOR DEBRIS FALLING INTO ATTIC AREAS. CUSTOMER SHOULD COVER VALUABLES. GREAT CARE WILL BE USED TO PROTECT THE STRUCTURE AND FOLIAGE.HOWEVER,SOME MARRING AND OR MINOR DAMAGE COULD OCCUR. HAND NAIL ONLY,NO NAIL GUNS TO BE USED. SPECIAL INSTRUCTIONS: THE ABOVE PROPOSAL INCLUDES ALL ROOF SECTIONS OF THE HOUSE COMPLETE. CHIMNEY FLASHING:THESE MAY(?) NEED NEW FLASHING AS PROPOSED ABOVE SO THAT FUTURE LEAKS DO NOT OCCUR. SKYLIGHTS:REMOVE THE FLASHING KITS.WRAP THE CURBS WITH ICE AND WATERSHIELD AND REINSTALL THE KITS. VENTED DRIP EDGE:REMOVE AND INSTALL STANDARD 8"ALUMINUM DRIP EDGE.COVER FASCIA BOARDS WHERE THIS DRIP EDGE IS INSTALLED WITH NEW WHITE CUSTOM FORMED TRIM STOCK. GUTTERS:REPLACE GUTTERS ON THE FRONT OF THE GARAGE.INCLUDED WITH THIS PROPOSAL. WARRANTY UPGRADE:THE CERTAINTEED WIND WARRANTY WILL BE UPGRADED FROM Vp MPH TO 130 MPH WITH AN UPGRADE TO THE HIGH PERFORMANCE HIP&RIDGE CAPS AND STARTER COURSE AT NO ADDITIONAL COST.YE ) WARRANTY-All work warranted to be free of installation defects for 5 years;This is limited to the installed item(s)and their repair only.Material warranted by mfg.to be free of defects for 50 years,see the manufacturers warranty for exact warranty performance. Customer has legal right under federal law to cancel this contract without penalty or obligation within four business days from the date of signing this agreement via Priority Mail Delivery Confirmation. Please see reverse side for cancellation procedures. Once all items in this contract are completed as agreed,customer has 3 days to fulfill payment schedule.All parties agree that all disputes shall be settled by the dispute resolution process.-on the�iback of this agreement. Please see reverse side,Dispute Resolution. Signing this Proposal mans you haveccept d all the terms as stated on the front and back of this agreement. Please see reverse side. Date of Acceptance 21 Signature r'� Signature p /l Jr, PLEASE SEE REVERSE SIDE -� OP ID:SA ACORO" DATE(MM1DDmYY) CERTIFICATE OF LIABILITY INSURANCE 04/05/12 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). CNTACT PRODUCER 978-744-6715 NAME: AHMED Insurance Agency,Inc. PHONE ' FAX PO BOX 449 978-741-0127 A!c No Ext=—_—_ — --ylA/c,No)_---__--- Salem,.MA 01970 'MAIL ADDRESS: Stephen G.Ahmed PRODUCER ---- ------------- --___ --__..--___-- CUSTOMER ID#-ABCAR-1 — i INSURER(S)AFFORDING COVERAGE - NAIC# INSURED A B Carnes Inc INSURER A:Essex Insurance Co 30 Arrowhead Farms Road — INsuRERs-:Safe Insurance Company__— 133618 Boxford;MA 01921 INSURER C INSURER D INSURER E_ .. .. INSURER F: ---- - ---- "-`— _--_._.- � '----..—..--- COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHAT THAT. POLICIESQF�IN_S_iLf3ANCE LISTED-SEL©W-kIAV t.SM EStUEEtJ`TG-744 INSt4RE-B-NAMED=A$OVE'FOR-TRE-POL-ICY-PE—R1'OD----' - - 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[' ADDL POLICY EFF -POLICY EXP --- ___......._.....___._-__. LTR ! —^ TYPE OF INSURANCE - i POLICY NUMBER ) MMIDDIYYYY I MMIDD/YYYY LIMITS GENERAL LIABILITY ( ) EACH OCCURRENCE I$ 1,000,00 A I038/12 03/18/13 D AG T RENTED i$ — 5O OO COMMERCIAL GENERAL LIA131LITY 3DF9266PREMISESSEa occurrence � I CLAIMS MADE (_'_`J OCCUR I MED EXP(Any one person) $ `_ 1,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE —1$ 200,00 I GEN'L AGGREGATE LIMIT.APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 X POLICY PRO- n LO c ) 1PD Deduct —--`$ -- -500 JECT AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT ( $ 1,0001000 I ', (Ea,accidenl) BODILY INJURY ANY AUTO - --- -- 1 . _.._. i BODILY INJURY(Per person). $ ALL OWNED AUTOS ' I i - --- B X..SCHEDULED AUTOS 16213192 05/02/11 05/02/12 ! (Per accident)I $ PROPERTY DAMAGE B i X HIRED AUTOS 6213192 05/02/11 05/02/12 (Per accident) $ In B I"X� NON-OWNED AUTOS 1 16213192 i 05/02/11 05/02/12 _ $ UMBRELLA LIAR I OCCUR EACH OCCURRENCE I$ CESS LIAR it CLAIMS-MADE, I AGGREGATE I$ DEDUCTIBLE i$__..... I I RETENTION $ �'----- $ WORKERS COMPENSATIONI i WC STATU-L OTH- AND EMPLOYERS'LIABILITY /N I 4 TTORY LIMITS _EL2 ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT 1 $ -- i OFFICERlMEMBER EXCLUDED? .N.1 A .. - (Mandatory In NH) E L.DISEASE-EA EMPLOYEE{ $. If es,describe under -- I DESCRIPTION OF OPERATIONS below - I E.L.DISEASE-POLICY LIMIT I $ I i DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks.Schedule,if more space is required) Roofing contractor CERTIFICATE HOLDER CANCELLATION NONE001 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,` NOTICE WILL BE DELIVERED IN None ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD Y Tite Commo'awealth of Massachusetts art►neut of Industrial Accidents fi plyke of Investigations 600 Wasi`tington Street Boston, AA 02111 www.massgov/dia Workers' Compensation Insuranc.e Affidact Builders/C,,ontractorstElectricians/Plulmbers Applicant ant Infe matlan Please Print IR i Name(Business/Urganzazon/individuai); Address: A &,-A ,�d City/State/Zip: 1 Phone#: 92 r. Are you an employer?Check the appropriate baa: Type ofproject(required): I am a employer with 4. ❑ I atn a general contractor and I 6. ❑New construction . . have hired the subcontractors employees(full and/or. art-time). 7. ❑Remodelinglisted on the attached sheet 2.0 I am a sole proprietor or partner- These sub-contractors have S. C]Demolition ship and have no employees employees and.have workers' working for mein any capacity. n Building addition i 9. � [No workers'comp.insurance, XWe are a corporation and its 10.Q Electrical repairs or additions required.] 3.Q 1 am a homeowner doing.all work officers have exercised their 11.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 1:2Roof repairs insurance required.]t .: c• 152,§1(4),and we have no 13.Q Other, employees. [No workers' comp.insurance required.] 'Any applicant that checks box##I must also fill aut the section'belova shaxm- g their workers'compensation policy infiotntation. Ilomeowncn who submit this affidavit indicating they are doing all work and then hire outside contractors must sabmit a new affidavit indicating such. tconttactors that check this box must attached an additional sheat showing Ste name of the sub-contractors and state whether or notthose entities have employees. if the sub contractors have employees,they mist provide their workras'oomp•policy n>n aber. I am an employer that is providing workers'compensation insrrrrmee for nw employees. Below is file pohe3'and job site information. Insurance Company Name: ... Policy#or Self--ins.Lic.#: Expiration.Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a line 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 insurance coverage verification. Ido hereby e ` under d:e iris and penalties of perjury that the+irimformatwn prof d d abnve is inle rind correct Si tore: Date: , p ane {/ Official arse only. Uo not lite in this area,to be completed by city or town officiat City or Town: PermiVUeense:# Issuing Authority(circle one): 1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.:other Contract Person: Phone#: FORM 153. The Commonwealth of Massachusetts DIA Use Only Department of Industrial Accidents Office of Investigations-Dept. 153 1 Congress Street,Suite 100,Boston,Massachusetts 021142017 http:I/www.mass.gov/dia InvestJSWO ID#: AFFIDAVIT OF EXEMPTION FOR.CERTAIN CORPORATE OFFICERS OR DIRECTORS Chapter 169:.of the Acts of 2002 amended M.G.L. c. 152, §1(4) by adding the following paragraph.: "This chapter shalt be elective for an officer or director of a corporation who owns at least 25 percent of the issued and outstanding stock of the corporation.Notwithstanding section 46, these provisions.shall apply only if the corporate officer provides the commissioner of industrial accidents with a written waiver of his rights under this chapter. Said commissioner shall promulgate regulations to carry out the purpose of this paragraph. Violations of this P �'aPh shall subject the corporation to the penalties set forth in section 25C." Pursuant to M.G L. c. 152, §1(4)as amended, !/We the undersigned officers of: AB Carnes, Inc. 30 Arrowhead Farm Rd Boxford; Ma 01921 (Name of Corporation and Address) each holding at least 25%of the issued and outstanding stock in said corporation, do.hereby invoke the. right to be exempt from the provisions of M.G.L. c. 152, §25A and therefore are not required to carry a workers' compensation policy covering the undersigned.corporate officer(s) or director(s). I/We the undersigned do also waive any and all rights to make claims for benefits as defined in M.G.L. c. 152 for any injuries that may be sustained while in the employ of the above-named corporation. Further, I/we the undersigned do understand that, should the above-named corporation hire or have in its employ any employee(s) in addition to the undersigned corporate officer(s) or director(s), said corporation is required to obtain workers' compensation coverage for the employee(s) as prescribed by M.G.L. c. 152, §25A, I/We the undersigned have read and understand the statements and obligations as delineated above and I/we have checke he appropriate box below my/our name(s) indicating my/our desire to be exempt or not o be pt fr the provisions of M.G.L. c. 152. ed under t pains and penalties of perjury: Barry.Carnes, President 04/3/2012 Si re Print Name&Title: Date(mm/dd/yyyy) �✓ wish to exercise my right of exemption or ❑ I wish NOT to exercise my right of exemption Anastasiya Carnes, Director 04/03/2012 Signature Print Name&Title Date(mm/dd/yyyy) Q✓ I wish to exercise my right of exemption or I wish NOT to exercise my right of exemption Signature: Print Name&Title Date(mm/dd/yyyy) I wish to:exercise my right of exemption or E] I wish NOT to exercise my right of exemption Signature Print Name&Title Date.(mm/dd/yyyy) I wish to exercise my right of exemption or Q .I wish NOT to exercise my right of exemption Note:ALL ELIGIBLE CORPORATE OFFICERS MUST SIGN. THERE CAN BE NO MORE THAN 4 SIGNATURES. Instructions on back. Form 153-7/2010 MA SOC Filing Number: 201287835330 Date: 5/30/2012 9:10:00 PM The Commonwealth of Massachusetts NO Fee William Francis Galvin Secretary of the Commonwealth, Corporations Division One Ashburton Place, 17th floor Boston,MA 02108-1512 . tR ► Telephone: (617)727-9640 1. Exact name of the corporation: A. B. CARNES,INC. 2. Current registered office address: Name: BARRY S. CARNES No. and Street: 30 ARROWHEAD FARM ROAD City or Town: BOXFORD State: MA Zip: 01921 Country: USA 3. The following supplemental information has changed: Names and street addresses of the directors,president, treasurer, secretary Title Individual Name Address(no PO Box) First,Middle,Last,Suffix Address,City or Town,State,Zip Code PRESIDENT BARRY S.CARNES 30 ARROWHEAD FARM ROAD, BOXFORD,MA 01921 USA TREASURER BARRY S.CARNES 30 ARROWHEAD FARM ROAD, BOXFORD,MA 01921 USA SECRETARY BARRY S.CARNES 30 ARROWHEAD FARM ROAD, BOXFORD,MA 01921 USA DIRECTOR BARRY S.CARNES 30 ARROWHEAD FARM ROAD, BOXFORD,MAO 1921 USA DIRECTOR ANASTASIYA CARNES 30 ARROWHEAD FARM ROAD, BOXFORD,MA 01921 USA X Fiscal year end: October X Type of business in which the corporation intends to engage: GENERAL CONTRACTING&MARKETING X Principal office address: No. and Street: 30 ARROWHEAD FARM ROAD City or Town: BOXFORD Stater MA Zip: 01921 Country: USA X g. Street address where the records of the corporation required to be kept in the Commonwealth are located (post office boxes are not acceptable): No. and Street: 30 ARROWHEAD FARM ROAD City or Town: BOXFORD State: MA Zip: 01921 Country: USA which is X. its principal office _ an office of its transfer agent an office of its secretary/assistant secretary _ its registered office :Signed by BARRY S. CARNES , its PRESIDENT on this 30 Day of May,2012 ©2001 -2012 Commonwealth of Massachusetts All Rights Reserved MA SOC Filing Number: 201287835330 Date: 5/30/2012 9:10:00 PM . THE COMMONWEALTH OF MASSACHUSETTS n f this document duly submitted to me it appears I hereby certify that, upon examination o y pp that the provisions of the General Laws relative to corporations have been complied with, and I hereby approve said articles; and the filing fee having been paid, said articles are deemed to have been filed with me on: May 30, 2012 09:10 PM WILLIAM FRANCIS GALVIN Secretary of the Commonwealth 111M Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Super%isor License: CS-000230 BARRY S CARNES 30 ARROWHEAD FAI11tD BoxfordMA--01921 f r "xpiration Commissioner 03/07/2014 Office of Consumer Affairs and Business Regulation c 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement C_oritractor Registration - ---- Registration: 100733 Type: Private Corporation Expiration: 6/23/2014 Tr# 223142 A. B. CARNES, INC. Barry Carnes = - - 30 Arrowhead Farm Rd. - Boxford, MA 01921 Update Address and return card.Mark reason for change. DPS-CA1 0 50M-04/04-G101216 F] Address ❑ Renewal Employment Lost Card NORTH ANDOVER WASTE AFFIDAVIT As a result of the provisions of MGL Ch.40-s54, I acknowledge that as a condition of building permit# all debris resulting from the construction activity governed by this building permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL Ch.111-s150A. Waste Disposal or Solid Waste Facility: ALLIED WASTE Address: 300 FOREST ST Town/City, State, Zip: PEABODY, MA 01960 NAME OF HAULER: AB CARNES, INC. DATE: 9-13-2012 SIGNATURE OF APPLICANT: NO DUMPSTERS USED BY US. ALL DEBRIS HAULED BY OUR OWN TRUCKS